Podejrzenie nowotworu pęcherzykowego czy nowotwór pęcherzykowy? Dylemat patologa i chirurga

  Introduction: Cytological material obtained from Fine Needle Aspiration Biopsy (FNAB) does not permit us to distinguish between follicular carcinomas, adenomas, and hyperplastic nodules. The limitations of the method are: lack of possibility to assess the presence of tumour capsule, eventual capsular invasion, and angioinvasion. An unequivocal conclusion of whether what we have to deal with is a neoplastic or benign lesion is possible only after histopathological examination. The aim of the study was to confirm justification for using the term “Suspicious for Follicular Neoplasm” (SFN) in cytological diagnostics of thyroid carcinoma. Material and methods: Three hundred and fifty-two primary SFN FNAB diagnoses (diagnostic category IV [DC IV] — according to Bethesda System) obtained from 2010 to 2015 in the Institute of Oncology in Gliwice were analysed, and their correlation with histopathological diagnoses was verified. Results: In the Institute of Oncology in Gliwice, 352 primary SFN diagnoses (diagnostic category IV [DC IV] — according to Bethesda System) were established. Surgical treatment was undertaken after first FNAB in six cases, giving confirmation of a neoplasm in five cases, one of which was a follicular carcinoma. Second FNAB performed in 90 patients confirmed DC IV diagnosis in 53 cases. Third FNAB concerned 26 patients, providing another 14 diagnoses of DC IV. 26 out of 352 patients were subjected to surgery, and then histopathological examination confirmed a neoplasm in 19 cases (which comprises 73%), five of which were carcinomas. Conclusions: High positive predictive value PPV = 73% of SFN diagnosis justifies undertaking surgical treatment in any case of this diagnosis. (Endokrynol Pol 2016; 67 (1): 17–22)    Wstęp: Materiał cytologiczny biopsji aspiracyjnej cienkoigłowej (BAC) tarczycy nie pozwala na zróżnicowanie raków pęcherzykowych, gruczolaków i guzków rozrostowych. Ograniczeniem metody jest brak możliwości określenia obecności torebki guza, jej ewentualnego nacieku oraz angioinwazji. Jednoznaczne rozstrzygnięcie czy mamy do czynienia ze zmianą nowotworową czy łagodną jest możliwe dopiero po badaniu histopatologicznym. Celem pracy było uzasadnienie celowości używania terminu „podejrzenie nowotworu pęcherzykowego” w diagnostyce cytologicznej raka tarczycy. Materiał i metody: Poddano analizie 352 wyniki BAC tarczycy wykonanych w Instytucie Onkologii (IO) w Gliwicach w latach 2010–2015 i ich korelację z rozpoznaniem histopatologicznym. Wyniki: W IO rozpoznanie podejrzenie nowotworu pęcherzykowego (grupa IV wg Systemu Bethesda) postawiono pierwotnie w 352 przypadkach. Leczenie operacyjne podjęto po pierwszej BAC w 6 przypadkach uzyskując potwierdzenie nowotworu w 5 przypadkach w tym jednego raka pęcherzykowego. Powtórna BAC przeprowadzona u 90 pacjentów potwierdziła rozpoznanie grupy IV w 53 przypadkach. Trzecią BAC przeprowadzono u 26 chorych, uzyskując kolejnych 14 rozpoznań grupy IV. Leczeniu operacyjnemu poddano 26 pacjentów na 352 rozpoznania nowotworu pęcherzykowego, uzyskując potwierdzenie nowotworu w 19 przypadkach, co stanowi 73% w tym raka 5 razy. Wnioski: Wysoka dodatnia wartość predykcyjna PPV = 73% rozpoznania „podejrzenie nowotworu pęcherzykowego” uzasadnia podjęcie leczenia operacyjnego w każdym przypadku tego rozpoznania. (Endokrynol Pol 2016; 67 (1): 17–22)

Znaczenie zakresu i czasu leczenia operacyjnego u chorych na zróżnicowane raki tarczycy

