Efficacy of tamoxifen ± aminoglutethimide in normal weight and overweight postmenopausal patients with hormone receptor-positive breast cancer: an analysis of 1509 patients of the ABCSG-06 trial.

BACKGROUND: There exists evidence that body mass index (BMI) impacts on the efficacy of aromatase inhibitors in patients with breast cancer. The relationship between BMI and the efficacy of tamoxifen is conflicting. We investigated the impact of BMI on the efficacy of single tamoxifen and tamoxifen plus an aromatase inhibitor in the well-defined prospective study population of the ABCSG-06 trial. METHODS: ABCSG-06 investigated the efficacy of tamoxifen vs tamoxifen plus aminoglutethimide in postmenopausal women with hormone receptor-positive breast cancer. Taking BMI at baseline, patients were classified as normal weight (BMI=18.5-24.9 kg m(-)(2)), overweight (BMI=25-29.9 kg m(-)(2)), and obese (30 kg m(-)(2)) according to WHO criteria. RESULTS: Overweight+obese patients had an increased risk for distant recurrences (hazard ratio (HR): 1.51; Cox P=0·018) and a worse overall survival (OS; HR: 1·49; Cox P=0·052) compared with normal weight patients. Analysing patients treated with single tamoxifen only, no difference between overweight+obese patients and normal weight patients regarding distant recurrence-free survival (HR: 1.35; Cox P=0·24) and OS (HR: 0.99; Cox P=0·97) could be observed. In contrast, in the group of patients treated with the combination of tamoxifen plus aminoglutethimide, overweight+obese patients had an increased risk for distant recurrences (1.67; Cox P=0·03) and a worse OS (1.47; Cox P=0·11) compared with normal weight patients. CONCLUSION: BMI impacts on the efficacy of aromatase inhibitor-based treatment but not single tamoxifen.

Adjuvant intraperitoneal chemotherapy with carbon-adsorbed mitomycin in patients with gastric cancer: results of a randomized multicenter trial of the Austrian Working Group for Surgical Oncology.

PURPOSE: Previous studies have demonstrated a beneficial effect of intraperitoneally applied mitomycin bound to activated carbon particles (M-CH) in preventing intraabdominal recurrence following curative surgery for gastric cancer. The Austrian Working Group for Stomach Cancer, a subgroup of the Austrian Working Group for Surgical Oncology, initiated a multicentric phase III trial to evaluate the safety and efficacy of this treatment regimen. PATIENTS AND METHODS: A total of 91 patients with a radically resected gastric cancer infiltrating the serosal surface were randomly assigned to receive either 50 mg mitomycin bound to a solution of 375 mg carbo adsorbens intraperitoneally before closure of the abdominal wound (n = 46) or served as a surgical control group (n = 45). Postoperative complications and recurrence-free and overall survival were evaluated to analyze the risks and benefits of this treatment. RESULTS: After a median observation period of 597 days (range, 72 to 1,096), a significantly higher postoperative complication rate was observed in the M-CH group (35%) compared with the control group (16%) (P < .02). In accordance with this finding, the postoperative (60 days) mortality rate was also significantly elevated in the M-CH group (11% v 2% in the control group). Since analysis of overall and recurrence-free survival failed to show any beneficial effect of M-CH therapy, the protocol committee decided to stop further recruitment of patients onto this study. CONCLUSION: Adjuvant intraperitoneal therapy of gastric cancer by mitomycin bound to activated carbon particles is associated with an increased rate of postoperative complications. However, no benefit for prognosis following radical resection of locally advanced tumors was observed in this multicenter phase III trial.

Malignant hemangioendothelioma of the thyroid. Its immunohistochemical discrimination from undifferentiated thyroid carcinoma.

Eighteen cases of malignant hemangioendothelioma (MHE) of the thyroid and 16 cases of undifferentiated thyroid carcinoma were investigated immunohistochemically with antibodies against endothelial cell specific markers (factor VIII-related antigen, BMA 120, blood group isoantigens, Ulex europaeus agglutinin I), thyroglobulin, and the intermediate filament proteins vimentin and cytokeratin. All MHE were positive for factor VIII-related antigen and vimentin, in 14 of 18 cases for BMA 120, and in 9 of 18 cases for U. europaeus. All other markers were negative in MHE. Endothelial cell specific markers were commonly negative in undifferentiated carcinomas with one exception (one case was moderately positive for U. europaeus). Twelve of 16 undifferentiated carcinomas showed vimentin positivity, and 8 of 16 showed cytokeratin positivity. Four cases showed a vimentin/cytokeratin coexpression. It is concluded that the endothelial origin of MHE can be shown by certain endothelial cell markers in almost all cases.

