Outcome of Patients With Systolic Heart Failure Who Underwent Sympathectomy for Ventricular Arrhythmia.

Cardiac sympathetic denervation (CSD) is a surgical procedure increasingly used for managing ventricular arrhythmia refractory to conventional medical therapy. Long-term outcomes of CSD in patients with systolic heart failure has not been well studied. This observational study aimed to evaluate the medical co-morbidities and outcomes of patients with systolic heart failure who underwent CSD performed as treatment for ventricular arrhythmia refractory to conventional therapy. A retrospective analysis in adult patients with ventricular arrhythmia and systolic heart failure who underwent unilateral or bilateral CSD at a single center was performed. Unadjusted Kaplan-Meier survival curves were constructed to evaluate survival after CSD. Between June 1, 2011 and March 31, 2021, 32 adult patients (age 62 ± 11.6 years, 88% male, left ventricular ejection fraction 22% ± 8.2%) with systolic heart failure underwent unilateral left (n = 4), unilateral right (n = 1), or bilateral CSD (n = 27). Mean survival after CSD was 613 ± 745 days, and the mean time from CSD to death was 291 ± 447 days. The cumulative probability of survival 1 year after CSD was 61.4%. In this single-center observational study, CSD performed for refractory ventricular arrhythmia showed favorable survival in patients with systolic heart failure. In conclusion, this study lays the groundwork for a more in-depth analysis of the potential survival benefits of CSD in this patient group.

Low Muscle Mass and Radiodensity Associate with Impaired Pulmonary Function and Respiratory Complications in Patients with Esophageal Cancer.

BACKGROUND: Sixty percent of patients with esophageal cancer display signs of cachexia at diagnosis. Changes in body composition are common, and muscle mass and quality are measurable through imaging studies. Cachexia leads to functional impairments that complicate treatments, including surgery. We hypothesize that low muscle mass and quality associate with pulmonary function testing parameters, highlighting ventilatory deficits, and postoperative complications in patients receiving esophagectomy. STUDY DESIGN: We performed a retrospective review of patients receiving esophagectomy between 2012 and 2021 at our facility. PET/CT scans were used to quantify skeletal muscle at the L3 and T4 levels. Patient characteristics were recorded, including pulmonary function testing parameters. Regression models were created to characterize predictive associations. RESULTS: One hundred eight patients were identified. All were included in the final analysis. In linear regression adjusted for sex, age, and COPD status, low L3 muscle mass independently associated with low forced vital capacity (p < 0.005, ß 0.354) and forced expiratory volume in 1 second (p < 0.001, ß 0.392). Similarly, T4 muscle mass independently predicted forced vital capacity (p < 0.005, ß 0.524) and forced expiratory volume in 1 second (p < 0.01, ß 0.480). L3 muscle quality correlated with total lung capacity ( R 0.2463, p < 0.05). Twenty-six patients had pleural effusions postoperatively, associated with low muscle quality on L3 images (p < 0.05). Similarly, patients with hospitalization more than 2 weeks presented with lower muscle quality (p < 0.005). CONCLUSIONS: Cachexia and low muscle mass are common. Reduced muscle mass and quality independently associate with impaired forced vital capacity, forced expiratory volume in 1 second, and total lung capacity. We propose that respiratory muscle atrophy occurs with weight loss. Body composition analyses may aid in stratifying patients. Pulmonary function testing may also serve as a functional endpoint for clinical trials. These findings highlight the need to study mechanisms that lead to respiratory muscle pathology and dysfunction in tumor-bearing hosts.

Esophageal Carcinoma Cuniculatum Diagnosed on Mucosal Biopsies Using a Semiquantitative Histologic Schema: Report of Two Esophagectomy-Confirmed Cases.

Esophageal carcinoma cuniculatum is a rare variant of squamous cell carcinoma characterized by a unique and common histologic pattern including hyperkeratosis, acanthosis, dyskeratosis, deep keratinization, intraepithelial neutrophils, neutrophilic microabscess, focal cytologic atypia, koilocyte-like cells, and keratin-filled cyst/burrows observed in the resection specimens. Preoperative diagnosis can be extremely difficult. A semiquantitative histologic scoring system has been previously proposed for mucosal biopsies, which has been associated with improved diagnostic yield. However, this histologic schema for the diagnosis of carcinoma cuniculatum has not been applied prospectively. Herein, we describe two cases of esophageal carcinoma cuniculatum in patients presenting with progressive dysphagia and esophageal mass. Presurgical endoscopic mucosal biopsies showed features consistent with carcinoma cuniculatum, and a preoperative diagnosis was achieved by applying the aforementioned semiquantitative histologic schema. Both patients underwent neoadjuvant chemoradiation followed by esophagectomy. Both esophagectomy specimens showed residual adventitia-invading carcinoma cuniculatum, negative lymph nodes, marked tumor regression, and an exuberant histiocytic and giant response. To our best knowledge, these represent the first two cases of esophageal carcinoma cuniculatum diagnosed by applying this semiquantitative histologic schema to mucosal biopsies. Large studies are needed to further confirm these preliminary findings and validate this histologic scoring system.

