Diagnostically challenging human papillomavirus-associated primary squamous cell carcinoma of the rectum with metastasis in both ovaries: a case report

Introduction

Squamous cell carcinomas of the rectum are extremely rare and their pathogenesis is still under debate. Their proper diagnosis and treatment may thus be challenging.

Case presentation

A 52-year-old Caucasian woman was transferred to our department with a history of pelvic pain. Colonoscopy revealed a small tumorous lesion of the upper rectum and an endoscopic biopsy showed infiltration of the rectal mucosa by a squamous cell carcinoma. Afterward, tumorous lesions were found on imaging in both her ovaries. A laparoscopy with adnexectomy and anal mapping was performed and revealed tumor masses of squamous cell carcinoma in both ovaries. Based on the large size of the ovarian tumors and the concurrence of extensive, partly ciliated, macrocystic epithelium in one of the ovaries, a diagnosis of ovarian squamous cell carcinoma arising from a mature teratoma was rendered. However, human papillomavirus genotyping analyses were positive for human papillomavirus-16 in both the rectal tumor and ovarian tumors leading to a final diagnosis of a human papillomavirus-associated rectal squamous cell carcinoma metastatic to both ovaries. Neoadjuvant chemoradiation therapy of her rectum, total mesorectal excision, and hysterectomy were performed followed by adjuvant chemotherapy.

Conclusion

Colorectal squamous cell carcinoma is a rare disease. In cases of colorectal squamous cell carcinoma, metastatic disease at any other location has to be excluded. Human papillomavirus genotyping is essential in this context. Discussion of the treatment strategies should be interdisciplinary and include chemoradiation therapy and radical surgery.

Granulocyte Elastase, Tumor Necrosis Factor-α and Urokinase Levels as Prognostic Markers in Severe Infection

We have examined the prognostic value of the levels in the blood of granulocyte elastase-α1-proteinase inhibitor (E-α1-PI) complex, tumor necrosis factor-α (TNF-α) and urokinase-type plasminogen activator (u-PA) in 35 patients with severe infection upon admission to an Intensive Care Unit. Fourteen patients died.

No differences for E-α1-PI complex were found between survivors and nonsurvivors, but in all patients the levels on admission were eight-fold higher than the reference value.

TNF-α levels, measured by immunoassay, on admission were four times higher in the nonsurvivors than in the survivors (p = 0.0003) and correlated with the severity of the disease (APACHE II score, r = 0.43, p <0.05). TNF-α was not detectable by bioassay.

Total u-PA antigen (u-PA Ag), plasmin-activatable single-chain u-PA (scu-PA) and inactive, nonactivatable u-PA (u-PA#) were on admission all two-fold higher in the nonsurvivors (p = 0.0006, 0.003 and 0.0003, respectively), while normal in the survivors. In both, survivors and nonsurvivors, the ratio between scu-PA and u-PA Ag was significantly decreased (p <0.001, compared to a reference group of healthy volunteers), indicative for enhanced conversion of scu-PA to active two-chain u-PA (tcu-PA) and inactive u-PA# during severe infectious disease. tcu-PA was detected in nine of the 35 patients, while virtually undetectable in controls. scu-PA correlated with the Child-Pugh score on admission (r = 0.42, p <0.05). TNF-α correlated with u-PA Ag (r = 0.38, p <0.05) and with u-PA# (r = 0.47, p <0.01).

In a stepwise logistic regression analysis, documentation of infection and plasma levels of u-PA Ag contributed most significantly to prediction of patient outcome. Serum levels of TNF-α did not. These results suggest that, in addition to a number of other clinical and laboratory parameters, u-PA Ag can be used as a prognostic marker in patients with severe infection admitted to an Intensive Care Unit.

