Chemoocclusion vs chemoperfusion for treatment of advanced hepatocellular carcinoma: a randomised trial

AIMS

Transarterial chemoembolization (TACE) can be associated with considerable toxicity and treatment-associated mortality. Transient transarterial chemoocclusion (TACO) using degradable starch microspheres (DSM) has been proposed as a potentially safer alternative while maintaining anti-tumour efficiency. In a randomised phase II trial TACO was compared to transarterial chemoperfusion without DSM (TACP).

METHODS

Seventy-four patients with advanced HCC were randomised to two treatment arms: (i) TACO (600-1200 mg DSM) and (ii) TACP. In both arms regional chemotherapy consisted of cisplatin (100 mg/m2) and doxorubicin (60 mg/m2). Both arms were corresponding in terms of age, gender, liver performance state, and tumour-stage. A maximum of six treatment cycles was applied in monthly intervals. Follow-up was performed in terms of tumour response, time to progression, survival and quality of life.

RESULTS

Tumour response rates did not differ significantly between the two treatment arms, however, there was a tendency towards higher response rates in the TACO arm (TACO vs TACP): partial response: 26 vs 9%, stable disease: 41 vs 55%, progressive disease: 33 vs 36%. Time to tumour progression (32 vs 27 weeks), and overall survival (60 vs 69 weeks) were not significantly different. Grade 4 adverse events were rare in both arms and treatment-associated mortality was not observed. In addition, there was no significant difference in terms of quality of life under therapy (EORTC).

CONCLUSION

TACO with DSM did not improve response or survival significantly compared to TACP in advanced non-resectable HCC.

Erdheim-Chester disease versus multifocal fibrosis and Ormond's disease: a diagnostic dilemma

AIM

The aim of the study was to evaluate the effectiveness of different imaging techniques with respect to diagnosis and differential diagnosis between Erdheim-Chester disease (ECD) and multifocal fibrosis (MF)/Ormond's disease (OD).

METHOD

Three cases of ECD were included, two of which were misdiagnosed as MF/OD. Findings in different imaging techniques [plain radiography, skeletal scintigraphy, computed tomography (CT) and magnetic resonance imaging (MRI)] of the lower extremities, chest MRI, craniofacial MRI, abdominal CT and MRI) were compared and ranked with regard to diagnostic efficacy.

RESULTS

Differentiation between ECD and MF/OD is only possible by imaging the long bones. Bone roentgenograms and skeletal scintigraphy, followed by MRI and CT of the lower extremities are the most effective imaging techniques.

CONCLUSION

A low threshold for carrying out plain radiography of the lower limbs in case of RF/MF will increase the number of ECD-cases.

[Integration of modern technologies in therapy of sarcomas of the pelvis. Computer-assisted hemipelvectomy and implantation of a "custom-made" Bonit gentamycin coated partial pelvic prosthesis]

The resection of primary malignancies in the pelvis is technically demanding as organs and structures are to be preserved and reconstruction of the defect as well as the postoperative function and rehabilitation are dependent on an optimal prosthesis. We present two patients with a sarcoma of the pelvis where for the first time a structured concept of technology integration led to a press-fit implantation of a hemipelvic prosthesis. This concept includes the design and production of a "custom-made" prosthesis as a hemipelvic substitute and the coating of this prosthesis with Bonit, a second-generation calcium phosphate, and gentamycin in watery solution. The tumor resection was done with computer-assisted surgery based on computed tomographies (CT) of the pelvis model done by rapid prototyping rather than on the CT of the patients' pelvis. With this procedure the presurgically simulated resection could be executed precisely with complete resection of the tumors and an accuracy which allowed an exact implantation of the prosthesis. The course was uneventful with primary healing and no sign of an infection or loosening after 6 months.

[Osteosarcoma of the pelvisTwo case reports and review of the literature]

Primary malignant neoplasms of the bone are rare. One of the most common bone tumors is osteosarcoma, most often localized in the metaphysis of adolescent long bones. The sacrum is concerned in only about 1%. Primary bone sarcomas of the pelvis are usually recognized after they have grown to a considerable size. Osteosarcoma patients from Germany, Austria, and Switzerland are treated by neoadjuvant chemotherapy combined with complete surgical excision according to the Cooperative Osteosarcoma Study Group (COSS). Based on a review of the literature, diagnosis, treatment, and complications of two cases of sacrum osteosarcoma are introduced.

