Kai Plambeck

Mucoepidermoid carcinoma of salivary gland origin: classification, clinical-pathological correlation, treatment results and long-term follow-up in 55 patients

Over a period of 30 years, 55 patients with mucoepidermoid carcinomas (MEC) of the salivary glands underwent surgical treatment. Reclassified TNM-stage (Hermanek et al., 1992) at the time of initial diagnosis varied (T0: 0, T1: 26, T2: 20, T3: 2, T4: 7; N0: 49, N1: 4, N2: 2; M0: 53, M1: 2). In 46% (n = 24), the history of symptoms ranged from 6 months to 2 years without any specificity of features. The therapy of choice is a radical ablative surgery of the primary tumour. The resection of the related lymphatic system has to be included in the therapeutic concept in patients suspected of having metastases of the regional lymph nodes. The prognosis is excellent in patients with a localized manifestation of the disease only. Our patients who died for reasons of tumour metastasis had all been classified as stage III or IV at the time initial diagnosis (n = 5). Distant metastases are rarely found even decades after surgical therapy (n = 1). This is why a long-term follow-up is recommended for patients with MEC of the salivary glands.

Interstitial high-dose rate brachytherapy with iridium-192 in patients with oral squamous cell carcinoma

Thirty-four patients with recurrent oral and oropharyngeal carcinomas were treated over a period of 4 years, by interstitial high-dose rate (HDR) brachytherapy (BT) using an iridium-192 source (Gammamed 2i and 12i equipment, Sauerwein, Germany) and fractionated application (1 up to 3 times, weekly recovery phases, single maximum dose 10 Gy). Pretreatment characteristics of patients in terms of irradiation (RT) and surgery differed (22 had external RT alone, with a total dose between 60.0 and 75.6 Gy; RT and surgery: 7; surgery alone: 1). The initial TNM-stages (UICC, Hermanek et al., 1987) of patients were: I = 2, II =3, III = 7, IV = 22. In the majority of cases, clinical indications for HDR-BT included tumour recurrence or progression following external RT, and second primary tumours of the oral cavity. Therapy was successful in most cases, i.e. complete remission: 11, partial remission: 16, no change: 2, progression: 5. Local control and overall survival rates, including patients surgically treated after BT, were at 6 months 58% and 62%, and 44% and 53% at 12 months, respectively. This type of treatment is recommended in patients with local recurrence or second primary tumours after previous external RT in the head and neck region. However, the benefit of interstitial HDR-BT remains questionable, particularly in patients with large tumours and lymph node metastases.

Limitations of B-scan ultrasound for diagnosing fractures of the mandibular condyle and ramus

Abstract The aim of this study was to analyse the applications and limitations of B-scan ultrasonography for diagnosing fractures of the mandibular condyle and ramus. Thirty-two patients with 39 radiologically proven fractures of the mandibular condyle and ramus were in- cluded in the study. The patients were examined with a 7.5 MHz small-part applicator. Five patients without fractures of the facial skeleton acted as controls. Normal sonoanatomical findings had been obtained for patients without mandibular fractures. B-scan ultrasonography enabled the experienced examiner to identify dislocated fractures of the mandibular ramus and the articular process in 67% of the fractures. The main disadvantage of ultrasonography was the inability of this technique to identify non-dislocated fractures. Because of its low sensitivity and specificity, B-scan ultrasonography does not provide an alternative to X-ray diagnosis of mandibular condyle and ramus fractures.

Salvagebehandlung fortgeschrittener Plattenepithelkarzinome der Mundhöhle und des Oropharynx

