Metastatic Clear Cell Renal Carcinoma Without Evidence of a Primary Renal Tumour Mimicking Advanced Stage of Malignant Lung Tumour.

BACKGROUND: Clear cell renal carcinoma (ccRC) accounts for 65-70% of renal carcinomas with peak occurrence at the 6th and 7th age decade, predominantly in males. At the time of diagnosis, especially pulmonary metastases can be found in one-third of patients. There have also been described as late metastases for several decades after nephrectomy. In our case report, clinical course indicated primary lung tumour. Histological differential diagnosis included malignant pleural mesothelioma, lung adenocarcinoma and squamous cell carcinoma with clear cell differentiation or primary clear cell adenocarcinoma of the lung. However, using immunohistochemistry, all these possible diagnoses were excluded. CASE REPORT: We present a case of 62-year old man with 3 months history of progressive dyspnea accompanied with a cough and recurrent pleural effusions. PET/CT scan revealed metastatic tumour spread with right-sided pleural thickening, multiple pulmonary tumour foci, mediastinal, cervical, abdominal para-aortic and pelvic lymph node involvement and skeletal metastasis. The patient died one day after administration of palliative chemotherapy. The autopsy showed the majority of changes in the right hemithorax, was caused by a diffuse yellowish, extremely tough tumour infiltrating parietal and visceral pleura with adhesions and obliteration of truncus pulmonalis. In left lung and both renal cortices we could see scant nodules, mimicking primary lung tumour metastasis. In close proximity to the left renal hilum we found unusual homogeneous white round to oval tissue of 80 × 86 × 72mm in diameter, with identical histological pattern. Extensive immunohistochemical profile (positivity of CK18, PAX8, vimentin, androgen receptor, napsin A; negativity of mesothelial markers, TTF-1, CK7, CK20, CDX-2, CD10, PSA, CK34B12 and PAS-D) was compatible with metastatic ccRC. CONCLUSION: We present an extremely rare case of morphologically verified metastatic ccRC without evidence of primary lesion in the kidneys. There is speculated the possibility of spontaneous regression of primary tumour. In our case, however, we cannot exclude the possibility of generalized primary tumour of ectopic kidney. This hypothesis is based on the finding of isolated tumour mass adjacent to left renal hilum.

Perfusion of a Kidney Graft From a Donor After Cardiac Death Based on Immediately Started Pulsatile Machine Perfusion-An Experimental Study on a Small Animal.

INTRODUCTION: There is still a lack of organs for kidney transplantation. The aim of our experimental animal study was to improve the quality of the kidney grafts from donors after cardiac death (DCD) using immediate start of machine perfusion instead of perfusion based on hydrostatic pressure. METHODS: Ten rabbits were used as an experimental model. In group A, 5 kidneys after ischemic injury were perfused in situ using hydrostatic pressure. In group B, 5 kidneys were perfused in situ using machine pulsatile perfusion. After nephrectomy kidney parenchyma was histologically analyzed. We have evaluated the maximum perfusion flow rate, temperature drop rate, and degree of parenchymal injury. RESULTS: The flow rate in the group of machine-perfused animals (group B) was significantly higher than in the control group (group A), and temperature was significantly decreased in group B (P < .001). Qualitative histopathologic evaluation of the perfusion quality of the grafts was statistically significant, again in favor of machine perfusion in group B (P = .005). DISCUSSION: According to our results, the immediate start of machine perfusion is a superior method of kidney graft preservation in DCDs. All observed modalities were superior in the group with machine perfusion compared with usual clinical practice.

Options to improve the quality of kidney grafts from expanded criteria donors experimental study.

