Transanal ekscizija za rektalni karcinom - multidisciplinarni pristup?

Incidence of rectal cancer in Croatia was 1174 cases in 2012. Most cases were diagnosed at an advanced stage, however there are a few diagnosed in cT1-2N0M0 stage which opens a window for transanal resection. These patients have to be staged meticulously not to disregard possible local spread of disease and nodal involvement. Endorectal ultrasound is not always easily available, therefore MRI is usually the method of choice for preoperative staging. Nevertheless, since the implementation of this mode of treatment advances in neoadjuvant and adjuvant therapy and multidisciplinary approach to treatment have blurred these clear cut indications. In this paper we discuss specificities in selection, treatment and follow up of these patients.Incidencija karcinoma rektuma u Hrvatskoj je oko 1174 slučajeva u 2012 godini. Većina slučajeva je dijagnosticirana u poodmaklim stadijima bolesti, ipak odre|en broj se dijagnosticira u cT1-T2N0M0 stadiju što otvara mogućnost za transanalnu eksciziju. Pacijenti kod kojih se predvi|a trananalna ekscizija moraju biti u potpunosti slikovno obrađena kako se preoperativno ne bi previdjela proširenja bolest. Endorektalni ultrazvuk nije široko dostupan, tako da se najčešće koristi MR pri odluci o vrsti zahvata. Unatoč dosta jasno definiranim indikacijama za ovaj zahvat, napredak u neoadjuvantom i adjuvantnom pristupu te multidisciplinarnosti liječenja je iste relativizirao. U ovom preglednom radu raspravit ćemo izbor, vrstu liječenja i praćenja ovih pacijenat

Kirurško liječenje kolorektalnih metastaza u jetri

Approximately 50% of patients with colorectal cancer (CRC) will developduring their lifespan. Majority of colorectal liver metastases (CLM) patients will be unresectable at the time of diagnosis due to extensive intrahepatic and/or extrahepatic disease. R0 liver resection is still the only available treatment that allows long-term survival. In last two decades, the 5-year overall survival (OS) after curative liver resection of CLM has increased up to 58%. These improved outcomes are mainly due to multidisciplinary treatment of these patients. The definition of resectability has changed, so nowdays, the goal is the completion of R0 resection and normal liver function maintenance. Conversional (neoadjuvant) chemotherapy, portal vein embolization, two-stage hepatectomy, and tumour ablation are effective approaches to improve resectability for initially unresectable patients. The role of perioperative chemotherapy, for clearly resectable patients, still needs to be clarified. It results in longer disease-free survival (DFS) and OS times, but it is not clear whether it is the neoadjuvant or the adjuvant component that provides the benefit.Disadvantages of neoadjuvant chemotherapy are either progression or complete remission during treatment, and their managment is challenging. According to available data the efficacy of adjuvant chemotherapy after CLM resection is questionable. However, the ideal chemotherapy and its optimal sequencing in the course of treatment are uncertain.Equally, the influence of chemotherapy-associated toxicity on the outcome of liver resection needs to be further explored. There is debate over whether the primary tumour and metastases should be removed at the same time or in a staged manner. Targeted therapy with novel biological agents such as bevacizumab and cetuximab, in addition to traditional chemotherapy, has been shown to improve the survival of unresectable CLM patients. The majority of patients will develop recurrent disease in the liver within the first two years after surgery, despite any mode of treatment that they have received. Therefore, a repeat resection is recommended as the only chance to prolong DFS and OS. Consequently, all of these issues demand an modern oncosurgical and multidisciplinary approach to the each individual with liver surgeon having a central role in treatment planning.Oko 50% bolesnika s rakom debelog crijeva razviti će metastaze u jetri tijekom svog životnog vijeka. Nažalost, većina bolesnika sa metastatskim kolorektalnim karicnomom će biti inoperabilna u vrijeme postavljanja dijagnoze zbog opsežne intrahepatičke i / ili ekstrahepatičke bolesti. R0 resekcija jetre je još uvijek jedini dostupni oblik liječenja koji omogućuje dugoročno preživljenje. U posljednja dva desetljeća, 5-godišnje preživljenje nakon kurativne resekcije jetre poraslo je na 58%. Ti poboljšani rezultati su uglavnom posljedica multidisciplinarnog liječenja tih bolesnika, iako je optimalnog algoritam još uvijek upitan. Definicija resektabilnosti se promijenila, pa se danas kao cilj liječenja postavlja mogućnost R0 resekcije uz normalno postoperativno održavanje jetrene funkcije. Neoadjuvantna kemoterapija, embolizacija poralne vene, hepatekto mija u dva akta ilokalna ablacija su učinkoviti pristupi u konverziji inicijalno inoperabilnih pacijenata u operabilne. Ulogu perioperativne kemoterapije, za evidentno operabilne bolesnike, još treba razjasniti. Perioperativna kemoterapija rezultira duljim periodom bez bolesti i ukupnim preživljenjem, ali nije jasno da li je neoadjuvanta ili adjuvantna komponenta ta koja pruža korist. Potencijalni nedostaci neoadjuvantne kemoterapije su ili napredovanje ili potpuna remisija tijekom liječenja, a liječenje tih bolesnika je izazov. Prema sadašnjim podacima iz literature, učinkovitost adjuvantne kemoterapije nakon resekcije metastatskog kolorektalnog karcinoma je upitna. Isto tako, idealni kemoterapijski protokol, sa ili bez bioloških agensa, i njeno optimalno sekvenciranje u tijeku liječenja je upitno. Isto tako, utjecaj, s kemoterapijom povezane toksičnosti, na ishod kirurškog liječenja treba dodatno istražiti. Još uvijek se raspravlja o tome da li primarni tumor i metastaze treba ukloniti u isto vrijeme ili operacijama u dva akta. Za jasno inoperabilnog bolesnika, još je uvijek upitno da li primarni tumor treba resecirati. Ciljana terapija s novim biološkim agensima, kao što su bevacizumab i cetuksimab, uz tradicionalne kemoterapijske protokole, dokazano poboljšava preživljenje kod definitivno inoperabilnih bolesnika. Većina bolesnika s metastatskim kolorektalnim karcinomom (55% -60%), će se razviti intrahepatalni recidiv unutar prve dvije godine nakon kirurškog zahvata, bez obzira na modalitet liječenja. Stoga se ponovljene resekcije jetre preporučuju kao jedina moguća opcija koja može produžiti život ovim bolesnicima. Prema tome, sva ova otvorena pitanja zahtijevaju suvremenionko-kirurški pristup svakom pojedinom bolesniku, u sklopu multidisciplinarnog tima, s kirurgomu glavnoj ulozi kod planiranja liječenja

