J. Hoffmann

Orbital reconstruction with individually copy-milled ceramic implants

Diagnostic advances such as computed tomography and new surgical techniques have dramatically improved both the functional and aesthetic outcome of orbital reconstructions. Taking a further approach, we designed ceramic implants (Bioverit) on the basis of stereolithographic models. After copy milling a resin template with a commercially available dental unit (Celay), the prefabricated implants were inserted for reconstruction of the lamina papyracea (n = 1), zygomatic complex (n = 2), infraorbital floor (n = 5), and rim (n = 3). Intraoperatively, only slight modifications of the implants had to be performed. The results were encouraging, as all cases showed a good aesthetic and functional postoperative outcome. Preoperative evaluation of the osseous defect and prefabrication of the required implant reduced operating time and patient morbidity significantly.

Relevance of SCC-Ag, CEA, CA 19.9 and CA 125 for diagnosis and follow-up in oral cancer

The prognosis of oral cavity carcinoma is limited by recurrent disease or lymph node metastasis. Secondary to surgery and radiotherapy, anatomical structures are often severely changed and make early diagnosis of renewed tumour growth by clinical and radiological examination difficult. We studied the course of serum SCC-Ag, CEA, CA 19.9 and CA 125 in 121 patients with untreated squamous cell carcinoma of the head and neck (SCCHN) before and after therapy and evaluated their relevance for diagnosis and follow-up in oral cancer. CA 19.9 and CA 125 seemed to be useless for this tumour entity. CEA resembled more the alcohol consumption and smoking habits of the patients examined than their state of disease. Only SCC-Ag correlated with the tumour burden and represented the disease course. In the event of relapse, half the patients had an exponential increase in SCC-Ag, 1-2 months prior to diagnosis.

Classifying breast cancer surgery: a novel, complexity-based system for oncological, oncoplastic and reconstructive procedures, and proof of principle by analysis of 1225 operations in 1166 patients

BackgroundOne of the basic prerequisites for generating evidence-based data is the availability of classification systems. Attempts to date to classify breast cancer operations have focussed on specific problems, e.g. the avoidance of secondary corrective surgery for surgical defects, rather than taking a generic approach.MethodsStarting from an existing, simpler empirical scheme based on the complexity of breast surgical procedures, which was used in-house primarily in operative report-writing, a novel classification of ablative and breast-conserving procedures initially needed to be developed and elaborated systematically. To obtain proof of principle, a prospectively planned analysis of patient records for all major breast cancer-related operations performed at our breast centre in 2005 and 2006 was conducted using the new classification. Data were analysed using basic descriptive statistics such as frequency tables.ResultsA novel two-type, six-tier classification system comprising 12 main categories, 13 subcategories and 39 sub-subcategories of oncological, oncoplastic and reconstructive breast cancer-related surgery was successfully developed. Our system permitted unequivocal classification, without exception, of all 1225 procedures performed in 1166 breast cancer patients in 2005 and 2006.ConclusionBreast cancer-related surgical procedures can be generically classified according to their surgical complexity. Analysis of all major procedures performed at our breast centre during the study period provides proof of principle for this novel classification system. We envisage various applications for this classification, including uses in randomised clinical trials, guideline development, specialist surgical training, continuing professional development as well as quality of care and public health research.

Hematogenous and lymphatic tumor cell dissemination may be detected in patients diagnosed with ductal carcinoma in situ of the breast

