Langenbecks Arch Surg (2005) 390:556–573 DOI 10.1007/s00423-005-0585-0

ABSTRACTS

© Springer-Verlag 2005

24th Annual Meeting of the Surgical Working Group of Endocrine Surgery (CAEK) of the German Society of Visceral Surgery, 25–26 November 2005, Hamburg, Germany

Scientific Chairman and Organization:

Location:

J. Kußmann M.D. Professor Allgemeines Krankenhaus Wandsbek I. Chirurgische Abteilung 22043 Hamburg, Germany [email protected]

EAST Hotel Hamburg Simon-von-Utrecht-Strasse 31 20359 Hamburg Germany

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S 25.01.01 CALCITONIN SCREENING – CLINICAL IMPACT Günther Klein1, Karin Köhrer2, Dieter Depisch1, Evelyne Bareck1, Wolfgang Stiglbauer3, Paul Hajek4, Konrad Weiss5 1 Chirurgische Abteilung 2 Zentrallabor 3 Pathologisches Institut 4 Zentralröntgeninstitut 5 Nuklearmedizin im Zentralröntgen, Schwerpunktkrankenhaus Wiener Neustadt, Österreich Background: Calcitonin is a well known marker for the C-cellcarcinoma. Until 2002 our diagnosis of C-cell-carcinoma was a pure chance in almost all cases. We performed calcitonin screenings since and pentagstrin stimulation tests in selected cases. Methods: From 2002-6/2005 we performed 2534 calcitonin screenings. On patients with elevated basal calcitonin pentagstrin stimulation tests were performed. In case of a positive stimulation test (calcitonin >100pg/ml or increase >30pg/ml) surgery was offered. Results: Elevated basal calcitonin was found in 66 patients. The pentagastrin stimulation showed pathology in 26 of these patients. Thyroidektomie was performed on 22 patients; 4 patients preferred conservative management. Histological findings revealed physiological C-cell-hyperplasia in 15 patients (calcitonin <100pg/ml), “neoplastic” C-cell-hyperplasia in 3 patients (calcitonin 101-180pg/ml) and C-cell-carcinoma in 4 patients (calcitonin 102-2468pg/ml). Genetic screening showed no familiar carcinoma. Follow-up showed normal calcitonin and negative tests with all patients, whereas in a historical control group of patients with C-cellcarcinoma (n=15; 1992-2002) complete remission was documented in 3 patients. Conclusion: These data suggest an impact of calctonin screening and pentagastrin stimulation test on the early diagnosis of C-cellcarcinoma. The risk of unnecessary surgery seems to be negligible as compared to the good chance of complete healing the C-cell-carcinoma. S 25.01.02 CALCITONIN MEASUREMENT IN THYROID DISEASE AND IN PERCHANCE LABORATORY SCREENING: SURGICAL MANAGEMENT OF MINIMAL HYPERCALCITONINEMIA Thomas J. Musholt1, Petra B. Musholt1,2, Christian Fottner2, Matthias M. Weber2 1 Endocrine Surgery, Gutenberg University Medical School, Mainz 2 Endocrinology, Gutenberg University Medical School, Mainz Objective: Besides routine calcitonin screening in patients with thyroid disease, measurements due to nondistinctive complaints increased. The surgeon is confronted with the decision on the extent of surgery in cases of mild hypercalcitoninemia. Methods: From 11/2003 to 8/2005, 13 patients with pathological basal calcitonin (bC) – with and without pathological stimulated calcitonin test – were examined and treated. Todate, 9 patients underwent thyroidectomy (1) with either lymph node dissection of the central compartment (7) or of both lateral compartments (1), while in 2 patients lobectomies were performed. 2 patients are continuously followed-up. Results: In 5/13 patients, elevation of bC was diagnosed during laboratory work-up for non-thyroidal disease. Histopathological examination indicated multinodular goiter with concomitant thyroiditis in 1/10 patients (preoperative bC 15-20pg/ml) and C-cell-hyperplasia in 5/10 patients (bC 11-20pg/ml), accompanied by marked thyroiditis in one case. Medullary thyroid carcinoma (0.3-2cm) was identified in 5/10 individuals (bC 25-407pg/ml) with metastatic disease in a MEN2A patient. 5/6 patients with hypercalcitoninemia ≤20pg/ml insisted on surgical intervention.

Conclusions: Thyroidectomy is justified if the bC exceeds 20pg/ml. In case of only slightly elevated bC, neck sonography and close follow-up is recommended. But in our experience, worries nourished by repeated testing and ambiguous recommendations of different physicians often prompt the patient to demand definitive treatment. S 25.01.03 RESULTS OF CALCITONIN-SCREENING IN A PRIVATE PRACTICE FOR NUCLEAR MEDICINE Wolfgang Braun Nuklearmedizinische Praxis, Augsburg Objective: Aim of the study was to evaluate the efficacy of Calcitonin screening in patients with nodular goiter for the early detection of medullary carcinoma of the thyroid (MTC) in a private practice. Methods: From March 2003 to July 2005 basal calcitonin was determined in 2467 patients. 74 patients with elevated calcitonin underwent a pentagastrin-test. 8 patients with a pathological pentagastrin-test have been operated. Results: 67 men and 114 women had a basal calcitonin of >10 pg/ml, 12 patients a pathological pentagastrin-test (stimulated calcitonin levels >100 pg/ml), among them 7 men and 5 women. In 3 women histology was MTC (diameter of the tumors 3, 5 and 9 mm), one woman had C-cell hyperplasia. All MTCs were of the sporadic form. None of the 4 operated men had MTC. Conclusions: With great likelihood a pathologic pentagastrin-test predicts MTC in women, whereas in men the test is nonspecific. It seems that the outcome of sporadic MTC in women can be substantially improved by calcitonin screening. Perhaps elevation of the cutoff of the stimulated calcitonin levels could makr the test more specific in men. S 25.01.05 MEDULLARY MICRO-CARCINOMA (MMTC) IN PATIENTS WITH SLIGHTLY ELEVATED CALCITONIN Christian Vorländer, Robert Lienenlüke, Robert A. Wahl Chirurgische Klinik, Bürgerhospital Frankfurt am Main e.V. Objective: There is consense in measuring stimulated calcitonin (sCT) in patients with elevated basal calcitonin (bCT). sCT over 100pg/ml requires surgery. Within the grey zone of sCT up to 300pg/ml (500pg/ml) without clinical evidence for FMTC we perform – due to the absence of c-cells in the isthmus – the isthmus preserving total bilobectomy (IPTB) instead of thyroidectomy as the best fitting procedure for CCH. Methods: From 10/2001 to 7/2005 69 patients were operated with the intention of IPTB. If MTC was proven intraoperatively conversion to total thyroidectomy with systematic lymphadenetomy was performed (TTX+LNX). Results: No c-cell-pathology was found in 7 patients (10%), c-cellhyperplasia (CCH) in 52 (75%), MmTC in 10 (15%). All but 2 MmTC (2 and 3 mm) were proven intraoperatively. bCT was not different in cases with CCH and MmTC (x?=15 [6-41] vs. x?=26 [8,5-118]). sCT overlapped widely in both groups CCH x?=105[35344] and MmTC x?=243[155-470]. Postoperative bCT was non measurable in all but one: this patient (f, 78y.) with a 5mm MmTC (pN0 0/29) showed elevated bCT and sCT (18,7 to 75,8pg/ml) after 6 months. Conclusions: IPTB is suitable for slightly elevated CT. Most MmTC are detectable intraoperatively with the consequence of radical surgery (TTX+LNX).

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S 25.01.06 “LATE ONSET” MUTATIONS FOR FAMILY MEDULLARY THYROID CARCINOMA (F-MTC), DETECTED VIA GENERAL SCREENING FOR SERUM-CALCITONIN BEFORE THYROID SURGERY – CASE REPORT Robert A.Wahl, Phillip Eger, Robert H. Lienenlüke, Christian Vorländer Chirurgische Klinik, Bürgerhospital Frankfurt am Main e.V. Objective: Apparently sporadic cases with moderately elevated Calcitonin, representing both – micro-MCT or C-Cell-hyperplasia (CCH) only, can turn out to be index cases of families with “lateonset” mutations of the RET-proto-oncogen. Methods: Among >800 patients referred to thyroid surgery from 07/04 to 06/05 serum-Calcitonin was elevated into the “grey zone” in 29 cases. Postoperative genetic screening of patients with microMTC (n=5) and/or CCH (n=20) led to identification of 3 index-patients for f-MTC, each with RET-mutation in Codon 791 Results: Age Sex

Calcitonin C-cell preop. pathology (pg/ml) basal/ stimulated

Operative procedure

IPTB TTX+LNX

<2 <2

<2 <2

IPTB

<2

<2

1 2

37 36

f f

9 19

61 195

3

54

m

23

104

CCH unilat. MTC(4mm) N0 (0/15) CCH bilat.

Calcitonin postop. (pg/ml) basal/ stimulated

* IPTB= Isthmus Preserving Total Bilobectomy Family screening of the is still going on.

Conclusions: 1 – Serum-Calcitonin should be known before thyroid surgery. 2 – According to the sex-specific different upper normal limit of s-Calcitonin, attention must be payed also to Calcitonin > 5 < 10 pg/ml basal and >50<100, in females. 4 – “Biochemical cure” is represented by postop. non-measurable rather than by “normalized” s-Calcitonin. This can be reached by IPTB for CCH. 5 – “Late-onset”-mutations for f-MTC in apparently sporadic MTC and CCH ar more frequent than is assumed up to now. S 25.01.07 MARKED HYPERCALCITONINEMIA WITHOUT INTRAOPERATIVE VERIFICATION OF THYROID MALIGNANCY: SHOULD BILATERAL LYMPHADENECTOMY BE PERFORMED ? Thomas J. Musholt1, Petra B. Musholt1,2, Christian Fottner2, Beate Schamberger2, Matthias M. Weber2 1 Endocrine Surgery, Gutenberg University Medical School, Mainz 2 Endocrinology, Gutenberg University Medical School, Mainz Objective: The decision for extended lymphadenectomy (LA) in patients with hypercalcitoninemia is dependent on the verification of medullary thyroid carcinoma (MTC) by frozen section, tumor size, or the presence of suspicious lymph nodes. The question remains whether in cases of lacking intraoperative evidence of malignancy the extent of calcitonin elevation should be considered for decision-making. Methods: A case-report of a 68-year-old MEN 2A patient is presented. The patient underwent bilateral subtotal thyroid resection 25 years ago and was recently informed about the diagnosis of the neoplasia syndrome in relatives. Screening examination revealed an inapparent pheochromocytoma that was laparoscopically resect-

ed. Basal calcitonin was elevated to 266pg/ml (normal <5). Neck sonography displayed no thyroid tumor or lymphadenopathy. Results: Completion thyroidectomy with systematic LA of the central compartment was performed. Neither palpation or visual inspection of the incised thyroid remnant and central/lateral nodes nor frozen section detected malignant growth. Therefore, lateral LA was abandoned. However, the final pathology report demonstrated multifocal MTCs (<1 cm) as well as micrometastases in 12/17 nodes. Because of persistent hypercalcitoninemia (68pg/ml), systematic bilateral LA is scheduled. Conclusions: To avoid secondary interventions, extended LA during primary operation may be indicated in cases of markedly elevated calcitonin irrespective of the intraoperative diagnosis of MTC. S 25.01.08 FOLLOW UP OF 271 PATIENTS WITH C-CELL-CARCINOMAS OF THE THYROID Kenko Cupisti, Andreas Raffel, Achim Wolf, Daniel Miersch, Claus Ferdinand Eisenberger, Wolfram Trudo Knoefel Department of General and Visceral Surgery, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf Objective: C-cell-carcinomas are a special entity among all thyroid tumors. Recurrence and occult tumor persistance are common. Reoperative surgery and individual procedures are often requested. Methods: We report the long-term results (19 years) of 271 patients with sporadic or hereditary C-cell-carcinoma. Median follow-up-time was 8 years. Results: Sixty-four patients died of their tumor (23,6%). The median survival of these patients was 5 years after diagnosis. We performed: partial thyroid resection (9%), thyreoidectomy (17%), thyreoidectomy with unilateral neck dissection (26%), thyreoidectomy with bilateral neck dissection (24%), additional mediastinal dissection with sternal split (20%) and additional liver resection (4%). Table 1: Correlation between tumor-stage (UICC 1997), lymphatic spread and mortality. We found also a strong correlation between postoperative serum calcitonin and tumor stage. tumor stage

total

lymph node positive %

died

%

T0 T1 T2 T3 T4 unknown total

13 79 78 27 49 25 271

0 20 51 23 46

0 3 19 13 22

0% 4% 24% 48% 44%

0% 25% 65% 85% 100%

Conclusions: The initial tumor stage showed a close correlation to the occurrence of lymphatic spread even if not diagnosed at first operation, long-term survival and the probability of occult tumor persistance.

