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Lege Artis Medicinae

JULY 20, 2017

[Fulvestrant: long-term survival and quality of life in a patient with hormone receptor-positive advanced breast cancer]

PINTÉR Tamás

[INTRODUCTION - There are lot of evidence showing the efficacy of fulvestrant therapy in HER-2 negative, HR-positive advanced metastatic breast cancer. CASE REPORT - A 75-year-old female had a mastectomy, followed by series of adjuvant and radiotherapy about 30 years ago. Later cutan metastases were removed several times. The endocrine therapy had to be stopped because of intolerance. An ER, PR positive, HER-2 negative cutan metastasis was resected 7 years ago for the last time. During regular checkup, 5 years ago pulmonary nodule and bone metastases were found, - PET-CT disclosed multiple metastatic lymph nodes as well. We started fulvestrant and bisphosphonate therapy. Thereafter, as imaging revealed, the malignant disease has stabilized, the patient has a good performance status, her musculo-skeletal pain has a presumably degenerative origin. DISCUSSION - Reported case corroborates the potential efficacy of fulvestrant and ibandronate in hormone sensitive breast cancer with good prognostic markers, even in the case of metastases in soft tissue and bone. This case supports the data, that in patients with not progressive bone metastases the frequency of administration of parenteral bisphosphonates may be reduced to every 3 months. Advanced metastatic breast cancer may be converted to a chronic disease in properly selected cases, and it could mean long-term survival with a good quality of life.]

Clinical Oncology

MAY 20, 2016

[Treatment of childhood tumors of mesenchymal origin]

CSÓKA Monika

[Mesenchymal cells can be differentiated into skeletal muscle, smooth muscle, adipose tissue, fi brous tissue, bone and cartilage. Tumors can be originated from these tissues as benign tumors - fibroma, lipoma, osteoma, chondroma, haemangioma, myoma, etc. or as malignant tumors - in childhood, most commonly rhabdomyosarcomas, osteosarcoma, Ewing sarcoma, less often fi brosarcoma, liposarcoma or other rare types. Clinically, the outcome of these tumors have improved signifi cantly in the last decade due to the use of multi-modality treatment (chemotherapy, surgery, irradiation, in some cases targeted therapy). The better treatment results are based on early diagnosis and adequate management according to international treatment protocols in pediatric oncology centers.]

Clinical Neuroscience

JANUARY 20, 2017

Combination of severe facial and cervical vascular malformation with obstructive sleep apnea syndrome: diagnostic and therapeutic approaches

FALUDI Béla, IMRE Marianna, BÜKI András, KOMOLY Sámuel, LUJBER László

The combination of obstructive sleep apnea syndrome and vascular malformation within the head and neck region is a rare condition, and interestingly, only a few cases have recently been published. Propagation of the vascular mass to the larynx and pharynx can cause breathing and swallowing difficulties. Due to these sypmtoms, examination and initiation of appropriate therapy for such patients are indeed challenging. We reviewed the literature available and present our case of a 64 year old woman emphasizing the complaints of sleep apnea syndrome and vascular malformation of the face and neck region. Polygraphic examination detected severe obstructive sleep apnea syndrome. The MR examination of the neck revealed extensive vascular mass narrowing the pharyngo-laryngeal region, thereby causing temporal bone destruction on the right side with intracranial propagation. ENT examination demonstrated significant narrowing of the pharyngeal lumen and the laryngeal aditus caused by multiple hemangiomas. CPAP titration showed the minimalization of the apnea-hypopnea index on the effective pressure level. Regular CPAP usage resulted in diminishing a majority of the patient’s complaints. Our examination clearly demonstrates, obstructive sleep apnea syndrome coupled with significantly obstructing vascular malformation in the head and neck region can be effectively treated safely with a CPAP device, if surgical therapy is not possible. We summarized our findings and the data available in the literature to set up recommendations for the appropriate examination and therapy (including mask fit, etc.) of vascular malformations and hemangiomas causing pharyngo-laryngeal obstruction.

