[Recurrent acral lentigous melanoma successfully treated with Mohs' micrographic surgery. Case report and review of the literature]. / Recidív acralis lentiginosus melanoma sikeres eltávolítása Mohs-féle mikrográfikus sebészi technikával. Esetismertetés és irodalmi áttekintés.

Mohs' micrographic surgery is an approach to selected skin cancer removal that aims to achieve the best prospect of total tumor excision simultaneously with maximal functional and cosmetic preservation. The advantage of the technique is that 100% of the surgical margin of the specimen, including the periphery and deep surface, can be examined intraoperatively by horizontally oriented frozen sections. This method offers cure rates significantly higher than conventional excision or other modalities. Mohs' micrographic surgery is the method of choice for removal of large, recurrent or incompletely excised skin cancers or for tumors located in functional and aesthetic relevant anatomic regions. The authors present a case of a 75-year-old man with a second time recurrent plantar invasive malignant melanoma successfully treated with Mohs' micrographic surgery technique and an immediate reconstruction using split-thickness skin graft.

[Long-term experience with therapy of a female patient with Gardner's syndrome, first presenting with extra-abdominal desmoid tumor, and review of the literature]. / Extraabdominalis desmoid tumorral megjeleno Gardner-syndromás beteg kezelésével szerzett hosszú távú tapasztalataink és irodalmi áttekintés.

Gardner's syndrome is a clinical subgroup of familial adenomatous polyposis, an autosomal dominant disease. It is characterized by gastrointestinal polyps and extra-intestinal manifestations including multiple osteomas, skin and soft tissue tumours. Aggressive desmoid tumours can be very difficult to manage in patients with Gardner's syndrome. We present a case of a 17-year-old female who presented with an aggressive desmoid tumor arising of the lumbar area as part of her Gardner's syndrome. She was treated with surgery, nonsteroidal anti-inflammatory drugs, tamoxifen and radiotherapy, and was followed up for 80 months. We conclude that desmoid tumors can precede gastrointestinal manifestations of familial adenomatous polyposis or Gardner's syndrome. Such patients should be evaluated with genetic testing followed by colonoscopy. Desmoid tumours should be managed in a multidisciplinary setting, as well.

[Surgical treatment options of metastatic tumours in the gastrointestinal tract (stomach, small and large bowel)]. / A tápcsatorna (gyomor, vékonybél, vastagbél) másodlagos daganatainak sebészete.

Metastatic tumours in the gastrointestinal tract are infrequent findings and usually represent advanced disease at the time of their diagnosis. In these cases, radical surgical resection is rarely possible due to dissemination, but palliative surgery can be relatively effective. Operative treatment can be indicated as a life saving measure in patients with gastrointestinal bleeding, perforation or obstruction. Radical resection of metastases may prolong survival, if R0 resection is achieved. In these disease free patients, the surgical treatment should be tailored to the primary tumour and combined with neoadjuvant or adjuvant therapy. 1053 gastrointestinal tumours were treated surgically by the authors between 01.01.2000. and 31.12.2005. Of those, secondary tumours were found in 24 cases in the gastrointestinal tract (11 in the stomach, nine in the small bowel and four in the large bowel). The authors summarize their experience and review the relevant literature.

[Rectum carcinomas treated with Kraske procedure in elderly patients]. / Kraske-amputációval kezelt rectumcarcinomák idoskorú betegeken.

Kraske procedure is an option that can be chosen to treat rectal tumours in elderly patients with multiple co-morbidities, in order to minimize complications and stress caused by surgery. In the past six years, 382 rectal resections were performed in our department: 154 abdominoperineal rectum resections, 219 anterior rectum resections and 9 Kraske procedures in high anaesthetic risk patients. Kraske resection was applied for mid- and lower third rectal cancers, providing a short term survival for more than half of these patients. The authors discuss their experience with the Kraske procedure.

[Histologic response after neoadjuvant therapy in rectal adenocarcinoma: own experience and review of the literature]. / Rectumcarcinomák neoadjuváns kezelést követo szövettani regressziójának vizsgálata: saját tapasztalatok és irodalmi áttekintés.

