Detection of lymphatic invasion in early stage primary colorectal cancer with the monoclonal antibody D2-40.

PURPOSE: The purpose of this study was to investigate the presence of lymphatic invasion detected by D2-40 immunostaining compared to conventional hematoxylin-eosin (HE) staining in primary colorectal cancer (CRC) and the development of focal new lymphangiogenesis and peritumoral lymphatic proliferation in relation to the tumor stages. Additionally, we analyzed the relation of peritumoral inflammatory reaction (PIR) to tumor stages in CRC. The identification of new categories of patients with high-risk CRC would be very helpful in improving treatment strategies and patient outcome especially in early CRC. PATIENTS AND METHOD: Biopsies were taken from 41 patients with colorectal adenocarcinomas at different stages of disease. Immunohistochemistry was performed on paraffin-embedded sections. First, the whole section was screened for the presence of lymphatic invasion and PIR with routine HE staining. After analysis of the HE-stained slides, the slides were destained and reused for immunohistochemistry with the D2-40 monoclonal antibody. D2-40-immunostained sections were screened for the presence of lymphatic invasion, the proliferation of lymphatic vessels and focally newly developed lymph vessels. RESULTS: Using the D2-40 antibody for immunostaining, our results demonstrate a significantly higher detection (p < 0.05) of lymphatic vessel invasion compared to routine HE staining in primary CRC. 22% more patients with lymphatic vessel invasion could be identified compared to routine HE staining, especially in node-negative tumor stage (UICC II). The positive predictive value of lymphatic invasion evaluated by D2-40 immunostaining to predict lymph node metastasis is 92% (negative predictive value 81%). High PIR was shown in UICC stage I and II. These infiltrations were rarely seen in UICC stage III and were absent in UICC stage IV. Higher UICC tumor stage is associated with a higher rate of focally newly developed lymphatic vessels. In UICC stage I we found peritumoral lymphatic vessel proliferation only in one case (14%) and in UICC stage II no case was found. 47% of the cases in UICC stage III and 50% of the cases in UICC stage IV showed focal peritumoral lymphatic vessel proliferation. CONCLUSIONS: Immunostaining with D2-40 significantly increased the detection rate of lymphatic invasion compared to conventional HE staining in primary CRC. The D2-40 antibody specific for lymphatic endothelium cells has the potential for a prognostic marker in early stage CRC. Further prospective studies are necessary to evaluate the prognostic value of lymphatic invasion and the induction of tumor lymphangiogenesis and its role in human cancer progression.

Human recombinant EGF protein delivered by a biodegradable cell transplantation system.

We have previously shown a new approach to expand cultured human keratinocytes and reconstitute the epidermis in full-thickness wounds using a new microsperical transport system. This was a new approach to increase the cell yield for seeding without altering the anchoring proteins by enzymatic steps. That time we used Cytodex 3 which failed to be degraded and induced an inflammatory reaction in a t-cell-deficient organism. Therefore, we have investigated another microcarrier consisting of PLGA, which is a well-known carrier material for cell culture and transplantation. After coating the PLGA carrier with gelatine the seeding time of viable cells reached 4 h and the cell gain after 7 days of spinner culture was 16-fold. At 14 days after transplantation, we could detect a new stratified epithelium in our full-thickness wound healing model. Because cytokines play a major role in wound healing, we loaded this carrier material with different concentrations of rhEGF, showing a dose dependent release of the protein in vitro and in vivo. This result might lead to a different approach in the treatment of wounds.

Plasmid gene delivery to human keratinocytes through a fibrin-mediated transfection system.

We have developed a matrix-mediated transfection system to deliver plasmids to human keratinocytes. The matrix is a soluble, self-hardening fibrin matrix (Tissucol), Baxter) that has been used clinically. Recently it has been shown that full thickness burn wounds can be successfully treated with a keratinocyte fibrin glue suspension. Further, it has been demonstrated that hEGF transfected cells accelerate wound healing. In this study, we inoculated the matrix with the hEGF expression plasmid and resuspended the matrix with either cultured or noncultured human keratinocytes. We obtained successful transfection rates of these cells (up to a 100-fold increase compared to controls containing no EGF expression plasmid) in vitro. After transplantation to full thickness wounds on athymic mice we were able to show a 180-fold increase in EGF concentration compared to controls, which persisted over the entire 7-day monitored period, decreasing from 180 to 20 pg/mL at day seven. This unique approach indicates the possible utility to combine a matrix for cell transplantation with a transfection system to release therapeutic proteins in vitro and in vivo.

