SPECT/CT for SLN dissection in vulvar cancer: Improved SLN detection and dissection by preoperative three-dimensional anatomical localisation.

OBJECTIVE: In this study, we assessed the feasibility and clinical advantages of single photon emission computed tomography with CT (SPECT/CT) for sentinel lymph node (SLN) detection in vulvar cancer. METHODS: This is a unicentric prospective trial. Vulvar cancer patients underwent preoperative SLN marking (10MBq Technetium (TC)-99m-nanocolloid) and subsequent planar lymphoscintigraphy (LSG) and SPECT/CT for SLN visualization. Directly before surgery, a patent blue dye was injected. We assessed detection rates of SPECT/CT and those of planar LSG and intraoperative detection. We analyzed the sensitivity, negative predictive value and false negative rate. RESULTS: At Hannover Medical School, 40 vulvar cancer patients underwent SLN dissection after preoperative LSG and SPECT/CT. The mean diameter of all tumors in final histology was 2.23 (0.1-10.5) cm with a mean tissue infiltration of 3.93 (0.25-11) mm. In preoperative imaging, SPECT/CT identified significantly more SLNs (mean 8.7 (1-35) LNs per patient) compared to LSG (mean 5.9 (0-22) LNs, p<0.01). In addition, SPECT/CT led to a high spatial resolution and anatomical localization of SLNs. Thus, SPECT/CT identified aberrant lymphatic drainage in 7/40 (17.5%) patients. There were no significant differences, but significant correlation was found between SPECT/CT and intraoperative SLN identification. Regarding inguino-femoral LNs, for all patients who underwent complete groin dissection, sensitivity was 100%, NPV was 100% and false negative rate was 0%. CONCLUSION: SPECT/CT leads to higher SLN identification compared to LSG in vulvar cancer. Due to its higher spatial resolution and three-dimensional anatomical localisation of SLNs, SPECT/CT provides the surgeon with important additional information, facilitates intraoperative SLN detection and predicts aberrant lymphatic drainage.

Isthmocervical labelling and SPECT/CT for optimized sentinel detection in endometrial cancer: technique, experience and results.

OBJECTIVE: We evaluated the clinical feasibility of a new injection technique for sentinel detection in endometrial carcinoma (EC), transcervical subepithelial injection into the isthmocervical region of the myometrium. We compared detection of sentinel lymph nodes (SLN) by single photon emission computed tomography with CT (SPECT/CT) with planar lymphoscintigraphy. METHODS: This is a unicentric prospective study. In all patients, transcervical injection of 10 MBq Technetium-99m-nanocolloid was performed into the isthmocervical myometrium without anaesthesia. After 40 (30-60) min, lymphoscintigraphy and SPECT/CT were performed. Patent blue was administered before surgery. The number and localisation of SLN detected in SPECT/CT and lymphoscintigraphy were recorded and compared to the SLN and non-SLN dissected intra-operatively. RESULTS: Between August 2008 and March 2012, 31 patients with EC were enrolled. The new transcervical injection of labelling substances led to high intra-operative (90.3%) detection rates, pelvic bilateral (57%), para-aortic (25%). SPECT/CT significantly identified more SLN than lymphoscintigraphy (mean 2.2 (1-8) to 1.3 (1-7)) in more patients (29/31 (93.5%) to 21/31 (68%), p<0.01). If SLN were identified in one hemi-pelvis, the histological evaluation of the SLN correctly predicted lymph node (LN) metastases for this basin which led to sensitivity 100%, negative predictive value (NPV) 100%, and false negative results 0%. CONCLUSION: Transcervical SLN marking in combination with SPECT/CT is easily applicable and leads to high physiologic detection rates in pelvic and para-aortic lymphatic drainage areas. Non-affected SLN truly predicted a non-affected LN basin. Combining both methods SLN dissection may be a safe and feasible staging technique for clinical routine in EC.

Effects of autotransplanted lymph node fragments on the lymphatic system in the pig model.

