UDC 616-006(05)(497.1) GODEN RDIUA 4 YU ISSN 0485-893X RADIOLOGIA IUGOSLAVICA ANNO 24 1990 FASC 3 PROPRIETARII IDEMOUE EDITORES: SOCIETAS RADIOLOGORUM IUGOSLAVIAE AC SOCIETAS MEDICINAE NUCLEARIS IN FOEDERATIONE SOCIALISTICA REI PUBLICAE IUGOSLAVIAE LJUBLJANA Radiol lugosl July-September, 1990 ;24 :203-311 Nova generacija cepiv HEPAGERIX B® injekcije cepivo proti hepatitisu B, 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 D • dosega skoraj 100 % serokonverzijo • lahko ga dajemo v vseh starostnih obdobjih • vsi ga dobro prenašajo Bazicno cepljenje opravimo s 3 intramuskularnirni 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 suspenzije. Nov9rojencki 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)(4971) CODEN RDIUA 4 YU ISSN 0485-893X RADI O LOG IA IU G0SLAVI C A PROPRIETARII IDEMOUE EDITORES: SOCIETAS RADIOLOGORUM IUGOSLAVIAE AC SOCIETAS MEDICINAE NUCLEARIS IN FOEDERATIONE SOCIALISTICA REI PUBLICAE IUGOSLAVIAE LJUBLJANA ANNO24 1990 FASC.3 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 B. 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 Staff: Bebar S, Ljubljana -Guna F. Ljubljana -Kovac V. Ljubljana -Pavcnik D. Ljubljana ­Plesnicar S, Ljubljana -Rudolf Z, Ljubljana -Snoj M. Ljubljana Radiol lugosl July-September, 1990; 24:203-311 RADIOLOGIA IUGOSLAVICA Revija za rendgendijagnostiku, radioterapiju, onkologiju, nuklearnu medicinu, radiofiziku, radiobiologiju i zaštitu od ionizantnog zracenja -The review tor 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 -Ivkovic 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 tor English language: Shrestha Olga UDC i/and Key words: mag. dr. 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Naklada: 1150 Tisk -Printed by: Tipograf, Rijeka UDC 616-006 (05) (497.1) CODEN RDIUA 4 YU ISSN 0485-893X RADIOLOGIA IUGOSLAVICA ANNO 24 1990 FASC. 3 SADRŽAJ/CONTENTS Radiološka dijagnostika -Radiological diagnostic Radiološki prikaz trupa petog lumbalnog kralješka Radiologic presentation of the fifth lumbar vertebra body (orig sci paper) 209 Miladinovic K, šecerov D, 2eljo-Kulenovic A Duplikacija žucnog mjehura Duplication of the gall-bladder (case report) 215 Zamberlin R, Smolcic S, Bedek D Divertikuli rektuma Diverticula of the rectum (case report) 219 Frkovic M, Mandic A Karlica Otto-Chrobak Otto-Chrobak pelvis (review article) 223 Goldner B, Dodic M, Penev B Ohronoza i kalcifikati u zglobnim hrskavicima Ochronosis and calcifications within the cartilages of the joints (case report) 227 Presecki V, Mihordin N Iz prakse ta prakso -Prikaz primera Fram practice for practice -Case report (case report) 231 Us J CT i UZ -CT and US Approach to the stereoscopic visualisation of the real-tirne ultrasound images (preliminary report) Kurbel S, Dicic M 233 Neurofibrom perikarda -Prikaz slucaja Pericardial neurofibroma -Case report (case report) Dalagija F, Najdanovic M, Bukša M, Bešlic š, Spasojevic S 237 Nuklearna medicina -Nuclear medicine 99mrc uptake in thyroid; pinhole collimator nonuniformity correction (orig sci paper) Loncaric S, Samaržija M, Popovic S, Težak S 241 Lung scan interpretation -Comparison of different criteria (orig sci paper) Budihna N, Milcinski M, Šuštaršic J, Grmek M, Grošelj C, Porenta M 245 131 1-MIBG body retention in a case of neuroblastoma -Case report (case report) Maštrovic Z, Kasal B, Ivancevi{: V, Bajc M, lvancevic D 249 Onkologija -Oncology Liver metastases from colorectal cancer; the impact of primary tumor removal on survival (orig sci paper) Snoj M, Lukic F 253 Radiol lugosl July-September, 1990; 24:203-311 Circulating Ca 15-3 and CEA v.lues in monitoring patients with breast cancer (orig sci paper) Vrbanec D, Cvrtila D, Bolanca A 257 Testing of the valve tor controlling the excretion of faeces and stomatherapy in the experiment on dogs (orig sci paper) Košorok P 261 Radioterapija -Radiotherapy High dose rate lr-192 implants in the treatment of cancer of the vocal cord (orig sci paper) Hammer J, Hochleitner F, Seewald DH, Meindl J, Labeck W 269 Radiotherapy following quadrantectomy in stage T1 -T2 breast cancer (orig sci paper) Roncadin M, Candiani E, Arcicasa M, Bortolus R, lnnocente R, De Paoli A, Franchin G, Trovo MG, Bassignano G, Rossi C 276 Preliminary report on radiotherapy in stage III ovarian cancer pretreated by surgery and chemotherapy (orig sci paper) Arian-Schad KS, Hackl A, Juettner FM, Lahousen M, Pickel H 277 Treatment of the malignant germ celi tumor (orig sci paper) Clemm Ch, Sala! Ch, Ehrhart H, Wilmanns W 283 Radiofizika i zaštita -Radiofisics and protection Local dosimetric functions and lung correction factor under 60Co TBI (orig sci paper) Vrtar M 289 192Ir implantat u radioterapiji anorektalnog karcinoma: dozimetrija 192Ir implant in the anorectal carcinoma radiotherapy: the dosimetry (profess paper) Lakner V, Pokrajac B, Lakner P 297 Humic acids -Model molecules tor monitoring the degree of environmental pollution (orig sci paper) Huljev D 303 Radiol lugosl July-September, 1990; 24:203-311 Sodelavcem ! V letu 1991 bo pricel izhajati 25. letnik naše revije. Z željo da bi jubilejni letnik predstavili najširšemu številu strokovnjakov v svetu, smo v uredništvu sklenili, da izdamo posebno jubilejno številko, ko bo v celoti pisana v anglešcini ali v drugem svetovnem jeziku. V njej naj bi naši in povabljeni tuji strokovnjaki s podrocij, ki jih objavlja revija, predstavili svoje dosežke v obliki originalnih znanstvenih prispevkov ali preglednih clankov. Vse, ki so pripravljeni sodelovati, vljudno naprošamo, da nam to sporocijo do 30. septembra 1990. 25. letnik revije RADIOLOGIA IUGOSLAVICA Priimek in ime avtorja Naslov Predviden naslov prispevka št. strani ................... . »RAOIOLOGIA IUGOSLAVICA« Uredništvo Onkološki inštitut L1ublIana Vrazov trg 4 -61 000 Ljubljana Saradnicima ! U godini 1991 štampat ce se 25-godišnjak revije. U želji da jubilejni godišnjak predstavimo najširem broju strucnjaka u svetu, zakljucili smo da se štampa vanredan jubilejni broj koji ce biti u celosti pisan na engleskom ili drugem svetskom jeziku. U tom broju neka bi naši i pozvani strani strucnjaci iz podrucja koja objavljiva revija, predstavili svoja dostignuca u obliku originalnih naucnih ili preglednih clanaka. Sve, koji su spremni saradivati, uctivo molimo da nam to jave do 30. septembra 1990. 25. godišnjak revije »RADIOLOGIA IUGOSLAVICA« Prezime i ime autora ..................................... . Naslov Predvideni naslov clanka Broj stranica .................. .. »RADIOLOGIA IUGOSLAVICA« Uredništvo Onkološki inštitut Ljubljana Vrazov trg 4 -61000 Ljubljana MEDICINSKI FAKULTET SARAJEVO INSTITUT ZA ANATOMIJU RADIOLOŠKI PRIKAZ TRUPA PETOG LUMBALNOG KRALJEŠKA RADIOLOGIC PRESENTATION OF THE FIFTH LUMBAR VERTEBRA BODY Miladinovic K, šecerov D, Zeljo-Kulenovic A. Abstract -Precise marking of the fifth lumbar vertebrae body on tomograms allows exact distinguishing of normal appearance of this part of lumbosacral dynamic segment from an affected one. Therefore, we made marking of this segment on lateral tomograms (»scout view«) in an attempt to obtain exact numerical information of its appearance. We analysed 68 tomoqrams of 68 patients who were divided in two qroups. Twenty-six patients had normal lumbosacral seqment, without any pathologic process, and 42 patients had pathologic process on this segment. The most frequent condition was giscus hernia (61 % ). Analysing the pooled data, we ooMined numerical information on apperance the of the fifth lumbar vertabrae body. Normal appearance of corpus of fifth lumbar vertebrae showed tendency to wedged shape. Comparing this shape between two groupes of patients, we noticed higher prevalance of wedged shape in the group of patients with pathologic processes. Significant differences showed parametars of posterior hight and inferior depth of the fifth lumbar vertebrae body on lateral tomograms. Positive Kaiser's sign was found in 20% of ali examinated cases. UDC :616.711.6-073. 756.8 Key words:lumbar vertebrae-radiography, tomography Orig sci paper Radiol lugosl 1990; 24:209-13. Uvod -Varijabilni izgled trupa petog lumbal­nog kralješka u domenu normalne anatomije kao i onaj ciji je izgled izmijenjen patološkim proce­sima pokazat ce promjene na radiogramima kompjuterizirane tomografije u smislu promje­njene visine i dubine ovog dijela US dinamskog segmenta. Utvrdivanje numericke informacije o izgledu ovog dijela dinamskog segmenta na ra­diološkem materijalu, istraživanje obima indivi­dualnih varijacija, kao i njegovog oblika u smislu eventualnog prisustva kongenitalnih anomalija omogucit ce vidjanje eventualne anatomske predispozicije za nastajanje nekih patoloških pro­cesa. Upotrebom striktnog kriterijuma za postavljanje markera na radiogramima lumbalne kicme omo­gucila bi se reproducibilna mjerenja koja bi sma­njila intra i interobservacijske greške. Materija! i metode -Analizi je bilo podvrgnuto 68 tomograma pacijenata Instituta za radiologiju i onkologiju u Sarajevu, koji su pod uputnom dijagnozom došli na rendenografske i CT pre­trage lumbalne kicme. Nakan obavljenog pre­gleda radiolog je dao dijagnozu na osnovu koje su ispitanici bili rangirani u dvije grupe. Od ukupno 68 ispitanika, 26 je nakan radiološke eksploracije imalo nalaze u fiziološkim granica­ma, tj. US segment je bio bez prisutnog patolo­škog procesa. Dakle, u ovoj grupi analizi je bilo podvrgnuto 26 tomograma. Druga grupa je obu­hvatila 42 ispitanika sa prisutnim patološkim pro­cesom na US dijelu kicmenog stuba. Od ovih ispitanika 8 je imalo deformirajucu spondilozu, 8 degenerativne promjene US segmenata, 13 dis­kus herniju US diskusa, 5 diskus herniju LJL5 diskusa, a 8 diskus herniju i LJL5 i US diskusa. 26 pacijenata je imalo diskus herniju, procen­tualno 61 %. Na pocetku snimanja uradi se lateralni torno­gram (topogram) sa visokem rezolucijiom od 512 HE (Hounsfieldovih jedinica), što omoguci vrlo dobru vizualizaciju. U novijoj literaturi ovakav radiogram nosi naziv »scout views«. Za vrijeme snimanja pacijent je u ležecem, ako je moguce, fiksiranem položaju. Kriterijum za pozicioniranje markera je uzet iz Farfanove (2) metode. Markeri su postavljeni na ekstremnim anteriornim i posteriornim tackama terminalnih ploha korpusa petog lumbalnog kra­lješka (shema 1 ). U statistickoj obradi i analizi podataka upotrebljeni su x, (SD)2, (SD), (SD)x, x2 t-test, koeficijent linearne korelacije (r) i (Hi kvadrat) test. Received: May 18, 1990 -Accepted: June 8, 1990 Miladinovic K et al. Radiološki prikaz trupa petog lumbalnog kralješka II L__j Sheme 2 -The shapes of L5 vertebrae body o:} procesa iznosila je 24,31 mm a u onoj sa patolo­/'--..... ,s škim procesom na US segmentu 22,44 mm. Q I Razlika je iznosila 1,87 mm (p,0,01 ). To je bila I ,..._',4 I vrijednost koja je odredila visoku signifikantnost ( SHAPE Cf RECTANGLE ) 2. UKLINJENI OBLIK SA GLAVOM KLINA PREMA NAffilJED ( WEDGED SHAPE WITH HEAD OF CJ WEDGE TURNED TOWARD FORWARD ) 3. UKLINJENI OBLIK SA GLAVOM KLINA PREMA GORE ( WEDGED SHAPE WITH HEAD OF D WEDGE TURNED TOWARD UP) D ( DOUBLE WEDGED SHAPE ) Shema 2 -Oblici korpusa petog lumbalnog kralješka I 7( I / ', I'-?' /', I 'v 2 Shema 1 -Markiranje trupa petog lumbalnog kralješka Sheme 1 -Marking of the fifth lumbar vertebrae body Rezultati -Na osnovu vrijednosti parametara koje smo dobili konstatovali smo 4 vrste oblika korpusa petog lumbalnog kralješka (shema 2). Od 26 ispitanika bez patološkog procesa na US segmentu 15 je bilo sa oblikom 2 (58%), 9 sa oblikom 1 (38%) i dva sa oblikom 3 (4%). Sa oblikom 3(4%) su bila 2 ispitanika, oba u starijoj dobnoj skupini (preko 60 godina starosti). Od 42 ispitanika sa prisutnim patološkim pro­cesom na US segmentu 16 je bilo sa oblikom 2 (38% ), 13 sa obli kom 1 (31 % ), 4 sa oblikom 3 (9%) i devet sa oblikom 4 (22%). Analizirajuci parametre koji su odredili oblik petog lumbalnog kralješka može se zakljuciti da velicina parametra koji odreduje posteriornu vi­sinu trupa ovog kralješka igra veliku ulogu u formiranju njegovog oblika na lateralnim radio­gramima. On je i pokazao signifikantne razlike na topogramima izmedu grupa ispitanika. Njegova prosjecna visina u grupi ispitanika bez patoloških razlika (tabela 1 ). Signifikantnu razliku u vrijedno­sti pokazao je i parametar koji je odredio infe­riornu dubinu trupa L5 kralješka. Njegova srednja vrijednost u grupi ispitanika bez patološkog pro­cesa iznosila je 34, 15 mm, a u grupi sa prisutnim patološkim procesom 32,63 mm. U našem materijalu naišli smo na dva primjera lumbalizacije prvog sakralnog segmenta, jedan slucaj spondilolisteze, kao i na 8 slucajeva (oko 20% od ispitivanih slucajeva) defekta donjeg posteriornog ugla korpusa petog lumbalnog kra­lješka (»moljcev izjed«) koji su uputili na hernija- ..., ciju lumbosakralnog diskusa (slika 1, 2). Ova hernijacija je potvrdena u svim slucajevima na transverzalnim tomogramima. Diskusija -Rezultati ovog istraživanja pokazju prevalenciju uklinjenog oblika kod ispitanika sa patološkim procesom. Dvostruko uklinjeni oblik je veoma karakteristican za ovu grupu ispitanika (22% ), narocito kod onih sa degenerativnim pro­mjenama. Takoder se cešce pojavio i uklinjeni oblik sa glavom klinika okrenutom prema gore. Kod oba oblika je zajednicko da im je parametar koji odreduje donju dubinu pršljenskog tijela ma­nji. Signifikantne razlike izmedu grupa ispitanika pokazao je i parametar koji definiše stražnju visinu trupa L5 kralješka. Witt (5) je našao da su degenerativne pro­mjene cešce uzrok bola nego prolabirani diskus Radio! lugosl 1990; 24 :209-13. Miladinovic K et al. Radiološki prikaz trupa petog lumbalnog kralješka Slika 1 -Defekt donjeg posteriornog ugla korpusa L5 kralješka Fig. 1 -The law posterior angle defect of the fifth lumbar verteb,ae corpus Slika 2 -Herniia US diskusa Fig. 2 -Hernia of US disc i to na nivoima L4/L5 i US. Našao je i to da su slucajevi sa klinasto oblikovanim vertebralnim tijelima signifikantno frekventniji kod pacijenata mladih od 40 godina starosti u grupi koja je imala bolove. Iz biomehanickog aspekta gledano ovi srna­njeni parametri bi mogli poremetiti ravnotežu i disperziju sila u procesu prenošenja nošajne težine i na taj nacin više opteretiti segmente ispod sebe, intervertebralni diskus. U diskusu bi se tada stvorili uslovi za poreme6enu nutriciju i nastanak degenerativnih promjena. Zbog toga bismo uklinjene oblike trupa petog lumbalnog kralješka mogli smatrati kao eventualne anatom­ske predispozicije za nastanak nekih patoloških procesa. CT generirani digitalni radiogram se uglavnom upotrebljava da selektira intervertebralni diskusni prostor koji treba biti ispitan, te da izabere stalni ugao za mjerodavni paralelizam presjeka i samog diskusa. Da su ovi, visoko rezoluirani, tzv. »scout views« radiogrami, gene­ralno podcjenjeni kao dijagnosticka slika, prika­zao je na šest slucajeva Kaiser i sar. (3). Radilo se o novom radiološkom znaku discus herniae, koja je kasnije operativno bila potvrdena. Ovaj znak je indetificiran na visokoj rezoluciji »scout views« lumbalne kicme kao koštani defekt donjeg posteriornog ugla odgovarajuceg pršljena, i na­den je kao indikacija za postereiornu discus herniu. Najcešce se susre6e na LJL5 i US nivoima. Autori nisu mogli identificirati ovaj znak na konvencionalnim x-zracnim filmovima kod pa­cijenata gdje su topogrami (»scout views«) i aksijalni skenovi bili definitivno pozitivni. Stoga su zakljucili da ista pojava može biti vizuelizirana standardnim radiogramima jedino u prisustvu velike rubne avulzije. Gubitak zapremine diska pri 6emu dolazi do smanjenja njegovog vertikalnog promjera samo za 0,7 mm utice na pojacano optercenje u apofiz­nom zglobu, osobito kod osoba sa izraženom lordozom. Debevc (1) je primjetio da stopa opterecenja US diskusa ovisi o njegovoj inklina­ciji koja uslovljava US lordozu. Ako je inklinacija ve6a manje je optere6enje diskusa. Nagorni (4) je konstatovao da je »shear« naprezanje najvece na US segmentu, što je i objašnjenje za najceš6e diskalne rupture kojima ne prethodi diskalna degeneracija. Diskalne rup­ture se mogu prevenisati pove6anjem lumbalrie lordoze. Ovo su neka objašnjnja zašto se u našoj studiji susre6e veca US lordoza kod ispitanika sa pato­loškim procesom. Odnosno, pošto je ravnoteža vertebralnog dinamskog segmenta kod ovih ispi­tanika poreme6ena pove6ano je optere6enje na Radiol lugosl 1990; 24:209-13. <'i gi .., "' o o, o, Tabela 1 -Vrijednost parametra trupa petog lumbalnog kralješnjaka na laterarnim tomogramima Tabela 1 -Value of the fifth lumbar body parameters on lateral tomograms ISPITIVNI PARAMETRI STATISTICKI PARAMETRI (STATISTICAL PARAMETARS) VRIJEDNOST t-TESTA 1 . KOMPJUTERIZIRANE GRUPE SIGNIFIKANTNOST RAZLIKA "" TOMOGRAFIJE ISPITANIKA 1JROJ ARITMETICKA STANDARDNA STANDARDNA IZME0U GRUPA ISPITANIKA Q) -"' (EXAMINATED (PATIENT'S ISPITANIKA SREDINA (MM) DEVIJACIJA GREŠKA PARAMETARS OF CT) GROUPES) (NUMBER OF (ARITHMETIC (STANDARD (STANDARD 8' C: ni LJ E .2 (VALU ES OF t-TEST AND SIGNIFICANT DIFFERENCES PATIENTS) MEAN (MM) DEVIATION) ERROR) BETWEN GROUPES OF PATIENTS I ANTERIORNA VISINA SA PATOLOGIJOM TRUPA L5 KRALJEŠKA (A) (WITH PATHOLOGY) n x a a, 26,88 2,82 0,44 1=2,0210 RAZLIKE SU SIGNIFIKANTNE "' (ANTERIOR HEIGHT OF L5 BEZ PATOLOGIJE (DIFFERENCES ARE SIGNIFICANT) a. s i;j "" C. POSTERIORNA VISINA SA PATOLOGIJOM 26 25,58 2,14 0,42 VERTEBRAE BODY (A)) (WITHOUT PATHOLOGY) (p<0,05) :;;; "" 22,44 2,81 0,44 RAZLIKE VISOKO SIGNIFIKANTNE TRUPA L5 KRALJEŠKA (P) (WITH PATOLOGY) o o 'o (POSTERIOR HEIGHT OF BEZ PATOLOGIJE (DIFFERENCES ARE HIGH SIGNIFICANT) "' 26 24,31 2,16 0,42 a: L5 VERTEBRAE BODY (P)) (WITHOUT PATHOLOGY) (p<0,01) 1=2,8776 ni ;; SUPERIORNA DUBINA SA PATOLOGIJOM t=0,3073 42 34,45 2,80 0,43 "' TRUPA L5 KRALJEŠKA (S) (WITH PATHOLOGY) RAZLIKE NISU SIGNIFIKANTNE "' ·;; (SUPERIOR DEPTH OF L5 BEZ PATOLOGIJE (DIFFERENCES ARE NOT SIGNIFICANT) o 26 34,23 3,02 0,59 C: VERTEBRAE BODY (S)) (WITHOUT PATHOLOGY) INFERIORNA DUBINA SA PATOLOGIJOM 1=1,7112 41 32,63 3,36 0,52 TRUPA L5 KRALJEŠKA (1) (WITH PATHOLOGY) RAZLIKE NISU SIGNIFIKANTNE ZA (INFERIOR DEPTH OF L5 BEZ PATOLOGIJE p<0,05 ALI SU SIGNIFIKANTNE ZA 26 34,15 3,83 0,75 VERTEBRAE BODY (1)) (WITHOUT PATHOLOGY) p<0, 1 O (0,053gy SCIENTIFIC PROGRAMME: -EPIOEMIOLOGY ANO VIROLOGY OF BURKITT-LIKE L YM­PHOMA -PATHOLOGY ANO IMMUNOLOGY OF BURKITT-LIKE LYM­PHOMA -SYMPTOMATOLOGY ANO OIAGNOSTICS OF BURKITT-LIKE LYPHOMA -SPECIAL LECTURE: IMMUNITY IN MALIGNANCIES -POSTER PRESENTATIONS ANO A SERIES OF SHORT LECTU­RES FROM INSTITUTIONS, CLINICS ANO WORKING GROUPS WITH EXPERIENCE IN OIAGNOSTICS ANO TREATMENT OF BUR­KITT-LIKE L YMPHOMA -CLOSING LECTURE: PRESENT STATUS ANO TREATMENT OF BURKITT LIKE L YMPHOMA lnformation and registration: BLL Organizing Committee, Ms. Olga Shrestha, Institute of Oncology, Zaloška 2, 61000 Ljubljana, Yugosla­via. Tei 061-327 955 KLINICKA BOLNICA »DR M STOJANOVIC:«, ZAGREB ZAVOD ZA RADIOLOGIJU I ONKOLOGIJU DUPLIKACIJA ŽUCNOG MJEHURA DUPLICATION OF THE GALL-BLADDER Zamberlin R, Smolcic S, Bedek D Abstract -The authors report on a new case of gall-bladder duplication and their experiences in the diagnosis of gall-bladder anomalies (double gall-bladder and duplication) so far. The double gall-bladder anomalies and duplications were researched at our institution from June 1951 to June 1988. In that period 39000 patients were examined. Totally, 16 anomalies of the gall-bladder were diagnosed (10 double gall-bladders and 6 duplications), i. e. 1 per 2500, or 0.04%. In the literature the rate of 1 per 4000, or 0.02% is stated. The data show that the frequency of these anomalies is twice as large as that described by other authors. UDC: 616.366--007.256 Key words: gallbladder-abnormalities Case report Radlol lugosl 1990; 24:215-7. Uvod -Anomalije dvostrukog žucnog mjehura i mjehura svrstava u dvostruke holeciste i dijeli ih duplikacije su rijetke kongenitalne anomalije kod u tri skupine (slika 1 ). ljudi. Prvu duplikaciju žucnog mjehura opisao je Plinije 31. godine prije naše ere, a holecistog­ rafski ju je dijagnosticirao i opisao Climan 1929. godine. 1956. godine Antoine sa suradnicima opisuje 97 slucajeva, a najnoviji podaci u stranoj literaturi spominju 150 slucajeva dvostrukih holecista (1,2,3). Patoanatomske i kirurške statistike utvrdenih dvostrukih žucnih mjehura su znatno skromnije od gore spomenutih zbirnih podataka, i iznose svega 32 slucaja ove anomalije. U našoj litetaturi malo je pisano o ovim anomalijama. Naš patolog Kneževic je na 22 -godišnjem patoanatomskom materijalu opisao svega jedan slucaj. 1960. godine Softic u statis­ Slika 1 -Duplikacije žucnog mjehura prema Boydenu tickoj obradi anomalija žucnog mjehura navodi a -Duplikacija žucnog mjehura -1 cistikus dva slucaja dvostruke holeciste (4). Do ovog b -Dvostruki žucni mjehur -2 cistikusa s spajaju najnovijeg slucaja na našem Zavodu je do sada u formi slova Y pred utjecanjem u holedokus c -Dvostruki žucni mjehur -2 cistikusa se odva­ dijagnosticirano ukupno 15 slucajeva ovih jeno ulijevaju u holedokus u formi slova H anomalija (2,3). Fig. 1 -Gall-bladder duplication according to Boyden a -Gall-bladder duplication -one cystic duet Djsproporcije u zbirnim te patoanatomskim i b -Double gall-bladder -two cystic ducts are kirurškim statistikama dosad objavljenih forming Y before pouring into the bile duet slucajeva uvjetovane su neslaganjem autora u c -Double gall-bladder -two cystic ducts pourig nazivu anomalija. Boyden duplikaciju žucnog into the bile duet separately, forming H Received: December 16, 1988 -Accepted: March 29, 1990 Zamberlin R et al. Duplikacija žucnog mjehura U skupinu a Boyden u dvostruku holecistu ukljucuje duplikaciju žucnog mjehura, gdje ne dolazi do kompletine podjele holeciste na dvije odvojene žucne vrecice. U ovim slucajevima žucni mjehur je podijeljen longitudinarnim sep­tumom. Septum može zahvatiti samo fundus -parcijalna podjela -ili holecistu do njenog vrata -potpuna podjela -, u oba slucaja jedan cistikus se ulijeva u holedokus. Boyden razlikuje dvije vrste potpuno odvojenog žucnog mjehura: tip Y (slika 1 b), kada se dva cistikusa spajaju poput slova Y pred utok u holedokus, i tip H (slika 1 c), kod kojeg se cistikusi odvojeno ulijevaju u holedokus (1,2). Autori koji se ne slažu sa Boydenom (Ramberg, Katunari6) duplikaciju žu­cnog mjehura nazivaju holecista bilobata, dup­likacija žucnog mjehura ili lažna dvostruka holecista, a kao prave dvostruke holeciste smat­raju one gdje postoje dva potpuno odvojena žucna mjehura sa odvojenim cistikusima (2,3). Materija! i metode -U tridesetsedmogodišn­jem razdoblju izvršili smo 39000 pregleda što iznosi oko 1050 pregleda godišnje. Naša dijag­nostika zasnivala se na rentgenskim metodama pretrage, peroralne holecistografije i intravenske i infuzijske holangioholecistografije. Pretrage smo radili kod odraslih osoba uz primjenu op­timalnih položaja pacijenta sa slikanjem pod kon­trolom TV -ekrana. Rezultati i diskusija -Napravljeno je 39000 radioloških pregleda bilijarnog trakta i nadeno ukupno 16 anomalija žucnog mjehura, i to 1 O pravih dvostrukih žucnih mjehura i 6 duplikacija. Posljednji slucaj duplikacije dijagnosticirali smo 1988. godine i njega prikazujemo (slika 2a). U opisanim anomalijama žucnog mjehura vrlo cesto se mogu naci konkrementi, a Alfredo je opisao slucaj sa nadenim parazitom oxiurisom (1,2). Stijenka žucnog mjehura kod ovih anomalija može biti obložena vapnom (por­celanski žucni . mjehur), u pravilu kod ovih anomalija nalazimo i hipokinetsku diskineziju (slika 2b). Simptomatologija dvostruke holeciste ovisi o popratnim pojavama i eventualnim ud­ruženim malformacijama. U diferencijalnoj dijag­nozi dolaze u obzir divertikli žucnog mjehura, višestruki septumi, a ova anomalija se najcešce zamjenjuje sa presavijenim žucnim mjehurom (slika 3). Slika 2 -Naš slucaj duplikacije žucnog mjehura a -2ucni mjehur prije podražajnog obroka b -2ucni mjehur nakan pocjražajnog obroka Fig. 2 -Our case of gall-bladder duplicat1on a -Gall-bladder before excitatory meal b -Gall-bladder after excitatory meal Zakljucak -Dvostruke holeciste i duplikacije žucnog mjeh'ura su vrlo rijetke anomalije kod covjeka. Na našem Zavodu smo do sada dijag­nosticirali ukupno 16 ovih anomalija, od toga 1 O pravih dvostrukih žucnih mjehura i 6 duplikacija, što iznosi 0,04% s omjerom 1 :2500 a što je Aadiol lugosl 1990; 24:215-7. Zamberlin R et al. Duplikacija žucnog mjehura Slika 3 -Presavijenbi žucni mjehur koji imitira duplika­ ciju, a u kome se vidi manji konkrement Fig. 3 -Bent gall-bladder that imitates duplication, with a minor gall-stone in it skoro dvostruko više od statistickih podataka iznesenih u dostupnoj literaturi od 0,02% s om­jerom 1 :4000. Dijagnostiku duplikacija i dvostrukog žucnog mjehura izvodili smo rentgenskim metodama pre­trage, pregledanim i ciljanim snimkama u raz­licitim položajima te tomografskom obradom. Ove rijetke anomalije imaju klinicko i prakticno znacenje, jer su redovito popracene ili pred­stavljaju podlogu za druge patološke promjene žucnog mjehura, diskinezije, konkremente, por­celanski žucni mjehur itd, a mogu biti udružene sa drugim kongenitalnim anomalijama. Sažetak Autori iznose novi slucaj duplikacije žucnog mjehura, te iskustva u dosadašnjoj dijagnostici anomalija žucnog mjehura (dvostruke holeciste i duplikacije). Anomalije dvostruke holeciste i duplikacije prate se na našem Zavodu od lipnja 1951. godine do lipnja 1988. godine. U tom razdoblju pregledano je 39000 pacijenata i dijagnosticirano ukupno 16 anomalija (1 O dvostrukih žucnih mjehura i 6 dupliakcija), što iznosi 1 anomalija na 2500 pacijenata ili 0,04% a u literaturi je naveden podatak od 1 slucaj na 4000 pacijenata ili 0,02%. Ovi podaci nam govore da su anomalije žucnog mjehura (dvostruke holeciste i duplikacije) skoro dvos­truko ucestalije kod pregledanih na našem Zavodu, nego u opisu drugih autora. Li teratura 1. Boyden EA. The anomalies of the gall bladder. Am J Anat 1926; 38 : 177. 2. Katunaric D. Rentgenska simptomatologija dvo­struke holeciste. Acta med lug 1974; 28 : 161-76. 3. Katunaric D. Slucaj dvostruke holeciste. Anali Boin »dr M. Stoj.« 1963; suppl 2 : 19. 4. Softic N. Statisticka obrada anomalija žucnog mjehura. Lij vjesn 1960; 82 : 583. Adresa autora: Dr Ratko Zamberlin, Zavod za radiologiju i onkologiju Klinicke bolnice »Dr M Stojanovic«, Vinogradska cesta 29, 41000 Zagreb 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 Radio/ /ugasi 1990; 24 :215-7. II. SIMPOZIJ PEDIJATRIJSKE JUGOSLAVENSKE RADIOLOGIJE BEOGRAD, 2-3. XI 1990 god. Obaveštavamo Vas, da ce se u Beogradu održati u Institutu za majku i dete SR Srbije, Radoje Dakica 6, na Novam Beogradu 11070, sa pocetkom u 9,30h , Simpozij cija je vodeca tema: 1. DIGESTIVNI TRAKT NOVOROfJENE BEBE, PREDŠKOLSKOG I ŠKOL­SKOG DETETA 2. S/obodne teme mogu obuhvatiti sva podrucja decje radiologije u trajanju od 8 min. 3. DISKUSIJA OKO OKRUGLOG STOLA: Kakav je kvalitet rendgenskog filma potreban da bi dete dobilo minimalnu zracnu dozu, kao i snimak dobrog kvaliteta ? Mole se ucesnici da se za sve informacije obrate sekretaru Pedijatrijsko radiološke sekcije Jugoslavije (tel. O 11-603-022, lok. 38, Doc. Dr Pravdoljub Komar, Decja radiologija). Sa kolegijalnim pozdravom Predsednik Sekcije za Jugoslovensku Sekretar Sekcije pedijatrijsku radiologiju Doc. Dr Pravdoljub Komar, dr med. Prof. Dr Nada Grivceva-Janoševic, dr med. SPONZOR: EI NIŠ KLINICKI BOLNICKI CENTAR -REBRO MEDICINSKI FAKULTET U ZAGREBU ZAVOD ZA RADIOLOGIJU DIVERTIKULI REKTUMA DIVERTICULA OF THE RECTUM Frkovic M, Mandic A Abstract -Rectal diverticula are rare. We have found them in three patients (0.95%) with diverticular disease of the colon. Rectal diverticula are not of great clinical importance, except in the cases when complicated with inflammation, perforation or malignant alteration. In such cases rectal diverticula can cause some differential diagnostic problems. lrigoradiography with double contrast is the diagnostic method of choice in the demonstration of rectal diverticula. UDC: 616.351-007.64 Key words: diverticulosis colonic, rectal diseases Case report Radiol lugosl 1990; 24:219-22. Uvod -lako prvi opisi divertikuloze kolona potjecu od Littrea i Frienda (3) s pocetka 18. stoljeca, tek u zadnja tri desetljeca javljaju se prvi prikazi slucajeva rektalne divertikuloze (1,3,5,9). No, još uvijek neki autori (4,7) tvrde da se divertikuli rektuma nikad ne javljaju. O etiologiji divertikula rektuma postaje razlicite pretpostavke. Smatra se da najvjerojatnije na­staju kao posljedica prirodene insuficijencije sti­jenke rektuma uz moguce dodatne cinitelje, kao što su atrofija mišicnih dijelova stijenke, odsut­nost potpornih struktura (coccigis), fokalno postu­palno ili posttraumatsko slabljenje stijenke rektu­ma, nepravilnosti intraluminalnog tlaka (1,9). Nalaz divertikula rektuma relativno je malog klinickog znacenja, izuzev ako se komplicira upalom, perforacijam ili mogucom malignom alte­racijom. 