ZusammenfassungHintergrundEs wurde retrospektiv der Einfluß der interstitiellen High-dose-rate-(HDR-)Brachytherapie mit Iridium 192 auf die lokale Tumorkontrolle und Gesamtüberlebenszeit von Patienten mit fortgeschrittenen, perkutan vorbestrahlten Mundhöhlen- und Oropharynxkarzinomen untersucht.Patienten und Methode38 Patienten mit Plattenepithelkarzinomen der Mundhöhle und des Oropharynx wurden während eines Zeitraums von sieben Jahren (1988 bis 1994) mit der interstitiellen Brachytherapie nach dem HDR-Afterloading-Verfahren (Gammamed® 12i, Iridium 192) behandelt. Die Vorbehandlung von 34 Patienten variierte entsprechend der individuellen Krankheitsverläufe: perkutane Strahlentherapie bei 33 Patienten (60 bis 75,6 Gy), davon bei acht Patienten Bestrahlung und ablative Tumoroperation. Ein Patient war non in sano voroperiert. Vier Patienten waren weder operiert noch perkutan bestrahlt worden. Die Indikationen zur Brachytherapie waren überwiegend Rest- oder Rezidivtumoren nach vorausgegangener externer Strahlentherapie.ErgebnisseDie klinische und morphologische Beurteilung ergab eine komplette Remission in zwölf, eine partielle Remission in 19, keine Veränderung in zwei und einen lokalen Progreß in fünf Fällen. Nach einer mittleren Nachbeobachtungszeit von 15 Monaten betrug die lokale Tumorkontrolle nach sechs Monaten 59% und nach zwölf Monaten 47%. Die Überlebensrate der Patienten nach diesen Zeiten lag bei 81% bzw. 49%.Schlußfolgerung enDie interstitielle Brachytherapie nach dem HDR-Afterloading-Verfahren wird empfohlen für Patienten mit Lokalrezidiven und Zweitkarzinomen von Plattenepithelkarzinomen der Mundhöhle und des Oropharynx, die bereits perkutan bestrahlt worden sind und für die keine erneute perkutane Bestrahlung mehr anwendbar ist. Eine Kombination der interstitiellen Brachytherapie mit chirurgischer Sanierung ist für diese Patienten anzustreben.AbstractPurposeThe clinical effect of high-dose-rate (HDR) interstitial brachytherapy combined with tumor resection was investigated in this retrospective study on patients with recurrent oral and oropharyngeal squamous cell carcinoma.Patients and MethodsOral and oropharyngeal squamous cell carcinoma in 38 patients were treated over a period of 7 years (1988–1994) by HDR interstitial brachytherapy using Gammamed 12i® equipment. Pretreatment of patients in terms of irradiation and surgery differed (33 irradiated with a total dose between 60.0 and 75.6 Gy, including 8 patients with additional surgery; 1 patient with surgery alone, and 4 patients without any pretreatment). Indications for interstitial brachytherapy differed according to individual responses to treatment and medical histories.ResultsInterstitial brachytherapy was successful in the majority of patients, i. e. complete remission: 12, partial remission: 19, no change: 2, progression: 5. Local control and overall survival including patients with surgical treatment was 59% and 81% at 6 months and 47% and 49% after 12 months, respectively.ConclusionInterstitial HDR brachytherapy with Iridium 192 is recommended in patients with local recurrences or second primary carcinomas after previous external radiotherapy in the head and neck region. Combination of interstitial brachytherapy and surgery is preferable for these patients.PURPOSE The clinical effect of high-dose-rate (HDR) interstitial brachytherapy combined with tumor resection was investigated in this retrospective study on patients with recurrent oral and oropharyngeal squamous cell carcinoma. PATIENTS AND METHODS Oral and oropharyngeal squamous cell carcinoma in 38 patients were treated over a period of 7 years (1988-1994) by HDR interstitial brachytherapy using Gammamed 12i equipment. Pretreatment of patients in terms of irradiation and surgery differed (33 irradiated with a total dose between 60.0 and 75.6 Gy, including 8 patients with additional surgery; 1 patient with surgery alone, and 4 patients without any pretreatment). Indications for interstitial brachytherapy differed according to individual responses to treatment and medical histories. RESULTS Interstitial brachytherapy was successful in the majority of patients, i.e. complete remission: 12, partial remission: 19, no change: 2, progression: 5. Local control and overall survival including patients with surgical treatment was 59% and 81% at 6 months and 47% and 49% after 12 months, respectively. CONCLUSION Interstitial HDR brachytherapy with Iridium 192 is recommended in patients with local recurrences or second primary carcinomas after previous external radiotherapy in the head and neck region. Combination of interstitial brachytherapy and surgery is preferable for these patients.

Nachweis von extrazellulärem Matrixprotein (Laminin) in experimentellen arteriellen Anastomosen

Es war das Ziel dieser Untersuchung, den Nachweis von Laminin in experimentellen mikrovaskulären Anastomosen zu führen. Autointerponate (4 mm) der linken A. carotis communis von 20 Wistar-Ratten wurden 4 Wochen nach dem Eingriff nach Perfusionsfixierung immunhistochemisch auf den Nachweis von Laminin untersucht. Es konnte gezeigt werden, daß der Nachweis und das Verteilungsmuster des Laminins die Qualität jeder einzelnen Naht widerspiegelten. Im Bereich der Intima war eine bindegewebsreiche Neubildung v. a. lumenseitig ausgebildet und abhängig vom Abstand und der Vitalität der Gefäßstümpfe. Die Media hatte in ihrer Achsenrichtung die geringste reparative Potenz zur Behebung der Kontinuitätsunterbrechung. Die ausgeprägte Adventitiamanschette war von zirkulär einsprossenden Laminin-positiven Vasa vasorum durchwachsen. Im Anastomosenbereich trat regelmäßig eine myointimale Hyperplasie auf, die die Schichtdicke der Media übertreffen konnte. Die Untersuchungen belegen die Forderung nach einer atraumatischen mikrovaskulärchirurgischen Nahttechnik. To investigate the distribution of Laminin in experimental microvascular surgery. Autografts (4 mm) of the left common carotid artery in 20 Wistar rats were harvested after 4 weeks. The specimens were investigated immunohistochemically for the demonstration and distribution of Laminin. The demonstration and distribution pattern of Laminin was a function of the accuracy of each single suture. In the intima, the organisation and amount of Laminin was directed to the lumen and dependent from the distance and vitality of the vessel segments’ cells. The media had in its axis direction the lowest reparative potency to regenerate the continuity break. The adventitia formed a thick cuff around the anastomosis, which was circularly grown through with Laminin-positive vasa vasorum. The marked myointimal hyperplasia in the area around the anastomosis and in the entire autograft was constituted of Laminin-positive extracellular matrix. Our results support the demand for a careful and atraumatic suture technique in microvascular surgery.

