RESUMO
OBJECTIVE: Patients with acute type A aortic dissection demonstrate a wide range of aortic insufficiency. Outcomes after valve resuspension and root repair are not well studied in the long term. We evaluated the long-term effects of preoperative aortic insufficiency in patients undergoing emergency root-preserving surgery for acute type A aortic dissection. METHODS: From 2002 to 2017, 558 of 776 patients with acute type A aortic dissection underwent native aortic valve resuspension and root reconstruction. Patients were stratified into 4 groups by preoperative aortic insufficiency grade (n = 539): aortic insufficiency less than 2+ (n = 348), aortic insufficiency = 2+ (n = 72), aortic insufficiency = 3+ (n = 49), and aortic insufficiency = 4+ (n = 70). Multivariable ordinal longitudinal mixed effects and multi-state transition models were used to assess risk factors for recurrent aortic insufficiency. RESULTS: The prevalence of cardiogenic shock in patients presenting with preoperative aortic insufficiency less than 2+, 2+, 3+, and 4+ was 53 of 348 (15.2%), 12 of 72 (16.7%), 10 of 49 (20.4%), and 24 of 70 (34.3%), respectively (P = .002). Postoperatively, 94.0% of patients had aortic insufficiency 1+ or less at discharge. Operative mortality was 34 of 348 (9.8%), 10 of 72 (13.9%), 6 of 49 (12.2%), and 12 of 70 (17.1%) (P = .303). In an ordinal mixed effects model, preoperative aortic insufficiency was associated with more severe postoperative aortic insufficiency. The multi-state transition model demonstrated that severe aortic insufficiency was associated with progression from no to mild aortic insufficiency (hazard ratio, 2.14; 95% confidence interval, 1.35-3.38), and progression from mild to moderate aortic insufficiency (hazard ratio, 5.70; 95% confidence interval, 1.88-17.30). CONCLUSIONS: Preoperative aortic insufficiency is an important predictor of recurrent aortic insufficiency in patients undergoing valve resuspension with root reconstruction for emergency acute type A aortic dissection repair. Increased echocardiographic surveillance for recurrent aortic insufficiency may be warranted in this cohort.
Assuntos
Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Insuficiência da Valva Aórtica/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Idoso , Aorta/cirurgia , Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/mortalidade , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tratamentos com Preservação do Órgão/efeitos adversos , Tratamentos com Preservação do Órgão/mortalidade , Reoperação/mortalidade , Estudos RetrospectivosRESUMO
OBJECTIVE: This study is performed to explore the pathological characteristics and oncologic outcomes of T1 multifocal renal cell carcinoma (RCC). METHODS: The clinical data of 600 patients (442 males and 158 females) between the age of 29 and 73 years, diagnosed with T1 RCC were collected from three hospitals in China, out of which 421 cases had undergone nephron-sparing surgery (NSS) and 179 cases had undergone radical nephrectomy (RN) between December 2010 and January 2015. RESULTS: Tumor was identified with multifocality in 32 patients (5.33%), out of which 21 were set to receive NSS, and 11 to receive RN, respectively; 21 cases of clear cell tumor, 8 cases of papillary tumor, 1 case of chromophobe tumor and 2 cases of Xp.11.2 translocation RCC. Among 568 cases of monofocal tumors, 400 patients underwent NSS, and the remaining 168 patients underwent RN, respectively. After a median follow-up of 5 years, 13 patients were found with recurrent tumors out of those who had undergone NSS, 11 with monofocal tumors and 2 with multifocal tumors containing satellite tumor nodules (p = 0.13). Out of the 32 individuals with multifocal RCC, 4 cases were reported to have died of cancer, 2 of NSS and 2 of RN. From these findings, the cancer-specific survival for NSS and RN was estimated to be 90.48% and 81.82%, respectively (p = 0.48). CONCLUSION: The findings from the study suggested that there were pathological differences in multifocal renal tumors, and that papillary carcinoma may be more common than clear cell carcinoma. The recurrence rate and survival rate of multifocal RCC were similar to monofocal tumors. Tumor recurrence may be related to satellite tumor nodules, which can only be detected once surgery is performed.
