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Tumor pain occurs in 70-80% of all cancer patients who have reached an advanced tumor stage. In the case of failure or poor response to chemotherapy and in cases of recurrence following radiotherapy, tumors will often become enlarged with infiltration of organs, nerve roots or bone which causes severe pain to the patient. Interventional radiological minimally invasive local tumor therapy is often the last resort for tumor patients suffering from severe pain. Interventional radiologists have several options to treat tumor pain but firstly the cause of the pain must be identified. This article presents a classification of patients suffering from tumor pain which can help therapists to decide on the correct form of treatment. Treatment options are discussed using typical case histories and it is shown that patients suffering from severe tumor pain must be treated sequentially, which means that treatment is carried out in multiple steps and each cycle of therapy has to be adapted to the stage of the disease. Local pain treatment is fundamentally based on individual case decisions which should be discussed within an interdisciplinary tumor board and the panel should arrive at a consensus decision. In addition, the radiologist performing the procedure should have many years of experience in interventional oncological radiology. By fulfilling these conditions the interventional radiologist can help the patient in a variety of ways because the available treatment options are effective and do not result in much distress for the patient.

Zusammenfassung Aus radiologischer Sicht werden die Untersuchungstechniken und die pathologischen Befunde bei Erkrankungen des Kolons dargestellt. Zu den einzelnen Untersuchungsverfahren sind wesentliche Aspekte der technischen Durchfuhrung, die Bedeutung, aber auch die Grenzen der Diagnostik aufgefuhrt. Folgende Techniken sind tabellarisch erfasst: Endoskopie, Rontgen-Abdomenubersicht, Sonographie, Kolonkontrasteinlauf, Gastrografin ® -Kontrasteinlauf, Computertomographie (inklusive Triple-CT), virtuelle Koloskopie, Magnetresonanztomographie, Angiographie, Endosonographie, Szintigraphie, FDG-PET. Fur die Diagnostik von Kolonpolypen, das kolorektale Karzinom, die Mesenterialarterienembolie, den Morbus Crohn, die Colitis ulcerosa, die Divertikulose und die akute (Sigma-)Divertikulitis werden die Untersuchungstechniken der ersten und zweiten Wahl angegeben. Daran schliesen sich – mit zahlreichen Abbildungen – jeweils die typischen Befunde an.

PURPOSE: High-resolution MR imaging of the layers of the gastrointestinal wall to provide a foundation for tumor staging based on morphological criteria. MATERIALS AND METHODS: Over a period of 12 months, miscellaneous parts of the gastrointestinal tract of 15 human specimens and 30 porcine specimens were scanned using a 1.5 Tesla clinical MRI scanner combined with an endoluminal receiver coil. The sequences used were T 1-weighted opposed-phase, T 2-weighted turbo spin echo with fat saturation and fast T 2-weighted inversion recovery. The number of differentiable layers, their width and the signal intensity were documented. Then, the results were compared with histological specimens in order to link the imaged wall layers to the anatomical layers. Spearman’s Rank Correlation was used to determine the soundness of the link between the images and their related histology. RESULTS: For both human and animal specimens, the MRI scanning produced 3 to 5, maximum 6 (pig), differentiable layers. The mucosa, submucosa and muscularis could be differentiated with a hyperintense, hypointense and intermediary signal, respectively. The subserosal layer displayed a hypointense signal. CONCLUSION: High-resolution MRI is able to produce differentiable images of the anatomical layers of the gastrointestinal wall in both humans and pigs. Accordingly, it is possible to use MR imaging to diagnose the extent of local tumor infiltration of the gastrointestinal wall.

PURPOSE Evaluation as to whether diagnosis of large bowel disease and TNM staging of colorectal carcinoma are possible by colorectal hydrosonography (HUS). METHOD 52 patients with suspected neoplastic or inflammatory large bowel disease, underwent HUS. Before performing abdominal ultrasound, the colon was filled with fluid. Morphological alterations of the bowel wall were judged benign or malignant. Colorectal carcinomas were classified according to the TNM system. RESULTS Laparotomy was performed in 46 of 52 patients. Correlation with surgery and histopathology showed that 77% of morphologic alterations of the colonic wall were detected by HUS. While benign lesions of the colonic wall occasionally mimicked malignant disease, colonic carcinomas were reliably diagnosed by HUS, because destruction and invasion of the bowel wall was visible. Carcinomas of the lower part of the rectum, however, were missed in most cases. Accuracy to determine the infiltration depth of colorectal carcinomas was 89%, but hydrosonographic N-staging was unreliable. Inflammatory disease of the large bowel as well as changes complicating the inflammatory bowel disease were accurately diagnosed by HUS. CONCLUSION In selected patients, colorectal HUS is suited for diagnosis and staging of colonic tumours. It also helps to evaluate inflammatory bowel disease, because small and large bowel can be reliably distinguished from each other and the degree of stenosis of inflamed colonic segments becomes visible. Furthermore, HUS increases the visibility of fistulas.

Tumor pain occurs in 70-80% of all cancer patients who have reached an advanced tumor stage. In the case of failure or poor response to chemotherapy and in cases of recurrence following radiotherapy, tumors will often become enlarged with infiltration of organs, nerve roots or bone which causes severe pain to the patient. Interventional radiological minimally invasive local tumor therapy is often the last resort for tumor patients suffering from severe pain. Interventional radiologists have several options to treat tumor pain but firstly the cause of the pain must be identified. This article presents a classification of patients suffering from tumor pain which can help therapists to decide on the correct form of treatment. Treatment options are discussed using typical case histories and it is shown that patients suffering from severe tumor pain must be treated sequentially, which means that treatment is carried out in multiple steps and each cycle of therapy has to be adapted to the stage of the disease. Local pain treatment is fundamentally based on individual case decisions which should be discussed within an interdisciplinary tumor board and the panel should arrive at a consensus decision. In addition, the radiologist performing the procedure should have many years of experience in interventional oncological radiology. By fulfilling these conditions the interventional radiologist can help the patient in a variety of ways because the available treatment options are effective and do not result in much distress for the patient.

