[HPV-associated oropharyngeal carcinoma. Status quo and relationship with cancer of unknown primary]. / HPV-assoziierte oropharyngeale Karzinome. Aktueller Stand und Verhältnis zum Karzinom unbekannter Herkunft.

Carcinomas of the oropharynx with association to high-risk types of human papillomavirus (HPV) have been identified as a new tumour entity with favourable prognosis, distinct from classical nicotine- and alcohol-associated carcinoma. They develop through oncogenic transformation of the basal cells of reticulated cryptal epithelium of the palatinal tonsils and the base of the tongue. Positivity for HPV strongly correlates with an atypical, non-keratinizing histological differentiation and cystic transformation of lymph node metastases. Strong immunohistological positivity for p16 reliably detects transcriptionally active infection with high-risk HPV. Hence, p16 staining has been regarded as an effectual diagnostic tool in the appropriate setting. Frequent nodal metastasation as well as considerable size of (cystic) metastases, and frequent small size as well as submucosal location of primary tumours all contribute to frequent initial manifestation of cervical cancer of unknown primary (CUP). In a situation of CUP diagnostic testing for HPV (in negative cases in addition to EBV) is recommended in lymph node metastases, due to the high predictive value for the localization of occult primary carcinomas. Intense clinicopathological cooperation is mandatory for improved detection of small, occult primary carcinomas. The relevance of this new carcinoma entity will increase, as the incidence continues to increase worldwide.

[Ultrasound-guided image fusion with computed tomography and magnetic resonance imaging. Clinical utility for imaging and interventional diagnostics of hepatic lesions]. / Ultraschallgestützte Bildfusion mittels CT und MRT. Klinische Bedeutung für die bildgebende und interventionelle Diagnostik von Leberläsionen.

Abdominal ultrasound is often the first-line imaging modality for assessing focal liver lesions. Due to various new ultrasound techniques, such as image fusion, global positioning system (GPS) tracking and needle tracking guided biopsy, abdominal ultrasound now has great potential regarding detection, characterization and treatment of focal liver lesions. Furthermore, these new techniques will help to improve the clinical management of patients before and during interventional procedures. This article presents the principle and clinical impact of recently developed techniques in the field of ultrasound, e.g. image fusion, GPS tracking and needle tracking guided biopsy and discusses the results based on a feasibility study on 20 patients with focal hepatic lesions.

[Management of salivary gland diseases with contrast-enhanced ultrasound]. / Management von Speichel-drüsenerkrankungen mittels Kontrastmittelapplikation.

Obstructive diseases of the salivary glands are a common problem in otorhinolaryngology. They are mostly due to sialolithiasis followed by duct stenosis and other rarer causes. Several diagnostic modalities exist which allow classification of the disease; however, in 5-10% of all cases ultrasound and conventional radiological imaging do not provide a clear diagnosis. Ultrasound examination with contrast material injected into the duct (IA-CEUS, intraductal administered contrast-enhanced ultrasound) enables improved evaluation of obstructive diseases of the salivary glands and at the same time an evaluation of the parenchyma of the glands is possible. As a complementary method to conventional investigation techniques IA-CEUS is an economic and rapid method with low side-effects which improves the diagnostic assessment of ultrasound and results in a better treatment for patients.

[Contrast-enhanced ultrasound in animal models]. / Kontrastverstärkter Ultraschall der Skelettmuskulatur.

In the past the detection of tumor perfusion was achieved solely via invasive procedures, such as intravital microscopy or with the help of costly modalities, such as multidetector computed tomography (MDCT), magnetic resonance tomography (MRT) or the combined use of positron emission tomography and computed tomography (PET/CT). Ultrasound offers the non-invasive display of organs without usage of ionizing radiation and it is widely available. However, colour-coded ultrasound and power Doppler do not allow the detection of tumor microcirculation. The introduction of contrast-enhanced ultrasound (CEUS) as well as new high-frequency ultrasound probes made it possible to detect and quantify tumor microcirculation with high resolution. CEUS has been used clinically on human beings for more than 10 years. During the last years different tumor models in experimental animals were used for the establishment of this new technique, e.g. in rats, hamsters and mice. CEUS allows the detection of functional parameters, such as the angiogenetic metabolic status of tissue pretreatment and posttreatment. Further research is required to solve the problems of absolute quantification of these perfusion parameters to allow the comparison of CEUS with other modalities (e.g. MRT and CT).

