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Zusammenfassung Ziel Die ultraschallgestützte Stanzbiopsie (CNB) gilt als Standardbewertung für die Diagnose sonografisch nachweisbarer verdächtiger Brustläsionen. Basierend auf nicht randomisierten Studien, empfehlen die aktuellen deutschen Leitlinien die Biopsie von mindestens 3 Zylindern mit ≤ 14-Gauge(G)-Nadel. Es wird jedoch keine Empfehlung abgegeben, wie viele Proben bei kleinerer Nadelstärke von z. B. 16-G benötigt werden oder ob die koaxiale Führung die diagnostische Genauigkeit (Treffsicherheit) und Qualität verbessert. Daher wurde in einer prospektiven, monozentrischen, nicht verblindeten, randomisierten, kontrollierten klinischen Nichtunterlegenheitsstudie die diagnostische Genauigkeit der Stanzbiopsie mit 16-G- versus 14-G-Nadel mit und ohne Koaxialführung bewertet. Material und Methoden 1065 Brustbiopsien wurden aufgenommen, um die Zahl der erforderlichen Stanzproben zu analysieren, um eine entsprechende diagnostische Qualität zu erhalten, die für die histologische Beurteilung ausreicht, und um eine hohe diagnostische Genauigkeit und Ausbeute zu erreichen. Die histologischen Ergebnisse wurden durch eine Operation oder eine Langzeitbeobachtung von mindestens 2 bis zu 5 Jahren bestätigt. Ergebnisse Um eine additive diagnostische Genauigkeit von > 99 % zu erreichen, waren mindestens 2 Zylinder mit 14-G-Biopsie erforderlich. Die diagnostische Genauigkeit und die Qualität der 14-G-Biopsie wurden durch die koaxiale Technik nicht beeinträchtigt. Bei der Durchführung einer 16-G-Biopsie waren 5 Zylinder erforderlich, um eine additive diagnostische Genauigkeit von > 99 % zu erreichen. Ohne koaxiale Führung benötigte die CNB mit 16-G mindestens 3 Proben, während 5 Nadelpassagen mit koaxialer 16-G-Biopsie erforderlich waren. Schlussfolgerung Die diagnostische Genauigkeit und die Qualität der ultraschallgeführten Stanzbiopsie waren unabhängig vom Einsatz einer koaxialen Technik mit der 16-G-Nadel geringer als mit der 14-G-Nadel.

Ultrasound-guided core needle biopsy (CNB) is considered the standard assessment to diagnose sonographically visible suspicious breast mass lesions. Based on nonrandomized trials, the current German guidelines recommend at least three cylinders with ≤ 14-gauge needle biopsy. However, no recommendation is made as to how many specimens are needed with a smaller needle size, such as 16-gauge, or if biopsy with coaxial guidance improves diagnostic accuracy and quality. Therefore, in a prospective monocentric unblinded randomized controlled clinical noninferiority trial, the diagnostic accuracy of 16-gauge versus 14-gauge core needle biopsy, with and without coaxial guidance, was evaluated. 1065 breast biopsies were included in order to analyze the number of core samples necessary to obtain an appropriate rate of diagnostic quality adequate for histological evaluation, and to achieve high diagnostic accuracy and diagnostic yield. Histological results were verified by surgery or long-term follow-up of at least two years up to five years. In order to obtain an additive diagnostic accuracy of 99 %, a minimum of two cylinders with 14-gauge biopsy were required. The diagnostic accuracy and the diagnostic quality of 14-gauge biopsy were not affected by the coaxial technique. When performing a 16-gauge biopsy, five cylinders were required to achieve an additive diagnostic accuracy of 99 %. Without coaxial guidance, 16-gauge CNB required at least three samples, whereas five needle passes with coaxial-guided 16-gauge biopsy were needed. The diagnostic accuracy and quality of ultrasound-guided 16-gauge core needle biopsy were inferior to the 14-gauge needle size, regardless of the use of a coaxial technique.ZIEL: Die ultraschallgestützte Stanzbiopsie (CNB) gilt als Standardbewertung für die Diagnose sonografisch nachweisbarer verdächtiger Brustläsionen. Basierend auf nichtrandomisierten Studien empfehlen die aktuellen deutschen Richtlinien die Biopsie von mindestens 3 Zylindern mit ≤ 14-Gauche (G)-Nadel. Es wird jedoch keine Empfehlung abgegeben, wie viele Proben bei kleinerer Nadelstärke von z. B. 16-G benötigt werden, oder ob die koaxiale Führung die diagnostische Treffsicherheit und Qualität verbessert. Daher wurde in einer prospektiven, monozentrischen, nicht verblindeten, randomisierten, kontrollierten klinischen Nichtunterlegenheitsstudie die diagnostische Treffsicherheit der Stanzbiopsie mit 16-G-versus 14-G-Nadel mit und ohne Koaxialführung bewertet. 1065 Brustbiopsien wurden aufgenommen, um die Anzahl der erforderlichen Stanzproben zu analysieren, um eine entsprechende diagnostische Qualität zu erhalten, die für die histologische Beurteilung ausreicht und um eine hohe diagnostische Genauigkeit und Ausbeute zu erreichen. Die histologischen Ergebnisse wurden durch eine Operation oder eine Langzeitbeobachtung von mindestens 2 bis zu 5 Jahren bestätigt. Um eine additive diagnostische Genauigkeit von 99 % zu erreichen, waren mindestens 2 Zylinder mit 14-G-Biopsie erforderlich. Die diagnostische Genauigkeit und Qualität der 14-G-Biopsie wurden durch die koaxiale Technik nicht beeinträchtigt. Bei der Durchführung einer 16-G-Biopsie waren 5 Zylinder erforderlich, um eine additive diagnostische Genauigkeit von 99 % zu erreichen. Ohne koaxiale Führung benötigte die CNB mit 16-G mindestens 3 Proben, während 5 Nadelpassagen mit koaxialer 16-G-Biopsie erforderlich waren. Die diagnostische Treffsicherheit und Qualität der ultraschallgeführten Stanzbiopsie waren unabhängig vom Einsatz einer koaxialen Technik mit der 16-G-Nadel geringer als mit der 14-G-Nadel.

The objective of the present study was to analyze the prognostic relevance of pretreatment serum CA125 ≥500 U/ml and its role as a non-invasive factor for estimating optimal cytoreduction (≤1 cm) in primary serous ovarian cancer. Clinicopathological parameters and CA125 levels prior to primary cytoreductive surgery were retrospectively evaluated in all 261 consecutive patients with primary epithelial ovarian cancer from a single centre. Inclusion criteria were existing preoperative CA125 level, serous ovarian cancer and performed full primary treatment (surgery/platinum-based chemotherapy). A total of 136 patients met the criteria. Among them, 74 patients had CA125 ≥500 U/ml. The other 62 patients that met the aforementioned criteria and had CA125 1,404 U/ml had a higher rate of suboptimal cytoreduction (32.4%) compared with lower CA125 levels. A pretreatment CA125 level ≥500 U/ml had significantly worse prognostic impact after optimal cytoreduction compared with CA125

A young male infant was referred to the emergency department with apparent acute sepsis. The laboratory results were compatible with a viral infection except for a slightly elevated procalcitonin level. Due to the clinical severity intravenous antibiotic treatment was started immediately. Cerebrospinal fluid and urine testing initially showed no infection focus but then SARS-CoV‑2 was detected in the lower pharynx and cerebrospinal fluid. The clinical condition of the infant rapidly improved but whether this was due to symptomatic or antibiotic treatment remained unknown. There is still a considerable lack of experience regarding diagnostics and treatment of pediatric SARS-CoV-2 infections.

