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Studienziel und Methode: Im Rahmen einer prospektiven Untersuchung wurde an 113 Patientinnen mit einem Mammatumor der Gefaswiderstand (mean RI) im Tumorareal und im gesunden Brustdrusenqewebe mittels gepulster farbkodierter Dopplersonographie ermittelt. Ergebnisse: Die Gruppe der Karzinome wies einen signifikant hoheren mean RI (0,71 ± 0,09 SD) im Vergleich zu den benignen Tumoren (0.66 ± 0.09 SD) auf (p = 0,003). Dieser Unterschied war innerhalb der nach dem Menopausenstatus aufqeschlusselten Untergruppen allerdings nicht mehr nachweisbar, wobei der mean RI in der Postmenopause qrundsatzlich hoher lag. Nur pramenopausale Patientinnen wiesen im Karzinomareal einen signifikant hoheren mean RI (0.69 ± 0,1 SD) im Vergleich zum gesunden Brustdrusengewebe (0,65 ± 0,07 SD. p = 0,02 ) auf. Von allen untersuchten Prognosefaktoren korrelierte der mean RI im Karzinomareal mit der S-Phasenfraktion: r = -0,53 (p = 0.003). Schlusfolgerung: Der mean RI spiegelt den Gefaswiderstand wider, ermoglicht aber nach den vorliegenden Untersuchungsergebnissen keine sichere Dlqnltatsdiskriminierung und wird vom Menopausenstatus signifikant beeinflust. Proliferationskinetik des Tumors und niedriger Gefaswiderstand sind offensichtlich voneinander abhangig. Maligne Tumoren mit hoher Zellkinetik wiesen einen deutlich erhohten diastolischen Blutflus und damit einen niedrigen mean RI auf (p = 0,003). Diese Befunde sollten bei allen dopplersonographischen Untersuchungen der weiblichen Brust bzw. deren Bewertungen berucksichtigt werden. Aim and Method: In a prospective study of 113 patients with breast tumours. we measured the vascular resistance index (mean RI) of physiologic tissue and the tumour by using pulsed colour coded Doppler sonography. Results: The group of carcinomas showed a significantly higher mean RI (0.71 ± 0.09 SD) compared to the group of benign tumours (0.66 ± 0.09 SD) (p = 0.003). After dividing the groups according to men opausal status, this difference disappeared. In general the mean RI was higher in postmenopausal women. Only premenopausal women showed a significantly higher mean RI within the carcinoma (0.69 ± 0.1 SD) compared to physiological tissue (0.65 ± 0.07 SD. P = 0.02). The mean RI measured in the tumour area from carcinomas correlated with the S-phase fraction: r = -0.53 (p = 0.003). Conclusion: Mean RI reflects vascular resistance but does not allow discrimination between benign or malignant and is significantly influenced by menopausal status. The dynamics of proliferation and low vascular resistance seem to depend on each other. All these facts should be considered when doing Doppler sonographic examination of the breast.

The therapy of obstipation must always be multicausal. This becomes especially difficult when a laxative abuse is present. When the patient cannot be offered successfully an effective and causal therapy, he/she quickly falls back on his/her "proven” but rather harmful remedies. With the change to enzymatically produced, partially hydrolyzed Guar gum powder it is possible, to achieve a return to a regular bowel movement, which is above the average. In contrast to other roughage, the active principle of partially hydrolyzed guar core flour is based on the water solubility, so that after finding an individual dose (in about 8-10 days), the regulative therapeutic effect develops.

For gynecological/obstetrical ultrasound examination the abdominal wall constituted the first and for a long time the only acoustical window that could be used to visualize the female reproductive organs. Only recently transvaginal/transrectal endosonography has opened new approaches in this diagnostic field. Apart from the above-mentioned procedures, the female perineum can be regarded as a useful window to demonstrate the cervix uteri, the bladder and the urethra. At the Universitats-Frauenklinik Heidelberg this examination procedure was used since June, 1985, to evaluate its clinical reliability in obstetrics and gynecology.

In a group of 65 twin pregnancies the difference of perinatal findings and antepartal test results was evaluated in relation to amnionicity and chorionicity. Monochorionic placentation was found in 33% of the pregnancies. The rate of foetal malformation (11%), neuromuscular dysfunction (6%), perinatal mortality (11%) and duration of neonatal intensive care was increased in those cases. The most useful diagnostic tool was B-Mode-ultrasound (first detection and surveillance of multiple pregnancy, especially diagnosis of inter-twin growth discordancy). Non stress test and Doppler sonography were found to be of value as additional tests for detection of functional differences between both twins. There were no differences between findings in first and second twin as well as between findings in pregnancies with mono- or dichorionic placentation.

Sonographic examination of the female breast has now been generally accepted as a clinical examination method. 1 719 patients were subjected to echomammography within the framework of a prospective study. Histologically confirmed results were obtained from 496 palpable findings. Basing on these findings, the value of echomammography was developed in respect of preoperative clarification of palpable carcinomas of the breast. X-ray mammography served as reference method. In benign findings, echomammographic accuracy is 73%, whereas the accuracy of x-ray mammography was found to be 58% only. Fibroadenomas were recognised as a benign process by both methods with an equal quota of accuracy (71% and 73%, respectively). 82% of all fibrocystic mastopathy findings which could be localised via palpation, were sonographically graded as benign, whereas mammography classified only 49% as benign cases. This difference is statistically significant (p less than 0.001). Palpable carcinomas wee considered to be malignant via sonography in 91% of the cases (179 out of 197), whereas x-ray mammography yielded a rate of 82% only. The intraoperative T1 stage was established by sonography in 85% of the palpable carcinomas, whereas x-ray mammography yielded a figure of 76% only. These results underline the importance of echomammography in preoperative clarification of palpable carcinomas of the breast.

