Imaging of lumpectomy surface with large field-of-view confocal laser scanning microscope for intraoperative margin assessment - POLARHIS study

INTRODUCTION

Breast-conserving surgery (BCS) in case of breast cancer and/or in-situ-carcinoma lesions (DCIS) intends to completely remove breast cancer while saving healthy tissue as much as possible to achieve better aesthetic and psychological outcomes for the patient. Such modality should result in postoperative tumor-free margins of the surgical resection in order to carry on with the next therapeutical steps of the patient care. However, 10-40% of patients undergo more than one procedure to achieve acceptable cancer-negative margins. A 2nd operation or further operation (re-operation) has physical, psychological, and economic consequences. It also delays the administration of adjuvant therapy, and has been associated with an elevated risk of local and distant disease relapse. In addition, a high re-operation rate can have significant economic effects - both for the service provider and for the payer. A more efficient intraoperative assessment of the margin may address these issues. Recently, a large field-of-view confocal laser scanning microscope designed to allow real-time intraoperative margin assessment has arrived on the market - the Histolog Scanner. In this paper, we present the first evaluation of lumpectomy margins assessment with this new device.

MATERIALS AND METHODS

40 consecutive patients undergoing BCS with invasive and/or DCIS were included. The whole surface of the surgical specimens was imaged right after the operation using the Histolog Scanner (HLS). The assessment of all the specimen margins was performed intraoperatively according to the standard-of-care of the center which consists of combined ultrasound (IOUS) and/or conventional specimen radiography (CSR), and gross surgical inspection. Margin assessment on HLS images was blindly performed after the surgery by 5 surgeons and one pathologist. The capabilities to correctly determine margin status in HLS images was compared to the final histopathological assessment. Furthermore, the potential reduction of positive-margin and re-operation rates by utilization of the HLS were extrapolated.

RESULTS

The study population included 7/40 patients with DCIS (17.5%), 17/40 patients with DCIS and invasive ductal cancer (IDC NST) (42.5%), 10/40 patients with IDC NST (25%), 4/40 with invasive lobular cancer (ILC) (10%), and 1/40 patients with a mix of IDC NST, DCIS, and ILC. Clinical routine resulted in 13 patients with positive margins identified by final histopathological assessment, resulting in 12 re-operations (30% re-operation rate). Amongst these 12 patients, 10 had DCIS components involved in their margin, confirming the importance of improving the detection accuracy of this specific lesion. Surgeons, who were given a short familiarization on HLS images, and a pathologist were able to detect positive margins in 4/12 and 7/12 patients (33% and 58%), respectively, that were missed by the intraoperative standard of care. In addition, a retrospective analysis of the HLS images revealed that cancer lesions can be identified in 9/12 (75%) patients with positive margins.

CONCLUSION

The present study presents that breast cancer can be detected by surgeons and pathologists in HLS images of lumpectomy margins leading to a potential reduction of 30% and 75% of the re-operations. The Histolog Scanner is easily inserted into the clinical workflow and has the potential to improve the intraoperative standard-of-care for the assessment of breast conserving treatments. In addition, it has the potential to increase oncological safety and cosmetics by avoiding subsequent resections and can also have a significant positive economic effect for service providers and cost bearers. The data presented in this study will have to be further confirmed in a prospective phase-III-trial.

Challenging behaviour in students with intellectual disabilities: the role of individual and classmates' communication skills

BACKGROUND

Children and adolescents with intellectual disabilities (ID) are at increased risk of developing challenging behaviour. Challenging behaviour may be partially explained by low individual communicative competences. However, communication involves at least two partners, thus outcomes may also vary according to each interaction partners' abilities. We therefore investigated the degree to which the interplay between individual and classmates' communication skills predicts changes in challenging behaviour among students with ID.

METHODS

This study used a longitudinal design with two measurement points across one school year. Challenging behaviour and communication skills were measured by teacher reports in 1125 students with ID attending special needs schools. Applying a multilevel approach, we investigated (1) whether higher individual communication skills at the first measurement were related to a subsequent decrease in challenging behaviour and (2) whether this effect was moderated by classmates' levels of communication skills. In addition, we examined (3) if classroom communication skills were indirectly related to a decrease in challenging behaviour by influencing individual communicative abilities.

RESULTS

Higher individual communication skills at the first measurement were significantly related to a decrease in general challenging behaviour over the school year. This effect was not moderated by classroom-level communication skills. However, classmates' communication skills exerted an indirect influence by enhancing individual communicative abilities. Further analyses suggested classroom contextual effects related to a decrease in several sub-domains of challenging behaviour.

CONCLUSIONS

The study results suggest that both individual communicative competences and those of the classroom context are relevant to understanding challenging behaviour development in ID. Perspectives for counteracting such behaviour in light of the present findings are discussed.

No implant, no solution, lost cases to surgery: orthopedic trauma triage for surgery in an NGO hospital in Sierra Leone

INTRODUCTION

In low-income countries (LIC), international surgeons face the fact that there are patients they cannot treat. The goal of this study was to identify and analyze patients lost to treatment.

