To Feed or Not to Feed - Nutritional Risk Assessment and Support in Elective Colorectal Surgery. A Prospective Study on the Effect of Screening.

Colorectal cancer (CRC) is the third most common malignant tumor and resection remains the key element in its treatment. The correction of preoperative malnutrition reduces morbidity and mortality. Our study demonstrates a nutritional state mass screening protocol to steer nutritional support. Two hundred fifty-nine patients with planned colorectal resection were prospectively enrolled. Preoperative telemedicinal assessment determined the risk of malnutrition using Nutritional Risk Screening 2002 (NRS 2002) score. Patients with a score ≥3 were offered optimized oral nutritional supplement. Three groups were investigated. Group I (NRS 2002 < 3, n = 98) received no supplement. Group II- (NRS 2002 ≥ 3, n = 118) was offered but did not finally receive clinical nutrition. Group II+ (NRS 2002 ≥ 3, n = 43) accepted and received adequate clinical nutrition. 98 patients (37.8%) had no risk, 154 patients (59.5%) had increased risk and 7 (2.7%) had severe malnutrition. Severe complications (Clavien-Dindo >2) rate was similar in Group I (2%) and Group II+ (2.3%) with no mortality. Severe complications more often occurred in Group II- (5.1%) along with 1.7% mortality (p > 0.05). Length of stay was the highest in Group II- while the lowest in Group II+ (p < 0.01). Preoperative telemedicinal screening is applicable in identifying patients with malnutrition. NRS 2002 used by a nutritional team reduces length of stay.

Reinfection, recontamination and revaccination for SARS-CoV-2.

The reports on coronavirus disease 2019 (COVID-19) describe the pandemic in waves. Similar to the ocean's waves, the frequency and amplitude of the number of new cases and the number of deaths were globally quite regular; nevertheless, they showed important regional irregularities and the direction of spread has been generally rather unpredictable for COVID-19. One of the major reasons for the repeated outbreaks is the mutating capacity of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that allows the virus to infect persons who have natural immunity or have been vaccinated. Vaccination began in vast campaigns from the second year of the pandemic that was supposed to decrease the magnitude of the waves. Although it reduced the complications, the expected attenuation of the disease expansion has not yet been met. This paper provides a short overview of the most recent data on the rate of reinfection in vaccinated and non-vaccinated individuals. It points out that testing positive for a second time for SARS-CoV-2 does not necessarily mean a reinfection; it can also be interpreted as recontamination. The symptom free outcome as well as the rapid reconversion of the polymerase chain reaction test may help to determine the difference between reinfection and recontamination. Awareness of this phenomenon may be valuable in times of human resource difficulties. The available evidence may suggest that the protective value of a prior infection could be better considered for vaccine distribution in the future.

Emlorák hasüregi áttétei - Egy szokatlan entitás klinikopatológiai jellemzoi.

Case report: A sixty-five-year-old female patient underwent surgery for severe gastrointestinal symptoms, following an alarming CT image. Laparotomy revealed irresectable gastric cancer and peritoneal carcinosis. Palliative gastro-jejunostomy and ileo-descendostomy were performed. The endoscopic diagnosis - linitis plastica - and the intraoperative macroscopic appearance matched and agreed on the histologically presumed shigillocellular carcinoma. Three years following the initial abdominal symptoms, histological samples taken from newly detected cutaneous metastases which developed during oncological palliative treatment verified occult lobular breast carcinoma. Histological revision of the sample taken from abdominal exploration confirmed the latter diagnosis. The hormone receptor positive, human epidermal growth factor receptor-2 negative malignancy showed very good regression for the palliative hormone treatment. Discussion: About ten percent of breast cancer cases are lobular carcinomas, which are more often multicentric, bilateral, occult and have a propensity to metastasize to serous membranes, abdominal and pelvic viscera. Due to the increasing survival of breast cancer patients, the number of abdominal metastases of breast cancer is expected to increase. Histological confirmation is indispensable even in case of advanced abdominal malignancies, especially in the case of an unusual medical history. The currently rare case demonstrates the need for multidisciplinary cooperation in all diagnostic and therapeutic fields of breast cancer.

Narrative review of theoretical considerations regarding HITHOC between past and future.

