Contents

Current problems
Nikolov I - Current modalities for bone density evaluation: diagnosis of osteoporosis and fracture risk prediction

Surveys
Naumov N - Diagnosing trauma induced changes in the bladder
Nikolova T, Grigorova M - Biodosimetry in radiation breakdown events: an overview of practically implemented cytogenetic techniques and outlooks

Original articles
Stojanov D, Bosnjakovic P, Zivkovic M, Ristic S, Petrovic S, Stefanovic I, Stojanovic N - Dolichoectasia and dissection of the intracranial vertebrobasilar artery

Kirova G, Simidchiev A, Kalaydjiev D, Kostadinov D - The role of HRCT in the differential diagnosis of pulmonary parenchymal opacifications 
Pomakov P, Lyutskanova E, Batanova S, Rusev P - Defecography (a modified method and diagnostic relevance)
Taseva V, Naumov N, Mushekov V - Gastrointestinal complications after renal transplantation

Ninyo S,  Palashev Y, Kovacheva S, Neycheva T,  Petkova D - 99mTc liposomes in diagnosing pulmonary embolism in rabbits
Vassileva J, Nedjalkov S - Alteration in image quality and radiation exposure of the patient during chest radiography with increased sensitivity of the film-screen combination

Historical facts and events
Problems relating to education
Impressions from congresses
News of the EAR
News of the BAR
Book reviews
Abstracts of current literature
Forthcoming scientific events
News items
Instructions to authors
 

Current modalities for bone density evaluation: 
diagnostics of osteoporosis and fracture risk prediction

I. Nikolov
Department of Imaging Diagnostics, Military Medical Academy - Sofia
Summary. Osteoporosis is one of the most commonest metabolic diseases affecting million people throughout the world.  The relationship established between low bone mass and heightened fracture risk  has stimulated the development of multiple noninvasive densitometric methods. Up-to-date techniques for fracture risk assessment involve measurement of bone density at different sites of the human skeleton, with the results being usually age-matched. The data from bone density measurements promote optimal prediction of fracture risk, and improvement of treatment of osteoporotic patients. In the survey presented currently available techniques for assessing bone density and structure, namely: dual-energy x-ray absorptiometry, quantitative CT, quantitative US, high-resolution CT and high-resolution MRI are discussed, along with comparative evaluation of the accuracy and cost-effectiveness of the various procedures.

Key words: bone density. osteoporosis. DXA. QCT. QUS.

Address for correspondence: Dr. I. Nikolov, CT Division, Department of Imaging Diagnostics, Military Medical Academy - Sofia, 3, St. G. Sofijski street, 1606 Sofia, Bulgaria

Diagnosing trauma induced changes in the bladder

N. Naumov
Department of uroradiology, Clinic of emergency and children urology, MBALSM "N. I. Pirogov" - Sofia

Summary. Nowadays trauma is considered as one of the underlying causes of hospitalization and invalidization of population worldwide. At the same time, isolated injuries are ever more rarely seen, and in the great majority of cases a constellation of traumatic changes involving various systems are observed.
The urinary bladder, owing to its anatomic position, is relatively well protected from trauma, and its isolated lesion is an exceptionally rare finding. The different patterns of traumatic changes, their classification and methods of diagnosing are briefly outlined. A treatment protocol used in patients suspected for bladder injury is also presented. It is a protocol practicable in virtually any hospital.

Key words: Bladder. Trauma. Retrograde cystography. Ultrasound diagnosis (US). Computed tomography (CT). Magnetic resonance (MR).

Address for correspondence: Dr N. Naumov, Department of Uroradiology, Clinic of Urology, Institute "Pirogov", 21, Blvd. Totleben, 1606 Sofia, Bulgaria
 

Biodosimetry in radiation breakdown events: an overview of practically implemented cytogenetic techniques and outlooks

T. Nikolova, M. Grigorova
National Center of Radiobiology and Radiation Protection - Sofia

Summary. Detection of occupational or environmental accidental exposure to ionizing radiation necessitates accurate assessment of the possible biological effects with a view to undertake adequate medical treatment of the persons involved. The frequency of chromosome aberrations in peripheral blood lymphocytes may serve as an indicator for quantitative evaluation of radiation-induced changes in the human organism.  In radiation breakdown events where the ionizing radiation source causing the accident is unavailable for performing physical dosimetry, or else certain time has elapsed after the exposure, biodosimetry proves to be the only method of estimating the dose absorbed (retrospective biodosimetry). To assess the degree of chromosomal damage in lymphocytes a number of endpoints can be used, namely: dicentrics (and/or rings), translocations (in metaphase), micronuclei (in cytochalasin B-blocked binucleated lymphocytes), premature condensed chromosome - PCC, in interphase. Utilization of chromosome specific DNA libraries for fluorescence in situ hybridization (FISH) makes possible easy identification of stable aberrations, such as translocations, thereby creating conditions for their future implementation in retrospective estimation of the dose absorbed in previous exposures. To assay the individual dose it is necessary to compare the yield of chromosome aberrations using appropriate calibration dose-response curves generated in vitro. The choice of endpoints practically used in biodosimetry depends on the urgency and accuracy needed for dose assessment in the concrete radiation breakdown event.

Key words: biodosimetry, dicentrics, micronuclei, translocations.

Address for correspondence: Dr. T. Nikolova, National Center of Radiobiology and Radiation Protection, 132, Kliment Ohridski Blvd., Sofia 1756, Bulgaria
 

Dolichoectasia and dissection of the intracranial 
vertebrobasilar artery 

D. Stojanov1, P. Bosnjakovic1, M. Zivkovic2, S. Ristic1, St. Petrovic1, 
I. Stefanovic3, N. Stojanovic3
1Institute of Radiology, 2Clinic of Neurology, 3Clinic of Neurosurgery, Faculty of Medicine - Nis, Yugoslavia

Summary. Purpose: To determine the clinical and neuroradiological features of dolichoectatic intracranial vertebrobasilar artery dissection.  
Methods and Materials: The clinical features, native and post-contrast CT scans of 5 patients (4men and 1 woman; age range from 25 to 68 years) with dolichoectatic intracranial vertebrobasilar artery dissection were analyzed retrospectively for a period of 3 years. Diagnosis was confirmed by vertebral angiography.
Results: Clinical symptoms due to ischemic cerebellar and/or brain stem lesions were present in 4 patients, two of them had Wallenberg syndrome. Occipital and/or posterior neck pains   were found in 4 patients. Subarachnoid hemorrhage was shown in one patient. The incidence of previously documented hypertension was 60% (3 of 5 patients). The prognosis was relatively good. Dolichoectasia was detected by native, post-contrast CT scans and reconstructions in all patients. Intimal flap was visualized with post-contrast CT scans in on patient. Extension of the basilar artery tip into the third ventricle was detected in 3 patients. Ischemic low-density lesions were detected in 3 patients and subarachnoid hemorrhage in one patient. Vertebral angiography disclosed elongation and dilatation of the vertebral and basilar arteries, double lumen sign - the presence of a true and false lumen and an intimal flap, double density and retention of contrast medium.  
Conclusion: Ischemic symptoms and head and/or neck pain were the most common clinical findings. The double lumen sign, considered as the only pathognomonic angiographic finding of arterial dissection, was found in all patients. Angiography is still considered the "gold standard" for diagnosis of intracranial vertebrobasilar artery dissection.        

Key words: basilar dolichoectasy. dissection. CT. vertebral angiography.

Address for correspondence: Prof. Dr. Petar Bosnjakovic, Institute of Radiology UMC Nis, Brace Taskovica 48, 18000, Nis, Yugoslavia

The role of HRCT in the differential diagnosis of pulmonary parenchymal opacifications

G. Kirova, Al. Simidchiev, G. Kalaidjiev, D. Kostadinov
Department of Radiology, National Oncological Center - Sofia

Summary. It is the purpose of the study to determinate whether or not HRCT is helpful in making differential diagnosis of patients with multifocal pulmonary parenchyma infiltrative opacifications.
The HRCT scans of 99 patients, selected on the basis of the presence of multifocal alveolar and/or ground-glass patterns, are retrospectively reviewed. They are distributed in three groups, as follows: group one (n=34) - patients with imunologic genesis of the disease where corticosteroids is the treatment of choice, two (n=24) - infectious diseases, and three (n=34) - malignant diseases. The presence of 15 different indicators in the scanograms of all patients are analyzed.
In group one the changes most frequently encountered include the zones with ground-glass attenuation, subpleural and septal lines, peripheral distribution of the lesions and pleural thickenings. In group two the prevailing changes include acinar nodules, centrilobular branching structures, ground-glass attenuation and segmental distribution of the changes. Ground-glass attenuation, air bronchiolograms, air alveolograms, pleural effusions and peribronchovascular bundle thickening are the commonest findings in group three.
In conclusion the assumption is warranted that HRCT affords additional information in diagnosing patients presenting multifocal infiltrative changes in pulmonary parenchyma. The study contributes to gain better insight into the pathomorphological changes and their distribution pattern.

Key words: HRCT. alveolar syndrome. diffuse lung diseases. Pulmonary infections. immunological disorders.

Address for correspondence: G. Kirova, MD, Department of Radiology, National Oncologic Center, 6,Plovdivsco pole str, 1756 Sofia, Bulgaria, e-mail: krassi@omega.bg

Defecography 
(modified method and diagnostic relevance)

P. Pomakov1, E. Lyutskanova1, S. Batanova2, ?. Rusev2
1Department of Radiology at Medical Institute of the Ministry of Internal Affairs, 2 Department of Radiology, University Hospital "Queen Giovanna" - Sofia

Summary. The classical method of defecography is comprehensively described in the pertinent literature, but it is hardly practicable under local conditions. For this reason a modified method of defecography is developed with acceptable diagnostic relevance. A conventional irrigography is carried out where the barium must be seen in the ileum terminale loops. Defecation is accomplished by tenesmus, and thereafter the patient is examined in erect standing position with rotation. Pelvis minor is examined at right lateral position by taking a target x-ray. The apex of os coccygis is joined to tuberculum pubicum by a straight line ("normala") tangent to the lowest point of excavatio rectouterina. The perpendicular from this line to anus defines the depth of the pelvis minor - about 3.5 cm and anorectal angle about 90ø. The rectum is inspected throughout its full circumference.
Two patterns of x-ray images are noted: 1/ Changes in the ratio between oarts of the intestinal tract and the minor pelvis organs: a/ penetration of small intestinal loops into excavatio rectointerian (enteroceles) and b/ penetration of parts of colon sigmoideum into excavatio rectouterina  (sigmoidocele). These changes are observed only in women, usually multiparae at middle or advanced age, with complaints of abdominal discomfort and chronic obstipation alternating with diarrhea    syndrome.
2/ Impaired configuration of the rectum along its longitudinal axis: a/ ventral or dorsal pseudopropulsion diverticulum (rectocele) and b/ sigmo- or recto-rectal pseudoinvagination (intususception), usually seen in men above middle age, not infrequently in patients with hemorrhoidal tags. After defecation they feel incomplete release, and in case of ulcerations rectorrhage occurs suspected for neoplastic process.

