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.

Aggressive angiomyxoma: irradiation for recurrent disease.

BACKGROUND: Aggressive angiomyxoma (AAM) is a tumor of the soft tissues predominately occurring in the genital and pelvic area with a strong propensity to local recurrences. The entity was first described in 1983. The tumor is regarded as low-grade sarcoma by some authors; its cause and pathogenesis are presently unknown. PATIENT AND METHOD: This is a case report on a 27-year-old man who underwent 4 surgical procedures of the left lower extremity because of a recurrent soft tissue neoplasm, initially (August 1993) diagnosed as a myxolipoma. The patient suffered from recurrences in February 1995, September 1996 and February 1998. The diagnosis was revised at the time of the latest recurrence. A palliative resection with macroscopic residuals left was performed in February 1998, followed by a radiation therapy with 56 Gy total dose and a concomitant administration of the radiosensitizer razoxane per os. The single radiation doses were 200 cGy 5 times a week. RESULTS: The small residuals of the tumor obviously regressed although an objective response could not be shown because the lesion was not clearly measurable. A follow-up 2 years after the radiation treatment revealed no recurrence. The time of the local control achieved as yet is already longer than any former time to regrowth between the surgical procedures. This is, to our knowledge, the first description of a therapeutic irradiation of a recurrent aggressive angiomyxoma. CONCLUSION: Radiation therapy combined with the sensitizer razoxane is able to control a recurrent AAM for an unknown time. It remains open whether a radiation treatment alone would have had a similar effect.

[Advanced breast biopsy instrumentation (ABBI). Histopathologic evaluation of a new investigation method]. / Advanced breast biopsy instrumentation (ABBI). Histopathologische Evaluierung einer neuen Untersuchungsmethode.

The ABBI (advanced breast biopsy instrumentation) system has only recently been available for diagnostic excisional biopsy of small, non-palpable lesions of the breast. Between 1.1.1998 and 31.3.1999 this method was utilized in 40 patients with suspicious microcalcifications (n = 25), newly developed densities (n = 11) and a combination of microcalcifications and densities (n = 4). In 12 cases malignancy was diagnosed, in 11 cases a subsequent resection was performed. In every case sufficient tissue for diagnosis was obtained, in not a single case the diagnosis had to be revised in case of subsequent resection. Orientation within the specimen is accurate, the resection margins can be judged unequivocally. Any necessary special examinations can be performed on the resected tissue. In our experience, ABBI is a valuable and elegant tool for diagnosing small suspicious lesions of the breast.

[Focal proliferation in reactive hyperplastic parathyroid tissue in end-stage renal failure--implication for autotransplantation after total parathyroidectomy]. / Fokale Proliferationen in reaktiv hyperplastischen Nebenschilddrüsen bei terminaler Niereninsuffizienz-Implikation für die Autotransplantation nach totaler Parathyreoidektomie.

Total parathyroidectomy with simultaneous autotransplantation may be associated with recurrence of graft-dependent hyperfunction due to excessive proliferation. We performed macroscopic tissue selection with a stereomicroscope prior to autotransplantation, which resulted in very low recurrence rates. As this technique greatly depends on experience, we investigated the possibility of additionally using proliferation staining (PCNA, MIB-1) for the detection of dysfunctional tissue. Selected tissue from 26 patients was investigated. Serial sections of freshly removed parathyroid tissue were correlated with their macroscopic appearance, HE and immunohistochemically stained paraffin sections, and with semithin Epon sections. The asymptotic growth mode of clonal proliferating regions was reflected by highest staining intensity (1-5%) in small to medium sized foci (diffuse, up to 3 mm in diameter) and very low staining in large areas (diffuse or nodular, 5-15 mm in diameter, from 0.03 to 0.003% positive cells). Thus, very large dysfunctional regions with (almost) no proliferation could not be detected by this method. However, they were very evident on macroscopic investigation. In conclusion, multiple fulminant recurrence after parathyroidectomy can be prevented by selecting tissue after proliferation staining. This may allow a delayed autotransplantation after total parathyoidectomy for those surgeons lacking experience in macroscopic tissue classification.

[Sentinel node biopsy in breast cancer--a minimally invasive procedure for staging of the axilla]. / Die Sentinel Node Biopsy beim Mammakarzinom--ein minimal invasives Verfahren zum exakten Staging der Axilla.

