[Total pelvic exenteration - strategy and extent of surgery]. / Totální pánevní exenterace - strategie a rozsah operacního výkonu.

INTRODUCTION: Pelvic exenteration is an essential part of complex treatment of advanced tumours of the small pelvis. The strategy of surgery is well known and consensual. However, the optimal extent of lymphadenectomy is still under discussion. The aim of this paper is to summarize the strategy of surgery and the extent of lymphadenectomy. METHODS: Review of the literature and retrospective analysis of 63 patients of our cohort, operated on at the Department of Surgery of the First Faculty of Medicine, Charles University and Thomayer Hospital between 1999-2015. CONCLUSION: The paper describes indications for pelvic exenteration, the strategy of surgery and the necessary extent of lymphadenectomy.

[Quality of life after extensive pelvic surgery]. / Kvalita zivota po extenzivních pánevních operacích.

INTRODUCTION: Multiorgan resections in the small pelvis are standard procedures in oncosurgery and some indications have no alternative. In advanced pelvic cancer, pelvic exenteration with en bloc resection of the involved organs and structures, including portions of the bony pelvis, is indicated. The 5-year survival rate is fairly good, around 50%, but little is known about the long-term quality of life. The aim was to describe the quality of life of long-term total pelvic exenteration survivors. METHOD: In total, 63 pelvic exenterations were performed between 2000 to 2015 at the Department of Surgery, Thomayer Hospital, First Faculty of Medicine, Charles University in Prague, mostly for primary or relapsed rectal cancer. In this retrospective cohort study, the quality of life was assessed using the EORTC QLQ-C30 (version 3.0) and the EORTC QLQ-CR29 questionnaires. The completed questionnaires were scored according to EORTC instructions. RESULTS: At the time of this survey, 24 patients after TPE were surviving longer than one year after the surgery. The five-year survival of all patients was 49%, median survival 4.6 years, and median follow-up 15 months. Most of our patients reported a good level of their physical, emotional, cognitive and social functions. Some patients reported a worse body image, and of course a worsening in their sexual life. Regarding symptom-oriented questions, some patients evaluated the necessity of more frequent care of the stomia as slightly problematic; most patients reported impotence (men) or painful sexual intercourse (women). CONCLUSION: Long-term quality of life in survivors of pelvic exenteration for rectal cancer is comparable with reported results following primary rectal cancer resection with the exception of the sexual function. The quality of life gradually improves in the course of weeks to months from the surgery. KEY WORDS: pelvic exenteration quality of life.

[Pelvic exenteration in the treatment of advanced tumours of the small pelvis]. / Pánevní exenterace v lécbe pokrocilých nádoru malé pánve.

INTRODUCTION: Pelvic exenteration is the essential part of complex treatment of advanced urologic, gynaecologic and colorectal tumours of the small pelvis. The aim of this work is to summarize the individual types of pelvic exenteration, their indications, contraindications and long-term results. METHODS: Overview of the current literature and retrospective analysis of our cohort of 37 patients operated on at the Department of Surgery of the First Faculty of Medicine, Charles University, and Thomayer Hospital during the period 1999-2012. CONCLUSION: This work summarizes the classification, indications and types of pelvic exenteration.

[Total pelvic exenteration - strategy of the surgery]. / Totální pelvická exenterace - strategie výkonu.

INTRODUCTION: Total pelvic exenteration (TPE) has a key role in the complex treatment of advanced T4 tumours of the small pelvis, which cannot be radically removed by a less invasive procedure. The aim of this work is to summarize the strategy of TPE, perioperative care of the patients, complications of the intervention and their management. METHODS: Overview of the current literature and the authors experience, based on our own group of 37 patients after TPE performed during the period 1999-2012. CONCLUSION: This article aims to summarize the strategy of TPE, complications and the authors own experience.

Mutation-based detection and monitoring of cell-free tumor DNA in peripheral blood of cancer patients.

