[Salvage liver transplantation for hepatocellular carcinoma]. / Salvage-transplantatsiia pecheni pri lechenii gepatotselliuliarnoi kartsinomy.

OBJECTIVE: To analyze clinical course and the results of salvage liver transplantation in patients with recurrent hepatocellular carcinoma (HCC) after liver resection. MATERIAL AND METHODS: A 54-year-old man with HCV-infection and HCC and 22-year-old woman with fibrolamellar variant of HCC underwent resection of the right and left liver lobe, respectively. The first patient experienced recurrent HCC four times with an interval of 3-6 months within 2 years after surgery. Repeated liver resection was made in first three cases, right liver lobe transplantation - after the fourth recurrence. In the second patient, HCC recurred in 4 months after resection and was accompanied by subtotal portal vein thrombosis. Therefore, repeated liver resection was excluded and patient underwent right liver lobe transplantation. RESULTS: Patients are alive in 5 and 3.5 years after liver resection and in 2.5 and 3 years after transplantation, respectively. There are currently no signs of recurrent HCC in the graft.

[Pure laparoscopic DP-CAR procedure with portal vein resection]. / Polnost'yu laparoskopicheskaya dp-car s rezektsiei vorotnoi veny (klinicheskoe nablyudenie).

OBJECTIVE: To improve short- and long-term outcomes of locally advanced pancreatic body-tail cancer followed by major vessels invasion. MATERIAL AND METHODS: A case report of pure laparoscopic DP-CAR procedure with portal vein resection for locally advanced pancreatic body-tail cancer followed by severe abdominal pain in a 49-year-old patient is presented. RESULTS: Liver or stomach ischemia was not observed. Portal wall resection wasn't associated with any complication and resulted R0-resection. Postoperative period was complicated by Grade B pancreatic fistula. Preoperative abdominal pain completely disappeared after surgery. Surgery time was 330 min, intraoperative blood loss - 300 ml. The patient is currently undergoing FOLFIRINOX adjuvant chemotherapy. CT in 90 days after surgery confirmed no progression of disease or liver/stomach blood supply congestion. CONCLUSION: Modern technologies provide the opportunity to perform pure laparoscopic advanced surgical procedures with major vessels resection. Pure laparoscopic DP-CAR procedure with portal vein resection is effective and safe procedure that can be performed with all principles of open surgery and is associated with acceptable short- and long-term results.

[Prediction of the acute pancreatitis after surgery on the pancreas].

RESEARCH OBJECTIVE: Study preoperative and intraoperative risk factors for acute postoperative pancreatitis after surgical treatment of the pancreatic diseases. MATERIAL AND METHODS: Predictive value of the probable preoperative and intraoperative risk factors of the acute postoperative pancreatitis after surgical treatment of the proximal and distal pancreatic cancer were explored and evaluated. Patients were divided at the high risk group and mild risk group using a specially developed formula. RESULTS: Preoperative and intraoperative risk factors of the acute postoperative pancreatitis were detected and had predictive value. Much of the identified preoperative risk factors indirectly or objectively showed morphology and function of the pancreas. The importance at the development of the acute postoperative pancreatitis playing the conditions of sur gical intervention, its volume and features of technology, results of the intraoperative research of the pathological focus and status of the pancreatic tissue. Its risk factors have been ranked to intraoperative risk factors. The Identification of the intraoperative risk factors of the acute postoperative pancreatitis allowed to make correction of the risk of complications determined at the preoperative stage. CONCLUSION: The data on the effect of various technological solutions and surgical tactics to the possibility of the development of the acute postoperative pancreatitis should be considered in predicting the development of complications and in develop the most effective and safe technologies of the surgical treatment of the pancreatic diseases, as well as in optimization of the prevention of the acute postoperative pancreatitis and postoperative complications.

Normal pressure hydrocephalus as an unusual presentation of supratentorial extraventricular space-occupying processes: report on two cases.

