Biomedical subjects
Publications and source records attributed to N Jaeger.
In intravesical sonography artificial reflexes often lead to optical misinterpretation and mistaken diagnosis. In several experiments we followed up the ultrasound-capacity of dissolution and demonstrate different phenomena of reflexes. The findings are compared with intravesical and intrarectal sonograms; they are of use to interpret intracavitary B-Scan-Ultrasound.
Radioimmunoscintigraphy was performed in 52 patients with a variety of malignant tumors (colorectal, melanoma, lung, testicular, ovarian, bladder, carcinoid). Respective antibodies or their F(ab')2 fragments against CEA (n = 23), melanoma antigen 225.28 S (n = 18), TPA (n = 4), beta HCG (n = 5) and HMFG2 (n = 2) were selected by immunohistochemistry of the primary tumor. Most patients were suspected of recurrence or of hitherto unknown distant or local metastases. Overall accuracy was 61% (32/52). False negatives amounted to 33% (17/52). Useful additional clinical information-not available by CT, ultrasonics or serum levels of tumor markers-was obtained in 17 out of 52 patients (= 33%). From these results it seems obvious that antibodies used for radioimmunoscintigraphy should be selected on the basis of immunohistochemistry.
The two competitive methods available for operative treatment of female stress incontinence are the suspension procedures according to Marshall-Marchetti and according to Burch. With respect to continence, equally favorable results are achieved using both dethods. One way of assessing their value is by measuring the complications involved. A report is presented on osteomyelitis of the pubic symphysis in two cases after the Marshall-Marchetti operation and hydronephrosis in one case after the Burch operation. In all three patients, the complications were accompanied by postoperative fever as an early symptom.
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Based on experience in the treatment of 627 patients with germinal testicular tumor and referring to recent literature, the age distribution (children, 3.6%, men over 50 years, 6.3%), importance and possibilities of early detection as well as sensitivity, specificity and accuracy of tumor markers, ultrasonography and X-ray examinations are described. In N0M0 stage seminomas, cure can be effected by radiotherapy in almost 100% of the cases. An alternative 'watch policy' is discussed. In N1-2M0 stage seminomas, cure can be achieved by irradiation in more than 90% of the cases. Primary polychemotherapy is needed in stage N3M0 or M1 as well as in stage N4M0 and N1-4M1 seminomas. Complete remission can be obtained in more than 90% of the patients if salvage operation, further chemotherapy or radiotherapy is performed in cases without complete remission after semicastration and primary chemotherapy. In N0M0 stage non-seminomas (excluding pT4 cases, choriocarcinoma, and patients with persistently elevated markers following semicastration), 'watch policy' has the disadvantage of requiring optimal monthly follow-ups and progression in 20% of the cases. While modified lymphadenectomy reduces the progression rate to 10% with low operative morbidity, it leads to an irreversible loss of ejaculation in 12% of the patients. With both modalities, if progression is detected, full recovery can be expected with immediate polychemotherapy. In stage N1-2M0 non-seminomas, a tumor-free condition can be obtained in close to 100% of the cases by lymphadenectomy and adjuvant chemotherapy. In stage N3,4 and/or M1, first primary polychemotherapy is carried out. In the case of a residual tumor this is followed by salvage operation and, if active tumor is found, by salvage chemotherapy. With this treatment, recovery can be achieved in 70-80% of the cases depending on the involvement of surrounding organs.
