UDC 616-006(05)(497 1) CODEN RDIUA 4 YU ISSN 0485-893X RADIOlOGIA IUGOSlAVICA ANNO 24 1990 FASC 4 PROPRIETARII IDEMOUE EDITORES SOCIETAS RADIOLOGORUM IUGOSLAV1AE AC SOCIETAS MEDICINAE NUCLEARIS IN FOEDERATIONE SOCIALISTICA REI PUBLICAE IUGOSLAVIAE LJUBLJANA Radiol lugosl October -December 1990; 24:313-431 Nov. generacija cepiv HEPAGERIX B® injekcije cepivo proti hepatitisu 8, izdelano z genetskim inženiringom • metoda genetskega inženiringa .izkljucuje prisotnost cloveške krvi • popolnoma varno in široko preskušeno cepivo • visoko ucinkovito cepivo, ki varuje pred vsemi znanimi podvrstami hepatitisa B in pred hepatitisom O • dosega skoraj 100 % serokonverzijo • lahko ga dajemo v vseh starostnih obdobjih • vsi ga dobro prenašajo Bazicno cepljenje opravimo s 3 intramuskularnimi dozami po eni izmed shem (O, 1, 6) ali (O, 1, 2): a) osebe, ki so izpostavljene manjšemu ali zmernemu tveganju infekcije: prva doza: dan po izbiri (O) druga doza: mesec dni po prvi dozi (1) tretja doza: 6 mesecev po prvi dozi (6) b) osebe, ki potrebujejo hitro zašcito ali so pogosteje izpostavljene infekciji: prva doza: dan po izbiri (O) druga doza: mesec dni po prvi dozi (1) tretja doza: 2 meseca po prvi dozi (2) Odrasli in otroci starejši od 1 O let: 20 µ.g proteina površinskega antigena v 1 ml ,1 suspenzije. Novorojencki in otroci do 1 O let: 10 µ.g proteina površinskega antigena v 0,5 ml suspenzije. Podrobnejše informacije in literaturo dobite pri proizvajalcu. t(. KRK. tovarna zdravil, p. o., Novo mesto UDC 616-006(05)(497 1) GODEN ROIUA 4 YU ISSN 0485-893X RADIOLOGIA IUGOSLAVICA PROPRIETARII IOEMOUE EDITORES: SOCIETAS RADIOLOGORUM IUGOSLAVIAE AC SOCIETAS MEDICINAE NUCLEARIS IN FOEDERATIONE SOCIALISTICA REI PUBLICAE IUGOSLAVIAE LJUBLJANA ANN024 1990 FASC. 4 Redakcijski odbor -Editorial Board Bajraktari Xh, Priština -Benulic T, Ljubljana -Bicaku E, Priština -Borota R, Novi Sad ­Brzakovic P, Beoqrad -Fazarinc F. Celie -Granic K. Beoqrad -Grivceva-Janoševic N. Skooie -lvancevic D, Zagreb -Jevtic V, Ljubljana -Karanfilski 8, Skopje -Kicevac -Miljkovic A, Beograd -Kostic K, Beograd -Lekovic A, Rijeka -Lovrencic M, Zagreb -Miric S, Sarajevo -Mušanovic M, Sarajevo -Nastic Z, Novi Sad -Odavic M, Beograd -Plesnicar S, Ljubljana-Popovic L, Novi Sad -Popovic S, Zagreb -Škrk J, Ljubljana -Spaventi š, Zagreb-Tabor L, Ljubljana -Varl B, Ljubljana -Velkov K, Skopje Glavni i odgovorni urednik -Editor-in-Chief: Benulic T. Ljubljana Tehnicki urednik -Technical Editor: Serša G, Ljubljana Uredici -Editorial Statt: Bebar S, Ljubljana -Guna F. Ljubljana -Kovac V, Ljubljana -Pavcnik D. Ljubljana ­Plesnicar S. L1ubljana -Rudolf Z, Ljubljana -Snoj M, Ljubljana Radiol lugosl October -December 1990; 24:313-431 RADIOLOGIA IUGOSLA VICA Revija za rendgendijagnostiku, radioterapiju, onkologiju, nuklearnu medicinu, radiofiziku, radiobiologiju i zaštitu od ionizantnog zracenja -The review for radiology, radiotherapy, oncology, nuclear medicine, radiophysics, radiobiology and radiation protection. lzdavaci -Publishers: Udruženje za radiologiju Jugoslavije i/and Udruženje za nuklearnu medicinu Jugoslavije lzdavacki savet -Advisory Board: Lovrincevic A, Sarajevo predsednik (president) -Catic Dž, Sarajevo -Dedic M, Novi Sad -Dujmovic M, Rijeka -Grunevski M, Skopje -Guna F, Ljubljana -lvkovic T, Niš -Jašovic M, Beograd -Kocic D, Sarajevo -Kovacevic D, Zagreb -Ledic S, Beograd -Lovasic 1, Rijeka -Milutinovic P, Beograd -Mitrovic N, Beograd -Plesnicar S, Ljubljana -Pocajt M, Maribor -Porenta M, Ljubljana -Radojevic M, Skopje -Radovic M, Titograd -Rudolf Z, Ljubljana -Stankovic R, Priština -Šimunovic 1, Zagreb -Šimunic S, Zagreb -Tadžer 1, Skopje Lektor za engleski jezik -Reader for English language: Shrestha Olga UDC i/and Key words: mag. dr. 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Naklada: 1200 Tisk -Printed by: Tipograf, Aijeka CODEN RDIUA 4 YU ISSN 0485.893X UDC 616.006(05) (497.1) RADIOLOGIA IUGOSLAVICA ANNO 24 1990 FASC. 4 SADRŽAJ/CONTENTS Rendgen dijagnostika -Diagnostic radiology Digitalna VS konvencionalna splenoportografija Digital VS conventional splenoportography (orig sci paper) Jankulov V, Lincender L, Lovrincevic A, Obradov M, Jokic A 319 Endoscopic retrograde cholangiopancreatography in the diagnostics of choledochal cyst (profess paper) Rubinic M, lvaniš N, Peršic M, Banic D 323 Iz prakse za prakso -Prikaz primera From practice for practice -Case report (case report) Us J 327 Nuklearna medicina -Nuclear medicine Cardiac sestamibi spect: inter -and intraobserver reproducibility (orig sci paper) Milcinski M, Henze E, Weller R, Clausen M, Adam WE, Porenta M 329 Scintigrafija s 131-J MIGB pri feokromocitomu 131-J MIBG scintigraphy in pheochromocytoma (orig sci paper) Grmek M, Budihna N, Porenta M, Gantar-Rott U, Pfeifer M, Preželj J Interakcija bubrežnog i tumorskog 99 mrc-DMS kompleksa sa proteinima humanog seruma lnteraction of the renal and the tumorotropic complex of Tc-99m-DMS with human serum proteins (orig sci paper) Vanlic-Razumenic N, Petrovic J, Tomic M, Ajdinovic B, Rastovac M 337 Ultrazvuk -Ultrasound lnterventional sonography for diagnosis and therapy (orig sci paper) Otto R Ch 341 A comparison of sinusoscopic, radiographic and ultrasonographic findings in the diagnosis of maxillary sinus diseases (orig sci paper) Rišavi R, Mladina R, Subaric M, Markov D, Pisl Z ls .ultrasonically guided breast puncture a reasonable approach to the treatment of nonpalpable cysts? ( orig sci paper) Vlaisavljevic V 353 Radiol lugosl October -December 1990; 24:313-431 Ultrasound guided fine needle aspiration biopsy in the diagnostics of pancreatic cancer (protess paper) Drinkovic 1, Kos N, Odak D, Kardum-Skelin 1, Vidakovic Z 357 lntraoperative sonography in the surgery of chronic pancreatitis (orig sci paper) Winternitz T, Flautner L, Tihanyi T 361 Application of intraoperative ultrasound in discovering choledocholithiasis (profess paper) Drinkovic 1, Bezjak M, Deskovic E, Kos N, Odak D, Vidakovic Z 365 Percutaneous diagnosis and therapy of pyogenic liver abscesses (case report) Varga Gy, Varga PI 369 Fine needle aspiration biopsy of focal liver lesions: results and complications (profess paper) Kos N, Drinkovic 1, Odak D, Kardum 1, Šuštaršic D, Vidakovic Z Ultrasound (US) guided fine needle aspiration biopsy of the liver (profess paper) Bucuk E, cengic F, Miric S Urologic indications for fine needle aspiration biopsy and alcohol sclerosation of renal cyst formations (orig sci paper) Hromadko M, Palcic 1, Drinkovic 1 379 lndications and values of ultrasound guided aspiration biopsy of focal kidney lesions (profess paper) Odak D, Drinkovic 1, Kos N, Kardum-Skelin 1, Vidakovic z 383 Ultrasonography of paranasal sinuses in routine clinical interventions (orig sci paper) Cvetnic V, Drinkovic 1, Munitic A 385 The percutaneous nephrostomy-experiences in about 1 000 cases (profess paper) Feiber H 389 Ultrasounds guided percutaneous drainage of abdominal abscesses (profess paper) Frolich E, Striegel K, Heller Th, Frank U, Muhr T, Eberle S, Seeger G 393 Transcervical and transabdominal chorionic villus sampling (profess paper) Podobnik M, Singer Z, Kukura V, Bulic M, Profeta K 397 Exposure to ultrasound in medica! diagnostics: an experimental investigation (orig sci paper) Cardinale A, Lagalla R 401 ROC comparison of intraoperative ultrasound probes (profess paper) Boko H 405 New catheter set for US-guided procedures (orig sci paper) Drinkovic 1, Jukic T, Kos N, Odak D, Vidakovic Z 409 Onkologija -Oncology Vloga scintigrafije s 57Co-bleomycinom v odkrivanju in zamejitvi planocelularnih rakov The role of scintigraphy with 57Co-bleomycin in the detection and staging of planocellular carcinomas (case report) Jancar B, Šuštaršic J, Mackovšek M 413 The use of MCA and CEA in prostatic cancer follow up (orig sci paper) Novakovic S, Marolt F, Serša G 417 The state and problems of radiotherapy in Slovenia (review paper) Debevec M 423 Varia Radiol lugosl October -Decebmer 1990; 24; 313-431 Sodelavcem ! V letu 1991 bo uredništvo revije izdalo posebno, jubilejno številko ob pricetku 25. letnika revije. V že uveljavljenih poglavjih želimo predstaviti domace in tuje dosežke tako, da bo možno dopolnjevanje in primerjanje. Vsebinsko in oblikovno pricakujemo prispevke kot pregledne in/ /ali, originalne znanstvene clanke; vsi prispevki morajo biti napisan, v anglešcini in po naših navodilih avtorjem. O posebni številki smo naše bralce obvešcali z oglasi, k sodelovanju smo povabili radiološke, izotopne, onkološke in druge ustanove v Jugoslaviji, vabila smo poslali obema Združenjema ter vecim inozemskim avtorjem. K sodelovanju smo pritegnili ugledne domace strokovnjake kot redaktorje in recenzente za posamicna poglavja. Do sedaj smo prejeli okoli 30 pismenih potrdil sodelovanja naših in tujih avtorjev. Z jubilejno številko (knjigo) nameravamo ucinkoviteje predstaviti naše dosežke doma in v inozemstvu, povecati in razširiti mrežo narocnikov in avtorjev v JugoslaviF; _deželah Alpe-Ja­dran in v sosednjih državah. P·ublikacijo bomo poslali vsem vecjim zdravstvenim ustanovam in ' • knjižnicam v Jugoslaviji in v inozemstvu. Rok za dostavo rokopisov je 30. junij 1991. Knjiga bo izšla koncem leta 1991. Vse, ki so zamudili rok prijave naprošamo, da naknadno in pismeno potrdijo svoje sodelovanje. »RADIOLOGIA IUGOSLAVICA« Uredništvo Onkološki inštitut v Ljubljani Zaloška c. 2 -61000 Ljubljana Saradnicima ! U godini 1991 uredništvo revije 6e izdati vanredan, jubilejni broj, prilikom 25. godišnjaka revije. U ve6 uvaženim poglavljima želimo predstaviti domaca i strana dostignuca, tako da 6e biti moguce dopunjavanje i usporedivanje. što se tice sadržaja i oblika želimo objaviti pregledne i/ili originalne naucne radove; svi doprinosi treba da su pisani na engleskom jeziku i po našim uputstvima autorima. O vanrednom broju naše smo citaoce obaveštavali oglasima, ka saradnji pozvali smo radiološke, izotopske, onkološke i druge ustanove u Jugoslaviji, pozive slali smo obojici Udruženja te vecem broju inozemnih autora. Ka saradnji pritegnuli smo prominentne domace strucnjake kao redaktore i recenzente za pojedina podrucja. Dosada primili smo oko 30 pismenih potvrda saradnje sa strane naših i stranih autora. Jubilejnim brojem (knjigom) želimo efikasnije predstaviti naša dostignuca u domovini i inostranstvu, uvecati i proširiti mrežu pretplatnika i autora u Jugoslaviji, zemljama, Alpe-Adria i u granicnim državama. Publikaciju 6emo predstaviti svim :vecim zdravstvenim ustanovama i bibliotekama u Jugoslaviji pa i u inostranstvu. Rok za dostavu rukopisa je 30. jun 1991. godine. Knjiga 6e izaci krajem 1991. godine. Sve, koji su zakasnili rok prijave, molimo da naknadno i pismeno potvrde svoju saradnju. »RADIOLOGIA IUGOSLAVICA« Uredništvo Onkološki institut u Ljubljani Zaloška c. 2 -61000 Ljubljana UNIVERZITETSKO MEDICINSKI CENTAR INSTITUT ZA RADIOLOGIJU I ONKOLOGIJU, SARAJEVO DIGITALNA VS KONVENCIONALNA SPLENOPORTOGRAFIJA DIGITAL VS CONVENTIONAL SPLENOPORTOGRAPHY Jankulov V, Lincender L, Lovrincevic A, Obradov M, Jokic A Abstract -The aim of the paper was to evaluate the advantages of digital splenoportography in patients with portal hypertension. Twenty-three patients with clinic indications underwent digital splenoportography, followed by conventional splenoportography. Comparing the results, the authors concluded that the d1g1tal method of imaging provided the same information, although small amount of diluted contrast material was administered (30% contrast material with iodine concentrentration 300 mg/ml). Relating to the smaller gauge of puncture needle tor digital techniques, the method proved to be more practic and less risky. UDC: 616.149.4-073.75 Key words: portography-methods Orig sci paper Radiol lugosl 1990; 24:319-22. Uvod -Splenoportografija kao metoda evalua­ cije portalnog krvotoka se izvodi od 1951. godi­(1,2l ne. Kontrastni prikaz sistema vene porte nakon punkcije slezene je superiorniji u ojnosu na prikaz u toku indirektne splenoportografiie (31 4, 5). Uvodenjem digitalne subtrakcione angiografije pruža se nova dijagnosticka dimenzija u evalua­ciji ovog dijela krvotoka (6, 7). Pacijenti i metod rada -Vršena je evaluacija splenoportograma kod 23 pacijenta sa postavlje­nem sumnjom ili klinicki dokazanem portalnom hipertenzijom. Nakon standardne laboratorijske obrade vršena je punkcija slezene u srednjoj aksilarnoj liniji što bliže hilusu. Punkcija je vršena iglom od 20 gauge sa teflonskim sheath-om. Snimanja su vršena u dva akta. U prvom aktu snimanje je vršeno preko aparata za digitalnu subtrakcionu angiografiju (DVl2 -Philips), a za­lim u produžetku procedure na istom stolu serio­grafsko snimanje preko spot-kamere na formatu filma 1 O x 1 O cm. Aplikacija kontrastnog sredstva je vršena rucno, uz protok od 7-8 cm3 . Za digitalni prikaz korišteno je razblaženo kontrastno sredstvo u odnosu 1 :2 sa fiziološkem otopinom u kolicini tecnog medijuma od 20 ml. Za konvencionalni prikaz korišteno je nerazbla­ženo kontrastno sredstvo u ukupnoj kolicini od Received: April 9, 1990 -Accepted: May 11, 1990 40 cm3. U toku rada nismo mjerili pritiske obzirom da na stolu na kojem smo izvodili pretrage nemarno mogucnost snimanja preko aparata za digitalnu angiografiju. Nakon pretrage pacijenti su provodili cca 6 sati u krevetu. Rezultati -Prikazani su na tabeli 1. Iz nje se vidi da smo kod digitalne tehnike snimanja uz· aplikaciju razblaženog kontrastnog sredstva u 18/23 slucajeva dobijali dobar prikaz portalnog krvotoka (sl. 1 a, 1 b, 2 a, 2 b), dok smo kod konvencionalnog metoda kod istih pacijenata do­bivali adekvatan prikaz u 10/23, odnosno 43,6% slucajeva. U jednom slucaju nismo dobili prikaz portalnog sistema jer se radilo o trombozi v. lijenalis. Diskusija -Splenoportografija je još uvijek nezamjenjiva metoda prikaza portalnog krvotoka kod pacijenata sa portalnom hipertenzijom koji su kandidati za hirurški zahvat (3, 8, 9). Uvode­njem digitalne subtrakcione angiografije omogu­cen je odlican kontrastni prikaz vaskularnih struk­tura uz smanjenu kolicinu kontrasta, zahvaljujuci vecoj kontrastnoj rezoluciji u poredenju sa kon­vencionalnem angiografijom (7), (sl. 3). Tehnika digitalne splenoportografije uz korište­nje punkcione igle od 21 gauge se opisuje u Jankulov V et al. Digitalna VS konvencionalna splenoportografija Tabela 1 -Korelacija angiografskih nalaza izmedu digitalne i konvencionalne splenoportografije Table 1 -Correlation of angiographic results of digital and conventional splenoportography Digitalna Konvencionalna splenoporto­ splenoporto­ grafija grafija Digital Conventional splenoporto splenoporto graphy graphy Dobar prikaz kola­ teralnog krvotoka 18 (78,2%) 12(52,1%) Good presentation of collateral circulation Nedovoljan prikaz kolateralnog krvotoka 4(17,5%) 10 (43,6%) lnadequate pre­sentation of collateral circulation Bez prikaza sistema vene porte 1 (4,3%) 1 (4,3%) No presentation of vena porta system Ukupno 23 (100%) 23 (100%) Total Slika 1 b -Digitalna splenoportografija kod istog paci­jenta Fig. 1 b -Digital splenoportography-the same patients Slika 2a -Konvencionalna splenoportografija: portalna hipertenzija sa kolateralnim krvotokom preko gastricnih vena Fig. 2a -Conventional splenoportography: portal hy­pertension with collateral circulation through gastric veins Radiol lugosl 1990; 24:319-22 Jankulov V et al. Digitalna VS konvencionalna splenoportografija literaturi (2). U tim studijama se nije vršila kompa­racija sa konvencionalnom splenoportografijom. Kod nekih naših pacijenata smo pokušali aplici­rati kontrastno sredstvo preko takve igle, ali nismo mogli postici adekvatan protok prilikam manuelne aplikacije. Smatramo da se kod ove procedure kontrastno sredstvo mora aplicirati rucno. Kod naših pacijenata nismo imali kompli­kacija nakon procedure. Kod digitalnog nacina prikaza mogu se javiti problemi sa slikom usljed respiratornih i peristaltickih pokreta. Davanjem instrukcija pacijentima, kao i parenteralnom pri­mjenom antikolinergickih lijekova neposredno prije procedure, ovakvi problemi se mogu preva­zici kod vecine slucajeva. U radu smo prven­stveno željeli prikazati prednosti tehnike digitalne subtrakcione angiografije kod prikaza kolateral­nog krvotoka u portalnoj hipertenziji. Zakljucak -Metoda digitalne subtrakcione splenoportografije nam je pružila više podataka kod pacijenata sa portalnom hipertenzijom u poredenju sa konvencionalnom splenoportografi­jom. Zahvaljujuci odlicnoj kontrastnoj rezoluciji minimalne kolicine razblaženog kontrastnog sredstva su bile dovoljne za dobar prikaz sistema vene porte. Sažetak Cilj rada je da se evaluiraju prednosti digitalne splenoportografije kod pacijenata sa portalnom hiper­tenzijom. Kod 23 pacijenta sa klinickom indikacijam izvedena je digitalna splenoportografija, a nakan nje u nastavku pretrage, konvencionalna splenoportografija. Nakan iz­vršene komparacije nalaza došli smo do zakljucka da smo pomocu digitalne tehnike snimanja dobili iste podatke iako su se koristile manje kolicine razblaženog kontrastnog sredstva (30% kontrastnog sredstva kon­centracije joda od 300 mg/ml.). Obzirom da se kod digitalne tehnike koristi punkciona igla manjeg kalibra, metoda se pokazala prakticnijom i sa manje potencijal­nih rizika. Literatura 1. Probst P, Rusavy JA, Ampatz K. lmproved Safety of Splenoportography by Plugging of the Needle Tract. AJR 1978; 131 :445-9. 2. Braun SO, Newman GE, Dunnick NR. Digital Sple­noportography. AJR 1985; 144 :1003-4. 3. Gmelin E. Digitale subtraktionsangiographitz. Thieme 1987. 4. Bergstrand l. Splenoportography in: Abrams HL, Cook HP. eds. Angiography. Boston: Little Brown and Co., 1971: 1029-72. 5. Bergstrand l. The localization of portal obstruction by splenoportography. AJR; 85:121. 6. Gvozdanovic V, Hauptmann E. Further experience with percutaneous lieno-portal venography. Acta Radiol 1955; 43:177. Jankulov V et al. Digitalna VS konvencionalna splenoportografija 7. Futugawa S, Fukazawa M, Horisawa M, Muska H, 9. L'Hermine C. Radiology of !iver circulation. Boston, lto T, Suziura M, Kameda H, Okuda K. Portographic Dordrecht, Lancaster: Martinus Nijhoff Publishers, !iver changes in idiopathic noncirrnotic portal hyper­1985:1-174. tenzion. AJR 1980; 134:1917-23. 1 O. Lincender L, Boškovic S, Lovrincevic A, Alihodžic H, !zgled splenoportograma kod promjene hemodi­namike jetre. Radio! lugosl 1977; 11 :411-13. 8. Burchart F, Nielbo N, Andersen B. Percutaneous transhepatic portography. II. Comparsion with sple­Adresa autora: Jankulov dr Vladislav, Institut za radio­noportography in portal hypertension. AJR 1979; logiju i onkologiju UMC-a Sarajevo, Moše Pijade 25, 132:183-5. 71000 Sarajevo. TOSAMA Proizvaja in nudi kvalitetne izdelke: Komprese vseh vrst Gazo sterilno in nesterilno Elasticne ovoje Virfix mrežo Micropore obliže Obliže vseh vrst Gypsona in mavcene ovoJe Sanitetno vato PhJ 111 Zdravniške maske in kape Sanitetne torbice in omarice Avtomobilske apoteke Radiol lugosl 1990; 24:319-22 FACULTY OF MEDICINE ANO CLINICAL HOSPITAL CENTRE, RIJEKA INTERNAL MEDICINE ANO PEDIATRIC CLINIC1, INSTITUTE FOR RADIOLOGY2 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN THE DIAGNOSTICS OF CHOLEDOCHAL CYST Rubini6 M, 1 lvaniš N, 1 Perši6 M, 1 Banic D.2 Abstract -The importanee of endoseopie retrograde eholangiopanereatography (ERCP) in the diagnostie of eystie dilatations of the eholedoehal duet is reviewed. The method is very effeetive in seanning the size, form, position and eontent of the eyst, a faet of great importanee when planning surgieal intervention as the only possible eure. An analysis is presented of the results of 2672 ERCP-s earried out during the past ten years, during whieh period three eholedoehal eysts had been found in temale patients of various age groups. UDC: 616.367-007 .63-072.1 Key words: eommon bile duet diseases, eysts, eholongiopanereatography endoseopie retrograde Profess paper Radiol lugosl 1990; 24:323-6 lntroduction -The choledochal cyst is a rare development anomaly, in the majority of cases congenital, of the biliary tract. The anomaly was tor the first tirne described in 1723 by Vater. Later on, in 1852, Douglas delineated its patho­anatomical characteristics, and in 1894 Swain described the first surgical intervention in these patients in the form of choledochojejunostomy (1 ). Up to 1980, 1375 cases of this impairment had been described, one third of them coming from Japan. So far in our country a number of intere­sting congenital choledochal cysts have also been described (2,3). ERCP has helped a great deal towards making these diagnoses. By 1975 only some 955 cases had been described (69,3%), and after the introduction of ERCP into routine practice another 382 (30,7%) cases were described in only five years, i.e. up to 1980 (1 ). Hence this review of diagnosing this rare disease in our material of ten years is made to point out the importance of ERCP. Materials and methods -An analysis · is presented of 2672 endoscopic retrograde cholan­giopancreatography made in the period of ten years from 1980 to 1990. The technique to carry out ERCP was that described and acepted by numerous authors (4, 5, 6). In cases of this kind it is important to have an exact representation of the ampular region, as well as the localization and size of the cyst in order to eliminate dilatation of ducts and other etiologies (7). Results -In the period of ten years from 1980 to 1990 only three choledochal cysts, or O, 1 pro mille of the examined patients, has been diagno­sed. The leading indication in conducting this examination in a patient of eight years of age was acute pancreatitis of unknown etiology (Fig. 1 ). With the other two cases the indication tor ERCP was obstructive jaundice, with one of the patients having pain, while the other felt no pain in spite of stones in the cyst (Fig. 2 and 3). The first patient was 19 years old, and the other 36. Discussion -Choledochal duet cyst is a rare congenital disease of the biliary tract occurring on the average in O, 1 to 1,6 pro mil le cases. In our ten-year ERCP material it occurred in O, 1 pro mille cases. It occurs more often in temale that in male patients, the temale to male ratio being 4:1 (3,8). The three patinets presented in this survey were females. To this day there is a great deal of discussion going on as to the etiology of Reeeived: November 6, 1990 -Aeeepted: November 19, 1990. Rubinic M et al. Endoscopic retrograde cholangiopancreatography in the diagnostics of choledochal cyst Fig. 1 -Choledochal cyst (c) intrahepatal ducts (a). this disorder. It is belived that the most frequent, causes of this aberation are: segmenta! fibro-· muscular displasia or hypoplasia of the choledoc­hal duet, functional changes of Oddi's sphincter, stenosis or abnormal development of the distal part of the choledochal duet (1,7,8). The sympto­matology is usually or most often in the form of palpable tumour under the dextral costal arch, and obstructive jaundice which is, in any case, the most frequent indication far ERCP (4,5,6). In the diagnostics of these dieseases we first use convetional radiologic methods with little sucess and nonivasive diagnostics procedures such as radio isotope hepatobiliary images and ultra­sound imaging with a 75 per cent success. (8, 9). Here it is important to point out the fact that when deciding on the method of precise diagnostics of diseases of the biliary tract, and especially cystic dilatations, ERCP yeields a 94 percent success. In exceptional cases we use in diagnosties per­cutaneous trans hepatic cholangiography (4,5,6, 1 O, 11 ). Fig. 2 -Choledochal cyst (c) dilated intrahepatical ducts (a). Today ERCP is practicable without difficulty even in children whom these anomalies primarily occur (9, 12). This method permits determination of the size, form and position of the cyst. Thanks to this metohod it was also possible to accept the classification of the choledochal cyst into three types, or five types of biliary dilatation (Scheme 1) (14, 15). Another advantage of this method is the detai­led analysis of the content of the cyst, particulary of minute stones often contained in the cyst, as was the case with one of our three patients (8). In the therapy of the said cystic dilatations surgi­cal intervention is a method of choice. Small cysts in the centre of the choledochus are com­pletely removed by termina-terminal anastomo­sis. Large cysts require biliodigestive anastomo­sis with resection of the cyst if possible. This is important in view of any possible malignant alteration of the remainder of the sac (1, 8, 13, 14). Radiol lugosl 1990; 24 :323-6 Rubinic M et al. Endoscopic retrograde cholangiopancrealography in lhe diagnoslics of choledochal cyst 6% 7 // J(/ N 2% 2% j )( ct o{r3 3% Scheme 1 -Fram the bibliography (N = 760) schematic presentation of the incidence of cystic dilatation of biliary tract (N-normal). Radiol lugosl 1990; 24:323-6 Rubinic M et al. Endoscopic retrograde cholangiopancreatography in the diagnostics of choledochal cyst Fig. 3 -Choledochal cyst filled with numberless stones varying size-arrows. Sažetak ENDOSKOPSKA RETROGRADNA HOLANGIOPAN­KREATOGRAFIJA U DIJAGNOSTICI CISTICNIH DI­LATACIJA DUCTUS HOLEDOKUSA U radu je prikazana važnost endoskopske retro­gradne holangiopankreatografije (ERHP) u dijagnostici cisticnih dilatacija duktus holedokusa. Metoda s vrlo velikim uspjehom prikazuje velicinu, formu, položaj i sadržaj ciste a šlo je pak neobicno važno za planiranje operativnoga zahvala kao jedinoga nacina lijecenja. Analiziraju se vlastiti rezultati 2672 ERHP u zadnjih 10 godina gdje su nadene tri ciste duktus holedokusa i sve u ženskih bolesnica razlicite starosti. References 1. He>ss W. Konnatale erkrankungen der Gallen­wege und des Pankreas. In: Hess W and Rohner A ed. Die erkrankungen der Gallenwege und des Pankreas. Padova: Piccin 1986; 494-512. 2. Bakran 1, Kneževic S. Kongenitalna cisticna dila­tacija koledokusa. Lijec Vjesn 1969; 91 :757-62. 3. Peršic M, Lekovic A, Fuckar 2, Rubinic M. Akutni pankreatitis uzrokovan kongenitalnom cistam du.tus koledokusa. Lijec Vjesn 1988; 110:319-22. 4. Soehendra N. Technik, Schwerigkeiten und Er­gebnisse der endoskopisch-retrograden Cholangio­Pankreatikographie (ERCP). Chirurg 1977; 48 :98-104. 5. Križman 1, Tavcar B. Endoskopska retrogradna ,holangiopankreatografija. Lijec Vijesn 1980; 102:725­19. 6. Rubinic M, švalba B. Endoskopska retrogradna holangiopankreatografija (ERHP). Radiol lugosl 1984; 18 (2) :95-8. 7. Lee SS, Min PC, Kirn GS, Hong PW. Choledochal cyst. A report of nine cases and revuew of the literature. Arch Surg 1969; 99:19-28. 8. Grili W. Anomalien der Gallenblase und der Gal­lengange. In: Demling Led. Klinische Gastroenterolo­gie Stuttgart-New York: Georg Thieme Verlag, 1984 :322-8. 9. Klotz D, Cohn BO, Kottmeier PK. Choledochal cysts: diagnostic and therapeutic problems. J Pediatr Surg 1973; 8 :271-83. 10. Nuesch HJ, Hahnloser P, Fumagalli 1, Deyhle P. Endoskopisch-retrograde Cholangiographie: Methode der Wahl zur Diagnose der Choledochuszyste. Dtsch med Wschr 1973; 98:2069-70. 11. Huchzermeyer H, Otto P, Seifert E. Wertigkeit verschidener diagnostischer Methoden bei kongenita­len Dilatationem der Gallenwege. Leber Magen Darm 1976; 6 :350-7. 12. Urakami Y, Seki H, Kishi S. Endoscopic retro­grade cholangiopancreatography (ERCP) performed in children. Endoscopy 1978; 9 :86-91. 13. Franke F. Die Gallengangszyste. Chir Praxis 1980; 26:61-7. 14. Gali FP, Franke F. Chirurgische Mciglichkeiten und Grenzen der Cholangiodrainage. In: Demling L and Riemann JF ed. Endoskopische Prothetik. Nur­nberg: Heumann, 1982; 59-66. 