Fate of the transpedicular intervertebral bone graft after posterior stabilisation of thoracolumbar fractures

The authors present a retrospective clinical and radiological study addressing the outcome after posterior stabilisation of thoracolumbar fractures with intervertebral fusion via transpedicular bone grafting. The study included computed tomographic (CT) scan after implant removal for analysis of the intervertebral fusion and incorporation of the intervertebral bone graft and its influence on postoperative re-kyphosing. Twenty-nine patients with acute fractures of the thoracolumbar spine, treated between 1988 and 1995 at the Department of Trauma Surgery, Hannover Medical School, underwent posterior stabilisation and interbody fusion with transpedicular cancellous bone grafting. This study group was followed clinically and radiologically for a mean of 3.5 years. All patients underwent spiral CT scan with sagittal reconstruction after implant removal. Twenty-four type A, four type B, and one type C lesion were posteriorly stabilised and transpedicular intervertebral bone grafting was performed. The operative time averaged 2 h 50 min, the intraoperative fluoroscopy time 4 min 7 s, and the mean intraoperative blood loss was 376 ml. Four patients out of six with an incomplete neurologic lesion (Frankel/ASIA D) improved to Frankel/ASIA grade E. Two complications were observed: one delayed wound healing and one venous thrombosis with secondary pulmonary embolism. Compared to the preoperative status, our follow-up examinations demonstrated permanent social sequelae: the percentage of individuals able to do physical labor was reduced, whereas the proportion of unemployed or retired patients increased. The assessment of complaints and functional outcome with the Hannover Spine Score reflected a significant difference ( P<0.001) between the status before injury (96.6/100 points) and at follow-up (64.4/100 points). The radiographic follow-up revealed a mean loss of correction of 7.8 degrees ( P<0.005). CT scans after implant removal showed an interbody fusion and incorporation of the transpedicular bone graft in ten patients (34%). In another ten patients (34%), the CT scans demonstrated the interbody fusion at the anterior and posterior walls of the vertebral body via direct contact due to collapse of the disc space. In these patients, the bone graft was not incorporated and no central interbody fusion could be found. In nine patients (31%) neither interbody fusion nor incorporation of the transpedicular graft was achieved. A frequent and reliable intervertebral fusion could not be achieved with the described technique of transpedicular bone grafting. The ineffectiveness of the intervertebral graft was found to be a reason for postoperative re-kyphosing.

[Post-traumatic osteoid osteoma. Case report and review of the literature]

Osteoid osteoma is a painful benign bone neoplasm that is rarely described after trauma but should be suspected. A case of osteoid osteoma 19 years after a tibial fracture is presented. The patient had pain in the tibia for 6 years before the osteoid osteoma was confirmed. He had been operated on twice for suspected osteomyelitis although the clinical symptoms suggested an osteoid osteoma. The radiographic appearance as well as a bone scan confirmed the diagnosis. Removal of the nidus resulted in immediate pain relief. A precise preoperative diagnosis of the lesion based on clinical findings, standard radiographs, high-resolution CT, and bone scan is mandatory. It is important to recognize this uncommon entity to avoid morbidity associated with a prolonged delay in diagnosis.

Larger numbers of CD4(bright) dendritic cells in donor bone marrow are associated with increased relapse after allogeneic bone marrow transplantation

Relapse is the major cause of death after allogeneic bone marrow transplantation (BMT). This study tested the hypothesis that the numbers of donor mononuclear cells, lymphocytes, and CD34(+) cells influence relapse and event-free survival (EFS) after BMT. The study population consisted of 113 consecutive patients with hematologic malignancies who underwent non-T-cell-depleted BMT from HLA-matched siblings. Sixty-four patients had low-risk diagnoses (ALL/AML CR1, MDS RA/RARS, and CML CP1); 49 patients had high-risk diagnoses (all others). CD34(+) cells, T cells, B cells, natural killer cells, monocytes, and a rare population of CD3(-), CD4(bright) cells in the allografts were measured by flow cytometry. The CD3(-), CD4(bright) cells in bone marrow had the same frequency and phenotype as CD123(bright) type 2 dendritic cell (DC) progenitors, and they differentiated into typical DCs after short-term culture. Cox regression analyses evaluated risk strata, age, gender, and the numbers of nucleated cells, CD3(+) T cells, CD34(+) hematopoietic cells, and CD4(bright) cells as covariates for EFS, relapse, and nonrelapse mortality. Recipients of larger numbers of CD4(bright) cells had significantly lower EFS, a lower incidence of chronic graft-versus-host disease (cGVHD), and an increased incidence of relapse. Recipients of larger numbers of CD34(+) cells had improved EFS; recipients of fewer CD34(+) cells had delayed hematopoietic engraftment and increased death from infections. In conclusion, the content of donor CD4(bright) cells was associated with decreased cGVHD and graft-versus-leukemia effects in recipients of allogeneic bone marrow transplantation, consistent with a role for donor DCs in determining immune responses after allogeneic BMT.

