Long tail balloon as a new approach for fetoscopic tracheal occlusion for a treatment of severe congenital diaphragmatic hernia.

Severe congenital diaphragmatic hernia (CDH) remains a significant challenge for neonatal specialists. In order to reduce complications during extraction of the surgical balloon after fetoscopic tracheal occlusion (FETO) CDH, we have developed a FETO with a 'long tail balloon' of 2.5 mL volume. Here we describe two successful uses of the device with observed/expected total fetal lung volume (o/e TFLV) of 15% and with o/e TFLV of 24% and 'liver up'. The o/e TFLV increased to 134% in first case and to 47% in second fetus. The balloon was successfully extracted at 34 weeks' gestation by pulling the long tail suture during second fetoscopy. In the second case the fetus pulled out the balloon from trachea itself by traction onto the balloon's long tail. Both neonates were operated on for their CDH with a good outcome. This work showed the feasibility of this long tail balloon for FETO to reduce the technical difficulty of the balloon extraction and the possibility that fetuses are able to extract the balloon by itself by pulling the balloons' long tail. Further development of long tail balloon for FETO could facilitate its extraction thereby reducing neonatal complications.

Correlations between intravoxel incoherent motion (IVIM) parameters and histological findings in rectal cancer: preliminary results.

Our purpose was to correlate different intravoxel incoherent motion (IVIM), histopathological and clinical parameters in rectal cancer. 17 patients with histologically proven rectal cancer investigated on a 3.T device were included into the study. DWI was performed using a multi-slice single-shot echo-planar imaging sequence with b values of 0, 50, 200, 500 and 1000 s/mm.2 A polygonal region of interest was drawn within the tumors on every b image. The following parameters were retrieved from IVIM: apparent diffusion coefficient (ADC), true diffusion (D), pseudo diffusion coefficient (D*), perfusion factor (f), and relative perfusion f·D*. In every case, cell count, nucleic areas, proliferation index KI 67, and microvessel density were estimated on histopathological specimens. Pearson's correlation coefficient was used to analyze the association between the parameters. ADC correlated well with KI 67 index and D tended to correlate with cell count and KI 67. ADC and D tended to correlate with total nucleic area. The perfusion factor f correlated well with stained vessel area, total vessel area, and vessel count. D* and fD* correlated with mean vessel diameter. Distant metastasized tumors had higher D* and fD* values. IVIM parameter reflected different clinical and histopathological features in rectal cancer.

Diffusion-Weighted Imaging Using a Readout-Segmented, Multishot EPI Sequence at 3 T Distinguishes between Morphologically Differentiated and Undifferentiated Subtypes of Thyroid Carcinoma-A Preliminary Study.

BACKGROUND: Thyroid carcinomas represent the most frequent endocrine malignancies. Recent studies were able to distinguish malignant from benign nodules of the thyroid gland with diffusion-weighted imaging (DWI). Although this differentiation is undoubtedly helpful, presurgical discrimination between well-differentiated and undifferentiated carcinomas would be crucial to define the optimal treatment algorithm. Therefore, the aim of this study was to investigate if readout-segmented multishot echo planar DWI is able to differentiate between differentiated and undifferentiated subtypes of thyroid carcinomas. PATIENTS AND METHODS: Fourteen patients with different types of thyroid carcinomas who received preoperative DWI were included in our study. In all lesions, apparent diffusion coefficient (ADC)min, ADCmean, ADCmax, and D were estimated on the basis of region of interest measurements after coregistration with T1-weighted, postcontrast images. All tumors were resected and analyzed histopathologically. Ki-67 index, p53 synthesis, cellularity, and total and average nucleic areas were estimated using ImageJ version 1.48. RESULTS: Analysis of variance revealed a statistically significant difference in ADCmean values between differentiated and undifferentiated thyroid carcinomas (P=.022). Spearman Rho calculation identified significant correlations between ADCmax and cell count (r=0.541, P=.046) as well as between ADCmax and total nuclei area (r=0.605, P=.022). CONCLUSION: DWI can distinguish between differentiated and undifferentiated thyroid carcinomas.

Thymic pathologies in myasthenia gravis: a preoperative assessment of CAT scan and nuclear based imaging.

