Mismatch repair deficiency, chemotherapy and survival for resectable gastric cancer: an observational study from the German staR cohort and a meta-analysis.

PURPOSE: In a post hoc analysis of the MAGIC trial, patients with curatively resected gastric cancer (GC) and mismatch repair (MMR) deficiency (MMRd) had better median overall survival (OS) when treated with surgery alone but worse median OS when treated with additional chemotherapy. Further data are required to corroborate these findings. METHODS: Between April 2013 and December 2018, 458 patients with curatively resected GC, including cancers of the esophagogastric junction Siewert type II and III, were identified in the German centers of the staR consortium. Tumor sections were assessed for expression of MLH1, MSH2, MSH6 and PMS2 by immunohistochemistry. The association between MMR status and survival was assessed. Similar studies published up to January 2021 were then identified in a MEDLINE search for a meta-analysis. RESULTS: MMR-status and survival data were available for 223 patients (median age 66 years, 62.8% male), 23 patients were MMRd (10.3%). After matching for baseline clinical characteristics, median OS was not reached in any subgroup. Compared to perioperative chemotherapy, patients receiving surgery alone with MMRd and MMRp had a HR of 0.67 (95% CI 0.13-3.37, P = 0.63) and 1.44 (95% CI 0.66-3.13, P = 0.36), respectively. The meta-analysis included pooled data from 385 patients. Compared to perioperative chemotherapy, patients receiving surgery alone with MMRd had an improved OS with a HR of 0.36 (95% CI 0.14-0.91, P = 0.03), whereas those with MMRp had a HR of 1.18 (95% CI 0.89-1.58, P = 0.26). CONCLUSION: Our data support a positive prognostic effect for MMRd in GC patients treated with surgery only and a differentially negative prognostic effect in patients treated with perioperative chemotherapy. MMR status determined by preoperative biopsies may be used as a predictive biomarker to select patients for perioperative chemotherapy in curatively resectable GC.

A new option for the management of urethral trauma: primary reconstruction of posterior urethral disruption with a buccal mucosa transplant.

Up to now, the management of traumatic posterior urethral disruption ranges from primary realignment to delayed urethroplasty. However, we reconstructed the membranous part of the urethra with an onlay graft of buccal mucosa after traumatic complete disruption as a first line therapy. After 7 months followup, the clinical outcome is very good. Because primary reconstruction of the urethra with a buccal mucosa graft after traumatic disruption has not yet been reported, the question arises whether this technique should be routinely included as an option for primary urethral reconstruction after trauma of the posterior urethra.

[Subjective patient satisfaction after injection of botulinum-a toxin in detrusor overactivity]. / Subjektive Patientenzufriedenheit nach Botulinumtoxin-A-Injektionen bei Detrusorhyperaktivität.

PURPOSE: The established treatment for overactive detrusor function consists of anticholinergic drugs. But this treatment can fail or produce intolerable side effects. We therefore investigated the effect of botulinum-A toxin in treating overactive detrusor function in patients with neurogenic and nonneurogenic bladder dysfunction. We were particularly interested in patient satisfaction with this therapy. MATERIAL AND METHODS: The subjects were 38 patients who had overactive detrusor function of different origins and in whom therapy with anticholinergic drugs had failed. To measure results, we used urodynamic studies and a questionnaire that consisted of 27 validated questions ("Urogenital Distress Inventory UDI-6", "Symptom Severity Index" and "Symptom Impact Index") as well as a satisfaction questionnaire. We injected 200 - 300 U of botulinum-A toxin (Botox) cystoscopically. RESULTS: At least 4 weeks after injection, 90 % of the patients reported clear improvement of their voiding situation and 93 % stated that they would undergo this procedure again. The frequency of micturition decreased by 29 % in average, and the increased postvoid residual volume was clinically irrelevant. Patients reported side effects or complications in 6.7 % of cases. The satisfaction scale (0 - 10) averaged 6.9. Urodynamically, reflex volume increased by 85 %, maximal bladder capacity increased by 47 %, and bladder pressure decreased by 33 %. CONCLUSIONS: Botulinum-A toxin injection into the overactive detrusor muscle seems to be very effective. The effect is not only reflected in urodynamic studies but also in the subjective patient satisfaction.

Primary hyperlipoproteinemias as risk factors in peripheral artery disease documented by arteriography.

In a controlled study on 121 patients with peripheral vascular disease (PVD) (75 patients with primary hyperlipoproteinemia, 15 diabetics, 31 patients without metabolic disease) the relationship between risk factors (hyperlipoproteinemia, obesity, hypertension, abnormal glucose tolerance, smoking) and the degree and localisation of sclerotic lesions was investigated by angiography. The degree was directly related in all patients to the number of risk factors, in Type IIa to cholesterol levels, in diabetics and Type IV with abnormal glucose tolerance to age. The latter patients were 5-10 years older than patients with Type IIa and showed 2 or more additional risk factors. The sclerotic lesions affected in Type IIa, less in Type IIb, predominately the pelvic vessels. Diabetics and Type IV patients showed a distal arterial involvement. The difference was significant. The degree of sclerotic lesions in arteries of the pelvis and the distal lower limb was positively correlated with the cholesterol-triglyceride ratio. Smoking aggravated the pelvic lesions in Type IV. Hypertension lead to more pronounced lesions of the distal lower limb in Type II. S-shaped tortuosities of the big vessels were shown to be typical, independent of localisation or degree.

