Sentinel lymph node dissection in prostate cancer using superparamagnetic particles of iron oxide: early clinical experience.

PURPOSE: Superparamagnetic nanoparticles of iron oxide (SPION) were shown to be non-inferior to standard radioisotope tracer in breast cancer and may be used as an alternative to identify sentinel lymph nodes (SLN). The aim of this study was to assess the feasibility of sentinel lymph node dissection (SLND) using SPION in prostate cancer and to evaluate its diagnostic accuracy. METHODS: Twenty patients with intermediate- and high-risk prostate cancer were prospectively enrolled in 2016. After intraprostatic injection of SPION, SLND using magnetometer was performed the following day. Extended pelvic lymph node dissection (ePLND) was added as a reference standard test. The diagnostic performance of the test were evaluated, as well as the rate of in vivo detected SLN. Surgical times of SLND and ePLND were compared using paired two-sample t test. RESULTS: In total, 97 SLN were detected with median 5 (IQR 3-7) per patient. Non-diagnostic rate of the procedure was 5%. In total, 19 nodal metastases were found in 5 patients, of which 12 were located in SLN. The sensitivity per patient for the whole cohort was 80% and per node 56%. If only patients with at least one detected SLN were considered, the sensitivity per patient and per node reached 100 and 82%, respectively. A median of 20 LNs (IQR 18-22) were removed by subsequent ePLND. Surgical times of SLND and ePLND differed significantly, with medians of 17 and 39 min, respectively (p < 0.001). CONCLUSIONS: SLND with SPION is feasible and safe in prostate cancer and the diagnostic accuracy is comparable to the published results of radioguided procedures. In open surgery, SPION may be used as an alternative tracer with its main advantage being the lack of radiation hazard.

[SentiMag--the magnetic detection system of sentinel lymph nodes in breast cancer]. / Magnetická detekce sentinelových uzlin u karcinomu prsu metodou SentiMag.

INTRODUCTION: The aim of this study was to assess the feasibility of the new detection system of sentinel lymph nodes in breast cancer (SentiMag) and to compare its use to the standard method of detection with a radioisotope and a gamma-probe. METHODS: Twenty breast cancer patients scheduled for sentinel lymph node biopsy underwent standard lymphatic mapping with a radioisotope and also with the Sienna+ tracer. During the surgery, sentinel lymph nodes were identified preferably with the SentiMag system. The gamma-probe was used only at the end of the surgery to verify whether all sentinel lymph nodes had been harvested. RESULTS: The sentinel lymph node was detected in all cases. Both methods agreed in 18 cases, i.e. the lymph node with the highest magnetic value ex vivo was the same node as the one with the highest radioactivity. A metastasis in the sentinel lymph node was found in three patients. It is very likely that with the sole use of the SentiMag system, the results would have been identical to those of using the standard method with a radioisotope and the gamma-probe. CONCLUSION: The new magnetic detection method of sentinel lymph nodes (SentiMag) is feasible and clinically comparable to the gold standard method of detection with a radioisotope and the gamma-probe in patients with breast cancer. The new method could find its use not only in hospitals where the department of nuclear medicine is not available but in all hospitals performing sentinel lymph node biopsies in breast cancer and possibly other types of cancer.

[A case report: patient with metastatic goblet cell carcinoid]. / Pacientka s metastatickým karcinoidem z pohárkových bunek.

BACKGROUND: Goblet cell carcinoid represents a unique entity of appendiceal neoplasia. Its pathological features and clinical behavior are distinct from the classic carcinoid tumor as well as primary adenocarcinoma of the appendix. Correct histopathological classification and diagnosis provide guidelines for treatment and prognosis. Morphological transformation of the Goblet cell carcinoid from typical Goblet cell carcinoid to adenocarcinoma morphology is likely associated with accumulation of additional genetic changes that is why subclassification of this group of tumors is needed. Investigation of molecular genetic changes could increase our understanding of this exotic but clinically important group of tumors. CASE: We present the case of a patient with metastatic goblet cell carcinoid involving terminal ileum, ascendent colon, ovary, omentum and peritoneal spreading, treated with debulking surgery and chemotherapy (FOLFOX4 regimen) with good response, reduction of disease on CT and PET complete remission. Improvement of clinical symptoms as well as quality of life was reached by combined palliative treatment. CONCLUSION: Correct diagnostics and therapeutic efforts bring patient benefit even in metastatic setting. Better knowledge of rare tumors and understanding of their biology help improve therapeutic approaches.

[Multimodal treatment of glioblastoma multiforme: results of 86 consecutive patients diagnosed in period 2003-2009]. / Výsledky multimodální lécby glioblastoma multiforme: Konsekutivní série 86 pacientu diagnostikovaných v letech 2003-2009.

