Schwannoma of the phrenic nerve. A case report.

BACKGROUND: Neurogenic tumors are the third most common tumors occurring within the mediastinum. Predominantly completely asymptomatic, they are most often found in the posterior mediastinum, although they may also be located, albeit rarely, in the middle mediastinum. Thus, in the cases of tumors localized in the middle mediastinum, schwannomas of the phrenic nerve must always be considered. CASE REPORT: In this case, a male patient presented with a tumor of the middle mediastinum. PET/CT scan determined that it was a circumscribed tumor without signs of dissemination. However, due to the tumor's location, a preoperative biopsy of the tumor was not possible. Therefore, the patient underwent videothoracoscopic extirpation of the tumor, including the necessary resection of the phrenic nerve that passed through the centre of the tumor. Subsequent histological analysis definitively confirmed a schwannoma with low proliferative activity. CONCLUSIONS: Differential diagnosis of mediastinal tumours is very difficult; however, in the case of circumscribed tumours not invading the surrounding tissues, proceeding to surgical revision, with the complete removal of the tumour, is possible, even without determining the histological nature. Minimally invasive surgical techniques dominate the treatment of neurogenic tumors of the mediastinum; they are associated with minimal complications and allow a rapid return of the patient to their normal activities.

Clinical and prognostic significance of detecting CEA, EGFR, LunX, c-met and EpCAM mRNA-positive cells in the peripheral blood, tumor-draining blood and bone marrow of non-small cell lung cancer patients.

Background: Surgical treatment of early-stage non-small cell lung cancer (NSCLC) yields highest expectations for recovery. However, the frequency of further disease progression remains high since micro-metastatic disease may be undetected by conventional diagnostic methods. We test the presence and prognostic impact of circulating tumor cells (CTCs) in peripheral blood (PB), tumor-draining pulmonary blood (TDB) and bone marrow (BM) samples from NSCLC patients. Methods: The presence of circulating/disseminated tumor cells (CTCs/DTCs) was detected by quantitative reverse transcriptase polymerase chain reaction (qRT-PCR) analysis in PB, TDB and BM samples before surgery in 119 stage IA-IIIA NSCLC patients (Clinical Trial NS10285). Results: NSCLC patients with the presence of carcinoembryonic antigen (CEA) mRNA-positive CTCs/DTCs in TDB and BM had significantly shorter cancer-specific survival (CSS) (P<0.013, resp. P<0.038). Patients with the presence of epithelial cellular adhesion molecule (EpCAM) mRNA-positive CTCs in TDB samples had significantly shorter CSS and disease-free survival (DFS) (P<0.031, resp. P<0.045). A multivariate analysis identified the presence of CEA mRNA-positive CTCs in the PB as an independent negative prognostic factor for DFS (P<0.005). No significant correlation of CTCs/DTCs presence and other prognostic factors was found. Conclusions: In NSCLC patients undergoing radical surgery, the presence of CEA and EpCAM mRNA-positive CTCs/DTCs is associated with poorer survival.

Analysis of Bacterial Pathogens Causing Complicating HAP in Patients with Secondary Peritonitis.

BACKGROUND: Diffuse peritonitis is an acute abdominal condition characterized by high mortality. The main treatment modality is surgery, requiring a subsequent prolonged hospital stay. These patients are, among other things, at risk of developing hospital-acquired pneumonia (HAP), which considerably worsens their treatment outcomes. This study aimed to extend the existing knowledge by providing more detailed microbiological characteristics of complicating HAP in patients with secondary peritonitis, including the identification of isolated bacterial pathogens and their potential sources. METHODS: The 2015-2019 retrospective study comprised all patients with an intraoperatively confirmed diagnosis of secondary diffuse peritonitis who were classified in accordance with the quick Sepsis Related Organ Failure Assessment scoring system. RESULTS: HAP developed in 15% of patients. The 90-day mortality rates were 53% and 24% in patients with and without HAP; respectively. The most frequent pathogens responsible for HAP were Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli, Enterobacter cloacae complex and Enterococcus faecalis. Multidrug resistance to antibiotics was found in 38% of bacterial pathogens. Clonal spread of these bacterial pathogens among patients was not detected. Rather, the endogenous characteristic of HAP was confirmed. CONCLUSIONS: The initial antibiotic therapy of complicating HAP in patients with secondary peritonitis must be effective mainly against enterobacteria, including strains with the production of ESBL and AmpC beta-lactamases, Pseudomonas aeruginosa and Enterococcus faecalis. The study further highlighted the importance of monitoring the respiratory tract bacterial microflora in patients with secondary peritonitis. The results should be used for initial antibiotic treatment of complicating HAP instances.

