Breast-conserving surgery in breast cancer.

The breast cancer treatment is based nowadays on new surgical options: breast-conserving surgery, which applies at least for the first and second stage cancer, with radical intention. We have been practicing breast-conserving surgery for the last 16 years and we have performed 303 breast conserving operations from a total of 673. We recorded 12 local recurrences (3,96%) and 2 deaths due to cancer progression. Our protocol includes removal of the primary tumor with enough surrounding tissue to ensure negative margins of the resectable specimen, associated with axillary lymph-node dissection and postoperative breast irradiation. Our oncologist indicated chemotherapy on different postoperative conditions: tumor size, axillary lymph node involvement, patient's age, etc. The purpose of this paper is to emphasize our modest experience, nevertheless to draw the attention on important results, obtained by long-term monitoring of the patients who underwent breast-conserving surgery, in a two prospective protocols, and demonstrate the importance and applicability of breast conserving therapy. The conclusion of this study is that breast-conserving surgery followed by breast irradiation is reliable, as the results are similar with radical mastectomies; the main objective is to obtain a good cosmetic result, which depends on tumor size / breast size.

EGFR, HER2÷neu and Ki67 immunoexpression in serous ovarian tumors.

In this study, we analyzed EGFR, HER2/neu and Ki67 immunoexpression for 26 benign, borderline and malignant serous ovarian tumors. EGFR and HER2/neu immunoreactions were present in some benign/borderline tumors with high/low intensity of immunostain. In poorly differentiated adenocarcinomas, the EGFR/HER2/neu reaction was intense compared to well-differentiated ones. The Ki67 medium proliferation index was 2.1% for benign tumors, 6% in the borderline and 47.7% in malignant tumors. EGFR, HER2/neu and Ki67 can be used to identify benign/borderline tumors with progression potential and the malignant aggressive tumors.

The study of p53 and p16 immunoexpression in serous borderline and malignant ovarian tumors.

The study assessed p53 and p16 immunoexpression in 20 cases of ovarian serous carcinomas and four cases of serous borderline tumors, the results being statistically analyzed in relation to clinicopathological data of the cases. The p53 immunoreaction was observed in 85% of cases, the medium percentage of positivity being 15% for borderline tumors, 45% for low-grade carcinomas and 60% for high-grade carcinomas. The p16 immunoreaction was observed in 75% of cases, the medium percentage of positivity being 30% for borderline tumors, 25% for low-grade carcinomas and 62% for high-grade carcinomas. The p53 and p16 reaction was also identified at the tubal epithelium in cases of invasive carcinomas. Statistical analysis indicated significant differences in p53 expression depending on tumor type and for p53 and p16 expression compared to the degree of tumor differentiation. The study indicated a diffuse immunostain for p53 and p16 in high-grade serous ovarian carcinomas. The presence of "p53 signature" and areas with variable tumor differentiation and reactivity, in the case of high-grade carcinomas, supporting the existence of multiple mechanisms of their occurrence and progression.

[Diseases mimicking advanced-stage epithelial ovarian cancer]. / Afectiuni mimând cancerul ovarian epitelial în stadiu avansat.

This paper draws attention towards 3 cases with different pathologies all of which suggesting however both clinically and by imaging means as the most likely diagnosis advanced-stage epithelial ovarian cancer since all these three postmenopausal women had been admitted to the hospital with ascites, pelvic masses and deterioration of the physical wellbeing (fatigue, decreased appetite, weight loss, pallor). Findings during exploratory laparotomy on all these three pacients included ascites (hemorragic in one case) diffuse tumorous implants throughout the abdominal and pelvic peritoneal surfaces (in two cases) and the ovarian tumour. Postoperatively, the final histopathologic diagnoses consisted of primary peritoneal carcinoma (one pacient), peritoneal tuberculosis (TB, one pacient) and hepatic cirrosis with an incidental benign adnexial mass (one pacient). Moreover, nonmalignant ovarian tumours were certified in all three cases under current presentation. The differential diagnosis of the ovarian cancer and a tailored approach to treatment for each of these three pathologic entities will also be described in detail.

