Ultra-Hypofractionated vs. Moderate Fractionated Whole Breast Three Dimensional Conformal Radiotherapy during the COVID-19 Pandemic.

Background and Objectives: Reducing time of treatment during COVID-19 outbreaks has been recommended by the leading Radiation Oncology societies. Still minimizing radiation induced tissue toxicity is one of the most important issues in breast cancer patients. The study aimed to investigate compliance, clinical and dosimetry normal tissue toxicity, and cosmetic results between moderated and ultra-fractionated regimes for breast cancer patients during COVID-19 pandemic. Materials and Methods: This pilot prospective randomized study included 60 patients with early breast cancer after preserving surgery, 27 patients advocated to ultra-hypofractionated whole-breast three dimensional (3D) conformal radiotherapy of 26 Gy in 5 fractions over 1 week and 33 patients with moderate fractionated breast 3D conformal radiotherapy patients between March 2020 and July 2020, during the COVID pandemic outbreak. The compliance to treatment, dosimetric parameters, acute and late skin toxicity, subcutaneous tissue toxicity, cosmetic results and clinical follow up for 18 months for the two regimes were analyzed and compared. Results: When two regimes were compared 5 fraction group had significantly lower prevalence of newly infected cases of SARS-CoV-2 and thus delayed/interrupted treatment (p = 0.05), comparable grade 1 CTCAE v5, acute skin toxicity (p = 0.18), Grade 1 Radiation Morbidity Scoring Scheme (RESS) subcutaneous tissue toxicity (p = 0.18), Grade 1 RESS late skin toxicity (p = 0.88) and cosmetic results (p = 0.46). Dosimetric results reveled that patients in 5 fraction group received significantly lower median ipsilateral lung doses (p < 0.01) in addition to left breast cancer patients that received significantly lower median heart dose (p < 0.01) and median left anterior descending artery (LAD) dose (p < 0.01). Conclusion: Ultra-hypofractionated radiotherapy for breast cancer is comparable to moderate hypofractionation regimen regarding grade 1 acute skin toxicity, grade 1 subcutaneous tissue toxicity, late skin toxicity and cosmetic results. Application of ultra-hypofractionated radiotherapy with significantly lower radiation doses for lung and heart could be crucial in reducing the risk of acute/late pulmonary and heart radiation-induced toxicity.

[Peripheral Primitive Neuroectodermal Tumor of the Small Bowel Mesentery - Report of a Case].

INTRODUCTION: Primitive neuroectodermal tumor or Ewing's sarcoma is a tumor of undifferentiated small round cells that arise from the soft tissues, and is believed to be of neural origin. It occurs most often in children, followed by adolescents and young adults. CASE OUTLINE: A case of a 24-year-old patient with ulcerostenosans Ewing's sarcoma of the initial part of the small intestine is presented in our paper. Reviewing the literature and using as an example the case of a female patient with signs of sideropenic anemia caused by primitive neuroectodermal tumor of the small intestine, an attempt was made to clarify the etiology, clinical presentation, diagnosis and therapy with the aim of its rapid detection and treatment. CONCLUSION: Mesenteric primitive neuroectodermal tumor is a rare neoplasm in adults, while it usually occurs in children and young adults. Surgical resection of the lesions with the application of chemotherapy is the main form of treatment of patients suffering from this disease.

Importance of positron emission tomography-computed tomography (PET-CT) examination in rectal cancer staging--initial clinical experience.

AIM: Accurate preoperative staging is essential in determining optimal therapeutic procedures and planning for individual patients. Advances in imaging technology have raised interest in the potential role of positron emission tomography-computed tomography (PET-CT) examination for staging of rectal cancer. The primary end point of the study was the correct classification of the tumor node-metastases (TNM) tumor stage using whole-body PET-CT examination. METHODS: This prospective study was performed from October 2011 to October 2012. Patients with histopathological diagnosis of rectal cancer after biopsy underwent PET-CT before surgical treatment and TNM staging. Twenty patients who fulfilled inclusion criteria were included in the study. All of the patients were operated and histopathology served as the standard of reference. RESULTS: There was no statistical significance in T staging comparing PET-CT and histopathological staging, according to the Monte Carlo simulation (p=.066). Also, there was no statistical significance between two methods in mesorectal fascia involvement analysis (p=1). There was statistical difference between PET-CT and histopathological staging. Sensitivity of the PET-CT for N staging was 86.7% and it was higher than for the histopathology. Two patients showed liver metastases. CONCLUSION: Positron emission tomography-computed tomography examination could play an important role in the initial staging for the rectal cancer. Good patient selection for preoperative chemoradiotherapy ensures survival benefit. Avoidance of unnecessary therapeutic procedures allows an acceptable quality of patient's life.

