Abdominal emergencies in surgical oncology.

INTRODUCTION: In general, abdominal emergencies are urgent situations that require a prompt and correct diagnosis and treatment. They involve a broad spectrum of diagnoses and can occur in all age groups. The situation is often modified in oncologic patients according to the extent and level of progression of the primary oncological disease. METHODS: A retrospective study was conducted to analyze the group of adult patients with abdominal emergencies treated in Masaryk Memorial Cancer Institute between 2011-2017. RESULTS: In total, 601 patients underwent emergency surgery during the 7-year period. The causes included gastrointestinal obstruction (43%), intra-abdominal inflammatory complications (33%) and bleeding (17%). Acute appendicitis or cholecystitis was the cause in only less than 4% of all patients. CONCLUSION: The problems of acute abdominal emergencies in oncologic patients are substantially different from those in the general population, particularly in terms of the causes where gastrointestinal obstruction is the leading cause.

Iodine seed localisation of non-palpable lesions in breast surgery first experience.

Surgical therapy of non-palpable malignant breast lesions requires precise preoperative localisation. Recently, radioactive iodine seed localisation has excelled among the number of localisation methods. We present our first experience with this method at our department. We describe the structure of the radioactive iodine seed, the principles of preoperative localisation and peroperative detection of the seed, the specimen transport process, histopathological examination, storage and disposal of the seed, as well as aspects of radiation protection.

Pagets disease of the breast - observational retrospective study of the past 20 years.

INTRODUCTION: Pagets disease of the breast (PD) is a rare type of carcinoma that affects the skin of the nipple-areolar complex. Unresolved issues exist regarding its diagnosis and therapy. The aim of the study was to gather data on how the therapy of the disease is approached in clinical practice, and to formulate current diagnostic and therapeutic recommendations. METHODS: Retrospective evaluation of data from medical records of patients with PD who underwent surgery at our department between 2001 and 2020. The data was evaluated using basic statistical methods. RESULTS: Sixty four female patients with the mean age of 62.5 years. In 58 women, PD was confirmed before surgery, with the median of 20 weeks from initial symptoms to diagnosis. Forty seven of the patients were operated for presumed isolated PD; in 38 cases, histopathological evaluation of the specimen revealed an associated malignancy in the mammary gland. Primary breast-conserving surgery (BCS) was performed in 46 patients; surgical revision was indicated in 17 cases. In 6 patients with PD associated with non-invasive breast cancer treated by BCS without radiotherapy (RT), a local recurrence appeared in 3 cases, which is significantly more compared to the group of patients undergoing total mastectomies (p=0.032). No local recurrence appeared in 9 cases of isolated PD treated by BCS, including 6 patients without RT. The tumors associated with PD were mostly ER-negative (44/57) and HER2-positive (22/25). CONCLUSION: In cases where PD is suspected, careful clinical examination and the use of available diagnostic imaging techniques including MRI are appropriate. BCS without RT is not an adequate oncological therapy where an associated malignancy of the breast is found.

Phyllodes tumours - a retrospective review of 83 clinical cases.

INTRODUCTION: Phyllodes tumours are rare, accounting for 0.3-1.0% of all primary breast tumours. According to biological behaviour, they are divided into three categories: benign, borderline and malignant. Due to the rare incidence, the requirements for the radicality of surgical treatment are not well known. According to respected foreign recommendations, resection with a free margin of 10 mm or more is desirable. METHODS: A retrospective review of patients, who underwent surgical treatment due to phyllodes tumour in the Masaryk Memorial Cancer lnstitute in 2003-2014. RESULTS: 83 patients were evaluated with a median follow-up of 68.0 months. Benign tumours accounted for 62.3%, borderline tumours accounted for 16.9% and malignant accounted for 20.8% of all tumours. Malignant phyllodes tumours reached a bigger average size (84.9 mm) than borderline (41.4 mm) and benign tumours (33.3 mm) and occurred in older patients (mean 56.4 years) than benign (mean 42.5 years). Results from preoperative core-cut biopsy were often inaccurate. In 70 cases, the primary resection was breast preserving, but the free margin above 1 mm was achieved only in 13 cases. The width of the resection edge never exceeded the recommended 10 mm. Nevertheless, there was a relapse in benign tumours in two cases and in the borderline tumours only in one case. Malignant tumours recurred more frequently, even after total mastectomy. Four patients with malignant tumours experienced distant metastases. There has never been a death caused by benign or borderline tumour. CONCLUSION: The 10 mm resection margin is unachievable in our conditions. However, it seems that such radicality is not necessary in benign tumours, because they rarely recur even with close margins. Conversely, neither total mastectomy of the malignant phyllodes tumours will protect against local progression or distant metastasis.

