Medium-term follow-up data after sentinel node biopsy alone for breast cancer.

AIMS: In patients with early breast cancer sentinel node biopsy (SNB) proved to be an accurate procedure for axillary staging with significantly reduced morbidity. Medium- and long-term observational studies are needed to establish, whether SNB alone is able to prevent locoregional recurrence without impairing long-term survival. METHODS: 298 patients with invasive breast cancer were subjected to SNB in a prospective audit. Lymphatic mapping was performed with blue dye and radiocolloids. 180 patients had SNB alone (group 1), while 118 subsequently underwent axillary dissection (AD; group 2). In ten patients AD was omitted despite the tumor burden in the SN. Clinical follow-up studies were performed at regular intervals. The mean follow-up time was 47months in group 1 (range 7-90) and 46months in group two (range 1-87months). RESULTS: Sentinel nodes were identified in 286 out of 298 patients (96%). One patient in group 1 developed axillary and simultaneous supraclavicular lymph node recurrence. After AD regional relapses have so far not been observed. One ipsilateral local recurrence was detected in each group. Five patients in group 1 and 15 patients in group 2 developed distant metastases. Three out of six and eight out of nine patients, respectively, died of their advanced disease. All patients with SN tumor infiltration not subjected to AD are alive and well. CONCLUSIONS: Axillary recurrence is rare after sentinel node biopsy alone. Its rate is comparable to that after AD, even in patients with SN micrometastases. These conclusions are confirmed by reports in the literature.

Updated results on intestinal neuronal dysplasia (IND B).

BACKGROUND: Intestinal neuronal dysplasia (IND B) is still a subject of controversy. The aim of this paper is to review the present state of knowledge on IND B. A summary is given of the technical and diagnostic criteria which have to be considered in order to arrive at a reliable diagnosis. In addition, the available therapeutic interventions are discussed. METHODS: Between 1992 and 2001, 3984 colonic mucosal biopsies from 1328 children were investigated. Nerve cell staining was performed on native tissue sections: 15 microm thick cryostat sections, which, after spreading and drying on a microscopic slide, have a final thickness of 4-5 microm, with dehydrogenase reactions (lactic dehydrogenase, nitroxide synthase, succinic dehydrogenase). The biopsies were taken 8-10 cm above the dentate line (proximal to the ampulla recti, because of the caudo-cranial increase of giant ganglia proximal to the 4 cm biopsy) with a sufficient amount of submucosa. The criteria for IND is 15-20 % submucosal giant ganglia with more than eight nerve cells in 30 sections of a single biopsy (i.e. four to seven giant ganglia). RESULTS: The diagnosis of IND B is quantitative. A diagnosis of IND B was made over the past 10 years in 51 Hirschsprung resections (about 5 per year; 6 % of all Hirschsprung cases), and in 92 children with chronic constipation (about 9 children per year; 2.3 % incidence). Up to their fourth year of life, most children with isolated IND can be treated conservatively. This is due to the delayed maturation of the enteric nervous system which is characteristic of IND B. Only children who showed an additional hypoplastic hypoganglionosis were treated surgically. Children with Hirschsprung's disease (HD) and IND B proximal to the aganglionosis often showed, in those cases with a disseminated IND, postoperative disturbances in intestinal motility. CONCLUSION: The diagnosis of IND B requires that biopsies are taken proximal to the ampulla recti (about 8-10 cm above the dentate line) with a sufficient amount of submucosa. The biopsies must be cut rectangular to the surface of the mucosa. A diagnosis of IND B can be made only if, in the submucosa of 30 serial sections, 15-20 % of all ganglia are giant ganglia with more than eight nerve cells. Ganglioneuromatosis (MEN2B) must be clearly differentiated from IND. The clinical course of IND B depends on the extent of disturbed bowel innervation, the severity of motility failure, and the coexistence of MH. The conservative management of isolated IND is possible in most children. In individual cases, however, a transient enterostomy or a segmental resection is unavoidable.

Immunohistochemical typing of non-small cell lung cancer on cryostat sections: correlation with clinical parameters and prognosis.

AIMS: To investigate the immunohistochemical expression of a panel of biologically relevant markers in patients with non-small cell lung cancer using fresh frozen specimens and to test their prognostic relevance for identification of patients at risk. METHODS: Seventy nine tumour infiltrated lung cancer specimens and 66 adjacent histologically tumour free tissues were analysed; 11 postmortem specimens from patients who did not suffer from a malignant disease served as a control group. Cryostat sections were stained with monoclonal antibodies against epidermal growth factor receptor (EGFR), c-erbB-2, c-erbB-3, CD82, Ki-67, p120, p53, bcl-2, and CD31. RESULTS: At least one of the tested markers was raised above the defined cut off point in 75 of the tumours. In 55, three to six factors were increased. EGFR was raised in 32, c-erbB-2 in 29, c-erbB-3 in 46, p53 in 29, bcl-2 in 26, Ki-67 in 36, p120 in 46, and CD31 in 29. None of the tested parameters was significant in univariate survival analysis. In a second step, three variables were combined (c-erbB3, p53, and microvessel density), and cases with increased expression of two or three parameters proved to have a significantly lower survival probability than those expressing none or only one factor. In the tumour free group only 10 showed raised marker expression. CONCLUSION: Characterisation of tumour cells in surgical specimens with immunohistological markers could help identify those patients at risk for early cancer death who could possibly profit from adjuvant treatment after curative tumour resection.

