[Placenta percreta as a cause of massive intraabdominal bleeding]. / Placenta percreta a její atypická lokalizace jako prícina silného nitrobrisního krvácení.

OBJECTIVE: To inform about a rare cause of massive intraabdominal bleeding due to perforation of uterine corner by unrecognized placenta percreta. DESIGN: Case report. SETTING: Department of Gynecology and Obstetrics, University Hospital Ostrava. CASE REPORT: We report a case of acute haemoperitoneum in pregnant woman at 34th week of gestation. We have detected the cause of the bleeding during emergency caesarean section - perforation of left uterine corner by placenta percreta. CONCLUSION: Placenta percreta is the most severe form of abnormal placental villous adherence. In rare cases, chorionic villi may penetrate surrounding organs and cause acute intraabdominal bleeding. Due to increasing number of surgical interventions on uterus, these disorders are on the rise. It is crucial to anticipate an abnormal placental villous adherence in women with atypical placenta localization. These women should be thoroughly observed and referred to perinatal center with intermediary or intensive care for further management before delivery.

NOD2/CARD15 mutations and the risk of reoperation in patients with Crohns disease.

INTRODUCTION: Three NOD2/CARD15 gene variants (3020insC, R702W, G908R) have been identified as genetic risk factors for Crohns disease patients. However the diagnostic and therapeutic relevance for clinical practice remains limited. The aim of this study was to evaluate the association between these variants, the risk of reoperation and disease phenotype. METHODS: In 76 Crohns disease patients (41 female, 35 male) with a minimum 5 year follow-up, three polymorphisms of the NOD2/CARD15 gene (R702W, G908R, 3020insC) were tested. Detailed clinical and medical history including surgical procedures and reoperations were obtained by reviewing the medical charts and completed prospectively. Association between the need for reoperation, disease phenotypes and gene variants were analyzed. RESULTS: 24 patients (32%) showed at least one NOD2/CARD15 mutation. 25 patients (33%) required reoperation, 51 (67%) represented the control group. The expected trend that patients with NOD2/CARD15 variants have a higher frequency of reoperations was not confirmed to a level of statistical significance (p=0.2688). Two of the four patients (50%) with the 3020insC variant required further surgery. We did not confirm any association between NOD2/CARD15 mutations and age at diagnosis (p=0.4356), behavior (p=0.6610), or localization (p=0.4747) according to the Montreal classification. CONCLUSION: NOD2/CARD15 polymorphisms did not significantly affect the reoperation rate. Homozygosity for the 3020insC variant in the NOD2/CARD15 gene is associated with a high risk of reoperation. NOD2/CARD15 gene variants are not significantly associated with specific disease phenotypes.

[Hepatic pseudolesions adjacent to the falciform ligament]. / Hepatální pseudoléze v blízkosti falciformního ligamenta.

INTRODUCTION: Accurate detection of hepatic pseudolesions using multi-detector CT and MRI examinations is crucial for the differentiation of benign alterations from primary and secondary malignant lesions in hepatic parenchyma. METHOD: The authors conducted a systematic literature review in PubMed. "Liver" and "pseudolesion" were used as keywords in English and Czech, and papers/articles published from 2000 to 2014 were retrieved. RESULTS: The authors presented a literature review. In addition, the authors performed a retrospective evaluation of a group of patients treated for liver disease at University Hospital Ostrava where this anomaly was encountered in 7 cases.In 3 of the patients, diagnostic laparoscopy was done, with visual examination of the lesion accompanied by intraoperative ultrasound exam (IOUS) and partial excision, to establish the diagnosis. Subsequent histological assessment of the specimens confirmed the diagnosis of a steatotic lesion in each of these 3 patients. Additional 2 of the 7 patients underwent liver surgery for concurrent metastatic lesions of colorectal cancer and an open-access revision of the suspected lesions was performed. Visual inspection and intraoperative ultrasound (IOUS) was followed by excisional biopsy. The histology revealed macro- and micro-vesicular steatosis and excluded malignant changes. The last 2 patients still continue to be followed-up regularly on a 6-month routine check-up basis at our hepatology unit. CONCLUSION: The authors presented their own experience gained through inter-disciplinary cooperation at Multidisciplinary conferences. A literature overview of this unusual subject is also included. Particularly in oncologic patients, correct interpretation of these pseudolesions may help to avoid unnecessary biopsies, further imaging examinations and diagnostic laparoscopies and/or explorative laparotomies.

Differentiating autoimmune pancreatitis from pancreatic cancer.

