[Lay version of the 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis : Translation into German and linguistic validation in German-speaking countries with people affected]

BACKGROUND

Physical activity and exercise are beneficial for people with rheumatic diseases; however, recommendations for the management of rheumatoid arthritis (RA), spondyloarthritis (SpA) and hip- and knee osteoarthritis (HOA/KOA) are usually unspecific with respect to mode and dose of exercise. This is why the 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis were formulated. The recommendations consist of 4 overarching principles and 10 recommendations. These were also published as a lay version in the English language.

AIM

Translation of the lay version into German and its linguistic validation in Austria, Germany and Switzerland.

METHODS

A professional translation was reviewed by the authors, including people with, RA, SpA, HOA/KOA from the three German-speaking countries, which provided a prefinal lay version. Subsequently, eight interviews with people with RA, SpA, HOA/KOA were conducted in each country to evaluate understandability, wording, completeness and feasibility of the prefinal lay version. Finally, the authors, i.e. those with RA, SpA, and osteoarthritis, anonymously rated their agreement to the final lay version on a 0-10 scale.

RESULTS

The professional translation was substantially revised by the authors and based on the interviews. Formulations were adapted to increase readability and understandability and specify statements. Comments that would have changed content or structure were not considered. Average agreement with the particular recommendations was between 10 (SD 0) and 7.6 (SD 1.67).

DISCUSSION

For people with RA/SpA/HOA/KOA the EULAR physical activity recommendations should be available in their mother language. The final German lay version is valid and accepted across all three German-speaking countries. Thus, the physical activity recommendations can be provided to people with rheumatic diseases in an understandable and feasible way.

Clinico-genetic spectrum of limb-girdle muscular weakness in Austria: a multi-centre cohort study

Background and purpose

Hereditary myopathies with limb‐girdle muscular weakness (LGW) are a genetically heterogeneous group of disorders, in which molecular diagnosis remains challenging. Our aim was to present a detailed clinical and genetic characterization of a large cohort of patients with LGW.

Methods

This nationwide cohort study included patients with LGW suspected to be associated with hereditary myopathies. Parameters associated with specific genetic aetiologies were evaluated, and we further assessed how they predicted the detection of causative variants by conducting genetic analyses.

Results

Molecular diagnoses were identified in 62.0% (75/121) of the cohort, with a higher proportion of patients diagnosed by next‐generation sequencing (NGS) than by single‐gene testing (77.3% vs. 22.7% of solved cases). The median (interquartile range) time from onset to genetic diagnosis was 8.9 (3.7–19.9) and 17.8 (7.9–27.8) years for single‐gene testing and NGS, respectively. The most common diagnoses were myopathies associated with variants in CAPN3 (n = 9), FKRP (n = 9), ANO5 (n = 8), DYSF (n = 8) and SGCA (n = 5), which together accounted for 32.2% of the cohort. Younger age at disease onset (p = 0.043), >10× elevated creatine kinase activity levels (p = 0.024) and myopathic electromyography findings (p = 0.007) were significantly associated with the detection of causative variants.

Conclusions

Our findings suggest that an earlier use of NGS in patients with LGW is needed to avoid long diagnostic delays. We further present parameters predictive of a molecular diagnosis that may help to select patients for genetic analyses, especially in centres with limited access to sequencing.

Cancer catecholamine conundrum

Exercise, psychosocial stress, and drugs such as adrenergic agonists and antagonists increase the concentrations of catecholamines and/or alter adrenergic signaling. Intriguingly, exercise studies universally suggest that catecholamines are cancer-inhibiting whereas cancer stress studies typically report the opposite, whereas β-blocker studies show variable effects. Here, we term variable effects of catecholamines in cancer the cancer catecholamine conundrum. Variable effects of catecholamines can potentially be explained by variable expression of nine adrenergic receptor isoforms and by other factors including catecholamine effects on cancer versus immune or endothelial cells. Future studies on catecholamines and cancer should seek to understand the mechanisms that explain variable effects of catecholamines in cancer to utilize beneficial or block detrimental effects of catecholamines in cancer patients.

Portkatheterbrüche bei 361 implantierten Portsystemen Ursachenanalyse – Lösungsmöglichkeiten – Literaturübersicht

INTRODUCTION

The use of a venous port-catheter-system is known as a relatively safe implant. Besides infections, the breakage of PIPS is the most common reason for explanation before term. The purpose of this study is to analyse port-related complications and to show ways of preventing them.

METHOD

Between 1.1.1994 and 31.12.1999, 391 PIPS were implanted in the V. subclavia with the Seldinger technique at Surgical Clinic 1 of the University of Leipzig. Subsequently, 311 of them were followed up until 31.12.2000, with a mean observation time of 45 months.

RESULTS

We registered 48 complications altogether (15.4% of 311), 21(6.7%) of which occurred immediately after implantation (up to 30 days postoperatively). These could be divided either into wound-healing disorders/pulmonary distress (4.5%, n = 14) or complications concerning the catheter systems (2.3%, n = 7). Long-term complications after 31 days were evident in 27 patients (8.7%), due either to infections (4.5%, n = 13) or catheter-associated problems (4.5%, n = 14). Catheter lesions occurred in nine cases (2.9% out of 311) at the point of entry into the musculus pectoralis, i.e., where the catheter had to change direction. Typically these were lengthways tears caused by the catheter. We observed one full breakage without dislocation, and two dislocated catheter fragments in the systemic circulation. We consider the change of direction to be responsible for wear on the silicon catheter. During implantation, extreme change of direction of the catheter should be avoided because this is where breakage happens. Catheter implantation by means of exposure of the vena basilica in the infraclavicular triangle is the method of choice.

Gene expression in hair follicle dermal papilla cells after treatment with stanozolol

Doping with anabolic agents is a topic in sports where strength is crucial, e.g. sprinting, weight lifting and many more. Testosterone and its functional analogs are the drugs of choice taken as pills, creams, tape or injections to increase muscle mass and body performance, and to reduce body fat. Stanozolol (17β-hydroxy-17α-methyl-5α-androst-2-eno[3,2c]pyrazol) is a testosterone analogue with the same anabolic effect like testosterone but its ring structure makes it possible to take it orally. Therefore, stanozolol is one of the most frequently used anabolic steroids.

Common verification methods for anabolic drugs exist, identifying the chemicals in tissues, like hair or blood samples. The idea of this feasibility study was to search for specific gene expression regulations induced by stanozolol to identify the possible influence of the synthetically hormone on different metabolic pathways. Finding biomarkers for anabolic drugs could be supportive of the existing methods and an additional proof for illegal drug abuse.

In two separate cell cultures, human HFDPC (hair follicle dermal papilla cells) from a female and a male donor were treated with stanozolol. In the female cell culture treatment concentrations of 0 nM (control), 1 nM, 10 nM and 100 nM were chosen. Cells were taken 0 h, 6 h, 24 h and 48 h after stimulation and totalRNA was extracted. Learning from the results of the pilot experiment, the male cell culture was treated in 10 nM and 100 nM concentrations and taken after 0 h, 6 h, 24 h and 72 h. Using quantitative real-time RT-PCR expression of characteristics of different target genes were analysed.

