[Frequency of thromboembolic complications in patients with lung cancer]. / Häufigkeit thromboembolischer Komplikationen bei Patienten mit Lungenkarzinom.

BACKGROUND: Clinicians are frequently confronted by thromboembolic events in patients with lung cancer, yet few data are available about their incidence. In order to obtain data on the frequency of thromboembolic events in the venous and arterial systems, all patients with lung cancer diagnosed in our hospital were retrospectively evaluated with regard to such an event. PATIENTS/METHODS: All patients with a primary diagnosis of lung cancer between January 2008 and December 2010 were prospectively recorded within our tumour registry and retrospectively evaluated with regard to tumour stage, histology and platinum-based chemotherapy. Thromboembolic complications of the arterial and the venous system were included (pulmonary embolism, deep venous thrombosis, myocardial infarction, mesenterial ischaemia, acute limb ischaemia, ischaemia of the renal artery and ischaemic stroke). RESULTS: Within those 36 months 1940 patients (1209 men, 731 women) were diagnosed with lung cancer. SCLC and NSCLC in 156 (8 %) and 1784 cases (92 %), respectively. Thromboembolic events were documented in 190/1940 (9.8 %) cases, venous thromboembolic complications in 148/190 patients (78 %), arterial thromboembolic complications in 51/190 patients (27 %). We documented 82/148 (55 %) deep venous thrombosis, 98/148 (66 %) pulmonary embolisms and arterial thromboembolic events: ischaemic stroke 23/51 (45 %), coronary arteries 14/51 (28 %), peripheral arteries 12/51 (24 %), mesenterial arteries 4/51 (7.8 %), extracranial cerebral arteries 3/51 (5.9 %). CONCLUSIONS: Thromboembolic complications are a common event in patients with lung cancer. Thus, the benefit of primary prevention anticoagulation in lung cancer patients should be prospectively evaluated.

[Staging with 18F-FDG-PET/CT influences stage-specific survival in advanced non-small cell lung cancer (NSCLC)]. / Der Einfluss des F-18-FDG-PET/CT auf das stadienbezogene Gesamtüberleben beim fortgeschrittenen nicht-kleinzelligen Lungenkarzinom (NSCLC).

BACKGROUND: PET/CT investigation with 18F-fluorodeoxyglucose (FDG) has a high sensitivity (89 - 100 %) and good specificity (79 - 95 %) for the diagnosis of NSCLC. Currently, it is mainly used in preoperative staging. This leads in approximately 15 % of these cases to the diagnosis of metastatic disease that was neither clinically suspected nor seen in previously performed conventional imaging. We hypothesised that including these cases in the palliative stage IV group would have an influence on overall survival. AIM: The aim of this study was to compare the overall survival (OS) of patients with stage IV NSCLC who underwent FDG-PET/CT staging with patients in whom conventional imaging procedures were performed. METHODS: We analysed the OS of all stage IV NSCLC patients diagnosed in our clinic in 2009 (n = 254), 96/254 (38 %) patients were staged with PET/CT and 158/254 (62 %) with conventional imaging (CT group). Survival data were compared by Kaplan-Meier statistics. RESULTS: Patients in the PET/CT group were younger (65 ± 11) than in the CT group (68 ± 10 years; p = 0.008). The median OS of all patients was 246 (range: 217 - 275) days; 338 (range: 247 - 429) days in the PET/CT group and 207 (range: 161 - 253) days in the CT group (p = 0.001), stating a difference of 131 days (4.4 months) in median OS. CONCLUSION: The use of FDG-PET/CT staging mainly in the preoperative setting leads to stage migration of patients with a better prognosis into the worst stage (IV) and thus longer survival within this subgroup. This survival benefit is unrelated to treatment and needs to be addressed in future studies.

[Diagnostic imaging in pleural diseases]. / Bildgebende Diagnostik bei Pleuraerkrankungen.

Imaging plays a major role in the diagnosis and management of pleural diseases. Generally chest radiography remains the initial examination, however, today with digital technique. Depending on first imaging findings and the clinical aspect the diagnostic course may be followed by ultrasound, computed tomography examinations, or magnetic resonance imaging. Radionuclide imaging has not been played a significant role up to now, until positron emission tomography (PET) has gained clinical relevance. However, the role of PET in pleural diseases is not yet defined and scientific works are still in progress.

