Effects of testosterone replacement therapy on cortical and trabecular bone mineral density, vertebral body area and paraspinal muscle area in hypogonadal men.

Loss of bone and muscle mass are major findings of male hypogonadism. In order to determine the long-term effect of testosterone replacement therapy on spinal bone and muscles, the trabecular and cortical bone mineral density, vertebral body area and paraspinal muscle area were assessed by quantitative computed tomography in 32 testosterone-substituted patients, aged 18-74 years, with idiopathic hypogonadotropic hypogonadism (n=6), pituitary insufficiency (n=5), Klinefelter syndrome (n=12) or other forms of primary hypogonadism (n=9). They were followed for a mean period of 3.2+/-1.7 years (mean+/-S.D.), ranging from 1 to 7 years. A significant correlation between initial serum testosterone levels and bone mineral density was found in patients with congenital forms (r=0.58; P<0.05) but not in those with acquired forms. A significant increase in trabecular and cortical bone mineral density (P<0.001) was documented in the course of replacement therapy in all patients regardless of the type of hypogonadism and age of patients. A slight but significant increase in paraspinal muscle area was observed if all patients were taken together (P<0.01). The area of paraspinal muscle correlated with body weight (r=0.58; P<0.001) and moderately with trabecular bone mineral density (r=0.4; P<0.01). Its increase did not correspond to the change observed for trabecular and cortical bone mineral density. Vertebral body area did not change over time. It correlated only with height and weight but not with bone mineral density. In conclusion, testosterone therapy of hypogonadal men improves both trabecular and cortical bone mineral density of the spine independently of age and type of hypogonadism while vertebral area remains unchanged. The effects seen on paraspinal muscles emphasize the clinical benefit of adequate replacement therapy for the physical fitness of hypogonadal men.

Cystic pelvic mass in a patient having recurrent carcinoma of the cervix.

The diagnostic difficulties encountered with atypical tumor growth are reported in a 29-year-old female with recurrent carcinoma of the uterine cervix. Following a Wertheim-Meigs procedure and resection of local tumor recurrence eight months later, a second recurrence was detected on CT as a purely cystic lesion in the left pelvic wall. Although the size of the cyst subsequently increased, the patient remained asymptomatic until slight pain developed in the left leg 28 months after initial therapy. One month later, limping was noticed; plain radiography showed a large osteolytic lesion of the left hip and on I.V.U., a dilatation of the left renal collecting system was observed. Pelvic CT showed only minimal solid tissue components within a large cyst. Multiple needle aspirations of the cyst and cytological examinations of the fluid obtained showed no evidence of tumor cells. A definitive histological diagnosis of metastasizing squamous cell carcinoma was only reached after surgery.

In-vitro high-resolution ultrasonography of benign and malignant lymph nodes. A sonographic-pathologic correlation.

RATIONALE AND OBJECTIVES: The authors assess the value of combining high-resolution ultrasonography (HRUS) findings in a scoring scale for distinguishing malignant from reactive lymphadenopathy and explain the pathologic causes of altered nodal sonographic architecture. MATERIALS AND METHODS: Sixty-one nodes obtained from 32 consecutive patients were prospectively scanned with 7.5-MHz ultrasound probes in a waterbath. Three sonographic features--long-to-short axis ratio (L/S), hilar width, and cortical width--were graded on a 5-level scoring scale (0-4). Nodes scored > or = 3 were considered malignant and < or = 2 benign. Subsequently, all nodes were microsectioned in a plane matching the sonograms, allowing direct sonographic-pathologic correlation. RESULTS: Eighty-two percent of nodes were correctly characterized using the above cut-off point (sensitivity: 87%, specificity: 74%). Eighty-three percent of nodes scored 4 were malignant and 95% scored 0 were benign. Eighty-two percent of nodes with L/S < 2, 81% with no hilus, and 70% with eccentric cortical widening were malignant, whereas 72% with L/S > or = 2, 86% with a wide hilus, and 91% with a narrow cortex were benign. Sonographic-pathologic correlation showed that tumor infiltration results in rounded nodal shape, loss of hilar echogenicity and cortical widening, whereas reactive disease tends to preserve nodal architecture. CONCLUSION: Morphologic changes detectable using HRUS help distinguish benign from malignant lymph nodes.

