Pelvic lymphadenectomy in vulvar cancer and its impact on prognosis and outcome

BACKGROUND

The value of pelvic lymphadenectomy (LAE) has been subject of discussions since the 1980s. This is mainly due to the fact that the relation between lymph node involvement of the groin and pelvis is poorly understood and therewith the need for pelvic treatment in general.

PATIENTS AND METHODS

N = 514 patients with primary vulvar squamous cell cancer (VSCC) FIGO stage ≥ IB were treated at the University Medical Center Hamburg-Eppendorf between 1996 and 2018. In this analysis, patients with pelvic LAE (n = 21) were analyzed with regard to prognosis and the relation of groin and pelvic lymph node involvement.

RESULTS

The majority had T1b/T2 tumors (n = 15, 78.9%) with a median diameter of 40 mm (11-110 mm). 17/21 patients showed positive inguinal nodes. Pelvic nodal involvement without groin metastases was not observed. 6/17 node-positive patients with positive groin nodes also had pelvic nodal metastases (35.3%; median number of affected pelvic nodes 2.5 (1-8)). These 6 patients were highly node positive with median 4.5 (2-9) affected groin nodes. With regard to the metastatic spread between groins and pelvis, no contralateral spread was observed. Five recurrences were observed after a median follow-up of 33.5 months. No pelvic recurrences were observed in the pelvic nodal positive group. Patients with pelvic metastasis at first diagnosis had a median progression-free survival of only 9.9 months and overall-survival of 31.1 months.

CONCLUSION

A relevant risk for pelvic nodal involvement only seems to be present in highly node-positive disease, therefore pelvic staging (and radiotherapy) is probably unnecessary in the majority of patients with node-positive VSCC.

[Supply of emergency physicians for patients with stroke in the Münster area. A cross-sectional study of the quality of regional health care]

BACKGROUND AND OBJECTIVE

Advances in understanding the pathophysiology and treatment of stroke have led to changed requirements, including the prehospital phase, for the care of patients with acute stroke. Rapid transport to a regional stroke centre is nowadays considered to be the standard for optimal quality of care. A retrospective cross-sectional analysis was undertaken in 1996 in the region of the town of Münster to test the quality of medical care provided by physicians on emergency call.

PATIENTS AND METHODS

250 of 3001 protocols (8.3%) filled in by emergency call physicians were selected in which the initial diagnosis of transitory ischaemic attack, stroke or cerebral haemorrhage had been made. Quality of patient care was assessed according to the following criteria; (1) complete medical treatment (blood sugar, blood pressure, cardiac rhythm and arterial oxygen saturation, including relevant treatment of any abnormality) (2) action time (arrival of emergency doctor within 12 min and arrival at hospital within 50 min); (3) type of the admission hospital (stroke centre defined as a hospital experienced in the treatment of stroke, with neurological and medical departments, as well as 24-hour cover for computed cranial tomography). A summated indicator of "optimal care" was used to determine whether the three stated criteria were met.

RESULTS

Mean age of the stroke patients was 72.3 years. While the above mentioned quality criteria for the action time were met in 93.5% of patients, only 56.0% were admitted to a stroke centre, and this was significantly more often the final destination for patients under the age of 65 years than for older ones (p = 0.049). The quality indicator "complete medical treatment" was met for 27.2% of the transported patients. Measured according to present-day criteria, only 18.6% of patients received such optimal treatment.

CONCLUSION

This analysis indicates that modern prehospital treatment of stroke patients does not reach adequate standards. In particular, it is not comprehensive. While the "action time" is usually adequate, there are deficiencies regarding the quality of medical care and the choice of the admission hospital. Further education for emergency physicians with respect to the management of stroke syndrome should be an integral part of any regional quality programme. The number of hospitals with adequate competence in the acute management of stroke cases is still insufficient.