Sentimag biopsija limfnog čvora stražara u konzervativnoj kirurgiji dojke – preliminarni rezultati

Segmentectomy and sentinel lymph node biopsy is a golden standard for early breast cancer (clinical and radiological cT1-2, c N0). Recently, superparamagnetic iron oxide (SPIO) nanoparticle tracer has been introduced enabling intraoperative tracer injection. We prospectively recorded data on tumor histology, marked lymph nodes and their final histology and patient characteristics for early breast cancer patients who underwent breast conservative surgery. At 128 female breast cancer patients underwent sentinel lymph node biopsy by SentiMag. Three patients were excluded from further analysis because the postoperative pathology report was ductal carcinoma in situ (DCIS). The identifi cation rate was 95.2 % (119 of 125). Of the 19.2 % (24 of 125) patients with lymph node involvement, 1.6% (2 of 125) had micrometastasis, and 1 % (1 of 125) had single tumor cells within the sentinel, l at least a micrometastasis. Of 30 positive lymph nodes removed, 24 (80 %) were true sentinel nodes. The average lymph node retrieval rate was 2.3 nodes per patient. SentiMag’s performance was comparable to published data and to standard sentinel with blue patent die and/or technetium. The benefi t of easier application and logistics is a great advantage.Segmentektomija i biopsija limfnog čvora stražara zlatni su standard za kirurško liječenje ranog raka dojke (klinički i radiološki cT1-2, c N0). Čestice superparamagnetskog željeznog oksida (superparamagnetic iron oxide, SPIO) od nedavno se koriste kao unutaroperacijski nanočestični obilježivač. Prospektivno smo bilježili demografske podatke o bolesnicama, histologiju tumora te označenih i neoznačenih limfnih čvorova. U 128 bolesnica učinjena je biopsija limfnog čvora stražara u aksili detektorom SentiMag. Tri bolesnice su isključene, jer je konačan patohistoloski nalaz bio carcinoma ductale in situ (DCIS). Limfni čvor je pronađen u 119 od 125 bolesnica (95.2%), pozitivne limfne čvorove su imale 24 (19.2%), makrometasaze 2 (1.6%) i mikrometastaze 1 bolesnica (0.08%). Od 30 pozitivnih odstranjenih limfnih čvorava, obilježenih je bilo 24 (80 %). Prosječno su po bolesnici izvađena 2.3 limfna čvora. Mogućnost otkrivanja limfnog čvora stražara SentiMagom usporediva je s dosad objavljenim podatcima i zlatnim standardom. Prednosti metode su lakše rukovanje i minimalna logistika

