Multiple Sclerosis and Cancers in Croatia – A Possible Protective Role of the »Mediterranean Diet«

Multiple sclerosis (MS) is an autoimmune disease triggered by a combination of genetic and environmental risk factors which are however individually insufficient to provoke the disease. Previous investigations studied the coexistence of cancer in MS patients, and only a few relations between the geographic distribution of MS and that of cancer. The aim of this research was to find an environmental link between the aetiology of MS and cancers in Croatia. Incidence and prevalence of MS in Croatia were compared with the incidence of the most frequent cancer sites: stomach cancer, cancer of the colon and the rectum, pancreatic cancer, lung cancer, cancer of the kidneys and brain cancer. Data for MS were collected from seven population-based epidemiologic studies which used Poser’ s diagnostic criteria and reported the number of cases and the magnitude of the studied population. Data for cancers were drawn from the Croatian National Cancer Registry. The analysis was done for single municipalities, grouped in their belonging regions or counties, and separately for the continental and the coastal area. For each rate a 95% confidence interval was calculated. The differences between rates were tested with the chi-square test as well. In addition, MS incidence or prevalence were correlated with the corresponding cancer incidence data. Pearson’s correlation coefficients were used to measure the correlation between both diseases. Calculations were done with the statistical package Statistica V 7.1. and the Smith’s Statistical Package freeware In the continental area of Croatia the mean annual incidence (per 100,000 inhabitants) of MS was nearly two folds higher than in the coastal area: 2.1 vs. 1.3 (p=0.0029). The difference was lower when expressed by prevalence: 46.5 vs. 36.7 (p=0.0601). Among the malignant neoplasms, in the continental area significantly higher incidence rates were found for stomach (32.9 vs. 20.8; p=3.14E-14) and lung cancer (55.8 vs. 46.4; p=1.21E-05), whilst colon cancer alone (20.4 vs. 15.7; p=9.44E-05) or colorectal cancer (38.3 vs. 31.6; p=8.18E-05) had a significantly higher incidence in the coastal area. The geographic distribution of MS expressed by incidence was significantly correlated with pancreatic (r=0,62024, df=23, p=0.00094) and lung cancer (r=0,46380, df=23, p=0.01953). This research adds further malignant neoplasms, possibly exposure-related, to the list of diseases with geographic distribution like MS. The similarity of MS distribution with the named malignancies is unlikely to be incidental. MS in Gorski Kotar and Slavonia seems to be associated with a diet rich in meat and fat. A diet rich in fat and meat and poor in vegetables is a risk factor for stomach, colorectum, pancreatic as well as lung cancers. Some authors have documented a possible protective role of the »Mediterranean diet« for the named cancers. Olive oil is the main source of fat in the »Mediterranean diet«. Oleocanthal, a phenolic compound of the extra-virgin olive oil was found to inhibit the cyclooxigenase enzymes which are involved in demyelination and tumorigenesis. We hypothesize that the »Mediterranean diet«, olive oil and particularly oleocanthal, to have a protective role in MS too

Malignant Skin Melanoma in Croatia

Global heating and increased solar ultraviolet irradiance have caused an increase in number of many diseases, particularly skin malignant diseases. Aim of this study was to investigate the influence of climate changes on the health of the population of the Primorsko-goranska and Istria Counties. We gathered and analyzed data about the frequency of skin malignant melanoma in the period of eight years (1998–2005). The data were collected from the Croatian cancer registry. The incidence of malignant skin cancer was estimated overall, by age group and gender. We found that the incidence of the skin melanoma was approximately the same in both counties during the period 1998–2005. However, significant increase has been noted when compared to the situation in the period 1977–1996 (p=4.95 E–13) The incidence of malignant skin melanoma has risen during the last ten years. It is differently distributed between gender and age groups in Primorsko-goranska and Istria County. It can be related to climate changes, but also to different ways way of life between these two counties

Surgical Treatment of Kidney Cancer in Elderly

The aim of this study was to analyze our patients over the age of 70 suffering from kidney cancer that had undergone surgical treatment. During the 2000–2012 period 634 patients with kidney cancer were treated, 197 of whom were over the age of 70. In this group there were 117 (59.4%) men and 80 (40.6%) women. In most of these patients (156 patients – 79.2%) the clear cell type of renal carcinoma was diagnosed. According to TNM classifi cation the dominant stages were T1b in 62 patients (31.8%) and T1a in 48 patients (24.6%). The most common grade was G2 (73 patients – 37%). Radical nephrectomy was performed in 103 (52.3%) patients, simple nephrectomy in 86 patients (43.7%), enucleation of the tumor and resection of the kidney in 6 (3.1%) patients, while in 2 patients the tumor was inoperable. Early postoperative complications developed in 21 (10.8%) patients. They included complications in distant organs in 11 (5.6%) patients and surgical complications in 10 (5.4%) patients. Five patients (2.6%) died during early postoperative period. Surgery is recommended treatment for elderly patients with kidney cancer with complications comparable with those in younger patients