[Sonographic analyses of obstructive diseases of the salivary gland using intraductal applications of contrast agent]. / Sonografische Analyse von obstruktiven Speicheldrüsenerkrankungen mittels intraduktaler Kontrastmittelapplikation.

Obstructive diseases of the salivary glands are a common problem of the salivary glands; often based on Sialolithiasis, duct stenosis, or other rarer reasons. There exist several diagnostic features to classify the disease; however, ultrasound or conventional radiological imaging does not provide a diagnosis in 5-10% of all cases. The intraductal applied contrast-enhanced ultrasound (IA-CEUS) improves the visualization of obstructive diseases of the salivary glands; simultaneously an evaluation of the parenchyma of the glands is possible. We think IA-CEUS is a promising tool, which improved the diagnostic assessment capabilities of ultrasound and results in a better treatment for patients with obstructive salivary gland diseases.

[Secondary high-malignant transformation of a low-malignant epithelial-myoepithelial carcinoma]. / Sekundäre hochmaligne Transformation eines niedrigmalignen epithelial-myoepithelialen Karzinoms.

The rare entity of epithelial-myoepithelial carcinoma (EMC) belongs to a group of tumors with a biphasic ductular growth pattern, mostly with a dominating myoepithelial component and low-grade malignancy. We report on the rare constellation of a primary low-malignant EMC with high malignant transformation (so-called dedifferentiation) into a highly malignant myoepithelial carcinoma. In the eight published cases so far, the high-malignant component was reported to be either adenocarcinoma or undifferentiated carcinoma or was otherwise not specified. To the best of our knowledge, this is the first case report of a high-grade myoepithelial carcinoma transforming from a low-grade EMC. We discuss interesting parallels to the pathogenesis of secondary transformation of carcinoma ex pleomorphic adenoma.

[Pleomorphic adenoma: pitfalls and clinicopathological forms of progression]. / Das pleomorphe Adenom: Pitfalls in der Diagnostik und klinisch-pathologische Progressionsformen.

In the majority of cases the diagnosis of pleomorphic adenoma (PA) is straightforward. In "monomorphic" types of PA problems may result: Epithelial-rich PA need to be distinguished from basal cell adenoma or canalicular adenoma. PA dominated by mesenchymal, spindle-shaped differentiation need to be distinguished from myoepithelioma or soft tissue tumours like schwannoma. Focal biphasic-tubular differentiation with CK7/18-positive ductal cells is good evidence for a tumour within the wide spectrum of PA. Focal peripheral pseudoinfiltration can represent physiological growth pattern of PA; this may render a difficult distinction from low-malignant carcinomas like adenoid-cystic or epithelial-myoepithelial carcinoma, harbouring also tubular structures. The different progression steps of carcinoma ex pleomorphic adenoma (CEPA), starting with intraductal carcinoma, are highly relevant with respect to prognosis and therapy. Early stages including CEPA with minor extracapsular invasion show favourable prognosis, while cases with extensive extracapsular invasion carry a dismal prognosis.

[An unusual case of carotid arrosion bleeding]. / Ein ungewöhnlicher Fall einer Karotisarrosionsblutung.

Carotid bleeding is one of the most severe complications in ear, nose and throat (ENT) surgery. It is a rare complication in patients with cancer of the head and neck after radiochemotherapy. We report the case of a 65-year-old man who suffered from cancer of the tonsils (pT2pN1M0) and was treated in 1987 with surgery and local chemotherapy. Since then he reported recurrent bleeding in the left cervical region especially during physical exertion. The patient was re-operated and during surgery the tip of a catheter was found in the external carotid artery, obviously a remnant from a catheter for intra-arterial chemotherapy. The tip was removed, the defect closed and covered with a pectoralis major muscle flap.

