Inherited thrombophilia

Pojam trombofilija podrazumijeva nasljedne i/ili stečene poremećaje sustava zgrušavanja krvi koji predisponiraju razvoj tromboze. Nasljedna trombofilija obuhvaća stanja u kojima naslijeđene genetske mutacije dovode do abnormalne količine ili funkcije proteina uključenih u sustav koagulacije, što za posljedicu može imati povećanu sklonost venskim i, znatno rjeđe, arterijskim trombozama. Nedvojbeno definirana nasljedna trombofilna stanja nedostatak su antitrombina, proteina C i proteina S te pojava faktora V Leiden i protrombinskih varijanti. Još uvijek ne postoje jednoznačne preporuke za testiranje nasljedne trombofilije, a profilaksa i liječenje tromboembolijskih događaja moraju biti individualizirani.The term thrombophilia implies inherited and/or acquired disorders of the hemostasis mechanism that predispose to the development of thrombosis. Inherited thrombophilia includes conditions in which an inherited genetic mutations affect the amount or function of proteins involved in the coagulation system, and as a consequence, an increased tendency to venous and, much less frequently, arterial thrombosis. Undoubtedly defined inherited thrombophilic conditions are the deficiency of antithrombin, protein C and protein S and the appearance of factor V Leiden and rothrombin\u27s variants. There is still no clear recommendation for testing hereditary thrombophilia, and the prophylaxis and the treatment of thromboembolic events must be individualized

Utjecaj preoperacijske magnetske rezonancije dojki na kirurško liječenje Novodijagnosticiranog raka dojke

Introduction: Breast cancer is the most commonly diagnosed malignancy in women and the leading cause of cancer death in women. Tumor size is a critical factor in determining the type and extent of surgical and oncologic treatment. It is accurately determined by imaging modalities such as mammography, ultrasound, and magnetic resonance imaging (MRI), which provide a more reliable determination of tumor size. The aim of our study was to investigate the impact of preoperative breast magnetic resonance imaging on surgical treatment of newly diagnosed breast cancer. Material and Methods: The study retrospectively reviewed the records of 241 participants with newly diagnosed breast cancer who underwent preoperative mammography, breast ultrasound, and MRI between 2016 and 2020 at University Hospital Centre Rijeka. Patients were diagnosed with invasive ductal carcinoma, invasive lobular carcinoma, ductal carcinoma in situ, or a combination of the types. Surgical treatment included one of the following procedures: simple quadrantectomy, quadrantectomy and sentinel lymph node biopsy, quadrantectomy and axillary lymph node dissection, mastectomy and sentinel biopsy, or mastectomy and axillary dissection. Results: Compared with histopathologic tumor size, breast MRI overestimated size in 10% of patients. T stage was underestimated in 5% of patients (p>0.050). In comparison, breast ultrasound overestimated tumor size in 12% and underestimated it in 48% (p<0.001). Similarly, mammography overestimated tumor size in 14% and underestimated it in 62% (p<0.001). Conclusion: In patients with newly diagnosed breast cancer, the use of preoperative breast MRI as an adjunct to mammography and ultrasound for locoregional staging significantly alters subsequent surgical treatment.Uvod: Rak dojke je najčešće dijagnosticirana zloćudna bolest u žena i vodeći uzrok smrti od raka u žena. Veličina tumora je ključan čimbenik u određivanju vrste i opsega kirurškog i onkološkog liječenja. Točno se utvrđuje slikovnim modalitetima poput mamografije, ultrazvuka i magnetske rezonancije (MRI) koja omogućuje najpouzdanije određivanje veličine tumora. Cilj našeg istraživanja bio je istražiti utjecaj preoperativne magnetske rezonancije dojke na kirurško liječenje novodijagnosticiranog raka dojke. Materijal i metode: U studiju su bile retrospektivno uključene 241 bolesnice s novodijagnosticiranim karcinomom dojke koje su podvrgnute preoperativnoj mamografiji, ultrazvuku dojke i magnetskoj rezonanci između 2016. i 2020. godine u KBC-u Rijeka. Pacijentima je dijagnosticiran invazivni duktalni karcinom, invazivni lobularni karcinom, duktalni karcinom in situ ili kombinacija tipova. Kirurško liječenje uključivalo je jedan od sljedećih zahvata: kvadrantektomiju, kvadrantektomiju i biopsiju sentinel limfnog čvora, kvadrantektomiju i disekciju pazuha, mastektomiju i sentinel biopsiju ili mastektomiju i disekciju pazuha. Rezultati: U usporedbi s histopatološkom veličinom tumora, MRI dojke je precijenio veličinu u 10% bolesnica. T stadij je podcijenjen u 5% bolesnica (p>0,050). Za usporedbu, ultrazvuk dojke precijenio je veličinu tumora u 12%, a podcijenio u 48% slučajeva (p<0,001). Slično, mamografija je precijenila veličinu tumora u 14%, a podcijenila u 62% slučajeva (p<0,001). Zaključak: U bolesnica s novodijagnosticiranim rakom dojke, primjena preoperativne MRI dojke kao dopune mamografiji i ultrazvuku za lokoregionalno određivanje stadija značajno mijenja naknadno odluku kirurškog liječenja raka dojke

