Tam Metin - Marmara Medical Journal

Transkript

Marmara Medical Journal
Marmara Üniversitesi Tıp Fakültesi Dergisi
Editör
Prof. Dr. Mithat Erenus
Koordinatörler
Seza Arbay, MA
Dr. Vera Bulgurlu
Editörler Kurulu
Prof. Dr. Mehmet Ağırbaşlı
Prof. Dr. Serpil Bilsel
Prof. Dr. Safiye Çavdar
Prof. Dr. Tolga Dağlı
Prof. Dr. Haner Direskeneli
Prof. Dr. Kaya Emerk
Prof. Dr. Mithat Erenus
Prof. Dr. Zeynep Eti
Prof. Dr. RainerVV. Guillery
Prof. Dr. Oya Gürbüz
Prof. Dr. Hande Harmancı
Prof. Dr. Hızır Kurtel
Prof. Dr. Ayşe Özer
Prof. Dr. Tülin Tanrıdağ
Prof. Dr. Tufan Tarcan
Prof. Dr. Cihangir Tetik
Prof. Dr. Ferruh Şimşek
Prof. Dr. Dr. Ayşegül Yağcı
Prof. Dr. Berrak Yeğen
Doç. Dr. İpek Akman
Doç. Dr. Gül Başaran
Doç. Dr. Hasan Batırel
Doç. Dr. Nural Bekiroğlu
Doç. Dr. Şule Çetinel
Doç. Dr. Mustafa Çetiner
Doç. Dr. Arzu Denizbaşı
Doç. Dr. Gazanfer Ekinci
Doç. Dr. Dilek Gogas
Doç. Dr. Sibel Kalaça
Doç. Dr. Atila Karaalp
Doç. Dr. Bülent Karadağ
Doç. Dr. Handan Kaya
Doç. Dr. Gürsu Kıyan
Doç. Dr. Şule Yavuz
Asist. Dr. Asım Cingi
Asist. Dr. Arzu Uzuner
Marmara Üniversitesi T p Fakültesi Dergisi
DERGİ HAKKINDA
Marmara Medical Journal, Marmara Üniversitesi Tıp Fakültesi tarafından
yayımlanan multidisipliner ulusal ve uluslararası tüm tıbbi kurum ve personele
ulaşmayı hedefleyen bilimsel bir dergidir. Marmara Üniversitesi Tıp Fakültesi
Dergisi, tıbbın her alanını içeren özgün klinik ve deneysel çalışmaları, ilginç olgu
bildirimlerini, derlemeleri,
davet edilmiş derlemeleri, Editöre mektupları,
toplantı, haber ve duyuruları, klinik haberleri ve ilginç araştırmaların özetlerini ,
ayırıcı tanı, tanınız nedir başlıklı olgu sunumlarını, , ilginç, fotoğraflı soru-cevap
yazıları (photo-quiz) ,toplantı, haber ve duyuruları, klinik haberleri ve tıp
gündemini belirleyen güncel konuları yayınlar.
Periyodu: Marmara Medical Journal -Marmara Üniversitesi Tıp Fakültesi Dergisi
yılda 3 sayı olarak OCAK,MAYIS VE EKİM AYLARINDA yayınlanmaktadır.
Yayına başlama tarihi:1988
2004 Yılından itibaren yanlızca elektronik olarak
yayınlanmaktadır
Yayın Dili: Türkçe, İngilizce
eISSN: 1309-9469
Temel Hedef Kitlesi: Tıp alanında tüm branşlardaki hekimler, uzman ve öğretim
üyeleri, tıp öğrencileri
İndekslendiği dizinler: EMBASE - Excerpta Medica ,TUBITAK - Türkiye Bilimsel
ve Teknik Araştırma Kurumu , Türk Sağlık Bilimleri İndeksi, Turk Medline,Türkiye
Makaleler Bibliyografyası ,DOAJ (Directory of Open Access Journals)
Makalelerin ortalama değerlendirme süresi: 8 haftadır
Makale takibi -iletişim
Seza Arbay
Marmara Medical Journal (Marmara Üniversitesi Tıp Fakültesi Dergisi)
Marmara Üniversitesi Tıp Fakültesi Dekanlığı,
Tıbbiye cad No:.49 Haydarpaşa 34668, İSTANBUL
Tel: +90 0 216 4144734
Faks: +90 O 216 4144731
e-posta: [email protected]
Yayıncı
Plexus BilişimTeknolojileri A.Ş.
Tahran Caddesi. No:6/8, Kavaklıdere, Ankara
Tel: +90 0 312 4272608
Faks: +90 0312 4272602
Yayın Hakları: Marmara Medical Journal ‘in basılı ve web ortamında yayınlanan yazı, resim,
şekil, tablo ve uygulamalar yazılı izin alınmadan kısmen veya tamamen herhangi bir vasıtayla
basılamaz. Bilimsel amaçlarla kaynak göstermek kaydıyla özetleme ve alıntı yapılabilir.
www.marmaramedicaljournal.org
Marmara Üniversitesi Tıp Fakültesi Dergisi
YAZARLARA BİLGİ
Marmara Medical Journal – Marmara
Üniversitesi Tıp Fakültesi Dergisine ilginize
teşekkür ederiz.
Derginin elektronik ortamdaki yayınına
erişim www.marmaramedicaljournal.org
adresinden serbesttir.
Marmara Medical Journal tıbbın
klinik
ve
deneysel
alanlarında
özgün
araştırmalar, olgu sunumları, derlemeler,
davet edilmiş derlemeler, mektuplar, ilginç,
fotoğraflı soru-cevap yazıları (photo-quiz),
editöre mektup , toplantı, haber ve
duyuruları,
klinik
haberleri
ve
ilginç
araştırmaların özetlerini yayınlamaktadır.
Yılda 3 sayı olarak Ocak, Mayıs ve Ekim
aylarında
yayınlanan
Marmara
Medical
Journal
hakemli
ve
multidisipliner
bir
dergidir.Gönderilen
yazılar
Türkçe
veya
İngilizce olabilir.
Değerlendirme süreci
Dergiye gönderilen yazılar, ilk olarak
dergi standartları açısından incelenir. Derginin
istediği forma uymayan yazılar, daha ileri bir
incelemeye gerek görülmeksizin yazarlarına
iade edilir. Zaman ve emek kaybına yol
açılmaması için, yazarlar
dergi kurallarını
dikkatli incelemeleri önerilir.
Dergi kurallarına uygunluğuna karar
verilen yazılar Editörler Kurulu tarafından
incelenir ve en az biri başka kurumdan olmak
üzere iki ya da daha fazla hakeme gönderilir.
Editör, Kurulu yazıyı reddetme ya da
yazara(lara) ek değişiklikler için gönderme
veya
yazarları
bilgilendirerek
kısaltma
yapmak hakkına sahiptir.
Yazarlardan
istenen değişiklik ve düzeltmeler yapılana
kadar,
yazılar
yayın
programına
alınmamaktadır.
Marmara Medical Journal gönderilen
yazıları
sadece
online
olarak
http://marmaramedicaljournal.org/submit.
adresinden kabul etmektedir.
Yazıların bilimsel sorumluluğu yazarlara
aittir. Marmara Medical Journal yazıların
bilimsel sorumluluğunu kabul etmez. Makale
yayına kabul edildiği takdirde Yayın Hakkı
Devir Formu imzalanıp dergiye iletilmelidir.
Gönderilen yazıların dergide yayınlanabilmesi
için daha önce başka bir bilimsel yayın
organında yayınlanmamış olması gerekir.
Daha önce sözlü ya da poster olarak
sunulmuş
çalışmalar,
yazının
başlık
sayfasında
tarihi
ve
yeri
ile
birlikte
belirtilmelidir. Yayınlanması için başvuruda
bulunulan makalelerin, adı geçen tüm
yazarlar tarafından onaylanmış olması ve
çalışmanın başka bir yerde yayınlanmamış
olması
da
yayınlanmak
üzere
ya
değerlendirmede olmaması gerekmektedir.
Yazının son halinin bütün yazarlar tarafından
onaylandığı ve çalışmanın yürtüldüğü kurum
sorumluları
tarafından
onaylandığı
belirtilmelidir.Yazarlar tarafından imzalanarak
onaylanan üst yazıda ayrıca tüm yazarların
makale
ile
ilgili
bilimsel
katkı
ve
sorumlulukları yer almalı, çalışma ile ilgili
herhangi bir mali ya da diğer çıkar çatışması
var ise bildirilmelidir.( * )
( * ) Orijinal araştırma makalesi veya vaka
sunumu ile başvuran yazarlar için üst yazı
örneği:
"Marmara Medical Journal'de yayımlanmak
üzere sunduğum (sunduğumuz) "…-" başlıklı
makale,
çalışmanın
yapıldığı
laboratuvar/kurum
yetkilileri
tarafından
onaylanmıştır. Bu çalışma daha önce başka
bir dergide yayımlanmamıştır (400 sözcük –
ya da daha az – özet şekli hariç) veya
yayınlanmak
üzere
başka
bir
dergide
değerlendirmede bulunmamaktadır.
Yazıların hazırlanması
Derginin
yayın
dili
İngilizce
veya
Türkçe’dir. Türkçe yazılarda Türk Dil Kurumu
Türkçe
Sözlüğü
(http://tdk.org.tr) esas
alınmalıdır. Anatomik terimlerin ve diğer tıp
terimlerinin
adları
Latince
olmalıdır.
Gönderilen yazılar, yazım kuralları açısından
Uluslararası Tıp Editörleri Komitesi tarafından
hazırlanan “Biomedikal Dergilere Gönderilen
Makalelerde Bulunması Gereken Standartlar “
a ( Uniform Requirements For Manuscripts
Submittted to Biomedical Journals ) uygun
olarak hazırlanmalıdır.
(http://www. ulakbim.gov.tr /cabim/vt)
Makale içinde kullanılan kısaltmalar
Uluslararası kabul edilen şeklide olmalıdır
(http..//www.journals.tubitak.gov.tr/kitap/ma
knasyaz/)
kaynağına
başvurulabilir.
Birimler, Ağırlıklar ve Ölçüler 11. Genel
Konferansı'nda
kabul
edildiği
şekilde
Uluslararası Sistem (SI) ile uyumlu olmalıdır.
Makaleler
Word,
WordPerfect,
EPS,
LaTeX, text, Postscript veya RTF formatında
hazırlanmalı, şekil ve fotoğraflar ayrı dosyalar
halinde TIFF, GIF, JPG, BMP, Postscript, veya
EPS formatında kabul edilmektedir.
Yazı kategorileri
Yazının gönderildiği metin dosyasının
içinde sırasıyla, Türkçe başlık, özet, anahtar
sözcükler, İngilizce başlık, özet,
İngilizce
anahtar
sözcükler,
makalenin
metini,
kaynaklar, her sayfaya bir tablo olmak üzere
tablolar ve son sayfada şekillerin (varsa) alt
yazıları şeklinde olmalıdır. Metin dosyanızın
içinde, yazar isimleri ve kurumlara ait bilgi,
makalede
kullanılan
şekil
ve
resimler
olmamalıdır.
Özgün Araştırma Makaleleri
Türkçe ve İngilizce özetler yazı başlığı
ile birlikte verilmelidir.
(i)özetler: Amaç (Objectives), Gereç ve
Yöntem
(Materials and Methods) ya da
Hastalar
ve
Yöntemler
(Patients
and
Methods), Bulgular (Results) ve Sonuç
(Conclusion) bölümlerine ayrılmalı ve 200
sözcüğü geçmemelidir.
(ii) Anahtar Sözcükler Index Medicus
Medical Subject Headings (MeSH) ‘e uygun
seçilmelidir.
Yazının diğer bölümleri, (iii) Giriş, (iv)
Gereç
ve
Yöntem
/
Hastalar
ve
Yöntemler, (v) Bulgular, (vi) Tartışma ve
(vii) Kaynaklar'dır. Başlık sayfası dışında
yazının hiçbir bölümünün ayrı sayfalarda
başlatılması zorunluluğu yoktur.
Maddi kaynak , çalışmayı destekleyen
burslar, kuruluşlar, fonlar, metnin sonunda
teşekkürler kısmında belirtilmelidir.
Olgu sunumları
İngilizce ve Türkçe özetleri kısa ve tek
paragraflık olmalıdır. Olgu sunumu özetleri
ağırlıklı olarak mutlaka olgu hakkında bilgileri
içermektedir. Anahtar sözcüklerinden sonra
giriş, olgu(lar) tartışma ve kaynaklar şeklinde
düzenlenmelidir.
Derleme yazıları
İngilizce ve Türkçe başlık, İngilizce ve
Türkçe özet ve İngilizce ve Türkçe anahtar
kelimeler yer almalıdır. Kaynak sayısı 50 ile
sınırlanması önerilmektedir.
Kaynaklar
Kaynaklar yazıda kullanılış sırasına göre
numaralanmalıdır.
Kaynaklarda
verilen
makale yazarlarının sayısı 6 dan fazla ise ilk
3 yazar belirtilmeli ve İngilizce kaynaklarda
ilk 3 yazar isminden sonra “ et al.”, Türkçe
kaynaklarda ise ilk 3 yazar isminden sonra “
ve ark. “ ibaresi kullanılmalıdır.
Noktalamalara birden çok yazarlı bir
çalışmayı tek yazar adıyla kısaltmamaya ve
kaynak sayfalarının başlangıç ve bitimlerinin
belirtilmesine dikkat edilmelidir. Kaynaklarda
verilen dergi isimleri
Index Medicus'a
(http://www.ncbi.nim.nih.gov/sites/entrez/qu
ery.fcgi?db=nlmcatalog) veya Ulakbim/Türk
Tıp Dizini’ne uygun olarak kısaltılmalıdır.
Makale: Tuna H, Avcı Ş, Tükenmez Ö,
Kokino
S.
İnmeli
olguların
sublukse
omuzlarında kas-sinir elektrik uyarımının
etkinliği.
Trakya
Univ
Tıp
Fak
Derg
2005;22:70-5.
Kitap: Norman IJ, Redfern SJ, (editors).
Mental health care for elderly people. New
York: Churchill Livingstone, 1996.
Kitaptan Bölüm: Phillips SJ, Whisnant JP
Hypertension and stroke. In: Laragh JH,
Brenner
BM,
editors.
Hypertension:
Pathophysiology,
Diagnosis,
and
Management. 2nd ed. New York: Raven Pres,
1995:465-78.
Kaynak web sitesi ise:
Kaynak
makalerdeki gibi istenilen bilgiler verildikten
sonra erişim olarak web sitesi adresi ve
erişim tarihi bildirilmelidir.
Kaynak internet ortamında basılan
bir dergi ise:
Kaynak makaledeki gibi
istenilen bilgiler verildikten sonra erişim
olarak URL adresi ve erişim tarihi verilmelidir.
Kongre
Bildirileri:
Bengtsson
S,
Solheim BG. Enforcement of data protection,
privacy and security in medical informatics.
In: Lun KC, Degoulet P, Piemme TE, Rienhoff
O, editors. MEDINFO 92. Proceedings of the
7th World Congress on Medical Informatics;
1992 Sep 6-10; Geneva, Switzerland.
Amsterdam: North-Holland; 1992:1561-5.
Tablo, şekil, grafik ve fotoğraf
Tablo, şekil grafik ve fotoğraflar yazının
içine yerleştirilmiş halde gönderilmemeli.
Tablolar, her sayfaya bir tablo olmak üzere
yazının gönderildiği dosya içinde olmalı ancak
yazıya ait şekil, grafik ve fotografların her biri
ayrı bir imaj dosyası (jpeg yada gif) olarak
gönderilmelidir.
Tablo başlıkları ve şekil altyazıları eksik
bırakılmamalıdır. Şekillere ait açıklamalar
yazının gönderildiği dosyanın en sonuna
yazılmalıdır. Tablo, şekil ve grafiklerin
numaralanarak
yazı
içinde
yerleri
belirtilmelidir. Tablolar yazı içindeki bilginin
tekrarı olmamalıdır.
Makale yazarlarının, makalede eğer daha
önce yayınlanmış alıntı yazı, tablo, şekil,
grafik, resim vb var ise yayın hakkı sahibi ve
yazarlardan yazılı izin almaları ve makale üst
yazısına ekleyerek dergiye ulaştırmaları
gerekmektedir.
Tablolar Metin içinde atıfta bulunulan
sıraya
göre
romen
rakkamı
ile
numaralanmalıdır. Her tablo ayrı bir sayfaya
ve tablonun üst kısmına kısa ancak anlaşılır
bir başlık verilerek hazırlanmalıdır. Başlık ve
dipnot açıklayıcı olmalıdır.
Sütun başlıkları kısa ve ölçüm değerleri
parantez
içinde
verilmelidir.
Bütün
kısaltmalar
ve
semboller
dipnotta
açıklanmalıdır. Dipnotlarda şu semboller:
(†‡¶§) ve P değerleri için ise *, **, ***
kullanılmalıdır.
SD veya SEM gibi istatistiksel değerler
tablo veya şekildin altında not olarak
belirtilmelidir.
Grafik, fotoğraf ve çizimler ŞEKİL olarak
adlandırılmalı, makalede geçtiği sıraya gore
numaralanmalı ve açıklamaları şekil altına
yazılmalıdır Şekil alt yazıları, ayrıca metinin
son sayfasına da eklenmelidir. Büyütmeler,
şekilde uzunluk birimi (bar çubuğu içinde) ile
belirtilmelidir.
Mikroskopik
resimlerde
büyütme
oranı
ve
boyama
tekniği
açıklanmalıdır.
Etik
Marmara Medical Journal’a yayınlanması
amacı
ile
gönderilen
yazılar
Helsinki
Bildirgesi, İyi Klinik Uygulamalar Kılavuzu,İyi
Laboratuar Uygulamaları Kılavuzu esaslarına
uymalıdır. Gerek insanlar gerekse hayvanlar
açısından etik koşullara uygun olmayan
yazılar yayınlanmak üzere kabul edilemez.
Marmara Medical Journal, insanlar üzerinde
yapılan araştırmaların önceden Araştırma Etik
Kurulu tarafından onayının alınması şartını
arar. Yazarlardan, yazının detaylarını ve
tarihini bildirecek şekilde imzalı bir beyan ile
başvurmaları istenir.
Çalışmalar deney hayvanı kullanımını
içeriyorsa, hayvan bakımı ve kullanımında
yapılan
işlemler
yazı
içinde
kısaca
tanımlanmalıdır. Deney hayvanlarında özel
derişimlerde ilaç kullanıldıysa, yazar bu
derişimin kullanılma mantığını belirtmelidir.
İnsanlar
üzerinde
yapılan
deneysel
çalışmaların sonuçlarını bildiren yazılarda,
Kurumsal Etik Kurul onayı alındığını ve bu
çalışmanın yapıldığı gönüllü ya da hastalara
uygulanacak prosedürlerin özelliği tümüyle
kendilerine anlatıldıktan sonra, onaylarının
alındığını gösterir cümleler yer almalıdır.
Yazarlar, bu tür bir çalışma söz konusu
olduğunda, uluslararası alanda kabul edilen
kılavuzlara ve TC. Sağlık Bakanlığı tarafından
getirilen ve 28 Aralık 2008 tarih ve 27089
sayılı Resmi Gazete'de yayınlanan "Klinik
araştırmaları Hakkında Yönetmelik" ve daha
sonra yayınlanan 11 Mart 2010 tarihli resmi
gazete ve 25518 sayılı “Klinik Araştırmalar
Hakkında Yönetmelikte Değişiklik Yapıldığına
Dair Yönetmelik” hükümlerine uyulduğunu
belirtmeli ve kurumdan aldıkları Etik Komitesi
onayını göndermelidir. Hayvanlar üzerinde
yapılan çalışmalar için de gereken izin
alınmalı; yazıda deneklere ağrı, acı ve
rahatsızlık verilmemesi için neler yapıldığı
açık bir şekilde belirtilmelidir.
Hasta
kimliğini
tanıtacak
fotoğraf
kullanıldığında,
hastanın
yazılı
onayı
gönderilmelidir.