Lipoma of the sigmoid colon.

INTRODUCTION: Lipoma is a benign tumor of adipose tissue, the most common tumor of the human body soft tissues. As such, it can be found almost anywhere in the human body including the gastrointestinal system (incidence below 0.5%), but rarely in the sigmoid colon. CASE REPORT: This is a case report on symptomatic polyp of the sigmoid colon, which after one year, at control colonoscopy, caused suspicion to malignancy. Endoscopically diagnosed polipoid lesion was laparoscopically removed. The pathohistological diagnosis determined benign, submucosal, incapsulated lipoma of the sigmoid colon. CONCLUSION: Although lipomas of the gastrointestinal tract are rare, this case clearly indicates that we should not prematurely and without histological confirmation of malignancy do more extensive resection for a suspected malignancy.

Preoperative evaluation in the era of laparoscopic surgery.

To confirm the importance of preoperative evaluation of a patient's health state, to reduce perioperative morbidity and mortality after laparoscopic surgery. A total number of 1,070 patients were selected into groups based on a type of intervention, gender, ASA and NYHA classification. The most common laparoscopic procedure that was performed was cholecystectomy in 920 (86%) patients. Cardiovascular disease had been presented in 952 (89%) patients, 1006 (94 %) of patients were ASA class I- III, while 1049 (98%) patients were NYHA class I and II. Frequency of lethal outcome was 0.1% due to postoperative thromboembolic complications. A lower mortality rate is a result of prescribed protocol and adequate preoperative examination.

A rare case of benign omentum teratoma.

INTRODUCTION: Mature teratomas (benign cystic teratomas or dermoid cysts) are among the most common ovarian tumours; however, teratomas of the omentum and mesentery are extremely rare. Teratoma in the intraperitoneal cavity is uncommon and atypical, and it is even more uncommon in adulthood. CASE OUTLINE: An 82-year-old female was admitted to our department with clinical signs of abdominal tumour. The ultrasound scan and preoperative laboratory tests were done. Explorative laparotomy revealed tumour with torsion on its pedicle at the greater omentum. After removal of the mass and the incision a tooth and hair were found, characteristics of teratoma. CONCLUSION: The excision was very effective and also definitive treatment for this case. The patient recovered well and was discharged 3 days later. The patient probably carried the tumour all her life asymptomatically until admission.

Lipomas of the gastrointestinal system.

Lipomas are rare benign tumors in the gastrointestinal system. Within the gastrointestinal system, 65% of the lipomas are located in the colon (sigmoid part of the colon or rectum) and rarely in the stomach and esophagus. The paper presents two gastrointestinal lipomas. First is the case of lipoma of the sigmoid colon and the other one is gastric lipoma. In both cases the material was sent for histopathological analysis due to suspicion of malignancy of the lesions. In both cases, the histopathologic analysis showed tumor made of mature adipocytes, localized in the submucosa both of the stomach and intestine. Hypercellularity and/or atypia of the cell was found in neither case. Lipomas are shown because of its atypical localization and clinically suspicious malignancy in the stomach and sigmoid colon. These cases show that the applied methods of preoperative diagnosis of tumors in the gastrointestinal system are not sufficient to determine the origin and biological behavior of tumors. Histopathological diagnosis provides a correct insight into the nature of tumors and determine the course of treatment. This paper presents a rare localization of lipomas in the gastrointestinal system. The preoperative diagnosis of lesions in the gastrointestinal system may not be sufficient to determine the origin and biological behavior of the lesions, hence the histopathological diagnosis gives an accurate insight into the nature of the change, preventing the possibility of further aggressive therapy.

Laparoscopic body-tail pancreatic resection for insulinoma.

