Phyllodes tumor and its malignization into invasive ductal carcinoma a case report.

INTRODUCTION: Phyllodes tumors of the breast are rare and very distinct types of mammary neoplasms. They are characterized by their biphasicity, i.e. the presence of stromal and epithelial components at the same time. Malignancy is determined by the degree of stromal differentiation. The coexistence of the malignant epithelial component is a very rare phenomenon. Dozens of cases of simultaneous phyllodes tumor and epithelial malignancy have been reported so far. Nevertheless, the biological nature of this process is still an unexplained and a controversial topic. CASE REPORT: In this paper, we present a case of a patient with a suddenly enlarging lesion in the breast. According to the first surgical resection, a diagnosis of high-grade malignant phyllodes tumor was made with fibrosarcoma differentiation, stromal overgrowth and suppression of the epithelial component. Examination of scar resistence in early postoperative period revealed a triple-negative invasive low-differentiated breast carcinoma with very high proliferative activity, thus malignization of the epithelial component of the tumor occurred. Shortly, a diagnosis of second recurrence was made, treatment included axillary lymph node dissection (ALND) with a negative histological findings. The patient underwent complex adjuvant chemotherapy and radiotherapy and remained disease free 3 years after the surgery. CONCLUSION: Coexistence of phyllodes tumor and the breast carcinoma is very rare. The article describes the first published case, which documents the subsequent development of invasive low-differentiated ductal carcinoma immediately after resection of high-grade phyllodes tumor. Treatment and prognosis are generally determined by the characteristics of the carcinomatous component.

Preoperative CT for postoperative radiotherapy planning in breast cancer.

INTRODUCTION: The exact location of the original tumor should be known for a targeted increase in the dose to the tumor bed after breast cancer surgery. Therefore, at our site, we perform CT examinations of patients in the radiation position before breast cancer surgery. METHODS: Preoperative native CT scans were performed in the patients in the planning position for radiotherapy; these data were fused with standard planning CT for boost irradiation. We evaluated whether the tumor was accurately identifiable in preoperative CT scans. We also contoured one irradiation volume in the standard planning CT scans and the other in the fusion CT scans with preoperative examination, and compared these volumes. RESULTS: Out of the total number of 554 patients, we were able to identify the exact location of the breast tumor in 463 cases (83.6 %). In a group of 50 randomly selected patients, the clinical target volume for the boost dose to the postlumpectomy cavity was changed in 20 patients (40%) - decreased in 9 cases (18%) and increased in 11 cases (22%). CONCLUSION: As shown by the results of our study, preoperative CT in the planning position can be used in patients with confirmed breast cancer. This method allows us to more accurately locate the tumor bed and thus more accurately draw the target volume for boost irradiation. We confirmed that preoperative CT had an impact on the size of the target volume.

Is There a Benefit of HER2-Positive Breast Cancer Subtype Determination in Clinical Practice?

BACKGROUND: Breast cancer (BC) with increased expression of human epidermal growth factor receptor 2 with tyrosine kinase activity (HER2+) is a clinically and bio-logically heterogeneous dis-ease. In terms of gene expression, there are four major molecular subtypes - Luminal A, Luminal B, HER2-enriched (HER2-E), and Basal-like. The most common subtype is HER2-E (50- 60%). In hormone-dependent (HR+) HER2-positive tumors, the subgroup HER2-E represents 40- 50% of cases; others are luminal A and B subtypes. PURPOSE: The aim of this review is to provide information on the significance of the distribution of HER2-positive tumors accord-ing to subtype, which is considered a predictive parameter for guid-ing treatment decisions. For example, HER2-E subtype is characterized by a higher probability of achiev-ing complete pathological remission when treated with chemother-apy and antiHER2 ther-apy, and it is thought that it could be treated us-ing a dual HER2 blockade without chemother-apy. Currently, triple-positive tumors, a specific subtype of breast cancer characterized by HER2+ and HR+, are more often subjects of interest. Their unique bio-logical properties are due to complex interactions between HER2 and estrogen receptor (ER) signalling, which result in lower effectiveness of endocrine ther-apy in these patients than in HR+ and HER2-negative patients and, at the same time, the ER positivity in HER2+ tumors can result in resistance to antiHER2 ther-apy. This type of BC is a non-homogeneous group where the impacts of HER2 positivity on tumor malignant behavior and activity of the estrogen-driven signal-ing pathway are inconsistent. Current studies focus on test-ing new treatments such as dual HER2 block-ing or immunother-apy, in combination with antiHER2 targeted ther-apy with fulvestrant, aromatase inhibitors, cyclin dependent kinase 4/ 6 inhibitors, or inhibitors of the PI3K (phosphatidylinositol-3-kinase) pathway. CONCLUSION: The distribution of HER2+ BC accord-ing to individual subtype provides information that can contribute to achiev-ing more accurate decisions about the most appropriate ther-apy. Key words breast cancer - subtype - HER2 - trastuzumab - HER2 positive - triple positive - HER2 enriched The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers. Submitted: 27. 9. 2018 Accepted: 26. 11. 2018.

