Papillary carcinoma in a thyroglossal duct cyst: management and algorithm for treatment of a rare entity.

Thyroglossal duct cyst carcinoma is a very rare finding and its presentation is similar to that of a benign cyst, which is the most common congenital lesions of the neck. The diagnosis is usually made postoperatively after histological examination. A case of a surgically treated 47-year-old patient with a papillary carcinoma in a thyroglossal duct cyst is presented. The patient underwent the Sistrunk procedure. After stratification in the proposed high risk group, subsequent total thyroidectomy and radioiodine therapy were performed successfully. The patient remains tumor-free 18 months postoperatively. Sistrunk procedure is recommended as the most promising treatment generally including total thyroidectomy with or without lymph node dissection. Subsequent radiotherapy is recommended in selected patients, depending on the classification into high- or low-risk patients. Diagnostic and therapeutic features are discussed with the current literature and a definitive algorithm for treatment based on risk group stratification is proposed.

[Pharmaceutical care in a visceral surgical ward]. / Pharmazeutische Betreuung einer viszeralchirurgischen Station.

BACKGROUND: Medication errors and subsequent drug-related problems (DRPs) result from lack of sufficient information during the prescribing step. The objectives of this study were to evaluate the contribution of having a pharmacist participate in clinical routine on a surgical unit by studying DRPs, and the classification of DRPs in the Pharmaceutical Care Network Europe (PCNE) system. MATERIALS AND METHODS: The pharmacotherapy of all patients of a visceral surgical ward was evaluated by a pharmacist in a prospective study design over a six-month period. The identified DRPs were classified using the PCNE system. RESULTS: In 29 131 prescription lines, 697 DRPs were registered. This corresponds to a mean intervention rate of 2.4 %. All DRPs were classified into the modified PCNE system with 910 causes and 1 148 interventions. The most frequent DRPs were "lack of home medication" (35.6 %), drug dosing problems (18.6 %), the inappropriate duplication of drugs of the same therapeutic group (6.7 %) and drug interactions (6.5 %). 78.6 % vs. 3.7 % of all registered DRPs were completely vs. near completely resolved by pharmacist. CONCLUSIONS: We consider the PCNE system with the four-level of classification to be a practical and easy-to-use tool in the daily hospital setting. Although we did not notice clinically relevant impairments of patient safety, a pharmacist may support the drug therapy and improve patient safety in clinics supporting the free choice of the drug therapy by the physician.

[Psychiatric comorbidities in visceral surgery patients with cancer]. / Psychische Begleiterkrankungen bei Krebspatienten in der Viszeralchirurgie.

BACKGROUND: Cancer patients with mental disorders suffer from a decreased quality of life (QoL) and are in need of appropriate treatment. METHODS: A total of 99 cancer patients were interviewed during surgical inpatient treatment with a structured clinical interview for diagnosis of mental disorders (SCID). The QoL and distress were examined prospectively using the validated questionnaires EORTC QLQ-C30 and HADS. Patient psychological well-being and the need for psycho-oncological treatment were assessed by 31 doctors and 41 nurses. RESULTS: Of the patients 19% were diagnosed with having a mental disorder and in 10% immediate treatment was deemed necessary. This was identified by doctors and nurses in 38-60% and by HADS in 78% of the cases. The QoL of patients with psychiatric comorbidities was diminished 6 months after surgery, while patients without comorbidities recovered significantly better. CONCLUSION: Of the visceral surgery cancer patients studied 10% had a relevant mental disorder. To prevent symptoms becoming chronic they should be detected and treated early and efficiently.

[Acute pancreatitis]. / Akute Pankreatitis.

Acute pancreatitis is potentially fatal. It can be diagnosed based on present history, clinical appearance, and typical findings from laboratory and radiologic investigations. All patients must be admitted to hospital, as the disease course cannot be predicted at initial presentation. Increasing severity demands increasingly individualized therapy. The most important interventions are fast fluid resuscitation and analgesic therapy with opioids. Therapeutic agents specific to pancreatitis have failed to show any advantages so far. The roles of antibiotic therapy and nutritional support in the therapeutic regimen have been profoundly reassessed during recent years. Surgery and endoscopic interventions may be necessary and beneficial in carefully selected patients. In this review we summarize clinically relevant issues of acute pancreatitis.

[The preoperative multislice spiral CT in the surgical management of pulmonary metastases]. / Die präoperative Dünnschicht-Computertomografie im Management der Lungenmetastasenchirurgie.

