Acupuncture from the perspective of evidence-based medicine - options of clinical use based on National Comprehensive Cancer Network (NCCN) guidelines.

BACKGROUND: Acupuncture is one of the oldest therapeutic methods. The traditional view of acupuncture is represented by influencing energy pathways through stimulation of specific points. The original meridian theory, which works with the assumption of normalization of the flowing energy Qi in the organism is, with increasing evidence, supplemented with information about the bio-logical impact of the use of acupuncture from the perspective of Western medicine. Specific stimulation of particular points on the body leads to the activation of hypothalamus and pituitary gland through neurotransmitters, resulting in a wide range of systemic effects. Stimulation of nerves in the muscle, which then trans-mits a signal to the spinal cord, midbrain, and hypothalamic-pituitary system, releases neurotransmitters, endogenous opioid peptides, or hormones. Stimulation of acupuncture points changes the levels of proinflammatory cytokines, including IL-1-beta, IL-6, IL-17, and TNF-alpha. Currently, according to the National Comprehensive Cancer Network (NCCN) guidelines, the following symptoms are indicated for acupuncture treatment: pain including neuropathic pain, arthralgia, and myalgia, especially in the aromatase inhibitors therapy, nausea, and vomiting, fatigue, vasomotor symptoms in women and vasomotor symptoms in men caused by androgen deprivation therapy. Acupuncture seems to be an effective and safe treatment method for many of the cancer symptoms or the side effects of cancer treatment, but, like any other treatment method, it has its indications and contraindications. PURPOSE: This work aims to provide a comprehensive overview of the use of acupuncture in defined indications, according to current international guidelines. Thus, the therapeutic possibilities of symptomatic treatment of cancer and therapy of adverse events of oncological treatment can be extended.

Anisocoria as a side effect of paclitaxel treatment.

BACKGROUND: Paclitaxel is one of the most common cytostatics used in oncology; it is part of the therapeutic protocols of many malignancies. One of its most common side effects is peripheral neuropathy. This symptomatology often leads to a reduction in the dose intensity of chemotherapeutic drugs or to early discontinuation of the treatment. CASE: In our case report, we describe a rare case of paclitaxel-induced anisocoria in a young woman with breast cancer. CONCLUSION: Ocular side effects related to taxanes are rare, with an estimated frequency of about 1%. In addition to relatively frequent obstruction of the nasolacrimal duct, the cystoid macular edema or ischemic retinopathy have been reported. However, in most cases paclitaxel-induced ocular side effects, there is no need to reduce or discontinue therapy. However, the collaboration of an oncologist with an experienced and trained ophthalmologist is essential.

[Kombinovaná lécba mekkotkánového sarkomu v oblasti pánve]. / Kombinovaná lécba mekkotkánového sarkomu v oblasti pánve.

Soft tissue sarcomas (STS) constitute a heterogeneous group of rare malignant tumors of mesenchymal cell origin and they may develop in any part of the body. They can form enormous masses in certain localizations. A case report of a young woman with locally advanced liposarcoma in the pelvic cavity is presented. This example emphasizes the significance of early diagnosis, as only radical surgery can be potentially curative in sarcoma therapy.Key words: advanced pelvic sarcoma multimodal treatment multidisciplinary.

[Extraoseus Ewings Sarcoma, Primary Affection of Uterine Cervix--Case Report]. / Extraoseální Ewinguv sarkom, primární postizení delozního cípku--kazuistika.