Cannabinoid receptor 2 expression in early-stage non-small cell lung cancers identifies patients with good prognosis and longer survival.

Background: Non-small cell lung cancer (NSCLC) is a leading cause of cancer-related death with a 5-year survival of only 21%. Reliable prognostic and/or predictive biomarkers are needed to improve NSCLC patient stratification, particularly in curative disease stages. Since the endogenous cannabinoid system is involved in both carcinogenesis and anticancer immune defense, we hypothesized that tumor tissue expression of cannabinoid 1 and 2 receptors (CB1 and CB2) may affect survival. Methods: Tumor tissue samples collected from 100 NSCLC patients undergoing radical surgery were analyzed for CB1 and CB2 gene and protein expression using the quantitative reverse-transcriptase polymerase chain reaction (qRT-PCR) and immunohistochemistry (IHC). The gene and protein expression data were correlated with disease stage, histology, tumor grading, application of chemotherapy, and survival. Additional paired tumor and normal tissue samples of 10 NSCLC patients were analyzed independently for comparative analysis of CB1 and CB2 gene expression. Results: Patients with tumors expressing the CB2 gene had significantly longer overall survival (OS) (P<0.001), cancer specific survival (CSS) (P=0.002), and disease-free survival (DFS) (P<0.001). They also presented with fewer lymph node metastases at the time of surgery (P=0.011). A multivariate analysis identified CB2 tumor tissue gene expression as a positive prognostic factor for CSS [hazard ratio (HR) =0.274; P=0.013] and DFS (HR =0.322; P=0.009), and increased CSS. High CB2 gene and protein expression were detected in 79.6% and 31.5% of the tested tumor tissue samples, respectively. Neither CB1 gene nor CB1 or CB2 protein expression affected survival. When comparing paired tumor and tumor-free lung tissue samples, we observed reduced CB1 (P=0.008) and CB1 (P=0.056) gene expression in tumor tissues. Conclusions: In NSCLC patients undergoing radical surgery, expression of the CB1 and CB2 receptor genes is significantly decreased in neoplastic versus tumor-free lung tissue. CB2 tumor tissue gene expression is strongly associated with longer survival (OS, CSS, DFS) and fewer lymph node metastases at the time of surgery. More studies are needed to evaluate its role as a biomarker in NSCLC and to investigate the potential use of CB2 modulators to treat or prevent lung cancers.

Prognostic Significance of Simple Scoring Systems in the Prediction of Diffuse Peritonitis Morbidity and Mortality.