Tumor cell dissemination in bone marrow (BM) and lymph nodes is considered an important step in systemic disease progression and is associated with poor prognosis. Only invasive cancers are assumed to shed isolated tumor cells (ITC) into the bloodstream and infiltrate lymph nodes. However, latest studies indicate that tumor cell dissemination may occur before stroma invasion, i.e., in ductal carcinoma in situ (DCIS). Therefore, the purpose of this study was to examine the incidence of ITC in bone marrow and sentinel lymph nodes (SN) in patients diagnosed with DCIS and its correlation with clinicopathological factors. 266 patients who were treated at the Department of Gynecology and Obstetrics (University Hospital Tuebingen, Germany) between 2003 and 2009 with DCIS were included into this study. BM aspirates were analyzed by immunocytochemistry (pancytokeratin antibody A45-B/B3) using ACIS system (Chromavision) according to the ISHAGE evaluation criteria. SN were analyzed in 221 of these patients by extensive step sectioning and hematoxylin–eosin staining. In 34 of 266 patients (13%), ITC in BM could be detected. There was no correlation found between tumor size, grading, histology, or Van Nuys Prognostic Index and tumor cell dissemination. In two cases, metastatic spread into lymph nodes was observed (pN1mi), whereas in one case, ITC in lymph nodes were detected; however, additional sectioning and immunohistochemical staining of the primary lesion in the cases with positive SN did not reveal invasive cancer. Interestingly, all the three patients were BM negative. Tumor cell dissemination may be detected in patients diagnosed with DCIS. Either these cells have started already to disseminate from preinvasive mammary lesions or from occult invasive tumors or represent the earliest step of microinvasion in a preinvasive lesion. The clinical relevance of these cells has to be further evaluated.

Temporary intermaxillary fixation using individualized acrylic splints permits image-data-based surgery of the lower jaw and oropharynx

Objectives/Hypothesis: Image–data‐based surgical navigation is used as a helpful device in the operating room to localize critical structures with a high degree of accuracy. It also enables physicians to plan therapeutic performance. Because it relies on preoperatively acquired computed tomography (CT) or magnetic resonance imaging (MRI) data, there is restricted access for navigation of surgical instruments in areas that show motion uncorrelated with radiologic data. Thus, in the case of moveable structures, for example the lower jaw, navigational procedures could not yet be applied.

The HER2 status of disseminated tumor cells in the bone marrow of early breast cancer patients is independent from primary tumor and predicts higher risk of relapse

Overexpression of the HER2-receptor in early breast cancer (EBC) patients is associated with aggressive tumor behavior. However, women suffering from HER2-positive EBC benefit from trastuzumab treatment. As the HER2 status of the primary tumor may differ from that of disseminated tumor cells (DTC) in bone marrow (BM), the aim of this study was (1) to compare the HER2 status of the primary tumor (prim-HER2-status) with that of DTC (DTC-HER2-status) and (2) to analyze the influence of the DTC-HER2-status on patient survival. For this purpose, BM aspirates from 569 EBC patients were analyzed for the presence of DTC. The DTC-HER2-status was identified by a double-staining procedure against cytokeratin and the HER2-receptor. DTC were detected in 151 (27xa0%) patients. The concordance between the HER2 status of DTC and the primary tumor was 51xa0%. In patients with detectable DTC, mean disease-free survival was 77.44 (95xa0% CI 74.72–80.17) months for DTC-HER2-negative and 55.15 (95xa0% CI 48.57–61.79) months for DTC-HER2-positive patients (pxa0=xa00.044). The multivariate analysis showed that the DTC-HER2-status was an independent predictor of disease-free survival. In conclusion, the presence of HER2-positive DTC in EBC patients is associated with an increased risk of relapse. Due to the low concordance between the HER2 status of the primary tumor and DTC, only a minority (13xa0%) of the DTC-HER2-positive patients was treated with trastuzumab. These patients might, however, benefit from HER2-directed therapy.

Complications after microsurgical tissue transfer in the head and neck region

In recent years, the use of microsurgically re-anastomosed free transplants has become a proven technique for the reconstruction of defects in the head and neck region, which is demanding from both aesthetic and functional points of view. A retrospective catamnestic study on 227 free tissue transfers in the Department for Oral and Maxillofacial Surgery at the University of Tübingen showed good healing with relatively low failure rates of the transplants used. A significant proportion of local complications, arising postoperatively, was to some degree due to pre-existing medical conditions, tumour-specific pretreatments and the particular wound-healing situation found in head and neck interventions. The highest relative rate of complications at the site of origin was seen amongst osteomuscular transplants (20%) whilst (fascio) cutaneous and visceral transplants were found to result in a low percentage of problems (4%). In contrast, the healing of iliac crest transplants was accompanied by various local complications in 12% of the cases, slightly higher than 20% amongst (fascio) cutaneous and abdominal transplants and well above 30% for latissimusdorsi and scapular transplants. General complications, in particular of a respiratory and/or psychiatric nature, were found in 23% of the patients.

