Louis A. Lanza

Primary cardiac sarcomas

In marked contrast to benign cardiac tumors, primary cardiac sarcomas occur infrequently. Moreover, there is no uniform approach to treating such patients, and the benefits of postoperative chemotherapy are unclear. Between 1964 and 1989, 21 patients with primary cardiac sarcomas underwent surgical resection alone (n = 7), chemotherapy alone (n = 1), or combined operation and postoperative chemotherapy based on adriamycin (n = 13). Twenty-four operations were performed on 20 patients with relief of symptoms in all. Eleven patients had complete resection. Operative mortality was 8.3% (2/24). Histology and originating chamber(s) included angiosarcoma (n = 7; 6/7 in right atrium, 1 in left atrium), malignant fibrous histocytoma (7; all in left atrium), fibrosarcoma (2; 2/2 in left atrium), rhabdomyosarcoma (2; 1 in left atrium, 1 in right ventricle), leiomyosarcoma (2; 1 in left atrium, 1 in left ventricle); and one undifferentiated sarcoma (right atrium). Overall actuarial survival was 14% at 24 months after resection. Patients with complete resection had a median survival of 24 months compared with only 10 months in all other patients (p = 0.035). Postoperative chemotherapy did not enhance survival in patients with incomplete resection. At this time, aggressive and complete surgical resection seems to offer the best hope for palliation and survival in an otherwise fatal disease.

Long-term survival after resection of pulmonary metastases from carcinoma of the breast

Resection of isolated pulmonary metastases may yield improved survival in select patients. Between 1981 and 1991, 44 women (median age, 55 years) with a history of breast cancer underwent 47 thoracotomies with no operative deaths and only three minor postoperative complications (3/47, 6.4%). Confirmation of the metastatic origin of the lung lesion was made by direct histological comparison with the primary. Three patients had benign nodules and were excluded, and 4 patients had less than complete resection at thoracotomy. The median survival after thoracotomy of the remaining 37 patients with completely resected metastases was 47 +/- 5.5 months, and their actuarial 5-year survival was 49.5%. Patients with a disease-free interval of longer than 12 months had a longer survival (median survival, 82 +/- 6 months; 5-year survival, 57%) than patients with a disease-free interval of 12 months or less (median survival, 15 +/- 3.6 months; 5-year survival, 0%) (p = 0.004). Patients with estrogen receptor-positive status (n = 14) tended to have longer survival after resection than patients with estrogen receptor-negative status (n = 15) (median survival, 81 +/- 9 months versus 23 +/- 6 months, respectively; p = 0.098). Other clinical variables analyzed did not predict survival after thoracotomy. We conclude that resection of pulmonary metastases in patients with breast cancer can be done safely and may result in long-term survival for a substantial number of patients. Patients with a disease-free interval of longer than 12 months have an excellent prognosis after complete resection.

Response to chemotherapy does not predict survival after resection of sarcomatous pulmonary metastases

Between 1979 and 1988, 26 patients with pulmonary metastases from adult soft-tissue sarcomas were treated with Adriamycin (doxorubicin hydrochloride), Cytoxan (cyclophosphamide), and DTIC before metastasectomy. Thirty-eight thoracotomies were performed with postoperative complications in 5 patients (5/38, 13.2%) and one postoperative death (1/38, 2.6%). Two patients had benign lesions at thoracotomy and were excluded from further survival analysis. The median survival of the remaining 24 patients after thoracotomy was 18.5 +/- 5.9 months, and the actuarial 5-year survival was 22%. Five patients (5/24, 21%) achieved a clinically complete response with preoperative chemotherapy, but all had recurrence in the lung and underwent resection of pulmonary metastases. Seven patients (7/24, 29%) achieved a partial response and had residual disease resected at thoracotomy. Twelve patients (12/24, 50%) showed either no change or disease progression while receiving chemotherapy and were referred for resection. Postthoracotomy disease-free survival and postthoracotomy overall survival did not differ significantly between the three groups. One patient in the group showing no change or progression of disease while receiving chemotherapy is alive without recurrence 57 months after initial pulmonary metastasectomy. Chemotherapy can be used for the initial treatment of pulmonary metastases from adult soft-tissue sarcomas. However, survival after resection of pulmonary metastases cannot be accurately predicted based on the clinical response to preoperative chemotherapy.

