[A new perspective on axillary dissection in situations of metastatic sentinel node]. / Nový pohled na exenteraci axily pri metastáze v sentinelové uzline.

INTRODUCTION: Breast cancer is the most common malignant disease in women and represents a worldwide problem. Up-to-date diagnostics methods, mammography screening and complex treatments have resulted in a substantial reduction of mortality rates. However, the incidence of the disease keeps growing constantly, although in a moderate way. The struggle against this disease has several levels, such as prevention, primary tumour therapy as well as the management of recurrent or generalized disease. Therefore, it is very significant to evaluate the prognosis on the basis of biological characteristics of the tumour and to determine the right individual therapy in each patient. AIM OF THE STUDY: Our aim was to determine a group of patients with malignant breast disease based on biological characteristics of the tumour who can be treated without axillary exenteration even with a metastasis in the sentinel lymph node, thereby reducing the morbidity associated with this surgery, without worsening the prognosis. METHOD: The research project lasted from June 2012 to June 2015. It was a prospective randomized study where the main investigated group consisted of women with primarily surgically treated mammary cancer undergoing sentinel lymph node biopsy (SNB) during their surgery. These patients were divided into three groups: group 1 - positive SNB without axillary exenteration (axillary dissection - AD); group 2 - positive SNB with AD; and group 3 - negative SNB. Group 4 consisted of patients with primarily performed AD. We investigated statistically significant prognostic factors of metastatic lymph nodes and early disease progression. The results were statistically processed and differences between individual groups were evaluated, determining prognostically usable biological characteristics of the tumour in connection with metastases in lymph nodes and progression-free survival. RESULTS: The study included 214 patients with breast cancer. No metastases of axillary lymph nodes were found in 136 patients (64%); on the other hand, 78 patients (36%) had positive axillary lymph nodes and included: 28 (13%) patients with a micrometastasis in the sentinel lymph node; 38 (17%) patients with 13 positive lymph nodes; 8 (4%) patients with 49 positive lymph nodes; and 4 (2%) patients had more than 10 metastatic lymph nodes. A statistically significant difference with respect to metastatic lymph node involvement was found for the tumour size, expression of oestrogen receptors, proliferative activity and grading. CONCLUSION: The following prognostic factors of metastatic lymph nodes and early disease progression were shown to be statistically significant: tumour size over 2 cm, negative expression of oestrogen receptors, tumours with moderate and high proliferative activity, and tumour grades G2 and G3. In the course of the three years of this study, no regional recurrence was found in axillary lymph nodes in any patient, and therefore, it clearly follows that the completion of axillary exenteration can be omitted in the case of tumour sizes below 2 cm, present expression of oestrogen receptors, low proliferative activity and grade 1 even if one or two positive sentinel lymph nodes are present, provided that adjuvant radiation therapy can be used. Also, axillary exenteration is not needed if a micrometastasis or isolated tumour cells are found in the sentinel lymph node.Key words: breast cancer - sentinel lymph node biopsy - axillary exenteration - prognostic factors.

[Avoidance of axillary lymph node dissection in breast cancer patients with metastatic sentinel node - a pilot study]. / Vynechání disekce axily u karcinomu prsu pri pozitivní sentinelové uzline - pilotní studie.

INTRODUCTION: Axillary lymph node dissection (ALND) is a standard procedure for locoregional control in metastatic sentinel lymph nodes (SN). A number of studies have provided evidence that avoiding ALND does not worsen the general prognosis. METHODS: A group of 249 female patients with sentinel lymph node biopsy was analysed retrospectively for a 3-year period. The patients were divided into two groups - with non-metastatic SN and with metastatic SN. In the metastatic SN group, the patients were further divided into a group with ALND and a group without ALND, and additional lymph nodes (non-sentinel) in ALND and oncological treatment were evaluated. The goal was to find out whether ALND and oncological treatment affect the disease-free interval (DFI) and overall survival (OS) in the group of patients with metastatic SN and to compare the results with the control group. The histopathology and biology of the primary tumour, its size and the number of metastatic SN were subsequently evaluated as the factors that may be useful for predicting metastatic non-sentinel lymph node positivity. RESULTS: There was a high risk of metastatic non-sentinel lymph nodes in the cases of metastatic SN (63%). Addition of ALND does not prolong either DFI or DFS without post-operative radiotherapy and systemic oncological treatment, both of which can provide a comparable length of DFI as well as DFS without ALND. Patients with metastatic SN with and without ALND had a DFI of 70 and 72 months, respectively, and a 5-year survival of 84% and 80%, respectively. Tumours over 2 cm, tumours with high proliferative activity and a high grade can be regarded as predictors of metastatic non-sentinel lymph nodes. CONCLUSION: In a small patient group it has been demonstrated that the avoidance of ALND in 1 or 2 metastatic SN, regardless of the prognostic factors, does not affect either DFI or DFS if adjuvant oncological treatment is administered. High-grade tumours, tumours with high proliferative activity and tumours larger than 2 cm carry a significantly higher risk of metastatic non-sentinel lymph nodes. Nowadays, the avoidance of ALND in metastatic SN is not a lege artis procedure; further large studies are needed to create scientific guidelines.Key words: metastatic sentinel lymph node - avoidance of axillary dissection - breast cancer.

