[Pathological diagnosis--costs and benefit]. / Die pathologische Diagnostik--Kosten und Nutzen.

The autopsy rate in Germany has drastically diminished in the last decades and is below 10% nowadays. Possible reasons for this development are discussed. Pressure of cost is a quoted cause, although it is not so high. There is a large discrepancy between the clinically supposed cause of death and the by autopsy confirmed diagnosis (40-60%). This especially applies to mycoses. Every year in Germany 1200 crimes of causing death and 11.000 non-natural deaths are not found because of missing autopsy. Another important aspect for a sufficient number of autopsies is their value for the quality assurance in diagnosis and therapy and also in education and further training of physicians and students.

[Pulmonary embolism caused by aspergillosis (so-called fungal embolism)]. / Lungenembolie durch Aspergillose (sog. Pilzembolie).

A 71-year-old man developed a cardiac tumour in the right ventricle and a pulmonary embolism caused by aspergillosis after implantation of a pacemaker because of arrhythmia. Repeated revisions during pocket infections. Emergency operation and tricuspid valve replacement with a Carpentier Edwards xenograft. The pacing electrodes and the endocardium were infected by Aspergillus in form of an aspergilloma. This case is an example of the rare condition of a pulmonary embolism with pure fungal material.

Non-palpable breast lesions in asymptomatic women: diagnostic value of initial ultrasonography and comparison with mammography.

AIM: This prospective double-blind study was designed to assess (i) if primary breast screening by ultrasonography is capable of detecting breast cancer independent of tissue density and (ii) if the rate of unnecessary biopsies remains acceptable when diagnostics are based on ultrasonography. PATIENTS AND METHODS: Bilateral breast ultrasonography was performed in 448 asymptomatic women as the initial diagnostic method. Sonograms were interpreted using a set of standardized diagnostic criteria. Subsequently, mammograms were obtained. The radiologists reading the mammograms were blinded to the sonographic results. RESULTS: Overall, 3 non-palpable breast cancers were detected by ultrasound and mammography. All 3 ultrasonographically detected breast cancers were smaller than 1 cm (0.7, 0.7, 0.6 cm). All 3 carcinomas were correctly detected by both methods. For ultrasonography, the false positive rate was 1.1% (n=5) and for mammography 0.6% (n=3). When both methods were combined, the rate of unnecessary open biopsies was 1.6% (n=7). The ratio of benign to malignant lesions was 3.7/1. CONCLUSION: Without prior mammography, primary high-resolution breast ultrasonography is capable of detecting non-palpable breast carcinomas in asymptomatic women at an early stage. The rate of unnecessary open biopsies is low and the ratio of benign to malignant biopsies acceptable.

Non-diagnosed pheochromocytoma as a cause of sudden death in a 49-year-old man: a case report with medico-legal implications.

Pheochromocytomas are known to be rare causes of sudden death. A 49-year-old man with a medical history of arterial hypertension and diabetes mellitus complained about nausea and malaise in the morning. During the day his condition deteriorated. He went to the emergency department, where he was given intravenous drugs against nausea and was sent home. On the way back, his condition deteriorated dramatically so that his wife drove back to the emergency room, where he collapsed and sustained cardiac arrest; resuscitation efforts were unsuccessful. Autopsy revealed a large tumour of the left adrenal gland. The strong suspicion of pheochromocytoma was confirmed by histology, immunohistochemistry and biochemical investigations. An acute hypertensive crisis, caused by the hitherto unknown pheochromocytoma was ascertained as the cause of death. The morphological findings are presented, the difficulty to diagnose pheochromocytoma and the medico-legal implications are discussed.

The height of the patella: an anatomical study.

The anterior region of the left knee joint of fifty fresh human cadavers (37 males, 13 females) was dissected and the following measurements were carried out: length of the patella (LP), width of the patella (WP), length of the patellar tendon (LT), and width of the patellar tendon (WT). The ratio LT/LP for assessment of the vertical position of the patella was 1.00 (range 0.72-1.38; SD 0.14) and found to be in full agreement with radiographic studies carried out first by Insall and Salvati in 1971 and later by other authors. There was no significant statistical difference between the Insall-Salvati index in males and females. The length and width of the patella as well as the length of the patellar tendon were found to be significantly larger in males than in females (P less than 0.001).

Hormonal inhibition of endometrium for transcervical endometrial ablation--a prospective study with a 2-year follow-up.