Venous access in cancer patients.

The most commonly used permanent venous access devices in cancer patients are the port, PICC port and PICC catheter (peripherally inserted central catheter). It is always necessary to consider the type of venous access needed for each individual cancer patient. Implantation should be performed using modern instruments to minimize the risk of early and late complications and thereby a delay in oncological treatment. The use of ultrasound is recommended at all stages of introduction. Precise tip placement of the central catheter in the sinoatrial junction region further reduces the number of thromboses arising in the catheter. A trend towards the treatment of catheter infections is certainly to maintain the venous access without compromising the patients health. Permanent venous access devices allow the application of chemotherapy and repeated blood sample collections with minimal impact on the quality of life in cancer patients.

A comparative analysis of different automated von Willebrand factor glycoprotein Ib-binding activity assays in well typed von Willebrand disease patients.

Essentials Von Willebrand ristocetin cofactor activity (VWF:RCo) is not a completely reliable assay. Three automated VWF activity assays were compared within a von Willebrand disease (VWD) cohort. Raw values for all three assays were virtually the same. An overall problem within type 2A/IIE VWD using VWF:GPIb-binding activity/VWF:Ag was observed. SUMMARY: Background von Willebrand disease (VWD) is an inherited bleeding disorder caused by quantitative (type 1 and 3) or qualitative (type 2) von Willebrand factor (VWF) defect. VWD diagnosis and classification require numerous laboratory tests. VWF: glycoprotein Ib (GPIb)-binding activity assays are used to distinguish type 1 from type 2 VWD. Objectives Three different automated VWF:GPIb-binding activity assays were compared. Patients and methods BC-VWF:RCo (Siemens Healthcare Diagnostics), HemosIL® VWF:RCo (Instrumentation Laboratory) and INNOVANCE® VWF:Ac (Siemens Healthcare Diagnostics) were performed in a well typed VWD cohort (n = 142). Results Based on the three most used VWD parameters (FVIII:C, VWF:Ag and VWF:GPIb-binding activity) and using a cut-off of <0.70 for type 2 VWD revealed sensitivity and specificity of, respectively, 92% and 72.4% for VWF:RCo/VWF:Ag, 84% and 89.7% for VWF:GPIbR/VWF:Ag, and 92% and 85.1% for VWF:GPIbM/VWF:Ag, whereas a lowered cut-off of < 0.60 resulted in reduced sensitivity with increased specificity for all assays. Conclusion VWD classification based on FVIII:C, VWF:Ag and VWF:GPIb-binding activity revealed an overall problem with normal VWF:GPIb-binding activity/VWF:Ag within type 2, especially type 2A/IIE. Although all assays were practically identical, BC-VWF:RCo had higher %CV compared with both new assays but comparable lower limit of quantification (LLOQ) ~4 IU dL-1 . No clear improved distinction between type 1 and 2 VWD with new assays was seen. BC-VWF: RCo and HemosIL® are ristocetin dependent, whereas INNOVANCE® does not rely upon ristocetin and is not influenced by VWF polymorphisms increasing VWF:GPIb-binding activity levels. INNOVANCE® seems to be the best choice as a first-line VWF:GPIb-binding activity assay, providing the best balance between sensitivity and specificity for type 2 VWD.

