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.

Spiral T1 Spin-Echo for Routine Postcontrast Brain MRI Exams: A Multicenter Multireader Clinical Evaluation.

BACKGROUND AND PURPOSE: Spiral MR imaging has several advantages compared with Cartesian MR imaging that can be leveraged for added clinical value. A multicenter multireader study was designed to compare spiral with standard-of-care Cartesian postcontrast structural brain MR imaging on the basis of relative performance in 10 metrics of image quality, artifact prevalence, and diagnostic benefit. MATERIALS AND METHODS: Seven clinical sites acquired 88 total subjects. For each subject, sites acquired 2 postcontrast MR imaging scans: a spiral 2D T1 spin-echo, and 1 of 4 routine Cartesian 2D T1 spin-echo/TSE scans (fully sampled spin-echo at 3T, 1.5T, partial Fourier, TSE). The spiral acquisition matched the Cartesian scan for scan time, geometry, and contrast. Nine neuroradiologists independently reviewed each subject, with the matching pair of spiral and Cartesian scans compared side-by-side, and scored on 10 image-quality metrics (5-point Likert scale) focused on intracranial assessment. The Wilcoxon signed rank test evaluated relative performance of spiral versus Cartesian, while the Kruskal-Wallis test assessed interprotocol differences. RESULTS: Spiral was superior to Cartesian in 7 of 10 metrics (flow artifact mitigation, SNR, GM/WM contrast, image sharpness, lesion conspicuity, preference for diagnosing abnormal enhancement, and overall intracranial image quality), comparable in 1 of 10 metrics (motion artifacts), and inferior in 2 of 10 metrics (susceptibility artifacts, overall extracranial image quality) related to magnetic susceptibility (P < .05). Interprotocol comparison confirmed relatively higher SNR and GM/WM contrast for partial Fourier and TSE protocol groups, respectively (P < .05). CONCLUSIONS: Spiral 2D T1 spin-echo for routine structural brain MR imaging is feasible in the clinic with conventional scanners and was preferred by neuroradiologists for overall postcontrast intracranial evaluation.

Review: Early life predisposing factors for biting in pigs.

The pig industry faces many animal welfare issues. Among these, biting behaviour has a high incidence. It is indicative of an existing problem in biters and is a source of physical damage and psychological stress for the victims. We categorize this behaviour into aggressive and non-aggressive biting, the latter often being directed towards the tail. This review focusses specifically on predisposing factors in early life, comprising the prenatal and postnatal periods up to weaning, for the expression of aggressive and non-aggressive biting later in life. The influence of personality and coping style has been examined in a few studies. It varies according to these studies and, thus, further evaluation is needed. Regarding the effect of environmental factors, the number of scientific papers is low (less than five papers for most factors). No clear influence of prenatal factors has been identified to date. Aggressive biting is reduced by undernutrition, cross-fostering and socialization before weaning. Non-aggressive biting is increased by undernutrition, social stress due to competition and cross-fostering. These latter three factors are highly dependent on litter size at birth. The use of familiar odours may contribute to reducing biting when pigs are moved from one environment to another by alleviating the level of stress associated with novelty. Even though the current environment in which pigs are expressing biting behaviours is of major importance, the pre-weaning environment should be optimized to reduce the likelihood of this problem.

Lateral root growth in Arabidopsis is controlled by short and long distance signaling through the LRR RLKs XIP1/CEPR1 and CEPR2.

Plants rely on lateral roots to explore their soil environment and to maximize their uptake of essential minerals and water. Here we present evidence that the receptor kinases XIP1/CEPR1 and CEPR2 regulate both the initiation of lateral root primordia and emergence of lateral roots locally in the root, while also controlling lateral root extension in response to shoot-derived sucrose in Arabidopsis plants. In addition, mutation of both of these receptors prevents seedlings from responding to sucrose in the media, resulting in longer lateral roots. These results, combined with previous data, establish XIP1/CEPR1 and CEPR2-dependent roles in short- and long-distance pathways regulating different stages of lateral root growth.

Approaches to assess IgE mediated allergy risks (sensitization and cross-reactivity) from new or modified dietary proteins.

