[Malignant epithelioid angiomyolipoma of the kidney: a rare case]. / Malignes epitheloides Angiomyolipom der Niere: ein seltener Fall.

Epitheloide angiomyolipoma (EAML) is a very rare type of benign mesenchymal angiomyolipoma. In contrast to classical angiomylipoma, lymph node metastases, local recurrence and distant metastases occur in one third of patients with EAML. We report the case of a 49-year-old patient with a large recurrence of EAML of the left kidney. According to the literature, this is the first case of a malignant EAML with local recurrence in Germany.

Investigation of the impact of magnesium versus titanium implants on protein composition in osteoblast by label free quantification.

Metallic implant biomaterials predominate in orthopaedic surgery. Compared to titanium-based permanent implants, magnesium-based ones offer new possibilities as they possess mechanical properties closer to the ones of bones and they are biodegradable. Furthermore, magnesium is more and more considered to be "bioactive" i.e., able to elicit a specific tissue response or to strengthen the intimate contact between the implant and the osseous tissue. Indeed, several studies demonstrated the overall beneficial effect of magnesium-based materials on bone tissue (in vivo and in vitro). Here, the direct effects of titanium and magnesium on osteoblasts were measured on proteomes levels in order to highlight metal-specific and relevant proteins. Out of 2100 identified proteins, only 10 and 81 differentially regulated proteins, compare to the control, were isolated for titanium and magnesium samples, respectively. Selected ones according to their relationship to bone tissue were further discussed. Most of them were involved in extracellular matrix maturation and remodelling (two having a negative effect on mineralisation). A fine-tuned balanced between osteoblast maturation, differentiation and viability was observed.

Inflammatory response to magnesium-based biodegradable implant materials.

Biodegradability and mechanical properties of magnesium alloys are attractive for orthopaedic and cardiovascular applications. In order to study their cytotoxicity usually bone cells are used. However, after implantation, diverse and versatile cells are recruited and interact. Among the first ones coming into play are cells of the immune system, which are responsible for the inflammatory reaction. Macrophages play a central role in the inflammatory process due to the production of cytokines involved in the tissue healing but also in the possible failure of the implants. In order to evaluate the in vitro influence of the degradation products of magnesium-based alloys on cytokine release, the extracts of pure magnesium and two magnesium alloys (with gadolinium and silver as alloying elements) were examined in an inflammatory in vitro model. Human promonocytic cells (U937 cells) were differentiated into macrophages and further cultured with magnesium-based extracts for 1 and 3 days (simulating early and late inflammatory reaction phases), either at 37 °C or at 39 °C (mimicking normal and inflammatory conditions, respectively). All extracts exhibit very good cytocompatibility on differentiated macrophages. Results suggest that M1 and even more M2 profiles of macrophage were stimulated by the extracts of Mg. Furthermore, Mg-10Gd and Mg-2Ag extracts introduced a nuancing effect by rather inhibiting macrophage M1 profile. Magnesium-based biomaterials could thus induce a faster inflammation resolution while improving tissue repair. STATEMENT OF SIGNIFICANCE: Macrophage are the key-cells during inflammation and can influence the fate of tissue healing and implant performance. Magnesium-based implants are biodegradable and bioactive. Here we selected an in vitro system to model early and late inflammation and effect of pyrexia (37 °C versus 39 °C). We showed the beneficial and nuancing effects of magnesium (Mg) and the selected alloying elements (silver (Ag) and gadolinium (Gd)) on the macrophage polarisation. Mg extracts exacerbated simultaneously the macrophage M1 and M2 profiles while Mg-2Ag and Mg-10Gd rather inhibited the M1 differentiation. Furthermore, 39 °C exhibited protective effect by either decreasing cytokine production or promoting anti-inflammatory ones, with or without extracts. Mg-based biomaterials could thus induce a faster inflammation resolution while improving tissue repair.

Is there still a place for retroperitoneal lymph node dissection in clinical stage 1 nonseminomatous testicular germ-cell tumours? A retrospective clinical study.