Targeted axillary dissection and sentinel lymph node biopsy in breast cancer patients after neoadjuvant chemotherapy - a retrospective study.

INTRODUCTION: No consensus exists as yet regarding the optimal extent of surgery on the lymph nodes in breast cancer patients after neoadjuvant treatment. In addition to axillary dissection and sentinel lymph node biopsy (SLNB), a new approach called Targeted Axillary Dissection (TAD) was introduced. It requires the marking of metastatic nodes before the neoadjuvant treatment. METHOD: A retrospective observational study on patients with breast cancer and neoadjuvant chemotherapy treated surgically at a single institution in 2017. RESULTS: The analysis included 121 cancers in 120 patients. Clinical regression of lymphadenopathy occurred in 29 out of 74 cases. Axillary dissection was performed 34x, SLNB 52x and TAD 35x. In TAD procedures, the marked lymph node was found 30x and was among the sentinel nodes in 19 cases. No case occurred in which the marked node was assessed as negative with a metastasis found in the other nodes. On the contrary, there were 3 cases with negative sentinel nodes whereas the marked node was positive. Out of 74 cases with initially pathologic nodes, 23 patients were spared axillary dissection. CONCLUSION: Clinical assessment of the lymph node status is rather inaccurate. In cases with initially pathologic nodes we recommend marking of the most explicit metastatic node to enable TAD. The marked node is likely to reflect the status of the lymph nodes after neoadjuvant treatment more accurately than common sentinel nodes. A considerable proportion of patients can be spared axillary dissection in this way. However, the long-term oncologic safety of TAD still needs to be verified. Key words: breast cancer - neoadjuvant treatment - axillary dissection - sentinel lymph node biopsy - targeted axillary dissection.

[Lymphoedema Following Regional Lymph Node Surgery for Breast Cancer]. / Lymfedém po operacích na spádových lymfatických uzlinách pro karcinom prsu.

BACKGROUND: The treatment of breast cancer is based on the multimodal principle and surgery of regional lymph nodes is an inseparable part of this. Indication criteria are changing constantly folowing advances in other modalities. It is necessary to consider not only the diagnostic or therapeutic benefit but also to take into account adverse effects. Previous studies have demonstrated that axillary dissection (ALND) is burdened by a high frequency of chronic lymphoedema of the arm or chest wall; however, a considerable percentage of patients may also suffer from lymphoedema after sentinel lymph node biopsy (SLNB). AIM: This paper focuses on the pathophysiology of lymphoedema, its potential predictive factors, and its complications. Furthermore, it presents an overview of published studies comparing the incidences of lymphoedema after current axillary surgery for breast cancer together with current trends designed to radically reduce the number of these operations. It also briefly refers to the possibilities of implementing preventive or therapeutic operations for lymphoedema. CONCLUSIONS: Both ALND and SLNB are burdened by a clinically significant risk of lymphoedema. This risk is more serious after ALND. In the medium term, approximately 7-59% of operated patients suffer from lymphoedema. The incidence of lymphoedema after SLNB, considered a very gentle method, is also not negligible (0-14%). As the number of patients surviving breast cancer treatment continues to increase, monitoring the undesirable effects of axillary surgery over the long term will become more important. The results of published studies support research into treatment methods that have the potential to reduce the radicality of axillary surgery while preserving or improving total medical effectiveness.Key words: breast neoplasms - sentinel lymph node biopsy - axillary dissection - adverse effects - breast cancer lymphedemaThis work was supported by the grants MEYS - NPS I - LO1413 and MH CZ - DRO (MMCI, 00209- 805).The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 7. 11. 2016Accepted: 5. 12. 2016.

[Von Meyenburg complexes - multiple biliary hamartomas mimicking metastatic liver lesions]. / Von Meyenburgovy komplexy - mnohocetné biliární hamartomy imitující metastatický jaterní proces.

