[Epiphysiolysis of the medial clavicle with posterior dislocation : Video article]. / Epiphysiolyse der medialen Klavikula mit posteriorer Luxation : Videobeitrag.

OBJECTIVE OF SURGERY: The goal of surgery is the anatomical reduction and stable internal fixation of an epiphysiolysis of the medial clavicle with posterior luxation in a child without harming intrathoracic structures. INDICATIONS: This case describes an acute epiphysiolysis of the medial clavicle Aitken type 0 with posterior dislocation. CONTRAINDICATIONS: Soft tissue infections within the region of the surgical access. Allergies against any materials used in the procedure. Successful closed reduction. Additional fracture of the clavicular shaft. SURGICAL TECHNIQUE: A detailed overview of the surgical technique is available through the video, which is accessible online as well as the graphic overview in this article. Longitudinal incision over the medial clavicle up to the sternoclavicular joint and preparation onto the bony structures. Display of the epiphysiolysis. Reduction of the medial clavicle. Introduction of two Kirscher wires along the longitudinal axis in the direction of the epiphysis and introduction of two sutures. Puncture of the cartilaginous epiphysis with the two sutures. Anatomical reduction of the medial clavicle and fixation by knots. With the continuous use of the sutures, fixation to the anterior periosteum and closure of the periosteum. Wound closure. FOLLOW-UP: For 6 weeks postoperative limitation of anteversion and abduction to 90°, afterwards unlimited functionality. No routine X­ray control. RESULT: After 6 months postoperative the patient is free of pain and has full range of motion. The Constant score is 97/100.

Evaluation of Real-world Data for Breast-MRI BI-RADS IV Lesions.

BACKGROUND/AIM: Magnetic resonance imaging (MRI) is an important diagnostic tool in the detection of breast cancer. The Breast Center of the municipal Hospital Holweide, Cologne, annually cares for and treats patients with changes in the breast. A special problem is posed by Breast Imaging-Reporting and Data System (BI-RADS) 4 lesions. If a BI-RADS 4 finding is present, is a vacuum biopsy indicated in every case or, if there is already an indication for surgery due to other findings, can the corresponding finding be removed openly without histological clarification? We require real world data regarding the actual in-center likelihood of a BIRADS 4 lesion to be DCIS (Ductal carcinoma in situ) or invasive disease. PATIENTS AND METHODS: This is a retrospective study of 1,641 patients who received MRI examination in the radiological department of the municipal hospital Holweide in 2012 and 2013. Each BI-RADS 4 finding (or higher) classified by MRI was compared with the final histological result. RESULTS: 347 MRIs showed BI-RADS 4 findings or higher and 280 (80.7%) cases showed benign histology. In 67 (19.3%) cases, histology showed DCIS or invasive carcinoma. CONCLUSION: BI-RADS 4 lesions have a low probability of malignancy based on real-world data from this center. If there is already an indication for surgery due to other lesions, the patient can also be offered a simultaneous open biopsy in the context of the already initiated surgical treatment. Each center should know the sensitivity and specificity of the MRI imaging performed and counsel patients based on that.

Sarcoidosis involvement of the diaphragm leading to right diaphragmatic elevation: a case report.

A 69-year-old male Caucasian presenting with dyspnea on exertion related to unilateral diaphragmatic dysfunction as caused by sarcoidosis is described. First, right diaphragmatic elevation was unexplained, while the patient presented with a restrictive pattern in lung function testing using bodyplethysmography and with reduced global and diaphragmatic respiratory muscle strength as evidenced by respiratory pressures. Subsequently, surgical diaphragm plication was performed, unfortunately, without any clinical improvement. Microscopic examination of diaphragm sections revealed a lymphocytic myositis with granulomatous pleuritis showing multiple non-caseating epithelioid granulomas. Accordingly, a lymphocytic alveolitis (26% lymphocytes) with an elevated CD4/CD8 T cell ratio of 8.0% and elevated serum parameters (neopterin and sIL-2 receptor) were established. Consequently, the diagnosis of pulmonary sarcoidosis with diaphragm involvement but without extrapulmonary involvement has been established. Therefore, sarcoidosis needs to be considered in any patient presenting with unilateral diaphragmatic dysfunction. The optimal treatment strategy, however, needs to be established in the future.

