[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.

[Differential diagnosis of acute arthritis. Quickly assessing infectious etiology]

Acute arthritis of abrupt onset producing symptoms showing peak intensity within a matter of hours, have a largely uniform clinical presentation. Urogenital or gastrointestinal infections (= reactive arthritis) or infectious conditions (= septic genesis) in the patient's history may provide further information of relevance for the differential diagnosis, which includes--in particular in the case of the reactive, infectious/allergic forms--direct and serological demonstration of pathogens. In contrast, imaging procedures in the early stages are of little help in clarifying causes.

[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.

[Routine hip ultrasonography in inflammatory rheumatoid diseases. Results in 119 consecutive patients of a rheumatism clinic]

METHOD

In 119 consecutive inpatients with rheumatic diseases--mainly rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis--both hips were routinely investigated by sonography.

RESULTS

In 52 of the 119 patients definite or possible pathological findings (in 18 cases bilateral) were observed. The relative frequency of sonographic findings in 223 evaluable hips was 33% and was somewhat higher in patients with rheumatoid arthritis than in those with other diagnoses. Changes were found significantly more often when the patient had joint complaints, limitation of movement, pathological X-ray changes or serological signs of inflammation (elevated ESR, positive C-reactive protein). The relative frequencies were higher than were expected on the basis of data in the literature. Of the pathological sonographic findings, 22% occurred in clinically and radiologically asymptomatic patients.

CONCLUSIONS

In view of the therapeutic consequences and the importance of early treatment, routine sonographic examination of the hip joint is recommended.

[Basic therapy of rheumatoid arthritis. Comparison of methotrexate and sulfasalazine]

In a retrospective analysis a total of 167 patients with rheumatoid arthritis (RA) who had been treated with the basic therapy formulas of methotrexate (MTX) or sulfasalazine (SUL) were evaluated with respect to therapeutical result and side effects after a period of 12 months. There was no randomization as to either MTX (n = 87) or SUL therapy (n = 80), but deliberate use of therapy according to prior treatment and activity of the illness. Apart from a significantly higher number of inflammatory joint conditions in the MTX group there was no difference in the two patient groups at the beginning of the study. MTX treatment led clearly to a more conspicuous activity decrease of the illness (ESR, joint index) and a more favourable effect on the locomotor function. Furthermore, the sphygmomanometer readings (for grip strength determination), the dose reduction of the concomitant prednisolone medication as well as the doctor's opinion were in favour of MTX. The portion of patients who had to discontinue the therapy because of side effects (= 11%) and lack of effect (= 9%) was exactly identical in both groups of patients. Both substances have shown to be effective basic therapy formulas for rheumatoid arthritis, while methotrexate has a few advantages.

[Behçet's syndrome. Possible differential diagnosis in multi-system symptoms]

Behçet's syndrome was described as a triad with recurrent ulcers of the mouth, aphthae of the genitals as well as changes of the eyes. A fourth later added main criterion comprises multifarious dermatological symptoms. Facultative signs of a disease, which, however, occasionally may stand also in the centre of the clinical picture are vascular, gastrointestinal and central-nervous participations, arthritic pains and swellings as well as an epididymitis. On account of the infrequency of the disease outside the endemic regions and the development of the individual manifestations over larger periods it is often recognized very late. Out of the six casuistics described three of them fulfilled the criteria of a complete Behçet's syndrome with evidence of all four main criteria, in the remaining casuistics the incomplete clinical picture was present with three main and one to four side criteria. In all cases the course was relatively benign. Recently, streptococcal antigens were considered to be etiological factors; correlations with the HLA-system are ascertained for patients from endemic regions. In phases of clinical activity the combination of immunosuppressive agents with cortisonoids is the therapy of choice.

[Employment of the antigen-specific rosette test in the diagnosis of rejection following allogeneic orthotopic kidney transplantation in the pig]

Investigations of the course were performed by means of an antigenspecific rosette test using a poolantigen from tissue samples of approximately 100 pigspleens with the help of the model of allogenic renal transplantation in 26 female pigs. The animals received no immunosuppressive treatment. In our study with this test 75% all of the rejection episodes by clinical acute and chronic rejection were predictably. In acute rejection a maximum rosette forming cell response was examined in general 2-3 days before a pathological rise of serum creatinine or in the course of a bad clinical state. Under chronic rejection this reaction can be seen 5-14 days before the kidney function will go poor. In spite of the high individuality of original curves statistical analyses indicate a good correlation of the number of antigenbinding cells toward pathological deviation of serum creatinine, as long as blocking factors not protect the transplant against the attack of persisting immunocompetent cells or their effectors. These blocking factors can be monitored in a rosette inhibition test with autolog serum.

[Animal model for the study of the anhepatic state]

Hepatectomy in the pig is impossible without simultaneous removal of intrahepatic caval vein. The authors covered the vascular gap using a siliconized glass prosthesis, completed with rubber tubes. 16 animals were operated upon in this manner and survived between 6 and 34 hours. In only two cases thrombi were found in the prosthesis.

Quantitative alterations of immune serum globulin concentrations in pigs transplanted with a renal allograft

The variation of immune serum globulin concentrations in 14 pigs was determined after unilateral allogenic renal transplantation. Measures by which it is possible to exert certain immunological influences were not taken. Subsequent to transplantation there was observed a significant decrease in both IgM and IgG which was not correlated with the behaviour of plasma proteins and albumin. Because of the relatively small loss of IgG in the urine of animals on which transplantations were performed, this cannot be considered to be the cause of the decrease in immunoglobulin. It was already on the 3rd day after transplantation that an increase in IgM was observed which after reaching a peak of about + 30% was again followed by a distinct decrease of which the minimum was noted between the 6th and 15th days after transplantation. 10 animals died within the first phase, and in 4 of them death occurred on account of rejection for which histological evidence could be obtained. Although 3 of the 4 animals surviving for a longer period of time were also observed to suffer from distinct rejective crises between the 8th and 15th day after transplantation, they were able to overcome those crises without any therapeutical intervention. After some time, however, they were experiencing another IgM peak (this time greater than + 80%) which was followed, after 3 to 11 days, but the final crisis of rejection and death of the animal. In a few cases, glomerular IgM deposits were found in transplanted kidneys.

[Morphological, clinical and biochemical findings on the swine-liver after heterologous perfusion for treatment of fatal ammonium bichromate poisoning]

A 23-year old man died after intake of ammonium bichromate. For treatment among others was used the extracorporal heterologous liver perfusion with the liver of a pig. Therefore technical problems, clinical and biochemical findings as well as pathologo-anatomical changes on the livers of pigs after heterologous perfusion are reported and their significance as well as pathogenesis are discussed taking into consideration literary data.