Precise diagnostic work up of a suspected thymic pathology in patients with myasthenia gravis (MG) is very important for potential surgical implications and further disease course. In this study the diagnostic value of combined preoperative radiological (CAT scan) and nuclear based imaging (octreotide and thallium scintigraphy) in patients with MG was evaluated. Twenty four patients were included. Histopathology revealed thymoma in nine patients, thymic carcinoma (TC) in one patient, lymphofollicular hyperplasia in seven patients, and involuted thymus in another seven patients. Diagnostic sensitivity for detecting thymoma/TC was 80 % in CAT scan as well as in somatostatin scintigraphy; the combination of both procedures reached 90 %. However, the diagnostic specifity to exclude thymoma in CAT scan was 100 % and in octreotide scintigraphy 85.7 %. Semiquantitative octreotide uptake significantly correlated with histological grading of thymoma/TC (r = 0.764) and histological proliferation rate Ki67 (r = 0.894). Thallium scintigraphy was positive only in one out of four thymoma cases. In this study, somatostatin scintigraphy has been shown to be a useful additional diagnostic technique in detecting thymic malignancies in patients with MG. These results might be especially helpful in patients with late onset MG as these patients are in general no candidates for thymectomy.

Diffusion-weighted imaging of skeletal muscle lymphoma.

OBJECTIVE: Muscle lymphoma (ML) is a relatively uncommon condition. On magnetic resonance imaging (MRI), ML can manifest with a broad spectrum of radiological features. The aim of this study was to demonstrate the features of DW images of muscle lymphoma (ML). MATERIALS AND METHODS: In our database, ten patients (six women and four men) with ML were identified who were investigated by magnetic resonance imaging including acquisition of DW images. DW images were obtained using a multi-shot SE-EPI pulse sequence. Apparent diffusion constant (ADC) maps were also calculated. Furthermore, fusion images were generated manually from DW and HASTE or T2W images. RESULTS: On T2W images, all recognized lesions were hyperintense in comparison to unaffected musculature and on T1W images they were homogeneously hypointense. All lesions demonstrated low signal intensity on ADC images. The calculated ADC values ranged from 0.60 to 0.90 mm(2)s(-1) (mean value 0.76 ± 0.10; median value 0.78). On fusion images, all lesions showed high signal intensity. CONCLUSIONS: ML demonstrated low ADC values and high signal intensity on fusion images suggesting high cellularity of the lesions.

Pulmonary embolism in oncologic patients: frequency and embolus burden of symptomatic and unsuspected events.

BACKGROUND: Pulmonary embolism (PE) is a common cause of morbidity and mortality in oncologic patients. Furthermore, PE is an unsuspected finding in many cases. PURPOSE: To determine the frequency and embolus burden of PE in a consecutive oncologic patient group including symptomatic as well as incidental and initially unreported events. MATERIAL AND METHODS: In a retrospective, single-center study from June 2005 to January 2010 all patients with an oncologic disease (ICD-10 code C00 to C96) that received at least one contrast-enhanced computed tomography (CT) examination of the chest were reviewed. The study group included 3270 patients with 6780 examinations. A validated pulmonary artery obstruction index (Mastora score) was used to assess embolus burden. RESULTS: PE was found in 240 of 3270 (7.3%) oncologic patients. The frequency was highly variable among different malignancies ranging from 0% to 25%. In the present study about half of all PE were unsuspected. The mean embolus burden was significantly higher in symptomatic PE than in unsuspected PE (P <0.001). The risk of developing a PE was 1.5 times higher in patients with metastases compared to patients without metastases (P <0.005). Age and sex had no influence on PE risk and embolus burden. CONCLUSION: PE is a frequent unsuspected finding in staging examinations: particularly in patients with malignancies of the ovary, brain, and pancreas, and in patients with metastases. Therefore, the status of the pulmonary vasculature should be assessed in every staging examination that includes the chest. The effect of therapeutic actions on PE events and the unsuspected finding of PE in follow-up CT examinations require further prospective studies.

Muscle metastases: comparison of features in different primary tumours.

BACKGROUND: Muscle metastases (MM) from solid tumours are rare. The aim of this study was to describe radiological features of MM, and to compare their patterns in different malignancies. METHODS: A retrospective search in the statistical database of our institution revealed 61 cases of MM. Additionally, a retrospective search in Pubmed database was performed. Together with our cases the present analysis comprises 461 patients (682 MM). RESULTS: MM derived from the following malignancies: lung cancer (25.1%), gastrointestinal tumours (21.0%), and urological tumours (13.2%). Other neoplasias with MM were rare. MM were localised most frequently in the thigh muscles, the extraocular musculature, and the gluteal and paravertebral muscles. The localisation of MM was different in several primary malignancies. CONCLUSION: MM present with a broad spectrum of radiological features. Different CT imaging findings of MM were observed in different primary tumours. The localisation of MM also varies with different primary malignancies.

Imaging of nonthrombotic pulmonary embolism: biological materials, nonbiological materials, and foreign bodies.

