Treatment of supraglottic squamous cell carcinoma with advanced technologies: observational prospective evaluation of oncological outcomes, functional outcomes, quality of life and cost-effectiveness (SUPRA-QoL).

BACKGROUND: Over the past decade, therapeutic options in head and neck supraglottic squamous cell carcinoma have constantly evolved. The classical total laryngectomy has been partially replaced by alternative organ- and function-sparing techniques with the same prognosis but less morbidity, such as Radiotherapy, Transoral Laser Microsurgery (TLM) and Trans-Oral Robotic Surgery (TORS). Up to now, a prospective comparison of these innovant techniques has not been conducted. METHODS/DESIGN: We will conduct an original international multicentric prospective nonrandomized clinical trial to compare the efficacy between these treatments (Arm 1: Radiotherapy ± chemotherapy; Arm 2: TLM and Arm 3: TORS) with 4 classes of outcomes: quality of life (QoL), oncological outcomes, functional outcomes and economic resources. The population will include cT1-T2 /cN0-N1/M0 supraglottic squamous cell carcinoma. The primary outcome is a Clinical Dysphagia QoL evaluation assessed by the MD Anderson Dysphagia questionnaire. Secondary outcomes include others QoL evaluation, oncological and functional measures and cost parameters. The sample size needs to reach 36 patients per arm (total 108). DISCUSSION: In the current literature, no prospective head-to-head trials are available to compare objectively these different treatments. With the increase of highly efficient treatments and the increase of oncological survival, it is imperative also to develop management strategies that optimize QoL and functional results. We will conduct this innovate prospective trial in order to obtain objective data in these two main issues. TRIAL REGISTRATION: NCT05611515 posted on 10/11/2022 (clinicaltrial.fgov).

Extended induction chemotherapy does not improve the outcome for high-risk neuroblastoma patients: results of the randomized open-label GPOH trial NB2004-HR.

BACKGROUND: Long-term survival of high-risk neuroblastoma patients is still below 50% despite intensive multimodal treatment. This trial aimed to address whether the addition of two topotecan-containing chemotherapy courses compared to standard induction therapy improves event-free survival (EFS) of these patients. PATIENTS AND METHODS: An open-label, multicenter, prospective randomized controlled trial was carried out at 58 hospitals in Germany and Switzerland. Patients aged 1-21 years with stage 4 neuroblastoma and patients aged 6 months to 21 years with MYCN-amplified tumors were eligible. The primary endpoint was EFS. Patients were randomly assigned to standard induction therapy with six chemotherapy courses or to experimental induction chemotherapy starting with two additional courses of topotecan, cyclophosphamide, and etoposide followed by standard induction chemotherapy (eight courses in total). After induction chemotherapy, all patients received high-dose chemotherapy with autologous hematopoietic stem cell rescue and isotretinoin for consolidation. Radiotherapy was applied to patients with active tumors at the end of induction chemotherapy. RESULTS: Of 536 patients enrolled in the trial, 422 were randomly assigned to the control arm (n = 211) and the experimental arm (n = 211); the median follow-up time was 3.32 years (interquartile range 1.65-5.92). At data lock, the 3-year EFS of experimental and control patients was 34% and 32% [95% confidence Interval (CI) 28% to 40% and 26% to 38%; P = 0.258], respectively. Similarly, the 3-year overall survival of the patients did not differ [54% and 48% (95% CI 46% to 62% and 40% to 56%), respectively; P = 0.558]. The response to induction chemotherapy was not different between the arms. The median number of non-fatal toxicities per patient was higher in the experimental group while the median number of toxicities per chemotherapy course was not different. CONCLUSION: While the burden for the patients was increased by prolonging the induction chemotherapy and the toxicity, the addition of two topotecan-containing chemotherapy courses did not improve the EFS of high-risk neuroblastoma patients and thus cannot be recommended. CLINICAL TRIALS. GOV NUMBER: NCT number 03042429.