1 tada su eventualne komplikacije manje rizicne od komplikacija divertikula intraperitoneal­nih dijelova kolona. Jedini opis bolesnika s perfo­racijam divertikula rektuma dao je Kurten 1971. godine (2). Metoda i bolesnici -U razdoblju od 1986. do 1989. godine metodam irigoradiografije s dvo­strukim kontrastom pregledali smo 2292 bolesni­ka. Medu njima identificirali smo 316 (13,8 % ) bolesnika s divertikuloznom bolešcu kolona, i to 159 (50,3 %) žena i 141 (49,7 %) muškaraca u dobi od 19 do 86 godina. U troje (0,95 %) bolesnika s divertikuloznom bolešcu kolona našli smo divertikule rektuma. A.F., muškarac, 63 godine. Na irigoradiografiju je upucen zbog recidivirajucih, povremeno grcevi­tih bolova u donjem lijevom hemiabdomenu. Zbog duodenalnog ulkusa lijeci se vec 7 godina, a pati od kronicne opstipacije. Oskudne tragove krvi u stolici primijetio je u dva navrata u skorije vrijeme. Na rektosigmoidoskopiji evidentirana je divertikulozna bolest, nema posebnog osvrta na divertikule rektuma. Pri irigoradiografiji prikazan je rektum u cijelosti uži, a na njegovoj ventralnoj i lijevoj lateralnoj konturi vide se kontrastom ispunjeni divertikuli promjera 25 do 30 mm (slika 1 a, 1 b). Brojni divertikuli, naznaceno suženje lumena, haustreole, vidljivi su u podrucju sigme, a nekoliko divertikula velicine do 15 mm nalazi se i u proksimalnim dijelovima kolona. Ž.K., muškarac, 57 godina. U anamnezi nema simptoma za bolesti debelog crijeva. Na irigora­diografiju je upucen s ciljem da se nade lokaliza­cija primarnog malignog procesa, buduci da su ultrazvukom i kompjutoriziranom tomografijam jetre identificirani multipli hipoehogeni, odnosno Received: March 29, 1990 -Accepted: June 1, 1990 Frkovi6 M, Mandi6 A. Divertikuli rektuma hopodenzni, žarišni procesi, metastaze. lrigografskim pregledom evidentira se diverti­kulozna bolest sigme i prikaže divertikul na desnoj konturi rektuma velicine 15 mm (slika 2). Nije naden maligni proces kolona. Slika 1 a -Pri prealedu bariievom kontrastnem klizmom prikazala su se dva rektalna divertikula. Fig 1 a -Barium enema film demonstrates two rectal diverticula V.B., žena, 49 godina. Zbog upala dermoidnih cista sakralne regije operirana je 1977. i 1986. godine. U veljaci 1989. godine operirana je zbog ciste desnog ovarija. Osam mjeseci potom dolazi zbog boli uz rektum, posebno intenzivnih prilikom Slika 2 -Divertikul rektuma Fig 2 -Diverticulum of the rectum sjedenja uz povremene septicne temperature. U fizikalnom nalazu dominira opsežno, inflamirano podrucje sakrokokcigealne regije s obilnom seropurulentnom sekrecijom. Digitorektalni je pregled bolan, a u Douglasovu prostoru pipa se tvorba velicine muške šake. Na rendgenogramu sakrokokcigealnog seg­menta kralješnice vidljiva je demineralizacija do gotov@ potpunog brisanja koštane strukture kok­cigisa. Kompjutorizirana tomografija opisuje cis­ticnu ekspanziju ovarija koja imprimira rektum sprijeda ( !). Rektroskopski se na 2 cm od anokutane granice, na 12 sati, vidi otvor promjera 1 cm kroz koji se može uci u retrorektalnu cisticnu šupljinu. Endoskopicar smatra da je ovaj nalaz posljedica jatrogene fenestracije retrorektalne ciste. Nema znakova upalne reakcije sluznice rektuma ( ! ?). lrigografski je nalaz impresivan. Neposredno iznad analnog kanala, kroz vrat širine oko 2 cm u kojem se prate sluznicki nabori, kontrastnom klizmom puni se orijaški divertikul, promjera oko 7 cm. On je utisnut u retrorektalnom prostoru i rektum potiskuje ventralno. Konture su divertikula pravilne, a njegova se velicina mijenja pri prom­jeni intraabdominalnog tlaka (slika 3 a, b). Zbog neadekvatnog odgovora na konzer­vativnu terapiju ponovno je indiciran operativni zahvat inflamiranih dermoidnih cista sakrokok­cigealne regije. U ranom postoperativnom toku u Radiol lugosl 1990; 24:219-22. Frkovic M, Mandic A. Divertikuli rektuma složiti buduci da smo u vlastitoj praksi našli tri bolesnika s divertikulima rektuma i njih smo prikazali u ovom radu. Ova tri bolesnika cine približno 1 % u grupi bolesnika u kojih smo evidentirali diveretikuloznu bolest kolona, od­nosno O, 13 % svih bolesnika kojima smo ucinili irigografiju. lspitivanjima na slicno definiranom uzorku bolesnika Walstad (9) prezentira rezultate da se divertikuli rektuma javljaju u približno 0,08 % bolesnika kojima je ucinjena irigografija, od­nosno u 2 % bolesnika s divertikuloznom bolešcu , crijeva. Isti autor daje prikaz bolesnika s dvama t divertikulima rektuma, dosad, prema dostupnoj nam literaturi, jedini takav slucaj. Naš bolesnik A. F. ima dva divertikula rektuma. Slika 3 -Orijaški divertikul rektuma ciia se velicina Rezultate slicne Walstadovim, da je ucestalost mijenja pri promjeni intraabdominalnog tlaka a) u maksimalnom ekspiriju rektalnih divertikula 2,4 % (prikaz 4 slucaja), dali . b) u maksimalnom inspiriiu su još 1927. godine Spriggs i Marxer (9). Fig 3 -Gigantic diverticulum of the rectum whose size Kolika je stvarna incidencija dLvertikula rek­tuma, teško je utvrditi, buduci da se najcešce a) on max. expiration radi o sporadicnim, pojedinacnim slucajevima ili b) on max. inspiration o vrlo malom uzorku bolesnika, bez zakonitosti u pojavljivanju. Stoga, u naprijed iznesenim operativnom polju pojavila se sterkoralna fistula. podacima vidljive manje statisticke razlike ne Potvrdena je kontrolnom irigoradiografijom kao smatramo signifikantnima. Takoder, u ovako komunikacijama izmedu stražnjeg zida diver­malom uzorku neprimjereno je govoriti o dis­tikula rektuma i interglutealne regije-jatrogena tribuciji bolesnika po spolu. S obzirom na dob lezija (slika 4). Bolesnica je u daljnjem kirurškom bolesnika, 49 -63 godine, možemo napomenuti tretmanu. da su sva tri naša bolesnika u dobi kada je i inace najveca incidencija divertikulozne bolesti Rasprava i zakljucak -Da su divertikuli rek­kolona. turna doista rijetki, govori podatak da u literaturi Divertikuli rektuma najcešce su pravi (1 ), re­ nalazimo malo izvještaja o njihovom pojavljivanju dovito veci od divertikula na proksimalnim di­ (1,3,6,9). Dapace, neki autori iznose posve op­jelovima kolona, a kao etiološki uzrok njihovog recnu tvrdnju: da se divertikuli rektuma nikad ne nastanka možemo smatrati sve one cinitelje koji javljaju (4,7). S posljednjim se teško možemo dovode do slabljenja stijenke rektuma. U radiološkoj dijagnostici divertikuli rektuma, ako nisu komplicirani upalom, krvarenjem ili ::, . 1 eventualnom malignom alteracijom (2,3,8) ne cine znacajnijih diferencijalnodijagnostickih . poteškoca. Osim spomenutih mogucih 1 komplikacija, dodajemo i vlastitu iskustvenu im­plikaciju -valja paziti da se divertikul rektuma ne zamijeni eventualnom cistom ili apscesom spontano ili jatrogeno fenestriranim u rektum. Smatramo da je metoda izbora u dijagnostici rektalnih divertikula, kao i uopce u dijagnostici patoloških stanja kolona, korektno izvedena irigo­radiografija s dvostrukim kontrastom. Sažetak Divertikuli rektuma su rijetki. Našli smo ih utri (0,95%) bolesnika s divertikuloznom bolešcu kolona. Nemaju vece klinicko znacenje, izuzev u slucajevima kada se kompliciraju upalom, perforacijam ili malignom alteraci- Radiol lugosl 1990; 24:219-22. 221 Frkovic M, Mandic A. Divertikuli rektuma jom. Tada mogu uzrokovati i vece ili manje diferencijal­nodijagnosticke poteškoce. U pravilu se dokazuju irigo­radiografijom, metodam dvostrukog kontrasta. Literatura 1. Halpert RD, Crnkovich FM and Schreiber MH: Rectal Diverticulosis: A Case Report and Review of the Literature.Gastrointest Radiol 1984; 1989. 14:274. Ra­diol 1984; 14:274-6 2. KOrten -Rothes R: Perforation eines extraperito­nealen Rektumdivertikels bei einem Kontrasteinlauf. Ri:ifo 1967; 106:155-7. 3. Kyaw MM and Haines JO: Rectal Diverticula. Radiology 1971 ; 100 :283-4. 4. Mann CV: Problems of the diverticulae disease. Proctology 1979; 1 :20-5. 5. Mayo WJ: Diverticula of surgery. Surgery 1930; 92:739-43. 6. Mcllwain AJ: Acquired diverticulum of the rectum. JMissAssoc 1968; 9:362. 7. Morson BC: Muscle abnormality in diverticular disease of sigmoid colon. Brit J Radiology 1963; 36:393-406. 8. Tweddell TN: Diverticulitis of the rectum. Canad MAJ 1954; 70:569. 9. Walstad PM, Sahibzada AR: Diverticula of the rectum. Dis Colon Rectum 1959; 2:458-64. Adresa autora: Dr. Marija Frkovic, mr. sci, Zavod za radiologi ju Rebro, Klinicki bolnicki centar Zagreb 41000 Zagreb, Kišpaticeva 12 "".'i>.,_P" coL00"1 k: 1:;:i:.. . (,.4 l'xJ . 'L" C [j C) ,--, ii!: '" o 7,. & \9--,2: . <;)./ti CJ[l 3 C \­ UDRU:Ž:ENJE KANCEROLOGA JUGOSLAVIJE organizira VIII. KONGRES KANCEROLOGA JUGOSLAVIJE s medunarodnim sudjelovaniem Zagreb, 9.-11. svibnJa 1991. godine S ..-f;KA,t,. f t . r :::: o 7 . 'Yp r::-,. ;-<'llr''JSOO Za sve ostale informacije obratiti se na adresu: Dr Branko Malenica Središnji institut za tumore i slicne bolesti 41000 Zagreb, !lica 197 Radiol lugosl 1990; 24 :219-22. UNIVERZITETSKI KLINICKI CENTAR U BEOGRADU INSTITUT ZA ENDOKRINOLOGIJU, DIJABETES I BOLESTI METABOLIZMA KLINICKO-BOLNICKI CENTAR ZEMUN ODELJENJE ZA RENDGENOLOŠKU DIJAGNOSTIKU MEDICINSKI CENTAR BOSILEGRAD RENDGENOLOŠKA SLUL'.BA KARLICA OTT.HROBAK OTTO--CHROBAK PEL VIS Goldner B, Dodic M, Penev B Abstract -The term Otto--Chrobak pelvis was first used to describe bilateral acetabular protrusion as a late complication of the rheumatoid arthritis. However, this type of pelvic deformity may be a congenital or developmental abnormality, and may be encountered in numerous acquired diseases such as: acute or chronic osteoarthritis, deforming osteoarthrosis, ankylosing spondylitis, osteomalatia and rickets,-Paget's disease, involl.ltive osteoporosis or may be ofJraumatic origin. Hyperthyroidism and hemophilia coul. also be added to the presen! list of possible causes of this condition. Pertinent radiographic findings of some diseases, including two new causes which may be responsibile for bilateral acetabular protrusion, are rewieved. Key words: acetabulum, osteoarthritis hip UDC:616.718.16-007.57 Review article Radiol lugosl 1990; 24:223-5. Uvod -Obostrana protruzija acetabuluma je retka urodena ili stecena deformacija kukova, koja nastaje zbog razlicitih patoloških procesa cije je primarno sedište u acetabulumu ili njego­voj okolini (1,2,3). Prvobitan opis obostrane protruzije acetabu­luma koji se odnosio na komplikaciju reumatoid­nog artritisa poznatu kao karlice Otto--Chrobak ili arthocatadysis, vremenom je proširen na niz patoloških stanja i oboljenja koja u osnovi me­njaju strukturu acetabuluma i susednih kostiju. Do sada su u literaturi opisani: akutni i hronicni osteoartritis, deformišuca osteoartroza, ankilozi­rajuci spondilitis, osteomalacija i rahit, Pagetova bolest, involutivna osteoporoza i traume (1,3). Cilj ovog saopštenja je rendgenografski prikaz nekih patoloških procesa, od kojih se primarni hiperparatiroidzam i hemofilija po prvi put uklju­cuju kao moguci uzroci obostrane protruzije. Materija! i metode -U toku višegodišnjeg bavljenja koštanozglobnom patologijom, izdva­jani su i klasifikovani rendgenogrami pojedinih manje ili više zastupljenih entiteta iz raznovrsne politicko-stacionare populacije bolesnika. Odatle poticu i rendgenski snimci patoloških karlica tipa Otto-Chrobak koje u ovom radu prikazujemo. Rezultati -Od brojnih rendgenskih snimaka karlica, na kojima se uz osnovnu, najcešce pre­poznatljivu bolest nalazi i obostrana protruzija acetabuluma, zbog skucenosti prostora prikazu­jemo samo cetiri slucaja redih patoloških pre­mena koje za ishod imaju karlicu Otto-Chrobak. Morbus Paget sa karakteristicnim distrofic­nim premenama na karlicnim kostima u kojima se preplicu polja poroze, hipertroficne atrofije i skleroze, zbog razmekšanja i patološke pregrad­nje, ima za posledicu obostranu protruziju aceta­buluma ( slika 1 ). U osteomalaciji karlica trpi najvece premene, pa je uz generalizovanu demineralizaciju kostura u celini, cest nalaz deformisane karlice tipa Otto­Chrobak (slika 2). Primarni hiperparatiroidizam slicno kao kod osteomalacije strukturalno menja i deformiše kar­licu. Pored nalaza izmenjenog oblika karlice sa slikom »srca u kartama« moguca je protruzija acetabuluma sa glavama butnih kostiju (slika 3). Osteoarthrosis haemophilica takode može da bude uzrok obostrane protruzije acetabuluma, bilo da su premene samo u zglobovima kukova Received: May 15, 1989 -Accepted: April 16, 1990 Goldner B et al. Karlica Otto-Chrobak Slika 1 -Deformisana karlica u Pagetovoj bolesti. Obostarna protruzija acetabulama i superacetabularno polje skleroticne kosti. Ostaci kontrastnog sredstva u spinalnom kanalu posle mijelografije Fig. 1 -Deformed pelvis in Paget's disease. Bilateral acetabular protrusion and supraacetabular areas of osseous sclerosis. The remnants of contrast medium in the spina! channel after a myelography Slika 3 -Snimak karlioo u bolesnika sa primarnim hiperparatiroidizmom. Asimetricna, deformisana karlica sa izrazitom osteoporozam, obostranom protruzijom acetabulama i patološkim frakturama na ishijadicnim kostima Fig.3 -An X-ray film of the pelvis in a patient with primary hyperparathyroidism. Asimmetrical and defor­med pelvis with severe osteoporosis, bilateral acetabu­lar protrusion and pathological fractures in the ischiadic bones Slika 2 -Osteomalaticna karlica sa obostranom protru­zijom acetabulama, simetricnim pseudofrakturama (Looserove zone) na gornjim granama pubicnih kostiju i pubicno-ishijadicnim spojevima (strelice) Fig. 2 -Osteomalatic pelvis with bilateral acetabular protrusion and symmetrical pseudofractures (Looser's zones) in the superior public ramus and ischio-public junctions (arrows) ili da se uz njih nalaze opsežna razaranja u susednim delovima karlice (slika 4). Diskusija -Prikazani snimci patološko iz­menjenih karlica ukazuju na promene koje su uslovile obostranu protruziju acetabuluma, a ciji je zajednicki supstrat: gubitak koštane mase i strukturne promene u acetabulumu i susednim kostima karlice. Primarni proces postupno razara koštano dno acetabuluma a potom i polumeseca­stu zglobnu hrskavicu u njemu. Koštano dno acetabuluma nestaje, a glave butnih kostiju gu­beci cvrsto uporište se utiskuju u zaostalu ve­zivnu opnu dna put unutra u šupljinu karlice. Acetabulum se ne širi vec produbljuje pomerajuci granicu preko terminalne linije. Na utisnutoj ve­zivnoj opni se stvara nova kost oblikujuci novi acetabulum skleroticnog dna. Kohlerova figura suze ili kapi koja se sa dna normalnog acetabu­luma pruža medijalno i kaudalno kao ovoidna transparencija, kod protruzije se deformiše i gubi (3). Na spoljnjem rubu acetabuluma se stvaraju osteofiti. Zglobni prostor kuka se sužava i defor­miše. Glave butnih kostiju mogu da izmene oblik, Aadiol lugosl 1990; 24:223-5. Goldner B et al. Karlica Otto-Chrobak Slika 4 -Karlica Otto-Chrobak u bolesnika sa hemofili­jom A. Obostrana protruzija acetabuluma i koštane ankiloze koksofemoralnih zglobova. Opsežan hemofi­licni pseudotumor u levom glutealnom delu prouzroko­ vao je ekstenzivnu osteolizu leve ilijacne kosti. Fig. 4 -Otto-Chrobak pelvis in a patient with hemophi­lia A. Bilateral acetabular protrusion and osseous anky­losis in the coxofemoral joints. A voluminous gluteal hemophylic pseudotumor with extensive osteolysis of left iliac bone. da se spljošte bilo zbog opšte razmekšalosti skeleta i mehanickog pritiska ili zbog uzura na zglobnoj površini glave (4). Ankiloza nije pravilo, s napomenom da se kod reumatoidnog artritisa nikada ne razvija. Vratovi butnih kostiju mogu da slede pramene u glavama, acetabulima i sused­nim kostima karlice ili da se deformišu zbog gubitka mineralnog sadržaja a u sklopu osnovne bolesti. Oni se svijaju i poprecno postavljaju gradeci sa glavama butnih kostiju poznatu sliku »pastirskih štapova«. Obostrana protruzija acetabuluma je retko posledica traume. Cešci je jednostrani nalaz tzv. centralne luksacione frakture kod koje glava fe­mura probije dno acetabuluma i zadje u karlicu. Anamnezni podaci o traumi rešavaju dijagnozu. Sažetak Naziv karlice Otto-Chrobak prvi je put upotrebljen da oznaci obostranu protruziju acetabulama i glava femura u karlicu kod slucajeva sa hronicnim reumatoid­nim artritisom. Medutim, ovakav tip deformacije karlice može da bude urocen ili razvojni poremecaj, da se nade u brojnim slecenim oboljenjima kao: akutni ili hronicni osteoartritis, deformirajuca osteoartroza,anki­lozirajuci spondilitis, osteomalacija i rahit, Pagetova bolest, involutivna osteoporoza ili da je traumatskog porekla. Postojecoj listi bolesti mogli bismo da prido­damo još primarni hiperparatiroidizam i hemofiliju kao moguce uzroke. Rendgenografski nalazi koji se odnose na ovakav tip deformacija karlice, ukljucujuci i dva nova uzroka koja mogu da budu odgovorna za obostranu protruziju acetabulama, prikazani su u ovom radu. Literatura 1. Mechan l. Roentgen signs in diagnostic ima­ging. WB Saunders Go, Philadelphia, London, Toronto, 1985; 2(2): 166, 418. 2. Murray RO, Jacobson HG. The radiology of sceletal disorders. Churcil Livingstone, Edinburgh, Lon­don, New York, 1977; 1(2): 652-3. 3. Smokvina M; Klinicka rendgenologija kosti i zglobova. Jugosl Akademija znanosti i umjetnosti, Za­greb, 1959; 250: 415-7. 4. Kicevac-Miljkovic A, L'.ivkovic M: Radiološki atlas reumaticnih bolesti. Univerzitet »Veljko Vlahovic« Titograd, 1984; 17-37, 57-9. Adresa autora: Doc. dr Branislav Goldner, Institut za endokrinologiju, dijabetes i bolesti metabolizma, rendgen odeljenje, dr Subotica 13, 11 000 Beograd. Radiol lugosl 1990; 24:223-5. ZBOR LIJECNIK A HRV ATSKE Podružnica Slav. Brod kao suorganizator, poziva Vas na sudjelovanje u medunarodnom kongresu BUDUCNOST MEDICINE U NOVOJ EVROPI -medicina i obitelj -eticki aspekti - koji ce se održati od 7 -9. IX 1990. u Slavonskom Brodu, kongresni centar »EJuro Salaj«, trg Salvadorea Alendea 12. U organizaciji sudjeluju i: -Svjetska federacija lijecnika koji poštuju ljudski život -Human Lite lnternational iz SAD -Udruženje medicinskih sestara i tehnicara -podružnica Slav. Brod -Obiteljski Centar Slav. Brod Najavljen je veci broj predavaca i sudionika iz zemlje i inozemstva. Za informacije, program i prijave, obratite se na: Obiteljski Centar, Kumiciceva 16, 55000 Slavonski Brod telefoni: -055/ 235-658 -055/ 234-859 -055/ 235-690 Kotizacija u iznosu od 200 din. može se uplatiti na adresu: Obiteljski Centar -Marko Majstorovic, Kumiciceva 16, Slav. Brod, žiro racun: 34300-621-16-80700-3084514 ili prilikam dolaska. Za studente i ucenike kotizacija iznosi 50 din. Uz hotelski smještaj, predvida se i besplatni smještaj po obiteljima. Za sve sudionike se osigurava rucak i vecera po vrlo pristupacnim cijenama. DOM ZDRAVLJA »DR VJEKOSLAV STANCIC:« V. GORICA KABINET ZA RADIOLOGIJU OHRONOZA I KALCIFIKATI U ZGLOBNIM HRSKAVICAMA OCHRONOSIS AND CALCIFICATIONS WITHIN THE CARTILAGES OF THE JOINTS Presecki V, Mihordin N Abstract -A oatient with severe skeleta! ochronosis is reoorted. On radiographic examination there was a linear density surrouonding the knee joints. Calcifications within the cartilages and the menisci of the knee joints, as well as cartilages ofshoulder, carpal and other joints and intervertebral discs were found. Pigmentary deposits 'in the skin of the hand and sclerae were seen. Homogentisuria was verified. UDC: 616.72-018.3-003.84 Key words: ochronosis, cartilage articular, chondrocalcinosis Case report Radiol lugosl 1990; 24:227-30. Uvod -Ohronoza je klinicko stanje u kojem dolazi do odlaganja modro-crnog pigmenta u hrskavice, tetive i tkiva u gradi kojih prevladava kolagen (1, 2). Poremecen je katabolizam tiro­zina i fenilalanina u nivou homogentizinske kise­line (HK) (1, 2, 3). Defekt katabolizma je potpun, kolicina HK izlucene u mokraci je u relaciji s kolicinam razgradenih proteina u organizmu. Tkivo jetre bolesnika od ohronoze ne sadrži oksidazu homogentizinske kiseline pa se HK ne katabolizira (1, 2). Dio HK se izluci mokracom a dio se polimerizira i odlaže irverzibilno u kolagen (1, 2, 3). Ta mjesta u histološkom preparatu oboje se oker smede pa otuda potjece ime ohronoza (2, 4). HK prisutna je u mokraci od rodenja. Ohronoza je kompleks simptoma skeletne i ekstraskeletne manifestacije. Klinicki nalaze se sivo--plavkaste mrlje po bjeloocnicama, nepra­vilne pigmentacije kože (cešce dijelovi izloženi svijetlu) a vidljive tetive plavkasto prosijavaju kao i hrskavice uške i nsa. Odlaganje polimerizirane homogentizinske kiseline (PHK) izraženije je u fibrozne prstenove intervertebralnih prostora, sinhondroze, hrska-vice zglobova, traheje i rebara, tetive mišica, ligamente i zglobne kapsule (2, 3, 5, 6). MacKenzie i suradnici našli su histokemijski odlaganje kalcium pirofosfata u ekscidiranim teti­vama bolesnika od ohronoze na mjestima gdje je odložena PHK (6). Odlaganje kalcija u periartiku­larne strukture i fibrozne prstenove intervertebral­nih prostora smatraju kao pokušaj reparacije degenerativne lezije (2, 7, 8). Prikaz bolesnika -Bolesnica J.M. rodena 1924. godine, M.br. 8116/88. Otac je sa 30 godina bolovao od »vode u kaljenima«, teže se kretao zbog bolova u kukovima i kicmi, umro je u 54. godini života od bolesti želuca. Bolesnica unatrag 1 O godi na pati od bo lova u kol jen ima koja joj povremeno oticu, teže se krece. Traume velikih zglobova i kostiju negira. Iz statusa: na dorzumu obih šaka vidljive su sivo--plavkaste mrlje promjera oko 4 cm, koje postaje dulje od tri godine. Mrlje (pigmentacije) slicne boje, ptomjera 2-3 mm vide se po bjelooc­nicama u okolini rožnice. Uške su sivo-plavka­ste. Desno kaljeno je oteceno, patela balotira što upucuje na tekucinu u zglobu kaljena. Received: January 30, 1989 -Accepted April 12, 1990 Presecki V, Mihordin N. Ohronoza i kalcifikati u zglobnim hrskavicama Ucinjeni su radiogrami: torakalnih organa, -mrljaste sjene tvrdoce vapna uz cirkumfe­oba ramena, oba lakta, oba rucna zgloba, kicme­rencije glave oba femura, manifestnije lijevo te u nog stuba, oba zgloba kuka, oba koljena i skoc­sinhondrozi simfize. nih zglobova. Na radiogramima videno je: -kalcificirane hrskavice traheja i glavnih bronha, okoštavanje rebranih hrskavica. -mrljaste sjene tvrdoce vapna uz rub cir­kumferencije glave humerusa i glenoida skapule (u hrskavici) obostrano, manifestnije lijevo. -mrljaste sjene tvrdoce vapna u meniscima oba koljena, uz rub kondila lijevog femura te prugaste sjene u mekim cestima poplitealne fose (zglobna kapsula ?). -na kostima kralješnice videne su pro­mjene deformirajuce spondiloze sa suženim in­tervertebralnim prostorima. U dva interverte­bralna prostora lumbalne kr;alješnice viden je vakuum fenomen. Mrljasto odlaganje vapna u intervertebralnim prostorima svih kralješaka. -mrljaste sjene tvrdoce vapna u hrskavi­cama oba rucna zgloba -artrotske promjene, manje ili više izra­žene su i na ostalim zglobovima sa manjim odlaganjem vapna u zglobne hrskavice. U urinu poslanom u biokemijski laboratorij KBC-a potvrdena je prisutnost homogentizinske kiseline i tirne je potvrdena dijagnoza ohronoze. Slika 1 a i 1 b -Kalcifikacije u mernsc1ma kol jena i poplitealnoj losi Slika 2 -Kalcifikacije u hrskavicama ramenog zgloba Fig. 1 a and 1 b -Calcifications within the knee joint Fig. 2 -Calcifications within the cartilages of the menisci and popliteal fossa shoulder joint Radiol lugosl 1990; 24:227-30. Presecki V, Mihordin N. Ohronoza i kalcifikati u zglobnim hrskavicama , . . . . . .. Slika 3-KalcIfIkac1Je u hrskav,cama karpalnih zglobova Fig. 3 -Calcifications within the cartilages of the carpal joints Diskusija -Bolest je dominantno nasljedna s slabom ekspresijom gena (2, 4) pa je klinicka manifestacija od slucaja do slucaja razlicita, ske­letna i ekstraskeletna. Bolest tijekom života ne pravi smetnje i dijagnosticira se slucajno ili pak kada nastupe komplikacije zbog odlaganja PHK i naglašenog razvoja degenerativnih promjena zglobova i kicmenog stupa u cetvrtom ili petom deceniju života. Nije nam namjera da_ prikazujemo klasicnu radiološku simptomatologiju vec da ukažemo na prisutnost kalcija u hrskavicama zglobova i sin­hondrozama koji kao radiološki znak nije opisi­van. Odlaganje vapna u zglobne hrskavice i meniske koljena »opisuje samo Pomeranz 1941. dok drugi autori ne spominju ... « citat je O'Brien i suradnika iz pregleda svjetske literature (1584­1962) (2). Intenzivno kalcificirane traheobronhalne hr­skavice i hrskavice rebara u drugom i trecem deceniju života našli su u 9 od 11 bolesnika od ohronoze Kolar i suradnici (8). Odlaganje vapna u intervertebralne prostore i periartikularne ve­zivne srukture neki smatraju kao znacajne za radiološku dijagnostiku ohronoze (2, 7, 8). Prisutnost kalcija (kao radiološki relevantan znak) na mjestima gdje se odlaže PHK ima opravdanje u histokemijskom dokazu kalcijum pirofosfata kako su utvrdili MacKenzie i suradnici (6) kod bolesnika od ohronoze. Kod naše bolesnice vjerojatno je ekspresija gena snažna, pa je simptomatologija, skeletna i ekstraskeletna, dobro izražena, osobito odlaga­nje kalcija u hrskavice i vezivo gdje se deponira PHK. Zakljucak -Odlaganje polimerizirane ho­ mogentizinske kiseline u kolagen tjelesnih i zglobnih hrskavica, meniske koljena, tetive, zglobne kapsule i fibrozne strukture interverte­bralnih prostora dovodi do degenerativnih pro­mjena. Odlaganje kalcijum pirofosfata u podrucje deponirane polimerizirane homogentizinske kise­line, za pretpostaviti je, pretstavlja primarni radio­loški znak skeletne ohronoze. Naglašene artrot­ske promjene zglobova, suženi intervertebralni prostori i jaca marnfestna spondiloza najvjerojat­nije su sekundarni. Definitivno postavljanje dijagnoze ohronoze neosporno je dokaz prisutnosti homogentizinske kiseline u mokraci bo lesnika. Sažetak Prikazana je bolesnica sa manifestnom skeletnom ohronozom. Radiografskom metodam pregleda nadene su linearne tvrde sjene u okolini kaljenih zglobova. Kalcifikacije u hrskavicama i meniscima zglobova kolje­na, kao i u hrskavicama ramenih, rucnih i drugih zglobova te intervertebralnim prastarima. Zapaženo je odlaganje pigmenta u kožu šaka i bjeloocnice. Homo­gentizurija je bila dokazana. Literatura 1. Galdston M, Steele JM and Dobriner K. Alcap­tonuria and ochronosis. With a report of three patients and metabolic studies in two. Am J Med 1952; 13: 432-52. 2. O'Brien WM, LaDU BM, Bunin JJ. Biochemical, pathological and clinical aspects of alcaptonuria, ochro­nosis and ochronotic arthropathy: Review of world literature (1584.-1962.) A J Med 1963; 34: 813-38. 3. Guhl B, Modder B, Guhl C. Das klinische und radiologische Bild der Alkaptonurie und Ochronose. Rcintgenblatter 1981; 34 (6): 220-2. 4. Steele MJ. Alkaptonurija i ochronoza. U: Bee­son and McDermott eds. Interna medicina. Beograd­Zagreb: Medicinska knjiga, 1967: 1476-7. 5. Deeb Z, Frayha RA. Multiple vaccum discs and early sing of ochronosis. Radiologic findings in two brothers. J Rheumatology 1976; 3 (1): 82-7. Radiol lugosl 1990; 24:227-30. Presecki V, Mihordin N. Ohronoza i kalcifikati u zglobnim hrskavicama 6. Mac.Kenzie CR, Major P, Hunter T. Tendon 8. Kolar J, Križek V. Rcintegenologische Merkmale involment in a case of ochronosis. J Rheumatology der alkaptonurischen Ochronose. Fortschr. geb. Rcin­1982; 9 (4): 634-6. tgenstr. Nuklearmed 1968; 109 (2): 203-8. 7. cervenansky J, Sitaj š. Die ochronotische Spondylarthropathie. Beitrage zur Ortopedie und Trau­Adresa autora: dr. Vladimir Presecki, Ostrogovi­matologie (Berlin) 1970; 17 (10): 637-9. ceva 3, 41020 Zagreb Mijelografija OMNIPAQUErM joheksol neionsko kontrastno sredstvo gotovo za upotrebu GLAVNE PREDNOSTI OMNIPAQUEA U MIJELOGRAFIJI • vrlo niska neurotoksicnost • nikakvi ili klinicki beznacajni ucinci na EEG, kardiovaskularne parametre i rezultate labora­torijskih pretraga cerebrospinalnog likvora • vrlo mala ucestalost i slab intenzitet subjektiv­ nih reakcija bolesnika • odsustvo neocekivanih ili ireverzibilnih reakcija • vrlo mala vjerojatnost kasnih upalnih reakcija (arahnoiditis) • visokokvalitetni mijelogrami IZ NYCOMEDA-INOVATORA U PODRUCJU KONTRASTNIH SREDSTAVA Omnipaque je zašticeno ime RADIOLOGIJI · Proizvodac Nycomed A/S Oslo, Norveška !skljuciva prava prodaje u Jugoslaviji ima firmaLECLERC & CO. Schaffhausen/Švicarska. Zastupstvo za Jugoslaviju ima: REPLEK-MAKEDONIJA, 91000 Skopje, Jurij Gagarin bb, 091/237-266, 237-272, 232-222, 232-350 Zastupstvo 091/233-138, Telex 51431 NYCOMED . Contrast Media ,.1 r f!.:'.i}.. M .-i.;. :,. .. '1 . r. ---. 