The quality of life of Croatian women after mastectomy: a cross-sectional single-center study.

BACKGROUND: Measuring the quality of life (QoL) of women with breast cancer is an important aspect of measuring treatment success. In Croatia, no QoL studies have been carried out with a focus on patients after mastectomy. The aim of this study was to examine QoL 1 month and 1 year after mastectomy. METHODS: This cross-sectional single-center study of quality of life was conducted in 101 patients, 50 of whom had undergone a mastectomy 1 month prior, and 51 of whom had undergone a mastectomy 1 year prior. The study was conducted from July 2015 to June 2016. The questionnaires used in the study were developed by the European Organisation for Research and Treatment of Cancer (EORTC). The questionnaire EORTC QLQ-C30 assesses the QoL of cancer patients, and the questionnaire EORTC QLQ-BR23 is a disease-specific breast cancer module. A chi square test, Fisher's exact test, Kolmogorov-Smirnov test, Student's t-test and Mann-Whitney U test were performed in the statistical analysis using the statistical program SPSS (Inc. Released 2008. SPSS Statistics for Windows, Version 17.0. Chicago: SPSS Inc.). RESULTS: Patients who had undergone a mastectomy a year earlier placed a higher value on their health state than did those who had undergone a mastectomy a month earlier. The most affected values of functional status on the EORTC QLQ-C30 scale were emotional functioning (37.5 [95% CI 33.3-61.6]) and sexual functioning (16.67 [95% CI 0-33.3]) 1 month and 1 year after mastectomy, respectively. The most affected symptoms on the EORTC QLQ-C30 scale were hair loss 66.67 [95% CI 33.3-100]) and fatigue 33.33 [95% CI 24-44]) 1 month and 1 year after mastectomy, respectively. CONCLUSION: In our study, both functional and symptom scales were more affected in women 1 month after mastectomy. QoL was considerably improved in women 1 year after the surgery compared to 1 month after mastectomy. The results of this study could contribute to the public awareness of the QoL of breast cancer patients.

BREAST CANCER IN YOUNG WOMEN: PATHOLOGIC AND IMMUNOHISTOCHEMICAL FEATURES.

- A young woman with breast cancer is considered to be a woman younger than 40. According to the literature, breast cancer in the population of young women usually is of a higher histologic grade, unfavorable hormonal status, and overall higher mortality rate when compared with breast cancer occurring in older population. We compared pathologic and immunohistochemical features of breast carcinoma in women under 40 years of age with the respective features in women over 60 years of age. The following parameters were observed in these two groups: tumor size, lymph node status, histologic grade, hormonal receptor status, Ki-67 prognostic index, Her2/neu status, and histologic type of the tumor. Early onset breast carcinoma was found to have a higher frequency of tumor grade 3 (29% vs. 17%) and estrogen receptor negativity (45% vs. 23%). In the group of young women, breast carcinoma was mostly multicentric (23% vs. 5%), triple-negative (32% vs. 10%), and was found to have higher proliferation index Ki-67 (25% vs. 10%). Our results confirmed differences between the young and older groups of patients. In the group of young women, we found predominantly unfavorable prognostic parameters of the disease.

Giant primary pleomorphic adenoma of the lung presenting as a post-traumatic pulmonary hematoma: a case report.

BACKGROUND: Pleomorphic adenomas, also known as benign mixed tumors, are the most common tumors of glandular origin in the head and neck and although they are generally benign they can undergo malignant transformation. Primary pleomorphic adenomas of the lung are extremely rare tumors with less than 40 cases reported in the literature by now. This is the first case in the literature describing overlapping with a traumatic event and also one of the rare cases describing primary adenoma of the lung reaching this impressive size. CASE PRESENTATION: We report a rare case of a giant primary pleomorphic adenoma of the lung presenting as a post-traumatic pulmonary hematoma. A 38-year-old Caucasian male patient came to the Urgent Trauma Center after being hit in the chest by a bull and, after a number of tests, was diagnosed with primary pleomorphic adenoma of the lung. Operative treatment was performed and the surgical excision was successfully done. CONCLUSIONS: Our conclusion is that the surgical excision is the main treatment for pleomorphic adenoma of the lungs and we recommend lifelong follow-up and regular check-ups. Furthermore, we consider our case an interesting one due to its concurrence with the chest trauma and the dilemma about the optimal approach considering the entity could have been a large interlobular hematoma.

