[Rare differential diagnosis on suspected liver tumor]. / Seltene Differenzialdiagnose bei Verdacht auf Lebertumor.

This case report describes a 77-year old woman with a leiomyosarcoma of subhepatic inferior caval vein. The presented symptom was unspecific abdominal pain. Ultrasound and CT suggested a primary liver tumor. MRI revealed retroperitoneal location of the neoplasm. The tumor was resected completely and ICV was replaced by a PTF-graft. Vascular leiomyosarcoma is a rare tumor entity, which often is diagnosed in advanced stage. Depending on location it can be mistaken for neoplasms of other organs.

Therapy of hepatocellular carcinoma with 131I-lipiodol: patient dosimetry.

AIM: Dosimetry in (131)I-lipiodol therapy for hepatocellular carcinoma (HCC) in the hitherto largest existing patient cohort. PATIENTS, METHODS: 38 courses of intra-arterial (131)I-lipiodol therapy with a total activity up to 6.7 GBq were performed in 18 patients with HCC. Liver and tumour volume were measured by computed tomography (CT) and (131)I-activity by scintigraphy on day 3, 6, 14, 28 and 42 after injection. Lipiodol deposition in tumour nodules as shown by CT rendered definite attachment to scintigraphic data possible. The radiation dose in tumour nodules, liver and lungs was calculated according to the MIRD concept and the tumour dose related to pre-therapeutic tumour volume, response and survival. RESULTS: Mean tumour dose was 23.6 +/- 3.6 Gy (14.2 +/- 2.1 mGy/MBq) with maximal 162 Gy (90.1 mGy/MBq) after one and 274 Gy after three courses. The dose to nontumourous liver was 1.9 +/- 0.2 Gy (1.2 +/- 0.1 mGy/MBq) and the mean dose ratio of tumour / nontumourous liver 11.1 +/- 1.7 (max. 82). The pulmonary dose was 25.9 +/- 1.8 mGy (16.3 +/- 1.2 microGy/MBq) and therefore much lower. There was a reciprocal relation between tumour dose and pretherapeutic tumour volume. Tumour dose had no effect on response or survival. CONCLUSION: High radiation doses are particularly in small tumour nodes achievable but not necessarily related to tumour response. The dose of non-tumourous liver and lungs is much lower.

Therapy of hepatocellular carcinoma with iodine-131-lipiodol. Results in a large German cohort.

AIM: To evaluate the efficacy and tolerance of iodine-131-lipiodol ((131)I-lipiodol) for hepatocellular carcinoma (HCC) in German long term patients and comparison with medically treated controls. PATIENTS, METHODS: 38 courses of intra-arterial (131)I-lipiodol therapy with a total activity up to 6.7 GBq were performed in 18 patients with HCC (6 with portal vein thrombosis). Liver and tumour volume and lipiodol deposition were measured by computed tomography and (131)I activity by scintigraphy. Therapeutic efficacy was determined by tumour volume change and matched-pairs analysis in comparison to medically (i.e. tamoxifen or medical support) treated patients. RESULTS: Tumour volume decreased in 20/32 index nodules (63%) after the first course. Repeated therapy frequently resulted in further tumour reduction. Overall response to treatment was partial in 11 nodules, minor response in 4 nodules, and disease was stable in 12 and progressive in 5. Significant response was associated with pretherapeutic nodule volume up to 150 ml (diameter of 6.6 cm). Survival rate after 3, 6, 9, 12, 24 and 36 months was 78, 61, 50, 39, 17, and 6%. Matched-pairs analysis of survival revealed (131)I-lipiodol to be superior to medical treatment. The most important side effect was a pancreatitis-like syndrome whereas overall tolerance was good. CONCLUSION: The long term results confirm that HCC therapy with (131)I-lipiodol is effective and probably superior to medical treatment. Tumour nodules of up to 6 cm diameter are well suited for this therapy even in the presence of portal vein thrombosis.

Recombinant human thyrotropin in thyroid cancer and hypopituitarism due to sella metastasis.

We present a patient with thyroid cancer and hypopituitarism who required recombinant human thyrotropin (rhTSH) for 131I scanning with respect to subsequent therapy. The thyroid cancer had been unknown until central neurological symptoms developed, leading to the diagnosis of a huge metastasis to the sella that was the only manifestation of metastatic spread. The failure to generate endogenous thyrotropin (TSH) was overcome by the use of rhTSH for performing a 131I test. Unfortunately, the 131I uptake was not sufficient for therapy. This subject is the first reported case who required the application of rhTSH due to a single thyroid cancer metastasis in the sella region with secondary failure to generate endogenous TSH.

