[Vaginal foreign body -- cause for a rectovaginal fistula]. / Vaginaler Fremdkörper als Ursache einer rektovaginalen Fistel.

A case of 56-year-old patient is presented with the diagnosis "carcinoma of the cervix". She suffered from brown, bad smelling vaginal discharge since half a year without any pain. Three weeks before she had noticed a postmenopausal bleeding. At the examination under anaesthesia with cysto- and rectoscopy we saw a rectovaginal fistula. In the vagina a white plastic object was found which could not be removed. Some days later a hysterectomy with extraction of the foreign body (aerosol cap) was done and the fistula was treated together with the surgeons. There was no evidence of a carcinoma. The patient suffers from multiple sclerosis since 20 years. On asking she told us that the foreign body was in place since about two years. She was not willing to relate any other information.

Cystic leukoencephalopathy without megalencephaly: a distinct disease entity in 15 children.

OBJECTIVE: To describe a distinctive syndrome of nonprogressive encephalopathy, normo- or microcephaly, and early onset of severe psychomotor impairment in 15 white patients, including two siblings and two first cousins. METHODS AND RESULTS: MRI revealed bilateral cysts in the anterior part of the temporal lobe and white matter abnormalities with pericystic abnormal myelination and symmetric lesions in frontal and occipital periventricular regions. None of the usual inborn errors of metabolism/infectious diseases associated with leukoencephalopathy and bilateral anterior temporal lobe cysts were detected. CONCLUSIONS: These patients' clinical signs and cranial MRI abnormalities are strikingly similar and may represent a distinctive disease with autosomal-recessive inheritance: cystic leukoencephalopathy without megalencephaly.

[MRT diagnosis for degenerative changes in the spine]. / MRT-Diagnostik von degenerativen Veränderungen der Wirbelsäule.

MRT is very well suited to the diagnosis of degenerative alterations in the spine. The option of imaging in multiple planes, the excellent soft-tissue contrast offering tissue differentiation, the absence of hardening artefacts and the avoidance of exposure to radiation have led to a shift in favour of MRT for diagnosis. In the present paper the MRT characteristics of the most important degenerative alterations that affect the spine are discussed.

An approach for cure: PEI-chemotherapy and regional deep hyperthermia in children and adolescents with unresectable malignant tumors.

BACKGROUND: Elevated temperatures of 40 - 44 degrees C increase the actions of various anticancer drugs including N-lost derivatives, cytotoxic antibiotics and platinum analoga. In clinical usage thermochemotherapy (TCH) should facilitate surgical resection and ameliorate local tumor control. PATIENTS AND METHODS: From 07/1993 to 12/2002 a total of 39 patients have been enrolled onto a phase-II study (female = 24, male = 15, age 1 - 37.5 years, median 5.2). Among these, 24 patients had extracranial non-testicular germ cell tumors and 15 patients soft tissue or chondrosarcomas. INDICATION: locoregional relapse (n = 29) or unresectable tumor after neoadjuvant chemotherapy (n = 10). Among these two groups, there were ten patients with poor response or progressive disease under primary or relapse chemotherapy. Ten out of the 29 relapse patients had more than one relapse. Tumor site: pelvis (30), abdomen (4), head and neck (2), proximal leg (2) and lumbar spine (1). Thermochemotherapy (TCH): 1800 - 2000 mg ifosfamide/m (2) and 100 mg etoposide/m (2) on days 1 - 4 and 40 mg cisplatin/m (2) on days 1 + 4 combined with regional deep hyperthermia (42 - 44 degrees C, 1 h) on days 1 + 4. RESULTS: In 39 protocol patients a total of 166 TCH courses (332 heat sessions) were applied. 20 patients achieved complete response, and 10 patients achieved partial response. TCH was followed by surgical tumor resection in 28/39 patients and/or radiotherapy in 13/39 patients. At a median follow-up of 27 months, outcome in this high-risk patient population was 22 NED, 3 AWD, 12 DOD, 2 DOC. Five year event free (EFS) and overall survival (OS) for the whole study cohort was 0.39 +/- 0.11 (20/39 patients) and 0.52 +/- 0.11 (25/39 patients), respectively. CONCLUSION: TCH shows substantial therapeutic efficacy and facilitates complete tumor resection in 14 out of 28 operated patients. Multimodal treatment including TCH, surgical resection and/or radiotherapy leads to sustained remission in the majority of patients with locoregional tumor recurrence. The therapeutic effect is most pronounced, if TCH is administered at first relapse. Due to the clinical and histologic heterogeneity the number of patients eligible for TCH is limited. Therefore, a more valid assessment of treatment efficacy can only be made by a matched-pair comparison in cooperation with the clinical registers.

