[Unilateral agenesis of pulmonal artery in adults: a rare disease frequently undiagnosed]. / Unilaterale Agenesie der Pulmonalarterie bei Erwachsenen. Eine häufig nicht diagnostizierte seltene Erkrankung.

INTRODUCTION: Unilateral absence of a pulmonary artery (UAPA) in adults without any other cardiovascular anomalies is a very rare clinical entity. Usually UAPA in adults remains undetected because of the symptom-free clinical course. The most common symptoms are hemoptysis and recurrent pulmonary infections. PATIENTS AND THERAPY: During 2006 - 2014 four adult patients with UAPA were diagnosed and treated in our institution. Recurrent pulmonary infections in combination with existing bronchiectasis and hemoptysis led to hospital treatment for three of the patients. In two cases, because of persevering hemoptysis and pathologically enlarged systemic arteries (intercostal, bronchial, diaphragm), pneumonectomy was indicated. Preoperative embolization of the enlarged arteries reduced the systemic arterial perfusion of the lung and led to minimal intraoperative blood loss. DISCUSSION: UAPA in the adulthood can frequently lead to hypertrophic systemic arterial perfusion of the lung. This abnormal systemic perfusion in combination with the co-existing bronchiectasis and persevering hemoptysis can cause a life-threatening clinical scenario. A combined interdisciplinary treatment through pneumology, thoracic surgery and radiology is therefore indicated.

[The small lung nodule: dealing with a frequent radiological finding]. / Der kleine Lungenrundherd: Umgang mit einem häufigen radiologischen Befund.

Small pulmonary nodules less than 10 mm in size are frequently found by multidetector CT in high-risk patients. The risk of malignancy is rather low. The individual cancer risk, the radiological appearance and the presence or absence of growth are guides towards the indication for invasive procedures. A risk adjusted algorithm should avoid unnecessary invasive procedures without missing a lung cancer.

[Neonatal traumatic epiphyseolysis of the humeral head. A rare occurrence]. / Geburtstraumatische Epiphysenlösung am Humeruskopf. Ein seltenes Ereignis.

Neonatal traumatic epiphyseolysis of the humeral head is rare, and only a few cases are reported in the literature. We present a case of a 13-day-old female newborn with malposition and relaxation of the left upper limb. The clinical examination showed distinct range of motion particularly for abduction. Magnetic resonance imaging (MRI) indicated epiphyseolysis of the humeral head. Closed reposition followed by immobilisation was done. The following MRI showed correct axis with adaption of the humeral head. Later, malposition of the axis with angulation in the ventromedial position was seen. This status was not followed by renewed repositioning. The x-ray examination 5 months later and MRI 9 months later showed a centered position of the epiphysis. In conclusion, neonatal traumatic epiphyseolysis of the proximal humeral head occurs rarely but should be considered, particularly with unclear relaxation of the limb.

"Occult" neuroendocrine component and rare metastatic pattern in cervical cancer: report of a case and brief review of the literature.

Distant metastases in small cell carcinomas of the uterine cervix are rare, and a disseminated manifestation of the disease is uncommon. This is a case report of a 40-year-old woman treated with platin-based radio-chemotherapy for a moderately differentiated squamous cell cervical cancer FIGO Stage IB 1 (with positive paraaortic lymph nodes). One year later she presented with remarkably unusual cutaneous metastases of the left thumb and scalp as the first signs of spread of disease, including kidney, lung and brain metastases. An advanced retrospective immunohistochemical staining of the cervical biopsy discovered a small neuroendocrine component of the carcinoma as the presumably causative factor for the rare metastastic pattern and poor prognosis.

[A teleradiotherapeutic network for lymphoma patients within the competence network malignant lymphomas]. / Aufbau eines teleradiotherapeutischen Netzwerks für Lymphompatienten im Rahmen des Kompetenznetzes Maligne Lymphome.

