[Extranodal manifestation of classical Hodgkin lymphoma in the head and neck region]. / Extranodale Manifestation klassischer Hodgkin-Lymphome im HNO-Bereich.

BACKGROUND: Extranodal lymphomas occurring in the head and neck region account for 12-15% of all malignant tumors of this locality. Classical Hodgkin lymphoma (cHL) is a rare subtype, representing around 1% of all lymphomas in Waldeyer's ring. Cases diagnosed in the Reference Centre for Lymph Node Pathology at the Pathological Institute of the University of Würzburg were further analyzed in this study. MATERIALS AND METHODS: Histological subtype and EBV association of 21 cases were reviewed in conjunction with clinical data. RESULTS: Data of 12 male and 9 female patients with an average age of 51 years (median 45; 35-72) were reviewed. All samples were taken from the lymphatic tissue of the Waldeyer's ring (nasopharynx n = 15, palatine tonsils n = 5, lingual tonsils n = 1). The most common symptoms leading to a consultation with an otorhinolaryngologist were otalgia, swelling, or impaired nasal breathing. Only four patients showed typical B­symptoms. In 6 cases (29%), an isolated extranodal manifestation was found, 15 patients (71%) showed simultaneous infiltration of cervical lymph nodes during staging, and 6 cases (29%) were EBV positive. CONCLUSION: An exclusively extranodal manifestation of cHL in Waldeyer's ring is rare, whereas infiltration of extranodal tissue in the case of a primary manifestation of lymphoma in cervical nodes can occur more frequently and may often remain undiagnosed. Therefore, a specialized ENT consultation could be a reasonable complementary module in tumor staging to determine the correct tumor extent.

[Ten years of telepathology for a mission hospital in Tanzania]. / 10 Jahre Telepathologie für ein Missionskrankenhaus in Tansania.

BACKGROUND: A collaboration between a hospital in Tanzania and a German institute for pathology was initiated in 2007 with the aim of establishing a working telepathological connection using the internet-based platform iPath to transmit static histological images. OBJECTIVES: This study aimed to describe the diagnostic spectrum evaluated in the course of an aid project in a developing country in Africa. MATERIAL AND METHODS: A total of 5230 diagnoses were analyzed, including cases that could only be definitively concluded after a second analysis of the paraffin-embedded material in Germany. The most frequent diagnoses in the five largest diagnostic groups from 17 different anatomical locations were surveyed. In addition, cases sampled from children/young adults and rare diagnoses were assessed separately. RESULTS: Altogether we diagnosed 2934 (56.1%) benign and 2134 (40.8%) malignant diseases. The number of cases sent to Germany for a second opinion was 734 (14%). The five most common anatomical locations were the uterine cervix (n = 1211), the prostate (n = 728), skin (n = 626), breast (n = 524), and lymph nodes (n = 340). Children comprised 504 cases (9.6%). Typical tropical diseases were only rarely seen in the whole collective of cases. CONCLUSIONS: By means of telepathology histopathological diagnoses can be supplied in a short period of time. Difficulties occurred mainly due to the unstable staff situation on site and because the quality of sampled biopsy material was not always sufficient for further investigations. Furthermore, it became clear in the course of this aid project that a predominance of standard diagnostic findings routinely seen in the pathology of tumors and infections can be anticipated rather than exotic diseases.

[Multiple carcinoids in the midgut causing intestinal gangrene--a case report]. / Intestinale Gangrän bei multiplem Karzinoidbefall des Dünndarms--Fallbericht.