Hemodynamically relevant hematuria several months after biopsy of a kidney graft: an unusual cause.

We report the case of a 52-year-old female patient, who after a complicated living donor kidney transplantation, underwent kidney biopsy for suspected rejection. Duplex scanning revealed a small, asymptomatic arteriovenous (AV) fistula which was assessed as being hemodynamically unimportant. During follow-up, several urinary tract infections occurred and recurrent short episodes of hematuria were attributed to cystitis, urethritis and urosepsis. Eight months later, the patient developed suddenly massive hematuria, tamponade of the urinary bladder and hemorrhagic shock as well as urosepsis. Duplex sonography showed a massive pseudoaneurysm in addition to the AV fistula. Arteriography confirmed the Duplex sonographic findings and embolization was performed after treatment of concomitant urosepsis. The fistula was closed completely and bleeding ceased. Although AV fistulas are rare complications of kidney biopsies and in most cases they remain asymptomatic, life-threatening hematuria can present several months after a biopsy due to the development of a pseudoaneurysm. Concomitant infectious complications of the urinary tract, bleeding disorders and other factors can be misleading during the assessment of the cause of gross hematuria. Regular Duplex sonographic follow-up examinations in patients with AV fistulas are advisable.

[Imaging of supradiaphragmatic manifestations of extranodal non-Hodgkin's lymphoma]. / Bildgebende Diagnostik supradiaphragmaler Manifestationen extranodaler Non-Hodgkin-Lymphome.

Malignant lymphomas are differentiated into Hodgkin's and non-Hodgkin's-lymphoma (NHL). The following article discusses the imaging of extranodal NHL in supradiaphragmatic localizations. Lymphoma can affect nearly all tissues, and represent a rare entity as primary extranodal NHL. A secondary involvement of non-nodal tissue as consequence of a generalized lymphoproliferative disease is more common,and may be seen as well in HIV-positive patients defining AIDS. As extranodal lymphoma mimic the radiologic appearance of other malignant tumors, direct diagnosis without histologic analysis is often impossible. The article describes typical manifestations of lymphoma of the lungs, the head and neck area including the large glands, and rare localizations as the heart or the breast.

[Does dynamic contrast-enhanced MRI enable recognition of development of vertebral fractures in multiple myeloma?]. / Ermöglicht die dynamische kontrastverstärkte MRT die Detektion frakturgefährdeter Wirbelkörper beim Multiplen Myelom?