Stome

Ostomies are relatively frequent in emergent and elective abdominal surgery but often neglected and relegated to the junior or less experinced members of the operating team. In Croatia there are about 5000 patients with either ileostomy or colostomy. Patients do receive preoperative and postoperative counseling about living with a stoma. Most patients can be reassured and made more comfortable with the concept. It is important to stress the necessity of stoma formation: sometimes it is the only option after intestinal resection or in emergency setting surgery, protection from severe abdominal infection or improvement quality of life in most patients with disordered bowel function (colitis, incontinence). There are also patient groups dealing with the issue. However, concept and stygma of ostomies should be delt with in a more general fashion and the entire multidisciplinary team and people dealing with these patients on primary care level should be aware of it. Finally, development of concept of enterostomal therapist- specialist available to aid the patient well after the surgery is crucial. In this paper we discussed ostomy formation, possible complications and members of the team dealing with ostomies.Kreiranje stoma je relativno čest problem u hitnoj i elektivnoj abdominalnoj kirurgiji no često zanemaren i prepušten mlađim ili manje iskusnim članovima operativnog tima. U Hrvatskoj postoji oko 5000 bolesnika koji žive sa ileostomom ili kolostomom. Bolesnici se preoperativno i postoperativno savjetuju kako živjeti sa stomom. Većini bolesnika se može osigurati potrebna skrb odnosno olakšati svakodnevno funkcioniranje sa stomom i komplikacijama koje se mogu pojaviti vezano uz stomu. Važno je naglasiti da je stoma ponekad neophodna: kao jedina opcija nakon resekcije crijeva ili u stanjima hitnosti, kao zaštita zbog teških abdominalnih infekcija ili poboljšanje kvalitete života u nekim stanjima (crijevne upalne bolesti, inkontinencija). Postoje radne grupe bolesnika koji žive sa stomom. Međutim, koncept života sa stomom i stigma koju ona nosi bolesniku mora se olakšati bolesniku i putem multidisciplinarnog medicinskog tima uključujući i liječnike obiteljske medicine. Na koncu ključno je razvijati koncept enterostomalnog terapeuta-specijalista koji će pomoći bolesniku po završetku kirurškog liječenja i otpuštanja iz bolnice. U ovome članku nastojali smo objasniti kirurške principe formiranja stome, moguće komplikacije i tim koji bi trebao biti na raspolaganju bolesniku kojem je kreirana stoma

Stome

Ostomies are relatively frequent in emergent and elective abdominal surgery but often neglected and relegated to the junior or less experinced members of the operating team. In Croatia there are about 5000 patients with either ileostomy or colostomy. Patients do receive preoperative and postoperative counseling about living with a stoma. Most patients can be reassured and made more comfortable with the concept. It is important to stress the necessity of stoma formation: sometimes it is the only option after intestinal resection or in emergency setting surgery, protection from severe abdominal infection or improvement quality of life in most patients with disordered bowel function (colitis, incontinence). There are also patient groups dealing with the issue. However, concept and stygma of ostomies should be delt with in a more general fashion and the entire multidisciplinary team and people dealing with these patients on primary care level should be aware of it. Finally, development of concept of enterostomal therapist- specialist available to aid the patient well after the surgery is crucial. In this paper we discussed ostomy formation, possible complications and members of the team dealing with ostomies.Kreiranje stoma je relativno čest problem u hitnoj i elektivnoj abdominalnoj kirurgiji no često zanemaren i prepušten mlađim ili manje iskusnim članovima operativnog tima. U Hrvatskoj postoji oko 5000 bolesnika koji žive sa ileostomom ili kolostomom. Bolesnici se preoperativno i postoperativno savjetuju kako živjeti sa stomom. Većini bolesnika se može osigurati potrebna skrb odnosno olakšati svakodnevno funkcioniranje sa stomom i komplikacijama koje se mogu pojaviti vezano uz stomu. Važno je naglasiti da je stoma ponekad neophodna: kao jedina opcija nakon resekcije crijeva ili u stanjima hitnosti, kao zaštita zbog teških abdominalnih infekcija ili poboljšanje kvalitete života u nekim stanjima (crijevne upalne bolesti, inkontinencija). Postoje radne grupe bolesnika koji žive sa stomom. Međutim, koncept života sa stomom i stigma koju ona nosi bolesniku mora se olakšati bolesniku i putem multidisciplinarnog medicinskog tima uključujući i liječnike obiteljske medicine. Na koncu ključno je razvijati koncept enterostomalnog terapeuta-specijalista koji će pomoći bolesniku po završetku kirurškog liječenja i otpuštanja iz bolnice. U ovome članku nastojali smo objasniti kirurške principe formiranja stome, moguće komplikacije i tim koji bi trebao biti na raspolaganju bolesniku kojem je kreirana stoma