PURPOSE: The aim of the subproject "Radiotherapy" within the competence network malignant lymphoma, funded by the Federal German Ministry of Education and Research (BMBF), was to build-up an electronic imaging transfer between five University departments of Radiation Oncology to improve communication between study centers and reference centers. MATERIALS AND METHODS: We describe our experiences with these modern teleradiotherapeutic possibilities, its feasibility within mutticentric clinical trials. RESULTS: Telemedical functions could successfully be integrated into the existing quality asssurance programs of radiotherapy. Since January 2001 more than 700 patients (trials HD10-HD15 of the German Hodgkin Study Group, GHSG) could be assessed after digital transfer via internet, on mobile data carriers or an ISDN-connection in the radiotherapy reference center Cologne. Transfer of digital imaging between participating study centers and the radiotherapy reference center allows immediate or a short-term evaluation of adequacy of treatment fields by expert radiation oncologists before the start of radiotherapy. This improves dialogue and consensus between radiotherapy reference centers and study centers and thus contributes towards high radiotherapy quality for lymphoma patients. CONCLUSION: The long-term aim is to network all those hospitals, institutions and private facilities taking part in the GHSG trials to achieve an integrated system of cooperation. This improves dialogue and consensus between the radiotherapy reference center and the study centers and thus contributes towards high radiotherapy quality for patients with Hodgkin's lymphoma.

Hybrid-procedures for the treatment of thoracoabdominal aortic aneurysms and dissections.

AIM: The conventional open repair of thoracoabdominal aneurysms and dissections remains complex and demanding and is associated with significant morbidity and mortality. We present our experience of hybrid open and endovascular treatment of thoracoabdominal aneurysms and dissections. METHODS: Within an experience of 226 aortic stent-grafts between 1998 and April 2006, 6 of the patients (median age 60 years, range 35 to 68 years) with thoracoabdominal aneurysms (Crawford type I, II, III, and V) were treated with a combined endovascular and open surgical approach. Five men and one woman, with median aneurysm diameter of 75 mm (range 70-100 mm), received revascularization of the renal arteries, the superior mesenteric artery, and the coeliac trunk accomplished via transperitoneal bypass grafting. Aneurysmal exclusion was then performed by stent-graft deployment. RESULTS: The entire procedure was technically successful in all patients. The patients were discharged a median of 9 days after the operation, while the postoperative studies revealed the patency of the vessels and no evidence of type I endoleak or secondary rupture of the aneurysm. During follow up (1 to 22 months) spiral-CT scanning revealed distinct shrinkage of the aneurysm, no graft migration or endoleak and patency of all revascularised vessels, except one renal artery in two patients. No patient experienced any temporary or permanent neurological deficit, and no dialysis was necessary. CONCLUSION: The combined endovascular and open surgical approach is feasible, without cross clamping of the aorta and with minimized ischemia time for renal and visceral arteries, and seems to be an appropriate strategy for patients with a thoraco-abdominal aortic aneurysm or dissection.

Extended field radiotherapy, combined modality treatment or involved field radiotherapy for patients with stage IA lymphocyte-predominant Hodgkin's lymphoma: a retrospective analysis from the German Hodgkin Study Group (GHSG).

BACKGROUND: Since there are no randomized studies, the treatment of choice for patients with early stage lymphocyte-predominant Hodgkin's lymphoma (LPHL) remains unclear. We thus reviewed all LPHL cases registered in the database of the German Hodgkin Study Group (GHSG) and compared the different treatment approaches, such as extended field (EF), involved field (IF) radiation and combined modality (CM) treatment for LPHL stage IA patients. PATIENTS AND METHODS: One hundred and thirty-one patients with LPHL in clinical stage IA without risk factors were analyzed. Forty-five patients were treated with EF radiotherapy, 45 patients with IF radiation and 41 patients received CM treatment. The median follow-up was 78 months in the EF group, 40 months after CM and 17 months after IF, respectively. RESULTS: A total of 129 patients achieved complete remission (CR and CRu): 98% after EF radiotherapy, 100% after IF radiation and 95% after CM. With a median follow-up of 43 months there were 5% relapses and only three patients died. Toxicity of treatment was generally mild with most events observed after CM. CONCLUSION: In terms of remission induction IF radiotherapy for stage IA LPHL patients is as effective as EF or CM treatment. However, longer follow-up is needed before final conclusion as the optimal therapy.