INTRODUCTION: Diffuse peritonitis is a serious disease. It is often addressed within urgent management of an unstable patient in shock. The therapy consists of treatment of the source of peritonitis, decontamination of the abdominal cavity, stabilization of the patient and comprehensive resuscitation care in an intensive care unit. A number of scoring systems to determine patient prognosis are available, but most of them require complex input data, making their practical application a substantial problem. OBJECTIVE: Our aim was to assess simple scoring systems within a cohort, evaluate the level of mortality, morbidity, and duration of hospital stay, followed by a comparison of the acquired data with the literature and determination of an easily implementable scoring system for use in clinical practice. MATERIAL AND METHODS: We evaluated a group of patients with diffuse peritonitis who underwent surgery in the 2015-2019 period. Medical history, surgical findings, and paraclinical examinations were used as the input for four scoring systems commonly used in practice-MPI, qSOFA, ECOG, and ASA. We compared the results between the systems and with the literature. RESULTS: Our cohort included 274 patients diagnosed with diffuse peritonitis. Mortality was 22.6%, morbidity 73.4%, with a 25.2 day average duration of hospital stay. Mortality and morbidity increased with rising MPI and qSOFA, well-established scoring systems, but also with rising ASA and ECOG, similarly to MPI and qSOFA. CONCLUSIONS: The utilized scoring systems correlated well with the severity of the condition and with predicted mortality and morbidity as reported in the literature. Simple scoring systems primarily used in other indications (i.e., ASA and ECOG) have a similar predictive value in our cohort as commonly used systems (MPI, qSOFA). We recommend them in routine clinical practice due to their simplicity.

Hybrid esophagectomy for oesophageal cancer: long-term results. A single-centre experience.

INTRODUCTION: The authors report long-term outcomes in patients who received neoadjuvant chemoradiotherapy and consequently underwent hybrid oesophagectomy for oesophageal cancer (OC). AIM: To evaluate long-term outcomes in patients suffering from OC, who underwent hybrid oesophagectomy. MATERIAL AND METHODS: Our cohort consisted of patients suffering from OC, who received neoadjuvant chemoradiotherapy. Hybrid esophagectomy was performed 8-10 weeks after oncological treatment. RESULTS: Ninety-four patients underwent surgery for OC from 2011 to 2015. Histology revealed adenocarcinoma in 60.6%, squamous cell carcinoma (SCC) in 36.2%, and other type of cancer in 3.2%. Seventy-three (77.7%) patients with advanced stage (T3-4, N0-2, M0) were indicated to receive neoadjuvant chemoradiotherapy (nCRT). Trans-hiatal hybrid oesophagectomy was performed in 83 (88.3%) patients. Transthoracic hybrid oesophagectomy was performed in 11 (11.7%) patients. Histology of the resected specimens of 18 (24.7%) patients did not reveal OC, i.e. pathological complete response (pCR). In our cohort, we proved an association between occurrence of pCR and age as well as disease-free survival (DFS). The patients who presented with pCR were significantly younger - below 60 years of age (p = 0.017). They also showed significantly higher mean DFS (p = 0.004). CONCLUSIONS: Combined oesophagectomy with neoadjuvant chemoradiotherapy results in a better long-term outcome in patients suffering from oesophageal cancer. In our set of patients who underwent hybrid esophagectomy, satisfactory short-term and especially long-term results of surgical treatment for oesophageal cancer were observed.

Thymoma - diagnostics options.

Various types of tumors (either benign or malignant) can be found in mediastinum. Early diagnosis and treatment may help to improve survival and quality if life in these patients. Compared to direct mediastinoscopy, used for obtaining a specimen for histological analysis in previous decades, modern imaging methods, specifically the CT navigated biopsy, represent an effective and less invasive approach to the diagnosis. In our publication, we present a patient with thymoma, rather rare type of anterior mediastinum tumor.

Indications and benefits of intraoperative esophagogastroduodenoscopy.

