Enhanced postoperative lymphatic staging of malignant melanoma by endoscopically assisted iliacoinguinal dissection.

Radical lymphadenectomy for malignant melanoma continues to be controversial. In order to reduce morbidity but preserve prognostic informations, a minimally invasive technique for the iliac part of dissection was developed. We evaluated the practicability of this intervention under routine conditions as well as its prognostic impact. A total of 106 patients with tumor cell involvement of at least one inguinal lymph node underwent open inguinal dissection combined with a minimally invasive iliac dissection. Perioperative and postoperative data on morbidity, survival, and histopathological features of the primary and the dissected specimens were collected. Histopathological data were evaluated statistically for their prognostic relevance. Of the 106 patients, 38 showed evidence of additional metastases in the resected specimen, of which 11 cases were related to the iliac portion. Detection of lymph node metastases in the specimen was significantly correlated with a poorer prognosis, while out of all factors implicated, a new prognostic factor comprising iliac tumor involvement and primary tumor ulceration showed the strongest statistical correlation with prognosis. The median dissection time was 137 min, 58 min devoted to the iliac part. Complications necessitating reoperation (n = 7) related only to the inguinal wound area. Minimally invasive iliac lymph node dissection is ready for clinical routine. The additional information obtained by the iliac dissection-in particular, in combination with primary tumor ulceration-is of important prognostic relevance. Further development of this technique performing a completely minimally invasive ilioinguinal dissection may confer additional advantages.

[Hiatoplasty reinforcement by means of a lightweight titanized polypropylene mesh fixed with fibrin glue]. / Verstärkung der Hiatoplastik durch ein leichtgewichtiges titanisiertes Polypropylennetz mit Fixierung durch Fibrinklebung.

INTRODUCTION: Suture-based hiatoplasty is associated with a high recurrence rate. Using meshes of different shapes and materials to reinforce these sutures reduces the risk of recurrences. On the other hand morbidity attributable to the suture and tack fixation of these meshes has been observed during the development phase of these techniques. Moreover, there are some experimental and clinical data about mesh migration into the oesophageus. For this reason we analysed the outcome of our patients who underwent a mesh-reinforced hiatoplasty with a lightweight titanised polypropylene mesh fixed by fibrin glue. PATIENTS AND METHODS: All the patients who under-went a mesh-reinforcement between 3 / 2006 and 12 / 2007 were collected retrospectively. The hiatoplasty was reinforced by means of a lightweight titanised polypropylene mesh that had been designed especially for that purpose (TiSure®, GfE). Mesh fixation was performed with 2  mL of fibrin glue (Tissucol®, Baxter). Postoperative data were elucidated for all patients via their general practitioner or by interviewing the patients by telephone using a dedicated questionnaire. RESULTS: 26  patients with a median age of 58  years and a median BMI of 27.5 kg / m² underwent laparoscopic mesh-reinforced hiatoplasty. There were 15  axial and 11  paraoesophageal hernias, in 5  cases with upside-down stomach and in 4  cases recurrent hernias. 15  patients underwent an additional dorsal 270°-fundoplication, the remaining 11 patients had a fundophrenicopexy, with conversion taking place in 2  cases. The median follow-up was 34.3  months. 3  patients suffered from dysphagia, 1  of them had to be re-operated and has been free of symptoms since then. 2  patients suffered from mild gastrooesophageal reflux which was treated conservatively. So far no mesh migration and no recurrences have been seen. CONCLUSIONS: Despite the short observation time, this study indicates the patients are not exposed to any danger by the lightweight titanised polypropylene mesh. Moreover, the mesh appears to enhance hiatorrhaphy safety even in the presence of extensive hiatal hernias as well as in the case of an upside-down stomach.

Rare cause of acute pain in the left upper abdominal quadrant.

We report a case of a 45-year-old man with acute pain in the left upper abdominal quadrant. Extensive diagnostic workup remained inconclusive. An exploratory laparotomy revealed herniation of the entire ascending colon, together with a part of the terminal ileum through the foramen of Winslow into the bursa omentalis. The internal hernia was further complicated by a perforated appendicitis within the bursa, explaining the acuteness of the symptoms. Reduction of the hernia, appendectomy and colopexy were performed consequently. This would be the first reported case of a perforated appendicitis within the lesser sack.

Urodynamic outcome of waterjet-assisted total mesorectal excision.

