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Ulster Med J 2017;86(3):213-214
Game Changers
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
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):
3. Noad RL et al. Pathway to earlier discharge following TAVI: Assessment
of safety and resource utilization. Catheter Cardiovasc Interv. 2016;
4. (Downloaded
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.
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
ResearchGate has not been able to resolve any citations for this publication.
IntroductionThere is considerable variability within the population of patients treated with transcatheter aortic valve implantation (TAVI), the procedural approach and time to discharge. In Belfast, from the commencement of our program, our approach has been to perform TAVI by the least invasive approach, where feasible, utilizing a percutaneous transfemoral route and local anesthetic. By analyzing our Belfast TAVI database we identified factors that predicted shorter admission times without impacting adversely on patient safety. Following this, we developed an early discharge pathway. The aim of this current study was to perform a prospective analysis of outcomes in our unit since implementation of this pathway assessing discharge time, mortality, serious adverse events, readmission, and resource implications for patients according to time to discharge.Methods Consecutive patients who underwent TAVI and were successfully discharged from 2013 to 2014 over a 14 month period were included, and analyzed according to time to discharge. Baseline and procedural characteristics, mortality, serious adverse events, readmission, and cost were assessed.ResultsIn total 120 patients were included, 26 (21.7%) were discharged the same/next day, 39 (32.5%) early (>1–4 days), and 55 (45.8%) discharged in the late group. There was no significant difference in baseline or preprocedural characteristics. The incidence of complications was low, and there was no difference in 30-day mortality (P = 0.167) or readmission rates between groups (P = 0.952). Resource analysis revealed the late discharge group cost £3,091.6 more per patient per TAVI than same/next day discharge group.Conclusion Same/next day discharge can be performed safely in appropriately selected patients. Although this will be achieved in a minority of patients (21.7% in this study using an early discharge pathway) it has potential for resource and cost savings. © 2015 Wiley Periodicals, Inc.
Traditionally, treatment for early stage vulvar cancer has included removal of the primary tumour and inguinofemoral lymph node dissection (IFLD). Sentinel lymph node biopsy (SLNB) has been proposed as an alternative to IFLD for early stage vulvar cancer patients. The aim of this project was to systematically review and assess the potential for harms and benefits with the SLNB procedure in order to make recommendations regarding the adoption of the procedure, selection of patients and appropriate technique and procedures. A working group with expertise in gynecologic oncology and health research methodology was formed to lead the systematic review and process of guideline development. MEDLINE, Embase and The Cochrane Database of Systematic Reviews were searched for relevant articles published up to September 2014. Outcomes of interest included detection, false negative, complication and recurrence rates and indicators related to pathology. Meta-analyses were conducted where appropriate. The evidence-base of a previously published health technology assessment was adopted. An additional search to update the HTA's evidence base located three systematic reviews, and eleven individual studies that met the inclusion criteria. According to a meta-analysis, per groin detection rate for SLNB using radiocolloid tracer and blue dye was 87% [82-92]. The false negative rate with SLNB was 6.4% [4.4-8.8], and the recurrence rates with SLNB and IFLD were 2.8% [1.5-4.4] and 1.4% [0.5-2.6], respectively. An internal and external review process elicited concerns about the necessity of performing this procedure in an appropriate organizational context. SLNB is recommended for women with unifocal tumours<4cm and clinically non-suspicious nodes in the groin, provided that specific infrastructure and human resource needs are met. Some recommendations for appropriate techniques and procedures are also provided. Copyright © 2015. Published by Elsevier Inc.
Currently, all patients with vulvar cancer with a positive sentinel node undergo inguinofemoral lymphadenectomy, irrespective of the size of sentinel-node metastases. Our study aimed to assess the association between size of sentinel-node metastasis and risk of metastases in non-sentinel nodes, and risk of disease-specific survival in early stage vulvar cancer. In the GROningen INternational Study on Sentinel nodes in Vulvar cancer (GROINSS-V), sentinel-node detection was done in patients with T1-T2 (<4 cm) squamous-cell vulvar cancer, followed by inguinofemoral lymphadenectomy if metastatic disease was identified in the sentinel node, either by routine examination or pathological ultrastaging. For the present study, sentinel nodes were independently reviewed by two pathologists. Metastatic disease was identified in one or more sentinel nodes in 135 (33%) of 403 patients, and 115 (85%) of these patients had inguinofemoral lymphadenectomy. The risk of non-sentinel-node metastases was higher when the sentinel node was found to be positive with routine pathology than with ultrastaging (23 of 85 groins vs three of 56 groins, p=0.001). For this study, 723 sentinel nodes in 260 patients (2.8 sentinel nodes per patient) were reviewed. The proportion of patients with non-sentinel-node metastases increased with size of sentinel-node metastasis: one of 24 patients with individual tumour cells had a non-sentinel-node metastasis; two of 19 with metastases 2 mm or smaller; two of 15 with metastases larger than 2 mm to 5 mm; and ten of 21 with metastases larger than 5 mm. Disease-specific survival for patients with sentinel-node metastases larger than 2 mm was lower than for those with sentinel-node metastases 2 mm or smaller (69.5%vs 94.4%, p=0.001). Our data show that the risk of non-sentinel-node metastases increases with size of sentinel-node metastasis. No size cutoff seems to exist below which chances of non-sentinel-node metastases are close to zero. Therefore, all patients with sentinel-node metastases should have additional groin treatment. The prognosis for patients with sentinel-node metastasis larger than 2 mm is poor, and novel treatment regimens should be explored for these patients.