[Correlation of adenomatous polyps and early colorectal cancer. Diagnostic and therapeutic implications]. / Relatia polip adenomatos--cancer colorectal precoce. Implicatii diagnostice si terapeutice.

AIM: To detect the patients with colorectal adenomatous polyps or those with adenocarcinoma areas with a view to prevent and to treat the malignant disease. MATERIAL AND METHOD: A prospective study including 309 patients hospitalized between 2000-2005 diagnosed with isolated adenomatous polyps after repeated colonoscopies. The research method was selective screening with identification of risk factors regarding the evolution of colorectal polyps in early cancer, using colonoscopy and histopathological examination. RESULTS: We identified 464 single or multiple isolated polyps of which 399 were adenomas, 59 hyperplastic polyps and 6 other types of lesions. Histologically we recorded 41 (13.27%) polyps with a low grade of dysplasia, 56 (18.12%) with severe dysplasia and 30 (9.7%) intramucosal adenocarcinoma with submucosal invasion. TREATMENT: Colonoscopic polypectomy was used for benign polyps and in situ carcinoma. In case of adenocarcinoma is probable the invasion of submucosal lymphatics being shown a colorectal resection as appropriate. We performed 279 colonoscopic polypectomies and 30 conventional resections. CONCLUSIONS: High grade of dysplasia, the number of polyps, ulceration, bleeding, intraepithelial areas of neoplastic transformation are predictive factors for early colorectal cancer. Depth of submucosal invasion of malignant transformed polyps are important pathological factors to predict lymphatic metastasis and to select the therapeutic procedure.

[Stress urinary incontinence. Diagnostic and therapeutic aspects]. / Incontinenta urinara de efort. Aspecte diagnostice si terapeutice.

OBJECTIVE: The paper analyses the incidence, diagnosis and treatment options available for stress urinary incontinence (SUI) in women with pelvic floor dysfunction admitted to Craiova's Surgery Clinic IV. METHODS: This is a retrospective 10-year study comprising a surgical cohort of 420 patients with significant enough to alter quality of life SUI associated to ureterocele and cystocele and in 353 cases with rectocele too. The highest incidence of SUI was encountered between 50 and 59 years of age (range 39 - 81 years). In 21 of this case series the diagnosis of SUI was established soon after the surgical repair of the urethro-cystocele. The diagnosis of SUI was based on careful history and physical examination with emphasis on the gynecologic survey of the abdomen and pelvis but in the absence (for objective reasons) of urodynamic testing which is especially useful for SUI pathophysiological evaluation and thus surgery success rate prediction. All our 420 severe SUI associated with vaginal wall hernias underwent surgical treatment by either open Burch retropubic urethropexy or anterior colporraphy. RESULTS: Among anterior colporraphy treated patients SUI persisted in 19.3% of the cases (33 patients). Complications of Burch urethropexy procedure (despite its high ability for cure) in our case series include: urinary retention, hemorrhage into the space of Retzius, intraoperative injury to the bladder and long-term postoperative incisional hernia. Moreover, 5 patients (2%) of the group who underwent Burch operation were readmitted with recurrent urinary incontinence between 2 and 6 months after the aforementioned surgical intervention despite its good anatomical results in all of these cases. CONCLUSIONS: SUI is a prevalent disorder of women that can be diagnosed easily with history and physical exam. If symptoms persist and severely affect quality of life, despite modern noninvasive treatments, several surgical procedures are now available.

[Postoperative biliary peritonitis--diagnosis and treatment difficulties]. / Peritonitele biliare postoperatorii--dificultati de diagnostic si tratament.