BACKGROUND: Ewing's sarcoma is usually diagnosed in adolescents and young adults, peak of incidence is around 15 years of age. Primary localization is mostly in the skeleton of long bones and chest wall. Primary extraosseous involvement rarely occurs, incidence increases with age. CASE: We present a case report of a 57-year-old patient with locally advanced tumors of the cervix, clinical stage IIB. Due to histological and molecular genetic examination revealing EWS -ERG fusion gene, Ewing's sarcoma was diagnosed. CT revealed pathological pelvic lymphadenopathy and multiple pulmonary bilateral methastases, scintigraphy did not prove any affection of skeleton. The patient underwent a two-stage intensive chemotherapy regimens VIDE (vincristine, ifosfamide, doxorubicin, etoposide) and VAI (vincristine, actinomycin D, ifosfamide). During the second phase, concomitant radiotherapy of pelvis was aplied. According to PET/CT, complete remission was achieved. Whole-lung irradiation was applied in consolidation of the result. CONCLUSION: Primary Ewing's sarcoma of the cervix is an extremely rare disease. To our knowledge, only 12 cases was presented until this time. The average age at time of dia-gnosis was 35 years. Unlike the previous reports, we initially diagnosed distant metastases. The treatment was led according to the protocol Ewing 2008 designed for primary skeletal Ewing's sarcoma. Currently, 18 months after the therapy, the patient is without signs of disease. However, long-term follow-up is necessary.

[Anticoagulation and Thrombembolism During Bevacizumab Treatment--To Be Careful or Fearful?]. / Antikoagulacní lécba a trombembolizmus pri lécbe bevacizumabem--opatrnost, ci obavy?

Inhibition of angiogenesis is a valid approach in today's medicine. Besides oncology, it is used in ophthalmology, as well. In oncology, angiogenesis inhibition has become a routine and accessible method. A combination of angiogenesis inhibition and other therapies, including anticoagulation and antiaggregation is common in many cases. Bevacizumab is the most used antiangiogenic agent and has been in use for the longest period of time. A concomitant administration of angiogenesis inhibitors and anticoagulation may be feared by oncologists. From the available literature it is obvious that concomitant administration of bevacizumab and anticoagulation is safe. Also, use of antiaggregation and bevacizumab is safe. The risk of venous and arterial thromboembolism is real during the treatment with bevacizumab. Therefore, concomitant anticoagulation is not only possible but also may be desirable.

[The current approach to the treatment of the patients with metastatic colorectal cancer]. / Soucasný prístup k lécbe pacientu s metastatickým kolorektálním karcinomem.

Colorectal cancer is one of the most common malignant tumors. Despite the constant promotion of prevention remains around 20- 30% of cases dia-gnosed in the metastatic stage and approximately 50- 60% of patients developed the late dissemination. In 80- 90% of them we can find already unresectable metastases. Although surgical treatment is basic modality of therapy, with using mo-dern targeted therapy in combination with chemotherapy we can achieve longterm complete remission in the cases of advanced tumor and we can significantly prolonged the life of patients with this disease now. About 40- 50% patients in advanced stages who underwent metastasectomy survives 5-years and 10year survival rate is up to 25%. When administered systemic treatment median overall survival in these cases reaches around 24 months.

[Malignant melanoma treated with radical chemotherapy, resemblance histology of melanoma to soft tissue sarcomas, case report]. / Maligní melanom lécený intenzivní chemoterapií, podobnost histologického obrazu maligního melanomu a nádoru mekkých tkání, kazuistika pacientky.

BACKGROUND: Malignant melanoma is considered to be highly resistant to chemotherapy, radiotherapy, hormonotherapy and standard immunotherapy (interleukin 2, interferon alpha). Radical surgery in the early stages of the disease is still the most efficient method. Since the development of immunotherapy and targeted therapy, the role of palliative chemotherapy for advanced disease may be changing. CASE: A case report regarding 44-year-old woman with extensive tumor of the pectoral wall with contralateral axillary lymphadenopathy is presented. On the basis of imaging methods, histology and immunohistochemistry, the tumor was defined as a sarcoma. Due to PAX7-FKHR fusion gene positivity, rhabdomyosarcoma was the most probable classification. The patient was treated with radical chemotherapy including iphosphamide, vincristine, actinomycin D and doxorubicin with the effect of partial regression of the tumor. This enabled radical surgery of the chest wall tumor. Pathology proved 70% necrosis of the tumor. A contralateral axillary dissection was performed with a finding of two lymph nodes infiltrated with melanoma. The immunohistochemistry markers S100, HMB-45 and Melan A were positive. This resulted in a reclassification of the chest wall tumor to malignant melanoma. The following PET/CT scan was negative. A massive progression of the disease occurred after 5 months. B-RAF mutation leads to a plan of targeted therapy with vemurafenib. CONCLUSION: The case demonstrates the limits of the sensitivity and specificity of immunohistochemical markers of melanoma and the ability of this tumor to imitate various tumors including soft tissue sarcomas. A rare -PAX7-FKHR fusion gene positivity considered specific for rhabdomyosarcoma was found. An extraordinary response to radical chemotherapy with surgical resection led to an improvement of the quality of life and to a prolonged survival comparable with the effect of new targeted treatment for malignant melanoma.

