Radiofrequency ablation in pancreatic cancer

INTRODUCTION

Clinical study evaluating the impact of intraoperative radiofrequency ablation in pancreatic cancer.

METHODS

Patients with histologically proved pancreatic cancer were included. Two groups were defined. In the RFA group (n=24) intraoperative RFA of the pancreatic tumour was performed. In the control group (n=24) only the bypass procedure was indicated (gastroenteric and hepaticojejunal anastomosis). No patient received neoadjuvant chemotherapy. Three-month morbidity and mortality, overall survival, quality of life, pain relief and radiological response were studied.

RESULTS

Overall three-month morbidity and mortality were 41.7% and 8.3%, respectively. RFA related morbidity and mortality reached 16.6% and 8.3%, respectively. The overall median survival time was 9.9 and 8.3 months in the RFA group and in the control group, respectively. The survival difference was not of statistical significance (p=0.758). QoL improvement after RFA was not proved. There was no statistically significant analgesic effect of RFA. Postoperative CT scan assessed as per RECIST criteria displayed progressive disease, stable disease, partial response and complete response in 41.6%, 45.8%, 8.3% and 0% cases, respectively.

CONCLUSION

Intraoperative RFA of locally advanced and metastatic pancreatic cancer is a feasible palliative method. A survival benefit of this method remains doubtful, even though some positive results have been achieved in patients with localized, well-differentiated tumours. Although RFA was not associated with any impairment of the quality of life, no convincing evidence of a positive impact thereof on QoL was shown, either, during the three-month postoperative period. Pain relief was not achieved during the first 3 months after RFA.

Estimating cancer incidence, prevalence, and the number of cancer patients treated with antitumor therapy in 2015 and 2020 - analysis of the Czech National Cancer Registry

BACKGROUND

Cancer burden in the Czech population ranks among the highest worldwide, which introduces a strong need for a prospective modelling of cancer incidence and prevalence rates. Moreover, a prediction of number of cancer patients requiring active antitumor therapy is also an important issue. This paper presents the stage-specific predictions of cancer incidence and prevalence, and the stage- and region-specific patients requiring active antitumor therapy for the most common cancer diagnoses in the Czech Republic for years 2015 and 2020. The stage-specific estimates are also presented with regard to the treatment phase as newly diagnosed patients, patients treated for non-terminal recurrence, and patients treated for terminal recurrence.

PATIENTS AND METHODS

Data of the Czech National Cancer Registry from 1977 to 2011 has been used for the analysis, omitting the records of patients diagnosed as death certificate only or at autopsy. In total, 1,777,775 incidences have been considered for the estimation using a statistical model utilizing solely the population-based cancer registry data. All estimates have been calculated with respect to the changing demographic structure of the Czech population and the clinical stage at diagnosis.

RESULTS

Considering year 2011 as the baseline, we predict 89%, 15%, 31% and 32% increase in prostate, colorectal, female breast and lung cancer incidence, respectively, in 2020 resulting in 13,153, 9,368, 8,695, and 8,604 newly dia-g--nosed cancer patients in that year, respectively. Regarding cancer prevalence in 2020, the estimated increase is 140%, 40%, 51%, and 17% for prostate, colorectal, female breast and lung cancer, respectively, meaning that more than 100,000 prevalent female breast cancer patients as well as more than 100,000 prevalent prostate cancer patients are expected in the Czech Republic. The estimated numbers of patients requiring active antitumor therapy for prostate, colorectal, female breast and lung cancer in the Czech Republic in 2020 are 23,652, 14,006, 14,759 and 8,272; respectively.

CONCLUSIONS

The analysis documents a serious increase in cancer incidence and prevalence in the Czech Republic in years 2015 and 2020 when compared to the situation in 2011. Regarding the estimated numbers of patients requiring active antitumor therapy, the model confirms a continuous increase that must be accounted for in the future planning of health care in the Czech Republic.

Cancer incidence and mortality in the Czech Republic

BACKGROUND

The Czech Republic ranks among the countries with the highest cancer burden in Europe as well as worldwide. The purpose of this study is to summarize longterm trends in the cancer burden and to provide up-to-date estimates of incidence and mortality rates after 2011.

DATA AND METHODS

The Czech National Cancer Registry (CNCR) was instituted in 1977 and contains information collected over a 34-year period of standardized registration covering 100% of cancer diagnoses within the entire Czech population. The CNCR analysis is supported by demographic data and by the Death Records Database. An overview of the epidemiology of malignant tumors in the Czech population is available online at www.svod.cz.

RESULTS

All neoplasms, including nonmelanoma skin cancer, reached a crude incidence rate of almost 802 cases per 100,000 men and 681 cases per 100,000 women in 2011. The annual mortality rate exceeded 258 deaths per 100,000 individuals; in other words, more than 27,000 individuals die of cancer each year. The overall incidence of malignancies has increased with a growth index of +27.6% during the last decade (2001- 2011), while the mortality rate has been stabilized over the time span (growth index in 2001- 2011: - 5.0%). Consequently, the prevalence has significantly increased in the observed period and exceeded 475,000 cases in 2011. In addition to demographic aging of the Czech population, the cancer burden has also increased due to the growing incidence of multiple primary tumors (recently more than 15% of the total incidence). The most frequent diagnoses include colorectal cancer, lung cancer, breast cancer, and prostate cancer. Although some neoplasms are increasingly diagnosed at an early stage (e. g. the proportion of stage I or II was 75.3% for female breast cancer and 84.2% for skin melanoma), the numbers of early diagnosed cases are generally insufficient, even in the case of highly prevalent cancers such as colorectal carcinoma (only 46.1% of incident cases are diagnosed at stage I or II, according to recent data).

CONCLUSION

Population-based data on malignant tumors are available in the Czech Republic. The data survey can help us define national cancer management priorities. The current priority is to achieve a sustained reduction of cases diagnosed at an advanced stage and reduction of the significant regional differences in diagnostic efficiency.

[Does an Independent Predictor of In-Hospital Mortality Exist for Patients with Isolated Proximal Femoral Fracture? A Retrospective Two-Year Observational Study]

PURPOSE OF THE STUDY

The primary objective of the study was to find out in-hospital mortality in patients undergoing surgery for proximal femoral fracture. The secondary objective was to identify independent predictors of in-hospital mortality.