Von Meyenburg complexes are benign liver lesions usually consisting of dilated bile ducts surrounded by fibrous stroma. Their discovery is usually incidental and unsuspected during the early phase of the operative procedure. The sovereign diagnostic method is intraoperative frozen section examination. The complexes are not important as regards their clinical or functional significance. However, this uncommon entity should be taken into consideration in the framework of differential diagnosis of metastatic liver lesions.

[Failed preoperative lymphoscintigraphy for sentinel lymph node biopsy in breast cancer, possible causes and implications for the surgery - the analysis of 3014 procedures]. / Neúspesná lymfoscintigrafie pred sentinelovou biopsií u karcinomu prsu, mozné príciny a dusledky pro chirurgický výkon - analýza výsledku 3014 vysetrení

INTRODUCTION: The aim of the study was to review the cases of sentinel lymph node biopsy for breast cancer in which preoperative lymphoscintigraphy had shown no axillary hot spot; to assess the frequency of failed examinations and possible causes of the failure; to analyze subsequent surgical procedures and hence to provide a general recommendation on what to do in such a situation. METHODS: A retrospective overview of 3014 lymphoscintigraphy examinations at the Masaryk Memorial Cancer Institute from 2001 to 2011 with a more detailed analysis of the cases with axillary hot spot visualization failure. RESULTS: The axillary hot spot was not shown in 71 examinations (2.4%). The frequency of failed lymphoscintigraphy during the time period did not change substantially. The possible risk factors of failed lymphoscintigraphy include: previous surgery on the breast or the axilla, obturation of the lymphatic drainage with the cancer, and the absence of the tracer injection site massage. The most common surgical procedures to respond to a failed examination were: the application of patent blue and surgical exploration of the axilla, no axillary surgery, or axillary dissection. CONCLUSION: When repeated scanning with the gamma camera through the first several hours is performed, the frequency of failed lymphoscintigraphy procedures remains very low (2.4%). If there is no axillary hot spot shown, patent blue is to be injected and the axilla should be surgically explored. This solution will be successful in most patients. If the sentinel lymph node cannot be detected even using the combined method, the surgical procedure needs to be selected with regard to the individual clinical context.Key words: breast cancer - sentinel lymph node - sentinel lymph node biopsy - lymphoscintigraphy - failed detection.

[Breast cancer patient satisfaction with immediate two-stage implant-based breast reconstruction]. / Spokojenost onkologických pacientek s okamzitou dvoudobou aloplastickou rekonstrukcí prsu.

BACKGROUND: For most breast cancer patients in the Czech Republic, breast reconstruction is available only in a delayed manner. In the Masaryk Memorial Cancer Institute (MMCI), suitable candidates are offered immediate breast reconstruction using tissue expander with later exchange to a permanent silicone implant. The aim of this study was to assess patient satisfaction with this type of reconstruction. PATIENTS AND METHODS: Sixty-two women who had undergone surgery at the MMCI from 2007 through 2013 were sent a simple questionnaire developed by our working team. Fifty-seven patients completed the questionnaire. The data were evaluated by description methods and statistical tests. RESULTS: Patient response was 92%. The absolute majority of patients (56/57) would opt for this method again. The vast majority of patients (48/57) are generally satisfied with their reconstruction. Most women (8/14) younger than 50 years after the unilateral surgery would prefer synchronous contralateral prophylactic mastectomy and bilateral reconstruction if they could choose again. After bilateral surgery, reconstructed breasts are more often regarded as a part of the patients body. Dressed women rate their look substantially better than when they are undressed. As for self-esteem, these women are feeling excellent or good. Their psychosocial well-being in common situations is predominantly excellent. Their sexual well-being is significantly worse, and almost half of these women indicate occasional pain in their reconstructed breasts. The patients emphasize the need for appropriate information before the surgery. CONCLUSION: Immediate two-stage implant-based breast reconstruction is a suitable option for some breast cancer patients. With regard to the less natural cosmetic result and feeling of the implant-reconstructed breast, appropriate selection of women for this type of surgery is necessary and potential candidates must be thoroughly informed in the preoperative setting.