Pneumocystis jirovecii-induced chronic interstitial lung disease in Waldenström's macroglobulinemia.

Infections with Pneumocystis jirovecii can result in asymptomatic colonization or induce life threatening clinical symptoms. However, there appears to be a 'gray area' between colonization and severe pneumonia that remains underestimated so far. We describe a case with chronic interstitial lung disease and chronic cough that was attributed to P. jirovecii. The patient's history of chronic cough, although very likely being fostered by the underlying Waldenström's macroglobulinemia and interstitial lung disease, was most likely caused by P. jirovecii infection. This gives raise to the hypothesis that P. jirovecii infections do not necessarily induce life threatening pneumonia. Consequently, serial testing is required in eligible patients with positive PCR results in order to discriminate between colonization, 'gray zone' infection, and beginning pneumonia.

Intensity-based 2D 3D registration for lead localization in robot guided deep brain stimulation.

Intraoperative assessment of lead localization has become a standard procedure during deep brain stimulation surgery in many centers, allowing immediate verification of targeting accuracy and, if necessary, adjustment of the trajectory. The most suitable imaging modality to determine lead positioning, however, remains controversially discussed. Current approaches entail the implementation of computed tomography and magnetic resonance imaging. In the present study, we adopted the technique of intensity-based 2D 3D registration that is commonly employed in stereotactic radiotherapy and spinal surgery. For this purpose, intraoperatively acquired 2D x-ray images were fused with preoperative 3D computed tomography (CT) data to verify lead placement during stereotactic robot assisted surgery. Accuracy of lead localization determined from 2D 3D registration was compared to conventional 3D 3D registration in a subsequent patient study. The mean Euclidian distance of lead coordinates estimated from intensity-based 2D 3D registration versus flat-panel detector CT 3D 3D registration was 0.7 mm ± 0.2 mm. Maximum values of these distances amounted to 1.2 mm. To further investigate 2D 3D registration a simulation study was conducted, challenging two observers to visually assess artificially generated 2D 3D registration errors. 95% of deviation simulations, which were visually assessed as sufficient, had a registration error below 0.7 mm. In conclusion, 2D 3D intensity-based registration revealed high accuracy and reliability during robot guided stereotactic neurosurgery and holds great potential as a low dose, cost effective means for intraoperative lead localization.

Moderate value of non-contrast magnetic resonance imaging after non-dislocating shoulder trauma.

PURPOSE: The purpose of the present study was to determine the value of shoulder magnetic resonance imaging (MRI) obtained in the community setting interpreted by musculoskeletal radiologists in patients with shoulder pain initiated by a single non-dislocating shoulder trauma. METHODS: In 56 of 61 consecutive patients who underwent shoulder arthroscopy due to pain after a single non-dislocating shoulder trauma, the data sets of non-contrast MRI were complete. These were retrospectively interpreted by three radiologists specialized on musculoskeletal MRI who were blinded for patients' history and who did not have access to the reports of arthroscopy. Standard evaluation forms were used to assess the MRIs for superior labrum anterior and posterior (SLAP) lesions, anterior or posterior labrum lesions, lesions of the long head of biceps tendon (LHB) and for partial tears of the supraspinatus tendon and the upper quarter of the subscapularis tendon. Quality of the MRI was assessed by each radiologist on a four-point scale. RESULTS: The pooled sensitivity for the three radiologists for the detection of SLAP lesions was 45.0 %, for anterior or posterior labrum tears 77.8 and 66.7 %, for lesions of the LHB 63.2 % and for partial tears of the supraspinatus or subscapularis tendon tears 84.8 and 33.3 %. Corresponding inter-rater reliabilities were poor (SLAP lesions) to substantial (anterior labrum tears). Quality of MRI only influenced the accuracy for the detection of posterior labrum tears. CONCLUSION: A non-contrast shoulder MRI obtained in the community setting after non-dislocating shoulder trauma has a moderate sensitivity for most intraarticular pathologies when interpreted by musculoskeletal radiologists. Accuracy is dependent on the observer and not on the assessed quality. LEVEL OF EVIDENCE: Case series, Level IV.