AIM: To point out the severity of the postoperative biliary peritonitis (PBP) and to established the most proper ways of diagnosis and treatment. MATERIAL AND METHODS: 14 PBP (6 males and 8 females, age between 42 and 76 years) admitted in the last 14 years were analyzed. The PBP occurred after biliary surgery in 13 cases and after gastro-duodenal surgery in 1 case. The delay between the first operation and the establishing of the diagnosis and reoperation varied between 24 hours and more than 3 days. All the patients were operated on; the operation had to fulfill 2 main objectives: the treatment of the peritonitis and to solve the biliary lesions. RESULTS: 6 patients had a fair evolution. We registered 8 complications with a morbidity rate of 57,14% and 2 deaths with a mortality rate of 14,3%. CONCLUSIONS: 1. Postoperative biliary peritonitis is one of the most severe complications of the biliary and gastro-duodenal surgery, due to preoperative unrecognized biliary lesions or occurring as postoperative accidents or complications. 2. The clinical picture, deeply modified by the complex postoperative treatment makes the early diagnosis very difficult and leads to a delay of the re-operation. 3. The treatment is exclusively a surgical one, with two main objectives: the biliary lesion repair and the treatment of the peritonitis. 4. The postoperative biliary peritonitis are charged by a high postoperative morbidity and mortality rate, the delay of the diagnosis and the time of reoperation being the main risk factor.

[The mirage of the first lesion (gallstones) and laparoscopic cholecystectomy are able to defer the diagnosis of colon cancer]. / Mirajul primei leziuni (litiaza veziculara) si colecistectomia laparoscopica pot întârzia diagnosticul de cancer colic.

The study's aim was to analyze a series of colon cancer cases in which the mirage of the first (clinically most obvious) lesion (gallstones) along with its minimally invasive approach - that explored only the biliary disease - had contributed to the delay of large bowel malignancy' diagnosis and treatment. 1327 patients aged between 17 and 83 years and diagnosed with cholecystolithiasis were operated upon laparoscopically in the Department of General Surgery of Craiova CFR University Hospital from 2000 through 2004. Four out of these 1327 patients (0,3%) were readmitted with the diagnosis of colon carcinoma between 1 and 16 months after the laparoscopic cholecystectomy. Our retrospective study gives a full report on these 4 cases insisting upon the links between their clinical - laboratory evaluations and final diagnosis. Despite the low laparoscopic cholecystectomy overlooked colon cancer' incidence it seems reasonable to both improve the technique of peritoneal cavity exploration during this type of surgery and extend the preoperative evaluation whenever the slightest suspicion of associated pathology is raised especially in patients over 50 years of age.

[Primary retroperitoneal tumors--diagnostic and therapeutic difficulties]. / Tumorile retroperitoneale primitive--probleme de diagnostic si tratament.

This paper emphasizes the diagnosis and therapeutic difficulties in primary retroperitoneal tumors. There were analyzed 68 primary retroperitoneal tumors (1992-2002): 16 (23.5%) benign tumors, 39 (57.35%) malignant tumors and 13 tumors with unknown histological structure. The preoperative diagnosis was clinically suggested and confirmed by ultrasound and CT examination; the operability was always established by laparotomy. All cases were operated on: complete resection of tumor was possible in 39 cases (57.35%); partial resection in 11 cases (16.17%) and 18 (26.47%) cases were inoperable. There were 5 major intraoperative vascular lesions: 1 inferior vena cava lesion, 1 superior mesenteric vein lesion, 1 left common iliac vein lesion and 2 lumbar artery lesions. Postoperative mortality was represented by 2 cases. Postoperative complication was represented by 3 postoperative hemorrhages, 2 severe pulmonary infections, 1 postoperative evisceration, 1 postoperative acute pancreatitis and 1 acute myocardial infarction. In conclusion the primary retroperitoneal tumors represent a challenge for all surgeons, especially due to surgical approach difficulties, because of problems in tumors intraoperative exploration and resection and because of difficulties in hemostasis.

