Primary mediastinal large B-cell lymphoma: a clinicopathologic study of 43 patients from the Nebraska Lymphoma Study Group.

PURPOSE: To investigate whether primary mediastinal large B-cell lymphoma (PMLBL) is a distinct clinicopathologic entity with a more aggressive course than other diffuse large B-cell lymphomas (DLBL). MATERIALS AND METHODS: All patients with CD20-positive DLBL who presented with a mediastinal mass measuring at least 5.0 cm and were treated with curative intent were identified. A control group of 352 patients with nonmediastinal DLBL was selected for comparison. RESULTS: The 43 patients with PMLBL had a male to female ratio of 20:23 and a median age of 42 years. Stage I/II disease was present in 58% of the patients, with only 9% having bone marrow involvement. A complete remission was achieved in 63% of the patients, and the 5-year overall and failure-free survivals were 46% and 38%, respectively. Among the clinical variables, an elevated serum lactate dehydrogenase level, a low performance score, more than one extranodal site, and an intermediate or high International Prognostic Index score were predictive of poor survival. When compared with the DLBL group, a younger median age was the only clinical feature that was significantly different in the PMLBL group. CONCLUSION: The clinical features of PMLBL do not appear to be significantly different from those of nonmediastinal DLBL. Although the younger age of onset, slight female predominance, mediastinal location, and size of the mass may justify the recognition of PMLBL as a clinical syndrome, additional evidence is needed to define it as a distinct disease entity.

Hematopoietic recovery after allogeneic blood stem-cell transplantation compared with bone marrow transplantation in patients with hematologic malignancies.

PURPOSE: To compare hematopoietic recovery, duration of hospitalization, and 100-day survival in patients who received allogeneic-blood stem cells (BSC) or conventional allogeneic bone marrow transplantation (BMT). PATIENTS AND METHODS: From December 1994 to August 1995, 21 patients participated in a phase II study of allogeneic BSC transplantation. Cells mobilized with granulocyte colony-stimulating factor (G-CSF; 5 micrograms/kg/ d) were collected from human leukocyte antigen (HLA)-matched related donors and cryopreserved. Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporine and methotrexate. G-CSF (10 micrograms/kg/d) was administered posttransplant. The outcomes were compared with 22 identically treated historical patients who received allogeneic BMT. RESULTS: The median infused CD34+ cell and granulocyte-macrophage colony-forming unit (CFU-GM) content were 7.73 x 10(4)/kg and 41.6 x 10(4)/kg, respectively. The median time to a neutrophil count greater than 500/ microL was 11 days after BSC and 16.5 days after BMT (P = .0003). A trend toward faster platelet and RBC recovery after BSC was observed. BSC patients received fewer platelet transfusions: 10 versus 19 (P = .015). The median length of hospitalization was shorter after BSC transplantation: 25 versus 31.5 days (P = .0243). The 100-day survival rates were similar: 83% after BSC and 75% after BMT (P = .3585). The incidence of acute GVHD grade II to IV was 57% and 45% for BSC and BMT, respectively (P = .4654). CONCLUSION: In comparison to BMT, allogeneic BSC transplantation may result in faster hematopoietic recovery, shorter hospital stay, and similar early survival. Whether allogeneic BSC are superior to bone marrow needs to be determined in randomized trials.

Semiquantitative assessment of lower limb atherosclerosis from routine angiographic images.

In the present report a score system is introduced with the aim of analysing routine angiographic images. The system consists of a vectorial score, which codes the pattern of occlusions, stenoses and plaques, and of an additive score describing the severity of the lesions visualised. The technique is suitable for computerised data analysis.

Endovascular irradiation--a new method to avoid recurrent stenosis after stent implantation in peripheral arteries: technique and preliminary results.

