[A mass in the popliteal fossa and leucocytosis caused by a paraneoplastic leukemoid reaction]. / Een massa in de knieholte en leukocytose door een paraneoplastische leukemoïde reactie.

A 65-year-old woman was referred with a mass in the right popliteal fossa, fever and leucocytosis reaching 105 x 10(9)/l. Her medical history included the excision of a melanoma from the right ankle more than 20 years before. Ultrasound, CT and positron-emission tomography showed the mass in the right knee but no other lesions. The process was drained. Histological examination ofa subcutis biopsy indicated malignancy. Due to deterioration in her clinical condition amputation of the right leg was performed after which her leucocyte count normalized. The pathology specimen revealed a high-grade undifferentiated soft tissue tumour of unclear origin. Preoperatively assessed serum levels of granulocyte-stimulating factor (G-CSF), interleukin 6 and interleukin 8 were elevated to 241, 91 and 82 pg/ml respectively. After the amputation these levels returned to almost normal. This extreme leucocyte count may be explained by a paraneoplastic leukemoid reaction. It is hypothesized that the tumour cells produce G-CSF and other cytokines causing leucocytosis. Normalisation of the cytokine levels postoperatively supports this hypothesis.

[Diagnostic image (306). A man with a painful inguinal swelling]. / Diagnose in beeld (306). Een man met een pijnlijke zwelling in de lies.

A 45-year-old man presented with an acute painful swelling in the right groin due to an incarcerated Meckel's diverticulum in an inguinal hernia: Littré's hernia.

The fate of mechanically induced cartilage in an unloaded environment.

According to mechanobiologic theories, persistent intermittent mechanical stimulation is required to maintain differentiated cartilage. In a rat model for bone repair, we studied the fate of mechanically induced cartilage after unloading. In three groups of rats, regenerating mesenchymal tissue was submitted to different loading conditions in bone chambers. Two groups were immediately killed after loading periods of 3 or 6 weeks (the 3-group and the 6-group). The third group was loaded for 3 weeks and then kept unloaded for another 3 weeks (the (3 + 3)-group). Cartilage was found in all loaded groups. Without loading, cartilage does not appear in this model. In the 3-group there was no clear ongoing endochondral ossification, the 6-group showed ossification in 2 out of 5 cartilage containing specimens, and in the (3 + 3)-group all cartilage was undergoing ossification. These results suggest a tendency of the cartilage to be maintained also under unloaded conditions until it is reached by bone that can replace it through endochondral ossification.Additional measurements showed less amount of new bone in the loaded specimens. In most of the loaded specimens in the 3-group, necrotic bone fragments were seen embedded in the fibrous tissue layer close to the loading piston, indicating that bone tissue had been resorbed due to the hydrostatic compressive load. In some specimens, a continuous cartilage layer covered the end of the specimen and seemed to protect the underlying bone from pressure-induced resorption. We suggest that one of the functions of the cartilage forming in the compressive loaded parts of a bone callus is to protect the surrounding bone callus from pressure-induced fluid flow leading to resorption.

[The HITT syndrome: heparin-induced thrombocytopenia and thrombosis as a cause of paradoxically occurring thromboembolisms]. / Het HITT-syndroom: door heparine geïnduceerde trombocytopenie en trombose, als oorzaak van paradoxaal optredende trombo-embolieën.

Heparin since the early sixties has played an important part in prevention and treatment of thromboembolic processes. It has hardly any side effects like allergic reactions but haemorrhage is seen more frequently. A less well-known complication is so-called heparin-induced thrombocytopenia and thrombosis (HITT). There are two different forms: a mild thrombocytopenia, characterised by a decrease in platelet count to 100-150 x 10(9)/l. This form causes no clinical symptoms. The more severe form occurs between the 7th and the 11th day after heparin administration and is characterised by paradoxically occurring thromboembolic complications. This syndrome results from formation of an antigen-antibody complex. If heparin has been administered in the past patients may develop this severe form at the moment of renewed administration. In our hospital during the past 8 years we observed 9 patients with the HITT syndrome presenting with thromboembolic complications. A thrombocyte aggregation test is diagnostically useful. Heparin-free plasma of the patient is mixed with donor thrombocytes, and heparin is added; in the HITT syndrome aggregation occurs. The main therapy is stopping the heparin administration and giving antiaggregants such as dextrans.

Herniation of the stomach into the pericardial sac combined with cardiac luxation caused by blunt trauma: a case report.

Cardiac luxation caused by blunt thoracic trauma carries a high mortality rate. We present a case of traumatic diaphragmatic rupture, in combination with herniation of the stomach into the pericardial sac, pericardial rupture, and cardiac luxation. The recent literature is reviewed and diagnostic difficulties and procedures are discussed.

Cryosurgery for locally recurrent rectal cancer.

Locally recurrent rectal cancer is, in most cases, unresectable and incurable. Palliative treatment is warranted in many cases because of the presence of severe distressing symptoms. In recurrent disease, intraluminal cryotherapy is an option for palliation. Twenty patients with local recurrence after anterior resection were treated palliatively with cryosurgery for their local symptoms. Six patients had previously had a colostomy before they were referred for palliative treatment. Thirteen patients had more than one symptom. Distant metastases were present in ten cases. The beneficial effect of cryosurgery was evident after two to three sessions. In nine patients cryotherapy achieved complete relief of local symptoms. In these patients the symptom free interval varied from 1 to 24 months (median 11 months); five patients died of disease without local symptoms. Three of these nine patients underwent a bowel diversion at a later stage because of complete stenosis. The number of treatment sessions in this group of patients varied from three to 14. The palliative index varied from 37 to 100% (mean 78%). In nine patients cryotherapy of the local recurrence gave no relief at all. Our results show that in almost half of the patients cryosurgery can palliate local complaints resulting from recurrent tumor growth after anterior resection.

