"The Red Flags" in Clinical Approach to Acute Ataxia-the Experience in Cohort of 76 Children.

The aim of our study is to define the most frequent etiology, clinical presentation, and predictive factors of outcome in children with acute ataxia (AA) and to determine "the red flags" in the diagnostic approach to children with AA. The retrospective study included the patients with AA treated in the institute from 2015 to 2021. The inclusion criteria were children aged 1-18 years, evolution time of ataxia within 72 h, and diagnosis made by a physician. The exclusion criteria were anamnestic data about ataxia without confirmation by any physician, chronic/persistent ataxia, and psychogenic or postictal ataxia. Clinical presentation was divided into two categories: (1) isolated cerebellar signs (CS): ataxic gait, dysmetria, dysdiadochokinesia, intention tremor, dysarthria, and nystagmus; (2) CS-plus symptoms which included CS associated with any of other symptoms such as encephalopathy (GCS < 15), awareness disturbances, vomiting, headache, a new onset limb or facial paresis, torticollis, hypotonia, and opsoclonus. The outcome was assessed at the end of hospitalization and was defined as complete or incomplete recovery. The study included 76 children, with a mean age of 5.7 years (IQR 2.1-8.3). The most frequent causes of AA were immune-mediated/infective cerebellar ataxia in 27 (35.5%), and intoxication in 24 (31.6%) cases, followed by vestibular ataxia, opsoclonus-myoclonus-ataxia syndrome, and intracranial expansive process. Forty-two (56%) cases experienced isolated CS, and 35 (46%) cases had CS-plus. Complete recovery was experienced by 62 (81.6%) patients. Analysis of some risk factors (sex, age, presence of previous infection, "cerebellar plus symptoms," and structural abnormalities/neuroimaging abnormalities) and their relation to outcome was performed. Analysis showed that presence of additional symptoms to ataxia, so called "cerebellar plus symptoms" (p = 0.002) and structural abnormalities (p < 0.001), had statistically higher frequency of poor outcome. Statistical significance remained in the univariate analysis. Significant data was included in multivariate logistic regression analysis which also showed that presence of "cerebellar plus symptoms" (p = 0.021) and structural abnormalities (p = 0.002) is related to a poor outcome. Most of the children with AA have "benign" etiology such as intoxication and post/parainfectious cerebellar ataxia with favorable outcomes. On the other hand, AA might be the first manifestation of CNS neoplasm or paraneoplastic phenomena. "The red flags" associated with cerebellar signs are limbs or facial palsy, hypotonia, GCS < 15, vomiting, opsoclonus, headache, myoclonus, visual impairment, torticollis, and vertigo. The presence of those signs and/or structural brain abnormalities was related to poor outcomes in children with AA.

Single versus double stapling anastomotic technique in rectal cancer surgery.

PURPOSE: The present study was designed to investigate whether there is a difference in the anastomotic leakage rate (AL) between the single stapling (CSA) and double stapling (DSA) anastomosis techniques. METHODS: One hundred consecutive rectal cancer patients who underwent rectal resection with primary anastomosis were enrolled in this study. RESULTS: The overall rate of clinical anastomotic leakage in both groups was 7 % (7/100); 6 % (3/50) in the CSA group and 8 % (4/50) in the DSA group. The anastomotic technique did not have any significant influence on the rate of AL. All AL were seen in low anastomoses (7 cm and below). The rate of AL in patients with a diverting stoma (13 %, 3/23) was not significantly different from that of the patients without (5.2 %, 4/77) (p = 0.195). The mean length of the operation was significantly shorter in the DSA group compared to the CSA group, at 127 and 141 min, respectively (p = 0.005). There were significantly higher rates of AL in patients receiving preoperative long course radiotherapy (15.4 %, 6/39) compared with those who did not receive radiotherapy (1.63 %, 1/61) (p = 0.014). CONCLUSIONS: The CSA and DSA techniques are equally safe for the creation of a rectal anastomosis, without any significant difference in the AL rate. However, we recommend using the DSA technique because it has other definite advantages. In cases of neoadjuvant treatment and a low anastomosis, proximal diversion is recommended.

