Relevance and methods of interventional breast sonography in preoperative axillary lymph node staging.

Reduction of therapy-induced morbidity is an important goal for the improvement of the quality of breast cancer treatment. The introduction of sentinel lymph node biopsy (SLNB) significantly contributed to the reduction of surgery-induced morbidity in the shoulder-arm region. However, a clinically positive nodal status is still considered a contra-indication for SLNB. The current data constellation clearly shows that the clinical and also the sonographic malignancy assessment is insufficient for the accurate identification of the nodal status. A merely clinical and/or image-based appraisal of the axillary lymph node status would lead to overtreatment due to unnecessary axillary dissection in approximately 40 % of patients. In order to reduce the rate of unnecessary axillary dissection (AD), pretreatment interventional clarification is necessary to provide more detailed information about the histological condition of the lymph node. Comparing the currently available methods, fine needle aspiration (FNA) is the best in terms of cost and time requirement, practicability and complication rate. However, considering the sensitivity, it is inferior to ultrasound-guided core needle biopsy (CNB). Thus, a negative FNA outcome requires further clarification, which possibly can be performed with CNB. With a specificity of nearly 100 % and therefore a low rate of false positive cases for FNA, complete AD can be indicated by a positive FNA result. In the context of the interventional procedure, it must be stressed that FNA requires a high level of expertise on the part of both the examiner and the cytologist. The prerequisite for optimal interventional diagnostics of lymph nodes is an adequate sonographic assessment on the basis of standardized sonomorphological criteria.

An innovative, safe and sterile sigmoid access (ISSA) for NOTES.

BACKGROUND AND STUDY AIMS: The use of a transcolonic approach for natural orifice transluminal endoscopic surgery (NOTES) offers relevant advantages compared with a transgastric procedure. However both techniques are still limited by specific shortcomings that need to be resolved before the transluminal approach can be translated to human applications. In this article we describe an innovative method for a transcolonic procedure, which might represent the next step forward in NOTES. PATIENTS AND METHODS: In three acute and five survival porcine models we evaluated a specially designed guide tube, which is inserted via a transcolonic approach into the abdominal cavity after intraperitoneal instillation of a decontamination solution. After endoscopic evaluation of the abdomen the closure of the entry site was performed surgically. Main parameters obtained in the study were the feasibility and safety of the approach, the bacterial contamination due to the transcolonic procedure, and the safe closure of the entry site. Animals in the survival model were euthanized 10 days after the procedure. RESULTS: The transcolonic approach took place without complications. There was no bleeding or laceration of adjacent organs. The surgical closure guaranteed a leak-proof closure of the entry site. All pigs in the survival model showed an excellent postinterventional course. At necropsy, the colonic incision sites were completely closed and appeared well healed. No abscesses or any sign of inflammation could be identified. CONCLUSIONS: The transcolonic approach using an innovative guide tube is feasible and safe. The technique described offers mentionable advantages and therefore reduces the known shortcomings of NOTES. However, further studies are needed to approve our results of an initial evaluation.

Microcirculation of subepithelial gastric tumors using contrast-enhanced ultrasound.

OBJECTIVES: The evaluation of subepithelial tumors of the stomach is normally the domain of gastroscopy and endoscopic ultrasound. We investigated these rare tumors using transabdominal B-mode ultrasound and performed perfusion analysis of these tumors with contrast enhanced ultrasound. METHODS: Patients with gastrointestinal stromal tumors (GIST, n = 3), leiomyoma (n = 1) and schwannoma (n = 1) were routinely examined using conventional B-mode-ultrasound, colour Doppler ultrasound and contrast-enhanced ultrasound (contrast media: Sonovue; ultrasound device: Siemens Acuson Sequoia 512). Gastroscopy, endosonography with puncture of the subepithelial tumor and computed tomography were also performed in all patients. After surgery, the resected stomach tumors were correlated with the preoperative imaging findings. RESULTS: All calculated tumor sizes using any imaging modalities showed a good correlation with the macroscopic tumor sizes ex-vivo. Histologically increased tumor size of the GISTs was correlated with large, central avascular areas. The GISTs and the leiomyoma presented with mixed echogenicity in B-mode-ultrasound. Colour Doppler ultrasound was able to detect some vessels in the periphery of the tumor only. Using contrast-enhanced ultrasound the GISTs and the leiomyoma presented hypervascular. The contrast pattern of these lesions was from the periphery to the centre or diffuse or a progressive centrifugal fill in during the arterial phase. We also registered slowly progressive washout starting at the end of the arterial phase and increasing into the late phase. The contrast media behaviour in the schwannoma was different from that describt above within the GISTs: it was noted to have a diffuse intralesional pattern at the start of the arterial phase followed by an early, rapidly progressing washout-phenomenon. CONCLUSION: In our pilot study B-mode transabdominal ultrasound was able to visualise gastric subepithelial tumors larger than three centimetre. Contrast-enhanced ultrasound is a proven method in clinical practice for the perfusion analysis of gastric subepithelial tumors. It can also be used for the planning of ultrasound-guided biopsies to avoid punctures of necrotic tumor parts.

