Comparison of whole-body MR imaging and conventional X-ray examination in patients with multiple myeloma and implications for therapy.

Skeletal X-ray survey is the established method of diagnosis in patients with multiple myeloma; however, whole-body magnetic resonance imaging (wb-MRI) has become an important additional tool. The aim of this study was to compare the different patterns of infiltration on conventional X-ray examinations (X-ray survey) with findings from wb-MRI to subsequently determine the influence of wb-MRI on therapy changes. In 60 patients with a mean age of 65.1 +/- 11.7 years, wb-MRI examinations were correlated with a recent X-ray survey. The results were independently assessed by two radiologists and the patterns of infiltration were described in both modalities. Subsequently, the disease was staged according to Salmon and Durie and Salmon and Durie PLUS. Additionally, the influence of MRI on potential changes in therapy was assessed using a three-range Likert-type scale. In all, 480 skeletal regions were compared. In 183 skeletal regions, an increased degree of infiltration was identified on wb-MRI. Significant differences (p < 0.05) between the modalities could be found in the thorax, spine, pelvis, and both lower extremities. Based on wb-MRI, tumor stage was upgraded in 19 of the 60 patients using the Durie and Salmon PLUS classification. In ten out of these 19 patients (42%), the wb-MRI result was essential for making the decision to initiate further therapy due to the degree of infiltration, extramedullary tumor extension, and/or further risk of fracture. Whole-body MRI provides a more detailed assessment of the pattern of bone marrow infiltration and strongly influences therapeutic strategies.

Congenital diaphragmatic hernia: a modern day approach.

Centralization of all complicated congenital diaphragmatic hernias (CDH) was organized in Germany from 1998, collecting 325 consecutive patients with striking increasing survival rates. This series report 244 patients from 2002 to 2007. Today, large defects are detected early in pregnancy by ultrasound and magnetic resonance imaging (MRI). In extracorporeal membrane oxygenation (ECMO) patients, prenatal lung head ratio (LHR) was 1.2 (median) at the 34th week of gestation or less than 25 ml lung tissue in MRI. This means that all patients below LHR of 1.4 should be transferred prenatally in a tertiary center. High risk group for survival was defined as LHR below 0.9, ie, 10 ml in MRI planimetry. Inborn patients show better results than outborns. In algorithm therapy, gentle ventilation plays an important role in preventing damage to the lung tissue and avoiding long term ventilation. When PaCO(2) was more than 75 mmHg, ventilation was changed to high frequency oscillatory ventilation (HFOV). Indication for ECMO was seen in preductal PaO(2) less than 50 mmHg over 2-4 h or less than 40 mmHg over 2 h. ECMO related risks included intracerebral bleeding (9%), intrapulmonary bleeding (14%), and convulsions (16%). Surgically, a longitudinal midline incision for exposure of the defect, the duodenal kinking, and probably for abdominal patching was perfect. A cone formed goretex patch provided more abdominal space and reduced abundant intrathoracical cavity. No drain was used. Postoperative complications were described. Overall survival in 244 consecutive patients was 86.5% for all patients born alive. All those who needed ECMO survived in 71%, underlining ECMO as a treatment of last choice. Follow-up for quality of life after CDH is described.

Preoperative staging of rectal tumors: comparison of endorectal ultrasound, hydro-CT, and high-resolution endorectal MRI.

AIM: The aim of this study was to compare transrectal ultra-sound (TRUS), hydro-computed tomography (hydro-CT), and endorectal magnetic resonance imaging (MRI) in the preoperative staging of rectal cancer. PATIENTS AND METHODS: 23 patients with rectal adenocarcinoma underwent TRUS, hydro-CT, and MRI (1 Tesla) with endorectal coil. The results were correlated with the histopathological findings based on the TNM classification. RESULTS: T staging with TRUS, hydro-CT, and endorectal MRI correlated with the histopa-thological findings in 83% of patients (19/23). Tumors were overestimated by TRUS in 2/23 patients, by CT in 3/23, and by MRI in 3/23 patients. Tumor size was underestimated by TRUS in 2 patients, by CT and MRI in 1 case each. Local lymphatic node involvement was correctly diagnosed with CT and MRI in 87% and 83%, respectively. Using TRUS, false-negative results in the staging of lymph node involvement were seen in 3/23 patients, whereas 1 patient was over-staged. Using hydro-CT as well as endorectal MRI, overstaging of the local lymph nodes took place in 2/23 patients. CONCLUSION: All methods are limited because peritumoral inflammation cannot be precisely distinguished from infiltration by the tumor. Correct lymph node staging is hampered in advanced disease using TRUS. In these patients, further cross-sectional imaging may be required.

Extrapulmonary sarcoidosis of liver and pancreas: a case report and review of literature.

