[Is our treatment of well-differentiated thyroid cancer too aggressive? Hemithyroidectomy versus total thyroidectomy]. / Behandelen we goed gedifferentieerde schildklierkanker te agressief?

Recent literature shows that hemithyroidectomy is a safe alternative for total thyroidectomy in the treatment of patients with well-differentiated thyroid cancer up to 4 cm in diameter and a low risk of recurrence. According to criteria of the 2015 American Thyroid Association guidelines, more than 28% of patients with well-differentiated thyroid cancer of a Dutch cohort would be eligible for hemithyroidectomy instead of the total thyroidectomy they actually underwent. However, standardisation and high quality pre- and postoperative diagnostics are required for responsible implementation of this new guideline in Dutch healthcare.

Ossification of abdominal scar tissue: a case series with a translational review on its development.

PURPOSE: Bone formation in abdominal scar tissue is a form of heterotopic ossification. It is a rare and underreported phenomenon following abdominal surgery. Heterotopic ossification (HO) is the formation of bone where normally no bone is present and two theories on its pathogenesis prevail: (1) physical dislocation of small bony fragments from the xyphoid process or os pubis into the wound, (2) differentiation of locally available multipotent mesenchymal stromal cells into osteoblasts resulting in the calcification of extracellular matrix. Multipotent mesenchymal stromal cells can differentiate into different cell types by exposing them to different stimuli. We hypothesize that pro-osteogenic signals derived from e.g., macrophages steers multipotent mesenchymal stromal cells involved in the wound healing towards osteogenesis. METHODS: In a retrospective case study we analyzed ossified tissue, patient demographics, medical history, number of laparotomies, scar location, indication for surgery and time in which HO occurred. RESULTS: Ten (8 male, 2 female) patients had proven HO. The mean age was 62 (46-80) years. The mean time for HO to occur was 99 (24-382) days after the previous laparotomy. The mean number of relaparotomies was 3 (1-9). CONCLUSION: We conclude that ossification of abdominal scar tissue is a rare but innocent finding and provides interesting leads to other fields of research.

[Subtotal parotidectomy for a parotid gland tumour in two players of wind instruments, with preservation of facial nerve function]. / Subtotale parotidectomie wegens een parotistumor bij twee blaasmuzikanten, met behoud van de N.-facialisfuncties.

Two professional musicians, a 55-year-old clarinet player and a 58-year-old trumpet player, presented to the surgical outpatient clinic with a Warthin's tumour and a pleomorphic adenoma in the deep lobe of the parotid gland, respectively. The several branches of the facial nerve form the virtual plane between the superficial and deep lobes of the parotid gland. Due to the localisation of this nerve, parotid surgery entails a significant risk of neurapraxia of the facial nerve branches. Before the operation, both patients were informed carefully about both the necessity and the risks of surgical excision of parotid tumours. Even slight damage to the facial nerve during parotidectomy could have severe implications for their careers. Both underwent subtotal parotidectomy. Postoperatively, there was clinically a temporary minor marginal branch dysfunction in one patient. Pre- and postoperative electromyography did not indicate asymmetrical function of the facial muscles. A few weeks after the operations, both musicians could resume playing; subtotal parotidectomy can apparently be safely performed in players of wind instruments.

[Distinguishing nodal naevus from melanoma metastases in the sentinel node in patients with melanoma]. / Een nodale naevus in de schildwachtklier bij patiënten met melanoom: onderscheid met melanoommetastase.

OBJECTIVE: Establishing the frequency of nodal naevi in lymph-node dissections from patients with a melanoma who have undergone a sentinel-node procedure and/or regional node dissection and distinguishing naevi from melanoma metastases. DESIGN: Retrospective and descriptive. METHODS: Patients with a nodal naevus in the sentinel node were selected from a database containing clinical and pathological data on all 65 patients who underwent a sentinel-node procedure for melanoma at our hospital between 1998 and 2001. Also data from the pathology department on the case frequency and the nodal frequency of nodal naevi in the total number of patients with melanoma in whom a sentinel-node procedure and/or therapeutic node dissection had been carried out during the same period, were examined. RESULTS: In 5 patients a nodal naevus was found in the sentinel node. The case frequency was 6.2% and the nodal frequency 0.65%. Distinction from melanoma metastases was made by the use of H&E colouring, localization, architectural and morphological features of the melanocyte cell clusters in the lymph node and sometimes after consultation with the National Melanoma Panel. Immunohistochemical markers provided supplementary information only. CONCLUSION: Nodal naevi in lymph nodes were not uncommon in people with melanoma and can be distinguished from the micrometastases from melanoma.