MATERIAL AND METHODS

A retrospective single-centre observational study PROXIMORT of patients operated on for isolated proximal femoral fracture at the University Hospital (FN) Brno in the years 2011 and 2012. The 30-day and overall one-year mortality in the study group and the impact of observed parameters on mortality were also assessed. The observed parameters were: patient age and sex, ASA score, time from injury to surgery (hr), daily (7-20 hr) or night (20-7 hr) time of surgery, type of anaesthesia (general vs spinal), initial haemoglobin and haematocrit levels, intra-operative administration of blood products and vasopressors, and erudition of the anaesthesiologist and surgeon. To evaluate the relationship of in-hospital mortality to the observed characteristics, we used univariate logistic regression modelling and odds ratio, using SPSS 22 software (IBM, USA).

RESULTS

Data were obtained from 414 patients and 369 patients were included (male, n = 91; female, n = 278). Due to exclusion criteria, 45 patients were excluded (not an isolated injury). In-hospital mortality was 6.5% (n = 24), 30-day mortality was 8.4% (n = 31) and total mortality of the study group was 35.8% (n = 132). Statistically significant effects on in-hospital mortality included: older age of the patient (p = 0.013), ASA score of 3 or more (p = 0.002) and general anaesthesia administration (p = 0.043). For 30-day mortality, this was older age (p = 0.012), ASA score of 3 and more (p < 0.001), general anaesthesia administration (p < 0.001), lower weight (p = 0.028), lower BMI (p = 0.006) and intra-operative administration of vasopressors (p = 0.023). The influence of other observed parameters on post-operative mortality was not statistically significant.

DISCUSSION

In-hospital mortality in the PROXIMORT study was 6.5% (95% confidence interval (CI) 4.2 to 9.5%), which was significantly higher than in-hospital mortality in unselected surgically treated patients in the Czech Republic, as reported in the EuSOS study (2.3% with 95% CI 0.9 to 3.7%). Administration of general anaesthesia was determined as an independent predictor of in-hospital and 30-day mortality, which was concordant with the results of meta-analysis published by Rodgers et al. and Barbosa et al in 2013. Postponing surgery for perioperative optimisation had no effect on mortality according to the PROXIMORT study. Patorn et al. have supported this conclusion by the results of a selected group of patients with surgery delayed for more than 24 hours; the patients mortality, regardless of anaesthesia, was up to 2.5%.

CONCLUSIONS

The PROXIMORT study identified the higher patient age, ASA score of 3 and more and general anaesthesia administration as independent predictors of in-hospital mortality.

[Cost analysis of radiotherapy provided in inpatient setting - testing potential predictors for a new prospective payment system]

BACKGROUND

As a part of the development of a new prospective payment model for radiotherapy we analyzed data on costs of care provided by three comprehensive cancer centers in the Czech Republic. Our aim was to find a combination of variables (predictors) which could be used to sort hospitalization cases into groups according to their costs, with each group having the same reimbursement rate. We tested four variables as possible predictors -  number of fractions, stage of disease, radiotherapy technique and diagnostic group.

METHODS

We analyzed 7,440 hospitalization cases treated in three comprehensive cancer centers from 2007 to 2011. We acquired data from the I COP database developed by Institute of Biostatistics and Analyses of Masaryk University in cooperation with oncology centers that contains records from the National Oncological Registry along with data supplied by healthcare providers to insurance companies for the purpose of retrospective reimbursement.

RESULTS

When comparing the four variables mentioned above we found that number of fractions and radiotherapy technique were much stronger predictors than the other two variables. Stage of disease did not prove to be a relevant indicator of cost distinction. There were significant differences in costs among diagnostic groups but these were mostly driven by the technique of radiotherapy and the number of fractions. Within the diagnostic groups, the distribution of costs was too heterogeneous for the purpose of the new payment model.

CONCLUSION

The combination of number of fractions and radiotherapy technique appears to be the most appropriate cost predictors to be involved in the prospective payment model proposal. Further analysis is planned to test the predictive value of intention of radiotherapy in order to determine differences in costs between palliative and curative treatment.

[On the importance of standardization in the assessment of population-based cancer patient survival in the Czech Republic - methodology and results from the Czech National Cancer Registry]

BACKGROUND

Calculating 5-year overall and relative survival is the standard method for population-based analyses in oncology. Survival rates based on population data do not, however, guarantee standardized benchmarks for comparison of different patient populations, which is especially true when compared populations differ considerably in age structure and representation of clinical stages. In this paper, we present and compare statistical methods for standardization of cancer survival rates.

PATIENTS AND METHODS

Using data of the Czech National Cancer Registry, we estimated 5-year overall and relative survival estimates for periods 2001- 2005 and 2006- 2010. To demonstrate the effect of standardization, we calculated crude and age -standardized survival rates as well as survival rates standardized for both age and clinical stage.

RESULTS

Our results show that the particular standardization method influences resulting 5-year overall and relative survival rates regarding both within and between time periods comparisons. In addition, our results document a recent improvement in 5-year relative survival between periods 2001- 2005 and 2006- 2010 for 19 of 20 evaluated diagnoses. All most prevalent cancers including prostate, lung, colorectal, breast, kidney, and uterine cancer and melanoma were observed among the diagnoses with statistically significantly improved patient survival.

CONCLUSION

Unless the use of standardization to the age and stage of tumor is limited due to a small number of patients in individual age-  and stage- specific subgroups, this method can be considered as a proper statistical methodology for the population assessment of Czech cancer patient survival rates.

[Standardization of pancreatic cancer specimen pathological examination]

INTRODUCTION

The frequency of R1 resections for pancreatic cancer in studies where a non-standardized protocol of pathological evaluation of the specimen is used varies from 17 to 30%. The aim of our study is to apply the standardized (so-called Leeds) protocol of resected pancreatic specimen pathological examination, and to evaluate the frequency of R1 resections for pancreatic cancer using this new protocol.

MATERIAL AND METHODS

Ninety-one patients who underwent pancreatoduodenectomy for pancreatic cancer were included in the study. This group was divided into two subgroups: patients examined by the Leeds protocol (n=20) and those examined by a non-standardized pathological protocol (n=71). The R1 resection rate was evaluated separately in each group. The positivity rate of every individual resection margin was specified in the Leeds protocol group. The correlation of R1 resection rate and "tumour - resection margin distance" parameter was evaluated. The tumour infiltration of peripancreatic adipose tissue was assessed in the non-standardized group.

