Stroke-Associating Acute Limb Ischemia Due to the Rupture of a Hydatid Cyst.

(1) Background: Hydatidosis, or human cystic echinococcosis, is a zoonotic disease. Endemic in some areas, recently it has an increasing incidence in wider regions, determined by population migration. Clinical features depend on the localization and level of infection: asymptomatic or with signs related to hypersensitivity, organic functional deficiencies, expanding mass effects, cyst infection and sudden death. In rare cases, the rupture of a hydatid cyst causes emboli formation by the residual laminated membrane. (2) Methods: We performed an extensive literature review, starting from the case of a 25-year-old patient presenting with neurologic symptoms relevant for acute stroke, associating right upper limb ischemia. (3) Results: Imaging investigations revealed the source of the emboli as the rupture of a hydatid cyst, the patient presenting multiple pericardial and mediastinal localizations. Cerebral imaging confirmed an acute left occipital ischemic lesion, with complete recovery of the neurological deficit after therapy, while surgery for acute brachial artery ischemia had a favorable postoperative evolution. Specific anthelmintic therapy was initiated. An extensive literature review using available databases revealed the scarcity of data on embolism as a consequence of cyst rupture, highlighting the significant risk of clinicians overlooking this possible etiology. (4) Conclusions: An associated allergic reaction should raise the hypothesis of a hydatid cyst rupture as a cause of any level acute ischemic lesion.

A Surgical Challenge Generated by Colonic Malakoplakia in Disguise as a Locally Advanced Colonic Malignancy-A Case Report.

Colonic malakoplakia is an uncommon granulomatous development of cells resulting from the impaired capacity of the mononuclear cells to eliminate the phagocytosed bacteria, and in rare cases it can also affect the gastrointestinal tract. We report the case of a 78-year-old female patient that was admitted to hospital by The Emergency Department with the diagnosis of bowel obstruction, confirmed by the clinical and paraclinical investigations. We decided to surgically manage the case for suspicious symptomatic colonic neoplasm. The histological examination of the surgical specimens revealed colonic malakoplakia, characterized by the presence of the aggregated granular histiocytes and Michaelis-Gutmann bodies. Through this paper, we want to raise awareness for Malakoplakia, which remains an extremely rare disease that may affect multiple organs, and because it does not present specific symptoms or clinical manifestations, the final diagnosis remains the histopathological study. The clinical conduct should be decided after taking into consideration all the aspects of this pathology along with the benefits and risks for the patient.

Exploring the Dynamic Role of Bacterial Etiology in Complicated Urinary Tract Infections.

Background and Objectives. Numerous studies have been conducted to explore the epidemiological characteristics of urinary tract infections (UTI) and sepsis. However, there is still a lack of relevant bacteriological features and prognostic information regarding urosepsis based on bacteriological etiology. The current study aims to evaluate the bacterial etiology of complicated UTI (cUTI) and bacterial resistance to antibiotics and whether they present an intrinsic risk of developing urosepsis. Materials and Methods. A retrospective study was performed that included 102 patients who were diagnosed with cUTI and admitted to the urology department of the "Sfântul Apostol Andrei" County Emergency Clinical Hospital (GCH) from September 2019 to May 2022. Results. A considerable number of patients, n = 41 (40.2%), were diagnosed with multi drug-resistant (MDR) infection. Escherichia coli (E. coli) was identified as the prevailing pathogen, accounting for 51 patients. Klebsiella manifested itself as the subsequent causative agent in 27 instances. The presence of Enterococcus spp. infection was documented in 13 patients, whereas Pseudomonas emerged as the etiological perpetrator in the clinical context of 8 patients. The current study found a substantial prevalence of resistance to first-line antibiotics. The overall resistance rate was 74.5% for penicillin, 58.82% for trimethoprim-sulfamethoxazole and 49% for fluoroquinolones; cephalosporin resistance displayed an inverse correlation with antibiotic generation with fourth-generation cephalosporins exhibiting a resistance rate of 24.5%, and first-generation cephalosporins demonstrating a resistance rate of 35.29%. Conclusions. Age, comorbidities and indwelling urinary catheters are risk factors for developing MDR infections. While the intrinsic characteristics of the causative bacterial agent in cUTI may not be a risk factor for developing urosepsis, they can contribute to increased mortality risk. For empiric antibiotic treatment in patients with cUTI who are at a high risk of developing urosepsis and experiencing a potentially unfavorable clinical course, broad-spectrum antibiotic therapy is recommended. This may include antibiotics, such as amikacin, tigecycline, carbapenems and piperacillin-tazobactam.