BACKGROUND: Primary retroperitoneal lymph node dissection (RPLND) ultimately lost its role as the standard management of clinical stage (CS) 1 nonseminomatous (NS) testicular germ cell tumours (GCTs) in Europe when the European Germ Cell Cancer Consensus Group released their recommendations in 2008. Current guide-lines recommend surgery only for selected patients but reasons for selection remain rather ill-defined. We evaluated the practice patterns of the management of CS1 patients and looked specifically to the role of RPLND among other standard treatment options. METHODS: We retrospectively evaluated the treatment modalities of 75 consecutive patients treated for CS1 NS at one centre during 2008-2017. The patients undergoing RPLND were selected for a closer review. Particular reasons for surgery, clinical features of patients, and therapeutic outcome were analyzed using descriptive statistical methods. RESULTS: Twelve patients (16%) underwent nerve-sparing RPLND, nine surveillance, 54 had various regimens of adjuvant chemotherapy. Particular reasons for surgery involved illnesses precluding chemotherapy (n = 2), patients´ choice (n = 4), and teratomatous histology of the primary associated with equivocal radiologic findings (n = 6). Five patients had lymph node metastases, two received additional chemotherapy. Antegrade ejaculation was preserved in all cases. One patient had a grade 2 complication that was managed conservatively. All RPLND-patients remained disease-free. CONCLUSIONS: Primary RPLND is a useful option in distinct CS1 patients, notably those with concurrent health problems precluding chemotherapy, and those with high proportions of teratoma in the primary associated with equivocal radiological findings. Informed patient's preference represents another acceptable reason for the procedure. RPLND properly suits the needs of well-selected patients with CS1 nonseminoma and deserves consideration upon clinical decision-making.

[Ruptured vascular adrenal cyst after being hit by a wave]. / Rupturierte vaskuläre Nebennierenzyste durch Badeunfall.

Endothelial cysts of the adrenal gland are a rare entity of adolescents. We here present the case of a 19-year-old woman, who developed right abdominal pain after trauma. Magnetic resonance imaging showed a tumor in the right adrenal gland with suspicious signs for malignancy. Histopathological examination revealed the diagnosis of an endothelial (vascular) adrenal cyst. In most cases, cysts of the adrenal gland remain clinically inapparent. In cases of clinically manifest symptoms, surgical intervention represents the standard for therapy.

Complication and local recurrence rate after endoscopic resection of large high-risk colorectal adenomas of ≥3 cm in size.

PURPOSE: Endoscopic resection is a widely used technique for treatment of large colorectal adenomas, but few data are available including only lesions larger than ≥2 cm. The aim of this study is to evaluate the complication and recurrence rate after endoscopic resection of high-risk colorectal adenomas ≥3 cm in size. METHODS: Retrospective analysis of a prospectively maintained database of patients undergoing polypectomy of large colorectal polyps of ≥3 cm. RESULTS: In 341 patients, 360 colorectal adenomas with a mean size of 3.9 cm were resected endoscopically. In 25 patients, a complication including 22 delayed bleedings (6.5%) and three perforations (0.9%) occurred. Single-variate analysis showed an increasing risk of complications for larger adenomas (3.9 vs. 4.6 cm; p ≤ 0.05). Two hundred twelve patients with 224 adenomas had undergone at least one documented follow-up endoscopy with a medium follow-up period of 16 months. In 95 resected lesions (42.4%), a residual adenoma occurred in the first follow-up colonoscopy (n = 88, 92.6%) or a recurrent adenoma occurred after at least one negative follow-up colonoscopy (n = 7, 7.4%). In multivariate analysis, risk factors were lesion size, sessile growth pattern, and the performing endoscopist. The complication and recurrence rate correlated inversely between endoscopists. CONCLUSIONS: The present study is the largest study showing complication and recurrence rates after colorectal polypectomy of advanced colorectal adenomas of ≥3 cm in size. Polyp size was identified as the most important risk factor for complications. For the first time, this study shows that the complication rate after colorectal polypectomy of large adenomas is correlated inversely with the residual and/or recurrence rate.

