Electrochemotherapy in the treatment of metastatic malignant melanoma: a prospective cohort study by InspECT.

BACKGROUND: (ECT) is an effective local treatment for cutaneous metastasis. Treatment involves the administration of chemotherapeutic drugs followed by delivery of electrical pulses to the tumour. OBJECTIVES: To investigate the effectiveness of ECT in cutaneous metastases of melanoma and to identify factors that affect (beneficially or adversely) the outcome. METHODS: Thirteen cancer centres in the International Network for Sharing Practices on Electrochemotherapy consecutively and prospectively uploaded data to a common database. ECT consisted of intratumoral or intravenous injection of bleomycin, followed by application of electric pulses under local or general anaesthesia. RESULTS: In total, 151 patients with metastatic melanoma were identified from the database, 114 of whom had follow-up data of 60 days or more. Eighty-four of these patients (74%) experienced an overall response (OR = complete response + partial response). Overall, 394 lesions were treated, of which 306 (78%) showed OR, with 229 showing complete response (58%). In multivariate analysis, factors positively associated with overall response were coverage of deep margins, absence of visceral metastases, presence of lymphoedema and treatment of nonirradiated areas. Factors significantly associated with complete response to ECT treatment were coverage of deep margins, previous irradiation of the treated area and tumour size (< 3 cm). One-year overall survival in this cohort of patients was 67% (95% confidence interval 57-77%), while melanoma-specific survival was 74% (95% confidence interval 64-84%). No serious adverse events were reported, and the treatment was in general very well tolerated. CONCLUSIONS: ECT is a highly effective local treatment for melanoma metastases in the skin, with no severe adverse effects noted in this study. In the presence of certain clinical factors, ECT may be considered for local tumour control as an alternative to established local treatments, or as an adjunct to systemic treatments.

An observational study of the macro- and micro-haemodynamic implications of epidural anaesthesia in children.

The haemodynamic implications of epidural anaesthesia in children are poorly documented. We report macro- and micro-haemodynamic data from an observational study of 25 children ranging from neonates to six-years old, who underwent surgery conducted with a specific combination of monitoring systems. We analysed 90 min of study-related monitoring after epidural catheterisation, with skin incision taking place after around 30 min. We recorded macrohaemodynamic parameters (monitored using LiDCOrapid) including heart rate, mean arterial pressure, cardiac output, stroke volume, systemic vascular resistance and stroke volume variation. Microhaemodynamic parameters (monitored using Invos™) included cerebral and peri-renal oxygenation. Based on the entire 90 min of study-related monitoring, we found significant increases in cardiac output (p = 0.009), stroke volume (p = 0.006) and stroke volume variation (p = 0.008), as well as decreases in systemic vascular resistance (p = 0.007) around 30 min after epidural blockade. There were no significant changes in heart rate, arterial pressure and cerebral or peri-renal oxygenation during these 90 min. Considering that the microhaemodynamic parameters were not affected by the macrohaemodynamic changes, we conclude that autoregulation of the brain and the kidneys was maintained in children under epidural anaesthesia.

Multiphasic helical computerized tomography for the assessment of microscopic hematuria: a prospective study.

PURPOSE: We evaluated multiphasic helical computed tomography for the detection and characterization of lesions responsible for hematuria not diagnosed on prior urological surveillance studies. MATERIALS AND METHODS: A total of 393 men and 207 women with recurrent microscopic hematuria but negative urological surveillance studies were examined at 4 participating institutions by multiphasic helical computerized tomography, consisting of pre-enhancement, arterial corticomedullary, parenchymal and excretory phase sequences generating 2 to 5 mm slices through the kidney and lower pelvis. RESULTS: The cause of microscopic hematuria was established in 256 of 600 patients with prior negative urological surveillance examinations with 0.91 sensitivity and 0.94 specificity. The diagnosis was correct in all subsequently proven cases of calculous and renal vascular disease. A total of 67 of 70 inflammatory kidney lesions, 24 of 25 renal neoplasms, 15 of 16 bladder neoplasms, 27 of 35 inflammatory bladder conditions and 21 of 23 ureteral lesions were also correctly diagnosed. The diagnosis of renal medullary and papillary necrosis, and neoplastic lesions of the kidney and bladder allowed the early institution of medical therapy or appropriate surgery. CONCLUSIONS: Multiphasic helical computerized tomography diagnosed lesions responsible for microhematuria in 42.6% of 600 patients with negative urological surveillance examinations. This relatively low cost and low co-morbidity examination is advocated for patients with negative urological surveillance examinations or even as a first examination.

