Surgery for primary hyperparathyroidism in Germany, Switzerland, and Austria: an analysis of data from the EUROCRINE registry

PURPOSE

EUROCRINE is an endocrine surgical register documenting diagnostic processes, indication for surgical treatment, surgical procedures, and outcomes. The purpose was to analyse data for PHPT in German speaking countries regarding differences in clinical presentation, diagnostic workup, and treatment.

METHODS

All operations for PHPT performed from 07/2015 to 12/2019 were analysed.

RESULTS

Three thousand two hundred ninety-one patients in Germany (9 centres; 1762 patients), Switzerland (16 centres; 971 patients) and Austria (5 centres; 558 patients) were analysed. Hereditary disease was seen in 36 patients in Germany, 16 patients in Switzerland and 8 patients in Austria. In sporadic disease before primary operation, PET-CT showed the highest sensitivity in all countries. In re-operations, CT and PET-CT achieved the highest sensitivities. The highest sensitivity of IOPTH was seen in Austria (98.1%), followed by Germany (96.4%) and Switzerland (91.3%). Operation methods and mean operative time reached statistical significance (p<0.05). Complication rates are low. Overall, 656 (19.9%) patients were asymptomatic; the remainder showed bone manifestations, kidney stones, fatigue and/or neuropsychiatric symptoms.

CONCLUSION

Early postoperative normocalcaemia ranged between 96.8 and 97.1%. Complication rates are low. PET-CT had the highest sensitivity in all three countries in patients undergoing primary operation as well as in Switzerland and Austria in patients undergoing re-operation. PET-CT could be considered a first-line preoperative imaging modality in patients with inconclusive ultrasound examination. The EUROCRINE registry is a beneficial and comprehensive data source for outcome analysis of endocrine procedures on a supranational level.

How I treat medullary thyroid cancer

Medullary thyroid cancer (MTC) represents a rare neuroendocrine neoplasm originating from neoplastic C-cells in the thyroid gland. While localized disease is potentially curable with an optimized surgical approach, the number of relapses is high, and a considerable number of patients present with primary metastatic disease. Multidisciplinary management including standardized surveillance following surgery, but also early involvement of medical oncologists, is therefore important. Several oncogenic pathways are involved in the pathogenesis of MTC including vascular endothelial growth factor receptor, epidermal growth factor receptor, MET, and most importantly RET, and the multi-tyrosine kinase inhibitors vandetanib and cabozantinib have been approved for advanced MTC based on data from phase III studies. As activating RET mutations represent the most important driver, specific RET inhibitors were introduced and suggest high response rates with limited off-target toxicities. The current review provides a practical overview on clinical presentation and management from early to advanced MTC.

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Systemic treatment options in advanced MTC remain limited with particularly immunotherapy being ineffective.

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Multi-tyrosine kinase inhibitors remain the standard of care for advanced MTC.

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Recent approval of selective RET inhibitors is promising.

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Testing of RET mutations should be included routinely into the diagnostic algorithm.

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Multidisciplinary teams should be involved to guarantee the best outcome for our patients.

[EUROCRINE®: adrenal surgery 2015-2019- surprising initial results]

Hintergrund

Seit 2015 erfolgt in Europa mithilfe des EUROCRINE®-Registers eine systematische Dokumentation endokrin-chirurgischer Operationen. Ziel dieser ersten Auswertung war eine Darstellung der Versorgungsrealität für Nebenniereneingriffe in einem homogenen Versorgungsumfeld, entsprechend des deutschsprachigen Raums – bzw. des Präsenzgebiets der Chirurgischen Arbeitsgemeinschaft Endokrinologie (CAEK) der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV) – einschließlich einer Analyse der Adhärenz zu geltenden Therapieempfehlungen.

Methodik

Es erfolgte eine deskriptive Analyse der präoperativen Diagnostik, der angewandten Operationstechniken sowie der zugrunde liegenden histologischen Entitäten der zwischen den Jahren 2015 und 2019 über EUROCRINE® in Deutschland, Österreich und der Schweiz dokumentierten Nebennierenoperationen.