MATERIAL AND METHODS

We analyzed retrospectively the data of 282 trauma victims from a non-governmental organizational (NGO) hospital in Sierra Leone, Africa. During a 3-month period (10.10.2015-08.01.2016), these patients had 367 injuries and underwent 263 orthopedic surgeries. Despite a clear indication, some patients did not receive surgical treatment. We identified these injuries and the reason why they could not be operated. The anatomic region of the injury was evaluated and if they had a bone or soft tissue defect or were infected.

RESULTS

We identified 95 (25.89%) injuries in 70 patients (47 males; 23 females) that were not be operated. The reasons were lack of specific implants (no implant group; N = 33), no treatment strategy for the injury (no solution group; N = 29), and patients that were lost (lost patient group; N = 33), almost equally distributed by 1/3. In the no implant group were mainly closed fractures and fractures of the pelvis and the proximal femur. The implants needed were locking plates (N = 19), proximal femoral nails (N = 8), and implants for pelvic surgery (N = 6). In the no solution group were nearly all bone (P < 0.0000), soft tissue defects (P < 0.00001) and infections (P = 0.00003) compared to the rest and more open fractures (P < 0.00001). In the lost patients group, most fractures were closed (24 out of 33, P = 0.033). These fractures were mostly not urgent and were postponed repeatedly.

CONCLUSION

One quarter of the patients did not receive the surgical treatment needed. Besides acquisition of implants, surgical skills and expertise could be a solution for this issue. Nevertheless, these skills must be passed to local surgeons.

Combining ACL Reconstruction and Refixation: the Single Anteromedial Bundle Biological Augmentation and Refixation (SAMBBAR) Technique

PURPOSE OF THE STUDY Anterior cruciate ligament (ACL) preservation surgical techniques have been rising lately. In the acute setting, proximal ACL tears and femoral avulsions of the ACL are good indications for primary repair of the ACL. However, literature shows a wide range of failure rates. An intact synovial membrane seems to be a predicational factor for the outcome of primary ACL repair. Disruption of the synovial membrane is associated with higher failure rates. We describe a surgical technique repairing the ACL in combination with a semitendinosus augmentation for proximal ACL tears with or without disruption of the synovial membrane. MATERIAL AND METHODS The procedure preserves as much of the original anatomy as possible by repairing the synovial membrane and ACL remnant to the femoral origin. To accomplish this, we have built on the so-called "Single Anteromedial Bundle Biological Augmentation (SAMBBA) technique" and developed it further to the "Single Anteromedial Bundle Biological Augmentation and Refixation (SAMBBAR) technique", which we firstly describe here. RESULTS All three patients treated with the SAMBBAR technique showed very good short-term clinical outcomes comparable with successful standard ACL reconstruction. There were no complications. Twelve months postoperatively, patients had no pain. They had normal range of motion in the affected knee without any signs of instability. DISCUSSION The SAMBBAR technique seems to be an adequate procedure to preserve as much proprioceptive native tissue as possible, while at the same time ensuring high tissue strength in order to reduce failure rates. Prospective randomized controlled trials are needed to compare the new SAMBBAR technique with standard ACL reconstruction, with the original SAMBBA technique, and with techniques of ACL refixation. CONCLUSIONS With the presented surgical procedure, it is possible to perform a standard ACL reconstruction using an autologous semitendinosus graft and at the same time preserving the tissue remnant of the ACL in all proximal tear patterns. This might contribute to improved proprioception and rehabilitation without sacrificing stability. Key words: anterior cruciate ligament, Lachman test, Ligamys, knee instability, semitendinosus tendon.

War surgery in Afghanistan: a model for mass causalities in terror attacks?

PURPOSE

The aim of the study was to identify solution strategies from a non-governmental (NGO) hospital in a war region for violence-related injuries and to show how high-income countries (HIC) might benefit from this expertise.

METHODS

NGO trauma hospital in Lashkar Gah, Afghanistan. Four hundred eighty-four war victims admitted in a three month period (February 2016-May 2016) were included. Patients´ characteristics were analyzed.

RESULTS

The mean age was 23.5 years. Four hundred thirty-four (89.9%) were male, and 50 (10.1%) were female. The most common cause of injury was bullet injuries, shell injuries, and mine injuries. The most common injured body region was the lower extremity, upper extremity, and the chest or the face. Apart from surgical wound care and debridements, which were performed on every wound in the operation theatre, laparotomy was the most common surgical procedure, followed by installation of a chest drainage and amputation.

CONCLUSION

The surgical expertise and clear pathways outweigh modern infrastructure. In case of a mass casualty incident, fast decision-making with basic diagnostic means in order to take rapid measurements for life-saving therapies could make the difference.

Abortion in women with Down syndrome

BACKGROUND

Nearly two-thirds of pregnancies in women with Down syndrome (DS) end in abortion. The aim of the present study was to determine if these high abortion rates might relate to specific characteristics of women with DS, their life situation and the course of pregnancy.

METHODS

In a sample of 351 pregnancies in Switzerland (1998 to 2009), women with DS were compared with women with other forms of intellectual disability (ID) and women without ID, regarding the type of abortion, personal characteristics and pregnancy complications that might increase the probability of abortion.