In order to study the efficacy of three different chemotherapy regimens and the prognostic significance of residual disease after chemotherapy, we analyzed 84 patients with bulky germinal tumors. Chemotherapy, consisting of vinblastine, bleomycin/adriamycin, cisplatin (VB/AP) was administered sequentially to 37 patients. 19 patients were treated with the cisplatin, vinblastine, bleomycin (PVB) regimen and 17 patients with cisplatin, vinblastine, bleomycin, ifosfamide (PVBI). The initial complete remission (iCR) was 71% (52 of 73) with a relapse rate of 29% (15 of 52). 10 of 73 (14%) patients achieved partial response and 11 of 73 (15%) showed progression due to multidrug resistance. There was no statistically significant difference in iCR, continuous complete remission (cCR), relapse and survival between the PVB, PVBI and VB/AP regimens. In 50 patients, the residual tumor after chemotherapy was examined histologically. cCR was achieved in 75% (15 of 20) of patients with necrosis or fibrosis, in 50% (5 of 10) with adult teratoma and in 25% (5 of 20) with malignant tumor. Comparison of survival curves according to residual histology revealed statistically significant differences (p = 0.02). Our findings suggest that in patients with germinal bulk disease PVBI-regimen and VB/AD-therapy are not superior to the standard regimen. Residual disease seems to be an important prognosticator.
An untreated malignancy of an anatomic or functional single kidney is fatal. However, tumor enucleation, including examination of the abscission surfaces by immediate per operative section should be considered as a curative treatment. Of 15 patients who underwent tumor enucleation during the past 10 years, 1 died of postoperative complications, while 3 patients died of tumor progression; 9 are alive at 9-49 months with no evidence of disease, and 2 are alive, one with a metastasis and the other with a locoregional relapse in the contralateral kidney bed. Because of the low incidence of complications, superficial hypothermia with ice should be preferred to extracorporeal surgery. The characteristic pseudocapsule allows an enucleation of the malignoma with protection of vessels and optimal preservation of the healthy parenchyma.
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With 66.5% the total reliability of the transurethral sonography is significantly higher than that of all methods hitherto used. If one restricts oneself to the differentiation between muscle-invasive and superficial carcinomas the share of impacts is even 77.5%. Considering an error of nevertheless 33% and 23%, respectively, in the T-classification of the carcinoma of the urinary bladder the new method could, however, not fulfil the high expectations which were set into it at the beginning. Particularly a differentiation between mucosa and lamina propria as well as superficial and deep musculature is not possible. According to this the transurethral sonography is not suited as the only method for preoperative T-classification and basis of therapy planning. Difficulties appear above all in large and echo-dense carcinomas, respectively, as well as in pretreated urinary bladders. Consequently, a sufficient experience in the judgment of sonogrammes is necessary, in order to avoid wrong interpretations as to a tumor infiltration. Nevertheless, the transurethral sonography is an essential enlargement of the hitherto scanty spectre of the T-classification of the carcinoma of the urinary bladder. Supplementing the computer tomogram, the method brings the operator a quick survey of a possible infiltration of the wall of the bladder and a perivesical growth of the tumour. In deeply infiltrating, not radically resectable carcinomas in many cases an extensive staging-TUR may thus be avoided.
In our clinic 483 lymphnode dissections were performed during the last 17 years. Different complications were found under operation in 2.7% and postoperatively in 9.9%. The mortality rate was 0.8%. Three years ago we started a different technique for lymph node dissection. The lowest incidence of complications during this period was found in the modified unilateral resection technique (8.9%), far higher after the bilateral (radical) (24%), the second-look lymphadenectomy (33%) and the so-called "salvage-lymphadenectomy" (42.9%). Causes of complications, therapy and prevention are discussed.
A retroperitoneal relapse of germ cell tumors following retroperitoneal lymphadenectomy (RLA) demands a new treatment regimen aiming towards cure. The combination of primary chemotherapy and subsequent second-look operation has proved successful. The results reviewed are concerned with a revision operation (n = 22) usually following cytostasis (n = 15). In 6 cases, a nonoperable situs was discovered after false-positive findings on examination. In 7 other patients the proposed radical removal of the relapse tumor was successful. Nine times the operation only had a palliative character. After histological examination of the dissectate, we found highly malignant tumor fragments in 9 cases; five times we resected 'mature teratomas'; two times we found only necrotizing or fibrotically degenerated malignoma remnants. The result of the pathological-histological examination has a decisive meaning for the younger patient.