[Trends in Vienna radiology--from roentgen laboratory to university clinic for radiodiagnosis]. / Die Wege der Wiener Radiologie--vom Röntgenlaboratorium zur Universitätsklinik für Radiodiagnostik.

In Vienna/Austria, with leading representatives of the so-called second Viennese medical school at the turn of the 19th to the 20th century, the detection of x-rays by W. C. Röntgen was observed with special interest. In the general hospital of Vienna, where still today the medical school of the university of Vienna is hosted, high research activities to understand the origin and the effects of X-rays were performed. Guido Holzknecht (1872-1931) was the first chairman of the central roentgen laboratory. Today, the scientific and the clinical activities at the department of diagnostic radiology are manifold and virtually all fields of imaging are covered.

[Virtual multislice computed tomographic colonoscopy]. / Virtuelle Multislice-Computertomographie-Kolonoskopie.

Virtual colonoscopy or computed tomographic (CT) colonography is a rapidly evolving technique for imaging the entire colon and detection of colorectal polyps. It uses standard helical computed tomography images of the colon and advanced imaging software to produce reformatted two- and three-dimensional views of the entire colorectum. Multi-detector row helical computed tomography has several technical advantages over single-detector row computed tomographic, including faster imaging times with the acquisition of thinner sections. The improved speed and spatial resolution of multislice computed tomography promises an increase of sensitivity and specificity, especially for the detection of colorectal lesions.

[Middle field and low field magnetic resonance tomography in wrist injuries]. / Mittelfeld- und Niederfeld-Magnetresonanztomographie bei Handgelenkverletzungen.

PURPOSE: To evaluate the diagnostic value of magnet resonance imaging in comparison of a dedicated 0.2-T unit and a 1.0-T unit in patients with clinically suspected scaphoid fractures and other wrist fractures. MATERIAL AND METHODS: In 20 patients (14 m/6 f) with clinically suspected scaphoid fractures and a normal six view radiographic exam, magnet resonance imaging was performed first with the dedicated 1.0-T unit and afterwards with the 0.2-T unit within 7 days after trauma. T1 weighted spin-echo, STIR and T2-weighted 3D GRE sequences were performed. RESULTS: The 0.2 Tesla dedicated system is inferior to the 1.0 Tesla unit concerning the outcome of the 3 examiners. Especially the areas of bone bruise showed different results: each examiner detected at least two more cases of bone bruise with the 1.0 Telsa unit, which could not be defined with the 0.2 Tesla unit. CONCLUSIONS: This study shows, how utmost sensitive magnet resonance imaging is referring to unremoved fractures of the scaphoid and to other wrist abnormalities. Results with the 0.2 Tesla dedicated system was inferior compared to the 1.0 Tesla unit.

[Value of endoanal sonography in the assessment of faecal incontinence]. / Wertigkeit der Endoanalsonographie in der Abklärung bei fäkaler Inkontinenz.

PURPOSE: The aim of this study was to assess the value of endoanal ultrasound (EUS) in comparison to anal manometry and operative findings in patients suffering from faecal incontinence. Patient history, localisation of sphincter defects and therapeutic modalities were analysed. METHODS: Over a 3-years period, 92 patients with faecal incontinence were investigated by endoanal ultrasound. Results were compared with anal manometry in 81 cases. RESULTS: At EUS, 27 patients (29 %) showed no sphincter defect, 18 (20 %) had an isolated internal sphincter defect, 13 (14 %) an isolated defect of the external sphincter and 34 (37 %) presented with a combined internal/external sphincter defect. Manometry correlated in 30 % with endoanal ultrasound. Compared with surgery, endoanal ultrasound was correct in 100 % and manometry in only 54 %. An obstetric trauma was most frequently related to faecal incontinence. CONCLUSION: Endoanal ultrasound is a very sensitive method for localizing anal sphincter defects and is mandatory in the assessment of patients with faecal incontinence.

Evaluation of perianal sepsis: comparison of anal endosonography and magnetic resonance imaging.

The purpose of this study was to compare prospectively the diagnostic yield of anal endosonography (AES) and magnetic resonance imaging (MRI) in the assessment of perianal fistulae and abscesses. There were 39 patients (14 men, 25 women; mean age, 40 years) who underwent AES, performed with a 10-MHz rotating endoanal probe and MRI at 1.0 T (axial and coronal T2-weighted turbo spin-echo (TSE) and turbo-STIR sequences). Fistulae were classified as subcutaneous, intersphincteric, transsphincteric, high (i.e., high extrasphincteric or suprasphincteric), rectovaginal, and horseshoe and were compared with the surgical findings in all patients. Overall, 58 fistulae (subcutaneous, N = 7; intersphincteric, N = 9; transsphincteric, N = 16; high, N = 17; rectovaginal, N = 5; and horseshoe, N = 4) were detected at surgery. MRI showed a sensitivity of 84% and AES of 60% (P <.05). False-positive diagnoses were made in 6 patients (15%) with MRI and in 15 patients (26%) with AES, for a specificity of 68% and 21%, respectively (P <.05). Our findings show that MRI is superior to AES in the assessment of fistula-in-ano before major surgery. AES should be used only for orientation before minor procedures, such as incision or drainage of subcutaneous fistulae.