RESULTS

All abortions among women with DS were medically induced. In women with DS and ID, abortions were more likely to occur due to unwanted pregnancy than in women without ID. In addition, women with DS and ID were more often diagnosed with fetal complications and maternal health problems. However, no correlation between fetal complications or maternal health problems and pregnancy outcome was found.

CONCLUSIONS

The group differences found do not directly explain the high abortion rates among women with DS. Maternal diagnosis of DS appears to be the most important predictor of abortion. Possible explanations for this finding are discussed.

Repeated Occurrence of Skin Necrosis Twice Following Coumarin Intake and Subsequently During Decrease of Vitamin K Dependent Coagulation Factors Associated with Cholestasis

A female patient is described who developed skin and subcutaneous fat necrosis on two occasions after intake of acenocoumarol.

Several months later identical skin changes occurred during an episode of cholestasis associated with a prolongation of the prothrombin time to an extent comparable with therapeutic anticoagulation; intake of oral anticoagulants could be excluded.

This association gives new insights in the pathogenetic mechanisms responsible for the so-called coumarin necrosis and indicates that it may be not due to drug toxicity or allergy.

Fibrinogen Zurich I: Impaired Release of Fibrinopeptide A

Fibrinogen Zurich I is characterized by an abnormal fibrin monomer polymerization. It consists of two fractions of molecules, one with a normal aggregation and one not aggregating at all and interfering with the aggregation of the normal population. Using a radioimmunoassay for fibrinopeptide A, only approximately half of the expected fibrinopeptide A could be recovered after thrombin or Defibrase proteolysis. The defective fibrinopeptide A release could be confirmed by measurement of the N-terminal Gly/Tyr ratio. It is likely that the abnormal fibrin monomer aggregation of the abnormal fraction of fibrinogen Zurich I is due to the defective fibrinopeptide A release of this fraction.

[Use of Bone Morphogenetic Proteins (BMPs) for the Treatment of Pseudarthroses - Efficiency and Therapy Failure]

In the therapy for pseudarthroses of the proximal tibia, the human recombinant bone morphogenetic proteins (BMP-2 and BMP-7) have been used for several years. Despite their limited and specified use as local mediators of bone healing, no conclusions regarding the therapeutic success can be made beforehand. The regulatory mechanisms have turned out to be much more complex and patient-specific than had been assumed before. To help understand the cell biological processes (signalling) and the current possibilities of predicting a successful use of BMP, this article summarises the relevant findings.

Sinonasal hemangiopericytoma

Hemangiopericytoma (HPC) is a rare entity that is found in only 1% of vascular tumours. Only 5% of HPC are localized in the nasal cavity or paranasal sinuses. The exact incidence is not stated in the literature.

CASE REPORT

A case of a 76-year-old female patient is presented. As she suffered from stroke a cranial CT was performed and the tumour of the paranasal sinuses was diagnosed incidentally. The patient had a history of paranasal sinus surgery under local anaesthesia twenty years ago. The former histological diagnosis was stated as "angiofibroma with signs of proliferation ". The histopathologic diagnosis after endonasal sinus surgery was primarily a neoplasia with spindle-shaped cell formation. Just additional immunocytochemistry revealed the finding of primitive mesenchymal cells. This confirmed the diagnosis of a hemangiopericytoma. The two years follow-up showed no signs and symptoms of recurrent tumour on endoscopic examination and CT scans.

CONCLUSION

Hemangiopericytoma is a rare endonasal or sinonasal tumour. Occasionally histological diagnosis is difficult. Its characteristics are marked cellularity, vascularity and a dense net of reticular fibres. The entity shows a considerable tendency to recurrence, malignant transformation and metastasizing. After complete sinonasal surgery a regular short term follow up is advisable.

Papilläres Schilddrüsenkarzinom in einer medianen Halszyste

Thyroglossal duct cysts are the most common anomaly in thyroid development. The occurrence of carcinoma in a cyst is reported to be about 1% of cases. Histopathological examinations reveal a papillary thyroid carcinoma in about 94% of these. We report the case of 38-year-old female having a massive, cervical cystic mass over a period of 18 months. An ectopic papillary thyroid carcinoma was diagnosed. A total thyoidectomy and bilateral neck dissection were performed. This revealed a small thyroid carcinoma and three positive lymphatic nodes. Whether the cystic carcinoma is the primary or a metastasis of the thyroid carcinomais discussed.

Childhood personality influences on social-cognitive development: a longitudinal study

The relation of childhood personality to the development of friendship understanding and moral judgment in adolescence was considered in a longitudinal study. Personality at age 7, assessed with the California Child Q-Set, was characterized in terms of ego-resiliency and ego-control. IQ and social class were also measured. Friendship understanding was assessed when the participants were ages 7, 9, 12, 15, and 19, and moral judgment was elicited when the participants were 12, 15, and 19. Ego-resiliency was found to predict social-cognitive development in adolescence, even after the effects of IQ and childhood measures of social-cognitive development were controlled for. Analyses indicate that the effects of ego-resiliency on social-cognitive development are largely unmediated by the ability to focus attention or by social participation.