Key words: Defecography. Enterocele. Sigmoidocele, Rectocele. Intususception.

Address for correspondence: Assoc. prof. P. Pomakov, 63, Tzar Assen I Str., 1463 Sofia, Bulgaria
 

Gastrointestinal complications after renal transplantation

V. Taseva1, N. Naumov2, V. Mushekov3
1Clinic of Emergency Imaging Diagnostics, 2Department of Uroradiology and 3Centrum of Haemodialysis 
"St. Pantaleimon", by Emergency Medicine Institute - Sofia 

Summary. This is a report of the results of ultrasonographic study (US) of abdominal parenchymatous organs and gallbladder, carried out in 42 patients with kidney transplantation. In 16 patients are performed 36 conventional US, followed by triplex echographic assessment of the transplanted kidney. Hepato- and splenomegaly are found in 14 cases. In two instances acute pancreatitis is diagnosed of which one is subjected to operation. Changes in the indices measured (pulse index - PI and resistance index - RI) are documented in all patients with transplantation, with an increase in the values above the ones accepted for normal in the literature - 1.6 and 0.70, respectively. Pathological changes described in other abdominal organs, discovered in the postoperative period of patients, should be also borne in mind during US. The development of pathological changes is likewise associated with altered indices during triplex ultrasonographic study.
 

Key words: Renal transplantation. Gastrointestinal changes. Acute pancreatitis. Triplex sonography.

Address for correspondence: Dr V. Taseva, Clinic of Emergency Imaging Diagnostics, Emergency Medicine Institute "N. I. Pirogov", 21, Totleben blvd., 1606 Sofia, Bulgaria
 

99mTc liposomes in diagnosing pulmonary embolism in rabbits

S. Ninyo1 , Y. Palashev2 , S. Kovacheva3, T. Neycheva1, D. Petkova1
1Institute of Biophysics, Bulgarian Academy of Sciences, 2University Hospital "St. Ivan Rilski" and 3University Hospital "Aleksandrovska" - Sofia

Summary. The possibility of using multilamellar 99mTc-labelled liposomes at 2:1 phosphatidylcholine-to-cholesterol ratio for testing pulmonary perfusion and ventilation was investigated. For the purpose an experimental model of pulmonary embolism by iv injection of air into the rabbit ear vein is used.  Comparative assessment is done of pulmonary perfusion with 99mTc-liposomes and 99mTc-Lyo MAA, and pulmonary ventilation with 99mTc DTPA and 99mTc liposomes following embolism. The advantage of the liposomes created is their smaller size compared to Lyo MAA particles which in fact allows the perfusion of arterioles and venules and the obtaining of scans with rather marked homogeneity and density in a healthy lung, and more precise evaluation of segmental and subsegmental disorders in the lobe involved. During pulmonary perfusion scanning 99mTc-liposomes demonstrate a  more detailed picture of the changes in the affected lung, as compared to the one with 99mTc-Lyo MAA. Proceeding from the obtained results the assumption is warranted that 99mTc-liposomes may be used for clinical testing of pulmonary perfusion and ventilation. Studies on 99mTc-liposomes utilization as an inhalatory radiopharmaceutic agent are in course.

Key words: 999mTc labelled liposomes.  pulmonary embolism.  pulmonary perfusion and ventilation.

Address for correspondence: Assoc. Prof. D. Petkova, Institute of Biophysics, Bulgarian Academy of Sciences, 1113 Sofia, Bulgaria
 

alteration in image quality and radiation exposure 
of the patient during chest radiography with an increas¥ 
in the sensitivity of the film-screen combinations 

J. Vassileva1, S. Nedjalkov2
1Faculty of Natural Sciences, University "Ep. K. Preslavsky" and 2Department of Radiology, Multiprofiler Hospital for active cure - Shoumen

Summary. The purpose of the investigation is to study the alteration in image quality and patient radiation exposure during the chest (lung and heart) radiography with an increase in the sensitivity of the film-screen combination. Three methods are applied consecutive. The first method is objective and includes determination of the sensitometric properties of the film-screen combinations - sensitivity (speed), average gamma, optimal optical density. The second method consists in visual analysis of the x-ray images of the phantom with inserted test objects. The entrance air kerma is directly measured. The third method comprises subjective evaluation of the image quality using ten anatomic criteria for the radiographs of adult patients. The entrance air kerma for each patient is determined using indirect method and equivalent dose and effective dose are calculated using Monte Carlo method. The results derived using the three methods are similar. The conclusion is made that four times increased speed of the film-screen combinations is lead to 3.7 times on the average decrease of the entrance air kerma, which is put the values close to the international reference levels. The effective dose is decreased at the rate of 3.6 times, which reduces the radiation risk. The increased sensitivity of the film-screen combination lowers the motion unsharpness of the image and does not deteriorate its low contrast perception. The necessity of an optimisation of the mean optical density of the radiographs is considered. The applied three methods are not competitive but are complementary, therefore it is recommended their combined application.

Key words: film-screen combination. RADIATION exposure. image quality. sensitometry. CHEST radiography.

Address for correspondence: J. Vassileva, Department of Theoretical and Applied Physics, Faculty of Natural Sciences, University "Ep. K. Preslavsky", 9712 Shoumen, Bulgaria, e-mail: j.vassileva@shu-bg.net
 

Abstracts of current literature

Magnetic Resonance Perfusion lmaging in Acute Ischemic Stroke Using Continuous Arterial Spin Labeling

JA Chalela, DC Alsop, JB Gonzales-Atavales, JA Maldjian, SE Kasner, JA Detre

Department of Neurology, University of Pennsylvania Medical Center, 3400 Spruce St, Philadelphia, PA 19104.

Stroke 2000; 31: 680 - 7.

Background and purpose. Continuous arterial spin-labeled perfusion MRI (CASL-PI) uses electromagnetically labeled arterial blood water as a diffusible tracer to noninvasively measure cerebral blood flow (CBF). We hypothesized that CASL-PI could detect perfusion deficits and perfusion/diffusion mismatches and predict outcome in acute ischemic stroke.
Methods. We studied 15 patients with acute ischemic stroke within 24 hours of symptom onset. With the use of a 6-minute imaging protocol, CASL-PI was measured at 1.5T in 8-mm contiguous supratentorial slices with a 3.75 mm in-plane resolution. Diffusion-weighted images were also obtained. Visual inspection for perfusion deficits, perfusion/diffusion mismatches, and effects of delayed arterial transit was performed. CBF in predetermined vascular territories was quantified by transformation into Talairach space. Regional CBF values were correlated with National Institutes of Health Stroke Scale (NIHSS) score on admission and Rankin Scale (RS) score at 30 days.
Results. Interpretable CASL-PI images were obtained in all patients. Perfusion deficits were consistent with symptoms and/or diffusion weighted imaging abnormalities. Eleven patients had hypoperfusion, 3 had normal perfusion, and I had relative hyperperfusion. Perfusion/diffusion mismatches were present in 8 patients. Delayed arterial transit effect was present in 7 patients; serial imaging in 2 of them showed that the delayed arterial transit area did not succumb to infarction. CBF in the affected hemisphere correlated with NIHSS and RS scores (P = 0.037 and P = 0.003, Spearman rank correlation). The interhemis-pheric percent difference in middle cerebral artery CBF correlated with NIHSS and RS scores (P = 0.007 and P = 0.0002, respectively). 
Conclusions. CASL-PI provides rapid noninvasive multislice imaging in acute ischemic stroke. It depicts perfusion deficits and perfusion/diffusion mismatches and quantifies regional CBF. CASL-PI CBF asymmetries correlate with severity and outcome. Delayed arterial transit effects may indicate collateral flow.
 
 
 

Thrombolytic Reversal of Acute Human Cerebral lschemic Injury Shown by Diffusion/Perfusion Magnetic Resonance Imaging

CS Kidwell, JL Saver, J Mattiello

UCLA Stroke Center. 710 Westwood Plaza, UCLA Medical Center, Los Angeles, CA 90095.

Ann Neurol 2000; 47: 462 - 9.

Diffusion magnetic resonance imaging provides an early marker of acute cerebral ischemic injury. Thrombolytic reversal of diffusion abnormalities has not previously been demonstrated in humans. Serial diffusion and perfusion imaging studies were acquired in patients experiencing acute hemispheric cerebral ischemia treated with intra-arterial thrombolytic therapy within 6 hours of symptom onset. Seven patients met inclusion criteria of prethrombolysis and posttrombolysis magnetic resonance studies, presence of large artery anterior circulation occlusion at angiography, and achievement of vessel recanalization. Mean diffusion-weighted imaging lesion volume at baseline was 23 cm3 (95 % confidence interval [95 % CI], 8 - 38 cm3) and decreased to 10cm3 (95 % Cl, 3 - 17 cm3) 2.5 to 9.5 hours after thrombolysis. Mean apparent diffusion coefficient lesion volume decreased from 9cm3 (95 % Cl, 2 - 16 cm3) at baseline to 1 cm3 (95 % Cl, 0.4 - 2 cm3) early after thrombolysis. A secondary increase in diffusion volumes was seen in 3 of 6 patients at day 7. In all 4 patients in whom perfusion imaging was obtained before and after treatment, complete resolution of the perfusion deficit was shown. Diffusion magnetic resonance signatures of early tissue ischemic injury can be reserved in humans by prompt thrombolytic vessel recanalization. The ischemic penumbra includes not only the region of diffusion/perfusion mismatch, but also portions of the region of initial diffusion abnormality.
 
 
 

Early X-Ray Hypoattenuation of Brain Parenchyma Indicates Extended Critical Hypoperfusion in Acute Stroke

M Grond, R von Kummer, J Sobesky

Klinik und Poliklinik f¼r Neurologie der Universit¤t zu K¶ln, Joseph-Stelzmann Strasse 9, D-50924 Koln, Germany.

Stroke 2000; 31: 133 - 9.

Background and Purpose. The presence of early x-ray hypoattenuation is an important selection criterion for thrombolytic therapy. However, knowledge about the pathophysiological constellation reflected by this hypoattenuation is lacking. Our objective was to study the relationship between the presence of early CT hypoattenuation and the volumes of critical hypoperfusion.
Methods. In 32 patients with acute ischemic stroke, CT was performed 20 to 170 minutes (mean, 94 minutes) after symptom onset, and [15O]H2O-PET 20 to 120 minutes (mean, 67 minutes) later. CTs were scrutinized for the presence of hypoattenuation. On the PET scans, the volumes of critical cortical hypoperfusion were assessed.
Results. CT hypoattenuation was present in 18 patients, (56 %), all of whom had critical cortical hypoperfusion and developed infarction. Of the 14 patients with normal CTs, critical hypoperfusion was found in 6, and 7 developed infarction. The mean volumes of critically hypoperfused tissue differed significantly (P  = 0.0001, Wilcoxon test) between the CT normal (mean 13.9 cm3, range 0 to 71 cm3) and the CT abnormal (mean 116.3 cm3, range 4 to 389 cm3) groups.
Conclusion. Early presence of hypoattenuation is indicative of extended volumes of critically hypoperfused cortical tissue. The extent of hypoperfusion may exceed that of hypoaftenuation, and some of that tissue might still be salvageable.
 