Objective: Preoperative staging of gastric carcinoma is limited by the fact that available imaging modalities do not enable accurate evaluation of the depth of infiltration of the gastric wall. The aim of this study was to evaluate the efficiency of conventional magnetic resonance imaging (MRI) in local staging of gastric carcinoma. Methods: Sixty-five specimens of patients with proven gastric carcinoma were examined immediately after gastrectomy. Examination was performed with a 1-T MRI and included Tl-weighted, T2-weighted, and opposed phase images. Images were analyzed for the number of visible wall layers and their signal intensity characteristics, for tumor localization and depth of infiltration. T-stage was classified according to the TNM system. Finally, the staging by MRI was compared with the histopathological staging of the specimens. Results: The mucosal, submucosal, and proper muscle layers could be differentiated by the typical signal intensities. Depiction of the subserosa or serosa was not possible. In 65 specimens, 67 carcinomas were found by the pathologist. Sixty-four of 67 (96%) histologically proven carcinomas were correctly localized by MRI; T-staging accuracy was 50% only, mainly because of overstaging pT2 tumors as T3. Conclusions: MRI enables differentiation of gastric wall layers and, therefore, technically allows the evaluation of the local tumor stage of gastric carcinomas. However, infiltration of the subserosal and serosal layer cannot be proved accurately. Overstaging pT2 tumors is one of the most predominant problems. Yet further technical developments in high-resolution imaging of the gastric wall may improve T-staging in the near future and overcome today's staging limitations.

To evaluate the influence of continuous infusion of acetic acid 50% during radiofrequency ablation (RFA) on the size of the thermal lesion produced.Radiofrequency (RF) was applied to excised bovine liver by using an expandable needle electrode with 10 retractable tines (LeVeen Needle Electrode, RadioTherapeutics, Sunnyvale, CA) connected to a commercially available RF generator (RF 2000, RadioTherapeutics, Sunnyvale, CA). Experiments were performed using three different treatment modalities: RF only (n = 15), RF with continuous saline 0.9% infusion (n = 15), and RF with continuous acetic acid 50% infusion (n = 15). RF duration, power output, tissue impedance, and time to a rapid rise in impedance were recorded. The ablated lesions were evaluated both macroscopically and histologically.The ablated lesions appeared as spherical or ellipsoid, well-demarcated pale areas with a surrounding brown rim with both RF only and RF plus saline 0.9% infusion. In contrast, thermolesions generated with RF in combination with acetic acid 50% infusion were irregular in shape and the central portion was jelly-like. Mean diameter of the coagulation necrosis was 22.3 +/- 2.1 mm (RF only), 29.2 +/- 4.8 mm (RF + saline 0.9%) and 30.7 +/- 5.7 mm (RF + acetic acid 50%), with a significant increase in the RF plus saline 0.9% and RF plus acetic acid 50% groups compared with RF alone. Time to a rapid rise in impedance was significantly prolonged in the RF plus saline 0.9% and RF plus acetic acid 50% groups compared with RF alone.A combination of RF plus acetic acid 50% infusion is able to generate larger thermolesions than RF only or RF combined with saline 0.9% infusion.

Purpose: To evaluate the prevalence of latent and manifest hyperthyroidism in a non-selected group of patients admitted for contrast enhanced CT studies blood samples were tested for the levels of thyroid-stimulating hormone (TSH). Material and Methods: TSH blood levels were obtained in 548 consecutive patients who were scheduled for contrast-enhanced (Iopromide; 300 mg iodine/ml) CT scanning. In case of TSH levels < 0.4 mU/l, blood samples were also tested for triiodothyronine (T3) and tetraiodothyronine (T4) blood levels, and treatment with Irenat® (sodium perchlorate) was commenced before scanning. In case of TSH levels < 0.1 mU/l, CT scanning was not performed but further evaluation of the thyroid function was initiated. Results: TSH blood levels ranged from 0.4 to 7.5 mU/l in 512 patients, and 36 patients (6.6%) had TSH blood levels < 0.4 mU/l and 9 patients blood levels < 0.1 mU/l, with 32 of those patients (5.8%) having regular T3 and T4 blood levels consistent with latent hyperthyroidism. In 4 patients (0.8 %), T3 or T4 blood levels were increased consistent with manifest hyperthyroidism. Conclusion: In South Germany, the prevalence of latent or manifest hyperthyroidism in a non-selected patient group is high. Therefore TSH blood levels should be obtained prior to contrast-enhanced CT studies.

PURPOSE A retrospective analysis of long-term efficacy of combined transcatheter arterial chemoembolization (TACE) and percutaneous ethanol injection (PEI) and TACE monotherapy was conducted in patients with large, non-resectable hepatocellular carcinoma (HCC). METHODS AND MATERIALS Fifty patients with large, unresectable HCC lesions underwent selective TACE. Liver cirrhosis was present in 42 patients, due to alcohol abuse (n = 22) and viral infection (n = 17). In three patients, the underlying cause for liver cirrhosis remained unclear. Child A cirrhosis was found in 22 and Child B cirrhosis in 20 patients. Repeated and combined TACE and PEI were performed in 22 patients and repeated TACE monotherapy was performed in 28 patients. Survival and complication rates were determined and compared. RESULTS The 6-,12-, 24- and 36-month survival rates were 61 %, 21 %, 4 %, and 4 % for TACE monotherapy and 77 %, 55 %, 39 % and 22 % for combined TACE and PEI (Kaplan-Meier method). The kind of treatment significantly affected the survival rate (p = 0.002 log-rank test). Severe side effects were present in two patients of the monotherapy group and in three patients of the combination therapy group. CONCLUSION The combination of TACE and PEI is an effective and safe method in the palliative treatment of large HCC that has the potential of improving long term survival compared to TACE monotherapy.