Utjecaj biopsije sentinel limfnog čvora nakon neoadjuvantnog sistemskog liječenja na klinički ishod bolesnica oboljelih od karcinoma dojke sa inicijalno pozitivnom aksilom

Introduction: After the consensus conference in St. Gallen and updated NCCN guidelines, we started doing sentinel lymph node biopsy (SLNB) in May 2017, for breast cancer patients who achieve clinical axillary remission following neoadjuvant treatment. This study’s primary goal was to evaluate the clinical impact of SLNB after neoadjuvant therapy in the group mentioned above. Methods: We retrospectively analyzed all neoadjuvant breast cancer patients from May 2016 until May 2018 at Clinical Hospital Center Rijeka. Our preliminary results recorded the appearance of locoregional and distant recurrence. Results: From 65 patients involved in this analysis, 48 patients were node-positive at the time of diagnosis, and 45.83% among those achieved complete pathological axillary remission. After the first postoperative year, there were no locoregional relapses nor statistically significant differences in the prevalence of distant recurrences, regardless of the extent of surgical procedure. However, results showed higher rates of locoregional and distant relapse for the group of patients that did not attain complete axillary remission. Conclusion: SLNB is a reliable alternative to ALND for locoregional and overall disease control for breast cancer patients who achieve complete clinical axillary remission after preoperative systemic treatment. The clinical axillary lymph node status, after neoadjuvant therapy, is a more relevant prognostic factor than the clinical axillary lymph node status at the beginning of the treatment.Uvod: Nakon konsenzusa postignutog na konferenciji u St. Gallen-u i revizije NCCN-ovih smjernica za liječenje karcinoma dojke, u svibnju 2017. godine u Kliničkom Bolničkom Centru Rijeka, biopsija sentinel limfnog čvora uvedena je u kliničku praksu kirurškog liječenja bolesnica oboljelih od karcinoma dojke koje su neoadjuvantnim liječenjem postigle kliničku remisiju u aksili. Primarni cilj ovog istraživanja bila je evaluacija kliničkog utjecaja metode u gore navedenoj skupini pacijentica. Metode: U ovu retrospektivnu analizu uključene su sve bolesnice oboljele od karcinoma dojke, liječene u KBC Rijeka u period od svibnja 2016. do svibnja 2018., kod kojih je preoperativno provedeno sistemsko onkološko liječenje. U prvoj postoperativnoj godini praćena je pojava lokoregionalnog i sistemskog recidiva. Rezultati: Četrdeset i osam od sveukupno 65 bolesnica uključenih u analizu prezentiralo se je sa pozitivnim aksilarnim limfnim čvorovima u vrijeme postavljanja dijagnoze, od kojih je 45.83% postiglo kompletnu patološku aksilarnu remisiju. Kod ove skupine pacijentica u prvoj postoperativnoj godini nije zabilježen niti jedan slučaj lokoregionalnog recidiva, niti statistički značajna razlika u pojavnosti udaljenih metastaza u korelaciji sa opsegom kirurškog zahvata u aksili. Međutim, u komparaciji sa ovom skupinom, kod bolesnica koje nisu postigle kompletnu aksilarnu remisiju zabilježene su više stope i lokoregionalnog i distalnog recidiva. Zaključak: Biopsija sentinel limfnog čvora je pouzdana alternativa aksilarnoj disekciji za postizanje lokoregionalne kontrole i kontrole bolesti uopće, kod bolesnica oboljelih od karcinoma dojke koje neoadjuvantnim sistemskim liječenjem postignu kompletnu kliničku aksilarnu remisiju. Odgovor aksilarnih limfnih čvorova na neoadjuvantno liječenje važniji je prognostički čimbenik od statusa limfnih čvorova na početku liječenja