15. Kobayashi A, Ohne Y. Choledochal cyst in in­fancy and childhood. Arch Dis Child 1977; 52:121-28. Author's address: Rubinic M, MD, Interna klinika-ga­stroenterologija KBC Rijeka. Radiol lugosl 1990; 24 :323-6 Iz prakse za prakso IZ PRAKSE ZA PRAKSO KVIZ št. 3 PRIKAZ PRIMERA Bolnik star 71 let, po poklicu pravnik. Prihaja na diagnosticno obdelavo zaradi težav z želodcem. V anamnezi poda naslednje: Pred 22 leti operiran po metodi Biltorh II zaradi rane visoko v korpusu želodca. Navaja, da so se težave (bolecine in tišcanje v predelu želodca, zaspanost, utrujenost, po zaužitju hrane) pricele približno osem let po operaciji želodca. Trajajo od 20 minut do ene ure. Zadnja leta se težave stopnjujejo. Pred enajstimi leti je bil zdravljen zaradi raka na grlu. Ugotovili so mu rak desne glasilke. Histološko je bil potrjen kot plošcatocelicni rak s poroženevanjem. Zdravljen z radikalnim obsevanjem na kobaltu. Sedaj nima težav s strani grla. Navaja jutranji kašelj. Krvi v sputumu ni opazil. Alkohol uživa zmerno. Od alkoholnih pijac uživa obcasno vino, žganih pijac ne konsumira. V družini ni duševnih ali rakastih obolenj. Kaditi je pricel že v zgodnji mladosti. Kadi stalno, ceprav so mu kajenje zaradi raka grla prepovedali, se kajenju ne more odreci. Status: astenicne konstitucije, nekoliko podhranjen. Orjentiran v casu in prostoru. V statusu ne najdemo odstopanj od normalnega, le koža desno na vratu nekoliko atroficna in hiperpigmentirana. Na abdomnu v mediani crti tipicna brazgotina po zgornji laparotomiji. Srce kompenzirano. Srcni toni tihi, akcija ritmicna. Dihanje emfizematozno." Povecanih bezgavk ni tipati. Planirane preiskave: rtg torakalnih organov, rtg pregled želodca, gastroskopija, proktološki pregled. Kompletna krvna slika, biokemicne preiskave. Laboratorijski izvidi: SR 40 mm, eritrociti 4.07, Hb 136 g/L, L 7,56, DKS: nevtro. seg. 0,71, limfo 0,23, mono 0,05, pl 0,01, urin brez posebnosti. Na 141 mmol/L, K 4.2 mmol/L, kloridi 101 mmol/L, kreatinin 88 mmol/L, urat 267, µmol/L. Alkalna fosfataza 2,30 u kotkat/L, gama GT 0,53 µmol/L, bilirub. cel. 7 µmol/L, bilirubin dir. 2 µmol/L, AST (GOT) 0,30 µkat/L, ALT (GPT) 0,30 µkat/L, holesteroli 3,9 µmol/L, kisla fosfataza 20 nkat/L, železo 10,4 µmol/L, amilaza 1,45 µkat/L, UIBC 39 µmol/L. Rentgen torakalnih organov (PA): Glej sliko 1 na strani 328 ! Aadiol lugosl 1990; 24:327-8 Iz prakse za prakso Slika 1 -RTG torakalnih organov Naloga: Opiši sli ko Navedi difere ncial no diagnozo! Navedi nadaljne potrebne prei skave ! Pos tavi diagnozo! Terapija? Od gov or: glej stran 359! Radio! lugosl 1990; 24 :327-8 UNIVERSITY MEDICAL CENTRE, NUCLEAR MEDICINE, LJUBLJANA, YUGOSLAVIA1 UNIVERSITY MEDICAL SCHOOL, NUCLEAR MEDICINE, ULM, WEST GERMANY2 CARDIAC SESTAMIBl SPECT: INTER-AND INTRAOBSERVER REPRODUCIBILITY Milcinski M1 , Henze E2, Weller R2, Clausen M2 , Adam WE2, Porenta M1 Abstract -Repeated quantitied studies are used tor evaluation ot medical or interventional treatment in coronary artery disease. lnter-and intraobserver reproducibility ot tomographic Sestamibi studies processing in patients with stable coronary artery disease using semiautomatic quantitication program was analyzed. Our results gave very good correlation (r = 0.94) tor bigger perfusion detects (19% ot normalized standard pertusion area), tor smaller defects (8% ot predicted supply area) the variability in study processing was bigger. There-tore we can advise careful interpretation ot small differences in results of comparative studies as they can result from more Ihan one observer processing individual studies. UDC: 616.24-005.7:539.163 Key words: Tc-99m Sestamibi -quantitative SPECT -reproducibility -coronary artery disease -MIBI Orig sci paper Radiol lug osi 1990; 24 :329-32 lntroduction -Quantitation in nuclaar medi­vessel coronary artery diesease, proven with cine helps to objectify results of separate studies coronary angiography without known previous and allows direct comparison of results of repea­myocardial infarction. No ischemic event bet­ted studies. New technetium radiopharmaceitu­ween both study days was allowed. Resi study cals are currently used for coronary blood flow with 370 MBq Tc-99m Sestamibi, followed by investigations (1, 2, 3) and as repeated studies first stress study with 740 MBq Tc-99m Sestamibi are not always processed by the same observer, six hours later was performed on the first study the possible error using quantitation program day. Two repeated stress tests were accomplis­remains unknown and can influence the results hed on the second study day, the second one of such studies. The aim of present study is the after placebo or pharmacological substance ap­evaluation of inter-and intraobserver variability plication with equal doses of Sestamibi as on the in processing of cardiac Sestamibi (Tc-99m-Met­first study day. hoxy lsobutyl lsonitrile) tomographic studies using semiautomatic quantitation program. Data acquisition and processing -Tomograp­ Patients and Methods -Ten patients with hic acquisition began one hour after Sestamibi stable coronary artery disease, mean age 58.8 application on Siemens Orbiter 3700 (using a years (range 41 to 72), eight men and two 180 degree are from LPO to RAO, 32 angles in women, were included in double blind pharmaco­16 minutes, matrix 64 X 64) and Max-Delta. logical trial with one rest and three stress Sesta­mibi tomographic studies on two separate days. Data were processed using modified quantifi­ Therefore four studies of each patient were cation protocol, described in detail by Clausen available and they served for reproducibility ana­(5). Operator-depending steps are: axis determi­lysis. The study protocol is described elsewhere nation, inner and outer myocardial wall delinea­(4). In short, the patients had stable one or two tion and short-axis circular profile outlining. Com- The work was performed at Nuclear Medicine Department in Ulm and presented at Yugoslav Nuclear Medicine Congress in Sarajevo 1990 Received: October 1 O, 1990 -Accepted: October 24, 1990 Milcinski M et al. Cardiac sestamibi speci: inter-and intraobserver reproducibility puter transversal reconstruction uses Butter­worth-filter of 5th order and cut-off frequency of 0.4 during the back projection of individual slices. Rearrangement into short and long axis slices and circumferential profiles is performed with compression into polar coordinates. Color-coded results are expressed in percents of significantly reduced tracer uptake compared to the Cedars original data-base for standardized perfusion areas, namely LAD, RCA, LCX and TOTAL perfusion defect. Data analysis -40 studies were available for interobserver analysis and 28 of them present the interobserver analysis group. Data were sta­ tistically evaluated using commercial statistical program (Statgraphic). Correlation analysis was used to compare the results of repeated studies. Average defect size is presented with modal and Results -are shown graphically on figure 1 and in table 1. The size of significantly reduced tracer uptake for separate perfusion regions is expressed in percentage of normalized supply area and the average defects are presented for both observers. The biggest defects were found for the LAD perfusion area, namely average 18.9% and the srna/lest for the LCX region, the average size of hypoperfused myocardium for all Table 1 -Summarized results ot quantitative SPECT Tc-99m Sestamibi myocardial perfusion evaluation for standard pertusion areas from interobserver (40 stu­dies) and intraobserver (28 studies) reproducibility analysis Number Average Region of studies detect (%) Range Median Mode 40 40 19.8 19. 5 0-87.2 0-81.9 11.4 8.0 o o 68 studies measuring 8.4% of normalized stan­dard perfusion area. Range, mode and median values for every observer and separate regions are presented in table 1 as well. The results of correlation analysis are presented in table 2. The best correlation was found for LAD perfusion area, namely 0.94, the poorest for the LCX region and a good overall correlation is demons­trated for total perfusion abnormalities. Table 2 -Correlation coefficients (r) tor separate standard pertusion areas - LAD RCA LCX Total deteci Two observers 0.94 0.88 0.76 0.90 One observer 0.94 0.79 0.27 0.87 Average perfu- median values. s ion detect (%) 18.9 10.4 14.1 Table 2 -1 -Correlation coefficients and correlation equations tor two observers and standard pertusion areas Two observers 40 studies LAD r=0.94 y=0.91x+2.31 RCA r=0.88 y = 0.78x + 0.76 LCX r=0.75 y = 0.64x -0.55 Total r=0.90 y=0.80 x+1.91 Table 2 -2 -Correlation coefficients and correlation equations tor standard perfusion areas tor repeated processings of one observer Single observer 28 studies LAD r=0.94 y=1.06 x-3.11 RCA r=0.79 y=1.03x+1.79 LCX r=0.27 y = 0.25x + 4.54 Total r=0.87 y=1.15x-2.64 LAD 28 17.3 0.81.9 o 28 19.2 0-73.8 o 40 8.9 0.64.1 o o 40 10.1 0-79.5 o o Discussion -Quantitation of myocardial per­ RCA 28 11.6 0.79.5 o o fusion defects has special clinical importance as 28 0-60.4 o o it serves tor objective evaluation of results of medical or interventional treatment on myocardial 0-46.4 o o 40 40 9.1 09.60.2 3.6 o perfusion. Newer technetium tracers have advan­ LCX 28 7.0 0-38.8 4.1 o tages over standard thallium 201 because of 28 9.6 0-30.2 5.9 o better imaging characteristics. The sensitivities and specificities of planar imaging with thallium 13.8 0-57.9 9.2 o or technetium are comparable for high grade Total 40 14.9 0.4-60.5 9.3 detect 28 13.7 0.4-60.5 9.1 8.0 stenoses and Te-99m-Sestamibi has superior 28 14.2 0-53.0 10.6 10.0 sensitivity in detection of moderate stenoses (6). Radiol lugosl 1990; 24:329-32 Milcinski M et al. Cardiac sestamibi speci: inter-and intraobserver reproducibility INTEROBSERVER PROCESSING ANAL YSIS % of hypoperfused myocardium 25%r-----------------------, 20% 10% ;a .fl 0% LAD RCA LCX TOTAL Two observers [fij Observer D Observer 2 INTRAOBSERVER PROCESSING ANAL YSIS Percent of hypoperfused myocardium (%) 20%>-----------­ 15% ,_ 10% 5% t, !f ._, 1 0% LCX TOTAL v,::/::::j Second observation Fig 1 a, b -Graphic presentation of variability in results tor standard perfusion areas tor bolh observers (40 studies, above) and reprocessing tor one observer (28 studies, below). LAD-left anterior descending artery, RCA­right coronary artery, LCX-left circumflex artery, TOT AL -total left ventricular perfusion delec!. Radiol lugosl 1990; 24:329-32 Milcinski M et al. Cardiac sestamibi spect: inter-and intraobserver reprocucibility Tomographic techniques are superior over planar ones (7). The aim ot our study was the evaluation ot possible technical errors resulting from repea­ted processing using semiautomatic quantitica­tion program (8), widely used in most cardiac nuclear medicine centers. As the repeated stu­dies are often processed by ditterent observers and the quantitied results are used tor direct comparison, a possible mistake in treatment evaluation can result from variability in proces­sing. Our analysis shows good reproducibility ot comparative studies tor bigger pertusion detects, both tor inter-or intraobserver reprocessing. Smaller detects have statistically higher variabi­lity in our study, resulting partly from the magni­tude ot the detects and partly from smaller number ot ali studies that had pertusion abnor­malities in those regions. Normal pertusion was tound in 14% ot studies tor LAD region, in 59% tor RCA region and in 34% tor LCX pertusion area. Part ot the variability is attributed to opera­tor depending steps in the processing, most ot this resulting from axis determination. The shitt in axis can result in borderline areas being attribu­ted to one or another ot the detined pertusion regions resulting in varying results as well. However, the overall results show good repro­ducibility especially tor bigger pertusion detects tound with tomographic Sestamibi evaluation ot myocardial pertusion. We can suggest caretul interpretation ot smaller differences in results ot repeated studies tor treatment evaluation as they can be attributed to variability in processing even when the same observer processes repeated studies. Povzetek PONOVLJIVOST PROCESIRANJA SRCNIH SPECT SESTAMIBI ŠTUDIJ Kvantifikacija perfuzijskih defektov, ugotovljenih s tomografskimi preiskavami, je pomembna zaradi pri­merjave rezultatov ponovljenih preiskav ter ocene me­dikamentoznega ali interventnega zdravljenja koro­narne srcne bolezni. Pri bolnikih s stabilno koronarno boleznijo smo ocenjevali ponovljivost tomografskih Se­stamibi študij, ce je študije racunalniško obdeloval isti opazovalec dvakrat ali pa ce sta jih procesirala dva razlicna opazovalca. Ugotovili smo zelo dobro korela­cijo med rezultati ponovljenih preiskav v obeh primerih, ce je bil perfuzijski defekt velik (poprecna velikost defekta 19% normaliziranega perfuzijskega podrocja, r=0.94), vecja odstopanja pa smo našli pri manjših defektih (velikost defekta 8%, r=0.75). Zato svetujemo previdno oceno uspeha zdravljenja, ce so tomografski defekti manjši, saj so razlike med rezultati ponovljenih študij lahko posledica veckratnega procesiranja. References 1. lskandrian SA, Heo J, Kong B, Lyons E, Marsch S. Use of technetium-99m isonitrile in assessing left ventricular perfusion and function at rest and during exercise in coronary artery disease, and comparison with coronary arteriography and exercise thallium-201 SPECT imaging. Am J Cardiol 1989; 64:270-5. 2. Maddahi J, Merz R, Van Train KF, Roy C, Berman OS. Tc-99m MIBI (RP-30) and Tl-201 myocardial perfu­sion scintigraphy in patients with coronary disease: quantitative comparison of planar and tomographic techniques tor perfusion intensity and defect reversibili­ty. J Nucl med 1987; 28:654 (abstr). 3. Taillefer R, Lambert R, Dupras g, Gregoire J, Leveille J, Essiambre R, Phaneuf DC. Clinical compari­son between thallium-201 and Tc-99m-methoxy isobu­tyl isonitrile (hexamibi) myocardial perfusion imaging tor detection of coronary artery disease. Eur J Nucl Med 1989; 15 :280-286. 4. Milcinski M, Henze E, Lietzenmayer R, Clausen M, Weller R, Hombach V, Adam WE, Porenta M. Reproducibility of cardiac Sestamibi SPECT. Eur J Nucl Med; in press. 5. Clausen M, Weller R, Henze E, Bitter F, Adam WE. Differenzierende Darstellung and Quantifizierung der Myokardnarbe und der Belastungsischamie in Po­larkloordinaten tur die Myokard-ETC. Klinische und Technische Aspekte. NucCompact 1988; 19:50-52. 6. JK Kahn, McGhie 1, Akers MS, Sills MN, Faber TL, Kulkarni PV, Willerson JT, Corbett JR. Quantitative rotational tomography with Tl-201 and Tc-99m met­hoxy-isobutyl-isonitrile. A direct comparison in normal individuals and patients with coronary artery disease. Circulation 1989; 79:1282-1289. 7. Kiat H, Maddahi J, Train KV, Friedman J, Resser K, Berman OS. Comparison of technetium 99m met­hoxy isobutyl isonitrile and thallium 201 tor evaluation of coronary artery disease by planar and tomographic methods. Am Heart J 1989; 117:1-11. 8. Garcia EV, Van Train KF, Maddahi J, Prigent F, Friedman J, Areeda J, Waxman A, Berman OS. Quan­tification of rotational Thallium-201 myocardial tomo­graphy. J Nucl Med 1985; 26:17-26. Author's address: Metka Milcinski, MD, Nuclear Medicine Department, University Medica! Centre, Zalo­ška 7, 61000 Ljubljana Radiol lugosl 1990: 24:329-32 UNIVERZITETNI KLINICNI CENTER LJUBLJANA KLINIKA ZA NUKLEARNO MEDICINO1 KLINIKA ZA ENDOKRINOLOGIJO2 SCINTIGRAFIJA S 131-J MIBG PRI FEOKROMOCITOMU 131-J MIBG SCINTIGRAPHY IN PHEOCHROMOCYTOMA Grmek M1 , Budihna N1, Porenta M1 Gantar-Roti U2, Pfeifer M2, Preželj J2 Abstract -The aim of the study was retrospective evaluation of 131-J MIBG scintigraphy (Se) in patients with suspected pheochromocytoma. Results of se, ultrasound (US) and computerized tomography (eT) were compared with histological diagnosis in 18 patients. Four hypertensive patients where pheochromocytoma was practicaly excluded on the basis of endocrinological tests and clinical course served as normals. Sensitivity of se to detect intraadrenal tumors was 80%, eT 100% and US 92%. Overal sensitivity including 2 cases with extraadrenal tumors and 1 patient with adrenomedullary hyperplasia was for se 83%, US 73% and eT 94%. The main advantage of se over eT and US is in its ability to identify functional chromaffine tissue localized in intraadrenal and extraadrenal areas or metastatic spread. UKC: 616-008.488-073 :539.163 Key words: pheochromocytoma-radiomuclide imaging, iodine radioisotopes Orig sci paper Radiol lugosl 1990; 24 :333-6 Uvod -V zacetku 80. let je bila uvedena scintigrafija z meta-jodobenzilgvanidinom (MIBG), fiziološkim analogom noradrenalina, ki se kopici v granulah kromafinega tkiva (1, 2, 3). Sredica nadledvicnih žlez se pri scintigrafiji s 131-J MIBG obicajno ne prikaže, obcasno pa se šibko nakaže (1 ). Kopicenje pa je dovolj inten­zivno v hipertroficni sredici nadledvicne žleze, ki postanejo tako scintigrafsko vidni. Feokromoci­tom, ki je dokaj redek tumor, je v približno 90% lokaliziran v nadledvicni žlezi, v 10% pa izven nje v poteku verige simpaticnih ganglijev. Obi­cajno je benigen, v 10% pa maligen (1 ). Bolniki in metode -V študijo smo vkljucili 22 bo In i k o v, pri katerih je bil na osnovi tipicne anamneze in statusa ali patoloških hormonskih testov postavljen sum na feokromocitom. Met ode: Vsem bolnikom smo dolocili vredno­sti kateholaminov, VMA in metanefrinov v urinu (hormonski testi) ter opravili scirtigrafijo s 131-J MIBG. Vecina bolnikov je imela opravljeno še ultrazvocno preiskavo trebuha ter racunalniško tomografijo (tabela 1 ). Diagnozo smo postavili na osnovi histološkega izvida in postoperativne nor­malizacije hormonskih testov, oziroma srr ; feo­kromocitom na podlagi normalnih endokrinolo­ških testov izkljucili. Scintigrafska metoda: Bolnikom z bloki­rano šcitnico (s perkloratom ali lugolom) smo pocasi i. v. vbrizgali! 20 do 35 MBq 131-J MIBG. 48 in 72 ur po aplikaciji radioindikatorja smo opravili scintigrafijo vratu, prsnega koša in ledve­nega predela v posteriorni projekciji, medenice pa v anteriorni projekciji. Zaradi natancnejše lokalizacije tumorjev smo v nekaterih primerih posneli še dodatne projekcije. Ob sumu na meta­staze smo naredili scintigrafijo vsega telesa. Uporabljali smo kamero gama s kolimatorjem za visoke energije. Vsako projekcijo smo snemali 10 do 15 minut. 'Rezultati -17 bolnikov je imelo histološko dokazan feokromocitom, v 1 primeru pa je bila dokazana bilateralna hiperplazija sredice nadle­dvicnih žlez. Pri 4 bolnikih s sumom na feokromo­citom, ki so imeli normalne rezultate hormonskih testov in negativen SC izvid smo z nadaljno diagnostiko prenf'fiali. Rezultati so zbrani v tabeli 1. Senzitivnost pri odkrivanju vseh oblik feokro­mocitoma je pri scintigrafiji znašala 83%, pri ultrazvoku 73% ter pri racunalniški tomografiji 94%. Senzitivnost pri lokali2...1ciji feokromocitoma v nadledvicnih žlezah pa je znašala pri scintigra­fiji 80%, pri ultrazvoku 92% ter pri racunalniški Received: November 7, 1990 -Accepted: November 19, 1990 Grmek Med al, Scintigrafija s 131-J MIBG pri feokromocitomu Tabela 1 -Primerjalni rezultati hormonskih testov (HT), scintigrafije 131-J MIBG (SC), ultrazvoka (UZ) in racu­nalniške tomografije (CT) z dokoncno diagnozo (DG) Table 1 -comperative results of hormona! tests (HT), 131-J MIBG scintigraphy (SC), ultrasound (US) and computerised tomography (CT) with confirmed diagno­sis (DG) DG št HT uz CT se No. IF 15 15+ 11+1-3* 15+ 12+3­EF 2 2+ 2-1+1-2+ HSS 1 1+ 1-1* 1+ AH4 4 4-4* 4-­ Skupaj IF -intraadrenalni feokromocitom pozitiven izvid intraadrenal pheochromocytoma + positive result EF -ekstraadrenalni feokromocitom extraadrenal pheochromocytoma -negativen izvid HSS -hiperplazija sredice nadledv. negative result adrenomedullary hyperplasia AH -arterijska hipertenzija preiskava ni arterial hypertension opravljena št -število bolnikov without study No. of patients tomografiji 100%. Lažno pozitivnih rezultatov preiskav nismo zasledili. Pri 2 bolnikih s histološko potrjenim malignim feokromocitomom smo preiskavo ponovili. V pr­vem primeru, kjer je bil na predoperativnem scintigramu viden le primarni tumor v nadledvicni žlezi, smo na kontroli nekaj tednov po operaciji našli številne metastaze v kosteh in mehkih tkivih. V drugem primeru ektopicnega malignega feokromocitoma se patološka žarišca na kontrol­nem scintigramu, opravljenem slab mesec po operaciji tumorja, niso prikazala, biokemicno in klinicno niso bili prisotni znaki metastaz. Diskusija -131-J MIBG se kot fiziološki ana­log noradrenalina kopici v granulah kromafinega tkiva in tako omogoci prikaz feokromocitoma oziroma hiperplasticne sredice nadledvicne žle­ze. lntraadrenalni feokromocitom smo prikazali z razlicno intenzivnostjo v 12 primerih (slika 1 ). V 3 primerih histološko dokazanega foekromoci­toma pa kopicenja v tumorjih nismo opazili. Kromatini tumorji se lahko na scintigramih prikazujejo z razlicno intenziteto zaradi razlicne gostote granul, kar je posledica njihove razlicne Slika 1 -Scintigram, opravljen v posteriorni projekciji 48 ur po aplikaciji 131-J MIBG, prikaže feokromocitom v desni nadledvicni žlezi Fig 1 -131-J MIBG image acquired 48 hours after tracer aplication in posterior projection. The right adre­nal pheochromocytoma is visualised diferenciacije (3). Tako poskušamo pojasniti 2 primera lažno negativnega scintigrafskega izvi­da. V enem izmed teh dveh primerov smo ob reevalvaciji scintigrama ugotovili kopicenje, ki pa je bilo komaj zaznavno višje kot v kontralateralni zdravi nadlevicni žlezi (slika 2a, b). V tretjem primeru pa je bil histološko ugotovljen cisticno degeneriran tumor. Da se tumor ni prika­zal, si v tem primeru razlagamo z majhno maso tumorsklih celic na volumsko enoto tumorja in s tem manjšo kontrastnostjo na scintigramu. Racu­nalniška tomografija je v vseh treh primerih prika­zala tumor, vendar nam ni posredovala podatka o vrsti tumorja. Problem lokalizacije in vrste tumorja pa je še vecji v primeru ekstraadrenalnih feokromocito­mov. Tako lokalizirane feokromocitome smo s scintigrafijo prikazali pri 2 pacientih (slika 3ab). Zaradi enostavnosti preiskave vsega telesa, vi­dimo prednost scintigrafije pred morfološkimi preiskavami še v primeru iskanja metastaz (4, 5). Z oziram na naše rezultate menimo, da je poleg hormonskih testov v detekciji feokromoci­toma primerna kombilnacija scintigrafije in racu­nalniške tomografije (6). Ker je ultrazvok manj senzitiven kot racunalniška tomografija, je prime­ren predvsem kot presejalni test. Radiol lugosl 1990; 24:333-6 Grmek Med al, Scintigrafija s 131-J MIBG pri feokromocitomu r .. ,. ·· .. ,..?:t..:.-;_/ifr.; ....t:-.....>.:...,;;; . . ;_ ( i t_. Slika 2a -Scintigram opravljen v posteriorni projekciji 72 ur po aplikaciji 131-J MIBG z minimalno asimetric­nostjo kopicenja radioindikatorja v predelu nadledvicnih žlez. Prvotno smo to interpretirali kot normalen izvid. Fig 2a -131-J MIBG study acquired 72 hours after tracer aplication in posterior projection. Slight asymme­ try in adrenal uptake of 131-J MIBG on the right side is noted. On first reading the scan was interpreted as normal. Zakljucek -V retrospektivni študiji, ki je obse­gala 22 primerov, ugotavljamo 83% senzitivnost scintigrafije s 131-J MIBG glede na diagnozo ob odpustu iz bolnišnice. Rezultati zaradi majhnega števila primerov niso reprezentativni, so pa Slika 2b -CT prikaže tumor v desni nadledv1c111 zlezi Fig 2b-CT scan shows tumor in the right adrenal gland Radiol lugosl 1990; 24:333-6 *H ffIN*I nv•r PA ,.·.>(.t!.':;J ...... ,; .• _,;.;."'<.;.- 1 . ·'4,,c ,. ,,, }.1 ... ..-;."."•" ":4": ·. , ... . ,/'\'g-, :,;_-". *.,/ .­ --,-. '··!••-• .,.,...... t .. . .. , ,._ = ;?..:.; l ,• •• .. ··?•1t_.-;-; .-.-,,.__·• __ • . "' ,. ·,,.s,· -_-' ,' .-. .. .- Slika 3a -Posteriorni (levo) in anteriorni (desno) scintigram s 131-J MIBG opravljen 96 ur po aplikaciji z vidnimi normalnimi nadledvicnimi žlezami in nenormal­ nim žarišcem pod desno nadledvicno žlezo. Fig 3a -131-J MIBG study acquired 96 hours after injection in posterior (left) and anterior (right) projection with visible normal adrenal glands, and abnormal tracer accomulation below the right adrenal gland. Slika 3b -CT Je na tem mestu dokazal tumor Fig 3b -CT scan proved this as tumor skladni s podatki iz literature (7). Ugotavljamo, da je senzitivnost scintigrafije pri detekciji feokro­mocitoma v predelu nadlevicnih žlez slabša kot pri morfoloških preiskavah. Bistvena prednost scintigrafije pa je vizualizacija kromatinih tumor­jev, kar je pomembno predvsem v primeru lokali­zacije teh tumorjev izven nadledvicnih žlez ter pri iskanju metastaz. Grmek Med al, Scintigrafija s 131-J MIBG pri feokromocitomu Povzetek Namen naše študije je bil retrospektivna evalvacija scintigrafije z 131-J MIBG (SC) pri pacientih s sumom na feokromocitom. Rezultate SC, ultrazvoka (UZ) in racunalniške tomografije (CT) smo primerjali s histolo­ško diagnozo pri 18 pacientih. Pri 4 hipertenzivnih pacientih pa smo feokromocitom na podlagi endokrino­loških testov prakticno izkljucili. Senzitivnost SC pri detekciji tumorjev, lokaliziranih v nadledvicni žlezi, je bila 80%, pri CT 100% in pri UZ 92%. Skupna senzitivnost, vkljucujoc še 2 primera tumorja ležecega izven nadledvicnih žlez ter 1 bolnika z hiperplazijo sredice nadledvicnih žlez, je bila pri SC 83%, pri UZ 73% in pri CT 94%. Zmožnost ugotavljanja funkcionalnega kromafinega tkiva, lokaliziranega v ali izven nadledvicnih žlez ter v metastazah, je glavna prednost SC pred CT in UZ. Li teratura 1. Me Ewan AJ, Shapiro B, Sisson JC, Beierwaltes WH, Ackery DM. Radio-iodobenzylguanidine for the scintigraphic locatin and therapy of adrenergic tumors. Semin Nucl Med 1985; 2:132-53. 2. Ackery DM, Tippett PA, Condon BR, Sutton HE, Wyeth P. New approach to the localization of phaeoc­ hromocytoma: imagining with iodine-131-meta-iodo­benzylguanidine. Brit Med J 1984; 288:1587-91. 3. Bomanji J, Levison DA, Flatman WD, Horne T, Bouloux PG-M, Ross G, Britton KE, Besser GM. Uptake of iodine-123 MIBG by pheochromocytomas, paragan­gliomas and neuroblastomas: a histological compari­son. J Nucl Med 1987; 28:973-8. 4. Francis IR, Glazar GM, Shapiro B, Sisson JC, Gross BH. Complementary roles of CT and 131-J MIBG scintigraphy in diagnosing pheochromocytoma. AJR 1983; 141 :719-25. 5. Fischer M, Vetter W, Witerberg B, Hengstmann J, Zedek W, Friemann J, Vetter H. Scintigraphic localiza­tion of phaeochromocytomas. Ciin Endocrinol 1984; 20:1-6. 6. Gough IR, Thompson NW, Shapiro B, Sisson JC. Limitations of 131-J MIBG scintigraphy in locating pheochromocytomas. Surgery 1885; 98 :115-20. 7. Shapiro B, Copp JE, Sisson JC, Eyre PL, Wallis J, Beierwaltes WH. lodine-131 metaiodobenzylguani­dine far the locasing of suspected pheochromocytoma: experience in 400 cases. J Nucl Med 1985; 26 :576-85. Naslov autorja: dr. Marko Grmek, UKC, Univerzitetna klinika za nuklearno medicino, Zaloška 7, 61000 Ljub­ljana KOMPAS je ena beseda za popolni turisticni servis' orgctn1z1rane poc:,tnice v domov1n1 1n v tupn• turist,cna potovanoI a v dornov,ni ,n tujin, ,zlet,. piknik,. ogled, znamenitost, z avtobus,. letali ,n h1drogl1seq1 strokovna potovan1a -organ,zacqa kongresov. sernInarI ev navt1cn1 turizem. lov. ribolov proda1a dornac1h In mednarodnih letalskih In ielczniških vozovnic posredovan1e avtobusnih pr­ I TRUE FALSE a.. POSITIVE (TP) POSITIVE (FP) <( + ([ 32 9 ('.) o FALSE TRUE NEGATIVE (FN) NEGATIVE (TN) <( 11 88 o­ ([ Table 5 -Me Nemar's for paired dala measurements between ultrasonographie maxillary sinus findings and >­I a.. <( ([ ('.) o z+ o (fJ <( ([ f-­_J ::::> sinusoseopie findings SINUSOSCOPY TRUE POSITIVE (TP) 32 FALSE NEGATIVE (FN) 3 FALSE POSITIVE (FP) 7 TRUE NEGATIVE (TN) 78 p < 0.19 SENSITIVITY = 0.74 SPECIFICITY = 0.91 p < 0.12 SENSITIVITY = 0.91 SPECIFICITY = 0.92 Radiol lugosl 1990; 24:347-51 Rišavi R et al. A comparison of sinusoscopic, radiographic and ultrasonographic findings in the diagnosis of maxillary sinus diseases Table 6 -Comparison between ultrasonographic and radiographic maxillary sinus findings and sinusoscopic >­findings with Me Nemar's test in series I o... >­ SINUSOSCOPY . I a: o... TRUE FALSE o a: Z0+ POSITIVE (TP) POSITIVE (FP) 00 98 4 (f)­ .o FALSE TRUE a: . -NEGATIVE (TN) 1-­NEGATIVE (FN) ....J 3 35 ::, p < 0.21 SENSITIVITY = 0.97 SPECIFICITY = 0.90 Comments -Comparison between the radio­graphic and ultrasonographic findings (Table 1) shows agreement in 91.6% (33/36) of negative ultrasonographic findings and in 82.7% (86/104) of positive ultrasonographic findings. This shows a high agreement in negative findings. The agreement in positive findings is somewhat lo­wer, for the small amount of liquid in the sinuses which does not reach the back wall of the sinus cannot be registered; in addition, owing to va­rious thicknesses of the sinus mucosa, the utra­sonic beam can give a false positive result in the cases of mucosal thickening, polyp or cyst (12, 13). Analysis of the ultrasonographic and sinusos­copic findings (Table 2) shows a high agreement of negative sinusoscopic findings (92.1 % ) , and a lower agreement of positive findings (84.3% ). There were 8.8% false positive findings in cases of mucosal thickening, 12.5% false positive fin­dings in cases of complete filling, and 3.5% false negative and 14.3% false positive findings in cases of polyp or cyst ( 14). Table 3 shows !hal the agreement of negative sinusoscopic findings in relation to the radiograp­hic findings (88.9%) was lower Ihan the agree­ment between the radiographic and ultrasono­graphic findings and the agreement between the ultrasonographic and sinusoscopic findings; this is due to the fact !hal radiography is not always able to give precise information about the state of the sinus mucosa; as a result, there is a somewhat higher percentage of false negative and false positive findings, particularly in cases of complete filling, polyp or cyst (15, 16). The agreement between the sinusoscopic and radio­graphic positive findings is practically the same as the agreement between the radiographic and ultrasonographic findings. The agreement bet­ween sinusoscopic and radiographic false nega­tive findings ranges from 7.1 % to 8.8%, and that of false positive findings from 8.8% to 14.4%. McNemar's Test for Paired Data Measure­ments shows no significant difference between the findings of radiography and sinusoscopy and between ultrasonography and sinusoscopy. It also shows that ultrasonography is more reliable in terms of specificity and sensitivity. With a combination of tests in series (Table 6) the sensitivity index is 0.97, which is an optimal result. This indicates that it advisable to perform radiographic and ultrasonic examination prior to sinusoscopy and to perform ultrasonography du­ring follow-up (17, 18). The results show that comparing ultrasono­graphic and radiographic findings with sinusosco­pic findings provides a higher percentage of accurate findings and radiographic examination during diagnosis. Ultrasongraphy in the A-or B-mode is useful in the follow-up period with patients after conservative or surgical treatment, and also with pregnani women since radiation during check-ups is thus significantly reduced. Sažetak USPOREDBA SINUSOSKOPSKIH, RADIOGRAFSKIH 1 UL TRAZVUCNIH NALAZA U DIJAGNOSTICI OBO­LJENJA MAKSILARNIH SINUSA Ovaj rad predstavlja usporedbu sinusoskopskih, ra­diografskih i ultrazvucnih nalaza u dijagnostici oboljenja maksilarnih sinusa. utvrdeno je da se te tri metode u velikom postotku slažu u negativnim nalazima, dok je postotak podudarnosti u patološkim stanjima nešto niži. Raspravlja se o koristi usporedbi tih nalaza, kao i njihovim razmimoilaženjima. References 1. Axelsson A, Grebelius N, Chidekel N, Jensen C. The correlation between the radiological examination and irrigation findings in maxillary sinuses. Acta Otola­ryngol (Stockh) 1970; 69 :302. 2. Axelsson A, Brorson J, Jensen C. Akut sinuit. Astra lakemedel. Bri:iderna Ekstrand tryckeri, Lund, 1978. Radiol lugosl 1990; 24:347-51 Rišavi R et al. A comparison of sinusoscopic, radiographic and ultrasonographic findings in the diagnosis of maxillary sinus diseases 3. Keidel W. 0ber die Verwendung des Ultraschalls in der klinischen Diagnostik. Artzliche Forschung 1947; 1 :349. 