Management of patients with extensive locally advanced thyroid cancer: results of multimodal treatments

PURPOSE

Surgery plays a key role in the treatment of thyroid cancer (TC) patients. Locally advanced cases, however, can require an extensive surgical approach with technical issues and a high risk of complications. In these cases, a multidisciplinary evaluation should be carried out to evaluate pros and cons. The aim of this study was to share our experience, as a multidisciplinary team, in the management of patients with locally advanced TC with a particularly extensive local disease, whose surgical approach could be challenging and part of a multimodal treatment.

METHODS

We retrospectively evaluated clinical, surgical, and oncologic features of all patients with locally advanced TC who had undergone multidisciplinary surgery from January 2019 to June 2020.

RESULTS

Six patients (two cases each of poorly differentiated, papillary, and medullary TC) were included. Four out of six were suffering from symptoms related to the advanced disease. At pre-surgical evaluation, a multidisciplinary team proposed extended surgery with radical intent via cervicotomy and sternotomy, considering other therapies not feasible or probably ineffective without it. No one passed away in intra- or perioperative time. At the end of follow-up (median 2.6 years), all patients presented a remission of symptoms due to the advanced disease, four patients were submitted to adjuvant therapies and only one patient died for a cause unrelated to the disease.

CONCLUSION

This series of very advanced TCs shows the effectiveness of a surgery performed by a multidisciplinary team in controlling symptoms, allowing adjuvant therapies, and improving the survival of patients whose cases would otherwise be very difficult to manage.

Post-traumatic ventricular septal defect following coronary bypass surgery

A 60-year-old patient underwent triple coronary artery bypass grafting following an inferoseptal myocardial infarction and early onset of exertional angina. Four years later he was involved in a car accident during which he sustained an abdominal and thoracic trauma. Approximately 1 month after discharge, a ventricular septal defect was diagnosed by two-dimensional Doppler echocardiography with patency of all grafts at coronary angiography. Closure of the septal defect was successfully accomplished through a right atrial approach. Rupture of the ventricular septum following blunt chest trauma in a patient with previous myocardial revascularization has not been previously reported.

Hemodynamic assessment of the Medtronic Mosaic bioprosthesis in the aortic position

BACKGROUND AND AIM OF THE STUDY

The Medtronic Mosaic bioprosthesis (MMB) is a newly developed tissue valve which incorporates several features such as a low-profile semi-flexible stent, zero-pressure tissue fixation, and anti-mineralization pretreatment with alpha-amino oleic acid aimed to improve hemodynamics and prevent structural deterioration.

METHODS

Between November 1995 to June 1999, 62 patients underwent aortic valve replacement (AVR) with the MMB; 41 of these who reached the one-year follow up interval and who had isolated AVR without any concomitant procedure with size 23 mm and 25 mm MMB were evaluated by serial echocardiography after three, six and 12 months.

RESULTS

For size 23 mm valves, mean and peak gradients were 12+/-3 and 21+/-6 mmHg at 3 months, 12+/-3 and 20+/-5 mmHg at 6 months, and 12+/-4 and 20+/-6 mmHg at 12 months. For size 25 mm valves, mean and peak gradients were 13+/-2 and 22+/-4 mmHg at 3 months, 12+/-3 and 21+/-5 mmHg at 6 months, and 12+/-4 and 22+/-6 mmHg at 12 months. In patients with 23 mm MMB, left ventricular mass index (LVMi) was reduced from 181+/-34 g/m2 before surgery to 158+/-32, 150+/-28 and 140+/-25 g/m2 at 3, 6 and 12 months after AVR (p <0.001); in patients with 25 mm MMB, LVMi was reduced from 182+/-28 g/m2 before surgery to 165+/-25, 156+/-24 and 146+/-19 g/m2 at 3, 6 and 12 months after AVR (p <0.001).

CONCLUSION

Our results indicate that MMB is associated with low mean and peak gradients and significant reduction in LVMi throughout the postoperative period. Thus, the MMB appears to be an excellent cardiac valve substitute in elderly subjects who require AVR.

Concomitant aortic valve replacement and surgical angioplasty of left main coronary ostium

The association of calcific aortic valve disease and isolated coronary ostial stenosis is rare. A 80-year-old woman was found to have severe aortic stenosis with critical narrowing of the ostium of the left main coronary artery. She was successfully managed by simultaneous aortic valve replacement and patch angioplasty of the left main coronary artery, using a patch of autologous pericardium fixed in glutaraldehyde. Angiographic control at 1 month coupled with intravascular echographic imaging showed adequate relief of the ostial stenosis and patency of the left main trunk.

Performance of 21-mm size perimount aortic bioprosthesis in the elderly

BACKGROUND

Aortic valve replacement in elderly patients with a small aortic annulus may pose difficult problems in terms of prosthesis selection. We have evaluated the hemodynamic performance of the 21-mm Carpentier-Edwards Perimount bioprosthesis implanted in elderly patients.