INTRODUCTION: Inspection and palpation of the ventilated and exhausted lung reflect the guideline-compliant surgery of pulmonary metastases. Because a huge number of pulmonary nodules are missed on preoperative CT, metastases must be diagnosed by the surgeon's examination of the lung under exclusion of the video-assisted approach. The purpose of our study was to assess whether a special multislice (MS) spiral CT may close this diagnostic gap and change the management of pulmonary surgery. PATIENTS AND METHODS: We performed a prospective study to address this question. Operative and histological results of 60 patients with pulmonary nodules (7/2002 and 12/2004) were compared with the preoperative predictions of MS-CT. RESULTS: In 81 operations, 166 pulmonary metastases were confirmed histologically. The MS-CT predicted 229 suspicious metastases; 38% could not be confirmed histologically. However, in 14% of surgically confirmed metastases the radiological correlate was absent. 44% of these metastases were 4 mm; and were from the following primary entities: 48% hypernephroma, 30% sarcoma, 17% colorectal carcinoma and 4% breast cancer. The radiological prediction of 1 to 3 vs. 5 to 11 metastases implied 30% vs. 70% additional filiae, whereas radiologically non-described metastases were found in 12% of all operations. In contrast, the group with radiopaque material showed only 5% of metastases without a radiological correlate or 8% of non-described metastases. The overall sensitivity of MS-CT was 86%, whereas the group with radiopaque material had a sensitivity of 95%. CONCLUSION: The preoperative MS-CT does not resolve the problem of overlooked metastases and has no influence on the management of pulmonary surgery.

[Male breast cancer: history, epidemiology, genetic and histopathology]. / Das Mammakarzinom des Mannes - Historie, Epidemiologie, Atiologie, Genetik und Histopathologie.

Breast carcinoma is a rare disease in men. The incidence is 1 per cent of the incidence in women. Relative hyperestrogenemia and environmental factors seem to be important for the development of the disease. In recent years, germline mutations have been observed in male breast carcinoma patients in several genes, BRCA2, the androgene receptor gene and PTEN. Suspected genetic factors include the cell-cycle checkpoint kinase (CHEK)2 protein truncating mutation 1100delC that has been shown to confer a 10-fold increase of breast cancer risk in men. The c.1-34T > C 5' promoter region polymorphism in cytochrome P450c17 (CYP17), a key enzyme in the biosynthesis of estrogen, has been associated with male breast cancer risk, hemochromatosis gene (HFE) mutations, the mismatch repair genes (hMSH2, hMLH1,hPMS1,hPMS2) and PTEN mutations (Cowden syndrome) are associated with male breast cancer. The majority of tumors is seen retromamillarly. Ductal carcinoma in situ comprises 5-10 % of all cancers. In case of invasive growth, 85-90 % are invasive ductal carcinomas (NOS), 2.5 % are papillary tumors; lobular cancers are exceptionally rare. About 3/4 of all cancers express estrogen and progesterone receptor with increasing positivity with increasing patient age. HER-2 / neu overexpression is seen in the same frequency as in female breast cancer. Poor prognostic factors are tumor size > 2 cm, poorly differentiated tumors, receptor negativity, axillary lymph node involvement and more than four affected nodes.

[The male breast carcinoma: a center experience]. / Das männliche Mammakarzinom - Erfahrungen eines Zentrums.

Male breast carcinoma represents a rare tumor entity and is not the focus of major research activities although an increasing incidence has to be noticed. Registry data on 67 males diagnosed and treated for breast carcinoma during the period 1985-2005 in the metropolitan area of Leipzig were retrospectively analyzed. The median age at diagnosis was 65 years (39-92 years) with an incidence peak in the age group 60-70 years. According to the TNM classification a carcinoma in situ was diagnosed in 8 % (n = 5) of the cases and an invasive carcinoma T1 in 39 % (n = 26 ), T2 in 38 % (n = 25), T3 (n = 0) and T4 in 15 % (n = 11). The lymphnode status presented in 56 % negative and in 44 % positive (N1 + N2) nodes. Solid organ metastasis was detected in only 6 % of the patients. The overall 5-year survival is 72 % and comparable with published data. Respective survival rates for patients diagnosed with UICC-stadium 1-4 are 81 %, 76 %, 65 % and 0 %. These rates are similar to those of female patients. Considering the low incidence of male breast carcinoma and the limited knowledge on this rare disease surgeons should apply diagnostic and therapeutic guidelines that are established for the treatment of female breast carcinoma unless powerful evidence based data will become available.

Histopathological outcome of 597 isolated soft tissue tumors suspected of soft tissue sarcoma: a single-center 12-year experience.

