[Biopsy diagnosis of papillary adenoma of the lung by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA)]

The papillary adenoma of the lung is a rare benign neoplasia with intraparenchymal localisation and is thus, in general, difficult to access for biopsy diagnosis. Due to the rarity of this lesion, the intra-operative histological diagnosis by frozen section may be problematic. We report on a 75-year-old male patient with a lung nodule, biopsied by means of bronchoscopy with TBNA. The tissue obtained was processed histologically as a cell block and examined microscopically. The diagnosis of a papillary adenoma was made. Our case is the first report on the diagnosis of a papillary adenoma of the lung by TBNA biopsy. For our patient with impaired lung function the diagnostic procedure described here represented a less invasive alternative to the diagnostic evaluation by surgery with intraoperative frozen section examination. This case shows that the TBNA biopsy combined with processing of the tissue as a cell block may represent a contribution to the appropriate management of the patients and serve as an aid for therapy planning.

Bone regeneration in segmental defects with resorbable polymeric membranes: IV. Does the polymer chemical composition affect the healing process?

Diaphyseal segmental defects 10 mm in length in the radii of 36 skeletally mature rabbits were covered with tubular microporous membranes prepared from poly(L/D-lactide) (18 rabbits) and poly(L/DL-lactide) (18 rabbits) to determine whether chemical composition of the membrane affected the bone healing in the defect. The results of a previous study in which similar defects of the rabbits radii were not covered with membranes or covered with poly(L-lactide) membranes were used as controls. The control defects were rapidly filled with overlying muscle and soft tissues, producing a radio-ulnar synostosis. The osseous activity of control defects was limited to the bone ends. The defects covered with membranes were progressively filled with new bone. At 1 year, complete bone regeneration in the defects covered with the poly(L/D-lactide) membrane was found in 16 cases, no regeneration in 1 animal and pseudoarthrosis in 1 animal. For the poly(L/DL-lactide) membrane there was complete bone regeneration in 17 cases (1 animal died during surgery). The quality of the interface between the new bone and the membrane seemed to be affected by the chemical structure of the polylactides used for membranes preparation. For poly(L/D-lactide), the connective tissue layer entirely separated the new bone from the polymeric membrane. This has been observed before for poly(L-lactide) membranes. In the case of poly(L/DL-lactide) the new bone was formed in some places in direct contact with the membrane and the membrane fragments were osteointegrated. The differences in chemical composition of the polylactide membranes did not have an evident effect on the bone regeneration process in segmental defects of the rabbit radii.

Unilocular toxoplasmosis simulating intracerebral tumor

Toxoplasmosis is a common infection with increased incidence in patients suffering from AIDS. In this paper we report a rare case of toxoplasmosis without evidence of AIDS: The patient had a singular tumor-like lesion in the right parietal lobe in CT and MRI. In neurosurgical intervention no tumor was found. Finally, different histopathological examinations led to the diagnosis of toxoplasmosis. Diagnostic and therapeutic regimes in patients with suspect tumor-like lesions should be discussed.

[The preoperative marking of nonpalpable breast lesions: the technic and results]

189 non-palpable breast lesions in 182 patients were localized using conventional mammographic apparatus, a wire grid compression plate and a cannula with a hooked mandrin. The technique of the examination for defining the lesion in three planes and fixation of the lesion with the wire is described. In 173 instances (91.5%), the lesion was found at the first biopsy and subsequent biopsies were necessary on only 24 occasions. One lesion (0.5%) was missed completely. 47 carcinomas were found (24.9%) and the incidence of malignancy increased from 14.3% to 33.3% during the series. The mean ratio defining the size of the biopsy and the size of the lesion was 3.3 and indicates good preservation of breast tissue. Radiographs of the specimen taken with compression showed 186 lesions (98.4%). The method, which is comfortable for the patient, provides satisfactory detection and localization of the lesions; results are similar to those of stereotactic methods but this method is quicker and much less expensive.