Ergebnisse

In den insgesamt 21 teilnehmenden Kliniken des deutschsprachigen EUROCRINE®-Gebiets wurden 658 Operationen an Nebennieren durchgeführt. In 90 % erfolgten unilaterale, in 3 % bilaterale Adrenalektomien und in 7 % andere Resektionsverfahren. Die in 41 % der Operationen dokumentierte histologische Hauptdiagnose war das adrenokortikale Adenom. In 15 % lagen maligne Befunde zugrunde (einschließlich 6 % Nebennierenrindenkarzinome (ACC) und 8 % Nebennierenmetastasen). 23 % der Operationen erfolgten bei Phäochromozytomen. Diese wurden zu 82 % minimal-invasiv operiert, Nebennierenrindenkarzinome lediglich zu 28 % und Nebennierenmetastasen zu 66 %.

Schlussfolgerung

Überraschenderweise wurden nach Nebennierenadenomen und Phäochromozytomen an dritthäufigster Stelle Nebennierenmetastasen unterschiedlicher Primärtumoren reseziert. 28 % der ACC waren für minimal-invasive Techniken vorgesehen, wobei 20 % dieser Fälle eine Konversion zur offenen Operation erforderten. Die aktuelle Analyse deckte Diskrepanzen zwischen Versorgungsrealität und Leitlinienempfehlungen auf, aus denen sich zahlreiche Fragestellungen ergeben, welche nun in ein überarbeitetes EUROCRINE®-Modul zur Dokumentation von Nebennierenoperationen einfließen werden.

Omission of lateral lymph node dissection in medullary thyroid cancer without a desmoplastic stromal reaction

BACKGROUND

Medullary thyroid cancer can be subdivided during surgery into tumours with or without a desmoplastic stromal reaction (DSR). DSR positivity is regarded as a sign of disposition to metastasize. The aim of this study was to analyse whether lateral lymph node dissection can be omitted in patients with DSR-negative tumours.

METHODS

This was a retrospective cohort study of a prospectively maintained database of patients with medullary thyroid cancer treated using a standardized protocol, and subdivided into DSR-negative and -positive groups based on the results of intraoperative frozen-section analysis. Patients in the DSR-negative group did not undergo lateral lymph node dissection. Long-term clinical and biochemical follow-up data were collected, and baseline parameters and histopathological characteristics were compared between groups.

RESULTS

The study included 360 patients. In the DSR-negative group (17.8 per cent of all tumours) no patient had lateral lymph node or distant metastases at diagnosis or during follow-up, and all patients were biochemically cured. In the DSR-positive group (82.2 per cent of all tumours), lymph node and distant metastases were present in 31.4 and 6.4 per cent of patients respectively. DSR-negative tumours were more often stage pT1a and were significantly smaller. The median levels of basal calcitonin and carcinoembryonic antigen were significantly lower in the DSR-negative group, although when adjusted for T category both showed widely overlapping ranges.

CONCLUSION

Lymph node surgery may be individualized in medullary thyroid cancer based on intraoperative analysis of the DSR. Patients with DSR-negative tumours do not require lateral lymph node dissection.

Management of endocrine surgical disorders during COVID-19 pandemic: expert opinion for non-surgical options

Purpose

The COVID-19 pandemic brought unprecedented conditions for overall health care systems by restricting resources for non-COVID-19 patients. As the burden of the disease escalates, routine elective surgeries are being cancelled. The aim of this paper was to provide a guideline for management of endocrine surgical disorders during a pandemic.

Methods

We used Delphi method with a nine-scale Likert scale on two rounds of voting involving 64 experienced eminent surgeons and endocrinologists who had the necessary experience to provide insight on endocrine disorder management. All voting was done by email using a standard questionnaire.

Results

Overall, 37 recommendations were voted on. In two rounds, all recommendations reached an agreement and were either endorsed or rejected. Endorsed statements include dietary change in primary hyperparathyroidism, Cinacalcet treatment in secondary hyperparathyroidism, alpha-blocker administration for pheochromocytoma, methimazole ± β-blocker combination for Graves’ disease, and follow-up for fine-needle aspiration results of thyroid nodules indicated as Bethesda 3–4 cytological results and papillary microcarcinoma.

Conclusion

This survey summarizes expert opinion for the management of endocrine surgical conditions during unprecedented times when access to surgical treatment is severely disrupted. The statements are not applicable in circumstances in which surgical treatment is possible.

