[Benefits of the classical approach in surgery for pulmonary metastases]. / Prednosti klasického operacního prístupu v chirurgické lécbe plicních metastáz.

INTRODUCTION: Distant metastases remain a significant problem in the treatment of malignancies. Surgical management of pulmonary metastases is considered valuable from the oncological view only on condition that R0 resection can be achieved. The whole spectrum of resection procedures can be used, however most commonly, extraanatomic lung resections are employed. It has not been fully evaluated whether the same efficacy can be obtained with thoracoscopic procedures. AIM OF THE STUDY: The aim was to compare the study complication rates with literature data. The secondary aim was to evaluate the benefit of intraoperative lung palpation examination. MATERIAL AND METHODS: The authors present a retrospective study in a group of subjects operated for secondary pulmonary malignancies in the Motol Charles University 2nd Medical Faculty and Faculty Hospital Surgical Clinic, from 2003 to 2007. The authors compared the patient group's morbidity and 30-day mortality rates with literature data. Preoperative CT findings, intraoperative palpation findings and histological examination findings were assessed. RESULTS: Postoperative morbidity of the operated subjects was 16.5%, postoperative 30-day mortality was 0%. The authors compared the preoperative diagnostic data based on CT, the intraoperative findings and histological findings. During the total of 77 surgical procedures, including open and VATS procedures, the authors performed intraoperative palpation examination and detected 60 foci (24.6% out of the total removed foci) previously undetected on CT. All of the foci were of less than 5mm and in 55 cases, the foci were proved metastases. CONCLUSION: The outcome data showing low postoperative morbidity rates and nul 30-day mortality have confirmed that pulmonary metastasectomy is a safe method, a part of the complex oncological management. A surgeon's palpation finding is considered unsubstitutable in the detection of all lung foci and for necessary orientation in order to identify the safety margin in wedge resections. Therefore, the authors prefer the open or videoassissted approach to purely miniinvasive procedures.

Free latissimus dorsi muscle flap for chronic bronchopleural fistula.

The author presents experience with the treatment of chronic bronchopleural fistula in a patient who suffered a gunshot injury to his right chest. During the primary assessment the patient underwent resection of two lobes of the right lung, and the patient healed without complications. Four years later the patient presented with bronchopleural fistula with empyema. We had to proceed with right sided pneumonectomy and close up the fistula. The fistula recurred, and the patient underwent repeated operations by chest surgeons without success. Finally, the situation was solved by a contralateral latissimus dorsi muscle free flap. The free-flap was wrapped around the bronchial stump, and the muscle also filled the chest cavity. We discuss the post-surgical course and present the final result.

[Bronchoplastic surgery for non small-cell lung cancer]. / Bronchoplastické operace pro nemalobunecný plicní karcinom.

Bronchoplastic surgery enlarge the spectrum of standardlung resections as a treatment of non-small cell lung career with preserved oncological radicality. The aim of our study is to assess, based on our own experience with 39 patients that underwent this kind of surgery, the results in terms of post-operative morbidity and mortality, to point out the risks of complication linked with this kind of resection and to define the factors suitable to minimize these risks. Very good immediate as well as long-term results place the bronchoplastic surgery to the same level of importance to standard lung resections. In case of the convenient localization of the central tumors, there is an indication for all patients regardless of the respiratory function parameters.

[Treatment of benign stenoses of the large airways at the Faculty Hospital Praha-Motol during 1998-2003]. / Lécba benigních stenóz velkých dýchacích cest ve Fakultní nemocnici Praha-Motol v letech 1998-2003.

The authors present diagnostic and therapeutical results in the group of 80 patients with benign stenoses of large airways, who were hospitalized at the TRN ward (Department of TB and respiratory disorders) of the Faculty hospital Motol in Prague between the years 1998-2003. 62 patients sufferred from stenoses in cosequence of their tracheal intubation or tracheostomy. In 18 cases the stenoses resulted from other disorders or pathological condidtions (Wegener's granulomatosis, status post lung transplantation, etc.) 38 patients were sent for surgery. Up until the date of the assessment (September 2003), 8 of them had had a relaps of the condiditon. 6 operated subjects had their restenosis corected using bronchological methods, 2 subjects had to undergo reoperation, which is 5.2% of the total number of the operated subjects. The remaining 42 patients were treated using the interventional bronchological methods (electrocauther, laser, stents) which proved curative in 35 patients, i.e 44% of the whole group. In 7 inoperable patients the above methods failed, 6 of them having a permanent tracheostomy and one female-patient exited 2 days after an incomplete recanalization. In the subgroup of 18 patients with other than postintubation stenoses, stent operations were the most frequent (12 times), 4 patients were cured using other methods of interventional bronchology, and resection of the stenosis was indicated in two cases. Up until the date of the assessment, 65 subjects had survived and 15 exited. 5 of them died 3-14 months (median of 4 months) following the surgical procedure of other disorders than of the respiratory airways stenoses. 10 unoperated patients, with a single exception, also died due to other causes than the tracheobroncheal lesions (the survival rate median was 9 months). Following the initial freeing of the airways, the authors call for considering a surgical therapeutical option in each case. Provided the surgical approach was contraindicated, the interventional bronchological methods would replace it appropriately.

