Bouveret syndrome / Bouveret-szindróma.

Összefoglaló. A Bouveret-szindróma egy bilioenteralis fistulán keresztül a vékonybélbe - az esetek 85%-ában a duodenumba - jutó nagy epeko okozta bélelzáródást jelenti. Leggyakrabban idos nok körében fordul elo. Jelen közleményünk célja e kórkép tüneteinek, diagnosztikájának és terápiás lehetoségeinek ismertetése egy esetbemutatás kapcsán. A 79 éves nobeteg felvételi hasi panaszainak hátterében típusos gyomorkimenet-obstrukciós szindrómát okozó, a duodenumban beékelodött epeko, Bouveret-szindróma igazolódott. A diagnózist az elvégzett natív hasi röntgen és hasi ultrahangvizsgálatok már felvetették, de megerosítésére további képalkotó vizsgálatot (hasi CT) és endoszkópos beavatkozást végeztünk. Ezt követoen sebészeti beavatkozás történt, melynek során a cholecystoduodenalis fistula zárása és az epeko eltávolítása után a beteg gyógyultan távozott. Közleményünkben a diagnózisfelállítás idejének fontosságáról, illetve a terápiás lehetoségekrol számolunk be, valamint szeretnénk felhívni a figyelmet az epeko okozta gyomorürülési zavar ezen ritka formájára. Orv Hetil. 2021; 162(49): 1982-1986. Summary. Bouveret syndrome is a rare form of bowel obstruction resulting to the small intestine - in 85% of the cases to the duodenum - caused by a gallstone from a bilioenteral fistula. It occurs most commonly in elderly women. The aim of the present study is to describe the symptoms, diagnostic and therapeutic options of Bouveret syndrome due to our case report. The background of epigastric pain of the 79-year-old woman was the typical gastric outlet obstruction syndrome caused by Bouveret syndrome with an impacted gallstone into the duodenum. This diagnosis was suggested by abdominal X-ray and abdominal ultrasound; however, it was confirmed with abdominal computer tomography and upper gastrointestinal endoscopy. This was followed by surgical intervention to close the cholecystoduodenal fistula and remove the gallstone, finally the cured patient was discharged. In our study, we summarize the importance of timely diagnosis and therapeutic options, respectively, furthermore, draw attention to this rare form of gallstone-caused gastric outlet obstruction syndrome. Orv Hetil. 2021; 162(49): 1982-1986.

Predictive and prognostic value of FDG-PET/CT imaging and different response evaluation criteria after primary systemic therapy of breast cancer.

OBJECTIVES: (1) To predict pathological complete remission (pCR) and survival after primary systemic therapy (PST) in patients diagnosed with breast cancer by using two different PET/CT based scores: a simplified PERCIST-based PET/CT score (Method 1) and a combined PET/CT score supplemented with the morphological results of the RECIST system (Method 2) and (2) to assess the effect of different breast carcinoma subtypes on tumor response and its evaluation. METHODS: Eighty-eight patients were enrolled in the study who underwent PET/CT imaging before and after PST. PET/CTs were evaluated by changes in maximum Standardized Uptake Value (SUVmax) and tumor size. Method 1 and 2 were applied to predict pathological complete remission (pCR). Kaplan-Meier analyses for survival were performed. Classification into biological subtypes was performed based on the pre-therapeutic tumor characteristics. RESULTS: A total of 30/88 patients showed pCR (34.1 %). Comparing pCR/non-pCR patient groups, significant differences were detected by changes in SUVmax (p < 0.001) and tumor size (p < 0.001) regarding the primary breast lesions. To predict pCR, Method 2 had higher sensitivity (72.4 % vs. 44.8 %) and negative predictive value (57.9 % vs. 45.8 %) with lower false negativity rate (16 vs. 32) than Method 1. pCR rate was higher in Her2-positive and triple negative tumors. Despite the significant differences detected between the biological subtypes regarding changes in primary tumor SUVmax (p = 0.007) and size (p = 0.015), the subtypes only had significant impact on response evaluation with Method 2 and not with Method 1. In our study, neither clinical nor pathological CR were predictors of longer progression-free survival. CONCLUSIONS: Our results suggest that combined PET/CT criteria are more predictive of pCR. The effect of biological subtypes is significant on pCR rate as well as on the changes in FDG-uptake and morphological tumor response. Response evaluation with combined criteria was also able to reflect the differences between the biological behavior of breast tumor subtypes.