Optimization of axillary staging among patients converting from clinically node-positive disease to clinically node-negative disease through primary systemic therapy is needed. We aimed at developing a nomogram predicting the probability of positive axillary status after chemotherapy based on clinical/pathological parameters. Patients from study arm C of the SENTINA trial were included. Univariable/multivariable analyses were performed for 13 clinical/pathological parameters to predict a positive pathological axillary status after chemotherapy using logistic regression models. Odds ratios and 95%-confidence-intervals were reported. Model performance was assessed by leave-one-out cross-validation. Calculations were performed using the SAS Software (Version 9.4, SAS Institute Inc., Cary, NC, USA). 369 of 553 patients in Arm C were included in multivariable analysis. Stepwise backward variable selection based on a multivariable analysis resulted in a model including estrogen receptor (ER) status (odds ratio (OR) 3.916, 95% confidence interval (CI) 2.318–6.615, p

Purpose:To developin vitromethods to assess binding by sodium hyaluronate in eye drops to corneal surfaces.Methods:Two different, complementary corneal binding set-ups were developed. In a dynamicin vitromodel, confluent corneal epithelial cells (HCE-T) were assembled in chamber slides and a declining channel. A static model was constructed withex vivoporcine corneas clamped in Franz cells. To test the predictive capacity of models, four different eye drops containing sodium hyaluronate were spiked with tritium-labeled sodium hyaluronate to standardize quantification. In both settings, eye drops were applied for 5 min and physiological conditions were mimicked by flushing with artificial tear fluid. Spreading experiments on HCE-T next to synthetic membranes were used for further characterization.Results:Binding was more pronounced in dynamic HCE-T model. Three of the four eye drops demonstrated sigmoidal elution of sodium hyaluronate, suggesting pronounced binding. One solution eluted distinctly faster, likewise the buffer control. The static method produced a similar ranking but at lower levels. When eye drops in which phosphate buffer was replaced by citrate buffer (i.e., to prevent calcification) were used, binding was not influenced. All eye drops spread immediately when placed on HCE-T and at the same order of magnitude on glass and polyethylene terephthalate surfaces.Conclusion:Dynamic and static models performed on different corneal sources were used to determine sodium hyaluronate binding kinetics in solutions under physiological conditions. These methodologies resulted in a ranking of the capacity of sodium hyaluronate to bindin vitroto corneal surfaces.

Burner or stinger syndrome is a rare sports injury caused by direct or indirect trauma during high-speed or contact sports mainly in young athletes. It affects peripheral nerves, plexus trunks or spinal nerve roots, causing paralysis, paresthesia and pain. We report the case of a 57-year-old male athlete suffering from burner syndrome related to a lumbar nerve root. He presented with prolonged pain and partial paralysis of the right leg after a skewed landing during the long jump. He was initially misdiagnosed since the first magnet resonance imaging was normal whereas electromyography showed denervation. The insurance company refused to pay damage claims. Partial recovery was achieved by pain medication and physiotherapy. Burner syndrome is an injury of physically active individuals of any age and may appear in the cervical and lumbar area. MRI may be normal due to the lack of complete nerve transection, but electromyography typically shows pathologic results.

Background Among patients with breast cancer undergoing neoadjuvant chemotherapy (NACT), the association between pathological complete remission (pCR) in the breast and clinical/pathological parameters is well established, whereas the association between these parameters and residual axillary involvement after NACT remains unclear. Methods Patients with clinically occult nodal metastases (i.e. negative by clinical assessment but positive by SLNB prior to NACT, i.e. Arm B of the SENTINA trial) were included in the presented analysis. All patients received a second sentinel lymph node biopsy (SLNB) and axillary dissection after NACT. Univariate and multivariate analyses were carried out to evaluate the association between clinical/pathological parameters and axillary involvement after NACT. Results Arm B of the SENTINA study contained 360 patients, 318 of which were evaluable for this analysis. After NACT, 71/318 (22.3%) patients had involved SLNs or non-SLNs after NACT. Overall, 71/318 (22.3%) patients achieved a pCR in the breast. Associations of extranodal spread, lack of multifocality and pCR in the breast with residual axillary burden were statistically significant. In a descriptive analysis including all patients with clinically negative axilla before NACT in the SENTINA trial 1.2% of triple negative (TN) patients and 0.5% of HER/2 positive patients had residual axillary disease in case of a breast pCR. Conclusions Patients in the SENTINA trial with clinically negative axilla and involved SLNs still carried a significant risk of nodal metastases after NACT. However, the risk of residual axillary burden was particularly low in TN and HER/2 positive tumors in case of a breast pCR.

Breast-conserving therapy is associated with a risk of tumor-involved margins. For intraoperative orientation, non- palpable or indistinctly palpable lesions are wire-marked prior to surgery. Ultrasound-guided surgery has the potential to reduce the number of tumor-involved margins. In the MAC 001 trial we evaluated ultrasound-guided breast-conserving surgery compared to wire-guided surgery with regard to free tumor margins, duration of surgery and resection volume. In this randomized, prospective, single-center controlled trial, patients with ductal invasive breast cancer were recruited for either ultrasound-guided or wire localization surgery. Primary outcomes were tumor-free resection margins, the reoperation rate and the resection volume in each group. The results were analyzed by intention to treat. The trial was registered under ClinicalTrials.gov NCT02222675. 56 patients were assessed, and 47 patients were evaluated in the trial. 93 % (25/27) of the patients in the ultrasound arm had an R0 reoperation compared to 65 % (13/20) in the wire localization control arm. This result was statistically significant (p = 0.026). No statistical difference was found for the resection volume or the duration of surgery between the two arms. No major complication was seen in either arm. Ultrasound-assisted breast surgery significantly increases the possibility of tumor-free margins and therefore reduces the risk of reoperations. Breast surgeons should be trained in ultrasound and ultrasound should be available in every breast surgery operating room.ZIEL: Die brusterhaltende Therapie des Mammakarzinoms unterliegt dem Risiko der R1-Resektion. Zur intraoperativen Orientierung werden nicht oder unsicher palpable Tumoren vor der Operation mittels Draht markiert. Mittels der ultraschall-assistierten Tumorchirurgie kann die Rate an R1 Resektionen reduziert werden. Die MAC 001 Studie verglich die ultraschall-assistierte Tumorchirurgie mit der konventionellen drahtmarkierten Chirurgie und untersuchte dabei die R0-Resektionsrate, Operationszeit und das Resektionsvolumen. Patientinnen mit einem invasiv duktalen Mammakarzinom wurden in die prospektiv, randomisierte, unizentrische Studie eingeschlossen und entweder in den ultraschall-assistierten oder Draht markierten Arm randomisiert und ausgewertet. Die Studie war unter ClinicalTrial.gov NCT02222675 registriert worden. 56 Patientinnen erfüllten die Einschlusskriterien von dehnen 47 ausgewertet werden konnten. 93 % (25/27) der Patientinnen im ultraschall-assistierten Arm hatten im Vergleich zu 65 % (13/20) im Draht markierten Kontrollarm eine R0 Resektion. Das Ergebnis war statistisch signifikant (p = 0.026). In Bezug auf das entnommene Resektionsvolumen und die Operationsdauer wurde kein signifikanter Unterschied beobachtet. Revisionspflichtige Komplikationen traten nicht auf. Die ultraschall-assistierte Tumorchirurgie kann im Vergleich zur konventionellen Draht markierten Tumorchirurgie die R0-Rate bei brusterhaltender Operation signifikant erhöhen. Aus unserer Sicht sollten Brustchirurgen im Ultraschall ausgebildet sein. Ein Ultraschallgerät sollte Bestandteil jedes Brustoperationssaales sein.

