Comparison of narrow-band imaging with autofluorescence imaging for endoscopic detection of squamous cell carcinoma of the tonsil.

PURPOSE: Early detection of mucosal neoplastic lesions is crucial for a patient's prognosis. This has led to the development of effective optical endoscopic diagnostic methods such as narrow band imaging (NBI) and autofluorescence (AFI). Independent of each other, both of these methods were proven useful in the detection of mucosal neoplasias. There are limited reported data comparing both methods for oropharyngeal cancer diagnostics. The aim of the study was to compare NBI and AFI endoscopic visualization of signs in identifying tonsillar squamous cell carcinoma (SCC) and assessing its extent and to determine whether the score was related to the evaluator's experience. METHODS: Patients with tonsillar SCC underwent endoscopic pharyngeal examination using NBI and AFI. Fiftyseven video sequences of examinations of lesions proven to be SCC were evaluated by three reviewers. The accuracy of determination of lesion extent and visualization of its endoscopic signs of malignancy were evaluated. RESULTS: Endoscopic visualization of tumour spread was significantly better using AFI than NBI (p = 0.0003). No significant difference was found between NBI and AFI in the visualization of endoscopic malignancy determining signs (p = 0.1405). No significant difference was found among the three reviewers in the visualization of tumour spread and for identifying malignancy-determining signs in NBI endoscopy or AFI endoscopy. CONCLUSIONS: The results show that AFI obtained better results for assessing the extent of tonsillar cancers than NBI. Both methods were proven to be equal in the visualization of endoscopic malignancy-determining signs. Both are useful even for less experienced evaluators.

Effect of shock waves combined with cytostatics on the growths of tumors in vivo.

Based on their field of application, the physical parameters of shock waves differ. Experiments referred to in this article used tandem shock waves generated on the surface of a composite anode. There, individual pores of the anode produce multichannel discharges. The composite anode may have a variety of shapes, which, consequently, influence the arrangement of the entire apparatus and the area of their application. Experiments referred to in this article utilise an anode divided into two parts that generated tandem shock waves. The previously conducted experiments have clearly shown that the effect of a tandem shock wave can be very well localized in the focal area, causing necrosis and apoptosis of the tumor cells, and enhancing the effect of cytostatics. This study investigated the effect of tandem shock waves with concomitantly administered cytostatics. We conducted our experiments on Lewis rats. The rats were injected with syngeneic sarcoma tumor cells intradermally and caudally on both the right and left sides. The highest rate of tumor growth inhibition was observed in the cisplatin-treated group that was subsequently treated with shock waves. The effect of shock waves on cell membranes is well described as they increase their permeability due to sonodynamic effect induced by cavitation. The results of experiments referred to in this article conducted in vivo in experimental animals enable us to note that the shock wave increases the effect of chemotherapy administered.

Pilot study: Association between Helicobacter pylori in adenoid hyperplasia and reflux episodes detected by multiple intraluminal impedance in children.

OBJECTIVES: The aim of this pilot study was to investigate an association between laryngopharyngeal reflux detected by combined multiple intraluminal impedance and pH monitoring and Helicobacter pylori in adenoid hyperplasia detected with real time polymerase chain reaction (PCR). METHODS: The study group consisted of 30 children (median age 5.34 years) with extraesophageal symptoms of gastroesophageal reflux disease with adenoid hyperplasia. All children underwent adenoidectomy with subsequent PCR detection of H. pylori DNA in the tissue and multiple intraluminal impedance and pH monitoring. The most proximal impedance sensor was located 1cm caudal to the entrance of the oesophagus. RESULTS: We found significant differences in the number of reflux episodes among patients with PCR positivity (median 35) and negativity (median 0) of H. pylori (p-value of Mann-Whitney U-test 0.0056). Patients with PCR positivity of H. pylori had significantly more reflux episodes reaching the upper oesophageal sphincter (p-value of Mann-Whitney U-test 0.023). The absence of reflux episode was the only independent factor for PCR negativity of H. pylori in the multiple logistic regression model. CONCLUSIONS: These results support the hypothesis that reflux episodes reaching the upper oesophageal sphincter may play an important role in the transmission of H. pylori into lymphoid tissue of the nasopharynx and thus may contribute to adenoid hyperplasia in children.