Translocation t(1;3)(p36.3;q25) is a nonrandom aberration in epithelioid hemangioendothelioma

The cytogenetic findings for two epithelioid hemangioendotheliomas are reported. An identical chromosomal translocation involving chromosomes 1 and 3 [t(1;3)(p36.3;q25)] was detected in both cases of epithelioid hemangioendothelioma, possibly representing a characteristic rearrangement for this histopathologic entity. The presence of clonal karyotypic abnormalities supports a neoplastic origin for the epithelioid variant of hemangioendothelioma. Identification of the 1;3 translocation may be useful diagnostically. Should additional studies confirm these data, this could lead to the identification of the gene(s) central to this neoplastic process.

[Post-traumatic osteolysis of the distal clavicle. A case report and review of the literature]]

The post-traumatic osteolysis of the distal clavicle is very infrequent and the etiology and pathology is poorly understood. It is important to consider this possibility for differential diagnosis when continued pain in the acromio-clavicular joint (AC joint) follows blunt shoulder trauma. The course of the disease may result in a 3 cm loss of length of the distal clavicle. Months and years may pass until osteolysis becomes manifest, but the earliest radiological findings are present 4 weeks after trauma. The disease is self-limiting and usually does not leave residues. We report a case of a 35-year-old man with a post-traumatic osteolysis of the distal clavicle after blunt shoulder trauma. The diagnosis was determined several months after pain persisted in his shoulder. Using this case we discuss the possible pathogenic mechanism, differential diagnosis and treatment options for the post-traumatic osteolysis of the distal clavicle.

[Bone manifestations in non-Hodgkin's lymphoma in childhood and adolescence]

PURPOSE

Skeletal manifestation of Non-Hodgkin's lymphoma is rare in pediatric patients. Objective of the study was to determine imaging features, before and after treatment, and to correlate these features with clinical outcome.

METHODS

A retrospective analysis of 1246 patients from two therapy studies (NHL-BMF-90 and 95) was performed. Imaging studies of 63 patients with bone involvement of lymphoma were reevaluated.

RESULTS

Incidence of initial bone involvement in Non-Hodgkin's lymphoma was 6.8%. Distribution was best assessed by bone scan, MRI revealed larger areas of marrow involvement and detected additional lesions. Sites of predilection were long bones of the lower extremities with epiphyseal involvement in 39%. Residual signal alterations in MRI after successful therapy remained in 71%. Osteonecrosis after therapy was a common finding. Clinical outcome war not correlated to the presence of bone involvement.

CONCLUSIONS

Since clinical outcome is not effected by bone involvement in childhood NHL, value of screening may be limited. Knowledge of imaging characteristics is mandatory for initial evaluation of primary osseous lymphomas and symptomatic lesions as well as for therapy controls.

Pitfall: a pseudo tumor within the left liver lobe presenting with abdominal pain, jaundice and severe weight loss

A 51 year old male patient with a history of chronic alcohol consumption and recurrent pancreatitis was referred to our hospital with jaundice, epigastric pain, severe diarrhoea and weight loss of 28 kg within the last 12 months. A CT scan of the abdomen 4 months before admission had shown a pancreatitis with free fluid around the corpus and tail of the pancreas as well as dilated intrahepatic bile ducts and a cavernous transformation of the portal vein. Moreover, a tumor (3.5 x 3.0 x 3.6 cm) with irregular contrast enhancement was seen within the left liver lobe. The patient was referred to us for further evaluation and treatment. The initial B-Mode sonogram revealed a bull's eye like well defined lesion (8.1 x 7.5 x 7.0 cm) within the left liver lobe, consistent with a tumour or abscess. Prior to a diagnostic needle biopsy a PTCD was performed in this case presenting with dilated intrahepatic bile ducts and having a history of Billroth II operation. An additional colour coded Duplex Doppler ultrasonography demonstrated a visceral artery aneurysm and prevented us from performing the diagnostic puncture. The aneurysm was assumed to originate from a variant or a branch of the left hepatic artery. Angiography revealed a pseudoaneurysm of the pancreaticoduodenal artery and coil embolization was performed because of the increasing size and the risk of a bleeding complication. Postinterventional colour duplex ultrasound measurement showed no blood flow within the aneurysm. Retrospectively, the pseudoaneurysm must have led to a compression of the common bile duct, since the patient did not develop cholestasis after embolization and removal of the PTCD. Thus, a pseudoaneurysm of the pancreaticoduodenal artery must be included in the differential diagnosis of liver tumours in patients with chronic pancreatitis, despite its unusual localization near the liver. Therefore, we suggest that colour coded ultrasonography should be applied to any unclear, bull's eye like lesion, even though this method alone cannot exactly determine the origin of the pseudoaneurysm. Interventional angiography remains the gold standard for the diagnosis and therapy of visceral artery aneurysm.