Effect of intraoperative nerve monitoring on postoperative vocal cord palsy rates after thyroidectomy: European multicentre registry-based study

Background

Intraoperative nerve monitoring (IONM) of the recurrent laryngeal nerve (RLN) predicts the risk of vocal cord palsy (VCP). IONM can be used to adapt the surgical strategy in order to prevent bilateral VCP and associated morbidity. Controversial results have been reported in the literature for the effect of IONM on rates of VCP, and large multicentre studies are required for elucidation.

Methods

Patients undergoing first‐time thyroidectomy for benign thyroid disease between May 2015 and January 2019, documented prospectively in the European registry EUROCRINE®, were included in a cohort study. The influence of IONM and other factors on the development of postoperative VCP was analysed using multivariable regression analysis.

Results

Of 4598 operations from 82 hospitals, 3542 (77·0 per cent) were performed in female patients. IONM was used in 4182 (91·0 per cent) of 4598 operations, independent of hospital volume. Postoperative VCP was diagnosed in 50 (1·1 per cent) of the 4598 patients. The use of IONM was associated with a lower risk of postoperative VCP in multivariable analysis (odds ratio (OR) 0·34, 95 per cent c.i. 0·16 to 0·73). Damage to the RLN noted during surgery (OR 24·77, 12·91 to 48·07) and thyroiditis (OR 2·03, 1·10 to 3·76) were associated with an increased risk of VCP. Higher hospital volume correlated with a lower rate of VCP (OR 0·05, 0·01 to 0·13).

Conclusion

Use of IONM was associated with a low rate of postoperative VCP.

[Update of the S2k guidelines : Surgical treatment of benign thyroid diseases]

Thyroid resections represent one of the most common operations with 76,140 interventions in the year 2016 in Germany (source Destatis). These are predominantly benign thyroid gland diseases. Recommendations for the operative treatment of benign thyroid diseases were last published by the CAEK in 2010 as S2k guidelines (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V. [AWMF] 003/002) against the background of increasingly more radical resection procedures. Hemithyroidectomy and thyroidectomy are routinely performed for benign thyroid disease in practice. The operation-specific risks show a clear increase with the extent of the resection. Therefore, weighing-up of the risk-indications ratio between unilateral lobectomy or thyroidectomy necessitates an independent evaluation of the indications for both sides. This principle in particular has been used to update the guidelines. In addition, the previously published recommendations of the CAEK for correct execution and consequences of intraoperative neuromonitoring were included into the guidelines, which in particular serve the aim to avoid bilateral recurrent laryngeal nerve paralysis. Moreover, the recommendations for the treatment of postoperative complications, such as hypoparathyroidism and postoperative infections were revised. The updated guidelines therefore represent the current state of the science as well as the resulting surgical practice.

Surgical therapy of adrenal tumors: guidelines from the German Association of Endocrine Surgeons (CAEK)

BACKGROUND AND AIMS

Previous guidelines addressing surgery of adrenal tumors required actualization in adaption of developments in the area. The present guideline aims to provide practical and qualified recommendations on an evidence-based level reviewing the prevalent literature for the surgical therapy of adrenal tumors referring to patients of all age groups in operative medicine who require adrenal surgery. It primarily addresses general and visceral surgeons but offers information for all medical doctors related to conservative, ambulatory or inpatient care, rehabilitation, and general practice as well as pediatrics. It extends to interested patients to improve the knowledge and participation in the decision-making process regarding indications and methods of management of adrenal tumors. Furthermore, it provides effective medical options for the surgical treatment of adrenal lesions and balances positive and negative effects. Specific clinical questions addressed refer to indication, diagnostic procedures, effective therapeutic alternatives to surgery, type and extent of surgery, and postoperative management and follow-up regime.

METHODS

A PubMed research using specific key words identified literature to be considered and was evaluated for evidence previous to a formal Delphi decision process that finalized consented recommendations in a multidisciplinary setting.

RESULTS

Overall, 12 general and 52 specific recommendations regarding surgery for adrenal tumors were generated and complementary comments provided.

CONCLUSION

Effective and balanced medical options for the surgical treatment of adrenal tumors are provided on evidence-base. Specific clinical questions regarding indication, diagnostic procedures, alternatives to and type as well as extent of surgery for adrenal tumors including postoperative management are addressed.

