One-Stage Intrathoracic Repair of Extended Aortic Aneurysms

Aneurysms of the entire thoracic aorta are usually approached in two to three stages. From 1990 to 1994, we performed one-stage aortic replacement from the root to the diaphragm in 16 patients (8 men and 8 women with a mean age of 55.7 years, range 49 to 73). There were 11 type A dissections, 7 of which were acute. Six patients underwent aortic valve reconstruction; seven had aortic root replacement by Bentall or Cabrol techniques. In two cases, the Innominate artery had to be replaced by a vascular graft separately in addition to reimplantation of the supraaortic branches as an island flap into the arch prosthesis. In eight cases, a median sternotomy was used; eight had a bilateral transverse thoracotomy. The procedure was performed under deep hypothermlc circulatory arrest in all cases (mean duration 50.5 mln, range 38 to 62 min). Two patients, both operated upon for an acute dissection, expired perioperatively: one due to a bronchopneumonia, and one because of a thrombosed Cabrol graft to the right coronary artery. No patient developed bleeding or neurological complications. At a mean follow-up of 26.9 months (1 to 50 months), all patients discharged from the hospital were still alive. Four patients underwent subsequent thoracoabdominal aortic replacement. This experience suggests that complete thoracic aortic replacement can be performed in a single session with an operative risk comparable to that of the conventional two-stage approach. The bilateral transverse thoracotomy affords excellent exposure. The lack of spinal cord ischemia may be the result of spinal cord protection with hypothermic circulatory arrest and use of the open-clamp technique. (J Card Surg 1994;9:604–613)     

Sumatriptan and Cerebral Blood Flow Velocity Changes During Migraine Attacks

Transcranial Doppler studies on the effects of sumatriptan on cerebral hemodynamics have shown conflicting results. We evaluated blood flow velocity changes in 21 patients suffering from migraine with (n = 4) or without aura (n = 17) during a spontaneous attack, before and after treatment with sumatriptan. Flow velocity in the internal and external carotid, middle cerebral, and basilar arteries was measured by means of transcranial Doppler. During the attack, measurements were taken before subcutaneous sumatriptan injection, then after 30 minutes, 2 hours, and 24 hours. An additional measurement was taken 1 week later, in a headache-free state. We found a significant reduction of flow velocity during the attack in the middle cerebral artery on both sides (P < 0.05). After sumatriptan administration, flow velocity increased in the internal carotid artery on both sides (P < 0.05) and in the middle cerebral artery on the headache side (P = 0.0001), but not in the external carotid and basilar arteries (P > 0.05). Flow velocity changes may reflect the vasodilation present at the onset of the migraine attack followed by vasoconstriction in the internal carotid and middle cerebral arteries after sumatriptan treatment. Since vasoconstriction occurs in responders and nonresponders to treatment, it is unlikely to be the primary mechanism by which sumatriptan relieves headache.     

Myelodysplastic syndrome and sagittal sinus thrombosis.

After a 5-day illness beginning with severe headache, a 46-year-old man with myelodysplastic syndrome died of complications from cerebral venous thrombosis. Considering the underlying hematologic abnormality, multiple therapies, and potential for leukemic transformation, we suggest that patients with myelodysplastic syndrome may be at increased risk for developing cerebral venous thrombosis.     

Facilitation of voluntary intake of ethanol by hypothalamic stimulation reward in cats

Three cats, deprived 4 h of food, but not of water, refused to drink 10 or 20% ethanol in milk (with a 0.02% addition of saccharin); however, they willingly drank these solutions when drinking was rewarded with electrical stimulation in the lateral hypothalamic “reward region.” More stimulation episodes were required to induce drinking of 20% than of 10% ethanol. With training sessions conducted daily, the amount of 10% ethanol consumed gradually increased. At the same time, the number of stimulation episodes required for inducing consumption of 1 ml of ethanol solution gradually decreased. When the stimulation “reward” was withheld, two cats stopped drinking, but the third cat continued to drink the ethanol solution in succeeding sessions, although in smaller amounts than before. We conclude that two mechanisms were involved in facilitation of ethanol intake in our study. One was instrumental conditioning, with the drinking of the ethanol solution as a response, and the hypothalamic stimulation as a “reward.” The other mechanism could be a local alteration in the cellular physiology of hypothalamic structures related to taste reception which was caused by the electrical stimulation; this change could be responsible for the lasting facilitation of ethanol intake observed after the cessation of electrical stimulation in one cat.     

Indium-111 octreotide scintigraphy in neurofibromatosis

Scintigraphy with the radiolabelled somatostatin analogue indium-111-DTPA-D-Phe-l-octreotide has recently been proposed for the imaging of CNS neoplasms expressing somatostatin receptors. While meningiomas are imaged with high sensitivity, neurinomas do not take up octreotide owing to the lack of somatostatin receptors. Neurofibromatosis is a relatively uncommon disorder in which meningiomas and neurinomas often occur in the same patient. Differential diagnosis between these two tumours by computed tomography and magnetic resonance imaging can be difficult. This study reports on^{1 11}In-octreotide scintigraphy in four patients with neurofibromatosis.¹¹In-octreotide scintigraphy was shown to be very helpful in the in vivo differential diagnosis: all four meningiomas showed intense tracer uptake, while all 15 neurinomas were negative (P<0.001 by Fisher's exact test). It may be concluded that scintigraphy with¹¹¹In-octreotide is a useful diagnostic procedure in neurofibromatosis, complementing standard neuroradiological imaging procedures.     