Biomechanical considerations on some postoperative problems of directly anchored total hip replacements

Uncemented total hip replacements have resulted in a higher incidence of postoperative complaints than cemented ones. The theoretical explanation of these not well defined discomforts is based on the differences of the stress and strain fields around the distal portions of the femoral components. While the noncemented stems are press-fitted and most of them tapered distally, thus creating hoop stresses and strains in the surrounding cortical bone, the shrinkage of the cement prevents these mechanical irritations. The relatively sudden disappearance of these discomforts within the first 2 postoperative years is attributed to the shift of the main zone of load transmission from the distal to the proximal portion of the stems following bone remodeling.

[Gangliocytic paraganglioma of the duodenum]

In a 49-year-old patient who was investigated because of abdominal complaints we found a polypoid tumor in duodenum near the papilla of Vater. The histological investigation after endoscopical polypectomy showed the rare case of a gangliocytic paraganglioma. After complete endoscopical removal no further intervention is necessary.

How useful is tricalcium phosphate ceramic in middle ear surgery?

In our experiments on the hypotympanum of the pig, resorbable porous tricalcium phosphate ceramic has proved to be serviceable for reducing radical mastoidectomy cavities and as a substitute for osseous walls. For our initial clinical trials with porous tricalcium phosphate ceramic in middle ear surgery, we had implants made especially for the purposes of replacing osseous walls and reducing radical mastoidectomy cavities. When implants have been used to replace osseous walls, insufficient ventilation of the tympanic cavity has frequently coincided with complications in the covering between implant and auditory canal. Follow-up operations have afforded opportunities for histologic examination of fifteen implants, which served as wall replacements for nine to thirty months. There were only the slightest traces of resorption and replacement by bone. In contrast with our findings on the replacement of walls with ceramic implants, postoperative observation for periods of up to four years has shown that granules of porous tricalcium phosphate ceramic are well suited to reducing radical mastoidectomy cavities.

[Polyglactin 910 (Vicryl) net in myringoplasty. An animal experiment and clinical study]

According to studies by Dociu (1978), the resorption of Vicryl sutures causes only a slight foreign-body reaction in the back musculature of rats. Similarly, in experimental studies by Bowald et al. (1978) Vicryl mesh is reported to be an excellent material for use in the reconstruction of arteries; the chief virtue attributed to it is that it promotes cell proliferation during the healing process, and so promotes the growth of new arterial walls. Stimulated by Dociu's and Bowald's favourable results, we decided to study the influence of an impregnated, and hence stiffer, Vicryl mesh on the outcome of myringoplasties. Myringoplasties were performed on both ears of 15 cats. One ear drum of each cat was reconstructed with fascia and Vicryl mesh, the other (= control) ear drum with fascia only. In addition, myringoplasties with autologous fascia and Vicryl mesh were performed on 18 patients. The absorption of Vicryl mesh results in a temporary but pronounced foreign-body reaction. In consequence, the tympanic membrane temporarily thickens and is thoroughly vasculated. According to our findings Vicryl mesh does not promote the growth of a new tympanic membrane. In our patients we noticed pulpy swelling of the fascia after myringoplastic surgery with fascia and Vicryl mesh. From the above we conclude that Vicryl mesh is not suitable for splintage in myringoplastic surgery.

Heart muscle necroses following normobaric hyperoxia: modification by beta-blocking agents and calcium antagonists

Heart muscle necroses can be produced in rabbits by normobaric hyperoxia. The pathogenesis of these lesions is controversial. In our investigations we found that such necroses can be prevented by beta blockers, but not by a calcium antagonist. This can be explained by the different action of the two drugs on the coronary arteries. The result supports the view that heart muscle necroses after normobaric hyperoxia are a direct toxic effect of oxygen on the heart muscle fibers.