Yazı takip ve sorularınız için iletişim:
Seza Arbay
Marmara Universitesi Tıp Fakültesi
Dekanlığı,
Tıbbiye Caddesi, No: 49, Haydarpaşa
34668, İstanbul
Tel:+90 0 216 4144734
Faks:+90 0 216 4144731
e-posta: [email protected]
İÇİNDEKİLER
Orjinal Araştırma
FROM THE ANESTHESIOLOGIST’S PERSPECTIVE RETROSPECTIVE ANALYSIS OF
PERIOPERATIVE COMPLICATIONS OF TRANSSPHENOIDAL PITUITARY SURGERY
Arzu Gerçek, Deniz Konya, Zafer Toktaş, Türker Kılıç, M. Necmettin Pamir……………………….…104
THE ROLE OF CONTRASTED DYNAMIC MULTI-DETECTOR COMPUTERIZED
TOMOGRAPHY IMAGING ON SURGICAL DECISION MAKING IN BREAST CANCER
PATIENTS
Taner Yiğit, Unsal Coskun, Mentes Oner, Cengizhan Yigitler, Gulec Bulent, Müjdat Balkan, Orhan
Kozak, Tufan Turgut……………………………………..…………………………………………...………...109
COMPARING OF THE IMMUNOHISTOCHEMICAL AND MORPHOLOGICAL
FEATURES OF THE TESTICULAR SEMİNOMA AND INTRACRANIAL GERMNOMA
Ahmet Midi, Süheyla Bozkurt, Aydın Sav, M Memet Özek, Necmettin Pamir………………………......116
EVALUATION OF INITIATING, CONTINUING AND WEANING TIME OF
BREASTFEEDING
Ruhusen Kutlu, Kamile Marakoğlu......................................................................................................121
IDIOPATHIC SUDDEN SENSORINEURAL HEARING LOSS
Ufuk Derinsu, Şengül Terlemez, Ferda Akdaş……………………………………………………………....127
Olgu Sunumu
RADIONUCLIDE IMAGING IN DIFFERENTIAL DIAGNOSIS OF TORSION AND
INFECTIONS OF TESTIS AND EPIDIDYMIS REVISITED
Yasemin Şanlı, Işık Adalet, Handan Tokmak, Öner Şanlı, Orhan Ziylan, Sema Cantez…………….…132
SPINOCEREBELLAR ATAXIA TYPE 2 IN A TURKISH FAMILY
Kadriye Ağan, Deniz Kutlu, Nazlı Başak, Önder Us, Dilek İnce-Günal…….…………………...……...135
AN UNUSUAL CASE OF MULTIFOCAL MOTOR NEUROPATHY WITH CRANIAL
NERVE INVOLVEMENT AND HYPERREFLEXIA
Hande Türker, Oytun Bayrak, Levent Güngör, Murat Sarıca, Musa Onar………………..……....……139
NON-FUNCTIONING KIDNEY RESULTED FROM PRIMARY HYDATID CYST OF THE
PSOAS MUSCLE
Engin Kandıralı, Atilla Semerciöz, Ahmet Metin, Muzaffer Eroglu, Bülent Uysal……………………..145
GALL BLADDER TORSION: A CASE REPORT
Sabahattin Aslan, Nemci Yücekule, Bahadır Çetin, Melih Akıncı, Ahmet Seki, Aybala Ağaç, Recep
Çetin, Abdullah Çetin…………………………………………………………………………………………...147
ORIGINAL RESEARCH
FROM THE ANESTHESIOLOGIST’S PERSPECTIVE RETROSPECTIVE ANALYSIS OF
PERIOPERATIVE COMPLICATIONS OF TRANSSPHENOIDAL PITUITARY SURGERY
Arzu Gerçek1, Deniz Konya2, Zafer Toktaş2, Türker Kılıç2, M. Necmettin Pamir2
1
Marmara Üniversitesi Nörolojik Bilimler Enstitüsü, Anesteziyoloji ve Reanimasyon, İstanbul, Türkiye
2
Marmara Üniversitesi Nörolojik Bilimler Enstitüsü, Beyin Cerrahisi, İstanbul, Türkiye
ABSTRACT
Objective: Pituitary surgery presents unique challenges for the anesthesiologist due to the distinct medical
co-morbidities associated with various adenomas. The aim of this study was to investigate the perioperative
complications throughout the transsphenoidal pituitary surgery from the anesthesiologist’s perspective.
Methods: Retrospectively, 82 ASA physical status I-II patients, who underwent transsphenoidal surgery
between 1st Jan 2002-1st Jan 2006, were included in the study. The following general information was
recorded for each patient: demographic data, airway management, cardiovascular and electrocardiographic
abnormalities, duration of procedures, pituitary pathology, and any complications during the perioperative
period.
Results: After induction, four patients developed severe bradycardia and ventricular premature beats with
bizarre QRS complex with hypotension, non-responsive to atropine and ephedrine. Three patients
experienced intubation problems.In 12 patients, following submucosal injection, a hypertensive response was
observed.Only two patients (2.4%) had experienced temporary diabetes mellitus after surgery. Overall, 21
patients (25.6%) experienced complications during the perioperative period of transsphenoidal pituitary
surgery.
Conclusion: Anesthesiologists must be wary of the possibility of difficult intubation, hypertensive episode at
the time of intranasal submucosal injection of vasoconstrictor-supplemented local anesthetic, and
hemodynamic and electrocardiographic abnormalities related to the underlying overlooked cardiac
pathologies at any time during surgery.
Keywords:Anesthesia, Cardiomyopathy, Complications, Difficult intubation, Transsphenoidal pituitary
surgery
ANESTEZİST GÖZÜYLE TRANSSFENOİDAL HİPOFİZ CERRAHİSİNDE PERİOPERATİF
DÖNEMDE GÖRÜLEN KOMPLİKASYONLARININ GERİYE DÖNÜK DEĞERLENDİRİLMESİ
ÖZET
Amaç: Pitüiter cerrahi adenomların tiplerine göre, farklılık gösteren morbiditeler nedeniyle anestezi doktoru
için yoğun uğraş gerektiren girişimlerdir. Bu çalışmanın amacı, transsfenoidal cerrahi sırasında ortaya çıkan
komplikasyonları anestezi doktorunun bakış açısıyla değerlendirmektir.
Yöntem: 1 Ocak 2002-1 Ocak 2006 tarihleri arasında transsfenoidal hipofiz cerrahisi geçiren ve ASA skoru
I-II olan 82 hasta retrospektif olarak çalışmaya alındı. Her hasta için; demografik özellikler, havayolu
sağlanması, cerrahi süre, kardiyovasküler ve elektrokardiyografik anormallikler, patolojik tanı ve perioperatif
dönemde ortaya çıkan komplikasyonlar kaydedildi.
Bulgular: Anestezi indüksiyonunu takiben 4 hastada medikal tedaviye cevap vermeyen ağır bradikardi ve
geniş QRS kompleksin eşlik ettiği ventriküler premature atımlar görüldü. Üç hasta entübasyon sırasında
problem yaşadı. Oniki hastada ise submukozal enjeksiyon sonrasında hipertansif yanıt gözlendi. Erken
postoperatif dönemde 2 hastada (%2.4) geçici diabetes insipid görüldü. Hastaların hiçbirinde rinore veya
nazal kanama görülmedi. Bu bağlamda 21 hastada (%25.6) perioperative dönemde komplikasyon oldu.
Sonuç: Anestezistler zor entübasyon, vazokonstriktör eklenmiş lokal anesteziğin submukozal enjeksiyonuna
bağlı hipertansif yanıt ve anestezi indüksiyonu sonrasında subklinik kardiyak patolojilerin klinik bulgu verir
hale gelme olasılığını göz önünde bulundurmalıdır.
Anahtar Kelimeler: Anestezi, Kardiyomiyopati, Komplikasyon, Zor entübasyon, Transsfenoidal hipofiz
cerrahisi
İletişim Bilgileri:
Arzu Gerçek
e-mail: [email protected]
Marmara Üniversitesi Nörolojik Bilimler Enstitüsü, Anesteziyoloji ve Reanimasyon,
İstanbul, Türkiye
104
Marmara Medical Journal 2006;19(3);104-108
Arzu Gerçek, et al.
From the anesthesiologist’s perspective retrospective analysis of perioperative complications of transsphenoidal pituitary
surgery
any further cardiovascular investigation was not
conducted.
Anesthesia management
Standard anesthesia was applied to all patients:
Normoventilation was instituted following loss of
consciousness with IV remifentanil 1 µg kg-1 and
propofol 1-2 mg kg-1. Once an adequate mask
airway was assured, IV vecuronium bromide 0.15
mg kg-1, dexamethasone 0.2 mg kg-1 and
ondansetron 0.1 mg kg-1 were administered. In
case of inadequate mask airway ventilation,
vecuronium bromide was not injected, and
patients were intubated with or without 1.5mg kg-1
succinylcholine. Anesthesia was maintained with
0.5% isoflurane 50% N2O in O2 and remifentanil
0.25 µg kg-1 min-1 infusion. Aspiration of
postnasal blood drainage was prevented with a
wet sponge placed into the oropharynx. During
surgery, the lungs were normoventilated in order
not to displace the pituitary gland with hyper- and
hypo-ventilation.
At the end of the surgery, a three-point headrest
was taken off. Remifentanil infusion was stopped
and the lungs were ventilated with 100% O2. The
wet sponge was taken off from the oropharynx,
and IV neostigmine 30µg kg-1 and atropine 10µg
kg-1 were administered for the reversal of
neuromuscular blockade. After spontaneous
adequate respiration and the patient’s response to
the verbal comment was achieved, the lungs were
extubated. The patient was reminded to breathe
orally, as told before the operation. After 24-hour
follow up in the Intensive Care Unit the patient
was discharged on postop day 7.
Visual analogue scale was used for the evaluation
of the patient’s postoperative pain. Pethidine
hydrochloride (Aldolan, Liba, Turkey) was
titrated intravenously in order to keep the patient’s
score equal or below to 3.
Surgical management
After induction, the patient was positioned for
surgery with the head fixed in a three-point
headrest and secured with pins anchored into the
cranium itself. To reduce venous engorgement,
the operation table was adjusted to fifteen-degree
Fowler position. After nasal cleaning, the patient
received submucosal injections of 2 ml of 2%
lidocaine and 1:100,000 epinephrine mixture to
reduce bleeding and facilitate dissection. Then,
transsphenoidal surgery was performed under
INTRODUCTION
The pituitary gland has a very important role in
human life. It regulates the function of the thyroid
gland, the adrenal glands, the ovaries and the
testes. Besides controlling lactation, uterine
contractions during labor and the linear growth, it
regulates the osmolality and volume of
intravascular fluid by providing absorption of
water in the kidney1.
Tumors of the pituitary gland frequently originate
from the anterior lobe. They account for
approximately 10-15% of diagnosed brain
neoplasms2,3. Particular problems in such patients
relate to primary hormonal hypersecretion and its
complications, and mass effects of the macro
adenomas. Although medical therapy is available
for most hyperfunctioning states, it is not
curative4,5.
Transsphenoidal pituitary surgery has become
common due to its safety and effectiveness in the
management of various problems associated with
the region of the sella turcica. Pituitary surgery
presents unique challenges for the anesthesiologist
due to the distinct medical co-morbidities
associated with various adenomas. This
retrospective study analyzed the correlation
between the perioperative events and the pituitary
pathology from the anesthesiologist’s perspective.
PATIENTS AND METHODS
Retrospectively, 82 ASA physical status I-II
patients, who underwent transsphenoidal surgery
between 1st Jan 2002-1st Jan 2006, were included
in the study.
Preoperative evaluation
Upon receiving the history and physical
examination of the patient, the Mallampati
classification, thyromental distance and mouth
opening were evaluated in order to predict the
possibility of difficult intubation. None of these
patients had thyromental distance under 5 cm,
Mallampati Class III-IV and mouth opening lesser
than 1 cm as an indicator of difficult intubation6.
Preoperative blood levels of the growth hormone
(GH), luteizing hormone (LH), follicule
stimulating hormone (FSH), prolactin (PRL),
adrenocorticotropin hormone (ACTH), and
thyroid hormone levels (free T3 and T4) were
measured. In the absence of known-cardiovascular
pathology and electrocardiographic abnormality,
105
From the anesthesiologist’s perspective retrospective analysis of perioperative complications of transsphenoidal
pituitary surgery
progress, therefore, surgery was cancelled, and the
patients were awakened. Cardiology consultation
revealed that these four patients had moderate
cardiomyopathy.
In one (4%) of the patients with PRL secreting
adenoma, intubation was attempted
four
times.The laryngoscopic appearance of the vocal
cord was Cormack-Lehane grade IV. During these
attempts, the patient never experienced hypoxia.
Because a fiberoptic bronchoscope was not
available, surgery was cancelled. In two (13%) of
the patients with GH secreting adenoma,
endotracheal intubation was achieved at the third
attempt due to Cormack-Lehane grade III vocal
cord appearance.
In 12 patients (14%), following submucosal
injection, a hypertensive response was observed
(Table I). The patients’ blood pressure increased
by 30%. In one patient, systolic blood pressure
rose as high as 260 mm Hg. Esmelol and
remifentanil were used to control these increases
in blood pressure. Nineteen patients (23%) had
experienced intraoperative complications during
transsphenoidal pituitary surgery.
After cessation of anesthetic agents, all patients
responded to verbal comment within 5 min. And
their lungs were extubated. None of the patients
experienced nausea and vomiting during
emergence from the anesthesia and the
postoperative 24-hour Intensive Care Unit follow
up. Only two patients (2.4%) had experienced
temporary diabetes mellitus after surgery. Overall,
25.6 % of the 82 patients had experienced
perioperative
complications
during
the
transsphenoidal pituitary surgery.
microscope and recorded on compact disc. Fatty
tissue taken from the abdominal wall was placed
onto the sella turcica. Nasal tampon was placed.
Data analysis
The following general information was recorded
for each patient: demographic data, airway
management (such as difficult intubation
requiring more than three attempts and inability to
intubate,
etc.),
duration
of
procedures,
cardiovascular
and
electrocardiographic
abnormalities, immunohistochemical diagnosis of
pituitary pathology, and any complications during
the perioperative period.
RESULTS
Eighty-two patients (39 female / 43 male) were
included in the study. The mean age of the
patients was 42.69±14.63 years (range: 18-75
years). The mean operation duration was 105±15
min. The patient distribution based on the
pathologies and intraoperative complications, is
provided in Table I.
After induction, three (20%) of the patients with
GH secreting adenoma, and one (6%) of the
patients with non-secreting adenoma developed
severe bradycardia (range: 25-35 beat per min)
and ventricular premature beats with bizarre QRS
complex. Apart from cardiac arrhythmia, they
were also slightly hypotensive. Blood pressure
values in these patients were 40% lower than the
previous value. Patients’ cardiovascular statuses
were non-responsive to the medical treatment with
repeated doses of atropine and ephedrine. Twenty
minutes after the induction of anesthesia, the
patients’ cardiovascular statuses did not show any
Table 1: The patients’ demographic features, pathologies and intraoperative complications
Intraoperative
Etiology
Pt.
(n)
Cardiovascular
Hypertension
Airway management
Arrhythmias+Hypotension
Apoplexy
3
Benign cystic
Adrenocorticotropic hormone secreting
adenoma
2
2
Plurihormonal secreting adenoma
11
3
Prolactin secreting adenoma
27
4
Luteizing hormone secreting adenoma
4
1
Growth hormone secreting adenoma
15
1
3
Null cell (non-secreting adenoma)
17
2
1
Malignant melanoma
Total
1
12
4
82
Postoperative
Difficult*
Enabled
Hormonal
Temporary Diabetes
Insipidus
1
1
1
1
1
2
2
2
*: Difficult intubation was described as a case in that more than three attempts were needed for intubation of the trachea.
106
surgery
Intranasal
submucosal
injection
of
vasoconstrictor-supplemented local anesthetics
may result in a hypertensive episode, as in these
12 patients12,13. All patients who underwent
transsphenoidal pituitary surgery received a
prophylactic dose of dexamethasone 0.2 mg kg-1
IV at the induction of anesthesia. While acute,a
synthetic corticosteroid injection may cause a side
effect of systemic hypertension, the magnitude of
which is typically small compared to the
responses in these 12 cases14,15. Chelliah et al16
reported a case of postoperative myocardial
infarct related to the intraoperative submucasal
epinephrine-induced hypertension. We believe
that close proximity of the injection side of
vasoconstrictor-supplemented local anesthetics to
the hypothalamus-pituitary axis, results in the
increase in the incidence tachycardia and
hypertension even after a small dose.
DISCUSSION
The perioperative care of patients presenting for
pituitary surgery requires careful preoperative
assessment
and
meticulous intraoperative
management using principles common to all
intracranial procedures7.
A safe airway supply is essential for the
management of anesthesia. In literature, the
incidence of difficult intubation shows great
variability and ranges between 0.05 and 18%6,8,9.
In this study, overall incidence of difficult
intubation was 3.9%, while in patients with GH
secreting adenoma, its incidence increased to
13%. Excessive GH results in the coarsening of
features with bony proliferation that can
concomitantly involve macroglossia, prognathia
with malocclusion and hypertrophy of soft tissues
(esp. the tongue), epiglottis and aryepiglottis
folds10. All these changes make
tracheal
intubation difficult in these patients. Colao et al11
have shown that adolescents with prolactinoma
have osteopenia or osteoporosis. In our study, the
patient whose tracheal intubation could not be
achieved had a problem at her neck due to the
osteoporotic changes. Neck extension was limited
to 300. The patient was 50 years-old. These
osteoporotic changes might be related to PRL
secreting adenoma, not age. However, the
literature does not provide information on
increased incidence of difficult intubation in
patients with PRL secreting adenoma11.
In patients undergoing transsphenoidal surgery,
balanced anesthesia with remifentanil provides
faster awakening time compared with high
concentration of volatile anesthetics, without the
risk of postoperative opioids respiratory
depression17.
In conclusion, transsphenoidal pituitary surgery
entails careful preoperative evaluation.The
anesthesiologist must be wary of the possibility of
difficult intubation, hypertensive episode at the
time of intranasal submucosal injection of
vasoconstrictor-supplemented local anesthetic and
haemodynamic
and
electrocardiographic
abnormalities related to the underlying overlooked
cardiac pathologies at any time during surgery.
In acromegalic patients, cardiac muscles are also
affected, and the incidence and severity of cardiac
hypertrophy is related to the duration of the
disease4. After induction, three patients had
experienced severe bradycardia ventricular
premature beats with bizarre QRS complex and
hypotension, non-responsive to the medical
treatment with repeated doses of atropine and
ephedrine. In the preoperative visit, these patients
did not have any problems related to the
cardiovascular system, and both auscultation and
electrocardiographic findings were within normal
range. Therefore, preoperative echocardiography
was not planned. Our results showed that
intraoperative incidence of clinically presentedcardiomyopathy was 13% in acromegalic patients,
and overall incidence in patients who had
undergone pituitary surgery was 2.4%. In the light
of these results, routine echocardiography should
be performed, particularly on acromegalic
patients, to rule out the cardiac disorders.
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Faglia G, Ambrosi B. Hypotalamic and pituitary
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Rose DK, Cohen MM. The airway: problems and
predictions in 18,500 patients. Can J Anaesth
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Baykan N, Gercek A. Supratentorial tumour surgery and
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Ezri T, Warters RD. The incidence of Class “Zero”
airway and the Impact of Mallampati Score, Age, Sex
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Grade. Anesth Analg 2001;93:1073-1075.
8. Gercek A, Lim S, Isler FB, Eti Z, Gogus FY. Prediction
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MarmaraMed J 2003;16:36-39.
9. Rossi L, Thiene G, Caregano L, Giardano R, Laura S.
Dysrhythmias and sudden death in acromegalic heart
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10. Pasternak JJ, Atkinson JL, Kasperbauer JL, Lanier WL.
Hemodynamic responses to epinephrine-containing local
anesthetic injection and to emergence from general
anesthesia in transsphenoidal hypophysectomy patients.
J Neurosurg Anesthesiol 2004;16:189-195.
11. Colao A, Di Somma C, Loche S, et al. Prolactinomas in
adolescents: persistent bone loss after 2 years of
prolactin normalization. Clin Endocrinol 2000;52:319327.
12. Horrigan RW, Eger EI, Wilson C. Epinephrine-induced
arrhythmias during enflurane anesthesia in man: a
nonlinear dose-response relationship and dosedependent protection from lidocaine. Anesth Analg
1978;57:547-550.
13. Randell T. Prediction of difficult intubation. Acta
Anaesthesiol Scand 1998;42:136-137.
14. Oyesiku NM. Assessment of pituitary function. In:
Recgachary SS, Ellenbagen RG, eds. Principles of
Neurosurgery. 2nd ed. Edinburg: Elsewier-Mosby,
2005:559-591.
15. Keegan MT, Atkinson JLD, Kasperbauer JL, Lanier
WL. Exaggerated hemodynamic responses to nasal
injection and awakening from anesthesia in a cushingoid
patient having transsphenoidal hypophysectomy. J
Neurosurg Anesthesiol 2000;12:225-229.
16. Chelliah YR, Manninen PH. Hazards of epinephrine in
transsphenoidal pituitary surgery. J Neurosurg
Anesthesiol 2002;14:43-46.
17. Gemma M, Tommasino C, Cozzi S, et al. Remifentanil
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108
ORIGINAL RESEARCH
THE ROLE OF CONTRASTED DYNAMIC MULTI-DETECTOR COMPUTERIZED
TOMOGRAPHY IMAGING ON SURGICAL DECISION MAKING IN BREAST CANCER
PATIENTS
Taner Yiğit1, Ünsal Coşkun2, Öner Menteş1, Cengizhan Yiğitler1, Bülent Güleç1, Müjdat Balkan1, Orhan
Kozak1, Turgut Tufan1
1
Gülhane Askeri Tıp Akademisi, Genel Cerrahi AD, Ankara, Türkiye 2Gülhane Askeri Tıp Akademisi,
Rehabilitasyon Hastanesi, Ankara, Türkiye
ABSTRACT
Objective:. The success of surgical treatment of breast carcinoma depends mainly on prevention of local
recurrence. Nowadays magnetic resonance imaging is being intensively used for the diagnosis of breast
lesions. In this study we investigated the effect of the multi-detector computed tomography as an alternative
to magnetic resonance in the evaluation of satellite breast cancer and the relation of the tumor margins with
surrounding tissue, which plays an important role in local recurrence.
Methods: In an 18 months' period, 30 patients with breast cancer, for whom breast-conserving surgery was
planned, were given a multi-detector computed tomography in the preoperative period.
Results: In two (10%) patients a very close correlation between the tumor and pectoral fascia was found; in
three (15%) patients a satellite tumor focus was detected. It was also reported that one of these patients had
both satellite lesions and a primary tumor-pectoral fascia connection. Four patients received a modified
radical mastectomy in accordance with their informed consent.
Conclusion: Multi-detector computed tomography is a good alternative for magnetic resonance imaging in
some cases and provides useful data in the determination of satellite tumor focus and the relation of the
primary tumor to the pectoral fascia.