4. Kitamura T, and Keneko T. Le diagnostic des affections du sinus maxillaire par ultrasons impulsifs. Ann Otolaryngol (Paris) 1965; 82:711. 5. Kitamura T, Keneko T, Asano H, Muira T. Ultraso­nic diagnosis in otolaryngology. Eye Ear Nose Throat Mon 1969; 48:329. 6. Mann W. Die Ultraschalldiagnostik der Nasenne­benh6Ien und ihre Anwendung in der Freiburger HNO­Klinik. Arch Otorhinolaryngol 1975; 211 :145. 7. Mann W. Die Ultraschalldiagnostik der NNH-Er­krankungen mit A und B-acan. Laryngol Rhinol Otol 1976; 55 :48-53. 8. Revonta M. Ultrasound in the diagnosis of maxil­lary and frontal sinusitis. Acta Otolaryngol (Stockh), Suppl 370. 9. Revonta M, Suonpaa J: Diagnosis of subacute maxillary sinusitis in children. J. Laryngol Otol 1981 ; 95:133. 1 O. Stanton A, Glank. Primer of Biostatistics. McGraw-Hill lnc. Second edilion, 1987; 195-7. 11 . Mausner J S, Bahn A K. Epidemiology Phyladel­phia: W. B. Sauders Company, 1974; 227. 12. Jannert M, Andreasson L, Holmer N G, L6rinc P. Ultrasonic Examination of the Paranasal Sinuses. Acta Otolaryngol (Stockh) Suppl. 389. 13. Mang L W, Bauer J W. Ultraschalldiagnostik der Nasennebenh6hlen: Ein Fortschritt in der HNO-Praxis? Laryng. Rhinol. Otol. 1984; 63:601-3. 14. Bauer J W, Bockmeyer M, Mang L W. Endosko­pisch kontrollierte Ultraschalldiagnostik der Kieferh6­hlen, Laryng. Rhinol. Oto l. 1983; 62 :443-5. 15. Mann W, Beck C, Apostolidis T. Liability of Ultrasound in Maxillary Sinus Disease. Arch. Oto­Rhino-Laryngol 1977; 215:75-9. 16. Mann W. Ultraschalldiagnostik im A-und B-Bild bei Erkrankumgen der Nebenh6hlen und der fazialen Weichteile. Radiologe 1986; 26:427-32. 17. Fouad H, Khalifa C M, Labib T et al. Diagnostic Ultrasonography in maxillary sinus disease. The Jour­nal of Laryngol and Otol 1984; 98 :887-94. 18. Jensen C, Sydow C. Radiography and Ultraso­nography in Paranasal Sinuses, Acta Radiologica 1987; 28:31-5. Author's address: Rišavi R, M D, ENT Glinic. Medical Faculty, 41000 Zagreb, Šalata 4, Yugoslavia Izvozno uvozno podjetje za promet z medicinskimi instrumenti, aparati, zdravili, opremo za bolnice, laboratorije in lekarne LJUBLJANA, Cigaletova 9 Predstavništvo: Telefon: (061) 317-355 ZAGREB, Šulekova 12 Telex: 31-668 sanlab yu Telefon: (041) 233-369 Telefax: 325-395 Telefax: (041) 228-298 40 .-·1 k-:t Iz prodajnega programa trgovine na debelo nudimo široko izbiro domacega in uvoženega blaga po konkurencnih cenah in sicer: rentgenske filme in kemikalije proizvajalcev »Fotokemika«, »KODAK«, »3 M -TRIMAX«, »AGFA GEVAERT« in drugih, medicinske instrumente, specialno medicinsko in sanitetno blago, potrošno blago za enkratno uporabo, medicinske aparate in rezervne dele zanje ter bolniško in drugo opremo, tekstilne izdelke, konfekcijo in obutev za potrebe zdravstvenih, proizvodnih in varstvenih organizacij, laboratorijske aparate, opremo, laboratorijsko steklovino, reagente, kemikalije in pribor, aparate, instrumente in potrošno blago za zobozdravstvo V prodajalni na Cigaletovi 9 v Ljubljani prodajamo izdelke iz asor-timana trgovine na debelo, s posebnim poudarkom na blagu za zobozdravstvo, nego bolnikov, ortopedskih pripomockih in ostalemu blagu za široko potrošnjo. Radiol lugosl 1990; 24:347-51 EiRLU5 L J U 8 L J A N A p. o. 61000 LJUBLJANA, MAŠERA-SPASICEVA ul. 10 Telefoni: n.c. (061) 371 744-direktor: 371 689 prodaja: 374 436,374 809,374 981,372 219 O SKRB UJE lekarne, bolnišnice, zdravstvene domove ter druge ustanove in podjetja s farmacevtskimi, medicinskimi in drugimi proizvodi domacih proizvajal­cev, s proizvodi tujih proizvajalcev pa s pomocjo lastne zunanjetrgovinske službe. Proizvaja ALLIVIT® IN ALLIVIT PLUS® Kapsule cesna z dodatkom zdravilnih zelišc. Prodajna in dostavna služba posluje vsak dan neprekinjeno od 7. do 16. ure, GENERAL HOSPITAL MARIBOR, DEPARTMENT OF GYNECOLOGY, BREAST DIAGNOSTIC CENTER IS UL TRASONICALL Y GUIDED BREAST PUNCTURE A REASONABLE APPROACH TO THE TREATMENT OF NONPALPABLE CYSTS? Vlaisavljevi6 V Abstract -A comparison between the efficacy ot echography and cytologic analysis ot breast cysts was made with the intention ot comparing the ability ot each method to indicate the intracystic growth (ICG). 1708 breast cyst aspirates were certified cytological. In this group three (0.17%) intracystic cancers and tour (0.23%) intracystic papillomas were diagnosed. AII cancers had positive cytological and clinical tindings. In the group of 283 patients examined by ultrasound and mammography and/or pneumocystography there were 5 patients with ICG and none were missed by ultrasound. We recorded one (0.3%) talse positive echographic sign tor the presence ot ICG and no talse negative result. The author concludes !hal the accuracy ot echographic veritication ot the cystic nature ot breast lesions tor the presence ot ICG is so high !hal there is no diagnostical reason tor cytologic veritication of ultrasonographically confirmed simple cysts. UDC: 618.19-006.6-73:534-8 Key words: breast neoplasms, ultrasonic diagnosis, punctures, mammography Orig sci paper Radiol lugosl 1990; 24 :353-5 lntroduction -At present, it is generally ac­cepted that native mammography is the only method suitable for the detection of breast can­cer. Echomammography is not so accurate that it could be used as an independent method of detection. But that does not mean that tumors revealed by detective mammography can also be visualized by echomammography. lf the solid tumor is 5 -1 O mm in diameter, it can frequently be visualized by ultrasound even though it is not clinically manifest. Unfortunately, neither of the two methods can always determine the nature of tumors, not even when they can be visualized by these methods. Nevertheless, in this case echo­mammography has a certain advantage in the differentiation of cysts from solid tumors. The differentiation of malignant from benign solid breast tumors is not successful to such an extent that we could conclude on the nature of the tumor merely on the basis of the echographic findings (1 ). It is necessary to verify the tumor by aspiration cytology. We applied interventional ultrasound in cases where nonpalpable circums­cribed lesions were found on the nalive mammo- (4). Methods -AII the laws that are ordinarily valid for interventional echography are also valid for this kind of investigation. They mean above all sterile equipment and contact medium for the investigation. The skin is desinfected by an appli­cation of betadine iodine solution. Because of its viscosity, it is usually not necessary to apply a contact medium to the skin. The probes are desinfected by cetavlone or alcohol. Usually the following three puncture techniques are used: 1. The technique of marking the puncture site followed by blind puncture. This technique is merely used for marking of the puncture site. A linear probe is used. An injection needle is positioned under it. The needle is moved under the probe until the shadow of the needle covers the lesion to be punctured. Tb_e point of intersection of needle and probe denotes the puncture site. The puncture is carried out The material was presented on the First lnternational Symposium on lnterventional and lntraoperative Sonography, Zagreb, May 1989. Received: November 2, 1989 -Accepted: November 12, 1989 VlaisavljeviC V. 1s u1trasonically guided breast puncture a reasonable approach to the treatment of nonpalpable cysts? perpendicularly to the determined site of the puncture. This technique is only adequate for lar.9er cysts. 2. The technique of puncture »by free hand«. A linear probe is used which is placed so that the tumor lies closer to one of its edges. The needle is inserted under the skin and its progress toward the desired site is followed on the monitor. Corrections of its path can be made during the entire course of the intervention. 3. The technique of puncture using a probe adjusted for puncture. Today probes designed for puncture usually enable a continued following of the needle on the monitor. The needle can be easily and quickly inserted at the marked place and in the direction of the lesion. This technique is simple and safe even in small lesions. At the Breast diagnostic Center Maribor, the influence of echographic diagnostics of cystic breast lesions was evaluated in a ten year period. For this purpouse we analysed cytologic manife­station of breast cyst aspirates and changes in diagnostic procedures related to breast cyst diag­nosis induced by interventional ultrasound. Results -A total of 1708 breast cyst aspirates were analysed in our center. Among ali of these aspirates, there were only 3 (0.17%) positive findings. Although we had more positive samples (n=8) they were aspirated from the same malig­nant tumor. These findings which were positive too are not counted in calculation of the incidence of positive aspirates. In ali cases, the reason for positive cytologic findings was an intracystic ma­lignant tumor. We had not registered any false positive findings. In all of these intracystic can­cers were clinically manifest after intracystic fluid was evacuated. In 31 (1.8%) cases the results of cytologic evaluation were classified as suspect. In one of these cases, an intracystic tumor was confirmed by ultrasound and histologically certified as ma­lignant. In 5 patients the benign intracystic papil­lomas were certified by open biopsy. Ali were visualized by ultrasound. In 6 patients with suspi­cious citology, no ultrasonographic and histologic reasoris for such a result were certified. In 20 cases cytologic findings were classified as indi­stinct cases (Papanicolaou 2-3). Observation and follow up was recomanded. No malignant tumor was diagnosed in this group during the 1 O years follow up period. In the whole group, 324 (18.9%) aspirates were not adequate for cytologic analysis. In this period a total of 283 breast cysts were evaluated by echography. There were 5 benign intracystic papillomas and 2 false positive fin­dings on ultrasound. In one of these cases, a galactocele with large intracystic particle was found by open biopsy. In a second case, there was no. histologic substrate for ultrasonogram which was suspicious on intracystic growth. There were no false negative results for the presence of malignant intracystic growth. A comparison of the number of pneumocysto­grams (PCG) and echomammograms of breast cysts in the period of ten years showed us that the accuracy of echomammography in breast cyst evaluation is so high that pneumocysto­graphy was recently nearly completely abando­ned. Pneumocystography was a frequently used procedure in the period before we introduce ultrasound in breast diagnostics. In the period between 197 4 and 1978, a to tal of 149 PCG were made in 392 clinically manifest breast cysts. After that, a total of 97 PCG were indicated although a larger number of breast cysts were aspirated (1316 cases) and many of them were not palpable. In the last three years only 8 PCG were done. The analysis of the last 190 pneumocysto­grams showed us that we had 8 (4.1 %) indistinct or inadequate pneumocastograms which need histologic verification. In ali of these cases, open biopsy was overtreatment because no patology was find. There were no intracystic malignancies detec­ted by ultrasonographic visualization or ultraso­nographically guided puncture of unpalpable breast cysts in the period of 9 years. Discussion -Although echomammography is extremely precise in diagnosing of the cystic nature of lesions, it has no great value in palpable tumors. They would in any case have to be .punctured because of cytologic verification, so this would prove the cystic nature of the lesion. lts role in verification of unpalpable cysts is far more important (2, 5). Often small cysts detected on the x-ray mam­mogram cannot be correctly determinated as fluid filled lesions on the basis of these findings. Echomammography can make the decision for biopsy of solid lesions easier and more precise with correct interpretation of cystic lesions (5, 6). The next problem is the verification of unpalpa­ble lesions in the radiographically dense, opaque Radiol lugosl 1990; 24:353-5 Vlaisavljevic V. 1s ultrasonically guided breast puncture a reasonable approach to the treatment of nonpalpable cysts? breast in which such changes can usually be visualized without difficulty by ultrasound. Be­cause ot overlapping ot typical signs ot solid and cystic lesions on the mammogram, aspiration can quite simply contirm the diagnosis (4). This is ot special importance in cases when a breast with multiple cysts must also be investigated by mammography because ot the possible simulta­neous presence ot cancer. Aspiration ot cyst before mammography eases mammographic in­terpretation ot the breast. Generally, because ot the high accuracy ot echomammography cytologic analysis ot breast cyst aspirates had no such value as in the period betore the introduction ot ultrasound in diagnostic procedure. The reason tor aspiration ot nonpalpable breast cysts by ultrasonically guided puncture is at this moment more the need tor veritication ot echographic tinding than the need tor analysis ot aspirates. The risk tor positive cytologic tinding ot cyst aspirates is very low. It the echographic diagnosis is clear, and there are no clinical reasons tor aspiration, we can omit the procedu­re. This means that ultrasound complitely elimina­tes the need tor puncture in fluid tilled lesions. The value ot ultrasound guided puncture in breast pathology seems to lie in the evaluation ot solid tumors. But in this tield ot application, the value ot each negative cytologic tinding must be discussed in the same way as in ordinary pun­cture ot palpable breast lesions althought the tip ot the needle was visualized during the aspira­tion. Sažetak DA LI JE UL TRAZVUKOM VODENA PUNKCIJA DOJKE PRIMJERNA ZA LIJECENJE NEPALPABIL­NIH CISTA? S namjerom da se usporedi uspješnost citologije i ehomamografije u pronalaženju intracisticnih prolifera­tivnih procesa u dojci (ICP), analizirano je 1708 citolo­ških nalaza aspirata cista dojke. U analiziranoj grupi bila su tri (O, 17%) intracisticna karcinoma i cetiri (0,23%) intracisticna papilarna. U svih karcinoma bili su pozitivni citološki i klinicki nalazi. U grupi 283 pacijentica pregledanih ultrazvukom i nativnom mamografijam telili pneumocistografijom bilo je i pet pacijentica s ICP. U svih je bio nalaz ehomamo­grafije pozitivan. U jedne pacijentice analizirane grupe našli smo jedan (0,3%) lažno pozitivan nalaz ICP. Autor zakljucuje, da je tocnost ehografske verifikacije cisticnih lezija dojke tako visoka, da je citološka verifika­cija aspirata ehografski potvrdenih jednostavnih cista postala nepotrebna. Referen ces: 1. Vlaisavljevic V. Differentiation of solid breast tu­mors on basis of their primary echographic characteri­stics as revealed by real tirne scanning of uncompres­sed breast. Ultrasound Med Biol 1988; 14 (supl 1) :75­80. 2. Vlaisavljevic V. lnterventional ultrasound in breast diseases. Excerpta medica ICS 1986; 701 :85-93. 3. Vlaisavljevic V. Dijagnostika raka dojke ehoma­mografijom. Libri oncol 1981; 1 O :239-41. 4. Vlaisavljevic V. Sonographically guided needle biopsy of breast lesions. Excerpta medica ICS 1984; 640:49-52. 5. Harper P. Fine needle aspiration biopsy of breast using ultrasound techniques -superficial localization and direct visualization. Ultrasound Med Biol 1988; 14 (supl 1):5-11. 6. Hogg J, Harris K, Skolnick L. The role of ultra­sound guided needle aspiration of breast masses. Ultrasound Med Biol 1988; 14 (supl 1) :13-21. Author's address: Vlaisavljevic V, M. D. General Hospital Maribor, 62000 Maribor, Yugoslavia Radiol lugosl 1990; 24:353-5 Visoko ucinkovit selektivni virostatik v obliki injekcij za infuzijo, mazila za oci in kreme VIR Q LEX® (aciklovir) za zdravljenje in preprecevanje infekcij, ki jih povzrocajo virusi herpes simplex tipa 1 in tipa 2 ter varicella zoster • visoko selektivno deluje na viruse • hitro zaustavi razmnoževanje virusov • hitro odpravi simptome infekcije • bolniki ga dobro prenašajo VIROLEX® -injekcije za infuzijo za zdravljenje -infekcij s herpesom simplexom pri bolnikih z oslabljeno imunostjo -hudih oblik primarnega genitalnega herpesa simplexa -primarnih in rekurentnih infekcij z varicello zoster pri osebah z normalno in oslabljeno imunostjo herpes simplex encefalitisa (fokalnega in difuznega) -za preporecevanje infekcij s herpesom simplexom pri bolnikih z zelo oslabljenim imunskim sistemom (tran.plantacije, zdravljenje s citostatiki) VIROLEX® -mazilo za oci za zdravljenje -keratitisa, ki ga povzroca herpes simplex VIROLEX "' -krema za zdravljenje -infekcij s herpesom simplex na koži in sluznicah Podrobnejše informacije in literaturo dobite pri proizvajalcu. . KRKA, tovarna zdravil, n. sol. o., Novo mesto KRKA UNIVERSITY HOSPITAL »DR O. NOVOSEL« CENTER FOR UL TRASOUND »ZAGREB«, ZAGREB ULTRASOUND GUIDED FINE NEEDLE ASPIRATION BIOPSY IN THE DIAGNOSTICS OF PANCREATIC CANCER Drinkovic 1, Kos N, Odak D, Kardum-Skelin 1, Vidakovic Z Abstract -Despite of numerous diagnostic possibi!ities, pancreatic cancer stili presents a problem tor diagnostics, esp. in its early stage, i. e. when surgery could stili be of help. We presen! our results of aspirated biopsy of the pancreas obtained in the last 8 years. It has been performed on 126 patients. With this method the diagnosis of pancreatic cancer, was confirmed in 41 pathents, while in foum patients the material obtained was insufficient and in two patients it was false negative. The accuracy of the ultrasonographical examinations was 90%. This method has proved itself as a simple, quick, cheap and accurate one, bul of no considerable value in especialiy important early diagnosing of the disease. UDC: 616.37-006.6-07:534-8 Key words: pancreatic neoplasms, biopsy needle, ultrasonic diagnosis Profess paper Radiol lugosl 1990; 24:357-9 lntroduction -Although today there is a large number ot diagnostic posibilities tor diagnosing pancreatic cancer, such as computerised tomo­graphy, magnetic resonance, ultrasound, retro­grade pancratography, humorous tumoral mar­kers, the diagnosis ot pancreatic cancer is stili reached in a late stage ot the disease. Very otten an aspirated biopsy ot the change is needed, in order to verify the diagnosis preoperatively, which is very important as the torecast and guidance tor the surgical procedure. In our prac­tice we use aspirated biopsy ot the pancreas tor discovering and shortening the diagnostic treat­ment ot the pancreatic cancer. Material and methods -Aspirated biopsy ot the pancreas has been pertormed on 126 pa­tients in whom there were doubts on a malignant pancreatic process. The indications tor aspirated biopsy were loss of weight, abdominal pain, and ultrasonographicaly enlarged echogenic structu­res. As an indication we also considered changed computerised tomography findings, or an unclear finding of retrograde pancreatography. The pro­cedure was performed on hospitalised patients only, using the Sonel 303 with a lateral puncture guider. The material was taken by means of a fine needle (22 G), through one initiative puncture with several inner punctures of the pancreas, with help of the negative pressure inside the lesion. During the puncture a cytologist-patholo­gist was always presen! to judge the validity of the material. In case of the insufficient material the puncture was repeated. Results -By puncturing the malignant process on the suspected pancreas, the diagnosis of pancreatic cancer was contirmed in 41 patient. In 66 patients degenerative cells ot pancreas were found, with suspicions on chronic changes due to intlammations. In tive patients cy1ologic tindings indicated acute inflammations. In three patients normal pancreatic cells were obtained, while in tour patients the punctures ot the surrounding lymphatic nodules and two duodenum diverticullu­ses were performed. In four patients the material obtained was insufficient, while in two patients it was talse negative. The accuracy ot the ultraso­nographical examinations was 90% (Table 1 ). The material was presented on the First lnternational Symposium on lnterventional and lntraoperative Sonography, Zagreb, May 1989. Received: November 2, 1989 -Accepted: November 12, 1989 DrinkoviC I et al. Ultrasound guided fine needle aspiration biopsy in the diagnostics of pancreatic cancer Table 1 -Results of ultrasound guided fine needle or sometirnes even a histologic biopsy of the aspiration biopsy in diagnosing pancreatic cancer pancreas should be rnade. In our practice aspira­ted biopsy proved as a quick, accurate and No.o! cheap rnethod. The diagnostic period has been DIAGNOSIS patients % considerably shortened, although the analysis of Carcinoma 41 Benignant cells 66 53 the surgical results did not show any betterment in the lile expectancy of the patients operated. Acute pancreatitis 5 5 Surrounding structures 4 3 Pancreatic cells (normal) 3 2 lnsufficient material 4 3 False negative 2 1,5 Total 126 100 Discussion -Ultrasound guided aspirated biopsy of the pancreas is an additional diagnostic rnethod completing the field of diagnostic possibi­lities in discovering pancreatic cancer. As distin­guished from the other irnaging techniques, ultra­sound and aspirated biopsy can directly confirm and solve etiology of the pancreatic changes, which very often rernains unclear, even after all the other examination techniques have been applied (1, 2, 3). Aspirated biopsy of the pan­creas was false negative in only 1.5% of patients of this group. The material was false negative due to the fact that it was !aken from a central necrosis of tumor. So it is of great irnportance at every biopsy, that the samples be taken from the borderlines of tumorous rnasses, too (Fig. 1, 2). The number of false negative and false positive findings can be considerably reduced in this way. In case of insuficient material or an indefinite diagnosis, aspirated biopsy should be repeated, Aspirated biopsy enables quick verification of turnorous proceses, but its genesis is such that the patient comes to the examination having the symptoms already. Conclusion -Aspirated biopsy of the pan­creas is a quick, cheap bul an agressive method of diagnosing of tumorous change of the pan­creas. It shortens the diagnostic procedure and makes the decision tor operation more sirnple and easier. However, retrospective analysis of the punctured carcinornas did not show a major shift in the diagnostic procedure regarding the succes of an operation. Sažetak ASPIRATIVNA BIOPSIJA U DIJAGNOZI RAKA PANKREASA Usprkos brojnim dijagnostickim mogucnostima, rak pankreasa je još uvijek problem dijagnosticirati, naro­cilo u ranoj fazi, kad bi operativni zahval bio od koristi. !znosimo rezultate aspirativnih biopsija pankreasa dobi­vene u našoj praksi u zadnjih 8 godim•. Radena je bila kod 126 bolestika, na ovaj nacin smo rak pankreasa potvrdili kod 41 bolesnika, samo kod cetiri bolesnika smo dobili nezadovoljavajuci materija! i kod dva lažno negativan. Preciznost pretrage je bila 90%. Ova se metoda pokazala jednostavnom, jeftinom i tocnom, ali bez vece vrijednosti u bitno ranijem dijagnosticiranju ove bolesti. Fig. 1 -Head of the pansreas enlarged, with a needle Fig. 2 - Cytologic material: malignant cells of the in the tumorous mass pancreas 358 Radiol lugosl 1990; 24 :357-9 Drinkovic I et al. Ultrasound guided fine needle aspiration biopsy in the diagnostics of pancreatic cancer References 1. Hancke S, Pederson J F. Percutaneous puncture of pancreatic cysts guided by ultrasound. Surg Gynae­col Obstetr 1976; 142 :551-2. 2. Hancke S, Holm H H, Koch F. Ultrasonically guided percutaneous fine needle biopsy of the pan­creas. Surg Gynaecol Obtetr 1975; 140 :361-4. 3) Hovdenak N, Lees W R, Pereira J, Beilby Jow, Cotton Pb. Ultrasound guided percutaneous fine needle aspiration cytology in pancreatic cancer. Br Med J 1982; 285:1183-4. Author's address: Dr. Ivo Drinkovic dr sci Klin. boin. »Dr O. Novosel«, Zajceva 19, 41000 Zagreb, Yugosla­via IZ PRAKSE ZA PRAKSO KVIZ št. 3 Odgovor: V diferencialno diagnosticnem pogledu prihaja v poštev tako benigna kakor tudi maligna narava spremembe, tomografija primera definitivno ne pojasni. CT toraksa ni bil opravljen, ceprav bi dal zelo koristne podatke o obsegu lezije, v morfološkem pogledu ne omogoci verifikacije procesa. Verifikacija je možna le mikroskopsko. Z ozirom na anamnesticni podatek, da je bila opravljena resekcija želodca pred 22 leti, bi morda diferencialno diagnosticno prišel v poštev rak želodca z metastazo. Vendar so take metastaze pri raku želodca neobicajne. V diferencialni diagnozi pride v poštev metastaza neznanega raka. Metastazo raka grla po zdravljenju pred enajstimi leti izkljucuje drugacna morfološka slika novo odkritega raka. Adenom bronhusa izkljucuje že starost bolnika. Da pa ne gre za tuberkulom je razvidno iz rentgenogramov izpred 3 let, kjer lezija ni bila vidna. Verifikacija malignoma iz sputuma; bolnik je tri dni zaporedoma zbiral jutranji sputum, ki so ga citološko pregledali; ni uspela. Tomografija je pokazala 3,5 x 4,5 cm veliko dokaj ostro omejeno zgostje levo ob hilusu. Lezija je bila vidna že na nalivnem posnetku toraksa. Pri bolniku so z bronhoskopijo in transbronhialno punkcijo potrdili rak bronha zgornjega lobusa levega pljucnega krila. Zaradi starosti in zaradi obsega bolezni je primer inoperabilen, zlasti še, ker je bil histološko potrjen mikrocelularni anaplasticni rak. lndicirana je bila kemo-in radioterapija. Ko mentar: Okrogle lezije v pljucih nujno zahtevajo bronhološko obdelavo in r;nikropsko verifikacijo. Vzrok nastanka raka grla, kakor tudi nastanka raka bronhusa je po vsej verjetnosti v dolgoletnem kajenju, ki ga bolnik navaja. Dopustiti moramo možnost, da pri enem bolniku ugotovimo istocasno ali v presledku, obstoj dveh ali vec primarnih malignih obolenj. Naslov avtorja: prim. dr. Jurij Us, Onkološki inštitut Ljubljana, Zaloška 2, 61000 Ljubljana. Radiol lugosl 1990; 24:357-9 i:-, . & ­ -;:. ,f} . 0; '1 .,m,!li, i :· 'Q.Q[l '3 \: \­ UDRUŽENJE KANCEROLOGA JUGOSLAVIJE organ1z1ra VIII. KONGRES KANCEROLOGA JUGOSLAVIJE s medunarodnim sudjelovanjem Zagreb, 9.-11. svibnJa 1991. godine ..... o Za sve ostale informacije obratiti se na adresu: Dr Branko Malenica Središnji institut za tumore i slicne bolesti 41000 Zagreb, !lica 197 1st SURGICAL DEPARTMENT OF SEMMELWEIS MEDICAL UNIVERSITY, BUDAPEST,HUNGARY INTRAOPERATIVE SONOGRAPHY IN THE SURGERY OF CHRONIC PANCREATITIS Winternitz T, Flautner L, Tihanyi T Abstract -lntraoperative echography (IOE) was performed in 72 patients with chronic pancreatitis. Seventy pseudocysts or necrotic cavities were tound in 59 patients. The IOE proved to be helpful in 73.1 % of these operations. With the help of IOE, in patients who had small cysts in the head of the pancreas a new transparenchymal pseudocysto-duodenostomy was performed instead of resection. Our conclusion is, that IOE should be performed routinely in operations for chronic pancreatitis. UDC: 616.37-002-089 :534-8 Key words: pancreatitis-surgery, intraoperatic period, ultrasonic diagnosis Orig sci paper Radiol lugosl 1990; 24:361-3 lntroduction -The most frequent indication tor pancreatic operations are the complications of pancreatitis, especially pancreatic pseudo­cysts. These generally become known on surge­ry, but often they are not palpable. On the other hand, small cysts in the head of the pancreas are often unidentifiable before surgery, and are very often unpalpable. We found that in more than 50% of 150 pancreato-duodenectomy cases the pathological examination of the removed speci­men showed small cysts or necrotic cavities, not diagnosed bofore surgery. IOE can be helpful in this field of surgery, but it is used mainly at the surgery of pancreatic malignancies and endocrine tumors (1, 2, 3, 4, 5, 6, 8). Little literature can be found on the intrao­perative echography in chronic pancreatitis (7, 9, 1 O, 11 ). We wondered how useful IOE could be in this particular field of surgery. Material and method -Since 1986 we have performed intraoperative echography at 98 pan­creatic operations. The diagnoses are shown in table 1. We used TOSHIBA SAL 55 AS and PICKER LS 5000 ultrasound units with 5 MHz linear array intraoperative transducers. The tran­sducers was sterilised in formaldehyd steam. Acoustic coupling material was not used. The pancreas was first explored surgically. The head palpated after a Kocher's maneuver, and the body and the tail were explored after the dissection of the gastro-colic ligament. On exami­nation, the mesenteric and the lienal veins were used as a landmark. Results -Out of the examined 72 patients with chronic pancreatitis, we found pseudocysts in 59 patients. They had 70 pseudocysts; 20 cysts found in 18 patients were in the tail or in the body (Fig. 1 ), 7 of. them were not known before operation, and 4 were not palpable. According to our experiences, the most impor­tant are the cysts of the head of the pancreas, because they play a major role in maintaining symptoms caused by chronic pancreatitis. At 41 pancreatic operations we found 50 cysts in the head of the pancreas, 21 of these were not known before operation and 12 were not palpable on surgery (Fig 2, 3, 4), (Table 2). The material was presented on the First lnternational Symposium on lnterventional and lntraoperative Sonography, Zagreb, May 1989. Received: November, 1989 -Accepted: January 11, 1990. Winternitz T et al. lntraoperative sonography in the surgery of chronic pancreatitis Fig 1 -Preoperatively localised, bul in the enlarged, imflammed pancreas unpalpalpable cyst in the body. Fig 2 -Small, preoperatively unlocalised, unpalpable pseudocysts in the head of the pancreas. In the patients with pancreatic head cysts we pertormed a transparenchymal, agressive pseu­docysto-duodenostomy (Fig. 5). There was no postoperative mortality, and the early results ot these patients looked good atter 2 year tollow-up period. Conclusions -lntraoperative sonography is a very helptul imaging method during surgery tor chronic pancreatitis. It is an excellent modality tor discovering hollow spaces in parenchymal organs. It appears to be an ideal procedure tor the localisation ot pancreatic pseudocysts, ab­scesses. The method can help the surgeon to reduce tissue aissection and operative tirne. Winternitz T et al. lntraoperative sonography in the surgery of chronic pancreatitis Table 1 -Diagnoses in 98 patients in whom intraopera­tive sonography was performed during surgery for chronic pancreatitis Diagnosis Number ot patients Pseudocysts 59 Chronic pancreatitis w/o cysts 13 Carcinoma 20 Hyperinsulinism 6 Table 2 -Distribution ot cysts according to the anatomic location tound during surgery tor chronic pancreatitis Head Body/tail AII No. ot patients 41 18 No. ot cysts 50 20 70 Fig 5 -The lransparenchimal-pseudocysto-duodeno­ Were not known betore op. 21 7 28 (40%) Were not palpable 12 4 16 (22.8%) 3. stomy with a closed, blunt peans forceps. Gozetti G, Mazziotti A, Bolondi L. Ecografia intrao­ IOE enables the surgeon to change the tac­ticts, and perform drainage operation instead of resection. This can reduce the morbidity and mortality of pancreatic surgery. Sažetak INTRAOPERATIVNA SONOGRAFIJA U KIRURGIJI KRONICNOG PANKREATITISA lntraoperativna sonografija (1OS) je izvršena na 22 pacijenta koji boluju od kronicnog pankrea­titisa. Kod 59 nadeno je 70 pseudocista odnosno nekroticnih šupljina. 