1 Radiol lugosl 1990; 24:227-30. Iz prakse za praksu IZ PRAKSE ZA PRAKSU KVIZ Br. 2 PRIKAZ PRIMERA Bolesnica: 47 godina Zanimanje: ekonomski tehnicar Iz istorije bolesti -odpusno pismo, koje donosi sa sobom: Primljena u bolnicu zbog bolova u predelu slabina, malaksalosti i povišene temperature. Tegobe su pocele dve nedelje pre prijema, kada je osjetila jake bolove u slabinama, više desno, groznicu, drhtavicu, temperatutu 37,5° C. Preležala je djecje bolesti, pre 20 godi na operacija vanmatericne trudnoce. Od 197 4 g. hipertenzija. Pre jedne godine operacija žuci. Anamneza po sistemima: osecala je malaksalnost i gubitak apetita. lmala je ceste i veoma jake glavobolje »da gubi svest od bolova«. Nije kašljala i nije imala tegobe sa disanjem. Povremeno je osecala bolove u predelu srca, »preskakanje« srca. Stolica uredna. Pušac. Nije uzimala alkohol. Negira porodicna oboljenja. Objektivni nalaz: bolesnica je savestna, orjentisana. Aktivno pokretna, pravilne ostemuskularne gradnje. Temperatura 37,8° C. Glava, vrat, grudni koš, kicmeni stub uredni. Abdomen: vidljiv ožiljak po laparotomiji. Bubrežne lože osetljive na grubu perkusiju i bimanuelnu palpaciju. Edema nema. TA do 22,6/16,0 Laboratorijski nalazi: EKG levogram, sinusni ritam, fr. 65 u min. sa znacima opterecenja levog srca. Urin 1-2L, sveži erit., bel. 1., pH 5. KKR uredna Kostna srž: jako hipercelularna usred hiperplazije eritrocitne loze, koja je normoblastna slabije sat. Hgb. Na celijama granulocitne loze se vidaju displasticne pramene dok je maturacija ocuvana. Megakariociti su u dovoljnom broju. Mieloperoksidaza je pozitivna u celijama granulocitne loze. LE cel. fenomen neg. C3c = 1,62g/L, C4 = 0,62g/L SE 94/126 Holesterol, urea, ukupni proteini, albumini, ŠUK, bilirubin, alkalna fosfataza, kisela fosfataza, fibrinogen, elektroliti, SGOT, SGPT sve u granicama normalnog. Radiorenogram: insufiniencija desnog bubrega, izražene drenažne smetnje levog bubrega. Urografija, uredna. CT bubrega: desno izmedu aorte i v. cavae vidljiva okruglasta mekotkivna senka, gustine oko 40 HU, koja ispred sebe pomera v. renalis a potiskuje i aortu i v. cavu. Posle davanja kontrasta formacija se samo ivicno obojava kontrastom, a centralno pokazuje zrakast hipodenzitet. Diagnoza: TU retroperitonealis lat. dex. (Lymphangioma). Scintigrafija limfnih cvorova: nalaz je suspektan na zahvatanje paraaortalnih limfonodusa patološkim procesom. Radiol lugosl 1990; 24:231-2. Iz prakse za praksu Limfografija: nalaz prikazanih limfnih cvorova uredan do visine L 2. Desno na visini L 1 pršljena izgleda, da postoji ekspanzivna formacija, koja sprecava daljni prodor limfe. Ponovni CT pregled -stanje nepromenjljivo. Pod diagnozam lnfiltratio reg. retroperitonealis. Anem. sec. Hypertrnsio arterialis. Gor hypertensivum comp., premeštena na daljnu obradu. Obav ljene dodatne pretrage Kavografija: vidi sliku 1 Aspiracijka biopsija vodžena sa CT: neadekvatni material. Mi šljenje: daljnje pretrage? Koje? :-,r..,:. Postupak lecenja? Odgovor: vidi stranu 307 Radiol lugosl 1990; 24 :231-2. GENERAL HOSPITAL OSIJEK DEPARTMENT OF ONCOLOGY ANO RADIOTHERAPY APPROACH TO THE STEREOSCOPIC VISUALISATION OF THE REAL -TIME UL TRASOUND IMAGES Kurbel s, Dicic M Abstract -The short theoretical paper deals with the possible use of stereoscopy as an optional display mode in a real tirne ultrasound. The proposed concept consists of: a/a special probe with two arrays crossed in the middle under an acute angle tor generating left and right ultrasound images b/a monitor that alternatively displays left and right images in sequence c/ liquid crystal spectacles of controlled alternative transparency that allows images to be seen only by the coresponding eye. The 'b' and 'c' components are alredy available as parts of the commercial stereoscopic video equipment. UDC: 534-8:611-018.06 Key words: ultrasonic diagnosis, biometry Preliminary report Radiol lugosl 1990; 24:233-5. lntroduction -Attempts to improve the real -tirne ultrasound visualisation are numerous and different (1-4). A possible new approach might be to try to generate a true stereoscopic ultrasound image that might improve the impres­sion of depth. Stereoscopic pictures are known from the beginnings of photography (5). A pair of pictures are simultaneously taken from two points that are 65 or more milimeters appart. Observed through special prismatic spectacles, two images can be mentally fused to form a single stereo­scopic image with exellent impression of depth. They are used in aerial cartography, conventional radiology etc. Historical attemps have been made to intro­duce stereoscopic movies. The principle was to project simultaneously left and right images on the same screen, one in red and the other in blue colour. The spectators were using coloured spec­tacles so that the left eye would watch only the left images and vice versa. The system was abandoned mainly because of unnatural colours and today it can be sporadically seen in computer games or experimental video. Received: April 4, 1990 -Accepted: May 15, 1990 A new system of stereoscopic video display has been recently introduced in the field of entertainment electronics. Left and right colour video images are being alternatively displayed in a fast sequence on the monitor screen. The spectator is using liquid crystal spectacles that can quickly turn dark or transparent by means of electricity. The spectacle transparency is gov­erned by the special video recorder that allows images to be seen only by the coresponding eye. Description of the proposed concept ­Conventional real tirne ultrasound can display stereoscopic ultrasound images as an additional option if the built-in computer is powerful enough to display 16 or preterably more trames per second. Higher trame rate is important since each eye is watching only a halt ot the frames. To have real tirne ultrasound, each eye should receive at least 16 frames per second. Each frame can be displayed twice to reduce screen blinking in case the liquid crystal filters are able to react tast enough. The high trame rate is also a limiting tactor ot the image depth. It could be improved by reducing actual frame rate per second and displaying the same images trice. Kurbel S, Dicic M. Approach to the stereoscopic visualisation of the real -tirne ultrasound images The special linear array probe for stereo­scopic ultrasound display requires two narrow arrays crossed in the middle under an acute angle, as shown in Fig. 1. Convex electronic sector probes can also be used. Stereoscopic probes with two mechanical sectores would be much more complicated. / // ,:c,n•._.1enl iona l. 1. i.neat' at't'a1. u l lra..ound probe // .. tuo-p lanes l i.near array u l tra.-ound probe f,:,r ·=· tereo·;cop i.c d i.-;p lay Fig. 1 -The comparison between the conventional linear array ultrasound probe (upper half) and the proposed two array probe (lower half) with arrays crossed under an acute angle r ... -. -. -. C: . .. ';'..>--r/1 . \ ! 1 pleme #1 1 pl.cme #2 ) \ l ! ! 1 f 1 1 1 l 1 L1 .-­ ti Fig. 2 -The image planes of the proposed two array ultrasound probe Kurbel S, DiciC M. Approach to the stereoscopic visualisation of the real -tirne ultrasound images transparency is able to fuse left and right image References into a single stereoscopic picture. Sažetak STEREOSKOPSKI NACIN UL TRAZVUCNOG PRIKAZA Kratki teoretski clanak se bavi mogucom upotre­bom stereoskopije kao moguceg nacina ultrazvucnog prikaza. Predloženo rješenje se sastoji iz: a) posebna ultrazvucna sonda s dva linearna sek­tora koji se pod oštrim kutom križaju u sredini (u obliku oštrog x) za dobivanje lijevih i desnih ultrazvucnih prikaza b) monitor koji naizmjence prikazuje lijeve i desne prikaze u nizu c) naocare s tekucim kristalima kontrolirane alter­nativne transparentcije koje omogucuju da pojedini prikaz vidi samo odgovarajuce oko. Komponente navedene pod 'b' i 'c' se mogu nabaviti na tržištu kao dijelovi komercijalne video opre­me. 1. ltoh K, Yasuda Y, Suzuki O et al. Studies on frequency--dependent attenuation in the normal liver and spleen and in liver diseases using the spectral­shift-zero--crossing method. J Ciin Ultrasound 1988; 16:553-62. 2. Henley DS, Ralls PW, Johnson MB et al. FM sonography in gallbladder disease: efficacy and com­parison with conventional sonography. J Ciin Ul­trasound 1988; 16 :563-8. 3. Kurbel S, Dicic M. Simulation of the computer aided postprocessing of the sequentially taken real tirne ultrasound images. Rad Med Fak Zagrebu 1989; 30:1-7. 4. Kurbel S, Dicic M. Possible technical solution to the simulation of static compound ultrasound images on a real-tirne ultrasound unit. Radiol lugosl 1989; 23:159-61. 5. Hedgecoe J. The book of photography. Lon­ don: Dorling Kindersley Ud, 1976. Author's address: Sven Kurbel MD, Department of On­cology and Radiotherapy, General Hospital Osijek, 54000 Osijek, Yugoslavia .KOMPAS. -,. E EUROCARC . JUGOSLAVIJA KOMPAS je ena beseda za popolni turisticni servis! -or9.anizirane pocitnice v domovini in v tujini -turisticna potovanja v domovini in tujini -izleti. pikniki, ogledi znamenitosti z avtobusi, letali in hidrogliserji -strokovna potovanja -organizacija kongresov, seminarjev -navticni turizem. lov, ribolov -prodaja domacih in mednarodnih letalskih in železniških vozovnic -posredovanje avtobusnih prevozov -izposojevanje vozil Kompas Hertz rent-a-car -zastopstvo Eurocard, Mastercard. JBC -mejni turisticni servis -brezcarinske prodajalne -hotelska in gostinska dejavnost: 22 hotelov, 3 moteli, 3 avtokampi, turisticna naselJa, 29 restavracij -mreža predstavništev v tujini s sedežem firme KTI-Kompas Touristik lnternational v Frankfurtu -zastopnik Digital Equipment Corporation za·-Jugoslavijo KOMPAS JUGOSLAVIJA, turisticna in gostinska delovna organizacija, Pražakova 4. 61000 Ljubljana, tel. 0611327 771. teleks 31 209, telefaks 0611319 888 Radio/ /ugasi 1990; 24 :233-5. JUGOSLOVENSKO DRUŠTVO ZA ZAŠTITU OD ZRACENJA DRUŠTVO ZA ZAŠTITU OD ZRACENJA . SR SRBIJE PRIRODNO MATEMATICKI FAKULTET KRAGUJEVAC ORGANIZUJU trece Savetovanje sekcije JDZZ za prirodnu radioaktivnost sa temom /ZLAGANJE POJEDINACA I STANOVNIŠTVA ZRACENJU KOJE POTICE OD RADONA, RADONOVIH POTOMAKA I DRUGIH RADIONUKLIDA U ŽIVOTNOJ SREDINI Vrnjacka Banja 15, 16. i 17. oktobra 1990 Informacije dr Dragoslav Nikezic; Prirod no materna ticki fakultet; R. Domanovica 12, 34000 Kragujevac; tel 034 60 251 UNIVERZITETSKO MEDICINSKI CENTAR U SARAJEVU INSTITUT ZA RADIOLOGIJU I ONKOLOGIJU NEUROFIBOM PERIKARDA -PRIKAZ SLUCAJA PERICARDIAL NEUROFIBROMA -CASE REPORT Dalagija F, Najdanovic M, Bukša M, Bešlic š, Spasojevic S Abstract -The authors have presented a case of 49--year old male without clinical symptoms, with occasional radiologic finding of cardiomegaly and suspicion tor echinococcus cyst. Preoperativelly, ali avilable diagnostic methods, including computed tomography (CT) were performed. Although the echocardiographic finding was accurate in localization and relation to the surrounding structures, it was inaccurate in definition of tissue consistency. CT accurately presented an oval tumorous mass with 10x12 cm diameter, solid tissue density, intrapericardially, next to the left cardiac ventricle. Operatively, the pericardial (epicardial} tumor was extracted completely with pathohistologically confirmed neurofibroma. The value of CT and difficulties in diagnosis of pericardial tumoros were discussed. UDC: 616.11-006.38.03 Key words: pericardium, neurofibroma Case report Radiol lugosl 1990; 24:237-40. Uvod -Primarni tumori srca su, kao što je poznata, opcenito rijetki, a primarni tumori perikarda rijedi od intrakardijalnih tumora. Od be­nignih tumora perikarda srecu se: lejomiomi, hemangiomi, lipami, a najcešce teratomi i inter­perikardijalne bronhogene ciste. Utvrdeno je da više od polovine primarnih tumora perikarda cine maligni tumori, predominantno mezoteliomi i sar­komi (fibrosarkomi), dok su od svih tumora koji zahvataju perikard najcešci metastatski tumori (1, 2, 3, 4, 5). Benigni tumori perikarda se vecinom prezen­tiraju bez simptoma kao neobjašnjiva kar­diomegalija. Ako su simptomi prisutni, oni ovise od velicine i lokalizacije tumora, kao i stepana kompresije srca i velikih krvnih žila (2, 5, 6). Postojecim brojnim dijagnostickim metodama kao što su klinicko-laboratorijske, konvencionalne radiološke metode, ehokardio­grafija itd., u posljednjih desetak godina pridružila se i kompjuterizirana tomografija (CT}. Kao superiorna nad konvencionalnim radiološkim dijagnostickim metodama, ona se pokazala veoma korisnom i u dijagnostici tumora srca, odnosno perikarda (1, 5, 7, 8, 9, 1 O, 11, 12, 13). Received: April 9, 1990 -Accepted: May 9, 1990 Prikaz slucaja -Radi se o 49-godišnjem muškarcu bez klinickih simptoma, kod koga je na ambulantno ucinjenoj standardnoj radiografiji pluca i srca slucajno otkrivena kardiomegalija. Zbog sumnje na ehinokoknu cistu, a u cilju daljnje dijagnosticke obrade i eventualne opera­tivne intervencije, pacijent je upucen u kliniku za grudnu hirurgiju. Kod prijema, svi laboratorijski nalazi, kao i krvni pritisak, bili su u granicama normale, Aus­kultatorno srcana akcija je bila ritmicna, uspore­na, prvi ton tmuo. EKG je pokazao sinusnu bradikardiju frekvence oko 55 u minuti sa zna­cima ishemije lijeve komore. Standardna radiografija pluca i srca (po­stero-anteriorna i profilna projekcija) kao i radio­skopija potvrdile su izraženu kardiomegaliju na racun lijeve srcane komore (slika 1 ). . Ehokardiografija je ukazala na postajanje eho strukture, moguce ciste, dužine do 1 O cm, koja dijelom potiskuje zid i smanjuje šupljinu lijeve komore (slika 2). Kompjuterizirana tomografija (CT) je jasno prikazala ovalnu tumorsku masu, promjera 1Ox12 cm, vizuelno izodenzne strukture, stepena gu­stoce solidnog tkiva, ali nešto nižih vrijednosti. Dalagija F et al. Neurofibrom perikarda -prikaz slucaja Ista je smještena intraperikardijalno, lijevo, sa impresijom lijeve komore, ali bez potiskivanja srca u cjelini {slika 3). Nakon aplikacije kontrast­nog sredstva u vidu »bolusa« masa se nešto intenzivnije opacificirala. , j ; Slika 1 -PA radiogram pluca i srca: izražena kardiome­galija Fig. 1 -PA chest roentgenogram: expressed cardio­megaly Intravenozna digitalna subtrakciona angio­grafija je pokazala smanjenje i impresiju lijeve srcane komore prema kaudalno {slika 4). Preoperativno su ucinjene i desna kateteri­zacija srca, lijeva pneumoaniografija i lijeva ven­trikulografija, ciji su nalazi bili uglavnom u grani­cama normale. Sinekoronarografija je otkrila ati­pican tok dijagonalnih grana koje su bile »nateg­nute i izravnate«. Postojeca tumorska masa je Dalagija F et al. Neurofibrom perikarda -prikaz slucaja hipovaskularizirana od grana ramus interventri­kularis anterior, koje su iregularnog lumena i kružnog toka na podrucju od preko 2/3 prednjeg zida. Operativno je u cjelini odstranjen perikardi­jalni (epikardijalni) tumor »poput vece muške pesnice«. Patohistološki je utvrdeno da se radi o neurofibromu. Postoperativni tok je bio produžen zbog nakupljanja tecnosti u perikardijalnoj šuplji­ni, pa je izvršena i perikardijalna punkcija. Kod otpusta iz bolnice, nalazi kontrolne ra­diografije, ehokardiografije i CT, sem mjestimic­nih znakova perikardijalnih priraslica, ne poka­zuju drugih patomorfoloških promjena. Srcana sjena odgovarajuce velicine. Diskusija -Klinicka slika benignih tumora perikarda, kao što je vec unaprijed navedeno, nije karakteristicna. Stoga se oni cesto otkrivaju slucajno na standardnoj radiografiji. Diferenci­jalno dijagnosticki dolaze u obzir tumori medija­stinuma kao što su: struma štitne žljezde, der­moidna cista, timom, ehinokokna cista medijasti­numa ili perikarda, aneurizma aorte ili srca itd. Tvrdi se da je do pojave kompjuterizirane tomografije (CT) evaluacija kardijalnih i perikardi­jalnih tumora pomocu radiografije, radioskopije, konvencionalne tomografije, angiografije i eho­kardiografije bila veoma otežana, a preopera­tivna dijagnoza specificnih entiteta vecinom i .emoguca (2, 5, 13, 14). Transverzalnim prikazom bez superpozicije, CT obezbjeduje tacno utvrdivanje lokalizacije i odnosa lezije prema okolnim strukturama. Spo­ sobnošcu preciznijeg diferenciranja apsorpcionih razlika, ona omogucuje i karakterizaciju intraperi­ kardijalnih masa na bazi njihove radiografske gustoce. Stoga je ona superiorna nad konvencio­ nalnim radiološkim dijagnostickim metodama u procjeni njihove tkivne konzistencije bilo da se radi o tecnom sadržaju, solidnom ili masnom tki­ vu, kalciju, koštanim ili dentalnim strukturama, a osobito kod neuspješnog ili nesigurnog ehokar­ diografskog pregleda (2, 6, 7, 8, 9, 1 O, 11, 12, 13, 15, 16, 17). Gore navedeno potvrdeno je i u prezentiranom primjeru. Dok je nalaz ehokardio­ grafije bio nesiguran, CT je riješila dilemu o eventualnoj cisticnoj prirodi lezije. Jasno je poka­ zala da se radi o tumorskoj masi gustoce solid­ nog tkiva. Uz dobar prikaz forme i velicine, tocno je definisala njenu intraperikardijalnu lokalizaciju, kao i odnos prema srcu u cjelini i lijevoj komori posebno. Konacno, intenzivnija opacifikacija na­ kon aplikacije kontrastnog sredstva ukazala je na njenu prokrvljenost (dokaz više protiv njene cisticne prirode). Svi navedeni podaci potvrdeni su operativno. lpak upozoreno je i na teškoce, pa i greške u dijagnostici pojedinih bronhogenih i drugih me­dijastinalnih, kao i perikardijalnih cista na osnovu CT gustoce. Ove ciste mogu biti ispunjene gustim mukoidnim sadržajem koji daje visoke CT vrijed­nosti gustoce, sugerišuci solidnu masu. Stoga, visoki CT brojevi ne iskljucuju benignu perikardi­jalnu cistu (15, 18, 19, 20). Zakljucak -Nalaz kompjuterizirane tomo­grafije (CT) u prezentiranom slucaju, koji je ope­rativno potvrden, u skladu je sa iskustvima stra­nih autora o vrijednosti CT u dijagnostici perikar­dijalnih tumora. Uz ostale vrijedne dijagnosticke metode, ona komplementarno, a cesto i odlucujuce doprinosi njihovoj tacnijoj evaluaciji. Sažetak U radu je prezer'ltiran slucaj 49-godišnjeg muškarca bez klinickih simptoma sa slucajnim radiografskim nala­ zom kardiomegalije i sumnjom na ehinokoknu cistu. Peoperativno su izvršene sve raspoložive dijagnos­ ticke metode ukljucujuci i kompjuteriziranu tomografiju (CT). Mada je u pogledu lokalizacije i odnosa lezije prema okolini, nalaz ehokardiografije bio tacan, u pogledu njene tkivne konzistencije bio-je nesiguran. CT je, medutim, jasno prikazala ovalnu tumorsku masu, pro­mjera 1Ox12 cm, stepena gustoce solidnog tkiva, intra­perikardijalno uz lijevu srcanu komoru. Operativno je u cjelini odstranjen perikardijalni (epikardijalni) tumor, a patohistološki utvrden neurofibrom. Diskutovano je o vrijednosti CT, kao i odredenim teškocama u dijagnostici perikardijalnih tumora. Li teratura 1. Borts FT, Rohatgi PK, Sehgal E. Bronchogenic cavoatrial tumor thrombus: CT demonstration. Case report. J Comput Assist Tomogr 1985; 9 (6): 115-7. 2. Moncada R, et al. CT diagnosis of congenital intrapericardial masses. J Comput Assist Tomogr 1985; 9(1):56-9. 3. Silverman NA. Primary cardiac tumors. Ann Surg 1980; 191: 127-38. 4. Suzuki M et al. CT of mediastinal teratomas. J Comput Assist Tomogr 1983; 7: 74-6. 5. Williamson BRJ et al. Epicardial lipoma: a CT diagnosis. Computerized Radio! 1985; 9 (3): 169-71. 6. Silverman PM, Harell GS, Korobkin M. CT of the abnormal pericardium. AJR 1983; 140: 1125-9. 7. Crowe JK, Brown LR, Muhm JR. CT of the mediastinum. Radiology 1978; 128: 75-87. 8. Harada J, Tada S, Arait T. CT of the chest: cardiovascular system. Kyobu geka 1979; 32 (1 O): 726-31. Radiol lugosl 1990; 24 :237-40, ' Dalagija F et al. Neurofibrom perikarda -prikaz slucaja =f .le1vetius MEDICAL SUPPLIES Radiogrami visoke kakovosti »anticrossover« tehnologija, ob 90% zmanjšanju žarkovne doze ki zagotavlja visoko locljivost in veliko v primerjavi z obicainimi sistemi hitrost ter s tem izboljšano kakovost posnetka. Pri JC emulziji (J-vezava in oglata zrna) je uporabljena najnovejša 3M "' <' i ..>·... 1 \:>; ebl. -1 .... !w i,_ ... __ .,. 9. Houang MTW, Arozena X, Shaw DG. Demons­tration .of the pericardium and pericardial effusion by CT. J Comput Assist Tomogr 1979; 3 (5): 601-3. 1 O. Modic MT, Janicki PC. CT of mass lesions of the right cardiophrenic angle. J Comput Assist Tomogr 1980; 4: 521-6. 11. Munro JC. CT of the thorax. Radiography 1982; 48: 95-101. 12. Pugatch RD et al. CT diagnosis of pericardial cysts. AJR 1978; 131: 515-6. 13. Shin MS, Jolles PR, HO KJ. CT evaluation of distended pericardial recess presenting as a mediastic nal mass. J Comput Assist Tomogr 1986; 10: 860-2. 14. Aronberg OJ, Peterson RR, Glazer HS. The superior sinus of the pericardium: CT appearance. Radiology 1984; 153: 489-92. 15. Brunner DR, Whitley NO. A pericardial cyst with high CT numbers. AJR 1984; 142: 279-80. 16. Pugarch RD et al. CT diagnosis of benign mediastinal abnormalities. AJR 1980; 134: 685-95. 17. Shin MS et al. Mediastinal cystic hygromas: CT characteristics and pathogenetic consideration .• J Comput Assist Tomogr 1985; 9: 297-301. 18. Marvasti MA, Mitchell GE, Burke WA. Mislead­ing density of mediastinal cyst on CT. Ann Thorac Surg 1980; 31: 167-70. 19. Mendelson DS et al. Bronchogenic cysts with high CT numbers. AJR 1983; 140: 463-5. 20. Nakata H et al. CT of mediastinal bron­chogenic cysts. J Comput Assist Tomogr 1982; 6: 733-8. 21. Shin MS et al. Primary angiosarcoma of the heart: CT characteristics. AJR 1987; 148: 267-8. Adresa autora: Doc. dr sci. Faruk Dalagija, Institut za radiologiju i onkologiju, UMC-a, Moše Pijade br. 25., Sarajevo e Radiol lugosl 1990; 24:237-40. CUNICAL HOSPITAL CENTER -REBRO, ZAGREB DEPARTMENT OF NUCLEAR MEDICINE 99"'Tc UPTAKE IN THYROID; PINHOLE COLLIMATOR NONUNIFORMITY CORRECTION Loncaric S, Samaržija M, Popovic S, Težak S Abstract -In order to determine thyroid structure and function simultaneously, we have developed a method that uses 99"'Tc pertechnetate, gamma camera and computer. 130 MBq (3.5 mCi) of 99"'Tc Pertechnetate is intravenously injected to the patient and 20 minutes la.ter a scintigram is acquired with pinhole coliimator positioned at optimal distance over the patient's neck. Tc-uptake in thyroid is calculated by FORTRAN program that makes ali corrections· necessar tor pinhole nonuniformity, isotope decay and extrathyroidal activity. Method was also tested by the thyroid phantom that imitates real conditions in the human neck, and on the group of 56 patients. The developed method with pinhole planer non-uniformity correction enables us to examine gland as a whole and also regionaliy. Ali relevant data about thyroid structure and function can be obtained within 40 minutes after clinical examination. UDC: 616.441-073:539.163 Key words: thyroid gland-radionuclide imaging, technetium Orig sci paper Radiol lugosl 1990; 24 :241-4. lntroduction -It has been shown (1, 2, 3, 4, 5, 6, 7) that 99 "'Tc Pertechnetate can be used to measure thyroid tunction, and that owing to its physical characteristics it provides high quality scintigrams. The main problem ot technetium method is low, nonselective thyroid uptake. Thyroid ac­cumulates only 2% ot applied dose, what makes only 40-50% ot total counts seen by whole gamma camera tield ot view. Because ot so high extrathyroidal activity, and hence necessary background correction, technetium tixation can­not be measured by usual scintillation uptake set that is normally used tor 131-1 uptake measure­ment. Gamma camera and computer are needed. In that way extrathyroidal activity can be subtracted and ali necessary corrections can be done to get accurate value tor 99"'Tc uptake in thyroid. We make corrections tor nonunitormity ot the pinhole collimator, isotope decay and distance ot collimator from the patient's neck; correction tor attenuation by neck tissue is not made. Materials and methods -For measurement and calculation ot 99"'Tc uptake in thyroid we use gamma camera PHO/GAMMA V with pinhole collimator with 5 mm aperture, and PDP-11 computer with GAMMA-11 system. Method con­sists ot tour parts. The tirst part is acquisition ot the scintigram ot the syringe that contains 130 MBq 99"'Tc in volume ot 1 ml. The distance from the collimator is 1 O cm and preset count is 100000. Because ot the heavy distance dependence ot the counting efficiency tor pinhole collimator (8,9), we caretully determine distance with cardboard pieces ot precise lenght. The second part is preparation and imaging ot the patient. Activity is injected intravenously and 20 minutes later, when thyroid activity reaches plateau, the scintigram is acquired. Plateau persists from the 15th to the 30th minute after injection. Again, preset count is 100 000 counts. Patient is in supine position, and collimator is positioned at optimal distance from the neck. That is usually 5-1 O cm and depends upon the thyroid size. Thyroid has to be positioned inside the tield ot view ot camera in such a way that representative extrathyroidal area can be easily determined. The third part is imaging ot the used syringe to determine the amount ot activity left after injec­tion. Distance from collimator is 10 cm _and preset tirne is one minute. The tourth part con­sists ot image unitormity corrections, definition ot Recived: April 24, 1990 -Accepted: May 3, 1990 Loncarit S et al. 99mTc Uptake in thyroid; pinhole collimator nonuniformity correction target and background regions of interest, and o 200 running the developed FORTRAN program for u uptake calculation. !! Corrections and calibration -Response or geometric efficiency of a pinhole collimator for a point source is nonuniform and given by (10) cf • sin3 (0) G= 16 · b2 d -effective aperture of the collimator, b -distance from aperture to the source of activity, e -the ray angle. During the measurement of 99"'Tc uptake 50% of total count within the field of view are from extrathyroidal activity. Therefore, it is neces­sary to subtract activity of overlaing and underla­ing structures to get net thyroidal activity. Thyroid is positioned in the image center, and the background area near it (what means toward periphery), so it is very important to correct the image for collimator nonuniformity. In fact the same reasoning apply equally well for every pixel or the part of the thyroid. We make corrections in the following way: We take a flood study of 57-Co flood source with 3 000 000 preset count. Afterwards, every scintigram is corrected with standard GAMMA-11 flood correction command (»FCD #«). From flood study GAMMA-11 creates cor­rection matrix that increases the low-response areas and decreases the high-response areas. Then, by multiplying each patient image by the correction matrix, one can compensate for the irregularities in the image due to poor camera response or, as in our case, for severe collimator nonuniformity. GAMMA-11 creates a flood-cor­rection matrix in the following manner. 1. AII cells whose counts lie outside the display thresholds are zeroed. 2. The average celi count AVO of the re­maining nonzero cells is computed. 3. AII cells below the cutoff m, that is, with counts smaller than m% of AVO, are zeroed. A new average celi count AV of the nonzero cells now remaining is calculated. 