Sentinel node biopsy in gastric cancer: preliminary results.

BACKGROUND: Extent of lymphadenectomy in gastric cancer is one of the still unresolved and ongoing questions. Whether extensive procedures lead to better survival remains controversial. The detection of sentinel node could become a helpful method to define the desirable extent of lymph node dissection for each particular patient. MATERIAL AND METHODS: Prospective, single-centre, clinical trial. Sentinel node is identified using vital blue dye. After performance of D2 lymphadenectomy, the pathologist minutely investigates all lymphatic nodes by histological and immunohistochemistry techniques. RESULTS: During a period of 36 months, an attempt to localise the sentinel node for biopsy was made in 22 patients. The successful rate of sentinel node detection with a good relation between metastatic involvement of the sentinel node and other nodes was 56% (13 out of 22 patients). All these patients suffered from small tumours and early stage of the disease. In large tumours and advanced stages, blue dye stained the tissue around the tumour diffusely rendering the identification of true sentinel node impossible. Fresh frozen section of the sentinel node resulted in two patients in a false negative outcome because of micrometastatic involvement. CONCLUSIONS: Sentinel node biopsy in gastric cancer using vital staining is a feasible method. Reliable results were seen in early stage of the disease. Fresh frozen section of sentinel node has probably a low sensitivity for detection of micrometastases.

[Lymphadenectomy in gastric carcinoma--present status, new trends and personal experience]. / Lymfadenektomie u karcinomu zaludku--soucasný stav, nové trendy, vlastní zkusenosti.

The only hope for long time survival in gastric cancer is radical surgery with complete tumour removal. Lymphadenectomy as a part of surgical procedure helps to remove tumour completely. The value of lymphadenectomy for staging is clear and surgeons have no doubt about it. Therapeutic effect of lymphadenectomy with improvement of the prognosis remains uncertain. In this work we would like to discuss current trends in lymphadenectomy in gastric cancer, especially evaluating the value and extent of the procedure.

[Surgical treatment of bronchogenic carcinoma 1970-2001]. / Operacní lécba bronchogenního karcinomu v letech 1970-2001.

BACKGROUND: Lung cancer (LC) is a permanent medical and social problem. 5709 patients died in the year 2000 of this disease in Czech Republic. Its incidence in men is 100/100,000 and it shows only small trend to decrease. In women the incidence has reached 22/100,000 and is still rising. The ratio males/females in the whole country is 4:1, in pulmonary department of University hospital Motol is close to 2:1. The optimal way of treatment is a surgery. METHODS AND RESULTS: From the data about diagnostics and operability in Pneumological Clinic of the 1st Medical Faculty of the Charles University (former 2nd Clinic of Tuberculosis and Respiratory Diseases) and from adequate data obtained from the Pulmonary department of University hospital Motol we can see that the number of operated patients increased from 20% in 1970 to 28% in 2001. When compared two set of patients operated in the period 1985-1990 and 1998-2001 we learned the change of the ratio males/females (from 17:1 to 2:1), lower number of pneumonectomies (from 34% to 31%), lower number of exploratory thoracotomies (from 13% to 5%), decrease of perioperative mortality from 10% do 2%. The percentage of correct clinical when compared to pathological TNM staging was similar in both periods (55% in the period 1985-1990 and 53% in the period 1998-2001). In the article we describe also results of diagnostics, induction and adjuvant treatment and possibilities of the increase of operability of the patients with lung cancer. CONCLUSIONS: The authors think that despite some improvements in several parameters, the 5-year survival of patients with lung cancer is in our country and the whole world still unsatisfactory. We recommend the revision of current attitude to the screening of lung cancer and we recommend joining the running European-American trials of screening of such patients with the help of low-dose spiral CT.

[Benign stenoses of the large respiratory airways]. / Benigní stenózy velkých dechových cest.