Elevation of glutathione transferase activity in human lung tumor

Glutathione transferase activity in the cytosolic fractionsof human lung tumors was found to be significantly higher thanthat present in the corresponding non-tumor cytosolic fractions.The relative activities of ‘cationic’, ‘near-neutral’and ‘acidic’ glutathione transferases of both tumorand non-tumor cytosols were estimated after isoelectric focusing.More than 90% of activity in both tumor and non-tumor cytosolswas found to be associated with the ‘acidic’ (pI4.6) activity peak. In the chromatogram of tumor tissues theactivity associated with the ‘acidic’ peak was foundto be increased in comparison with non-tumor tissues. When theprotein fractions associated with the ‘acidic’ peakof both tumor and non-tumor tissues were tested against theantibodies raised against human placenta transferase (transferase) a continuous precipitin line was obtained. An increased amountof immunoreactive glutathione transferase was also found intumor cytosols as compared with non-tumor cytosols. Thus, ourstudies indicate that the predominant glutathione transferaseof human lung appears to be electrophoretically and immunologicallyvery similar or identical to transferase and that the elevationof transferase activity measured in the lung tumor cytosolswas mainly due to increased quantity of this isoenzyme.     

Long-term results of PRRT in advanced bronchopulmonary carcinoid

Purpose

Peptide receptor radionuclide therapy (PRRT) for the treatment of neuroendocrine tumours (NET) has been explored for almost two decades, but there are still few trials that have exclusively investigated well-differentiated and moderately differentiated NET arising from the respiratory tree. Thus, the aim of this study was to explore the outcome in patients affected by bronchopulmonary carcinoid (BPC) following PRRT.

Methods

We retrospectively analysed 114 patients with advanced stage BPC consecutively treated with PRRT at the European Institute of Oncology, Milan, from 1997 to 2012 and followed until October 2014. The objective responses, overall survival (OS) and progression-free survival (PFS) were rated, and three different PRRT protocols (⁹⁰Y-DOTATOC vs. ¹⁷⁷Lu-DOTATATE vs. ⁹⁰Y-DOTATOC?+?¹⁷⁷Lu-DOTATATE) were compared with regard to their efficacy and tolerability.

Results

The median OS (evaluated in 94 of the 114 patients) was 58.8 months. The median PFS was 28.0 months. The ¹⁷⁷Lu-DOTATATE protocol resulted in the highest 5-year OS (61.4 %). Morphological responses (partial responses?+?minor responses) were obtained in 26.5 % of the cohort and were associated with longer OS and PFS. The ⁹⁰Y-DOTATOC?+?¹⁷⁷Lu-DOTATATE protocol provided the highest response rate (38.1 %). Adverse events were mild in the majority of patients. However, haematological toxicity negatively affected survival. No severe (grade 3/4) serum creatinine increase was observed. Patients treated with ⁹⁰Y-DOTATOC alone more frequently showed a mild/moderate decrease in renal function. In patients treated with chemotherapy before PRRT had a shorter OS and PFS, and a higher risk of developing nephrotoxicity.

Conclusion

In a large cohort of patients with advanced BPC treated in a “real-world” scenario and followed up for a median of 45.1 months (range 2 – 191 months), PRRT proved to be promising in prolonging survival and delaying disease progression. Despite the potential selection biases, considering the risk-benefit ratio, ¹⁷⁷Lu-DOTATATE monotherapy seems the best option for PRRT. Our results indicate that the use of PRRT in earlier stages of the disease could provide a more favorable outcome.

     

Radiofrequency ablation versus magnetic resonance guided focused ultrasound surgery for minimally invasive treatment of osteoid osteoma: a propensity score matching study

Objectives

To compare outcomes in pain relief and motor functional recovery in patients with an osteoid osteoma treated by magnetic resonance guided focused ultrasound surgery (MRgFUS) or radiofrequency ablation (RFA) using a propensity score matching study design.

Methods

Thirty patients with osteoid osteomas were included in this institutional review board (IRB)-approved study. MRgFUS was performed in 15 subjects. These subjects were matched by propensity analysis with a group of 15 subjects treated by RFA. Pain relief in terms of complete response (CR) and motor functional recovery were measured.

Results

A similar proportion of subjects treated by MRgFUS (94 %) or RFA (100 %) experienced CR 12 weeks after treatment, with no significant difference. The improvement in pain control following MRgFUS or RFA paralleled with improved motor functional recovery. The treatment failure rate was 6.6 % in the MRgFUS group and 0 % in the RFA group. No major complications were observed following either ablative treatment.

Conclusions

Although this study involved a limited number of patients, MRgFUS favourably improves perceived pain and motor functional recovery, with no major complications. No difference was found in the achievement of primary and secondary outcome measures with respect to RFA.

Key Points

? To demonstrate the effectiveness of a recent technique for treating osteoid osteoma ? MRgFUS results compared with results of the gold standard treatment (RFA) ? MRgFUS is effective both from a clinical and functional point of view ? No significant side effects compared with RFA