PURPOSE: A high dose rate (HDR) afterloading technique for prevention of vascular stenosis or occlusion after percutaneous transluminal arteriography and subsequent stent implantation caused by intimal hyperplasia is presented. METHODS AND MATERIALS: The frequency of recurrent stenosis or occlusion following implantation of stents into peripheral arteries is relatively high. The cause of relapse is rapid intimal hyperplasia. To prevent proliferation of the intimal layer, intravascular brachytherapy was performed in cases of recurrent vascular occlusion or severe stenosis. After recanalization by percutaneous transluminal angioplasty and stent implantation, a 9-French-ReKa catheter was placed within the lumen of the stent. This catheter served as a guide for a 5-French flexible applicator. Then after individual calculation of the isodose, 12 Gy were applied to the vessel wall. This procedure was followed by 72 h of heparinization. Follow-up by Doppler digital subtraction angiography and magnetic resonance imaging was done 3, 6, and 12 months after the procedure and later on once a year. RESULTS: Intraluminal irradiation was performed in 13 patients (nine male and four female). All patients had a clinically relevant restenosis or reocclusion in the superficial femoral artery (clinical stage according to Fontaine IIb-III). Follow-up time ranged from 3-27 months. After irradiation the stented area remained patent in all cases and there were no signs of recurrent stenosis in the treated arterial segment. CONCLUSION: With high dose rate 192Ir afterloading after percutaneous transluminal angioplasty and subsequent stent implantation restenosis or reocclusion caused by intimal hyperplasia can be prevented.

192IR endovascular brachytherapy for avoidance of intimal hyperplasia after percutaneous transluminal angioplasty and stent implantation in peripheral vessels: 6 years of experience.

PURPOSE: Percutaneous transluminal angioplasty (PTA) with or without stent implantation is the accepted standard in the therapy of occlusive arterial disease. Despite improvements in the technique and medical equipment, there is still a restenosis rate of up to 40%. A high-dose-rate afterloading technique to avoid vascular stenosis or occlusion after PTA and subsequent stent implantation caused by intimal hyperplasia is presented with long-term results. METHODS AND MATERIALS: Intravascular brachytherapy with a 10-Ci 192Ir source was performed in cases of recurrent vascular occlusion or stenosis which appeared within 6 months after a previous PTA. After recanalization by PTA and stent implantation, a 9-Fr ReKa catheter was positioned within the stent to center the applicator with its tip 2 cm below the stent. This catheter served as a guide for a 5-Fr flexible applicator. After this procedure the isodose was calculated and a 12-Gy to 3-mm source distance was applied. The procedure was followed by 72 h of heparinization. RESULTS: From May 1990 to June 1996, 28 patients (21 male and seven female) were treated with endovascular brachytherapy. All patients had a clinically relevant restenosis or reocclusion of the arteria femoralis. Follow-up time ranged from 1 to 71 months. Twenty-eight patients had a sufficient follow-up time; 25 of these patients were examined. Twenty-one patients had treated vessel segments; four patients had no flow in the treated area. Two patients moved away with unknown addresses, and one patient died without any follow-up examination. Radiation-associated side effects were not notable. CONCLUSION: Intraluminal brachytherapy with 192Ir is a safe and useful procedure to avoid endovascular hyperplasia after transluminal percutaneous angioplasty.

Effect of aortic sclerosis on bone mineral measurements by dual-photon absorptiometry.

Measurements of the bone mineral content (BMC) of lumbar spine by dual-photon absorptiometry (DPA) are performed mainly in the anteroposterior (AP) projection. Due to superimposition of the abdominal aorta, the BMC measured for patients with aortic calcification usually is too high. To determine the influence of aortic calcifications, DPA scans were performed in the AP-projection on 100 dissected abdominal aortae with different degrees of atherosclerosis placed on a human lumbar spine cast in lucite. The measured values were compared with those obtained in the same projection without the aortae. The average increase of the BMC values relative to the mean for the vertebrae L2 to L4 for aortae with severe complicated lesions, i.e., those containing larger amounts of calcium, was 0.03 g/cm2, with a maximum deviation of 0.09 g/cm2. Aortae with fatty streaks or fibrous plaques did not cause significant increases of the BMC. The mean deviation for aortae with mild complicated lesions, i.e., those containing smaller amounts of calcium, was within the range of instrument precision.

Results of low speed rotational angioplasty for chronic peripheral occlusions.