Experiences with the standardized classification of surgical complications (Clavien-Dindo) in general surgery patients

Background

The standardized Clavien-Dindo classification of surgical complications is applied as a simple and widely used tool to assess and report postoperative complications in general surgery. However, most documentation uses this classification to report surgery-related morbidity and mortality in a single field of surgery or even particular intervention. The aim of the present study was to present experiences with the Clavien-Dindo classification when applied to all patients on the general surgery ward of a tertiary referral care center.

Methods

We analyzed a period of 6 months of care on a ward with a broad range of general and visceral surgery. Discharge reports and patient charts were analyzed retrospectively and reported complications rated according to the most recent Clavien-Dindo classification version. The complexity of operations was assessed with the Austrian Chamber of Physicians accounting system.

Results

The study included 517 patients with 817 admissions, of whom 463 had been operated upon. Complications emerged in 12.5%, of which 19% were rated as Clavien I, 20.7% as Clavien II, 13.8% as Clavien IIIa, 27.6% as Clavien IIIb, 8.6% as Clavien IVa, and 10.3% as Clavien V. No Clavien grade IVb complication occurred within the investigation. Patients having undergone more complex surgery or with higher scores experienced significantly longer lengths of hospital stay.

Conclusion

The Clavien-Dindo classification can easily be used to document complication rates in general surgery, even though this collective was not included in the original validation studies of Clavien et al. and consisted of more heavily impaired patients.

Bone metabolism in patients with primary hyperparathyroidism before and after surgery

Primary hyperparathyroidism (PHPT) is accompanied with a reduced bone mineral density (BMD) and an increased risk of fracture. Surgery is the only option for cure. It is hypothesized that in patients with PHPT bone metabolism normalizes after parathyroidectomy (PTX) and that BMD gradually increases. Fifty-two patients with PHPT who underwent surgery were prospectively followed for 1 year. Biochemical analyses were performed at baseline and 1, 4, 7 days; 6 weeks; and 3, 6, and 12 months, and BMD before and one year after surgery. Parathyroid hormone (PTH), calcium, and the bone resorption marker dropped immediately, but transiently after PTX, bone formation decreased more slowly. Osteoprotegerin (OPG) as well as cathepsin K did not show significant changes. BMD of the lumbar spine, but not of the femoral neck, increased significantly within one year after surgery. Moderate correlations existed between the changes of total calcium, ionized calcium, as well as bone-specific alkaline phosphatase and changes of the lumbar BMD. Patients who needed postoperative supplementation with calcium and vitamin D had significantly higher PTH levels. Some gender-specific differences in patients with PHPT were observed. In patients with PHPT, males appear to be more severely affected than females. Within the first year after PTX, bone metabolism normalized, and BMD of the lumbar spine increased. Patients who needed a supplementation with calcium and vitamin D after PTX preoperatively had higher serum levels of PTH.

Accuracy of concepts in female pelvic floor anatomy: facts and myths!

The pelvic floor is characterized by a complex morphology because different functional systems join here. Since a clear understanding of the pelvic floor region is crucial for female pelvic surgery and fundamental mechanisms of urogenital dysfunction and treatment, we here describe the accurate and functional anatomy of important pelvic structures and landmarks, clarify their terminology and point out possible errors or misunderstandings as to their existence.

Comparison of different phosphorus-containing ligands complexing 68Ga for PET-imaging of bone metabolism

99mTc-phosphonate structures are well established tracers for bone tumour imaging. Our objective was to investigate different 68Ga-labelled phosphonate ligands concerning labelling kinetics, binding to hydroxyapatite and bone imaging using μ-PET. Seven macrocyclic phosphorus-containing ligands and EDTMP were labelled in nanomolar scale with n.c.a. 68Ga in Na-HEPES buffer at pH∼4. Except for DOTP, all ligands were labelled with >92% yield. Binding of the 68Ga-ligand complexes on hydroxyapatite was analysed to evaluate the effect of the number of the phosphorus acid groups on adsorption parameters. Adsorption of 68Ga-EDTMP and 68Ga-DOTP was >83%. For the 68Ga-NOTA-phosphonates an increasing binding with increasing number of phosphonate groups was observed but was still lower than 68Ga-DOTP and 68Ga-EDTMP. μ-PET studies in vivo were performed with 68Ga-EDTMP and 68Ga-DOTP with Wistar rats. While 68Ga-EDTMP-PET showed uptake on bone structures, an excess amount of the ligand (>1.5 mg EDTMP/kg body weight) had to be used, otherwise the 68Ga3+ is released from the complex and forms gallium hydroxide or it is transchelated to 68Ga-transferrin. As a result, the main focus of further phosphonate structures has to be on complex formation in high radiochemical yields with macrocyclic ligands with phosphonate groups that are not required for complexing 68Ga.