INTRODUCTION: Insulinomas are the most common endocrine tumours of the pancreas. They are more frequent in females, and they are commonly less than 2 cm in diameter. If conservative treatment of typical clinical symptoms fails, detailed diagnostic procedures are necessary and surgical treatment is indicated.The aim of this report was to emphasize the need of pancreatic resection when insulinoma is poorly visualized during surgery and when it is not possible to perform intraoperative ultrasonography. CASE OUTLINE: A 27-year-old female patient suffered from hypoglycaemic episodes during physical efforts and fasting periods. After examination, diagnostic procedures and preoperative preparation, laparoscopic surgery was performed. The tumour was less than 10 mm in diameter, and it could not be visualized during laparoscopic exploration. The body and the tail of the pancreas were mobilized using ultrasound scissors and the resection was performed by two Endo GIA staplers. The surgical specimen was removed in an endo-bag. The postoperative course was without complications and the glycemic level was normalized. Macroscopic examination of the resected specimen showed a solitary, poorly demarcated, dark grey lesion, 0.8 cm in diameter, with a solid consistence in comparison with the surrounding gland tissue. Histological examination showed a poorly demarcated, subcapsular tissue in this area, consisting of uniform, irregular, cubic and short cylindrical cells, organized in clusters with pseudoglandular and "zellballen" formations. CONCLUSION: In case when the insulinoma is so small in size that it cannot be visualized during operation, pancreas resection is a surgical procedure of choice. Laparoscopic surgery is preferred because of less postoperative complications and faster recovery.

[Breast reconstruction: correlation between different procedures, reconstruction timing and complications].

INTRODUCTION: Improved psychophysical condition after breast reconstruction in women has been well documented. OBJECTIVE: To determine the most optimal technique with minimal morbidity, the authors examined their results and complications based on reconstruction timing (immediate and delayed reconstruction) and three reconstruction methods: TRAM flap, latissimus dorsi flap and reconstruction with tissue expanders and implants. METHODS: Reconstruction was performed in 60 women of mean age 51.1 years. We analyzed risk factors: age, body mass index (BMI), smoking history and radiation therapy in correlation with timing and method of reconstruction. Complications of all three methods of reconstruction were under 1.5-2-year follow-up after the reconstruction. All data were statistically analyzed. RESULTS: Only radiation had significant influence on the occurrence of complications both before and after the reconstruction, while age, smoking and BMI had no considerable influence of the development of complications. There were no statistically significant correlation between the incidence of complications, time and method of reconstruction. CONCLUSION: Any of the aforementioned breast reconstruction techniques can yield good results and a low rate of re-operations. To choose the best method, the patient needs to be as well informed as possible about the options including the risks and benefits of each method.

Intraoperative air testing of colorectal anastomoses.

INTRODUCTION: Intraoperative anastomotic air testing of stapled colorectal anastomosis is performed by filling the pelvis with saline solution and insufflating the rectum with air through a sigmoidoscope. The presence of air bubbles indicates anastomotic leaks which are resolved during surgery. OBJECTIVE: The aim of this prospective, randomized study was to perform a comparative analysis regarding the number of anastomotic dehiscences in patients checked by air leak testing and in the control group without air testing. METHODS: After stapled colorectal anastomosis was performed, patients were randomized into two groups of 30 patients. The first group patients underwent intraoperative anastomotic air testing, whereas in the control group this procedure was not performed. The two groups were matched for age, sex, diagnosis and surgical procedure. RESULTS: Intraoperative air tests were positive in seven cases and anastomotic defects were repaired. After surgery, there were three clinical leaks in this group of patients. In the control group, there were six leaks (Unilateral Fischer's exact test, p = 0.24). The incidence of colorectal anastomotic dehiscences in the study group was lower than in the control group by 50%. However, this finding was not statistically significant in our sample. CONCLUSION: In our opinion, intraoperative air testing of colorectal anastomosis is a good method for prevention of anastomotic dehiscence.

[Thoracoabdominal teratoma--rare location].