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S 25.01.09 CLINICAL DECISION MAKING WITH RARE VARIANTS OF MEDULLARY THYROID CARCINOMA Maximilian Bockhorn1, Sien-Yi Sheu2, Kurt W. Schmid2, Andreja Frilling1, Christoph E. Broelsch1 1 Department of General Surgery and Transplantation Surgery, University Hospital Essen, Germany 2 Department of Pathology, University Hospital Essen, Germany Background: The variety of variants of medullary thyroid carcinoma (MTC) make the diagnosis difficult. Histology, serum or tumor markers will not always point toward the correct diagnosis, leaving the surgeon with an uncertainty what type of resection is best for the patient. Here we present our experience with extremely rare subgroups of MTC. Materials and methods: From 4/1998 to 7/2005, we treated 5 presented with rare variants of MTC. 1 patient lacked serum elevation of Calcitonin (CT) and Carcinoembryonic Antigen (CEA), and 2 patients showed elevation of CEA only with no increase in CT. Another patient showed high CT and CEA levels, but pathomorphological characteristics for MTC were absent and 1 patient presented with neuroendocrine hepatic metastases of unknown origin. Results: In 3 cases, the experience of the investigating clinician suggested the existence of a MTC. In the 2 remaining cases, extensive immunohistochemical studies diagnosed a paraganglioma-like and a C-cell hyperplasia correctly. All patients received surgical treatment. Conclusion: There are subgroups of MTC in which missing typical morphologic or clinical characteristics make the diagnosis difficult. In these cases, diagnosis, operative decisions, and follow-up strategies should be based on pre-operative biochemical markers, imaging findings, and clinical parameters in accordance to the guidelines for classic MTC. S 25.02.01 CASE REPORT: RAPIDLY GROWING METASTATIC PRIMARY THYROID FIBROSARCOMA Andrea Kosow, Christoph Nies Klinik für Allgemein-und Viszeralchirurgie, Marienhospital Osnabrück We present a case of a primary thyroid fibrosarcoma with pulmonary metastases. In January 2004 a 55-year-old- patient presented with a rapidly growing thyroid mass. The patient complained of an inconsistent feeling of pressure in the neck and a hearse voice. He did not take any thyroid medicaments. We saw large gostre with a hard, immobile mass in the left thyroid. Ultrasonic examination confirmed an irregular large mass with adjacent suspicious lymph nodes. Thyroid Szintigraphy revealed virtually no uptake in the left thyroid. Computerized tomography showed a left thyroid mass with central necrosis, a displaced trachea and esophagus to the right side. The left vocal card was nearly immobile. We performed a thyroidectomy with lymphadenectomy in the central and the left lateral compartment. Histological examination showed a primary fibrosarcoma pT2bpNOpMO G3, completely resected. Radiation therapy was adminstered to the neck (59,4 Gy). Six months later the patient presented with local recurrency. Further work-up revealed multiple pulmonary metastases. The local recurry was resected, further radiation was given. Four weeks later the patient returned with an ulcerated mass in the central neck region, invading trachea and esophagus. The patient died.

S 25.02.02 METASTATIC DISEASE OF THE THYROID GLAND: STATISTICS AND CLINICAL CONSEQUENCES Evelyne Bareck1, Günther Klein1, Dieter Depisch1, Paul Hajek2, Konrad Weiss2 1 Department of Surgery, General Hospital Wiener Neustadt, Austria 2 Department of Radiology and Nuclear Medicine, General Hospital Wiener Neustadt, Austria Objective: In literature secondary tumours of the thyroid gland are found at autopsy in about 25% of patients with malignant metastatic disease. In vivo the frequency of detection is considerably lower. Therefore a retrospective analysis from 1982 to 2004 was performed. Methods: On average 250 patients underwent surgical treatment due to an uni – or multifocal cold nodule of the thyroid per year. In 11 cases (7 female/4 male) a metastatic disease was detected, lymphomas and cancer by direct extension were excluded. Results: The most frequent primary site of thyroid metastasis was renal cell carcinoma (55%), followed by breast cancer (18%). Rare sources of primary tumours included osteosarcoma, skin melanoma, nasopharyngeal and prostate carcinoma. 82% showed a single lobe metastasis, presented as a nodule with about 3 cm in diameter. In 46% of these patients the secondary tumour of the thyroid was the initial sign of a malignant disease. Only 18% of all patients had a fine needle aspiration biopsy (FNAB) preoperatively. Conclusions: Although secondary tumours of the thyroid gland are rather rare, we should keep this possibility in mind concerning patients with a previous carcinoma in history. FNAB should be considered and frozen section seems to be mandatory in these cases. S 25.02.03 RENAL CELL CARCINOMA METASTASES TO THE THYROID GLAND – 5 CASES REPORTED Igors Iesalnieks1, Arnold Trupka2, Gabriel Glockzin1, Matthias Woenckhaus3, Hans J. Schlitt1, Ayman Agha1 1 Klinik und Poliklinik fuer Chirurgie, Klinikum der Universitaet Regensburg 2 Chirurgische Klinik, Klinikum Starnberg 3 Institut fuer Pathologie, Klinikum der Universitaet Regensburg Objective: Clinically significant, solitary metastases to the thyroid gland is a rare occurrence. The renal cell carcinoma(RCC) is the most common primary tumor site. Late recurrence is a notable feature of RCC. Solitary metastases in the thyroid gland occur as late as 100-120 months from the date of nephrectomy. Methods: Five patients aged between 58 and 70 years with late thyroid metastasis after nephrectomy because of RCC are reported. All metastases were resected by subtotal or total thyroidectomy. Several years before thyroidectomy four of the five reported patients developed pancreatic or peripancreatic metastases followed by surgery. Results: Two of the five reported patients died 174 and 252 months after nephrectomy, three patient are still alive. In consistence with the literature and regarding our own cases there is a clear survival benefit in selected cases if surgical approach to the thyroid metastases is chosen. Conclusions: (1) In rare cases the thyroid metastasis can be the first clinical sign of RCC. (2) Complete resection of solitary thyroid metastasis in patients with RCC mostly leads to increased 5 year survival rates. (3) First data indicate that there is possibly a subpopulation of RCC showing late recurrence with preferential metastasis to endocrine tissue.

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S 25.02.04 PREDICTIVE VALUE OF PRE- AND INTRAOPERATIVE DIAGNOSTIC DEVICES IN THYROID LYMPHOMA Katrin Brauckhoff1, Udo Bilkenroth2, Michael Brauckhoff1, Kerstin Lorenz1, Phuong Nguyen Thang1, Henning Dralle1 1 Department of Surgery, Martin-Luther-University Halle-Wittenberg 2 Instiute of Pathology, Martin-Luther-University Halle-Wittenberg Background: Thyroid lymphoma (TL) are rare. Clinically, TL shows rapid and infiltrative growth such as undifferentiated thyroid carcinoma (UTC). This retrospective analysis was undertaken to clarify the impact of several diagnostic devices. Patients: Fourteen consecutive patients (1995-2004) with TL (10 females, 4 males, mean age 55 (9-82) years) underwent thyroid surgery. Results: In all patients, rapid tumor growth was observed. Six patients had dysphagia and/or dyspnoea. In 12 patients, preoperative imaging procedures (computed tomography (CT) or magnetic resonance imaging (MRI)) revealed extrathyroidal tumor infiltration. In all patients, serum level of carcinoembryonic antigen (CEA) were normal. Fine-needle-biopsy (FNB) was suspicious in 3 of 7 examined patients. In summary, in 12 patients, an UTC was preoperatively suspected. Intraoperatively, correct diagnosis of TL was made only in 4 cases using frozen section. Definitive histopathological examination revealed B-cell-non-Hodgkin-lymphoma in all patients. In all examined 8 patients, serum level of lactat dehydrogenase (LDH) and β2-microglobulin (β2-MG) were elevated. Conclusions: Clinical symptoms, CT, MRT, FNB and intraoperative examinations have only low predictive value in patients with TL. In CEA-negative patients with rapid and infiltrative tumor growth, serum levels of LDH and β2-MG should be measured routinously during preoperative examinations to avoid unnecessary surgery. S 25.02.05 LONG-TERM OUTCOME OF PATIENTS WITH T4 INSULAR CARCINOMA OF THE THYROID: THE INSULAR HISTOTYPE IS AN INDEPENDENT PREDICTOR OF POOR PROGNOSIS Ayman Agha1, Igors Iesalnieks1, Matthias Woenckhaus2, Wolfgang Dietmaier2, Gabriel Glockzin1, Hans J. Schlitt1 1 Klinik und Poliklinik für Chirurgie, Klinikum der Universität Regensburg 2 Institut für Pathologie, Klinikum der Universität Regensburg Objective: Insular thyroid carcinoma is a tumor with aggressive behaviour, and patients usually appear with advanced tumor stage. Whether the insular component is an independent factor for poor prognosis is unclear. Therefore we compared the survival of patients with advanced (T4) insular, follicular and papillary thyroid cancer. Methods: The clinical behaviour of tumors in three groups of patients with T4 thyroid carcinoma - 8 patients with insular thyroid carcinoma, 11 patients with follicular thyroid carcinoma, and 21 patients with papillary thyroid carcinoma was compared. Diseasefree survival and disease-specific death were assessed with KaplanMeier analysis and were compared using the log-rank test. Cox regression analysis was used to evaluate the influence of histotype and other prognostic factors. Results: After 4-years the survival was 37% among patients with insular thyroid carcinoma, 74% among those with follicular thyroid carcinoma and 87% among those with papillary thyroid carcinoma (p=0.02). Disease-free survival was worst in patients with insular thyroid carcinoma (25%) compared to those with follicular thyroid carcinoma (37%) and those with papillary thyroid carcinoma (86%).

Conclusions: Patients with insular thyroid carcinoma have a poorer outcome in comparison to patients of similar stage who have follicular or papillary thyroid carcinoma. S 25.02.06 THE EGF/EGF-R SYSTEM AS A POSSIBLE TARGET OF ANTIPROLIFERATIVE/ANTIANGIOGENIC THERAPY IN THYROID CANCER S. Hoffmann1, A. Wunderlich1, K. Maschuw1, A. Burchert2, I. Celik3, A. Zielke1 1 Department of Surgery, Philipps-University of Marburg, Germany 2 Department of Medicine, Division of Haematology, Philipps-University of Marburg, Germany 3 Institute of Theoretical Surgery, Philipps-University of Marburg, Germany Objective: The aim of this study was to analyze the regulation of proliferation and VEGF secretion by thyrotropin EGF and to evaluate EGF targeting drugs in anaplastic thyroid cancer. Methods: The EGF-R was documented in two anaplastic thyroid cancer cell lines (Hth74, C643). Basal and EGF stimulated (1ng/ml to 100ng/ml) VEGF mRNA expression and VEGF protein secretion as well as tumor cell proliferation were analyzed in vitro. The antiprolifereative and antiangiogenic effect of EGF-R targeting antibodies (Erbitux®) and of the EGF-R/VEGF-R supressing dual tyrosine kinase inhibitor (AEE 788®) on anaplastic thyroid cancer cell lines was examined in vitro. Results: Basal and EGF stimulated VEGF protein secretion were different between cell lines (C643:1449±319pg/ml versus 2101±883pg/ml, Hth74:150±80pg/ml versus 1830±215pg/ml), similar to VEGF mRNA expression. Erbitux® did not affect tumor cell proliferation in vitro, reduction of EGF mediated VEGF secretion was 10-15% in C643 and up to 90% in Hth74. AEE 788® lead to dose dependent inhibition of tumor cell proliferation by 75% in C643 and 95% in Hth74. VEGF secretion was reduced by AEE 788 to 55% in C643 and 5% in Hth74. Conclusions: The EGF/EGF-R system resembles a powerful VEGF-stimulating pathway that can be inhibited by admission of neutralizing antibodies. However EGF-R/VEGF-R supressing dual tyrosine kinase inhibitor appear to be more effective. S 25.04.01 PITFALL AFTER PARATHYROIDECTOMY FOR PRIMARY HYPERPARATHYROIDISM (PHPT): PERSISTANCE OF ELEVATED PARATHYROID HORMONE (IPTH) MAY BE DUE TO “HUNGRY BONE” SYNDROME Christine Gebhardt1, Mechthild Hermanns1, Heiko Tuchelt2, Reinhard Finke2, Thomas Steinmüller1 1 Department of Visceral and Vascular Surgery, Humboldt Klinikum, Berlin 2 Centre of Endocrinology, Berlin. Methods: A 64-year old lady presented with a classic constellation for pHPT and underwent minimally-invasive parathyroid surgery. A very large parathyroid adenoma was removed, the other parathyroids were not inspected. Intraoperative iPTH decreased to normal values. Postoperatively, the patient was hypocalcaemic and was treated with calcium and 1,25 Vit.D. – Within the next week, elevated iPTH levels were elucidated with varying calcium levels. This led to the presumtion of a “sleeping adenoma” and a re-operation was discussed. Results: However, the re-operation was not performed and the patient was treated with calcium and 1,25 Vit.D for a calcium deficiency and a “hungry-bone” syndrome. This therapy led to a normalisation of calcium and iPTH.

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Conclusions: With elevated iPTH levels after parathyroid surgery, a “hungry bone” syndrome may be present with varying severity. A calcium or Vit D deficiency with a secondary elevation of the iPTH must be considered, particulary if a low blood calcium is present.

Conclusion: “Minimal” extrathyroid extension occurs in small PTC’s already. It is connected to a higher risk of lymph node metastasis, involving the lateral compartment, too. This fact should not be neglected, as it is suggested by the new TNM-classification.