BACKGROUND: The aim of this present report was to analyze the patients referred to us with the presumptive diagnosis of soft tissue sarcoma (STS). METHODS: We reviewed all patients referred to us with suspected soft tissue sarcoma (STS) of the extremities or trunk over a 12-year period. RESULTS: We treated 597 patients with soft tissue tumors. Open biopsy revealed soft tissue sarcoma in 318 cases, benign mesenchymal tumor in 124 cases and isolated metastases (ISTM) from carcinomas in 98 patients; other pathologies were found in 57 patients. The primary carcinomas were lung cancer in 26 patients, breast cancer in 19 patients, renal carcinoma in 16 patients, carcinoma of the esophagus in 12 patients, colonic carcinoma in 5 patients, thyroid gland cancer in 6 patients, and in 14 patients carcinoma of unknown primary was diagnosed. CONCLUSIONS: In our collective with soft tissue tumor, 50% of the patients had the diagnosis of soft tissue sarcoma, 20% presented with a metastasis of carcinoma and 20% had a benign tumor. Referring to our results, in patients with the presumptive diagnosis of soft tissue sarcomas, soft tissue metastasis of a primary carcinoma was unexpectedly common, indicating that greater consideration should be given to this differential diagnosis.

High efficacy and low toxicity of weekly docetaxel given as first-line treatment for metastatic breast cancer.

BACKGROUND: Docetaxel is one of the most effective antitumor agents currently available for the treatment of metastatic breast cancer (MBC). This phase II multicenter study prospectively analyzed the efficacy and toxicity of docetaxel given on a weekly schedule as first-line treatment of metastatic breast cancer. PATIENTS AND METHODS: All patients received docetaxel, 35 mg/m(2) weekly for 6 weeks, followed by 2 weeks of rest. Subsequent cycles (3 weeks of treatment, 2 weeks of rest) were given until a maximum of 5 cycles or disease progression. Premedication consisted of 8 mg dexamethasone intravenously 30 min prior to the infusion of docetaxel. RESULTS: Fifty-four patients at a median age of 58 years with previously untreated MBC were included in the study. A median of 10 doses (median cumulative dose 339 mg/m(2)) was administered (range: 2-18). The overall response rate was 48.1% (95% CI: 34-61%, intent-to-treat). Median survival was 15.8 months and median time to progression was 5.9 months (intent-to-treat). Hematological toxicity was mild with absence of neutropenia-related complications. Grade 3 neutropenia was observed in 3.7% of patients and grade 3 and 4 anemia was observed in 5.6 and 1.9% of patients, respectively. CONCLUSION: The weekly administration of docetaxel is highly efficient and safe as first-line treatment for MBC and may serve as an important treatment option specifically in elderly patients and patients with a reduced performance status.

[Tracheobronchial ruptures: classification and management]. / Tracheobronchiale Verletzungen Klassifikation und Therapiestrategie.

BACKGROUND: Tracheobronchial ruptures are rare surgical emergencies with significant mortality. We present management and outcome of such ruptures treated at the University of Leipzig in Germany and propose a novel therapeutic algorithm-a new classification system for stratifying treatment of patients with tracheobronchial ruptures. METHODS: We retrospectively studied 24 patients 19 to 88 years old who were treated in our institution for tracheobronchial injury. RESULTS: Eighty-seven percent of the injuries were caused iatrogenically. Fifty-four percent were type I injuries (isolated tracheal lesions), 38% type II (involvement of carina or main stem bronchi), and 8% type III (distal lesions of lobar or segmental bronchi). Seventy-five percent of the patients were operated via right-sided dorsolateral thoracotomy. In four (22%), insufficiency of the tracheal closure occurred, with mediastinitis possibly being a significant risk factor for this event (P<0.001). In surgically treated patients, rupture-related and overall mortality were 5.5% and 28%, respectively, whereas in medically treated patients, mortality was 33%. CONCLUSION: The proposed classification of tracheobronchial injuries enables stratifying the treatment of patients with tracheobronchial ruptures. Type I lesions can be surgically closed either by a right-sided thoracotomy or transcervical-transtracheal approach. In contrast, surgical management of type II and III injuries always requires thoracotomy.

[Wound infection and infection-promoting factors in breast cancer surgery -- a prospective multicenter study on quality control]. / Wundinfektionen und sie begünstigende Faktoren im Rahmen der Mammakarzinomchirurgie -- prospektive Multizenterstudie zur Qualitätssicherung.