RESULTS

In the Leeds protocol subgroup, R1 and R0 resection rate was 60% (12/20) and 40% (8/20), respectively. Resection line positivity rates were as follows: dorsal 45% (9/20), ventral 35% (7/20), VMS 20% (4/20), cervical 20% (4/20), AMS 15% (3/20). The correlation between the tumour - resection line distance and R1 resection frequency was the following: direct infiltration 30% R1, tumour-resection margin border 0.5 mm 50% R1, 1mm 60%, 1.5 mm 75% R1, 2 mm 80% R1, >2 mm 80% R1. If the criterion of resection line positivity ( 1mm) was set, the R1 resection rate difference between the two groups was of statistical significance. In the subgroup where the non-standardized protocol was used (n=71), R1 resection was recorded in 25 (35.2%) patients. The main cancer-positive areas were peripancreatic adipose tissue in 26.8% (19/71) of cases, and VMS, AMS or retroperitoneal line in 8.5% (6/71), respectively. R0 resection was achieved in 46 (64.8%) patients. The statistically significant (p=0.046) difference in R0 and R1 resection rates was detected (Leeds protocol and non-standardized one: R0 40.0% vs. 64.8% and R1 60.0% vs. 35.2%, respectively) in the studied groups.

CONCLUSION

The rate of R1 resections for pancreatic cancer increased in all studies, including ours, where the standardized (Leeds) protocol of pancreatic specimen pathological examination was used. The higher R1 resection rate when using the Leeds protocol is approaching to the local recurrence rate of pancreatic cancer. Therefore, the Leeds protocol can provide more realistic evaluation of local radicality of pancreatoduodenectomy and can also offer more accurate evaluation of the surgical and adjuvant therapy of pancreatic cancer.

[Objective need for cancer prevention in the Czech Republic and Europe, and the state thereof]

There is no doubt today of the need for cancer prevention. The growing incidence of cancer itself provides a sufficient justification for prevention programmes. A review of literature presented in this paper also documents the strong background of evidence-based cancer prevention programmes. The article also provides a critical analysis of the current status of primary cancer prevention and cancer screening in the Czech Republic in contrast with available international comparisons. Relevant international data have been obtained from the regularly repeated "Health at a Glance" studies (published by the OECD). Although the Czech Republic is one of the countries with the highest cancer burden in Europe, it has failed to develop and support a cancer prevention policy on a central level, and this also applies to smoking prevention. The Czech population needs an effective national strategy for the support of cancer prevention, as well as a strategy which would ensure equitable cancer care in terms of both quality and correct indication; a strategy which would be sustainable for at least 10 to 15 years to come.Key words: oncology - screening - risk factor - prevention - population burden This study was supported by the project 36/14//NAP "Development and implementation of methodology for the evaluation of effectiveness of personalised invitations of citizens to cancer screening programmes" as part of the pro-gram-me of the Czech Ministry of Health "National action plans and conceptions". The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE "uniform requirements" for biomedical papers.

[Epidemiology of screening-targeted cancers according to new data of the Czech National Cancer Registry]

The Czech Society for Oncology has developed an information system which combines the population-based Czech National Cancer Registry with clinical databases in order to cover the main areas of health care assessment - monitoring of the population burden, prediction of the number of cancer patients, diagnostic and treatment results. The presented data demonstrate a high cancer burden within the Czech population - each year there are approximately 8,000 new cases of colorectal cancer, 6,500 new cases of breast cancer, and 1,000 new cases of cervical cancer. And each year, about 4,000 people die from colorectal cancer, around 2,000 women die from breast cancer, and approximately 400 women die from cervical cancer in the Czech Republic. Population-based screening programmes focus on all of the above-mentioned groups of malignant tumours; therefore, it is essential to monitor epidemiological trends in order to assess the screening impact. Despite the high incidence rates of all three cancer types, the trend in mortality rates has been stable or has even decreased in the long term, which has inevitably led to a significant increase in the total prevalence of cancer patients. In 2011, the prevalence of colorectal cancer, breast cancer and cervical cancer amounted to 51,064 people, 67,261 women and 17,398 women, respectively. When compared with the year 2001, there was a 59%, 69% and 25% increase in the prevalence of colorectal cancer, breast cancer, and cervical cancer, respectively. Undoubtedly, taking care of high numbers of cancer patients will continue to require significant financial resources in the near future. As the epidemiological burden is still on the increase, preventive programmes need to be further promoted, including secondary prevention, which is provided through organised screening programmes. Although effective methods exist for timely diagnosis of all three of the above-mentioned cancer types, the epidemiological situation in the Czech Republic is being steadily worsened by a relatively high proportion of primary cancers being diagnosed too late. Each year, more than 50% of new colorectal cancer cases are diagnosed in clinical stage III or higher; in cervical cancer, this proportion is nearly 35%. By contrast, the well-promoted breast cancer screening programme has led to more than 75% of new cases of breast cancer being diagnosed in stages I or II, when the chance of successful treatment is significantly higher.

[The effectiveness of anagrelide treatment in patients with Ph negative myeloproliferative diseases: influence on the incidence of thrombosis in the data from the Registry of patients with essential thrombocythemia and thrombocythemia associated with other myeloproliferative diseases treated with Thromboreductin® to the end of 2012]

