Current two EGFR mutations in lung adenocarcinoma -  case report.

Nowadays, EGFR TKIs (epidermal growth factor receptor-tyrosine kinase inhibitors) targeted therapy is well established treatment for patients with the so-called EGFR common mutations with advanced or metastatic nonsmall cell lung cancer. The efficacy for the so-called rare and especially for the very rare complex EGFR mutations is not clear. We describe a case of a 63- year-old female with metastatic nonsmall cell lung cancer with complex EGFR mutation (G719X + S768I) who had been treated by gefitinib. She achieved progression free survival within eight months. Then, we discuss our case with other literature case reports. Together, it seems that described complex EGFR mutation has a relatively good sensitivity for EGFR TKIs treatment.Key words: nonsmall cell lung cancer -  EGFR gene -  EGFR protein -  complex mutations -  rare EGFR mutations -  EGFR TKIs.

Typical signs of oncocytic papillary renal cell carcinoma in everyday clinical praxis.

PURPOSE: Types 1 and 2 by Delahunt of papillary renal cell carcinoma (PRCC) are traditionally differentiated. An oncocytic variant of PRCC (O-PRCC) has recently been described. We compare clinical data of O-PRCC with other subtypes of PRCC such as the main tumour size, necrotic changes, presence of pseudocapsula and real extrarenal growth in retrospective study. METHODS: From 1/1992 to 10/2009, 1,398 patients with 1,436 renal tumours were surgically treated in our institution. PRCCs were described in 109 (7.6%). Among PRCC, O-PRCCs were in 12 (11%), PRCC type 1 in 86 (78.9%), PRCC type 2 in 8 (7.3%) and others in 3 (2.8%) cases. RESULTS: The patient's mean age with O-PRCC (M:F ratio = 2:1) was 67.5 +/- 10.9 versus 63.5 +/- 14.1 in type 1 and 57.9 +/- 5.7 in type 2, the mean tumour size was 35 +/- 12 mm versus 47 +/- 22 and 37 +/- 17, respectively. The follow-up of O-PRCC is 35.3 +/- 12.3 months and all cases are without recurrence. We did not find any pseudocapsula in O-PRCC but it was a major sign of PRCC type 1 (32.6%). Huge microscopic necrotic changes were described in 33.3% of O-PRCC, in 33.7% of PRCC type 1 and 62.5% of PRCC type 2. Extrarenal growth was found only in 16.7% O-PRCC versus 40.7% in PRCC type I. CONCLUSIONS: None of the O-PRCC had pseudocapsula and none had massive necroses in comparison of O-PRCC with PRCC types I and II. Extrarenal growth in O-PRCC is relatively rare. The malignant potential of O-PRCC is low.

[Laparoscopic adrenalectomy]. / Laparoskopická adrenalektomie.

OBJECTIVE: Laparoscopy has become the gold standard for the treatment of adrenal tumours in urology. We evaluate our experience with laparoscopic adrenalectomy (LA) in this work. MATERIAL, METHODS: We performed 38 LA between 2003-2008. We use computer tomography (CT) and magnetic resonance imaging (MRI) for the initial evaluation. Indication for procedure is made in cooperation with endocrinologist. We use transperitoneal approach with 3 or 5 ports. RESULTS: Mean age was 57.7 +/- 11.7 year (range 32-74.9 year). Nine LA were made in men (24%), in women 29 (76%). Sixteen tumours (42%) were hormonal active (7 pheochromocytoma, 6 primary hyperaldosteronism, 3 peripheral hypercortisolism). Twenty-two tumours were without hormonal activity. Mean tumour size was 4.1 +/- 2 cm (range 1-10.1 cm), mean operation time was 89 +/- 38 minutes (range 32-220 minutes), mean blood loss was 33 +/- 75 ml (range 0-400 ml), mean hospitalization time was 6.1 days (range 3-12 days). There were histologically 15 cortical adenomas, 5 nodular cortical hyperplasia, 1 calcificated hematoma, 3 cysts, 2 potentional malignant tumours on interface between adenoma and carcinoma, 1 cortical carcinoma and 7 pheochromocytoma. We found 3 metastases of renal carcinoma in adrenal gland and one metastasis mesenchymal chondrosarcoma too. Transperitoneal approach was chosen in 20 patients (53%) after previous abdominal operation (open cholecystectomy, appendectomy, transperitoneal nephrectomy, aortofemoral bypass). Complications were in 3 cases from 38 (8%). It was one perforation of diaphragm, which was resolve with laparoscopic suture, one postoperative delirium with fudge and agitation, one abscess in wound after extraction of specimen. We have got any conversion in our collection. The body mass index was higher than 38 in 3 patients. CONCLUSION: LA is a quick and safe procedure with minimal morbidity and mortality. This procedure requires very experienced surgeon. Patients profit especially from miniinvasivity and short convalescence. Especially benign tumours of smaller size (by 8 cm) are indicated, extensive and especially malignant tumours remain a domain of open approach. Previous operations in abdominal cavity do not have to be a contraindication for LA and operation is possible in patients with monster obesity.