Intraarterial HCC therapy with I-131-Lipiodol.

We report on our 2-year experience with intraarterial liver therapy with I-131-Lipiodol in patients with hepatocellular carcinoma in Germany. 30 therapies with intraarterial delivery of I-131-labeled Lipiodol were performed in 14 patients with hepatocellular carcinoma (HCC) with or without portal vein thrombosis during hepatic angiography. The patients were monitored for 1) distribution of Lipiodol by CT, 2) distribution of applied activity by planar scintigraphy and SPECT, and 3) tumor response by CT, MRT and 18-FDG-PET. In 5 patients the tumor size was reduced after the first treatment (responder). Eight patients, primarily with big tumors (> 7 cm), had stable (4) or progressive disease (4), and 1 patient died because of renal failure. CT and SPECT showed pronounced I-131-lipiodol accumulation in the tumor tissue in all patients with variable distribution patterns. One patient had an acute pancreatitis like syndrome together with elevation of liver enzymes, probably due to arterial spasm. 9 patients had transient and mild symptoms in the upper abdomen, fever to 40 degrees C, and a leukocytosis. Two patients had a transient mild elevation of pancreatic enzymes. All patients had a transient rise in liver enzymes. In conclusion, therapeutic efficacy was dependent on the tumor mass. Side effects due to the radiopharmaceutical were tolerable, and other side effects may result from the angiography procedure related manipulations. These results are encouraging for tumors up to a moderate mass.

[CT guided percutaneous drainage of retro- and extraperitoneal abscesses and fluid collection]. / CT-gesteuerte perkutane Drainage retro- und extraperitonealer Abszesse und Flüssigkeitsverhalte.

PURPOSE: Evaluation of course, success rate and complications after CT-guided percutaneous drainage of retroperitoneal and extraperitoneal abscesses and fluid collections (PAFD). METHODS: Retrospective review of 47 PAFD in 42 consecutive patients (27 male, 15 female, age 58 [27-80] years) over a period of 7 years was performed. RESULTS: 47 clinically suspected abscesses proved to be 40 abscesses, three haematomas and 4 lymphoceles. Primarily, 67 drainage catheters were needed, which included three catheters in 4 patients and 4 catheters in one patient. Drainage time averaged 17.6 days (2-50). The most frequent drainage location was the iliopsoas region (27/47 collections). The cure rate was 87.2% (41/47 collections). Temporization was achieved in 8.5% (4/47); there were two drainage failures (one sepsis, one recurrence). No major complications were observed. Three catheter dislocations occurred as minor complications. CONCLUSION: CT-guided percutaneous drainage of retroperitoneal and extraperitoneal abscesses and fluid collections is safe, with a high cure rate and few complications.

[Color-coded duplex ultrasonography in the diagnosis of renal artery stenosis]. / Farbkodierte Duplexsonographie in der Erkennung von Nierenarterienstenosen.

PURPOSE: Colour-coded duplex sonography was performed for diagnosis of renal artery stenosis to define standards and criteria for stenosis. MATERIAL AND METHODS: In 20 normotensive volunteers and 123 patients with arterial hypertension, bilateral intrarenal Doppler spectra were examined and the following parameters including side ratios were calculated: pulsatility index (PI), resistance index (RI), acceleration time index (AT) and acceleration index (AI). RESULTS: In 29 of the 123 patients, angiography showed unilateral renal artery stenosis. Acceleration index (AI) was found as the most reliable parameter with a sensitivity of 100% and a specificity of about 94% for stenoses grading at least 70%. CONCLUSIONS: Colour-coded duplex sonography can depict relevant stenoses reliably, but anatomical variations may limit its value as a single screening method. Colour-coded duplex sonography can be, therefore, recommended as an adjunct to angiography for assessment of haemodynamic relevance.

I-131-Lipiodol therapy in liver neoplasms.

