An unusual case of gastrointestinal tract occlusion, Ladd's syndrome and neuroendocrine tumour of the appendix in a 19-year-old female patient

Ladd's syndrome is a complex gastrointestinal anomaly that occurs based on congenital intestinal malrotation and leads to midgut volvulus and intestinal obstruction. It is mostly discovered in paediatric patients and presents itself in 90% of cases within the first year of life. It is a rare diagnosis in adult patients. We present the case report of a 19-year-old female patient with chronic abdominal pain and upper-type dyspeptic syndrome. MRI examination of the abdomen showed an abnormal location of the loops of the small intestine predominantly in the right part of the abdomen, caecum and c. ascendens in the epigastrium, duodenojejunal transition compressed and stenotized between upper mesenteric vessels and the aorta, with prestenotic dilatation of the duodenum and stomach and the "whirlpool sign" in mesentery. The patient was indicated for operational procedure and Ladd's operation was successfully performed laparoscopically, where "Ladd's bands" were divided; the procedure also included adhesiolysis, mobilization of the duodenum with its straightening, widening of the base of the mesentery, appendectomy and removal of an incidental solitary mesothelial cyst. A highly differentiated incidental neuroendocrine tumour of the apex of appendix was confirmed by histology. In the discussion, we focus on the rarity of intestinal malrotation in adulthood, clinical manifestation of the disease, diagnostic options and surgical treatment.

Pancreatic stiffness and anthropometric parameters in healthy volunteers

PURPOSE

The aim of this study was to define the values of percutaneous ultrasound shear-wave and strain elastography of the pancreas in healthy volunteers.

METHODS

This is a single-center prospective study conducted on volunteers who underwent examination of percutaneous point shear‑wave elastography and strain elastography. Both the shear-wave speed (Vs) and strain histogram were measured 3 times and median values were evaluated. Relevant recorded clinical data were age, sex, and height.

RESULTS

 From May 2020 to October 2021 a total of 90 patients (21 male, 69 female) were included in the study. Their average age was 26 years (from 22 to 65). The average SWM in kPa was 6.07 (2.58-17.29). The average value of SE was 134.44 (78.51-184.35). Most of the patients had BMI in the range of normal weight with an average value of 22.75 (17.5-28). The average depth of the localization of the pancreas was 4.5 cm. The effect of BMI on the strain histogram was significant (p < 0.05). We found a significant relationship between the strain histogram and the depth of localization of the pancreas (p < 0.01).

CONCLUSION

 We described normal values for pancreatic stiffness using ultrasound elastography by 2D-SWE and strain elastography. Our results indicate changes in values depending on BMI and depth of the pancreas. (Tab. 1, Fig. 5, Ref. 19).

Distal pancreatectomy

NTRODUCTION

Distal pancreatectomy is a standard surgical procedure for selected benign, premalignant, and malignant lesions localized in the pancreatic body or tail. Surgical resection remains the only curative option for patients diagnosed with adenocarcinoma of the pancreas.

PATIENTS AND METHODS

Perioperative and postoperative clinical courses were retrospectively assessed in patients, who underwent distal pancreatectomy during the 2011‒2021 period.

RESULTS

During the 2011‒2021 period, a total of 112 distal pancreatectomies were performed. 67 patients (59.8%) underwent laparoscopic distal pancreatectomy, and 45 patients (40.2%) open laparotomy. The conversion was necessary for 13 patients (11.6%). Distal pancreatectomies performed laparoscopically were associated more often with biochemical leak and the development of grade B fistula, on the other hand grade C fistula developed only in patients operated by open laparotomy (LPT). The mean operating time was slightly longer in the laparoscopic group (227.1 min vs 214.6 min). The mean estimated blood loss was significantly higher in the LPT group (540.4 ml vs 191.9 ml). The mean hospitalization time was slightly longer in the LPT group (11.8 days vs 9.3 days). The rates of early reoperations were comparable between both groups (6 vs 5).