Improvements of diagnostic accuracy and visualization of vertebral metastasis using multi-level virtual non-calcium reconstructions from dual-layer spectral detector computed tomography.

OBJECTIVE: To evaluate feasibility and diagnostic performance of multi-level calcium suppression in spectral detector computed tomography (SDCT) for assessment of bone metastasis. MATERIALS AND METHODS: Retrospective IRB-approved study on 21 patients who underwent SDCT (120 kV, reference mAs 116) and MRI. Thoracic and lumbar vertebrae (n = 357) were included and categorized as normal (n = 133) or metastatic (n = 203) based on MRI (STIR, T1w, ±contrast). The multi-level virtual non-calcium (VNCa) algorithm computes dynamic soft tissue/calcium pairs allowing for computation of different suppression index levels to address inter-individual variance of prevalent calcium composition weights. We computed images with low, medium, and high calcium suppression indices and compared them with conventional images (VNCa_low/med/high and conventional images (CI)). For quantitative image analysis, regions of interest were placed in normal and metastatic bone. Two readers reviewed the datasets independently in multiple sessions. They determined the presence of vertebral metastases on a per vertebra basis using a binary scale. Statistic assessment was performed using ANOVA with Tukey HSD, Student's T test, and ROC analysis. RESULTS: Attenuation of both normal and metastatic bone was lower in VNCa images than that in conventional images (e.g., CI/VNCa_low, - 46.3 to 238.8 HU/343.3-60.2 HU; p ≤ 0.05). VNCa_low+med improved separation of normal and metastatic bone in ROC analysis (AUC, CI/VNCa_low/VNCa_med = 0.74/0.95/0.98; p ≤ 0.05). In subjective analysis, both sensitivity and specificity were clearly improved in VNCa_low as compared with CI (0.85/0.84 versus 0.78/0.82). Readers showed a good inter-rater reliability (kappa = 0.65). CONCLUSIONS: Multi-level VNCa reconstructed from SDCT improve quantitative separation of normal and metastatic bone and subjective determination of bone metastases when using low to intermediate calcium suppression indices. KEY POINTS: • Spectral detector CT allows for multi-level calcium suppression in CT images and low and medium calcium suppression indices improved separation of normal and metastatic bone. • Thus, multi-level calcium suppression allows to optimize image contrast in regard to dedicated pathologies. • Low-level virtual non-calcium images (index 25-50) improved diagnostic performance regarding detection of metastasis.

Effects of early contrast-enhanced computed tomography on clinical course and complications in patients with acute pancreatitis.

PURPOSE: To investigate the effect of an early contrast-enhanced computed tomography (CECT) on clinical course and complications of acute pancreatitis (AP). MATERIAL AND METHODS: 58 patients with AP who had at least one CECT examination were analyzed retrospectively. Laboratory as well as clinical data, and results from the assessment of disease severity (CT severity index (CTSI) and its modified (MCTSI) version) were analyzed. The primary endpoint was the development of severe complications, defined as death, respiratory failure, acute renal failure, and the need for invasive interventions. Patients were divided into two groups: an early group (CECT within the first 48 h after the onset of symptoms, n = 32) and a late group (CECT > 48 h after the onset of symptoms, n = 26). Multivariate regression analysis was performed to identify risk factors for severe complications. RESULTS: There were no statistically significant differences between both groups concerning baseline characteristics, CTSI, and MCTSI. Complications occurred more often in the early CECT group (p = 0.008). Multivariate logistic regression analysis identified an early CECT and a severe MCTSI as independent risk factors for the occurrence of severe complications (p = 0.02 and p = 0.002, respectively). CONCLUSION: CECT performed within the first 48 h after the onset of symptoms is associated with an unfavorable outcome in AP.

Efficacy and safety of enzyme replacement therapy with alglucosidase alfa for the treatment of patients with infantile-onset Pompe disease: a systematic review and metanalysis.