[Occult anal sphincter tear--up-to-date knowledge]. / Okultní ruptura análního sfinkteru behem porodu--soucasné znalosti.

OBJECTIVE: Summary of the current knowledge of sonographically and clinically detectable anal sphincter injury. DESIGN: Review. SETTING: Department of Gynaecology and Obstetrics, Charles University and University Hospital Pilsen. SUMMARY: Review of the current international literature covering the given problem. Occult anal sphincter tear is defined as an injury, which is clinically undetectable and recognizable just on endoanal ultrasonography. Total frequence of anal sphincter defects detected by sonography varies between 19-67%. At any rate majority of them likely seem to be injuries which are clinically detectable, however undiagnosed and missed. Isolated defect of internal anal sphincter is an example of real occult anal sphincter injury. This is found in around 2% of all vaginal deliveries. A diligent digital examination of perineum after the delivery and a proper education of perineal anatomy is the cornerstone in improving of the diagnostics. Endoanal ultrasound may serve as a tool in facilitation of the diagnosis.

[Renal angiomyolipoma, histology, diagnostics and therapy]. / Renální angiomyolipom, histologie, diagnostika a terapie.

BACKGROUND: Renal angiomyolipoma is a benign mezenchymal tumour with prevalence of 0.3-3% of all surgically resected renal tumours. Tumour is often associated with tuberous sclerosis complex or with another fakomatosis. Tumour has typical pathological image in computer tomography notation that enables the diagnosis. Symptomatology and possible complications depend on the tumour size. Large or symptomatic tumours are indicated for resection, nephrectomy or local ablation. METHODS AND RESULTS: 612 patients with renal tumour were operated at the Department of Urology faculty hospital in Pilsen. Angiomyolipoma occurred in 7 patients. Average age at the time of operation was 64 years, ratio female and male was 5:2. Clinical symptomatology was expressed in 3 patients. The size of tumour was 2 to 8 cm, in 5 patient the tumors were solitary. Translumbal tumour resection was performed in 3 patients. These tumours were at the same time multifocal. Suspicion from tuberous sclerosis was pronounced in some care. The angiomyolipoma was accidentally found in 2 cases of nephrectomy, which was indicated for other diagnosis. CONCLUSIONS: We define diagnosis by means of CT notation in the most of patients. This notation is not typical by any version of angiomyolipoma and we choose therefore surgical revision.

[A postoperative bronchopleural fistule--a success of the conservative treatment (a case review)]. / Pooperacní bronchopleurální pístel--uspech konzervativní lécby (kazuistika).

Disintegration of the bronchial stub following the lung resection procedures together with development of the bronchopleural fistule and the postoperative empyema of the thorax, remain a feared complication following all lung resections, but especially pneumonectomies. In this case review, the authors report on a successful conservative management case, which followed an unsuccessful surgical revision and an attempt for the endobronchial stent introduction. 20 months following the closure of the fistule, the patient shows no signs of a relapse of the disorder.