INTRODUCTION: Teratomas are tumours derived from pluripotent germ cells. They appear most frequently on ovaries. However, other locations are also possible: testicles, retroperitoneum, stomach, neck, and bottom of the mouth cavity. It is not very common to find teratomas in two different body cavities. CASE REPORT: A 51-year-old patient visited her doctor complaining of an intensive pain which suddenly appeared in her low back. The computed tomography scan of the abdomen was performed, which revealed cystic formation, 12.5 x 18 cm in size, with remarkable capsule visualization. It had paraaortic, subdiaphragmatic, retropancreatic and suprarenal left localisation with signs of compression and pancreatic dislocation. The cystic formation had a septated appearance filled with clear fluid in all its parts except at the bottom, where it was dense. The intra-operative finding was left retroperitoneal mass placed above the left kidney, dislocating surrounding structures and their infiltration could not be excluded for sure. A tumour mass passed through the diaphragmatic hiatus and continued in the left thoracic space. The cyst was only drained and the fenestration was performed. Three months later, the second operation was performed--splenectomy, left suprarenaladenectomy, left nephrectomy, aortic deliberalisation, the left diaphragmatic crus was opened and tumour mass was completely removed from the thoracic space. The histological examination showed mature teratoma with morphological characterisations of the skin, so the definite diagnosis was dermoid cyst. CONCLUSION: The patient presented with thoracoabdominal teratoma. Although without malignant transformation, the teratoma required splenectomy, supraadrenalectomy and nefrectomy due to its position and size.

An unusual case of ascariasis of the appendix.

INTRODUCTION: Amongst various causes responsible for the obstruction of digestive tract, intestinal ascariasis is certainly one of the least frequent. CASE OUTLINE: We report an extremely rare case of a 5-year-old male patient operated on for appendicitis due to adult Ascaris Lumbricoides worms intraoperatively detected in the appendiceal lumen. CONCLUSION: On examination patient's clinical features indicated acute appendicitis. Therefore, the treatment-of-choice could only be surgical. Classic appendectomy was performed and the postoperative course was uneventful, with full recovery.

Primary closure of the common bile duct in the treatment of choledocholithiasis.

Surgical institutions equipped to apply endoscopic retrograde cholangiopancreatography with papillotomy do not treat non-complicated choledocholithiasis in a surgical way any more. However, those institutions which have not yet started to perform cholangiopancreatography apply surgical treatment of choledocholithiasis, and therefore, choledochography is still an option to end the exploration of choledochus with or without the concrement removal. Since cholangiopancreatography has not become a routine treatment in our institution, we have tried to determine the role of the primary closure of the choledochus in the treatment of choledocholithiasis as well as the indications and contraindications for its application.

[Streptococcal toxic shock syndrome].

INTRODUCTION: Streptococcal toxic shock syndrome is now recognized as a toxin-mediated, multisystem illness. It is characterized by an early onset of shock with multiorgan failure and continues to be associated with high morbidity and mortality, caused by group A Streptococcus pyogenes. The symptoms for staphylococcal and streptococcal toxic shock syndrome are similar. Streptococcal toxic shock syndrome was not well described until 1993, when children who had suffered from varicella presented roughly 2-4 weeks later with a clinical syndrome highly suggestive of toxic shock syndrome. CHARACTERISTICS, COMPLICATIONS AND THERAPY: It is characterized by a sudden onset of fever, chills, vomiting, diarrhea, muscle aches and rash. It can rapidly progress to severe and intractable hypotension and multisystem dysfunction. Almost every organ system can he involved. Complications of streptococcal toxic shock syndrome may include kidney failure, liver failure (and even death. Crystalloids and inotropic agents are used to treat the hypovolemic shock aggressively, with close monitoring of the patient's mean arterial pressure and central venous pressure. An immediate and aggressive management of hypovolemic shock is essential in streptococcal toxic shock syndrome. Targeted antibiotics are indicated: penicillin or a beta-lactam antibiotic is used for treating group A streptococci, and clindamycin has emerged as a key portion of the standard treatment.

The first case of endoscopic submucosal dissection of cecal adenoma in Serbia.

Endoscopic submucosal dissection is a therapeutic procedure for the removal of early stage gastrointestinal cancer. In 2006, we performed a colonic ESD in Serbia. ESD had never been performed until then in Serbia, nor do we have a written report, so this article is a document of the first performed procedure of this kind. On the 21st of October 2006, the patient was admitted to the General Hospital MC in Novi Sad for the performance of ESD of the cecal lesion. A flat-elevated type of lesion on the upper lip of ileocecal valve with a size of 8 mm was found on the colonoscopy. The adenoma was removed en bloc and prepared for further histopathological examination. Histopathological examination showed that the tumor was a "flat adenoma" of the colon mucosa with a low grade dysplasia. The procedure lasted for 30 minutes and went without complications. The first case of ESD in Serbia was performed in 2006, only four years after it was developed in Japan. To have more ESD cases in our country a screening program for detection of early cancers is needed as well as education of endoscopists in performing ESD.