Različiti pristupi u liječenju urolitijaze u bolesnika s transplantiranim bubregom - prikaz slučaja

Urolithiasis is a rare urologic complication after kidney transplantation, and its diagnosis and treatment can be challenging for clinicians. In our 52-year-old male patient, graft hydronephrosis was found six months after transplantation. The patient had recurrent urinary tract infections followed by macrohematuria and an increase in creatinine levels. Computerized tomography revealed a 13-mm diameter stone in the ureter of the transplanted kidney as the cause of obstruction. Percutaneous nephrostomy was placed in the graft to solve the obstruction. Initial endoscopic treatment with a retrograde approach failed. An antegrade approach through a previously placed nephrostomy was not successful either. By a repeated retrograde approach, laser lithotripsy was performed successfully. The patient has been monitored for six months and has stable graft function without hydronephrosis or stones. As in our patient’s case, the diagnosis and treatment of urolithiasis in kidney transplant patients is challenging, and minimally invasive procedures are the treatment of choice.Urolitijaza je rijetka urološka komplikacija nakon transplantacije bubrega dijagnosticiranje i liječenje koje predstavlja izazov za kliničare. Kod našeg 52-godišnjeg bolesnika uočena je hidronefroza grafta šest mjeseci nakon transplantacije. Bolesnik je imao ponavljajuće uroinfekcije praćene makrohematurijom, a došlo je i do porasta vrijednosti kreatinina. Kompjutorizirana tomografija pokazala je kako je uzrok opstrukcije kamenac promjera 13 mm u distalnom dijelu uretera transplantiranoga bubrega. Za rješavanje opstrukcije bolesniku je postavljena perkutana nefrostomija u presadak. Inicijalno endoskopsko liječenje retrogradnim pristupom bilo je neuspješno. Anterogradni pristup preko ranije postavljene nefrostomije također nije bio uspješan. Ponovljenim retrogradnim pristupom uspjela se učiniti uspješna laserska litotripsija. Bolesnik se prati šest mjeseci i nema kamenaca niti hidronefroze, a funkcija grafta je stabilna. Dijagnosticiranje i liječenje urolitijaze u bolesnika s transplantiranim bubregom je, kao i u našeg bolesnika, izazovno, a minimalno invazivne metode predstavljaju metodu izbora u liječenju ovih bolesnika

POSTAVLJANJE KATETERA ZA PERITONEJSKU DIJALIZU PRIMJENOM REGIONALNE ANESTEZIJE: ULTRAZVUČNO VOĐENI TAP BLOK

Peritoneal dialysis (PD) is an established method for renal replacement therapy in patients with end-stage renal disease (ESRD). Transversus abdominis plane (TAP) block is a regional anesthesia technique, since recently used for PD catheter placement. The main aim of this study was to evaluate the efficacy of PD catheter placement using ultrasound-guided TAP block. We studied 43 ESRD patients from our center that underwent PD catheter placement under TAP block between June 2011 and December 2014. TAP block was successful in 38 (91.4%) of 43 patients. The remaining five (8.6%) patients required general anesthesia. All procedures were performed without complications. ESRD patients have a substantially greater number of comorbid conditions compared to general population, many of which are adversely influenced by general anesthesia. Opposite to general anesthesia, regional anesthesia has no systemic effect and using this technique may prove beneficial in this group of patients. In conclusion, TAP block is an effective method for PD catheter placement and should be especially considered in ESRD patients with major comorbidities.Peritonejska dijaliza (PD) je učinkovita metoda nadomjesne terapije bubrežne funkcije u bolesnika koji se nalaze u terminalnom stadiju bubrežnog zatajenja (ESRD). Transversus abdominis plane (TAP) blok spada u regionalnu anesteziju i nedavno se počeo primjenjivati i i kod implantacija katetera za PD. Cilj ove studije bio je procijeniti učinkovitost postavljanja katetera za PD uz pomoć ultrazvučno vođenoga TAP bloka. Analizirali smo 43 bolesnika s ESRD iz našega centra u kojih je postavljen kateter za PD uz pomoć TAP bloka između lipnja 2011. i prosinca 2014. godine. TAP blok bio je uspješan u 38 (91,4%) od 43 bolesnika. U ostalih pet bolesnika bilo je potrebno primijeniti i opću anesteziju. Svi zahvati su prošli bez komplikacija. Bolesnici s ESRD imaju značajan i uvećan broj popratnih bolesti u odnosu na opću populaciju, od kojih se mnoge mogu pogoršati djelovanjem opće anestezije. Za razliku od opće anestezije, regionalna anestezija nema sistemskog učinka te uporaba ove tehnike može biti korisna u ove skupine bolesnika. Zaključno, TAP blok je učinkovita metoda kod postavljanja katetera za PD, pogotovo u bolesnika s ESRD koji imaju brojne popratne bolesti