Comparison of Helicobacter pylori genotypes obtained from the oropharynx and stomach of the same individuals - a pilot study.

Helicobacter pylori has been recently detected in the oral cavity and oropharynx. However, the role it plays in oral and oropharyngeal pathogenesis remains unclear. The virulence of H. pylori strains can be distinguished according to the virulence factors genes carried. Our research has been focused on realtime PCR analysis of cagA and vacA genes of H. pylori strains in tonsils and tonsillar squamous cell cancer and their comparison with H. pylori strains obtained from the gastric mucosa of the same patients. Urea breath test (UBT) test was used to detect a gastric H. pylori infection in 20 patients with previously proven H. pylori in the oropharynx. Genotyping of H. pylori in gastric biopsies was performed in patients with positive gastric infection. Out of 20 patients positive for oropharyngeal H. pylori, 8 were positive for concurrent gastric H. pylori infection. In 6 of them gastric biopsies were obtained. Comparison of oropharyngeal and stomach H. pylori genotypes showed important differences. Four of 6 patients had different H. pylori strains in the oropharynx and stomach. The differences were found in cagA gene as well as in vacA gene. The finding of oral presence of H. pylori without concurrent stomach infection was confirmed using UBT. The results show that more than one H. pylori strain can be present in oropharynx and stomach in the same patient. The oropharyngeal infection seems to be independent to the gastric infection.

Biological effects of tandem shock waves demonstrated on magnetic resonance.

OBJECTIVES: The shock wave is used for the treatment of kidney stones, eventually of gall stones, for more than 20 years. It is a pressure wave, which breaks through soft tissues easily and it is possible to focus it into a small volume. The excellent results of the treatment of concrements led to considerations about another usage of the shock wave. The research is now concentrated on the possibility of the damage to tumour tissues. METHODS: In contrast to concrements tumour tissues are not different from healthy tissues as for their acoustic attributes. That is why a new source of shock waves was used in this work. The source allows generating two successive shock waves focused into a common focus, so-called tandem shock waves. The biological effects of the tandem shock waves generated by the new source on rats hepatic tissue and rabbit femoral muscle in vivo were studied in this work. The damage is demonstrated by magnetic resonance imaging. RESULTS: MR images showed tissue damage in focus. There was damage of the liver tissue, muscle and also stomach wall. CONCLUSIONS: We found that the tandem shock waves are able to damage the acoustically homogeneous soft tissue in the focus, i.e. in the depth. In tissues in front of the focus, there is, however, no damage (Fig. 10, Ref. 15).

Effects of tandem shock waves combined with photosan and cytostatics on the growth of tumours.

Shock waves, pressure waves manifested as a sharp increase in positive pressure followed by a decrease and the negative part of the wave, are not only used to treat concrements in medicine. Recently, research has been focused on the possibility of their use for damaging the tumour tissue. In contrast to concrements, which are different from the surrounding tissue by their acoustic impedance, the tumour tissue has the same acoustic impedance as the surrounding soft tissue. Therefore, we have developed a new source of shock waves, which is based on the principle of multichannel discharge. This new source generates two successive shock waves (tandem shock waves). The first shock creates acoustic non-homogeneity and cavitations in the tissue, and the second shock is damped in it. In this work we demonstrated the effect of tandem shock waves on the muscle tissue in depth. The damage is shown on the images from the magnetic resonance imaging and histological sections. In the further part of the experiment, we investigated the in vivo effects of tandem shock waves in combination with Photosan and cisplatin on the tumour tissue. The application of tandem shock waves resulted in the inhibition of tumour growth, compared with controls, in both parts of the experiment. The largest inhibition effect was observed in the groups of tandem shock waves combined with Photosan and in the second part with cisplatin.

Helicobacter pylori in tonsillar and adenoid tissue and its possible role in oropharyngeal carcinogenesis.