Prognosis of solid cancers is generally more favorable if the disease is treated early and efficiently. A key to long cancer survival is in radical surgical therapy directed at the primary tumor followed by early detection of possible progression, with swift application of subsequent therapeutic intervention reducing the risk of disease generalization. The conventional follow-up care is based on regular observation of tumor markers in combination with computed tomography/endoscopic ultrasound/magnetic resonance/positron emission tomography imaging to monitor potential tumor progression. A recent development in methodologies allowing screening for a presence of cell-free DNA (cfDNA) brings a new viable tool in early detection and management of major cancers. It is believed that cfDNA is released from tumors primarily due to necrotization, whereas the origin of nontumorous cfDNA is mostly apoptotic. The process of cfDNA detection starts with proper collection and treatment of blood and isolation and storage of blood plasma. The next important steps include cfDNA extraction from plasma and its detection and/or quantification. To distinguish tumor cfDNA from nontumorous cfDNA, specific somatic DNA mutations, previously localized in the primary tumor tissue, are identified in the extracted cfDNA. Apart from conventional mutation detection approaches, several dedicated techniques have been presented to detect low levels of cfDNA in an excess of nontumorous (nonmutated) DNA, including real-time polymerase chain reaction (PCR), "BEAMing" (beads, emulsion, amplification, and magnetics), and denaturing capillary electrophoresis. Techniques to facilitate the mutant detection, such as mutant-enriched PCR and COLD-PCR (coamplification at lower denaturation temperature PCR), are also applicable. Finally, a number of newly developed miniaturized approaches, such as single-molecule sequencing, are promising for the future.

[Treatment outcomes of colon cancer surgery combined with radical lymphadenectomy]. / Výsledky chirurgické lécby karcinomu tracníku s uplatnením radikální lymfadenektomie.

The authors analyzed a group of 1281 subjects with colorectal cancer operated and followed up in a single institution from I/1992 to VIII/2007. Colon carcinoma patients were assessed separately (C18). Patients with rectal and rectosigmoid tumors are not included in the presentation. A total of 846 patients were operated for colon carcinomas. In 546 subjects, radical R0 resections were achieved. In the R0 group, the male/female ratio is 315/231, age 29-94 years, the mean age of 69 years. The R0 group stratification by TNM classification was: I 17.8%, II 49.6%, III 24.0%, IV 8.1%, TNMx 0.5%. Irrespective of the TNM staging, three-year, five-year and ten-year survival rates were 80%, 71%, and 51%, resp. The median survival time was 9.85 years. Postoperative morality was 5.5%, morbidity 29.8%, anastomic leak occured in 5.7%. Systematic lymph node dissection up to the apical level, had been gradually introduced as an integral part of the R0 surgery. The aim of the study is to analyze outcomes of the colon carcinoma surgical management, combined with radical lymphadenectomy. Furthermore, effects of the extensive procedure on the postoperative morbidity and moratility rates are analyzed as well.

[Colorectal carcinoma as a cause of acute abdominal illness]. / Kolorektální karcinom jako prícina náhlých príhod brisních.

Colorectal carcinoma (KCR) is the commonest malignancy in male patients and the second commonest in female patients in the Czech Republic. During 1990-2006, 1162 patients with colorectal carcinomas were operated in the FTNsP (Faculty Thomayer Hospital) Surgical Clinic. 212 patients aged between 39 to 94 y.o.a.(the median of 70 y.o.a) were managed urgently for acute abdominal illness. In this group of urgently managed patients, the mortality rate was 17% and the morbidity rate was 38%. Future prospects of any colorectal carcinoma patient with acute abdominal illness depend on the procedure's radicality, which is limited by the overall patient's condition. The preoperative care aims to improve the patient's overall condition to such a degree, to allow for surgery fulfilling principles of oncosurgical radicality. According to this report's data, such urgent surgical procedures do not result in increased mortality or morbidity rates, compared to these in planned procedures, and show the best results in this patient group.

Tumor markers in staging and prognosis of colorectal carcinoma.

The precise preoperative staging of colorectal cancer is fundamental for surgical strategy, incomplete staging means incomplete treatment and poor outcome. Large-scale clinical evaluations of predictive markers are currently in progress, including determination of their ability to predict response of patients to therapy for advanced disease and for adjuvant treatment. Lack of specificity and sensitivity preclude the use of all existing serum markers for the early detection of colorectal carcinoma. The aim of the study was to investigate the clinical significance of serum tumor markers and biological activity markers -- oncofetal tumormarker CEA, mucin tumormarkers CA19-9, CA242, proliferative tumor markers Thymidine kinase, soluble cytoceratines fragments TPS, TPA, adhesive molecules ICAM - 1, VCAM -1, IGF-1, and adipocytokinins Adiponectin, Leptin in patients with colorectal cancer before primary operation. The study included 142 patients between the ages of 35 - 89 years. Operated between November 2003 to March 2006. We have confirmed that CA19-9 is besides CEA an important marker in colorectal cancer. Comparing CA19-9 and CA242 in preoperative staging, CA242 is more specific. Statistical significant difference between early and metastatic stage of colorectal cancer was not confirmed in markers: ICAM-1, VCAM, adiponectin, leptin. Statistical significant difference between early and metastatic stage of colorectal cancer was confirmed in markers: CEA, CA19-9, CA242, TPS, TPA, TK, IGF-1. None of the used markers was able to distinguish stage II and III, in other words to identify patients with infiltration of lymph nodes. This fact is very important in our aspirations to find which marker from periferal blood could help to poit out patients in risk of lymphatic infiltration and to indicate these patients for adjuvant therapy. Combination of CEA and either CA19-9 or CA242 can be recommended for preoperative investigation. CA 242 in this study seems to have slightly better results in preoperative staging.