Nonthrombotic pulmonary embolism is defined as embolization to the pulmonary circulation caused by a wide range of substances of endogenous and exogenous biological and nonbiological origin and foreign bodies. It is an underestimated cause of acute and chronic embolism. Symptoms cover the entire spectrum from asymptomatic patients to sudden death. In addition to obstruction of the pulmonary vasculature there may be an inflammatory cascade that deteriorates vascular, pulmonary and cardiac function. In most cases the patient history and radiological imaging reveals the true nature of the patient's condition. The purpose of this article is to give the reader a survey on pathophysiology, typical clinical and radiological findings in different forms of nonthrombotic pulmonary embolism. The spectrum of forms presented here includes pulmonary embolism with biological materials (amniotic fluid, trophoblast material, endogenous tissue like bone and brain, fat, Echinococcus granulosus, septic emboli and tumor cells); nonbiological materials (cement, gas, iodinated oil, glue, metallic mercury, radiotracer, silicone, talc, cotton, and hyaluronic acid); and foreign bodies (lost intravascular objects, bullets, catheter fragments, intraoperative material, radioactive seeds, and ventriculoperitoneal shunts).

Prevalence and imaging of hepatic involvement in malignant lymphoproliferative disease.

From January 2005 to January 2010, 668 consecutive patients with lymphoproliferative disease were retrospectively identified. Hepatic infiltration was present at initial staging in patients with non-Hodgkin's lymphoma [12 of 364=3.3%; age median=45; male:female (M:F)=10:2] but also Hodgkin's disease (5 of 41=12.2%; age median=19; M:F=0:5) and multiple myeloma (3 of 162=1.8%; age median=60; M:F=2:1). There were no cases of hepatic infiltration in 101 patients with leukemia. There are typical radiological patterns of hepatic involvement in lymphoproliferative disease with typical lesions characteristics.

Prevalence and patterns of renal involvement in imaging of malignant lymphoproliferative diseases.

BACKGROUND: Renal involvement in patients with lymphoproliferative disease is an uncommon radiological finding. PURPOSE: To determine its prevalence and radiological appearances in a patient population. MATERIAL AND METHODS: All forms of lymphoproliferative disease (ICD: C81-C96) were considered. From January 2005 to January 2010, 668 consecutive patients with lymphoproliferative disease were identified with the help of the radiological database and patient records. Inclusion criteria were complete staging including appropriate CT scan and/or MRI. All stored images (initial staging and follow-up examinations) were reviewed. RESULTS: Review of all stored images revealed renal infiltration in patients with non-Hodgkin lymphoma (11 of 364 = 3.0%; median age = 65 years, m:f = 6:5) but also multiple myeloma (2 of 162 = 1.2%; median age = 72 years; m:f = 1:1) and leukemia (5 of 101 = 4.9%; median age = 12 years; m:f = 2:3). There were no cases of renal infiltration in 41 patients with Hodgkin's disease. In total there were six patients with solitary lesions, five patients with diffuse renal enlargement, four patients with perirenal lesions, and two patients with direct invasion of the kidney. CONCLUSION: In leukemia the most common imaging pattern is diffuse enlargement. In the other subtypes of lymphoproliferative disease no specific correlation between typical CT patterns and subtype of lymphoproliferative disease can be found. The prevalence of renal involvement is in line with earlier studies. Contrary to earlier reports, multiple lesions were not found to be a common pattern.

Late sequelae of retained foreign bodies after world war II missile injuries.

A number of people injured during the second world war harbour foreign bodies such as grenade splinters or bullets in some part of the body. Most of these metal fragments remain clinically silent. Some of them, however, may cause delayed complications. The purpose of this study was to determine the characteristics of delayed complications associated with foreign bodies after world war II injuries. 159 patients with retained foreign bodies after world war II injuries were retrospectively identified radiologically in our data bases in the time interval from 1997 to 2009. Diverse delayed complications secondary to the metal objects were diagnosed in 3 cases (2%): one patient with grenade splinter migration into the choledochal duct, one case with pseudotumoural tissue reaction, and one patient with late osteomyelitis. The time from injury to clinical presentation varied from 56 to 61 years. PubMed and Medline were screened for additional cases with delayed sequelae after foreign body acquisition during the 2nd world war. A 30 year search period from 1980 up to date was selected. 15 cases were identified here. Our study demonstrates that health consequences of the 2nd world war extend into the present time, and therefore physicians should be aware of the presence of hidden foreign bodies and their different possible late reactions.

Intramammary incidental findings on staging computer tomography.

