AN UPDATE IN AORTIC VALVE INTERVENTION AND EARLY DISCHARGE

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Ulster Med J 2017;86(3):213-214
Game Changers
AN UPDATE IN AORTIC VALVE INTERVENTION
AND EARLY DISCHARGE
Dr H Douglas, Dr M Spence
Department of Cardiology, Royal Victoria Hospital, Belfast,
BT12 6BA
Severe aortic stenosis is common and carries signicant
morbidity and mortality in an ever-growing elderly
population.
It is now fteen years since the advent of Transcatheter Aortic
Valve Implantation (TAVI). The rst ever case was performed
in 2002.1 Since then data from randomised controlled trials
supporting favourable outcomes with TAVI for patients
in whom surgical aortic valve replacement is considered
high risk have led to its inclusion in the latest International
guidelines for management of valvular heart disease2.
The TAVI programme at the Royal Victoria Hospital was
commenced in 2008. Over 700 cases have been performed
to date. All cases are considered at our regional heart team
meeting (comprising a minimum of general cardiologist,
interventional cardiologist and cardiac surgeons) and
implementation of our early discharge pathway in 2013 has
already shown locally that in a cohort of carefully selected
patients next day and even same day discharge can be safely
facilitated3. Currently, cases from Belfast are included in
ongoing international registry work around the feasibility and
safety of early discharge4.
The TAVI programme continues to thrive, providing patients
evaluated by our heart team with a transcatheter solution with
short recovery time, reduced length of stay in hospital and
good outcomes.
1. Cribier A et al. Percutaneous transcatheter implantation of an
aortic valve prosthesis for calcic aortic stenosis: rst human case
description. Circulation. 2002; 106: 3006–3008
2. Nishimura RA et al. “2014 AHA/ACC Guideline for the management of
patients with valvular heart disease.”, J Am Coll Cardiol. 2014; 63(22):
e57-e185.
3. Noad RL et al. Pathway to earlier discharge following TAVI: Assessment
of safety and resource utilization. Catheter Cardiovasc Interv. 2016;
87(1):134-42.
4. https://clinicaltrials.gov/ct2/show/NCT02404467 (Downloaded
05/07/2017).
SENTINEL BIOPSY IN VULVAL CANCER –
ESTABLISHING A REGIONAL SERVICE IN
NORTHERN IRELAND
Dr F McCloskey,Dr T Lynch, Dr H Nagar, Dr E Murtagh
Departments of Radiology, Nuclear Medicine and
Gynaecology, Belfast City Hospital, BT9 7AB
Sentinel node biopsy has an established role in the
management of breast cancer and an evolving role in
melanoma management. It now also plays a key part in the
management of selected vulval cancers.1+2
It was introduced to Northern Ireland in 2015 and to date
20 patients with vulval cancer, ranging from FIGO stage
1b-3c, have received sentinel node localisation, using a peri-
tumoural injection of Tecnetium-99 radiolabelled nanocolloid.
The sentinel nodes were identied using a GE SPECT CT
gamma camera system. In theatre, nodes are located using
a hand-held detector, localising the most proximal draining
node (sentinel) from the tumour. 90% of sentinel node
biopsies were negative for disease. The 2 biopsy-positive
patients were of a higher FIGO stage, they underwent groin
node dissection and remain disease free.
The GROINSS-V study found that 1-5 % of vulval cancers
will metastasise to non-sentinel lymph nodes. This was
reected in our regional experience, with one biopsy-negative
patient presenting with metastatic disease within 1 year.3 This
should be interpreted in the context of a 10-15% recurrence
rate in vulval cancer overall.
Careful patient selection in accordance with local guidelines
and patient counselling preoperatively is of utmost
importance. Implementation of this technique has led to a
dramatic reduction in rates of groin node dissection with its
associated morbidity.
1. Covens et al. Sentinel node biopsy in vulvar cancer: Systemic review,
meta-analysis and guideline recommendations. Gyneacologic Oncology,
2015; 137(2): 351-61
2. Guidelines for the diagnosis and management of vulval carcinoma,
RCOG guidelines, May 2014.
3. Oonk MH et al. Size of sentinel-node metastasis and chances of non-
sentinel-node involvement and survival in early stage vulvar cancer:
results from GROINSS-V, a multicentre observational study. Lancet
2010; 11(7): 646-52.
IMMUNOTHERAPY FOR LUNG CANCER – A
GAMECHANGER!
Dr GM Walls, Dr GG Hanna
Department of Oncology, North West Cancer Centre,
Altnagelvin and Belfast City Hospital
Cancer evades the ability of the immune system by turning on
cell surface proteins which turn off immune-surveillance cells
such as T-helper cells1. Immunotherapy treatments such as the
immune checkpoint inhibitors overcome cancer’s ability to
switch off the immune response to altered cells. Randomised
trials studying immunotherapy have demonstrated a patient
benet across a number of disease sites, in both curative and
non-curative settings.
Pembrolizumab, a monoclonal antibody for the PD-1 receptor
(B cells and T cells), has been NICE-approved in 2017
for the treatment of metastatic non-small-cell lung cancer
(NSCLC) in second-line therapy and is available via the