In a group of 79 pregnancies with highly abnormal Doppler-flow findings in foetal vessels the value of antepartal CTG criteria was evaluated in detail. In cases with absent enddiastolic flow (AEDF) the prognostical value was not further increased by antepartal pathological CTG findings. In cases with permanently normal antepartal CTG's, however, foetal outcome was fairly good (median duration of pregnancy 38 + 6 weeks, median foetal birth weight 2,545 grams, arterial pH < 7.20 in 9%). This was true also in the presence of pathological Doppler-flow findings except AEDF. In cases with pathological antepartal CTG findings in the antepartal course of pregnancy the loss of acceleration was most frequent (82%), followed by decreased frequency (53%) or narrowed amplitude (38%) of the foetal heart rate variation. Combination of both methods (Doppler sonography and CTG) is recommended clinically because the rate of uncertain findings can be reduced. Especially in cases with AEDF an active management would be justified before CTG's become pathological.

"Reverse Flow" as a Doppler sonographic finding indicates the appearance of retrograde blood flow in the diastolic part of the cardiac cycle. It has so far not been observed in uncomplicated pregnancies and seems to be an indicator of severe deterioration of the foetal condition. Several pathophysiological hypotheses are discussed in this paper on the basis of own results and the findings of other investigators.

Preoperative sonographic data in 317 patients who underwent surgery at the University Women's Clinic Heidelberg for an ovarian tumour during a 6 years' observation period, were compared with the results of clinical examination. The prognostic value of both techniques was examined, by relating the findings (as to tumour size, demarcation from the uterus) to the postoperative histological or cytological diagnosis. In the 214 cases of benign and 103 of malignant ovarian tumours a correct diagnosis was provided by ultrasound in 88% and 74% respectively. Thus significantly more often than by clinical examination alone (p less than 0.001 for benign and p less than 0.01 for malignant tumours). The sonographic findings in 49 patients during follow-up after surgery for ovarian carcinoma and polychemotherapy were checked by a second look laparotomy. The detection rate of tumour progression, recurrence, residual tumour or remission was of 98%.

Objective Higher risks of infertility have been found in overweight women. The purpose of the present study was to explore whether protein metabolism profiles related to body mass index (BMI) and to find out whether these parameters should affect IVF/ICSI outcome. Patients and methods 52 patients were enrolled in this study. All patients underwent an ovarian stimulation either with recombinant follicle stimulating hormone (Gonal-F) or human menopausal gonadotropin (Menogon) after pituitary down-regulation with Goserelin (Zoladex) or Triptorelin (Decapeptyl Gyn). Five blood samples were taken: before treatment, at the beginning of ovarian stimulation, on the day of HCG injection for the ovulation induction, on the day of follicle aspiration and 14 days after embryo transfer. The blood samples were analysed with regard to the serum concentrations of total protein, albumin, total bilirubin and urea. According to the BMI values the patients were divided into two groups: BMI 25 kg/m (2) (GII, n = 24). The results of IVF/ICSI outcome were compared in both groups. Results In both groups, the serum concentrations of total protein, albumin, total bilirubin and urea decreased during ovarian stimulation. In GII, albumin concentration decreased significantly on the day of follicle aspiration (46.0 +/- 2.3 g/l versus 43.5 +/- 2.5 g/l, p 25 kg/m (2) 33.1 % (p = 0.34). Conclusions Serum concentrations of albumin and total bilirubin are influenced by BMI. Excess weight defined as BMI > 25 kg/m (2) has a negative impact on IVF outcome leading to decreased chances of pregnancy.

BACKGROUND Prematurity is a main issue in modern obstetrical care. The purpose of the present study was to evaluate the perinatal outcome of premature infants weighing less than 1500 g according to the mode of delivery. PATIENTS AND METHODS 122 patients with infants weighing less than 1500 g were enrolled in this retrospective study (26 to 32 weeks of gestation). The perinatal outcomes of 26 infants born by vaginal delivery were compared to 96 infants delivered by caesarean section. RESULTS The rates of rupture of membranes, preterm labour and intravenous tocolysis were significantly increased in patients after vaginal delivery. Preeclampsia and pathological cardiotocograms were increased in patients after caesarean section. Infants born by vaginal delivery showed a significant increase of peri- and intraventricular haemorrhage grade III, periventricular leukomalacia, C-reactive protein 24 hours postpartum and mortality until the seventh day of life. However, the rate of bronchopulmonary dysplasia was significantly increased in infants born by caesarean section (p < 0.05). CONCLUSIONS These data suggest that the mode of delivery affects the perinatal outcome of infants weighing less than 1500 g. Based on the results of the present study, it appears unclear which mode of delivery should be preferred, depending on particular material and fetal factors.

UNLABELLED BACKGROUND/PATIENTS: A reverse flow in the umbilical artery and/or fetal aorta is associated with a higher perinatal and neonatal mortality. 30 fetuses showed a reverse flow using pulsed wave Doppler sonography (group I). A matched-pair control group including 30 fetuses with the same gestational age as well as a normal Doppler flow pattern in the umbilical artery and/or fetal aorta was taken for comparison (group II). RESULTS In the group with reverse flow the rates of pregnancies with pre-eclampsia (n = 19/30, p < 0.0001), intrauterine growth retardation (n = 25/30, p < 0.0001), oligohydramnios (n = 21/30, p < 0.0001) and nicotine abuse (n = 15/30, p < 0.01) were significantly higher compared to the control group. Postnatal data showed significantly lower pH values in group I (p < 0.01). 40 % of the fetuses with reverse flow died in utero whereas in 67 % the reverse flow was accompanied by an insufficiency of the placenta (IUGR, oligohydramnios, histopathological abnormalities of the placenta). None of the fetuses in the control group died in utero. The incidence of IUGR (< 5ht percentile) was 83 % in group I but only 3 % in group II. The perinatal and overall mortality (including neonatal mortality 7 - 28 days after birth) amounted to 27 % and 53 % in group I, respectively, compared to 3 % and 0 % in the control group (p < 0.001). In addition cerebral anomalies could be found by ultrasound in 50 % of the neonates who presented a reverse flow prenatally. In 28 % of the surviving newborns an intracerebral hemorrhage (ICH) could be detected. None of the newborns of group II developed an ICH. CONCLUSIONS Pregnancies with a reverse flow in the umbilical artery and/or fetal aorta have to be considered as a high risk group with a poor prognosis. The reverse flow is mainly caused by chronic placental insufficiency with IUGR. With respect to the further neuromotor development the incidence and severity of cerebral lesions in affected fetuses should be considered when discussing the perinatal situation with the parents.

