[Anesthesiological management of awake craniotomy : Asleep-awake-asleep technique or without sedation]. / Anästhesiologisches Management zur Wachkraniotomie : Schlaf-Wach-Schlaf-Technik oder ohne Sedierung.

Awake craniotomy is indicated in deep brain stimulation (DBS) for treatment of certain movement disorders, such as in Parkinson disease patients or in the surgery of brain tumors in close vicinity to the language area. The standard procedure is the asleep-awake-asleep technique where general anesthesia or analgosedation is intermittently interrupted for neurological testing. In DBS the intraoperative improvement of symptoms, stereotactic navigation and microelectrode reading guide to the optimal position. In brain tumor resection, reversible functional impairments during electrical stimulation on the brain surface (brain mapping) show the exact individual position of eloquent or motoric areas that should be protected.The anesthesiology procedures used are very variable. It is a balancing act between overdosing of anesthetics with impairment of respiration and alertness and underdosing with pain, strain and stress for the patient. For the asleep-awake-asleep technique high acceptance but also frequent and partly severe complications have been reported. The psychological stress for the patient can be immense. Obviously, a feeling of being left alone and being at someone's mercy is not adequately treated by drugs and performance of the neurological tests is undoubtedly better and more reliable with less pharmacological impairment. Cranial nerve blocks can reduce the amount of anesthetics as they provide analgesia of the scalp more efficiently than local infiltration. With these nerve blocks, a strong therapeutic relationship and a specific communication, sedatives can be avoided and the need for opioids markedly reduced or abolished. The suggestive communication promotes for instance dissociation to an inner safe refuge, as well as reframing of disturbing noises and sensations. Each of the methods applied for awake craniotomy can profit from the principles of this awake-awake-awake technique.

[Communication with children: practical hints and tools for the anesthesiology routine]. / Kommunikation mit Kindern: Praktische Strategien und Hilfsmittel für den anästhesiologischen Alltag.

BACKGROUND: Pediatric patients represent a special challenge both for the management of anesthesia and for communication, especially the anxious and screaming child. Children have specific features of fears, cognition, comprehension and skills depending on the stage of development. In addition, behavior and anxiety are strongly shaped by the parents who have to be incorporated. AIM: This article presents the special features of children as well as practical strategies and aids for dealing with children in a perioperative setting. MATERIAL AND METHODS: In children suggestibility and susceptibility to placebo and nocebo effects are increased. This makes them more sensitive to negative factors but can also be utilized for positive, constructive effects. Possibilities are presented which make use of the special characteristics of children. A number of examples from daily clinical routine are given. RESULTS: A child's imagination, creativity and capability for dissociation in particular allow an effective application of indirect suggestion, metaphors, stories, changes in focus of attention, retreat to an inner or imagined safe place, reframing of disturbing noises and events, pacing and leading in small steps and an activation of inner resources. A hand puppet, a pet toy, a little magic trick, introducing a magic friend, acupoint for palpitations with self-affirmation, stick figure drawings, ceiling pictures or holding hands can be quite helpful. All medical devices and interventions can be explained in a way that children can understand and in positive statements without lying or neglecting the need for information. CONCLUSION: Meeting at eye level, talking to the child instead of just about it, a language appropriate for children but not childish, comprehensible information and explanations, return of control and care more than pure technical distance, all play an important role. A serious look into such communication strategies can help the anesthetist to overcome uncertainties that a child can easily sense.

[Optimization of blood gas analysis in intensive care units : Reduction of preanalytical errors and improvement of workflow]. / Optimierung von Blutgasanalysen auf der Intensivstation : Reduzierung präanalytischer Fehler und Verbesserung der zeitlichen Abläufe.