Prognostic significance of computed tomography in resected N2 lung cancer

We reviewed 124 patients from 1982 to 1988 who had a resected primary non-small cell lung cancer metastatic to mediastinal (N2) lymph nodes and a preoperative assessment of the mediastinum with computed tomography of the chest. Sixty-three patients studied had computed tomographic evidence of mediastinal lymph node enlargement. In these patients the survival at 5 years was only 6.6%, compared with the 5-year survival of 13.5% in 61 patients in whom the mediastinum was normal. Plain chest roentgenography with evidence of mediastinal adenopathy did not predict a poorer outcome. In addition, patients with tumors located in the left upper lobe were found to have an improved survival. These patients had a 5-year survival of 20.8%. Tumor histology, central location of the tumor, extranodal extension, and type of resection did not result in a significant survival difference.

Coccidioidal pericarditis: Implications of surgical treatment in the elderly

Coccidioidal pericarditis, an uncommonly diagnosed entity, may evolve to a constrictive process. Constrictive coccidioidal pericarditis requires pericardiectomy and antifungal therapy. In the elderly, pericardiectomy may be complicated by coagulopathy and septic shock. Despite potential toxicity, use of antifungal therapy early postoperatively offers the best chance for survival.

Left atrial appendage exclusion during mitral valve surgery and stroke in atrial fibrillation

PurposeThe purpose of this study was to determine whether surgical left atrial appendage (LAA) exclusion performed during mitral valve surgery is associated with a reduction in cerebrovascular events in patients with atrial fibrillation.MethodsWe retrospectively studied patients with atrial fibrillation who underwent mitral valve surgery from 1/1/2001 through 12/31/2014. We screened 1352 patients using ICD-9 codes and included 281 patients in the study. The primary end point was a composite of strokes and transient ischemic attacks occurring within 5xa0years after surgery. Secondary end points were stroke, transient ischemic attack, and all-cause mortality.ResultsThe LAA exclusion group (nu2009=u2009188) had a lower prevalence of female gender, hypertension, and diabetes mellitus compared with the non-LAA exclusion group (nu2009=u200993). The CHA2DS2VASc scores were comparable between groups (2.6 vs 2.9, Pu2009=u2009.11), as was anticoagulant use (82.4% vs 85.0%, Pu2009=u2009.60). Concomitant surgical ablation was performed in 73.9% of patients who underwent LAA exclusion. Nine cerebrovascular events occurred in the LAA exclusion group and 13 in the non-LAA exclusion group (HR 0.30 [0.12–0.75], Pu2009=u2009.01). There was no difference in all-cause mortality between groups. On multivariate analysis of the primary end point of strokes or transient ischemic attacks, significant variables were LAA exclusion (HR 0.31 [0.12–0.76], Pu2009=u2009.01) and CHA2DS2VASc score (HR 1.44 [1.11–1.87], Pu2009=u2009.006). The benefit of LAA exclusion was detected only when performed together with surgical ablation (HR 0.27 [0.09–0.72], Pu2009=u2009.01).ConclusionsLAA exclusion was associated with fewer cerebrovascular events. However, this benefit was seen only with concomitant surgical ablation.

ATRIAL MECHANICAL ABNORMALITIES ON SPECKLE TRACKING ECHOCARDIOGRAPHY CORRELATE WITH DEGREE OF FIBROSIS IN PATIENTS WITH ATRIAL FIBRILLATION

Atrial structural remodeling, particularly fibrosis with aging and/or chronic heart disease increases predisposition to atrial fibrillation (AF). Two-dimensional speckle tracking echocardiography is a novel noninvasive tool that can characterize atrial mechanical function and the substrate for AF.