Neoadjuvant sequential chemoradiotherapy versus radiotherapy alone for treatment of high-risk extremity soft tissue sarcoma: a single-institution experience.

AIM OF THE STUDY: Patients with large and high-grade extremity soft-tissue sarcoma are at significant risk for distant metastasis and sarcoma-related death. There is no randomized trial comparing chemoradiotherapy to radiotherapy in the neoadjuvant setting for high risk extremity soft-tissue sarcoma. The aim of this study is to evaluate the outcomes of patients treated with two different modalities (neoadjuvant sequential chemoradiotherapy vs. radiotherapy alone) in a single center. MATERIAL AND METHODS: Data of 67 patients were analyzed retrospectively. Thirty-four patients received neoadjuvant sequential chemoradiotherapy (2-3 cycles of doxorubicin (75 mg/m2) and ifosfamide (6 g/m2) followed by radiotherapy of 28 Grays (Gy) administered as 8 fractions of 35 Gy) and 33 patients received radiotherapy alone. R0 resection rates and 3-year survival estimates were evaluated. RESULTS: Median follow-up time was 37 months. The estimated 3-year overall and disease-free survival rates for the whole patient group were 79% (95% CI: 67.0-86.4) and 57.9% (95% CI: 46.3-69.0), respectively. The most common side effects were nausea and leucopenia. Three-year overall, disease-free, local recurrence-free and distant recurrence-free survival rates did not differ significantly. All patients except one underwent wide excision or compartmental resection. R0 resection rate for the whole patient group was 92.5% (n = 62). Sites of progression were similar across both treatment arms. CONCLUSIONS: Preoperative hypofractionated radiotherapy alone or sequentially with chemotherapy result in high rates of limb salvage and acceptable toxicity. Our study results did not show a statistically significant treatment effect regarding survival and patterns of failure.

Same Chemotherapy Regimen Leads to Different Myelotoxicity in Different Malignancies: A Comparison of Chemotherapy-Associated Myelotoxicity in Patients With Advanced Ovarian and Non-Small-Cell Lung Cancer.

Carboplatin-paclitaxel chemotherapy combination is the standard first-line treatment of advanced ovarian cancer and is the most commonly used treatment combination shown to be effective in advanced non-small-cell lung cancer (NSCLC). The most important dose-limiting side effect is hematologic toxicity. In this study, the severity of treatment-related myelotoxicity is compared in patients with advanced ovarian and lung cancers who received same schedule of carboplatin-paclitaxel. The study was prospectively performed from February 2009 to July 2011 and involved 103 patients with stages Ic-IV ovarian (n = 51) and advanced NSCLC (n = 52) who were administered a maximum of 6 cycles of carboplatin-paclitaxel as a first-line treatment. Full blood counts were measured before treatment, before each chemotherapy cycle during therapy, and at the first and sixth month after therapy. The median ages were 59 years (range, 35-77 years) for patients with NSCLC and 56 years (range, 38-75 years) for patients with ovarian cancer. The frequencies of anemia were 17% and 28.6% before the initiation of chemotherapy, 39.2% and 68.0% at the third cycle of treatment, and 44.2% and 45.2% at the sixth cycle of treatment in patients with NSCLC and ovarian cancer, respectively. Initial leukopenia rates were 3.4% and 0%; at the third cycle 46.0% and 41.2%; and at the sixth cycle 41.9% and 48.8% in patients with NSCLC and ovarian cancer, respectively. At the third cycle, 2.5% of the patients with NSCLC and 10.4% of the patients with ovarian cancer had thrombocytopenia, and at the sixth cycle, 23.3% of the patients with NSCLC and 25% of the patients with ovarian cancer had thrombocytopenia. Hemoglobin, leukocyte, and platelet values at the third cycle were significantly lower than those at admission in both cancer groups. Declines in hemoglobin levels in patients with NSCLC and in platelets in patients with ovarian cancer at the sixth cycle were statistically significant compared with the third cycle. In conclusion, the same schedule of chemotherapy may lead to different myelotoxicities in different types of cancer. These results should be taken into consideration in terms of supportive care and management of toxicity.