[Predictive factors for non-sentinel lymph nodes affection in breast carcinoma--outcomes of a Czech multicenter study of sentinel lymph nodes]. / Prediktivní faktory postizení nonsentinelových uzlin u karcinomu prsu--závery ceské multicentrické studie sentinelových uzlin.

BACKGROUND: The aim of the study was to assess positivity nonsentinel lymph nodes in patients with macro, micro and submicrometastases in sentinel lymph nodes and find predictive factors of positivity nonsentinel lymph nodes. Study was conducted at the Department of Surgery in Pardubice, Pilsen, Ostrava and Zlín. MATERIAL AND METHODS: Sentinel lymph nodes were assessed based on standards of Czech Pathological Society. Detection of sentinel lymph nodes was performed based on radionavigation or combination of radionavigation and blue dye method. RESULTS: In group N1 (macrometastases) there was found positivity of nonsentinel lymph nodes in 50% (45 from 90 patients). In group N1 Mi (micrometastases) there was found positivity of nonsentinel lymph nodes in 26.7% (16 from 60 patients). In group NO I+ (sub-micrometastases) there was found positivity of nonsentinel lymph nodes in 6.7% (1 from 15 patients). Predictive factors were size of metastasis, number of positive sentinel lymph nodes and grading. Size of tumor was not found to be a predictive factor of positivity nonsentinel lymph nodes. DISCUSSION: High positivity of nonsentinel lymph nodes in pacients with macro and micrometastases in sentinel lymph nodes advocates to perform axillary lymph nodes dissection. Due to small number of patients with submicrometastases it is not possible to assess if axillary dissection is necessary or not. Predictive factors of positivity of nonsentinel lymph nodes are size of metastasis in sentinel lymph nodes, number of positive sentinel lymph nodes and grading. Size of tumor was not found to be a predictive factor due to small tumors in the study. In spite of this it is necessary to consider it like a predictive factor of positivity nonsentinel lymph nodes. CONCLUSION: In patients with macro and micrometastases it is necessary to perform axillary dissection. In patients with submicrometastases in sentinel lymph nodes it is necessary to consider predictive factors.

[Caroli disease--dilatation of intrahepatic bile ducts]. / Caroliho nemoc--dilatace intrahepatálních zlucových cest.

Caroli disease is a rare congenital condition characterized by a non-obstructive saccular or fusiform multi-focal segmental dilatation of the intrahepatic bile ducts and the frequent formation of the intrahepatic calculi. It can affect the entire liver with manifestations in the childhood, or only some segments, which may be an asymptomatic condition found accidentally in the adulthood. In other cases, the condition is manifested primarily with tract infections. The authors of the three case reports describe pitafalls of the diagnosis and treatment of the segmental Caroli disease, which is manifested in the adulthood. The treatment was a resection of the affected liver segments.

[Can tumor markers predict outcomes of portal vein branch embolization in patients with primary inoperable liver tumors?]. / Mohou nádorové markery predpovídat výsledek embolizace vetve portální zíly u nemocných s primárne inoperabilním nádorem jater?

INTRODUCTION: Portal vein embolization (PVE) is one of the options to increase the number of resecable cases in patients with primary inoperable liver tumors. However, insufficient growth of liver parenchyma or postoperative tumor progression remains problematic in PVE procedures. Generally, tumor markers are of significance in patient postoperative monitoring for the disease recurrence. The aim of this study is to assess the potential of tumor markers in predicting PVE outcomes. METHOD: The study group included 43 subjects with primary or secondary tumors, in whom serum alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), thymidine kinase (TK), tissue polypetide antigen (TPS) and MonoTotal levels were assessed 28 days following PVE. The liver parenchyma growth or tumor progression were assessed based on computer tomography. RESULTS: Sufficient liver parenchyma hypertrophy was recorded in 27 (62.8 %) patients with subsequent liver resection. Insufficient post-PVE liver parenchyma growth was recorded in 5 (11.6 %) patients and tumor progression was recorded in 11 (25.6 %) subjects. The following tests were considered significant predictive tumor markers of PVE outcomes: serum levels of CEA, TPA, Mono Total prior to PVE, and serum levels of TK, TPA, Mono Total within 28 days following PVE. CONCLUSION: Tumor markers may be significant in predicting PVE outcomes in patients with primary inoperable liver tumors. However, in order to make final conclusions on their clinical significance, larger patient group studies should be performed.