S 25.04.02 PITFALLS IN A PATIENT WITH HYPERPARATHYROIDISM – HISTORY OF A PATIENT WITH THE DIAGNOSIS OF A PARATHYROID CARCINOMA Markus Krausch, Kenko Cupisti, Andreas Raffel, Achim Wolf, Claus Ferdinand Eisenberger, Wolfram Trudo Knoefel Department of General Surgery, Heinrich-Heine-University Düsseldorf, Germany

S 25.04.04 PITFALLS IN THYROID SURGERY Marc Boucher, Moritz Meyer, Dietmar Simon Department of Endocrine and Visceral Surgery, Bethesda Krankenhaus zu Duisburg, Germany

Introduction: Parathyroid carcinoma is. Between 04/86 and 04/05 we saw in 9 of 1241 cases of our own patients a parathyroid carcinoma. Case report: We report about a 79-year-old patient with dizziness and hypercalcemia. Ultrasound showed nodular goiter and parathyroid adenoma right caudal. 01/02 the patient was operated by hemithyreoidectomy and adenoma extirpation right caudal. Because of persisting hypercalcemia additional examinations were done. Sesta-Mibi-Szintigraphy was negative. A tumour mass was presumed by MRI and a venous stimulation catheter of the left upper chest. 02/02 the patient was operated a second time by an exploration of the neck and the mediastinum performed by sternotomy. Surprisingly histology showed a invasive parathyroid carcinoma. Because of still persistent symptoms of hyperparathyreodism additional examinations were done again (Ultrasound, Sesta-Mibi-Szintigraphy, MRI). Tumour mass are still persistent on the left side of the neck (calcium: 3.7 mmol/l, parathyroid hormone: 1558 pg/ml). A third operation was done by a completion thyroidectomy including a block resection of the tumour. Histology showed a parathyroid carcinoma with blood and lymphatic vessel invasion again. Conclusion: An extensive high parathyroid hormone, except by renale hyperparathyreoidism, should lead in the differential diagnosis to a parathyroid carcinoma. Therefore therapy should only done in an experienced endocrine centre to avoid pitfalls. S 25.04.03 PAPILLARY THYROID CARCINOMA (PTC). LYMPH NODE METASTASIS RELATED TO PRIMARY TUMORS WITH AND WITHOUT “MINIMAL” EXTRATHYROID INFILTRATION R. H. Lienenlüke, Ch. Vorländer, R. A. Wahl Chirurgische Klinik, Bürgerhospital Frankfurt am Main Background: “Minimal” extrathyroid growth is now (UICC 2002) summarized in pT3 (former pT4a). This had to be questioned under the aspect of lymph node involvement. Patients and methods: 93 out of 210 patients with PTC, treated from 06/1994 to 12/2000, fulfilled the inclusion criteria: first therapy, total thyroidectomy, systematic compartmental lymph node dissection, documented number of removed and of involved nodes, stages pT1-3a. Group 1: pT1-3a,n=61 was compared to group 2: pT3b (“minimal” extrathyroid infiltration), n=32. Results: Group 1: 47 females and 14 males (ratio 3:1), average age: 42±13 years, average tumor size: 24 (4-45)mm. Group 2: 23 females and 9 males (ratio 3:1), average age: 39±14 years, average tumor size: 25(9-40)mm. (no difference) Positive nodes were found in 29% (group 1) and 84% (group 2) (χ2,p<0,01). In node-positive cases the central compartment was involved in 94% (group 1) and 78% (group 2) (n.d.). The lateral compartment contained metastases in 44% (group 1) and 81% (group 2) (χ2,p>0,05).

Objective: Thyroid surgery is the third most frequent operation in Germany. Considering the presented case we will exemplify some pitfalls in thyroid surgery. Methods: We present the case of a 54 year old men with recurrent goiter. The patient was operated in 1984 due to scintigraphic cold nodule. The patient had an extension of a cold nodule in the left neck. The ultrasound showed an 80ml nodule in the left lobe and a fossiled small one in the right. January 2005 left lobectomy was performed. Frozen section showed the suspicion of papillary carcinoma. The laryngeal nerve was not certainly identified. The operation was discontinued. A second operation with removal of the remnant thyroid gland was performed. In the histopathologic examination a second papillary carcinoma was found. Postoperative radioiodine scan revealed left sided lateral lymph node metastasis. A third operation with radical neck dissection was done. Results: The patient needed three operations for recurrent goiter hiding a metastatic papillary thyroid carcinoma (pT3, pN1b). Conclusions: Complete ultrasound examination of the neck including lymph nodes is necessary. Fine needle aspiration biopsy could have revealed diagnosis preoperatively. Neuromonitoring is essential in finding and testing the laryngeal nerve. If localisation is unclear MRI or scintigraphic scan can be done. S 25.04.05 THE COINCIDENCE OF HASHIMOTO’S THYROIDITIS (HT) AND PAPILLARY CARCINOMA OF THE THYROID (PTC): SURGICAL TREATMENT AS A FIRST OPTION? Hannelore Heidemann, Klaus Gellert Klinik für Allgemein- und Visceralchirurgie, PARITÄTISCHES Krankenhaus Lichtenberg Oskar-Ziethen, Berlin Objective: Various published articles reported about the fact of increased coincidence of PTC among HT-cases over the last years. This current study aimed to analyse our patients in relation to the above-mentioned assumption and its related possible therapeutic consequences. Methods: From 1994 to 2004 we practiced 3998 thyreoid operations, 147 in patients with HT. In 307 cases a different carcinoma was found. Results: The coincidence of HT and PTC duplicated almost within 10 years (16.2% vs. 8.67%). Simultaneously increased the incidence of HT significantly among the total number of the investigated cases in the thyroid surgery from 1.8% to 4.9%, whereas the thyroid carcinomas increased moderately from 5.86% to 8.13%. Furthermore, we observed an elevation of the low degree tumorstages of PTC (range 63% to 72%) as an effect by the high percentage (61%) of microcarcinomas measuring ≤1cm. In the patients with HT a contrary observation was found: more than 2/3 of the this pathients a tumorstage ≥pT2 was detected. Conclusions: The increase of advanced PTC tumorstages within the autoimmunthyreoiditis cases within the investigated group at our institution supports the following statement: the indication for radical thyroidectomy in patients with HT combined with nodular le sions should be initiated as early as possible.

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S 25.04.06 POSTOPERATIVE MORBIDITY AFTER BILATERAL THYROID SURGERY FOR GRAVE’S DISEASE: 15 YEARS EXPERIENCE IN A SPECIALIZED CENTER Iyad Hassan1, Michael Koller2, Sebastian Hoffmann1, Mathias Rothmund1, Andreas Zielke1 1 Department of Visceral-, Thorax- and Vascular Surgery, Philipps University Marburg 2 Institute of Theoretical Surgery, Philipps University Marburg Objective: We evaluated the risk factors for postoperative morbidity after bilateral thyroid surgery for Graves Disease (GD). Methods: The present study is based on a cross sectional design analysis of case histories from our Department; the median followup period was 112 months (14-205). Peri- and postoperative morbidity, improvement of endocrine orbitopathy (EO) and recurrence were the main outcome measures. Results: 153 patients with a median of 36 years of age (10-75) underwent thyroid resections (45 patients (29,4%) received bilateral near total resection; 96 patients (62,7%) received Hartley-Dunhill resection and 12 patients (7,8%) were treated by total thyroidectomy) by 32 surgeons, of whom twenty performed ≤3, seven ≤9, and five ≥9 such procedures. Postoperative morbidity concerned 4 cases (2,6%) of hemorrhage necessitating reintervention; 14 cases (9,1%) of transient and 3 cases (1,9%) of permanent vocal cord palsy; 26 cases (16,9%) of transient and 10 cases (6,5%) of permanent hypocalcaemia. No recurrence. There was no correlation between postoperative morbidity and surgical experience or procedure. Morbidity was significantly associated to the weight of the resected thyroid tissue (p<0.05). Conclusions: A standardized teaching program to bilateral surgery of Grave’s disease enabled to perform thyroid resections with low morbidity. S 25.04.07 LIVER AS THE SITE OF PRIMARY MANIFESTATION IN NEUROENDOCRINE TUMORS Alexandra Daum, Maximilian Bockhorn, Andrea Frilling, Frank Weber, Christoph E. Broelsch Klinik für Allgemein- und Transplantationschirurgie, Universitätsklinikum Essen Objective: Most carcinoid tumors occur within the gastrointestinal tract and the liver is the most common site for metastases. Recent reports point toward primary hepatic carcinoids as a rare entity, which are based on immunohistological confirmation and exclusion of extrahepatic manifestation. Methods: From 1994 to 2005, we treated 17 patients with liver manifestation of a neuroendocrine tumor, all histologically confirmed by biopsy. The detection of the primary carcinoid included serum markers, octreotide scintigraphy or the 68Ga-DOTATOCPET-CT-scan. Results: In 15 of 17 patients no extrahepatic manifestations could be found. In 2 patients, which were claimed to have a primary liver carcinoid, we found a primary carcinoid of the lung and in the midgut 1 and 5 years after the initial diagnosis. The treatment was tailored to the individual need of each patient and included liver resection (5), liver transplantation (2), and radiofrequency ablation (2). Symptomatic treatment was performed using octreotide- (3) or 68Ga-DOTATOC-therapy (2). Conclusions: Even years after the intial diagnosis, the primary tumor can be detected. In our series, we had to revise the intial diagnosis 1 and 5 years later, to consider that in patients with neuroendocrine liver tumors, recurrent clinical and radiological reevaluation is mandatory.

S 25.04.08 LIVER SURGERY IN METASTATIC MEDULLARY THYROID CANCER: EFFECTIVE LONG-TERM PALLIATION? Achim Wolf, Kenko Cupisti, Claus Eisenberger, Andreas Raffel, Stefan Benedikt Hosch, Wolfram Trudo Knoefel Department of General Surgery University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany Objective: Metastatic medullary thyroid cancer still remains a diagnostic and therapeutic challenge. Increased calcitonin levels indicate recurrent disease biochemically. Nevertheless, localisation of the metastasis and therapy of metastatic disease is often difficult. Methods: Between 1986 and 2005 271 patients with medullary thyroid cancer were treated in our department. 27 of these 271 patients developed liver metastasis. 12 patients underwent liver surgery. We present 12 patients (7 female/5 male) with metastatic medullary thyroid cancer who underwent liver surgery. 6 patients were suffering from MEN II and 6 patients had sporadic disease. Results: We performed two hemihepatectomies, 7 segmental resections and 3 excisional biopsies. Postoperatively, none of the patients had normal calcitonin levels. Eight patients died, four patients were still alive at follow-up. Mean survival of the eight patients was 5.2 years (range: 2.3–7.9). The mean follow-up of the four patients was 10.1 years (range: 5.8-11.9). All four patients had elevated calcitonin levels at the last follow-up. Conclusions: Liver surgery remains a treatment option for isolated liver metastasis. There are only very few case reports in the current literature addressing this specific problem. Surgical treatment of those patients remains an individual decision. S 25.05.01 CLINICAL AND PATHOLOGIC SIGNIFICANCE OF MIB-1 EXPRESSION IN NEUROENDOCRINE TUMORS OF THE PANCREAS Andreas Raffel1, Markus Krausch1, S. Heikhaus2, Achim Wolf1, Kenko Cupisti1, Claus Ferdinand Eisenberger1, Wolfram Trudo Knoefel1 1 Department of General and Visceral Surgery, Heinrich-Heine-University Düsseldorf, Germany 2 Institute of Pathology, Heinrich-Heine-University Düsseldorf, Germany Because of low malignant potential of neuroendocrine tumors, post-operative follow-up and diagnosis is of considerable importance. Therefore the significance of the MiB-1 proliferationindex should be demonstrated. The objective was to test the clinical usefulness. Prognostic factors should be be identified and a threshold value should be established. The expression of the cell-cycle associated Ki 67 antigen from 38 paraffin-embedded malignant pancreatic-NET were examined with a MiB-1 monoclonal antibody. The MiB-1 proliferationindex was first defined (microscopically counting of the relationship of MiB1 positive cells for the total cell count; 5 representative fields of vision, magnification factor: 400) and then correlated for clinical, morphologic and histologic parameters. All parameters were summarized with the inclusion of follow-up. A microscopic counting of tumour cells was made. On average 3500 tumour cells per patients (spanning: 1464-5920) were microscopically counted (spanning of the MiB-1 postive tumours cells: 1-426). A threshold value (relationship of MiB-1 positive/negative cells could be identified. Additional prognostic factors could also be identified depending on survival, recurrence or metastases. The MiB-1 proliferationindex is an easily attainable, representative clinical tool for the prediction of the behaviour of neuroendocrine tumours. It could routinely be determined as required care in the postoperative follow-up period.