Secondary lymphedema often develops after removal of lymph nodes in combination with radiation therapy, in particular in patients with breast cancer, inguinal cancer, cervical cancer and melanoma. No convincing treatment for the prevention and therapy of acquired lymphedema exists so far, therefore we wanted to show the reintegration of transplanted avascular lymph node fragments in the lymphatic system and positive effects of the transplanted fragments on the restoration of the lymphatic flow in this study. A total of 26 minipigs underwent lymphadenectomy of both groins. A minimum of one lymph node was retransplanted. The lymph nodes were cut into small pieces and retransplanted in the left groin (n = 17) or in both groins (n = 9). Different retransplantation techniques were investigated, transplantation of large versus small fragments, with and without capsule. The lymph flow was evaluated 5 and 8 months after surgery, using SPECT/CT and Berlin Blue. The results were confirmed by dissection. The lymph node transplants were assessed histologically. In contrast to the lymph flow in the transplanted groin, the lymph flow in the non-transplanted groin was often malfunctioning. Large lymph node fragments were found reintegrated in the lymphatic system more often than small slices of lymph node fragments. About 5 months after surgery impairment of lymph flow was seen especially after retransplantation of small slices of lymph node fragments. In seven out of eight minipigs a dermal backflow developed in the non-transplanted groin, 8 months after surgery. Only one minipig of these groups developed dermal backflow in both groins. All lymph node fragments showed an organized structure histologically. Autologous lymph node transplantation has positive effects on the regeneration of lymph vessels and restoration of lymph flow after lymphadenectomy.

Excision of the dilated pelvis is not necessary in laparoscopic dismembered pyeloplasty.

PURPOSE: The surgical treatment of choice for significant hydronephrosis is dismembered pyeloplasty. While in open surgery, extensive resection of the dilated pelvis is common practice, laparoscopically usually only a sparing resection is performed. We compared the treatment results of both techniques to investigate whether extensive resection is necessary or not in dismembered pyeloplasty procedures. METHODS: To obtain comparable renal units, matched pairs according to age and relative kidney uptake as shown by (123)J-orthoiodohippurate renography were selected out of a total of 76 patients who underwent dismembered pyeloplasty between 2000 and 2007. Twenty-four patients complied with the criteria for inclusion in the study. Changes in urinary drainage preoperatively and at three months postoperatively were compared between both groups. RESULTS: The mean age in the sparing resection group was 3.8 years (range 0.3 to 14 years); in the extensive resection group it was 3.4 years (range 0.5 to 10 years). Mean urinary drainage improved significantly in both groups from 35.1 +/- 10.7 % to 75.2 +/- 13.2 % (sparing resection) vs. 45.1 +/- 23.7 % to 70.2 +/- 22 % (extensive resection). There were no differences between the groups (p > 0.05). CONCLUSIONS: We conclude that extensive resection of the renal pelvis is not necessary in dismembered pyeloplasty procedures since there were no differences in the renographic outcome of comparable patients treated by the different surgical methods.

Early predictors of success of Kasai operation in children with biliary atresia.

AIM: Aim of the study was the evaluation of early predictive parameters of event-free survival (not listed for liver transplantation, not transplanted, no death) in children suffering from biliary atresia after hepatoportoenterostomy (Kasai procedure) in order to optimize pretransplant management. PATIENTS AND METHODS: Sixty-seven infants were treated with the Kasai operation at our institution over a 20-year period from 1978 until 1998. Median age at time of operation was 51 days after birth (range 19 - 180 days). Of these 67 infants, 24 children with complete datasets and an observation time of at least one year were evaluated retrospectively using a Cox regression model. The response variable was event-free survival after a median observation time of 4.9 years (1.11- 10.37 years). Six variables were entered as covariates: alanine aminotransferase (ALAT), cholinesterase activity, bilirubin, age at the time of Kasai operation and tracer excretion and uptake during hepatobiliary scintigraphy (HBSS). All variables were evaluated six weeks after operation. For subsequent cut-off determination, a receiver operating analysis (ROC analysis) was carried out. RESULTS: Tracer excretion shown by HBSS showed the highest prognostic power to predict event-free survival after Kasai operation (log rank 18.68, p < 0.0001) followed by bilirubin and ALAT as further significant parameters in the first univariate step of the Cox regression model. In the subsequent multivariate step, the prognostic power of HBSS was improved only by bilirubin (log rank 24.6, p < 0.0001). The ROC analysis determined a cut-off for bilirubin concentrations of 57 micromol/l for event-free survival with a sensitivity of 80 % and a specificity of 78.6 %. The five-year event-free survival-rate was 100 % in the group with good tracer excretion and a bilirubin concentration of 57 micromol/l and 27 % for the other group (log rank test, p < 0. 0001). CONCLUSION: Early predictors of success of the Kasai operation in children with biliary atresia are free tracer excretion as shown by HBSS and a serum bilirubin concentration < 57 micromol/l six weeks after the operation. Thus, children with bilirubin concentrations above this level should be carefully and frequently monitored with regard to a transplantation requirement in order to optimize pretransplant management.