Möglichkeiten der intraoperativen Diagnostik mit einem fahrbaren Computertomographen

Hintergrund. Computertomographische Untersuchungen erlauben eine v. a. im Kopf- und Halsbereich bedeutsame überlagerungsfreie Darstellung anatomischer Strukturen. In der Regel genügt eine präoperative Untersuchung zur Beurteilung des Ausgangszustands, bei bestimmten Indikationen ist jedoch eine intraoperative Kontrolle des Behandlungserfolgs wünschenswert. Methode. Wir beurteilten die Möglichkeiten der Untersuchung mit Hilfe des fahrbaren Computertomographen Tomoscan M (Philips Medical Systems, Eindhoven, NL). Dieses auf Rollen gelagerte Gerät kann aufgrund seiner in, bezogen auf die Körperachse des Patienten, axialer Richtung durchführbaren Bewegung der Gantry in Kombination mit den meisten Operationstischen eingesetzt werden. Als Stromversorgung genügt eine reguläre Stromzuführung (220 V, 20 A). Patienten und Ergebnisse. Der fahrbare Computertomograph kam an unserer Klinik bislang in 6 Fällen für die intraoperative Diagnostik ausschließlich traumatologischer Eingriffe zum Einsatz. In diesen ausgewählten Fällen erlaubte die intraoperative Schichtbildgebung eine sehr gute Kontrolle der Fragmentstellung nach Reposition. Insbesondere aus strahlenhygienischen Gründen kann keine mehrfache Kontrolle des Behandlungserfolgs stattfinden. Die Gantry ermöglichte eine ausschließlich axiale Schichtführung, eine sekundäre koronare Rekonstruktion war nur mit hohem Zeitaufwand und unzureichender Bildqualität durchführbar. Schlussfolgerungen. Die Verwendung überlagerungsfreier Schichtbilder hat sich zur intraoperativen Kontrolle des Therapieergebnisses bewährt. Jedoch rechtfertigt der hohe technische Aufwand bei eingeschränktem Indikationsspektrum keine routinemäßige Verwendung dieser Methode. Aims. The possibility of performing intraoperative computed tomography may add to the safety and efficiency of some maxillofacial procedures. It would be preferable for intraoperative image data acquisition to be available to a surgeon on demand for immediate control of therapy results. Methods. In a pilot study, the use of a mobile computed tomographic scanner (Philips Tomoscan M, Philips Medical Systems, Eindhoven, Netherlands) was evaluated in our unit. The scanner is equipped with wheels, draws power from wall outlets in combination with batteries, and has a translating gantry. Results. Experience to date with six patients has confirmed the feasibility of intraoperative CT. All patients operated on were treated for craniofacial trauma. The CT images showed good spatial resolution. In all cases, visualization of the correct fragment position was excellent without causing significant delay of the operative procedure. Conclusions. Intraoperative computed tomography could be the new state-of-the-art method for direct control of treatment results in maxillofacial traumatology. Nevertheless, the high expenses for installation of such technical infrastructure has to be pointed out; therefore, the routine use of this technique might be questioned.

