[Surgery of the colorectal polyps and early stage cancer - Expected standards]. / Colorectalis polypok és korai rákok sebészete ­ Elvárható standardok.

Benign polyps and early-stage cancer of the colon and rectum traditionally belong to the territory of endoscopic removal. Even though the quality of endoscopic imaging systems and additional diagnostic methods have undergone a substantial evolution over the past decade, large, sessile and lateral-spreading lesions of the large bowel still represent a significant risk of malignancy. This doubt may be undispellable until the removal of the lesion. Therefore endoscopists need to be highly cautious, and keep a very low threshold to involve an expert surgeon even at the phase of diagnostics, as well as treatment. We summarise state-of-the-art treatment principles of benign polyps and early malignant colorectal cancer. Finally, we propose national quality measures of surgical interventions for colorectal polyps.

Paraneoplastic Kelch-like protein 11 antibody-associated cerebellar and limbic encephalitis caused by metastatic "burned-out" seminoma - A scar(r)y phenomenon.

INTRODUCTION: The diagnosis of paraneoplastic neurologic syndromes is challenging when the primary tumor masquerades as scar tissue (i.e. "burned-out"). METHODS: Case report. RESULTS: A 45-year-old male patient presented with progressive cerebellar symptoms and hearing loss. Initial screening for malignancy and extensive testing of paraneoplastic and autoimmune neuronal antibodies gave negative results. Repeated whole-body FDG-PET CT revealed a single paraaortic lymphadenopathy, metastasis of a regressed testicular seminoma. Anti-Kelch-like protein-11 (KLHL11) encephalitis was finally diagnosed. CONCLUSION: Our case highlights the importance of continued efforts to find an often burned-out testicular cancer in patients with a highly unique clinical presentation of KLHL11 encephalitis.

Long-term nutrition in patients candidate to neoadjuvant and adjuvant treatments.

To improve outcomes, to decrease the rate of local recurrence and development of distant metastases neoadjuvant and adjuvant therapies are employed in cancer patients in forms of radiation, chemo-, endocrine-, targeted-, and immunotherapy or their combination. Nutrition therapy plays important role in all phases of the cancer journey. From neoadjuvant therapy to prehabilitation, early postoperative nutrition, and long-term nutrition care during the adjuvant phase and survivorship determines the survival and quality of life of cancer patients. During the neoadjuvant phase patients may be in poor nutritional condition which can be aggravated by the applied oncological treatment. Beside this apparent threat this period also gives an excellent opportunity to maintain or even improve the nutritional status of the patients by nutrition therapy. After surgery the burdening effects of the operation may jeopardize the execution of adjuvant therapy. After early postoperative feeding a long-term nutrition strategy should be developed for cancer patients in order to avoid nutritional deterioration during the usually lengthy postoperative therapy. In this narrative review we discuss how preoperative nutritional status and medical nutrition therapy influence the results of surgery and after the operation what is the available evidence about nutritional status and outcome and the potentials to influence them by nutrition therapy.

Improved Accuracy of Lymph Node Staging and Long-Term Survival Benefit in Colorectal Cancer With Ex Vivo Arterial Methylene Blue Infiltration.

Introduction: Ex vivo methylene blue (MB) injection into the main supplying arteries of the colorectal specimen after surgical removal is an uncomplicated technique to support lymph node harvest during pathological evaluation. The primary aim of this randomized, interventional, bicentric trial was to evaluate the impact of MB injection on lymph node yield, with secondary aims assessing the accuracy of lymph node staging and the effect on 5-year overall survival for patients undergoing resection of colorectal cancer. Methods: In the study period between December 2013 and August 2015, 200 colorectal resections were performed at two independent onco-surgery centers of Hungary. Following surgical resection, each specimen was randomly assigned either to the control (standard pathological work-up) or to the MB staining group before formaldehyde fixation. Patient-level surgical and clinical data were retrieved from routinely collected clinical datasets. Survival status data were obtained from the National Health Insurance Fund of Hungary. Results: A total of 162 specimens, 82 in the control and 80 in the MB groups, were included for analysis. Baseline characteristics were equally distributed among study groups, except for specimen length. Both the median of total number of lymph nodes retrieved (control 11 ± 8 [0-33] nodes vs. MB 14 ± 6 [0-42] nodes; p < 0.01), and the ratio of cases with at least 12 removed lymph nodes (36/82, 43.9% vs. 53/80, 66.3%; p < 0.01) were higher in the MB group. The rate of accurate lymph node staging was non-significantly improved. As for rectal cancer, nodal staging accuracy (16/31, 51.6% vs. 23/30, 76.7%; p = 0.04) and the proportion with minimum 12 lymph node retrieval (7/31, 22.6%, vs. 18/30, 60%; p < 0.01) was improved by MB injection. In Mantel-Cox regression, a statistically significant survival benefit with methylene blue injection at 5 years post-surgery was proven (51.2% vs. 68.8%; p = 0.04). Conclusion: In our experience, postoperative ex vivo arterial methylene blue injection appears to be an uncomplicated technique, improving lymph node yield and decreasing the chance of insufficient nodal staging. The technique might also associate with a 5-year overall survival benefit.