Morphological and pathological response in primary systemic therapy of patients with breast cancer and the prediction of disease free survival: a single center observational study.

AIM: To identify breast cancer subtypes likely to respond to primary systemic therapy (PST or neoadjuvant therapy) and to assess the accuracy of physical examination (PE) and breast ultrasonography (US) in evaluating and predicting residual size of breast carcinoma following PST. METHODS: 116 patients who received at least two cycles of PST between 1998 and 2009 were selected from a prospectively collected clinical database. Radiological assessment was done by mammography and US. Prior to PST, tumors were subclassified according to core biopsy (NCB) and/or fine-needle aspiration-based immunohistochemical profiles of NCB. Pathological response rates were assessed following the surgeries by using Chevallier classification. Tumor measurements by PE and US were obtained before and after PST. Different clinical measurements were compared with histological findings. Disease-free survival (DFS) was assessed. RESULTS: Pathological complete remission (pCR=Chevallier I/II) was observed in 25 patients (21.5%), 44% of whom had triple negative histology, 28% Her2 positive and 76% had high-grade tumor. Of 116 patients, 24 received taxane-based PST, 48 combined taxane + anthracycline treatment, 8 trastuzumab combinations, 21 anthracycline-based treatments, and 15 other treatments. In the taxane treated group, the pCR rate was 30%, in the taxane + anthracycline group 25%, in the anthracycline group 9.5%, and in trastuzumab group 37.5%. After PST, PE and US were both significantly associated with pathology (P<0.001 and P=0.004, respectively). Concerning OS, significant difference was observed between the Chevallier III and IV group (P=0.031) in favor of Chevallier III group. In the pCR group, fewer events were observed during the follow-up period. CONCLUSIONS: Our results show that even limited, routinely used immunohistochemical profiling of tumors can predict the likelihood of pCR to PST: patients with triple negative and Her2-positive cancers are more likely to achieve pCR to PST. Also, PE is better correlated with pathological findings than US.

Complexity of Response Evaluation During Primary Systemic Therapy of Breast Cancer: Scoring Systems and Beyond-Preliminary Results.

BACKGROUND: Precise and standardized response evaluation enables clinicians to tailor primary systemic therapy (PST). PATIENTS AND METHODS: Breast cancer patients underwent (18)F-fluoro-deoxy-glucose positron emission tomography and computerized tomography (FDG-PET/CT) before and after PST. Response was assessed by maximal Standardized Uptake Value (SUVmax); morphological changes and Ki-67 labeling index (LI). In parallel response assessment was performed by European Organization for Research and Treatment of Cancer (EORTC); PET Response Criteria in Solid Tumors (PERCIST); World Health Organization (WHO); Response Evaluation Criteria in Solid Tumors (RECIST); Chevallier and Sataloff classifications, and by a novel Ki-67 score. Accuracy of different scoring systems was evaluated. RESULTS: In the 42 enrolled patients, SUVmax, size, and Ki-67 LI decreased significantly on PST. Significant differences between patients with versus those without pathological complete response were observed for pre-treatment Ki-67 LI and SUVmax and for post-treatment Ki-67 LI, SUVmax and size. Change in Ki-67 LI was the best predictor of pathological complete response. Correlation patterns of the directly measured metabolic, morphological, and proliferation responses differed from those determined by scoring methods. CONCLUSION: During PST, FDG-PET/CT enables for robust assessment of treatment efficacy, but more reliable scoring systems are still needed for more precise response evaluation.

Primary systemic therapy for breast cancer: Does the patient's involvement in decision-making create a new future?