OBJECTIVE: To determine the best pretreatment of the endometrium prior to roller ball endometrial ablation. STUDY DESIGN: Forty patients with recurrent hypermenorrhea underwent diagnostic hysteroscopy and dilation and curettage. They were then assigned to receive either no pretreatment or pretreatment with danazol, a GnRH-analogue, or a gestagen prior to roller ball endometrial ablation. Endometrial suppression was estimated by the surgeon at the time of the procedure, and endometrial biopsies were obtained. Patients were followed for 24 months. RESULTS: The subjective estimation of the surgeon showed a sufficient pretreatment after danazol or a GnRH-analogue in 90% of the cases. Histological findings correlated with these findings. The highest level of amenorrhoea at 2 years of follow-up was also reached after danazol or GnRH-analogue pretreatment. CONCLUSIONS: Danazol- or GnRH-analogue should be used for pretreatment prior to endometrial ablation using the roller ball technique.

[Occurrence of naphthol-AS-D-chloracetate-esterase-activity in mast cells with special references to cutaneous mastocytoses (author's transl)]. / Nachweis der Naphthol-AS-D-Chloracefat-Esterase-Aktivität in Mastzellen unter besonderer Berücksichtigung cutaner Mastocytosen.

The enzyme naphthol-AS-D-chloracetate esterase (NASDCE) was demonstrated histochemically in mast cells of tissues of laboratory animals and men under normal and pathological conditions using the method after Leder (1964). Investigating the possible action of different fixations as Bouin's and Carnoy's fluid as formaldehyde also cryostate sections were studied for comparison. After tissue fixation the activity of the NASDCE is localized strongly in the granules of mast cells. The type of fixation is without influence on the histochemical reaction and localization. Differences concerning the investigated species could not be demonstrated. In benign neoplasias of mast cells such as diffuse (urticaria pigmentosa) and localized cutaneous mastocytosis as well as benign systemic mastocytosis with skin involvement (Sagher) the granule bound reaction is very intensive. The NASDCE can be recommended as a marker for the microscopical localization of mast cells, especially in the histological diagnosis of their benign and malignant neoplasias.

[Topochemical and electron microscopical analysis of the pancreas of dogs after pancreatic denervation]. / Histotopochemische und elektronenmikroskopische Untersuchungen am Pankreas von Hunden nach Denervierung des Pankreas.

Histochemical and electronmicroscopic findings on chronically and selectively denervated pancreata of 8 dogs are described. Most nerve fibers showed marked degeneration and perineuritis, and there was an inflammation of intrapancreatic ganglia. There was no change in the number of islets or in the A-B-cell ratio. Insulitis frequently has been observed. Both immunohistochemically demonstrable insulin in the B-cells, and glucagon in the A-cells were reduced in relation to that in non-denervated controls. There were single A- and B-cells within the acini in an apparently normal frequency. Many pancreata showed a chronic infiltration and fibroblastic inflammation within the acini but their extent varied considerably between the animals. Intrapancreatic blood vessels were generally dilated, hyperemic, and perivascular fibrosis was seen in some cases; the vessels contained many leucocytes. Acinar cells were often subjected to vacuolic degeneration. Another part of them showed, however, increased appearance of ergastoplasm, mitochondria, and of Golgi apparatus as a sign of increased functional stimulation. There were fibrosis and mononuclear infiltration in the medium-sized and large pancreatic ducts.

Gastric lipoma: A rare cause of gastrointestinal bleeding.

Full text is available as a scanned copy of the original print version.

Recurrent disease after breast preserving therapy (BPT) and radiation therapy for breast cancer--diagnostic yield of palpation, mammography and ultrasonography.

PURPOSE: According to the S-3 guidelines for the diagnosis and treatment of breast cancer, only palpation and mammography are mandatory follow-up examinations. Ultrasonography is only mentioned as an optional technique. Aiming to elucidate the diagnostic yield for detecting recurrent disease after breast-preserving therapy (BPT) and radiation treatment, we analysed the sensitivity of palpation, mammography, ultrasonography, and combinations of these methods. MATERIALS AND METHODS: Over a period of 12 years, 27 suspicious lesions in patients status post BPT and radiation therapy were biopsied (histologic results: 16 benign lesions: 59.3 %, 11 malignant lesions: 40.7 %). Prior to biopsy, the benign or malignant character of each lesion was predicted by palpation, mammography and ultrasonography (BIRADS). Sensitivity, specifity, positive predictive value (ppv), negative predictive value (npv), and efficiency were calculated from a contingency table. RESULTS: For lesions status post BPT and radiation treatment, palpation had a sensitivity of 72.7 % and was 25 % specific. For mammography, the respective values were 36.4 % and 87.5 %, and for ultrasonography 90.9 % and 68.8 %. Palpation and mammography combined were 81.8 % sensitive and had a specificity of 6.2 %. The computed sensitivity for the 3 methods applied together was 100 %. Adding ultrasonography to palpation and mammography therefore increases sensitivity by 18.2 %. CONCLUSION: For diagnosing recurrent disease in patients status post BPT and radiation therapy, ultrasonography is superior to palpation and/or mammography and should become an obligatory follow-up tool. The role of mammographic follow-up appears overrated and the role of ultrasonographic assessment underrated. The S-3 guidelines will need to be changed accordingly.