Single center experience of endoscopic submucosal dissection (ESD) in early Barrett's adenocarcinoma.

BACKGROUND: Endoscopic mucosal resection (EMR) or radical surgical resection are the standard treatment options for patients with early Barrett's adenocarcinoma (EBAC). Endoscopic submucosal dissection (ESD) is a new endoscopic technique, which allows--in contrast to EMR--endoscopic en-bloc resection of neoplastic lesions greater than 2 cm with complete histological evaluation of the resected specimen. In contrast to Western countries, Barrett's esophagus is less common in Asia indicating the low volume of published data of ESD in EBAC in Japanese series. Therefore, the aim of the present study is to describe the results of ESD in patients with EBAC performed in a German tertiary referral center. METHODS: Between November 2009 and April 2014 ESDs were performed in 22 patients with histologically proven EBAC. Data were given for the en-bloc, the R0, the R0 en-bloc, and the curative resection rate as well as for the complication and the local recurrence rate. RESULTS: ESD was technically possible in all of the 22 patients. 20 of the resected EBAC were mucosal carcinomas, whereas in two patients the tumor showed submucosal invasion. The en-bloc, R0, R0 en-bloc, and curative resection rates were 95.5, 81.8, 81.8 %, and 77.3 %, resp. Complication rate was 27.3 % (perforation n = 1, bleeding n = 2, stenosis n = 3). In case of curative tumor resection, only one local tumor recurrence (5.9 %) occurred after a medium follow-up of 1.6 years. CONCLUSIONS: Despite the small number of patients and a relatively short follow-up, the present data underline the value of ESD, especially in case of curative resections in the definite and less invasive therapy of EBAC. Attention should be drawn toward subsquamous extension of EBAC requiring a sufficient safety margin as an obligate condition for curative R0 resections. Due to the required learning curve and the management of potential complications, ESD should be restricted to greater endoscopic centers.

[Single centre experience of endoscopic submucosal dissection (ESD) in premalignant and malignant gastrointestinal neoplasia]. / Single-Center-Erfahrung mit der Endoskopischen Submukosa-Dissektion (ESD) bei prämalignen und malignen gastrointestinalen Neoplasien.

INTRODUCTION: Worldwide endoscopic submucosal dissection (ESD) of early GI cancers or premalignant neoplasia is becoming increasingly important. In Germany ESD is restricted to larger endoscopic institutions and only a few literature reports are available. The aim of the present study is to describe the results of 46 ESDs conducted in a German endoscopic centre. MATERIAL AND METHODS: Between June 2007 and May 2012 46 ESDs in 45 patients (33 men, 12 women, mean age 66.1 years) were performed in the oesophagus (n = 17), stomach (n = 23) and rectum (n = 6). Data were collected for the en-bloc, R0 and R0 en-bloc resection rates as well as for complications, the curative resection and the local recurrence rates. In order to demonstrate a learning curve, results were evaluated for two periods (June 2007 to November 2010 vs. December 2010 to May 2012). RESULTS: ESD was technically possible in 93.5%. En-bloc, R0, R0 en-bloc and curative resection rates were 90.7%, 74.4%, 67.4% and 65.1%, respectively. The complication rate was 13%. In the second period en-bloc and R0 en-bloc resection rates increased from 81% to 100% and, respectively, from 52.4% to 81.8%. After a medium follow-up of 11.4 months, local tumour recurrence occurred in 10%. In cases of curative R0 en bloc resection of malignant tumours no tumour recurrence occurred. DISCUSSION: Despite the small number of patients, the present data underline the value of ESD, especially in cases of R0 en-bloc resections in the therapy for premalignant and early malignant GI tumours. Due to the required learning curve, ESD should be restricted to larger endoscopic centres in Germany.

