Breast-conserving surgery with resection of the nipple-areola complex for subareolar breast carcinoma.

INTRODUCTION: Breast-conserving therapy for centrally located tumours has in the past been viewed with reservation, but is now an accepted treatment. There is little published evidence, however, to show that it is safe and cosmetically acceptable. METHODS: In a prospective investigation carried out between 1996 and 2002, 44 women had surgery for 45 breast carcinomas with suspected nipple involvement. The breast was conserved and the nipple-areola complex removed. Secondary mastectomy was performed in three women because the tumour was found to reach the resection margin. Forty-one women underwent further observation. The mean tumour size at the time of operation was 18 (range 4-50) mm. Six women received preoperative chemotherapy. RESULTS: Histologically, there were seven preinvasive and 35 invasive cancers. No local failure had occurred at a median follow-up of 51 months. Six women developed distant metastasis, of whom five died. The mean score for cosmetic results (evaluated on a scale of 1-5 where a score of 1 was excellent) was 1.5 for patients and 1.7 for physicians. CONCLUSION: Breast-conserving therapy is a safe and cosmetically acceptable alternative to mastectomy for subareolar breast cancer.

[Squamous cell carcinoma of the liver. A rare diagnosis in the course of intrahepatic cholangiolithiasis]. / Plattenepithelkarzinom der Leber. Ein seltener Zufallsbefund im Rahmen einer intrahepatischen segmentalen Cholangiolithiasis.

We report the rare case of a squamous cell carcinoma of the liver in a 69-year-old female Asian suffering from cholangitis and a liver abscess due to segmental intrahepatic cholangiolithiasis. The patient was an immigrant who had been living for several years in Austria. After pigtail drainage of an abscess in segment II and III, a bisegmentectomy was performed. Histopathological examination of the specimen showed structures of an invasive squamous cell carcinoma close to the resection margin.For that reason we performed a left lobectomy. Seven years thereafter the patient is well and free of local and distant recurrences. The case is discussed based on a review of the literature.

[The value of F-18 fluorodeoxyglucose in positron emission tomography diagnosis of breast carcinoma]. / Wertigkeit der F-18-Fluorodeoxy-Glukose-Positronenemissionstomographie-Diagnostik beim Mammakarzinom.

Fluorodeoxyglucose-positron emission tomography (F-18-FDG-PET) has become an important issue in the diagnosis of malignant tumors within the last years. In breast cancer PET has been established in the diagnosis of the primary tumor as well as in recurrences with a sensitivity of 90% and a specificity of 75%-100%; additional a sensitivity of more than 90% and a specificity of about 75% is also seen in axillary lymph nodes detection. With our own results we were able to prove sensitivity of positron emission tomography in diagnosing the primary lesion, locoregional lymph nodes and the staging of metastases. Furthermore, positron emission tomography seems to be superior to conventional imaging modalities in staging primary and recurrent breast cancer, distant metastases and lymph nodes outside the axilla.

[18F-fluorodeoxyglucose positron emission tomography in colorectal cancer: value in primary staging and follow-up]. / 18F-Fluorodeoxyglukose-Positronenemissionstomographie beim kolorektalen Karzinom: Wertigkeit in Primärstaging und Follow-up.

Positron emission tomography using 18F-fluorodeoxyglucose (FDG-PET) is a encouraging imaging technique allowing a highly sensitive whole-body search for malignant foci detected by their increased glucose metabolism compared with benign tissues. Several studies are now available that indicate its added value for diagnosis and staging of colorectal cancer. In all, patient management seems to be changed in 20-30% of patients who undergo Fluorodeoxyglucose positron emission tomography in addition to standard staging procedures. Fluorodeoxyglucose positron emission tomography is also useful in monitoring radiation therapy and chemotherapy. Regarding preoperative staging of primary colorectal cancer the literature is very limited.

Is sentinel lymph node biopsy reliable and indicated after preoperative chemotherapy in patients with breast carcinoma?

