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PubMed2006

Plasma levels of metalloproteinases-9 and -2 in the acute and subacute phases of type A and type B aortic dissection.

OBJECTIVES: Aortic dissection is characterized by an acute phase of medial dissection and a subacute-chronic phase of vessel wall repair. Matrix metalloproteinases (MMPs), through degradation of extracellular matrix, may play an important role in these processes. Elevation of MMPs might represent an opportunity to diagnostically characterize acute or chronic aortic processes. We examined the potential diagnostic role of MMP-9 and MMP-2 in different phases of aortic dissection. METHODS: Plasma levels of MMPs were evaluated by enzyme-linked immunosorbent assay technique in 13 patients affected by acute aortic dissection (nine type A, four type B). Ten healthy subjects were used as controls. In patients with type B aortic dissection treated medically, plasma curves (1, 3, 6, 12, 24, 48 and 96 h; 1 and 2 weeks; and 2 months from symptom onset) were also assessed. Aortic tissue samples obtained during surgery were evaluated by immunohistochemistry and western blot for MM-9 and tissue inhibitor of metalloproteinase-1 expression. RESULTS: MMP-9 plasma levels were increased in patients affected by type A and type B aortic dissection presenting within 1 h from onset of symptoms compared to controls (29.3 +/- 16.1 and 16.7 +/- 2.1 ng/ml versus 7.74 +/- 1.6 ng/ml, P < 0.03, respectively). No differences were detected in MMP-2 plasma levels compared to controls (4.84 +/- 1.2 ng/ml for type A and 6.16 +/- 0.6 ng/ml versus 3.17 +/- 1.0 ng/ml for controls, P = NS, respectively). In type B aortic dissection, mean MMP-9 plasma levels increased significantly from hospital admission to 2-month follow-up (16.7 +/- 2.1 ng/ml versus 58.0 +/- 8.2 ng/ml, P < 0.0001). Conversely, no difference in MMP-2 plasma levels was evident during follow-up (6.16 +/- 0.6 ng/ml versus 4.28 +/- 0.4 ng/ml, P = NS, respectively). Low-moderate (+/++) expression of MMP-9 was evident at immunohistochemistry in the acute phase whereas a marked expression (++++) was detected in the subacute phase. CONCLUSIONS: This pilot study suggests that the acute and subacute phase of both type A and type B aortic dissection is characterized by an increase of MMP-9 plasma levels. A marked increase is also evident in the subacute phase of medically treated type B aortic dissection as an expression of aortic wall remodelling. An increase of proteolytic activity could accompany attempts of the dissected aorta to heal itself but such a phenomena might further weaken the aortic wall, predisposing it to dilation and/or rupture.

Acute Disease↗

PubMedDate not supplied

Internal carotid artery dissection: an animal model?

This paper describes an internal carotid artery (ICA) dissection model in a rabbit. An animal model for ICA dissection has not been described. New Zealand White rabbits were anaesthetized and surgical microdissection performed to expose the right internal carotid artery. A small arteriotomy was performed and a subadventitial plane of dissection created using blunt dissection and injected heparinized saline. The adventitia was sutured and the animals were recovered after closure of the wound. The procedure was repeated on the left ICA after 7 days with removal of the left ICA for control samples and removal of the right ICA to obtain sample specimens. The brain was also removed. A total of 11 control specimens and 9 sample specimens were obtained. The mean length of these specimens (n = 20) was 5.5 mm (range 5-6 mm). The mean length of dissection of the control specimens (n = 11) was 2.2 mm (range 2-3 mm). The mean length of dissection on sample specimens (n = 9) was 2 mm (range 1-3 mm). There was no extension of the arterial dissection. There was no intraluminal thrombosis or cerebral infarction. This model was able to induce arterial wall dissection in a rabbit. There was no extension of the induced dissection over 7 days. No local arterial or cerebral ischemic complications developed from the dissection.

Aortic Dissection↗

PubMed2002

Operative mortality rate for elective abdominal aortic aneurysm repair is not increased by the presence of a previous or concurrent thoracic or thoracoabdominal aortic dissection.