[Sentinel lymph node examination in breast carcinoma in situ]. / Vysetrení sentinelové uzliny u in situ karcinomu prsu.

INTRODUCTION: Breast carcinoma in situ is defined as non-invasive form of carcinoma. However, we can see infiltration of sentinel lymph node even in this disease. The aim of this work was to determine indication criteria for detection of sentinel lymph node in breast carcinoma in situ. MATERIALS AND METHODS: Summary of current knowledge about examination of sentinel lymph node in breast carcinoma in situ. Comparison of the results with our own results. RESULTS: We summarized the results of 10 trials studying ductal carcinoma in situ (DCIS) and 4 studies with DCIS with microinvasion. Sentinel lymph node infiltration is described in 0 to 7.3%, or 9.3 to 29.4%. In our department during the period of one year, we diagnosed 7 carcinomas in situ, in the final histology examination 5 DCIS, 1 DCIS with microinvasion and I lobular carcinoma in situ (LCIS) with microinvasion. Sentinel lymph node infiltration was diagnosed only in LCIS with microinvasion. The other, non-sentinel axillary lymph nodes, were negative in this patient. The indication criteria for sentinel lymph node examination in breast carcinoma in situ in our department include: greater extent of microcalcifications, indication for total mastectomy for diffuse involvement, microcalcifications with palpable resistance, preoperative diagnosis of carcinoma in situ from core-cut biopsy, carcinoma in situ G3 confirmed in open extirpation. CONCLUSIONS: The sentinel lymph node examination in breast carcinoma in situ can change staging of the disease, as well as the treatment modality. In case that the sentinel lymph node is positive, the disease is undoubtedly invasive and the invasive part of the tissue was not seen in the biopsy sample.

[Spontaneous bilio-cutaneous fistula in cholecystolithiasis]. / Spontánní biliokutánní pístel pri cholecystolitiáze.

Spontaneous cholecystocutanea fistula is very rare disorder. The occurrence is very frequent in women above 60 years old. The symptoms of this disorder are nonspecific. The diagnosis is not made when the symptoms are not search actively. The first type of examination is fistulography. Laparotomic scheduled chelocystectomy is preferred in therapy. Conservative approach is suitable therapy only for polymorbid patients.

Pathological complete response after primary chemotherapy in a mother and daughter with hereditary breast carcinoma: two case reports.

The prognosis of patients with BRCA1-related breast carcinomas is inferior to the patients without BRCA1 mutation, but most of these tumors have a so-called triple negative phenotype characterized by increased chemosensitivity. Information regarding the chemosensitivity of BRCA1-related breast carcinomas is limited. We present a case of a mother and daughter with hereditary breast carcinoma treated with primary chemotherapy using the dose-dense combination of doxorubicin and cyclophosphamide and sequential weekly paclitaxel administration. Pathological complete response was observed in both patients. Subsequent genetic analysis revealed the same BRCA1 mutation with exon 5-14 deletion in both women. The present experience as well as other reports indicate increased sensitivity of BRCA1-related breast carcinoma to primary chemotherapy.

Mitogen-induced lymphocyte proliferation and systemic immune activation in cancer patients.

AIMS AND BACKGROUND: Proliferative response of lymphocytes to mitogens is known to be decreased in cancer patients. Depressed proliferation of lymphocytes in other disorders has been linked to systemic inflammatory response. METHODS: Lymphocyte proliferation in response to phytohemagglutinin (PHA) and concanavalin A, as well as urinary neopterin, plasma interferon-gamma and interleukin-4, were investigated in 41 patients with solid tumors. RESULTS: The proliferative response to PHA was significantly depressed in cancer patients at most of the concentrations examined. Urinary neopterin and plasma interferon-gamma were significantly elevated in cancer patients, whereas interleukin-4 was undetectable in all the subjects. A negative correlation was observed between urine neopterin and lymphocyte proliferative response to mitogens. CONCLUSIONS: Lymphocyte proliferative response to PHA is significantly diminished in cancer patients, and this depression appears to be partly linked to systemic inflammatory response. Plasma interferon-gamma was significantly increased in cancer patients, whereas interleukin-4 was undetectable.

[Complications of subclavian and femoral cannulas]. / Komplikace podklíckových a femorálních kanyl.