[Augmented tenoplasty in a case of tibialis anterior tendon rupture]

A tendon transfer or interposition tendon graft is usually recommended for treatment of late diagnosed ruptures of the tibial anterior tendon. A new operative technique using augmented tenoplasty is described in one patient. After 3 years the patient was asymptomatic and showed normalized function. The operative method has the advantage of no additional loss of function in comparison with other methods.

Parasitation with Pseudoterranova decipiens (Nematoda) influences the survival rate of the European smelt Osmerus eperlanus retained by a screen wall of a nuclear power plant

A total of 354 adult European smelts Osmerus eperlanus (L.) were tested for their ability to survive the screen system of the cooling water inflow of a power plant. With increasing number of musculature parasitic third-stage larvae of Pseudoterranova decipiens, the survival rate of O. eperlanus decreased while the total number of externally visible injuries as well as the number of seriously injured specimens increased. The results indicate that even a single specimen of P. decipiens influences resistance and stamina and affects overall mortality of 7 to 20 cm long smelts. The initial effect of the parasites is to reduce swimming speed of infested fish, which leads to more frequent contact of these fish with the fine meshed screen of the cooling water inlet before they are removed by the automatic cleaning system. If the separated fishes are returned to the main stream, it becomes apparent that the cooling water inflow selectively reduces the number of living parasitised smelt in the area. Thus, the number of parasitic third-stage P. decipiens larvae in the local smelt population which are able to complete their life-cycle is also reduced. P. decipiens makes infested smelt more susceptible to negative anthropogenic influences such as cooling water intake or trawl fisheries.

Initiation and perpetuation of rat adjuvant arthritis is inhibited by the anti-CD2 monoclonal antibody (mAb) OX34

OBJECTIVE

The purpose of this study was to investigate the therapeutic potential of the anti-CD2 mAb OX34 first with regard to bone protection in established rat adjuvant arthritis (AA) and secondly with regard to prevention of AA induction.

METHODS

Established AA was treated with dexamethasone (1 mg/kg body weight) for two days plus OX34 mAb or control mAb over three days (2 mg and then 1 mg) starting at different time points of the disease. For prevention studies animals were injected as above with mAb before induction of AA. Arthritis score (AS), hindpaw thickness, and body weight were blindly measured three times per week. Flow cytometry and hindpaw radiography were performed at the end of the study (day 29).

RESULTS

Treatment of early AA with OX34 mAb combined with dexamethasone but not dexamethasone plus control mAb dramatically suppressed established AA as assessed by AS and hind paw thickness (> 65% and > 80% reduction, respectively; p < 0.05). Most importantly, early treatment in the course of AA almost completely prevented bone destruction in established AA. When given before AA induction OX34 alone prevented the initiation of arthritis compared with controls (AS reduction 83-95%, p < 0.05). In addition, OX34 plus dexamethasone treatment resulted in depletion of CD4+ T cells but not CD8+ T cells. IL2R+ and CD45RC- ('memory') T cells were significantly reduced.

CONCLUSIONS

Anti-CD2 mAb treatment prevents AA induction confirming the role of CD4+ T cells in the induction phase of AA. In addition, early OX34 plus dexamethasone treatment resulted in pronounced clinical improvement and joint protection. OX34 treatment therefore inhibits the initiation and the perpetuation of rat AA.

Der(16)t(1;16)(q21;q13) as a secondary structural aberration in yet a third sarcoma, extraskeletal myxoid chondrosarcoma

Cytogenetic analysis of an extraskeletal myxoid chondrosarcoma revealed a der(16)t(1;16)(q21;q13) in addition to the t(9;22)(q22;12) described as characteristic for this chondrosarcoma clinicohistopathologic subtype. An identical der(16) has been identified as the most common secondary structural aberration in Ewing's sarcoma and alveolar rhabdomyosarcoma.