Interdisziplinäres Konzept zur Diagnostik und Therapie gefäßreicher Fehlbildungen im Gesichts- und Halsbereich

Fragestellung. Patienten mit gefäßreichen Fehlbildungen im Kopf- und Halsbereich stellen Mund-, Kiefer- und Gesichtschirurgen, Dermatologen und interventionelle Radiologen in vielen Fällen vor schwierige therapeutische Entscheidungen. Wir stellen ein Konzept der interdisziplinären Klassifikation der Befunde und der Therapie dieser Patienten vor. Methoden und Patienten. Die Klassifikation unterscheidet zwischen Hämangiomen als proliferierenden Neubildungen und vaskulären Malformationen als anlagebedingten Fehlbildungen. Nach Hämodynamik und Gefäßbett werden Letztere in langsam durchströmte, kapillare, venöse oder lymphatische Malformationen und in rasch durchflossene, arterio-venöse (a. v.) Malformationen unterteilt. Seit Anfang des Jahres 2000 werden Patienten mit ausgeprägter Manifestation entsprechender Veränderungen in einer interdisziplinären Sprechstunde betreut. Die klinische Untersuchung wird bei Patienten mit Hämangiomen und venösen Malformationen durch die farbkodierte Duplexsonographie und Magnetresonanztomographie ergänzt, die Angiographie bleibt der Therapieplanung bei a.-v.-Malformationen vorbehalten. Hämangiome werden, in Abhängigkeit von ihrer Wachstumsdynamik, kryo- oder laserchirurgisch, medikamentös oder chirurgisch therapiert. Bei venösen Malformationen erfolgt vor einer geplanten Resektion eine perkutane Sklerosierung; a.-v.-Malformationen werden vor einer möglichst vollständigen Exzision transarteriell embolisiert. Ergebnisse. Im Untersuchungszeitraum wurden 73 ausgewählte Patienten betreut, darunter 53 Patienten mit Gesichtshämangiomen, 7 Patienten mit venösen Malformationen, 2 mit kapillaren Malformationen und 5 mit lymphatischen Malformationen. Bei 6 Patienten lagen rasch durchflossene a.-v.-Malformationen vor. Schlussfolgerungen. Das interdisziplinäre Vorgehen erleichtert die Diagnosestellung und ermöglicht es den beteiligten Abteilungen, v. a. für Patienten mit ausgeprägten vaskulären Fehlbildungen individualisierte Therapiepläne zu erstellen. Purpose. In patients with extended vascular anomalies in the head and neck, therapeutic decisions may pose a challenge to maxillofacial surgeons, dermatologists, and interventional radiologists. We analyzed the value of an interdisciplinary classification and treatment concept. Patients and methods. The classification distinguishes hemangiomas and vascular malformations. Whereas hemangiomas are endothelial proliferations, vascular malformations are considered to be developmental anomalies, which are further classified into high-flow or low-flow lesions and according to the vascular channels into capillary, venous, or lymphatic malformations. Since 2000 we have provided interdisciplinary consultation for patients with vascular anomalies. In patients with hemangiomas and venous malformations, the clinical diagnosis is confirmed by color-coded duplex sonography and magnetic resonance imaging; angiography is performed as part of the treatment planning for patients with arteriovenous malformations. Patients with hemangiomas are treated surgically by cryosurgery or laser surgery or conservatively according to lesion size and behavior. In patients with venous malformations, percutaneous sclerotherapy is combined with surgical reduction; patients with arteriovenous malformations undergo transarterial embolization prior to surgical excision of the nidus. Results. A total of 73 patients attended the interdisciplinary consultation. This group included 53 patients with facial hemangiomas, 7 with venous malformations, 2 with capillary malformations, 5 with lymphatic malformations, and 6 with high-flow arteriovenous malformations. Conclusions. The interdisciplinary protocol increases diagnostic accuracy and helps to establish individual treatment plans for patients with extended vascular anomalies.

Cystosarcoma phyllodes of the breast: a rare diagnosis: case studies and review of literature

Cystosarcoma phyllodes (CP), otherwise known as phyllodes tumour (PT) of the breast, is a very rare but locally aggressive fibroepithelial tumour in its malignant form, and accounts for 0.3–1% of all breast neoplasias. Using 4 cases reports with different histological classifications as examples (benign—borderline—malignant), we describe the (differential) diagnosis and treatment options of this tumour entity and give an additional review of the available literature.