In the Czech Republic, anagrelide (Thromboreductin®) [29] is used according to the recommendations of the Czech Working Group on Myeloproliferative Disorders (CZEMP) for treatment of thrombocythemia associated with Ph negative myeloproliferative disorders (MPDs). The patient data are collected in the Registry of patients with essential thrombocythemia (ET) and thrombocythemia associated with other MPDs treated with Thromboreductin®. At the end of 2012, the Registry contained data on 1,161 patients. Out of these, 1,159 patients with the dia-gnosis of a Ph negative MPD were evaluated. In 844 patients, precise WHO based dia-gnosis was known at start of therapy: 442 (52.4%) had ET, 108 (12.8%) had polycythaemia vera (PV) and 243 had primary myelofibrosis (PMF). The median age was 51 years at the time of diagnosis. At the time of the evaluation of the population, the median was 59 years. Every year, the proportion of patients newly treated with anagrelide as a firstline treatment in accordance with the CZEMP guidelines has been increasing. A growing proportion of patients has been treated with an additional cytoreducing drug, such as hydroxyurea and interferon. The majority of the patients received also an antiaggregant (or anticoagulant). More than a half of patients harbors the JAK2 mutation. A prompt decrease of platelet counts (as the response to Thromboreductin® treatment) was documented in most of the patients. After one year, 86.9% of patients had a full or partial response. In poorer responders, combination cytoreductive treatment was administered rather then the escalation of the Thromboreductin® dosage. There were 461 thrombotic manifestations in 363 patients and 61 haemorrhagic events in 57 patients recorded in the patients history. In the course of treatment (followup; F U), thrombosis was diagnosed only 179-times in 136 patients. There were more haemorrhagic events during F U: 109 events in 83 patients. Upon comparison of the number of events during F U to their numbers in history, we found a twofold decrease in arterial thrombosis, an almost twofold decrease in microvascular thrombosis and even a 6.6- fold decrease in venous thromboembolism events. Bleeding episodes increased 1.8-fold during F U. However, the vast majority of these hemorrhagic events were clinically insignificant. In conclusion, the treatment strategy according to the CZEMP guidelines incorporating anagrelide is highly effective in reducing the platelet counts, strongly prevents venous events, reduces arterial events, and leads to an increase of minor hemorrhages.

[Epidemiological and clinico-pathological characteristics of patients with renal carcinoma: a single institution analysis of 544 cases]

BACKGROUND

The incidence of renal cell carcinoma in the Czech Republic is one of the highest in the world. Curative treatment is still possible only surgically, while in the palliative treatment, partial success was reached using targeted therapies. While prognostic factors and models are commonly used in clinical practice, unfortunately, predictive biomarkers have not been found. The aim of our study was to verify the validity of selected prognostic factors on a consecutive patient cohort from the Czech population.

PATIENTS AND METHODS

The patient cohort consisted of 544 patients with RCC diagnosed and/or treated at our institute from 2003 to 2010. Individual clinical and histological prognostic factors and Heng prognostic model were validated.

RESULTS

Median time of follow-up for our cohort was 42 months (range 0.3-326 months), median age at diagnosis was 62 years, and almost 64% of patients were men. Distribution of clinical stages was as follows: 46.5% of I, II. 10.7%, III. 13.1%, IV. 20%. 26.4% of patients in stage I-III relapsed. We diagnosed mainly clear cell (84.6%) and papillary carcinoma (9.2%). Initially, 95.8% of patients underwent surgical treatment, systemic adjuvant and palliative treatment was applied in 3.7 and 37.7% of patients, respectively. Palliative targeted therapy was received by a total of 163 patients (30%). In first-line targeted therapy, the following median TTP was reached (in months): 10.8 for sunitinib, 6.3 for sorafenib and 5.2 months for immunotherapy. The most significant prognostic factors (p < 0.00001) were: stage of disease (HR = 9.61), size of the primary tumor (HR = 5.83), lymph nodes (HR = 8.26), presence of sarcomatoid tumor sections in the tumor (HR = 7.29), and tumor grade (HR = 4.0). Besides these, we also confirmed the prognostic importance of presence of eosinophilic granulations in the tumor (HR = 1.91, p = 0.02). When applying the Heng prognostic model, we achieved similar results for patients treated with targeted therapies.

CONCLUSION

The obtained epidemiological and clinico-pathological data are consistent with previously published data. These prognostic factors can be used for a differentiated approach to patients with RCC, both for establishing follow-up plan for patients after surgery as well as indication for targeted therapies.

[Cost analysis of XELOX and FOLFOX-4 chemotherapy regimens for colorectal carcinoma]

BACKGROUND

The aim of our study was to compare healthcare-related costs of treatment with XELOX and FOLFOX4 chemotherapeutic regimens in patients with colorectal cancer. We have evaluated costs claimed to the health insurance by the hospital administering these cancer therapies. This study is a pilot project utilising the new I-COP database developed by the Institute of Biostatistics and Analyses of the Masaryk University in Brno, Czech Republic.

PATIENTS AND METHODS

First, we estimated the costs based on current prices of procedures, medication, and materials from public sources. Using the I-COP database, we then carried out a matched-pair comparison of 26 patients treated with FOLFOX4 or XELOX for colorectal cancer. We evaluated a period of three months of therapy (i.e. 6 cycles of FOLFOX4 or 4 cycles of XELOX). Statistical analysis was done using the Wilcoxon matched pairs test.

RESULTS

The estimated cost for three months of therapy was 148,288 Czech crowns (CZK) for FOLFOX4 (including CZK 101,064 for chemotherapy drugs) and CZK 123,756 for XELOX. The overall costs claimed to the insurance companies were CZK 160,158 and CZK 151,176 for FOLFOX4 and XELOX, respectively (p = 0.221). The XELOX regimen had significantly higher costs for chemotherapy drugs (CZK 131,705 versus 114,531, p = 0.023) whereas other costs were lower than those for FOLFOX4.

CONCLUSIONS

FOLFOX4 and XELOX regimens can be considered as equivalent in terms of costs claimed by the hospital administering cancer treatment.

[Thrombohaemorrhagic syndrome in patients with a myeloproliferative disease with thrombocythemia]

Thrombohaemorrhagic syndrome is a clinical syndrome manifesting with concurrent bleeding and thrombosis. It is associated with a range of pathological states, typically with myeloproliferative diseases, paraproteinaemia, liver disease as well as disseminated intravascular coagulation and similar syndromes (so called DIC-like syndrome). Thrombohaemorrhagic syndrome might be a symptom of chronic myeloproliferations, particularly if these are associated with thrombocythemia. It is most frequently linked to essential thrombocythemia. However, in this disease, it seems that the clinical symptoms of bleeding and thrombosis might not be directly determined by the number of platelets, as it would suggest itself, but that this can be consequent to other changes. These may include predisposition to thrombophilia, cardiovascular risk, leukocytosis etc. as well as, for example, platelet dysfunction. The present study focuses on platelet dysfunction in conjunction with clinical symptoms of bleeding and thrombosis.