Childhood personality influences on social-cognitive development: a longitudinal study

The relation of childhood personality to the development of friendship understanding and moral judgment in adolescence was considered in a longitudinal study. Personality at age 7, assessed with the California Child Q-Set, was characterized in terms of ego-resiliency and ego-control. IQ and social class were also measured. Friendship understanding was assessed when the participants were ages 7, 9, 12, 15, and 19, and moral judgment was elicited when the participants were 12, 15, and 19. Ego-resiliency was found to predict social-cognitive development in adolescence, even after the effects of IQ and childhood measures of social-cognitive development were controlled for. Analyses indicate that the effects of ego-resiliency on social-cognitive development are largely unmediated by the ability to focus attention or by social participation.

Differential diagnosis of neonatal adrenal haemorrhage and congenital neuroblastoma by colour coded Doppler sonography and power Doppler sonography

The differentiation between neonatal neuroblastoma and adrenal haemorrhage may be very difficult in the individual case. We investigated eight neonates with adrenal haemorrhage and one patient with congenital neuroblastoma by colour coded Doppler sonography and power Doppler sonography. Six haemorrhages were cystic, whereas the neuroblastoma and four adrenal haemorrhages had a solid appearance. Colour coded Doppler sonography and power Doppler demonstrated vessels within the neuroblastoma. In none of the ten adrenal haemorrhages could flow be shown either with conventional colour coded Doppler sonography or power Doppler sonography.

CONCLUSION

Conventional colour coded Doppler sonography and power Doppler sonography are useful to differentiate between neuroblastoma and adrenal haemorrhage.

Evaluation of polarographic measurements of basal muscle oxygen tension in type I diabetic patients

Microcirculatory changes occur early in insulin-dependent diabetes mellitus (IDDM) and are believed to be an early feature of late diabetic complications, leading to reduced oxygen pressure and hypoxia in the skin and other tissues. Whether muscle oxygen supply is also altered is unknown. Therefore, the authors analyzed polarographic measurements of muscle oxygen tension in 44 healthy type I diabetic patients (mean age 28 years; mean diabetes duration 7 years) and in 57 healthy controls, matched for age, sex, and body mass index, and the corresponding influencing factors. Two measurements were taken at rest 60 minutes apart in the anterior tibial muscle. Muscle oxygen tensions did not differ between IDDM patients and controls (23.0 +/- 8.6 vs 25.3 +/- 9.0 mmHg) and were reproducible on repeated measurements (25.3 +/- 9.7 vs 25.5 +/- 7.4 mmHg). Coefficients of variation were 13.5 +/- 10.8% in IDDM patients and 13.1 +/- 9.3% in controls. Compared with controls, in IDDM patients hemoglobin A1c (HbA1c) and blood glucose concentrations were elevated, and arterial oxygen pressure was significantly lower. Muscle oxygen tensions were positively correlated with blood glucose concentrations in IDDM patients (Rho=0.48, P=0.002) but not with HbA1c or with insulin concentrations. The authors conclude that the polarographic measurement of muscle oxygen tension is a reliable method with good reproducibility. Hypoxia in the anterior tibial muscle of type I diabetic patients can be excluded. In IDDM patients the level of muscle oxygen tension is correlated with the level of blood glucose concentration.

Children's attachment representations: longitudinal relations to school behavior and academic competency in middle childhood and adolescence

A longitudinal study examined children's (N = 108) attachment representations in relation to behavior and academic competency at school during middle childhood and adolescence. Attachment representations were assessed from children's responses to a separation story at age 7 years. At ages 9, 12, and 15, teachers rated children on four dimensions of school behavior: attention-participation, extroversion, disruptive behavior, and insecurity about self. Children's grade point average (GPA) in school was also examined. Children's attachment representations (secure vs. insecure) did not predict either disruptive behavior or extroversion, but they were significantly linked to attention-participation, insecurity about self, and GPA, with secure representations being associated with more favorable outcomes. The study controlled for social class, gender, IQ, perspective-taking ability, and prior competency.

Children's attachment representations: longitudinal relations to school behavior and academic competency in middle childhood and adolescence

A longitudinal study examined children's (N = 108) attachment representations in relation to behavior and academic competency at school during middle childhood and adolescence. Attachment representations were assessed from children's responses to a separation story at age 7 years. At ages 9, 12, and 15, teachers rated children on four dimensions of school behavior: attention-participation, extroversion, disruptive behavior, and insecurity about self. Children's grade point average (GPA) in school was also examined. Children's attachment representations (secure vs. insecure) did not predict either disruptive behavior or extroversion, but they were significantly linked to attention-participation, insecurity about self, and GPA, with secure representations being associated with more favorable outcomes. The study controlled for social class, gender, IQ, perspective-taking ability, and prior competency.