Normal pressure hydrocephalus (NPH) is a clinical and radiographic syndrome characterized by ventriculomegaly, abnormal gait, urinary incontinence, and dementia. The condition may occur due to a variety of secondary causes but may be idiopathic in approximately 50% of patients. Secondary causes may include head injury, subarachnoid hemorrhage, meningitis, and central nervous system tumor. Here, we describe two extremely rare cases of supratentorial extraventricular space-occupying processes: meningioma and glioblastoma multiforme, which initially presented with NPH.

Long-term survival with primary glioblastoma multiforme: a clinical study in bulgarian patients.

Glioblastoma multiforme (GBM) is the most common and aggressive primary brain tumor with an extremely poor prognosis in spite of multimodal treatment approaches. The estimated median survival in cases with GBM is about 12-16 months. Those patients who survive =3 years after the initial diagnosis are defined as long-term survivors. In this study, we retrospectively analyze 50 consecutive cases of Bulgarian patients with newly diagnosed GBM surgically treated at our institution for a period of 1 year. Four of them survived for more than 36 months after the initial intervention. The histological re-examination revealed features typical of primary GBM in 3 of these cases, which are described in detail in the present paper. A brief review of the relevant literature is also given.

[Treatment possibilities in patients with glioblastoma multiforme].

Glioblastoma multiforme is the most common primary malignant brain tumor in adults. The actual treatment approach includes surgical excision of the lesion followed by radio- and chemotherapy in standard doses and regimens. In most cases, in spite of aggressive treatment, the survival does not exceed 12-16 months after the initial diagnosis. The present survey provides systematic information about the current treatment modalities for control of the disease as well as the perspectives of introduction of some experimental methods in clinical practice.

[Characteristics and prognosis of visual deficit caused by parasellar meningiomas].

UNLABELLED: Meningiomas are the most common slow growing tumors of the central nervous system which arise from the arachnoid cells. One certain group of them--tuberculum sellae (TS), cavernous sinus (CS), anterior clinoid (AC), and planum sphenoidale (PS) meningiomas, a group often called "parasellar", present with monocular or binocular visual deterioration, which is often unrecognized by patients until visual loss is severe and the tumor has reached a significant size. AIM: To describes the type of visual deficit, severity of the symptoms and surgical treatment of tumors with the above mentioned localization. MATERIAL AND METHODS: During the period 2003-2007 year, 93 patients (31 man, 62 women) diagnosed with meningiomas of the TS (31 cases), CS (16 cases), AC (21 cases), PS (17 cases), (see text) - 8, were diagnosed and operated on in the Department of Neurosurgery, University Hospital "St. Ivan Rilsky", Sofia, Bulgaria. Retrospective analysis was done. RESULTS: Age at diagnosis ranged from 12 to 74 years, but the majority of cases were in the 5th and 6th decade of life. Localization of was: TS 33%, CS 17%, AC 24%, PS 18% and with more than one area affected in 8 %. The most common symptom was slowly progressing loss of monocular visual acuity (81% of cases). 68% of patients presented with already severely deteriorated vision (0.1-0). Neuro-ophthalmological examination (see text) the patients. Computed tomography and magnetic resonance imaging were the main diagnostic methods. "Gross" total resection was achieved in 62%, subtotal in 12%, partial in 26% of the cases. There was early improvement in 57% of the patients. Death due to cardio-respiratory insufficiency occurred in one case. CONCLUSION: the progressive monocular visual deficit is often the first clinical symptom of the parasellar menigiomas. The early diagnosis is important for the success of surgery. Close collaboration between different specialists (ophthalmologists, neurologist and neurosurgeons) is essential for treatment of these tumors and prevention of the visual deterioration.

Long-Term Survival of a Patient with Giant Cell Glioblastoma: Case Report and Review of the Literature.