Intravascular ultrasound-guided percutaneous fenestration of the intimal flap in the dissected aorta

BACKGROUND

Aortic dissection with branch obstruction is associated with high morbidity and mortality. Fenestration of the dissection flap to relieve distal vessel ischemia is at present largely performed surgically. The surgical mortality and morbidity are high, because most patients are poor candidates for anesthesia or surgery.

METHODS AND RESULTS

Nine percutaneous fenestrations (one with additional stenting of the infrarenal true aortic lumen) were performed under local anesthesia in seven patients with aortic dissection. The presenting symptoms were abdominal angina or claudication. By the transfemoral approach, the intimal flap was initially punctured with a needle-catheter combination through which a guidewire was placed across the dissection flap. The fenestration was carried out with a balloon catheter introduced over the guidewire. The procedure was performed under on-line guidance with intravascular ultrasound imaging. The procedure was performed successfully and without complications in all patients. After intervention, symptoms resolved in all seven patients.

CONCLUSIONS

Intravascular ultrasound-guided percutaneous fenestration of the intimal flap in symptomatic aortic dissections with distal vessel involvement is a technically feasible and safe procedure that can effectively relieve the patient's symptoms.

MRI of breast cancer: influence of chemotherapy on sensitivity

MR mammography (MRM) seems to be a sensitive method for detection of breast cancer. The effect of cytotoxic agents on the dynamics of contrast medium uptake in primary breast carcinoma or recurrent disease is not known. This study addresses this question and evaluates MRM as a method of monitoring therapeutic success. A total of 13 patients (age range 34-62 years) with histologically confirmed breast cancer were investigated. The patients received neoadjuvant intravenous (iv) chemotherapy. MRM and interpretation of the dynamic measurements were performed in a standardized manner after positioning the patient in a double breast coil. A gradient echo sequence (Flash 3D, TE 5 ms, TR 12 ms, flip angle 25 degrees) was acquired before and 1, 2, 3 and 8 min after intravenous injection of Gd-DTPA 0.15 mmol kg-1 body weight. A T2 weighted SE sequence (TE 103 ms, TR 6900 ms, 4 mm, field of view 350 mm) was also obtained. MRM was performed prior to histological evaluation and after chemotherapy. All cases of malignancy were correctly diagnosed with MRM. Based on MR findings, eight patients were classified as "responders" and the remaining as "non-responders". In the "responders" a flattening of the Gd-DTPA uptake curve after the first cycle of chemotherapy of complete absence of Gd-DTPA uptake after the fourth cycle was observed. The change in Gd-DTPA uptake behaviour led to an underestimation of the extent of tumour in two patients and false negative findings in four patients. MRM provides information regarding response to therapy following the first cycle. MRM does not provide information regarding invasive tumour tissue in "responders".

Cytogenetic findings in 73 osteosarcoma specimens and a review of the literature

Tumor-specific chromosomal abnormalities have been identified in several histologic subtypes of sarcomas. Characterization of recurrent chromosomal abnormalities has provided direction for molecular investigations of pathogenetically important genes. Cytogenetic reports of osteosarcoma, the most common primary malignant bone tumor, are relatively rare. In this study, 73 osteosarcoma specimens from 51 patients were cytogenetically analyzed following short-term culture. Clonal chromosomal abnormalities were detected in 47 and included one haploid specimen, 18 near-diploid specimens, 17 near-triploid, 8 near-tetraploid, 1 near-hexaploid, and 2 specimens with multiple clones of different ploidy levels. Examination of the present data and previously published data (111 clonally abnormal osteosarcoma specimens) reveals that chromosomal bands or regions 1p11-13, 1q10-12, 1q21-22, 11p15, 12p13, 17p12-13, 19q13, and 22q11-13 are most frequently rearranged and the most common numerical abnormalities are +1, -9, -10, -13, and -17. Partial or complete loss of the long arm of chromosome 6 also was seen in all cases of the present study and all previously published cases describing structural abnormalities of 6q. Parosteal osteosarcoma, a prognostically favorable osteosarcoma subtype, was characterized by the presence of a ring chromosome accompanied by no or few other abnormalities. Complex karyotypes were seen nearly exclusively in the high-grade lesions. These findings indicate that specific chromosomal bands and/or regions are nonrandomly involved in osteosarcoma and may provide useful clinical information.