SPECT-CT: a valuable method to document the regeneration of lymphatics and autotransplanted lymph node fragments.

PURPOSE: The transplantation of lymph node fragments and stimulation of lymph vessel regeneration seems to be a promising model to prevent lymphoedema in patients after mammary tumour excision combined with axillary lymph node dissection and irradiation. This study evaluated the advantages of SPECT-CT in studying the regeneration of lymph vessels and lymphoid tissue after autologous lymph node transplantation. METHODS: Five minipigs underwent autologous lymph node transplantation in the left groin. The lymph node was excised, cut into six pieces and embedded into two newly created subcutaneous pouches on this side. The superficial lymph node of the right groin was removed as a control. Five months after surgery the lymph flow of both legs was investigated using conventional lymphoscintigraphy and SPECT-CT with 10 MBq(99m)Tc-nanocolloid in combination with Berlin Blue injected subcutaneously into the draining area. RESULTS: The integration of the transplanted lymph node fragments was shown. The SPECT-CT results correlated with the in situ findings observed at dissection. Afferent and efferent lymph flow could be followed up to the lumbar trunks. The use of SPECT-CT allowed exact localisation of the lymph node fragments in three-dimensional space and the regeneration of the lymph node fragments was documented histologically. CONCLUSION: SPECT-CT is a good method to evaluate lymphatic flow and document lymph node regeneration. The data suggest that autologous lymph node transplantation is a promising model for prevention of lymphoedema.

[Splenosis--important differential diagnosis in splenectomized patients presenting with abdominal masses of unknown origin]. / Splenose -- eine wichtige Differenzialdiagnose unklarer abdomineller Raumforderungen bei splenektomierten Patienten.

A 40-year-old female patient was admitted for work-up of multiple abdominal masses. The lymphoma-mimicking tumors were detected accidentally during an ultrasound course. The past medical history was unremarkable besides a status post-traumatic splenic rupture and splenectomy. The patient was asymptomatic, especially there were no complaints of fever, night sweats or weight loss. Laboratory tests did not show pathological results. Ultrasound of the abdomen revealed multiple hypoechoic mesenterial and peritoneal enlarged tumors as well as a subhepatic mass (30 x 20 mm). Transmission computed tomography (CT) showed a normal chest, excluded abnormal thoracal masses and confirmed the multiple abdominal nodules. Microparticles were trapped only by tissue with phagocytosis function as cells of the reticulohistiocytary system in liver and spleen. Uptake of (99 m)Tc-labeled microparticles is specific for splenic tissue. All abdominal masses were detectable by single photon emission computed tomography (SPECT) after intravenous administration of this radiotracer. Ultrasound-guided biopsy proved the presence of spleen tissue with follicular hyperplasia. In conclusion, we report a case of post-traumatic splenosis. In 16 - 67 % of patients who experienced traumatic splenic rupture autotransplanted spleen tissue can be detected. Splenosis therefore is an important differential diagnosis of abdominal masses in splenectomized patients.

The ex-vivo-shunt-model: novel approach for assessing the thrombogenicity of vascular implants.

OBJECTIVE: Disadvantages associated with commercially available vascular implants necessitate alternative strategies to develop new vascular prostheses. Although many tissue characterizing strategies have been defined, no valid test for thrombogenicity exists. Here we introduce a novel concept for thrombogenicity testing of vascular implants METHODS: Silastic tubes were implanted into the carotid arteries of 12 sheep. After placing these shunts, tc99m-labeled platelets were administered and test-vessels were put in between the shunts. Native autologous (n=6), as well as native/acellularized allogeneic (n=6/n=6), and xenogeneic (n=6/n=6) carotid arteries and allogeneic (n=6/n=6) and xenogeneic (n=6/n=6) carotid arteries reseeded with allogeneic endothelial-cells, fibroblasts and myocytes were evaluated. Number and time course of intra-operatively deposited platelets were evaluated with a Geiger-counter; certain areas of platelet deposition located, envisioned and characterized by a gamma-camera and scanning electron-microscopy afterwards. RESULTS: Counter results revealed no significant different platelet depositions when comparing silastic tubes with either autologous or allogeneic native carotid arteries. However, starting 5 minutes after placement, acellularized/reseeded allogeneic (p=0.001/p=0.00004), and xenogeneic (p=0.0001/p=0.01) carotid arteries showed significantly more platelet depositions than native autologous carotides. Moreover, it was possible to show that almost no platelets adhere to native vessels or silastic tubes, thus proving the test method itself. CONCLUSION: The Ex-Vivo-Shunt-Model is a valid method to measure and envision the intrinsic thrombogenicity of vascular implants.