Helicobacter pylori is a well-known gastric pathogen. It plays a major role in the pathogenesis of chronic gastritis, duodenal and gastric ulcers, adenocarcinoma and gastric lymphoma. HP infection is one of the most common bacterial infections worldwide. Recently, the oral cavity was proposed as an extragastric reservoir of HP infection. HP was detected by culture and PCR in both dental plaque and saliva. It is supposed that HP infection can cause the same immunological changes in the oropharyngeal mucosa as in gastric mucosa and can also contribute to the progression of oropharyngeal diseases. HP can induce production of different cytokines and regulatory molecules, which are suggested to play a role in carcinogenesis of the oropharynx. Only a few studies have explored the presence of HP in tonsillar and adenoid tissue, where MALT is present similar to the gastric mucosa. The results of these studies were inconsistent. The question of persistence of HP in tonsillar and adenoid tissue and its role in the pathogenesis of oropharyngeal diseases still remains unclear. In this review, recent findings about oral HP are considered. Possibilities of diagnostics of HP in oral specimens are discussed.

Expression of endothelial and inducible nitric oxide synthase and caspase-3 in tonsillar cancer, chronic tonsillitis and healthy tonsils.

Neoangiogenesis and inhibition of apoptosis are two factors considered as major leading causes of tumorigenesis. NO, synthesized by NOS, plays an important role in tumour growth, dissemination and vascularization. Caspase-3 is an executive enzyme of apoptosis. The presented research work has been focused on the comparative evaluation of localization of the angiogenic and proapoptotic cytokines expressed in tonsillar diseases. The immunohistochemical reaction of eNOS, iNOS and caspase-3 in tonsillar cancer (N = 17), chronic tonsillitis (N = 11) and clinically healthy tonsils (N = 8) was detected. High eNOS occurrence in endothelial cells of highly vascularized regions in tonsillar cancer, variable eNOS expression in the vessels of lamina propria in chronic tonsillitis and high expression in the cytoplasm of endothelial cells of small veins in healthy tonsillar tissue was ascertained. Increased iNOS expression was found in cancer tissue in comparison with the healthy tonsils. Nevertheless, the highest expression of iNOS was found in chronic tonsillitis. Higher expression of caspase-3 was discovered in germinal centres of lymphoid follicles of the chronic tonsillitis tissue. However, the positivity in the interfollicular zone and surface squamous epithelium was weak only. Merely isolated caspase-3-positive cells were found in tonsillar cancer. Very low expression of caspase-3 was detected in the lymphatic follicles of the healthy tonsils. Research results showed high expression of eNOS in the carcinomatous tissue. The eNOS expression in chronic tonsillitis confirms its role in regulating the lymphocyte circulation. Low expression of caspase-3 in malignant epithelial cells of tonsillar cancer shows decreased capability of apoptosis compared to chronic tonsillitis tissue, where apoptosis seems to be rather frequent and concentrated in the germinal centres of lymphatic follicles. The differences in localization of eNOS and caspase-3 expression between benign and malignant processes may be a promising tool for precise morphological distinction of chronic inflammation and tumours.

Helicobacter pylori isolated from patients with tonsillar cancer or tonsillitis chronica could be of different genotype compared to isolates from gastrointestinal tract.

Helicobacter pylori from patients with different diseases, including so-called autoimmune thyroiditis, chronic tonsillitis and tonsillar cancer, was isolated and cultured. It was identified according to the genotype using labeled hybridization probes complementary to six sequences of cagA and vacA genes. Different types of strains were found in isolates from gastrointestinal tract and patients suffering from thyroiditis. Six out of seven genotyped isolates from patients in our Department of Otorhinolaryngology and Head and Neck Surgery exhibited the same genotype, differing from isolates obtained from other patients; the 7th isolate originated from a patient who had undergone surgery for deviatio septi nasi, at the same time suffering from autoimmune thyroiditis, having confirmed gastric infection by H. pylori from biopsy. This data made it possible to formulate the hypothesis on probable association of specific H. pylori genotype with chronic tonsillitis and tonsillar cancer. We assessed commercial transport media and improved nucleic acid isolation techniques and the RT-PCR-based tests, which allowed us to skip a culture step and to test directly the patients' samples; however, for full confirmation of our hypothesis and explanation of possible mechanisms of the contribution of Helicobacter sp. to the pathogenesis of the disease further data are to be collected and evaluated.

Colour Doppler ultrasound in diagnosing venous insufficiency. A comparison to descending phlebography.