Totally 13 genes were selected according to their functionality by screening the actual literature and composed to functional groups: factors of apoptosis regulation were Fas Ligand (FasL), its receptor (FasR), Caspase 8 and Bcl-2. Androgen receptor (AR) and both estrogen receptors (ERα, ERβ) were summarized in the steroid receptor group. The growth factor group included the insulin like growth factor receptor (IGF1R) and growth hormone receptor (GHR). Fibroblast growth factor 2 (FGF2) and keratinocyte growth factor (FGF7) were summarized in the hair cycle factor group. 5α-Steroidreductases (SRD5A1, SRD5A2) represented the enzyme group. Three reference genes were taken for relative quantification: ubiquitin (UBQ), glycerinaldehyde-3-phsophate-dehydrogenase (GAPDH), and β-actin (ACTB).

In cell culture 1 AR, FasR, FGF2 showed significant regulations within one treatment time, significant gene expressions over time were analysed for Caspase 8. In cell culture 2 AR, FasR and SRD5A2 were significantly regulated within one treatment time.

In this feasibility study first biomarker for a screening pattern of anabolic agents could be identified providing the rationality to investigate modified, metabolic pathways in the whole hair follicle.

Successful antibiotic treatment of Borreliosis associated pseudolymphomatous systemic infiltrates

The clinical management of late stage Borreliosis can be difficult due to various associated symptoms and signs and cumbersome microbiological tests. We report a case of successful antibiotic treatment of Borreliosis-associated pseudolymphomatous infiltrates in bone marrow and lymph nodes, which were diagnosed by bone marrow trephine biopsy and positron emission tomography.

[Wound infection and infection-promoting factors in breast cancer surgery -- a prospective multicenter study on quality control]

INTRODUCTION

The quality of treatment of cancer of the female breast is reflected not only in such parameters as local recurrence rate and survival times, but also in the development of surgical complications. Within the framework of a study investigating the performance and quality assurance in surgical treatment of breast cancer, therefore, the wound infection rate (WIR) and factors influencing it were analysed in a large patient population.

METHODS

In the period between 1.1.2000 and 31.12.2000, 84 surgical departments participated in a prospective multicenter study to investigate primary surgery for breast cancer. A total of 1 416 patients were recruited to the study, the organization and conduction of which was in the hands of the former surgical department 1 of the University of Leipzig under the patronage of the East German Working Group for Performance and Quality Control in Surgery in cooperation with the An Institute for Quality Control in Operative Medicine of the Otto-von-Guericke University in Magdeburg. In addition to parameters characterizing patients, tumors and diagnostic work-up, we also analysed the surgical treatment and its possible complications with the aid of a questionnaire. The definition of wound infection was based on the criteria of the "Hospital Infection Control Practice Advisory Committee".

RESULTS

The overall WIR was 4.5 % (n = 65). 21 (32 %) of the wound infections (WI) were diagnosed exclusively on a clinical basis without establishing the responsible pathogens. In 44 (68 %) of the WI, a search for the pathogen was undertaken which in 3 cases (7 %) was negative, and in 41 cases (93 %) positive. 118 (8.3 %) of the patients received perioperative antibiotic cover. The following parameters were found to have a significant influence on WIR: local drainage, blood transfusion, the time lapse between biopsy and definitive surgery, and the size of the primary tumor.

DISCUSSION

Some of the above factors (transfusion, time lapse, drainage) can be influenced by the therapist. The wound infection rate is a marker for treatment quality.

[Differential diagnosis of soft tissue sarcomas]

INTRODUCTION

Soft tissue sarcoma often goes undetected.

PATIENTS AND METHODS

Over a 10-year period, the patients referred to us with a soft tissue tumor (STT) of the extremities and wall of the trunk were analyzed retrospectively. The aim of the present study was to investigate the differential diagnoses, the number of incompletely operated STS, and local recurrences together with their percentage fluctuations.

RESULTS

A total of 490 patients with an STT were referred to our department, and of these patients 55% were diagnosed with an STS. In addition to STS, the differential diagnoses for STT included 2% lymphomas, 18% isolated carcinoma metastases, 18% benign mesenchymal tumors, 5% inflammatory processes, and 2% old hematomas. Only 45% of the STS had not undergone previous surgery. Of these, 15% had been incompletely resected, while 39% of the STS patients were admitted with a local recurrence. Within the 10-year period, referrals with STT and STS remained relatively constant, but referrals of patients with incompletely resected or recurrent STS doubled in the last 2 years under observation.

DISCUSSION

In view of the numerous differential diagnoses of an STT, both the possibility of an STS and also carcinoma manifestations in the soft tissues should receive more attention. With the aim of reducing the relatively high number of STS re-resections and local recurrences, the treatment of patients with suspicious STT should be reserved for a specialized center.

CYP2C and IL-6 expression in breast cancer

Besides hepatic P450 (cytochrome P450) metabolism, there is increasing interest in the possibility of intratumoral activation of oxazaphosphorines by P450. Therefore, we investigated the expression of P450 (CYP2C8, CYP2C9, CYP2C18, and CYP2C19) by RT (reverse transcriptase)-polymerase chain reaction (PCR) and of CYP2C9 by Western blotting in 10 different breast tumor samples. Since P450 may be down regulated by interleukin (IL) IL-6, the receptor (R) for IL-6 was analyzed by RT-PCR and IL-6 in supernatants was calculated from ELISA data. None of the breast tumors was positive for CYP2C18 and CYP2C19 mRNA, whereas CYP2C8 and CYP2C9 were detected in all 10 breast tumors. Correspondingly, all breast tumors tested (9 of 10) revealed low, but nevertheless positive, staining of the CYP2C9 protein. All 10 samples were positive for the IL-6 receptor mRNA. ELISA measurement of IL-6 cytokine in supernatants revealed that all measured samples (8 of 10) were producing IL-6, the amounts ranging from 0.004 to 3.1 ng/g(tumor tissue). In summary, we have demonstrated that tumors of the breast express two out of four members of the CYP2C family, indicating that activation of such prodrugs as oxazaphosphorines may take place intratumorally. The presence of the IL-6 receptor and of IL-6 cytokine, which is produced in an autocrine manner, opens up the possibility that the well-known down regulating effect of IL-6 also takes place in breast tumors and might explain the weak or even absent expression of different CYP2C members.