BACKGROUND: Point of care testing with blood gas analysis (BGA) is an important factor for intensive care medicine. Continuous efforts to optimize workflow, improve safety for the staff and avoid preanalytical mistakes are important and should reflect quality management standards. AIM: In a prospective observational study it was investigated whether the implementation of a new system for BGA using labeled syringes and automated processing of the specimens leads to improvements compared to the previously used procedure. MATERIAL AND METHODS: In a 4-week test period the time until receiving the final results of the BGA with the standard method used in the clinical routine (control group) was compared to the results in a second 4-week test period using the new labeled syringes and automated processing of the specimens (intervention group). In addition, preanalytical mistakes with both systems were checked during routine daily use. Finally, it was investigated whether a delay of 10 min between taking and analyzing the blood samples alters the results of the BGA. RESULTS: Preanalytical errors were frequently observed in the control group where non-deaerated samples were recorded in 87.3 % but in the intervention group almost all samples (98.9 %) were correctly deaerated. Insufficient homogenization due to omission of manual pivoting was seen in 83.2 % in the control group and in 89.9 % in the intervention group; however, in the intervention group the samples were homogenized automatically during the further analytical process. Although a survey among the staff revealed a high acceptance of the new system and a subjective improvement of workflow, a measurable gain in time after conversion to the new procedure could not be seen. The mean time needed for a complete analysis process until receiving the final results was 244 s in the intervention group and 201 s in the control group. A 10-min delay between taking and analyzing the blood samples led to a significant and clinically relevant elevation of the values for partial pressure of oxygen (pO2) in both groups compared to the results when analyzing the samples immediately (118.4 vs. 148.6 mmHg in the control group and 115.3 vs. 123.7 mmHg in the intervention group). When using standard syringes the partial pressure of carbon dioxide (pCO2) was significantly lower (40.5 vs. 38.3 mmHg) whereas no alterations were seen when using the labeled syringes. CONCLUSION: The implementation of a new BGA system with labeled syringes and automated processing of the specimens was possible without any difficulties under daily clinical routine conditions in this 10-bed intensive care unit (ICU). A gain of time could not be measured but a reduction in preanalytical errors using the labeled syringes with automated processing was found. Delayed analysis of blood samples can lead to significant changes in pO2 and pCO2 depending on the type of syringe used.

[Nocebo effects and negative suggestion in anesthesia]. / Noceboeffekte und Negativsuggestionen in der Anästhesie.

Anesthetists have an impact on patients and healing processes not only through drugs, interventions and therapy but also significantly by their words and personality. A substantial part of observed side effects is caused by nocebo effects and negative suggestion, i.e. by the doctor and the medical surroundings. Every symptom of an illness, side effect or complication can also be induced by the wrong way of talking about it. Patients perceive medical situations, such as an emergency, anesthesia or intensive care as extreme or even as life-threatening. This can induce a natural trance, an altered state of consciousness characterized by increased suggestibility. Suggestions affect mental functions, such as anxiety and pain as well as physical functions. Strong figurative words, ambiguity, misunderstandings, incidental conversations, medical jargon and risk information are prone to generate negative suggestion. Not the informed consent per se but the way it is presented should be under scrutiny. Knowledge about nocebo effects and negative suggestion can help recognize and avoid these more easily. These negative factors depend on the context, i.e. they are strongly influenced by the individual background history and anxieties of the patient and also by the physician-patient relationship. The best protection against harm from informed consent and negative suggestion is a supportive therapeutic relationship.

[Placement of a central venous catheter in cases of persistent left superior vena cava]. / Anlage eines zentralen Venenkatheters bei persistierender V. cava superior sinistra.

This article presents a case report on the placement of a central venous catheter (CVC) in a patient with an unknown persistent left superior vena cava (PLSVC). Normally, PLSVCs remain asymptomatic but can be associated with disastrous consequences for the patient during placement of a CVC particularly due to vascular perforation and pulmonary injury. A PLSCV is particularly common in association with congenital heart defects; however, otherwise healthy patients can also be affected. As the presence of a PLSCV is normally unknown special attention must be paid in every patient during placement of a CVC.

[Secondary sclerosing cholangitis after multiple trauma and long-term intensive care treatment: case report of a characteristic course]. / Sekundär-sklerosierende Cholangitis nach Polytrauma und Langzeitintensivtherapie : Fallbericht eines charakteristischen Verlaufs.

This article reports on a patient who needed intensive care treatment because of multiple trauma. The patient had no preexisting liver disease but developed secondary sclerosing cholangitis and finally died. The etiology, diagnosis and therapeutic options of this clinical picture are discussed and a review of the literature is presented.

[Anesthesiological aspects of deep brain stimulation : special features of implementation and dealing with brain pacemaker carriers]. / Anästhesiologische Aspekte der tiefen Hirnstimulation : Besonderheiten bei der Anlage und im Umgang mit Hirnschrittmacherträgern.