BACKGROUND: Waterjet dissection has been proposed for total mesorectal excision. The present study investigated its impact on urodynamic function and oncological outcome. METHODS: Thirty patients with rectal cancer were recruited to this prospective study, of whom 25 underwent urodynamic evaluation both before and after surgery. RESULTS: All patients were capable of spontaneous micturition at a median of 5 months after surgery. Urodynamic measurements revealed a decrease in detrusor pressure of more than 30 mmHg, and residual urine volumes of between 100 and 200 ml, in three patients. No patient had a complete neurogenic voiding disorder. Local recurrences developed in two of 22 patients. CONCLUSION: The extent of micturition disorders observed after total mesorectal excision using the waterjet method in this small series is encouraging.

Magnetic resonance-guided biopsy of suspicious breast lesions with a handheld vacuum biopsy device.

PURPOSE: To evaluate a handheld vacuum-assisted device system for magnetic resonance image (MRI)-guided breast lesion biopsy. MATERIAL AND METHODS: In 32 patients, a total of 42 suspicious breast lesions (mean diameter 7.5 mm for mass lesions, 11.6 mm for non-masslike diffuse lesions) seen with MRI (no suspicious changes in breast ultrasound or mammography) were biopsied (27 lateral, 15 medial) using a 10G vacuum-assisted breast biopsy device under MR guidance. Histology of biopsy specimens was compared with final histology after surgery or follow-up in benign lesions. RESULTS: In all biopsies, technical success was achieved. Histology revealed 11 lesions with ductal carcinoma in situ (DCIS) or invasive cancer, three with intermediate lesions (LCIS) and 28 with benign breast lesions (adenosis, infected hematoma). In one patient with discordant results of MRI and histology, surgical excision revealed medullary cancer. In the follow-up (mean 18 months) of the histological benign lesions, no breast cancer development was observed. Besides minor complications (hematoma, n = 6), with no further therapeutic interventions, no complications occurred. CONCLUSION: MRI-guided breast lesion biopsy using a handheld vacuum-assisted device is a safe and effective method for the work-up of suspicious lesions seen with breast MRI without changes in mammography or ultrasound. In the case of discordant histology of vacuum biopsy and breast MRI appearance, surgical excision is recommended.

[Increasing abdominal pain caused by abdominal tumor in a 21-year-old female]. / Zunehmende abdominelle Schmerzen durch einen grossen Unterbauchtumor bei einer 21-jährigen Patientin.

Lymphangiomas are congenital malformations which occur mostly in the neck and head region of children. They are rarely located in the mesenterium or retroperitoneum in adults. We present a case of mesenteric cystic lymphangioma in a young woman who was admitted to hospital with a history of increasing abdominal pain. We discuss diagnostic means, differential diagnosis, and therapeutic management of the disease.

New concepts of staging in gastrointestinal tumors as a basis of diagnosis and multimodal therapy.

The therapy of gastrointestinal tumors is becoming more and more sophisticated and complex. This is due to an improved understanding of the pathogenesis of tumors, a more detailed classification and increasing therapeutic options. The basis of optimized therapeutic concepts is the exact evaluation of tumor spread and exact staging. The following review describes some of the most recent staging concepts in gastrointestinal tumors. Multislice computed tomography (CT), positron emission tomography (PET) and new supraparamagnetic iron oxide contrast agents for magnetic resonance imaging enable an increasing quality of the visualization of tumors and metastases. 3D imaging will be used for planning of surgical interventions in the future. Optical coherence tomography may contribute to an improved tumor staging and, thus, to the safety of limited interventions in early oesophageal- and gastric cancer patients. Laparoscopy and laparoscopic ultrasound become increasingly important for the identification of small metastases in the peritoneum, in lymph nodes and in the liver. The sentinel lymph node concept will contribute to an improved staging and individualized therapy as well.

Outcome analysis of 189 consecutive cancer patients referred to the intensive care unit as emergencies during a 2-year period.