[Endothelial adrenal cyst mimicking cystic echinococcosis in a Turkish woman]. / Endotheliale Nebennierenzyste als Differenzialdiagnose zur zystischen Echinokokkose bei einer türkischen Patientin.

BACKGROUND: Cystic liver lesions include hepatic echinococcosis as an important differential diagnosis, especially in patients from endemic countries. Serology might be false negative in a relevant percentage of the patients. Thus, modern clinical imaging techniques are the most important non-invasive means for making or excluding the diagnosis of hepatic echinococcosis. CASE REPORT: A 37-year-old Turkish woman was admitted to hospital because of abdominal pressure, lack of appetite and weight loss. The suspected radiological diagnosis of hepatic echinococcosis was made based on a septated, cystic liver process with calcifications seen in an already performed computered tomography. The physical examination and laboratory findings did not show any specific pathology. The serological tests for echinococcosis were negative. The MRI scan of the liver showed a 10 x 7.5 cm large, multi-segmented, cystic lesion between the right kidney and the right liver lobe. The cyst was discussed as possibly having an origin from the right adrenal gland and very unlikely from the liver or kidney. Ultrasonography (Siemens-Acuson Sequoia 512, Mountain View) showed a cystic lesion with septated structures and calcifications between the right kidney and the liver without a typical capsule. Contrast-enhanced ultrasound after fractionated injection of 4.8 mL Sonovue (Bracco, Milano) showed an intensive perfusion of the septa in the cyst. We admitted the patient for surgery. Interoperatively a right adrenalectomy and cystectomy was performed. Histology showed an epithelial adrenal cyst. The patient was asymptomatic twelve months after surgery. CONCLUSION: High-end-ultrasonography with microbubble contrast media of the second generation is the primary diagnostic tool for the differential diagnosis of cystic lesions of the liver and adrenal glands. MRI or CT scans might be additionally indicated in the case of poor ultrasound conditions in a patient or before planned surgery, but can also fail to correct determine the origin of a cyst.

[Molecular diagnosis of mycobacterial infections]. / Molekulare Mykobakterien-Diagnostik.

Tuberculosis remains a leading cause of morbidity and mortality worldwide. A rapid and reliable diagnosis and discrimination from infections with nontuberculous mycobacteria (NTM) is critical. Frequently, formalin-fixed, paraffin-embedded (FFPE) tissues remain the only source for detection of micro-organisms in suspected cases of mycobacterial infection. Recently, numerous methods, including PCR assays, in situ hybridization and immunohistochemistry have been developed for detection of mycobacteria in FFPE samples. PCR-based assays are directed either against M.tbc.-specific sequences, such as IS6110, or amplify regions common to many mycobacterial species, e.g. the 65 kDa antigen, and then require sequencing or restriction fragment length polymorphism for species identification. Whereas the detection of DNA of M.tbc. in the correct setting is always of clinical relevance, the presence of various NTM species has to be interpreted with great caution due to their ubiquitous nature. However, the routine application of molecular tests has demonstrated that NTM infections are more common than previously thought, even in non-immunosuppressed hosts. The introduction of real-time PCR technology allows precise quantification of mycobacterial DNA and can be used for species identification through melting point analysis or appropriate DNA probes. Application of these assays originally developed for clinical microbiology offer a great opportunity for diagnostic improvement in molecular pathology as compared to qualitative PCR, mainly due to an increased specificity and a lower risk of contamination. Given the clinical impact of a positive molecular result for M. tbc., future efforts have to be aimed at standardization and quality control.