1OS se pokazala tocnom u 73, 1 % navedenih operacija. Uz pomoc 1OS, kod pacijenata koji su u glavi pankreasa imali manje ciste, umjesto resekcije izvršena je nova transpa­renhimska pseudocisto-duodenostomija. Naše je mišljenje da bi 1OS trebalo rutinski primjenjivati u zahvatima na kronicnom pankreatitisu. References 1. Angelini L, Bezzi M, Tucci G at al. The ultrasonic detection of insulinomas during surgical exploration of the pancreas. World J Surg 1987; 11 :642-7. 2. Gorman B, Charboneau J W, James E M at al. Benign pancreatic insulinoma: Preoperative & intraope­rative sonographic localisation. A J R 1986; 147:929­34. peratoria in chirurgia epato-biliare e pancreatica. Milan: Masson ltalia 1986. 4. lto T, Harihara Y, Ohnishi H at al. Ultrasound during pancreatic surgery. In: WFUMB 85 Proceding 161. 5. Jakimowicz J J, Carol E J, Jurgens P T H. The peroperative use of real tirne B-mode ultrasound ima­ging in biliary and pancreatic surgery. Dig Surg 1984; 1 :55-60. 6. Klotter H J, Ruckert K, Kummerle F at al. The use of intraoperative sonography in endocrine tumors of the pancreas. World J Surg 1987; 11 :635-41 . 7. Rifkin MD, Wiss::; M. lntraoperative sonographic identification of nonpalpable pancreatic masses. J Ul­trasound Med 1984; 3 :409-11 . 8. Sigel B, Coelho J C U, Nyhus L N at al. Detection of pancreatic tumors by ultrasound during surgery. Arch Surg 1982; 117:1058-61. 9. Sigel B, Machi J, Kikuchi T at al. The use of ultrasound during surgery tor complications of pancrea­titis. World J Surg 1987, 11 :659-63. 1 O. Sigel B, Machi J, Ramos J R at al. The role ot imaging ultrasound during pancreatic surgery. Annals of Surg 1984; 200 :486-93. , 1. Winternitz T, Flautner L, Tihanyi T. lntraopera­tive sonography in pancreatic surgery. In: Surgical Updating 1988 VII. Endocrin Surgery 1988; 197-200. Author's address: Dr Winternitz T., 1st Surgical Department of Semmelweis Medica! University, 1082 Budapest, ulli:ii ut 78, Hungary Aadiol lugosl 1990; 24:361-3 ALPE-ADRIA z > -< t"" trj o -< 7) . . . tl ::o -< > NV"HCTV.Hid1:V rt ALPS-ADRIA CONGRESS ON HEPATO -PANCREATO ­BILIARY SURGERY ANO MEDICINE HRSTANNOUNCEMENT .... , OCTOBER 3-5, 1991 CANKARJEV DOM, LJUBLJANA UNIVERSITY HOSPITAL »DR O. NOVOSEL« CENTER FOR UL TRASOUND »ZAGREB« APPLICATION OF INTRAOPERATIVE ULTRASOUND IN DISCOVERING CHOLEDOCHOLITHIASIS Drinkovic 1, Bezjak M, Deskovic E, Kos N, Odak D, Vidakovic z Abstract -During the period from 1985, till today, we focused our attention on the renal cyst formations, their urologic indications for fine needle aspiration biopsy and alcohol sclerosation under ultrasonic guidance. We divided 40 patients with a single our multiple cysts into two main group in relation to the size and localization in the renal parenchyma. lf the renal cyst was less Ihan 3 cm in diameter, our attitude was to wait and control the cyst growth by ultrasound examination. Percutaneous cyst aspiration biopsy with cytological analysis of the obtained liquid and simultaneous alcohol sclerosation were performed in peripheraly located cysts of medium size, i. e. 3-1 O cm in diameter. The operation was a method of choice in large cysts with a diameter over 1 O cm. UDC: 617-089:534-8 Key words: ultrasonic diagnosis, intraperatic period Profess paper Radiol lugosl 1990; 24:365-7 lntroduction -In surgical practice biliar tract diseases are quite common. A whole range of preoperative diganostic procedures has been devoloped in order to discover them: ultrasono­graphy, cholangiography, retrograde cholangio­graphy, CT and MR. But despite their high accuracy, obstructive icterus in many patients stili remains of vague genesis. The most common cause are, by far, choledochus calculi, secondary findings in 25% of cases of cholelithiasys. Carci­nomas, benign hiperplasya of choledochus, ste­notic or sclerotic papilitis, as well as iatrogenic and traumatic lesions, chronic inflammations and pancreatic carcinoma may presen! difficulties in diagnostics of obstructive icterus. Preoperative suspicions or diagnosis should be confirmed or opposed by surgical intervention. During such diagnostic intervention, besides palpation and inspection, we use US, cholangiography with radiometry, choledoscopy and, in the cases of choledocholithiasis, choledochus rinsing or cat­heterisation by Fogarty baloon (1, 2, 3). Employing standard examinations, choledoc­ hus calculi remain after bile surgery in 3.8% of patients, and in 4%-5% after choledochus surge­ry. lntroducing intraoperative US the range of diagnostic possibilities has been completed by a noninvasive technique, free of radiation and toxic solutions. Endoluminous and extraluminous changes can be analysed without choledochus lesioning. Ana­lysis of the size of tumors, depth of their penetra­tion, as well as relation of tumors to blood vessels and surrounding structures is possible. Material and methods -UIS was carried out on 19 patients on whom preoperative diagnosis was not fina!, or where there was a suspicion on choledochus calculi. In our practice the examina­tions are carried out by sectoral and linear 7 .5 MHz transducers of Sonel 3000 and Scanel 300, after surgical preparation and exposure of chole­dochus and head of pancreas respectively. The transducers are sterilized by means of sterile ruber cover and sterile parafine oil which is applied to ensure contact between the transducer and the ruber cover. By applying greater quanti- The material was presented on the First lnternational Symposium on lnterventional and lntraoperative Sonography, Zagreb, May 1989. Received: November 2, 1989 -Accepted: November 8, 1989 DrinkoviC I et al. Application of intraoperative ultrasound in discovering choledocholithiasis ties of oil -oil bed up to 1 cm deep, it is possible to visualise abdominal structures and at the same tirne complications connected with the near field picture analyses are avoided. However. because of the compression of choledochus by transducer, we also apply a physiological solution into abdomen, i. e. choledochus is analysed with no physical contact with the transducer. The examination begins with the analysis of gallblad­der, its wall and lumen. It is continued with the analyses of ductus cisticus and choledochhus to papilla. At this point, the analysis of the head of pancreas and haepatic parenchyma is performed routinely. By forced filling of the choledochus with a physiological solution, via dissected ductus cistucus or by puncture, we analyse its lumen and wall, passableness of the papilla and the wall of duodenum in the papilla region filled with water. Results -US examination of choledochus was carried out on 19 patients. It was not possi­ble to bring the examination to its end because of anatomic variations in one patient. In one patient the analysis found out choledochus carci­noma, while preoperative examination led to outer compression (Fig. 1 ). In one patient the cause of obstruction was pancreatic cancer. In one it was chronic pancrea­titis. producing stenosis. In two patients there Fig. 2 -Terminal section o! choledochus filled with concrements were no caiculi choledochus found, and in one, a slone was skipped in papilla vateri. In ali 11 patients cholelithiasis with choledoholithiasis or choledocholithiasis were found, while in two cho­ledochus was completely filled with mud or small calculi. The accuracy of US was 95% and in gallbladder 100% (Fig 2). Discussion -IUS is a new diagnostic method in biliar tract analysis. A very detailed analisyis of the region is possible due to the application of high resolution transducers, i. e. we are able to analyse choledochus wall and to find out inflama­tions, degenerative or tumorous changes. Even one mm calculi can be traced with a 100% accuracy in gallbladder which cannot be said for palpation and preoperative preparations. We are able to see and evaluate the kind of choledochus obstruction, and to make the analysis of tumor, its largness, structure and relation to, as well as its invasion, on other organs and blood vessels Finding out of hepatic metasthases and metast­hases on surrounding lymphatic nodules does­not present a problem. One should also stress high accuraccy in finding out of calculi and differentiation between mud, solitary, impacted and floating calculi, as well as micro calculi of up to two mm which in seven % of cases can be skipped by intraoperative cholangiography. Fig. 1 -Three concrements in choledochus 5 mm large Radiol lugosl 1990; 24 :365-7 Drinkovic I et al. Application of intraoperative ultrasountl in discovering choledocholithiasis Exact analysis ot choledochus wall can be done. Compared to other diagnostic methods, ultrasonography ot biliar tract can be performed in completely physiological conditions, with no radiation, or surgical lesions ot ductus choledoc­hus, which as a consequence can, by developing scar changes, cause postcholecystomic impedi ments. Applying physiological solution by torce we can also analyse passableness ot papilla and the duodenum wall. lntraoperative sonography is, due to its price, simplicity tor application and accuracy, first diagnostic method which in case ot positive tindings does not call tor a turther diagnostic intraoperative interventions, while in case ot unclear tindings this method should be complemented by intraoperative cholangiograp­hy, choledoscopy or other known intraoperative diagnostic possibiliiies. Conclusion -IUS is a new diagnostic method which complements diagnostics ot biliar tract. The method is a quick one, sate, free from radiation and use ot toxic solutions. The price ot the apparatus and its maintenance is acceptable tor smaller hospitals, too. The analysis ot biliar tract can be performed in physiological condi­tions, and tinding ot tumors and calculi, as well as the analysis ot surounding structures, which can consequently lead to changes on biliar tract, can also be done. Accuracy ot gallbladder diagnostics is 100% and ot choledochus calculi tindings 95%. Sažetak UPOTREBA INTRAOPERATIVNE SONOGRAFIJE U OTKRIVANJU HOLEDOHOLITIJAZE lntraoperativna holangiografija je široko raširen prihvacen nacin analize bilijarnog stabla. lntraopera­tivna ultrazvucna (UIS) analiza holedohusa otkriva. bilijarne kamence, ali u fiziološkim uvjetima može takoder analizirati lumen i stijenku holedohusa, kao i okolne strukture. IUS pregled je izvršen na 19 pacije­nata pod sumnjom na holedoholitijazu. Pregledi su izvršeni koristeci sondu od 7.5 MHz preko tankog vodenog jastuka ili tankog sloja parafina. U 14 pacije­nata potvrden je preoperativni nalaz. Kod jednog paci­jenta analiza nije mogla biti izvršena zbog fizioloških varijacija. U dva slucaja nije bilo kamenaca u žucnim vodovima, a u jednom slucaju previden j_e kamenac u papili vateri. Tocnost ultrazvucnih nalaza bila je 90%. Ova metoda nam omogucuje analizu i manjih žucnih kamenaca, procjenu širine lumena i debljinu stijenke žucnih vodova, kao i otkrivanje tumoroznih tvorbi. References 1. Knight R P, Newell J A. Operative use of ultraso­nics in cholelithiasis. Lancet 1963; 1:1023-5. 2. Lane R J, Coupland G A E. Ultrasonic indications to exploring the common bile duet. Surgery 1982; 91 :268-74. 3. Makuuchi M, Hasegawa H, Yamazaki S. lntraope­rative ultrasonic examinations tor hepatectomy. Jpn Journal Ciin Oncol 1981; 11 :367-90. Author's address: Dr. Ivo Drinkovic, dr sci, Klin. boin. »Dr O. Novosel«, Zajceva 19, 41000 Zagreb, Yugosla­via 36T Radiol lugosl 1990; 24:365-7 JADROAGENT RIJEKA MEOUNARODNA POMORSKA I SAOBRACAJNA AGENCIJA INTERNATIONAL SHIPPING ANO FREIGHT AGENCY Sjedište -Main Office: 51000 RIJEKA, Trg Ivana Koblera 2, P.O.B. 120 JUG OSLAVIJA Kucna centrala -Switchboard: 214-444 Brzojavi -Cables: J A O R O A G E N T Telex: YU JADRAG 24153, 24189, 14354. Fax: 213-696 OSNOVNE DJELATNOSTI: -PRIHVAT I OTPREMA BRODOVA U LUKAMA -ZAKLJUCIVANJE VOZARINSKIH UGOVORA (BOOKING) -OPERATIGN KONTEJNERA -MEDUNARODNA ŠPEDICIJA -ZAKLJUCIVANJE BRODARSKIH UGOVORA (CHARTERING) -KUPOPRODAJA BRODOVA -PUTNICKA SLULBA P & 1 REPRESENTATIVES LLOYD'S AGENTS Clan: -BIMCO -The Baltic ans lnternational Maritime Conference, Copengahen -FIATA-e, medunarodnog udruženja špeditera, Zurich -MUL TIPORT Ship Agencies Network, Rotterdam COUNTY HOSPITAL, ZALAEGERSZEG, DEPARTMENT OF RADIOLOGY, HUNGARY PERCUTANEOUS DIAGNOSIS AND THERAPY OF PYOGENIC LIVER ABSCESSES Varga Gy, Varga P 1 Abstract -This report summerizes the result of percutaneous aspiration of intraabdominal abscesses, mainly primer liver abscesses of unknown origin. The percutaneous aspiration is a very simple method and can be repeated several limes. Diagnostic and technical considerations tor successful aspiration of hepatic abscesses are disscussed. Percutaneous needle aspiration should be attempted as a first choise of treatment in all pyogenic hepatic abscesses. Unsatisfactory aspiration has to be followed by continous drainage technic. UDC: 616.36-002.3-089.48 Key words: liver obscess, drainage-methods Case report Radiol lugosl 1990; 24:369-72 lntroduction -In most cases the pyogenic liver abscess is on unexpected finding and most of them -like other abdominal abscesses -are easily aspirated percutaneously and could be cured to complete recovery. The authors recom­mend this very simple method for both the diag­nosis and the therapy of primer liver abscesses. Neither special instrumentation nor surgical isola­tion is necessary for such procedures. Percutaneous drainage is the treatment of choise for most abdominal abscesses. The crite­ria for percutaneous management has been mo­dified, particularly in the treatment of postopera­tive or critically ill patients, who are poor candida­tes of surgery. Most liver abscesses can be successfully treated by simple needle aspiration, supported by local and parenteral antibiotic the­rapy. This report describes two cases of the six liver abscesses. The most serious one has the largest fluid-containing cavity in the liver, while the other has the smallest. Materials and methods -460 interventional procedures were performed on 187 patients in the last two years in the Department of Radiology of the County Hospital of Zalaegerszeg. 48 in­traabdominal abscesses were detected. 19 of the abscesses were postoperative ones. 29 of them were unsuspected, without characteristic anamnesis, clinical and radiological symptoms. Six primary liver abscesses were found (Table 1 ). About half of the interventions were performed on the first occasion, after local desinfection and local anesthesia, without special transducer and steril isolation. The optimal -possibly a perpendi­cular -plane was determined and photographed after the standard localisation of the suspected abscess with the convex tranducer of the Picker LSC 7000 / Hitachi EUB 40 /. This served the optimal route tor needle guidance. The penetra­tion was controlled with acute-angle, directed US beam from beside the needle with the so-called »free hand« technic. The obtained purulent mat­ter was to be sent to the laboratory tor bacterial identification. The material was presented on the First lnternational Symposium on lnterventional and lntraoperative Sonography, Zagreb, May 1989. Received: November 2, 1989 -Accepted: November 20, 1990. Varga Gy, Varga P l. Percutaneous diagnosis and therapy of pyogenic liver abscesses Table 1 -Patients and results Number of the patients: 6 primary liver abscesses (women) 2 infected, non-posttraumatic bilomas (men) Actual condition of the patients: 5 patients in relatively good condition 2 patients in poor condition 1 patient inoperable Age of the patients: 56 -78 year Therapic punctions: 5 patients (2-8 limes, 1-3 places) Continuous drainage: 3 patients (including the 2 bilo­mas) Results: Complete cure: 5 liver abscesses 1 infect biloma Surgery needed: 1 liver abscess 1 infect biloma Case Reports Patient 1 (Fig 1 a, b, c) A 59-year-old overweight temale, with psychosis schizophreniformis and cholecystlithiasis in her anamnesis. She had a two weeks history of fever and antibiotic therapy was used because of suspected but not proved pneumonia. Presen! status: slight cholestasis and exsiccosis. Labora­tory dates: We 7i3 mm/h and leucocytosis. US: extensive, confluent fluid-containing cavi­ties in the !iver. There was a pseudocyst in the head of pancreas, that was responsible for the choledochal dilatation. Percutaneous aspiration of the pseudocyst resulted the ductus choledoc­hus to return to normal. On the 6th day the patient became septic and was in an inoperable condi­tion. Progression of the liver abscess was confir­med by US control. At puncture purulent content of the abscess had been evacuated (11 O ml pus was gained). The process was repeated several „ Fig 1b Fig. 1 a, b, c, d -Ultrasound examinations of the patient 1 Radiol lugosl 1990; 24:369-72 Varga Gy, Varga P l. Percutaneous diagnosis and therapy of pyogenic liver abscesses Fig. 2a Fig. 2c Fig. 2b Fig. 2d Fig. 2a, b, c, d -Ultrasound examinations of the patient II limes -about every third day -and altogether 380 ml pus was evacuated. Starting from the 8th day the patient's temperature became normal. On the 36th day when discharged, there was no abscess cavity, only a Cefobid reflexion remai­ned. Two months later she was admitted for cholecystectomy, the result of examinations was complete recovery. Patient II (Fig. 2a, b, c, d, e) A 74-year-old temale in bad general condition, with diabetes mellitus, relapsing fascitis necroti­sans and immunodefficiency syndrom in her anamnesis. Presen! status: clinical suspition of tumorosus process, subfebrile condition, elevated sedimen­tation rate and leucocytosis. US: little doubble echopoor focus in the liver. Diagnostic punction: 8 ml thick pus-content. The x-ray sinogram proved to be confluent. On the 20th day the foci became cystic and 4+8 ml purulent content was aspirated. On the 44th day the echopoor lesions were punctured again, but no more pus was gained. After 4 months she was admitted again because of empyema thora­cis. She was recovered by permanent thoracic drainage. There was no liver abscess on the controll US and CT examination. Results and discussion -There is a growing rate of findings of unsuspected abdominal ab­scesses. Only some of the cases are evident in the postoperative period, most of them are unsu­spected, with atypical clinical picture. Conside­ring the fact that is suppurative content to be found in ultrasonography not only in the gas-for­ming and cystic process, therefore we do perform a percutaneous punction in every uncertain ca­ses. Plain X-ray examination has lost its impor­tance because none of our 8 cases has had gas content in the abscesses. Successful treatment can be achieved in most cases by nonsurgical percutaneous aspiration which can be combined with percutaneous catheter drainage and orga­nism specific antibiotics. Radiol lugosl 1990; 24:369-72 Varga Gy, Varga P l. Percutaneous diagnosis and therapy of pyogenic !iver abscesses In most of the cases special transducer, drai­nage set and surgical isolation is not necessary. 29 patients -with unexpected intraabdominal ab­scesses -were verified by US diagnostic inter­vention. 22 of them had been cured by percuta­neous punction, 20 resulted complete abscess­free recovery. Five of the hepatic abscesses had no characte­ristic symptoms at all, nor typical ultrasonographic appearence and the patients were observed in a relative good condition at the medical depar­tment. Two of them were outpatients when diag­nostic puncture was performed. In three cases ­2 primer liver abscesses and 1 infected biloma -cholestasis with septical cholangitis was to be considered the ethiological factor. In 5 cases was the ethiological factor of unknown origin. The early diagnosis is very important, when the clinical symptoms and the US morphology are less typical. In the early stage the interventional diagnosis and therapy are the simplest and at the same tirne the most effective procedures. The early diagnostic percutaneous needle pun­ction had differentiated from necrotic malignant tumor, haemangioma or other cystic lesions, resulted purulent content of the abscess for laboratory identification. The liquid content of the abscess had been evacuated and the procedure was repeated se­verni times in all the five patients. Only in three cases with bigger cavities was necessary to introduce catheter: one primary hepatic abscess and two infected bilomas. One liver abscess and one biloma couldn't be solved completly, in these cases surgary was needed. Sažetak PERKUTANA DIJAGNOSTIKA I TERAPIJA PIOGENIH ABSCESA JETRE Najcešce se piogeni abscesi jetre otkrivaju slucajno, i vecinu ih se -kao i druge abdominalne abscese -lako perkutano aspirira te su potpuno izljecivi. Autori ovu sasvim jednostavnu metodu preporucuju i za dijag­nostiku i terapiju pocetnih abscesa jetre. Za takav zahval nije potrebna posebna kirurška priprema niti posebni instrumenti. Perkutana drenaža je metoda izbora u vecine abdo­minalnih abscesa. Uvjeti za perkutanu obradu su pojed­nostavljeni, posebno kod obrade postoperativnih ili kriticnih pacijenata koji nisu podobni za operaciju. Vecinu abscesa se može upsješno tretirati jednostav­nom iglenom aspiracijam, uz podršku lokalne i parente­ralne terapije antibioticima. Ovaj rad opisuje -pored rezultata perkutane aspiracije intraabdominalnih abce­sa, narocilo primarnih jetrenih abcesa -i dva slucaja sa šest abscesa jetre. Najozbiljniji ima veliku šupljinu u jetri ispunjenu tekucinom, dok drugi ima manju. References 1. Gerzof SG, Johnson WC, Robbins AH, Nabseth DC. lntrahepatic pyogenic abscesses: treatment by percutaneous drainage. Am J Surg 1985; 149/4:487­94. 2. Greenwood LH, Collins TL, Yrizarry JM. Percuta­neous management of multiple liver abscesses. AJR 1982; 139 :390-2. 3. Gronvall S, Gammelgaard J, Haubek A, Holm HH. Drainage of abdominal abscesses guided by sono­graphy. AJR 1982; 138:527-9. 4. Johnson RD, Mueller PR, Ferrucci JT Jr et al. Percutaneous drainage of pyogenic liver abscesses. AJR 1985; 144:463-7. 5. Kandel G, Marcon NF. Pyogenic liver abscess: new concepts in an old disease. Am J Gastroenterology 1984; 79/1/:65-71. 6. Kerlan R, Jeffrey RB Jr, Pogany AC, Ring EJ. Abdominal abscess with low output fistula: successful percutaneous drainage. Radiology 1985; 15n :631-5. 7. Kuligowska E, Conners SK, Shapiro JN. Liver abscess: sonography in diagnosis and treatment. AJR 1982; 138-253-6. 8. Maklad NF, Doust BO, Baum JK. Ultrasonic diag­nosis of postoperative intra-abdominal abscesses. Ra­diology 1974; 113:417-22. 9. Mueller PR, Ferrucci JT Jr, Simeone JF, et al. Detection and drainage of bilomas: special considera­tions. AJR 1983; 140:715-20. 1 O. Mueller PR, Van Sonnenberg E, Ferrucci JT Jr. Percutaneous drainage of abdominal abscesses and fluid collections in 250 cases. Part II: Current procedu­ra! concepts. Radiology 1984; 151 :343-7. 11. Van Sonnenberg E, Mueller PR, Ferrucci JT Jr. Percutaneous drainage of abdominal abscesses and fluid collections in 250 cases. Part 1 : Results, failures and complications. Radiology 1984; 151 :337-41 . 12. Vujic 1, Brock JB. Biloma: aspiration tor diagno­sis and treatment. Gastrintest Radiol 1982; 7 :251-4. Author's address: Varga Gy, M D, Department of Radiology, County Hospital, Zalaegerszeg, Hungary Radio! lugosl 1990: 24 :369-72 CLINICAL HOSPITAL »DR. O. NOVOSEL«, CENTER FOR ULTRASOUND »ZAGREB« ZAGREB FINE NEEDLE ASPIRATION BIOPSY OF FOCAL LIVER LESI ON S: RESULTS AND COMPLICATIONS Kos N, Drinkovic 1, Odak D, Kardum 1, Šuštaršic D, Vidakovic Z Abstract -As a parenchymal organ, the liver is very suitable tor ultrasound diagnosis, as well as ultrasound .uided aspiration biopsy. ·However, every interventional procedure brings along some complications. Here we jescribe our results and complications we came acros in 200 of performed cytological aspiration biopsies of focal ,iver lesions. Cytological examinations and evaluations showed following results: 98 patients had metastases, 46 had primary liver tumors, 16 cases were hemangiomas, 24 had normal !iver cells (cyrhosys), four had melanomas, two cysts, four absceses, one hemangiopericitom, one hemangiosarcoma, four cases were false negative. Some procedures were accompanied with complications: 2.5% of cases suffered severe pain, 0.5% collapsed, and 0.5% had lethal result. Ultrasound guided fine needie aspiration biopsy is a good diagnostic method in cases with focal liver lesions, but it can be accompanied by grave complications. UDC: 616.36-006.6-07:534-8 Key words: liver neoplasms, biopsy needle, ultrasonic diagnosis Profess paper Radiol lugosl 1990; 24 :373-4 lntroduction -One can easily say that the liver is an organ most simple tor approach tor bolh noninvasive as well as interventional ultra­sound diagnostics. It can be analysed by other methods too, but in case of focal lesions we do not get sufficient information on etiology of the lesion, while by using ultrasound system with a needle guider we can very quickly make a diag­nosis thorugh a cytologic or histologic aspirated biopsy of the focal lesion (1, 4). In this paper we would like to present our experience and results together with complications we accosted on 200 cytologic aspirated biopsies of various focal liver lesions. Material and methods -The patients were performed aspirated biopsy of the liver on, were either previously hospitalised in our institution or were out-patients. Previous to the biopsy, they were hospitalised too. A complete blood and coagulation tests were made before the interven­tion. lndications for the intervention were all types of focal liver lesions, including cystic ones. In such cases we had to exclude echinocock and cavernous hemangioma. The punctures were performed using 20 G and 22 G Chiba needles, on ultrasound system CGR, with mechanic secto­ral 3 MHz transducer, with the lateral needle guider. The guider was sterilised by detergicide, and the transducer was sterilised by a rubber cover. As a contact medium we used Hibitan. To get higher subpressure we used the aspiration piston, while by combination of the subpressure and the needle manuver, we allways managed to get sufficient material. A cytologist was present at every puncture to give his oppinion and to manipulate the material onto the glass slides for immediate cytologic examination. Results -On 200 punctures of focal liver lesions we got the tollowing results (Table 1 ). Complications were strong pain in five patients (2.5%), one patient collapsed (0.5%), and we had lethal result in one case (0.5%) (Table 2). Discussion -Apart from echinocock cyst and hemangioma, any tocal lesion is suitable for diagnostic cytologic aspirated biopsy. Using fine needles (20 G or 22 G) even if we enter a capilar The material was presented on the Fi;st lnternational Symposium on lnterventional and lntraoperative Sonography, Zagreb, May 1989. Reccived: November 2, 1989 -Accepted: November 8, 1989. Kos N et al. Fine needle aspiration biopsy of focal liver lesions: results and complications Table 1 -Fine needle aspiration biopsy results DIAGNOSE no of patients percentage (%) metastase 98 49 primary CA 46 23 cyrhosis 24 12 hemangi oma 16 8 melanoma 4 2 absces 4 2 cyst 2 1 hemangi opericitoma 1 0.5 hemangi osarcoma 1 0.5 false neg ative res. 4 2 TOTAL: 200 100 Table 2 -Complications we had in fine needle aspira­tion biopsy of the liver lesion SMALLER no of HEAVIER no of perc. patients % perc. patients % temporary pain collaps 5 1 2.5% 0.5% massive hemor­rhagewith lethal result 1 0.5% TOTAL: 5 3.0% 1 0.5% hemangioma or an echinocock cyst, there should be no complications. There are several cases ot the echinocock cyst puncture described with no complications, as well as their treatment. It the lesion is near the surface ot the liver it should be punctured trom the side where there is more parenhim, which will act as a tampon. In the patient with the lethal result ot the puncture, the liver was dittusely changed, so there was no suspicions on hemangiosarcoma. The coagulation tests were normal, and the indications tor the intervention were presen!. The patient was laparotomised the same day, but hemorrhagia could not been stopped. The sur­tace ot the liver was completely covered with small angiomatic changes. There was no expla­nation tor transitory pain which was gone atter the application ot analgetics. The pain did not return any more. The collaps in one puncture was ot short duration and with