The relation of childhood personality types to adolescent behavior and development: a longitudinal study of Icelandic children

The relation of childhood personality types, or configurations of personality traits, to adolescent development was examined. Three personality types were identified in an inverse factor analysis of California Child Q-Sort data on 128 Icelandic 7-year-olds: resilient, overcontrolled, and undercontrolled. Growth curve analyses demonstrated that in comparison to children of the other 2 types, children of the resilient personality type had higher levels of academic achievement and lower levels of concentration problems throughout adolescence; resilient children also developed sophisticated friendship reasoning and an internal locus of control more quickly. Children of the overcontrolled type were found to be more prone to social withdrawal and low levels of self-esteem during adolescence than children of the other 2 types. In contrast to the other 2 types, children classified as undercontrolled showed an increase in aggressive behavior in adolescence. Implications of the findings for research on personality development are discussed.

Pain intensity and blood pressure reactions during a cold pressor test in IDDM patients

OBJECTIVE

To determine the contribution of altered pain perception to the impaired blood pressure reactions during a cold pressor test in diabetic patients. Reduced blood pressure increases have been observed in diabetic patients during a cold pressor test and have been attributed to an impaired efferent sympathetic function.

RESEARCH DESIGN AND METHODS

We investigated pain intensities and blood pressure reactions simultaneously during a cold pressor test in 30 IDDM patients (diabetes duration 12 +/- 6 years, HbA1c 7.5 +/- 1.4%) and in 30 normal control subjects with comparable sex distribution, age, height, BMI, physical fitness, and smoking habits.

RESULTS

Initial pain intensities and respective time courses did not differ between the two groups. The initial blood pressure response was significantly smaller in diabetic patients (P < 0.002). Correlations of diastolic blood pressure increases in diabetic patients with initial pain intensity, standard cardiovascular reflex tests, age, clock time, smoking habits, disease duration, and actual blood glucose concentrations did not reach statistical significance. Pain intensity and diastolic blood pressure increases, however, were correlated to HbA1c concentrations in diabetic patients.

CONCLUSIONS

Impaired pain perception is not the cause of the impaired reactions of blood pressure in diabetic patients during the cold pressor test, leaving very early deterioration of either cerebral processing of pain stimuli, cardiac function, efferent sympathetic nerves, or decreased vascular reactivity as possible explanations.

[Penis carcinoma in a young chimney sweep. Case report 200 years following the description of the first occupational disease]

We report on a 32-year-old patient who, following exposure to soot over a total of 78 weeks as a professional chimney sweep, developed squamous cell carcinoma of the penis. Since the epoch-making description of occupational cancer of the scrotum by Percivall Pott in 1775, soot-related cancer of the scrotum and penis has become anecdotal. As our patient presented with inguinal lymph node metastases, a wide circumcision was performed, followed by preoperative chemotherapy and bilaterial lymphadenectomy. The patient has been free of disease for over 9 years with no functional loss.

[Pheochromocytoma as dominant manifestation of v. Hippel-Lindau syndrome]

A diagnosis of von Hippel-Lindau syndrome was made in two families originating from the same part of the Black Forest but apparently unrelated. Nine affected persons (seven males and two females) had a total of 17 tumours: retinal angioma (4), haemangioblastoma of the CNS (1), and phaeochromocytoma (12). Three of the affected persons and eight of the tumours (six phaeochromocytomas, two retinal angiomas) were diagnosed by family screening. Phaeochromocytoma was diagnosed in eight persons; in four it was the only symptomatic lesion. After extensive diagnostic tests the phaeochromocytoma was the sole tumour in four. Despite severe symptoms the diagnosis of von Hippel-Lindau syndrome had not been made prior to the screening examinations because either the common aetiology of the tumour was not known or there was insufficient exchange of information between the two families.--It is recommended that in each case of phaeochromocytoma von Hippel-Lindau syndrome should be excluded so that lesions can be discovered early in other organs and in other affected family members. If the syndrome is present, annual examinations are indicated because of asynchronous and multi-focal tumour growth.

[Ultrasonic studies of craniocerebral injuries in infants]

This is a report on the sonographic diagnostic possibilities in 46 closed-head injured infants. Cerebral examination via the anterior fontanelle is completed by additional sections of the surface of the brain. The traumatic oedema is limited in most cases and - besides the increase in echogenicity - an increase of the arterial pulsation at the border of the oedema is seen in real-time scanning. The sonographic signs of the epidural and subdural haematomas are described and also the differentiation between both. Surgical treatment was necessary in three cases of subdural haematoma because of increasing ICP. Treatment of extradural and chronical subdural haematomas or effusions is discussed in connection with the sonographic follow-up. Alterations in symmetry and compression of the ventricular system is often caused by intracerebral haemorrhages and-or traumatic local oedema. Parenchymal cysts may occur after liquefaction of cerebral necrosis or clots. The advantage of the cerebral sonographic examination is the uncomplicated follow-up. In connection with the clinical state and with continuous registration of ICP, sonographic findings facilitate the decision if, where and when trepanation must be performed.

Value of ultrasound in the treatment of solitary kidneys in infancy and childhood

Every second patient with a solitary kidney suffers from renal disease. This accumulation of renal diseases of varying origin makes special care for these children necessary. The quality of diagnostic methods is decisive for the choice of therapy. The advantages of primary ultrasound diagnosis and sonographical function tests are described. Sonographical differentiation of disturbances of the urinary transport is possible by means of forced-diuresis ultrasonography, whereas a vesico-ureteral reflux can be detected by means of voiding sonocystography. The value of ultrasound for primary diagnosis, assessment of therapeutic course and postoperative long-term follow-up is discussed.

