[Speech Ability and Psychological Outcome After Treatment of Oral Cancer]. / Sprechqualität und psychische Beeinträchtigung nach der Therapie von Mundhöhlentumoren.

BACKGROUND: In recent years interactions between surgical treatment of oral carcinoma and incidence of anxiety or depression have become a subject of discussions. This prospective study is a comparison between the extent of loss of speech intelligibility and presence of depressive symptoms or anxiety as a result of oral carcinoma. MATERIAL AND METHODS: One year after surgical therapy for oral carcinoma, 90 patients of an average age of 60±12 years were examined. Their speech intelligibility degree was measured using standardized automatic speech recognition (word recognition rate, WR). Symptoms of anxiety and depression were detected by use of HAD-Scales (HADS). Next to the relationship between WR and HADS other influential variables related to WR and HADS were statistically evaluated. RESULTS: The WR average was 53.2±17.2. Female WR was better than male. The difference between tumor classifications T1 and T4 compared to the WR reached statistical significance. Significant differences were detected between WR and "tumor localization", "graft donor site", "graft morphology", "tongue motility", and "tracheostoma" groups. There was a relationship between tongue motility and graft morphology, graft donor site and tumor localization. HAD-Scores in the mean were elevated: HADS-Total=43.3%, HADS-A=43.3% und HADS-D= 51.1%. WR correlates with HADS-D-Subscale, but not with HADS-A-Subscale. CONCLUSION: Communication disorders as a result of neoplasmic orofacial surgery may be related to extent of the treatment and to affective impairments. This should receive attention in the concept of rehabilitation.

Evaluation of a single-tube real-time PCR for detection and identification of 11 dermatophyte species in clinical material.

We developed a dermatophyte-specific single-tube real-time PCR assay based on internal transcribed sequences. This assay allows the rapid detection and identification of 11 clinically relevant species within the three dermatophyte genera Trichophyton, Microsporum and Epidermophyton in nail, skin and hair samples within a few hours. Analysis of 145 clinical samples (107 nail, 36 skin scale, and two hair) by both real-time PCR and a PCR-reverse line blot (PCR-RLB) assay described earlier revealed that 133 of the 145 samples had concordant real-time PCR and PCR-RLB detection results (83 positive, 49 negative, and one inhibited). Six samples were positive by real-time PCR and negative by PCR-RLB, and two were negative by real-time PCR and positive by PCR-RLB. Four samples demonstrated inhibition in one of the two PCR assays. Only one of 83 positive samples had discordant identification results between both assays (Trichophyton verrucosum and Trichophyton erinacei by real-time PCR and Trichophyton erinacei by PCR-RLB). Dermatophytes present in seven positive samples that were incompletely identified as Trichophyton sp. by PCR-RLB were identified to the species level by real-time PCR as Trichophyton interdigitale and Trichophyton rubrum in six cases and one case, respectively. One hundred and twenty of 145 samples were also analysed by conventional dermatophyte culture and by direct microscopy. Our single-tube real-time PCR assay proved to be suitable for direct detection and identification of dermatophytes in nail, skin and hair samples with minimal total assay time (4 h after overnight lysis) and hands-on time, without the need for post-PCR analysis, and with good sensitivity and specificity.

[A 65-year-old female patient with gastric outlet obstruction of unknown origin]. / 65-jährige Patientin mit unklarer Magenausgangsstenose.

Gastric outlet obstructions can be of benign or malignant origin. In the case of the female patient described in this article, the extended diagnostic procedure with computed tomography and bone marrow biopsy was the key to a definite diagnosis and treatment planning.

Device-specific outcomes following endovascular aortic aneurysm repair.