no consequences. Conclusion -As a conclusion one can say that cytologic aspirated biopsy ot the liver is worthy and easy to perform method Very quickly we get an accurate diagnosis. The intervention is otten described as an intervention with no need tor hospitalisation, but we believe, although com­plications happen very rarely, and having expe­rienced one lethal result, that every patient should be hospitalised. Sažetak ASPIRACIJSKA BIOPSIJA FOKALNIH LE::ZIJA JETRE REZULTATI I KOMPLIKACIJE Kao parenhimni organ jetra je vrlo pogodna za ultrazvucnu dijagnostiku i ultrazvucno vodenu aspiri­ranu biopsiju. Dakako, svaki intervencijski zahvat nosi i svoje komplikacije. Ovdje opisujemo rezultate i kompli­kacije na koje smo naišli u 200 izvedenih slucajeva citoloških aspiracionih biopsija lokalnih lezija jetre. Rezultati -citološka ispitivanja i ocjenjivanja pokazala su sljedece rezultate: 98 pacijenata je imalo metastaze, 46 je imalo tumor jetre, 16 su bili hemangiome, 24 su imala normalne slanice jetre (cyrhosys), cetiri su imali melanome, dvije ciste, cetiri abscesa, jedan hemangio­pericitom, jedan hemangiosarkom, cetiri slucaja su bili lažno negativni. Neke su zahvale pratile komplikacije: u 2,5% smo imali jak bol, u 0,5% kolaps, a u 0,5% smrtni ishod. Ultrazvucno vodena fino iglena aspira­ciona biopsija je dobra dijagnosticka metoda u slucaje­vima lokalnih lezija jetre, ali može biti pracena i vrlo leškim komplikacijama. References 1. Holm H H, Kristensen J K, Rosmusse S N, et al. Ultrasound as a Guide in Percutaneous Puncture Tec­hnique. Ultrasonics 1972; 1 O :83-6 2. Otto R Ch, Wellonre J. Ultraschallgefuhrte Biop­sie. Springer Verlag, Berlin-Heidelberg-Tokyo; 1985 3. Smith E H. The Hasards In Fine Needle Aspiration Biopsy. Ultrasound Med Biol 1984; 10:629-34 4. Triller J.: Ultraschall gezielte abdominale Punktio­nen. Radiologie 1979; 19 :173-7 Author's address: dr. Nenad Kos, Klinicka bolnica »Dr O. Novosel«, Zajceva 19, 41000 Zagreb, Yugosla­via Radiol lugosl 1990; 24:373-4 UNIVERSITY MEDICAL CENTER SARAJEVO INSTITUTE OF RADIOLOGY ANO ONCOLOGY UL TRASOUND (US) GUIDED FINE NEEDLE ASPIRATION BIOPSY OF THE LIVER Bucuk E, cengic F, Miric S Abstract -14 patients underwent ultrasonographic analysis of the \iver and the diagnosis of the suspected malignant \iver process was made. Then, the target aspiration biopsy of the suspected \iver area was performed under real-tirne controle, using 22 gauge fine need\e. Pathohistologic finding (PH) was positive in 11 cases (hyperhromatic and polymorphous nucleus, giant cells atypic mitosis). PH finding was negative in two cases and unrepresentative in one case. UDC: 616.36-006.6-07:534-8 Key words: \iver neoplasms, biopsy needle, ultrasonic diagnosis Profess paper Radiol lugosl 1990; 24:357-7 lntroduction -Real-tirne ultrasonography is the simplest method for guidance of percuta­neous puncture (3). Real tirne ultrasonography can guide the needle during the course of liver puncture, following the top and the complete needle (3). Fine needle aspiration biopsy of the liver improves the diagnosing of liver malignoma (8). Material and methods -During a period of 24 months, 14 patients (8 females and 6 males), with previously ultrasonographically confirmed localised, mostly solid, unclearly or clearly unre­gularly shaped lesion with 2-6 cm diameter, underwent the US guided punctures using 22 gauge fine needle (Fig. 1 ). The obtained micros­copic preparations were analysed at the Patholo­gic Institute of the School of Medicine Sarajevo. US investigations were made at Toshiba unit Sonolayer -L SAL -77 A with the sector probe PVE 393 M -3,75 MHz (Fig. 2). US puncture was performed in the sterile conditions at the same unit with the probe Toshiba GCE -406 M -4 MHz. (in the sterile bag), fine needle (with the The material was presented in the the First lnternational Symposium on lnterventiona\ and lntraoperative Sonography, Zagreb, May, 1989. Received :November 2, 1989 -Accepted: November 24, 1989. Bucuk E et al. Ultrasound (US) guided fine needle aspiration biopsy of the liver Fig. 2 -Solid hypoechogenic liver area with the fine needle into the lesion drin, the authors used 20 ml syringe tor aspiration of the material and making the microsopic prepa­rations. The patients rested 24 hours after pun­cture. There were no complications after punctu­re. The patients underwent examination on in-pa­tient and out-patient basis. In 8 cases the authors punctured twice (with two needles -one by one), in 6 cases once. In one case 4 microscopic preparations were made, in all others from 7 to 22. Chronologically, in the last 1 O patients, the half of microscopic preparations were fixed by fixation according to Papanicolau (spray) prior to sending to cytopathologist. Results -In 13 cases (92,8%) PH findings were representative. In 11 cases (78,6%) PH finding were positive (»tumorous cells with hy­perchromatic nucleus, primary hepatocellular cancer, anaplastic cancer, metastatic changes«), in 2 cases (14,2%) PH findings were »normal liver-finding« and »without tumorous cells in liver preparations«, in one case (7,2%) PH finding was unrepresentative. In the last case, the pun­cture occured once, with only 4 microscopic preparations, not fixed according to Papanicolau. Discussion -The authors have considered the smaller needles as better, which do not bend during the puncture. The fine 22 gauge puncture of the liver tumors guided by real-tirne US has been performed for the long tirne (1, 2, 3, 4, 5, 6, 7). A number of authors report the use of the thinner 23 gauge fine needle (1, 4, 5, 6). Fig. 3 -L1near array probe. Fine needle placed into the solid liver's lesion guided by linear array probe Many authors suggest the fixation of microsco­pic preparations according to Papanicolau and May-Grunwald-Giemsa, after the puncture, with the aim to improve the presentation of celi mate­rial (3, 5, 6, 7, 8). Zornoza et al (9) report the success of fine needle punctures guided by US in 86% out of 36 punctures. Conclusion -Our initial results with 22 gauge fine needle punctures guided by US are encoura­ging although the series is small. The aspirated material, with such a quality and quantity, has been sufficient for PH citologic analysis. Sažetak FINO-IGLENA BIOPSIJA JETRE V00ENA UL TRAZVUKOM Ultrazvucnim pregledom jetre izvršenim na 14 pacije­nata potvrdena je pretpostavljena dijagnoza malignih procesa. Koristeci finu iglu od 22 gauga izvršena je Radiol lugosl 1990; 24:375-7 Bucuk E et al. Ultrasound (US) guided fine needle aspiration biopsy of the liver ciljana aspirativna biopsija jetre pod kontrolom real tirne aparata. Patohistološki (PH) nalazi su bili pozitivni u 11 slucajeva (hiperhromatske i polimorfne jezgre, atipicna mitoza gigantskih slanica). PH nalazi su bili negativni u dva slucaja a nerepre­zentativni u jednom. References 1. Brauner M et al. Apoort de la cytoponction et de la microbiopsie hepatique guidee par echographie dans les lesions focales du foie. J Radiol 1988; 69/10:567-9. 2. Bret PM et al. Une technique simple de guidage des punctions percutanees par echographie en temps reel. J Radiol 1982; 63 :363-5. 3. Bret PM et al. Hepatocellular Carcinoma: Diagno­sis by Percutaneous Fine Needle Biopsy. Gastrointest Radiol 1988; 13 :253-5. 4. Montali G et al. Fine needle aspiration biopsy of liver focal lesions ultrasonically guided with real-tirne probe. Br J Rad 1982; 55:717-23. 5. Nosher LJ et al. Fine Needle aspiration of the Liver with Ultrasound Guidance. Radiology 1980; 136:177-80. 6. Otto ChR et al. Ultrasound -Guided Biopsy and Drainage. Berlin: Springer-Verlag, 1985. 7. Ricotier E et al. Ponction a 1 aiguille fine guidee par echotomographie dans le diagnostic des tumeurs hepatique. JEMU 1988; 8:232-6. 8. Tanaka S et al. Early Diagnosis of Hepatocellular Carcinoma: Usefulness of Ultrasonically Guided Fine Needle Aspiration Biopsy. J Ciin Ultrasound 1986; 14:11-6. 9. Zornoza J et al. Fine-Needle Aspiration Biopsy of the Liver. AJR 1980; 134:331-4. Author's address: Bucuk Esad, M. D. University Medical center, Institute of Radiology and Oncology, Moše Pijade 25, Sarajevo, Yugoslavia Radiol lugosl 1990; 24 :375-7 GODIŠNJI STRUCNISASTANAK RADIOLOGA SRBIJE Vrnjacka Banja 17-19. april 91. TEME SASTANKA 1. GLAVNE TEME -Radiologija digestivnog trakta -Savremena angiografija -Interventna radiologija 2. SLOBODNE TEME ORGANIZATORI -SRPSKO LEKARSKO DRUŠTVO SEKCIJA ZA RADIOLOGIJU -MEDICINSKI FAKULTET U KRAGUJEVCU -KBC KRAGUJEVAC -ZAVOD ZA RADIOLOGIJU Prijava autora, referata i sažetaka: na formularu ili fotokopiji. Vratiti na adresu: Medicinski Fakultet Kragujevac (za sastanak radiologa) po. box 124 Korespodencija: Asis. drž. Markovic, Tel. (034) 47770 KLINICKA BOLNICA »DR. O. NOVOSEL«, ZAGREB ODJEL ZA UROLOGIJU UROLOGIC INDICATIONS FOR FINE NEEDLE ASPIRATION BIOPSY AND ALCOHOL SCLERO­ SATION OR RENAL CYST FORMATIONS Hromadko M, Palcic 1, Drinkovic 1 Abstract -During the period from 1985, till today, we focused our attention on the renal cyst formations, their urologic indications tor fine needle aspiration biopsy and alcohol sclerosation under ultrasonic guidance. We divided 40 patients with a single our multiple cysts into two main groups in relation to the size and localization in the renal parenchyma. lf the renal cyst was less Ihan 3 cm in diameter, our attitude was to wait and control the cyst growth by ultrasound examination. Percutaneous cyst aspiration biopsy with cytological analysis of the obtained liquid and simultaneous alcohol sclerosation were performed in peripheraly located cysts of medium size, i. e. 3-1 O cm in diameter. The operation was a method of choice in large cysts with a diameter over 1 O cm. UDC: 616.61-006.2-07:534-8 Key words: kidney cystic, biopsy needle, ultrasonic diagnosis, sclerosation Orig sci paper Radiol lugosl 1990; 24:379-81 lntroduction -The frequently used, non-inva­sive ultrasound examination of the upper abdo­men, reveals a surprisingly great number of incidentally detected renal tumors (1-3). The most common finding of such a tumor is a cyst formation (4). However, there is always a que­stion whether this is a cyst or a solid tumor. Simple cysts do not represent a serious problem as long as no complications supervene (infected cysts, haemorrhagic cyst, a cyst compressing the pyelon and ureter) (5). However, such simple cysts reduce the valua­ble renal tissue by compression, and can cause sepsis as a result of late suppuration. Extremly important is the mental state of the patient when he finds out that he is carrying a cyst which tor him is actually a tumor. This fact often compels him to ask the doctor to eliminate the cyst. So, in many patients the psychological moment is one of the factors which leads us to perform evacua­tion of the cysts content by needle aspiration biopsy and alcohol sclerosation. This is a simple and elegant way of healing the patient patient (5, 6, 7). Patients and methods -From 1985 till today, 40 patients with a single or multiple cysts have been treated on the Department of Urology, University Hospital »Dr O. Novosel«, and divided into two main groups in relation to size and localization in the renal parenchyma. Ultrasonic technique with evacuation and alco­hol sclerosation was sufficient in peripheral cysts, but in medially located cysts beside the ultrasonic examination the excretory urogram was used as well. The excretory urogram was used in order to obtain the detailed relationship between the cyst, pyelon and ureter. In the case when the ultra­sound examination raised doubts that it could be the question of the tumor, computerized tomo­graphy or angiography were performed too. Be­side the location of the cyst, the size is very important so we divided them into three groups: small cysts less than 3 cm, medium cysts 3-1 O cm, and large cysts over 1 O cm in diameter. The material was presented on the First lnternational Symposium on lnterventional and lntraoperative Sonography, Zagreb, May 1989. Received: November 2, 1989 -Accepted: November 15, 1989. Hromadko M et al. Urologic indications far fine needle aspiration biopsy and alcohol scleroSation or renal cyst formations Table 1 -Oistribution ot simple cysts in relation to male -temale PATIENTS NUMBER % MALE 24 60 FEMALE 16 40 ALL 40 100 cm in diameter. In those patients our altitude was to wait, observe, and control the growth of the cyst using the ultrasound examination every three to six months. In four patients we noticed that the cyst was growing, so needle aspiration biopsy and alcohol sclerosation were performed. The biggest group (25 patients or 62%) was a group with medium size cystss, and that means Table 2 -Localization and size -indication tor treatment LOCALIZATION TREATMENT SIZE PERIPHERAL MEOIAL CYST ALL % CYST OBSERVATION SMALLCYST <3cm 9 2 11 27 BIOPSY ANO MEOIUM CYST OBLITERATION 3-10cm 25 25 62 OPERATION LARGE CYST >10cm 2 2 4 11 Table 3 -lncidence ot localization ot simple cysts 3-10 cm in diameter. Percutaneous cyst aspira­tion biopsy with cytological analysis of the obtai­ned liquid and simultaneous alcohol sclerosation INCIOENCE MALE FEMALE ALL % were performed in most of the patients. LOCALIZATION In four patients (10%) large cysts with a diame­ RIGHT KIONEY 12 6 18 ter over 10 cm, were detected. In those patients LEFT KIONEY 10 7 17 42 RIGHT ANO LEFT KIONEY 2 3 5 13 ALL 24 16 40 100 Table 4 -lndicence ot relapses ot the simple cyst RELAPSES NUMBER % FIRST 8 20 SECONO 2 5 THIRO 1 3 ALL 11 28 Results -Most of our patient were male (24 males, 16 females) (Table 1 ). In 90% of the patient the cysts were asymptomatic, while only four patients (10%) had symptoms such as flank pain, hypertension, and microscopic haematuria. Only one patient had signs of infection, characte­rized by fever and chills, and it was found that he had an infected cyst which was evacuated and drained percutaneously. There were 11 (27%) patients with small cysts, that means less than 3 the operation was a met hod of choice (Table 2). What regards localization, according to the left or right kidney, we find out that a somewhat bigger number of cysts was located in the right kidney. In five patients we detected bilateral, simple cysts. In one patient, who had a large cyst, we also found an angiolipoma in the perire­nal area (Table 3). It by needle aspiration biopsy a haemorrhagic liquid was obtained the operation was inavitable. The observation and the follow-up of our pa­tients in whom needle aspiration biopsy and alcohol sclerosation were performed, revealed that in 28% of the patients there was a relaps of the cyst. In eight patients (20%) there was only one relaps, and in two patients (5%) there were two relapses of the cyst. In one patient alcohol sclerosation had to be performed three limes (Table 4). Discussion -In this paper we wanted to point out, that the renal cyst formation could be treated in a simple way, by fine needle aspiration biopsy and alcohol sclerosation, what is already known (6, 7). Radiol lugosl 1990; 24:379-81 Hromadko M et aL Urologic indications for fine needle aspiration biopsy and alcohol sclerosation or renal cyst formations At the same tirne this is our contibution for the indications tor such a method of treatment, since as far as we know, the indications when to operate, and when to perform alcohol sclerosa­tion, have not yet been determined. In our opi­nion, these called cyst of a medium size, with a serous liquid, should be evacuated and oblitera­ted. Large cysts over 10 cm in diameter can also be evacuated and obliterated, but we think that they should be operated, because a large quan­tity of alcohol used for sclerosation will cause perirenal changes, which will later be the cause of the patients trouble. A malign process inside the cyst can rarely be seen (4, 8). We had three patients with such a malign process: therefore we consider that every cyst with a haemorrhagic content should absolu­tely be operated. In some patients we had relap­ses of the cyst, but these could be treated with repeated fine needle aspiration biopsy and alco­hol sclerosation. Sažetak UROLOŠKE INDIKACIJE ZA FINO IGLENU ASPIRA­CIONU BIOPSIJU I ALKOHOLNU SKLEROZACIJU CISTICNIH FORMACIJA BUBREGA cesto korišten, neinvazivan pregled gornjeg abdo­mena ultrazvukom, otkriva iznenadujuce velik broj slu­cajno nadenih tumora bubrega. Najcešci nalaz kod takvih tumora je cisticna formacija. Dakako, uvijek postaji pitanje da li imamo cistu ili solidan tumor. Ciste, same za sebe ne predstavljaju problem sve dok se ne pojave komplikacije (infekcija, hemoragicna cista, pielon i ureter). Dakako, takve jednostavne ciste smanjuju vrijedno tkivo bubrega kompresijom, a mogu uzrokovati i sepsu kao rezultat kasnijom supuracijom. Veoma je važno i mentalno stanje pacijenta; kad sazna da nosi cistu ona za njega predstavlja tumor. Ta ga cinjenica najcešce navadi da od lijecnika zahtijeva njeno odstranjenje. U velikog broja pacijenata psihicki momenat je jedan od faktora koji nas navodi na pristupanje evakuaciji cistic­nog sadržaja aspirativnom biopsijam finom iglam alkoholnu sklerozaciju, kao jednostavnim i finim naci­nom ozdravljenja pacijenta. References 1. Baltarowich OH. Sonographic evaluation of renal masses. Uro! Radio! 1987; 9:79-7. 2. Di Paolo B. Role of ultrasonographic diagnosis in cystic neophropathies. Minerva Uro! Nefrol 1985; 37:429-3. 3. Lang EK. Rena! cyst puncture studies. Uro! Ciin Norih Am 1987; 14 :91-2. 4. Natali A. Association of cysts and tumors in the same kidney. Minerva Uro! Nefrol 1985; 37 :69-4. 5. Campbell MF. Urology. 5th Edition. Philadelphia: WB Saunders 1987: 1778. 6. Koci K. Percutaneous treatment of renal cysts. Rozhl Chir. 1986; 65 :730-3. 7. Kumanov KH. Treatment of solitary kidney cysts by percutaneous puncture under echographic control Khirurgiia (Sofiia) 1985; 38 :95-8 8. Kawashima H. A report of three cases of renal celi carcinoma whith multilocular cystic changes. Rin­sho Hoshasen 1986; 31 :1473-6. Author's address: Hromadko M, M. D. Univ. Hosp. »O. Novosel« 41000 Zagreb, Zajceva 19, Yugoslavi..1 Radiol lugosl 1990; 24:379-81 XXIV JUGOSLOVENSKI SASTANAK NUKLEARNE MEDICINE Prvo obaveštenje Kopaonik 25 -28 septen:abar 1991 ORGANIZATORI: Sekcija za nuklearnu medicinu Srpskog lekarskog društva Sekcija za nuklearnu medicinu Srpskog lekarskog društva -Društva lekara Vojvodine Klinicko bolnicki centar » Kragujevac« Odeljenje nuklearne medicine, Kragujevac ORGANIZACIONI ODBOR: Predsednik: Dr Mirjana Živkovic Sekretar: Assist. Dr Milovan Matovic Blagajnik: Dipl. fiz. Radmilo Krstic CLANOVI: Prof. Dr sci. Miodrag Odavic Prof. Dr sci. Kasta Kostic Prof. Dr sci. Vladimir Bošnjakovic Doc. Dr sci. Ruben Han Prim. Dr Milica Maleševic Dr sci. Angel Lazarov Assist. Dr Boris Ajdinovic Teme sastanka mogu biti iz svih oblasti nuklearne medicine sa težištem ka funkcionim, metabolickim i hemodinamskim ispitivanjima, kao i savremenoj dijagnostici i terapiji benignih i malignih tumora. lstovremeno ce se održati i XII Sastanak tehnicara nuklearne medicine Jugoslavije, kao i izložba nuklearno -medicinske opreme i radiofarmaceutika. PRIJAVA UCEŠCA do 28. februara 1991. REZIME RADOVA DOSTAVITI do 30. aprila 1991. U drugam obaveštenju dobicete informacije o visini kotizacije, društvenom programu, rezervaciji smeštaja i mogucnostima prevoza do Kopaonika. Sastanak se održava u Kongresnom centru hotela apartmanskog tipa »A« kategorije »Konaci« na Kopaoniku. Adresa organizatora: KBC »Kragujevac« Odeljenje nuklearne medicine Zmaj Jovina 30, 34000 Kragujevac telefoni: 034/41-130, lokali 281, 251 i 226 034/44-356 fax: 034/44-356 UNIVERSITY HOSPITAL »DR O. NOVOSEL«, ZAGREB CENTER FOR UL TRASOUND INDICATIONS AND VALUES OF ULTRASOUND GUIDED ASPIRATION BIOPSY OF FOCAL KIDNEY LESIONS Odak D, Drinkovic 1, Kos N, Kardum-Skelin 1, Vidakovic Z Abstract -Ultrasonography is an important method in diagnosis of focal kidney lesions. For a valuable diagnosis, findings of cystic lesions are sufficient. However, in cases with solid mases and atypical cystic lesions ultrasound guided aspirated biopsy'in necessary. Ultrasound guided aspirated biopsy has been carried out on 179 previously hospitalised patients. Puncture has been carried out with 20 G and 22 G needles. Ultrasound guided aspiration biopsy of renal cystic lesions has been performed as a procedure initial to embolisation with 95% alcohol. In 10% of patients the puncture has been carried out because of atypical picture of cystic lesions. Solid mases have been punctured in 29 patients (12 hypernephromas, five absceses, two feochromocytomas, two Mb. Hodgkin, two malignant lymphomas, four haemathomas and one false posiltive cas§). Despite the false positive finding ultrasound guided fine needle aspiration biopsy is a very good method in tne diagnosis of unclear changes. UDC: 616.61-006.6-07:534-8 Key words: kidney neoplasms, biopsy needle, ultrasonic diagnoses Profess paper Radiol lugosl 1990; 24:383-4 lntroduction -Nephrosonography is an im­portant method in the diagnostics of focal renal lesions. Besides standard methods of examina­tions, like those using contrast media, in our hospital nephrosonography is one of the techni­ques of finding out of localised pathologic chan­ges. Ultrasound is a sufficient method in cases when cystic lesions are suspected. But in cases of focal lesions, like neoplastic proceses, angio­graphy is a method of choice, as a proof of pathologic vascularisation. In cases of focal le­sions, like absceses, inflammated cysts, limpho­mas and small angiographically unclear tumors, or unclear renal tumefactions, ultrasound guided cytologic puncture is applied (1-9). Material and methods -Fram 1985 till 1989 cytologic puncture of localised renal lesions has been performed on 179 previously hospitalised patients, aged between 21 and 79 years. Cytolo­gic punctures were performed in all cases of liquid and solid renal lesions, where the diagnosis could not have been reached by other methods. The punctures were performed using the Sonel 303 system, with a sectoral transducer, with a lateral needle guider, which enables us constant visualisation of the needle tip. We used Chiba needle 0.7 mm wide. The materials were sent for cythologic, biochemical and bacteriological ana­lysis. Results -The cythologic punctures were per­formed on all patients with previously localised liquid or solid tumorous mases, but have remai­ned unclear after performing other diagnostic methods, i. e. intravenous urography or angio­graphy, as well as on the patients with ultrasound clear findings of solitary cystic mases. Alcohol embolisation followed, and in only 10% of cases cytologic aspiration was performed as primary intervention. Out of 179 patients, 150 had clear findings of renal cysts. The evacuation of liquid contents, folowed by alcohol embolisation with 96% alcohol, has been performed on all 29 patients. The findings of localised renal lesions were not clear, so ultrasound guided cythologic The material was presented on the First lnternational Symposium on lnterventional and lntraoperative Sonography, Zagreb, May 1989. Received: November 2, 1989 -Accepted: August 13, 1990. Odak D et al. lndications and values of ultrasound guided aspiration biopsy of tacal kidney lesions puncture had to be performed. Atter cythologic Sažetak analysis ot the punctates the following was pro­ INDIKACIJE I VREDNOST UL TRAZVUCNO VODENIH ved: 12 cases were renal tumors, six were ASPIRACIJSKIH BIOPSIJA FOKALNIH BUBREŽNIH absceses, two teochromocytoma, two limphoma, LEZIJA two primary Hodgkin, four haematomas, one talse positive case. There were no complications after the perfor­med punctures. Discussion -Localised focal expanded renal mases are, most otten diagnosed with the first symptoms ot diseases, or by chance it, during ultrasound examination ot an organ or region, tor example ot upper region ot abdomen, when the kidneys are examined routinely. Today, modem methods like ultrasound or computerised tomography enable us to tind tocal lesions considerably earlier, while betore, intu­sive urography was the only possibility to prove, indirectly, their existence. It during an examina­tion, focal lesions are diagnosed, liquid or solid, and clinical treatment, including angiography does not provide an adequate result, aspirated puncture ot the tocal lesion is performed. Conclusion -The techniques mentioned intusion urography, which is the standard one, angiography, and ultrasound, sholud be sufficient tor planing turther medical treatrr.ent ot focal renal lesions. However, tor accurate veritication ot malignancy or benignity ot a proces, or ot an unclear case ot liquid or solid lesion, ultrasound guided puncture should be done. It a solid tocal renal proces is tound out angiographically or by ultrasound, it should be sufficient for a surgical treatment. But it the contents tound are liquid, they may be typical or atypical. In the cases ot typical localised liquid renal cystic contents, they are evacuated by puncture and alcohol embolisa­tion ot the cyst. However, in case ot atypical localised changes a puncture and cythologic examinations are indicated. As atypical liquid tocal changes we consider liquid tormations ot unclear contours and thickened wall. Solid tocal leasions are .punctured tor cythologic tests rarely, because ot dangers ot propagation ot the proces, bul also because angiography is, as a method ot choice, very explicit (in 90% ot patients). But angiography is not sufficient in cases ot small solid tumors, so ultrasound cythologic puncture is used as a method ot choice. Ultrasonografija je važna metoda u dijagnostici lokal­nih lezija bubrega. Za punovrijednu dijagnozu dovoljno je naci cisticne lezije. Dakako, u slucajevima solidnih masa i atipicnih cisticnih lezija, potrebna je ultrazvucno vodena aspirativna biopsija. Ultrazvucno vodena biopsija je izvedena na 179 prethodno hospitaliziranih bolesnika. Punkcije su izvr­šene iglama od 20 G ili 22 G. Ultrazvucno vodena aspirativna biopsija cisticnih le­zija bubrega je izvršena kao inicijalni zahval emboliza­ciji 95% alkoholom. U 10% bolesnika punkcija je izvršena zbog atipicne slike cisticnih lezija. U 29 bole­snika punktirana je solidna masa (12 hypernephroma, pet abscesa, dva feochromocytoma, dva Mb. Hodkin, dva maligna limphoma, cetiri haemathoma i jedan lažno pozitivni nalaz). Usprkos tog lažno pozitivnog nalaza, ultrazvucno vodena fino iglena aspirativna biop­sija je vrlo dobra metoda za dijagnosticiranje nejasnih promjena. References 1. Burstein J, Woodside Jr. Malignant haemorhagic renal cyst with occult neoplasm. Radiology 1977; 123:599-604. 2. Clarke B G, Gwade W J Jr, Rudy HI, Rockwood L. Diferential diagnosis between cancer and solitary cyst of the kidney. J Urol 1965; 75 :922-5. 3. Heckemann R. Finenadelbiopsie der Nieren. Ra­diologie 1988; 28:257-64. 4. Heckemann R, Heimann H, Meyer-Swickerath M, Paar D. Ultraschallgefuhrte Nierencystenpunktion -Biochemische und ri:intgenologisch Befunde. Fortsch. Ri:intgenstr. 5. Holmes J H. Early diagnostic ultrasonography. J Ultrasound 1983; 2933-43. 6. Lang E K. Ri:intgenographic assessment of asym­ptomatic renal lesions. Radiology 1973; 109 :257-64. 7. Sherwood T, Trott P A. Needling renal cysts and tumors. Cytology and Radiology. Brit Med J. 1975; 3:755-61. 8. Wetanebe, Makuski M. lnterventional real tirne ultr.sound. lgaku -Shoin, Tokio -New York, 1985. 