Jana Dvorackova

Endoscopic ultrasound-guided fine needle aspiration of pancreatic masses: The utility and impact on management of patients

Abstract Objective. It is controversial whether endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is beneficial in all patients with suspected pancreatic cancer. The aim of this study was to assess diagnostic yield, safety and impact of EUS-FNA on management of patients with solid pancreatic mass. Material and methods. Consecutive patients undergoing EUS-FNA of solid pancreatic mass were enrolled. Gold standard for final diagnosis included histology from surgical resection. In patients without surgery, clinical evaluation methods and repeated imaging studies were used for the comparison of initial cytology and final diagnosis. Patients were followed-up prospectively focusing on subsequent treatment. Results. Among 207 enrolled patients, final diagnosis was malignant in 163 (78.6%) and benign in 44 (21.4%). The sensitivity, specificity and accuracy of EUS-FNA in diagnosing pancreatic cancer were 92.6% (95% CI: 87.20–95.96), 88.6% (95% CI: 74.64–95.64) and 91.8% (95% CI: 87.24–94.81), respectively. No major and five (2.4%) minor complications occurred. Of 151 true-positive patients by EUS-FNA, 57 (37.7%) were surgically explored, of whom 28 (49.1%) underwent resection. Ten of 12 patients with false-negative cytology were explored based on detection of mass on EUS, of whom two had a delay due to false-negative cytology without curative treatment. From the whole study cohort, EUS-FNA had positive and negative impacts on subsequent management in 136 (65.7%) and 2 (0.9%) patients, respectively. Conclusions. EUS-FNA provides accurate diagnosis in 92% and has positive therapeutic impact in two-thirds of patients with solid pancreatic mass. Despite negative cytology, surgical exploration is recommended in clinical suspicion for pancreatic cancer and solid mass on EUS.

What is the risk for parametrial involvement in women with early‐stage cervical cancer with tumour <20 mm and with negative sentinel lymph nodes?

To evaluate the incidence of parametrial involvement in women with early‐stage cervical cancer with tumour <20 mm and with negative sentinel lymph nodes (SLN).

The changes of angiogenesis and immune cell infiltration in the intra- and peri-tumoral melanoma microenvironment.

Malignant melanoma (MM) urgently needs identification of new markers with better predictive value than currently-used clinical and histological parameters. Cancer cells stimulate the formation of a specialized tumor microenvironment, which reciprocally affects uncontrolled proliferation and migration. However, this microenvironment is heterogeneous with different sub-compartments defined by their access to oxygen and nutrients. This study evaluated microvascular density (MVD), CD3+ lymphocytes (TILs) and FOXP3+ T-regulatory lymphocytes (Tregs) on formalin-fixed paraffin-embedded tissue sections using light microscopy. We analyzed 82 malignant melanomas, divided according to the AJCC TNM classification into four groups—pT1 (35), pT2 (17), pT3 (18) and pT4 (12)—and 25 benign pigmented nevi. All parameters were measured in both the central areas of tumors (C) and at their periphery (P). A marked increase in all parameters was found in melanomas compared to nevi (p = 0.0001). There was a positive correlation between MVD, TILs, FOXP3+ Tregs and the vertical growth phase. The results show that MVD, TILs and FOXP3+ Tregs substantially influence cutaneous melanoma microenvironment. We found significant topographic differences of the parameters between central areas of tumors and their boundaries.

Addition of platelet concentrate to Dermo-Epidermal Skin Graft in deep burn trauma reduces scarring and need for revision surgeries

BACKGROUND [corrected] Deep skin burn injuries, especially those on the face, hands, feet, genitalia and perineum represent significant therapeutic challenges. Autologous dermo-epidermal skin grafts (DESG) have become standard of care for treating deep burns. Additionally, human autologous thrombin activated autologous platelet concentrate (APC) has gained acceptance in the setting of wounds. While each of these interventions has been independently shown to accelerate healing, the combination of the two has never been evaluated. We hypothesized that the addition of platelets (source of growth factors and inhibitors necessary for tissue repair) to the DESG (source of progenitor cells and of tissue proteases necessary for spatial and temporal control of growth regulators released from platelets) would create the optimal environment for the reciprocal interaction of cells within the healing tissues. METHODS We used clinical examination (digital photography), standardised scales for evaluating pain and scarring, in combination with blood perfusion (laser Doppler imaging), as well as molecular and laboratory analyses. RESULTS We show for the first time that the combination of APC and DESG leads to earlier relief of pain, and decreased use of analgesics, antipruritics and orthotic devices. Most importantly, this treatment is associated with earlier discharges from hospital and significant cost savings. CONCLUSIONS Our findings indicate that DESG engraftment is facilitated by the local addition of platelets and by systemic thrombocytosis. This local interaction leads to the physiological revascularization at 1-3 months. We observed significant elevation of circulating platelets in early stages of engraftment (1-7 days), which normalized over the subsequent 7 and 90 days.