BACKGROUND/AIM Only 30-50% of patients with sentinel lymph node (SLN) metastases present with further axillary lymph node metastases. Therefore, up to 70% of patients with positive SLN are overtreated by axillary dissection (AD) and may suffer from complications such as sensory disturbances or lymphedema. According to the current S3 guidelines, AD can be avoided in patients with a T1/T2 tumor if breast-conserving surgery with subsequent tangential irradiation is performed and no more than two SLNs are affected. Additionally, use of nomograms, that predict the probability of non-sentinel lymph node (NSLN) metastases, is recommended. Therefore, models for the prediction of NSLN metastases in our defined population were constructed and compared with the published nomograms. PATIENTS AND METHODS In a retrospective study, 2,146 primary breast cancer patients, who underwent SLN biopsy at the University Women's Hospital in Tuebingen, were evaluated by dividing the patient group in a training and validation collective (TC or VC). Using the SLN-positive TC patients, three models for the prediction of the likelihood of NSLN metastases were adapted and were then validated using the SLN-positive VC patients. In addition, the predictive power of nomograms from Memorial Sloan Kettering Cancer Center (MSKCC), Stanford, and the Cambridge model were compared with regard to our patient collective. RESULTS A total of 2,146 patients were included in the study. Of these, 470 patients had positive SLN, 295 consisted the training collective and 175 consisted the validation collective. In a regression model, three variants - with 11, 6 and 2 variables - were developed for the prediction of NSLN metastases in our defined population and compared to the most frequently used nomograms. Our variants with 11 and with 6 variables were proven to be a particularly suitable model and showed similarly good results as the published MSKCC nomogram. CONCLUSION Our developed nomograms may be used as a prediction tool for NSLN metastases after positive SLN.

Purpose The purpose of this study was to assess the mid-term clinical and radiological results as well as patient safety in terms of complication and reoperation rates in patients treated with a novel anterior stand-alone fusion (ASAF) device (Synfix-LR, DePuy Synthes, West Chester, PA, USA) in a cohort of patients with predominant and intractable low back pain originating from monosegmental degenerative disc disease at the lumbosacral junction.

Background:The association between pathological complete remission (pCR) in the breast and clinical/pathological parameters is well established, whereas the role of these parameters in the prediction of residual axillary involvement after NACT is unclear. The goal is to identify a subset of patients who do not need axillary treatment. We used data from Arm B of the SENTINA trial to analyze this association. Methods:Patients from arm B of the SENTINA trial with clinically and sonographically unsuspicious axillary nodes but with histologically proven involvement of SLNs prior to NACT were analyzed. All patients had SLNB and axillary dissection after NACT. Univariate analyses were performed to evaluate the association between clinical/pathological parameters and axillary involvement after NACT. Results:Arm B of the SENTINA study contained 360 patients, 318 of which were evaluable with respect to the above parameters. After NACT 71/318 (22.3%) patients had involved SLNs or non-SLNs; 71/318 (22.3%) had a pCR in the breast. We observed a significant association between pCR in the breast and negative ER status, negative PR status, positive HER2 status, triple negative (TN) status, tumor size before and after NACT, multifocality, lobular morphology and axillary involvement after NACT. Regarding residual axillary burden only the associations with lobular morphology, extracapsular invasion, multifocality, positive HER2 status and pCR in the breast were statistically significant. Conclusion:Our analysis demonstrates that patients enrolled in the SENTINA trial with clinically and sonographically unsuspicious axillary nodes but proven histological involvement of SLNs prior to NACT have positive axillary nodes in 22.3 % after NACT. This rate is confirming similar results from other groups. Although we found statistically significant associations between pCR in the breast and clinical/pathological parameters, only the association between lobular type, extracapsular invasion, positive HER2 status and pCR in the breast and residual axillary involvement after NACT were statistically significant. We cannot clearly identify a subset of patients for whom axillary treatment after NACT could be safely omitted if SLNs were positive. Our data are well in line with recently presented data demonstrating that the association between pCR in the breast and free axillary nodes after NACT is particularly strong in patients with TN and HER2 positive tumors. This question will be addressed in future trials currently under development. Citation Format: Kolberg H-C, Liedtke C, Bauerfeind I, Fehm T, Fleige B, Hauschild M, Helms G, Lebeau A, Schmatloch S, Schrenk P, Schwentner L, Stäbler A, Loibl S, Untch M, Kühn T. Residual axillary involvement in early breast cancer in patients with positive sentinel nodes after neoadjuvant chemotherapy (NACT) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD8-02.

Reduction of therapy-induced morbidity is an important goal for the improvement of the quality of breast cancer treatment. The introduction of sentinel lymph node biopsy (SLNB) significantly contributed to the reduction of surgery-induced morbidity in the shoulder-arm region. However, a clinically positive nodal status is still considered a contra-indication for SLNB. The current data constellation clearly shows that the clinical and also the sonographic malignancy assessment is insufficient for the accurate identification of the nodal status. A merely clinical and/or image-based appraisal of the axillary lymph node status would lead to overtreatment due to unnecessary axillary dissection in approximately 40 % of patients. In order to reduce the rate of unnecessary axillary dissection (AD), pretreatment interventional clarification is necessary to provide more detailed information about the histological condition of the lymph node. Comparing the currently available methods, fine needle aspiration (FNA) is the best in terms of cost and time requirement, practicability and complication rate. However, considering the sensitivity, it is inferior to ultrasound-guided core needle biopsy (CNB). Thus, a negative FNA outcome requires further clarification, which possibly can be performed with CNB. With a specificity of nearly 100 % and therefore a low rate of false positive cases for FNA, complete AD can be indicated by a positive FNA result. In the context of the interventional procedure, it must be stressed that FNA requires a high level of expertise on the part of both the examiner and the cytologist. The prerequisite for optimal interventional diagnostics of lymph nodes is an adequate sonographic assessment on the basis of standardized sonomorphological criteria.

PURPOSE: Evaluation of a newly developed Clip (Tumark Professional) for MRI-guided lesion localization after MRI-guided vacuum-assisted biopsy (VAB) with regard to the exactness of positioning, migration, and visibility on mammography (MG), ultrasound (US) and MR imaging (MRI). MATERIALS UND METHODS: 27 consecutive patients with 29 suspicious breast lesions detected with MRI were prospectively evaluated. The location of the lesion was determined with Tumark (Somatex, Teltow, Germany) after MRI-guided VAB. The distance between the clip and lesion was measured via MRI. The qualitative visibility of the clip was assessed by means of a 5-point scale from very good (1 point) to not visible (5 points). The analysis was performed for MG, US and MRI separately. Clip movement was measured via MG. RESULTS: 9 lesions were malignant (31 %). All but one lesion (96 %) were able to be localized exactly with a clip-lesion distance of ≤ 10 mm. The Tumark was visible in 27 cases (93.1 %) in US and in 25 cases (86.2 %) in MRI. The visibility of the clip was moderate for both modalities (mean 3.2 points). Its visibility in MG was always very good (1 point). The clip position was stable at the time of short term follow-up (1 - 7 months; mean deviation 4.5 mm). CONCLUSION: Precise positioning of the Tumark Professional is usually possible. The clip is mostly visible in US. At the time of short-term follow-up, there was no relevant movement. Therefore, Tumark seems to be suitable for MRI-guided lesion localization after MRI-guided VAB of suspicious breast lesions. Further improvement of US visibility would be beneficial.

Of 129 patients with an acute lumbar root compression syndrome due to disc herniation 21, who were symptom-free, were examined by computed tomography (CT) on average 276 days after a three-step regimen of conservative treatment. In no instance had there been a deterioration of the original findings. In 14 patients the CT picture continued to demonstrate disc herniation, although the patients were without symptoms. In two patients a moderate, in five a marked regression of herniation was demonstrated by CT. Clinical improvement without change in the CT picture points to the compression syndrome not being explainable solely in mechanical terms. As a matter of fact, a possible cause may be a disturbance of radicular blood supply resulting in oedematous root swelling which is usually masked in the CT by prolapsed disc tissue. There is as yet no easy explanation for regression in case of prolapsed, perhaps even sequestered, disc tissue. It is possible that there have been reparative processes, such as have been described histopathologically in form of ingrown vessels. More plausibly would be a separation of the herniated and/or sequestered disc tissue in form of an asymptomatic sliding into the terminal caudal region.