Deep brain stimulation (DBS) provides a very effective treatment for a number of neurological diseases including Parkinson's disease, movement disorders and epilepsy. In DBS microelectrodes are positioned in defined cerebral target areas and connected to a pacemaker. It is most often performed as an awake craniotomy with intraoperative testing. Various anesthesiological regimes are used to protect the patient from surgical stress on the one hand and to achieve ideal test conditions on the other. They include local anesthesia or scalp blocks, intermittent general anesthesia or analgosedation with or without airway protection; however, anesthetic agents interfere with hemodynamic stability and ventilation, with vigilance and cooperation and in addition with the symptoms and microelectrode recording. Guidance and communication have a pivotal impact on patient needs for pharmacological interventions. With increasing numbers of DBS procedures, anesthesiologists are more often faced with patients carrying brain pacemakers. For anesthesia the characteristics of the disease as well as the respective long-term medication have to be considered. In addition, the rules for handling patients with pacemakers need to be followed to avoid both dysfunction of the generator and tissue damage due to overheating of the electrodes.

MR-guided interstitial laser thermotherapy of colorectal liver metastases: efficiency, safety and patient survival.

PURPOSE: Evaluation of MR-guided interstitial laser thermotherapy (ILT) of colorectal liver metastases under consideration of efficacy, safety and patient survival. MATERIALS AND METHODS: Sixty-six inoperable patients with a total of 117 colorectal liver metastases were treated with MR-guided laser therapy in 96 sessions. 40.9% of patients presented metastases from rectum carcinoma, 30.3% from sigmoid carcinoma and 28.8% from colon carcinoma. Inclusion criteria were < or =5 metastases < or =5 cm in greatest diameter and no extrahepatic tumor spread. Internally water-cooled 9F power-laser-applicators were placed under CT-fluoroscopy. For MR-guided ILT, a 1064 nm Nd-YAG-lasers with a beam divider with multi applicator technique was used. The energy applied was 10 watt per centimeter diffusor length, with the diffusor length ranging from 20 to 40 mm. The mean duration of the energy application was 23 minutes (range: 15 - 37 minutes). The endpoint of the laser ablation was defined as the absence of hyperintense tumor tissue in the continuously monitored T2-w fat saturated gradient-echo sequences. Follow-up included contrast-enhanced MRI using T1- and T2-weighted spin-echo and gradient-echo sequences every three months after treatment. Survival times were calculated using the Kaplan-Meier method. RESULTS: The median follow-up was 8.7 months (mean 11.8; standard deviation 9.9; range 1 to 36). The overall median progression free survival was 6.1 months (range, 0.3 to 27+ months). Median survival was 23 months (95% CI, 17-29 months). The rate of major complications was 2.1% (n = 2) and peri-procedural mortality (30 days) was 3% (n = 2). After 3, 6, 9, and 12 months, local tumor control was 98.3%, 91.4%, 76.1%, and 69.4%, respectively. In no patient metastatic deposits along the catheter access route were found. CONCLUSIONS: In patients with colorectal liver metastases, interstitial laser thermotherapy is an effective and safe therapeutic option and therefore suitable not only in palliative situations.

Determination of the optimal MRI sequence for the detection of malignant lung nodules.

OBJECTIVE: For staging, follow-up and even screening (www.screening.info) an "all-in-one" imaging examination is desirable. In the concept of whole body MRI, lung imaging prevails as the weakest link. The purpose of our study was to determine the optimal MRI sequences for the detection of malignant lung nodules. PATIENTS AND METHODS: On the basis of 6 lung cancer, 46 metastases and one tuberculoma in 13 patients eight MRI sequences--HASTE, IR-HASTE, fat saturated TrueFISP, STIR, VIBEipat = 2, and contrast-enhanced (CE) VIBE (with ipat = 2, 0, 4) performed with parallel imaging and 12 matrix coil elements--were compared in terms of contrast-to-noise ratio (CNR) and quality in the visualization of the lung nodules using multidetector CT as standard of reference. The parameters of the sequences were pragmatically selected to minimize the imaging time to allow for imaging the entire lung within one breathold interval. RESULTS: The STIR sequence was found to be the best for detecting malignant lung nodules (p<0.01) followed by the FS TrueFISP, CE VIBE subsetipat = 0, CE VIBE subsetipat = 2, IR-HASTE, HASTE, CE VIBE subsetipat = 4, and VIBE. The STIR sequence visualized malignant nodules down to 2 mm in size and did not display the 19 mm tuberculoma. CONCLUSION: The STIR sequence should be included in future studies investigating if MRI can compete with CT in the early identification (detection and classification) of malignant lung nodules.