Contrast-enhanced ultrasound (CEUS) and gallbladder diseases - A retrospective mono-center analysis of imaging findings with histopathological correlation.

BACKGROUND: Radiologic imaging, especially ultrasound has an important role in the assessment of gallbladder alteration. Contrast-enhanced ultrasound (CEUS) is an easy and fast imaging technique that overcomes the limitations of greyscale ultrasonography. It is a safe tool that can be used as an additional imaging modality in order to elucidate and differentiate gallbladder pathological findings. OBJECTIVE: The aim of this retrospective study analysis is to assess the diagnostic performance of CEUS in gallbladder alterations and compare the results to the histopathological findings. METHODS: A total of 17 patients between 2009 and 2017 with uncertain gallbladder appearance were retrospectively analysed. A single experienced physician with more than fifteen years' experience performed CEUS examinations by applying a second-generation blood pool agent (SonoVue®, Bracco, Milan, Italy). Archived images were interpreted by the same physician and compared to the histopathological findings. RESULTS: CEUS results, when correlated to the respectively pathologic findings, presented a sensitivity of 100%, a specificity of 100%, a positive predictive value (PPV) of 100% and a negative predictive value (NPV) of 100%. All patients were successfully examined without any adverse reaction. CONCLUSION: In conclusion, the excellent results in this study acknowledged that CEUS is a feasible alternative tool to differentiate gallbladder pathologic alterations.

[Demonstration of angiogenesis and the effect on an antiangiogenetic therapy with 99mTc labeled erythrocytes]. / Darstellung der Angiogenese und der Effekte einer antiangiogenetischen Therapie mit 99mTc-markierten Erythrozyten.

AIM: To evaluate, whether scintigraphic studies with radiolabeled erythrocytes may be used to demonstrate the formation of new vessels during angiogenesis and if an effect on antiangiogenetic therapy could be detected. METHODS: As an angiogenesis model we used the ingrowth of blood vessels in matrigel, subcutaneously injected into mice. In order to measure the relative blood volume in the matrigel non-invasively, mouse erythrocytes were labeled with Technetium-99m DTPA. The amount of activity in the matrigel was measured 30 minutes after injection of the radiolabeled erythrocytes with a gammacamera (in-vivo) and a gammacounter (ex-vivo). These results were correlated with the concentration of hemoglobin in the matrigel and the immunhistochemically evaluated density of blood vessels. The influence of the angiogenesis stimulating growth factor (bFGF) and the antiangiogenetic effect of the cyclooxigenase type 2 inhibitor (COX-2) NS398 were tested. RESULTS: There was a close correlation between the activity concentration in the matrigel and the hemoglobin content. Treatment with bFGF significantly increased the activity concentration from 1.74% +/- ID/g to 4.06% +/- 0.36 (p < 0.01), whereas treatment with NS398 significantly inhibited tracer uptake from 2.83% ID/g +/- 0.33 to 0.87% ID/g +/- 0.12 (p < 0.01). CONCLUSION: These results demonstrate the feasibility of using (99m)Tc labelled erythrocytes for scintigraphic imaging to assess the effects of angiogenesis stimulating and inhibiting interventions non-invasively.

[Impaired wound healing following tonsillectomy]. / Wundheilungsstörung nach Tonsillektomie.

Tonsillectomy is one of the most commonly performed surgical procedures in the field of otorhinolaryngology. The first tonsillectomy was done about 600 B.C. [3]. This operation is indicated for patients with recurrent tonsillitis, peritonsillar abscess, hypertrophy or asymmetry of the tonsils. Even though a routine procedure, it has a relatively high risk of complications such as post operative hemorrhage, infection or impaired wound healing. The reported case involves a 20 year old female patient who developed velopharyngeal insufficiency as a result of impaired wound healing after tonsillectomy. The patient was treated conservatively and is free of discomfort after 2 months.