CYP3A4, CYP2C9 and CYP2B6 expression and ifosfamide turnover in breast cancer tissue microsomes

Ifosfamide is a prodrug that requires bioactivation by cytochrome P450 for antitumour activity. Up to now, little is known, to what extent in addition to the liver the ifosfamide metabolism may occur intratumorally. For this purpose, we investigated the expression of CYP3A4, CYP2C9 and CYP2B6 in breast cancer tissue using Western Blotting. Ifosfamide turnover was determined by detection of metabolites of the ifosfamide 4-hydroxylation and N-dechloroethylation in tumour microsomal incubations using HPLC/UV and LC/MS. The results demonstrate that all mammary tumours (n=11) reveal CYP3A4 expression; contents varied from 0.5 to 63 pmol mg(protein)(-1). CYP2C9 (n=9) was present in all tested breast tumour samples, too, while CYP2B6 (n=10) protein could not be detected. All measured breast cancer microsomes (n=4) showed an ifosfamide N-dechloroethylation capacity in the range from 0.04 to 0.21 pmol min(-1) mg(protein)(-1), while metabolites of the 4-hydroxylation could not be determined. In conclusion, the detected presence of CYP3A4 and CYP2C9 in breast tumours offers the possibility of intratumoral turnover of ifosfamide. For the first time in the literature, we could demonstrate a turnover of ifosfamide by microsomal preparations from human breast cancer tissue. A calculated modulation of intratumoral ifosfamide turnover could considerably influence its therapeutic efficiency.

Rating of isolated disseminated tumor cells in bone marrow in comparison with other factors of prognosis in breast carcinoma

BACKGROUND

Despite the use of radical loco-regional therapeutic methods and although conventional methods of diagnosis give no indication of metastases at the time of operation, distant metastases develop in approximately 50 percent of the carcinoma patients within 5 years. While with the R0 resection of solid tumors local relapses are mainly a matter of concern for the operating surgeon, distant metastases can be traced back to systemic dissemination of tumor cells at the time of operation.

AIMS

The goal of our prospective six year continuous study is to compare the rating of the IDT BM with established prognosis factors and to reach conclusions for the practice.

METHODS

A prospective study is represented in which 197 patients suffering from breast carcinoma were analyzed for prognostic relevance of detected isolated disseminated tumor cells in the bone marrow (IDT BM). The patients were operated between 1993-1997 and subsequently observed until 1999. The monoclonal antibodies CK II and A45-B/B3 were used with the immuno-cytochemical standard method for detecting IDT BM. For the purpose of cell cultivation, the cells were marked with the HEA 125 antibody and separated by means of magnetic cell sorting (MACS). In this investigation, only the presence of isolated disseminated tumor cells detected by the

RESULTS

A45-B/B3 antibody proved to be an independent prognostic factor for survival time. The risk of an earlier death increased with the detection of IDT BM at least by a factor of two. The detection of IDT BM also represented an independent prognostic factor for the time until advancement of the tumor. The risk of an earlier relapse of the tumor increased with the detection of disseminated tumor cells in the bone marrow containing the A45-B/B3 antibody by at least a factor of four.

CONCLUSION

A generally acknowledged standardization of the method is desirable. Due to the importance of the independent prognostic IDT BM factor, this method of ascertaining the pathological stage should be established at institutions of higher learning.

[Prospective multicenter study for quality management of breast cancer surgery]

Over the last 10 years a dramatic decrease became apparent in primary treatment of breast cancer in general surgical departments. A prospective 1-year observational study involving 84 surgical departments was carried out to describe the current therapeutic situation. A total of 1,416 patients undergoing primary surgical treatment for mammary carcinoma were recorded, and their data evaluated. 68.9% of the carcinomas were treated in departments with an annual case load for this disease of more than 20 operations, with 50% of them being operated on in 8 departments with a case load of 40-100 procedures per year. 94.4% of the carcinomas were confirmed histologically, and in 91% of the patients surgery was performed in curative intention. The rate of breast-preserving procedures was 40%, and breast amputations accounted for 60%. An analysis of the data allowed an evaluation of this specific patient group in the surgical departments. Deficits in terms of management quality are identified.

[Inflammatory pseudotumor of the ileopsoas muscle with femoral paralysis caused by massive metal abrasion of a hip endoprosthesis]

Case report of a 62-year-old patient with a presumed loosening of a hip endoprosthesis after 10 years and a planned replacement. In addition, the patient suffered pain in the thigh and had paresis of the femoral nerve. A CAT-Scan substantiated the diagnosis either of a suppurating or a neoplastic tumour in the left iliac foss. The wide excision revealed a rare inflammatory tumour in the left ileopsoas muscle due to the excessive abrasion of the metal hip endoprosthesis.

Conservative functional treatment of ankle fractures

Thirty-eight patients (mean age 49 years; range 19-91 years; nine of them over 60 years; 28 women, 10 men) suffering from an isolated Weber B fracture with a dislocation of less than 1 mm underwent functional therapy using a pneumatic ankle brace and were included in a prospective study. The clinical outcome was measured according to the Olerud-Molander ankle score. Functional therapy was finished in 34 cases successfully. Twenty-one patients were scored after 17 months on average (range 8-27 months) with the Olerud-Molander ankle score. A very good result was seen in 18 patients, including 12 with 100 points, a complete remission. The remaining 3 patients showed good results (1 had 90, 2 had 85). However, functional treatment failed in 4 cases due to secondary dislocation. These patients underwent surgery without further complications. The control group, 31 operated patients, did not show as good results. Functional therapy of stable Weber-B ankle fractures appears to be superior to surgery. We were able to avoid surgery in 90% of our patients and got better results than with patients undergoing open reduction and internal fixation.

[A giant malignant tumour of the skull-Case report and differential diagnosis]

The case of a 72-year-old woman with a high-partially located tumor grown within a half year to a magnitude of 8.5 x 11 x 11 cm is reported. The patient remembered a mastectomy and axillary lymphadenectomy followed by chemotherapy and radiation 8 years ago. Therefore we assumed a skeletal metastasis of a breast cancer. After wide excision, an unusual morphology was found, allowing only a classification as a pleomorphic sarcoma. Searching for the pathohistological evaluation of the former breast tumor, a cystosarcoma phylloides malignum could be found out. The tumor described here can be identified as a metastasis of this rare neoplasm.

Mechanism and site of action of a ribosome-inactivating protein type 1 fromDianthus barbatuswhich inactivatesEscherichia coliribosomes

A single chain ribosome-inactivating protein with RNA N-glycosidase activity, here named Dianthin 29, was isolated from leaves of Dianthus barbatus L. Incubation of intact Escherichia coli ribosomes with Dianthin 29 and subsequent aniline treatment of the isolated rRNA releases a rRNA fragment of 243 nucleotides from 23 S rRNA. Nucleotide sequence studies showed that the site of N-glycosidic bond cleavage is at A-2660 within the universally conserved sequence 5'-AGUACGAGAGGA-3' near the 3'-end of 23/28 S rRNAs. To our knowledge, Dianthin 29 is the first ribosome-inactivating protein which is shown to inactivate intact prokaryotic ribosomes in the same manner as eukaryotic ribosomes.