INTRODUCTION: Intraoperative esophagogastroduodenoscopy (IOG) is a diagnostic and therapeutic method for a variety of special conditions in upper gastrointestinal (UGI) pathology. The indication remains individual due to insufficient evidence and limited training of surgeons in digestive endoscopy. AIM: To evaluate the indications, benefits and risks of IOG. MATERIAL AND METHODS: A single-center retrospective study of 110 consecutive IOGs in 104 patients was performed. The preoperative plan, the timing of IOG, preoperative evaluation, intraoperative finding, localization of the pathology, type of the procedure, change of expected therapy and complications were assessed. RESULTS: The cohort comprised 29 esophageal tumors, 5 tumors of the cardia, 36 gastric tumors, gastrointestinal bleeding (8), esophageal diverticula (3), perforations (3), GERD (5), mediastinal pathology (3), fistula (4), assessment of nutrition (10), duodenal adenoma (2), ulcer disease, esophageal stenosis and gastric volvulus. The indication for IOG was established preoperatively in 79% and intraoperatively in 21%. The lesion was localized in 96.4%. The therapy was altered to a wider resection (11), smaller resection (5), localization and surgical therapy of bleeding (8) or allowed minimally invasive surgery (25). A total of 3 postoperative complications included gastric perforation and positivity of resection line (following EMR/ESD) and recurrent bleeding. The 30-day mortality reached 3.6% without a specific cause in IOG. CONCLUSIONS: The IOG is a complementary method in the diagnosis and treatment of UGI pathology. It enables minimally invasive finalization of the procedures and individualization of the therapy.

Early simultaneous esophagopleural and bronchopleural fistula after right pneumonectomy.

BACKGROUND: Esophagopleural and bronchopleural fistulas represent a rare, but life-threatening complication after lung resections, most often after a right pneumonectomy. CASE STUDY: A 64 years old woman was indicated for right pulmectomy for local recurrence of initially stage IIB lung cancer treated by lower lobectomy. On the postoperative day 34, an esophagopleurobronchial fistula occurred. Further course required thoracostomy with closure of the bronchial stump and vacuum-assisted closure therapy and two-phase esophagectomy with 6 weeks interval to the esophageal reconstruction. Patient represents 2 years of disease-free survival with good functional results. CONCLUSION: The therapy of esophagopleural and bronchopleural fistula is long-term and complicated, requiring a multidisciplinary approach and several basic principles must be adhered to the management including treatment of infection and prevention of sepsis, local treatment of the fistula and pleural empyema, and adequate ventilation and nutritive care.

Different clinical presentations of metachronous pulmonary metastases after resection of pancreatic ductal adenocarcinoma: Retrospective study and review of the literature.

AIM: To analyze pancreatic cancer patients who developed metachronous pulmonary metastases (MPM) as a first site of recurrence after the curative-intent surgery. METHODS: One-hundred-fifty-nine consecutive pancreatic ductal adenocarcinoma (PDAC) patients who underwent radical pancreatic surgery between 2006 and 2013 were included in this retrospective analysis. The clinical data including age, sex, grade, primary tumor location, pTNM stage, lymph node infiltration, microangioinvasion, perineural invasion, lymphovascular invasion, the therapy administered, and follow-up were all obtained from medical records. Further analysis covered only patients with metachronous metastases. Clinical and histopathological data (age, sex, grade, primary tumor location, pTNM stage, lymph node infiltration, microangioinvasion, perineural invasion, lymphovascular invasion, the therapy administered and follow-up) of patients with metachronous non-pulmonary metastases and patients with metachronous pulmonary metastases were statistically assessed. Disease-free survival (DFS) from pancreas resection until metastases onset and overall survival (OS) were calculated. Wilcoxon test, χ2 test and survival functions computed by the Kaplan-Meier method were used. Statistical significance was evaluated by the log-rank test using SPSS. A P-value of less than 0.05 was considered statistically significant. RESULTS: Metachronous pulmonary metastases were observed in 20 (16.9%) and were operable in 3 (2.5%) of PDAC patients after a prior curative-intent surgery. Patients with isolated pulmonary metastases (oligometastases and multiple metastases) had estimated prior DFS and OS of 35.4 and 81.4 mo, respectively, and those with metachronous pulmonary metastases accompanied by other metastases had prior DFS and OS of 17.3 and 23.4 mo, respectively. Patients with non-pulmonary metastases had prior DFS and OS of 9.4 and 15.8 mo, respectively. Different clinical scenarios according to the presentation of MPM were observed and patients could be divided to three subgroups with different prognosis which could be used for the selection of treatment strategy: isolated pulmonary oligometastases, isolated multiple pulmonary metastases and pulmonary metastases accompanied by other metastases. CONCLUSION: Surgery should be considered for all patients with isolated pulmonary oligometastases, but the risk of intervention has to be individually weighted for each patient.