Statistical learning confirms the diagnostic significance of the anemia panel in breast cancer.

BACKGROUND: Diagnostic value of available tumor markers, such as cancer antigen CA 15-3 and carcinoembryonic antigen (CEA) in breast cancer is limited. There is an ongoing search for additional, potentially better diagnostic blood markers with improved clinical utility. The aim of this study is to evaluate performance of the approach based on routine blood tests accompanied by a statistical learning tool to the diagnosis of breast cancer. METHODS: Blood was collected from total of 104 subjects which were divided into two groups: breast cancer patients and a control group that consisted of asymptomatic volunteers and patients who had benign breast lesions at the time of blood collection. Random forest statistical learning method and the external method validation have been applied to evaluate diagnostic performance of 31 routine blood tests. RESULTS: The applied statistical learning approach assigned the highest diagnostic importance to the anemia panel among all analyzed blood tests that also included CA 15-3. External validation has shown utility of selected statistical approach - we were able to select tests that provide a diagnostic accuracy comparable to some diagnostic tools described in literature and based on more demanding laboratory techniques, such as gene expression microarrays. CONCLUSIONS: Inclusion of tests for anemia significantly improves diagnostic accuracy for the breast cancer in comparison to the diagnostic accuracy of the CA 15-3 alone. Application of the random forests also enables the reduction of number of laboratory tests needed for the establishment of diagnosis. Differences in relevant test values between the cancer and control group are small but application of multiparametric statistical learning ensured diagnostic accuracy of 72.0% associated by a sensitivity of 64.7% and specificity of 84.9%.

Surgical treatment of patients with penetrating chest injuries sustained in war.

AIM: To show our experience in treatment of patients with penetrating chest injuries sustained during the Homeland War in Croatia METHODS: It was a retrospective study based on the records of the Department of Surgery of the University Hospital of Osijek (Croatia). All patients surgically treated during the wartime period (1991.-1995.) were analysed with respect to death rate, causes of injuries, frequency of injuries of thoracic organs and frequency of combined injuries of thorax and abdomen. Most of our patients were treated with thoracotomy as opposed to the common protocol (thoracostomy) applied in usual treatments. RESULTS: The study includes 157 patients with penetrating chest wounds, 111 (70.7%) of which were from metal fragments of bursting artillery, 37 (23.6%) of the wounded were exposed to gunshot bullets, and 9 (5.7%) had stab injuries. Lung injuries had 134 (85.4%) patients, and 15 (9.6%) had injuries of the heart. Chest injuries combined with injuries of abdominal organs happened in 30 (19%) cases. The abdominal organs in question were the liver, spleen, stomach, and colon, in eight (26.6%), seven (23.3%), four (13.3%), and three (10.0%) cases, respectively. Thoracotomy was performed in 144 (91.7%) cases, 13 (8.3%) of the patients underwent thoracostomy, and 134 (85.3%) patients stayed alive. CONCLUSIONS: It points out that, in our case due to organizational problems, aggressive surgical procedure of patients with penetrating chest and multiple injuries sustained in war was the good choice.

Surgical treatment of liver echinococcosis--open or laparoscopic surgery?

Human echinococcosis remains a significant medical issue in endemic areas. Hydatid cysts can rupture, which is the most severe complication of echinococcosis as it can cause anaphylactic reaction and seeding of secondary cysts. Traditionally, hydatid cysts were evacuated by open surgical procedure in order to remove the entire cyst or by unroofing method, with evacuation of the cyst content. Recently, an increasing number of such operations are performed using laparoscopic approach. This study was prospectively conducted in a 5-year period, from 2004-2008. Altogether, 25 surgically treated patients were included in this study. Clinical examination, specific serological test, abdominal ultrasound and computed tomography were used for establishing diagnosis. Open surgery was initially performed in 17 patients and laparoscopic in 8. Three of those 8 patients required conversion to open surgery. Open pericystectomy was performed in 11 patients and laparoscopic pericystectomy in 3 patients. Open partial pericystectomy according to Papadimitriou was performed in 9 patients with hydatid cyst and laparoscopic partial pericistectomy in 2 patients. Our experience indicates that in the case of liver hydatid cyst disease, laparoscopic exploration, and if possible, laparoscopic pericystectomy or partial pericystectomy, should be performed in selected patients.

The proximal femoral nail antirotation (PFNA) in the treatment of proximal femoral fractures.