[Luxation of the clavicle as rare cause of monstrous thrombus formation of the internal jugular vein]

Summary.A 55-year-old female with massive painless swelling of the right cervical soft tissue was admitted for surgical exploration. The operation revealed an ectasia of the internal jugular vein with a diameter up to 7 cm which was obliterated by thrombotic material. We discussed a retrosternal dislocation of the clavicle proved by chest X-ray. We resected the internal jugular vein from the basis of the skull to the upper thoracic aperture. The postoperative course was uneventful.

[Nonpalpable carcinoma of the breast - diagnosed by vacuum core breast biopsy and surgical management]

The wire-localized extirpation is the "gold standard" for the examination of nonpalpable lesions suspicious of malignancy. Less invasive techniques were introduced in the last years, offering also a high diagnostic reliability, e. g. stereotactic core needle biopsy, the "advanced breast biopsy" and the vacuum core biopsy. Based on an analysis of 40 vacuum core breast biopsies and the following interventions in the case of carcinoma recommendations for the management of the nonpalpable breast carcinoma diagnosed by vacuum core biopsy should be developed. In 12 patients (33 %) carcinomas were found necessitating further operations. These were 92 % pTis or pT1pN0M0-carcinomas and only in one case an occult pT2pN1M0-carcinoma. We recommend a short interval between core biopsy and operation, a preoperative localization of the clips e. g. the residual microcalcification, and the controlled placement of the hooked wire that should also be performed at the Mammotome(R) using the same way to the tumor. Furthermore it is necessary to excise the core biopsy localization channel en bloc together with a wide tumour excision. An intraoperative histological examination of the specimen should be performed to confirm tumour-free excision borders. For this, the position of specimen should be marked by a thread and a specimen radiography should be made for the orientation of the pathologist and for documentation. A long-term follow-up of these patients under study conditions should be considered. Patients with benign diagnosis, not undergoing general anesthesia and operation with the consequences for later radiological evaluation, mostly profit from vacuum core breast biopsy. For patients with carcinoma the costs of the perioperative management increase. This should have consequences for the quality assurance of this method.

Low detection rate of p53 antibodies in sera of soft tissue sarcoma patients

Accumulation of the p53 gene product can lead to its immunogenic appearance and the generation of p53 serum antibodies (p53ab). In different cancer types the occurrence of detectable p53ab has an independent prognostic impact. In spite of the known p53 protein overexpression rate in soft tissue sarcomas (STS), up to 70%, there have been no investigations done on p53ab in serum in STS patients. In this prospective study of 50 STS patients, we investigated the presence of serum p53ab using an enzyme-linked immunosorbent assay system and the presence of p53 overexpression in the appropriate tissue specimen immunohistochemically. Using Kruskal-Wallis chi(2) and Kaplan-Meier tests the results were then correlated to histopathological and clinical data. Six of the 50 patients (12%) showed p53ab detectable in the serum, and 56% (28/50) of the tumors were p53 immunohistochemically positive. Four of the six p53ab positives (66%) had immunohistochemically p53 positive and two (33%) had negative tumors. Altogether four of the 50 patients (8%) were positive for p53ab in serum as well as for p53 immunohistochemistry in tumor tissue specimens. Twenty patients (40%) were negative for both. All of the p53ab positive patients had stage I or II tumors. Excluding tumor stage there was no p53ab correlation to histopathological, clinical or prognostic parameters. We conclude that in STS patients, p53ab also occurs but in contrast to other tumor types at a relatively low frequency. According to our results, the clinical value of p53ab seems to be limited in STS patients.

[Surgical quality assurance exemplified by operative therapy of colorectal carcinoma]

Quality management of physicians' performance is supposed to guarantee optimal diagnostic and therapeutic procedures for patients. Quality control in the scope of prospective multicenter quality securing programs are based on the overall analysis of cases with selected tracer diagnoses. It serves as voluntary self-regulation for surgeons who perform an evaluation of their results in a team-based setting. Using colorectal cancer as an example, the quality management of diagnostic issues and surgical treatment are used to outline a treatment protocol for a surgical condition under quality securing aspects. We present the treatment protocol of colorectal cancer on the basis of three studies from 1985/1986, 1991/1993 and 1999. We emphasize our opinion that quality management should be addressed as an concern of the surgical profession, and not as an administrative problem.

[Quality assurance in excision of suspected malignant, preoperatively marked and unmarked, breast lesions. A one-year analysis]

The breast cancer incidence is increasing for all industrial countries in the last years. Therefore the relevance of screening methods especially of mammography for early registration of suspected lesions becomes more and more important. One result of using screening methods is an increased rate of patients with lesions which are suspected for cancer but non palpable. For the background of that fact we are describing our one year experience with the therapy of cancer suspected breast lesions in 136 female patients. In 47 cases (34.6%) there was a palpable and in 89 cases (65.4%) a non-palpable lesion. The need for mammography was assured in 43 patients (48.3%) through mastopathic controls, in 23 patients (25.8%) within the frame work of a preventive first mammography and in 15 patients (16.8%) through controls after operative therapy for breast cancer. All non-palpable lesions were marked preoperatively through mammography 88.8% (n = 79), sonography 6.7% (n = 6), or through magnet resonance imaging MRI 4.7% (n = 4). Every mammographic marked case was followed by an intraoperative specimen mammography. In 16.8% (n = 15 from 89) of the non-palpable marked areas, a carcinoma was found. 16.7% (n = 3) of the detected cancers were diagnosed in an in-situ-stage, all others in an early stage (pT1-, pN0-, M0-stage) and treated. Besides the early diagnosis of breast cancer and the resulted improvement of prognosis also the rate of breast saving therapies can be increased. Reflecting our datas it should be demanded a regular screening for defined risk groups. In conclusion to improve the prognosis of breast cancer patients and reduce the risk of ablative therapies it is necessary to release a consequent marking of non-palpable cancer suspected breast lesions, a consequent aseptic handling before operation, an intraoperative mammography of the resected area and a frozen section.

[Improved prognosis in breast carcinoma by excision of non-palpable carcinoma-suspected lesions. Analysis of 319 ambulatory surgery operations]

A retrospective study is described according to which 319 outpatients had been operated on for suspected carcinoma because of breast lesion, in the course of three years in this hospital. In 113 cases (35.4%) the lesion was palpable, in 206 cases (64.6%) it was not. In the non-palpable cases, mammography was indicated in 98 patients (47.6%) undergoing controls for mastopathy, in 41 patients (19.9%) undergoing a first mammography in the course of preventive check-ups, and in 33 patients (16.0%) undergoing a check-up after operative therapy of breast cancer. Prior to operation, 84.0% (n = 173) of the non-palpable lesions were marked by mammography, 11.2% (n = 23) by sonography, and 4.8% (n = 10) by magnet resonance imaging (MRI). Intraoperative specimen mammography was made in every case marked by mammography. In 19.4% (n = 40) out of the 206 cases of marked though non-palpable focuses a tumour was found. 25% (n = 10) of all marked tumours were diagnosed and treated as in-situ stage tumours, 65% (n = 26) were diagnosed and treated as tumours in the pT1 stage. As regards the nodal stage, 85% (n = 34) of the tumours were diagnosed and treated as being pN0 tumours, and 100% (n = 40) were found to be free from any distant metastases. Consequently, for improving prognosis and, at the same time, for reducing the rate of breast amputations as a means of curative therapy of breast cancer, regular screening in defined risk groups is necessary. Surgical treatment of patients with small and non-palpable findings should be reserved for departments with marking and quick-freezing facilities.