Fibrinolysis and Coagulation in Patients with Infectious Disease and Sepsis

Sepsis is often associated with hemostatic dysfunction. This study aimed to relate changes in fibrinolysis and coagulation parameters to sepsis and sepsis outcome. Urokinase-type plasminogen activator (u-PA) antigen, tissue-type plasminogen activator (t-PA) antigen and activity, plasminogen activator inhibitor (PAI) type 1 antigen, PAI activity, antithrombin (AT) III activity, and protein C activity were measured in 24 patients suffering from sepsis or septic shock and the results were compared with those observed in 30 non-sepsis patients with severe infectious disease. The u-PA level was markedly increased in plasma of sepsis patients as compared to non-sepsis patients (11.5 ± 9.4 versus 1.6 ± 1.5 ng/ml, p <0.0001). PAI-1 antigen and t-PA activity showed a significant increase in sepsis patients (320 ± 390 ng/ml versus 120 ± 200 ng/ml, and 3.0 ± 3.6 IU/ml versus 1.0 ± 0.7 IU/ml, respectively, p <0.01). AT III was decreased in sepsis patients (58 ± 28% in sepsis versus 79 ± 26% in severe infectious disease, p <0.01) as was protein C (30 ± 18% versus 58 ± 27%, p <0.001). No significant difference was found for t-PA antigen nor for PAI activity. Nonsurvivors of sepsis were distinguished mainly by a high u-PA antigen level and increased t-PA activity. It is concluded that plasma u-PA antigen showed the strongest significant difference, among the parameters evaluated, between sepsis and severe infection. u-PA antigen may be of prognostic value in patients admitted to the medical intensive care unit for severe infectious disease.

[Chronic, refractory ulcer on the ring finger : Manifestation of distal epithelioid sarcoma]

The epithelioid sarcoma classic, "distal" type was first published in 1970. It is a very rare, malignant, aggressive subcutaneous soft tissue sarcoma that shows characteristic positivity for both epithelial and mesenchymal immunohistochemical markers. It grows very slowly and mostly presents in young men. Clinically the tumor is characterized as a coarse cutaneous or subcutaneous nodular induration that often ulcerates in the course of the disease. An association with trauma is often described and can lengthen time to diagnosis. Most frequently it is found on the flexural side of fingers, the back of the hands, soles of the feet, and extensor sides of arms and legs. Specific for this type of sarcoma is the progression along nerves, tendons, and fasciae. Treatment of choice should be wide excision of the tumor, sentinel node biopsy, and possibly even localized postoperative radiation therapy. Unfortunately the epithelioid sarcoma is very likely to recur and is then associated with metastases in the lung and lymph nodes.

Early recognition of malignant lactic acidosis in clinical practice: report on 6 patients with haematological malignancies

BACKGROUND

Malignant lactic acidosis is a potentially overlooked but life-threatening complication in patients with haematological malignancies. The aim of this study is to describe the features of six patients with malignant lactic acidosis and to discuss how its initial presentation can be differentiated from that of severe sepsis.

METHODS

We prospectively collected data of all consecutive patients with haematological malignancies, admitted to the Ghent University Hospital Intensive Care Unit (ICU) between 2000 and 2007.

RESULTS

Of 372 patients with haematological malignancies admitted to the ICU for life- threatening complications, 58 presented with lactic acid levels > or = 5 mmol/L. Six were diagnosed with malignant lactic acidosis. All patients with malignant lactic acidosis had high-grade lymphoblastic malignancies and were referred with a tentative diagnosis of severe sepsis or septic shock; lactic acid levels exceeded 9.45 mmol/L and lactate dehydrogenase (LDH) levels were at least 1785 U/L. Two patients had hypoglycaemia. All had a pronounced polypnea. In all patients hepatic malignant involvement was suspected. Two of the six patients survived their episode thanks to the early recognition of malignant lactic acidosis and the prompt administration of chemotherapy. One patient was still alive 6 months after initiating chemotherapy.

CONCLUSION

Malignant lactic acidosis is a rare and often rapidly fatal metabolic complication if not promptly recognized and treated. An elevated lactic acid concentration, in disproportion with the level of tissue hypoxia, together with high serum LDH are cornerstones in the diagnosis. In contrast to septic shock patients, pronounced polypnea (Kussmaul's breathing pattern) rather than the haemodynamic instability is prominent.