OBJECTIVE: Primary systemic therapy (PST) followed by surgery is the standard initial treatment for locally advanced breast cancer (LABC). However, some patients are averse to mastectomy or breast-conserving surgery and do not consent to these procedures. The reasons for this controversial decision, the factors influencing the decision-making and optimal solutions for decision aiding need to be investigated. METHODS: We addressed these questions by a review of literature on the possibilities associated with different patient choices and subsequent treatment options in relation to LABC. RESULTS: A total of 5 reviews and 22 clinical studies were summarized in relation to decision making and the most successful decision aids. A discussion is given of the issues of those few patients who cannot be convinced to undergo surgery. CONCLUSION: Currently there is no guideline for the treatment of patients who reject the surgical procedures after PST. Medical oncologists should be able to apply decision aid modalities in a personalized manner to give all needed information to their patients thereby ensuring a deliberate decision-making process, facilitating acceptance of a need for surgery, and thus improving the chances of prolonged survival. PRACTICE IMPLICATIONS: Currently multidisciplinary tumor boards are the most suitable decision aids in oncological practice.

[The role of FDG-PET-CT in the evaluation of primary systemic therapy in breast cancer: links between metabolic and pathological remission]. / Az FDG-PET-CT szerepe az emlorák primer szisztémás kezelése során: a metabolikus változások és a patológiai remisszió összefüggései.

INTRODUCTION: FDG-PET-CT is highly sensitive in detection of viable tumour tissue, giving an importance for that in oncological diagnostics. AIM: The authors analysed retrospectively the relationship between metabolic response and changes in Ki-67, a proliferation marker. METHODS: Staging FDG-PET-CT scans (before and after therapy) SUVs (Standardized Uptake Value), and morphological changes in the primary tumour and axillary lymph node region were evaluated in 30 patients with breast cancer. Calculated ΔSUV were compared with Ki-67 proliferation marker (measured in biopsies and surgical specimens). RESULTS: The decrease of SUV and size were significant in the primary tumour and the axillary lymph node region. Decrease of Ki-67 was significant. Significant correlation was found between Ki-67 and SUV before therapy, initial Ki-67 and ΔSUV, and ΔKi-67 and ΔSUV. CONCLUSIONS: The metabolic changes were more sensitive in the measurement of the therapeutic response than morphological remission, and they correlated well with the pathological response, in not standardized clinical conditions even.

[Treatment of pregnancy associated breast cancer]. / A várandósság alatti emlorák kezelése.

Pregnancy-associated breast cancer (PABC) is defined as cancer of the breast diagnosed during pregnancy and up to 1 year postpartum. The crude incidence is 1/3000 pregnant women. As women delay childbearing the incidence of PABC increases with age. Young patients with PABC do not have worse prognosis compared with those with non-PABC; however, pregnancy can contribute to a delay in breast cancer diagnosis, evaluation, and treatment. Primary care physicians and gynecologists should be careful in the thorough workup of breast symptoms in the pregnant population to expedite diagnosis and allow multidisciplinary treatment as early as possible following the established diagnosis. Authors report a case of a 30-year-old pregnant woman, who detected inflammatory signs of her right breast and a palpable axillary mass at the 21st week of gestation. Her symptoms did not improve with administration of antibiotics. Therefore fine needle aspiration biopsy of the axillary lump was performed, with the result of unequivocal diagnosis of metastatic invasive carcinoma. The patient was referred to the multidisciplinary tumor board of our Department at the 27st week of gestation with the symptoms of inflammatory breast cancer, palpable right axillary and supraclavicular lymph nodes. Core biopsy showed an ER and PR negative, Her-2 positive, grade 3, infiltrating ductal carcinoma of the breast. After multidisciplinary team consultation the patient declined any kind of therapy during her pregnancy. On the 30th week of gestation caesarean section was performed. The premature baby girl was treated in the Neonatal Intensive Care Unit. Imaging modalities revealed no evidence of distant metastases short after the delivery. After 6 cycles of chemotherapy (docetaxel-doxorubicin-cycclophosphamid) the patient underwent right mastectomy and axillary lymph node dissection. Complete pathological response was diagnosed, since no residual tumor was found in the surgical resection specimen. After radiotherapy, trastuzumab medication was initiated. To date, there is no evidence of local recurrence or distant metastases during her 24 months follow-up. The newborn is on close neurohabilitation follow-up due to the evidence of generalized muscle dystonia. Had the patient accepted chemotherapy, the damage of the newborn baby would have been avoidable.