Keywords: Breast cancer, Multi-detector CT, Diagnosis, Treatment
MEME KANSERLİ HASTALARDA CERRAHİ TEDAVİNİN PLANLANMASINDA
KONTRASTLI DİNAMİK MULTİ-DEDEKTÖR TOMOGRAFİ GÖRÜNTÜLEMENİN
ROLÜ
ÖZET
Giriş: Meme kanserinin cerrahi tedavisinin başarısı temel olarak hastalık tekrarının önlenmesi prensibine
dayanmaktadır. Günümüzde manyetik rezonans görüntüleme meme kanserinin tanısında yoğun olarak
kullanılmaktadır. Buna karşın kapalı alan korkusu olan hastalara bu tetkikin uygulanmasında güçlükler ve
kolay ulaşılabilirliğin kısıtlı olması manyetik rezonans görüntülemenin uygulanabilirliğinin sınırlamaları
olarak karşımıza çıkmaktadır. Bu çalışmada bölgesel hastalık tekrarı gelişiminde önemli etkenlerden olan
tümörün çevre yapılarla olan ilişkisi ve uydu tümör odaklarının varlığının incelenmesinde kontrastlı dinamik
çok detektörlü tomografinin manyetik rezonans görüntülemeye alternatif olarak kullanılabilirliğini araştırdık.
Materyal Yöntem: 18 aylık dönem içinde meme kanseri tanısı konmuş ve meme koruyucu cerrahi
planlanan toplam 30 hastaya kontrastlı dinamik çok detektörlü tomografi uygulandı.
Sonuçlar: İki hastada (10%) tümörün pektoral kas kılıfına çok yakın sonlandığı, üç hastada (15%) uydu
tümör odağı varlığı tespit edildi. Bu hastaların birinde ise uydu tümör odağına ilave olarak pektoral kas
kılıfına yakın sonlanma tespit edildi. Hastaların dördüne de aydınlatılmış onamları alınarak meme koruyucu
cerrahi yerine modifiye radikal mastektomi ameliyatı uygulandı.
Tartışma: Kontrastlı dinamik çok detektörlü tomografi, seçilmiş vakalarda manyetik rezonans
görüntülemeye iyi bir alternatiftir. Kontrastlı dinamik çok detektörlü tomografi ile ana tümörün pektoral kas
kılıfına ile olan ilişkisi ve uydu tümör odakları hakkında yararlı veriler elde edilebilmektedir.
Anahtar Kelimeler: Meme kanseri, Çok detektörlü CT, Tanı, Tedavi
Taner Yiğit
Gülhane Askeri Tıp Akademisi, Genel Cerrahi AD, Ankara, Türkiye
109
Taner Yiğit, et al.
The role of contrasted dynamic multi-detector computerized tomography imaging on surgical decision making in breast
cancer patients
mammography and pathology), c) patient's choice
d) surgeon’s experience.
All patients were given a thorough physical
examination at the time of first admission.The
dimensions of the lesion, condition of the contra
lateral breast and both axilla were noted along
with a detailed patient history. All patients were
given bilateral breast and axillary USG and
mammography as a standard procedure for
screening. Patients with a suspicious malignant
breast lesion were reevaluated with focused USG
and also given a fine needle aspiration biopsy
(FNB) or open biopsy. Patients given and
diagnosed with open biopsy were excluded from
the study in order to prevent possible side effects
of the procedure on the contrasted dynamic
MDCT results. Patients having T1-T2 tumor and
candidates for BCS were assigned to the study
group. Patients’ preference of treatment as to
which operation they wanted was determined after
giving
detailed
information
concerning
complications, recurrence and disease-free-overall
survival rates, and effect on their quality of life
after surgery and radiotherapy following the BCS.
According to these data, patients who selected
mastectomy were excluded from the study.
Finally, patients with T1 and T2 tumors, who
chose BCS, were included in the study and all
data of these patients including age, USG,
mammography, MDCT and FNC results, tumor
size,
histology,
localization
and
TNM
classification were recorded.
INTRODUCTION
Breast cancer (BC) occurs in more than 8% of
women during their lifetime and this ratio
continues to increase 1,2. Thus, it is one of the
major causes of death among women 40-55 years
of age 3,4. Despite the advantages in both
diagnostic tool and treatment strategies, the
mortality rates of BC still remain significant.
Currently, the overall survival rate is 73% at five
years and 59% at 10 years 2.
While mastectomy was formerly the mainstay of
treatment, today breast-conserving surgery (BCS),
which offers nearly similar survival rates, is
extensively used. Even if disease-free and overall
survival rates are nearly similar, local recurrence
rates are higher after BCS than after
mastectomy5-7. Many factors such as the patient’s
age, tumor size, pregnancy, collagen vascular
disease, resection margin, satellite tumor focus,
tumor nature, axillary lymph node involvement,
tumor grade, mononuclear cell infiltration, were
reported as accounting for local recurrence in
previous studies 8-12. Among the factors listed
above, resection margin and satellite tumor focus
are unique factors which can be controlled during
the preoperative period.
In this prospective study, we aimed to evaluate the
potential role of contrasted dynamic multidetector computed tomography (MDCT) as an
additional imagining modality in the detection of
occult satellite tumors in the targeted breast tissue
and the relationship of the tumors with
surrounding tissue and pectoral fascia. All of these
are important regarding local recurrence in
patients with a diagnosis of BC. Furthermore, we
also evaluated the effect of the contrasted
dynamic MDCT on the treatment planning of
breast cancer.
All patients who were recruited for the study were
given a contrasted dynamic MDCT two days
before the surgery. Patients were examined before
and after the contrast injection. Patients who were
known to have an allergic reaction for contrast
dye were not given the contrasted dynamic
MDCT and were also excluded from the study.
Before the contrasted images of the breast tissue
were made, plain images were collected. Using an
MDCT scanner (Picker, MX Twin, Israel) set for
1-mm collimation and a pitch of 5.5, we scanned
our patients from the level of the axilla to the
lower edge of the breast. Patients were asked to
hold their breath four times both before and 1, 3,
and 8 min after an IV rapid bolus administration
of nonionic contrast material. We infused 100 mL
of nonionic contrast material (Ultravist
[iopromid], Schering, Germany) at a rate of 3.0
mL/sec. The data were reconstructed at 0.6 mm
increments. Patients underwent MDCT in the
supine position because it allowed surgical
PATIENTS AND METHODS
The study comprises all patients who applied to
the breast clinic between September 2003 and
February 2005 either for routine breast checkups
or for a breast mass diagnosed by selfexamination. Among these patients, women who
were diagnosed with BC by physical examination,
ultrasonography (USG), mammography and
pathological analysis were identified as potential
candidates for BCS and were recruited for the
study. Candidacy of the patients for BCS was
determined using four major criteria; a) physical
examination, b) laboratory tests ( USG,
110
cancer patients
simulation on three-dimensional data displays.
After reconstruction, the images were transferred
to a workstation. Multiplanar reconstructions
(axial, coronal, and sagittal) and maximal
intensity projections were used for the evaluation
of tumors. One radiologist reviewed all detected
lesions for morphologic features and time-density
curve patterns. All detected lesions were classified
as either mass or nonmass enhancing lesions. For
mass lesions, margin, shape and enhancement
patterns were evaluated. Irregular contour and
shape, early contrasting and washout were
assigned as malignancy criteria.
Clinical TNM classification of the patients
revealed that 11(36.6%) patients had T1N1M0
tumors, six (20%) patients had T1N2M0 tumors,
five (16.7%) patients had T2N0M0 tumors, three
(10%) patients had T2N1M0 tumors and five
(16.7%) patients had T2N2M0 tumors (Fig. 2).
Mean tumor size was 21.7 (range10-40) mm.The
tumor was localized in the upper outer lobe in
17(56.6%) patients, lower outer lobe in 4 (13.3%)
patients, lower inner lobe in 2 (6.6%) patients and
upper inner lobe of the left breast in 7 (23.5%)
patients.
Contrasted dynamic MDCT results revealed that 2
(6.7%) patients had a tumor with a very close
margin or connection to the pectoral fascia
(Fig.3), 3(10%) patients had a satellite tumor,
which had not been noticed in the USG and
mammography during the preoperative period
(Fig. 4) (Table-I). One of these two patients with
pectoral connection also had satellite tumor focus.
Detailed specifications of those four patients have
been given in table. (Table-II) Finally, these 4
(13.3%) patients who seemed to have
contraindication for BCS were given a modified
radical mastectomy (MRM) with their informed
consent.
Patients’ candidacy for BCS was reevaluated
according to contrasted dynamic MDCT results.
Patients with a satellite tumor requiring large
breast tissue excision and / or patients with a
lesion which was related to the pectoral fascia
were designated as patients who were not eligible
for BCS. These groups of patients were also
informed about the potential risks of BCS under
these conditions and they were prepared to
undergo mastectomy with their informed consent.
Accuracy of the contrasted dynamic MDCT
results was controlled by retrospectively
comparing these data with excision materials’
pathology results.
Primary outcomes of this study were finding a
ratio of the patients who were given MDCT and
diagnosed having additional tumor with/or
pectoral muscle infiltration to the total number of
cohort who were recruited to the study. Hereby,
we aimed to investigate of the accuracy of MDCT
in protection to the patients from local recurrence.
All steps of this study design were approved by
the Gulhane Military Medical Academy Human
Subject Review Committee and meet the
guidelines of this governmental agency.
Fig. 1: Distribution of the tumor according the pathological
classification.
RESULTS
Thirty elegible patients were identified and
recruited for the study. The mean age of the
patients was 46.7 (range 33-66) years old.
All patients were reported as having one solid
lesion in their breast detected by USG and
mammography. Malignancies in all patients were
diagnosed using FNB. According to the FNB
results, three (10%) patients had infiltrative
lobular carcinoma, two patients (6.6%) had
infiltrative ductal + infiltrative lobular carcinoma
(mixed type) and 25 (83,4%) patients had
infiltrative ductal carcinoma (Fig. 1).
Fig. 2: Distribution of the tumor according the TNM
classification
111
The role of contrasted dynamic multi-detector computerized tomography imaging on surgical decision making
in breast cancer patients
Fig. 3: Pectoral invasion of the primary tumor.
Fig. 4: Conglomerate LAP and satellite tumor.
Table 1: Primary tumor and axillary assessment results according to the contrasted dynamic MDCT
Single lesion
Satellite lesion
Pectoral Invasion
26(%86.7)
2(%6.7%)
1(3.3%)
Satellite lesion +
Pectoral Invasion
1(3.3%)
Table II: Detailed specifications of patients diagnosed satellite tumor and pectoral invasion detected with MDCT
Patient 1
Patient 2
Patient 3
Patient 4
Age
35
35
48
40
Tumor Localization
Upper outer
Upper outer
Upper outer
Lower inner
Satellite
No
Yes
Yes
No
Pectoral invasion
Yes
Yes
No
Yes
and although mastectomy continues to be
appropriate for some patients, nowadays many
authors recommend BCS for surgical treatment of
BC. Clinical trials have revealed that overall and
disease-free survival rates are equal or nearly
equal for mastectomy and BCS with postoperative
radiotherapy.5-7,13,14
Patients who had abnormal findings in contrasted
dynamic MDCT and who were given MRM were
reevaluated during the postoperative period using
pathology examination results. Two pectoral
fascia connections and two satellite tumors,
noticed in contrasted dynamic MDCT, were
confirmed with pathology results. As for other
satellite tumor focus, it was not confirmed by
pathology. But this patient also had a pectoral
fascia involvement, which was identified by
contrasted dynamic MDCT and further confirmed
by pathology examination.
BCS has advantages in helping the patient retain a
better body image, better sexual condition and less
negative effect on a patient’s emotional state. It
also offers better quality of life 15,16. Although it
has many advantages, local recurrence rates have
been reported as 3-17% after the BCS and 2-10%
for mastectomy 7. Even local recurrence rates
have been reported higher than for mastectomy
with similar rates for distant metastasis. Overall
mortality and BC specific mortality rates have
already been reported 17.
DISCUSSION
Surgical treatment of breast carcinoma has
improved in recent decades. While mastectomy
has been the historical mainstay of surgical
treatment of stage-I and stage-II BC for decades
112
The role of contrasted dynamic multi-detector computerized tomography imaging on surgical decision making
in breast cancer patients
examination due to certain contraindications,
serious claustrophobic syndrome or lack of a
machine. In this study we aimed to verify the
diagnostic value of contrasted dynamic MDCT in
patients with certain conditions listed above. Data
obtained in this study revealed that 4 patients for
whom a BCS was planned were not suited for this
operation due to satellite tumor focus and /or close
margin of tumor to the pectoral fascia. These 4
patients’ operation strategies were changed from
BCS to MRM. We think that by doing so we
prevented our patients from local recurrence,
which may have developed in the future. Bilateral
thoracic wall examination capacity, suitability for
easier approach to imaging-guided fine needle
aspiration and hookwire localization are the other
advantages provided by contrasted dynamic
MDCT 33-35. The main problem related to the use
of contrasted dynamic MDCT in the diagnosis of
BC is the X-ray exposure. A previous study,
comparing the radiation doses delivered to the
breast during conventional breast CT with those
involved in mammography, revealed that for
conventional CT the doses are almost 10 times
higher than those administrated in standard
mammographic examination 36. In our opinion,this
is sufficient reason to choose MRI over CT in the
diagnosis of BC. On the other hand, extra X-Ray
exposure of healthy breasts and lungs seems
negligent in patients diagnosed with BC because
these patients are usually going to have
postoperative radiotherapy after having undergone
BCS. Additionally, a study performed by Boone
et al 37 in 2001 revealed that the total X-Ray dose
in the CT performed with 80 kVp, 300 mAs and 5
mm slice are nearly equal with X-Ray dose in
mammography performed to the 5 cm compressed
breast tissue. They also reported that the X-Ray
dose is one-third less in CT than when using
mammography of a large breast, which is thicker
than 5 cm with compression. Allergic reaction to
the contrast agent used for CT is another side
effect of the CT. But we believe that this
possibility is not a contraindication for CT
because it is not any higher in CT than in other
radiological contrasted procedures.
Local recurrence has a negative effect on a
patient’s quality of life. Furthermore, additional
operation requirements make this clinical
dilemma difficult to accept for the patient. In
order to prevent local recurrence of the cancer,
everything possible will be attempted according to
the patient’s wishes and, hopefully, such efforts
will increase the patient's satisfaction with
treatment. Multicentricity and positive or close
resection margin are two important factors in the
development of local recurrence. Patients with
satellite tumors are poor candidates for BCS 16.
Satellite tumors usually require extensive
resections and negatively affect cosmetic
outcome. Additionally in case of misdiagnosis,
satellite tumors cause local recurrence after BCS.
Liberman et al.18 reported that magnetic resonance
imaging identified additional occult lesions in
addition to the index breast lesion in 19(27%) of
70 consecutive women. Studies have shown
unacceptably high false-negative rates for both
USG and mammography, with detection of very
few clinically occult carcinomas 19,20.
To minimize the risk of local recurrence, the
surgical management of breast cancer relies on
complete excision of the tumor with a margin of
normal tissue 21. The local recurrence rates at 5
years have been reported as between 2% and 24%
for patients with invaded margins, 6%-16% with
close margins,and 2%-7% with clear margins 22-24.
The initial surgical biopsy of breast cancer results
with positive margins were between 45% to 54%
of the patients 25,26. Although Schmitt-Urlich et al
25
demonstrated that local recurrences could be
virtually eliminated by adjusting the magnitude of
the extension site boost dose to the relative degree
of margin clearance, some authors claimed that
with proper selection criteria, it may be safe to
omit adjuvant radiotherapy in patients with
adequate margins 27,28. It is obvious that a clear
margin is important in preventing local recurrence
and intensive radiotherapy protocols. Additional
diagnostic tools aim to identify any occult satellite
lesions or penetration of the tumor to the deeper
tissues (pectoral fascia) and are beneficial in
preventing patients from local recurrence.
In conclusion, contrasted dynamic MDCT offers
valuable data in the determination of satellite
tumor focus and the relation of the primary tumor
to the pectoral fascia especially for patients with
certain
contraindications
for
MRI
and
claustrophobia and in case of absence of the MRI
unit. We believe that MDCT is a good alternative
to MRI in patients who are planning to have a
BCS and requiring additional radiologic
Recently magnetic resonance imagining (MRI) of
the breast gained a role in clarifying uncertain
cases (suspicious tumor focus which can not be
identified with conventional techniques) after
mammography and / or USG, and in detecting
multifocal, multisentric, and bilateral breast
cancers 29-32. Nevertheless, a not negligible
number of patients cannot undergo MRI
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surgical and adjuvant considerations. Curr Op Obst
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18. Liberman L, Morris EA, Dershaw DD, Abramson AF,
Tan LK. MR imaging of the ipsilateral breast in women
with percutaneously proven breast cancer. Am J
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19. Edeiken S. Mammography in the symptomatic woman.
Cancer 1989;63:1412-1414.
20. Jackson VP. What is the role of sonographic breast
imaging for detecting occult cancer in a patient with a
strong family history of breast cancer and
mammographically dense breasts without obvious
masses? AJR 1995; 165:1004
21. Noguchi S, Koyama H, Kasugai T, et al. A case-control
study on risk factors for local recurrences or distant
metastases in breast cancer patients treated with breastconserving surgery. Oncology 1997:54:468-474.
22. Smitt MC, Nowels KW, Zdeblick MJ. The importance
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outcome of patients treated with definitive irradiation for
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Int J Radiat Oncol Biol Phys. 1989;17:733-738.
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non-palpable breast cancer. J Surg Oncol 1995;58:225228.
27. Silverstein MJ. Ductal carcinoma in situ of the breast:
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28. Veronesi U, Luini A, Del Vecchio M, et al.
Radiotherapy after breast-preserving surgery in women
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29. Heywang SH, Wolf A, Pruss E. MRI of the breast with
Gd-DTPA: use and limitations. Radiology 1989;171:95103.
30. Heywang-Kobrunner SH, Beck R. Contrast-enhanced
MRI of the breast. 2nd ed. Berlin: Springer-Verlag, 1995
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ARAŞTIRMA YAZISI
TESTİS SEMİNOMU VE İNTRAKRANYAL GERMİNOMUN İMMÜNHİSTOKİMYASAL
VE HİSTOMORFOLOJİK ÖZELLİKLERİNİN KARŞILAŞTIRILMASI
Ahmet Midi1, Süheyla Bozkurt1, Aydın Sav1, M Memet Özek2, Necmettin Pamir2
Marmara Üniversitesi Nörolojik Bilimler Enstitüsü, Talia Balı Aykan Patoloji Laboratuarı,
İstanbul, Türkiye 2Marmara Üniversitesi Tıp Fakültesi, Nöroşirürji Anabilim Dalı, İstanbul, Türkiye
1
ÖZET
Amaç: Kranyal germinom, testis seminomu ve over disgerminomu histolojik olarak benzer özelliklere sahip
ancak farklı lokalizasyonlarda yerleşen tümörlerdir. Bu çalışmada testis seminomu ile kranyal germinomlar
tümör içerisindeki lenfosit ve eozinofillerin oranı, Ki–67, PLAP, vimentin immünhistokimyasal boyanma
özellikleri bakımından karşılaştırılmıştır.
Gereç ve Yöntem: M.Ü. Nörolojik Bilimler Enstitüsünde 1995–2002 yılları arasında tanı almış 10 adet
intrakranyal germinom ve 2 adet testis seminomuyla Marmara Üniversitesi Tıp. Fakültesi Patoloji Anabilim
Dalı’nda 1998–2003 yılları arasında tanı almış 6 adet testis seminomu olgusu çalışma kapsamına alınmıştır.
Olgulara PLAP, vimentin, Ki–67, tümör içerisindeki lenfosit yoğunluğunu saptamak için CD45
immünhistokimyasal boyamalar yapılmıştır.
Bulgular ve Sonuç: Germinom olgularının yaş aralığı 9–30 olup ortalama yaş 17 dir. Seminom olgularının
yaş aralığı 15–49 olup ortalama yaş 32,6’dır. Çalışmamızda kranyal germinom ve seminomlarda tümör içi
lenfosit ve eozinofil varlığı yanısıra PLAP ve vimentin immünhistokimyasal boyanma özellikleri bakımından
istatistiksel olarak anlamlı fark bulunmamıştır. MIB-1 (Ki-67) proliferasyon indeksi seminomda %44,
germinomda %25 olarak bulunmuştur ve fark istatistiksel olarak anlamlıdır.
Anahtar Kelimeler: Kranyal germinom, Testis seminomu, Lenfosit, Eozinofil, Ki–67, PLAP
COMPARING OF THE IMMUNOHISTOCHEMICAL AND MORPHOLOGICAL FEATURES OF
THE TESTICULAR SEMİNOMA AND INTRACRANIAL GERMNOMA
ABSTRACT
Objective: Cranial germinoma, testicular seminoma and ovarian dysgerminoma are tumours with similar
histological features but located at different localizations. In this study; cranial germinoma and testicular
seminoma, has been compared for the ratio of the tumor infiltrating lymphocytes, eosinophils, and
immunohistochemical staining features for the Ki–67, PLAP, and vimentin.
Materials and Methods: Cases were obtained from the archives of the Pathology Laboratory, Marmara
University Hospital, Institute of Neurological Science (10 IKG and 2 testicular seminoma in the time period
of 1995 to 2002 ), and Pathology Laboratory, Marmara University Hospital (6 testicular seminoma, in the
time period of 1998 to 2003 ). We performed immunohistochemical staining for PLAP, vimentin, CD45 and
Ki–67.
Results and Conclusion: The germinoma cases were aged between 9–30, (median age 17). The seminoma
cases were aged between 15–49, (median age 32, 6).