Nesteroidni protuupalni lijekovi u liječenju cistoidnog makularnog edema

Nonsteroidal antiinflammatory drugs (NSAIDs) have become a significant therapeutic adjunctive tool in the routine and complicated intraocular surgery. Topical NSAIDs prevent intraoperative miosis, reduce pain, postoperative inflammation and incidence of cystoid macular edema (CME). Although there is no established protocol for prophylaxis of pseudophakic CME, due to the relationship between proinflammatory prostaglandins and CME, using corticosteroids and NSAIDs could prevent CME. NSAIDs have a synergistic antiinflammatory effect with steroids, but can also be used alone when corticosteroid therapy could be harmful. Prospective clinical trials need to define treatment protocol for topical NSAIDs use, due to their powerful influence to prevent perioperative complications.Nesteroidni protuupalni lijekovi (NSAID, engl. nonsteroidal antiinflammatory drugs) postali su značajna dodatna terapija u rutinskim i kompliciranim intraokularnim operacijama. Topički NSAID-i sprječavaju intraoperativnu miozu, smanjuju bol, postoperativnu upalu i učestalost cistoidnog makularnog edema (CME). Iako nema uspostavljenog protokola za profilaksu pseudofakičnog CME-a, zbog veze između proupalnih prostaglandina i CME-a primjena topičkih kortikosteroida i topičkih NSAID-a može spriječiti CME. NSAID-i imaju sinergistički protuupalni učinak sa steroidima, ali se mogu upotrijebiti i sami kada bi kortikosteroidna terapija mogla biti rizična. Zbog njihovog snažnog utjecaja na prevenciju perioperativnih komplikacija potrebna su prospektivna klinička istraživanja za definiranje protokola terapijske primjene topičkih NSAID-a

EVALUATION OF PHYSICIANS EXPECTATION REGARDING COURSES OF CONTINUOUS MEDICAL EDUCATION OF CROATIAN MEDICAL ASSOCIATION · BRANCH RIJEKA

Reorganisation of medical system and introduction of obligatory continuos medical education resulted in exceeded numbers of different courses of medical education. Croatian medical Association /branch Rijeka since eighties started with additional medical training by courses of continuous medical education (CME) once or twice a months. In aim to improve quality of training and find out which are the most attractive themes during the may 2001. questionnaire was performed The questionnaire consisted of 34 fields of medicine (basic and clinical). Physicians were asked to decide, regarding their personal needs and necessity from which of these fields they want courses “regularly”, “occasionally” or “rare”. All together 1200 questionnaires were sent, 270 were received and 229 were analysed. These represent 19% of Croatian Medical Association / branch Rijeka total members. Physicians would like “regularly” courses from the fields of emergency/intensive medicine (66.4%), and then laboratory diagnostic, cardiology, family medicine, rheumathology, gastroenterology, infektology, clinical pharmacology, paediatric, and psychiatric (in the range from 35% do 25%). At the group of “occasionally” courses the first five places took dermatology, ear/nose/throat, endocrinology, nephrology and alergology. Physicians would like “rare” to have course with themes from medical economy, clinical pathology, sports medicine, basic medical sciences and transplantation medicine. It is interesting to point out that neither oncology, surgery or gynaecology/obstetricion were not found in “top ten”. Fifty percent doctors quoted important influence and one third very important influence of CME on every day work. These results revealed particular necessities in CME and they may be used as a guides in planning accurate and direct prolonged courses of medical educatio