INTRODUCTION: There is a worldwide discrepancy between the number of donors and the number of organs needed for transplantation, leading to certain expansion of criteria, resulting in acceptance of donor organs. This means that organs with worse parenchymal qualities may be harvested for transplantation. One possibility, how to ameliorate the quality of these organs, is to change the concept of their preservation during cold ischemia or even after sudden circulatory arrest, prior to the collection of the organ itself. The goal of our experimental study was to try to improve organ quality from these marginal donors. METHODS: In the first part of our experimental study, we tested retrograde oxygen persufflation (ROP) in preservation of ischemically damaged kidney grafts. In ten animals (domestic pig), we compared standard intra-arterial perfusion of the grafts using cooled perfusion solution (N=5), with a retrograde oxygen persufflation method (N=5). The main criterion for evaluation was the histopathological analysis of renal parenchyma after transplantation of the kidney graft. In the second part of our experimental study, again using an animal model of an ischemic kidney (laboratory rabbit), we compared machine perfusion of the kidney graft with routinely used perfusion by hydrostatic pressure. For evaluation, we added another two criteria - the volume of perfusate that flowed through the graft and the temperature drop during perfusion. RESULTS: In the first part of the study, we proved the ability of ROP to preserve and even ameliorate the quality of ischemically damaged kidney grafts. Results of histopathological analysis of samples taken during ROP were without statistically significant difference in comparison with those taken during standard intra-arterial perfusion. In the second part of the study, we observed a significant difference in maximal flow rate measured during perfusion of the kidney grafts, favoring mechanical perfusion over perfusion using hydrostatic pressure (p=0.004). The same situation was seen with the drop of temperature measured in the parenchyma of the grafts (p<0.001). Finally, histopathological evaluation of the renal parenchyma found better washing out of blood particles from the capillaries during mechanical perfusion (p=0.005). CONCLUSION: The presented results of our experimental studies establish that alternative methods of preservation during cold ischemia and before removal of kidney grafts from the donor may be beneficial for its function after transplantation. We believe that these methods may be suitable especially for so-called marginal grafts from extended criteria donors.Key words: transplantation donors after circulatory death controlled organ perfusion in situ perfusion retrograde oxygen persufflation.

[A new perspective on axillary dissection in situations of metastatic sentinel node]. / Nový pohled na exenteraci axily pri metastáze v sentinelové uzline.

INTRODUCTION: Breast cancer is the most common malignant disease in women and represents a worldwide problem. Up-to-date diagnostics methods, mammography screening and complex treatments have resulted in a substantial reduction of mortality rates. However, the incidence of the disease keeps growing constantly, although in a moderate way. The struggle against this disease has several levels, such as prevention, primary tumour therapy as well as the management of recurrent or generalized disease. Therefore, it is very significant to evaluate the prognosis on the basis of biological characteristics of the tumour and to determine the right individual therapy in each patient. AIM OF THE STUDY: Our aim was to determine a group of patients with malignant breast disease based on biological characteristics of the tumour who can be treated without axillary exenteration even with a metastasis in the sentinel lymph node, thereby reducing the morbidity associated with this surgery, without worsening the prognosis. METHOD: The research project lasted from June 2012 to June 2015. It was a prospective randomized study where the main investigated group consisted of women with primarily surgically treated mammary cancer undergoing sentinel lymph node biopsy (SNB) during their surgery. These patients were divided into three groups: group 1 - positive SNB without axillary exenteration (axillary dissection - AD); group 2 - positive SNB with AD; and group 3 - negative SNB. Group 4 consisted of patients with primarily performed AD. We investigated statistically significant prognostic factors of metastatic lymph nodes and early disease progression. The results were statistically processed and differences between individual groups were evaluated, determining prognostically usable biological characteristics of the tumour in connection with metastases in lymph nodes and progression-free survival. RESULTS: The study included 214 patients with breast cancer. No metastases of axillary lymph nodes were found in 136 patients (64%); on the other hand, 78 patients (36%) had positive axillary lymph nodes and included: 28 (13%) patients with a micrometastasis in the sentinel lymph node; 38 (17%) patients with 13 positive lymph nodes; 8 (4%) patients with 49 positive lymph nodes; and 4 (2%) patients had more than 10 metastatic lymph nodes. A statistically significant difference with respect to metastatic lymph node involvement was found for the tumour size, expression of oestrogen receptors, proliferative activity and grading. CONCLUSION: The following prognostic factors of metastatic lymph nodes and early disease progression were shown to be statistically significant: tumour size over 2 cm, negative expression of oestrogen receptors, tumours with moderate and high proliferative activity, and tumour grades G2 and G3. In the course of the three years of this study, no regional recurrence was found in axillary lymph nodes in any patient, and therefore, it clearly follows that the completion of axillary exenteration can be omitted in the case of tumour sizes below 2 cm, present expression of oestrogen receptors, low proliferative activity and grade 1 even if one or two positive sentinel lymph nodes are present, provided that adjuvant radiation therapy can be used. Also, axillary exenteration is not needed if a micrometastasis or isolated tumour cells are found in the sentinel lymph node.Key words: breast cancer - sentinel lymph node biopsy - axillary exenteration - prognostic factors.