Keywords: Cranial germinoma, Testicular seminoma, Lymphocite, Eosinophils, Ki-67, PLAP
morfolojik ve immünhistokimyasal olarak
karşılaştıran 2 çalışma bulunmaktadır 5,6.
Germinom primer intrakranyal tümörlerin
yaklaşık % 0,5-2'ini oluşturan en sık görülen
intrakranyal germ hücre kaynaklı tümördür.
GİRİŞ
Seminoma ve kranyal germinom (KG) benzer
histolojik özellikler gösteren farklı yerlerde
oluşan
germ
hücreli
tümörlerdir1-4.
Kaynaklarda seminoma ve germinom'u
Ahmet Midi
Marmara Üniversitesi Nörolojik Bilimler Enstitüsü, Talia Balı Aykan
Patoloji Laboratuarı, İstanbul, Türkiye
116
Ahmet Midi ve ark.
Testis seminomu ve intrakranyal germinomun immünhistokimyasal ve histomorfolojik özelliklerinin karşılaştırılması
En sık pineal bölge ve suprasellar bölgede
yerleşirler 2,3,7. KG seminomlar gibi
radyoterapiye oldukça duyarlı tümörlerdir 4.
Germinom iri, yuvarlak veziküler nükleuslu,
düzensiz, pleomorfik nükleolu olan, PAS
pozitif boyanan geniş sitoplazmalı, iri
neoplastik hücreler ile değişen yoğunlukta
lenfositlerden meydana gelen iki hücre
popülâsyonundan oluşmaktadır 2. Germ
hücreleri alkalen fosfataz pozitif olup nadir
olgularda ‘'ß-human chorionic gonadotrophin''
(ß-HCG)
pozitif
boyanan
sinsisyotrofoblastlarda bulunabilir 2.
Seminoma tüm germ hücreli tümörler
arasında en sık görülen germ hücreli
tümördür. Mikroskopik olarak birbirlerine
benzeyen hücreler tabakalar oluşturur ve
fibröz septumlarla lobüllere ayrılır. Hücreler
iri, yuvarlak ya da çok kenarlı olup belirgin
hücre membranlı olan sitoplâzmaları berrak
görünümdedir. Hücrelerin büyük kısmının 1
ila 3 belirgin nükleolu olan iri ve merkezi
yerleşimli nükleusları bulunur 6,8.
Kaynaklarda ekstra gonad kökenli germ
hücreli tümörlerin kemoterapiye testisin germ
hücreli tümörlerinden daha az yanıt verdiği
belirtilmektedir 2. Bu durum iki farklı
lokalizasyonla yerleşmiş germ hücreli
tümörün morfolojik ve immünhistokimyasal
özelliklerinin farklı olabileceği ihtimalini akla
getirmektedir. Bu nedenle bu çalışmada testis
seminomu ile KG'nin tümör içi lenfosit,
eozinofil
yoğunluğu
bakımından
karşılaştırılması ve immünhistokimyasal
olarak
PLAP,
vimentin
Ki–67
immünekspresivitelerinin
belirlenmesi
amaçlanmıştır.
GEREÇ VE YÖNTEM
On KG ve sekiz testis seminomu olgusu
çalışmaya alınmıştır. Olgulara PLAP,
vimentin ve Ki–67 immünhistokimya boyaları
uygulanmıştır. Değerlendirmeler kalitatif
yapılmıştır. Buna göre PLAP, vimentin ve
Ki–67
boyalarının
boyanan
hücre
yaygınlığına göre (negatif, fokal pozitif,
dağınık pozitif, yaygın pozitif) ve boyanma
şiddetine göre 0–3 arasında sayısal
değerlendirme yapılmıştır. ( 0:boyanma
izlenmedi, 1: zayıf boyanma, 2: orta şiddette
boyanma, 3: şiddetli boyanma). Tüm
olgularda tümör içi lenfosit, eozinofil
yoğunluğu kantitatif değerlendirilmiştir ve 0–
3 arası sayısal değere dönüştürülmüştür. (0:
yok, 1: seyrek, 2:orta yoğunlukta, 3 yoğun).
Sonuçların değerlendirmesinde istatistiksel
olarak Mann-Whitney U-testi kullanılmıştır.
İmmünhistokimya
İmmünohistokimyasal Boyama Yöntemi
Rezeksiyon
materyalleri
%4'lük
tamponlanmış formaldehitte fikse edildikten
sonra parafinle bloklanmıştır. Parafin
bloklardan 3 aminopropyltriethoxysilane kaplı
lamlara 2µ kalınlıkta kesitler alınarak
immünohistokimyasal boyama yapılmıştır.
Boyamada sırası ile şu işlemler yapılmıştır.
1. Kesitler etüvde 60ºC de 1 saat deparafinize
edildi.
2. Daha sonra ksilende 10 dakika, %100'lük
alkolde 5 dakika bekletildi ve su ile yıkandı.
3. %10'luk sitratla tamponlanmış solüsyon
içine yerleştirilen lamlar mikrodalgada
maksimum güçte (800 watt) 15 dakika
bekletildi.
4. Daha sonra güç yarıya düşürülerek 20
dakika daha mikrodalgada bekletildi.
5. Mikrodalgadan çıkarılan lamlar oda
sıcaklığında 20 dakika bekletildi.
6. Endojen peroksidaz aktivitesi %3'lük
hidrojen peroksitte 20 dakika bekletilerek
giderildi.
7. Distile su ile yıkanan lamlar 3x5 PBS ile
muamele edildikten sonra üzerlerine protein
blokajı damlatıldı.
8. Beş dakika sonra blokaj yıkanmadan
lamların üzerine PLAP, vimentin, Ki–67
antikoru damlatıldı.
9. Primer antikorda 30 dakika bekletildikten
sonra PBS'e alınarak 5 dakika yıkandı.
10. Daha sonra biyotinlenmiş sekonder
antikor ile 20 dakika muamele edildi ve
PBS'te 5 dakika yıkandı.
11. Peroksidaz konjuge antikor ile 20 dakika
bekletildi. Daha sonra 5 dakika PBS'te
yıkandı.
12. Kromojende (DAB) 5 dakika bekletildi.
13. Musluk suyu altında yıkanan lamlar
hematoksilen ile karşıt boyama yapıldı.
14. Dehidrate edildi, kurutuldu ve entellan ile
kapatıldı.
117
Ahmet Midi ve ark.
yoğunluğu bakımından gruplar arasında
istatisitksel olarak anlamlılık saptanmamıştır
(p= 0.96). Ki–67 ortalama değeri seminomda
%44 (%15-%76), germinomda %25 (%0%62) olarak bulunmuştur ve fark istatistiksel
olarak
anlamlıdır
(p=0.026).
PLAP
immünhistokimya boyası ile 3 germinoma ve
1 seminoma olgusunda boyanma olmazken, 7
germinoma (%70) ve 7 (%87) seminoma
olgusunda değişen yoğunlukta boyanma
izlenmiştir.
PLAP
boyanma
özelliği
bakımından gruplar arasında istatistiksel
olarak anlamlılık saptanmamıştır (p= 0.49).
Vimentin ile 4 (%40) germinoma, 2 (%25)
seminoma olgusunda fokal ya da dağınık
boyanma izlenmiştir. Altı germinoma ve 6
seminoma olgusunda boyanma olmamıştır.
Vimentin boyanma özelliği bakımından
gruplar arasında istatistiksel olarak anlamlı
fark saptanmamıştır (p= 0.57).
BULGULAR
KG olgularının yaş aralığı 9–30 olup ortalama
yaş 17 dir. Olguların 1'i kadın 9' u erkektir.
Seminom olgularının yaş aralığı 15–49 olup
ortalama yaş 32 dir.
Tablo-1'de germinomların (Resim 1,2,3),
Tablo-2'de seminomların (Resim 4,5)
demografik, immünhistokimyasal özellikleri,
lenfosit
ve
eozinofil
yoğunlukları
belirtilmiştir.
CD45 immünhistokimya boyası ile saptanan
lenfosit her iki grupta tüm olgularda değişik
yoğunlukta (+ veya +++) izlenmiş olup
gruplar arasında istatisitksel olarak anlamlılık
saptanmamıştır
(p=
0.14).
Eozinofil
germinoma olgularının 7'sinde değişik
yoğunlukta (+ veya ++) saptanırken 3 olguda
izlenmemiştir. Seminoma olgularının ise
6'sında değişen oranda izlenirken (+ veya ++)
2
tanesinde
görülmemiştir.
Eozinofil
Tablo 1: Germinomaların demografik, morfolojik ve İHK özellikleri
No
1
2
3
4
5
6
7
8
9
10
Yaş/Cin
siyet
15/E
?/E
?/E
28/E
11/E
12/E
12/E
19/E
30/E
9/K
Lenfosit
Eozinofil
+++
+++
++
+
+++
++
+++
++
++
+++
+
+
+
+
+
++
++
Ki–67
(%)
7
28
50
1
55
1
0
20
62
28
PLAP
Vimentin
Diffüz ++
Diffüz +++
Diffüz +++
Diffüz ++
Fokal ++
Diffüz +++
Dağınık ++
-
Fokal +++
Dağınık ++
Dağınık ++
Dağınık ++
Tablo 2: Seminomalarin demografik, morfolojik ve İHK özellikleri
No
1
2
3
4
5
6
7
8
Yaş
?
21
40
15
38
35
49
31
Lenfosit
++
+++
+
+
++
+++
+
+
Eozinofil
+
++
+
+
+
+
Ki–67
(%)
76
48
52
36
46
15
29
50
118
PLAP
Diffüz ++
Diffüz +++
Diffüz ++
Diffüz +++
Diffüz ++
Diffüz +++
Diffüz +++
Vimentin
Dağınık ++
Dağınık ++
-
Ahmet Midi ve ark.
Resim 1: Germinoma H&E X 400; germ hücreleri,
lenfosit ve eozinofilller.
Resim 2: Germinoma Ki-67 X 200; germ hücrelerinde
nükleer boyanma.
Resim 4: Seminoma H&E X 100; lenfositik zeminde
tabakalar halinde germ gücreleri.
Resim 3: Germinoma CD45 X 400; lenfositlerde yoğun
boyanma.
TARTIŞMA
KG histolojik olarak over disgerminomu ve
testis seminomuna benzer. Nispeten düşük
dereceli bir malignite özellikleri gösterir.
Ancak çevre yapıları infiltre edebilir.
Ependim
boyunca
ventriküllere
ve
subaraknoid alana yayılma eğilimi gösterirler
7
. Yüksek proliferatif aktiviteye sahip
olabilirler. Martinazzi M ve ark.'nın
çalışmasında Ki–67 proliferatif indeksi
seminomada %23,8 bulunmuştur 8. Mevcut
çalışmada 3 KG ve 3 seminoma olgusunda
Ki–67 proliferatif indeksi %50 veya üstünde
bulunmuştur.
Resim 5: Seminoma PLAP X 200; germ hücrelerinde
boyanma.
119
Ahmet Midi ve ark.
Vimentin
Nakagawa
Y
ve
ark'nın
çalışmasında 7 germinomanın 3'ünde pozitif
iken, gonadal germ hücreli tümörlerde negatif
olarak bulunmuştur 5. Bentley AJ ve
arkadaşlarının çalışmasında germinoma ve
seminoma olgularında vimentin ile boyanma
izlenmemiştir 6. Mevcut çalışmada vimentin
ile 4 (%40) germinoma, 2 seminoma (% 25)
olgusunda fokal ya da dağınık boyanma
izlenmiştir.
Hattab EM ve ark.'nın çalışmasında KG'de
PLAP % 92 olguda pozitif izlenmiştir 9.
Klasik seminomada ise %100 pozitif
boyanma bildirilmiştir 10. Mevcut çalışmada
PLAP ile 7 germinoma (%70) ve 7 (%87)
seminoma olgusunda değişen yoğunlukta
boyanma izlenmiştir.
Kaynaklarda KG ve seminomada eozinofil
yoğunluğu ile ilgili çalışma bulunmamaktadır.
Çalışmamızda KG'da %70 olguda değişen
yoğunlukta eozinofil izlenmiştir. KG ayırıcı
tanısına giren histiyositozis x'de yoğun
eozinofil izlenir. Bir çalışmada eozinofil
varlığının histiyositozis x'e spesifik olmadığı
KG'da da bulunabilmesi nedeniyle bu
lezyonların ayırıcı tanısında, özellikle iğne
biyopsilerinde
eozinofil
varlığının
histiyositozis x'e spesifik bir bulgu olarak
yorumlanmaması gerektiği vurgulanmıştır11.
Ingilizce literatürde seminom ve KG'da
lenfositlerin immünohistokimyasal özellikleri
ile ilgili çalışmalar olmakla birlikte lenfosit
yoğunlu ile ilgili 1 çalışmaya rastlanmıştır
1,12,13
. Mevcut çalışmada değişen yoğunlukta
lenfosit tüm olgularda izlenmiş olup lenfosit
yoğunluğu bakımından seminom ve KG
benzer özellikler göstermiştir.
İntrakranyal
germinomun
ve
testis
seminomunun aynı hücreden köken almaları
nedeniyle Ki–67 proliferatif indeksinin
mevcut çalışmada farklı çıkmasının anlamı
açık değildir. Hsu YJ ve arkadaşlarının
çalışmasında ekstra gonad kökenli germ
hücreli tümörlerin kemoterapiye testisin germ
hücreli tümörlerinden daha az yanıt verdiği
belirtilmektedir 2. Her ne kadar seminomda
Ki–67 proliferatif indeksin germinomdan
yüksek çıkması tedavilere farklı yanıt
vermelerini destekleyen bulgu olarak gözükse
de, serimizin az sayıda olgudan oluşması
nedeniyle bu farklılığı seminomdaki hücre
proliferasyonunun fazlalığına ve bu nedenle
kemo-radyoterapiye duyarlılığının artışına
bağlanamamıştır. Bu konuda bölgesel ve
çevresel etkenlerin proliferatif indeksin
üzerine etkisinin araştırılmasına gerek vardır.
KAYNAKLAR
1.
Parker C, Milosevic M, Panzarella T, Banerjee D, Jewett
M, Catton C, et al. The prognostic significance of the
tumor infiltrating lymphocyte count in stage 1 testicular
seminoma managed by surveillance. Eur J Cancer 2002;
38 (15):2014-9.
2. Hsu YJ, Pai L, Chen YC, Ho CL, Kao WY, Chao TY.
Extragonadal germ cell tumors in Taiwan: an analysis of
treatment results of 59 patients. Cancer 2002; 95:766–
74.
3. El Abbadi N, Maagili MR, Arkha Y, Amarti A,
Bellakhdar F. Cerebellar primary germinom. Case
report. Neurochirurgie 2002; 48:351-4.
4. Wolden SL, Wara WM, Larson DA, Prados MD,
Edwards MSB, Sneed PK. Radiation therapy for primary
intracranial germ-cell tumors. Int J Radiat Oncol Biol
Phys. 1995; 32:943–47.
5. Nakagawa Y, Perentes E, Ross GW, Ross AN,
Rubinstein LJ. immunohistochemical differences
between intracranial germinomas and their gonadal
equivalents. An immunoperoxidase study of germ cell
tumors with epithelial membrane antigen, cytokeratin,
and vimentin. J Pathol. 1988; 156(1):67-72.
6. Bentley AJ, Parkinson MC, Harding BN, Bains RM,
Lantos PL. A comparative morphological and
immunohistochemical study of testicular seminomas and
intracranial
germinomas.
Histopathology.
1990;17(5):443-9.
7. Tekkok IH, Sav A. Aggressive spinal germinom with
ascending metastases. J Neurooncol. 2005;75(2):135–
41.
8. Martinazzi M, Zampieri A, Martinazzi S, Crivelli F,
Mauri MF, Calandra C.Proliferative activity of stage I
testicular neoplasms: evaluation by image analysis of
immunoreactive MIB-1. Pathologica. 1998; 90(6):783-7.
9. Hattab EM, Tu PH, Wilson JD, Cheng L. OCT4
immunohistochemistry is superior to placental alkaline
phosphatase (PLAP) in the diagnosis of central nervous
system germinoma. Am J Surg Pathol. 2005 ;29(3):36871.
10. Bailey D, Marks A, Stratis M, Baumal R.
Immunohistochemical staining of germ cell tumors and
intratubular malignant germ cells of the testis using
antibody to placental alkaline phosphatase and a
monoclonal anti-seminoma antibody. Mod Pathol. 1991;
4(2):167-71.
11. Midi A, Bozkurt S, Yapıcıer Ö, Sav A.. Langerhans Cell
Histiocytosis and Intracranial Germinoma: Are
Immunohistology Techniques Helpful in Distinguishing
Two Entities?. Journal oj Neurological Sciences
(Türkish) . 2006; 23 (3): 209-214
12. Bell DA, Flotte TJ, Bhan AK. Immunohistochemical
characterization of seminoma and its inflammatory cell
infiltrate. Hum Pathol. 1987; 18(5):511-20.
13. Grobholz R, Verbeke CS, Schleger C, Kohrmann KU,
Hein B, Wolf G,et al. Expression of MAGE antigens
and analysis of the inflammatory T-cell infiltrate in
human seminoma. Urol Res. 2000; 28(6):398-403.
120
ORIGINAL RESEARCH
EVALUATION OF INITIATING, CONTINUING AND WEANING TIME OF
BREASTFEEDING
Ruhusen Kutlu, Kamile Marakoğlu
Selcuk Üniversitesi, Meram Tıp Fakültesi, Aile Hekimliği Anabilim Dalı, Konya, Türkiye
ABSTRACT
Objective: The aim of this study was to evaluate the knowledge and behavior of mothers related to the
initiation time, duration and affecting factors of breastfeeding.
Methods: This descriptive and cross-sectional study included 214 mothers who had children aged between
1-72 months. These mothers were selected from the pediatric policlinics of the Meram Medical Faculty. Data
were obtained via questionnaire form by interviewing. Statistical analyses were performed using the software
package SPSS version 10.0.
Results: The mean age of the mothers was 28.96 (SD±6.06). 187 mothers (87.4 %) delivered in the hospital.
20 mothers (9.3 %) delivered in a primary health care center. The rate of exclusive breast-feeding for at least
6 months was 37.7 %. The rate of breast-feeding initiation time in the first 1-2 hours after delivery was 78.9
%. The mean breast-feeding weaning duration was 10.6 months (SD±5.69).
Conclusion: In our study, 96.7 % of the mothers delivered their babies in a hospital or primary health care
center under the control of a nurse or a doctor. All health professionals should have the necessary knowledge
and skills in order to protect, promote and support breastfeeding. Consequently, prenatal and postnatal
breastfeeding education and support courses should be provided everywhere.
Keywords: Breastfeeding, Education program, Mother’s health
ANNE SÜTÜNE BAŞLAMA, DEVAM VE KESME ZAMANININ DEĞERLENDİRİLMESİ
ÖZET
Amaç: Bu çalışmada anne sütüne ilk başlama zamanı, süresi ve bunu etkileyen faktörlerle ilgili annelerin
bilgi ve davranışlarını değerlendirmeyi amaçladık.
Yöntem: Tanımlayıcı ve kesitsel tipteki bu çalışma 1-72 aylık bebeği olan 214 annede yapıldı. Çalışmaya
katılan anneler Meram Tıp Fakültesi çocuk kliniğinden seçildi. Veriler anket yoluyla ve yüz yüze
görüşülerek elde edildi. İstatistik analizler bilgisayarda SPSS 10.0 programı kullanılarak yapıldı.
Bulgular: Annelerin yaş ortalaması 28,86 (SD±6.06) olup, 187 anne (%87.4) hastanede, 20 anne(%9.3)
sağlık ocağında doğum yapmıştı. En az 6 ay süre ile etkili anne sütü verme sıklığı %37.7. idi. Doğumdan
sonraki ilk 1-2 saat içinde anne sütüne başlama sıklığı %78,9 olup, anne sütünü kesme süresinin ortalama
değeri 10,6 ay (SD±5.69) idi.
Sonuç: Bizim çalışmamızda tüm annelerin %96,7’si hastane veya bir sağlık ocağında hekim ya da bir
hemşire kontrolü altında doğum yapmıştı. Bu nedenle, sağlık personeli anne sütünün desteklenmesi,
korunması ve devam ettirilmesi konularında gerekli bilgi ve beceriye sahip olmak zorundadır. Bu yüzden,
her yerde doğum öncesi ve sonrası anne sütü eğitimi ve destekleme kursları düzenlenmelidir.
Anahtar Kelimeler: Anne sütü, Eğitim programı, Anne sağlığı
active compounds including hormones, cytokines
and enzymes which are important not only for the
maturation of the immune system but also for
neurological development, especially in premature
infants. Breastfeeding is the healthiest way to feed
INTRODUCTION
Breast milk is the ideal food for newnates and
infants. Breastfeeding also has many advantages
in regard to the mother’s health1-4.Breast milk
contains many different kinds of biologically
Ruhusen Kutlu
Selcuk Üniversitesi Meram Tıp Fakültesi, Aile Hekimliği AD, Konya,
Türkiye
121
Ruhusen Kutlu, et al
Evaluation of initiating, continuing and weaning time of breastfeeding
a baby. It is possible, but difficult, for mothers to
reverse a decision not to breastfeed or to re-start
breastfeeding once they have stopped. Introducing
partial bottle feeding will reduce a mother's breast
milk supply5-7.