Validation of a New Prognostic Score in Patients with Ovarian Adenocarcinoma.

Background and Objectives: This study aimed to assess the impact of clinical prognostic factors and propose a prognostic score that aids the clinician's decision in estimating the risk for patients in clinical practice. Materials and Methods: The study included 195 patients diagnosed with ovarian adenocarcinoma. The therapeutic strategy involved multidisciplinary decisions: surgery followed by adjuvant chemotherapy (80%), neoadjuvant chemotherapy followed by surgery (16.4%), and only chemotherapy in selected cases (3.6%). Results: After a median follow-up of 68 months, in terms of progression-free survival (PFS) and overall survival (OS), Eastern Cooperative Oncology Group (ECOG) performance status of 1 and 2 vs. 0 (hazard ratio-HR = 2.71, 95% confidence interval-CI, 1.96-3.73, p < 0.001 for PFS and HR = 3.19, 95%CI, 2.20-4.64, p < 0.001 for OS), menopausal vs. premenopausal status (HR = 2.02, 95%CI, 1.35-3,0 p < 0.001 and HR = 2.25, 95%CI = 1.41-3.59, p < 0.001), ascites (HR = 1.95, 95%CI 1.35-2.80, p = 0.03, HR = 2.31, 95%CI = 1.52-3.5, p < 0.007), residual disease (HR = 5.12, 95%CI 3.43-7.65, p < 0.0001 and HR = 4.07, 95%CI = 2.59-6.39, p < 0.0001), and thrombocytosis (HR = 2.48 95%CI = 1.72-3.58, p < 0.0001, HR = 3.33, 95%CI = 2.16-5.13, p < 0.0001) were associated with a poor prognosis. An original prognostic score including these characteristics was validated using receiver operating characteristic (ROC) curves (area under the curve-AUC = 0.799 for PFS and AUC = 0.726 for OS, p < 0.001). The median PFS for patients with none, one, two, three, or four (or more) prognostic factors was not reached, 70, 36, 20, and 12 months, respectively. The corresponding median overall survival (OS) was not reached, 108, 77, 60, and 34 months, respectively. Conclusions: Several negative prognostic factors were identified: ECOG performance status ≥ 1, the presence of ascites and residual disease after surgery, thrombocytosis, and menopausal status. These led to the development of an original prognostic score that can be helpful in clinical practice.

Correlation Between Serum Procalcitonin Levels and 28-Day Mortality in Patients with Surgical Sepsis and Septic Shock.

Background: Sepsis is a major medical emergency accounting for approximately 48.9 million cases and 11 million deaths worldwide, representing 19.7% of all global deaths. This study was conducted to evaluate the correlation between procalcitonin values and 28-day mortality. Methods: A retrospective study was conducted that included patients with sepsis and septic shock, treated in the surgical departments of the Sf. Apostol Andrei Galati County Emergency Clinical Hospital between January 2020 and December 2021. Results: 125 patients (mean age 65 years), mostly men (56%, n=70) were included. The mean procalcitonin value at admission in the sepsis group (28%, n=35) was 5.98 ng/mL, and in the septic shock group (72%, n=90) was 40.09 ng/mL. The most significant correlation was between procalcitonin at discharge, 28-day mortality (r = 0.437; p 0.0001) and SOFA score (r = 0.356; p 0.0001). Conclusions: Procalcitonin at discharge was positively correlated with 28-day mortality and SOFA score. The procalcitonin value at discharge can be used in the prognosis of the patient with surgical sepsis, but for better results the association between procalcitonin, SOFA score and the clinical status of the patient is recommended.