Hydroxyethyl starch and modified fluid gelatin maintain plasma volume in a porcine model of septic shock with capillary leakage.

OBJECTIVE: To compare the effects of different volume replacement therapies on maintenance of plasma volume in septic shock and capillary leakage syndrome. DESIGN AND SETTING: Prospective randomized, controlled animal laboratory study in a university animal laboratory. MEASUREMENTS AND RESULTS: Twenty-five fasted, anaesthetized, mechanically ventilated and multi-catheterized pigs (20.8+/-1.8 kg) received 1 g/kg body weight faeces into abdominal cavity to induce sepsis and were observed over 8 h. Five animals each received volume replacement therapy with modified fluid gelatin 4% or 8% (MFG4%, MFG8%), 6% HES 200/0.5, or Ringer's solution and were compared to controls receiving 6% HES 200/0.5. Infusion rate was titrated to maintain a central venous pressure of 12 mmHg. Plasma volume was determined using (51)Cr-labelled erythrocytes and standard formulae. Albumin escape rate was calculated using technetium (99m)Tc-labelled albumin. Colloid osmotic pressure, systemic haemodynamics and oxygenation were obtained before and 4 and 8 h after induction of sepsis. Plasma volume was reduced in the Ringer's solution group (-46%) but was maintained in HES (+/-0%), MFG4% (+4%), MFG8% (+23%) groups. Albumin escape rate increased in HES (+52%), MFG4% (+47%), MFG8% (+54%) and the Ringer's solution group (+41%) compared to controls. CONCLUSION: In this porcine septic shock model with concomitant capillary leakage syndrome, confirmed by an increased albumin escape rate, the artificial colloids HES, MFG4%, and MFG8% maintained plasma volume and colloid osmotic pressure. These results suggest the intravascular persistency of artificial colloids in the presence of albumin leakage. An editorial regarding this article can be found in the same issue (http://dx.doi.org/10.1007/s00134-002-1283-9)

Successful therapy of subcutaneously growing human hepatoblastoma xenografts with topotecan.

BACKGROUND: Human hepatoblastoma is an infrequent liver tumor in children. Although many hepatoblastomas can be treated adequately with well-defined treatment regimens, problems still persist with advanced and non-resectable tumors; in these cases, an effective chemotherapy is necessary to improve the patients' prognosis. This underlines the need for alternative anti-tumor agents in the treatment of human hepatoblastoma. The aim of this study was to investigate the therapeutic effects of topotecan, a water-soluble camptothecin analog (topoisomerase-I-antagonist), in an in vivo model of three human hepatoblastomas xenografted subcutaneously into nude mice. PROCEDURE: Hepatoblastoma cell suspensions from three children were transplanted subcutaneously into nude mice NMRI (nu/nu). Treatment with topotecan was initiated when the tumors reached a volume between 50 and 80 mm(3). A dose of 6.6 mg/kg of topotecan were given intraperitoneally every 4 days on four occasions. The tumor volume development and alpha-fetoprotein alterations were measured and statistically analyzed. After the treatment, the tumors were investigated histologically and by immunohistochemistry. RESULTS: There was a significant reduction of tumor growth in all treated tumor xenografts vs. untreated control groups (mean relative volume 3.1 vs. 47.4; P = 0,0015-0,0079). Serum alpha-fetoprotein levels were reduced in all three cell lines, in two of them significantly (mean 44,535 kU/l vs. 228,883 kU/l; P = 0.005-0.246). Histologically, the tumor necrosis rates were higher and immunohistochemistry showed lower proliferation activities in the treated tumor xenografts vs. the control groups. CONCLUSION: The data show that topotecan is an effective agent in the treatment of human hepatoblastoma xenografts. From these results, treatment with topotecan appears to be a promising alternative in the pre- and postoperative therapy of patients suffering from human hepatoblastoma

Evaluation of noninvasive determinants for capillary leakage syndrome in septic shock patients.