METHODS
This descriptive and cross-sectional study was
carried out among 214 mothers who had 1-72
months old babies between July 10th and December
30 th
2003. The hospitals where the deliveries took
place were not taken into consideration but the
types of delivery were listed. After finishing this
study, the midwives, nurses, pediatricians and
gynecologists were trained in a three-day course
on the Ten Steps to successful breastfeeding. In
this training and promotion course, the techniques,
benefits, initiation, continuing and weaning time
of breastfeeding were explained. It is emphasized
that breastfeeding should begin as soon as
possible after birth, usually within the first half
hour, and exclusive breastfeeding should continue
for the first 6 months. It is also recommended that
breastfeeding continue for at least 24 months.1,14
In the pediatric hospital, a breastfeeding room was
organized. Posters supporting breastfeeding were
placed on the walls of the hospital. Booklets
informing all pregnant women and lactating
mothers about the benefits and management of
breastfeeding were delivered. An exclusive
handout about breastfeeding policy for all health
care staff was prepared. We held public meetings
to advertise the Baby Friendly Hospital Initiative.
Then we organized breastfeeding support groups
between mothers. We plan to carry out another
study to evaluate the results obtained from the
breastfeeding education program later on.
Epidemiologic research shows that human milk
and breastfeeding of infants provides advantages
in terms of general health, growth and
development. Breastfeeding also significantly
decreases the risk of a large number of acute and
chronic diseases. In addition to reducing
childhood infections, breastfeeding may also
protect against sudden infant death syndrome,
insulin-dependent diabetes mellitus, Crohn’s
disease, ulcerative colitis, lymphoma, allergic
diseases and other chronic digestive diseases.5,8,9
Breastfeeding has also been related to possible
enhancement of cognitive development.6,10
There are also a number of studies that indicate
some possible health benefits of breastfeeding for
mothers. It has been known for a long time that
breastfeeding increases the level of oxytocin,
resulting in less postpartum bleeding and more
rapid uterine involution. Lactational amenorrhea
causes less menstrual blood loss over the months
after delivery. A lactating woman returns to her
normal weight much earlier. The risk of ovarian
cancer and pre-menopausal breast cancer
decreases.6,11
The Baby Friendly Hospital Initiative (BFHI) is a
global program initiated in 1991 by the World
Health Organization (WHO) and the United
Nations Children’s Fund (UNICEF) in response to
the Innocent Declaration (1990)12. WHO and
UNICEF recommend exclusive breastfeeding
until the sixth month and breastfeeding combined
with a gradually diversified food intake until the
age of 2.1,6,13,14
A pediatrician interviewed mothers who were
included in this study. Information was recorded
on a standardized form. The questionnaire
included 21 items and revealed the women’s
sociodemographic characteristics, education and
details of the pregnancy, economic status,
smoking habit during pregnancy, type of delivery,
place of delivery, smoking status of their
husbands,
child’s
weight
and
height
characteristics at birth, initiation of breastfeeding,
duration of exclusive breastfeeding, the weaning
of breastfeeding, and the use of a pacifier.
In
practical
terms,
a
Baby
Friendly
Hospital/Maternity facility encourages and helps
women to successfully initiate and continue to
breastfeed their babies. Since the inception of the
program, over 15,000 hospitals worldwide have
received the Baby Friendly designation12.
The commercial SPSS 10.0 software was used for
data entry on the computer. This software was
also used in the classification and statistical
analyses. The variables were described by
frequency, mean and standard deviation (SD). The
Chi–square test was used for statistical analysis.
P<0.05 was considered significant.
We planned this study as a pre-test before starting
education related to BFHI. In this study, we aimed
to evaluate the knowledge and behavior of
mothers related to the initiation time, duration
and affecting factors of breastfeeding.
122
sociodemographic characteristics and perinatal
conditions of mothers and infants are shown in
Table I. Three mothers refused to breastfeed. The
rate of breastfeeding initiating time in the first 1-2
hours after delivery was 78.9 %. 175 babies were
aged 6 months and older. In this group, the rate of
exclusive breastfeeding for at least 6 months was
37.7 %. The mean weaning time was 10.6
months
(SD±5.69).
The
breastfeeding
characteristics of the babies are shown in Table II.
RESULTS
The mean age of the mothers was 28.96
(SD±6.06). Sixty-one mothers were primiparous
and one hundred and eighty-seven mothers
delivered their babies in a hospital. All the women
were married. Twenty babies were delivered by
the help of a midwife in a primary health care
center,and seven mothers delivered spontaneously
at home. The mean age (month) of the last baby
was 20.9 (SD±16,89) and the mean birth weight
(g) of the last baby was 3075.2 (SD±399,13). The
Table 1: Sociodemographic characteristics and perinatal conditions of mothers and infants
Characteristics
n
%
28
105
47
34
13.1
49.1
22.0
15.8
10
102
60
42
4.7
47.7
28.0
19.6
175
34
5
81.8
15.9
2.3
Consanguinity with her husband
To share the same house with a grandparent
Presence of handicapped child among close relatives
Smoking status of husbands
Perinatal conditions
45
55
22
113
21.0
25.7
10.3
52.8
Smoking during pregnancy and lactation
Number of prenatal visits during the last pregnancy
None
1-3
4-6
7 and ↑
Primiparous
Place and type of delivery
Home,self-delivery
Primary health care center, by a midwife
Hospital
Delivery by cesarean section
19
8.9
18
65
48
83
61
8.4
30.4
22.4
38.8
28.5
7
20
187
63
3.3
9.3
87.4
29.4
Last child’s characteristics
Age (month)
0-6
7-12
13-18
19-24
25 and over
50
50
25
27
62
23.4
23.4
11.7
12.5
29.0
Maternal demographics
Age (years)
18-23
24-29
30-35
36 and over
Education
Illiteracy
Primary School
Middle and High School
University
Employment
Housewife
White-collar
Blue-collar worker
123
The status of breastfeeding initiation after delivery
between normal spontaneous delivery and
cesarean section was significantly different
(X2=32.653, p=0.000) as shown in Table III.
In the 6 month or over exclusive breastfeeding
group, the prevalence of initiation of
breastfeeding within half an hour was higher than
in the group who was exclusively breastfed for
less than 4 months (p=0.004).
There was no significant difference between the
educational levels of the mothers and the rate of
exclusive breastfeeding for at least 6 months
(p=0.159).
There was no significant difference between the
employment status of the mothers and the rate of
exclusive breastfeeding for at least 6 months
(p=0.996).
In the group of babies aged over 1 year (n=131),
the rate of the continuing breastfeeding until the
12th month and breastfeeding combined with a
gradually diversified food intake was 38.9%.
The rate of using pacifier was significantly lower
among children exclusively breast-fed until the
sixth month than among the children exclusively
breastfed until the fourth month (p=0.001).
Table II: The breastfeeding characteristics of the babies
Breastfeeding Characteristics
Initiation of breastfeeding
Within 30 minutes after delivery
Within 1-2 hours after delivery
Later
Interval of breastfeeding
Whenever baby wants
Specific interval
At least 6 months exclusive breastfeeding
Breast discomfort or infection
Artificial nipple
Weaning of breastfeeding (x)
0-5 months
6-11 months
12-17 months
18-23 months
24 months and over
Duration of exclusive breastfeeding (month)
1 month
3 months
6 months
x
n
%
85
84
45
39.7
39.2
21.1
193
21
66
79
100
90.2
9.8
37.7
36.9
46.7
32
53
31
10
12
23.2
38.4
22.5
7.2
8.7
172
142
66
98.3
81.1
37.7
current breastfeeding (n=76) were not included
Table III: The status of breastfeeding initiation after delivery and kind of delivery
Breastfeeding status
Within 30 minutes
Within 1-2 hours
Later
Total
Normal spontaneous delivery
%
n
81.2
69
67.9
57
35.6
16
66.4
142
Cesarean section
%
16.8
32.2
64.4
33.6
n
16
27
29
72
X2=32.653, p=0.000
was not entirely representative of the Turkish
population. The rates of breastfeeding may be
considered low, as this study was carried out
before BFHI.
DISCUSSION
Before discussing the results, the limitations of the
study must be considered. The cases who applied
to pediatric policlinics for any reason within a
certain period were included in this study. The
research period can be found as short by some. In
addition, although quite a close match, the sample
Breastfeeding is the best form of nutrition for
infants. Family physicians and healthcare workers
can have a significant role in the initiating and
124
maintenance of breastfeeding if they have
sufficient knowledge of the benefits of
breastfeeding and the necessary clinical
management skills or habits. Over one million
infants worldwide die every year because they are
not breastfed or because they are given other
foods too early. Millions of people live in poor
health, exposed to preventable diseases and
malnutrition. A woman’s ability to feel self
confidence and secure with her decision to
breastfeed are challenged by her family and
friends, the media, and health care providers1,13,15.
ratio of breastfeeding until the 12th month
combined with a gradually diversified food intake
was 38.9 %. Whereas, breastfeeding education,
lactation consultation, and other postpartum
supports may improve a woman’s chance of
starting and continuing to breast-feed her
baby.5,11,15
Breast discomfort or infection was seen in 36.9%
of all mothers. If the mothers are well-informed
this negative rate can decrease.
The rate of using an artificial nipple was 46.7 %
(n=100). This rate was significantly lower in
exclusively breastfed babies for six months, than
among babies exclusively breastfed for less than
four months (p=0.001). The use of an artificial
nipple is an unhealthy habit.14,16 Unfortunately,
the nonexclusive breastfeeding group has a
tendency to use a pacifier.
The rate of breastfeeding initiation within the first
1-2 hours after delivery was 78.9 % and after two
hours it was 21.1 %. The rate of breastfeeding
initiation within the first 1-2 hours in normal
spontaneous delivery significantly showed higher
prevalence than in cesarean section cases
(X2=32.653, p=0.000). Cesarean delivery (C/S)
has a negative effect on early, successful
breastfeeding.16,17 We recommend that an attempt
be made to initiate lactation before the end of the
first hour (and no later than two hours) after the
birth following cesarean delivery. Positioning may
be more difficult because of postoperative pain
after C/S. The lateral decubitus position for
breastfeeding might be preferable. Special pillows
may also be used to provide support for
breastfeeding.16
In our study, most of the mothers were from
middle/low educational levels. The educational
level and working status did not significantly
affect the rate of exclusive breastfeeding for at
least 6 months.
The rate of smoking during pregnancy and
lactation was 8.9 %. This rate was lower than in
other countries.20-23 Smoking is an important
public health problem. Especially, during
pregnancy and lactation, smoking negatively
affects both the mother’s and the baby’s health.
To prevent and reduce tobacco use in the young
and in pregnancy, further research should be
carried out to develop more effective smoking
cessation programmes.23,24
The rate of breastfeeding whenever the baby
wanted was 90.2 %, and the ratio of breastfeeding
with certain intervals was 9.8 %. This finding
shows
similarity
to
the
recommended
breastfeeding practices of WHO.11,14
In our study, in the group of babies aged 6 months
and older , exclusive breastfeeding rates in the 1st,
3rd and 6th months postpartum were 98.3 %, 81.1
% and 37.7 % respectively. According to Anne
Merewood, MA, IBCLC, in 2001, the mean
breastfeeding initiation rate in US Baby- Friendly
hospitals was 84.8%, compared to a national
breastfeeding initiation rate of 69.5%.18 According
to Kramer MS. et al, the exclusive breastfeeding
rate at 6th month was 7.9% in the Republic of
Belarus in 1997.19 Durand M. et al evaluated a
training program about breast feeding at the
maternity section of Obstetrics, Gynecology and
Reproductive Medicine at Grenoble University
Hospital Center in 2002. The exclusive
breastfeeding rates in a pre-and post sample
survey were 14.0% and 28.0% respectively. In the
same study, the initiating rate of breastfeeding
was 76.0%.1 In our study, this rate was higher. In
the group of babies older than 1 year (n=131), the
In our country, traditional marriages between
relatives are common. In this study, the rate of
relativity among couples was 21 %. To share the
same house with grandparents is also a traditional
custom. This rate was 25.7 %. Having a
grandparent in the same house positively supports
and encourages this ideal form of nutrition for
infants.
Human milk is the preferred feeding for all
infants, including premature and sick newborns.11
Prenatal support, hospital management and
subsequent pediatric and maternal visits are allimportant
components
of
breastfeeding
promotion.2,5,15,17 Therefore, health professionals
should have the necessary knowledge and skills
for managing the different stages of lactation.
REFERENCES
1.
125
Durand M, Labarere J, Brunet E, Pons JC. Evaluation of
a training program for healthcare professionals about
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
breastfeeding. Eur J Obstet Gynecol Reprod Biol. 2003;
106:134-138.
Moran VH, Bramwell R, Dykes F, Dinwoodie K. An
evaluation of skills acquisition on the WHO/UNICEF
Breastfeeding Management Course using the prevalidated Breastfeeding Support Skills Tool (BeSST).
Midwifery 2000; 16:197-203.
Egemen A, Kusin N, Aksit S, Emek M, Kurugol Z. A
generally neglected threat in infant nutrition: incorrect
preparation of infant formulae. Turk J Pediatr 2002;
44:298-303.
Giugliani ER. Breastfeeding in clinical practice. J
Pediatr (Rio J) 2000; 76:238-252.
Earle S. Factors affecting the initiation of breastfeeding:
implications for breastfeeding promotion. Health Promot
Int 2002; 17: 205-214.
L.Parker. Breastfeeding and cancer prevention. Eur J
Cancer 2001; 37: 155-158.
Yngve A, Sjostrom M. Breastfeeding determinants and a
suggested framework for action in Europe. Public
Health Nutr 2001; 4: 729-739.
Booth I. Does the duration of breastfeeding matter? BMJ
2001; 322: 625-626.
Moreland J, Coombs J. Promoting and supporting
breastfeeding. Am Fam Physician 2000; 61: 2103-2104.
Gomez-Sanchez M, Canete R, Rodero I, Baeza JE,
Avila O. Influence of breastfeeding on mental and
psychomotor development. Clin Pediatr (Phila) 2003;
42: 35-42.
Rea MF. [Breastfeeding and the use of human milk:
what the American Academy of Pediatrics recommends]
J Pediatr (Rio J) 1998; 74: 171-172.
Baby-Friendly
in
BC
Survey
Results.
http://www.bcbabyfriendly.ca/bfhi.html. was reached at
10 July 2004
Breastfeeding:
Ideal
for
Infants.
http://www.cdc.gov/breastfeeding/compendbabyfriendlywho.htm.was reached at 12 July 2004.
14. Moreland J, Coombs J. Promoting and Supporting
Breast-feeding. Am Acad Pediatr 2000; 61: 2093-2100.
15. Deshpande AD, Gazmararian JA. Breastfeeding
education and support: association with the decision to
breast-feed. Eff Clin Pract 2000; 3: 116-122.
16. Sınusas K, Gaglıardı A. Initial management of
breastfeeding. Am Fam Physician 2001; 64: 981-988.
17. de la Torre MJ, Martin-Calama J, Hernandez-Aguilar
MT; Spanish Committee on Human Lactation, Spanish
Paediatric Association. Breastfeeding in Spain. Public
Health Nutr 2001; 4: 1347-1351.
18. Merewood A, Philipp BL, Mehta S, Chamberlain LB.
Baby-Friendly Hospital Initiative in the US:Rates,
barriers, and associations from the first national
survey.(Abstract) Submitted for presentation in the
132nd Annual Meeting (November 6-10, 2004) of
APHA.
19. Kramer MS, Chalmers B, Hodnett ED, Sevkovskaya Z,
Dzikovich I, Shapiro S, Collet JP, Vanilovich I, Mezen
I, Ducruet T, Shishko G, Zubovich V, Mknuik D, et all.
Promotion of Breastfeeding Intervention Trial
(PROBIT): a randomized trial in the Republic of
Belarus. JAMA 2001;285:413-420
20. Balle J, Olofssson MJ, Hilden J. Cannabis and
pregnancy. Ugeskr Laeger 1999; 161: 5024-5028.
21. Ebrahim SH, Floyd RL, Merritt RK 2nd, Decoufle P,
Holtzman D. Trends in pregnancy-related smoking rates
in the United States. 1987-1996. JAMA 2000; 283: 361366.
22. Pagano R, La Vecchia C, Decarli A. Smoking in Italy,
1995. Tumori 1998; 84: 456- 459.
23. Chatenoud L, Chiaffarino F, Parrazini F, Benzi G,
Vecchia CL. Letters. Prevalence of smoking among
pregnant women is lower in Italy than England. Br Med
J 1999; 318: 1012.
24. Altman DG, Wheelis AY, McFarlane M, Lee H,
Fortmann SP. The relationship between tobacco access
and use among adolescents: a four community study.
Soc Sci Med 1999; 48: 759-775.
126
ORIGINAL RESEARCH
IDIOPATHIC SUDDEN SENSORINEURAL HEARING LOSS
Ufuk Derinsu, Şengül Terlemez, Ferda Akdaş
Marmara Üniversitesi Tıp Fakültesi, Odyoloji Bilim Dalı, İstanbul, Türkiye
ABSTRACT
Objective: The purpose of this study is to present our patients with ISSHL and to assess the shape of the
audiogram and the recovery incidence of the patients.
Methods: 28 patients who were referred to our clinic under diagnosis as idiopathic sudden sensorineural
hearing loss during two years (between 2004 - 2006) were included in the study. Routine audiological
evaluation was performed to all patients. Shape of initial audiograms was classified in 3 groups: (1) flat
audiogram; (2) upsloping audiogram; (3) downsloping audiogram. Differences in PTA and WDS between
pre and post-treatment were calculated to assess the recovery of hearing.
Results: In this study, recovery rate was high in each of the three groups. There was no difference in the
recovery rate between the groups. There was no relation between recovery and early referral to therapy. The
groups were very small for statistical analysis.
Conclusion: It is necessary to enlarge the study group to compare the effects of the factors on idiophatic
sudden sensorineural hearing loss.
Keywords: Idiopathic sudden hearing loss, sudden hearing loss, sensori-neural
İDİOPATİK ANİ SENSORİNÖRAL İŞİTME KAYBI
ÖZET
Amaç: Bu çalışmanın amacı idiopatic ani sensorinöral işitme kayıplı hastalarımızı sunmak ve bu hastaların
odyogram şekillerini, iyileşme oranlarını değerlendirmektir.
Metot: 2004-2006 yılları arasında idiopatic ani sensorinöral işitme kaybı tanısı alan hastalar çalışmaya
alındı. Bütün hastalara rutin odyolojik değerlendirmeler yapıldı. İlk başvurudaki odyogram şekilleri (1) düz
odyogram, (2) yüksek frekanslara doğru eğimli odyogram ve (3) alçak frekanslara doğru eğimli odyogram
olmak üzere sınıflandırıldı. İşitmedeki düzelmeyi değerlendirmek için tedavi öncesi ve sonrasında saptanan
saf ses eşikleri ve ayırdetme puanları arasındaki farklılıklar hesaplandı.
Sonuçlar: Bu çalışmada bütün gruplarda iyileşme oranı yüksek bulundu. Gruplar arasında iyileşme oranı
açısından farklılık görülmedi. İyileşme ile tedaviye erken başlama olgusu arasında bir ilişki saptanmadı.
İstatistiksel analizler için gruplardaki hasta sayıları yetersiz bulundu.
Tartışma: İdiyopatik ani sensorinöral işitme kaybına ilişkin özellikleri ve etken faktörleri ortaya koyabilmek
için, çalışmanın sürdürülmesine karar verildi.
Anahtar Kelimeler: İdiopatik ani işitme kaybı, ani işitme kaybı, sensorinöral
generally used to refer to hearing losses of
sensorineural origin, which have evolved over a
period of a few days2. Sudden hearing loss is
known to be causally related to viral infection,
circulatory disturbance in the area of the anterior
inferior cerebellar artery, acoustic tumor and
perilymphatic fistula and so on3,4. As there is no
single known etiology for sudden hearing loss, the
treatment of this disease is largely empirical and
involves a wide variety of therapies5.
INTRODUCTION
Idiopathic sudden sensorineural hearing loss
(ISSHL) is characterized by sudden hearing
impairment up to deafness within a short period of
time and is possibly associated with vestibular
dysfunction, tinnitus and pressure sensation in the
affected ear. In a majority of cases, ISSHL is
unilateral1. There is no universal consent on the
standard definition of sudden sensorineural
hearing loss. The term sudden hearing loss is
Ufuk Derinsu
Marmara Üniversitesi Tıp Fakültesi, Odyoloji Bilim Dalı, İstanbul, Türkiye
127
Ufuk Derinsu, et al.
immitancemeter
audiometer.
Clinically, sudden sensorineural hearing loss has
been seen in association with other autoimmune
diseases
such
as
rheumotoid
arthritis,
inflammatory bowel disease, and polyarteritis
nodosa. The improvement in hearing after
corticostereoid and immunosuppressive therapy,
as well as plasmapheresis, further suggests an
autoimmune response as the cause of hearing loss
in these conditions6.
and
Interacoustics
AC
40
Tympanometry was performed on all patients to
verify the pure sensorineural hearing loss.
Tympanograms were accepted as normal, when
middle ear pressure was ≥ 75 mm H2O.
Air- and bone-conducted pure tone audiometry
was performed in the range of 250 Hz to 8000 Hz
and 500Hz to 4000 Hz respectively. Speech tests
included speech reception thresholds and
monosyllabic speech discrimination tests.
Marmara University Monosyllabic Word Lists in
Turkish were used for evaluating the speech
discrimination.
Spontaneous complete hearing recovery is
reported in The literature 7-10. The likelihood of
recovery is influenced by the shape of the
audiogram, the age of the patient, and the
presence or absence of vertigo2.
The purpose of this paper is to present patients
with ISSHL and to assess the shape of the
audiogram and the recovery incidence of the
patients.
The shape of initial audiograms was classified in 3
groups: (1) flat audiogram; (2) upsloping
audiogram; (3) downsloping audiogram.
Eighteen of the patients had flat audiogram, 7 had
upsloping and 3 had downsloping audiogram. 2
patients with flat audiogram had bilateral hearing
loss. Characteristics of the patients are shown in
Table I.
