Whole-body SPECT/CT for bone scintigraphy: diagnostic value and effect on patient management in oncological patients.

PURPOSE: This study was designed to assess the additional value of SPECT/CT of the trunk used in conjunction with conventional nuclear imaging and its effects on patient management in a large patient series. METHODS: In 353 patients, whole-body scintigraphy (WBS), SPECT, and SPECT/CT were prospectively performed for staging and restaging. SPECT/CT of the trunk was performed in all patients. In the 308 evaluable patients (211 with breast cancer, 97 with prostate cancer), clinical follow-up was used as the gold standard. Bone metastases were confirmed in 72 patients and excluded in 236. Multistep analyses per lesion and per patient were performed. Clinical relevance was expressed in terms of downstaging and upstaging rates on a per-patient basis. RESULTS: In the total patient group, sensitivities, specificities, and negative and positive predictive values on a per-patient basis were 93 %, 78 %, 95 % and 59 % for WBS, 94 %, 71 %, 97 % and 53 % for SPECT, and 97 %, 94 %, 97 % and 88 % for SPECT/CT, respectively. In all subgroups, specificity and positive predictive value were significantly (p<0.01) better with SPECT/CT. Downstaging of metastatic disease in the total, breast cancer and prostate cancer groups using SPECT/CT was possible in 32.1 %, 33.8 % and 29.5 % of patients, respectively. Upstaging in previously negative patients by additional SPECT/CT was observed in three breast cancer patients (2.1 %). Further diagnostic imaging procedures for unclear scintigraphic findings were necessary in only 2.5 % of patients. SPECT/CT improved diagnostic accuracy for defining the extent of multifocal metastatic disease in 34.6 % of these patients. CONCLUSIONS: SPECT/CT significantly improved the specificity and positive predictive value of bone scintigraphy in cancer patients. In breast cancer patients, we found a slight increase in sensitivity. SPECT/CT had a significant effect on clinical management because of correct downstaging and upstaging, better definition of the extent of metastases, and a reduction in further diagnostic procedures.

New tip design and shock wave pattern of electrohydraulic probes for endoureteral lithotripsy.

A new tip design of a 3.3F electrohydraulic probe for endoureteral lithotripsy was evaluated in comparison to a regular probe. The peak pressure, as well as the slope of the shock front, depend solely on the voltage. Increasing the capacity leads merely to broader pulses. A laser-like short high-pressure pulse has a greater impact on stone disintegration than a corresponding broader low-pressure pulse of the same energy. Using the regular probe, only positive pressures were obtained. Pressure distribution around the regular tip was approximately spherical, whereas the modified probe tip "beamed" the shock wave to a great extent. In addition, a negative-pressure half-cycle was added to the initial positive peak pressure, which resulted in a higher maximal pressure amplitude. The directed shock wave had a greater depth of penetration into a model stone. Thus, the ability of the new probe to destroy harder stones especially should be greater. The trauma to the ureter was reduced when touching the wall tangentially. No difference in the effect of the two probes was seen when placing the probe directly on the mucosa.

Pneumatic v electrokinetic lithotripsy in treatment of ureteral stones.

Recently, a new device (Combilith) for electrokinetic lithotripsy (EKL) has become available which is very similar to the well-known device for pneumatic (ballistic) lithotripsy (Swiss Lithoclast). The Lithoclast uses air pressure to push a projectile within the handpiece against the end of a metal probe, which is thereby accelerated and thrown like a jackhammer against the stone. In principle, the same stroking movement of a small metal probe is provided by EKL; the difference is that instead of a projectile, a magnetic core within the handpiece is accelerated by the electromagnetic principle. This paper compares the clinical efficacy and the features of the two devices. Testing the devices on a stone model, taking into account stone propulsion, the systems turned out to equally effective regarding stone disintegration. However, stone displacement was more pronounced with the Lithoclast applied on easily breaking stones. In a second experiment, an optoelectronic movement-measuring apparatus (Zimmer camera) was employed to measure the range and velocity of the movement of the probe tip without any contact. The linear acceleration velocity ranged from 5 to a maximum of 12.5 m/sec with both systems, but the maximum height of the stroke was 2.5 mm with the Lithoclast and 1 mm with EKL. After the initial break-up of soft stones, further impact of the probe tip against the stone resulted merely in propulsion; thus, the greater probe stroke height is the cause of the stone displacement. In a clinical trial, 22 ureteral stones were treated with the Lithoclast and 35 with the EKL. The two devices were equally effective in terms of stone disintegration and safety margin. Fixation using a Dormia basket was necessary in 12 cases (8 Lithoclast, 4 EKL). Although a difference in probe stroke height was noted when comparing pneumatic and electrokinetic lithotripsy, there were no clinically significant differences in the efficacy of stone fragmentation or stone-free rates. At the current time, EKL is less costly.