Scaphoid fractures: evaluation with high-spatial-resolution US initial results.

PURPOSE: To evaluate the diagnostic accuracy of high-spatial-resolution ultrasonography (US) in the diagnosis of scaphoid fractures. MATERIALS AND METHODS: In 72 hours after acute wrist trauma, 15 consecutive patients were examined for possible scaphoid fractures clinically and with conventional radiographs, including scaphoid views. Thereafter, high-spatial-resolution US was performed by two experienced radiologists blinded to the results of the previously performed investigations. High-spatial-resolution US of the scaphoid bones was performed from the palmar, lateral, and dorsal directions in the longitudinal and transverse planes. US findings indicative of a scaphoid fracture were cortical discontinuity and/or periosteal elevation. Finally, magnetic resonance (MR) images (short inversion time inversion-recovery, T1- and T2*-weighted) (ie, the standard) of the affected wrist were obtained and evaluated for a possible scaphoid fracture by two radiologists in consensus. RESULTS: Nine of 15 patients had scaphoid fractures. Seven (78%) of nine patients had positive findings at high-spatial-resolution US and five (56%) had such findings at conventional radiography (ie, four occult scaphoid fractures), with an accuracy of 87% and 73%, respectively. Two (50%) of four radiographically occult scaphoid fractures were depicted with high-spatial-resolution US. Sonographic findings of scaphoid fractures were either cortical discontinuity (n = 4), periosteal elevation (n = 2), or a combination of these two findings (n = 1). CONCLUSION: High-spatial-resolution US is a reliable diagnostic tool for the evaluation of occult scaphoid fractures and should be considered an adequate alternative diagnostic tool prior to computed tomography or MR imaging.

[Evaluation of a computer-assisted diagnosis system in breast carcinoma]. / Evaluierung eines computerassistierten Diagnosesystems in der Erkennung des Mammakarzinoms.

PURPOSE: Evaluation of a computerassisted diagnosis (CAD) system (R2 linage Checker 1.2). Comparison of the results of three readers with and without knowledge of the computer results. MATERIALS AND METHODS: The mammograms of 52 patients, bilaterally in two planes each, with histologically proven carcinoma of the breast were included in the study. They were first scanned by the CAD machine and subsequently read by three readers with different degrees of experience in two sessions with and without knowledge of the computer results. RESULTS: Of the 91 views of carcinomas, the readers detected 96%, 89%, and 85%, respectively. With CAD, the values rose to 97%, 93%, and 96%. The increase of the first observer was not significant. As for the 49 areas of malignant microcalcifications, the first reader showed a significant decrease of sensitivity, the other two readers showed no significant change. The sensitivity of CAD was 74% for masses and 86% for microcalcifications at a rate of 1.8 false positive markers per image. All but two tumors were correctly marked in at least one plane. CONCLUSIONS: Use of the CAD machine led to a significant increase of sensitivity in the detection of malignant masses by two of three observers. In the case of malignant microcalcifications, and for the most experienced observer, CAD did not improve the results. The most important problem is the high rate of false positive markers.

Complications after laryngeal surgery: videofluoroscopic evaluation of 120 patients.

AIM: Videofluoroscopic assessment of the spectrum and incidence of swallowing complications after state-of-the-art laryngeal cancer surgery. MATERIALS AND METHODS: We retrospectively studied videofluoroscopic examinations of 120 patients (94 men, 26 women; mean age, 58 years) with suspected complications after laryngeal resection (partial laryngectomy, 65; total laryngectomy, 55). Swallowing function (i.e., oral bolus control, laryngeal elevation and closure, presence of pharyngeal residue, aspiration) and structural abnormalities such as strictures, fistulas and tumour recurrence were assessed by videofluoroscopy. RESULTS: Abnormalities were found in 110 patients, including strictures in nine, fistulas in six and mass lesions in 13 patients. Aspiration was found in 63 patients overall (partial laryngectomy, 61/65; total laryngectomy, 2/55), occurring before swallowing in five, during swallowing in 34, after swallowing in nine and at more than one phase in 15 patients. Pharyngeal paresis was detected in three and pharyngeal weakness in 19 patients. Pharyngo-oesophageal sphincter dysfunction was observed in 10 cases. CONCLUSION: Aspiration is a very common complication after partial laryngeal resection. It is mainly caused by incomplete laryngeal closure, sphincter dysfunction or pharyngeal pooling. Videofluoroscopy is the only radiological technique able to identify both disordered swallowing function and structural changes after laryngeal resection. Detection of these complications is crucial for appropriate further therapy.Kreuzer, S. H. (2000). Clinical Radiology55, 775-781.