[The experience at the 4th Surgery Department of the University Hospital C.F. Craiova in the surgical treatment of inguinal hernia]. / Experienta Clinicii Chirurgicale IV a Spitalului Universitar C. F. Craiova în folosirea plaselor sintetice în tratamentul chirurgical al herniilor inghinale.

This paper aim is to present the experience of Surgery Department IV of University Hospital C. R. Craiova in groin hernias treatment using prosthetic meshes, also describing an original technical procedure of mesh-plasty that we have been practicing successfully in our clinic. The study is based on a number of 1757 groin hernias operated in Surgery Department IV of University Hospital C. F. Craiova during a period of 11 years (1993-2003). There have been used prosthetic meshes in a number of 230 hernias operated for the most part in the last years since mesh repair has become habitually. We have been using so far only prosthetic mesh made in Romania (polyester mesh). We had a single recurrent hernia and the immediate complications were minimal. The study refers us to practice prosthetic mesh repair in an extensive way and offers a technical alternative in using of prosthetic meshes by a simple and efficient procedure with good postoperative results.

[False surgical acute abdomen with intermittent acute porphyria]. / Fals abdomen acut chirurgical în cadrul unei porfirii acute intermitente.

This article presents a case of acute intermittent porphyria admitted to the Surgery Department of C.F. Craiova Hospital between 18.08.2003-26.08.2003 then transferred to the Colentina Hospital in Bucharest for diagnosis confirmation and adequate treatment. The purpose of this paper is to bring attention on a rare metabolic inherited disease that, due to its non-specific and often noisy symptoms and limited possibilities of biochemical, enzymatic and genetic diagnosis, could generate potential serious confusions. The presentes case illustrates the fact that sometimes the acute attack may be mistaken for an acute surgical affection which requires an emergency operation with all the aggravating consequences and delay in the real diagnosis. About 1% of acute attacks of porphyria may be fatal. Only the drugs known as safe should be prescribed. Basic treatment consists in oral and intravenous glucose and hematin administration.

[Ovarian cancer--diagnostic dilemmas and unusual therapeutic response]. / Cancerul de ovar între dileme de diagnostic si "capriciile" raspunsului terapeutic.

The aims of this paper are both to highlight some dilemmas concerning the diagnosis of primary epithelial ovarian carcinoma mainly in its early stages and to underline the capricious responses of this type of malignancy to an otherwise well coded modern management. This study is based on the analysis of the records of 78 patients with ovarian carcinoma admitted for diagnosis and surgical treatment to the Department of General Surgery of Craiova C.F.R. Clinic from 1993 through 2003. The results of this analysis are difficult to interpret due to loss to follow up (in terms of response rates) of some of our 78 operated on ovarian carcinoma patients who went on with their platinum-based chemotherapy (following surgical cytoreduction) under the supervision of different Oncology Departments nationwide. Nevertheless, it is worth mentioning that most of this study patients (71.9%) presented with advanced-stage (III and IV) ovarian carcinoma which sometimes seemed quite confusing by its clinical polymorphism but its prognosis was very much related to both the degree of surgical cytoreduction accomplished and tumor sensitivity to chemotherapy. Finally, although this study does not allow us to draw firm conclusions it is an attempt to share out our current perception on the primary epithelial ovarian cancer management.

[Locoregionally advanced rectosigmoid cancer: diagnosis, surgical approach, late results]. / Neoplasmul rectosigmoidian avansat locoregional. Probleme de diagnostic, rezultate la distanta, atitudine terapeutica chirurgicala.