INTRODUCTION: The quality of treatment of cancer of the female breast is reflected not only in such parameters as local recurrence rate and survival times, but also in the development of surgical complications. Within the framework of a study investigating the performance and quality assurance in surgical treatment of breast cancer, therefore, the wound infection rate (WIR) and factors influencing it were analysed in a large patient population. METHODS: In the period between 1.1.2000 and 31.12.2000, 84 surgical departments participated in a prospective multicenter study to investigate primary surgery for breast cancer. A total of 1 416 patients were recruited to the study, the organization and conduction of which was in the hands of the former surgical department 1 of the University of Leipzig under the patronage of the East German Working Group for Performance and Quality Control in Surgery in cooperation with the An Institute for Quality Control in Operative Medicine of the Otto-von-Guericke University in Magdeburg. In addition to parameters characterizing patients, tumors and diagnostic work-up, we also analysed the surgical treatment and its possible complications with the aid of a questionnaire. The definition of wound infection was based on the criteria of the "Hospital Infection Control Practice Advisory Committee". RESULTS: The overall WIR was 4.5 % (n = 65). 21 (32 %) of the wound infections (WI) were diagnosed exclusively on a clinical basis without establishing the responsible pathogens. In 44 (68 %) of the WI, a search for the pathogen was undertaken which in 3 cases (7 %) was negative, and in 41 cases (93 %) positive. 118 (8.3 %) of the patients received perioperative antibiotic cover. The following parameters were found to have a significant influence on WIR: local drainage, blood transfusion, the time lapse between biopsy and definitive surgery, and the size of the primary tumor. DISCUSSION: Some of the above factors (transfusion, time lapse, drainage) can be influenced by the therapist. The wound infection rate is a marker for treatment quality.

[Differential diagnosis of soft tissue sarcomas]. / Differentialdiagnose von Weichteilsarkomen Zehnjahresanalyse eines Zentrums mit 490 unter Weichteilsarkomverdacht zugewiesenen Patienten.

INTRODUCTION: Soft tissue sarcoma often goes undetected. PATIENTS AND METHODS: Over a 10-year period, the patients referred to us with a soft tissue tumor (STT) of the extremities and wall of the trunk were analyzed retrospectively. The aim of the present study was to investigate the differential diagnoses, the number of incompletely operated STS, and local recurrences together with their percentage fluctuations. RESULTS: A total of 490 patients with an STT were referred to our department, and of these patients 55% were diagnosed with an STS. In addition to STS, the differential diagnoses for STT included 2% lymphomas, 18% isolated carcinoma metastases, 18% benign mesenchymal tumors, 5% inflammatory processes, and 2% old hematomas. Only 45% of the STS had not undergone previous surgery. Of these, 15% had been incompletely resected, while 39% of the STS patients were admitted with a local recurrence. Within the 10-year period, referrals with STT and STS remained relatively constant, but referrals of patients with incompletely resected or recurrent STS doubled in the last 2 years under observation. DISCUSSION: In view of the numerous differential diagnoses of an STT, both the possibility of an STS and also carcinoma manifestations in the soft tissues should receive more attention. With the aim of reducing the relatively high number of STS re-resections and local recurrences, the treatment of patients with suspicious STT should be reserved for a specialized center.

[Prospective multicenter study for quality management of breast cancer surgery]. / Prospektive Multizenterstudie zur Qualitätssicherung der Chirurgie des Mammakarzinoms.

Over the last 10 years a dramatic decrease became apparent in primary treatment of breast cancer in general surgical departments. A prospective 1-year observational study involving 84 surgical departments was carried out to describe the current therapeutic situation. A total of 1,416 patients undergoing primary surgical treatment for mammary carcinoma were recorded, and their data evaluated. 68.9% of the carcinomas were treated in departments with an annual case load for this disease of more than 20 operations, with 50% of them being operated on in 8 departments with a case load of 40-100 procedures per year. 94.4% of the carcinomas were confirmed histologically, and in 91% of the patients surgery was performed in curative intention. The rate of breast-preserving procedures was 40%, and breast amputations accounted for 60%. An analysis of the data allowed an evaluation of this specific patient group in the surgical departments. Deficits in terms of management quality are identified.

[Port catheter fractures in 361 implanted port systems. Analysis of the causes--possible solutions--review of the literature]. / Portkatheterbrüche bei 361 implantierten Portsystemen. Ursachenanalyse--Lösungsmöglichkeiten--Literaturübersicht.