BACKGROUND: Neoadjuvant therapy has improved outcomes for patients with locally advanced rectal cancer. AIM AUTHORS: We studied the degree of histopathological regression after radiotherapy regimens commonly used in their clinical practice, and its effect on the pathology of by clinically founded T3-T4 rectal cancer. PATIENT AND METHODS: A total of 57 patients were investigated who underwent neoadjuvant radiotherapy or chemoradiotherapy--commonly used at our institute--for biopsy proven primary mid or lower third rectum adenocarcinoma between January and December 2004. The standard surgical treatment was anterior resection sec Dixon, Lloyd-Davies--and Hartmann's procedure, all with total mesorectal excision. RESULTS: The surgical specimens were examined by selected pathologists and a modified pathologic staging system the Rectal Cancer Regression Grade (RCRG) was used. (I) "good" response (n=12, 21%), (II) "median" response (n=25, 44%), (III) "poor" response (n=20, 35%). Significant tumor regression (RCRG I-II.) was seen in 37 patients (65%). Six patients (10.5%) have had complete pathological regression and 6 patients (10.5%) have had only microscopic foci of adenocarcinoma. CONCLUSION: Comparing of pretreatment and pathologic staging revealed that the depth of invasion was significantly downstaged. The authors also reviewed the literature of neoadjuvant therapy, total mesorectal excision, prognostic and predictive factors of rectal cancer.

[The role of sentinel lymph node biopsy in breast cancer non-invading-duct]. / Az orszemnyirokcsomó-biopszia jelentosége nem invazív duktális emlorákban.

INTRODUCTION AND AIMS: The clinical significance of sentinel lymph node biopsy for staging patients with ductal carcinoma in situ has not yet been solved. Determining the role of this method for the treatment of in situ ductal carcinoma has been the aim of this study. PATIENTS AND METHOD: Dual agent guided sentinel lymph node biopsy with preoperative lymphoscintigraphy was performed on 36 patients with breast ductal carcinoma in situ from January 2001 to March 2004 at the Department of General and Thoracic Surgery, National Institute of Oncology, Budapest. Completion axillary lymph node dissection was not performed routinely. The sentinel lymph nodes were histologically examined at 0.5-1 mm levels with routine hematoxylin and eosin staining. RESULTS: One patient has been excluded from the final analysis because of contralateral invasive breast cancer and simultaneous local recurrence in her medical history. Micro- or submicrometastases were found in 2 patients. If our patient number is completed with the 5 patients operated on for ductal carcinoma in situ during the period of our feasibility study (from December 1997 to March 2000) then the rate of patients with positive sentinel lymph node(s) will be 5% (2/40). All metastases were less than 2 mm in size. Metastases were found only in patients with high risk, extended ductal carcinoma in situ who finally underwent mastectomy. Completion axillary lymphadenectomy has not been performed even for patients with positive sentinel lymph node and no regional recurrence has yet been observed. DISCUSSION AND CONCLUSIONS: Our results corresponds well to the international ones. Performing sentinel lymph node biopsy for ductal carcinoma in situ of the breast is not recommended on the basis of the international and our own experiences. Sentinel lymph node biopsy is essential for patients undergoing mastectomy. In other cases when preoperative diagnostic studies do not verify invasion unequivocally we advise to perform sentinel lymph node biopsy (if necessary) after the final histological result of the excised breast specimen.

[The feasibility and the role of sentinel lymph node biopsy after neoadjuvant chemotherapy in breast cancer]. / Az ôrszemnyirokcsomó-biopszia alkalmazhatósága és jelentôsége neoadjuváns kemoterápia után emlôrákban.