[Experimental results of stepped titanium shafts for hip endoprostheses]

Among the materials which can be used for hip prostheses to be implanted without bone cement, ceramics and titanium possess the best overall properties for insuring long-term stability in the light of present knowledge. However, considered separately, the two materials are most suitable for different special requirements. Results of long-term animal experiments conducted by different working groups on functionally stressed hip and tooth-root implants made of bio-inert Al2O3 ceramic and titanium have furnished knowledge of the possibilities and limitations of the adaptation reaction of the bone tissue. The present authors investigated whether, by combining Al2O3 ceramic and titanium, a cement-free total hip replacement can be adapted to specific local stresses, taking biomechanical rules and anatomical factors into account. In recent experimental series it proved possible to limit the problems which had occurred in previous series, reported elsewhere. Positive results in dogs led to a human implant which has so far been used 15 times, with Al2O3 (FRIALIT) acetabula and heads, which have been implanted successfully for a number of years, in combination with the new stepped titanium shaft. In addition to a short review of follow-up findings thus far, the results of the experimental investigations are presented.

[Frequency of kidney cyst wall cancer--results of 22,000 ultrasound studies]

In 22 198 sonographic examinations of the epigastric region, the authors identified 759 renal cysts (3.4%) and 165 renal tumours (0.74%). The percentage of incidence of the renal cysts is identical with that found in post-mortem examinations, whereas tumours were distinctly more frequent. Tumours of the cystic wall had been found in 0.5% of all sonographically diagnosed cysts and in 4% of renal cysts examined via fine-needle biopsy. Of the latter cysts (i.e. out of the 4% of cysts diagnosed by fine-needle biopsy), which were associated with tumours, two had been diagnosed as tumour suspects via sonography. Hence, the sonographic absence of abnormal findings in carcinoma of the renal cyst wall is rare. However, cysts diagnosed via sonography which cannot be subjected to fine-needle biopsy, should be rechecked and followed up at regular intervals. If all possible methods of diagnosis are utilised (I.V. urography, sonography, fine-needle biopsy guided by sonography, computed tomography, angiography), successful differential diagnosis of localised pathological conditions of the kidneys can be achieved in 97% of all cases. Patient risk and cost of diagnosis can be kept at a minimum by proceeding in steps as described in the article. Primary surgical exposure of the kidneys in case of a cystic renal process would now appear justified for therapeutic reasons only, not for the purpose of arriving at a diagnosis.

[Obliteration of the mastoid cavity with porous tricalcium phosphate ceramic. Results 12 and 18 months after ceramic implantation in the hypotympanon of the pig]

The paper reports on the obliteration of mastoid cavities with resorbable tricalcium phosphate ceramic. As a model, we chose the pneumatic air cell system of the pig's hypotympanon, which resembles the human mastoid. At the time of surgery, the specimens were 10-12 weeks old. In a first group the cells of the hypotympanon were totally removed and the operation cavity was obliterated with adjacent layers of porous tricalcium phosphate ceramic. In a second group of specimens the air cell system was partly removed, leaving the apical part of the hypotympanon intact; the operation cavity was obliterated again with porous tricalcium phosphate ceramic. After 12 and 18 months survival the hypotympanons were removed and prepared for histological investigations. Those ceramic plates, lying close to the bony shell were strongly resolved and replaced by new bone. Other ceramic plates, however, especially those in the center of the implant, showed few signs of resorption and bony remodelling. Inside the ceramic implant there was hardly connective tissue. The space between the still unsolved ceramic plates was filled up with new bony tissue. This bone was partly structured and adjoined directly to the ceramic. The ceramic was integrated into the new bony tissue without any sign of an inflammation.