Review of renal anastomosing hemangioma with focus on clinical and pathological aspects.

Renal anastomosing hemangiomas (RAH) has been recently proposed as a new entity. In this article, we summarize the clinicopathologic features of this tumor. RAH usually develops on a background of end-stage renal disease. Macroscopically, tumors are well-defined and their cut surface shows mahogany brown spongy tissue with epicenter in the renal medulla. Tumors are usually small, but larger lesions are reported. On microscopic examination, the tumor consists of sinusoid-like vascular channels lined by cuboidal endothelial cells with occasional hobnail-like appearance of endothelial cells closely mimicking splenic sinusoids. Eosinophilic hyaline globules may be present in the cytoplasm of neoplastic endothelial cells. Extramedullary hematopoiesis containing erythroid precursor and megakaryocytes may be present in the vascular lumens. Immunohistochemically, endothelial cells are positive for CD31 and CD34, but negative for D2-40, GLUT-1 and HHV8. The surrounding stroma around endothelial cells demonstrates positivity for  smooth muscle action. To date, there are no studies on molecular genetic aspects of RAH. This tumor is indolent based on site and size of the lesion, partial or nephrectomy is sufficient as a therapeutic modality.

Review of succinate dehydrogenase-deficient renal cell carcinoma with focus on clinical and pathobiological aspects.

Succinate dehydrogenase (SDH)-deficient renal cell carcinoma (RCC) was first identified in 2004 and has been integrated into the 2016 WHO classification of RCC. Succinate dehydrogenase (SDH) is an enzyme complex composed of four protein subunits (SDHA, SDHB, SDHC and SDHD). The tumor which presents this enzyme mutation accounts for 0.05 to 0.2% of all renal carcinomas. Multiple tumors may occur in approximately 30% of affected patients. SDHB-deficient RCC is the most frequent, and the tumor histologically consists of cuboidal cells with eosinophilic cytoplasm, vacuolization, flocculent intracytoplasmic inclusion and indistinct cell borders. Ultrastructurally, the tumor contains abundant mitochondria. Immunohistochemically, tumor cells are positive for SDHA, but negative for SDHB in SDHB-, SDHC- and SDHD-deficient RCCs. However, SDHA-deficient RCC shows negativity for both SDHA and SDHB. In molecular genetic analyses, a germline mutation in the SDHB, SDHC or SDHD gene (in keeping with most patients having germline mutations in an SDH gene) has been identified in patients with or without a family history of renal tumors, paraganglioma/pheochromocytoma or gastrointestinal stromal tumor. While most tumors are low grade, some tumors may behave in an aggressive fashion, particularly if they are high nuclear grade, and have coagulative necrosis or sarcomatoid differentiation.

[Castleman disease - unusual finding after operation of retroperitoneal tumor of young patient]. / Castlemanova choroba - neobvyklý nález pri operaci tumoru retroperitonea u mladého nemocného.

UNLABELLED: Castleman disease is rare diagnosis. It was first mentioned in literature in 1954 by doctor Castleman and Lown. It is rare sickness which primary affects lymfatic nodes. There are four histo-morfologic subtypes and two clinic manifestations (uni and mulicentric). Comon clinical picture is simple lymfadenopathy of neck, medistinal a retroperitonal lymfatic nodes. Signs of this disease are heterogenic and depend on histological subtype. Also prognosis depends on type of illness. It should take place as benign diagnosis (unicentric form) but also can be potencionally malignant form which shlould exacerbate to malignant lymfoproliferation (multicentric form). Authors present the case of 29 years old men with clinical manifestation (jundice, intermitent bowel obstruction) of lagre retroperitoneal tumor in subhepatal localization. The treatment was radical surgical extirpation, surgery was without complications. Definitive histological diagnosis was confirmed as hyaline-vascular type of Castleman disease. Because the patient´s clinical form was multicentric, he is now undergoing adjuvant oncological treatment. KEY WORDS: Castleman disease reproperitoneal tumor.

