[Ten years of laparoscopic living kidney donation. From an extravagant to a routine procedure]

Ten years ago the first laparoscopic living donor nephrectomy (LDN) was performed. Today, LDN is a routine operation in many US-American transplantation centers and an increasing number of centers in Europe are practicing LDN. In this article the different aspects of LDN for donor, kidney, recipient and operating surgeon are evaluated. We performed a literature research concerning LDN and the different aspects. Our own experience, as the largest LDN center in Germany, is part of the evaluation. Laparoscopic extraction of a kidney from a living donor is as safe for the donor as the open approach. At the same time, LDN offers multiple advantages like reduced pain and shorter convalescence. For the donated kidney and the recipient no disadvantages occur from the laparoscopic technique, as long as special intra- and perioperative demands are met. For the operating surgeon multiple developments have expanded the technical armentarium. LDN is safe for donor, recipient and kidney. Central issue of an optimal LDN is sufficient experience with laparoscopic urological techniques.

Histone deacetylase inhibition by valproic acid down-regulates c-FLIP/CASH and sensitizes hepatoma cells towards CD95- and TRAIL receptor-mediated apoptosis and chemotherapy

Hepatocellular carcinoma (HCC) is highly resistant to chemotherapy, leading to a poor prognosis of advanced disease. Inhibitors of histone deacetylase (HDACi) induce re-differentiation in tumor cells and thereby re-establish sensitivity towards apoptotic stimuli. HDACi are entering the clinical stage of tumor treatment, and several substances are currently being tested in clinical trials to prove their efficacy in the treatment of leukemias and solid tumors. In this study, we investigated the impact of the HDACi valproic acid (VA) on TRAIL- and CD95-mediated apoptosis in hepatoma cells, as well as its sensitizing effect on a chemotherapeutic agent. Treatment of HepG2 cells with VA increased sensitivity to CD95-mediated apoptosis (4% apoptosis vs. 42%), and treatment with epirubicin (74% vs. 90% viability). Caspase-3 activity was significantly enhanced in cells treated with VA plus anti-CD95 antibodies compared to cells treated with antibodies alone. In parallel, VA strongly augmented the effect of TNF-related apoptosis-inducing ligand (TRAIL or Apo2 ligand) on HepG2 cells (10% vs. 58% apoptosis). VA induced down-regulation of cellular FLICE-inhibitory protein (c-FLIP/CASH, also known as Casper/iFLICE/FLAME-1/CLARP/MRIT/usurpin), providing a possible molecular mechanism underlying the increased sensitivity towards cell death-mediated apoptosis. HDAC inhibitors are a promising class for the treatment of leukemias. In addition, among other class members, VA deserves further evaluation as a treatment option for patients with advanced HCC.

Production of dense plasmas with sub-10-fs laser pulses

Close to solid state density plasmas with peak electron temperatures of about 190 eV have been generated with sub-10-fs laser pulses incident on solid targets. Extreme ultraviolet (XUV) spectroscopy is used to investigate the K shell emission from the plasma. In the spectra, a series limit for the H- and He-like resonance lines becomes evident which is explained by pressure ionization in the dense plasma. The spectra are consistent with computer simulations calculating the XUV emission and the expansion of the plasma.

Eine neue Methode zur standardisierten Diagnostik nach Nierentransplantation

Ultrasound (US) imaging is an important diagnostic tool following renal transplantation. Unfortunately, due to the heterogeneity of the recipients and their multimorbidity, imaging procedures in the early phase after kidney transplantation are difficult and of limited use. We performed a study to evaluate the use of a contrast enhancer for US examination as a standardized method in the follow-up of kidney transplant recipients.The study included 40 recipients: 32 were examined on the 5th to 7th day following transplantation and 8 patients at the time when clinically suspicious findings occurred (acute rejection, tumor, acute tubular necrosis). Following the intravenous application of the contrast medium, pictures were taken during the arterial and parenchymatous phase and compared with conventional B-mode and power Doppler pictures of the same visual plane. Three examiners assessed different parameters of the transplant organ (max. vascularized area, suspected hematomas, tumors, rejection, acute tubular necrosis). Findings were confirmed by histological results of a biopsy if rejection, tumor, or acute tubular necrosis were suspected. Application of ultrasound contrast medium significantly increased visualization of the vascularized kidney area. Also, US findings in the follow-up after acute rejection therapy corresponded with the clinical course; 19 hematomas could be detected with contrast medium compared to only 9 without. With contrast medium a perfusion deficit was detectable in three patients compared to one patient with power Doppler US. Also, US contrast medium helped to detect tumor vascularization in two patients in whom conventional sonography suspected no abnormality. Ultrasound contrast medium enhancement is a reproducible, reliable, and easy to apply method which is superior to conventional sonography in the follow-up after kidney transplantation. This method is also helpful to detect and control acute rejections and to better visualize hematomas, deficits of perfusion, and tumors.

Cine magnetic resonance imaging vs high-resolution ultrasonography for detection of adhesions after laparoscopic and open incisional hernia repair: a matched pair pilot analysis

BACKGROUND

Intraabdominal adhesions represent nonspecific complications before or after laparoscopic or open incisional hernia repair. The objective of this matched control pilot study was to display long-term adhesions noninvasively by applying functional cine magnetic resonance (MR) imaging, as compared with applying high-resolution ultrasonography (US).