Unterarmfrakturen zahlen zu den haufigsten Verletzungen wahrend des Wachstumsalters. Trendsportarten wie Skateboarding oder Inline-Skating haben dabei in den letzten Jahren immer mehr an Bedeutung gewonnen. Bislang existieren allerdings nur wenige Studien, die den Zusammenhang zwischen Unfallmechanismus und dem daraus resultierenden Verletzungsmuster beschreiben. Ziel dieser Untersuchung war es daher, Epidemiologie und Atiologie kindlicher Unterarmfrakturen sowie den Zusammenhang zwischen sport- und freizeitbedingten Unfallursachen und deren Verletzungsfolgen zu untersuchen. Gleichzeitig erfolgte die Ermittlung der Therapieergebnisse anhand klinischer Parameter. Im Rahmen einer retrospektiven Untersuchung fanden primar 263 Patienten (Median: 9,93; Range 6–14 Jahre) Eingang in die Studie. Neben einer Klassifizierung der Unfallursache und des radiologischen Verletzungsmusters erfolgte eine klinisch/funktionelle Untersuchung unter Verwendung etablierter Scores (DASH-Score, Score nach Schmittenbecher et al.). Auf Grundlage unseres Behandlungskonzeptes wurden stabile Frakturen konservativ sowie instabile Frakturen operativ therapiert. Durchschnittlich 55 Monate (Range: 12–100) nach initialer Vorstellung konnten 212 Patienten klinisch und funktionell evaluiert werden. Hinsichtlich der Epidemiologie und Atiologie war mit 21,3 % der Falle Inline-Skating die haufigste Unfallursache. 82 % der Patienten trugen hierbei keine Handgelenkschoner. Ein bestimmtes Verletzungsmuster ergab sich nur fur die einfachen Sturze im Niveau, die signifikant haufiger auch zu einfachen Frakturen (Wulst-/Grunholzfraktur) fuhrten (p = 0,008). Bezogen auf das Gesamtkollektiv erreichten 75,0 % der Patienten, gemessen anhand der Einteilung nach Schmittenbecher et al., ein sehr gutes Ergebnis. Einfache Frakturen lieferten hierbei signifikant haufiger ein sehr gutes Ergebnis (p = 0,029). Das Therapieregime hatte hingegen keinen signifikanten Einfluss auf das Therapieergebnis.

Whiplash injury of the cervical spine is a frequent issue in medical expertises and causes enormous consequential costs for motor insurance companies. Some authors accuse posttraumatic changes of alar ligaments to be causative of consequential disturbances, although biomechanical experiments achieve contradictory results and neuropsychiatric studies do not support this thesis. MRI provides excellent visualization of alar ligaments. However, signal alterations of alar ligaments must be differentiated from common normal variants. Functional MRI provides no diagnostic yield.

Purpose Whiplash injury of the cervical spine is a frequent issue in medical expertise and causes enormous consequential costs for motor insurance companies. Some authors accuse posttraumatic changes of alar ligaments to be causative for consequential disturbances. Materials and methods Review of recent studies on biomechanics, anatomical and clinical MR imaging. Results Biomechanical experiments can not induce according injuries of alar ligaments. Although MRI provides excellent visualization of alar ligaments, the range of normal variants is high. Conclusion Biomechanical studies give no evidence of alar ligament involvement in whiplash disease. Using MRI, signal alterations of alar ligaments can hardly be differentiated from common normal variants. Functional MRI provides no diagnostic yield.

Summary Bone marrow edema (BME) of the foot and ankle is a common finding in sportive people. Based on the causative factors, this condition can be classified into four different groups: mechanical, reactive, ischemic and metabolic caused BME. Mechanical BME: „Bone bruises“, trabecular fractures, micro fractures and stress fractures. Ischemic BME: osteochondritis dissecans, osteonecrosis. Reactive BME: degenerative or inflammatory arthritis, tendonitis, tumorous lesions, postoperative conditions. Metabolic BME: Transient osteoporosis (syn. bone marrow edema syndrome). The understanding of the causative factors is mandatory to develop a strategy for treatment. Mechanical BME caused by overuse or acute trauma are the most frequent findings in sports, however, BME can be find in up to 80% of pain free runners. Edema caused by overload can hardly be distinguished from subtle injuries of the trabecular bone. Especially tiny micorfracutres are often not visible at the MRI, but can become apparent on high resolution CT. A close cooperation with the radiologist is mandatory to make a precise diagnosis. Non weight bearing in addition with analgesics and physiotherapy are the major principles in the treatment. However, if possible, local overload or a hind foot malalignment should be reduced by insoles. The off label use of ilomedin or bisphosphonates can be helpful, although there is still a lack of scientific evidence.

Knochenmarkodeme (KME) an Fus und Sprunggelenk sind ein haufiger Befund. Basierend auf den zugrundeliegenden Pathomechanismen lassen sich Knochenmarkodeme in vier Gruppen klassifizieren: Mechanisch induzierte, reaktive, ischamische und metabolische Knochenmarkodeme. Die mechanisch induzierten KME umfassen Diagnosenwie das „Bone bruise“, trabekulare Frakturen und Mikrofrakturen sowie die Stressfrakturen. Ischamisch bedingte KME sind die Osteochondrosis dissecans und die Osteonekrose. Reaktive KME entstehen auf der Basis degenerativer oder entzundlicher Gelenkerkrankungen sowie postoperativ oder bei Weichteilaffektionen. Die transiente Osteoporose (Syn. Knochenmarkodem- Syndrom) ist aufgrund histologischer Daten als metabolisches KME einzustufen. Das Verstandnis der zugrundeliegenden Pathologie ist der Schlussel zur Behandlung der Erkrankung. Im Bereich des Sports finden sich uberwiegend mechanisch induzierte KME. Dabei sind diskrete trabekulare Frakturen auf den MRT-Aufnahmen nicht sichtbar, konnen aber mit Hilfe der hochauflosenden CT dargestellt werden. Die enge Kooperation mit dem Radiologen ist fur eine exakte Diagnose von entscheidender Bedeutung. Entlastung in Kombination mit Analgetika und Physiotherapie sind die Grundprinzipien der Behandlung. Wenn moglich sollten Fusfehlstellungen durch Einlagen korrigiert werden. Der „off label“ Gebrauch von Ilomedin oder Bisphosphonaten kann hilfreich sein, eine abschliesende wissenschaftliche Einstufung dieser Behandlungsverfahren ist aber noch nicht moglich.

Summary Midfoot sprains present with a wide spectrum of injuries of the Lisfranc ligament complex. The injury can be classified into sprains, partial ruptures and complete ruptures of the Lisfranc ligament complex. Weight bearing dorsoplantar X-rays are mandatory to demonstrate the diastases between the base of the first and second meta-tarsal. In complete ruptures, the longitudinal arch flattens in eightbearing lateral X-rays. MRI can show in detail the ligament rupture, additional microfractures and minor displacement of the Lisfranc joint line. Nonoperative management is suggested for stage I injuries, whereas early ORIF is recommended for stage II and III injuries. We have treated 12 patients with Lisfranc ligament injuries within the last 5 years. Five patients with stage I injuries were treated conservatively; 7 patients with stage II and III injuries underwent ORIF. One case with delayed diagnoses was treated with an arthrodesis of the first TMT joint due to severe degenerative arthritis. All patients with grade I injuries returned to sports without limitations. In 2 of the 4 patients with stage III injuries no limitations in doing sports are reported; however in high intensity performance they feel some restrictions. Early restoration and maintenance of the anatomic alignment of the Lisfranc ligament complex seems to be the key to good clinical results. A delay in diagnosis and treatment seems to increase the risk for limitations in performance in sports.

Die hereditaren motorischen und sensorischen Neuropathien (HMSN), insbesondere die Charcot-Marie-Tooth-Erkrankungen (Typ 1), betreffen nahezu ausschlieslich das periphere Nervensystem. Wir berichten uber eine 48-jahrige Patientin mit einer autosomal-dominanten HMSN vom Typ I, die im Verlauf der Erkrankung sowohl Zeichen einer Kompression der Cauda equina als auch schubformig auftretende Symptome einer demyelinisierenden Erkrankung des zentralen Nervensystems entwickelte. In der lumbalen MRT zeigte sich eine ausgepragte Hypertrophie der Cauda equina. In der kranialen MRT stellten sich periventrikular demyelinisierende Lasionen der weisen Substanz dar. Dieser Fall legt nahe, dass die Mechanismen dieser peripheren, demyelinisierenden Neuropathie auch das zentrale Myelin involvieren konnen.