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S 25.05.02 THE VALUE OF HARMONIC SCALPEL IN THYROID SURGERY – PROSPECTIVE RANDOMIZED PARALLEL GROUP STUDY . Marek Dedecjus1, Grzegorz Strózyk1, Krzysztof Kuzdak2, 1 Jan Brzezi´nski 1 Department of Endocrine Surgery, Chair of Endocrinology and Metabolic Diseases, Medical University of Łódż, Polish Mother Memorial Research Institute, Poland 2 Department of Endocrinological and General Surgery, Medical University of Łódż, The M. Kopernik Memorial Hospital, Łódż, Poland Objective: The use of the harmonic scalpel (UHS) is well established in surgery. Since its use in thyroid surgery is limited, we prospectively compared UHS with electrocoagulation and ligatures in thyroidectomies. Methods: Sixty patients were randomized into UHS and standard technique using electrocautery and ligatures as the primary hemostatic method. Endpoints: Pre-, peri-, postoperative biochemical, clinical, surgical and economical variables. Results: The two groups were age- and sex-matched. Mean operative time was shorter in the UHS group compared with the conventional technique group for total or nearly total thyroidectomy. Median number of ligatures in the HS group was 1 (range, 0-6) versus 18 (range, 8-32). Mean blood loss, estimated by gauze weight, was lower in UHS group as well as the drainage during the first 24 postoperative hours. We did not find statistical differences between the two techniques regarding transient postoperative complications. Length of hospitalization and the incision length were similar in both groups. There were no deaths, no blood transfusions, no intraoperative complications, and no postoperative definitive sequelae. The global costs were lower in the UHS group Conclusions: Use of the harmonic scalpel in thyroid surgery is a safe and resulted in a reduction operative time and blood loss. Moreover it was cost-effective. S 25.05.03 LIGATURE-FREE THYROID OPERATION – A CRITICAL RECORD M. Meyer, M. Boucher, A. Kätsch, D. Simon Department of Endocrine and Visceral Surgery, Bethesda Krankenhaus zu Duisburg, Germany Several instruments for ligature-free operations are available. Easy handling, secure bleeding control and cost are the crucial factor. Erbe’s Biclamp is a HF-Generator that distinguishes itself through its reusability and easy appliance. The Biclamp was tested in terms of handling, complications and costs of elective thyroid-operations. For this purpose, extend of resection, operating time, complication rate and the qualification of the surgeon were recorded. 160 operations have been evaluated: 65 with Biclamp and 95 conventional. Operations were divided into four groups in terms of extend resection. 1: one-sided resection, 2: both sides, rest tissue >8 ml, 3: rest tissue <8 ml, 4: thyroidectomy. The average operation time was 79 to 87 min. (Biclamp vs. ligature-free) is not significantly better. The post-operative calcium decrease shows no difference. The comparison of the early post-operative recurrent nerve palsies shows a significant difference in the Biclamp-group (3.7 nerves at risk vs. 1 nar). The price of the clamp is about 45¤ per use. Overall, the Biclamp is effective for secure fusion medium-sized vessels and transection of parenchyma, no postoperative hemorrages with the Biclamp. The operation time tends to be shorter. Biclamp should not be used in the immediate vicinity of nerves.

S 25.05.04 ENDOSCOPIC THYROID RESECTIONS WITH AN 20 MM AXILLARY ACCESS Kai Witzel Chirurgie, HELIOS St. Elisabeth Klinik Hünfeld Objective: Endoscopic thyroid resections should meet the standards of minimally invasive surgery. Consequently, a minimally invasive resection of the thyroid gland should not be a compromise: it should be as secure as open surgery,and the thyroid gland must be extracted without enlarging the incision. Besides, it should meet cosmetic demands, which means that it should be carried out without leaving a prominent scar in the front neck region. Methods: We will present the intermediate results of our proof of concept study. In the course of this study we will show that a resection of the thyroid gland using a 20 mm axillary access and a 3,5 mm incision in the jugulum is possible, thus avoiding the above mentioned scar. For this technique, a modified axilloscope and an ultrasonic scalpel are used, which permit a total resection of the ispilateral thyroid gland with partial resection of the contralateral side. Results: The technique has already been successfully used on thyroid gland operations of corpses and a live pig. Three patients were already operated in the presented technique. Conclusions: At present, the results suggest that this technique is likely to become a standard alternative to open thyroid surgery for up to 20 percent of all patients. S 25.05.05 SELECTIVE EMBOLIZATION OF THYROID ARTERIES – OWN EXPERIENCE Kaurzel3, Józef Tazbir1, Marek Dedecjus2, Zbigniew . Andrzej Lewi´nski4, Grzegorz Strózyk2, Krzysztof Kuzdak2, Jan Brzezi´nski2 1 Department of Emergency Medicine, Medical University of Łódż, the M. Kopernik Memorial Hospital, Łódż, Poland, 2 Department of Endocrine Surgery, Chair of Endocrinology and Metabolic Diseases, Medical University of Łódż, Polish Mother Memorial Research Institute, Poland 4 Department of Endocrinology and Metabolic Diseases, Chair of Endocrinology and Metabolic Diseases, Medical University of Łódż, Polish Mother Memorial Research Institute, Poland Objective: Although, there exist multiple effective modes of treatment of thyroid diseases, there still remain difficult cases that may not be amenable to current therapeutic options. The aim of the present study was to evaluate selective embolization of the thyroid arteries (SETA) as a possible alternative for the treatment (or pretreatment to surgery) of thyroid tumors. Methods: The study group comprised of 30 patients with thyroid diseases: 7 cases of advanced stage of inoperable anaplastic thyroid carcinoma, 10 cases of differentiated thyroid carcinoma, and 13 cases of large toxic goitre. The study protocol was approved by the local Ethics Committee. All the patients underwent SETA of the superior and/or inferior thyroid arteries. After SETA, selective thyroid arteries angiography was performed to ensure that the targeted arteries were completely occluded. Results: In this study, we are presenting clinical characteristic, imaging diagnostics and the follow up of the patients who underwent SETA. Conclusions: After analysis of obtained results, we conclude that SETA is an effective, minimally invasive, and save method of treatment of thyroid tumors.

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S 26.01.01 NATIONAL SURVEY ON THE MANAGEMENT OF PRIMARY HYPERPARATHYROIDISM BY SWISS ENDOCRINOLOGISTS Thomas Clerici1, Rene Warschkow1, Frederic Triponez2, Katja Wolff1, Michael Brändle3 1 Klinik für Chirurgie, Kantonsspital St. Gallen 2 Service de chirurgie thoracique, Hôpitaux Universitaires de Genève, Genf 3 Fachbereich Endokrinologie und Diabetologie, Departement für Innere Medizin, Kantonsspital St. Gallen Objective: Aim of this study was the evaluation of the preoperative diagnostic workup by endocrinologists and of their referral practice to surgery. Methods: Survey by a questionnaire sent to all members of the Swiss Society for Endocrinology and Diabetes in spring 2005. Results: The questionnaire was send back by 68 of 124 practising endocrinologists. The median annual number of patients with pHPT seen by an endocrinologist was 6. The mean fraction of these patients referred to surgery was found to be 59%±25%. In the German-speaking part of Switzerland this fraction was significantly higher than in the French-speaking part (50.5±27.4% versus 65.3 ±23.2%). 68% of the endocrinologist routinely perform localisation studies before referring the patient to a surgeon. The impact of the availability of minimally invasive surgical procedures on the amount of patients referred to surgery is considerable. 62% of the participants would enlarge the indication for surgery if the operation could be done by a limited surgical approach. Conclusions: In a relevant fraction of patients with pHPT, endocrinologists still consider curative therapy not mandatory. Minimally invasive procedures seem to lower the threshold for a referral to surgery. S 26.01.02 POSITIVE INFLUENCE OF PARATHYROIDECTOMY ON QUALITY OF LIFE AND DEPRESSION IN PRIMARY HYPERPARATHYROIDISM Isabella Hense1, Monika Keller2, Alexander Pietsch3, Ulf Hinz1, Tobias Schilling4, Ernst Klar3, Markus W. Büchler1, Theresia Weber1 1 Chirurgische Klinik der Universität Heidelberg 2 Sektion für Psychoonkologie der Klinik für Psychosomatik der Universität Heidelberg 3 Chirurgische Klinik der Universität Rostock 4 Abteilung für Endokrinologie der Klinik für Innere Medizin der Universität Heidelberg Objective: Neuropsychological disorders in patients with primary hyperparathyroidism (pHPT) alone are often not accepted as an indication for surgery. Our prospective study evaluates the influence of parathyroidectomy on postoperative operative quality of life and depression. Methods: Between October 2002 and January 2005, 68 patients underwent parathyroidectomy for pHPT were prospectively enrolled in the study. The Hospital Anxiety and Depression Scale (HADS) were used to evaluate depressive symptoms. Health-related quality of life was measured with SF-12. The questionnaires were answered preoperatively, 2 weeks and 6 months postoperatively. Results: In patients with serum calcium levels 32.8 mmol/l major symptoms of depression were found in 18.9% compared to 0% with calcium levels <2.8 mmol/l (p=0.035). Physical component summary score of median 43.0 and mental component summary score (SF-12) of median 43.5 were lower than in general population. Six months postoperatively symptoms of anxiety (p=0.014) and depression (p=0.311) decreased and were found in 9.4% and 7.6% of the patients. Physical comment score did not change sig-

nificantly, whereas mental component score improved to 49.8 (p<0.001). Conclusions: Preoperative symptoms of depression (HADS) correlated statistically significant with serum calcium levels. Postoperatively depressive symptoms decreased (HADS) und health-related quality of life (SF-12) improved. S 26.01.03 DIFFERENCES IN THE CLINICAL PRESENTATION OF PRIMARY HYPERPARATHYROIDISM WITH AND WITHOUT NEPHROLITHIASIS Ingrid Ramelsberger1, Matthias Rothmund2, Christoph Nies3 1 Klinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Dietrich- Bonhoeffer-Klinikum, Neubrandenburg, Deutschland, 2 Klinik für Visceral-, Thorax- und Gefäßchirurgie, Klinikum der Philipps-Universität Marburg, Deutschland, 3 Klinik für Allgemein- und Viszeralchirurgie, Marienhospital Osnabrück, Deutschland Objective: Some patients with primary hyperparathyroidism (pHPT) do have nephrolithiasis whereas some other patients with pHPT do never have nephrolithiasis. The purpose of this study was to compare the both subgroups with regard to clinical symptoms, biochemical parameters and bone mineral density (BMD). Methods: In a prospective, epidemiological observational design pHPT patients were studied. 40 patients were included (20 with and 20 without nephrolithiasis). Investigated were study parameters such as age, gender, weight of the excised parathyroid adenoma, biochemical parameters and BMD. Results: In patients with pHPT and nephrolithiasis were 5 men and 15 female. The mean age was 62,9 year (range: 45-77). In patients with pHPT and without nephrolithiasis were 4 men and 16 female. The mean age was 63,9 year (range: 26-76). Considering age, sex ratio, biochemical parameters, weight of excised adenoma or BMD we found no significant difference between both subgroups. Conclusions: We could not find any significant differences between pHPT-patients with or without nephrolithiasis considering clinical presentation, biochemical parameters and BMD. Obvious and main differences between those subgroups can be excluded. To confirm or to exclude subtle differences larger numbers of patients have to be studied. S 26.01.04 VIRTUAL NECK EXPLORATION IN PATIENTS WITH HYPERPARATHYROIDISM AND FORMER CERVICAL OPERATIONS Rupert Prommegger1, Tonja Sauper1, Peter Kovacs2, Michael Gabriel3, Reto Bale2, Christoph Profanter1 1 Department of General and Transplant Surgery, Medical University of Innsbruck, Austria 2 Department of Radiology I, Medical University of Innsbruck, Austria 3 Department of Nuclear Medicine, Medical University of Innsbruck, Austria Objective: In patients with hyperparathyroidism (HPTH) and previous cervical operations, parathyroidectomy is challenging. The aim of this study was to investigate the value of preoperative MIBI SPECT alone, compared with CT-MIBI SPECT image fusion. Methods: Twenty two consecutive patients with HPTH and previous cervical operations underwent CT-MIBI image fusion as preoperative localization procedure. The results of MIBI-SPECT alone were compared with CT-MIBI SPECT image fusion. Results: The exact position of the pathological parathyroid glands could be localized with CT-MIBI SPECT image fusion in 18/22 patients (82%), with MIBI SPECT alone, only in 8/22 (36%). In 8 patients minimal invasive, in 8 unilateral focused, and in 6 bilateral operations (simultaneous thyroidectomies) were performed.

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Conclusions: CT-MIBI-SPECT image fusion is superior to MIBISPECT alone in preoperative localization of enlarged parathyroid glands. In patients with HPTH and former cervical operations anatomic landmarks, supplied by the CT component, are very useful to find the enlarged parathyroid glands. S 26.01.05 SECRETION OF PTH FRAGMENTS DURING PARATHYROID EXPLORATION Philipp Riss1, Klaus Kaczirek1, Christian Bieglmayer2, Bruno Niederle1 1 Section of Endocrine Surgery, Division of General Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria 2 Clinical Institute for Medical and Chemical Laboratory Diagnostics, Medical University of Vienna, Vienna, Austria Objective: An increased secretion of PTH and its fragments during parathyroid exploration may influence the PTH-curve and its interpretation during PTH- monitoring. Methods: In six patients undergoing open minimally invasive parathyroidectomy the enlarged gland was manipulated manually for 30 seconds after visualization. Blood samples were drawn at the beginning of the manipulation and 30 seconds, 2, 5, 10 and 15 minutes later. 1-84-PTH was measured and 7-84-PTH was calculated. Results: An increased PTH secretion was documented in four of six single adenomas (mean PTH ±SD: 312±497 pg/ml. In one patient PTH rose from 343 to 1747 pg/ml. The ratio of 1-84-PTH to 7-84-PTH was median (±SD) 1.3 (±0.6): 1 at baseline and 1.4 (±0.2): 1 after manipulation. The coefficient of determination (R2) for the baseline values is R2=0.9819 and for the values after manipulation R2=0.9985, respectively. Conclusions: Not all glands react with appropriate secretion of PTH after “manipulation”. PTH-fragments circulate in the same ratio as before manipulation. Manipulation was not a problem during PTH- monitoring applying the “Vienna Criterion”. S 26.01.06 RAPID PARATHYROID HORMONE ASSAY ON PARATHYROID ASPIRATES OF PARATHYROID ADENOMA VERSUS HEALTHY PARATHYROID GLAND – A PILOT STUDY Marcin Barczy´nski, Stanisław Cicho´n, Aleksander Konturek, Wojciech Cicho´n Department of Endocrine Surgery, 3rd Chair of General Surgery, Jagiellonian University College of Medicine, Kraków, Poland Objective: The intact parathyroid hormone (iPTH) content of tissue aspirates is an accurate indicator of parathyroid tissue succesfully replacing frozen section during parathyroid surgery. This study investigated the differences in iPTH levels in tissue aspirates from healthy parathyroid gland and parathyroid adenoma. Methods: Fifteen solitary parathyroid adenomas were aspirated through a 0.8mm needle into 0.5ml saline immediately after removal. Controls included 15 healthy parathyroid tissue aspirates obtained before elective parathyroid gland autotransplantation during thyroidectomy for cancer. Quick Intraoperative-iPTH-Assay was used to determine iPTH levels of analyzed aspirates and serum samples. Results: Mean iPTH aspirates level was significantly higher in parathyroid adenomas versus healthy parathyroid tissue (2073.0±465.8, range 1621–2767pg/ml vs. 652.2±104.3, range 431-834pg/ml, respectively; F-test: p<0.001). Conclusions: Parathyroid adenomas aspirates have significantly higher iPTH levels than healthy parathyroid tissue. Further studies on a large series are necessary to clarify the usefulness of iPTH assay of parathyroid aspirates in distinguishing double adenoma from parathyroid hyperplasia.