The colorectal cancer continues to be diagnosed in advanced stages in our country, mainly due to unapplying of a programmer of active diagnosis through screening on the population with risk for colorectal cancer, and inefficiency of primary care system. In the department of General Surgery CFR Craiova Hospital between 1991-2001 were operated a number of 231 patients with colon cancer and 104 patients with rectal cancer. The results, showing an increased number of recurrences in cases of resection performed for advanced loco-regional tumors of rectosigmoid, made us to reconsider the attitude of avoiding the abdominoperineal resection even when the distance between the inferior limits of the tumors and the anal edge exceeded the distance considered being standard for a low anastomosis performing. The follow-up of the patients with paraclinic technique that didn't prove efficient led in the most cases to a delaying in diagnosis of local recurrences until the moment of resectability was exceeded. The applying of efficient methods in early diagnosis of colorectal cancer and follow-up could provide in the future better results for anterior resections with low anastomosis.

[Clinical course of an ileal carcinoid with mesenteric metastasis]. / Evolutie particulara a unui carcinoid ileal cu metastaza ganglionara în baza mezenterului.

This paper aim is to present the case of a male patient, age 63 admitted in hospital for non-specific gastroenterologic symptoms easily attributed to colecyst calculosis; the anamnesis and careful clinical examination have avoided a useless cholecystectomy and permitted to establish indication for laparotomy; during that was found an ileal tumor with massive metastasis in the base of mesentery. The surgical attitude was dictated by histological diagnostic difficulties (prostate adenocarcinoma metastasis), so it has given up the idea of tumor excision (unjustified intraoperative risk for a metastasis), performing a bypass of the ileal tumor by an enteroenterostomy, then the patient was sent to the Oncological Department. Postoperative evaluation of the patient finally permitted to establish the neuroendocrine origin of the tumor; after oncological treatment (chemotherapy), about 10 months after operation the patient didn't present any sign of tumor (tumor markers and CT scan within normal). The paper emphasizes the problem of practicing an aggressive surgical treatment for carcinoid intestinal tumors with mesenteric metastasis but also brings attention to nonsymptomatic forms of cholecyst calculosis that may hide associated malignant tumors undetected by laparoscopic cholecystectomy.

[Breast conserving surgery --7 years of experience]. / Chirurgia conservatoare a sânului--7 ani de experienta.

The breast cancer treatment is based nowadays on a new surgical option: breast-conserving surgery, which is reliable at least for the first and second stage of cancer, with radical intention, obviously. We have started to practice the breast-conserving surgery in our surgical clinic (at CFR Hospital, from Craiova) for 7 years; until now we have performed 159 breast-conserving operation and, as results, we have recorded 3 local recurrences (2.12%) and 1 death due to cancer evolution. Our protocol includes removal of the primary tumor with enough surrounding tissue to ensure negative margins of resectable specimen, associated with total axillary lymph-node dissection and postoperative breast irradiation. Our oncologist on different postoperative conditions indicated the chemotherapy: tumor size, axillary lymph node involvement, patient age, etc. The purpose of this paper is to emphasize our unassuming experience but especially to draw attention on important results, obtained by long-term monitoring the patient who underwent breast-conserving surgery, in a two prospective protocols, which demonstrate the importance and applicability of breast-conserving therapy. The conclusion of this study is that breast-conserving surgery followed by breast irradiation is reliable, as the results are similar with the radical mastectomies; the main objective is to obtain a good cosmetic result, which depends on tumor size/size of the breast ratio.

[Tumour-host interaction and prognosis in patients with gastric cancer]. / Aspecte ale relatiei tumora-gazda cu implicatii în aprecierea prognosticului la pacientii cu cancer gastric.

The study analyzed the prognostic significance of a group of three histologic markers belonging to intra- and peritumorous stroma as derived from a series of 66 patients with gastric adenocarcinoma operated upon in Craiova CFR General Surgery Clinic. To this end we attempted to uncover any possible correlation between the three stromal parameters represented by type of angiogenesis, peritumorous inflammatory infiltrate and desmoplastic reaction and both the depth of malignant invasion through the gastric wall and the histologic type of gastric cancer. The results of our investigation highlighted that type A2 angiogenesis is displayed mostly by gastric carcinomas with well-differentiated tubular and secretory structure (class 2 Goseky) whereas type A3, angiogenesis is mainly a feature of gastric cancer with a poorly-differentiated tubular morphology (classes 3 and 4 Goseky). Moreover there was no statistically significant correlation between the intensity of inflammatory infiltrate and both the Goseky classes and the depth of neoplastic spread. Finally a clearly desmoplastic reaction was encountered in less than 50% of our patient series and represented almost a characteristic of both poorly-differentiated tubular structured malignancies and serosa invading tumors.

