[Hand ischemia and increased CRP level in a 75-year-old female patient]. / Handischämie und erhöhter CRP-Wert einer 75-jährigen Patientin.

The complexity of the diagnosis and therapy as well as the deficits in care are presented on the basis of the casuistry of a 75-year-old female patient with giant cell arteritis and a complicative course.

[Recurrent multifocal osteomyelitis in the absence of skin disease]. / Rezidivierende multifokale Osteomyelitis ohne Dermatose.

HISTORY AND ADMISSION FINDINGS: A 64-year-old man complained of pain and a symmetric swelling of the clavicles. There were no fever and chills. 27 years earlier, a resection of the mandible was necessary, due to osteomyelitis. In the past, he complained of recurrent episodes of pain in the sternum and in the thoracic spine. Skin disorders were not reported. INVESTIGATIONS: The leucocyte count was within the normal range, however, levels of c-reactive protein and the erythrocyte sedimentation rate were increased. Autoantibodies and blood cultures were negative. On X-ray, osteosclerotic and cystic lesions in both clavicles were found, consistent with osteomyelitis. A bone scintigraphy revealed increased radionuclide activity in the clavicles and the sternum. A bone biopsy sample from the clavicle revealed signs of osteitis with fibrosis together with CD 68 und CD 138 positive cells. These findings indicated the diagnosis of a SAPHO syndrome (Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis) without skin disease. TREATMENT AND COURSE: NSAIDs, bisphosphonates and azithromycin were administered , thereby sufficient pain relief was rapidly achieved. CONCLUSION: SAPHO syndrome is a rare disease complex including osteoarticular disorders which are frequently accompanied by skin disease. However, the diagnosis may be difficult due to a variable clinical manifestation and especially - like in our case - if skin disease is absent. Current treatment options are not evidence-based due to the rarity of the syndrome but include NSAIDs, bisphosphonates and glucocorticoids.

[Acetone compression. A fast, standardized method to investigate gastrointestinal lymph nodes]. / Acetonkompression. Schnelle, standardisierte Methode zur Untersuchung von Lymphknoten im Gastrointestinaltrakt.

Lymph node staging is the most important prognostic parameter in malignant gastrointestinal tumors. Manual dissection of adipose tissue is time-consuming and also depends on the experience of the individual examiner. By combining elution with acetone and mechanical compression using simple equipment it was possible to completely embed adipose tissue from 404 surgical specimens (colon 348, stomach 28, greater omentum 14, other location 14) without manual dissection. As a result of the procedure, the weight of the adipose tissue could be reduced by 90%-95%, making full histological examination possible. The colon specimens included an average of 43.8 lymph nodes (14-109) in 14 embedding cassettes (1-38) with a native fat weight of 234.7 g (42.8-820 g). The quality of histological staining, including immunohistochemical and molecular investigations, is of comparable quality to routine work-up. Elution with acetone enables the prompt, standardized and full histological work-up of adipose tissue without manual dissection. Moreover, additional costs are low. The number of lymph nodes required by medical associations was attained in all cases and often exceeded. This method was successfully used in other organs (greater omentum, breast).

[Bronchopulmonary sequestration presenting with flank pain]. / Bronchussequester als seltene ursache von flankenschmerzen.

INTRODUCTION: Flank pain is a classical symptom in urological patients and can have various causes. We now present a case in which we were able to diagnose retroperitoneal bronchial sequestration as a very rare cause of flank pain. CASE REPORT: In the work-up of left flank pain in a 37-year-old woman, a suprarenal mass, about 5 cm in diameter, was diagnosed in a CT scan. The patient underwent surgery and a pulmonary sequestration was identified histologically. This very rare differential diagnosis of suprarenal masses belongs to pulmonary malformations and normally is an asymptomatic accidental finding. Up to now, only few reports are documented in literature where pulmonary sequestration showed symptoms like flank pain. In this case, the pain seems to be due to mucus retention in the sequester. The literature on this disease is presented here.

[Extraosseous osteosarcoma of the thyroid gland]. / Extraossäres Osteosarkom der Schilddrüse.

Extraosseous osteosarcomas are very rare malignant neoplasms that have been published in 300 cases so far. Manifestation within the thyroid gland was described in 6 cases only. We report a 69 year old female who suffered from enlarged recurrent struma after primary resection and radiotherapy 5 years ago. Histology revealed a high grade extraosseous osteosarcoma. Presenting the patient's clinical, radiological and histological findings the therapeutical options of this rare tumor entity are discussed.

[Clear cell chondrosarcoma of the larynx. A rare tumor in an uncommon location]. / Klarzellchondrosarkom des Larynx. Ein sehr seltener Tumor in einer aussergewöhnlichen Lokalisation.