[Chronic occlusion of a renal artery with aneurysms in the para-aortic collateral circulation and multiple aneurysms in both kidneys (author's transl)]. / Chronisch-zentraler Nierenarterienverschluss mit Aneurysmen in der paraaortalen Kollateralarterie und multiplen Aneurysmen beider Nieren.

Chronic occlusion of the main renal artery may be followed by the development of a collateral circulation through ureteric and para-aortic arteries, and through lumbar and suprarenal arteries. A patient with occlusion of the left main renal artery is described, who developed a collateral circulation between the common iliac artery and the distal portion of the renal artery. The para-aortic collateral vessel developed one large and several small aneurysms, and there were aneurysms in both kidneys.

Clinical features of inflammatory joint and spine manifestations in Crohn's disease.

167 patients with Crohn's disease were investigated for joint and spine inflammation. Arthritis was observed in 23 patients (14%), sacroiliitis in 24 (14%), and sacroiliitis in combination with arthritis in 11 patients (7%). 15 patients (9%) had ankylosing spondylitis; 9 of them were HLA-B27 positive (60%). A parallel pattern in the course of bowel disease and joint inflammation was observed in 22 out of 34 patients with arthritis (59%). An association between the localization of Crohn's disease and the type of spondylarthritis could not be demonstrated. Patients with arthritis alone developed erythema nodosum (35%) or aphthous stomatitis more often (21%) than patients without spondylarthritis+ (6% and 12%, respectively). Other extra-intestinal manifestations of Crohn's disease did not reveal any association with the development of spondyloarthritis.

[Renal arterial aneurysms--diffuse renal arterial ectasia. (Review and case histories) (author's transl)]. / Nierenarterienaneurysma--diffuse Nierenarterienektasie. (Ubersicht und kasuistische Mitteilung)

Two cases of renal arterial aneurysm or diffuse renal arterial dilatation are presented. Frequency, pathogenesis, clinical appearance, and prognosis of this disorder are discussed. Major complications include rupture or thrombosis of the renal artery, and hypertension due to renal ischemia; the latter is best diagnosed by renin determination in renal venous blood collected by selective catheterization.

[Case of a malignant angiolipoleiomyoma of the kidney -- angiographic and pathohistologic findings in hamartomas of the kidney (author's transl)]. / Maligne entartetes angiolipoleiomyom der Niere--Renovasographie und Pathohistologie bei Nierenhamartomen

A malignant angiolipoleiomyoma and two benign angiomyolipomas are analyzed. Angiography and pathohistology are opposed. The renovasographic signs of these tumors are not specific for hamartomas and similar to those of hypernephroid carcinoma.

[Collateral circulation through uretral arteries caused by chronical central renal artery obstruction (author's transl)]. / Kollateralkreislauf über Ureterarterien bei chronischem Verschluss der zentralen Nierenarterie.

In 48-year old hypertonic patient, angiography showed obstruction of the right renal arterial ramus ventralis. Collateral circulation, especially through the ureteral plexus and lumbal arteries, developed. Differential diagnosis, embryologic background, and therapy are discussed.

Efficacy of botulinum-A toxin bladder injections for the treatment of neurogenic detrusor overactivity in multiple sclerosis patients: an objective and subjective analysis.

AIMS: We studied the use of botulinum-a toxin (BTX-A) injections into the bladder as an alternative approach in patients with neurogenic detrusor overactivity due to multiple sclerosis (MS) with drug-refractory overactive bladder (OAB) symptoms. METHODS: Sixteen MS patients--11 women, 5 men; mean age 48.6 years--with refractory OAB symptoms were included in a one-center prospective study. For outcome analysis, we used a bladder diary, a complete urodynamic study, and validated questionnaires for subjective assessment. We injected 300 U of BTX-A (Botox) into the bladder and into the external sphincter muscle to reduce the probability of posttreatment urine retention. RESULTS: There was an increase in residual volume from 81.3 +/- 23.8 to 126.3 +/- 32.9 ml after 4 weeks. In one woman, transient self-catheterization was unavoidable. Four weeks and 3 and 6 months after BTX-A injection, the significant results were as follows: daytime frequency was reduced by 29%, 44%, and 30%, respectively. Nocturia diminished by 33%, 72%, and 40%. Use of pads was be reduced by 38% after 4 weeks and by 64% after 3 months. Urodynamically, reflex volume and maximal cystometric bladder capacity increased by 73%, 77%, and 58% (at 6 months, the increase was not significant) and by 36%, 27%, and 36% (not significant). Maximal detrusor pressure decreased by 35%, 22%, and 57%. Subjective outcome indicated significant improvement of symptoms at 4 weeks and 3 months, but not at 6 months. Patient satisfaction with the therapy was very high. CONCLUSIONS: BTX-A detrusor injections are very effective in the treatment of drug-resistant OAB symptoms in MS patients as reflected in urodynamic measurements and in patient satisfaction. Build up of residual urine remains a problem of which patients must be informed.