Diagnostic performance of contrast-enhanced ultrasound (CEUS) for the evaluation of gallbladder diseases1.

BACKGROUND: Contrast-enhanced ultrasound (CEUS) has been used as an additional imaging technique to conventional ultrasound in order to clarify gallbladder findings, CEUS is easy and fast to perform, overcomes the limitations of gray-scale ultrasonography and is a safe tool. OBJECTIVE: The aim of this retrospective mono-center analysis study is to evaluate the diagnostic performance of CEUS in the assessment of gallbladder disease by comparing its results with additional CT findings. METHODS: A total of 24 patients between 2009 and 2017 with unclear gallbladder appearance were retrospectively analysed. The contrast agent administered was a second-generation blood pool agent (SonoVue®, Bracco, Milan, Italy). Examinations were performed and interpreted by a single experienced radiologist with more than fifteen years' experience. RESULTS: 24 patients were successfully examined without any adverse reaction. CEUS presented a sensitivity of 75%, a specificity of 100.0%, a positive predictive value of 100.0% and a negative predictive value of 95%. CONCLUSIONS: In conclusion, the excellent results in this study acknowledged that CEUS is a feasible alternative tool to differentiate gallbladder pathologic alterations.

[Isolated apical petrositis: an atypical case of Gradenigo's syndrome]. / Isolierte apikale Petrositis: Ein atypisches Gradenigo-Syndrom.

In 1904 Guiseppe Gradenigo described an infection of the apex of the petrous part of the temporal bone from acute otitis media with the clinical symptoms of unilateral pain around the eye, diplopia due to sixth nerve paralysis and persistant otorrhea. While this infection became evident by inward extension from petrositis in the majority of fatal cases from acute otitis media in the preantibiotic era, it has now become very rare. Today, cases mainly derive from cholesteatomas or chronic osteomyelitis of the petrous bone. However, due to intense antibiotic treatment in acute otitis media clinical signs of petrositis may be less typical compared to former times. We report on a 12-year-old boy with rapid onset of sixth nerve paralysis without clinical signs of acute otitis media or mastoiditis. CT and NMR imaging confirmed infection of the petrous apex. He was treated by mastoidectomy with exploration of a posterior cell group from the epitympanon around the semicircular canals and subsequent high dose intravenous antibiotics. The patient recovered without any loss of inner ear or facial nerve function. The paralysis of the sixth nerve disappeared completely within 6 weeks.

Preoperative Embolization to Improve the Surgical Management and Outcome of Juvenile Nasopharyngeal Angiofibroma (JNA) in a Single Center: 10-Year Experience.

PURPOSE: Juvenile nasopharyngeal angiofibroma (JNA) is a rare benign neoplasm that occurs almost exclusively in the nasopharynx of adolescent male individuals. METHODS: We performed a retrospective study to determine the efficacy and safety of preoperative embolization and the surgical outcome in patients with JNA in a single-center institution. Fifteen cases undergoing embolization and surgical treatment between April 2003 and February 2013 were evaluated retrospectively. The demographic data, clinical presentation, and treatment were reviewed including the kind of preoperative embolization and different surgical approaches performed. The parameters investigated were the amount of blood loss, the tumor stage, and the rates of recurrence. Subsequently, a comparison was made between patients who had undergone Onyx® embolization versus those who had been embolized with the standard approach. RESULTS: In these 15 patients (mean age, 15 years), a total of 27 surgical procedures were performed. One patient was at stage Ia, two were at stage Ib, two were at stage IIa, six were at stage IIb, one was at stage IIc, and three were at stage IIIa based on the Radkowsky classification. All patients underwent preoperative embolization and subsequent surgery. The surgical approach and the embolization technique varied and evolved during time. The embolization procedure decreased the intraoperative blood loss to a minimum of 250 ml, and with the advent of intratumoral embolization, the rate of recurrence diminished. CONCLUSION: Preoperative Onyx® embolization facilitates the shift in the treatment to endoscopic excision in selected patients, which reduces recurrence rates and overall morbidity.