Transrectal sonography of anal sphincter infiltration in lower rectal carcinoma.

OBJECTIVE: The purpose of the study was to assess the accuracy of transrectal sonography in determining invasion by lower rectal cancer into the anal canal. SUBJECTS AND METHODS: Thirty-eight patients (14 women, 24 men; mean age, 65 years) with lower rectal cancer underwent transrectal sonography before surgery. Both depth of infiltration and tumor invasion into the anal canal were assessed, and results were compared with histopathology of the resected specimens. RESULTS: Infiltration into the anal canal was found histopathologically in 12 (32%) of 38 patients. Transrectal sonography revealed a true-positive diagnosis in 11 of these 12 patients. A false-positive diagnosis of anal canal infiltration was made in two patients for a sensitivity of 91%, a specificity of 85%, and an accuracy of 92%. In the 11 patients diagnosed correctly on transrectal sonography, the depth of tumor infiltration into the anal canal corresponded with histopathology. CONCLUSION: This study shows that transrectal sonography is an accurate method for assessment of anal canal infiltration in lower rectal cancer.

Detection of focal hepatic lesions: comparison of unenhanced and SHU 555 A-enhanced MR imaging versus biphasic helical CTAP.

The purpose of this study was to compare the diagnostic sensitivity of unenhanced magnetic resonance (MR) imaging, and MR imaging with a new superparamagnetic iron oxide (SPIO)-enhanced contrast agent (SHU 555 A) with biphasic helical computed tomography during arterial portography (CTAP) in patients with focal liver lesions. Eighteen patients with a total of 91 (78 malignant, 13 benign) proven liver lesions underwent unenhanced short tau inversion recovery (STIR), T2-weighted (T2-w) TSE, and SHU 555 A-enhanced T2-w turbo spin-echo (TSE) MR imaging and biphasic helical CTAP. The standard of reference was histopathologic analysis of resected specimens in 59 lesions, intraoperative ultrasound with biopsy in 20 lesions, and CT-guided biopsy and follow-up in 12 lesions. Diagnostic performance of the imaging modalities was compared quantitatively and qualitatively by assessing lesion involvement in liver segments. There were 68 lesions detected on unenhanced T2-w TSE, which resulted in a sensitivity of 75%. With the STIR sequence, 76 lesions were detected, for a sensitivity of 84%, and with SHU 555 A-enhanced MRI, 84 lesions were detected, for a sensitivity of 92%. CTAP detected 88 lesions, for a sensitivity of 97%. The accuracy for unenhanced T2-w TSE was 98%, for STIR 99%, for enhanced-MRI 100%, and for CTAP 95%. The specificity was 100% for SHU 555 A-enhanced MRI and 95% for CTAP. SHU 555 A-enhanced MRI was superior to nonenhanced MRI (P < 0.05) and equivalent to CTAP in terms of sensitivity. Due to the absence of false-positive results on SHU 555 A-enhanced MRI, the specificity and accuracy of enhanced MRI were higher than those of CTAP, but the difference was not statistically significant (P = 0.134).

[Thoracic CT scan in intensive care unit patients: information supplementary to thoracic radiography]. / Thorakale Computertomographie am Intensivpatienten--Zusatzinformation zum Thorax-Röntgen.

PURPOSE: To assess the diagnostic value of thoracic CT-scans in comparison with conventional chest radiographs in ICU-patients. METHODS: Chest radiographs and corresponding thoracic CT-scans of 25 consecutive surgical ICU-patients were reviewed and interpreted independently by two radiologists. We analyzed the additional information provided by CT-scans and the diagnostic and therapeutic relevance of these findings. RESULTS: In 22 patients (88%), thoracic CT revealed 35 single additional findings, in comparison with the corresponding bedside radiographs. In 7 cases (28%), these findings (tube-malpositioning, mediastinitis, mediastinal abscess and pneumothorax) required modification of patient management. Of 7 patients with tube thoracostomy, 3 tubes were malpositioned, which was only depicted on CT-scans. In 10 of 21 cases (48%), pleural effusions could only be visualized by CT. 3 of 5 (60%) pneumothoraces were detected by CT-scans only. There were no significant complications during transport or CT-examination. CONCLUSION: Thoracic CT may provide significant information in addition to plain chest radiographs, particularly when specific problems or questions, referring to the management of ICU-patients, arise.