[Leiomyosarcoma of the mandibular canal. Possible differential diagnosis of cystic processes of the mandible]

Leiomyosarcomas in the mandible are extremely rare. The cases of a 40-year-old woman with a leiomyosarcoma in the mandible is reported. Diagnostic and therapeutic problems are discussed.

Descriptive and metric classification of jaw atrophy. An evaluation of 104 mandibles and 96 maxillae of dried skulls

A study was carried out on 104 mandibles and 96 maxillae from anthropologic collections to challenge or support the studies of Cawood & Howell (1988, 1991). The data provided reveal considerable individual variations that cast some doubt on the practical use of the classification. It is suggested that the use of individual three-dimensional models will largely replace current modes of depicting resorbed jaws.

[The musculus pectoralis major rib flap. Personal experiences with 7 cases]

We present a report of our experience with one-step reconstruction of the mandible after resection in tumor cases using an osteomyo-cutaneous flap. We performed a pectoralis major flap with a segment of the fifth rib, blood supplied by the periosteum. In seven cases we had one pseudoarthrosis. The complications in the donor site were none. We see in the pectoralis major-rib flap an alternative to microsurgical techniques, especially in patients with defects in the horizontal part of the mandible.

Low-M(r) urokinase-type plasminogen activator as a reporter protein

A reporter plasmid coding for the low-molecular-weight (low-M(r)) form of single-chain urokinase-type plasminogen activator (low-M(r) u-PA; Leu144-Leu411) has been constructed and used to analyze promoter activity. Vectors containing the low-M(r) u-PA cDNA coupled to hormone-responsive promoters were introduced to mammalian cells. Following hormone treatment, the activity of the secreted reporter protein was determined in aliquots of cell culture supernatants. The assay is based on plasminogen activation by low-M(r) u-PA and subsequent cleavage of the plasmin-specific tripeptide substrate, S-2251. The resulting chromophore, p-nitroanilide, was quantified colorimetrically at 405 nm. Transient and stable expression of the low-M(r) u-PA reporter gene in different eukaryotic cells demonstrates the suitability of the system for the quantification of the activity of eukaryotic promoter elements in a rapid and highly sensitive manner, while maintaining cell integrity.

[Primary reconstruction of the mandible with a pedicled muscle and bone transplant--the pectoralis major and rib flap]

The one-step reconstruction of the mandibular after tumor resection with a pedicle flap is reported. We used an osteomyocutaneous flap of teh pectoralis-mayor-muscle with a periosteal vascularized segment of the 5th rip. Our results in 8 cases are demonstrated. Technique and indications are introduced and discussed.

Retroperitoneal sarcoma in a series of 51 adults

Fifty-one patients with retroperitoneal sarcoma underwent surgery at the University Clinics of Hamburg from 1970 to 1988. Malignant schwannoma, liposarcoma and malignant fibrous histiocytoma were the most common histological types. High grade sarcomas (G3) predominated (42%), while 26% were graded G2 and 33% G1. Complete resection was possible in 59% of cases. Reoperation for local recurrence and debulking in case of not completely resectable disease was common. Regional lymph node metastasis was found in 20% of cases. The peritoneum was the preferred location of metastatic spread. All adjuvant chemotherapies were followed by tumour recurrences. After adjuvant radiotherapy three of six patients remained free of disease. In cases of residual tumour we observed few partial responses on chemo- and radiotherapy, and all patients died because of the disease. The mean survival time was 60 months, the 5- and 10-year survival rates were 35% and 15%, respectively. Factors influencing prognosis in univariate analysis included grade, size, resectability, presence of metastatic spread, histological type, microscopic local growth (infiltrative vs intact pseudocapsule of fibrous tissue) and local recurrence. With multivariate analysis grade, size and lymph node metastasis retained their prognostic significance.