Introduction: Pompe disease (PD) is a glycogen disorder caused by the deficient activity of acid alpha-glucosidase (GAA). We sought to review the latest available evidence on the safety and efficacy of recombinant human GAA enzyme replacement therapy (ERT) for infantile-onset PD (IOPD). Methods: We systematically searched the MEDLINE (via PubMed) and Embase databases for prospective clinical studies evaluating ERT for IOPD on pre-specified outcomes. Meta-analysis was also performed. Results: Of 1,722 articles identified, 16 were included, evaluating 316 patients. Studies were heterogeneous and with very low certainty of evidence for most outcomes. A moderate/high risk of bias was present for most included articles. The following outcomes showed improvements associated with alglucosidase alfa, over natural history of PD/placebo, for a mean follow-up of 48.3 months: left ventricular (LV) mass {mean change 131.3 g/m2 [95% confidence interval (CI) 81.02, 181.59]}, time to start ventilation (TSV) [HR 0.21 (95% CI: 0.12, 0.36)], and survival [HR 0.10 (95% CI: 0.05, 0.19)]. There were no differences between the pre- and post-ERT period for myocardial function and psychomotor development. Adverse events (AEs) after ERT were mild in most cases. Conclusion: Our data suggest that alglucosidase alfa potentially improves LV mass, TSV, and survival in IOPD patients, with no important safety issues. Systematic Review Registration: PROSPERO identifier (CRD42019123700).

A systematic review of the predictive value of 18F-fluoro-2-deoxyglucose positron emission tomography on survival in locally advanced rectal cancer after neoadjuvant chemoradiation.

AIM: Treatment of locally advanced rectal cancer (LARC) includes preoperative radiation therapy with or without chemotherapy followed by radical surgery, but the clinical outcome is uncertain. A systemic review was carried out to determine the predictive value of (18)F-fluoro-2-deoxyglucose positron emission tomography ((18)FDG-PET) for assessing disease-free (DFS) and overall survival (OS) in LARC. METHOD: A literature search (PubMed/MEDLINE, EMBASE, Cochrane) up to January 2012 to identify full papers with sequential (18)FDG-PET and survival data, using indexing terms and free text words. The inclusion criteria were: a study of at least 10 patients, having sequential (18)FDG-PET imaging before and after adjuvant chemoradiation and a minimal follow-up of 24 months. Studies were selected by two of the authors. A meta-analysis was performed for DFS and OS using the hazard ratio (HR) as the primary outcome. RESULTS: Five eligible studies were identified including 330 patients (mean age 63 years, 64% men), in which PET-CT or PET imaging was used. The American Joint Committee on Cancer stage distribution was as follows: Stage I, 2%; Stage II, 44%; Stage III, 52%; Stage IV, 1%. The pooled HRs for complete metabolic response versus partial or no response were 0.39 (95% CI 0.18-0.86; P = 0.02) for OS and 0.70 (95% CI 0.16-3.14; P = 0.64) for DFS. The lack of significance for DFS might be explained by different follow-up characteristics. There was also clinical heterogeneity among the different studies. CONCLUSION: This systematic review indicates that complete metabolic response on sequential (18)FDG-PET data after preoperative chemoradiation of LARC is predictive of OS, but not of DFS.

Partial economic evaluation of clinical pharmacy interventions on the prescription of direct oral anticoagulants in a teaching hospital.

BACKGROUND: Potential inappropriate use of direct oral anticoagulants (DOACs) increases the risk of thromboembolic and haemorrhagic events. PURPOSE: To determine the net cost benefit of clinical pharmacy interventions on the prescription of DOACs. METHOD: We constructed a decision tree model using a public payer perspective. The appropriateness of the prescription was assessed using the Medication Appropriateness Index. The theoretical risks were collected from the literature and the individual potential risks were calculated using the Nesbit risk assignment conducted by two independent clinical pharmacists. Different costs were included based on diagnosis-related group coding and data in the literature. A univariate sensitivity analysis was performed. RESULTS: Thirty-six of 75 patients had an inappropriate prescription of DOACs. The saved difference between avoided costs (7954€) and annualised medication costs and pharmacist cost (4323€) was 3631€ for 75 patients. CONCLUSIONS: In addition to the enhancement of the quality of the prescription, our results indicate that pharmacist interventions provide a positive net cost benefit.