Clinical significance of serum interleukin-17 levels in colorectal cancer patients.

PURPOSE: The proinflammatory cytokine, interleukin-17 (IL-17) plays a potent role in T-cell mediated angiogenesis and promotes tumorigenicity. The objective of this study was to determine the clinical outcomes of colorectal cancer (CRC) patients in relation to serum IL-17 levels. METHODS: Ninety-six CRC patients were enrolled in this study. Pre-treatment serum IL-17 levels were determined by enzyme- linked immunosorbent assay (ELISA). Thirty age - and sex-matched healthy controls were included in the analysis. RESULTS: The median patient age was 60 years (range: 24-84) and the most frequent localization was colon (N=59;61%). Median follow-up time was 14 months, 27 patients (28%) experienced disease progression, and 20 of the remaining patients (20%) died. The estimated and 1-year progression-free survival (PFS) and 2-year overall survival (OS) rates for the whole patient group were 26.9% (95% confidence interval [CI]=9.9-44.0) and 71% (95% CI=56.0- 85.0), respectively. The number of patients who received neoadjuvant treatment was 25. Of the patients who received palliative treatment, 11 had oxaliplatin whereas 18 and 7 had irinotecan and FU/capecitabine, chemotherapy (CTx). Twenty-four and nine of the patients who received targeted therapy had bevacizumab and cetuximab, respectively. Thirty-three percent of 36 metastatic patients who received palliative CTx were CTx-responsive. The baseline median serum IL-17 levels were significantly lower in patients with CRC than in the healthy control group (p=0.01). Moreover, known clinical variables including older age, poor grade and low albumin levels were found to be correlated with high serum IL-17 concentrations (p=0.02, p=0.02, and p=0.04, respectively). No statistically significant serum IL- 17 concentrations were noted regarding PFS and OS. CONCLUSION: Serum levels of IL-17 may be diagnostic marker in CRC patients. However, no predictive and prognostic values were determined.

Diagnostic value of serum M30 and M65 in patients with nasopharyngeal carcinoma.

M30 and M65 are circulating fragments of cytokeratin 18 released during apoptotic cell death and regarded as markers of cell death in patients with various tumor types. Our aim was to investigate the clinical and prognostic significance of the serum M30 and M65 concentrations in patients with advanced nasopharyngeal carcinoma. Thirty-two patients with nasopharyngeal cancer and 32 control subjects were investigated. Serum samples were obtained on first admission before any treatment was initiated. Serum M30 and M65 concentrations were measured by quantitative enzyme-linked immunosorbent assay. Median serum M30 (181.5 vs. 45.5 U/L, p < 0.001) and M65 (384.2 vs. 179.1 U/L, p < 0.001) concentrations were significantly higher in patients with advanced nasopharyngeal carcinomas than in controls. receiver operating characteristic (ROC) analysis showed that a cutoff for M30 of 225 U/L had a sensitivity of 62.5% and a specificity of 73.9% (area under the curve (AUC) = 0.592, 95% confidence interval (CI) 35.3-83.2, p = 0.44), while a cutoff for M65 of 423.4 U/L had a sensitivity of 75.1% and a specificity of 65.6% (AUC = 0.562, 95 % CI 36.0-76.5, p = 0.60). However, serum M30 and M65 were not important prognostic factors for progression-free survival. There were no statistically significant correlations between serum M30 and M65 concentrations and clinicodemographical variables. Serum M30 and M65 concentrations were found to have a diagnostic value in nasopharyngeal cancer. However, neither M30 nor M65 serum levels played a prognostic role in the outcome in nasopharyngeal cancer patients.

Coagulation tests show significant differences in patients with breast cancer.

