Preoperative nutritional support in cancer patients with no clinical signs of malnutrition--prospective randomized controlled trial.

PURPOSE: Preoperative nutrition is beneficial for malnourished cancer patients. Yet, there is little evidence whether or not it should be given to nonmalnourished patients. The aim of this study was to assess the need to introduce preoperative nutritional support in patients without malnutrition at qualification for surgery. METHODS: This was a prospective, two-arm, randomized, controlled, open-label study. Patients in interventional group received nutritional supplementation for 14 days before surgery, while control group kept on to their everyday diet. Each patient's nutritional status was assessed twice--at qualification (weight loss in 6 months, laboratory parameters: albumin, total protein, transferrin, and total lymphocyte count) and 1 day before surgery (change in body weight and laboratory parameters). After surgery, all patients were followed up for 30 days for postoperative complications. RESULTS: Fifty-four patients in interventional and 48 in control group were analyzed. In postoperative period, patients in control group suffered from significantly higher (p < 0.001) number of serious complications compared with patients receiving nutritional supplementation. Moreover, levels of all laboratory parameters declined significantly (p < 0.001) in these patients, while in interventional arm were stable (albumin and total protein) or raised (transferrin and total lymphocyte count). CONCLUSIONS: Preoperative nutritional support should be introduced for nonmalnourished patients as it helps to maintain proper nutritional status and reduce number and severity of postoperative complications compared with patients without such support.

[Pseudomyxoma peritonei spread into the right inguinal hernia sac--a case report]. / Sluzak rzekomy otrzewnej ze wszczepem do worka przepukliny pachwinoweJ prawel--opis przypadku.

Pseudomyxoma peritonei (PMP) is a rare, progressive disease of unknown origin. The incidence is estimated at about 1-2/100,000,000 per year. The primary tumor site is usually discovered in the appendix or- in case of women--in ovaries, appearing as tumors of low malignancy. Making an accurate diagnosis causes difficulties--symptoms tend to be misleading, suggesting more frequent pathologies of the abdominal cavity. It is also not rare that the patient is for a long time asymptomatic. We present a case of a 68-year-old patient of the Surgical Oncology Department treated for pseudomyxoma peritonei, diagnosed incidentally at the time of clinical examination for the reasons of chronic hypertension. The symptoms reported by the patient did not suggest any neoplastic process of the peritoneal cavity. Systemic chemotherapy of two paths (a total number of 10 cycles) did not result and at the time of post-treatment control, due to no response to standard chemotherapy, it was decided to administer chemotherapy intraperitoneally in hyperthermia (HIPEC). During the operation, peritoneal cytoreduction prior to the scheduled HIPEC was performed; the right-sided inguinal hernia was repaired. Within the hernia sac the implanted myxoid cells were found, their presence inside was probably the main reason of clinical manifestation of the disease.

The analysis of the therapeutic decisions in a patient with gigantic ovarian leiomyoma.

Complicated or unusual cases appear in clinical practice. It's important to know how to react when we face clinical difficulty. The more unusual the case, the longer or more demanding the decision-making process is. In this case we present a patient with a gigantic ovarian tumor whose diagnosis was overturned, and the choice of the surgical procedure changed, which makes this case a very educative example of why we should consult our patients, whenever we may encounter doubts or difficulties in a therapeutic process.

Case Report: Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Application in Intraperitoneally Disseminated Inflammatory Myofibroblastic Tumor and in the Youngest Patient in the World: New Indication and Modification of Technique.