Evaluation of multimodality imaging using image fusion with MRI and CEUS in an experimental animal model.

PURPOSE: To evaluate the diagnostic benefits of multimodality imaging using image fusion with magnetic-resonance-imaging (MRI) and contrast-enhanced-ultrasound (CEUS) in an experimental small-animal-squamous-cell-carcinoma-model for the assessment of tissue hemodynamics and morphology. MATERIAL AND METHODS: Human hypopharynx-carcinoma-cells were injected subcutaneously into the left flank of 15 female athymic nude rats. After 10 daysof subcutaneous tumor growth, CEUS and MRI measurements were performed using a high-end-ultrasound-system and 3-T-MRI. After successful point-to-point or plan registration, the registered MR-images were simultaneously shown with the respective ultrasound sectional plane. Data evaluation was performed using the digitally stored video sequence data sets by two experienced radiologists using a subjective 5-point scale. RESULTS: CEUS and MRI are well-known techniques for the assessment of tissue hemodynamics (score: mean 3.8 ± 0.4 SD and score 3.8 ± 0.4 SD). Real-time image fusion of MRI and CEUS yielded a significant (p <  0.001) improvement in score (score 4.8 ± 0.4 SD). Reliable detection of small necrotic areas was possible in all animals with necrotic tumors. No significant intraobserver and interobserver variability was detected (kappa coefficient = +1). CONCLUSION: Image fusion of MRI and CEUS gives a significant improvement for reliable differentiation between different tumor tissue areas and simplifies investigations by showing the morphology as well as surrounding macro-/microvascularization.

Evaluation of multimodality imaging using image fusion with ultrasound tissue elasticity imaging in an experimental animal model.

PURPOSE: To evaluate the ultrasound tissue elasticity imaging by comparison to multimodality imaging using image fusion with Magnetic Resonance Imaging (MRI) and conventional grey scale imaging with additional elasticity-ultrasound in an experimental small-animal-squamous-cell carcinoma-model for the assessment of tissue morphology. METHOD AND MATERIALS: Human hypopharynx carcinoma cells were subcutaneously injected into the left flank of 12 female athymic nude rats. After 10 days (SD ± 2) of subcutaneous tumor growth, sonographic grey scale including elasticity imaging and MRI measurements were performed using a high-end ultrasound system and a 3T MR. For image fusion the contrast-enhanced MRI DICOM data set was uploaded in the ultrasonic device which has a magnetic field generator, a linear array transducer (6-15 MHz) and a dedicated software package (GE Logic E9), that can detect transducers by means of a positioning system. Conventional grey scale and elasticity imaging were integrated in the image fusion examination. After successful registration and image fusion the registered MR-images were simultaneously shown with the respective ultrasound sectional plane. Data evaluation was performed using the digitally stored video sequence data sets by two experienced radiologist using a modified Tsukuba Elasticity score. The colors "red and green" are assigned for an area of soft tissue, "blue" indicates hard tissue. RESULTS: In all cases a successful image fusion and plan registration with MRI and ultrasound imaging including grey scale and elasticity imaging was possible. The mean tumor volume based on caliper measurements in 3 dimensions was ~323 mm3. 4/12 rats were evaluated with Score I, 5/12 rates were evaluated with Score II, 3/12 rates were evaluated with Score III. There was a close correlation in the fused MRI with existing small necrosis in the tumor. None of the scored II or III lesions was visible by conventional grey scale. CONCLUSION: The comparison of ultrasound tissue elasticity imaging enables a secure differentiation between different tumor tissue areas in comparison to image fusion with MRI in our small study group. Therefore ultrasound tissue elasticity imaging might be used for fast detection of tumor response in the future whereas conventional grey scale imaging alone could not provide the additional information. By using standard, contrast-enhanced MRI images for reliable and reproducible slice positioning, the strongly user-dependent limitation of ultrasound tissue elasticity imaging may be overcome, especially for a comparison between baseline and follow-up measurements.