[Analysis of prognostic factors in osteosarcoma adult patients, a single institution experience]. / Prognostické faktory konvencního osteosarkomu dospelých pacientu

BACKGROUND: The objective of this report was to estimate long-term outcome and prognostic factors in adult patients with high-grade osteosarcoma. The intended therapeutic strategy included preoperative and/or postoperative chemotherapy as well as surgery of all operable lesions. PATIENTS AND METHODS: We reviewed the clinical data of 36 newly diagnosed adult patients (aged 19-82, average 37.5, median 28.5 years) with high-grade osteosarcoma of the trunk or limbs evaluated by a multidisciplinary team and treated between 1999 and 2010 in Brno. Forty-five percent of patients were over thirty, more than 36% over forty. Thirty-one percent of patients had metastasis at the time of diagnosis. Demographic parameters, tumor-related and treatment-related variables included possible prognostic factors and their impact on response, overall survival (OS) and event-free survival (EFS) were analyzed. RESULTS: All the patients were followed up after treatment. Seventy-three percent of patients were poor responders to chemotherapy. Sixteen patients are alive, and twenty patients died. The survival time ranged from 2 to 177 months (average 45 months, median survival 23 months). The 5-year OS of all patients was 52.4%. OS of patients without metastasis was 68.12%, while 2-year OS with metastasis was 26% only. 5-year EFS was 38.7%. Univariate analysis revealed that the prognosis of adult osteosarcoma patients was significantly related to distant metastasis (p = 0.006), surgical stage (p = 0.00582), serum alkaline phosphatase (ALP) level (p = 0.00841) and serum lactatdehydrogenase (LD) level (p = 0.047). The other analyzed prognostic factors including age had no statistically significant influence on outcome of osteosarcoma in adult patients. CONCLUSION: The prognosis of osteosarcoma in adult patients was significantly correlated to surgical stage, distant metastasis, serum ALP and LD.

Bile duct malignancies.

Bile duct malignancies include intrahepatic cholangiocarcinoma (ICC), extrahepatic cholangiocarcinoma (ECC), gall bladder carcinoma (GC) and carcinoma of Vater's ampulla (ampulloma). Bile duct neoplasms are rare tumours with overall poor prognosis. The overall incidence affects up to 12.5 per 100,000 persons in the Czech Republic. The mortality rate has risen recently to 9.5 per 100,000 persons. The incidence and mortality have been remarkably stable over the past 3 decades. The survival rate of patients with these tumours is poor, usually not exceeding 12 months. The diagnostic process is complex, uneasy and usually late. Most cases are diagnosed when unresectable, and palliative treatment is the main approach of medical care for these tumours. The treatment remains very challenging. New approaches have not brought much improvement in this field. Standards of palliative care are lacking and quality of life assessments are surprisingly not common. From the scarce data it seems, however, that multimodal individually tailored treatment can prolong patients'survival and improve the health-related quality of life. The care in specialized centres offers methods of surgery, interventional radiology, clinical oncology and high quality supportive care. These methods are discussed in the article in greater detail. Improvements in this field can be sought in new diagnostic methods and new procedures in surgery and interventional radiology. Understanding the tumour biology on the molecular level could shift the strategy to a more successful one, resulting in more cured patients. Further improvements in palliative care can be sought by defining new targets and new drug development. The lack of patients with bile duct neoplasms has been the limiting factor for any improvements. A new design of larger randomized international multicentric clinical trials with prompt data sharing could help to overcome this major problem. Defining standards of palliative care is a necessity. Addressing health-related quality of life could help to assess the real benefit of palliative treatment.