Lenalidomide in relapsed refractory myeloma patients: impact of previous response to bortezomib and thalidomide on treatment efficacy. Results of a medical need program in Belgium

The prognosis of multiple myeloma patients has significantly improved since the introduction of the novel agents thalidomide, bortezomib and lenalidomide. We report the data of a medical need programme with lenalidomide plus dexamethasone, conducted in Belgium between August 2007 and March 2008, and including 98 relapsed refractory multiple myeloma patients. In addition to chemotherapy and steroids, all patients had received prior treatment with bortezomib, and 84% of them had been exposed to thalidomide. In 52 patients response data could be retrieved by post-hoc analysis. A partial remission or better was achieved in 52% (49% partial and 3% complete response) of patients, despite a median of 5 previous anti-myeloma treatment lines. Responses were rapid while the majority of patients received lenalidomide with once weekly (also called low-dose) dexamethasone. Treatment with lenalidomide plus dexamethasone did prolong overall survival by nearly half a year in this population with end-stage myeloma. Overall response and quality of response were independent of previous response to thalidomide and bortezomib, although the time to progression tended to be shorter in thalidomide- and bortezomib-refractory patients. It can be concluded that lenalidomide plus dexamethasone is an effective and safe treatment regimen in highly refractory multiple myeloma patients, and that these responses are irrespective of previous exposure or sensitivity to thalidomide and bortezomib.

Myeloma of the central nervous system: report of a single center case series

BACKGROUND

Neurologic manifestations often complicate the course of multiple myeloma, but direct involvement of the central nervous system (CNS) is rare.

OBJECTIVE

To describe the clinical course, neurological symptoms, laboratory findings and imaging of patients with CNS myeloma. This additional information may contribute to better recognition and more effective management of this complication in the future.

METHODS

We retrospectively identified 6 MM patients with CNS involvement diagnosed at our centre between April 2003 and April 2009. The clinical, biochemical and imaging data were collected and compared with previously reported cases.

RESULTS

At time of diagnosis of CNS myeloma, 3 patients had progressive disease and 3 were in good partial remission. The presenting symptoms included diplopia, vision loss, extremity weakness and paresis. All cases showed one or more features of aggressive disease at diagnosis, including high tumour burden, plasmablastic morphology and high-risk cytogenetic abnormalities. Prognosis was poor with a median survival of 4.8 months.

CONCLUSION

CNS myeloma should be considered in patients with aggressive MM and unexplained neurological symptoms. The prognosis is poor despite intensive therapy.

[Small intestine, pancreas and islet cell transplantation]

The past decade has seen substantial improvements in patient and graft survival after intestinal transplantation. This improvement has been achieved by advances in donor and recipient selection, patient management, immunosuppression and surgical techniques. Intestinal transplantation is therefore considered a therapeutic option in the treatment of short bowel syndrome. Mile stones include the development of the calcineurin inhibitor Tacrolimus for immunosuppression as well as induction therapy using immune modulating substances like interleukin-2 receptor antagonists and antilymphocyte preparations. In addition to improvements in immunosuppression, antimicrobial prophylaxis and diagnosis of rejection, advances in surgical techniques have been crucial to achieving increased graft survival. Pancreas transplantation, generally with simultaneous kidney transplantation, is now available as a treatment option for patients with labile diabetes mellitus (usually type 1). Allogeneic islet transplantation was developed in the 1990s as a minimally invasive alternative to pancreas transplantation. Pancreatic islets are isolated enzymatically from the donor pancreas, in most cases infused into the portal vein and thus engrafted into the liver. Currently, technical and medical problems as well as high costs prevent the application of islet transplantation as a therapeutic option for a larger number of patients with diabetes mellitus.