[Guidance for transanal operations]. / Transzanális mutéti útmutató.

We summarized diagnostic, surgical treatment and follow-up principles of benign and early malignant lesions of the rectum. Our aim is to provide a nationwide practical synopsis of transanal minimally invasive surgical techniques which might be the basis of a Hungarian national audit of rectal polyp management.

[Enhanced Recovery Program in colorectal surgery]. / "Enhanced recovery after surgery" bevezetése a vastagbél sebészetében.

INTRODUCTION: Enhanced recovery after surgery (ERAS) programme has been described and practiced for twenty years in the perioperative management of colorectal patients. ERAS is a complex, evidence based strategy which proved to be extremely effective when linked to laparoscopy in reducing morbidity, length of hospital stay, as well as reducing cost of colorectal service. AIMS: We gradually adapted elements of ERAS protocol along with laparoscopy in the colorectal surgical treatment at a county hospital from 2013. This study reports a retrospective clinical audit of ERAS programme of two years, between 2015-2016. METHODS: In this timeframe we compared clinical results of traditional and ERAS perioperative colorectal management protocols. The two groups were assessed on the basis of demographic, cancer-related parameters and clinical outcomes. RESULTS: Over the two years of audit we treated 130 patients under "traditional" and 84 cases according to ERAS protocol. Mean length of hospital stay was 8 and 6 days median, respectively. Earlier discharge in the ERAS group did not cause any increase in the readmission rates. Morbidity (Clavien-Dindo grade 2 or more) was found to be less in ERAS group: 8,3% vs. 27,4%. ERAS programme success rate, characterized by discharge by 7th postoperative day, was over 70%, keeping well with rates of the experienced centres of ERAS. CONCLUSION: Therefore we can report a successful introduction of ERAS programme for colorectal service in a Middle-Eastern European county hospital. Based on the favourable outcome results of the retrospective audit we have extended ERAS protocol as first choice perioperative scheme for each elective colorectal case from the beginning of 2017.

[New perspectives in rectal cancer surgery: Transanal total mesorectal excision. Initial experiences]. / Új távlatok a végbélrák sebészetében: Transanalis teljes mesorectum excisio. Kezdeti eredményeink.

INTRODUCTION: Colorectal cancer is the second most frequent cause of oncologic mortality. Its key prognostic factors are operability and surgical quality. Total mesorectal excision is the gold standard of rectal cancer surgery, however, it is hardly achievable with the laparoscopic technique in a number of cases due to anatomical issues. Transanal total mesorectal excision (TaTME) is a new operative concept, which may address this technical problem. AIM: We aimed to present the initial Hungarian experiences with the new technique. METHOD: Retrospective analysis of clinical data of the first year case series at two Hungarian centers initiating the technique. RESULTS: A total of 17 transanal total mesorectal excision (TaTME) operations were performed at two centers. Major perioperative complications happened in two cases. There was no 30-day mortality. CONCLUSIONS: Early Hungarian experiences with transanal total mesorectal excision (TaTME) give hope of a brand new era of rectal cancer surgery. Orv Hetil. 2018; 159(1): 16-22.

[TAMIS, transanal minimally invasive surgery]. / TAMIS - transanalis minimálisan invazív sebészet.