Differential diagnosis between autoimmune pancreatitis (AIP) and pancreatic cancer can be very difficult. The main clinical symptoms in patients with autoimmune pancreatitis are jaundice, weight loss, abdominal pain and new onset of diabetes mellitus. Unfortunately, the same symptoms could be observed in patients with pancreatic carcinoma too. Imaging methods as computed tomography (CT) scan, magnetic resonance imaging (MRI) and endosonography (EUS); together with serological examination (IgG4 and Ca 19-9) play the important role in differentiation autoimmune pancreatitis from pancreatic cancer. Extrapancreatic findings are distinctive in patients with autoimmune pancreatitis. In some cases the pancreatic biopsy is indicated, mainly in patients with focal or multifocal form of autoimmune pancreatitis. Response to steroids (decreased pancreatic or extrapancreatic lesion or damage) is distinctive to AIP. In clinical practice, CT scan seems to be the most reasonable tool for examining the patients with obstructive jaundice with or without present pancreatic mass. Stratification the patients with possible AIP versus pancreatic cancer is important. In patients with AIP it may avoid pancreatic resection, as well as incorrect steroid treatment in patients with pancreatic carcinoma.

[Lung metastases as the first manifestations of occult medullary microcarcinoma]. / Metastázy do plic jako první projevy okultního medulárního mikrokarcinomu.

The article is concerned with medullary microcarcinoma of the thyroid. Similarly to medullary macrocarcinoma, this may metastasize to distant sites. Reported is a case of a 54year- old male who had suffered from chest tightness and dry irritating cough. Chest Xray showed small nodules with poorly- defined borders of unknown etiology. Lung biopsy was performed, which detected amyloid- rich neuroendocrine carcinoma. Examination of the thyroid was recommended to confirm or rule out suspected medullary carcinoma. The biopsy examination also suggested G1 and G2 primary neuroendocrine carcinoma of the lung or diffuse idiopathic pulmonary neuroendocrine cell hyperplasia. Numerous examinations using imaging methods (CT, MRI, PET- CT) were carried out with no positive results in the thyroid. Despite that, thyroidectomy was performed. Subsequent biopsy examination revealed medullary microcarcinoma sized 0.6 cm. Apart from lung metastases, tumor lesions were found in cervical lymph nodes. This case is an example of a close cooperation between a pathologist and a clinician -  endocrinologist. Based on serum calcitonin levels, this may aid in differential diagnosis.

[Improving the quality of histopathological examination of colorectal cancer specimens through standard protocol implementation]. / Zvýsení kvality histopatologického hodnocení preparátu kolorektálního karcinomu prostrednictvím zavedení standardního protokolu.

INTRODUCTION: Detailed, high-quality histopathological examination of colorectal carcinoma is an essential component of accurate disease staging. The aim of this study was to evaluate the influence of standard pathological protocol implementation on the quality of colorectal cancer specimen evaluation. MATERIAL AND METHODS: The standard protocol for colorectal cancer specimens evaluation was created on the basis of the NCCN guidelines for colorectal carcinoma and in accordance with the American Joint Committee on Cancer (AJCC) recommendations. The protocol has been implemented into the practice of University Hospital Ostrava since 1 January 2013. All patients who underwent resection for colorectal cancer in University Hospital Ostrava between 1 January 2011 and 30 June 2013 were included into the study. Histopathological reports (before and after protocol implementation) were analysed with a focus on the presence of the parameters being monitored; the differences underwent statistical analysis. RESULTS: In total, 235 patients who underwent resection of colorectal cancer (184 patients before and 51 patients after protocol implementation) were included into the study. The mean number of investigated lymph nodes was 12.5±6.3 (colon) and 12.6±6.2 (rectum) before protocol implementation. The mean number of lymph nodes was 15.0±4.6 (colon) and 16.8±6.7 (rectum) after protocol implementation; the differences are statistically significant. Before protocol implementation, the limit of 12 investigated lymph nodes was not reached in 49 patients with colon carcinoma (43.8%) and in 32 patients with rectal carcinoma (44.4%). Statistically significant improvement was noted after protocol implementation - the limit of 12 lymph nodes was not reached in 5 patients (18.5%) with colon and 4 patients (16.7%) with rectal carcinoma. There were also differences in the number of macroscopic mesorectal excision quality evaluation, circumferential resection margin reports and signs of microscopic tumour aggressiveness, in favour of histopathological reports after standard protocol implementation. CONCLUSIONS: Our retrospective study proved that the implementation of the standard protocol for colorectal cancer resection specimens leads to an improved quality of definitive histopathological reports.

