Secondary Breast Malignancy from Renal Cell Carcinoma: Challenges in Diagnosis and Treatment-Case Report.

Renal cell carcinoma represents about 2% of all malignant tumours in adults. Metastases of the primary tumour in the breast make up to about 0.5-2% of the cases. Renal cell carcinoma metastases in the breast are extremely rare and have been sporadically recorded in the literature. In this paper, we present the case of a patient with breast metastasis of renal cell carcinoma 11 years after primary treatment. Case presentation: An 82-year-old female who had right nephrectomy due to renal cancer in 2010 felt a lump in her right breast in August 2021, whereby a clinical examination revealed a tumour at the junction of the upper quadrants of her right breast, about 2 cm, movable toward the base, vaguely limited, and with a rough surface. The axillae were without palpable lymph nodes. Mammography showed a circular and relatively clearly contoured lesion in the right breast. Ultrasound showed an oval lobulated lesion of 19 × 18 mm at the upper quadrants, with strong vascularisation and without posterior acoustic phenomena. A core needle biopsy was performed, and the histopathological findings and obtained immunophenotype indicated a metastatic clear cell carcinoma of renal origin. A metastasectomy was performed. Histopathologically, the tumour was without desmoplastic stroma, comprising predominantly solid-type alveolar arrangements of large moderately polymorphic cells, bright and abundant cytoplasm, and round vesicular cores with focally prominent nuclei. Immunohistochemically, tumour cells were diffusely positive for CD10, EMA, and vimentin, and negative for CK7, TTF-1, renal cell antigen, and E-cadherin. With a normal postoperative course, the patient was discharged on the third postoperative day. After 17 months, there were no new signs of the underlying disease spreading at regular follow-ups. Conclusion: Metastatic involvement of the breast is relatively rare and should be suspected in patients with a prior history of other cancers. Core needle biopsy and pathohistological analysis are required for the diagnosis of breast tumours.

Evaluation of central corneal thickness in patients with ocular hypertension and primary open-angle glaucoma.

AIM: To determine correlation between central corneal thickness (CCT) and applanation intraocular pressure (IOP) in normal patients with primary open angle glaucoma and patients with ocular hypertension. METHODS: Two-year retrospective study designed to determine correlation between CCT and IOP. Records of 121 patients were included in the study. Inclusion criteria were: IOP higher than 22 mm Hg for a group with ocular hypertension but without functional, morphological damage and progression, diagnosis of glaucoma for a group with open-angle glaucoma and normal ophthalmological results for a control group. Patients who were mono-oculus, patients with secondary glaucoma and who had surgical treatment were excluded. The patients were selectively grouped according to types of glaucoma, by gender and age. The IOP values were measured by Goldman's applanation tonometer, CCT values were determined using ultrasonic pachymeter, in the period from January 2011 to December 2012. RESULTS: Of total 121 subjects, 51 had primary open angle glaucoma (POAG), 40 had ocular hypertension (OHT) and 30 had normal ophthalmological findings (control group). The CCT values in OHT group 529.37+/-25.18 µm were greater than of both POAG, 501.02+/-14.04 µm and control group, 497.37+/-14.90 µm. The IOP values in OHT group were 20.25+/- 3.62 mm Hg, and in POAG group were 18.25+/-2.70 mm Hg, while in the control group they were 13.53+/- 3.62 mm Hg. CONCLUSION: Determination of CCT in patients with glaucoma is crucial, considering its impact on IOP values, which represents a parameter in glaucoma diagnosis, as well as monitoring further progress of ocular hypertension and patients diagnosed with glaucoma.

Tumor of orbit / Tumor orbitário

The cavernous hemangiomas are the most common intra orbital tumors found in adults of the middle age. Although histological benign, they can encroach on intra orbital or the adjacent structures (optic nerve) and be considered anatomically or positional malignant. We present a case report of orbital cavernous hemangioma of right orbit in young women after pregnancy, from Topola near Kragujevac (Central Serbia) with visual compromise and it's by trans-nasal endoscopic surgical management. Our patient was controlled and treated with the symptomatic therapy, topical therapy with artificial tears and surgical treatment. Our patient has optimal visual acuity of affected right eye after surgical treatment of orbital tumor. Surgical treatment of symptomatic orbital cavernous hemangioma is safe and effective, so that the cosmetic results are the important parameter to evaluate the clinical outcome.

