Occult breast cancer: a case report and current management of treatment.

Occult breast cancer is a very rare type of cancer which presents with axillary lymphadenopathy with no visible mass in the breast. Advances in imaging methods (MRI, PET/CT, PET/MRI, etc.) have enabled the detection of a large number of lesions which are not visible using basic imaging methods, such as mammography and ultrasound. To date, optimal management of this type of cancer is lacking. Generally, treatment of occult breast cancer is that of primary breast cancer with axillary lymph node involvement. This includes neoadjuvant oncological therapy, axillary dissection with adjuvant radiation therapy and either mastectomy or radiation to the breast. However, several recent studies have shown that similar results may be achieved with less radical treatment. The paper describes the case of a 62-year-old patient with occult breast cancer, the procedure and results of imaging assessments, and subsequently the treatment management. Furthermore, the paper reports on current treatment trends published in the literature.

Role of the radiologist during neoadjuvant systemic therapy for breast cancer.

INTRODUCTION: Neoadjuvant therapy (NT) is one of the possible oncological treatment strategies for breast cancer. Its aim is to achieve down-staging of the tumour in the breast and axilla and thus the possibility of converting mastectomy to a breast-conserving procedure, and also to allow for a less burdensome and more targeted operation of the axillary lymph nodes. The role of the radiologist is to utilise imaging procedures for precise local staging of the malignancy prior to NT, to evaluate the effect of treatment during its course and upon its completion, and to perform restaging of the cancer in the breast and axilla. CASE REPORTS: The authors present three case reports of female patients with breast cancer who underwent neoadjuvant chemotherapy (NCT). They describe the diagnostic procedure and imaging methods used to establish local staging of the cancer prior to treatment, to monitor the disease during the course of treatment, and to perform restaging of the cancer after completing NCT. The radiological response after NCT completion was correlated with the pathological response. CONCLUSION: Correct determination of the extent of the cancer in the breast and axilla by the radiologist before NT and precise histological analysis of the tumour by the pathologist are fundamental for selecting the appropriate treatment for patients at the multidisciplinary breast tumour board.

Esophageal cancer results of surgical treatment at the Department of Surgery I. at the University Hospital Olomouc.

The authors present the results of surgical treatment of esophageal cancer at Department of Surgery I, University Hospital Olomouc between 20062016. The aim of the study was to use retrospective analysis to evaluate the results of patients operated for esophageal cancer and statistically evaluate the results based on the type of surgical approach (transhiatal, transthoracic). Method: A total of 240 patients with esophageal cancer were operated at Department of Surgery I between the beginning of 2006 and the end of 2016. We evaluated respiratory complications, the incidence of anastomotic fistula and complications based on the Clavien-Dindo classification of complications, based on the type of surgical approach selected (transhiatal or transthoracic esophagectomy). Results: The patient set included 207 men (86.3%) and 33 women (13.7%). The mean patient age was 60.4 years. The histological type was adenocarcinoma in 145 (60.4%) and squamous cell carcinoma in 90 (37.5%) patients; another type of carcinoma was observed in 5 cases. Transhiatal esophagectomy was performed in 194 patients (80.2%) (transhiatal laparoscopic in 190 and classic Orringer in 4 patients). Transthoracic approach was used in 46 patients (19.2%), thoracoscopic in 16, and thoracotomic in 30 patients. A gastric conduit was used in 236 patients and coloplasty was performed in 4 patients. The mean duration of surgery was 217 min for the transhiatal approach, 239 min for the thoracoscopic approach and 277 min for the thoracotomic approach. Total blood loss per patient was 562 ml on average for all the operated patients. Peri- or postoperative blood transfusions were administered to 148 patients. Lymphadenectomy was performed as part of the procedure in all patients; the mean of 16.1 lymph nodes were removed. The average hospital stay was 20.7 days. In the patient set, 30-day mortality included 12 patients (respiratory complications 10, MI 1, conduit necrosis 1) and 90-day mortality included 4 (multi organ failure during ARDS). Based on statistical analysis, the incidence of respiratory complications significantly correlated with ASA classification (p=0.0001) and Clavien-Dindo classification (p.

[Solid pseudopapillary neoplasms of the pancreas]. / Solidní pseudopapilární tumor pankreatu.