I-131 uptake in an ovarian tumor: differential diagnosis for abdominal I-131 uptake.

A 69-year-old woman was seen with well-differentiated papillary thyroid cancer with metastases in the neck lymph nodes, which was treated twice with 200 mCi (7.4 GBq) I-131. Several diagnostic scans during the next 12 years were negative. The last diagnostic scan with 8 mCi (300 MBq) I-131 revealed a large focus of I-131 uptake in the abdomen. An ultrasound was performed and was compatible with a large anechoic septal mass (21 × 16 × 9 cm) in the right side of the abdomen. Laparotomy with intraoperative evaluation and intraoperative histologic procedure confirmed ovarian granulosa cell tumor.

Semi-spherical Radiofrequency Bipolar Device - A New Technique for Liver Resection: Experimental In Vivo Study on the Porcine Model.

The incidence of colorectal carcinoma is still growing in the Czech Republic and also all around the world. With success of oncological treatment is also growing a number of potential patients with liver metastases, who can profit from surgical therapy. The aim of this study was to confirm on porcine models that this method by using new surgical device is effective and safe for patients who have to undergo liver resection. The primary hypothesis of the study was to evaluate whether this new device is able to consistently produce homogeneous and predictable areas of coagulation necrosis without the Pringle maneuver of vascular inflow occlusion. The secondary hypothesis of the study was to compare the standard linear radiofrequency device and a new semi-spherical bipolar device for liver ablation and resection in a hepatic porcine model. Twelve pigs were randomly divided into two groups. Each pig underwent liver resection from both liver lobes in the marginal, thinner part of liver parenchyma. The pigs in first group were operated with standard using device and in the second group we used new developed semi-spherical device. We followed blood count in 0th, 14th and 30th day from operation. 14th day from resection pigs underwent diagnostic laparoscopy to evaluate of their state, and 30th day after operation were all pigs euthanized and subjected to histopathological examination. Histopathological evaluation of thermal changes at the resection margin showed strong thermal alteration in both groups. Statistical analysis of collected dates did not prove any significant (p < 0.05) differences between standard using device and our new surgical tool. We proved safety of new designed semi-spherical surgical. This device can offer the possibility of shortening the ablation time and operating time, which is benefit for patients undergoing the liver resection.

Lymphangiogenesis and Its Correlation with the VEGF Expression and the Sentinel Lymph Node in Cutaneous Melanomas

The aim of the study is to evaluate the density of intratumoral and peritumoral lymphatic vessels in primary cutaneous melanomas and to assess their correlation with the status of sentinel lymph nodes and the VEGF expression in tumor cells and stromal cells. A total of 40 patients were enrolled in the study: the melanomas were radically excised with the extirpation of the sentinel lymph node. The study subjects were divided into two groups: 20 cases with positive and 20 cases with negative sentinel lymph node results. The density of lymphatic vessels was evaluated by the antibody D2-40 and the VEGF expression was investigated in the semiquantitative way. The VEGF expression in melanoma cells and the stromal cells was negative to variable positive at both SLN negative and SLN positive patients in all pT stages. In the group of SLN positive patients, the density of intratumoral lymphatic vessels was low up to moderate, while it was observed to be absent, somewhere on the low level in the group of SLN negative patients. On the other side, the density of peritumoral lymphatic vessels was equally numerous at both SLN negative and SLN positive patients. The lymphatic invasion was found out at 4 SLN positive patients only. The ulceration was chiefly in the group of LN positive patients. The results show that the density of lymphangiogenesis and the intensity of the VEGF expression are considered to be an unreliable predictor of melanoma metastasis to the sentinel lymph node, but the ulceration and the lymphatic invasion can predict the potential for metastasis.