[Successful retrieval of a portcatheter from the pulmonary artery]. / Erfolgreiche Bergung eines in die Pulmonalarterie dislozierten Portkatheters.

We report on a 66-years-old oncological patient with a spontaneous dislocation of a portcatheter into the pulmonary artery. The catheter fragment had a loop formation, both ends were located in the proximal right segment arteries. The first attempt of a removal of the catheter via the right heart into the inferior caval vein by means of a hooked pulmonalis-catheter failed. In a second manoeuvre, the catheter fragment was successfully fixed by means of a catheter with an extendable loop configuration (goose-neck) and retrieved from the pulmonal artery into the inferior caval vein. Then, the entire system could be removed together with the introducer sheet under mild traction from the femoral vein without any complications. In conclusion, the percutaneous interventional method appears to be a minimally-invasive approach to deal with catheter fragments dislocated in the central veins and the pulmonary arteries.

Bacterial Contamination During Diagnostic and Interventional Neuroangiography is a Frequent Finding: But Does It Matter? An Observational Study.

INTRODUCTION: Bacterial contamination during angiographic procedures is a potential source of bacteremia. It is largely unknown whether it is clinically relevant. Our aim was to evaluate the incidence of contamination of liquids during catheter-based neuroangiographic examinations, the spectrum of microorganisms, a comparison of two different trolley-settings, and a follow-up of all patients with regard to clinical and lab signs of infection. METHODS: A total of 170 patients underwent either diagnostic angiography (n = 111) or arterial neuroendovascular procedures (n = 59). To study the impact of airborne contamination of sterile liquids, we randomly assigned equal numbers of procedures to two distinct setups. Group A with standard open-surface bowls and group B with repetitive coverage of liquids throughout the procedure. Patient preparation was performed with utmost care. After each procedure, samples of the liquids were sent for microbiological evaluation. Patients were followed for signs of infection (fever, white blood cell count, C-reactive-protein). RESULTS: Of all samples, 25.3 % were contaminated. Contamination consisted of resident skin microbiota only and was more common with procedures (28.8 %) than with diagnostic angiography (23.4 %) and less common in uncovered (23.5 %) than in covered bowls (27.1 %). However, these differences were insignificant. None of the patients developed clinical or lab signs of infection. CONCLUSION: Contamination during diagnostic and interventional angiography does occur and cannot be avoided by intermittent coverage. Despite a surprisingly high incidence, our findings support the common strategy that antibiotic coverage is unnecessary in most patients undergoing arterial angiography as it lacks clinical impact. Airborne contamination does not appear to play a role.

Treatment options for metastatic colorectal cancer in patients with liver dysfunction due to malignancy.

BACKGROUND: The survival of colorectal cancer patients is frequently determined by the extent of metastatic invasion to the liver; in cases of major involvement, therapeutic strategies are limited because the liver is necessary for drug metabolism. MATERIAL AND METHODS: We have reviewed articles about the pharmacokinetic profiles of each drug used in colorectal cancer patients with hepatic dysfunction to determine which of these treatments are most feasible. RESULTS: Some drugs appear to be feasible options for patients with hepatic insufficiency. Agents such as 5-fluorouracil and oxaliplatin, as well as monoclonal antibodies such as bevacizumab, cetuximab, and panitumumab, can potentially be used in these cases. On the other hand, irinotecan and regorafenib cannot be recommended because of the risk of increased toxicity. CONCLUSION: Treatment of patients with colorectal cancer and liver dysfunction represents a major challenge because the prognosis is usually very poor and alteration of liver function is normally an exclusion criterion in clinical trials. In this review, we present evidence regarding the use of each drug in patients with colorectal cancer and hepatic impairment.

Coronary flow reserve during coronary angioplasty in patients with a recent myocardial infarction: relation to stenosis and myocardial viability.

