Vol 47, No 8 (2019)

Cover Page

Full Issue


Results of superior vena cava resection in patients with lung and mediastinal tumors

Alexandrov O.A., Pikin O.V., Ryabov A.B.


Background: Thoracic tumors involving the superior vena cava (SVC) are common in the practice of a thoracic surgeon treating cancer patients. Extended combined procedures that allow for complete removal of the tumor improves overall and disease-free survival and as such are justified from an oncologist’s perspective. In some patients, due to a long-standing SVC syndrome, the development of venous collaterals would increase the early postoperative risk of thrombus formation in the prosthesis. In such a case, it is possible to perform circular SVC resection without subsequent prosthetic replacement. 

Aim: To evaluate the short-term results of SVC resection in patients with chest tumors, to develop an algorithm and to identify the patient group in whom circular SVC without prosthetic replacement is feasible.

 Materials and methods: Twenty eight (28) patients were included into the study (22 men and 6 women, with the mean age of 55 [range, 21 to 70 years]; all of them had undergone SVC resection within the intervention for a lung or mediastinal malignancy for 10 years (from 2008 to 2018) in the Department of Thoracic Surgery, Moscow Research Institute of Oncology named after P.A. Herzen. We analyzed their short-term results of the procedures, the postoperative course, and technical particulars of the procedures. 

Results: Locally advanced lung cancer was diagnosed in 19 (67%) of the patients, thymoma in 3 (10%), lung metastatic disease in 2 (7%), germ-cell mediastinal tumors in 2 (7%), thymus cancer in 1 (3%), and residual lymphoma in 1 (3%) patient. In the majority of the patients (15 cases, 53%), the complicated clinical course had been diagnosed before surgery. In 4 patients with protracted SVC syndrome, we performed circular resection without any prosthetic replacement. In 22 patients (78%), the postoperative course was uneventful. Postoperative mortality was 7%. 

Conclusion: SVC resection can be safely performed in patients with primary mediastinal and lung tumors. With a long-standing SVC syndrome, the newly developed cava-caval anastomoses can provide significant functional support; in such patients with compensatory collateral blood flow, the circular SVC resection without prosthetic replacement is relatively safe.

Almanac of Clinical Medicine. 2019;47(8):677-684
pages 677-684 views

Chromogranin A and serotonin for evaluation of treatment efficacy of neuroendocrine tumors

Lyubimova N.V., Timofeev Y.S., Churikova T.K., Markovich A.A., Emelianova G.S., Stilidi I.S., Kushlinskii N.E.


Background: The utility of biochemical markers in the monitoring of treatment efficacy in patients with neuroendocrine tumors (NETs) goes beyond any doubt. However, there are still no clear criteria for the assessment of clinically significant abnormalities of the main NET biomarkers chromogranin A (CgA) and serotonin.
Aim: To evaluate the value of serial measurement of serum CgA and serotonin in the monitoring of the treatment effect in NET patients.
Materials and methods: Serum CgA and serotonin levels were measured in 107 patients with NETs at baseline and at 3–4 weeks after the end of treatment (chemotherapy, biotherapy), as well as in 60 healthy controls. We used enzyme immunoassay based on Chromogranin A NEOLISA (Euro Diagnostica) and Serotonin ELISA (IBL International GmbH) test systems.
Results: There was an association between CgA levels and the efficacy of chemotherapy in NET patients. With progression of the disease, median CgA increased significantly from 412 to 2679 ng/mL (p = 0.012), whereas in the patients with partial response it decreased from 811 to 254 ng/mL (p = 0.023). The ROC analysis showed the 33% cut-off for significant CgA changes for progression, with sensitivity of 80.0% and specificity of 95.6%. A decrease (of more than 33% compared to baseline levels) or absence of significant CgA changes was associated with stabilization of the disease or with partial response to treatment. Significantly decreased CgA levels were found in 75.0% cases of partial response and 43.48% of stabilized patients, whereas the absence of any significant changes in 25 and 66.7%, respectively. There was no association between serotonin levels and the disease behavior under treatment.
Conclusion: CgA could be used as a sensitive marker of NET progression on chemotherapy.