Diseases of the lower and middle third of the rectum, the so called "no-man's territory" traditionally represent a major surgical problem. Minimally invasive surgical techniques significantly contribute to the safe and precise management of this part of the rectum. Traditional laparoscopic instruments via a specifically designed operative anoscope with single-port surgical technique are used during TAMIS (transanal endoscopic minimally invasive surgery). Since the description of the procedure in 2009 a number of case series have proven the feasibility and safety of the technique in the treatment of rectal adenomas. Furthermore, TAMIS seems to be sufficient in the primary treatment of early rectal cancers, as well. Recent studies also challenge the rigid protocols of the management of advanced rectal adenocarcinomas. Transanal wide local excision techniques (including TAMIS) with low morbidity rates seem to be effective in cases of histologically proven pCR (complete pathological response) after neoadjuvant treatment by selecting the group of patients not requiring radical TME (total mesorectal excision). Finally, TAMIS technique provide a suitable way for down-up transanal TME (TaTME), which technique is expected to potentially improve surgical grade in selected cases of advanced rectal cancer surgeries. In this paper we demonstrate our initial experiences with TAMIS at a single institution, as well as summarize the relevant literature.

Transanal endoscopic microsurgery in the management of rectal wall endometriosis.

A 29-year-old woman with known history of endometriosis was referred to colorectal outpatient clinic from gynaecology with a history of intermittent rectal bleeding and no associated bowel symptoms. Flexible sigmoidoscopy in concordance with pelvic MRI revealed a 3×2×2 cm sessile lesion in the anterior rectal wall. The lesion was also palpable as a firm mass on digital rectal examination. From the gynaecological point of view no intra-abdominal exploration was required; the sole rectal wall lesion was removed with the minimally invasive surgical technique of transanal endoscopic microsurgery. Full thickness rectal wall excision sample was reported to be histologically complete and confirmed endometriosis. No recurrence was detected at endoscopic follow-up at 6 months. The patient remained symptom free. Therefore, we demonstrated a case of minimally invasive removal of a rectal wall large endometriosis nodule in a fertile woman with a complete, symptomatic, uneventful recovery.

Single-incision laparoscopic (SIL) sigmoid colectomy and uterus-preserving repair for colo-uterine fistula secondary to severe diverticular disease: an unusual technical solution for an unusual presentation of a common disease.

Colouterine fistula as a potential complication of chronic diverticulitis is a rare entity with less than 30 cases reported worldwide. Generally, patients require a multidisciplinary approach including a major laparotomy with hysterectomy and sigmoid colectomy, and, occasionally, temporary colostomy. We report the first attempt of a novel, minimally invasive technique for managing a case of benign colouterine fistula with single-incision laparoscopic (SIL) sigmoid colectomy and uterus preservation. A small, 3 cm incision site provided access for the whole operation, as well as played a role as the specimen extraction site. Malignant fistulas and large uterine defects may require hysterectomy, however, laparoscopic closure of uterine wall defects can be considered as a reasonable alternative in selected patients, avoiding the higher risks associated with hysterectomy and keeping fertility at younger ages. Single incision laparoscopy in complicated diverticular disease and fistula formation cases is a challenging but technically feasible option, in experienced hands.

The novel panel assay to define tumor-associated antigen-binding antibodies in patients with metastatic melanomas may have diagnostic value.

We aim to harness the natural humoral immune response by various technologies to get novel biomarkers. A complex antibody analysis in sera and in the tumor microenvironment leads to reveal tumor-specific antibodies. More strategies were introduced to select the most effective one to identify potential tumor antigen-binding capacity of the host. Epstein-Barr virus transformation and cloning with limiting dilution assay, magnetic cell sorting and antibody phage display with further methodological improvements were used in epithelial and neuroectodermal cancers. Column-purified sera of patient with melanoma were tested by immunofluorescence assay, while sera of further melanoma patients were processed for membrane-binding enzyme-linked immunosorbent assay. Some supernatants of selected B cell clones and purified antibodies showed considerable cancer cell binding capacity by immunofluorescence FACS analysis and confocal laser microscopy. Our native tumor cell membrane preparations helped to test soluble scFv and patients' sera for tumor binder antibodies. A complex tumor immunological study was introduced for patients with melanoma (ethical permission: ETT TUKEB 16462-02/2010); peripheral blood (n = 57) and surgically removed primary or metastatic tumors (n = 44) were gathered and processed at cellular immunological level. The technological developments proved to be important steps forward to the next antibody profile analyses at DNA sequence level. Cancer cell binding of patient-derived antibodies and natural immunoglobulin preparations of pooled plasma product intravenous immunoglobulins support the importance of natural human antibodies. Important cancer diagnostics and novel anticancer strategies are going to be built on these tools.