In many radiological departments conventional radiography has been replaced by digital radiography. Therefore, the purpose of this study was to analyze the visual detection of osteopenia/osteoporosis with both digital and conventional radiographs. In 286 patients we retrospectively evaluated radiographs of the lumbar spine in two planes. One hundred twenty-eight patients had conventional and 158 patients had digital radiographs. Patients with pre-existing vertebral fractures were excluded. Four experienced musculoskeletal radiologists blinded to the values of DXA and to the patients' ages assessed independently from each other whether the bone density of the lumbar spines was normal or decreased. The results of dual X-ray absorptiometry served as the standard of reference. The threshold value for the diagnosis of osteopenia was a T-score less than -1 SD according to the WHO classification of osteoporosis. Sensitivity/specificity was 86%/36% for conventional and 72%/47% for digital radiographs. The overall diagnostic accuracy was 68% for conventional and 64% for digital radiographs. Eighty percent of the patients with osteopenia and 96% of the patients with osteoporosis were correctly assessed as true positive on conventional radiographs and 65% (osteopenia) and 82% (osteoporosis) on digital radiographs. Interobserver agreement was markedly lower for digital (35%) than for conventional radiographs (73%). However, the differences were not statistically significant. There is no major difference in diagnostic accuracy in the assessment of osteopenia/osteoporosis using digital and conventional radiographs, respectively. However, the high interobserver variance on digital radiographs indicates that visual assessment of osteoporosis/osteopenia is problematic, which may be due to image processing and postprocessing algorithms that manipulate the visual aspect of bone density.

Purpose To determine the detection of diffuse bone marrow infiltration with MRI in comparison with histopathological findings. Materials and methods MRI was performed on 45 patients with histologically proven multiple myeloma and on 30 healthy individuals. Three experienced radiologists read separately Tl-weighted SE sequences, STIR sequences and the combination of Tl-weighted SE and STIR sequences of the spine. Additionally, Tl-weighted SE sequences were obtained after gadolinium administration and the percentage increase in signal intensity was calculated. Bone marrow histology was used as gold standard for assessing the grade of infiltration. A dichotomous decision (infiltration yes/no) was made when assessing the MRI examinations. Results For the visual detection of diffuse infiltration, the best sensitivity was found with Tl-weighted SE sequences, achieving 71 % on average. The specificity was 89 %. The STIR sequences showed a sensitivity of 61 % and a specificity of 98 %, and the combination of Tl-weighted/STIR-sequences achieved a sensitivity of 65 % and a specificity of 94 %. In comparison with the histological findings, the sensitivity of the Tl-weighted sequences was 35 % for low-grade, 89 % for moderate and 100 % for high-grade infiltration. The application of contrast material with calculation of the percentage signal increase improved the detection by 7 %. Conclusion The sensitivity of the visual detection of diffuse multiple myeloma with unenhanced MRI is limited for low-grade or moderate infiltration, whereas the sensitivity for high grade infiltration is reliable. The specificity is high and the diagnostic confidence improves after application of contrast material with calculation of the percentage increase in signal intensity.

Atlanto-axial rotatory displacement is known to be a cause of childhood torticollis and may as well be responsible for chronic neck pain after rear-end automobile collisions. The objective was to determine whether quantification of C2 malrotation is possible by plain radiographs in comparison to CT as the golden standard. MR imaging was evaluated as to whether it was of equal value in the detection of bony landmarks. C2 vertebra of five human cadaveric cervical spine specimens, ligamentously intact, were rotated using a Steinmann pin in steps of 5 degrees up to 15 degrees right and 15 degrees left. Plain radiographs, CT and MRI images were taken in each rotational step. Data were analyzed for quantification of C2 rotation by three independent examiners. A rotation of 5 degrees led to a spinous process deviation (SPD) from the midline of 3 mm as measured on an a.p. plain radiograph. A coefficient of rotation was calculated (1.62 degrees mm(-1)). Data analyzed by three examiners revealed a small coefficient of variation (0.03). MRI and CT measurements showed comparable results for the quantification of rotation; however, in both techniques the 15 degrees rotation was underestimated. Quantification of upper cervical spine malrotation was possible on plain radiographs using the SPD and a rotation coefficient. MRI and CT were equally successful in the assessment of C2 malrotation.

BACKGROUND Up to now, reliable data has not been available on the actual costs of treating oncological patients. However, such data material is urgently required in view of the institution of the health service reform with the concomitant introduction of the G-DRG remuneration system. PATIENTS The medical services and their costs for 66 patients comprising several stays in hospital, part-time hospitalization and outpatient visits to the clinic categorized "establishment of the diagnosis", "stem cell therapy (SCT)" and "chemotherapy" were recorded in parallel to treatment over a time period of three months. It was thus possible to relate a cost volume of 2.7 million euro to more than 2800 nursing days (full and partial hospitalization) and more than 500 outpatient visits. METHODS All pertinent costs were collated with the various stays/movements of the patients over 100 calendar days. This was very largely possible thanks to a sophisticated costing and setting off of payments within the hospital on the part of the service providers in the hospital in direct allocation to patients and the third-party payers. Additionally, partial and full surveys as well as questionnaires enabling allocation to the individual case as far as possible, especially the staff requirement, were used. A breakdown of the costs in terms of the patient nursing days was only effected in marginal areas such as the "hotel function" or the general administrative costs. A further subdivision of the stays and movements as well as the phases of the stays applied to the service or the treatment progress above and beyond the areas of treatment. In the case of chemotherapy, a distinction was therefore made between "protocol blocks" and "stays due to complications" and in the case of SCT inter alia even individual phases such as "conditioning". RESULTS AND CONCLUSIONS It is problematical to represent these patients within an DRG case flat rate system because of frequent and very divergent residence periods with regard to services and costs. The multiplicity of treatment sessions is manifested in the compact "establishment of the diagnosis" to determine a therapy protocol which entails very elaborate inpatient measures under hospitalization, in the expensive and individual "stays due to complications" which usually take place between the "chemotherapy blocks", and the expensive long-term care of the SCT patients after the end of the residence limit (GVD). Owing to the small and divergent numbers of cases in Germany (2000 new patients in 50 centers and 330 SCT per year) and per center, this problem cannot be dealt with by means of a quantity compensation argumentation, as is doubtless justified elsewhere. The actual individual case costs of oncological patients would be 166,72 euro; per outpatient contact and covered by 459,30 euro; per day of hospital care and 808,20 euro; per inpatient treatment day (admission plus discharge day calculated separately and comprised stem cell transplantation patients beyond the residence limit) is covered. The level of the currently applicable case flat rate payments for stem cell transplantations and heterologous donors, mismatched heterologous donors and family donors appear appropriate in relation to the GVD. (The true costs of all oncological patients would indeed be even higher if the GOA payment of the ILV did not only relate to a house-internal low pricing of the GOA scoring value, but would also relate to HLA typing, unpaid physician overtime and the costs of the study centers to the individual cases. From 2002, there will be changes consequent on the judgment of the European Court that stand-by is working time, so that more physicians must be employed and there are expensive changes in the infrastructure owing to the need for a GMP clean area laboratory to process stem cells according to the medical products law.) The indeterminate bound-aries between the three treatment categories place in question the dual financing by the Panel Doctor's Association and the health insurance funds and indicate that a total-sum remuneration appears appropriate.

