[Secondary prevention of cancer]
Onkologischer Dienst, Zentralinstitut der Walliser Spitaler, Sitten.
Annual screening for cervical cancer is recommended from the onset of sexual maturity onward. Mammography has been recommended after the age of 50 to 70. Colorectal cancer should be looked for by hemoccult-test after 40 to 50 years of age. The negative consequences of false positive test results are in general considered acceptable. They seem unacceptable at the time being for cancer of the breast between 40 and 50 years of age and for cancer of the prostate.
[Correlation between serious ovarian tumors and extra-ovarian peritoneal tumors of the same histology]
Kunz J. Rondez R.
Schweiz, Pflegerinnenschule, Zurich.
The occurrence of serous peritoneal tumors (SPT) with the same histology as serous neoplasms arising within the ovary is explained by the common origin of the peritoneum and the ovaries from the coelomic epithelium. They occur alone or in combination with analogous tumors of the ovary and are often misinterpreted as metastatic ovarian carcinomas. Their histology shows considerable variations. As lesions with and without invasive properties may coexist, visible lesions should be resected and examined as completely as possible. The prognostic significance of some histological findings is still under study. It appears that besides invasion the grade of nuclear atypia is of importance. It is therefore possible that the use of cytometry provides new prognostic criteria, allowing the identification of high risk groups. This holds also for the malignant forms of SPT, which seem to have a similar prognosis to analogous tumors of the ovary. For this purpose, peritoneal cytology is of special value and constitutes an integral part of the investigations.
[Clinical significance of hepatitis B virus mutants]
Moradpour D. Blum HE.
Abteilung Innere Medizin II, Medizinische Universitatsklinik Freiburg (D).
Hepatitis B virus (HBV) mutants have recently been identified in patients with acute or fulminant as well as chronic infections. Naturally occurring mutations have been identified in all viral genes and regulatory elements. Mutations in the gene coding for the hepatitis B surface antigen (HBsAg) may result in infection or viral persistence despite the presence of antibodies against HBsAg (anti-HBs) ("vaccine escape" or "immune escape"). Mutations in the gene encoding the pre-core/core protein (pre-core stop codon mutant) result in a loss of hepatitis B e antigen (HBeAg) and sero-conversion to antibodies to HBeAg (anti-HBe) with persistence of HBV replication (HBeAg minus mutant). Mutations in the core gene may lead among others to an immune escape due to a T cell receptor antagonism. Mutations in the polymerase gene can be associated with viral persistence or resistance to nucleoside analogues. Thus, HBV mutations may affect the natural course of infection, viral clearance and response to antiviral therapy. The exact contribution of specific mutations to diagnosis and therapy of HBV infection as well as patient management in clinical practice remain to be established.
[Status febrilis and jaundice]
Knechtle B. Kaufmann A. Diem M. Vogt M.
Medizinische Klink, Kantonsspital Zug.
A 49 year old patient was admitted with fever and jaundice. Laboratory evaluation showed leukocytosis, elevated values for C-reactive protein, transaminases, bilirubin and alkaline phosphatase. Ultrasound and subsequent CT-scan revealed multiple liver lesions and a liquid mass in the bursa omentalis. A CT-guided catheter-drainage was performed and streptococcus milleri isolated from the abscess and one blood culture. After empiric broad spectrum treatment with Piperacillin/Tazobactam (Tazobac) and Netilmicin (Netromycin), Ceftriaxon (Rocephin) was given for a total treatment time of 10 days. Further evaluation revealed a perforated peptic ulcer as possible etiology for the described localized infectious complication.
[Febrile state, bloody diarrhea and megacolon]
Hellermann J. Hofliger M. Hangartner PJ. Kehl O.
Medizinische Abteilung, Kantonales Spital Altstatten.
We report about a forty year old female patient with severe bloody diarrhoea and fever over a period of 14 days due to an infection with Salmonella enteritidis. X-ray of the abdomen showed a toxic megacolon. With the diagnosis of an infectious colitis we started therapy with ciprofloxacin i/v. The toxic megacolon progressed despite intensive care and parenteral nutrition. Additionally the patient received metronidazole i/v and in combination with a roll technique in bed in the knee-elbow-position the leucocytosis and the megacolon decreased. A toxic megacolon is in about 3% associated with an infection with Salmonella enteritidis. It is essentially diagnosed by X-ray. Patients should receive intensive care, and because of the high mortality rate an interdisciplinary management is required. The article discusses the major differential diagnosis of the toxic megacolon, as well as the pathogenesis and therapy of Salmonella ent, infection. In case of an infection with Salmonella ent. physicians should acknowledge the possibility of development of a toxic megacolon.