4. Each of these remaining nonzero cells is converted into a flood-correction factor by re­placing its contents with the value AV/CT, where CT is the original number of counts in the celi. In that way we equalized the weight of every matrix element in the scintigram. Thyroid and C: .2 ,a g • " u • 100 90 • 80 • 70 • &O :1 • 4 s 6 7 8 9 10 cm Fig. 1 -Calibration factors which are collimator-neck distance dependent background can be positioned anywhere within the field of view. Some authors (8) have tried to solve the problem of nonuniformity by calibrating for the thyroid size. Strictly speaking such a procedure is not completely correct with respect to the position of the thyroid within the field of view and regarding to correction for the overlyng structures. To be able to quantify 99"'Tc uptake in thyroid we have calibrated our system with »Searle« neck phantom with known activity. In phantom we have put plastic tube with 2% of previously measured activity and contained in 5 ml volume. It has been imaged at distances 5-10 cm from collimator, and calibration factors has been calculated (Fig. 1 ). It was easy to calculate calibration factors for every distance, because we have known that tube in the neck phantom had exactly 2% uptake. D·P F=-­ U F -calibration factor, P..:.. per cent of accumulation D -injected activity U-accumulated activity. Radiol lugosl 1990; 24:241·4. Loncarit S et al. 99mTc Uptake in thyroid; pinhole collimator nonuniformity correction The second degree polynomial has been fitted to the obtained set of distance dependent factors. Forl background subtraction, and distance and decay corrections we have written FORTRAN program. Distance calibration factors for particu­lar distance is calculated by fitted polynomial. Results -Algorithm correctness has been checked by measuring and calculating various activities in the neck phantom. We got high correspodence for whole range 0.5-5% of the applied dose. Also, program has been tested under the real, strictly controlled, conditions on the phantom we have made to imitate real situa­tion in the human neck. That is plastic bowl, whose diameter is 15 cm, filled with water that contains activity corresponding to the extrathyroi­dal activity. The pair of syringes simulating thyroid have been immersed in the bowl. Measurements have been done for various volumes (10-100 ml). Ali data have been analyzed twice. With uniformity correction and without it. Table 1 shows exellent results for corrected data, while noncorrected data gave results that differ considerably from the true value of 2% and depends on volume of simulated thyroid. Table 1 -Results of uptake measurement in our phan­tom tor various thyroid volumes and different modes of calculation VOLUME (ml) 99m-Tc UPTAKE (%) UNCORRECTED CORRECTED 10 2.56 2.15 20 2.40 2.04 40 2.23 2.01 60 2.09 1.84 100 1.87 1.92 MEAN ± S.O. 2.23 ± 0.06 1.99 ± 0.01 Method was also applied to the group of 56 patients (Table 2). In the euthyroid group of patients the mean value of 99"'Tc pertechnetate thyroid uptake is 1.99±0.07% (X±S.D.). The normal range defined as X±2S.D. is 0.3-3.73%. The method separates very well euthyroid pa­tients from patients with hypo or hyper thyroid function. Table 2 -HHmTc uptake in euthyroid, hyperthyroid and hypothyroid patients GROUP RANGE EUTHYROID (n=40) 0,3 -3,7 % (x ± 2 SO) HYPERTHYROID (n = 8) 4,3 -11,8% (apsolute range) HYPOTHYROID (n= 8) 0,02 -0,14% (apsolute range) Discussion -The thyroid size and position within a camera field of view does not influence the calculated value for Te uptake when ali of the acquired pictures are corrected far the pinhole collimator non-uniformity (Table 1 ). On the other hand, correction far the neck distance makes possible to get closer to the thyroid which means to obtain high quality scintigrams with well de­lineated thyroid structures, while at the same tirne not effecting the uptake measurement . Only one pictures is necessary in contrast to Atkins (12) where two acquisitions are nedded for complete procedure. The evaluation of described computer prog­ram for pinhole non-uniformity correction indi­cates that pinhole collimator can be used for quantitative thyroide imaging as well as specially designed collimator thyroid imaging proposed by German Association of Nuclear Medicine (7). The metod described in this article can be made more practical for routine work by measuring filled and empty syringe in the dosecalibrator. It is only necessary to establish transfer factor between that instrument and gamma camera. Developed method for evaluation of thyroid function by the use of 99"'Tc, tested on the phantoms and the group of patients, gave very satisfactory results. Hence, this work should be continued further for wider group of euthyroid and especially pathological cases. Because of successful uniformity correction and hence ability to measure regional uptake, we extended our study to this direction. Sažetak UPOTREBA HHmTc PERTEHNETATA, GAMA KA­MERE I KOMPJUTERA U ODRE0IVANJU STRUK­TURE I FUNKCIJE ŠTITNJACE. U nastojanju da istovremeno odredimo strukturu i funkciju štitnjace razvili smo metodu koja koristi 99mTc pertehnetat, gama-kameru i kompjuter. lspitaniku se intravenski injTcira 130 MBq (3.5 mCi) 99"'Tc, a tiroidna aktivnost snima se nakon 20 minuta pomocu gama-ka­mere i »pinhole« kolimatora koji su postavljeni na optimalnoj udaljenosti. Stupanj akumulaciji u štitnjaci odreduje se kompjuterski pomocu FORTRAN-skog pro­grama koji vrši neophodne korekcije za neuniformnost »pinhole« kolimatora, vrijeme poluraspada izotopa i Radiol lugosl 1990; 24:241-4. Loncaric: S et al. 99mTc Uptake in thyroid; pinhole col1imator nonuniformity correction aktivnost okolnih struktura vrata. Metoda je provjerena na fantomu vrata i štitnjace koji oponaša realne uvjete u organizmu te na grupi od 56 ispitanika. Svi relevantni podaci o strukturi i funkciji štitnjace dobivaju se 40 minuta poslije klinickog pregleda. Razvijena metoda omogucava odredivenje stupnja akumulacije 99"'Tc kako u cijelom organu tako i u pojedinim dijelovima štitnjace. References 1. Dodds WJ, Powell MA. Thyroid scanning with technetium 99m pertchnetate. Radiology 1986; 91: 27-31. 2. Dos Remedios LV, Weber PM, Jasko IA. Thyroid scintigraphy in 1000 patients: Rational use of Tc-99m and 1-131 compounds. J Nucl Med 1971; 12: 673-7. 3. Hurley PJ, Strauss HW, Pavoni P, et al. The scintillation camera with pinhole collimator in thyroid imaging. Radiology 1971 ; 101 : 133-8. 4. Atkins HL, Klopper JF, Lambrecht RM. A com­parison of technetium 99m and iodine 123 tor thyroid imaging. Am J Roentgenal Radium Ther Nucl Med 1973; 117: 195-201. 5. Karelitz JR, Richards JB. Necessity of oblique views in evaluating the functional status of a thyroid nodule. J Nucl Med 1974; 15: 782-5. 6. Arnold JE, Pinsky S. Comparison of Tc-99m and 1-131 tor thyroid imaging. J Nucl Med 1976; 17: 261-7. 7. Ausschuss der Deutchen Gessellschaft tur Nuklearmezin (DGN): Klinische qualitatskontrolle von nuklearmedizinschen ln-vivo-Untersuchungen. 1. Empfehlung. Nucl Med 1989; 28: 4 Suppl: 8-10. 8. Hurley PJ, Maisey MN, Natarajan TK, et al. A Computerized System tor Rapid Evaluation of Thyroid Function. J Ciin Endocr 1972; 34: 354-60. 9. Smidt KP, Andrews JT. A new gamma camera method tor the measurement of thyroid uptake of technetium 99m pertechnetate. Brit J Radiol 1978; 51 : 50-1. 10. Rollo FD. Nuclear medicine physics, in­strumentation, and agents. The C.V. Mosby Company, Saint Louis 1977. 11. Atkins HL. Technetium 99m pertechnetate uptake and scanning in the evaluation of thyroid func­tion. Semin Nucl Med 1971; 1 : 345-55. 12. Atkins HL, Klopper JF. Measurement of thyroi­dal technetium uptake with gamma camera and compu­ter system. AM J R 1973; 118: 831-5. Author's address: Srecko Loncaric, Ph. D., Depar­tment of Nuclf)ar Medicine, Clinical Hospital Center -Rebro, Kišpaticeva 12, 41 000 Zagreb 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 Sk.Jži ;:a 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 ispitivanja T3-RIA T4-RIA lnsulin -RIA HR-RIA u 19il8. godi ni pustili smo u redovan promet: CEA-RIA Pribor za odredivanje karcinoembrionalnog antigena (CEA) u serumu metodam radioimunološke analize. Radiol lugosl 1990; 24:241·4. UNIVERSITY GLINIC FOR NUCLEAR MEDICINE, LJUBLJANA 1 INSTITUTE OF ONCOLOGY, LJUBLJANA2 LUNG SCAN INTERPRETATION -COMPARISON OF DIFFERENT CRITERIA Budihna N1 , Milcinski M1 , Šuštaršic J2, Grmek M1 , Grošelj c1 , Porenta M 1 Abastract -Authors reevaluated lung perfusion seans performed for suspected pulmonary embolism in 1988 and 1989 using new criteria proposed by international prospective study for pulmonary embolism diagnosis (PIOPED (5)). The difference between the first reading and the reevaluation was found in 200 (25,35%) of patients examined by lung perfusion scaning using 99mTc-macro-aggregated albumin (99mTc-MAA). The probability of lung embolism increased in 185 (92,5%) of patients where the disagreement between the first and the second reading was found. The degree of discordance is low in the patients under 30 years of age (9,59%) and in the interpretation of normal lung perfusion scan (2,14%). Ventilation lung scanning by 99mTc-diethylenetriaminepentaacetate aerosol (99mTc -DTPA), which was performed after perfusion lunq scanninq in 59 patients, influenced the diagnosis in 14 (23, 72 % ) of patients by lowering the predicted probability of lung embolism as assessed by perfusion scanning alone. The systematic two-observer approach-to lung perfusion scan analysis using PIOPED criteria is more sensitive for the diagnosis of pulmonary embolism than single-observer method. Ventilation scanning helps to avoid overdiagnosis of lung embolism specially in intermediate and high probability of pulmonary embolism. UDC: 616.24-005.7:539.163 Key words: pulmonary embolism-radionuclide imaging Orig sci paper Radiol lugosl 1990; 24 :245-8. lntroduction -Diagnosis of pulmonary em­bolism (PE) is difficult if only clinical and biochemical criteria are considered. Lung scintig­raphy is one of the most important noninvasive imaging techniques. The interpretation of lung seans is liable to errors. As it has been proven with prospective studies, the systematic aproach is most succesful in the correct diagnosis of PE (1, 2, 3, 4). Since the systematic aproach has not been accepted in our laboratory before, we compared the results of nonsystematic lung scan interpretation to the aprofch suggested by Na­tional Heart, Lung and BloQd Institute in USA (5). Patients and methods -Lung perfusion scanning was performed in 789 patients (pts) because of clinically suspected pulmonary em­bolism (PE) in the period of two years (from 1988 to 1989). The pts were from 1 O to 90 years old, 448 (57,5%) were females. Lung perfusion scanning was performed with a large view field gamma camera after intraven­ous application of 99mTc-human serum albumin macroaggregates {99mTc-MAA). During the in­jection the pts were supine, but the seans were taken in the sitting position whenever there were no serious contraindications. The seans were per­formed mostly in four projections: anterior, post­erior, left and right posterior oblique. Few pts had seans taken only in anterior and both anterior oblique projections. Ventilation lung scanning by 99mTc-diethy­lenetriaminepentaacetate aerosol (99mTc­DTPA) was performed after perfusion lung scan­ning in 59 patients in the same positions as perfusion scanning. At the first diangnostic reading the seans were evaluated by several nuclear medicine physicians (sometimes they were less experi­enced) without strict criteria for lung scan in­terpretation. When ventilation lung scanning was not available, a recent thorax radiograph was compared to the lung scan serving as an estima­tion of the lung ventilation in the pts. On reevaluation PIOPED criteria were used (Table 1 ). These are essentially modified Biello's criteria, known as PIOPED {prospective study of pulmonary embolism diagnosis (5)).According to them, the seans were assessed by two observers as normal, concordant with low, intermediate or high probability of lung embolism. Received: May 14, 1990 -Accepted: May 21, 1990 Budihna N et al. Lung scan interpretation -comparison of different criteria Table 1 -PIOPEO eriteria tor diagnostie reading of lung perfusion seans PROBABILITY OF PE PIOPEO CRITERIA NORMAL NORMAL PERFUSION LOW (1) SMALL Q OEFECTS REGAROLESS OF NUMBER, V OR CXR FINOINGS (2) Q OEFECT SUBST ANTIALL Y SMALLER THAN CXR OEFECT (V IRRELEVANT) (3) V-Q MATCH IN :s 50% ONE LUNG OR :s 75% OF ONE LUNG ZONE CXR NORMAL OR NEARL Y NORMAL (4) SINGLE MOOERATE Q WITH NORMAL CXR (V IRRELEVANT) (5) NONSEGMENTAL Q OEFECT INTERMEOIATE (1) ABNORMALITY THAT IS NOT OEFINEO BY EITHER »HIGH« OR »LOW« HIGH (1) TWO OR MORE LARGE Q. V ANO CXR NORMAL (2) TWO OR MORE LARGE Q IN WHICH Q IS SUBSTANTIALL Y LARGER THAN EITHER MATCHING V OR CXR (3) TWO OR MORE MOOERATE Q ANO ONE LARGE Q. V ANO CXR NORMAL (4) FOUR OR MORE MOOERATE Q. V ANO CXR NORMAL Legend: Q = perfusion, V= ventilation, CXR = ehest X ray (ehest roentgenogram) Table 2 -The degree of diseordanee between the first and the seeond interpretation of lung perfusion of lung perfusion seans aeeording to the age of the patients AGE(YEARS) No OF PTS No OF OISCOROANT % OF OISCOROANCE INTERPRETATIONS 73 7 9.59 83 22 26.51 40-49 119 28 23.54 50-59 136 27.21 60-69 189 50 26.46 2: 70 189 56 29.63 ALL 789 200 25.35 Table 3 -The degree of diseordanee between the first and the seeond interpretation of lung perfusion seans aeeording to the seintigraphie probability of pulmonary embolism SCAN RESULT No OF PTS No OF OISCOROANT PER CENT OISCOROANCE INTERPRETATIONS NORMAL SCAN 140 3 2.14 % LOW PROBABILITY OF PE 213 35 16.43 % INTERMEOIATE PRO­ BIBILITY OF PE 181 92 50.83 % HIGH PROBABILITY OF PE 255 70 27.45 % ALL 789 200 25.35 % Radiol lugosl 1990; 24:245-8. Budihna N et al. Lung scan interpretation -comparison of different criteria Results -The disagreement between the first interpretation of lung perfusion seans and the reevaluation by two observers was found in 200 (25,35%) dof 789 patients. The probability of lung embolism increased in 185 (92,5%) of patients where the disagreement between the first and the second reading was found. The degree of discordance is low in the patients under 30 years of age (9,59% (Table 2)) and in the interpretation of normal lung perfusion scan (2,14%), (Table 3). Ventilation lung scanning by 99mTc-dieth­ylenetriaminepentaacetate aerosol (99mTc­DTPA), which was performed after perfusion lung scanning in .59 patients, influenced the diagnosis in 14 (23,72%) of patients by lowering the predicted probability of lung embolism as asses­sed by perfusion scanning alone. Discussion -Dis.greement in repeated read­ ings of diagnostic pictues was first studied in radiology. According to Smith (7), following dou­ ble reading of 300 consecutive radiologic exami­ nations, diagnostic disagreements occur in about one-third of all filmreadings and about two-thirds of all errors are found by modified dual-reading techniques. In our study, lung scintigrams performed in last two years were reevaluated by two experi­ enced nuclear medicine physicians using PIOPED criteria and compared to the results of random aproach of several individual, sometimes less experienced, nuclear medicine physicians who were not strictly using special criteria for lung scan interpretation. The percent of discor­ dance between the first and the second reading of the seans in our study was comparable to the results putJlished by Smith. An important differ­ ence was found in some of the patients in whom repeated reading increased the probability of lung embolism from low to intermediate or from intermediate to high. In the latter group, the disagreement was partly due to illdefining of larger than segmenta! defects composed of sev­ era! juxtaposed segments thus overlaying the anatomic borders. Further, problems have arisen as already noted by Sullivan (6), in the definition of the size of the subsegmental defects. The multiobserver aproach is of great value in these cases. In our pts the ventilation seans mostly de­ creased the probability of lung embolism esti­ mated on the basis of perfusion seans only. Unfortunately they were not performed frequently enough in all patients. We conclude that the systematic applying of PIOPED criteria, especially with multiobserver aproach, surpasses the nonsystematic scan analysis particularly in the borderline seans. Sub­stantial experience is necessary for interpreters. Ventilation scan is peremptory in the cases of intermediate and high probability of lung em­bolism estimated on the base of perfusion scan, to avoid the scintigraphic overdiagnosis of high probability of lung embolism. Povzetek PONOVNA OCENA SCINTIGRAMOV PLJUC BOLNIKOV S SUMOM NA PLJUCNO EMBOLIJO Avtorji porocajo o ponovni oceni scintigramov pljuc pri 789 bolnikih, ki so jih preiskovali v letih 1988 in 1989 zaradi klinicnega suma na pljucno embolijo. Pri vseh bolnikih je bila izvedena perfuzijska scintigrafija pljuc z 99mTc-albuminskim makroaqreqatom (99mTc-MAA). Ventilacijsko scintigrafijo pljuc z aerosolom (99m Tc-die­tilentriaminopentaacetata (99mTc-DTPA) so izvedli po perfuzijski scintigrafiji 59 bolnikom. Pri ponovnem ocenjevanju scintigramov avtorji uporabljajo merila priporocena v mednarodni prospek­tivni študiji za diagnostiko pljucnih embolizmov (PIO­PED (5)). Pri 200 (25,35%) bolnikih od 789 se razlikujejo rezultati prvega in drugega odcitanja perfuzijskih scinti­gramov pljuc. Stopnja neskladja je najmanjša pri bolni­kih mlajših od 30 let (9,59%) in pri normalnih scintigra­mih pljuc (2,14%). Z uporabo kriterijev PIOPED se pri 185 (92, 5%} bolnikih od 200 poveca verjetnost pljucnih embolizmov. Pri 14 (23,72%) bolnikih od 59 rezultat dodatne ventilacijske scintigrafije pljuc zmanjša verjentnosi ob­ stoja pljucnih embolizmov. Interpretacija scintigramov pljuc z dvema odcito­ valcema,ki uporabljata merila PIOPED, poveca obcutlji­ vost (in s tem možnost lažno patoloških rezultatov) perfuzijske scintigrafije v diagnostiki pljucnih emboli­ zmov v primerjavi s tehniko z enim odcitovalcem. Ventilacijska scintigrafija pljuc, ki sledi perfuzijski scin­ tigrafiji, zmanjša število lažno patoloških rezultatov perfuzijske scintigrafije, posebno tistih, ki kažejo sred­ njo in visoko verjetnost pljucnih embolizmov. References 1. McNeil BJ, Holman BL, Adelstein SJ. The scintigraphic definition of pulmonary embolism. JAMA 1974; 227: 753-6. 2. Vea HW, Sirota PS, Nelp WB. Ventiolation perfusion scanning for pulmonary embolism: refine­ment of predictive value through Bayesian analysis. AJR 1985; 145: 967-72. 3. Biello DR, Mattar AG, McKnight RC, Siegel BA. Ventilation perfusion studies in suspected pulmonary embolism. AJR 1979; 133: 1033-7. 4. Hull RD, .Hirsh J, Carter CJ, Raskob GE, GILL GJ, Jay RM, Leclerc JR, David M, Coates G. Diagnostic Radiol lugosl 1990; 24:245-8. Budihna N et al. Lung scan interpretation -comparison of different criteria value of ventilation perfusion lung scaning in patients with suspected pulmonary embolism. Chest 1985; 88: 819-21. 5. Sostman HD, Rapoport S, Gottschalk A, Green­span AH. lmaging of pulmonary embolism. lnvest. Radio!. 1986; 21 : 443-53. 6. Sullivan DC, Coleman RE, Mills SR, Ravin CE, Hedlund LW. Lung scan interpretation: effect of diffe­ rent observers and different criteria. Radiology 1983; 149: 803-7. 7. Smith MJ: Errors in diagnostic radiology on the basis of complacency. Amer J Roenigenol Rad Ther Nucl Med 1965; 94: 689-703. Author's address: Dr Nataša Budihna, Univerzitetna klinika za nuklearno medicino, Zaloška 7, Ljubljana ::SJ&NOUIBOR 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 ' ,< I' 40 let J Vll/J"J'l.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, enkratno uporabo, organizacij, -aparate, instrumente in potrošno blago za zobozdravstvo V prodajalni na Cigaletovi 9 v Ljubljani prodajamo izdelke iz asoriimana trgovine na debelo, s posebnim poudarkom na blagu za zobozdravstvo, nego bolnikov, ortopedskih pripomockih in ostalemu blagu za široko potrošnjo. Radio! lugosl 1990; 24 :245-8. ZAVOD ZA NUKLEARNU MEDICINU, MEDICINSKI FAKULTET U ZAGREBU, KLINICKO BOLNICKI CENTAR REBRO, ZAGREB 1311-MIBG BODY RETENTION IN A CASE OF NEUROBLASTOMA -CASE REPORT Maštrovic Z, Kasal B, lvancevic V, Bajc M, lvancevic o Abstract -The case of a little girl with neuroblastoma of the left hemithorax is presented. Surgery was performed at the age of 26 months. There was clinical evidence of diffuse bone marrow infiltration, and the disease progressed in spite of heavy chemotherapy. At the age of 30 months scintigraphy with 131-I-meta-iodobenzyl­guanidine (131-1-MIBG) was performed. Pathological accumulations could be seen in the left hemithorax, the entire bone marrow and in the evident metastases in the skull and oral cavity. Urinary and fecal activity in napkins and underwear were measured daily for 96 hours. A monoexponential retention curve having a T(1/2) of 18.5 h with an additional body retention constant of about 51 % was found. Due to the measuring protocol, a faster, also urinary component, described by other authors, could not be identified. UDC: 616-006.487 :539 .163 Key Words: neuroblastoma -radionuclide imaging, iodine radioisotopes Case report Radiol lugosl 1990; 24: 249-52. Case report -A 26-month-old girl was hospitalized on suspicion of skull base fracture and a tumor in the left hemithorax. One month before hospitalization the girl began to lose weight. There were periods of febrility up to 38.5 C0 which were ascribed to respiratory infectons. A haematoma occurred under her left eye. Two days before hospitalization the girl fell on the head after which moderate orbital haematomas developed around both eyes. Consequently, a skull X-ray was performed which was suspicious of scull base fracture. At the same tirne a through pediatric examination revealed a pathological lung X-ray, hepatosplenomegaly, hypochromic anaemia and slightly elevated hepatic enzymes and ESR. Liver and spleen ultrasound scan excluded the presence of focal lesions. A posterolateral thoracotomy of the left hemithorax was performed and tumor was found originating from the paravertebral sulcus and extending into the thorax, thus completely infil­trating the fifth and largely the fourth rib. Therefore, an »en bloc« resection was per­formed. Also a minor metastatic dissemination into the parietal pleura and paravertebral sulcus was found, the lung being intact. Pathology verified a neuroblastoma. From the local city Received: May 22, 1990 -Accepted: June 27,1990 hospital the child was referred to the hematolog­ical and oncological ward of our University paediatric clinic. In spite of a very aggresive chemotherapy and numerous transfusions, the disease progressed and the child died at the age of 33 months. A 133-I-MIBG whole body scan was done at the age of 30 months, the girl already being very weak. She was conscious but immobile, cachectic and extremely pale with purple rings around the eyes and exophthalomos (Fig. 1 ). Numerous metastatic tumors were visible on the head and a red-brown necrotic, bleeding and fetid tumorous mass jutted out of the mouth. The nose was also filled with tumorous masses. lnspection of the body revealed the surgical cut extending from the left anterior chest wall to the left scapula. Congested subcutaneous veins could also be seen. The abdomen was tense and painful, the liver and spleen markedly enlarged. The lower half of the left thigh showed a spindle­shaped tumor. The thyroid was blocked with sodium per­chlorate 24 hours prior to and for seven sub­sequent days after the injection of 4.44 MBq (120 µ.Ci) of 131 -1-MliJG. Static scintigrams, 50 kcounts each, of the head, trunk and thigs were 249 MaštroviC Z et al. 131 1-MIBG retention in a case of neuroblastoma -case report Fig. 1 -Numerous metastases disfiguring the patient's head and causing exophthalmos and protrusion of the tongue taken on a GE Maxicamera 400T linked to a POP 11/34 computer. Numerous metastases were found in the skull, the entire skeleton and left hemithorax (Fig. 2a and b). At the same tirne ali the girl's excreta to­gether with napkins, underwear and sheets were collected for 96 hours. The activity of the excreta was measured on a daily basis. We insisted on measuring the retention for several days because of wide-spread metastases for which we ex­pected an elimination dynamics different from cases in which a normal body retention predomi­nates. For our measurements the opposite probes of a dual detector whole body scanner »Elscint« were used Na1 (T1) crystals of 5x2 inches, with­out collimator). The samples were packed in equally dimensioned, hermetically sealed plastic containers and measured in well defined fixed geometry. A calibration source of 185 kBq (µ,Ci) 131-1 dilluted in 300 ml of water and spilled over clean napkins was measured under equal geometric and other experimental conditions. Uncontaminated underwear was measured as background. Each sample activity was calculated . - Fig. 2-131-I-MIBG whole body scan: a) anterior view: metastases in the skull, mouth, left hemithorax and pelvis b) posterior view: in addition to described pathology also infiltration of the head of left humerus and entire vertebra as the geometric mean of the upper and lower detector measurements. 131-1-MIBG whole body retention, expres­sed in% of administered activity, is presented as a monoexponential curve with a biological half­life of 18.5 hours with an additional body retention constant of about 51 % (Fig. 3). Discussion -After Wieland et al 1980 (1) published a study on 131-I-iodobenzyl-guanidine, a newly synthetized radiopharmaceutical, for the imaging of adrenergic tissue, several authors (2, 3, 4, 5) reported on the clinical value of 131-I-MIBG in the diagnosis of tumors of the suprarenal gland. Furter investigations showed that 131-1-MIBG could be used in the diagnosis of other endocrine and neuroendocrine tumors, e.g. medullary carcinoma of the thyroid (6, 7), carcinoids (8, 9) and neuroblastomas (10, 11, 12). A of this radiopharmaceutical (12). MIBG elimination blood is described in the sparse literature refer­ring specifically to the kinetics and biodistribution of this radiopharmaceutical (12). MIBG elimination Radiol lugosl 1990; 24: 249-52. MaštroviC Z et al. 131 1-MIBG retention in a case of neuroblastoma -case report 100 50 z: o t;:; 10 y•y1•Y2 i y • 46e-0.9t + SI . 5 š 1 o l 2 3 4 5 6 7 P0STINJECTI0N TIME (oAvs) Fig. 3 -Whole body retention curve (y), expressed as a percentage of administered 131-1.MIBG activity: Exponential component (y1), having a biological half-life of 18.5 h with an additional body retention constant (y2) of about 51 % from the body is described as being ac­complished by urinary excretion and also follow­ing a two-exponential model (5, 12). Owing to the fast excretion at the beginning the authors mea­sured the rate of the second component of urinary excretion only, which, according to Lashtord (12), amounts to 19-45 hours (mean 35 hours). Retention measurement in an 11-year-old boy with suspicion of pheochromocytoma or ad­renomedullar hyperplasia (13) showed a three-ex­ponential MIBG retention consisting of compo­nent with half-lives of 0.35, 1.3 and 5.9 days. Simultaneously measuring the thyroid activity, these authors calculated the thyroid to whole body activity ratio of 0.001, although the thyroid had been blocked. In our study we did not measure the activity accumulation of the thyroid, Radiol lugosl 1990; 24: 249-52. but scintigrams in the anterior projecton did not show any visible accumulaton of 131-1. Thus, any faint activity in this region seems to be largely due to metastases in the cervical ver­tebra. Obviously, with such a high 131-I-MIBG retention in the girl's body, the contribution of unbound 131-1 is negligible. In our study we investigeted the cummula­tive 131-1-MIBG excretion in a two and a half­year-old child tor tour days. Because ot the child's age it was impossible to measure urine and taces separately and the elimination could not be mesaured any longer tor technical reasons. On account ot this and the way ot elimination we could not record the tastest com­ponent with an expected biological halt-lite ot tew minutes (12). Our four-day retention curve with a halt-lite of 18.5 hours (fig. 3) is in agreement with Lashford's results (12). The stili hypothetical tast component ot urinary elimination cannot be ide­ntified with such an investigation setting. We assume that this component contributes to a higher MIBG elimination in the first 24 hours, and therefore the tirst dot in the retention curve has a relatively low value as compared to the follow­ing days. Also, the sum ot the values ot the exponential componerit and the constant body retention does not reach 100 % , possibly be­cause part ot the eliminated activity may belong to the tastest component which we could not measure directly. A certain measurement error has to be considered also. The constant 131-I­MIBG body retention ot 51 % is puzzling. A high body accumulation can be explained with a large tumor mass and active MIBG uptake. However, some long term elimination ot 131-1-MIBG or 131-1 can be expected because of in vivo 131-I-MIBG elution or 131-1 dissociation from the complex, in spite ot the changed biochemistry in the tumor in comparison to normal tissues with catecholaminic activity. As our measurements ·merely extended over tour days, it seems possible that we did not identity the 131-I-MIBG elution from tumor tissue or 131-1 dissociation, if either process was very slow. The patient received cytostatic therapy which could also influence the kinetics ot 131-1­MIBG in tumors. Most important tor tumor therapy with 131-1-MIBG, beside tumor mass estimation, is knowing the retention cuvre is influenced by the various tactors mentioned and can be defined accurately only by individual measuring, Maštrovic Zet al. 131 1-MIBG retention in a case of neuroblastoma -case report Sažetak RETENCIJA 131 I-MIBG-a U BOLESNIKA S NEUROBLASTOMOM -PRIKAZ SLUCAJA Prikazan je slucaj djevojcice s neuroblastomom lijevog hemitoraksa. U dobi od 26 mjeseci izvršena je operacija. Postajali su klinicki znaci difuzne infiltracije koštane srži i, unatoc intenzivnoj kemoterapiji, bolest je proaredirala. U dobi od 30 mjeseci ucinjena je scintigra­ 131 fija s I-meta-iodobenzyl-guanidineom (131 I-MIBG). Nadena je patološka akumulacija u lijevom himitoraksu, cijeloj koštanoj srži i vidljivim metastazama u lubanji i usnoj šupljini. Tijekom 96 sati mjerena je urinarna i fekalna aktivnost pelena. Nadena je monoeksponenci­jalna retenciona krivulja s T(112J 18.5 sati i tjelesna retenciona konstanta od oko 51 1/o. Radi nacina mjere­nja brža, takoder urinarna komponenta, koju su opisali drugi autori nije se mogla identificirati. References 1. Wieland DM, Wu JI, Brown LE, Mangner T J, Swanson DP, Beierwaltes WH. Radiolabeled adrener­gic neuroblocking adrenomedullary imaging with 131 I-io­dobenzylguanidine. J Nucl Med 1980; 21 :349-53. 