OBJECTIVE The ovarian stimulation increase the estradiol concentration in comparison to the one observed in the menstrual cycle. The aim of the study was to determine the influence of ovarian stimulation on serum concentrations of lipids and ketone bodies in patients undergoing IVF/ICSI treatment. PATIENTS AND METHODS 50 patients were included in this study. All patients underwent an ovarian stimulation either with recombinant follicle stimulating Hormone (Gonal-F, n = 28) or human menopausal gonadotropin (Menogon, n = 22) after pituitary down-regulation with Goserelin or Triptorelin. Five blood samples were taken: before treatment, at the beginning of ovarian stimulation, on the day of HCG injection for the ovulation induction, on the day of follicle aspiration and 14 days after embryo transfer. Afterwards, the samples were analysed with regard to the concentrations of triglyceride, total-cholesterol, HDL-/LDL-cholesterol, acetoacetate, beta-hydroxybutyrate and alpha-ketoglutarate. RESULTS During the ovarian stimulation, total-cholesterol andA'LDL-cholesterol decreased significantly (p(Chol) < or = 0.001; p(LDL) < or = 0.001), whereas the concentration of HDL-cholesterol increased significantly (p(HDL) < or = 0.001). Furthermore, a significant increase of beta-hydroxybutyrate and alpha-ketoglutarate has been detected (p(HBS) = 0.039; p (KG) = 0.023). CONCLUSIONS The observed changes in serum concentrations of lipids and ketone bodies began with the application of gonadotrophins for stimulation and persisted until the end of the treatment. Therefore, the increase of estradiol, stimulated by gonadotrophins, seems to be responsible for the changes in the serum concentrations of lipids and ketone bodies. All women undergoing ovarian stimulation should be monitored for long-term thrombogenic and atherogenic risks.

Background Fetuses with a reversed enddiastolic flow in the umbilical artery and/or aorta are at risk pregnancies and show a higher incidence of perinatal morbidity and mortality. The aim of this study was to evaluate the pathological changes in the terminal villous tree in fetuses with a reverse flow in the fetal aorta or umbilical artery. Materials and methods In this retrospective study, 16 cases with a reverse flow in the fetal aorta or umbilical artery (Gr. 1) were compared with gestational age matched 16 healthy pregnant women (Gr. 2). The following morphometric parameters were evaluated in 50 sections in each placenta (1600 measurements): mean vessel diameter, volume density of the villous tissue, stem villi and terminal villi. Measurements were performed using a computerized Video Image Analysis system. Results The mean gestational age at birth was similar in both groups (30 + 4 weeks gestation vs. 30 + 6 weeks gestation, respectively, for Gr. 1 and Gr. 2). The birth weights (985 g vs. 1780 g) and the placental weights (216 g vs. 385 g) were significantly lower in the reverse flow group. There was a significant reduction in the proportion of total villous tissue (19 % versus 45 %) and in the diameter of tissue at the terminal villi (2.1 % versus 7.6 %) in the reverse flow group. Although the mean number of vessels at the terminal villi was lower than the control group (4.1 versus 5.6), the mean and total areas of the vessels were not different. Conclusion Our observations showed a significant association between the placental morphometric parameters and reversed enddiastolic flow in the umbilical artery or fetal aorta. The reduced number of functional placental units is responsible for the diminished exchange function of the placental vessels in "reverse flow" cases. This could partially explain the adverse outcome in this clinical situation.

Objective: Evaluation of the influence of postmenopausal hormone replacement therapy (HRT) on microcirculation. Patients and Methods: Using the method of video-capillary microscopy, we compared blood flow velocity in capillaries and vascular reactivity to ischaemic stress in 22 postmenopausal women under HRT receiving either estrogens only or estrogens combined with gestagens and in 24 postmenopausal women without HRT. Additionally, we analysed serum levels of estrogen and follitropin alpha, haematocrit, plasma viscosity, as well as erythrocyte and platelet aggregation. Results: Postmenopausal hormone replacement therapy leads to a significant increase (p=0.003) of 0.125mm/s (18%) of blood flow velocity in capillaries and to a significant reduction (p = 0.038) of 0.54 (29%) of the index for vascular reactivity to ischaemic stress. This reflects a vasodilatation of capillaries under HRT. The further dilatation due to ischaemic stress seems to be limited. There were no significant differences between the women receiving estrogens only compared to females taking estrogens combined with gestagens. Furthermore, we found no correlation between the serum levels of estrogens and the dynamic parameters of the microcirculatory system. Under HRT, there was a significant reduction of the erythrocyte aggregation (p = 0.011), whereas the other rheological parameters showed no significant differences. Conclusion: Postmenopausal hormone replacement therapy leads to an increased perfusion in capillaries. These changes in the microcirculatory system are most likely a result of a direct effect of female sex steroids on the vessels, whereas rheological changes seem to play a minor role in the alteration of capillary blood flow.