[The quality of life following laparoscopic fundoplication in correlation with preoperative symptomatology]

AIM

Gastroesophageal reflux disorder (GERD) is a serious health problem in the Western world, with prevalence rates between 9 and 42%. The correct preoperative diagnostics including assessment of symptomatology is a prerequisite for the establishment of adequate therapy, including surgery. The aim of this study was to assess the quality of life in patients with GERD, based on their preoperative symptomatology.

METHODS

From IX/2004 to XII/2008, a total of 237 patients underwent antireflux procedures in the Brno Faculty Hospital (FN Brno) Surgical Clinic. The patients underwent preoperative and postoperative gastroenterological examination, including endoscopy, manometry, pH-metry. The patients were asked to fill in the GIQLI (GastroIntestinal Quality of Life Index) questionnaire. The results were statistically assessed and evaluated.

RESULTS

The study included a total of 178 patients. 135 subjects (76.7%) presenting with typical symptomatology and 41 subjects (23.3%) with atypical symptomatology were indicated for surgery. The mean preoperative quality of life index, based on the GIQLI questionnaire, was 101.6 points, while at 6 months after the procedure, the quality of life was evaluated with 106.9 points. There is a statistically significant difference in the quality of life between the patients with atypical and the patients with typical symptomatology, both prior to the procedure (p = 0.002), as well as after the procedure (p = 0.006), with the atypicaly symptomatology patients declaring poorer quality of life than the typical symptomatology ones. The risk of prolonged dysphagia (over 6 weeks after the procedure) is higher in the atypical symptomatology subjects, with statistical significance of p < 0.001.

CONCLUSION

Laparoscopic antireflux surgery increases the quality of life independent of the preoperative symptomatology. Patients with atypical symptoms must be carefully examined and indicated with caution, considering the higher risk of prolonged postoperative dysphagia.

[Femoral lengthening. A critical review of ten-year results]

PURPOSE OF THE STUDY

To evaluate the results of femoral lengthening in the patients treated from 2000 to 2009 in whom complete radiographic data were available and the lengthening procedure involved mainly the use of a Mephisto fixator.

MATERIAL AND METHODS

A total of 28 femoral lengthening procedures were carried out in 26 patients,16 girls and 10 boys. The external fixator Mephisto was used in 24 cases; fixators Prospon and Orthofix in one and three cases, respectively. Fifteen patients were treated for congenital short femur, the rest had secondary femoral shortening due to following pathologies: distal femoral epiphysiolysis in five children, proximal femoral osteomyelitis in one child, avascular necrosis of the femoral head in one, diaphyseal femur fracture in one, enchondromatosis of the distal femur with growth plate destruction in one, and contralateral femur overgrowth following a fracture in one child. The average age at the beginning of treatment was 11 (range, 4-16) years. Complications were classified as mild, serious and critical. The results were statistically analysed using several statistical tests.

RESULTS

The average parameter values for the group included: total femoral lengthening, 40.2.mm (SD±11.1); osteotomy index (OI), 41 % (SD±9.8); lengthening percentage (LP), 10.9 % (SD±3.8); lengthening index (LI), 14.5 (SD±3.5) days/cm; hea- ling index (HI), 52.6 (SD±20.1) days/cm; and consolidation index (CI), 93.3 (SD±40.0) days/cm. Mild complications were recorded in 11 (39.2 %), and serious and critical in eight patients (28.6 %). Fourteen patients (53.8 %) were free of any complications. Two complications were concurrently found in five patients (17.9 %). There was a statistically significant difference in the LP values related to the number of complications (p=0.019). No significant relationship was recorded on comparison of the HI value with the patient's age at the time of surgery (p=0.836) and patient's gender (p=0.546) (Mann- Whitney test). The relationship of the OI value to the HI value was non-significant (p=0.492), as was the relationship between the osteotomy technique (oscillating or Gigli saw osteotomy) and the occurrence of complications (p=1.000) (Fisher's exact test). Correlation between the LI and HI values was significant (p<0.001).

DISCUSSION

The results of healing after lengthening, as assessed by the healing and the consolidation index, were in agreement with other authors' data. The lower number of complications, particularly fractures of bone regenerate, can be explained by the facts that, in our study, the lengthening percentage was lower and that the post-operative care was strictly observed, including dynamic axial loading which stimulates bone consolidation at the lengthened section, with adherence to the proof of three developed cortices.

CONCLUSIONS

Our results did not confirm the assumption that slower lengthening will have a favourable effect on the healing index. Key words: femoral lengthening, external fixator, complications.

[Essential thrombocythaemia and other myeloproliferative disorders with thrombocythaemia treated with Thromboreductin. A report from the database of register for the 1st quarter of 2010]

In the Czech Republic, anagrelid is used according to the recommendations of the Czech Working Group on Myeloproliferative Disorders for treatment ofthrombocythaemias associated with chronic myeloproliferative disorders--mainly essential thrombocythaemia and, regularly, reports are being presented from the Register of Patients Treated with Thromboreductin, most recently last year (Vnitr Lék 2009; 55: I-XII). The Register commenced in 2005 and from then it aims to determine detailed clinical and laboratory profiles of the patients. The structure of the Register has changed significantly in the course of its existence, reflecting the reports from each of the analyses conducted so far. Also, the data entry in the database improves every year and it reaches 97% on some of the items. The longest evaluation period in some of the patients is 108 months. By April 2010, the Register database contained data on 717 patients. Of these, 672 patients with the diagnosis of a Ph-negative chronic myeloproliferative disorder were evaluated. This year's analysis included the patients with essential thrombocythaemia, polycythaemia vera and primary myelofibrosis only. The analysis included 418 women and 254 men with median age of50 years. Unlike the first years, 2/3 of the current sample are non pretreated patients, meaning that the patients reach the specialized centres early in their treatment. Also, patients, and the older patients in particular, are more frequently treated with combined regimens including Thromboreductin. We increasingly observe hypertension as one of the monitored risk factors preceding the disease and laboratory parameters showJAK2 mutation in more than a half of patients while some form ofthrombotic diathesis is found in the anamnesis of 7-10% of patients. Some bleeding is observed in 1-5% of the registered patients. In comparison to the previous years, this is a decrease in the prevalence of clinical symptoms prior to the disease onset; this is very likely associated with an earlier patient diagnosis within the asymptomatic phase of the disease. Therapeutically, we achieve a fast treatment response but there still are 16.3% of sufficient afterone year of treatment. Thromboreductin dose is increasing but even in this group it does not exceeds the mean of 2.38 mg per 24 hours. Complications are observed in 6.2% of patients in the first year of therapy, and ofthese, thrombotic events in about 2.5% and (small) bleeding complications in 4% of patients. The data suggest that we still do not reach treatment response in a certain proportion of patients after a year of their therapy. Even though the care results from the analysed data improve every year, the Register helps to uncover some issues that still remain, such as treatment intensification and other treatment modifications.