[Therapeutic strategies in malignant soft tissue tumors. Results of the soft tissue tumor register study of the Surgical Oncology Working Group]

INTRODUCTION

This study, carried out by the Surgical Oncology Working Group (CAO) of the German Society for Surgery, was performed to analyse the strategies in the treatment of soft tissue sarcomas in adults.

METHODS

In a period of 19 months the data on 292 patients suffering from soft tissue sarcomas, treated in 99 surgical departments in Germany, were analysed prospectively. A special questionnaire was developed including pretherapeutic biopsy, previous treatment, definitive surgical treatment, combined modality approach and histopathological results.

RESULTS

Thirty-nine per cent of the tumours were treated in university hospitals, 36% in medical centres, 24% in regional hospitals. During the observation period two patients were treated on average (median) by each hospital. Limb-sparing treatment was performed in 96% of the extremity tumours. There was no significant difference in the frequency of R0 resections between the different hospitals. At the university hospitals local extended operations and additive measures were used more often. The indication for adjuvant radiotherapy differed: after compartmental resection, adjuvant radiotherapy was performed in 39% of cases (19/49); after wide-excision of high-grade tumours, in 45% of cases (20/44) no adjuvant radiotherapy was necessary. In spite of less radical treatment in tumours of the trunk, additional radiotherapy was not more frequently performed.

CONCLUSION

To improve the quality in the treatment of soft tissue sarcomas it seems to be of great importance to avoid inadequate initial treatment (18%), to respect the rules of oncological surgery (tumour rupture in 7% of cases), to improve the histopathological examination (no R classification in 5-12%) and to develop guidelines for multimodality treatment.

Crohn's disease: bowel resection to protect the proctium in severe perianal disease?

Patients with anal Crohn's disease generally have a bad prognosis. Up to 50% end up with an anus praeter or proctectomy. Many of these young people develop psychological and social problems causing them to become invalids. Local surgery and conservative therapy in such aggressive cases of Crohn's disease presenting with recurring perianal fistulae and abscesses are often unsuccessful; the destruction of the proctium continues. The purpose of our study was to look at the outcome of our patients with regard to these aspects. We included all 56 patients suffering from Crohn's disease treated at our clinic from 1984 until 1991 in a retrospective study and focused on the 13 patients with anal manifestation. The mean follow-up was 15.8 years (3-28 years). Often there was no improvement of perianal disease without resection of the involved bowel, especially in cases where both the colon and the rectum were affected. Anal destruction went on. Seven of the 13 patients suffering from anal complications finally received an anus praeter. An previous bowel-resection or the construction of a temporary anus praeter seem to be necessary to protect the proctium irrespective of abdominal symptoms in patients with recurrent severe perianal Crohn's disease.

Detection of cytokeratin-positive cells in bone marrow in breast cancer and colorectal carcinoma in comparison with other factors of prognosis

A prospective study is presented in which 293 patients suffering from breast cancer and colorectal carcinoma were analyzed for prognostic relevance of detected isolated disseminated tumor cells in bone marrow (IDTBM). The patients underwent surgery in the period from 1995 to 1997 and remained under observation until 1999. The monoclonal antibody A 45-B/B3 was used in the standard immuno-cytochemical method for detecting IDTBM, which represented an independent prognostic factor for survival time in patients with breast cancer or colorectal cancer. In breast cancer, when IDTBM were detected, the survival period was reduced by at least half. When disseminated tumor cells containing the A45-B/B3 antibody were detected in bone marrow, the risk of an earlier relapse of the tumor increased at least fourfold. In colorectal cancer, detection of IDTBM reduced survival time by a factor of 1.2-4.3. The risk of earlier relapse increased when disseminated tumor cells containing the A45-B/B3 antibody were detected in bone marrow by 2.8-8.1. Therefore, the use of IDTBM as an independent prognostic factor would provide an important method for determining the pathological stage of various cancers. Standardization of this technique into a generally accepted method would be especially desirable in treatment of patients with breast or colorectal cancer.

[Monstrous venous hemangioma of the retroperitoneum: problems of diagnosis]

The venal haemangioma is defined as a benign tumor consisting of veinlike vessels. The preoperative diagnosis and its inherent problems are illustrated using a coincidentally diagnosed monstrous haemangioma tumor of the retroperitonial space in a twenty year old patient. With respect to our patient, X-ray, computer tomography and angiography all failed as diagnostic tools. Only the use of Doppler sonographic flow signals suggested the presence of a haemangioma. The morphology, prognosis and clinical significance of blood vessel tumors are multifaceted. The most important differential diagnoses to the venous haemangioma are the cavernous and the capilliary haemangioma. The venous haemangioma distinguishes itself through the presence of blood vessel walls. Haemangiomas are common benign tumors. In the presence of highly developed muscular components, there exists a transition to angiomyomas and to leiomyomas. Venal haemangiomas are extremely rare in the demonstrated localisation of the retroperitoneal space. Here they can grow to monstrous preportions whilst remaining undetected. Thus the patient is under the potential danger of bleeding to death through trivial injuries. The therapy of choice remains total surgical excision. In situations of unclear clinical results with respect to preoperative diagnosis especially amongst young adults, one should at least consider the possibility of a haemangioma as the root of the problem.

[Hepatocellular carcinoma in an additional pedunculated liver lobe in the lower abdomen: differential diagnosis problems]

The case described is that of a 36 years old patient with a known tumor in her lower abdominal cavity which has been observed to increase in size for the passed 16 years. Intraoperatively, one observed a very rare finding of an extra liver lobe of the left liver lobe and located in the lower abdominal cavity. Located within is a multifocal therapeutically treatable hepatocellular cancer.

Cytokeratin-positive cells in bone marrow in comparison with other prognostic factors in colon carcinoma

BACKGROUND AND AIMS

Despite the use of radical locoregional therapeutic methods and although conventional methods of diagnosis give no indication of metastases at the time of operation, distant metastases develop in approximately 50% of carcinoma patients within 5 years. While local relapses after the R0 resection of solid tumors are mainly a matter of concern for the surgeon, distant metastases can be traced back to the systemic dissemination of tumor cells at the time of operation.

PATIENTS/METHODS

A prospective study is presented in which 145 patients suffering from colon carcinoma were analyzed for the prognostic relevance of isolated disseminated tumor cells detected in the bone marrow (IDT BM). The patients were operated on between 1993 and 1997 and subsequently observed until 1999.