Oral Mucositis Induced by Chemoradiotherapy in Head and Neck Cancer-A Short Review about the Therapeutic Management and the Benefits of Bee Honey.

Background and Objectives: Oral mucositis, a severe non-hematological complication, can be induced by chemoradiotherapy. It is associated with severe local dysfunction, severely affecting the patient's quality of life; it increases the risk of oral infections and interrupts oncological treatment, thus prolonging the duration and cost of hospitalization. Besides all of the agents used in the prevention and treatment of oral mucositis induced by oncological treatment, can there be found an easier one to administer, with an effective preparation, high addressability, both for adults and paediatric patients, without side effects, and at the same time cheap and easy to purchase? The aim of the present paper is to demonstrate the existence of this product, which is available to everyone, having multiple benefits. Materials and Methods: For the purpose of writing this article, materials were searched in electronic databases in between 2019 and 2021, taking into consideration papers where authors have demonstrated the effectiveness of this product through its topical or systemic use. Results: Numerous studies have highlighted the benefits of honey on oral mucositis. Through its analgesic, anti-inflammatory, anti-cancerous and antibacterial action, honey has proved to have a major impact on the patient's quality of life and nutritional status by promoting tissue epithelialization and healing of the chemoradiotherapy-induced lesions. Conclusions: Superior to many natural agents, bee honey can be successfully used in both preventing and treating oral mucositis. There are currently numerous studies supporting and recommending the use of bee honey in the management of this oncological toxicity.

The Urosepsis-A Literature Review.

Urosepsis is a very serious condition with a high mortality rate. The immune response is in the center of pathophysiology. The therapeutic management of these patients includes surgical treatment of the source of infection, antibiotic therapy and life support. The management of this pathology is multidisciplinary and requires good collaboration between the urology, intensive care, imaging and laboratory medicine departments. An imbalance of pro and anti-inflammatory cytokines produced during sepsis plays an important role in pathogenesis. The study of cytokines in sepsis has important implications for understanding pathophysiology and for development of other therapeutic solutions. If not treated adequately, urosepsis may lead to serious septic complications and organ sequelae, even to a lethal outcome.

Challenges and Solutions in Choosing the Surgical Treatment in Patients with Complicated Colon Cancer Operated in an Emergency - A Retrospective Study.

Introduction: Choosing the optimal treatment for patients with complicated colon cancer operated in an emergency remains a challenge. The study aims to identify the factors that influence the therapeutic decision in these patients. Patients and Methods: We included in this retrospective study 449 patients operated in emergency for complicated colon cancer, in the Clinical Emergency County Hospital "St. Ap. Andrei" Galati between 2008-2017. The patients data were collected from the observation sheets, the surgical, imaging and laboratory protocols. Results: The operations performed were: resections with a stoma in 37.63% of cases, resections with anastomosis in 36.97%, stomas in 16.26% and internal derivations in 9.13% of patients. Elderly age was correlated with stomas with or without tumour resection (p 0.05). Preoperative diagnosis of IDH was associated with resections with anastomosis, those with occlusion were associated with internal derivations and those with digestive perforations with resections with a stoma (p 0.05). The stomas were associated with the presence of intraoperatively detected complications (p 0.05). Conclusions: Complicated colon tumours operated on in an emergency require surgical treatment tailored to each patient. It is important to choose the type of treatment taking into account the patient's condition at admission, clinical-paraclinical data, tumour location, tumour complication and the presence of other complications detected intraoperatively.

Cutaneous and Inguinal Lymph Nodes Metastases Disseminated from an Endometrial Serous Carcinoma - Case Report and Literature Review.