Fragestellung. Bei Patienten mit symptomatischer Tendinosis calcarea der Schulter beeinflusst die rontgenmorphologische Gestalt der Verkalkungen, im deutschen Sprachraum regelmasig klassifiziert nach Gartner,Therapie und Prognose. Ziel war es die Intraoberserverreproduzierbarkeit und Interobserverreliabilitat dieser Klassifikation zu uberprufen. Methodik. Die Rontgenbilder (a.p.-Projektion) von 100 Patienten mit symptomatischen Verkalkungender Supraspinatussehne wurden von 6 unabhangigen Untersuchern unterschiedlichen Ausbildungsstandes und verschiedener Fachdisziplinen 2-mal innerhalb von 4 Monaten entsprechend der Kriterien von Gartner klassifiziert.Die Intraoberserverreproduzierbarkeit und Interobserverreliabilitat wurden gemas dem κ-Index nach Cohen bestimmt. Ergebnisse. Die κ-Werte der Intraobserverreproduzierbarkeit lagen im Mittel bei 0,4208 (SD 0,1299),der Interobserverreliabilitat bei 0,490 fur die 1.Untersuchung und 0,474 fur die 2.Untersuchung. Schlussfolgerungen. Die Intraobserverreproduzierbarkeit ergab ein ungenugendes bis befriedigendes, die Interobserverreliabilitat zu beiden Untersuchungszeitpunkten eine ausreichende Ubereinstimmung. Die klinische Verwendung der Klassifikation nach Gartner zur Therapieplanung und Prognosestellung bei symptomatischer Tendinosis calcarea ist nur eingeschrankt zu empfehlen.

The purpose of this study was to evaluate the performance of standard-dose and low-dose cesium iodide (CsI)-doted amorphous silicon (a-Si) flat-panel detector technology (FDT) as compared with storage-phosphor technology (SPT) in the depiction of relevant anatomical structures in chest radiography. In 75 patients referred for thoracic CT, digital chest radiographs were randomly obtained with either SPT at a standard dose (speed class S400, n=25), standard-dose FDT (S400, n=25) or FDT at a low dose (S800, n=25). Five radiologists evaluated the visibility of eight pulmonary and mediastinal anatomical structures using a five-point rating scale. To determine statistically significant differences between the three groups, the Mann-Whitney U-test was employed. No statistically significant differences were found in the depiction of eight criteria between SPT and standard-dose or low-dose FDT chest radiographs. The performance of FDT S400 was equal to SPT for most criteria and better for retrocardiac structures and soft tissue. FDT S800 was inferior to both SPT and FDT S400. Standard-dose FDT is equivalent to SPT in the depiction of relevant anatomical structures of the chest. Our results also indicate that a dose reduction of 50% with FDT may result in small but not significant decrease of image quality.

Today the clinical use of extracorporeal shock-wave application (ESWA) for the treatment of lateral tennis elbow is hampered by the lack of results from randomized controlled trials and of predictive parameters of clinical outcome. The present prospective study aimed to provide the latter by means of magnetic resonance imaging (MRI). Twenty-three female and 19 male patients with unilateral chronic tennis elbow of the dominant site were clinically examined before and after repetitive low-energy ESWA. MRI was performed before ESWA to evaluate signal intensity changes or contrast enhancement of the common extensor tendon and the lateral epicondyle. After ESWA (mean follow-up period 18.6 months for all patients), clinical evaluation showed a significantly better mean clinical performance after ESWA than before treatment. Interestingly, male patients showed a significantly better mean clinical performance after ESWA than female patients, and male and female patients differed significantly in the signal intensity of the common extension tendon cross-section and tendon thickening on MRI. For female patients, MRI scans could be applied for predicting a positive clinical outcome of ESWA. This study reports the first indication of predictability of positive clinical outcome of the treatment of chronic lateral tennis elbow by ESWA using imaging prior to treatment. This may serve as an important step towards overcoming the therapeutic nihilism with respect to the non-operative management of this condition recently in the literature.

Primary and secondary malignant hepatic tumors are the most common tumors with a much more higher incidence of hepatic metastases. Chemotherapy and radiation therapy are in general ineffective. Therefore, surgical resection is considered the method of choice in the treatment of malignant hepatic lesions. Due to systemic disease, general medical or procedure-related reasons hindering surgery, only 25 to 45% of the patients with metastatic disease of the liver are suitable for a curative surgical therapy. In resectable lesions thermoablative methods can offer an alternative to the surgical therapy. The most experience exists in radiofrequency ablation techniques. Technique, indications, contraindications, and limitations of the radiofrequency ablation will be discussed together with a presentation of own cases and a review of the literature. In 37 patients the primary technical success rate of the ablation was 97.3% (72 of 74 lesions). In 4 cases a hematoma of the liver capsule occurred. One of these had to be treated interventionally. During the limited follow-up period of 9 months no local recurrency was seen, however 4 patients developed new hepatic metastases. Beside differences in practicability it is not yet clarified if there are differences in the therapeutic efficacy of the different thermoablation methods. Nevertheless, the results of the ablation therapy may parallel the results of the surgical resection. Interstitial thermotherapy can provide a valuable contribution to local tumor control. However, the final significance of the thermoablation techniques within oncological therapy regimens has to be evaluated in further multidisciplinary studies.

PURPOSE To assess the value of MR imaging in demonstrating ongoing spondylolysis in adolescents. METHODS MRI was performed in 9 juvenile patients (3 female, 6 male aged 8-16 years; mean 12.5 y) with pain during hyperextension. In 6 patients a CT scan and in 5 a plain film was available. RESULTS In all patients bone marrow edema was found in the pars interarticularis and the pedicle, which was bilateral in 4 patients. In 7/9 cases the L5 vertebra was affected, in 2/9 cases spondylolysis was found in L4. In 3 cases the edema reached the middle third of the vertebral body and a tumor was suspected. In all CT scans a bilateral incomplete or complete cleft in the pars inter-articularis was found. In 4/6 CT-scans a sclerosis was seen in the area of the bone marrow edema. Only in 1/5 plain films was there a suspicion for a spondylolysis, four examinations were completely normal. CONCLUSIONS To eliminate underlying causal conditions of spondylolysis and to install specific therapy, early diagnosis is mandatory. MR imaging should be the first and only imaging modality in young patients with low back pain during and after exercise and pain with hyperextension. Bone scans and CT scans should be avoided due to irradiation, plain films usually do not reveal pathological findings in developing sponylolysis.

PURPOSE The purpose of this work was to determine the frequency and etiology of the intravertebral vacuum phenomenon (IVP). METHOD CT examinations of 96 vertebral fractures were evaluated for IVP. Bone mineral density (BMD) was determined in nonfractured vertebrae. For calibration purposes, densities of a standard phantom measured in 30 patients who underwent quantitative CT examinations in the same time period were used and precision was calculated. RESULTS Eleven of 96 fractures (11.5%) showed IVP. IVP was present in 4 of 20 fractures at T12 (20%), in 4 of 23 at L1 (17.4%), and 1 IVP was found at L2-4 each. Mean +/- SD age of patients with IVP was 68.3 +/- 10.5 years and without 47.8 +/- 19.4 years (p < 0.001). Mean +/- SD density of nonaffected vertebra was 45.9 +/- 17.0 mg of hydroxyapatite/ml for patients with IVP and 139.5 +/- 62.6 mg/ml for those without IVP (p < 0.0005). An average precision of 1.2% was calculated for the density measurements over the investigated time. CONCLUSION Following vertebral fractures, IVP on CT scans is more common than presumed and increases with age. There exists a significant inverse correlation between the BMD and the frequency of IVP.

In general, carpal coalitions are considered to be asymptomatic. Incomplete separated joints and associated changes similar to osteoarthritis and pseudoarthrosis are known as possible causes of wrist pain. We present the clinical history, plain-film, and MR imaging findings of two patients with symptomatic fibrous lunato-triquetral coalition. Conventional films disclosed a narrowed space between the lunate and triquetral bone with cysts and sclerosis similar to pseudoarthrosis. Magnetic resonance imaging showed bone marrow edema adjacent to the incomplete separated lunato-triquetral joint and Gd-DTPA enhancing fibrovascular tissue in the synovium and subarticular cysts, explaining the pain over the ulnar-sided wrist. Patients with congenital lunato-triquetral coalition may poorly tolerate stress loading or trauma, resulting in a symptomatic state similar to degenerative arthritis or pseudoarthrosis, which is demonstrated by enhanced MR imaging.