The clinical role of micrometastatic disease in sentinel lymph nodes in breast cancer.

PURPOSE: Complete axillary lymph node dissection (cALND) is the standard procedure in treating the patients with tumor-positive sentinel nodes (SLNs). However, approximately half of these patients have not additional metastases in their axilla and therefore do not benefit from cALND. Our aim was to examine the outcome of patients with tumor-positive SLNs without cALND. METHODS: All patients (n=591) were women with clinically T1-2N0-1M0 breast cancer. SLN marking was performed with blue dye (Patentblau V) and radiotracer (antimony sulfide marked with Tc99m). Both contrast media were applied peritumorally or periareolarly. After SLN biopsy all patients underwent breast-conserving surgery or mastectomy with or without lymph node dissection of level I and II (depending on SLN status). RESULTS: In 37 (17.84%) out of 185 patients cases SLNs contained micrometastases. In 19 of 37 cases (57.58%) cALND was performed, and in 14 (42.42%) was not. The mean and median duration of follow-up were 50.59 and 55 months, respectively (range 4-108). Two cases without cALND developed ipsilateral enlarged lymph nodes at 26 and 59 months. Biopsy showed that the enlarged nodes were tumor-free. In all other cases with micrometastases in SLNs neither axillary lymphadenopathy nor distant metastases were seen. After performing surgical treatment, all patients received adjuvant chemotherapy or hormonotherapy and radiotherapy. CONCLUSION: Patients with SLN micrometastases who had not undergone cALND showed no regional recurrence and distant metastases. ALND is not necessary for regional control in patients with micrometastatic or isolated tumor cells in SLNs. By avoiding cALND the number of complications was reduced and the quality of life was improved.

Breast MRI: intraindividual comparative study at 1.5 and 3.0T; initial experience.

PURPOSE: To prospectively and intraindividually compare breast magnetic resonance imaging (MRI) at 1.5 Tesla (T) and 3.0T. METHODS: A prospective intraindividual Ethics Committee- approved study was performed in 31 women (average age 58.6±12.3 years), with 114 lesions (9 benign, 105 breast cancers; 24 patients with unilateral and 7 with bilateral cancers). Axial bilateral breast high-spatial resolution contrast-enhanced dynamic MRI was performed at 1.5T using 3 dimensional (3D) dynamic gradient-echo sequences in all patients (spatial resolution 1.1×0.7×2 mm; temporal resolution 41 sec per dynamic acquisition), and after 24-48 h at 3.0T (0.6×0.6×1.7 mm; temporal resolution 65 and 72 sec per dynamic acquisition). Contrast enhancement ratio, number and features of enhancing lesions, image quality and reliability were compared by two radiologists independently. RESULTS: 102 cancer lesions were detected at 1.5T and 105 cancer lesions were detected in 31 patients at 3.0T. One cancer lesion was observed at 1.5T which was missed at 3.0T, and 3 cancer lesions and one high-risk lesion (LCIS) were detected at 3.0T while missed at 1.5T. Enhancement rates were significantly higher at 1.5T (224.5±100.2) compared to 3.0T (133.7±38.3). Better image quality was observed at 3.0T. Interobserver reliability was higher at 3.0T (p= 0.684) compared to 1.5T (p= 0.351). CONCLUSION: Detection of breast cancer shows a trend of better performance at 3.0T than at 1.5T.

Usefulness of beta hCG as tumor marker in the diagnosis and follow up of patients with ovarian cancer.