BACKGROUND: The objective of this study was to determine the likelihood of mortality after abdominal aortic aneurysm (AAA) repair in patients with thoracic or thoracoabdominal aortic dissection. METHODS: Fourteen patients (11 men, three women) with known thoracic or thoracoabdominal aortic dissections underwent elective AAA repair from 1986 to 2001, including three patients with acute dissections (less than 14 days) and 11 patients with chronic dissections (14 days or longer). All 14 patients had type III aortic dissections. Stent graft exclusion of the aortic dissection was performed in one patient before AAA repair. Preoperative patient characteristics, intraoperative events, perioperative complications, and 30-day and 1-year mortality rates were assessed. RESULTS: Elective AAA repair in the setting of thoracic or thoracoabdominal aortic dissection in this series was associated with no 30-day mortality and a 1-year mortality rate of 7.1%. Furthermore, preoperative patient characteristics, intraoperative events, and perioperative complications did not appear to be associated with late, 1-year, mortality. CONCLUSION: Elective AAA repair in the setting of acute or chronic aortic dissection is associated with mortality rates similar to those generally attributed to elective AAA repair without accompanying aortic dissection. Nevertheless, the conduct of the operation is usually complex, especially in the setting of an acute aortic dissection.

Acute Disease↗

PubMed1992

[Meta-analysis of the prognosis of thoracic aortic dissection: changing mortality in the last four decades].

The acute dissection of the thoracic aorta is a potentially lethal event with a death rate of 1 to 2% per hour urging for undelayed diagnosis and adequate treatment. First, this paper highlights both the demographic characteristics and the classification according to anatomical and prognostic criteria, i.e. class I to III according to DeBakey and type A and B according to Daily (or Stanford). Moreover, the etiology of aortic dissection is explained, including factors such as degenerative changes of the aortic media layer, chronic trauma from hypertension, primary connective tissue disease and acute deceleration trauma. Second, the clinical criteria of acute (within 14 days of the index event) and chronic dissection (> 14 days) is discussed with respect to the current literature. The dominant part of this paper represents a meta-analytic approach comprising all available literature sources with respect to emerging changes in the prognosis of thoracic aortic dissection over 40 years as a function of either the type, the anatomic location, the acuity or the impact of medical or surgical treatment of this disorder. The meta-analysis revealed that in acute and chronic type A dissection medical treatment alone failed to lead to a significant improvement of 30 day-mortality rate (Tables 1 and 2, Figure 1). However, with surgical interventions the 30 day-mortality rate was continuously lowered from 60% to 10% within the past 30 years. A similar evolution was observed for the chronic type A dissection (Tables 3 and 4, Figure 2). Furthermore, the meta-analysis revealed that the acute type B dissection benefits from medical treatment, especially antihypertensive medication since the 30 day-mortality of 40% in 1960 decreased to less than 10% at present with monitoring and effective medication (Tables 1 and 2, Figure 3). In case of chronic type B dissection the literature survey revealed mortality numbers fluctuating between 2% and 20% without a clearcut beneficial effect of medical therapy throughout these years, though possibly revealing some advantage over surgical treatment. Thus, both for the acute and chronic type B dissection the antihypertensive therapy is considered treatment of first choice, whereas surgical interventions may be necessary for complicated and progressive cases. In summary, compared to the natural course of thoracic aortic dissection with only 10% survival-rate after one year of onset (Table 9, Figure 5), any effective mode of treatment may significantly lower the high spontaneous death rate.(ABSTRACT TRUNCATED AT 400 WORDS)

Aortic Dissection↗

PubMed2004

Multisection CT angiography compared with catheter angiography in diagnosing vertebral artery dissection.