9. Woodroff J H, Chalek C C, Ottoman R E, Wilk S P. The Ri:intgen diagnosis of renal neoplasma. J Urol 1955; 75:615-621. Author's address: Dr D. Odak, Klinicka bolnica »Dr. Ozren Novosel, Zajceva 19, 41000 Zagreb, Yugoslavia Radio! lugosl 1990; 24 :383-4 CLINICAL HOSPITAL »DR O. NOVOSEL«, ZAGREB ORL DEPARTMENT ANO UL TRASOUND DEPARTMENT UL TRASONOGRAPHY OF PARANASAL SINUSES IN ROUTINE CLINICAL INTERVENTIONS Cvetnic V, Drinkovic 1, Munitic A Abstract -For four years now, ultrasonography of paranasal sinuses has been routinely used at our Department. The method is considered valuable tor its rapid performance, high percentage of diagnostic accuracy and possibility of interventions under a direct ultrasound control. There is no ionizing radiation associated with the method, which is of particular importance in children and pregnani women. The examination does not require any preoperative procedures. By use of ultrasonography, the number of x-ray examinations of paranasal sinuses has been reduced by almost 40%. Prior to each intervention, ultrasonography is, as a rule, carried out in patients in whom x-ray of paranasal sinulses has already been done. In almost 90% of cases, this method will either confirm or rule out the sinus pathologic finding. The number of negative sinus interventions has thus been considerably reduced. UDC: 616.216-002-073 :534-8 Key words: paranasal sinus diseases, ultrasonic diagnoses Orig sci paper Radiol lugosl 1990; 24:385-7 lntroduction -In the diagnostics of the para­nasal sinuses diseases a whole set of tests is used today: case history, rhinoscopy, sinus x-ray, tomography, test puncture, bacteriologic exami­nation, cytologic examination, histologic exami­nation, sinusoscopy, rhinomanometry, sinusoma­nometry, immunology, ciliary device function, ul­trasonography, computerized tomography, nuc­lear magnetic resonance, scintigraphy, operating microscope (1 ). However, to make a diagnosis, only some of them are necessary, and the choice depends primarily on the clinician's experience. We have been using ultrasonography routinely for four years now at our department, and find it very important for seve ral reasons: it provides visual presentation of changes, sometimes the method alone is sufficient for diagnosis, it provi­des targeted diagnosis, controls therapeutic ef­fects, it is non-invasive, it does not produce ionizing radiation, it can be repeated when ne­cessary, and is very suitable for children and pregnant women. In everyday clinical practice some of patients come to ORL department for a consilium exami­nation with a sinus X-ray, while some of them are sen! because of suspicion on sinusitis. In bolh cases we use ultrasonographical exa­mination. In this way we complement sinus x-ray findings, confirm or exclude pathological findings of the sinuses, which is extremly important be­cause of possible intervention -lavage of the sinuses, local application of antibiotics and corti­costeroides. Sometimes a diagnosis can be made by ultrasonography solely, so the need tor x-rays has been significantly decreased. Material and methods -Between 1985 1988, 412 patients, age from 7 to 64 years (246 .women and 166 men) were examined ultrasono­graphically. We use 8-mod of ultrasonographical examinations because, using this technique, we get patomorphological picture of maxillar and frontal sinuses, as well as anterior etmoidal cells (2). Results -On the basis of ultrasonographical examinations of this group of patients with chro­nic inflamation of paranasal sinuses, we were The material was presented on the First lnternational Symposium on lnterventional and lntraoperative Sonography, Zagreb, May 1989. Received: November 2, 1989 -Accepted: November 15, 1989. Cvetnic V et al. Ultrasonography of paranasal sinuses in routine clinical interventions Fig. 1 -X-ray finding: diffusely shaded left maxillary sinus able to establish compatibility between the x-ray and ultrasound findings in about 90% of cases (4). It is also of importance that exact diagnosis in a number of patients has been achieved by ultrasound solely (Fig. 1, 2, 3, 4). Discussion and conclusion -By using men­tioned B-mod of ultrasonography on this group of patients, we were able to establish a series of pathologic entities of paranasal sinuses: inflam­mation of mucosa with oedema, polipoid forma­tions in the sinuses, and free contents in the sinuses, which is especially important. Because of its two-dimensional representation B-mod is a method of choice in the diagnostics of mucocele and piocele of maxillar sinuses. By this we do not want to lessen the validity of the A-mod. On the contrary, we believe that both moduses comple­ment each other (3). In this way the number of negative interventions has been reduced to the smallest possible number. Using ultrasono­graphy as the first laboratory method in the diagnostics of chronic inflammation of paranasal sinuses the number of x-ray examinations has been reduced for about 40%, which is not irrele­vant. However, it should be stressed again that Fig. 2 -Ultrasound finding: maxillary sinus of the same patient, with fluid level Cvetnic V et al. Ultrasonography of paranasal sinuses in routine clinical interventions ultrasonography of paranasal sinuses is only a References complementary method (5). Sažetak UL TRASONOGRAFIJA PARANAZALNIH SINUSA KOD RUTINSKIH KLINICKIH INTERVENCIJA Na našem odjelu izvodimo ultrasonografiju parana­zalnih sinusa rutinski vec cetiri godine. Metodu sma­tramo vrijednom zbog vizualizacije promjena, visokog postotka tocnosti dijagnostike i mogucnosti intervencije pod direktnom kontrolam ultrazvuka. Primjenom ove metode izbjegnuto je ionizirajuce zracenje što je od narocite važnosti u djece i trudnica. Pregled ne zahti­jeva nikakove preoperativne pripreme. Primjenom ultra­sonografije broj rendgenskih pregleda paranazalnih sinusa je smanjen za skoro 40%. Prethodno svakom zahvatu, ultrasonografija se, u pravilu, izvodi i u pacije­nata kod kojih je vec izvršen rendgenski pregled para­nazalnih sinusa. U skoro 90% slucajeva ova ce metoda ili potvrditi ili iskljuciti patološki nalaz sinusa. Time je osjetno smanjen broj negativnih intervencija na sinusi­ma. 1. Cvetnic V, Munitic A. Current Trends in the Diagnostics of Chronic Naso-Paranasal Sinusitis. Pluc bol 1987; 39:119-24. 2. Mann W J. Ultraschall in Kopf-Hals-Bereich. Springer Verlag, Berlin-Heidelberg-New York -Tokio, 1984. 3. Umezaki T, Shin T, Watanabe H. Effectiveness of A-mode Ultrasonography in Paranasal Sinus Disease. Vlth ISIAN Symposium, Abstracts, p. 88, 1987. 4. Bbckman P, Andreasson L, Holmer N G, Jannert M, Jannert P. Ultrasonic versus Radiologic lnvestiga­tion of the Paranasal sinuses. Rhinology 1982; 20 :111­9. 5. Cvetnic V, Drinkovic 1, Munitic A, Kos N, Odak D, Nosso D, Boka H. Practical values of Ultrasonographi­cal Diagnostics in Otorhynolaryngology and Cervicofa­cial Surgery. In press: Chirurgia Maxillofacialis & Plasti­ca, 1989. Author's address: Dr V. Cvetnic, Klinicka bolnica »Dr Ozren Novosel«, Zajceva 19, 41000 Zagreb, Yugosla­ via Radiol lugosl 1990; 24 :385-7 er% d d {(\ \ne\,e\d\lc\s an 'o" i'IJ'\ies '" , ?too\o?es an d taae ,ao\\ out a c\ae\\'IJet. o. • \ . f\ ,ne sc o? 9es o(1\ d ua,n\09 so\o?es ta" ns\l\\a\'o" an • _ '-'ora\O 'l oe\e(r1'1fla­·1 'Q\e \o(\'f\8 us\aflceS \ 3\.1 \ O . -.ii\(o-\es\S a(.o\ogicall. ac O 0\ne( 'o fl9 in ones an l 1 o .i,ne \o \10fl o\ 'flO(f(\ ---- Radioimmunoassay FSH RIA TSH -RIA tor the determination ol Follitropin Radioimmunoassay lor the determination ol Thyrotropin Radloimmunoassay for the determination ol Human Growth Hormone Radioimmunoassay HGH -RIA T 3 -RIA tor the determination ot total Trllodthyronlne Radioimmunoassay T 4 -RIA LH -Rt.A for the determination ol total Thyroxin Aadiolmmunoassay for the determlnatlon ol Lutropin R I A Radiolmmunoassay PROLACTIN tor the determlnation ol Prolactln Radioimmunoassay f3-HCG-RIA tor the determination ol Chorlonlc R I A Radlolmmunoassay - tor the determlnation ol Estradiol E S T R A D I O L Radiolmmunoassay lor the determination ol lnsulin INSULIN -RIA Radioimmunoassay DIGOXIN -RIA for the determlnatlon ol Dlgoxln VE AuBen-und Binnenhandelsbetrieb Robert-Ri:issle-StraBe 10 Berlin DDR-1115 German Democratic Republic (iisocommerz UROLOGISCHE UNIVERSITATSKLINIK, KLINIKUM LAHNBERGE, D 3550 MARBURG/L THE PERCUTANEOUS NEPHROSTOMY-EXPERIENCES IN ABOUT 1000 CASES Feiber H Abstract -The sonographically guided percutaneous nephrostomy has meanwhile become an approved and mostly uncomplicated method of direct urinary derivation and has to be advised especially as a temporary measure. In case of a high risk of operation it has to be looked upon, as the method of choice. Referring to this in our clinic the open nephrostomy has lost its value. The special problems of permanent derivation and palliative measures with inoperable tumours will be discussed. UDC: 616.61-089.86:534-8 Key words: nephrostomy precutaneous, ultrasonic diagnoses Profess paper Radiol lugosl 1990; 24 :389-91 lntroduction -Thirty years ago Godwin et al., already reported about their experiences with the percutaneous nephro-pyelostomy. Whereas Godwin made the puncture of the renal pelvis by X-ray, in the recent limes more and more an ultrasound-guided transrenal puncture is applied. According to the last development of ultrasound and the meanwhile better handling of the pun­cture systems, it is getting more and more impor­tant. In the following we are going to report our experiences with this method in a considerable number of patients. Material and methods -Between January 1979 and May 1989 we made 930 percutaneous nephrostomies. Normaly, the puncture of the pyelon is made through lower calix. The patient is lying on his abdomen and we apply a local anaesthesia. At first we used the COOK puncture set, bul now we exclusively use the PND set of ANGIOMED, including the new puncture needle with MS cut tip for ultrasound guided puncture, a guide wire, teflon bougies and a pigtail dranaige catheter. Results and discussion -The first 117 percu­taneous nephrostomies were made with a com­pound scanner with a 2.5 MHz transducer. The puncture needle was lead through a central boring to its transducer. Later on the punctures were made with a raeltime sector scanner (Com­bison 310/320 of KRETZ). It has a fixed puncture direction. Especially in cases of a slight or no dilatation of the pyelon the number of mispun­ctions could be lowered considerably, because the needle can be placed under sight with this system. The procedure accords to the Seldinger technique. Table 1 shows the indications. As we can see postrenal obstructions represent the main indications for nephrostomy. Sometimes a nephrostomy is made for the judgement of the recovery of the renal function after derivation or for drying out a urinary fistula. 1 especially want to stress the importance of this method in the septical ureter stones. After ali if the attempt of retrograde derivation by a ureter catheter or an inner splint fails, we have the opportunity to derivate the highly dangered pa­tient with his infected pyelon briefly and without The material was presented on the the First lnternational Symposium on lnterventional and lntraoperative Sonography, Zagreb, May, 1989. Received: November 2, 1989 -Accepted: August, 13, 1990. Feiber H. The percutaneous nephrostomy-experiences in about . 000 cases Table 1 -lndications for perc. nephrostomy Gyn. carcinoma 178 Rectum-carcinoma 78 Prostate-carcinoma 99 Bladder-carcinoma 129 Ureter-carcinoma 15 Stenosis of the ureter -M. Ormond 23 -retroperit. lymphoma 27 -unknown aetiology 15 -retrocavale ureter 1 Urotuberkulosis 9 Stones of the ureter 248 Pyonephrosis 25 Stenosis of ureter after kidney -transplantation 6 Anomalia of the urinary tract 24 latrogenic fistula of the ureter 9 Diagnosis of renal function 40 Shrinkage of the bladder + reflux 4 Total 930 Tab. 2 -Percutaneous nephrostomy (N=930) ­-complications Hematuria (temporary) 168 Perirenal hematoma 12 Tamponade of the pyelon 6 Urosepsis ( ?) 1 Urinoma Perinephritic abscess any strain. To a later point of tirne the necessary causal intervention can take place under better conditions. In the course of the extracorporal shock waves the percutaneous nephrostomy is due to an important role as an auxiliary measure. The percutaneous nephrostomy has to be thought of as an invasive method which naturally contains possible risks (Table 2). Occasionally it comes to temporary hematuria, only seldom we find a perirenal or subcapsular hematoma. We never had a massive hemorrhage, which forced us to an operative intervention. Among our pa­tients we did not find an urinoma which someti­mes is described in literature. We think that this can be prevented by avoiding a direct punction of the renal pelvis. Neither did we see a perinep­hritic abscess in an infected kidney as it is described in the literature as well. In one case the nephrostomy has to be discussed as a possible factor causing a urosepsis. In every particular case percutaneous nephro­stomy can be looked upon as a temporary, permanent or palliative urinary derivation. In ca­ses of high operation risk, because of bad gene­ral state of health, uremia or septical status the temporary percutaneous nephrostomy can help to a considerable economy of tirne. Therefore a causal intervention can be made on easier terms. There are more or less problems in using the catheter as a permanent urinary derivation con­cerning the incrustration of the catheter or tis total obstruction. Concerning the pal/iative urinary derivation the indication can become problematical. Thinking of patients with a stenosis of the ureter on bolh sides because of an inoperable tumor we can prevent uremia but this elongation of life can be full of anguish for him. In a retrospective examination of 87 patients with tumors we found 51 who had died until then with a working urinary derivation, 1 /3 stili in our clinic or after a transfer to an outward clinic or sanatorium. The average survival was 1 1/2 months. 2/3 of the patients could be released at home temporarily. Here we had an average survival of 6 months. In 19 of 51 patients after percutaneous nephro­stomy a further antitumor therapy was applied. The average survival of these patients were 177,7 days in contrary to those who were not medically treated with an average survival of 115,6 days. The antitumor treated patients had survived the non treated ones in an average of 2 months. This retrospective study also showed that nep­ hrostomy had not been always the reasonable treatment concerning the prolongation of lite. We sometimes heard of a painful progress of the disease. Concerning these cases we have to discuss the question if quality of lite must not have priority to lengthening of life at any price, especially if we cannot apply an effective antitu­ mor therapy. This is a question of ethics in general as well as a special one in the code of medical ethics. In such individual confines only an individual decision can be made, which de­ mands courage to a matter of conscience. Radiol lugosl 1990; 24:389-91 Feiber H. The percutaneous nephrostomy-experiences in about 1000 cases Sažetak ULTRAZVUCNO VO0ENA PERKUTANA NEFRO­STOMIJA Ultrazvucno vodena perkutana nefrostomija je po­stala provjerenom i potpuno jednostavnom metodom direktne urinarne derivacije, te ju, narocilo kao privre­menu mjeru, treba preporuciti. U slucaju operacije visokog rizika treba ju smatrati metodom izbora. S obzirom na to, otvorena nefrostomija je na našoj klinici izgubila svoju vrijednost. Raspravlja se o posebnim problemima permanentne derivacije i palijativnih mjera kod neoperabilnih tumora. Author's address: Dr. Helmut Feiber, Urologische Universitatsklinik, Klinikum Lahnberge, D 3550 Mar­gurg/L, West Germany 9.le1vetius MEDICAL SUPPLIES Dobavitelj Radiogrami visoke kakovosti »anticrossover« tehnologija, ob 90% zmanjšanju žarkovne doze ki zagotavlja visoko locljivost in veliko v primerjavi z obicainimi sistemi hitrost Pri JC emulziji (J-vezava in oglata zrna) ter s tem izboljšano kakovost posnetka. je uporabljena najnovejša 3M 1986 Film Trimax XD/A, XUA "anticrossover" JC 34132 Trst -Italija, Piazza Liberta, 3, Tel.: 040/65577 -Tlx 461109 HELTS-1 Radiol lugosl 1990; 24:389-91 SIEMENS lr ,!lili 1!!11; i 11i11 ... It !II .. __ . "llil3 Der neue MR-Standard. Magnetom SP Magnetom 42 SP, das Hoch­leistungs-MR-System fur Bildgebung oder Magnetom 63 SP, das Hoch­leistungs-MR-System fur Bildgebung und Spektro­skopie. • Bildrekonstruktion unter 1 Sekunde • lntegrierte 3 O Bildakqui­sition, inklusive aller 3 O Bildrekonstruktions­moglichk.iten • Voll,g neuart,ge. kt,nisch opt;mierte Benutzerober­flache mit Maus-oder Trackba/1-Bed,enung. Siemens AG Medica/ Engineering Group Henkestraf3e 127. 0-8520 Erlangen Banex Trg Sportova ·11, Poštanski fah 48 YU-41000 Zagreb Tei (041)3 133 34 Jurija Gaganna 216, Blok 61 YU-11 O 70 Beograd Tel. (O 11) 1 5 00 65 Banex-Meditehna Novi Skopski Sajam, Belasica bb, Rayon 40 YU-91000 Skopje Tel. (091)203073 MEDIZINISCHE KLINIK 1, KRANKENHAUS LUDWIGSBURG ULTRASOUND GUIDED PERCUTANEOUS DRANAIGE OF ABDOMINAL ABSCESSES Fr6Iich E, Striegel K, Heller Th, Frank U, Muhr T, Eberle S, Seeger G Abstract -In 37 patients 40 abscesses were treated percutaneously by ultrasound guidance: 5 limes needle evacuation alone, and 25 limes drainage by catheter was tollowed by healing without operation, overall curing rate being 81 % . In comparison with 60 operated abscess-patients the drainage-period was 11.9 days versus 16 and the hospital stay 17.6 versus 32.7 days respectively. Complication rate in the percutaneous-group was 5.4% versus 8.3% in the OP-group. None of the deaths (2.7% in the percutaneous versus 10.8% in the OP-group) was related to the drainage. UDC: 616-002.3-073 :534-8 Key words: abscess, abdomen, drainage, ultrasonic diagnoses Profess paper Radiol lugosl 1990; 24 :393-5 lntroduction -Ultrasound guided fine needle puncture is an excellent method to differentiate intraabdominal liquids. Once the abscess is esta­blished, drainage either by surgical methods or percutaneous catheter is essential. Material and methods -The abscess is punctured with an 18-gauge needle. Smaller abscesses, holding less than 50 cl liquid contents are evacuated and irrigated with 0.93 NaCl. lntervening loops of bowel and the urinary blad­der are passed through with the needle without hesitating. In larger abscesses with ropy contents the 18-gauge needle is replaced by Seldinger technique, by a 7.6 F pigtail catheter. lntervening bowel loops must not be transversed with the catheter. Results -In 37 of 88 patients with intraabdo­minal liquids 40 abscesses were identified and percutaneously treated from November 82 to April 85. 12 limes an abscess was treated by percutaneous needle evacuation (PNE), 5 limes followed by healing. 25 of 32 patients having percutaneous catheter drainage (PCD) were cu­red by this method. 12 cases had to be operated (OP), so the overall curing rale by percutaneous manipulations was about 81 %. The size of the abscesses in case of PNE was 12-200 cl, in case of PCD varying from 20-90 cl. We differentiated the abscesses according to their sites. In 6 of 11 liver abscesses treatment was tried by PNE, 2 of them were cured. Their size was about 20 cl. Another 5 of 7 liver abscesses with the mean size of 120 cl were successfully treated by PCD. The drainage tirne was 12-21 days. In case of pancreas one abscess with the size of 50 cl was treated by PNE without success. One of two others, having a size of 220 cl was successfully tre2·ed by PCD within draining tirne of 37 days. In the group of 21 abdominal absces­ses 3 of 5 abscesses with the mean size of 45 cl were successfully treated by PNE. Another 16 of 18 abscesses with the mean size of 190 cl were successfully treated by PCD within draining tirne of 2-21 days. Two of the abscesses treated by PCD had to be operated, in one case because of rising temperature, in the other because · the The material was presented on the First lnternational Symposium on lnterventional and lntraoperative Sonography, Zagreb, May 1989. Received: November 2, 1989-Accepted: November 16, 1989. Fr61ich E et al. Ultrasound guided percutaneous dranaige of abdominal abscesses catheter had passed the cecum and the fistula had to be oversewed. In case of retroperitoneal abscesses 3 of 5 with the mean size of 130 cl were successfully treated by PCD within draining tirne of 4-22 days. Two others had to be operated as the tempera­ture raised after 48 hours. In comparison with a group of 60 operated patients, the whole period of drainage was 11.9 days of the PCD-group and 16 days of the operated patients. The average duration of stay in hospital was 17.6 days, compared to 32.7 in the operated group. As far as the curing rale is concerned, 81 % of the PCD-group in comparison to 93% of the operated patients could be discharged as cured. The complication rate was 5.4% in the PCD group and 8.3% in the OP group. In none of the cases death was caused by drainage. Death unrelated to drainage happened in 2. 7% in the PCD group and in 10.8% in the OP group. hed. In many cases an operation is performed because the whole situs can be overlooked extensively, whereas the ultrasound method for draining abscesses is stili new and unexplored. It cannot cure the cause of an abscess nor overlook its smaller and septated parts. We suggest the following proceeding: Before each percutaneous drainage a trial puncture is essential to make sure that there is a pus in the abscess cavity. In the following close cooperation with a surgeon is important. In case of the percutaneous way of draining an antibiotic should be given in order to avoid chills. Abscess holding less Ihan 50 cl and being liquid should be treated by PNE and NaCl irrigation. lnterventing loops of bowel and urinary bladder are passed through with a needle. Abscess holding more than 50 cl ropy content and being superficial (pleura and bowel must not be passed through) should be treated by PCD. An operation may be Trial-puncture: PUS -<50 cl -liquid (pass hollow organs) PNE ropy \/ superf. \ ->50 cl -ropy -superticial (do not pass hollow organs) PCD COMPLICATION (e. g. bleeding) FEVER 2-3 d \ -causal therapy e.g. appendictis insuffic. suture 1 -ropy -deep OP 1 Fig. 1 -Decision tree tor percutaneus drainage of abdominal abscesses (PNE= percutaneous needle evacuation; PCD = percutaneous catheter drainage; OP = operation) Discussion -We assume the ultrasound gui­ded percutaneous drainage of abdominal ab­scesses is an excellent method that helps to avoid a reoperation in many cases. Unfortunately the selection criteria for the two methods percutaneous drainage and operative drainage have not clearly enough been establis-necessary by rising temperature after 48-72 hours when additional abscesses or septatitons have been made sure by control sonography or computer tomography, or when a complication occurs related to drainage. No percutane. ous drainage and a primary operation should be done when a persisting cause of the abscess is suspected (e. g. appendictis, ulcus perforated,' Radiol lugosl 1990: 24:393-5 Frblich E et al. Ultrasound guided percutaneous dranaige of abdominal abscesses References : cholecystitis, insufficient suture ... ) or if a deeply situated abscess, being superimposed by lung or 1. Glass C et al. Drainage of lntraabdominal Absces­ intestine, cannot be evacuated by PNE. ses. Am J Surg 1984; 147:315-7. 2. Gary R et al. Percutaneous Abscess Drainage. Sažetak Gastrointest Radiol 1985; 10:79-84. ULTRAZVUCNO VODENA PERKUTANA DRENA2A ABDOMINALNIH PROCESA Perkutano pod kontrolom ultrazvuka je tretirano 40 abscesa u 37 pacijenata: 5 samo evakuacija iglom, 25 drenaža kateterom, nakon cega je uslijedilo ozdravlje­nje bez operacije, sveukupna stopa izljecenja 81 %. U usporedbi sa 60 operiranih abscesa-pacijenata period drenaže je bio 11,9 dana prema 16, a boravak u bolnici 17,6 odnosno 32, 7 dana. Stopa komplikacija u perku­tane grupe je bila 5,4% prema 8,3% kod operirane grupe. Niti jedan od smrtnih ishoda (2,7% kod perku­tane prema 10,8% kod operirane grupe} nije doveden u vezu sa drenažom. 3. Gronwall S et al. Drainage of Abdominal Absces­ses Guided by Sonography. AJR 1982; 138:527-9. 4. Johnson WC et al. Treatment of Abdominal Ab­scesses. Ann Surg 1981; 194:510-9. 5. Van Sonnenberg E et al. Percutaneous Drainage of Abscesses and Fluid Collections: Technique, Re­sults and Applications. Radiology 1982; 142:1-10. 6. Van Sonnenberg E et al. Percutaneous Drainage of 250 Abdominal Abscesses and Fluid Collections. Radiology 1984; 151 :337-41. Author's address: Dr. E. Fr61ich, Medizinische Klinik 1, Krankenhaus, Ludwigsburg, Posilipostr. 49, D 7140 Ludwigsburg, Deutschland Radiol lugosl 1990; 24 :393-5 UNIVERSITY OF ZAGREB, DEPARTMENT OF OBSTETRICS ANO GYNECOLOGY CLINICAL HOSPITAL »DR O. NOVOSEL« TRANSCERVICAL AND TRANSABDOMINAL CHORIONIC VILLUS SAMPLING Podobnik M, Singer Z, Kukura V, Bulic M, Prateta K Abstract -We present our initial experience in developing a chorionic villus sampling in our clinic. In phase one we performed transcervical chorionic villus sampling in 35 patients and in 10 patients transabdominal chorionic villus sampling prior to elective first trimester abortion, assessing the reliability and reproducibility, or obtaining adequate villus samples and performing cytogenetic analysis by means of bolh the direct and culture methods. In phase two diagnostic aspiration of chorionic frondosum was performed on 50 patients, 25 had transcervical and 25 transabdominal chorion frondosum aspiration. The overall abortion rate in diagnostic series was 2%. We found in 3 (6%) patients abnormal karyotypes (45XX, -9, 45X, 47XY, +13). Significant post chorionic villus sampling AFP elevation took place in 17 (34%) of 50 chorionic villus sampling. No relation between rise in AFP and miscarriage was demonstrated. No corelation between AFP elevation and the amount of villi aspirated was found either. UDC: 618.344-076 Key words: chorionic villi sampling -methods Profess paper Radiol lugosl 1990; 24:397-400 lntroduction -Prenatal diagnosis of fetal mal­formations and genetic disorders is the foremost concern of antenatal medicine. The technique of trofoblast biopsy, which is obtained by transcervi­cal or transabdominal, ultrasound guided chorion frondosum aspiration has been more thoroughly tested in a number of centers throughout the world since 1983 (1-6). Transscervical aspiration of chorionic villi has been performed at our clinic since 1985, whereas we started performing transabdominal aspiration towards the end of 1986. After a two year study of samples !aken from women undergoing abor­tions for non-medical reasons, we started using the tested method in clinical practice in high-risk pregnancies. We analysed pregnancies involving heterozygot couples, carriers of X related reces­sive disorders and carriers of balanced chromo­some aberrations. By the direct method, short­term cultivation, synchronisation and the enzyme procedure, we obtained the required material for karyotypisation, biochemical micromethods and DNK tests. We discovered normal karyotypes and ensured the continuation of the desired pregnancies, bul also abnormal results which indicated the need tor terminating such hopless pregnancies. Material and methods -Each woman was first examined ultrasonically (Toshiba SAL 77 with a linear and curvilinear probe of 3.75 MHz and 5 MHz), and GRL, by which the gestation period is determined, was measured. Aspiration was performed between 7 and 12 weeks of gestation. Women who had transcervical aspira­tion of chorion frondosum were prior to this given Papanicolau's test and a microscopic examina­tion of the smear, both of which were in order. To perform the aspiration we used a 26 cm long Portex catheter with a 1 .3 mm inner diameter and 1.8 mm outer diameter (Trophocan CVS­USA) or the 24 cm long Holzgreve-Angiomed catheter, with a 1.13 mm inner diameter and 1.45 mm outer diameter. Ultrasonically we located the position of chorion frondosum. Before inserting the catheter it must be bent depending on the location of chorion frondosum. Under ultrasonic guidance the catheter is inserted about 1 cm into the chorion frondosum. Before inserting the cat­heter it must be bent depending on the location The material was presented on the First lnternational Symposium on lnterventional and lntraoperative Sonography, Zagreb, May 1989. Received: November 2, 1989 -Accepted: November 15, 1989 Podobnik M et al. Transcervical and transabdominal chorionic villus sampling of chorion frondosum. Under ultrasonic guidance the catheter is inserted about 1 cm into the chorion frondosum tissue. By rotating the cathe­ter the tissue is aspirated into a 20 ml plastic syringe. The syringe contains 5 ml of MEM, 1 O IU/ml heparin and 1 % Garamycin. 5 to 25 mg of chorion frondosum tissue is obtained and is immediately taken to the laboratory. In case of a negative test the procedure is repeated one more tirne. The contents of the syringe are placed in Petri's sterile plastic dish and examined in a stereo microscope (power 50 X). A small quantity of recognizable decidue is separated from the finger-shaped villi. With needles and a scalpel it is split into up to ten tiny pieces which are sufficient for making one tissue culture or the direct method of karyotypization, as well as tor the X and Y test (Fig. 1 ). Transabdominal aspira­tion was performed when chorion frondosum is in the anterior position, whilst transcervical aspi­ration is prefered when it is in the posterior position. We use a 90 mm spinal needle, gauge 20. Upon the disinfection of the anterior abdomi­nal wall and with the urinary bladder empty, the needle is inserted, under ultrasonic guidance, into the middle of chorion frondosum, the angle is changed by 20° and with a slow movement, in the presence of negative pressure, up to 20 ml of chorion frondosum tissue is aspirated into a syringe containing the medium specified earlier in the paper. When the results of the test are negative aspiration is repeated one more tirne. In case of each patient alfa-fetoprotein (AFP) was determined before and after aspiration of chorion frondosum, and so was fetal heart rate (FHR) by an M-mode. Special consideration was given to any complications that may have arisen, such as bleeding, perforation of the gestation sac and chorioamnionitis (Fig. 2). In the first stage of the research we performecl transcervical aspiration of chorion frondosum in 25 women, and we terminated the pregnancies two to four hours after the aspiration procedure. In 15 patients transcervical aspiration was perfor­med, in 1 O transabdominal. The pregnancies were terminated seven to fourteen days after the Fig. 2 -Transabdominal aspiration of chorion frondo­aspiration. In the second stage diagnostic aspira­sum at gestation age of 11 weeks. tion of chorion frondosum was performed on 50 patients, 25 had transcervical and 25 transabdo­effect, and in 4.5% of the cases we caused the minal chorion frondosum aspiration. perforation of the gestation sac. Transcervical aspiration of chorion frondosum Results -In the first experimental stage tran­was performed on 15 patients, transabdominal scervical aspiration of chorion frondosum was on 1 O. Results of the tests were positive in performed on 25 women. Results were positive 95.5% of the patients and negative in 4.53/,. in 82.9% of the cases and negative in 17.1 %. In Positive karyotypization was done in ali 95.5% of 20.5% of the cases bleeding resulted as a side the cases. In 16.7% of the women there was Radiol lugosl 1990; 24:397-400 Podobnik M et al. Transcervical and transabdominal chorlonic villus sampling Table 1 -Materna! serum alfa-fetoprotein (AFP) and featal heart rate (FHR) before and after chorionic villi sampling in 17 pregnancies progressed normaly NO. Pre-CVS Post-CVS Pre-CVS Post-CVS AFP AFP FHR FHR ng/ml ng/ml FHR/min FHR/min 1. 110 145 155 150 125 160 145 52 145 160 3. 25 4. 65 105 160 130 6. 80 105 145 150 150 155 7. 70 100 150 130 8. 85 155 165 9. 25 50 150 140 160 140 10. 25 11. 80 150 130 12. 105 145 160 180 13. 75 125 140 160 14. 85 135 150 130 Fig. 3 -lntentionally caused perforation of the gestation 15. 45 90 160 170 sac by Portex catheter. CRL 31 for 10 1/7, chorion 16. 50 110 150 130 frondosum in the posterior position, in it a Portex Catheter (left), Portex catheter in the amnion (right). 