Detection and mapping of intraabdominal adhesions by using functional cine MR imaging: preliminary results

PURPOSE

To identify and map intraabdominal adhesions by using functional cine magnetic resonance (MR) Imaging.

MATERIALS AND METHODS

Twenty-seven patients suspected of having intraabdominal adhesions were examined. Section-by-section dynamic depiction of induced visceral slide throughout the whole abdomen was achieved by using a transverse or sagittal true fast imaging with steady-state precession sequence. Location and type of diagnosed adhesions were documented by using the nine segments of the abdominal map. These criteria and intraoperative results were compared in 13 patients.

RESULTS

MR images depicted a total of 42 intraabdominal adhesions; 21 (50%) were in the lower abdomen. The most common types of adhesions were located between the ventral abdominal wall and small-bowel loops (n = 10 [24%]) and between adjacent small-bowel loops (n = 9 [21%]). Comparison with the intraoperative results showed a sensitivity of 87.5% and a specificity of 92.5%. MR imaging was most accurate in depicting adhesions to the abdominal wall (15 [94%] of 16) and subperitoneal space (eight [100%] of eight). The presence of adhesions between bowel loops was overestimated.

CONCLUSION

Detection of visceral slide at functional cine MR imaging is easy to perform and represents a well-tolerated and accurate procedure for use in the identification of intraabdominal adhesions in patients with chronic pain and equivocal clinical findings.

Assessment of 5-aminolevulinic acid-induced porphyrin fluorescence in patients with peritoneal endometriosis

OBJECTIVE

The purpose of this study was to examine the diagnostic potential for patients with endometriosis of porphyrin fluorescence after oral administration of 5-aminolevulinic acid.

STUDY DESIGN

Fifteen women referred for laparoscopy because of suspected endometriosis received 1 or 10 mg/kg 5-aminolevulinic acid orally. After 1.5 to 6 hours endoscopic fluorescence spectral analysis and video inspection were performed.

RESULTS

With 10 mg/kg 5-aminolevulinic acid and application intervals of >3 hours we observed a significantly higher porphyrin fluorescence in active peritoneal endometriosis than in adjacent normal peritoneum. Pigmented and nodular endometriosis showed weak to negative fluorescence. A strong fluorescence of the fimbrial mucosa was seen. A 1-mg/kg dose of 5-aminolevulinic acid was insufficient for fluorescence diagnosis. No side effects were recorded.

CONCLUSION

Porphyrin fluorescence after oral administration of 5-aminolevulinic acid may be beneficial in diagnosis of peritoneal endometriosis. The strong fluorescence of fimbrial mucosa may limit the applicability of this technique in young women, however, because phototoxic damage cannot be excluded at present.

[Effects of tubal sterilization]

OBJECTIVE

Besides manifestations of hormonal deficits, psychological problems are also known as possible negative effects of tubal sterilization (here termed "operative contraception"--OC). It is generally assumed that the age at time of operation and the number of children play a crucial role in enabling the patient to come to terms with surgical contraception. We investigated whether these patients were satisfied and the frequency of a desire for refertilization as well as further factors possibly affecting our patients.

PATIENTS AND METHODS

A standardized questionnaire was sent to 274 women in whom surgical contraception was performed from 1984 to 1990 in our hospital. Besides physical symptoms, the questions mainly inquired as to satisfaction, degree of regret and desire for refertilization.

RESULTS

5.4% of women were not satisfied with the operation. 13.7% of the patients regretted the operative contraception and 6.5% wished to have refertilization. The negative appraisal did not correlate with the number of children and age at the time of operative contraception. Altogether, satisfaction was very much greater in patients who had completed family planning than in patients who had received operative contraception for medical reasons. Appraisal of operative contraception was especially negative in women in whom the operation had been performed on the occasion of a cesarean section.

CONCLUSION

Our follow-up investigation confirmed that operative contraception was experienced as being very liberating by most women and was accordingly appraised positively on the whole. The number of children and age only played a subordinate role in how patients came to terms with their situation. For a positive experience of operative contraception, the time of the operation appears to be of major importance. In particular, "favorable opportunities" on the occasion of cesarean section and the if anything doubtful need for this measure in the condition after prior cesarean sections must be avoided, since in these cases a free decision in favor of operative contraception, which the woman concerned feels to be autonomous, is not possible.

