Metastatic renal cell carcinoma to the thyroid with cervicothoracic venous tumor thrombosis

INTRODUCTION

Metastatic renal cell carcinoma (RCC) represents 25%-42% of metastatic thyroid malignancies. Propensity for RCC to demonstrate intravascular extension to the inferior vena cava is well documented. We present an analogous phenomenon of intravascular extension to the internal jugular vein (IJV) from thyroid gland metastasis.

METHODS

A 69-year-old male presented with metastatic RCC of the right thyroid lobe. Imaging demonstrated tumor thrombosis of the ipsilateral IJV, extending inferiorly to the junction of the brachiocephalic, subclavian, and internal jugular veins within the mediastinum.

RESULTS

Surgical excision required control of both the IJV in the neck and mediastinal venous great vessels via sternotomy, prior to subtotal thyroidectomy and venotomy for en bloc resection.

CONCLUSION

This case report describes metastatic RCC to the thyroid gland with cervicothoracic venous tumor thrombosis successfully treated with subtotal thyroidectomy, sternotomy for venotomy and tumor thrombectomy, and preservation of IJV conduit.

Perioperative diltiazem therapy was not associated with improved perioperative and long-term outcomes in patients undergoing on-pump coronary artery bypass grafting

Background

Diltiazem has been used during the perioperative period in patients undergoing coronary artery bypass grafting (CABG) to prevent arterial graft spasm. However, its long-term outcome effects remain unclear.

Methods

Patient records obtained from the Society of Thoracic Surgeons and the Geisinger Clinic electronic health records between October 2008 and October 2018 were screened. Adult patients who had isolated CABG with cardiopulmonary bypass were included. Cohorts of patients who received diltiazem (DILT) and those who did not (non-DILT) were matched by propensity scores based on age, gender, surgical year, Society of Thoracic Surgeons mortality and morbidity scores, and number of arterial grafts. Incidence rate ratios (IRRs) were estimated for DILT vs non-DILT on short-term adverse outcomes. Long-term survival over time was compared between DILT vs non-DILT using Kaplan-Meier curves.

Results

Among the 1004 patients included in the analyses, IRRs for the DILT group relative to the non-DILT group were: 30-day all-cause mortality, IRR: 2.33, 95% confidence interval (CI): 0.91-5.96, P=0.07; postoperative myocardial ischaemia, IRR: 1.10, 95% CI: 0.60-2.02, P=0.75; new onset atrial fibrillation, IRR: 1.06, 95% CI: 0.78-1.43, P=0.73; stroke/transient ischaemic attack, IRR: 0.76, 95% CI: 0.17-3.38, P=0.71. For long-term survival, Kaplan-Meier curves stratified by diltiazem revealed no differences in survival rates between DILT and non-DILT groups.

Conclusion

For patients undergoing on-pump CABG, perioperative diltiazem therapy did not show significant short- or long-term outcome advantages over those who did not receive diltiazem.

The role of extracorporeal life support for patients with COVID-19: Preliminary results from a statewide experience

Objective

There is a paucity of clinical data on critically ill patients with COVID‐19 requiring extracorporeal life support.

Methods

A statewide multi‐institutional collaborative for COVID‐19 patients was utilized to obtain clinical data on the first 10 critically ill COVID‐19 patients who required extracorporeal membrane oxygenation (ECMO).

Results

Of the first 10 patients that required ECMO for COVID‐19, the age ranged from 31 to 62 years with the majority (70%) being men. Seven (70%) had comorbidities. The majority (80%) of patients had known sick contact and exposure to COVID‐19 positive patients or traveled to pandemic areas inside the United States within the 2 weeks before symptom onset. None of the patients were healthcare workers. The most common symptoms leading to the presentation were high fever ≥103°F (90%), cough (80%) and dyspnea (70%), followed by fatigue and gastrointestinal symptoms (both 30%), myalgia, loss of taste, pleuritic chest pain, and confusion (all 10%). All patients had bilateral infiltrates on chest X‐rays suggestive of interstitial viral pneumonia. All patients were cannulated in the venovenous configuration. Two (20%) patients were successfully liberated from ECMO support after 7 and 10 days, respectively, and one (10%) patient is currently on a weaning course. One patient (10%) died after 9 days on ECMO from multiorgan dysfunction.