Os hemangiomas cavernosos são os tumores intraorbitais mais comuns encontrados em adultos de meia-idade. Embora histológico benigno, eles podem invadir a área orbital ou intraorbital ou ainda as estruturas adjacentes (nervo óptico) e ser considerado anatomicamente ou posicional maligno. Apresentamos um relato de caso de hemangioma cavernoso orbital da órbita direita em mulheres jovens após a gravidez, a partir de Topola perto Kragujevac (Central Sérvia), com comprometimento visual e medicado por tratamento cirúrgico endoscópico transnasal. O paciente foi controlado e tratado com terapia, terapia tópica sintomático de lágrimas artificiais e tratamento cirúrgico. Nosso paciente tem acuidade visual ideal do olho direito afetada após o tratamento cirúrgico de tumor orbital. O tratamento cirúrgico do sintomático hemangioma cavernoso orbital é segura e eficaz, de modo que os resultados cosméticos são o parâmetro importante para avaliar o resultado clínico.

Congenital blindness and visual impairment cause infection or non infection.

CONFLICT OF INTEREST: none declared. INTRODUCTION: Authors are from reference documentation to archive at Organization of Federation of blind and visually impaired in central Serbia (Kragujevac), by retrograde analysis, of 2007-2012, comprehend two groups by etiology-clinical characteristics of congenital blindness and visually impaired, caused infection or non infection example. AIM: to analyze relationship between infectious and non infectious of congenital blindness and visually impaired in our referent region and compare with world references. MATERIAL/METHODS: With 6-years analysis included the most frequency cases of congenital blindness and visually impaired in two groups, according to presence or absence infectious causes. From infectious causes of congenital blindness and visually impaired are included: CMV - infection, congenital rubella syndrome, congenital toxoplasmosis, congenital syphilis and rare mixed syndrome. From non infectious causes are included: retinitis pigmentosa, retinopathy prematurity, primary congenital glaucoma, Leber's congenital amaurosis and rare syndrome. RESULTS: From total number of registered blind and visually impaired - 1308 (100%), over the last 6 years, the registration was 349 (26.68%) with congenital blindness and visually impaired. From recorder with the number of the most common congenital blindness and visually impaired-194 (55.59%) with infections cause, and 155 (44.41%) non infection cause. CONCLUSION: Congenital blindness has shown permanent increase in past 6 years, in group with infectious and with non infectious causes. Congenital blindness and visually impaired of the most common etiology among registered members of our association in Kragujevac is subject of our correlation and global trends mentioned observation of these diseases.

Cataract surgery in patients with ocular pseudoexpholiation.

MATERIAL AND METHODS: Retrospective 5-year study based on general and ophthalmic history records, and including 268 eyes (174 patients), aged 50 years and over. Ophthalmological examination involved visual acuity, measuring of intraocular pressure, slit lamp examination and indirect ophthalmoscopy. Type of surgical treatment was tailored for each patient (extra capsular cataract extraction, phaco-emulsiphication). RESULTS: Preoperative slit lamp examination showed phacodonesis in 17.91% (47), iridodonesis in 2.98% (8), pigment dispersion in 6.72% (18), lens subluxation in 4.85% (13) on the total. Extra capsular cataract extraction was performed in 36.94% (99) and phaco-emulsiphication in the others. Analysis of intra operative complications showed: posterior capsular rupture 17.91% (48), zonular dialysis or break 5.97% (16), lens subluxation 1.86% (5), intraocular bleeding 2.98% (8), vitreous loss 13.80% (37). Postoperative complications include: anterior chamber reaction 45.90% (123), intraocular lens tilt 15.67% (42), endothelial decompensation 21.64% (58), subluxation/luxation IOL 3.73% (10), secondary cataract 21.46% (58), pigment dispersion 37.68% (101), increased IOP 13.80% (37), residual lens matter 13.80% (37), hyphema 3.73% (10), posterior synechiae 6.72% (18), iris prolapsus 2.73% (8). CONCLUSION: Cataract surgery in PES will frequently encounter small pupils, shallow anterior chambers, posterior adhesions, weak zonular support, partial subluxation or complete dislocation of lens. Authors presented the best possible approach on PES and surgical methods for patients with cataract with special accent of possible surgical complications.