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Intracavitary sonography proved to be advantageous with regard to the T-classification of urinary bladder tumours in comparison with conventional diagnostic methods. Besides the good practicability, the high degree of correspondence between sonography and histopathological findings is emphasized. In 97 patients with urothelial bladder cancer this method yielded 63% correct results. In 32% overstaging was noticed, possible factors of which were exemplified. Part of the sonographic failures can be avoided by means of technical manipulation (gain-modification) together with increasing experience of the examiner. In particular benign bladder disease, which can be sonographically confused with cancer, has to be considered. These cases indicate the need to correlate particular sonographic findings with histopathology.
The treatment of advanced metastasized germ cell tumor consists in a combination of chemotherapy and surgical tumor resection. The sequence of treatment measures is still not uniform. 55 patients with clinically apparent retroperitoneal metastases ('bulky disease') and/or extensive parenchymal metastases are reported. Chemotherapy was performed initially in 40 cases with subsequent resection of the retroperitoneal or parenchymal residues. Of 28 patients with the finding of necrosis/fibrosis or mature teratoma in the dissection preparation, 23 b1e alive and free of tumors. Of 14 patients with the finding of highly malignant tumor, 9 died. In 15 cases, we carried out 'surgical debulking' before chemotherapy: 5 of these patients died as a result of progression in the further course. The advantages and disadvantages of the two treatment modalities are described and discussed. Advanced stages of germ cell tumor with distant metastases should initially be treated with inductive chemotherapy and the tumor residues should subsequently be removed by delayed resection. The sequence in the case of a retroperitoneal 'bulky tumor' without distant metastases is a matter of further discussion and needs a prospective randomized study.
The role chemotherapy plays in the improvement of prognosis of malignant testicular germ cell tumors is discussed in the light of the development of chemotherapeutic conceptions and stage related strategies. The course of disease in 117 own patients being subjected to cytostatic treatment in 1978-1982 is analysed in detail. In 70% of the cases a complete remission was achieved. Partial remissions generally were of short duration. All toxic side effects are described, the vital threat of panmyelopathy with resulting septicaemia being emphasized. The therapeutic countermeasures are mentioned. Protocols of two prospective clinical trials attempting to answer some of the still open questions regarding chemotherapy are presented.
This report concerns 18 patients with germinal testicular tumors in whom the resection of pulmonary metastases was indicated following resection of the primary tumor and combined cytostatic therapy. Nine patients underwent a retroperitoneal lymphadenectomy immediately after semi-castration. Upon follow-up examination, circular pulmonary foci were visualized by conventional films or computerized tomography. These patients developed pulmonary metastases on the average 8 months after the first operation (semi-castration and lymphadenectomy). Since 1978, a combined cytostatic treatment has preceded the lymphadenectomy and resection of parenchymal metastases. No evidence of disease (NED) could be achieved in 9 patients by resection of pulmonary metastases, with an average follow-up period of 30 months. The results in surgery of metastases are judged as the more advantageous, the longer the free interval is between initial disease onset and the occurrence of metastases.
25 Patients with metastatic non-seminomatous testicular neoplasms were treated by surgery and cytostatic therapy using a combination consisting of Velban, Bleomycin, Cis-Platinum and/or Ifosfamid. In 22 patients this procedure induced a persistant complete remission with a mean observation time of 23 months. 2 patients died because of post-surgical complications after a second-look-lymphadenectomy. They suffered from rapidly progressive tumor disease. One patient died in a septicemia during chemotherapy. Our experience is that morbidity of an effective chemotherapy should not be underestimated. Transient bone marrow suppression, anorexia, alopecia and hyperpigmentation are unavoidable. However, severe vomiting, disturbed electrolyte metabolism, hemorrhagic cystitis, anemia and septicemia can well be managed by respective supportive care. Septicemia, for instance, may be treated with appropriate antibiotics without inducing tubular necrosis. Supportive measures also will avoid severe chronic defects of ear and kidney function.