[Granulomatous inflammation in differential diagnosis of hepatobiliary malignancy]. / Granulomatózní zánety v diferenciální diagnostice malignit hepatobiliárního traktu - kazuistiky.

UNLABELLED: The authors present two case reports to demonstrate wide differential diagnosis of granulomatous disorders of the hepatobiliary tract. Isolated granulomatous disorders are very rare in this area. Differantial diagnosis includes infectious and systemic diseases or chemical irritation. Granulomas often immitate malignant tumors and the surgeon could be first to diagnose this disease during liver resection or cholecystectomy. KEY WORDS: granulomatous inflammation hepatic granuloma non-specific inflammation liver resection cholecystectomy.

[Avoidance of axillary lymph node dissection in breast cancer patients with metastatic sentinel node - a pilot study]. / Vynechání disekce axily u karcinomu prsu pri pozitivní sentinelové uzline - pilotní studie.

INTRODUCTION: Axillary lymph node dissection (ALND) is a standard procedure for locoregional control in metastatic sentinel lymph nodes (SN). A number of studies have provided evidence that avoiding ALND does not worsen the general prognosis. METHODS: A group of 249 female patients with sentinel lymph node biopsy was analysed retrospectively for a 3-year period. The patients were divided into two groups - with non-metastatic SN and with metastatic SN. In the metastatic SN group, the patients were further divided into a group with ALND and a group without ALND, and additional lymph nodes (non-sentinel) in ALND and oncological treatment were evaluated. The goal was to find out whether ALND and oncological treatment affect the disease-free interval (DFI) and overall survival (OS) in the group of patients with metastatic SN and to compare the results with the control group. The histopathology and biology of the primary tumour, its size and the number of metastatic SN were subsequently evaluated as the factors that may be useful for predicting metastatic non-sentinel lymph node positivity. RESULTS: There was a high risk of metastatic non-sentinel lymph nodes in the cases of metastatic SN (63%). Addition of ALND does not prolong either DFI or DFS without post-operative radiotherapy and systemic oncological treatment, both of which can provide a comparable length of DFI as well as DFS without ALND. Patients with metastatic SN with and without ALND had a DFI of 70 and 72 months, respectively, and a 5-year survival of 84% and 80%, respectively. Tumours over 2 cm, tumours with high proliferative activity and a high grade can be regarded as predictors of metastatic non-sentinel lymph nodes. CONCLUSION: In a small patient group it has been demonstrated that the avoidance of ALND in 1 or 2 metastatic SN, regardless of the prognostic factors, does not affect either DFI or DFS if adjuvant oncological treatment is administered. High-grade tumours, tumours with high proliferative activity and tumours larger than 2 cm carry a significantly higher risk of metastatic non-sentinel lymph nodes. Nowadays, the avoidance of ALND in metastatic SN is not a lege artis procedure; further large studies are needed to create scientific guidelines.Key words: metastatic sentinel lymph node - avoidance of axillary dissection - breast cancer.

Reduction of renal function during mechanical ventilation of healthy lungs in an animal biomodel.

OBJECTIVES: To identify factors involved in reno-pulmonary interactions during mechanical ventilation. MATERIALS AND METHODS: The study included a total of 25 domestic piglets. The animals were divided into three groups based on different strategies of ventilation. Group A; spontaneously breathing piglets; group B animals ventilated with tidal volume of 6 ml.kg-1 and group C with animals ventilated with tidal volume 10 ml.kg-1. Clinical monitoring and laboratory tests were performed for all groups at baseline and then at 1 hour and 12 hours for groups B and C. Ventilation indices, hemodynamics, urine output, creatinine clearance, glomerular filtration index, fractional excretion of sodium, free water clearance and tissue samples were recorded. The data obtained were statistically analysed. RESULTS: Lower creatinine clearance and renal indices were seen in group B (p < 0.05) and in group C (p < 0.001) at 1 hour, and a difference in urine output for group C (p < 0.01) compared to group A was observed. At 12 hours, there was a further reduction in creatinine clearance and renal indices for group B (p < 0.05) and group C (p < 0.01). The lung mechanics and hemodynamics were not significantly influenced. CONCLUSIONS: The study showed a causal relationship between renal dysfunction and positive pressure mechanical ventilation with respect to tidal volume and time (Tab. 4, Fig. 2, Ref. 17).