METHODS

The study group, composed of 17 consecutive patients (12 men and 5 women; mean age, 52 years), underwent laparoscopic intraperitoneal onlay mesh repair using expanded polytetrafluoroethylene (ePTFE) mesh. Their mean body mass index was 30 kg/m(2), and the size of the hernia was 95 cm(2). Another group, matched for age, gender, and type of hernia, was subjected to open abdominal wall repair using the preperitoneal sublay technique with a large-pore, low-weight polypropylene mesh. For cine MR imaging (1.5 T), section-by-section dynamic depiction of induced visceral slide throughout the entire abdomen was achieved by applying transverse or sagittal true fast imaging with steady-state precession sequences. The location and type of adhesions were compared with high-resolution ultrasonography using nine segments of the abdominal map.

RESULTS

The patients subjected to laparoscopic and open incisional hernia repair were examined 16 and 28 months after surgery. The findings showed functional cine MR imaging as superior to high-resolution ultrasonography for assessing the amount of intraabdominal adhesions (n = 53 vs n = 3; p < 0.01). Most frequently, adhesions were seen between small bowel loops and the abdominal wall (n = 22), followed by bowel-to-bowel adhesions (n = 19; p < 0.05). However, adhesions between small bowel loops and the abdominal wall occurred more frequently after open mesh repair (p < 0.05). Furthermore, a strong correlation was observed between patient complaints and findings with cine MR imaging (p < 0.05). Maximum pain correlated significantly with the region of the most distinctive adhesions (p < 0.05).

CONCLUSIONS

Functional cine MR imaging represents a reliable noninvasive technique for detecting long-term adhesions after open and laparoscopic incisional hernia repair. The study results suggest that this approach has distinct advantages over high-resolution ultrasonography.

[Radioimmunotherapy with yttrium-90 ibritumomab tiuxetan. Clinical considerations, radiopharmacy, radiation protection, perspectives]

90Y-ibritumomab tiuxetan (Zevalin) is currently approved for radioimmunotherapy of patients with relapsed or refractory follicular non-Hodgkin's lymphoma pretreated with rituximab. Future directions are the combined use of 90Y-ibritumomab tiuxetan as part of the initial treatment and as first-line multi-agent therapy of relapsed disease. Current studies investigate patients with other than follicular indolent histologies, e. g. diffuse large cell lymphoma. Labelling of 90Y ibritumomab tiuxetan is a safe procedure, the radiochemical purity is not disturbed by a higher room temperature or by metallic impurity. Quality control is recommended by thin layer chromatography (TLC), strips >15 cm are favourable. TLC cannot distinguish between the correctly radiolabelled antibodies and radiocolloid impurity. If necessary, additional HPLC should be performed. Radiocolloid impurities are absorbed to the solid phase and do not reach the eluate. If the radiochemical purity test is insufficient (<95%), the additional cleaning using EconoPac 10 DG columns (Biorad, Hercules, CA, USA) is a reliable procedure to reduce the percentage of free radionuclide. However, this procedure is not part of the approval.

[Prevention of preeclampsia]

Preeclampsia is accompanied by high fetal and maternal morbidity and mortality and to a high degree responsible for preterm delivery. The pathophysiologic mechanisms underlying this disease remain poorly understood. Accordingly, only few causative or preventive therapeutical strategies are known. One such example for a preventive strategy is the use of aspirin (ASA) which directly affects the imbalance of vasodilative prostacycline and vasoconstrictive thromboxane. Recently, some studies are indicating a preventive effect of vitamin C and E substitution. In contrast, early antihypertensive therapy did not prevent later progression of the disease. Furthermore, sodium restriction, calcium and magnesium substitution, fish oil substitution, or steroid therapy are without any effect regarding the later development of preeclampsia. It is of utmost importance to further elucidate underlying pathophysiological mechanisms to improve therapeutical and preventive strategies.

Systemic eight-cycle anti-CD20 monoclonal antibody (rituximab) therapy in primary cutaneous B-cell lymphomas - an applicational observation

BACKGROUND

Primary cutaneous B-cell lymphomas (PCBCLs) are characterized by restriction to the skin and a variable but mostly favourable prognosis. Since 1997 the recombinant, chimeric anti-CD20 antibody rituximab has been used in patients suffering from non-Hodgkin's B-cell lymphomas. Different studies have shown that the effectiveness and safety in the treatment of patients with low-grade follicular lymphoma is comparable to or even higher than the standard CHOP chemotherapy. So far it has been unclear whether an extended duration of therapy leads to a benefit for the patients with PCBCL.

OBJECTIVES

To evaluate the objective response rate, time to progression, remission quality and histological changes and to compare our data with the literature.

PATIENTS/METHODS

Ten patients with PCBCL [eight with follicle centre cell lymphoma (FCCL), one with marginal zone lymphoma (MZL) and one with diffuse large B-cell lymphoma of the leg (DLBCL)] were treated by intravenous application of a chimeric antibody against the CD20 transmembrane antigen (rituximab) with a dosage of eight cycles, 375 mg m(-2) body surface, weekly.

RESULTS

The treatment regimen resulted in clinical overall response in 9 of 10 patients, in particular there were seven complete responses (70%) plus two partial responses (20%). The median duration of remission (durable remission, DR) is 23 months (4-30 months) to date. Histological assessment of responses in four patients showed no tumour-specific infiltration. In two patients histology revealed a residual infiltration and in one patient an increasing infiltration. In two patients no histology was taken after treatment; one patient developed a new lesion. No severe side-effects occurred. Observed side-effects were two bacterial infections, two patients with shivering during infusion, one patient with sweating for months and one patient with persisting itching. As expected the B-cell count in peripheral blood was depressed in all patients after infusion.

CONCLUSIONS

Intravenous therapy with eight cycles of the anti-CD20 antibody rituximab is a non-toxic and effective treatment for a subset of patients with PCBCL (relapsed, aggressive entity, old patients, multiple lesions) with a long DR.