INTRODUCTION AND AIMS: The feasibility, accuracy and clinical significance of sentinel lymph node biopsy for patients with breast cancer after neoadjuvant chemotherapy has not yet been determined. The aim of this study was to investigate these questions. PATIENTS AND METHOD: Dual agent-guided sentinel lymph node biopsy with preoperative lymphoscintigraphy was performed on 17 breast cancer patients after neoadjuvant chemotherapy at the Department of General and Thoracic Surgery, National Institute of Oncology, Budapest, from April 2004 to August 2005. Patients with clinically lymph node-negative breast cancer less than 3 cm in size after neoadjuvant chemotherapy were enrolled in the study. RESULTS: Lymphoscintigraphy showed no axillary lymphatic drainage in 7 patients (41%), and no sentinel lymph node could be identified during surgery in these patients. Axillary lymph nodes were histologically positive in 6 (86%) out of these 7 patients. Sentinel lymph node biopsy was successful in 10 patients (59%), and in 8 (80%) of them the sentinel lymph node proved to be positive pathologically. False negative sentinel lymph node biopsy did not occur. Axillary lymph node status was histologically positive in 14 (82%) out of the 17 patients. The predictable value of the clinical examination of the axilla after neoadjuvant chemotherapy, for the histological nodal status, was very low. DISCUSSION AND CONCLUSIONS: Our sentinel lymph node identification rate is lower than the published average in the literature. This difference can be explained by the differences in the indication for neoadjuvant chemotherapy. Our false negative rate (0%) is, however, significantly better than that of others. On the basis of international experiences sentinel lymph node biopsy after neoadjuvant chemotherapy is technically feasible, but its accuracy is not satisfactory and its clinical significance has not yet been determined. Our success rate is specifically low, which cannot be explained by the lack of practice. Taking the histologically very high axillary positive rate into consideration, sentinel lymph node biopsy has no clinical role in our practice after neoadjuvant chemotherapy.

[Cytoreductive surgery and intraperitoneal hyperthermic chemoperfusion for peritoneal carcinomatosis caused by recurrent inflammatory myofibroblastic sarcoma: a case report and review of the literature]. / Peritonealis carcinomatosist okozó recidív inflammatoricus myofibroblastos sarcoma miatt végzett citoreduktív sebészi beavatkozás es intraoperatív intraperitonealis kemohipertermia. Irodalmi attekintés es esetismertetés.

Peritoneal carcinomatosis is a fatal diagnosis, associated with poor prognosis and quality of life. Survival is usually estimated in month. Traditionally surgery for peritoneal carcinomatosis was indicated only for palliative effort. Advances in tumour biology, cytoreductive surgery and pharmacology have improved the approach for this condition. An aggressive combined approach to peritoneal surface malignancy involves peritonectomy and intraperitoneal perioperative hyperthermic chemotherapy. Cytoreductive surgery reduces carcinomatosis to microscopic residual disease so that intraperitoneal hyperthermic chemotherapy is able to eradicate cancer. Hyperthermic chemotherapy enhances the cytotoxicity of the drugs and increases their penetration into the cancerous tissue. Careful patient selection is crucial for this multimodality approach. Quantitative prognostic indicators are useful in the assessment of outcome, like peritoneal cancer index and completeness of cytoreduction score. Cytoreductive surgery combined with intraperitoneal hyperthermic chemotherapy improves survival but is associated with significant morbidity and mortality. This review is based on a case report of a 22-year-old female patient who had peritoneal carcinomatosis of inflammatory myofibroblastic sarcoma and was treated by cytoreductive surgery and intraperitoneal hyperthermic chemotherapy at our department.

[Leiomyosarcoma of the oesophagus: a case report]. / Nyelocso leiomyosarcomákról, egy operált esetünk kapcsán.

Authors treated a oesophageal sarcoma in a 46 year old female patient in July 1999. The tumor caused retrosternal pain and weight loss but did not disturb swallowing. After resecting the tumor, an intrathoracic oesophago-gastrostomy was performed. On the 18th postoperative day the patient went home without any complaints. Histologically the tumor proved to be a leiomyosarcoma. The patient has had no complaints in the past 6 years. On account of this case report the authors review the literature on this rare disease.

[Administration of clexane 4000 U/0.4 ml (40 mg) for preventing venous thromboembolic complications in patients undergoing surgery for malignant tumors. A follow-up study]. / A Clexane 4000 E/0.4 ml (40 mg) injekció alkalmazásának nyomonkövetése vénás thromboemboliás szövodmény profilaxisa során onkológiai mutéten átesett bete- gek esetében.

