Surgical management of giant skin tumor - A case report.

INTRODUCTION: Malignant non-melanoma skin cancers (NMSC) are of two main types: basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). In rare occasions, some of the malignant skin lesions show histopathological characteristics of both BCC and SCC and are known as basosquamous carcinomas (BSC). In some cases of large tumors, extensive reconstructive surgery might be needed to correct the skin defect after the primary excision. PRESENTATION OF CASE: We report a case of a 76-year-old Bulgarian male patient who presented with a neglected giant cutaneous tumor with more than a 15-year history of a growing mass in the right deltoid area. On physical exam an enormous exophytic ulcerated and crusted skin lesion measuring around 11×11cm was found. Wide local excision of the lesion with 10-mm resection margins and partial resection of the underlying deltoid muscle were performed due to signs of infiltration. A full-thickness total skin graft from the left inguinal area was harvested to cover the skin defect. Final histopathological examination showed metatypical carcinoma with mixed characteristics of SCC and BCC - BSC, with infiltration of the fatty tissue, deltoid muscle and clear margins of resection, staged as T4R0. Two and a half years after surgery there are no signs of upper arm motor dysfunction and no evidence of local recurrence and distant metastasis on a follow-up PET/CT. DISCUSSION: Following current National Comprehensive Cancer Network's guidelines for primary treatment of BCC, surgical candidates should undergo standard excision with wider surgical margins, postoperative margin assessment and second intention healing, linear repair, or skin graft. Therapeutic strategy for non-operable cases includes administration of radiotherapy or system therapy in the face of Hedgehog pathway inhibitors and programmed cell death protein 1 inhibitor. They can provide an alternative solution to unresectable or difficult-to-treat locally advanced cases of BSC. CONCLUSION: Similarly to BCC and SCC, the first-line treatment option for BCS is surgical excision, but surgical margins should be wider than those for low-risk BCC due to the infiltrative growth pattern of this tumor. Favorable esthetic outcome requires precise planning of the reconstructive technique.

Macroscopic and microscopic fluorescence spectroscopy of colorectal benign and malignant lesions - diagnostically important features.

Fluorescence spectroscopy is a sensitive, fast and non-invasive tool for a diagnostics of cancerous gastrointestinal lesions. It could be applied for in situ detection of tumours during primary endoscopic observations or as add-on measurement modality during microscopic observations of tissue histology slides for their initial or retrospective diagnosis. Therefore, we are looking for diagnostically important features of normal and cancerous tissue areas in a broad spectral range for gastrointestinal tissues ex vivo using two steady-state macroscopic fluorescent spectroscopic modalities and by confocal fluorescent microscopic detection. Results obtained from autofluorescence spectroscopy of benign and malignant lower part gastrointestinal tract (GIT) lesions from freshly excised tissues during surgical removal of the lesions in 18 patients (22 lesions), were compared with the spectral measurements obtained during confocal fluorescent microscopy observations of unstained tissue slides using 405 nm excitation. Excitation-emission matrices (EEMs) were used for ex vivo measurements with applied excitation in 280-440 nm spectral region and emission observed between 300 and 700 nm. Synchronous fluorescence spectroscopy (SFS) approach was also applied to improve the spectral resolution of the observed complex emission spectra. Specific fluorescent features observed, related to presence of structural proteins, co-enzymes and endogenous porphyrins in the tissues investigated, allow discriminating normal mucosa from benign polyps and malignant carcinoma lesions with diagnostic accuracy up to 94.4%.

Endorectal power Doppler ultrasonography is a reliable method for evaluation of rectal cancer angiogenesis.

OBJECTIVE: We aimed to assess the preoperative rectal cancer angiogenesis with Endorectal Power Doppler Ultrasonography by using the Power Doppler Vascularity Index (PDVI) calculated by imaging analysis software, and to compare it with the microvessel density (MVD) in surgical specimens PATIENTS AND METHODS: This study included 110 patients (39 females; mean age 61.5 years) with rectal cancer. Immunohistochemical staining of surgical specimens with anti-CD-31 antibody was used for MVD evaluation. The PDVI of each tumor was calculated using Endorectal Power Doppler with computer-assisted quantification of colour pixels. RESULTS: Mean MVD - 163 ± 69 microvessels/mm2 (50-328) was used as a cutoff point, differentiating two groups of tumors with high (> 160 mm2) and low (≤ 160 mm2) angiogenic activity. Mean PDVI of 8.9 ± 6.0% (0-27.3) was used as a cutoff point, dividing two groups of tumors with high (> 8%) and low (≤ 8%) PDVI. The MVD and the PDVI showed a good positive correlation (r = 0.438, p = 0.002). Patients with low PDVI had 25 months longer overall survival (p < 0.05) than patients with high PDVI. Patients with low MVD had 36 months longer survival (p < 0.05). CONCLUSIONS: Endorectal Power Doppler Ultrasonography is a reliable and noninvasive method for assessment of the extent of rectal cancer angiogenesis. Tumor angiogenesis assessed by the PDVI correlated with histological MVD determination and could predict survival rates. Endorectal Power Doppler examination is a useful and reproducible method for in vivo preoperative quantitative assessment of tumor vascularization.