Clear cell chondrosarcoma is a rare bone tumor of low malignancy. It constitutes only 2% of all chondrosarcomas and shows a particular predilection for the epiphyses of long bones. So far, there have only been three cases of clear cell chondrosarcoma of the larynx published in the literature. We report the case of a 46 year old man who suffered from slowly worsening dyspnoea. Diagnostic evaluation revealed a directly subglottic stenosis of the larynx, narrowing the lumen to 1/3. When we tried to resect the stenosis via splitting the ring cartilage from outside, tumorous infiltration of the whole ring cartilage was found. Extended biopsies were taken and histology revealed a clear cell chondrosarcoma. The therapy of choice for this tumor is wide surgical resection. Additional radio- and/or chemotherapy are not recommended. Therefore, the patient underwent laryngectomy. Histologically, the clear cell chondrosarcoma can be easily confused with the highly malignant osteosarcoma or the conventional chondrosarcoma, both requiring more aggressive treatment. Thus, clear cell chondrosarcoma should be kept in mind and, when necessary, a reference histology by a bone tumor register should be requested.

[Hemangiosarcoma of the liver with unusual expression of neuron-specific enolase (NSE)]. / Hämangiosarkom der Leber mit ungewöhnlicher Expression von Neuronen-spezifischer Enolase (NSE).

A 68-year-old male patient presented with unspecific decline of general health, multiple tumours in the liver discovered by ultrasound examination and a focus suggestive of tumour on chest x-ray. He was hospitalised because of suspected metastatic lung carcinoma. Laboratory analysis revealed a distinct elevation of serum neuron-specific enolase (NSE, 26,1 micro g/l). A CT scan of the abdomen confirmed the presence of multiple tumour foci in both hepatic lobes, while the lung, however, was found to be free of tumour on CT-examination. Bronchoscopy, gastroduodenoscopy and colonoscopy were unremarkable. Subsequently, an ultrasound guided fine-needle biopsy of the liver was performed. Histological examination disclosed hemangiosarcoma with unusual, though unequivocal expression of NSE in tumour cells. As even follow-up examinations were unable to trace out any extrahepatic primary tumour, the hemangiosarcoma was concluded to be of hepatic origin. The patient succumbed to his disease 6 months later, an autopsy was not performed. This case report of a NSE-producing primary hemangiosarcoma of the liver clearly outlines that a histological confirmation of an allegedly clear clinical diagnosis should always be performed because malignant tumours are capable of (co-)expressing so called tumour markers independently of their histogenesis.

Quantitative reverse transcription-polymerase chain reaction detection of cytokeratin 20 in noncolorectal lymph nodes.

PURPOSE: Unexpected reverse transcription-PCR detection of cytokeratin 20 (CK20) in samples from healthy individuals and cancer types not expected to express CK20 has cast uncertainty on the role of CK20 as a specific marker of disseminated colorectal cells. We aimed to clarify the specificity of CK20 by examining its expression profile by real-time reverse transcription-PCR. EXPERIMENTAL DESIGN: A quantitative real-time PCR assay on the LightCycler instrument was developed and used to examine CK20 expression in tumors and lymph nodes from subjects with colorectal and breast carcinoma, head and neck and vulval squamous cell carcinoma, and melanoma. To select a method for reproducible quantification, four approaches were evaluated. RESULTS: The developed assay allowed rapid, convenient-to-use, specific, sensitive, and reproducible CK20 quantification amenable to large-scale analysis. For quantity calculation, an efficiency-adjusted relative ratio method was selected that controls for RNA loading and integrity as well as inefficient PCR reactions and provides a platform for standardization across laboratories. Using this assay, we detected CK20 in 41 of 89 (46%) lymph nodes from noncolorectal cancer types. There was a strong association between CK20 detection and lymph node metastasis determined by histology (P < 0.0001). Quantitatively, CK20 expression levels in colorectal cancer lymph nodes significantly exceeded the levels obtained in lymph nodes of extracolonic carcinomas (P < 0.05). Mean CK20 levels in lymph nodes and tumors from subjects with colorectal and breast cancers were similar in a tumor-type specific fashion. CONCLUSIONS: These results characterize low-level, epithelial cell-specific CK20 expression in infiltrated lymph nodes from subjects with noncolorectal cancer types and demonstrate the potential advantages of detecting circulating epithelial cells by quantitative PCR.

[Clinical and histopathological characteristics of early Leser-Trélat syndrome]. / Klinische und histopathologische Charakteristika des initialen Leser-Trélat-Syndroms.

Leser-Trélat-syndrome is characterized as the eruptive appearance of multiple seborrheic keratoses in association with underlying malignant disease. A 73 year old female patient with a metastatic adenocarcinoma of the colon presented with this paraneoplastic change. The rapid appearance of solitary seborrheic keratoses with associated inflammation, seen clinically and histologically, may be an early sign of Leser-Trélat-syndrome. The recognition of this inflammatory component as an early sign may contribute to the prompt diagnosis of this paraneoplasia, even before the eruption of numerous seborrheic keratoses.