Supplemental screening ultrasound increases cancer detection yield in BRCA1 and BRCA2 mutation carriers.

INTRODUCTION: This study aimed at evaluating the efficacy of ultrasound for the early detection of breast cancers in BRCA1/2 mutation carriers. METHODS: Between 01/1997 and 10/2008 221 BRCA1/2 mutation carriers participated in a breast cancer screening program which included semi-annual ultrasound in combination with annual mammography and magnetic resonance imaging (MRI). Women underwent on average (median) five semi-annual screening rounds with a range of one to 22 appointments, totaling 1,855 rounds of screening. All three imaging modalities were coded according to the American College of Radiology (BI-RADS classification). RESULTS: In total, we detected 27 BRCA-associated breast cancers in 25 patients. The sensitivity was 77% for ultrasound, 27% for mammography, and 100% for MRI. Three tumors were detected directly as a result of only the semi-annual ultrasound screen. CONCLUSIONS: Due to the specific tumor morphology and the considerably elevated tumor doubling time, mutation carriers benefit from the addition of semi-annual ultrasound screening as a sensitive and cost-effective method.

Transmurality of scar influences the effect of a hybrid-intervention with autologous bone marrow cell injection and aortocoronary bypass surgery (MNC/CABG) in patients after myocardial infarction.

BACKGROUND: Cell therapy (CTx) is a strategy to support cardiac regeneration after myocardial infarction (MI). Thus far, clinical studies provided mixed results. Here, we investigated whether transmurality of the infarct may play a relevant role. METHODS: 18 patients (63 ± 3 years, 15 male) undergoing elective coronary artery bypass graft (CABG) surgery 2.2 ± 0.7 months post MI participated. 10 had transmural and 8 non-transmural infarct scars assessed by Tc-99m-MIBI Single-Photon Emission Computed Tomography (SPECT) and F18-FDG-Positron-Emission-Tomography (PET). During surgery, 10 ml of sternal bone marrow were obtained, mononuclear cells (MNC) were isolated. At the end of surgery MNC were injected into the infarctions' center and border zones (10 injections, 2 ml total, 6.6 ± 1.3 × 10(7) MNC). RESULTS: No major complications attributable to cell therapy were observed. The sizes of non-transmural scars were reduced at 3 and 24 months after treatment (7.7 ± 1.1% and 5.5 ± 1.8 vs. 17.5 ± 4.9%, P=0.05 and P=0.04), while transmural scars remained unchanged (23.5 ± 2.6% and 23.8±3.2 vs. 23.5 ± 2.6%, P>0.99 and P=0.95). A trend towards improved LVEF was seen in patients with non-transmural scars (MRI: 48.8 ± 5.1% vs. 30.6 ± 8.7%, P=0.3; SPECT: 54.1 ± 3.1 vs. 41.0 ± 4.0, P=0.086), but not in patients with transmural scars (MRI: 36.7 ± 3.9 vs. 34.3 ± 5.0, P=0.63, SPECT: 37.8 ± 3.1 vs. 37.9 ± 2.3%, P=0.96). CONCLUSIONS: A single hybrid intervention of MNC recovery, purification and injection with CABG-surgery (MNC/CABG) may be an attractive modality for cell therapy. However, no regeneration of avital transmural scar tissue seems to occur, while the contribution of MNC to improved perfusion in non-transmural myocardial infarct scars remains to be determined.

3D breast ultrasound: a significant predictor in breast cancer reduction under pre-operative chemotherapy.

BACKGROUND: The objective was the investigation of a possible predictive quantitative impact of initial tumor sphericity, measured by 3D sonography, on response to pre-operative chemotherapy. PATIENTS AND METHODS: This 3D ultrasound study was conducted on 41 consecutive primary breast cancer patients who received pre-operative epirubicin and paclitaxel chemotherapy; the tumors were measured by 3D sonography and by pathology after chemotherapy. Sphericity was defined as the ratio of the smallest to the largest extent by 3D sonography. RESULTS: A predictive impact of initial tumor sphericity on response to pre-operative chemotherapy was quantitatively identified for the first time. Sphericity was a significant predictor of pathological complete remission with a rank difference of 0.34 or about 1/3 i.e., spherical tumors were more likely to show successful remission. CONCLUSION: Tumor sphericity as defined from 3D sonography could be predictive of response to pre-operative chemotherapy regimens; prospective investigation is suggested.