Detection of minimal residual disease in lung cancer.

BACKGROUND: Even after successful radical treatment of lung cancer, patients in stages I and II of the TNM system very frequently suffer recurrence, which end lethally. Detection of subclinical residual disease after surgery is thus one of the most important emerging diagnostic methods. Minimal residual disease (MRD) is defined as the presence of isolated tumor cells or circulating cells in a patient after curative primary tumor removal and at the same time, no clinical signs of cancer. Conventional methods cannot detect minimal residual disease and hence there is a need for detection using new molecular biological methods. METHODS: We searched the PubMed database for original and review articles on minimal residual disease in lung cancer. Search words were "lung cancer", "minimal residual disease" and "detection of minimal residual disease". The publications we found were compared with the results of our own studies on the detection of minimal residual disease in lung cancer and the personal experiences are described. Examination of blood samples from 98 healthy volunteers and bone marrow from 12 patients with non inflammatory and non tumour illness, were used to determine cut-off values for specific markers in the compartments. Subsequently, expression of selected markers in tumor tissue was analysed in a pilot sample of 50 patients with lung cancer and the presence of MRD was measured as expression of values of the tested markers correlated with clinico-pathological characteristics. CONCLUSIONS: Recent studies on other malignancies apart from lung cancer have shown the importance of MRD detection in the determination of disease progression and prognosis. The methods of MRD diagnostics are based on detection of specific tumor markers. Of these, the most specific for lung cancer, appears to be the LunX protein. The best method for determining MRD is probably RT-PCR. Further studies should expand knowledge in this area: to refine understanding of the importance of tumor markers for prognosis, as well as to confirm the significance of these findings in clinical practice.

Videothoracoscopic identification of chondromatous hamartoma of the lung.

INTRODUCTION: The main disadvantage of a videothoracoscopic procedure is the lack of touch sensation. The probability of easily finding the lesion is usually estimated according to computed tomography (CT). AIM: To find useful parameters of location of chondromatous hamartoma of the lung parenchyma in relation to its size to assess the probability of successful search via a videothoracoscopic approach only. MATERIAL AND METHODS: A group of 55 patients operated on for chondromatous hamartoma of the lung at the First Department of Surgery in Olomouc from January 2006 to June 2011 was analyzed. Initially, the tumor's longest diameter and its nearest distance to the pleural surface were measured on CT scans. Subsequently, the surgery began using the videothoracoscopic approach. A short thoracotomy with direct palpation followed when videothoracoscopy failed. RESULTS: No significant differences in age, sex and side of localization between the group with and without successful videothoracoscopic detection were found. A significant difference was found in the median size (p = 0.026) and the depth of the tumor (p < 0.0001) and in the calculated index "tumor size/depth" (p < 0.0001). Deeper analysis revealed that the parameters "depth" and "index size/depth" are considered to be good predictors but the parameter "size" is not a suitable predictor. CONCLUSIONS: The main predictors of successful videothoracoscopic detection of lung chondromatous hamartoma are considered to be the depth of the tumor in the lung parenchyma with a cut-off value ≤ 7.5 mm and the index "size/depth" with a cut-off value ≥ 1.54; the tumor size is not considered to be a good predictor.

Infectious complications after esophagectomy.