CONCLUSION

Laparoscopic techniques are preferred in centers around the world to bring patients benefits by using a minimally invasive approach. These techniques are also preferred in our center, in nearly 60% of all distal pancreatectomies performed during 10 years, but on the other hand, there is a much more careful approach chosen in cases of malignant disease to achieve adequate radicality (Tab.4, Ref. 20).

Differential gene expression of immunity and inflammation genes in colorectal cancer using targeted RNA sequencing

Introduction

Colorectal cancer (CRC) is a heterogeneous disease caused by molecular changes, as driver mutations, gene methylations, etc., and influenced by tumor microenvironment (TME) pervaded with immune cells with both pro- and anti-tumor effects. The studying of interactions between the immune system (IS) and the TME is important for developing effective immunotherapeutic strategies for CRC. In our study, we focused on the analysis of expression profiles of inflammatory and immune-relevant genes to identify aberrant signaling pathways included in carcinogenesis, metastatic potential of tumors, and association of Kirsten rat sarcoma virus (KRAS) gene mutation.

Methods

A total of 91 patients were enrolled in the study. Using NGS, differential gene expression analysis of 11 tumor samples and 11 matching non-tumor controls was carried out by applying a targeted RNA panel for inflammation and immunity genes containing 475 target genes. The obtained data were evaluated by the CLC Genomics Workbench and R library. The significantly differentially expressed genes (DEGs) were analyzed in Reactome GSA software, and some selected DEGs were used for real-time PCR validation.

Results

After prioritization, the most significant differences in gene expression were shown by the genes TNFRSF4, IRF7, IL6R, NR3CI, EIF2AK2, MIF, CCL5, TNFSF10, CCL20, CXCL11, RIPK2, and BLNK. Validation analyses on 91 samples showed a correlation between RNA-seq data and qPCR for TNFSF10, RIPK2, and BLNK gene expression. The top differently regulated signaling pathways between the studied groups (cancer vs. control, metastatic vs. primary CRC and KRAS positive and negative CRC) belong to immune system, signal transduction, disease, gene expression, DNA repair, and programmed cell death.

Conclusion

Analyzed data suggest the changes at more levels of CRC carcinogenesis, including surface receptors of epithelial or immune cells, its signal transduction pathways, programmed cell death modifications, alterations in DNA repair machinery, and cell cycle control leading to uncontrolled proliferation. This study indicates only basic molecular pathways that enabled the formation of metastatic cancer stem cells and may contribute to clarifying the function of the IS in the TME of CRC. A precise identification of signaling pathways responsible for CRC may help in the selection of personalized pharmacological treatment.

Hypermethylated GRIA4, a potential biomarker for an early non-invasive detection of metastasis of clinically known colorectal cancer

Introduction

Colorectal cancer (CRC) can develop through several dysregulated molecular pathways, including the serrated pathway, characterized by CpG island methylator (CIMP) phenotype. Although the tumor tissue is a commonly tested material, sample types such as stool or plasma, bring a new, non-invasive approach. Several cancer-related methylated genes have been identified in CRC patients, including gene GRIA4, showing promising diagnostic potential. The aim of our study was to develop a sensitive droplet digital PCR (ddPCR) assay to examine GRIA4 hypermethylation status in CRC patients and evaluate its diagnostic potential in tissue and liquid biopsy samples.

Methods

In total, 23 patients participated in this study, 7 patients with primary CRC and 16 patients with liver metastasis of clinically known CRC. We obtained tumor and non-tumor tissues (N=17), blood samples pre- and post-surgery (N=22), and blood of five volunteers without a personal cancer history. We have developed and optimized a ddPCR assay for GRIA4 hypermethylation detection, from tissue and plasma samples.