Organ blood flow in Fischer-344 rats bearing MCA-induced sarcoma.

Although blood flow is central to systemic metabolism, little is known about the effect of tumor on the perfusion of host tissues. This study evaluated the effects of a methylcholanthrene-induced sarcoma on blood flow to intra-abdominal organs and skeletal muscle of Fischer-344 rats anesthetized with pentobarbital sodium. Animals were studied by aortic injection of radiolabeled microspheres when the tumors reached 20% of body weight. Total-organ arterial flows in spleen, liver, small intestine, and pancreas were each increased to 50-150% in tumor bearers relative to controls (P less than 0.05). Portal venous flow and flow per gram to hindlimb muscle were 60 +/- 20 and 300 +/- 100% greater, respectively, in tumor-bearing animals (P less than 0.005). This study shows that tumor growth can be associated with large changes in organ flow and distribution of cardiac output. The increase in skeletal muscle flow in the tumor bearers, which lost normal tissue weight relative to pair-fed controls (P less than 0.05), is in marked contrast to decreased muscle flow previously observed in simple starvation.

Evaluation of palliative surgical procedures in unresectable pancreatic cancer.

To update our experience with palliative surgical procedures in unresectable adenocarcinoma of the pancreas, the records of 297 patients surgically treated at Memorial Sloan-Kettering Cancer Center were reviewed. Between October 1983 and November 1989, 117 patients underwent exploratory laparotomy as a single procedure: 24 patients had gastric bypass, 38 biliary bypass, and 118 both gastric and biliary bypass. The postoperative in-hospital mortality rate was 4.4 per cent. Overall morbidity was 29.7 per cent; the morbidity rate in patients with a double bypass was 29.7 per cent. Median (s.e.m.) survival was 231(20.3) days. Statistical analysis showed a significantly increased risk of morbidity in patients who underwent one therapeutic and one prophylactic bypass. Survival was decreased in patients who had a therapeutic gastric bypass (median(s.e.m.) survival 136(70.2) days) or a combination of two therapeutic bypasses (median(s.e.m.) survival 93(85.9) days). These data emphasize the poor prognosis of patients with pancreatic adenocarcinoma who cannot be resected. The need for therapeutic double bypass is a bad prognostic indicator, and a prophylactic bypass added to a therapeutic bypass increases morbidity without prolonging survival.

Solitary hamartoma of the lung: is thoracotomy still mandatory?

Solitary pulmonary hamartomas are the most common benign tumors of the lung, and have to be distinguished from primary or secondary malignant pulmonary lesions. The data of 20 patients operated for a solitary hamartoma of the lung are presented with special attention to the diagnostic methods which can contribute to the diagnosis. To avoid a surgical procedure, CT-densitometry and fine-needle aspiration biopsy have become of major interest for the diagnosis of hamartoma. Using in succession chest X-rays, CT-densitometry and fine-needle aspiration biopsy, a conservative approach can be advised in specific cases. However, exploratory thoracotomy is mandatory when a patient presents with a solitary pulmonary lesion of more than 2.5 cm or when the lesion shows a tendency to grow.

[The treatment of rectal carcinoma in the elderly patient. Is there room for local treatment?]. / De behandeling van het rectumcarcinoom bij de bejaarde patiënt. Is er een plaats voor lokale behandeling?

The treatment of choice for low rectal carcinoma is an abdominal perineal excision of the rectum or an anterior resection. These surgical procedures have a significant morbidity and mortality, especially in elderly patients. An abdominal perineal excision of the rectum requires a permanent colostomy. In elderly and so called high risk patients local treatment is an attractive alternative. For many years local excision electrocoagulation, contact irradiation and cryotherapy have been well known local treatment modalities. Indications for and results of the various methods of local treatment are discussed.

[Cryotherapy of rectal tumors in the elderly patient]. / Cryotherapie van rectumtumoren bij de bejaarde patiënt.

Until now 29 patients (older than 70 years of age) have been treated by cryotherapy for a rectal carcinoma. In 8 patients the tumour disappeared while in 14 good palliation was achieved. Small tumours of the rectal wall can be treated curatively by cryotherapy. In larger tumours local symptoms can be diminished avoiding a permanent colostomy. Complications due to cryotherapy are rare.

[Developments within the university scientific staff]. / Ontwikkelingen binnen het universitair wetenschappelijk personeel.

The Faculty in Dutch Universities grew considerably during the period from 1959 to 1973; among other thing this increase resulted in a very extensive recruitment of new members of this professional group. The Faculty had a dominating influence on this process of recruitment; the author did research on the mechanisms (which were highly functional in this situation) that were developed by the Faculty, and some of their effects are examined in detail. Based upon the study of the Dutch Faculty and its development in the past, a number of notes regarding recent government measures, designed to alter the cost and personnel structure, are included and some suggestions are made concerning improvements.