[Are porous tricalcium phosphate ceramics suited for the replacement of bony walls in ear surgery? An animal experiment study of the hypotympanum of the domestic swine]

The purpose of this study was to examine the possibility of a partially or totally posterior canal and lateral attic wall reconstruction with a more stable and therefore less porous tricalcium phosphate ceramic plate (S8). The hypotympanon of 4 pigs was drilled out, leaving the bony shell intact. In the middle part of this cavity a 2 mm thick S8-ceramic plate was placed horizontally. The hypotympanon of further 11 pigs was drilled out and obliterated with a more porous tricalcium phosphate ceramic (S5). Additionally, a single S8 ceramic plate served as a wall to the cavum tympani. 1 to 18 months after operation the pigs were sacrificed; sections of the hypotympanon were investigated with light microscopy. After few weeks, the S8-ceramic plate was covered by granulation tissue and epithelium on the tympanic side. After three months newly formed bony tissue could be observed between the peripheral parts of the S8-ceramic plate and the tympanic epithelium. After six months both sides of the S8-ceramic plate were completely covered by new bone; moreover this bone is covered by the mucosa on the tympanic side. At this time the S8-ceramic plate has a tight bony contact to the shell of the hypotympanon and bone growth can be observed in the macropores of this plate. The bony layer on the tympanic side of the S8-ceramic plate remained slim, there was no exophytic growth after 12 months. After 18 months the S8-ceramic plate shows distinct signs of resorption and bony replacement. However, in comparison to the S5-ceramic this occurs slower and later.

The influence of fine surface structures on the osseo-integration of implants

The availability of inert materials like dense, pure Al2O3-ceramic or titanium allows the study of purely biomechanical influences of surface modulations or lacune on the osseo-integration of implants at different locations of the skeleton. The discovery of the "load-line-shadow" phenomenon in lacune of dental implants and the observation of the same effect in the grooves of hip sockets (Lindenhof type) indicate the general validity of the rules controlling the remodelling ability of bony tissue. Their application to the problems concerned with load transmission via surfaces which are mainly loaded by shear can contribute to achieve a well defined anchorage of implants.

[Obliteration of the mastoid air cell system with porous tricalcium phosphate ceramic. An animal experiment of the bulla tympanica of the pig (author's transl)]

The paper reports on an animal experiment on the obliteration of mastoid cavities with tricalcium phosphate ceramic. The pneumatic air cell system of the bulla tympanica of pigs of 11-12 weeks of age was totally removed in one group of animals and partially removed in the second group. In this second group, apical part of the bulla was left intact. The operation cavity was then obliterated with adjacent layers of porous tricalcium phosphate ceramic. Histological sections wee evaluated for both groups of animals after survival time of 1, 3 and 6 months. Initially, an ingrowth of granulated tissue between the ceramic layers and into the porous surface can be observed. This dissolves the ceramic material, which is substituted by bony tissue. Pneumatic cells in the apical part of the bulla, which were left intact in the second group of animals, do not obliterate after the air supply has been cut off by sealing the basal part. Cystic cavities remain which contain a serous exudate. After 6 months, the mucous membrane of such cells shows signs of "sclerosis". Formation of spongy bony tissue with marrow spaces can be seen in most of the apical areas of the growing bulla. There is no formation of air-containing cells. It appears from our preliminary results obtained from animal experiments that porous tricalcium phosphate ceramic may be a suitable material for the obliteration of mastoid cavities.

[The diagnostic value of mammographic signs of malignancy in clinically occult breast carcinoma (author's transl)]

Two hundred and twenty clinically occult carcinomas of the breast were discovered by mammography as part of a preventive programme. They were histologically verified and the radiological features were analysed with reference to their value as a sign of their malignancy. In all cases a radiogram of the lesion was prepared during the operation, or before histological analysis. Dense, irregular foci could be recognised in only 28% of our early carcinomas. The most important, as well as the earliest, definite sign of malignancy was well defined microcalcification: in 72%, microcalcification was the major feature which led to a correct diagnosis; in 48%, it was the only sign, so that even the radiograph of the specimen failed to show an infiltrative focus. Very early, often before infiltration can be recognised radiologically, small carcinomas produce indirect changes in neighbouring tissues. Parallel lines are particularly important. In 14% we have observed slightly dilated tortuous vessels near the tumour. The nearly microscopic details to be demonstrated, and the delicate changes in the breast and complex pathology, make the highest demands on the radiologist and on mammographic quality.