Introduction: To analyze the impact of time and extent of operation on overall and disease-free survival in patients with differentiated thyroid carcinoma (DTC). Material and methods: Retrospective analysis of 1235 DTC patients, a representative probe of patients diagnosed or treated between 1986 to 1998 was performed. 277 patients were staged T1M0 and 958 ones staged > T1M0. 10-year outcomes were analyzed by Kaplan-Meier survival curves and Cox proportional-hazard model. Results: The T1M0 patients were characterized by the best overall and disease-free survival independently of the time and the extent of operation (98% and 96% respectively); in > T1M0 group the survival was better in patients who were treated by total thyroidectomy (94% and 68% respectively) than in patients treated by non-total thyroidectomy (78% and 47% respectively). In patients treated by completion of total thyroidectomy delayed more than 1 year post cancer diagnosis the incidence of carcinoma in postoperative pathological material was twice as high in comparison to the group in whom total thyroidectomy was performed within the first year of therapy (p = 0.000). Conclusions: 1. In differentiated thyroid carcinoma the prognosis is related to the extent of operation only in patients staged more than T1M0. 2. A delay > 12 months in completion surgery in patients with differentiated thyroid cancer (tumors > 1 cm of diameter) significantly increases the risk of progression of multifocal disease in thyroid remnants.Wstęp: Celem niniejszej analizy była ocena wpływu czasu i zakresu leczenia operacyjnego na 10-letnie przeżycie całkowite i bezobjawowe chorych na zróżnicowane raki tarczycy (DTC, differentiated thyroid carcinoma). Materiał i metody: Retrospektywnej analizie poddano reprezentatywną grupę 1235 chorych na DTC leczonych lub diagnozowanych w latach 1986-1998. Było to 277 chorych w stopniu zaawansowania T1M0 i 958 chorych o wyższym stopniu zaawansowania (> T1M0). Ocenę aktualizowanego przeżycia całkowitego i bezobjawowego przeprowadzono metodą Kaplana-Meiera oraz testem χ2. Wyniki: Chorych w stopniu zaawansowania T1M0 cechowało bardzo dobre przeżycie całkowite i bezobjawowe (odpowiednio: 98% i 96%), niezależnie od czasu i zakresu leczenia operacyjnego. Dla chorych z grupy > T1M0 prawdopodobieństwo przeżycia po operacjach całkowitego, pierwotnego lub wtórnego wycięcia tarczycy było znamiennie lepsze niż chorych po niecałkowitym wycięciu narządu i wynosiło: 94% (przeżycie całkowite) i 68% (przeżycie bezobjawowe) oraz 78% i 47%, odpowiednio dla chorych po operacjach niecałkowitego wycięcia tarczycy. W grupie osób poddanych operacjom wtórnego, opóźnionego całkowitego wycięcia tarczycy odsetek ognisk nowotworowych znajdowanych w materiale histopatologicznym był ponad 2-krotnie wyższy niż u chorych, u których radykalne leczenie operacyjne wykonano w pierwszym roku terapii (p = 0,000). Wnioski: 1. W zróżnicowanych rakach tarczycy rokowanie jest także uzależnione od zakresu leczenia operacyjnego, jego znaczenie ujawnia się jednak dopiero u chorych na nowotwór o średnicy większej niż 1 cm. 2. U chorych na raka tarczycy z guzem o średnicy większej niż 1 cm nie powinno się opóźniać wtórnej operacji, gdyż opóźnienie o ponad rok wiąże się z większym ryzykiem wystąpienia wieloogniskowego wzrostu raka w resztkowym miąższu gruczołu pozostawionym po pierwszym zabiegu

Multidisciplinary approach to a patient with end-stage heart failure and colon adenocarcinoma — intra aortic balloon pump-supported tumor resection and bridge to heart transplantation

Non-cardiac, potentially curative surgeries in patients with chronic end-stage heart failure and significant arrhythmias are associated with very high risk of adverse events and mortality. A hemodynamic support in this clinical scenario is a novel and reasonable approach. Intra-aortic balloon pump (IABP), with its feasibility, long-term safety record, minimal invasiveness and availability, constitutes the best and valid option. As an example we present a case of an IABP supported colon adenocarcinoma resection in a patient with end stage heart failure.Niekardiologiczne, naprawcze zabiegi operacyjne u chorych w schyłkowej fazie niewydolności serca oraz z istotnymi zaburzeń rytmu serca są obarczone bardzo wysokim ryzykiem wystąpienia niepożądanych zdarzeń lub zgonu. W tej sytuacji wsparcie hemodynamiczne może być nowatorskim i uzasadnionym wyborem. Kontrapulsacja wewnątrzaortalna, metoda szeroko dostępna, mało inwazyjna i bezpieczna wydaje się być najbardziej interesującą opcją. Wobec powyższego prezentujemy przypadek implantacji kontrapulsacji wewnątrzaortalnej przed operacją resekcji gruczolakoraka okrężnicy u chorego w schyłkowej fazie niewydolnością serca