After experimental investigation using postmortem human arteries, 19 patients with chronic peripheral artery occlusions were treated with a new angioplasty technique between December 1986 and October 1987. In 17 patients the superficial femoral artery and in 2 patients the popliteal artery were completely occluded. The length of the occlusions ranged between 5 and 25 cm (mean 11). The duration--estimated according to patients' history--was 5 to 48 months (mean 17). In 5 patients, durations of up to 30 months had been documented by angiography. A flexible, blunt, motor-driven rotating catheter was introduced through an 8 or 9Fr sheath and rotational angioplasty was performed at low speeds (up to 200 rpm). In 11 of 14 patients in whom this new technique was used as the primary intervention, the occlusions could be successfully reopened. In 2 patients after failure of conventional techniques the rotating catheter could not bypass the preexisting dissections in the same intervention. In 2 of 3 further patients after failure of conventional techniques the occlusions could be successfully reopened in a second intervention after several weeks. In none of the 19 patients did a perforation occur. It is concluded that with the new technique chronic peripheral artery occlusions can be reopened with a high success rate and without the danger of arterial wall perforation. The method can also be used in patients in whom conventional techniques have failed.

Lymphocyte reconstitution after allogeneic blood stem cell transplantation for hematologic malignancies.

Forty-one patients were studied at set times after allogeneic blood stem cell transplantation (alloBSCT) for recovery of lymphocyte numbers and function. Cells were mobilized with G-CSF from HLA-matched related donors and cryopreserved. Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporine and methotrexate; G-CSF was administered post-transplant. Median time to absolute lymphocyte count (ALC) >500/microl was 17 days vs 41 and 49 days in historical alloBMT patients with G-CSF (n = 23) or no cytokine (n = 29) post-transplant, respectively (P < 0.0001). CD4/CD8+ ratio was 1.9 on day 28 after alloBSCT, then gradually declined to 0.8 at 1 year due to more rapid CD8+ cell recovery. Mean phytohemagglutinin-induced T cell responses were lower than normal on day +28 (P < 0.05), then tended to recover towards normal values. Natural-killer cytotoxicity remained low from day +28 to 1 year post-alloBSCT, but considerable lymphokine-activated killer cytotoxicity was induced from cells already obtained on day +28. Faster lymphocyte recovery correlated with better survival in alloBSCT patients (median follow-up 287 days, P = 0.002), ALC recovery was not affected by acute GVHD, CMV infections or doses of infused cells. ALC recovery did not correlate with survival in either historical alloBMT group. These data suggest that after alloBSCT lymphocyte reconstitution is faster than after alloBMT, and that quicker lymphocyte recovery predicts better survival in the alloBSCT setting.

Outcome of allogeneic stem cell transplantation for B cell chronic lymphocytic leukemia.

The objective of this study was to describe the outcome of allogeneic stem cell transplantation (alloSCT) in a series of patients with B cell chronic lymphocytic leukemia (B-CLL). Twenty-three B-CLL patients were transplanted between 1988 and 1997 using stem cells from a related (n = 20) or an unrelated donor (n = 3). The median age of the patients was 46 years, and the median number of prior chemotherapy regimens received was two. At transplantation, 14 patients had chemorefractory disease and 12 of these were refractory to fludarabine. The preparative regimens included total body irradiation (TBI) in 22 of the 23 cases. All patients received graft-versus-host disease (GVHD) prophylaxis with cyclosporine and methotrexate. Twenty patients (87%) achieved a complete remission (CR). The incidence of grade II-IV acute GVHD was 54%. Fourteen (61%) patients are alive and disease-free, including two with unrelated donors, at a median of 26 months (range, 9-115 months). Nine patients (39%) have died, one of whom had progressive B-CLL. The only favorable prognostic factor for failure-free survival (FFS) and overall survival (OS) after alloSCT was the use of a cyclophosphamide/TBI rather than an etoposide/cyclophosphamide/TBI regimen (P = 0.03). The projected 5-year FFS, OS, and relapse rates after alloSCT were 65% (95% CI, 48-88%), 62% (95% CI, 43-88%), and 5% (95%, CI 0-13%), respectively. These findings demonstrate the potential of high-dose therapy and alloSCT for inducing and maintaining a remission in patients with advanced or chemorefractory B-CLL. The low relapse rate may be due to an allogeneic graft-versus-leukemia effect.