INTRODUCTION: Solid pseudopapillary neoplasm (SPN) is a very rare neoplasm that occurs in girls and young women in 90% of cases; the range is 779 years of age, and the median is 28 years of age. This tumour was first described by Virginia Frantz in 1959 as a papillary cystic tumour of the pancreas. METHODS: The aim of this retrospective study was to analyse the incidence of SPN in all patients with a pancreatic tumour operated at the 1st Dept. of Surgery, University Hospital Olomouc between years 2006 and 2015. Clinical symptoms, imaging methods used, tumour marker positivity, histological findings, postoperative complications and disease-free interval were all evaluated. RESULTS: Of the 454 patients operated on between 20062015, the diagnosis of SPN was made in five female patients. The following imaging methods were used in the preoperative diagnostic process: CT, MRI, PET/CT and endosonography. In four patients the tumour was localised in the tail of the pancreas; these women underwent left-sided pancreatectomy. In one patient, the tumour was located in the pancreatic head and a pylorus-preserving pancreaticoduodenectomy was performed. Complications were seen only in one patient who underwent revision on the first postoperative day for bleeding from the pancreatic cut surface. Pancreatic fistula was not observed in any of the patients. The procedures were considered as sufficient from the oncological viewpoint due to the radical resection procedure and negative resection margin, and therefore no adjuvant oncological treatment was indicated in any of the patients. During the follow-up period, recurrence was not observed in any one of the patients. CONCLUSION: Solid pseudopapillary neoplasm of the pancreas is a rare disorder with a low malignant potential occurring primarily in young women. Generally, SPN has a good prognosis; however, advanced stages of the disease with distant metastases may be encountered in rare cases. The only curative treatment is radical surgical resection.Key words: solid pseudopapillary neoplasm Frantzs tumour pancreas.

[Proximal gastrectomy for adenocarcinoma of the gastroesophageal junction in a selected set of patients immediate and long-term results]. / Proximální gastrektomie u selektovaných pacientu s adenokarcinomem gastroezofageální junkce, bezprostrední a dlouhodobé výsledky operacní terapie.

INTRODUCTION: The authors present the results of surgical resection in the form of proximal gastrectomy in a selected set of patients with adenocarcinoma of the gastroesophageal junction. The selection criteria included: ASA III-IV, internal comorbidities and elderly patients. METHODS: Between 2007 and 2015, 28 patients with adenocarcinoma of the gastroesophageal junction underwent proximal gastrectomy at the 1st Department of Surgery. The patient set consisted of 19 (67.8%) men and 9 (32.3%) women aged 5289 years with the median age of 72.5 years. Endoscopic examination revealed a tumour of the gastroesophageal junction, which was evaluated according to the Siewert classification: type I was present in 4 (16.7%) cases, type II in 12 (42.3%), and type III in 12 (42.3%). Histological analysis revealed adenocarcinoma in all cases. Proximal gastrectomy with lymphadenectomy was performed in all patients. Splenectomy was performed in eleven patients. The continuity of the gastrointestinal tract was ensured by esophagogastroanastomosis, and pyloromyotomy was performed as a standard procedure. Cryostatic examination revealed positive resection margins in the esophagus in five patients, which led to the resection of the distal esophagus from the right-sided thoracotomy. RESULTS: Injury to the biliary tract was observed in one case in the perioperative period, which was treated by hepaticojejunoanastomosis onto an excluded jejunal loop. The following complications were observed postoperatively: bleeding, respiratory complications, anastomotic dehiscence, laparotomy wound dehiscence, and inflammatory infiltration in the abdominal cavity. Thirty-day mortality was 10.7% in our patient set. CONCLUSION: Proximal gastrectomy with lymphadenectomy is an appropriate alternative for polymorbid patients with adenocarcinoma of the gastroesophageal junction and provides good short- and long-term results.Key words: cancer of gastroesophageal junction proximal gastrectomy complications of therapy.

Sarcomatoid carcinoma of the lung -  a case report.