2. Nakayo M, Shapiro B, Copp J, Kalff V, Gross J, Sisson JC, Beierwalts WH. The normal and abnormal distribution of the adrenomedullary ima.ing agent m-(I­ 131) lodobenzylguanidine (I-131-MIBG) in man: Eva­luation by scintigraphy. J Nucl Med 1983; 24:672-82. 3. Shapiro B, Copp EJ, Sisson JC, Patti LE, Wallis J, Beierwaltes WH. lodine-131 metaiodobenzylguani­dine for the locating of suspected pheochromocytoma: 1 Experience in 400 cases. J Nucl Med 1985a; 26:576­85. 4. Shapiro B, Sisson JC, Eyre P, Copp JE, Dmu­chowski C, Beierwaltes WH. 131 I-MIBG. A new agent in diagnosis and treatment of pheochromocytoma. Car­diology 1985b; 72: suppl. 1, 137 °42. 5. Sisson JC, Frager MC, Valk TW, Gross MD, Swanson DP, Wieland DM, Tobes NW. Scintigraphic localization of pheochromocytoma. N Engel J Med 1985; 305:12-7. 6. Connell JMC, Hilditch TE, Elliott A. 131 I-MIBG and medullary carcinoma of the thyroid. Lancet 1984; 2:1273-4. 7. Endo K. Shiomi K Kasagi K. lmaging of medul­lary thyroid cancer with 131I-MIBG. Lancet 1984; 2:233. 8. Feldman JM, Blinder RA, Lucas KJ, Coleman RE. Lodine-131 Metaiodobenzylguanidine scintigraphy of carcinoid tumors. J Nucl Med 1986; 27:1691-6. 9. Hoefnagel CA, den Hartog Jager FCA, Taal BG, Abeling NGGM, Engelsman EE. The role of I-131­MIBG in the diagnosis and therapy of carcinoids. Eur J Nucl Med 1987; 13:187-91. 1 O. Ficher M, Galanski M, Winterberg B, Vetter H, Localization procedures in pheochromocytoma and neuroblastoma. Cardiology 1985; 72: suppl. 1, 143-6. 11. Hadley GP, Rabe E. Scanning with iodine-131 MIBG in children with solid tumors: An initial appraisal. J Nucl Med 1986; 27:620-6. 12. Lashford LS, Moyes J, Ott R, Fielding S, Babich J, Mellors S, Gordan J, Evans K, Kemshead JT. The biodistribution and pharmacokinetich of meta-iodo­benzylguanidine in childhood neuroblastoma.Eur J Nucl Med 1988; 13:574-7. 13. Ertl S, Deckart H, Blottner A, Tautz M. Radio­pharmacokinetics and radiation absorbed dose calcula­tions from 131 I-Metaiodobenzylguanidine (131 I-MIBG) Nucl Med Comm 1987; 8 :643-53. Author's address: Zora Maštrovic, Zavod za nukleamu medicinu KBC i Medicinskog fakulteta u Zagrebu, Rebro, Kišpaticeva 12, 41 000 Zagreb Radiol lugosl 1990; 24: 249-52. THE INSTITUTE OF ONCOLOGY, LJUBLJANA LIVER METASTASES FROM COLORECTAL CANCER; THE IMPACT OF PRIMARY TUMOR REMOVAL ON SURVIVAL Snoj M, Lukic F Abstract-Presented work is aimed at showing some survival characteristic of colorectal cancer patients with liver metastases. We have reviewed 736 record of patients who had histologically verified colorectal cancer. Nearly 70% of these were rectal primaries, whereas in almost 30% the malignacy was localized in the rest of the colon. Patients were divided in two groups. In the first nonresectable liver metastases were present on admission. In this group diversion colostomy was performed and primary tumor was not removed. We had 121 such patients. Liver metastases could have been treated by systemic 5-FU regimen or liver irradiation. Median survival was 7,3 months. The second group comprised patients that we treated radically by surgery. We had 83 such patients. In 27 liver metastases appeared after some period. These were treated by the same means as the first group. Median survival after discoverv of metastases was 6,2 months. The difference in survival in these two groups was not statistically significant (x2 = 0,35; p<0,1). The removal of primary tumor seemed to have no impact on survival if nonresectable liver metestases were present. UDC: 616.36-006.6 :616.351/.352-006.6 Key words: Liver neoplasms-secondary, colonic neoplasms, rectal neoplasms Orig sci paper Radiol lugosl 1990; 24:253-5. lntroduction -Colorectal cancer (CRC) metastases in the liver are the object of long term research. In the last tirne especially, many re­searches have paid their attention to this subject, as by improved surgical techniques of primary tumor removal (1) metastatic disease came into focus. Liver metastases could be treated either by chemotherapy, irradiation or liver resection. It seems that only liver resection gives some chances far cure of at least improves the survival (2, 3, 4, 5). Unfortunately, only about 5% of CRC patients with liver metastates are suitable far resection (2). The rest of the patients are treated only with palliative intent. In these patients the treatment should be oriented to improving the quality of life and therefore overtreatment should be avoided. That is why we try to throw the light on the question whether the primary tumor resection in patients with hepatic metastases is justified or not. Patients and methods -In the research 736 records of patients with CRC were reviewed. Ali patients had histologically verified carcinoma. Received: May 3, 1990 -Accepted: June 2, 1990 They were treated between the years 1971 1981, almost 70% had rectal carcinoma, whereas in approximately 30% the disease was localized in other parts of the colon (Table 1 ). There were 261 patients with metastatic disease on admission. These were discovered and con­firmed during the operation or on !iver scintig­raphy. Of 163 surgically treated patients, 83 had radical surgery where as the rest were treated with palliative intent. Patients were divided in two groups. In the first !iver metastases were present on admission. Table 1 -Primary tumor site SITE % Rectum 70,5 C. sigmoideus 13,3 C. ascendens 4,5 Caecum 3,3 C. transversum 2,2 FI. hepatica 1,9 C. descendens 1,8, An6rectum 1,4 FI. lienalis 1, 1 Total 100,0 253 Snoj M, Lukic F. Liver metastases from colorectal cancer; the impact of primary tumor removal on survival These were considered nonresectable in princi­ple. In these patients only derivation colostomy was done. In about a quarter of patients liver metastases were treated by systemic 5-FU regi­men and/or liver irradiation. In the second group there were 83 patients treated by radical primary tumor removal. They had no liver metastases on admission. In 27 liver metastases appeared after some period. A few of them were treated by the same means as the first group. Statistical significance was assessed by nonparametric Chi-square test. Results -In the first group of patients (those with metastases on admission) median surival was 7.3 months, whereas in the second group (patients with colorectal metastases in the liver appearing after a tirne interval following primary cancer treatment) the median survival from the detection of hepatic metastases was 6.2 months (Table 2). Difference in median survival was not statistically significant (p<0.1 ; x 2 = 0.35). It seemed that primary tumor removal had no impact on the survival if liver metastases were present. Table 2 -Median survival in patients with hepatic metastases from colorectal cancer Group No.o! Median survival Range patients (months) (months) 1 121 7.3 1 -45 2 27 6.2 1 -25 On the other hand, the concepts of treating Discussion -We have retrospectively re­viewed the files of CRC patients with liver metas­tases, treated at the Institute of Oncology bet­ween years 1971-1981. It has been found that there was no statistically significant difference in survival between those who primary tumor re­moved and those who had not. The patients that we treated had in principle surgically non resectable metastases. In those years we belived thart liver metastases from CRC could not be treated surgically, unless they were solitary, superficial and small. We had no such cases in our study. Some of the patients had liver irradiation (up to 2000 RAD), whereas others received systemic 5-FU. It was proved, that these two modalities had no influence on the survival, although they often resulted in on objec­tive response (6, 7). Therefore we did not try to elicit that fact in our study. There was no in­traarterial application of the drugs. The question whether it improves the survival or not has not been solved yet (8). No patient underwent liver resecion. The opinions about importance of this method are diverging. Most authors agree that it could be performed for a solitary !iver metastasis (2, 3, 4), however some recent results (9) suggest that up to four metastases could be resected. Median survival of our patients was 7.3 or 6.2 months. Patients with CRC metastases in the liver have longer survival than those who had gasfric, pancreatic or biliary carcinoma (7). The same author reports a similar survival than that obtained in our study, i.e. 160 days; the patients with colostomy and those with resection of prim­ary tumor had the same survival. Wood (4) reported survival of 7.7 months after discovery of liver metastases that were not treated. The pa­tients with disease limited to one segment of the liver and those with solitary metastases had longer survival. Patients with liver metastases from CRC have bad prognosis and according to our results, their survival is not influenced by primary tumor removal. We think that in the case of nonresect­able liver metastases, the removal of primary tumor is not indicated unless the tumor is so symptomatic (pain, bleeding, destruction etc.) tha its removal would result in a significant symptomatic improvement. In these cases only palliative approach should be intended (deriva­tion colostomy, laser destruction, irradiation). liver metastases from CRC has changed. With the development of liver surgery and introducing of intraoperative ultrasound in to clinical practice, the resectability of hepatic metastases has in­creased considerably (10). The only factors that might themselves be considered contraindica­tions for liver resection are the presence of positive nodes, the presence of resectable ex­trahepatic metastases, or the presence of four or more metastases (9). It seems that nowdays the outlook for the patients with hepatic metastases from CRC is promising, so more and more patients could be treated with curative intent. References 1. Ohman U. Colorectal carcinoma. A survey of 1345 cases 1950-1984. Acta Chir Scand 1985; 151: 674-9. 2. Adson MA. Hepatic metastases in perspective. Am J Rentgenol 1983; 140 :695-700. Radio! lugosl 1990: 24 :253-5. Snoj M, Lukic F. Livar metastases from colorectal cancer; the impact of primary tumor removal on sorvival 3. Wilson SM, Adson MA. Surgical treatment of hepatic metastases from colorectal cancer. Arch Surg 1976; 111 :330-4. 4. Wood CB, Gillis CR, Blumgart LH. A retrospec­tive study of the natura! history of the patients with liver metastases from colorectal cancer. 5. Foster JH, Ensminger WF. Treatment of meta­stasic cancer to the liver. In: De Vitla VT, Hellmann S, Rosenberg SA(eds.). Cancer: principles and practice in Oncology (2. ed.). Philadelphia, Lippincot 1985; 2117-32. 6. Borgelt 88, Gelber R, Brady LW, Griffin T, Hendricson FR. The palliation of hepatic metastases: results of the radiation therapy Oncology Group pilot study. 1 nt J Radia! On col Biol Phys 1981 ; 7 :587-91 . 7. Jaffe BM, Donegan WL, Watson F, Sprati JS. Factor influencing survival of untreated hepatic meta­stases. Surg Gynecol Obstet 1968; 127:1-11. 8. Kemeny N, Daly J, Reichmann B, Geller N, Bolet J, Oderman P. lntrahepatic or systemic infusion of Fluorodeoxyridine in patients with liver metastases from colorectal carcinoma. Ann lntern Med 1987; 107 :459-65. 9. Hughes KS et al. Resection of the !iver tor colorectal carcinoma metastases: A multi institutional study of indications tor resection. Surgery 1988; 103 :278-87. 10. Benhamou G, Marmuse SP, Johane! H, Le Golf JY. Should liver metastases from colorectal cancer be treated surgically. Lancet 1990; 335:482-3. Author's address: Snoj M., MD, The Institute of Oncology, 61 000 Ljubljana ® SOL VOLAN (ambroksol) tablete, sirup nov sinteticni mukolitik in bronhosekretolitik • uravnava intracelularno patološko spremenjeno sestavo izlocka v dihalih • stimulira nastajanje in izlocanje surfaktanta iz celic pljucne strukture • povecuje baktericidnost alveolarnih makrofagov • zmanjšuje adhezijo bakterij in levkocitov ·r,a sluznico dihalnih poti • sprošca zastojni in žilavi izlocek s stene bronhijev in olajšuie izkašljevanje • odstranjuje bronhialni izlocek s spodbujanjem mukociliarnega prenosnega sistema in neposrednim vplivom na delo cilij • zmanjšuje viskoznost bronhialne sluzi • ublažuje neproduktivni kašelj • olajšuje dihanje Oprema 20 tablet 100 ml sirupa Podrobnejše informacije in literaturo dobite pri proizvajalcu. . .. KRKf\ tovarna zdravil. p. o .. Novo mesto Radiol lugosl 1990; 24:253-5. Byk Gulden Pharmazeutika @r. Konstanz/SR Nemacka RENTGENSKA KONTRASTNA SREDSTVA: HEXABRIX -kontrastno sredstvo niskog osmoaliteta, smanjene toksicnosti i gotovo bez­bolan u primeni. INDIKACIJE: Sva arteriografska ispitivanja, zatim 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 inf. (1 boca >< 250 ml) @) FABEG BykGulden 8 lnostrana zastupstva Predstavništvo: Pharmazeutlka Beograd Kosovska 17M Zagreb, Savska cesta 41M Konstanz/SR Nemacka telefoni: 321-440 i 321-791 telefoni: 539-355 i 539-476 INSTITUTE OF PATHOPHYSIOLOGY MEDICAL FACULTY, UNIVERSITY HOSPITAL REBRO, ZAGREB1 NUCLEAR MEDICINE ANO ONCOLOGY GLINIC »OR. M. STOJANOVIC:« UNIVERSITY HOSPITAL, ZAGREB2 CIRCULATING CA 15-3 AND CEA VALUES IN MONITORING PATIENTS WITH BREAST CANCER Vrbanec 01 , Cvrtila 02 , Bolanca A2 Abstract -Serum concentrations of CA 15-3 and carcinoembryonic antigen (CEA) were measured in 277 patients with breast cancer. Metastatic disease was detected in 74 of them. Three hundred and thirty-nine healthy subjects provided our normal CA 15-3 reference value. The upper limits of normal range for CA 15-3 and CEA were found to be 26.4 U/ml and 2.5 ng/ml, respectively. Both CA 15-3 and CEA values were higher in patients with metastases. Significantly more patients had elevated levels of CA 15-3 than CEA (67, 1 % versus 47,3%, p<0.05) as measured at various stages of the disesase. Concentrations of CA 15-3 and CEA varied significantly with the stage of disease, but also in the relation to treatment response. However, CA 15-3 is more closely associated with the clinical status assessed in the follow-up period. UDC: 618.19-006.6-074-097 Key words:antigens tumors-associated, carbohydrate, carcinoembryonic antigen, breast neoplasms Orig sci paper Radiol lugosl 1990; 24: 257-60. lntroduction -Since tumor markers like carcinoembryonic antigen (CEA), tissue polypep­tide antigen (TPA), mucin-like carcinoma as­sociated antigen (MCA) and CA 15-3 have been available, an attempt has been made to incorpo­rate serum determinations of these markers in the monitoring of breast cancer patients (1, 2, 3, 4). CEA, the most widely used cancer marker, has been shown to be of value for monitoring the response to treatment in about 60% of advanced metastatic breast cancer but lacks the sensitivity and specificity to detect small tumor burdens (5). The proliferation antigen TPA also shows the same sensitivity. However, in numerous benign, respiratorx inflamatory diseases nonspecific titer of CEA and TPA can be found. Carbohydrate an­tigen 15-3 (CA 15-3) is recently described breast cancer associated antigen (6, 7), defined by two different monoclonal antibodies. One antibody (DF3) was produced by Kute et al. (8) against a with membranes enriched fraction of human breast cancer metastases. This concerns an antigen with a molecular weight of 260 KO. The other antibody (115 08) was developed against human milk fat globule membranes. Antibody 115 08 recognizes a glycoprotein (MAM 6) antigen with a higher molecular weight, which is usually present in cases with cancer of the breast. This study was done to determine the signifi­cance of both these tumor markers in the diag­nosis and in the oncological follow-up in a group of subjects with breast cancer. Material and methods -Two hundred and seventy-seven patients with breast cancer were included in this study (622 serum samples were analyzed). Metastatic disease was detected in 74 patients. Breast cancer was histologically confirmed for ali these patients. The age of patients ranged from 29 to 84 years (mean value 57.6 years; median value 59 years). The patients were divided up into 2 group: 1. Patients with detectable metastases resp. recidivation (n = 74). The involed metasta­tic sites are given in Table 1. 2. Patients, who at the tirne of these results had no detectable distant metastases resp. re­cidivation (n = 203). Metastatic lesions were monitored using x­ray examinations, scintigraphy and in certain cases computed tomography. Patients with metastatic disease were treated with local (irradi­ation) and/or systemic therapy (CMFVP; ad­riamycin combinations and/or hormona! manipu­lations). Received: March 9, 1990 -Accepted: April 16, 1990 Vrbanec O et al. Circulating CA 15·3 and cea values in monitoring patients with breast cancer Table 1 -Number of involved metastatic sites Skeleta! 46 Lung 15 Liver 6 S.n 3 Gerebral 2 Gombination 7 Patients with metastatic disease Patients free of metastases GA15-3 (U/ml) 131.2±17.8 20.2±7.3 GEA 19.3 ± 8.1 1.5 ± 1.7 (ng/ml) In the control group we examined 339 pre- • sumably healthy person aged from 17 to 76 years (mean value 38.9 years; median value 39.5 years). CA 15-3 and CEA levels were meas1.1red simultaneously in specimens of serum collected during either outpatient visits or hospitalization and frozen at-20 ° C until assayed. CA 15-3 was measured by immunoradiomet­ric assay (obtained from CIS, France) and CEA was determined using IRMA-MAT CEA Kit (ob­tained from Byk-Sangtec Diagnostica, FR Ger­many). CEA values above 2.5 ng/ml were consi­dered elevated. The results were expressed by a mean value and a median value were appropriate. Chi-square test with the correction tor continuity in 2x2 tables was used to evaluate the signifi­cance of variables. The P values < 0.05 were considered significant. Results -In our control group CA 15-3 values were in the range from 3.5 to 39.9 U/ml (mean value 15.6 U/ml, median value 15.0 U/ml). Cut-off value was set at 26.4 U/ml, i.e., 95th at percentile. CA 15-3 was elevated in 44 out of 203 patients (21.7%), and CEA was elevated in 31 out of 203 patients (15.2%) who had no evidence of metastases (chi-square 2.355, P<0.2). CA 15-3 and CEA values were statistically higher in patients with metastases (Table 2). Significantly more patients with metastatic diseases had elevated circulating levels of CA 15-3 than CEA (49/74 patients, 67,1% and 29/74 patients, 47.3%, respectively; chi-square 9.785, 258 p<0.002). Using CA 15-3 and CEA in combina­tion, sensitivity (ei. at least one marker is ele­vated) can be increased, depending on the clini­cal stage of the disease. CA 15-3 serum levels in 7 4 patients with progresivve breast cancer in accordance to the localisation of metastases are shown in Figure 1. bone liver l lung combina Table 2 -Serum concentrations (mean ±S.O.) of 0 0 l!ion o o 1 GA 15-3 and GEA in patients with breast cancer CA 15-3 U/ml 80-, o 1 o o o o 6J o 1 o -i o o o 40--l o 0000 26 4f .2.2.0 ' 000 o -+*-+.­ O ­ 20 fľ>O 00 o .g 000 o Fig. 1 -GA 15-3 levels in patients with metastatic breast cancer (sites of metastatic involvement) CEA serum levels in patients with metas­tases in accordance to the localisation of metas­tases are shown in Figure 2. Concentration of CA 15-3 and CEA varied significantly with the stage of the disease but also in the relation to the treatment. In three patients who developed local recurencce there was no significant change of CEA and CA 15-3 levels between when they are tumor free and had evidence of local recurrence. Figure 3 shows the response of CA 15-3 and CEA serum levels to endocrine or citotoxic therapy in one patient with metastatic cancer. This patients had her breast removed 2 weeks before the beginning of the study. The receptor status was unknown. At the beginning of the study there was metastatic bone disease praven by scintigraphy and x-ray investigation. The pa­tients was treated with combined chemotherapy (CMFVP protokol) and tamoxifen. There was no therapy between 13-22 months because there was clinically stable disease. After month 22 there was clinical evidence of progressive dis­ease, and the therapy was changed to medroxyp­ RadioIIu90sI1990; 24:257-60. Vrbanec O et al. Circulating CA 15·3 and cea values in monitoring patients with breast cancer -g 600 J, C: c'.§ 140 . 500 120 400 1000 800 300 60 200 400 100 200 NO . NO o 13 18 22 28 o 13 18 22 28 DURA TION OF THERAPY (MONTHS) bone 2!10] oo°g°o CEA 9 o o o ""·: j o 2.: i-.:_ ··· OOJ.> J°š: o 80 oo o Fig. 2 -CEA levels in patients with metastatic breast cancer (sites of metastatic involvement) liver 000 1 1 1 o 1 0 O lung 1 comb,nat,on ooo o o 1 o 1 -.--L-.-+-­ r · 000 000 / O o 80 rogesteron. This therapy caused a clinical im­provement of the patient and there was an drop of the CEA and CA 15-3 levels. Discussion -This study confirm and amplify some previous reports concerning the usefulness of tumor markers in breast cancer (9, 1 O, 11 ). Among other tumor markers, CA 15-3 have been described as clinically useful laborat­ory tool in monitoring patients with breast cancer. The use of CEA in the follow up of patients with breast cancer is controversial. While it was ini­tially suggested as being a useful marker for breast cancer, not ali authors agree ( 12, 13, 14, 15, 16). In our patients we found the sensitivity of CEA to be poor, and therefore it is not itself very useful for detecting occult metastases. The present investigation makes it clear that high frequencies of elevated serum CA 15-3 and Fig. 3 -The relationship between treatment response and changes in tumor marker values. Between O and 13 months of the follow-up period, CMFVP protocol was used. There was no therapy between 13 and 22 months, and at 22nd month medroxyprogesteron (Depo Provera) was induced. Radiol lugosl 1990; 24:257-60. Vrbanec D et al. Circulating CA 15-3 and cea values in monitoring patients with breast cancer CEA concentration in breast cancer patients were seen only in cases of a disseminated disease. This finding may be used in the follow­up of patients, especially for early detection of recurrences and progression of disease and in monitoring of treatment success. The results also show that in patients with metastatic breast cancer, CA 15-3 levels were elevated more often than CEA levels. Thus, CA 15-3 levels were more useful than CEA for monitoring clinical course of patients undergoing treatment for metastatic breast cancer. Our results agree with those reported by others, i.e. that CA 15-3 appears to be a more sensitive marker compared with CEA for following breast cancer patients. Sažetak VRIJEDNOST CA 15-3 1 CEA U PRACENJU BOLESNICA S KARCINOMOM DOJKE U serumu 277 bolesnica s karcinomom dojke odredivane su vrijednosti CA 15-3 i karcinoembrion­skog antigena (CEA). 74 bolesnice imalo je metastatski tumor. Naše normale za CA 15-3 odredivali smo iz skupine koju je sacinjavalo 339 zdravih osoba. Gornja granica normalnih vrijednosti za CA 15-3 i CEA iznosila je 26.4 U/ml i 2.5 ng/ml. Bolesnice s metastatskim tumorom imale su povišene vrijednosti CA 15-3 i CEA. Odredivanje u razlicitim stadijima bolesti pokazalo je da je znatno veci broj bolesnica imalo više vrijednosti CA 15-3 nego CEA (67, 1 % prema 47,3%, p<0.05). Vrijednosti CA 15-3 i CEA znacajno su se razlikovale prema stadiju bolesti, ali i u toku terapije. CA 15-3 bio je znacajnije povezan s klinickim statusom tijekom perioda pracenja bolesnica. References 1. Delarue JC Mouriesse H, Dubois F, Friedman S, May-Levin F. Markers in breast cancer: does CEA add to the detection by CA 15-3. Breast Cancer Res Treat 1988; 11 :273-6. 2. Hayes DF, Zurawski VR, Kute DV. Comparison of circulating CA 15-3 and carcinoembryonic antigen levels in patients with breast cancer. J Ciin Oncol 1986; 4:1542-50. 3. Pons-Anicet DMF, Krebs BP, Mira R, Namer M. Value of CA 15-3 in the follow-up of breast cancer patients. Br J Cancer 1987; 55:567-9. 4. Vrbanec D, Lukinac LJ, Pokrajac 8, Spaventi š. Significance of serum concentrations of CA 15-3, TPA, CEA and ferritin in patients with breast cancer. Rad JAZU 1989; 447:47-52. 5. Beard DB, Haskell_ CM. Carcinoembryonic anti­gen in breast cancer. Am J Med 1986; 80:241-45. 6. Schmidt -Rhode P, Schulz KD, Sturm G, Raab­Frick A, Prinz H. CA 15-3 as tumor marker in breast cancer. lnt J Biol Marker 1987; 2:135-42. 7. Tondini C, Hayes DF, Gelman R, Henderson C, Kute W. Comparison of CA 15-3 and carcinoembryonic antigen in monitoring the clinical course of patients with metastatic breast cancer. Cancer Res 1988; 48 :4107­12. 8. Kute D, lnghirami G, Abe M, Hayes D, Justi­Wheeler H, Schlom J. Differential reactivity of a novel monoclonal antibody (DF3) with human malignant ver­sus benign breast tumors. Hybridoma 1984; 3 :223-32. 9. Tormey DC, Waalkes TP, Snyder JJ, Simon RJ. Biological markers in breast carcinoma. III. Clinical correlations with carcinoembryonic antigen. Cancer 1977; 39:2397-402. 1 O. Cove DH, Woods KL, Smith SCH, Burnett D, Leonard J, Grieve RJ, Howell A. Tumor markers in breast cancer. Br J Cancer 1979; 40 :710-8. 11. Pluygers EP, Beauduin MP, Baldewyns PE, Burion JA. Tumor markers tor cancer detection. 1 Cancer Detect and Prev 1986; 9:495-504. 12. Paulick R, Caffier H, Paulick M. Comparison Of serum CEA, PHI and TPA as tumor markers in breast cancer patients. Cancer Detect and Prev 1987; 10:197-203. 13. Neville AM, Patel S, Capp M. The monitoring role of plasma CEA alone and in association with other tumor markers in colorectal and mammary carcinoma. Cancer 1978; 42:1448-51. 14. L0thgens M, Schlegel G. CEA+TPA in clinical tumor diagnosis with special reference to breast cancer. Tumordiagnostic 1980; 1 :63-77. 15. Treidler J, Pompecki R, M0llerleile U, Gar­brecht M, Kleeberg UR. Prognostische Aussage des Serum-CEA und therapie-bedingte unzspezifiche CEA-Verlaufe beim metastasieredem Mammakar­zinom. Onkologie 1984; 7:328-33. 