Introduction: Peritoneal metastases occur in cancers that spread to the peritoneal cavity and indicate the advanced stage of the disease. In children they are mainly seen in sarcomas, Gastrointestinal Stromal Tumors and primary disseminated ovarian tumors. Inflammatory Myofibroblastic Tumor (IMT) is a very rare lesion, characterized by an unpredictable clinical course. The absorption of chemotherapeutic agents through the peritoneal-plasma barrier (PPB) is minimized, thus HIPEC procedure limits the systemic exposure to chemotherapy and permits the administration of its higher doses. The main purpose of HIPEC is to remove the visible macroscopic disease in order to achieve complete cytoreduction (CRS). HIPEC Procedure in Children: Several papers deal with the CRS and HIPEC in children and adolescents, however pediatric experience is still limited. Thus far, the HIPEC procedure has been carried out on patients over 2 years old. The most common indication for the surgery and the best outcome was experienced by patients with desmoplastic small round cell tumor (DSRCT). Most patients received intraperitoneal cisplatin. HIPEC Modification: A 5-month-old infant was admitted to the Department of Pediatric Oncology due to the abdominal distention and blood in the stool. The Computed Tomography (CT) revealed a solid-cystic mass in the right abdominal area. The primary tumor and numerous peritoneal metastasis were removed and the Inflammatory Myofibroblastic Tumor (IMT) was diagnosed. The patient underwent subsequently CRS and modified HIPEC procedure. To avoid overheating of the infant, the intraperitoneal normothermic chemoperfusion was performed. Due to the low body weight a modified dosage of intraperitoneal doxorubicin was used. The child underwent standard postoperative chemotherapy and received crizotinib therapy. At 12 months follow-up since treatment completion the patient remains in complete remission. To our knowledge this is the youngest patient, the only infant and the first pediatric patient with IMT who underwent the modified HIPEC procedure in the world. Conclusions: CRS and HIPEC is technically possible also in infants. For its safe course patients selection and technique modification are necessary. Use of HIPEC should be also considered in intraperitoneally disseminated IMT. A complete cytoreductive surgery as the first HIPEC step seems to be the key factor in survival.

Guidelines of the Association of Polish Surgeons and the Polish Society of Surgical Oncology on the accreditation of healthcare centers providing cytoreductive surgery and HIPEC for primary and secondary peritoneal cancers.

Surgical interventions in patients with peritoneal metastases combined with hyperthermic intraperitoneal chemotherapy (HIPEC) and systemic treatment are becoming more common and, when applied to selected patient groups, they reach 5-year survival rates of 32-52%. Good clinical outcomes require experienced and well-equipped healthcare centers, experienced surgical team and adequate patient qualification process. As a result of the discussion on the need for evaluation of quality of care and treatment outcomes and at the request of the Peritoneal Cancer Section of the Polish Society of Surgical Oncology, accreditation standards have been developed and the Accreditation Committee has been established for healthcare centers providing cytoreductive surgery and HIPEC for the management of primary and secondary peritoneal cancers.

Hyperthermic intraperitoneal chemotherapy (HIPEC) in combined treatment of locally advanced and intraperitonealy disseminated gastric cancer: A retrospective cooperative Central-Eastern European study.

BACKGROUND AND OBJECTIVES: Clinical experience in Western Europe suggests that cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are promising methods in the management of gastric cancer (GC) with peritoneal metastases. However, there are almost no data on such treatment results in patient from Central-Eastern European population. METHODS: A retrospective cooperative study was performed at 6 Central-Eastern European HIPEC centers. HIPEC was used in 117 patients for the following indications: treatment of GC with limited overt peritoneal metastases (n = 70), adjuvant setting after radical gastrectomy (n = 37) and palliative approach for elimination of severe ascites without gastrectomy (n = 10). RESULTS: Postoperative morbidity and mortality rates were 29.1% and 5.1%, respectively. Median overall survival in the groups with therapeutic, adjuvant, and palliative indications was 12.6, 34, and 3.5 months. The only long-term survivors occurred in the group with peritoneal cancer index (PCI) of 0-6 points without survival difference in groups with PCI 7-12 vs PCI 13 or more points. CONCLUSIONS: GC patients with limited peritoneal metastases can benefit from CRS + HIPEC. Hyperthermic intraperitoneal chemotherapy could be an effective method of adjuvant treatment of GC with a high risk of intraperitoneal progression. No long-term survival may be expected after palliative approach to HIPEC.

94% accuracy of intraoperative imprint touch cytology of sentinel nodes in skin melanoma patients.

UNLABELLED: The aim of the present study was to assess whether the reliability of imprint touch cytology (ITC) of sentinel nodes in skin melanoma patients allows intraoperative decisions regarding simultaneous radical lymphadenectomy to be made. PATIENTS AND METHODS: The results of ITC of sentinel nodes were compared with the results of standard histopathological and immunohistochemical examinations. RESULTS: A total of 148 sentinel nodes were identified in 98 lymph node groups in 85 skin melanoma patients. ITC revealed the presence of metastases in 7 out of 16 melanoma-positive sentinel nodes (sensitivity, 43.7%). There were no false-positive results of ITC of sentinel nodes (specificity, 100%). The negative predictive value of ITC was 93.6%, the positive predictive value was 100%, and the accuracy of the method was 93.9%. CONCLUSION: ITC of sentinel nodes is a reliable method. There was no risk of overtreatment due to false-positive results of sentinel node ITC in our study. High accuracy of the method warrants its clinical use.