BACKGROUND: Sarcomatoid carcinoma (SARC) of the lung is a very rare and aggressive type of nonsmall cell lung cancer. It belongs to a group of poorly differentiated carcinomas with partial sarcomatoid differentiation or with a direct sarcoma component. Characteristic findings include a large tumor with an invasive tendency, early recurrence and systemic metastases. CASE: The authors present a case of SARC in the 77-year-old patient. Preoperative staging confirmed sarcomatoid carcinoma of the lower lobe of the left lung without generalization on PET/CT. However, an infiltration of more than 2/3 of the diaphragm was ascertained. A resection was performed -  a left lower lobectomy with resection of the diaphragm and its replacement by a muscle flap made from the latissimus dorsi muscle with vascular pedicle. Histological findings confirmed the dia-gnosis of sarcomatoid (pleomorphic) carcinoma pT3N0M0. The patient underwent adjuvant chemotherapy; recurrence and systemic dissemination of the disease occurred after 20 months; the patient died 21 months after the surgery.

The benefit of PET/CT in the diagnosis and treatment of esophageal cancer.

INTRODUCTION: To evaluate the significance of PET/CT for the initial staging of esophageal cancer with emphasis on metastatic lymph node affection and detection of distant metastases. Furthermore, the aim of the work was to analyze the significance of PET/CT examination when evaluating the effect of neoadjuvant therapy. METHODS: A set of 354 patients with esophageal cancer treated at the 1st Department of Surgery, University Hospital Olomouc and Medical Faculty at Palacky University in Olomouc between the years 20062012 were analyzed in a prospective study. The initial PET/CT examination was performed in 349 patients. We analyzed the benefit of this examination in regard to disease staging and based on the result, therapeutic strategy was determined. The initial PET/CT showed varying degrees of disease generalization in 102 patients, these patients were indicated for palliative or symptomatic therapy. In 247 patients, the disease was limited only to the esophagus and /or regional lymph nodes. After considering the patients overall condition and taking into account the wishes of the patient, 188 patients were indicated for neoadjuvant chemoradiotherapy (CRT); 32 patients did not complete this treatment. In 156 patients a follow-up PET/CT scan was performed after an average of 8.4 weeks following completion of neoadjuvant therapy. Based on this examination, a complete response- CR, was observed in 38 patients (24.4%), regression of the tumor in 89 (57.0%), stationary findings were seen in 10 (6.4%), and progression in 19 (12.2%). Ninety-seven patients were indicated for surgical resection; however, esophagectomy was only possible in 85 patients, in the remaining 12 patients only an explorative laparotomy was performed due to disease progression. RESULTS: The initial PET/CT examination performed in 349 patients correctly described the extent of the disease in accordance with the histologically confirmed diagnosis in virtually all patients. A false positive result was seen in only 5 patients (1.43%). When evaluating the effect of neoadjuvant therapy, the patients were divided into groups based on the findings of the follow-up PET/CT after neoadjuvant therapy and their overall survival was evaluated. A significant difference (p=0.0004) in survival was observed between the groups based on the different reactions to neoadjuvant therapy (CR (n=38), regression (n=89), stationary findings (n=10), progression (n=19)) without taking into account the following treatment the patient received after neoadjuvant therapy. Patients who had a better response to neoadjuvant therapy had better survival results. There was also a significant difference in survival between the group of patients who completed neoadjuvant therapy and underwent radical surgical resection (n=85) versus those patients who completed neoadjuvant therapy but did not undergo subsequent surgery (n=59). The operated group had a significantly higher overall survival (p=0.003). The longest mean survival, 38.6 months (median 29.0 months), was achieved by the group of patients who completed neoadjuvant therapy, showed a complete response on the follow-up PET/CT, and underwent surgical resection. However, a significant difference was not observed (p=0.587) between the groups who underwent surgical resection and whose follow-up PET/CT results differed (regression or stationary findings). To date, the number of cases in the individual groups is not great enough to consider the obtained results conclusive, and we will continue to include more patients into the study and continue with the analysis. CONCLUSION: The work documents the significance and benefit of PET/CT in the initial staging of esophageal cancer, especially in detecting metastatic disease- positive lymph nodes as well as distant metastases. PET/CT has great importance in determining therapeutic strategy. Furthermore, the significance of PET/CT in evaluating the effect of neoadjuvant therapy was also studied.Key words: esophageal cancer PET/CT neoadjuvant therapy esophagectomy.

[Endosonography of the oesophagus in the diagnosis and treatment of oesophageal tumours]. / Endosonografie jícnu v diagnostice a lécbe tumoru jícnu.