EVALUATION OF PHYSICIANS EXPECTATION REGARDING COURSES OF CONTINUOUS MEDICAL EDUCATION OF CROATIAN MEDICAL ASSOCIATION · BRANCH RIJEKA

Reorganisation of medical system and introduction of obligatory continuos medical education resulted in exceeded numbers of different courses of medical education. Croatian medical Association /branch Rijeka since eighties started with additional medical training by courses of continuous medical education (CME) once or twice a months. In aim to improve quality of training and find out which are the most attractive themes during the may 2001. questionnaire was performed The questionnaire consisted of 34 fields of medicine (basic and clinical). Physicians were asked to decide, regarding their personal needs and necessity from which of these fields they want courses “regularly”, “occasionally” or “rare”. All together 1200 questionnaires were sent, 270 were received and 229 were analysed. These represent 19% of Croatian Medical Association / branch Rijeka total members. Physicians would like “regularly” courses from the fields of emergency/intensive medicine (66.4%), and then laboratory diagnostic, cardiology, family medicine, rheumathology, gastroenterology, infektology, clinical pharmacology, paediatric, and psychiatric (in the range from 35% do 25%). At the group of “occasionally” courses the first five places took dermatology, ear/nose/throat, endocrinology, nephrology and alergology. Physicians would like “rare” to have course with themes from medical economy, clinical pathology, sports medicine, basic medical sciences and transplantation medicine. It is interesting to point out that neither oncology, surgery or gynaecology/obstetricion were not found in “top ten”. Fifty percent doctors quoted important influence and one third very important influence of CME on every day work. These results revealed particular necessities in CME and they may be used as a guides in planning accurate and direct prolonged courses of medical educatio

Operabilni invazivni karcinom dojke u eri konzervativne kirurgije; retrospektivna analiza 5-godišnjeg preživljenja i kontrole bolesti

Background: Following breast cancer treatment recommendations, the conservative approach is accepted and highly respected in the Clinical Hospital Center (CHC) Rijeka. However, we have found that institutional follow-up data are lacking. This retrospective analysis aims to update institutional data on survival and disease control rates. Methods: From 2011 till 2014, 915 breast cancer patients underwent surgery at CHC Rijeka, and 615 were included in this analysis. The Institutional Ethics Committee approved the analysis. Results: All patients were female, and the average age was 59 years. In the 5-year postoperative period, local, regional, and distant recurrence-free survival rates and overall survival and disease-free survival were calculated. All rates negatively correlate with a higher T and N status and a higher stage of the disease. The analysis has also demonstrated that in the pT1-3 pN0-1 subgroup, sentinel lymph node biopsy (SLNB) was not inferior to axillary lymph node dissection (ALND) in terms of locoregional control of disease and overall survival. Conclusion: Besides updating institutional data, the analysis confirmed that overall survival and locoregional control of the disease in the upfront-surgery patients are similar between pN0 and pN1 subpopulations and between pN2 and pN3, but statistically significantly different between pN0-1 and pN2-3. Currently ongoing, prospective observational multicenter clinical trial aims to translate the significance of these results into the neoadjuvant era.Uvod: Temeljem suvremenih preporuka za liječenje karcinoma dojke, u Kliničkom bolničkom centru (KBC) Rijeka prihvaća se i zagovara konzervativni kirurški pristup. Međutim, na razini naše institucije, ali i na nacionalnom nivou, malo je obrađenih rezultata liječenja. Cilj ove retrospektivne analize je ažuriranje institucionalnih podataka o preživljenju i kontroli bolesti. Metode: U periodu od 2011. do 2014. godine, u KBC Rijeka operirano je 915 pacijentica oboljelih od karcinoma dojke, a njih 615 uključeno je u ovu analizu. Istraživanje je odobreno od Etičkog povjerenstva KBC Rijeka. Rezultati: Sve su pacjentice bile žene, prosječno stare 59 godina. Izračunate su ukupne stope preživljenja bez lokalnog, regionalnog i udaljenog recidiva, te stope ukupnog preživljenja i preživljenja bez povrata bolesti u petogodišnjem postoperativnom periodu. Sve su stope u negativnoj korelaciji sa višim T i N statusom kao i višim stadijem bolesti. Osim navedenog, rezultati su potvrdili da je biopsija sentinel limfnog čvora ekvivalentna aksilarnoj disekciji u smislu lokoregionalne kontrole bolesti kao i ukupnog petogodišnjeg preživljenja u pT1-3 pN0-1 podskupini. Zaključak: Osim ažuriranja podataka naše institucije, ova je analiza potvrdila da su stope preživljenja i lokoregionalne kontrole bolesti u eri primarnog kirurškog tretmana slične između pN0 i pN1 subpopulacija kao i među pN2 i pN3, međutim statistički značajno različite između pN0-1 I pN2-3 podskupina. Prospektivno, opservacijsko, multicentrično kliničko istraživanje koje je u tijeku pokušava istražiti značenje ovih rezultata u neoadjuvantoj eri