PURPOSE To evaluate multislice-CT versus MRI in the diagnosis and staging of pancreatic carcinoma in a prospective multi-reader analysis. MATERIALS AND METHODS Fifty patients with suspected pancreatic carcinoma underwent both multislice-CT (4-Row, "hydro-technique") and state-of-the-art MRI (two 1.5 T units). In correlation with histopathologic findings or in case of a non-lesion diagnosis by follow-up (6-month interval), we evaluated MRI versus CT in a multi-reader analysis (2 reader pairs) for: 1. diagnostic quality; 2. examination time; 3. accuracy of potential resectability; 4. kappa analysis of observer variations; and 5. overall diagnostic reliability. RESULTS A total of 28 lesions (n = 22 malignant, n = 6 benign) were present in the cohort group versus 22 patients without a focal lesion (n = 10 pancreatitis, n = 12 no tumor). For lesion detection, CT had a sensitivity of 100/89 % (reader pair 1/2) and specificity of 77 %, and MRI had a sensitivity of 75/89 % and specificity of 77/73 %. For the subgroup of adenocarcinomas of the pancreas (n = 17), we found a sensitivity of 100 % and a specificity of 61 % for CT versus a sensitivity of 82/94 % and a specificity of 67/61 % for MRI. The accuracy for determining the resectability was 91/82 % for CT and 90/82 % for MRI. The kappa analysis showed a good correlation for CT (0.71) and a moderate correlation of both groups for MRI (0.49). CONCLUSION CT and MRI showed comparable results in the detection of pancreatic carcinomas as well as in the determination of resectability. Chronic pancreatitis as a "tumor-like-lesion" was the major factor of a missed diagnosis. The results of multi-reader analysis for both reading groups were almost identical with a moderate to good kappa correlation. There is no reason to prefer MRI (more expensive) over CT for patients with the presumptive diagnosis of pancreatic cancer.

Objective:To modify an ex vivo test procedure for balloon expandable stents as a means to evaluate the mechanical properties of self-expanding stents.Methods:Ten stents each of 7 different stent models measuring 10 mm in diameter (LUMINEXX Vascular Stent/Memotherm-FLEXX Vascular Stent [identical to

Imaging studies, ultrasonography, play a central role for the diagnosis and follow-up of cystic echinococcosis (hydatid disease) due to the non-specific clinical symptoms and still inadequate sensitivity and specificity of currently available serological tests. Due to the increasing number of people immigrating to central Europe from countries with a high incidence of cystic echinococcosis, cystic echinococcosis has become an important differential diagnosis of cystic lesions. The imaging modality to localize and stage the disease depends on the organs affected. Ultrasonography is the most important imaging technique to screen for abdominal lesions (more than 75 % of the cases). Therefore, an expert committee of the WHO Working Group on echinococcosis has recently suggested a standardized ultrasonographic classification of hepatic cystic echinococcosis. This classification proofs to be very useful for staging echinococcal cysts with respect to parasite activity. Ultrasonography is not only an excellent tool for the primary diagnosis and therapeutic decision but also for follow-up of patients treated for cystic echinococcosis. Indications for computed tomography or magnetic resonance tomography are restricted to extra abdominal disease, patients not suited for ultrasonography because of obesity or meteorism, complicated cysts and planning of surgery or interventional therapy. Apart from surgery three other treatment options are well established: (1) chemotherapy with albendazole or mebendazole, (2) percutaneous drainage and sterilization (PAIR) and (3) observation of inactive echinococcal stages ("watch and wait" approach).

Die Sklerosierung ist eine weltweit ausgeubte und anerkannte Behandlungsmethode der Krampfadern. Ihre Komplikationsrate erscheint gering. Die Grundkenntnisse werden in speziellen Kursen der wissenschaftlichen Gesellschaften vermittelt, die Erfahrung lasst sich in der personlichen taglichen Routine validisieren. Vor allem kommt es auf die Beachtung der Indikationen und der Kontraindikationen an, um gute Erfolge zu verzeichnen und ernsthafte Nebenwirkungen zu vermeiden. Zur Behandlung der Stamm- und Perforansvarikose ist die Verodungstherapie im Prinzip nicht geeignet. Es sind verschiedene internationale Schulen der Sklerosierungstechnik bekannt. Neuere Varianten der Behandlung wie die ultraschallgefuhrte oder die Schaumsklerosierung versuchen, auch die Stamm- und Perforansvarikose in den Indikationsbereich einzubeziehen, konnen aber keine Langzeitergebnisse vorlegen. Im Anschluss an die partielle Saphenaresektion oder an die selektive Perforansdissektion darf von der Verodung eine Optimierung des Behandlungserfolges v. a. in asthetischer Hinsicht erwartet werden. Von groster Bedeutung ist die fruhe Erkennung und situationsgerechte Therapie der Nebenwirkungen. Fur den Patienten sind asthetische Residuen wie Pigmentierungen, Matting, kleine Hautnekrosen oder Rezidive manchmal sehr belastend, sodass es zu juristischen Auseinandersetzungen mit dem Therapeuten kommt. Die versehentliche intraarterielle Injektion wird glucklicherweise nur sehr selten beobachtet, zeigt dann aber einen dramatischen Verlauf, der moglicherweise bis zum Verlust der Extremitat fuhrt.