Endoscopic ultrasound examination (EUS) in oesophageal tumours is a widely used method with the need for further study of its benefits and indication. EUS plays an important role in the staging and management of further therapy. Following on from current world literature, we review the current importance of EUS in oesophageal tumours. We point out contemporary technical possibilities and comment on the importance of endosonography for early oesophageal carcinoma management, T-staging of primary tumour, benefits for N-stage diagnosis, the potential for the detection of generalised disease in comparison with CT and PET/CT, and the possibilities of histological evaluation. We mention in particular the impact of EUS on mesenchymal oesophageal tumour management. We consider EUS to be the golden standard for submucosal oesophageal tumour diagnosis. EUS has a special importance for early oesophageal carcinoma evaluation and the detection of celiac trunk lymph node involvement. Furthermore, EUS is a complementary method for higher-stage oesophageal carcinoma diagnostics. The benefits of the method, however, need further scientific evaluation. Key words: oesophageal endoscopic ultrasound - early oesophageal carcinoma - oesophageal carcinoma staging - submucosal oesophageal tumour.

[The influence of maternal age, parity, gestational age and birth weight on fetomaternal haemorrhage during spontaneous delivery]. / Vliv veku rodicky, parity, délky trvání tehotenství a hmotnosti plodu na fetomaternální hemoragii pri spontánním porodu.

OBJECTIVE: Determine the influence of maternal age, parity, gestational age and birth weight on the volume of fetal erythrocytes which enter the maternal circulation during spontaneous delivery. Determining these parameters would enable improving the guidelines for RhD alloimmunization prophylaxis. DESIGN: Prospective clinical study. SETTING: Department of Obstetrics and Gynecology, University Hospital, Olomouc. METHODS: A total of 2413 examinations were performed. The amount of fetal erythrocytes entering maternal circulation during uncomplicated spontaneous delivery of one fetus was determined by flow cytometry using the BDFACSCanto cytometer (Becton Dickonson International). Laboratory processing: Fetal Cell Count kit (Diagnosis of Feto-maternal transfusion by flow cytometry), IQ Products, IQP-379. Calculation of total volume of fetal erythrocytes entering maternal circulation: Scientific Subcommittee of the Australian and New Zealand Society of Blood Transfusion. Guidelines for laboratory assessment of fetomaternal haemorrhage. 1st ed. Sydney: ANZSBT, 2002: 3-12. RESULTS: The average maternal age when FMH 1.8 ml (95 perc) was 29.4 years vs. 29.1 years when FMH > 1.8 ml, median 30 years in both groups, the difference was not statistically significant (p = 0.501). The average gestational age when FMH 1.8 ml (95 perc) was 275.3 days vs. 276.9 days when FMH > 1.8 ml, median 278 days (39 weeks +5 days) vs. 276 days (39 weeks + 3 days), the difference was not statistically significant (p = 0.849). The average birth weight when FMH 1.8 ml (95 perc) was 3312 g vs. 3353 g when FMH > 1.8 ml, median 3340 g vs. 3330 g, the difference was not statistically significant (p = 0.743). FMH > 1.8 ml (5 perc) was present in 4.1% of primiparas (42/1023), in 4.2% of secundiparas (44/1050) and in 5.3% of multiparas (18/340), the difference was not statistically significant (p = 0.607). The difference in maternal age, parity, gestational age and birth weight were also not statistically significant for fetomaternal hemorrhage FMH > 2.1 ml (2.5 perc), FMH > 2.5 ml (n = 25), FMH > 5 ml (n = 5). CONCLUSION: Maternal age, parity, gestational age and birth weight does not present a risk factor for excessive fetomaternal hemorrhage during spontaneous delivery.

The significance of portal vein embolization in the treatment of colorectal liver metastases.

