Posttraumatic and postoperative cardiac luxation: computed tomography findings in nine patients.

BACKGROUND: Posttraumatic and postoperative cardiac luxation represents a serious complication of pericardial rupture, and early diagnosis is important. The purpose of this study is to determine signs of left cardiac luxation on computed tomography (CT). METHODS: CT scans in nine patients with pericardial rupture and cardiac luxation after blunt chest trauma (n = 7) and postoperatively after extended left pneumectomy (n = 2) were reviewed for abnormalities. We analyzed the clinical history, clinical findings, and the imaging findings. RESULTS: Dislocation of the heart to the left and pneumopericardium were seen in nine patients. Five of these nine patients revealed "entrapment" of the left heart between the proximal ascending aorta and the descending aorta. All patients underwent a pneumopericardium. All patients with a history of trauma showed a left-sided pneumothorax but no pericardial effusion. CONCLUSIONS: CT plays a key role for early diagnosis of cardiac luxation. Dislodgment of the heart, entrapment of the left atrium and ventricle, and pneumopericardium associated with pneumothorax are the most important CT findings.

Molecular staging in stage II and III melanoma patients and its effect on long-term survival.

PURPOSE: To assess the prognostic value of serial reverse transcriptase polymerase chain reaction (RT-PCR) -based measurements of tyrosinase mRNA in peripheral blood of stage II and III melanoma patients. PATIENTS AND METHODS: During routine follow-up of American Joint Committee on Cancer stage II and III melanoma patients, serial testing for tyrosinase transcripts in peripheral blood was performed by RT-PCR. The PCR results were compared with the clinical data collected during the follow-up. RESULTS: Over a period of 3 years, 111 patients (78 stage II and 33 stage III patients) were enrolled, and tyrosinase determinations were carried out. The 6-year disease-specific survival probability was 97% for patients always showing negative RT-PCR results and 67% for patients who tested positive at least once. In a Cox proportional hazards model, the prognostic value of sex, age, site of primary tumor, histologic subtype, stage, Breslow's tumor thickness, Clark level, and the time-dependent variable PCR result was assessed. Patients with a positive RT-PCR test had a distinctly higher risk of dying from melanoma, with a hazard ratio of 12.6 (95% CI, 3.4 to 46.3; P < .001). CONCLUSION: Our study shows a strong association between PCR and disease-specific survival time. Detection of tyrosinase mRNA in peripheral blood may be of similar importance for the clinical course of melanoma as the detection of micrometastatic disease in the sentinel lymph node. Whether a combination of these two factors leads to a better definition of the prognosis of melanoma patients is under investigation in current studies.

Impact of molecular staging methods in primary melanoma: reverse-transcriptase polymerase chain reaction (RT-PCR) of ultrasound-guided aspirate of the sentinel node does not improve diagnostic accuracy, but RT-PCR of peripheral blood does predict survival.

PURPOSE: This study analyzes (1) the value of tyrosinase reverse-transcriptase polymerase chain reaction (RT-PCR) of aspirates obtained by ultrasound-guided fine-needle aspiration cytology (US-FNAC) of sentinel nodes (SNs) in patients with melanoma before sentinel lymph node biopsy (SLNB) and (2) the value of RT-PCR of blood samples of all SLNB patients. PATIENTS AND METHODS: Between 2001 and 2003, 127 patients with melanoma (median Breslow depth, 2.1 mm) underwent SLNB. FNAC was performed in all SNs of all patients pre- and post-SLNB. The aspirates were partly shock-frozen for RT-PCR and were partly used for standard cytology. Peripheral blood was collected at the time of SLNB and at every outpatient visit thereafter. RESULTS: Thirty-four (23%) of 120 SNs were positive for melanoma. SN involvement was predicted by US-FNAC with a sensitivity of 82% and a specificity of 72%. Additional tyrosinase RT-PCR revealed the same sensitivity of 82% and a specificity of 72%. At a median follow-up time of 40 months from first blood sample, peripheral-blood RT-PCR was a significant independent predictor of disease-free survival (DFS) and overall survival (OS; P < .001). CONCLUSION: US-FNAC is highly accurate and eliminates the need for SLNB in 16% of all SLNB patients. RT-PCR of the aspirate or excised SN does not improve sensitivity or specificity. RT-PCR of blood samples predicts DFS and OS.

Primary stent placement for infrarenal aortic stenosis: immediate and midterm results.

PURPOSE: To evaluate the safety and the long-term clinical and hemodynamic results of primary stent placement of atherosclerotic calcified stenosis of the infrarenal aorta. MATERIAL AND METHODS: Between July 1996 and July 1999, 15 patients (nine male, si- female; mean age, 53.9 years) with symptomatic, calcified aortic stenosis were treated with primary stent placement. Patients underwent abdominal aortography and bilateral lower extremity arteriography. Follow-up was performed in all 15 patients. Technical success was defined as residual stenosis of less than 30% or a resting trans-systolic pressure gradient of less than 10 mm Hg after stent placement. Clinical patency was defined as the absence or improvement of symptoms after stent placement. Hemodynamic patency was defined as a normal triphasic Doppler waveform in the common femoral artery, an ankle-brachial index greater than 0.90, or the absence of a thigh-brachial pressure gradient at rest in either limb. RESULTS: Technical success was achieved in 13 of 15 patients. The two patients considered to be technical failures had resting trans-systolic pressure gradients of 12 and 13 mm Hg, respectively, after stent placement. After the mean follow-up of 36 months, primary clinical and hemodynamic patency rates were 85% and the secondary hemodynamic patency rate was 100%. Two of five symptomatic recurrences during the 36-month follow-up period (range, 12-46 months) were a result of aortic restenosis and were treated with repeated percutaneous transluminal angioplasty. None of the patients required aortic surgery. Complications of the primary procedure included one puncture site infection, one pseudoaneurysm, and one distal embolization, which delayed discharge of three patients. There was no morbidity during the secondary interventions. CONCLUSION: Primary stent placement as treatment of calcified infrarenal aortic stenosis proved to be safe and also provided durable long-term clinical improvement.

Role of power Doppler techniques and ultrasound contrast enhancement in the differential diagnosis of focal breast lesions.

The purpose of this article is to demonstrate the diagnostic impact of ultrasound in differentiating focal breast lesions with special regard on power Doppler and US contrast agents. The sonographic evaluation of breast lesions has become a standard procedure during the past 15 years. Especially the improvement of B-mode resolution and the use of high-frequency probes increased the diagnostic value of US. Assuming that the neoangiogenetic vascular architecture of solid breast lesions can be depicted reliably by color Doppler, many authors tried to differentiate between benignity and malignancy using Doppler criteria such as flow and morphologic aspects. Additionally, adjuvant techniques, such as harmonic imaging and new US contrast agents, are meant to be success-promising tools. Whereas the sensitivity and specificity of color Doppler have varied in different studies, prognostic prediction and treatment monitoring seem to be the future areas of application. To evaluate sufficiently flow signals of very small vessels with low flow velocity, the use of contrast-enhancing agents may be necessary. Nevertheless, an indispensable condition for successful Doppler-based assessment of the entity of breast lesions is the standardization of techniques, evaluation, analysis and weighting of the parameters.