METHODS
Subjects:
Twenty-eight patients who were referred to our
clinic diagnosed as having ISSHLfor two years
(between 2004 - 2006) were included in the study.
Biochemical blood analyses, serological tests and
MRI had been performed for all patients before
they were referred to our clinic. There was no
clearly defined cause for hearing loss in these
cases.
Table 1: Characteristics of the patients.
The age of the patients ranged between 7 and 69
years old. Mean age was 46 years. 19 Patients
were female and 9 patients were male.
The inclusion criteria were as follows: (1) sudden
hearing loss with a history not exceeding 10 days;
(2) sensorineural hearing loss for at least three
contiguous frequencies, averaging 30 dB or more
compared with that for normal hearing.
The interval between onset and initiation of
therapy ranged from 22 hours to eleven days.
All patients had tinnitus at the beginning of the
hearing loss. None of them complained of vertigo.
Two patients’ hearing losses were bilateral; so 30
ears of 28 patients were included in the study. 13
of them were left ears and 17 ears were right.
The degree of hearing loss ranged from mild to
profound at the first audiological evaluation.
Routine audiological evaluation was carried out in
standard soundproof booths (Industrial Acoustic
Company),
using
Interacoustics
AZ
7
128
Table 2: Changes in PTA, SRT and WDS between Pre
and Post-Treatment
The assessment of hearing recovery was made on
the basis of the patient’s impression and
audiological criteria. Audiological improvement
was defined as a 10 dB decrease at least in puretone average (PTA) or 16% improvement at least
in word discrimination score (WDS). PTA was
calculated from 0.5, 1, 2 and 4 kHz.
The same therapeutic protocol (corticosteroid)
was
applied
by
Marmara
University
Otorhinolaryngology Department for all patients.
RESULTS
Differences in PTA and WDS between pre and
post-treatment were calculated. These data are
shown in Table II.
Ten of 20 ears of the patients with flat audiogram
showed improvement in PTA and 6 of them in
WDS (Figure 1). There were positive changes in
PTA for one ear, but they were not enough to
accept as improvement, whereas SRT had an
improvement of 20 dB. Furthermore one ear had
an improvement of 35 dB in PTA, but speech tests
showed no changes (Table 2).
Five patients with upsloping audiogram showed
improvement in PTA whereas one of them had an
insignificant improvement and one of them
showed no change. Although one patient had
improvement of 12 dB in PTA, deterioration was
observed in SRT, but no change was found for
WDS (Figure 2).
Improvement in PTA and WDS was observed in
two patients with downsloping audiogram while
there was no difference in the other patient
(Figure 3).
Figure 1: Changes in PTA and WDS in Patients with Flat Audiogram
129
Figure 2: Changes in PTA and WDS in Patients with Upsloping Audiogram
Figure 3: Changes in PTA and WDS in Patients with Downsloping Audiogram
patient with vertigo in this study. The high
recovery rate could be explained by this factor.
DISCUSSION
In this study, the recovery rate was high in each of
the three groups. There was no difference in the
recovery rate between the groups. Mattox and
Simmons reported that recovery was influenced
by the shape of the audiogram9. This finding was
not compatible with our study. However, it is
necessary to emphasize that the number of
subjects in the downsloping and the upsloping
groups was very small. Therefore, statistical
analysis of the data was not possible. In the
literature, vertigo has been accepted as one of the
poor prognostic indicators9,12. There was no
There were slightly more females than males in
this study, unlike to the equal gender distribution
in literature11,13.
Some studies reported that the duration between
onset of the hearing loss and referral to therapy
was essential14-16. We did not observe this
relationship. Our observation is compatible with
Huy and Sauvaget’s findings17. Hearing recovery
was obtained in the patient referred 11 days after
the onset of hearing loss, whereas there was no
130
improvement in the patient referred on the same
day of the onset of hearing loss.
7.
In the data analysis stage, we concluded that our
findings can give an idea about ISSHL, but it is
necessary to enlarge the study group in order to
compare the effects of the factors on ISSHL.
8.
9.
10.
REFERENCES
1.
2.
3.
4.
5.
6.
11.
Chen CY, Emmerling O, Ilgner J, Westhofen M.
Idiopathic sudden sensorineural hearing loss in children.
Int J Pediatr Otorhinolaryngol 2005;69:817-821.
Cole RR, Jahrsdoerfer R. Sudden hearing loss. Am J
Otol 1988;9:211-215.
Nakashima T, Tanabe T, Yanagita N, Wakai K, Ohno Y.
Risk factors for sudden deafness: a case control study.
Aurus Nasus Larynx 1997;24:265-270.
Zadeh M H, Storper I.S, Spitzer JB. Diagnosis and
treatment of sudden-onset sensorineural hearing loss: A
study of 51 patients. Otolaryngol Head Neck Surg
2003;128:93-98.
Kroenenberg J. Vasoactive therapy versus plasebo in the
treatment of sudden hearing loss: A double-blind clinical
study. Laryngoscope 1992;102.
Matteson EL Use of methotrexate for autoimmune
hearing loss. Ann Otol Rhinol Laryngol 2000;109:710714.
12.
13.
14.
15.
16.
17.
131
Chen CY, Halpin C, Rauch SD. Oral steroid treatment
of sudden sensorineural hearing loss: a ten year
retrospective analysis. Otol Neurotol 2003;24:728-733.
Weinaug P. Spontaneous remission in sudden deafness.
HNO 1984;32:346-351.
Mattox D E, Simmons FB. Natural history of sudden
sensorineural hearing loss. Ann Otol Rhinol Laryngol
1977;86:463-480.
SnowJB Jr. Sudden deafness. In: Paparella MM,
Shumrick DA, eds. Otolaryngology. Philadelphia: W.B.
Saunders, 1980:1757-1766.
Mattox DE, Lyles CA.Idiopathic sudden sensorineural
hearing loss. Am J Otol 1989; 10:242-247.
Psifidis AD, Psillas GK, Daniilidis JCh. Sudden
sensorineural hearing loss: Long-term follow-up results.
Otolaryngol Head Neck Surg 2006;134:809-815.
Shaia FT, Sheehy JL. Sudden sensorineural hearing
impairment: A report of 1220 cases. Laryngoscope
1976;86:389-398.
Laird N, Wilson WR. Predicting recovery from
idiopathic sudden hearing loss. Am J Otolaryngol
1983;4:161-165.
Byl FM. Sudden hearing loss: eight years' experience
and suggested prognostic table. Laryngoscope
1984;94:647-661.
Fetterman B, Saunders J, Luxford W. Prognosis and
treatment of sudden hearing loss. Am J Otol
1996;17:529-536.
Huy PT, Sauvaget E. Idiopathic sudden sensorineural
hearing loss is not an otologic emergency. Otol
Neurootol 2005;26:896-902.
CASE REPORT
RADIONUCLIDE IMAGING IN DIFFERENTIAL DIAGNOSIS OF TORSION AND
INFECTIONS OF TESTIS AND EPIDIDYMIS REVISITED
1
Yasemin Şanlı1, Işık Adalet1, Handan Tokmak1, Öner Şanlı2, Orhan Ziylan2, Sema Cantez1
Departments of Nuclear Medicine Medical Faculty of Istanbul, University of Istanbul 2Departments
of Urology, Medical Faculty of Istanbul, University of Istanbul
ABSTRACT
Differential diagnosis of acute scrotum especially with acute epididymis and testicular torsion should be
made promptly, as testicular torsion is a true surgical emergency of the highest order. In this manuscript, two
demonstrative cases introducing with acute scrotum and diagnosed with scintigraphy and color Doppler
ultrasonography were presented to recall the knowledge.
Keywords: Testicular torsion, radionuclide imaging, color Doppler ultrasonography
RADYONUKLİD GÖRÜNTÜLEME METODU İLE TESTİS TORSİYONU TEŞHİSİ VE
TESTİS VE EPİDİDİMİS ENFEKSİYONLARI
ÖZET
Akut skrotumun ayırıcı tanısı özellikle akut epididimit ve testis torsiyonu için hızla yapılmalıdır. Çünkü
testiküler torsiyon gerçek bir cerrahi acildir. Bu makalede akut skrotal ağrısı olan ve tanısında testis
sintigrafisi ve Doppler Ultrasonografisi kullanılan iki vakayı sunmayı ve bu konudaki bilgileri gözden
geçirmeyi amaçladık.
Anahtar Kelimeler: Testis torsiyonu, radynüklid görüntüleme, renkli Doppler Ultrasonografi
ultrasonography
(CDU)
demonstrated
an
heterogenious right testis with hypoechoic
paranchyma. And vascularity was diminised in the
body of testis but increased in the peritesticular
area. Left testis was completely normal in
physical examination and CDU. An immediate
testicular scintigraphy was performed due to the
insignificant evidence of the testicular torsion on
CDU. While patient was in the supine position in
the gamma camera, 10 mCi Tc-99 m O4 was
injected intravenously and 60 frames for 2
seconds were taken as a dynamic study. After that,
statical images were recorded for 10 minutes.
Testicular scintigraphy demonstrated an increased
activity (perfusion) in the dynamical phase and a
hypoactive center with a hyperactive hologram in
the late static phase (Figure 1). Prompt scrotal
exploration revealed the torsion of right testis with
540º, both testis and epididiymis were purple
(necrotic) in color and showed no bleeding or
significant change in the color after detorsion.
Cord was clamped and orchiectomy was
performed (Figure 2).
INTRODUCTION
Scrotal pain is an urgent condition that Urologists,
Pediatricians and Pediatric surgeons frequently
encounter and may have various etiologies.
However, the most common two causes of this
acute symptom are torsion of testicles and acute
epididymitis. Differentiation of torsion from
infections of testis and epididymis has a great
importance because of the major differences in
treatment modalities 1 Mostly, physical
examination combined with color Doppler
ultrasonography or testicular scintigraphy is used
in differential diagnosis 2,3. In this manuscript, we
aimed to recall the utility of testicular scintigraphy
in these two acute conditions using two cases.
CASE REPORT
Case 1
Twenty two years old white male presenting with
right scrotal pain extending to the right inguinal
region for 36 hours administered to our outpatient
Urology clinic. Physical examination revealed
right testicular tenderness and hyperemia in
scrotal skin. Assessment with color Doppler
Yasemin Şanlı
İstanbul Tıp Fakültesi, Nükleer Tıp AD, Çapa, İstanbul
132
Yasemin Şanlı, et al.
Radionuclide imaging in differential diagnosis of torsion and infections of testis and epididymis revisited
Case 2
An eight year old boy presenting with pain and
tenderness in the left testicle administered to the
outpatient clinic of department of Pediatric
Surgery. His CDU revealed an expanded and
heterogenious left testis and epididiymis with a
slightly increased vascularity. These findings were
demonstrating an acute epididimo-orchitis. In
order to confirm the diagnosis, testicular
scintigraphy was performed. In dynamic phase,
the activity was increased in the area suiting to the
left testicle compared with the other side. In the
static phase, the activity was diffusely increased
on the left testis (Figure 3). This image was
interpreted as epididymoorchitis. He had received
an antibiotherapy regimen for 10 days and his
symptoms improved within a few days.
Figure 1: Testicular scintigraphy demonstrated an
increased activity in the dynamical phase and a
hypoactive center with a hyperactive hologram in the late
static phaseon the right testis.
DISCUSSION
Torsion is the twisting of the testis on the
spermatic cord, resulting in strangulation of the
blood supply and infarction of the testis. The
patient usually presents with the sudden onset of
pain and swelling of the involved testis. The pain
may radiate through groin and abdomen. On
physical examination, it is difficult to distinguish
testis from epididymis because of localised
swelling. For this reason the condition is
frequently
misdiagnosed
as
epididymitis.
Therefore, imaging of the scrotum is very
important for the diagnosis of the specific etiology
of the patients presenting with acute scrotum.
Prompt differential diagnosis should be made
between acute testicular torsion and acute
infections of testis and epididimytis, since torsion
of the testicle is a true surgical emergency of the
highest order. An immediate surgical exploration
(and detorsion if needed) should be performed to
the patients diagnosed with acute testicular
torsion. Irreverible ischemic injury to the
testicular paranchyma may begin as soon as 4
hours after occlusion of the cord 4.
Figure 2: Scrotal exploration revealed torsion of the testis
with 540º, all testis and epididymis were purple in color
(arrows).
Color duplex ultrasonography has proved to be a
valuable tool in the differential diagnosis of
epididymis and torsion. This method uses visual
color coding of flow velocities in blood vessels
superimposed on the grey scale ultrasound to
determine increases and decreases. Wilbert and
collegues found that CDU had a sensitivity of
82% and specificity of 100% for torsion 5. In
addition, the sensitivity and specificity for
epididymis were found to be70% and 88%
respectively. False-negative CDU imaging in
torsion was generally due to partial torsion with
some residual blood flow in the testicle and
Figure 3: In dynamic phase, the reactivity was increased in
the area suiting to the left testicle compared with the other
side. In the static phase, the activity was diffusely on the left
testis (arrows)
133
Yasemin Şanlı, et al
Radionuclide imaging in differential diagnosis of torsion and infections of testis and epididymis revisited
epididymitis. Thus, in this imaging modality,
operator should be highly experienced. In our first
case, diminished blood flow (not complete loss)
was detected. However, specific etiology of the
acute scrotum couldn’t be diagnosed as testicular
torsion, while the second case was diagnosed
accurately as epididymo-orchitis.
Radionuclide scintigraphy of the scrotum is the
most accurate method of diffrential diagnosis.
Levy and collegues found the study to have a
positive predictive value of 75%, a sensitivity of
90% and specificity of 89% 6. In the early phase
of torsion ( <5 to 7 hours after onset of symptoms)
in which there is only a minimal edema or
congestion and minimal or no reactive hyperemia
in dartos, the angiographic phase of the
scintigraphy demonstrates normal or diminished
blood flow to the affected side. Static images
taken for 5-10 minutes demonstrate a central
photopenic defect in the involved hemiscrotum7.
Inflammation has not yet occurred in the dartos,
therefore no rim of activity is identified in the
hemiscrotum. In missed torsion, the angiographic
phase of the radionuclide scintigraphy may show
normal or increased blood flow to the affected
scrotum. Occasionally a nubbin sign may be
present. This represents increased blood flow
secondary to hyperemia in the dartos. Static
images demonstrate a central photopenic defect
with a variable degree of reactive hyperemia
appearing as a rim of activity surrounding the
testicle. The scan is interpreted as missed torsion
because testicular viability has been jeopardised.
On the other hand, in acute epididymitis, the
radionuclide
angiogram
shows
increased
perfusion to the affected hemiscrotum. If the
inflammation involves only the epididymis,
radionuclide activity is seen principally at the
superolateral pole of the testis and if inflammation
has progressed to involve the entire scrotum
(epididymo-orchitis), the entire hemiscrotum will
have increased activity when compared with the
contralateral side7. Likewise in the second case,
diagnosis of left epididymo-orchitis was
supported by scintigraphic findings.
In conclusion, evidence from literature reveals
that sonography and scintigraphy show similar
sensitivity for diagnosing testicular torsion. One
should keep in mind that, false negatives of
sonography which is inherently operator
dependent,
may
be
compansated
with
scintigraphy.
REFERENCES
1.
2.
3.
4.
5.
6.
7.
134
Schneck FX, Bellinger MF, Abnormalities of the testes
and scrotum and their surgical management. In:Retik
AB, Vaughan ED Jr, Wein AJ (eds). Campbell’s
Urology. Philedelphia: Saunders 2002: 2353-2394.
Nussbaum Blask AR, Bulas D, Shalaby-Rana E,
Rushton G, Shao C, Majd M. Color Doppler sonography
and scintigraphy of the testis: a prospective, comparative
analysis in children with acute scrotal pain. Pediatr
Emerg Care 2002;18: 67-71.
Wu H, Sun SS, Kao A et al, Comparison of radionuclide
imaging and ultrasonography in the differentiation of
acute testicular torsion and inflammatory testicular
disease. Clin Nuc Med 2002; 27: 490-493.
Bartsch G, Frank S, Marberger H, Mikuz G.Testicular
torsion: late results with special regard to fertility and
endocrine function. J Urol 1980; 124: 375-378.
Wilbert DM, Schaerfe CW, Stern WD, Strohmaier WL,
Bichler KH Evaluation of the acute scrotum by colorcoded Doppler ultrasonography. J Urol 1993; 149: 14751477.
Levy OM, Gittelman MC, Strashun AM, Cohen EL,
Fine EJ.Diagnosis of acute testicular torsion using
radionuclide scanning. J Urol 1983; 129: 975-977.
Beltran MR, Testicular Imaging. In: Henkin RE, Boles
MA, Dillehay CL (eds). Nuclear Medicine Vol II.
Mosby-Year book, Inc. 1996: 1110-1121.
CASE REPORT
SPINOCEREBELLAR ATAXIA TYPE 2 IN A TURKISH FAMILY
1
Kadriye Ağan1, Deniz Kutlu1, Nazlı Başak2, Önder Us1, Dilek İnce-Günal1
Marmara University, School of Medicine, Department of Neurology, Istanbul, Türkiye 2Boğaziçi
University, Molecular Biology and Genetics, Istanbul, Türkiye
ABSTRACT
Spinocerebellar ataxias are classified according to the clinical signs, affected neuroanatomical regions and
genetic features. Spinocerebellar ataxia type II (SCA 2) is characterized by gait and limb ataxia, dysarthria,
ophthalmoplegia, and polyneuropathy . Extrapyramidal system signs and dementia are observed at late
clinical stages. SCA 2 is caused by an expanded (CAG) trinucleotide repeat on the chromosome 12 resulting
in production of abnormal protein called ataxin-2. Here we report a family who was affected by SCA 2 for
three generations. Gait ataxia was the first symptom in all cases, followed by dysarthria and ophthalmoplegia
respectively. None of the patients had extrapyramidal signs or cognitive decline. Axonal polyneuropathy was
established with EMG in one patient and brain MRI showed pure cerebellar atrophy in all patients. An
autosomal dominant cerebellary ataxia was the preliminary diagnosis on the virtue of family history,
neurological examination and laboratory and scaning techniques. Genetic studies disclosed a mutation on the
SCA 2 locus. Spinocerebellary ataxias are a group of disorders classified according to associating clinical
signs and symptoms.Therefore, it is important to establish an accurate clinical classification as it would lead
to a clue for the discovery of new gene locuses.
Keywords: Ataxia, Spinocerebellar ataxia, Autosomal dominant
SPİNOSEREBELLAR ATAKSİ TİP 2 İLE İZLENEN AİLE SUNUMU
ÖZET
Spinoserebellar ataksiler, ataksiye eşlik eden diğer nöroanatomik yapıların etkilenip etkilenmemesine ve
genetik özelliklerine göre sınıflandırılır. Spinoserebellar ataksi tip II (SCA-2) yürüyüş ve ekstremite ataksisi
ile başlayan, dizartri, oftalmopleji, periferik sinir tutulumu ile şekillenen geç klinik evrelerde ekstrapiramidal
sistem bulguları ve demansında eklendiği bir SCA tipidir. İlk bulguların 3-4. dekadda başladığı SCA-2 12.
kromozoma lokalize edilmiş, ataksin-2 genini kodlayan bir trinükleotid tekrar hastalığıdır. Bu yazıda 3 kuşak
boyunca etkilenimin olduğu bir aile sunulacaktır. Tüm olgularda yürüyüş ataksisi ile başlayan semptomlara
sırası ile dizartri ve oftalmoplejinin eklendiği gözlendi. Piramidal, ekstrapiramidal ve kognitif etkilenim
saptanmadı. Bir hastanın EMG’sinde aksonal tutulumun ön planda olduğu polinöropati saptandı. Üç hastada
yapılan kranial görüntülemelerde saf serebellar atrofi bulundu. Klinik, radyolojik ve elektrofizyolojik
çalışmaların sonucu ve aile öyküsü nedeni otozomal dominant spinoserebellar ataksi düşünülen hastalarda
gerçekleştirilen genetik çalışmada SCA-2 lokusunda mutasyon saptandı. Spinoserebellar ataksiler, serebellar
bulgulara eşlik eden nörolojik semptomlara göre sınıflanan ve her yeni tanımlanan semptoma göre yeni bir
lokusun bulunduğu bir hastalık grubudur. Hastaların klinik bulgularının iyi sınıflandırılması lokusun
saptanması için önemlidir.
Anahtar Kelimeler: Ataksi, Spinoserebellar ataksi, Otozomal dominant
INTRODUCTION
SCA 2 is caused by an expanded (CAG)
trinucleotide repeat on the chromosome 12
resulting in production of abnormal protein called
ataxin-22. The symptoms usually begin in the third
or fourth decade of life 2.
Spinocerebellar ataxias are classified according to
the clinical signs, affected neuroanatomical
regions and genetic features. Spinocerebellar
ataxia type II (SCA 2) is characterized by gait and
limb ataxia, dysarthria, ophtalmoplegia, and
polyneuropathy1,2. Extrapyramidal system signs
and dementia are observed at late clinical stages.
Here we will report a Turkish family who was
affected by SCA 2 for three generations.
Kadriye Ağan
Marmara University Faculty of Medicine, Neurology, Istanbul, Türkiye
135
Kadriye Ağan, et al.
Spinocerebellar ataxia type 2 in a turkish family
The second patient (III-1) was a 26 year old son of
the index case. He was complaining of head
titubation which started approximately a year ago.
Neurological examination revealed dysarthria,
bilaterally restricted lateral eye movements and
limb ataxia. MRI showed cerebellar atrophy
(Figure 3)
CASE REPORT
The index case (II-1) was a 49 year old female.