[Minimally invasive surgical therapy of gynecomastia: liposuction and exeresis technique]. / Minimal-invasive, chirurgische Therapie der Gynäkomastie. Liposuktion und Exhäresetechnik.

INTRODUCTION: A number of techniques are available for the correction of gynecomastia. Nonscarring sparing methods are preferred, and the minimally invasive technique is to use liposuction for the gland and the fatty tissue exclusively. In this retrospective study we present our experience with a combination of liposuction and subsequent resection of the remaining gland. METHODS: Sixty-two patients (112 breasts) were surgically treated for gynecomastia from January 1996 and September 2000. From 1996 to 1997 all patients suffering from gynecomastia grade Simon I-II were treated by the method described by Rosenberg and Stark, which is exclusively suction of the fatty and glandular tissue. In a retrospective chart study a high recurrence rate was found in these patients. Subsequently we changed our technique to liposuction of the fatty tissue followed by sharp excision of the glandular tissue through the incision made for the liposuction cannula in the submammary fold. RESULTS: Suction alone was not sufficient to remove the glandular tissue; the rate of recurrence after suction was 35%. When sharp resection of the glandular tissue was carried out after the liposuction the recurrence rate dropped to under 10%. In total our complication rate was 50% including minor sequelae. The most frequent complication was unacceptable scarring of the nipple-areola complex. Hypesthesia of the nipple-areola occurred in 13.4% of the patients. CONCLUSION: The combination of liposuction and resection of the glandular tissue is a minimally invasive correction that can be used in all cases of gynecomastia grade Simon I-II.

Management of hypovascularized wounds not responding to conventional therapy by means of free muscle transplantation.

BACKGROUND: Chronic ulceration as a complication of arteriosclerotic disease, venous congestion or diabetes mellitus is still a serious clinical problem, resulting in immobilization, extended hospitalization and cost-intensive treatment. Other than standard conservative treatment protocols or early amputation, microsurgical free transfer of well vascularized muscle tissue onto chronic wounds can induce angiogenesis and improve wound healing even in the hypovascularized wound. PATIENTS: From 1993-1999 we treated 12 patients (mean age: 46 years) with vascular ulcers of the lower extremity with free muscle or fasciocutaneous tissue transfer. RESULTS: The average hospitalization was 51.4 days. The perioperative mortality was zero. In one patient with factor V deficiency a partial flap necrosis occurred. Two revisions of the micro anastomoses had to be performed. Two seromas occurred at the donor site. No secondary flap loss was observed. Extremity or stump length preservation was achieved in all cases. CONCLUSIONS: Optimal postoperative treatment with physiotherapy and orthopaedic shoe support is important. If all these factors are present and if the patient is highly motivated a reintegration into normal life can be achieved.

Tissue engineering in plastic reconstructive surgery.

Tissue engineering (TE) is a new interdisciplinary field of applied research combining engineering and biosciences together with clinical application, mainly in surgical specialities, to develop living substitutes for tissues and organs. Tissue engineering approaches can be categorized into substitutive approaches, where the aim is the ex vivo construction of a living tissue or organ similar to a transplant, vs. histioconductive or histioinductive concepts in vivo. The main successful approaches in developing tissue substitutes to date have been progresses in the understanding of cell-cell interactions, the selection of appropriate matrices (cell-matrix interaction) and chemical signalling (cytokines, growth factors) for stimulation of cell proliferation and migration within a tissue-engineered construct. So far virtually all mammalian cells can be cultured under specific culture conditions and in tissue specific matrices. Future progress in cell biology may permit the use of pluripotent stem cells for TE. The blueprint for tissue differentiation is the genome: for this it is reasonable to combine tissue engineering with gene therapy. The key to the progress of tissue engineering is an understanding between basic scientists, biochemical engineers, clinicians, and industry.

Effect of ultrasonic assisted lipectomy (UAL) on breast tissue: histological findings.

As the use of ultrasound-assisted liposuction (UAL) increases, the technique grows more popular in breast surgery, especially in reduction mammaplasty and treatment of gynecomastia. The aim of our study was to investigate the effect of UAL on breast tissue using histological examinations, and analyze the effect of this technique on a cellular level. Biopsies from 10 patients undergoing ultrasonically assisted lipectomy prior to classic reduction mammaplasty were taken from the treated areas of the breast. Biopsies were fixed in formalin and embedded in paraffin. Sections were stained with hematoxilin-eosin, and analyzed for defective adipocytes, and the effects of UAL on breast tissue. Untreated breast tissue and breast tissue that had been treated only with conventional aspiration lipectomy served as controls. Sections were analyzed using light microscopy. Compared to the breast tissue treated only with conventional lipectomy, a stronger destruction of the cellular structure of adipocytes could be detected. The destruction was visible even in areas more distant from the aspiration channel. In contrast, the breast tissue was mostly intact, no signs of ultrasonic-induced cellular destruction were visible. The glandular structure was kept intact. Beside the direct mechanical destruction by the probe and the canula, no further alterations of the cellular integrity of the glandular parts were visible. In conclusion our results indicates that UAL is also a safe technique for use in breast surgery. Besides easy handling and improved modelling, the destructive effect of the ultrasound does not include the glandular breast tissue.

