Wulf Siggelkow

Histological analysis of silicone breast implant capsules and correlation with capsular contracture

BACKGROUND A study was undertaken to investigate long-term histological changes in the environment of breast implants and their correlation with complains at the time of capsular contracture defined by the Baker score. METHOD The collagenous capsules of 53 silicone breast implants from 43 patients (23 smooth and 30 textured devices) were evaluated histologically for capsular thickness, the presence of histiocytes, the amount of silicone and calcification in the capsule, and the presence of synovial-like metaplasia of the inner surface of the capsule with light microscopy and polarised light. All parameters were correlated with the Baker score. RESULTS A significantly higher degree of the Baker score was found with increasing patient age (p<0.001), implant duration (p<0.02), and capsular thickness (p<0.009). A trend towards greater capsular thickness was documented in patients who had a breast augmentation for cosmetic reasons. Synovial-like metaplasia was seen in 28 capsules (52.8%). The highest incidence was found in textured implants with a duration of less than 5 years. Histiocytic inflammation was more common in patients with clinical symptoms (p<0.001) and around subglandular implants (p<0.096). CONCLUSIONS The histological findings of breast capsules were related to: the nature of the device surface (smooth versus textured), implant duration, and the degree of capsular contracture. Capsular contracture (Baker score of 3 or 4) was related to implant duration, capsule thickness, patient age, and inflammation.

Prognostic Effect of Epithelial Cell Adhesion Molecule Overexpression in Untreated Node-Negative Breast Cancer

Purpose: Epithelial cell adhesion molecule (Ep-CAM) recently received increased attention not only as a prognostic factor in breast cancer but also as a potential target for immunotherapy. We examined Ep-CAM expression in 402 consecutive node-negative breast cancer patients with long-term follow-up not treated in the adjuvant setting. Experimental Design: Ep-CAM expression was evaluated by immunostaining. Its prognostic effect was estimated relative to overexpression/amplification of HER-2, histologic grade, tumor size, age, and hormone receptor expression. Results: Ep-CAM status was positive in 106 (26.4%) patients. In multivariate analysis, Ep-CAM status was associated with disease-free survival independent of age, pT stage, histologic grade, estrogen receptor (ER), progesterone receptor (PR), as well as HER2 status (P = 0.028; hazard ratio, 1.60; 95% confidence interval, 1.05-2.44). Recently, so-called triple-negative (HER-2, ER, and PR) breast cancer has received increased attention. We noticed a similar association of Ep-CAM with disease-free survival in the triple-negative group as for the entire cohort. Conclusion: In this study of untreated breast cancer patients, Ep-CAM overexpression was associated with poor survival in the entire cohort and in the subgroup of triple-negative breast cancer. This suggests that Ep-CAM may be a well-suited target for specific therapies particularly in HER-2–, ER-, and PR-negative tumors.

Anal sphincter injury during vaginal delivery--an argument for cesarean section on request?

Abstract Aims: Fear of damage to the pelvic floor from vaginal delivery and long-term sequelae (urinary and anal incontinence) sometimes being cited as an indication for cesarean section on request. The aim of the present study was to compare the effects of vaginal delivery versus elective cesarean section on anal sphincter function. Material and methods: We studied 71 consecutive women six weeks before delivery, 52 of them 4–6 weeks after delivery, and all patients with occult sphincter lesions 3months after delivery. A bowel function questionnaire was completed, and anal endosonography, manometry, and measurement of the pudendal-nerve terminal motor latency were performed. Results: Forty-two (80,8 percent) patients were delivered vaginally, ten (19,2 percent) by elective cesarean section at term. Clinically recognized anal sphincter injuries occurred in 9.5 percent (4) of patients, two of them developed incontinence for gas. The overall incidence of anal incontinence after vaginal delivery was 4.8 percent. Occult sphincter defects were identified endosonographically in 19 percent (8) of women, there was no reported case of any anal incontinence 3 months after delivery. No woman delivered by cesarean section had altered anal continence or any significant change in anal pressures, rectal sensibility, and PNTML. Conclusion: Severe sphincter tear is the single most important factor leading to anal incontinence in women, whereas occult sphincter defects are rarely associated with short-term sequelae, but may predispose to the development of anal incontinence later on in life. Elective cesarean section should be recommended for women at increased risk for anal incontinence.