UNLABELLED: The first aim of the present paper was to evaluate hypertrophy of liver parenchyma after portal vein embolization in patients after systemic chemotherapy for colorectal carcinoma metastases and planned extensive liver resections. The second aim was to study whether hypertrophy of the liver parenchyma remnant after could influence the postoperative course large liver resections in long-term chemotherapy within complex therapy of colorectal carcinoma.The prospective study comprised of 43 patients with colorectal hepatic metastases in whom liver resections of 4-5 segments were planned (Table 1). All patients underwent complex therapy of colorectal carcinoma, including chemotherapy consisting of 6-12 therapeutic cycles. Time interval between chemotherapy and liver resection was 2-24 months (mean interval of 8 months). Twenty patients whose presumed liver parenchyma remnant was less than 40% of total liver volume were indicated for portal vein embolization (mean liver parenchyma remnant of 29%). This was always embolization of the right portal branch. Twenty-three patients were primarily indicated to liver resection. RESULTS: Hypertrophy of the left liver lobe occurred in all 20 patients. After portal vein embolization, the volume of left liver increased on average from 476 ml (282-754) to 584 ml (380-892) (P < 0.05). Mean hypertrophy of left liver lobe after portal vein embolization was 28.5%. The measured parenchyma remnant after tumor resection increased from 29% up to 38% by hypertrophy. Mean values of ALT and AST in the postoperative period were significantly different in the groups in this study. The values of alkaline phosphatase (ALP) and gamma glutamyl transpeptidase (GMT) were lower in patients after portal vein embolization (P < 0.05). Significant differences were in postoperative level of serum bilirubin, bilirubin levels in patients after portal vein embolization were 2-3 times lower than in the group of patients after immediate surgery (P < 0.05). he values of prothrombin time were also significantly lower in patients who underwent surgery without previous portal vein embolization (P < 0.05).

[Video-assisted esophageal resection for carcinoma--ten-year experience]. / Videoasistovaá resekce jícnu pro karcinom--desetileté zkusenosti.

INTRODUCTION: Esophageal procedures belong to the most complicated gastrointestinal procedures. Therefore, esophageal carcinoma patients have been and still are concentrated into specialized centres, equipped with all diagnostic and therapeutic means. At the Ist Surgical Clinic of the LF UP (Medical Faculty of the Palacky University) in Olomouc, esophageal surgery has a long lasting tradition. In the management of malignant esophageal disorders, the clinic prefers the use subtotal esophageal resection, attaching the esophagus transplant to a cervical esophageal stud, to the use of more saving resection with the anastomosis site in the mediastinum. In order to substitute for the resected esophagus, the authors normally use a tubulized gastric flap. In cases, where the stomach cannot be used, the authors use transverse colon to replace the resected esophagus. Classical esophageal procedures have nearly entirely been replaced by video-assisted procedures. Most esophageal resections are performed using video-assisted laparoscopic transhiatal approach. In the management of esophageal tumors which are located at the level of tracheal bifurcation, or below it, the authors use right- sided thoracoscopic approach. MATERIAL AND METHODS: During the past 10 years, 178 patients have undergone subtotal esophageal resection for esophageal carcinoma. In 81 patients (45.5%), the esophagus was resected using classical approach. 35 subjects underwent transhiatal "blind"extirpation according to Orringer, in 46 subjects right-sided thoracotomy was used (subjects with tumors located in the middle third of the thoracic esophagus and higher). Video-assisted approach was used in 97 patients, which included 88 subjects with laparoscopic transhiatal modification of the procedure and 9 subjects, who underwent video-thoracoscopy. OUTCOMES: The mean procedure duration was 242 minutes. The authors recorded the following complications: pneumothorax in 29 patients (16%) and n. laryngeus recurrens palsy in 16 subjects (9%). 13 patients (7%) developed a fistule in anastomosis, which was managed by drainage of the cervical wound. Pulmonary complications were recorded in 55 patients (31%). The mean duration of hospitalization was 12 days, intraoperative death rate was 4.5%. Only 2 out of 8 deaths occurring during the early postoperative period, were surgery-related. In the both cases, mediastinitis developed, resulting from a transponate necrosis in one of the cases and from a bronchial fistule in the other subject. Five subjects exited because of ARDS, which included one case of myocardial infarction. CONCLUSION: When esophageal carcinoma is managed at a clinic equipped with the latest modern diagnostic and therapeutical means, the procedure of esophageal resection is a fairly safe procedure with low death and morbidity rates.

[Risk of colorectal carcinoma in a patient with ulcerative colitis]. / Riziko kolorektálního karcinomu v terénu ulcerózní kolitidy.

Colorectal cancer, in patients with ulcerative colitis, is detected in the resected tissue of approximately 5% of patients, according to the literature. In our set of 82 patients operated on between the years 2000-2009, malignancy was confirmed in 9/82 patients (11%). In two young patients, the peroperative findings showed inoperable generalized carcinoma. The greater incidence of malignity is surely associated with inconsistent dispensarization of these patients.