Laparascopic-assisted endoscopic mucosal resection of a polyp in sigma and laparoscopic right hemicolectomy for adenocarcinoma in colon ascendens - case report

Today, endoscopic polypectomy has become a daily-performed routine procedure in the operating room. Almost every polyp in the colon can be removed endoscopically, but there are some problematic adenomas which are either large in size or difficult to approach. We present 80 years old white woman with a tubulo­villous adenoma with high-grade dysplasia on a flat surface located in sigma with 4 x 5cm in size and also synchronously found in colon ascendens a well differentiated G1 adenocarcinoma with 2 x 2cm in size on a flat surface. The abdominal ultrasound did not find any liver metastases. Because of the difficult location and the size of the two lesions in the right and left colon, we make a decision for a laparoscopic-assisted en­doscopic mucosal resection (piece-meal) of the polyp in sigma and for the adenocarcinoma in colon ascen­dens the procedure was followed by laparoscopic right hemicolectomy in one step approach. The both inter­ventions were performed without complications and good postoperative period. Hybrid endoscopic and lap­aroscopic interventions are very effective approach that can resect large tubulovillous polyps and adenocar­cinoma of the colon, with a lesser risk of complications. Combining the methods in one surgery save time, make endoscopy more easy to perform and can save one-half of the colon in cases of synchronous lesions of the colon. Scr Sci Med 2017; 49(3): 49-5

Eruptive Basaliomas: ʺWhy we have to Perform Surgery? ʺ Or Said Otherwise: ʺCatch The Metatypical! ʺ

BACKGROUND: Keratinocyte cancers are malignant diseases with a broad incidence of spread which tends to increase during the last couple of decades. The solar radiation plays a dominant role in the occurrence of BCC, but certain genetic phenotypes appear to be risky from an etiological point of view. Metatypical basal cell carcinoma (MTBCC) is a rare variant of BCC which combines the clinical and histological characteristics of BCC and SCC. Clinically they are indistinguishable from the conventional BCC, and only the histological examination can differentiate them. The MTBCC is a histological subtype which is considered more aggressive due to its ability to produce local recurrences or distant metastases.CASE REPORT: We present a 44-year old patient with multiple BCCs disseminated on the face and body. The biopsy established mixed type histology: three metatypical and four solid BCCs. The lesions were removed via elliptical excision with a field of operational security of 0.5 cm in all directions.CONCLUSIONS: The eruptive (multiple) BCCs are a challenge about the choice of a therapy option. This is because clinically completely identical tumours show different histopathological characteristics, namely those with a tendency to metastasise. Having in mind one of the hypotheses of metatypical BCC emergence - the improper or inadequate radiotherapy (as a choice of therapy) could trigger the transition of a conventional tumour to a metastasising one, the surgical treatment appears to be the most secure treatment method

Successful Craniotomy for Advanced Basal Cell Carcinomas with Cranial Bone Invasion and Dura Mater Infiltration - Unique Presentation in a Bulgarian Patient

BACKGROUND: Basal cell carcinomas (BCC) located in the sun-exposed regions are a serious therapeutic challenge. Therefore early diagnosis and adequate therapy should be of a high priority for every dermatologic surgeon.CASE PRESENTATION: We are presenting a patient with multiple BCCs, located on the area of the scalp, who had been treated several years ago with electrocautery and curettage after histopathological verification. However, the last few years the tumours have advanced, infiltrating firstly the tabula external and a year later the tabula interna of the cranium. A computed -tomography (CT) imaging and radiography of the skull were performed to reveal the definite tumour localisation, needed for planning an one - step surgical intervention. Both of the instrumental examinations confirmed the existence of osteolytic tumour lesions. Craniotomy with precise removal of the BCCs infiltrating the cranial bone in all of its thickness was performed. Partial resection of dura mater was also performed also because intraoperative findings established the involvement of the dura. Histopathological verification revealed bone and dural invasion with clean resection margins. The bone defect was recovered with hydroxyapatite cement. Reconstruction as the shape of the skull was carefully modified and adapted to its initial size and form. Layered closure of the skin and soft tissues were performed after the complete removal of the BCCs. The postoperative period had no serious complications.CONCLUSION: Precisely managed therapy of BCC is curative in most of the cases as it ensures good prognosis for the patient