It has been evident since the first publication by Armand Trousseau (1865) that there is correlation between venous thromboembolism (VTE) and malignant tumors. This correlation has also been shown by recent studies. In patients with malignant tumors not only the incidence of VTE is higher but the course of VTE is more severe and relapses are more frequent. The procedures applied for the management of tumors (surgery, chemotherapy, radiotherapy, tamoxifen, central venous catheters) also increase the risk of VTE. It is generally accepted in Europe and in the U.S.A. (and also this constitutes the basis of the Hungarian guidelines) to group surgical patients by the risk of VTE by taking into account the characteristics of both the patients and the procedures. Recommendations also agree that for patients with medium or higher risk pharmacological prophylaxis is needed. Heparin or low molecular weight heparins in risk dependent doses and duration are administered most frequently. According to the recommendation of the American College of Chest Physicians (ACCP) patients with malignant tumors should receive thromboprophylaxis in accordance with their actual risk category and independent of the treatment they are receiving (surgery or chemotherapy). In a placebo controlled study with prolonged pharmacological thromboprophylaxis for patients with operated malignancies 60% VTE risk reduction could be reached and this risk reduction could also been observed after 3 months while the incidence of hemorrhagic complications was not significantly increased. Recent guidelines recommend 4 week long prophylaxis for patients with malignancies.

[Experience with radiofrequency ablation in the treatment of unresectable pelvic recurrence of rectal cancer]. / A radiofrekvenciás tumorablatió alkalmazásának lehetóségei recidív, kismedencei, irreszekábilis carcinomák kezelésében.

More than half of colorectal cancers are located in the rectum, and the number of such cancers is increasing. In Hungary colorectal cancers are diagnosed predominantly in advanced stages. In the last five years 736 patients with colorectal cancer were operated on at our Department, with the following stage distribution: Dukes A 10%, BI 10%, B2 31%, C 36% and D 13%. The local recurrence rate is decreasing since the introduction of total mesorectal excision and preoperative radiation. Effective treatment options are however poor for unresectable pelvic recurrences. Chemo- and radiotherapy have severe limitations in this advanced stage cancer. In recent years there are a few publications on the minimal-invasive radiofrequency tumour ablation (RFTA) technique, which is an effective treatment for primary and metastatic liver carcinomas and is a new palliative for the local treatment of pelvic recurrence. The aim of this study was to assess the response to treatment using ultrasound-guided radiofrequency ablation in two patients with unresectable pelvic recurrent rectal cancer.

[The similarities between the mechanism of wound healing and tumor development--literature review on the occasion of a patient with colonic adenocarcinoma metastasis in a dog-bite wound]. / A sebgyógyulás és a tumorprogresszió mechanizmusának közös lépései. Irodalmi áttekintés egy kutyaharapás sebében kialakult colonadenocarcinoma metasztázis esete kapcsán.

For more than a century, the role of wound healing in the growth of tumours has been implied based on observations in experimental and clinical studies. In the recent 10-15 years processes such as cell adhesion, angiogenesis, metastatic cascade and growth factors (fe: EGF, TGF-alpha, TGF-beta, IGF-1, IGF-II, PDGF) have been identified to play key roles in different stages of wound healing as well as in tumor progression. Experimental and clinical studies have established that wound healing creates a suitable environment favouring tumour growth and metastatic potential. Based on these observations, the clinical relevance of surgical procedures comes up, may playing a role in tumor recurrence after primary resection for cancer. This makes the opportunity of the development of completely new targeted approaches (antiangiogenic therapy, dormancy therapy) for the treatment of cancer. This review article is based on a case report of a 63-year-old female patient who had colonic adenocarcinoma metastasis of the hand after biting by a dog.

Subareolar injection of radioactive colloid for sentinel lymph node identification in breast cancer patients.

Sentinel lymph node biopsy (SLNB) is becoming the standard for staging the axilla in breast cancer patients in many institutions. The best method of injection is still questionable. The purpose of this study was to compare the results of SLNB using the peritumoral or the subareolar injection site. Between December 1997 and March 2000, we performed 100 SLNBs. Technecium-labeled colloidal human serum albumin was injected peritumorally (Group A, 31 patients; Group B, 31 patients) or subareolarly (Group C, 38 patients). Patent blue dye was given periareolarly (Group A) or peritumorally (Groups B and C). Preoperative lymphoscintigraphy was performed in all patients. SLNB was successful in 94 patients (94%). The identification rate improved from 80 per cent (first 25 patients) to 99 per cent (last 75). The subareolar injection of the colloid did not adversely influence the results of SLNB compared with the peritumoral injection (identification rate, 100% vs 97%; false negative rate, 6% vs 14%). The subareolar injection of colloid is a simple and at least as accurate technique as the peritumoral one. This technique can also improve the identification rate of SLNB for breast cancer patients.