[Phyllodes breast tumors]. / Fyloidní nádory prsu.

INTRODUCTION: Phyllodes tumour is a breast tumour occurring very rarely. It accounts for only in 1% of all cases of breast tumour. The diagnosis of phyllodes tumours can be difficult in consideration of the small number of cases. Treatment of phyllodes tumours is always surgical. METHODS: In 2004-2013, we operated on twelve female patients with phyllodes tumours out of the total number of 1564 surgeries for breast tumours (0.8%) at the Department of Surgery at Teaching Hospital in Pilsen. We evaluated the age, the biological behaviour of the tumour depending on the tumour size and duration, the distant metastases, therapy and survival. RESULTS: The average age at the time of surgery was fifty years (2684), the duration of disease to the surgical solution ranged from one month to ten years. Tumour size was in the range of two to twenty-nine centimetres, tumours measuring less than five centimetres were always benign. Tumour excision for benign phyllodes tumour was performed seven times. Malignant phyllodes tumour was diagnosed five times with mastectomy performed in each case, and the axilla was exenterated in three cases where nodes were benign in each of them. In one case, mastectomy was followed by radiotherapy because the tumour reached the edge of the resected part; the other patients were only monitored. In two patients, tumour spreading into the lungs was diagnosed at five to ten months after breast surgery. One patient with generalized disease died, the other ones live with no local recurrence of this disease. Median survival is fifty-two months; the disease-free interval is fifty months. CONCLUSION: The results show that if phyllodes tumour is diagnosed in time, it is almost exclusively benign. If the case history is longer and the tumour is growing, the likelihood of malignancy increases. Surgical treatment is also sufficient in the case of malignant forms. The breast surgery does not need to be supplemented with exenteration of axilla.Key words: breast - phyllodes tumour.

[Sarcoma of the chest wall after radiotherapy for breast carcinoma - a case report]. / Sarkom hrudní steny po ozárení pro karcinom prsu kazuistika.

INTRODUCTION: Sarcoma occurring in soft tissues after radiotherapy is a rare complication of radiation treatment of tumours. It was most often described after treatment for breast cancer as well as for non-Hodgkin lymphoma and cervical carcinoma. The time interval between the radiation therapy and the development of the sarcoma can be very wide. Treatment demands radical surgical resection of the sarcoma with the edge of the resected tissue without tumour cells. In some cases, this is followed by chemotherapy or radiotherapy. The median survival time is 23 months, the longest survival being associated with sarcomas removed in a radical way. CASE REPORT: We present the case of a female patient with recurring leiomyosarcoma of the chest wall after radiotherapy for cancer of the right breast. In 2006, this 62-year-old patient was operated on to keep her right breast with axilla exenteration. After the surgery, hormonal therapy was followed by adjuvant radiotherapy of the right breast and the adjacent axilla. We used a linear accelerator and the total amount of radiation was 50 Gy (2 Gy fractionally once a day, five days a week). Four years after the operation, leiomyosarcoma was diagnosed in the pectoral muscle at the site where the tumour of the right breast had been excised. Between 2011 and 2013, a total of five operations of re-occurring sarcoma were performed - two excisions of the tumour, a mastectomy, rib resection and, at last, block resection of the chest wall. Adjuvant oncological treatment was not indicated. The patient, now being 69 years old, is still in a good physical and mental condition without any generalization of the disease. CONCLUSION: Sarcoma of the chest wall is a relatively rare consequence of radiotherapy for breast cancer. Sarcoma treatment involves radical surgical resection of the tumour whenever possible. The surgery is mostly followed by radiotherapy which, however, is impossible in a patient after breast-preserving surgery for carcinoma with radiotherapy. Chemotherapy is not very effective in sarcomas. Therefore, the operation needs to be performed by an experienced surgeon in a sufficiently radical way.

Review of renal tumors associated with Birt-Hogg-Dubé syndrome with focus on clinical and pathobiological aspects.