17. 80 160 140 bleeding, in 2.8% the perforation of the gestation sac. Chorioamnionitis, as a side effect occurred in one patient (4%). From this group of patients one woman had a miscarriage fourteen days after the procedure and at the same tirne cho­rioamnitis (Fig. 3). In the second stage diagnostic aspiration of chorion frondosum was performed in 25 patients by the transcervical route and in the same num­ber by the transabdominal route. We received positive results, as well as positive karyotypisa­tion in all 50 women (100% ). Bleeding, as a side effect of the procedure, occurred in 20% of the women; there was no perforation of the gestation sac in any of the women, nor were there any instances of chorioamnionitis. In 3 patients (6%) early amniocentesis was performed. In 3 (6%) we found a pathological karyotype (45 XX, -9, 45 X, 47 XY, +13). Of the 50 patients one had a miscarriage (2%). Twenty of the women gave birth to temale children after a full term pregnan­cy; fifteen born male children also after a full term pregnancy. Fourteen pregnancies were pro­gressed normally between the fifteenth and thirty­second week. In 17 of the 50 subjects (34%) (Table 1) we found a significant change in AFP concentrations prior and following aspiration of chorion frondo­sum (p < 0.01 ). We found no correlation between the change in AFP concentration and the quantity of material aspirated. There was no statistically significant change in FHR before or after aspira­tion of chorion frondosum (p < 0.01 ). Radiol lugosl 1990; 24:397-400 Mean 59,71 97,18 153,23 147,35 so 25,69 30,79 6,17 15,25 p< 0,01 p > 0,01 CVS = Chorionic villus sampling AFP = Alfa -fetoprotein FHR = Featal heart rale Conclusion -When chorion frondosum is in the posterior position we perform transcervical aspiration, when it is in the anterior position or in the fundus, transabdominal aspiration is perfor­med. Using the techniques suggested in the paper there were no instances of chorioamnioni­tis, 2% of the subjects had a miscarriage, whe­reas a pathological karyotype was found in 6% of the subjects. In 17 women (34%) we found a statistically significant change in the level of AFP before and after aspiration. However it was in no correlation with the extent of the bleeding, nor the quantity of the aspirated material or the number of miscarriages. We found no significant change in FHR before or after aspiration of chorion frondosum. Sažetak TRANSCERVIKALNA I TRANSABDOMINALNA ASPIRACIJA HORIJALNIH RESICA Prikazujemo naše pocetne rezultate aspiracije hori­jalnih resica u našoj klinici. U prvoj fazi ucinili smo u 35 bolesnica transcervikalnu aspiraciju horijalnih resica, a u 1 O bolesnica transabdominalnu aspiraciju horijalnih resica, a prije artificijelnog pobacaja u prvom tron:je­ 399. Podobnik M et al. Transcervical and transabdominal chorionic villus sampling secju trudnoce, ocjenjujuci kvalitetu dobivenih horijalnih resica i izvodeci citogenetsku analizu direktnom karioti­pizacijom i kulturam tkiva. U drugoj fazi dijagnosticku aspiraciju horijalnih resica izveli smo na 50 bolesnica -u 25 bolesnica transcervi­calno a u 25 transabdominalno. U sveukupno 2% bolesnica imali smo spontani poba­caj. U 3 bolesnica (6%) našli smo patološki kariotip (45XX, -9, 45X, 47XY, +13). U 17 (34%) bolesnica našli smo signifikantni porast razine alfa fetoproteina nakon aspiracije horijalnih resi­ca. Nije utvrdena povezanost razine alfa fetoproteina i spontanih pobacaja. Takoder nije utvrdena korelacija izmedu promjene razine alfa fetoproteina i aspiracije horijalnih resica. References 1. Boogert A, Mantingh A, Visser G H A. The imme diate effects of chorionic villus sampling on letal move­ments. Am J Obstet Gynecol 1987; 157:137-9. 2. Brambati B, Oldrini A, Lanzani A. Transabdominal chorionic villus sampling: a freehand ultrasound guided technique. Am J Obstet Gynecol 1987; 157:134-7. 3. Hogge W A, Schonberg S A, Golbus M S. Chorio­nic villus sampling: experience of the first 1000 cases. Am J Obstet Gynecol 1986; 154:1249-52. 4. McKenzie W E, Deborah S H, John R N. A study comparing transcervical with transabdominal chorionic villus sampling (CVS). Br J Obstet Gynaecol 1988; 95:75-8. 5. Smidt Jensen S, Hahnemann N, Jensen P K A, Thekelsen A J. Transabdominal chorionic villi sampling tor first trimester letal diagnosis. In: Fraccaro M, Simoni G, Brambati B eds.: First trimester letal diagnosis. New York: Springer-Verlag, 1985; 51-3 6. Soothil P W, Nicolaides K H, Rodeck C H: lnvasive techniques tor prenatal diagnosis and therapy. J Perinat Med 1987; 15:117-27. Author's address: Dr Podobnik Mario, K. 8. »Dr O. Novosel«, Zajceva 19, 41000 Zagreb, Yugoslavia RO INSTITUT ZA NUKLEARNE NAUKE »BORIS KIDRIC«, VINCA OOUR INSTITUT ZA RADIOIZOTOPE »RI« 11001 Beograd, p. p. 522 Telefon: (011)438-134 Telex: YU 11563 Telegram: VINCA INSTITUT ACTH-RIA Sfuži za odredivanje hipofunkcije adrenalnih žljezda (primarna i sekundarna) i hiperfunkcije adrenalnog korteksa (Conn-ov, Cushing-ov i adrenogenitalni sindrom). Uz našu redovnu proizvodnju i snabdevanje korisnika pribora za in vitro ispitivan1a: T3-RIA T4 -RIA lnsulin -RIA HR-RIA u 19c38. godini pustili smo u redovan promet: CEA-RIA Pribor za odredivan1e karc,noembrionalnog ant,gena (CEA) u serumu metodom radioimunološke analize. Radiol lugosl 1990; 24 :397-400 UNIVERSITY OF PALERMO, DEPARTMENT OF RADIOLOGY EXPOSURE TO ULTRASOUND IN MEDICAL DIAGNOSTICS: AN EXPERIMENTAL INVESTIGATION Cardinale A, Lagalla R Abstract -Experimental animals were exposed to increasing US doses in order to detec! biological effects -il any -due to US similar to those used lor diagnostic purposes. Electron microscope, hemochemical and histoenzymatic studies were then carried out on adult rats and ral embryos. Results showed the occurrence ol liver cytolysis proportional to exposure limes. Cytolysis was shown to be correlated to H3-thymidine incorporation and to enzyme kinetics. Clinical-experimental investigations on humans are in progress, and are aimed at detecting possible effects on embryo liver cells. UDC: 534.78:616-001.2-092.8 Key words: ultrasonics-adverse effects, rats Orig sci paper Radiol lugosl 1990; 24 :401-3 lntroduction -There is no definitive and univocal agreement on effective biological safety of ultrasounds (US) (1 ). It depends on the extreme variability of experi­mental evidence, both in vivo and in vitro of the lack of reproducibility and on the difficulty of optimizing and unifying several physical, acoustic and operative parameters of US exposure (2). We have carried out »in vivo« experiments aimed at clarifying whether morphological and functional alterations of some parenchymes (li­ver, kidney, ovary) and tissues could be shown in experimental animals (Wistar rats) following US exposure with parameters similar to those employed in diagnostic echography (3, 4, 5, 6). Experiments performed on experimental ani­mals do not clarify whether the same results may be extrapolated to humans. This is the most important question in radiobiological and protec­tion research at present: in fact, the research on US bioeffects in man consists chiefly in retro­spective and epidemiological analyses which are not quite significant from a statistical and experi­mental point of view (7, 8, 9, 10). Material and methods -Different groups of Wistar rats were exposed to pulsed US beam (intensity 100 mw/cm2) from 1 O" to 500" and sacrificed 1 h,24h and 8 weeks after US exposu­re. As reported in table 1, many morphological and functional parameters were evaluated in adult rats and in rat's embryo. Recently we also performed a series of experiments on human embryos studied after voluntary interruption of pregnancy and expulsion of the embryo after prostaglandin administration. Results -Liver parenchyma, both in adult and embryo rats has been shown to be quite sensitive to US action. Progressive celi vacuolization has been shown to occur by increasing exposure times until 80' and to be associated with cytopla­sma depletion, reaching almost cytolysis with nuclear piknosis which exposure ranged from 160" to 500". Clearly detectable connective tis­sue neogenesis, probably a reparation process, is shown to occur 8 weeks after US exposure. The material was presented on the First lnternational Symposium on lnterventional and lntraoperative Sonography, Zagreb, May 1989. Received: November 2, 1989 -Accepted: August, 17, 1990. Cardinale A, Lagalla R Exposure to ultrasound in medica! dia:gnostics: an experimental investigation Table 1 -Experimental research carried _ Exp.t. Survey liver 10"-500" 1h-24h-8w • Morphological investigation kidney 45 1h-24h (light and electron microscope) ovary 45" 24h embryo liver 120" 24h Liver lysosome enzymes (acid phosphatase) 80"-160" 24h-4w • lsoenzyme assay: Oxydizing liver enzymes (succinate dehydrogenase) 80"-160" 24h-4w • Biohumoral assay (Gamma-G-T) 20"-500" 24h • Nucleic acid kinetics (H3-thymidine incorporation) 20"-500" 1h Mitochondria showed the most marked injuries among cytoplasma organelles (6, 11, 12). The occurrence of liver parenchymal damage was confirmed by the finding of altered biochemi­cal markers of liver cytolysis (gamma-GT) and by reduced ability to incorporate H3-thymidine (13, 14). Morphological and structural alterations des­cribed hitherto were associated with changes of kinetics of oxidizing and lysosomial enzymes in rat liver (15). US action upon liver enzymes seems to cause an early increase of lysosome enzyme activity followed by an altered behaviour of oxidizing enzymes showing an anomalous location troug­hout liver lobules. In experimental animals, kid- ney and ovary tissue failed to show any morpho­ logical and any structural alterations (4). Evaluation of US action upon human embryos was performed by investigating liver parenchy­ ma. Prelimanary results obtained from controls and from embryos exposed to US far 1 O' before induction of abortion do not show morphological and structural changes in liver cells (Fig. 1 ). Discussion -Our preliminary experiments show that the results obtained with animals cannot be immediately extrapolated to humans and particularly to embryos. Although further investigation is indispensable to clarify the mechanism of action of US waves, it is quite likely that tissue damage is probably caused by physico-chemical factors involving celi structure and function (16, 17, 18, 19). Biological damage due to US is practically determined by haet production, by mechanical action (microstreaming) and by chemical factors (formation of free radicals) and is proportional to the duration of exposure. The possible formation of cavities within tissue stili raises a number of problems. Since a definitive interpretation of results is stili lacking, ultrasound examination should be car­ ried out cautiously and carefully, only if clinically justified and technically optimized. Sažetak !ZLAGANJE UL TRAZVUKU U MEDICINSKOJ DIJAG­NOSTICI: EKSPERIMENTALNO ISTRAŽIVANJE Da bi se ustanovili mogu6i biološki efekti, pokusne su životinje bile izlagane pove6anim dozama ultrazvu­ka. Elektronski mikroskop, hemokemijske i histoenzi­matske studije su nakan toga bile provedene na odras­lim štakorima i zamecima štakora. Rezultati su poka­zali pojavljivanje citolize jetre proporcionalno vremenu izlaganja zracenju. Pokazalo se da je citoliza u vezi sa inkorporiranim H3-thymidinom i kinetikom enzyma. Kli­nicko-kineticka istraživanja na covjeku su u toku, a imaju za cilj otkrivanje mogu6ih posljedica na stani­ _cama jetre ljudskog embrija. References 1. A. l. U. M. Bioeffects considerations tor the safety of diagnostic ultrasound. J of Ultrasound in Med. 1988; 7: no. 9. 2. Carson P L, Fischella P R, Oughton TV. Ultraso­nic power and intensities produced by diagnostic ultra­sound equipment. Ultrasound Med Biol 1978; 3 :341. 3. Cardinale A E, Lagalla R, De Maria M and Coli. Biologic Effects of ultrasound on liver cells of ral embryos. Acta Radiol 1987; 28:221-3. Radiol lugosl 1990; 24:401-3 Cardinale A, Lagalla R. Exposure to ultrasound in medical diagnostics: an experimental investigation 4. Cardinale A E, Lagalla R, De Maria M and Coli. :Jiological effects of ultrasounds. An experimental con­tribution on liver and ovaries. ltal Curr Radiol 1984; 2:115. 5. Lacani A, Cardinale A, Lagalla R, Valentino B. La intera·zione degli ultrasuoni con i tessuti biologici. Mo­derne prospettive in radiologia. Valutazioni sperimentali degli effetti biologici conseguenti all'impiego diagno­stico di radiazioni non ionizzanti di tipa ultrasonico. Atti 31 Congresso Nazionale S.I.R.M.N., Monduzzi Edit, Bologna, 1984. 6. Cardinale A, Lagalla R, De Maria M, Valentino B, Lacani A. Ricerche sperimentali su ecodiagnostica e possibili effetti biologici: analisi ultrastrutturale su em­brione di ratto. Radiol Med 1985; 71 :505-6. 7. Waldenstrom V, Axelsson O, Nilsson S and Coli. Effects of routine one-stage ultrasound screening in pregnancy: a randomised controlled trial. Lancet 1989; 8e11 :585. 8. Waldenstrom U, Nilsson S, Fali O, Axelsson O, Eklund G, Lindeberg S. Effetti dello screening ecogra­fico di routine in gravidanza: uno studio randomizzato controllato. Lancet {ltalian edition) 1989; 2 :64-7. 9. Persson P H, Kullander S. Lang term experience of general ultrasound screening in pregnancy. Am J Obstet Gynecol 1983; 146 :942-7. 1 O. Eiknes S H, Okland O, Aure J C, Ulstein M. Ultrasound screening in pregnancy: a randomized con­trolled trial. Lancet 1984; 1 :1347. 11. Torbit C A, Groth D G, Edmonds P D. Mitochon­drial changes resulting from ultrasound irradiation. In: Ultrasound in Medicine. Edited by White D N, Brown R E. Plenum Press, New York, 1978. 12. Trump B, Golblatt P J, Stowell R E. Studies on necrosis of mouse liver in vitro. Ultrastructural altera­tions in the mitochondria of hepatic parenchyma cells. Lab. lnvest 1978; 14 :343. 13. Cardinale A, De Maria M, De Simone G F, Grisafi D, Lagalla R, Palma A, Valentino B. Possibili effetti biologici degli ultrasuoni, impiegati a scopo diag­nostico sul parenchima epatico di ratto. Modificazioni morfologiche e ultrastrutturali e ricerche sperimentali su eventuali modificazioni di parametri bioumorali. Min Med 1983; 7 4 :45-50. 14. Cardinale A, De Maria M, De Simone G F, Lagalla R, Grisafi D, Palazzoadriano M. Effetti biologici degli ultrasuoni impiegati a scopo diagnostico. Ricerche sperimentali sull'incorporazione Min. Med. 1982; 73:3475-6. 15. Cardinale A, Lagalla R, Tessitore V. Biological effects of ultrasound (U_ S.) employment for diagnostic purposes: histochemical investigation on rat liver enzy­mes. Radiol. lugosl. 1988; 22:2. 16. Edmonds P D, Sancier k M. Evidence for free radical production by ultrasonic cavitation in biological media. Ultrasound Med Biol 1983; 6:635. 17. Hredziza l. Changes in cells ultrastructure under direct action of ultrasound. High Energy Ultrasound. 1970; 59 :457. 18. Nyborg W. L. and Steele R. B. Temperature elevation in a beam of ultrasound. Ultrasound Med Biol 1983; 6:611. 19. Stephens R J, Hart C P, Torbit C A, Edmonds P D. Reproducible subcellular alterations in hepatocytes resulting from ultrasound. Ultrasound Med Biol 1980; 6:239. Author's address: Prof. Adelfio Cardinale, lstituto di Radiologia dell'Universita Policlinico „p_ Giacone«, via del Vespro 129, 90127 Palermo, ltalia Radiol lugosl 1990; 24:401-3 . ;:._· ,,: : . ' .. •" . : , . . ' . . . --:?· .. -.-.". / ' -.'!-lJ;,. =:.\}'it.:; '.:. . CLINICAL HOSPITAL »0R O. NOVOSEL«, ZAGREB INSTITUTE FOR RADIOLOGY ROC COMPARISON OF INTRAOPERATIVE ULTRASOUND PROBES Boko H Abstract -lmaging objectivity of both extracorporal and intraoperative ultrasonic probes was measured by means of ROC analysis. The results have shown significantly higher precision of intraoperative probe. UDC: 617-089:534-8 Key words: ultrasonic diagnoses, intraoperatic period Profess paper Radiol lug osi 1990; 24 :405-7 lntroduction -Recent development of intrao­perative sonography is due to technological solu­tions that enable constant visualisation of the position of biological structures during operation. Until recently, the position of a lesion was deter­mined only approximately. The achieved level of miniaturisation also enables constant application in vivo. In a previous paper of the same author (1) borderline resolution of intraoperative ultrasound probes was researched. By researching actual effects of resolutions in medical practice, this paper is a continuation of the previous one. Abilities of a researcher to recognize biologic structures using intraoperative and extracorporal probe respectively, placed close to a biologic structure, have been statistically compared. Material and methods -As examination ma­terial we used two ultrasonic probes of the same manufacturer (CGR Thomson) and of similar technologic characteristics: linear extracorporal, frequency 3.5 MHz, and intraoperative linear, frequency 7.5 MHz. As a biologic material, fresh hepatocelular carcinoma placed into the liver of a pig was used. The characteristics that two hepatocellular car­cinomas be differentiated as two separate sam­ples was tested in an experiment. The results were statistically analysed using ROC analysis (receiving operating characteri­stics) (2, 3), which gives coresponding sensitivity of a method tor all the specific values of a biomedical treatment. The results showing it was possible to differen­tiate biologic structures put apart up to 3 mm (1) were taken as a starting point of the experiment. This stage of the experiment was repeated so that the samples of hepatocelular carcinoma were pur apart laterally up to 2 mm, the pig's liver and luke warm water respectively simulating hu­man intracorporal biologic structures. In this way a common linear ultrasonic probe was placed about 8 cm from the »lesion«, while intraopera­tive probe was placed only 1 cm from the structu­re. The task of researchers, experienced in the field of ultrasonography, was to give their jud- The material was presented on the First lnternational Symposium on lnterventional and lntraoperative Sonography, Zagreb, May 1989. Received: November 2, 1989 -Accepted: November 15, 1989 Boko H. ROC combarison of intraoperative ultrasound probes ; II---------r---------r---------I---------r---------II g'l I I . I I .2': I **I ·"55 I ****** I ***** I I 5 I **** **** I Q) I I **** I I I *** I I I *** I I *tt I I *·*: I I *** I I ** I I ** I I *** I I* I I I II---------r---------1---------r---------r---------II false positive result Graph 1 -ROC curve of extracorporal ultrasonographic probe :::, II---------r---------1---------r----****************I (f) I *********** I I ****·** I I **** I ·u; I *** I o Q. I *** I Q) I ** I I * I I ** I I * I I** I I I I I I I I I I I I I I I I I I I II---------r---------I---------r---------r---------II false pozitive result Graph 2 -ROC curve of intraoperative ultrasonographic probe Radiol lugosl 1990; 24 :405-7 Boka H. ROC combarison of intraoperative ultrasound probes gment of a structure whose position and structure they did not know, and to categorize it in one of the following categories relevant for ROC analy­sis: 1 do not see biological structure 1 see biological structure very vaguely 1 see a compact biological structure 1 see a compact biological structure which seems to be separated into two sections -1 see two biological structures clearly Results -None of the 17 researchers, using extracorporeal probe, has chosen the highest category (1 can clearly see two biological structu­res). Ten of the researchers noticed a »lesion«, but only four (23%) of them remarked that the structure »might not have been a compact one«. As many as seven (41 % ) examiners have not noticed a particular biologic structure at all. On the contrary, using on intraoperative probe, all the examiners (100%) have, with certainty, noticed the biologic structure, while 13 of them (76%) have also noticed possible non-homoge­neity of the lesion. Nine of 17 examiners have registered and exactly identified biologic struc­ture as a double one. Conclusion -Comparative representation of the ROC curves obtained tor extracorporal and intraoperative probe respectively, are shown in graph 1 and 2. As the ROC analysis gives simoul­taneous presentation of the sensitivity and speci­ficity of a method tested, ultrasonic probes in our case provided considerably favourable perfor­mance of the intraoperative probe. Refe·rences: 1. Boko H, Drinkovic 1, Kos N, Vidakovic Z. Rezolu­cija intraoperativnih ultrazvucnih sondi. Radiol lugosl 1989; 22(4):365-7. 2. Metz C E. Basic Principles of ROC Analysis, Seminars in Nuclear Medicine 1978; Vlll(4):282-98. 3. Swets J A. ROC Analysis Applied to the Evalua­tion of Medical lmaging Techniques, lnvestigative Ra­diology 1979; 14:109-21. Author's address: mr se Haris Boko, Klinicka bolnica ,,Dr Ozren Novosel«, Zavod za radiologiju, Zagreb, Zajceva ul. 19, Yugoslavia Radiol \ugasi 1990; 24 :405-7 Najnovejše v zdravljenju ulkusne bolezni ® UL TOP (omeprazol) kapsule 20 mg prvi selektivni inhibitor protonske crpalke nova ucinkovina z bistveno drugacnim nacinom delovanja od vseh doslej znanih antiulkusnih zdravil • hitrejša zacelitev ulkusa dvanajstnika, želodca in požiralnika • hitrejše prenehanje bolecin • ucinkovit tudi pri bolnikih rezistentnih proti dosedanjemu zdravljenju • zdravilo izbire za bolnike s Zollinger-Ellisonovim sindromom Indikacije Duodenalni ulkus, želodcni ulkus, refluksni ezofagitis, Zollinger-Ellisonov sindrom. Doziranje Ouodenalni ulkus 1 kapsula (20 mg) Ultopa 1-krat dnevno pred zajtrkom; ce ulkus ne zaceli v 2 tednih, zdravljenje podaljšamo še 22. 2 tedna. Želodcni ulkus in refluksni ezofagitis 1 kapsula (20 mg) Ultopa 1-krat dnevno pred zajtrkom 4 tedne; ce ulkus ne zaceli, zdravljenje podaljšamo še za 4 tedne. Bolnikom, ki ne reagirajo na druga zdravila, priporocamo 40 mg (2 kapsuli Ultopa) na dan, 4 tedne pri duodenalnem ulkusu, oz. 8 tednov pri želodcnem ulkusu ali refluksnem ezofagitisu. Zollinger-Ellisonov sindrom Priporocamo zacetno dozo 60 mg (3 kapsule Ultopa) dnevno. Nadaljnje doziranje je individualno, zdravljenje pa traja, dokler je indicirano. ce je dnevna doza višja od 80 mg, jo razdelimo v dve posamezni dozi. Kontraindikacije Niso znane. Oprema 14 kapsul po 20 mg Podrobnejše informacije in literaturo dobite pri proizvajalcu. ... KRK. tovarna zdravil, p. o., Novo Mesto UNIVERSITY HOSPITAL »DR O. NOVOSEL« CENTER FOR UL TRASOUND »ZAGREB« NEW CATHETER SET FOR US-GUIDED PROCEDURE$ Drinkovic 1, Jukic T, Kos N, Odak D, Vidakovic Z _A.stract -A large number of catheters is used for US guided drainages, different in their construction and for different purposes. Small lumen catheters enable better US visualisation and are less traumatic. For US guided drainages a new universal type of catheter has been constructed, very suitable because of simple positioning, good visualisation, and very helpful in bringing a procedure to a successful end. UDC: 617-089.48:534-8 Key words: drainage, ultrasonic diagnoses, catheters Orig sci paper Radiol lugosl 1990; 24:409-11 lntroduction -Today a large number of diffe­rent types of catheters for US guided drainages and therapeutic interventions is offered by diffe­rent manufacturers. Specific catheters have been developed for the drainage of different organs, systems and contents too. Depending on their type and manufacturer, the catheters are placed by Seldinger or modified Seldinger technique, as well as by trocar techni­que, all under US guidance. However the most simple for US guidance is the last one. On the other hand, despite of constant visuali­sation of the needle tip in US guided drainages, very often we encounter problems of localisation of both the needle tip and the catheter, especially in performing punctures of small collections or puncturing narrow channel systems or ducts. Not seldom is US used for initial puncture only, while the intervention is continued under radiologic guidance. Depending on the collection or sy­stems which are to be drained, catheters of various lumens, ranging from 4 F to 14 F are used. However, under US guidance wider cathe­ters may present a problem because of difficul­ties in using a guide wire and dilatators. For our everyday practice, we tried to construct a catheter set which is easier to manipulate, smaller in lumen and therefore less traumatic while passing through other structures (intesti­neum), and whose tip has better visualisation. lts price was also an important factor. Material and methods -The drainage set consists of a needle with stiffening cannula and a pigtail catheter made of poliurethane, with a stopcock mechanism, making it thus possible to connect either a container bag or suitable tor more often used negative pressure. As a catheter guidance, we used a needle 19.5 G wide, with a stiffening cannula. For the purpose of better visualisation of the needle tip we used an MS cut needle. A catheter 27.5 cm long with a perforated pigtail 1.5 cm wide and 4.5 cm long is drawn on the needle. The catheter is placed by trocar technique with previous incision and anasthesia. The material was presented on the First lnternational Symposium on lnterventional and lntraoperative Sonography, Zagreb, May 1989. Received: November 2, 1989 -Accepted: November 8, 1989 Orinkovic 1 et al. New catheter set far US-guided procedwes ( Fig. 1 -5F catheter set, produced by ANGIOMED code name. ASKS 5, by Dr. Drinkov,c Fig. 2 -P1gta1l catheter with a needle, ready tor use lts width enables us to perform a puncture through the guider, thus making the intervention easier as well as more accurate, i. e. makes it applicable in cases of very small collections or dilated ducts. The catheter is made by Angiomed and is available under the code ASKS 5 (Fig. 1, 2). The application of the set is very simple. The unnecessary manipulation with guider or dilators is avoided, because after performing the US guided puncture and setting the needle tip in the wanted structure, the catheter is pushed forward along the needle, and after a few centimetres the needle is simultaneously pulled out. Using this technique 61 drainages of various abdominal collections, gallbladder and bile ducts, as well as widened renal channel system and pericardial effusion were performed on the in-patients. Results -Testing the set in vitro proved that its width is sufficient tor the aspiration of thick contents, and that the visualisation of the needle, compared to other sets, is improved from 10% to 15%. The catheter does not change its characte­ristics in absolute alcohol nor in detergent solu­tions. By applying the catheter in vivo 61 pun­cture of collections and channel systems were performed, plus six outer drainages of pancreatic pseudocysts. On 30 patients alcoholic sclerosa­tion of renal cysta was carried out. In five patients !iver abscesses have been drained suc­cesfully, while in four patients we performed drainages of intestinal abscesses. Two cholecy­stic drainages and three drainages of peripheric dilated bile ducts were accomplished, as well as 11 urgent nephrosthomas. In one case we car­ried out the drainage of pericardial effussion. The needle tip was visualised in 94% of pa­tients, while in 6% the visualisation was insuffi­cient or impossible. The average duration of drainage was from 15 min to 30 days. Discussion -US drainage of abdominal col­lections and dii· ,ed channel systems is a sate diagnostic and therapeutic method, due to real tirne sonogra· v characterized by high accuracy and effective. .ss. However, due to well known problems of visualisation of the needle tip and Radiol lugosl 1990; 24:409-11 Drinkovic I et al. New catheter set far US-guided procedures catheter, especially dilators and guide wires, US is often used for the initial opacificative puncture only. Using the small lumen catheter, its manipula­tion is simplified, while its positioning remains identical to US guided puncture. Due to better visualisation of the needle tip we are able to apply the catheter to very small changes, collec­tions, dilated ducts and channels. Small lumen reduces the tissue trauma and shortens the tirne of intervention. Application of contrast media and exposure to radiation are excluded. A small lumen catheter also gives a patient more freedom for movement. It drains liquid as well as thick substances, except the purulent contents, which can be found out by previous US examination. Setting up the catheter and not succeding in sucking the contents should not be considered a failure, since by inserting the guide wire the intervention can be continued by applying a wider catheter. This catheter set enables a drainage of abdominal collections, of hydronephrotic renal changes, gallbladder and dilated bileducts, excluding the use of radiograp­hic techniques. It can also be used in the drainage of pericard effusion. Because of its characteristics, i. e. good visualisation of the needle tip, small lumen, good US guidance and simple application, the catheter is of the polivalent usage. However, small in lumen, it asks for more careful care. Conclusions -The small lumen catheter for drainage and therapeutic interventions proved very useful in the drainages of various collections and substances. Quick application, small trauma and possibility of application by the guide needle alltogether increase the accuracy of the puncture. Better viualisation of the needle tip make it applicable on biliar and pancreatic ducts as well as small hydronephrotic changes. Sažetak NOVI KATETER U UZ-VOE>ENI DRENAL'.1 Za ultrazvucno (UZ) vodene drenaže koristimo velik broj katetera, razlicitih po svojoj konstrukciji i za razlicite svrhe. Kateteri malog lumena omogucuju bolju vizuali­zaciju vrha igle i manje su traumatski. Za UZ vodenu drenažu konstruiran je novi univerzalni tip katetera, vrlo pogodan zbog lakog postavljanja, dobre vizualizacije, i vrlo koristan u privodenju zahvala uspješnom završet­ku. References 1. Martin E C, Fankuchen E 1, Neff R A. Percuta­neous Drainage of Abscesses: A report of 100 Patients. Ciin Radiol 1984; 35 :9-11. 