Almanac of Clinical Medicine. 2019;47(8):685-690
pages 685-690 views

Bayesian assessment of the prevalence of BRCA-associated breast cancer in Moscow

Viskovatykh A.V.


Rationale: For many years, breast cancer has been leading in the cancer structure in women, accounting for 21% from the total number of newly diagnosed cases of malignancies in Russia. The literature on the prevalence of the BRCA-associated breast cancer is heterogeneous, which might be related to the specifics of the frequentist analysis. 

Aim: To assess the prevalence of BRCA-associated breast cancer and the probability of sporadic breast cancer in women of the Moscow region by Bayesian statistics. 

Materials and methods: The literature search in the E-library.ru database from January 2010 to March 2019 identified 13 original studies and 8 literature reviews with the data on hereditary breast cancer in the territories of the Russian Federation, Republic of Belarus and Ukraine. The assessment of the prevalence of BRCA gene mutation based on the Bayesian statistics and the full probability equation for incompatible events was performed on the data obtained in one study based on molecular genetic tests of 3826 female patients with breast cancer living in the Moscow Region, aged from 22 to 90 years (Russian Scientific Center of Roentgenoradiology). This was the most comprehensive study among those performed in Russia, covering almost all age ranges, with detailed description of the study design, diagnostic methods and the mutations spectrum analyzed.

 Results: The prevalence of BRCA1-associated breast cancer in Moscow among women is about 0.037%. The general population prevalence of the most frequent mutations of the BRCA1 gene (5382insC, 185delAG, 300T>G, 2080delA, 3819delGTAAA, 4153delA) in the female population in Moscow is about 0.05%, or about 0.1% from the total population. The probability of sporadic breast cancer in the female population of Moscow without any gene dominant mutations associated with breast cancer is about 1%. Conclusion: For the first time, the Bayesian statistics was used to analyze the prevalence of mutations in the BRCA1/2 genes in Russia. The results obtained are in good agreement with similar data for the Belgorod region and the Siberian region of Russian Federation, and the Grodno region of Belarus.

Almanac of Clinical Medicine. 2019;47(8):691-701
pages 691-701 views

Reoperations after the correction of partial abnormal venous return: a clinical case series

Akatov D.S., Belov V.A., Bukhareva O.N., Khomich D.E., Makarov A.A., Kotov S.N., Schneider Y.A.


Rationale: The surgical procedure for partial abnormal pulmonary venous return (PAPV) implies the formation of a tunnel between the orifices of the right pulmonary veins and the left atrial cavity with the interatrial septum repair. To avoid any obstruction of the tunnel, a direct anastomosis between the superior vena cava (SVC) and the right atrial appendage is placed in a number of cases. However, the reparative procedure is potentially associated with such complications as SVC stenosis and/or pulmonary vein stenosis.

 Aim: To present our experience of reoperations for stenosis of systemic and pulmonary veins after primary PAPV repair.

 Materials and methods: From 2014 to 2018, seven patients (boys, 4) with SVC stenosis and/or with stenosis of the right pulmonary veins have been admitted to the FCHMT (Kaliningrad). Their mean bodyweight was 29.1 kg (± 12.5 kg), mean age 9.3 years (± 3.6 years). Three patients had an isolated SVC stenosis. In two patients, there was a combination of SVC stenosis and pulmonary vein obstruction (from stenosis to complete occlusion); in one patient the right pulmonary vein stenosis had been caused by thrombosis. SVC stenosis with subaortal obstruction after the repair of double-outlet right ventricle was diagnosed in one case. In six patients, various procedures for correction of SVC and/or pulmonary vein stenosis were performed. Only in one case the obstruction of systemic veins, confirmed by cardiac catheterization, turned out to be non-significant, making a reoperation unnecessary. 

Results: There were no deaths in this patient group. Endovascular procedures were performed in two patients. In one case, there was an unsuccessful attempt of transluminal balloon angioplasty for SVC stenosis, with subsequent Warden procedure. In another case, a 16-year old patient with SVC stenosis and high pulmonary hypertension was admitted after two previous surgeries had failed. We used a homograft as SVC prosthesis; however, after one year, a re-stenosis was identified. In this case, a SVC stent placement was successful. Due to sick sinus syndrome at one year after the Warden procedure and the repair of pulmonary veins by a homograft, an implantation of electric cardiac pacemaker was necessary in one patient. 