PURPOSE: Incidental findings are a common feature in computer tomographic examinations of the chest. Breast incidentalomas, however, were described only sporadically. The purpose of this study was to evaluate retrospectively incidental breast findings and to compare radiological features of benign and malignant breast lesions. MATERIALS AND METHODS: From January 2006 to December 2010 a total of 8105 computer tomographic examinations were performed at our institution. In 89 patients incidental breast lesions were diagnosed. 64 of the identified patients were referred for further clinical, radiological, and hystopathological examination. All patients were female with a median age of 62 years, range 39-82 years. RESULTS: A total of 98 breast lesions were identified in the 64 patients. The mean size was 12.0±8.0 mm. Primary breast carcinoma was identified in 9, breast metastases in 27, and benign findings in 28 patients. Malignant lesions demonstrated more often marked enhancement and showed a higher density compared with benign lesions. Benign findings were more often lobular in shape and had spiculated margins. Most of the breast metastases were round or oval in shape with circumscribed margins and marked homogenous enhancement. There was no significant difference between the breast cancer and benign findings groups in the characteristics of the lesions. CONCLUSION: The breast is a very important region and should be carefully evaluate on chest CT. There are no certain radiological criteria to differentiate between malignant and benign breast lesions on CT. Therefore all breast incidentalomas should be evaluated by further radiological/histological investigations.

Lymphomas and metastases of the extra-ocular musculature.

INTRODUCTION: The involvement of extra-ocular muscles in malignant diseases has been described only sporadically. The purpose of this study was to estimate the prevalence of orbital muscle lymphoma and metastases and to analyse their radiological findings. METHODS: In the time period from January 2000 to January 2010, 11 patients with extra-ocular muscle malignancies (EOMM) were retrospectively identified in the radiological database of our institution. There were four women and seven men with a median age of 58 years (range, 47 to 72 years). In three patients non-Hodgkin lymphoma (NHL), in seven cases intramuscular metastases of solid tumours and in one patient plasmacytoma of orbital muscles were diagnosed. In all, magnetic resonance imaging (MRI) was performed on 11 patients using a 1.5-T MRI scanner (Magnetom Vision Sonata Upgrade, Siemens, Germany). The diagnosis of EOMM was confirmed histopathologically by muscle biopsy in all cases. RESULTS: The prevalence of orbital muscle involvement in plasmacytoma was 0.3%, in NHL 0.4% and in carcinomas 0.1%. Clinically, EOMM presented as painless proptosis and motility disturbance. Medial and lateral rectus muscles were involved in most patients. On T2-weighted images, the lesions were isointense or mixed iso-to-hyperintense in comparison to the unaffected musculature. On T1-weighted images, all tumours were homogeneously isointense. After intravenous administration of contrast medium, most lesions showed moderate heterogeneous enhancement. CONCLUSION: Lymphomas and metastases are rare lesions of the extra-ocular musculature with a prevalence below 0.5%. Their radiological and clinical signs are non-specific and include painless muscle enlargement or masses. They should be considered in the differential diagnosis of diseases of extra-ocular muscles.

Magnetic resonance imaging of intramuscular metastases.

OBJECTIVE: The aim of the present study was to analyse magnetic resonance findings of intramuscular metastases (IM) in a relatively large series. MATERIALS AND METHODS: From January 2000 to January 2010, 28 patients (207 metastases) were retrospectively identified in the radiological database of the Martin-Luther-University. Several different scanning protocols were used depending on the localisation of IM. In 12 patients diffusion-weighted (DW) images were obtained with a multi-shot SE-EPI sequence. Apparent diffusion coefficient (ADC) maps were also calculated. Furthermore, fusion images were manually generated between the DW and half-Fourier acquisition single-shot turbo spin echo (HASTE) images. RESULTS: On T2-weighted images, 97% of the recognised IM were hyperintense in comparison to unaffected musculature, and 3% were mixed iso- to hyperintense. On T1-weighted images most IM (91%) were homogeneously isointense in comparison to muscle tissue, whereas 4% were hypointense, and 5% lightly hyperintense. ADC maps were calculated for 91 metastases ranging from 0.99 to 4.00 mm(2)s(-1) (mean value 1.99 ± 0.66). ADC values of low (<1.5) signal intensity (SI) were identified in 26%, moderate SI (from 1.5 to 3.0) in 68%, and high SI (>3.0) in 6%. Of the IM that were investigated with contrast medium, 88.5% showed marked enhancement. It was homogeneous in 88% and heterogenous in 6%. Rim enhancement with central low attenuation was seen in 6%. There was no difference in enhancement characteristics with respect to ADC values or fusion patterns. Peritumoral enhancement was identified in 2.4%. CONCLUSION: Magnetic resonance features of muscle metastases are relatively typical and consist of round or oval intramuscular masses with well-defined margins, marked enhancement, low or moderate ADC values, and moderate to high signal intensity on fusion images.