Przerzuty do otrzewnej raka jelita grubego.

Czestosc przerzutów do otrzewnej w raku jelita grubego wynosi 5%-15% w przypadku przerzutów synchronicznych i az 40% w przypadku wystapienia wznowy miejscowej. Najlepsze wyniki leczenia uzyskuje sie poprzez skojarzone wykonanie zabiegu cytoredukcyjnego w polaczeniu z dootrzewnowa chemioterapia perfuzyjna w hipertermii (HIPEC). Wyniki takiego leczenia sa zdecydowanie lepsze i pozwalaja na osiagniecie przezyc 5-letnich na poziomie 30%-50%. Zabiegi te wymagaja duzego doswiadczenia w chirurgii jamy brzusznej, sa czasochlonne (sredni czas procedury chirurgicznej wynosi 6-8 godzin) i obarczone powiklaniami zwiazanymi nie tylko z zabiegiem operacyjnym, ale takze podaniem cytostatyku do jamy otrzewnej w podwyzszonej temperaturze (41,5 st. C). Chorzy po zabiegu wymagaja pobytu na oddziale intensywnej terapii, co jest zwiazane z wystapieniem potencjalnych powiklan spowodowanych rozlegloscia zabiegu, dlugoscia procedury chirurgicznej, zastosowaniu chemioterapii w polaczeniu z hipertermia. Prowadzenie pooperacyjne tych chorych wymaga doswiadczenia calego zespolu lekarskiego i pielegniarskiego. Zabiegi cytoredukcyjne w polaczeniu z HIPEC jako wysoce specjalistyczne procedury medyczne powinny byc merytorycznie ocenione pod katem korzysci dlugoterminowych dla chorych i odpowiednio skalkulowane pod wzgledem realnej wysokosci refundacji. Jako procedura zalecana w wytycznych Kionsultanta Krajowego d.s. Chirurgii Onkologicznej oraz wytycznych ESMO, niezbedna jest jej realna wycena i refundacja pokrywajaca jej calkowite srednie koszty.

Peritoneal metastases of colorectal origin - cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). The financial aspect.

The incidence of peritoneal carcinomatosis of colorectal cancer amounts to 5%-15% for synchronous metastases and as much as 40% in cases of local recurrence. Best results are obtained for cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC). This treatment offers much better outcomes, leading to 5-year survival rates of as much as 30%-50%. The procedures require significant experience in abdominal surgery, are time-consuming (mean duration of the procedure ranging from 6 to 8 hours) and are burdened by complications that are due not only to the procedure itself but also to the intraperitoneal administration of the cytostatic drug at elevated temperature (41.5 °C). After the procedure, patients are required to be admitted to intensive care units due to potential complications associated with the extent and duration of the procedure as well as chemotherapy administered in hyperthermia. Postoperative management of these patients requires appropriate experience of the entire medical and nursing team. Cytoreductive surgeries combined with HIPEC as highly specialized medical procedures should be assessed for their potential long-term benefits and their costs should be appropriately calculated with consideration to realistic reimbursement rates. Realistic valuation and reimbursement covering the overall average cost of the procedure is recommended by the National Consultant in Surgical Oncology as well as the ESMO consensus guidelines.

Possibilities of improving the parameters of hyperthermia in regional isolated limb perfusion using epidural bupivacaine and accurate temperature measurement of the three layers of limb tissue.