[EHEC-associated colon stenosis after ulcerous-chronic haemorrhagic colitis and consecutive resulting ileus]. / EHEC-assoziierte Kolonstenose nach ulzerös-chronisch hämorrhagischer Kolitis mit konsekutivem Ileus.

We report on the case of a segmentally emphasised, ulcerous chronic haemorrhagic colitis with the development of granulation tissue und scarred fibrosis with consecutive resulting stenosis of the colon. A 49-year-old male patient was infected with enterohaemorrhagic Escherichia coli bacteria during the EHEC-epidemic in northern Germany in early summer 2011. In the course of the infection the patient suffered from haemolytic uraemic syndrome (HUS) with acute renal failure and neurological symptoms. Haemodialysis and plasmapheresis had become mandatory. A simultaneous ileus was estimated to be of paralytic origin. One month after treatment of the acute phase of the infection a CT scan of the abdomen was performed and discovered a symptomatic stenosis of the proximal colon transversum. This obstruction needed to be treated by performing a right hemicolectomy with an ileo-transverso anastomosis. After surgery the patient recovered continuously. The histopathological examination verified an ulcerous-chronic haemorrhagic colitis on the background of an EHEC infection.

[Tubular ectasia of rete testis: a pitfall in ultrasonographic diagnostics of intratesticular cysts]. / Tubuläre Ektasie des Rete testis : Die Differenzialdiagnose von zystischen Veränderungen im Hoden.

BACKGROUND: Tubular ectasia of the rete testis (TERT) sonographically consists of a cluster of anechoic foci located at the mediastinum testis. TERT is important diagnostically, because it might be confused with malignant teratoma that may likewise contain cystic areas. PATIENTS AND METHODS: Twenty-four patients with TERT were identified sonographically. Ten of these patients underwent additional magnetic resonance imaging (1.5 T), and three had contrast-enhanced scrotal sonography. A descriptive analysis was done regarding clinical details and sizes of the single anechoic foci and of the entire areas involved with cystic changes. RESULTS: The median age of the patients with TERT was 60 years. Diagnosis was based on incidental findings or uncharacteristic symptoms in three quarters of the cases. The size of the single cysts was ≤ 3 mm, 4-6 mm and ≥ 7 mm in 12, 6 and 6 patients, respectively. The size of the entire area involved with cystic changes ranged from 0.5 x 1.2 cm to 2.5 x 3.0 cm. Six patients had TERT bilaterally, and 18 had concomitant spermatoceles. T2-weighted MRI demonstrated high signal intensity of the cystic areas. No signal enhancement was found in these areas after application of contrast agent. Contrast-enhanced sonography did not show uptake in the TERT areas. Histological evidence for dilatation of the rete testis was found in the two patients undergoing diagnostic surgery. CONCLUSIONS: TERT is a benign lesion of the testis that is increasingly detected sonographically. Knowledge of TERT is essential for the urologic sonographer to avoid unwarranted diagnostics and surgery as well as costs.

[Presacral schwannoma with degenerated areas ("ancient schwannoma")]. / Präsakrales Schwannom mit degenerativ veränderten Anteilen ("ancient schwannoma").

A presacral, degenerative schwannoma ("ancient schwannoma") is a rare entity. The clinical signs are nonspecific, and a reliable preoperative diagnosis is difficult. Tumor heterogeneity with calcifications may be seen in degenerated schwannomas on MRI or CT but not necessarily. First-line treatment is complete surgical excision. We present the case of a 44-year-old male who required surgery for a presacral mass. Histopathological examination revealed the diagnosis of a schwannoma with degenerated areas.

The mucin profile of noninvasive and invasive mucinous cystic neoplasms of the pancreas.