Hepatocellular transplantation into the lung in chronic liver failure following bile duct obstruction in the rat.

Injection of hepatocytes or cell-free supernatant into the lung was able to prevent death from surgically induced fulminant hepatic failure in the rat in over 90% and 53% of subjects, respectively. The aim of this study was to investigate whether this technique can be applied in chronic liver failure. Chronic liver failure was induced in Lewis rats by ligation and transection of the common bile duct, which led to cirrhosis after 3-5 wk in all animals. Four groups of animals were formed: group 1 (n = 5), normal rats, serving as control; group 2 (n = 15), cirrhotic rats, no further treatment; group 3 (n = 14), hepatocyte transplantation by injection of cell suspension transcutaneously into the right lung of cirrhotic animals four wk after bile duct ligation; group 4 (n = 17), injection of 1 mL cell-free supernatant intravenously at two-day intervals, starting 4 wk after ligation. Liver function tests, prothrombin time and serum protein levels were measured weekly before and every two days after transplantation. In group 2 all animals had died 56 (49-69) days after ligation. Survival in groups 3 and 4 was similar: all rats had died from liver failure 61 (51-72) and 60 (49-76) days following bile duct ligation. Survival rates and laboratory investigations showed no significant differences between treated and untreated cirrhotic animals. These data suggest that hepatocyte transplantation into the lung as well as supernatant injection do not have any significant effect on chronic hepatic failure, at least in the rat model.

Laparoscopic repair of recurrent inguinal hernias.

BACKGROUND: Repair of recurrent inguinal hernias is associated with recurrence rates as high as 30% and complication rates higher than for primary hernias. PATIENTS AND METHODS: In a prospective study, results were evaluated after laparoscopic transabdominal preperitoneal hernia repair in 192 patients with 200 recurrent inguinal hernias. A total of 132 hernia repairs followed one previous repair, 41 followed two repairs, 17 followed three repairs, 6 followed four, 3 followed five, and 1 followed six previous repairs. The surgical technique is described. RESULTS: Follow-up ranged from 9 to 31 months (mean 18.4). Twelve patients (6%) had groin seromas or hematomas; 3 (1.5%) had transient thigh numbness. One patient (0.5%) underwent laparoscopy a second time because of a large hematoma. In 1 patient (0.5%), a staple on the n. cutaneus femoris lateralis was removed laparoscopically. Patients described postoperative pain as being much less severe compared with their previous operation. Of the total group, 76% of patients were able to return to work within 2 weeks of surgery. One recurrence (0.5%) occurred after 6 months because of too small a prosthetic mesh. CONCLUSIONS: This laparoscopic technique can be applied to recurrent hernias, even in difficult cases, with low morbidity rates. Recurrence rates as low as for laparoscopic repair of primary hernias can be expected.

Hepatocyte transplantation into the lung for treatment of acute hepatic failure in the rat.

The lung was investigated as a matrix for transplanted hepatocytes in the rat model. Surgically induced fulminant hepatic failure was successfully treated by injection of 5 to 7 x 10(7) isolated hepatocytes into the pulmonary parenchyma in 86% of the animals. No animal, however, survived injection of hepatocytes into the jugular vein. It was found that liver failure is a prerequisite for the intrapulmonary survival of hepatocytes. After regeneration of the native liver, the majority of hepatocytes are cleared away within 6 months.

Civilian popliteal artery trauma.

An 18 year experience involved 36 civilian popliteal artery injuries is described. There were no operative or hospital deaths and the amputation rate was 3.6%. Penetrating traumas accounted for 30.6% and blunt traumas for 69.4%. In 20 patients (55.5%) the popliteal artery injury was associated with fracture and/or dislocation of the long bones and/or the knee joint. The average ischaemic time was 7.3 hours and postoperative angiography was performed in 25 patients (69.4%). Surgical reconstruction of the popliteal artery was accomplished by interposition or bypass of autogenous saphenous vein graft in 29 (80.5%), by saphenous vein patch in 5 (13.9%) and by primary end-to-end anastomosis in 1 (2.8%) and by PTFE prosthesis in 1 patient (2.8%). In all cases with bone fracture and/or dislocation bone stabilization was followed by the vascular procedure. The average time of follow-up was 76 months, 28 patients could be evaluated in the postoperative study: in 25 (89.2%) the reconstruction was patent, in 3 (10.8%) occluded. In 13 patients (46.4%) there was a complete success, 7 had a nerve deficit (25.0%), 3 had a claudication (10.7%), in one patient an amputation was necessary (3.6%) and 4 (14.3%) suffered from miscellaneous skeletal problems. Of the 36 patients originally operated, 29 (80.5%) received anticoagulant therapy for at least one year.