Cutaneous metastases from endometrial cancer are rare and unusual. This is the case of a 72 years old female patient, diagnosed in 2018 with G3 endometrial serous carcinoma (ESC). At 18 months from the surgical intervention, the patient developed bilateral inguinal lymph nodes metastases and skin secondary lesions; histological and immunohistochemical tests were performed. Computed tomography scan did not indicate visceral secondary lesions, local or regional relapses. We present the treatment practiced, the case's evolution and we discuss about epidemiology, molecular biology, treatment options and management of advanced and local lesions. The appearance of skin metastases in theses cases is associated with poor prognosis and treatment options are limited to palliative chemotherapy and radiotherapy.

Management of Epicardial Metastasis in Breast Cancer.

Background: Cardiac metastasis may be encountered more frequently than primary cardiac tumors. They are discovered at autopsies with an incidence between 1.5 - 20%. The primary tumors that generate cardiac metastasis are malignant melanomas, lymphoma, the lungs, the breast, the esophagus. The organ most affected is the pericardium (62-81%). In 90% of cases from a clinical point of view, they are generally silent. In the case of patients diagnosed with breast cancer and who have undergone radiotherapy, differential diagnosis with fibrosis post radiotherapy interferes. The treatment is palliative and should be administered according to the primary location of the tumor and the patient's performance status. Case presentation: We are presenting the case of a 73-year-old diagnosed and treated for a breast neoplasm in the left breast in 2006. After a period of time of 9 years, the patient presents secondary sternal bone determination, radio-treated and for which she once again goes under hormonal therapy. In 2018, patient performed an imaging evaluation that revealed lung metastases. At the moment of stage review, performed in 2020, secondary epicardial determinations are noted. We present the case, the therapeutic management, diagnostic procedures and treatment and also, we discuss the data from literature. Conclusion: Cardiac metastases are rare and and in most cases are silent. The incidence has changed due to treatment options and imaging investigations. Stereotactic body radiation therapy can be considereda a therapeutic option in the cases with good performance status and with oligometastatic disease.

Perforated Ileal GIST Associated with Meckel Diverticulum - A Rare Pathological Entity of Surgical Acute Abdomen.

Introduction: The GIST tumors are very rare entities ( 1% of all tumors). They originate in the Cajal interstitial cells, which are part of the autonomic nervous system of the intestine. Their most common location is the stomach, followed by the small intestine. The aim of this paper is to present a very rare case of perforated ileal GIST, associated with Meckel diverticulum. Case report: A 71 years old patient with comorbidities is admitted in emergency for symptoms and signs of acute surgical abdomen. The exploratory laparotomy reveals generalized acute peritonitis due to perforated ileal tumor and Meckel's diverticulum. A segmental enterectomy is performed, with favorable postoperative evolution. The histological examination of the resection piece shows the appearance of GIST, confirmed immunohistochemically. Conclusions: The GIST tumors of the small intestine are unusual tumors and the spontaneous perforation and life-threatening hemorrhage are a rarity. The main treatment for this form of GIST is the resection, with a favorable clinical outcome.

Innovative Surgical Approaches That Improve Individual Outcomes in Advanced Breast Cancer.

Breast cancer is the most common cause of cancer death in women and the second cause in the general population. The incidence has increased over time. Women in developing countries often present at an advanced stage where initial surgery is not feasible. Short disease-free intervals, the number of metastatic organs and liver metastasis were consistently associated with poor overall survival. Surgery is an integral part of the therapeutic plan for locally advanced breast cancer. The integration of surgical care into the management of patients with advanced cancer has changed substantially with the use of neoadjuvant chemotherapy. Also, more recently, neoadjuvant endocrine therapy and targeted therapies offer new opportunities to downsize the tumor burden and transform the role of surgery for this population from palliation to largely curative intent. Innovative surgical approach to the primary tumor in metastatic disease may provide survival benefits and local control in some patients. Similar to systemic therapy, surgical therapy for secondary dissemination should be considered in certain cases for improved individual outcomes. Advances in reconstructive techniques have improved the quality of life of these patients.

Immunotherapy Combined with Radiation in Malignant Melanoma without BRAF Mutations Brain Metastases-Favorable Response after Immunotherapy Continued beyond Progression.