The aim of this study was to determine the relationship between the ovarian stimulation protocol (with HMG or FSH) after down-regulation with GnRH anologa and protein (total protein and albumin) as well as bilirubin and urea in serum. Furthermore, it was intended to find out the effect of these parameters on IVF/ICSI outcome. 50 patients were included in this study. All patients underwent controlled ovarian hyperstimulation for assisted reproduction therapy either with FSH (Gonal-F) or HMG (Menogon). Ovulation induction was induced by human chorionic gonadotrophine (HCG, Predalon) 10 000 IU i. m. The protein concentration (total protein, albumin) as well as bilirubin and urea concentrations were determined before down-regulation with GnRHa, at the beginning of ovarian stimulation with FSH or HMG, on the day of ovulation induction with HCG, during oocyte retrieval and fourteen days after embryo transfer. The age, body mass index and etiology of infertility showed no significant difference between patients stimulated with HMG or FSH. Total protein and albumin concentration decreased significantly (p=0.001) from 77.45 +/- 5.90 g/L and 47.02 +/- 3.41 g/L to 74.60 +/- 4.6 g/L and 45.04 +/- 2.39 g/L, respectively at the time of oocyte retrieval. Whereas, no significant change with bilirubin and urea concentration was observed. However, the mean concentration of total protein, albumin, bilirubin of patients who become pregnant was higher of those who did not. In conclusion, this study shows that total protein and albumin concentration in plasma decreased during the follicular phase significantly with the application of exogenous gonadotrophins and steroid hormones in comparison to the value before down-regulation. The mean value of total protein, albumin, bilirubin of patients who become pregnant was higher (but not significant) of those who did not. However, the high individual variation in the present results shows that these parameters are not useful as a predictor of IVF/ICSI outcome.

SummaryThe monoclonal antibody MAb-170 is directed against adenocarcinomas of different origin. Recent experience in radioimmunoscintigraphy revealed a positive uptake of this MAb in peritoneal metastases of ovarian carcinoma (FIGO lll/IV). Aim: The present investigation should clarify the question whether this antibody could be of use in an adjuvant intraperitoneal radioimmunotherapy (RIT) in patients with minimal residual disease after first-look surgery. Methods: Four patients underwent intraperitoneal application of Tc-99m MAb-170. Subsequent quantitative whole-body scintigraphy, serum and urine sampling were performed for a 48 h period. In one case tumour tissue specimen were sampled during the first surgical procedure 15 h p.L Results: The quantitative evaluation revealed no relevant accumulation in liver, spleen and bone marrow never exceeding 5 % of the whole-body activity. The critical organs are the kidneys that showed 8 to 11 % uptake at 24 h pi. The effective serum curve had a maximum at 24 h pi, the second phase gave a elimination half-time of 53 h. Assuming the worst case, the mean dose to red bone marrow was 0.3 Gy/370 MBq injected dose (ID). Conclusion: These results confirm that a RIT with Re-186 MAb-170 is feasible with activities of up to 3.7 GBq. A kit for labelling MAb-170 with Perrhenate is under investigation.

OBJECTIVES The intrauterine growth retardation (IUGR) contributes specially to perinatal mortality and morbidity. An effective treatment is not yet available. The purpose of this study is to analyse the perinatal data of a cohort with IUGR-infants including mortality and morbidity and to describe prematurity and IUGR as a combination of high risk. STUDY DESIGN We have analysed the perinatal data of a cohort of 220 patients with IUGR-infants including mortality and morbidity. Regularly we examined fetal ultrasonographic growth, doppler measurements of fetal and maternal vessels and CTG, as well as indicated amniocentesis, placentesis and cordocentesis. Entry criteria were: normal menstrual period before pregnancy, clear gestational age, complete history of pregnancy. RESULTS At the Department of Gynaecology & Obstetrics, University Hospital, Homburg/Saar, the incidence of IUGR (< 10th Percentile) in premature babies and newborns was 13.1% over five years (1993-1997). The percentage of premature babies with IUGR was 18.6%. The overall mortality was 4.1%, the perinatal mortality was 3.6% and the neonatal mortality was 2.7%. In 1.4% intrauterine foetal death was observed, all associated with a birthweight below the 3th percentile. The average duration of pregnancy was 34 + 4 weeks. A high perinatal mortality of 13.1% and an overall mortality of 14.7% was observed. 11.4% of the premature babies with IUGR showed deformities and about 2% presented chromosome aberrations. 46.4% of children have been transferred to the Neonatal Intensive Care Unit. 57.1% of the postnatal complications have been related to the lungs, 26.5% to the cardiovascular system and 14.3% to the cerebrum. Maternal complications were referred to: SIH/EPH-gestosis (65.4%), HELLP-syndrome (5.8%), nicotine abuse (31.4%), pregnancy anaemia (17.3%) and gestational diabetes with insuline therapy (7.7%). On the placental site the most noticeable conditions have been placental insufficiency (40.6%) and placental infarction (28.7%). CONCLUSION Children with IUGR are exposed to high perinatal mortality and postnatal morbidity. Premature babies in association with an IUGR are at high risk. The surveillance of the pregnant women and the new-born children should be performed in a perinatal centre.