Her symptoms began in the fourth decade of life
with dysequilibrium and dysarthria respectively.
Two years later clumsiness in fine finger
movements and writing has been developed. The
family history is depicted in Figure 1. Her
minimental status test score was 29/30.
Neurological examination revealed dysarthria,
bilaterally restricted upward and lateral eye
movements, limb and gait ataxia. Magnetic
resonance imaging (MRI) showed cerebellar
atrophy (Figure 2). Electrophysiological studies
revealed axonal sensory polyneuropathy.
The brother (II-3) of the index case was a 47 year
old man. He experienced dysequilibrium which
began in the fourth decade.
The mother (I-4) of the index case was 69 years
old. Her history of dysequilibrium and explosive
speech began in the sixth decade. MRI of this case
showed cerebellar atrophy, too.
Figure 1: Family history
Figure 3: MRI shows cerebellar atrophy
Figure 2: MRI shows cerebellar atrophy
136
type 2 was confirmed by genetic study. One
patient (III-1) showed head titubation, which was
rarely reported in the literature7 .
Acquired vitamin E deficiency, vitamin B 12
deficiency, hypothyroidism, other familial and
neurodegenerative diseases (multi-system atrophy,
cerebellary malformations, stroke, multiple
sclerosis, psychogenic disorders, CreutzfeldtJakob Disease, Behçet’s Disease) were excluded
by neurologic examination, laboratory and
scanning techniques.
The SCAs show anticipation and different degrees
of expansion in maternal or paternal
transmission.7. There is a negative correlation
between CAG repeat size and age of disease
onset, therefore young patients suffer from more
severe and rapidly progressing disease8. DNA
analysis showed a normal CAG repeat of 23 on
one chromosome and abnormally amplified CAG
repeat of over 41 on the other chromosome in
index case and her son III-1. Blood samples from
the mother and brother of the index case were not
available. Therefore, the degree of anticipation
and the existence of paternal imprinting were not
analyzed. The widest range of age onset is
observed in individuals with allele numbers
between 38-45 CAG repeats9 .
The family showed autosomal dominant
inheritance and anticipation resulting in onset of
symptoms, in the latest generation, in the third
decade; earlier generations had onset in the fifth
or sixth decade. The testing showed a normal
CAG repeat of 23 on one chromosome and
abnormally amplified CAG repeat of over 41 on
the other chromosome in index case and her son
III-1. Genetic studies disclosed an autosomal
dominant cerebellary ataxia, SCA 2.
DISCUSSION
Testing for dominant ataxias should be included
in the evaluation of patients with ataxia, especially
in cases with a positive family history for
spinocerebellar ataxia. New gene locuses which
are linked to SCA‘s, are discovered every other
day. Genetic study is significant in defining SCA
types which are common in our country.
Spinocerebellar ataxia (SCA) type 2 is a CAG
trinucleotide repeat disorder characterized by
progressive ataxia. In 1982, Harding classified
autosomal dominant cerebellar ataxias (ADCA)
into three types1. ADCA I is characterized by
ataxia with signs of neurodegeneration outside the
cerebellum
including
pyramidal
and
extrapyramidal involvement, ophthalmoplegia,
peripheral neuropathy, and dementia1. ADCA II
represents ataxia with extracerebellar neurologic
findings, plus retinal degeneration. ADCA III is a
pure form of ataxia and degeneration restricted to
the cerebellum1. SCA – 1, 2, 3 and 6 fit into the
ADCA I clinical category1. SCA 2, 15% (13-40%)
is the second common form of ADCA I and
characterized by slowly progressive ataxia and
dysarthria associated with the ocular findings of
nystagmus, slow saccadic eye movements, and in
some individuals ophthalmoparesis3,4. We
describe a family with ataxia, dysarthria,
ophthalmoplegia and peripheral neuropathy.
There are studies which revealed dementia, Ldopa responsive Parkinsonism, fasciculations,
dystonia, and/or chorea at SCA 2 patients5. The
Parkinsonian
phenotype
is
associated
predominantly with a shorter abnormal range of
CAG repeat lengths and older onset age6. In the
present report all of the four patients had
cerebellar dysfunction. Most patients began with
dysarthria and gait ataxia. As the disease
progressed, limb ataxia became more pronounced.
Family members who were examined showed
ophthalmoparesis
and
peripheral
nerve
involvement, and the clinical suspicion of SCA
REFERENCES
1.
2.
3.
4.
5.
6.
7.
137
Harding AE. The clinical features and classification of
the late onset autosomal dominant cerebellar ataxias. A
study of 11 families, including descendants of the ‘the
Drew family of Walworth’. Brain 1982; 105: 1–28.
Pulst SM, Nechiporuk A, Nechiporuk T, et al. Moderate
expansion of a normally biallelic trinucleotide repeat in
spinocerebellar ataxia type 2. Nat Genet. 1996; 14:
269–276.
Geschwind DH, Perlman S, Figueroa C P, Treiman L J,
Pulst S M. The prevalence and wide clinical spectrum of
the spinocerebellar ataxia type 2 trinucleotide repeat in
patients with autosomal dominant cerebellar ataxia. Am
J.Hum Genet 1997; 60: 842-850.
Cancel G, Durr A, Didierjean O, et al. Molecular and
clinical correlations in spinocerebellar ataxia 2: a study
of 32 families. Hum Mol Genet 1997; 6:709-715.
Belal S, Cancel G, Stevanin G, et al. Clinical and
genetic analysis of a Tunisian family with autosomal
dominant cerebellar ataxia type 1 linked to the SCA2
locus. Neurology 1994; 44: 1423-1426.
Lu CS, Wu Chou YH, Kuo PC, Chang HC, Weng YH.
The Parkinsonian phenotype of spinocerebellar ataxia
type 2. Arch Neurol 2004; 61:35-38.
Kim JM, Shin S, Kim JY, et al. Spinocerebellar ataxia
type 2 in seven Korean families: CAG trinucleotide
expansion and clinical characteristics. J Korean Med
Sci 1999; 14:659-664.
8.
Babovic-Vuksanovic D, Snow K, Patterson M C,
Michels V V. Spinocerebellar ataxia type 2 (SCA 2) in
an infant with extreme CAG repeat expansion. Am
J.Med Genet 1998; 79: 383-387.
9.
138
Giunti P, Sabbadini G, Sweeney MG, Davis MB,
Veneziano L, Mantuano E, Federico A, Plasmati R,
Frontali M , Wood NW. The role of the SCA2
trinucleotide repeat expansion in 89 autosomal dominant
cerebellar ataxia families. Frequency, clinical and
genetic correlates. Brain 1998; 121: 459–467.
CASE REPORT
AN UNUSUAL CASE OF MULTIFOCAL MOTOR NEUROPATHY WITH CRANIAL
NERVE INVOLVEMENT AND HYPERREFLEXIA
Hande Türker, Oytun Bayrak, Levent Güngör, Murat Sarıca, Musa Onar
Ondokuzmayıs University, Faculty of Medicine,Department of Neurology, Samsun, Türkiye
ABSTRACT
Multifocal motor neuropathy is characterized by progressive, asymmetric weakness of the limbs with
persistent conduction blocks (CB). Sensory loss is very rare and it also rarely presents with cranial nerve
involvement and hyperreflexia. Here we described a 32-year-old woman with progressive weakness of hand
muscles associated with weakness of orbicularis oculi muscles and fasciculations of tongue. The
electrophysiological examination revealed persistent conduction blocks in both of the ulnar, right median and
left posterior tibial nerves together with F-waves with abnormal persistence. These findings and the
persistency of conduction blocks along with a response to IVIG made it likely that the diagnosis was
multifocal motor neuropathy. The case seemed to be worth reporting because of her unusual clinical
findings.
Keywords: Multifocal motor neuropathy, Cranial nerve involvement, Hyperreflexia
KRANİAL SİNİR TUTULUMU VE HİPERREFLEKSİ İLE GİDEN MULTİFOKAL
MOTOR NÖROPATİ: OLGU SUNUMU
ÖZET
Multifokal motor nöropati (MMN), kalıcı iletim bloklarının eşlik ettiği, ilerleyici, asimetrik ekstremite
güçsüzlüğüyle karakterizedir. Duysal etkilenim çok seyrek olarak görülür. MMN’nin kranial sinir tutulumu
ve refleks artışı ile birlikteliği nadiren bildirilmiştir. Burada, el kaslarındaki ilerleyici güçsüzlüğe, orbikularis
okuli kaslarında güçsüzlük ve dilde fasikülasyonun eşlik ettiği 32 yaşında MMN’li bir kadın hasta
sunulmuştur. Elektrofizyolojik incelemede her iki ulnar, sağ median ve sol posterior tibial sinirlerde iletim
blokları ve F dalgalarında persistans anormalliği saptandı. Bu bulgularla birlikte, ileti bloklarının persistansı
ve tablonun İVİG’e yanıtlı olması bize multifokal motor nöropati tanısını düşündürttü. Hasta, kliniğindeki
seyrek rastlanır öğeler nedeniyle rapor edilmeye değer bulundu.
Anahtar Kelimeler: Multifokal motor nöropati, Kranial sinir tutulumu, Refleks artışı
cranial nerve symptoms4,5. In this report, we
describe a case of MMN with hyperreflexia and
cranial nerve symptoms and we want to
emphasize that the lesion distribution may be
more widespread than it is considered.
INTRODUCTION
Multifocal motor neuropathy (MMN) is
characterized by slowly progressive, asymmetrical
weakness of the limbs without sensory loss. The
upper extremities are often affected in the first
place and distal muscles are affected more than
proximal muscles. On electrophysiological
examination there may be evidence of
demyelination and persistent conduction blocks
(CB)1-3. Differentiation of MMN from motor
neuron disease is important because MMN is a
treatable disorder.
CASE REPORT
A 32-year-old woman was admitted to our
department because of the progressive weakness
of her hand muscles. Her complaints had started
in her left hand, one year before her admittance
and had progressed to involve her right hand 4
months later. Two prior electromyograms, the first
10 months and the second 5 months prior to
admission, were reported as carpal tunnel
syndrome and C8-T1 root involvement. She had
Upper motor neuron signs and cranial nerve
involvement are usually absent1 although MMN is
rarely reported presenting with hyperreflexia and
Hande Türker
Ondokuzmayıs University, Faculty of Medicine, Department of
Neurology, Samsun, Türkiye
139
Hande Türker, et al
An unusual case of multifocal motor neuropathy with cranial nerve involvement and hyperreflexia
had surgery on her left hand but her symptoms
continued to progress. Her cervical computerized
tomography (CT) revealed only a C5-6 posterior
central bulging. On neurological examination the
orbicularis oculi muscles were bilaterally weak
and there were fasciculations on her tongue. The
muscle strength of the thenar abductors and
hypothenar abductors were 2/5, wrist extensors,
elbow extensors and elbow flexors were 4/5, wrist
flexors were 3/5, and arm abductors were 3/5
bilaterally (According to MRC). She had a claw
finger deformity of the second digit of her left
hand (Fig. 1). The strength of the ankle dorsalflexors, plantar-flexors, knee extensors and knee
flexors were 5/5 bilaterally and hip flexors were
4/5 on the left, 5/5 on the right side. Her deep
tendon reflexes were increased. The sensory
examinations were normal. Plantar responses were
flexor.
She did not have any other systemic diseases or
history of usage of any drugs. Laboratory
examinations including blood count, renal and
liver function tests, thyroid function tests and
erythrocyte sedimentation rate were all within
normal limits. Antiganglioside antibodies (anti
GM1 Ab) were negative.
Electrophysiological studies:
The electrophysiological studies including nerve
conduction
studies
(NCs)
and
needle
electromyography (EMG) were performed on
Nihon
Kohden
Neuropack
8
at
our
neurophysiology laboratory. The patient’s skin
temperature was kept between 31-32ºC.
least 40% or 50% reduction of proximal versus
distal CMAP amplitude with minimal dispersion
(less than 30 % increase in CMAP duration) or at
least 50% or 60% reduction of amplitude with
moderate dispersion (31-60 % increase in CMAP
duration)6.
Median, ulnar and sural sensory nerve action
potentials (SNAPs) were obtained antidromically,
recording from digit III for median and from digit
V for ulnar nerves.
Fig. 1: Claw finger deformity of left hand
Table I and II show the results of the NCs. The
median, ulnar and sural SNAPs were all in normal
limits bilaterally. On the left side the amplitudes
of the median and ulnar CMAPs were reduced and
CMAPs could not be recorded at the Erb’s point
although the stimulus was supramaximal (0.1-0.2
ms duration at 50 mA) and the recordings were
repeated. There was an amplitude reduction of 64
% in the ulnar nerve at the axilla and prolongation
of duration was lower than 30 %. The distal
latency of the ulnar CMAP was normal and the
latency of the median CMAP was prolonged.
Ulnar CV was normal. Persistences of F-waves of
the ulnar and median nerves were reduced. The
latency and the amplitude of the peroneal CMAP
were normal but persistence of F-waves was again
reduced. The latency and the amplitude of the
posterior tibial CMAP and the persistence of Fwaves were normal. Peroneal and posterior tibial
CVs were normal. There was a reduction of
CMAP amplitude of the posterior tibial nerve by
74 % at the popliteal fossa. According to the
consensus criteria for the diagnosis of partial
conduction block, the tibial nerve may only have
probable partial conduction block and amplitude
reduction should be over 50 percent when there is
minimal temporal dispersion (duration increased
by 30% or less). Our patient’s NCs of posterior
tibial nerve fulfilled this condition.
Nerve conduction studies:
Median, ulnar, peroneal and posterior tibial motor
NCs including F-waves were performed
bilaterally. NCs were performed comprising the
stimulation of the Erb’s point and the popliteal
fossa for median and ulnar nerves and peroneal
and posterior tibial nerves respectively. For
compound muscle action potentials (CMAPs), we
measured the latency, amplitude and motor
conduction velocity (CV). We also measured
amplitude reduction and percentage of
prolongation of duration on proximal versus distal
stimulation. The American Association of
Electrodiagnostic Medicine has proposed the
criteria for the definition of definite and probable
CB as follows: a) Definite CB: Presence of at
least 50% or 60% reduction of proximal versus
distal CMAP amplitude in the nerves of the upper
and lower extremities with minimal temporal
dispersion (less than 30 % increase in CMAP
duration). b) Probable CB: presence of either at
140
Hande Türker, et al.
Table I: Motor nerve conduction studies of the patient
Side
Nerve
Recording
Latency
N
Amplitude
N
Duration
(mv-µV)
NCV
N
(m/s)
F
N
min.
(mv-µV)
latenc
y
Left*
Ulnar
2.7
<3.2
4
elbow
6.8
<7.0
above
8.0
<10.3
ADM
>6.0
5.5
54.3
4
5.1
76.9
3.9
4.5
76
1.4
6.4
wrist
>50.
26
6
4/16
>50.
35
6
6/16
>47.
28
<27.
3
7/16
7
>47.
29.6
<27.
<28
elbow
DPCB
Right*
axilla
9.7
DPCB
erb
No
CMAP
at erb
Ulnar
ADM
3.5
<3.2
4.2
elbow
7.5
<7.0
above
9.3
>6.0
7.0
50.5
3.4
6.3
59.1
<10.3
1.4
6.2
>80
1.2
6.9
wrist
DPCB
<28
elbow
Left*
DPCB
axilla
10.2
DPCB
erb
No
CMAP
at erb
Median
APB
4.8
<3.6
0.7
elbow
8.3
<7.8
axilla
11.1
erb
No
CMAP
at erb
APB
4.1
<3.6
1
>6.0
4.3
57
0.7
4.6
61
0.7
5.0
wrist
Right*
Median
>6.0
4.6
31
3
wrist
DPCB
Left
Peroneal
elbow
10.2
1
4.6
90
axilla
11.5
<7.8
1
5.0
38
erb
13.0
0.5
4.5
EDB
4.2
<5.1
3
>2
5.7
53
>41
ankle
Right
Peroneal
cap. fib.
10.2
3
6.6
poplitea
10.9
3
6.9
EDB
3.4
<5.1
4
>2
7
42.9
<63.
4/16
4
42
<63.
90
5.8
42
90
<41
ankle
Left*
Post.tibial
4
cap. fib.
9.5
4
6.7
poplitea
10.2
4
7.0
AHL
4.2
<5.0
13.7
>3
6.6
57.8
>38
48.8
ankle
Right
6
PPCB
poplitea
10.0
Post.tibial
AHL
3.6
6.9
3.5
<5.0
6.7
>3
6.1
ankle
poplitea
<55.
40.2
>38
46
<55.
6
12.3
4.8
141
4.8
Table II: Sensory nerve conduction studies of the patient
Side
Nerve
Recording
Latency
N
Amplitude
N
(mv-µV)
Distance
NCV
(cm)
(m/s)
N
(MvµV)
Left
Ulnar
Sensory
2.7
<3.6
65 µV
>10.0
12
44
>39
Sensory
3.2
<3.5
90 µV
>16.0
14
43
>40
Sensory
2.7
<3.6
87 µV
>11.0
12
43
>40
Sensory
3.4
<3.5
52 µV
>10.0
14
40
>40
5th finger
Left
Median
3rd finger
Right
Ulnar
5th finger
Right
Median
3rd finger
Left
Sural
Sensory
3.0
<4
20
>9
14
46
>32
Right
Sural
Sensory
2.9
<4
22
>9
14
47
>32
Footnotes: Abbreviations for both tables
APB: Abductor pollicis brevis
NCV: Nerve conduction velocity EDB: Extensor digitorum brevis
ADM: Abductor digiti minimi
Min. latency: Minimal latency
AHL: Adductor hallucis longus
N: Normal value (According to our lab. normals in the same age group)
cap.fib: Caputulum fibulum
mv: milivolt DPCB: Definite partial conduction block
PPCB: Probable partial conduction block
* Pathologic values are written in bold
fasciculation potentials and positive sharp waves
at rest. We found a moderate neurogenic
involvement
of
orbicularis
oculi,
sternocleidomastoid and lingual muscles.
The latency of the right ulnar CMAP was
prolonged, the amplitudes were reduced and an
amplitude reduction of 58 % was found at the
axilla (Fig. 2). The persistence of F-waves was
reduced. The latency of the median CMAP was
prolonged, the amplitudes and the CV were
reduced and an amplitude reduction of 50 % was
found at the Erb’s point. The minimal F-wave
latency was prolonged. The latencies, amplitudes
and CVs of the peroneal and posterior tibial
nerves together with the minimal latencies and the
persistence of F-waves were normal.
Needle EMG:
Tibialis anterior, extensor digitorum communis,
first dorsal interosseous, deltoid, biceps brachii,
genioglossus and lingual muscles were examined
on the left side whereas deltoid, extensor
digitorum communis, first dorsal interosseous,
orbicularis oculi and sternocleidomastoid muscles
were examined on the right. All extremity muscles
that were examined, except tibialis anterior,
showed a severe neurogenic involvement with
reduced recruitment of polyphasic, large
amplitude, long duration motor unit potentials
with a moderate number of fibrillation and
Fig. 2: Motor nerve conduction study of right ulnar nerve.
There is definite conduction block at the axillary and Erb
stimulation points
142
The asymmetrical onset of weakness of distal
hand muscles in a young patient together with the
conduction blocks in proximal segments in NCs
made the diagnosis of MMN very likely although
there was cranial nerve involvement and
hyperreflexia. The patient was given 0.4g/kg/day
intravenous immunoglobulins (IVIG) for 7 days.
Three weeks after the administration of IVIG,
conduction block in the left ulnar nerve quite
improved although improvement of muscle
weakness was slight (the muscle strength of the
thenar abductors and hypothenar abductors
became 3/5, wrist extensors, elbow extensors and
elbow flexors were 4/5, wrist flexors were 3/5,
and arm abductors were 4/5 bilaterally, according
to MRC, in the follow-up examination). We
planned to continue IVIG administration once a
month for a year and the patient was admitted to
the physical rehabilitation program.
indicated that corticospinal tract was at least
functionally involved in some patients with MMN
showing hyperreflexia5.
Our patient was negative for anti Gm1 Ab.
Although other antiganglioside antibodies such as
antiGD1b were not sought for, a diagnosis of
MMN does not require that every patient should
have these antibodies. About one half of MMN
patients lack elevated levels of these antibodies
and many others have only modest elevations, to a
degree often seen in other neurological and even
non-neurological disorders9.
The electrophysiological examination of our
patient revealed CBs in proximal segments with
reduction in the persistence of the F-waves.
However, in our patient, the amplitudes of the
median CMAPs were significantly reduced. This
progression could have resulted because of distal
conduction failure leading to axonal degeneration.
Similar cases in which initially reduced CMAPs
were found without major indication of
demyelination were reported. The authors of these
reports concluded that the conduction blocks
could have resulted from immune mediated
conduction failure at the nodes of Ranvier without
underlying demyelination in the cases10-12. There
are also patients of MMN in whom CB may
decrease or even disappear after several years of
the disease because of a progressive reduction of
the distal CMAP amplitude, which may reflect
either secondary axonal degeneration or the
appearance of previously unrecognized very distal
CB13. Our patient may also have a similar
situation.
DISCUSSION
The clinical diagnosis of MMN is based on the
presence of chronic and progressive asymmetrical
limb weakness with a multineuropathic
distribution pattern affecting the muscles of at
least two different motor nerves and lasting for at
least two months. There is also minimal or no
sensory loss. Absence of upper motor neuron
involvement is almost a rule7. Our case had distal,
progressive weakness in her hand muscles with an
asymmetrical onset for approximately one year.