Validation of open-surgery VR trainer.

VREST (Virtual Reality Educational Surgical Tools) is developing a universal and autonomous simulation platform which can be used for training and assessment of medical students and for continuing education of physicians. With the VREST - Virtual Lichtenstein Trainer, simulating the open surgery procedure of the inguinal hernia repair according to Lichtenstein, the validation of the simulator is ongoing. Part of this trajectory is the evaluation of the transfer of training of the virtual incision making. One group of students trained incision making on the VREST platform where the control group did not. In an experiment both groups has to perform several incision tasks on a manikin. The results are not available yet but will be presented at the MMVR14 conference.

Open surgery in VR: inguinal hernia repair according to Lichtenstein.

VREST (Virtual Reality Educational Surgical Tools) is developing a universal and autonomous simulation platform which can be used for training and assessment of medical students and for continuing education of physicians. A workstation consisting of two haptic devices and a 3D vision system is part of the VREST platform. Another part of the platform is a generic software environment in which lessons can be built by the teacher and performed by their students. Using the platform one can see, feel and decide as in reality. With the assessment tool the progress and skills of the students can be supervised. The first lesson build on the VREST platform is an inguinal hernia repair according to Lichtenstein. This is an open surgery procedure. The VREST platform is used prior to the first operating room surgery of the resident. Interactive models and case dependent feedback is used to enlarge the residents' cognition. This should reduce the training time in the operating room.

[A malignant tumour in the breast is not always primary breast cancer]. / Een maligne mammatumor: niet altijd een primair mammacarcinoom.

In a 75-year-old woman with a swelling in her left breast, a 39-year-old woman with an anal fissure due to diarrhoea and a 65-year-old woman with chest pain, a mammary tumour was diagnosed that did not originate in mammary tissue. These were a recurrent melanoma, a carcinoma of the thyroid and a B-cell lymphoma, respectively. All patients were treated. The first patient developed new metastases one year later, the second died, partly as a result of the tumour, and the third showed no recurrence of the tumour after two years. Breast cancer is one of the most frequently occurring neoplasms in women. Primary tumours in the breast from other origins and metastatic lesions to the breast from extramammary tumours are rare. Most of these cases concern haematological malignancies and metastases from melanoma and lung cancer. Despite the fact that metastases to the breast are rare, one should always consider the possibility.

The continued utility of needle localised biopsy for non-palpable breast lesions.

AIM: To analyse the results of needle localised biopsy (NLB) for non-palpable breast lesions in our hospital and to compare them with data on stereotactic large-core biopsy (SCB), which has been recently introduced as a new less invasive method for evaluating mammographic abnormalities. METHODS: We evaluated the results of all consecutive NLB procedures in our hospital in the period 1998-2000 and compared them with data from literature. Clinical, mammographic and pathological data were reviewed. RESULTS: In the present study 314 patients with 319 non-palpable mammographic abnormalities were included. Seventy percent of patients were referred to us from the national screening program. In all but one patient the NLB procedure was successful. The mean duration of hospital stay was 3 (1-10) days. Histological diagnosis was invasive carcinoma in 31%, invasive carcinoma with DCIS in 32%, DCIS alone in 13% and benign in 24%. The invasive carcinoma group scored tumour-free margins after the first operation in 77% of patients, for both the DCIS with invasive carcinoma group and DCIS alone group the tumour-free margin rate was 47%. Patients with invasive carcinoma and/or DCIS were re-operated in 88%. Of all procedures, 91% was performed without complications. CONCLUSION: NLB is a safe, relatively simple procedure with a high diagnostic accuracy combined with a lower failure and false-negative rate compared to SCB.

[A retained gauze as a cause of unexplained abdominal complaints]. / Een achtergebleven gaas als oorzaak voor onbegrepen buikklachten.

Three patients, two men aged 36 and 62 years and one woman aged 41 years, developed serious symptoms after abdominal surgery which appeared to be based on a retained gauze. In one patient the interval was 15 years, in the second patient the surgery was a minor procedure and in the third patient a surgical towel was retained in the abdominal cavity. After repeated surgery and complementary treatment the patients made a good recovery. Despite all of the precautions taken during surgical procedures, retained foreign bodies continue to be a clinical problem. This can only be overcome if all the members in an operation team work together meticulously.

[Tumor of the omentum in 2 patients with a large, mobile mass in the upper abdomen]. / Omentumtumor bij 2 patiënten met een grote, mobiele zwelling in de bovenbuik.