[Therapy of persistent bleeding esophageal varices using intrahepatic portosystemic stent shunt and immediate liver transplantation]

A 41-year-old patient with liver cirrhosis due to autoimmune hepatitis received an emergency transjugular portosystemic stent shunt for uncontrolled acute variceal hemorrhage. Because of markedly impaired liver function, liver transplantation was considered to be indicated and was performed on the following day. Intraoperatively, one of the intrahepatic metal stents migrated unnoticed into the pulmonary artery. The postoperative course was uncomplicated and the displaced stent was left in situ. Eighteen months after the transplantation the patient is well with normal liver function and no pulmonary problems.

Hibernoma

Hibernoma is a rare, benign soft tissue tumor composed of brown fat. A 42-year-old white man presented with an enlarging soft tissue mass located in his left medial thigh. This was evaluated radiographically by CT as well as MR imaging. An open biopsy revealed a hibernoma. The mass was subsequently excised in its entirety, maintaining a cuff of normal tissue. The patient has done very well postoperatively. Although nearly 100 cases have been reported, this case is presented to review the clinical and pathological presentation of this tumor and to describe its MR imaging characteristics.

A model of genital Chlamydia trachomatis infection using human xenografts in severe combined immunodeficiency mice

We developed a new model of human genital Chlamydia trachomatis infection in order to characterize the pathogen-host relationship in a clinically relevant system using a human strain of C. trachomatis instead of the commonly employed mouse biovar (MoPn). Human endometrial tissue was xenografted into the skin of mice homozygous for the mutation severe combined immunodeficiency and inoculated with C. trachomatis serovar K. C. trachomatis efficiently infected the endometrium as shown by cell culture and immunofluorescence microscopy and persisted for more than 6 weeks. Chlamydial inclusions detected by direct immunofluorescence and electron microscopy appeared to be smaller than those produced by in vitro cell culture-grown chlamydiae. A pattern of localized mild infection prevailed, and infiltrative uncontrolled spread of chlamydiae was observed in only 1 of 10 infected grafts. This might correspond to the well-known tendency of the agent to cause asymptomatic infections. This model allows the study of a human genital infection resembling the clinical situation and offers the possibility to better characterize the host-parasite relationship with respect to pathogenicity and therapy.

Diarrhea, massive ascites, and portal hypertension: rare case of a splenic arterio-venous fistula

Portal hypertension is a result of chronic liver disease in the majority of cases. Rare, potentially curable causes of portal hypertension include vascular conditions such as hepatic or portal venous thrombosis and arterio-portal fistulas. We present the rare case of a spontaneous splenic arterio-venous fistula in a 40 year old multiparous woman. The young woman presented with massive diarrhea, ascites, abdominal pain, and an abdominal machinery type bruit and represents the second ever reported case with diarrhea as presenting symptom of splenic arterio-venous fistula. The diagnosis was confirmed by color Doppler ultrasound. Transfemoral aortography was performed to assess the possibility of catheter embolization. Surgical intervention was initially complicated by collateral arterial tributaries of the fistula and finally resulted in a dramatic recovery with persistent resolution of all symptoms. This case report demonstrates a curable form of portal hypertension that must be considered in acute onset portal hypertension in multiparous women and in the absence of liver disease. A machinery type bruit in the upper left abdominal quadrant represents an important and simple diagnostic symptom found by auscultation. Color Doppler ultrasound represents a non invasive, universally applicable and fast method of establishing the diagnosis. The literature and management of splenic arterio-venous fistulas are reviewed.

Stable engraftment of human female genital mucous membrane xenografts on SCID mice

We developed a model in which full-thickness human genital mucous membranes (fallopian tubes, endometrium) were heterotopically xenografted into the skin of severe combined immunodeficient (SCID) mice. The transplanted tissue retained its human phenotype for at least 4 weeks including the glandular epithelium, the lamina propria, and main parts of the grafted vessels. By using an occlusive chamber filled with covering phosphate-buffered saline we created a system that protected the moist human epithelial surface. This system will allow the study of the interaction of test substances, or of invasive, pathogenic microorganisms, with epithelial cells and other cellular components of the human genital mucosa under in vivo conditions.

Treatment of portal vein thrombosis by thrombectomy and regional thrombolysis

BACKGROUND

Portal vein thrombosis is a rare disorder. The prognosis of both the acute and the chronic forms is determined by the resulting acute or chronic portal hypertension. The therapeutic approach of choice is controversial.

METHODS

A case of etiologically unclear thrombosis of the portal vein system in a young man is reported, which was treated successfully by means of portal vein thrombectomy combined with intraoperative and postoperative thrombolysis with recombinant tissue plasminogen activator (rTPA).