Activated coagulation and fibrinolytic system in cancer patients is associated with tumor stroma formation and metastasis in different cancer types. The aim of this study is to explore the correlation of blood coagulation assays for various clinicopathologic factors in breast cancer patients. A total of 123 female breast cancer patients were enrolled into the study. All the patients were treatment naïve. Pretreatment blood coagulation tests including PT, APTT, PTA, INR, D-dimer, fibrinogen levels, and platelet counts were evaluated. Median age of diagnosis was 51 years old (range 26-82). Twenty-two percent of the group consisted of metastatic breast cancer patients. The plasma level of all coagulation tests revealed statistically significant difference between patient and control group except for PT (p<0.001 for all variables except for PT; p=0.08). Elderly age (>50 years) was associated with higher D-dimer levels (p=0.003). Metastatic patients exhibited significantly higher D-dimer values when compared with early breast cancer patients (p=0.049). Advanced tumor stage (T3 and T4) was associated with higher INR (p=0.05) and lower PTA (p=0.025). In conclusion, coagulation tests show significant differences in patients with breast cancer.

High serum transforming growth factor beta 1 (TGFB1) level predicts better survival in breast cancer.

The transforming growth factor beta 1 (TGFB1) is a regulatory cytokine with both tumor suppressor and tumor-promoting effects in breast cancer (BC) cell lines and tissue. Data about level of circulating TGFB1 and its prognostic significance in BC patients is conflicting. The objective of this study is to determine the clinical significance of the serum TGFB1 levels in BC patients. We enrolled 96 female patients with histopathologically diagnosed BC who did not receive chemotherapy (CT) or radiotherapy. Serum TGFB1 levels were measured by ELISA method and compared with 30 healthy controls. The mean serum TGFB1 level of BC patients was significantly higher than controls (0.08 vs. 0.04 ng/ml, p < 0.001). There was no significant difference according to known disease-related clinicopathological or laboratory parameters. Serum TGFB1 level had a significant impact on overall survival in both univariate (p = 0.01) and multivariate analysis (p = 0.013). Serum TGFB1 level is elevated in BC patients and has a favorable prognostic value. However, it has no predictive role on CT response.

The behavior of Turkish cancer patients in fasting during the holy month of Ramadan.

OBJECTIVE: Fasting during the holy month of Ramadan is one of the major obligations for all adult Muslims. We performed a survey of Turkish Muslim cancer patients to examine the extent of their fasting status and to compare various clinical characteristics of fasting and non-fasting cancer patients during the month of Ramadan. METHODS: This study was conducted on 701 adult cancer patients who attended ambulatory patient care units answered the questionnaires. RESULTS: The population comprised 445 women (63.5%), and the median age was 54 years. Before diagnosis of cancer, 93.1% of the patients used fast consists of completely (78.3%) and partial (14.8%). However, 15% of cases were fasting on the day of interview, either partially (7.4%) or completely (7.6%) with equal distributions. Patients who were females, those with good performance status, those without any comorbid disease, who had non-metastatic disease, those with history of surgery, those treated with radiotherapy and those being treated with oral chemotherapeutic agents were more likely to be fasting than others. The fasting ones had more prevalent among patients with lymphoma, urogenital cancer and breast cancer; conversely, the rate of fasting status among patients with lung and gastrointestinal cancer was quite low. Only 20.8% of all patients asked their physician whether it was alright for them to fast and physicians generally had a negative attitude towards fasting (83.2%). CONCLUSIONS: Majority of cancer patients are not fasting during the month of Ramadan, and a small part of patients consult this situation to their physician.

Clinical and prognostic significance of coagulation assays in advanced epithelial ovarian cancer.

OBJECTIVE: Epithelial ovarian cancer (EOC) is the leading cause of death among gynecological tumors and usually diagnosed at advanced stage. We aimed to identify the clinical and prognostic relevance of coagulation tests and their correlation with serum CA-125 levels in advanced EOC. MATERIALS AND METHODS: A total of 33 advanced-stage (stages III and IV) EOC patients were enrolled in the study. Of these patients, 17 had received neoadjuvant chemotherapy and 16 patients received chemotherapy after optimal debulking surgery. Several clinicopathologic factors, coagulation assays, routine biochemistry tests, and serum CA-125 levels were evaluated before treatment and compared with healthy subjects. RESULTS: All coagulation tests including prothrombin time (PT), activated partial thromboplastin time, international normalized ratio, fibrinogen, D-dimer, and platelet revealed statistically significant difference between patients and control subjects (P ≤ 0.001). Elevated CA-125 levels were correlated with higher D-dimer values (P = 0.03). Prolonged PT was associated with poorer both overall (P = 0.03) and progression-free survival rates (P = 0.04). CONCLUSIONS: Correlation of CA-125 with D-dimer is supposed to reflect hyperactivation of fibrinolytic pathway in the presence of a higher tumor load. Alterations in coagulation pathway reflected by prolonged PT support prognostic effects on survival of advanced-stage EOC patients.