Lege Artis Medicinae

OCTOBER 20, 2016

[Many faces of thyroid hormone deficiency]

MOLNÁR Ildikó

[The timely detection of thyroid hormone deficiency is crucial to inhibit the dangerous consequences of related diseases, such as obesity, cardiovascular diseases, type 2 diabetes mellitus, breast cancer, bone wasting, menstruation disturbance, and goitrogenesis. Subclinical hypothyroidism (<10 mU/l TSH) can initiate the above mentioned symptoms and diseases, therefore its early detection and treatment is necessary. The manuscript details from a practical point of view the causes leading to thyroid hormone deficiency, their consequences and gives recommendation for starting the treatment. The increased occurrence of breast and colorectal cancers associated with thyroid hormone deficiency is explained, and the attention to concomitantly elevated prolactin levels is called. Finally, the paper gives proposals for the clinical practice, when we should think of thyroid hormone deficiency and reports on the algorithm of the treatment of subclinical hypo­thyroidism recommended by the European Thyroid Association (ETA) in 2013.]

Clinical Neuroscience

JULY 30, 2016

Syndrome of trephined-underestimated and poorly understood complication after decompressive craniectomy

LÁNG József, GANAU Mario, PRISCO Lara, BOZSIK Krisztina, BANCZEROWSKI Péter

Decompressive craniectomy (DC) is still a matter of debate, with a numerous complications as expansion of haemorrhagic contusions, external cerebral herniation, subdural hygromas, post-traumatic hydrocephalus (HC). The often overlooked “syndrome of the trephined” (ST) as a delayed complication of DC also known as sinking skin flap sy initially described in 1939.ST is characterised by the neurological changes associated with alteration of the pressure/volume relationship between intracranial pressure (ICP), volume of cerebrospinal fluid (CSF), blood, and brain tissue in patients with large bone defects. This review aims at elucidating the mechanisms responsible for the development of ST, and providing useful tips and red-flag signs for healthcare professionals involved with care of post DC patients. Symptoms identified on time could help to develop appropriate treatment strategies for this suddenly deteriorating, but possible reversible condition. Although the treatment strategy is straightforward, calling for a prompt cranioplasty, the correction of HC through CSF diversion devices might require a lengthy optimisation period. Continuous changes in the setting of the shunting systems or spinal tap might lead to dangerous swinging of the midline structures causing further neurological deterioration. Thus, finding the right balance in terms of clinical management often represents a significant challenge.

Lege Artis Medicinae

JUNE 20, 2016

[Neurological symptoms in a patient with treated multiple myeloma]

ZOMBORI Tamás, PIUKOVICS Klára

[INTRODUCTION - Meningeal infiltration by multiple myeloma is rare. Its incidence among cases of multiple myeloma is 1%. CASE REPORT - Multiple myeloma was diagnosed in a 53-year-old woman in December 2014. After chemotherapy, the disease was treated with autologous bone marrow transplantation in June 2015. Remission was observed through two months, but in August the patient was hospitalized due to severe headache with neck stiffness. Meningitis or viral encephalitis were suspected following her investigation. She was taken to the Intensive Care Unit because of a progression to status epilepticus. The EEG-examination revealed generalized slow wave activity and a right temporal epileptiform focus manifesting rarely. Clinical brain death developed on the 17th day in hospital. DISCUSSION - Although meningeal infiltration is infrequent in multiple myeloma, the present case report draws attention to this possibility. ]

Clinical Oncology

MAY 20, 2014

[Management of prostate cancer today]

PETRÁNYI Ágota Eszter, BODROGI István

[Although metastatic prostate cancer remains an incurable disease, the past years witnessed an extraordinary progress in the management of patients with castration resistant prostate cancer (CRPC). Development of novel agents that modulate the androgen receptor pathway, growth factor signaling pathways, immune functions and bone targeting machinery has been the focus of therapeutic strategies because of its signifi cance in the biology of prostate cancer progression. The arrival of several new agents — cabazitaxel, abiraterone acetate, enzalutamide, sipuleucel-T, denosumab and radium-223 — is changing the options and management of patients with metastatic castration resistant prostate cancer (mCRPC). Prostate cancer is a heterogeneous disease, therefore, in treatment must be considered the clinical characteristics of the disease as it manifests in an individual patient. The aim of this review is to summarize the most important new fi ndings for metastatic prostate cancers according to the different molecular pathways and to discuss their potential role on the management of this disease.]