Conclusions

These preliminary multi‐institutional data from a statewide collaborative offer insight into the clinical characteristics of the first 10 patients requiring ECMO for COVID‐19 and their initial clinical course. Greater morbidity and mortality is likely to be seen in these critically ill patients with longer follow‐up.

Esophagectomy: Comparison of Short-Term Outcomes between Single-versus Two-Team Approach

Literature about combining expertise of two specialties in esophageal cancer surgery is limited. We present the experience at a single institute comparing single-team (ST) versus two-team (TT) approach combining thoracic and abdominal surgeons. This is a retrospective study from a single tertiary care center. Data were collected from electronic medical records. Patients undergoing esophagectomy for esophageal cancer from November 2006 until August 2014 were included. The primary outcome measured was 30-day postoperative morbidity, secondary outcomes measured were operative time, intraoperative blood loss, and 30-day mortality. Results are reported as mean with an interquartile range. Forty-nine patients underwent esophagectomy by an ST and 51 patients by TT. Patient demographics, tumor characteristics, stage, pathology, and use of neoadjuvant therapy were comparable between groups. Charlson comorbidity index was significantly higher in TT group [3 (2, 4) vs 2 (2, 3), P = 0.02]. The TT group had a significantly shorter operative time compared to the ST group [304 (252,376) minutes vs 438 (375, 494] minutes, P < 0.0001). Intraoperative blood loss was 300 (200, 550) mL for the TT group and 250 (200,400) mL for the ST group (P = 0.29). There was no difference in 30-day postoperative morbidity (68.6% for TT, 59.2% for ST, P = 0.32) and mortality (2% each, P = 1) between the two groups. In conclusion, the operative time by the TT approach was significantly shorter than the ST approach with comparable postoperative morbidity and mortality. Long-term follow-up is needed to study this approach's effect on long-term survival.

Esophagectomy: Comparison of Short-Term Outcomes between Single-versus Two-Team Approach

Literature about combining expertise of two specialties in esophageal cancer surgery is limited. We present the experience at a single institute comparing single-team (ST) versus two-team (TT) approach combining thoracic and abdominal surgeons. This is a retrospective study from a single tertiary care center. Data were collected from electronic medical records. Patients undergoing esophagectomy for esophageal cancer from November 2006 until August 2014 were included. The primary outcome measured was 30-day postoperative morbidity, secondary outcomes measured were operative time, intraoperative blood loss, and 30-day mortality. Results are reported as mean with an interquartile range. Forty-nine patients underwent esophagectomy by an ST and 51 patients by TT. Patient demographics, tumor characteristics, stage, pathology, and use of neoadjuvant therapy were comparable between groups. Charlson comorbidity index was significantly higher in TT group [3 (2, 4) vs 2 (2, 3), P = 0.02]. The TT group had a significantly shorter operative time compared to the ST group [304 (252,376) minutes vs 438 (375, 494] minutes, P < 0.0001). Intraoperative blood loss was 300 (200, 550) mL for the TT group and 250 (200,400) mL for the ST group ( P = 0.29). There was no difference in 30-day postoperative morbidity (68.6% for TT, 59.2% for ST, P = 0.32) and mortality (2% each, P = 1) between the two groups. In conclusion, the operative time by the TT approach was significantly shorter than the ST approach with comparable postoperative morbidity and mortality. Long-term follow-up is needed to study this approach's effect on long-term survival.

Laparoscopic transhiatal esophagectomy for esophageal adenocarcinoma identified at laparoscopic Roux-en-Y gastric bypass

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Preoperative endoscopy is indicated bariatric patients with history of gastroesophageal reflux.

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Laparoscopic transhiatal esophagectomy can be safely performed in patient with history of Roux-en-Y gastric bypass.