16. Lokich J, zamchek N, Lowenstein M. Sequen­tial carcinoembryonic antigen levels in the therapy of metastatic breast cancer. Ann lntern Med 1987; 89:902-5. Author's address: dr. Damir Vrbanec, Institute of pathophysiology, University hospital, Rebro, Kišpaticeva 12, 41 000 Zagreb Radiol lugosl 1990; 24:257-60. UNIVERSITY MEDICAL CENTRE LJUBLJANA UNIVERSITY DEPARTMENT OF GASTREONTEROLOGIC SURGERY TESTING OF THE VALVE FOR CONTROLLING THE EXCRETION OF FAECES AND STOMATHERAPY IN THE EXPERIMENT ON DOGS Košorok P Abstract-A valve tor controling the axcretion of faeces and stomatherapy of diverted bowel has been developed on the dog. The valve is installed in the terminally diverted flexure of the sigmoid colon. The inner elastic ring is inserted into the bowel and expands in the lumen of the bowel at the inner side of the abdominal wall. The greatest diameter of the inserted ring has been 55 mm, and it has been possible to continously keep the prosthesis in place tor up to one week. The bowel has not been damaged by the inserted prosthesis. In the dog the prosthesis can be changed without anaesthesia. So far the need for a new surgical technique does not appear necessary; the simple terminal diversion of the bowel is sufficient. The success of this experiment on dogs makes it appear that the valve has been developed to a stage where it could be experimentally used in human patients with rectal carcinoma who have undergone the amputation of the rectal sigmoid and require the application of anus praeter. UDC: 616.352-089.844-092.9 Key words: colostomy -methods, prosthesis, feces, dogs Orig sci paper Radiol lugosl 1990; 24:261-5. lntroduction -Patients with rectosigmoid carcinoma who have had to undergo the amputa­tion of the rectum and installation of a diverted bowel into the abdomen (anus praeter) require special post-operative rehabilitation. Hitherto used means for such treatment have comprised self-adhesive collecting appliances with or with­out the skin barrier, made either in the form of a closed pouch or a pouch with an outlet. One method of post-operative care, which also ena­bles good rehabilitation, is irrigation (self....:Clyster­ing through the diverted bowel). This method is feasible at the terminally divertted sigmoid colon. According to the type and behaviour of the diverted bowel, various means are being con­structed. Vet, none of these treatments is perfect. Patients need to be informed about different types of treatment, since they are supposed to choose the appropriate sort according to various conditions, changes of the season, as well as periodic changes in digestion. It was decided to test a new appliance which is not intended to be fastened to the skin. It is, rather, inserted through the diverted bowel into the very lumen of the bowel, in such a way that the inner elastic ring is attached to the inner side Received: May 13, 1990 -Accepted: May 24, 1990 of the abdominal wall. We wanted to avoid damange to the skin, since the skin is exposed to the strongest burdening in the hitherto men­tioned manners of enterostomal therapy. The anchoring of the prosthesis in the classical treat­ment depends on the strenght of the adhesive area and on the condition of skin. In case of skin inflammation, the adhesiveness is questionable, which causes danger of leakage of faeces to the surrounding skin, missing the pouch. Another difficulty is that the pouch may become detached; if it falls off it allows the uncontrolled leakage of faeces out of the diverted bowel. We are suggesting a new means of enteros­tomal therapy consisting of a valve with an inner elastic ring which can be inserted into the lumen of the bowel. After installation, the elastic ring again expands into the bowel. The abdominal pressure attaches it against the inner side of the abdominal wall. Since the diameter of the in­serted ring is larger than that of the bowel, the ring cannot fall out. In this manner, the inner anchoring of the prosthesis is achieved -thus avoiding the severe burdening of the skin which was one of the worst problems in the types of therapy used so far. In the past, the skin has be_en damaged by the mechanical burdening of Košorok P. Testing of the valve tor controlling the excretion of faeces and stomatherapy in the experiment on dogs the weight of the appliance, frequent stripping off the applances with strongly adhesive surface and, in the classical self-adhesive appliance, also by the steam closure, which is disables the skin to breathe. Materials and methods -In the experiment on dogs we applied the surgical technique of terminal diversion of the distal colon. The distal part of the bowel is blind ended. According to the plan, we utilized the prosth­eses with growing diameters of the inner ring. We tried various external parts of the prosthesis, used for the retention -prevention of the slipping of prosthesis into the abdomen (Fig. 1 ). The external part of the prosthesis can be prolonged by an additional piece with an open bottom, thus achieving the leading away of the faeces to the furthest possible distance from the animal (Fig. 2}. To prevent the animal from biting off the prosthesis from the artificial anus, a safety basket was attached to its collar. During the whole period of the experiment, the experimantal animal was fed with food con­taining no thick residues. The experiment was performed on four ani­mals; in the years 1982 and 1983 on two dog s (German shepherds), and in 1987, one experi­ment on a German shepherd and the other on a karst shepherd. The experiments were carried out at the Glinic for Carnivorous Animals at the Veterinary Faculty in Ljubljana (Department of Veterinary Hospital, Cesta v Mestni log 40, Ljubljana), in collaboration with M. Se. Zlatko Pavlica, veterina­rian. In human patients, the sigmoid stoma is applied in cases of rectal cancer, after amputa­tion of the complete rectal sigmoid. In the experiment on a dog, the colon was discontinued at the level of the sigmoid colon, the distal part blindly sutured, and the stump left in the abdominal cavity. The terminal sigmoid colon was diverted through the trephine hole of the abdominal wall in the left lower quadrant of the abdomen. The sugery resembles the Hartman type of resection in human patients. Results -Surgical diversion of the terminal sigmoid, as applied in patients with rectal car­cinoma in which the amputation of rectosigma is necessary, was experimentally carried out in four dogs. t o ., ........•.. :)k. ............ ,;;..:­ Fig. 1 -Different form s of the prosthetis; demonstration of the longitudinal elasticity of the rubber tube Fig. 2 -Torsion of the elastic tube -emphasis on the small bulge of the rubber tube, which connects bolh pieces In the first dog (German shepherd), the diversion of the sigmoid was performed in an already sacrificed animal in order to study the anatomy and the surgical technique. In the recently sacrificed dog the colon was discontinued in the sigmoid level and the sigmoid stoma diverted through the trephine hole in the left lower quadrant of the abdomen. The distal stump of the colon was sutured in two layers and left in situ, as in the Hartman procedure (Fig. 3). In the order dog, the identical procedure was carried out under endotracheal anaesthesia. The animal recovered in a few days; in three week's tirne we started testing the prosthesis. Here, we ran across unexpected trouble. The animal pulled out the prosthesis with its teeth; the prosthesis had to be reinstalled. During the installation, the animal was (intraveneously) se­dated by an injection of Combelen. Radiol lugosl 1990; 24:261-5. Košorok P. Testing of the valve far controlling the excretion of faeces and stomatherapy in the experiment on dogs ···.r,:,:G-.;,;;, Fig. 4 -Valve inserted into a diverted bowel Since the dog continued removing the pros­thesis, we decided to fix the external part of the prosthesis to the skin. The operation was per­formed in premedication with Combelene and under barbiturate anasthesia (Nesdonal}. The external tube of the prosthesis (Fig. 4) was fixed with polidec stitches. The animal now tolerated the prosthesis because it was sutured onto the skin and its removal would cause pain. The prosthesis re­mained in place for a week. Later, though, the dog managed to bite through the sutures and eliminate the prosthesis. The third dog, a mongrel -German shepherd, was somewhat smaller. For that reason we tried to expand the terminal part of the sigmoid with a few cuttings and a surgical trans­formation. Unfortunately, the animal was unsuffi­ciently purged before surgery. This provoked leakage and peritonitis owing to which the animal survived for only two days after the surgery. The second dog -the karst shepherd was of suitable proportions, whereupon we decided to carry out a simple discontinuance of the sigmoid and a terminal sigmoid stoma. The opreration was successful. After three weeks it was possible to insert the valve as in the primary version (from the years 1982 and 1983), and to suture the external ring onto the skin. It turned out that the inner ring of the valve was too small (35 mm). This provoked the leaked of faeces to the area around the valve. The valve remained positioned for 3 to 4 days; later the animal managed to remove and destroy it without trace. In further experiments we installed a number of valves. The insertion was done without sutur­ing, mainly in order to alow the attachment of the inner ring against the inner abdominal wall. A negative effect appared when the prosthesis was sutured to the skin because it was then not possible to adjust the length of the rubber tube. The prosthesis was attached to the skin while the inner ring floated loose in the lumen of the bowel. This caused leakage of faeces at the side of the inner ring. At the changing of the prosthesis, the diameter of the largest one was 55 mm, which was double the width of the lumen of the bowel in the experimental animal. In one case the symptoms of ileus were observed. The animal vomited after feeding, yet appeared lively during the later walk. Clinically, no symptoms of peritonitis could be observed. We removed the prosthesis and palpated the distal bowel. In the lumen of the bowel we could find a few lumps of faeces mixed with hay, which literally obturated approximately 1 O cm of the terminal bowel. The extraction of the prosthesis, digital evacuation of the hay lumps and the revised insertion was performed without any problems. The animal became lively again. With the exception of this short interrup­tion, the 55 mm prosthesis remained installed for another day (totalling 4 days). Later, the pros­thesis repeatedly fell out and was reinserted. AI together, the total period that the prosthesis was installed was one week. Finally the prosthesis fell out and could not be found any more. Discussion -The experiment showed that the terminally diverted colon successfully witstood the dilation with the elastic ring for up to the lenght which twice exceeded the width of the bowel. It was found unnecessary to enlarge the prosthesis ov.r the double diameter of the lumen of the bowel, as the satisfactory inner anchoring could be achieved at smaller diameters. Suturing of the external retention ring on the skin gave negative consequences. Not only did Radiol lugosl 1990; 24:261-5. Košorok P. Testing of the valve tor controlling the excretion of faeces and stomatherapy in the experiment on dogs this method damage the animal, it also suppres­sed the genuine fitting of the inner ring. Notice­able leakage of faeces at the side of the inner ring was observed. In other prostheses which were not sutured on the skin, the leakage of faeces was not observed. Nevertheless, minor leakage might be presumed, this being impossible to estimate owing to poorer hygienic conditions. A number of external retention rings had been applied -from the simplest thin ring to the 5 cm tube. The longer tube was adequate for the adjustment of the prolongation and for the regulation of stretch­ing of the tube. Vet, at the same tirne it provoke negative effects -it worked as a lever which luxated the prosthesis out of the bowel in case the animal lay on it. The external prolongation, as used in our experiment, enabled the excretion of faeces in the furthest possible distance from the animal, thus avoiding dirtyng of the animal. The negative side was that it was within easy reach for the animal to puli it out with its teeth. Such a removal of the prosthesis was quite successfully avoided by installing the safety basket on the animal's collar. A number of intresting conclusions were derived from the phase of the experiment in which ileus occurred. The obturation of the pros­thesis with the hay lumps provoked a stronger dilation of the bowel than usual. The increased pressure inside the bowel pressed the ring against the abdominal wall even harder, thus raising the possibility for the forming of pressure sore necrosis. The latter had been considered the worst danger for the use of the prosthesis. The ileus lasted approximately one day. The distension of the bowel additionally aggravated the blood circulation in the inestinal wall. In spite of ali this, the bowel was not damaged at the place where the prosthesis was inserted. From this incident we gain more insight into the experiment. The prosthesis could easily be extracted without sedative (Combelen) or anaesthetic (Nesdonal). The hey lumps were easly digitally removed from the lumen of the bowel. This brought us to the conclusion that the insertion and changing of the prosthesis was not an axtraordinarily painful and disagreeble proce­dure for the experimental animal; it could be expected that this would be true also in human patients. The obstruction of the prosthesis with the lumps implies another favourable possibillity for human patients. The complete tightening up of Fig. 6 -lnserted prosthesis with the collecting pouch. The puli stresses the firmness of installation of the inner ring. the prosthesis could be desirable as a possibe way of assuring complete continence of the artificial anus. Considering the fact that the most approp­riate place for the • diversion of the bowel in_ Radiol lugosl 1990; 24:261-5. Košorok P. Testing of the valve tor controlling the excretion of faeces and stomatherapy in the experiment on dogs human patients is the left lower quadrant of the abdomen, we used the same location in dogs. In our opinion, a more suitable location when the operation is repeated would Qe in the median line, perhaps involving the excision of the um­bilicus. So far, no need far a new surgical technique has been observed. The performance of the prosthesis, applied hitherto (Fig. 5, 6) satisfied the set goals. It appears reasonable to pass on to the experimen­tal use of this prosthesis in human patients. Only their observations and feelings could give us the necessary feed-back information and guidance far further adjustments, or changes of the primary construction of the prosthesis. Only one published source which deals with the application of a similar prosthesis could be found in the literature. It is manufactured by the firm Johnson-Johnson(1 ). In the national litera­ture, the installation of the rumen fistula in a calf, which was in use at the Institute of Psyhology of the VeterinaryFaculty in Ljubljana, far the study of digestion in the calf, should be mentioned (2). The commercial prosthesis far the rumen fistula with the valve, used experimentally far studying the digestion in the calf is known as well. It can be installed far an optional period of tirne (3). When studying the animal digestion the permanent intestinal canilas (Brueggemann­Jovanovic type) (4) in open fistulas are used. Generally, the analysis of the literature which was available to the author showed no attempts to control the excretion of faeces at the diverted bowel in a similar way (MEDLARS register, Koeln). Povzetek PREISKUS ZAKLOPKE ZA KONTROLO IZLOCANJA BLATA IN NEGO IZPELJANEGA CREVESA V EKSPERIMENTU NA PSU V poskusu je bila uporabljena vrsta zaklopk za kontrolo izlocanja blata pri izpeljanem crevesu, ki smo jih vstavljali v svetlino crevesa. Zeleli smo preiskusiti ali notranji elasticni obroc more povzrociti dekubitalno okvaro crevesne stene. Crevo je ostalo nepoškodovano tudi v slucajno nastalem ileusu. Menimo, da ta izvedba proteze ne okvaria crevesa. Predpostavljamo, da bi enak tip proteze lahko poskusno uporabili tudi pri bolnikih, ki bi nam lahko dali koristne povratne informa­cije. Te bi nam služile pri daljnjem razvoju proteze. Slucajno nastali ileus zaradi zacepljenja proteze naka­zuje še drugo možnost, ki bi bila pri bolnikih z anus praetrom zaželjena. S poklopcem na zunanjem na­stavku bi dosegli kontinenco anus praetra. Menimo, da je v tem eksperimentu zaklopka že razvita do stopnje, ko jo je možno uporabiti pri bolnikih s karcinomom rektuma, ki imajo amputirano rektosigmo in narejen anus praeter. References 1. Johnson-Johnson. The first major advance in ostomy appliance technology in over three decades. J Enterostom Ther 1985; 12(3) :71. 2. Pardubsky T. Postupak fistuliranja i kaniliranja buraga mlade teladi. Vetserum 1967; 9-10:564-6. 3. Vatovec S. Fiziologija prebave v predželodcih prežvekovalcev. Ljubljana: Univerza v Ljubljani, Bioteh­nicka fakulteta, 1971 ; 26-8. 4. Jovanovic M. Fiziologija domacih životinja. Beo­grad; Zagreb: Medicinska knjiga, 1984 ;300-1. Author's address: Dr. Pavle Košorok, University Medica! Centre Ljubljana, University Department of Ga­stroenterologic Surgery, Hospital Dr. Peter Deržaj, Vodnikova 62, 61 000 Ljubljana, Yugoslavia Radiol /ugasi 1990; 24 :261-5. th• 1ield ,n0uct• 30d O v · - -' . \.r:::. o u"' \ot . . •"dtt••"'"g. . ttn1ne f,gn\ 9a1,oe"' t l th• o•ct ges 1,off\ •" \\&t · isotol"'• r n •• ol nceoc••• co"5" io" i o\11 di tecnoo...o gtant,::---:,­ ol st•l>1• •"d 13 ..ne· • . \Stot c\\o\C3. f'I o,a"''"" g. oos\S .\ o,,ne••'"' uostances·. . sts a{e a...,a1\ab ·, ... "\uo -\-abotog\3 call?,; "''""' .;;«;t===I . . \­ 1 • '" ""0 ;.,ne< n\o 10• 10•'°"''"° an l"flo0es ­ 1\ofl ol no{ Radioimmunoassay FSH RIA for the determination of Follitropln Radioimmunoassay TSH -RIA for the determination of Thyrotropin Radioimmunoassay for the determination of Human Growth Hormone HGH -RIA Radioimmunoassay T 3 -RIA for the determination of total Trllodthyronlne Radioimmunoassay T 4 -RIA for the determination of total Thyroxin Radiolmmunoassay LH -RIA tor the determlnation of Lutropln R I A Radiolmmunoassay PROLACTIN for the determlnatlon of Prolactln Radioimmunoassay (3 -HCG -RIA for the determination of Chorlonlc R I A Radlolmmunoassay -for the determlnatlon of Eatradlol ESTRA D I O L Radiolmmunoassay for the determlnation of lnsulln Radioimmunoassay INSULIN -RIA DIGOXIN -RIA for the determlnatlon of Olgoxln VE Aul3en-und Binnenhandelsbetrieb Robert-R6ssle-Stra8e 1 O Berlin DDR-1115 German Democratic Republic Sisocommerz ALPE-ADRIA . z . > ...-i . . tj H ­ NV"HQVf3:d'1V 1st ALPS-ADRIA CONGRESS ON HEPATO -PANCREATO ­BILIARY SURGERY AND MEDICINE FIRST ANNOUNCEMENT ... ,, OCTOBER 3-5, 1991 CANKARJEV DOM, LJUBLJANA VENUE Cankarjev dom Cultural and Congress Centre Kidricev park 1, 61000 Ljubljana, Yugoslavia ORGANIZER -University Medical Centre Ljubljana, University Depar­tment of Gastroenterologic Surgery, Zaloška 7, 61000 Ljubljana, Yugoslavia Telephone: 38 61 322 282, Fax: .38 61 325 760 -Institute of Oncology Ljubljana, Zaloška 2, 61000 Ljubljana, Yugoslavia TECHNICAL ORGANIZER ANO SECRETARIAT Cankarjev dom Cultural and Congress Centre Kidricev park 1, 61000 Ljubljana, Yugoslavia Congress Department Telephone: 38 61 210 956 Telex: 32111 CK KKC, Fax: 38 61 217 431 OFFICIAL LANGUAGE The official language of the Congress will be English SCIENTIFIC PROGRAMME Dilemmas in HPB Surgery and Medicine Topics: HPB trauma liver metastases HPB malignancies biliary stones chronic pancreatitis tumors of biliary tract transplantations will be presented and discussed in: PLENARY SESSIONS, with pro and contra lectures, round table discussion and free papers VIDEO SESSIONS, presenting surgical and nonsurgical techniques, POSTER SESSIONS, where the posters of the above mentioned topics will be discussed and prizes will be awarded to the besi posters. INVITED LECTURERS DR. S. BENGMARK DR. L. H. BLUMGART DR. O. BOECKL DR. F. P. GALL DR. GOZZETTI DR. J. G. KREJS DR. U. LEUSCHNER DR. N. J. L YGIDAKIS DR. B. C. MANEGOLD DR. R. MARGREITER DR. R. OTTENJANN DR. K. J. PAQUET DR. T. SAUERBRUCH DR. J. SCHEELE DR. N. SOEHENDRA DR. l. TAYLOR DR. H. TROIDL and others SOCIAL PROGRAMME Welcome Reception Reception an the T own Hall Concerts Tours of lake Bled, Postojna Caves, Lipica ACCOMMODATION A number of rooms -single and double -will be reserved for the Congress Participants and their Accom­panying Guests at hotels in Ljubljana, all within walking distance from the Congress venue. EXHIBITION An exhibition of pharmaceutical and surgical equipment will be held at Cankarjev dom. Lund Bern Salzburg Erlangen Bologna Graz Frankfurt/Main Amsterdam Mannheim Innsbruck Munchen Bad Kissingen Munchen Erlangen Hamburg Southampton K61n DEPARTMENT OF RADIOTHERAPY1, ENT -DEPARTMENT2 HOSPITAL BARMHERZIGE SCHWESTERN, LINZ, AUSTRIA HIGH DOSE RATE lr-192 IMPLANTS IN THE TREATMENT OF CANCER OF THE VOCAL CORD Hammer J 1, Hochleitner F2, Seewald DH1, Meindl J2, Labeck W1 Abstract -Since September 1986 an lr-192 source with a high dose rale has been used for interstitial boosting of the tumor-bearing vocal cord in the organ-preserving management of larynx carcinoma. So far 6 patients with 8 vocal cord tumors have been treated. 5 patients presented with a T1 tumor, 2 of them with an in situ carcinoma in the contralateral vocal cord, and 1 patient presented with a T2 stage. AII patients except 1 underwent local tumor removal. The treatment method included external radiotherapy with a dose of 5000 cGy to the larynx. The patient who refused surgery was treated with 6000 cGy. 1 to 2 weeks after external radioll:!erap_y an interstitial implant into the vocal cord was performed. Using two needles per cord a boost dose of 1000 cGy was given to the tumor area. T.e method of implantation and the needle set-up will be described. The median follow-up tirne is 34 months (range 44-20, calculated May 1990). So far no local or regional failures occured. None of the patient had intra-or postoperative complications. Ali patients have preserved their voice, 2 of them presen! with a mild hoarsness. Concerning the late effects, 1 patient developed a mild submental edema, 1 patient presents with teleangiectasia on the treated vocal cord. The number of patients is very low, bul the psycho-social aspects of preserving the ability to speak is of high value. UDC: 616.22-006.6:615.849.2 Key words: laryngeal neoplasms-radiotherapy, vocal cords, brachytherapy, iridium radioistopes Orig sci paper Radiol lugosl 1990; 24: 269-72. lntroduction -In the first half of our century vocal cord carcinomas were treated with Radium implantations (1, 2, 3, 4) and this method has been preferred by some radiation expert in the last 3 or 4 decades (5, 6, 7). Brachytherapy has been replaced by the introduction of teletherapy and in part by surgical procedures. Recently brachytherapy has come back into use, using mainly the isotope lridium-192. Most centers use wires with a low dose rate source. Usually radia­tion treatment is the initial treatment prescribed for early lesions, with operation reserved for salvage of irradiation failures. While chordectomy or hemilaryngectomy will produce comparable cure rates for selected T1 and T2 vocal cord lesions, irradiation is the preferred initial therapy. The major advantage of irradiation compared to chordectomy or hemilaryngectomy is that the voice quality is likely to be better. The voice after hemilaryngectomy remains hoarse. After suc­cessfull irradiation the voice is usually better than before therapy, a worsening of voice quality is uncommon. Hemilaryngectomy may be used as a salvage operation in suitable cases after irradi­ation failure. Complete stripping of the mucosa of the cord is sometimes curative for lesions vari­ously classified as leukoplakia, dysplasia or car­cinoma in situ. In these patients early use of irradiation means a better chance of preserving a good voice. The difficulties in differentiating of carcinoma in situ from microinvasion tend to put the decision towards radiation. There is an increasing use of the laser surgery in removing benign lesions and very early carcinomas involving the true vocal cords (8). Preservation of the voice and quality of life should be considered before deciding on the treatment method (9). Occasionally radiation therapy leads to a permanent hoarsness (1 O, 11 ), but in general after surgery -even after conservation of the vocal cord -a considerable reduction of the voice quality is to be expected (12). The reduction of speechability and the quality of voice results in a reduction of life quality (13, 14, 15). The results after laryngec­tomy and the complete loss of voice are well known: The patient retreats from his social sur­rounding, from his workplace as well as from the family. Often these circumstances results in The material was presented on Synposium: »New arhievements in radiotherapy«, Ljubljana, October, 1989. Received: June 26, 1990 -Accepted: July 17, 1990 ·, Hammer J et al. High dose rale lr-192 implants in the treatment of cancer of the vocal cord chronic alcoholism. Many patients are not able to continue with the treatment or to cooperate be­cause of their low social status. After laryngec­tomy only a small percentage of patients are able to use the offered help, e.g. to learn the socalled esophagus speech', or to use electronic aids. Patients and Method -Since December 1986 an lridium 192 source has been used for interstitial boosting of the tumor -bearing vocal cord in the organ preserving management of larynx carcinoma. Until September 1988 6 pa­tients with 8 vocal cord tumors have been treated: 2 patients presented with tumors on both cords and were treated simultaneously. 5 pa­tients presented with a T1 tumor, 2 of them with an in situ carcinoma in the contralateral vocal cord, and 1 patient with a T2 stage. AII except 1 T1 patient underwent tumor excision or cord stripping. lrradiation for early vocal cord cancer is delivered by small portals, covering only the primary lesion. Tretment fields for T1 and T2 tumors usually extend from the thyroid notch superiorly to the inferior border of the cricoid. The posterior border depends on the posterior extension of the tumour. The field size ranges from 4x4 cm to 6x6 cm. The incidence of lymp node involment is so small (0% -1 %), that elective irradiation of nodes usually is recom­mended only for T3 or T4 lesions, or for T2 lesions with poorly differentiated histology (16). Our treatment method included percutaneous radiotherapy with a dose of 5000 cGy to the larynx with 2 treatment portals in the size of 5*5 or 6*6 cm using wedge filters. The patient who refused surgery was treated with a dose of 6000 cGy. 1 to 2 weeks after external radiotherapy an interstitial implant into the vocal cord has been performed. Using 2 needles per cord a boost dose of 1000 cGy was given to the tumour area by means of a high dose rate lr-192 source. lts maximum activity is 8 Ci. The procedure is performed under general anesthesia of the pa­tient. Using a Kleinsasser or Weerda device the needles were inserted by the ENT-surgeon under direct view of the cord. The distance between the needles is 1 O mm in the range of 7 to 12 mm. The dose of 1000 cGy is calculated to that isodose which covers the entire area of the primary lesion. Fig. 1 shows the combied isodose-plot of external and interstitial radiotherapy. An interoperative prednisolone i.v.­dose prevents the patients from major edemas. The treatment tirne per needle depends on the actual activity of the lr-source and is usually in the range of 1 to 2 minutes. The lr-source oscillates inside the needle and the lenght of oscillation can be adjusted from 1 to 4 cm by mechanical disk. Using the 4 cm oscillation path the tratment volume, this is the 1000 cGy isodose shell, shows a size of about 1 to 2 to 4 cm. Until May 1990 16 patients have been treated in the same method. AII the statements mentioned above remain true concerning all pa­tients. Results -The median follow up tirne of these 6 patients is 32 months in a range of 18 to 42 months refferred to March 90. So far no local or regional failure ocurred. AII patients are free of ISODOSES O 7000 1 6000 2 5500 3 5000 4 4000 y A Fig. 1 : Dose distribution of the combined plan of external radiation and interstitial therapy. lsodose No. 1 marks the 6000 cGy area, No. 2 5500 cGy, and No. 3 5000 cGy. Radiol lugosl 1990; 24: 269-72. Hammer J et al. High dose rate lr-192 implants in the treatment of cancer of the vocal cord disease. None of the patients had intra -or postoperative complications. The side effects to the glottic mucosa are slight and transient. An intraoperative prednisolone i.v.-dose prevents the patients from major edemas. Ali patients have preserved their voice. 2 of 6 present with a mild horsness. No functional troubles in swallow­ing have been observed. Concerning the late effects 1 patient developed a mild submental edema, 1 patient presents with teleangiectasia on the treated vocal cord. Discussion -In the treatment of T1 -T2 tumours with radiation therapy, a high percen­tage of disease free survival can be expected (17). The goal of radiation therapy, on the one hand, is cure with the best functional result and the least of serious complications (18), and on the other hand, is to reduce the rate of local recurrences as much as possible, both by carefull planning of the radiation and adequant dose application (19, 20). The main advantage of radiotherapy in comparison to laryngectomy or hemilaryngectomy is the preservation of the voice (21 ). In case of a local recurrence surgical operation to remove the tumor can be underta­ken. A decision to perform a hemilaryngectomy or a total laryngectomy depends on the extent of the tumour. A survey by Stalpers concerning the rate of local recurrences and survival shows a survival-rate of 86% after primary radiation (in the range of 80% to 91%) and of 88% after primary surgery. The rate of local recurrences after primary radiation is 30% and after surgery 20%. The possibility of salvage surgery after local recurrences is 50% in the radiation therapy group and 30% in the surgery group. After salvage surgery the rate of persistent local re­currences in the radiotherapy group therefore is 15%. In the group of patients with primary surgery (and a 20% local recurrence rate) only 6% could be considered tumour free after sal­vage surgery (14% unsalvaged). These are aver­age data from different cancer centers and clinics. It is to be noted that each individual center or clinic offers differe'nt results wich could lead to different conclusions. Some authors report a correlation of the incidence of local recurrences, on the one hand to the applied dose and to the other hand to the size of the treatment portals dependent of the tumour stage (16, 22). Some papers indicate no noticable reduction of local recurrences with in­creased radiation doses (23). Accelerated fractio­nation seems to be successfull (8, 18, 24). Pene (25) reports about in situ carcinomas in the stage T1 and T2 showing the same rate of local recurrences as invasive tumours. He as­sumes that these are not true recurrences but a new tumour deriving from the primary dysplastic epithelium. It is to be considered that along with every diagnosed in situ carcinoma other invaded areas may be present. The number of patients in our series treated with high-dose--rate lridium implantations is very low, therefore the data are of limited value, but the psyche>--social aspects of preservation of the ability to speak is of high value. The preliminary results are encouraging: so far no local or reg­ional recurrence have occured. It remains to be seen if a boost using lridium implantation directly into the vocal cord results in a noticable reduction of local recurrences. References 1. Escat E. Radiumtherapie laryngee par fenestra­tion thyreoidenne laterale. Presse Med 1921 ; 31 :1067. 