Radial scar/complex sclerosing lesion of the breast--value of ultrasound.

PURPOSE: Although benign, radial scar/complex sclerosing adenosis is a lesion which histopathologically resembles tubular carcinoma. On physical examination, it is difficult to distinguish radial scar from a malignant tumour. Mammography cannot differentiate radial scar from malignancy. This clinical study aims to delineate the role of preoperative ultrasonography with emphasis on the question whether ultrasonography could lower the number of false-positive readings and therefore the number of open biopsies required. MATERIALS AND METHODS: In this examination, we present the clinical, mammographic, ultrasonographic, and histopathological features of 6 cases of radial scars. RESULTS: Although most authors describe radial scars as non-palpable, 2 of 6 lesions were indeed palpable. On mammograms, radial scars have a spiculated appearance, a feature observed in all of our cases. Numerous ultrasonographic characteristics are listed in the literature, but ultrasonography is not reported to have clear-cut advantages. CONCLUSION: Although this study did not elucidate any unique ultrasonographic features to characterise these lesions, the analysis of all ultrasonographic results made us recognise a set of "nearly specific ultrasonographic features" of radial scars. Current B-mode imaging does not appear to lead to the desirable reduction of the rate of unnecessary open biopsies.

Ultrasound and mammography guided wire marking of non-palpable breast lesions: analysis of 741 cases.

PURPOSE: Aim of the study were to evaluate the success of ultrasound and mammography guided wire marking of non-palpable breast lesions and the results of specimen mammography/ultrasonography, completeness of resection, and number of secondary resections (during the initial surgical session and as a separate intervention) were analysed. MATERIALS AND METHODS: Between May 1994 and December 2004, 668 women with 741 non-palpable breast lesions underwent surgery at the Greifswald University Department of Gynaecology and Obstetrics. Ultrasound directed wire marking was used in 418, mammography directed marking in 284 cases. In 39 lesions, both techniques were combined. RESULTS: Out of all lesions approached with ultrasound directed wire marking, 88 (21.1 %) were malignant. Among lesions marked during mammography, 52 (19.3 %) were malignant. Specimen ultrasonography indicated that 90.9 % of lesions were resected completely. Specimen mammography demonstrated complete resection in 89.1 %. On histological examination, 19.5 % of the malignant lesions marked with sonographic guiding and 36.5 % of the malignant lesions marked with mammographic guiding did not have clear margins. Secondary resections (during the first procedure) for incomplete specimens were needed in 10 patients in whom sonographic localisation had been used, and in 25 patients in whom mammographic localisation had been employed. A second surgical session for secondary resection was required in 5.5 % of lesions marked with ultrasound and in 12.3 % of lesions marked with mammography guidance. CONCLUSION: Sonography directed wire localisation appears to be superior to the respective mammographic method. Ultrasound guided wire marking should be considered the preferred method for all mammographic lesions with an ultrasonographic equivalent and no micro-calcifications.

Parenchymal leiomyoma of the breast--clinical, sonographic, mammographic and histological features.

BACKGROUND: Intraparenchymal leiomyomas of the breast are quite rare. Areolar lesions are distinguished from intraparenchymal leiomyomas, which are less frequent. Clinically, leiomyomas appear as nodules; mammographically, they show up as round lesions. Reports on sonographic criteria are rare, and the criteria are nonspecific. Based on our case of an intraparenchymal leiomyoma, we describe additional sonographic features. The clinical, mammographic and sonographic characteristics of an intraparenchymal leiomyoma of the breast were evaluated. After surgery, the diagnosis was confirmed histologically. RESULTS: The clinical presentation of our patient with deep-seated leiomyoma of the breast included skin dimpling and a reduction in tissue mobility, differing from more commonly reported characteristics. Mammographically, the lesion was dense and only partly demarcated clearly, corresponding to other reports. On breast ultrasonography, the leiomyoma appeared as a hypodense, well demarcated, inhomogeneous lesion with posterior acoustic shadowing. A central tumour vessel was visible on Doppler imaging, and Cooper's ligaments were discontinuous. Acoustic shadowing, the hypodense character, hyperechoic border and the central tumour vessel are therefore additional ultrasonographic characteristics of an intraparenchymal leiomyoma of the breast. This type of lesion is usually described as isodense to hyperdense and homogeneous, possibly containing semicystic components. Previous reports have only described posterior acoustic enhancement, but not acoustic shadowing. CONCLUSION: On breast ultrasonography, an intraparenchymal leiomyoma of the breast can present with posterior acoustic shadowing, hypodense echogenicity, a hyperechoic border and a central tumour vessel. Neither imaging studies nor palpation allow distinction between benign and malignant lesions.