[Importance of rapid MR imaging for tumor diagnosis in the area of the kidneys and adrenals]. / Bedeutung der schnellen MR-Bildgebung für die Tumordiagnostik im Nieren- und Nebennierenbereich.

Gradient-echo pulse sequences with fast acquisition times permit examinations in short breath-holding intervals. In this way an improvement of MR imaging of upper abdominal organs can be expected. In 41 patients with space-occupying lesions of kidneys and adrenals, influence of external parameter variations on resulting contrasts was analyzed and results were compared to other imaging methods. Gradient-echo sequences demonstrated a high sensitivity in detection of tumorous lesions of kidneys and adrenals, the specificity being similar to that of CT. Further differentiation was only possible by performing dynamic perfusion studies using paramagnetic contrast agents.

Biochemical classification of kidney carcinoma biopsy samples using magic-angle-spinning 1H nuclear magnetic resonance spectroscopy.

High resolution 1H nuclear magnetic resonance (NMR) spectra using spinning at the magic angle (1H MAS NMR) have been obtained on intact normal and pathological kidney tissue samples from patients undergoing surgery for renal cell carcinoma (RCC). The spectra were measured on ca. 80 mg samples and provided high resolution 1H NMR spectra in which effects of dipolar couplings, chemical shift anisotropy and magnetic susceptibility differences are minimised thus yielding high spectral resolution. Conventional one-dimensional and spin-echo spectra and two-dimensional J-resolved, TOCSY and 1H-13C HMQC spectra were also measured on selected samples and these allowed the assignment of resonances of endogenous substances comprising both cytosolic and membrane components. The tumour tissues were characterised principally by an increased lipid content. These are the first reported results on human tumour tissues using this technique and the approach offers potential for the rapid classification of different types of tumour tissue.

[Adjustable electrohydraulic lithotripsy for minimally invasive ureteroscopic stone treatment]. / Regelbare elektrohydraulische Lithotripsie zur minimal invasiven ureteroskopischen Steinbehandlung.

We report on 82 ureteroscopies and electrohydraulic lithotripsies performed with small semirigid ureteroscopes with a minimum outer diameter of 6.5 F and probes of 2.4 F and 3.3 F. Prototypes of new lithotripters were employed, which incorporate infinitely variable energy within a range of 265-1382 mJ per pulse. Increased energy was provided by a rise in voltage, thus modifying the peak pressure and the initial slope of the shock wave. One third of the stones were situated in the upper ureter, 15% in the middle and 46% in the lower ureter. In 54% of these cases previous ESWL (Dornier MFL 5000) had been performed without success. Over 85% of the manipulations were performed under local anesthesia and i.v. sedation. Stone contact was achieved in 99%. Lithotripsy was fully successful in over 90%. The average energy per pulse was 450 mJ. In 7% partial disintegration was achieved and the residual stone was flushed back into the renal pelvis followed by further effective ESWL treatment. One stone had to be removed by open surgery. There were no major complications, such as perforations, due to the electrohydraulic lithotripsy itself. One perforation was caused when the endoscope was advanced into the ureter. No strictures were seen at the 6-month follow-up examination. An indwelling stent was placed in 48% of cases, as the stone burden or an inflamed stone bed suggested this was necessary. We conclude that electrohydraulic lithotripsy with adjustable energy resulting in various peak pressures of the shock wave is a safe and effective method of endoureteral stone treatment.