METHODS

From July 1996 to June 1998, 19 patients (17 women and 2 men, mean age 76+/-4 years and mean body surface area 1.73+/-0.13 m2), had aortic valve replacement with a 21-mm Carpentier-Edwards Perimount bioprosthesis. The hemodynamic performance of the valve was evaluated in 16 patients, who completed at least a 6-month follow-up interval, with transthoracic color-Doppler echocardiography with particular reference to peak and mean transprosthetic gradients, effective orifice area index, and regression of left ventricular mass index.

RESULTS

There were no late deaths and no major postoperative complications. At a mean follow-up of 12+/-7 months, compared to discharge, all patients showed clinical improvement with a significant reduction of peak gradient (from 23+/-4 to 21+/-6 mm Hg, p = 0.04) and left ventricular mass index (from 181+/-23 to 153+/-20 g/m2; p<0.001), whereas mean gradient (from 13+/-3 to 13+/-4 mm Hg, p = not significant) and effective orifice area index (from 1.12+/-0.34 to 1.13+/-0.28 cm2/m2, p = not significant) remained substantially unchanged.

CONCLUSIONS

The use of a 21-mm Carpentier-Edwards Perimount bioprosthesis is associated with low transprosthetic gradients and significant reduction in left ventricular hypertrophy after aortic valve replacement. The results of our study suggest that a 21-m Carpentier-Edwards Perimount bioprosthesis should be considered a valid option in elderly patients with aortic valve disease and a small aortic annulus.

The Edwards Prima stentless valve: hemodynamic performance at one year

BACKGROUND

The Edwards Prima stentless valve (EPSV) is a porcine aortic root cylinder with resected coronary ostia, fixed in glutaraldehyde at low pressure. The purpose of this study was to evaluate the hemodynamic performance of the EPSV 1 year after aortic valve replacement.

METHODS

From December 1994 to February 1996, 29 patients underwent aortic valve replacement with EPSV used in the subcoronary position (group 1, n = 23) or as a root replacement (group 2, n = 6). Hemodynamic performance of EPSV was assessed by two-dimensional Doppler echocardiography at 1 week, 6 months, and 1 year by calculating peak transprosthetic velocity, peak and mean gradients, effective orifice area, degree of aortic regurgitation, and regression of left ventricular hypertrophy.

RESULTS

There were no operative deaths. One patient in group 2 died after 3 months at reoperation for endocarditis. In group 1 early mean gradient (25+/-5 mm Hg for 23 mm and 19+/-5 mm Hg for 25 mm) decreased at 6 months and 1 year in the 23-mm size (17+/-7 mm Hg and 15+/-4 mm Hg, p < 0.01) and at 1 year in the 25-mm size (14+/-4 mm Hg, p = 0.03) without modifications of the effective orifice area in both sizes. A significant reduction in left ventricular hypertrophy occurred at 6 months and 1 year in both sizes. In group 2 lower early gradients were recorded with subsequent improvement at follow-up; reduction in left ventricular hypertrophy occurred as well.

CONCLUSIONS

The EPSV used in the subcoronary position has shown high early gradients, which partially regressed at 6 months, with further improvement at 1 year. Gradients are attributed to inward folding of the Dacron cloth at the right coronary ostium, being more evident in patients with aortic stenosis without dilatation of the aortic root and coronary ostia close to the annulus. In such patients a better early hemodynamic result can be obtained by using the EPSV as a root replacement.

Recurrent myxoma of the left ventricle. Case report and review of the literature

A 29-year-old female was found to have a left ventricular mass while in the 14th week of gestation. Seven years earlier she had undergone removal of a left ventricular myxoma. At re-operation, after elective interruption of pregnancy, a recurrent left ventricular myxoma was successfully excised. According to a review of the literature recurrence of an isolated, localized left ventricular myxoma has not been previously reported.

Late patency of recycled internal mammary artery: verification by Doppler echocardiography and coronary angiography

We report the case of a 57-year-old man who had presented with exertional angina early in 1997 and had subsequently undergone myocardial revascularization with the use of both internal mammary arteries. Two months after surgery, the patient was readmitted to the hospital with unstable angina. Coronary angiography revealed a 90% occlusion of the left internal mammary artery anastomosis, which was attached to the left anterior descending coronary artery. At reoperation, the left internal mammary artery was detached from the left anterior descending coronary artery, probed and injected with papaverine, checked for patency, and regrafted to the same coronary artery. Recycling of the left internal mammary artery was facilitated by the harvesting and routing technique that had been used during the previous operation. At the patient's 1-year follow-up visit, both Doppler echocardiography and coronary angiography showed patency of the recycled graft. We conclude that recycling of the left internal mammary artery is a safe and effective option in selected patients who require reoperation after myocardial revascularization.