[Different histological findings in two specimens from pulmonary metastasectomy in the same patient]. / Tüdómetastasectomia során eltávolított több góc különbözó szöveti szerkezettel.

INTRODUCTION: Out of the 3310 thoracic surgical procedures performed between 1980 and 2000 at the Department of Surgery of the National Institute of Oncology in Budapest, 258 were pulmonary metastasectomies involving 236 patients. Primary tumors were the following in order of decreasing frequency: testicular cancer, colorectal cancer, renal cancer, soft tissue tumor, breast cancer and others. METHODS: In the present study the authors report two patients with multiple pulmonary metastases. The primary tumor was non-seminoma testicular cancer in case one and endometrial cancer in case two (previously treated for thyroid cancer). Histological examination of resected specimens revealed unsuspected focal inactive tuberculosis in the first case and medullary thyroid cancer in the second. CONCLUSIONS: In the reported two cases the following conditions of metastasectomy were given: 1. satisfactory cardiopulmonary status, 2. possibility of surgical radicality, 3. locoregional disease control, 4. prior chemotherapy in chemosensitive tumor (case one). The generally accepted condition of metastasectomy-lack of clinically manifest disease in other distant organs--was not fulfilled in case two (suspected liver metastases).

Heterozygote deficiency in thymidylate synthase enhancer region polymorphism genotype distribution in Hungarian colorectal cancer patients.

Thymidylate synthase (TS) gene polymorphisms are important as prognostic factors in cancer chemotherapy, but recent results describe that the TS enhancer region (TSER) polymorphic genotypes may also modulate risk for malignancies. Two functionally important and ethnically diverse polymorphisms are present on the TS transcript, TSER, a repeat polymorphism (2 or 3 repeats; 2R, 3R) affecting TS expression, and a 6 bp ins/del polymorphism on the 3' UTR (position TS1494, del6 or ins6), which may influence mRNA stability. Hungarian population has one of the highest colorectal cancer (CRC) mortality rates in Europe, and several elevated dietary risk factors affect a large part of the population. In our study (99 primary CRC cases), population analysis of the patient group genotype frequencies revealed a departure from the Hardy-Weinberg equilibrium and significant heterozygote deficiency (p < 0.05) at the TSER locus. Despite the strong linkage between the 2 polymorphic loci, case TS1494del genotype frequencies were normally distributed, as well as the genotype frequencies of the healthy control population (n = 102), at both loci. Case-control comparison demonstrated a lower relative risk of TSER heterozygotes (OR = 0.47; CI = 0.27-0.83; p = 0.008) and a possible higher prevalence of the 3R3R&ins6/del6 in the CRC group. The observation that heterozygotes are those less susceptible for CRC in the Hungarian population may support the possibility of 2 different pathways in which TS may play a role in colorectal carcinogenesis, probably nutrient (or folate)-dependently. The lack of similar genotype effect seen with TS1494del polymorphism and the increased presence of one genotype combination (3R3R&ins6/del6) in the patient group suggest a possible TS haplotype effect influencing CRC risk.

[Change of attitude in the surgical treatment of lung metastases]. / Szemléletünk alakulása a tüdoáttétek sebészi kezelésében.

There has been no major change in surgical technique of lung metastasectomy till the last decades. In the latest years the variety of diagnostic tools and methods grew significantly. There are more chemotherapy possibilities and more palliative surgical techniques (VATS, ITP, RFTA) to treat certain types of lung metastases. Based on data of the International Registry of Lung Metastases the most important prognostic factor for metastasectomy is how radical the procedure was (clear resection margin). The more aggressive approach (even pneumonectomy for R0 resection) is becoming more popular.

[Clinical significance of bone marrow micrometastases of breast tumors]. / Az emlótumor csontveló mikrometasztázisának klinikai jelentósége.