[The liver splenosis in a patient following a procedure for the malignant seminoma]. / Splenóza jater u nemocného po operaci maligního seminomu.

Splenosis is characterized by a presence of islets of the splenic tissue in the abdominal and, rarely, also in the thoracic cavity, most frequently as a consequence of the splenic injury. The authors describe a case of splenosis in a patient followed-up after surgery and radiotherapy for the testicular seminoma and who, 42 years ago, had splenectomy for polytrauma. With respect to the location of the splenosis in the hepatic region, the differential diagnosis was difficult, bearing in mind a possibility of the malignancy relaps. Although splenosis was highly suspected, based on the results of the examinations conducted, with respect to the preexisting malignancy, the tumor was excised. The histopathologist confirmed the diagnosis of splenosis. This case is rare in the literature, considering the time gap between the diagnosis of splenosis and the trauma.

Gastric lipoma presenting as upper gastrointestinal obstruction.

A 61-year-old man presented with an upper gastrointestinal obstruction caused by a submucosal gastric lipoma in the prepyloric area. The diagnosis was made coincidentally during his admission for another disease. Gastric resection was performed because of a large lipoma combined with florid gastric ulcers. The frequency of gastric lipoma, its differential diagnosis, means of diagnosis, and treatment are discussed.

Visualization of the cystic artery after injection of Pancreozymin.

In 84 patients selective angiography of the common hepatic artery before and after injection Pancreozymin was performed. The results prove that: 1. Pancreozymin produces visualization of the cystic artery and its branches and of the gall-bladder wall in the majority of these normal gall-bladders that are not visualized during angiography without Pancreozymin. 2. Pancreozymin improves visualization of many normal and pathological gall-bladders seen only faintly on angiography without Pancreozymin. 3. In a patient with an angiographically normal liver the non-visualization of the branches of the cystic artery or of the gall-bladder wall after injection of Pancreozymin is a reliable sign of organic gall-bladder disease, or of a collapsed gall-bladder seen sometimes in patients with bile duct or pancreatic tumour.

Successful surgical treatment of the brachial plexus paresis in leiomyosarcoma of the subclavian artery.

Described here is a unique case of surgical treatment of brachial plexus paresis in a 63-year-old female patient. The paretic condition was considerably improved by excision of a tumor in the upper mediastinum, growing from the left subclavian artery, and classified as leiomyosarcoma.

[Treatment of acetabular fractures]. / Lécení zlomenin acetabula.

The authors present an account of 85 patients with fractures of the acetabulum treated at the Orthopaedic Clinic, Faculty Hospital Plzen in 1985-1991. The fractures are classified according to Lettournel-Judet. The authors investigated associated injuries which prolong the interval between injury and operation as well as the correlation between the mechanism of injury and the patient's age and the incidence of injuries in different months of the year. For indication for operation the quality of reposition evaluated by computed tomography is essential. The authors analyze the length of the interval between injury and operation, administration of antibiotics and anticoagulants. As to early complications, they pay attention in particular to bronchopneumonia, infection and thromboembolic disease. The paper deals also with the most serious late complication--avascular necrosis--and the authors discuss the causes of its development as well as possibilities to influence it. The paper presents also results evaluating patients as regards their return to work, subjective evaluation of gait, pain of the joints and satisfaction with treatment. The case-history is followed by discussion concerned with the importance of computed tomography, the surgical approach, importance of treatment of the sacroiliac complex, the development of heterotopic and ectopic ossifications and the essential time of relief of the operated joint. In the conclusion the authors summarize the basic principles of fractures of the acetabulum.

[Incidence of aneurysms of the abdominal aorta in the Czechoslovak population and possibilities of its detection]. / Výskyt aneurysmatu abdominální aorty v nasí populaci a moznosti jeho depistáze.