Evaluation of the therapeutic benefits in relation to the extent of surgery in patients with differentiated thyroid carcinoma

Wstęp: Celem pracy była ocena korzyści terapeutycznych z zastosowania określonego zakresu operacji w zależności od zaawansowania raka tarczycy i obserwowanego ryzyka powikłań pooperacyjnych. Materiał i metody: Retrospektywnej analizie poddano grupę chorych na zróżnicowane raki tarczycy (DTC, differentiated thyroid carcinoma) w stopniu zaawansowania T1M0 (klasyfikacja TNM, tumor nodes metastases z 1997 roku) w porównaniu z grupą chorych w stopniu zaawansowania T2-T4M0. Chorych diagnozowano lub leczono w Centrum Onkologii IMSC w Gliwicach w latach 1986-1998, a leczenie operacyjne wykonano w różnych polskich ośrodkach chirurgicznych. W pracy oceniono ryzyko powikłań pooperacyjnych, częstość zgonów i nawrotów. W celu oceny korzyści terapeutycznych posłużono się metodą tak zwanych drzew decyzyjnych. Wyniki: Na podstawie analizy danych z historii chorób odnotowano wysoki odsetek powikłań pooperacyjnych (bez rozgraniczenia powikłań trwałych od przejściowych). U 21% chorych obserwowano niedowład lub porażenie nerwu krtaniowego wstecznego, a u 15,8% odnotowano zaburzenia gospodarki wapniowo-fosforanowej. U chorych w stopniu zaawansowania T1M0 nie zaobserwowano wyraźnych korzyści terapeutycznych przy całkowitym wycięciu tarczycy (współczynnik zysku wynosił 0,96 dla całkowitego wycięcia gruczołu i 0,98 dla niecałkowitego usunięcia tarczycy). Podobna analiza przeprowadzona w grupie T2-T4M0 przemawiała zdecydowanie na korzyść całkowitego usunięcia narządu, gdyż współczynnik zysku terapeutycznego wynosił 0,92 w porównaniu z 0,69 dla operacji niecałkowitego usunięcia narządu. Wnioski: W analizie korzyści terapeutycznych potwierdzono zasadność stosowania granicy 1 cm jako dopuszczalnej dla niecałkowitego wycięcia tarczycy oraz potrzebę stosowania całkowitego wycięcia gruczołu w wyższych stopniach zaawansowania klinicznego choroby, gdyż dla tych chorych korzyści wynikające z przedłużenia życia i zmniejszenia ryzyka nawrotu przeważają nad stratami wynikającymi z powikłań.Introduction: Evaluation of the therapeutic benefits in relation to the stage of thyroid cancer and to the extent of surgery and the risk of postoperative complications. Material and methods: Retrospective analysis of differentiated thyroid carcinoma (DTC) patients staged T1M0 versus T2-T4M0 was performed. All of them were treated or diagnosed in Institute of Oncology in Gliwice between 1986-1998. Previously they were operated in various surgical centers all-over Poland. The risk of death, local relapse and postoperative complications were analyzed using the decisiontree model to evaluate the therapeutic benefits. Results: The recurrent laryngeal nerve injury (transient or permanent) was observed in retrospective analysis in 21% of patients, while postoperative hyperparathyroidism in 15.8%. The analysis of the therapeutic benefit index showed no advantage of total thyroidectomy in the T1M0 group (0.96 vs. 0.98 in patients treated by less than total thyroidectomy). The advantage of radical surgery was confirmed in T2-T4M0 group. The therapeutic benefit index was 0.92 in patients treated by total thyroidectomy and 0.69 in those who received less extensive operation. Conclusions: The analysis of therapeutic benefits confirmed the limit of 1 cm tumor diameter between less extensive surgery and total thyroidectomy. It showed that total thyroidectomy brings a significant therapeutic benefits in patients in > T1M0 stage. The improvement of overall survival and decrease of local relapse far outweigh the disadvantages related to postoperative complications

