Early detection of ductal breast cancer: the diagnostic procedure for grouped microcalcifications.

Mammography and xeroradiography for grouped microcalcifications are considered the most effective diagnostic methods to detect occult breast carcinoma. Radiography must direct the surgeon to excise the nonpalpable area. The removal of the tissue with grouped microcalcifications must be confirmed by intraoperative radiological control. The histologic preparation must be guided by radiographic controls. Tissue with calcific deposits is examined by step sections. The diagnostic success depends upon the cooperation between the radiologist, the surgeon, and the pathologist. Our results from 1964 to 1977 have shown a frequency of 14.4% of occult carcinoma. Ductal or lobular carcinomata in situ have been diagnosed in 8.9%. In 9.9% of the patients, cystic disease with severe and atypical proliferations has been encountered.

Early detection of ductal breast cancer: the diagnostic procedure for pathological discharge from the nipple.

Pathologic discharge from the nipple may be the only symptom of an early stage of carcinoma. Galactography is then the diagnostic method of choice to locate intraductal, nonpalpable lesions. The technique of galactography, the adequate surgical approach of pathologic galactographs (milk-duct segment resection), and the appropriate histological work-up of the surgical specimen are demonstrated. We report on 1918 galactographies in 1363 women with pathological discharge. In only 427 cases was a milk duct segment resection necessary (31.4%). In 8.5%, we found invasive intraductal cancer and in 2.9% ductal carcinomata in situ. Only 1 patient with breast cancer had axillary metastases. Extensive intraductal solid, papillary or adenomatous proliferations were found in 11.9% of the patients with excision. In 46.7% of the patients, papillomas were excised, a definitive treatment for this process. The supposition for success in the early diagnosis of cancer is close teamwork among the radiology, surgery and pathology services: the diagnostic result depends upon this. We attribute our yield of exact diagnosis to a very sophisticated histological work-up. We believe that this is necessary to avoid diagnostic failures.

Intraductal carcinoma (DCIS) of the breast. Risk-adapted tumor surgery with axillary lymphadenectomy?

Between 1963 and April 1994, 3823 women were treated both at the Universitäts-Frauenklinik Berlin-Charlottenburg as well as at the I. Frauenklinik der Universität München, for a malignant condition of the breast gland. 161 of these (4.2%) exhibited an intraductal carcinoma stage pTis, whilst 99 (61.5%) were axillary lymphadenectomised. During the observation time-span of up to 24 years, 9 patients (5.6%) developed local recurrence. In neither patients of the group with axillary nor without axillary dissection could a regional recurrence be observed within this period. Also, a generalisation of this condition was not recorded in any patient. On the basis of our own results and those from the literature we postulate that, under the auspices of a risk adapted tumor surgery, axillary lymphadenectomy is no longer necessary under certain conditions in non-invasive breast carcinoma.

[Hepatitis-B-surface antigen and panarteritis (author's transl)]. / Australiaantigenpositive Hepatitis und Panarteriitis.

A case of an acutely beginning histologically proved panarteritis is described which was initiated by hepatitis B caused by blood transfusions. After one year of steroid therapy the arteritis was no longer seen histologically, Australia-antigen became negative. Terminally the patient developed an apoplexy, renewed gastric bleeding, septicemia with obstructive jaundice, nose bleeding, increasing renal insufficiency, and cardiac failure. The Australia-antigen reappeared in the serum. It could be assumed that the panarteritis had progressed. Immune complexes of Australia-antigen and corresponding antibodies which are deposited in the vascular wall and cause an inflammatory reaction, are being held responsible for the panateritis. They were proved serologically and by immunofluorescence in the vascular wall. In cases of panarteritis of unknown origin Australia-antigen can be found in a high percentage, as was demonstrated by a second case.

[Early diagnosis of cancer in operative gynaecology. II. On the general effects of preventive cancer examinations on operative gynaecology (author's transl]. / Krebsfrüherkennung und operative Gynäkologie. II. Uber allgemeine Auswirkungen der Vorsorgeuntersuchung auf die operative Gynäkologie.

Beyond early diagnosis of cancer and treatment of cancer the increase of gynaecological operation is primarily due to a liberalization of the indications. That more women have gynaecologic disease in the framework of the classical indications than before cannot be substantiated. The causes of the changes in indications are outlined. Demands of patients as consumers on a new expansive medical care system are among the changes. Self interests of the Obstetricians and Gynaecologists who constitute a larger percentage of medical specialists at present are part of the reason. The principle of preventive examinations has a psychological impact and the practice of the preventive examinations has an administrative impact on the increasing number of gynaecological operations. This trend is discussed with the example of hysterectomy. The experience of other countries is mentioned in which the advantages and disadvantages of an increasing number of gynaecological operations is analyzed and in which a regulation is attempted to prevented escalating costs. It can be assumed that a similar analysis and regulation will become necessary in Germany.