PURPOSE: To compare the value of MRI sequences with dynamic MRI measurements (d-MRT) for the assessment of risk of lumbar vertebral fractures in patients with multiple myeloma. MATERIAL AND METHODS: In 10 patients with multiple myeloma a sagittal T 1 -, T 2 -weighted spin-echo and an inversion-recovery sequence were performed. For dynamic measurements a fast gradient-echo sequence (turbo fast low angle shot 2 D) with machine-controlled Gd-DTPA administration was used. The presence of bone marrow abnormalities was determined and additionally the value of the highest signal increase (amplitude Alpha) was calculated for each of the 50 vertebral bodies. The subsequent development of vertebral fractures was assessed by MRI at a mean time interval of 6.2 months after the initial d-MRI. The pattern of marrow involvement and the amplitudes of the vertebral bodies that collapsed in the observation period were statistically compared with those of the vertebral bodies that did not collapse. RESULTS: During the follow-up period newly or progressive fractures occurred in 6 of 10 patients (7 of 50 vertebral bodies). The degree of pathological signal changes that preceded fractures was not significantly different (p > 0.05) from that of the other contemporary lesions identified in vertebral bodies that did not collapse in follow-up. In contrast, the amplitude of vertebrae that collapsed (A: 33.1 +/- 8.2) was significantly higher (p < 0.0001) than the amplitude of vertebrae that did not collapse (A: 16.7 +/- 4.2). The amplitude was a reliable predictor of vertebrae that collapsed in all cases. CONCLUSION: In contrast to the analysis of marrow lesions detected with non-dynamic MRI, this study suggests that the perfusion-parameter amplitude in dynamic contrast-enhanced MRI is a potentially relevant value to predict the risk of vertebral fractures in patients with multiple myeloma.

Sexual precocity and recurrent beta-human chorionic gonadotropin upsurges preceding the diagnosis of a malignant mediastinal germ-cell tumor in a 9-year-old boy.

Numerous disorders are known to cause sexual precocity. Beta-human chorionic gonadotropin (beta-HCG)-secreting germ-cell tumors are one of the sources that have to be considered in the differential diagnosis of processes inducing a peripheral precocious puberty. Germ-cell tumors might be located in the ovaries or testes, retroperitoneum, mediastinum or the cranium. We present the case of a 9-year-old boy with sexual precocity and a recurrent transient beta-HCG elevation. After an interval of 2 years with repeated radiological examinations including the mediastinum, a mediastinal tumor was identified by magnetic resonance imaging. To our knowledge, this is the first case of a diagnosis of a mediastinal choriocarcinoma with a recurrent serum beta-HCG elevation. So far, factors that might be responsible for the repeated spontaneous beta-HCG decline are unknown.

Comparative follow-up of enhancement phenomena with MRI and Proton MR Spectroscopic Imaging after intralesional immunotherapy in glioblastoma--Report of two exceptional cases.

The morphologic pattern of contrast enhancement in magnetic resonance imaging (MRI) of glioblastoma patients could be non specific and metabolic investigations can be useful for the differentiation of tumorous and non tumorous enhancement. Following initial therapy secondary tissue changes can occur and non specific non tumorous enhancement phenomena have been observed after local immuno- and gene therapy strategies. Magnetic resonance spectroscopic imaging (MRSI) has the potential to give more specific information on the metabolism of the suspective tissue and to differentiate enhancing phenomena. We demonstrate two cases of patients suffering from a glioblastoma with simultaneous MRI and MRSI follow-up after multimodal treatment with surgery, radiation, intralesional immunotherapy (IL-4 toxin) and ongoing chemotherapy. MRI demonstrated extensive and increasing enhancement. This was highly suspicious of rapid progressive local tumor recurrency in both patients. Simultaneously obtained MRSI did not show the expected result of extensive and increasing choline concentration within these enhancing areas. This indicated that the enhancement did most likely not reflect vital tumor tissue. Chemotherapy treatment was continued and further MRI follow up revealed nearly complete regression of all enhancement. In pretreated glioblastoma metabolic data of MRSI seem to be potentially helpful to differentiate tumorous and non tumorous enhancement phenomena after local immunotherapy, which might be useful for further treatment decisions.

[Dynamic contrast-enhanced MRI for evaluating bone marrow microcirculation in malignant hematological diseases before and after thalidomide therapy]. / Dynamische kontrastverstärkte MRT zur Beurteilung der Knochenmarksmikrozirkulation bei malignen hämatologischen Erkrankungen vor und während einer Thalidomidtherapie.