In vitro correlation of intravascular ultrasound and direct magnification radiography for calcified arterial lesions.

RATIONALE AND OBJECTIVES: Intravascular ultrasound (IVUS) is an adjunct to contrast angiography that gives additional information concerning the morphology of the vascular wall. The authors examined the accuracy of intravascular ultrasound (IVUS) in the evaluation of calcified lesions within the abdominal aorta and the iliac artery. METHODS: Forty-nine human specimens (iliac artery, 26; abdominal aorta, 23) were examined using a 20-MHz 6.0-F ultrasound catheter, followed by magnification radiography of the same specimens using a newly developed microfocus x-ray tube. Magnification radiographs and ultrasound images were divided into identical sectors to analyze the morphology of calcified arteriosclerotic lesions. RESULTS: A total of 644 sectors was analyzed. Sensitivity of intravascular sonography was 70%, specificity 53%. Sensitivity strongly depended on the morphology of the calcified lesions. CONCLUSION: The detection of calcified arteriosclerotic lesions by means of IVUS revealed a sensitivity of 70% in an in vitro study using human specimens. However, the specificity of IVUS was only 53%, which is basically a random chance occurrence.

Artificially produced cartilage lesions in small joints: detection with optimized MRI-sequences.

The purpose of this study was to evaluate different magnetic resonance imaging (MRI) pulse sequences in the detection of artificial cartilage lesions in small joints using an animal model. A total of 32 artificial cartilage lesions were created in the knee joints of 20 rabbits. Twenty lesions were produced 4 weeks and 12 lesions 1 h before the MRI examination, performed in an extremity coil at 1.0 T. All joints were examined with five imaging sequences: (1) a conventional T1-weighted spin-echo (SE)-sequence (repetition time [TR] 600 ms, echo time [TE] 15 ms), (2) a T2-weighted turbo-SE-sequence (TR 2000 ms, TE 85 ms), (3) a two-dimensional (2D) gradient echo (GE)-sequence (TR 440 ms, TE 10 ms, flip angle 60 degrees) and (4,5) two three-dimensional (3D) GE-sequences (TR 40 ms, TE 7 ms, flip angle 40 degrees, with fat suppression (FS) and TR 30 ms, TE 9 ms, flip angle 40 degrees). Two examinations had to be excluded because of insufficient image quality and the remaining examinations were analyzed by two experienced radiologists. The MRI images were correlated with the pathologic findings and anatomical structures were scored according to a 5-level scale. Direct comparison of the pathological and MRI findings showed that 19 of the 30 artificially induced cartilage lesions were detected with the FS 3D GE-sequence, 13 with the 2D GE-sequence, 11 with the 3D GE-sequence, 3 with the T1-weighted SE-sequence, and 2 with the T1-weighted SE-sequence. The highest percentage of artificial cartilage lesions was demonstrated using a fat-suppressed 3D GE-sequence. However, the analysis of cartilage defects in small joints with optimized sequences as well as clinical routine hardware and software had limitations. Therefore a pilot study was performed analyzing newly developed high resolution FS 3D GE images obtained from 5 rabbit knees with 10 cartilage lesions at 1.5 T. Two sequences were used with 1.0 and 0.5 mm slice thickness, a matrix of 256 x 256 and 512 x 256 and a field of view of 12 x 6 and 8 x 6 cm. In this small subset detection rates were substantially higher than in the 30 rabbit knees examined before.

Texture analysis of direct magnification radiographs of vertebral specimens: correlation with bone mineral density and biomechanical properties.