[The results of patients with essentials thrombocythemia and other myeloproliferation-related thrombocythemia--a report of patients treated with Thromboreductin]

The registry of patients treated with Thromboreductin (anagrelide) in the Czech Republic contains data concerning patients that have been treated using this drug since 2004. As of June 2009, the total number of patients was 549. The current analysis focused mainly on evaluation of anagrelide dosage needed to achieve a complete response in high-risk patients: reduction in platelet count to below 400 x 10(9)/l, which was also considered as reaching the therapeutic goal. The outcomes of the registry confirm that although anagrelide (Thromboreductin) is a very effective platelet-reducing agent, the administration of which is related to a low incidence of adverse effects and complications, the therapeutic goal is not achieved in all cases and or despite a quick treatment response, the therapeutic goal is achieved more slowly.

[Epidemiology and treatment of colorectal carcinoma--Czech population data]

The analysis of therapeutic load and evaluation of quality of care require data collected on a long-term basis. The Czech Society for Oncology develops a comprehensive information system that combines data from population-based and clinical registries and that covers all key aspects of health care assessment: monitoring of population risks and associated therapeutic burden, predictions of number of patients to be treated, evaluation of results of diagnostics and of cancer care outcomes. Accessible data proves high cancer burden in the Czech population, colorectal carcinoma being a typical example. Czech population reveals one of the highest incidence of colorectal cancer in the world. Regardless of steadily increasing incidence of colorectal carcinoma, Czech cancer care has managed to stabilize mortality of this disease and also probability of 5-yr relative survival was significantly improved in last 15 years. Developed data base allows to assess burden and results of all therapeutic modalities, including surgery. This work is aimed to present Czech data platform that can be employed in any relevant health care assessment. To keep its position in current financially limited health care system, modern surgery must effectively use all accessible data sources.

CORD: COmparsion of Recommended Doses of ACE inhibitors and angiotensin II receptor blockers

OBJECTIVES

The CORD trials tested ramipril and losartan in patients with hypertension.

PATIENTS AND METHODS

CORD IA involving switching from an angiotensin-converting enzyme inhibitor (ACEI) to the angiotensin II receptor blocker (ARB) losartan. 4,016 patients with blood pressure (BP) < 160/100 mm Hg who had been treated with an ACEI for > 3 months were enrolled. The mean age was 62.6 +/- 11.6 years and 53.1% were women. The patients discontinued ACEI and switched to losartan 50 mg once daily. BP, heart rate, biochemistry, blood counts and ECGs were measured at day 1 and months 1, 3, 6 and 12. If the BP was > or = 140/90 mm Hg after 1 month or more, the dose of losartan was increased to 100 mg. After 1 month the BP decreased from 147.4 +/- 14.8/87.7 +/- 9.3 mm Hg to 139.7 +/- 11.8/83.0 +/- 9.3 mm Hg (p < 0.001) and after 1 year to 133.7 +/- 11.3/79.1 +/- 7.06 mm Hg (p < 0.001). The rate of adverse events did not significantly increase and no changes in plasma sodium, potassium, urea or creatinine were observed. CORD IB compared ramipril and losartan. 3,813 patients with BP > or = 140/90 mm Hg who were not being treated with an ACEI or ARB were enrolled. The mean age was 60.5 +/- 12.2 years and 50.5% were women. The patients were randomised to ramipril 5 mg (n = 1,926) or losartan 50 mg (n = 1,887). The dose was doubled if BP after 1 month was > or = 140/90 mm Hg. If the BP after 3 months still was > or = 140/90 mm Hg, another antihypertensive drug was added, typically athiazide diuretic.

RESULTS

After 1 yearthe BP decreased in the ramipril group from 155.9 +/- 13.1/93.0 +/- 8.9 mm Hg to 134.1 +/- 11.2/81.5 +/- 6.8 mm Hg (p < 0.001) and in the losartan group from 156.5 +/- 13.1/93.4 +/- 8.8 to 134.55 +/- 11.3/80.16 +/- 6.6 mm Hg (p < 0.001). No significant differences were found between the groups. A slight increase in plasma potassium (0.2 mmol in both groups) and urea (0.3 mmol in both groups) was observed, but no change in plasma creatinine. There was a small, insignificant decrease in plasma uric acid (in the ramipril group from 325.5 to 320.7 micromol/l and in the losartan group from 321.6 to 318.3 micromol/l) and a slight decrease in plasma glucose and triglycerides (0.2 mmol/l in both measures in both groups). No severe adverse events were observed, but dry cough was 8 times more frequently reported in the ramipril group.

CONCLUSION

CORD IA confirmed that switching from an ACEI to losartan is safe and effective. Titrating the dose upwards or adding diuretics leads to good BP control in the majority of patients (2/3). CORD IB showed no differences between ramipril and losartan in lowering BP and both drugs showed a trend to improve metabolic parameters such as glycaemia, triglyceridaemia and uric acid equally. Dry cough was more frequent after ACEI.

CORD: COmparison of Recommended Doses of ace inhibitors and angiotensin II receptor blockers

The CORD trials tested ramipril and losartan in patients with hypertension. CORD A randomised 4016 patients with blood pressure (BP) <160/100 mm Hg, who had been treated with an ACEI for >3 months. The patients discontinued ACEI and switched to losartan. After 1 month the BP decreased to 7.7/4.7 mm Hg (p<0.001) and after 1 year to 13.8/8.7 mm Hg (p<0.001). CORD B compared ramipril and losartan in 3813 patients with hypertension who were not being treated with an ACEI or ARB. The patients were randomised to ramipril (n=1926) or losartan (n=1887). After 1 year the BP decreased in the ramipril group to 21.8/13.7 mm Hg (p<0.001) and in the losartan group to 22.0/13.3 mm Hg (p<0.001). No significant differences were found between the groups. No differences were in serious adverse events. Dry cough was more frequently after ramipril (33 vs 4, p<0.001).