[Digital X-ray mammography: comparison of the image quality achievable with a wet laser imager, a dry infrared laser imager and a dry laser imager using direct thermography]. / Digitale Röntgenmammographie: Bildqualitativer Vergleich eines Nasslaserdruckers, eines infrarotbasierten Trockenlaserdruckers und eines thermographiebasierten Trockendruckers.

PURPOSE: To compare the image quality of digital X-ray mammographies obtained with wet imagers with that of standard dry imaging technology. MATERIAL AND METHODS: Beginning 03/08/2003, 200 X-ray mammographies with a digital fullfield mammography system (Lorad Selenia, Lorad/Hologic) were prospectively and consecutively documented with a wet laser imager (Scopix LR 5200, Agfa), a dry infrared laser imager (DryView 8610, Kodak) and a dry imager using the principle of direct thermography (Drystar 4500M, Agfa, N = 166). One X-ray exposure was systematically chosen from each examination and was presented in an anonymous and randomized form to three radiologists who evaluated the films using a structured questionnaire. RESULTS: The visualization of normal anatomic structures was considered being good to excellent for all imagers with the mean assessments 1.0 - 2.4 for the Drystar 4500M, 1.0 - 2.1 for the DryView 8610 and 1.1 - 2.0 for the Scopix LR 5200. The mean assessments were 0.1 - 0.6 points lower in dense than in normal parenchyma, thus, the parenchymal density is the predominant factor for image quality. CONCLUSION: In view of the comparable image quality obtained with the different imagers used in the study, individual decisions to purchase a specific imager will be based on economics rather than on diagnostic points of view.

Experimental bile duct protection by intraductal cooling during radiofrequency ablation.

BACKGROUND: The use of radiofrequency ablation (RFA) for liver tumours is limited by the proximity of large bile ducts to the targeted lesion. The aim of this randomized study was to evaluate intraductal cooling as a mean of protecting the bile ducts during RFA. METHODS: Twelve pigs underwent RFA adjacent to the right bile duct. After placement of an intraductal cooling catheter and a RFA probe, pigs were randomized to cooling or no cooling. Intraductal temperature was measured in all animals. The bile ducts were assessed by magnetic resonance imaging (MRI) and cholangiography 1 and 28 days after the procedure. RESULTS: Intraductal cooling abolished the increase of intraductal temperature seen in the absence of cooling. Concurrent cholangiography and MRI showed a biliary lesion in one of six pigs subjected to intraductal cooling and in five of six without cooling (P = 0.040). The biliary injuries were barely visible by MRI on day 1 but were clearly visible on day 28. CONCLUSION: Intraductal cooling can prevent biliary injury induced by RFA. The exact parameters for intraductal cooling require further investigation to establish the best compromise between bile duct protection and complete ablation of surrounding tissue.

[MR-coronary angiography: comparison of SSFP and spoiled GRE sequence (bright blood technique) and a TSE sequence (black blood technique) in healthy volunteers]. / MR-Koronarangiographie: Vergleich von SSFP- und gespoilter GRE-Sequenz (Brightblood-Technik) und TSE-Sequenz (Blackblood-Technik) bei gesunden Probanden.