BACKGROUND AND PURPOSE: Multisection CT angiography is a minimally invasive technique that can provide high-resolution and high-contrast images of the arterial lumen and wall. To our knowledge, the ability of multisection CT angiography in detecting vertebral artery (VA) dissection has never been evaluated. We assessed the sensitivity and specificity of a routine, standardized, multisection CT angiographic protocol for the detection of VA dissection. METHODS: We retrospectively reviewed multisection CT angiograms of 17 patients with VA dissection and 17 control subjects. The acquisition protocol for multisection CT angiography was 1.25-mm nominal section thickness, a table speed of 7.5 mm per rotation (9.4 mm/s), and a 0.8-second gantry rotation period. Two radiologists assessed the maximum intensity projection and axial source images. The sensitivity and specificity of this technique in depicting VA dissection were determined. RESULTS: Conventional angiography depicted 15 normal and 19 dissected VAs (including five stenotic, seven occlusive, and seven aneurysmal dissections) in the patient group and 28 normal and six atherosclerotic VAs in the control group. Multisection CT angiography enabled successful diagnosis of all 19 dissected VAs and 48 (98%) of 49 nondissected VAs but misidentified a severe atherosclerotic lesion as an aneurysmal-type dissection. The sensitivity, specificity, accuracy, and positive and negative predictive values of multisection CT angiography in diagnosing VA dissection were 100%, 98%, 98.5%, 95%, and 100%, respectively. CONCLUSION: Multisection CT angiography was a sensitive and accurate technique for the diagnosis of VA dissection.

Adult↗

PubMed2005

[Selective neck dissection in the management of tongue squamous cell carcinoma with clinically negative nodes].

OBJECTIVE: To compare the effectiveness of selective neck dissection (SND) with radical or modified radical neck dissection (RND) for the management of tongue squamous cell carcinoma with clinically negative nodes (cN0). METHODS: There were 33 patients who were treated with SND (including 14 supraomohyoid neck dissection and 19 level I -IV neck dissection ) between January 1998 and December 2002. According to T classifications, treatment modality and pathological status of lymph node (pN), the control group of 33 patients were randomly selected from the cN0 tongue squamous cell carcinoma patients who were treated with RND between January of 1980 and December of 1997. Kaplan-Meier was used to calculate the rate of regional recurrence and 5-year survival rate. RESULTS: The neck recurrent for RND population was 9.1% (3 patients), which was not statistically different from the neck recurrent in the SND population 12.1% (4 patients). Also, the 5-year survival rates were no statistic difference between SND and RND groups (82.9%, 28 patients vs 78.8%, 26 patients). The rate of recurrent outside the dissection area for level I -IV neck dissection population was 0, which was statistically different from the rate of recurrent outside the dissection area in the supraomohyoid neck dissection population (14.3%, 2 patients). CONCLUSIONS: Comparing to the radical or modified neck dissection, the SND offered the same oncologic compromise for patients with cN0 tongue squamous cell carcinoma. I -IV neck dissection was recommended.

Carcinoma, Squamous Cell↗

PubMed2006

[A case of vertebral artery dissection with recurrent brain embolism].

We report a 63-year-old case of the vertebral artery dissection with recurrent brain embolisms. She was admitted to the hospital because she suffered a visual symptom. She was examined by magnetic resonance imaging (MRI) and diagnosed a left vertebral artery (VA) dissection. Digital subtraction angiography (DSA) revealed the string sign on the left VA supporting the evidence of dissection. However, after DSA, multiple brain embolic stroke was occurred. She was treated with anti-platelet drug (sodium ozagrel), then, recanalization of the pseudo-lumen at the dissecting lesion was observed by MRI examination. Anti-platelet medicine (cilostazol) was taken for preventing reattack although the dissecting lesion was not closed. Following 4 weeks, brain embolisms were observed in the posterior circulation system. MRI revealed a dilated pseudo-lumen at the dissecting lesion with recurrent VA. This time, she was treated only with free radical scavenger (edarabone). After the occlusion of the dissected VA was observed, she started to take anti-platelet medicine again. It is generally accepted to use anti-platelet drug or anti-coagulant drug as a treatment of VA dissection causing brain ischemia. However, it should be assessed more carefully in cases showing recanalization of the pseudo-lumen as observed in this case. Surgical treatments should be taken into consideration at the early stage, especially for the cases presenting fragile dissecting lesions. Further study need to decide the effective treatment of the vertebral artery dissection.