An Evaluation of the Efficacy of Microvascular Breast Reconstruction Techniques

The aim of the studywas to evaluate the efficacy of different microvascular techniques in breast reconstruction with the analysis of postoperative complications. The additional goal of the study is to analyze the quality of life of patients after microvascular breast reconstruction in comparison to the control group of patients who underwent only mastectomy without any reconstructive procedures. Also the algorithm of breast reconstruction is presented as the result of own experiences. Material and methods.Clinical material contain 2 groups of patients - women after surgical treatment in Department of Oncological and Reconstructive Surgery, Cancer Center in Gliwice in the year 2004-2009 where in 53 cases immediate and in 26 delayed breast microvascular reconstruction were performed. In all cases the diagnosis of cancer was proved by histopathological biopsy before the treatment. The type of radical resection (mastectomy) depended on histopathological type of cancer and its localization. The reconstruction - immediate vs delayed was carefully planned together with oncological treatment of the cases. Everywhere this plan was established based on carefully examinations of inferior epigastric vessels and theirs perforators. The choice between immediate and delayed microvascular reconstruction was based on prognosis and predictive factors. The QOL was analyzed due to own questionnaire when functional, aesthetics and social effects were evaluated. ResultsFree flap survival rate for all types of free flap was 95%. In cases where classic TRAM was used the rate was 85%, in cases where muscle sparring TRAM was chosen the survival rate was 100% and in remaining cases of DIEP reconstructions the rate was 89%. Generally the complications after microvascular reconstruction occurred in 13 cases (16%). In 9 cases the problems with flaps perfusion were notified. Total flap necrosis was observed in 2 TRAM and in 2 DIEP cases. In all those cases salvage surgery was administered in which the microanastomoses were explored and repaired. In 5 cases the cause of the complications was venous thrombosis, in 2 cases the vascular pedicle was kinked, and in remaining 1 the arterial thrombosis was found. The second type of complication was fat necrosis (<25% of flap volume) which was observed in 5 cases between 1 and 4 months after surgery, and it request minor plastic surgery. Donor site complications were noted in 4 cases. In two of those hernia in cicatrices was diagnosed (both were classic TRAM’s), in remaining 2 in which also fully muscle TRAM was classic the weakness of abdominal wall was observed. In group were msTRAM and DIEP were used no donor site complications occurred

Evaluation of Outcomes and Treatment Safety of Patients with Metastatic Colorectal Cancer to the Liver with Estimation of Prognostic Factors

Liver resection is essential part of colorectal cancer liver metastases (CLM) treatment. Mean 5-year overall survival after resection achieves 30-45%. There are many factors influencing long-term outcomes, and among them the inflammatory response to tumor plays an important role. The aim of the study was evaluation of outcomes and treatment safety of patients with metastatic colorectal cancer to the liver with estimation of prognostic factors. Material and methods. 130 consecutive patients (70 men and 60 women) operated in MSC Institute and Cancer Center in Gliwice from 2001 to 2009 due to colorectal liver metastases were analysed. Age of the patients ranged from 33 to 82 years (median 60 years). 96 (74%) patients underwent potentially radical resection, and in remaining 34 (26%) was performed radiofrequency ablation (RFA) alone or combined with the resection. In the resection group 37 right hepatectomies, 11 left hepatectomies, 28 segmentectomies and 20 metastasectomies were performed. Disease-free survival (DFS) and overall survival (OS) were statistically analysed using the Kaplan-Meier method. Factors determining DFS and OS were analysed using Cox regression model. Results. In the resection group the 3- and 5-years OS was 64,5% and 46,6% respectively, and the 3- and 5-years DFS was 32% and 30,5% respectively. In the RFA group the 3- and 5-years OS was 33% and 9,5%. Statistically significant prognostic factors in the resection group in uni- and multivariate analysis were: grade and nodal involvement of the primary tumor, diameter of metastatic focus, positive and narrow (<1 mm) resection margins, preoperative fibrinogen level, preoperative neutrophil to lymphocyte ratio and leukocyte amount of the peripheral blood. The perioperative mortality rate was 3%. Conclusions. Liver resection due to colorectal liver metastases is a safe and effective method resulting in high survival rates. We confirmed some generally accepted prognostic factors influencing longterm outcomes and shown the impact of inflammatory response. We also confirmed the hypothesis that preoperative plasma fibrinogen level influences outcomes after liver resection due to CLM