The present study presents the author's modification of the method, which aims to create proper parameters of the treatment. The selected group consisted of 15 women and eight men, with a mean age of 57.2 years (range from 26 to 72 years). The patients were divided into two groups, depending on whether they were given epidural bupivacaine (group I - 13 patients treated between the years 2001 and 2004) or not [group II (control) - 10 patients treated earlier, between the years 1997 and 2000]. We observed a significant change in the temperature of thigh muscles (P=0.009) and shank muscles (P=0.006). In the control group II, there was a statistically significant difference (P=0.048) in the temperatures between the muscles and subcutaneous tissue on the one hand and the shank skin on the other. That difference was mean 0.67 degrees Celsius (from 0.4 to 0.9) during the perfusion after applying the cytostatic. The temperature of the skin was lower than the temperature of the deeper tissues of the shank and did not exceed 39.9 degrees Celsius. Such a difference in the temperatures was not observed in case of the group I patients who were given bupivacaine into the extrameningeal space before applying the cytostatic. The difference in the temperatures was on average 0.26 degrees Celsius and was not statistically significant (P=0.99), whereas the shank skin temperature was 40.0-40.6 degrees Celsius. The attained results imply that despite the noticeable improvement in the heating of the limb muscles after application of bupivacaine, the improvement in the heating of the skin and subcutaneous tissue is still not satisfactory, although the growing tendency implies such a possibility.

Coexistence of hepatocellular carcinoma and gastrointestinal stromal tumor: a case report.

Malignant gastrointestinal stromal tumors (GIST) are rare mesenchymal tumors originating from the wall of the gastrointestinal tract. Their coexistence with other tumors originating from other germ layers is unique. We have reported a case of a 63-year-old GIST patient presenting as an epigastric mass associated with hepatic tumor. Histologically, the mesenteric tumor was composed of spindle cells showing both neural and smooth muscle differentiation. Immunohistochemical examination showed positive staining for CD117, vimentin, S-100, and SMA, while CD34 antigen was negative. The hepatic tumor was diagnosed as hepatocellular carcinoma (HCC). To the best of our knowledge, this is the first case of GIST and HCC coexistence. The rarity of the case, however, should not lead to ignoring such a possibility in differential diagnosis.

K-RAS point mutation, and amplification of C-MYC and C-ERBB2 in colon adenocarcinoma.

The routine multidisciplinary management of colon cancer is based mainly on tumor staging, histology, grading and vascular invasion. In this approach, important individual information derived from molecular characteristics of the tumor may be missed, especially since significant heterogeneity of molecular aberrations in cancer cells has been observed, and recognition of every of relationships between them may be of value. K-RAS, C-MYC and C-ERBB2 are protooncogenes taking part in carcinogenesis and tumor progression in the colon. They influence cell proliferation, differentiation and survival. K-RAS point mutation, as well as amplification of C-MYC and C-ERBB2 were searched in 84 primary colon adenocarcinomas resected with curative intent. Multiplex polymerase-chain reaction and restriction fragment length polymorphism were performed to assess codon 12 K-RAS point mutation. Amplification of C-MYC and C-ERBB2 genes was evaluated by densitometry after agarose gel separation of the respective multiplex PCR products. No relation was found among mutated and/or amplified genes, and between searched molecular aberrations and pathoclinical features. In multivariate analysis, nodal status appeared to be the only independent prognostic indicator. In colon adenocarcinoma, codon 12 K-RAS point mutation and amplification of C-MYC and C-ERBB2 seem to occur independently in the process of tumor progression. Amplification of C-ERBB2 tends to associate with more advanced stage of disease. Concomitant occurrence of codon 12 K-RAS mutation, C-MYC and C-ERBB2 amplification was of no prognostic value in respect to survival.

Comparison of peritumoral and subareolar injection of Tc99m sulphur colloid and blue-dye for detection of the sentinel lymph node in breast cancer.

BACKGROUND: The new trend in diagnosis of the lymph node is sentinel node biopsy. This method has become increasingly accepted as a minimally invasive alternative to routine axillary dissection. Although the results of numerous studies have shown that sentinel node biopsy can accurately determine the axillary nodal status, the identification rates and false-negative rates have been variable. The sentinel lymph node is defined as the first node in the lymphatic basin that receives the primary lymphatic flow. MATERIAL AND METHODS: Between September 1998 and August 2002 123 patients with primary operative breast cancer without clinical palpable axillary lymph nodes were enrolled in the study. There were two groups of patients according to sentinel node identification technique: 51 patients (Group I) received parenchymal, peritumoral injection of 1.0 ml of 16 MBq Tc(99m)-radiolabelled sulphur colloid and single intradermal injection of blue-dye over the tumour. The next 72 patients (Group II) received intradermal, periareolar one-site injection of 0.5 ml of 16 MBq Tc(99m)-radiolabelled sulphur colloid and blue-dye. RESULTS: Sentinel lymph node was found in 41 (80.4%) cases in Group I and in 67 (93.0%) cases in Group II (p = 0.028). The localisation of the axillary lymph node as a "hot spot" visualised by lymphoscintigraphy was successful in 39/51 (76.5%) cases in Group I and 67/72 (93.0%) in Group II, p = 0.004). In both groups the success of sentinel node identification in the axillary region by lymphoscintigraphy was connected with sentinel lymph node finding during surgery (Group I: p < 0.001, Group II: p < 0.001). CONCLUSIONS: This study shows that intradermal, periareolar one-site injection of Tc(99m)-radiolabelled sulphur colloid and blue-dye is superior to peritumoral 4-sites injections Tc(99m)-radiolabelled sulphur colloid and single intradermal injection of blue-dye over the tumour in sentinel lymph node identification.