[Surgical management of intrahepatic cholelithiasis--two case reviews]. / Chirurgická lécba intrahepatální cholelitiázy --dve kazuistiky.

INTRODUCTION: Intrahepatic lithiasis (IHL) has a low incidence rate in countries with high social-economical level, with mostly secondary ethiology. The commonest signs include: cholangoitis, obstruction icterus, liver absces and secondary biliary cirrhosis. Although a wide range of treatment methods is available, in some cases, surgical management is the only alternative. METHODS: The authors present two case reviews of IHL patients. The first case includes a 56-year old male, unsuccessfuly operated in another clinic. The patient was referred to the author's clinic for a relaps of septic complications. He underwent extensive revision of his bile ducts up to the segmental bile duct level with a mechanical removal of concrements, introduction of the T-drain and postoperative cholangiography for secondary IHL of the left hepatic duct. A resection procedure was not indicated due to absence of the liver parenchyma impairment. The other patient, a 77-year old male, underwent left lateral bisegmentectomy for a primary IHL of the SII and SIII liver segments with signs of irreversible bile duct impairment, which could not be managed endoscopically. RESULTS: No complications during the first patient's postoperative course were recorded. A postoperative Day 7 cholangiographic examination detected free intrahepatic bile ducts. The patient has not shown any signs of a IHL relaps. The second patient's postoperative course was complicated by biliary secretion from the drain, which was managed endoscopically. A histological examination confirmed the preoperative diagnosis. CONCLUSION: IHL which cannot be managed by endoscopy or other procedures, is indicated for surgery. The type of the surgical procedure depends on the extent of the intrahepatic bile duct and liver parenchyma impairment.

[Laparoscopic management of epidermoid spleen cyst]. / Laparoskopické resení epidermoidní cysty sleziny--kazuistika.

Spleen cysts are rare in the surgical practice. They may be primary or secondary. Primary cysts (true, with own lining) represent 30-40% of all cysts and occur mostly in children and young adults. Secondary cysts (pseudocysts, with no lining) are more frequent. Primary cysts are mostly asymptomatic and usually occur as accidental findings during ultrasound examinations. Cysts over 50 mm or cysts with clinical symptomatology should be managed surgicaly. Laparoscopy may be used. The authors present laparoscopic management of a spleen epidermoid cyst in a young female.

[Re-laparotomy for complications of urgent abdominal disorders]. / Relaparotomie pro komplikace náhlých príhod brisních.

Urgent abdominal disorders are a daily work routine at surgical departments. Therefore, all surgeons are familiar with the problematics, including all its pitfalls, e.g. high morbidity rates and mortality rates of the patients managed. The authors record urgent abdominal disorders mortality rates as well as rates of serious surgical complications requiring re-operations and their effect on the patients' prognosis. The trial group includes 1861 patients urgently operated during 2001-2004. 36 patients (1.9%) underwent re-laparotomies. Peritonitis in some form (50%), dehiscence of the laparotomy (31.2%), necrosis of the intestine, ileus, bleeding and some less frequent complications, were the most frequent indications for re-laparotomies. The thirty-day mortality rate in patients, operated for urgent abdominal disorders, was 4.8%. In the re-operated group, the mortality rate reached 19.4%.

Clinical relevance of tumor markers for the control of chemotherapy.