[A new vacuum extraction system with a ball joint and detachment warning--in vitro studies and clinical use]

BACKGROUND

The vacuum extractor is used in about 5% of deliveries. It is associated with a lower maternal morbidity than is forceps extraction. On the other hand, cephalhematomas, hyperbilirubinemia and cerebral hemorrhages in the baby are observed more frequently. The sudden detachment of the vacuum extractor with appreciable fluctuations in intracranial pressure in the baby is especially dangerous. In order to improve the conventional Malmström system, we have developed a new vacuum extractor and investigated its handling in vitro and in clinical application.

PATIENTS AND METHODS

The essential constructional principle of the new vacuum extractor consists in a pivot lowered by ball bearings and a volume reduction of one third. Moreover, in two-chamber vacuum it is possible to give a warning of sudden detachment. The possible tractional force in kiloponds was determined at various angles (0 degree, 15 degrees, 30 degrees und 45 degrees) comparing the Malmström extractor with the new one and two-chamber system in a standardized apparatus. In addition, the new vacuum extractor was also used clinically in 43 women; besides the obstetric parameters, the handling was also appraised.

RESULTS

In the in-vitro experiments, a distinct decrease of the possible tractional force with increasing angles was shown for the Malmström extractor (0 degree--15.7 kp, 15 degrees--12.7 kp, 30 degrees--8.6 kp, 45 degrees--7.3 kp). The values for the new one-chamber system were significantly greater from a tractional angle of 15 degrees (0 degree--15.6 kp, 15 degrees--14.4 kp, 30 degrees--14.0 kp, 45 degrees--13.8). The clinical application of the new vacuum system was unproblematic and confirmed the feasibility of good traction. A very much smaller caput succedaneum was found in the baby. Especially in the training situation, the warning system enables a good surveillance before sudden detachment, but reduces the possible tractional force.

CONCLUSIONS

The new vacuum system appears to enable the vaginal surgical delivery to be improved compared to the conventional Malmström extractor. After these promising approaches, a multicenter study was commenced in order to enable better evaluation of their clinical significance.

Photodynamic therapy of vulvar intraepithelial neoplasia using 5-aminolevulinic acid

Photodynamic (PDT) therapy is a relatively new technique with unique properties that make it attractive for the local treatment of superficial epithelial disorders. The objective of this study was to investigate the clinical response of PDT with the photosensitizing agent 5-aminolevulinic acid (5-ALA) in patients with vulvar intraepithelial neoplasia (VIN) grades 1 to 3. Twenty-five patients with 111 lesions of VIN 1-3 were topically sensitized with 10 ml of a 20% solution of 5-ALA and treated with 57 cycles of laser light at 635 nm (100 J/cm(2)). Seventy (64%) of the 111 VIN lesions regressed after various PDT cycles. A complete response was achieved in 13 patients (52%) with 27 lesions. All patients with VIN 1 and mono- and bifocal VIN 2-3 showed complete clearance. However, a complete response could be achieved in only 4 (27%) of 15 women with multifocal VIN 2-3, whereas a partial response was noted in 9 of these patients with a total of 70 lesions, out of which 44 (63%) lesions disappeared. No response was seen in 2 patients with multifocal VIN 3. Histological assessment of the fluorescence-directed biopsies revealed that increased pigmentation and hyperkeratosis of the lesions were associated with low response rates. PDT using 5-ALA represents an alternative treatment modality for VIN which is easy to perform and has the advantage of minimal tissue destruction, low side effects and excellent cosmetic results. However, multifocal VIN disease with pigmented and hyperkeratinic lesions remains difficult to treat.