S 26.01.07 MINIMALLY INVASIVE OPEN THYROID AND PARATHYROID SURGERY UNDER LOCAL/REGIONAL ANESTHESIA Rumen Pandev, E. Hadgiev, I. Tersiev German Clinic Bulgaria, Queen Johanna Hospital, Medical University Sofia, Bulgaria Background: The purpose of this prospective study was to verify the feasibility of minimally invasive technique and its applicability in clinical practice. Material and methods: Between April 2002 and July 2005 a total of 97 patients with thyroid disease and 12 patients with primary hyperthyroidism underwent minimally invasive open surgery at our institution. Selection criteria were biochemical evidence of pHPT, thyroid nodules not exceeding 4.5 cm of diameter, patient motivation for local anesthesia, and an absence of thyroiditis, previous neck surgery, or irradiation. Results: Operations consisted of 39 hemithyroidectomies, 26 total lobectomies, 20 subtotal thyroidectomies, 12 partial thyroidectomies, and 12 parathyroidectomies. Local infiltration with Lidocain alone was performed in 31 cases and superficial cervical plexus block in 78 cases. No conversion to general anesthesia was necessary. The mean operating time was 64 minutes. The mean postoperative stay was 1.5 days. The mean follow-up period was 15 months. Conclusion: Minimally invasive open thyroid and parathyroid surgery is an effective, alternative approach, which can be performed safely under local/regional anesthesia with favourable cosmetic results and high patient satisfaction. S 26.01.08 MINIMALLY INVASIVE PARATHYROIDECTOMY UNDER LOCAL ANESTHESIA FOR PRIMARY HYPERPARATHYROIDISM – PHPT. EXPERIENCE WITH 55 PATIENTS Elias Karakas, A. Zielke, M. Rothmund Klinik für Visceral-, Thorax- und Gefässchirurgie, Philipps-Universität Marburg Objective: While bilateral cervical exploration (BCI) with identification of all parathyroid glands has been considered the gold standard for treatment of pHPT, today a minimally invasive strategy even in local anesthesia can be chosen. However, 80-90% of patients with pHPT have a solitary parathyroid adenoma. In addition preoperative non-invasive localization procedures became more reliable. Methods: Between 1999 and 2005 in 55 patients a MIP was done. Identical results of two preoperative localization procedures were prerequisite. In this period 400 patients underwent first-time operation for pHPT. Results: 54 patients were cured by primary operation. Conversion to BCI was necessary in three cases. Twice parathyroid adenoma was not found through the 2cm incision. Another patient was unable to continue the operation under local anesthesia. In one patient high postoperative serum calcium levels led to reoperation and resection of another two and a half hyperplastic glands. Operating time was significantly shorter in MIP. Conclusions: Success rate of MIP is equal to BCI. Targeted MIP reduces operating time significantly and can even be done under local anesthesia.

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S 26.01.09 RADIOGUIDED MINIMALLY INVASIVE PARATHYROIDECTOMY Roman Bühlmann1, Lukas D. Frey2, Jörg Wydler1, Rolf Schlumpf1 1 Klinik für Chirurgie, Kantonsspital Aarau, Schweiz 2 Institut für Nuklearmedizin/PET-Zentrum, Kantonsspital Aarau, Schweiz Background: 99mTc-sestamibi scintigraphy including SPECT allows preoperative localisation of a hyperfunctional parathyroid gland. With rapid assay of iPTH, adequacy of resection can be confirmed intraoperatively. As a result, MIP as treatment for hyperparathyroidism becomes popular. The role of intraoperative gamma probing remains controversial. Patients and methods: Since 2001, we evaluated all patients with hyperparathyroidism (except those requiring total parathyroidectomy) for radioguided MIP. If localisation with sestamibi scintigraphy was clear, we planned radioguided MIP using a handheld gamma probe. Adequacy of resection was intraoperatively confirmed by high gamma probe activity, decrease of iPTH-level and histopathology. Results: 50 patients were evaluated. 8 received classical treatment because of insufficient tracer uptake or simultaneous contralateral thyroid surgery. 42 qualified for radioguided MIP with primary, recurrent or tertiary hyperparathyroidism. The MIP-group (including all 11 patients with previous para-/thyroid surgery) had shorter operating time and hospital stay with no difference in complications. Atypical gland localisations were found in 13 cases. 1 MIP had to be converted. Conclusions: According to our experience, the major benefit of the radioguided MIP is the easier and faster localisation of hyperfunctional parathyroid glands in patients with previous para-/thyroid surgery, especially if located atypically. Experience in handling the gamma probe is best achieved by routine-use. S 26.01.10 HEREDITARY PARATHYROID CARCINOMA: A CASE FOR PREVENTIVE TOTAL PARATHYROIDECTOMY? Kerstin Lorenz1, Oliver Gimm1, Phuong Nguyen-Than1, Ulrich Schneyer2, Marc Bloching3, Viive M. Howell4, Deborah J. Marsh4, Bin T. Teh5, Ulf Krause6, H. Dralle1 1 Department of General, Visceral and Vascular Surgery, 2 Department of Internal Medicine, Endocrinology, 3 Department of Ear-Nose-Throat, Facial and Neck Therapy, 4 Kolling Institute of Medical Research, Royal North Shore Hospital and University of Sydney, Australia 5 Laboratory of Cancer Genetics, Van Andel Research Institute, Grand Rapids, Michigan, USA 6 Department of Pathology, Martin-Luther University of Halle-Wittenberg, Halle/Saale, Germany Recently, the gene for the HPT-JT, HRTP 2 was allocated on chromosome 1q25. There is a 50% chance of gene-transmittance and 15% risk of malignancy. Three kindred were operated for HPT-JT. Patient 1 displayed orofacial dysplasia and osteofibroma. Surgery at 23 years showed hormone inactive parathyroid carcinoma. Following reinterventions for local recurrences, laryngectomy and implantation of vocal cord prothesis was performed at 36 years. Patient 2, male cousin of patient 1, presented with pHPT at 20 years and orofacial dysplasia. Surgery revealed 3-gland hyperplasia and one normal parathyoid was left in situ. Patient 3, father of patient 2 developed pHPT at 50 years and also had orofacial dysplasia and osteofibroma. Total parathyroidectomy with synchronous autotransplantation for four gland hyperplasia was performed. All 3 patients tested positive for HRTP2 (c.76delA) with additional somatic mutation (c.686delGAGT) in patient 2. Follow-up in patient 2 and 3 revealed no recurrence.

Identification of HRTP2 mutation enables early screening of first degree relatives. This is of paramount importance for the affected patient to obviate recurrent, extensive surgery and malignant development. No clear genotype-phenotype correlation is established, however preventive total parathyroidectomy in all HRTP2 gene carriers should be discussed because of potential malignancy. S 26.02.01 RENAL HYPERPARATHYREOIDISM: A PROSPECTIVE LONG-TERM FOLLOW-UP STUDY OF 80 PATIENTS AFTER PARATHYREOIDECTOMY Alexander Vossough1, Kenko Cupisti2, Q. Yang3, Christian Ohmann3, Cornelia Dotzenrath1 1 Klinik für Allgemeine- und Endokrine Chirurgie, Kliniken St. Antonius Vogelsangstrasse, Wuppertal, 2 Klinik für Allgemein- und Viszeralchirurgie, Heinrich-Heine-Universität Düsseldorf, 3 Koordinierungszentrum für klinische Studien (KKS), Heinrich-Heine Universität Düsseldorf Objective: This 14-year long-term follow-up study was launched to investigate the results of parathyreoidectomy and to evaluate the clinical effectivness and improvement of the main symptoms bone pain, pruritus and extraskeletal tissue calcification in certain patients and the mortality rate of the patients. Methods: From May 1986 to November 1992, 80 patients underwent surgery for renal hyperparathyreoidism in the Department of general surgery of the Heinrich-Heine-Universität Düsseldorf. 49 patients had subtotal and 31 had total PTX with AT. Results: Survival analysis showed male gender, renal transplantation, age under 55 years, coronary heart disease, glomerulonephritis, no extraskeletal calcification and a low serum level of alkaline phosphatase switch to be important predictors of survival. Especially cardiovascular disease plays a major role. Nine years after parathyreoidectomy 60% of the patients without cardiovascular calcifications are still alive compared with only 20% of patients with cardiovascular disease. Within the first month 90% of the patients recovered from bone pain with a 75% long term success rate. There was no significant effect on pruritus and soft tissue calcifications. Conclusions: Mortality of patients after parathyreoidectomy is mainly influenced by patients risk factors and co-morbid risk-factors. Parathyreoidectomy is an effective procedure to reduce bone pain as the main symptom of renal hyperparathyreoidism. S 26.02.02 EFFECT OF TOTAL PARATHYREOIDECTOMY WITHOUT AUTOTRANSPLANTATION ON BONE TURNOVER IN THE LONG TERM Mechthild Hermanns1, Peter T. Froehling2, Ulrich Stabell3, Hannelore Hampl4, Thomas Gruner5, Thomas Steinmüller1 1 Department of Surgery, Humboldt Klinikum Berlin 2 Private Center of Nephrology, Potsdam 3 Private Center of Radiology and Nuclear Medicine, Berlin 4 Department of Nephrology, Charité Campus Virchow University Hospital, Berlin 5 Department of Nephrology, Humboldt Klinikum Berlin Objective: Total parathyreoidectomy without autotransplantation remains controversial. Methods: 58 patients (44 on hemodialysis and 14 after kidney transplantation) were assessed from 7 to 112 months (49 month on average) after total parathyreoidectomy without autotransplantation. During the total observation period PTH was undetectable in 25 cases and in a very low range (median 0.52 pmol/l; norm 1.2 6.0 pmol/l) in the other cases. Five different bone turnover parameters were determined for the estimation of osteoblastic and osteoclastic activity (native osteocalcin by RIA, CT-X and PINP by E

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170 Roche, bone alcaline phosphatase and tartrate resistance acid phosphatase (TRAP) by enzyme immuno assay). All patients were treated with Calcitriol. A deficiency of OHD was prevented by the administration of Vitamin D. Results: All median values of the bone turnover parameters remained in the normal range in spite of low PTH values. No fractures or radiological findings of renal osteodystrophy were elicited. In those patients who presented with marked radiological symptoms before surger a good recovery was observed during the first two years thereafter. Conclusions: Our results prove that total parathyreoidectomy without autotransplantation is an effective and safe method for the treatment of severe hyperparathyreoidism. The risk for the development of a low bone turnover disease seems to be small if t. This assumption is in contrast to the K-DOQUI-guidelines. S 26.02.03 SURGERY FOR RENAL HYPERPARATHYROIDISM: BEFORE OR AFTER KIDNEY TRANSPLANTATION? Nada Rayes1, Daniel Seehofer1, Frank Ulrich1, Martin Stockmann1, Petra Reinke2, Ralf Schindler2, Ulrich Frei2, Peter Neuhaus1 1 Department of General-, Visceral- and Transplant Surgery, 2 Department of Nephrology, Charité Campus Virchow, Humboldt University, Berlin, Germany Only few data on the long-term outcome of parathyroidectomy in kidney transplant recipients exist. Patients: 106 patients underwent subtotal parathyroidectomy between 01/1997 and 05/2005. 42 patients were operated after (group 1), 64 patients prior to transplantation (group 2). Results: group 1: Mean interval between transplantation and parathyroidectomy was 18±3 months. Preoperative iPTH was 466±72 (mean±SEM) ng/l. iPTH 12, 24 and 36 months postoperatively was 60±15, 76±22 and 63±22ng/l. Calcium two years postoperatively was 2,26±0,07mg/dl. Preoperative creatinine of 1,6±0.2mg/dl slightly increased to 2,0±0,3mg/dl and 2,0±0,3mg/dl at 12 and 36 months after parathyroidectomy. Two years following transplantation, creatinine was 2,68±0,53mg/dl. In the long-term follow-up, ten patients (23,8%) had graft failure; five of them died. group 2: Mean interval between pretransplant parathyroid surgery and transplantation was 21±2 months. Preoperative iPTH was 801±69ng/l. iPTH 12, 24 and 36 months postoperatively was 86±30, 109±39 and 114±49ng/l. Calcium two years postoperatively was 2,35±0,05mmol/l. Two years following transplantation, creatinine was 2,09±0,2mg/dl. Five patients (7,8%) lost their graft; one of them died. Conclusion: Although calcium and iPTH levels in the long-term were slightly higher if parathyroidectomy was performed before kidney transplantation, graft function and survival were better compared to the patients in whom parathyroidectomy was performed after transplantation. S 26.02.04 PARATHYROID HORMONE MONITORING IN RENAL HYPERPARATHYROIDISM Klaus Kaczirek, Philipp Riss, Reza Asari, Christian Scheuba, Bruno Niederle Section of Endocrine Surgery, Division of General Surgery, Medical University of Vienna, Vienna, Austria Objective: Cross reactivity of parathyroid hormone (PTH) fragments with first generation PTH assays may be the reason for failure to predict (in)complete resection of hyperfunctioning parathyroid tissue in renal hyperparathyroidism (RHPT). Methods: 35 consecutive patients underwent total parathyroidectomy, central neck dissection, bilateral thymectomy and immediate autotransplantation. PTH levels were measured by two different genera-