OBJECTIVES: In the present study, we examined post-stenotic coronary flow before and after percutaneous transluminal coronary angioplasty (PTCA) in patients with and without a recent myocardial infarction (MI) and related it to stenosis severity and residual viability. BACKGROUND: Post-stenotic coronary blood flow velocity reserve (CFVR) has been used with success to estimate functional stenosis severity in patients with stable angina. However, in patients with a recent MI, the impaired coronary vasodilator response of the reperfused myocardium may substantially alter the flow dynamics of the infarct-related artery. METHODS: Distal coronary flow velocities were recorded before and after PTCA in 36 patients at day 13 +/- 7 (mean +/- SD) after acute MI and in 38 patients without MI. The CFVR was assessed by the ratio of distal hyperemic to baseline average peak velocity, using a 0.014-in. Doppler guide wire. Stenosis severity was analyzed by quantitative coronary angiography, and infarct size was assessed scintigraphically. RESULTS: For similar angiographic stenosis severity, pre- and post-PTCA values of CFVR were significantly lower in patients with than without MI: 1.22 +/- 0.26 versus 1.50 +/- 0.45 before PTCA (p < 0.05) and 1.72 +/- 0.43 versus 2.21 +/- 0.74 after PTCA, respectively (p < 0.01). Although CFVR increased significantly (p < 0.0001) after angiographically successful PTCA in both study groups, abnormal CFVR (< or = 2.0) was still observed in 80% of patients with MI and in 44% of those without MI (MI vs. no MI, p = 0.001). Patients with an extensive infarction (relative infarct size > or = 50%) and those with a small infarction (relative infarct size < 50%) had comparable levels of post-PTCA CFVR (1.6 +/- 0.3 vs. 1.8 +/- 0.5, p = NS). Among a variety of factors, angiographic stenosis severity was the most important determinant of CFVR in both study groups. CONCLUSIONS: In patients with a recent MI, CFVR was significantly lower than in those without MI, both before and after PTCA. Besides the presence of this postreperfusion-related impairment of the coronary vasodilating response, CFVR was mainly influenced by stenosis severity and not by residual viability.

[Digital X-ray mammography: comparison of the image quality achievable with a wet laser imager, a dry infrared laser imager and a dry laser imager using direct thermography]. / Digitale Röntgenmammographie: Bildqualitativer Vergleich eines Nasslaserdruckers, eines infrarotbasierten Trockenlaserdruckers und eines thermographiebasierten Trockendruckers.

PURPOSE: To compare the image quality of digital X-ray mammographies obtained with wet imagers with that of standard dry imaging technology. MATERIAL AND METHODS: Beginning 03/08/2003, 200 X-ray mammographies with a digital fullfield mammography system (Lorad Selenia, Lorad/Hologic) were prospectively and consecutively documented with a wet laser imager (Scopix LR 5200, Agfa), a dry infrared laser imager (DryView 8610, Kodak) and a dry imager using the principle of direct thermography (Drystar 4500M, Agfa, N = 166). One X-ray exposure was systematically chosen from each examination and was presented in an anonymous and randomized form to three radiologists who evaluated the films using a structured questionnaire. RESULTS: The visualization of normal anatomic structures was considered being good to excellent for all imagers with the mean assessments 1.0 - 2.4 for the Drystar 4500M, 1.0 - 2.1 for the DryView 8610 and 1.1 - 2.0 for the Scopix LR 5200. The mean assessments were 0.1 - 0.6 points lower in dense than in normal parenchyma, thus, the parenchymal density is the predominant factor for image quality. CONCLUSION: In view of the comparable image quality obtained with the different imagers used in the study, individual decisions to purchase a specific imager will be based on economics rather than on diagnostic points of view.

[Value of postmortem computed tomography in comparison to autopsy]. / Prospektive Untersuchung zur Wertigkeit der postmortalen Computertomographie im Vergleich zur Autopsie.