Results

We detected significantly increased GRIA4 methylation in tumor tissues compared to their adjacent non-tumor tissue, p<0.0001. Receiver operating characteristic (ROC) analysis defined cutoff values to separate primary tumors and metastases from non-tumor colon/rectum, specifically 36.85% for primary tumors and 34.81% for metastases. All primary tumors were above this threshold. When comparing the methylation levels of metastatic vs. non-tumor tissue, a smaller increase was observed in liver metastasis versus colon tissue (3.6× gain; p=0.001), then in liver metastasis versus adjacent liver tissue (17.4× gain; p<0.0001). On average, GRIA4 hypermethylation in primary tumor plasma was 2.8-fold higher (p=0.39), and in metastatic plasma, 16.4-fold higher (p=0.0011) compared to healthy individuals. Hypermethylation in metastatic plasma was on average 5.9 times higher (p=0.051) than in primary tumor plasma. After tumor removal surgery, average hypermethylation decrease in plasma was 1.6× for primary (p=0.037) and 4.5× for metastatic patients (p=0.023).

Discussion

Based on our data, it can be inferred that GRIA4 serves as a tissue specific biomarker for the colon/rectum tissue, thus is suitable for cancer classification. This biomarker showed the potential to be an attractive target for early non-invasive detection of metastases of clinically known CRC, although additional analysis has to be performed.

Expression of OCT4 isoforms is reduced in primary colorectal cancer

Introduction

Colorectal cancer (CRC) is one of the most common types of cancer worldwide. The carcinogenesis of CRC is indeed complex, and there are many different mechanisms and pathways that contribute to the development of malignancy and the progression from primary to metastatic tumors. The OCT4A, encoded by the POU5F1 gene, is a transcription factor responsible for the phenotype of stem cells, maintaining pluripotency and regulation of differentiation. The POU5F1 gene is made up of five exons that can create numerous isoforms through alternative promoter or alternative splicing. In addition to OCT4A, other isoforms called OCT4B are also translated into protein; however, their role in cells has been unclear. The aim of our work was to investigate the expression patterns of OCT4 isoforms in primary and metastatic CRC, providing us with useful information about their role in the development and progression of CRC.

Methods

Surgical specimens from a total of 78 patients were collected and isolated from primary tumors (n = 47) and metastases (n = 31). The relative gene expression of OCT4 isoforms was investigated using the RT-qPCR method together with the TaqMan probes for particular OCT4 isoforms.

Results

Our results suggest significantly downregulated expression of the OCT4A and OCT4Bs isoforms in both primary (p = 0.0002 and p < 0.0001, respectively) and metastatic tumors (p = 0.0006 and p = 0.00051, respectively) when compared with the control samples. We also observed a correlation between reduced expression of all OCT4 isoforms and both primary and left-sided tumors (p = 0.001 and p = 0.030, respectively). On the other hand, the expression of all OCT4 isoforms was significantly upregulated in metastases compared with primary tumors (p < 0.0001).

Discussion

Unlike previous reports, we found out that the expression of OCT4A, OCT4Bs, and all OCT4 isoforms was significantly reduced in primary tumors and metastases compared with control samples. On the other hand, we supposed that the expression rate of all OCT4 isoforms may be related to the cancer type and side, as well as to liver metastases. However, further studies are required to investigate the detailed expression patterns and significance of individual OCT4 isoforms in carcinogenesis.

Clostridium septicum foot gangrene associated with colorectal cancer

INTRODUCTION

Since the second half of the 20th century, an association between the occurrence of Clostridium septicum and Streptococcus gallolyticus infections in patients with colorectal cancer has been described in specialist literature. Infections are manifested by bacteremia, septic embolism, cellulitis, myonecrosis, and gas gangrene of the limbs.

MATERIAL AND METHODS

The authors present a case of a rare association between lower limb gangrene caused by the septic embolization of a Clostridium septicum infection and malignancy of colon ascendens in a polymorbid patient. Gangrene of the lower limb led to septic shock requiring acute amputation treatment. After managing the acute condition, the patient was operated on for a malignant colon tumour.

DISCUSSION

The process of carcinogenesis often takes years and is almost asymptomatic. The occurrence of S. bovis/S. equinus (SBSEC) and C. septicum bacteremia, respectively, is relatively rare, but their presence is often associated with the occurrence of malignancy, most often of the lower gastrointestinal tract. This paraneoplastic symptom may be the first manifestation of a malignant disease. The effect of exotoxins can lead to sepsis or even septic shock with a mortality of 48-56%.