Conclusion: The curative repair of partial abnormal venous return is a well-established surgical technique with satisfactory shortand long-term results. A potential complication of the procedure is an obstruction of systemic and pulmonary veins. To prevent such complications during primary defect repair, as well as with reoperations for vein stenosis, the Warden procedure seems effective and highly reproducible technique associated with lower surgical risks.

Almanac of Clinical Medicine. 2019;47(8):702-706
pages 702-706 views


Is there a place for multivisceral resections in the treatment of gastric cancer?

Smirnov A.V., Cherepanin A.I., Ishchenko R.V.


It is known that multivisceral resections (MVR) are associated with significant numbers of post-operative complications. However, the effectiveness of MVR in increasing the patients' life expectancy remains a matter of debate. Are the risks of extended volume resections justified? It has been previously assumed that the removal of adjacent organs could improve the prognosis of the disease, even in the absence of direct invasion. However, in the era of the big potential of chemoand radiation therapy, the implementation of an over-extensive surgical volume in the absence of tumor invasion is doubtful. In the presence of regional lymphatic nodes metastases, MVR do not improve prognosis, compared to that after palliative resections. If the patient has distant metastases, or the operation has been obviously not radical enough, MVR worsen the prognosis. In grade T4b invasion and with the absence of life threatening complications, it is optimal to start with neoadjuvant or perioperative chemotherapy. In the case of intraoperative suspicion of adjacent anatomical structures involvement, with no distant metastases, en bloc resection in combination with D2 lymphodissection is indicated. In approximately 30–60% of cases, invasion is not confirmed by histology. The only way to improve the results of surgical treatment of gastric cancer patients is to carefully assess the extension of the disease at the preoperative stage, select patients and team work of surgeons with chemotherapists, radiologists and specialists in diagnostics.

Almanac of Clinical Medicine. 2019;47(8):707-711
pages 707-711 views

The diagnosis of metastatic uveal melanoma. What has changed during 10 years?

Grishina E.E., Stepanova E.A., Bogatyrev A.M.


Uveal melanoma is the most common intraocular malignancy. Despite significant progress in the treatment of the primary tumor, uveal melanoma continues to be the most aggressive tumor due to its high potential for hematogenous metastatic spread. Uveal melanoma metastases are located mostly in the liver. Overall survival of patients with liver metastases is 4 to 15 months. There is no adjuvant systemic therapy to prevent metastases of uveal melanoma. In this paper, we aim to analyze achievement in diagnosis of metastatic uveal melanoma made during the last 10 years and to show advantages and disadvantages of the main diagnostic methods. The last years showed the emergence of understanding the differences between skin and uveal melanoma based on different molecular genetic abnormalities and different signaling pathways of these tumors. The success of target treatments for skin melanoma is not applicable to uveal melanoma. Skin and uveal melanoma responds differently to immune checkpoint inhibitors. Insufficient efficacy of systemic chemotherapy, immune and target therapy has made it necessary to develop techniques of local chemoembolization and radioembolization of uveal melanoma metastases. At present, there are no available assessment algorithms for the management of patients with uveal melanoma and suspected metastases. Ultrasonography, if seen as available techniques for radiology diagnostics, should be enhanced either by the intravenous contrast, or by qualifying computed tomography. The use of positron emission tomography / computed tomography has not demonstrated the maximal diagnostic value in identification of liver metastases, and, taken into account its high costs, low availability, and large radiation dose, it cannot be considered as a  feasible method for every 6  months' application. The most effective diagnostic method is magnetic resonance imaging with the liver-specific contrast agents, due to the possibility to detect metastases of less than 1  cm in diameter. However, this technique has not been widely accepted clinically due to high costs, contraindications and a big proportion of false positive results. Current armamentarium of radiation techniques that could be potentially applicable for visualization of hepatic focal abnormalities is rather impressive and is being continuously updated; however, the problem of the metastatic uveal melanoma diagnosis remains unsolved.
Almanac of Clinical Medicine. 2019;47(8):712-720
pages 712-720 views


Appendiceal cancer: the differential diagnosis of a clinical case

Stashuk G.A., Dubrova S.E., Smirnova D.Y.