Videofluoroscopy of swallowing in symptomatic patients who have undergone long-term intubation.

OBJECTIVE: The aim of this study was to evaluate whether specific patterns of swallowing dysfunction occur in symptomatic patients after long-term intubation. SUBJECTS AND METHODS: Twenty-one patients (16 men, five women; mean age, 66 years) who presented with clinical signs of aspiration after long-term intubation (mean duration, 24.6 days) underwent videofluoroscopy. They were analyzed for functional abnormalities of the tongue, soft palate, epiglottis, hyoid and larynx, pharynx, and the upper esophageal sphincter. We assessed the presence or absence of aspiration, the type of aspiration (pre-, intra-, and postdeglutitive), and a spectrum of other swallowing abnormalities. RESULTS: There were 18 patients (86%) with radiologically proven aspiration. In another patient only laryngeal penetration occurred. There were 11 combinations of pre-, intra-, and postdeglutitive aspiration. Predeglutitive aspiration was predominant and present in 52% of our patients. We found functional abnormalities of the tongue in 48%, of the soft palate in 10%, of the epiglottis in 48%, of the pharynx in 71%, and of the upper esophageal sphincter in 24%. CONCLUSION: Patients who are symptomatic after undergoing long-term intubation do not develop a specific type or pattern of swallowing dysfunction or aspiration, but show a large variety of aspiration types and associated swallowing disorders. Nevertheless, videofluoroscopy has the ability to reveal complex deglutition disorders and to aid precise planning of individualized functional swallowing therapy.

[Radiologic staging of thoracic and abdominal tumors in childhood]. / Radiologisches Staging von thorakalen und abdominalen Tumoren im Kindesalter.

Thoracoabdominal tumors in childhood can arise from all organs and affect children from the neonate to the adolescent. Better prognosis of childhood tumors, due to better biological understanding and improvement of chemotherapy, require sufficient radiological staging. Sufficiency in radiological staging needs modern cross-sectional techniques with high resolution, good availability and lower radiation dose. In general computed tomography (CT) is being used for radiological staging; increasingly MR imaging is being used because of multiplanar imaging techniques. Replacement of invasive techniques such as myelography and lymphography and modern cross-sectional techniques create painless staging conditions. Nevertheless, scintigraphy will always be a major examination technique, especially for evaluation of metastases and postoperative control examinations. The most common thoracoabdominal tumors in childhood and their staging are described.

[Preoperative staging of colorectal carcinoma]. / Präoperatives Staging des Kolorektalen Karzinoms.

Carcinoma of the colorectum is one of the most frequent neoplasias, with an incidence of 40 in 100,000. For the effective use of new, differentiated, less invasive treatment options, exact preoperative staging of the tumor is essential. The introduction of endosonography in rectal tumor staging allows for exact differentiation of the rectal wall layers and thus of tumor stages 1-3 with median accuracy of 89%. Magnetic resonance imaging of the rectum, especially in double-contrast technique, can also be employed in high and stenosing tumors and leads to an average accuracy of 85% for the stages 1-4. Computed tomography is the method of choice in screening for metastases. In lymph node staging, all modalities show only moderate accuracy around 75%.

[Characterization of adrenal gland space-occupying lesions. Can diagnostic imaging replace biopsy?]. / Charakterisierung von Nebennierenraumforderungen. Kann die Bildgebung die Biopsie ersetzen?

This paper describes the diagnostic value of new imaging techniques in characterization of adrenal masses and evaluates the role of adrenal biopsy. For differentiation of benign and malignant adrenal lesions, sensitivities and specificities of 85-100% can be reached by unenhanced computed tomography (CT) methods, chemical shift techniques in magnetic resonance imaging (MRI), delayed enhanced CT techniques, and by evaluation of wash-out curves in contrast-enhanced CT. The diagnostic value of all CT techniques depends on threshold values. The value of dynamic contrast-enhanced MRI is under discussion and should be reevaluated by using delayed enhanced series. Biochemical and scintigraphic methods (NP 59 iodine iodomethyl-norcholesterol and MIBG meta-iodobenzylguanidine scintigrams) are valuable for the diagnosis of functional adrenal masses; however, they do not allow differentiation of benign and malignant tumors. According to excellent results of new imaging techniques in characterization of adrenal masses, the indications for fine-needle aspiration biopsy have already regressed, as have complications associated with this invasive technique.