Detection of nano- and micro-sized particles in routine biopsy material - pilot study

BACKGROUND Nanotechnology is receiving enormous funding. Very little however is known about the health dangers of this technology so far. Chronic tonsillitis is one of a number of diseases called idiopathic. Among other factors, the tonsils are exposed to suspended particles in inhaled air including nano particles. The objective of this study was to detect and evaluate metallic particles in human tonsil tissue diagnosed with chronic tonsillitis and in amniotic fluid as a comparison. METHODS . Scanning electron microscopy with energy dispersive X-ray spectroscopy (SEM-EDX) was used for identification of solid particles in a total of 64 samples of routinely analyzed biopsy and cytologic material. RESULTS Almost all samples were found to contain solid particles of various metals. The most frequent, regardless of diagnosis, were iron, chromium, nickel and aluminium. The size, determined using SEM, varied from around 500 nm to 25 µm. The majority formed aggregates of several micrometers in size but there were a significant number of smaller (sub-micrometer or nano-sized) particles present. The incidence of metallic particles was similar in child and adult tissues. The difference was in composition: the presence of several metals in adults was due to occupational exposure. CONCLUSIONS The presence of metallic particles in pathologically altered tissues may signal an alternative causation of some diseases. The ethiopathogenic explanation of these diseases associated with the presence of nano-sized particles in the organism has emerged into a new field of pathology, nanopathology.

Low intrapatient variability of histomorphological findings in periprosthetic tissues from revised metal/ceramic on polyethylene joint arthroplasties

The type of tissue response to implant by-products can be determined by examination of periprosthetic tissues. However, little is known about the most suitable location for tissue sampling. The main goal of this study was to evaluate the extent of variability in tissue response in relation to location of tissue sampling, implant fixation, age and sex in total joint arthroplasties with metal-on-polyethylene or ceramic-on-polyethylene bearing pairs. We processed 236 histology slides from 21 patients and focused on the association between the location of tissue samples and histological features. The presence of the synovial hyperplasia showed a significant association with the particular sampling site. A higher density of high endothelial cell venules was seen in the samples from around the joint, and polyethylene particles were more abundant in noncemented TJA but both findings did not show statistically significant association with the sampling site. The results showed a relatively small variance in the tissue response to prosthetic by-products among tissues sampled from the same patient. Our findings indicate that tissue samples retrieved from similar distance from around the TJA during the revision operation show comparable results of histological analysis.

Primary neuroendocrine carcinoma of the kidney.

BACKGROUND The objective of the study was to report a rare case of primary neuroendocrine carcinoma of the right kidney in a 36 year old male. METHODS The patient was clinically assessed; CT and OctreoScan scintigraphy were performed and levels of 5-HIAA, vanillylmandelic acid and NSE were determined. The tumor and metastases were histologically and immunohistochemically examined. RESULTS The imaging methods showed a cystic tumor in the lower pole of the right kidney. Macroscopically, the entire tumor was sized 8x8x7 cm. Histologically, it was made up of ribbon-line or trabecular patterns of tumor cells. Occasional adenomatoid and cystic structures were present. The tumor cell nuclei were round or oval, with no irregularities and fine lumpy chromatin. The mitotic count was < 1 /10HPF and the proliferation marker Ki-67 was < 1 % of tumor cells. Immunohistochemically, the tumor cells were positive with antibodies against chromogranin A, synaptophysin, CD56 (focally), cytokeratins AE1-AE3 (focally), vimentin (most cells), glucagon (focally), and pancreatic polypeptide (PP; focally). Antibodies against serotonin, somatostatin, gastrin, vasoactive intestinal polypeptide (VIP) and calcitonin did not react with the tumor. The results of biochemical markers (5-HIAA, vanillylmandelic acid and NSE) did not correlate with development or treatment of the tumor. CONCLUSIONS Primary neuroendocrine carcinoma of the kidney was diagnosed both histologically and immunohistochemically. The patient was clinically investigated using CT and OctreoScan scintigraphy. Within two years from nephrectomy, metastases were found in the right humerus and retrocaval lymph nodes. The metastatic lesions were surgically removed. Currently, the patients condition is good, with no tumor progression detected.