Angiography, Digital Subtraction↗

PubMed1990

A balloon-expandable intravascular stent for obliterating experimental aortic dissection.

Acute aortic dissection is a life-threatening condition. Aggressive hypotensive drug therapy is the initial treatment of choice, although emergent surgical intervention is often warranted. We evaluated the efficacy of a balloon-expandable intravascular stent for the internal obliteration of aortic dissection. It is a flexible, continuous, complex coil cut to the length needed at the time of insertion. It can be positioned in curved vessels, including the aortic arch. The stent was inserted in the thoracic and abdominal aorta of 12 dogs (group I). Six weeks after implantation the dogs underwent angiography and the stents were explanted for light and scanning electron microscopy. There were no instances of stent migration or change in configuration. The aortas did not rupture. All branch vessels remained patent. Light and scanning electron microscopy illustrated neointimal incorporation into the vascular wall except at orifices. Thoracic dissections were created surgically in an additional 24 mongrel dogs. Twelve dogs received stents immediately after creation of the dissection (group II). All 12 dissections were obliterated. Twelve dogs were allowed to recover after creation of the dissection to observe the natural history of that lesion (group III). Within 1 week, in group III, there were three deaths because of aortic rupture; eight dissections persisted, and one resealed spontaneously. Stents were placed in the eight persistent dissections. All eight dissections were obliterated. In both groups, after 6 weeks of stent placement, aortography was repeated, and stents were explanted for light and scanning electron microscopy. There were no instances of rupture. All branch vessels remained patent with no evidence of thrombosis. We conclude that because of its unique characteristics, the stent effectively obliterates the false lumen of experimental acute aortic dissections without occlusing side branches, damaging the aorta, or inducing thrombosis.

Aortic Dissection↗

PubMed1995

[Surgical treatment of type A aortic dissection based on the location of the entry].

From 1987 to February of 1994, 42 cases of acute aortic dissection and 31 cases of chronic dissection have been operated in out institution. Our surgical technique for the treatment of aortic dissection is a tubular graft replacement following a resection of the segment of aorta containing the intimal tear. The location of the entry was, therefore, important to determine the extension of graft replacement and to select the circulatory support method during operation. 52%, 33% and 14% of cases in acute aortic dissection had entries in ascending, arch and descending aorta, respectively. Entries of 52%, 32% and 16% of cases in chronic dissection located in ascending, arch and descending aorta, respectively. In cases with the entry in ascending aorta, ascending aorta and partial aortic arch replacement was performed in 12 and 10, respectively, for acute dissection, whereas more extensive graft replacement procedure was selected for chronic dissection including complete arch replacement in three cases and two of them had concomitant Bentall type operation. Likewise, with the entry in aortic arch, partial arch replacement was performed more often in 9 than complete arch replacement in 5 for acute dissection, on the other hand, complete arch replacement procedure tended to be preferable in 6 cases for chronic dissection. For retrograde dissection with the entry in descending aorta, ascending aorta and complete arch replacement were performed in 4 and 6 cases, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1994

Dissection of the descending thoracic aorta extending into the ascending aorta. A therapeutic challenge.