Transfusion-related acute lung injury: report of two cases.

Transfusion-related acute lung injury (TRALI) is a severe life-threatening complication of blood transfusion, characterized by acute lung injury developing within 2-6 h of transfusion. However, TRALI is difficult to diagnose, and the initial report or suspicion of TRALI depends on close collaboration between clinical departments and transfusion centres. A total of 17 adverse post-transfusion reactions were reported to the Blood Centre of the University Hospital Ostrava as suspected TRALI between 2005 and 2010. We report two cases of serious TRALI with different pathogenetic mechanisms.

[Primary hepatic neuroendocrine carcinoma]. / Primární neuroendokrinní karcinom jater.

UNLABELLED: Primary neuroendocrine carcinoma of the liver is a rare tumour, probably arising from scattered neuroendocrine cells of the bile duct. We present the case of a 72-year-old male who experienced gradual weight loss and diarrhoea. Given the fact that he had stayed in the Dominican Republic, a parasitic disease was initially suspected. However, this was not confirmed. Further examination showed tumour infiltration of the liver. Fine needle aspiration cytology of the tumour site was performed. The diagnostic procedure revealed neuroendocrine carcinoma. The tumour cells expressed the following neuroendocrine markers (chromogranin, synaptophysin, CD56 and NSE) as well as the epithelial marker AE1-AE3. The tumour was considered metastasis of the primary tumour located in the gastrointestinal tract. A thorough clinical examination was performed including gastroscopy, colonoscopy, In-111 Octreoscan scintigraphy, computed tomography and magnetic resonance imaging. These methods revealed metastases in the vertebrae, pelvis, long bones and skull. No other tumour sites were found in the lungs, gastrointestinal tract or pancreas. The patient became increasingly cachexic and later died. An autopsy showed massive multicentric tumour infiltration of the liver. Histological examination revealed well differentiated neuroendocrine carcinoma which transformed into intermediate and small cells. The autopsy found no tumour sites in the gastrointestinal tract, lungs or pancreas. The results were suggestive of primary neuroendocrine carcinoma of the liver. KEYWORDS: neuroendocrine carcinoma - liver - primary tumour.

[A giant gastrointestinal stromal tumour - a case report]. / Obrovský gastrointestinální stromální tumor - kazuistika.

Gastrointestinal stromal tumours represent a group of non-epithelial gastrointestinal tumours that have both benign and malignant character. Most frequently, they occur in the stomach and the intestine; however, as regards their overall incidence, they are rather infrequent tumour lesions. The present case report describes a rare bulky extragastrointestinal stromal tumour originating from the mesenterium in a young patient. Its anatomical and histological picture, diagnosis and treatment are described. Our work points to the necessity for physicians to also bear in mind the less likely options and highlights the role of surgery in the treatment of such voluminous findings.

Coincidence of chronic lymphocytic leukaemia with Merkel cell carcinoma: deletion of the RB1 gene in both tumors.

The authors report a case of a 64-year-old man with chronic lymphocytic leukaemia (CLL) diagnosed 5 years ago. Recently, the patient was admitted with a tumour of the skin in the left lumbar region. Histological and immunohistochemical examinations established the diagnosis of Merkel cell carcinoma (MCC). Electron-microscopic examination revealed the formation of spherical aggregates of intermediate-sized filaments in the perinuclear region. The coincidence of MCC and CLl is rather rare and in published cases, no cytogenetic examinations were performed. We examined the RB1 gene using the interphase FISH method. A biallelic deletion in CLL tumour cells was detected; in MCC tumour cells, biallelic deletion was found in 33% of the cells and monoallelic deletion in 57% of the cells. In addition, chromosome 6 trisomy and 1p36 deletion were detected. Examination of non-neoplastic cells of the patient's skin showed a biallelic presence of the RB1 gene. According to the relevant literature, examination of the RB1 gene in CLL has informational value as a prognostic factor. The relationship between deletion of the RB1 gene and prognosis in MCC has not yet been determined and needs more research.

[Primary hepatic carcinoid]. / Primární jaterní karcinoid.

Primary hepatic carcinoid (PHC) is considered to be particularly sporadic diagnosis; in current world literature about 60 cases have been reported. Most of the patients present with abdominal pain, diarrhea, icterus, flush, weight loss or respiratory disease; even though the course of the disease might stay asymptomatic for a long time. An illuminating case of at presentation oligosymptomatic 72-year-old patient, which was after extensive examination based on OctreoScan and histological verification diagnosed to have generalized PHC, is reported. Paliative therapy with somatostatine analogues followed. At autopsy 8 months later the clinical diagnosis of PHC was confirmed. PHC is difficult to diagnose both due to radiological similarity to other hepatic lesions and demanding exclusion of other primary foci. The diagnosis of PHC is based on negative imaging techniques result in other possible localizations. Minimal symptomatology in stage of generalization, atypical primary localization and rapid progression is of interest in current case.