OBJECTIVE: To determine the effect of hypertensive disorders in pregnancy on the neonatal outcome of growth restricted fetuses. There is conflicting data on the effect of hypertension during pregnancy on the incidence of neonatal respiratory distress syndrome (RDS) and intraventricular hemorrhage. Some studies report a lower incidence of RDS and intraventricular hemorrhage in infants of hypertensive mothers, whereas other studies report a similar or higher incidence in infants born to hypertensive mothers. STUDY DESIGN: We performed a retrospective analysis of 220 growth restricted fetuses born between January 1, 1996 to July 1, 1997 at the Department of Obstetrics and Gynecology of the University-Hospital at Homburg/Saar. Data were obtained by review of the medical records. Growth restricted infants born to preeclamptic women or women with HELLP syndrome were compared to growth restricted fetuses born to mothers without hypertensive disorders. RESULTS: Growth restricted fetuses born to hypertensive mothers had a significant lower birth weight (p < 0.05). The incidence of RDS in children born to hypertensive mothers was significantly higher (p < 0.05, p < 0.01) and they stayed significantly longer in the neonatal intensive care unit (p < 0.01). In contrast to infants born to mothers with HELLP syndrome (n = 7) there was no difference in the incidence of intraventricular hemorrhage, infection, sepsis, necrotizing enterocolitis or cardiac complications (arrhythmia, insufficiency) in case of preeclampsia (n = 68). The perinatal mortality of infants born to hypertensive mothers was significantly higher (p < 0.05, p < 0.01). CONCLUSION: This study does not support the contention that hypertensive disorders in pregnancy have a beneficial effect on the postnatal course of IUGR infants.

Introduction: The efficiency of mammography screening in highly specialized diagnostic centres has been well proven for the age group 50-64 years. Few data is available concerning the value of such a screening under decentralised, population-wide conditions. Since 1992, a mammography screening program (LMSP) organised in this way is being offered in Luxembourg to the age group 50-64 years. Materials and methods: The early outcome indicators of this screening programme were evaluated retrospectively. The pathological characteristics of all the diagnosed breast cancers, their diagnosis and their therapy before (1989) and after (1993) the introduction of the mammography screening programme were compared and analysed. Results: The early outcome indicators of Luxembourg's mammography screening programme were just below the comparable values of other specialised centres. Since the introduction of this programme one notes a significant increase in the number of open breast biopsies in comparison to the period before the screening programme (p = 0.0001), with a highly significant increase in benign biospies (p=0.00001). The ratio cancer/all biopsies dropped non-significantly from 0.35 to 0.28 (p = 0.09). Atypical proliferative hyperplasias and in situ carcinomas increased significantly in number (p = 0.01) as did the number of early invasive cancers (p=0.0015). The lymph node status did not change significantly although there was an increase in node-negative tumours (p=0.11). The number of conservative surgical procedures increased significantly (p = 0.00001). In the age group analysis these changes were significant only in the age group 50-64 years (p=0.0002). All these changes were not only due to the evolution within the screening cohort, but also to the changes among the tumour patients diagnosed outside the screening programme. Conclusion: The early outcome indicators of this mammography screening prove a possible efficiency even under population-wide, non-specialised screening conditions. Nevertheless, studies over a longer period of time will be necessary to analyse the evolution of cancer-specific mortality.

Fibromatosis of the breast is a very rare disease with an incidence of less than 0.2% of all tumours of the breast. Less than 100 cases have been reported so far. A case of fibromatosis of the breast occurring in a 58-year old woman is described in this report. The patient was admitted with a suspected diagnosis of a concealed breast tumour with retraction of the skin for more than 1 year. Mammography was inconspicuous whereas ultrasound revealed a suspicious structure. The histology showed a fibromatosis of the breast of the desmoid type with negative oestrogen and progesterone receptors. It is anticipated that fibromatosis of the breast will behave similiar to fibromatosis occurring at other sites; i.e. as a local aggressive lesion exhibiting a high incidence of local recurrence following incomplete excision. Metastases are not known. There is no indication of mastectomy for fibromatosis of the breast of the desmoid type with no multicentricity. Primary organ-preserving operative therapy should be the aim of all treatment because spontaneous involution and longterm healing were observed. There are no indications of reducing the risk of recidivation by adjuvant postoperative radiotherapy or chemotherapy, whereas many successful treatments by endocrine therapies are described.

Aim: the impact of massive obesity (Broca-lndex >130% and >100kg body weight) on pregnancy, delivery and puerperium were studied in 118 matched pairs. Methods: Match criteria were: age, parity and time of delivery. Results: Massively obese pregnant women were significantly more likely to have an multitude of adverse outcomes, including hypertension antedating pregnancy (p = 0.007; these patients were excluded from the obese group for statistical analysis), oedema, proteinuria, gestational hypertension (each p

The aim of this study was the validation of the minimal Resistance Index (min RI) measured by colour Doppler sonography as parameter of tumour neoangiogenesis. 107 patients with clinically or radiologically diagnosed breast tumour with a sonographically detectable lump had preoperative measurements and analysis of blood flow in the tumour area and in the healthy parenchyma of both breasts. The min RI was compared with histology, menopausal status and age. In all 107 patients blood flow could be measured in the tumour area and in 98% of the bilaterally investigated quadrants. Irrespective of tumour status the mean min RI was lower in the tumour area (0.62) than in the other quadrants of the affected (RI = 0.65, p = 0.002) or contralateral breast (RI = 0.65, p = 0.0003). The mean min RI of benign tumours was 0.60 (+/- 0.11 SD) and of malignant tumours 0.64 (+/- 0.11 SD), this difference was not significant (p = 0.07). Irrespective of tumour status postmenopausal patients had a higher mean min RI than premenopausal patients. This was true for the tumour area (RI = 0.64 vs 0.60, p = 0.11) and also for the quadrants (RI = 0.68 vs 0.62, p = 0.0002). In postmenopausal women there was a statistically significant correlation with age (r = 0.58, p = 0.0001). We conclude that the min RI is of no diagnostic relevance for the classification of breast tumours as benign or malignant.