Twelve patients with liver neoplasms [10 HCC, 1 CCC, 1 multiple breast cancer metastases (BCM)] were treated by transarterial I-131-Lipiodol. Computed tomography (CT) and single photon emission CT (SPECT) showed pronounced I-131-Lipiodol accumulation in the tumor tissue in all cases. In three patients with HCC a reduction of tumor size was achieved after the first treatment. The remaining patients had big tumor masses; 5 of these (4 HCC, 1 CCC) had stable disease after the first treatment, and 2 HCC were progressive. One patient died immediately after therapy due to other reasons. The BCM proved significant reduction in number and size. Eighteen-FDG-PET (positron emission tomography with fluor-18-deoxy-glucose) and CT controls showed in part different results with pretherapeutic PET proving high interindividual variability in tumor activity. Side effects were tolerable. In summary, the therapy procedure with transarterial I-131-Lipiodol is safe and effective in tumors with moderate tumor mass.

[Graves' disease and papillary thyroid cancer--coincidence or association?]. / Basedow-Struma mit papillärem Schilddrüsenkarzinom--Zufall oder Zusammenhang?

HISTORY AND ADMISSION FINDINGS: A 41-year-old woman presented with hyperhydrosis, tremor, restlessness, sleeplessness and diarrhea. She had a tachycardia and later she developed soreness of her conjunctives. A tender goitre could be palpated. INVESTIGATIONS: Laboratory results showed thryeotoxicosis and later elevated TRAK. Ultrasound revealed a thyroid nodule. Scintigraphic uptake was generally elevated. Graves disease was diagnosed. TREATMENT AND COURSE: After 12 months of thyreostatic medication recurrence occurred and a thyroidectomy was performed. Histologically a papillary cancer was found and postoperative radioiodinetherapy was added. CONCLUSION: Due to leading symptoms of thyreotoxicosis the thyroid nodule has preoperatively not been paid enough attention to. A pathophysiologic association of Graves disease and differentiated thyroid cancer is controversely discussed but seems possible considering present literature data. Scintigraphically "cold" nodules in graves disease, as in simple nodular goitre, have a higher probability of malignancy.

Inotropic changes in ischaemic and non-ischaemic myocardium and arrhythmias within the first 120 minutes of coronary occlusion in pigs.

In 16 anaesthetized open-chest pigs occlusion of the distal third of the LAD was performed. Local myocardial contractility within and outside the ischaemic area, measured using electromagnetic and ultrasonic probes, arrhythmias and plasma catecholamine concentrations were monitored during 180 min before and 120 min after occlusion of the distal LAD. 5 pigs developed ventricular fibrillation (VF) during phase 1 a of arrhythmias (1-6 min post occlusion) and a further 5 pigs during phase 1 b (10-30 min post occlusion). Segment lengthening within the ischaemic area, measured at the beginning of ventricular ejection, started within a few seconds of ischaemia and reached 11-13.5% of end-diastolic length prior to occlusion after 2 min of ischaemia. Between 2 min and 120 min after the onset of occlusion, no further segment lengthening was observed. There were no significant differences in segment lengthening between VF and non-VF pigs. However, within the VF group, mechanical alterations 2 min after the onset of ischaemia were more marked in pigs developing VF within phase 1 a than those with VF in phase 1 b. VES increased markedly after 50 min of occlusion and seemed to occur independently of further mechanical alterations, VF within the first 30 min of ischaemia often occurred without preceding VES.

[Sentinel lymph node excision. Treatment method of the N0 neck in patients with oral and oropharyngeal carcinoma]. / Sentinel-Lymphknotenexstirpation. Behandlungsmethode des N0-Halses bei Patienten mit oralen und oropharyngealen Karzinomen.

BACKGROUND: The clinically non-metastatic neck is an unsolved problem in the treatment of oral and oropharyngeal squamous cell carcinomas. A rational procedure is looked for which is neither exaggerated nor neglects the needed safety. PATIENTS AND METHODS: 15 patients with primary squamous cell carcinomas of the oral cavity and the oropharynx, staging T1-4N0M0 were examined. After peritumoral intramucodermal injection of tc99m-labeled colloidal albumin the lymphoscintigraphy using gamma-camera imaging prior and hand-held gamma-probe during operation were used for identification of the nodes. Selective sentinel lymph node exstirpation was followed by radical tumor resection. RESULTS: In all cases (n = 41) lymph nodes could be detected, 40 of them were sentinel lymph nodes, distributed to all neck levels, in 5 cases bilateral drainage. 92.5% of sentinel lymph nodes could be actually removed. All but 1 (97.5%) were true-negative. In the positive case modified radical neck dissection harvested another affected node. CONCLUSIONS: Methodically seen, the sentinel procedure works well and might lead to reduced post-surgical morbidity in about 50% of patients with oral cancer. To date, the procedure should be confined to studies with special requirements to diagnostics and subsequent treatment.