Differentiation between malignant and benign solitary pulmonary nodules with proton density weighted and ECG-gated magnetic resonance imaging.

OBJECTIVE: To estimate performance of MRI for differentiating malignant from benign solitary pulmonary nodules (SPN) using morphological characteristics. MATERIAL AND METHODS: MRI in 46 patients with SPN (mean diameter: 19 mm) was carried out on 1.0 Tesla scanner using ECG-gated, gradient echo sequence. Morphological signs of SPN were determined and compared with previously performed helical-CT, where final diagnosis served as reference with 52% frequency of malignancy. Furthermore, three observers evaluated all images. RESULTS: Significant differences between the two groups were found for nodules shape, margin, inhomogeneity and the vessel-sign in MRI, nodules shape, margin, the vessel-sign, and presence of spicules in CT. Using these signs, AUC were 0.746 for MRI and 0.765 for CT. The mean sensitivity, specificity, and accuracy of observers for MRI/CT were 89%/95%, 42%/41%, 66%/68%, respectively. CONCLUSIONS: Despite discrepancies in morphologic appearance, no significant difference of accuracy between MRI and CT was determined. Further investigations are necessary to demonstrate the clinical use in combination with functional parameters, establishing MRI as a comprehensive diagnostic modality for SPN.

Human SPRY2 inhibits FGF2 signalling by a secreted factor.

Growth factor signalling pathways and their inhibitors coordinate the formation of three-dimensional patterns of vertebrates and invertebrates. Temporal and spatial restriction of the response to a few well-defined cells is crucial and needs the integration of positive and negative signals. Recently, Spry has been identified as an inhibitor of fibroblast growth factor (FGF) signalling during Drosophila trachea development. Spry has been described as an intracellular protein that can exert its function in a cell autonomous or a paracrine manner. Here we describe the role of SPRY2, a human homologue of Spry, in human FGF2 signalling. We show that in primary human dermal endothelial cells (MVEC) SPRY2 mRNA is transiently upregulated in response to FGF2. Overexpression of SPRY2 in A375 cells leads to the secretion of a soluble factor that inhibits FGF2- but not VEGF-stimulated proliferation of MVEC. Direct administration of recombinant SPRY2 protein has no effect on MVEC proliferation. However, SPRY2 protein binds the intracellular adaptor protein GRB2, indicating an intracellular localization. A SPRY2/GFP fusion protein remains in the cell, further supporting the intracellular localization of SPRY2. So the intracellular protein SPRY2 is involved in the non-cell autonomous inhibitory effect indirectly, via regulating the secretion of an inhibitor of FGF2 signalling in vertebrates, the evidence of which is presented here for the first time.

[Detection of pulmonary nodules with breath-hold magnetic resonance imaging in comparison with computed tomography]. / Detektion von Lungenrundherden mit der Magnetresonanztomographie in Atemanhaltetechnik im Vergleich zur Spiral-Computertomographie.

PURPOSE: Evaluation of sensitivity and false positive findings of two fast MRI sequences for the detection of pulmonary nodules in comparison with spiral CT by two independent observers. MATERIALS AND METHODS: All 30 enrolled patients had a spiral CT or MSCT as base line study. MRI was performed with a 1.5 T MR scanner (Sonata, Siemens) using a transverse 3D gradient echo sequence (3D-GRE: TR/TE/flip = 2.9 ms/1.1 ms/5 degrees ) and a half-Fourier single-shot fast spin-echo sequence (HASTE: TR/TE/flip = 800/25/150 degrees ) acquired in three planes. A separate analysis for both sequences was carried out prospectively by two independent readers (A and B) with different experience regarding pulmonary MRI. Additionally, a retrospective reading with knowledge of the CT scans was done. Results were calculated for all lesions and for lesions larger than 4 mm. RESULTS: The sensitivities were 73 %, 70 % and 84 % for the 3D-GRE sequence (reader A, reader B, retrospective reading) and 65 %, 68 % and 81 % for the HASTE sequence. For lesions larger than 4 mm, the sensitivities were 93 %, 89 %, 96 % for the 3D-GRE sequence and 85 %, 85 %, 96 % for the HASTE sequence. The rate of false positive findings depended on the reader's experience, but was generally lower for the 3D-GRE sequence with 2 and 16 (reader A and B) false positive nodules compared to 4 and 40 false positive findings for the HASTE sequence. The 3D-GRE sequence was more accurate for both readers (reader A: p = 0.08, reader B: p = 0.00003). CONCLUSION: The sensitivity of MRI for the detection of lung nodules was only acceptable for lesions larger than 4 mm. The 3D-GRE sequence is superior to the HASTE sequence due to the reduced amount of false positive findings with comparable sensitivity.