[Endoscopic sclerotherapy of bleeding Mallory-Weiss mucosal tear]. / Endoskopische Sklerosierungsbehandlung bei blutendem Mallory-Weiss-Schleimhautriss.

Based on a review of 66 patients with the Mallory-Weiss syndrome, the problems of diagnosis and treatment in general, and the application of sclerotherapy in particular in patients with bleeding tears is discussed. At emergency endoscopy 32 patients (48.4%) had an acute bleeding episode which could be stopped by sclerotherapy in 26 of 27 cases. The importance of control endoscopy after 48 hours and its influence on prognosis are emphasized.

[Malignant hemangioendothelioma of the thyroid gland. Pathology, clinical aspects and prognosis]. / Das maligne Hämangioendotheliom der Schilddrüse. Pathologie, Klinik und Prognose.

Malignant hemangioendothelioma (MHE) of the thyroid still constitutes a relatively important part of our surgical material, with 23 MHE (2.0%) among 1153 primary thyroid tumors diagnosed between 1952 and 1987 (biopsy material of the Innsbruck Pathology Institute). 18 of these cases were investigated immunohistochemically; in 14 cases the data on clinical findings and follow-up were complete. Immunohistochemical results confirm the endothelial origin of this tumor and allow MHE to be definitively distinguished from anaplastic carcinomas. Follow-up and prognosis are determined by the aggressive nature of local tumor spread. 13 patients died after a median survival period of 2.4 months (R: 1.2-9.4). Only one patient has remained alive since over 4 1/2 years now. An improvement of the hitherto dismal prognosis is thought to depend on early tumor diagnosis and an ameliorated combined modality treatment.

[Infectious complications in the early phase following kidney transplantation]. / Infektiöse Komplikationen in der Frühphase nach Nierentransplantation.

A retrospective analysis of 533 patients receiving kidney transplantation was performed to study the incidence of infection in the early postoperative period. Mostly localized in the lungs and renal system, bacterial complications arose in 133 patients. As compared with the unproblematic management of the urinary tract infections, 45 pulmonary infections were characterized by difficulties in diagnosis and treatment. Poor graft function was closely related to pulmonary infections: mean creatinine was 2.4 mg% (in patients without pneumonia - 1.5 mg%). Out of 45 patients with pneumonia, the graft failed in 16 patients. 6 patients died as a result of pneumonia. Rapid detection of the pathogenic organism is required, if necessary by invasive diagnosis. The administration of erythromycin before identification of the responsible pathogen may be indicated, in view of the fatal outcome in several patients subsequently diagnosed as having Legionella infection.

[Peptic ulcer with a visible non-bleeding vascular wall--early elective surgery or endoscopic therapy?]. / Das peptische Ulkus mit nicht-blutendem sichtbarem Gefässbürzel--Frühelektive Operation oder endoskopische Therapie?

The records of 71 patients with the endoscopic finding of a peptic ulcer with a non-bleeding visible vessel, treated between 1982 and 1987 were retrospectively analysed. 16 patients underwent early surgical treatment (group I), 15 patients were treated conservatively (group II) and 40 patients by endoscopic haemostasis (group III). Recurrent bleeding was observed in 6.25% patients in group I, in 53.3% in group II and in 25% in group III, in which case endoscopy was performed again. The patients with arterial bleeding underwent early elective operation after endoscopic haemostasis. Deaths occurred only in the postoperative period: group I 6.25%, group II 13%, and group III 5%. These findings indicate that primary endoscopic treatment in selected patients leads to results equal to those achieved with early surgery. Conservative therapy cannot, however, be recommended.

[Laparoscopic surgery of inguinal hernia by transperitoneal implantation of an artificial mesh. Technique and early results]. / Laparoskopische Leistenhernienoperation durch transperitoneale Implantation eines Kunststoffnetzes. Technik und Frühergebnisse.

We report on 250 patients with 342 inguinal hernias operated laparoscopically by pre-peritoneal implantation of a prosthetic mesh. 167 hernias were indirect, 175 direct, including 92 bilateral, 71 recurrent and 4 femoral hernias. There were four major complications: two lesions of the urinary bladder, treated in one case by laparotomy and two foreign body reactions against the mesh, which had to be removed. Two recurrences (0.6%) occurred during a 2-12 months follow-up. The mean hospital stay was 4 (3-10) days. Return to full activity was possible after one week.