PURPOSE: To test the possibility of using beta human chorionic gonadotropin (ß-hCG) as a tumor marker in ovarian cancer by determining its diagnostic and prognostic value, and see for any relationship between disease stage, histological tumor types and serum and ascitic fluid ß-hCG levels, as well as to identify false positive and false negative results. METHODS: This was a prospective study in 60 surgically treated patients with ovarian cancer in the period 2006- 2010. The diagnosis was confirmed postoperatively based on the histopathological findings and the continuous determination of ß-hCG serum levels, during the 2 postoperative years at regular quarterly intervals. The obtained results were statistically processed using multivariate analysis. RESULTS: ß-hCG showed no reliable diagnostic value in ovarian cancer. A statistically significant difference between serum ß-hCG levels and different FIGO stages was noted, but not between ß-hCG levels and different histological groups of tumors. There were 10.2% of false positive and 18.9% of false negative results in all measurements. CONCLUSION: The use of ß-hCG as a tumor marker for ovarian cancer is justified only in patients with preoperatively high levels in advanced FIGO stages (III and IV), regardless of histological type of tumor.

Early complications after nipple-sparing mastectomy and immediate breast reconstruction with silicone prosthesis: results of 214 procedures.

BACKGROUND AND AIMS: breast reconstruction with silicone prosthesis following nipple-sparing mastectomy has become widely accepted as a reconstruction option in women requiring mastectomy for cancer. The purpose of this study was to evaluate the incidence and some factors influencing early local complications in patients undergoing NSM with immediate implant reconstruction. MATERIAL AND METHODS: prospective study was performed on a consecutive series of 214 breast reconstructions in 205 patients. All complications during the six weeks after surgery were recorded. 42 prostheses were implanted after neoadjuvant chemotherapy, 27 patients previously had radiotherapy due to breast conserving surgery and in all other cases surgery was the pri-mary treatment for cancer. RESULTS: the overall six-week complication rate was 16% (35) and included: major skin flap necrosis (4%, 9 procedures), minor skin necrosis (3%, 7), major infection (2%, 5), minor infection (3%, 7), prolonged seroma formation (3%, 6), haematoma (1%, 2) and epidermolysis (1%, 2). In 6% (12) reconstruction procedures explantation of prosthesis was done. Neoadjuvant chemo-therapy and radiotherapy were not associated with higher rate of complications. CONCLUSION: nipple-sparing mastectomy with immediate implant reconstruction has acceptable morbidity rate in the hand of experienced oncoplastic surgeon and therefore should be considered as treatment option to women requiring mastectomy.

Accuracy of endorectal ultrasonography in staging locally advanced rectal cancer after preoperative chemoradiation.

AIM: The aim of our study was to determine the accuracy of endorectal ultrasonography (ERUS) in staging locally advanced rectal cancer after preoperative neoadjuvant chemoradiation and to point out the most common reasons for false interpretation. METHODS: Forty-four patients with locally advanced rectal cancer received neoadjuvant chemoradiation followed by radical surgery. Restaging was done 1-2 weeks before surgery and the results of ERUS staging were compared with histopathology findings of the resected specimen. RESULTS: The accuracy of ERUS for T stage after chemoradiation was 75% (33/44). Overstaging occurred in 18% (8/44) of patients, and 7% (3/44) were understaged. The majority of overstaging occurred in patients with ERUS T3 tumors, eventually found to have pathological pT0-pT2 staging. Five patients (11.4%) had complete histology regression and only one of these patients was staged correctly while others were overstaged. In the detection of perirectal lymph node metastases, ERUS was accurate in 68% of patients (30/44). Twenty percent (9/44) of patients were overstaged and 11% were (5/44) understaged. CONCLUSIONS: ERUS provides a good accuracy rate for staging rectal cancer after neoadjuvant chemoradiation. However, it is insufficient in detection of complete pathological response.

Blue dye versus combined blue dye-radioactive tracer technique in detection of sentinel lymph node in breast cancer.