CONCLUSION

Clostridium septicum and Streptococcus gallolyticus infections are rare in clinical practice. However, their presence can be a first paraneoplastic symptom, and therefore the doctor should look for a possible oncological disease when they are detected. The main diagnostic methods include colonoscopy and imaging, especially CT scan.

The role of proteinuria, paricalcitol and vitamin D in the development of post-transplant diabetes mellitus

INTRODUCTION

Post-transplant diabetes mellitus (PTDM) occurs most frequently during the first year after transplantation. We focused on parameters of calcium-phosphate metabolism and proteinuria as possible new risk factors for PTDM after kidney transplantation.

MATERIALS AND METHODS

We have prospectively identified risk factors for post-transplant diabetes mellitus with follow-up of 12 months in a set of 167 patients after kidney transplantation. Patients with diabetes mellitus type 1 and type 2 as well as patients using ciclosporin A or mTOR inhibitor have been excluded from the monitoring. From the perspective of immunosuppression it was a homogeneous set of patients.

RESULTS

We identified the following independent risk factors for PTDM in our set: average proteinuria > 0.300 g/24 h (HR 3.0785, (95 % CI 1.6946-5.5927), p=0.0002), level of vitamin D<20 ng/ml (HR 5.4517, (95 % CI 2.3167-11.8209), p1.45 mmol/l (HR0.0821, (95 % CI0.0042-1.5920), p=0.0439). The lowest occurrence of PTDM and proteinuria was recorded in patients whose treatment included paricalcitol (p<0.0001) and these patients had at the same time the highest level of vitamin D (p<0.0001).

CONCLUSION

Deficit of vitamin D, proteinuria and hyperphosphatemia have been independent risk factors for the development of PTDM in our set. We identified the usage of paricalcitol as protective factor with regard to the PTDM development (Tab. 6, Fig. 4, Ref. 29).

Ureteral Stenosis of Transplanted Kidney

Introduction: Ureteral stenosis is one of the most commonly reported urological complications after kidney transplantation. Material and methods: This is a retrospective analysis of the risk factors for ureteral stenosis (type of donor, age of donor, presence of interior polar arteria, unilateral dual transplantation, diabetes mellitus of the recipient and the donor, BK positivity, child recipient, cold ischaemia time, and delayed graft function), as well as the causes and types of treating ureteral stenoses. Results: In the group of 278 patients, the occurrence was 7.2 %. The medial of occurrence of ureteral stenoses was 24.6 months. The independent risk factor for ureteral stenosis in our group was the age of the donor ≥ 70 years [HR 6.5833; 95 % CI 2.2448-19,3070 (P = 0.0006)], BK positivity [HR 13.6667; 95 % CI 6.9127-27.0196 (P<0.0001)], cold ischaemia time > 1080 min [HR 4.0368; 95 % CI 1.7250-9,4465 (P = 0.0013)], and diabetes mellitus in the donor’s history [HR 16.2667; 95 % CI 7.8629-33.6525 (P <0.0001)]. The most frequent type of treating the ureteral stenosis in our group was retroureteroneocystostomy. After surgical treatment, we recorded no recurrence of stenosis. Conclusion: In our analysis, the confirmed independent risk factor was diabetes mellitus of the donor. However, further monitoring and analyses of large groups of patients are necessary. Surgical treatment of ureteral stenosis is safe. However, the most important momentum in surgical treatment of ureteral stenosis still remains the surgeon´s experience in the given type of treatment.

Effect of Smoking on Development of New Onset Diabetes Mellitus after Transplantation (NODAT) of Kidney

Purpose: Cigarette smoking has adverse effects on kidney transplant recipients, causing cardiovascular disease, kidney function impairment, and cancer. New onset diabetes mellitus after transplantation (NODAT) represents serious complication of transplantation of solid organs.