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The gastric remnant provides a good conduit for reconstruction following esophagectomy in patients with a previous Roux-en-Y gastric bypass.

Introduction

More than one third of Americans are obese. Obesity is a risk factor for gastroesophageal reflux disease (GERD) and esophageal adenocarcinoma (EA). The only durable treatment for morbid obesity and its comorbid conditions is bariatric surgery. There is no consensus among bariatric surgeons, however, regarding the role of preoperative screening upper endoscopy in bariatric surgery.

Presentation of case

Two cases of incidental EA were identified by completion EGD following laparoscopic Roux-en-Y gastric bypass (LRYGB). EGD was done for anastomotic surveillance and provocative leak testing. Esophageal masses were identified and biopsies demonstrated adenocarcinoma. In both cases a laparoscopic transhiatal esophagectomy (LTHE) was completed using the gastric remnant as conduit; the biliopancreatic limb was divided proximal to the jejunojejunostomy and anastomosed to the proximal roux limb to complete the reconstruction.

Discussion

Obesity is a risk factor for GERD and EA. The role of EGD prior to bariatric surgery is unclear. Studies have demonstrated routine EGD prior to bariatric surgery may diagnose foregut pathology; however, few of the findings alter the planned treatment. The cost effectiveness of this strategy is questionable. There are reports of EA developing after bariatric surgery; however, we found no previous case reports of EA identified at LRYGB.

Conclusion

Our institution has opted for selective preoperative endoscopy in patients with preoperative gastrointestinal symptoms. In post gastric bypass patients LTHE can be performed with good results.

Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans

BACKGROUND

The combination of complete diaphragm inactivity and mechanical ventilation (for more than 18 hours) elicits disuse atrophy of myofibers in animals. We hypothesized that the same may also occur in the human diaphragm.

METHODS

We obtained biopsy specimens from the costal diaphragms of 14 brain-dead organ donors before organ harvest (case subjects) and compared them with intraoperative biopsy specimens from the diaphragms of 8 patients who were undergoing surgery for either benign lesions or localized lung cancer (control subjects). Case subjects had diaphragmatic inactivity and underwent mechanical ventilation for 18 to 69 hours; among control subjects diaphragmatic inactivity and mechanical ventilation were limited to 2 to 3 hours. We carried out histologic, biochemical, and gene-expression studies on these specimens.

RESULTS

As compared with diaphragm-biopsy specimens from controls, specimens from case subjects showed decreased cross-sectional areas of slow-twitch and fast-twitch fibers of 57% (P=0.001) and 53% (P=0.01), respectively, decreased glutathione concentration of 23% (P=0.01), increased active caspase-3 expression of 100% (P=0.05), a 200% higher ratio of atrogin-1 messenger RNA (mRNA) transcripts to MBD4 (a housekeeping gene) (P=0.002), and a 590% higher ratio of MuRF-1 mRNA transcripts to MBD4 (P=0.001).

CONCLUSIONS

The combination of 18 to 69 hours of complete diaphragmatic inactivity and mechanical ventilation results in marked atrophy of human diaphragm myofibers. These findings are consistent with increased diaphragmatic proteolysis during inactivity.

Early changes of lung function and structure in an elastase model of emphysema--a hyperpolarized 3He MRI study

Early changes of lung function and structure were studied in the presence of an elastase-induced model of emphysema in 35 Sprague-Dawley rats at mild (5 U/100 g) and moderate (10 U/100 g) severities. Lung ventilation was measured on a regional basis (at a planar resolution of 3.2 mm) by hyperpolarized 3He MRI at 5 and 10 wk after model induction. Subsequent to imaging, average alveolar diameter was measured from histological slices taken from the centers of each lobe. Changes of mean fractional ventilation, mean linear intercept, and intrasubject heterogeneity of ventilation were studied during disease progression. Mean fractional ventilation was significantly different between healthy controls (0.23 +/- 0.04) and emphysematous animals at both time points in the 10-unit group (0.06 +/- 0.02 and 0.12 +/- 0.05, respectively). Changes in average alveolar diameter were not statistically observable until the 10th wk between healthy (37 +/- 10 microm) and emphysematous rats (73 +/- 25 and 95 +/- 31 microm, for 5 and 10 units, respectively). Assessment of function-structure correlation suggested that the majority of the decline in fractional ventilation occurred in the first 5 wk, while enlargement of alveolar diameters appeared primarily between the 5th and 10th wk. A thresholding metric, based on the 20th percentile of fractional ventilation over the entire lung, was utilized to detect the onset of the disease with confidence, independent of whether the regional ventilation measurements were normalized with respect to the delivered tidal volume and estimated functional residual capacity of each individual rat.