2. Tores W E, Evert MB, Baumgartner B R, Bernan­dino M E. Percutaneous Aspiration and Drainage of Pancreatic Pseudocysts. AJR 1986; 147:1007-9. 3. Newhouse J H, Pfister R C. Percutaneous Cathe­terisation of the Kidney and Perinephric Space: Trocar Technique. Urol Radiol 1981; 2:157-64. Author's address: Dr. Ivo Drinkovic dr sci, Klin. boin. »Dr O. Novosel«, Zajceva 19, 41000 Zagreb, Yugosla­via Radiol lugosl 1990; 24:409-11 Byk Gulden Pharmazeutika .i. Konstanz/SR Nemacka RENTGENSKA KONTRASTNA SREDSTVA: HEXABRIX kontrastno sredstvo niskog osmoaliteta, smanjene toksicnosti i gotovo bez­bolan u primeni. INDIKACIJE: Sva arteriografska ispitivanja, zalim cerebralna angiografija, i flebografija, kao i selektivna koronarografija. PAKOVANJA: Hexabrix amp. (5 amp. X 10 ml) Hexabrix amp. (20 amp. X 20 ml) Hexabrix boc. (2 boc. X 50 ml) Hexabrix boc. (1 boc. X 100 ml) Hexabrix inf. (1 boc. X 200 ml bez pribora za infuziju) DIMER X ampule 5 X 5 ml -kontrast za lumbosakralnu mielografiju TELEBRIX kontrast za urografije, angiografije, periferne i selektivne arteriografije. PAKOVANJA: Telebrix 300 amp. (20 amp. X 30 ml sa špricom) Telebrix 300 amp. (20 amp. X 30 ml bez šprica) Telebrix 380 amp. (20 amp. X 30 ml sa špricom) Telebrix 380 amp. (20 amp. X 30 ml bez šprica) Telebrix 380 za inf. (2 boc. X 50 ml) Telebrix 300 za inf. (2 boc. x 50 ml) Telebrix 30 za inf. (1 boca X 100 ml) Telebrix 45 za in!. (1 boca X 250 ml) @) FABEG BykGulden 8 lnostrana za!ltupstva Predstavnittvo: Pharmazeutlka Beograd Kosovska 17 M Zagreb, Savska cesta 41M Konstanz/SR Nemacka telefoni: 321-440 i 321-791 telefoni: 539-355 i 539-476 ONKOLOŠKI INŠTITUT, LJUBLJANA VLOGA SCINTIGRAFIJE S 57Co-BLEOMYCINOM V ODKRIVANJU IN ZAMEJITVI PLANOCELU­ LARNIH RAKOV THE ROLE OF SCINTIGRAPHY WITH 57Co-BLEOMYCIN IN THE DETECTION ANO STAGING OF PLANOCELLULAR CARCINOMAS Jancar B, Šuštaršic J, Mackovšek M Abstract -Opinions on usefullness ol 57Co-bleomycin in the diagnostics of planocellular carcinomas have been differing. This method was reported in early 70-ties, but was never generally accepted because of some physical characteristics of 57Co (hali-lile ol 57Co 270 days). The authors report two cases in which radiography and imaging with this agent helped to provide correct diagnosis: an unclear case ol Pancoast tumor and a case ol metastatic involvement ol thoracic wall alter laryngeal carcinoma. UDC: 616-006.6:539.163 Key words: carcinoma planocellular-redionuclide imaging, cobalt radioisotopes, bleomyicin Case report Radiol lugosl 1990; 24:413-6 Uvod -Bleomycin je antibiotik s citostaticnim delovanjem, ki se uporablja v kemoterapiji plano­celularnih rakov. Oznacen z razlicnimi radionu­klidi ( 131 J, 111 In, 57Co), se normalno akumulira v ledvicah, jetrih in hrustancnih delih, bistvena lastnost pa je akumulacija v planocelularnih ra­kih. Bleomycin, oznacen s 57Co, je v primerjavi z ostalimi radionuklidi najstabilnejši in kaže naj­vecjo tumorsko specificnost, zato so ga priceli klinicno uporabljati že v zgodnjih sedemdesetih letih (1 ). Zaradi dolge fizikalne razpolovne dobe 57 Co (T/2 je 270 dni) in visoke absorbirane radiacijske doze ter nespecificnega kopicenja tudi v vnetno spremenjenih tkivih, ni nikoli prišel v širšo uporabo. V našem clanku prikazujemo dva bolnika, pri katerih smo s pomocjo rentgenskih preiskav in kasnojše scintigrafije s 57Co-Bleomycinom uspješ­no diagnosticirali Pancoast tumor plj_uc in razšir­jenost metastatskega procesa pri raku grla. Prikaz bolnikov -Prvi bolnik -82-letni bolnik je prišel na pregled zaradi povecane prostate in štiri do pet mesecev trajajocin bolecin v desnem ramenskem sklepu. Klinicni pregled je pokazal mocno palpatorno obcutljivost desne lopatice ter zgornjega dela prsnega koša desno. Prostata je bila zmerno difuzno povecana. Laboratorijske preiskave so pokazale povišano sedimentacijo (51 mm/h) ter povišano koncentra­cijo karcinoembrionalnega antigena v serumu (CEA 21 ng/ml, normala je 2,5 ng/ml) in v urinu 50 ng/ml (normala je 2,5 ng/ml). Ostali hematološki in biokemicni izvidi so bili v mejah normale. Citološka preiskava povecane prostate ni pokazala rakavih celic. Na rentgeno­gramih pljuc so bile vidne obsežne spremembe po preboleli tuberkulozi in zadebeljena apikalna plevra desno. V desnih rebrih in desni lopatici so bile prisotne zmerne spremembe v smislu strukturne atrofije, brez rentgenskih znakov metastaz. V vratni hrbtenici so bile vidne izrazite degenerativno-in­volutivne spremembe; tudi tu metastaz ni bilo videti. Naredili smo scintigrafijo skeleta s 99mTc, ki je pokazala le zmerno povišano kopicenje izotopa v prvem in drugem rebru desno zadaj. Bolnik je bil zdravljen z analgetiki, fizioterapijo in blokadami brahialnega pleksusa, brez vecjega uspeha. Pet mesecev po prvem pregledu so bile bole­cine v desnem ramenskem sklepu mocnejše, Received: September 11 , 1990 -Accepted: October 15, 1990 Jancar 8 et al. Vloga scintigrafije s 57Co-Bleomycinom v odkrivanju in zamejitvi planocelularnih rakov Slika 1 -Rentgenogram pljuc pokaže obsežne fibrozne post-tuberkulozne spremembe v obeh hilusih in v zgor­njem delu desnega pljucnega krila, ki prekrivajo pri­ marni tumor. Fig. 1 -Radiograph of the lungs showing widespread post-tuberculotic fibrous changes in bolh hiluses and in the upper pari of the right lung, obscuring the primary tumor. desna ocesna reža je postala širša, vrednosti CEA v serumu so se povišale na 24,3 ng/ml. povišana je bila tudi sedimentacija (70 mm/h). V levi nadlehti se je pojavila zatrdlina premera dveh centimetrov, v kateri je citološka preiskava pokazala metastazo slabo diferenciranega plano­celularnega raka. Tudi citološka analiza sputuma je odkrila celice enakega raka. Ponovni rentgenogram pljuc je še vedno kazal le obsežne fibrozne spremembe in zadebeljeno apikalno plevro desno (slika 1 ). Glede na citološki izvid smo se odlocili za scintigrafijo s 57Co-bleomycinom. Bolniku smo intravenozno aplicirali lmC (37 MBq) 57Co-bleo­mycina in po 24 urah na gamma kameri posneli scintigram, ki je pokazal jasno patološko kopice­nje v zatrdlini leve nadlehti in v zgornjem delu desne strani prsnega koša, kar je topografsko ustrezalo zadebelitvi plevre na rentgenogramu (sliki 2 in 3). Ponovno slikanje desnih reber je tokrat poka­zalo zacetno osteoliticno destrukcijo srednjega dela drugega rebra. Na osnovi teh preiskav smo postavili diagnozo Pancoast tumorja. Po obsevanju primarnega tumorja so se bole­cine v desnem ramenskem sklepu bistveno Slika 2 -Scintigram s 57 Co-Bleomycinom (lmCi oz. 37 MBq, 24 h p.i.) desne strani prsnega koša kaže poleg fiziološkega kopicenja v hrustancih (H), jetrih (J), pato­loško kopicenje v zgornjem delu prsnega koša desno (pušcica), (kamera gamma General Electric WFOV, racunalnik Star, cas zbiranja 1000 sekund). Fig. 2 -Scintigram with 57 Co-Bleomycin {lmCi -37 MBq, 24 h p.i.); anterior view of the right thoracic reg ion showing normal accumulation in cartilages {H) and liver (J). and an abnormal one in the upper pari of the right lung (arrow), (General Electric WFOV camera, Star Computer, acquisition tirne 1000 sec). zmanjšale; nastopila je delna remineralizacija osteoliticne destrukcije v drugem rebru. Drugi bolnik: 58-letni bolnik je bil leta 1986 operiran zaradi epidermoidnega raka grla (T1 N0M0). Dve leti kasneje so pri bolniku rentge­nološko našli metastazo v prvem rebru levo. Novembra istega leta so prizadeto rebro opera­tivno odstranili, vendar so med operacijo našli še metastatsko prizadetost sprednjega dela dru­gega rebra, leve polovice manubriuma sterni in medialnega dela kljucnice. Vsa prizadeta mesta so operativno odstranili. Histološki izvid je potrdi metastaticno prizade­tost odstranjenega tkiva (metastatski planocelu­larni rak). Meseca decembra je bil prizadeti del prsnega koša obsevan. Dva meseca po zakljucenem obsevanju so se pri bolniku pojavile bolecine vzdož prsne hrbtenice in leve strani prsnega koša. Rentgenogrami pljuc, levih reber in prsne hrbtenice so pokazali spremembe po operativ- Radiol lugosl 1990: 24:413-6 Jancar B et al. Vloga scintigrafije s 57Co-Bleomycinom v odkrivanju in zamejitvi planocelularnih rakov Slika 3 -Scintigram s 57 Co-Bleomycinom (37 MBq, 24 h p. i.) prsnega koša zadaj kaže poleg fiziološkega kopicenja v jetrih (J) patološko kopicenje v dveh meta­stazah v gornjem delu prsnega koša levo (enojna pušcica) in desno (dvojna pušcica), (kamera gama General Electric WFOV, racunalnik Star, cas zbiranja 1000 sekund). Fig. 3 -Scintigram with 57 Co-Bleomycin (37 MBq, 24 h p. 1.), posterior thoracic view showing normal accumu­lation in the liver (J) and an abnormal one in two metastases of the carcinoma in the upper thoracic region left (arrow) and on the right side (double arrow), (General Electric WFOV camera, Star Computer, ac­ quisition tirne 1000 sec). nem posegu, osteoliticne defekte v ostanku dru­gega rebra in v zadnjem delu tretjega rebra. Zasumili smo, da ti defekti niso posledica opera­tivnega posega, temvec da predstavljajo ponovi­tev metastatskega procesa (slika 4). Scintigrafija s 57Co-bleomycinom (lmC oz. 37 MBq) je na istem mestu pokazala obsežno patološko kopicen­ je. Po dodatnem obsevanju so bolecine popustile, kar je spet potrdilo, da je rezultat scintigrafije s 57 Co-bleomycinom pravilen. Diskusija -Mnenja o uporabnosti scintigrafije s 57Co-Bleomycinom so še vedno deljena. Frede­riksen in sodelavci 62) menijo, da s to preiskavo lahko v vecini primerov prikažemo primarni pljucni tumor in cesto tudi metastaze planocelu­larnih rakov v prsnem košu, medtem ko Georgy (3) trdi, da tovrstna scintigrafija v sodobni diagno­stiki ni vec potrebna. V odgovoru k našemu prejšnjemu porocilu (4) Georgi (5) ugotavlja, da v naše porocilo o bolniku Radiol lugosl 1990; 24:413-6 Slika 4 -Rentgenogram levega hemitoraksa po resek­ciji 1. in dela 2. rebra in medialnega dela kljucnice. Pušcica kaže destrukcijo zadnjega dela 3. rebra. Fig. 4 -Radiograph of the left hemithorax after resec­tio,1 of the first and pari of the second rib and medial pari of the clavicula. The arrow points to a large destruction of dorsal part of the 3rd rib. nismo vkljucili rezultate CT-ja in standardne ren­tgenske tomografije ter dodaja lastne izsledke, po katerih je gornja preiskava sicer potrdila tumor pri vseh 33 bolnikih z rakom bronhusa, vendar ni dala dodatnih klinicno pomembnih diagnosticnih informacij poleg rezultatov konvencionalne ren­tgenske tomografije in CT-ja (6). Njegovi rezultati se skladajo tudi z izsledki Frederiksena in sode­lavcem (2), ki je s 57Co-Bleomycinom potrdil tumor pljuc pri 22 od 25 bolnikov, vendar pa ni uspel prikazati metastaz (v bezgavkah) v enaki 57 Jancar B et al. Vloga scintigrafije s Co-Bleomycinom v odkrivanju in zamejitvi planocelularnih rakov meri kod je tumor. Kljub temu Frederiksen in sodelavci menijo, da se lahko s to preiskavo velikokrat izognemo nepotrebni torakotomiji (2) Lorenz in sodelavci (7) omenjajo poleg obve­znih preiskav za zamejitev raka bronhusa še nekatere nuklearnomedicinske preiskave, ki lahko dopolnijo informacijo o razširjenosti bole­zni. To so ventilacijska scintigrafija pljuc, perfuzij­ska scintigrafija pljuc in scintigrafija s 67Ga-citra­tom, ki se tudi kopici v pljucnih tumorjih. Prei­skave s 57Co-Bleomycinom ta avtor ne omenja. Ceprav je vecina avtorjev do scintigrafije s 57Co­Bleomycinom prej kriticna kot ne, pa je ne mo­remo izlociti kot popolnoma nepotrebno. Medtem ko rentgenske preiskave kažejo morfologijo in strukturo bolezensko spremenjenega tkiva, kaže naša preiskava biološko aktivnost: kopicenje ra­diaktivnega sledilca v tumorju. Zakljucek -Menimo, da kljub upravicenim pomislekom proti scintigrafiji s 57Co.-Bleomyci­nom, lahko ta metoda odlocilno vpliva na potek diagnostike in zdravljenja v nekaterih nejasnih primerih planocelularnega raka. Povzetek Mnenja o uporabnosti 57 Co-Bleomycina v odkriva­nju in zamejitvi planocelularnih rakov so deljena. To metodo so priceli uporabljati v zgodnjih sedemde­setih letih, vendar zaradi nekaterih fizikalnih lastnosti 57 Co (razpolovna doba 270 dni) ni nikoli prišla v širšo uporabo. Avtorji porocajo o dveh bolnikih, pri katerih so s tem radiofarmakom in z rentgenskimi preiskavami uspešno razrešili nejasen primer Pancoast tumorja pljuc in dolocili obseg metastatske prizadetosti torakalne stene pri primarnem raku grla. Literatura 1. Grove RB et al. Clinical evaluation of radio­labelled bleomycin for tumor detection. J Nucl Med 1974; 15:386. 2. Frederiksen PB et al. 57Co-Bleomycin scin­tigraphy for the preoperative detection and sta­ging of lung tumors. Nucl Med 1988; 27 :79-82. 3. Georgy P. Maligne Tumoren. In: Buli U Hor G Hsgb. Klinische Nuklearmedizin. Weiheim: Edition Medizin VCH 1 1987 :229. 4. Šuštaršic J, Jancar B, Mackovšek M, Erja­vec M, Movrin T. 57Co-Bleomycin Scintigraphy for the Preoperative Detection and Staging of Lung Tumors. Nucl Med 1989; 28:160-1. 5. Georgi P. Leserbrief-Letter to the Editor. Bettrifft: 57Co-Bleomycin Scintigraphy for the de­tection and Staging of Lung Tumors. Nucl Med 1989; 28:162. 6. Georgi P, Schaaf J, Vogt-Moykopf 1, Loe­hlein A, Sinn H. Zur Frage der klinischen Rele­vanz der 111 ln-Bleomycin-Szintigraphie bei intrat­horakalen Erkrankungen. Strahlentherapie 1979; 155:622-7. 7. Lorenz J, H Jakob, R Ferlinz. Das Bron­chial-karzinom -eine zunehmende Herausforde­rung in Klinik und Praxis. Therapiewoche 1989; 39: 1368-78. Naslov avtorja: Dr. Jancar Breda, Onkološki inštitut v Ljubljani, Zaloška 2, 61000 Ljubljana, Jugoslavija Radiol lugosl 1990: 24:413-6 THE INSTITUTE OF ONCOLO GY, LJUBLJAN A THE USE OF MCA ANO CEA IN PROSTATIC CANCER FOLLOW UP Novakovic S, Marolt F, Serša G Abstract -lmmunodiagnosis in oncology is based on the detection of tumor products in body fluids such as serum, urine, pleural fluid and peritoneal fluid. The products specific tor some tumors are called tumor markers. The aim of the presen! study was to establish possible relationship between urine and serum concentrations of MCA and CEA tumor markers and prostatic cancer spread. Compared to healthy donor values, urine MCA levels were highly elevated in some prostatic cancer patients with progressed disease, whereas serum MCA levels in these patients were moderately elevated; this finding might contribute to a better understanding of the information on urine MCA values. In contrast, the urine CEA concentrations were not elevated above the cut-ott limit whereas the serum CEA concentrations were moderately elevated; this finding might contribute to a better understanding ot the intormation on urine MCA values. In contrast, the urine CEA concentrations were not elevated above the cut-off limit, whereas the serum CEA concentrations were elevated in patients with bone metastases. MCA and CEA in bolh urine and serum have not proved sufticiently specific tor follow up of prostatic cancer. Nevertheless, MCA in urine proved somewhat more useful in this respect, whereas CEA in serum was tound to be more eftective tor follow-up prostatic cancer patients with bone metastases. UDC: 616.65-006.6-097 Key words: prostatic neoplasms, carcinoembryonic antigen, tunar markers biological Orig. sci paper Radiol lug osi 1990; 24 :417-21 lntroduction -Mucin-like carcinoma associa­ted antigen (MCA) is a glycoprotein with molecu­lar mass of 350 000 daltons, recently described by Stahli et al. (1, 2). It is produced also by some cells of normal healthy tissue, such as dueta! epithelium of the breast, renal epithelium, prosta­tic epithelium and apithelium of the endometrium (3). lncreased MCA serum concentrations were found in epithelial carcinomas, most frequently in mucinous carcinoma of the breast (4, 5). Murine monoclonal antibodies 8-12 against MCA antigen have been proved to react also with carcinomatous tissue of the prostate. The reaction between b-12 monoclonal antibodies and MCA antigen determinant was found to be presen! in 1 O of 11 prostatic adenocarcinomas (3). Our preliminary study was therefore aimed to establish the MCA and CEA urine and serum concentrations in patients with prostatic carcino­ma, in relation with spread of the disease, and compare the obtained values with those in the control group of healthy males. Material and methods -In the present investi­gation 18 patients with prostatic carcinoma (se­rum and 24-hour urine samples) were included. The patients were distributed by stage of disease as follows: a) Eight patients with the diagnosis of prostatic carcinoma, but without presen! evidence of di­sease (N ED); these were either the patients with completed treatment (n=5), or treatment under way (n=3), their age ranging between 54-81 years. b) Ten patients with the diagnosis of prostatic carcinoma, and evidence of progressive disease (PD). On sample taking, 3 of these patients with advanced primary disease and skeleta! metasta­ses were without therapy, whereas 2 were recei­ving hormona! therapy. The remaining 5 patients in this group had progression in the bones and were receiving treatment with antiandrogen agent (cyproteronacetat). The age of patients in this group ranged between 60 and 83 years. Co n t r o I s -The first control group (CG) com­prised urine samples of 34 healthy Sanford-nega­tive males; their age ranged from 40-82 years. The second control group consisted of serum samples collected in 15 healthy male blood donors aged 28-60 years. Received: November 15, 1990 -Accepted: November 26, 1990. Novakovic S et al. The use of MCA and CEA in prostatic cancer follow up Met hod s : Mucin-like carcinoma -associa­ted antigen levels were measured using MCA EIA »Roche« kits. The method is a two-step phase enzyme immunoassay based on the san­dwich principle (6). The monoclonal antibody used was a highly specific murine monoclonal antibody b-12 (MAb b-12) to MCA. For carcinoembryonic antigen determination in the urine serum samples the CEA EIA Dumob 60 »Roche« kits were used. This is a solid phase enzyme immunoassay based on the sandwich principle using highly specific murine monoclonal antibodies to CEA (7). Statistical evaluation: From the obtai­ned data, arithmetic mean (AM), standard devia­tion (SD), standard error (SE), median value (M) and cut-off value were calculated (4). Results: Control groups with MCA urine and serum concentrations and CEA urine con­centrations are presented in Table 1 and Figures 1-2. Arithmetic mean (AM) of MCA urine concentra­tions in the control group was 97.9 U/ml (SD = 82.0 U/ml), whereas AM of MCA serum concen­trations in the control was 9.4 U/ml (SD = 4.0 U/ml). The cut-off value of MCA serum concentration was 17 U/ml (4). The cut-off value of MCA tumor marker in the urine was determined as well and was found to be 180 U/ml (Fig. 1 ). AM of CEA urine concentrations in the control group was 6.1 ng/ml (SD = 10.3 ng/ml), whereas the calculated cut-off value of CEA urine concen­trations was 17 ng/ml (Fig. 2). Data of Hoffman la:-Roche company were used as a control group for CEA tumor marker in the serum (cut-off level was 2.5 ng/ml) (7). -Pati en t s : 1 n patients with no evidence of disease, presented in Table 2, AM of MCA urine " "I l 250 .. -200 E = - C o _.__ . 150 u C o ..,u .. :::i,: 100 . _\-_ 50 .. -­ . 1 " v CG NEO PD Fig. 1 -MCA levels in urine samples of control group (CG), prostatic cancer patients with no evidence of disease (NED), and prostatic cancer patients with progressive disease (PD). ---cut-off level - ___ _ median value -arithmetic mean concentrations was 74.8 U/ml (SD = 50.8 U/ml) (Fig. 1 ), whereas the AM of MCA serum concen­trations was 1 O. 7 U/ml (SD = 4.2 U/ml). Table 1 -llrine and serum levels of MCA and urine levels of CEA in normal (males) healthly donors (CG) TUMOR No.o: MCA and CEA levels MARKER Ca!'' AM SD SE Median Min-Max MCA-Urine+ 97,9 82,0 14,0 84,5 9,8-334,6 (U/ml) MCA-Serum 15 1,0 10,1 1,4-15,1 (U/ml) CEA -Urine + (ng/ml) 34 6,1 10,3 1,8 2,2 0,1 ­49,0 + Urine samples were Sanford negative .418 Radiol lugosl 1990; 24:417-21 Novakovic S et al. The use of MCA and CEA in prostatic cancer follow up ''"f l 50 -40 E - en C C o . 30 C o u -« ...., '-' 20 )),-------;--------------:-----­ 10 _t.,.. -. CG NED PO Fig. 2 -CEA levels in urine samples of control group (CG), prostatic cancer patients with no evidence of disease (NED), and prostatic cancer patients with progressive disease (PD). --cut-off level ___ _ median value --arithmetic mean AM of CEA urine concentrations in NEO pa­tients was 4.8 ng/ml (SO = 3.2 ng/ml) (Fig. 2) and AM of CEA serum concentrations 3.5 ng/ml (SO= 2.7 ng/ml) resp.ctively (Fig. 3). Basic characteristics' of patients with progres­sed disease are presented in Table 3. AM of MCA urine concentrations was 385.2 U/ml (SO = 570 U/ml) (Fig. 1) and AM of MCA serum concentrations 25.0 U/ml (SO = 29.7 U/ml). In this group, AM of CEA urine concentrations was 9.3 ng/ml (SO = 8.9 ng/ml) (Fig. 2) and serum concentrations 463.3 ng/ml (SO= 1336.9 ng/ml) (Fig. 3). In the group of patients with progressed disea­se, elevated CEA serum concentrations (over 2.5 ng/ml were established in 80.0% of cases; in only 2 of 1 O patients these concentrations were Radiol lugosl 1990; 24:417-21 "'l ] 20 E en C C o "' C ., u C ::! 10 -« ...., .. §AUBA\.; 24:429-30 INSTRUCTIONS TO AUTHORS The journal RADIOLOGIA IUGOSLAVICA publishes original scientific papers, professio­ nal papers, rewiew articles, case reports and varia (reviews, short communications. profes­ sional information ect.) pertinent to radiology, radiotherapy, oncology, nuclear medicine, ra­ diophysics, radiobilogy, radiation protection and allied subjects. Submission of. manuscript to the Editorial Board implies that the paper has not been published or submitted for publication elsewhe­ re; the authors are responsible for all state­ ments in their papers. Accepted articles be­ come the property of the journal and therefore cannot be published elsewhere without written permission from the Editorial Board. Manuscripts written either in English should be sent to the Editorial Office, Radiologia lugo­ slavica, Institute of Oncology, Zaloška c. 2, 61105 Ljubljana, Yugoslavia. Ali articles are subject to editorial review and review by two independent referees selected by the Editorial Board. Manuscrips which do not comply with the technical requirements stated here will be returned to ·1he authors for correction before. the review of the referees. Rejected manuscripts are generally returned to authors, however, the· journal cannot be held responsible tor their loss. The Editorial Board reserves the right to require from the authors to make appropriate changes in the content as well as grammatical and stylistic corrections when necessary. The expenses of additional editorial work and requests for reprints will be charged to the authors. General instructions Type the manuscript double space on one side with a 4 cm margin at the top and left hand sides of the sheet. Write the paper in gramma­tically and stylistically correct language. Avoid abbreviations unless previously explained. The technical dala should conform to the SI system. The manuscript, indluding references may not exceed 8 typewritten pages, and the number of figures and tables is limited to 4. II appropriate, organize the text so that it includes: lntroduc­tion, Material and Methods, Results and Dis­cussion. Exceptionally, the resulls and discus­sion can be combined in a single section. Start each section on a new page and number these consecutively with Arabic numerals. First page -complete address of institution for each author -a brief and specific tille avoiding abbrevia­tions and colloquialisms -family name and initials of ali authors -in the abstract of not more Ihan 200 words cover the main factual points of the article. and illustrate them with the most relevant dala, so that the reader may quickly obtain a general view of the material. Apart from the English abstract, an adequate translation of this including the title into one of the Yugoslav languages should be provided on a separate sheet of paper following the Discus­sion. For foreign writers the translation of the abstract will be provided by the Editorial Board. lntroduction is a brief and concise section, ·stating the purpose of the article in relation to other already published papers on the same subject. Do not presen! extensive reviews of the literature. Material and methods should provide enough information to enable the experiments to be repeated. Write the Results clearly and concisely and avoid repeating the dala in the tables and figures. Discussi'on should explain the resulls, and not simply repeat them, interpret their signifi­cance and draw conclusions. Graphic material (figures, tables). Each item should be sent in triplicate, one of them marked original for publication. Only high-con­trast glossy prints will be accepted. Line dra­wings, graphs and charts chould be done professionaly in indian ink. AII lettering must be legible after reduction to column size. In photo­graphs mask the identities of patients. Label the figures in pencil on the back indicating author's name, the first few words of the title and figure number; indicate the top with an arrow. Write legends to figures and illustrations on a separate sheet of paper. Omit vertical lines in tables and write the text to tables overhead. Label the tables on their reverse side. References should be typed in accordance with Vancouver style, double spaced on a separate sheet of paper. Number the referen­ces in the order in which they appear in the text and quote their corresponding numbers in the text. The authors names are followed by the title of the article and the title of the journal abbreviated according to the style of the lndex Medicus. Following are some examples of references from articles, books and book chap­ters. 1. Deni RG, Cole P. In vitro maturation of monocy1es in squamous carcinoma of the·lung. Br J Cancer 1981; 43: 486-95. 2. Chapman S, Nakielny R. A guide to radio­logical procedures. London: Bailliere Tindall, 1986. 3. Evans R, Alexander P. Mechanisms of extracellular kiling of nucleated mammalian cells by macrophages. In: Nelson OS ed. lm­munobiology of macrophage. New York: Aca­demic Press, 1976; 45-74. Author's address should be written following the References. lzdavanje revije potpomaže Raziskovalna skupnost Slovenije u svoje ime i u ime istraživackih zajednica svih drugih republika i pokrajina u SFRJ -The publication of the review is subsidized by the Assembly of the Self managing Communi1ies for Research Work of the Republics and Provinces of Yugoslavia, and the Research Community of Slovenia. Doprinosi ustanova na osnovu samoupravnih dogovora -Contribution on the basis of the self-m.naging agreements: -Institut za radiologiju, MF u Prištini -Institut za rendgenologiju, UMC-a Sarajevo -Inštitut za rentgenologijo, UKC Ljubljana -Klinicka bolnica »Dr Vukašin Markovic« Titograd -Klinika za nukleano medicino, UKC Ljubljana -Medicinski centar »Zajecar« u Zajecaru -Onkološki inštitut, Ljubljana -OOUR Institut medicinskih službi, Novi Sad; -RJ Institut za patološku fiziologiju i laboratorijsku dijagnostiku u Novom Sadu -RJ Institut za radiologiju u Novem Sadu -RO Institut za nuklearne nauke „Boris Kidric«, Vinca-OOUR Institut za radioizotope »RI«, Beograd -Sekcija za radiologiju Makedonskog lekarskog društva, Skopje. Pomoc reviji i narucnici reklama -Donators and Advertisers -ANGIOMED, Karlsruhe, BRD -BAYER PHARMA JUGOSLAVIJA, Ljubljana -BYK GULDEN, Konstanz, SR Nemacka -zastupstvo FABEG, Beograd -FOTOKEMIKA, Zagreb -F. HOFFMANN -LA ROCHE & CO., Basel, Švica -zastupstvo JUGOMONTANA, Beograd -HELVETIUS, Trst, Italija -ISOCOMMERZ / lnterwerbung, Berlin, DOR -OZEHA, Zagreb -JADROAGENT, Rijeka -JUGOLINIJA, Rijeka -KRKA, Novo mesto -KOMPAS, Ljubljana -MEBLO, Nova Gorica -NYCOMED NS Oslo, Norveška -predstavništvo LECLERC & Co. Schaffhausen, Švica -zastupstvo za Jugoslaviju REPLEK-MAKEDONIJA, Skopje -PHILIPS -zastopstvo AVTOTEHNA, Ljubljana -RO INSTITUT ZA NUKLEARNE NAUKE „BORIS KIDRIC«. Vinca -OOUR INSTITUT ZA RADIOIZOTOPE »RI«, Vinca -SALUS, Ljubljana -SANOLABOR, Ljubljana -SIEMENS, Erlagen, BRD -zastupstvo BANEX, Zagreb -TOSAMA, Domžale -ZAVAROVALNA SKUPNOST IMOVINE IN OSEB »CROATIA«, Zagreb -poslovna enota v NOVI GORICI PROIZVODNI PROGRAM ZA MEDICINU -Medicinski rendgen filmovi: SANIX RF-90 SANIX ORTHOHS 90-2 -Film za memografiju: SANIX M -Zubni rendgen filmovi: SANIX DENT -20 STATUS-d -Film za nuklearnu medicinu, OTi ultrazvuk: SANIX FNM-1 -Filmovi za koronarografiju -35 mm SANIX COR -17 Mlc,ropaque® SANIX COR -21 ;'n-.;;s·f,,li,;.,.k,·. . .. :..;. •• ,cc:-.c. ..• .... >,;:;.;.-;;,:,:,,, .•• -..:C-:-; ,;.;; =,-, .... ·. -KEMIKALIJE ZA OBRADU MEDICIN­SKIH FOTOMATERIJALA .@u@..[Ra].. generalni zastupnik 002 003 POLAROID FILM crno-bijeli 667 Micropaque kolar 339 Colon Micropaque SANIX ORTHO pojacavajuce folije [F©lf©...DM Poduzece za proizvodnju i promet fotografskih materijala i opreme s p.o. ZAGREB, Hondlova 2, TEL. 041/231-833, Telex: 22-214 YU FOKEM, Telefax: 041/232-653 (\. avtotehna PHILIPS TOMOSCAN CX/S Znacilnosti Philipsovega CT-ja (racunalniškega tomografa): 11111111111111111111111111111111111111 • izredna kvaliteta slike • enostavno in hitro roko­vanje • uporaba keramicne SRC cevi nekajkrat po­daljša življenjsko dobo cevi in odpravi prekini­tve dela zaradi pregre­vanja cevi • ugodno razmerje cena/ kvaliteta; • številne aplikacije: -dinamicno skeniranje -vecravninska rekonstrukcija -30 rekonstrukcija -analiza mineralov v kosteh II l l l l l l 1111111111111111111111111111 AVTOTEHNA d. d. Ljubljana, Tel. 061/317 044 Fax: 061/320 589 Zagreb, Tel. 041/426 562 Fax: 041/424 469 Beograd, Tel. 011/322 677 III III III III II III III II l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l 1111111111111111111111111111111