PURPOSE: The aim of the study was to measure microcirculation parameters by dynamic contrast-enhanced MRI (d-MRI) and to evaluate the anti-angiogentic effects during treatment with thalidomide in different hematologic malignancies. METHODS: In 20 healthy normal persons, 20 patients with myelodysplastic syndromes (MDS), 10 patients with multiple myeloma (MM) and 10 with myelofibrosis (MF) a fast gradient echo sequence (Turbo fast low angle shot 2D) with a pump controlled bolus infusion of gadolinium-DTPA was performed before and in 18 of these after beginning (average of 4.3 months) of a thalidomide therapy. Two pharmacokinetic parameters--the amplitude and exchange-rate-constant--were calculated and a statistical comparison of these values between healthy persons and patients as well as a correlation with the clinical course was executed. RESULTS: Compared with the normal controls the patients showed a higher amplitude (normal persons 14.4 +/- 5.2, MDS 24.8 +/- 8.1, MF 35.9 +/- 4.3, MM 23.4 +/- 3.6) and exchange-rate-constant (normal persons 0.124 +/- 0.042, MDS 0.136 +/- 0.036, MF 0.144 +/- 0.068, MM 0.131 +/- 0.034). In the d-MRI-follow-up examinations a significant (p < 0.005) reduction of the amplitude and exchange rate constant values was evident in 14 of 18 patients undergoing a thalidomide therapy. Clinically all of these patients showed a therapy responding with complete or partial diseases remission. CONCLUSIONS: In patients with hematologic malignancies significantly higher d-MRI-microcirculation parameters of the lumbar spine can be demonstrated than in normal persons. During anti-angiogenetic treatment with thalidomide a decrease of these values was observed in case of a responding to therapy.

[Dynamic MRI of the lumbar spine for the evaluation of microcirculation during anti-angiogenetic therapy in patients with myelodysplastic syndromes]. / Dynamische MRT der Lendenwirbelsäule zur Beurteilung der Mikrozirkulation unter anti-angiogenetischer Therapie bei Patienten mit myelodysplastischen Syndromen.

PURPOSE: Evaluation of MRI perfusion parameters of the lumbar spine in patients with myelodysplastic syndromes (MDS) to determine the vascularisation and anti-angiogenetic effects of thalidomide therapy. MATERIAL AND METHODS: In 20 healthy normal persons and 28 MDS patients a dynamic contrast-enhanced MRI (d-MRI) of the lumbar spine was performed. After the initial d-MRI-investigation 24 of the 28 MDS patients received an anti-angiogenetic therapy with thalidomide. With an average of 4.2 months after the beginning of therapy a d-MRI-follow-up examination in 9 of these patients was performed. The amplitude and exchange-rate constant were calculated and a statistical comparison of these values between healthy persons and MDS patients as well as a correlation with the clinical course was executed. RESULTS: Compared with the normal controls the MDS patients showed a higher amplitude (normal persons: 14.4 +/- 5.2, MDS: 24.8 +/- 8.1) and exchange-rate constant (normal persons: 0.124 +/- 0.042, MDS: 0.136 +/- 0.036). In 7 of 9 MDS patients undergoing thalidomide therapy a reduction of the amplitude and exchange rate constant values was evident in the d-MRI follow-up examinations. Clinically these patients showed a therapy response with complete or partial disease remission. CONCLUSIONS: In MDS patients significantly higher d-MRI parameters can be demonstrated than in normal persons. Under anti-angiogenetic treatment these values decrease in case of a response to therapy. Thus, d-MRI seems suitable for the evaluation of anti-angiogenetic therapy effects.

Diagnostic difficulties in childhood bilateral thalamic astrocytomas.

We report on two children with bilateral thalamic astrocytomas. The first patient developed psychomotor regression at the age of 20 months followed by rapidly progressive ataxia, intention tremor, slurred speech, and bouts of drowsiness. Magnetic resonance imaging (MRI) of the brain showed swelling and high signal intensity in both thalami accompanied by supratentorial hydrocephalus. The second patient presented with progressive cerebellar ataxia, headache, and vomiting at the age of 11 years. MRI of the brain revealed symmetrical, hyperintense and sharply delineated swelling of both thalami. Additional lesions were seen in the cerebellum and the right temporal lobe. In both cases proton magnetic resonance spectroscopy (MRS) of the lesions showed a striking decrease of the neuronal marker N-acetylaspartate, an increase of choline-containing compounds, and a minimal lactate peak. Stereotactic biopsies from the thalamus of the first patient and from a cerebellar lesion of the second patient finally revealed glial tumors, namely a diffuse astrocytoma of World Health Organization (WHO) grade II in the first patient and an anaplastic astrocytoma of WHO grade III in the second patient. We conclude that the clinical manifestations and MRI patterns of bilateral thalamic astrocytomas are very similar to those of encephalitis and neurometabolic disorders and should therefore be included in the differential diagnosis of these encephalopathies.