Pathomorphological changes after radiofrequency ablation in the liver.

Radiofrequency ablation (RFA) has become a widespread treatment option for liver carcinoma. There is limited knowledge regarding the macroscopic and histomorphological changes of induced lesions. Twelve domestic pigs underwent RFA using a Starburst XL device with ablation diameter of 3 cm. One animal died within 24 h, two animals were killed after 2 weeks, and nine after 4 weeks. Their livers were used for macroscopic and histological investigation. Six human liver resection specimens after previous treatment with RFA were also investigated. In pig samples, acute RFA change showed a necrosis zone demarcated by resorption zone with granulocytes and hyperemia. In subchronic and chronic RFA change, the zone of thermofixation was followed by a fibrous capsule and a liver reaction zone. Small blood vessels in the lesions showed damage involving endothelial destruction and thrombosis. Larger vessels within the lesions were observed with intact vessel walls, surrounded by a rim of vital hepatocytes. In the human samples, tumor-infiltrating lymphocytes were reduced (CD3+ cells: 8.4 +/- 3.7/10 high-power fields (HPF); CD4+ cells: 4.2 +/- 1.9/10 HPF), whereas the number of histiocytes was found to be increased (CD68+ cells: 15.5 +/- 9.02/10 HPF). The recognition of thermofixation and the process of resorption of the RFA lesion is important for the interpretation of biopsies and surgical resection specimens.

Focal nodular hyperplasia of the liver in longterm survivors of neuroblastoma: how much diagnostic imaging is necessary?

OBJECTIVES: Focal nodular hyperplasia of the liver is a tumor-like lesion, uncommon in children, but it has recently been more frequently observed in children treated for malignant diseases, especially neuroblastoma. The aetiology is unclear, the pathogenesis remains controversial. Focal nodular hyperplasia of the liver is suspected to be a sequela of tumor therapy. METHODS: Besides the clinical data we evaluated the imaging modalities needed to diagnose focal nodular hyperplasia of the liver in children with neuroblastoma who have been followed in our institution for more than 5 years. RESULTS: Out of 60 children six developed focal nodular hyperplasia at a median time of 10.5 years after diagnosis of neuroblastoma and 9.4 years after the end of treatment. The diagnosis of focal nodular hyperplasia was based on imaging criteria which are variable in ultrasonography and specific in MRI. Only one child underwent surgical biopsies to rule out liver metastases. CONCLUSIONS: Longterm survivors of neuroblastoma are at risk of developing focal nodular hyperplasia, especially if they underwent toxic chemotherapy and/or radiotherapy to the liver during initial treatment. The recommended diagnostic imaging tools are ultrasonography for detecting liver lesions and MRI for confirming and characterizing these lesions as focal nodular hyperplasia.

Effects of the anti-VEGF monoclonal antibody bevacizumab in a preclinical model and in patients with refractory and multiple relapsed Hodgkin lymphoma.

No curative treatment is currently available for refractory or relapsed Hodgkin lymphoma (HL) after high-dose chemotherapy. Thus, new drugs with different modes of action are needed. Vascular endothelial growth factor (VEGF), a key regulator of tumor-angiogenesis, is elevated in sera of patients with HL. Hodgkin and Reed-Sternberg cells also express the growth-stimulating VEGF-R2 receptor suggesting that VEGF could contribute to the pathophysiology of this malignancy. We investigated the effects of the humanized anti-VEGF monoclonal antibody bevacizumab (BV) against human HL xenografts in severe combined immune deficiency mice and in a compassionate use program in HL patients with multiple relapsed and progressive diseases. After a 4-week run-in phase of single agent BV, combined gemcitabine and BV therapy was administered. In the animal model, BV delayed the growth of HL tumors significantly (P=0.0004). Out of 5 patients included, BV alone had biologic effects as determined by tumor size, blood flow, fluorodeoxyglucose-uptake, and serum markers CCL17/thymus and activation-related chemokine, and sCD30 in 4 patients. The combination of BV and gemcitabine led to partial or complete remission in 3 of 5 patients. Accordingly, VEGF deprivation by the anti-VEGF antibody BV has antitumor activity in established HL tumors in a preclinical model. Furthermore, BV single agent therapy has biologic effects in HL patients indicating clinical activity. On the basis of these results, a prospective clinical study has been initiated to further investigate the impact of this antiangiogenic approach in HL.