A significant increase not only in the number of operations for AAA but also in the incidence of autopsy findings of AAA from 1.5 per cent to 4.5 per cent has been observed during the last 20 years. Ultrasound screening of the abdominal aorta in patients examined for other reasons revealed asymptomatic dilatation of the infrarenal aorta to more than 4 cm in 3.8 per cent of men older than 60 years. AAA should be actively searched for at every physical and ultrasound examination of the abdomen in men over 60 years of age.

[Comparison of radionuclide venography with roentgen phlebography]. / Srovnání radionuklidové venografie s rtg-flebografií.

The authors evaluated a group of 78 patients where in addition to radionuclide venography (RNV) also X-ray phlebography was used (RTGF) within a time interval of not more than 72 hours. The results of 102 examinations were compared, 276 areas were correlated at six different sites. Agreement was recorded in 249 instances (90%), a false negative finding in 23 (8%) and a false positive finding in 4 (2%). Sensitivity was low in the area of the calf (55%), high in the femoral area, iliac area and in the area of the inferior vena cava (92-100%). The specificity was in all areas, incl. the calf, relatively high (94-100%). The investigation revealed the disadvantages of RNV--a low reliability in the area of the calf, the impossibility to detect small and parietal thrombi, the inability to assess the "activity and age" of the thrombus, the more difficult interpretation in insufficiency of venous perforators, and advantages of RNV--a great reliability at higher parts of the venous system and after administration of radiopharmaceutical preparations (RF) into peripheral veins, the possibility of simultaneous examination of pulmonary perfusion without further administration of RF, a low failure rate of intravenous administration of RF (less than 2%); RF do not irritate the venous endothelium and therefore thrombosis cannot develop; in case of paravenous escape of RF local inflammations do not develop, the radiation load is low, there is a small probability of allergic reactions, the method is non-invasive, it can be frequently repeated and used for the follow-up of treatment.

[Spindle cell and cuboidal renal cell carcinoma (loopoma). 10 case reports]. / Vretenobunecný a kuboidální renální karcinom (loopom). Popis 13 prípadu.

BACKGROUND: Current classification systems of neoplasms arising from renal parenchyma distinguish 5 categories of renal cell carcinoma (RCC), i.e. conventional RCC, papillary RCC, chromophobe RCC, collecting duct/medullary RCC and unclassified RCC. We present 13 cases of unusual and unclassified spindle and cuboidal renal cell carcinomas. METHODS AND RESULTS: The studied group consisted of 13 patients (7 men and 6 women). They ranged in age from 22 to 65 years (mean 57.3). Generally, the tumours were well circumscribed and confined to the kidney, whitish to grey on section with a diameter 4.5-13 cm (mean 8.6 cm). One patient was investigated for loin pain and nocturia. Three patients had staghorn nephrolithiasis and vague sonographic findings in renal parenchyma. In one patient the renal tumour was found when examined on follow-up examination for prostatic adenocarcinoma. None of our patients was known to have elevated levels of parathyroid hormone due to hyperplasia, adenoma or carcinoma of the parathyroid gland. Clinical follow-up of the patients ranged from 9 months to 8 years (mean 2.3 years). Microscopically, the tumours were composed of two main populations of cells: flattened, spindle cells with sparse cytoplasm and small cuboidal cells with clear to light eosinophilic cytoplasm. Eight patients are currently well without signs of recurrence or metastasis, one had metastasis in the regional lymph node at the time of nephrectomy, one died of unrelated cause, and three were lost to follow-up. CONCLUSIONS: We present 13 cases of unclassified RCC. Our cases were histologically, immunohistochemically and ultrastructurally similar to the hitherto reported case reports of this variant of RCC. It is obvious, that that variant of RCC should be recognised as a new subtype of RCC.

[Papillary renal cell carcinoma surrounded by unusual fibrotic reaction resembling inflammatory pseudotumour--a case report]. / Papilární renální karcinom lemovaný neobvyklou fibrózní reakcí pripomínající zánetlivý pseudotumor--kazuistika.