In a group of 45 patients who had been conventionally irradiated, a multivariate analysis of prognostic factors was performed to find criteria for patient selection for surgery and radiotherapy or radiotherapy only. Nine patients underwent resection of metastases before irradiation. In most cases 10 x 3 Gy over 2 weeks were administered. 28 patients received concomitant hormonal treatment. Complete remission was seen in 30% of the non-operated cases (partial remission 25%). Symptomatic relief was seen in 67% of all cases. Median survival was 4 months (9.5 months after surgery) (p = 0.02). Survival of patients having had simultaneous extracerebral metastases and low Karnofsky performance status was disappointing. All long-time survivors received either hormonal treatment or chemotherapy. Karnofsky performance status and interval between the diagnosis of the primary tumour and the development of brain metastases were the most important prognostic factors. The influence of age and extracerebral metastases was less pronounced. In case of favourable prognostic factors and solitary metastases surgical treatment should be considered. Primary irradiation seems to be appropriate for the majority of patients. In any case an additional hormonal or chemotherapy must be considered. It seems to be questionable if patients with poor Karnofsky performance status and extracerebral metastases should be irradiated.

ZusammenfassungDie Vorteile multimodaler Bildgebung sind in den letzten Jahren beschrieben worden. Zumeist wird diese unter Verwendung kostspieliger Hard- und Software im Bereich des Neurocraniums angewandt. In der vorliegenden Pilotstudie wurde ein einfaches und kostengünstiges Verfahren für Bildfusion im Bereich des Beckens entwickelt. Die Bilddaten von Immunszintigraphie (SPECT) und Magnetresonanztomographie (KST) wurden auf einen Personalcomputer transferiert und mit einem konventionellen Bildbearbeitungsprogramm fusioniert. Die Ergebnisse bei insgesamt elf Patientinnen zeigen, daß hier eine adäquate Bildfusion zu erreichen ist. Die Resultate weisen in Richtung einer höheren Spezifität und Genauigkeit der Methode im Vergleich zu SPECT und KST alleine. Zusammenfassend bestätigt diese Studie, daß alternativ zu den kostspieligen Problemlösungen der Gerätehersteller preisgünstige Alternativen auf der allgemein verfügbaren PC-Plattform möglich sind. Trotz Einschränkungen liefern sie klinisch wertvolle Zusatzinformationen.

Oestrogen receptors were demonstrated immunohistochemically in 120 breast cancer cases; in 90 cases, progesterone receptors were additionally assessed. Immunohistochemical staining was evaluated by the so-called «immuno-reactive score» and quantified densitometrically by a method of computer-assisted image analysis. The measuring method allowed an objective evaluation of the portion of receptor-positive cells, the mean optical density and the distribution pattern of receptor concentrations within receptor-positive nuclei. Image analysis was compared with the semiquantitative evaluation by IRS. In 29 out of 58 weakly stained sections, which were scored as receptor-negative, receptor-positive cells could be demonstrated by image analysis because of the definition of an objective cut-off level for specific staining. Furthermore, three different patterns of distribution of receptor concentration could be distinguished: Type 0: receptor-negative carcinomas Type 1: homogeneous receptor expression within receptor-positive cells Type 2: heterogeneous receptor expression with high receptor concentrations in single cells. Type 2 patterns were almost exclusively found in postmenopausal patients, a dependence of expression pattern from grading was not demonstrated. These distribution patterns were found in the same manner in the expression analysis of progesterone receptor. With immunohistochemical staining only 45% of ER-negative carcinomas expressed PR, but 74% of ER-positive carcinomas. When ER was expressed heterogeneously (Type 2) PR was expressed in the same way in 62 % of the cases. Beneath the exact determination of the portion of receptor-positive cells the analysis of the pattern of distribution is only possible by image analysis. These different distribution patterns of receptor expression are of interest not only for cellular biology but also as potentially important factors for clinical prognosis

In a prospective randomised study, the effects of an intracervical gel containing 0.5 mg PgE2 and an intravaginal tablet containing 3 mg PgE2 were compared in their efficiency to induce delivery at term. When only gel was used, induction failed in 45% of the cases, especially with an initially immature cervix score. However, these patients did show significant improvement of the Bishop score. The vaginal tablet was more effective with regard to the induction of delivery. When using the vaginal tablet alone, induction failed in only 5% of cases (p < 0.001). Best results, however, were obtained with a combination of both application forms. In this group there were no failures. Tablet application induced delivery within 24 hours in 56% of the cases, gel application in only 27% (p < 0.001). There were no significant differences observed in these groups during the course of labour. The length of the latency period was identical, whether a tablet or a gel was used in initiating labour. In 29% of the cases, beta-sympathicomimetics had to be used because of tetanic contractions or polysystolia. No significant differences in the occurrence of these contractions were seen in either the gel or the tablet group. Even in a high-risk collective with 25% pathological Doppler-flow findings, no higher rate of operative deliveries or fetal acidoses was observed after prostaglandin induction, if careful surveillance of the patients and early use of tocolytics in experienced hands were administered. Our results further confirm the concept of a differential induction of labour with prostaglandins.(ABSTRACT TRUNCATED AT 250 WORDS)

In a study group of 41 pregnant women of postpartally confirmed placental abruption, the prognostic value of clinical and diagnostic findings was investigated. The incidence of placental abruption was 1.4% of all deliveries within a three-year interval. 51% of patients showed vaginal bleeding before delivery. Retroplacental haematoma was found in 49% of cases ultrasonographically. A total of 75% had a pathological CTG test. More than 95% of these findings occurred within 3 days before delivery. Abnormal Doppler flow findings in foetal vessels more than 3 days before delivery were seen in 62% of cases. In the last three days before delivery, 86% were abnormal. Preterm delivery before 37 weeks of gestation was registered in 82% of patients. Perinatal mortality amounted to 12%. The rate of severely dystrophic newborn was 30%. Even in cases with lack of the clinical and/or sonographical findings, the possibility of placental abruption should be considered, if an acute deterioration of cardiotocographic or Doppler-sonographic findings.