BACKGROUNDS: Glioblastoma multiforme is the most common malignant primary tumor of the brain in adults. Standard therapy consists in maximal surgical resection and adjuvant concurrent chemoradiotherapy and adjuvant therapy with temozolomid. This approach improves survival in comparison with postsurgical radiotherapy alone. PATIENTS AND METHODS: Consecutive patients with histologically confirmed glioblastoma multiforme in the period from January 2003 to December 2009 underwent postoperative radiotherapy (1.8-2.0 Gy/d, total of 60 Gy) plus concurrent daily chemotherapy (temozolomide 75 mg/m2/d), followed by 6 cycles of temozolomide (150 to 200 mg/m2 for 5 days, every 28 days) and were analyzed retrospectively. The primary end point was to describe the correlation between known clinical factors, treatment and progression free survival (PFS) and overall survival (OS). We assessed the toxicity and safety of the chemoradiotherapy. RESULTS: Eighty-six patients (median age, 56 years; 60% male) were included. Most of them (> 80%) were of performance status (PS) 0-1 at the beginning of chemoradiotherapy. Total macroscopic resection was performed in 20% of the patients, subtotal in 65%, partial in 9%, and just biopsy in 6%. Median PFS was 7.0 months (2.0-35.5), median OS was 13.0 months (2.5-70). Postoperative performance status (PS), the extent of resection, and administration of planned treatment without reduction had statistically significant influences on PFS and OS. Median PFS and OS were 22.0, 7.0 and 6.0 months for PFS (p = 0.0018) in patients with PS O, 1 and 2 respectively and 32.0, 13.0 and 9.0 months for OS (p = 0.0023). Patients with total removal of tumor had longer PFS (14.0 vs 6.0 months, HR = 0.5688; p = 0.0301) and OS (23.0 vs 12.0 months, HR 0.4977; p = 0.0093), as did patients without dose reduction of radiotherapy and/or chemotherapy. Patients with radiotherapy dose of over 54 Gy had PFS 8.0 vs 3.0 months (HR = 0.3313; p = 0.0001) and OS 15.0 vs 5.0 months (HR = 0.1730; p < 0.0001). Similarly, treatment with concurrent chemotherapy for more than 40 days was also important: PFS 8.0 vs 5.0 months (HR = 0.5300; p = 0.0023) and OS 17.0 vs 9.5 months (HR = 0.5943; p = 0.0175). Age, gender and position of tumor had no significant influence. Treatment-related hematology toxicity grades 3 and 4 occurred relatively often: thrombocytopenia (9%), leukopenia (6%), neutropenia (6%) and lymphopenia (25%). Thrombo-embolic events were dominant in non-hematology toxicity. Serious toxicity occurred mainly in the subgroup of patients with PS 2. Treatment of progression was useful in selected patients. Second surgery was of the most benefit (OS 24.0 vs 12.5 months, HR = 0.5325; p = 0.0111). CONCLUSION: Postoperative performance status, extent of resection, successful administration of the majority of planned concurrent chemoradiotherapy and possibility of surgical treatment at the time of recurrence correlate with better prognosis for our patients with glioblastoma. Our experience indicates that performance status should be the main factor in decisions about treatment intensity. Treatment of malignant glioma requires a multidisciplinary team.

MicroRNA-181 family predicts response to concomitant chemoradiotherapy with temozolomide in glioblastoma patients.

MicroRNAs are endogenously expressed regulatory noncoding RNAs. Previous studies showed altered expression levels of several microRNAs in glioblastomas. In this study, we examined the expression levels of selected microRNAs in 22 primary glioblastomas and six specimens of adult brain tissue by real-time PCR method. In addition, we examined methylation status of MGMT promoter by methylation-specific real-time PCR, as this has been shown to be a predictive marker in glioblastomas. MGMT methylation status was not correlated with response to concomitant chemoradiotherapy with temozolomide (RT/TMZ). MiR-221 (p=0.016), miR-222 (p=0.038), miR-181b (p=0.036), miR-181c (p=0.043) and miR-128a (p=0.001) were significantly down-regulated in glioblastomas. The most significant change was observed for up-regulation in miR-21 expression in glioblastomas (p<0.001). MiR-181b and miR-181c were significantly down-regulated in patients who responded to RT/TMZ (p=0.016; p=0.047, respectively) in comparison to patients with progredient disease. Our data indicate for the first time that expression levels of miR-181b and miR-181c could serve as a predictive marker of response to RT/TMZ therapy in glioblastoma patients.

Minimally invasive treatment of posterior fossa craniopharyngioma by means of navigated endoscopy.

The aim of the paper is to present an unusual case of ectopic posterior fossa craniopharyngioma after repeated surgeries for primary suprasellar tumor. The clinical condition of the patient favored minimally invasive neuroendoscopic surgery. After presurgical planning with the help of neuronavigation system a trajectory from the contralateral side through the cisterna magna was chosen. Endoscopic cyst fenestration and cyst wall resection were safely performed with an excellent outcome. The possible origin of this posterior fossa craniopharyngioma is discussed together with tumor dissemination pathways. The endoscopic contralateral approach to the tumor utilized the wide working space provided by the cisterna magna and the great versatility of the navigated neuroendoscopic approach was proven.