[Visibility in ultrasonography as the strongest invasion predictor in ductal carcinoma in situ in a retrospective study]

BACKGROUND

Detection of ductal carcinoma in situ (DCIS) of the breast has markedly increased since the introduction of screening mammography. Current management of this preinvasive lesion comprises complete margin-free resection of the tumour. Lymph node staging is still not indicated as a standard procedure but we can find published cases of pure DCIS with lymph node involvement as well as a high proportion of invasive carcinomas in the final histopathology. The aim of this study was to determine the proportion of invasive tumours in our group of patients operated on for DCIS, to analyse the predictive factors of invasion and to assess the frequency of lymph node metastases.

DESIGN AND SUBJECTS

From 2006 to 2008, a retrospective review was conducted of 179 patients operated on at Masaryk Memorial Cancer Institute for the initial diagnosis of DCIS carried out by core-needle biopsy; in 117 of them, regional lymph node staging was performed.

METHODS AND RESULTS

In the final histopathological results, an invasive lesion was found in 34% of cases. The expected predictive factors of invasion were statistically analysed by Fisher's exact and Chi-square test. Preoperative ultrasound-guided core-needle biopsy (p = 0.014) related to ultrasound detection of the lesion (p = 0.023) was shown to be the statistically most significant predictive factor. Mammographic character (p = 0.105) or size (p = 0.077), histopathological grade (p = 0.104), multifocality (p = 0.544) and age (p = 0.212) did not show any statistical significance. Lymph node metastases were detected in fewer than 10% of cases of invasive carcinoma. There was no detection of lymph node involvement in pure DCIS.

CONCLUSIONS

We recommend performing primary sentinel node biopsy in DCIS unambiguously detected by ultrasound and in patients treated by total mastectomy where, in the case of invasive carcinoma, subsequent identification of the sentinel node would be difficult.

Mannose-binding lectin gene polymorphic variants predispose to the development of bronchopulmonary complications but have no influence on other clinical and laboratory symptoms or signs of common variable immunodeficiency

Mannose-binding lectin (MBL), activating protein of the lectin pathway of the complement system, is an important component of the non-specific immune response. MBL2 gene polymorphisms, both in the coding and promoter regions, lead to low or deficient serum MBL levels. Low serum MBL levels were shown to be associated with serious infectious complications, mainly in patients in whom other non-specific immune system barriers were disturbed (granulocytopenia, cystic fibrosis). We have analysed two promoter (-550 and -221) and three exon (codons 52, 54 and 57) MBL2 polymorphisms in a total of 94 patients with common variable immunodeficiency (CVID) from two immunodeficiency centres. Low-producing genotypes were associated with the presence of bronchiectasis (P = 0.009), lung fibrosis (P = 0.037) and also with respiratory insufficiency (P = 0.029). We could not demonstrate any association of MBL deficiency with age at onset of clinical symptoms, age at diagnosis, the number of pneumonias before diagnosis or serum immunoglobulin (Ig)G, IgA and IgM levels before initiation of Ig treatment. No association with emphysema development was observed, such as with lung function test abnormalities. No effect of MBL2 genotypes on the presence of diarrhoea, granuloma formation, lymphadenopathy, splenomegaly, frequency of respiratory tract infection or the number of antibiotic courses of the patients was observed. Our study suggests that low MBL-producing genotypes predispose to bronchiectasis formation, and also fibrosis and respiratory insufficiency development, but have no effect on other complications in CVID patients.

[What is the current treatment of patients with essential thrombocytopenia and other myeloproliferations accompanied with thrombocythemia [corrected] and what can be the predictive sign of the risk of thrombosis in such patients--a report from the registry of patients treated by Thromboreductine]

The registry of patients treated with Thromboreductine (anagrelid) in the contributing centres in the Czech Republic has been updated with data on the patients receiving this medication since 2004. The original purpose of the registry was to record responses to Thromboreductine therapy and adverse drug reactions in patients with essential thrombocytopenia. However, data on additional Ph negative myeloproliferations, as well as data on cytoreductive therapies other than exclusively that using Thromboreductine has also been recorded in the course of its compilation, including data on combined regimes. At present, the database contains data on 421 patients, and valid conclusions can be drawn if the level of data filling is enhanced. Evaluation has been currently focused on the analysis of the risk of development of clinical symptoms of thrombosis and on the standards of treatment from the viewpoint of the achieved treatment response. Analyses of data from the registry corroborate the special importance of the proof of JAK2 mutation, and of the test for factor V Leiden mutation, and of protein of S for the assessment of the risk of thromboembolic complications. The output of the analysis confirms that anagrelid is a very efficient thromboreductive agent the administration of which is associated with a low incidence of non-serious adverse effects (10.9%). However, in spite of a fast response to therapy, the therapeutic goal consisting in the reduction of the platelet count below 400 (or below 600) x 10(9)/l, i.e. the complete (or partial) treatment response, is relatively slow to achieve. This is likely to be due to lack of radical corrections in the dosage of the drug for different reasons.

[Dyslipidaemia inducted by antiretroviral agents]

The clinical course of HIV/AIDS has been substantially modified by up-to date therapy in the recent years. The progress of the disorder has changed--today it is a chronic disease of many years course. Already in 1997 and 1998 it turned out that adverse metabolic changes which significantly affect the subsequent progress of the disease were produced by long-term HAART (highly active antiretroviral therapy). Gradually, more and more anthropometric, metabolic and coagulation changes are detected, closely resembling the changes seen in the metabolic syndrome, well known from cardiology and internal medicine--dyslipoproteinaemia, insulin resistance, abdominal obesity and so on. A combination of these disorders is clinically significant due to their role in the development of atherosclerosis and their, by no means negligible, involvement in the onset of ischaemic heart disease. In view of the much lower average age of HIV-positive individuals the earlier mentioned complications should be expected in much lower age categories than with HIV-negative individuals. Plasma lipid fractions (total cholesterol, triglycerides, LDL-cholesterol, HDL-cholesterol, apoA-I, apoB, LDL/HDL, apoA-I/apoB) have been investigated in 69 HIV infected subjects and the changes of these parameteres in the course of progression of HIV/AIDS due to cumulative time of exposure to HAART were explored. Significant increase of the level of proatherogenic plasma lipid fractions with tendency to develop at time course was found. These disturbances are observed in the course of very good immunological stabilization and viral suppression. No unambiguous data and results of long term studies are available, that would confirm the increase of cardiovascular risk in HIV infected subjects. Nevertheless, this increase is required and anticipated.