Performance status of patients is the major prognostic factor at all stages of pancreatic cancer.

BACKGROUND: The aim of this study was to identify and evaluate the clinicopathologic factors and to elucidate the clinical importance of performance status on the outcome of patients with pancreatic cancer. MATERIALS AND METHOD: The data of 335 patients with histologically confirmed diagnosis of pancreatic cancer who were treated and followed up between 2000 and 2010 were recorded from medical charts. RESULTS: The median age of the patients was 59 years (range 25-88 years) and 226 (67.5%) were male. The study group comprised localized disease (18%), locally advanced disease (36%) and metastatic disease (46%). The median survival of all patients was 280 days and the 4-year survival rate was 5%. Univariate analysis indicated that initial poor performance status of patients (PS 2-4) was significantly associated with shorter survival in localized (p = 0.015), locally advanced (p = 0.01), metastatic stage (p < 0.001) and in the whole group (p < 0.001). Multivariate analyses also showed the same findings except in local disease (p = 0.04 for locally advanced disease, p = 0.002 for metastatic stage, and p < 0.001 for all stages). In patients with poor performance status, severe weight loss (>10%) (p = 0.007), large tumor diameter (>3 cm) (p = 0.046), and especially metastatic disease (p < 0.001) were associated with significantly shorter overall survival. CONCLUSIONS: The performance status of a patient is the major prognostic factor predicting overall survival for all stages of pancreatic cancer. Severe weight loss, large tumor, and metastatic disease were found to be unfavorable prognostic factors in patients with poor performance status.

Robotic Mitral Valve Surgery With Intracardiac Ultrasound-Guided Septal Myectomy.

Hypertrophic obstructive cardiomyopathy requires surgical myectomy when heart failure symptoms persist despite best medical therapy. Minimally invasive myectomy with robotic surgery can be performed in experienced centers, allowing for surgical correction of accompanying mitral valve pathologies. The extent of myectomy is important to relieve left ventricular outflow tract obstruction while care should be taken to prevent iatrogenic ventricular septal defects or heart blocks caused by excessive removal of septal tissue. We report the use of intracardiac ultrasonography during robotic surgery to intraoperatively assess the myocardium before and after myectomy to increase the safety of this procedure.

Noncutaneous melanoma have distinct features from each other and cutaneous melanoma.

OBJECTIVE: Compared to the cutaneous melanoma, noncutaneous melanomas are relatively rare and have a distinct pattern of behavior. We performed this study to define the clinical characteristics and outcomes of patients with noncutaneous melanomas and emphasize how they differ from cutaneous melanomas. METHODS: 216 patients who were diagnosed with noncutaneous melanoma were assessed and their medical records between 2000 and 2010 were retrieved from the cancer registry. 475 patients with cutaneous melanoma were used for comparison. RESULTS: Of the 216 noncutaneous melanoma patients, 83 had mucosal melanoma, 101 had ocular melanoma and 32 had unknown primaries. For mucosal melanoma, the head and neck was the most common anatomic site (53%), followed by the gastrointestinal tract (37%), female genital (6%) and urinary tract (4%). The majority of the ocular melanomas (94%) originated in the uvea. 32 patients demonstrated a primary unknown disease with regional metastasis as the dominant behavior (72%). Age was found to be statistically significantly different among melanoma patients (p < 0.001). Younger patients had more cutaneous and unknown primary melanomas, whereas older patients had more ocular and mucosal melanoma. In subset analyses, we found significant differences between cutaneous and ocular (p = 0.038) or mucosal (p < 0.001) melanomas. The ratios of metastasis on admission were higher in patients with mucosal (27.7%) and unknown primary (28.1%) melanomas, and lower for ocular (3%) melanomas (p < 0.001). Patients with cutaneous melanoma had an intermediate (12%) ratio. Patients with ocular melanoma had better outcome than patients with other melanoma sites (p < 0.05). While overall survival for cutaneous melanoma was significantly negatively correlated with male gender (p < 0.001), advanced stages (p < 0.001) and old age (p = 0.005), stage IV disease was the only independent prognostic factor in patients with ocular melanoma (p = 0.006). No prognostic factor for outcome was found for either mucosal or unknown primary melanomas. CONCLUSION: The clinical presentations and prognoses of different primary sites of melanoma are distinctive. Therefore, approaches to these melanomas should be different.