OBJECTIVE: To evaluate the technique of ultrasound colour Doppler in diagnosing venous valvular incompetence in the lower leg. DESIGN: Prospective clinical study. SETTING: Department of clinical physiology. MATERIALS: 44 patients (56 legs) referred with a clinical diagnosis of deep venous insufficiency. CHIEF OUTCOME MEASURES: Colour Doppler and descending phlebography. MAIN RESULTS: Using phlebography as a "gold standard" the accuracy of the colour Doppler technique varied between 93% and 55% for the different veins. For the superficial and deep femoral veins, the popliteal vein and the long and short saphenous veins the accuracy was between 90% and 70%. The lowest correlation was found for the deep calf veins (55-66% accuracy). CONCLUSIONS: Colour Doppler was found to be a suitable technique for non-invasive investigation of patients with suspected venous insufficiency. Since the colour Doppler technique is non-invasive it is well suited for follow-up studies. Descending phlebography should be reserved as an adjunct technique in patients scheduled for valve reconstructive surgery.

Demonstration of hepatic veins by computed tomography using axial and angulated scanning.

The main hepatic veins run obliquely into the inferior caval vein. They are often poorly demonstrated on conventional axial computed tomography (CT) performed with a vertical gantry. In order to determine whether CT with caudal tilting of the gantry could improve demonstration of the hepatic veins, 30 consecutive patients of whom 20 had focal lesions in the liver were examined with both a vertical and a 20 degree caudally tilted gantry. As a reference group, 10 patients were examined with a 20 degree cranially tilted gantry. In 14/30 (47%) of the non-enhanced examinations caudally angulated CT demonstrated the hepatic veins better than axial CT, while axial CT was the better technique in one patient. No additional tumors were detected with either technique, but the caudal angulation improved the anatomical location of tumors due to a better demonstration of their relation to hepatic veins. CT with cranial angulation did not in any patient improve the demonstration of veins when compared to axial CT. Angulated CT also included examination with contrast enhancement using bolus technique. In 20 out of 27 (74%) examinations with a caudally tilted gantry and contrast enhancement considered optimal for tumor detection, veins containing contrast medium were depicted for an anatomical description. Caudally angulated CT is a non-invasive technique which should be performed in patients in whom liver resection is considered.

Contrast enhancement of liver parenchyma and biliary tract related to liver function at delayed computed tomography.

Computed tomography (CT) of the liver was performed in 53 patients before, during and 4 to 6 hours after intravenous administration of approximately 60 g of iodine in metrizoate. At delayed CT, contrast medium was observed in the extrabiliary ducts in 20 patients (38%) and in the gallbladder in 28 (68%) of the 41 patients with no previous cholecystectomy. The increase in attenuation of liver parenchyma at delayed CT compared with the non-enhanced baseline CT ranged between 2 and 26 HU (mean 13.9). The material was divided into three groups with regard to liver function: normal, intermediate and pathologic. In the normal group contrast medium was observed in the gallbladder in 81 per cent and in the bile ducts in 57 per cent and the mean increase in attenuation of the liver parenchyma was 14.5 HU. In the pathologic group the same parameters were 40 per cent, 7 per cent and 10.6 HU, respectively. Contrast medium in the gallbladder and biliary ducts improved the information about anatomy. Pathology of the gallbladder and tumour growth along the hepatoduodenal ligament were better demonstrated. Delayed CT is a simple and non-invasive technique that may improve planning of liver surgery.

Comparison of non-enhanced, bolus enhanced, and delayed scanning techniques in computed tomography of hepatic tumours.

Non-enhanced, bolus contrast medium enhanced and 4 to 6 hours delayed computed tomography of the liver was performed in a prospective study of 53 patients. Forty patients had focal lesions, in 12 of these they were hypervascular. Contrast medium was administered as an initial bolus followed by a rapid injection of meglumine metrizoate (Isopaque Cerebral). The total iodine dose varied between 56 and 63 g, which gave an average increase in attenuation of 14 HU in normal parenchyma comparing delayed with non-enhanced scanning. Presence and extent of focal lesions were evaluated in a randomized and independent analysis by two radiologists. The percentage of examinations with correct tumour description was higher with bolus scanning (observer I 73%, observer II 75%) and delayed scanning (observer I 75%, observer II 78%) than with non-enhanced scanning (observers I and II 67%). An optimal bolus technique requires an exact timing of the contrast medium administration and scanning. Delayed scanning provides an excellent supplement when the bolus examination is suboptimal or shows equivocal findings.

Evaluation of percutaneous cholangiography and percutaneous biliary drainage in obstructive jaundice.

