Zlatko Hrgovic

Phyllodes tumors of the breast diagnostic and therapeutic dilemmas.

Background: This article compares experiences in the diagnosis and treatment of phyllodes tumors from 2 regional institutions with the relevant literature. Patients and Methods: From 1991 to 2005, 2,848 breast cancer patients were treated in our institutions, 36 (1.44%) for phyllodes tumors. The average tumor size was 5.1 cm (range 1.4-19.6). Triple assessment was the standard diagnostic algorithm. Wide excision with tumor-free margins was carried out in 29 (80.5%) cases and mastectomy in 7 (19.4%) cases. Axillary lymphadenectomy was performed in patients with positive lymph nodes. Results: Histology showed the phyllodes tumors to be benign in 27 (75.0%), malignant in 6 (16.6%), and borderline in 3 (8.3%) cases. Follow-up was from 5 months to 16 years. In this period, recurrences of 3 (8.3%) malignant and 2 (5.6%) benign phyllodes tumors were diagnosed and treated. 10 (27.7%) patients treated with wide local excision showed deformities in the form of scarring. The steroid receptor status was of no prognostic value in our patients, and chemotherapy was used in only 1 (2.7%) patient. 5-year survival was 86.2%. Conclusion: Our study shows that tumor size, margin infiltration, mitotic activity and degree of cellular atypia are important prognostic factors. Problems in diagnosing this condition arise from its similarity to fibroadenoma. Although wide local excision is usually the treatment of choice, tumor recurrence is common. Axillary lymphadenectomy in malignant phyllodes tumors is, in our opinion, still controversial.

Malignant Melanoma of the Urethra: A Rare Histologic Subdivision of Vulvar Cancer with a Poor Prognosis

Malignant melanoma of the urethra is a rare tumour that is difficult to diagnose and treat, resulting in a poor prognosis. In this paper, we present the case of a 65-year-old woman who was referred to a gynaecologist because of a urethral mass that mimicked a caruncle. The tumour was removed by local excision, and a pathological analysis revealed a malignant melanoma. Distal urethrectomy was performed after three months with no evidence of residual tumour. There was no evidence of disease at a six-year followup. In this paper, we compare the epidemiology, treatment, staging, and prognosis of vulvar cancer in general to malignant melanoma of the vulva in particular.

Penile injury and effect on male sexual function

Penile injury is common as an emergency and should be accurately diagnosed and treated. We analysed 22 patients with penile injury admitted to the emergency unit of Dubrava University Hospital during a 4‐year period. According to the American Association for the Surgery of Trauma five‐grade classification of penile injuries, there were 14 grade I, 6 grade II and 2 grade III cases. Diagnosis was mainly based on clinical and ultrasonography findings, and in some cases on cavernosography. Nineteen patients underwent immediate surgery and three patients received conservative therapy. On outpatient follow up, sexual function was assessed by use of the 5‐item International Index of Erectile Function (IIEF‐5) test at 3 and 12u2003months of injury. At 3‐month follow up, moderate, mild and no erectile dysfunction was recorded in 5, 6 and 11 patients respectively (mean IIEF‐5: 19.62). At 12‐month follow up, mild erectile dysfunction was found in only one patient (IIEF‐5: 20), whereas all other patients were free from erectile dysfunction (mean IIEF‐5: 23.75). The 12‐month follow up yielded a higher statistical difference (Pu2003<u20030.001) when compared with 3‐month follow up. Study results indicated that appropriate treatment of penile injuries resulted in complete recovery of sexual function within 12u2003months.

Diagnosis and therapy of gestational breast cancer: a review.

PURPOSEnIn spite of the general consensus on the issue, to point to major dilemmas which appear in this matter of multidisciplinary interest, and to review current concepts on how to achieve optimal diagnostic and therapeutic outcome.nnnRESULTSnRecent literature data show that the rate of gestational breast cancer, according to most protocols, range from 0.2% to 3.8%. By definition, the clinical manifestation of this type of carcinoma is expected to occur during pregnancy or within one year after delivery. The mode of treatment and prognosis is identical to those of women with breast carcinoma beyond pregnancy, except for radiotherapy that is not indicated during pregnancy and selective use of cytostatics in polychemotherapy during the first trimester. The only exceptions to this practice are women with any advanced stage of the disease due to delayed diagnosis. Results of large studies indicate that the therapy for breast cancer has no adversarial effect on the prognosis of subsequent pregnancy.nnnCONCLUSIONnThe evaluation and management of women with gestational breast cancer requires a multidisciplinary approach. A chemotherapeutic regimen should be individualised to a maximum reduction of risk, if applied in the second and third trimester. Surgical therapy may include mastectomy and sparing operative procedures. Sentinel node biopsy should be considered in node negative patients. Radiotherapy should be postponed to the postpartum period.

Metastatic prostate cancer in an asymptomatic patient with an initial prostate-specific antigen (PSA) serum concentration of 21,380 ng/ml.

Background: Prostate cancer is the second most common cause of cancer death in men, being responsible for approximately 13% of all cancer deaths. Due to the high specificity for prostate tissue, prostate-specific antigen (PSA) is the primary serum tumor marker for prostate cancer. To our knowledge, in published data, the highest reported PSA level on initial presentation was 5,666 ng/ml. Case Report: We present a 64-year-old Caucasian man with no specific urologic or pain symptoms and with an initial PSA serum value of 21,380 ng/ml. Initial laboratory studies showed chronic anemia and elevated alkaline phosphatase, most likely from bone marrow infiltration due to metastatic disease. Prostate biopsies diagnosed an adenocarcinoma of the prostate (Gleason score 9). Computed tomography (CT) showed multiple liver metastases with retroperitoneal lymph nodes of up to 1 cm. The prostate was moderately enlarged (estimated weight 35 g). Both kidneys were normal (no hydronephrosis present). A bone scintigraphy demonstrated diffuse osseous metastasis. Treatment was initiated with bilateral subcapsular orchiectomy and bicalutamide therapy in an effort to create total androgen blockade. After 3 months of follow-up, the serum concentration of PSA was 29 ng/ml. Conclusion: This case presents an asymptomatic prostate cancer patient with bone and liver metastasis, enlarged retroperitoneal lymph nodes and the highest PSA level published to date.