Incidence, clinical evaluation and surgical treatment of patients with renal cell cancer: 40-years of experience in the University Hospital Rijeka

Cilj: Ispitati učestalost, kliničku evaluaciju i kirurško liječenje pacijenata s karcinomom bubrega (KB). Pacijenti i metode: Retrospektivnim istraživanjem bili su obuhvaćeni svi pacijenti u Kliničkom bolničkom centru Rijeka koji su između 1. siječnja 1972. i 31. prosinca 2012. godine operirani zbog KB-a. Rezultati: U promatranom razdoblju u našem centru zbog KB-a bilo je operirano 1045 pacijenata. Broj pacijenata se tijekom vremena povećao, s 5 pacijenata godišnje početkom 70-ih godina na preko 50 posljednjih nekoliko godina. Broj asimptomatskih pacijenata povećao se s 6 % na 75 %. Prosječna dob pacijenata bila je 63 godine (raspon 21 – 86 godina). Nefrektomija je učinjena u 95,3 % pacijenata, u 2,6 % parcijalna nefrektomija, a u 2,1 % eksplorativna lumbotomija. U promatranom razdoblju 5-godišnje preživljenje bilo je u 64 %, a 10-godišnje preživljenje 47 %. Zaključak: Učestalost KB-a se tijekom posljednja četiri desetljeća višestruko povećala. Novije dijagnostičke metode omogućuju njegovo otkrivanje u ranijoj fazi, a samim time se omogućuje poštednije kirurško liječenje, ne umanjujući onkološki učinak.Aim: To evaluate incidence, clinical evaluation and surgical treatment of our patients with renal cell cancer (RCC). Patients and methods: We retrospectively analyzed all patients with RCC operated in University Hospital Rijeka from January 1st 1972 to December 31st 2012. Results: In observed period 1045 patients were operated because of RCC. Number of operated patients has increased during time from 5 in the begining of 70-ties to more than 50 in the few last years. The number of asymptomatic patients has increased from 6% to 75%. The mean age was 63 years (range 21-86). Nephrectomy wasperformed in 95.3% patients, nephron sparing surgery in 2.6% and explorative lumbotomy in 2,1% of patients. The 5-year survival was 64% and 10-year survival 47%. Conclusion: The incidence of RCC substantialy increased during time. The new diagnostic methods found RCC in earlier phase and the nephron sparing surgery can be performed without negative influence on oncological outcome

The development of panurothelial carcinoma after kidney transplantation in patient with endemic nephropathy

Cilj: Endemska nefropatija (EN) je kronična bubrežna bolest koja nastaje zbog dugotrajnog izlaganja aristolohičnoj kiselini. EN je povezan s razvojem terminalnog stadija bubrežne insuficijencije, ali i s razvojem karcinoma urotela, poglavito gornjeg dijela mokraćnoga sustava. U radu ćemo prikazati pacijenticu s endemskom nefropatijom, u koje se nakon presađivanja bubrega razvio panurotelijalni karcinom. Prikaz slučaja: U 76-godišnje pacijentice s EN-om je 2013. godine učinjena uspješna kadaverična transplantacija bubrega. Nakon transplantacije otkriven joj je površinski karcinom mokraćnoga mjehura koji je više puta liječen transuretralnim putem. Zbog pojave karcinoma u gornjem dijelu mokraćnoga sustava učinjena joj je i obostrana nefroureterektomija. Unatoč promjeni imunosupresivne terapije i kirurškom liječenju razvila se metastatska bolest uz letalni ishod tri godine po transplantaciji uz funkcionirajući presadak. Zaključak: U pacijenata s EN-om može doći do razvoja panurotelijalne bolesti, a posebno su ugroženi pacijenti u kojih je učinjena transplantacija bubrega. U ove skupine pacijenata vrlo je važna prijetransplantacijska obrada, kao i praćenje nakon transplantacije bubrega.Aim: Endemic nephropathy (EN) is a chronic kidney disease caused by long-lasting exposure to aristolochic acid. EN is linked to the development of end-stage renal disease but also with the development of urothelial carcinoma, especially upper urinary tract carcinoma. We present a rare case of patient with EN who developed panurothelial cancer after kidney transplantation. Case report: In a 76-year-old woman with EN, a successful kidney transplantation was performed in 2013. After the transplantation, superficial bladder cancer was diagnosed and therefore treated with transurethral resection a few times. Later on, carcinoma of the upper urinary tract was also diagnosed so the bilateral nephroureterectomy was performed. Despite modified immunosuppression and surgical treatment, the metastatic disease was developed and the patient died three years after the transplantation, with the graft still being functional. Conclusion: Patients with EN have a higher risk of developing panurothelial carcinoma. Special attention must be given to EN patients who had kidney transplantation. In this group of patients, special considerati on must be emphasized on pretransplant evaluation and follow-up after kidney transplantation