Radiation exposure and radiation protection of the physician in iodine-131 Lipiodol therapy of liver tumours.

Intra-arterial iodine-131 labelled Lipiodol therapy for liver cancer has been investigated for safety and efficacy over a number of years, but data on radiation exposure of personnel have remained unavailable to date. The aim of this study was to assess the radiation exposure of the physician during intra-arterial 131I-Lipiodol therapy for liver malignancies and to develop appropriate radiation protection measures and equipment. During 20 intra-arterial administrations of 131I-Lipiodol (1110-1924 MBq), radiation dose equivalents (RDE) to the whole body, fingers and eyes of the physician were determined for (a) conventional manual administration through a shielded syringe, (b) administration with an automatic injector and (c) administration with a lead container developed in-house. Administration by syringe resulted in a finger RDE of 19.5 mSv, an eye RDE of 130-140 microSv, and a whole-body RDE of 108-119 microSv. The injector reduced the finger RDE to 5 mSv. With both technique (a) and technique (b), contamination of angiography materials was observed. The container allowed safe transport and administration of the radiopharmaceutical from 4 m distance and reduced the finger RDE to <3 microSv and the eye RDE to <1 microSv during injection. During femoral artery compression, radiation exposure to the fingers reached 170 microSv, but the whole-body dose could be reduced from a mean RDE of 114 microSv to 14 microSv. No more contamination occurred. In conclusion, radiation exposure was high when 131I-Lipiodol was administered by syringe or injector, but was significantly reduced with the lead container.

Fluorine-18 fluorodeoxyglucose positron emission tomography findings in spondylodiscitis: preliminary results.

Nuclear medicine procedures can be helpful in diagnosing spine infections. The purpose of the study was to evaluate the findings of positron emission tomography with fluorine-18 fluorodeoxyglucose (FGD-PET) in the detection of spondylodiscitis. We performed FDG-PET in 16 patients with suspected spondylodiscitis. All the patients were operated and underwent histopathological examination. The FDG-PET findings were graded and evaluated by two independent nuclear medicine physicians. Of the 16 patients, 12 had a histopathologically confirmed spondylodiscitis. In all these 12 patients, FDG-PET was true-positive. In the four patients without spondylodiscitis, FDG-PET showed three true-negative and one false-positive result. In spondylodiscitis, the mean standard uptake value (SUV) of FDG was 7.5 (SD+/-3.8). The PET scans depicted the paravertebral soft tissue involvement in cases of spondylodiscitis. Our first results showed that FDG-PET is a very sensitive imaging procedure in the detection of spondylodiscitis. Compared to other nuclear medicine procedures, PET enables a rapid imaging with acceptable radiation dose and high spatial resolution.

[Color-coded duplex ultrasound in chronic dissecting abdominal aortic aneurysm. Differentiation between true and false aortic lumen with reference to the blood supply to larger abdominal arteries]. / Farbkodierte Duplexsonografie bei chronischem disseziierendem Bauchaortenaneurysma. Differenzierung zwischen wahrem und falschem Aortenlumen hinsichtlich der Versorgung der grossen Baucharterien.

PURPOSE: This study was carried out to evaluate the ability of color-coded duplex sonography (CCDS) to differentiate between true and false aortic lumen with regard to the blood supply to the major aortic branches in cases of chronic dissecting abdominal aortic aneurysm. METHODS: In eight patients with aortic dissection, the Doppler spectrum was analyzed for maximum systolic velocity (Vmax), pulsatility index (PI), acceleration time (AT), acceleration index (HAN-DA index, AI), and, in renal arteries, for the side ratio of AT and AI (AT-R, AI-R). Computerized tomography and angiography were used to define blood supply to the aortic branches by true and false aortic lumen. RESULTS: Four of five iliac arteries with continued dissection showed differences between true and false lumen in all Doppler parameters; one showed no difference. In the remaining iliac arteries and the viseral branches, blood supply by true or false aortic lumen could not be differentiated by CCDS. CONCLUSION: In cases of chronic dissecting abdominal aortic aneurysm, CCDS is not able to differentiate between true and false aortic lumen with regard to the blood supply to the major aortic branches.