Her neurological examination revealed muscle
weakness in the distribution of more than two
different motor nerves besides hyperreflexia and
cranial nerve involvement. Axelsson and
Liedholm reported a similar case to ours,
diagnosed as MMN with cranial nerve symptoms:
an old man with a slight atrophy in the hands and
right-sided hypoglossal palsy4. They suspected
motor neuron disease at first, but the
electrophysiological studies revealed bilateral
ulnar CBs indicative of MMN. They treated the
patient with IVIG. Leon et al reported a case of
MMN with an abnormal blink reflex8. Their
findings allowed them to suggest that the
distribution of involvement pattern in MMN
seemed to be more widespread than generally
considered.
Motor conduction velocities are usually normal or
slightly reduced outside areas of CB and are
sometimes normal even at the level of segments
of CB or adjacent segments confirming the
predominantly focal nature of the demyelination13.
This situation also takes place in our case and it is
noteworthy that it did not happen because of the
technical artifacts.
The clinical presentation of our case and
electrophysiological findings as CBs in both ulnar
nerves, right median and left posterior tibial
nerves with reduction in the persistence of the Fwaves together with the response to IVIG therapy
were thought to be consistent with MMN. In our
patient the progression of the disease took a year.
Such acute or subacute progression is unusual but
cases similar to ours were also reported11. There
are 9 cases reported in the literature as acute
multifocal motor neuropathy (AMMN) and the
Oshima et al. investigated patients with
hyperreflexia who exhibited paralysis with CB.
To determine whether hyperreflexia corresponded
to corticospinal tract dysfunction, they evaluated
central motor conduction time with magnetic
stimulation in these patients. Their findings
143
pathophysiological mechanisms of AMMN
probably overlap with those of chronic MMN11.
The differential diagnosis of MMN from motor
neuron disease is important because MMN is a
treatable disorder. There may still be some
patients in whom the differential diagnosis of
MMN from motor neuron disease is quite hard.
The literature contains some examples of these
patients. Parry et al reported 5 cases of MMN who
had muscle atrophy, cramps and fasciculations
with preserved reflexes. Although the clinical
picture of these cases led to an initial diagnosis of
motor neuron disease, nerve conduction studies
revealed multifocal CBs predominantly involving
proximal nerve segments14. Kaji et al reported 2
patients with MMN whose clinical signs included
atrophy of the tongue and limb muscles closely
resembling that of motor neuron disease and nerve
conduction studies revealed multifocal CBs
without sensory abnormalities15. However the
classical motor neuron disease presents with
needle EMG findings, which cannot be seen in
MMN. The most important of these findings are
the reinnervation motor unit action potentials seen
together with chronic denervated motor unit
action potentials and this provides evidence for a
continuous degeneration and regeneration pattern
of involvement16. Our patient lacked these EMG
findings. Her age and sex, the neurological
examination findings and the clinical progression
which were related with a multineuropathic
distribution pattern together with the response to
IVIG therapy were not found consistent with
motor neuron disease. Nevertheless, it can still be
debated that the definite diagnosis of our patient
may become more clear in the upcoming followups. We emphasize that in patients with distal,
progressive asymmetrical weakness, MMN should
be kept in mind even if they have cranial nerve
involvement and hyperreflexia. A detailed
electrophysiological examination should also be
performed for detection of CBs in proximal
segments of the nerves, especially at the upper
extremities.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
REFERENCES
1.
Preston DC, Shapiro BE. Electromyography and
Neuromuscular Disorders. 2nd ed. Philadelphia:
Elsevier, 2005: 389-420.
144
Biessels GJ, Franssen H, van den Berg LH, et al.
Multifocal motor neuropathy. J Neurol 1997; 244:143152.
Nobile- Orazio E. Multifocal motor neuropathy.
J
Neuroroimmunol 2000; 115:4-18.
Axelsson G, Liedholm LJ. Multifocal motor neuropathyunusual cause of hypoglossal palsy. Lakartidningen
2002; 99:1448-1450.
Oshima Y, Mitsui T, Yoshino H, et al. Central motor
conduction in patients with anti-ganglioside antibody
associated neuropathy syndromes and hyperreflexia. J
Neurol Neurosurg Psychiatry 2002; 73: 568-573.
Olney RK. Consensus criteria for the diagnosis of partial
conduction block. Muscle Nerve 1999; 22: 225-229.
Nobile-Orazio E, Cappellari A, Meucci N, et al.
Multifocal
motor
neuropathy:
clinical
and
immunological features and response to IVIG in relation
to the presence and degree of motor conduction block. J
Neurol Neurosurg Psychiatry 2002; 72:761-766.
Leon-S FE, Pradilla G, Chavez AM, DeLeon MA,
Rueda OL, Bayona J. Contralateral early blink reflex in
multifocal motor neuropathy. Electromyogr Clin
Neurophysiol 1998; 38:419-422.
Parry GJ. Antiganglioside antibodies do not necessarily
play a role in multifocal motor neuropathy. Muscle
Nerve 1994; 17:97-99.
Caposso M, Caporale CM, Pomilio F, Gandolfi P,
Lugaresi A, Uncini A. Acute motor conduction block
neuropathy. Another Guillian- Barre syndrome variant.
Neurology 2003; 61: 617-622.
Lefaucheur JP, Gregson NA, Gray I, von Raison F,
Bertocchi M, Creange A. A variant of multifocal motor
neuropathy with acute, generalized presentation and
persistent conduction blocks. J Neurol Neurosurg
Psychiatry 2003; 74: 1555-1561.
Rajabally YA, Strens LHA, Abbott RJ. Acute motor
conduction block neuropathy followed by axonal
degeneration and poor recovery. Neurology 2006; 2:
287-288.
Orazio EN, Terenghi F. Other dysimmune neuropathies.
peripheral neuropathy. American Academy of
Neurology Continuum. 2003; 9:70-76.
Parry GJ, Clarke S. Multifocal acquired demyelinating
neuropathy masquerading as motor neuron disease.
Muscle and Nerve. 1988; 11: 103-107.
Kaji R, Shibasaki H, Kimura J. Multifocal
demyelinating motor neuropathy: cranial nerve
involvement and immunoglobulin therapy. Neurology
1992; 42: 506-509.
Preston DC, Shapiro BE. Electromyography and
Neuromuscular Disorders. 2nd ed. Philadelphia:
Elsevier, 2005: 423-437.
CASE REPORT
NON-FUNCTIONING KIDNEY RESULTED FROM PRIMARY HYDATID CYST OF THE
PSOAS MUSCLE
Engin Kandıralı, Atilla Semerciöz, Ahmet Metin, Muzaffer Eroglu, Bülent Uysal
Abant İzzet Baysal Üniversitesi, İzzet Baysal Tıp Fakültesi, Üroloji Anabilim Dalı, Bolu, Türkiye
ABSTRACT
Hydatid cyst is rarely located in the psoas muscle. Herein, we report a case with non-functioning kidney
resulted from a primary hydatid cyst located at the psoas muscle obstructing upper segment of the ureter.
Keywords: Psoas muscle; Kidney; Hydatid cyst; Treatment
PRİMER PSOAS KİST HİDATİĞİ SONUCU OLUŞAN NONFONKSİYONE BÖBREK
ÖZET
Psoas kasında nadiren kist hidatik görülür. Bu vakada primer psoas kası kist hidatiği sonucu oluşmuş
nonfonksiyone böbrek vakası bildirilmiştir.
Anahtar Kelimeler: Psoas kası, Böbrek, Hidatik kist, Tedavi
INTRODUCTION
Hydatid cyst is a parasitic infection prevalent in
most sheep raising in the Mediterranean countries.
Primary cyst may localize anywhere in the body
but commonly they are found in the liver (5570%) and lungs (20-30%), location in the
muscular tissue accounts for 2-3 % of all cases1.
Herein, we report a case with non-functioning
kidney resulted from a primary hydatid cyst
located at the psoas muscle obstructing upper
segment of the ureter.
CASE REPORT
A 42-year-old woman presented with right loin
pain for 2 years. She did not complain of any
voiding symptoms and history was unremarkable.
Physical
examination
was
normal.
Ultrasonography revealed a well defined right
retroperitoneal cystic lesion adjacent to the right
hydronephrotic kidney. Intravenous urogram
showed a non-functioning right kidney and
normal left kidney (Fig. 1). Computerized
tomography revealed a cystic formation having
vesicles with well defined wall suggestive of
hydatid disease in the right retroperitoneum (Fig.
2). Also right ureter was compressed by cystic
lesion. Imaging studies detected no other cyst
anywhere in the body. Serological studies were
normal.
Fig. 1: Intravenous urogram shows a nonfunctioning right kidney.
Medical therapy with oral albendazole
(10mg/kg/day) was administered 7 days before
surgery. Right flank incision was made and a
cystic lesion obstructing right ureter was
observed. After the operative field was protected
with swabs soaked with 3% cetrimide, the area
around the cyst was incised and the cyst content,
Engin Kandıralı
Abant İzzet Baysal Üniversitesi, İzzet Baysal Tıp Fakültesi, Üroloji AD,
Bolu, Türkiye
145
Engin Kandıralı, et al
Non-functioning kidney resulted from primary hydatid cyst of the psoas muscle
composed of numerous daughter cysts and a
water-like fluid with debris, was evacuated.
Drainage was followed by partial cystectomy and
simple right nephrectomy of the non-functioning
kidney. A prophylactic large-caliber passive tube
drain was placed in the cyst cavity and removed at
the sixth postoperative day. Postoperative stay
was uneventful and the patient was discharged 8
days after surgery with continuous albendazole
therapy for 6 months. No recurrence of hydatid
disease was observed by the same examinations
done after 1 year follow up period.
Fig. 2: CT shows a cystic formation having vesicles with
well defined wall suggestive of hydatid cyst adjacent to the
right hydronephrotic kidney.
DISCUSSION
Hydatid cyst may occur in any part of the body.
When the hydatid cyst located in the muscle
tissue, the diagnosis of hydatid cyst may be
difficult and late, because this localization is
unexpected and the cyst is asymptomatic until it
enlarges and compresses adjacent organs.
Although skin and serological tests (i.e. specific
antibodies titres) are widely used to confirm
diagnosis, they are often negative because the
capsule isolates the parasite from the host’s
immune system. Hydatid cyst is rarely located in
the psoas muscle. If it does not compress the
kidney, ureter or vertebra, it is generally
asymptomatic and may be diagnosed incidentally.
Radiologic
investigations
(particularly
ultrasonography and CT) are used to establish the
diagnosis when daughter cysts are identified and
are very helpful in determining the extent of the
disease. Recently, magnetic resonance imaging
(MRI) has been gaining popularity for
investigating hydatid disease involving soft
tissues2. Cystic or complex retroperitoneal tumor,
pyogenic abscess of the psoas and even
tuberculosis must be considered in the differential
diagnosis of retroperitoneal hydatid cyst3.
Although the diagnosis of hydatid disease is
mainly clinical and radiologic, clinic suspicion is
the most important factor for its diagnosis.
After preoperative diagnosis of hydatid cyst is
confirmed, adequate surgical excision of cyst, and
sterilization of the cavity with scolocidal agents
(such as hypertonic saline, cetrimide, hydrogen
peroxide) for preventing the seeding should be
done. Percutaneous drainage and alcoholization
could be used to reduce the size of the cyst and
sterilizing, but Melis et. al. reported a case with no
significant changes within the size of the cyst after
this
procedure1.
Medical
therapy
with
mebendazole or albendazole is used as
prophylaxis and postoperatively to prevent
recurrences. Preoperative medical therapy should
be initiated at least 4 days before the operative
procedure and continued for at least a month or
preferably several months postoperatively4,5.
Extraperitoneal approach is preferred in order to
avoid intraperitoneal dissemination and partial
cystectomy, simple nephrectomy, and combined
with medical therapy was the treatment choice in
our case. Total cystectomy is not required in the
muscular hydatid disease, because disease is
diffuse in the muscle3. Angulo et al. recommended
irrigation of the cavity with scolocidal agents via
drain tube for several weeks following surgery
and some authors did not advise postoperative
irrigation1,3.
In summary, the case presented here is notable for
two reasons; one is the rarity of it and the other is
that of its compression leading to a non-functional
kidney.
REFERENCES
1.
2.
3.
4.
5.
146
Melis M, Marongiu L, Scintu F et al. Primary hidatid
cysts of psoas muscle. ANZ J Surg 2002; 27: 443-445.
Claikens B, Van Hoe L, Vansteenbergen W. Images in
clinical radiology. MRI features of hydatid disease.
JBR-BTR 1999; 82:167.
Angulo JC, Granell J, Muguerza J, Sanchez-Chapado M.
Primary bilateral hydatidosis of the psoas muscle. J Urol
1999; 161:1557-1558.
Morovic M Human hydatidosis in Dalmatia, Croatia
Epidemiol Infect 1997; 119:271–276.
Gluncic I, Roje Z, Bradaric N, Petricevic A, Pisac VP,
Gluncic V. Primary Echinococcosis of the
sternocleidomastoid muscle. Croat Med J 2001;42:196–
198.
OLGU SUNUMU
SAFRA KESESİ TORSİYONU: OLGU SUNUMU
Sabahattin Aslan, Nemci Yücekule, Bahadır Çetin, Melih Akıncı, Ahmet Seki, Aybala Ağaç, Recep Çetin,
Abdullah Çetin
Ankara Onkoloji Eğitim Araşırma Hastanesi, I. Cerrahi Kliniği, Ankara, Türkiye
ÖZET
Safra kesesi torsiyonu nadir rastlanan ve sıklıkla intraoperatif tanı konulan bir akut batın nedenidir. Wendel
tarafından ilk kez tanımlanmasından sonra yaklaşık 300 olgu bildirilmiştir. Olgumuzda ayırıcı tanıda akılda
tutulması gerektiği sonucuna ulaştığımız inkomplet torsiyone olmuş safra kesesinin yol açtığı tablo sunulmuş
ve ek olarak hastalığın etyolojisi, klinik prezentasyonu ve tedavisi değerlendirilmiştir.
Anahtar Kelimeler: Safra kesesi, Torsiyon, Kolesistit, Akut batın
GALL BLADDER TORSION: A CASE REPORT
ABSTRACT
Gall bladder torsion is a rare cause of acute abdomen and usually diagnosed intraoperatively. After Wendel
reported the first case, nearly 300 cases have been reported in the literature. Here, we present a clinical case
caused by an incomplete torsion of the gall bladder which should be kept in mind in the differential diagnosis
and we review the etiology, clinical presentation and the treatment of the disease.
Keywords: Gall bladder, Torsion, Cholesystitis, Acute abdomen
ultrasonografide; karaciğerin normal olduğu, safra
kesesi içerisinde 15 mm taş saptandığı, safra
kesesinin hidropik olduğu ve arka duvar
lokalizasyonunda safra çamuru izlendiği rapor
edildi. Tiroid fonksiyon testlerinde subklinik
hipotiroidisi bulunan hasta operasyona alındı. Sağ
subkostal kesi ile batına girildiğinde safra
kesesinin hidropik ve sistik kanalın uzun olduğu,
safra kesesinin sistik kanal etrafında saat yönünde
yaklaşık
180º torsiyone olduğu
görüldü
(Resim 1-2).
GİRİŞ
Çok sık görülen bir klinik durum olmayan ve
etiyolojisi tam anlaşılmayan safra kesesi
torsiyonuna ait ilk vaka 1898’de Wendel
tarafından bildirilmiştir1-5. Günümüze kadar
literatürde 300 den fazla vaka rapor edilmiştir1.
Bununla beraber vaka raporlarındaki son
zamanlardaki artış insidansın aslında tahmin
edilenden yüksek olduğunu düşündürmektedir3.
Safra kesesi torsiyonunun tedavisi cerrahidir ve
tedavi seçimi kolesistektomidir. Günümüzde çoğu
vakaya cerrahi sırasında tanı konmaktadır.
Bununla beraber hastalığın klinik paterni şüphe
uyandırmalı ve yapılacak radyolojik tetkiklerle
ayırıcı tanıda akılda bulundurulmalıdır.
OLGU SUNUMU
29 yaşında bayan hasta iki gündür olan sağ üst
kadran ağrısı, bulantı ve kusma şikâyeti ile
kliniğimize
başvurdu.
Tıbbi
geçmişinde
hipotiroidizm mevcut olan hasta 50 mcg
levotiroksin tb kullanıyordu. Başka bir sistemik
hastalık öyküsü saptanmadı.
Laboratuar tetkiklerinde WBC 6400 cell/µL,
hemoglobin 14,1 g/dl, glikoz 71 mg/dl, böbrek ve
karaciğer fonksiyon testleri ve elektrolitler normal
sınırlarda rapor edildi. Hastaya yapılan abdominal
Resim 1: 180 derece torsiyone olmuş hidropik safra kesesi
uzun sistik kanal nedeniyle abdominal kesi açıklığından
rahatlıkla görülmekte
Sabahattin Aslan
Ankara Onkoloji Eğitim Araşırma Hastanesi, I. Cerrahi Kliniği,
Ankara, Türkiye
147
Sabahattin Aslan ve ark.
Safra kesesi torsiyonu: olgu sunumu
Akut batın kliniği ile başvuran hastalarda
preoperatif safra kesesi torsiyonu ayırıcı tanısı
yapmak oldukça güçtür ve sıklıkla operasyon
sırasında tanı konulur. Yapılan abdominal
USG’lerde yüzen safra kesesi karaciğer altında
ancak karaciğere temas etmiyor şekilde
izlenebilir. Safra kesesi boynunda konileşme,
safra kesesi duvarında ödem ve kalınlaşma,
inflamasyon
ve
gangrenöz
değişiklikler
gözlenebilir ancak hiç birisi safra kesesi torsiyonu
için özellikli değildir. Yaklaşık %20–33 hastada
safra kesesi taşı ile birliktelik bulunur5. Safra
kesesi torsiyonu gangren ve perforasyon ile
katastrofik bir kinik tabloya yol açabilir.
Gangrenöz safra kesesinde erken tanı ile
perforasyondan korunulur ve cerrahi mortalite %5
den azdır6.
Safra kesesi detorsiyone edilerek kolesistektomi
uygulandı ve postoperatif ikinci gün hasta
problemi olmadan taburcu edildi.
Resim 2: Torsiyone hidropik kesenin uzun sistik kanalı
görülmekte
En sık görülen klinik durum bulantı ve kusma ile
sağ üst kadran ağrısıdır. Otuz hastanın birinde sağ
üst kadranda kitle palpe edilir. Kitle defans nedeni
ile palpe edilemeye bilir ancak perküsyonla matite
alınabilir.Lökositoz sıklıkla izlenir. Hastada
sarılık ve toksemi bulguları genellikle izlenmez.
Incomlete torsiyon safra kesesi koliğini taklit
edebilir2,3.
TARTIŞMA
Safra kesesi torsiyonu nadir görülen akut batın
nedenlerindendir ve hastanede yatan 365.520
hastadan birinde görülür. İleri yaş kadın
hastalarda insidansı daha yüksektir ancak her yaş
gurubunda görülebilir. Erkek/kadın oranı 1/3
‘dür2. Safra kesesi torsiyonu insidansı beklenen
yaşam süresinin artması ile artmaktadır.
Bizim hastamızda sağ üst kadran ağrısı ile birlikte
safra kesesinde taş izlenmiş ve akut kolesistit
atağı düşünülerek opere edilmiştir. Operasyon
sırasında görülen incomplete torsiyonun uzun
sistik
kanal
varlığına
bağlı
olduğunu
düşündürmektedir. Sarılık olmadan başlayan ani
karın ağısı, bulantı, kusma ve palpabl safra kesesi
bulgusu olan hastaların ayırıcı tanısında safra
kesesi
torsiyonu
da
akılda
tutularak
değerlendirilmelidir.
Safra kesesi torsiyonunun etyolojisi tam
bilinmemektedir, birçok faktörün rol oynadığı ileri
sürülmektedir.
Gross tarafından iki tip safra kesesi konjenital
anomalisi
tanımlanmıştır3.
Bu
anomaliler
toplumun %5’inde bulunur ve safra kesesi uzun
bir mezenter ile asılı durumdadır. Yaşlılarda bu
mezenter ile ilgili ameliyat bulguları konjenital
deformite
ve/veya
kazanılmış
generalize
visseropitozla ilişkili olabilir. Bu durumda
anatomik yerleşim safra kesesi mobilitesini arttırır
sonradan ortaya çıkan tetikleyici olaylar safra
kesesinin sistik kanal etrafında rotasyonuna neden
olur. Karaciğer atrofisi, yaşlanma ile visseral yağ
ve elastisite kaybı, kilo kaybı ve spinal deformite
safra kesesinin farklı konumlarda bulunmasına ve
torsiyonuna neden olur. Ateroskleroz, sistik kanal
tortisitesi ve kolelithiazis ile akut dilatasyon
torsiyon için dayanak noktası olabilir. Ani
hareketler ve yoğun komşu organ peristaltizmi
torsiyona yol açabilir3.
KAYNAKLAR
1.
2.
3.
4.
5.
6.
Safra kesesi torsiyonu complete (270º-360º) veya
incomplete (180º) olabilir2,4. Torsiyon meydana
geldiğinde venöz kan akımının blokajına bağlı
kanlanma azalır ve gangrene yol açar. Safra kesesi
kan akımı doppler USG ile değerlendirilebilir4.
148
Jorge OG, Martha PR, Francisco GC, Ricardo Gerardo
VC. Volvulus of the gallbladder. Digest Dis Scien
2003;48:116-117.
Vosswinkel JA, Colantonio AL. Torsion of the
gallbladder laparascopic identification and treatment.
Surg Endscop 1999;13:1154-1156.
Losken A, Wilson BW, Sherman R Torsion of the
gallbladder. Am Surg 1997;63:975-978.
Jeffrey M Nicholas Gallbladder volvulus Arch Surg
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