[The number of removed axillary sentinel lymph nodes and its impact on the diagnostic accuracy of sentinel lymph node biopsy in breast cancer]. / Pocet odebíraných axilárních sentinelových uzlin a jeho vliv na diagnostickou presnost sentinelové biopsie u karcinomu prsu.

INTRODUCTION: The number of lymph nodes removed during the sentinel lymph node biopsy in patients with breast cancer usually ranges from 1 to 3. In some cases, multiple nodes are identified and removed, which could be associated with increased risk of postoperative morbidity. The objective of the study was to assess the number of sentinel lymph nodes removed in patients treated in our hospital, to analyze factors that may influence the amount of the removed nodes, and to find if there is an upper threshold number of lymph nodes that should be removed without sacrificing the diagnostic accuracy of the sentinel lymph node biopsy. MATERIAL AND METHODS: Clinical data of four hundred and forty (440) breast cancer patients who underwent sentinel lymph node biopsy in Masaryk Memorial Cancer Institute during the year 2011 were retrospectively collected and analyzed. RESULTS: The number of sentinel lymph nodes ranged from 0 to 9 (average 1.7, median 1). The number of sentinel lymph nodes was significantly influenced by the age of the patient, the operating surgeon and the laterality of the surgery. In 275 cases the sentinel lymph nodes were negative, in the other cases macrometastases (n = 101), micrometastases (n = 46) or isolated tumor cells (n = 17) were found. In all the cases, but one, the staging of the axilla was determined by the status of the first three sentinel lymph nodes removed. Only in one case the first detected macrometastasis was present in the fifth node. CONCLUSION: In the vast majority of cases, the first three sentinel lymph nodes are sufficient to accurately assess the axillary status. However, with respect to the described case of first detected metastasis in the fifth node, to the present literary data and to the variability of clinical situations, we generally recommend to remove all lymph nodes meeting the criteria of the surgical definition of sentinel lymph node.

[Positive sentinel node in breast cancer - when and why also opt for axillary dissection?]. / Pozitivní sentinelová uzlina u karcinomu prsu - kdy a proc doplnovat axilární disekci?

One of the central concerns of contemporary mammary surgery is to verify the actual need for axillary dissection (AD) in patients with early breast cancer and positive sentinel lymph node biopsy. Several studies have addressed this issue (ASOCOG Z0011, IBCSG 23-01, MIRROR, EORTC AMAROS). So far, the preliminary results of the ASOCOG Z0011 trial with a median follow-up of 6.3 years and the results of the IBCSG 23-01 trial with a median follow-up of 5 years have been published. The conclusions of both randomized studies have implied that under specific circumstances, there is no significant difference in the local or regional recurrence between patients who had undergone completion AD compared to the patients in whom AD had been omitted. This article summarizes the current knowledge regarding indications for AD in patients with positive sentinel nodes. Key words: breast cancer - sentinel lymph node biopsy - axillary lymph node dissection - ACOSOG Z0011 trial.

[Essential thrombocytemia and other myeloproliferations with thrombocytemia in the data of the register of patients treated with Thromboreductin till the end of 2006]. / Esenciálni trombocytemie a dalsí myeloproliferace s trombocytemií v údajích registru pacientu lécených Thromboreductinem do konce roku 2006.

Since 2005, registers of patients treated with Thromboreductin (anagrelid) kept by some centres in the Czech Republic have been supplied with data concerning patients whose treatment with this preparation started in 2004. The purpose of the register is to record responses to therapy by Thromboreductin and adverse events in patients with essential thrombocytemia and other myeloproliferations, and to subsequently analyse the data. Another objective is to detect predisposition to clinical symptomatology and disease complications. Apart from thrombocyte count, additional risk factors are monitored. The database currently contains data for 336 patients. Initial analyses of data from the register point to the fact that anagrelid is a highly effective thromboreductive agent the administration of which is associated with relatively low incidence of adverse events (11.8 %) of mild and usually transitory nature. The therapeutic objective is attained at a relatively slow rate (according to overall stratification under 400 or under 600 x 10(9)/l thrombocytes), which is probably due to insufficient dose adjustment.