 
 

Magnetic Resonance Imaging of Intracranial Hypotension Syndrome with Pathophysiological Correlation

TC Brightbill, S Goodwin, RG Ford

Department of Radiology, Baptist Medical Center-Montclair, 800 Montclair Road, Birmingham, AL 35213

Headache 2000; 40: 292 - 9.

Objective. To correlate the pathophysiology of intracranial hypotension syndrome with abnormalities in the brain and spine found through magnetic resonance imaging.
Methods. In a series of 11 patients with intracranial hypotension syndrome, brain magnetic resonance scans were evaluated for the thickness, distribution, morphology, and pattern of meningeal enhancement coincident with subdural fluid collections and the descent of the brain toward the skull base. Spinal magnetic resonance studies were reviewed for extra-arachnoid fluid collections, meningeal enhancement, and distended epidural veins.
Results. Diffuse, continuous dural-arachnoid enhancement was present in all patients with abnormal brain studies. The dura was thickest in patients with very low intracranial pressures. Subdural fluid collections and descent of the brain were seen in patients with the thickest meninges and were not present in the absence of meningeal enhancement. Extra-arachnoid or paraspinal fluid collections were found in all patients who had spinal magnetic resonance scans.
Conclusion. In the brain, diffuse dural-arachnoid enhancement is the most common imaging abnormality and is probably the earliest magnetic resonance manifestation of intracranial hypotension syndrome, while subdural fluid collections and descent of the brain are indicators of a more severe hypotensive state. Extra-arachnoid fluid collections are common spinal imaging abnormalities.
Role of computed tomographic scanning of the thorax prior to bronchoscopy in the investigation of suspected lung cancer

C Laroche, I Fairbairn, H Moss

Thoracic Oncology Unit, Papworth and Addenbrooke's NHS Trusts, Cambridge CB3 8RE, UK

Thorax 2000; 55: 359 - 63.

Background. Fibreoptic bronchoscopy (FOB) is the usual initial investigation of choice in patients with suspected endobronchial carcinoma, but it is often non-diagnostic. Once a positive diagnosis has been made, many patients undergo staging by computed tomographic (CT) scanning to assess the extent of the disease and its suitability for radical treatment. To determine whether initial CT scanning before FOB is a cost effective way of reducing subsequent unnecessary or unhelpful invasive diagnostic procedures, a study was undertaken in 171 patients with suspected endobronchial carcinoma.
Methods. A randomised two group study was performed with all patients undergoing an initial CT staging scan. In group A the CT scans were reviewed before FOB, allowing cancellation or a change to an alternative invasive procedure if considered appropriate. In group B all patients proceeded to FOB with the bronchoscopist blinded to the result of the CT scan until after the procedure.
Results. In group A six of 90 patients (7 %) required no further investigations as the CT scan was either normal, consistent with benign disease, or consistent with widespread metastatic disease. Of the remainder, bronchoscopy was diagnostic in 50 of 68 (73 %) in group A compared with 44 of 81 (54 %) in group B (p = 0.015). Overall, a positive diagnosis was made after a single invasive investigation in 64 of 84 patients (76 %) in group A compared with only 45 of 81 patients (55 %) in group B (p = 0.005). Only seven of 90 patients (8 %) in group A required more than one invasive investigation compared with 15 of 81 patients (18.5 %) in group B. In patients with malignancy, bronchoscopy was more likely to be diagnostic in group A (50 of 56 patients (89 %)) than in group B (44 of 62 (71 %); p = 0.012), and the diagnosis was more frequently made on the initial invasive investigation (group A, 63 of 70 (90 %); group B, 44 of 62 (71%); p = 0.004). Because of the lower number of invasive procedures performed in group A than in group B, the cost of performing CT scans before FOB in all patients in group A would have equated to a projected cost of performing CT scans in 60 % of patients after FOB in group B.
Conclusion. Performing initial CT thoracic scans before bronchoscopy in patients with suspected endobronchial malignancy is a cost effective way of improving diagnostic yield from invasive diagnostic procedures and occasionally may obviate the need for any further investigation.
 
 

Clinical and radiological characteristics of lung disease in inflammatory bowel disease

R Mahadeva, G Walsh, CDR Flower, JM Shneerson

Respiratory Medicine Unit, Clinic 2A, Box 40, Addenbrookes Hospital, Hills Roads, Cambridge C82 2QQ UK

Eur Respir J 2000; 15: 41 - 8.

The pulmonary associations of inflammatory bowel disease (IBD) are poorly characterized. The clinical, physiological and high-resolution computed tomographic thorax characteristics of the lung disease in patients with IBD presenting with respiratory symptoms are described.
Detailed clinical information was obtained and standard pulmonary physiological tests and thorax high-resolution computed tomography performed on 14 patients with ulcerative colitis (UC) and three with Crohn's disease (CD), 10 male, aged 38 - 83 yrs.
Respiratory symptoms had been present for 2 - 50 yrs and extraintestinal manifestations were present in three (17.6 %). Normal pulmonary physiology (six patients) was associated with the high resolution computed tomographic changes of bronchiectasis, mosaic perfusion and air trapping suggestive of obliterative bronchiolitis and a pattern of centrilobular nodules and branching linear opacities ("tree in bud" appearance) suggestive of either cellular bronchiolitis or bronchiolectasis with mucoid secretions. Bronchiectasis was found in 13 patients (11 UC, 2 CD), 11 had air trapping and five had a "tree in bud" appearance on computed tomography. One patient had a predominantly peripheral reticular pattern at the lung bases similar to that found in cryptogenic fibrosing alveolitis and one patient had a mixed reticular and groundglass pattern in the midzones with a  patchy distribution in the central and peripheral portions of the lungs with air trapping. Eleven patients (three with alveolitis) exhibited a clinical and/or physiological response to steroids. 
Pulmonary abnormalities in ulcerative colitis and Crohn's disease can present years after the onset of the bowel disease and can affect any part of the lungs. Early recognition is important as they can be strikingly steroid-responsive.
 
 

MR-angiography in the diagnosis of pulmonary embolism

P Steiner, TH Hany, G McKinnon, F Follath, JF Debatin

Department of Internal Medicine, University Hospital Zurich, R¤mistr. 100, CH-8091 Zurich, Switzerland.

Intensivmed 2000; 37 (Suppl. 1): 163 - 170.

The purpose of this article is to describe the role of 3 dimensional (3D), breathhold, contrast enhanced magnetic resonance angiography (MRA) in the diagnosis of acute pulmonary embolism. In a volunteer study, two MRA techniques were adopted. One of which enabled acquisition of the pulmonary vasculature in 18 seconds. The other technique was coupled with a higher spatial resolution, leading to a scan time of 23 seconds. Additionally, the impact of breathing motion on vessel delineation was assessed. The breathheld 23 second scans revealed excellent image quality and near complete visualization of central and segmental, as well as 81 % of subsegmental, pulmonary arteries. Imaging time can be shortened to 18 seconds with only marginal loss in visualization performance (p < 0.05). Respiratory motion was found to cause significant worsening of image quality and vessel detectability. To maintain relevance in a clinical setting, imaging time can be minimized at the cost of a reduction in spatial resolution. According to data available from patient studies, the sensitivity, specificity, positive and negative predictive values of 3D MRA in comparison to conventional angiography amounts to 100, 95, 87, and 100 %, respectively.
However, breathhold duration and spatial resolution need further optimization if 3D MRA should replace conventional angiography as the gold standard in the future.
Conclusion. The preliminary experience suggest that gadolinium-enhanced, three dimensional, breathhold, magnetic resonance angiography shows promise as a safe, rapid, accurate and cost-effective imaging technique for the diagnosis of pulmonary embolism. In combination with its ability to perform deep venous studies and the potential aspect of MR-perfusion studies of the lung parenchyma, pulmonary MRA might in the future turn out to be the "one stop shop' for diagnosing pulmonary embolism.
 
 

Suspected acute pulmonary embolism: cost-effectiveness of chest helical computed tomography versus a standard diagnostic algorithm incorporating ventilation-perfusion scintigraphy

G Larcos, KKG Chi, A Shiell, G Berry

Department of Nuclear Medicine and Ultrasound, Westmead Hospital, Westmead, NSW 2145

Aust NZ J Med 2000; 30: 195 - 201.

Background. There is a controversy regarding the investigation of patients with suspected acute pulmonary embolism (PE).
Aims. To compare the cost-effectiveness of alternative methods of diagnosing acute PE. Chest helical computed tomography (CT) alone and in combination with venous ultrasound (US) of legs and pulmonary angiography (PA) were compared to a conventional algorithm using ventilation-perfusion (V/Q) scintigraphy supplemented in selected cases by US and PA.
Methods. A decision-analytical model was constructed to model the costs and effects of the three diagnostic strategies in a hypothetical cohort of 1000 patients each. Transition probabilities were based on published data. Life years gained by each strategy were estimated from published mortality rates. Schedule fees were used to estimate costs.
Results. The V/Q protocol is both more expensive and more effective than CT alone resulting in 20.1 additional lives saved at a (discounted) cost of $ 940 per life year gained. An additional 2.5 lives can be saved if CT replaces V/Q scintigraphy in the diagnostic algorithm but at a cost of $ 23,905 per life year saved.
Conclusions. The more effective diagnostic strategies are also more expensive. In patients with suspected PE, the incremental cost-effectiveness of the V/Q based strategy cost over CT alone is reasonable in comparison with other health interventions. The cost-effectiveness of the supplemented CT strategy is more questionable.
 
 

18-FDG positron emission tomography in the evaluation of malignant pleural diseases - a pilot study

A Carretta, C Landoni, G Melloni

Department of Thoracic Surgery, University of Milan. Scientific Institute H San Raffaele, Via Olgettima. 60-20132 Milan, Italy

European Journal of Cardio-thoracic Surgery 2000; 17: 377 - 83.