The referral of critically ill cancer patients to an intensive care unit (ICU) is a matter of controversial debate. This study was conducted by an interdisciplinary clinical group to evaluate the outcome of ICU treatment in cancer patients according to their characteristics at the time of referral. A retrospective analysis was used to identify relevant subgroups among 189 consecutive cancer patients referred as emergencies to one of four ICUs during a 2-year period. Reasons for ICU referral were pneumonia (29.6%), sepsis (27.0%), fungal infection (11.1%), another infection (9.5%), gastrointestinal emergency (16.9%), treatment-related organ toxicity (6.9%), or other, non-infectious complications (43.9%). Vasopressor support was required in 50.3%, mechanical ventilation in 49.7%, and haemodialysis/-filtration in 26.5% of the patients. Overall, 41.3% died during ICU treatment, 12.2% died after transfer from ICU to a non-ICU ward, and 35.4% were discharged alive. Sepsis, mechanical ventilation, vasopressor support, renal replacement therapy and neutropenia were independent risk factors for fatal outcome, but no single risk factor unequivocally predicted death. All patients with fungal infection who required vasopressor support and either had sepsis (n=13) or needed mechanical ventilation (n=14) died during ICU treatment, while all non-septic patients. who did not require mechanical ventilation, were younger than 74 years of age and had a non-infectious underlying complication (n=29), survived. This analysis may help to early identify relevant subgroups of cancer patients with different prognoses under ICU treatment. A prospective study to confirm the predictive usefulness of this approach is needed. Cancer patients should not be excluded from referral to the intensive care unit in an emergency solely due to their underlying malignant disease or a single unfavourable prognostic factor.

Histopathological correlation to MRI findings during and after laser-induced thermotherapy in a pig pancreas model.

RATIONALE AND OBJECTIVES: To investigate whether percutaneous laser-induced thermotherapy (LITT) with continuous magnetic resonance (MR) monitoring of thermal effects within the pancreas is feasible in a porcine model. METHODS: Laser applicators were placed in the pancreas of 15 female pigs. A temperature-sensitive (thermo--fast low-angle shot) sequence was used for continuous monitoring of thermal effects during LITT at 1.5 T. Follow-up MR images were acquired, the pigs were observed for 7 days, and then a pathological examination was performed after sacrifice. RESULTS: Continuous MR monitoring visualized thermal effects in pancreatic tissue and thermal damage of the spleen (n = 1), the left kidney (n = 1), and peripancreatic fat (n = 4) but missed the thermal damage of the duodenum (n = 2). Thermal-induced lesions (10--32-mm diameter) were clearly visualized on contrast-enhanced T1-weighted images. CONCLUSIONS: Laser-induced thermotherapy of pancreatic tissue was feasible in this porcine model, and online monitoring was practicable. Further studies are necessary to increase the accuracy of online MR imaging of thermal effects.

Near-infrared fluorescent dyes for enhanced contrast in optical mammography: phantom experiments.

Optical mammography with near-infrared (NIR) light using time-domain, frequency-domain, or continuous-wave techniques is a novel imaging modality to locate human breast tumors. By investigating excised specimens of normal and diseased mamma tissue we were able to demonstrate that differences in their scattering properties are a poor predictive parameter for normal and diseased mamma tissue. This paper describes the application of a NIR dye to improve the differentiation between breast tumors and normal tissue in a rat model. The NIR dye furnished a high tumor-to-tissue contrast ratio (6:1) in fluorescence images. Furthermore, this dye was used to develop liquid scattering phantoms with absorbing and fluorescent inhomogeneities. Using frequency-domain and time-domain instrumentation these inhomogeneities were localized at sufficient contrast by their increased absorption and fluorescence. Contrast between inhomogeneities and surrounding medium could be improved by combining fluorescence and transmittance images.

[Staging and neoadjuvant therapy of squamous cell carcinoma of esophagus]. / Staging und neoadjuvante Therapie des Plattenepithelkarzinoms des Osophagus.

Once the diagnosis of esophageal cancer is established, the decision on treatment will depend on the stage of the disease. Since improvement of prognosis can only be expected in patients with complete removal of their tumor, preoperative staging plays a pivotal role in the decision-making process. Preoperative diagnostic procedures should define the tumor in its relation to the tracheal bifurcation (site), determine the depth of tumor invasion (T status), evaluate regional lymph node metastases (N1 disease) and exclude distant metastases (M1 disease). Endosonography represents currently the most accurate imaging technique for detecting the correct T stage over the correct N stage. A higher accuracy rate may be achieved by combining endosonography with other staging modalities such as computed tomography. Chest x-ray, and percutaneous ultrasonography (abdominal, neck) form the diagnostic basis in staging M1 disease. Computed tomography (neck, chest and abdomen) is currently the best method to detect metastases in the liver and in celiac nodes. Staging laparoscopy when combined with laparoscopic ultrasonography shows a higher sensitivity than ultrasonography and computed tomography in the diagnosis of smaller metastases and peritoneal seedings. En bloc esophagectomy together with the regional lymph nodes remains the treatment of choice in medically fit patients with localized esophageal carcinoma (Stage I-IIB, T1-T2/N0-N1/M0). Due to early involvement of mediastinal structures, curative resection is unlikely to be achieved in patients with locally advanced esophageal carcinoma (Stage III, T3-T4/N0-N1/M0). Most available data indicate that neoadjuvant radiochemotherapy leads in a significant number of patients to downstaging of the tumor, increases the rate of R0 resection, improves local tumor control, and prolongs the recurrence free interval. However, neoadjuvant radiochemotherapy resulted in a marked increase of morbidity and postoperative mortality without improvement of survival. At present, neoadjuvant therapy is still experimental and there is no consensus for an optimal treatment regimen. Its use outside of an investigational setting can not be recommended. Future research must focus on more effective and less toxic neoadjuvant modalities (e.g. new chemotherapy agents, hyperthermia).