Image fusion of CT and MRI for the visualization of the auditory and vestibular system.

The aim of this study was to perform a realistic visualization of the auditory and vestibular system using volume data sets from high-resolution computed tomography (HR-CT) and high-resolution magnetic resonance imaging (HR-MRI). - In 10 patients with conductive and/or sensorineural hearing loss, vertigo and tinnitus, HR-CT and HR-MRI of the petrous bone were performed consecutively. CT was performed with a 16-slice computed tomography scanner using a high spatial resolution. MRI was performed with a 3.0 Tesla scanner using a three-dimensional-constructive interference in steady state (3D-CISS) gradient-echo, and T2-weighted, unenhanced and gadolinium (GD)-enhanced T1-weighted turbo spin-echo sequences. The middle ear structures were interactively segmented and visualized with a color-coded shaded-surface rendering method using the HR-CT volume data sets. The inner ear structures were interactively segmented and visualized with a color-coded shaded-surface rendering method using the high-resolution 3D-CISS MRI volume data sets. Finally, both shaded-surface rendered models were superimposed semi-automatically using a commercial available software program to visualize the auditory and vestibular system. - The representation of the middle and inner ear structures with image fusion of HR-CT and HR-MRI takes advantage of both the high bony contrast of HR-CT and the high soft tissue contrast discrimination and sensitivity to fluids of HR-MRI, as well as the high spatial resolution of both modalities. In comparison to the fused axial CT/MRI, the images of 3D CT/MRI fusion facilitates a clear representation and better spatial orientation. - The middle and inner ear consists of bony structures, soft tissue structures and fluid-filled spaces. For this reason, the image fusion of volume data sets from HR-CT and HR-MRI allowed an optimized and realistic visualization of the auditory and vestibular system.

Anesthesiologic regimen and intraoperative delirium in deep brain stimulation surgery for Parkinson's disease.

BACKGROUND: In many centers the standard anesthesiological care for deep brain stimulation (DBS) surgery in Parkinson's disease patients is an asleep-awake-asleep procedure. However, sedative drugs and anesthetics can compromise ventilation and hemodynamic stability during the operation and some patients develop a delirious mental state after the initial asleep phase. Further, these drugs interfere with the patient's alertness and cooperativeness, the quality of microelectrode recordings, and the recognition of undesired stimulation effects. In this study, we correlated the incidence of intraoperative delirium with the amount of anesthetics used intraoperatively. METHODS: The anesthesiologic approach is based on continuous presence and care, avoidance of negative suggestions, use of positive suggestions, and utilization of the patient's own resources. Clinical data from the operations were analyzed retrospectively, the occurrence of intraoperative delirium was extracted from patients' charts. The last 16 patients undergoing the standard conscious sedation procedure (group I) were compared to the first 22 (group II) psychologically-guided patients. RESULTS: The median amount of propofol decreased from 146 mg (group I) to 0mg (group II), remifentanyl from 0.70 mg to 0.00 mg, respectively (P<0.001 for propofol and remifentanyl). Using the new procedure, 12 of 22 patients (55%) in group II required no anesthetics. Intraoperative delirium was significantly less frequent in group II (P=0.03). CONCLUSIONS: The occurrence of intraoperative delirium correlates with the amount of intraoperative sedative and anesthetic drugs. Sedation and powerful analgesia are not prerequisites for patients' comfort during awake-DBS-surgery.

Identification of gcpE as a novel gene of the 2-C-methyl-D-erythritol 4-phosphate pathway for isoprenoid biosynthesis in Escherichia coli.

The 2-C-methyl-D-erythritol 4-phosphate (MEP) pathway for isoprenoid biosynthesis is essential in most eubacteria and plants and has remarkable biotechnological interest. However, only the first steps of this pathway have been determined. Using bioinformatic and genetic approaches, we have identified gcpE as a novel gene of the MEP pathway. The distribution of this gene in bacteria and plants strictly parallels that of the gene encoding 1-deoxy-D-xylulose 5-phosphate reductoisomerase, which catalyses the first committed step of the MEP pathway. Our data demonstrate that the gcpE gene is essential for the MEP pathway in Escherichia coli and indicate that this gene is required for the trunk line of the isoprenoid biosynthetic route.