Congenital upper eyelid coloboma with ipsilateral eyebrow hypoplasia.

INTRODUCTION: Coloboma is a Greek word, which describes the defect of all layers of the organ, and it can be congenital or as the result of an injury, operation, or some disease. Congenital upper eyelid coloboma is a rare anomaly, with the unknown incidence. The size of the defect is different, but it always involves all layers of the eyelid. This malformation is more frequent at the upper eyelid, and unilaterally, at the junction of the medial two thirds. Sometimes, it can also involve the eye, and may be a component of many syndromes (Goldenhar, Fraser, Manitoba, CHARGE, Cat eye). CASE REPORT: We are describing the case of the upper eyelid coloboma with the rare eyebrow anomaly at the three- month old girl, and the result of reconstruction. The baby was treated conservatively with lubricants and overnight patching. Pentagonal excision of the defect was performed in general anesthesia. Three layers of the eyelid were prepared: the skin, muscle and tarsoconjunctival layer. Because of orbicularis muscle malposition, reinsertion and reposition of the muscle fibres were performed. Then, lateral canthotomy was made and the suture of three layers of the eyelid. Catgut suture 7-0 was used for the conjunctiva and muscle. Nylon 6-0 was used for skin suture. Z-plasty was done on the upper part of the pentagonal excision in order to reduce skin tension at the suture line. The operation lasted about 60 minutes and the hospitalization three days. The occlusive dressing was applied for two days. The stitches were removed after seven days. The postoperative swelling of the upper and lower eyelid disappeared in five days. There were no complications in the postoperative period. CONCLUSION: The main principle of the treatment of eyelid coloboma is surgical reconstruction of all layers of the eyelid, in optimal period, using different surgical methods, which depends on the size of the defect. An early diagnosis is of the greatest importance, as well as the treatment of associated anomalies. Complications of the upper eyelid coloboma depend on the size of the defect, presence of the eye anomalies and the method of reconstruction.

Cyclocryotherapy in neovascular glaucoma treatment.

The main goal in the struggle with neovascular glaucoma is to control intraocular pressure (IOP) and pain. 152 patients, e.g., 203 eyes, were examined at the Clinic of Ophthalmology, Clinical Centre of Kragujevac, Serbia, in period between 01. 01. 2005 - 31. 12. 2010. Cyclocryoanemisatio was performed for all patients. Measurments of IOP showed statistical significant changes before and after the treatment for every patients. There was no difference in sex distribution, but a difference was noted in age distribution. Early posttreatment complications included hyphema, fibrin's exudation, chemosis. Cyclocryotherapy is usefull and accessible method for control of intensive pain in neovascular glaucoma.

Evaluation of the patients with Grave's ophthalmopathy after the corticosteroids treatment.

BACKGROUND/AIM: Graves' ophthalmopthy is one of the most common causes of exophthalmos as well as the most common manifestation of Graves' disease. The treatment of Graves' ophthalmopathy includes ophthalmological and endocrinological therapy. The aim of this study was to clinically evaluate the patients with Graves' ophthalmopathy treated with corticosteroids. METHODS: Evaluation of 21 patients was performed in the Ophthalmology Clinic and Endocrinology Clinic, Clinical Centre Kragujevac, in the period from 2009 to 2010. They were treated with pulse doses of intravenous corticosteroids. They were referred to ophthalmologist by endocrinologist in euthyroid condition in the active phase of Graves' ophthalmopathy (ultrasonography of orbit findings and positive findings of antithyroid stimulating hormone receptor antibody--anti-TSH R Ab). The clinical activity score (CAS) and NO SPECS classification for evaluation of disease severity were used. Ophthalmological examination includes: best corrected visual acuity, slit-lamp exam, Hertels' test, direct ophthalmoscopy and ultrasonography of the orbit. RESULTS: According to our results 76.19% of the patients were female; mean age of the patients was 35.2 +/- 5.6 years. According to CAS classification after 6 months of the treatment recovery was shown in 23.81% of the patients, partial amelioration in 47.62% and no clinical amelioration in 28.57% of the patients. We achieved better results with male, young patients with high clinical activity score. Good results were observed after the first dose of corticosteroids, much better CAS after the third dose, which maintained until 6 months after the first treatment. CONCLUSION: Our results signify that intravenous pulse dose of corticosteroids treatment of the patients with Graves' ophthalmopthy is safe, comfortable, clinically justified and accessible for the clinicians and patients. Positive results are achieved after the first dose with increasing trend up to the third dose, which was maintained for the next three months.