Detection of hematogenous micrometastases (MM) in bone marrow might play important role in determining stage, prognosis and multimodality treatment strategy of invasive breast cancer. Therefore we studied the presence of occult tumor cells in bone marrow of outpatients operated on with breast cancer by detecting cytokeratin 20 mRNA using the RT-PCR method. In 182 primary breast cancer patients 54 (29.7%) micrometastases were detected while in 128 patients (70.3%) no tumor cells were found in the bone marrow aspirates. Correlation of MM with HER-2, c-met, nm23, p53 and estrogen receptor (ER) were studied. The presence of MM was correlated with HER-2, nm23- and p53 positivity and with low frequency of nm23 and ER. The possible role of bone marrow MM in selecting node negative breast cancer patients for adjuvant therapy should be tested in randomized prospective clinical trials.

Clinical significance of sentinel lymph node involvement in malignant melanoma.

In the period 1997-2002, sentinel lymph node (SLN) surgery was performed on 179 primary skin melanoma patients, one to two months after the removal of the primary. Staining with patent blue was combined with an isotope technique. Histological evaluation of the sentinel lymph nodes was performed in serial sections. Immunohistochemical detection of S100, HMB-45, or Melan-A was used in the case of suspected micrometastases. Demonstration of positive sentinel lymph node was followed, preferably within 2-3 weeks, by regional block dissection. In these cases interferon-a2 in low doses or BCG immune therapy were applied as adjuvant therapy. Bimonthly follow-up of the patients included physical examination and the use of imaging techniques as specified in the melanoma protocol. Sentinel lymph node surgery was successful in 177/179 cases (98%). Positive sentinel lymph node was identified in 26/177 patients (14.7%). In node positive patients the thickness of the primary tumour was significantly greater than that of node negative ones (p<0.00001). Patients with micrometastases had significantly poorer symptom-free and overall survival by the Mantel-Cox test than those of the other group (p=0.0001 and p=0.0007 respectively). Comparison of the tumor thickness and positive SLN by discriminance analysis, yielded 81.7% and 79.9%, respectively for correct classification rates. Based on our study and data from the literature, we suggest SLN-positivity as equally strong poor prognosis factor for skin melanoma as the tumor thickness.

[Radioguided excision of non-palpable breast lesions with simultaneous sentinel lymph node biopsy]. / Nem tapintható emlóelváltozások radioizotópos jelöléses eltávolítása egyidejú órszem nyirokcsomó-biopsziával.

As a result of mammographic screening nonpalpable breast lesions are found with increasing frequency. The surgical management of these lesions presents two main problems: (1) How to localize the lesion pre- and intraoperatively; (2) What should be the extension of the axillary dissection for malignant lesions. This study is aimed to evaluate the technical feasibility of radioguided excision of nonpalpable breast lesions and the possibility of performing simultaneous sentinel lymph node biopsy for malignant lesions. Radioguided breast excisions have been performed in our Department since November 2000. The basis of this method is that radioisotope labelled colloid is injected into the lesion under stereo tactic or sonographic guidance. A gamma-probe is used intraoperatively to locate the lesion and guide its excision. Dual agent guided technique is used for sentinel lymph node biopsy. Radioguided breast excision was performed on 85 patients (93 lesion) till February 2002. The localization and excision were successful in 84 patients (92 lesions) (99%). Multifocal lesions were successfully localized and excised in 7 patients. There were 61 parenchyma lesions (66%) and 31 microcalcifications (34%). Localization was performed under sonographic guidance in 44 patients (52%) and under stereotactic guidance in 40 patients (48%). There were 25 benign (27%) and 67 malignant (73%) lesions. Second surgical procedure (mastectomy) was needed in 4 patients (6.5%) because of histologically incomplete excision. Sentinel lymph node biopsy was performed in 50 patients. The biopsy was successful in 45 patients (90%). The sentinel lymph node was histologically positive in 2 patients (4.4%). Radioguided localization with the intraoperative use of a gamma-probe is an easy, rapid and highly accurate technique for removing nonpalpable breast lesions and allows simultaneous sentinel lymph node biopsy for malignant lesions.