Einsatz von Autointerponaten nach akuter Schädigung der Arteria carotis communis

The objective of our investigation was to study the patency rates of anastomoses in arteries, damaged by a balloon dilatation, in a training model of microvascular surgery. In general anaesthesia, a balloon dilatation was repeated 5 times in 31 left common carotid arteries of female Wistar rats (body weight: 250 to 350 g). A common carotid artery autograft of 4 mm was harvested 1 minute after reflow, turned 180 degrees, and reinserted into the artery. The reflow of the vessels was investigated by micro-Doppler ultrasound equipment. Autografts without balloon dilatation or any other intended damage were performed in further 26 common carotid arteries. In addition, in further 14 common carotid arteries the balloon dilatation was the sole damage. The vessels were harvested and investigated postoperatively after perfusion with 3% glutaraldehyde at 1 day, 7 days, and 1 month. The balloon dilatation in no instance caused an occlusion of the vessel as judged by the micro-Doppler ultrasound. One vessel was found to be occluded after reflow was allowed following insertion of the autograft in the group without balloon dilatation. However, this vessel proved to be patent after explantation (patency rate: 100%). In the group with balloon dilatation preceding the autograft insertion, by micro-Doppler ultrasound, 16 vessels were occluded and 14 were patent. At different times of follow-up, in this group the summarized patency rates were 50%. The patency differences in both groups with autografts proved to be significant, both after micro-Doppler imaging and by histological evaluation (p < 0.001). For clinical use the balloon dilatation is recommended to remove a thrombus or to dilate a spastic vessel segment in anastomized vessels threatening the success of microvascular flaps. In this training model of microvascular surgery we demonstrated the thrombogenic effect of balloon dilatation.ZusammenfassungDie Durchgängigkeit experimentell vorgeschädigter und mikrovaskulär anastomosierter Arterien wurde an einem Übungsmodell der Mikrovaskularchirurgie untersucht. Von 31 Wistar-Ratten (250 bis 350 g) wurde die linke Arteria carotis communis in Allgemeinanästhesie mit einem 2F-Ballonkatheter dilatiert. Danach wurde ein 4 mm langes Segment der Arteria carotis communis entnommen und nach Drehung um 180° reinseriert. Zum Vergleich wurden an 26 Arteriae carotis communes Interponate ohne intendierte Vorschädigung der Arterien durchgeführt. Bei weiteren 14 Arterien wurde nur eine Ballondilatation vorgenommen. Die Durchgängigkeit der Arterien wurde intravital mittels Mikro-Doppler-Sonographie (20 MHz) und histologisch zu unterschiedlichen Nachuntersuchungszeiten (Perfusionsfixierung) bestimmt. Die Ballondilatation als einzige schädigende Maßnahme führte zu keinem Gefäßverschluß. Wurde die Ballondilatation vor der Insertion des Gefäßsegmentes vorgenommen, resultierten in der Hälfte der Gefäße definitive Gefäßverschlüsse. Interponate ohne Vorschädigung waren zum Zeitpunkt der Perfusion in allen Fällen durchgängig. Die Unterschiede der Durchgängigkeitsraten zwischen beiden Untersuchungsgruppen waren für beide Untersuchungsmethoden signifikant (p<0,001). Für die klinische Anwendung ist die Ballondilatation zur Entfernung von Thromben mikrovaskulärer Anastomosen oder zur Dehnung von Gefäßspasmen empfohlen worden. In diesem Übungsmodell mikrovaskulärer Anastomosen konnte eindeutig der thrombogene Einfluß der Ballondilatation auf die Durchgängigkeitsrate mikrovaskulärer Interponate nachgewiesen werden.AbstractThe objective of our investigation was to study the patency rates of anastomoses in arteries, damaged by a balloon dilatation, in a training model of microvascular surgery. In general anaesthesia, a balloon dilatation was repeated 5 times in 31 left common carotid arteries of female Wistar rats (body weight: 250 to 350 g). A common carotid artery autograft of 4 mm was harvested 1 minute after reflow, turned 180°, and reinserted into the artery. The reflow of the vessels was investigated by micro-Doppler ultrasound equipment. Autografts without balloon dilatation or any other intended damage were performed in further 26 common carotid arteries. In addition, in further 14 common carotid arteries the balloon dilatation was the sole damage. The vessels were harvested and investigated postoperatively after perfusion with 3% glutaraldehyde at 1 day, 7 days, and 1 month. The balloon dilatation in no instance caused an occlusion of the vessel as judged by the micro-Doppler ultrasound. One vessel was found to be occluded after reflow was allowed following insertion of the autograft in the group without balloon dilatation. However, this vessel proved to be patent after explanation (patency rate: 100%). In the group with balloon dilatation preceding the autograft insertion, by micro-Doppler ultrasound, 16 vessels were occluded and 14 were patent. At different times of follow-up, in this group the summarized patency rates were 50%. The patency differences in both groups with autografts proved to be significant, both after micro-Doppler imaging and by histological evaluatio (p<0.001). For clinical use the balloon dilatation is recommended to remove a thrombus or to dilate a spastic vessel segment in anastomized vessels threatening the success of microvascular flaps. In this training model of microvascular surgery we demonstrated the thrombogenic effect of balloon dilatation.