Proximal femoral fractures, especially in elderly persons with osteoporosis, present a challenge for the traumatologist. While the dynamic hip screw (DHS) became the implant of choice for the treatment of stable fractures, the ideal implant for the treatment of unstable fractures remains an issue. In our experience, Proximal Femoral Nail Antirotation (PFNA) is an excellent device for osteosynthesis as it can be easily inserted, it provides angular and rotational stability and allows early weight bearing on the affected limb. Between February 2007 and August 2009, 76 patients underwent the PFNA fixation for proximal femoral fractures (15 men and 61 women). Forty seven fractures were pertrochanteric, 14 subtrochanteric, 2 pathological and 5 ipsilateral trochanteric and diaphyseal fractures whereas in 8 cases the PFNA was used in reosteosynthesis. The mean age of patients was 73.4 years (range 22-91 years). The fractures were reduced on a traction table and the implant was inserted using minimally invasive technique. Four patients developed superficial postoperative wound infection. No cases of implant breakage have been recorded; there was one cut-out; delayed union was noted in three patients. The majority of patients regained their pre-injury mobility status. The PFNA is an excellent implant for stabilisation of both trochanteric and complex combination fractures as well as an exceptional device for reosteosynthesis. It is easily inserted with few intra- and postoperative complications and allows early weight bearing on the affected limb as well as quicker rehabilitation of patients.

Laparoscopic repair of perforated peptic duodenal ulcer.

Although prevalence of peptic ulcer is decreasing, the number of peptic ulcer perforations appears to be unchanged. This complication of peptic ulcer is traditionally surgically treated. In recent years, a number of papers have been published where the authors managed perforated duodenal peptic ulcer in selected patients using laparoscopic approach. Laparoscopic treatment of perforated duodenal ulcer has been described as safe and advantageous compared to open technique but advantages are still not clear due to small number of cases in published studies. Based on these recommendations we decided to establish our own protocol for laparoscopic treatment of perforated peptic duodenal ulcer. In this prospective study we evaluated the first 10 patients in whom we performed laparoscopic repair of perforated duodenal ulcer. There were no conversions to open procedure and no early postoperative complications. The patients were contacted by phone a year after the operation, and all were satisfied with the operation and the appearance of postoperative scars. We regard laparoscopic repair of selected patients with perforated duodenal ulcer as a safe and preferable treatment.

"Signet-ring" cell invasive lobular carcinoma of the breast - accidental finding associated with intraductal papilloma: a case report.

BACKGROUND: A 57-year old woman had only unilateral milky dischardge of the right breast. Clinical and mammography findings were normal. CASE PRESENTATION: Cytological diagnosis of intraductal papilloma was established which was galactographically confitmed and patient underwent to surgery. Ductulolobular segmentectomy was made. Histopathologically beside intraductal papilloma numerous single dispread malignant "signet ring" cells in the fibrous retromammilary stroma were found. Imunohistochemically findings were: cytokeratin 8 positive, ER H-score 80, PR H-score 50, HER-2/neu negative. Diagnosis of "signet ring" cell lobular invasive carcinoma was made, followed by mastectomy, axillary limphadectomy and contra lateral breast biopsy. CONCLUSION: Residual tumor were found only in the breast tissue, while axillary lymph nodes and contra lateral breast biopsy were negative. Patient underwent to oncology therapy.

Intercostal catheter analgesia is more efficient vs. intercostal nerve blockade for post-thoracotomy pain relief.

A pain after thoracotomy may result in a postoperative hypoventilation and lead to atelectases and pneumonia. This study was aimed to compare two analgesic regimens after posterolateral thoracotomy. 80 patients (40-70 years) undergoing thoracotomy were randomized to intercostal catheter analgesia (group A, n = 40) and intercostal nerve block (group B, n = 40). Patients in group A were given 20 mL of 0.5% bupivacaine injections twice a day by intercostal catheter. Intercostal nerve blockade was performed using 5 mL of 0.5% bupivacaine. Intercostal nerve in thoracotomy wound, nerves below and above thoracotomy wound was also injected. PaO2, PaCO2, FVC, FEV1 and visual analog pain scale (VAS) were obtained preoperatively, 24, 48 and 72 hours after operation. Postoperative complications were recorded at the patient discharge. Differences between groups were calculated using Mann-Whitney, KW test and chi square test. The arterial blood gas analyses did not show statistically significant change in any group and time according to the baseline values. FVC and FEV1 decreased significantly in both groups at first postoperative day according to baseline measurements. Patients in B group had significantly higher FEV1 values in the third postoperative day (73.05 +/- 11.25 in A vs. 83.50 +/- 9.17 in B group, p < 0.05). Intercostal catheter analgesia resulted in significantly lower postoperative VAS scores and reduced opioid requirement as compared to intercostal nerve blockade. No differences in the postoperative complications were observed between groups.