Birt-Hogg-Dubé syndrome (BHDS) is an autosomal dominant inherited disorder characterized by clinical features of skin lesions, pulmonary lesions and renal tumor. The gene responsible for this syndrome is located on chromosome 17p11.2 and designated as FLCN. In this article, we review renal tumors associated with BHDS with a focus on clinical and pathobiological aspects. Renal tumors often occur multifocally or bilaterally in the imaging analyses or gross examination. Histological examination of renal tumors includes a variety of subtypes such as hybrid oncocytic tumor, chromophobe renal cell carcinoma (RCC), oncocytoma, clear cell RCC and papillary RCC. The histologic discordance in multiple tumors seems to be characteristic of this syndrome. Oncocytosis is observed histologically in about half of the cases. Several investigations have elucidated that folliculin may be involved in the mammalian target of rapamycin (mTOR) pathway recently. Renal tumors composed of clear cells may behave in an aggressive fashion. However, renal tumors including hybrid oncocytic tumor, chromophobe RCC and oncocytoma behave mostly in an indolent fashion.

Review of tubulocystic carcinoma of the kidney with focus on clinical and pathobiological aspects.

Tubulocystic carcinoma of the kidney (TCK) is a recently established entity in renal neoplastic pathology. This review aims to give an overview of the clinical and pathobiological aspects of TCK. Grossly, the TCKs are well-demarcated multicystic lesions giving a "wrapped bubble" or "spongy" appearance. Microscopically, the tumors are composed of multiple, variably sized cysts separated by thin fibrous septa lacking ovarian stroma or desmoplastic reaction. The cysts are lined by tumor cells with eosinophilic cytoplasm and nuclear atypia of variable, but not infrequently of high grade corresponding to Fuhrman grade 3. A frequent association with papillary tumors has been reported. Recent molecular genetic studies of TCK have revealed distinct features separating this subset of renal cell carcinomas (RCCs) from other types of renal tumors including collecting duct carcinoma of Bellini and renal medullary carcinoma as well as pointing towards a close kinship with papillary RCC. Tubulocystic carcinoma of the kidney generally pursues an indolent clinical course. However, several cases with aggressive clinical behavior have been reported. We strongly feel that there is enough clinicopathological evidence to corroborate TCK as a separate entity and that it should be incorporated into the next WHO classification of renal tumors as a separate neoplastic category.

Review of renal carcinoid tumor with focus on clinical and pathobiological aspects.

Renal carcinoid tumor is a rare neoplasm. In this article, we review this neoplasm with a focus on clinical and pathobiological aspects. The majority of patients present in the fourth to seventh decades, but there is no gender predilection. Clinically, patients with renal carcinoid tumor frequently present with abdominal, back or flank pain. This tumor is occassionally associated with horseshoe kidney and/or mature cystic teratoma located in the kidney. Macroscopically, these tumors are well demarcated with a lobulated appearance and yellow or tan-brown color cut surface. Microscopically, these tumors are composed of monomorphic round to polygonal cells with granular amphophilic to eosinophilic cytoplasm. Tumor cells are arranged in trabecular, ribbon-like, gyriform, insular, glandular and solid patterns. The nuclei are round to oval and with evenly distributed nuclear chromatin, frequently with a "salt and pepper"-pattern. Immunohistochemically, tumor cells demonstrate immuno-labeling for chromogranin A and synaptophysin. Ultrastructurally, the neoplastic cells contain abundant dense core neurosecretory granules. In previous genetic studies, abnormalities of chromosomes 3 or 13 have been reported. The clinical behavior of renal carcinoid tumors is variable, but is more indolent than most renal cell carcinomas. Further investigations are warranted in order to elucidate the critical genetic abnormalities responsible for the pathogenesis of this rare entity in renal neoplastic pathology.

[Complications of breast augmentation - a case report]. / Komplikace augmentace - kazuistika.

As with any surgery, breast augmentation does have certain risks and complications. The aim of this article is to point out a rare complication of breast augmentation - axillary silicone lymphadenopathy (defined as the presence of silicone in the lymph nodes). The authors present a case report of silicone lymphadenopathy in a young woman after the rupture of a silicone breast implant. As the number of women with breast implants is increasing, it is necessary to bear this rare complication of breast augmentation in mind in differential diagnosis of axillary lymphadenopathy.

[Pseudotumors of the testis and testicular adnexa]. / Pseudotumory varlete a adnexálních testikulárních struktur.