OBJECTIVE: To compare aneurysm morphology, initial outcomes and mid-term results in patients receiving Talent or Zenith grafts for elective endovascular aneurysm repair (EVR). METHODS: Over a 6-year time period ending in 2007, 286 patients underwent elective EVR of infra-renal abdominal aortic aneurysms using Talent or Zenith devices. Patient demographics, aneurysm morphology and initial outcomes (primary-assisted technical success rates, 30-day limb occlusion, re-intervention and mortality) were compared using chi-squared tests or Student's t-tests. Kaplan-Meier curves were calculated to compare cumulative rates of freedom from type I or III endoleak, re-intervention, endograft patency and overall survival over mid-term follow-up. RESULTS: Adverse aneurysm morphology was more common in patients receiving Zenith stent grafts, with a greater proportion of shorter neck lengths (<10mm, 12.9% vs 0%; p60 degrees , 25.0% vs 10.3%; p=0.002). Equivalent primary-assisted technical success rates were achieved with both Talent and Zenith grafts (94.0% vs 96.1%; p=0.41). A significant number of adjunctive procedures were required in both groups to obtain a proximal endograft seal, with relatively more procedures performed in the Talent group (28.6% vs 12.4%; p=0.003). Early outcomes were similar for 30-day re-intervention (5.3% vs 3.9%; p=0.91), 30-day limb occlusion (1.5% vs 2.6%; p=0.51), 30-day morbidity (6.8% vs 11.8%; p=0.15) and 30-day mortality (4.5% vs 3.9%; p=0.80). The cumulative incidence of freedom from re-intervention was 88.3+/-2.9%, 86.1+/-3.3% and 84.1+/-3.9% at 1, 2 and 3 years respectively. There were no significant differences between Talent and Zenith groups for re-intervention, type I or III endoleak or limb occlusion rates over the same time period. Overall patient survival was 88.4+/-2.85% at 1 year, 83.7+/-4.0% at 2 years and 78.9+/-5.5% at 3 years. CONCLUSIONS: Equivalent primary-assisted technical success rates can be achieved using either Talent or Zenith endografts for endovascular aneurysm repair, but operating teams should be prepared to perform additional adjunctive procedures to obtain a primary proximal seal with either stent. The Zenith endograft performed well in the context of less favourable pre-operative aneurysm morphology. Both Talent and Zenith endografts appeared equally durable in the medium term.

Validation of PCR-reverse line blot, a method for rapid detection and identification of nine dermatophyte species in nail, skin and hair samples.

A dermatophyte-specific PCR-reverse line blot (PCR-RLB) assay based on internal transcribed sequences was developed. This assay allows the rapid detection and identification of nine clinically relevant species within the three dermatophyte genera Trichophyton, Microsporum and Epidermophyton in nail, skin and hair samples within 1 day. Analysis of 819 clinical samples (596 nail, 203 skin and 20 hair) revealed a positive PCR-RLB result in 93.6% of 172 culture-positive and microscopy-positive samples. PCR-RLB was superior to culture and direct microscopy, in both detection and species identification. Comparison of identification results of 208 PCR-positive and culture-positive clinical samples showed five discrepancies (2.4%) between PCR-RLB identification and classical microscopic/biochemical identification of isolates. Comparison of PCR-RLB identification and classical identification of 98 other isolates (dermatophytes and non-dermatophytes) revealed 13 discrepancies (13.3%) and five incomplete identifications of Trichophyton spp. Sequence analysis of ITS1 regions of 23 samples with discrepant or incomplete identification results (four Centraalbureau voor Schimmelcultures dermatophyte strains, four clinical samples and 15 clinical isolates) confirmed identification results of PCR-RLB in 21 of the 23 analyzed samples. PCR-RLB proved to be extremely suitable for routine detection and identification of dermatophytes directly in nail, skin and hair samples because it is rapid, sensitive, specific and accurate.

Objective risk-scoring systems for repair of abdominal aortic aneurysms: applicability in endovascular repair?

OBJECTIVES: Recent studies propose the use of objective risk-scoring systems as a clinical tool for selecting patients for open or endovascular abdominal aortic aneurysm repair (EVR). The aim of this study was to evaluate four established risk-scoring systems for accuracy of prediction of early mortality and morbidity following EVR. PATIENTS AND METHODS: 266 consecutive patients undergoing elective EVR at St. George's Vascular Institute between July 2001 and January 2007 were studied using a prospective database. The Glasgow Aneurysm Score (GAS), the Vascular Physiology and Operative Severity Score for the enUmeration of Mortality and Morbidity (V-POSSUM), the modified Customised Probability Index (m-CPI) and the Customised Probability Index (CPI) were applied for prediction of 30-day mortality and morbidity. Accuracy of prediction was compared using receiver operating characteristics (ROC) curve analyses. RESULTS: 30-day mortality and morbidity rates were 4% (11/266) and 8% (22/266) respectively. For prediction of mortality, GAS, V-POSSUM, m-CPI and CPI ROC curve analyses showed areas under the curves (AUCs) of 0.68 (95% confidence interval (CI), 0.48-0.87; p=0.046), 0.66 (95% CI, 0.51-0.81; p=0.067), 0.63 (95% CI, 0.45-0.81; p=0.148) and 0.65 (95% CI, 0.49-0.80; p=0.101) respectively. Corresponding AUCs for prediction of morbidity were 0.64 (95% CI, 0.51-0.76; p=0.511), 0.62 (95% CI, 0.51-0.74; p=0.505), 0.54 (95% CI, 0.41-0.67; p=0.416) and 0.55 (95% CI, 0.42-0.68; p=0.451). CONCLUSIONS: GAS, V-POSSUM, m-CPI and CPI were poor predictors of early mortality and morbidity following EVR in this series. Caution should be applied to the use of these scoring systems for pre-operative risk stratification and treatment selection for endovascular repair of abdominal aneurysms.