Hyppocrates constructed the medicines-surgery-energy triangle which includes all therapeutical modalities. Hyperthermic intraoperative chemotherapy (HITHOC) is a synergy-based single stage multimodality treatment encompassing the locoregional manifestation of the systemic malignant process. Pleural space, thermal effect, lavage/irrigation and chemotherapy represent the basic science ports of the network hub: HITHOC. The malignant transformation and process of the pleural surface (and underlying lung) challenges space management and tissue control. Thermotherapy without local chemotherapy is insufficient, similar to the normothermic local irrigation aligned with anticancer agents. The local administration of combined heat-transfer fluid and chemotherapy with or without subsequent surgical removal offers reasonable outcome in extensive primary pleural neoplasms (malignant mesothelioma), advanced (> Stage IIIA) NSCLC, functionally inoperable lung cancer and pleural carcinosis from extrathoracic malignancies. Measured by symptom-free survival and the quality of life, HITHOC in its present form, offers a modest yet fully substantiated solution. HITHOC in combination with the local application of targeted therapy and/or immunotherapy administered in the pleural space are currently under investigation. Additional development including new acting substances, their solvents and the means regarding surgical delivery and anesthesiology techniques are sign posts up ahead. Level 2 evidence are required in order to stepping up the recommendation levels, rewriting protocols and guidelines, in which HITHOC earns its revered position in the decision making process it deserves.

Perioperative nutritional state as a surgical risk in oncologic patients / A perioperatív tápláltsági állapot mint kockázati tényezo az onkológiai sebészetben.

Összefoglaló. Bevezetés: A tumorsebészetben a malnutritio független rizikófaktor. A kockázatcsökkentés egyik fontos eleme a perioperatív tápláltsági állapot felmérésén alapuló klinikai táplálás. Az irodalomban jól dokumentált az idoben végzett rizikószurés fontossága, de ennek módja, különösen hazai környezetben, kidolgozatlanabb. Célkituzés: A malnutritio szempontjából esendobb csoportot alkotó onkológiai sebészeti betegek azonosíthatóságának igazolása, a szurési metódus vizsgálata. Módszer: 2016. október és 2018. november között öt kórcsoportban (emlo, máj, pancreas, mellkas, gyomor-bél rendszer) az igazolt vagy gyanított malignitás, illetve gyulladásos bélbetegség miatt mutétre váró betegeket telemedicina-módszerrel kerestük fel. A rizikócsoportokat (nincs rizikó - alultápláltság valószínusítheto - súlyos alultápláltság) a sebész és dietetikus által közösen vezetett 'Nutritional Risk Score 2002' (NRS 2002) szuro pontrendszerrel állapítottuk meg. Az NRS 2002 pontértékeket a posztoperatív lefolyással vetettük össze (kórházi tartózkodás, 30 napon belüli szövodmények Clavien-Dindo szerinti osztályozása). Prospektív vizsgálatunkban 1556 beteg szerepel. Eredmények: Az emlosebészeti betegek (n = 314) 95,2%-a rizikómentes. A májreszekcióra várók (n = 79) 43%-a valószínuleg vagy biztosan alultáplált. A hasnyálmirigymutétre elojegyzett betegek (n = 122) 81,2%-a emelt rizikójú. A kuratív célú pancreasreszekción átesett betegek pontértéke alacsonyabb, mint a palliatív mutétben részesüloké (p>0,05). A tüdoreszekcióra váró (n = 219) betegeknél 40,7% került emelt rizikócsoportba. Az emelkedett NRS 2002 érték magasabb szövodményaránnyal járt (p<0,05). Béltraktust érinto mutétek (n = 822) esetén a betegek 71,2%-a valószínuleg vagy biztosan súlyosan alultáplált. Az elorehaladott tumorok és a szövodmények egyaránt eros összefüggést mutattak az NRS 2002 értékkel (p<0,01). Következtetés: Az NRS 2002 szuromódszer prediktív értékkel bír mind a tumorstádium, mind a szövodmények tekintetében. Módszerünkkel idoben felismerheto a fokozott rizikót jelento betegcsoport, így a pontérték alapján célzott mesterséges táplálás tervezheto. Orv Hetil. 2021; 162(13): 504-513. INTRODUCTION: Malnutrition is an independent risk factor in oncologic surgery. Perioperative screening and aimed clinical nutrition are key elements in risk reduction. The importance of timely screening has been well published, but its method is underdeveloped, especially in Hungary. OBJECTIVE: Evaluation of a malnutrition screening method to identify patients at risk in oncologic surgery. METHOD: Patients were enrolled from October 2016 to November 2018 in five groups (breast, liver, pancreas, thoracic and gastrointestinal surgery). All patients awaiting surgery for suspected or proven malignancy or for inflammatory bowel disease were screened preoperatively via telephone (telemedicine). Probability for malnutrition (no risk - suspicion for malnutrition - severe malnutrition) was jointly assessed by surgeon and dietitian using Nutritional Risk Score 2002 (NRS 2002). Screening results were compared to the postoperative course (including length of stay and 30-day morbidity/mortality using Clavien-Dindo classification). A total of 1556 patients were identified prospectively. RESULTS: 95.2% of breast surgery patients (n = 314) were not at risk. Malnutrition was suspected or detected in 43% of patients awaiting liver resection (n = 79). Increased risk is present in 81.2% of pancreatic surgery cases (n = 122). Pancreas resections with curative intent were associated with lower scores than in palliative operations (p>0.05). 40.7% of the 219 patients scheduled for lung resection had increased malnutrition risk. Higher NRS 2002 resulted in increased morbidity rate (p<0.05). Surgery on the intestines was performed on 822 cases. 71.2% of them had suspected or severe malnutrition. Presence of advanced cancer and complication rate showed strong relations with increased NRS 2002 (p<0.01). CONCLUSION: Screening with NRS 2002 has predictive value on both tumor stage and complications. Our method is sound to identify patients at malnutrition risk in time, and thus an aimed clinical nutrition therapy can be planned. Orv Hetil. 2021; 162(13): 504-513.