[IGF1 and tumor markers in different breast cancer stages]. / IGF1 a nádorové markery ve stadiích nádoru prsu.

INTRODUCTION: In our work we asked ourselves whether it would be possible to use growth factors for a quick orientation in the clinical status of patients prior to biopsy and histological examination. MATERIAL AND METHODS: Our patient group included 82 patients with breast cancer. Serum samples were collected preoperatively. Histological examination findings were available for each patient. Our set was divided into three groups based on the disease stage. The values of analytes in different tumor stages were statistically evaluated and statistical comparisons of Stage I and II, and then of Stage II and III were performed. RESULTS: Tumor markers CEA, CA 15-3, TK, TPA-M and MonoTotal correlate with the disease severity. Serum levels of the growth factor IGFI negatively correlated with the severity of cancer. There was aa statistically significant increase in the EGF growth factor serum levels between Stage I and II. No statistically significant differences between Stage I vs. II and Stage II vs. III were detected when HGF and VEGF growth factor serum levels were assessed. CONCLUSION: The growth factor EGF is one of the candidates to become a tumor growth marker in early disease stages. The IGFI, HGF and VEGF growth factors can not be used for quick and correct orientation in the clinical condition of patients in the early stages of tumor growth.

[Abdominal aortic aneurysms--long-term treatment results]. / Aneuryzma abdominální aorty--dlouhodobé výsledky lécby.

OBJECTIVE: To evaluate the single center experience in the treatment of patients with AAA. METHODS: 586 patients undergoing open resection (OR) and EVAR (2000-2009). The average age was 72.2 +/- 7.7 years. AAA diameter was 8.3 cm (range 5.0-13.1 cm). 451 (76.9%) patients had asymptomatic AAA, 135 (23.1%) RAAA. 448 patients (76.5%) suffered from various co-morbidities. 430 (73.4 %) OR, 156 (26.6%) EVAR and 52 (8.9%) one staged procedure (for concomitant diseases) was performed. RESULTS: 30 days mortality rate of elective OR and EVAR was 6.2, resp. 2.9% (n.s.) versus 36.6% of RAAA (p < 0.0001). 30 days mortality rate of one staged and single procedure was 19.5, resp. 3.6% (p < 0.0001). 30 days morbidity rate was in the whole group 52.1% (80.7% in RAAA x 43.4% in asymptomatic AAA - p < 0.0001), in one-stage procedures 60.8% x 51.1% in single procedures - n.s., 45.1% in OR x 39.0% in EVAR - n.s. Redo procedures were significantly higher in EVAR x OR in the long-term period after primary procedure. 1-, 3-, 5-, and 8 years survival of patients with asymptomatic AAA and RAAA was 91.6, 85.9, 81.1 and 73.6%, resp. 54.9, 48.9, 45.9 and 43.5 years (p < 0.0001). 1-, 3-, and 5 years patients survival with single versus one staged procedures was 85.5, 80.5 and 71.0% versus 71.1, 68.0 and 74.6% (n.s.). 1-, 3-, and 5- years patients survival after OR or EVAR was 91.2, 87.1 and 80.6%, resp. 90.7, 79.9 and 74.6 % (n.s.). The significant influence on patients long-term survival had RAAA, age of patients, postoperative complications and one stage procedures. CONCLUSION: High percentage of polymorbidity was the cause of the significant 30 days postoperative mortality of patients after OR. EVAR and OR have similar long-term results. One staged procedures should be used very carefully in selected patients due to the higher mortality rate and worse long-term patients survival.

[Liver metastases of other than colorectal origin]. / Jaterní metastázy jiného nez kolorektálního puvodu.

