Multidisciplinary Approach in Comorbid Patients

Introduction: Comorbidity is very common among patients with cancer and it is a real challenge to be treated. Multidisciplinary team (MDT) meetings are defined as a model for managing cancer in comorbid patients. The importance of communication between different specialists correlates with the effectiveness of the treatment and survival rate of patients.Materials and Methods: The records of all patients were evaluated retrospectively. The preoperative evaluation for all patients included physical examination, laboratory tests, X-ray, ECG, echocardiography, and computed tomography.Results: Our study presents 9 patients diagnosed with tumors, involving more than one organ and compressing adjacent organs. MDT approach was performed in all of them at the Department of Cardiac Surgery at the St. Marina University Hospital, Varna. Five of the patients were diagnosed with renal cell carcinoma, and one with papillary renal cell carcinoma. In one, a mediastinal cyst was found, another patient was diagnosed with mediastinal malignant carcinoid. One patients had a solitary fibrous tumor localized in right chest. In 8 of them median sternotomy was performed, in 1- mini-sternotomy, in 1- thoracotomy, in 1- bispinal transverse laparotomy, in 3 of them upper midline laparotomy with right transverse incision was performed; in 1- transverse right incision. The MDT meetings in 6 patients included a urologist, a vascular and a cardiac surgeon. In 3 other patients, the MDT approach involved a cardiac and a thoracic surgeon. All of the patients except one survived and were discharged. Resection of the tumor gives an opportunity for better results from target therapy.Conclusion: Treatment in every patient and each disease is individual. The goal in carcinoma patients is to increase the therapeutic and surgical benefit and improve the quality of the patient`s life. Multidisciplinary approach in patients with this comorbidity is a necessary and effective treatment of choice

INFLAMMATORY MYOFIBROBLASTIC TUMOUR OF THE KIDNEYS - CASE REPORT

Introduction: Inflammatory myofibroblastic tumour (IMT) is a rare condition which includes proliferation of myofibroblasts accompanied with inflammatory infiltrates. It is known to have a wide age range and to affect both males and females. Although its most common site is the lungs, IMT also has extrapulmonary locations which most often include the bladder and rarely the kidneys. Its biological nature varies from a completely benign to a malignant tumour with fatal outcome.Material and Methods: We report a case of a 61-year-old woman, admitted to a hospital with high temperature and anaemia, five months after left nephrectomy due to a myofibroblastic tumour of the kidney. The performed laboratory tests revealed a significant impairment of the GFR and anaemic syndrome. The conducted MRI-scan found multiple hypodense lesions in the right kidney with enlarged paraaortical lymph nodes. PET-scan and CT-scan confirmed the findings. The results of the examinations illustrated a slow progressive chronic failure of the solitary kidney, which suggested a paraneoplastic process due to recurrence of the IMT.Results: Because of the high CRP rates, the patient underwent an antibiotic therapy with Meropenem, without any clinical and laboratory improvement and deterioration of the signs of inflammation. The findings of hypodense lesions and chronic failure combined with the contraindication of nephrectomy, because of a solitary kidney, suggested the admission of Prednisolone, as this type of tumour is cortisol-sensitive. In connection with the glucocorticoids usage, the patient is scheduled for bone density test. She remains under constant observation.Conclusions: The case presents an uncommon occurrence of inflammatory myofibroblastic tumour with the kidneys as a site of progression. It illustrates the recurrent nature of this type of neoplasm and the complications that it brings, according to the organs, which affects

EXPERIMENTAL MODEL OF SUBCLINICAL VITAMIN K DEFICIENCY: ADAPTATION OF THE STUDY OF OSTEOCALCIN

Introduction: Vitamin K (VK), comprising VK1 and VK2, is involved in the post-translational gamma glutamyl-carboxylation of VK dependent proteins (Gla-proteins). The VK dependent factors of coagulation are carboxylated in the liver with the participation of VK1. Other Gla-proteins, among which osteocalcin, are dependent on the extrahepatic pool of VK2. To study the physiological functions of osteocalcin, we utilized warfarin as a VK antagonist to impair the carboxylation of osteocalcin, based on the original method of Price et al. (1994). An added suitable dose of VK1 was supposed to prevent bleeding, yet allowing the effect of warfarin on osteocalcin.Materials and Methods: To establish the necessary doses of drugs, we conducted two consecutive experiments each including 20 male Wistar, divided into a control and an experimental group. Initially, the experimental rats were treated with high dose subcutaneous warfarin with simultaneous administration of VK1 by gavage. Because of hemorrhages that developed in some rats, the dose of warfarin was reduced after the first week and the dose of VK1 was increased. Six rats out of ten survived at the end of the 4 weeks of treatment. In the second 4 weeks of the experiment it was confirmed that the selected doses were well-tolerated. Subsequently, plasma levels of uncarboxylated (ucOC) and carboxylated (cOC) osteocalcin were determined using ELISA kits.Results: As expected, the levels of cOC in the experimental group were significantly lower and those of ucOC were about ten times higher compared to the control group. With the doses of warfarin and VK1 thus determined, we were able to selectively inhibit the carboxylation of osteocalcin by VK2, while avoiding the risk of bleeding.Conclusion: The model of subclinical VK deficiency can be useful as a tool to study the physiological roles of Gla proteins and particularly of osteocalcin