Objective. The diagnostic approach to pleural diseases may be difficult. The CT scan, which is the current diagnostic technique, has limited accuracy both in the differentiation between benign and malignant pleural diseases and in the diagnosis of primary and metastatic pleural neoplasms. lnvasive procedures, such as thoracoscopy, are therefore frequently required to complete the diagnostic approach. The increasing incidence of malignant pleural mesothelioma has led to the development of new treatment strategies, which still need to be fully validated. There is, therefore, a need for new diagnostic techniques that can lead to a definite diagnosis and a satisfactory evaluation of the response to treatment. Encouraging results have been reported with the F-1 8-labeled analogue of 2-deoxyglucose (18-FDG) positron emission tomography (PET) in the evaluation of chest tumors such as lung cancer. The aim of this study was to evaluate the role of 18-FDG PET in the diagnostic assessment of pleural diseases.
Methods. Patients with CT scan evidence of pleural thickening, or fluid, entered a study to evaluate the accuracy of 18-FDG PET in diagnosing pleural diseases. Image analysis was performed both with visual interpretation and using a semiquantitative method, standardized uptake values (SUV), on coronal, sagittal and axial reconstructions. The results of PET imaging were compared to histological data. PET was also performed before and after treatment in patients who underwent chemotherapy to evaluate the accuracy of this technique in the assessment of the response.
Results. Fourteen patients entered the study. Histology demonstrated a malignant pleural disease in 13 patients; malignant pleural mesothelioma  in ten patients, adenocarcinoma  in two and liposarcoma  in one. Benign pleural disease was diagnosed in the remaining patient. PET assessment demonstrated significant 18FDG uptake in 12 of the 13 patients with a malignant disease, also revealing distant metastases in two of them. A false-negative result was observed in a patient with an epithelial mesothelioma. The overall accuracy wad 92 %. A benign pleural disease without significant uptake was correctly diagnosed in another patient. An aspecific uptake was observed in two patients who had undergone pleurectomy and intrapleural chemotherapy. A decreased tracer uptake was observed after chemotherapy in four patients.
Conclusions. These preliminary results demonstrate that 18-FDG PET may have a great potential, both in the differential diagnosis of pleural diseases and in the evaluation of the response to treatment. At present, however, histological thoracoscopic diagnosis remains mandatory before planning treatment. Further studies in larger groups of patients are needed to draw definite conclusions on the role of PET in the assessment of pleural diseases.
The Role of Staging CT Scans in the Treatment of Prostate Cancer: A Retrospective Audit

RJ Burcombe, PJ Ostler, AW Ayoub, PJ Hoskin

Centre for Cancer Treatment, Mount Vernon Hospital, Rickmansworth Road, Northwood, Middlesex HA6 2RN, UK

Clinical Oncology 2000; 12: 32 - 5.

A retrospective audit was performed to review the use of diagnostic and planning computed tomographic (CT) scans in the management of patients treated with radical radiotherapy for prostate cancer at Mount Vernon Hospital. All 97 patients had a planning CT scan. In addition, 85 also underwent a diagnostic scan for staging purposes. Fifty-one (60 %) had both pelvic and abdominal imaging.
Twenty abnormalities were detected in 19 patients. Although 13 of these were "malignant" abnormalities considered to represent metastatic disease, only four altered the treatment intent. Overall, only 4 % of patients were denied radical treatment of the basis of CT findings. Malignant intra-abdominal disease was not identified in the absence of metastatic disease in the pelvis.
This study confirms that abdominal CT scans contribute very little useful prognostic information in men with prostate cancer, and are not necessary for routine staging prior to radiotherapy. We propose that a single CT scan of the pelvis in patients who are suitable for radical radiotherapy can provide adequate information for both staging and planning purposes, resulting in significant reductions in cost, radiation exposure and scanner time.
 
 

Magnetic Resonance Imaging of Prostatic Cancer: Does Detection Vary between High and Low Gleason Score Tumors?

S Ikonen, P K¤rkk¤inen, L Kivisaari

Department of Radiology, Helsinki University Central Hospital, P.O. Box 380, H-00029 Hyks, Finland

The Prostate 2000; 43: 43 - 8.

Background. Both Gleason score and prostate-specific antigen (PSA) concentration are prognostic factors for prostate cancer. We assessed our ability to localize cancer lesions based on Gleason scores and PSA values by endorectal coil magnetic resonance imaging (MRI). We also evaluated whether the size of the prostate affects tumor detectability.
Methods. We compared the findings of MRI and histopathological results of radical prostatectomy specimens from 63 patients; they were divided into four groups, based on Gleason score and also on serum PSA concentration. Furthermore, the possible effect of prostatectomy specimen weight on MRI interpretation was examined.
Results. A highly significant difference appeared in detection of cancer lesions based on their differentiation grade. No statistically significant difference existed between PSA groups in detection of tumors, but the large size of the prostate seemed to render image interpretation more difficult.
Conclusion. Endorectal MRI detects poorly differentiated prostate cancer lesions more accurately than clinically insignificant tumors.

The positive yield of imaging studies in the evaluation of men with newly diagnosed prostate cancer: a population based analysis

PC Albertsen, JA Hanley, LC Harlan

Division of Urology, University of Connecticut Health Center, Farmington Connecticut

The Journal of Urology 2000; 163: 1138 - 43.

Purpose. We determine the positive yield of imaging studies performed on men with newly diagnosed prostate cancer.
Materials and methods. A prospective, population based survey was conducted on 3,690 men with prostate cancer diagnosed between October 1, 1994 and October 31, 1995. Cases were identified by the rapid case ascertainment systems used in 6 geographic regions participating in the Surveillance, Epidemiology and End Results Program. Based on information captured in primary medical record reviews we estimated the positive yield of bone scans, computerized tomography (CT) and magnetic resonance imaging.
Results. The positive yield of bone scan and CT was less than 5 % and 12 %, respectively, for all men with prostate specific antigen (PSA) 4 to 20 ng./ml., and less than 2 % and 9 %, respectively, for those who also had a Gleason score of 6 or less. Only men with PSA greater than 50 ng./ml. and those with Gleason scores 8 to 10 and PSA greater than 20 ng./ml. had positive yields greater than 10 % and 20 % for bone scan and CT, respectively.
Conclusion. Imaging studies designed to identify metastases and/or extracapsular extension in men with newly diagnosed prostate cancer frequently have a low positive yield. Wide variations exist in the use of imaging studies and are associated with tumor factors, such as Gleason score and serum PSA, and nontumor factors, such as state of residence. More extensive cost-effectiveness analyses are needed to define appropriate guidelines for ordering imaging studies to optimize the positive yield among men with newly diagnosed prostate cancer.
 
 

Limitations of computerized tomography in staging invasive bladder cancer before radical cystectomy 

ML Paik, MJ Scolieri, SL Brown, JP Spirnak, MI Resnick

Department of Urology, Case Western Reserve University, School of Medicine, Cleveland, Ohio

The Journal of Urology 2000; 163: 1693 - 6.

Purpose. Computerized tomography (CT) of the abdomen and pelvis is often routine in the preoperative staging assessment of invasive transitional cell carcinoma of the bladder. We determine the accuracy of staging CT findings, usefulness before planned extirpative surgery and impact on surgical management of this disease.
Materials and methods. We retrospectively reviewed the medical records, including radiographic, operative and pathological reports, of 82 consecutive cases. All patients presented with muscle invasive bladder tumors, were considered candidates for radical cystectomy and underwent preoperative staging CT of the abdomen and pelvis between July 1994 and June 1998. The ability of CT to provide additional staging information in terms of depth of tumor invasion, local extent of tumor, pelvic lymph node involvement and distant metastases was examined. We determined whether CT findings altered surgical management for individual patients.
Results. CT was able to discriminate depth of invasion in only 1 patient (1.2 %) and correctly identified extravesical tumor spread in 4 (4.9 %). Lymph node and distant metastases were accurately determined in 4 (4.9 %) and 2 (2.4 %) cases, respectively. The overall accuracy of CT was 54.9 %, with an under staging and over staging rate of 39.0 % and 6.1 %, respectively. CT provided accurate, additional staging information in only 8 cases (9.8 %). Surgical management was altered in 3 cases (3.7 %) and only 1 (1.2 %) avoided an unnecessary operation as a result of CT findings.
Conclusion. Staging CT of the abdomen and pelvis in patients with invasive bladder carcinoma has limited accuracy, mainly because of its inability to detect microscopic or small volume extravesical tumor extension and lymph node metastases. CT tends to under stage advanced disease and failed to alter surgical management in nearly all of our cases.
 
 

Is the Renal Space Closed?

R Wolfram-Gabel, J-L Kahn, E Rapp

Institut d'Anatomie Normale, Faculty of Medicine, University Hospitals, Strasbourg, France

Clin Anat 2000; 13: 168 - 76.

The aim of this study is to verify the aperture or the closure of the renal space. The study is undertaken on histological sections of feruses in the horizontal and sagittal planes. On each side, the kidney and the suprarenal gland are disposed in a space that is closed on all sides. The anterior and posterior layers of the renal fascia fuse at the upper pole of the space to become continuous with the inferior fascia of the diaphragm. Likewise, they merge at the lower pole and at the lateral border of the space to become continuous with the fasciae of the parietal muscles. At the medial border of the space, the two layers merge to continue medially with the peri-aortocaval connective tissue; they penetrate the hilum and beneath it enclose the ureter.
 
 

Heterogeneity of Renal Cortical Circulation in Hypertension Assessed by Dynamic Computed Tomography

S Kojima, Y Yoshitomi, M Yano

Department of Clinical Research, Tohsei National Hospital, Nagasawa 762 - 1, Shimizu-cho, Sunto-gun, Shizuoka, 411 - 8611, Japan.

Am J Hypertens 2000; 13: 346 - 52.

The aim of this study was to assess the grade of heterogeneous disturbance in the renal cortical circulation using dynamic computed tomography and to investigate the relationship between the heterogeneity of renal cortical circulation and hypertension. We studied 125 patients who underwent dynamic computed tomography (CT) for various abdominal diseases and had no serious hemodynamic abnormalities. In dynamic computed tomography under appropriate conditions, each pixel (image element), less than 1 mm2, has a CT number that is in proportion to the concentration of contrast media, which reflects the blood volume in the pixel. The image was constructed at the hilus level about 50 s after the start of a continuous infusion of contrast medium. The mean and standard deviation were calculated from the CT numbers in the renal cortex. The coefficient of variation, ie, the standard deviation divided by the mean value, was used as the index of the heterogeneity of renal cortical circulation. The coefficient of variation was significantly (P < .001) greater in the hypertensive patients (n = 48, 0.174 + 0.006 [mean + SE]) than in normotensive subjects (n = 77, 0.140 + 0.004). The coefficient increased in parallel with the patient's age and with the grade of renal surface irregularity. In the patients whose serum creatinine levels were normal, this parameter also had a significant relationship (r = 0.367, P < .0001) with serum creatinine. These results suggest that the heterogeneity of renal cortical circulation is increased in hypertension and is also associated with aging. This parameter may become a sensitive indicator to detect slight deterioration in the renal cortical circulation.
Color-Coded Duplex Ultrasonography of the Origin of the Vertebral Artery: Normal Values of Flow Velocities.