Expression of aurora kinase A is associated with metastasis-free survival in node-negative breast cancer patients.

BackgroundInhibitors targeting the cell cycle-regulated aurora kinase A (AURKA) are currently being developed. Here, we examine the prognostic impact of AURKA in node-negative breast cancer patients without adjuvant systemic therapy (n = 766).MethodsAURKA was analyzed using microarray-based gene-expression data from three independent cohorts of node-negative breast cancer patients. In multivariate Cox analyses, the prognostic impact of age, histological grade, tumor size, estrogen receptor (ER), and HER2 were considered.ResultsPatients with higher AURKA expression had a shorter metastasis-free survival (MFS) in the Mainz (HR 1.93; 95% CI 1.34 – 2.78; P < 0.001), Rotterdam (HR 1.95; 95% CI 1.45– 2.63; P<0.001) and Transbig (HR 1.52; 95% CI 1.14–2.04; P=0.005) cohorts. AURKA was also associated with MFS in the molecular subtype ER+/HER2- carcinomas (HR 2.10; 95% CI 1.70–2.59; P<0.001), but not in ER-/HER2- nor in HER2+ carcinomas. In the multivariate Cox regression adjusted to age, grade and tumor size, AURKA showed independent prognostic significance in the ER+/HER2- subtype (HR 1.73; 95% CI 1.24–2.42; P=0.001). Prognosis of patients in the highest quartile of AURKA expression was particularly poor. In addition, AURKA correlated with the proliferation metagene (R=0.880; P<0.001), showed a positive association with grade (P<0.001), tumor size (P<0.001) and HER2 (P<0.001), and was inversely associated with ER status (P<0.001).ConclusionsAURKA is associated with worse prognosis in estrogen receptor positive breast carcinomas. Patients with the highest AURKA expression (>75% percentile) have a particularly bad prognosis and may profit from therapy with AURKA inhibitors.

FDG PET and tumour markers in the diagnosis of recurrent and metastatic breast cancer

Breast cancer continues to be one of the most common cancers in North America and Western Europe. Positron emission tomography with 2-[fluorine-18]-fluoro-2-deoxy-d-glucose (FDG PET) represents a non-invasive functional imaging modality that is based on metabolic characteristics of malignant tumours. In breast cancer, FDG PET is more accurate than conventional methods for staging of distant metastases or local recurrences and enables early assessment of treatment response in patients undergoing primary chemotherapy. Recent data indicate a rationale for the use of FDG PET in cases of asymptomatically elevated tumour marker levels in the presence of uncertain results of conventional imaging. Despite the fact that PET cannot rule out microscopic disease, it does have particular value in providing, in a single examination, a reliable assessment of the true extent of the disease. This technique is complementary to morphological imaging for primary diagnosis, staging and re-staging. It may become the method of choice for the assessment of asymptomatic patients with elevated tumour marker levels. This method, however, cannot replace invasive procedures if microscopic disease is of clinical relevance.

