Prognostic factors in seminomas with special respect to HCG: results of a prospective multicenter study. Seminoma Study Group.

OBJECTIVE: In a prospective multicenter trial, it was our intention to elucidate clinical prognostic factors of seminomas with special reference to the importance of human chorionic gonadotropin (HCG) elevations in histologically pure seminomas. METHODS: Together with 96 participating urological departments in Germany, Austria, and Switzerland, we recruited 803 seminoma patients between 1986 and 1991. Out of 726 evaluable cases, 378 had elevated, while 348 had normal HCG values in the cubital vein. Histology was reviewed by two reference pathologists. HCG levels were determined in local laboratories and in a study laboratory. Standard therapy was defined as radiotherapy in stages I (30 Gy) and IIA/B (36 Gy) to the paraaortal and the ispilateral (stage I) and bilateral (stage IIA/B) iliac lymph nodes; higher stages received polychemotherapy and surgery in case of residual tumor masses. Statistics included chi-square tests, linear Cox regression, and log-rank test. RESULTS: The HCG elevation is associated with a larger tumor mass (primary tumor and/or metastases). HCG-positive and HCG-negative seminomas had no different prognostic outcome after standard therapy. The overall relapse rate of 6% and the survival rate of 98% after 36 months (median) indicate an excellent prognosis. The calculation of the relative risk of developing a relapse discovered only stage of the disease and elevation of the lactate dehydrogenase concentration and its prolonged marker decay as independent prognostic factors for seminomas. A more detailed analysis of the prognostic significance of the stage revealed that the high relapse rate in stage IIB seminomas after radiotherapy (24%) is responsible for this result. CONCLUSIONS: We conclude that HCG-positive seminomas do not represent a special entity. Provided standard therapy is applied, HCG has no influence on the prognosis. Patients with stage IIB disease should be treated with chemotherapy because of the demonstrated higher relapse rate outside the retroperitoneum.

[Snow white small intestinal villi in hypobetalipoproteinemia]. / Schneeweisse Dünndarmzotten bei Hypobetalipoproteinämie.

In contrast to the severe clinical picture of abetalipoproteinemia patients with hypobetalipoproteinemia are often asymptomatic. We demonstrate a 52-years-old female patient with a white mucosa of the small intestine casually observed by endoscopy. The white appearance of the mucosa was limited to the villi. As demonstrated by light and transmission electron microscopy this was caused by fat loaded enterocytes similar to the picture of abetalipoproteinemia. Fasting serum lipids and apolipoproteins were only if the lower norm level for some parameters, but no increase of the serum lipids was observed after an oral fat load. Because of the missing symptoms, the typical histomorphology and laboratory findings the snow white mucosa of the small intestine is due by the hetocygote form of the autosomal dominant hypobetalipoproteinemia with fat loaded enterocytes.

[A rare form of heart metastasis: hypernephroma. Successful surgical treatment]. / Seltene Form von Herzmetastasen: Hypernephrome. Erfolgreiche chirurgische Behandlung.

An unusual cardiac metastasis, occurring in a 63-year-old man 19 years after nephrectomy because of renal cell carcinoma, is reported. The tumor extended from the right ventricle apex to the mid-portion of the interventricular septum. A complete excision could be achieved. To our knowledge, this is the third case of a renal cell carcinoma metastasis to the right ventricle which could be detected during a patient's lifetime and treated surgically. A review of the literature is also reported.

[Malignant lymphomatous polyposis--a rare disease entity of malignant centrocytic lymphoma with characteristic endoscopic appearance]. / Die maligne lymphomatöse Polypose--eine seltene Krankheitsentität des malignen zentrozytischen Lymphoms mit charakteristischem endoskopischen Aspekt.