RESULTS

Initial thrombectomy established sufficient venous return. However, rethrombosis of the portal vein occurred 2 days later. In a second operation rethrombectomy was followed by intraoperative regional application of rTPA, which was continued after operation during a period of 48 hours through a catheter inserted in a mesenteric vein. Patency of the portal system was confirmed 1 week after the procedure. The 1-year follow-up reconfirmed this result (through indirect portography and Doppler sonography). The patient received the anticoagulant phenprocoumon.

CONCLUSIONS

The combination of surgical thrombectomy and regional thrombolysis with rTPA could offer a feasible therapeutic option for selected patients with acute prehepatic portal vein thrombosis.

Nipple discharge and abnormal galactogram. Results of a long-term study (1964-1990)

In case of abnormal nipple discharge of the female breast, galactography can detect variations of ductal calibre, intraductal alterations and ductal discontinuities. Between 1964 and 1990 we examined 2588 women by galactography and performed 826 duct excisions. In one out of 8 patients (13.4%) we diagnosed invasive carcinoma or ductal carcinoma in situ. In more than 40% a solitary ductal papilloma was detected. 13.7% of the patients were found to have extensive intraductal solid papillary or adenomatous epithelial proliferations. Comparison with collected statistical data reveals that other investigators are able to detect malignant changes in 1-23% of cases. We have managed the largest number of cases and have diagnosed pathologic ductal secretion in more than 3% of women we screened by physical inspection, mammography and sonography. The colour of the ductal discharge is of minor importance, as histologic analysis is mandated by the presence of ductal system alterations.

[Life expectancy of clinically occult breast cancer. Study of a comparative patient sample since 1975]

We have been observing 2 groups of 50 female patients with occult or clinical breast cancer each of whom was initially treated at the Gynaecologic Hospital of the University of Erlangen-Nürnberg between 1975 and 1978. During the follow-up period, 2 patients out of the group of occult cancer and 13 out of the group of clinical carcinoma died of their primary disease. Four women out of the group of occult cancer and 3 from the group of "clinical carcinoma" have developed recurrences. The differences in survival times according to Kaplan-Meier are immense, even if they are not significant owing to the small number of patients. But it is difficult to obtain and to evaluate larger groups of patients and longer follow-up periods due to the low percentage of occult cancer (7.7 to 10.5% only). There are 30 women out of the group of occult breast cancer living without relapse after an observation period up to 15 years. 27 patients out of the group of "clinical cancer" have not shown any evidence of recurrence up to now. This small difference after such a long follow-up period can be explained by the general life expectancy and by the age at initial treatment.

[Optimization of filtration and lighting parameters in pictures of the hand using digital luminescence radiography]

The appearance of digital radiographs were markedly influenced by post-processing. To optimise images of the hand, radiographs of 7 patients with arthritis were modified by various filters. 6 observers evaluated the presence or absence of erosive changes during an ROC study and the advantages of low filtration were demonstrated. Further images were prepared of anatomical preparations in which para-articular defects had been made and of a hand phantom covered in perforated plexiglass. Limited filtration and low enhancement factors again provided the best results. Dose reduction of 50% resulted in a significant deterioration in the ability to recognise erosions and artificial lesions.

[Arthritic changes in small and large joints in digital and conventional x-ray images]

In order to evaluate the suitability of digital radiography for the diagnosis of skeletal abnormalities, inflammatory joint changes were used to test this technique. Early erosive changes, fine irregularities and marginal lamellar abnormalities demand a high degree of resolution from the imaging method. 6 observers studied images of the hand of 67 and of the foot of 19 patients. Joint changes were staged according to the scheme proposed by Larsen; in this study the early stages predominated. With similar techniques there were no significant differences between the digital and conventional techniques. Images of 39 large joints (knee, shoulder, elbow, ankle) were compared only subjectively since even minor differences in projection were able to obscure some erosions. However, in this case also both techniques appear to be of similar value.

[Complications of osteosynthesis in the x-ray picture]

Internal and external fixation devices are widely used in traumatology and orthopedic surgery. Early radiographic detection of complications due to bone surgery is based on a thorough knowledge of the different types of implants and their biomechanical properties. The development of early and late complications is demonstrated.