tions of PTH assays at induction of anaesthesia and in 5 min intervals after excision of the last parathyroid gland. Parathyroidectomy was considered “total” in patients with PTH levels <10 pg/ml (subgroup 1), “subtotal” between 10 and 65 pg/ml (subgroup 2) and “insufficient” >65 pg/ml (subgroup 3) within the first postoperative week. Results: First generation assay PTH levels dropped to <22% of preoperative levels independent of kidney function in all 3 subgroups whereas second generation assay PTH levels dropped into the normal range only after “total” and “subtotal” resections and indicated “insufficient” parathyroidectomy in 4 of 5 patients (80 %). One failure was caused by devascularisation of remaining parathyroid tissue. An intraoperative differentiation between “total” and “subtotal” resection was not possible. Conclusions: Intraoperative monitoring with quick “second generation assays” for PTH (1-84) seems to be a valuable new tool in surgery for RHPT. S 26.02.05 INTRAOPERATIVE PTH MEASUREMENT FOR TERTIARY HYPERPARATHYROIDISM: RESULTS ON 35 CONSECUTIVE CASES Frédéric Triponez1,*, David Dosseh1, Marc Hazzan2, Christian Noel2, Benoit Soudan3, Arnold Boersma3, Martha Mozzon1, Jonathan Lokey1, Charles A. G. Proye1 1 General and Endocrine Surgery, University Hospital, Lille, France 2 Nephrology and Hemodialysis, University Hospital, Lille, France 3 Endocrine Biochemistry, University Hospital, Lille, France, * Current address: Thoracic and Endocrine Surgery, University Hospital of Geneva, Geneva, Switzerland Objective: IOPTH profile is not known in the setting of tertiary hyperparathyroidism (3HPT), a unique situation where normal renal function is always associated to multiglandular disease. Methods: Retrospective analysis of 35 3HPT patients who underwent subtotal parathyroidectomy and IOPTH monitoring. 35 patients with 2HPT undergoing subtotal parathyroidectomy and 35 patients with 1HPT undergoing one gland excision by focused approach were randomly selected as comparison groups. Results: Mean follow-up was 2.2±1.4 years. One patient (2.8%) presented persistent disease and was cured after reoperation. Four cured patients had a decrease of <50% at 5 minutes and 2 of them had a decrease <50% at 10 minutes. At 20 minutes, all patients (including the patients with persistent disease) had a decrease >50%. Using the Miami criteria for cure, the overall accuracy of the IOPTH was 91%. Conclusions: After subtotal parathyroidectomy in 3HPT patients, IOPTH profile resembles that of postadenoma resection by 1HPT patients however the interindividual variability is bigger. With a false negative rate (abnormal PTH decrease by cured patients) of 11.5% and 6% at 5 and 10 minutes respectively, we recommend to perform other PTH measurements before excising more parathyroid tissue in these patients to avoid definitive hypoparathyroidism. S 26.03.01 PERIOPERATIVE KINETICS OF PARATHYROID HORMONES AFTER THYROIDECTOMY AND IMPACT OF PARATHYROID GLAND DISSECTION – PRELIMINARY DATA OF A PROSPECTIVE STUDY Johannes Ott, Regina Promberger, Michael Karik, Michael Hermann Chirurgische Abteilung, Kaiserin Elisabeth Spital, Wien, Österreich Objective: Recent multicentric studies show a rate of 1,5 to 2,5% continuous parathyroid hypofunction after thyroid surgery, in total thyroidectomy up to 8,5%. A standardization of intraoperative parathyroid gland(PG) preservation is claimed.

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Methods: We carried out a prospective study on 172 patients undergoing thyroidectomy with documentation of each single PG by a detailed protocol. An intra- and postoperative PTH Monitoring (bioPTH 6-40pg/ml) was performed. Results: Our preliminary data showed an average decline of 43% for intraoperative PTH during thyroidectomy. The early clinical symptoms(sy) increased with the number of presented PG: 0PG0%sy, 1PG-10%sy, 2PG-3%sy, 3PG-22%sy, 4PG-21%sy. Discoloration of PG does not necessarily result in prolonged hypoparathyroidism: PTH-levels of our 12 patients with 3 or 4 discolored glands declined intraoperatively from 22 to 11, but increased to 20 and 22pg/ml on day 3 and 14. In contrast, 4 patients, who underwent double autotransplantation, fell from PTH 21 to 11pg/ml intraoperatively and did not substantially increase on day 3 and 14 (PTH 13 and 8pg/ml). Conclusions: There is no evidence-based recommendations over the requested number of presented PG. The meaning of intraoperative color changes of PG is overestimated. Autotransplantation should not generally be recommended in case of discoloration. S 26.03.02 POSTOPERATIVE HYPOPARATHYROIDISM FOLLOWING THYROIDECTOMY Alexandra Zahn, Michael Gruß, Jochen Kußmann I. Chirurgie, AK Wandsbek Hamburg Background: In comparison with Data of 2003 we analysed Data of 2004 regarding hypoparathyreoidism in patients after thyreoidectomy for benign disease. Materials and methods: 199 patients underwent thyroidectomy for benign disease in 2004. Clinical symptoms, PTH ,calcium levels on day 1 were recorded prospectively. Follow-up examination in 7/2005. Results: Postoperative hypoparathyroidism (PTH <15 ng/l) on day 1 occurred in 26% of patients (2003: 36%). Of 44 patients (22%) with hypocalcemic symptoms (2003: 14 %), in 28 patients (63%) symptoms disappeared after a single calcium-substitution. Of 16 patients who required calcium after discharge all had PTH <15 ng/l on day 1. When identifying at least 3 parathyroid glands postoperative hypoparathyroidism occurred in 28 % of patients (2003: 42%). Autotransplantation was performed in 24 % of patients (2003: 27%). Half of these patients developed transient hypoparathyroidism (2003: 56 %). There was no permanent hypoparathyroidism at follow-up examination. Conclusions: Preservation of parathyroid gland during thyroidectomy is most effective to avoid a permanent hypoparathyroidism. Patients with PTH level <15 ng/l on day 1 are in danger to develop hypocalcemic symptoms for more than 1 week and should be substituted on discharge.

S 26.03.03 CLINICAL APPLICATION OF QUICK INTRAOPERATIVE PARATHYROID HORMONE ASSAY FOR PREDICTION OF HYPOCALCEMIA IN THYROID SURGERY Marcin Barczy´nski, Stanisław Cicho´n, Aleksander Konturek, Wojciech Cicho´n Department of Endocrine Surgery, 3rd Chair of General Surgery, Jagiellonian University College of Medicine, Kraków, Poland Objective: The study aimed at clarifying the usefulness of intraoperative quick intact parathyroid hormone assay (IOPTH) in predicting postoperative hypocalcemia after thyroid surgery. Methods: In 200 patients IOPTH was used preoperatively and at 10min after total thyroidectomy. Serum calcium was evaluated at 12, 24, 48 and 72h postoperatively. Incidence and severity of hypocalcemia were matched to IOPTH results. Results: Mild (2.0-2.15mmol/l), moderate (1.8-1.99mmol/l) and severe (<1.8mmol/l) hypocalcemia were observed in 27, 10 and 4 cases, respectively. Mean PTH serum level decrease at 10min was 41.3±6.9%, 51.7±7.2%, 55.6±3.7 and 61.4±3.2% in normocalcemic, mild, moderate and severe hypocalcemic patients, respectively (p<0.05). Seven patients had PTH serum level <12pg/ml including all 4 patients with severe and 3 of 10 patients with moderate hypocalcemia. Conclusions: IOPTH used during thyroidectomy helps to identify patients at risk of clinically significant hypocalcemia. Both PTH serum level <12pg/ml and PTH decrease 50% or higher at 10min after thyroidectomy are strongly suggestive of increased risk of postoperative hypocalcemia.

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Posters P 01 SARCOMA AS DIFFERENTIAL DIAGNOSIS TO ANAPLASTIC THYROID CANCER (ATC) Barbara Wojciechowski, Jochen Kußmann I. Chirurgie, AK Wandsbek Hamburg Objective: The anaplastic carcinoma is rare and lethal. In some cases the first histological diagnosis is ATC and the following immunohistochemical staining shows a different neoplasm with a probably different prognosis. Methods: From 1998 till now 269 Patients underwent surgery for thyroid malignancies. We retrospectively compared the result of frozen sections with the final result in patients with poorly differentiated tumors. Results: In 7 Patients (2,6%) the initial diagnosis was ATC. In two of these patients (39 and 62 years old) immunohistochemical workup changed the diagnosis to sarcoma (Histiocytoma, Synovial Sarcoma). Both underwent extended lobectomy with radical resection of the tumor and infiltrated tissue (RLN in both, esophageal wall in one). The patient with Synovial Sarcoma underwent adjuvant external radiation. He is alive and well 6 years after the operation. The patient with the Histiocytoma had chemotherapy and died 9 months after the operation. Conclusions: It is important to consider the differential diagnosis of the ATC especially in young people with poorly differentiated thyroid tumors. An extend surgical and adjuvant treatment can be of benefit in some patients. P 02 RAPIDLY PROGRESSING SQUAMOUS CELL CARCINOMA OF THE THYROID IN AN ELDERLY WOMAN – A CASE STUDY Wolfgang Braun Nuklearmedizinische Praxis Augsburg Objective: Squamous cell carcinoma of the thyroid is one of the most infrequent malignant tunors of this endocrine organ. The despriction of one impressive case may show the extreme aggressiveness of this entity. Methods: Female patient of age 72, complaining of lassitude and involuntary weight gain, diagnosed on her first visit as chronic lymphocytic thyroiditis by ultrasonography of the neck, scintiscan and laboratory tests (TSH, anti-TPO) could be reexamined six months later. Results: Within half a year, the goiter had grown enormously, presenting as cold nodule, which cytologically and histologically turned out to be a squamous cell carcinoma of the thyroid. Despite surgery and external radiation, the patient died a few weeks after these non curative therapeutic measures from tumor progression. Conclusions: To the best knowledge of the author, this is the first despription of a sqaumos cell carcinoma of the thyroid, evolving in a thyroid with preexisting chronic lymphocytic thyroiditis. This tumor seems to be one of the most aggressive in thyroid pathology. P 03 PRIMARY HYPERPARATHYROIDISM IN PREGNANCY: A CASE REPORT OF A HUGE PARATHYROID ADENOMA IN A 34 YEAR OLD WOMAN Maike Eden, C. Vorländer, R. A. Wahl Chirurgische Klinik, Bürgerhospital Frankfurt/M. Background: Primary hyperparathyroidism during pregnancy is an uncommon endocrinopathy but carries significant risks to mother and fetus. Parathyroidectomy is the only definitive therapy.