[Congenital skull depression. Case report and review of the literature]

A 40-week gestational age infant was delivered by cesarean section because of intense contractions and pathological fetal heart rate pattern. The umbilical artery pH was 7.03, Apgar scores were 1/4/7 at 1, 5 and 10 min of age. The 3,250-gram infant had a skull depression of 5 x 7 cm in the left temporal-parietal region with a depth of 1.5 cm. There were no edemas or hematomas in this area; neurological examination was normal. A CT scan did not show a fracture, but the cortex below the depression appeared slightly compressed. At the age of 11 days, the depressed part of the parietal squama was surgically elevated. The child was discharged in good condition 8 days later and remained well at a 6-month follow-up examination.

Photodynamic therapy in women with cervical intraepithelial neoplasia using topically applied 5-aminolevulinic acid

Photodynamic therapy (PDT) is a novel treatment modality that produces local tissue necrosis with laser light after prior administration of a photosensitizing agent. We performed a study of topically applied 5-aminolevulinic acid (5-ALA) in the photodynamic treatment of women with high-grade cervical intraepithelial neoplasia (CIN) using fixed 5-ALA doses and application protocols derived from previous in vitro and in vivo results. Three to 5 hr prior to PDT, 10 ml of a 20% solution of 5-ALA was topically applied using a cervical cap. PDT was performed with irradiation of 100 J/cm2 at an irradiance of 100-150 mW/cm2 with an argon-ion-pumped dye laser at 635 nm. For the endocervix, a specifically designed cylindrical applicator was used. Ten treatment cycles of PDT using 5-ALA were performed in 7 patients with high-grade CIN. Non-thermal laser treatment with 100-150 mW/cm2 was well tolerated. Local toxicity was minor as several patients reported burning sensations and vaginal discharge, but no necrosis, sloughing or scarring occurred. After 3 months, a significant reduction in the size of the ectocervical CIN lesions was noted in only 3 patients, who underwent a second PDT cycle. However, no significant improvement in CIN lesions was noted since cold knife conization revealed persistent CIN in all 7 cases. Therefore, PDT after topical application of 5-ALA using an irradiation of 100 J/cm2 produces only minimal side effects. However, it does not appear to be effective in treating CIN.

Photodynamic therapy of vulvar lichen sclerosus with 5-aminolevulinic acid

OBJECTIVE

To evaluate the therapeutic effect of photodynamic therapy on vulvar lichen sclerosus.

METHODS

Twelve women with lichen sclerosus were enrolled in a prospective, single-arm pilot study. Four to 5 hours before photodynamic therapy, 10 mL of a 20% solution of 5-aminolevulinic acid was applied topically to the vulva. Photodynamic therapy was administered with an irradiation of 80 J/cm2 at an irradiance of 40-70 mW/cm2. Light with a wavelength of 635 nm was delivered by an argon ion-pumped dye laser. The degree of pruritus was evaluated using a horizontal visual analog scale before and after 6-8 weeks, and patients were followed tri-monthly after photodynamic therapy.

RESULTS

Two women underwent two cycles of photodynamic therapy, one underwent three cycles, and the remaining nine women underwent one cycle each. Treatment was tolerated moderately well, with eight patients not requiring any analgesia; three treated with opioids intravenously during the procedure, due to burning sensations; and one undergoing separation of adhesions under general anesthesia. Minimal local toxicity included vulvar erythema but no necrosis, sloughing, or scarring. No generalized cutaneous photosensitivity was present. Six to 8 weeks after photodynamic therapy, pruritus significantly improved in ten of the 12 women. A prolonged effect of photodynamic therapy was reported, with a mean of 6.1 months.

CONCLUSION

Photodynamic therapy after topical application of 5-aminolevulinic acid produced statistically significant relief of symptoms of vulvar lichen sclerosus for an average of 6.1 months with minimal side effects.