Endoscopic submucosal dissection of gastric ectopic pancreas.

Patients with gastric tumors usually present with symptoms of discomfort or pain in the epigastrium, regurgitations, nausea, vomiting or melena. Treatment options include open and laparoscopic total or partial gastrectomy and recently endoscopic mucosal resection. A case of successful endoscopic submucosal dissection is described with the unusual pathological finding of heterotopic pancreatic tissue forming a gastric tumor. The 67-year-old male patient was operated on due to the initial diagnosis of gastro-intestinal stromal tumor of the gastric trunk. Two intra-operative biopsies were negative for cancer cells. Submucosal endoscopic dissection was performed with IT and Hook knives (Olympus). A literature review was performed. The operative time was 180 min with hospital stay of 6 days. During the injection of the carmine dye and the air insufflation pneumoperitoneum occurred and remained clinically silent during the observation period. The pathology result showed a heterotopic pancreatic tissue type 2 according to Heinrich's classification with microfoci of intestinal metaplasia. Preoperative diagnostics of gastric masses might be misleading and such tumors not necessarily should be excised. There are several surgical options with endoscopic submucosal dissection being probably the safest one and a non-disabling approach. Patients tolerate that kind of surgery well with good postoperative functional outcomes.

Paraesophageal hernia repair followed by cardiac tamponade caused by ProTacks.

We describe a case of cardiac tamponade caused by ProTacks Autosuture used for mesh fixation during a laparoscopic Nissen operation with giant paraesophageal hernia repair. Perforations of the posterior descendent artery and epicardial vein of the right ventricle were caused by ProTacks used for Parietex Composite Mesh fixation. Protruding ProTacks were secured from inside the pericardiac sac with a synthetic vascular patch during emergency sternotomy. Quick and multidisciplinary cooperation ended with emergency cardiothoracic procedure saving the patient's life and preventing further damage to the heart muscle and its vessels.

Totally laparoscopic feeding jejunostomy - a technique modification.

In oncological patients with upper gastrointestinal tract tumours, dysphagia and cachexy necessitate gastrostomy or jejunostomy as the only options of enteral access for long-term feeding. In this article the authors describe a modified technique of laparoscopic feeding jejunostomy applied during the staging laparoscopy. A 48-year-old male patient with gastroesophageal junction tumour and a 68-year-old male patient with oesophageal tumour were operated on using the described technique. Exploratory laparoscopy was performed. Then the feeding jejunostomy was made using a Cystofix(®) TUR catheter. The jejunum was fixed to the abdominal wall with four 2.0 Novafil™ transabdominal stitches. Two additional sutures were placed caudally about 4 cm and 8 cm from the jejunostomy, aiming at prevention of jejunal torsion. Total operating time was 45 min. There was no blood loss. There were no intraoperative complications. The only adverse event was one jejunostomy wound infection that responded well to oral antibiotics. There were no mortalities. The described technique has most of the benefits of laparoscopic feeding jejunostomy with some steps added from the open operation making the procedure easier to perform as part of a staging operation with a relatively short additional operating time. The proposed transabdominal stitches make the technique easier to apply. Two additional 'anti-torsion sutures' prevent postoperative volvulus. Use of the Cystofix catheter allows easy introduction of the catheter into the peritoneal cavity and the jejunal lumen, providing a good seal at the same time. Further studies on larger groups of patients are required to assess long-term outcomes of the proposed modified technique.