Axillary Dissection in the Case of Positive Sentinel Lymph Nodes: Results of the Innsbruck Consensus Conference.

The prognosis of breast cancer is most heavily influenced by the status of the axillary nodes. Until a few years ago, this knowledge was gained through radical axillary lymph node clearance. In the meantime, sentinel lymph node clearance has become an established part of the surgical treatment of breast cancer. With the development of this procedure, the morbidity caused by axillary dissection has been reduced significantly. Although comprehensive prospective, randomised data regarding the safe use of the sentinel concept are only now available, the focus currently, however, is on the question of whether in the case of positive sentinel lymph nodes, an axillary dissection can be done away with altogether without having any negative impact on the risk of loco-regional recurrence or on progression-free survival and overall survival. The results of the American ACOSOG-Z001 study have changed the fundamental perspective of this. In this study on the advantages of axillary dissection following the confirmation of tumour tissue in the sentinel lymph nodes, there were no statistically significant advantages from axillary dissection for women with a favourable overall risk profile who had received radiotherapy and systemic therapy. If this concept takes hold, the surgical treatment of node-positive breast cancer, at least in the axilla, would be reduced to a minimum, and the focus of treatment would in future lie more on the systemic treatment of this condition. As part of an interdisciplinary consensus meeting, a standardised approach for Austria with regard to this question was decided upon.

[Gallstone ileus]. / Gallensteinileus.

From 1965 to 1985 gallstone ileus was diagnosed and treated in 19 patients. The mean preoperative period of symptoms was five days; the correct diagnosis was made in only half the cases. Enterolithotomy alone has proven to be, in comparison with other methods, a reliable procedure with the fewest postoperative complications. Treatment of bilioenteric fistula was limited to symptomatic cases. Improvement of the results can be expected once the interval from first symptoms to operation is reduced.

[Aneurysm of the popliteal vein as the source of a lung embolism]. / Aneurysma der Vena poplitea als Quelle einer Lungenembolie.

A case of pulmonary embolism secondary to a clinically unsuspected aneurysm of the popliteal vein is presented. The importance of venography in establishing the source of pulmonary emboli is stressed in comparison to other diagnostic investigations such as ultrasonography, computed tomography or pletysmography. The aneurysm was suitable for local venous reconstruction. Previously reported cases are reviewed, etiology, diagnosis and treatment of this uncommon condition are discussed.

[Modified ureterocystostomy: a low rate of urological complications in kidney transplantation]. / Modifizierte Ureterozystostomie: niedrige Rate an urologischen Komplikationen bei Nierentransplantationen.

A total of 31 urological complications (4.6%) were noted between January 1974 and July 1987 among 670 renal transplantations: ureteral stenoses (n = 18), ureteral leaks (n = 8), vesicorenal reflux in the transplant with chronic urinary-tract infection (n = 1), and urolithiasis in the area of the transplant (n = 4). There were six ureteral leaks among 110 extravesical ureterocystoneostomies, while there were only two leaks among 560 anastomoses done by a modified method of Leadbetter and Politano. Restoration of urinary flow integrity was achieved without organ loss or functional impairment.

[Is selective use of intraoperative cholangiography in elective cholecystectomy justified?]. / Ist der selektive Einsatz der intraoperativen Cholangiographie (IC) bei der elektiven Cholecystektomie (CHE) gerechtfertigt?

Operative cholangiography (IC) represents the most reliable investigation for common bile duct stones even during laparoscopic cholecystectomy (CHE). To reduce operating time, safety of selective IC was analysed in the last 308 consecutive patients undergoing conventional elective CHE. Obvious indication for common bile duct investigation excluded, IC was performed only in case of elevated liver function tests (n = 83, 26.9%), in 12 cases (14.5%) with positive in 2 cases (2.4%) with false positive result. In 255 (73.9%) patients IC was omitted. All patients were controlled after 4 months: no retained duct stone became evident in any case. Selective IC is safe and cuts time.

Vascular lesions after percutaneous biopsies of renal allografts.

On the basis of two arteriovenous fistulas, one arteriocaliceal fistula, and the literature concerning these complications, clinical symptoms, diagnostic measures, and therapeutic strategies are discussed. Decreased renal function, severe hypertension, and a bruit over the transplant site - particularly after core biopsy - are said to be indicative of an arteriovenous fistula, while persisting hematuria is seen as evidence of an arteriocaliceal fistula. In both cases, angiographic evaluation is indicated. Therapeutic possibilities include selective angiographic embolization and surgical repair. Large intraparenchymal fistulas may require wedge resection.