[Reconstruction of abdominal-wall midline defects--The Abdominal-Wall Components Separation]. / Rekonstruktion von Mittelliniendefekten - Die Bauchwand-Komponentenseparation -

AIM OF THE STUDY: The recurrence rate of midline defects like incisional hernias is high. Alloplastic material in sublay or onlay technique is often be used if the suture tension is to high for a primary closure. Free or pedicled musculocutaneous flaps transfer denervated muscle and lack dynamic resistance against the intraabdominal pressure. The separation of the lateral abdominal wall achieves autogenous, dynamic material for a tension free closure in small and moderate midline defects. METHODS: In 1990 Ramirez described a technique, which separates parts of the lateral abdominal wall and advances it towards the midline. The innervation and blood supply of the advanced part is maintained. With this technique it is possible to close defects tension free with dynamic abdominal wall. 9 patients were treated with this technique and followed up. RESULTS: Midline defects up to 16 cm at the waistline could be closed without tension. There were no major complications (one small delayed wound healing). There were no recurrences in a follow up time of 14.2 months. CONCLUSION: The separation of parts of the lateral abdominal wall can achieve tension free closure of e.g. incisional hernias of small and moderate size. The advancement of the medial component provides well innervated muscle for dynamic resistance against the abdominal pressure.

[An uncommon form of gastric rupture in giant scrotal hernia]. / Eine ungewöhnliche Form der Magenruptur bei riesiger Skrotalhernie.

The spontaneous gastric rupture without a preexisting gastric ulcer is an extremely rare event. In the case presented we report the occurrence of a gastric rupture in context with a giant left scrotal hernia. The entire intestine was transposed into the hernial sack and this obviously led to a chronic distension of the stomach and finally to the spontaneous gastric rupture. Other reasons of a spontaneous gastric rupture as well as the surgical therapy are discussed. Important are a fast diagnosis and surgical revision in order to prevent patients from a massive diffuse peritonitis.

[Gene therapy perspectives in modulation of wound healing]. / Gentherapeutische Perspektiven zur Modulation der Wundheilung.

A variety of reasons can afflict wound healing. Current research is focussed on the acceleration of wound healing by stimulating molecular processes. Gene therapy may offer completely new ways to treat chronic wounds. Possible advantages of gene therapeutic modulation of wound healing might be a long term efficiency, systemic or local regulation of gene expression and low side-effects. Current goals comprise the improvement of transfection efficiency and specificity. In vivo applications are therefore focussed on optimized inducible or even cell-type specific promotors, as well as on improved local application techniques. Studies from our laboratory demonstrate the possibility to combine modern cell culture techniques with different types of gene transfer. This enables the simultaneous grafting of manipulated cells to the wound with the continuous delivery of specific proteins of interest. Experimentally, this lead to accelerated closure of partial and full thickness animal wounds. Clinically, gene therapy for the treatment of chronic wounds seems to be a realistic goal within the next years and might be applicable for a variety of novel indications.

Hemangiosarcoma of the left hand in a patient with the rare combination of Maffucci's and Stewart Treves syndrome.

We describe a patient with the previously unseen combination of Maffucci's and Stewart Treves syndrome who presented with an angiosarcoma of the hand. Maffucci's syndrome is characterized by the presence of multiple enchondroma and soft tissue hemangioma. The syndrome is a rare nonhereditary condition with a usual onset in childhood. Malignant transformations are a common feature of this syndrome. In 1948, Stewart and Treves first described six cases of lymphangiosarcoma after radical mastectomy. This syndrome is an unusual form of angiosarcoma occuring as a complication of lymphedema. Chronic lymphedema and lymphangiectasia preceding lymphangiosarcoma may not only be induced by radical mastectomy with axillary lymph node dissection and postoperative radiation therapy. Posttraumatic, congenital or spontaneous chronic lymphedema may also be associated with lymphangiosarcoma. A time interval of many years seems to be required before malignant transformation develops. Generally the syndrome has a very poor prognosis. Both syndromes described above are of a rare frequency. We report this case because of prior unknown coincidence of both syndromes.