The development and introduction of new dietary protein sources has the potential to improve food supply sustainability. Understanding the potential allergenicity of these new or modified proteins is crucial to ensure protection of public health. Exposure to new proteins may result in de novo sensitization, with or without clinical allergy, or clinical reactions through cross-reactivity. In this paper we review the potential of current methodologies (in silico, in vitro degradation, in vitro IgE binding, animal models and clinical studies) to address these outcomes for risk assessment purposes for new proteins, and especially to identify and characterise the risk of sensitization for IgE mediated allergy from oral exposure. Existing tools and tests are capable of assessing potential crossreactivity. However, there are few possibilities to assess the hazard due to de novo sensitization. The only methods available are in vivo models, but many limitations exist to use them for assessing risk. We conclude that there is a need to understand which criteria adequately define allergenicity for risk assessment purposes, and from these criteria develop a more suitable battery of tests to distinguish between proteins of high and low allergenicity, which can then be applied to assess new proteins with unknown risks.

[CLINICAL IMPLEMENTATION OF CELL-FREE DNA ANALYSIS IN MATERNAL BLOOD IN SCREENING FOR ANEUPLOIDIES IN SINGLETON PREGNANCIES].

OBJECTIVE: Clinical implementation of cell free(cf) DNA testing in maternal blood for aneuploidies in singleton pregnancies. METHODS: This is a retrospective study conducted in two centers for fetal medicine in Sofia, Bulgaria, between October 2013 and August 2015. We examined the clinical implementation of cf DNA testing in the routine practice for trisomies 21, 18 and13 after the performance of the first trimester combined test, second trimester biochemical test and/or the combination between first and second trimester integrated test. RESULTS: Cell-free DNA testing was performed in 170 singleton pregnancies with a median maternal age of 35 (range 22-46) years. The primary risk assessment for aneuploidies was derived from 95 cases after the first trimester combined screening test, 39 cases after the second trimester biochemical screening test, 16 cases after the integrated screening test and 20 cases there were no screening test performed. The results from the first line screening test were : 8 pregnancies with risk for trisomy 21 > 1: 100; 23 pregnancies with risk for trisomy 21 from 1:100 to 1: 300; 43 pregnancies with risk for trisomy 21 from 1:300 to 1:1000 and 76 pregnancies with risk for trisomy 21 < 1: 1000. No pregnancies with high risk for T13/T18 were identified. The analysis of cf DNA in the maternal blood reported 3 cases with T21 and no cases with T18 or T13. There was only one case of T21 in the group with risk >1:100 identified by the cf DNA analysis which was also identified by the first trimester combined screening test. The positive results were confirmed with invasive testing: CVS in the first trimester (one case) and Amniocentesis in the second trimester (two cases). CONCLUSION: Clinical implementation of cell-free DNA analysis in the contingent policy for screening could improve the detection rate for T21 and could reduce the rate of invasive procedures.

[LAPAROSCOPIC TREATMENT OF PRIMARY ABDOMINAL PREGNANCY: A CASE REPORT AND REVIEW OF THE LITERATURE].

Abdominal pregnancies are 1.4% of all ectopic pregnancies. They are mostly complicated and usually managed by laparotomy, but laparoscopy is an alternative method which some surgeons perform instead of laparotomy, especially in early pregnancy. We reported a 29 year old woman with supra pubic pain and vaginal bleeding. After sonographic evaluations, ectopic pregnancy was diagnosed and the patient underwent laparoscopic surgery for termination of pregnancy. Laparoscopy is a successful alternative method of surgery for abdominal pregnancies in first trimester.

[Inguinal endometriosis: two case reports and literature review].

Endometriosis is a common gynecological disease that is characterized by the presence of endometrial glands and stroma outside the uterus. Ectopic endometrial tissue can be localized in all organs of the human body, but it affects most often organs in the pelvis. The localization in the inguinal canal is extremely rare - 0.3% -0.6% of all cases of endometriosis. We report two cases of inguinal endometriosis in patients with a history of previous surgery in the pelvis. Both patients is formation in the inguinal region of increasing volume, accompanied by severe pain especially in the premenstrual period. The diagnosis was based on an exact medical history and histological examination. The main methods of treatment of inguinal endometriosis is radical surgical excision of the lesion. We recommend hormone therapy as an adjunct to treatment.