2. Finzi NS, Harmer D. Die Radiumbehandlung des primaren Kehlkopfkarzinoms. Strahlentherapie 1929; 32:81. 3. Jakobi H. Die Radiumbestrahlung der Stimm­bandkarzinome. HNO 1951; 2:349. 4. Minnigerode B. Radiumbehandlung des Stimm­bandkarzinoms. Stuttgart: G Thieme Verlag, 1966. 5. Jatho K. Zur Radiumkontaktbestrahlung des ein­seitigen Stimmbandkarzinoms. Arch 0hr Nas Kehlk Heilk 1963; 182:518. 6. Minnigerode B, Karduck W, Bausch J. Die Stellung der Radiumkontaktbestrahlung innerhalb der aktuellen Strahlentherapie des Stimmband-Karzinoms. Tumor Diagn Therap 1983; 4:213-5. 7. Pfander F. Einseitige Schildknorpelfensterung und Radiumeinlage bei Kehlkopfkarzinom unter 0bers­chreitung der bisher ublichen lndikationsstellung. Arch 0hr Nas Kehlk Heilk 1951; 159:159. 8. Symposium Funktionserhaltende Therapie des fruhen Larynxkarzinoms. G6ttingen, BRD, November 1989. 9. Fletcher GH. Functional surqery and radiothe­rapy in head and neck cancer. In: Withers HA, Peters LJ Eds. lnnovations in Radiation Oncology. Berlin: Springer Verlag 1988; 35-40. 1 O. Stoicheff ML. Voice following radiotherapy. Laryngoscope 1975; 85 :608-18. 11. Stoicheff ML, Ciampi A, Passi JE, Fredrickson JM. The irradiated larynx and voice: a perceptual study. J Speech Hearing Res 1983; 26:482-5. 12. Harwood AR, Tierie A. Radiotherapy of early glottic cancer. II. lnt J Radia! Oncol Biol Phys 1979; 5:477-82. 13. King PS, Fowlks EW, Person GA. Rehabilita­tion and adaptation of laryngectomy patients. Am J Phys Med 1986; 47:192-203. 14. Minear D, Lucente F. Current attitudes of laryngectomy patients. Laryngoscope 1979; 89 :1061-5. Radiol lugosl 1990; 24: 269---72. Hammer J et al. High dose rate lr-192 implants in the treatment of cancer of the vocal cord '-.;.., 41() O (' "'>-. . ..... ?'!-. '. .. . --'!", C\ ('Q. '-9 . . 80 % , no radiological evidence ot distant metastases, normal renal and hepatic tunction, no history ot The material was presented on Symposium »New achievements in radiotherapy«, Ljubljana, October, 1989. Received: April 30, 1990-Accepted: May 17, 1990 Arian-Schad KS et al. Prelimina,x report on radiotherapy in stage III ovarian cancer pretreated by surgery and chemotherapy malignant disease aside from basal celi carci­ noma and no severe concomitant medica! iliness. Preoperative radiological work-up consisted of chest x-ray, CT scan of the abdomen and pelvis, and intravenous pyelogram (IVP). lf indi­ cated, ultrasound of the !iver was performed in addition to help rule out hepatic metastases. The surgical procedure was aggressive and included hysterectomy, bilateral oophorectomy, omentectomy and attempted radical lymph node dissection of both the pelvic and paraaortic no­ des. lf tumor showed involement of adjacent organs or structu(es, either partial cystectomy, appendectomy, abdominoperineal resection or resection of parts of the intestinum were perfor­ med. Exploration of the diaphragmatic surface and peritoneal washings were carried out routine­ ly . Postoperatively the complete surgical speci­ men was examined to determine stage, lymph node involvement, tumor subtype and grade. Two to 3 weeks after surgery systemic the­ rapy was initiated with the aim to deliver 6 cycles of a multidrug regimen containing cis-platinum (PAC). Subseqent to the completion of chemothe­ rapy a complete clinical and radiological resta­ ging was performed. lf blood counts showed at least 3000/mm3 leukocytes and 100 000/mm3 platelets, respectively, radiation therapy was ini­ tiated. The treatment fields were planned using a CT-aided planning system. The radiation techni­ que chosen was similar to the technique descri­ bed by Schray et al. (21) with miner modifications with regard to blocking of the kidneys and !iver, an enlarged width of the subdiaphragmatic boost field and the simultaneous treatment of abdomi­ nal lymph nodes and the true pelvis. First, an open abdominal AP/PA field (WAP) encompas­ sing the entire peritoneal cavity was applied up to a total dose of 30 Gy (1 .5 single fraction per day,5 days a week). After a 2-week rest a subdiaphragmatic boost field with 12 Gy was added in cases with negative paraaortic nodes. lf involvement of these nodes had been assessed histologically the field was extended to cover the entire subdiaphragmatic and paraaortic lymph node region. Simultaneously, the true pelvis was treated in ali patients up to a total dose of 51.6 Gy with a single fraction of 1.8 Gy per through AP/PA shaped fields. Blood counts were performed once a week or more often if indicated. Foliow-up exams . 278 were scheduled on a 3-month basis and included physical examination, blood chemistry, asses­sment of tumor markers, and radiological work­up. Statistical analysis -Survival was measured from the onset of surgical therapy and the onset of radiation utilizing the Kaplan-Maier product limit method (22). The Cox proportional hazard model was used tor the determination of prognostic factors correlating with overali or di­sease-free survival (DFS). The statistical diffe­rences between the various factors were asses­sed by the Mantel-Haenszel test; those included: exent of residual disease at the tirne of surgery (none visible vs :s 2 cm vs > 2 cm), histologic subtype, tumor grade, lymph node involvement of the pelvis, paraaortic region or both. Results -Maximum cytoreductive surgery was performed in ali but 2 patients, in whom praaortic lymph node sampling was performed only. In one case partial bladder resection was done and in two cases parts of the intestinum had to be removed because of tumor infiltration into these organs. Chemotherapy was given to ali patients ran­ging from 4-10 cycles (median, 6 cycles). Dose reduction in the last cycle of chemotherapy was necessitated in 6 cases, which was due to acute hematologic toxicity in 5 patients and hepatitis in one patient. Ali cases presented with FIGO stage III carcinoma based on the presence of widespread and bulky intraabdominal disease. In addition, histopatological staging revealed nodal involvement in 75% of cases. In 3 patients positive findings were restriced to pelvic nodes, in one case paraaortic involvement without con­comitant pelvic disease was diagnosed and in 11 (55%) patients involvements of both lymph node regions were noted. Histopatological assessment of tumor subty­pes revealed 12 serous, 3 endometroid, 2 muci­nous, 2 clear-cell and one undifferentiated ade­nocarcinoma. Grading of the tumors was almost equally distributed by 5 weli, 7 poorly, and one undifferentiated carcinoma. Maximum debulking with no macroscopic disease visible in the abdomen was achieved in 8/20 (40%), in 3/20 (15%) tumor of equal or less than 2 cm, and in 9/20 (45%) more than 2 cm had to be left in the peritoneal cavity. The radiation treatment was well tolerated aside from the expected side-effects of WAP Radiol lugosl 1990; 24: 277--B1. Arian-Schad KS et al. Preliminary report on radiotherapy in stage III ovarian cancer pretreated by surgery and chemotherapy radiation such as inapetence, diarrhea, general f,atique and nausea. In one patient treatment was interrupted on request because of vomiting, in two others the course of radiation was not com­pleted due to prolonged bone marrow depletion after 10 and 12.5 Gy, respectively. Five patients (29%) required treatment breaks ranging from 8 to 16 days (median 12 days) because of transient leukocytopenia or thrombocytopenia, of whom all were finally able to receive the prescribed dose. Overall and DFS at 3 years from date of surgery for the patients who completed the full course of radiation was 69% and 47%, respecti­vely, with a follow-up for overall survival ranging from 19 to 53 months. Overall survival and DFS from initiation of radiotherapy was 71 % and 23.8% (follow-up: 10 to 45 months). The tirne to recurrence was 17 to 37 months (median, 20) and 9 to 29 months after surgery or onset of radiation, respectively. Seven patients (41 % ) recurred in the abdo­men alone, one failed in the left supraclavicular lymph node and another patient relapsed in both supraclavicular nodes at 20 and 38 months, as sole sites of disease. Thus, the overall relapse rate was 53% in the patients who had completed the trimodality approach. The sites of failure were located at the dome of the diaphragm in 3 cases, paraortic and paracaval lymph nodes in 1 case and the pelvis in two cases. One patient developed recurrent disease at the diaphragm and in the pelvis simultaneously. Recurrences in the abdomen were diagnosed at a median tirne of 23 months (range: 17-25 months). The interval from detec­ tion of recurrent tumor and death was short, ranging from 1 to 8 months (median 3 months). Statistical analysis showed that among all factors evaluated only the amount of residual mass left after surgery significantly influenced DFS and overall survival (none vs < 2 cm or > 2 cm, p < 0.001 ). Correlation with the amount of residual disease at surgery over tirne showed that survival was 100% for patients with no visible disease, 66. 7% for < 2 cm residual and only 26. 7% for patients with more than 2 cm residual mass. The 3-year intraabdominal DFS after surgery was 54.4%, respectively. Discussion -The lack of uniformity in the treatment of advanced ovarian carcinoma makes it difficult to compare the various treatment moda­lities described in literature (2, 3, 4, 8, 9, 1 O, 11, 15, 16, 17, 19, 20, 23, 24). This refers to more or less aggressive surgical approaches, the number of cycles and the differing drug combinations applied, the performance of pathological or clini­cal restaging for the evaluation of respo.se to chemotherapy, and the differing doses and treat­ment techniques chosen for radiation therapy. Prospective trials randomizing postoperative chemotherapy to primary radiotherapy are lac­king and little is known about the optimum se­quence of the various modalities employed so far. Although the number of patients in our series is small the feasibility of combining a maximum debulking surgery with combination chemothe­rapy and high-dose radiation with acceptable toxicity has been shown. The comparatively low rate of acute hematologic toxicity and severe complications with regard to bowel injury might be related to the relatively low number of che­motherapy cycles employed and the renunciation of second-look laparotomy (2, 7, 9, 18, 21 ). Careful attention was paid to selection crite­ria for the patients treated with this protocol. AII patients presented with bulky abdominal disease and were not classified as stage III based on positive nodal involvement only. Prospectively radical dissection of both pelvic and paraaortic nodes was attempted in order to minimize possi­ble residual tumor in the peritoneal cavity and to determine the percentage of paraaortic lymph node involvement. lnspite or aggressive surgery, however, residual disease of > 2 cm in 45% and less than 2 cm in 15% of cases could not be completely removed. This was particulary true when tumor was located at the right diaphragma­tic surface, which occurred in 9 of 20 patients in our series. The efficacy of chemotherapy in eradicating macroscopic residual disease has been demon­ strated with clinical response rates of 90% with regimens containing cis-platinum -the patholo­ gically confirmed complete responses (pCR), how­ ever, revealed that only 30-40% of patients were free of tumor on second-look laparotomy. Despite of histopathologically verified tumor con­ trol, up to 50% of patients have been shown to relapse (2, 3, 8, 1 O, 14, 25, 26). Thus, the potential benefit of adjuvant radiotherapy for consolidation of response in this subgroup of patients warrants further investigation. The role of second-look laparotomy (SLL) is controversial. SLL has praven useful in asses­ sing the response to different chemotherapy protocols and was considered helpful in selecting subgroups of patients, in whom adjunctive treat­ ment might be indicated (2, 3, 4, 9, 13, 19, 20). Radiol lugosl 1990; 24: 2n--e1. Ariari-Schad KS et al. Preliminary report on radiotherapy in stage 111 ovarian cancer pretreated by surgery and chemotherapy For nonresponders, however, second line treatments showed poor results. In an attempt to alter the course of disease, secondary debulking at SLL was suggested, but the impact of such procedure also seems unclear. Rizel et al. (8) reported on 12 patients with secondary complete removal of the tumor, of which only 4 patients remained free of disease. Ho et al. (26) failed to demonstrate an impact on survival comparing two groups of patients with and without SLL. The analysis of pattern of failures in our patient series showed, that ali patients recurred at sites of initial macroscopic residual mass. This is in agreement with other reports, which showed that the exent of residual disease left in the abdomen does correlate significantly with survi­val (2, 3). The specific role that either chemothe­rapy or radiotherapy contributed in our series stili remains unclear. In agreement with other studies, however, it seems that maximum debulking at the initial operative procedure is predictive in terms of overali and DFS regardless of aggres­sive adjuvant therapies available at that tirne (2, 25, 27). Conclusion -This study demonstrated that high dose radiation is weli tolerated inspite of preceding radical surgery and multidrug chemot­herapy. Based upon the relatively low number of chemotherapy cycles employed as compared to other studies in literature, and the omission of SLL, acute toxicity was moderate and serious complications were restriced to one patient in our series. The 3-year overali and DFS rates of 69% and 47%, respectively, compare favorably to those reported in previous studies, particulary considering that only patients with widespread intrabdominal disease were included into this protocol. However, this approach seems to be of value only for patients with no or minimal disease after surgery. A randomized study is warranted to verify the benefit of adjuvant radiation in this particular subgroup of patients. References 1. Bruckner H W, Cohen C J, Goldberg J D, Kabakow B, Wallach R C, Deppe G, Greenspan E M, Gusberg S B, Holland J F. lmproved chemotherapy for ovarian cancer with cis--urc scminoma millignant teratoma 'l'D, MTI, MTU MTT with high hCG or MTT with low hCG pure cl1orion carcinoma 1 stag8 stage stage stlge sta.e stagestage I-I Il3 IIC III,IV 1, IIA IIIl IIC, F-IV III,IV Radiation Retroperitoneal lymphadenektomy 1 1 \ Control Control Adjuvant Chemotherapy CombinationChemotherapy Vinblastine was substituted by etoposide to avoid the polyneuropathy induced by vinca alka­loids (6). Some studies recommend total renun­ciation of bleomycin when there is minimal or slight tumor mass and reduce the combination polychemotherapy to cistplatinum and etoposide (7). When dealing with an extended tumor mass in the sence of ,;bulky« disease, therapy has to .be highly intensive from the start. Here we have had very good results with a regimen of etoposi­de, cisplatinum, bleomycin and cyclophospha­mide (ECBC). Even in very advanced stages of disease, we managed to obtain more than 60% complete remissions. In the case of brain meta­stases, the prognosis is no longer fatal. Here the extent of cerebral metastases is as important as the extent of lung metastases and their ability to respond to therapy. Brain metastases of the malignant grem celi tumor react weli to total brain irradiation of 60 Gy. With 3 patients in this advanced stage of disease we achieved a long term complete remission with no evidence of disease that has now been lasting for more than 3 years. There is an indication for surgery only in the case of solitary brain metastases. Apart from the radiation of brain metastases, radiation remains the therapy of choice when pure semi­noma is classified. Even when metastases are 5 cm in diameter, cure with radiation therapy of a total of 30 (to 40) Gy is possible. Only when the lymph nodes exceed 1 O cm in diameter, are the results not convincing when radiation alone is implemented.Where nodes are between 5 cm Radiol lugosl 1990 24:283-7. and 1 O cm in size, the question of curative radiotherapy is heavily discussed. In the Munich Tumor Center we have agreed on recommending primary chemotherapy for ali cases where lymph nodes exceed 5 cm in diameter (8, 9). After obtaining good results with teratoma patients, we advise a combination chemotherapy for semi­noma patients consisting of Cisplatinum 20 mg/m2 days 1-5 lfosfamide 1 ,2 g/m2 days 1-5 Etoposide 75 mg/m2 days 1-5 Carboplatinum is less nephrotoxical than cisplati­num, but more toxic to the bone marrow. When used as a monotherapy for seminoma, it achie­ves good results, but these must be further documented in additional studies (1 O}. Results of therapy -Our table (Table 4) shows the results of therapy in 250 patients with malignant germ celi tumor who were treated at our Center between 1979 and 1989. The 222 teratoma patients were subdivided into 167 histo­logicaliy pure teratomas, the remaining 55 pa­tients showed a combination of teratoma and seminoma (25%). While the pure seminoma patients showed a remission rate of 90% (28/32 patients) even in advanced stage of disease IIC-IV after having received chemotherapy, tera­toma patients show a stage-dependent complete remission rate of 50-100%. In the unfavorable subgroups (IIC-IV) with advanced visceral and cerebral metastases, it is possible to achieve complete remission only for a few patients. Clemm Ch et al. Treatment of the malignant germ celi tumor Secondary surgery -After completion of chemotherapy in the case of patients with »bul­ky« disease, i.e. large tumor mass, secondary surgery is indicated when remains of tumor are evident. Hereby retroperitoneal lymphmetasta­ses remains are radically removed and histologi­caliy examined, after diagnosis in the cat scan. Remaining uni-or bilateral lung metastases can be removed radicaliy by thoractomy. From 1979­1989, 82 of our patients underwent either retro­peritoneal lymphadenectomy or thoracotomy, to­taliing 103 operations. Secondary surgery brought to light 3 types of histology -malignant undifferentiated tera­toma {MTU) in 12 cases, diferentiated teratoma (TD) in 46 cases, and necrotic tissue in 45 cases. Of all 82 patients, 70 remained tumor-free after secondary surgery. Twelve patients achieved only partial remission and relapsed in the months following surgery. Therapy depends on the histo­logical results. lf vital tumor remains are evident, »salvage« chemotherapy with etoposide, ifosfa­mide and cisplatinum {EIP) is necessary. Unwanted effects of chemotherapy and operation -In addition to the acute toxicity ­especially to bone marrow -and nephrotoxicity with cisplatinum, chronic toxic side effects due to chemotherapy or surgery have to be taken into consideration. Bone marrow toxicity, e. g., is the major factor leading to dosage reduction of ci­splatinum, etoposide and ifosfamide. Bleomycin is not toxic to bone marrow, but has pulmonary toxicity dependent on the dosage. lf this exceeds a total of 400 mg irreversible lung fibrosis can occur as a result (11 ). Thus it is advisable to substitute bleomycin with ifosfamide in cases with a large dosage or in older patients or those having received prior radiotherapy. With older seminoma patients, ifosfamide should be given. Vinca alkaloids have been replaced by eto­poside because of their ability to induce polyneu­ropathy. It stili remains unclear whether carbopla­tinum can be used entirely as a substitute for cisplatinum, because while reducing the oto­and nephrotoxic side effects, it is highly toxic to bone marrow. Here it is also important to note that its therapeutic value in the case of nonsemi­noma as compared with cisplatinum stili remains to be proven. When judging long-term side effects, two factors must be taken into account: testicular cancer patients are usualiy young and often wish to have children. Here the question of gonadoto­ xicity must play an important role in the choice of therapy. While resection of the testis is without Table 4 -Treatment results in testicular cancer Stage Number of patients complete remission Seminoma Teratoma IIC-IV 1 IIA 11B IIC Bulky II (A-C) III IV A/B 28/32 37/40 23/24 38/38 7/14 68/76 12/19 53/37 88% 93% 96% 100% 50% 89% 63% 61% influence on the endocrinological function and the production of semen in the contralateral testis, retroperitoneal lymphnode resection often impairs ejaculation reflexes. Due to the seve­rance of the L2/L3 ganglion on both sides, a retrograde ejaculation can take place. Here it helps already to limit the operation to one testis and use standardized and modified operating techniques in lieu of radical retroperitoneal lymp­hadenectomy. The sides effects of chemotherapy are often reversible. There remains the possibility of prior kryoconservation of sperm, but here one must consider the fact that in about 50% of patients a greatly reduced sperm production exists at the tirne of diagnosis (oligo/azoosper­mia). The second question that arises here is whether intensive chemotherapy induces secon­dary tumors. After more than 1 O years of studies, single cases of patients with a secondary tumor are reported, yet this low rate cannot serve as a reason for restricting adjuvant chemotherapy. Yet, of course, ali new results should be closely studied {12, 13). Follow up -In order to quantify the effects of therapy, patients have to be controlied at regular intervals. The most important effect of a careful foliow-up programme with compliance on the part of the patient is the posibility of early detection of a relapse. This occurs in the case of prior chemotherapy in about 10% of our patients. Most of these relapses occur within the first two years foliowing treatment (90%), which docu­ments the importance of close foliow-up schedu­les. After this period, patients should be checked at least for 5, better for 1 O years in order to detect late relapses (14). References 1. Einhorn LH. Testicular Cancer as a model tor a curable neoplasm. Cancer Res 1981; 3275-80. Radiol lugosl 1990; 24:283-7. Clemm Ch et al. Treatment of the malignant germ celi tumor 2. Schmoll HJ, Weissbach L. Diagnostik und The­rapie von Hodentumoren. Berlin-Heidelberg-New York 1988. 3. Clemm CH, Sauer H, Hartenstein R. Behand­lung nichtseminomatciser Hodentumoren im Stadium I-11B. DMW 1989; 1276-82. 4. Urogenitaltumoren. Emptehlungen zur Diagno­stik, Therapie und Nachsorge. Manual des Tumorzen­trums Munchen, 1989. 5. Logothetis CJ, Swanson DA, Dexeus F et al. Primary Chemotherapy tor Clinical Stage II Nonsemino­matous germ celi tumor ot the testis: A Follow-up ot 50 Patients. J Ciin Oncol 1987; 5 :906-11. 6. Williams SD, Birch R, Einhorn L, et al. Treat­ment ot disseminated germ celi tumors with cisplatin, bleomycin, and either vinblastine or etoposide. New Engl J Med 1987; 316:1435. 7. Stoter G, Kaye S, Jones W et al. Cisplatin and VP 16/ +/-Bleomycin (BEP versus EP) in good risk patients with disseminated nonseminomatous testicular cancer. ECCO 4 1987; 179. 8. Clemm CH, Hartenstein R, Willich N et al. Vinblastine-ltostamide-Cisplatin Treatment ot Bulky Seminoma. Cancer 1986; 58:2203-7. 9. Clemm CH, Hartenstein R, Willich N et al. Combination Chemotherapy with Vinblastine, lfosfa­mide and Cisplatin in bulky seminoma. Acta Oncologica 1989; 28 :231-5. 10. Horwich A, Dearnaley DP, Williams M et al. Simple Non-Toxic Treatment ot Advanced Metastatic Semminoma with Carboplatin. J Ciin Oncol 1989; 7:1150-6. 11. Clemm CH, Hartenstein R, Mayr B. Bleomy­cin-induzierte Lunqeninfiltrate bei der Behandlung von Hodenkarzinomen. Klin Wschr 1984; 62:138-44. 12. Roth BJ, Einhorn L, Greist A. Long-term complications ot Cisplatin-based Chemotherapy tor Testis Cancer. Seminars in Oncology 15, 1988; 5 :345­50. 13. Wiliams SD, Stablein DM, Einhorn L et al. lmmediate Adjuvant Chemotherapy versus Observa­tion with Treatment at Relapse in Patholoqical Stage II Testicular Cancer. New Engl J Med 1987; 317:1433-8. 14. Clemm CH, Berdel WE, Hartenstein R et al. Munchner Naschsorgeschema bei tortgeschrittenen nichtseminomatcisen Hondentumoren. DMW 1986; 111:1181. Author's address: Priv. Doz. Dr. Ch. Clemm, De­partment of Interna! Medicine 111, Klinikum Grosshadern ot the University of Munich, Marchioninistrasse 15,; D-8000 Munchen. 70, Deutchland. Radiol lugosl 1990; 24:283-7. danes najuspešnejši kinolonski preparat Cenin® /Ciprobay@ ciprofloksacin širokospektralni kemoterapevtik • hitro baktericidno delovanje na gram pozitivne in gram negativne mikroorganizme kakor tudi na problemske klice ..,.,,. • izrazito delovanje na psevdomonas • hiter terapevtski uspeh zaradi visoke ucinkovitosti • dobra prenosljivost • samo dvakratna dnevna uporaba, kar pomeni veliko olajšanje v klinicni in splošni praksi • prednost tudi zaradi oralnega zdravljenja na domu Kontraindikacije: preobcutljivost za ciprofloksacin; otroci in mladi v dobi rasti; nosecnost, dojenje; previdnost pri starejših bolnikih in poškodbah osrednjega živcevja. Bayer-Pharma Jugoslavija Ljubljana INSTITUTE OF ONCOLOGY ANO RADIOTHERAPY, KBC, REBRO ZAGREB, YUGOSLAVIA LOCAL DOSIMETRIC FUNCTIONS AND LUNG CORECTION FACTOR UNDER 6°Co TBI Vrtar M Abstract -The points where the absorber doses in a phantom under 60Co TBI conditions have to be determined, are equally important regardless their being in central or off-axis position, but the basic dosimetric tunctions, such as TAR and POD, reter only to the central ray measurments. Theretore, we introduced the local dosimetric tunctions which depended on the specific distribution ot the scattering centers around the location ot interesi. It means that the location became a center ot an effective tield. For the purpose ot measurments an anatomic-cu­boidal water phantom, representing the man lying on his side, was constructed.Further, a theoretical model, based on sector integration method, adapted tor TBI, was established. The agreement between experiment and theory tor the local TAR was better than 2% tor the depths ot AP/2 on average, tor ali investigated locations. In this model the lung's correction tactor depends on the local TAR in water, contours ot the lungs ·and TBI phantom at a certain depth, density ot inhomogeneity and dose distribution ot the primary beam. The experimental values ot the correcti;:m tactor differ trom the theoretical ones tor 3.3% on average, tor ali tlepths. The correlation to the literature data was discussed. UDC: 616.24-006.6 :615.849.2 Key words: Jung neoplasms-radiotherapy, radiotherapy dosage Orig sci paper Radiol lugosl 1990; 24; 289-96. lntroduction -In TBI (Total Body lrradia­tion) the whole patient is situated in a large field which extends beyond the body's limit, so that only the central part of the body (abdomen) is near to the axis, the others are situated in off-axis regions, even in the corners of the field. Up to date it was usual to use the central axis data, for example TAR (Tissue Air Ratio) values, in TBI conditions, but eventually extrapolated for large fields and corrected for »finite« phantom thickness, as by Van Dyk (1 ). However, except for the primary component, the specific distribu­tion of the scattering centers around the point on the beam axis, where the dose is determined, contribute to TAR owing to the secondary or higher scattered photons in a certain amount To take into account all these contributions from the surroundings to the point on beam axis, some methods were established for TBI phantoms. For example, the peak scatter factor by Podgorsak (2) or the beam-zone method by Quast (3). But, all the points in TBI phantom are equally impor­tant in dosimetric sense, regerdless of being in central axis or off-axis position. It follows that the conventional dosimetric functions must be modi­fied under TBI conditions. Also, the human body, or the suitable shaped phantom, has the charac- Received: May 8, 1990 -Accepted: May 22, 1990 teristic dimension and mass arrangement of the constituent parts, so TAR must be volume depen­dent (4). It means that there appears a need to define the local dosimetric functions for any off ­axis point (location) in TBI phantom. Material and methods -Ex pe rime nta 1 te c h ni q u e s : for the purpose of measurement, in order to establish conditions as similar to real situation as possible, an anatomic-cubical phan­tom was constructed. It represented the patient lying on his side, as in parallel opposite AP-PA irradiation technique. The TBI phantom consisted of 8 basins with thickness of 0.5 cm polystyrene, opened from above and filled with water. In this way it was possible to move continously the dosimetric system. Lung's inhomogneity was re­presented by cork (0.27g/cm3). The position of the phantom in 6°Co beam is given in Figure 1. The radiation field analysis was performed with a combination of RFA-3 dosimetry system (which was adapted for measurements in TBI phantom) and DPD-5 dosimeter connected with a special n-type Si detector (all Therados). The detector was produced exclusively for our measure­ments under TBI conditions in 6°Co field, that is in the case of low dose rate, where the signal 289 GEOMETRY distance 420 cm 2 field 168x168 cm 238 cm 1 : 1 F K L T A Lg H S N H 1 ____ t ----­ 1 .. __ j LOCATIONS H -Heod N -Neck s -Shoulder M -Hediostinum Lg-Lung (without corr L -Abdomen T -Thigh L -Leg K -Knee F -Foot INHOHOGENITY CORRECTION LUl\!GS --( -"1 r _ --::::: _[[J . _113 cm m c .