Authors report clinicopathological features of an unusual case of composite renal lesion occuring in 32-year-old Caucasian male. The patient was followed for cystic lesion of retroperitoneal-renal region for 5 years. He was indicated for resection of the cystic lesion because of changes of the retroperitoneal mass on CT scan. A cyst was located on upper renal pole. A huge cystic mass filled mainly by necrotic material was resected and submitted for histological examination. The wall of the cyst was composed of fibrous tissue, indistinguishable from inflammatory pseudotumor on histological level. The vital intracystic tissue was formed by well-differentiated papillary renal cell carcinoma. The most important step within differential diagnosis is distinguishing of sarcomatoid differentiation in renal cell carcinoma. This very rare case demonstrates the importance of careful examination of all spindle cell lesions of the kidney.

[Pseudophlebothromobsis]. / Pseudoflebotrombóza.

Rational antithrombotic treatment in vascular occlusions is a marked advance in the therapeutic results, incl. reduced mortality. The prerequisite of success is early adequate thrombolytic or anticoagulant treatment taking into account absolute and relative contraindications. Despite this it is necessary to foresee the risk of haemorrhagic complications and orientate diagnosis with the aspect in mind. As an example three case-histories are presented, their common sign being haemorrhage into the lower extremities during antithrombotic treatment. Attention is drawn to the difficulty of differential diagnosis of venous thrombosis and haemorrhage into muscles or intermuscular spaces where at a given site computer tomography is a great asset. In the treatment in addition to surgical intervention in particular hyperbaric oxygen therapy proves useful.

[Drug therapy in vascular occlusions of the lower extremities]. / Medikamentózní terapie tepenných uzáveru dolních koncetin.

The authors report their three-year experience with application of thrombolytic treatment in 31 patients with vascular occlusions of the lower extremities. They were successful in two thirds of the patients. The authors analyze the advantages and shortcomings of systemic or selective administration of antithrombotic therapy. Concurrent administration of hyperbaric oxygen is a rational therapy.

[Echinococcus cysts (hydatids)]. / Echinokokové (hydatické) cysty.

INTRODUCTION AND MATERIAL: This work is based on rich experience of the first-stated author. During a three-year expertise in Botswana he operated 80 patients with hydatic cysts and he took part in treatment of other patients affected by the Echinococcus granulosus infection. In 59 cases the infectious focus was located in the liver, in 18 cases in the lungs, in 2 cases in the spleen and in one case the foci were multiple peritoneal. METHODOLOGY: During the expertise period, the patients were observed prospectively, throughout the diagnostic decision-making and the treatment. Prior to the surgical procedure, they had been, in a long-run, treated with albendazole. In 18 cases out of the total number of the liver cysts, the experts chose a two-step procedure followed by a secondary plombage of the reduced cavity of the cyst with the omentum. The rest of the cysts were removed. Miniinvasive methods were not applied. However, the authors discuss their risks. RESULTS: None of the patients exited, in 3 cases a peroperational anaphylactic reaction was managed. Throughout the expertise, no cases of the echinococcus dissemination in the operated subjects were recorded. The team even managed to treat the hydatic cysts in patients who were HIV/AIDS positive and who were, originally, in a serious state of immunodeficiency. Five cases are presented in the form of brief case reviews. CONCLUSIONS: Benefits of the long-term preparation with albendazole--plombage operations are beneficial to be conducted in two steps, Betadin is the most suitable lavage solution, miniinvasive surgical procedures (PAIR) may bring on specific complications.

[Surgical problems in acute acalculous cholecystitis]. / Chirurgická problematika akutní akalkulózní cholecystitidy.

The authors report on the prevalence of acute cholecystitis in the absence of calculi with special attention paid to the development of this disease as a complication of prolonged parenteral nutrition. In 1990-1993 at the Surgical Clinic in Plzen 125 cases of acute cholecystitis were operated, incl. 14 acalculous ones (11.2%). These 14 patients comprised 5 (28.6%) who were on parenteral nutrition for a prolonged period. The authors analyze the causes of the development of acute acalculous cholecystitis. They deal with the problem of diagnosis where in severe postoperative and posttraumatic cases ultrasonography proved useful.