Mucoepidermoid Carcinoma (MEC) of Parotid Gland with Massive Cutaneous Involvement: Bilateral Pedicle Advancement Flap (U - Plasty) As Adequate Surgical Approach

Neoplasms of the major and minor salivary glands are morphologically and a clinically diverse group of neoplasms which lead the clinician to diagnostic and management challenges. This article aims to report a case of mucoepidermoid carcinoma in 83 – year - old woman who presented in the dermatology clinic with a tumour mass in the left auricular area. The patient complained of pain and abnormal bleeding of the mass. The lesion was examined, and surgical treatment was performed. A tumour was extirpated, and partial resection of both the parotid gland and the sternocleidomastoid muscle was done. Lymphatic dissection was performed. Post recovery was uneventful with no functional defects and abnormalities. The pathohistological result confirmed the diagnosis of mucoepidermoid carcinoma of the parotid gland with massive infiltration of the skin and the subcutaneous tissue. Lymph nodules with total metastasis of mucoepidermoid carcinoma and capsular invasion were additionally presented. Postoperative radiation therapy was planned

Sarcoidosis in A. C. Milan (1899)?

The pathogenesis, diagnosis and therapy of sarcoidosis as an autonomous disease are subjects of spirited discussions, which haven’t found definitive conclusion yet. Distinguishing between sarcoidosis and sarcoid-like reactions (sarcoid - type granulomas) is not currently a medical “gold standard†and is not implemented in clinical practice. This leads to 1) misinterpretation of numerous available data; 2) difficulty in the interpretation of other unverified data, which is often followed by 3) inappropriate or inadequate therapeutic approach. Similarly to many other diseases, in sarcoidosis and sarcoid - types of reactions the concept of personalised approach and therapy should also be introduced. This methodology of clinical guidance is difficult, complex and not always achievable in the current medical status and relations (doctor-patient relationship; financial factor; time factor). It is appropriate to note that in some cases the guidelines or the so-called standards are neglected or not possible to put into practice with the aim of better therapeutic practices and strategies, as well as the achievement of optimal final clinical results (especially in patients with sarcoid granulomas). The sarcoid granuloma, even when it is sterile, should not be considered as the equivalent of sarcoidosis, i.e., sarcoidosis as an autonomous disease. Sure enough, exactly because of this fact, the personalised approach should not be an exception, but it has to gradually become a rule in medical practice. When clinical decisions are conformed to some of the latest modern concepts, officialised in the international databases, often the achieved results can be much better.We present a patient with a tattoo of AC Milan (1899) on his right arm, who subsequently developed localised sterile sarcoid granulomas in the area of the tattoo. Later the process became generalised on his whole body’s skin, lungs and lymph nodes. It is unclear for the moment whether this condition should be interpreted as sarcoidosis as an autonomous disease or, instead, as a sarcoidal type of reaction with subsequent generalisation due to cross-reactivity against antigens present in other tissues with similarities to the exogenous pigments. Following the modern concepts regarding the pathogenesis of these two conditions, we introduced, in this case, an innovative, non-standard approach: 1) systemic and local immunosuppressive therapy, combined with 2) recommеndation for immediate surgical excision of the tattoo to remove the possible trigger of molecular and antigen mimicry

Primary Cutaneous CD30+/ALK- ALCL with Transition into sALCL: Favourable Response after Systemic Administration with Brentuximab Vedotin! Unique Presentation in a Bulgarian Patient!