Assuntos
Carcinoma Papilar/mortalidade , Carcinoma de Células Renais/mortalidade , Neoplasias Renais/mortalidade , Nefrectomia/mortalidade , Néfrons/cirurgia , Tratamentos com Preservação do Órgão/mortalidade , Adulto , Idoso , Carcinoma Papilar/patologia , Carcinoma Papilar/cirurgia , Carcinoma de Células Renais/patologia , Carcinoma de Células Renais/cirurgia , Feminino , Seguimentos , Humanos , Neoplasias Renais/patologia , Neoplasias Renais/cirurgia , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
BACKGROUND: Worsening voice and speech quality was frequently reported in head-and-neck patients after radiotherapy to the neck; omitting the lower neck and sparing the glottic larynx in node-negative nasopharyngeal carcinoma (NPC) patients might be safe and feasible, and improve voice and speech outcomes. METHODS: From January 2009 to January 2013, 71 patients were analyzed. All patients received bilateral neck irradiation. Upper group (UG) patients spared the glottic larynx while lower group (LG) patients did not. Voice and speech quality were evaluated at two time-points (T1 and T2) using the Communication Domain of the Head and Neck Quality of Life (HNQOL) instrument and the Speech question of the University of Washington Quality of Life instrument. RESULTS: At a median follow-up time of 32 months (T1),71.6% of patients reported worsened voice and speech quality. UG patients resulted in significant decreases in glottic larynx dose. With a median follow-up time of 71 months (T2), no patients experienced out-of-field nodal recurrence;there was no difference in the 5-year overall survival and nodal recurrence-free survival between two groups (P = 0.235 and 0.750, respectively). At T1, in patients who without concurrent chemotherapy (CCT), UG patients showed significantly better patient-reported voice quality, (P = 0.022). UG patients without CCT also showed higher scores in the HNQOL communication domain and pain domain (P = 0.012 and P = 0.019). CONCLUSIONS: For node-negative NPC patients, omitting the lower neck and sparing the glottic larynx was safe and feasible, and better voice outcomes were achieved in patients without CCT. Further prospective longitudinal studies to investigate whether this approach would be beneficial to node-negative patients are warranted.
Assuntos
Quimiorradioterapia/efeitos adversos , Glote , Neoplasias Nasofaríngeas/terapia , Pescoço , Tratamentos com Preservação do Órgão/mortalidade , Qualidade de Vida , Distúrbios da Voz/prevenção & controle , Adolescente , Adulto , Idoso , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/terapia , Estudos de Viabilidade , Feminino , Seguimentos , Humanos , Linfonodos/patologia , Masculino , Pessoa de Meia-Idade , Neoplasias Nasofaríngeas/patologia , Medidas de Resultados Relatados pelo Paciente , Prognóstico , Taxa de Sobrevida , Distúrbios da Voz/etiologia , Qualidade da Voz , Adulto JovemRESUMO
Despite progress in the treatment of head and neck squamous cell carcinoma (HNSCC) in recent decades, including new surgical techniques, radiotherapy advances and chemotherapy schedules, the prognosis for the affected patients has not improved at the same pace, and still, most HNSCC patients are diagnosed in advanced stages. To increase their survival, the development of better screening methods for early detection is required and appropriate tailored therapeutic interventions are desired. The aim of the present study was to evaluate miRNAs as prognostic biomarkers in patients undergoing organ preservation protocol for locally advanced HNSCC. For this purpose, we assessed the global miRNA expression profile of 15 HNSCC patients ('screening set') to identify miRNAs differentially expressed in responders and non-responders to therapy. Four miRNAs differentially expressed in HNSCC samples from the 'screening set' were validated in a different cohort of patients (47 samples - 'validation set'). The results from the 'validation set' showed that the higher expression of one of these miRNAs, miR-21, was negatively associated with the treatment response to the organ preservation protocol (p=0.029). A multivariate analysis showed that, in a model adjusted for age, tumor site, p16 immunoexpression and tumor resectability, high expression of miR-21 remained an independent predictor of poor response to the organ preservation protocol (OR=5.69; 95%CI 1.27-25.58; p=0.023), together with clinical stage IV (OR=5.05; 95%CI 1.22-20.88; p=0.025). Furthermore, considering the entire cohort, patients with high expression of miR-21 had worse survival. A multivariate Cox regression analysis also showed miR-21 (HR=2.05; 95%CI 1.05-4.02; p=0.036) and clinical stage IV (HR=3.17; 95%CI 1.49-6.77; p=0.003) as independent prognostic factors (model adjusted for age, tumor site, tumor resectability, and sets 'screening' or 'validation').In conclusion, the results of this study suggest that the evaluation of miR-21 expression could be an important tool for treatment planning and a prognosis predictior for HNSCC patients undergoing organ preservation protocols.