It is considered as special gastrointestinal manifestation on the nodal centrocytic lymphoma of intermediate malignancy. We demonstrate a 77 years old male patient, who underwent colonoscopy because of rectal bleeding. We found the colonic mucosa dotted with small, flat, lentiform polyps. In the terminal ileum these polyps were much larger. No changes were seen in the esophagus. In the antrum we found flat elevations and in the duodenum again lentiform nodules. Presenting in stage IV of non-Hodgkin's lymphoma the patient was treated with five cycles of combined chemotherapy with prednimustin and mitroxanthrone without side effects. Restaging showed distinct remission of the disease with significant reduction of the mucosal alterations.

Management of ureteral strictures by different modalities and effect of stents on upper tract drainage.

Ureteral strictures were induced experimentally by unilateral partial ligation of the upper ureter on the left side in 56 female rabbits. Six weeks later, stricture stability was documented by intravenous urography. In all cases, there was fibrosis of the muscular wall of the ureter. The lumen, although narrowed to various degrees, was preserved in most animals, and moderate to marked hydronephrosis resulted. Control animals were not treated in order to study the natural progress of the stricture. The other strictures were treated either by dilation (catheter or balloon) with or without ureteral stenting, by intubated external ureterotomy, or by excision of the strictured segment and stented end-to-end anastomosis. Follow-up studies consisted of intravenous urography, renography, and histologic examination for 24 weeks. Ureteral dilation without and with 2 weeks of stenting could be an adequate treatment of strictures associated with a moderate degree of hydronephrosis. Intubated external ureterotomy did not give satisfactory results in any animal. Excision of the strictured segment with a stented anastomosis produced satisfactory results and has a great role in the treatment of the strictured ureter in comparison with the variable outcome of endourologic treatment. Stenting of the unobstructed ureter, tested in six rabbits, showed a positive correlation between renal obstruction and long-term ureteral stenting.

[Morphologic criteria for the evaluation of beta-HCG positive seminoma]. / Morphologische Kriterien zur Beurteilung beta-HCG-positiver Seminome.

Histopathological work-up of 47 pure seminomas detected in patients with elevated serum beta-HCG levels was performed as part of the multicentre study on the prognosis of beta-HCG-secreting seminoma. There was no relation between number of specimens and the detection of syncytitrophoblastic giant cells. Invasion of lymph vessels, however, was not found in even 1 case when only 1-10 specimens were examined, whilst when 21-30 specimens were examined this was detected in 33.3%. Invasion of small veins was seen in 8.3% with 1-10 specimens and in 33.3% with 21-30 specimens. That is to say that with increasing number of specimens the rate of detection with be enhanced. To take allow economic factors to be taken account of as well as the clinical demand for comprehensive pathological diagnosis, a diagnostic screening test is recommended. This includes the anatomy of testicular veins and lymph vessels and macroscopic features, to increase the probability that vascular invasion will be detected.

Frequency of urogenital tuberculosis in an unselected autopsy series from 1928 to 1949 and 1976 to 1989.

The evaluation of a total of 12,211 autopsy protocols prior to the introduction of chemotherapy (1928-1949) and in the recent years (1976-1989) had the following results: the frequency of renal tuberculosis has dropped from 2.0 to 0.6% of all autopsies in men and from 1.7 to 0.9% in women. While the frequency of miliary tuberculosis infections in general has decreased to about one fourth (from 2.7 to 0.6% of all autopsies), renal involvement in patients with miliary tuberculosis has rather increased (from 35.4 to 52.2 for men and from 37.5 to 68.0% for women). The frequency of miliary tuberculosis of the kidneys was two times higher in girls than in boys (3.8% of girls and 1.8% of boys). Tuberculosis of the renal pelvis, ureter or urinary bladder secondary to a renal tuberculous infection has decreased from 65 to 4.3% of all tuberculous infections with renal involvement in males and from 25 to 0% in females. In the second period, the frequency of genital tuberculosis has in all dropped to about one tenth.

Anatomy and pathophysiology of Peyronie's disease and congenital deviation of the penis.