PURPOSE: Comparison of a free breathing steady-state free precession (SSFP), a spoiled gradient-echo (GRE) and a turbo spin-echo sequence (TSE) for imaging of the coronary arteries (MRCA) in healthy volunteers. MATERIALS AND METHODS: Twenty-two healthy volunteers were imaged with a standard clinical scanner (1.5 T, Intera, Philips), with the right coronary system imaged in 11 and the left coronary system in the other 11 volunteers. Images were obtained with a 3D-SSFP (balanced TFE, TR 6.2 ms, TE 3.1 ms, alpha 65 degrees ), a 3D-GRE (TFE, TR 7.2 ms, TE 2.2 ms, alpha 30 degrees ) and a 2D-TSE (Dual-IR, TR 2RR, TE 25 ms) sequence. The in plane resolution was 0.7 x 0.8 mm for both the SSFP and GRE sequence with an effective slice thickness of 1.5 mm. For the TSE sequence, an in-plane resolution of 0.7 x 0.9 mm and a slice thickness of 3.0 mm were used. All investigations were performed using prospective navigator gating and slice-following technique. The signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) for the blood pool to myocardium and blood pool to epicardial fat were calculated. Image quality and measurement artifacts were assessed for all sequences by 5 independent investigators using a 4- and 5-point grading scale. RESULTS: CNR was significantly higher for the GRE sequence compared with the SSFP sequence and TSE sequence (mean 20.8 +/- 4.8 vs. 14.6 +/- 5.0 and 10.1 +/- 3.7 for blood pool to myocardium; mean 27.5 +/- 6.3 vs. 16.4 +/- 5.4 and 18.1 +/- 5.7 for blood pool to fat). The SNR revealed no significant differences between the SSFP and GRE sequences. The SSFP and the TSE sequences showed significantly more artefacts than the spoiled GRE sequence. Image quality was graded slightly higher for the GRE than for the SSFP sequence for the right coronary system, while there was no substantial difference in the left coronary system (median 2.1 +/- 0.6 and 2.5 +/- 0.6 vs. 2.5 +/- 0.8 and 2.6 +/- 0.7 for the right and left coronary system). In comparison, image quality was lower with the TSE sequence (median 2.9 +/- 0.5 for the right coronary system with p < 0.05 vs. GRE sequence and 3.0 +/- 0.3 for the left coronary system). CONCLUSION: For the scan parameters chosen in this study, the GRE-sequence represents the most robust technique for imaging of the coronary arteries. Currently, the TSE sequence is no alternative.

Successful treatment of radiofrequency-induced biliary lesions by interventional endoscopic retrograde cholangiography (ERC).

BACKGROUND: Radiofrequency ablation (RFA) of malignant liver lesions is considered a procedure with low morbidity. However, RFA performed close to hilar structures carries the risk of heat-induced biliary tract damage and subsequent septic episodes. METHODS: We performed an analysis of complications in 42 patients with 211 liver lesions treated with a combined approach of liver resection and RFA. RESULTS: One patient died due to postoperative liver failure. There was one case of temporary liver dysfunction, one vena cava thrombosis, and six febrile episodes. Four of the six febrile episodes were related to bile duct injuries. They became evident 3-5 weeks after the procedure. All four patients were treated successfully by the placement of stents within the biliary tract. None of the patients developed a hepatic abscess. CONCLUSION: Biliary tract damage is a complication that can occur weeks after RFA. Immediate endoscopic intervention can obviate the occurrence of prolonged septic complications.

Imaging of renal lesions: evaluation of fast MRI and helical CT.