KIDNEY TRANSPLANTATION IN PATIENTS WITH PREVIOUSLY PERFORMED URINARY DIVERSION AND BLADDER AUGMENTATION

U nekih bolesnika s kongenitalnim ili stečenim poremećajima donjeg dijela mokraćnog sustava neophodno je prije transplantacije učiniti odgovarajuću urinarnu derivaciju ili augmentaciju mjehura. Prikazat ćemo naša iskustva u bolesnika u kojih je učinjena transplantacija bubrega koristeći urinarnu derivaciju ili augmentaciju mjehura. Na Klinici za urologiju Kliničkog bolničkog centra u Rijeci, između 30. siječnja 1971. i 17. svibnja 2018. godine ukupno smo učinili 1135 transplantacija bubrega. Retrospektivno smo analizirali bolesnike u kojih je učinjena transplantacija bubrega koristeći urinarnu derivaciju ili augmentirani mokraćni mjehur. Do sada je u 6 takvih bolesnika (ilealni konduit – 3 bolesnika, Mainz-Pouch I - 1 bolesnik, Mainz-Pouch III – 1 bolesnik, augmentacija mjehura s kolonom – 1 bolesnik) učinjena transplantacija bubrega. Uzrok disfunkcije donjeg dijela mokraćnog sustava bio je: neurogeni mjehur (3 bolesnika), karcinom mokraćnoga mjehura (2 bolesnika) i valvule stražnje uretre (1 bolesnik). Jednogodišnjeg preživljenja presatka bilo je 83 %, a bolesnika 100 %. Jedan bolesnik je četiri godine nakon transplantacije umro zbog mezotelioma pleure uz funkcionirajući transplantat. U svih ostalih bolesnika transplantat je i dalje funkcionalan. Bolesnicima s urinarnom derivacijom ili augmentacijom mjehura može se uspješno dati transplantat. Iako se radi o kirurški zahtjevnom zahvatu, dugotrajni rezultati su podudarni s rezultatima transplantacije u standardnoj populaciji te je neophodno poticati uvrštenje ovih bolesnika na listu čekanja za transplantaciju bubrega.Kidney transplantation is the most effective treatment for patients with end-stage renal disease. The prerequisite for kidney transplantation is the normal lower urinary tract system. In some patients with congenital or acquired disorders of the lower urinary tract, it is necessary to form adequate urinary diversion or bladder augmentation. This should be done prior to kidney transplantation. We present experience from our center with renal transplantation using urinary diversion or bladder augmentation. At Department of Urology, Rijeka University Hospital Centre, 1135 kidney transplantations were performed between January 30, 1971 and May 17, 2018. We retrospectively analyzed transplant patients with urinary diversion or bladder augmentation. During the observed period, we performed 6 kidney transplantations in patients with urinary diversion or bladder augmentation. Ileum conduit was performed in 3 patients, and Mainz pouch I and Mainz pouch III in one patient each. One patient had bladder augmentation with colon. The cause for urinary reconstruction was neurogenic bladder (3 patients), bladder cancer (2 patients) and posterior urethral valve (1 patient). Transplantation was heterotopic in five patients and orthotopic in one patient. One-year graft survival was 83% and one-year patient survival was 100%. In one patient, graftectomy was performed because of venous thrombosis. One patient died four years after transplantation because of pleural mesothelioma but with functional graft. All other grafts are still in function (1-23 years after kidney transplantation). Patients with urinary diversion and bladder augmentation could be successfully transplanted. Instead of more complicated operation, long-term results are comparable with the results of standard transplant population. This must encourage us to include patients with urinary diversion and bladder substitution on the waiting list for kidney transplantation