Gerhard Böhm

Closure of bronchopleural fistula after pneumonectomy with a pedicled intercostal muscle flap

OBJECTIVES The value of the pedicled intercostal muscle flap for the closure of postpneumonectomy bronchopleural fistulas was studied retrospectively. METHODS Bronchopleural fistula was suspected in case of fever, cough, putrid or haemorrhagic expectoration, in combination with a rise of WBC and CRP. Fistula diagnosis was established bronchoscopically. Two patients underwent an initial trial of bronchoscopic sealing, the rest were reoperated immediately after fistula diagnosis. Immediately after operation antibiotic irrigation according to culture sensitivity was started via a single chest tube drainage twice a day. After instillation of antibiotics the drain was kept clamped for 3 h. Culture samples were obtained twice a week. Empyema was considered eradicated, if three subsequent cultures showed no bacterial growth. After drain removal the patients were kept in hospital for another week and observed for clinical signs of infection, WBC and CRP were controlled. Age, side, sex, histology, TNM-stage, duration of hospital stay after fistula diagnosis (days), duration of treatment (defined as the duration of chest tube drainage in days after operation), total hospital stay (including the initial hospital stay for primary resection and the hospital stay for fistula treatment in case of readmission), fistula size (mm), interval (days) between primary operation and fistula formation, and bacteriology were recorded. RESULTS Eight patients (seven male) were treated. Age ranged from 46 to 70 years (mean 57.86). Six fistulas were located on the right side. All patients had non small cell lung cancer. Interval ranged from 2 to 72 days (mean 26.9 days). Fistula size ranged from 1 to 7 mm (mean 3.43). Seven fistulas were successfully closed. Duration of treatment lasted from 15 to 28 days in those patients treated successfully (mean 17). Hospital stay ranged from 15 to 31 days (mean 24.4). In one patient the flap became necrotic, he was successfully treated with total thoracoplasty. One patient died on the 38th day after rethoracotomy due to aspiration pneumonia. At postmortem examination the bronchial stump was closed. CONCLUSION The use of the pedicled intercostal muscular flap is an efficient method for the closure of bronchopleural fistula after pneumonectomy.

Glyco- and immunohistochemical refinement of the differential diagnosis between mesothelioma and metastatic carcinoma and survival analysis of patients.

The aim of this study was to analyse the diagnostic value of selected glyco‐ and immunohistochemical probes for discrimination between mesotheliomas and metastatic carcinomas within the pleura, and to evaluate prognostic indicators in the tested panel. A panel of nine markers (five antibodies, two neoglycoproteins, and labelled hyaluronic acid) was applied to a total of 264 specimens with mesotheliomas (118 cases) and metastatic carcinomas in the pleura (146 cases); the material consisted exclusively of surgical specimens. The diagnosis obtained by standard procedures was further substantiated through a detailed follow‐up and clear‐cut descriptions of primary sites. The metastatic tumours originated from the lung (82 cases), breast (47 cases), colon (three cases), and kidney (two cases); in 12 cases, however, the tumour origin could not be ascertained. In detail, the probes tested included antibodies against carcinoembryonic antigen (CEA), vimentin, calretinin, mesothelial cells (HBME‐1), calcyclin and keratin‐5; and also biotinylated neoglycoproteins with ganglioside GM1 and N‐acetyl‐D‐glucosamine (GlcNAc) as the ligand part, and hyaluronic acid. Carrier‐immobilized ganglioside GM1 and hyaluronic acid displayed the highest specificity and sensitivity for mesotheliomas, followed by calretinin and HBME‐1, whereas keratin‐5 and vimentin were of low specificity (43% and 52%, respectively). Metastatic carcinomas could be discerned by CEA detection and application of GlcNAc‐bearing neoglycoprotein with similar sensitivity (76% and 72%, respectively) and specificity (91% and 86%, respectively). In cases of breast carcinoma, the maximum specificity (59%) and sensitivity (67%) were low for all markers. Patients with mesothelioma survived longer than those with metastatic carcinoma, especially those with detectable binding sites for hyaluronic acid. No association of tumour type and binding properties of the other applied probes with survival of the patients could be found at a statistically significant level. It is concluded that in routine practice, the application of carrier‐immobilized GM1, hyaluronic acid, and antibodies against calretinin and HBME‐1 is useful for confirmation of mesothelioma, whereas the detection of CEA and GlcNAc‐specific binding sites is useful for distinguishing metastatic carcinoma from mesothelioma. Despite the rather infrequent occurrence of mesotheliomas in women, particular attention should be given to exclude or confirm metastatic breast carcinoma in cases of unknown history or long metastatic interval. Copyright

Reactions of surrounding tissue to the cementless hip implant Ti-6Al-4V after an implantation period of several years

SummaryThree femoral endoprosthetic stems implanted without cement, made off Ti-6Al-4V alloy, with implantation periods of between 2 and 4 years were examined histologically in the form of undecalcified thin ground sections after having been split into segments and embedded in plastic. During the implantation period total osseointegration in the metadiaphyseal region takes place, while in the proximal area reaction forms with direct contact between metal and bone on the one hand and with an interposed membrane of connective tissue and adjacent secondary bony shell on the other must be distinguished. The osseointegration of the stem is the result of a primary healing of the bone and is due to the biocompatibility of the metal alloy and to the primary stability obtained by the press-fit method.