We present the case of a patient who was diagnosed in 2018 with nodular Malignant Melanoma (MM) without BRAF V 600 mutations stage 3 C (pT4b pN1a M0), and who underwent adjuvant citokines treatment with Interferon alpha 2b-48 weeks. Immunotherapy was initiated in January 2021 for lung and lymph node metastases. In June 2021, there was a partial response of the lung and lymph node metastases, but there was also progression to brain metastases. Immunotherapy was continued and Whole Brain Radiotherapy (WBRT) was performed. In September 2023, the imaging investigations revealed a favorable response, with no lesions suggestive of secondary determinations. The combination of Radiotherapy (RT) and Immunotherapy (IT) with Immune Checkpoint Inhibitors (ICI) has an abscopal effect. There is a coordinated action in the combination of RT and IT in order to obtain a common result, with the antitumor effect being greater than if RT or IT acted separately.

Case Report. Diagnostic Challenges: Liver Metastases from Mammary Gland Origin or Cholangiocarcinoma?

Liver metastases are secondary malignant tumor formations due to the dissemination of primary malignant tumors, which are often the first clinical manifestation of mammary cancer. We present the case of a 52-year-old female patient from an urban area who came to the walk-in service at the "Sf. Ap. Andrei" Emergency County Hospital, Galati, for laboratory investigations. These revealed a significant increase in CA 15-3 tumor markers and a slight increase in CA 125 and CA 19-9 markers; however, clinical examination did not reveal tumors in the breast and there were no axillary adenopathies. CT exam revealed a large tumor formation in the hepatic right lobe and, close to it, a smaller one. The mammograph showed millimetric lesions at the level of the left mammary gland and bilateral axillary adenopathies. Subsequently, the patient underwent two liver biopsies in two different hospitals, which produced different histological and immunohistochemical results. PET-CT drew attention to a lung tumor and disclosed a different origin of metastases. In the end, correlating all investigations, the final diagnosis was cholangiocarcinoma with liver metastases and lung tumor with lung and bone metastases.

Considerations Regarding Online Group Psychotherapy Sessions for Breast Cancer Patients in Active Phase of Oncological Treatment.

INTRODUCTION: The aim of this study is to evaluate the results of online group meetings for breast cancer patients in the active phase of treatment. The group therapy sessions took place weekly, synchronously, online, on Zoom, with a total of 12 meetings lasting about 2.5 h per session, between December 2021 and February 2022. We analyzed the topics of discussion chosen by the participants, the structure of the group, the results obtained at the main scales of evaluation/monitoring of quality of life and the motivation of patients to participate in the therapeutic group. All patients were in the active phase of treatment (chemotherapy, radiotherapy, hormone therapy, etc.). The main goal of the group therapy was to reduce the stress related to the disease. MATERIAL AND METHODS: Systematic observations included ABS psychological tests, EQ-5D-5L, HADS-Hospital Anxiety and Depression Scale, and the Recurrence Fear Questionnaire; the questionnaires were administered at the beginning and at the end of the therapeutic intervention; the participation in the therapy and in the research of the patients began after signing the informed consent document; the intervention was evaluated at the end using a feedback questionnaire. The group was closed, and the participants signed an informed consent document and agreed to have the sessions recorded. RESULTS: Comparing the initial with the final results of the psychological tests administered, there was an improvement in the quality of life of the participants in all areas, with a clinically significant decrease in the areas of pain and depression, along with an increase in perception of well-being, a decrease in FoP scores and an increase in the level of rationality about the disease. CONCLUSIONS: Group therapy for cancer patients was useful in improving the quality of life; the closed group, even online, provided a safe environment in which they could share feelings. A close correlation was noted between the scores obtained on the FoP-Q and HADS scales. It is evident that there is a strong relationship between FoP and depression. Results on these scales correlated well with results on the EQ-5D-5L quality of life questionnaire.

Principles of Treatment and Clinical-Evolutionary Peculiarities of Deep Cervical Spaces Suppurations-Clinical Study.