[Abdominal pain and flatulence. Intestinal and pulmonary tuberculosis. IgG kappa paraproteinemia]
Schulthess G. Osterwalder P. Valentini T. Bicik I. Widmer U.
Departement fur Innere Medizin, Universitatsspital Zurich.
A 21-year-old woman suffered from cramplike abdominal pain, flatulence and occasional diarrhoea for about one year. Over the past few weeks the abdominal symptoms exacerbated, besides productive cough and subfebrile temperatures developed. Coloscopy revealed two isolated, short ulcers in the proximal colon. The histological examination of the biopsies taken from these ulcers indicated granulomatous inflammation. Moreover small acinar infiltrates in both pulmonary apices were visualized. The findings in this patient originating from Turkey were suspicious for intestinal and pulmonary tuberculosis. Though sensitive methods were used (Ziehl-Neelson stam, amplified M. tuberculosis direct test, a polymerase chain reaction) direct tests allowed no detection of mycobacteria. Antituberculous therapy was initiated on a probatory basis to which the patient responded well and promptly. The diagnosis was confirmed by culture results: M. tuberculosis was grown from colonic biopsies, morning sputa and bronchioalveolar lavage.
[Ascites. Tuberculous peritonitis]
Osterwalder P. Widmer M. Widmer U. Schulthess G.
Departement fur Innere Medizin, Universitatsspital Zurich.
Because of deteriorating general health, weight loss of 5 kg and leftsided epigastric pain a 44 year old innkeeper was evaluated unsuccessfully for 1 month. Thereafter a protein- and lymphocyte-rich ascites developed. CT-scans revealed a thickened visceral peritoneum and multiple, marginally increased retroperitoneal lymph nodes. The history of the patient originating from former Jugoslavia was suspicious for inadequately treated tuberculous pericarditis. Hence this diagnosis tuberculous peritonitis became probable but for practical reasons could not be proven neither by biopsy nor by culture. Under probatory antituberculous treatment the patient's general condition improved rapidly, the ascites disappeared and initially elevated parameters for infection normalized.
[Return from the tropics: relevant diagnosis and rational therapy]
Facharzt FMH fur Innere Medizin und Tropenmedizin, Zurich.
Gastrointestinal disorders, particularly diarrhoea, are the main reason to consult a physician after travelling to the tropics. Although mostly of infectious origin specific pathogens frequently cannot be demonstrated. As the majority of acute diarrhoeal episodes resolve without any specific therapy, bacterological and parasitological investigations should initially be ordered with reserve and economically. Fever after a stay in the tropics has to be always a matter of concern as it could be the expression of a potentially dangerous infection, e.g. falciparum malaria. The primary objective must be the exclusion of potentially life-threatening infections requiring a specific treatment. Numerous asymptomatic travellers returning from the tropics want their physicians to exclude an inapparent exotic infection. The value of such check-ups can be questioned, and there are just a few rational investigations in this particular context.
[Severe chronic iron deficiency in a 17-year-old student]
Beglinger C. Hess B. Ruchti C.
A 17 year old male suffered from iron deficiency of undetermined cause for 2 years. Iron substitution was able to correct it for short periods. With the exception of fatigue and recurring abdominal pain attributed to oral iron therapy no further symptoms were present. The physical status on admission was unremarkable. The laboratory detected intestinal disorders, an anemia of the chronic type without evidence for malignancy or renal failure suggested an inflammatory gastro-intestinal disorder. In spite of a twice negative noninvasive test for gluten-intolerance the clinician favored in his differential diagnosis non tropical sprue over inflammatory bowel disease (IBD, Crohn's disease, Whipple's disease). Histopathology of small bowel specimens did not indicate sprue. An ileo-colonoscopy revealed severe ulcerating ileitis and mild chronic colitis. The histologic specimen revealed a severe ileal inflammation with cosinophilia and the colon specimens epitheloid microgranuloma. These findings are highly compatible with the diagnosis of Crohn's disease. Iron deficiency anemia is common in Crohn's disease. In the current case it is due to disturbed iron uptake. Iron deficiency anemia as sole symptom of Crohn's disease is extremely rare.
[Dysphagia as a symptom of myxedema]
Klinik und Poliklinik fur Hals-Nasen-Ohren-Heilkunde, Universitatsklinikum Dresden.
We present a 79 year old female patient with dysphagia since two years. She showed also a lack of initiation and dysphonia. In the region of the larynx an edema was found and the tongue was hypertrophied. The X-ray examination demonstrated a dilated esophagus without impairment of the passage way. Esophagoscopy showed also important edema in the hypopharynx and the entry into the esophagus. The TSH-0 was 74.45 mmu/l, the T3 0.23 and the T4 was 24 nmol/l. Scintigraphically an only cherry-stone small region with active thyroid tissue was revealed. Severe hypothyroidism responsible for secondary dysphagia was diagnosed. L-Thyroxin was administered (150 micrograms/d). There was a dramatical improvement. The signs of edema and the dysphagia decreased. The examination a half year later demonstrated a patient without any dysphagia or edema. The symptom dysphagia is defined and an interdisciplinary approach emphasized.
