Dieter zur Nedden

Ultrasound of prostate cancer: recent advances

Prostate cancer is the most common cancer in men. In the future, a significant further increase in the incidence of prostate cancer is expected. Therefore, improvement of prostate cancer diagnosis is a main topic of diagnostic imaging. The systematic prostate biopsy (“ten-core biopsy”) is now the “gold standard” of prostate cancer diagnosis but may miss prostate cancer. Contrast-enhanced colour Doppler ultrasound (US) and elastography are evolving methods that may dramatically change the role of US for prostate cancer diagnosis. Contrast-enhanced colour Doppler US allows for investigations of the prostate blood flow and consequently for prostate cancer visualization and therefore for targeted biopsies. Comparisons between systematic and contrast-enhanced targeted biopsies have shown that the targeted approach detects more cancers and cancers with higher Gleason scores with a reduced number of biopsy cores. Furthermore, elastography, a new US technique for the assessment of tissue elasticity has been demonstrated to be useful for the detection of prostate cancer, and may further improve prostate cancer staging. Therefore, contrast-enhanced colour Doppler US and elastography may have the potential to improve prostate cancer detection, grading and staging. However, further clinical trials will be needed to determine the promise of these new US advances.

Diagnostic Performance of 64-Slice Computed Tomography in Evaluation of Coronary Artery Bypass Grafts

OBJECTIVE The purpose of this study was to compare the diagnostic accuracy of 64-slice CT with that of invasive angiography in the detection of greater than 50% graft stenosis within 2 weeks of coronary artery bypass grafting and to investigate the clinical value of 64-slice CT. SUBJECTS AND METHODS Forty-one patients (70 grafts, 46 arterial and 24 venous) underwent 64-slice CT a mean of 2.6 years after minimally invasive or conventional coronary artery bypass surgery. RESULTS All 70 grafts were assessable, and none of the grafts was excluded from analysis. For the detection of 50-90% graft stenosis, the sensitivity of CT was 75%, the specificity was 95%, the positive predictive value was 67%, and the negative predictive value was 97% (true disease prevalence, 8/70 grafts; 11%). Greater than 50% graft stenosis and occlusion pooled together (prevalence, 14/70; 20%) were detected with a sensitivity of 85%, specificity of 95%, positive predictive value of 80%, and negative predictive value of 96%. Vein graft disease was found in eight (42%) of 19 patent vein grafts (graft age, 15.6 +/- 2.3 years). The disease was nonobstructive in three (16%) of the 19 grafts. The course of the left internal mammary artery was median retrosternal (< 1 cm deep) in 33.3% of conventionally sutured grafts. CONCLUSION Sixty-four-slice CT angiography can be used for accurate exclusion of greater than 50% graft stenosis, but detection of distal anastomotic stenosis is limited, and the degree of stenosis can be overestimated. The advantages of CT, however, are that it is noninvasive, vein graft disease can be diagnosed at an early stage, and complementary evaluation of extracardiac anatomic features provides useful information before coronary artery bypass grafting is redone.

Value of contrast-enhanced ultrasound and elastography in imaging of prostate cancer.

Purpose of review Prostate cancer is the most commonly diagnosed malignancy in men. Gray-scale ultrasound-guided systematic biopsy is the standard of care for prostate cancer detection in men with an elevated prostate-specific antigen or an abnormal digital rectal examination. Systematic biopsy may miss up to 35% of clinically relevant cancers. Color and power Doppler ultrasound, ultrasound contrast agents, and elastography have and will dramatically change the role of ultrasound in prostate cancer diagnosis. Recent findings Several reports have demonstrated that contrast-enhanced ultrasound investigations of the blood flow of the prostate allow for prostate cancer visualization and therefore, for targeted biopsies. Comparisons between systematic and contrast-enhanced ultrasound-targeted biopsies have shown that the targeted approach detects more cancers with a lower number of biopsy cores. Furthermore, contrast-enhanced ultrasound has been shown to detect cancers with higher Gleason scores compared with the systematic approach, which seems to improve prostate cancer grading. In addition, elastography is a new ultrasound technique that allows for the assessment of tissue elasticity. Summary Contrast-enhanced ultrasound and elastography improve prostate cancer detection and may be useful for prostate cancer grading and staging. Future clinical trials will be needed to determine the promise of these new advances for ultrasound of the prostate evolving into clinical applications.