Pediatric clerkship experience and performance in the Nebraska Education Consortium: a community vs university comparison.

OBJECTIVE: To compare the reported experiences and performance on end-of-course examinations of students completing their pediatric clerkship at the University of Nebraska Medical Center (UNMC), Omaha, with that of students completing their clerkship in a community pediatrician's practice (CPP) outside the Omaha metropolitan area. DESIGN: Cohort study. SETTING: Private and/or institutional practices with both ambulatory and hospital components. PARTICIPANTS: For the academic year 1996-1997, all 113 students completing the 8-week third-year pediatric clerkship returned a questionnaire detailing their opinions of the experience. They also completed written (multiple-choice and essay questions) and oral (standardized parent interview) examinations, locally prepared and based on clerkship curriculum objectives provided to the students at orientation. Prior to student placement in the CPP, the clerkship goals, content, and evaluation methods as well as techniques for teaching in a busy office practice were reviewed with the CPP physicians. Eighty-one students performed their clerkship at UNMC while 31 spent all but the first week of the clerkship in the CPP. MAIN OUTCOME MEASURES: The students' opinions about their experiences and their performances on the end-of-course examinations were compared. Statistical analysis of the questionnaire was done using the Fisher exact test and the Mantel-Haenszel chi2 test while examination performance was compared using the t test and the Wilcoxon rank sum test. RESULTS: The UNMC and CPP groups reported similar opinions of their experiences in the newborn nursery and the inpatient portion of the clerkship, but the CPP students were much more positive about their learning experience in the clinic (P=.001). The CPP students reported more involvement in the patient's overall care (P<.001) and in other aspects of clinic operation (P<.001). The UNMC and CPP students had similar opinions of curriculum content, reading material, and didactic instruction. No group differences were found regarding interest in pediatrics as a career. Most importantly, no group differences were found in performance on any portion of the end-of-course examinations. CONCLUSIONS: Community-based education at the third-year clerkship level can be accomplished without a significant effect on student examination performance if students and faculty are aware of and adhere to a common set of goals. The end result is a much more robust experience for students who spend the clerkship in the practice of a community-based pediatrician.

Hypervascular spinal tumors: influence of the embolization technique on perioperative hemorrhage.

BACKGROUND AND PURPOSE: Corporectomy is an effective treatment for vertebral metastases; however, massive perioperative hemorrhage is often associated with this procedure. We compared preoperative particle, particle-coil, and coil embolizations of hypervascular spinal tumors prior to vertebral body replacement to determine which prevented perioperative hemorrhage most effectively. METHODS: The vertebral tumors of 59 patients were embolized prior to corporectomy. In 26 cases, only coils were used for the proximal occlusion of feeding segmental arteries. Twenty-four patients received a combination of polyvinyl alcohol (PVA) particles and coils, and nine tumors were embolized with particles alone. We compared intraoperative blood loss between the three groups and 10 other patients who did not undergo embolization prior to corporectomy. RESULTS: Estimation of intraoperative hemorrhage showed a median value of 4350 mL in patients without embolization, 2650 mL in cases of coil embolization, 1850 mL in cases of particle-coil embolization, and 1800 mL in cases of particle embolization. The difference between unembolized patients and those who underwent coil embolization was not statistically significant. Particle and particle-coil embolizations showed very similar results, and reduced hemorrhage significantly as compared to unembolized and proximal coil occlusion cases. Residual bleeding came from the venous system and the neighborhood of the embolized region. CONCLUSION: Particle embolization prior to corporectomy can reduce perioperative hemorrhage. The additional benefit of proximal coil occlusion of arterial feeders is questionable.

[Quality assurance measures within DIN 6856: the adaptation of film viewing boxes and their specifications in the radiology department of a university hospital. Deutsche Industrie-Norm]. / Qualitätssicherungsmassnahmen im Rahmen der DIN 6856: Anpassung der Filmbetrachtungsgeräte und -bedingungen der Röntgenabteilung einer Universitätsklinik.