CASE REPORT: We report the case of multiple midgut carcinoids causing segmental intestinal ischaemia in a 77-year-old man. He was admitted to our hospital because of a 2-month history of postprandial abdominal pain with nausea / vomiting and anaemia. The extensive diagnostic examinations (blood tests, ultrasound, computed tomography, hydro magnetic resonance) did not reveal any pathological findings. The small-bowel capsule endoscopy demonstrated multiple areas of bleeding. A laparotomy showed a local ischaemia of the small bowel, a segmental resection of the jejunum / ileum was performed. There were no signs of occlusion of the mesenteric artery. The pathological examination revealed 8 carcinoids of the midgut (jejunum / ileum). Immune histology demonstrated serotonin-synaptophysin-chromogranin-producing carcinoids. The patient was re-operated because of suspected ongoing mesenteric ischaemia, but no further pathologies were found. The postoperative course was uneventful. A subsequent octreotide scan was negative for metastases. DISCUSSION: Carcinoids may become symptomatic mimicking intestinal ischaemia. Although this coincidence is considered to be typical, it is still a rare event. The diagnosis is often delayed. EVS ("elastic vascular sclerosis") of the mesenteric artery is pathognomonic for these carcinoids but, as our case demonstrates, not mandatory. According to the literature, the stage of the disease corresponds to the extent of the intestinal ischaemia.

[Middle ear adenoma/middle ear carcinoid--an unproblematic tumor?]. / Mittelohradenom/Mittelohrkarzinoid--ein unproblematischer Tumor?

OBJECTIVES: Adenomas/carcinoid tumors of the middle ear are very rare tumors of young to middle aged patients. The terms adenoma and carcinoid tumor of the middle ear can be used as synonyms, with the WHO favouring the term middle ear adenoma (MEA). These tumors usually present with unspecific clinical symptoms and a long case history. They are classified as benign tumors with only very few reported cases of regional metastasis after years of disease. According to recent literature, the clinical course is usually uncomplicated with complete surgical excision being adequate therapy. METHODS AND PATIENTS: This study describes the clinical course and the diagnostic challenges in four cases of this rare tumor entity. RESULTS: The selected patients (2 males, 2 females, 25-38 years old) showed very similar clinical findings with decreased hearing acuity, tinnitus and sometimes pain. After the primary surgical excision up to 10 further operations were necessary, this being in contrast to the usual clinical course as described in the literature. In two cases a tumor recurrence was documented with one case recurring six times. In this case adjuvant radiotherapy (70 Gy) was performed. The histological differential diagnosis can also be problematic; in one case with a highly atypical morphology it was impossible to arrive at a definite diagnosis during the analysis of a frozen section. CONCLUSION: Adenomas of the middle ear can have a much more complicated clinical course than is suggested by the recent literature. The presented cases in this study and the analysis of previously published cases shows that the typical progression described by the current WHO-classification with unproblematic surgical management of the tumor and an uncomplicated further clinical course does not always correspond to reality. The main reason for this is the difficulty in obtaining a complete surgical excision. Therefore, a well-planned and comprehensive surgical management with a high frequency of follow-up examinations should be chosen. In complicated individual cases adjuvant radiotherapy can be helpful.

[Predictors of nodal metastasising in laryngeal squamous cell carcinomas as decision support for neck dissection: comprehensive analysis of literature]. / Prädiktoren der nodalen Metastasierung des Larynxkarzinoms als Entscheidungshilfe bei der Neck Dissection: Literaturanalyse zur Frage zuverlässiger Parameter.

BACKGROUND: A subset of advanced laryngeal squamous cell carcinomas (SCC) does not metastasize in regional lymph nodes (pN0). However, more than 30 % of tumors without signs of metastasizing in the clinical examination (cN0) show occult metastases. The guidelines of the German ENT-Society intend the extent of neck dissection (ND) depending on clinical stage of tumor and lymph nodes. If laryngeal surgery is followed by an adjuvant radiation/chemotherapy, ND is not always necessary. Histomorphological, immunohistochemical, or molecular parameters with predictive value for nodal metastasizing could support the planning for ND, especially in patients with cN0. METHODS: Within the last 20 years there were many publications concerning this problem. Herein, we analyzed the results of 455 publications. We have chosen studies regarding the predictive value of tumor stage, grading, peritumorous inflammation, invasion of lymphatic vessels, angioneogenesis, proliferation, overexpression of p53 or cyclin D1, inhibitors of cyclin-dependent kinases, growth factors, apoptosis, cell-adhesion, nm23, metalloproteinases, DNA/ploidy as well as tumor genetics. RESULTS: All examined parameters did not allow a fail-safe prediction of the risk for nodal metastasizing. CONCLUSIONS: Up to now, reliable predictors do not exist. The investigation of above mentioned parameters in pre-operative tumor biopsies is not helpful for the planning of ND in the stage cN0 (out of T1).