Influence of stress related to war on biological and morphological characteristics of breast cancer in a defined population.

PURPOSEnTo assess differences between patients with breast cancer before, during and after the 1991-1995 war in Croatia.nnnMATERIAL AND METHODSnWe analyzed 660 patients of Pozesko-Slavonska County, during the three periods. Relative predictive values of patients characteristics and stage of tumor were assessed using the X2-test, and survival with Kaplan-Meier analysis.nnnRESULTSnTumors were significantly more often of higher stages (IIA and IIB) and with axillary lymph node metastases (N1) during the war, than in pre-war and post-war period.Breast cancer was significantly more frequent in patients who previously experienced death in the family (35,3%). The Kaplan-Meier analysis showed correlation between survival, T and N stages of tumor and clinical stage of tumor.nnnCONCLUSIONnThe war aggression towards Croatia with its impact on our patients, contributed to modification of characteristics of breast cancer in the analyzed period.

Xanthogranulomatous epididymitis: clinical report and immunohistochemical analysis

ZusammenfassungDie xanthogranulomatöse Epididymitis (XE) ist ein seltener nicht-neoplastischer Prozess mit Zerstörung von Gewebe, welches durch eine eindrucksvolle zelluläre Infiltration mit schaumigen Makrophagen, dichten Lymphozyten und Plasmazellen ersetzt wird. Wir berichten über einen 72-jährigen Mann mit der klinischen Anamnese einer inadäquat behandelten arteriellen Hypertonie, der bei uns mit einer seit 10 Tagen bestehenden schmerzhaften Tumormasse rechts im Bereich des Skrotums vorstellig wurde. Bei der physikalischen Untersuchung wurde ein Eiter sezernierendes, hyperämisiertes und ödematöses Skrotum bei normaler Körpertemperatur festgestellt. Die Tumormarker für maligne Hodenerkrankungen waren negativ. Die Ultraschalluntersuchung (US) des rechten Hodens zeigte ein ödematös geschichtetes Skrotum sowie ein heterogenes Areal mit schlecht definierter Abgrenzung im Hoden und Nebenhoden. Es bestand eine minimale Hydrocele, der rechte Funikulus hatte einen normalen Durchmesser ohne Ödem oder andere pathologische Formationen. Die Progression der klinischen Befunde, der US und auch der Farb-US zusammen mit den negativen Tumormarkern ergaben letztlich die Indikation zur chirurgischen Sanierung. Es wurde eine Orchiepididymektomie rechts nach entsprechender präoperativer Therapie durchgeführt. Die Histologie bestätigte die Diagnose einer XE.SummaryXanthogranulomatous epididymitis is an uncommon non-neoplastic process with destruction of tissue and replacement by striking cellular infiltration of foamy macrophages, dense lymphocytes and plasma cells. We report on a 72-year-old man with a clinical history of inadequately treated arterial hypertension, who presented with a right scrotal mass associated with right scrotal pain for 10 days. Physical examination revealed pyogenic discharge from the hyperemic and edematous scrotum, with normal body temperature. Testicular tumor markers were normal. Ultrasonography (US) of the right testis showed edematous scrotal layers and a heterogeneous area of poorly defined margins within the testis and epididymis. There was minimal hydrocele, and the right funiculus was of normal diameter with no edema or pathologic formation. The progression of clinical findings, inflammatory parameters, US and color Doppler US findings with negative testicular tumor markers indicated surgical treatment. After preoperative treatment, right orchiepididymectomy was performed. Histology confirmed the diagnosis of xanthogranulomatous epididymitis.

A Definite and Less Invasive Treatment with a Monarc Transobturator Sling after Several Failed Operations for Urinary Incontinence in Women

Stress urinary incontinence (SUI), defined as a leakage of small amounts of urine during physical movement (coughing, sneezing, exercising), is a common problem in women of all ages. The epidemiologic data showed that incontinence increases in prevalence during young adult life (20–30%), with a broad peak around middle age (30–40%), and then a steady increase in elderly women (30–50%) [1]. SUI is the most common form of transurethral urinary incontinence in women (49%) and especially predominates in young and middle-aged women [1]. The most common reason is weakness of the pelvic floor muscles caused by a variety of etiologies such as pregnancy, childbirth or menopause. There is strong evidence to support the causal role of obesity and urinary incontinence [1]. The treatment of this disorder is even more non-uniformed: there have been about 100 operations proposed for it. The Burch procedure has become probably the most popular even though its success rate is about 80%, and the results may be not durable [2–4]. Recently, some minimally invasive procedures to treat SUI have been proposed. Based on the Integral Theory as described by Petros and Ulmsten [5], these procedures tend to restore the defective connection between the urethra and the vagina and thereby reinforce the suburethral hammock. Although it is effective and easy to perform [6–10], retropubic placement of suburethral tension-free vaginal tape (TVT) for the treatment of SUI can be associated with bowel, vascular, nerve and bladder injury [11–15]. Such complications appear to be related to the unique upward vaginal passage of metallic sling trocars through the retropubic space. Newel slings eliminate the upward approach, but still require routine cystoscopy to confirm an intact bladder and urethra. A new tension-free suburethral sling addresses these shortcomings using an innovative transobturator route [16, 17].