In the course of 15 years in the author's department some 15,000 cannulas were inserted into the subclavian or femoral vein. This number included cca 2300 cannulas inserted to dialyzed patients. 213 patients (inl. 28 dialyzed) died with the inserted cannula. In these patients the incidence of complications was evaluated. A parietal thrombosis was the most frequent complication and was recorded in 119 cases, i.e. in 56% (in non-dialyzed in 57% and in dialyzed in 50%). In two non-dialyzed patients it was the cause of embolization into the lungs. In the incidence of complications there is no significant difference in dialyzed and non-dialyzed patients. For completeness the authors present a preliminary calculation per approximate number of inserted cannulas during this period. From the total number of 15,000 inserted cannulas fatal complications occurred in 0.06% (in dialyzed in 0.13% and non-dialyzed in 0.047%).

[Intraoperative enteroscopy--personal experience from 1995 to 2002]. / Intraoperacní enteroskopie--vlastní zkusenosti z období 1995-2002.

Authors present their experience with the intraoperative enteroscopy method--an invasive technique of small bowel examination. It is performed under narcosis at an operating theatre (i.e. in co-operation with surgeon and anaesthesiologist). The endoscopy-performing physician becomes one of the members of the operating team. The advantage of the method is the possibility to examine of the whole small intestine and to solve immediately the pathological findings by endoscopic or surgical intervention. The examination is invasive and the correct indication is mandatory. Authors report their results of 18 intraoperative panendoscopies of small intestine.

[Xanthogranulomatous processes in the area of the large vessels]. / Xantogranulomatózní proces v okolí velkých cév.

A case is described of 68 years old woman suffering from a peculiar xanthogranulomatous process terminated with fatal renal complication. The clinical symptomatology was not characteristic and did not lead to diagnosis during the life. The process was localized around the cerebral basilar arteries, and was also in close connection with the adventitia of the thoracic aorta and of coronary arteries. Identical xanthogranulomatous infiltrate was found in the peripelvic fat of both kidneys where it led to stenosis of proximal parts of both ureters; less extensive infiltrates were present periportally in the liver and in the bone marrow. Histological findings are suggestive of the diagnosis of Erdheim-Chester disease. The differential diagnosis of the process is discussed.

[Aberrant mammae, personal experience]. / Mamma aberrata, nase zkusenosti.

The authors present information of a group of 63 patients (60 women and 3 men) treated in 1976-1998 where supernumerous aberrant or accessory mammary gland tissue was found. The diagnosis in the majority of the patients was based on histological examination. The tissue of an aberrant mammary gland is subject to the same physiological influences as the mamma proper and can be affected by the same pathological processes--benign and malignant. This is the reason why the authors recommend early extirpation.

[Secondary malignant tumors of the mammary gland]. / Sekundární maligní nádory prsní zlázy.

The authors present three case-reviews of rare metastatic affections of the female mammary gland by the following disorders--a malignant lymphoma, a Grawitz carcinoma of the kidney and by a malignant melanoma. Histological examinations of the tumors and restrospective examinations of the respective patients anamneses resulted in the primary focus determination in two cases.

[Mesenchymal extraperitoneal tumors in the elderly]. / Mezenchymální extraperitoneální nádory u senioru.

Incidence rates of solid tumors increase with age in our population. Epithelial tumors are the most frequent tumors of the old age. On the contrary, extraperitoneal mesenchymal tumors are rare. Surgical treatment remains the most important and the most effective therapeutic modality to manage solid tumors. The risk level of the surgical treatment in the elderly is influenced by many factors, which may often be substancially reduced. Therefore, the elderly should not be excluded from curative surgical procedures on their calendary age basis.

[Activation of the immune system in colorectal carcinoma and its assessment]. / Aktivace imunitního systému u kolorektálního karcinomu a moznost jeho stanovení.

The immune system of the patients with colorectal cancer is activated. Urinary neopterin is an index of this systemic immune activation, reflecting the circulating activity of interferon-gamma. We have measured urinary neopterin excretion in 34 patients with colorectal cancer. This excretion was significantly higher in our patients compared to reference group (325 +/- 267 vs 169 +/- 62 mumol/mol creatinine, neopterin concentrations were considerably higher in Dukes' stage D disease compared with Dukes' stage B and C disease/561 +/- 372 vs 188 +/- 47 and 250 +/- 142 mu/mol creatinine. Increased neopterin detected the presence of metastatic disease with 90% sensitivity and 87.5% specificity. Authors conclude that urinary neopterin measurement may be useful in the staging of colorectal cancer.

A xanthogranulomatous process encircling large blood vessels (Erdheim-Chester disease?).

The case of a strange type of generalized xanthogranulomatosis, ending by a lethal kidney complication, is described in a woman aged 68. The clinical symptoms of the patient were not characteristic and did not lead to the actual diagnosis. The process was located along the basal brain arteries, it adhered to the adventitia of the descending thoracic aorta and of the coronary arteries. An identical xanthogranulomatous infiltrate was found in the peripelvic adipose tissue of both kidneys, where it led to stenosis of the proximal ends of both ureters; to a lesser extent such infiltrates appeared also in the periportal areas of the liver and in the bone marrow. Histological findings grant the possibility of the Erdheim-Chester disease. Differential diagnosis is subjected to discussion.