Valerio Kuhl, Anke Visbeck, Barbara Tettenborn, B Martin Eicke, Stefanie Meckes

J. Neuroimaging 2000,10:17-21.

The introduction of color-coded duplex ultrasonography has improved the ease of performing ultrasound investigations of the vertebral arteries. So far, normal values of flow velocities have been reported only for the intertransverse region of the vertebral artery (V2 segments). Atherosclerotic disease at the origin of the vertebral arteries (V0 segment) is frequent and is one of the risk factors for vertebrobasilar ischemic disease. Normal values of flow velocities of the vertebral artery origin are needed to assess pathologic findings, such as vertebral artery origin stenosis or dissection. The aim of this study was to describe the normal flow velocities of vertebral artery origin (V0 segment) and the pre- (V1 segment) and intertransverse (V2 segment) part in 50 age-matched neurologic patients (mean age 54) without ischemic cerebral disease. The V0 segment could be visualized in 46 persons (92 %) on the right side and in 43 (86 %) on the left. The peak systolic blood velocity ranged from 30 to 100 cm/s (mean 63.6 + 17.5 cm/s), and end-diastolic blood velocity, ranged from 10 to 35 cm/s (mean 16.1 + 5.l cm/s). Analysis of side-to-side differences showed no significant differences of flow velocities in all subjects. It is concluded that color duplex ultrasonography is a feasible method to insonate the origin of the vertebral artery, and that nomogram data could be established. It is suggested that color-coded duplex ultrasonography of the vertebral artery origin should be performed in all patients with clinical symptoms or signs of vertebrobasilar ischemic disease. Nevertheless, further studies are needed to determine the normal and pathologic values of flow velocities of the vertebral artery origin and their reproducibility.

A twenty-year history of alveolar echinococcosis: analysis of a series of 117 patients from eastern France.
Solange Bresson-Hadni, Dominique-Ang¨le Vuitton, Brigitte Bartholomot, Bruno Heyd, Denis Godart, Jean-Philippe Meyer, Stefan Hrusovsky, Marie-CIaude Becker, Georges Mantion, Dani¨le Lenys and Jean-Philippe Miguet

Eur. J. Gastroenterol Hepatol 12:327-36.

Objectives. Alveolar echinococcosis of the liver is a very rare and severe parasitic disease due to the growth of the larva of Echinococcus multilocularis. The aim of this paper was to describe a 20-year study of the epidemiological, clinical and therapeutic aspects of alveolar echinococcosis in eastern France.
Design. One hundred and seventeen consecutive cases, diagnosed and followed in our liver unit, were studied from 1972 to 1993.
Methods. Data from 85 patients followed since 1983 (period B) were compared to data from a first series of 32 patients (period A) collected from 1972 to 1982; 1983 was chosen as the cut-off year because of the numerous changes that occurred in the diagnosis, follow-up and treatment of the disease at this time, in particular the introduction of parasitostatic benzimidazoles.
Results. The results of patient follow-up were evaluated in December 1997. The cumulative prevalence was 2.5 per 100000 persons in period A whereas it reached 6.6 per 100000 in period B. The annual incidence in period 6 was 7.3 on average, compared with 2.7 in period A. Twenty-nine per cent of patients from period B were asymptomatic at the time of diagnosis compared with 10 % in period A. This change was correlated with less advanced liver lesions, and was related to the extensive use of abdominal ultrasound, and from 1987, serological screening. Curative resections were performed in 24 % of the cases in period B versus only 3 % in period A. From 1986, liver transplantations were performed in eight patients from period A and 13 patients from period B. In period B, palliative surgery was frequently replaced by radiological non-operative procedures to treat abscesses and jaundice. From 1982, 73 patients received benzimidazoles for a period of time ranging from 4 to 138 months. Stabilization of the lesions was observed in two-thirds of the patients. Episodes of jaundice or digestive haemorrhage due to portal hypertension were 31.5 and 11 times less frequent respectively in patients from period B compared with period A. Actuarial survival at 5 years improved from 67 % in period A to 88 % in period B in patients of similar age. Conclusions. Radical changes in the diagnosis and the management of alveolar echinococcosis have occurred during the last decade. Together they have contributed to an improvement in the status of the patients affected by this very severe parasitic disease.
 
 

Local Staging of Rectal Cancer with Transrectal Ultrasound and Endorectal Magnetic Resonance Imaging: Comparison with Histologic Findings.

Gian Franco Gualdi, Emanuele Casciani, Antonio Guadalaxara, Carlo d'Orta, Elisabetta Polettini, Giuseppe Pappalardo

Dis Colon Rectum 2000; 43:338-45.

Purpose. The aim of the present study was to compare the accuracy of endorectal coil magnetic resonance imaging with transrectal ultrasound in staging rectal carcinoma.
Methods. Twenty-six consecutive patients with rectal carcinoma, histologically proven by endoscopic biopsy, were staged with both endorectal coil magnetic resonance imaging and transrectal ultrasound and then underwent radical surgery. The preoperative staging was compared with histologic findings of the operative specimen according to TNM classification.
Results. Endorectal coil magnetic resonance imaging showed better results but was not statistically significantly different from transrectal ultrasound in evaluating T accuracy, 84.6 vs 76.9 %: four over-staged and no understaged cases for the former and five overstaged cases and one understaged case for the latter. Both procedures showed similar results in evaluating N: 81 % sensitivity and 66 % specificity for endorectal coil magnetic resonance imaging and 72 % sensitivity and 80 % specificity for transrectal ultrasound.
Conclusions. An accurate locoregional staging of rectal cancer is essential for the planning of optimal therapy for rectal cancer. Endorectal coil magnetic resonance imaging and transrectal ultrasound showed similar results; the former is more expensive, whereas the latter is operator dependent. At present the use of endorectal coil magnetic resonance imaging seems to be justified only in selected low rectal cancers where transrectal ultrasound yielded doubtful results. However, a more extensive study is necessary to compare the advantages of these diagnostic techniques. 
Key words: Rectum. Rectal cancer. MRI surface coil. Transrectal ultrasound.
 
 

Phase I Clinical Trial of Allogeneic Mixed Lymphocyte Culture (Cytoimplant) Delivered by Endoscopic Ultrasound - Guided Fine-Needle Injection in Patients with Advanced Pancreatic Carcinoma.

Kenneth J Chang, Phuong T Nguyen, James A Thompson, Thomas T Kurosaki, Linda R Casey, Edwin C Leung, Gale Granger

Cancer 2000;88:1325-35.

Background. To the author's knowledge, there are no other published clinical studies that have employed either systemic or local biologic response modifiers in the treatment of patients with pancreatic carcinoma. The purpose of this study was to determine the feasibility and safety of allogeneic mixed lymphocyte culture (cytoimplant) delivered by endoscopic ultrasound (EUS) - guided fine-needle injection (FNI) in patients with advanced pancreatic carcinoma.
Methods. Eight patients with unresectable adenocarcinoma of the pancreas were enrolled: 4 patients in Stage II, 3 in Stage III, and 1 in Stage IV. Cytoimplants were delivered locally into the tumor using a novel EUS-guided FNI technique. Escalating doses of 3, 6, or 9 billion cells were implanted into the pancreatic tumor by a single EUS-guided FNI. Toxicity (modified National Cancer Institute criteria) was assessed at Day 1, Week 1, and Months 1 and 3. Clinical end-points included Karnofsky performance status (KPS), CA 19-9, tumor response (computed tomography and/or EUS), and survival with follow-up examinations and imaging tests on months 3, 6, 9, 12, and 24. 
Results. There were no bone marrow, hemorrhagic, infectious, renal, cardiac, or pulmonary toxicities. There were 3 transient Grade 3 gastrointestinal toxicities, and 3 patients had transient episodes of hyperbilirubinemia that were reversed by replacement of biliary stents. Seven of 8 patients (86 %) experienced low grade fever that responded to acetaminophen, and all fever was resolved within the first 4 weeks. There were no procedure-related complications. There were 2 partial responses and 1 minor response, with a median survival of 13,2 months.
Conclusions. A single injection of cytoimplant immunotherapy by EUS-guided FNI appears to be feasible and is not associated with substantial toxicity.
 
 

Imaging Changes in the Pancreas in Cystic Fibrosis: A Retrospective Evaluation of 55 Cases Seen Over a Period of 9 Years.

Jean Feigelson, Yvette P(c)cau, Myriam Poquet, Patricia Terdjman, Jacqueline Carr¨re, Jean-Pierre Chazalette and Claude Ferec

JPGN 30:145-151, 2000 c 2000 Lippincott Williams & Wilkins, Inc.

Background. Pathologic changes of the pancreas have been observed as early as the recognition of the disease termed initially "cystic fibrosis of the pancreas". Atrophy of the gland and its fatty infiltration were considered as usual features. The aim of this study was to follow-up the evolution of cystic fibrosis pancreas and to define its successive stages in correlation with the clinical, biochemical, and imaging findings.
Methods. Fifty-five patients were followed up during 9 years. The patients'genetic backgrounds were systematically performed. Blood lipase levels were analyzed systematically at each consultation of the patients and in the event of bouts of abdominal pains. Imaging using mainly echograms and tomodensitometric scans were regularly performed: echograms every 6 months, and tomodensitometric scans every 1 to 2 years. Magnetic resonance imaging was performed in four patients. 
Results. Five groups of patients were identified on the basis of tomodensitometric scan findings: normal pancreas (n = 4), incomplete lipomatosis of the pancreas (n = 9), complete lipomatosis of the pancreas (n = 23), cystic pancreas (n = 5), macrocystic pancreas (n = 1), atrophic pancreas (n = 1), atrophic pancreas (n = 13). Pancreas exocrine function was not correlated with findings. Forty episodes of pancreatitis were observed in seven patients. They had bouts of abdominal pain and elevation of lipase levels. Five of these patients were composite heterozygotes (D508/other). Incomplete lipomatosis represents an intermediate stage leading toward complete lipomatosis or toward atrophy after pancreatitis.
Conclusions. Studies of pancreatic function should be performed routinely in cystic fibrosis, especially in pancreatic sufficiency or in patients with normal pancreas images. Acute pancreatitis should be diagnosed and properly identified to be differentiated from other acute abdominal syndromes occurring in cystic fibrosis.

50 % of the cases. These data had a direct influence on surgical treatment. Histologic examination showed that, in 28 out of 29 cases, fibrosis was the most dominant component of the irradiated lesions, varying by more than 50 to 100 % of the lesion (four cases pTO). A comparison of postradiation endorectal ultrasound with histopathology revealed that fibrosis became the morphologic basis of ultrasound images; therefore, after radiotherapy, what endorectal ultrasound staged was no longer the tumor but the extent of fibrosis in the rectal wall. A histopathologic examination showed that the residual tumor, when present, was always within the fibrosis, never outside or separate from it. Postradiation endorectal ultrasound showed echo-pattern changes. Some of the changes (more echogenic and nonhomogeneous lesions) were histologically related to the persistence of the tumor to a considerable degree; other changes (reappearance of parietal layers) were related to complete sterilization of lesions in two of three cases.
Conclusions. From the morphologic and quantitative point of view, postradiation endorectal ultrasound provides oncologists and surgeons useful information to assess treatment effectiveness and plan the surgical approach. From the tumor staging point of view our report presents a completely new concept: that six to eight weeks after radiotherapy, endorectal ultrasound no longer stages the tumor, but rather the fibrosis that takes its place. However, postradiation endorectal ultrasound is a valid tool, because the extent of fibrosis in the rectal wall is a direct indication of the depth of residual cancer. A residual tumor, when present, is always inside the fibrosis. Finally, however as regards the capacity of endorectal ultrasound to exclude or indicate complete sterilization of the lesion, the actual significance of the echo-pattern changes we observed needs to be assessed further by studies on a large number of cases. 