Magnetic resonance imaging in distinguishing malignant from benign pleural disease.

OBJECTIVE: To explore the role of magnetic resonance imaging (MRI) in distinguishing malignant from benign pleural disease. METHODS: All 64 patients were examined with both computed tomography (CT) and MRI. The morphologic features of pleural lesions and MR signal intensity on T1-weighted, T2-weighted and contrast-enhanced T1-weighted images were evaluated. RESULTS: Mediastinal pleural involvement, circumferential pleural thickening, nodularity, irregularity of pleural contour, and infiltration of the chest wall and/or diaphragm were most suggestive of a malignant cause on CT and MR images. Contrary to what has been reported in the literature, pleural thickness greater than 1 cm either on CT or on MRI did not reveal a significant difference between malignant and benign pleural disease (P > 0.05, chi-square test). Using morphologic features in combination with signal intensity features, MRI had a sensitivity of 98% and a specificity of 92% in the detection of pleural malignancy. CONCLUSIONS: Compared with those on CT, the morphologic features on MRI allowed a mostly equal and in some cases superior detection and evaluation of the spread of pleural disease. In combination with signal intensity and morphologic features, MRI is very useful in distinguishing malignant from benign pleural disease.

MRI and CT in the differential diagnosis of pleural disease.

STUDY OBJECTIVE: To explore the role of MRI in the differential diagnosis of pleural disease. PATIENTS: Forty-two patients with pleural disease were included. METHOD: Retrospective study. All patients were examined with both CT and MRI. The morphologic features of pleural lesions and magnetic resonance signal intensity on T1-weighted, T2-weighted, and contrast-enhanced T1-weighted images were evaluated. RESULTS: Mediastinal pleural involvement, circumferential pleural thickening, nodularity, irregularity of pleural contour, and infiltration of the chest wall and/or diaphragm were most suggestive of a malignant cause both on CT and MRI. Pleural calcification on CT was suggestive of a benign cause. Contrary to what has been previously reported in the literature, neither on CT nor on MRI, pleural thickness >1 cm revealed significant difference between malignant and benign pleural disease (p>0.05, chi(2) test). High signal intensity in relation to intercostal muscles on T2-weighted and/or contrast-enhanced T1-weighted images was significantly suggestive for a malignant disease. Using morphologic features in combination with the signal intensity features, MRI had a sensitivity of 100% and a specificity of 93% in the detection of pleural malignancy. CONCLUSION: When signal intensity and morphologic features are assessed, MRI is more useful and therefore superior to CT in differentiation of malignant from benign pleural disease.

[Malignant lymphoma: magnetic resonance tomography findings in residual supradiaphragmatic space-occupying lesions]. / Malignes Lymphom: Magnetresonanztomographische Befunde bei residuellen supradiaphragmalen raumfordernden Läsionen.

PURPOSE: Evaluation of MR imaging in patients with Hodgkin's lymphoma and high grade non-Hodgkin's-lymphoma and mediastinal residual mass after first line chemotherapy. MATERIALS AND METHODS: MR imaging (1.5 T) was performed in 36 patients (Hodgkin's lymphoma n = 26, NHL n = 10) after first line chemotherapy). Twenty patients had inactive residual mass, 16 patients had residual lymphoproliferative lesions. T1- and T2-weighted spin echo images were visually analysed by a score index (range 1-5) as well as quantification of enhancement by signal-intensity-ratios SImax/SIplain). RESULTS: For the differentiation between residual lymphoproliferative activity and inactive residual mass, the highest accuracy was obtained for the signal intensity of residual mass on T2-w-SE compared to pectoralis muscle (94% sensitivity, 80% specificity, likelihood ratios: 4.0 [LR+]; 0.3 [LR-]). The cut-off value of the SI ratio was calculated retrospectively at 1.96 (p > 0.05). CONCLUSIONS: Differentiation between inactive (fibrotic) and lymphoproliferative (active) residual mediastinal mass is possible by MR imaging using as parameter the size reduction after therapy and the signal intensity on T2-w-SE in comparison to pectoralis muscle. Thus study suggests an additional value using the SI ratio for the differentiation.