[Immobilizing muscle weakness accentuated in leg and proximal muscles]
Wuttke M. Meyer M. Varga Z. Stoll T.
Medizinische Klinik, Stadtspital Waid, Zurich.
A 54 year old waiter was referred to the hospital because of proximal muscle weakness, most pronounced in his legs, which progressed to an inability to stand or walk within weeks. Myopathy was diagnosed based on the muscle biopsy findings and myositis was ruled out by laboratory and biopsy results. Further investigations led us to exclude an endocrine cause, hypovitaminosis D, infectious myopathy or a paraneoplastic syndrome. Heteroanamnesis revealed severe alcoholism, lasting for more than 30 years. The presumed alcohol induced hepatopathy was confirmed by liver biopsy. There were no signs of an acute alcoholic myopathy, as the weakness had developed rather insidiously, there was no elevation of the CK serum level nor myoglobinuria and a type 2 fibre atrophy was found by muscle biopsy. As expected the weakness improved under abstention. Thus the final diagnosis of a chronic alcohol induced myopathy was established.
[Conservative medical treatment of chronic pancreatitis]
Medizinische Klinik C, Abteilung fur Gastroenterologie, Kantonsspital St. Gallen.
The conservative medical treatment of chronic pancreatitis entails dealing prevalently with exocrine and endocrine insufficiency, diet and pain. As steatorrhoea can cause malabsorption, it is advisable to reduce first the fat content of the diet and secondly to prescribe, where necessary, pancreatic enzymes. Several factors can lead to a poor therapeutic enzyme effect. Attention should be given to the pharmacological properties of the enzyme-preparation and to the secretion of acid in the stomach. An endocrine insufficiency is more difficult to treat compared to a classical diabetes mellitus, for lack of endocrine regulatory mechanisms. Pain is the consequence of several pathophysiological processes. Before initiating analgetic treatment, a minimal diagnostic program should be completed allowing the exclusion of those primary causes of pain which require an alternative approach such as interventional endoscopy or surgery.
[Respiratory insufficiency and absent left radial pulse after hemicolectomy]
Streuli RA. Laissue JA.
Medizinische Poliklinik, Universitat Bern.
A 65 year old female developed right thoracic pain, productive cough and fever four weeks after hemicolectomy because of a cancer of the sigmoid. In spite of antibiotic treatment the condition of the patient deteriorated and she was admitted to the hospital with pneumonia of an upper lobe. Chest X-ray visualized prominent proximal pulmonary arteries. Progressive respiratory failure developed and blood gas analysis revealed hypocapnic hypoxemia. The patient had to be intubated and ventilated mechanically. Later, left arm blood pressure measurements could no longer be taken and the radial pulse was missing. Thereafter, an ischemic syndrome of the right leg developed. Embolectomy from the superficial femoral artery was carried out the same day. The patient died five days later. Autopsy revealed an almost complete occlusion of the pulmonary arteries. The organization of thrombotic material indicated recurrence. Emboli were also found in the systemic circulation. A large patent foramen ovale together with signs of pulmonary arterial hypertension are indicative of paradoxical thromboembolism.
[Prognostic factors in stomach carcinoma]
Gabbert HE. Muller W. Wirtz C. Noguchi T.
Institut fur Pathologie, Medizinische Einrichtungen der Heinrich-Heine-Universitat, Dusseldorf.
The classical prognostic factors of the pTNM system are still most valid. Nevertheless, vascular invasion as well as the molecular marker E-cadherin proved to be independent new prognostic factors responsible for a significant shift in patient survival. Thus, in pTNM-stage II patients, a highly significant drop in survival is observed when patients showing no E-cadherin expression and at the same time vascular invasion are compared with E-cadherin-positive patients who do not show vascular invasion (Fig. 11). These conspicious shifts in survival underline the necessity to continue our search for new molecular and non-molecular markers which in future may help us to predict the outcome of gastric cancer patients more precisely and more individually.
[How accurate is preoperative staging as a basis for treatment decisions in gastric carcinoma?]
Heyer T. Frieling T. Haussinger D.
Klinik fur Gastroenterologie, Hepatologie und Infektiologie, Heinrich-Heine-Universitat, Dusseldorf.