Functional radiographic analysis of the cervical spine in flexion and extension position is increasingly used as screening method for the diagnosis of segmental functional disorders. The objective of this study was to prove Penning's evaluation method for the metrical recording of segmental angles in the sagittal plane for selectivity, reliability and usability. Passive functional radiographs of the cervical spine in flexion and extension were taken of 20 patients with painful limitation of mobility of the cervical spine and 20 subjects, similar in sex and age, without complaints. The radiographs were duplicated. Five physicians measured the angles of segmental mobility in a blind study. Statistical analysis was conducted using the t-test and calculating the correlation coefficient "r". The results of the study prove that the evaluation method by Penning shows a usable and, for segments C3/C4 to C6/C7, significant selectivity. The selectivity of p 0.8). The measured values, however, have to be considered, in connection with the appropriate clinical symptoms, as still "normal" or "functionally disordered" in the context of segmental hypo-resp. hypermobility.

PURPOSE Purpose of this study was to evaluate whether spiral-CT allows judgment of right ventricular failure in patients with acute pulmonary embolism. MATERIALS AND METHODS 61 patients underwent spiral-CT due to suspicion of acute pulmonary embolism. Patients with pulmonary embolism were divided into subpopulations according to the severity of pulmonary embolism in the CT scan. Cardiac measurements were performed on axial spiral-CT images and compared to those of patients without suspicion of pulmonary embolism or cardiac diseases. RESULTS In 30 patients spiral-CT revealed acute pulmonary embolism. Significant differences in cardiac measurements in patients with severe and less severe pulmonary embolism were found on comparing the following dimensions: left ventricular width (p = 0.0003), left (p = 0.008) and right (p = 0.009) ventricular cross-sectional area, proportion of right to left ventricular width (p = 0.0003) and proportion of right to left ventricular cross-sectional area (p = 0.0001). The proportion of the cross-sectional areas (r = 0.65) and the proportion of the width (r = 0.60) of both ventricles correlated well with the severity of central pulmonary embolism. CONCLUSION Besides reliable assessment of pulmonary embolism spiral-CT allows the evaluation of cardiac dimensions for judgment of right ventricular failure.

A 40-year-old white man presented with fever, muscle pain, skin nodules and persistent hypereosinophilia over a period of 1 year. In addition, he had ventricular arrhythmias with episodes of tachycardia. Besides a lack of response to antiparasitic therapy, laboratory and pathological data excluded the diagnosis of trichinosis or any other parasitic infection. The patient's course of the disease over the previous 1(1)/2 years was compatible with hypereosinophilic syndrome. In a muscle biopsy several eosinophilic perivascular and leucocytic intravascular infiltrates were found, indicative of muscle involvement by the disease. This is a report on the MRI findings of muscle involvement in idiopathic hypereosinophilic syndrome.

Eine 60jahrige Patientin mit einem 9 Monate zuvor resezierten Nebenschilddrusen-Karzinom wurde mit Muskelschwache, Polyurie, Polydipsie und unstillbarem Erbrechen in somnolentem Zustand stationar aufgenommen. Bei der klinischen Untersuchung imponierten eine deutliche Dehydratation, Paresen der Extremitatenmuskulatur sowie eine Hyperreflexie. Laborchemisch bestand eine schwere Hyperkalzamie und ein Hyperparathyreoidismus. Morphologische Untersuchungen zeigten drei Raumforderungen zwischen rechtem Schilddrusenlappen und Sternoklavikulargelenk. Der Verdacht auf ein lokoregionales Rezidiv konnte durch eine 99m-Tc/MIBI-Szintigraphie sowie eine selektive Parathormon-Katheteruntersuchung mit Spitzenspiegeln im Bereich des Zusammenflusses von Vena jugularis interna und Vena subclavia weiter erhartet werden. Die hyperkalzamische Krise konnte durch Infusionstherapie, Furosemid- und Pamidronat-Gabe klinisch und laborchemisch gunstig beeinflust werden, so das bei normalem Bewustseinszustand am dritten Tag des stationaren Aufenthaltes eine En-Bloc-Resektion des Rezidiv-Tumors mit Entfernung zervikaler und mediastinaler Lymphknoten durchgefuhrt werden konnte. Die Patientin konnte mit normalen Kalzium- und Parathormonspiegeln im Serum entlassen werden und ist nach nunmehr 12 Monaten postoperativen Verlaufs ohne Hinweis auf ein neuerliches Rezidiv. Als Komplikation verblieben eine rechtsseitige Recurrensparese und Horner-Symptomatik.

Eine 22jahrige Patientin wurde wegen seit 2 Monaten bestehenden Lumbalgien sowie Fieber, Nachtschweis und Gewichtsverlust stationar aufgenommen. Bei deutlich erhohten laborchemischen Entzundungsparametern erbrachte die bildgebende Abklarung die Diagnose einer vertebralen Osteomyelitis in LWK 1 und LWK 2. Nebenbefundlich wies die Patientin Randkantenabtrennungen von den Deckplatten zweier Lendenwirbelkorper auf. Inwieweit diese sogenannten Limbuswirbel als Ausdruck einer chronischen Traumatisierung der Wirbelsaule einen Risikofaktor fur die vertebrale Osteomyelitis darstellen, ist unbekannt. Die Problematik der klinischen Diagnose der vertebralen Osteomyelitis ist das weitgehende Fehlen spezifischer Symptome. Leitsymptom ist der Ruckenschmerz. Diagnostisches Verfahren der Wahl ist heute das MRT. Ziel mus sein, moglichst fruhzeitig die Diagnose zu stellen und den ursachlichen Keim zu isolieren. So kann haufig eine Operation vermieden und das Ansprechen auf Antibiotikatherapie (gemas Antibiogramm) gewahrleistet werden. Unter Beachtung der Operationsindikationen und korrekter Durchfuhrung der Antibiose ist allerdings auch dann noch eine Ausheilung wahrscheinlich, wenn – wie heute leider noch ublich – die Diagnose erst nach Monaten gestellt wird.

Erdheim-Chester (EC) disease belongs to the group of lipoid granulomatosis. Symmetric sclerosis of the meta- and diaphysis of long tubular bones are pathognomonic radiologic changes. Additionally, other skeletal segments can be affected. Extraskeletal manifestations can occur in almost all organs; lungs, pericardium, retroperitoneum, skin, and orbita play particularly important roles. The last case of 38 cases of Erdheim-Chester disease with an extraordinary mediastinal and perirenal involvement is described. For the second time following the initial description by Chester, an axial skeletal pattern of eburnated vertebra is shown.

Die Lungenembolie zahlt in den westlichen Industrienationen zur dritthaufigsten Todesursache. Versagt die medikamentose, antikoagulative Therapie, ist sie kontraindiziert oder besteht anderweitig ein erhohtes Risiko einer Lungenembolie, so kann die perkutane Implantation eines Kavafilters indiziert sein. Die derzeit verfugbaren Kavafilter unterscheiden sich hinsichtlich ihres Designs (konus-, korbchen-, maschenformig), des verwendeten Materials und der eventuellen Wiederentfernbarkeit. Einzelne Filtertypen neigen eher zu Komplikationen (Kavathrombose, Filterfraktur) und unterscheiden sich in In-vitro-Studien bezuglich ihrer Wirksamkeit. Klinische Studien zeigten bei den gebrauchlichen Filtern keine signifikanten Unterschiede hinsichtlich ihrer Fahigkeit, Embolien abzufangen. Bei etwa 4% aller Patienten mit Kavafiltern treten noch Lungenembolien auf, von denen ca. ein Viertel todlich verlaufen. Abhangig vom Filtertyp ist die Kavathrombose die haufigste Komplikation, die in bis zu 25% der Falle beobachtet wird. Die Implantation von Kavafiltern ist durch den interventionell tatigen Radiologen einfach durchzufuhren. Die Indikation ist kritisch zu stellen, da bisher kein durch randomisierte Studien gefestigter Indikationskatalog besteht.