The purpose of this study is to compare triphasic helical CT and fast MRI with respect to detection, characterization and staging of suspected renal masses. To achieve this triphasic helical CT (plain, corticonephrographic and tubulonephrographic phase) and MRI with fast T(1) weighted and T(2) weighted sequences were performed in 29 patients with a suspected renal lesion. Image quality, lesion characterization and lesion extent were assessed for both methods in all patients. The acquisition phase for CT and the image sequence for MRI offering the best image quality and best diagnostic information regarding renal parenchyma, renal vessels, detection of enlarged lymph nodes, and other abdominal organs were determined. Histologically confirmed renal cell carcinomas (n=18) were staged based on the Robson classification. Quantitative data were obtained from operator-defined regions of interest (ROIs) in all acquisition phases (CT) and all image sequences (MRI). For most criteria the rating of image quality for helical CT was generally higher as compared with fast MRI. CT and MRI detected all 24 histologically proven masses, while no false positive solid tumour was diagnosed with both imaging modalities. All three acquisition phases in CT and all applied image sequences in MRI were regarded as necessary in order to gain important diagnostic information. Altogether, 12 of 18 renal cell carcinomas (67%) were correctly staged by CT and MRI. Helical CT and fast MRI allow the correct detection and characterization of suspicious renal lesions. Both imaging modalities can be recommended for clinical routine application. Although the correct histological staging of renal cancer remains difficult for both imaging methods, both are excellent in providing the critical staging information needed before surgery. Helical CT offers a significantly shorter acquisition time to cover the entire abdomen.

Spleen involvement in Hodgkin's lymphoma: assessment and risk profile.

Diagnostic laparotomy is no longer routinely performed in Hodgkin's lymphoma and noninvasive diagnosis of spleen involvement remains uncertain. In order to assess the probability of splenic involvement based on clinical parameters, we retrospectively analyzed data on patients of the German Hodgkin's Lymphoma Study Group (GHSG) who underwent staging laparotomy and for whom splenic weight and size were available. Our study included 376 patients with Hodgkin's lymphoma who underwent staging laparotomy and splenectomy according to the treatment policy of the GHSG between February 1981 and January 1993. Univariate and multivariate analyses of pretherapeutic clinical characteristics and splenic weight were performed in order to predict the probability of splenic involvement. Computed tomographic (CT) images of 25 patients were available and used to correlate radiological splenic size and pathological splenic weight. In 171 of 376 patients spleen involvement was found. Average weight of the spleens was 258 g (+/-257) ranging from 55 to 3290 g. All spleens with a weight above 2000 g showed disease involvement, while those under 150 g were never involved. In the multivariate analysis, splenic weight ( p<0.001), erythrocyte sedimentation rate ( p<0.001), and clinical stage ( p<0.01) were found to be independently prognostic for spleen involvement. Splenic weight was highly correlated with a spleen index defined as the product of length, width, and thickness measured by CT (correlation coefficient: 0.93). By applying the identified risk factors in clinically staged patients spleen involvement can be determined. Spleen weight can be estimated with the help of a spleen index. Above an index of 1000 the probability of spleen involvement is higher than 90%. This might be of outstanding importance for patients being scheduled for involved field radiation.

Organic cation transporter capable of transporting serotonin is up-regulated in serotonin transporter-deficient mice.

The serotonin (5HT) transporter (5HTT) regulates serotonergic neurotransmission by mediating the reuptake of 5HT from the synaptic cleft. Although lacking the high affinity and selectivity of the 5HTT, the brain expresses a large number of other transporters, including the polyspecific organic cation transporters (OCTs). OCT1 and OCT3, members of the potential-sensitive organic cation transporter gene family, physiologically transport a wide spectrum of organic cations. In addition, both transporters mediate low-affinity 5HT transport and, therefore, may participate in the clearance of excessive 5HT. Because concentrations of extracellular 5HT are increased in the brain of 5HTT-deficient mice, they are a model for investigating the role of OCTs in 5HT system homeostasis. Here, we analyzed OCT1 and OCT3 gene expression in the brain of 5HTT knockout mice by semiquantitative competitive polymerase chain reaction and in situ hybridization. We demonstrate that, in 5HTT-deficient mice, OCT3 mRNA concentrations were significantly increased in the hippocampus, but not in other brain regions, including cortex, striatum, cerebellum, and brainstem. In contrast, no difference in OCT1 expression was detected between 5HTT knockout and control mice. Up-regulation of OCT3 expression and enhanced low-affinity 5HT uptake may limit the adverse effects of elevated extracellular 5HT and may play a critical role in maintaining 5HT-dependent functions of the hippocampus in the absence of 5HTT.