Optic disc and choroidal metastasis from sporadic medullary thyroid carcinoma: case report and review of the literature.

BACKGROUND: Choroidal metastasis is a very rare clinical manifestation of thyroid cancer. Herein, we report on a patient with non-familial medullary thyroid carcinoma (MTC), who presented with choroidal metastasis. CASE REPORT: A 63-year-old male patient with MTC presented with sudden loss of vision in his right eye for 1 month. The patient had a history of complete thyroidectomy and chemotherapy for disseminated MTC. Ophthalmological examination showed optic disc and choroidal metastases in the right eye and a small choroidal metastasis in the left eye. The patient was scheduled for external irradiation therapy for the ocular area but died 2 months after choroidal metastasis was diagnosed. CONCLUSIONS: Choroidal metastasis must be considered in MTC patients who develop loss of vision. This is a very rare clinical situation that generally occurs in the late advanced stages of the disease and carries a poor prognosis for these patients.

Long-term results of coronary surgery with endoscopic vein harvesting.

BACKGROUND: In this study, we aimed to evaluate early and longterm outcomes of both isolated or concomitant coronary artery bypass grafting with the endoscopic vein harvesting technique. METHODS: Between November 2012 and May 2017, a total of 324 patients (259 males, 65 females; mean age: 63.2±9.8 years; range, 36 to 91 years) who underwent coronary artery bypass grafting, with or without concomitant procedures, using the endoscopic vein harvesting technique were retrospectively analyzed. Early postoperative outcomes and long-term follow-up data of the patients, such as cardiovascular or cerebral events, cardiac reinterventions, and the images of coronary angiography were recorded. RESULTS: Median logistic EuroSCORE and in hospital mortality was 3.99 (0.8-81) vs. 0 .9% f or i solated c oronary surgery and 13.34 (1.5-76.4) vs. 1.5% for concomitant procedures. The long-term data could be obtained in 288 patients with a median of 59.6 (7-90) months of follow-up. During this period, 22 (7.6%) patients underwent coronary angiography for control or treatment, 12 (4.2%) patients needed revascularization, and none of the patients underwent redo coronary surgery. CONCLUSION: Our study results suggest that the endoscopic vein harvesting technique during coronary artery bypass grafting is safe in experienced hands.

Current adjuvant treatment modalities for gastric cancer: From history to the future.

The discrepancy between the surgical technique and the type of adjuvant chemotherapy used in clinical trials and patient outcomes in terms of overall survival rates has led to the generation of different adjuvant treatment protocols in distinct parts of the world. The adjuvant treatment recommendation is generally chemoradiotherapy in the United States, perioperative chemotherapy in the United Kingdom and parts of Europe, and chemotherapy in Asia. These options mainly rely on the United States Intergroup-0116, United Kingdom British Medical Research Council Adjuvant Gastric Infusional Chemotherapy, and the Asian Adjuvant Chemotherapy Trial of S-1 for Gastric Cancer and Capecitabine and Oxaliplatin Adjuvant Study in Stomach Cancer trials. However, the benefits were evident for only certain patients, which were not very homogeneous regarding the type of surgery, chemotherapy regimens, and stage of disease. Whether the dissimilarities in survival are attributable to surgical technique or intrinsic biological differences is a subject of debate. Regardless of the extent of surgery, multimodal therapy may offer modest survival advantage at least for diseases with lymph node involvement. Moreover, in the era of individualized treatment for most of the other cancer types, identification of special subgroups comprising those who will derive more or no benefit from adjuvant therapy merits further investigation. The aim of this review is to reveal the historical evolution and future reflections of adjuvant treatment modalities for resected gastric cancer patients.