Exceptional symptomatology of a lipoma beneath the third ventricular floor and successful neuroendoscopic treatment.

The aim of this paper is to present the exceptional case of a lipoma located beneath the floor of the third ventricle in front of right mamillary body manifesting with psychiatric symptoms and treated by navigated neuroendoscopy. A 58-year-old male was referred for neurosurgical treatment because of paroxysmal disturbances of consciousness accompanied by aggressive behaviour. Because electroencephalographic evaluation failed to confirm the epileptic origin of the presenting symptoms, the final psychiatric diagnosis was syndrome of amentia. However, when the MRI investigation revealed two tiny lipomas with one of them located in front of the right mamillary body, a hypothesis was established that this lipoma might be the cause of the clinical symptoms. After a thorough analysis of the patient's symptoms and taking into special consideration the functional role of hypothalamic structures the decision to remove the lipoma endoscopically was accepted. After stereotactic planning and functional correlation using digital stereotactic atlases, the lipoma located in front of the right mamillary body was endoscopically removed. The clinical course after navigated neuroendoscopic surgery proved complete disappearance of symptoms and problems supported by the results of imaging techniques, psychological investigations and neurological findings. Detailed anatomic analysis with pathophysiological consideration substantiated the excellent result of minimally invasive endoscopic surgery for lipoma removal.

[Meningiomas with skull bone involvement]. / Meningiomy s postizením kostních struktur lebky.

One of factors responsible for meningioma recurrencies is tumorous involvement of calvarial and basal bone structures. Primary intraosseous meningiomas should be distinguished from secondary involvement in prevailing intracranial tumor and hyperostotic reactive changes. The paper is based on prospective study of 167 patient operated on for intracranial meningioma. Based on clinical investigation, radiological and intraoperative data bone invasion was suspected in 20 patients and histologically confirmed in 17. In 14 patients bone involvement was secondary, meningothelial hamartoma was described in one patient and in 2 patient primary intraosseous meningioma was found. Prevalence of tumors to periorbital area and bone sutures is confirmed. Neuronavigation is used to optimise tumor resection and limit the risk for neurovascular structures. Results were good in 87.5% of patients and poor in 12.5% of patients (extent of tumor and general condition). Discussion provides analysis of intraosseous meningiomas formation, pathological classification (Lang), causes of bone invasion and surgical possibilities. It is necessary to undeline the problems of intraosseous meningiomas both from the aspects of diagnosis and subsequent treatment.

[Effect of histologic classification on surgical treatment of peripheral nerve tumors]. / Vliv histologické klasifikace na moznosti chirurgické lécby tumoru periferních nervu.

The influence of histological classification on the options of the peripheral nerve tumors surgery Peripheral nerve sheath tumors (PNST) constitute significant part of all tumors of peripheral nerves. In 1998-2000 years we have operated 7 such patients--3 females, 4 males in our department. The definite diagnosis was made by histology. Total removal was performed in all patients. The nerve continuity was preserved in 4 cases (3x neurofibroma, 1x schwannoma) and nerve had to be disconnected in 3 cases (1x neurobibroma, 1x plexiform neurofibroma as a part of von Recklinghausen disease (VRD), 1x malignant schwannoma). Good neurological outcome was in patients with preserved nerve continuity. Out of 3 patients with the need of nerve disconnection, graft and complete reinervation was performed in case of benign neurofibroma, but in the patient with von Recklinghausen disease and in the patient with malignant schwannoma the permanent leasion of nerve remained. We can conclude that histological classification directly predetermine the options of the peripheral nerve tumors surgery.

Microsurgery in the diabetic foot.

The treatment of serious tissue defects on the diabetic foot is complicated and tedious because of a combination of pathogenetic mechanisms that influence healing. Diabetic neuropathies (sensory, motor, vegetative), ischaemia and microangiopathies contribute in varying degrees to the adverse healing. The submitted three-year prospective study was focused on an analysis of the pathogenetic factors with the objective of defining the indications for one of three types of microsurgical transfer: 1. a free flap sutured directly to the vessels at the site of the defect (in predominantly neuropathic defects); 2. a free flap sutured to a politeopedal bypass (in predominantly ischaemic defects); 3. a "nourishing" flap sutured by means of a long venous graft to vessels of the medial and upper leg (in patients in whom an inadequate outflow tract does not make revascularisation possible). In the first year of the investigation, thirteen patients were operated on by means of a free muscle flap incl. three "nourishing" and ten sutured at the site of the defect. Twelve flaps were flaped healed; one patient died from myocardial infarction on the second day after surgery.