RATIONALE AND OBJECTIVES: The authors used direct magnification radiographs, combines with texture analysis, to investigate the trabecular structure of human vertebral specimens and compared these techniques with measurement of bone mineral density (BMD) by using quantitative computed tomography to predict bone strength. METHODS: Direct magnification radiographs and BMD measurements were obtained from 38 motion segments from the thoracolumbar spines of 11 female human cadavers. Maximum compressive strength (MCS) was determined with a materials testing machine. Morphologic parameters, digital skeletons, and fractal dimension were obtained from the radiographs in three different regions of interest. RESULTS: Correlations between BMD and MCS were statistically significant (r = .81, P < .01). With morphologic parameters, correlation coefficients of up to .64 (P < .01) were obtained. Use of multivariate regression analysis with one morphologic parameter (the width of the black pixels, or thicknessB) in addition to BMD improved correlations versus MCS (P < .01). CONCLUSION: In an experimental setting, BMD showed statistically significant correlation with bone strength, whereas the structural parameters demonstrated only modest correlations. BMD together with one of these measures (thicknessB), however, showed the highest correlation.

Ultrasonographic patterns of focal hepatic and splenic lesions in Hodgkin's and non-Hodgkin's lymphoma.

The sonographic patterns of focal lesions of the liver and spleen in 26 patients with Hodgkin's disease and non-Hodgkin's lymphoma are described. Thirteen out of 19 hepatic lesions and nine out of 11 splenic lesions corresponded to a nodular lymphomatous involvement. The remaining cases involved benign focal lesions of the liver and spleen. The vast majority of the hepatic and splenic lymphomatous nodules had a hypoechoic pattern with indistinct edges. Target lesions of the liver were seen only in non-Hodgkin's lymphoma. Echogenic lymphomatous nodules could not be detected. All echogenic lesions (three) were biopsied and found to be benign. Whereas a focal liver involvement almost always occurred in combination with hepatomegaly, only two out of nine patients with splenic foci had splenomegaly. The response of hepatic and splenic lymphoma to chemotherapy is described from follow-up examinations in 11 cases. Because of the inherent risk of over-treatment of the false positive interpretation of hepatic nodules, the large-scale use of needle biopsy in sonographically equivocal lesions is strongly advocated.

Radiation-induced malignant mesenchymoma of the chest wall following treatment for breast cancer.

21 years after radiotherapy for breast cancer, a 63-year-old woman developed a malignant mesenchymoma of the chest wall. The total irradiation dose was 132 Gy. The first clinical symptom of this second malignancy was a slight irregular calcification around the implanted silicon protheses observed in a conventional chest X-ray. Radiation-induced sarcoma is a very rare complication of radiotherapy. In cases of chest wall calcification after radiation therapy further investigation should be carried out, because some patients with radiation-induced sarcoma could be saved, if an early diagnosis is reached.

[CT studies following ethanol embolization of malignant kidney tumors]. / CT-Untersuchungen nach Athanolembolisation maligner Nierentumoren.

CT studies were carried out in 25 patients after alcohol embolisation. It was shown that the embolisation reaches the very periphery of the renal capsule. Nevertheless, contrast enhancement in renal tumours persists, due to capsular and collateral vessels. These subsequently permit further tumour growth. Intratumoral gas could be demonstrated in all patients. In the absence of symptoms, this must be regarded as a normal post-embolic event.

[Vertebral body lesions as an interference factor in quantitative computed tomography of the lumbar spine. An analysis of 1116 standardized performed measurements]. / Wirbelkörperläsionen als Störfaktor bei der quantitativen Computertomographie der Lendenwirbelsäule. Eine Analyse von 1166 standardisiert durchgeführten Messungen.

The type, frequency and location of lumbar vertebral lesions that may interfere with quantitative computed tomographic (QCT) estimation of bone mineral content were analysed in 1166 cases. All examinations were carried out with a standard protocol on the second, third and fourth vertebral body. A total of 130 lesions were identified, the majority of which included degenerative sclerosis of L4 and compression fractures of L2. Evaluation of 28 QCTs with compression fracture in one vertebral body showed that an accurate BMC value was obtained with an interendplate distance of 13 mm or more.