Evaluation of Serum Interleukin-17 (IL-17) Levels as a Diagnostic Marker in Pancreatic Adenocarcinoma.

BACKGROUND: Inflammatory cytokines modulate immune responses in the tumor microenvironment during progression. The role of interleukin (IL-17) in cancer is currently under debate. This study was conducted to investigate the serum levels of IL-17 in patients with pancreatic adenocarcinoma (PA) and the relationship with tumor progression and known prognostic parameters. MATERIAL AND METHODS: Thirty-five patients with PA were investigated. Serum samples were obtained on first admission before treatment and follow-up. Both serum IL-17 levels were determined using enzyme-linked immunosorbent assay (ELISA). Age- and sex-matched 35 healthy controls were included in the analysis. RESULTS: The median age at diagnosis was 61 years, range 38-84 years; 21 (60%) patients were men. The tumor was located in the head of pancreas in 24 (69%) patients. The most common metastatic site was liver in 20 patients with metastasis (n = 18, 90%). The median follow-up time was 24.0 weeks (range 1.0-191.0 weeks). At the end of the observation period, 12 (34%) patients experienced disease progression and 23 patients (66%) were dead. Forty-four percent of 18 metastatic patients who received palliative chemotherapy (CTx) were CTx-responsive. Median progression-free survival and overall survival of the whole group were 13.7 ± 2.3 weeks [95% confidence interval (CI) = 9-18 weeks] and 48.0 ± 12.8 weeks (95% CI = 23-73 weeks), respectively. The baseline serum IL-17 levels were significantly higher in patients with PA than in the control group (p = 0.001). Moreover, serum IL-17 levels were significantly higher in the patients with large pathologic tumor status and low albumin levels (p = 0.04 and p = 0.03, respectively). However, serum IL-17 assays had no prognostic roles on outcome. CONCLUSION: Although serum levels of IL-17 assays were found to be diagnostic value, no predictive and prognostic value was determined in PA patients.

Factors affecting progression-free survival in non-HIV-related Kaposi sarcoma.

BACKGROUND: Non-HIV related Kaposi sarcoma (NHKS) is a rare indolent neoplasm which is more common around Mediterranean origin. Data concerning factors that influence progression-free survival (PFS) for NHKS are insufficient. The purpose of present retrospective analysis was to distinguish the factors affecting PFS in patients with NHKS. METHODS: A hundred and twenty-eight consecutive patients with NHKS who were treated or observed between 1997 and 2014 at Istanbul University Institute of Oncology were included into the study. Treatment response and progression definitions were determined according to different treatment modalities administered at first line. RESULTS: Majority of patients were male (n = 97, 75.8%). Median age of the whole group was 66 years (28-85). Of the patients, 15 patients were immunosuppressant, whereas 113 patients had no disease that caused immunosuppression. Patients were treated with local excision (n = 57, 44.5%), chemotherapy (n = 32, 25.0%) and/or radiotherapy (n = 13, 10.2%) or observed without treatment (n = 26, 20.3%). At a median follow-up of 28 months, 71 (55.5%) patients had progression, while 3 patients (2.3%) died of NHKS. On univariate analysis, patients who had hypertension (HT) had poorer PFS compared with others (19 ± 12 versus 41 ± 22 months; p = 0.03), whereas plaque formation was associated with better outcome (25 ± 9 versus 54 ± 12 months; p = 0.03). In addition, heavy smoking (≥40 pack-years) had a borderline significance regarding better PFS time (23 ± 24 versus 45 ± 38 months, p = 0.06). On multivariate analysis, none of factors evaluated had any impact on PFS. CONCLUSIONS: HT was correlated with poorer outcome among NHKS patients. Patients with plaque formation and ≥40 pack-years of smoking had better PFS than others.