Aksilarnu limfadenektomiju trebalo bi izostaviti kod bolesnica sa karcinomom dojke i minimalnom rezidualnom bolesti u sentinel limfnom čvoru nakon neoadjuvantnog sistemskog liječenja

Background: In modern breast cancer management, SLNB is a standard of care. For the patients with limited sentinel lymph node involvement in the upfront surgery setting, ALND can be safely omitted. However, for any sentinel node metastasis detected following neoadjuvant systemic treatment (NST), ALND is still considered a mandatory procedure. Patients and methods: Present retrospective analysis has included all breast cancer patients submitted to surgery following NST in Clinical Hospital Centre (CHC) Rijeka in the period from 2017 till 2020. Results: SLNB was performed in 151 of 222 consecutive patients, and sentinel node metastasis was detected in 49 cases. The risk of non-sentinel lymph node involvement in sentinel node-positive patients was 34.7%, but exclusively for cases with macro-metastatic disease detected in the sentinel node. In addition, for the patients diagnosed with clinically uninvolved axilla, the risk of ypN2-3 status was only 2.8%. Conclusions: ALND following NST is overtreatment in 65.3% of sentinel node-positive patients. Axillary irradiation with the omission of ALND should be considered for the sentinel-positive patients with only micro-metastatic disease detected in the sentinel node following neoadjuvant chemotherapy, as well as for those with low volume macro metastatic disease, diagnosed with the uninvolved axilla.Uvod: U modernom kirurškom pristupu liječenja kacinoma dojke SLNB je univerzalno prihvaćeni standard. Izostavljanje ALND, u slučajevima sa metastazom pronađenom u do dva sentinel limfna čvora, ne utječe na onkološke ishode kod primarno kirurški liječenih pacijentica, Međutim, svaka metastaza detektirana u sentinel limfnom čvoru nakon provedenog neoadjuvantnog sistemskog liječenja još uvijek se smatra apsolutnom indikacijom za ALND. Pacijenti i metode: Sve pacijentice operirane zbog karcinoma dojke u Kliničkom Bolničkom Centru (KBC) Rijeka nakon provedene neoadjuvantne kemoterapije, u periodu od 2017. do 2020., uključene su u ovu retrospektivnu analizu. Rezultati: SLNB je učinjena kod 151 od 222 uzastopne pacijentice, a metastaza u sentinel čvoru pronađena je u 49 slučajeva. Rizik metastatske bolesti u ne-sentinel limfnim čvorovima kod sentinel-pozitivnih pacijentica je 34.7%, međutim isključivo u slučajevima sa makrometastazom u sentinel čvoru. Nadalje, kod skupine pacijenica dijagnosticiranih sa klinički i radiološki negativnom aksilom, rizik od ypN2-3 statusa je samo 2.8% Zaključak: Nakon neoadjuvantne kemoterapije ALND je overtreatment u 65.3% sentine-pozitivnih pacijentica. Izostavljanje ALND uz zračenje aksile nakon provedenog neoadjuvantnog liječenja je opcija koju bi trebalo razmotriti za sentinelpozitivne bolesnice sa mikro-metastazom u sentinel čvoru, kao i za bolesnice sa malim volumenom makrometastatske bolesti u sentinel limfnim čvorovima, a koje su inicijalno dijagnosticirane sa klinički negativnom aksilom

Concordance of estimated residual tumor size by magnetic resonance imaging and pathohistologic findings in breast cancer patients after neoadjuvant chemotherapy