BACKGROUND: Esophageal cancer is a serious diagnosis that has a relative incidence of 4/100,000 inhabitants in the Czech Republic. This disorder is managed predominantly by surgery. The steps to improving the outcome of treatment include a multifactorial approach. The role of operative technique in improving outcomes seems to have reached its limits. However, antibiotic prophylaxis and the treatment of complicating bacterial infections continue to play important roles. METHODS: A total of 85 patients with strictly defined antibiotic prophylaxis during surgical esophagectomy were included in our study. Bacterial strains were isolated from the patient's clinical materials after operation; only one strain from each patient, the first to be isolated, was tested for antibiotic sensitivity. RESULTS: Infectious complications were observed in 15.3% of patients and the mortality rate from infectious complications reached 30.8%. The most frequently documented complicated infection was pneumonia (69.2%) and the most frequent pathogens were enteric bacteria (56.5%). Some bacterial strains producing extended-spectrum beta-lactamases and AmpC beta-lactamases were found. CONCLUSIONS: The infections in our patient set were of endogenous origin. In cases of pneumonia, it is appropriate to begin with antibiotics effective against enteric bacteria and Pseudomonas aeruginosa.

Thoracoscopic treatment of benign esophageal tumors.

INTRODUCTION: Gastrointestinal stromal tumors are among the most frequent mesenchymal tumors of the gastrointestinal tract; the incidence of these tumors in the esophagus is less than 5%. Prognosis depends on localization, size, mitotic activity and possible invasion of surrounding structures. Minimally invasive surgery may be maximally utilized for removal of these tumors from the esophageal wall. This operation is usually performed thoracoscopically or laparoscopically and using the "rendez-vous" method - with endoscopic navigation. AIM: To evaluate a set of patients with benign tumor of the esophagus who were operated on at the First Department of Surgery from 2006 to 2011. MATERIAL AND METHODS: In the years 2006-2011 a total of 11 patients with benign tumors of the esophagus underwent operation. RESULTS: Of the 11 patients with esophageal tumor, 5 were diagnosed with gastrointestinal stromal tumor, 5 with leiomyoma and in one patient the lesion was described as heterotopy of the pancreas. We used the minimally invasive rendez-vous method with endoscopic navigation in 9 cases. All patients healed primarily and were released from hospital on the 4(th)-7(th) day. These patients are being followed up as outpatients and recurrence of the tumor has not been observed in any of them. CONCLUSIONS: Minimally invasive treatment of benign tumors of the esophageal wall is considered to the method of choice. Due to possible complications and the need for subsequent therapy in some patients, these procedures should be centralized to departments with experience in esophageal, thoracic and minimally invasive surgery.

Assessment of renal graft function depending on pre-transplant morphology.

BACKGROUND: Histopathological assessment of kidney prior to transplantation is a part of the comprehensive information gathered on the transplanted organ. In our study we monitor the influence of individual morphological findings (glomeruli, arteries, arterioles, interstitium, tubules) and degree of histopathological changes in the kidney function after transplantation. METHODS: From 1994 to 1997, 117 cadaveric kidneys were histopathologically examined and subsequently transplanted. Biopsy in a form of wedge excision was obtained during the organ procurement after in situ kidney perfusion and its removal from donor's body. Evaluated were glomerulosclerosis, intimal fibrosis of arteries, arteriolar hyalinization, interstitial fibrosis and tubular changes (vacuolar dystrophy of tubular epithelium, desquamation of tubular epithelium, brush border of proximal tubules, tubular dilatation, haemoglobin cylinders in distal tubules). Kidney recipients were monitored both for immediate function of transplanted organ and long-term kidney function for a period of five years following. RESULTS: In our group of patients, no unambiguously negative influence of histopathological change in individual morphologies was found either in the immediate or in the long-term function of the transplanted kidney. CONCLUSION: It is possible to transplant kidneys and attain satisfactory results even with these types of histopathological changes: glomerulosclerosis greater or equal to 20 %, mild degree of arterial lesion, moderate arteriolar lesions, moderate lesions of interstitial fibrosis and tubular lesions. The degree of arterial lesions, arteriolar lesions and the degree of interstitial fibrosis closely correlate to the donor's age, hypertension and nontraumatic cerebrovascular accident as the cause of death. Same outcomes were also confirmed with glomerulosclerosis, with the exception of the influence of the donor's age.