The Use of a Pedunculated, Extended Latissimus Dorsi Flap in Primary and Secondary Breast Reconstruction Procedures - Case Report

The extended latissimus dorsi flap (LD) is used in breast reconstruction since the 70's. LD flap is often used in corrective surgery in cases of unsatisfactory cosmetic results after breast-conserving therapy. In our department LD flap has several uses. In addition to free microvascular flaps - which applies in breast reconstructive surgery is routine, there are clinical situations where the use of pedicled LD flap is justified. The main indications for its use are: the inability to apply microvascular flap, the general condition (diabetes, advanced atherosclerosis), smoking, previous surgery of abdominal wall, abdominal obesity, patient preferences. Approximately 30% of patients after breast reconstruction require corrective procedures. Group which uses extended LD flap account for 24 patients. In 16 cases it was used for elective breast reconstruction. In the remaining eight cases it was used in the corrective procedures symmetry and shape of the previously reconstructed breast. Based on our own experience it can be concluded that the LD flap with an alternative to microvascular techniques. Complication rate when using the LD flap is relatively low and includes: seroma and slight motor disability of the shoulder girdle

The use of anterolateral thigh flap (ALTF) for functional tongue reconstruction with postoperative quality of live evaluati

The use of microsurgery for oral reconstruction of cancer patients, has become standard treatment in restoring oral function. The free anterolateral thigh flap is one of the most preferred options in reconstruction after total, subtotal or hemiresection of the tonque due to squamous cell cancer. The aim of the study was to present the reconstructive method using anterolateral thigh free flap with evaluation of quality of live. Material and methods. Clinical material includes 46 consecutive patients with tongue cancer, who underwent complex surgical treatment between 2009 and 2011. There were 36 males and 10 females and the M: F ratio was 3.6: 1. All of them were reconstructed using the anterolateral thigh free flap. The quality of life was evaluated 6 months after completing the treatment, based on postoperative functional and aesthetic status. Results. The overall flap survival rate was 96%. Surgical complications were observed in 8 patients (17%). Donor site was closed primarly in 42 cases and in remaining 4 skin graft was required. In all 46 cases understandable speech and return to unrestricted diet mastication and swallowing were achieved. The mean follow-up period after treatment was 32 months. Analysis of aesthetic effects evaluated in 23 cases and shows generally very good results. According to average transformed scores the QOL can be characterized as excellent for >90, very good for 76-90, good for 51-75, moderate for 25-50 and bad for <25 points. Conclusions. Anterolateral thigh flap, with its versatility in design, long pedicle with a suitable vessel diameter, low donor site morbidity, and very good aesthetic effects, could be the ideal flap for functional tongue reconstruction

Czerniaki złośliwe regionu głowy i szyi w materiale Kliniki Chirurgii Onkologicznej i Rekonstrukcyjnej Centrum Onkologii IMSC w Gliwicach

Introduction: About 25% of melanomas are localized in head and neck skin, and this particular localization is most difficult to treat, and the prognosis is less favorable. The depth of melanoma infiltration (Clark and Breslau grade) into the skin is the main factor of local advancement of the disease. Surgical treatment is an essential therapeutic modality in patients with melanoma. Aim: The aim of this study was to evaluate results of our surgical treatment of melanomas in head and neck localisation, treated from 1997 to 2007 in Department of Oncological and Reconstructive Surgery in Center of Oncology IMSC in Gliwice. Material: We analysed group of 47 patients (aged 26 to 75 years, mean 49), treated by surgical excision of malignant melanoma in the head and neck region. Most of the patiens required to use free fl aps or skin graft technique to close posexcisional defect, on basis of clinical considerations. Results: The 5-year total survival for all patients was 62% and were dependent on depht of melanoma infiltration and regional lymph node metastasis. The significant prognostic factors were: localization of primary focus, local progression of disease, free microscopical excision margins sex and age. Conclusions: Prognosis in the patients with melanoma of the head and neck is unreliable and dependent on local advancement of disease and localization of primary focus. Surgical treatment is an essential therapeutic modality in patients with melanoma. Adiuvant radiotherapy after surgical treatment of melanoma of the head and neck is intended for the patiens with high risk of local or regional recurence of disease