Proper management of dissections of the descending thoracic aorta with intimal disruption close to the left subclavian artery and retrograde extension of the dissection into the aortic arch or the ascending aorta is controversial, because the standard approach for ascending aortic aneurysms is surgical repair, which is difficult to achieve through a median sternotomy if the predominant aortic lesion is located in its descending part. Sixteen patients with descending thoracic aortic dissection, intimal disruption close to the subclavian artery, and extension of the dissection into the aortic arch or the ascending aorta are described here: Eleven patients underwent surgical repair including 9 emergency (82%) and 2 elective (18%) procedures. Retrograde aortic dissection included the aortic arch in 11 of 11 patients (100%) and the ascending aorta in 7 of 11 (63%). Pericardial effusion was present in 1 of 11 patients (9%) and mild aortic regurgitation was found in 1 of 11 (9%). Repair of the ascending aorta and arch with transaortic closure of the entrance tear in the descending thoracic aorta was performed in 4 of 11 patients (36%) via a median sternotomy. In 6 of 11 patients (55%) a lateral thoracotomy was used for repair of the descending thoracic aorta and closure of the entrance tear. Hospital mortality occurred in 1 of 11 patients (9%) and there was 1 late death. Paraplegia occurred in 1 of 11 patients (9%). Five patients with descending thoracic aortic dissection, intimal disruption close to the subclavian artery, and extension into the ascending aorta but without ascending aortic aneurysm (diameter 4.2 +/- 0.2 cm), pericardial effusion, or aortic incompetence were treated medically without early mortality. These results are compared with those achieved in 120 patients operated on during the same period for type A (89/120) and type B (31/120) aortic dissections. Considering the technical difficulties of simultaneous repair of dissections of the ascending and the descending thoracic aorta, we recommend that descending thoracic aortic dissection extending into the arch or the ascending aorta be managed in accordance with the site of the predominant lesion. Replacement of the arch with a varying portion of ascending aorta via a median sternotomy is recommended in patients with enlarged aortic diameter, pericardial effusion, and/or aortic insufficiency. Predominantly distal dissections with dilated descending thoracic aorta and/or distal complications are best approached via a lateral thoracotomy.

Adolescent↗

PubMed1993

[Clinical evaluation of cervical and superior mediastinal lymph node dissection for intrathoracic esophageal carcinoma].

From 1985 to 1989, 257 cases of carcinoma of the thoracic esophagus underwent esophagectomy and lymph node dissection with right thoracotomy based on preoperative staging. Bilateral cervical lymph node dissection was selected in cases in which preoperative examinations (CT, US, EUS, etc) revealed metastasis to cervical or superior mediastinal lymph nodes and cervical or superior mediastinal lymph nodes and in cases of tumors of the upper intrathoracic esophagus. All cases were classified into 3 groups according to region of lymph node dissection. In addition to dissection of the lymph node in the mediastinum and abdomen, group A (102 cases) underwent bilateral cervical and extensive superior mediastinal lymph node dissection (en bloc removal of tissue from the upper mediastinum), group B (61 cases) underwent extensive superior mediastinal lymph node dissection with or without left side cervical dissection and group C (94 cases) underwent standard dissection. Group A contained more advanced cases and cases with metastasis to the upper mediastinal lymph nodes compared to groups B and C. Postoperative complications were also more frequent in group A than groups B or C and were slightly more frequent in group C than group B. Recurrent nerve palsy was recognized in 21% of group A cases. Operative death (within 30 days) was highest in the group A (5.8%) particularly in the elderly group aged over 70 y or absolutely non-curatively resected cases, while in group C the operative mortality was 2.2%. Apart from absolutely non-curatively resected cases, there was no significant difference in the survival curves of the 3 groups, and there was no difference between group A and B cases with no cervical metastasis and group C cases. Also, this selection showed a favorable survival curve following esophagectomy in the period since 1985 compared to the earlier period (1980-1984), excluding absolutely non-curative cases and early stage cases (ep, mm cancer). The results suggest our evaluation methods and selection criteria were appropriate. All absolutely non-curatively resected cases had poor survival rates without significant difference among the 3 groups. In this category of cases, bilateral cervical lymph node dissection of absolutely non-curative cases was not effective. In cases with 1-3 metastatic lymph nodes of all, there was a significant difference in prognosis between group A and groups B and C, but there was no significant difference in cases with more than 4 metastatic lymph nodes. Those results suggest that when 1-3 lymph nodes are metastatic, it is necessary to dissect bilateral cervical lymph nodes.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗

PubMed1998

Surgical treatment of Marfan patients with aneurysms and dissection of the proximal aorta.