Demonstration of a melanoma-specific CD44 alternative splicing pattern that remains qualitatively stable, but shows quantitative changes during tumour progression.

The role of CD44 in the progression of human melanoma has mostly been characterised by qualitative changes in expression of its individual variable exons. These exons however, may be expressed to form a number of molecules, the alternative splice variants of CD44, which may be structurally and functionally different. Using real-time PCR measurements with variable exon specific primers we have determined that all are expressed in human melanoma. To permit comparison between different tumours we identified a stable CD44 variable exon (CD44v) expression pattern, or CD44 'fingerprint'. This was found to remain unchanged in melanoma cell lines cultured in different matrix environments. To evaluate evolution of this fingerprint during tumour progression we established a scid mouse model, in which the pure expression pattern of metastatic primary tumours, circulating cells and metastases, non-metastatic primary tumours and lung colonies could be studied. Our analyses demonstrated, that although the melanoma CD44 fingerprint is qualitatively stable, quantitative changes are observed suggesting a possible role in tumour progression.

Characteristics of CD44 alternative splice pattern in the course of human colorectal adenocarcinoma progression.

BACKGROUND: CD44 is considered as 'a' metastasis associated gene, despite the fact that it is an umbrella term for a group of molecules produced from a single gene by alternative splicing. However, little consideration is given to the above in the literature of colorectal carcinomas as well as other tumour types, leading to confusion and contradictory results about its possible role in tumour progression. METHODS: We compared the CD44 alternative splice pattern (ASP) of three genetically different human colorectal cancer cell lines (HT25, HT29, HCT116) using a series of PCR reactions and next- generation sequencing method, as well as identified a colorectal adenocarcinoma specific CD44 ASP. This ASP was further investigated in terms of its qualitative and quantitative stability in our experimental iso- and xenograft mouse models for colorectal cancer progression. A complex preclinical experimental set-up was established to separately test the different steps of tumour progression and the role of tumour microenvironment, respectively, focusing on the role of 'CD44' in this process. RESULTS: We managed to present a colorectal cancer-specific CD44 ASP, which remained unchanged from cell lines throughout primary tumour formation and metastatic progression. Furthermore, we report a unique roster of all expressed CD44 variant isoforms characteristic to colorectal cancer. Finally, on quantitative assessment of the variable exons v3 and v6, higher co-expression levels were found to be characteristic to metastatically potent tumour cells. CONCLUSION: Particular CD44 variant isoforms seem to act as "metastasis genes" via tumour microenvironment-driven shifts in v3 and v6 expressions. However, this function may just affect a minority of tumour subclones. This fact and the huge potential number of different CD44 splice variants that can contain v3 and v6 domains can explain incoherence of clinical studies regarding functional asessment of CD44 variants, as well as diminish the chances of using CD44 variants for predictive purpose.

Colonic obstruction caused by intraluminal haematoma.

We report a rare case of caecal obstruction in an anticoagulated elderly patient, who presented with abdominal pain and per-rectal bleeding. CT revealed obstruction in the ascending colon. The patient subsequently underwent a right hemicolectomy for a massively distended caecum containing a large intraluminal haematoma causing obstruction.

[Giant retroperitoneal liposarcoma--case report]. / Oriás retroperitoneális liposzarkóma--esetbemutatás.

Retroperitoneal liposarcomas are the most frequent soft tissue sarcomas and the second most frequent retroperitoneal tumours. They represent less then 0.1% of all human malignancies. Hereby we describe the treatment of our patient where of a 15-kg giant retroperitoneal liposarcoma was successfully removed and a local recurrence two years later was operated on as well. This was the 3rd largest retroperitoneal malignant tumor that was successfully removed according to the available literature of the last five decades. These typically symptom-free tumors usually grow extreme size before diagnosed. The "gold-standard" of treatment remains surgical total excision, but the high local recurrence rate (50-60%) hopefully can be reduced by adjuvant radio- and chemotherapy. Multidisciplinary treatment and long-time follow-up can provide as high as 40% 5-year survival rate. We summarize the recent clinical, diagnostic and therapeutic methods of this rare condition.