42 specimens from resected plaques of Peyronie's disease (IPP) and connective tissue obtained according to Nesbit were examined microscopically. The specimens were divided into three layers and the respective structures were counted in each layer in 15 fields of view with 100-fold magnification. 14 of 20 patients i.e. 70% of patients with IPP showed more than 10 perivascular infiltrates of lymphocytes and plasma cells/45 fields. 60% of all infiltrates were localized in the mid portions. 30% in the dorsal aspect and only 10% in the lower layers near the corpus spongiosum, where IPP is supposed to have its origin. A significant reduction of the quantity of inflammatory infiltrates related to the duration of the disease could not be proved. The same applies to vascular sections. The total number of vascular cross-sections found in the IPP plaque is 3 times as high as in the macroscopically inconspicuous tissue obtained according to Nesbit. 61% of blood vessels were localized in the mid portion, 22.3% in the dorsal aspect and only 16.5% in the basel portion near the corpus spongiosum. Bone formation was found in 4 of the 20 analyzed specimens from patients with IPP. These quantitative morphological studies have shown that the plaque undergoes reactive processes which even persist after years.

[Preparation for colonoscopy using Golytely--a sure method? Comparative histological and clinical study between lavage and saline laxatives]. / Vorbereitung zur Koloskopie mit "Golytely"--eine sichere Methode? Vergleichende histologische und klinische Untersuchung zwischen Lavage und salinischem Laxans.

UNLABELLED: Looking at clinical side-effects, effectiveness and tolerability, we compared the salinic solution "Golytely" vs. a conventional preparatory procedure (Cascara-Salax) in a prospective study including 28 patients with macroscopic normal mucosa. Mucosal changes in colonic step biopsies were investigated according to prefixed criteria. RESULTS: There was no significant difference concerning weight, blood pressure, pulse rate, body temperature or essential laboratory findings. Whereas preparation using Cascara-Salax was less molesting stated by the patients, there was no difference in the way colonoscopy itself was tolerated in both groups. The performing doctor's evaluation of the colonic cleaning effect and examination conditions showed "Golytely" significantly ahead of Cascara-Salax. Histologically, colonic mucous layers depicted changes in the control groups in 63% vs. 40% in the "Golytely" group. "Golytely" seems to provide a safe and effective method of preparation for colonoscopy.

Prostatic specific antigen: immunoreactivity in urachal remnants.

Urachal remnants were obtained at autopsy from 10 males and 15 females in order to determine whether prostatic specific antigen (PSA) is present in that tissue. Immunohistochemical staining was carried out using a commercially available antibody to PSA. Four cases (three females and one male) showed focal positive reaction of PSA, predominantly in narrow glandular structures of metaplastic origin. Therefore, it cannot be excluded that PSA might occur in urachal adenocarcinomas. PSA-staining is evidently not confined exclusively to tissue originating in the prostate.

Urothelial histopathology surrounding bladder carcinomas.

We studied the histological condition of the urothelium surrounding bladder carcinomas in 65 patients who underwent partial resection of the bladder. These examinations showed that urothelial abnormalities were always present, i.e. a direct transition from tumour to normal urothelium was never observed. The histological alterations were divided into 10 classes and their relative positions were determined with respect to the primary tumour site. The extension of urothelial alterations around the tumour and the severity of the alterations were related to the grade of the primary tumour. Extremely atypical abnormalities were usually found next to the tumour, whereas hardly altered urothelium was located more distant to the primary tumour site. We found three atypical types of hyperplasia more frequently than simple types of hyperplasia in the vicinity of high grade (G3) carcinomas. Total hyperplasia of basal cells was more frequent than partial hyperplasia. Furthermore, carcinoma in situ (CIS) with a persisting layer of normal superficial cells tended to be relatively far from the primary tumour site, whereas CIS without normal superficial cells was usually next to the primary site. Two models for the pathogenesis of the urothelial alterations surrounding bladder carcinomas are briefly discussed.

Capillarosclerosis of the renal pelvis: autopsy study for estimating the incidence of phenacetin and paracetamol abuse.