Role of endoscopic ultrasound and magnetic resonance imaging in the preoperative staging of pancreatic adenocarcinoma.

NA Ahmad, JD Lewis, ES Siegelman, EF Rosato. GG Ginsberg, ML Kochman

Am J Gastroenterol 2000; 95(8):1926-31.

Objective. Endoscopic ultrasound (EUS) and magnetic resonance imaging (MRI) have both been assessed individually as staging modalities for pancreatic cancer. The aim of our study was to assess whether tumor staging by both EUS and MRI in the same cohort of patients could predict resectability and unresectability in patients with pancreatic cancer.
Methods. A review of 63 patients evaluated preoperatively with both EUS and MRI for pancreatic adenocarcinoma between January 1995 and December 1998 was done. Patients were staged as resectable or unresectable by predefined criteria. Preoperative staging by both modalities was compared to surgical outcome and the sensitivity and predictive values of each modality for determining resectability and unresectability was determined.
Results. EUS did not allow for complete T- and N-staging in 10 patients; therefore, for EUS, the final analysis was done on 63 of 73 patients (86 %). EUS correctly staged 22 of 36 patients with resectable tumors. The sensitivity of EUS for resectability was 61 %, with a positive predictive value of 69 %. All 73 patients had complete MRI examinations; therefore, the final analysis was done on all 73 patients. MRI correctly staged 30 of 41 patients with resectable tumors. The sensitivity of MRI for predicting resectability was 73 % with a positive predictive value of 77 %. MRI and EUS both predicted resectability in 18 patients, of whom 16 (89 %) were found to be resectable on surgical exploration. MRI and EUS both predicted unresectability in 17 (27 %) patients, of whom 4 (24 %) were found to be resectable on surgical exploration. When both MRI and EUS agreed on resectability, the positive predictive value for resectability was 89%. When both MRI and EUS agreed on unresectability, the positive predictive value for unresectability was 76 %.
Conclusions. Neithe r MRI nor EUS alone were highly sensitive or predictive of resectability. However, when both tests agreed on resectability, nearly all patients were found to be resectable on-surgical exploration. 
Angioplasty and stenting of the extracranial carotid arteries.     
M Henry, M Amor, C Klonaris, I Henry, I Masson, Z Chati, E Leborgne, M Hugel

Tex Heart Inst J 2000; 27(2): 150-8

We performed percutaneous transluminal angioplasty and stenting in patients with carotid artery stenosis to determine the efficacy of these techniques as an alternative to surgical endarterectomy. From April 1995 through July 1999, 315 carotid angioplasty procedures were performed (right, 151; left, 164) in 290 patients ranging in age from 40 to 93 years. Of these patients, 42 % were symptomatic and 58 % were asymptomatic. Twenty-five patients underwent bilateral procedures. The mean percentage of stenosis was 82.3 % +/- 8.7 % SD. Angioplasty and stenting were performed without cerebral protection in 165 arteries and with protection in 150. Two methods of protection were used: the Theron technique and the PercuSurge Guardwire temporary occlusion and aspiration system. Balloon dilation and stent placement were successful in 289 patients; in the last patient, severe arterial tortuosity prevented catheterization and stenting. We observed 13 periprocedural neurologic complications due to ischemia (4.2 %): 4 transient ischemic attacks (1.3 %), 4 minor strokes (1.3 %), and 5 major strokes (1.6 %), including I death. At 6 month, 210 patients had a follow-up angiogram (155) or duplex ultrasound (55). There were 10 restenoses (4.7 %), 1 of which was symptomatic and 2 of which showed mild compression of a Palmaz stent without marked stenosis. Primary and secondary 4-year patency rates were 96 % and 99 %, respectively. These results demonstrate acceptable mortality and morbidity rates related to carotid angioplasty and stenting. However, we found the risk of embolic stroke to be substantial. Cerebral protection may improve the results of carotid angioplasty and expand the indications for this procedure.

Preoperative intraarterial thrombolysis before surgical revascularization
for popliteal artery aneurysm with acute ischemia.

E Steinmetz, O Bouchot, F Faroy, L Charmasson, B Terriat, F Becker, JP Cercueil, D Krause, R Brenot, M David

Ann Vasc Surg 2000; 14(4): 360-4.
Because a poplileal artery aneurysm (PAA) generates emboli that progressively deteriorate the distal arterial network, they can constitute limb-threatening lesions. In 20 to 40 % of cases, discovery of PAA coincides with sudden occlusion and resulting acute ischemia. In 40 to 60 % of these patients, surgical revascularization fails and amputation is required. The objective of this prospective study was to assess the value of intraarterial thrombolysis to restore distal runoff before surgical revascularization. Between January 1, 1992 and December 31, 1996, we treated 15 PAA causing acute ischemia in 15 mate patients with a mean age of 66.7 years (range, 44 to 87 years). Diagnosis was documented by clinical examination and ultrasound imaging. lntraarterial thrombolysis was performed under arteriographic control through a multiperforated catheter inserted by the anterograde femoral route to the thrombus. After an initial bolus of 100-000 U of urokinase, 600.000 to 1.600.000 U was continuously infused over a period of 6 to 18 hr. Heparin sodium was administered throughout thrombolysis. Surgical revascularization was performed, within 1 to 4 days (mean, 2 days) after thrombolysis by exclusion and bypass in 14 cases and percutaneous transluminal angioplasty with stenting in 1 case. The ensuing results showed that, if performed carefully, intraarterial thrombolysis can safety prepare patients presenting with occluded PAA with acute ischemia for surgical revascularization to restore distal runoff. We use this combined technique routinely in our department. Morbidity is low in comparison with the risks of amputation.

Prenatal detection of trisomy 21: combined experience of two British hospitals.

D Roberts, SA Walkinshaw, MJ Mc Cormack and Jill Ellis

Prenat Diagn 2000:20: 17-22.

A retrospective study was performed to determine the detection rate of trisomy in two British hospitals using a combination of:
1. second trimester serum screening with maternal age, ¡FP and hCGkaryotyping for raised maternal age and high background risk of aneuploidy; and second trimester fetal anomaly ultrasonography at 18 - 22 week gestation, 36410 women with a median age of 27 years were studied.
Trisomy 21 detected by the combination of methods in both hospitals was compared with the actual number of pregnancies affected by trisomy 21, to determine the detection rate. Serum screening at the backbone of the service detected 31/48 (65 %) trisomy 21 affected pregnancies
Background. Our purpose was to weigh various monographic parameters as predicting malignant cervical lymphadenopathy and build a reliable prediction rule.
Methods. One hundred and eighty-nine cervical lymph node lesions from 125 consecutive patients were used for building the prediction model. Sonographic variables, including 15 morphologic features of B-mode, 5 vascular parameters of color Doppler mode, along with age and sex, were analyzed with multivariate logistic regression to evaluate the joint effect of a set of independent variables. A prediction rule for malignant lymphadenopathy was established, and prospective validation was assessed on a new group consisting of 100 lymph nodes from another 60 consecutive patients.
Results. The association of heterogeneous content, long transverse diameter, pathologic vascular pattern, high vascular density, and older age provided the most robust prediction value. Scoring scale was designed as 1 x (age) + 2x (vascularity index) + 3x (short axis) + 4x (vascular pattern) + 4x (internal echo) according to the parameter estimates of multivariate logistic regression analysis. Cut-off value of score i 10 as malignancy resulted in 89.2 % sensitivity and 85.2 % specificity. Prospective validation also showed satisfactory results (sensitivity, 82.9 %; specificity, 86.2 %).
Conclusions. By measuring only 4 sonographic parameters and age, this prediction rule could provide the physician a nonconfusing and reliable probability reference for managing cervical lymphadenopathy.

An economic evaluation of sonographic examination of children with suspected appendicitis.

DA Axelrod, SS Sonnad, RB Hirschl

J. Pediatr Surg, 2000, 35 (8): 1236-41.

BackgroundIPurpose. Appendicitis is the most common surgical emergency presenting in the pediatric population. Approximately one third of these patients present with equivocal signs and symptoms frequently resulting in impatient observation or additional diagnostic investigation. Although sonographic examination of patients with suspected appendicitis has been shown to be a highly accurate diagnostic modality, the cost effectiveness of this technology in the pediatric population has not been addressed. The economic value of this technology in the pediatric population has not been addressed. The economic value of this examination can be evaluated using a structured decision analysis.
Methods. The authors constructed a decision analysis model of treatment strategies for 2 groups of patients with a suspected diagnosis of acute appendicitis. Patients were categorized as either presenting with a "definitive acute abdomen" or "equivocal examination." Data drawn from published literature reports of the sensitivity and specificity of ultrasound, institution-specific cost data, and expert judgment were used to construct 2 decision trees. These data were used to determine the least costly diagnostic strategy for each group of patients, and sensitivity analysis performed to assess the robustness of the conclusions.
Results. The use of ultrasonography in patients with "an acute abdomen" is not cost efficient and results in average additional cost of $ 234 per patient. In patients with equivocal diagnoses who are discharged from the emergency room after a negative ultrasound examination finding results in an average cost savings of $ 260 when compared with admission and observation. Patients who are discharged without examination incur an average additional cost of $ 373 as a result of the high cost of a missed diagnosis resulting in a perforated appendix. 
Conclusion. The use of ultrasonography can be recommended for children with suspected appendicitis and equivocal examinations who are discharged from the emergency room after a negative examination result.

Diagnosis of nonpalpable testes in childhood: comparison of magnetic
resonance  imaging and laparoscopy in a prospective study.

S Siemer, U Humke, M Under, U Hildebrandt, N Karadiakos, M Ziegler

Eur J Pediatr Surg 2000; 10 (2): 114-8.

In a prospective study, the accuracy of magnetic resonance imaging (MRI) and laparoscopy in the diagnosis of nonpalpable testes was evaluated. Advantages and disadvantages of the two procedures were compared. 29 boys with unilateral nonpalpable testis underwent MRI. When MRI failed to demonstrate a testis, laparoscopy with a 1.9 mm mini-laparoscope was performed. All cases were verified by operative exploration of the inguinal region. MRI demonstrated 10 inguinal and 7 abdominal testes. MRI revealed no testis in 12 boys. The false positive rate was 32 %, correct negative findings were confirmed in four patients. When laparoscopy was performed, preservable testis could be demonstrated in 8 of 12 patients (1 abdominal, 7 inguinal) which otherwise were not visible on MRI. The correct positive rate was 100 %. We encountered no complications with laparoscopy. In summary, laparoscopie evaluation is recommended as the preferable method in pediatric cases of nonpalpable testes.

