Alexander Tschammler

Vascular patterns in reactive and malignant lymphadenopathy

A total of 130 superficial lymph nodes were evaluated using color Doppler flow imaging (CDFI) in order to differentiate benign from malignant lympadenopathy. The patterns of intranodal flow signals detected at standardized conditions by CDFI were classified using eight self-defined criteria and were correlated with the histopathological or clinical diagnosis. Nonparametric discriminant analysis showed that four vascular patterns were suspicious of malignancy: (a) avascular areas, (b) displacement of intranodal vessels, (c) accessory peripheral vessels and (d) aberrant course of central vessels. Of the neoplastic lymph nodes (n = 73), 96 % showed at least one pathological vascular pattern. Malignancy could be excluded in 95 % of 57 reactive lymph nodes using these four criteria. Most reactive lymph nodes in contrast demonstrated a vascular hilus and/or vessels running at the long axis of the lymph node with branches to the cortex. There was a diagnostic accuracy of 41–82 % in the additionally evaluated sonomorphological (size, shape, echogenicity) and Doppler (increased Pourcelots or pulsatility indices) criteria. The definitive interpretation of the promising results of this retrospective study requires confirmation of examiner independency as well as prospective evaluation.

Spiral CT angiography of renal arteries: comparison with angiography

Abstract. A prospective study was carried out to determine the accuracy of spiral CT angiography (CTA) in the detection of renal artery stenosis (RAS). Eighty-two patients with arterial hypertension underwent CTA and digital subtraction angiography (DSA) to exclude RAS. For CTA a contrast medium bolus of 100–150 ml (flow rate 3 ml/s) was injected. A 24 or 40 s CTA was started at the origin of the superior mesenteric artery after a delay time determined by test bolus injection (collimation = 2 mm, pitch = 1/1.5). For stenosis detection transverse images supported by maximum intensity projections (MIP) or multiplanar reconstruction projections were used. Of 197 renal arteries examined (including 33 accessory arteries), 34 RAS were visualized using DSA. With CTA, one hemodynamic RAS was missed and one additional hemodynamic RAS was found. Sensitivity/specificity was calculated to be 94 %/98 %. For hemodynamically relevant RAS (> 50 %) the sensitivity/specificity was 96 %/99 %. CTA additionally depicted five adrenal masses. The high accuracy rate of RAS detection thus allows the use of CTA as a screening method in patients with arterial hypertension to exclude a renovascular cause.

Galactography and exfoliative Cytology in women with abnormal nipple discharge

Objective To evaluate galactography and cytology in women with nipple discharge without clinical or mammographic evidence of cancer. Methods During a 12.5-year period, 384 women (15–85 years, mean age 47.5 ± 14 years) were referred for galactography and smear cytology for recent onset of spontaneous, non-milky nipple discharge. Patients with clinical or mammographic evidence of tumor underwent excisional biopsy directly. Among 314 galactograms, 189 [60.2%; 95% confidence interval (CI) 54.5%, 65.6%] biopsies were recommended. A further 11 patients were scheduled for biopsy because of mammography or cytology. Results Sixteen of 182 biopsied patients had malignancies (8.8%; CI 5.3%, 14.1%). Combined rate of papillomas, papillomatous proliferation, and malignant tumors was 59.9% (109 of 182; CI 52.4%, 67.0%). Biopsy was malignant in three of 56 women (5%) with nonhemorrhagic discharge and in 13 of 97 (13%) with hemorrhagic discharge (P = .26). Exfoliative cytology revealed 11 false-negatives, four false-positives, five true-positives, and 153 true-negatives (sensitivity 31.2%, CI 11%, 58%; specificity 97.4%, CI 93%, 99%). In ten of 158 patients (6.3%) with suspicious galactography, cancer was found by biopsy. Sensitivity of galactography for malignancy was 83% (CI 51.6%, 97.9%) and specificity was 41% (CI 35.2%, 46.5%). Galactographic sensitivity for any (benign or malignant) neoplasm was 94% (93 of 99; CI 87%, 98%) and specificity was 55% (119 of 215; CI 48%, 62%). Half of the cancers were detected exclusively by galactography. Conclusion Cytology is helpful when positive and galactography localizes the source of discharge. Biopsy is indicated when palpation, mammography, cytology, or galactography is suspicious.

Differential diagnosis of lymphadenopathy: power Doppler vs color Doppler sonography

Abstract. Our objective was to compare color and power Doppler sonography of superficial lymph nodes. One hundred ninety-three lymph nodes in 161 patients were assessed by color and power Doppler sonography using standardized settings. We tested which modality displayed more intranodal vessels and checked if these differences would have altered the diagnosis. Additional vessels were seen by color Doppler sonography in 18 nodes and by power Doppler sonography in 58 nodes. Amongst those nodes were 15 nodes which showed no vascularization in color Doppler sonography and 23 nodes with only few intranodal flow signals; however, the better sensitivity of power Doppler sonography had no impact on the diagnosis in 42 of 58 nodes. Diagnostic confidence was increased in 7 nodes which showed normal vessels only in power Doppler sonography, although missing flow signals were defined as a benign finding. Pathological vessels were displayed only by power Doppler sonography in 9 nodes, but 6 of these 9 results proved to be false positive. Power Doppler sonography displays more intranodal flow signals than color Doppler sonography, but the diagnostic impact is low because of an increased risk of false-positive results.