A mobile mass in the right upper abdomen was felt in an 81-year-old woman with nausea and a 45-year-old man with exertional dyspnoea. Radiological investigations did not reveal sufficient information, whereupon laparotomies were carried out. In both cases, a tumour was found at the exit of the greater omentum. Following resection, the tumour recurred in the woman five months later, and she died as a result; the man made a rapid recovery and remained tumour-free two years later. Tumours originating in the omentum majus are rare. The presentation of these tumours is late, due to late presentation of complaints. These tumours are usually only detected once they reach a diameter of more than 10 centimetres. In general, it is difficult to establish whether the tumour is benign or malignant either pre- or peri-operatively. Surgery is the only curative option. A wide resection is preferable, with resection of any (parts of) organs which may be involved.

[Two patients with osteochondroma of the cervical spine]. / Twee patiënten met een osteochondroom van de cervicale wervelkolom.

In two patients, both women of 32 years old, who had a local tumour in the neck firmly attached to the spine, radiologic imaging and biopsy led to the diagnosis of osteochondroma. Both patients recovered, but one had an episode of atrophy of the M. trapezius and the M. rhomboideus. If a solid mass is palpated in the neck a malignant process and cervical exostosis should be considered in the differential diagnosis. Exostoses usually are benign symptomless tumours, diagnosed in the second or third decade of life. They may compress spinal nerves and in rare cases cause severe complications by compression of vital structures such as myelum and arteries. An exostosis should be resected only if it is symptomatic or if a malignant process is suspected. In case of doubt surgical intervention is indicated with special attention to surrounding structures such as nerves and blood vessels.

[Inguinal pain caused by iliopsoas bursitis]. / Liesklachten door bursitis iliopectinea.

Four patients, three men aged 69, 55 and 45 years and one woman aged 72 years, complained of pain in and around the inguinal region without clear cause. The crippling symptoms were of a few days' to 8 years' standing. Passive hip movements were not restricted. Presence of pain after pressure on or stretching of the bursal wall during provocation tests and absence of other disorders resulted in a probability diagnosis of iliopectineal bursitis. This diagnosis was confirmed by marked abatement of the pain after an injection of lidocaine into the bursa. Inflammation of the iliopectineal bursa may occur after injury or overstrain and cause various kinds of complaints. The diagnosis injection of lidocaine as a rule constitutes an adequate treatment as well.

[Phyllodes tumor in the breast]. / Fyllodestumor in de mamma.

In three women aged 51, 37 and 58 years, with a palpable tumour in the breast, excision and pathological examination led to the diagnosis of 'phyllodes tumour'. During 3-5 years after radical excision, in one patient followed by radiotherapy, no recurrences were seen. This rare breast tumour with a variable clinical course usually affects women between the ages of 30 and 50. There is often a large tumour and (or) rapid growth. Mammography and ultrasound are unhelpful diagnostically. Cytology is unreliable as the tumour is heterogeneous. Histologically the tumour can be benign, borderline malignant or malignant. Surgical excision with a margin of > or = 1 cm is the therapy of choice. The risk of recurrence after insufficient excision is considerable and histological deterioration can occur. Multiple samples, examination of resection margins and investigation into atypia, mitotic activity and stromal overgrowth are essential for making a prognosis and a treatment plan. In case of doubt regarding radicality, surgeon and pathologist should compare views; non-radicality necessitates re-excision.

[Pilomatrixoma often not identified as such]. / Pilomatrixoma veelal niet als zodanig herkend.

OBJECTIVE: To inventory incidence, diagnosis and treatment of pilomatrixoma. DESIGN: Retrospective. METHOD: Patients treated in the period 1984-1996 in the department of Surgery of the Medical Spectrum Twente, Enschede for a pilomatrixoma were traced via the Dutch Automatic Morbid-Anatomical Records Office (PALGA). Data were collected by status study. Also, the patients or their parents were interviewed by telephone about recurrences. RESULTS: Forty-eight patients with 54 pilomatrixomas had been treated. The ages varied from 2 to 77 years, 14 patients were younger than 14 years. The correct diagnosis had been made preoperatively in 11 patients (20%) in four of whom (7%) the manifestation was not the first one. In many cases (69%), the condition was mistaken for an atheromatous cyst, in children as well (in 47% of the cases). The pilomatrixoma was localized in the head and neck area 25 times, in eight of these in the parotid region. Owing to incorrect interpretation of the abnormality, three children with a pilomatrixoma in the head and neck area underwent a more radical operation than necessary. CONCLUSION: The clinical diagnosis was frequently missed. In cutaneous tumours occurring in children or localized in the head and neck area the diagnosis of pilomatrixoma should be considered.