The use of an extra-corporeal graft to maintain cerebral perfusion during thoracic endovascular aneurysm repair.

Endovascular access for aneurysm repair can be challenging in patients with iliofemoral occlusive disease. The carotid artery is an alternative access site, but may increase the risk of cerebral hypoperfusion during stent delivery. We describe a novel approach, where temporary extra-corporeal bypass was used to maintain cerebral perfusion during endovascular thoracic aneurysm repair via the carotid artery, in a patient with significant aorto-iliac and arch vessel disease.

Mucinous cystadenoma of the ovary in a 15-year-old girl.

Benign neoplasms of the ovary originating from epithelial tissue are common tumors in adult women. They are, however, rarely seen in children or adolescent girls. Here the authors present a case of an ovarian mucinous cystadenoma in a premenarchal girl. To our knowledge, there are only 5 other cases reported in the literature.

Sites of simian foamy virus persistence in naturally infected African green monkeys: latent provirus is ubiquitous, whereas viral replication is restricted to the oral mucosa.

Foamy viruses (FV), retroviruses of the genus Spumavirus, are able to infect a wide variety of animal species and replicate in nearly all types of cultured cells. To identify the cells targeted by FV in the natural host and define the sites of viral replication, multiple organs of four African green monkeys naturally infected with simian FV type 3 were investigated for the presence of FV proviral DNA and viral transcripts. All organs contained significant amounts of FV proviral DNA. In addition to proviruses containing the complete transactivator gene taf, proviral genomes carrying a specific 295-bp deletion in the taf gene were detected in all monkeys. As in the case of human foamy virus the deletion leads to the formation of the bet gene that is regarded to be instrumental in the regulation of viral persistence. FV RNA was detected by RT-PCR and in situ hybridization only in the oral mucosa of one monkey. No other samples contained detectable levels of viral transcripts. Histopathological changes were not observed in any of the tissue samples analyzed. Our results show that the natural history of FV is characterized by latent infection in all organs of the host and by minimal levels of harmless viral replication in the oral mucosa. The broad host cell range in vivo further encourages the development of FV-derived vectors for therapeutic gene delivery.

Detection of Bartonella henselae DNA by two different PCR assays and determination of the genotypes of strains involved in histologically defined cat scratch disease.

Cat scratch disease (CSD) is a common cause of subacute regional lymphadenopathy, not only in children but also in adults. Serological and molecular studies demonstrated that Bartonella henselae is the etiologic agent in most cases of CSD. Amplification of B. henselae DNA in affected tissue and detection of antibodies to B. henselae are the two mainstays in the laboratory diagnosis of CSD. We designed a retrospective study and investigated formalin-fixed, paraffin-embedded lymph nodes from 60 patients (25 female, 35 male) with histologically suspected CSD by PCR amplification. The sensitivities of two different PCR assays were compared. The first primer pair amplified a 296-bp fragment of the 16S rRNA gene in 36 of the 60 samples, corresponding to a sensitivity of 60%. The second primer pair amplified a 414-bp fragment of the htrA gene in 26 of the 60 lymph nodes, corresponding to a sensitivity of 43.3%. Bartonella DNA could be detected in a total of 39 (65%) of the 60 lymph nodes investigated. However, histopathologic findings are typical but not specific for CSD and cannot be considered as a "gold standard" for diagnosis of CSD. The sensitivity of the PCR assays increased from 65 to 87% if two criteria (histology and serology) were used in combination for diagnosis of CSD. Two genotypes (I and II) of B. henselae are described as being involved in CSD. Genotype I was found in 23 (59%) and genotype II was found in 9 (23%) of the 39 PCR-positive lymph nodes. Seven (18%) lymph nodes were negative in both type-specific PCR assays. Thirty (50%) of our 60 patients were younger than 20 years old (15 were younger than 10 years), 20 (33%) were between 21 and 40 years old, and 10 (17%) patients were between 41 and 84 years old. Our data suggest that detection of Bartonella DNA in patients' samples might confirm the histologically suspected diagnosis of CSD.

Two different genotypes of Bartonella henselae in children with cat-scratch disease and their pet cats.

