Dendritic cell-based vaccination in solid cancer.

PURPOSE: Dendritic cell (DC)-based immunotherapy is rapidly emerging as a viable tool in cancer treatment. This approach has been used mostly in patients in the presence of defined tumor antigens such as melanoma. In this study, cancer patients with advanced disease that lacks defined tumor antigens were vaccinated with tumor lysate-pulsed DCs. PATIENTS AND METHODS: Twenty patients (pancreatic, hepatocellular, cholangiocellular, and medullary thyroid carcinoma) with stage IV disease were enrolled in the study. In 3-week intervals, freshly isolated autologous CD14 magnetic bead-selected monocytes were cultured in granulocyte-macrophage colony-stimulating factor and interleukin-4 to obtain immature DCs. These cells were pulsed with autologous tumor lysate and matured with tumor necrosis factor alpha. Mature DCs were applied into a groin lymph node, under ultrasound guidance. Adjuvant interleukin-2 (20,000 U/kg) was given subcutaneously daily, for 12 days, after each vaccination. Toxicity, tumor marker profile, immune response, and clinical response were determined. RESULTS: Vaccination was well tolerated. No physical signs of autoimmunity were detected. DC vaccination induced delayed-type hypersensitivity reactivity in 18 patients. Tumor marker responses were observed in eight patients. In addition, in three patients the generation of interferon gamma-positive T cells was induced during the vaccination. Objective changes in measurable lesions or tumor markers were evident in seven of 20 assessed patients. None of the patients was found to meet the criteria for partial or complete responses. CONCLUSION: These data indicate that vaccination with autologous tumor-pulsed DCs generated from peripheral blood is safe and can induce tumor-specific cellular cytotoxicity. Clinical responses are achievable, even in patients with advanced disease.

Ultrasound of the kidney: obstruction and medical diseases.

Ultrasound has emerged as the primary imaging modality in conditions where either renal obstruction or renal medical disease is suspected on the basis of clinical and laboratory findings. In urinary tract obstruction, pathophysiologic changes affecting the pressure in the collecting system and kidney perfusion are well understood and form the basis for the correct interpretation of real-time US and color Doppler duplex sonography (CDDS). Ultrasound is very sensitive for the detection of collecting system dilatation ("hydronephrosis"); however, obstruction is not synonymous with dilatation, as either obstructive or nonobstructive dilatation may be present. To differentiate these conditions, CDDS with measurement of the resistive index (RI) in the intrarenal arteries is extremely helpful, as obstruction (except in the peracute stage) leads to intrarenal vasoconstriction with a consecutive increase of the RI above the upper limit of 0.7, whereas nonobstructive dilatation does not. Diuretic challenge to the kidney may further enhance these differences in RI between obstruction and dilatation. Based on these findings, the present value of US and CDDS in the assessment of the patient with flank pain or renal colic is suggested, especially with respect to promising results for spiral CT and based on cost analysis. In renal medical disease, distinguishing different pathologic conditions using gray-scale US and CDDS (RI) criteria is still very difficult. Nevertheless, US is the fist-line imaging modality in the patient with renal insufficiency.

Lung manifestation in asymptomatic patients with primary Sjögren syndrome: assessment with high resolution CT and pulmonary function tests.

The authors studied 37 consecutive patients with primary Sjögren syndrome and normal chest radiographs. Thin-section CT images were analyzed using a semiquantitative grading system. The presence, distribution, and severity of 9 morphologic parameters were assessed. In 34 patients, CT findings were correlated to pulmonary function tests (PFTs). Abnormal high resolution CT (HRCT) findings were seen in 24 of 37 patients (65%): interlobular septal thickening, n = 9; micronodules, n = 9; ground glass attenuation n = 4; parenchymal cysts, n = 5. Intralobular opacities, honey combing, bronchial wall thickening, bronchiectasis, and pleural irregularities were less frequent. Both HRCT and PFTs were normal in 10 patients. Computed tomography was normal in four patients with PFTs that indicated the presence of small airway disease. High resolution CT abnormalities were found in seven patients with normal PFT. The overall correlation between HRCT and PFTs was poor. High resolution CT and PFTs appear to be sensitive for both the early detection of parenchymal abnormalities and a decreases in lung function in asymptomatic patients with primary Sjögren syndrome. However, abnormal HRCT findings do not necessarily indicate a substantial alteration in PFTs.

Ultrasound with Levovist in the diagnosis of suspected calf vein thrombosis.