[The sigmoid vagina: experiences in the treatment of congenital absence or later loss of the vagina]. / Die Sigmascheide: Erfahrungen in der Behandlung bei angeborenem Fehlen oder späterem Verlust der Vagina.

Construction of a neovagina by means of a pedicled sigmoid transplant is considered a successful and for the patient satisfactory method in congenital vaginal aplasia or loss of the vagina after radical cancer surgery in the pelvis. The operative procedure and the anatomical and functional results obtained in 23 patients treated by the author are reported and discussed.

[Differentiated operative therapy of endometrial carcinomas]. / Differenzierte operative Therapie des Endometriumkarzinoms.

The traditional surgical procedure to treat operable endometrial cancer is the removal of the uterus and both adnexa. In the trend of modern gynecological oncology this standardized operation should be changed in favour to a more individual procedure adapted to preoperative and intraoperative stage of the disease. A carefully fractioned curettage (of the cervix and the corpus uteri) is necessary to differ stage I (T1) and stage II (T2). Further important prognostic factors as myometrial invasion, nodal status, lymph vessel and blood vessel involvement and the intraabdominal findings (T3) are details of the post-surgical evaluation. A differentiated surgical treatment of the endometrial cancer includes for a stage I disease hysterectomy, bilateral adnectomy and pelvine lymphonodectomy. We recommend this additional procedure in all stages of the disease: The nodal status is for almost all genital cancers and breast cancer the most important prognostic factor. Postoperative adjuvent therapy (radiotherapy, hormonal therapy, chemotherapy) may be indicated by that. The surgical procedure for stage II (corpus and cervix involved) disease is a radical hysterectomy (Wertheim), bilateral adnectomy and pelvine lymphonodectomy. A paraaortal lymphonodectomy may be recommended, but most of the patients are 70 years and more and have a multimorbidity. Therefore, we indicated this additional procedure only in 7.5% of the operated patients. The surgical strategy in the (rare) stage III individual cancer is similar to the procedure in progressive ovarian cancer: Cytoreduction and debulking (e.g. omentum majus, peritoneum, involved bowel) has to be performed subsequent to hysterectomy, bilateral adnectomy and lymphonodectomy to improve the poor prognosis.

[Does oral contraception cause cancer? (author's transl)]. / Begünstigt die "Pille" Krebs

A complete answer to the question of the relationship between malignant tumors in man and the administration of contraceptive steroids is at present not possible. Difficulties of the investigation are caused by the multiplicity of compounds used for contraception, the generally slow development of malignant tumors and the difficulty of the epidemiologic and statistical investigations on the multi-factorial etiology of cancer. Nevertheless, it can be stated with a high degree of certainty that "cancer due to the pill" does not exist in man and that a direct hormonal induction of malignant tumors in man cannot be proved. The question whether oral contraceptives may favor the development of cancer indirectly is explored in this paper regarding cancer of the female genital tract and the breast. No correlation between oral contraception and squamous cell carcinomas of the vulva and vagina and tumors of the ovary is known. As yet no statistics are available on the incidence of carcinoma of the endometrium in women who took oral contraceptives during their reproductive life span. Because of the direct hormonal suppression of the endometrial growth by oral contraception, a protective effect against endometrial hyperplasia and endometrial cancer must be expected. For cancer of the female breast no protective and no enhancing cancer risk due to progestational agents can be postulated. The known fragmentary data suggest a more protective value. Regarding dysplasia and carcinoma in situ of the uterine cervix large investigations in high numbers of patients are available. An increase of the risk to develop cancer of the cervix by using oral contraception cannot be shown with sufficient accuracy at our present state of knowledge by statistical means. Some observations suggest that oral contraception increases the relevant exogenous factors for carcinogenesis of the uterine cervix such as sexual behavior and hygiene.

PIP: The effect of oral contraceptives on the development of cancer indirectly is explored with regard to cancer of the female genital tract and the breast. No correlation between oral contraception and squamous cell carcinomas of the vulva and vagina and tumors of the ovary is known. As yet no statistics are available on the incidence of carcinoma of the endometrium in women who took oral contraceptives during their reproductive life span. Because of the direct hormonal suppression of the endometrial growth by oral contraception, a protective effect against endometrial hyperplasia and endometrial cancer must be expected. For cancer of the female breast no protective and no enhancing cancer risk due to progestational agents can be postulated. The known fragmentary data suggest rather a protective effect. Regarding dysplasia and carcinoma in situ of the uterine cervix, large investigations with great numbers of patients are available. An increase of the risk of developing cancer of the cervix by using oral contraception cannot be shown with sufficient accuracy at our present state of knowledge by statistical means. Some observations suggest that oral contraception increases the relevant exogenous factors for carcinogenesis of the uterine cervix such as sexual behavior and hygiene.