[Predictive factors for non-sentinel lymph nodes affection in breast carcinoma--outcomes of a Czech multicenter study of sentinel lymph nodes]. / Prediktivní faktory postizení nonsentinelových uzlin u karcinomu prsu--závery ceské multicentrické studie sentinelových uzlin.

BACKGROUND: The aim of the study was to assess positivity nonsentinel lymph nodes in patients with macro, micro and submicrometastases in sentinel lymph nodes and find predictive factors of positivity nonsentinel lymph nodes. Study was conducted at the Department of Surgery in Pardubice, Pilsen, Ostrava and Zlín. MATERIAL AND METHODS: Sentinel lymph nodes were assessed based on standards of Czech Pathological Society. Detection of sentinel lymph nodes was performed based on radionavigation or combination of radionavigation and blue dye method. RESULTS: In group N1 (macrometastases) there was found positivity of nonsentinel lymph nodes in 50% (45 from 90 patients). In group N1 Mi (micrometastases) there was found positivity of nonsentinel lymph nodes in 26.7% (16 from 60 patients). In group NO I+ (sub-micrometastases) there was found positivity of nonsentinel lymph nodes in 6.7% (1 from 15 patients). Predictive factors were size of metastasis, number of positive sentinel lymph nodes and grading. Size of tumor was not found to be a predictive factor of positivity nonsentinel lymph nodes. DISCUSSION: High positivity of nonsentinel lymph nodes in pacients with macro and micrometastases in sentinel lymph nodes advocates to perform axillary lymph nodes dissection. Due to small number of patients with submicrometastases it is not possible to assess if axillary dissection is necessary or not. Predictive factors of positivity of nonsentinel lymph nodes are size of metastasis in sentinel lymph nodes, number of positive sentinel lymph nodes and grading. Size of tumor was not found to be a predictive factor due to small tumors in the study. In spite of this it is necessary to consider it like a predictive factor of positivity nonsentinel lymph nodes. CONCLUSION: In patients with macro and micrometastases it is necessary to perform axillary dissection. In patients with submicrometastases in sentinel lymph nodes it is necessary to consider predictive factors.

CCND1 and ZNF217 gene amplification is equally frequent in BRCA1 and BRCA2 associated and non-BRCA breast cancer.

Breast cancer associated with BRCA1 and BRCA2 gene mutations differs from non-BRCA tumors in several respects. We determined whether there was any difference in CCND1 (11q13) and ZNF217 (20q13) gene amplification with respect to BRCA status. Of 40 breast cancer samples examined, 15 and 9 were from BRCA1 and BRCA2 mutation carriers, respectively, and 16 from patients without mutation. Fluorescence in situ hybridization showed that eight tumors exhibited CCND1 amplification (20%; 3 BRCA1, 3 BRCA2, 2 non-BRCA). ZNF217 amplification was observed in three of 38 cases (8%; 2 BRCA1, 1 non-BRCA). There was no significant difference in CCND1 and ZNF217 amplification between BRCA1, BRCA2 and non-BRCA tumors. CCND1 amplification was associated with decreased disease-free (P = 0.045) and overall survival (P = 0.015). BRCA1 tumors with CCND1 amplification were estrogen receptor negative, in contrast to CCND1 amplified BRCA2 and non-BRCA tumors, suggesting that concurrent CCND1 amplification and estrogen and progesterone receptor negativity may predict germline BRCA1 gene mutation. All ZNF217 amplified tumors were of the medullary histological type (P = 0.002). There was no statistical correlation between CCND1 and ZNF217 amplification and estrogen receptor, progesterone receptor, and ERBB2 expression and TNM classification. CCND1 amplification did not correlate with EGFR expression.

[Alveolar echinococcosis--a new emerging disease?]. / Alveolární echinokokóza--nove se objevující onemocnení?

Alveolar echinococcosis is a rare zoonotic disease caused by the cestode larval stages of Echinococcus multilocularis. The Larva develops as a tumour like cyst (hydatid). Due to a slow cyst development, the early stage of the infection is always asymptomatic and the clinical symptoms develop after years later. In the Czech Republic the disease is still very rare. Only one alveolar echinococcosis case was reported 30 years ago. However, new alveolar echinococcosis cases occurred during last two years and some of them indicate autochtonic character of the transmission. With regard to the recent increasing risk of infection with E. multilocularis in Central Europe, we present two case reports of alveolar echinococcosis in a 33-year old woman and a 24-year old man. The reports show diagnostic process and therapy of the infection.