Clinical examinations and imaging methods are not sufficiently reliable for an exact staging of axillary nodes in breast cancer. The sentinel node biopsy concept is a minimally invasive procedure to locate and remove the first and important nodes responsible for draining a tumor. Histologic examinations using immunohistochemical methods permit more accurate staging than hematoxylin and eosin staining alone. Between 4/1997 and 9/1998 a total of 62 patients with 65 breast cancers underwent surgery. The sentinel node procedure with radio tracers and/or blue dye was performed in patients with clinically negative or unclear positive findings in the axilla, with a primary tumor size less than 5 cm; 11 patients had received preoperative chemotherapy. The sentinel node biopsy was followed by axillary dissection in 44 cases. In 58 (89%) cases we found one or more (on an average 1.4) sentinel nodes with radio tracers (in 73%) and/or the blue dye method (in 85%). Axillary nodal status was correctly predicted in 43 of 44 (97.7%) cases; only in one patient was the sentinel node false negative. After preoperative chemotherapy sentinel nodes were found in 9 cases; all of these were predictive. Micrometastases were found in two patients only after cytokeratine staining. Our results concur with the experience of other study groups in regard of sentinel node biopsy. The sentinel node concept is a fascinating method; its importance in breast cancer treatment appears to be comparable with introduction of breast saving surgery in the 1980's.

[Correlation of histology of the primary tumor with liver metastases in colorectal carcinoma]. / Beziehung zwischen der Histologie des Primärtumors und der Lebermetastasierung beim kolorektalen Karzinom.

The histology of colorectal tumors was correlated with the presence of liver metastases in a retrospective study performed on 179 patients who were autopsied between 1975 and 1990. For the analysis of metastatic patterns, 116 cases with at least one distant metastatic site were selected. A distinct relationship between mucin expression of colorectal tumors and liver involvement was found. Pure adenocarcinomas and their papillary variants showed the highest affinity to the hepatic tissue regarding the frequency as well as extent of involvement. A subtotal replacement of the liver by metastases was restricted to these two variants. An extracellular mucin component was associated with a lower frequency of liver involvement and a tendency to solitary or oligotopic metastases. Ten cases of signet ring cell carcinomas had no metastases in the liver. The results described here for colorectal cancers are similar to those previously reported for gastric cancer. The therapeutic implications were discussed. A detailed link between these clinical findings and the results found at the level of molecular biology is yet to be determined.

[Malignant hemangioendothelioma of the thyroid gland: new results on pathogenesis, therapy and prognosis]. / Das maligne Hämangioendotheliom der Schilddrüse: Neue Resultate zur Pathogenese, Therapie und Prognose.

BACKGROUND: Malignant hemangioendothelioma of the thyroid is a rare tumor predominantly described in areas with endemic goiter like the Alpine regions. The estimated incidence of the disease is between 0.15 and 0.25 per 100,000 inhabitants per year for Western Austria. The prognosis is reported to be dismal. MATERIALS AND METHODS: Between 1982 and 1995, 10 cases with immunohistochemically confirmed malignant hemangioendotheliomas of the thyroid were referred to our department for postoperative or palliative treatment. Two patients with clear margins at surgery received no adjuvant radiotherapy and were only observed. By surgery, clear margins (R-0 resection) were achieved in 5, microscopic residuals (R-1) were left in 3, and gross residual disease in 1 patient. One patient had an inoperable primary tumor. Postoperative radiotherapy was administered in 6 cases, 4 of them additionally received the radiosensitizer razoxane. Total tumor doses ranged between 58 and 65 Gy. RESULTS: Local tumor control was achieved in 9 of 10 patients; 4 of 10 lived longer than 4 years. The median survival time has not yet been reached and is presently between 7.5 and 21+ months.--Noteworthy is a complete regression of 2 lung metastases in a 72-year-old man by a combination of vindesine, razoxane and radiotherapy. The patient is still in complete remission under a maintenance therapy with vindesine and razoxane since 14 months.--It may also be of interest that 4 of the 10 patients were strongly exposed to vinyl chloride and other polymeric materials during their occupational life. CONCLUSIONS: This small series may indicate that the outcome of this disease may not be uniformly deleterious, and that the resistance to radiotherapy reported in the literature may be questioned.--The data offer new evidence of the occurrence of vinyl chloride-induced angiosarcomas outside the liver, and support observations which have already been published in case reports.