Increased expression of galectin-1 during the progression of cervical neoplasia.

Galectin-1, a member of the beta-galactoside-binding family, is widely expressed in epithelial and immune cells. It is involved in several normal and pathologic processes, such as cancer progression, metastasis, and immunobiology. Galectin-1 was found to be overexpressed in various cancer cells and the corresponding benign tissue. Therefore, it has been described as a marker for tumor progression in some malignancies. In the current study, the expression of galectin-1 was examined in 80 formalin-fixed, paraffin-embedded cervical tissues: 20 benign cervical specimen, 20 low-grade squamous intraepithelial lesions (LGSIL), 20 high-grade squamous intraepithelial lesions (HGSIL), and 20 invasive squamous cell carcinomas (ISCC). Immunohistochemical analyses showed that the intensity of the galectin-1 expression on stromal cells next to the transformed cells increased according to the pathologic grade: benign cervical tissue < LGSIL < HGSIL < ISCC (P < 0.001). The epithelial cells were always negative for galectin-1. These results suggest that galectin-1 expression on stromal cells increases with the histopathologic grade of cervical tissues, and it can be concluded that this increase is associated with the progression of cervical neoplasia.

[Interface pressure measurement in the treatment of pressure sores. Comparison with subcutaneous pressure values measured in healthy volunteers]. / Auflagedruckmessung in der Dekubitusbehandlung. Vergleich mit einer subkutanen Druckmessung an gesunden Probanden.

BACKGROUND: Pressure relief is an important factor to determine the quality of anti-decubitus devices. Many studies have been carried out to measure the interface pressure, but because the results differed markedly, we made a study to assess the measurement devices. METHODS: The systems FSA, a device for internal use in the Lück company, the X-Sensor and an invasive subcutaneous pressure measurement over the os-sacrum (COACH: piezoelectric probe, MIPM) were tested on 20 healthy volunteers (average age 27 years, average BMI 21.8). RESULTS: The values of interface measurement showed obvious deviations from subcutaneous pressure in two cases (FSA +1.8%, Lück -33%, X-Sensor +65%) and some results showed extreme variations (FSA +18 mmHg, Lück -21 mmHg, X-Sensor +27 mmHg). CONCLUSIONS: The interface pressure measurement (with a few volunteers) is not suitable for a correct assessment of anti-decubitus devices. Furthermore, the use of this method is not necessary to monitor pressure relief in intensive care patients. These systems can, however be useful in the training of nursing staff.

[Body stalk anomaly--a case report on a rare congenital defect]. / Body-Stalk-Anomalie (Syndrom der kurzen Nabelschnur)--Kasuistik einer seltenen Fehlbildung.

INTRODUCTION: A body stalk anomaly is a rare congenital defect. The anomaly is one of the anterior abdominal wall defects. It is characterized by severe clefts of the abdominal wall with absence of or very small, umbilical cord. CASE REPORT: We report on a patient in the 21st week of gestational age with the ultrasonographic findings of multiple fetal anomalies including a singular umbilical artery and an ahydramnion. She was sent to hospital for termination of the pregnancy. The karyotype was normal (46 XX). Ultrasonographic evaluation of the fetal anterior abdominal wall was impossible due to ahydramnion. Clinical examination showed an omphalocoele with herniation of the stomach, the small intestine, the liver and the spleen. A very short umbilical cord was observed which was attached to the omphalocoele. The lower limbs were deformed. Furthermore, anal atresia with an extroverted coele was found. Autopsy confirmed the clinical diagnosis of a body stalk anomaly. DISCUSSION: It is important to distinguish a body stalk anomaly from other types of anterior abdominal wall defects because of their prognosis and an appropriate medical management. A body stalk anomaly is a sporadic defect and not associated with chromosomal abnormalities. This congenital defect is invariably lethal.