Diagnosing calf vein thrombosis (CVT) by color Doppler ultrasound (US) is often a difficult task because of swelling or obesity. The purpose of this study was to assess if IV infusion of Levovist can improve the accuracy and reduce the rate of indeterminate examinations. A total of 20 patients with suspected CVT underwent color Doppler US without and with Levovist followed by ascending venography as the "gold standard," which detected calf clots in 7 patients (35%). Compared to routine noncontrast sonography, Levovist examination reduced the rate of indeterminate scans from 55% to 20% and improved the specificity for the detection of CVT from 25% to 67% without compromising sensitivity (100% to 86%) notably. Image quality was improved in 13 (65%) of 20 scans. In conclusion, we can say that Levovist improves the quality of duplex examination of the calf veins, especially in cases with difficult conditions due to obesity or swelling.

Early pulmonary involvement in ankylosing spondylitis: assessment with thin-section CT.

AIM: To determine the frequency and the distribution of early pulmonary lesions in patients with ankylosing spondylitis (AS) and a normal chest X-ray on thin-section CT and to correlate the CT findings with the results of pulmonary function tests and clinical data. MATERIALS AND METHODS: Twenty-five patients with clinically proven AS and no history of smoking underwent clinical examinations, pulmonary function tests (PFT), chest radiography, and thin-section CT. Four of 25 patients (16%), who had obvious signs on plain films suggestive of pre-existing disorders unrelated to AS were excluded. RESULTS: Fifteen of 21 patients (71%) had abnormalities on thin-section CT. The most frequent abnormalities were thickening of the interlobular septa in seven of 21 patients (33%), mild bronchial wall thickening in (6/21, 29%), pleural thickening and pleuropulmonary irregularities (both 29%) and linear septal thickening (6/21, 29%). In six patients there were no signs of pleuropulmonary involvement. Eight of 15 patients (53%) with abnormal and four of six patients (67%) with normal CT findings revealed mild restrictive lung function impairment. CONCLUSION: Patients with AS but a normal chest radiograph frequently have abnormalities on thin-section CT. As these abnormalities are usually subtle and their extent does not correlate with functional and clinical data, the overall routine impact of thin-section CT in the diagnosis of AS is limited.

Subjective differentiation of normal and pathological bronchi on thin-section CT: impact of observer training.

The effect of observer training on sensitivity, specificity and interobserver agreement in the differentiation between normal and pathological bronchi on computed tomography (CT) was studied. The wall thickness of bronchi with normal walls and with pathologically thickened walls were subjectively scored by three independent observers before and after a training period of 2 weeks. Sensitivity, specificity and interobserver agreement were calculated for reading sessions before and after training. Increase and decrease in agreement after training were determined. There was a statistically significant difference (p=0.001) between objectively measured wall thickness of normal and pathological bronchi, both for reference bronchi and for bronchi used for reading sessions. While training increased interobserver agreement, it had no effect on sensitivity (0.46 versus 0.44 after training) and specificity (0.71 versus 0.72 after training) in detecting pathological bronchi. Increased agreement after training was significantly (p=0.001) more frequent than decreased agreement. There is a discrepancy between the effect of training on interobserver agreement and on sensitivity and specificity in the subjective differentiation between normal and pathological bronchi. Interobserver agreement alone is not a reliable indicator of a beneficial effect of training in the evaluation of this parameter.

Pulmonary alveolar proteinosis in a child: HRCT findings before and after bronchoalveolar lavage.

We demonstrate the high-resolution computed tomography (HRCT) findings of pulmonary alveolar proteinosis in a child before and after bronchoalveolar lavage. The CT pattern in our case differs from the pattern described in previous reports. We found a more homogeneous distribution of the pulmonary changes and a "crazy paving" pattern. High-resolution CT may be helpful in the differential diagnosis of this rare disease and in the follow-up of the pulmonary changes after bronchoalveolar lavage.

[Trauma of the facial bones and skull]. / Trauma des Gesichtsschädels und der Schädelkalotte.

Facial trauma is frequent and mainly caused by motor vehicle accidents. Due to this main etiologic factor, trauma to the facial skeleton is often associated with serious injuries, commonly involving the brain, chest or abdomen. As a consequence, the initial clinical management of these patients includes control of hemorrhage and immediate assessment of life-threatening injuries, including the maintenance of the airways. Patients presenting with facial trauma are initially evaluated with a systematic clinical examination because many fractures can be accurately diagnosed by inspection and palpation alone. In these cases plain film radiographs serve only for confirmation and documentation of the diagnosis. In many other cases accompanying and extensive soft tissue swelling may clinically obscure fractures. A complete and accurate evaluation of these patients requires additional radiological imaging methods. A series of plain films may be generally sufficient but in most of the cases they can be regarded as initial screening methods for more thorough diagnosis with computed tomography (CT). In trauma patients CT is the imaging method of choice because it shows more fracture lines and displaced fragments than any other imaging modality. CT delineates soft tissue and bony structures and can localize and even characterize foreign bodies. A complete and accurate characterization of the fracture type and potentially associated complications in mandatory for the appropriate treatment and can only be achieved by careful radiological (CT) evaluation.