Proton MR spectroscopy of the lumbar spine in patients with glycogen storage disease type Ib.

Glycogen storage disease type Ib is an autosomal recessive inherited metabolic disorder resulting from deficiency of the microsomal glucose-6-phosphatase enzyme system. Six patients (three of which were treated with granulocyte colony stimulating factor) suffering from this disease were examined using image guided localized proton magnetic resonance (MR) spectroscopy. The relative signal intensities of water and lipid protons of the lumbar spine were determined. Comparison was made with iliac crest biopsies in the glycogen storage disease type Ib patients and localized proton MR spectroscopic values of the lumbar spine obtained by thirteen healthy volunteers. The data demonstrate for the first time that hypercellularity and myeloid hyperplasia in subjects with glycogen storage disease type Ib due to functionally impaired leucocytes results in a strongly increased water proton signal with a very low or absent lipid signal in localized proton MR spectroscopy. Upon granulocyte colony stimulating factor treatment, the water proton signal in the lumbar spine is not further augmented.

MR imaging of bone marrow in glycogen storage disease type IB in children and young adults.

OBJECTIVE: Patients with glycogen storage disease type IB have neutropenia and neutrophil dysfunction that predispose them to frequent infections, for which they are given granulocyte colony--stimulating factor. Because neutropenia is a consequence of defects in myeloid maturation, the bone marrow aspirations show hypercellularity due to myeloid hyperplasia. This study evaluated MR imaging of bone marrow in glycogen storage disease type IB with and without granulocyte colony-stimulating factor. CONCLUSION: As confirmed by the histologic results in bone marrow aspirations, abnormal findings on MR images of bone marrow in patients with glycogen storage disease type IB indicate an increased myelopoietic activity, which is augmented by treatment with granulocyte colony-stimulating factor.

[MRI of the cerebellopontine angle in patients with cleidocranial dysostosis]. / MRT der Kleinhirnbrückenwinkel-region bei Patienten mit Dysostosis cleido-cranialis.

PURPOSE: Cleidocranial dysostosis (CCD) is an autosomal dominant bone disorder in which deafness is common secondary to malformation of the middle ear structures. The study aimed at MRI evaluation of the cerebellopontine angle in 7 patients with a history of CCD--two generation spanned relatives. MATERIAL AND METHODS: Cranial MRI in 7 patients with CCD (4 women/3 men aged between 8 and 46 years) was performed. In two patients hearing disorders were present. The examinations encompassed multi-planar spinecho sequences of the cerebellopontine angle in 3-mm slice thickness before and after administration of contrast medium. RESULTS: The clinically most conspicuous female patient (hearing loss, ataxia, headache) showed a strongly contrast-enhancing tumor in MRI that was histologically proved to be an acoustic schwannoma. Concerning the other family members, no pathological findings were noted except for non-pneumatized mastoids. CONCLUSION: The first report of a patient with CCD and an acoustic schwannoma shows that in case of hearing loss in these patients also a retrocochlear cause must be considered.

[MRI follow-up study of aseptic osteonecrosis (AON) in children treated with chemotherapy for malignant diseases]. / MRT-Verlaufsbeurteilung aseptischer Knochennekrosen (AON) bei Kindern mit chemotherapierter maligner Grunderkrankung.