As medical-surgical emergencies, regardless of the causal agent, deep cervical space suppurations are not only a diagnostic challenge, but also a therapeutic one. In some cases, in spite of proper therapeutic measures, extremely severe complications can develop. A 5-year retrospective study (2016-2020) was conducted on a group of 107 patients suffering from cervical suppurations, being hospitalized and treated in the ENT Clinic of the "Sf. Apostol Andrei" Emergency County Hospital of Galați. This research is a clinical-statistical study based on the experience of this ENT clinic and was carried out based on the analysis of the patients' medical records. Descriptive analysis' statistical methods of the data series collected from the clinical observation sheets were used, with the patients' informed consent for the processing of the aforementioned data, with the agreement of the Ethics Commission of the Emergency Clinical Hospital "Sf. Apostol Andrei" Galați and the College of Physicians Galați, România. The patients' clinical and multidisciplinary treatment features included in the study group are presented. The results highlight the clinical particularities of deep cervical space suppurations treatment, including under COVID-19 impact, or with other comorbidities, having consequences on the case mix index increase or directly on the costs, admittance duration and the clinical status of the patient at discharge. The conclusions of the clinical study are based on the fulfillment of the research objectives in terms of treatment and symptomatology of deep cervical space suppurations and under the impact of comorbidities (global health crisis and pandemic, triggering of comorbidities due to health care access difficulty in the context of anti-COVID-19 government-implemented measures and the infection-rate that overburdened the medical system in the early period of the pandemic). Individualized treatment of deep cervical space suppurations is recommended to be approached multidisciplinary. Of particular importance is early diagnosis combined with prompt and correctly instituted multidisciplinary treatment. In this context, an appropriate medical measure that we recommend is patient health education, as it was observed in the clinical study: most times, patients address medical services with advanced disease, hence the generally unfavorable prognosis and outcome (about 25% of patients develop unfavorable prognosis and 4% die).

Prognostic Role of Vascular Endothelial Growth Factor and Correlation with Oxidative Stress Markers in Locally Advanced and Metastatic Ovarian Cancer Patients.

BACKGROUND: Vascular endothelial growth factor (VEGF) plays an important role in tumor progression in ovarian cancer, but the complex mechanism and interaction with oxidative stress are not fully understood. METHODS: A prospective study included 52 patients with ovarian adenocarcinoma stage IIIA-IV. Serum VEGF and reactive oxygen species (ROS) such as malondialdehyde and ceruloplasmin were measured. RESULTS: VEGF levels were elevated (mean 1014.7 ± 165 pg/mL), especially in patients with macroscopic residual disease (1058 vs. 810 pg/mL, p = 0.0001). Median progression-free survival (PFS) and overall survival (OS) were 6 and 40 months in patients with a very high VEGF (over 1200 pg/mL), 11 and 48 months in patients with VEGF between 1000-1200 pg/mL, 18 and 84 months in patients with VEGF between 800-1000 pg/mL, and not reached in patients with normal VEGF. Increased VEGF values were associated with a 2.6-fold increased risk of disease progression (HR = 2.60, 95% CI 1.69-3.99), and a 1.4-fold increased risk of death (HR = 1.4, 95% CI 1.15-1.91, p = 0.002). Receiver operator characteristic (ROC) curves were used to validate VEGF as a prognostic factor and the area under the curve (AUC) was 0.814, p = 0.036 for PFS and 0.729, p = 0.043, for OS. There was a positive correlation between VEGF and malondialdehyde, Pearson coefficient of 0.35, p = 0.0001. CONCLUSIONS: VEGF and malondialdehyde are important prognostic markers in ovarian cancer, especially in macroscopic residual disease, and there is a positive correlation between angiogenesis and oxidative stress.

The Benefits and Challenges of the Multimodal Treatment in Advanced/Metastatic Malignant Melanoma.