Another case of coincidental Giardia infection and pancreatic cancer.

Until now, few cases of coincidental giardiasis and pancreatic tumors have been described. Among these cases, three described giardiasis cases coincided with confirmed pancreatic cancer. We present another case of Giardia infection coexisting with pancreatic cancer in a 67-year-old man who suffered from stenosis of the distal ductus choledochus combined with a hypoechoic mass in the head of the pancreas. The diagnostic conclusion of suspicious adenocarcinoma was based on endoscopic ultrasound fine-needle aspiration (EUS-FNA) biopsy and confirmed by a partial duodenopancreatectomy. On bloody cytology smears prepared from the EUS-FNA specimen, trophozoites of Giardia intestinalis accompanying an inflammatory background and features that fulfilled the morphological criteria of malignancy were observed. In histological sections from the duodenopancreatectomy specimens, the parasites were observed attached to the epithelium, but individual Giardia parasites were also observed beneath the epithelial lining. According to conventional genotyping, the infecting Giardia belonged to sub-assemblage AII.

A molecularly genetic determination of prognostic factors of the prostate cancer and their relationships to expression of protein p27kip1.

Loss of a part of chromosome 8p22, containing the gene LPL and amplifications of the field 8q24 comprising the c-myc oncogene are the most frequent chromosomal aberrations in prostate cancer. We aimed to find the frequency of these chromosomal abnormalities and assess their relationship to the prognosis of prostate cancer patients in relation to Gleason score and expression of p27Kip1. We chose a subgroup of 17 monitored patients who had died during five years following diagnosis, and a group of 31 surviving patients whose Gleason score exceeded 5 (Group of Gleason score 2-3). Owing to lack of tumor cells in puncture biopsies, we made hybridizations in situ and objectively evaluated the result in 35 patients out of 48. Amplification in the field for oncogene c-myc was found in 19 cases (54.2%), in 15 of these (78.9%) polyploidy of the chromosome 8 was also confirmed. Deletion of a part of chromosome 8p22 was found in 21 cases (60%). Normal findings were shown in 8 cases (22.8%) and genetic abnormalities were revealed in 27 patients (77.2%). A Chi-squared test showed the dependence of Gleason score on amplification of the c-myc gene in nonmetastasing prostate cancer. In the case of a Gleason score of group 3, abnormalities in amplification of c-myc were statistically more significant than a Gleason score of group 2 using significance according to the Fisher Exact Probability test (p=0.039). We showed that the level of expression of protein p27 Kip1 was related to abnormality of amplification of the c-myc gene. We also came to the conclusion that decreased expression of protein p27 Kip1 is related the c-myc amplification.

[Problems of suitability laser's excision of pigmented dermal lesions: case report of minimal deviation melanoma]. / Problematika vhodnosti laserového odberu pigmentových kozních lézí: kazuistika minimálne deviovaného melanomu.

The paper describes a case of a 23-year-old woman, in whom an intradermal pigmented nevus was removed by an excision using a CO2 laser. In histological examination a minimal deviation melanoma (MDM) was found, occurring sparsely in the centre of the nevus. A sufficiently wide excision is important not only in terms of the pathologist who assesses the lesion but also, in particular, in terms of the prognosis to the patient. In problematic diagnoses where it is necessary to assess the extent of the lesion as well as its edges and base in particular, the sample taken by laser may be insufficient. The authors report widely used methods of nevus laser surgery and highlight the necessity of a sufficiently radical exstirpation of a nevus.

[Frequency view on genome changes testing]. / Frekvencní pohled na vysetrení odchylek genomu.

Laboratories dealing with human genome, both inherited and acquired changes, dispose with similar methods and technology. The spectrum of genetic tests is relatively broad and the number of mutations or variants tested differs substantially. Also the number of examinations carried out in individual laboratories varies. Data presented in the tables come from the year 2004 and indicate the number of examinations requested and number of positive results. Many laboratories mentioned in the registry CZDDNAL (http://www.uhkt.cz/lab_a_vysetreni/nr lab_dna_diag/dna_lab_db) perform the same tests but there is also a great number of tests carried out by only one laboratory. Reasons of the request, cost-effectiveness and clinical utility of genetic testing is being discussed.