Abstract P4-09-02: Prognostic and Predictive Value of Centrally Reviewed Ki67 Labeling Index in Postmenopausal Women with Endocrine-Responsive Breast Cancer: Results from Austrian Breast and Colorectal Cancer Study Group Trial 8

Purpose: The aim of the present study was to assess the prognostic and predictive value of Ki67 labeling index in postmenopausal hormone receptor-positive early breast cancer patients who were treated with adjuvant tamoxifen or anastrozole after tamoxifen. Patients and Methods: We determined the expression of Ki67 by immunohistochemistry on whole tissue sections of breast carcinoma patients who had been enrolled in Austrian Breast and Colorectal Cancer Study Group (ABCSG) Trial 8 and received tamoxifen for 5 years or tamoxifen for 2 years followed by anastrozole for 3 years. Ki67 labeling index was evaluated as continuous variable or dichotomized at 10%. Distant recurrence and death were analyzed using Cox models adjusted for clinical and pathological factors.

Results: High Ki67 labeling index was observed in 394 of 1587 (23%) tumors and was associated with poor outcome. Patients with high Ki67 labeling index had a significantly shorter distant recurrence-free survival (adjusted hazard ratio [HR] for distant recurrence 2.16, 95% confidence interval [CI] 1.43-3.25, P &lt; 0.001) and overall survival (adjusted HR for death 1.77, 95% CI 1.30-2.42, P &lt; 0.001) as compared to patients with low Ki67 labeling index. No interaction between Ki67 labeling index and treatment was observed (P = 0.84).

Conclusion: High Ki67 labeling index is an independent poor prognostic factor for distant recurrence and death in postmenopausal women with early-stage, hormone receptor-positive breast cancer but is not predictive for outcome of adjuvant treatment with either tamoxifen or tamoxifen followed by anastrozole.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-09-02.

Adverse effects of polyvinylidene fluoride-coated polypropylene mesh used for laparoscopic intraperitoneal onlay repair of incisional hernia

BACKGROUND

Polyvinylidene fluoride-coated polypropylene meshes have been developed specifically for intraperitoneal onlay mesh repair. They combine a macroporous design with biomechanical characteristics compatible with the abdominal wall and are reported to have favourable antiadhesive properties. This retrospective study reports complications related to one of these materials, DynaMesh.

METHODS

Twenty-nine patients underwent intraperitoneal onlay mesh repair with DynaMesh at one of two hospitals. Patients characteristics, surgical procedures and postoperative analgesia were comparable at both sites.

RESULTS

Six patients developed DynaMesh-related complications that required surgical reintervention by laparotomy within 1 year of operation. Surgical reintervention was for adhesions in five patients and the mesh had to be explanted in three. One mesh was explanted because of early infection. Adhesions to DynaMesh were found in two patients who had surgery for unrelated reasons.

CONCLUSION

Laparoscopic intraperitoneal onlay DynaMesh repair was associated with a high rate of complications.

The Belgian 2010 consensus recommendations for the treatment of multiple myeloma

Since the introduction of novel therapeutic agents including thalidomide, lenalidomide and bortezomib, the prognosis of multiple myeloma (MM) has significantly improved. These agents have been incorporated into numerous treatment schedules for newly diagnosed as well as more advanced MM patients. Hence, the therapeutic options for MM have become more complex and subject to rapid changes. The multiple myeloma study group (MMSG) of the Belgian Hematological Society has established recommendations for the treatment of MM as based on an extensive review of the literature which is also summarized in this paper. The recommendations are the result of a consensus opinion between haematologists with experience in the field and representing most haematology centres in Belgium. Where applicable, reimbursement criteria are also taken into account. The consensus recommendations should be a reference for use by clinical haematologists in daily practice.

Abstract 5352: A high percentage of Merkel cell carcinomas is biologically associated with Merkel cell polyomavirus

Merkel cell polyomavirus (MCPyV) DNA has been detected by PCR in 75-100% of Merkel cell carcinomas (MCC), an aggressive neuroendocrine skin cancer. MCPyV is a 5.4 kb DNA virus that expresses tumor (T) antigen in tumor tissues. The aim of this study was to analyze which subset of MCC is biologically associated with MCPyV using various viral detection methods.