Increased urinary zinc and copper excretion in colorectal cancer.

Although several studies have described an increase in urinary zinc output in cancer patients, little attention has been paid to the excretion of copper. In this study, we investigated urinary excretion of zinc and copper, and serum levels of alpha-1 acid glycoprotein, an acute phase protein, in 22 patients with colorectal cancer. Urinary excretion of copper and zinc were significantly increased compared to the reference group (77 +/- 72 vs. 32 +/- 14 mumol/mol creatinine, P < 0.05, and 1.50 +/- 0.62 vs. 0.70 +/- 0.41, P < 0.002, respectively). In addition, a negative correlation was observed between urinary copper and serum alpha-1 acid glycoprotein (rs = -0.5256, P < 0.02). In conclusion, urinary excretion of copper, as well as that of zinc, appears to be elevated in colorectal cancer. The finding of a negative correlation between urinary copper and alpha-1 acid glycoprotein supports the postulated role of the latter in regulating renal glomerular permselectivity.

Urinary zinc excretion and acute phase response in cancer patients.

We investigated urinary zinc and serum levels of C-reactive protein, alpha-1 acid glycoprotein, haptoglobin, transferrin and prealbumin in 55 patients with solid tumors and 20 controls. Urinary zinc, serum C-reactive protein, alpha-1 acid glycoprotein and haptoglobin were significantly higher, and serum prealbumin was significantly lower in cancer patients. A significant positive correlation between urinary zinc and C-reactive protein, alpha-1 acid glycoprotein and haptoglobin, as well as a negative correlation with transferrin and prealbumin were observed. Hyperzincuria in cancer patients appears to be linked to the acute phase response. Our data provide further evidence implicating systemic inflammatory response in increased urinary zinc excretion.

Association between renal tubular cell dysfunction and increased urinary zinc excretion in cancer patients.

Although an increase in renal zinc excretion in cancer patients is well documented, the mechanisms involved are still disputed. As recent studies have raised the question of the role of renal tubular cell dysfunction in the elevation of urinary zinc output, we have examined urinary zinc excretion and the excretion of N-acetyl-beta-D-glucosaminidase (NAG), an indicator of tubular cell dysfunction, in 30 patients with cancer, 28 healthy controls and 20 patients with benign non-inflammatory disorders. As expected, urinary zinc excretion was significantly higher in the cancer patients compared with controls and patients with benign disorders (2.64 +/- 3.05 vs. 0.86 +/- 0.36 and 0.89 +/- 0.29 mmol mol creatinine-1, p < 0.001). NAG activity was also elevated (18.9 +/- 20.1 vs. 4.32 +/- 3.33 and 9.99 +/- 9.72 mukat mol creatinine-1, p < 0.001 and p < 0.05, respectively). A significant correlation between urine zinc and NAG was observed in all three groups (rho = 0.73, p < 0.001, rho = 0.55, p < 0.01 and rho = 0.45, p < 0.05, respectively). In conclusion, our data provide additional support for the role of renal tubular cell dysfunction in hyperzincuria in cancer. Urinary zinc measurement may represent an alternative approach to detecting renal tubular dysfunction in human pathology.

Increased urinary zinc excretion in cancer patients is linked to immune activation and renal tubular cell dysfunction.

Urinary zinc excretion is known to be increased in cancer patients, but the pathogenesis of this phenomenon remains uncertain. Both skeletal muscle catabolism and renal tubular cell dysfunction have been proposed to explain this observation. We have investigated urinary zinc and N-acetyl-beta-D-glucosaminidase (NAG), an indicator of renal tubular cell dysfunction, as well as serum neopterin, an index of systemic immune activation, in 22 patients with cancer and seven controls. Both serum neopterin and urinary zinc were significantly elevated in cancer patients (15.8 +/- 12.7 versus 7.3 +/- 2.3 nmol l-1 and 1.77 +/- 0.80 versus 1.21 +/- 0.41 mmol mol-1 creatinine, P < 0.02 and P < 0.05, respectively), while NAG was similar in cancer patients and the controls (13.58 +/- 13.80 versus 13.68 +/- 12.19 mu kat mol-1 creatinine). A significant correlation was observed between serum neopterin and urine zinc (rs = 0.5119, P < 0.02), serum neopterin and urine NAG (rs = 0.6761, P < 0.002), and urinary zinc and NAG (rs = 0.6348, P < 0.002). In conclusion, the present data indicate a link between urinary zinc excretion and immune activation as well as renal tubular cell dysfunction. In addition, renal tubular cell dysfunction appears to be linked to immune activation.