Real-time MR-guided wire localization of breast lesions by using an open 1.0-T imager: initial experience.

The purpose of this study was to prospectively evaluate technique and time factors for real-time magnetic resonance (MR) imaging-guided wire localization of suspicious breast lesions by using an open 1.0-T MR imager. It was conducted with institutional review board approval; informed consent was given by patients. Needle placement was monitored in 30 women (mean age, 50.5 years; range, 28-70 years) by using a dynamic balanced gradient-echo (single-shot turbo field-echo [TFE]) sequence with a temporal resolution of 0.5 second. In all patients, the tip of the needle was clearly identified during placement. Consistent with balanced TFE (BTFE) imaging, diagnostic MR imaging after the interventional procedure confirmed that the hookwires were placed 0-6 mm (mean, 3.3 mm) from the target lesions. The total procedure time ranged from 16-36 minutes. Results show that real-time MR-guided wire localization permits correction of the needle position during placement and reduces the interventional procedure time.

A Contribution to solve the problem of the need for consolidative radiotherapy after intensive chemotherapy in advanced stages of Hodgkin's lymphoma--analysis of a quality control program initiated by the radiotherapy reference center of the German Hodgkin Study Group (GHSG).

PURPOSE: The role of radiotherapy (RT) after intensive chemotherapy in patients with advanced stage Hodgkin's lymphoma (HL) is still unclear. The German Hodgkin Study Group (GHSG) randomized HD12 trial was designed to test whether consolidative RT in the region of initial bulky disease and of residual disease is necessary after effective chemotherapy. A quality control program based on a multidisciplinary panel of radiation oncologists, radiologists, and medical oncologists who reviewed all patients' staging and restaging imaging was initiated. METHODS AND MATERIALS: A total of 1661 patients aged 16 to 65 years with HL in Stage IIB (large mediastinal mass and/or E-lesions) or Stage III to IV were randomized from January 1999 to January 2003 according to a factorial design between: 8 esc.BEACOPP + RT (arm A), 8 esc.BEACOPP non-RT (arm B), 4+4BEACOPP + RT (arm C), 4+4BEACOPP non-RT (arm D). RESULTS: In the fifth interim analysis, 1449 patients were eligible for the arm comparison with regard to RT. After a median observation time of 48 months the FFTF rate was 86% and the OS 92%. The FFTF was 95% in the RT arms A+C and 88% in the non-RT arms B+D: no sequential significant difference. One thousand and eighty four patients were evaluated by the panel. The panel defined initial bulky disease in 800 patients and residual disease in 600 patients. The panel recommended continuation of therapy according to the randomization for 934 of 1084 patients and additive RT independently from the randomization arm for 145 of 1084 patients. CONCLUSIONS: The study showed that RT can be reduced substantially after effective chemotherapy. However, because of the irradiation of 10% of patients in the non-RT arms, equivalent effectiveness of a non-RT strategy cannot be proved. A substantial limitation of consolidative RT according to expert panel recommendations appears to be possible without reducing effectiveness.

Image quality of digital direct flat-panel mammography versus an analog screen-film technique using a phantom model.