Studies towards the development of lipophilic bifunctional N3S3 chelators for 68Ga

The present study is concerned with a concept of charge-neutral, lipophilic, macrocyclic bifunctional chelators, suitable for the introduction of a gallium-68 label into small molecules. The synthesis of a novel bifunctional N3S3-type chelator, derived from 1,4,7-triazacyclononane, initial 68Ga-radiolabelling and the determination of stability and calculated lipophilicity of the compound are described. The 68Ga-labelled chelate was obtained in a maximum radiochemical yield of 93±5% after a reaction time of 2 min. It remained intact over 3 h in a DTPA-challenge and a transferrin challenge experiment, indicating sufficient stability for PET studies.

Die Operation nach Vecchietti zur Bildung einer Neovagina: Technik und Ergebnisse

We performed Vecchietti's operation in 10 patients with absence of the vagina (8 Rokitansky-Küster-syndrome, 1 testicular feminization, 1 occlusion of the vagina after radiotherapy). There were no intra- or postoperative complications; on discharge the neovagina was patent for 2 fingers in all cases. On follow-up examinations 2 to 20 months postoperatively the neovagina was no longer patent in the patient after radiotherapy, all other patients had neovaginas with a length ranging from 5 to 9 cm and reported satisfactory coitus without dyspareunia. According to our experience the conditions for successful surgical formation of a neovagina are: good psychosocial adjustment, some preoperative sexual experience, higher age, preoperative counselling, and longterm follow-up.

Zur Klinik und Therapie von Wadenkrämpfen in der Schwangerschaft

Of 8204 gravidae, 486 (5,9%) complained at least once of muscle cramps during pregnancy. Muscle cramps were noticed most often in the second half of pregnancy. Gravidae with muscle cramps were on the average older and of higher parity; there was no relationship between muscle cramps and complications during pregnancy or unfavorable fetal outcome. In an uncontrolled therapeutic trial 21 women with muscle cramps received 1,8 g monomagnesium-aspartate twice daily per mouth for 4 weeks. 21 women with muscle cramps had no therapy. 4 weeks after the initiation of magnesium therapy 19/21 women were free of symptoms, compared to only 7/21 patients in the control group. Muscle cramps during pregnancy do not have to be considered a risk factor; they can be significantly improved by the administration of oral magnesium.

Nachweis und klinische Bedeutung von freizirkulierenden IgG-Immunkomplexen bei EPH-Gestose

With enzyme linked immunosorbent assays, using a solid phase Clq method, we determined free circulating immunocomplexes (CIC) in the serum of 47 pregnant women. In 30 normal pregnant women without EPH gestosis no CIC could be found. 3 normal pregnant women showed temporary CIC after viral infections. In 7 women with slight gestosis no traceable CIC concentrations were present. All 7 patients with medium or severe gestosis had clearly positive CIC levels simultaneous with hypertension and during the further course of the pregnancy. Hospitalisation and antihypertensive therapy had to be carried out because of increasing symptoms of gestosis. Thus only in medium and severe gestoses clearly demonstrable CIC concentrations could be measured. The presence of free circulating CIC might be a prognostically unfavourable indication for the further course of an EPH gestosis.

Updated recommendations on ultrasonography in urogynecology

Ultrasound is a supplementary, indispensable diagnostic procedure in urogynecology; perineal, introital, and endoanal ultrasound are the most recommended techniques. The position and mobility of the bladder neck can be demonstrated. In patients undergoing diagnostic work-up for urge symptoms, ultrasound occasionally demonstrates urethral diverticula, leiomyomas, and cysts in the vaginal wall. These findings will lead to further diagnostic assessment. The same applies to the demonstration of bladder diverticula, foreign bodies in the bladder, and bullous edema. With endoanal ultrasound, different parts of the sphincter ani muscle can be evaluated. Recommendations for the standardized use of urogenital ultrasound are given.