A comparison between the results of simple mastectomy and tumorectomy for breast cancer: the problem of local recurrence.

Between 1963 and 1981, 1139 patients had surgery for unilateral breast cancer at the Charlottenburg Gynaecological Clinic of the Free University Berlin. A total of 948 patients had a simple mastectomy and 191 patients had an extended tumorectomy (or lumpectomy) with subsequent radiotherapy (40 Gy). Retrospective analysis of "matched cases" treated by tumorectomy or mastectomy showed the rate of local recurrence after tumorectomy to be nearly double that after simple mastectomy (8.7% after tumorectomy, 4.7% after mastectomy). Life expectancy with a local recurrence after conservative surgery, was however, better than that after simple mastectomy.

[Inhuman practices in gynecology in national socialism and its victims. Study of concrete results]. / Uber inhumane Praktiken der Frauenheilkunde im Nationalsozialismus und ihre Opfer. Untersuchung zu konkreten Ereignissen.

In our opinion German gynaecology has failed to adequately face what came to pass during the Nazi period. This can be proved objectively, for there is no evidence that, after 1945, gynaecology had in any way cared to take notice--either thermatically or medically--of the thousands of victims of inhuman practices such as forced termination of pregnancy, compulsory sterilisation and the like. During the past 50 years recollections of enforced sterilisations, compulsory abortions, deliberate and hence criminal negligence and problematic approaches in research and teaching were almost completely banished from the area of conscious awareness and largely suppressed or silently ignored. Most of the medical directors of Departments of Gynaecology of German universities shared this view whenever they were questioned on the connections between gynaecology and Nazism. Now that two generations have passed it seems possible to examine and explore with less guilt feelings and shame the immensely fateful rôle of gynaecology in that context. Accent should be on the fate of the victims of that period. To bring back these events to memory, however, does not permit to conceal the part played by the physicians committing of these inhuman Nazi crimes. Data collected from a psychosomatically oriented examination of victims exemplify that to concretely recall gynaecology during Nazism a1-so offers a chance in several respects. One of the possibilities in this context is to signal "late apology" and regret to patients who had been victims, in one's own area of work, after one has psychically worked over their fate. Besides, a gynaecological-psychosomatic expertise will help e.g. that compulsorily sterilised women are granted financial aid that has at long last become a legal possibility and can be applied for since 1980. However, the relevant patient records do show very clearly that the inhuman practice of gynaecology during the so-called "Third Reich" was not only a collective problem but equally due to a failure of the individual conscience of numerous gynaecologists. Working over this complex may enhance our own sensitivity for psychosomatic and ethic problems and counteract any likelihood of a recurrence of an inhuman gynaecology.

[Benign cutaneous lymphadenosis (Bäfverstedt's disease) of the nipple (author's transl)]. / Die Lymphadenosis benigna cutis (M. Bäfverstedt) im Warzenbereich.

Benign circumscribed cutaneous lymphadenosis of the areola of the nipple (Bäfverstedt's disease) occurs in children and adults. We observed 11 cases: 3 men, 3 children and 6 women. The areola undergoes rapid swelling and becomes red. At times the nipple itself is included. Unilateral enlargment and distortion of the nipple area becomes apparent. Sometimes this is associated with a tumor-like infiltration of the retro-mammillary tissue. In Contradistinction to Pagets disease of the nipple and to a mammillary adenoma there is no eczema and no ulceration. The clinical features and the typical pruritic course establish the diagnosis. Healing is spontaneous, but protracted. The aetiology is probably of an inflammatory nature. Treatment with short courses of antibiotics and anti-inflammatory agents resulted in a faster reduction of the cutaneous signs and corroborated the clinical diagnosis. We consider surgical treatment as unnecessary because circumscript benign lymphadenosis of the nipple area has a harmless course.

[Extreme oedema of the ovaries: a contribution to conservative surgery for ovarian "tumours" (author's transl)]. / Monströses Odem der Ovarien: Ein Beitrag zur konservativen Chirurgie von Ovarial- "Tumoren"

A laparotomy for a suspected cystic ovarian tumour which was thought to extent as far as the costal arch, was carried out on a 24-year-old patient with a long history of oligomenorrhea and sterility. Due to excessive oedema, both ovaries were tremendously enlarged. The right ovary was twisted 360 degrees. No haemorrhagic infarct, however, was present. Both ovaries, which were about 40% of the normal size due to pressure from the oedema, were incized. The ovaries were than sutured and left in situ. Laparoscopy 9 weeks later confirmed that the ovaries had returned to a normal size. The patient's menstrual cycle became regular. Even though the process may be unusually extensive, conservative methods should be given preference when the patient is so young.