[Clodronate in the palliative therapy of bone-metastasized prostatic carcinoma]. / Clodronat in der palliativen Therapie des ossär metastasierten Prostatakarzinoms.

Activity and side-effects of clodronate (Ostac), an inhibitor of osteoclastic bone resorption, were recorded in an open prospective uncontrolled study on 35 patients with metastatic prostatic cancer. All patients had progressive symptomatic bone metastases despite prior hormone therapy. Clodronate was initially administered i.v. for 8 days with 300 mg/day. This was followed by a daily oral administration of 1600 mg. The analgesic effect was evaluated by using a visual analogue scale and by recording the daily consumption of analgesic drugs. Karnofsky index and routine blood examinations, including PSA, were assessed. Repeated bone scans and radiological evaluations were performed. An improvement in pain was observed in 71% of the patients. The mean duration of improvement was 4 weeks. Average survival time was 12 weeks. There were no side-effects after i.v. administration. Slight gastrointestinal discomfort was observed in 3 patients after oral administration. No effect was observed on the extent or biology of the metastases. Clodronate is an effective drug for palliative treatment of symptomatic bone metastases of prostatic carcinoma. It causes fewer and less pronounced side effects than other palliative drug therapies.

[Complete urethral rupture with symphysis injury and anterior pelvic ring fracture during spontaneous delivery]. / Komplette Urethraruptur mit Symphysensprengung und vorderer Beckenringfraktur unter Spontangeburt.

We report on a complete longitudinal rupture of the urethra in combination with a rupture of the pubic symphysis and pelvic fracture during spontaneous vaginal delivery. Only after stabilisation of the pelvic fracture by external skeletal fixation adaptation of the urethra was possible. Three weeks later after removing of the transurethral catheter a mild stress incontinence could be observed. In the follow up one year later the patient was completely continent. The cosmetic result was satisfactory. There was no cystocele. An unclear haematuria after delivery needs a meticulous urological examination. Early repair of urethral disruption minimize the risk of severe incontinence. Coordinated care between the trauma surgeon and urologist is required for successful treatment of this rare combined injury after birth.

[Clinical value of new rapid nuclear magnetic resonance tomography in preoperative assessment of hypernephroma. A prospective comparative study of CT and MR]. / Klinischer Nutzen der neuen schnellen Kernspintomographie in der präoperativen Beurteilung von Hypernephromen. Eine prospektiv vergleichende Studie zwischen CT und MR.

The new technique of rapid magnetic resonance imaging (MRI) with a paramagnetic contrast agent provides excellent imaging of the kidneys and their lesions. MR imaging of this anatomical region at short breath holding intervals matches the well-known quality of computed tomography (CT) for the first time. MR and CT studies were performed on 36 patients with proven renal cell carcinoma. Different investigators evaluated the staging of the tumor by means of both techniques in a prospective study. In all patients a radical nephrectomy was performed. Surgical and pathological findings were compared. Though little difference was found in diagnostic value between the two systems, MRI results concerning the T-stage were better. Venous invasion was clearly shown by MRI without the use of contrast medium. Furthermore, sagittal and transaxial images provided a more direct assessment of the extent of the tumor and its demarcation to healthy parenchyma. Thus, MRI is helpful in planning of the surgical approach when organ-sparing excision of renal tumors is to be performed.

[Gas-forming mycosis of the kidney]. / Gasbildende Mykose der Niere.

We report on the case of a 22-year-old heroin-dependent diabetic woman. She presented with a gas-forming fungal infection of the kidney caused by Candida tropicalis. The patient was successfully treated by conservative means. Problems in the diagnosis and therapy of this rare disease are discussed.

[Ultra-thin, flexible ureteropyeloscopy: a new diagnostic possibility. An animal experiment and clinical pilot study]. / Ultradünne, flexible Ureteropyeloskopie: eine neue diagnostische Möglichkeit. Eine tierexperimentelle und klinische Pilotstudie.