Recently, it was shown that ductal adenocarcinomas and intraductal papillary-mucinous neoplasms of the pancreas differ in their expression of the mucin markers MUC1 and MUC2 while both tumors express MUC5AC. It is not known whether mucinous cystic neoplasms of the pancreas have their own mucin profile. To clarify this issue, 22 mucinous cystic neoplasms were examined immunohistologically for their expression of MUC1, MUC2, MUC5AC, and MUC6 and also for the protein products of the tumor suppressor genes p53 and DPC4 and the mismatch repair genes. Noninvasive mucinous cystic neoplasms, regardless of the degree of cellular atypia, were all positive for MUC5AC and negative for MUC1, with the exception of the cyst-lining epithelium of a single case with eosinophilic cytology (case no. 16). Only in cases with an invasive component was MUC1 expression observed. MUC2 expression was restricted to goblet cells scattered within the epithelium of the mucinous cystic neoplasms and was often accompanied by endocrine cells, a further indication of intestinal differentiation. DPC4 expression was maintained in all tumors, except for three invasive carcinomas. p53 nuclear reactivity was found in one borderline tumor and four invasive mucinous cystic carcinomas. The results suggest that the epithelium of noninvasive mucinous cystic neoplasms does not differ in its expression of MUC5AC from ductal adenocarcinomas, intraductal papillary-mucinous neoplasms, and metaplastic pancreatic duct epithelium. The fact that noninvasive mucinous cystic neoplasms lack MUC1 expression (except for an eosinophilic variant) but express it when they become invasive might be used as a marker indicating the step of progression from noninvasiveness to invasiveness.

Radioprotection of salivary glands by S-2-(3-aminopropylamino)-ethylphosphorothioic (amifostine) obtained in a rabbit animal model.

BACKGROUND: Impairment of salivary gland function following high-dose radioiodine treatment (HDRIT) is a well-recognized side effect of the treatment. Because differentiated thyroid cancer has an excellent prognosis, reduction of long-term side-effects is mandatory. Therefore, the aim of this study was to investigate the radioprotective effect of amifostine in a rabbit animal model. METHODS: Salivary gland scintigraphy was performed in a total of 16 New Zealand White rabbits. Uptake of 99-Tc-pertechnetate was calculated in percentage of injected activity as a quantitative measure of both salivary gland and thyroid function. Reproducibility of salivary gland scintigraphy was evaluated in one rabbit without any intervention. Fifteen rabbits were studied prior to and up to 6 months after high-dose radioiodine treatment applying 2 GBq 131I. Ten animals received 200 mg/kg amifostine prior to high-dose radioiodine therapy, and 5 served as controls. Salivary glands were examined histopathologically. RESULTS: Variation coefficient of parenchymal function was less than 3.8% in salivary glands. Prior to HDRIT, thyroid uptake was 0.417+/-0.373% and 0.421+/-0.241% in control and amifostine-treated rabbits, respectively. Four weeks after HDRIT, complete ablation of the thyroid was achieved in both groups. Prior to HDRIT, uptake of 99mTc-pertechnetate in salivary glands of five control rabbits was not significantly different from ten amifostine-treated rabbits. In control rabbits 6 months after HDRIT, parenchymal function was reduced significantly (p < 0.0001) by 75.3+/-5.3% and 53.6+/-17.4% in parotid and submandibular glands, respectively. In contrast, in amifostine-treated rabbits, parenchymal function was reduced by 10.6+/-3.4% and 6.5+/-4.3% (p > 0.05) in parotid and submandibular glands, respectively. Histopathologically, marked lipomatosis was observed in control animals but was negligible in amifostine-treated animals. CONCLUSION: Parenchymal damage in salivary glands induced by high-dose radioiodine treatment can be significantly reduced by amifostine in this rabbit animal model. This corresponds to data obtained in patients with differentiated thyroid cancer.

Radioprotection of salivary glands by amifostine in high-dose radioiodine therapy.