This prospective study, carried out in an unselected autopsy series of 700 adults who died in or around Wuppertal, showed distinct capillarosclerosis of renal pelvic mucosa in 3% of all cases. In that renal capillarosclerosis is a partial morphologic marker of phenacetin and/or paracetamol abuse, the findings indicate that the incidence of analgesic abuse in hospitalized patients in our area is at least 3%. The incidence of renal pelvic capillarosclerosis was 1.5 times greater in females than in males.

[Capillarosclerosis of the efferent urinary tract as an indication of analgesic abuse. Incidence in unselected autopsies in a large West German town]. / Kapillarosklerose der ableitenden Harnwege als Indiz eines Analgetika-Abusus. Häufigkeit bei unausgewählten Obduktionen in einer westdeutschen Grossstadt.

In a prospective study conducted during one year, postmortem examination of 500 unselected adults revealed in 13 cases (2.6%) a marked capillarosclerosis of the mucosa of the renal pelvis, considered to be a reliable histological sign of phenacetin and paracetamol abuse. These results were obtained in four men (1.5% of the total number of autopsied men) and nine women (3.9% of the autopsied women). Thus, capillarosclerosis is 2.6 time more frequent in women than in men.

Primary hepatic cancer and liver cirrhosis. Autopsy study covering fifty years.

Autopsy reports from 1931 to 1980 were used to study the incidence of liver cirrhosis (LC) and the association between LC and hepatocellular carcinoma (HCC) in our area (Wuppertal, Germany). An increase in LC and in LC with HCC has occurred since World War II, with HCC being most frequently associated with postnecrotic cirrhosis. The prevalence of HCC in men with LC was highest (13.5%) in 1966-1970, whereas the prevalence of HCC with LC in women rose abruptly to a peak (11.8%) during the last 5 years of the study. Possible etiological factors for the association between LC and HCC are discussed.

[Solitary liver abscesses in chronic brucellosis]. / Solitäre Leberabszesse bei chronischer Brucellose.

In two patients from southern Italy, the sonographic finding of great solitary focal liver lesions was contributed to brucella-abscesses (brucelloma) according to the clinical and serological data and to the results of ultrasonically guided fine needle aspiration biopsies. In both cases, laparotomy confirmed the diagnosis. We discuss the clinical findings and differential diagnosis of this uncommon inflammatory focal liver lesion.

[Stomach neurinoma]. / Das Magenneurinom.

Between 10 and 15% of all benign nonepithelial tumors of the stomach are neurinoma. The majority of these tumors originating from the plexus myentericus do not cause clinical symptoms. They become clinically important because of complications like hemorrhage, perforation or displacement of neighbouring organs. Typical clinical symptoms, laboratory data, radiological or endoscopic findings do not exist. The diagnosis neurinoma can only be established by histological examination; differentiation of myogenic tumors is often difficult. The surgical procedure has to take into account extension, localisation, and relation of the tumor to the stomach wall. If multiple neurinoma extending from the cardia to the pylorus are present total gastrectomy may be necessary.

[Colitis in the non-functioning rectosigmoid after establishment of an end-sigmoid colostomy]. / Kolitis im funktionslosen Rektosigmoid nach Anlegen eines endständigen Anus praeternaturalis.

In 11 patients with a sigmoid end colostomy (and one additional patient with an end ileostomy), we examined the endoscopic and microscopic aspects of both the dysfunctioned bowel and the colon proximal to the colostomy. The latter showed in none of the cases signs of inflammation, while in 7 patients a remarkable or even severe colitis (mimicking ulcerative colitis) could be demonstrated endoscopically and/or histologically - irrespective to the duration of the dysfunction (one month up til 11 years). In the four patients with restoration of the intestinal continuity, macroscopic and microscopic findings of the rectal mucosa became normal as soon as two weeks after reoperation. We conclude, that the "dysfunctioned bowel-colitis" is somehow related to the mucosa's contact to the fecal stream.