104 patients with obstructive jaundice were referred for percutaneous transhepatic cholangiography (PTC) and percutaneous transhepatic biliary drainage (PTBD). The effects of PTBD on postoperative morbidity and mortality were evaluated as well as the occurrence of complications. The results were compared to a group of 33 patients with malignant bile duct obstruction operated without preoperative bile drainage. There was no significant difference in the rate of postoperative complications and mortality between these two groups.

Diagnosis and treatment of superior mesenteric artery syndrome.

Superior mesenteric artery syndrome (SMAS) is a rare clinical condition. Eleven cases of SMAS treated surgically are reported after follow-up periods of 6 months to 6 years. The value of hypotonic duodenography in the diagnosis of the syndrome is emphasized.

Angiographically discovered, non-operated renal artery aneurysms.

Angiographies (a total of approximately 9 500) and patient records revealed 56 patients with renal artery aneurysm during the period 1960 to 1974. Fifteen patients were operated upon electively and 3 were lost for follow-up. Rupture occurred in four leading to acute nephrectomy. Thus, 34 patients were left for studies on the natural course. They were 29-82 years old (mean 58 years) at diagnosis and were followed for at least 90 months. Twelve were males and 22 females. The aneurysms had a diameter of 3-25 mm (mean 12 mm), were fusiform in 7 and saccular in 27 cases; 9 were calcified. Repeated angiographies were carried out in 7 patients at intervals of up to 73 months showing slight enlargement of one aneurysm, disappearance of another and no change in 5. Sixteen patients were alive at the end of the follow-up period 90-220 months (mean 157 months) after the first or only angiography. Eighteen patients died after 2-204 months (mean 84 months), 14 of cardiovascular disease unrelated to the renal arteries, 3 of malignant tumour and one of pancreatitis. Autopsy in 12 patients did not show rupture of any renal artery aneurysm. Thus, in a considerable number of patients the disorder was uncomplicated and compatible with a long life.

False popliteal aneurysm caused by exostosis of the femur.

A 45-year-old woman with a false aneurysm of the left popliteal artery caused by an exostosis of the femur is described. The patient had a tender swelling in the distal part of the thigh and a soft-tissue tumor was initially suspected. Diagnosis was made by ultrasonography, plain X-ray and angiography. The aneurysm and exostosis were resected. The literature regarding this condition is reviewed. Surgical treatment of popliteal aneurysm is recommended mainly because of the risk of occlusion of distal vessels by peripheral embolism.

Surgical excision of an adrenal myelolipoma.

Myelolipoma of the adrenal gland is a benign tumour composed of fat and haematopoietic cells. It is usually asymptomatic and discovered as an incidental finding at autopsy. Only twenty-five patients have previously been described in whom an adrenal myelolipoma had been removed surgically. The patient reported in this paper had a myelolipoma in his left adrenal gland. The tumour was diagnosed by intravenous pyelography, ultrasonography, arteriography and computed tomography. No endocrine symptoms were present and hormonal analyses were normal. Surgical excision of the tumour was performed with an uneventful postoperative course. The diagnosis should be considered in patients with a suprarenal mass manifesting features that are atypical of other tumours of this region.

Percutaneous drainage of intraabdominal fluid collections.

Nine cases of percutaneous drainage of intraabdominal fluid collections in eight patients are reported. Ultrasonography and conventional radiography was utilized to make the diagnosis and to plan and perform puncture and drainage. In one case of subhepatic abscess only punction and aspiration was performed. In all other cases draining catheters were left between 3 and 21 days. Except in one case which later proved to be a cystic adenopapillary carcinoma of the kidney the results were good.

Hypotonic duodenography and secretin-CCK test in the diagnosis of pancreatic disease.

Sixty-five patients with possible pancreatic disease or long-lasting upper abdominal symptoms were examined by means of the secretin-CCK test and hypotonic duodenography. Both examinations were performed after one duodenal intubation. In patients with pancreatitis functional abnormalities were revealed in 85 per cent while the duodenography was abnormal in 43 per cent. In patients with carcinoma, 77 per cent had abnormal exocrine pancreas function and 70 per cent had abnormalities demonstrated at duodenography. The value of the two examinations for assessment of patients with upper abdominal symptoms and pancreatic disease is discussed.