Cilj. Cilj istraživanja je procijeniti podudarnost veličine rezidualnog tumora, izmjerene magnetskom rezonancijom (MR) i patohistološkom dijagnostikom (PHD) u pacijentica s karcinomom dojke nakon provedene neoadjuvantne kemoterapije (NAK) te procijeniti mogući utjecaj ypT stadija tumora na nepodudarnost veličina izmjerenih navedenim metodama. Ispitanici i metode: U retrospektivno istraživanje uključeno je 50 pacijentica. Uključni kriterij su pacijentice kod kojih je učinjen operativni zahvat uz prethodno proveden NAK karcinoma dojke, na što je odgovor praćen s najmanje dva MR pregleda. Veličina tumora na MR-u uspoređena je s veličinom na PHD-u (zlatni standard) pomoću regresijske analize Passing-Bablok te je izračunat njihov koeficijent korelacije. Analizirana su sva odstupanja i podudarnosti veličine, kao i eventualni utjecaj ypT stadija tumora na razliku između dviju metoda. Razlika od ± 0,5 cm u veličini tumora procijenjenih slikovnom metodom i u PHD nalazu smatrale su se podudarnima veličinama. Rezultati: Srednja vrijednost veličine rezidualnog tumora na MR-u iznosila je 19,1 ± 17,71 mm, dok je na PHD-u iznosila 16,87 ± 18,19 mm. Izračunati r koeficijent korelacije iznosi 0.64 (p < 0.001). Provedenom analizom potvrđeno je da nema značajne razlike izmjerenih veličina tumora na MR-u i PHD-u (p = 0.552) te se metode mogu smatrati podudarnima. Nije uočena statistički značajna razlika u ovisnosti o ypT stadiju tumora koja bi utjecala na nepodudarnost veličina. Zaključci: Među dvjema metodama nema konstantnog niti proporcionalnog odstupanja u mjerenjima te se metode mogu smatrati podudarnim. MR dojke je dobra metoda za procjenu veličine rezidualnog tumora dojke kod pacijentica koje su podvrgnute neoadjuvantnoj kemoterapiji usporedno s PHD-om (zlatni standard).Aim: The goal of this study is to evaluate the concordance between residual tumour size measured on magnetic resonance imaging (MRI) and pathohistological findings in patients who underwent neoadjuvant chemotherapy and operative procedure, and if any pathohistological features may affect that agreement. Respondents and methods: Fifty patients with breast cancer were retrospectively evaluated. Patients who underwent neoadjuvant chemotherapy before the operative procedure, and were assessed with at least two MRI examinations, where included in this study. The primary tumour size measured by MRI was compared with pathohistological findings, which was considered as the gold standard. All differences and size correspondence were analyzed as well as the possible influence of ypT stage of tumour between the two methods. Results: The mean value of residual tumour size on MRI was 19,2 ± 17,71 mm, while on pathohistological findings it was 16,87 ± 18,29 mm. A calculated correlation coefficient between the two methods was 0.64 (p < 0.001). There was no statistically significant difference between two methods for measuring residual tumour size (p = 0.552), as well as a statistically significant influence of ypT stage on measuring, so these methods may be considered to be concordant. Conclusions: There is neither a constant nor a proportional deviation in the measurements between the two methods, so these methods can be considered concordant. Breast MRI is a reliable method for estimating residual tumour size in patients undergoing neoadjuvant chemotherapy in comparison to pathology

Glomus Tumor of the Neck Detected With 99mTc EDDA HYNIC-TOC.

A 54-year-old woman was referred to thyroid evaluation because of a lump on the left side of the neck. Ultrasound exam did not show any thyroid abnormality, but highly perfused nodule at the left common carotid artery bifurcation was found. Because of the specific location, somatostatin receptor scintigraphy with Tc EDDA HYNIC-TOC was performed, starting with perfusion images and followed with SPECT/CT imaging at 2 and 4 hours. Well-perfused nodule with intensive accumulation and no other visible pathology in the body raised suspicion of a glomus tumor, consistent with MR exam performed later. Subsequent surgical removal confirmed carotid paragangliom