PURPOSE: To assess the diagnostic value of postmortem computed tomography (CT) in comparison to autopsy. MATERIALS AND METHODS: Twenty-seven cadavers were examined by sequential cranial CT and helical CT through the neck, thorax and abdomen and subsequently underwent an autopsy with histomorphologic examination of the pathologic specimens. The findings of CT, autopsy and histology were registered and compared by three radiologists and one specialist for forensic medicine, using a data entry form. RESULTS: In 19 of 27 cases, the findings explaining the cause of death were concordant for CT and autopsy. Intracranial, intraspinal and intracardiac gas accumulations (n = 12) were registered by CT alone. The detection of skull fractures was equal for both methods (n = 3). CT showed diagnostic problems in the assessment of pneumonic infiltrations (n = 16) and pulmonary edema (n = 21). CONCLUSION: CT is a useful and complementary method to autopsy.

Influence of hip replacement on sagittal alignment of the lumbar spine: An EOS study.

INTRODUCTION: Changes in pelvic position can influence the sagittal alignment of the lumbar spine. The restoration of hip kinematics by hip replacement thus appears to offer the possibility of correcting sagittal alignment. This preliminary retrospective study used EOS imaging to investigate the influence of total hip arthroplasty on pelvic parameters in patients with normal preoperative pelvic parameters. METHODS: Twenty patients with hip osteoarthritis undergoing total hip arthroplasty (THA) between 2011 and 2012 received unilateral THA. To evaluate the preoperative and postoperative changes of the pelvic parameters, we analyzed EOS imaging of the patients to determine pelvic incidence, sacral slope, sacral tilt, pelvic tilt, anterior pelvic plane inclination and pelvic axial rotation. Additionally, anteversion and inclination of the acetabular cup position were determined. RESULTS: No statistically significant difference was found between the preoperative and postoperative measurements of pelvic parameters, although the change in pelvic tilt approached significance. Postoperatively, respective average values of 42.6° and 22.7° were measured for inclination and anteversion of the acetabular cup position. CONCLUSION: THA did not influence pelvic position and sagittal alignment in patients with normal preoperative pelvic parameters. A subsequent study will investigate whether corrections of pelvic parameters outside the norm in patients with OA are possible with THA.

Review of laxative utilization in a skilled nursing facility.

Laxatives are the most frequently prescribed drugs in long-term care facilities. Of all nursing home patients, 58 percent receive laxatives--often more than one, and usually on a "prn" basis. This pattern of dosage is probably used in an effort to prevent constipation. Selection of a laxative should be based on careful evaluation of the cause of constipation, with due consideration being given to differences in drug effectiveness and the incidence of side effects. A review of laxative utilization among 73 elderly patients in a large metropolitan skilled nursing facility showed a rational use of these drugs. However, more attention should have been paid to the dietary management of constipation.

Age related signal decrease in functional magnetic resonance imaging during motor stimulation in humans.

Right handed healthy volunteers underwent functional magnetic resonance imaging (fMRI) examinations on a 1.5 Tesla MRI-scanner (Gyroscan ACS NT; Philips, Best, NL). Blood oxygen level dependent (BOLD) images were obtained using a three dimensional multi-shot echo planar imaging sequence employing a shifted echo technique (Principles of echo shifting with a train of observations). Finger tapping of the right hand was used as a task for motor stimulation. A total of 86 subjects was included into statistical analysis. Absolute and relative signal differences and cluster sizes of activation for the left motor cortex were obtained. In addition, Z-score, pooled Z-score and cross correlation activation maps were calculated and matched with high resolution anatomic images. A significant decrease with age could be detected for absolute and relative signal intensity differences for the whole group and for the male subgroup. Correlation analysis for the female subgroup also bore negative albeit non-significant correlation coefficients. An age-related decline of BOLD-contrast can be assumed to explain signal decrease. This age-related effect should be considered in clinical fMRI applications.

Functional magnetic resonance imaging of human pontine auditory pathway.