Genomic DNA isolated from paraffin-embedded tissue of 61 MCC was analyzed by MCPyV-specific PCR. Using a 5kb MCPyV DNA probe, the physical status of MCPyV was determined by fluorescence in situ hybridization (FISH) using tyramide signal amplification and ApoTome microscopy. Expression of large T antigen was assessed by immunohistochemistry (IHC) using monoclonal antibody CM2B4 (kindly provided by Y. Chang).

A total of 44 of 61 (72%) MCC were positive for MCPyV by PCR. 34 of these 44 cases (77%) were also positive for MCPyV by FISH and 28 (64%) showed strong nuclear large T antigen expression by IHC. In contrast, none of the 17 PCR-negative tumors showed FISH signals and only 1 case showed a weak immunostaining for large T antigen. FISH analysis showed in 16 cases (47%) tumor nuclei with a single punctate signal indicating viral integration. In 8 of these tumors also areas were observed with a granular pattern with &gt;1 nuclear signals varying significantly in size and intensity, indicating the presence of episomal viral DNA and/or RNA. In the remaining 18 cases (53%) an exclusive granular FISH pattern was observed.

Our data indicate that a subset of MCC is caused by MCPyV as determined by PCR, FISH and IHC analysis (46% is positive with all 3 detection methods). FISH and IHC showed a strong positive and negative concordance. FISH signal evaluation furthermore suggests viral integration in half of the positive MCC and a non-clonal viral persistence in the remaining positive cases. Further studies have to validate these findings and elucidate the molecular mechanisms underlying MCV-positive and -negative MCC development.

Note: This abstract was not presented at the AACR 101st Annual Meeting 2010 because the presenter was unable to attend.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 5352.

Treatment of follicular lymphoma--a review

Follicular non-Hodgkin's lymphomas are indolent malignancies that have to be treated repeatedly when symptoms occur. Traditionally, several chemotherapeutic schedules are used. As a result there is a progressive shortening of the disease-free periods and no chemotherapeutical treatment has resulted in a survival benefit so far. The introduction of rituximab, a monoclonal anti-CD 20 antibody, and the association of rituximab with first-line chemotherapy has resulted in a prolongation of the progression-free survival (PFS) and seems to have an impact on (overall survival) OS. The low toxicity profile has even made maintenance therapy with rituximab possible. Trials with rituximab in maintenance suggest a survival benefit. The most optimal schedule of administration and the pharmaco-economical implications are, however, not obvious yet. Autologous stem cell transplantation (SCT) at first remission is another treatment option that has to be re-evaluated. Apart from that there is also the possibility of radio-immunotherapy, of which the advantage will have to become clear during follow-up of recent phase III trails.

Deguelin inhibits expression of IκBα protein and induces apoptosis of B-CLL cells in vitro

We investigated if deguelin, a naturally occurring rotenoid, was able to inhibit nuclear factor kappa B (NF-kappaB)-binding protein (IkappaBalpha) expression and to induce apoptosis in B-cell chronic lymphocytic leukemia (B-CLL) cells in vitro. Deguelin-induced cell death in the majority of B-CLL cells and was found to be more toxic toward B-CLL cells than to the normal mononuclear or B-cells, suggesting selectivity towards the malignant cells. Deguelin was found to reduce IkappaBalpha protein expression, and thus interacts with the NFkappaB pathway. The induced apoptosis was characterized by processing of caspase-9 and -3 and poly-(ADP)-ribose-polymerase cleavage. Exposure of B-CLL cells to deguelin resulted in Bcl2-associated protein (Bax) conformational changes and downregulation of the key survival protein myeloid cell leukemia sequence 1 (Mcl-1), which is associated with response to treatment in B-CLL patients. Deguelin retained its ability to induce apoptosis in B-CLL cells in the presence of interleukin-4, a pro-survival cytokine in B-CLL, and when cultured with 50% human serum. These data indicate that deguelin is able to induce apoptosis in B-CLL cells in the presence of pro-survival signals and thus merits further investigation for clinical application either as a single agent or in combination with other anticancer agents.