OBJECTIVE: Capillary leakage syndrome (CLS) is a frequent complication in sepsis, characterized by loss of intravasal fluids leading to generalized edema and hemodynamic instability despite massive fluid therapy. In spite of its importance no standardized diagnostic criteria are available for CLS. DESIGN: Prospective clinical study. SETTING: 1,800-bed university hospital PATIENTS: Six septic shock patients with CLS were compared to six control patients. MEASUREMENTS AND RESULTS: CLS was clinically determined by generalized edema, positive fluid balance, and weight gain. Plasma volume was measured by indocyanine green, red blood cell volume by chromium-51 labeled erythrocytes, and colloid osmotic pressure before and 90 min after the administration of 300 ml 20% albumin. Extracellular water (ECW) was measured using the inulin distribution volume and bioelectrical impedance analysis. Red blood cells averaged 20.2 +/- 1.0 ml/ kg body weight in CLS patients and 23.3 +/- 4.1 in controls. ECW was higher in CLS patients than in controls (40.0 +/- 6.9 vs. 21.7 +/- 3.71; p< 0.05). ECW of inulin was correlated with that measured by bioelectrical impedance analysis (r = 0.74, p< 0.01). The increase in colloid osmotic pressure over the 90 min was less in CLS patients than in controls (1.1 +/- 0.3 vs. 2.8 +/- 1.3 mmHg;p< 0.05). CONCLUSION: These results suggest that measurements of an increased ECW using bioelectrical impedance analysis combined with a different response of colloid osmotic pressure to administration of albumin can discriminate noninvasively between patients with and those without CLS.

[Bone manifestations in non-Hodgkin's lymphoma in childhood and adolescence]. / Ossäre Manifestationen beim Non-Hodgkin-Lymphom im Kindes- und Jugendalter.

PURPOSE: Skeletal manifestation of Non-Hodgkin's lymphoma is rare in pediatric patients. Objective of the study was to determine imaging features, before and after treatment, and to correlate these features with clinical outcome. METHODS: A retrospective analysis of 1246 patients from two therapy studies (NHL-BMF-90 and 95) was performed. Imaging studies of 63 patients with bone involvement of lymphoma were reevaluated. RESULTS: Incidence of initial bone involvement in Non-Hodgkin's lymphoma was 6.8%. Distribution was best assessed by bone scan, MRI revealed larger areas of marrow involvement and detected additional lesions. Sites of predilection were long bones of the lower extremities with epiphyseal involvement in 39%. Residual signal alterations in MRI after successful therapy remained in 71%. Osteonecrosis after therapy was a common finding. Clinical outcome war not correlated to the presence of bone involvement. CONCLUSIONS: Since clinical outcome is not effected by bone involvement in childhood NHL, value of screening may be limited. Knowledge of imaging characteristics is mandatory for initial evaluation of primary osseous lymphomas and symptomatic lesions as well as for therapy controls.

Immunoscintigraphy of xenotransplanted hepatoblastoma with iodine 131-labeled anti-alpha-fetoprotein monoclonal antibody.

BACKGROUND/PURPOSE: Hepatoblastoma (HB) is the most common primary malignant liver tumor affecting infants and young children. The alpha-fetoprotein level is elevated in 95% of all children with hepatoblastoma. Therefore, it is of interest to assess targeting of the HB marker alpha-fetoprotein by antibody imaging. In this pilot study, the authors investigated the radioimmunoscintigraphy of xenotransplanted HB in nude mice utilizing an anti-alpha-fetoprotein antibody. METHODS: HB cell suspensions from tumors of 3 children were transplanted subcutaneously into nude mice NMRI (nu/nu). A total of 200 microg of intact anti-alpha-fetoprotein antibody was injected intravenously into 8 animals from each HB. Before injection, the monoclonal antibody was labeled with iodine (I) 131 (specific activity of 75 MBq/mg, labeling yield of 95%) using the conventional iodogen method. Planar scintigraphic images of anesthetized mice in posterior views were acquired with a gamma camera immediately after injection, and after 1, 2, 3, 7, and 14 days. The biodistribution data were obtained by killing and dissecting animals, and the activity in the tissues was measured in a gamma counter. The alpha-fetoprotein levels in the animals' sera were recorded 15 days after imaging and were compared with the control group. RESULTS: A total of 66% of the hepatoblastomas could be detected by scintigraphy. Within 24 hours, the mean specific tumor uptake in nude mice hepatoblastomas with a volume of over 1,000 mm3, was 14% per injected dose (+/-3.9%). The biological half-life of the labeled antibody complex in the tumor was 3.86 (+/-0.84) days. Thyroid uptake of free I-131 was 2.85% per injected dose (+/-1.5%) reflecting the deiodination of the labeled antibody complex. CONCLUSIONS: The results show the possibility of imaging xenotransplanted hepatoblastoma with 131I-labeled anti-alpha-fetoprotein and may, in the future, determine tumor recurrence and extension, and thereby improve the prognosis of advanced HBs.