Glioblastoma multiforme (GBM) is the most common glial tumor of the central nervous system. Overall survival is less than a year in most of the cases in spite of multimodal treatment approaches. A 45-year-old female with histologically confirmed giant cell GBM was treated at our institution. Subtotal excision of the lesion situated in the right precentral area was performed during the initial stay in August 2005. The patient improved after the procedure with no hypertension and additional neurological deficit. Radiotherapy plus concomitant and adjuvant temozolomide was performed. The patient was symptom-free for 35 months after initial surgery. From July 2008 the patient developed partial motor seizures in the left side of the body and progressive hemiparesis. Local tumor progression was demonstrated on the neuroimaging studies. In December 2008, a second operative intervention was performed with subtotal excision of the tumor. Forty-five months after the initial diagnosis the patient is still alive with moderate neurological deficit. Microarray analysis of the tumor found the following numeric chromosomal aberrations: monosomy 8, 10, 13, 22, and trisomy 21, as well as amplifications in 4q34.1, 4q28.2, 6q16.3, 7q36.1, 7p21.3, and deletions in 1q42.12, 1q32.2, 1q25.2, 1p33, 2q37.2, 18q22.3, 19p13.2, Xq28, and Xq27.3. GBMs seem to be a heterogeneous group of glial tumors with different clinical course and therapeutic response. Microarray analysis is a useful method to establish a number of possible molecular predictors.

[Clinical, histopathological and cytogenetical findings in six cases with primary glioblastoma multiforme].

INTRODUCTION: Glioblastoma multiforme (GBM) is the most common malignant primary brain tumor. There is an increasing amount of data demonstrating that the routine histological examination has limited value to predict the tumor biological behaviour. AIM: To compare the clinical, histological and cytogenetical findings in a group of six patients with primary GBM surgically treated in the Department of Neurosurgery at University Hospital "St. Ivan Rilski"- Sofia, Bulgaria. MATERIAL AND METHODS: The studied group consisted of three women and three men with average age of 51 years and 6 months. In all patients the diagnosis was histologically confirmed. A microarray comparative genomic hybridization (CGH) analysis of fresh-frozen tumor tissue samples was also made. RESULTS: In two of the patients the tumor was localized in frontotemporal region, in another two- in frontoparietal, and in the other two- in parietal and occipital respectively. The onset was with headache in three of the cases. The median time between the onset and admission in the clinic was 70 days. Gross-total tumor removal was performed in one patient. In the other five subtotal excision was made. Three of the patients improved after the intervention. One patient deteriorated after the surgery. All patients demonstrated typical histological findings except one who had giant cell subtype of GBM. The microarray CGH analysis determined chromosome 10 monosomy in five patients, trisomy 7 - in four, trisomy 20 - in three, 3q23 deletion - in three, and Yp11.2 deletion - in three. CONCLUSION: GBMs are genetically heterogeneous tumors with different clinical response to standard multimodal treatment regimens. The microarray CGH analysis is a powerful method which can demonstrate the presence of a number of molecular markers with possible predictive value.

[Malignant progression of an anaplastic ganglioglioma into a glioblastoma multiforme--report on two cases and review of the literature].