Recent advances in fiberoptic technology have resulted in the development of fiberscopes with an outer diameter of less than 6 F and an irrigating or working channel. The feasibility, conditions and benefit of ureteropyeloscopy with ultrathin, flexible endoscopes were evaluated in two sets of investigations: (1) in 6 pigs and (2) in 12 patients during routine retrograde pyelography. Prototypes of flexible endoscopes with a passively deflectable tip, an outer diameter of 5.5 F (1.8 mm) and a 1.5 F (0.5 mm) channel were used. Fine-needle aspiration cytology is possible through the channel under endoscopic control. At present, the lack of maneuverability and the fragility of the fiberscopes limit this method. Its use in the clinical routine, in addition to retrograde ureteropyelography, under local anesthesia is of great promise, however.

[Follow-up of contralateral intratesticular oxygen pressure in unilateral testicular torsion]. / Verlauf des kontralateralen intratestikulären Sauerstoffdrucks während einseitiger Hodentorsion.

The intratesticular tissue oxygen tension (= IT-pO2) depends on the testicular perfusion. Polarographic microcatheter probes have recently become available and are suitable for continuous measurements of the tissue oxygen tension. In 20 adult albino rats flexible Clark-type oxygen electrodes (1.5 F) were used for simultaneous monitoring of IT-pO2 of the ipsi- and contralateral testicle during unilateral torsion. A counterclockwise 720 degrees torsion caused a decrease of IT-pO2 from 21 mm Hg (+/- 5 mm Hg) to 5 mm Hg (+/- 1.5 mm Hg) in the twisted testicle within 5-7 min. After detorsion the IT-pO2 returned to normal level in the following 25 min. The IT-pO2 of the contralateral testicle showed no significant changes during torsion for 1 h or after detorsion. Thus, if the oxygen utilization is unchanged a unilateral acute torsion for 1 h does not cause a decrease in perfusion in the contralateral testicle. It will probably also prove possible to use oxygen tissue tension measurements to improve our understanding of testicular perfusion in humans.

[Testicular epidermoid cyst: orchiectomy or enucleation resection?]. / Testikuläre Epidermiszyste: Orchiektomie oder Enukleationsresektion?

Our experience with 18 patients with simple epidermoid cysts of the testis is reported. In each patient the tumour was enucleated completely and two biopsies of the adjacent parenchyma were obtained for exclusion of associated germ cell cancer, scars or carcinoma in situ. There was no evidence of malignancy in any of the biopsy specimens. Preoperative evaluation included physical examination, testicular sonography, and determination of AFP and hCG serum levels. Although epidermoid cyst can be strongly suspected on sonography the ultrasound appearance is not specific, and inguinal testicular exploration was required in these patients. In 1 patient multiple epidermoid cysts of the right testis were associated with an adult teratoma containing embryonal carcinoma and choriocarcinoma of the left testis; no similar case has been described in the literature. On the basis of our results and experience we consider tumour enucleation and biopsy of the adjacent parenchyma to be adequate treatment for benign epidermoid cyst. The world literature concerning organ-sparing surgery in testicular epidermoid cyst is reviewed.

Biphosphonates as an adjunct to palliative therapy of bone metastases from prostatic carcinoma. A pilot study on clodronate.

Clodronate (Ostac) is a specific inhibitor of osteolysis from the group of biphosphonates. The efficacy and side effects of palliative treatment with the substance were investigated in an open prospective non-controlled pilot study in 41 patients with advanced, progressive, hormone-resistant prostatic carcinoma. All patients suffered from symptomatic bone metastases. Initially, they underwent an 8-day saturation course with 300 mg clodronate i.v. per day. A good to very good analgesic effect was achieved within 3 to 5 days in 29 patients (71%). The mean duration of action was 7 weeks and the mean survival time 12 weeks. There were no side effects after i.v. administration. Slight gastrointestinal discomfort was reported in 3 patients following oral administration. Delayed progression of the metastases was not observed. Clodronate is a promising addition to the other therapeutic possibilities in hormone-resistant prostatic carcinoma.

Impact of voltage and capacity on the electrical and acoustic output of intracorporeal electrohydraulic lithotripsy.