[Morphologic image processing operators: reduction of partial volume effects for improved 3D visualization of CT data]. / Morphologische Bildverarbeitungsoperatoren: Reduktion von Partialvolumenartefakten für eine verbesserte dreidimensionale Visualisierung von CT-Untersuchungen.

AIM: The quality of segmentation and three-dimensional reconstruction of anatomical structures in tomographic slices is often impaired by disturbances due to partial volume effects (PVE). The potential for artefact reduction by use of the morphological image processing operators (MO) erosion and dilation is investigated. DESIGN: The CT examinations of 31 patients with pathological alterations in lung or brain were segmented using automatic region growing and the MO were applied in a different number of iterations. The processed regions were 3D-reconstructed (shaded surface display, MIP, volume rendering) and the occurrence of PVE-related artefacts using the signal-to-background ratio (SBR) prior to and after MO application was compared. RESULTS: For all patients under review, the artefacts caused by PVE were significantly reduced by erosion (lung: mean SBRpre = 1.67, SBRpost = 4.83; brain: SBRpre = 1.06, SBRpost = 1.29) even with only a small number of iterations. Region dilation was applied to integrate further structures (e.g. at tumor borders) into a configurable neighbourhood for segmentation and quantitative analysis. CONCLUSIONS: The MO represent an efficient approach for the reduction of PVE artefacts in 3D-CT reconstructions and allow optimized visualization of individual objects.

Magnetic resonance (MR) imaging of the chest: state-of-the-art.

To date, magnetic resonance (MR) is established as an imaging modality in the diagnosis of chest diseases. Because of its excellent distinction of vessels and soft tissue, MR can be performed as the primary imaging procedure before computed tomography in patients with suspected vascular lesions, mediastinal masses, hilar lesions, and pathological changes of the pleura and the chest wall. In these cases, MR is able to provide all the necessary diagnostic information. In other patients, a limited number of MR images may be helpful in cases of equivocal or confusing CT or clinical findings. More detailed information can be obtained, using surface coils or special imaging sequences, i.e. high resolution MR images of the pleura or angiographic images of mediastinal and pulmonary vasculature. From a clinical viewpoint, the most important task for thoracic magnetic resonance nowadays is the pretherapeutic evaluation of intrathoracic masses, the differential diagnosis of benign versus malignant lesions, and the accurate documentation of tumour extent in malignancies including three-dimensional-display to improve surgical or radiation planning. Future directions in thoracic magnetic resonance will be predominantly influenced by postprocessing approaches, specialized imaging techniques, and magnetic resonance-guided interventional applications.

[Fractal surface analysis of intrapulmonary space-occupying lesions from high-resolution CT studies]. / Fraktale Oberflächenanalyse von intrapulmonalen Raumforderungen aus hochauflösenden CT-Untersuchungen.

PURPOSE: The visual assessment of shape and surface structures of pulmonary nodules (PN) (smooth edges vs. spiculae) serves as a qualitative, subjective criterion in differential diagnosis. These properties must be quantified by computer-assisted evaluation, an adequate mathematical model, and new quantitative shape parameters. METHODS: 12 patients were investigated by high resolution CT. Based on 3D reconstructions with increasing thresholds, the PN surface S, volume V, fractal dimension (FD = In(S)/ In(square root of V)), and fractal index (F1 = square root of S/ square root of V) were calculated. RESULTS: The relations between the reconstruction threshold and the calculated tumour surface, respective volume, are of a fractal nature: S = c1 x thres1/d, V = c2 x thres1/D (c1, c2, d, D: real constants). Whereas the absolute values of surface and volume strongly depend on the chosen threshold (mean volume differences of 249%), the derived parameter of the fractal dimension for a specific PN is nearly constant for all thresholds under review (r = 0.998, SD = 0.05). CONCLUSIONS: FD and FI are new diagnostic features for the assessment of PN surface structure and morphology. Thus, the assessment of pulmonary nodules can be supported by new quantitative parameters representing surface irregularity due to invasive tumour growth into adjacent tissue.

[Computer graphics methods for 3-dimensional imaging of intrapulmonary space-occupying lesions of CT and MRI images]. / Computergraphische Methoden zur dreidimensionalen Darstellung intrapulmonaler Raumforderungen aus CT- und MR-Bildern.