Hereditary hemorrhagic telangiectasia: effective protocol for embolization of hepatic vascular malformations--experience in five patients.

PURPOSE: To develop a hepatic artery embolization protocol and investigate its efficacy in a prospective study treating patients with hereditary hemorrhagic telangiectasia and predominant hepatic involvement. MATERIALS AND METHODS: One man and four women with hereditary hemorrhagic telangiectasia presented with symptoms of high-output heart failure, abdominal angina, or severe portal hypertension. The hepatic arteries were embolized in stages in three to five sessions at 1- to 15-week intervals. After peripheral embolization with polyvinyl alcohol particles, proximal arteries were embolized with coils. Computed tomography and assessment of cardiac output were performed before and after therapy and at the end of follow-up (median, 25 months; range, 12-55 months). RESULTS: After embolization, analgesics and antiemetics were necessary for a median of 5 and 2 days, respectively. Other than ischemic cholangitis (one patient), no complications were observed. The mean cardiac output decreased significantly (P < .05) from 14.2 L/min to 8.0 L/min. Symptoms of high-output heart failure, abdominal angina, and portal hypertension resolved in all patients. Seven months after embolization, one patient died of postoperative sepsis after an unsuccessful surgical attempt to create a portacaval shunt. Delayed recurrence of symptoms was not noted in the other patients. CONCLUSION: In symptomatic patients with hereditary hemorrhagic telangiectasia and predominant hepatic involvement, embolization of the hepatic arteries in stages is well tolerated by the patients and results in good clinical improvement at midterm follow-up.

[Diagnosis of liver tumors--when is scintigraphy of value?]. / Diagnostik von Lebertumoren--Wann ist die Szintigraphie von Bedeutung?

This paper illustrates the importance of utilizing radionuclide techniques to characterize in vivo benign liver masses. Examining the physiologic tumor function cholescintigraphy offers a highly specific pattern for identifying focal nodular hyperplasia (FNH): hypervascularisation, hepatocellular uptake and impaired transport of the bilirubin like tracer documented as trapping in later images. An hemangioma is diagnosed with high probability in case of a positive bloodpoolscintigraphy. But false-positive results have been reported. Therefore, a second unrelated examination, e.g. ultrasound, magnetic resonance imaging or dynamic computerized tomography is necessary to establish this diagnose in a sufficient certainty. If complications due to tumor growth are not expected, both, FNH and hemangioma need no further therapy. High sensitivity is necessary to establish resectability or tumor spread. Scintigraphic techniques are advantageous in scanning completely the whole body. On the other hand, there are limitations as low resolution and anatomical orientation, low specific activity in the tumor and artificial activity near by the tumor. To measure therapy effects and to detect recurrencies especially in borderline-cases positron emission computed tomography (PET)-technology is recommended, because PET offers a specific-parametric evaluation.

[Diagnostic and therapeutic strategies in hepatocellular adenoma]. / Diagnostische und therapeutische Strategie beim hepatozellulären Adenom.