INTRODUCTION: Ganglioglioma is an uncommon type of primary brain tumors. In most of the cases the tumor demonstrates benign clinical behaviour with long-term patients' survival. We present two cases ofhistologically confirmed anaplastic ganglioglioma in which malignant progression into a glioblastoma multiforme was seen. CASE 1: A 36 year-old female with known Turner syndrome and recent history of single generalized seizure. The contrast-enhanced magnetic resonance imaging (MRI) showed an infiltrating lesion of the left frontal lobe. The tumor was excised partially and the histological result was anaplastic ganglioglioma (World Health Organization - WHO. gr. III). No additional neurological deterioration occurred after the procedure. A postoperative radiotherapy was performed with total dose of 60 Gy. The patient was symptom-free for one year taking her anticonvulsant medications. Control neuroimaging studies (computer tomography - CT, and MRI) were made because of progressive headache, right limbs weakness and speech disturbances. A local tumor recurrence was found and the patient underwent second operative intervention with gross total tumor resection. The histological result was glioblastoma multiforme (WHO gr. IV glioma). The patient improved after the procedure. An involvement of the contralateral cerebral hemisphere was found on control CT-scan ten months later. The patient died after one month, 23 months after her initial diagnosis. CASE 2: A 17 year-old female with recent history of progressive headache and three generalized seizures preceded by involuntary movements of the right limbs. MRI data for large, heterointense tumor lesion in the left frontal lobe was found. A subtotal tumor removal was made. The histological result was anaplastic ganglioglioma (WHO gr. ILL). The patients' headache and right side hemiparesis improved after the intervention. She was seizure-free taking her anticonvulsant medications. Thirty-day-long fractionated radiotherapy was performed with total dose of 60 Gy. The patient remained symptom-free for thirteen months after initial surgical procedure. During the next month the patients, partial motor seizures relapsed. Progressive headache, diplopia, and visual acuity impairment also developed. The ventriculoperitoneal shunt was implanted with neuroimaging data for internal hydrocephalus development. The patients' headache and visual disturbances improved after the procedure. Data for additional local tumor growth was found on control CT-scan one month later. The patient underwent subtotal excision of the lesion and the actual histological result was glioblastoma multiforme. The patient deteriorated after the intervention according to her right limbs paresis and died one month and half later. 20 months after the initial diagnosis. CONCLUSION: The gangliogliomas are uncommon in clinical practice. The tumor behaviour may vary between the patients in spite of the similar histological characteristics which indicates the possible presence of different tumor subtypes.

[Orbital lymphoma].

INTRODUCTION: Orbital lymphomas are neoplasms with increasing incidence in recent years in immunocompromised, as well as immunocompetent patients, which defines their social importance. AIM: To describe and analyze the experience of the University hospital "'Sv. Ivan Rilski" with the treatment of this pathology for the period 1997-2008. MATERIAL AND METHODS: Fourteen patients (8 females, 6 males - 13 primary orbital lymphomas, 1 systemic lymphoma). Mean age at diagnosis was 65.6 years (from 50 to 80 years). In 2/3 of the patients the lesion was localized in left eye, without a case with bilateral orbital involvement. Seven cases the diagnosis was made 6 months from the onset of symptoms, 5 cases - 1 year and 2 cases - more than one year. The most common clinical symptoms were exophthalmus (12 case), tumor or bulging mass of the eyelid - 8, diplopy - 6, decreased visual acuity - 5. Intraconal localization of the tumor was in 6 cases, extraconal - 2. intra-extraconal - 6. The diagnosis was made by neuro-ophthalmologist and precised with the aid of CT and MRI. All the patients were operated on with the following approaches - fronto-orbital - 9 cases, lateral - 3, anterior orbitotomy (without bone resection) - 2 cases. In six cases "'gross total" resection was achieved, in the rest of the cases the resection was partial. On histological examination, a high grade lymphoma was established in 2 cases with primary orbital lymphoma and one case with systemic lymphoma. All other cases were diagnosed as low-grade B-call small lymphocytic non-Hodgkin's lymphoma. Long-term survival (over 5 years) was observed in 4 cases with primary lymphoma, whereas the patient with systemic form of the disease died 10 months after the operation.

Cerebellar gangliocytoma presenting with hemifacial spasms: clinical report, literature review and possible mechanisms.

Cerebellar lesions have classically been considered not to cause epilepsy. However, previous reports have attributed seizures, beginning as hemifacial spasms to lesions of the cerebellar peduncles. We report an example of paroxysmal facial contractions associated with a cerebellar gangliocytoma. The seizures began on the first day of life and consisted of paroxysmal contractions involving the left orbicularis oculi, often the left forehead and lower facial muscles, sometimes accompanied by nystagmoid eye movements to the right and by head deviation to the left. Video-EEG monitoring showed only artifacts from muscle contractions. Magnetic resonance imaging showed a mass arising from the left superior cerebellar peduncle and partially occupying the fourth ventricle. The lesion was removed subtotally and partial seizure control was achieved. The neuropathological findings were consistent with a gangliocytoma. The literature in the association of cerebellar lesions with hemifacial spasms is reviewed and its possible mechanisms discussed.