Combined radiation and chemotherapy for locally advanced transitional cell carcinoma of the urinary bladder

A prospective study was performed on 22 patients with locally advanced transitional cell carcinoma of the urinary bladder to evaluate the toxicity and efficacy of an integrated treatment with cis‐diamminedichloroplatinum (1.6 mg/kg body weight every 3 weeks for four cycles) and 60 G cobalt 60 or 18 MEV photons. Local and systemic toxicity caused by this treatment schedule was minor. Late sequelae consisted of contracted bladder in three patients. The rate of tumor‐free bladders after a mean follow‐up of 14 months was 17 of 22. Distant metastases occurred in three patients. Local recurrence of superficial tumor elsewhere in the bladder was observed in two patients. Six patients died 4 to 10 months after initiation of the integrated therapy, three of these without evidence of disease.

Diagnostic Performance of MDCT for Detecting Aortic Valve Regurgitation

OBJECTIVE This study evaluates whether ECG-gated 16-MDCT coronary angiography provides a reliable imaging technique for detecting aortic regurgitation (AR). SUBJECTS AND METHODS We examined 71 patients prospectively with 16-MDCT angiography using retrospective ECG gating during the mid-to-end diastolic phase. A visible central valvular leakage area was considered as a diagnostic criterion for AR. The central valvular leakage area was quantified in patients with positive transthoracic echocardiography (TTE). We compared 16-MDCT to Doppler TTE, the accepted diagnostic standard based on semiquantitative regurgitation jet analysis (grade 0-3+ for mild, moderate, and severe). RESULTS The overall sensitivity of 16-MDCT for the identification of patients with AR was 81%. The specificity was 91%, the negative predictive value was 70%, and the positive predictive value was 95%. Of the 71 patients, 48 had AR determined by TTE, and 16-MDCT correctly detected AR in 39 of those 48 patients. The sensitivity of 16-MDCT for the detection of patients with moderate and severe AR (grade > or = 1.5+) was 95%, and the specificity was 96% (20 of 21 patients). The sensitivity of 16-MDCT for identification of patients with mild AR (grade < or = 1+) was 70%, and the specificity was 92% (19 of 27 patients). Quantification of the central valvular leakage area was not possible in 50% of cases with AR by TTE because of valve calcifications. CONCLUSION Sixteen-MDCT coronary angiography provides an accurate, noninvasive imaging technique to detect moderate and severe aortic regurgitation (grade > or = 1.5+). However, severe valve calcifications and mild AR limit its results.

Finger injuries in extreme rock climbers. Assessment of high-resolution ultrasonography.

Dynamic high-resolution ultrasonography findings obtained in 34 extreme rock climbers with finger injuries were compared with those in 20 healthy volunteers. Thicknesses of the flexor tendon and A-2 flexor tendon pulley system were measured at the base of the proximal phalanx. The distance between the tendon and phalanx was evaluated with the finger in extension and in forced flexion as a measure of bowstringing. Gliding ability of the flexor tendons was assessed during active and passive motion. Compared with healthy volunteers, climbers showed a significantly increased thickness of the flexor tendons and the flexor tendon pulley system but no impairment of the gliding mechanism. Only in climbers did the distance between tendon and phalanx increase from 0.14 cm ( 0.07) during extension to 0.30 cm ( 0.09) during forced flexion. In three climbers with complete A-2 pulley ruptures this distance was up to 0.51 cm ( 0.15) during forced flexion. Clinically unsuspected synovial cysts, thickened joint capsules, fibrous tissue, or fluid collection were found only in climbers. We concluded that dynamic ultrasonography is a valuable tool for accurate assessment of early changes in “climbers finger.” It provides useful information, especially in cases where clinical evaluation is difficult, and should be performed to select appropriate therapeutic management.

Laparoscopic pyeloplasty for UPJ obstruction with crossing vessels: contrast-enhanced color Doppler findings and long-term outcome.