RESULTS

The monoclonal antibody A45-B/B3 was used with the immunocytochemical standard method for detecting IDT BM. For the purpose of cell cultivation, the cells were marked with the HEA-125 antibody and separated by means of magnetic cell sorting (MACS).

CONCLUSION

In this investigation the presence of isolated disseminated tumor cells, as indicated by the A45-B/B3 antibody, proved to be an independent prognostic factor for survival time. The risk of an earlier death increased in node-negative and metastases-free patients with the detection of IDT BM by a factor of 12.60. The detection of IDT BM also represented an independent prognostic factor for the time until advancement of the tumor. The risk of an earlier relapse increased with the detection of disseminated tumor cells in the bone marrow containing the A45-B/B3 antibody by a factor of 18.02. A generally acknowledged standardization of the method is desirable. Due to the importance of the independent prognostic IDT BM factor, this method of ascertaining the pathological stage should be established at institutions of higher learning.

[The radiological and surgical management of nonpalpable breast lesions]

In this retrospective study the results of surgical biopsy of suspected breast cancer in 319 outpatients are reported. In 113 cases (35.4%) the lesion was palpable, in 206 cases (64.6%) it was not. Concerning the nonpalpable lesions, mammography was performed in 98 patients (47.6%) for work-up of fibrocystic changes, in 41 patients (19.9%) for initial participation in a breast cancer prevention program, and in 33 patients (16.0%) for surveillance after breast conservation therapy. Prior to operation, 84.0% (n = 173) of the nonpalpable lesions were detected by mammography, 11.2% (n = 23) by sonography, and 4.8% (n = 10) by magnetic resonance imaging. Intra-operative specimen mammography was carried out in every case detected by mammography. In 19.4% (n = 40) of 206 nonpalpable lesions a malignant tumor was found. Twenty-five percent (n = 10) of all marked tumors were diagnosed and treated as in-situ stage tumors, while 65% (n = 26) were diagnosed and treated as tumors in the pT1 stage. As regards the nodal stage, 85% (n = 34) of the tumors were diagnosed and treated as pNO tumors, and 100% (n = 40) were found to be free from any distant metastases. Consequently, for improving prognosis and, at the same time, for reducing the rate of breast amputations as a means of curative therapy of breast cancer, regular screening in defined risk groups is necessary. Surgical treatment of patients with small and nonpalpable findings should be reserved for departments with marking and quick-freezing facilities.

[Therapeutic management of postoperatively diagnosed bilateral recurrent laryngeal nerve paralysis]

Bilateral vocal cord paralysis is a rare but potentially dangerous postoperative complication in thyroid gland surgery. There is a controversial discussion about therapeutic management of postoperative bilateral vocal cord paralysis.

METHODS

We analysed the frequency of bilateral nerve palsy in 985 operations. The disease of thyroid gland, the operative procedure, the exposure of laryngeal nerve, the mobility of vocal cord detected by an otolaryngologist, clinical symptoms and therapy of patients with bilateral paralysis were analysed. All patients were examined immediately postoperatively and 5 days, 14 days, 6 and 12 months after resection.

RESULTS

The overall transient bilateral palsy rate was 0.7%, the permanent 0.3%. The palsy rate depended on the disease of thyroid gland. After resection of simple goitre we found a 0.2% transient injury rate (0.1% permanent), after operation of thyroid cancer 2.0% transient (1.0% permanent) and in cases of recurrent goitre 5.9% transient (1.9% permanent) palsies. The immediate postoperative symptoms are also very different. There are patients suffering from stridor and dyspnoea, patients with dysphonia without dyspnoea and those without any symptoms. These different clinical symptoms are due to the different grade of laryngeal nerve damage and the resulting position of vocal cords. The bilateral paralysis was completely temporary in 4 cases. 12 months later 4 patients suffered from dysphonia. Only in 3 patients with thyroid cancer and a preoperative unilateral vocal cord paralysis tracheostomy was necessary after operation. The vocal cord mobility did not recover in these 3 cases after 12 months and the patients are not decannulated.

DISCUSSION

Bilateral paralysis is only relevant in thyroid cancer and recurrent goitre. The symptoms varies and no patient should leave the hospital without examination of the vocal cords by an otolaryngologist. Because vocal cord paralysis is temporary in most cases an emergency tracheostomy is seldom indicated.

A multifactorial prognostic model for adult soft tissue sarcoma considering clinical, histopathological and molecular data

Soft tissue sarcomas (STS) are malignant mesenchymal lesions with a high degree of prognostic variability. Different prognostic markers such as grading, staging, tumour type and localisation are known. The establishment of these markers was based on the evaluation at results of extensive cohorts of patients. Therefore, only the established markers provide us with information about probabilities in relation to other qualities. Considering as many different markers as possible in one prognostic statement should increase the value of the resultant information. Therefore, we developed a model involving known prognostic markers to formulate an individual prognostic index. In a retrospective analysis, different prognostic factors of 198 adult STS patients with histological tumour free resection margins were evaluated using a multifactorial analysis. On the basis of a Cox-Regression-Model with proportional hazards, the prognostic factors (tumour type, staging, localisation and type of surgical resection) were selected using previous knowledge and a statistical step backward selection procedure adjusting the immunohistochemical status of p53/Mdm2 expression. On the basis of the baseline survival function of our cohort (S0 (t)), the cumulative probability of survival for two S (2) and five S (5) years was estimated. As a result of our analysis the equations S (2) = (e-00393)P and S (5) = (e-00869)P can be used to estimate the individual two and five-year probability of survival in our cohort. Here p is the result of the amount of the estimated regression-coefficients of the exact variables of the respective individual patient. This model makes it possible to include all the evaluated prognostic factors which, in turn, increases the accuracy of the prognostic information for individual patients underlining the proportional hazards assumption.

[Recurrent laryngeal nerve paralysis as intubation injury?]

INTRODUCTION

Vocal cord paralysis is a important complication in thyroid gland surgery. A prospective study was conducted ascertain the frequency of laryngeal nerve palsy not caused by surgical trauma.

PATIENTS AND METHODS

Two hundred and ten patients were investigated laryngoscopically pre- and postoperatively after short-term intubation in the course of operations far removed from thorax or neck region. We noted the inner diameter of the tube, intubation problems, the qualification of the anaesthesiologist and the positioning of the patient.

RESULTS

Preoperatively we found previously unknown unilateral laryngeal nerve palsy in 1.9% of cases. Postoperatively there were pathological findings of vocal cords in 13 patients (6.2%). In 10 patients a direct lesion (oedema, rubor, haematoma, granuloma) was established. Three patients (1.4%) were found to have a movement disorder caused by a neural lesion without morphological findings, leading to restitutio ad integrum in two of three cases after 6 months.