Extended liver resection and hepatic ischemia in pigs: a new, potentially reversible model to induce acute liver failure and study artificial liver support systems

BACKGROUND

Extended hepatectomy is a valid model for the study of acute liver failure. Since the porcine liver is comparable in size, morphology and anatomy to the human liver, we describe a technique employing hepatic ischemia and extended liver resection to induce acute liver failure in a porcine model as a means of studying bioartificial liver support.

METHOD

A subtotal (75-80% resection) extended left hepatectomy was performed in 7 pigs after 60 min warm ischemia of the future remnant liver. After resection, the animals were given the best supportive care and observed until death.

RESULTS

All animals died within 18-48 h, none as a result of surgical complications. Gross appearance of the liver showed severe steatosis of the right lateral lobe, and histology revealed severe coagulative necrosis of the whole lobule.

CONCLUSION

This technique of extended liver resection after hepatic ischemia in the porcine model may be useful for studies of potentially reversible acute liver failure and experimental bioartificial support.

Nanocrystalline silver dressings as an efficient anti-MRSA barrier: a new solution to an increasing problem

The emergence of multi-drug-resistant strains of bacteria represents a particular challenge in the field of wound management. The aim of the current study was to investigate whether nanocrystalline silver dressings possess the physical properties to act as a barrier to the transmission of methicillin-resistant Staphylococcus aureus (MRSA) in the laboratory setting and in a clinical setting. Initially, MRSA suspension and colony culture experiments were performed showing that nanocrystalline silver dressings act as potent and sustained antimicrobial agents, efficiently inhibiting MRSA penetration. Subsequently, a double-centre clinical trial was initiated using nanocrystalline silver dressings as a cover for 10 MRSA colonized wounds in a total of seven patients. By delineating the MRSA load on the upper side of the dressing and the wound bed each time the dressing was changed (i.e. after 1, 24, 48 and 72 h), nanocrystalline silver dressings were found to provide a complete, or almost complete, barrier to the penetration/spread of MRSA in 95% of readings. In addition, 67% of all wound observations showed a decrease in the MRSA load with an eradication rate of 11%. We believe that nanocrystalline silver dressings may become an important part of local MRSA management, with cost benefits to both patients and the healthcare system.

All aggressive lymphoma subtypes do not share similar outcome after front-line autotransplantation: a matched-control analysis by the Groupe d'Etude des Lymphomes de l'Adulte (GELA)

BACKGROUND

Data are still conflicting on the indication of front-line autologous stem-cell transplantation (ASCT) as consolidation for aggressive lymphoma. To assess the therapeutic effect of ASCT among different aggressive lymphoma subtypes, we conducted a matched-control analysis by pooling the data from two Groupe d'Etude des Lymphomes de l'Adulte (GELA) trials.

PATIENTS AND METHODS

Between October 1987 and September 1998, 330 patients received ASCT after achieving complete remission with the ACBVP induction regimen. The histological slides showed: B aggressive non-Hodgkin's lymphoma (B-NHL) in 249 patients (75%), T-NHL in 52 patients (15%) (including 23 T anaplastic) and non-classified NHL in 29 patients. The age-adjusted International Prognostic Index (aaIPI) was 2 or 3 in 66%. Patients were matched with controls from the same GELA database but treated with chemotherapy only.

RESULTS

ASCT did not benefit non-anaplastic T-NHL patients [5-year overall survival (OS) 44% (chemotherapy) versus 49% (ASCT), P=0.87; disease-free survival (DFS) 38% versus 45%, P=0.89] in comparison with B-NHL [5-year OS 77% (chemotherapy) versus 79% (ASCT), P=0.64; DFS 67% versus 72%, P=0.13]. However, for B-NHL patients with aaIPI score 2 or 3, the benefit of ASCT was significant.

CONCLUSIONS

This cohort study confirms the high efficacy of front-line ASCT in responding aggressive B-NHL patients with adverse prognostic factors.