BACKGROUND: The authors retrospectively analyzed early and late results of surgical treatment for 79 Marfan patients with aneurysms and dissection of the proximal aorta. METHODS: From September 1979 to February 1996, 79 patients with Marfan syndrome underwent aortic root replacement using composite grafts (n=68, Bentall-technique 63, button-technique 5), and ascending aortic replacement with a valve-sparing procedure (n=11). There were 12 patients (15.2%) who simultaneously received partial or total arch replacement. 55 patients (69.6%) were male, and 24 female (30.4%). The average age was 33.8 years. Forty-one patient (51.9%) had non-dissecting aneurysms while the remaining 38 patients suffered from either acute (24.0%) or chronic aortic dissection (24.0%). The aortic valve was involved in 97.5% of all cases. RESULTS: The total early mortality (< or =30 days) was 3.8%, 10.5% for acute aortic dissection and 2.4% for non-dissecting aneurysms. There were no early postoperative deaths in patients after valve-sparing operation and in those with chronic aortic dissection. The follow-up rate was 98.7%. During a mean follow-up of 68+/-25 months 10 patients (13.3%) died and cardiac complications were a common cause of the late deaths. There was no late mortality in the valve-sparing operations during a mean follow-up period of 8+/-6 months, however, 1 required valve replacement. 19 (25.3%) of the 75 patients surviving late have undergone 25 secondary operations on the cardiovascular system. Reoperations at aortic sites distant from the original were much more frequent after primary repair for acute and chronic dissection when compared to non-dissecting aneurysms (p<0.005). Actuarial survival rate of all patients with composite graft replacement including early deaths was 91.2% at 1 year, 84.4% at 5 years and 75.2% at 10 years. CONCLUSIONS: Composite graft insertion has become the gold standard for treating Marfan-patients with non-dissecting and dissecting aneurysms of the aortic root. Our early experience in 11 patients with valve-sparing procedures indicated that this,variant may be the better choice in selected patients.

Adult↗

PubMed1996

Analysis of prognostic factors for recurrence after neck dissection.

OBJECTIVE: To analyze retrospectively several characteristics to verify the existence of further prognostic factors besides those already known for recurrence after neck dissection. DESIGN: From 1976 to 1993, 1 surgeon performed 1097 neck dissections as single surgical events in 705 patients. Radical neck dissection was performed only in the presence of fixed nodes and functional neck dissection in cases with mobile nodes or without detectable nodes (N0). Functional neck dissection was performed on laryngeal or hypopharyngeal N0 tumors without the dissection of the first level. External beam radiotherapy (RT) was performed based on the following conditions: microscopically positive margins of tumor, more than 2 positive nodes without capsular rupture (pN+R-), or capsular rupture (pN+R+). SETTING: Division of Otolaryngology, General Hospital of Pordenone, northeastern Italy. RESULTS: Nodal recurrences were observed in 38 patients (5.4%). Patient sex and age, histological grading and staging of primary tumor, second tumors, number of nodes, type of neck staging, surgeon's experience, type of dissection, alterations to the dissection, number of pN+R-, and postoperative RT were not significantly related to the recurrence. The clinical staging of nodes at greater than N1 and/or fixed; the neck levels IV, V, and multiple levels; previous RT with or without chemotherapy; the absence of a synchronous tumor operation; the assessment of the dissection as less than radical; the overall number of pN+ at 2 or more; and the presence of pN+R+ were related to higher recurrence rates. CONCLUSION: The treatment policy used herein is effective for pN+R-. A more aggressive multidisciplinary approach might be suggested for N2 and N3 and/or fixed nodes; nodes at levels IV, V, or multiple; nodes dissected less than radically; or pN+R+.

Adult↗

PubMed1994

Melanoma recurrence in a previously dissected lymph node basin.