CONCLUSION

The frequency of intubation-related recurrent nerve palsy is 1.4% transiently and 0.5% permanently. The reasons are discussed. Preoperative laryngoscopic investigation of vocal cords should be carried out before intubation.

[Demand for and use of blood supply for elective surgical procedures]

In elective surgical operations on thyroid gland and breast gland, in cholecystectomy, axillary or inguinal dissections and hernioplasties blood units are usually ordered for the operation. The aim of the study was to analyse the real requirement of transfusions during several years and to show that in the above-mentioned operations only in exceptional cases blood units must stand by.

METHODS

At the Surgical Hospital I of the University Leipzig, a retrospective analysis of the anaesthetic records and patient documentations from 1994 to 1997 was performed with regard to intraoperative blood transfusions.

RESULTS

There were 1122 operations on the thyroid gland (119 of it as total thyroidectomy), 465 operations on the breast gland, 413 cholecystectomies, 70 axillary and 60 inguinal dissections and 445 hernioplasties. Intraoperative transfusions were necessary in nine operations on the thyroid gland (0.8%), in six operations on the breast gland 1.3%), twice in cholecystectomy (0.5%) and only once in an axillary dissection (1.4%). The analysis of the patients' records showed in almost all of these cases special risk factors such as disorders of blood coagulation or thyroidal function, anaemia, serious other diseases or a necessary extension of the operation.

CONCLUSION

It is justified to perform the above-mentioned operations without a routine order of blood units. This would lead to enormous financial savings. Because the optimal care for the patients has priority, it is necessary to estimate the individual risk of a required transfusion preoperatively and to keep low the blood loss by the surgeon during the operation.

[Differential diagnostic problems of hepatocellular carcinoma in an abnormal additional liver lobe in the lower abdomen]

This case report describes a 36 years old patient with a known tumor in her lower abdominal cavity which increased in size in the last 16 years. Intraoperatively an additional liver lobe of the left liver located in the lower abdominal cavity was found in combination with a multifocal hepatocellular carcinoma which could be treated curatively.

[Monstrous venous hemangioma of the retroperitoneum. Problems in diagnosis]

The venous haemangioma is defined as a benign tumor consisting of vein-like vessels. The preoperative diagnosis and its inherent problems are illustrated by a coincidentally diagnosed monstrous haemangioma of the retroperitoneal space in a twenty year old patient. With respect to our patient, X-ray, computed tomography and angiography all failed as diagnostic tools. Only the use of Doppler-sonographic flow signals suggested the presence of an haemangioma. The morphology, prognosis and clinical significance of blood vessel tumors are manifold. The most important differential diagnoses of venous haemangioma are the cavernous and the capilliary haemangioma. The venous haemangioma distinguishes itself through the presence of blood vessel walls. Haemangiomas are common benign tumors. They can grow to monstrous proportions whilst remaining undetected. Thus the patient is endangered of bleeding to death because of trivial injuries. The therapy of choice consists in total surgical excision. In unclear clinical situations with respect to preoperative diagnosis especially amongst young adults, the diagnosis of an hemangioma should be taken into amount.

[Differential diagnosis of occult primary malignant melanoma]

Controversy exists in literature about therapy and prognosis of malignant melanoma of unknown primary site. We investigated frequency, differential diagnosis and follow-up of patients with occult primary malignant melanoma treated at the University of Leipzig in 1996. Among 135 patients with malignant melanoma (MM) seven were found without known primary. In two of seven cases the medical history pointed to regression of primary lesion of skin. In another two cases the diagnosis "melanoma" was changed to "lung cancer" after autopsy and in one case there was a relationship to a naevus blue resected nine months before. Recurrences or metastases occurred within six months after therapy. Two patients are still alive free of disease after a follow up of 33 and 24 months. Five patients died from tumor progression between 2 to 14 months postoperatively. Pitfalls in differential diagnosis and ways to find out the primary are discussed. Patients with unknown primary malignant melanoma should be treated similar to those with known primary. Radical surgery is indicated because it's impossible to determine the prognosis of patients with unknown primary malignant melanoma.

Clinical relevance of pRb and p53 co-overexpression in soft tissue sarcomas

The goal of this study was to examine the relationship between immunohistochemical pRb detectability and p53 overexpression in 198 soft tissue sarcomas (STS) with regard to its clinical relevance. Distinct pRb detectability multivariately shows a correlation to survival rate (relative risk (RR)=1.59, P=0.037). p53 positivity was also multivariately correlated to poor prognosis (RR=2.17, P=0.0014). Stratification of pRb staining to p53 results shows a prognostical graduation. Patients with negativity for both proteins have the most favorable prognosis (projected 5-year survival rate (psr)=54.5%). In contrast to this, positivity for both antibodies has the highest risk (RR=2.48, P=0.02) and the poorest prognosis (psr=17.4%). To conclude, these results explain that the clinical relevance of immunohistochemical pRb positivity in STS is connected with p53 in the form of having an increasing effect on the known prognostic relevance of p53 overexpression.

[p53 overexpression as independent prognostic marker in soft tissue sarcomas is antibody dependent]

Most changes in p53 result in a protein with prolonged half life. This permits immunohistochemical detection. P53-overexpression seems to have prognostical relevance in soft tissue sarcomas (STS). The goal of this study was to compare the prognostic relevance of five different p53 antibodies in immunohistochemistry of primary STS using a Cox regression model with adjustment to staging, localization, tumor type, and surgical therapy. We investigated 198 primary STS of six different tumor types for p53-overexpression using the antibodies DO-1, DO-7, Pab1801, Pab240, and CM-1. The rate of positivity (cut of point 10% positive tumor cells) was between 36.2% and 62.6% dependent on the applied antibody. Prognostic significance could be determined only for the N-terminal binding monoclonal antibodies (DO-1, p = 0.0014; DO-7, p = 0.005; Pab1801, p = 0.02) with the highest level for combination of DO-7 and Pab1801 positivity (RR = 2.57, p = 0.0098). Pab240 (epitope amino acids 213-217) and CM-1 (polyclonal) showed no prognostic relevance in the multivariate analysis. We therefore suggest that for immunohistochemical evaluation of p53-overexpression in STS a pannel of two N-terminal antibodies should be used at least.

Bendamustine as salvage treatment in patients with advanced progressive breast cancer: a phase II study

A phase II pilot study of bendamustine as salvage treatment in patients with advanced breast cancer was performed to determine the objective response rates and make further observations on the toxicity of this drug. A group of 37 patients, pretreated with chemotherapy for advanced disease, entered the trial. Treatment consisted of 150 mg/m2 bendamustine on days 1 and 2 of a 4-week treatment course. Patients continued to receive treatment until complete remission and then two further courses, until tumour progression or unacceptable toxicity ensued. A total of 36 patients received at least one treatment course and were assessable for toxicity; 33 patients were evaluable for treatment results. Dose-limiting grade 3 and 4 WHO toxicity occurred in 5 and 3 patients respectively; 27% of patients entered complete or partial tumour remission. The median time to tumour progression was 2 months with a range of 1-14 months. The efficacy of bendamustine was apparently independent of pretreatment with anthracyclines, suggesting a lack of cross-resistance between bendamustine and anthracyclines. It can be concluded that bendamustine in the dose and application schedule used here is active in the salvage therapy of women with advanced breast cancer. The toxicity was acceptable. Future studies have to confirm the data of this pilot trial and to define the role of bendamustine in the combination chemotherapy of metastatic breast cancer that has been suggested by previous trials.