[SUCCESSFUL LAPAROSCOPIC TREATMENT OF HETEROTOPIC PREGNANCY AFTER ICSI / FREEZE EMBRYO TRANSFER - A CASE REPORT.]

The coexistence of extrauterine and intrauterine or haeterotopic pregnancy (HP) is a rare condition with reported incidence of 1 in 8000 to 1 in 30 000 pregnancies in natural conceived pregnancies, but with the widespread application of assisted reproductive technologies (ART) the incidence of HP in women with ART has risen to about 0.09% to 1.00%. We have reported a case of a 36 old woman, pregnant in 9 gestation week, gravidity 2, 0 para, who have achieved a pregnancy after in-vitro fertilization - embryo-transfer of two freeze embryos, developed after an ICSI procedure with donor eggs. The patient attended our clinic because of acute abdominal pain. She was evaluated by trans-vaginal sonography and coexistence of ectopic tubal and intrauterine pregnancy has been confirmed. Emergency laparoscopy was carried out. Left tubal ectopic pregnancy and hemoperitoneum (1200 ml) were diagnosed. Left salpingectomy was performed. At present, the patient is at 24 gestation week and the pregnancy is developing in a proper manner. We report such a case due to the increase of the awareness to the condition and the possibility of a successful treatment by a laparoscopic surgery. Intrauterine pregnancy does not exclude extrauterine pregnancy especially in cases after in-vitro fertilization.

[Ultrasound Examination and Management of Twin Pregnancy.]

Twin pregnancies are found in about 3 % of all pregnancies and 2/3 are dizygotic and 1/3 are monozygotic. In the last 30 years after the introduction of assisted conception and increasing maternal age the rate of twin pregnancies dramatically increased. Compared to singletons, twins have more complications such as intrauterine demise, intrauterine selective fetal growth reStriction, congenital anomalies, miscarriage and preterm labour. Monochorionic twins are at high risk for unique complications because of blood exchange through vascular communications in the shared placenta. Twin pregnancies should be considered as a high risk pregnancies and the well-being of the two fetuses should be taken into account with a strict protocol for follow up and management options. CONCLUSION: Ultrasound examination olavs a maior role in fetal surveillance.

[THE VALUE OF COLPOSCOPY EXAMINATION IN DIAGNOSIS OF PRECANCEROUS AND CANCEROUS DISEASES OF THE CERVIX].

The aim of this study is to present the value of colposcopy examination in diagnosis of precancerous and cancerous diseases of the cenvix. A retrospective study analyze 127 patients at SA GBAL" Dr. Shterev Hospital" that undenNent, firstly cervical smear test and secondly a colposcopic punch biopsy The patients are divided in two groups--one group of cytologically non-signaled patients with results from the Pap test I-II and one group with cytologically -signaled patients with results from the Pap test III-IV The data shows a correlation between the cytological and histological results of the second group and absence of such a correlation in the first group. In the non-signaled group the mild precancerous lesions to Thvasive cen'ical cancer were left undiagnosed. The conduct of a routine colposcopy during preventive gynecological examination will reduce the deficiencies of the cytological method and by amplifying it, it will lead to better results of the diagnosis and treatment of the precanceroses and the cervical cancer.

MHC Class II Binding Prediction by Molecular Docking.

Proteins of the Major Histocompatibility Complex (MHC) bind self and nonself peptide antigens or epitopes within the cell and present them at the cell surface for recognition by T cells. All T-cell epitopes are MHC binders but not all MCH binders are T-cell epitopes. The MHC class II proteins are extremely polymorphic. Polymorphic residues cluster in the peptide-binding region and largely determine the MHC's peptide selectivity. The peptide binding site on MHC class II proteins consist of five binding pockets. Using molecular docking, we have modelled the interactions between peptide and MHC class II proteins from locus DRB1. A combinatorial peptide library was generated by mutation of residues at peptide positions which correspond to binding pockets (so called anchor positions). The binding affinities were assessed using different scoring functions. The normalized scoring functions for each amino acid at each anchor position were used to construct quantitative matrices (QM) for MHC class II binding prediction. Models were validated by external test sets comprising 4540 known binders. Eighty percent of the known binders are identified in the best predicted 15 % of all overlapping peptides, originating from one protein.