Percutaneous angioplasty of a renal artery stenosis may lead to dissection and acute thrombosis that may put the organ at risk. In this case, it should be discussed individually how to treat the patient and the decision on interventional therapy should be based on interdisciplinary consensus. Local fibrinolysis usually allows to recognize the cause of obstruction which then is the basis for further treatments. The case report presented in this article describes how a dissection involving two thirds of the renal artery and leading to significant obstruction may successfully be treated by means of interventional radiology.

Aim: It was the aim of this study to investigate the success of biceps tenoplasty in massive interval rotator cuff tears. Method: Fifteen patients, who had a massive rotator cuff tear in the area of the interval and a pathology of the long head of the biceps tendon, were examined clinically and by MRI. A primary reconstruction of the rotator cuff tear was possible in none of the patients. All patients had a secondary reconstruction with a biceps tenoplasty. The Constant Score was determined postoperatively and the satisfaction of the patients was explored. Results: The mean age at the time of the operation was 55 years. The examination was 23 months postoperatively. A simultaneus rupture of the supraspinatus- and subscapularis tendon was seen in 12 patients, an additional rupture of the infraspinatus tendon in 3 patients intraoperatively. The long head of the biceps was dislocated in 10 patients and subluxated in 5 patients. The postoperative determined Constant Score was 82,7 points. The personal satisfaction was investigated by asking for the German schoolmarks, which extend from 1 (excellent) to 6 (not satisfactory). The preoperative schoolmark was 5,2 and the postoperative schoolmark 1,4. In the MRI examination one rerupture could be seen, an atrophy of the supraspinatus tendon was evaluated in four patients. Knowing the postoperative result, all patients would have repeated the operation. Conclusion: The biceps tenoplasty is a suitable operative method to achieve a better function and relief of pain in massive interval rotator cuff tears with simultaneous pathology of the long head of the biceps tendon. A high degree of personal satisfaction for the patient can be achieved.

The aim of this study was to assess the value of contrast-enhanced three-dimensional MR angiography (CE 3D MRA) in the preoperative assessment of potential living renal donors, and to compare the accuracy for the depiction of the vascular anatomy using three different rendering algorithms. Twenty-three potential living renal donors were examined with CE 3D MRA (TE/TR=1.3 ms/3.7 ms, field of view 260-320x350 mm, 384-448x512 matrix, slab thickness 9.4 cm, 72 partitions, section thickness 1.3 mm, scan time 24 s, 0.1 mmol/kg body weight gadobenate dimeglumine). Magnetic resonance angiography data sets were processed with maximum intensity projection (MIP), volume rendering (VR), and shaded-surface display (SSD) algorithms. The image analysis was performed independently by three MR-experienced radiologists recording the number of renal arteries, the presence of early branching or vascular pathology. The combination of digital subtraction angiography (DSA) and intraoperative findings served as the gold standard for the image analysis. In total, 52 renal arteries were correspondingly observed in 23 patients at DSA and surgery. Other findings were 3 cases of early branching of the renal arteries, 4 cases of arterial stenosis and 1 case of bilateral fibromuscular dysplasia. With MRA source data all 52 renal arteries were correctly identified by all readers, compared with 51 (98.1%), 51-52 (98.1-100%) and 49-50 renal arteries (94.2-96.2%) with the MIP, VR and SSD projections, respectively. Similarly, the sensitivity, specificity and accuracy was highest with the MRA source data followed by MIP, VR and SSD. Time requirements were lowest for the MIP reconstructions and highest for the VR reconstructions. Contrast-enhanced 3D MRA is a reliable, non-invasive tool for the preoperative evaluation of potential living renal donors. Maximum intensity projection is favourable for the processing of 3D MRA data, as it has minimal time and computational requirements, while having similar or superior accuracy for the depiction of vessel anomalies or pathology compared with VR and SSD, respectively.

Zielsetzung. Bei der akuten Divertikulitis entscheidet eine exakte Stadieneinteilung der Erkrankung uber das therapeutische Vorgehen.Die Diagnostik mittels Computertomographie (CT) wird der klinischen Einteilung der akuten Divertikulitis und den sich daraus ableitenden therapeutischen Strategien gegenubergestellt. Material und Methode. Die Durchfuhrung der CT bei Verdacht auf akute Divertikulitis erfolgt nach transanaler, intraluminaler Kontrastierung des Darms mit positivem wasserloslichem Kontrastmittel, um eine Penetration oder Darmperforation nachzuweisen. Anschliesend erfolgt eine intravenose Kontrastmittelapplikation, um das Kontrastverhalten der abdominellen Strukturen/Organe, insbesondere der Darmwand, zu beurteilen und Abszesse zu diagnostizieren. Die CT-Morphologie der verschiedenen Stadien der akuten Divertikulitis wird beschrieben und anhand von Beispielen vorgestellt. Ergebnisse. Die CT kombiniert bei der notfallmasigen Abklarung einer akuten Divertikulitis als einziges Verfahren Sicherheit mit Genauigkeit.Auf der einen Seite ist die CT schnell und damit sicher im Hinblick auf die Uberwachung des Patienten.Auf der anderen Seite erlaubt die CT eine exakte Stadieneinteilung der Entzundung mit einer Sensitivitat und Spezifitat von bis zu 100%. Durch den sicheren Nachweis von Komplikationen wie die Ausbildung eines Abszesses, einer Penetration oder Darmperforation,hat die CT unmittelbaren Einfluss auf die Therapie des Patienten. Diskussion. Die CT ist bei Verdacht auf eine akute Divertikulitis aufgrund der hohen Relevanz fur die Therapie und das Management von Komplikationen die diagnostische Methode der Wahl.