Role of Transesophageal Endosonography-Guided Fine-Needle Aspiration in the Diagnosis of Lung Cancer.

Annette Fritscher-Ravens, Nib Soehendra, Lars Schirrow, Parupadi V.J. Sriram, Andreas Meyer, Hans-Peter Hauber and Almuth Pforte

CHEST 2000: 117:339-345.

Study objective. Bronchoscopie methods fail to diagnose lung cancer in up to 30% of patients. We studied the role of transesophageal endosonography (EUS)-guided fine-needle aspiration (FNA; EUS-FNA) in such patients.
Design. Prospective study. The final diagnosis was confirmed by cytology, histology, or clinical follow-up.
Setting. University hospital.
Patients. Thirty-five patients (30 male and 5 female; mean age, 60.9 years; range, 34 to 88 years) with suspected lung cancer in whom bronchoscopie methods failed. Patients with a known diagnosis, recurrence of lung cancer, or mediastinal metastasis from an extrathoracic primary were excluded.
Interventions. EUS and guided FNA of mediastinal lymph nodes.
Results. The procedure was uneventful, and material was adequate in all. The final diagnosis by EUS-FNA was malignancy in 25 patients (11 adenocarcinoma, 10 small cell, 3 squamous cell, and 1 lymphoma) and benign disease in 9 patients (5 inflammatory, 2 sarcoidosis, and 2 anthracosis). Another patient with a benign result had signet-ring cell carcinoma diagnosed on pleural fluid cytology (probably false-negative in EUS-FNA). The sensitivity, specificity, accuracy, and positive and negative predictive values were 96, 100, 97, 100, and 90 %, respectively. There were no complications. Reviewing the EUS morphology, the nodes were predominantly located in levels 7 and 8, of American Thoracic Society mediastinal lymph node mapping (subcarinal and paraesophageal region). In seven patients, the punctured nodes were < 1 cm (four malignant and three benign), which are difficult to sample by other methods. The malignant nodes had a hypoechoic, homogenous echotexture.
Conclusions. EUS-FNA is a safe, reliable, and accurate method to establish the diagnosis of suspected lung cancer when bronchoscopic methods fail, especially in the presence of small nodes.

Peripheral Hypoechoic Lesions of the Prostate: Evaluation with Color and Power Doppler Ultrasound.

Jeong Yeon Cho, Seung Hyup Kim, Sang Eun Lee

Euro Urol 2000: 37: 443-448.

Objective. To assess the usefulness of color and power Doppler ultrasound in predicting the benignity and malignancy of the peripheral hypoechoic lesion of the prostate.
Methods. Thirty-nine patients who had peripheral hypoechoic lesions on transrectal ultrasound were evaluated with color and power Doppler ultrasound followed by lesion-specific transrectal ultrasound-guided biopsies. The interpretation of color and power Doppler ultrasound was not performed separately and flow signals were categorized using a combination of the two modalities. The amount of flow signals within the lesion was evaluated and categorized into three groups: increased /equal/ decreased flow compared to surrounding normal tissue on ultrasound. Doppler spectra could be obtained from the lesions in 23 patients. The amount of flow signals and resistive indexes of the spectra of the lesions were compared with those of surrounding normal tissue using the MannWhithney U test.
Results. Transrectal ultrasound-guided biopsy of the hypoechoic lesions revealed prostate cancer in 20 patients and benign prostatic diseases in 19. Flow signals within the lesions were of increasded/equal/ decreased flow compared to surrounding normal tissue in 16/2/2 in the prostate cancer group and 3/9/7 in the benign disease group, respectively. The difference was statistically significant (p = 0.0003). Resistive indexes of the lesion were 0.58 - 1.0 (mean 0.75) in the prostate cancer group and 0.57 - 1.0 (mean 0.80) in the benign disease group, and there was no significant difference between the two groups (p = 0.82). If we consider an increased flow signal within a peripheral hypoechoic lesion as a sign of prostate cancer, color power Doppler ultra-sound has a sensitivity of 80 %, a specificity of 84 %, and an accuracy of 82 %.
Conclusion. Evaluation of peripheral hypoechoic lesions of the prostate with color and power Doppler may enhance the diagnostic capability of transrectal ultrasound.

The role of colour Doppler ultrasonography in detecting prostate cancer.

K Shigeno, M Igawa, H Shiina. H Wada, T Yoneda

BJU Int 2000 Aug; 86 (3): 229-233.

Objective. To determine the usefulness of colour Doppler ultrasonography (CDUS) in detecting prostate cancer, by comparing CDUS with grey-scale transrectal ultrasonography (TRUS) and magnetic resonance imaging (MRI).
Patients and methods. In all, 278 patients who underwent prostate biopsies because of an abnormal digital rectal examination, elevated prostate specific antigen levels, and/or abnormal TRUS between May 1998 and November 1999 were evaluated. The diagnostic accuracies of TRUS, CDUS, MRI and combinations of these imaging techniques in detecting prostate cancer were compared, based on the biopsy results.
Results. Carcinoma was detected in 233 of 1696 specimens, and 87 patients were diagnosed with prostate cancer. For each detected cancer site, the sensitivity of CDUS was lower than those of other imaging techniques, but CDUS had high a specificity and positive predictive value. The combination of grey-scale TRUS and CDUS or MRI improved the sensitivity and negative predictive value. The specificity and positive predictive value of the combination of grey-scale TRUS and MRI were less than those for grey-scale TRUS alone, while those for the combination of grey-scale TRUS and CDUS were higher than those for grey-scale TRUS alone. Five tumours were isoechoic but seen as hypervascular lesions with CDUS.
Conclusion. CDUS provides information useful for detecting prostate cancer when used in combination with grey-scale TRUS, and should be included in the routine examination for prostate cancer.

Prostate blood flow characteristics in the chronic prostatitis/pelvic pain syndrome.

R Cho, Thomas S Keener, Hahn V Nghiem, Thomas Winter and John N Krieger

Journal Urology 2000; 163; 1130-3

Purpose. We determine whether the chronic prostatitis/pelvic pain syndrome is associated with abnormal prostate blood flow.
Materials and Methods. We used color Doppler ultrasonography to examine 53 patients with inflammation, 80 men without inflammation and 22 healthy controls. Images were recorded and scored using standardized criteria to characterize the degree and distribution of prostatic vascularity.
Results. Flow was observed to the entire prostatic capsule in 77 % of patients but only 18 % of flow was classified as grade 2 in 74 % of patients compared to 27 % of controls (p < 0.0001). Similar findings were noted on a Doppler spot scale, with flow classified as grade 2 in 47 % of patients compared to 14 % of controls (p < 0.004). Patients also had more parenchymal Doppler spots than controls (p < 0.01). Diffuse blood flow throughout the prostatic parenchyma was observed in 63 %, of patients compared to 36 % of controls (p < 0.03). There was no significant difference in the amount or distribution of blood flow in patients with and without inflammation.
Conclusions. The chronic prostatitis/pelvic pain syndrome was associated with increased blood flow to the prostatic capsule and diffuse flow throughout the prostatic parenchyma. Despite technical limitations, color Doppler ultrasonography may provide objective documentation of prostate blood flow abnormalities in patients with this syndrome.

Endorectal magnetic resonance imaging as a predictor of biochemical outcome after radical prostatectomy in men with clinically localized prostate cancer.

AV D'Amico, R Whittington, B Malkowicz, M Schnall, D Schultz, K Cote, JE Tomaszewski, A Wein

Urol 2000; 164 (3 Pt 1): 759-63.

Purpose. Endorectal magnetic resonance imaging (MRI) of the prostate is sometimes performed before radical prostatectomy but to our knowledge its role for predicting outcome after radical prostatectomy is not yet established. We evaluated the clinical usefulness of endorectal MRI for predicting time to prostate specific antigen (PSA) failure after radical prostatectomy in 1.025 consecutive men with clinically localized or PSA detected prostate cancer. Our analysis controlled for PSA level, biopsy Gleason score, clinical T stage and percent of positive biopsies.
Materials and methods. Using Cox regression analysis we prospectively assessed time to PSA failure to determine the role of endorectal MRI in predicting PSA outcome after radical prostatectomy at our institution, where an expert prostate magnetic resonance radiologist is available. The main outcome measure was actuarial freedom from PSA failure.
Results. Endorectal MRI did not add clinically meaningful information in 834 of our 1.025 cases (81 %) after accounting for the prognostic value of PSA, biopsy Gleason score, clinical T stage and percent of positive biopsies. However, this modality provided a clinically and statistically relevant stratification of 5-year PSA outcome in the remaining 191 patients at intermediate risk based on established prognostic factors. Specifically when endorectal MRI was interpreted as indicating extracapsular versus organ confined disease the relative risk of PSA failure was 3.6 (95 % confidence Interval 2.0 to 6.3), and 5 year actuarial freedom from PSA failure was 33 % versus 72 % (P < 0.0001).
Conclusions. Despite expert radiological interpretation endorectal MRI had potential clinical value in less than 20 % of the cases in our study after accounting for established prognostic factors. While further study of the value of this modality for predicting clinical outcome after radical prostatectomy should be performed in this select cohort, routine use of endorectal MRI cannot be justified based on these data.

Transperineal magnetic resonance image guided prostate biopsy.

AV D'Amico, CM Tempany, R Cormack, N Hata, M Jinzaki, K Tuncali, M Weinstein, JP Richie

J. Urol 2000: 164 (2): 885-7.

Purpose. We report the findings of a transperineal magnetic resonance image (MRI) guided biopsy of the prostate in a man with increasing prostate specific antigen who was not a candidate for a transrectal ultrasound guided biopsy.
Materials and methods. Using an open configuration 0.5 Tesla MRI scanner and pelvic coil, a random sextant sample was obtained under real time MRI guidance from the peripheral zone of the prostate gland as well as a single core from each MRI defined lesion. The patient had previously undergone proctocolectomy, for ulcerative colitis and, therefore, was not a candidate for transrectal ultrasound guided biopsy. Prior attempts to make the diagnosis of prostate cancer using a transurethral approach were unsuccessful.
Results. The random sextant samples contained benign prostatic hyperplasia, whereas Gleason grade 3 + 3 = 6 adenocarcinoma was confirmed in 15 % and 25 % of the 2 cores obtained, from the MRI targeted specimens of 2 defined lesions. The procedure was well tolerated by the patient.
Conclusions. Transperineal MRI guided biopsy is a new technique that may be useful in detecting prostate cancer in men with increasing prostate specific antigen who are not candidates for transrectal ultrasound guided biopsy.

Intracorporeal imaging and differentiation of living tissue with an ultrahigh-frequency ultrasound probe.

Koichi Yokosawa, Kazuaki Sasaki, Shinichiro Umemura, Ryuichi Shinomura, Shizuo Ishikawa, Shyuzo Sano and Yukio Ito

Ultrasound in Me & Biol.