[Temporary stabilization of mandibular stumps]

The insertion of bridging plates following mandibular resections is usually complicated by the unphysiological and incorrect axial position of the jaw stumps and by tensions resulting in necrosis of the covering tissues in the area of the reconstructive plate. With the aid of temporary intraoperative pin fixation using a minifixateur (small fixateur from the ASIF armamentarium for hand and forearm surgery) it was possible to maintain the physiological axial position of the jaw stumps during the operation.

Efficacy of funnel-web spider antivenom in human envenomation by Hadronyche species

We describe the envenomation of three patients by Hadronyche versuta, Hadronyche infensa and Hadronyche cerberea (which all are species of funnel-web spider) and the reversal of symptoms by funnel-web spider antivenom. The importance of continuing to administer antivenom until symptoms are reversed is emphasized; all three patients required further doses of antivenom to reverse the symptoms completely. None of the patients had received first aid.

Infraciliature and morphogenesis of Paraholosticha sterkii (Garnjobst, 1934) n. comb. (Ciliophora, Hypotrichida)

The infraciliature and morphogenesis of Paraholosticha sterkii (Garnjobst, 1934) n. comb. (Basionym: Stylonethes sterkii) are described. Before division a cell encysts and after division each tomite forms an individual cyst within the common one. The ciliates cease to move and the kinetome is resorbed. With the beginning of morphogenesis new kinetosomes appear and an oral primordium is formed, where the differentiation of adoral membranelles is visible at an early state. At the same time the anlagen of the marginal rows of cirri, of the undulating membranes and the fronto-ventral complex of cirri develop. After differentiation of the kinetome the tomites hatch. If food is removed P. sterkii forms resting cysts. Encystation and excystation can be induced experimentally. The morphogenesis during excystation is apparently identical to the morphogenesis after division. It is synchronous in 80 to 90% of the cells. Paraholosticha Kahl, 1932 is separated from Keronopsis Penard, 1922 by the possession of transverse cirri. Thus, the species investigated is a typical representative of the genus Paraholosticha.

Combination of 5-fluoro-uracil and Co60 irradiation in the treatment of carcinoma of the oro-facial region. A follow-up investigation of 30 patients

During the years from 1974 to 1977, 30 patients were treated for carcinoma of the oro-facial region with a combination of 5-fluoro-uracil and telecobalt under the care of the Institute of Radiotherapy, Knappschafts-Krankenhaus, Recklinghausen. 13 of these patients were inoperable and had primary irradiation therapy, and the remaining 17 patients were irradiated postoperatively. The main effect that treatment showed was a rapid response in the inoperable tumors, while the 4- to 5-year survival rates of 1:13 of the inoperable cases and 6:17 of the operated patients are in accordance with generally accepted results. The possible radio-biologic relation to this is discussed.

[Possibilities for pain reduction by the prevention of edemas and elimination of endogenous pain producing substances]

The contemporary view of the cause of pain in case of histological lesions is discussed, i.e. the mechanisms of the formation of local high-protein oedemas in connexion with disorders of lymphatic drainage. 295 patients of an oral-surgical department were subjected to a systematic therapeutic study for investigating the possibilities of medicamentously influencing oedema and pain. Tested by way of comparison were a benzopyrone preparation (Venalot) and oxyphenbutazone. A group of control patients could only make use of an analgetic. The assessment of the reduction of oedema was done by means of anthropometric measurements. The analgetic action was judged by the need of analgetics. The result of it was that the benzopyrone preparation possesses a strong analgetic and antioedematous action which also exceeds that of the comparative therapy. The benzopyrones' clinical mechanisms of action are discussed in the light of experimental results.

[Malignant hyperthermia, chronic alcoholism and tubular aggregates (author's transl)]

A 24-year-old chronic alcoholic survived malignant hyperthermia which developed in connection with maxillo-facial operation. Electron-microscopic investigations of muscle biopsies disclosed so called tubular aggregates. The possible relations between these structures and the occurrence of malignant hyperthermia on the basis of an alcoholic myopathy are discussed. People suffering from idiopathic recurrent myoglobinuria have to be regarded as patients-at-risk.