Prostatic carcinoma bilateral iris metastases.

We described a patient with bilateral iris metastases resulted from prostatic cancer. Slit lamp and ultrasonography examination of the both eye demonstrated tumor of the iris, as an amelanotic vascular mass located on the superior temporal quadrant. On open biopsy revealed undifferentiated tissue that stained strongly positive for prostate carcinoma, confirming the diagnosis of metastasis prostate adenocarcinoma. Early diagnostic procedures are essential for the causal therapy of prostate carcinoma as the primary neoplasm.

[Clinical evaluation of Graves ophthalmopathy].

INTRODUCTION: Graves ophthalmopathy is an autoimmune disease, which is the consequence of thyroid dysfunction. Ocular manifestations occur in 50% of patients with Graves disease. The changes occur due to the inflammatory cell infiltration of retrobulbar fat tissue and extraocular muscles. Ultrasonography of eye orbit provides important information about the condition of retrobulbar adipose tissue and the thickness of extraocular muscles. OBJECTIVE: The aim of our study was to show the clinical significance of orbital ultrasonography in the diagnostics and follow-up of patients with Graves disease. METHODS: The authors examined 154 patients with Graves ophthalmopathy at the Clinic of Ophthalmology of the Clinical Centre in Kragujevac during the period 2008-2010. Ophthalmological examination included visual acuity testing (Snellen chart), biomicroscopy and applanation tonometry, direct and indirect ophthalmoscopy, dry eye testing and exophthalmometry (Hertel). Orbital ultrasonography examination and extraorbital muscle measurement was done by ultrasound B-scan. RESULTS: The disease was more frequent in women (79.87%) aged from 36-45 years. Most patients had hyperthyreoidism (54.55%). In relation to the duration of the disease, the most frequent clinical signs were bilateral ptosis, conjunctival chemosis and periorbital edema. According to our data the highest number of patients had enlarged medial straight muscle. CONCLUSION: Graves ophthalmopathy is the most frequent sign of thyroid disease. By orbital ultrasonography we detected extended echogram and measured the thickness of the extraocular muscle. Computerized tomography and magnetic resonance scan were utilized for cases of insufficiently manifested clinical signs of the disease. The advantages of ultrasonography lie in easy handling, patients' comfort, short time of examination and possibilities of repetition.

Orbital metastases from breast cancer: a case report.

We present a patient with a corneal ulcer of the right eye, with eye protrusion and without anamnesis of cancer. On CT examination there was a bulky soft tissue mass in the cranial aspect of the right orbit, without increasing in signal intensity after injection of contrast. Open biopsy revealed undifferentiated tissue that stained strongly positive for breast carcinoma, confirming the diagnosis of metastases of breast carcinoma.

[Reconstruction of the columella and the tip of the nose with an island-shaped forehead flap].

BACKGROUND: Posttraumatic and postoperative defects of columella and the tip of the nose are difficult to reconstruct. There are several operative methods described in the literature, and many of them are step-by-step procedures with long duration. The aim of this study was to present one-step procedure for reconstruction of the columella and the tip of the nose with island-shaped arterial forehead flap. CASE REPORT: A 45-year old man was submitted to surgical excision of basocellular skin cancer. After the excision, a defect of the columella and tip of the nose the remained, 3 x 2.5 cm in dimensions, with exposed alar cartilages. During the same operation, the defect was covered with an island-shaped arterial forehead flap. Postoperative one-year course was uneventful, without signs of tumor recurrence after one year, and further surgical corrections were unnecessary. CONCLUSION: Considering the results of our operative technique, we believe that middle island-shaped forehead flap is suitable for reconstruction of the columella and the tip of the nose, due to the following reasons: safe vascularization of flap, similarity of the transferred tissue with the excised one, the procedure is completed in one step, simple surgical technique and uncomplicated healing of a flap-harvesting site.