PURPOSE To compare hydrosonography (HUS), endosonography (EUS) and experimental sonography (PUS) with respect to TN-staging accuracy of gastric carcinoma. MATERIAL AND METHODS Thirty-six patients with gastric carcinoma underwent EUS (7.5/12 MHz transducer, Olympus GF-UM 20) and HUS (3.75 MHz transducer, Toshiba, Sonolayer SSA-270A) for TN-staging according to the UICC-classification. The resected specimens were reexamined (3.75/7.5 MHz transducer) and again TN-staging was performed. Findings were correlated with histopathological results. RESULTS T- and N-staging accuracies were as follows: EUS 54 % (19/35) and 79 % (27/34); HUS 41 % (15/37) and 61 % (22/36); and PUS 51 % (19/37) and 72 %(26/36). Sensitivities and specificities for the detection of lymph node metastases were as follows: EUS 87 % and 54 %; HUS 57 % and 69 %; and PUS 83 % and 54 %. CONCLUSIONS The accuracy of sonographic TN- staging is limited in patients with gastric carcinoma. Nevertheless, EUS may contribute to the preoperative management of patients with gastric carcinoma if indications are well defined. HUS is not suited for TN-staging of gastric carcinoma.

Purpose: To correlate gastric wall layers visible of MRI with the anatomical structure of the gastric wall. Methods: After macroscopic preparation 5 × 5 cm post-mortem tissue sections of the gastric antrum were evaluated using a 2.4 Tesla MR unit (Bruker, Ettlingen, Germany). MR imaging consisted of T2-weighted multi-spinecho sequences in longitudinal and axial directions. The specimens then were stained with hematoxylin-eosin for histological examination. After that histological correlation of the gastric wall layers visible on MRI was performed. Results: In all specimens four gastric wall layers could be clearly identified on MRI. The direct comparison of those layers to the histological findings showed the following correlation: 1) intermediate signal = mucosa, 2) hypointense signal = lamina muscularis mucosae, 3) hyperintense signal=submucosa, 4) intermediate signal = muscularis propria. Conclusions: Gastric wall layers visible on MRI were successfully correlated to the anatomic layers of the gastric wall. This allows us for the first time to classify invasion of gastric carcinoma using high spatial-resolution MR imaging. However, the subserosa and serosa are excluded from this conclusion, because so far a reliable statement concerning the value of MRI to depict these very variable layers is not possible.

Purpose To compare thin-section hydro-CT and MRI in the detection of pancreatic neoplasms. Evaluation of an oral, superparamagnetic contrast agent (OMP) for pancreatic MRI. Material and methods 45 patients with suspected pancreatic neoplasms were examined with consecutive thin-section helical CT (Hydro-CT, 3/6/3, 130 ml Ultravist, Schering) and MRI (1.0 T, breath-holding, T1w-GRE, T1w-GRE fat-sat, T2w-TSE). The MRI protocol included precontrast studies, studies after oral administration of OMP (Abdoscan, Nycomed Amersham) and studies after administration of OMP and Gadodiamide i.v. (Omniscan, Nycomed Amersham). All images were assessed by two independent radiologists in a blinded fashion. Radiologic diagnosis was correlated with histology or clinical follow-up (> or = 3 month). Results 39 patients could be included in analysis. In 13 cases a pancreatic neoplasm was proven by histology. Thin-section hydro-CT and MRI showed no statistically significant differences for the detection of pancreatic neoplasia. The sensitivity of helical hydro-CT was superior compared to MRI (88.5% vs. 65.44/73.1%/76.9%). The specificity of MRI was superior compared to helical hydro-CT (86.5% vs. 94.2%/90.4%/88.5%). Conclusion Thin-section hydro-CT and MRI show similar results for the detection of pancreatic neoplasms. Compared to thin-section helical CT, MRI still has the drawbacks of much more time consumption and, still, lower spatial resolution. The use of an oral, superparamagnetic contrast agent added no advantage for pancreatic MRI.

Bei der zystischen Adventitiadegeneration handelt es sich um eine seltene Veranderung der Adventitia mit Ausbildung muzinhaltiger Zysten. Die Erkrankung tritt v. a. an der A. poplitea auf und betrifft vorrangig Manner, mit einem Haufigkeitsgipfel in der 4. Dekade. Anhand der Fallbeschreibung eines Rezidivs einer zystischen Adventitiadegeneration werden die Moglichkeiten der modernen Schnittbildgebung diskutiert und die Vorteile der Magnetresonanztomographie und -angiographie fur die Diagnostik dieser Erkrankung aufgezeigt. Weiterhin werden die Atiologie und die zur Verfugung stehenden gefaschirurgischen Therapieverfahren erlautert.

Chronic inflammatory bowel disease is diagnosed and monitored by the combination of colonoscopy and small bowel enteroklysis. Magnetic resonance imaging has become the gold standard for the imaging of perirectal and pelvic fistulas. With the advent of ultrafast MRI small and large bowel imaging has become highly attractive and is being advocated more and more in the diagnostic work up of inflammatory bowel disease. Imaging protocols include fast T1-weighted gradient echo and T2-weighted TSE sequences and oral or rectal bowel distension. Furthermore, dedicated imaging protocols are based on breath-hold imaging under pharmacological bowel paralysis and gastrointestinal MR contrast agents (Hydro-MRI). High diagnostic accuracy can be achieved in Crohn's disease with special reference to the pattern of disease, depth of inflammation, mesenteric reaction, sinus tract depiction and formation of abscess. In ulcerative colitis, the mucosa-related inflammation causes significantly less bowel wall thickening compared to Crohn's disease. Therefore with MRI, the extent of inflammatory changes is always underestimated compared to colonoscopy. According to our experience in more than 200 patients as well as the results in other centers, Hydro-MRI possesses the potential to replace enteroklysis in the diagnosis of chronic inflammatory bowel disease and most of the follow-up colonoscopies in Crohn's disease. Further technical improvements in 3D imaging will allow interactive postprocessing of the MR data.