Objectives. To evaluate, in the present long-term follow-up study, contrast-enhanced color Doppler imaging (CDI) findings and the clinical outcome of patients with crossing vessels at the obstructed ureteropelvic junction (UPJ), who underwent laparoscopic pyeloplasty. In a previous study, contrast-enhanced CDI proved capable of detecting crossing vessels at the UPJ. Methods. A total of 23 patients, who had undergone laparoscopic pyeloplasty and displacement of crossing vessels for UPJ obstruction at least 2 years before this study (mean 27 months), underwent contrast-enhanced CDI, intravenous urography, and renography. Contrast-enhanced CDI was performed using intravenously administered Levovist to assess the displacement of the vessels relative to the UPJ. All patients completed analog follow-up pain scales and quality-of-life assessment questionnaires. Results. Contrast-enhanced CDI revealed a cranial displacement (mean 1.3 cm) of the crossing vessels from the UPJ in all 23 cases. Intravenous urography showed a decrease in the degree of hydronephrosis, with a success rate of 100% in low-grade and 86% in high-grade hydronephrosis. The split renal function improved from 39.7% to 48.1%. Analog pain scale measurements demonstrated a mean improvement in pain of 92% (range 73% to 100%) and a mean quality-of-life score of 94 (range 78 to 100). Conclusions. Our series of patients with crossing vessels at the UPJ treated by laparoscopic pyeloplasty showed an excellent long-term successful outcome. Contrast-enhanced CDI allows for preoperative detection, as well as postoperative assessment, of the displacement of the crossing vessel. We recommend that the presence of a crossing vessel be routinely determined preoperatively, because it may influence the choice of treatment modality and thereby the clinical outcome.

Age-Related Rhabdosphincter Function in Female Urinary Stress Incontinence Assessment of Intraurethral Sonography

Objective. To assess dynamic intraurethral sonography in the diagnostic evaluation of the function of the rhabdosphincter in female patients with urinary stress incontinence in relation to patient age. Methods. Sixty‐two patients with clinically proved urinary stress incontinence were investigated by means of intraurethral sonography with a 12.5‐MHz endoluminal 9F catheter. The omega‐shaped rhabdosphincter was visualized at rest and during voluntary contractions. Changes of muscle thickness and transducer‐sphincter distance were measured and considered as parameters of muscle function. The intraurethral sonographic data were compared with results of standard urodynamic tests. Results. Transducer‐sphincter distance and sphincter muscle thickness showed a significant decrease with positive linear dependency on patient age (P < .001). Patients with grade III urinary stress incontinence had complete loss of sphincter contractility. A negative correlation was revealed between urethral closure pressure and patient age. Conclusions. We found an age‐related decrease in rhabdosphincter function. Our results suggest that the rhabdosphincter is a substantial component of the continence mechanism in female urinary stress incontinence. Unlike urethral pressure profiles, which can only reveal zones of higher intraluminal pressure, transurethral sonography is highly specific for measurement of the function of the rhabdosphincter.

Value of magnetic resonance imaging in prostate cancer diagnosis

MRI has shown its potential in prostate cancer (PCa) imaging. MRI is able to demonstrate zonal anatomy with excellent contrast resolution. Furthermore it can detect PCa dependent not only on tumor-size, histological grading, PSA levels, but also on technical equipment and reader’s experience. Non-palpable PCas in the inner and outer gland can be detected by this technique. Another potential is that MRI is helpful for tumor staging and treatment planning as well as response evaluation. Besides the morphological information, MRI can give functional information based on metabolic evaluation with proton magnetic resonance spectroscopy and of tumor angiogenesis based on dynamic contrast-material enhanced MRI and diffusion-weighted imaging. In addition MRI can be used for targeted prostate biopsies; however, the clinical practicability is questionable. Furthermore many data about the value of MRI for PCa diagnosis are based on transrectal ultrasound (TRUS) biopsy findings. Since there is lack of accuracy in fusing MRI images with TRUS images these limit the results of MRI for cancer diagnosis. However, in the future MRI may play an additional role in planning and monitoring minimally invasive PCa therapies. Although, MRI of the prostate seems to be useful, nevertheless this method remains expensive and lacks availability regarding the oncoming requirements.

Schwannoma of the brachial plexus: cross-sectional imaging diagnosis using CT, sonography, and MR imaging.

Abstract. Primary brachial plexus tumors are rare, usually benign, and in general have a good prognosis after surgical excision. We present a case of a schwannoma in which sonography enabled the correct diagnosis of a probably benign brachial plexus tumor. Key to the diagnosis was the demonstration of a smooth-bordered, longish, and well-defined nodule along a brachial plexus nerve root. Cross-sectional imaging modalities that provide a high degree of soft tissue contrast and spatial resolution, such as sonography and MR imaging, were suitable methods to establish the correct preoperative diagnosis. Findings at CT, sonography, MR imaging, and surgery are discussed.