[Firs Case Report of Intraoperative Radiotherapy (IORT) for Early Breast Cancer in Bulgaria].

The intraoperative radiotherapy (IORT) is an innovative method for treatment of breast cancer, which can be used as a substitute of postoperative external beam radiotherapy )EBRT), or boost treatment to EBRT (1). Radiobiological advantages of IORT compared to EBRT are higher relative biologic effectiveness of low-dose radiation therapy and the presence of high dose in the tumor bed (where the possibility of remaining vital tumor cells is the highest), as this dose reduces rapidly with the distance from the applicator (2). Important feature of IORT alone is that it can be applied as a single fraction during the surgical intervention and spares 3 to 5 weeks of following radiation therapy. This means less time spent in hospital for the patients and for the radiotherapeutical units - reduced waiting lists and more machine time for other patients. Prolonged operative time as well as the need of additional staff are assumed as relative flaws of IORT (3). The INTRABEAM® system (Carl Zeiss Surgical Gmbh, Oberkochen, Germany) uses a single high dose of low-energy X-rays (mas 50kV), applied to the tumor bed immediately after the surgical excision of the tumor. These rays have high degree of absorption and low penetrating ability. This determines their advantage in comparison to EBRT to protect the surrounding healthy tissues (2). The data from the Targeted Intraoperative radioTherapy (TARGIT-A) and the Intraoperative radiotherapy versus external radiotherapy for early breast cancer (ELIOT): a randomized controlled equivalence trial show that when following the recommendations of The Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) Breast Cancer Working Group (2009) for an accelerated partial breast irradiation (APBI), IORT can be used as an equivalent of the postoperative radiotherapy (1,4,5,6). The purpose of this article is to show the results of the performed on 15 December 2015 for the first time in Bulgaria breast conserving surgery with intraoperative radiotherapy on a patient with early breast cancer.

EPIDEMIOLOGICAL REGISTRY OF NEUROENDOCRINE TUMORS IN BULGARIA--A PILOT SURVEY.

The National registry of patients with neuroendocrine tumors (NET) in Bulgaria was established in 2013 as a joint initiative of the Bulgarian Surgical Society and the Institute for Rare Diseases. The register aims to explore the epidemiology of NET in Bulgaria, as well as the different diagnostic and treatment approaches for the disease throughout the country. This the first of its kind retrospective study of NET in the country is covering the period January 2012 - January 2013. A total of 127 patients with NET were identified. At the time of the survey the average age of patients with NET was 58.61 ± 15.59 years. The data show almost equal distribution between the genders with a slight predominance of women. The largest relative part of NET is those of NET located in the gastrointestinal tract (54.10 ± 4.51%), followed by those located in the pancreas (12.30 ± 2.97%) and in the lungs (10.66 ± 2.79%). In 72.44 ± 3.96% of the patients a immunohistochemical diagnosis was performed. The study confirmed the leading role of the surgery method of the NET management. In 65.83 ± 4.33% of the patients a radical removal of the tumor was conducted, while the relative part of the undertaken partial resection was 7.50 ± 2.40%. A statistically significant association between the type of surgical treatment and during the follow-up of patients was found. An update of the information in the register will allow a more precise determining of the distribution and management of NET in Bulgaria.

Mucinous cystic neoplasm of the liver with low grade dysplasia of the liver.

Mucinous cystic neoplasm (MCN) with low grade dysplasia of the liver is rare. It had been previously called hepatobiliary cystadenoma and is seen almost exclusively in women without an associated invasive carcinoma. There are different theories for development of MCN of the liver. One of these is developing from endodermal immature stroma or primary yolk cells implanted during embryogenesis. Another theory refers to the prevalence of hepatic mucinous cystic neoplasm in segment IV, which may support an implant origin because hamartomatous lesions commonly develop in segment IV. The third theory concerns the expression of oestrogen receptor or progesterone receptor in ovarian-like stroma, which also supports a putative role for female hormones in the tumorogenesis. MCN of the liver is a cystic-forming epithelial neoplasm, usually showing no communication with the bile ducts, composed of cuboidal to columnar, variably mucin-producing epithelium, associated with ovarian-type subepithelial stroma. We present a case of MCN with low grade dysplasia of the liver in a young woman whose working surgical diagnosis was Echinococcus cyst. The MCN diagnosis was confirmed with Immunohistochemical study.

[Pseudomyxoma peritonei--a case report].

Pseudomyxoma peritonei is a rare condition consisting of mucinous ascites, most commonly arising from mucinous tumors of the appendix and occasionally from the ovary. Ronnett et al. have suggested a classification based on tumor pathology where they place all pseudomyxoma peritonei in three groups in order of decreasing prognosis: disseminated peritoneal adenomucinosis (DPAM), peritoneal mucinous carcinoma with intermediate or discordant features (PMCA) and peritoneal mucinous carcinoma (PMCA). Treatments are now standardized as a combination of cytoreductive surgery and perioperative intraperitoneal chemotherapy.