[Efficacy of recombinant interferon alpha-2 in 34 patients with hairy cell leukemia. Effect of splenectomy and dosage reduction results of therapy]

In a retrospective study of 34 patients with hairy cell leukemia treated with recombinant interferon-alpha 2, we have observed a hematological remission rate of 97%. The true complete remission rate based on bone marrow findings was 17%. Although complete remissions can be obtained only in a few cases, treatment with interferon is justified in cytopenic patients since long-standing clinically meaningful improvement of the peripheral blood values can be attained. If interferon is stopped in the remission phase, the blood values deteriorate in 40% of the patients within 5 months. In contrast, it appears that the remission can be maintained with intermittent administration of interferon weekly or even every other week. As compared to splenectomized patients, granulocyte recovery is delayed in nonsplenectomized patients. However, after several months of treatment there is no difference in peripheral blood values between splenectomized and non-splenectomized patients. In the light of the present results, primary splenectomy remains justified in a selected group of patients for whom the risk of surgery (due to low granulocytes and/or platelets) is low and for whom careful evaluation predicts a high potential for long-standing remission after splenectomy. In the other cases, initial interferon therapy seems justified.

[The significance of screening studies for the early detection of metastases in curatively operated breast carcinoma]

A retrospective analysis of 80 women with breast cancer operated on with curative intent showed that metastases developed within 8 years. The value of laboratory tests and radiological surveys for the early detection of metastases is considered. In fewer than 50% of the patients was the finding of a single abnormal laboratory result associated with tumor recurrence. However, when several findings were abnormal concomitantly this suggested tumor dissemination in about 90% of women. In 80% of the patients clinical symptoms were present at the time of tumor recurrence. In only 20% of the patients were metastases clinically silent. Since metastatic breast cancer cannot be cured by present treatment modalities, the relevance of detecting early recurrence is limited.

Prognostic significance of agar and liquid cultures in AML patients before treatment, early postinduction and in remission

In the present study, the growth and differentiation capacity of myeloid leukemic cells in agar and liquid cultures have been investigated in relation to their prognostic significance for treatment outcome and early detection of relapse. Prior to induction therapy, leukemic cells failed to differentiate and the colony or cluster number did not correlate with response to treatment. Seventeen to 42 days after induction, patients with BM cells producing greater than 10 colonies or greater than 30 clusters resp. had a high likelihood of achieving a complete remission. Cells from refractory patients had a significantly impaired differentiation capacity. During remission, a colony number greater than 50 was significantly associated with a high probability to remain in further remission for greater than 3 months. An impaired differentiation was significantly associated with the likelihood of relapsing within 3 months. In the light of these results, agar and liquid cultures appear to be useful for monitoring the effect of induction chemotherapy and detecting patients likely to relapse.

[Mycoplasma etiology of acute pancreatitis]

In a 10 year-old girl the clinical and laboratory findings led to the diagnosis of pancreatitis. At the same time an infection by mycoplasma pneumoniae was serologically stated. Since there could not be found another cause for pancreatitis, a relation between pancreatitis and infection by mycoplasms is very probable.

[Effectiveness and toxicity of high-dosage Ara-C. Clinical observations in 10 cases and review of the literature]

Ten patients with acute myeloid leukemia were treated with a high-dose ara-c regimen (3 g twice daily for 6 days). 5 patients (50%) achieved a complete remission lasting for a median duration of 5 months. These patients had all achieved a complete remission following standard treatment with ara-c. High-dose ara-c was ineffective in 2 patients resistant to standard ara-c protocols. The most important side effects of high-dose ara-c were conjunctivitis and cerebellar symptomatology. In one case a severe diffuse encephalopathy with cerebellar predominance set in at a remarkably late stage (45 days after starting treatment). Our results and those of other authors suggest that treatment with high-dose ara-c should be used with caution.

[Sonographic follow-up studies in purulent meningitis and its complications in infancy]

In 29 newborns and 18 infants ill with meningitis the following characteristic signs visible by sonographic examination of the brain mostly indicated complications: increase of the leptomeningeal echogenicity, increase of the periventricular echogenicity in ventriculitis, alterations of the configuration of the ventricles, typical echos in the CNS-fluid by increased cell and protein content, alterations of the Plexus chorioideus caused by inflammation, membranes in the enlarged ventricular system. In the first year of life the sonographic examination of the brain is ideal for early diagnosis of possible complications in meningitis to change the therapeutic management without any loss of time.