D-dimer and international normalized ratio (INR) are correlated with tumor markers and disease stage in colorectal cancer patients.

BACKGROUND: The aim of this study is to evaluate the correlation of coagulation tests with various clinicopathological variables and tumor markers among colorectal cancer (CRC) patients. MATERIALS AND METHODS: Ninety-four CRC patients were included for evaluation of clinicopathological factors, coagulation assays and tumor marker levels. RESULTS: Metastatic disease was related with elevated INR (p= 0.03). Stage III patients had higher D-dimer values compared with stage II patients (p= 0.03). Correlation of tumor markers indicated a tendency towards elevated D-dimer levels for CEA values higher than median (p= 0.01). High CA 19-9 levels were also associated with higher INR (p= 0.007). Elderly age, distant metastasis, high CEA, CA-19-9 and LDH levels were associated with poorer overall-survival. CEA level was the only independent prognostic factor in multivariate analysis. CONCLUSIONS: Coagulation assays can be utilized as predictors of disease extent in CRC. Elevated D-dimer and INR values may indicate higher disease stage. Correlation of D-dimer levels with CEA supports their value for assessing tumor burden.

Intolerance to sunitinib treatment in hemodialysis patients with metastatic renal cell carcinoma.

Sunitinib is a multiple tyrosine kinase receptor inhibitor that is approved for the treatment of metastatic renal cell carcinoma (RCC). However, neither an appropriate dose nor dosing schedule of sunitinib has yet been established for patients with metastatic RCC who are on hemodialysis. Here, we report on two hemodialysis patients who received sunitinib to treat metastatic RCC. Sunitinib was planned to be administered at a dosage of 25 mg/d for 4 of every 6 weeks. Although sunitinib toxicity was manageable in one patient, disease progression occurred after 4 months of treatment. In the second patient, acute pulmonary edema, caused by uncontrolled hypertension, developed on the 15th day of sunitinib therapy and the drug had to be discontinued. Sunitinib is thus not well tolerated in a hemodialysis setting. Close monitoring of toxicity and dose manipulation may be required if such therapy is attempted.

Robotic mitral valve replacement for severe rheumatic mitral disease: perioperative technique, outcomes, and early results.

OBJECTIVE: We report a case series of robotic mitral valve replacement in patients with severe rheumatic mitral disease. METHODS: From March 2010 to June 2013, a total of 63 patients underwent robotic cardiac procedures. Robotic procedures were performed using the da Vinci Si surgical systems (Intuitive Surgical, Inc, Sunnyvale, CA USA). Eighteen of the patients (28.5%) underwent robotic mitral valve replacement. Rheumatic disease was the underlying pathology in all patients. The mean (SD) follow-up period was 18 (10) months. RESULTS: The mean (SD) age and EuroSCORE of the patients were 51.2 (11) years and 4.1% (4%), respectively. Seven patients (38.8%) had an additional cardiac procedure. No operative and hospital mortality were observed. The mean (SD) cross-clamp time and cardiopulmonary bypass time were 116 (30) and 178 (54) minutes, the mean (SD) drainage was 430 (350) mL, the mean intubation time was 9.4 (7) hours, the rate of patients extubated within 6 hours or less was 94.4%, and the mean (SD) intensive care unit stay time was 30 (12) hours. Sixteen of the patients (88.8%) were discharged from the intensive care unit within the first 24 hours postoperatively. During the intensive care unit stay, one patient (5.5%) needed inotropic support. There was one early reoperation for bleeding (5.5%), one (5.5%) intensive care unit readmission, and one (5.5%) hospital readmission observed. During the midterm follow-up, there was no mortality and no need for reoperation or reintervention. CONCLUSIONS: Robotic mitral valve replacement for severe rheumatic mitral disease is technically feasible. Early results are encouraging. Patient selection criteria for robotic mitral valve surgery may be expanded to include valve replacements.