Quadricuspid aortic valve

A quadricuspid aortic valve was observed in a patient requiring aortic valve replacement because of severe aortic regurgitation, while in another it was accidentally detected by means of transesophageal echocardiography performed during coronary artery bypass grafting. This report discusses the apparent rarity of this malformation and stresses the need for periodical controls in patients known to have a quadricuspid aortic valve.

Aortic valve replacement for quadricuspid aortic valve incompetence

Quadricuspid aortic valve is an uncommon cause of aortic regurgitation. We report two patients who underwent aortic valve replacement because of severe aortic incompetence; the presence of a quadricuspid aortic valve was an accidental surgical finding. In one patient the aortic valve comprised two equal-sized larger cusps and two equal-sized smaller cusps, while in the other it comprised three cusps of similar size and a small accessory cusp between the right and non-coronary cusps. This report confirms the rarity of the disease and the fact that patients with quadricuspid aortic valves characterized by cusps of different sizes are more prone to develop progressive aortic incompetence because of unequal distribution of stresses on the valve. Therefore, such patients should undergo periodic, life-time echocardiographic assessment once this malformation is detected.

Enlargement of the aortic annulus with glutaraldehyde-fixed bovine pericardium during aortic valve replacement

BACKGROUND AND AIMS OF THE STUDY

Aortic valve replacement in patients with a small aortic annulus may represent a surgical challenge. We have evaluated a simplified technique to enlarge the aortic annulus which consists of extending the aortotomy incision to divide the commissure between the left and non-coronary cusps into the interleaflet triangle without opening the left atrium.

METHODS

This technique was used in 16 patients (15 women, one man; mean age 66 +/- 9 years) who underwent aortic valve replacement between August 1994 and February 1996. Aortic stenosis was the predominant valvular lesion. A mechanical prosthesis was implanted in 13 patients (81%) (21 mm in six, 23 mm in seven) while three received a bioprosthesis (21 mm in one, 23 mm in two). In all patients it was possible to insert a prosthesis at least one size larger than the original aortic annulus diameter.

RESULTS

There were no operative deaths and no late deaths. Mean follow up was 20 +/- 6 months (range: 12 to 30 months). Echocardiographic controls at 12 months postoperatively showed no evidence of periprosthetic leaks or mitral regurgitation. Comparison with preoperative data showed no significant variations of mean aortic diameter at the sinus level (30.7 +/- 2.2 mm versus 31.3 +/- 2.6 mm) or at the sinotubular junction (33.6 +/- 2.7 mm versus 34.3 +/- 2.9 mm) (p = NS). Significant reduction of left ventricular mass was observed (314 +/- 57 g versus 260 +/- 45 g; p < 0.001).

CONCLUSIONS

This technique is simple, reproducible and effective in allowing adequate enlargement of the aortic annulus and provides excellent clinical and hemodynamic results. Glutaraldehyde-fixed bovine pericardium used as a patch material showed no tendency to aneurysmal dilatation with progression of time at a maximum follow up of 30 months.

Hemodynamic performance of the Edwards Prima stentless valve

BACKGROUND AND AIM OF THE STUDY

Stentless porcine valves are considered to have a superior hemodynamic performance when compared with stented bioprostheses. In the present study we report our initial experience with the Edwards Prima stentless valve (EPSV), focusing on the hemodynamic performance of this device evaluated by means of transthoracic two-dimensional (2D) Doppler echocardiography.

METHODS

Between December 1994 and August 1995, 23 patients underwent aortic valve replacement with the EPSV implanted in the subcoronary position. Evaluation of hemodynamic performance of the EPSV was assessed before discharge (one week) and at six months follow up by means of transthoracic 2D echocardiography.

RESULTS

There were no operative deaths and no major postoperative complications. Hemodynamic data were available for comparison at one week and six months in 18 patients (23 mm, n = 8; 25 mm, n = 10). For 23 mm EPSV, peak gradient varied from 42.7 +/- 10.2 mmHg at one week to 29.7 +/- 9.8 mmHg at six months (p = 0.01); for 25 mm EPSV, peak gradient varied from 33.6 +/- 10.6 mmHg at one week to 29.5 +/- 6.5 mmHg at six months (p = N.S.).

CONCLUSIONS

The EPSV, when used in the subcoronary position, has been associated with high early transprosthetic gradients which only partly regress at six months. Gradients are probably caused by the inward folding of the Dacron cloth beneath the right coronary ostium and were recorded especially in patients with aortic stenosis in whom the right coronary ostium was close to the aortic annulus. In such patients alternative implantation techniques should be considered.

Post-traumatic tricuspid valve insufficiency. 2 cases of delayed clinical manifestation

We present 2 cases of tricuspid insufficiency following blunt chest trauma: 1 was diagnosed 5 months after the trauma and the other, 20 years after the trauma. In both patients, the tricuspid valve was replaced with a porcine bioprosthesis, because valve repair was not considered feasible. These cases emphasize the variability of clinical presentation of post-traumatic tricuspid valve insufficiency and indicate the need for close follow-up of patients after major thoracic trauma.