A combination of levobupivacaine and lidocaine for paravertebral block in breast cancer patients undergoing quadrantectomy causes greater hemodynamic oscillations than levobupivacaine alone.

AIM: To test for differences in hemodynamic and analgesic properties in patients with breast cancer undergoing quadrantectomy with paravertebral block (PVB) induced with a solution of either one or two local anesthetics. METHOD: A prospective, single-center, randomized, double-blinded, controlled trial was conducted from June 2014 until September 2015. A total of 85 women with breast cancer were assigned to receive PVB with either 0.5% levobupivacaine (n=42) or 0.5% levobupivacaine with 2% lidocaine (n=43). Hemodynamic variables of interest included intraoperative stroke volume variation (SVV), mean arterial pressure, heart rate, cardiac output, episodes of hypotension, use of crystalloids, and use of inotropes. Analgesic variables of interest were time to block onset, duration of analgesia, and postoperative serial pain assessment using a visual analogue scale. RESULTS: Although the use of 0.5% levobupivacaine with 2% lidocaine solution for PVB decreased the mean time-to-block onset (14 minutes; P<0.001), it also caused significantly higher SVV values over the 60 minutes of monitoring (mean difference: 4.33; P<0.001). Furthermore, the patients who received 0.5% levobupivacaine with 2% lidocaine experienced shorter mean duration of analgesia (105 minutes; P=0.006) and more episodes of hypotension (17.5%; P=0.048) and received more intraoperative crystalloids (mean volume: 550 mL; P<0.001). CONCLUSION: The use of 0.5% levobupivacaine in comparison with 0.5% levobupivacaine with 2% lidocaine solution for PVB had a longer time-to-block onset, but it also reduced hemodynamic disturbances and prolonged the analgesic effect.

Giant Spinal Schwannoma in a 76-year-old Woman--A Case Report.

A schwannoma is a benign nerve sheath tumor composed of Schwann cells. Spinal schwannoma originates from dorsal roots of the spinal cord, causing symptoms due to the compression of neighboring structures. We present a patient with a low back pain and left L2 and L3 radiculopathy. Neuroimaging techniques (CT, MRI) showed a large expansive mass in the left lumbar paraspinal area. The tumor was removed totally by the posterior approach and was verified to originate from the left L2 spinal nerve root. The histopathological examination revealed typical findings of a schwannoma. The pain was resolved promptly after the surgery, however the patient's neurological condition wasn't improved. Surgical treatment was a final treatment, and no additonal therapy was necessary.

Bilateral synchronous breast cancer.

We report a rare case of synchronous bilateral breast cancer in 79-year-old female patient treated at our hospital. The tumors were discovered one year ago after a complete clinical and radiological (mammography, US) examination with cytopunction of tumor masses. Results came back and showed carcinomas of both breasts. Patient underwent surgical re moval of the both breasts with bilateral axillary lymphadenectomy. Later histological examination confirmed earlier diagnosis of invasive ductal carcinoma in both breasts in a G3 stage. After surgical removal of the tumors patient was also treated with radiotherapy. One year after bilateral mastectomy and axillary lymphadenectomy, clinical and radiological examination that included mammography and ultrasound of breast with tumor marker C15-3 which was 2.8, we did not found recurrence of the tumor.

Blunt trauma of thorax with subclavian and axillary artery lesion--case report.

We report a rare case of blunt trauma of the axillary artery in a 20-year-old man who was injured as a motorcycle rider and received severe body injuries. Injuries included severe trauma of the left lower leg with contusion and extensive soft tissue and bone trauma of these regions with poor general condition and with the presence of clinical signs of traumatic shock. Upon arrival, we found that in addition to earlier clearly visible trauma to the leg, there was a hematoma of the medial side of the left supraclavicular region and the absence of the radial artery pulse with paralysis of the left arm. Given the clinical findings, emergency radiological examination was made to the patient (X-ray, US, CDFI, MSCT-angiography) and we found out that there was trauma of axillary artery with clear signs of thrombosis of extra thoracic part of subclavian artery due to its transition into the axillary artery. After hemodynamic stabilization, above knee amputation of the left leg was performed and emergency exploration of earlier mentioned arteries. Bypass of the damaged arteries with synthetic graft 6 mm in diameter was made. Control MSCT angiography showed normal flow in the arterial tree of the whole left hand and the MRI of the cervical spine and shoulder girdle did not found lesions of the brachial plexus. SSEP demonstrated the absence of pulses on the left hand. Patient on regular check-ups showed normal general condition, with adequate passable graft and pronounced paralysis on the left hand. In the process of rehabilitation physiotherapy was also included. Blunt trauma to the axillary artery is an extremely rare example of trauma of blood vessels which makes only 0.03% of all vascular injuries.

Neuroendocrine small cell carcinoma of the breast--a case report.

Neuroendocrine tumors are very rare tumors that occur most commonly in the gastrointestinal tract. The occurrence of neuroendocrine tumors outside gastrointestinal tract is very rare but not unknown. Thus, neuroendocrine tumors and their primary seat can be found in the bronchi and lungs, as well as in the testicles, ovaries, prostate, etc. The occurrence of neuroendocrine tumors as a primary seat in the breast is extremely rare phenomenon that is described in literature. We present the case of 55-year old female in where routine mammographic examination found suspicious lesions that we recommended for further processing. The patient made a breast ultrasound examination in which tumor formation was found in size 27 x 19 mm and cytological puncture found breast adenocarcinoma. Further pathohystologic and immunohistochemical analysis set the diagnosis of neuroendocrine carcinoma, small cell type, second grade. Tumor formation by ultrasound initially sized 27 x 19 mm and pathohistologic diagnosis showed tumor size 26 x 20 x 20 mm. The axillary lymph node biopsy did not found distant metastases in lymph nodes as well as gatherings in other organs. Neuroendocrine small cell carcinomas are exceedingly rare phenomena in the literature. By the year 2009 in the USA there were described only 50 cases of this extremely rare tumor of the breast.

The carcinoid tumour in Meckel's diverticulum: how to treat young adults with appendicitis?--Case report.

This case reports the concomitant and unexpected finding of carcinoid tumour within a Meckel's diverticulum presenting as an acute abdomen due to gangrenous appendicitis in a young adult male. Both Meckel's diverticula and carcinoid tumour are rare clinical entities, and carcinoid tumours occurring within a Meckel's diverticulum are even more uncommon. The initial clinical presentation of carcinoid tumours occurring in a Meckel's diverticulum is usually similar to that of appendicle carcinoids.Carcinoid tumours are the most common primary tumour of the small bowel. They resemble appendicle carcinoids to the extent that they are usually small, single, and asymptomatic. Surgical treatment of Meckel's diverticula is recommended procedure. By presenting this case we wished to stress the value of systematic identification and removal of the diverticulum during laparotomy and to underline the importance of exploration the Meckel's diverticulum particularly in case of young adult subjects.

Hernia of Morgagni--case report.

Morgagni's hernia is result of penetration of the abdominal contents into the chest through an anterior retrocostoxiphoid defect in the anterior midline of the diaphragm. It can be manifested with symptoms since birth as a bloated feeling, nausea and belching after meals. We present a patient with symptomatic herniation of the torqued antral part of stomach and loops of the transverse colon. In our case, chest and abdominal radiography after oral intake of contrast are used to diagnose this condition. Herniation was reduced surgically by a transabdominal approach. At the control examination one year after surgery in our patient all symptoms have disappeared, and was given 15 kg of body weight.