BACKGROUND: Benign stenoses of main respiratory pathways develop usually in patients after intubation or tracheostomy. Incidence of such states is not known, they are frequently diagnosed too late, and there are different views of their treatment. In order to contribute to the improvement of our knowledge of this serious impairment we followed prospectively all patients with this diagnose at our department since March 1998. METHODS AND RESULTS: The group of 31 patients with benign stenoses of non-tumorous origin diagnosed and treated at the TRN of the Teaching Hospital Motol in years 1998 to 2000 consisted of 24 males and 7 females, age median was 52 years. Stenosis was caused in 27 patients by intubation, in 4 patients by some other causes. At admission we performed in 30 patients electrocauterization and dilatation of stenosis, one patient was immediately indicated for surgery. Beside two cases we always achieved sufficient patency of stenosis and weighted indication to surgery. We sent for surgery 15 patients, 10 patients were permanently healed using methods of interventional bronchoscopy, including introduction of stent in 6 cases. From the remaining 6 patients, two of them are planned for resection of stenosis, four are inoperable from various reasons, and two died of causes not related to stenosis. CONCLUSIONS: Based on our experience we recommend as an optimal management of such patients is the dilatation or removal of stenosis and then always to consider resection of trachea. In inoperable cases methods of interventional bronchoscopy should be used. Authors recommend sending all patients intubated longer than 2 days for bronchoscopic examination in interval of 2 months.

[Occlusion of a post-pneumonectomy bronchopleural fistula using the Dumon stent]. / Okluze bronchopleurální pístele po pneumonektomii s vyuzitím DUMON stentu.

A postoperative bronchiopleural fistula associated with empyema of the chest is a serious complication in thoracic surgery, in particular when it develops after pneumonectomy. Some patients are in a condition which threatens their life and rules out extensive surgical interventions. Immediate thoracic drainage, thoracoscopic revision and sanation of the empyema cavity and endoscopic closure of the fistula are in indicated cases a therapeutic alternative of open surgical procedures. The justification of these miniinvasive procedures is confirmed by the submitted case-record of a successfully cured fistula associated with empyema of the chest after pneumonectomy. At the same time, based on assembled experience, the authors draw attention to the possible use of a stent.

[Importance of parenchymal-sparing operations in the treatment of bronchogenic carcinoma]. / Význam "parenchym setrících operací" v lécbe bronchogenního karcinomu.

Parenchyma-sparing operations or bronchoplastic operations are an important surgical technique in the surgical treatment of centrally located bronchogenic carcinoma. At present they are used in indicated cases also in patients without restricted pulmonary functions who are able to undergo pneumonectomy. For the patient bronchoplastic operations involve a smaller surgical stress as compared with pneumonectomy and a lower postoperative mortality and morbidity. Comparison of the two surgical techniques and the immediate results are presented by the authors. They fully confirm the conclusions of many other authors from abroad who prefer, in order to reduce postoperative complications, parenchyma-sparing operations to pneumonectomy regardless of functional respiratory parameters. Large groups provide evidence of at least a comparable period of survival in these operations as compared with pneumonectomies, and moreover a better quality of life.

[Radical treatment of a primitive neuroectodermal tumor of the thoracic wall]. / Radikální resení primitivního neuroektodermálního tumoru hrudní steny.

Primitive neuroectodermal tumours are one of the histological types of soft tissue sarcomas. Although the maximum incidence of these tumours is at a relatively young age, they may be encountered also after the fifth decade. As apparent from the submitted case-record, their clinical and histological diagnosis can be relatively difficult. Treatment is extremely pretentious and the only hope for the patient is radical surgery. After an extensive resection of the thoracic wall the authors decided to replace it by an allograft. The excellent functional and cosmetic results and the relatively long period without signs of a relapse are evidence that the selected procedure was justified.

CD5 is A potential selecting ligand for B-cell surface immunoglobulin: a possible role in maintenance and selective expansion of normal and malignant B cells.

Although the function of CD5 on B cells is unknown, previous studies suggested that CD5 interaction with V(H) framework regions of surface immunoglobulins (Igs) may contribute to survival and expansion of B cells. Here we used B-chronic lymphocytic leukemia (B-CLL) cells and transformed B-cell lines from normal and B-CLL patients to study CD5-Ig interactions. Immobilized Ig binds and permits isolation of CD5 from lysates of CD5-expressing cell lines. Immunoglobulins or Fab fragments of different V(H) families varied in their effectiveness as inhibitors of anti-CD5 staining of CLL cells, appendix and tonsil tissue sections. Human Ig also binds to purified recombinant CD5. We show here for the first time that the unconventional Ig-CD5 interaction maps to the extracellular CD5-D2 domain whereas conventional epitopes recognized by anti-CD5 antibodies are localized in the D1 domain of CD5. We propose that interactions of VH framework regions with CD5 as a ligand may maintain, select or expand normal, autoimmune or transformed B cells and also contribute to skewing of the normal V(H) repertoire.