Assuntos
Biomarcadores Tumorais/genética , Carcinoma de Células Escamosas/genética , Carcinoma de Células Escamosas/terapia , Quimiorradioterapia , Neoplasias de Cabeça e Pescoço/genética , Neoplasias de Cabeça e Pescoço/terapia , Neoplasias Laríngeas/genética , Neoplasias Laríngeas/terapia , MicroRNAs/genética , Tratamentos com Preservação do Órgão/métodos , Neoplasias Faríngeas/genética , Neoplasias Faríngeas/terapia , Carcinoma de Células Escamosas/mortalidade , Carcinoma de Células Escamosas/patologia , Quimiorradioterapia/efeitos adversos , Quimiorradioterapia/mortalidade , Distribuição de Qui-Quadrado , Progressão da Doença , Intervalo Livre de Doença , Feminino , Perfilação da Expressão Gênica , Neoplasias de Cabeça e Pescoço/mortalidade , Neoplasias de Cabeça e Pescoço/patologia , Humanos , Neoplasias Laríngeas/mortalidade , Neoplasias Laríngeas/patologia , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Tratamentos com Preservação do Órgão/efeitos adversos , Tratamentos com Preservação do Órgão/mortalidade , Seleção de Pacientes , Neoplasias Faríngeas/mortalidade , Neoplasias Faríngeas/patologia , Medicina de Precisão , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Reprodutibilidade dos Testes , Fatores de Risco , Carcinoma de Células Escamosas de Cabeça e Pescoço , Fatores de Tempo , Resultado do TratamentoRESUMO
AbstractObjective:To compare the results of the root reconstruction with the aortic valve-sparing operation versus composite graftvalve replacement.Methods:From January 2002 to October 2013, 324 patients underwent aortic root reconstruction. They were 263 composite graft-valve replacement and 61 aortic valve-sparing operation (43 reimplantation and 18 remodeling). Twenty-six percent of the patients were NYHA functional class III and IV; 9.6% had Marfan syndrome, and 12% had bicuspid aortic valve. There was a predominance of aneurysms over dissections (81% vs. 19%), with 7% being acute dissections. The complete follow-up of 100% of the patients was performed with median follow-up time of 902 days for patients undergoing composite graft-valve replacement and 1492 for those undergoing aortic valve-sparing operation.Results:In-hospital mortality was 6.7% and 4.9%, respectively for composite graft-valve replacement and aortic valve-sparing operation (ns). During the late follow-up period, there was 0% moderate and 15.4% severe aortic regurgitation, and NYHA functional class I and II were 89.4% and 94%, respectively for composite graft-valve replacement and aortic valve-sparing operation (ns). Root reconstruction with aortic valve-sparing operation showed lower late mortality (P=0.001) and lower bleeding complications (P=0.006). There was no difference for thromboembolism, endocarditis, and need of reoperation.Conclusion:The aortic root reconstruction with preservation of the valve should be the operation being performed for presenting lower late mortality and survival free of bleeding events.