Principles of surgical treatment of congenital, developmental and acquired female breast asymmetries.

BACKGROUND/AIM: There is a natural asymmetry in normal female brests. When the difference in the shape, size or position of the breast and nipple-areola complex is visible, surgical correction is the only treatment option and presents one of the greatest challenges for a plastic surgeon. Based on the Nahai classification presented in details, the aim of the study was to present the possibilities of plastic surgery to correct primary (congenital), secondary (developmental) and tertiary (acquired) brest asymmetries. METHODS: We conducted a retrospective analysis of female breast asymmetry surgeries performed in the Clinic for Plastic Surgery and Burns, Military Medical Academy (MMA), Belgrade over the last seven years (January 2002 - January 2009). RESULTS: During the above mentioned period, 82 female patients, 18 - 65 years of age, underwent surgery for breast asymmetry. The most frequent asymmetries were developmental, "pubertal" (n = 43); acquired asymmetries as a consequence of tumor surgery were found in the other 22 patients, while 7 patients were diagnosed with primary asymmetries such as congenital chest-wall asymmetry (Sy. Poland), accessory and tuberous breasts. All patients underwent preoperative ultrasound examination, while hormone status was determined in those with developmental, "pubertal" asymmetries. The selection of surgical procedure for correction of breast asymmetry depended upon clinical examination findings and patient's wish relating to the shape and size of the breasts. The most of breast asymmetries were corrected by a combination of surgical procedures including primary and secondary reconstruction, reduction, suspension or augmentation mammoplasty. Having combined different surgical procedures, we managed to achive satisfactory results. The hypertrophic scar formation after reduction mamoplasty was seen in some cases, however, they caused no significant patient's discomfort. CONCLUSION: Application of plastic, reconstructive and aesthetic surgical principles can considerably contribute to achieving excellent results in corrective surgery for breast asymmetries. In addition to most suitable breast asymmetry surgical procedures choice, motivation of a patient is also very important for achieving satisfactory results.

[Importance of proper initial treatment of moderate and major burns].

BACKGROUND/AIM: Burns are common injuries with frequency depending on human factors, development of protection, industry and traffic, eventual wars. Organized treatment of major burn injuries has tremendous medical, social and economic importance. The aim of this study was to analyze initial treatment of major and moderate burns, to compare it with the current recommendations and to signify the importance of organized management of burns. METHODS: In a prospective study 547 adult patients with major burns were analyzed, covering a period of eight years, with the emphasis on the initial hospital admission and emergency care for burns greater than 10% of total body surface area (TBSA). RESULTS: In the different groups of major burns, the percentage of hospital admission was: 81.5 in burns greater than 10% TBSA, 37.7 in burns of the functional areas, 54.5 in the III degree burns, 81.6 in electrical burns, 55.9 in chemical burns, 61.9 in inhalation injury, 41.0 in burns in patients with the greater risk and 100 in burns with a concomitant trauma. In the group of 145 patients with burns greater than 10% TBSA, intravenous fluids were given in 87 patients, analgesics in 45, corticosteroids in 29, antibiotics in 23 and oxygen administration in 14. In the same group, wound irrigation was done in 14.4%, removing of the clothing and shoes in 29.6%, elevation of the legs in 8.9% and prevention of hypothermia in 7.6% of the victims. There were no initial estimations of burn extent (percentage of a burn), notes about the patient and injury and tetanus immunizations. CONCLUSION: Based on these findings, it is concluded that there should be much more initial hospital admissions of major burns, and also, necessary steps in the emergency care of burns greater than 10% TBSA should be taken more frequently. On the other side, unnecessary or wrong steps should be avoided in the initial burn treatment.