Limitations of the salmonella/mammalian microsome assay (Ames test) to determine occupational exposure to cytostatic drugs

Urine samples of nursing personnel working in medical oncology divisions of several Swiss hospitals were examined for mutagenic activity. Urine samples were concentrated 100 times following XAD-2 chromatography and mutagenicity was determined using the Salmonella/mammalian microsome assay (Ames test). Apart from the urine samples of patients treated with cytostatic drugs and urine samples of nurses who are cigarette smokers, no mutagenic activity could be found. Also following exposure to an increased and defined quantity of cytostatic drugs no mutagenicity could be recovered from the urine. Four different nurses worked with cyclophosphamide, methotrexate, 5-fluorouracil, adriamycin and cis-platinum for 3-4 hr without using any protection such as gloves, masks or a vertical laminar airflow hood. Aqueous extracts of filters, through which air was pumped during the whole experiment (a personal air-sampler was fixed near the face of the test persons), were non-mutagenic. Parallel to the mutagenicity test chemical analyses were also done. The methotrexate content was determined in serum samples and the aqueous filter extracts and urine samples were examined for cis-platinum. All chemical determinations were negative. With the aid of urine concentrates of a patient treated with sub-therapeutic doses of cyclophosphamide as well as with normal urine to which single small amounts of different cytostatics (adriamycin, cyclophosphamide, cis-platinum) were added, the detection limits for the corresponding cytostatic drugs were determined and found to be in the range of 2-10 mg for cyclophosphamide and approx. 10 micrograms for adriamycin. Cis-platinum was lost during the passage through the XAD-2 columns. With these results at hand the sensitivity of the hitherto preferably used method (Ames test) for the monitoring of exposure to cytostatic drugs must be seriously questioned.

[Possibilities of pre-, intra- and postoperative sonography in hydrocephalus]

Short-term repeat sonographic examinations of the brain were performed in 90 newborn and infants with ventricular dilatation. Changes in the ventricular configuration are pointers to the intracranial pressure. Measurement of the ventricular system must be performed in the same way as for estimating progressive ventricular dilatation. If a shunt is necessary, the ventricular tube can be positioned in the anterior horn of the lateral ventricle under ultrasound guidance. This will help to avoid complications which are due to a wrong position near the plexus or in a clot. Complications like overdrained ventricles, haemorrhages, shunts blocked in proximal or distal areas may be visible even before the appearance of clinical signs or symptoms. Comparative postoperative examinations allow an assessment of shunt function.

Leukemic samples characteristics associated with clonogenic growth

In this study, we attempted to delineate readily assessable characteristics from 100 leukemic samples associated with in-vitro growth. Successful growth defined as production of greater than 30 clusters and/or colonies per culture dish was obtained in 68% of samples. More than 10 colonies were found in 59% and greater than 30 colonies in 51% of cultures, respectively. Leukemic cells from patients previously treated with aggressive cytotoxic chemotherapy grew significantly better than cells from untreated patients, independently of the above definitions of cloning success. Cells from peripheral blood had a weak, albeit significant growth advantage over bone marrow cells (p = 0.032) when cluster growth was taken into account for growth success. When colony growth alone was used as criterium, no growth advantage was found. The morphological subtype and the proliferation kinetics prior to cell plating did not affect cloning success. A high labeling index had predictive value for subsequent growth, but only in bone marrow cells. By multivariate analysis, we found that treatment status was the most important factor correlated with in-vitro growth.

Hairy cell leukemia: an interferon deficient disease?

rIFN-alpha 2 is an effective substance in the treatment of HCL. Although the complete eradication of hairy cells from the bone marrow is rarely possible, a dramatic improvement of profound cytopenias can be obtained in most patients, 12 out of 13 in this study. The response can be seen after a median treatment duration of about 2 months and appears to be independent of the presence of the spleen. Once a stable improvement of the peripheral blood values is achieved, one dose of rIFN-alpha 2 every other week may be sufficient to maintain the cell counts. The mechanism(s) by which IFN acts remain unclear. We speculate, that HCL is an IFN deficient syndrome because monocytes which are the major source of IFN-alpha are severely depressed in this lymphoproliferative disorder. Following this hypothesis, the IFN therapy would be comparable to the substitution of insulin in diabetic patients.

[Diagnostic value of sonography in vesico-ureteral reflux in infancy and childhood]

The direct demonstration of reflux by filling of the urinary bladder using real time sonography is a new method avoiding radiation exposure. Since 1979 we use this technique (Miktions-Cysto-Sonographie, MCS) as routine procedure. In 117 cases with 163 radiologically diagnosed refluxes we could demonstrate, that refluxes of grad II or higher gave a positive sonogram. As a consequence it is proposed, that for children with urinary tract infections the first examinations should be the sonography of kidneys and the sonographic evaluation of reflux. In the cases of conservatively treated refluxes the check-up of the reflux is carried out only sonographically. The same is valid for the control after antireflux surgery. Thus radiological examinations are necessary only for sonographically suspicious findings. The urinary tract obstruction after antireflux operations is detected sonographically, too. In 99 cases of antireflux operations it could be shown, that the urinary flow came back to the normal state within 3 months post operation.