Low-dose FSH stimulation in polycystic ovary syndrome: comparison of 3 FSH-preparations

In patients with PCOS low dose administration of follicle stimulating hormone is accepted as a safe treatment modality with low risk for an ovarian hyperstimulation syndrome or a multiple pregnancy. In this study we have retrospectively compared the efficacy of 3 different FSH preparations in low dose protocols-urinary FSH (FSH), highly purified urinary FSH (FSHHP) and recombinant FSH (rec. FSH). A total of 68 PCOS-patients, 36 lean and 32 moderately obese patients, were treated in 116 stimulation cycles. The mean age did not differ between the groups. A mean number of 1.7 cycles per patient was performed. PCOS was diagnosed in all patients by hormonal and sonographic means. Treatment was performed with daily injections of one ampoule FSH from day 3 onwards. Ovulation was induced with 10,000 IU HCG, when the leading follicle exceeded 16 mm in diameter and no more than 3 follicles were seen. The rate of monofollicular cycles was lowest in obese patients after FSHHP stimulation (30%) and after rec. FSH (66.6% in lean and 58.3% in obese patients, respectively). The number of FSH ampoules did not differ significantly between the groups. No severe hyperstimulation syndrome was registered. 21 pregnancies were achieved without significant differences between the different FSH preparations. Besides two abortions and one ectopic implantation, 12 pregnancies were ongoing singleton pregnancies, 3 twin pregnancies and 3 sets of triplets were noted. In conclusion, low-dose stimulation with FSH offers a safe and successful treatment option in patients with PCOS with an acceptable risk for multiple gestations.

Pharmacokinetics and selectivity of aminolevulinic acid-induced porphyrin synthesis in patients with cervical intra-epithelial neoplasia

Photodynamic therapy (PDT), due to its tumor selectivity, represents an alternative approach to diagnose and treat cervical intra-epithelial neoplasia (CIN) without altering normal surrounding tissue. Our aim was to investigate the pharmacokinetics and the selectivity of 5-aminolevulinic acid (5-ALA)-induced porphyrin fluorescence after topical administration, to obtain basic clinical data for future diagnostic fluorescence imaging and PDT protocols for CIN. Twenty-eight non-pregnant women with a cytological diagnosis of low-grade or high-grade squamous intra-epithelial lesions were included. An aqueous solution containing 3% 5-ALA was topically applied 1 to 6 hrs prior to conization using a cervical cap. After excision, porphyrin-induced fluorescence was quantified in dysplastic (n = 14) and normal epithelium (n = 28) by means of quantitative fluorescence microscopy. High values of porphyrin fluorescence were found in squamous epithelium between 150 and 450 min, with a maximum at 300 min following administration of 5-ALA. Ratios of porphyrin fluorescence of dysplastic vs. surrounding normal epithelium were 1.3 and 1.21 for CIN 1 (n = 3) and CIN 2 (n = 3), respectively. In CIN 3 patients (n = 8), this ratio was 2.35; the best selectivity of 5-ALA-induced porphyrin fluorescence in CIN 3 lesions (ratio 3) was observed with a topical administration time of between 150 and 250 min. Our results demonstrate that patients with CIN 3 show higher 5-ALA-induced fluorescence compared with normal epithelium. The optimal administration time of topically applied 5-ALA was between 3 and 4 hr. Our data suggest that topical ALA-PDT and photodynamic diagnosis might be suitable for detecting CIN.

[Hormonal treatment of proximal tubal pathology with the GnRH analogue leuprorelin]

In proximal tubal occlusions (PTO) the microsurgical anastomosis or in case of extensive tubal damage the in vitro-fertilisation (IVF) are the treatment modalities of choice. Aim of our study was to evaluate the effectivity of GnRH-analogues in the treatment of PTO. In 23 patients with repeatedly proven proximal tubal occlusion the GnRH-analogon Leuprorelin was applied for a 3 month period. 20 out of 23 patients completed the entire study including a further tubal patency test. 10 patients showed open tubes on both sides and in 2 cases one oviduct was patent. In 8 patients no effect of the hormonal treatment was found. Following the therapy 4 pregnancies occurred, 2 were located ectopically. Regarding tubal patency we could demonstrate a significant effect of hormonal treatment in proximal tubal occlusions (PTO). However, in respect to the pregnancy rate the results were not satisfactory. Therefore, the hormonal treatment of PTO by GnRH-analogues is limited to certain cases and doesn't represent a standard therapy.