PURPOSE: The aim of our study was to examine the quality and consistency of film viewing equipment and surroundings for radiological film viewing as stipulated by the recently released DIN 6856 standard specifications sheet. METHODS: 107 film viewers in 43 locations in the Department of General Radiology (Hospital of the Goethe University in Frankfurt, Germany) were examined with regard to viewer brightness (intrinsic luminous intensity) uniformity of viewbox brightness, colour of fluorescence tubes, dimensions, adjustable filters, positioning of the viewers and ambient light level. RESULTS: Requirements regarding brightness were met in 70%, whereas conditions regarding uniformity of brightness were fulfilled in only 27% and the required filters in only 20% of all cases. CONCLUSIONS: 89% of the examined film viewboxes did not comply with the strict specifications laid down in DIN 6856. The requirements regarding the ambient light level (recommended range 50-100 lx) were met by only 75% of the examined desks.

[Diagnosis of aortic rupture using digital subtraction angiography]. / Die Diagnose der Aortenruptur durch digitale Subtraktionsangiographie (DSA).

The typical signs of the rupture of the thoracic aorta in the chest radiographs of patients with this injury are shown. Because all these signs lack specificity only angiography was diagnostic till now. Digital subtraction angiography (dsa) as a new diagnostic procedure can replace invasive angiography. In four cases the rupture of the aorta was clearly diagnosed by means of digital subtraction angiography. In three additional cases it could be definitely excluded.

[Percutaneous extraction of gallstones by T-drainage (author's transl)]. / Perkutane Extraktion von Gallensteinen durch die T-Drainage.

Experience gained from the percutaneous extraction of biliary stones from 12 patients is reported. On three occasions the concrements could not be completely removed. A Zeiss sling proved more successful than a Dormia basket; with this it is not always necessary to use the guidable catheter. Conditions necessary for success are adequate thickness of the T-tube, and adequate time for the drainage (about three weeks) to permit the development of a track suitable for catheterisation. The method is so simple that it is recommended before an attempt is made to perform endoscopic extraction and papillotomy.

[Changes in the lungs and pleura following chemoembolization of liver tumors with mitomycin-lipiodol]. / Veränderungen der Lunge und Pleura nach Chemoembolisation von Lebertumoren mit Mitomycin-Lipiodol.

The authors performed 68 liver embolizations in 51 patients. As selectively as possible, Lipiodol, to block the capillary bed, and a chemotherapeutic agent were injected into the liver tumors. A CT performed 24 hours after treatment showed the distribution of the contrast medium which is also an indicator of the distribution of the chemotherapeutic agents. It was found that the contrast medium had accumulated not only in the liver but also in the lungs. Here, four different degrees of accumulation were found, according to the amount of Lipiodol used. Embolization of the liver thus involves potential hazards for the lungs, such as microembolisms, pneumonia, and toxic effects of the chemotherapeutic agents.

[Contrast medium concentration for intra-arterial digital subtraction angiography of vessels in the extremities]. / Kontrastmittelkonzentration zur intraarteriellen digitalen Subtraktionsangiographie der Extremitätengefässe.

The influence of iodine concentrations and different volumes of a conventional ionic contrast media and a contrast media with low osmolarity on the quality of the results of intra-arterial digital subtraction angiography of the lower extremities in patients who underwent percutaneous transluminal angioplasty (n = 52) are reported. According to our results, intra-arterial injections of a conventional ionic contrast medium diluted with 0.9% sodium chloride solution, resulting in an iodine concentration of 190 mg/ml injectable solution, reveals the best results when injected in an amount of 6 ml per injection. The use of low-osmolarity contrast-medium showed no advantages, the quality of the resulting pictures was inferior to that revealed with the ionic compound. Probably this is because the iodine concentration in the diluted low-osmolarity compound was less.

[The computed tomographic determination of intra-abdominal fat volume by single-layer measurement]. / Computertomographische Bestimmung des intraabdominellen Fettvolumens mittels Einschicht-Messung.