OBJECTIVES: To retrospectively assess whether completeness of node dissection has any bearing on regional control in cutaneous melanoma and to examine the efficacy of a subsequent dissection in patients with isolated nodal recurrence. DESIGN: Case series, 18-month minimum follow-up. SETTING: Academic surgical practice. STUDY PARTICIPANTS: Patients with cutaneous melanoma who had undergone a regional node dissection and subsequently developed recurrence in the same nodal basin in which a lymphadenectomy had been performed with no evidence of distant metastases. Of 1030 instances of regional node dissection, 28 met these criteria. MAIN OUTCOME MEASURES: Nodal recurrence in the previously dissected lymph node basin as the only site of recurrence and survival following a subsequent lymph node dissection. RESULTS: The 28 instances of isolated nodal recurrence represent a regional failure rate of 2.7%. In those cases where the first dissection was performed within our division, the rate is 0.8%. Recurrence for cervical, axillary, or inguinal sites was similar. In 71% of the cases, more than one node was positive at the time of recurrence. Four patients have shown disease-free survival greater than 3 years following a subsequent lymphadenectomy. CONCLUSION: Node dissection is a therapeutic procedure and, therefore, must consist of complete lymphadenectomy with meticulous attention to surgical detail. Approached in this fashion, only a small subgroup of patients will show recurrence in a previously dissected nodal basin, a few of whom can be salvaged by a second dissection.

Adult↗

PubMed1998

Planned postradiotherapy neck dissection in patients with advanced head and neck cancer.

BACKGROUND: Metastatic neck nodes in patients with squamous cell carcinoma of the head and neck are most commonly managed by surgery, radiotherapy, or combined-modality therapy. For combined-modality cases, the sequencing of surgery and radiotherapy is generally guided by which modality is considered preferable for treatment of the primary tumor. A postradiotherapy neck dissection is often considered for those patients with > N1 disease in which the primary is treated with radiotherapy alone. METHODS: Between February 1991 and October 1995, 25 patients with node-positive squamous cell carcinoma of the head and neck were treated with planned unilateral (n = 22) or bilateral (n = 3) neck dissection following high-dose radiotherapy. The primary tumor sites included: tongue base (n = 11), tonsil (n = 6), nasopharynx (n = 3), pyriform sinus (n = 2), supraglottic larynx, (n = 1), soft palate (n = 1), and unknown head and neck primary (n = 1). The specific nodal stage breakdown of the 28 individual neck dissections (25 patients) was N1 (n = 1), N2A (n = 5), N2B (n = 15), N3 (n = 7). RESULTS: Nineteen of the 28 neck dissections (68%) demonstrated no evidence of residual carcinoma. Of the nine positive neck dissections, six revealed malignant cells in a single nodal echelon. The 1- and 2-year rate of neck control in all 25 patients was 100% and 93%, respectively. The 1- and 2-year disease-specific survival for all 25 patients was 83% and 60%, respectively. With a minimum follow-up of 2 years, 64% of the 25 patients remain alive with no evidence of disease or dead of non-cancer causes. CONCLUSION: In this series of postradiotherapy neck dissections, two thirds of the dissections demonstrated no evidence of residual tumor (19/28, or 68%). However, there was not a direct correlation between pretreatment nodal size (neck staging), radiation dose delivered, and the likelihood of achieving a cancer-free neck dissection. Only one of 28 postradiotherapy neck dissections identified tumor outside of nodal stations II-IV. The predictable pattern of residual disease in pathologically positive cases suggests that a selective neck dissection encompassing levels II-IV may be appropriate in a majority of patients.

Adult↗

PubMed2002

[Dissection or irradiation of the axilla in postmenopausal patients with breast cancer? Long-term results and long-term effects in 655 patients].