Stellenwert der B-Bild-Sonographie in der Frakturdiagnostik des Gelenkfortsatzes des Unterkiefers

Ziel dieser Untersuchung war, den Stellenwert der B-Bild-Sonographie im Vergleich zur Röntgendiagnostik für die Diagnostik der Gelenkfortsatzfrakturen des Unterkiefers zu bestimmen. Es wurden 32 Patienten mit ¶39 Frakturen des Gelenkfortsatzes des Unterkiefers B-Bild-sonographisch und konventionell radiologisch untersucht. Die Sonographie hatte mit einer Rate von 67% richtig-positiven Frakturdiagnosen eine nur mäßige diagnostische Treffsicherheit. Insbesondere sind Diastasen, Achsabknickungen und interponierende Weichgewebe in den Frakturspalt sonographisch erkennbar. Radiologisch wurden alle Frakturen nachgewiesen. Trotz der oberflächennahen Lage des Unterkiefergelenkfortsatzes ergaben sich aufgrund der Charakteristik des Sonogramms, nur die laterale Fläche des Gelenkfortsatzes ausschnittsweise darzustellen, der beschränkten Applikationsfläche des Schallkopfs in diesem Bereich mit der Folge fehlender übersichtlicher Darstellung des Knochens in 2 senkrecht zueinander stehenden Ebenen und der in eigenen Untersuchungen limitierten Frequenzauswahl erhebliche Schwierigkeiten in der Interpretation der Befunde (Verlaufskontrolle, Differenzialdiagnose des Kapselrisses, fehlende Identifizierung nicht dislozierter Frakturen). Die Sonographie eignet sich nur sehr eingeschränkt als Untersuchungstechnik für Gelenkfortsatzfrakturen des Unterkiefers, ¶z. B. für Patienten, die eine Röntgenuntersuchung verweigern. In diesen Fällen ist eine Aufklärung über die engen Grenzen der Aufnahmetechnik erforderlich.The aim of this study was to analyse the value of B-scan ultrasonography in the diagnosis of mandibular condylar fractures. A total of 39 condylar fractures of the mandible in 32 patients were investigated by means of ¶B-scan ultrasound and standard X-ray projections. In 67% of positive cases ultrasound imaging enabled correct diagnosis of the fracture. Diastasis of fragments, deviations of the axis, and interposition of soft tissues into the fracture line were identified by B-scan ultrasonography. X-ray diagnosis confirmed all fractures. Despite the close topographic relation of the condyle to the covering skin, the imaging of the these fractures by ultrasound was impaired. There are various reasons for this. The first is that the transducer head can be applied to only a limited facial area (small diagnostic window) to image the region of interest. This means that ultrasonographs of the bone surface in two planes are not possible. Secondly, since ultrasound is used for diagnostic reasons at a frequency of 7.5 MHz, imaging of the fracture line is limited to the lateral aspect of fractures, i. e. the bone surface. The course of the fracture lines to the lingual surface was highly variable. In addition, the complete course of the fracture line could not be visualized by ultrasound in cases with a fracture in the sagittal plane. These are the reasons why in the case of condylar fractures of the mandible decisions on therapy cannot safely be made on the basis of ultrasound alone. Ultrasonographic imaging of mandibular condylar fractures is not the diagnostic tool of choice in this entity. It can be applied in patients refusing X-ray diagnosis, but it is mandatory to inform these patients about the limitations of B-scan ultrasonographic diagnosis in mandibular condylar fractures.