[The importance of PET in searching the primary tumor site in CUP patients -- a case report]. / Bedeutung der PET bei der Primärtumorsuche beim CUP-Syndrom -- ein Fallbericht.

A 58 years old male patient presented with a left cervical metastasis of a poorly differentiated squamous cell carcinoma, which was diagnosed by fine needle aspiration cytology. Clinical examination, MRT scans and panendoscopy did not detect the primary tumour site. The positron emission tomography localized an uptake of FDG in the left sided base of the tongue. The patient underwent an ipsilateral modified radical neck dissection and a lateral pharyngotomy. In the left tongue base an induration was palpable which was resected with security distance. The histopathological examination showed a poorly differentiated squamous cell carcinoma with a largest extension of 5 mm x 10 mm.

Intramuscular pressure, tissue oxygenation and EMG fatigue measured during isometric fatigue-inducing contraction of the multifidus muscle.

Simultaneous measurement of intramuscular pressure (IMP), tissue oxygen partial pressure (pO(2)) and EMG fatigue parameters in the multifidus muscle during a fatigue-inducing sustained muscular contraction. The study investigated the following hypotheses: (1) Increases in IMP result in tissue hypoxia; (2) Tissue hypoxia is responsible for loss of function in the musculature. The nutrient supply to muscle during muscle contraction is still not fully understood. It is assumed that muscle contraction causes increased tissue pressure resulting in compromised perfusion and tissue hypoxia. This tissue hypoxia, in turn, leads to muscle fatigue and therefore to loss of function. To the authors' knowledge, no study has addressed IMP, pO(2) and EMG fatigue parameters in the same muscle to gain a deeper sight into muscle perfusion during contraction. As back muscles need to have a constant muscular tension to maintain trunk stability during stance and locomotion, muscle fatigue due to prolonged contraction-induced hypoxia could be an explanation for low back pain. Sixteen healthy subjects performed an isometric muscular contraction exercise at 60% of maximum force until the point of localized muscular fatigue. During this exercise, the individual changes of IMP, pO(2) and the median frequency (MF) of the surface EMG signal of the multifidus muscle were recorded simultaneously. In 12 subjects with a documented increase in intramuscular pressure, only five showed a decrease in tissue oxygen partial pressure, while this parameter remained unchanged in six other subjects and even increased in one. A fall in tissue pO(2) was associated with a drop in MF in only five subjects, while there was no correlation between these parameters in the other 11 subjects. To summarize, an increase in IMP correlated with a decrease in pO(2) and a drop in MF in only five out of 16 subjects. High intramuscular pressure values are not always associated with a hypoxia in muscle tissue. Tissue hypoxia is not automatically associated with a median frequency shift in the EMG signal's power spectrum.

[Acute compartment syndrome. Results of a clinico-experimental study of pressure and time limits for emergency fasciotomy]. / Das akute Kompartmentsyndrom. Ergebnisse einer klinisch-experimentellen Studie zu Druck- und Zeitgrenzwerten für die Notfallfasziotomie.