Currently, the treatment of malignant melanoma offers the longest and the most studied experience of innovative treatments in malignant pathology. The algorithm of the therapeutic decision in advanced or metastatic melanoma must comprise: the timing of the therapeutic initiation, the sequencing of the specific oncological treatment (radiotherapy and chemotherapy still being therapeutic alternatives in selected cases), the diagnosis and the management of adverse reactions. We present the case of a patient diagnosed with metastatic malignant melanoma in November 2019, who progressed successively under new systemic treatment throughout the 3 years of treatment and experienced skin reactions of various degrees of severity. The comprehensive response to secondary hilar pulmonary lymphatic determinations under subsequent chemotherapy was specific to the presented case. The occurrence of vitiligo secondary to immunotherapy is a favorable prognostic factor, but the occurrence of secondary cerebral determinations is an extremely severe prognostic factor in malignant melanoma and a challenge in making the therapeutic decision. Previous treatment with immune checkpoint inhibitors may trigger a favorable response to systemic chemotherapy. The early and accurate diagnosis of the adverse events of the new therapies requires a multidisciplinary approach, because it can radically change the therapeutic decision.

The Efficacy of Immunotherapy in Long-Term Survival in Non-Small Cell Lung Cancer (NSCLC) Associated with the Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH).

INTRODUCTION: The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is the most common cause of hyponatremia in cancer patients, occurring most frequently in patients with small cell lung cancer. However, this syndrome occurs extremely rarely in patients with non-small cell lung cancer. The results of the clinical trials have revealed that immuno-oncological therapies are effective for long periods of time, providing hope for long survival and with a good quality of life. CASE PRESENTATION: We present the case of a female patient who was 62 years old at the time of diagnosis in 2016 who underwent surgery for a right pulmonary tumor (pulmonary adenocarcinoma) and subsequently underwent adjuvant chemotherapy. The patient had a left inoperable mediastinohilar relapse in 2018, which was treated using polychemotherapy The patient also had an occurrence of progressive metastasis and a syndrome of inappropriate antidiuretic hormone secretion (SIADH) in 2019 for which immunotherapy was initiated. The patient has continued with immunotherapy until the time this study began to be written (April 2023), the results being the remission of hyponatremia, the clinical benefits and long-term survival. DISCUSSION: The main therapeutic option for SIADH in cancer patients is the treatment of the underlying disease, and its correction depends almost exclusively on a good response to oncological therapy. The initiation of immunotherapy at the time of severe hyponatremia occurrence led to its remission as well as the remission of the other two episodes of hyponatremia, which the patient presented throughout the evolution of the disease, demonstrating an obvious causal relationship between SIADH and the favorable response to immunotherapy. CONCLUSIONS: Each patient must be approached individually, taking into account the various particular aspects. Immunotherapy proves to be the innovative treatment that contributes to increasing the survival of patients with metastatic non-small cell lung cancer and to increasing their quality of life.

The Complexity of Treatments and the Multidisciplinary Team-A Rare Case of Long-Term Progression-Free Survival in Prostate Cancer until Development of Liver and Brain Metastases.

INTRODUCTION: Prostate cancer has no initial clinical manifestation in the case of brain metastases since they are asymptomatic at first. This is why there is a high risk for clinicians to overlook these lesions, and they are often confused with other diseases. With all the improvements in diagnostic technological methods, which allow the early detection of lesions, and the progress in terms of systemic therapy associated with increased survival, an increase in incidence has also been noticed. MATERIALS AND METHODS: We report the case of a 64-year-old patient who presented himself to the Oncology Department of "St. Luca" Chronic Disease Hospital in Bucharest in November 2011 and received the following diagnosis: biopsied prostate neoplasm, local-regionally advanced, pelvic lymph node metastases. RESULTS: After receiving complex oncological treatment, this patient represents a rare case of long-term progression-free survival (15 years). DISCUSSIONS: This case has some particularities. According to the literature data, survival with metastatic prostate cancer is approximately 21 months, and cerebral metastases are found in only 2% of prostate cancer cases. This case is one of the few cases in the specialty literature that benefited from all therapeutic sequences; namely, total androgenic blockade, docetaxel, abiraterone, enzalutamide, and cabazitaxel. CONCLUSIONS: Brain metastases are an unfavorable prognostic factor in prostate cancer. The therapeutic options developed in recent years allow the improvement of survival.