Two genotypes (I and II) of Bartonella henselae are involved in cat-scratch disease (CSD). Lymph node biopsies were taken from 3 children suffering from CSD, and blood cultures were obtained from their pet cats. Cat-scratch disease was confirmed serologically, histologically and by detection of B. henselae DNA in all 3 lymph nodes by PCR. Bartonella henselae grew in all cats' blood cultures. The first 2 children were siblings. Both children and their pet cats were infected with B. henselae genotype II, and the third patient and her cat were infected with B. henselae genotype I. In all cases, there were no essential differences in the clinical manifestations of the infection caused by these 2 genotypes of B. henselae.

Primary pigmented nodular adrenocortical dysplasia.

A 29-year-old female patient presented clinical features of Cushing's syndrome. Biochemical tests suggested the presence of an autonomously functioning adrenocortical neoplasm. However, the adrenal glands were normal on MRI. Diagnostic adrenalectomy revealed a slightly enlarged organ studded externally and on multiple cut surfaces by small yellow and brown nodules. Microscopically, the nodules were composed of enlarged cortical cells with eosinophilic cytoplasm and nuclear pleomorphism, without mitotic figures. The morphology was consistent with primary pigmented nodular adrenocortical dysplasia (PPNAD). Additional right adrenalectomy was performed for curative treatment of Cushing's syndrome. The pathogenesis of PPNAD is not yet established, though, a defect on chromosome 16 was recently suggested. Since our patient had a malignant melanoma earlier in her history, the PPNAD may be a manifestation of the Carney complex.

Results after surgery in undifferentiated large cell carcinoma of the lung: the role of neuroendocrine expression.

OBJECTIVE: The objective of this study was to define the incidence of light microscopically undifferentiated large cell carcinomas, to analyze tumor stages, types of resections necessary and postsurgical survival. Additionally we tried to evaluate whether or not neuroendocrine expression influences the biological behavior of these tumors. METHODS: Light microscopic specimens of 105 patients having undergone surgery for undifferentiated large cell carcinoma were reviewed following the 1981 WHO criteria. Fifty eight cases were excluded because elements of adeno- or squamous cell carcinoma, neuroendocrine or combined patterns of histological differentiation were observed. The remaining 47 cases of pure undifferentiated large cell carcinoma were evaluated immunohistochemically for neuroendocrine differentiation using a combination of the markers neuron specific enolase, synaptophysin and chromogranin A. The hospital charts of the patients were analyzed retrospectively recording tumor stage, operative procedure, postoperative complications, postoperative adjuvant treatment procedures, actual tumor state and survival time. RESULTS: Thirteen patients (27.7%) had postsurgical tumor stage I, 5 (10.6%) stage II, 15 (31.9%) stage IIIA, 9 (19.1%) stage IIIB, and 5 (10.6%) stage IV. In 46 of 47 patients resections of lung parenchyma were performed (wedge resection n = 5, segmental resection n = 1, lobectomy n = 27, bilobectomy n = 3, pneumonectomy n = 10), in 6 patients combined with broncho- and/or angioplastic procedures. At the time of chart review 20 (42.5%) patients were still alive. The cause of death in the remaining patients was recurrent lung cancer in the majority of cases (24 or 92.30%). The overall mean survival of the 46 patients undergoing parenchymal resections was 19 months, the 3-year survival rate 31.7%. The immunohistochemical examination demonstrated expression of neuron specific enolase in 15 cases. Synaptophysin and chromogranin A were not detected in any case. For these 15 patients the mean survival was 25.6 months (+/- 4.3) and the 1-year survival rate 67% (confidence interval 43-91%) compared to 13.8 (+/- 2.1) months and 33.5% (confidence interval 15.3-51.7%) in the remainder. The difference was not significant (P = 0.06). CONCLUSIONS: The light microscopic diagnosis of undifferentiated large cell carcinoma revealed to be subject to considerable interobserver variability. Undifferentiated large cell carcinoma takes a more unfavorable clinical course than other non-small cell carcinomas. Despite lack of statistical significance, expression of neuron specific enolase appeared to be associated with less aggressive biological behavior of the respective neoplasms. Immunohistochemical evaluation of undifferentiated large cell carcinomas using a combination of neuron specific enolase, chromogranin A, and synaptophysin did not provide more therapeutically relevant information than that obtained by light microscopic assessment.

Signet ring cell carcinoma of the eccrine sweat glands in the eyelid.