[Preoperative imaging of varicose veins of the lower extremities. Classical pattern of insufficiency and its clinical use]. / Bildgebung zur präoperativen Abklärung bei Varikose der unteren Extremität. Klassische Insuffizienzmuster und klinische Wertigkeit.

UNLABELLED: Venous varicose are one of the most common diseases in industrial countries today. New surgical strategies, tailored to a patient's specific pattern of venous incompetence require more detailed preoperative imaging. METHODS: In this review of current literature we analyzed the value of ascending venography, color coded duplex sonography and descending venography for preoperative planning of varicose surgery. On the other hand, we describe variant anatomy of the superficial venous system like the different levels of escape points and perforating veins. RESULTS: Ascending venography and color coded duplex sonography are both excellent modalities for detection of reflux in the saphenofemoral and saphenopopliteal junction. The results of current literature indicate, that ascending venography is superior to color coded duplex sonography in the detection of incompetent perforators. CONCLUSIONS: Ascending venography and color coded duplex sonography provide improved information, that may be crucial for surgical planning. The high heterogeneity and broad distribution of valvular incompetence confirms the importance of detailed preoperative imaging.

[CT-phlebography. A new method for the diagnosis of venous thrombosis of the upper and lower extremities]. / CT-Phlebographie. Eine neue Methde zur Diagnostik von Venenthrombosen an der oberen und unteren Extremität.

UNLABELLED: Spiral CT venography is a new method in vascular imaging, which is an accurate tool for the evaluation of deep venous thrombosis in the evaluation of deep venous thrombosis in the lower and upper extremity. MATERIALS AND METHODS: 102 lower extremities and 12 upper extremities were evaluated for deep vein thrombosis using spiral-CT-venography. The results were compared with findings of ascending venography, color coded duplex sonography and clinical follow up. RESULTS: Spiral CT venography of the lower extremity showed a sensitivity of 100% and a specifity of 96%. The quality of venous opacification with CT venography compared with ascending venography was superior in all venous segments. DISCUSSION: Spiral CT venography is a valuable tool for the detection of deep venous thrombosis. Advantages of the method are the reduction of the amount of contrast material necessary for opacification and the detection of perivascular soft tissue alterations. The application of CT venography is limited due to higher costs and radiation dosage.

Double inversion recovery imaging of the brain: initial experience and comparison with fluid attenuated inversion recovery imaging.

The purpose of this study was to evaluate the diagnostic efficacy of the double inversion recovery fast spin echo (DIR-FSE) sequence for brain imaging compared to the fluid-attenuated inversion recovery (FLAIR) sequence. DIR-FSE and FLAIR-FSE sequences were obtained and compared side by side. Image assessment criteria included lesion conspicuity, contrast between different types of normal tissue, image quality, and artifacts. In addition, contrast ratios and contrast-to-noise ratios were determined. Scan time of DIR-FSE was 33% longer than scan time of FLAIR-FSE. Overall lesion conspicuity was equal on DIR-FSE and FLAIR-FSE; however, DIR-FSE showed particular advantages for infratentorial lesions and lesions with only poor contrast on T2-weighted images, whereas FLAIR was slightly superior for small superficial cerebral abnormalities. Gray-white differentiation was better with DIR-FSE. Cerebrospinal fluid suppression was equal on both sequences; cerebrospinal fluid pulsation artifacts were more pronounced on DIR-FSE but did not cause diagnostic difficulties on these images. We conclude that DIR-FSE might be obtained if infratentorial lesions and abnormalities with only slightly prolonged T2 relaxation times are suspected. Otherwise, FLAIR-FSE seems preferable.

Spiral CT evaluation of deep venous thrombosis.

Spiral CT venography is a technical innovation in vascular imaging that can optimize vessel contrast in the deep venous system and, therefore, is an accurate diagnostic tool to detect deep venous thrombosis. Compared with conventional venography, the amount of contrast material can be reduced by 80%. While using spiral CT as the primary imaging technique for the detection of pulmonary embolism, the cause of embolism can be evaluated within a short period of additional imaging time without further patient mobilization. This review outlines fundamental techniques in spiral CT venography and summarizes our clinical experience at Vienna University Medical Center.

Deep venous thrombosis of the lower extremity: efficacy of spiral CT venography compared with conventional venography in diagnosis.