OBJECTIVE: The objective of our study was to compare the detection and distinguishability of microcalcifications on mammograms obtained with a digital direct flat-panel detector versus an analog system using an anthropomorphic breast phantom. MATERIALS AND METHODS: Studies were performed with a digital mammography system (Selenia) and an analog mammography system (Mammomat 3). Sixty-five transparent films were used as test specimens. Randomly distributed round and heterogeneous silicate particles (diameter, 100-1,400 microm) and an anthropomorphic scatter body were applied to the films. All radiographs were taken at identical settings and exposures. Six radiologists rated the films and monitor-displayed images independently of each other in random order on a standardized electronic questionnaire. RESULTS: Interpretations based on monitor reading produced superior results over those based on digital image reading and analog film reading. In 41.1% (95% CI, 38.7-43.5%) of all the monitor readings, 20.2% (18.2-22.2%) of all digital images, and 19.6% (17.6-21.6%) of all analog films, the number of detectable microcalcifications agreed with the gold standard method. The diameter of visible microcalcifications was interpreted correctly in 35.6% (33.2-38.0%) of monitor readings, 19.0% (17.1-21.0%) of digital images, and 21.0% (18.9-23.0%) of analog films; and microcalcification shape was interpreted correctly in 53.8% (51.4-56.3%) of monitor readings, 28.2% (26.0-30.4%) of digital images, and 28.3% (26.0-30.5%) of analog films. Microcalcification number and size were underestimated more frequently than overestimated. Regardless of display medium, accuracy increased proportionately with the diameter of the simulated microcalcifications for all evaluation variables. CONCLUSION: Digital flat-panel mammography is superior to the analog screen-film method for the detection and morphologic characterization of microcalcifications larger than 200 microm in diameter when the display medium is a monitor.

Stent Grafts for Acute Traumatic Injury of the Thoracic Aorta: A Single-Centre Experience.

OBJECTIVES: The presented study reveals the single centre experiences with the minimally invasive endovascular repair for acute traumatic thoracic aortic lesions in the care of multitrauma patients. METHODS: We reviewed ten patients with acute traumatic thoracic aortic lesions treated with a thoracic aortic stent graft between April 2001 and December 2006. The prospective collected data included age, sex, injury severity score, type of endovascular graft, endovascular operation time, length of stay, length of stay in the intensive care unit, and mortality. Followup data consisted of contrast-enhanced spiral computed tomography at regular intervals. RESULTS: All patients (m:f 5:5; median age, 46 years; interquartile range [IQR], 29-68.5 years) suffered severe traumatic injury, the median Injury Severity Score was 39.5 (IQR 37.3-43). All endovascular procedures were technically successful, and the median operating time for the endovascular procedure was 90 min (IQR, 65-120 min). The overall hospital mortality was 20% (n = 2), and all deaths were unrelated to the aortic rupture or stent placement. No incidence of paraplegia was present. No intervention-related mortality occurred during a median follow-up of 14.7 months (IQR, 9.7-55.8 months). CONCLUSION: The endovascular approach to acute traumatic thoracic aortic lesions is feasible, safe, and effective in multitrauma patients. The low endovascular therapy-related morbidity and mortality in the postoperative period is encouraging. The results seem to be favorable to those published of open emergency repair.

Percutaneous embolization for cervicofacial neoplasms and hemorrhages.

OBJECTIVE: To retrospectively assess the effectiveness of percutaneous embolization for curative, preoperative or palliative management of hypervascular neoplasms, vascular malformations and bleedings of the head and neck area. METHODS: A retrospective 8-year analysis of outcomes in 85 patients undergoing preoperative embolization for tumors or vascular lesions of the head and neck or embolization for refractory tumor bleeding and epistaxis at our hospitals was performed by reviewing case records. Outcome of the preoperatively embolized patients was defined as successful if intraoperative bleeding was <500 ml and/or postinterventional angiogram showed complete occlusion of all tumor-feeding or bleeding vessels. RESULTS: Complete preoperative tumor embolization was achieved in 83.5% of the patients. Partial embolization was possible in 10.5%. All tumor bleedings refractory to conservative therapy and bleedings from epistaxis showed a successful outcome. CONCLUSIONS: In vascular lesions and tumors of the head and neck, preoperative percutaneous embolization improved the surgical outcome, reduced intraoperative blood loss significantly and facilitated tumor resectability. Cervicofacial bleeding resulting from a tumor, vascular malformation or epistaxis can be managed effectively by endovascular techniques.

CT and MR imaging in Hodgkin's disease--present and future.