BACKGROUND: Many studies support the concept and accuracy of sentinel lymph node biopsy (SNB) for staging patients with breast carcinoma, which can be performed with low morbidity in lymph node negative patients. Preoperative chemotherapy (PC) plays an important role in the treatment of patients with operable breast carcinoma and is another approach with which to reduce radical surgery in patients with more advanced disease. It is of interest whether the sentinel lymph node accurately represents the axillary status after PC and, thus, whether the sentinel node concept can be applied to both groups. METHODS: Thirty-three patients underwent SNB after chemotherapy and prior to axillary lymph node dissection. RESULTS: The average greatest tumor dimension before chemotherapy (33 mm +/- 2 mm) was significantly larger (P = 0.000) than after therapy (20 mm +/- 3 mm). Histopathologic complete remission was seen in only three patients. One or two sentinel lymph nodes (average, 1.7 lymph nodes) were identified with certainty in 29 of 33 procedures and accurately predicted axillary lymph node status in all of these patients. Breast-conserving surgery was possible in 21 patients (64%), and axillary lymph nodes were involved in 22 patients (67%). CONCLUSIONS: Even after patients undergo PC, SNB seems to be a reliable method for accurate staging of the axilla in those more advanced breast carcinoma. Thus, axillary dissection may be avoided in certain patients. Lymph node involvement seems to be likely in women with suspicious axillary findings before chemotherapy who have no visible sentinel lymph nodes on preoperative lymphosintigraphy and in patients without recurrent tumors. Further investigation of the SNB concept in this patient group should be evaluated in larger studies.

Small bowel perforation after extracorporeal shockwave lithotripsy of an ureter stone.

A 60-year-old man was treated by extracorporeal shock wave lithotripsy (ESWL) for an impacted ureter stone. Two days after the procedure he developed an acute abdomen. On laparotomy, a small bowel perforation in the area of an adhesion to the abdominal wall was found. The adherent intestinal segment was located exactly in the range of the ESWL field, so that excluding further reasons the shockwave lithotripsy must be assumed to be causative.

Transesophageal sonography in central bronchial carcinoma.

A new application of transesophageal sonography was tested in eight patients suffering from central bronchial carcinoma. Due to ultrasound technology, a real time investigation is feasible which enhances the diagnostic method of computed tomography (CT) by discriminating between tumour and mediastinal organs which cannot be delineated by CT only. Different sonographic densities and the movement between organ and tumour contribute to the diagnostic accuracy of sonography if operability is questionable due to possible organ infiltration by tumour. The method is limited by the air filled organs (trachea, bronchi), as ultrasound does not penetrate adequately.

[Intraoperative radiation treatment of carcinoma of the pancreas. Initial clinical results]. / Intraoperative Strahlenbehandlung beim Pankreaskarzinom. Erste klinische Erfahrungen.

Intraoperative radiotherapy (IORT) was administered to 13 patients with carcinoma of the pancreas, using high-velocity electrons of a LINAC accelerator in a single dose of maximally 25 Gy applied directly to the tumour or tumour bed with the abdomen open. There were no disorders of wound healing or other serious early complications which could be ascribed to the radiation. Stomach and intestines were excluded from the radiation field to avoid late radiation damage, such as stenoses or ulcers. The method is particularly indicated for locally non-resectable, non-metastasized pancreatic carcinoma, possibly also as tumour-bed radiation during radical surgery. Patients with distant metastases were not given radiation. First results point to IORT providing lasting improvement of pancreatic pain. It is too early to know whether survival time is favourable influenced.

[Problems of esophagojejunal anastomosis following gastrectomy]. / Zur Problematik der oesophagojejunalen Anastomose nach Gastrektomie.

Experiences with 76 patients with esophagojejunoplication after total gastrectomy are reported. Clinical results are compared with a control group of 33 patients who underwent gastrectomy followed by terminolateral esophagojejunostomy as we did formerly. Performing this method of esophagojejunoplication the rate of leakage (2/76 respectively 3/33) of the anastomosis was reduced as well as the occurrence of reflux complaints (9/62 respectively 15/21).