[Norms for determination of the physical development of the newborn Bulgarian children in the town of Plovdiv].

In the compound complex of factors, influencing the physical development, a significant role plays the ethnical belonging. The aim of the study is to work out norms for assessment of the physical development of the newborn Bulgarian children. In the period 01.01-01.12.2008 the primary information for the physical development of the newborn 789 children was registered at the Obstetric-Gynecological Clinic of Medical University-Plovdiv. One of the most precise methods for individual assessment--the Method of the percentiles was used. The extent of the excerpt gives a reason to consider that the norms for assessment of height, weight, head and chest measurement of the newborn children with Bulgarian origin are stable and statistically reliable and can be used by the obstetricians and micropediatricians for assessment of the physical development of the children in the next 8-10 years.

[Standards for determining the physical development of newborn children of Roma origin in city of Plovdiv].

In a complex set of factors affecting the physical development plays an important role and ethnicity. Purpose of the study was the development of standards for assessing the physical development of newborn children from the Roma ethnos. The information is registered in the Obstetric Clinic of Medical University Plovdiv and includes 338 newborns Roma children. Norms are made using one of the most accurate methods for individual assessment--method of percentile. The size of the sample gives reason to believe that the norms for evaluation of height, body mass and size of the head and breasts of newborn children of Roma origin are stable and statistically reliable and can be used by gynecologists, micro-pediatricians to assess physical development of children in the next 80-10 years.

[VATS in patients with solitary periferal pulmonary tumors].

UNLABELLED: The patients with periferal solitary pulmonary nodule often present a serious diagnostic and therapeuthic challenge.The aim of our study is to present our experience in VATS for diagnosis and treatment of patients with solitary periferal pulmonary tumors. MATERIAL AND METHODS: For the period of 1997-2009, 146 patients with periferal pulmonary tumors underwent VATS for resection of the tumor. RESULTS: 112 (74.2%) of the patients underwent radical VATS resection of the tumor after intraoperative frozen sections for diagnosis. In the rest 39 cases (25.8%) due to different reasons VATS was converted to open thoracotomy and wedge resection. 54.55% of the resected tumors were malignant and 45.45% of them were benign. In 18 patients the intraoperative frozen sections confirmed primary lung cancer, and the procedure was converted to thoracotomy and radical resection. In 13 patients the results from the intraoperative frozen sections were not definite and we were not able to differ wether the tumor was a pulmonary metastase or a primary lung cancer, and after the final histological examination the patients were submitted to radical resection in interval. In 33 of the cases we resected pulmonary metastases from an extrapulmonary primary tumor. CONCLUSIONS: Despite the advances in diagnostic technics, only the VATS resection of the pulmonary tumor and the histological examination assures definitive diagnosis, it allows the definitive treatment for the benign lesions and indicates the correct treatment for malignant lesions.

[Postoperative survival in patients with inoperable lung cancer].

UNLABELLED: Despite the advances in treatment in the last two decades, the prognosis in lung cancer remains infavourable. Only 20-25% of the patients are suitable for operative treatment. Almost 75% of the patients are inoperable at the time of diagnosis. MATERIAL AND METHODS: We present 148 patients, who underwent non-radical operation for the period 01.01.1997 - 31.12.2005 - 129 men (87.16%) and 19 women (12.84%), age range - 29-65 years (53.67 +/- 0.60). RESULTS: The mean time of survival for the group submitted to radiotherapy is 13.74 months, while for the group without postoperative radiotherapy is 9.31 months. The mean time of survival for the group submitted to chemotherapy is 9.99 months, while for the group without adjuvant chemotherapy is 10.27 months. CONCLUSIONS: The radiotherapy significantly improves the survival in the patients with inoperable lung cancer, while the chemotherapy don't increase the survival.