Cytokine response is lower after lung volume reduction through bilateral thoracoscopy versus sternotomy

BACKGROUND

Lung volume reduction surgery performed through bilateral video-assisted thoracoscopy (BVATS) was associated in the National Emphysema Treatment Trial with a statistically significant reduction in intensive care unit days, failure to wean, hospital stay, and cost, and earlier recovery compared with median sternotomy. Studies comparing other minimally invasive techniques with "open" procedures, including pulmonary lobectomy, have demonstrated reduced serum proinflammatory mediators postoperatively. We measured these levels after lung volume reduction surgery through BVATS and sternotomy.

METHODS

Serum cytokine levels were measured by radioimmunoassay in 9 consecutive, steroid-free patients undergoing sternotomy and lung volume reduction surgery and 6 undergoing BVATS and lung volume reduction surgery. The groups were not statistically different with respect to age, partial pressure of arterial carbon dioxide, percent forced expiratory volume in 1 second, percent residual volume, percent total lung capacity, diffusion capacity of the lung for carbon monoxide, 6-minute walk, or apical perfusion fraction. Proinflammatory interleukin 6 and interleukin 8 and antiinflammatory interleukin 10 were evaluated preoperatively and postoperatively on days 1, 4, and 5. Clinical data were prospectively collected.

RESULTS

There were no major postoperative complications or deaths. Interleukin 6 levels were lower in the BVATS than the sternotomy group (p = 0.016 by repeated measures analysis of variance). Interleukin 8 levels were lower in the BVATS group at most postoperative time points, but there were no significant differences in interleukin 8 or interleukin 10 levels between the sternotomy and BVATS groups at any individual time point or by analysis of variance.

CONCLUSIONS

Use of a BVATS approach to lung volume reduction surgery is associated with reduced postoperative release of proinflammatory cytokines compared with a sternotomy approach. This may account for the reduction in recovery time and some measures of postoperative morbidity seen with the BVATS approach.

Alterations in cell cycle genes in early stage lung adenocarcinoma identified by expression profiling

In normal lung epithelial cells, cellular division is an ordered, tightly regulated process involving multiple checkpoints that assess extracellular growth signals, cell size, and DNA integrity. In contrast, neoplastic lung cells develop the ability to bypass several of these checkpoints, particularly at the G1/S and G2/M boundaries. We used genomic profiling to compare gene expression levels in early stage lung adenocarcinomas and non-neoplastic pulmonary tissue in order to comprehensively identify alterations in the process of cell cycling. RNA extracted from node negative, poorly differentiated lung adenocarcinomas (15 patients) and non-neoplastic pulmonary tissue (5 patients) was hybridized to oligonu-cleotide microarray filters containing 44,363 genes. Ontological classification was used to extract genes involved with cell cycle progression. Further analysis discovered a subset of differentially expressed genes for further study. Of the 624 cell cycle genes on the microarray filters, 40 genes were predicted to be differentially expressed in lung adeno-carcinomas. Alterations in several genes (i.e., cyclin B1, cyclin D1, p21, MDM2) are consistent with published data in the literature. We also identified 19 novel genes that have neither been described in non-small cell lung cancer (i.e., cdc2, cullin 4A, ZAC, p57, DP-1, GADD45, PISSLRE, cdc20) nor in any other tumors (i.e., cyclin F, cullin 5, p34). These results identified several potential cell cycle genes altered in lung cancer.