Gene structure and 5'-flanking regulatory region of the murine serotonin transporter.

By modulating the magnitude and duration of postsynaptic responses, carrier-facilitated serotonin (5-HT) transport into and release from the presynaptic neuron is central to the fine tuning of serotonergic neurotransmission. The 5-HT transporter (5-HTT) is the prime target for widely used antidepressants, psychostimulants, drugs of abuse and neurotoxins. We have isolated the gene encoding the murine 5-HTT and determined the sequence of all exons including adjacent intronic regions and approximately 3.6 kb of the 5'-flanking regulatory region. The murine 5-HTT gene is composed of 14 exons spanning approximately 34 kb. The single gene transcript after splicing is 2744 bp in length and it contains 186 bp of 5' untranslated region (5'-UTR) and 668 bp of 3'-UTR. A TATA-like motif and several potential binding sites for transcription factors including AP1, AP2, AP4, SP1 as well as CRE- and GRE-like motifs are present in the GC-rich 5'-flanking region. The characterization of murine 5-HTT cDNA and genomic organization will facilitate studies of 5-HT uptake function with molecular pharmacologic and transgenic strategies as well as investigations of its role in quantitative traits and psychiatric disorders.

Hybrid 3D visualization of the chest and virtual endoscopy of the tracheobronchial system: possibilities and limitations of clinical application.

OBJECTIVE: A hybrid rendering method which combines a color-coded surface rendering method and a volume rendering method is described, which enables virtual endoscopic examinations using different representation models. MATERIALS AND METHODS: 14 patients with malignancies of the lung and mediastinum (n=11) and lung transplantation (n=3) underwent thin-section spiral computed tomography. The tracheobronchial system and anatomical and pathological features of the chest were segmented using an interactive threshold interval volume-growing segmentation algorithm and visualized with a color-coded surface rendering method. The structures of interest were then superimposed on a volume rendering of the other thoracic structures. For the virtual endoscopy of the tracheobronchial system, a shaded-surface model without color coding, a transparent color-coded shaded-surface model and a triangle-surface model were tested and compared. RESULTS: The hybrid rendering technique exploit the advantages of both rendering methods, provides an excellent overview of the tracheobronchial system and allows a clear depiction of the complex spatial relationships of anatomical and pathological features. Virtual bronchoscopy with a transparent color-coded shaded-surface model allows both a simultaneous visualization of an airway, an airway lesion and mediastinal structures and a quantitative assessment of the spatial relationship between these structures, thus improving confidence in the diagnosis of endotracheal and endobronchial diseases. CONCLUSIONS: Hybrid rendering and virtual endoscopy obviate the need for time consuming detailed analysis and presentation of axial source images. Virtual bronchoscopy with a transparent color-coded shaded-surface model offers a practical alternative to fiberoptic bronchoscopy and is particularly promising for patients in whom fiberoptic bronchoscopy is not feasible, contraindicated or refused. Furthermore, it can be used as a complementary procedure to fiberoptic bronchoscopy in evaluating airway stenosis and guiding bronchoscopic biopsy, surgical intervention and palliative therapy and is likely to be increasingly accepted as a screening method for people with suspected endobronchial malignancy and as control examination in the aftercare of patients with malignant diseases.

An evaluation of the tumour markers, carcinoembryonic antigen (CEA), cytokeratin marker (CYFRA 21-1) and neuron-specific enolase (NSE) in the differentiation of malignant from benign solitary pulmonary lesions.