AIM: To improve the pre-operative planning of interventional procedures in thorax surgery different methods of computer-graphical visualization of intrapulmonary lesions and adjacent anatomical structures based on CT and MR data were realized and compared to each other. DESIGN: In 21 patients with intrapulmonary lesions the image data was segmented by interactive and automatic algorithms and different reconstruction techniques were applied (maximum intensity projection; color-encoded and transparent surfaces; volume rendering). Based on these three-dimensional reconstructions, different views from arbitrary perspectives (including simulated endoscopic images) were generated and animated film sequences of the 3D scene were displayed with 30 frames/second. RESULTS: For all patients under review, a high-quality presentation of the relevant structures was obtained by use of the applied computer-graphical techniques. Even combinations of different visualization methods in one image can be generated with the software we developed. CONCLUSIONS: The various methods for image segmentation allow a fast and comfortable processing even of large data sets. The calculated values of tumor surface and volume can be used for quantitative studies and therapy control. The planning of surgical and interventional procedures can be supported by the simultaneous visualization of the intrathoracic lesion and the surrounding structures.

[Leiomyosarcoma of the pulmonary artery]. / Leiomyosarkom der Pulmonalarterie.

In a 58-year-old man, a leiomyosarcoma was found to be the cause of unclear thoracal pain on the right side. The initial diagnose was an embolus of the pulmonary artery. The MRI showed a suspicious area similar to an intravasal tumor.

[3-D visualization of thoracic tumors from MR images]. / 3-D-Darstellung von thorakalen Tumoren aus MR-Bildern.

AIM: In cooperation with the thoracic surgery department 3-D visualizations of tumors were generated to support the surgeons in preoperative planning. As opposed to 3-D reconstructions of CT data, those representations based on MRI images remain an exception. In this paper different methods of three dimensional visualization of lung tumors are presented and compared to each other. DESIGN: These methods are 1. contour based surface models, 2. threshold based surface models and 3. rendered scenes of segmented volume data with transparent, color-coded display. RESULTS: Combinations of all three methods in one single image are possible as well with the software we developed. Furthermore, cut planes through the original data can be integrated into the 3-D scene. The segmentation of anatomical objects is performed either manually or automatically with various procedures. CONCLUSIONS: Adequate possibilities of manipulation and archiving allow a fast handling and processing even of large data sets. The calculated volumes of the anatomical objects can be used for quantitative studies. Arbitrary views of the three dimensional reconstructions can be generated within a few seconds. Even animation can easily be calculated and displayed with 30 frames/second.

[Tuberculosis and radiologic diagnosis 100 years after W. C. Roentgen]. / Tuberkulose und radiologische Diagnostik 100 Jahre nach W.C. Röntgen.

The discovery of the x-rays by W. C. Roentgen 100 years ago significantly improved the diagnosis and follow-up of tuberculosis, therapy control became possible, and the basis for prevention was set by early detection. Within few years, the "Roentgen" rays had been made a triumphant progress around the world, and Roentgenology was established as an independent medical discipline. Even after a century of developments like tomography, ultrasound, conventional/-high resolution and spiral computed tomography, digital radiography, digital subtraction angiography, and magnetic resonance imaging, innovations in the field of medical imaging appear to be unlimited, an evolution, which had been initiated by Roentgen. Today, therapists and radiologists are again challenged by the renaissance of tuberculosis, partially in new "clothes" by increasing numbers of HIV-patients. These specific changes clinically and radiological often appear atypical, and require subtile radiological diagnostics with the use of new imaging modalities. CT and MRI allow for follow-up of chemotherapy in mediastinal lymph node disease, significantly improve pleural diagnosis, and both are methods of choice in vertebral and cerebral tuberculous disease. Digital radiography and digital net-work allow for x-rays at the lowest dose, improved comparison in the follow-up, as well as for "online"-evaluation of images on the department's screen. Today, optimal diagnosis of tuberculosis includes the bacteriologic and clinical diagnosis and radiological imaging. To face the challenge of recurrent tuberculosis in in the second century after after Roentgen successfully, an intensive interdisciplinary cooperation of therapists and radiologists is necessary.

[High-resolution magnetic resonance tomography (HR-MRT) of the pleura and thoracic wall: normal findings and pathological changes]. / Hochauflösende Magnetresonanztomographie (HR-MRT) von Pleura und Thoraxwand: Normalbefund und pathologische Veränderungen.