The role of transrectal ultrasound-guided biopsy in the postoperative follow-up of patients with rectal cancer.

BACKGROUND: The value of endorectal ultrasound (EUS) in the diagnosis of recurrent rectal cancer is limited by the inability to differentiate between malignant and benign lesions. We have prospectively investigated the role of EUS with transrectal ultrasound-guided biopsy in the postoperative follow-up of rectal cancer. METHODS: Since 1995, patients who had undergone a sphincter-saving operation for rectal cancer (n = 312) were followed-up by a standard program including rectal palpation, carcinoembryonic antigen monitoring, computed tomography, and EUS. Transrectal EUS-guided biopsy of perirectal lesions was performed in 68 patients with perirectal lesions by using a rigid endoprobe with a 10 MHZ multiplane transducer and special targeting device. RESULTS: Overall local recurrence was observed in 36 patients. Intraluminal recurrence was diagnosed by proctoscopy in 12 patients. Transrectal EUS-guided biopsy showed pelvic recurrence in 22 of 68 patients with perirectal lesions. Biopsy specimens with benign histology were obtained from 41 patients, and the procedure failed in 5 cases (accuracy, 92%). There was a strong agreement between transrectal biopsy results and the final diagnosis (kappa = 0.84), the sensitivity and specificity being 91% and 93%, respectively. In contrast, clinical examination (kappa = 0.27), computed tomography (kappa = 0.47), or EUS (kappa = 0.42) showed only a moderate level of agreement with the histopathologic diagnosis, mainly because of the limited specificity of all 3 methods (65% vs 46% vs 57%). EUS-guided biopsy was significantly more accurate than computed tomography and EUS (P <.01). The biopsy results had a considerable impact on the management in 18 of 68 patients (26%). CONCLUSIONS: Transrectal EUS-guided biopsy is a safe and efficient method for tissue sampling of perirectal lesions. This minimally invasive and inexpensive technique improves the accuracy of endorectal ultrasound in the diagnosis of recurrent rectal cancer.

Protoporphyrin IX occurs naturally in colorectal cancers and their metastases.

Colorectal cancers exhibit a red fluorescence. The nature of the responsible fluorophore and its eventual diagnostic potential were investigated. Thirty-three consecutive colorectal resection specimen, 32 of which with histologically confirmed cancer, and a total of 1053 palpable mesenteric nodes were fluorimetrically characterized ex vivo. Furthermore, frozen material from 28 patients was analyzed, selected for the availability of primary tumor material and metastatic tissue, e.g., lymphatic and liver metastases from the same patient. Biochemical characterization was carried out through chemical extraction and reversed phase high-performance liquid chromatography. The fluorescence spectra of tissues, tissue extracts, and standard solutions of porphyrins were determined using a pulsed solid-state laser system for excitation and an imaging polychromator, together with an intensified CCD camera for time-delayed observation. Protoporphyrin IX (PpIX) was identified as the predominant fluorophore in primary tumors and their metastases. The fluorophore occurred in the absence of necrosis and in sterile locations. In untreated cases (n = 24), PpIX fluorescence discriminates metastatically involved lymph nodes from all other palpable nodes with a sensitivity of 62% at a specificity of 78% (P < 0.0001). After neoadjuvant treatment of rectal cancer, the PpIX fluorescence level of the primary tumors was reduced and a discrimination of lymph nodes based on PpIX-fluorescence was impossible. We conclude that colorectal cancer metastases accumulate diagnostic levels of endogenous PpIX as a result of a tumor-specific metabolic alteration.