Dynamic glenohumeral joint stability

Stability of the glenohumeral joint with an anterior, posterior, and inferior displacement force of 50 N was measured in a dynamic shoulder model. Controlled hydrodynamic actuator forces were applied to the deltoid muscle and to the rotator cuff in seven anatomic specimens. During elevation of the arm the position of the humerus was measured with a six-degree-of-freedom ultrasonic sensor device. The rotational center of the humeral head was used as a reference point for translation. A displacement force of 50 N led to significant humeral head displacement anteriorly and posteriorly but not inferiorly. A 50% reduction of rotator cuff forces increased anterior displacement by 46% and posterior displacement by 31%. Venting of the glenohumeral joint space and of the subacromial bursa resulted in a 50% increase of anterior displacement, a 19% increase of posterior displacement, and significant inferior displacement. This study demonstrates that in addition to passive stabilizers and negative intraarticular pressure, rotator cuff force significantly contributes to stabilization of the glenohumeral joint during arm motion. Muscle strength and coordination should gain more emphasis in the diagnosis and treatment of shoulder instability.

Fertility after organ-preserving surgery of ectopic pregnancy: results of a multicenter study

OBJECTIVE

To evaluate the postoperative fertility rate after ectopic pregnancy (EP) and to compare the impact of different surgical techniques.

DESIGN

Prospective, multicenter trial.

SETTING

Twenty-five centers with microsurgical facilities.

PATIENT(S)

A total of 1,025 patients with EP were enrolled between 1984 and 1990.

INTERVENTION(S)

Organ-preserving operation and at least one patent remaining tube. Evaluation of postoperative outcome by standardized questionnaires.

MAIN OUTCOME MEASURE(S)

Postoperative fertility in terms of pregnancy rate (PR) and recurrent ectopic implantation.

RESULT(S)

The PR was similar after wedge resection (45.9%) and salpingotomy or milk out (42.0%). The recurrence rates did not differ between both groups (7.5% versus 8.2%). In patients with a blocked or absent contralateral tube, the PR was poor (31.2%), and the recurrence rate of EP was high (16.0%), indicating that most pregnancies are achieved through the contralateral tube.

CONCLUSION(S)

The postoperative fertility rate after an EP is reduced. The type of surgery usually has no significant impact. In the case of a blocked or absent contralateral tube, the patient must be informed about the significantly reduced fertility rate and the elevated risk for EP recurrence.

[Radiologic versus ultrasound fallopian tube imaging. Painfulness of the examination and diagnostic reliability of hysterosalpingography and hysterosalpingo-contrast-ultrasonography with echovist 200]

Evaluation of tubal patency is usually assessed with hysterosalpingography (HSG) or laparoscopy including chromopertubation. Sonographical visualisation with Echovist 200 (hysterosalpingo-contrast sonography-HyCoSy) provides a new noninvasive tool. Therefore we conducted a prospective controlled study to compare sonographic and radiological evaluation of the fallopian tube. Main test parameters were accuracy of both methods and patient discomfort.

PATIENTS AND METHODS

50 patients were enrolled in this study. All patients were examined by both techniques; the sequence was randomly chosen. The results of HSG and HyCoSy were compared. Patient discomfort was assessed with a standardised questionnaire using a visual analog scale (0-10).

RESULTS

Diagnosis of tubal patency identifying proximal or distal blockage was the primary end point using HSG as standard technique. Proximal and distal patency by HSG was sonographically confirmed in 82.9% (63/76) and 82.1% (46/56) tubes respectively. If HSG revealed proximal or distal occlusion, identical results were obtained in 91.7% (22/24) or 60% (12/20) by HyCoSy. No significant differences were found in patient discomfort. However a significant correlation was demonstrated between tubal patency and discomfort. The lowest score was obtained in patients with open tubes (4.6) increased in patients with distal occlusion (6.0) and reached a maximum with proximal pathology (8.7).

CONCLUSION

Compared to conventional HSG, HyCoSy provides a highly efficient evaluation of tubal pathology and can be successfully used as a noninvasive screening method.