[Cytoarchitecture of the human paraventricular hypothalamic nucleus].

INTRODUCTION: The significance of this research in terms of structure and biochemical processes in PVN contributes to further understanding of vital physiological processes from delivery and stress to delicate chemical processes that keep the hypothalamo-hypophysial axis in balance. CONCLUSION: Comparative studies of the human hypothalamus with the hypothalamus of other mammals enable further research, especially pharmacological and physiological ones. These are made possible with the aid of highly sophisticated equipment for examination of neurophysiological features of the brain.

[Complications in laparoscopic surgery].

The development of technology and improvement of laparoscopic equipment enhanced expansion laparoscopic surgeries. Various operations performed using classical operative approach are nowadays done laparoscopic technique. The expansion of the repertoire, the performance of most complicated surgical procedures and increase in the number of laparoscopic interventions result in the increased number of intraoperative and postoperative complications. They occur due to the basic disease that is the cause of surgery and surgical procedure, but also due to other factors. We cannot influence the very disease - it is the reason for surgical treatment. However, we can make some changes in approach concerning the laparoscopic technique, which can considerably influence possible development of complications. This involves a different approach to the operative field, but also to very surgery. In laparoscopic surgery such approach causes specific intraoperative and postoperative complications. These complications are mainly caused by technical factors, such as the quality of the equipment, instruments and human factors, such as inexperience, insufficient education and excessive self-assurance. To decrease the frequency of intraoperative and postoperative complications in laparoscopic operations we require perfect equipment and instruments, education in a referent institution, but also everyday training with laparascopic equipment and experimental animals.

[Nylon-Darn herniorrhaphy: the method of choice in treatment of primary inguinal hernia].

INTRODUCTION: Nylon-Darn herniorrhaphy is a classic, open technique, simple to perform with a low recurrence rate. It is a "tension-free" method of herniorrhaphy. The aim of study was to analyze the results of Nylon-Darn herniorrhaphy at our clinic and point out advantages and disadvantages of the technique. MATERIAL AND METHODS: This study, dating back to May 1999 and up to May 2005, included 116 patients who underwent Nylon-Darn herniorrhaphy for primary inguinal hernia. Patients were operated at the Clinic for Abdominal and Endocrine Surgery, Institute of Surgery, Clinical center Novi Sad and if without complications, left on the first postoperative day. Two patients had cholelithiasis and laparoscopic cholecystectomy was performed simultaneusly. Intra- and postoperative complications were analyzed. RESULTS: The overall complication rate in our study was 22.4%. There was no perioperative mortality and intraoperative complications. The mean age of 112 males and 4 females was 51 years. An average duration of the operative procedure was 49.2 min, and the patients left hospital after 2.17 days. General endotracheal anestesia was performed in 69 cases and spinal in 47. CONCLUSION: Based on the results of Nylon-Darn herniorrhaphy in our study and on the results in the literature, this technique could be the method of choice for primary inguinal hernia repair. It is suitable for registrars and young surgeons working in clinics not specialized in this pathology.

[C-fos protein expression in the parietal cortex and olfactory tubercle in the hypoxic rat brain].

INTRODUCTION: We have attempted to identify which parts of the brain react to ischemic attack using the four-vessel occlusion model in rats. MATERIAL AND METHODS: We have monitored the expression of c-fos protein in the parietal cortex (R3 and T3) and in the olfactory tubercle (R4 and T4), regions which are supplied with blood by different arteries. The four-vessel occlusion was performed using the Pulsinelli's method and rats were divided into two groups: total ischemia (ligation of four blood vessels or coagulation of the vertebral artheries with bilateral ligation of carotid arteries - R group) and transient ischemic attack (ligation of four blood vessels or coagulation of the vertebral arteries with bilateral repeated ligation of carotid arteries - T group of rats, the so-called preconditioned group). Each of these groups had a control group. RESULTS AND CONCLUSION: The results showed pronounced expression of c-fos neurons in T group of rats which can explain longer survival of neurons. We believe that this model can serve as a good starting point to developing new approaches to the therapy of brain ischemia.