[Generalized osteopathy with pathological fractures in a patient with long-term exposure to fluorine-containing plastics]. / Generalisierte Osteopathie mit pathologischen Frakturen bei einem Patienten mit Langzeitexposition gegenüber fluorhaltigen Kunststoffen.

In a 68-year-old man with a painful syndrome of the lower extremities which began at the age of 64 years, workup revealed a generalized osteopathy with sclerosis of the axial skeleton and osteopenia at the extremities associated with pathologic fractures. The occupational history showed exposure to several synthetics such as vinyl chloride, polyethylene, delrine and polyamides over 30 years. However, a presumptive connection between the skeletal disorder and the occupational exposure could not initially be substantiated. In a later analysis of the bone biopsies from 1991, a significant increase of fluorine in the tibia and fibula of the patient was detected and thus the diagnosis of industrial fluorosis established. The fluorine presumably originated from the workup of polytetrafluorethylene plates. A detailed analysis of the workplace is ongoing. The fluorosis may obviously appear as a variable skeletal disease. The clinical picture of fluorosis is incompletely described in most of the German textbooks. It calls for an extended description of the X-ray findings associated with fluorosis and a new definition of the disease.

[Prognosis and epidemiology of malignant hemangioendotheliomas of the thyroid gland]. / Zur Prognose und Epidemiologie des malignen Hämangio-endothelioms der Schilddrüse.

Five new cases of malignant hemangioendothelioma of the thyroid are reported. This rare malignant tumor is described predominantly in regions with endemic goiter such as the Alpine zone. The estimated incidence of the disease is between 0.15 and 0.25 per 100,000 inhabitants per year for Western Austria. Two of the five patients were heavily exposed to vinyl chloride occupationally for 9 and 30 years respectively. Surgically, a R-0 resection was performed in two patients, R-1 in two, and R-2 in one patient. Postoperative radiotherapy was given in four cases. The tumor doses were between 58 and 65 Gy. Three patients received the sensitizer razoxane in addition. Local tumor control was achieved in 4 of 5 patients. The survival times of the 5 patients were 78, 68+, 38+, 7.5 and 3 months. Two patients are still alive after 68 and 38 months. This small series may indicate that the outcome of the disease may not be uniformly deleterious and the resistance to radiotherapy reported in the literature [3, 10] is debatable.

[Experiences with total parathyroidectomy and autotransplantation of intraoperatively selected parathyroid tissue in reactive renal hyperparathyroidism]. / Erfahrungen mit der totalen Parathyreoidektomie und Autotransplantation intraoperativ ausgewählten Parathyreoidea-Gewebes beim reaktiven renalen Hyperparathyreoidismus.

Surgery is indicated in cases of therapy-resistant reactive renal hyperparathyroidism with clinical symptoms and signs. The method of choice is total parathyroidectomy, with autotransplantation of parathyroid tissue into the forearm musculature. Twenty-two patients were parathyroidectomized. In 19 cases the intraoperative selection of tissue for autotransplantation was made by means of a stereoscopic magnifying glass. With one exception, only fragments of type 1a glands and type 1a-like areas obtained from type 2 glands were transplanted. In 18 of the 22 cases parathyroid hormone levels decreased from 1131 +/- 657 preoperatively to 87 +/- 53 pg/ml postoperatively. In 4 patients with postoperative values over 200 pg/ml a transplant-related recurrence of hyperparathyroidism or a remaining 5th gland in the cervical region was suspected. In all 22 patients serum calcium, as well as alkaline phosphatase levels returned to normal and the clinical signs of hyperparathyroidism disappeared.

Resistance of gram-negative bacilli and staphylococci from blood cultures to aminoglycoside antibiotics. Comparison of 3 in vitro investigations from Austria 1982-1988.