[Sonography of coagulating blood: experimental and clinical findings]. / Sonographie des koagulierten Blutes: Experimentelle und klinische Befunde.

The sonographical morphology of the mechanisms of blood coagulation, as well as the changes occurring the old blood coagulae, were analysed in vitro. Examples of clinical cases show the variety of patterns produced by haemorrhages during sonographical examination. Fresh coagulae have a structure closely resembling that of liver parenchyma, whereas the very inhomogeneous appearance of relatively old coagulae looks more like malignant tumours which seem to be growing as though they had got out of control. It is pointed out that knowledge of the wide sonomorphological spectrum of the different forms and manifestations of "haematoma" is of great importance in critical sonographic examination of problematic cases in abdominal and thoracic surgery and also in traumatology.

Primary hepatocellular carcinoma with hepatitis B virus infection in a 16-year-old noncirrhotic patient.

Primary hepatocellular carcinoma metastasizing to abdominal lymph nodes and to the left lung was observed in a 16-year-old male patient. No clinically apparent chronic liver disease preceded the carcinoma and no signs of cirrhosis were detectable in the nonneoplastic liver. Hepatitis B surface antigen, hepatitis B e antigen and antibody to hepatitis B core antigen were found to be positive in the serum. By immunohistochemistry (peroxidase-antiperoxidase technique) hepatitis B surface antigen could be demonstrated in the nontumorous liver parenchyma, but not in the primary hepatocellular carcinoma itself. Serum alpha-fetoprotein was only moderately elevated (75 ng/ml), but immunohistochemically primary hepatocellular carcinoma revealed a considerable number of alpha-fetoprotein-containing cells, whereas nontumorous parenchyma did not. Carcinoembryonic antigen could be demonstrated immunohistochemically in some tumor cells of a lymph node metastasis, but not in the primary tumor or in the nontumorous liver parenchyma. We propose that primary hepatocellular carcinoma developed in this case in a symptomless hepatitis B virus carrier without preceding cirrhosis, an we exclude a simultaneous acute hepatitis B.

[Sonographic acute diagnosis in polytrauma]. / Sonographische Akutdiagnostik beim Polytrauma.

A series of 128 emergency cases is reported, suffering from polytrauma with suspected blunt abdominal or thoracic trauma. Screening for intraabdominal or intrathoracic hemorrhage requiring urgent operation was done by ultrasonography. In 127 cases clinically relevant hemorrhage was found or could be excluded, all cases proven by operation or close clinical follow up. For investigation was not evaluable in one case due to subcutaneous emphysema a diagnostic peritoneal lavage was carried out, a procedure which was not necessary in all other cases. Technique, diagnostic value and limits of ultrasonography in polytraumatic patients are described and discussed in comparison with diagnostic peritoneal lavage.

[Sonographic aspects of intramural duodenal bleeding (author's transl)]. / Sonographische Aspekte der intramuralen Duodenalblutung.

The characteristic sonographic appearance of intramural duodenal haematomas is described in three cases. Cystic and diffusely infiltrating intramural haematomas should be differentiated, and the resulting consequences for treatment are pointed out.

[Rationalisation of surgical diagnosis by means of real-time sonography]. / Rationalisierung der chirurgischen Diagnostik durch die Real-Time-Sonographie.

A report is given of the results obtained on implementing sonography routinely in the diagnosis of general surgical conditions. Fields in which this procedure has proved of particular value are acute surgical emergencies, polytrauma, biliary surgery, post-operative complications, septic processes, palpable abdominal masses and the investigation and follow up of patients with tumours. Ultrasound-directed fine-needle puncture plays an important role within this last-mentioned group of indications. In order to make optimum use of sonography in interpreting specifically surgical problems, this readily-available bedside examination is performed by the experienced surgeon himself. Further diagnostic tactics and their consequences are discussed.

[Pylethrombosis following splenectomy (author's transl)]. / Pfortaderthrombose nach Splenektomie: Sonographische Diagnostik.

Two cases of thrombosis of the portal vein following splenectomy for osteomyelofibrosis are described. The diagnosis could be made echographically in each case as a "beside investigation".