Effects of leukocyte interferon (E. coli) on human bone sarcoma growth in vitro and in the nude mouse

Effects of highly purified human leukocyte interferon (rIFN-alpha 2) on colony formation, DNA synthesis and proliferation in nude mice of tumor cells from eight bone sarcomas have been studied. rIFN-alpha 2 produced a dose-dependent inhibition of [3H]thymidine incorporation by sarcoma cells. Even at high doses (10(4) U/ml), however, [3H]thymidine uptake could not be completely blocked by rIFN-alpha 2. In a cloning assay three established sarcoma cell lines and five other sarcoma samples obtained after short-term in vitro culture were found to be sensitive to various degrees to rIFN-alpha 2, complete inhibition being seen only at 10(4) U/ml. Three sarcomas were sensitive in the nude mouse model. Scheduling experiments revealed that rIFN-alpha 2 produces a delay in tumor growth only when administered either before or shortly after tumor implantation. Therefore rIFN-alpha 2 appears to be most active when tumor size is small and growth not exponential, indicating that rIFN-alpha 2 may play a role in an adjuvant setting. Growth sarcomas strongly suppressed by rIFN-alpha 2 in the cloning assay was markedly inhibited in the nude mouse. One sarcoma which was only moderately sensitive in the cloning assay was resistant in the animal experiment, confirming the predictive value of the clonogenic assay. Although the present findings demonstrate strong antitumor activity of rIFN-alpha 2 against human bone sarcoma cells they should be interpreted with caution mainly because the high rIFN-alpha 2 levels used in the experiments cannot be maintained in patients over a prolonged period.

Hairy cell leukemia: kinetics and intercellular relationships of cells in leukemic colonies grown in a semisolid medium

We examined cellular relationships and cytokinetics of hairy cells in colonies formed in an in vitro cloning system. Cells in small colonies and at the periphery of larger ones were separated by wide, irregular intercellular spaces. Cells in the core of large colonies were elaborately intertwined by their cytoplasmic processes and so densely packed that their intercellularity was greatly reduced. Cell labeling with 3H-thymidine revealed indices ranging from less than 1% to 35%. The combination of autoradiography with a stain for tartrate-resistant acid phosphatase showed that the enzyme was not expressed by cells in S-phase. The cellular relationships of hairy cells in colonies grown in this system closely mimic those of their in vivo counterparts in the spleen and bone marrow.

[Is the use of adriamycin (doxorubicin) limited by its cardiotoxicity?]

Adriamycin (doxorubicin), one of the most active cytotoxic antineoplastic agents, can cause heart failure. This side effect is dose-dependent, the frequency of heart failure being 3% at a cumulative Adriamycin dose of 400 mg/m2 and 18% at 700 mg/m2. It is assumed that Adriamycin, or other anthracycline derivatives, are still active when the cardiotoxic level is reached. In this retrospective study of 171 patients with various metastatic malignant tumors, the total dose of Adriamycin given to the patients and the reasons for withholding the treatment have been analyzed. Overall, among the 171 patients treated by Adriamycin-containing combination chemotherapy, 54 objective remissions (31%) were observed. Remissions were more frequent in untreated patients (52%) than in previously treated patients (20%). In 36 of 54 patients the disease progressed before the cumulative cardiotoxic level was reached. Adriamycin could be discontinued in only 18 patients still in remission. 8 of 171 patients received more than 450 mg/m2 Adriamycin without cardiotoxic side effects being observed. Among the 171 patients, cardiotoxicity probably related to anthracyclines developed in 5 cases (3%), in all cases at a level below 450 mg/m2. These results suggest that in most cases Adriamycin becomes inactive before the dose-limiting cumulative cardiotoxic level is reached.

[Effect of interferon-alpha 2 (E. coli) in hairy cell leukemia]

Recombinant interferon-alpha 2 (E. coli) produced a clinically significant improvement in hemoglobin, granulocytes and platelets in 7 of 8 patients with hairy cell leukemia. Response to treatment was already noticeable in the fourth treatment week. In one case without improvement after 120 days, treatment was stopped. So far only one complete remission has been documented. Because of the remarkable improvement in the peripheral blood values, the induction of a complete remission may not be the ultimate goal of interferon treatment. The side effects of this subcutaneous low-dose treatment consisted mainly of mild flu-like symptoms of short duration. The results obtained with recombinant interferon-alpha 2 confirm the initial observation by Quesada et al. with partially purified leukocyte-interferon. In our experience, these results are superior to those obtained in similar conditions with chlorambucil.

Hairy cell leukemia. Ultrastructural and cytochemical evaluation of leukemic colonies grown in a semi-solid medium

We examined the fine structure and enzymatic activity of cells composing colonies grown from blood and/or spleen of eight patients with hairy cell leukemia. Mononuclear cells (MNC) were plated over an agar layer in a medium containing methylcellulose and leukocyte-conditioned medium. After 7-10 days incubation colonies were harvested for cytologic study. Colony cells possessed a euchromatic nucleus with an occasional nucleolus. Their cytoplasm contained a prominent Golgi region, numerous mitochondria and small vesicles, many short strands of rough endoplasmic reticulum (RER) and an infrequent phagosome. Well-developed ribosome-lamella complexes and what may have been their intermediate forms appeared in colony cells from three patients. Strong activity for tartrate-resistant acid phosphatase, localized in the RER, nuclear envelope and some Golgi vesicles, was evident in 50-95% of all colony cells. Our results indicate that a high proportion of MNC forming colonies in this culture system maintain the characteristic morphology and cytochemical activity of hairy cells.