A review article dealing with the most common pseudotumors of the testicular region. Nodules of immature tubules, pseudotumors in adrenogenital syndrome, fibromatous periorchitis, pseudosarcomatous myofibroblastic proliferation, posstraumatic mesothelial glandular inclusions and vasitis nodosa are described in detail, including morphologic and immunohistochemical features, altogether with a differential diagnostic approach.  Key words: testis - testicular adnexa - nodules of immature tubules - pseudotumors in adrenogenital syndrome - fibromatous periorchitis - pseudosarcomatous myofibroblastic proliferation - posstraumatic mesothelial glandular inclusions - vasitis nodosa.

[Difficult diagnosis of breast carcinoma]. / Obtízná diagnostika karcinomu prsu.

The breast carcinoma is the most frequent cancer in women. The diagnosis has certain rules but sometimes it brings diagnostic difficulties. The aim of this article is to point out specific cases of breast cancer and to transmit our practical experience with the situations when ordinary diagnostic methods failed. The authors present four cases of the patients with breast carcinoma.

[Predictive factors for non-sentinel lymph nodes affection in breast carcinoma--outcomes of a Czech multicenter study of sentinel lymph nodes]. / Prediktivní faktory postizení nonsentinelových uzlin u karcinomu prsu--závery ceské multicentrické studie sentinelových uzlin.

BACKGROUND: The aim of the study was to assess positivity nonsentinel lymph nodes in patients with macro, micro and submicrometastases in sentinel lymph nodes and find predictive factors of positivity nonsentinel lymph nodes. Study was conducted at the Department of Surgery in Pardubice, Pilsen, Ostrava and Zlín. MATERIAL AND METHODS: Sentinel lymph nodes were assessed based on standards of Czech Pathological Society. Detection of sentinel lymph nodes was performed based on radionavigation or combination of radionavigation and blue dye method. RESULTS: In group N1 (macrometastases) there was found positivity of nonsentinel lymph nodes in 50% (45 from 90 patients). In group N1 Mi (micrometastases) there was found positivity of nonsentinel lymph nodes in 26.7% (16 from 60 patients). In group NO I+ (sub-micrometastases) there was found positivity of nonsentinel lymph nodes in 6.7% (1 from 15 patients). Predictive factors were size of metastasis, number of positive sentinel lymph nodes and grading. Size of tumor was not found to be a predictive factor of positivity nonsentinel lymph nodes. DISCUSSION: High positivity of nonsentinel lymph nodes in pacients with macro and micrometastases in sentinel lymph nodes advocates to perform axillary lymph nodes dissection. Due to small number of patients with submicrometastases it is not possible to assess if axillary dissection is necessary or not. Predictive factors of positivity of nonsentinel lymph nodes are size of metastasis in sentinel lymph nodes, number of positive sentinel lymph nodes and grading. Size of tumor was not found to be a predictive factor due to small tumors in the study. In spite of this it is necessary to consider it like a predictive factor of positivity nonsentinel lymph nodes. CONCLUSION: In patients with macro and micrometastases it is necessary to perform axillary dissection. In patients with submicrometastases in sentinel lymph nodes it is necessary to consider predictive factors.

Signaling molecules for early detection of adverse interactions during mechanical ventilation in animal models.

AIM: The early identification of adverse interactions during mechanical ventilation, investigated by multiplexed immunoanalysis. MATERIALS AND METHODS: Twenty piglets (average age 7 weeks, weight 23 kg) were intubated and divided into groups: A, spontaneously breathing; B, protectively ventilated; C, ventilated with injurious strategy; D, ventilated with lung disability. At the 1st hour (time-1) and 12th hour (time-2) of the study, brain natriuretic peptide (BNP), intercellular cell adhesion molecules (ICAM-1), vascular cell adhesion molecules (VCAM-1), tumor necrosis factor-alpha (TNF-alpha), and interleukin-6 (Il-6) were analyzed in the blood. RESULTS: The injurious ventilated group C exhibited an increase in both cell adhesion molecules (p<0.01), TNF-alpha and BNP (p<0.05) at time-1, and at time-2 further increases (p<0.05). In group D, an increase in ICAM-1 and BNP (p<0.05) at time-1, and increases in Il-6 and ICAM-1 (p<0.05) at time-2, with notable decreases in urine output were observed. Overall, the lung damage correlated with TNF-alpha (r=0.904), Il-6 (r=0.740), and ICAM-1 (r=0.756) levels. CONCLUSION: All five monitored molecules quickly and reliably signaled adverse interactions.