[Inflammatory pseudotumor of the lung in hilus lymph node histoplasmosis]

The article deals with the case of an inflammatory pseudotumour of the lung in conjunction with histoplasmosis of the hilar lymph glands in a 35-year-old immunocompetent woman in a non-endemic area. She had been suffering from headaches and painful swelling of the lower legs, reddening and hyperthermia for 1.5 years. In addition to the above-mentioned symptoms she also complained of a typical flush syndrome which had begun a year later. The main paraclinical finding was a round mass in the right lung in chest radiography. After considering various differential diagnostic possibilities, thoracotomy and resection of the upper lobe of the right lung were performed. The histological diagnosis of the material removed was that of an inflammatory pseudotumour of the lung, combined with histoplasmosis of the hilar lymph glands. Following a postoperative period without complications, antimycotic treatment was performed. The discussion includes whether the simultaneous occurrence of these two diseases is coincidental or whether there is a causal relation between the two. The authors also discuss various treatments with reference to the relevant literature.

[Occult tumor cells of malignant melanoma and consequences for surgical treatment]

Immediate and complete surgical excision is the standard mode of treatment for primary malignant melanoma. There is still a controversy about the adequate resection margins. In this study we looked for microscopic satellites in order to estimate the extent of local therapy.

METHOD

19 patients with malignant melanoma of the trunk or extremities, treated by wide excision, were included. Clinical courses were documented. Postoperative follow-up was 1.4 years in the mean. In primary tumours and cutaneous excisions we looked for microscopic satellites with routine histology and immunohistochemistry (APAAP-technique, monoclonal antibody HMB-45).

RESULTS

Using APAAP-technique in combination with routine histology, we could show that microscopic satellites only occurred in specimens of melanomas of more than 5 mm thickness. In the two cases where evident microscopic satellites were present a systemic dissemination obviously evolved already before the first surgical treatment. Therefore, in those cases wide resection margins do not provide an increasing chance of survival.

CONCLUSION

The idea to remove microscopic satellites by wide surgical excisions and thus to reduce the risk for systemic dissemination and local recurrence cannot be supported.

[Indications and surgical therapy of thyroid gland diseases--analysis of 725 operated patients]

Diseases of the thyroid gland are an important part of elective surgical procedures. The adequate surgical therapy is at present standardized and requires a permanent qualitative control to reduce avoidable complications. The relation between men and women in our patients (n = 725) was 1 to 5. The mean age was 51.2 years. 10% (n = 79) of the patients were hyperthyroid. 646 patients had benign disease; and 79 patients were found to have malignancy of the thyroid gland. The most common indication for an operation was bilateral multinodular goitre (n = 325) in combination with a cold nodule (n = 123), in 79 patients latent hyperthyroidism or Morbus Basedow (n = 22). Struma nodosa with retrosternal extension (n = 49), recurrence of goitre (n = 34), thyroiditis (n = 12) and dystopic goitre (n = 2) were rare in these patients. Patients with malignancy of the thyroid gland were always treated by thyroidectomy or completed thyroidectomy with lymphnode dissection. In the cases of benign disease the surgical methods were variable, although the bilateral subtotal resection (n = 413) predominated. While doing so the radical resection of parenchyma with a persistent functioning remnant of goitre of 5 cm3 was favoured. The resulting postoperative complications are discussed. An endocrinological appropriate follow-up of the patients is necessary.

[Incidence of damage to the recurrent laryngeal nerve in surgical therapy of various thyroid gland diseases--a retrospective study]

We investigated the incidence of the recurrent laryngeal nerve (RLN) palsy after thyroid gland surgery in 725 cases. The incidence was correlated to the different diseases of the thyroid gland, to the operative procedure (subtotal resection, lobectomy, thyroidectomy), to the intraoperative exploration of the nerve and to the surgeons' state of training. RLN palsy was found in 7.6 per cent (4.8 per cent nerve at risk) five days after surgery. A permanent RLN damage was defined as a persisting paralysis of the vocal cord six months after surgery. Permanent nerve damage occurred in 2.1 per cent for euthyroid nodular goitre, for recurrent goitre in 11.7 per cent and for thyroid carcinoma in 10.1 per cent. There was a statistically significant difference between the number of RLN pareses occurring after nerve exposure with 4.2 per cent and that occurring after non-exposure with 1.1 per cent for subtotal lobectomy. 67.7 per cent of these pareses at day five were transient. The RLN palsy rate for Senior House Officers was 6.7 per cent but there where none for registrars and consultants.

CONCLUSIONS

The RLN damage five days after thyroid gland surgery is mainly caused by the great number of recurrent goitre and thyroid cancer (16.1 per cent), the rate of procedures performed by younger surgeons and the near total resection of euthyroid goitre. The exposure of RLN is important for the training to manage thyroid gland surgery.

[Is pyodermia fistulans sinifica of clinical importance?]

Pyodermia fistulans sinifica is a retention dermatopathy. We report on 12 men and 2 women with this disease, and our radical surgical treatment. The prognosis is favourable.

[Immunocytochemical detection of cytokeratin positive cells in human bone marrow of gastric and colorectal cancer patients]

We looked for disseminated tumour cells postoperatively in the bone marrow of 22 patients with gastric cancer and of 26 patients with colorectal cancer. On an average the follow-up was 6.5 months in the gastric cancer group and 9 months in the colorectal cancer group. In 27% of the gastric cancer group and in 30% of the colorectal cancer group follow-up aspirates were obtained. Micrometastases were detected in 96% of colorectal cancer patients and in 77% of gastric cancer patients. Both, postoperative and follow-up aspirations showed clear differences in the number of ck+ cells between the iliac crest sides. The majority of cells formed clusters from 2 to about 200 cells. In both groups no significant correlation was found between the number of tumour cells detected and the established risk factors (stage, tumour extension, lymph node involvement, distant metastasis) or the disease-free survival. In the gastric cancer group higher numbers of ck+ cells were seen in the low tumor stages I and II, as compared to stage III and IV. Besides, in this group significantly more ck+ cells were detected in younger patients (age under 63,5) than in the older group over 63,5 years. Colorectal cancer patients did not show this correlation. In follow-up aspirations the number of ck+ cells of the colorectal and also the gastric cancer group showed a tendency of rise in relapse and of fall in disease-free survival. There was a tendency of higher rates of ck+ cells in the colorectal cancer group when compared to gastric cancer patients.