AIM: To determine the value of high-resolution MRI in pleural and chest wall diseases, the normal and pathologic costal pleura and adjacent chest wall between paravertebral and the axillary region were examined with contrast enhanced high-resolution T1-weighted MRI images using a surface coil. MATERIAL AND METHODS: Normal anatomy was evaluated in 5 healthy volunteers and a normal specimen of the thoracic wall, and correlation was made with corresponding HR-CT and histologic sections. CT-proved focal and diffuse changes of the pleura and the chest wall in 36 patients underwent HR-MRI, and visual comparison of MRI and CT was done retrospectively. RESULTS: Especially sagittal T1-weighted HR-MRI images allowed accurate delineation of the peripleural fat layer (PFL) and the innermost intercostal muscle (IIM), which served as landmarks of the intact inner chest wall. PFL and IIM were well delineated in 3/4 patients with tuberculous pleuritis, and in all 7 patients with non-specific pleuritis, as opposed to impairment of the PFL and/or the IIM, which was detected in 15/18 malignancies as a pattern of malignant chest wall involvement. In one case of tuberculous pleural empyema with edema of the inner chest wall HR-MRI produced false positive diagnosis of malignant disease. CONCLUSION: HR-MRI images improved non-invasive evaluation of pleural and chest wall diseases, and allowed for differentiation of benign and malignant changes.

[Pleural diseases in magnetic resonance tomography (MRT)]. / Pleuraerkrankungen in der Magnetresonanztomographie (MRT).

MR images of 48 patients with histologically confirmed benign and malignant diseases of the pleura were retrospectively compared with CT and bioptically/surgically obtained findings. In 47/48 patients pathological changes of the pleura were visualized by increased signal intensities on T2-weighted and contrast enhanced T1-weighted MR images. This lead to a slightly improved sensitivity compared to CT, where pathological pleura findings were confirmed in 45/48 patients. MRI was able to identify 24/28 confirmed pleural effusions, whereas CT was successful in 26/28 patients. In two cases effusions not identified on CT were visible on T2-weighted MRI. 4 pleural effusions were missed with MRI.. On CT images differentiation of pleural changes vs effusions or adjacent lesions of lung parenchyma was successful in 20/28 and in 17/23 cases, respectively. Contrast enhanced T1-weighted images achieved the highest diagnostic accuracy with 22/28 and 20/23 cases, respectively. Signal intensities on MRI were unsuitable as sole criterion for the differentiation of benign and malignant diseases of the pleura. Contour and pattern of spreading of pleural changes were helpful in differential diagnosis. Nodular changes, thickening of more than 10 mm and mediastinal, circumferential and entire hemithoracic affection of the pleura were suggestive for malignant pleural disease. Infiltration of the diaphragm and the chest wall were most indicative for malignancy; here MRI (2/2 resp. 18/19 cases) was superior to CT (0/2 resp. 14/19 cases). CT was superior in the detection of pleural calcifications and osseous destruction.(ABSTRACT TRUNCATED AT 250 WORDS)

[Magnetic resonance tomography (MRT) in pleural diseases. A comparison with CT and histopathological findings]. / Magnetresonanztomographie (MRT) bei Pleuraerkrankungen. Vergleich mit CT und histopathologischen Befunden.

The MRI and CT appearances in 48 patients with histologically confirmed benign and malignant pleural abnormalities were compared retrospectively. Abnormal pleural changes were shown in 47 out of the 48 patients by high signal intensity of the pleura in T2-weighted sequences and in contrast enhanced T1-weighted sequences on MRI. CT showed abnormalities in 45 out of 48 patients. Delineation of pleural and pulmonary changes by CT was possible in 13 out of 23 cases, and pleural disease from effusions in 15 out of 28 cases. T2-weighted MRI was successful in 14 out of 23 and 4 out of 28 cases, respectively. T1-weighted images after contrast were successful in 20 out of 23 and 22 out of 28 cases, respectively. Indications of malignant pleural disease were the presence of mediastinal or circumferential involvement or involvement of the entire pleura, thickness of more than 10 mm and nodular changes. The most reliable sign of malignancy was infiltration of the thoracic wall and the diaphragm; this was better demonstrated by MRI (18 out of 19 and 2 out of 2 cases) than by CT (14 out of 19 and 0 out of 2 cases).