The electrical and acoustic output created by the spark discharge for electrohydraulic lithotripsy at the tip of a 3.3-F probe was evaluated. Spark generation was achieved by variable combinations of voltage and capacity. The effective electrical output was determined by means of a high-voltage probe, a current coil and a digital oscilloscope. Peak pressures, rise times and pulse width of the shock waves were recorded using a polyvinylidene difluoride needle hydrophone in 0.9% NaCl solution at a distance of 10 mm. The effective electrical output is lower than the calculated output, due to inductivities, capacities and resistances of the cables and plugs. The life of the probes is markedly shorter when a combination of high voltage and low capacity is used than with low voltage and high capacity corresponding to the same energy. The peak pressure and the slope of the shock front depend solely on the voltage, while the pulse width is correlated with the capacity. The pulse intensity integral of the shock wave is likely to be the best equivalent to the applied energy.

Evaluation of the shock-wave pattern for endoscopic electrohydraulic lithotripsy.

We evaluated the electrical events and the resulting shock waves of the spark discharge for electrohydraulic lithotripsy at the tip of a 3.3F probe. Spark generation was achieved by variable combinations of voltage and capacity. The effective electrical output was determined by means of a high-voltage probe, a current coil, and a digital oscilloscope. Peak pressures, rise times, and pulse width of the pressure profiles were recorded using a polyvinylidene difluoride needle hydrophone in 0.9% NaCl solution at a distance of 10 mm. The peak pressure and the slope of the shock front depend solely on the voltage, while the pulse width was correlated with the capacity. Pulses of less than 1-microsecond duration can be obtained when low capacity is applied and the inductivity of the cables and plugs is kept at a low level. Using chalk as a stone model it was proven that short pulses of high peak pressure provided by a low capacity and a high voltage have a greater impact on fragmentation than the corresponding broader shock waves of lower peak pressure carrying the same energy.

Ultrathin flexible endoscopes for ureteroscopy. A preliminary experimental and clinical study.

Recent advances in fiberoptic technology have resulted in the development of endoscopes with an outer diameter of less than 6 F, including an irrigating or working channel. After preliminary testing of these ultrathin fiberscopes for ureteroscopy on 6 pigs, 17 patients were examined during routine retrograde pyelography. Prototypes of flexible endoscopes without an actively deflectable tip and an outer diameter of 5.5 F (= 1.8 mm) and a 1.5 F (= 0.5 mm) channel were used. Fine-needle aspiration cytology was obtained through the channel. The feasibility, performance and benefits of ureteroscopy with ultrathin, flexible endoscopes were evaluated. At present the lack of maneuverability and the fragility of the fiberscopes limit this method. Yet its routine clinical use, in addition to retrograde ureteropyelography under local anesthesia, shows great promise.

[Current trends in clinical urology]. / Aktuelle Trends der klinischen Urologie.

Many recent developments in urologic diagnostic and therapy are also of interest for general surgeons. Flexible and semirigid ureteroscopes (6-8 F) provide easy and atraumatic access to the whole upper urinary tract. Beside extracorporeal shockwave-lithotripsy now various endourologic modalities to treat ureteral stones are available. Although useful, laparoscopic techniques are not yet widely accepted by urologists because there is a lack of indications in urologic laparoscopic surgery. The functional reconstruction of the urinary bladder by means of an ileal neobladder with an anastomosis to the urethra in the male or with a continent stoma and selfcatheterism provides better quality of life in patients after radical cystectomy. Nephron-sparing tumor surgery may become a routine procedure under certain precautions such as small tumor size, patient's compliance and good local medical infrastructure. Especially for urologic microsurgery, neurourology and different treatments of benign prostatic hyperplasia essential new and interesting improvements are expected.

Arteriovenous fistula simulating a solid tumor of the kidney.

In this report we describe a 57-year-old male hemophiliac with an acquired renal arteriovenous (AV) fistula presenting as a renal mass. Even after intravenous pyelography, ultrasound and computed tomography, a carcinoma seemed possible. Causes, symptoms and therapy of renal AV fistulas are shown and pitfalls in the usual diagnostic approach are discussed.