Long-Term Results of Vena Cava Filters: Experiences with the LGM and the Titanium Greenfield Devices

AbstractPurpose: Vena cava filter (VCF) application is the method of choice to prevent recurrent pulmonary embolism in patients with deep venous thrombosis. Because of the reported complications after VCF placement we summarize our long-term follow-up results with the LGM and Titanium Greenfield (TG) devices. Methods: Eighty-seven LGM VCF and 17 TG VCF were placed in 104 patients (average age 64 years). The follow-up examinations were performed by color-coded duplex sonography, plain radiographs, cavography, and computed tomography (CT). The maximum observation time was 81 months. Results: Filter migration occurred in 11% (8/76) of the LGM VCF and 15% (2/13) of the TG VCF. Vena cava thrombosis was seen in 17% (13/76) of the patients with an LGM VCF and in 31% (4/13) of those with a TG VCF. The patency rate was 95% (72/76) for the LGM VCF and 92% (12/13) for the TG VCF. Pulmonary embolism was noted in 3 patients after LGM VCF insertion and in no patient after TG VCF insertion. Conclusion: A VCF should only be inserted in a patient after pulmonary embolism and when there is strict proof of the indication.

Pathological angioarchitecture in lymph nodes: underlying histopathologic findings.

Pathologic changes of the intranodal angioarchitecture, as displayed by colour Doppler sonography, were used in recent studies to predict malignant infiltration of superficial lymph nodes. We searched for the underlying histopathologic findings in a prospective study including 100 lymph nodes in 86 patients. In the histopathologic specimens, we evaluated tumour infiltration, distribution of intranodal vessels, hilar structures, thickness of the capsule and tissue alterations (necrosis, sclerosis, lipo-/fibromatosis). Using the only prospectively tested classification, a pathologic angioarchitecture was described as displacement, aberrant course, avascular foci or subcapsular vessels. Testing these four criteria by multivariate regression analysis, the most important correlations were found between the following pairs of sonographic and histopathologic findings: displacement with perinodal tumour spread, aberrant vessels with intranodal sclerosis, avascular foci with intranodal necroses and subcapsular vessels with intranodal necroses. In conclusion, the criteria describing a pathologic angioarchitecture correlate with histopathologic findings that are frequently seen in malignant lymph nodes.

Multivariate analysis of the adjustment of the colour duplex unit for the differential diagnosis of lymph node alterations.

Abstract. Intranodal angioarchitecture was used as criterion for the differential diagnosis of lymph node alterations by colour duplex sonography. The influence of the adjustment of the duplex unit on the diagnostic accuracy and on the rate of lymph nodes with detectable intranodal flow signals was tested. A total of 243 superficial lymph nodes in 127 patients were included in a retrospective study. Diagnoses were approved by histopathology (n = 173) or clinical follow-ups (n = 70 reactive lymph nodes). The intranodal angioarchitecture and sonomorphology were assessed. We used nonparametric discriminant analysis in order to define appropriate settings for transducer frequency, flow mode, power and threshold which result in the best diagnostic quality. Of the lymph nodes, 87 % displayed flow signals using a threshold of ≥ 13 and the flow modes low or medium. Vascularisation was detected only in 47 % of the nodes assessed with different adjustments. Diagnostic accuracy dropped from 94 to 68–84 % if threshold was < 13 or power was less than –11 dB. An insufficient adjustment of the colour duplex unit decreases the chance of detecting intranodal flow signals and impairs the diagnostic quality of colour duplex sonography. Flow mode, power and threshold are the most important parameters which have to be adjusted properly.

Current value of double-contrast pharyngography and of computed tomography for the detection and for staging of hypopharyngeal, oropharyngeal and supraglottic tumors

Abstract. In light of recent endoscopic techniques the current value of double-contrast pharyngography (DCP) and of CT for detection and staging of hypo-, oropharyngeal, and supraglottic tumors is evaluated. The DCP of 151 patients and CT obtained from 99 of these patients were retrospectively analyzed in a double-blinded manner. We used a standard protocol which comprised all relevant anatomical subregions. Results were compared with direct microlaryngoscopy (DL), indirect laryngoscopy (IL), and post-operative histopathological findings. Sensitivity and specificity of DCP was 75.0 % and 86.7 %, respectively. The DCP and IL techniques together yielded a higher sensitivity (96.7 %) than each method separately. Sensitivity and specificity of CT was 87.5 and 100 %, respectively. In 74.7 % CT provided correct staging. Subregional analysis revealed that the results of DCP and CT depend highly on the localization of the tumor. Our results indicate that DCP represents an important screening method for diagnosing hypo-, oropharyngeal, and supraglottic tumors to complete IL and DL. We show that CT is a reliable method for preoperative staging, although small superficial tumors may occasionally be missed by this method.

Compression repair of ruptured pseudoaneurysms guided by color Doppler ultrasonography: Report of two cases

Noninvasive treatment of ruptured postcatheterization pseudoaneurysms is rare. We report the use of ultrasonographically guided compression repair for the treatment of ruptured pseudoaneurysms in 2 cases. To ensure the immediate stop of bleeding, more compression was applied than for nonruptured pseudoaneurysms, regardless of flow in the femoral artery or vein, thus maximizing the effectiveness of this therapy. With this method, complete thrombosis of the pseudoaneurysm could be achieved in less than 30 minutes. In both cases, ultrasonographically guided compression repair was faster than the time needed to prepare an operating room for surgical treatment. In follow‐up examinations, no recurrences or further complications were detected. Ultrasonographically guided compression repair can be used for noninvasive treatment of ruptured pseudoaneurysms in some cases, provided that more compression than indicated for nonruptured pseudoaneurysms is applied. Further clinical experience with more patients will be necessary to determine the exact benefits and possible limitations.