[Quantitative flow measurement of the carotid artery using a combination of intra-arterial digital subtraction angiography and ultrasound]. / Quantitative Flussmessung der A. carotis durch Kombination von intraarterieller DSA und Ultraschall.

Arterial blood flow was estimated using digital subtraction roentgen-densitometry in a model of the cervical arteries. The best results were obtained with two sampling windows calculating the mean passage time using the line of gravity of the contrast bolus. Mechanical contrast injection created a systematic error by acceleration. This procedure was then used for examining five patients. Quantitative blood flow measurements required knowledge of the transverse vessel area. This was determined by high resolution sonography. Blood flow was calculated as the product of cross-sectional area and mainstream velocity.

[Magnetic resonance angiography of the arteries supplying the brain]. / Magnetresonanzangiographie der hirnversorgenden Arterien.

In a prospective study involving 52 patients, magnetic resonance angiography (MRA) was compared with arterial digital subtraction angiography (IA-DSA). MRA was performed within three days of the IA-DSA. It was carried out without knowledge of the findings on IA-DSA. Of 38 stenoses of the carotid arteries or their branches, demonstrated by IA-DSA, 33 could be seen on MRA; in four cases the stenosis was outside the imaging area of the coil. Sixteen out of 17 carotid occlusions were diagnosed by MRA. There was one false positive. In the vertebral artery territory, eleven out of 13 stenoses and three out of four occlusions were diagnosed by MRA. In evaluating the degree of stenosis, there was agreement in only 16 out of 33 cases. MRA over-estimated the severity of stenoses in 15 cases and under-estimated it in two. MRA is a new non-invasive method in the diagnosis of cerebro-vascular disease which must be evaluated by further studies.

[Diagnostic value and interpretation of imaging bone densitometry based on quantitative CT]. / Aussagefähigkeit und Interpretation der bildgebenden Osteodensitometrie am Beispiel der quantitativen CT.

Quantitative CT of the axial skeleton (aQCT) may serve as an example of the evaluation and interpretation of bone densitometric data as it is the only state-of-the-art technique with valid longitudinal observations. The value of bone density measurements in interindividual cross sections refers to a grading derived from a representative reference population and provides an evaluation of fracture risk. The presence and rate of any bone loss can only be evaluated in an intraindividual longitudinal follow-up. Adequate follow-up for trabecular bone requires at least 3 to 5 years intervals to discriminate between different loss rates. Bone losses induced by steroid therapy or immobilisation may have faster kinetics apparent within months; bone density increase due to hormone substitution may be significant after one to two years. Morphological data allow critical evaluation of the quantitative measurements, eliminating false values and differentiating between rarefying and destructive osteopenia.

[A simplified technic in high-resolution MR tomography of the shoulder: ZEPRA (Zoom of Eccentric Positioned Regions by active Aliasing)]. / Vereinfachte Technik bei der hochauflösenden MR-Tomographie der Schulter: ZEPRA.

A fairly easy method for high-resolution MR imaging of the shoulder is described. The combination of a defined arrangement of the gradients with a small-volume Helmholtz coil provides the possibility of a high zoom of structures apart from the magnet's centre. The maximal achievable zoom factor depends on the ratio of FOV/sensitive coil volume. The ZEPRA method acts by phase-encoded aliasing only. With this technique all interesting soft tissue of the shoulder may readily be visualized in every direction and with every type of sequence.

[Sonographic diagnosis of pneumothorax]. / Sonographische Diagnostik des Pneumothorax.

The sonographic appearances of the pleura were studied in 20 normals and in eight patients with radiologically confirmed pneumothoraces. In all 20 normals it was possible to demonstrate the respiratory excursion of the visceral pleura. Moreover, the margin between pleura and aerated lung parenchyma was marked by artifacts resembling a comet's tail. In all eight patients with pneumothoraces pleural air could be inferred by the absence of pleural movement and of the comet-tail artifacts. In emergency situations, where it is not possible to obtain radiographs, or to obtain them with sufficient speed, sonography may make a crucial contribution to the diagnosis of a pneumothorax.