The role of the acute octreotide suppression test in detecting patients with neuroendocrine neoplasms

Background: Serum chromogranin A (CgA) is routinely used as a biomarker in patients with neuroendocrine neoplasms (NENs). Several conditions and comorbidities may be associated with falsely elevated CgA, often leading to extensive diagnostic evaluation, which may be costly and harmful. The aim of this study was to analyze the effectiveness of the acute octreotide suppression test (AOST) in differentiating falsely elevated serum CgA. ----- Methods: Our prospective study enrolled 45 patients from two different patient cohorts: (1) 29 patients with suspicion or presence of NENs (extensive workup and subsequent biopsy confirmed 16 NENs); (2) 16 consecutive patients admitted via the Emergency Department without NENs (non-NENs). AOST was performed after an overnight fast. Baseline CgA was measured, after which 0.25 mg of octreotide was administered subcutaneously. CgA was measured 3 and 6 h after administration. ----- Results: Baseline CgA levels were similar in NENs and non-NENs. At the end of the AOST, CgA decreased by a median of 83.3% (41.0-127.4) in non-NENs and 13.8% (0.0-43.6) in NENs (p < 0.001). In patients with increased baseline CgA, a decrease in CgA at the 6th hour of < 51.3% had 90.0% sensitivity and 88.9% specificity in detecting NENs. In patients with normal baseline serum CgA, a decrease in CgA at the 3rd hour of < 17.6% had 83.3% sensitivity and 81.8% specificity in detecting patients with NENs. The diagnostic accuracy of the AOST in the entire study population was 86.7%. ----- Conclusions: AOST is a promising tool to increase the diagnostic accuracy of serum CgA

Genome-wide Association Study of Anthropometric Traits in Korčula Island, Croatia

AIM: To identify genetic variants underlying six anthropometric traits: body height, body weight, body mass index, brachial circumference, waist circumference, and hip circumference, using a genome-wide association study. ----- METHODS: The study was carried out in the isolated population of the island of Korcula, Croatia, with 898 adult examinees who participated in the larger DNA-based genetic epidemiological study in 2007. Anthropometric measurements followed standard internationally accepted procedures. Examinees were genotyped using HumanHap 370CNV chip by Illumina, with a genome-wide scan containing 316730 single nucleotide polymorphisms (SNP). ----- RESULTS: A total of 11 SNPs were associated with the investigated traits at the level of P<10(-5), with one SNP (rs7792939 in gene zinc finger protein 498, ZNF498) associated with body weight, hip circumference, and brachial circumference (P=3.59-5.73 x 10(-6)), and another one (rs157350 in gene delta-sarcoglycan, SGCD) with both brachial and hip circumference (P=3.70-6.08 x 10(-6). Variants in CRIM1, a gene regulating delivery of bone morphogenetic proteins to the cell surface, and ITGA1, involved in the regulation of mesenchymal stem cell proliferation and cartilage production, were also associated with brachial circumference (P=7.82 and 9.68 x 10(-6), respectively) and represent interesting functional candidates. Other associations involved those between genes SEZ6L2 and MAX and waist circumference, XTP6 and brachial circumference, and AMPA1/GRIA1 and height. ----- CONCLUSION: Although the study was underpowered for the reported associations to reach formal threshold of genome-wide significance under the assumption of independent multiple testing, the consistency of association between the 2 variants and a set of anthropometric traits makes CRIM1 and ITGA1 highly interesting for further replication and functional follow-up. Increased linkage disequilibrium between the used markers in an isolated population makes the formal significance threshold overly stringent, and changed allele frequencies in isolate population may contribute to identifying variants that would not be easily identified in large outbred populations