BACKGROUND: Acute compartment syndrome of the leg is to be regarded as a traumatological emergency. Most specialists already agree that only a timely operative decompression of the afflicted compartment can prevent serious tissue damage. What still remains subject to discussion, however, is the precise tissue pressure above which the operation becomes imperative. Experimental human studies focusing on tissue pressure and muscle oxygenation have not yet been carried out. It was thus the aim of the present study to analyze oxygen partial pressure of the anterior tibial muscle and peroneal action potential in a model compartment syndrome in man. METHODS: In 22 healthy, normotensive volunteers, constant pressure values from 0 to 100 mmHg were induced in the anterior tibial muscle with antishock trousers. Over a period of up to 6 h measurements were made of (1) tissue pressure, (2) intramuscular oxygen partial pressure (pO2), and (3) muscle response potential (MRP) of the n. peroneus profundus by electroneurography. RESULTS: We achieved a 97.7% (Q25%/Q75%: 89.2/99.8) transfer of the pneumatic pressure to the lower leg. Already at intramuscular tissue pressures of 30-40 mmHg, hypoxia and reduction of MRP appeared. A reduction of the MRP to zero and pO2 < 1 mmHg was observed from a pressure of 50 mmHg. Tissue pressure values of over 75 mmHg resulted almost without exception in anoxia of the muscle. CONCLUSIONS: Even under normal perfusion conditions, already slight increases in pressure of above 30 mmHg lead to reduced tissue oxygenation and neural function. We have to consider that with additionally traumatized muscle the ischemic tolerance is markedly reduced and due to unknown influences such as local vasoreactivity and capacity of autoregulation the nutritive perfusion cannot be determined. In the case of a severely injured muscle, to be on the safe side decompressive fasciotomy should therefore be carried out if pressure values remain above 30 mmHg.

[The effect of soft care mattresses on subcutaneous tissue pressure and pO2 over the os sacrum]. / Einfluss moderner Weichlagerungssysteme auf Druck und pO2 im subkutanen Weichteilgewebe über dem Os sacrum.

In this study the influence of soft-care systems on subcutaneous tissue pressure and pO2 has been examined. In 14 volunteers 3 probes were implanted over the os sacrum for measurement during the 20-minute periods. Then the probands were asked to lie on a standard mattress, on 8 static beds of various kind and on 3 dynamic soft-care systems. The clinical mattress pressure values amounted to 25.5 mm Hg (+/- 5.2; n = 14). The gell-cushion showed increased values (26.9 +/- 9.5 mm Hg; n = 5). Compared to the standard mattress the other systems showed reductions in pressure from 32.7% to 83.1%. The lowest pressure was recorded with an air-supported mattress (8.3 +/- 2.3 mm Hg; n = 5). The pO2 initial values before lying down varied greatly from individual to individual (26.9-71.3 mm Hg). In the course of the 20-minute periods the pO2 value sometimes remained constant, sometimes increased and at other times it decreased. Under extreme conditions (with 8 probands asked to lie on the floor) a correlation (r = -0.787) between pressure and pO2 was observed (pressure values between 20.6 and 192.9 mm Hg). The results indicate the use of modern soft-care systems depending on the individual risk of pressure sores.

[The significance of intracompartmental pressure values for the diagnosis of chronic functional compartment syndrome. A meta-analysis of research studies of pressures in anterior M. tibialis during exercise stress]. / Die Bedeutung intrakompartimenteller Druckwerte für die Diagnose des chronisch-funktionellen Kompartmentsyndroms. Eine Metaanalyse von Studien des Druckverlaufs im M. tibialis anterior während einer Ubungsbelastung.