Intraoperative diagnostic tissue differentiation is expected to be useful clinically. We have fabricated a 3 mm diameter rod-shaped ultrasound (US) probe mounted with a 12O MHz transducer whose lateral resolution is the same as the cellular size of 13 pm. The probe can image a microscopic structure (i.e., the cellular arrangement inside intracorporeal living tissue). We imaged normal kidney tissue of a living mouse and tumor tissue implanted in another mouse kidney. We anesthetized the mice, exteriorized the kidneys, and punctured the kidneys with the probe. Renal corpuscle-like structures were seen in the healthy kidney, but a wavy spindle-like structure was seen in the tumor. The similarity between the ultrasonic images and histological sections taken from the imaged organs demonstrates the possibility, of real-time tissue differentiation by ultrahigh-frequency US.

Cone-beam computed tomography with a flat-panel imager: Initial performance characterization.

DA Jaffray and JH Siewerdsen

American Association of physicists in Medicine 2000; S0094-2405 (00) 01306-7.

The development and performance of a system for x-ray cone-bean computed tomography (CBCT) using an indirect-detection flat-panel imager (FPI) is presented. Developed as a bench-top prototype for initial investigation of FPI-based CBCT for bone and soft-tissue localization in radiotherapy, the system provides fully three-dimensional volumetric image data from projections acquired during a single rotation. The system employs a 512x512 active matrix of a-Si:H thin-film transistors and photodiodes in combination with a luminescent phosphor. Tomographic imaging performance is quantified in terms of response uniformity, response linearity, voxel noise, noise-power spectrum (NPS), and modulation transfer function (MTF), each in comparison to the performance measured on a conventional CT scanner. For the geometry employed and the objects considered, response is uniform to within 2 % and linear within 1 %. Voxel noise, at a level of ~20 HU, is comparable to the conventional CT scanner. NPS and MTF results highlight the frequency-dependent transfer characteristics, confirming that the CBCT system can provide high spatial resolution and does not suffer greatly from additive noise levels. For larger objects and/or low exposures, additive noise levels must be reduced to maintain high performance. Imaging studies of a low-contrast phantom and a small animal (a euthanized rat) qualitatively demonstrate excellent soft-tissue visibility and high spatial resolution. Image quality appears comparable or superior to that of the conventional scanner. These quantitative and qualitative results clearly demonstrate the potential of CBCT systems based upon flat-panel imagers. Advances in FPI technology (e.g., improved x-ray converters and enhanced electronics) are anticipated to allow high-performance FPI-based CBCT for medical imaging. General and specific requirements of kilovoltage CBCT systems are discussed, and the applicability of FPI-based CBCT systems to tomographic localization and image-guidance for radiotherapy is considered.
 

R. Yalow and S. Berson - authors of the radioimmunoassay technique which revolutionized the development of endocrinology and medicine

III emes journees francophones d'imagerie m(c)dicale 
IX eme symposium franco-hongrois
Budapest,  April 18 - 20, 2001

European congress of radiology
Vienna, March 2 - 6, 2001

Working seminar on radiology

Sofia, 9. - 10.04.2001
Royal College of Radiologists, Bracco International and Bulgarian Association of Radiology

Teaching atlas of mammography

With the contribution of Tibor tot 
3rd revised and enlarged edition

Laszlo Tabar, Peter B. Dean

Thieme,  Stuttgart - New York, 2001
246 ±²°., 566 ¨«¾±²° ¶¨¨ ¨ ±­¨¬ª¨

Periferal musculosceletal ultrasound 

A CD-ROM atlas

J. E. Cabay, B. Daenen 
¯(r)¤ °¥¤ ª¶¨¿²  ­  R. F. Dondelinger

Endoscopic evaluation and treatment of swallowing disorders

Susan E. Langmore

Georg Thieme Verlag, Stuttgart - New York, 2000
263 ±²°, 101 ´¨£., 25 ² ¡«., 16 ¯°¨«(r)¦¥­¨¿

Diagnostic breast imaging

Sylvia K. Heywang-Koburner, D. Dershaw, Ingrid Schereer

Georg Thieme Verlag, Stuttgart-New York, 2001
481±²°., 843 ¨«¾±²° ¶¨¨

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25.08. - 29.08.2001
Naples, Italy
 

13.09. - 16.09.2001
Ancona, Italy
 

14.09. - 16.09.2001
Rotterdam, 
The Netherlands

17.09. - 22.09.2001
Sevilla, Spain
 
 

22.09. - 26.09.2001
G¶teborg, Sweden
 
 

07.10. - 10.10.2001
Thessaloniki, Greece
 

15.10. - 18.10.2001
Capri, Italy
 

20.10. - 24.10.2001
Paris, France
 

21.10. - 25.10.2001
Lisbon, Portugal
 

25.11. - 30.11.2001
Chicago, USA
 

11.12. - 14.12.2001
Edinburgh, UK
 
 

01.03. - 05.03.2002
Vienna, Austria
 

19.03. - 23.03.2002
Barcelona, Spain
 

05.05. - 10.05.2002
Jerusalem, Israel
15.05. - 19.05.2002
Salzburg, Austria
 

12.06. - 16.06.2002
Ohrid, Macedonia
 
 

16.06. - 19.06.2002
Stockholm, Sweden
 
 

24.06. - 28.06.2002
Cancun, Mexico
 

26.06. - 29.06.2002
Paris, France
 

26.06. - 30.06.2002
Warsaw, Poland
 
 

30.06. - 5.07.2002
Oslo, Norway
 

Annual Meeting of the European Association of Nuclear Medicine (EANM)
Contact: Quality Associates, Eur. Ass. (r)f Nuclear Medicine, Van Breestraat 156, NL-1071 ZX Amsterdam, The Netherlands. Fax: 31-20-67-59410 

XXVII Congress of the European Society of Neuroradiology (ESNR)
Contact: Ms M. Carletti, ESNR Office, MGR, Via Ripamonti, 129, I-20141 Milano, Italy. Fax: 39-02-56609045, E-mail: m.carletti@mgr.it

8th European Symposium on Urogenital Radiology (ESUR)
Contact: Mrs T. Wilson, EMCO Secr., Erasmus University, P.O. Box 1738, NL-3000 DR Rotterdam, The Netherlands. Fax: 31-10-4089462, E-mail: info@emco.fgg.eur.nl

6th Biennial ESTRO Meeting on Physics and Radiation Technology for Clinical Radiotherapy
Contact: ESTRO office, Av. Mounierlaan 83, B-1200 Brussels, Belgium. Fax: 32-2-7795494, E-mail: info@estro.be

CIRSE 2001 - Annual Meeting of the Cardiovascular and Interventional Radiological Society of Europe
Contact: CIRSE 2001, Bellerivestrasse 42, CH-8008 Z¼rich, Switzerland. Fax: 41-1-3849339, E-mail: cirse@congressorg.ch

International Conference on Image Processing
Contact: Mrs Frosso Michali, Diastasi 30 Katsimidou Str., Gr-54639 Thessaloniki, Greece. Fax: 30-31-909269, E-mail: diastasi@spark.net.gr

Contrast Media Research Meeting
Contact: Prof. P. Pavone, Policlinico Umberto I, Viale Regina Elena 324, I-00161 Rome, Italy. Fax: 39-06-490243, E-mail: pavone@uniroma1.it

Journees Francaises de Radiologie - JFR 2001
Contact: Prof. Guy Frija, Secr. Gen. SFR, 20, av. Rapp, F-75343 Paris Cedex 07, France. Fax: 33-1-53595960, E-mail: sfr@stradiologie.org

ECCO 11 - The European Cancer Conference/20th Annual ESTRO Meeting
Contact: Mr Luc Hendrickx, ECCO 11 - FECS Conference Unit, Av. E. Mounier 83, B-1200 Brussels, Belgium. Fax: 32-2-7750200, E-mail: ECCO11@fecs.be

87th Meeting of the Radiological Society of North America (RSNA)
Contact: Steven T. Drew, Ass. Exec. Director, 920 Jorie Boulevard, Oak Brook, IL 60523-2251, USA. Fax: 1-630-5717837, E-mail: sdrew@rsna.org

EUROSON 2001: 13th Congress of the European Federation of Soc. for US in Medicine and Biology
Contact: Mrs Elaine Brown, Gen. Secretary BMUS, 36 Portland Place, W1N 3DG London, UK. Fax: 44-20-73232175, E-mail: euroson@bmus.org

14th European Congress of Radiology
Contact: ECR Office, Neutorgasse 9/2A, A-1010 Vienna, Austria. Fax: 43-1-5334064-9, E-mail: office@ecr.org

EBCC 3: 3rd European Breast Cancer Conference 
Contact: Ms Kris Vantongelen, FECS Conference Unit, Av. E. Mounier 83, B-1200 Brussels, Belgium. Fax: 32-2-7750245, E-mail: Kris@fecs.be
 
12th International Congress on Breast Diseases of the Senologic International Society 
Contact: Secretariat, Kenes, P. O. Box 50006, 61500 Tel Aviv, Israel. Fax: 972-3-5140077/5175674, E-mail: breast@kenes.com

7th International Meeting on Progress in Radio-Oncology/ICRO/OGRO 7
Contact: Univ. Prof. Dr. H. D. Kogelnik, Landeskl., St. Johanns-Spital, M¼llner Hauptstr. 48, A-5020 Salzburg, Austria. Fax: 43-662-4482887, E-mail: D.Kogelnik@1kasbg.gv.at

Third Macedonian Congress of Radiology with International Participation
Contact: Congress Secretariat, Institute of Radiology, University Clinical Center, Vodnjanska 17, 1000 Skopje, Republic of Macedonia. Fax: 389-2-236974, E-mail: rentgen@unet.com.mk

7th Meeting of the World Association of Sarcoidosis and other Granulomatous Disorders (WASOG)
Contact: Mr. Chr. Carlsson, Stockholm Convention Bureau, P. O. Box 6911, S- 102 39 Stockholm, Sweden. Fax: 46-8-348441

22nd International Congress of Radiology (ICR)
Contact: Fed. Mexicana de Radiologia e, Imagen, Coahuila No. 35, Col. Roma, C.P. 06700, Mexico, D.F. Fax: 52-5-5745374, E-mail: fmri@compuserve.com

CARS 2002 - Computer Assisted Radiology and Surgery
Contact: Mrs. Franziska Schweikert, CARS 2002 Conference Office, Im Gut 11/15, D-79790 K¼ssaberg, Germany. Fax: 49-7742-922438, E-mail: francis.cars@d-plus.net

EUROSON 2002 - 14th Congress of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB)
Contact: Polish Ultrasound Society, ul. Kondratowicza 8, 03-242 Warszawa, Poland. Fax: 48-22-8119591, E-mail: euroson@euroson.edu.pl

18th International Cancer Congress
Contact: Congrex Sweden AB, P.O. Box 5619, SE-114 86 Stockholm, Sweden. Fax: 46-8-6619125, E-mail: amelie.svanstrom@congrex.se