The aim of imaging of gastric carcinoma has to be to diagnose the carcinoma as early as possible and to sort out the tumors that are resectable. At the same time imaging of gastric carcinoma should reduce the number of futile laparotomies in patients with advanced, non-resectable tumors to a minimum. Today, endoscopy is the method of choice to diagnose gastric carcinoma. Endosonography is advantageous if small carcinomas have to be judged for depth of tumor infiltration (early gastric carcinoma vs. advanced gastric carcinoma) because high resolution images of the gastric wall are obtained. Staging of large carcinomas that have grown beyond the gastric wall is best performed by hydro-CT because CT scans most accurately delineate infiltrations of surrounding organs/structures and help to plan surgery. Nowadays MRI is not suited for gastric imaging. MRI, however, has the highest potential to fundamentally improve staging of gastric carcinoma if high resolution imaging of the gastric wall is combined with screening for metastases in one examination.

Beim Klippel-Trenaunay-Syndrom sind die Organe des kleinen Beckens, wie Rectum und Harnblase, selten betroffen, sie konnen in seltenen Fallen jedoch Ausgangsort fur lebensbedrohliche Blutungen werden. Wir berichten uber einen 39 jahrigen Patienten mit Klippel-Trenaunay-Syndrom der rechten unteren Extremitat und der rechten Beckenhalfte, bei dem seit Kindheit rezidivierende rectale Blutabgange bekannt sind. Zur stationaren Aufnahme zwang eine substitutionspflichtige, protrahierte rectale Blutung. Rectoskopisch zeigte sich eine vollstandig angiomatos veranderte Mucosa des Rectums und Sigmas mit Blutungsaktivitat aus mehreren Gefasconvoluten. Um einer starken intraoperativen Blutung vorzubeugen, wurde ein sequentielles Vorgehen gewahlt. Zunachst wurden die tumorversorgenden Gefase selektiv embolisiert und dann im Intervall nach 48 Std eine Rectumexstirpation unter Einbeziehung des distalen Sigmas durchgefuhrt. Bei Erhalt des Sphincterapparats wurde die Kontinenz durch eine colonpouchanale Anastomose mit protektivem Loop-Ileostoma wiederhergestellt. Der postoperative Heilungsverlauf gestaltete sich komplikationslos.

PURPOSE The purpose of this work was to define the accuracy of helical hydro-CT (HHCT) in the diagnosis and staging of gastric carcinoma. METHOD One hundred twelve patients with gastric carcinoma were preoperatively imaged by HHCT. Gastric distension was achieved by ingestion of up to 1,500 ml of water. Bolus tracking was performed, and peristalsis was minimized by intravenously administered spasmolytics. Contrast material was then injected, and helical scanning was performed at the time of peak enhancement of the liver. CT images were analyzed for tumor infiltration of the gastric wall, and TNM staging criteria were applied according to the International Union Against Cancer (UICC) classification. The results were correlated with histopathologic findings. RESULTS One hundred two of 115 (89%) gastric carcinomas were correctly diagnosed by HHCT. Small malignant ulcers (< or =2 cm) that corresponded to early gastric carcinoma were not visible on CT scans. T and N staging accuracies were 51% each; abdominal M staging was correct in 79% of all cases. The positive and negative predictive values of HHCT to foresee curative resection of gastric carcinoma were 75 and 84%, respectively. CONCLUSION Mural thickening as well as marked contrast enhancement of the gastric wall are firmly related to gastric carcinoma. The accuracy of HHCT is acceptable for M staging but inadequate for local staging of gastric carcinoma. Nonetheless, HHCT is a useful guide for choosing between tumor resection and nonoperative treatment of patients. We therefore recommend HHCT as the method of choice for preoperative imaging of gastric carcinoma.

For imaging of renal pathology a broad spectrum of radiologic diagnostic procedures are available which are, sometimes and particularly more recently, competing among each other in their diagnostic yield and relevance. For tumorous lesions ultrasound, computed tomography and magnetic resonance imaging are performed predominantly. Angiography is no longer required with the exception of highly selected cases and in some specific preoperative workup requirements. Until recently, catheter based digital subtraction angiography has been considered as gold standard. However, non-invasive techniques such as CT-angiography and MR-angiography are evolving parallel to their quantum leap of resolutions and readiness to use. Nevertheless, well accepted criteria for quality assessement of these new modalities are still lacking. More comparison studies are urgently warranted. Despite the availability of ultrashort pulse sequences applying the T1 relaxation reduction effect of gadolinium enhanced MR techniques overestimation of renal artery stenosis still poses a substantial problem. Renal intervention implies a variety of procedures such as plain angioplasty, stent placement, embolization of traumatic and both benign and malignant tumors. These methods have emerged over the last two decades from a more experimental nature to a fully accepted treatment option. When renal artery angioplasty is embedded in an aggressive approach including stenting as an adjunct for more complex cases, renal ostial lesions and a well organized follow-up regimen its therapeutic potential for treatment of renal insufficiency, malignant hypertension, for organ preservation bears a very high potential. Provided adequat periinterventional drug regimen restenosis rates may be as low as 10%. In highly selected cases capillary embolization might be used as an alternative to nephrectomy with a similar clinical outcome. Particularly the development of superselective small caliber embolization catheters parallel to further refinement of embolization material has aided to use superselective occlusion techniques in benign vascular lesions and renal trauma.