From 1970-1990, 159 patients with invasive malignant tumours of the vulva (150 squamous cell carcinomas) underwent surgery at the University Hospitals, department of gynaecology. Heidelberg (1970-1988) and Homburg/Saar (1988-1990). 73% of the patients were more than 60 years old and 3% were less than 40 years old. The mean age was 69 years. 30% of the patients had diabetes mellitus. As a standard therapy, 101 patients had radical vulvectomy with bilateral inguinal node removal in accordance with S. Way. If nodes were found to be positive, the inguinal/pelvic region was irradiated postsurgically with 40-50 Gy. The 5 years survival rate for all patients with vulvar carcinoma was 69%. For early stage carcinomas (pT1, depth of invasion 10 mm (p < 0.001), if stage was pT1 as opposed to pT2 to pT4 (p < 0.001) or if lymphangiosis carcinomatosa (p < 0.01) was present or not. Prognostic differences were also noticed, if cytological grading was done in accordance with Broders (p < 0.09). 27 patients had successful reconstructive surgery with local cutaneous or myocutaneous flaps at the time of initial surgery. The median recovery period after radical vulvectomy with bilateral inguinal lymph node excision was 22 days. The median recovery period after radical vulvectomy with bilateral node removal and reconstructive surgery was 25 days. Early recurrence of carcinoma (< or = 6 months after initial therapy) was 5.9%, late recurrence was 12%.

At the University Hospitals of Heidelberg (1970-1988) and Homburg/Saar (1988-1990), 182 patients with vulvar carcinoma were treated. 51 patients had a recurrence of vulvar carcinoma and 21 patients showed a persistence of this tumour. 19 women had a second recurrence of vulvar disease. In these cases, therapy ranged from local surgery to exenteration, depending on the site and tumour extension. 18 patients underwent successful reconstructive surgery. Prognosis was better in cases with local recurrence in comparison to distant sites of metastatic progression (i.e. inguinal nodes or disseminated disease) (p less than 0.001). The five-year survival (after diagnosis of recurrent disease) for patients with early onset of recurrence (less than 20 months after initial therapy) was 28% compared to 68% for patients with late onset of recurrent disease (p less than 0.01).

At present, there is an increasing discussion regarding the change of the prostacyclin/thromboxane ratio as an aetiological factor of pregnancy-induced hypertension (PIH). By means of videophotometric capillaroscopy in the capillaries of the nailfold, it is possible to visualise the resulting changes in the microcirculation. This method employs a special illumination microscope (magnification of the optical system x 560). Red blood cell velocity is measured under test conditions and microcirculatorical reaction capacity on ischaemic stress. Studies were conducted on healthy non-pregnant women and on healthy pregnant women as well as on patients suffering from pregnancy-induced hypertension. A markedly reduced velocity of red blood cells in patients with pregnancy-induced hypertension was seen as a sign of vasoconstriction, namely, 0.53 mm/sec. versus 0.74 mm/sec. Furthermore, these patients have a higher reactivity to ischaemic stress, probably also as a result of the already existing vasoconstriction; however, the duration of the hyperaemic phases is reduced in pregnancy-induced hypertension. By this method, an insight can be gained into microcirculation in pregnancy and in pregnancy-induced hypertension. In addition, as preliminary studies have already shown, the influence exercised by different medications on microcirculation can be assessed.

The endometrial carcinoma shows an increasing incidence and represents today the most frequent malignoma of the female pelvis. Until now all techniques of detection of this carcinoma or its precursors are invasive and thus are not suitable for screening investigations. Vaginosonography, as the first non-invasive diagnostic method, now supplies knowledge about the state of the endometrium. At the Gynaecological Department of the University of Homburg/Saar, West Germany, 221 patients had been preoperatively subjected to vaginosonography before they underwent surgery. Sonographical and histological findings corresponded in atrophic endometrium in 82%, in regular, perimenopausal endometrium in 91%, in endometrial polyps and hyperplasia of the endometrium in 56%, and in endometrial carcinoma in 79%. With regard to the detection of endometrial cancer, a specificity of 96%, a sensitivity of 93%, a positive predictive value of 79% and an accuracy of 96% were established. Thus, according to our experience, vaginosonography represents a valid, non-invasive diagnostical method as a suitable instrument for screening the endometrium.

Of 1950 pregnant patients (2870 Doppler ultrasound measurements) we observed, in a study group with highly abnormal Doppler-flow findings (n = 66, Feb. 1990), a correlation of Doppler flow and FHR-recordings. Among these 66 patients we retained 60 (91%) in the hospital. They had at least 2 FHR-recordings a day. The results of Doppler flow measurements in the fetal aorta and umbilical artery correlated well with diagnosis of IUGR. The comparison of the overall results of both fetal vessels did not indicate any significant difference. In 21% of all patients with highly abnormal Doppler flow findings, was no abnormal FHR record until delivery. 26% already showed an abnormal non-stress test before the first pathological Doppler assessment, in 44% abnormal FHR-recordings were observed later than the first abnormal Doppler flow finding in the course of pregnancy. The median interval was 13.5 days in cases with increased Doppler flow parameters but with detectable end-diastolic blood flow and was reduced to 8 days in cases with absent end-diastolic blood flow. In 9% of all cases, abnormal results were found with both methods on the same day. In 32% we observed a reproducible notch in Doppler flow velocimetry of uteroplacental vessels. The rate of congenital malformations was 14%. Thus abnormal Doppler flow signals can be estimated as "early" prognostic criterias for a compromised fetus at risk.