PURPOSE The aim was to present clinical findings and imaging criteria for patients with aortic ulcers of the thoracic aorta. METHODS From 1993 to 1996 computed tomography of patients suffering from acute thoracic pain and suspected pathologies of the aorta were reviewed for penetrating aortic ulcers. Pathoanatomical correlation was done by autopsy in three cases and with intraoperative inspection in two cases. MRI was available in three patients and angiography in 5 patients. RESULTS 9 patients with aortic ulcers could be identified. The imaging criteria in CT were: 1. Hyperdense wall thickening on unenhanced CT scans (medial haematoma). 2. Displaced intimal calcifications outlining the lumen. 3. Small contrast-filled ulcer. 4. Absence of a contrast-filled false lumen. In 4 of the 9 cases the aorta ascendens was affected. The clinical presentation is that of an elderly patient with acute onset of thoracic pain and generalised atherosclerosis due to hypertension and nicotine abuse. DISCUSSION Penetrating ulcers with haematoma of the media are a special case of aortic dissection, with different features on unenhanced and enhanced CT scans.

PURPOSE To evaluate retrospectively criteria in the differential diagnosis of erosive osteochondrosis (EO) and infectious spondylitis (IS) on the basis of MRI. METHODS T1-weighted sagittal images before and after Gd-DTPA application, T2-weighted TSE or T-STIR images of 23 patients with proven 15 and 41 patients with EO were evaluated. Criteria for this evaluation were morphology and extension of bone marrow edema, visibility of the low-intensity vertebral endplate, contrast enhancement and signal intensity in the disc space on T2-weighted and T-STIR images. RESULTS Bone marrow edema was more extensive in IS than in EO. The mean rated value for bone marrow edema on a four-level scale (0-3) was for IS 2.91 (+/- 0.29), for EO 1.32 (+/- 0.76, p < 0.001). In 37/41 cases of EO and in 22/23 cases of IS Gd-DTPA enhancement was found in the disc space (n.s.). In EO the low intensity endplate was visible in all parts in 36/41 cases (87.8%) on T1-weighted images, in IS not in a single case (0%). On T2-weighted or STIR images signal intensity of the discs was decreased in 82.1% of EO, 82.6% of segments in IS had water-equivalent signal intensity (p < 0.001). CONCLUSION If all the criteria are taken into consideration differential diagnosis of EO and IS on the basis of MRI findings is possible.

To evaluate the usefulness of diffusion-weighted magnetic resonance (MR) imaging of bone marrow for differentiating between benign and pathologic vertebral compression fractures.Thirty patients with 39 vertebral compression fractures were examined with MR imaging. Diffusion-weighted MR imaging was performed with a steady-state free precession sequence in 22 acute benign osteoporotic and/or traumatic fractures and 17 pathologic compression fractures. Biplanar radiographs, T1-weighted spin-echo (SE) MR images, and short inversion time inversion-recovery (STIR) MR images were available for all patients. The signal intensity characteristics were analyzed qualitatively and quantitatively (bone marrow contrast ratios and signal-to-noise ratios) for all sequences.At diffusion-weighted MR imaging, all benign vertebral compression fractures were hypo- to isointense to adjacent normal vertebral bodies. Pathologic compression fractures were hyperintense to normal vertebral bodies. Benign vertebral fractures had negative bone marrow contrast ratios at diffusion-weighted imaging, whereas pathologic vertebral fractures had positive values (P.001). The difference in bone marrow contrast ratios for benign and pathologic compression fractures at T1-weighted SE and STIR imaging was not significant (P.01).Diffusion-weighted MR imaging provided excellent distinction between pathologic and benign vertebral compression fractures.

Purpose The aim of this study was to compare various pulse-sequences employing the spine array coil while considering the different infiltration patterns in multiple myeloma, in order to develop a fast and cost effective screening method. Materials and methods In a prospective study, 50 patients with histologically proven multiple myeloma were examined with the following standardised sequences: T1-weighted SE, T2-weighted FSE, opposed phase GRE, FSE STIR, T1-weighted SE post gadopentate dimeglumine without and with fat saturation. The images were evaluated in a ROC analysis by three radiologists in consensus with a 5-grade scale separatively for diffuse and focal involvement. The gold standard was bone marrow histology in cases of diffuse infiltration and the combination of all sequences with the staging system according to Durie and Salmon. Results For focal bone marrow involvement the area under curve was greatest for FSE STIR sequences, in cases of diffuse infiltration the area under curve was superior for unenhanced T1-w SE-Sequenz images. The sensitivity can be increased by contrast material application and signal intensity measurements. A combined focal and diffuse infiltration and a "salt and pepper" pattern can be diagnosed with the combination of T1-w SE-Sequenz and FSE STIR sequences. Conclusion With T1-weighted SE-Sequenz sequences pre- and post-contrast and FSE STIR all therapeutical relevant infiltration patterns of plasmocytoma can be identified and bone marrow screening of the spine can be carried out with an acquisition time of 5.58 minutes.

Degenerative and overuse diseases as well as impingement syndromes of the hand are illustrated and discussed in this review article. Osteoarthritis of the interphalangeal joints as described by Heberden and Bouchard is a ubiquitous articular disease often associated with synovitis and erosive joint destruction. Osteoarthritis of the trapeziometacarpal joint is classified into four stages for proper indication of operation. Overuse can result in stenosing tenosynovitis around the wrist and in synovitis with or without impingement of the flexor or extensor tendons of the digitis or ruptures of the annular and cruciform pulleys. Although diagnosis of these entities is usually made by history and clinical investigation, ultrasound and MRI can be helpful tools in imaging of these diseases. Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) are the characteristic degeneration pattern of the wrist and represent the degeneration mechanisms in scapholunate insufficiency and nonunion of the scaphoid. SLAC wrist is a gradual degeneration classified in three stages and found in posttraumatic scapholunate rupture, calcium pyrophosphate dehydrate deposition disease (CPPD), rheumatoid arthritis, neuropathic diseases, trauma, and beta 2-microglobulin associated amyloid deposition. Ulna impaction syndrome is increasingly recognized as a cause of ulnar sided pain and exhibits a characteristic MRI appearance.

Komplikationen nach Lungentransplantation betreffen in erster Linie die Bronchusanastomose und die Pulmonalarterienanastomose. Sie sind ischamieinduziert oder auf chirurgisch-technische Probleme zuruckzufuhren. Bei 8 von 66 transplantierten Patienten traten postoperative Stenosen an der arteriellen Anastomose (n = 4) und an der Bronchusanastomose (n = 4) auf, die jeweils zu einem organ- bzw. lebensbedrohlichen Zustand der Patienten gefuhrt hatten. Die interventionelle Behandlung war bei allen Patienten erfolgreich; 4 Patienten wurden bei Anastomosenstenose bzw. Malazie der Bronchusanastomose mit Metallstent versorgt, 4 Patienten mit Stenosierung an der Pulmonalarterienanastomose wurden einer Ballondilatation bzw. zusatzlicher Stentimplantation zugefuhrt. Die Indikation zur Behandlung und die Uberprufung des Dilatationsergebnisses wurde anhand der Stenosegradienten ermittelt, zur ausreichenden Erweiterung war eine Ballonkaliberstarke von 15 bis 20 mm erforderlich. Indikation zur Stentimplantation war eine elastische Instabilitat bei einem Patienten. Der minimal-invasive Eingriff bei schwerkranken Patienten, die effiziente und komplikationslose Therapie und der erfolgreiche Langzeitverlauf sprechen dafur, bei Anastomosenproblemen nach Lungentransplantation interventionelle radiologische Verfahren primar einzusetzen.