The treatment of advanced gastric carcinoma by various neoadjuvant and adjuvant multimodal therapy regimes is under current investigation to improve the poor outcome of these patients. Therefore, pretherapeutic tumor staging according to the TNM classification is essential for the optimal application of various therapeutic modalities. According to recent studies, endoscopic ultrasonography (EUS) is the most sensitive technique in measuring tumor infiltration (T-staging). In addition, although less reliable compared to the T-staging, the sensitivity of EUS in assessing lymph node status (N-staging) is superior to computed tomography and conventional ultrasound. Pretherapeutic laparoscopic investigation may give additional important information about tumor stage. This overview describes the significance of various diagnostic techniques that can be applied in tumor staging investigations.
[Stage-adapted radical principles in gastric carcinoma]
Zentrum fur Chirurgie, Klinikum Krefeld.
The aim of any surgical approach to gastric carcinoma should be a complete resection with no residual tumor left behind, that is, a R0-resection according to UICC. Complete tumor resection in this respect refers to the primary tumor as well as to the lymphatic drainage and requires an adequate safety margin. The indications for surgical therapy of gastric cancer and the choice of procedure should consequently be guided by the tumor stage. This requires accurate preoperative staging, which can today be achieved with endoscopic ultrasonography and surgical laparoscopy. Gastric carcinoma stage IA (mucosa carcinoma) can be cured by local excision. In patients with tumor Stages IB (submucosa carcinoma), II, and IIIA, lymph node metastases are common. Based on the available data, this group of patients benefits from radical resection and D2 lymph node dissection. The overall 5-year survival rate of 50% for the large number of patients undergoing gastric resection for cancer seems to demonstrate convincingly the value of extended lymphadenectomy. In patients with advanced gastric carcinoma, that is, tumor stages IIIB and IV, a complete tumor removal usually can not be achieved by surgical dissection. Neoadjuvant therapeutic modalities should consequently be assessed in these patients. Based on tumor location and growth pattern, a total gastrectomy is the procedure of choice in patients with middle and proximal third gastric cancer. A subtotal gastrectomy may be performed in patients with tumors of the distal third and "Laurens intestinal type" growth pattern. The distal site of the main lesion must be investigated carefully to ensure that incidental concomitant lesions are not overlooked. Depending on the individual tumor situation, the gastrectomy can be extended toward varying portions of the distal esophagus or the pancreas, preserving splenectomy and resection of the retroperitoneal lymph nodes. The high incidence of locoregional recurrences and distant metastases after curative surgery for gastric cancer calls for improved locoregional control and systemic adjuvant treatment.
[Neo-adjuvants, adjuvants and palliative therapy for gastric carcinoma]
Patients with gastric cancer have a poor prognosis. Because curative surgery is often impossible (metastatic disease) or extremely difficult (locally advanced tumors), and the majority of patients undergoing curative resection relapse, chemotherapy has been actively studied in gastric cancer. Several combination chemotherapy regimens have been developed with high activity in locally advanced and metastatic disease. Among them are 5-fluorouracil (5-FU) plus high dose methotrexate plus doxorubicin (FAMTX). It represents the reference treatment in many clinical trials. Recent schedules like etoposid plus cisplatin (EAP); etoposid plus leucovorin plus 5-FU (ELF) and epirubicin plus cisplatin plus 5-FU (ECF) show encouraging response rates, their toxicity is considerable, however. Randomized trials comparing chemotherapy with best supportive care showed an increase in overall survival and in quality-of-life. Up to now adjuvant chemotherapy has failed to improve survival as compared with surgical controls. Only half of the patients with locally advanced gastric cancer (LAGC) undergo macroscopic and microscopic tumor-free resection. Preoperative chemotherapy has shown very promising results even in patients who had primarily unresectable tumors. Approximately half undergo R0 resection after downstaging induced by active chemotherapy and the long-term survival rises to about 20%. There are hopes that the newest regimes may do this: new cytostatic drugs and the immuno-chemical approach to combine cytostatic drugs with cytokines will be of great importance.
[Familial giant hemangiomas of the liver. Study of a family and review of the literature]
Moser C. Hany A. Spiegel R.
Kantonsspital Winterhur, Medizinische Klinik, Universitat Zurich.
In this report we present for the first time strong evidence for autosomal-dominant inheritance of grant liver hemangiomas. Furthermore, we review the current literature about incidence, pathogenesis, clinics, as well as diagnostic and therapeutic aspects of LH. A large family of Italian origin is described where three female patients in three successive generations suffered from large symptomatic LH. In addition, two other female relatives exhibited asymptomatic LH on sonographic scans. The restriction of the disease to the female gender could be explained by a sex-dependent difference in penetrance or expressivity of a presumable "liver-hemangioma" gene, or by known proliferative factors such as female sex hormones. We also observed an increased incidence of adenomas of the thyroidea among members with or without LH of the presented family. This uncommon familial association has also not yet been described and its genetic aspects are discussed.