UNLABELLED: Salivary gland impairment after high-dose radioiodine treatment is well recognized. Because differentiated thyroid cancer has a good prognosis, reduction of long-term side effects is important. This study investigated the radioprotective effects of amifostine in animals and humans receiving high-dose radioiodine therapy. METHODS: Quantitative salivary gland scintigraphy was performed in five rabbits before and up to 3 mo after high-dose radioiodine therapy applying 1 GBq 131I. Three animals received 200 mg/kg amifostine before high-dose radioiodine therapy, and two served as controls. All animals were examined histopathologically. Quantitative salivary gland scintigraphy also was performed in 17 patients with differentiated thyroid cancer before and 3 mo after high-dose radioiodine therapy with 6 GBq 131I. Eight patients were treated with 500 mg/m2 amifostine before high-dose radioiodine therapy, and nine served as controls. RESULTS: In two control rabbits, high-dose radioiodine therapy significantly reduced parenchymal function by 63% and 46% in parotid and submandibular glands, respectively. In contrast, there was no significant decrease in parenchymal function in amifostine-treated animals. Histopathologically, lipomatosis was observed in control animals but was negligible in amifostine-treated animals. Similar findings were observed in differentiated thyroid cancer patients. In nine control patients, high-dose radioiodine therapy significantly (p < 0.01) reduced parenchymal function by 37% and 31% in parotid and submandibular glands, respectively. Three patients exhibited Grade I (World Health Organization) xerostomia. In contrast, there was no significant decrease in parenchymal function in amifostine-treated patients and no incidence of xerostomia. CONCLUSION: Parenchymal damage in salivary glands induced by high-dose radioiodine therapy can be reduced significantly by amifostine. This may increase the quality of life of patients with differentiated thyroid cancer.

Dacron-covered stent-grafts for the percutaneous treatment of carotid aneurysms: effectiveness and biocompatibility--experimental study in swine.

PURPOSE: To evaluate the short-term effectiveness and biocompatibility of Dacron-covered stent-grafts for percutaneous treatment of carotid aneurysms. MATERIALS AND METHODS: In eight swine, nine aneurysms were created surgically in the common carotid artery. Percutaneous treatment was performed with Dacron-covered stent-grafts. Seven of eight swine underwent follow-up angiography at 2, 3, 4, and 5 weeks after stent implantation. Histologic examinations of tissue from the site of stent implantation were performed at the same intervals. RESULTS: Initial closing off of the aneurysm was possible in all swine. Angiographic follow-up revealed patency of only one Dacron-covered stent-graft after 2 weeks. In six of seven swine, the stent was occluded on the follow-up angiogram. One of the swine died of unclear cause after 1 week. The stent-graft of this swine was not occluded. In all Dacron-covered stent-grafts, inflammatory reaction with granulocyte infiltration was found next to the Dacron material. CONCLUSION: Primary treatment of carotid aneurysms with Dacron-covered stent-grafts is effective. However, the short-term patency rate is poor, which probably can be attributed to the limited biocompatibility of the Dacron cover. An acute inflammatory reaction against Dacron seems responsible for the poor patency rate.

Pharyngosellar pituitary: a rare developmental anomaly of the pituitary gland.

A rare malformation of the pituitary gland, termed pharyngosellar pituitary, is reported. The anterior pituitary gland was continuous from the pharyngeal roof to the sella turcica. This was found in a male fetus of gestational week 17 with an encephalocele and amnion adhesion malformation syndrome. The distribution of hormone-producing cells in the malformed pituitary tissue was irregular: thyrotropic hormone-, follicle-stimulating hormone- and luteinizing hormone-producing cells were nearly absent in the sellar and middle sections of the pituitary but were found in small numbers mainly in the pharyngeal section of the pituitary. The teratogenic determination period was estimated at between weeks 4 and 8 of gestation.

Birds that feed-on-the-wing have few isthmo-optic neurons.

The isthmo-optic system is less developed in birds feeding-on-the-wing, than in pecking avians. This was suggested previously. By intraocular horseradish peroxidase applications, we studied the central origin of this retino-petal system in thrush, haw finch, swift and swallow. Our data support the assumption on a correlation between feeding habits and the development of the isthmo-optic nucleus in adult avians as this brainstem region is more highly developed in thrush and finch than in swift and swallow. This is particularly relevant since the latter species is taxonomically related to the two pecking birds whereas it is unrelated to the swift that also feeds-on-the-wing.