BACKGROUND: Until 1993 postmenopausal women with breast cancer did not receive adjuvant chemotherapy in our institution even if axillary nodes were involved. So in these patients axillary dissection had no diagnostic value for further treatment. Therefore we started a prospective study in which dissection of axillary nodes was replaced by irradiation in postmenopausal cN0 patients. PATIENTS AND METHODS: From 1986 to 1993 we irradiated 655 patients with breast cancer after breast conserving surgery (BET). In all 144 cN1- and all 209 premenopausal cN0-patients axillary dissection was recommended. Of 302 postmenopausal cN0 patients 129 had breast surgery in our institution. In a total of 129 patients axillary dissection was replaced by irradiation (AxRT-group). They were compared with all 173 patients referred from other hospitals for irradiation after both breast conserving surgery and axillary dissection (AxOP-group). Dissected patients with gross tumor involvement of the axilla or less than eight nodes removed had additional axillary irradiation. Patients age, tumor size, vessel-, muscle- or skin invasion and grading were similar in both groups (Table 1). However, in the AxRT-group there were more patients with negative hormone receptors, multifocal and medial sited tumors. Late complications after dissection and/or irradiation of the axilla were evaluated in 502 patients free of locoregional relapse and with a minimal follow up of 3 years (median 9.5 years). RESULTS: After 5, 10 and 15 years tumor free survival rates were 90%, 82% and 79% in the AxOP-group vs 91%, 82% and 80% in the AxRT-group, respectively (p = 0.95) (Figure 1). Overall survival (p = 0.98) (Figure 2), local (p = 0.47) and axillary control (p = 0.12) were equal in both groups (Figures 3 and 4). However, serious problems like lymphedema of the arm, pain, mobility impairment occurred in 26% patients following axillary dissection but only in 1% after axillary irradiation. No difference in late sequelae after axillary dissection with or without irradiation could be detected (26 vs 27%) (Table 2). CONCLUSION: In postmenopausal cN0-patients axillary dissection should be replaced by axillary irradiation, since it offers the same chance for cure with much lower morbidity.

Aged↗

PubMed1991

Use of a morphologic classification to predict clinical outcome after dissection from coronary angioplasty.

To determine if morphology of procedure-associated dissections could help predict clinical outcome, angiograms of 691 coronary artery dissections resulting from percutaneous transluminal coronary angioplasty were categorized according to the National Heart, Lung, and Blood Institute classification system. Classes of dissection were then correlated with clinical outcome: 543 patients with type B dissections had no increase in morbidity and mortality when compared with patients without dissection, with a similar success rate of 93.7%. Complications in this group were low and compared favorably with complication rates in procedures not associated with dissection. One hundred forty-eight procedures associated with dissections of types C to F had a significant increase in in-hospital complications, including acute closure (31%), need for emergency coronary bypass surgery (37%), myocardial infarction (13%) and repeat angioplasty (24%). The overall clinical success rate for those with types C to F dissection was 38%. The differences in clinical success and acute complications between type B and types C to F dissections were statistically significant at p less than 0.0005 for all variables studied. The angiographic morphology of a dissection during coronary angioplasty can predict clinical outcome, aiding in selection of effective therapy.

Aged↗

PubMed1993

Two years of assisted fertilization by partial zona dissection in male factor infertility patients.

OBJECTIVE: To assess partial zona dissection in our routine IVF-ET program over a 2-year period. DESIGN: Partial zona dissection before insemination on the day of oocyte collection or 24 hours after unsuccessful conventional IVF. In a subgroup of patients, oocytes were randomized to either partial zona dissection before insemination or IVF. SETTING: University infertility clinic. PATIENTS: Couples who suffered principally from male factor infertility or who had failed fertilization previously. INTERVENTIONS: Micromanipulation of oocytes with partial zona dissection. MAIN OUTCOME MEASURES: Comparison of fertilization rate, embryo morphology, and implantation rate between partial zona dissection inseminated oocytes and conventional IVF inseminated oocytes (controls). RESULTS: Five pregnancies were established in 199 patients. The incidence of polyspermy was significantly higher in the partial zona dissection group than in conventional IVF (4.8% versus 1.3%). There were no significant differences in the remaining parameters. The fertilization rate of partial zona dissection and reinsemination was significantly higher than conventional IVF insemination (13.6% versus 4.5%) but similar to the rate obtained when partial zona dissection was applied before insemination (13.6% versus 15.7%). CONCLUSIONS: Oocytes treated by partial zona dissection did not exhibit a greater fertilization rate than conventional IVF inseminated oocytes. Partial zona dissection may not be a useful technique for treating severe male factor infertility.

Adult↗