Colonoscopically placed hemoclips as treatment for massive appendiceal stump bleeding.

Massive bleeding from an appendiceal stump is a rare but occasionally seen severe complication. The bleeding may drain into the abdominal cavity, the retroperitoneum, or the digestive tract. Gastrointestinal hemorrhage may occur early or even years after appendectomy. The typical management includes ligation of the bleeding vessel or cecal resection done by either emergency laparotomy or laparoscopy. An alternative treatment option would be an angiographic embolization of the bleeding vessel. We report on a 33-year-old woman with severe lower gastrointestinal hemorrhage 1 day after an apparently uncomplicated appendectomy for acute phlegmonous appendicitis with ligation and invagination of the appendiceal stump. Hemoglobin level dropped to 6.3 g/dl and made blood transfusion necessary. The cause of bleeding was a small intramural branch of the appendiceal artery at the appendiceal stump, which was diagnosed by emergency colonoscopy. The hemorrhage could be controlled endoscopically by placing hemoclips on the distinct vessel in combination with a biological tissue adhesive. The patient recovered thereafter without further intervention. Endoscopic clipping for the treatment of appendiceal stump bleeding is a novel, effective, and safe procedure. Thereby, conventional emergency laparotomy or laparoscopy or angiographic embolization can be avoided.

Pouch dilatation after gastric banding causing gastric necrosis.

BACKGROUND: Early or late pouch dilatations account for a moderate complication rate after restrictive bariatric operations. Various strategies were developed to prevent or treat pouch dilatations. METHODS: A case of necrosis of gastric wall in a concentric dilated pouch following laparoscopic adjustable gastric banding is reported as a severe complication of a conservative treatment attempt. RESULTS: Emergency laparotomy resulted in band removal, partial gastric resection and prolonged hospital stay. CONCLUSION: Conservative strategies in the treatment of pouch dilatations bear the risk of complications, with both failure of the bariatric procedure and critical clinical course. Indication for early operative reintervention is recommended.

Embolism of a metallic clip: an unusual complication following laparoscopic cholecystectomy.

A 32-year-old woman underwent laparoscopic cholecystectomy during which there was severe bleeding from the bed of the gallbladder. As application of metallic clips to control the bleeding was not successful, the operation was converted to an open laparotomy. Cholecystectomy was successfully completed without further complications, and the post-operative course was uneventful and the patient was discharged. Eighteen months later, the patient complained of dyspnea. Plain radiograph and computed tomography of the thorax showed a metallic clip in the branch of the pulmonary artery supplying the posterior basal segment of the inferior lobe of the left lung. There was no connection between the patient's symptoms and the clip embolism. Nevertheless, clip migration or embolism could cause severe complications. Therefore, metallic clips should not be used to stop bleeding from the gallbladder bed.

[Intestinal neuronal dysplasia in adults as a cause of chronic constipation: morphometric characterization of colon innervation]. / Intestinale neuronale Dysplasie des Erwachsenen als Ursache der chronischen Obstipation. Morphometrische Charakterisierung der Coloninnervation.

Intestinal neuronal dysplasia (IND) was initially described as a developmental abnormality of the submucous plexus in children. In recent years this abnormality has also been observed in adults with chronic constipation. The aim of this study was a morphometric characterization of this disease. The investigation was performed with 10 adults with IND, compared with 10 healthy control probands. The best diagnostic indicator of IND proved to be the detection of 6-10 giant ganglia with more than 7 nerve cells in 15 biopsy sections. IND is an interesting cause of chronic constipation which can be histologically verified.

Sialadenitis with crystalloid formation: a report of six cases diagnosed by fine-needle aspiration.

Six cases of sialadenitis diagnosed by fine-needle aspiration contained large numbers of crystalloids. Light microscopy, ultrastructure, and chemical analysis suggest that the crystalloids represent crystallized salivary alpha-amylase. The inflammatory swelling may mimic benign and/or malignant neoplasms of the salivary glands. Drainage and/or antibiotic therapy may allow surgery to be avoided in these patients.

[Hypertropic obstructive cardiomyopathy. A family study]. / Hypertrophe obstruktive Kardiomyopathie.

Eight patients with HOCM from the same family are presented. The clinical findings and the diagnostic and therapeutic procedures are discussed. Chest pain, palpitations and effort dyspnea were the main clinical symptoms. A characteristic systolic ejection murmur of late onset was present in all the cases. In 6 patients there were electrocardiographic signs of left ventricular hypertrophy and only 4 patients exhibited abnormal septal depolarization. Echocardiography revealed an enhanced diastolic interventricular septal to left ventricular posterior wall ratio (above 1.3), diminished left ventricular septum movement, systolic anterior motion of the mitral valve and mid systolic closure of the aortic valve. Cardiac catheterization showed a left ventricular out-flow gradient which was increased by isoproterenol infusion. In 5 patients the left ventricular angiogram disclosed systolic obliteration of the left ventricle and in 4 cases mitral regurgitation. In the therapy of HOCM, calcium antagonists are now widely used and seem to have replaced betablocking agents.