PURPOSE: Several studies emphasised the importance of the relationship between intra-abdominal and total body adipose tissue as a risk factor for the development of metabolic or cardiovascular diseases. Therefore, the aim of the present study was to examine whether a single-scan computed tomography is able to determine the whole intra-abdominal fat volume with high accuracy and reproducibility. MATERIALS AND METHODS: Regions of interests (ROIs) were drawn manually for measuring intra-abdominal fat in 51 unsuspicious abdominal CT. RESULTS: The sexual differentiation of adipose tissue already described in a lot of studies could be confirmed in this study. Fat still predominates in females in lower half of the body (gynecoid obesity). In men it predominates in the upper half (android obesity). Significant correlation concerning measuring the whole intra-abdominal fat volume could be found in L1-level in women (r = 0.992) and in L2-level in men (r = 0.992). Measurement of a single scan enables us to assess whole intra-abdominal fat volume due to a special formula. CONCLUSION: The determination of intra-abdominal fat measured by a single-scan computed tomography is a procedure associated with high accuracy and reproducibility.

[Determination of global and regional ventricular ejection fraction by a fully digitalized technic. Results of digital subtraction angiocardiography following peripheral venous contrast injection compared to cineventriculography, 2-dimensional echocardiography and radionuclide ventriculography]. / Bestimmung der globalen und regionalen Auswurffraktion des linken Ventrikels in volldigitalisierter Technik. Ergebnisse der digitalen Subtraktionsangiokardiographie (DSAK) nach periphervenöser Röntgenkontrastmittelinjektion im Vergleich zur Kineventrikulographie, Zweidimensionaler Echokardiographie und Radionuklidventrikulographie.

Subtraction angiocardiography (DSAK) with a fully digitalised system (DR 960) provides a well defined demonstration of the left ventricle after peripheral venous contrast injection. Cardiac volume and ejection fractions were calculated by a dedicated software programme and the findings correlated with cine ventriculography (CA) (r = 0.91), biplane echo cardiography (2 DE) (r = 0.77) and radionucleid ventriculography (RNV) (r = 0.85); the method can be used even with reduced cardiac output (EF less than or equal to 15%). Densitometric measurements of the EF on phantoms correspond with morphometric findings, but its clinical application is at present not possible because of the frequent appearance of artefacts. Analysis of regional disturbances of ventricular wall movements shows very good correlation between DSAK and CA and these appear more accurate than 2 DE. DSAK is a valuable, rapid and reproducible method with few side effects for cardiological diagnosis.

[Rotational angioplasty--recanalization of chronic arterial occlusion using a slowly rotating catheter. Clinical results with 100 patients]. / Rotationsangioplastik--Wiedereröffnung chronischer Arterienverschlüsse mit einem langsam rotierenden Katheter. Klinische Ergebnisse bei 100 Patienten.

Between December 1986 and January 1989, 100 patients with chronic occlusions of peripheral arteries were treated with the new technique of low speed rotational angioplasty. This uses a relatively thick, flexible and blunt catheter, which is driven by an electric motor (100 to 200 r.p.m.). The success rate in the superficial femoral and popliteal arteries of the initial intervention for occlusions less than 10 cm was 90%, for occlusions of less than 10 cm, it was 80%. Occlusions on which conventional techniques had failed were successfully recanalized in 65%. Recanalisation was also successful in seven out of 12 patients with occluded iliac arteries. There were no perforations or other serious complications. It is concluded that the new method is particularly effective and safe for recanalisation of chronic vascular occlusions and should also be considered for cases which previously could only be treated surgically.

[Thrombosis of the inferior vena cava in Behçet disease]. / Thrombose der Vena cava inferior bei Morbus Behçet.

Behçet's disease is considered to be a systemic process caused by a nonspecific vasculitis with a diversity of symptoms. It is defined by the coexistence of aphthous stomatitis, genital ulcerations, inflammatory conditions of the eye such as iritis and dermatological changes. Cardiovascular involvement includes both arteries and veins. We report an unusual case of thrombosis of the inferior vena cava with extensive collateral circulation of the superficial abdominal and paravertebral veins due to Behçet's disease diagnosed by phlebography and magnetic resonance imaging.