160 woman patients in whom the course of pregnancy was uneventful or pathological (intrauterine growth retardation, percentile less than 5) were investigated at the Department of Obstetrics and Gynaecology of the University of Homburg/Saar between the 28th and 42nd week of pregnancy, using a newly developed cardiotocograph (HP M1350A Hewlett-Packard, Boblingen, FRG). By means of the kinetocardiotocogram (KCTG), fetal mobility (fetal movements of the whole body or of the extremities) was recorded simultaneously with the conventional recording of the fetal heart rate and uterine contractions. One of the aims in developing the KCTG was to record as far as possible all fetal movements synchronous to the recordings of heart rate and uterine contractions. To this end, the recording algorithm of the KCTG was adapted to the examination results obtained by two simultaneously operating ultrasound investigators. After the 28th week of pregnancy it was possible to record by the KCTG fetal "movement clusters" (combined body and limb movements) independent of the weight of the fetus and of amniotic fluid volume or positional anomalies, reliably and with good correlation with the results of the sonographic control investigations (r = 0.88-0.97). In cases of intrauterine growth retardation (percentile less than 5) a significantly reduced motility was observed on average as early as 13 days before delivery (p less than 0.005). It must be emphasized that, at this stage, most of the antenatal CTGs were normal. These findings indicate that KCTG can contribute to improved monitoring in high-risk pregnancies.

This study describes a comparison between two different ultrasound methods used to localize a low-lying placenta or a placenta previa. The methods implemented were the abdominal ultrasound and the so-called "perineal scan", an ultrasound examination of the female urogenital tract, which is performed by using the perineum as an acoustic window. Between 1985 and 1988, 84 patients, suspected of having a low-lying placenta, were examined by perineal scanning. In all these cases it was possible to compare the results with those of abdominal ultrasound examinations documented in the patient's records. The "perineal scan"-examinations were performed "blind", i.e., without knowledge of the results of prior abdominal ultrasound. Abdominal sonography was performed by a different examiner using the full-bladder-technique. Perineal scanning was done a short time after voiding. The results showed considerable and significant (p less than 0.001) discrepancies between the two methods; perineal scanning more often demonstrated higher grade diagnoses (27 patients, 32%) than vice versa (9 patients, 11%). These differences may be at least partially explained by the influence of bladder distension. Probably a full bladder produces false negative results more often than previously suspected. An analysis of pregnancy outcome yielded positive predictive values of 78% (abdominal ultrasound) and 86% (perineal scanning). Perineal scanning therefore seems to provide an uncomplicated and reliable means to verify an abdominal placenta localisation.

In 50 cases with an end-diastolic zero flow or reverse flow all antenatal and perinatal abnormalities have been recorded. The fetal outcome was registered. The percentage of highly dystrophic newborns (percentile less than 5) was 88%. The perinatal mortality counted up to 16% and the percentage of congenital malformations (including chromosomal anomalies) was 12%. A reverse flow was registered in 4 cases. The perinatal mortality of those cases with reverse flow was 100%. In approx. one-quarter of those pregnancies and in 50% of the perinatally deceased newborns, there were no pathological or suspicious changes in the antepartal and/or subpartal CTG-recordings. The Duplex sonographical diagnosis of an end-diastolic zero flow/reverse flow, has a highly positive predictive value, whereas its sensitivity is low. It can be regarded as a very helpful parameter in clinical diagnosis, particularly as it is independent of borderline values. The correct choice of the high-pass wall filter (50-100 Hz) is important.

7000 pregnancies were analysed after genetic amniocentesis in respect of the further course and results of prenatal diagnosis (observation period 1975-1988). In 3.1% (217 cases) samples of amniotic fluid were discoloured. Vaginal haemorrhages prior to amniocentesis were recorded with significantly higher incidence (18%) in patients with discoloured amniotic fluid than in a control group (n = 217) with normal colour of the amniotic fluid (4.6%) (p less than 0.001). Miscarriages and chromosome anomalies occurred more often in the study group (3.7%/2.8%, control group: 0.9%/1.8%, n.s.). The risk of miscarriages was increased in cases with sanguineous amniotic fluid if the amniotic fluid alpha-fetoprotein values were enhanced at the same time. Significant differences were observed in respect of the incidence of foetal malformations in patients with discoloured amniotic fluid (7.8%) and in the control group (2.3%) (p less than 0.01). Borderline or definitely pathological amniotic fluid AFP concentrations were found often if the amniotic fluid was discoloured (6.9%, control group 3.2%). If discoloured amniotic fluid was sampled, foetal malformations should be excluded sonographically. In 82% of all cases with discoloured amniotic fluid and foetal malformations pathological sonographic findings and/or enhanced MS-AFP values were recorded even prior to amniocentesis.

A study on histological findings in 1047 patients who underwent total axillary lymph node dissection (topographical levels I-III), was conducted. A mean of 20.3 lymph nodes (LN) was assessed; LN metastases were detected in 492 cases. Retrospective analysis showed that, by mere dissection of LNs level I, 10 of the 492 nodal positive cases (2.0%) would have been classified false negative. Additionally, according to the number of positive LNs detected in stage I, 85 of the 492 patients (17%) would have been assigned to a group with a better prognosis (prognostic groups 1-3, 4-9, greater than or equal to 10 pos. LNs). By mere dissection of LNs levels I and II, only 1 of 492 (0.2%) patients would have been categorized false negative and only 24 patients (5%) would have been included in a group with a better prognosis, on the basis of the number of positive LNs dissected. Thus dissection of LNs stages I and II provides sufficient prognostic information. Since, however, in 145 nodal positive cases (14% of the entire collective e.g. 29.5% of all patients with positive lymph nodes), metastases were detected in level III, these LNs should be removed as well, in order to prevent axillary recurrences. One could only dispense with dissection of level III, if LN metastases levels I and II could be excluded during the operation.