Prevalence of female sexual dysfunction in gynecologic and urogynecologic patients according to the international consensus classification

OBJECTIVES

To evaluate the prevalence of female sexual dysfunction (FSD) in an outpatient gynecologic and urogynecologic clinic using the current International Consensus Classification.

METHODS

One hundred fifty-nine patients were asked to answer an anonymous survey about FSD. Patients in the gynecologic (group 1) and urogynecologic (group 2) clinics were compared.

RESULTS

The mean age in group 1 was 37.8 years (range 20 to 76) and in group 2 was 55.7 years (range 18 to 82). The prevalence of FSD was 50% in group 1 and 48% in group 2; 86% of group 1 and 66% of group 2 patients had been sexually active within the past 2 years. The differences found in FSD according to the consensus panel classification achieved no significance. Of the 159 patients, 96% were not embarrassed by filling out this questionnaire about their sexual function.

CONCLUSIONS

No statistically significant difference in FSD was found between the younger and older patients seeking help in a gynecologic or urogynecologic outpatient clinic. Because of the high incidence of FSD, we recommend integrating the inquiry about female sexual health concerns into routine gynecologic care. The simple survey based on the International Consensus Conference Classification of FSD gives reliable results, and this systematic framework facilitates methodologic examination.

The role of intraoperative quick PTH measurements in primary hyperparathyroidism

BACKGROUND

In patients with primary hyperparathyroidism (PHPT), circulating concentrations of intact parathyroid hormone (PTH), decline dramatically within minutes following surgical excision of hyperfunctioning parathyroid tissue. The magnitude of this decay correlates with the completeness of resection of hyperfunctioning parathyroid tissue and can be monitored during the operation.

METHOD

Intraoperative Quick PTH (QPTH) monitoring and pitfalls of more than 350 patients, who were operated because of primary hyperparathyroidism are analyzed. Special attention is given to correct baseline values and interpretation of QPTH values.

RESULTS

QPTH monitoring is able to distinguish reliably between single and multiple gland disease and is an indispensable prerequisite for any form of limited parathyroid exploration. Experience with QPTH monitoring is necessary to achieve the excellent results known from bilateral neck exploration.

CONCLUSION

Applying correct baseline values and cautious interpretation of QPTH values results in excellent results. Nevertheless more data must be collected to allow reliable interpretation of QPTH monitoring in all patients with PHPT.

The Austrian tension-free vaginal tape registry

In Austria a central registry for all TVT operations has been established in which more than 800 cases have so far been registered. The registry contains information on pertinent data on the operated patients and intra- and postoperative outcomes of the TVT surgery. No serious complications and no mortality have been registered until now.

The relevance of angiogenesis in benign and malignant epithelial tumors of the ovary: a quantitative histologic study

The ability of a tumor to grow and eventually to infiltrate adjacent tissues requires a sufficient blood supply. Many malignant neoplasms have been shown to induce neovascularization. We asked whether it is possible to characterize ovarian epithelial tumors on the basis of vascularization and whether vascularization can be used to differentiate between benign and malignant neoplasms. We examined 14 cases of benign cystadenomas and 18 carcinomas. The microvessels were identified by immunohistochemical staining of endothelial cells for factor VIII. They were counted within the most vascular area of a tumor (neovascular "hot spot") on a x 100 and a x 400 field. Mean vessel counts were 51.64 [standard error of the mean (SEM), 5.7] in the benign cystadenomas and 131.05 (SEM, 6.7) in the group of carcinomas at a x 100 magnification. The mean microvessel counts per x 400 field were 14.4 (SEM, 1.9) in the benign and 33.7 (SEM, 3.45) in the malignant tumors investigated. These differences were significant (t test for independent samples, P < 0.001). Since our study shows significantly fewer small blood vessels in the benign cystadenomas than in the malignant tumors, the histologically determinable vascular density may be the basis for imaging blood flow by means of color ultrasound.