Pain intensity following laparoscopy

The temperature of the gas used for insufflation during laparoscopy has a significant influence on postoperative shoulder and subphrenic pain according to a prospective randomized study of 103 female patients who filled out a standardized pain assessment questionnaire with a visual analogue scale from 0 to 10. Women in group B (n = 53), who had been insufflated with warm CO2 gas during laparoscopy, had significantly less pain than women in the control group (group A; n = 50). The declared value for shoulder pain at the first postoperative day was 3.6 with cold gas versus 2.5 with warm CO2 (p = 0.013). The strongest pain was found following long operations (5.4 vs. 4, respectively) and following high CO2 gas use (5.5 vs. 2.3); in both cases, a significant advantage was noted for the group treated with warmed CO2. Further research is needed regarding the etiology and possible prevention of postoperative pain following laparoscopy. As the use of warm CO2 gas leads to significant reduction of pain, technical and mechanical parameters should be changed accordingly.

[Diagnosis and therapy of extrauterine pregnancy]

The combined use of transvaginal ultrasound and serial quantitative determination of the serum human chorionic gonadotropin (HCG) concentration offers an early and exact diagnosis of an ectopic pregnancy before the onset of clinical symptoms. Therefore, a large variety of invasive and noninvasive treatment options can be chosen. In patients without severe clinical symptoms, the trophoblast activity should be determined via the HCG course before invasive treatment methods are performed, because a considerable proportion part of the patients show spontaneous resolution of the ectopic pregnancy without further measures. Recently systemic treatment with methotrexate alone or local injection of different substances like prostaglandins, glucose, and methotrexate, etc. became an alternative to surgical therapy, i.e., endoscopic salpingotomy or salpingectomy. The success rates are generally lower in comparison to surgical therapy. Therefore, medical treatment is useful only in patients with a low trophoblast activity (e.g., < 2,500 mIU/ml HCG). However, in cases with low HCG values, observation alone frequently leads to a resolution. Corresponding to the data being available up to now, the postoperative pregnancy rate does not depend on this decision.

[Measurement of glenohumeral joint translation with a dynamic shoulder model]

Translation of the glenohumeral joint was measured with a dynamic shoulder model, during elevation of the arm in eight cadaveric specimens. Controlled hydrodynamic actuator forces were applied to the deltoid muscle and the rotator cuff through wire cables. Using a constant force ratio, the glenohumeral joint was elevated to 90 degrees. The position of the arm in all spatial orientations was measured with an ultrasonic device. Reproducibility of glenohumeral joint motion was demonstrated on the basis of five cycles of glenohumeral joint elevation. The rotational center of the humeral head was used as the reference point for translation. Translation during elevation of the glenohumeral joint between 20 degrees and 90 degrees averaged 9.0 mm +/- 5.2 mm superiorly and 4.4 mm +/- 1.3 mm anteriorly. In vivo, this may be diminished by coordinated activity of the rotator cuff. The presence of significant glenohumeral joint translation underlines the importance of active, muscular guidance at the shoulder. Physiologic translation of total shoulder arthroplasty, in shoulder instability and in the impingement syndrome.

Conservative treatment of endometrial cancer permitting subsequent triplet pregnancy

We report on a 28-year-old woman who received conservative treatment of endometrial carcinoma by curettage and progestins. After regression of endometrial lesions the patient's infertility was treated by gamete intrafallopian transfer (GIFT). Intact triplet pregnancy was diagnosed 3 weeks later. The patient was delivered of three infants by caesarean section following premature rupture of membranes at 30 weeks of gestation. Subsequent standard treatment of endometrial cancer by abdominal hysterectomy and bilateral salpingo-oophorectomy after 4 weeks revealed no clinical or histological evidence of persistent carcinoma. One year after surgery the patient remained without evidence of disease. We believe that individualized cancer therapy may be safely performed in carefully selected cases.