Reliability of testing measures in Duchenne or Becker muscular dystrophy

In a multiinstitutional collaborative study, we ascertained the interevaluator and intraevaluator reliability of six physical therapists who performed assessment measures on 36 boys (11.7 +/- 3.9 years) with Duchenne or Becker muscular dystrophy. Upper and lower extremities were evaluated by manual muscle testing for function, range of motion, and strength. The data were analyzed using intraclass correlation coefficients (ICCs). For the interevaluator phase, ICCs were as follows: average muscle strength, .90; range of motion, .76; and upper extremity functional performance, .58. For the intraevaluator phase, corresponding ICCs were .80 to .96; .33 to .97; .34 to 1.00. Our results confirm and extend observations by others that these assessment measures are sufficiently reliable for use in a multiinstitutional collaborative effort. Such results can be used to design clinical trials that have sufficient statistical power to detect changes in the rate of disease progression. Investigators planning clinical trials in a multiinstitutional collaborative setting should first standardize the assessment methods, provide evaluator training, and document reliability.

[Chemical embolization of carcinoid metastases in the liver]

We performed chemo-embolisation with gel foam powder and epirubicin in 11 symptomatic patients with liver metastases from carcinoids. In all cases the symptoms regressed completely after the procedure. In two patients the liver was re-embolised because of tumour growth and both again became symptom-free. In one case, increasing extra-hepatic tumour growth was treated with interferon. One female patients died seven days after the procedure from renal failure and from complications of cerebral oedema. Two other patients died from extensive extra-hepatic tumour in the skeleton and lungs at 88 and 97 weeks after embolisation, respectively. The remaining patients are still symptom-free at 18 to 161 weeks.

Storage phosphor versus screen-film radiography: effect of varying exposure parameters and unsharp mask filtering on the detectability of cortical bone defects

Diagnostic performance with storage phosphor radiography is influenced by exposure parameters and digital filtering algorithms. The authors compared the detectability of cortical lesions in excised human femoral shafts on state-of-the-art screen-film radiographs and storage phosphor digital radiographs. For the digital system, the effect of varying exposure parameters (photon flux and tube voltage) and unsharp mask filtering (kernel size and enhancement factor) was tested. Analysis of receiver operating characteristics was performed for 10,560 observations made by eight radiologists. Under identical exposure conditions, storage phosphor imaging yielded no significant advantages over conventional screen-film radiography. Although large variations in exposure dose are possible with storage phosphors, the potential for dose reduction was limited even by means of an increase in tube voltage. The performance with unsharp masked images declined with decreasing kernel size and pronounced enhancement.

[Significance of neu-protein for prognosis of breast cancers]

In 147 primary breast carcinomas, over-expression of NEU-protein was detected immuno-histochemically. 20 tumours (13.6%) showed a positive reaction. Correlations with established prognostic factors, showed a significant relationship to unfavourable histological grading and negative oestrogen receptor status, as well as to the negative status of both oestrogen and progesterone receptors. However, no correlation could be demonstrated with the progesterone receptor alone. Only a trend without significance was demonstrated to the tumour size and proliferation rate-indicated by the Ki-67 antibody. No correlation existed to the status of the axillary nodes. Overexpression of NEU-protein proved to have a significant influence on the disease-free survival and overall survival in a median follow-up time of 31 months. Nevertheless, this could be shown only for tumours with metastasis in axillary nodes, but not for nodal negative tumours. A possible Longer follow-up time is necessary, to show a difference of results for the latter group.

[Cultivation technics for freshwater fish]

A general overview is presented on the various cultivation techniques in modern freshwater aquaculture. Included are overall production figures for finfish production in the most important producing countries of Europe. Major emphasis is placed on the situation of aquaculture development in the Federal Republic of Germany, providing details on the structure of the industry in the states of Bavaria, Lower Saxony, and Schleswig-Holstein. The trend towards intensification and its implications to system performance is described. The development of recirculation systems, particular for eel farming, is outlined, indicating the various problems related to system design, local conditions and species requirements. Future trends and research needs are identified.

Magnetic susceptibility effects of trabecular bone on magnetic resonance imaging of bone marrow

High-field spectroscopic studies at 5.88 tesla (T) indicate significant T2* shortening of water in suspensions of powdered bone, interpreted to be a result of magnetic susceptibility differences between bone particles and water. The authors investigated the effects of magnetic susceptibility differences between trabecular bone and water on magnetic resonance (MR) images at 0.6 T. The phantom was constructed of macerated intact trabecular human bone immersed in water. Although susceptibility-induced magnetic field inhomogeneities were detected by spectral line broadening by using an asymmetric spin-echo technique, the results show only a modest T2* shortening at this field strength. As expected, no T1 effect of trabecular bone was observed. Although susceptibility effects of trabecular bone may have a small impact on the signal intensity of MR images of bone marrow at midfield strength, the observed field strength dependence of these effects would predict significant susceptibility effects on clinical images at higher field strength.