[Actual state of ex vivo chemoresistance testing of malignant tumors in Masaryk Memorial Cancer Institute Brno]

Chemoresistance assay results may play a role in cancer management decision process. Since August 2006 testing chemoresistance has been tested according to a protocol that was designed for this reason in our institute (Masaryk Memorial Cancer Institute). Five groups of different types of cancer in particular clinical stages were defined for chemosensitivity testing with: (1) metastatic malignant melanoma, (2) soft tissue sarcoma (STS), either primary or recurrent/metastic, (3) primary or metastatic renal cancer, (4) recurrent ovarian cancer and (5) other diagnosis "on clinician's request". In the period from September 2006 to November 2007, 25 samples of malignant melanoma (reproducible results in 9 cases), 29 samples of STS (relevant data in 11 cases), 36 samples of renal cancer (relevant results in 20 samples) and 16 samples of ovarian cancer (reproducible results in 11 cases) were acquired. Sensitivity to certain chemotherapy agent observed ex vivo does not necessarily mean that the cancer would also be sensitive to the same agent in vivo, however, ex vivo resistance with following in vivo sensitivity of the tumour has not been observed to date. The cultivation of malignant cells is very uncertain in solid tumours, which consist of several malignant cell multiclones (benign/stromal cells may outgrow malignant cells). This cultivation uncertainty as well as the unique complexity of human metabolism makes clinical application of chemoresistance testing at least very questionable. The small number of successfully evaluated samples has not yet provided us to carry out proper statistical evaluation and clinical application.

[Subtalar stabilization of pes equinovalgus by conventional open surgery using bicortical iliac crest bone graft (mid-term results)]

PURPOSE OF THE STUDY

The aim of the study was to analyze the results of subtalar stabilization of the foot by conventional open surgery with the use of bicortical graft in cerebral palsy patients with pes equinovalgus and to compare our results with those of other authors.

MATERIAL

A total of 193 operations were performed, with bilateral surgery in 84, surgery on the right foot in nine and surgery on the left foot in 16 patients. The average follow-up was 5 years and 2 months.

METHODS

Before and after surgery, the clinical presentation in each patient was evaluated according to our subjective, description- based classification using a I-to-III scale (I, normal foot; II, moderate deformity; III, severe deformity). On lateral radiographs of the foot in a standing position, the talocalcaneal (TC) angle and that between the longitudinal calcaneus axis and foot-supporting surface (CS) were measured. The data was analyzed by statistical methods.

RESULTS

The pre-operative findings were compared with the post-operative ones on the basis of our I-III classification system. In all results obtained with the McNemar test, p-values were lower than 0.001; therefore, at a 5 % level, the null hypothesis can be ruled out and a conclusion can be drawn that this surgery has an effect on the change in foot shape, as defined by our classification. Surgery failed in 13 feet (6.7 %), i.e., it did not produce any change in the degree of deformity. Similarly, values of the TC and CS angles were compared. The null hypothesis of Wilcoxon's test is that the patient's condition (TC and CP angles) remains the same before and after surgery. In all cases, the p-values were lower than 0.001; therefore, at a 5 % level, the null hypothesis can be ruled out, with the conclusion that differences between pre- and postoperative conditions were statistically significant.

DISCUSSION

The results of this study, as compared with the relevant data, show that, for correction of pes equinovalgus, subtalar stabilization with bicortical iliac crest graft is a sufficiently reliable method even without metal fixation. The failure rate is only 6.7 %.

CONCLUSIONS

The method described here achieves good results, the validity of which is supported by statistical analysis. Key words: cerebral palsy, pes equinovalgus, subtalar extra-articular arthrodesis.

[Essential thrombocytemia and other myeloproliferations with thrombocytemia in the data of the register of patients treated with Thromboreductin till the end of 2006]

Since 2005, registers of patients treated with Thromboreductin (anagrelid) kept by some centres in the Czech Republic have been supplied with data concerning patients whose treatment with this preparation started in 2004. The purpose of the register is to record responses to therapy by Thromboreductin and adverse events in patients with essential thrombocytemia and other myeloproliferations, and to subsequently analyse the data. Another objective is to detect predisposition to clinical symptomatology and disease complications. Apart from thrombocyte count, additional risk factors are monitored. The database currently contains data for 336 patients. Initial analyses of data from the register point to the fact that anagrelid is a highly effective thromboreductive agent the administration of which is associated with relatively low incidence of adverse events (11.8 %) of mild and usually transitory nature. The therapeutic objective is attained at a relatively slow rate (according to overall stratification under 400 or under 600 x 10(9)/l thrombocytes), which is probably due to insufficient dose adjustment.

[Aorto-enteric fistula as a cause of massive gastrointestinal hemorrhage]

The authors describe a rare complication following femoral reconstruction operations, i.e. an aorto-enteral fistula associated with massive gastrointestinal haemorrhage. They draw attention to limited diagnostic possibilities and sometimes the necessity to perform urgent laparotomy. The diagnosis is facilitated by endoscopy, CT, sonography and aortography. Endoscopy can determine the site of haemorrhage, not its cause. At present when there is a high number of vascular reconstruction operations, this possibility should be taken into account. The authors recommend to prevent this complication by inserting a transplant from the omentum between the intestinal wall and the prosthesis, or possibly to cover the wound by preaortal adipose and lymphatic tissue and to stitch the peritoneum to prevent direct contact. To resolve complications direct stitch may be used, a patch. More frequently it is, however, necessary to exchange the entire prosthesis and sometimes to ensure nurture by an extra-anatomical bypass. In urgent situations clamping of the aorta may be of temporary assistance.