Fluorescence as a concept in colorectal lymph node diagnosis.

Fluorescence detection may constitute an appropriate means in gastrointestinal cancers to diagnose lymphatic tumor spread as opposed to gamma-scintillation methods. Photodiagnostic tracers have been shown to localize rapidly in malignant cells and may enable sensitive detection of small cell aggregates in lymph nodes. To reach a detection depth of several millimeters, a broad banded unspecific tissue autofluorescence may be controlled by so-called background subtracting techniques, generally based either on fluorescence observation at several wavelengths or on dual-wavelength fluorescence excitation. Using such comparative fluorescence detection techniques, some tumor entities can be differentiated soley based upon autofluorescence characteristics. Introducing a further enhancement in sensitivity for longer life-time fluorophores by time delayed fluorescence detection we ran a pilot trial comprising 174 lymph nodes from colorectal cancer specimen from 9 patients. Metastatically involved lymph nodes could be differentiated from all other palpable nodes in the mesenteric fat at a specificity of 85% with a sensitivity of 65%. Specific fluorescence features may be useful to preselect tissue samples for further histological analysis.

Telemedicine: the new must for surgery.

The vision of telesurgery comprises a multitude of new communicative elements influencing the way surgeons will treat their patients in the future. The first prerequisite for effective telecommunication is to digitize surgical data. Many medical imaging modalities provide primarily digital data sets, and digital image communication is already entering clinical practice under the labels of teleradiology and telepathology. However, for any surgical purpose, images must refer to tissues. Three-dimensional image reconstruction is warranted, and if such data shall be useful during surgery, different image sources must be combined into some virtual, multiparametric body model and matched to an intraoperatively distorted organ contour. A multitude of detail problems arise, beginning with image standards, data interfaces, data transport, image fusion, registering, contour matching, and, once the data are integrated, all the aspects of surgery-suitable data display and interaction. We refer here to several demonstration projects illustrating such a complex surgical data set and its interactive telecommunication. In all instances, telecommunication was to enable a concentration of distributed medical intelligence at the site where the patient was treated. With further technological development, such telesurgical applications will have a growing influence on patient management and surgical decision making. In the very near future, computer-aided navigation and robotic assistance, based on the same surgical data sets, will be available to all fields of surgery. How decisive the role these methods will play for specific procedures or diseases needs to be determined.

[Foreign body-induced thoracic actinomycosis as differential mediastinal space-occupying lesion diagnosis]. / Die fremdkörperinduzierte thorakale Actinomykose als Differentialdiagnose der mediastinalen Raumforderung.

Thoracic actinomycosis is a rare disease often mistaken for malignancy. Untreated actinomycosis is associated with high mortality, the disease should, thus, be considered early. We report the case of a 58-year-old male patient who was referred to us for a suspected thoracic sarcoma. He had 6-month a history of hemoptysis, and there was severe deterioration in his general health. Only in a roundabout way was the diagnosis of thoracic actinomycosis established; it was caused by an aspirated chicken bone, as found by bronchoscopy. All symptoms rapidly regressed by antibiotic therapy and definitive healing was obtained. In the diagnostic work up of thoracic masses that may represent inflammatory diseases, lymphoma, thymus-associated, sarcomatous and germ-cell tumors, bronchoscopy is of primary diagnostic importance.

Development of a time-domain optical mammograph and first in vivo applications.

We have developed a laser-pulse mammograph capable of recording optical mammograms within approximately 3 min by measuring time-resolved transmittance at each of typically 1500 scan positions, 2.5 mm apart. As a first application two patients who have tumors were investigated successfully. From measured distributions of times of flight of photons corrected for edge effects we derived (1) characteristic quantities, such as photon counts in selected time windows, to generate optical mammograms; (2) effective transport scattering and absorption coefficients of breast tissue at each scan position, assuming the breast to be homogeneous; and (3) optical properties of a selected tumor by applying the theory of diffraction of photon density waves by spherical inhomogeneity. Mammograms recorded at different lateral offsets between source and detector fiber were used to estimate the depth of inhomogeneities.

Advanced small cell pancreatic cancer: relevance of laparoscopic staging.

Small cell pancreatic cancer is a rare pancreatic malignancy. Thus, it offers substantial therapeutic perspectives. As demonstrated in this case, surgical laparoscopy might not only be used for staging in resectable pancreatic cancers but also in advanced cases for adequate tissue sampling and rapid diagnosis.