Methods: In the group of 252 patients after kidney transplantation, we identified smokers and current non-smokers (the patient who has not been smoking or who is ex smoker) for the period of minimum 24 months. In the monitored period of 12 months after transplantation, we detected presence of NODAT in both groups. The group contained only those patients who did not have diabetes mellitus (of type 1 and 2) at the time of kidney transplantation.

Results: The group of smokers was composed of 88 patients (34.9 %) and non-smokers 164 patients (65.1 %). The average age of smokers was 52 years ± 12.4, and of current non-smokers it was 44.8 years ± 12.8 (P < 0.0001). The smokers had significantly lower body mass index (BMI) at the time of kidney transplantation (P = 0.0059) and also 12 months after transplantation (P = 0.0069), lower weight gain 12 months after transplantation (P = 0.0220) and larger waist circumference 12 months after transplantation (P < 0.0001).

Conclusion: In our group, smoking had no effect on development of NODAT, the smokers had lower values of BMI and waist circumference, however, the guideline development group feels that, as for the general population, success of smoking cessation can be enhanced by offering structured smoking cessation programs.

Treatment of Ormond Disease and Idiopathic Membranous Glomerulonephritis by using Rituximab

Treatment of retroperitoneal fibrosis usually involves corticosteroids with or without other immunomodulating medications or tamoxifen.  Rituximab, a monoclonal antibody that specifically targets CD20 on the surface of B-cells, is effective in achieving complete remission of proteinuria in patients with idiopathic membranous nephropathy. We describe a case of a 45 years old man with idiopathic membranous glomerulonephritis (with proteinuria of more than 30 grams/24 hours) and simultaneously with idiopathic retroperitoneal fibrosis (with large number of cells CD20 in the histologic image). The patient did not tolerate the treatment by cyclophosphamide, and as rescue therapy, administration of rituximab was indicated with excellent effect. We recorded promptreduction of proteinuria and significant reduction of retroperitoneal fibrosis. Rituximab is effective in treatment of idiopathic retroperitonea lfibrosis with positivity of CD20 cells, as well as in treatment of idiopathic membranous glomerulonephritis.

Surgical treatment of hepatocellular carcinoma

The incidence of hepatocellular carcinoma (HCC) in Europe and throughout the world is currently increasing. This is caused by an increase in the number of patients with alcoholic liver damage, metabolic syndrome, and by increasing incidence of hepatitis B and C.From January 1, 2004 to December 31, 2013, resection or radiofrequency ablation of the liver was done in 360 patients with benign lesions or malignant tumors of the liver. In 28 patients HCC was diagnosed and histologically confirmed (7.8 %). Seven patients had HCC associated with liver cirrhosis (25 %), and 21 patients were without histologically confirmed cirrhosis (75 %). R0 resection was done in 18 (64 %) patients.Surgical complications occurred in 6 (21 %) patients and reoperation due to tumor relapse or progression was done eight times in 6 (21 %) patients. One-year and five-year patients' survivals were 64 % and 10 %, repectively, and did not statistically differ from the survival of the whole set of patients with tumor diseases in the given time period. In the future it will be possible to improve the long-term survival of patients with HCC by using screening methods for presymptomatic diagnosis of HCC, precise preoperative diagnosis and efforts for R0 resection (Tab. 1, Fig. 4, Ref. 11).

[Cystic feochromocytoma, mimicing a liver cyst. A case review]

Cystic feochromocytoma is a special subtype of supraadrenal tumors, with a specific clinical course, symptomatology, CT and MRI pictures and histological findings. The above factors frequently contribute to a wrong diagnosis and increased risk during its surgery. The authors present a case review of a patient with a cystic tumor of the right liver lobe. Its laparoscopic fenestration attempt resulted in hypertonic crisis with cardial decompensation and lung edema. Furthermore, attempts to embolize the tumor resulted in another hypertonic crisis, despite of the preoperative care as appropriate in feochromocytoma procedures. Only complete surgical removal of the tumor relieved the patient of the clinical symptoms. The authors discuss diagnostic and therapeutical problems of this specific and rare feochromocytoma subtype and suggest radical surgical management following a standard preoperative care as appropriate in all feochromocytoma procedures.