BACKGROUND: Modern drugs could sometimes be a good solution even to problematic patients. The cutaneous and systemic forms of the CD30 positive anaplastic large T-cell lymphoma could often be described as a suitable target for therapy with Brentuximab vedotin.CASE REPORT: We present the first case of a Bulgarian patient with a histologically confirmed primary cutaneous T-cell CD30+/ALK- large anaplastic cell lymphoma-cALCL (therapeutically resistant to therapy with Methotrexate, radiation therapy and systemic corticosteroid therapy) who was successfully treated with Brentuximab vedotin. In several years, the patient has developed a comparatively fast skin progression as well as an initial systemic one which impacts inguinal and mediastinal nodes. After the implementation of 4 therapy cycles with Brentuximab vedotin, complete regression of the described by previous hospitalisations lymph nodes as well as 80% reduction of the cutaneous and subcutaneous located tumour formations were observed.CONCLUSION: The therapy of CD30+/ALK- anaplastic large T-cell lymphoma is a significant challenge for oncologists and dermatologists because it requires maximally efficient and minimally traumatic treatment in parallel. Therapy with Brentuximab is a new direction which shows extremely good clinical results and can be applied to the cutaneous as well as to the systemic form of anaplastic large-cell CD30 positive lymphoma. The key element by treatment with Brentuximab is suppression of the CD30- expression which, in turn, could be the cause of relapses. On that ground, patients with these lymphomas should be strictly monitored

Въпроси на конкурентоспособността на земеделските стопанства на България

A holistic approach for understanding, evaluating and improving the competitiveness of agricultural holdings in Bulgaria has been refined and applied. A multi-criteria assessment of the competitiveness of farms of different types is made by using survey information. A multi-criteria assessment of the level of competitiveness of agricultural holdings as a whole and with different types of product specialization was also made by using statistical data and applying the method of principal components. A comparative analysis of the level and dynamics of competitiveness of Bulgarian farms in general and with different specializations for the period 2010-2020 was also carried out. A comparative analysis of the results of the assessment of competitiveness based on survey and statistical data was made and the advantages and disadvantages of the various approaches. An assessment was made of the level and factors of competitiveness of agricultural holdings with organic production, the relationships with the main characteristics of the farmer (gender, age, etc.) were established, the most significant factors and political instruments affecting competitiveness were highlighted and the intentions were identified of organic farms in the near future. A model of CPR factor analysis and an index method for measuring competitiveness in the sheep meat sector were applied. The restructuring and diversification of agricultural cooperatives for the period after the country's integration into the EU was analyzed and a comparative assessment was made with other forms of business organizations in agriculture. The multi-criteria evaluation of alternative business models and strategies for managing the agricultural enterprise and risk was carried out, and the factors of the competitiveness of Bulgarian farms were identified. A theoretical analysis of the meso-economic level of management was made, the attitudes of alternative farmers in our country for the use of meso-institutions were established, and the relationship with agrarian competitiveness at the current stage of development of the industry was rethought. The development of agricultural holdings for the period 2007–2020 in the country was analyzed and the development of rural areas and the agrarian sector in the South Central region was compared with the general situation, by means of the Localization Index. The new trends in agricultural marketing (digitalization, intelligent marketing, etc.) are revealed, the impact on the relationship between agricultural producers and end users and the effect on the competitiveness of farms are assessed. An algorithm for the development and implementation of new models for innovative activity of small and medium-sized enterprises in agriculture is proposed, which allows effective management decisions at different levels, quantification of the index for innovative activity and easy adaptation when developing an automated system. General conclusions have been drawn up about the level, trends and factors of competitiveness of Bulgarian farms of different types and recommendations have been made for improving the scientific and evaluation methods, the system for gathering agro-information, public policies, programs and forms of intervention, and of farming strategies to improve competitiveness

Small Dysplastic Congenital Melanocytic Nevi in Childhood as Possible Melanoma Imitators

Small pigmented lesions in children can represent a significant diagnostic challenge. If the diagnostic features and therapeutic approach are relatively well established in large and giant nevi, there is still much controversy regarding small and intermediate-sized congenital pigmented lesions that can lead to significant diagnostic challenges, both clinically and dermoscopically, and consequently to difficulty in defining the optimal approach in such cases. Although dermoscopy can be useful in the diagnosis of pigmented lesions, the diversity of clinical and dermoscopic features of pigmented nevi in children usually hinder the differentiation between them and melanoma. Histological findings after resection often show surprising results that do not correspond either to the clinical nor the dermoscopic features. With the present case, we want to emphasise the variable natural behaviour of melanocytic lesions in children, which sometimes leads to unnecessary surgical excisions, which should be avoided in pediatric patients