This presentation is based on our experience with tumor marker monitoring of surgery therapy and chemotherapy effects. The control of chemotherapy is one of the most important problems in oncological practice. The correlation between the clinical status of the patient and tumor size changes, based on the results of different imaging methods, has been the most important and most frequently used method. However, the therapy effect has been recently assessed by markers of the biological activity of the tumor. Using tumor markers for the assessment of the effect of surgery therapy is already part of routine practice in many different types of cancer. Pre-operative and post-operative values of tumor markers are essential for a proper evaluation. However, tumor marker monitoring of the effect of radiotherapy and chemotherapy has been used very rarely, mostly only for research purposes. Besides monitoring by classical tumor markers, monitoring by markers of angiogenesis and apoptosis seem to be promising for the assessment of chemotherapy effect. Measurement of circulating cancer cells by means of mRNA also seems to be intriguing for therapy effect control and monitoring of the course of disease. Unfortunately, the routine use of these methods has been applied in only a few institutes worldwide. A completely different situation has been observed in palliative treatment. In most cases, changes of serum levels of tumor markers correlate with therapy effect. Thus, the effect of treatment on tumor proliferation can be successfully estimated by decreasing tumor marker levels.

Changes of thymidine kinase (TK) during adjuvant and palliative chemotherapy.

UNLABELLED: Thymidine kinase is involved in nucleic acid synthesis and is, therefore, considered to be an important proliferation tumor marker. For this reason, we monitored this marker in the course of colorectal cancer chemotherapy. MATERIALS AND METHODS: We examined thymidine kinase (TK) levels in 30 patients with colorectal cancer who underwent adjuvant or palliative chemotherapy (CHT schemes). The condition for being included in the study was a minimum of 3 cycles of chemotherapy. TK was always assessed with radio-receptor analysis, before and after every chemotherapy cycle, together with other tumor markers. RESULTS: From the monitored tumor markers, only TK changed typically in the course of chemotherapy. In adjuvant chemotherapy, it was mostly low at the beginning of the cycle and its values usually increased considerably at the end. On the other hand, in palliative chemotherapy the dynamics of TK varied mainly depending on the effect of the therapy. Other tumor markers showed nonstandard behavior and minimal correlation with TK changes. CONCLUSION: Thymidine kinase seems to be a suitable parameter for monitoring the effect of adjuvant and palliative chemotherapy in colorectal cancer.

Markers of cellular adhesion in diagnosis and therapy control of colorectal carcinoma.

AIM: Early diagnosis of the progressive tumor disease and control of the effect of therapy in colorectal carcinoma are most frequently performed by monitoring CEA or CA 19-9 tumor markers. Their clinical application is, however, limited. The aim of our study was to demonstrate the contribution of adhesive molecule assessment to the early diagnosis of progression. We also wanted to find out if changes in the levels of cellular adhesion parameters correlate with the effect of antitumor therapy. MATERIALS AND METHODS: Intercellular cell adhesive molecule-1 (ICAM-1) and Vascular cell adhesive molecule-1 (VCAM-1) were assessed using the ELISA method, and the results were correlated with CEA and CA 19-9 tumor markers. Three hundred and sixty-four patients with colorectal carcinoma in Dukes' stages B-D were monitored. The results were processed with the SAS 6.2. statistical program and Statistica. RESULTS: In 92 patients with first clinical progression (occurrence of distant metastases irrespective of localization), significantly increased ICAM-1 and VCAM-1 values were demonstrated. In ROC evaluation of curves, we also demonstrated high sensitivity of adhesive molecules against both the control healthy group (n =89) and the no evidence of disease group (NED) (n=183). Adhesive molecule levels were closely connected with the type and course of therapy and are presented in the form of case reports. CONCLUSION: Soluble adhesive molecules are a prospective parameter both for the early diagnosis of progression and for control of the effect of therapy. There is a need for a large-scale study, preferably multicentric, which would verify the suitability of introducing cellular adhesion parameter assessment into routine practice.

[Gastrointestinal tract cancer and diabetes mellitus]. / Nádory trávicího traktu a diabetes mellitus.

Risk of development of some gastrointestinal tract cancers (colorectal cancer, pancreas cancer and liver cancer) is higher in type II diabetics. Another important risk factor is obesity (for gall bladder cancer in women and in men also for stomach and esophageal cancer). Pathogenetic factors have been explored especially in colorectal cancer (diet, hyperinsulinaemia, metabolic receptors activation, absence of physical activity). Our Czech study also proved up to 4 times increased risk of colorectal cancer in diabetics and, in accordance with literature, probable influence of persistent diabetes on tumour development. Type II diabetes mellitus should be considered as a risk factor especially for colorectal cancer, liver cancer, and pancreas cancer. In type I diabetics no risk of gastrointestinal tract cancers was proved.