PURPOSE: The aim of this prospective study was to assess the diagnostic value of the tumour markers carcinoembryonic antigen (CEA), cytokeratin 19 fragment marker (CYFRA 21-1) and neuron-specific enolase (NSE) in the differentiation of malignant (MSPLs) from benign solitary pulmonary lesions (BSPLs). METHODS: Solitary pulmonary lesions (SPLs) were diagnosed using plain radiography and spiral computed tomography (SCT) and then completely removed by surgery in 104 consecutive patients (MSPLs; n = 81, BSPLs; n = 23). The serum concentrations of the tumour markers were determined 1-3 days prior to surgery by ELISA for CEA and CYFRA 21-1 and by IRMA for NSE using commercially available assay kits. The cut-off values were set at 3 ng/ml (for non-smokers) and 5 ng/ml (for smokers) for CEA, at 3.3 ng/ml for CYFRA 21-1 and at 12.5 ng/ml for NSE. RESULTS: MSPLs were identified with a sensitivity between 13.6 and 45.7%, a specificity between 87.0 and 100% and an accuracy between 32.7 and 54.8%. Using the tumour markers alone, the highest sensitivity (27.2%) and accuracy (40.4%) was found with CEA, the highest specificity (100%) with CYFRA 21-1 and with NSE. Primary lung cancers (n = 39) were identified with a sensitivity between 17.9 and 61.5%, a specificity between 87.0 and 100% and an accuracy between 48.4 and 71.0%. Using the tumour markers alone, the highest sensitivity (35.9%) and accuracy (59.7%) was found with CYFRA 21-1, the highest specificity (100%) with CYFRA 21-1 and with NSE. The combination of all three tumour markers resulted in a greater sensitivity and greater diagnostic accuracy but a loss in specificity compared with CYFRA 21-1 and NSE. CONCLUSION: The use of the tumour markers alone or in combination showed a low sensitivity and low accuracy for the diagnostic differentiation of MSPLs from BSPLs and primary lung cancers from BSPLs. However, both CYFRA 21-1 and NSE exhibited a specificity of 100% and may be useful complements to standard clinical imaging methods.

Differentiation of malignant from benign solitary pulmonary lesions using chest radiography, spiral CT and HRCT.

OBJECTIVE: The aim of this prospective study was to summarize all of the qualitative and quantitative imaging criteria for the differentiation of solitary pulmonary lesions (SPLs) as malignant (MSPLs) or benign (BSPLs) described in the literature and to critically analyze the different characteristics in order to evaluate their clinical importance and usefulness as criteria for a discrimination during the primary diagnostic assessment of SPLs using chest radiography, spiral computed tomography (SCT) and high-resolution computed tomography (HRCT). MATERIALS AND METHODS: SPLs were examined, evaluated and then completely removed by surgery in 104 consecutive patients (MSPLs n=81, BSPLs n=23). No SPL was excluded by size. Chest radiography was performed with frontal and lateral views, SCT was carried out with a slice thickness of 8 mm and HRCT with a slice thickness of 1 mm and a 12-cm field of view. RESULTS: All the characteristics which enabled a reliable differentiation of MSPLs from BSPLs were characteristics which were observed significantly more frequently in MSPLs than BSPLs. Useful characteristics for the differentiation of MSPLs from BSPLs (1) using chest radiography were the indistinct edge (P<0.0001) and a ground-glass opacity of the lung parenchyma adjacent to the SPL (P<0. 05); (2) using SCT the presence of spicules (P<0.0005), the vessel sign (P<0.0005), necrotic areas (P<0.001), spicules extending to the visceral pleura (P<0.005), circumscribed pleural thickening (P<0. 005), inhomogeneity (P<0.01), a ground-glass opacity of the lung parenchyma adjacent to the SPL (P<0.01), the lesion density (P<0.05), pleural retraction (P<0.05) and the bronchus sign (P<0.05); and (3) using HRCT the presence of spicules (P<0.00005), spicules extending to the visceral pleura (P<0.0005), the vessel sign (P<0.0005), pleural retraction (P<0.001), circumscribed pleural thickening (P<0. 001), the bronchus sign (P<0.005), a ground-glass opacity of the lung parenchyma adjacent to the SPL (P<0.01), the lesion density (P<0.05) and the length of spicules (P<0.05). Using any one of the characteristics with a significance level of P<0.01, the identification of MSPLs (1) using chest radiography showed a sensitivity of 64.2% and a specificity of 82.6% (accuracy of 68.3%); (2) using SCT a sensitivity of 88.9% and a specificity of 60.9% (accuracy of 82.7%); and (3) using HRCT a sensitivity of 91.4% and a specificity of 56.5% (accuracy of 83.7%). CONCLUSIONS: Using chest radiography, SCT and HRCT, a precise morphological assessment of the periphery of the pulmonary lesion and the adjacent visceral pleura is necessary to distinguish MSPLs from BSPLs. In this respect SCT and HRCT are useful in differentiation of MSPLs from BSPLs. However, metastases strongly resembled benign lesions in terms of size and edge type and chronic inflammatory pseudotumors as a group mimic MSPLs.