Material: A 34 year old primipara 25 1/7 weeks gestation presented with gestational diabetes, anaemia and recurrent urinary infections. Further investigations showed primary hyperparathyroidism with serum calcium of 3,4mmol/l, phosphorus 0,65mmol/l and intact parathyrin (PTH) of 228pg/ml. Neck ultrasound demonstrated a huge mass dorsal of the right thyroid lobe. Parathyroidectomy was performed as unilateral approach using the quick PTH-assay which dropped from 269pg/ml before excision to 23pg/ml, after 10 minutes, 21pg/ml after 20 minutes. An 18grs. right upper parathyroid gland was the specimen. No complications occurred. To avoid postoperative tetany in the mother calcium supplementation was started immediately, serum calcium was adjusted to the upper normal level. The further course showed increasing haemoglobin and decreasing blood-sugar in the mother. Conclusions: Primary hyperparathyroidism in pregnant women is often unrecognized due to absence of calcium screening. To avoid maternal and fetal complications including growth retardation, intrauterine death, preterm delivery and postpartal fetal tetany parathyroidectomy has to be performed. The second trimester is the safest period, giving the fetus the chance to develop own parathyroid function prior to birth. P 04 REQUIREMENTS FOR PARATHYROID SURGERY IN SMALLER SURGICAL UNITS E. Thies, Cl. Schulze Abt. Chirurgie, Klinikum Elmshorn Background: Parathyroid surgery has changed, due to improvement in adenoma localization and intraoperative detection of parathormone. Procedures range from “all gland exploration” to strategies restricted to resection of affected glands. Diagnostic and surgical approach require technical and human support usually available in centers. The paper’s aim is to depict requirements for parathyroid surgery when performed in smaller units. Patients: From 2001 to 2005 24 parathyroidectomies were performed. In 23 cases first resection cured hyperparathyroidism. A second intervention was necessary in l patient (MEN-1) despite significantly decreased parathormone during the first operation.. Revision revealed adenomas in all remaining glands. One postoperative hypoparathyroidism was treated by replantation of cryopreseved tissue. In the remaining 22 cases no functional disorders occured. No major complications were identified. Mean hospital stay was 3 days, patients suffering from secondary hyperparathyroidism – usually in nephrological care – were discharged on postoperative day 1. Conclusion: Parathyroid surgery is a safe procedure even in a smaller surgical unit. To obtain results similar to those of larger centers this surgery requires: 1. Experience in thyroid resections. 2. intraoperative parathormone measurements 3. intraoperative frozen section diagnosis 4. Monitoring of recurrent laryngeal nerve function 5. cryoconservation

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P 05 TOTAL PARATHYREOIDECTOMY WITH AUTOTRANSPLANTATION INTO THE STERNOCLEIDOMASTOID MUSCLE: STILL AN APPROPIATE TECHNIQUE? Alexander Vossough1, Norbert Weyerbrock1, Maria Plett1, Ana-Karena Kätsch1, Holger Ulitzner1, Kenko Cupisti2, Cornelia Dotzenrath1 1 Klinik für Allgemeine- und Endokrine Chirurgie, Kliniken St. Antonius Vogelsangstrasse, Wuppertal, 2 Klinik für Allgemein- und Viszeralchirurgie, Heinrich-Heine-Universität Düsseldorf, Düsseldorf

P 07 DYSHORMONOGENETIC GOITER DUE TO INACTIVATING THYROID PEROXIDASE MUTATIONS: INCREASED RISK FOR THYROID CARCINOMA ARISING FROM MULTILOCAL FOLLICULAR NEOPLASMS Thomas J. Musholt1, Petra B. Musholt1,2, Nicole Pfarr3, Joachim Pohlenz3 1 Endocrine Surgery, Gutenberg University Medical School, Mainz 2 Endocrinology, Gutenberg University Medical School, Mainz 3 Pediatric Endocrinology, Gutenberg University Medical School, Mainz

Objective: Between 20-40% of the patients with end-stage renal disease (ESRD) develop renal autonomous hyperparathyreoidism. Subtotal resection of the parathyroid glands (SPTX) and total parathyreoidectomy with autografting of parathyroid tissue are standard surgical procedures. The persistence/recurrence rate is reported of up to 12%. Is the sternocleidomastoid muscle still an appropiate spot for the autotransplantation? Methods: From June 2000 to December 2004, 59 patients underwent surgery for renal hyperparathyreoidism. Nine patients were reoperated for persistent/recurrent renal hyperparathyreoidism after primary operation in an outher hospital. Results: Before the reoperations several test i.e. CASANOVATEST, MIBI-scans, MRI, CT-scans were performed to confirm the localisation. MRI, MIBI-scans and CT-scans could not differ between the autografted tissue in the neck and remaining parathyreoid tissue. The cervical operation required general anaesthesia, the forearm exploration was performed in local anaesthesia. The medium operation time for the cervical exploration was 125 minutes versus an average of 30 minutes for the forearm exploration. Intraoperative and postoperative PTH levels revealed the successful operation in all patients. Conclusions: We consider total parathyreoidectomy with immediate autotransplantation into the sternocleidomastoid muscle as an inappropiate technique.

Objective: Congenital primary hypothyroidism caused by genetic defects in thyroid hormonogenesis leads to multinodular dyshormonogenetic goiters in the respective children. Methods: A review of the literature regarding tumorigenesis in dyshormonogenetic goiters is completed by a case report of a boy with congenital hypothyroidism born to consanguineous parents. Due to the boy’s poor compliance in hormone substitution, the thyroid volume increased within 3years to 82ml at the age of 17years. The boy reported of increasingly discomforting neck tightness and difficulties to swallow food. Thyroid nodules were suspected of malignancy by ultrasound examination. In order to eliminate the clinical symptoms and to definitely rule out malignant growth, total thyroidectomy was performed. Mutation analysis of the thyroid peroxidase (TPO) gene was carried out. Results: The thyroid of 50gram harbored multiple nodules in both lobes that histologically appeared as encapsulated tumors ranging from diminutive hyperplastic nodules to (yet) benign follicular adenomas (max. 1.2cm). Malignant transformation to follicular carcinoma was not detected. Molecular analysis of the TPO gene revealed a novel, homozygous, loss-of-function, 10bp frame-shift deletion, altering the carboxyterminal part of the protein. Conclusions: Due to an increased risk for development of thyroid carcinoma in dyshormonogenetic goiters, an early decision for surgical intervention is suggested.

P 06 COMPLICATIONS FOLLOWING PARATHYROIDECTOMIE IN PATIENTS WITH SECONDARY HYPERPARATHYROIDISM Stephan Rautenbach, Sandra Daniel, Jochen Kussmann Abteilung für Allgemein-, Thorax- und Gefaesschirurgie, AK Wandsbek, Hamburg

P 08 CLINICAL SIGNIFICANCE OF NUCLEAR MORPHOMETRY, MICROVESSEL DENSITY, PCNA AND KI-67 AS PROGNOSTIC FACTORS IN THYROID CANCER Aleksander Konturek1, Marcin Barczynski1, Stanisław Cicho´n1, Jerzy Jamski1, Janusz Ry´s2 1 Department of Endocrine Surgery, 3rd Chair of General Surgery, Jagiellonian University College of Medicine, 2 Department of Tumor Pathology, Center of Oncology, Kraków, Poland

Objective: Patients with progressive secondary hyperparathyroidism (sHPT) due to chronic renal failure often suffer from a variety of concomitant diseases. Our retrospective analysis is focused on complications following total/subtotal parathyroidectomy in these patients. Methods: Between 1998 and 2004 83 patients with sHPT were treated (re do procedures excluded). Severe concomitant diseases were hypertension (76,8%), coronary heart disease (23,2%), valvular heart disease (13,4%), and previous heart/lung transplantation (2,4%). 96,7% of our patients were classiefied ASA III, one patient ASA IV. Operations performed were PTX (13,9%), PTX + AT (45,6%) and sPTX (40,5%). Results: The most common complication was hypocalcemia (<2,0 mmol/l) on day 1 in 12 patients (16%). Remarkably hypocalcemia was observed in 30% of patients with sPTX compared to 5% of patients with PTX + AT. 3 patients had severe clinical symptoms despite iv calcium with 1 readmission. 5 minor and 1 major bleedings were observed. There was 1 hypertensive crisis and 1 dialysis on day 1 (hyperkalemia). No RLN paralysis. Median LOS 2 days. Conclusions: Even in these critically ill patients parathyroidectomy is a save procedure. Iv calcium substitution and frequent controls are mandatory even after sPTX.

Objective: The aim was to investigate the nuclear and angiogenetic profile together with PCNA and Ki-67 scores as prognostic factors in locally advanced thyroid cancer. Methods: 61 patients after radical surgery have been followed-up for 73.2±12.1 months. Incidence of local recurrence and survival rate were matched to results of nuclear morphometry, microvessel density (MVD), PCNA and Ki-67 analysis. Results: 21/29 patients with low PCNA score survived and 15/32 with high PCNA score died (p=0.0033, p<0.05; respectively). The mean values of Ki-67 in metastasis positive patients were significantly higher than Ki-67 in metastasis free patients (p=0.0052). The survival rate was significantly higher in patients with Ki-67 below 6.0 (p=0.0001). Specificity, sensitivity and accuracy of the morphometric examination of nuclear area ranged between 75 and 80%. Conclusions: The PCNA, Ki-67, angiogenetic profile and nuclear morphometry analysis are useful in identifying patients after potentially curative resection having poor prognosis related to biologi-

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cally aggressive tumour behaviour. Further long-term follow-up is necessary to validate short-term results. P 09 INFLUENCE OF L-THYROXINE ADMINISTRATION ON POOR-PLATELET PLASMA VEGF CONCENTRATIONS IN PATIENT WITH INDUCED SHORT-TERM HYPOTHYROIDISM MONITORED FOR THYROID CARCINOMA Marek Dedecjus1,*, Krzysztof Kołomecki2, Jan Brzezi´nski1, Zbigniew Adamczewski3, Józef Tazbir4, Andrzej Lewi´nski3 1 Department of Endocrine Surgery, Chair of Endocrinology and Metabolic Diseases, Medical University of Łódż, Polish Mother Memorial Research Institute, Poland 2 Department of Endocrinological and General Surgery, Medical University of Łódż, Poland 3 Department of Endocrinology and Metabolic Diseases, Medical University of Łódż, Polish Mother Memorial Research Institute, Poland 4 Department of Emergency Medicine, Medical University of Łódż, Poland Objective: The Vascular Endothelial Growth Factor (VEGF) represents a family of specific endothelial cell mitogens, involved in normal angiogenesis and in tumour development. The aim of the present study was to estimate the influence of Lthyroxine administration on plasma VEGF concentrations in patients with induced short-term hypothyroidism, monitored for thyroid carcinoma. Methods: In the present study, plasma concentrations of VEGF, thyroglobulin, thyrotropin and free thyroid hormones were investigated in a population of 24 hypothyroid patients, who were withdrawn from L-thyroxine (L-T4) treatment for 5 weeks and studied before and after 2 months of L-T4 therapy. Only healthy female patients without any trace of metastasis in scintigraphy were included in the study. They were then compared with 20 healthy control subjects, matched for age, sex and body mass index (BMI). Results: The patients, untreated with L-T4, had significantly lower plasma VEGF concentrations, which increased significantly after the treatment. There was no significant difference in plasma VEGF levels between the patients, treated with L-T4 and the controls. Conclusions: Even short-time changes in thyrometabolic profile have an important influence on VEGF plasma concentrations, nevertheless thyroid tissue is absent. P 10 PTEN-EXPRESSION IN NEUROENDOCRINE TUMOURS OF THE PANCREAS Markus Krausch1, Andreas Raffel1, Sebastian Heikaus2, Kenko Cupisti1, Achim Wolf1, Claus Ferdinand Eisenberger1, Wolfram Trudo Knoefel1 1 Department of General Surgery, Heinrich-Heine-University Düsseldorf, Germany 2 Institute of Pathology, Heinrich-Heine-University Düsseldorf, Germany Objective: PTEN is a tumour-suppressor-gene, localisated on chromosome 10q23-24. It plays an important role in the control of cell growth, adhesion, migration and apoptosis. Genetic variations and loss of expression in different carcinomas are discribed. Only one paper describes PTEN as an differentiation marker of neuroendocrine tumours and loss of PTEN-expression. oss of PTEN-expression may play an important role in tumour progression of neuroendocrine tumours. Methods: We report 38 patients with malignant neuroendocrine pancreatic tumours. Tumour tissue was fixed in formalin and embedded in paraffin. The expression of PTEN was immunohistochemically examined with a monoclonal IgG1-antibody. As a posi-

tive control we used nerval tissue. We counted out from 5 representative fields of vision in each case in the microscope the relation of the positive cells to the whole cell number. Results: Different expressions were seen. Results were correlated with clinical and pathological parameters of every tumour, hormone function, metastasis development and outcome. Conclusions: The aim of the study was to proof the clinical applicability of PTEN expression and its suitability as a prediction factor. The representation of the results of the immunohistochemical processing of the tumor probes occurs in correlation with the outcome parameters of the patients. P 11 SYMPTOMATIC PURE PANCREATIC POLYPEPTIDE-CONTAINING TUMOR OF THE PANCREAS Andreas Raffel, Markus Krausch, Achim Wolf, Claus Ferdinand Eisenberger, Kenko Cupisti, Wolfram Trudo Knoefel Department of General and Visceral Surgery, Heinrich-Heine-University Düsseldorf, Germany Very little is known about physiologic function or the clinical implications of elevated circulating levels of pancreatic polypeptide (PP). The secretion of PP has been used as a marker for neuroendocrine tumors. PP producing tumors, also called “silent tumors”, most frequently originate from the pancreas and present as three pathologic lesions: pure PPomas, PP-cell hyperplasia and mixed tumors with minor PP-cell population. Only few reports of endocrine symptoms in association with PPcell hyperplasia or mixed PPomas exist. Pure pancreatic polypeptide-containing tumors are quite rare. We report about a patient with a symptomatic pure PPoma of the pancreas with multiple gastric and duodenal ulcers (ulcer perforation) in whom hypergastrinemia was excluded. Diagnostic showed a large tumor in the pancreatic head. Endoscopy showed acute duodenitis with hemorrhagic erosions. All laboratory findings were within normal limits, except for an elevated pancreatic polypeptide (411 ng/l; reference 51–326 ng/). Duodenopancreatectomy was performed. The PP-level decreased to normal limit (<100 ng/l) within 5 days after operation. Follow-up is now 8 years without any signs of tumor recurrence. This case illustrates that pure pancreatic polypeptide-containing tumors may produce recurrent ulcer disease. The physiology of PP with regard to ulcer formation needs to be explored. P 12 GHRELIN EXPRESSION IN NEUROENDOCRINE TUMOURS OF THE GASTROINTESTINAL TRACT WITH MULTIPLE ENDOCRINE NEOPLASIA TYPE 1 Andreas Raffel, Markus Krausch, Achim Wolf, Kenko Cupisti, Claus Ferdinand Eisenberger, Wolfram Trudo Knoefel Department of General and Visceral Surgery, Heinrich-Heine-University Düsseldorf, Germany Ghrelin is a novel gastrointestinal-brain hormone, first described by Kojima. It is isolated and purified in different tissues. The evidence of antiproliferative effects in neoplastic cells supports the hypothesis that ghrelin plays an important role in endocrine regulation. It is proposed that ghrelin is involved in tumor formation of NET of the gastrointestinal tract in the setting of MEN 1. The last 16 years 227 patients with a NET of the GIT were treated at our institution. In 12 patients mutations of the menin gene were identified. 11 islet cell tumours were localized to the pancreas and 1 to the stomach. Tumor tissues were surgically resected, formalin fixed and paraffin embedded. The tissues were examined by immunohistochemistry with a primary antibody for ghrelin. 3 out of 12