Angiographic embolization followed by piecemeal resection of giant posterior mediastinal schwannoma: Case report and concise review.

INTRODUCTION: Posterior mediastinal masses present unique diagnostic and therapeutic challenges, particularly when large highly vascularized tumors extend toward or emanate from the spinal cord. The rare nature of these tumors precludes the development of standardized management algorithms, underscoring the importance of case reports. PRESENTATION OF CASE: A 57 year old female presented with exertional dyspnea and right chest pressure. Chest radiography followed by computed tomography (CT) scan demonstrated a 13 cm posterior mediastinal mass involving the T7 vertebral body. CT-guided percutaneous biopsy confirmed benign schwannoma. During open exploration, the tumor bled easily with contact. Angiography with intercostal arterial embolization decreased tumor vascularity while preserving spinal cord perfusion. Subsequent piecemeal resection facilitated exposure of the tumor base and complete resection. Postoperative recovery was uneventful. DISCUSSION: Neurogenic tumors are most commonly located in the posterior mediastinum. When untreated, schwannomas continue to grow, and will inevitably cause compressive symptoms if given sufficient time. Therefore, resection is recommended. This may be performed thoracoscopically in select patients with small tumors, avoiding the morbidity of a thoracotomy incision. CONCLUSION: Large posterior mediastinal schwannomas require posterolateral thoracotomy and resection. Preoperative angiography helps identify arteries shared by the tumor and the spinal cord, and embolization may reduce tumor vascularity and operative blood loss thereby permitting safer resection.

Foreign body retained in the esophagus for more than a decade: thoracic esophagotomy for retrieval.

A foreign body (FB) lodged in the esophagus is not uncommon. Although endoscopic removal is successful in the majority of cases, it could prove to be difficult in those whose foreign bodies are large or have been incarcerated for a long time. We describe the case of a 23-year-old woman who had a FB in her esophagus for at least 13 years. She became symptomatic 2 years before presentation, but presented for treatment when dysphagia to both solids and liquids developed. Endoscopic retrieval of the incarcerated FB was unsuccessful, and she eventually required thoracotomy and esophagotomy for its extraction.

Strategies of dose escalation in the treatment of locally advanced non-small cell lung cancer: image guidance and beyond.

Radiation dose in the setting of chemo-radiation for locally advanced non-small cell lung cancer (NSCLC) has been historically limited by the risk of normal tissue toxicity and this has been hypothesized to correlate with the poor results in regard to local tumor recurrences. Dose escalation, as a means to improve local control, with concurrent chemotherapy has been shown to be feasible with three-dimensional conformal radiotherapy in early phase studies with good clinical outcome. However, the potential superiority of moderate dose escalation to 74 Gy has not been shown in phase III randomized studies. In this review, the limitations in target volume definition in previous studies; and the factors that may be critical to safe dose escalation in the treatment of locally advanced NSCLC, such as respiratory motion management, image guidance, intensity modulation, FDG-positron emission tomography incorporation in the treatment planning process, and adaptive radiotherapy, are discussed. These factors, along with novel treatment approaches that have emerged in recent years, are proposed to warrant further investigation in future trials in a more comprehensive and integrated fashion.

Empyema thoracis due to intrapleural migration of retained vascular catheter.

Intravascular retention and embolization of fragment of central venous catheters is a rare but well-documented complication of in-dwelling vascular access devices and ports. We describe the case of a 39-year-old male with fracture of the central venous catheter during removal of subcutaneous vascular access port. Over the next 3 years, the catheter fragment embolized through the pulmonary circulation and subsequently migrated into the left pleural space. He presented with empyema thoracis associated with thoracolumbar vertebral osteomyelitis. He required video-assisted thoracoscopy for retrieval of the catheter fragment, left lung decortication, and subsequent multilevel vertebral corpectomy and spine stabilization procedures.