Initial staging of Hodgkin's disease is crucial to determine the location and extent of disease, and is the hallmark for the choice of treatment. At present, the established radiological technique for staging Hodgkin's disease is computed tomography (CT). Modern multidetector row CT scanners allow fast imaging from the scull base to the groins during a single breath hold with a spatial resolution of approximately 1 mm. Both, nodal and extranodal involvement of Hodgkin's disease can be diagnosed with CT. Magnetic resonance (MR) imaging is another useful cross-sectional imaging modality for staging Hodgkin's disease. The development of fast MR imaging techniques has considerably reduced imaging time without compromising the quality of MR images. As a consequence, MR imaging is now considered to be as diagnostic as CT for staging Hodgkin's disease. The excellent soft-tissue contrast and the lack of exposure to ionizing radiation are the main advantages of MR imaging. For the detection of extranodal Hodgkin's disease, MR imaging is superior to assess involvement of the brain, the spinal cord and bone marrow; while CT allows excellent evaluation of lung disease. Common major problems in staging Hodgkin's disease are still the detection of nodal involvement in normal sized lymph nodes and residual tumor masses after therapy. In the future, newly developed lymphotropic contrast agents for MR imaging might be helpful to answer these questions.

Imaging in neurooncology.

Imaging in patients with brain tumors aims toward the determination of the localization, extend, type, and malignancy of the tumor. Imaging is being used for primary diagnosis, planning of treatment including placement of stereotaxic biopsy, resection, radiation, guided application of experimental therapeutics, and delineation of tumor from functionally important neuronal tissue. After treatment, imaging is being used to quantify the treatment response and the extent of residual tumor. At follow-up, imaging helps to determine tumor progression and to differentiate recurrent tumor growth from treatment-induced tissue changes, such as radiation necrosis. A variety of complementary imaging methods are currently being used to obtain all the information necessary to achieve the above mentioned goals. Computed tomography and magnetic resonance imaging (MRI) reveal mostly anatomical information on the tumor, whereas magnetic resonance spectroscopy and positron emission tomography (PET) give important information on the metabolic state and molecular events within the tumor. Functional MRI and functional PET, in combination with electrophysiological methods like transcranial magnetic stimulation, are being used to delineate functionally important neuronal tissue, which has to be preserved from treatment-induced damage, as well as to gather information on tumor-induced brain plasticity. In addition, optical imaging devices have been implemented in the past few years for the development of new therapeutics, especially in experimental glioma models. In summary, imaging in patients with brain tumors plays a central role in the management of the disease and in the development of improved imaging-guided therapies.

Magnetic resonance imaging in an orthotopic rat model: blockade of epidermal growth factor receptor with EMD72000 inhibits human pancreatic carcinoma growth.

The purpose of our research was to investigate the antiangiogenic effect of the epidermal growth factor receptor monoclonal antibody (anti-EGF-R MAB) EMD72000, in an orthotopic human pancreatic carcinoma model in rats, assessed by magnetic resonance (MR) imaging using angiogenic surrogate markers in comparison with histopathologic findings. Human pancreatic adenocarcinoma cells L3.6pl were injected orthotopically in the pancreas of 12 athymic nude rats. Through a 21-day course, groups of 6 rats were treated intraperitoneally with either EMD72000 or with saline solution for control animals. Dynamic contrast-enhanced MR imaging was performed before and after the treatment to assess microvascular permeability, estimated by the endothelial transfer coefficient (KPS) and fractional plasma volumes (fPV) of the pancreatic tumors. EMD72000-treated animals showed significantly less tumor volume progression (1,080 mm3 +/- 1,244; p = 0.012) and significantly lower values for microvascular permeability (KPS = 4.2 ml min(-1) 100 ml(-1) of tissue +/- 2.8; p = 0.015), fractional plasma volume (fPV = 0.018 ml ml(-1) of tissue +/- .015; p = 0.003) and microvessel density (MVD = 13 +/- 4 (0.159 mm2); p = 0.001) than saline-treated animals (6,544 mm3 +/- 5,202; 9.5 ml min(-1) 100 ml(-1) of tissue +/- 4.3, 0.056 ml ml(-1) of tissue +/- 0.019 and 25 +/- 5 (0.159 mm2), respectively). KPS and fPV values showed moderate positive correlation with MVD (r = 0.5, p = 0.103; r = 0.6, p = 0.065, respectively). Intraperitoneal injection of EMD72000 inhibits orthotopic human pancreatic carcinoma growth in rats. Antiangiogenic effects of anti-EGF-R MAB EMD72000 can be quantified and monitored noninvasively by dynamic MR imaging.