[Stage of disease as a prognostic factor in radically operated patients with non-small cell lung cancer].

UNLABELLED: Despite the better diagnostic and therapeutic opportunities, lung cancer is still the major cause for cancer mortality. The surgical-pathological TNM-stage is known as the most reliable prognostic factor for survival in patients with lung cancer. MATERIAL AND METHODS: We present 440 patients with non-small cell lung cancer, radically operated in the Clinic of Thoracic and abdominal surgery of University Hospital "St.George" - Plovdiv for the period 01.01.1997 - 01.09.2004 - 378 men (85.91%) and 62 women (14.09%), age range 23-82 years. RESULTS: The mean time of survival according to the stage is as follows: IA - 77 months, IB - 67, IIA - 55, IIB - 42, IIIA - 33 IIIB - 14, IV - 27 months. CONCLUSIONS: The stage of the disease is an important prognostic factor for patients with lung cancer. We found the lowest survival in stage IIIB. For selected patients in stage IV, the operative treatment leads to good results.

[Extent of resection as a prognostic factor in patients with non-small cell lung cancer].

UNLABELLED: Despite the new methods of treatment during the last two decades, prognosis in lung cancer remains unfavourable. Only 20-25% of the patients are suitable for surgery, and the surgical resection is the unique alternative with curable intent. The extent of resection is an important prognostic factor in lung cancer patients. MATERIAL AND METHODS: We present 440 patients with non-small cell lung cancer, radically operated in the Clinic of Thoracic and abdominal surgery of University Hospital "St.George" - Plovdiv for the period 01.01.1997 - 01.09.2004.191 underwent lobectomy, 12 - limited resection, 39 - bilobectomy, and 198 - pneumonectomy. RESULTS: 63 patients underwent lobectomy for stage I, and the 5-year survival was 63.49%. For the 12 patients with limited resection we found mean time of survival of 50 months, and the 5-year survival was 50%.331 of our patients were in stage II and III. 123 of them underwent lobectomy--the 5-year survival was 28.46%. 208 patients underwent bilobectomy and pneumonectomy--the 5-year survival in this group was 17.79%. CONCLUSIONS: In conclusion we found that the extent of resection is an important prognostic factor for lung cancer patients in stage I. The patients submitted to lobectomy have better survival compared with those submitted to limited resection. The survival is better for the group of patients who underwent lobectomy,compared with the one for the group with bilobectomy and pneumonectomy, which is probably due to the earlier stage of the disease.

[Prognostic value of estrogen receptors--ERalpha and ERbeta, in patients with lung cancer].

SUMMARY: There are over 150 prognostic factors in lung cancer, which allow to predict the outcome of the disease.Many molecular factors are known to have independent prognostic significance. At present these factors are not routinely used in the clinical practice, but they may play an important role in the future for precise individual prognosis. MATERIAL AND METHODS: The study included 122 patients with non-small cell lung cancer.Using immunohistochemistry we examined the expression of estrogen receptors--ERalpha and Erbeta. RESULTS: The median time of survival depending on the expression of Eralpha was 31 months, while for Erbeta was 73 months. CONCLUSIONS: Erbeta is a positive prognostic factor in patients with non-small cell lung cancer.

[Prognostic value of the molecular markers ICAM-1 and C-JUN in patients with lung cancer].

UNLABELLED: Many of the clinical and fundamental scientific studies are directed to the investigation of the prognostic factors in patients with lung cancer. Many molecular factors are known to have independent prognostic significance and although these factors are not routinely used in the clinical practice, they may play an important role in the future. MATERIAL AND METHODS: The study included 122 patients with non-small cell lung cancer. We examined the expression of ICAM-1 and C-Jun. RESULTS: The median time of survival for the group with poor expression of C-Jun was 39 months, and 26 months for the group with strong expresssion. The median time of survival for the group with poor expression of ICAM-1 was 51 months and only 9 months for the group with strong expresssion. CONCLUSION: The increased levels of ICAM-1 and C-Jun are negative prognostic factors for the patients with non-small cell lung cancer.