Der hämorrhagische Schock in der operativen Gynäkologie

ZusammenfassungDer hämorrhagische Schock gehört zu den häufigsten Ursachen der perioperativen Morbidität und Mortalität. Ursachen sind zumeist massive Blutungen bei Verletzung großer Gefäße oder diffuse, schwer beherrschbare Blutungen aus großen Wundgebieten, arrodierten Tumorgefäßen oder bei Verletzung von Venengeflechten im kleinen Becken.Schockmediatoren können in Verbindung mit der Zentralisation, der Mikrozirkulationsstörung mit Hämokonzentration und der schockspezifischen Vasomotorik zu einem multiplen Organversagen führen. Eine frühe Diagnose und rechtzeitige Therapie sind für die Prognose entscheidend, die v. a. von Dauer und Ausmaß des Schockzustandes bestimmt wird. Neben der raschen Beseitigung der Blutungsursache, muss eine adäquate Volumentherapie mit Kolloiden und Kristalloiden und eine rechtzeitige Applikation von Erythrozytenkonzentraten und Gefrierplasma erfolgen.Zur Prophylaxe des hämorrhagischen Schocks sind die Erhebung der Anamnese, die Erfassung hämostaserelevanter Medikamente, eine risikoadaptierte präoperative Gerinnungsdiagnostik, die Vermeidung einer Verlust- oder Verdünnungskoagulopathie durch die Gabe von Gefrierplasma sowie eine schonende Operationstechnik in Verbindung mit einer optimalen intraoperativen Blutstillung unerlässlich.AbstractShock states are among the most dangerous conditions that the gynecologist is likely to encounter. An understanding of the pathogenesis, clinical signs and symptoms, and management of shock is paramount because in many instances immediate recognition of the early manifestation of shock followed by aggressive treatment significantly reduces the likelihood of morbidity and mortality. Hypovolemic shock is a state of insufficient perfusion of vital organs with consecutive imbalance of oxygen supply and demand due to an intravascular volume deficiency with critically impaired cardiac preload. Although patients with losses of 20–30% of their blood volume may ultimately require red blood cell replacement, crystalloid or colloid is usually adequate for immediate resuscitation. The transition between the intermediate stages of the shock and irreversible shock is dependent on the duration and the severity of the hypovolemia.The prevention of the hemorrhagic shock states is possible by taking into consideration the patients history, especially drugs influencing coagulation, risk-adapted preoperative hemostatic examinations, and volume replacement therapy based on blood loss. Early application of fresh frozen plasma is sufficient to prevent hemostatic failure.

Histologische Befunde an Silikonimplantat-Kapseln der Brust in Abhängigkeit von der Liegezeit

Objective: The aim of this histological investigation of capsular tissue adjacent to silicone breast implants is to describe the time-dependent nature of changes in the fibrous implant capsule. Methods: Forty-one silicone breast implants were removed from 31 patients. The patients had a median age of 53.6 years. Twenty-three implants had smooth surfaces and 18 implants had textured surfaces. Implants and capsules were removed completely in every case. After analysis of the implant capsule, capsular thickness, signs of cellular inflammation, calcifications in the implant capsule, the presence of silicone degradation products and a synovia-like metaplasia are described. Results: Depending on the implant duration we found silicone degradation products in 32% of the capsules. Signs of cellular inflammation were recognised in 49.5% of the capsules without correlation to implant duration. Synovia-like metaplasia occurred mainly in the early implant period (p<0.001) and was more frequent around textured implants. Histological results in older implants are a greater capsular thickness (p < 0.001), calcification (p <0.001) and the clinical occurrence of a capsular contraction. Conclusions: In summary, the histologic changes around implants seem to be dynamic in nature, and implant duration and shell type play a significant role.

Das Plattenepithelkarzinom des kleinen Beckens nach zurückliegender Hysterektomie bei Benignität des Uterus - Kasuistiken und differenzialdiagnostische Darstellung

We describe two patients with disseminated squamous cell carcinoma in the pelvis 14 and 22 years after hysterectomy for benign reasons. Tumor spread was consistent with squamous cell carcinoma of the cervix. Both patients underwent complete surgical removal of all gross tumor and received postoperative radiochemotherapy. The differential diagnosis of squamous cell carcinoma in the pelvis after remote hysterectomy for benign indications includes recurrent cancer of the cervix or endometrium, vaginal cancer, squamous cell carcinoma of the ovary, and carcinoma arising from squamous metaplasia of the urogenital tract.