[Functional secondary megaduodenum]. / Megaduoden secundar functional.

This paper aim is to present the case of a 72 year old male, diagnosed with functional secondary megaduodenum. We intend to discuss the pathogenic and positive diagnostic difficulties (the presence or absence of a mechanical obstructive factor or the participated of the megaduodenum in an intestinal pseudo-obstruction syndrome). Also we outline the rare frequency of this disease and especially the therapeutic difficulties: inefficiency of conservatory treatment, delicate problems of surgical tactics and technique.

[Microbiology of nosocomial infections in a general surgery department]. / Microbiologia infectiilor de spital în clinica de chirurgie generala.

This paper aim is to outline the importance of nosocomial infections, characterized by great incidence, great mortality rate and specific bacteriology, in a surgery clinic. The study include 566 patients that developed 665 nosocomial infections (10.65% incidence), among the 5950 patients that underwent surgical operations in 5 years (1992-1996); 54 patients developed two or three nosocomial infections, which explain the incidence of nosocomial infection greater than number of patients. From bacteriological point of view predominance of Gram negative bacilli (especially E. coli) and pathogen staphylococcus characterized the nosocomial infections. The infection source was the patient himself, previously colonized with hospital specific microorganisms. Every clinical form of nosocomial infections was characterized by the present of specific pathogen microorganisms; the knowledge of these pathogen agents is very important for the antibiotic treatment applied before the bacteriological exam.

[Thoracic esophageal neoplasm-therapeutical problems and post-surgery evolution]. / Neoplasmul de esofag toracic--probleme terapeutice si evolutie postoperatorie.

The authors are presenting a few considerations on Thoracic Esophageal Neoplasm, as resulted from an 18-cases study performed on patients that were operated between 1994-1999. The esophageal resection rate was of 50%, as follows: 7 Esophageal Resections and 2 Superior Polar Esogastric Resections. The digestive transit was reestablished by means of intrathoracic transposition of the stomach (6 cases) or of the right ileo-colon (2 cases). In one of the cases an Esogastric Anastomosis was performed at the neck level (cervical-right). Immediate post-op mortality after Esophageal Resection (1 case) was due to an acute respiratory distress syndrome (ARDS). The post-op complications were as follow: one anastomotic fistula associated with a purulent pleurisy, 4 non-infectious pulmonary complications and 2 cardiac complications (paroxysmal supraventricular tachycardia). The Discussions and Conclusions of the present work are presenting samples of surgical techniques, post-op complications and prognosis.

[Post-operative temporary enteral nutrition methods]. / Cai temporare de nutritie enterala postoperatorie.

THE AIM: Of the present work is to promote duodenostomy as the postoperative enteral nutrition way, when surgery ends in an anastomosis in which one of the partners is the esophagus (esophagectomies, esogastrectomies and total gastrectomies). MATERIAL AND METHOD: Consisted of 45 cases 815 total gastrectomy, 14 esogastrectomy, 6 esophageal resections and 10-esophageal plasty) in which we used: nasofaringoesogastric or nasofaringoesojejunal probes (14 cases); Witzel jejunostomy (11 cases); gastrostomy (10 cases); duodenostomy (10 cases). THE CONCLUSIONS: Show the many advantages of duodenostomy as compared to other enternal nutrition methods: technical simplicity, patient's comfort, avoidance of complications involved by the use of nasopharingoesodigestive probe or by jejunostomy, etc.