[Chylothorax--a rare type of pleural effusion. Case report]. / Chylotorax--vzácný typ pleurálního výpotku. Kazuistika.

Chylothorax is a rare type of pleural exudate. The diagnosis, assessment of etiology, reflections on the type of treatment, as well as treatment are associated with various pitfalls. The authors present the case-history of a patient with spontaneous chylothorax on the right who was successfully treated by surgery after possible ways of conservative treatment were exhausted. Surgical treatment involved severing and ligature of the thoracic duct.

[The role of Czech physicians in the etiology, clinical aspects and epidemiology of exanthematous typhus]. / Podiel ceských lekárov na poznaní etiológie, kliniky a epidemiológie skvrnitého týfu.

Typhus fever was a lethal disease of mankind. Elucidation of its origin and spread was due to more or less unscientific approaches at the time. Only in the second half of the 19th and at the beginning of the 20th century the period of a scientific approach to knowledge of its etiology, clinical aspects and epidemiology started. A great contribution was made in this respect by Czech doctors. The latter included Professor Hlava who made a series of experiments which were among the first which investigated the etiology of this disease. He may be therefore quite rightly included among one of the discoverers of the origin of typhus fever.

B-cell superantigens may play a role in B-cell development and selection in the young rabbit appendix.

In order to develop protective antibodies against a wide range of potentially infectious pathogens, the young rabbit must diversify a limited initial repertoire by somatic mechanisms (the high copy number primary repertoire). The majority of rabbit B cells produce heavy chain variable regions by rearranging the VHa allotype-encoding VH1 gene. Thus in normal rabbits the majority of serum immunoglobulins bear VHa allotype (due to VH1 FR1 and FR3 sequences). The young rabbit appendix is a site of diversification of rearranged VH genes by gene-conversion-like and somatic hypermutation mechanisms. The newly generated B cells probably undergo selection processes that involve foreign and self-antigens and superantigens. We find preferential expansion and survival of B cells in normal and VH-mutant ali/ali rabbits based on their heavy chain FR1 and FR3 sequences (VHa allotype). This selection may involve "superantigen"-like interactions with endogenous as well as exogenous ligands.

Rabbit appendix: a site of development and selection of the B cell repertoire.

As early as 1963, it was proposed that the rabbit appendix was a homologue of the chicken bursa of Fabricius (ARCHER et al. 1963). The finding that the young rabbit appendix was thymus independent contributed to the concept of central primary lymphoid tissue. Today we know that appendix is a site that generates the high copy number primary repertoire through diversification of rearranged VH genes by gene conversion-like and somatic hypermutation mechanisms. Thus the appendix of young rabbits functions as a mammalian bursal equivalent. In the appendix, newly generated B cells also undergo selection processes involving self and foreign antigens and superantigens. Preferential expansion and survival of B cells in normal and mutant ali rabbits based on FR1 and FR3 expression may involve "superantigen"-like interactions with endogenous and exogenous ligands. One endogenous ligand appears to be CD5. Additional ligands may be produced by gut flora. Further studies in the rabbit model are needed to determine the fates of emigrants from primary GALT, their sites of postulated self-renewal in the periphery, and the nature of secondary diversification in secondary germinal centers where populations of B lymphocyte memory cells may develop. These data may also be helpful in understanding how the repertoire of human B cells is formed and how this repertoire might be manipulated for clinical benefit.

RAG1 and RAG2 in developing rabbit appendix subpopulations.

The appendix of young rabbits is a site of primary heavy chain variable region-gene diversification and B cell selection. Appendix cells from 6- to 9-wk-old rabbits were stained and sorted for surface CD43 and IgM. We found that the CD43+IgM- and double-negative CD43-IgM- cells contained RAG1 transcripts and RAG2 protein. The presence of RAG gene products in appendix raised the possibility that pro-/pre-B cells were present in young rabbit appendix. Although an early suggestion that RAG2 plays a role in variable region-gene diversification by gene conversion in chicken bursa was not supported by studies of RAG2 protein in this tissue, we produced anti-rabbit RAG2 Abs to determine whether RAG2 protein was present in rabbit appendix, where cells that recently underwent gene conversion are found. We detected RAG2 protein in the four subpopulations of rabbit appendix lymphocytes, distinguished by surface CD43 and IgM markers. The appearance of RAG gene products during different stages of B cell maturation may reflect the function of the young rabbit appendix as a site of both B cell development and diversification.