Nucleolar organizer regions as markers of endometrial proliferation: a study of normal, hyperplastic, and neoplastic tissue

Nucleolar organizer regions (NORs) are loops of DNA that transcribe to ribosomal RNA. They can be visualized as intranuclear black dots by histochemical staining with a colloid silver solution. We applied this method to 78 sections of endometrial tissue obtained either from curettage or from hysterectomy specimens. The histological diagnoses were as follows: normal proliferative (N = 9) or secretory (N = 5) endometrium, simple hyperplasia (N = 10), complex hyperplasia (N = 18), atypical hyperplasia (N = 8), and adenocarcinoma (N = 28). Mean silver-stained NOR (AgNOR) counts per cell were 3.2 (standard error of the mean [SEM], 0.2) in normal proliferative and 2.7 (SEM, 0.2) in normal secretory epithelium, and increased to 4.1 (SEM, 0.3) in simple hyperplasia, to 5.4 (SEM, 0.4) in complex hyperplasia, to 8.1 (SEM, 0.7) in atypical hyperplasia, and finally to 10.0 (SEM, 0.5) in endometrial carcinoma. The differences were significant (one-factor analysis of variance [ANOVA], P < .001). A slight increase but no significant difference was seen between the mean AgNOR counts in endometrial carcinomas of different histological grades. Our study suggests that AgNOR counts are reliable markers of endometrial proliferation and allow a clear distinction between benign, premalignant, and malignant epithelial changes. Our AgNOR findings in endometrial hyperplasia support the concept of various degrees of hyperplasia that can be differentiated on morphological grounds.

Localization of blood vessels and qualitative assessment of blood flow in ovarian tumors

OBJECTIVE

To study the localization of blood vessels within a tumor and the shape of the flow curve as a method of assessing ovarian neoplasms.

METHODS

We studied 39 patients with malignant tumors and 63 patients with benign ovarian tumors by means of vaginal color Doppler ultrasound, noting the localization of blood vessels in the tumors, the shape of the flow curve, and peripheral resistance.

RESULTS

Blood vessels could be visualized in 95% of the malignant tumors and in 70% of the benign tumors. Blood vessels tended to be localized centrally (65 versus 5%) in malignant tumors and peripherally in benign tumors (65 versus 0%). A diastolic notch was seen in 89% of the benign tumors, but in none of the malignant tumors. The mean resistance index (RI) +/- standard deviation was 0.48 +/- 0.19 in malignant and 0.69 +/- 0.09 in benign tumors (P < .05). The corresponding values for the pulsatility index (PI) were 0.56 +/- 0.13 and 1.06 +/- 0.07, respectively (P < .01).

CONCLUSIONS

Low RI and PI values are general indicators of tumor growth. The localization of blood vessels within an ovarian tumor and the presence or absence of a diastolic notch are the most useful variables in the evaluation of ovarian tumors.

[The birthing stool--an obstetrical risk?]

During 1992, 140 women out of a total of 1122 used the delivery chair at the department for obstetrics and gynaecology at the LKH Mödling. We compared them to a control group in the supine position. In order to evaluate the safety of deliveries on the delivery chair, we studied the duration of the stages of labour, rate and degree of soft tissue injuries, maternal blood loss, fetal outcome and complications in the puerperium. The use of the delivery chair showed no increased risk to either the mother or the fetus and therefore represents an appropriate alternative to the traditional supine position for delivery.

[HELLP syndrome in routine obstetrical care. Three case reports]

In recent years the syndrome of hemolysis, elevated liver enzymes and low platelets (H-ELLP) has attracted increasing interest in obstetrics as a serious complication of pregnancy, either alone or in combination with the classical symptoms of EPH-gestosis or eclampsia. In 1993, we observed 3 cases of severe HELLP syndrome in a total of 1126 deliveries. We present the clinical characteristics and the laboratory findings in these cases. A common symptom was general malaise and upper abdominal discomfort or pain. All patients were delivered by cesarean section of healthy infants. We conclude that it is no longer sufficient to emphasize edema, proteinuria and hypertension, but that the signs and symptoms of the HELLP syndrome present a new and increasingly important challenge in obstetric practice.

[Abdominal colposuspension--the gold standard in incontinence therapy?]

Abdominal colposuspension has become the operation of choice in moderate and severe urinary incontinence in the female. The operation involves an elevation of the bladder neck and approximation to the back of the symphysis pubis, resulting in an improved pressure transmission to the proximal urethra. These operative techniques have become standardised, while the various modifications differ in the exact location of the sutures in the vaginal fascia and connective tissue in the small pelvis. Most commonly, the sutures are placed lateral of the bladder neck and passed through the ileo-pectineal ligament (Cooper ligament). Even in unfavourable cases, success-rate lies between 70% and 90%.