BACKGROUND: Signet ring cell carcinoma of the eyelid is a rare variant of eccrine sweat gland carcinoma and has been reported previously in only five patients. METHODS: The authors report the clinical findings of a 55-year-old man with a signet ring cell carcinoma in the left eyelid as well as a clinical follow-up of 4.5 years. Several biopsies and the exenteration specimen were analyzed by routine light microscopy, electron microscopy, and comprehensive immunohistochemical stains on paraffin sections. RESULTS: Histologically, the tumor was shown to be a rare type of eccrine sweat gland carcinoma with signet ring cells and Indian file growth pattern reminiscent of invasive lobular carcinoma of the breast. Estrogen and progesterone receptors were identified immunohistochemically. On electron microscopy, intracytoplasmic pseudolumina with microvilli were positive for anti-human milk fat globulin and the lectin peanut agglutinin. Clinically, the tumor followed a malignant course with orbital invasion and lymph node metastases. CONCLUSIONS: Histologic recognition of this variant of eccrine sweat gland carcinoma is important because of its aggressive and malignant behavior and the wide range of differential diagnoses. Primarily, metastatic mammary carcinoma must be excluded. The treatment is primary excision with histologic control of the excision margins. In more advanced stages, radiation therapy, neck dissection, and anti-estrogen therapy should be considered.

[Primary pigmented nodular adrenocortical dysplasia. A rare cause of Cushing's syndrome]. / Primäre pigmentierte noduläre adrenokortikale Dysplasie. Eine seltene Ursache des Cushing-Syndroms.

HISTORY AND CLINICAL FINDINGS: A 29-year-old woman was found to have arterial hypertension (175/115 mm Hg). The 24-hour profile showed no diurnal cortisol variations with normal concentrations and 24-hour urinary cortisol was normal. 14 months later there was definite hypercortisolism with discrete Cushing signs and no amenorrhoea. She also had signs of depression. INVESTIGATIONS: Routine laboratory tests were unremarkable. ACTH and dehydroepiandrosterone levels were reduced and there was marked hypercortisolism (600 micrograms/24h). Bone densitometry showed osteoporosis. The low- and high-dose dexamethasone inhibition tests showed no suppression of 24-hour urinary cortisol, raising the suspicion of adrenal cortical adenoma or carcinoma. Magnetic resonance imaging (MRI) of both adrenals was normal, and scintigraphy showed physiological storage. MRI of the skull was normal. TREATMENT AND COURSE: As ACTH-independent hypercortisolism had been proven, unilateral adrenalectomy was performed. The specimen showed primary pigmented nodular adrenocortical dysplasia (PPNAD). While cortisol levels and blood pressure were at first normal, hypercortisolism had recurred 5 months postoperatively. The other adrenal was removed and showed a similar histology. A malignant melanoma of the shoulder was also found, perhaps part of a Carney syndrome. CONCLUSION: PPNAD should be included in the differential diagnosis of an ACTH-independent Cushing's syndrome with normal adrenal on imaging, perhaps as part of a Carney syndrome.

[Alveolar adenoma of the lung. Immunohistochemical characterization of type II pneumocytes]. / Alveoläres Adenom der Lunge. Immunhistochemische Charakterisierung von Pneumozyten Typ II.

The alveolar adenoma of the lung is a rare benign tumor in which the normal parenchymal architecture is imitated by a proliferation of both the alveolar epithelial cells and the mesenchymal septal cells. The first description, based on six cases, was published in 1986 by Yousem and Hochholzer. From their ultrastructural findings they presumed a type II pneumocytes differentiation of the epithelial cells. We investigated an alveolar adenoma of the lung immunohistochemical by means of antibodies against apoprotein B and C of human surfactant. Both the lining cells and the macrophages in the alveolar-like spaces were stained. The septal connection tissue cells did not react. These findings confirm the expression of surfactant constituents and, hence, the differentiation into type II pneumocytes of the epithelial cells of the alveolar adenoma.

EBV-associated lymphoproliferative syndrome with a distinct 69 base-pair deletion in the LMP-1 oncogene.

We describe an immunocompetent 12-year-old boy with chronic EBV infection and lymphoid interstitial pneumonitis. Lymph node biopsies showed effacement of the architecture with polymorphic cellular infiltrates, consisting predominantly of T cells and natural killer cells. No clonal rearrangement of TCR or immunoglobulin genes was seen. DNA was extracted from hilar lymph nodes; sequencing of the carboxy terminal region of the latent membrane protein 1 (LMP-1) oncogene revealed a 69 base-pair deletion and four point mutations. Immunosuppressive treatment with prednisone and cyclosporine reversed the lymphadenopathy.