INTRODUCTION: The chronic exertional compartment syndrome of the musculus tibialis anterior is thought to be responsible for a major part of complaints of the lower leg among active sportsmen. There is an important role of tissue pressure measurement in diagnosing chronic anterior compartment syndrome during muscular activity. However, there is a controversial debate about the relevant parameters. METHODS: Metaanalysis of all the 21 studies (1979-1998) measuring intracompartmental pressures during muscular activity. Parameters of analysis: type of exercise, catheter technique, recommendations of diagnostic criteria. RESULTS: Analysis of literature shows that there has been no standardisation concerning the type of muscular exertion (isometrics for 5-10 min, exercise on the treadmill between 3.2 and 12 km/h). In 8 of the 21 studies the results have been attained through the unsuitable Wick-catheter-technique. In the overall view none of the suggested criterions for diagnosis is taken up by other teams. There are considerable variations up to 500% regarding the recommended parameters. CONCLUSIONS: From all studies no uniform recommendation for parameters of diagnostic relevance can be derived. On this background it should be demanded that future research is conducted by a uniform regimen for examination and modern technique of measuring with a high temporal resolution. Under these standardised conditions the investigated parameters of the intracompartmental pressure curve should be reconsidered once more regarding diagnostic predictability by calculations of specifity and sensitivity.

[Decubitus ulcer. Basic treatment intervention is pressure unloading]. / Dekubitalulzera. Eckpfeiler der Behandlung ist die Druckentlastung.

With an incidence of between 3 and 34%, decubitus ulcers are common chronic wounds, many of which can be avoided by prophylactic measures. The most effective preventive measure is relieving pressure on the endangered part of the body, and this is most easily achieved by regularly changing the patient's position in bed. Since, however, this is not always possible for staff-shortage or illness-related (e.g. fractures of the spine) reasons, modern pressure-relieving systems are being increasingly used. The range of options extends from simple foam plastic underlays to water-filled cushions to pneumatic cushions or beds filled with tiny glass beads. Selection of the most appropriate system is often difficult. For effective prophylaxis, determination of the individual risk of developing a bedsore with the aid of special scales makes good sense. In this way, the measures required can be adapted to the particular needs of the individual patient. New approaches to decubitus ulcer prevention and wound management may help to ensure effective care of the endangered or affected patient.

[Reduced muscular oxygen tension and nerve impulse transmission from antishock hose. Reduction of oxygen tension in the tibial muscle and impulse transmission in the peroneal nerve from pneumatic -1 pressure from antishock hose]. / Muskuläre Sauerstoffspannung und nervale Impulsfortleitung bei Einsatz der Antischockhose. Verminderung der Sauerstoffspannung im M. tibialis anterior und Einschränkung der Impulsfortleitung im N. peronaeus profundus infolge pneumatischer Druckeinwirkung durch Antischockhose.

OBJECT OF THE STUDY: The aim of the study was to assess, whether the pneumatic pressure of an antishock-trouser (AST) of 20-40 mm Hg induces a decreased oxygenation of the anterior tibial muscle and attenuates muscular response potential (MRP) of n. peronaeus profundus? METHODS: Among 22 normotensive, healthy volunteers the AST were tested by applying pressure values between 0 and 100 mm Hg and measuring the intracompartmental pressure, the muscular oxygen pressure as well as the MRP by electroneurographic means within a period of 6 hours. RESULTS: The median initial intracompartmental pressure value of the m. tibialis anterior was 12.0 mm Hg (Q25%/Q75%: 8.9/17.3), the muscular oxygen pressure 14.8 mm Hg (Q25%/Q75%: 11.5/22.0). Transmission of the pneumatic AST-leg segment pressure to the muscle: 97.7% (Q25%/Q75%: 89.2/99.8). Already in the low AST pressure field (20-40 mm Hg) a severe hypoxia occurred in one case. A reduction of MRP was noticed at an AST pressure rate of 10 mm Hg. In 5 of 6 cases AST pressure values of 60 mm Hg led to pathological pO2-values within 5-20 minutes. Almost without exception AST-pressure rates < 60 mm Hg resulted in an anoxia of the muscle and loss of the MRP. CONCLUSIONS: We should demand that the AST are only applied with models where the pressure generated within the single segments can be controlled by pressure gauge. The application of the AST seems to be justified for polytraumatised in severe haemorrhagic shock where the risk of a local tissue ischemia with systemical consequences must deliberately be accepted.