The primary appendiceal cancer is one of the rarest malignancies. Its counts for 0.5% of all colon cancer and does not exceed few bips in all surgically removed appendices. The disease does not have specific signs. It can imitate acute appendicitis, its complications, or a disease of uterine appendages. The appendiceal cancer is commonly diagnosed during pathomorphological investigation after surgery. A clinical case of a 58-yearold female patient with a tumor of the appendix is presented in the paper. Initially the tumor was thought to be an appendicular infiltrate. During the patient's second hospitalization a differential diagnosis between a uterine appendages tumor and appendicular mucocele was performed. The histological examination identified mucosal adenocarcinoma (G1) of the appendix with invasion into the ileum wall. With the full range of radiation diagnostics that provides additional information to clinical assessment and laboratory work-up it is challenging even for practicians to diagnose the disease. Despite the rare frequency of appendiceal cancer, it should be included into the list for differential diagnosis. The paper presents the basics of the differential diagnosis with special emphasis on the awareness of this disease. The knowledge of specifics of its pre-operative diagnosis could be useful to practitioners.

Almanac of Clinical Medicine. 2019;47(8):733-739
pages 733-739 views

A clinical case of stepwise correction of the chest wall complications after combined treatment for breast cancer

Korymasov E.A., Medvedchikov-Ardiia M.A., Benian A.S.


Radiation-induced sternal osteomyelitis as a complication of combined therapy for breast cancer is quite rare. As a rule, these patients are treated not by oncologists, but by thoracic and general surgeons. We present a clinical case report of successful treatment of chronic radiation-induced sternal osteomyelitis in a 52-yearold woman, who developed it at 2 years after radical mastectomy for breast cancer. The patient recovered after long-term, stepwise treatment including surgical procedures. The infectious process was stopped by wound debridement and vacuum-assisted dressings. The reconstruction stage included the use of a flap from m. pectoralis major. Treatment of radiation-induced sternal osteomyelitis fits to a widely accepted algorithm of surgical care for patients with anterior thoracic wall infections; however, at each step of care the surgeon can come across difficulties related to the pathological effects of the ionizing radiation.

Almanac of Clinical Medicine. 2019;47(8):740-744
pages 740-744 views


Anemia in inflammatory bowel diseases: the approaches to its diagnosis, treatment and prevention

Gubonina I.V., Shchukina O.B., Stuklov N.I., Gaponova T.V., Abdulganieva D.I., Knyazev O.V., Gubonina N.S.


Anemia is a frequent systemic complication and extra-intestinal manifestation of inflammatory bowel diseases (IBD). Despite significant progress in IBD treatment, late diagnosis and insufficient correction of concomitant anemia remain a problem in routine clinical practice. The review describes the main pathophysiological mechanisms of IBD-associated anemia, such as iron deficiency, chronic inflammation (anemia of chronic disease) and B9 and B12 deficiencies. The authors highlight the main diagnostic principles of these conditions, present the strategy for their differential diagnosis, describe the state-of-theart approaches to the correction of iron-deficient anemia in IBD, and delineate the role of oral and parenteral medications for replacement therapy. Optimal treatment goals and prevention methods of an iron-deficient condition are given. Special attention is focused on the principles on red cell mass transfusions in acute massive blood loss. The authors describe the main differentiating features of anemia of chronic disease and its treatment in IBD patients with various grades of the inflammation. The paper contains the indications and treatment regimens for B12 and foliate-deficient anemia with consideration of the IBD course. The authors of the article are members of the Working Group of the Russian Society on the study of IBD and believe that the literature analysis performed would allow for its use to issue the Russian clinical guidelines on the management of patients with anemia in ulcerative colitis and Crohn's disease.

Almanac of Clinical Medicine. 2019;47(8):721-732
pages 721-732 views

This website uses cookies

You consent to our cookies if you continue to use our website.

About Cookies