[Dynamic stability of the glenohumeral joint. A biomechanical study]

Stability of the glenohumeral joint with an anterior, posterior and inferior displacement force of 50 Newton was measured in a dynamic shoulder model. Controlled hydrodynamic actuator forces were applied to the deltoid muscle and to the rotator cuff in seven anatomic specimens. During elevation of the arm, the position of the humerus was measured with a six-degree-of-freedom ultrasonic sensor device. The rotational center of the humeral head was used as reference point for translation. A displacement force of 50N led to significant humeral head displacement anteriorly and posteriorly, but not inferiorly. A 50% reduction of rotator cuff forces increased anterior displacement by 46% and posterior displacement by 31%. Venting of the glenohumeral joint space and of the subacromial bursa resulted in a 50% increase of anterior displacement, a 19% increase of posterior displacement and in significant inferior displacement. This study demonstrates that, in addition to passive stabilizers and negative intraarticular pressure, rotator cuff force significantly contributes to stabilization of the glenohumeral joint during arm motion. Muscle strength and coordination should gain more emphasis in the diagnosis and treatment of shoulder instability.

[Use of photodynamic laser therapy in gynecology]

OBJECTIVE

Dysplasia of the vulva and uterine cervix are often multicentric, tend to recur and have mostly to be treated by surgical procedures. The photodynamic laser therapy (PDT) may be an alternative, which selectively destroys neoplastic tissue after topical delta-aminolevulinic acid (ALA) used as a photosensitizer.

METHODS

We measured the distribution of fluorescence in dysplastic and nondysplastic tissue after topical application of ALA in 27 patients with dysplasia. In 3 vulvar and 2 cervical dysplasias, PDT was performed.

RESULTS

We could show a selective enrichment of endogenous porphyrins in dysplastic tissues, whereas benign tissue showed no fluorescence. The fluorescence was limited to the mucosa. The heterogeneous fluorescence pattern was influenced by the duration of ALA application. In the treated patients, cytological and clinical parameters showed improvement after use of PDT. The longest recurrence-free interval from treatment up to date is 15 months (range 3-15 months).

CONCLUSIONS

After first results of penetration studies and clinical follow-up, PDT after topical ALA application seems to be a good alternative to surgical procedures in dysplastic changes of the genital tract.

[The synergistic effect of delta-aminolevulinic acid and photodynamic laser therapy based on an in vitro model of the ATP tumor chemosensitivity test]

Photodynamic laser therapy (PDT) is under prospective clinical evaluation in gynecology. We used the ATP tumorchemosensitivity assay to detect the efficacy of delta-aminolevulinic acid (ALA) in combination with PDT. Two invasive cervical cancer cell lines were used, C33 and SIHA. The cell-damaging effect was quantified by measuring the intracellular ATP content. The 50% inhibitory concentration of ALA was 760 microM in the cell line C33 and 500 microM in the cell line SIHA. The combination of ALA incubation and PDT was synergistic in both cell lines. After in vitro experiments with this method, the combination is now used in a clinical phase II study. PDT after topical ALA application promises to become a possible alternative for the treatment of preinvasive and invasive malignancies in gynecology.

Translation of the glenohumeral joint with simulated active elevation

Translation of the glenohumeral joint was measured with a dynamic shoulder model during elevation of the arm in 8 cadaveric specimens. Controlled hydrodynamic actuator forces were applied to the deltoid muscle and the rotator cuff through wire cables. Using a constant force ratio, the glenohumeral joint was elevated to 90 degrees. The position of the arm in all spatial orientations was measured with an ultrasonic device. Reproducibility of glenohumeral joint motion was demonstrated on the basis of 5 cycles of glenohumeral joint elevation. The rotational center of the humeral head was used as the reference point for translation. Translation during elevation of the glenohumeral joint between 20 degrees and 90 degrees averaged 9.0 mm +/- 5.2 mm superiorly and 4.4 mm +/- 1.3 mm anteriorly. Physiologic variation of muscle activity, which is not yet fully understood, was not included in the model. In vivo, translation may be diminished by coordinated activity of the rotator cuff. The presence of significant glenohumeral joint translation underlines the importance of active, muscular guidance at the shoulder. Physiologic translation must be considered in the design of total shoulder arthroplasty, in shoulder instability, and in the impingement syndrome.