Experimental studies on microcirculation under normobaric hyperoxia using the microspheres method

The perfusion of the heart, kidneys, adrenals, stomach, intestines, brain and musculature under normobaric hyperoxia was studied in anaesthetized mini pigs using radioactively labelled microspheres. After a 2-hour control period using room air, the influence of normobaric hyperoxia on the perfusion of the organs was measured at 2-hour intervals. A significant increase in the perfusion of tissue was found in the kidneys, adrenals, gastro-intestinal tract and brain after 4-6 hours of exposure. No change in perfusion could be demonstrated for the myocardium. Values for the skeletal musculature (diaphragm and musculus psoas) were widely scattered, but an increase could be suspected. The increase in tissue perfusion at constant blood pressure and pulse rate must be interpreted as an expression of vasodilation. These results are contrary to the majority of statements in the literature, which mainly report vasoconstriction under normobaric hyperoxia.

[A rare form of Kaposi's sarcoma with intestinal symptoms (author's transl)]

Kaposi's sarcoma is a rare systemic disease with cutaneous and occasional visceral manifestations. A 39 year old male caucasian patient developed Kaposi's sarcoma 10 months after receiving a renal transplant; subacute pancreatitis was suspected because of the clinical symptoms on the first hand. Multiple, miliary, dark and well vascularized lesions appeared on forehead, cheeks, and trunk. In addition flat tumours of 1.5 cm in diameter, well vascularized and with a central indentation were found radiographically and endoscopically in the jejunum and colon. The diagnosis was confirmed bioptically using specimens of rectal mucosa and facial epidermis. The specimens taken were infiltrated by eosinophiles and granulocytes suggesting parasitosis, the correct diagnosis however could be made. After chemotherapy with actinomycin-D, vincristine and cyclophosphamide, cutaneous and visceral lesions vanished completely. Renal and pancreatic function remained normal. There are no symptoms of relapse of the disease 16 months after stop of chemotherapy by now.

Shock in pregnancy: pathophysiology and morphologic findings

Sepsis and non-septic shock in pregnancy show characteristic modifications which are caused a) by physiologic changes in hemostasis primarily in the third trimester of pregnancy, b) by etiologic distinctions of shock regarded as pregnancy-specific, c) by hemodynamic changes in the circulation during pregnancy, d) by the ability of the healthy, young organism to compensate adequately. In the dead fetus syndrome and in non-septic shock, i.e., in amnionic fluid embolism and in abruptio placentae, the clinical picture is often governed by marked secundary fibrinolysis. Retroplacental hematoma, the characteristic feature of premature placental separation, remains controversial as either the cause or sequela of the hemostatic disorder. Etiologic, pathogenetic, and morphologic similarities exist between septic abortion, chorioamnionitis, and puerperal sepsis, but the varying response of the maternal organism during the course of pregnancy leads to different clinical and morphologic pictures. Due to a decrease in fibrinolytic activity as a consequence of pregnancy, the hypercoagulability state in a septic endotoxic shock predisposes the kidneys to bilateral renal cortical necrosis, principally in the amnion infection syndrome.

[Experimental investigation on non-specific foreign body sarcoma induction of Al2O3-ceramic implants (author's transl)]

This investigation presents experimental results on possible non-specific foreign body sarcoma induction by Al2O3-ceramic implants. Solid and porous discs, subcutaneously implanted in rats produce a sarcoma rate of 17.4 resp. 17.8 p.c. while roughly perforated discs initiate sarcomas at a rate of 25.4 p.c. These values were found to be lower than comparative values in the literature produced with different metals and medical grade plastics. Powdered alumina implants did not produce any sarcomas. Only this latter result can mainly be transferred into prognostic assumptions concerning the clinical application of Al2O3-ceramic. The results are discussed extensively in the lights of the existing literature, this indicating that the tested ceramic itself may not possess a significant sarcogenetic potency in humans.