[Changes of the clinico-biochemical indices in the rumirid juice and urine in experimental aflatoxicosis of dairy cows]. / Zmeny klinicko-biochemických ukazatelu v brachorové tekutine a moci pri experimentální aflatoxikóze dojnic.

The health condition and course of fermentation processes in the rumen were studied in four cows of the Red Spotted breed at the age of four to nine years. The clinico-biochemical indices in the rumen liquor and urine were used. The experimental animals were exposed to a mixture of aflatoxins applied in the dose of 200 mg B1 and 80 mg B2. The toxic action of aflatoxins manifested itself as inappetence, increased temperature, changes in the pulse and respiration rate and reduced activity of the proventriculi. Diarrhoea was observed in two animals. The pH value, total acidity and ammonia level in rumen liquor ranged within the limits of reference values. The significant drop of the production of volatile fatty acids with changes in their proportions and a reduction of the acetic acid level with a simultaneous increase of the percentage of butyric acid testity to a disorder in the activity of rumen microflora. The reduction of the number of infusorians as a biological indicator of fermentation processes proves the correctness of this assumption. During the elimination of aflatoxins through the kidneys the function of the kidneys is impaired, showed proteinuria, ketonuria, glycosuria and haematuria.

[Changes in enzyme activity induced by experimental aflatoxicosis in dairy cows]. / Zmeny v aktivite enzymu pri experimentální aflatoxikóze dojnic.

The activities of GOT, GPT, LDH, gamma-glutamyltranspeptidase (gamma-GTP), alkaline phosphatase (AP), glutamate dehydrogenase (GLDH) and the concentrations of bilirubin in blood plasma after a single intraruminal application of aflatoxins were studied in four dairy cows. The maximum changes in the activities of the enzymes and the maximum bilirubin concentration in plasma were obtained in the first two to three days following the application of aflatoxins. The statistically significant increase of GOT activity, compared with activity before the application of aflatoxins, persisted until the 23rd day; in the case of LDH and GLDH the increase persisted until the 38th day from the application of aflatoxins. The activities of gamma-GTP and AP were slightly higher even on the 50th day. The increased concentration of bilirubin in plasma lasted until the 23rd day from aflatoxin application. The increased activities of enzymes testify to an impaired function of the liver, which is also proved by the specific enzymes GLDH, gamma-GTP, by increased bilirubin levels, and by histological changes known from literature. The evaluation of enzymatic activities and bilirubin concentration in plasma can make a valuable contribution to correct diagnosis of aflatoxicoses in cattle.

[Isolation of a toxicogenic strain of the fungus, Aspergillus flavus, and characteristics of the produced aflatoxins]. / Izolace toxigenního kmene plísne Aspergillus flavus a charakteristika produkovaných aflatoxinu

The authors demonstrate the production of the B1 aflatoxin by means of a strain of the fungus Aspergillus flavus which was captured on cereal feed in spring 1975. Besides the production of the mycotoxin, this fungus strain showed a very quick and intensive growth and development, in comparison with the laboratory strains of Aspergillus flavus. The obtained and isolated aflatoxin B1 could be identified by chromatography and spectral photometry only when the fungus strain was cultivated on a suitable substrate where it showed the lowest producting of the distrubing fluorescent metabolism by-products. That finding led to the conclusion that in some cases it is necessary, besides the classically used procedure of the diagnosis of aflatoxicosis, to require also the isolation of the possibly present strain of Aspergillus flavus and--after its recultivation in pure cultures on suitable media--the determination of aflatoxin production connected with their physical and chemical identification.