Randomized In Vitro and In Vivo Evaluation of Different Biopsy Needles and Devices for Breast Biopsy

In an experimental study (in vitro and in vivo) we evaluated the efficacy of various biopsy needles/devices for breast biopsy. In vitro, biopsies of five human cadaveric breast specimens were performed using 33 different needles/devices ranging from 14 to 20-gauge. Of these 33 needles/devices, 22 optimally performing needles were selected for the in vivo study. In the clinical part of the study, 44 breast lesions were randomly biopsied with each of the 22 needles/devices under stereotactic guidance. Tissue specimens were analysed quantitatively and qualitatively. Several automatic long-throw guns (Acecut, Asap, Biopty, Magnum) obtained greater tissue areas and had a better histopathologic score than the conventional type of a side-notch needle like Trucut, an aspiration needle like Surecut, or an end-cut needle like Autovac. The automatic long-throw guns performed better than the short-throw Monopty gun. Regardless of needle size (14-20-gauge), breast biopsies should be routinely performed with automated long-throw side-notch guns (Acecut, Asap, Biopty, Magnum).

Multiple endometrial stromal nodules with sparce cysts and glands in the lung – A nodular variation of endometriosis that may mimic metastases of sarcoma

We report an unusual case of a nodular variation of pulmonary endometriosis. To our knowledge, there is no previous report on a morphological investigation of this entity. The etiology of this rare condition is still a matter of discussion. The well-circumscribed nodular mass is composed of cells identical to, or closely resembling, those of endometrial stroma containing sparse cysts and glands. Immunohistochemically, the cells showed an extensive co-expression of cytokeratin AE1/AE3 and vimentin and were highly positive for progesterone receptor (PRICA) and estrogen receptor (ERICA). Cells lining the cysts and glands as a monolayer were reactive for Ber-Ep4, cytokeratin Pan and cytokeratin AE1/AE3 and negative to all other markers used including PRICA and ERICA. The differential diagnosis of this entity included fibrous tumor of the pleura and metastatic low-grade-endometrial-stromal-sarcoma. The morphological findings are correlated with immunohistochemical studies and results of cell image analysis. This study details the clinicopathological features of the nodular variation of pulmonary endometriosis.

Developmental regulation of presence of binding sites for neoglycoproteins and endogenous lectins in various embryonic stages of human lung, liver and heart

Protein-carbohydrate interactions are supposed to play key roles in the mechanisms of cell adhesion, biosignalling and intracellular routing, warranting the analysis of the developmental course of expression of epitopes of this system. Thus, a panel of carrier-immobilized carbohydrate ligands was used as probes, namely lactose,N-acetylgalactosamine,N-acetylglucosamine, mannose, fucose and maltose. Additionally, an antibody to an endogenous β-galactoside-binding lectin (anti-galectin-1), the biotinylated lectin and two further human lectins, namely the macrophage migration inhibitory factor-binding sarcolectin and serum amyloid P component (SAP) that displays selectivity for sulphated sugars and mannose-6-phosphate, were included. They enabled us to assess the extent of the presence of respective binding sites in fixed sections from human lungs (pulmonary epithelial cells), livers (hepatocytes) and hearts (myocard cells) of 10–50 weeks gestation. Invariably, specific binding was detected in the three organ types, at least in certain stages. In most of the cases, the intensity of staining exhibited developmental regulation. The apparent patterns reveal similarities between the different cell types, as seen with immobilizedN-acetylglucosamine as well as with labelled galectin-1 and sarcolectin. However, drastic differences among such patterns with nearly opposite developmental courses do also occur, as detected for carrier-attached mannose and maltose residues. These results point to a potential importance for the detected glycohistochemical features in human development and substantiate the possibility of differential regulation of the presence of binding sites for distinct sugars within a certain organ and between the individual cell types of the monitored organs.

Experimental study of bone-implant contact with a parabolic acetabular component (Hofer-Imhof)

Abstract Incomplete bone contact with threaded acetabular components is usually attributable to the tapered thread design and sclerotic bone, and might be the reason for early loosening. The self-tapping flat threads of the Hofer-Imhof cup allow accurate insertion without incarceration, even in sclerotic bone. To demonstrate the effectiveness of this threaded cup design based on digitized measurements of bone contact area, six Hofer-Imhof cups were implanted into three human cadavers. The bone contact area at the threads was digitally analyzed on cadaver-explanted cups cut into horizontal and coronal sections. In cups fixed with ideal form fit, bone contact was 31.6% (range 8–55%) at the threads and 28.5% (range 0–49%) between the threads on average. In cups with incomplete bone contact secondary to insufficient reaming, the bone contact area averaged 27.4% (range 10–44%) at the threads. In sclerotic bone, the highest bone contact at the threads was 69%. The threads were the first part of the cup to achieve primary bone contact. Factors contributing to poor contact were incomplete reaming, sections which passed through the incisura of the acetabulum, and incomplete contact with the medial aspect of the acetabulum. The aim was to achieve complete bone contact. Because of the higher contact areas observed in sclerotic bone, some sclerotic bone should remain after reaming.

Morphometric analysis of cartilaginous tumors

144 chondromas and chondrosarcomas have been investigated. Morphometry has been performed: the relative volume density of tumor cell nuclei (Vv%n) and the nuclear area have been measured. The results show that the relative volume density of nuclei is a useful parameter, regarding the localisation of the tumors, to discriminate chondromas and chondrosarcomas, while the nuclear area is no safe criterion to separate these entities.