AIM: Colorectal carcinoma is the commonest malignancy with liver metastases. Approximately 25-30% of these metastases are resectable with good long-term outcomes. Liver metastases of so called non-colorectal carcinomas are significantly less common, and considering different biological character of these metastases, compared to colorectal ones, surgical management of some of these types is debatable, however, in some cases remains highly successful. The aim of this study was to assess the authors' outcomes of surgical and termoablation therapy of non-colorectal liver metastases. METHODS: The authors present their experience with surgical treatment in 68 patients - mean age of 58.2 y.o.a (33.1-77.5) with liver metastases of non-colorectal carcinomas- NKJM (the commonest types: breast carcinoma--32.4%, carcinoid--20.6%, renal carcinoma--13.3%, gynecological tumors--13.3%, gastrointestinal stromal tumor--4.4%, gastric carcinoma--4.4% ) during 2001-2008. The mean time after primary surgery for carcinoma was 3.9 years (0-8.5 let). The surgical procedures included the following: radiofrequency ablation (RFA)--50 patients (73.5%), resections in 26.5%. Preoperative chemotherapeutical "downstaging" or portal vein embolization on the tumor side, in order to improve the NKJM resecability, was performed in 10 subjects (14.7%). Resecable or RFA--manageable extrahepatic metastases were removed using one- or more- step procedures in 25 subjects (36.7%). The total number of liver metastases within the whole study group ranged from 1 (28x) to 8 (1x) metastases. Postoperative adjuvant chemotherapy, combined with biological treatment in some patients, was administered to a total of 33 patients (48.5%). RESULTS: One year after the procedure and RFA, a total of 88.6% of patients were surviving, at 3 years 72.5 % and at 5 years 36.9% of the subjects. Considering four commonest tumors (breast carcinoma, carcinoid, gynecological carcinomas and renal carcinoma), the best 5-year survival rates were recorded in patients with carcinoid metastases (100%), 33.8% of patients with breast metastases were surviving at 5 years, 44.4% of patients with renal carcinoma metastases were surviving at 3 years and 72.9% of patients with gynecological tumors were surviving at 2 years. There were no statistically significant differences in long-term survival rates between RFA and resections. Patients with extrahepatic metastases had worse prognosis (p < 0.01). CONCLUSION: Liver resection and RFA have their definite place in multimodal treatment strategy in the management of non- colorectal carcinoma liver metastases (NKJM). Indication for surgery must be made on strictly individual basis, in particular in patients with NKJM, in order to achieve quality long-term survival in these patients.

[Neoplastic thrombosis of the inferior vena cava in kidney carcinoma]. / Nádorový trombus dolní duté zíly u karcinomu ledviny.

INTRODUCTION: Neoplastic thromboses of the inferior vena cava occur in about 4-15% of patients with conventional, clear-cell renal carcinoma, and significantly increase intraoperative mortality and morbidity rates. AIM: Assessment of outcomes of radical nephrectomies with inferior vena cava thrombectomies, performed in the PlzeN Faculty Hospital from 01-01-1999 to 31-12-2008. PATIENT GROUPS AND METHODS: The study included 16 patients, 12 males and 4 females of 63.6 years of age on average (44-75 y.o.a), suffering from conventional, clear-cell renal carcinoma and neoplastic thrombosis of the inferior vena cava. The main symptoms included hematuris in 7 subjects (43.8%), lumbar pressure pain in 4 subjects (25%), leg edema in 2 subjects (12.5%). In 2 patients (12.5%), the finding was accidental and in 1 patient (6.3%), the symptoms were caused by distant metastases. The diagnostic methods included duplex sonography, multidetector computed tomography, magnetic resonance imaging and cavography. In three subjects, the thrombus was located in the renal vein only (grade I), in 9 subjects, the thrombus propagated below the entry of the hepatic veins (grade II), in 3 subjects, the thrombus extended above the entry of the hepatic veins (grade III) and, in 1 patient, it reached the right atrium (grade IV). All the patients underwent transabdominal radical nephrectomy (pT3b,c,pN0-2,pM 0-1) and inferior vena cava thrombectomy. RESULTS: The average duration of IVC closure using vascular clips was 6.3 minutes (3-12 minutes), the average blood loss was 1.7 litres. The intraoperativev mortality rate of the whole study group was 0%. In a single patient, an incompletely removed thrombus resulted in massive pulmonary embolization on day 3, which was urgently managed by cardiosurgery with extracorporeal circulation, when the thrombotic mass was removed from the pulmonary artery. Three subjects (18.8%) died due to generalization of the underlying disease 5-17 months after the primary procedure. Two subjects (12.5%) are currently receiving symptomatic treatment for their generalized underlying disease. 11 subjects (68.8%) show no signs of a relaps of the underlying disease at 3 month-5 years after the procedure. CONCLUSION: Radical nephrectomy combined with complete removal of the neoplastic thrombus provides the best prospects for long-term survival rates of the patients.