Juvenile papillomatosis (JP) of the female breast (Swiss Cheese Disease) -- role of breast ultrasonography.

This report summarises the imaging findings of juvenile papillomatosis (JP) in a 16-year-old woman. Sonographically, the lesion was oval, well defined, heterogeneous with multiple small, cystic spaces. Ultrasonography can be helpful in differentiating between JP and similar cystic lesions, fibroadenomas, phyllodes tumours, intracystic papillomas and carcinomas. A core needle biopsy is still needed to confirm the diagnosis. An open biopsy with excision of the lesion is mandatory, mere observation is inadequate because of insufficient knowledge about the direct relationship between JP and subsequent cancer.

Papillary intracystic carcinoma of the female breast--role of ultrasonography.

We report on a 76-year-old patient with papillary intracystic breast carcinoma. Papillary intracystic carcinomas represent a rare entity. Among all malignant breast tumors, this lesion has an incidence of 0.5-2%. Palpation is not sufficient to distinguish benign from malignant findings. The same applies to mammography, unless the tumor infiltrates the cyst wall. The method of pneumocystography has become obsolete. Sonography is the preferred diagnostic modality to distinguish cystic from solid lesions and to differentiate simple cysts from cysts with intracystic growth. In this respect, Doppler and power Doppler sonography can be instrumental. It is feasible to obtain preoperative ultrasound guided FNAC or core biopsies of the cystic and solid components for cytological or histological verification. Complete excision of the cyst which should include the intracystic growth is considered the treatment of choice.

Candidosis and aspergillosis as autopsy findings from 1994 to 2003.

We analysed the autopsy records of the Greifswald University Institute of Pathology (located in Eastern Germany) in respect of findings of candidosis and aspergillosis from 1994 to 2003. We also present eight immature aborted fetuses and premature infants with a mycosis. In a total of 2027 autopsies we found 164 cases of invasive candidosis and aspergillosis (8.1%) including a combination of both on four occasions. Other authors cited between 0.7 and 7.3%. In these 10 years in our material mycoses and in particular candidosis increased in spite of slightly decreased numbers of autopsies. The differences comparing the 5-years periods (1994-98 and 1999-2003) are highly significant for both mycoses and candidosis. They are not significant for aspergillosis. A similar relationship was observed in the distribution of mycotic organs and causative origin for candidosis alone. In the last 5 years the gastrointestinal and respiratory tracts, including the peritoneum, were more frequently infected by Candida. Non-haematological neoplasia and pneumonia as basic diseases more often appeared in cases of candidosis. All eight immature aborted fetuses and premature infants suffered from candidosis. The survey confirms the importance of autopsy as a tool for education and quality control in medical diagnostic and therapeutic activity in the field of mycoses, too.

Nondistorting lateral edge support of large telescope mirrors.

Simply by push-pull shear action at their outer edge, large circular telescope mirrors can be laterally supported free from bending distortion, if the upright mirror is kept in balance by a cosine distribution of weak axial forces applied at its outer rim and possibly also at the central hole. The flexure-induced comalike wave-front aberration of a thin 8-m meniscus mirror was reduced to an rms value of 0.5 nm over the full aperture; the largest path difference was reduced to 2.4 nm. A comparable result has also been calculated for a meniscus mirror of different geometry and a material with different elastic constants. Realizing such possibilities in practice demands accurate engineering. A helpful artifice is investigated for the correct application of the tangential supporting forces.

[The nodular mesenteric pseudoxanthomatosis (Schaefer) (author's transl)]. / Die noduläre mesenteriale Pseudoxanthomatose (Schaefer).

A casus of so-called nodular mesenteric pseudoxanthomatosis (Schaefer) was investigated by a 73 years old woman. This special findings in the mesenteric lymphnodes were interpreted as changes after inflammatory or infectious diseases in the alimentary tract. For the exact designation was proposed the term lymphonodular mesenteric pseudoxanthomatosis.

[Aneurysms of the coronary arteries]. / Aneurysmen der Herzkranzarterien.

Report on a mycotic and arteriosclerotic aneurysm of the right coronary artery in a 13-year-old girl and a 43-year-old man. With the help of the casuistics and the existing literature the author adopts a definite attitude to genesis, frequency, localisation and complication of the aneurysma.