[Free microsurgical flap-plasty in reconstructive therapy of diabetic foot ulcer]. / Freie mikrochirurgische Lappenplastiken in der rekonstruktiven Therapie des diabetischen Fussulkus.

The diabetic foot ulcer is a significant clinical problem often resulting in frustranous conservative treatment or early amputation. In certain cases transfer of well vascularized tissue can improve wound healing and lead to a length-spearing therapy. In this study the concept of microsurgical tissue transfer in the treatment of diabetic foot ulcers is introduced. Following a radical debridement and, if necessary a atypical length-spearing amputation the wound is covered by a free transplanted muscle flap followed by a split-thickness skin graft. In six patients treated with this procedure the extremity could be saved. The perioperative mortality was 0%, average hospitalization was 47.6 days. One flap was lost, two vascular revision were necessary. Several necrectomies and skin grafts were performed and one donor side seroma was drained. One hernia was observed after free rectus abdominus transfer. Compared to conservative treatment or amputation this concept leads to a length-spearing therapy and can increase success rates of rehabilitation and quality of life.

[Keratinocyte transplantation and tissue engineering. New approaches in treatment of chronic wounds]. / Keratinozytentransplantation und Tissue Engineering. Neue Ansätze in der Behandlung chronischer Wunden.

Cultured keratinocytes have been used for the treatment of extensive burns since disease lethality is reduced. Consequently, the treatment of chronic wounds with keratinocytes may be promising. Cell culture technology allows to expand keratinocytes up to 6000-fold in vitro after taking a single biopsy from patient. Today the transplantation of these in vitro cultured keratinocytes in different modifications is an established clinical treatment regimen for therapy of extensive wounds. For example, keratinocyte-fibrin-glue-suspensions, mainly consisting of proliferative epidermal basal cells, were used for the treatment of burns in experimental and clinical settings to bypass the disadvantages of conventional sheet grafts. Other approaches in tissue engineering for wound healing aim at the (epi-)dermal repair by the combination of allodermis and biomaterials, i.e. collagen-sponges and microspheres. Due to most recent efforts in keratinocyte culture techniques, developments in tissue engineering, research for novel biomaterials and gene therapy, therapy of chronic wounds may prove to be more efficient. Furthermore, from the socio-economical point of view, overall costs for treatment of chronic wounds could be reduced.

Infiltration of tumescent anesthetic solution by a modified wound irrigation system.

An easily set-up, efficient infiltration system for subcutaneous infiltration of tumescent anesthetic solution is presented. It can be constructed from parts of a wound irrigation system usually available in surgical units. Thereby it is an economical means of precise and convenient infiltration procedures.

Leukocytes of the intestinal muscularis: their phenotype and isolation.

The basal presence of immunologically potent cells within the intestinal muscularis externa and their functional significance is unclear. Our aim was to investigate the basal distribution of various leukocyte populations within the rat jejunal muscularis. In addition, we sought to immunohistochemically phenotype the muscularis macrophage in jejunal whole-mounts, isolate these cells in primary culture, and investigate their ontogenesis. Macrophages form a regularly distributed network that expresses major histocompatibility complex class II, CD14 receptors, and a low level of CD11/CD18. The macrophages are activated by dissection and are present in fetal animals. Enriched macrophage cultures show a normal resident phenotype and remain present for weeks in dissociated muscularis cultures. The results also demonstrate the presence of neutrophils, monocytes, mast cells, and lymphocytes within the muscularis and suggest that the dense network of muscularis macrophages may be a potent resident trigger for inflammation in response to tissue injury or bacterial translocation.

[Surgically-induced angiogenesis as basic principle in treatment ov hypovascularized wounds--the nutritive flap]. / Chirurgisch induzierte Angiogenese als Grundlage der Behandlung hypovaskularisierter Wunden--der nutritive Lappen.

Chronic wounds of the lower extremity as a result of diabetes, arteriosclerosis and microangiopathy are of significant clinical relevance, as they result in immobilization, extended hospitalization and cost-intensive treatment. Via transfer of well-vascularized tissue onto chronic wounds as a free transplanted muscle flap, if necessary connected to a venous bypass, angiogenesis is induced and wound healing improved. This concept leads to nonamputational therapy.

[The free "emergency" rectus abdominis flap transfer for coverage of complex hand injuries]. / Der freie "Notfall"-rectus-abdominis-Transfer zur Defektdeckung bei komplexen Handverletzungen.

Standard local flaps may be insufficient to cover extensive soft tissue defects of the upper extremity. To prevent further damage of exposed vital structures, early microsurgical free-flap transfer may be necessary. The rectus abdominis free muscle flap is introduced as a new and reliable procedure for emergency coverage of upper limb defects.