Die bildgebende Diagnostik nach Nierentransplantation hat einen hohen Stellenwert in der Differentialdiagnostik peri- und postoperativer Komplikationen. Die Sonographie mit Doppler- und Farbduplexsonographie ist die Methode der ersten Wahl in der Diagnostik der akuten Transplantatabstosung. Die MRT kann als zusatzliche Methode in der Diagnostik der akuten Transplantatdysfunktion und insbesondere bei unklarer perirenaler Flussigkeitsansammlungen nach Transplantation eingesetzt werden. MR-Angiographie und MR-Urographie sind erganzende nichtinvasive Methoden, welche die Angiographie (DSA) und Pyelographie zunehmend ersetzen konnen. Die Angiographie, erganzt durch die CO2-Angiographie, ist weiterhin der Goldstandard in der Diagnostik von Transplantatarterienstenosen.

Purpose Evaluation by hydro-CT in diagnosing and staging of primary non-Hodgkin lymphoma of the stomach (MALT). Material and methods 15 patients with MALT lymphoma underwent imaging by hydro-CT (helical CT scanning optimised for parenchymal and vessel contrast with distension of the gastric wall by water). The CT scans were evaluated for the site, morphology, extent and contrast enhancement of gastric lymphoma; in addition, the number and location of abdominal lymph nodes were examined. The results of CT imaging were compared with the findings at endoscopy + biopsy and endosonography and in case of gastrectomy also with the histopathological results. Results All lymphomas were correctly diagnosed and were mostly located in the distal parts of the stomach. MALT lymphoma typically grew submucosally, infiltration of the mucosa was rare. Most tumours showed marked contrast enhancement of the mucosa and poor enhancement of the submucosa. Hydro-CT and endosonography had similar accuracies in respect of staging of compartment I and II lymph nodes. Staging of distant nodal groups was more accurate by hydro-CT. Conclusion Hydro-CT is non-invasive and may be used for diagnosis and staging of primary gastric lymphoma with a typical morphology of gastric lymphoma. Hydro-CT may be regarded as complementary to endosonography and is well suited for the initial diagnosis of gastric lymphoma as well as for the diagnosis of recurrent tumour.

Purpose: Our purpose was to determine the value of MRI in diagnosing pouch-related fistulas in patients with ulcerative colitis and to compare pulse sequences with and without contrast enhancement in their performance of visualization. Method: Forty-four patients with pelvic symptoms after restorative proctocolectomy underwent MRI. All 26 patients with pouch-related fistulas were treated surgically; 18 patients with pouchitis were treated conservatively. MRI was performed at 1.0 T with T1-weighted FLASH sequences before and after administration of Gd-DTPA, T2-weighted and proton density-weighted turbo SE sequences, and a T2-weighted fat saturation sequence. Images were analyzed for the presence of fistula; pulse sequences were additionally compared for best visualization on a four point scale of diagnostic confidence. Results: MRI detected 23 of 26 cases of fistulas; there were no false-positive diagnoses. Surgery revealed fistulas in three cases in which no pathology was found on MRI. Two patients had a short sinus tract at the pouch-anal anastomosis, and a third patient had a pouch-vaginal fistula. The Gd-enhanced FLASH sequence obtained the highest score, and second best was the T2-weighted fat saturation technique. Conclusion: MRI is a valuable technique for diagnosing pouch-related fistulas. However, there are limitations in detection of short sinus tracts and pouch-vaginal fistulas. Highest diagnostic confidence is obtained with a Gd-enhanced FLASH sequence, which might be helpful after pelvic surgery or if the fat saturation technique is equivocal.

Der Stellenwert der zwei neu entwickelten Untersuchungsverfahren Hydrosonographie (HUS) und Hydro-CT (HCT) wurde im Rahmen einer Prospektivstudie zur Diagnostik kolorektaler Karzinome evaluiert.

Purpose Evaluation of hydro-MRI in the diagnosis of chronic inflammatory bowel disease (IBD). Material and methods 33 patients with suspected Crohn's disease or ulcerative colitis were studied prospectively. After distension of the colon by a rectal enema, breathhold MR imaging was performed during bowel relaxation. Results were compared to the clinical diagnosis, endoscopy, barium studies and histopathology. Results 24/24 patients with active Crohn's disease were correctly diagnosed by MRI. Conversely, MRI was positive in only 2/5 patients with ulcerative colitis. In 5 patients the presence of IBD was excluded. There were no false positives. Conclusion Hydro-MRI is a very reliable modality in the diagnosis of Crohn's disease. In the differentiation of Crohn's disease from ulcerative colitis, hydro-MRI seems to be a promising imaging procedure.

Purpose To define the value of conventional radiography compared with CT in the follow-up of complicated, long-term tube drained pleural empyema after intracavitary application of contrast medium. Methods 28 patients with complicated pleural empyema (stage III) and long-term tube drainage were submitted to fluoroscopy of the pleural cavity and a CT of the thorax after contrast medium had been instilled into the pleural space. Both examinations were judged by the following criteria: number and morphology of pleural cavities, quality of drainage and accompanying thoracic disease. Results 49 pleural cavities were diagnosed. Judgement of drainage corresponded in 79% of cases and differed in 21% with proof of further not drained cavities only on CT. 4 bronchopleural fistulas were diagnosed by fluoroscopy, of which only 2 were evident on CT. Accompanying thoracic disease was reliably detected by CT only. Conclusions Diagnosis of bronchopleural fistulas and judgement of the pleural drainage is best possible using fluoroscopy after application of contrast medium into the pleural space. CT is most accurate to detect further cavities that have not been drained, to look for concomitant thoracic disease, and to judge the morphology of the pleural cavity. Conventional radiography of the pleural space is effective and recommended to be used as a first line investigation for the follow-up of stage III empyemas. Patients in poor general condition (fever, elevated blood markers indicating inflammation) should be examined by both fluoroscopy and CT.