Sarcoidosis is a chronic multisystemic granulomatous disease of unknown origin, which can involve nearly all organs. In the case of an infrequent gastrointestinal tract involvement in systemic sarcoidosis, granulomas of the liver are most commonly described while isolated pancreatic sarcoid lesions are rarely seen. We report a case of systemic sarcoidosis with exclusive extrapulmonal involvement of the liver and the pancreas in a 71-year-old white man. The diagnosis of liver involvement was confirmed by biopsy. Pancreatic surgery was needed because preoperative evaluation could not exclude pancreatic cancer and for biliary decompression. An extensive literature review of systemic sarcoidosis, focusing on reported cases with unusual presentation of sarcoidosis in the liver and the pancreas, its diagnosis, treatment, and prognosis was made.

Encouraging early clinical experience with deliberately delayed temporary fetoscopic tracheal occlusion for the prenatal treatment of life-threatening right and left congenital diaphragmatic hernias.

OBJECTIVE: In order to assess the effect of deliberately delayed percutaneous fetoscopic tracheal occlusion on survival of fetuses with life-threatening congenital diaphragmatic hernia. METHODS: Eight fetuses with life-threatening congenital diaphragmatic hernia underwent fetoscopic tracheal balloon occlusion between 29 + 0 and 32 + 4 weeks of gestation. Delayed occlusion was chosen in order to minimize potentially negative pulmonary effects from premature delivery as a result of fetal surgery. In addition, we wanted to become able to provide all available postnatal intensive care treatment means in these patients. RESULTS: Six of the 8 fetuses survived to discharge from hospital. CONCLUSION: Delayed fetoscopic tracheal balloon occlusion may be rewarded with lung growth sufficient to allow survival of fetuses with life-threatening congenital diaphragmatic hernia.

Anatomic changes after hyoid suspension for obstructive sleep apnea: an MRI study.

OBJECTIVE: To assess the effects of isolated hyoid suspension on subjective and objective parameters of obstructive sleep apnea and to evaluate changes in upper airway anatomy with the help of standardized magnetic resonance imaging. STUDY DESIGN AND SETTING: Fifteen patients received isolated hyoid suspension. Changes in respiratory disturbance index were assessed with polysomnography, and anatomical changes with standardized magnetic resonance imaging. Snoring, daytime sleepiness, and functional parameters were assessed with questionnaires. Lateral x-ray cephalometry was performed preoperatively. RESULTS: Mean respiratory disturbance index was reduced from 35.2 +/- 19.1 to 27.4 +/- 26.2. Forty percent of the patients were classified as responders. Daytime sleepiness improved significantly. Relevant changes in upper airway anatomy could not be detected. There were no remarkable differences between responders and nonresponders in regard to imaging. CONCLUSIONS: Hyoid suspension is effective only in a subgroup of patients and does not lead to relevant changes in airway diameters in the awake patient. Magnetic resonance imaging and x-ray cephalometry do not add additional information for patient selection. SIGNIFICANCE: The reported clinical effects of hyoid suspension are more likely due to functional changes in airway collapsibility than to an enlargement of the upper airway.

Evaluation of MR-angiography for pre-operative assessment of living kidney donors.

INTRODUCTION: Pre-operative magnetic resonance tomography (MR) and MR-angiography (MRA) have rendered favorable results for the assessment of renal anatomy preceding living-related kidney transplantation. However, limited value of MRA in the detection of accessory renal vasculature is reported. METHODS: We compared the results of pre-operative contrast-medium-enhanced MRA of the last 30 consecutively performed nephrectomies in living kidney donors with the intraoperative findings of vascular, parenchymal, and ureteral anatomy. RESULTS: Pre-operative MRA diagnosed a solitary renal artery in 24 cases (80%) and a normal venous, ureteral and parenchymal anatomy in all cases. Intraoperatively, the surgeon confirmed the normal pre-operative MRA findings of ureter and parenchyma. Yet, in 6 out of 30 patients (20%) vascular architecture differed from the pre-operative imaging: four of them, who had a radiologically regular anatomy, were found to have accessory vessels upon surgical preparation. In the fifth patient, MRA revealed an accessory lower polar artery, which was confirmed during surgery. An undiagnosed third arterial vessel, located behind the renal vein, led to an aortic bleeding. In the sixth case, the adrenal gland artery was misinterpreted as an accessory superior polar artery of the kidney in MRA. Additionally, a radiologically undetected inferior polar artery was dissected during nephrectomy and led to partial hypoperfusion of the graft. Subsequent retrospective reevaluation of the MRA by experienced radiologists was unable to identify the intraoperative anatomical discrepancies. Hence, sensitivity of MRA was 60% (6 out of 10 cases) for accessory renal vessel detection and 80% (24 out of 30 cases) for overall sensitivity in determining renal vessel number. DISCUSSION: MRA is a reliable method for the non-invasive investigation of living kidney donors and provides valuable information required by the surgeon. But, as the technique misses small diameter vessels, it cannot be recommended as sole diagnostic tool in unclear cases.