Clinical Oncology

DECEMBER 05, 2014

[Bone metastases - Current treatment strategy]

BOÉR Katalin, NÉMETH Zsuzsanna

[Bone is the most common site of metastatic disease in many solid tumours, mainly in breast, prostate and lung cancer. Patients with bone metastases are at risk for skeletal-related events such as bone pain, pathological fractures requiring surgery and/or radiation to bone lesions, hypercalcemia, and spinal cord compression. Skeletal-related events are major source of morbidity for cancer patients and may be associated with negative impact on quality of life and survival. Bisphosphonates inhibit osteoclast function and are widely used in the treatment of malignant bone disease, as preventive therapy against skeletal-related events. Recently, the NF-κappa B-ligand (RANKL)-mediated osteoclast activity and this pathway in bone metabolism became a prime target for the treatment of bone metastases. The fi rst drug targeting the RANK-RANKL pathway is denosumab, a fully monoclonal human antibody which binds to RANKL and inhibits osteoclast activity. Nowadays optimal treatment of bone metastases requires multidisciplinary management of patients including the administration of bone-modifying agents such bisphosphonates or denosumab. The use of bone-targeted agents is a valuable additional treatment in the fi ght against bone metastases and multiple, randomised trials have demonstrated the effectivity of these drugs in reducing skeletal morbidity caused by advanced cancer.]

Clinical Oncology

DECEMBER 05, 2014

[Tyrosine-kinase inhibitors and bisphosphonates in the treatment of metastases from renal cell carcinoma]

EDUARD Vrdoljak, TOMISLAV Omrčen

[Bone metastases (BMs) are common in patients with renal cell carcinoma (RCC) and approximately in 30% of patients with metastatic RCC (mRCC) will develop. Inhibition of vascular endothelial growth factor (VEGF) has been pursued as a therapeutic target in the treatment of metastatic clear cell RCC (mRCC). Tyrosine kinase inhibitors (TKIs), such as sunitinib, pazopanib, sorafenib, and axitinib, became the therapy of choice for patients with mRCC. Apart from the undisputed effi cacy of TKI in treatment of mRCC, the problem of metastatic bone disease still remains. There is evidence that the presence of BMs in m-RCC patients has a signifi cant and clinically-relevant negative impact on survival and potentially on the outcome of VEGF-targeted therapy. Also, common practice in the treatment of such patients is bonedirected therapy with BPs. Recent evidence shows a potentially synergistic effect on effi cacy but also a potential impact on increased toxicity of combining TKIs and BPs. This review highlights the importance of this subject and aims to facilitate further research and optimize the treatment of this important and common group of RCC patients.]

Clinical Neuroscience

JULY 30, 2015

[Treatment of post spondylodesis adjacent segment disease with minimally invasive, anterolateral surgery on lumbar spine: there is no need for dorsal operation?]

SCHWARCZ Attila, SZAKÁLY Péter, BÜKI András, DÓCZI Tamás

[Adjacent segment disease (ASD) occurs with a probability of 30% in the lumbar spine following spinal fusion surgery. Usually advanced degenerative changes happen cranially to the fused lumbar segment. Thus, secondary spinal instability, stenosis, spodylolisthesis, foraminal stenosis can lead to the recurrence of the pain not always amenable to conservative measures. A typical surgical solution to treat ASD consists of posterior revision surgery including decompression, change or extension of the instrumentation and fusion to the rostral level. It results in a larger operation with considerable risk of complications. We present a typical case of ASD treated surgically with a new minimally invasive way not yet performed in Hungary. We use anterolateral abdominal muscle splitting approach to reach the lumbar spine through the retroperitoneum. A discectomy is performed by retracting the psoas muscle dorsally. The intervertebral bony fusion is achieved by implanting a cage with large volume that is stuffed with autologous bone or tricalcium phosphate. A cage with large volume results in excellent annulus fibrosus tension, immediate stability and provides large surface for bony fusion. A stand-alone cage construct can be supplemented with lateral screw/rod/plate fixation. The advantage of the new technique for the treatment of ASD includes minimal blood loss, short operation time, significantly less postoperative pain and much less complication rate.]