[Pendulous endobronchial chondrolipoma (hamartoma) near the tracheal bifurcation (author's transl)]. / Bifurkationsnah pendelndes endobronchiales Chondrolipom (Hamartom)

The entitiy of hamartoma of the lung is defined and frequency, location, tissue components, and roentgenographic appearance are described. The clinical significance of this disease in one case of endobronchial location is discussed. It is reported about an own observation of an endobronchial, pendulous, polypoid chondrolipoma (hamartoma) which is located near the tracheal bifurcation. The following points about roentgenological procedures and diagnostic interpretation are concluded: 1. Indirect signs for occlusion of the right main stem bronchus by a pendulous polypoid hamartoma are a small-appearing right hilus and the overinflation of the right upper lobe caused by a valve-like mechanism. 2. The postoperative overinflation is located beyond the stalk of this lesion which originates in the right upper lobe, although the mass of this pendulous tumor is located in the right main stem bronchus, respectively in the right lower lobe bronchus (documented by tomography and surgery).3. The recognition of shape and inferior limitation of polypoid endobronchial neoplasmsis achieved best by tomography which is a simple, innocuous diagnostic procedure. Bronchoscopy and biopsy clarify preoperatively the criteria of the lesion.4. Bronchography of poststenotic areas of the lung in polypoid pendulous endobronchial neoplasm is contraindicated on account of threatening respiratory insufficiency.5. Development of an alternating broncho-tracheal syndrome must be considred in patients which undergo endoscopy in anesthesia.

[Umbilical collateral circulation in liver cirrhosis - Cruveilhier-v. Baumgarten syndrome (author's transl)]. / Umbilikale Kollateralzirkulation bei Leberzirrhose - Cruveilhier-v. Baumgarten-Syndrom.

Embryonal development and anatomy of the liver are shortly discussed; they do explain collateral circulation in liver cirrhosis. A case report is given of a patient with umbilical collateral circulation (Cruveilhier-v. Baumgarten syndrome), exhibiting impressive clinical and radiological findings. Such an umbilical collateral circulation will develop in up to 21% of all patients with an intrahepatic block. This is only one variant - not prone to complications by the way - of a multitude of different portosystemic shunts in liver cirrhosis. Therefore it should not be talked about as an independent syndrome.

[Diagnostic problems in the differentiation of achalasia and spasm of the oesophagus (author's transl)]. / Differentialdiagnostische Probleme bei der Abgrenzung von Achalasie und Osophagusspasmus.

In 15 patients suspected to have achalasia or diffuse spasm of the oesophagus we were unable to make the final diagnosis of their motility disorder in spite of radiologic, endoscopic, and manometric examinations. In 5 patients the radiologic and manometric results showed a discrepancy. In 4 patients only the lower oesophageal sphincter exhibited failure fo complete relaxations typical of achalasia; however, the motility of the body of the oesophagus was peristaltic in nature. In 6 patients the initial diagnosis had to be changed during follow-up. In conclusion, motility disorders occur in the oesophagus which cannot be classified according to existent definitions. It is possible therefore that achalasia and oesophageal spasm are different and not always fixed expressions of one nosologic entity.

[Malignant fibrous histiocytoma of the lung]. / Malignes fibröses Histiozytom der Lunge.

The malignant fibrous histiocytoma of the lung is one of the rarely diagnosed soft tissue sarcomas. With the presented case-history we want to remind of this kind of lung-tumour in particular of the possibility of pre-operative diagnostic and the radiological differential diagnosis.

[Localized retroperitoneal xanthofibrogranuloma simulating a pancreatic tumor]. / Lokalisiertes retroperitoneales Xanthofibrogranulom unter dem Bild eines Pankreastumors.

The diagnosis of xanthofibrogranuloma is difficult. This is examplified by observations in a 46-year-old man with a palpable tumor in the left upper abdomen. Even modern diagnostic procedures like ultrasound, angiography and ERCP were unable to clarify the diagnosis. Only when laparotomy demonstrated a circumscript tumor, 7 x 7 x 10 cm in size, below the pancreas which was enucleated, the suspicion of a pancreatic tumor could be dismissed. The different clinical pictures of xanthofibrogranuloma ware discussed. Etiology is still unknown. Therapy as a rule should be surgical.