The interdisciplinary guidelines at the S3 level on the diagnosis of and therapy for hepatocellular carcinoma (HCC) constitute an evidence- and consensus-based instrument that is aimed at improving the diagnosis of and therapy for HCC since these are very challenging tasks. The purpose of the guidelines is to offer the patient (with suspected or confirmed HCC) adequate, scientifically based and up-to-date procedures in diagnosis, therapy and rehabilitation. This holds not only for locally limited or focally advanced disease but also for the existence of recurrences or distant metastases. Besides making a contribution to an appropriate health-care service, the guidelines should also provide the foundation for an individually adapted, high-quality therapy. The explanatory background texts should also enable non-specialist but responsible colleagues to give sound advice to their patients concerning specialist procedures, side effects and results. In the medium and long-term this should reduce the morbidity and mortality of patients with HCC and improve their quality of life.

In bis zu 50 – 60% der Falle treten Poplitealaneurysmen bilateral, bei 30% der Patienten gleichzeitig mit einem BAA auf. Das unbehandelte symptomatische Aneurysma der Arteria poplitea geht mit Amputationsraten von 25 – 30% einher. Fur asymptomatische Aneurysmata werden Komplikationsraten von 24% im ersten Jahr und 68% in 5 Jahren nach Diagnosestellung beschrieben. Ursachlich ist eine progrediente Ischamie durch rezidivierende okkulte Embolisationen aus dem Aneurysma in den peripheren Abstrom. Symptomatische Aneurysmen werden immer und asymptomatische Aneurysmen ab einer Grose von 2 cm und/oder Thrombenbildung im Aneurysma behandelt. Die Ergebnisse einer Bypassanlage sind gunstig mit Reduktion der Majoramputationen um >50%. Die Beinerhaltungsrate nach 1 Jahr differiert zwischen akut (83%) und elektiv (96%) operierten Patienten. Der elektive Venenbypass besitzt eine 5-Jahres-Offenheitsrate von 85%. Die minimal-invasive Endograftanlage zeigt vergleichbare 1 – 3 Jahresoffenheitsraten. Die Eingriffs- und Hospitalisationszeiten der Patienten sind signifikant kurzer bei Endograftanlage. Die Komplikationsraten fallen ebenfalls gunstiger aus. Die 30/90 Tages-Mortalitat ist in beiden Gruppen vergleichbar, wahrend die Rate der Reinterventionen in der Endograftgruppe hoher liegt. Der Ausflustrakt (2/3 Gefasabstrom vs. schlechter 1 Gefasabstrom) beeinflust die Offenheitsrate der Endografts signifikant. In der Notfallsituation, bei alten Patienten und hohem Operationsrisiko ist der Endograft Verfahren der Wahl. Bei Patienten < 60 Jahren und anatomisch ungunstiger Situation fur einen Endograft wird dem operativen Verfahren der Vorzug gegeben. Lernziele: Korrespondierender Autor: Dux M Krankenhaus Nordwest, Radiologisches Zentralinstitut, Steinbacher Hohl 2 – 26, 60488 Frankfurt a.M. E-Mail: duex.markus@khnw.de

Ziel: Untersuchung der therapeutischen Effizienz der gepulsten Spruhlyse. Material und Methode: In einer prospektiven Studie wurde uber 10 Monate die gepulste Spruhlyse bei 28 arteriellen Verschlussen der unteren Extremitat durchgefuhrt und klinisch bewertet. 82 % der Patienten hatten eine gefahrdete Extremitat. Ergebnisse: Ein technischer Erfolg wurde in 89 %, ein klinischer Erfolg in 68 % erreicht. Das Zeitintervall bis zur Wiederherstellung einer Perfusion des verschlossenen Gefassegments betrug weniger als zwei Stunden, die gesamte mediane Therapiedauer 17 Stunden. Zwei Patienten musten wegen einer Blutung an der Punktionsstelle transfundiert werden. Bei einer Nachbeobachtungszeit von 6 Monaten sind 50 % aller behandelten Gefassegmente unverandert offen, die sekundare Offenheit liegt mit 53 % unwesentlich hoher. Bypasses haben eine signifikant niedrigere Offenheits- (p = 0,04) und hohere Amputationsrate (p = 0,009) als native Arterien. Bei einem schlechten Abstrom kommt es zu signifikant mehr initialen Miserfolgen (p = 0,05) und konsekutiven Amputationen (p = 0,025). Schlusfolgerungen: Entscheidender Vorteil der gepulsten Spruhlyse ist die schnelle Wiedereroffnung eines Gefasverschlusses und damit die effektive Behandlung der akuten Ischamie. Die Komplikationsrate ist niedrig. Purpose: To determine the clinical efficacy of pulse-spray thrombolysis. Material and methods: In a prospective trial 28 patients with acute arterial (n = 14) and bypass (n = 14) occlusions of the lower extremities were treated with pulse-spray thrombolysis. 23/28 legs were at risk. Results: Technical and clinical success were 89 % and 68 % respectively. Time interval until restitution of antegrade flow was less than two hours, the median duration of the complete intervention was 17 hours. Two patients (7.1 %) needed transfusions for inguinal haematomas. After six months 50 % of occluded segments remained patent, secondary patency is comparable at 53 %. Bypasses show significantly lower patency (p = 0.04) and higher amputation (p = 0.009) rates than native arteries. Bad run-off (≤ 1 artery patent) is a significant predictor for clinical failure and early amputation. Conclusions: The distinct advantage of pulse-spray thrombolysis is fast restoration of antegrade flow and thereby effective treatment of acute ischaemia. The complication rate is low without associated mortality.