[The value od needle biopsy for the microscopic diagnosis of diseases of the breast (author's transl)]. / Zum Wert der Stanzbiopsie für die histologische Diagnostik von Mammaerkrankungen

The accuracy of needle biopsies with the disposable biopsy needle TRU-cut was compared to the results of the microscopic examinations of excisional biopsies obtained after the needle biopsy in 276 patients. The diagnostic accuracy in relationship to the diameter of the lesion is listed for 140 patients with carcinoma of the breast, for 72 patients with benign tumors of the breast and for 64 patients with well localized palpable fibrocystic disease. In our experience, the following pre-requistes are necessary to obtain a high diagnostic accuracy for the needle biopsy: 1. A well filled circumscribed, well palpable nodule of uniform consistency. 2. A superficial site close to the skin. 3. A diameter of more than 2 cm. 4. Some experience with the use of the instrument. Needle biopsies of the breast are indicated for skin metastases, recurrences in the scar, and for in-operably advanced tumor or patients who should not have general anaesthesia. Needle biopsy as the biopsy method for a primary plan of management is only relatively indicated in large carcinomas of the breast, or smaller tumors located close to the skin, or tumors which are well accessable in a small breast. The needle biopsy is not suited for the diagnosis of benign tumors of the breast, fibroadenomas, lipomas, or papillomas since complete excision of these lesions is the aim of management. In fibrocystic disease, needle biopsy is not indicated. This clinical or radiological localized finding may correlate to variable microscopic entities with different plans of management. The very small portion of the process shown in the needle biopsy is insufficient in fibrocystic disease. An absolute contra-indication to needle biopsy of the breast is the diagnosis of obscure disease on the breast.

[The value of an exploration of the mesogastric and epigastric regions in laparotomies (author's transl)]. / Uber den Wert einer Mittel- und Oberbauchexploration bei Laparotomien.

The records of 4765 laparotmies including 1422 Caesarean sections were reviewed regarding additional surgical or medical findings. In 13.79% of the cases additional pathological findings were present which required additional general surgery or urologic surgery, or intra-operative or post-operative diagnostic steps. The exploration of the general abdominal cavity by inspection and/or palpation during the gynaecological or obstetric laparotomies was therefore very valuable. This simple preventive step requires very little time and maybe of considerable importance for the patient.

Postoperative urological complications after radical surgery for cervical cancer.

Functional disorders of the lower urinary tract must be considered inevitable after Wertheim hysterectomy. These disorders include disturbances of the collecting phase as well as of the voiding phase of the bladder, and the development of urinary stress-incontinence. Urodynamic studies are necessary to find out more about the pathophysiology of these disorders. The results of our follow-up studies confirm that during the early postoperative phase patients do not feel the urge to void, and, after micturition, have no idea whether or not the bladder is empty. Micturition itself becomes difficult. At a later stage, sensitivity in respect of the bladder contents is regained. Some months later the incidence of urinary stress-incontinence rises markedly. The dysfunction is due partly to direct trauma of the bladder and urethra. As a reason for the long-lasting fall in urethral closure pressure, combined with urinary stress-incontinence, some damage to the pelvic nerves must be assumed. Disorders of micturition have been poorly investigated. It is only during the postoperative phase that functional infravesical obstruction must be assumed. At a later stage micturition mostly becomes normal. In contrast to the results of others (Schüssler, 1988) the results of our studies confirm that these disorders are due not only to nerve lesions. Disorders of the collecting phase as well as of the voiding phase of the bladder are mostly transient. As a consequence we suggest that the direct operative trauma, with oedema, haematoma and scar formation, is responsible for bladder dysfunctions during the early postoperative stage at least.(ABSTRACT TRUNCATED AT 250 WORDS)

[Serous papillary adenocarcinoma of the endometrium]. / Das serös papilläre Adenokarzinom des Endometriums.

7 cases of serous-papillary adenocarcinoma of the endometrium (UPSC) were found in a retrospective study of 80 patients which were treated at the Department of Gynaecology of the University of Munich from August 1987 to December 1989 because of endometrial adenocarcinoma. Characteristic histologic findings and prognostic factors of the UPSC were examined by means of large scale sections of the completely worked-up uteri and compared with the usual adenocarcinoma of the endometrioid type (UEC). Despite only minimal myometrial infiltration in some cases, lymphangiosis carcinomatosa was almost always present (6/7) and more than 50% of patients showed evidence of blood vessel involvement. In all patients with pelvic lymph node dissection metastases were found. According to our results in line with the literature, UPSC is a highly malignant and morphologically distinct variant of endometrial adenocarcinoma without promising treatment to date.