Microscopic and pulse cytophotometric investigation of a carcinoma of the jejumum in a seven year old child

In a seven year old boy with acute abdominal pain and intestinal bleeding, laparotomy revealed an invaginated carcinoma adenomatosum cylindrocellulare in the distal part of the jejunum. Histological and pulse cytophotometric investigations support the diagnosis of a highly differentiated but locally destructive and malignant tumor.

[Experimentally induced heart muscle fiber necroses after premedication with strophanthin (author's transl)]

Number and degree of angiotensin-induced heart muscle necrosis in the rat (75 mg/kg body weight) are diminuished by premedication with strophanthin (2 X 10(-2) MG/KG BODY WEIGHT). The electron-microscopic findings are also changed: the application of angiotensin only results in vacuolization of mitochondria and a dilatation of theendoplasmatic reticulum while myofibrils are unaltered. Angiotensin in combination with strophanthin has a direct destructive effect on the myofibrils without evident changes of the mitochondria and tubular system of the heart. The protective action of Strophanithin on the heart muscle cell is discussed in the sense of an exonomization of the cellular metabolism under conditions of relative coronary insufficiency, induced by the vasoconstructive effect of angiotensin.

[Effectiveness of local and parenteral antibiotics in infection of aortic dacron grafts (author's transl)]

The effectiveness of local and parenteral antibiotic prophylaxis in infections of aortic dacron grafts was tested in animal experiments. In 20 foxhounds Dacron-interpositions, 4 cms in length, were inoculated with 50 million Staph aureus bacteria and then treated in 4 different ways: Nr. 1-5 no antibiotic treatment. Nr. 6-10 local antibiotic (Nebacetin, R) treatment. Nr 11-15 parenteral treatment with Gramaxin (R) i.m. Nr. 16-20 combined Nebacetin (R) and Gramaxin (R) treatment. The untreated dogs developed infection of laparotomy wounds, peritoneum udn prosthesis. Nebacetin gave improved results, whereas Gramaxin led to complete eradication of the infection. It is concluded, that antibiotic prophylaxis should be applied in vascular surgery, whenever alloplastic, homologous or autologous implants are used.

[Experimental heart muscle necorses in the rat after administration of 1-noreadrenaline and strophanthin. Light- and electron microscopic studies (author's transl)]

Female rats with a body weight of approximately 200 g regular show necroses of myocardial fibers after subcutaneous injection of 1-Noradrenaline (2.5 mg/kg body weight). After intraperitoneal premedication with Strophanthin k in a therapeutical dosage (2 X 10(-5 g/kg body weight), the increase in number and extent of the necroses is statistically significant. These findings argue against a preventive effect of Strophanthin k and can be explained by the mode of action of catecholamines and glycosides, as both substances, in a like manner, cause an increase in the mobilizable intracellular calcium of the myocardial fiber. Premedication with Strophanthin causes no alteration in the distribution pattern of necroses, nor in the electron-microscope findings in the case of myocardial necroses produced by Noradrenaline.

Light and electron microscopic examinations of experimentally produced heart muscle necroses following normobaric hyperoxia

Heart muscle necroses following normobaric hyperoxia as examined under a light microscope occur after 40 hours exposure in the rabbit and increase in intensity with prolongation of the exposition time. Simultaneous arterial blood gas analysis excludes a hypoxemis as the cause, In addition electron microscopic examination of the necroses demonstrate the primary changes in the myofibrils but not in the mitochondria. The ultramorphological picture is however, quite similar to the myocardial necroses after epinephrine application in the rabbit. A pathogenetic relationship between heart muscle necroses after normobaric hyperoxia and after epinephrine should be considered.