BACKGROUND: Sentinel lymph node biopsy in breast cancer can be used to select patients in which axillary lymph node dissection could be avoided. In this study we compared the value of two methods for identification of sentinel node (SN) using either only blue dye or combination of blue dye and radioactive tracer. MATERIAL AND METHODS: All patients were women with clinically T(1-2)N(0)M(0) breast cancer. They were randomized into two groups. In Group A (50 patients) SN marking was performed only with blue dye and in Group B (100 patients) combined SN marking with blue dye and radiotracer was done. We used 2 ml of blue dye Patentblau V (Byk Gulden). Radiotracer was Antimony sulfide marked with Tc 99m and of 0.3 mCy (11.1 MBq) activity. Application method of both contrasts was peritumoral. After SN biopsy all patients underwent mastectomy or conservative surgery with axillary lymph node dissection of levels I and II. RESULTS: In Group A mean of 1.7 SNs were identified (median 1, range 1-4). False-negative rate in this group was 3/17 (17.6%) with negative-predictive value 20/23 (86.9%), sensitivity 14/17 (82%), specificity 20/33 (60%) and accuracy 34/50 (68%). In Group B mean number of SNs excised per case was 1.6 (median 1, range 1-5). False-negative rate was 2/44 (4.5%), negative-predictive value 41/43 (95.3%), sensitivity 42/44 (95%), specificity 41/56 (73%) and accuracy 83/100 (83%). The combination technique was significantly superior to blue-dye alone technique for negative-predictive value (p=0.033) and overall accuracy (p=0.048). CONCLUSIONS: The prediction of axillary lymph node status in breast cancer patients using combined technique has significantly higher accuracy than marking of SN with blue dye alone and therefore should be preferred.

Early complications following total gastrectomy for gastric cancer.

BACKGROUND: The study shows operative results with complications occurring in first 30 days after total gastrectomy for stomach cancer. METHODS: A retrospective analysis was performed using medical documentation and histological findings for 76 patients after total gastrectomy was done between 1990 and 1997. Mortality and postoperative complications were analyzed. Complications were sorted as specific and nonspecific. All operations were performed either for intestinal gastric cancer located in proximal stomach or for diffuse stomach cancer. All anastomoses were hand sewn. RESULTS: There were 43 male and 33 female patients. Postoperative mortality was 14.4%. The most frequent complications were dehiscence of the oesophago-jejunal anastomosis in 15.8% of operated patients, postoperative temperature without apparent infection in 5.2%, thrombophlebitis in 5.2%, pneumothorax in 3.9%, hepatic necrosis in one patient (1.3%), and perforation of jejunal loop with nasogastric tube in another (1.3%) ended fatally. The average postoperative intra-hospital treatment lasted 12.3 days. Dehiscence of the oesophago-enteric anastomosis, resulted in generalized peritonitis in 66.6%. Six patients succumbed as a consequence, while two survived with subphrenic and interenteric abscesses. Pneumothorax in combination with total gastrectomy was always fatal. CONCLUSIONS: Routine use of stapling surgery, subspecialization in surgery, and better early intensive care monitoring and treatment could reduce the mortality rate.

Sentinel node biopsy in breast cancer.

Regional lymph node involvement is the most important prognostic indicator in most solid tumors. Lymph nodes first to receive the lymphatic flow from the peritumoral region are called sentinel nodes. Extirpation methodology of these nodes is rather short (around 10 years) and is related to the following names: Cabanas, Morton, Uren, Berman, Glass, Alex, Cragg.... There are two visualization methods of sentinel nodes: detecting dyes (isosulfan blue or patent-blau V) and radioactive detection (technetium-Tc-99m-antimony-sulfide, sulphur-colloid or human albumin). Scintigraphy is usually performed 24 hours prior to surgery, whereas staining immediately before operation. Extirpated nodes are histopathologically examined and then findings are compared with the findings of other axillary nodes which require obligatory dissection. Results of great studies (Veronesi, Paganelli) show that under precise criteria it would be possible to form a group of patients, prepared for breast cancer surgery, in whom axillary lymph dissection could be avoided.