Functional status of hip joint after surgical and conservative treatment of acetabular fracture.

Both conservative and surgical treatment of acetabular fractures alter biomechanical conditions in the hip joint resulting in various degenerative changes in the acetabulum and the femur head. These changes may progress to secondary coxarthrosis, causing dysfunction of the hip joint. The aim of this paper is to compare the outcomes of both conservative and surgical treatments in different types of acetabular fractures, so that clear indications for either conservative or surgical treatment could be determined. This paper is based on retrospective study of 103 patients with acetabular fracture (21 surgically treated and 82 conservatively treated). In this study the incidence of particular types of acetabulum fractures, the treatment period, the incidence of complications and the functional status of the hip after the treatment were analyzed. In patients with anterior fracture surgical treatment lasted three times less than conservative treatment and resulted in far better functional status of the hip joint compared to conservatively treated patients. However, in patients with transverse fractures the functional status was better and the treatment period shorter after the conservative treatment. We believe that the present treatment indications should be corrected so that in anterior column fracture the surgical method should be preferred, whereas the transverse fracture should be treated conservatively. In other types of acetabular fracture, with the radiographic roof arc angle of 45 degrees or less, the surgical method should be preferred to conservative method.

Phyllodes tumors of the breast diagnostic and therapeutic dilemmas.

BACKGROUND: This article compares experiences in the diagnosis and treatment of phyllodes tumors from 2 regional institutions with the relevant literature. PATIENTS AND METHODS: From 1991 to 2005, 2,848 breast cancer patients were treated in our institutions, 36 (1.44%) for phyllodes tumors. The average tumor size was 5.1 cm (range 1.4-19.6). Triple assessment was the standard diagnostic algorithm. Wide excision with tumor-free margins was carried out in 29 (80.5%) cases and mastectomy in 7 (19.4%) cases. Axillary lymphadenectomy was performed in patients with positive lymph nodes. RESULTS: Histology showed the phyllodes tumors to be benign in 27 (75.0%), malignant in 6 (16.6%), and borderline in 3 (8.3%) cases. Follow-up was from 5 months to 16 years. In this period, recurrences of 3 (8.3%) malignant and 2 (5.6%) benign phyllodes tumors were diagnosed and treated. 10 (27.7%) patients treated with wide local excision showed deformities in the form of scarring. The steroid receptor status was of no prognostic value in our patients, and chemotherapy was used in only 1 (2.7%) patient. 5-year survival was 86.2%. CONCLUSION: Our study shows that tumor size, margin infiltration, mitotic activity and degree of cellular atypia are important prognostic factors. Problems in diagnosing this condition arise from its similarity to fibroadenoma. Although wide local excision is usually the treatment of choice, tumor recurrence is common. Axillary lymphadenectomy in malignant phyllodes tumors is, in our opinion, still controversial.

Supracondylar fractures of the humerus in children caused by traffic.

A sample of 38 patients aged under 14 treated at the Surgery Clinic of the University Hospital Osijek has been used in showing therapeutic guidelines supported by patients' functional status after the completed treatment. The patients suffered from supracondylar fractures caused by traffic accidents and classified into three types according to Gartland. Not a single patient with neurocirculatory disturbances has been registered. The most common treatment was a conservative one while more than half of the patients with fractures from type III underwent surgery. The duration of immobilization approximated three weeks whereas patients' recovery considering their functional status has justified the choice of the treatment. However, a lot can be done in the field of prevention, which would greatly decrease the frequency of such injuries.

Tumor growth fraction, expression of estrogen and progesterone receptors, p53, bcl-2 and cathepsin D activity in primary ductal invasive breast carcinoma and their axillary lymph node metastases.