ResumoObjetivo:Analisar comparativamente os resultados da operação de preservação da valva aórtica e do tubo valvulado nas reconstruções da raiz da aorta.Métodos:No período de janeiro de 2002 a outubro de 2013, 324 pacientes foram submetidos à reconstrução da raiz da aorta. Foram 263 tubos valvulados e 61 preservações da valva aórtica (43 reimplantes e 18 remodelamentos). 26% dos pacientes estavam em classe funcional III e IV; 9,6% com síndrome de Marfan e 12% apresentavam valva aórtica bivalvulada. Houve predomínio dos aneurismas sobre as dissecções (81% contra 19%), sendo 7% de dissecções agudas. O seguimento completo de 100% dos pacientes foi realizado com tempo mediano de seguimento de 902 dias para pacientes submetidos à tubo valvulado e de 1492 para aqueles submetidos à preservação da valva aórtica.Resultados:A mortalidade hospitalar foi de 6,7% contra 4,9% respectivamente para tubo valvulado e preservação da valva aórtica (ns). No seguimento tardio, a insuficiência aórtica importante foi de 0% e 5,8%, e a insuficiência cardíaca crônica, classe funcional I e II de 89,4% e 94%, respectivamente, para tubo valvulado e preservação da valva aórtica (ns). A reconstrução da raiz da aorta com a preservação da valva aórtica apresentou menor mortalidade tardia (P=0,001) e menos complicações hemorrágicas (P=0,006). Não houve diferença para tromboembolismo, endocardite ou necessidade de reoperação.Conclusão:A reconstrução da raiz da aorta com a preservação valvar deve ser a operação a ser realizada por apresentar menor mortalidade e sobrevida livre de eventos hemorrágicos.
Assuntos
Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Aorta/cirurgia , Doenças da Aorta/cirurgia , Valva Aórtica/cirurgia , Cardiopatias Congênitas/cirurgia , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Tratamentos com Preservação do Órgão/métodos , Doenças da Aorta/mortalidade , Métodos Epidemiológicos , Cardiopatias Congênitas/mortalidade , Doenças das Valvas Cardíacas/mortalidade , Implante de Prótese de Valva Cardíaca/mortalidade , Síndrome de Marfan/cirurgia , Tratamentos com Preservação do Órgão/mortalidade , Complicações Pós-Operatórias , Reoperação , Reprodutibilidade dos Testes , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: To compare the results of the root reconstruction with the aortic valve-sparing operation versus composite graft-valve replacement. METHODS: From January 2002 to October 2013, 324 patients underwent aortic root reconstruction. They were 263 composite graft-valve replacement and 61 aortic valve-sparing operation (43 reimplantation and 18 remodeling). Twenty-six percent of the patients were NYHA functional class III and IV; 9.6% had Marfan syndrome, and 12% had bicuspid aortic valve. There was a predominance of aneurysms over dissections (81% vs. 19%), with 7% being acute dissections. The complete follow-up of 100% of the patients was performed with median follow-up time of 902 days for patients undergoing composite graft-valve replacement and 1492 for those undergoing aortic valve-sparing operation. RESULTS: In-hospital mortality was 6.7% and 4.9%, respectively for composite graft-valve replacement and aortic valve-sparing operation (ns). During the late follow-up period, there was 0% moderate and 15.4% severe aortic regurgitation, and NYHA functional class I and II were 89.4% and 94%, respectively for composite graft-valve replacement and aortic valve-sparing operation (ns). Root reconstruction with aortic valve-sparing operation showed lower late mortality (P=0.001) and lower bleeding complications (P=0.006). There was no difference for thromboembolism, endocarditis, and need of reoperation. CONCLUSION: The aortic root reconstruction with preservation of the valve should be the operation being performed for presenting lower late mortality and survival free of bleeding events.