INTRODUCTION: The use of a venous port-catheter-system is known as a relatively safe implant. Besides infections, the breakage of PIPS is the most common reason for explanation before term. The purpose of this study is to analyse port-related complications and to show ways of preventing them. METHOD: Between 1.1.1994 and 31.12.1999, 391 PIPS were implanted in the V. subclavia with the Seldinger technique at Surgical Clinic 1 of the University of Leipzig. Subsequently, 311 of them were followed up until 31.12.2000, with a mean observation time of 45 months. RESULTS: We registered 48 complications altogether (15.4% of 311), 21(6.7%) of which occurred immediately after implantation (up to 30 days postoperatively). These could be divided either into wound-healing disorders/pulmonary distress (4.5%, n = 14) or complications concerning the catheter systems (2.3%, n = 7). Long-term complications after 31 days were evident in 27 patients (8.7%), due either to infections (4.5%, n = 13) or catheter-associated problems (4.5%, n = 14). Catheter lesions occurred in nine cases (2.9% out of 311) at the point of entry into the musculus pectoralis, i.e., where the catheter had to change direction. Typically these were lengthways tears caused by the catheter. We observed one full breakage without dislocation, and two dislocated catheter fragments in the systemic circulation. We consider the change of direction to be responsible for wear on the silicon catheter. During implantation, extreme change of direction of the catheter should be avoided because this is where breakage happens. Catheter implantation by means of exposure of the vena basilica in the infraclavicular triangle is the method of choice.

[Inflammatory pseudotumor of the ileopsoas muscle with femoral paralysis caused by massive metal abrasion of a hip endoprosthesis]. / Entzündlicher Pseudotumor im M. ileopsoas mit Femoralisparese durch massiven Metallabrieb einer Hüftendoprothese.

Case report of a 62-year-old patient with a presumed loosening of a hip endoprosthesis after 10 years and a planned replacement. In addition, the patient suffered pain in the thigh and had paresis of the femoral nerve. A CAT-Scan substantiated the diagnosis either of a suppurating or a neoplastic tumour in the left iliac foss. The wide excision revealed a rare inflammatory tumour in the left ileopsoas muscle due to the excessive abrasion of the metal hip endoprosthesis.

[MR-guided preoperative localization and percutaneous core biopsy of suspected breast lesions. Possibilities and experience on the vertically open 0.5-T-system]. / MRT-gestützte Markierung und Stanzbiopsie suspekter Mammaläsionen. Möglichkeiten und Erfahrungen an einem vertikal offenen 0,5-T-System.

PURPOSE: To evaluate the feasibility of performing breast interventions in a vertically open 0.5 T MR system (SIGNA SP/i, GE Medical Systems). To develop fitted equipment and to establish preoperative wire localization and percutaneous breast core biopsy as clinical routine procedures. PATIENTS AND METHODS: Initially, we applied a localization method with the patient placed in a sitting position in 31 cases using a single loop coil and a self-developed fixation device. Subsequently, 46 wire localizations and 28 percutaneous core biopsies were carried out in prone patient position using an open breast coil with an integrated biopsy device. The used instruments were either MR-compatible (18 G biopsy needle and localization wire, 14 G coaxial needle, prototype of a 16 G double-shoot gun) or MR-safe (double-shoot gun with 16 G needle). RESULTS: After biopsy we found the needle tip (18 G for a wire localization and 14 G for a percutaneous core biopsy, respectively) placed either within or close to the lesions (< 10 mm distance) for all patients. Out of a total of 66 benign lesions and 39 malignant tumors we missed the lesion (12 mm mean diameter, 4-25 mm range) during open biopsy in two cases and obtained a false negative result for one percutaneous biopsy of a 5 mm lesion. CONCLUSION: Preoperative wire localization and percutaneous core biopsy of suspicious breast lesions demonstrated by MRI can be carried out a vertically open 0.5 T MR scanner. The degree of accuracy is comparable with that of X-ray or ultrasound-guided procedures. A follow-up has to be performed in cases with a negative biopsy.

[A giant malignant tumour of the skull-Case report and differential diagnosis]. / Ein gigantischer maligner Tumor der Kalotte - Fallbericht und Differentialdiagnose.

The case of a 72-year-old woman with a high-partially located tumor grown within a half year to a magnitude of 8.5 x 11 x 11 cm is reported. The patient remembered a mastectomy and axillary lymphadenectomy followed by chemotherapy and radiation 8 years ago. Therefore we assumed a skeletal metastasis of a breast cancer. After wide excision, an unusual morphology was found, allowing only a classification as a pleomorphic sarcoma. Searching for the pathohistological evaluation of the former breast tumor, a cystosarcoma phylloides malignum could be found out. The tumor described here can be identified as a metastasis of this rare neoplasm.