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NET in MEN 1 patients (25 %) showed expression of ghrelin. Comparison of biologic activities, morphlogic aspects and clinicopathological parameters between ghrelin-positive/-negative tumours shows no worth mentioning differences. The reported incidence of ghrelin expression in NET of the gastrointestinal tract by MEN 1 was not seen in our patients. If ghrelin has influence on tumour genesis of neuroendocrine tumours related to deficient menin-genes is unknown. Further research on ghrelin will be necessary. P 13 MORPHOLOGY AND FUNCTION ADAPTED THYROID SURGERY: ARE WE RADICAL ENOUGH? Stephan Timm1, Markus Luster2, Christoph Reiners2, Arnulf Thiede1, Wulf Hamelmann1 1 University Hospital of Würzburg, Center for Operative Medicine, 2 Clinic for Nuclear Medicine, University of Würzburg, Würzburg Objective: It was the aim of this investigation to evaluate the outcome of patients after thyroid surgery with particular interest in morphology and function. Methods: 400 patients, having been operated because of benign goiter between 1998 and 2002, were analysed. Results: 85% of the patients were free of thyroid nodules postoperatively, in 15% of patients remaining nodules were detected. Functional status was euthyroid in 48% and hypothyroid in 52% of patients. Between 1998 and 2000 the dominant procedure was bilateral subtotal resection, the majority of patients operated 2000-2002 at least received a hemithyroidectomy. Substitutive therapy: thyroid function

no therapy

jodine

jodine + thyroxine

thyroxine

euthyroid hypothyroid

12% 1,5%

30% /

31% 7,5%

27% 91%

Conclusions: The concept of an adaption of thyroid surgery to morphology and function does not always completely succeed in the clinical routine. 15% of our patients after surgery remain with residual nodules and iodine/thyroxine substitution has not consequently been performed. More radical thyroid surgery and quality control seem to be necessary to optimize results. P 14 TROPICAL DISEASES AFFECTING ENDOCRINE GLANDS Hinrich Sudeck, Gerd Burchard Klinische Abteilung des Bernhard-Nocht-Institutes Hamburg Imported tropical infections may cause a wide range of multiple organic manifestations and thus are also likely to affect endocrine as well as exocrine glands. We are actually facing a more and more increasing number of unusual and in former times mostly neglected manifestations of exotic infections - one of the consequences of growing tourism, increasing numbers of immigrants coming from African and Asian countries, and spreading HIV-infection leading to immunosuppression. Some of the pathogenic agents are characterized by quite a long latent period and thus might cause diseases even many years after the endemic area has been left. So the key to a correct diagnostic is – on one hand – good knowledge of pathogenic agents, their geographical epidemiology and duration of their prepatant periods and – on the other hand – the individual travel history of the patient. It goes without saying that diagnostics should

have lead to a result prior to a possible surgery instead of occurring as an incidental finding in the resected gland. We will present three case reports showing parasitic and fungal infections of pancreas, thyroid and testes. P 15 PRIMARY THYROID LYMPHOMA IN THE MATERIAL OF 25 000 THYROID OPERATIONS PERFORMED IN ONE DEPARTMENT Marek Dedecjus1, Urszula Pawlak1, Józef Tazbir3, Krzysztof Kuzdak1, Kazimierz Rybi´nski2, Grzegorz Stróżyk1, Jan Brzezi´nski1 1 Department of Endocrine Surgery, Chair of Endocrinology and Metabolic Diseases, Medical University of Łódż, Polish Mother Memorial Research Institute, Poland 2 Department of Endocrinological and General Surgery, Institute of Endocrinology, Medical University of Łódż, The M. Kopernik Memorial Hospital, Łódż, Poland 3 Department of Emergency Medicine Medical University of Łódż, The M. Kopernik Memorial Hospital, Łódż, Poland Objective: Primary thyroid gland lymphomas (PTLs) are rare tumors The clinical presentations of PTL include an enlarging neck mass, but patients may also present with symptoms of dysphagia, hoarseness and choking, or a cold thyroid nodule. Although PTL predominantly arises on a background of Hashimoto’s thyroiditis the mode of its (PTL) presentation, diagnosis and outcome are not well characterised. The aim of the study was to retrospectively evaluate the characteristics, natural history, results of treatment, and prognostic factors for patients operated on in our department because of primary thyroid lymphoma. Methods: Between 1974 and 2004, 26 621 thyroid operations were performed in our department. 29 patients had histopathological finding of primary thyroid lymphoma.. Results: Patient characteristics, treatment methods, and outcome were analyzed. We here describe also the results of clinical and laboratory tests including histological and immunohistochemical studies of a thyroid lymphoma. Conclusions: Overall, PTLs have a favorable outcome with appropriate therapy, but prognosis depends on both clinical stage and histology. Although the majority of patients with localized PTL have an excellent prognosis after undergoing chemotherapy or external irradiation therapy surgery plays a key role in proper diagnosis and treatment particularly in cases of advanced PTL.

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Author index (The numbers are the abstract numbers) Adamczewski, Z P 09 Agha, A S 25.02.03, S 25.02.05 Asari, R S 26.02.04 Bale, R S 26.01.04 Barczynski, M S 26.01.06, S 26.03.03, P 08 Bareck, E S 25.01.01, S 25.02.02 Bieglmayer, C S 26.01.05 Bilkenroth, U S 25.02.04 Bloching, M S 26.01.10 Bockhorn, M S 25.01.09, S 25.04.07 Boersma, A S 26.02.05 Boucher, M S 25.04.04, S 25.05.03 Brändle, M S 26.01.01 Brauckhoff, K S 25.02.04 Brauckhoff, M S 25.02.04 Braun, W S 25.01.03, P 02 Broelsch, CE S 25.01.09, S 25.04.07 Brzezinski, J S 25.05.02, S 25.05.05, P 09, P 15 Büchler, MW S 26.01.02 Bühlmann, R S 26.01.09 Burchard, G P 14 Burchert, A S 25.02.06 Celik, I S 25.02.06 Cichon, S S 26.01.06, S 26.03.03, P 08 Cichon, W S 26.01.06, S 26.03.03 Clerici, T S 26.01.01 Cupisti, K S 25.01.08, S 25.04.02, S 25.04.08, S 25.05.01, S 26.02.01, P 05, P 10, P 11, P 12 Daniel, S P 06 Daum, A S 25.04.07 Dedecjus, M S 25.05.02, S 25.05.05, P 09, P 15 Depisch, D S 25.01.01, S 25.02.02 Dietmaier, W S 25.02.05 Dosseh, D S 26.02.05 Dotzenrath, C S 26.02.01, P 05 Dralle, H S 25.02.04, S 26.01.10 Eden, M P 03 Eger, P S 25.01.06 Eisenberger, CF S 25.01.08, S 25.04.02, S 25.04.08, S 25.05.01, P 10, P 11, P 12 Finke, R S 25.04.01 Fottner, C S 25.01.02, S 25.01.07

Frei, U S 26.02.03 Frey, L, D S 26.01.09 Frilling, A S 25.01.09, S 25.04.07 Froehling, PT S 26.02.02 Gabriel, M S 26.01.04 Gebhardt, C S 25.04.01 Gellert, K S 25.04.05 Gimm, O S 26.01.10 Glockzin, G S 25.02.03, S 25.02.05 Gruner, T S 26.02.02 Gruß, M S 26.03.02 Hadgiev, E S 26.01.07 Hajek, P S 25.01.01, S 25.02.02 Hamelmann, W P 13 Hampl, H S 26.02.02 Hassan, I S 25.04.06 Hazzan, M S 26.02.05 Heidemann, H S 25.04.05 Heikhaus, S S 25.05.01, P 10 Hense, I S 26.01.02 Hermann, M S 26.03.01 Hermanns, M S 25.04.01, S 26.02.02 Hinz, U S 26.01.02 Hoffmann, S S 25.02.06, S 25.04.06 Hosch, SB S 25.04.08 Howell, VM S 26.01.10 Iesalnieks, I S 25.02.03, S 25.02.05 Kaczirek, K S 26.01.05, S 26.02.04 Karakas, E S 26.01.08 Karik, M S 26.03.01 Kätsch, AK S 25.05.03, P 05 Kaurzel, Z S 25.05.05 Keller, M S 26.01.02 Klar, E S 26.01.02 Klein, G S 25.01.01, S 25.02.02 Knoefel, WT S 25.01.08, S 25.04.02, S 25.04.08, S 25.05.01, P 10, P 11, P 12 Köhrer, K S 25.01.01 Koller, M S 25.04.06 Kolomecki, K P 09 Konturek, A S 26.01.06, S 26.03.03, P 08 Kosow, A S 25.02.01 Kovacs, P S 26.01.04 Krausch, M S 25.04.02, S 25.05.01, P 10, P 11, P 12 Krause, U S 26.01.10 Kußmann, J S 26.03.02, P 01, P 06

Kuzdak, K S 25.05.02, S 25.05.05, P 15 Lewinski, A S 25.05.05, P 09 Lienenlüke, RH S 25.01.05, S 25.01.06, S 25.04.03 Lokey, J S 26.02.05 Lorenz, K S 25.02.04, S 26.01.10 Luster, M P 13 Marsh, DJ S 26.01.10 Maschuw, K S 25.02.06 Meyer, M S 25.04.04, S 25.05.03 Miersch, D S 25.01.08 Mozzon, M S 26.02.05 Musholt, PB S 25.01.02, S 25.01.07, P 07 Musholt, TJ S 25.01.02, S 25.01.07, P 07 Neuhaus, P S 26.02.03 Nguyen-Than, P S 25.02.04, S 26.01.10 Niederle, B S 26.01.05, S 26.02.04 Nies, C S 25.02.01, S 26.01.03 Noel, C S 26.02.05 Ohmann, C S 26.02.01 Ott, J S 26.03.01 Pandev, R S 26.01.07 Pawlak, U P 15 Pietsch, A S 26.01.02 Plett, M P 05 Profanter, C S 26.01.04 Promberger, R S 26.03.01 Prommegger, R S 26.01.04 Proye, CAG S 26.02.05 Raffel, A S 25.01.08, S 25.04.02, S 25.04.08, S 25.05.01, P 10, P 11, P 12 Ramelsberger, I S 26.01.03 Rautenbach, SN P 06 Rayes, N S 26.02.03 Reiners, C P 13 Reinke, P S 26.02.03 Riss, P S 26.01.05, S 26.02.04 Rothmund, M S 25.04.06, S 26.01.03, S 26.01.08 Rybinski, K P 15 Rys, J P 08 Sauper, T S 26.01.04 Scheuba, C S 26.02.04 Schilling, S 26.01.02 Schindler, R S 26.02.03 Schlitt, HJ S 25.02.03, S 25.02.05 Schlumpf, R S 26.01.09 Schmid, KW S 25.01.09

Schneyer, U S 26.01.10 Schulze, C P 04 Seehofer, D S 26.02.03 Sheu, S-Y S 25.01.09 Simon, D S 25.04.04, S 25.05.03 Soudan, B S 26.02.05 Stabell, U S 26.02.02 Steinmüller, T S 25.04.01, S 26.02.02 Stiglbauer, W S 25.01.01 Stockmann, M S 26.02.03 Strózyk, G S 25.05.02, S 25.05.05, P 15 Sudeck, H P 14 Tazbir, J S 25.05.05, P 09, P 15 Teh, BT S 26.01.10 Tersiev, I S 26.01.07 Thiede, A P 13 Thies, E P 04 Timm, S P 13 Triponez, F S 26.01.01, S 26.02.05 Trupka, A S 25.02.03 Tuchelt, H S 25.04.01 Ulitzer, H P 05 Ulrich, F S 26.02.03 Vorländer, C S 25.01.05, S 25.01.06, S 25.04.03, P 03 Vossough, A S 26.02.01, P 05 Wahl, RA S 25.01.05, S 25.01.06, S 25.04.03, P 03 Weber, F S 25.04.07 Weber, MM S 25.01.02, S 25.01.07 Weber, T S 26.01.02 Weiss, K S 25.01.01, S 25.02.02 Weyerbrock, N P 05 Witzel, K S 25.05.04 Woenckhaus, M S 25.02.03, S 25.02.05 Wojciechowski, B P 01 Wolf, A S 25.01.08, S 25.04.02, S 25.04.08, S 25.05.01, P 10, P 11, P 12 Wunderlich, A S 25.02.06 Wydler, J S 26.01.09 Yang, Q S 26.02.01 Zahn, A S 26.03.02 Zielke, A S 25.02.06, S 25.04.06, S 26.01.08