While liver hemangioma and focal nodular hyperplasia are not considered an indication for surgery in asymptomatic patients resection has been recommended for hepatocellular adenoma because of the risk of rupture and malignant transformation. Problems arise from differential diagnosis and the appropriate surgical radicality including the indication for liver transplantation. This retrospective analysis deals with 58 patients who underwent surgery for hepatocellular adenoma: resection of different extension: n = 54, liver transplantation n = 4. In 39.6% of the patients the tumor was an incidental finding. In 62.0% of the character of the lesion was unclear prior to surgery. Tumor rupture and bleeding occurred in 17.2%, malignant transformation in 6.9%. Surgical morbidity was 27.6%, mortality 5.2% with the transplant patients alive for 1.5, 7, 9 and 10 years. Two and five years after resection 2 patients developed hepatocellular carcinoma in the liver remnant. The results confirm the indication for surgery in hepatocellular adenoma. Diagnostic approach for solid liver tumors without serum increase of tumor markers should rule out FNH and hemangioma. In all other patients surgery should be considered whenever possible with the radicality of malignant disease. Liver transplantation can be discussed even in asymptomatic patients with multiple adenoma.

Benign liver tumors: differential diagnosis and indications for surgery.

The differential diagnosis for hemangioma, focal nodular hyperplasia (FNH), and hepatocellular adenoma may be difficult. Reliable diagnosis is mandatory for the decision of whether to apply surgery or observation. Experience with long-term observation in nonoperated patients with hemangioma and FNH is limited. A group of 437 patients from a single institution were analyzed with regard to a diagnostic algorithm, the indications for surgery, and observation. There were 238 hemangiomas, 150 cases of FNH, 44 adenomas, and 5 mixed tumors. Of the 437 patients, 173 underwent surgery; 103 with hemangioma and 54 with FNH were observed at our own institution, whereas 117 patients underwent follow-up elsewhere or were lost. Among the operated patients with confirmed histology, a good diagnostic yield was found for a combination of ultrasonography (US), contrast (bolus)-enhanced computed tomography (CT), and labeled red blood cell (RBC) scanning: sensitivity 85.7%, specificity 100%, positive predictive value (PPV) 100%, negative predictive value (NPV) 81.8%, and accuracy 91.3%. For FNH and combination of US and CT plus cholescintigraphy showed a sensitivity 82.1%, specificity 97.1%, PPV 95.8%, NPV 84.6%, and accuracy 90.3%. Surgical mortality was 0.6%. Observation of patients with hemangioma and FNH for a median of 32 months revealed no increase in tumor size in 80% and a decrease in fewer than 7%. There was no tumor rupture and no evidence of malignant transformation. We concluded that liver hemangioma and FNH can be differentiated from adenoma with high sensitivity, specificity, and accuracy by labeled RBC scanning and cholescintigraphy in combination with US and contrast-enhanced CT. In the case of symptoms or an equivocal diagnosis with respect to adenoma or hepatocellular carcinoma, surgery can be performed with very low risk. Because in asymptomatic patients with observed hemangioma or FNH no increase of tumor size can be expected for many years, the indications for surgery must be carefully evaluated.

Use of sequential bone scintigraphy for monitoring onlay grafts to grossly atrophic jaws.

OBJECTIVES: To evaluate the capability of sequential bone scintigraphy for assessing the viability of avascular onlay grafts in combination with primary or secondary implant placement. METHODS: Forty-six patients with severe alveolar ridge atrophy received full-arch onlay grafts from the iliac crest. Twenty patients received primary insertion of endosseous implants, while secondary implant placement was performed in 26 patients after an average interval of 95 days. In cases of primary implant placement, bone scintigraphy was performed after grafting and before abutment connection. In patients with secondary insertion, bone scans were performed after grafting, before and after implant placement and before abutment connection. For bone scintigraphy, 8 MBq 99mTc-MDP/kg body weight were administered intravenously and anterior views of the skull were obtained 3 h later. Regions of interest were drawn over the grafted area and over the calvarium as a reference area. Ratios of count densities between jaw and calvarium were calculated as a measure of tracer uptake. RESULTS: Bone grafts with primary insertion of implants showed a significant decrease (P = 0.0001) in ratios calculated for the whole graft from a mean of 3.53 after grafting to 2.35 before abutment connection. In cases of secondary implant placement, ratios decreased significantly after grafting from 4.04 to 2.78 before implant placement (P = 0.0001). After implant placement, there was a significant increase to 3.28 (P = 0.0062), which was followed again by a significant decrease to a mean ratio of 2.58 (P = 0.0437). CONCLUSIONS: Sequential bone scintigrams can provide information about the viability of the graft at the time of implant insertion and may thus indicate the ability of the grafted bone to accomplish osseointegration.