The purpose of this study is to visualize brainstem auditory pathways by functional magnetic resonance imaging (fMRI). Eighteen healthy volunteers (age 28 to 42 years) with normal hearing function underwent fMRI examination on a 1.5 Tesla imaging system (Philips, Best, The Netherlands) with periodic click stimulation. Blood oxygen level dependent images were obtained using a three-dimensional EPI sequence with shifted echo technique (principles of echo shifting with a train of observations). Control scans without click stimulation were obtained in the identical setting. Cross correlation activation maps were calculated using a postprocessing tool (Philips). They were matched with anatomic slices of identical orientation and thickness. Five of 18 subjects were excluded because of motion artifacts. In 4/13 significant activation was observed at the root entry zone of the ipsilateral acoustic nerve corresponding to the cochlear nuclei. In 11/13 subjects, significant activation was found in the same slice contralaterally close to the floor of the 4th ventricle, corresponding to the expected region of the superior olivary nucleus. Activation of the rostral parts of the auditory pathway (inferior colliculus, medial geniculate body) was not found. In the absence of the stimulus no activation occurred in these structures. It was concluded that activation of the brainstem auditory pathways by click stimuli can be visualized by fMRI.

Diagnostic performance of digital subtraction angiography (DSA) and magnetic resonance angiography (MRA): preliminary results in vascular occlusive disease of the abdominal and lower-extremity arteries.

Fifty-nine patients with occlusive disease of the aorto-iliac and femoro-popliteal arteries were investigated prospectively by intravenous (IV) or intraarterial (IA) digital subtraction angiography (DSA) and magnetic resonance angiography (MRA). This was accomplished using a two-dimensional (2D) Inflow- (59 patients) and a 2D Phase Contrast- (RSE--rapid sequential excitation) sequence (29 patients). The spectrum of pathology included stenoses < 50%, stenoses 50-89%, stenoses 90-99%, occlusions, aneurysms and status following reconstructive surgery. MRA- and DSA-examinations were evaluated by four radiologists. The diagnoses were made by consent decisions of a radiologist and a vascular surgeon based on clinical and radiological findings. Diagnostic performance of IA-DSA was superior to all other imaging modalities. Vascular delineation of 2D Inflow-MRA was comparable to that of IV-DSA. The image quality of RSE-MRA was not adequate for diagnosis. In conclusion, 2D Inflow-MRA is a promising method for evaluating abdominal and peripheral arteriosclerotic disease. Interpretation of MR-angiograms, however, requires profound knowledge of MRA-techniques, X-ray angiography and hemodynamics.

Yolk sac tumor of the anterior mediastinum: the role of palliative surgery.

Primary endodermal sinus tumor (yolk sac tumor) of the mediastinum is a very rare extragonadal germ-cell neoplasm. Most patients are young and male. Since initial description of the endodermal sinus tumor in 1959, this neoplasm has been found more and more frequently. alpha-Fetoprotein is an important tumor marker. The treatment consists of multimodal therapy. A combined approach with chemotherapy followed by surgical resection of residual tumor seems to be the optimal management of this tumor. Even a palliative surgical resection in advanced tumors is indicated. We describe the case of a patient with an advanced yolk sac tumor that was refractory to chemotherapy. This patient was treated by palliative surgical resection.

[Gastrointestinal amyloidosis as a differential diagnostic problem]. / Gastrointestinale Amyloidose als differentialdiagnostisches Problem.

The diagnostic radiologist may have problems with the differential diagnosis of gastrointestinal amyloidosis combined with only uncharacteristic clinical symptoms. In the stomach upper gastrointestinal series show in most cases stenosing submucosal masses in the gastric antrum with diminished peristalsis and pliability. Sonography reveals a circular thickening of the gastric antrum wall. Only a synopsis of radiologic changes, the patients's history, laboratory tests and biopsies render a clue to the correct diagnosis. In the small bowel segmental or total intestinal dilatation with sonographically demonstrable thickening of the bowel wall and diminished motility, prolonged transit and eventually obstruction or paralytic ileus can be demonstrated. In patients with simultaneous plasmocytoma the radiologist has to take a gastrointestinal involvement by concurrent amyloidosis into account.