A total of 790 blood culture isolates was collected during 3 study periods in 1982/83, 1984/85 and 1987/88. Staphylococci were the most frequent bacteria in the first two periods (56.5% and 63%, respectively). During the last period, E. coli was the most frequent of all species (27%). Differences in the distribution of bacteria between the laboratories were considerable. In one laboratory in Vienna, coagulase-negative staphylococci dominated in all 3 study periods (32%, 33% and 47%). Susceptibility against gentamicin, tobramycin and netilmicin (MIC less than or equal to 4 mg/l), as well as against amikacin (MIC less than or equal to 8 mg/l) were determined by a microdilution method. The resistance rates against gentamicin (G) were 25%, 21% and 25%, against tobramycin (T) 27%, 19% and 25%, against netilmicin (N) 6%, 4% and 19%, and against amikacin (A), 5%, 2% and 19%. Most resistant strains were staphylococci (G 26%-41%, T 26%-46%, N 3%-31%, A 3%-36%), whereas gram-negative bacilli were more susceptible (G 12%-14%, T 7%-11%, N 7%-9%, A 1%-7.5%). The increase of resistance against netilmicin and amikacin in staphylococci was most striking. Nearly all those strain could be attributed to one laboratory in Vienna. Most of them were coagulase-negative staphylococci. In the first study period, the most frequent pattern was resistance against gentamicin and tobramycin, whereas in the last period resistance to all 4 aminoglycosides dominated. The study demonstrates considerable local differences in antibiotic resistance. Monitoring of antibiotic resistance in collaborative studies using standardized methods should be a valuable tool in planning strategies for controlling an epidemic spread of resistance.

Occult papillary carcinoma of the thyroid with pulmonary lymphangitic spread diagnosed by lung biopsy.

Distant metastases from occult papillary carcinoma of the thyroid, which is defined as a tumor less than 15 mm in diameter, are extremely rare. A 21-year-old patient with miliary micronodular densities in both lungs is described, in whom pulmonary lymphangitic spread of occult papillary thyroid carcinoma was diagnosed by transthoracic lung biopsy.

[Acute cardiac death in chronic-ischemic heart disease (CIHD)]. / Der akute Herztod bei der chronisch-ischämischen Herzkrankheit (CIHK).

Ischemic heart disease as a basic disease with accompanying findings and exogenous factors comes to a typical triad of SCD. There is a critical midlife situation due to O2-shortage. Dispositional and situational conditions come to be important, especially in cases in which morphological substrates are absent. The complex incident takes place on three levels (organism, heart, and myocardium). Several dying types may occur. Clinical accuracy and morphological diagnosis are of limited value for the relatively fatal importance of each of the single findings.

[Bronchial cancer from the viewpoint of 2 neighboring regional cancer registers]. / Das Bronchialkarzinom aus der Sicht zweier benachbarter regionaler Krebsregister.

From follow-up examinations on 460 male and 67 female patients with bronchial cancer during the years 1981 and 1982 in the cantons of St. Gallen and Appenzell/Switzerland, as well as from the region of Vorarlberg/Austria various morphological and clinically registered parameters of importance to oncology were comparatively analysed. These regional clinical cancer registers have existed for many years and are recognized legitimately and clinically as an important partial aspect in diagnostic, therapy and prophylaxis of malignant tumours.

[Intraoperative rapid biopsy of thyroid neoplasms and surgical procedures in atypical adenoma]. / Zur Problematik des intraoperativen Schnellschnitts bei Neoplasien der Schilddrüse und des chirurgischen Vorgehens beim atypischen Adenom.

For a differential diagnosis of atypical adenoma and highly differentiated follicular carcinoma cryosections are of value only if findings are positive. Between 1977 and 1982 we observed 85 thyroid carcinomas and 47 atypical adenomas. In 5 cases the diagnosis on the basis of a cryosection had failed to detect a carcinoma. In patients with atypical adenoma we performed a subtotal resection; a primary lobectomy was not carried out as it would have meant exposing an unnecessarily high percentage of patients to an increased risk of complications. 3-8 years postoperatively the patients show no pathological findings.

[A so-called atypical adenoma of the thyroid in an endemic struma area]. / Zur Problematik des sogenannten atypischen Adenoms der Schilddrüse im Strumaendemiegebiet.

In view of the benign clinical course of the atypical adenoma and the high diagnostic accuracy of our frozen sections we feel that subtotal strumectomy with in toto removal of the adenoma and closely spaced follow-ups constitutes an adequate treatment of this thyroid neoplasm. In our opinion primary lobectomy means unnecessarily exposing a disproportionately high percentage of patients to the higher complication risk of this more radical surgery. From 1977 to 1982 there were 47 cases of atypical adenoma among our patients. The ratio men: women was 1:3.7, the mean age of the patients was 44 years. The patients underwent subtotal strumectomy. In the period under review "atypical adenoma" diagnosed on the basis of frozen sections turned out to be carcinoma in 5 instances. The follow-up period of the 47 patients that underwent surgery ranges from 1 1/2 to 7 years. None of the patients has had tumor regrowth so far.