The aim of this paper is to determine similarities and differences between tumor cell subclones in cases of ductal invasive breast carcinoma, and which occupy primary tumor and local axillary lymph metastases. The tumor growth fraction evaluated by Ki-67 was analyzed along with the expression level of estrogen and progesterone receptors, protein p53, proto-oncogene protein bcl-2 and cathepsin D in 60 patients. Metastatic lymph node in axilla has a higher growth fraction of the tumor cells than the primary tumor (p = 0.045), as well as the higher level of bcl-2 overexpression (p = 0.014). No statistically significant difference was found in the presence of immunohistochemically identified estrogen receptors (p = 0.161) and progesterone receptors (p = 0.081) between the primary tumor and the metastatic lymph node in axilla. Likewise, no difference was found between the immunohistochemical evaluation of p53 (p = 0.356) and cathepsin D activity (p = 0.928). A higher growth fraction of the tumor cells and the higher level of bcl-2 overexpression in metastatic tumor cells indicate the more aggressive cell subclones. This study does not support the routine testing of both primary tumor and locoregional metastasis to evaluate the breast cancer hormone receptor status.

Assessment of intra-cranial pressure after severe traumatic brain injury by transcranial Doppler ultrasonography.

PRIMARY OBJECTIVE: To investigate the potential of transcranial Doppler ultrasonography in estimating post-traumatic intra-cranial pressure early after severe traumatic brain injury. RESEARCH DESIGN: The group of 24 patients was analysed for the observation of an early post-traumatic cerebral haemodynamic by middle cerebral artery blood velocity measuring. METHODS AND PROCEDURES: The standard method of measuring the mean blood middle cerebral artery velocity by transcranial Doppler ultrasonic device was performed. MAIN OUTCOMES AND RESULTS: The increased duration of intra-cranial hypertension correlated to the middle cerebral artery low blood velocity (p = 0.042; r = -0.498) (n = 17) and to elevated pulsatility indices (p = 0.007; r = 0.753) (n = 11) significantly. The increased duration of lowered cerebral perfusion pressure correlated to the middle cerebral artery low blood velocity significantly (p = 0.001; r = -0.619) (n = 24). CONCLUSIONS: The significance of transcranial Doppler ultrasonography as a method to estimate an early post-traumatic intra-cranial pressure after severe brain injury was confirmed. This simple and non-invasive technique could be easily used in daily clinical practice and precede intra-cranial pressure monitoring in selected patients.

[Lung lesions in penetrating war injuries of the chest]. / Ozljede pluca kod ratnih penetrantnih trauma prsnog kosa.

Presentation is made of 157 patients with lung parenchymal lesions due to penetrating war injuries of the chest, 50.3% civilians and 49.3% soldiers. The wounds were mostly inflicted by cluster projectiles (71.4%), followed by firearms (25.5%) and sharp instruments (3.1%). The injuries were characterized as a combination of laceration and lung contusion. In case of lung laceration, a moderate to massive hemopneumothorax develops. Clinically, the manifestation of lung contusion may range from hardly observable dyspnea and hemophthisis through tachypnea, tachycardia and cyanosis. Most lesions of pulmonary parenchyma can be managed by thoracic drainage, whereas in case of massive bleeding and air loss thoracotomy and appropriate operative procedures are recommended. We used anterolateral thoracotomy as a sparing procedure, which involves minimal thoracic wall disintegration. When deciding on the choice of surgical procedures for the lesions of pulmonary parenchyma, care was taken to ensure to maximally spare the intact parenchyma. Minor resections (sutures, atypical resection, segmentectomies) were performed in 92%, whereas major resection (lobectomy, pulmectomy) had to be performed in 8% of thoracotomized patients. Rethoracotomy was done in two patients due to postoperative hemorrhage. The patient submitted to pulmectomy because of the hilus vasculature lesion died after the surgery. Early resuscitation, volume and blood replacement, rapid diagnosis, and early surgical intervention are the crucial factors that influence survival in patients with lung lesions due to penetrating injuries of the thorax.

Intact radial and median nerve after open third degree distal fracture of the humerus.

A 54 year old man sustained a third degree open fracture at the distal part of the right humerus with massive soft tissue defect involving most of the upper arm. The radial and median nerves were completely bared and exposed by 6 cm for radial and 3 cm for median nerve. The nerves were in continuity, but there was complete rupture of surrounding muscles: biceps, triceps and brachialis. The fracture was stabilized by external fixation method--reinforced by wires. Preoperative and postoperative sensorimotor status of the right hand was good. One year later sensory and motoric status of right hand showed no deficiencies, but flexion and extension in elbow were limited to 100 and 180 degrees respectively. Pronosupination was restricted. This case report is consistent with results of biomechanical studies in vitro confirming high tolerance of radial and median nerve to stretching injury.