[Aortic arch angiography in the preoperative diagnosis of cerebrovascular diseases. Comparison of the conventional technic and intra-arterial DSA]. / Die Aortenbogenangiographie in der präoperativen Diagnostik zerebraler Gefässerkrankungen. Vergleich von konventioneller Technik und intraarterieller DSA.

Demonstration of the aortic arch is necessary in the investigation of cerebrovascular insufficiency for showing the origins and course of the cerebral arteries and for detecting steal syndromes and anatomical variations. Intra-arterial DSA is comparable in this respect with the traditional film technique; it has the advantage of reducing contrast doses by 75% and of reducing film costs and the examination time. Reliable evaluation of the carotid bifurcations is possible in less than half the cases. Selective carotid angiography cannot be replaced, therefore, by this technique. Selective angiography is also necessary for the pre-operative study of the intracranial vessels.

[The use of rapid sequences in craniocerebral MR diagnosis]. / Einsatz schneller Sequenzen bei der kraniozerebralen MR-Diagnostik.

MRI of the head is routinely performed with spin-echo sequences whereas gradient-echo sequences are still uncommon. Certain features of fast imaging sequences make them a promising tool for clinical investigations. The relative high signal-to-noise ratio/unit time demonstrates the usefulness of GE imaging as localising images. The extremely high contrast-flexibility is sometimes superior to SE imaging and may help to characterise structures and lesions. Flow dynamics are more clearly depicted than with SE sequences and lead to the dynamic evaluation of intracranial motion (CSF flow, blood flow). This information may be used in a special mode to achieve MR angiograms. Due to the very short repetition times, GE sequences are excellently suited to 3D application. This enables to reduce slice thickness to less than 1 mm with optional reconstructions in any virtual direction. In view of present developments in MR, GE imaging will be accepted in clinical diagnostic imaging in the near future.

[The MR tomographic findings in cranial manifestations of neurofibromatosis]. / MR-tomographische Befunde kranialer Manifestationen der Neurofibromatose.

Twelve patients with central neurofibromatosis underwent MR examination of the head. Among these, chiasma glioma was the most common CNS tumour (6/12). Seven patients had multifocal areas of increased T2-signal without mass effect predominantly involving the region of the basal ganglia. No corresponding CT abnormalities were present. These lesions may represent multifocal dysplasia and seem to be characteristic of central neurofibromatosis.

[Efficient use of flash sequences in the staging of bone and soft tissue tumors]. / Rationeller Einsatz von Flash-Sequenzen im Staging von Knochen- und Weichteiltumoren.

Delineation of neoplasms from normal tissue is possible using Flash sequences. These sequences prove useful in preoperative staging of bone tumours and soft tissue tumours. However, contrast between neoplastic and surrounding normal tissue is lower than in optimal selected spin-echo sequences. Flash-90 sequence is superior to Flash-10 sequence in the demonstration of intraosseous extension of predominantly sclerotic, calcified and purely fibrous tumours. In contrast, Flash-10 sequence proves superior for the demarcation of osteolytic tumours with minimal fibrous tissue content. Delineation of extraosseous tumour masses against muscle can best be achieved using Flash-90 sequence after intravenous administration of Gadolinium-DTPA. Flash-90 sequence enables sharp demarcation of extraosseous masses of bone tumours against surrounding fat, whereas Flash-10 sequence proves useful in the delineation of non-lipomatous soft tissue tumours against normal fat.

[Diagnosis and therapy of ergotism following the use of heparin-DHE in thrombosis prevention]. / Diagnostik und Therapie des Ergotismus nach Heparin-DHE-Thromboseprophylaxe.

Vasospastic complications have been reported in five patients following the use of heparin-dihydroergotamine for thrombo-embolic prophylaxis. The most important diagnostic procedure is angiography, which shows characteristic findings. Intraarterial prostaglandin is a promising form of treatment. Experience with two patients is reported.