[Color duplex sonographic findings in an iatrogenic arteriovenous fistula of the vertebral artery]. / Farbduplexsonographische Befunde bei iatrogener arteriovenöser Fistel der A. vertebralis.

The report describes a rare case of an iatrogenic arteriovenous fistula of the vertebral artery to the vertebral vein which arose after insertion of a central venous catheter via the jugular vein. We give special attention to the role of colour duplex sonography in the primary diagnosis of such fistulas. As can be seen from published reports with this non-invasive examination, the diagnosis of fistulas could not be established in all cases, where an abnormal communication between the vessels was later revealed by angiography. The most probable reason is the particular feature of the anatomical course of the vertebral artery which in its middle third is protected in a bony canal through the foramina transversaria of the cervical vertebrae and can be only partially visualised by sonography. Consequently only fistulas in the visible parts of the artery can be detected by sonography. In our case the most important criteria of duplex sonography for an arteriovenous fistula were fulfilled and the diagnosis was confirmed by angiography. This procedure with primary use of colour duplex sonography and additional clarification of uncertain findings by angiography, seems to be reasonable if the symptoms are compatible with the diagnosis of an arteriovenous fistula of the neck vessels.

Detection of porcine bone lesions and fissures: comparing digital selenium, digital luminescence, and analog film-screen radiography.

OBJECTIVE: The purpose of our study was to compare the diagnostic performance of a digital selenium detector (Thoravision) with that of analog film-screen systems and digital luminescence radiography in skeletal radiography for the detection of fissures and lesions in porcine bones. MATERIALS AND METHODS: One hundred bones taken from domestic pigs (50 ribs and 50 femurs) were divided into two equal groups. Fissures and bone lesions were created in 50 bones and 50 served as controls. The bones were examined using film-screen systems, digital luminescence radiography, and digital selenium radiography at various doses. Digital selenium radiography exposure values were adapted to the image geometry differing from the reference methods with a detector focus distance of 2.15 m. Four radiologists independently evaluated image quality and detectability of fissures and lesions on a five-point scale of confidence. Statistical evaluation was based on receiver operating characteristic curve analysis. RESULTS: Fissures and bone lesions were detected most reliably using the mammography film-screen system, but the difference in the results of the analog and digital reference images did not achieve statistical significance. CONCLUSION: Compared with analog film-screen systems, the lower spatial resolution of the digital selenium and digital luminescence radiography systems does not affect detectability of fissures and bone lesions in porcine bone. Selenium is effective in skeletal radiography for detecting fissures and bone lesions. With digital selenium and digital luminescence radiography, the surface dose can be cut to half that required for 200-speed film-screen systems without losing any diagnostically relevant information.

Image quality of digital chest X-rays: wet versus dry laser printers.

The aim of this study was to compare the image quality of digital chest x-rays (Thoravision) obtained with 2 "wet" laser imagers of different matrix sizes and a "dry" system. Fifty chest x-rays in 2 planes were printed out in normal (100%) and reduced (61%) format using 3 different systems: 2 "wet" laser imagers (Agfa Matrix LR 3300, 4256 x 5174 pixels, 315 dpi; Agfa Scopix LR 5200, 8512 x 10348 pixels, 630 dpi), and one "dry" system (Agfa Drystar 3000,4352 x 5295 pixels, 330 dpi). All tests yielded normal findings. Anonymous images were evaluated by 4 independent reviewers on record forms rating the detectability of predefined anatomic structures. When the image quality of diagnosis-relevant, anatomic structures was evaluated on digital chest x-rays reproduced in normal and reduced format, the wet laser imagers did not show significant advantages over the dry system, Agfa Drystar 3000. The Agfa Drystar 3000 system is a feasible alternative for reproducing digital images, particularly for decentralized archives.