PURPOSE: To compare the efficacy of spiral computed tomographic (CT) venography with conventional venography in the diagnosis of suspected deep venous thrombosis (DVT). MATERIALS AND METHODS: In a prospective study, 52 consecutive patients with clinically suspected unilateral or bilateral DVT were studied with CT venography and conventional venography. In cases in which conventional venographic findings were inconclusive, color-coded duplex sonography and follow-up examinations were performed to make a final diagnosis. CT venography of both extremities covered a 100-cm section from the ankle to the inferior vena cava (IVC). Contrast material diluted with saline was injected in a dorsal vein of each foot. CT and conventional venography (including color-coded duplex sonography and follow-up findings) were correlated for three venous regions for each patient. RESULTS: Correlation was excellent between CT and conventional venographic findings in the detection of DVT. The sensitivity of CT venography was 100% (confidence interval: 0.92, 1.00), specificity was 96% (confidence interval: 0.84, 0.98), positive predictive value was 91%, and negative predictive value was 100%. CT venography more clearly demonstrated thrombus extension of DVT into the pelvic veins and IVC than conventional venography alone. CONCLUSION: CT venography is a valuable tool in the diagnosis of DVT. Compared with conventional venography, CT requires use of 80% less contrast material.

Preoperative imaging of lower extremity varicose veins: color coded duplex sonography or venography.

We prospectively examined 137 limbs in 112 consecutive patients with clinical evidence of severe varicosis by color coded duplex sonography and ascending venography (including varicography in 48 limbs) to evaluate the diagnostic capabilities of color coded duplex sonography in the assessment of venous anatomy, variant varicosis, postthrombotic changes, and incompetence of the superficial and perforating venous system. Additionally, descending venography was performed in the first 52 limbs and compared to color coded duplex sonography in the diagnosis of deep and superficial venous reflux. Variant venous anatomy (21 cases) was missed in two limbs and misinterpreted in one limb by ascending venography compared to surgery. Color coded duplex sonography was inconclusive in two cases. Variant varicosis (59 cases) was missed in seven surgically proved cases by venography and in one case by color coded duplex sonography. Color coded duplex sonography was inconclusive in five cases. Ascending venography was slightly superior to color coded duplex sonography in the detection of postphlebitic changes. Good agreement was found between color coded duplex sonography and descending venography in the grading of superficial (k = 0.75) and deep venous reflux (k = 0.79). Excellent agreement was found between ascending venography in the grading of long (k = 0.96) and short (k = 0.94) saphenous vein reflux. More incompetent perforating veins were detected by ascending venography, (and varicography) than by color coded duplex sonography, but the latter technique allows direct preoperative marking of the skin, which is beneficial for the surgeon. We conclude that color coded duplex sonography is a valuable imaging tool before venous stripping and is capable of replacing invasive ascending and descending venography. Only patients with inconclusive color coded duplex sonographic results (e.g., complex variant venous anatomy) should proceed to venography.

[The experiences of a hospital radiology department with outside referrals for the preoperative marking of suspicious breast lesions]. / Erfahrungen einer radiologischen Spitalsabteilung mit auswärtigen Zuweisungen zur präoperativen Markierung suspekter Mammaläsionen.

PURPOSE: To outline the experience of a referral radiology department with preoperative localisation procedures on the basic of mammograms obtained by other facilities. MATERIAL AND METHODS: 342 consecutive female patients aged 56.5 +/- 11.9 years underwent preoperative breast localisation procedures prior to surgery. Of these patients 241 had their mammograms obtained in various private practices and 101 in the radiology department. Retrospectively all mammograms were classified by lesions morphology, lesion size and presence or absence of calcifications. RESULTS: The overall benign-to-malignant ratio (B/M-ratio) was 1.7:1. In the referred patient group the B/M-ratio was 1.9:1, compared to a B/M-ratio of 1.3:1 obtained by the radiology department. Referred patients presented significantly (p < 0.001) more often with calcifications that patients from the radiology department. CONCLUSION: Possible factors for the higher B/M-ratio in referred patients are prompt referral to surgical biopsy, misinterpretation of mammograms, failure in the written report, lack of a second opinion and lack of feedback and communication between surgeon, pathologist and radiologist.

[Phlebography of the leg veins. Study quality and sources of error]. / Phlebographie der Beinvenen. Untersuchungsqualität und Fehlerquellen.

In a retrospective study, 198 contrast venographies were evaluated by two blinded observers for quality of opacification of the venous system and quality of documentation. There was good correlation between the two observers in 91% of the cases. They found an adequate contrast quality in 183 cases (92.4%), while in 15 cases (7.6%) incomplete contrast was found in some parts of the calf or pelvic veins. Most venograms (195, or 98.5%) were adequately documented. In conclusion, contrast venography is an excellent method for evaluation of the venous system, if performed adequately. Nevertheless, there is room for improvement of both technique and documentation.