Complex oncologic therapy for loco-regionally advanced breast cancer associated with long-lasting SARS-CoV-2 PCR-positivity / Tartós SARS-CoV-2-PCR-pozitivitáshoz társuló, lokoregionálisan elorehaladott emlodaganat komplex onkológiai kezelése.

Összefoglaló. A COVID-19 mortalitását a súlyos társbetegségek, közöttük bizonyos daganatos betegségek is növelik. Immunszuppresszív hatásuk miatt felmerülhet a citotoxikus kezelések rizikónövelo hatása is. Ugyanakkor az onkológiai terápia megszakítása vagy halasztása, különösen az agresszívebb, kiterjedtebb és fiatalkorban jelentkezo daganatok esetében ronthatja a kórjóslatot. Egy 39 éves nobeteg esetét ismertetjük. A járvány során késlekedve felismert, lokoregionálisan kiterjedt emlodaganat miatt primer szisztémás kemoterápiában részesült. A kezelés 5. ciklusa során enyhe légúti tünetek kapcsán, az onkológiai ambulancián SARS-CoV-2-fertozése igazolódott. Kemoterápiás kezelését felfüggesztettük. A diagnózistól számított 3. napon tünetmentessé vált, ám SARS-CoV-2-PCR-pozitivitása még a 43. napon is fennállt. A 19. napon hormongátló kezelést indítottunk. Az 51. napon mastectomia és axillaris block dissectio történt. A 82. napon a megszakított kemoterápiát a hormongátló kezelés leállítását követoen G-CSF-profilaxis mellett újraindítottuk. A kezelés során fertozéses szövodményt nem észleltünk. Kemoterápia és mutét SARS-CoV-2-fertozött, tünetmentes daganatos betegnél szövodménymentesen végezheto elhúzódó virológiai pozitivitás esetén, felszabadító vizsgálat nélkül is. A daganatos betegek koronavírus-fertozése esetén az onkológiai protokolltól történo eltérés egyénre szabott optimalizálásával és a multidiszciplináris team szorosabb együttmuködésével az infektológiai és az onkológiai kockázat együttes alacsonyan tartása is megvalósítható. Orv Hetil. 2021; 162(16): 611-614. Summary. Mortality of COVID-19 is increased when certain co-morbidities, among others advanced malignancies are present. Deleterious effect of cytotoxic therapy, related to its immunosuppressive effect, may also be hypothesised. However, postponing or cancelling oncologic treatment, especially in younger patients with advanced and more aggressive tumors may worsen the prognosis. The case of a 39-year-old female patient is presented, who was diagnosed with loco-regionally advanced breast cancer during the pandemic. Primary systemic chemotherapy was started. The patient presented with acute respiratory tract symptoms during the fifth cycle and subsequently SARS-CoV-2 infection was diagnosed. Chemotherapy was cancelled. Symptoms resolved in three days after diagnosis. SARS-CoV-2 PCR remained positive up to day 43. Antihormonal therapy was introduced on day 19 and she underwent mastectomy with axillary lymph node dissection on day 51. Chemotherapy was reset postoperatively on day 82 with prophylactic G-CSF protection. No adverse event was observed throughout the treatment. Cytotoxic chemotherapy and surgery can be successfully delivered in breast cancer patients with prolonged asymptomatic SARS-CoV-2 PCR positivity, even without negative swab result. Individual optimisation of the therapy may require deviations from standard protocols. Closer multidisciplinary cooperation may contribute to the minimisation of both oncologic and infectious risks. Orv Hetil. 2021; 162(16): 611-614.