[Papillary and cystic tumor of pancreas--Frantz's tumor]. / Papilaren i kistichen tumor na pankreasa--tumor na Frantz.

The aim of the authors is to introduce one rare known pathology which the Frantz's tumor is, his clinical characteristic, clinical signs, diagnostic and treatment. We have observed two separate cases of this illness in Clinic of Surgery (University Hospital "Queen Yoanna") in comparison with evidence of famous world surgeons. We have made an attempt to introduce one disease, which even though not often observed is significant by the fact that affect young women (girls) and only surgical resection is a treatment of choice.

[Surgical treatment of complicated gastrointestinal forms of non-Hodgkin lymphomas]. / Khirurgichno lechenie na uslozhnenite gastrointestinalni lokalizatsii na non-Hodgkin limfom.

Authors represent their experience in surgical treatment of gastrointestinal forms of No-Hodgkin's lymphomas (NHL) combined with adjuvant therapy. We also represent an Ann Arbor Staging System and an Updated Kiel Classification. From 1991 to 2001 we analyzed 39 patients with different localization of gastro-intestinal NHL's lymphomas. In this aspect more common are stomach's lymphomas--27 patients (71%); small bowel's lymphomas--3 patients (8%); more uncommon are the localizations in colon--3 patients (8%), predominantly in caecum and right colon; rectum--3 patients (5%). Add to thus we described one mechanical icterus caused lymphoma, one multi-lobular spleen lymphoma and one case of anterior abdominal wall lymphoma. All patients underwent surgery. Eight of them were operated as an emergency cases. Operative treatment of NHL isn't radical but in combination with adjuvant therapy can be life saving event in complicated forms.

[The pathomorphology of complicated colorectal cancer and the stages in the development of the tumor process]. / Patomorfologiia na uslozhneniia kolo-rektalen rak i stadii na razvitie na tumorniia protses.

A comprehensive pathomorphological assessment is done in 385 patients presenting complicated colorectal carcinoma, covering the period 1990 through 1995. The patients are distributed in 4 groups according to stage, with those in stage III being the most numerous--141 cases. The growth pattern of the neoplasm is as follows: exophytic growth--110 cases, ulcerous growth--57, cup-like growth--13, and endophytic growth--205 cases. On establishing metastatic lymph nodes within I and II lymph collectors, prophylactic postoperative chemo- and immunotherapy are undertaken. In case of lymph nodes present in III lymph collector, the operation is taken to be relatively radical, and for that reason chemo- and immunotherapy assume a therapeutic character.

[The intraoperative determination of intestinal vitality with a fluorescent indicator]. / Intraoperativno opredeliane na chreven vitalitet s fluorestsenten indikator.

Intestinal obstruction due to strangulation is induced in dogs under experimental conditions, with intestinal wall vitality assessment done on the ground of standard clinical criteria, using fluorescence dye and UV rays, as well as histological study. Sensitivity, specificity and prognostic value of each of the methods employed are determined. The fluorescence method advantages are recorded, and the prospects of its clinical implementation are estimated.

[The importance of histological verification in the conservative surgery of breast cancer]. / Znachenie na khistologichnata verifikatsiia pri konservativna khirurgiia na raka na mlechnata zhleza.

The place and significance of the histological verification in the team method of approach in case of conservative breast cancer treatment are discussed. An accent is made on the histological risk factors increasing the recurrence appearance probability that gathers such patients in a high risk group. On the basis of our own material representing breast cancer patients treated in the period 1987-1993 the significance of the histological verification in the treatment approach is estimated. Requirements for comprehensive histological verification being much needed for breast cancer patients are risen for the pathohistologists.

[The systematization of APUD tumors]. / Kum sistematizatsiiata na APUD-tumorite.

The mechanisms involved in neuroendocrine transmission of peptides, underlying the so-called classification of multiple endocrine neoplasms (MEN), are described. Three cases from the clinical practice are followed up where facilitation of the diagnosis and the results of treatment are related to the tumor markers' values.

[Plasmacytomas of the upper respiratory tract]. / Plazmotsitomi na gornite dikhatelni putishta.

Nine cases of plasmocytoma of the upper airways in the current biopsy material are studied over a three-year period (1991-1993). Initially, all nine cases are clinically diagnosed as neoplasms: hemangiofibroma--one, chondrosarcoma--one, suspected carcinoma--five, and unspecified diagnosis--two. "Plasmocytoma" diagnosis is made on the ground of histological investigation of the material, supported histochemically and electron-microscopically. Some diagnostic problems (differential diagnosis inclusive) are discussed, as well as issues relating to the clinical and morphological evolution of the disease, and predilected gender and age groups.