PURPOSE: The aim of the study was to evaluate by MRI the course of aseptic osteonecrosis (AON) after chemotherapy in children with different malignancies. MATERIAL AND METHODS: Retrospective analysis of 72 MRI studies in 20 children (age: 3.2-18.4 years) presenting with AON after chemotherapy. 8 children were treated exclusively with relief of weightbearing structures, whereas 12 children were additionally treated with hyperbaric oxygen therapy (HBO). Within a range of 3-76 months each patient received 1-6 follow-up exams. The acquired series included multi planar spin-echo as well as fatt-suppressed inversion recovery sequences. The MRI examinations were evaluated by a point-score system (1-6) by two radiologists. RESULTS: AON was most commonly seen in the pedal bones (26.4%), in the hip (23.6%), and in the knee joints (19.4%). Initial findings revealed an average score of 3.1 points. Based upon these initial findings, subsequent analyses show a statistically significant (p < 0.05) score increase of 0.6 score-points. For the observed intervals a: < 6 months, b: 6-12 months, and c: > 12 months the mean scores were: a: 3.3, b: 3.7, and c: 4.5 points. During the observed time period 5 patients were surgically treated in the affected bone areas. CONCLUSION: The majority of chemotherapy associated AON which initially present with advanced findings showed in MRI a progression with frequent destruction of the joint surface over their further course. More discrete forms of AON, especially osteoedema, can be positively influenced by conservative therapy.

[Signal changes of the bone marrow in MRI under long-term treatment with granulocyte colony-stimulating factors]. / Veränderungen des Knochenmarksignals in der MRT unter Langzeittherapie mit Granulozytenkolonie stimulierenden Faktoren.

PURPOSE: Recurrent infections in patients with glycogen storage disease (GSD) type Ib resulting from an associated neutropenia are frequently treated with granulocyte colony-stimulating factors (G-CSF). The aim of this study was to evaluate the changes occurring in bone marrow by magnetic resonance imaging (MRI) in these patients. MATERIAL AND METHODS: The distal femoral and tibial bones of six patients with GSD Ib were evaluated by MRI. Four of these patients were treated with G-CSF for at least 3.9 to a maximum of 8.2 years (mean 5.8 years). The imaging sequences encompassed spin-echo as well as short-time inversion recovery sequences. 4 of the 6 patients had bone marrow aspirations. RESULTS: The patients who had undergone therapy with G-CSF showed a marked increase in signal strength in STIR sequences which encompassed the entire medullar cavity. In T1-weighted images these areas were hypointense. Biopsies obtained from these patients showed a bone marrow hypercellularity. The patients without G-CSF therapy showed the same signal intensity changes but with a more discrete and localized pattern in the metaphyseal cavities. CONCLUSION: In subjects with GSD Ib, an increased myelopoetic activity of the bone marrow which is intensified under long-term treatment with G-CSF can be demonstrated by MRI.

Imaging diagnosis of retroperitoneal ganglioneuroma in childhood.

PURPOSE: To demonstrate the typical appearance of retroperitoneal ganglioneuromas on CT and MRI. MATERIALS AND METHODS: Retrospective analysis of diagnostic imaging (five CT scans, three MRI scans) in five children aged 3-15 years with the histological diagnosis of ganglioneuroma. RESULTS: The scans showed large (maximum 11 cm diameter), round or oval tumours with sharply defined margins. Intraspinal tumour involvement occurred in two cases. Comparing CTwith MRI, MRI was more accurate in defining the intraspinal involvement. The ganglioneuromas were hypodense on unenhanced CT and showed moderate enhancement with administration of contrast medium. In three patients, CT demonstrated tumour calcification with a disseminated speckled pattern. On T1-weighted MRI the tumours were homogeneous and hypointense, showing marked enhancement after gadolinium administration. On T2-weighted scans the tumours were hyperintense. CONCLUSION: At the time of diagnosis, retroperitoneal ganglioneuromas are generally large tumours that can be shown well by CT and MRI. The appearance on CT more readily suggests the diagnosis, but MRI is superior for documenting local or intraspinal tumour extension and lacks radiation load.