Prognostic Factors in Patients With Aggressive Non-Hodgkin's Lymphoma Treated by Front-Line Autotransplantation After Complete Remission: A Cohort Study by the Groupe d'Etude des Lymphomes de l'Adulte

Purpose

Improved survival has been observed in aggressive non-Hodgkin's lymphoma (NHL) patients with adverse prognostic factors when autotransplantation (ASCT) was performed after complete remission. However, there is no agreement on the prognostic factors for patients treated with ASCT. We aimed to estimate the prognostic effect of clinical and biologic variables on relapse and survival rates by pooling the data from two trials.

Patients and Methods

Of the patients treated in the LNH87 and LNH93 trials, 330 under age 60 years achieved complete remission after high-dose cyclophosphamide, doxorubicin, vincristine, and prednisone, and received consolidative ASCT; 16% of patients had T-cell NHL. The International Prognostic Index (IPI) score was 0 for 11%, 1 for 23%, 2 for 51%, and 3 for 15%. Univariate and Cox multivariate survival analyses were retrospectively performed on this population.

Results

Overall survival was 75 ± 5% at 5 years and disease-free survival (DFS) 67 ± 5%. For T-cell NHL, these scores were 54% and 44%, respectively. The IPI score had no prognostic value and only the following parameters adversely affected overall survival and DFS (P < .05): marrow involvement; more than one extranodal site; histology (nonanaplastic T-cell v others); and type of anthracycline (mitoxantrone v doxorubicin, for DFS only).

Conclusion

These results suggest that ASCT can prevent relapse in patients with adverse IPI factors. However, patients presenting with a nonanaplastic T-cell phenotype, more than one extranodal site, or marrow involvement still have a higher risk of relapse. These factors should be taken into account when designing post-ASCT maintenance studies.

[Hyperparathyroidism -- a differential diagnosis of cystic bone tumors]

Clinical manifestations of primary hyperparathyroidism include neuromuscular, intestinal, and osseous symptoms with osteolytic lesions of the bone and pathological fractures. In most cases a primary adenoma of the parathyroid gland leads to an increased production of the parathormone with subsequent osteoclastic bone catabolism. Surgical treatment entails removal of the parathyroid adenoma. We present a female patient and the possible diagnostic and differential diagnostic difficulties encountered in interdisciplinary management.

[Clinical usefulness and perspectives of sentinel node biopsy in the management of breast cancer]

INTRODUCTION

In view of its predictive potential, axillary nodal status plays a particularly important role in breast cancer. The concept of sentinel node biopsy (SNB) revealed an accurate method with low postoperative morbidity for staging the axilla in patients with lymph node-negative breast cancer. The aim of this study was to show that SNB alone must have a place in routine clinical work and is reliable after preoperative chemotherapy (PC) and also in patients with multicentric tumors (MC).

PATIENTS AND METHOD

Between April 1997 and March 2002, a total of 300 SNBs were performed in patients with uni- or bilateral breast cancer. Of them, 45 who had completed PC and 13 with multicentric lesions underwent SNB followed by axillary dissection. The sentinel nodes (SN) were labelled with a blue dye and radioactive colloids. Median follow-up was 33.6 months (range 8.2-67.0) (StAw 1.4).

RESULTS

The detection rate in the learning phase was 81.8% and later 93.5%, independently of the size of the primary tumor. Overall accuracy and negative predictive value of the first 55 patients, after PC and in those with MC came to 97.8% and 96.7%, 97.6%, 95.8% and 100%, respectively. Through focused pathologic examination, staging was improved in 11.3% of patients. A year after the procedure, one patient developed recurrence. Morbidity after SNB alone was significantly lower than after axillary dissection.

CONCLUSION

Our experience shows SNB to be reliable and accurate for axillary staging in breast cancer patients. Morbidity after SNB alone was low. Conclusive data on the local recurrence rate are not yet available. Under certain conditions, SNB appears to have future clinical potential, even in patients with PC and MC, which must be confirmed in further multicentric studies. In the meantime, this method has attained definite value in the surgical therapy of breast cancer patients.