-c. 1 --1 1 EJtg= . :110 l l F9 t ' 1., ____ 150 cm -.-=-.l._c_.. 9 Lungia Fig. 1 -TBI model accordance with the statements by Rikner (5). In was very weak. The sensitivity of the sermicon­ addition, the spatial resolution in TBI is not of the ductor detector was 1 O times greater in relation same importance as in standard radiotherapy. to the standard p-type (1200 nC/Gy). The analy­ Also, the 1 mm Pb shielding of the detector sides sis of the detector (Figure 2) shows that due to reduces the overrespond to the low energies. increased sensitivity (by increasing the volume), Theoretical model : The absorbed dose the statistical noise was reduced. This is in Radiol lugosl 1990; 24: 289-96. Vrtar M. Local dosimetric functions and lung corection factor under 60Co TBI FFO == 410 cm Field = lb4 x 164 cm 2 "Jl.. Fantom RFA-3, Therados Sem1conductor detectors, Therados \t.,.,. ·1 "<\l.-., \1. ·--::_ ....... ­ ' 3 1 Ion1sat10n chamber, 0.1 cm M2332, PTW "l 1 1 j y. """'\.·­ ! Plotter, Omn1graph1c 2000 Houston Instr. - l . DIRECTIONAL DEPENOANCE ·,v 1 mm Pb cylinder sh1eld M._.,.·1. ... V\\ ., . : ·• OL:l 40. ;; .J ­ (Q) 90° 1 L RFA standard @ • Ionisation chamber Depth (cm) 90::J I ; . Fig. 2 -Comparison of measurments with different detectors in 60-Co TBI conditions calculation in TBI was performed by the use of adapted sector integration method, enlarged with some assumptions. These are: introduction of the local dosimetric function, knowledge of the phantom contour at a depth of consideration and taking into account the dose reduction factor because of the finite local phantom width in the neighborhood of each location where the effec­tive field was determined. We used the earlier results for the reduction of TAR (1 ), but an interpolation had to be performed to describe the local field defined by the range of scattered radiation contributions. Therefore, we define in any location (ad, bd) (Figure 3) in TBI phantom, local TAR Dd L TARL TBI (d) (RF). (1) DL d,air 21T Rg.) TAR.81(d)=(RF). [ TAR (0,d1)+ 2, . 1.. 0=0 r=0 L Here Dd is the total absorbed dose at depth d in the fixed point (ad, bd), Dd air is the in-air dose in the same point, and (RF). is the reduction factor. We must take into account the known in-air dose distribution f(xm, Ym) of 6°Co beam, (measured in L reference plane Rm), and the fact that Dd can be separated to the primary and scattered compo­nent. Also, the simple geometry connects the surface elements r t:,, r t:.0 situated in the varible point (x, y) in the plane of dose determination Rd and its projections to Rm. It follows Sar (Scatter Air.Ratio), was represented by its analytical form, valid in the case of extended fields by Habic (6), and in accordance with a range of scattering contributions for 6°Co irradia­tion up to 50 cm (7). f(i) is an abbrevation for f(2) t:.0 t:.SAR (r, d2) -2-] (2) f(1) rr Radiol lugosl 1990; 24: 289-96. : 1 f 60 ·/' .· , , 1 . ·y ,· .· '> R· 1 1 _; .. ------' 1 R m t 1 L --[ fixed points LUNG's DOSE CALCULATION ' ' r.-­ ' ' Rg(Q) PoP' = .p 1 -d . ' PRD1ARY TAR COMPONENT IN LUNGS : -Ji'_'. • ·1----, ' ' , P 1 2 ' 1 TARLg = 1 m Lg Lg )--(µ/p) p -µ ···-··••·•··• ·•·· •·e ·,, ·, ··,. ' ·, , ¦J1it aurf.c. ··,. ' ·,. '· 1 ' ·{ c::eE9::o -.6e -r _th .... 1 a.5 2 , 6 s 1. 12 14 16 1s :ie 22e 1 3 5 , 9 u.. n n . LOCAL TAR IN 60co Tlll -EXPEJllMOff ANO Ta:ORY UJCATlON I HEADJ t.20i----------.=======;--, ;. . ...__ .econtrv,utlon• RAnQ¦ of scattwv,q 1.10 In · ,. f c:.lculotlon 1.00 1 ··,,t . 0.50 · i · ·,.t (81 < SO an o.lli "·. 1 ttworv.•-···.•.. 0.,\1 presented in Figure 3. The mass attenuation coefficient for lung tissue can be found from: data concering the composition of body tissues (8), calculation of mass attenuation coefficient for a mixture of elements (9) and CT determined values for lung density (1 O). So the value (µ,/g)L9 = 0.06352 cm2/g was determined (for water, we have 0.0641 O cm2/g). The correction factor in the lungs is TARL9(r,d) CF(d) = o.fr) = (4) Dd(r) TAR(r,d) and after some easier calculations Rg(0) f(2) 1001 . C. go c:dJ1§ 80 FFD • 410 ca 70 60 S..j,conducta,-c:19t¦ct.or: ··• ..... 91 n-type. 4. nC/UV 50 1nc:r"waa.ci ....,.,uvity l-NI C'flindaf° •MLde ,o _ ... ...., 30 2 , 6 8 10 12 1' 16 18 20 22 LOCAL POO IN 60eo TBI -Ta:ORY 1.0CATIDN I HEAD> 1 100 -.... 90 , . 80 , .. , · · · 78 .. , '•,,. 60 ! ·-.. , .. ,. o. deoth (Cal 1 40 _.,, lca> 30 0.5 2e4 6 8 IO · 12 14 16 18 - z: ,. Fig. 4 -Local dosimetric functions. An example of results: location head Radio! lugosl 1990; 24: 289-96. Vrtar M. Local dosimetric functions and lung corection factor under 60Co TBI Results -The local TAR values, which are important tor TBI, were measured in 10 locations by the previously described dosimetric equip­ment. However, there is no reason to do it tor any other point. The calculation was performed by the computer program applied to the expression (2). As an example of results we present the local TAR.81 and PDD.81, (i.e. tor head, experiment and theory), together with the reduction factor (RF)., in Figure 4. The other locations can be presented in the same way, differing in their values from each other due to the position in TBI phantom and its surroundings which contribute the scattered irradiation in a different way. In the case of inhomogenieties (cork model of the lungs) the local dosimetric functions tor the lungs were measured tor a number of depths, while the theoretical approach was established according to the relation (5) concerning the cor­correction factor in local TAR method and modi­fied equiavalent TAR (11), can be found there too. The cited reference was pointed out because the similarities of shape and density in the region of lung inhomogenities were the closest to our Table 1 -Local TAR and POD values in the lungs (60-Co TBI, density 0.27 g/cm") experiment theory depth (cm) - TAR POD TAR POD 0.5 1.082 100.0 1.117 100.0 2 1.073 97.5 1.075 95.5 4 1.030 91.7 1.023 90.0 6 1.029 90.5 1.040 90.6 8 1.042 91.5 1.064 91.9 10 1.053 91.5 1.077 92.1 12 1.059 90.0 1.052 89.1 1.046 88.3 1.033 86.7 16 1.005 85.0 1.007 83.7 rection factor CF(d). This is given in Tables 1 18 0.942 79.5 0.941 and 2. Also, the experimental and theoretical 20 0.855 72.3 0.852 69.4 results of CF(d) (tor density 0.27 g/cm3) were 22 0.765 65.0 0.745 60.3 presented in Figure 5. A comparison of the ­ 1.6 1.5 II,. Local TAR method eksperimental values (E) theoretical model . . . :; : I u 2 1 ,, ', .. ·/I··I·.· 1.1 . /T 1 : /i --; 1 , .. -, ; 1 . ,: _:;a:: __ ---_,_, _J„ ;, .. .... -,,.. 1 f ,; : • : 1 1 , L_ L::: 1.0 2 u. 6 8 10 12 14 16 18 20 22 depth ·1 •·•·f-:>A<< ED . [ . ::, 1> :.; 1 6' C•l.4' Slika 1 -2 cm debela plocica od akrilika služi kao šablona za transperinealno paralelno uvodenje šupljih vodilica rasporedenih na Syedov nacin. Izvori se rucno ulažu u vodilice i oblikuju kružni implantat. Fig. 1 -2 cm thick acrylic plate is used as a template for transperineal parallel introduction of hollow guides in Syed type of pattern. The sources are manually entered in the guides to form a circular implant. mm). 2ica se, zbog lakšeg rukovanja, ulaže u plasticnu cjevcicu ,i reže na komade pogodne duljine {50-120mm) koji se mogu višestruko kori­stiti. Postavljanje vodilica radi se u opcoj aneste­ziji za litotomiju. Šablona se ucvršcuje za peri­nealnu kožu sa 4 šava kroz lateralne otvore, a zatim se transperinealno uvode vodilice. Oblikuje se implantat pravilnog rasporeda 18 paralelnih izvora, od kojih je svaki jednako (14 mm) udaljen od svih svojih prvih susjeda. Raspored vodilica kontrolira se radiografski. Tek kada su sve vodi­lice ispravno postavljene i pacijent se nalazi u sobi, rucno se ulažu prethodno pripremljeni 192Ir izvori i fiksiraju olovnim kapicama ili ljepljivom trakom. Ova manualna afterloading tehnika po­stave dozvoljava razumnu tocnost u pozicionira­nju izvora. Opisujuci dozimetrijski implantat, žicu 192Ir aproksimiramo linearnim izvorom koji prelazi sre­dinem šuplje vodilice. Brzina apsorbirane doze Ar u nekoj tocki T implantata izracunavana je tako da su u obzir uzeti efekti atenuacije zrace­nja; u žici i sloju platinske ovojnice zracenje se filtrira, dok se u metalnoj vodilici i tkivu zracenje raspršuje i apsorbira. Racun je preveden u dis­kretnem obliku za n izvora gdje se za svakog od njih dodatno smatra da je podjeljen u skup od m segmenata duljine / koji, u ovoj aproksimaciji, zrace kao tockasti izvori. Brzina apsorbirane doze je: Radiol lugosl 1990; 24: 297-302. Lokner V et al. 1921r lmplantat u radioterapiji anorektalnog karcinoma: dozimetrija n m la = Ar. I I f -f(0ij) g(0;j) h(r;j) [Gy/h], . 1=1 J=1 r;j 2 gdje je r;j udaljenost središta ij-tog segmenta i tocke T; r je specificna konstanta za gama zracenje 192Ir; er. je linearna gustoca izvora; 0;j je kut što ga r;j zatvara s okornicam na dulju os izvora; f(0;j) je faktor kose filtracije u iridijskoj žici i platinskoj ovojnici; g(0ii) je faktor koji opisuje raspršenje i apsorpciju u vodi lici; h(rii) je faktor koji opisuje raspršenje i apsorpciju u tkivu. f(0ii) je: µ,1d ---(1 -sin0ii) 2sin0ii f(0ii)= e gdje je u µ,1 efektivni linearni atenuacijski koefici­jent izvora (µ,1==0.43 mm --1 za lr-Pt kombinaciju), a d je njezin ukupni promjer (11, 12, 13). Apsor­pcija i raspršenje u stijenki vodilice (debljina 0.2 mm), opisani faktorom g(0ij), mogu se izracunati kao klasicna kosa atenuacija (µ,v=0.79 mm --1 za Fe). g(0;i) ne utjece kriticno na brzinu apsorbirane doze u tocki T; atenuacija je opcenito ispod 4%, osim za vrlo male kutove 0;i• Atenuacija u tkivu aproksimirana je onom za vodu. Korišten je faktor h(r;i) za homogeno tkivo: h(r;i) = 0.98342+ 1. 7536x104ii--2.2054x10 --\2 izveden iz Mante Carla simulacija za dozu u vodi koja okružuje tockasti izvor s izotropnom emisi­jam (14, 15). Izracunavanje doze u proizvoljnoj tocki implantata, implementirano je na personal­nom kompjuteru. Rezultati -lmplantat postavljen Syedovom šablonam ne zadovoljava uvjete Pariskog siste­ma; raspored izvora zracenja poštuje sva pravila i ogranicenja osim onog o ne mješanju railicitih osnovnih 6elija u CR. U prstenu kružnog implan­tata izmjenjuju se i istostranicni trokutovi i kvadra­ti. Zbog toga, formalno, nije moguca jednostavna dozimetrijska karakterizacija implantata s RD. Ovo odstupanje od Pariskog sistema, medutim, nije znacajno. Zbog specificnog rasporeda izvora prostorna je homogenost brzine doze u ravnini koja bi odgovarala CR implantata takva da se Pariski sistem dozimetrije ipak može primjeniti. Da bismo to potvrdili, analizirat 6emo primjer prostorne raspodjele doze za potpuni idealni kružni implantat postavljen Syedovom šablonam sa 18 izvora duljine7 cm i linearne gustoce 4.44 MBq/mm (120 µ,Ci/mm). Velicina osnovne 6elije je 14 mm. Ove vrijednosti opisuju implantat koji se standardno klinicki koristi. U izracunavanju BD Pariski sistem polazi od brzina doza u nekim geometrijski definiranim tockama implantata. To su središta osnovnih (istovrsnih) celija, buduci da su to tocke lokalnih minimuma brzine doze unutar implantata. Kako je implantat simetrican, dovoljno je promatrati samo jedan njegov segment od 60°. Za prikaz odabrati 6emo ravninu koje je CR implantata. Promjene brzine doza u implantatu pratimo pre­sjecima duž dva pravca C -C" te C -C' koji prolaze središtem implantata C i duž dva luka koji povezuju tocke A' -A i B ·-B (Sl. 2). Ovi presjeci prolaze kroz dvije, za Pariski sistem dozimetrije najinteresantnije, tocke implantata: središte jednakostranicnig trokuta i središte kva­drata. Dva vrlo povoljna svojstva karakteriziraju implantat: dobra prostorna homogenost doze unutar implantata i njezino vrlo brzo opadanje izvan granica (Sl. 3). Osim neposredno uz izvor, brzina se doze slabo mijenja u CR. Ako proma­tramo onaj dio implantata koji je omeden spojni­cama izvora u vanjskom prstenu (12-trokut s opisanom kružnicom polumjera -27 mm) i iskljucimo cirkularne zone promjera 5-8 mm oko izvora, razlika je medu ekstremalnim odstupa­njima -10% srednje brzine doze, za taj dio ravnine. Za sve cirkularne zone oko izvora ispu­njen je empirijski zahtjev Pariskog sistema da izodoza vrijednosti 200% one koja se koristi u kontroli terapije nema promjer veci od 1 O mm (16). lzvan granica 12-trokuta doza pada naglo; na udaljenosti 35 mm od središta implantata doza je polovica one u središtu, a na udaljenosti od 50 mm tek cetvrtina. Lucni presjeci A' -A i B' -B kroz implantat ukazuju na homogenost doze unutar elementarnih 6elija; brzine doza se ne razlikuju više od -6% (Sl. 4). Brzina doze u središtu kvadrata i one u središtu trokuta (mini­mumi brzina unutar osnovnih 6elija) razlikuju se man je od 1 % . Ovako visoki stupanj homogenosti potpunog kružnog implantata dozvoljava da se definicije BD i RD Pariskog sistema mogu bez ikakvih ogranicenja primjeniti. (Za usporedbu, prostorni implantat od 1 O izvora, uz istu velicinu izvora i njihov razmak kao i razmatrani kružni implantat, postavljen strogo u skladu s zahtje­vima Pariskog sistema u 5 kvadraticnih 6,elija, pokazuje razliku u središtima 6elija od gotovo 10%). Za razmatrani transplantat BD je 1.00 Gy/h, cemu odgovara RD od 0.85 Gy/h. Radiol lugosl 1990; 24: 297-302. Lakner Vet al. 1921r lmplantat u radioterapiji anorektalnog karcinoma: dozimetrija y -o, .. C' '· \ ' (X \ C" C .li () i: Slika 2 -·Idealni raspored 1 .i1r izvora u centralnoj ravnini. Oznacene su za Pariski sistem dozimetrije važne tocke. Izracunati cemo raspodjelu doze duž dva pravca (C-C" i C-C') i dva luka (A-A' i B-B'). Zbog .. &imetrije dovoljno je razmatrati samo šestinu implan­ tata. Fig. 2 -Ideal distribution of 1921r sources in the central plane. Relevant points tor Paris System dosimetry are marked. The dose distribution along two lines (C-C" and C-C') and two arcs (A-A' and B-B') will be calculated. Because of the symmetry it is sufficient to analyze one sixth of the implant. l. '5 .C: ' ;,.. C-C" ., 1 11 . \ 1 11 . C-C' ,.1 0 'O 1.0 (. ,\2, ·--.._ •<· v .. ·--,::i .g 1.00 J:> 0.90 1. 0.80 7 • 1 0.70 o 20 40 60 " o Slika 4 -Raspodjela brzina doza duž A-A' i B-B' lukova. Kut od 30° odgovara središtu kvadrata, a 0° središtu istostranicnog trokuta. Fig. 4 -The dose rale distribution along A·A' and B-B' arcs. 30° angle corresponds to the center of the square and 0° to the center of the equilateral triangle. Diskusija -Rezultati analize homogenosti odnose se na geometrijski implantat u smisluzahtjeva Pariskog sistema. U stvarnosti, idealnioblik implantata teško je ostvariti posebno kada se, kao u slucaju kružnog implantata, radi s vecim brojem izvora. Korištenje šablona i vodilice omogucava da se raspored izvora približi ideal­nome, odnosno, da odstupanja od paralelnostii/ili pravilnog oblika osnovnih celija u CR buduminimalna (Sl. 5). Primjena šablone Syedovog tipa dozvoljava jednostavnu postavu i tocno obli­kovanje kružnog 1921r implantata kojeg se, zboghomogenosti prostorne raspodjele brzine doze, može opisati Pariskim sistemom dozimetrije. Opadanje brzine doze s udaljenošcu od središtaštedi okolno tkivo i kriticne strukture (mjehur/rek­tum) na nacin kojeg nije moguce ostvariti zrace­njem uz upotrebu samo vanjskog snopa. Udarnu dozu od 20 Gy kružnim implantatom u ciljni volumen, koristimo kao nadopunu vanj­skom zracenju zdjelice. Vanjskim se zracenjem predaje doza do 50 Gy farakcionirano, u 4-5 tjedana. Promjenom velicine osnovnih celija na 1921r šabloni ili izborom drugih linearnih gustoca izvora (do 11. 1 MBq/mm (300 µ,Ci/mm)) vrijemetrajanja udarne terapije kružnim implantatom mo­guce je mijenjati. Kraca vremena terapije povolj­nija su za pacijenta, premda se moraju kretati uokvirima preporucenih brzina od 8-12 Gy na dan koje su vezane uz dobru toleranciju tkiva, s minimalnim akutnim ili odloženim komplikacija­ma. Isto tako, osnovne celije ne mogu biti vece od 20 mm buduci da promjer izodoza definiranih Radiol lugosl 1990; 24: 297-302. Lokner Vet al. 1921r lmplantat u radioterapiji anorektalnog karcinoma: dozimetrija Slika 5 -Rendgenska snimka implantata. Šablona omogucava postavu gotovo paralelnih izvora i minimalna odstupanja od. idealnog implantata. Frg. 5 -X-ray of the implant. The template enables almost parallel setting of the sources with the minimal deviation from the ideal implant. kao 200% RD prelazi spomenuti dozvoljeni mak­simum od 1 O mm. Valja naglasiti tri osnovne slabosti koje ka­rakteriziraju sve iridijske implantate postavljene Pariskim sistemom: prvo, neidealnost geometrije implantata povlaci (posebno kod duljih izvora) naglašene deformacije RD izodozne plohe u toj mjeri da se javljaju džepovi u kojima može doci do poddoziranja ciljnog volumena; drugo, po­stava izvora koja dobro zatvara ciljni volumen obicno znacajno zraci kožu; i trece, obicno ne­pravilni ciljni volumen teško je homogeno zraciti pravilnim implantatom. Dva dodatna problema utjecu na tocnost dozimetrijskog opisa iridijum­skih implantata; stvarna linearna gustoca izvora može se razlikovati i do 10% od nominalne, a nehomogenosti duž izvora mmogu iznositi od 10-12% od srednje gustoce. Ovo može promje­niti vrijednost brzine doze u nekaj tocki implan­tata do 10% (17). Zbog kratkog poluživota 192 1r korisni život izvora obicno ne prekazi 60 dana. Djelomicno postavljen kružni implantat (pri­ mjerice poluprsten od 9 izvora) još uvijek ima toliko homogenu raspodjelu brzine doze unutar osnovnih celija da se i na njega mogu primjeniti zakljucci ovog rada u potpunom implantatu. Isti nacin dozimetrijske kontrole implantata može biti primjenjen i na šablonu Syed/Nablettovog tipa koja je razvijena za primjenu 1921r u radioterapiji prostate, a dijelom se, u konstrukciji, razlikuje od Syedove šablone. Dobra dozimetrijska kontrola kružnih implan­ tata s pravilno rasporedenim izvorima može se postici pažljivim izvorom ciljnog volumena, kori­ štenjem šablone za tocno oblikovanje implantata i primjenom koncepta Pariskog sistema dozime­ trije. Sažetak Radioterapija je jedini izbor primarnog tretmana za jednu grupu pacijenata s anorektalnim karcinomom. Ovaj rad analizira dozimetrijsku kontrolu intersticijalnog kružnog implantata sa 192ir žicama. Koristi se tehnika rucnog afterloadinga. lmplantat predaje udarnu dozu ciljnom volumenu tako da bude nadopuna zracenju zdjelice vanjskim snopom. Pravilnu postavu izvora, kao i njihovu paralelnost, osiguravamo korištenjem metalnih vodilica. Koristi se Syedov tip šablone za transperi­nealno uvodenje vodilica u tkivo. U centralnoj ravnini implantata pravilan raspored 18 izvora oblikuju jedna­kostranicni trokutovi i kvadrati. Ovaj raspored narušava jedno od strogih pravila dozimetrije u Pariskom siste­mu. Analizirana je prostorna raspodjela doze za geo­metrijski idealan implantat izgraden od izvora duljine 7 cm te linearane aktivnosti 4.44 MBq/mm sa medusob­nom udaljenošcu od 14 mm u osnovnoj celiji. Može se vidjeti kako je homogenost brzine doze unutar implan­tata Syedovog tipa toliko dobra da su odstupanja od Pariskog pravila samo formalna. Dozimetrijska kontrola kružnog implantata oblikovanog Syedovom šablonam može se provesti koristeci koncept referentne doze Pariskog sistema. Literatura 1. Jackson BR. Contemporary management of rectal cancer: an overview. Cancer 1977; 40:2365-74. 2. Martinez A, Herstein P, Portnuff J. lnterstitial therapy of perineal and gynecological malignancies. lnt J Radiation Oncology Biol Phys 1983; 9:409-16. 3. Martinez A, Cox RS, Edmundson GK. A multi­ple-site perineal applicator (MUPIT) tor treatment of prostatic, anorectal and gynecological malignancies. lnt J Radiation Oncology Biol Phys 1984; 10:297-305. 4. Punthawala AA, Syed AMN, Gates TC, McNamara C. Definitive tratment of extensive anorectal carcinoma by external and interstitial irradiation. Cancer 1982; 50:1746-50. 5. Papillon J, Mayer M, Montbarbon JF, Gerard JP, Chassard JL, Bailly C. A new approach to the menagment of epidermoid carcinoma of the anal canal. Cancer 1983; 51 :1803-7. 6. Horgas G, Lakner V, Pokrajac B, Spaventi š. Brachytherapy with lr-192 in the management of early carcinoma of the breast. Rad JAZU 1988; 23 :49-58. 7. Syed AMN, Puthawala AA, Nablett D, Georg FW, Myint US, Lipsett JA, Jackson BR, Flemming PA. Primary treatment of carcinoma of the lower rectum and anal canal by combination of external irradiation and interstitial implant. Radiology 1978; 128:199-203. 8. Perez CA, Glasgow GP. Clinical application of brachytherapy. In: Perez CA, Brady LW eds. Principles and practise of radiation oncology. Philadelphia: JB Lippincott Company, 1987; 252-90. 9. Dutreix A, Marinello G, Pirequin B, Chassagne D, Houlard JP. Developpment actuel du systeme. de Paris. J Radiol 1979; 60:319-25. 1 O. Pirequin B, Dutreix A, Paine CH, Chassagne D, Marinello G, Ash D. The Paris system in interstitial radiation therapy. Acta Radiol Oncol 1978; 17:33-48. Radiol lugosl 1990; 24: 297-302. Lakner V et al. 1921r lmplantat u radioterapiji anorektalnog karcinoma: dozimetrija 11. Mayles WPM, Mayles HMO, Turner PCR. Physical aspects of interstitial therapy using flexible iridium -192 wire. British J of Radiology 1985; 58:529­35. 12. Welsh AD, Dixon-Brown A, Stedeford JBH. Calculation of dose distribution tor iridium-192 implants. Acta l=ladiologica Oncology 1983; 22:331-6. 13. Hall EJ, Oliver R, Shepstone BJ. Routine dosimetry with tantalum-182 and iridium-192 wires. Acta Radiologica 1966; 4:155-60. 14. Webb S, Fox RA. The dose in water surround­ing point isotropic gamma-ray emitters. British J of Radiology 1979; 52:482-4. 15. Dale RG. Monte Carlo derivation of paramet­ers tor use in the tissue dosimetry of medium and low energy nuclides. British J of Radiology 1982; 55:748­57. 16. Marinello G, Dutreix A, Pierquin B, Chassagne D. Present-day developement of the Paris system; First pari: Coplanar petterns and those called »in squares«. J Radiol Electrol 1978; 59:621-6. 17. Bello J, Oyarzun CO, Abrath FG, Sole J. Study of the characteristics of lridium-192 wire used in interstitial implants. Radiology 1982; 145 :224-5. Adresa autora: Lokner V, Klinika za nuklearnu medicinu i onkologiju, KB «Dr. Mladen Stojanovic«, Vinogradska c.19, Zagreb Visoko ucinkovit selektivni virostatik v obliki injekcij za infuzijo, mazila za oci in kreme VIR O 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 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 Radiol lugosl 1990; 24: 297-302. SREDIŠNJI INSTITUT ZA TUMORE I SLICNE BOLESTI, LABORATORIJ ZA EKSPERIMENTALNU KANCEROLOGIJU, ZAGREB HUMIC ACIDS -MODEL MOLECULES FOR MONITORING THE DEGREE OF ENVIRONMENTAL POLLUTION Huljev D Abstract -Humic acids (HA) have been isolated from soils affected ·by varying degrees of pollution, and totally hydrolyzed. The metals presen! in HAs and their hydrolysates were determined by neutron activation analysis (NAA). As shown by the experiments, HA molecules obtained from intensively fertilized soils and close to major settlements contain significantly elevated quantities of Cs and Co (Se reduced). Similarly, hydrolysates of HAs isolated from contaminated soils contain a higher percentage of phenols. The main HA components include amina acids, aromatics, phenols and suQars (carbohvdratesl. As shown by analyses, HAs isolated from contamined soils contain elevated level of metals (except Se) and organic fractions (phenols) belonging to pollutants. Because of this HA molecules can be used as markers of environmental pollut1on by heavy metals and organic compounds. UDC: Key words: environmental pollution-analysis, humic acids Orlg sel paper Radiol lugosl 1990; 24: 303-5. lntroduction -The purpose of this paper has been to present HA as a macromolecule which can be used as a model molecule in monitoring environmental pollution by heavy met­als and organic pollutants. HA molecules contain -NH2;-0H;-COOH; -NO2; -CONH2; -SH; -OCH3; =GO; and other functional groups. Because of this they can bind metals from their environment and from different compounds (1 ). HA molecules contain 2-15% of phenol. Under specific conditions HAs may bind phenols from their environment (2). Certain phenols are indicators of industrial soil and stream pollution. HA molecules obtained from different geographical sites contain different levels of phenols, amino acids, aromatics and sugars (3). The first attempts to totally hydrolyze HA can be traced back to quite a few years ago (4). In general, only specific compounds have been isolated from HA hydrolysates, but total hydrolysis of this important natura! mac­romolecule has also been carried out recently (5). Because of its specific chemical compound content, the humic acid molecule can serve as a model substance for the study of many biochem­ical reactions occurring in live organisms (6). Materials and Metheids -HAs may be isolated by a number of methods. In this case the method described earlier has been used (7). The same reference describes the NAA procedure. Soil samples were taken from four different sites according to the degree of soil pollution. Part of the isolated HAs was analyzed (NM), and the remainder drastically hydrolyzed. Figure 1 illus­trated an abridged scheme of total HA hydrolysis. Results -The results obtained by NM of HAs obtained from different sites (Zagreb, Kar­lovac, Banja Luka, Varaždin) are reviewed in Table 1. Due note should be paid to Cs and Co leve! data. Cs is a typical nonessential metal, whereas Co is a trace element. Both can be used as indicators of environmental pollution. Table 2 reviews the results of crude hyd­rolysis of HAs obtained trom the above men­tioned sites. Phenol is considered to be an indicator substance which can be used to mea­sure the degree of environmental pollution by organic substances (e.g., woodpulp industry). Discussion -Because of their functional groups, HAs may contain and bind quite a few metals. Distinction should be made between Received: June 14, 1990 -Accepted: June 30, 1990 Huljev D. Humic acids -model molecules tor monitoring the degree of environmental pollution Humic acids 24 hours heating 6 N 1-Cl Liquid phase: -alpha amino acids -phenols -metals ether extraction l i 1 Solid phasc: -condensed benzene core -sugars -metals 24 hours heating in I--10 2 .!, Organic phasc: Water phasc (6N HCl): Liquid phase: Solid ph;:ise: -phenols -alpha amino acids -sugars -condensed -metals -metals -metals benzene core -metals 1 Fig. 1 -Abridge sheme of lhe experimenlal procedure tor lolal hydrolysis of humic acids Table 1 -Neulron aclivalion analysis of humic acids (HAs) from four differenl localilies. The dala are given in JLg/g (ppm) of dry weight. Melals (JLg/g) ppm Localions Cs Co Ag Eu Fe Sb Se Se Sr Zagreb 16.0 6.0 0.4 0.4 2000 11 1.4 0.1 200 Karlovac 10.0 5.0 0.3 0.3 2500 30 1.0 0.1 400 Banja Luka 1.0 0.7 0.2 0.2 3000 20 2.0 1.0 100 Varaždin 0.5 0.3 0.1 0.1 1500 17 3.0 0.9 150 Table 2 -Resulls oblained by lolal hydrolisis of humic acid molecules from four differenl localiles. The dala are given in percenlages of each organic fraclion wilhin lhe humic acid molecule. Organic compounds (percenlages, % ) Localions Phenols Sugars Amino acids Aromatics Zagreb 10 2 40 48 Karlovac 5 3 Banja Luka 12 2 46 40 39 Varaždin 3 3 metals originating from a clean and balanced metals are also an important part of the structure environment, and those due to human activity of the HA molecule. NAA is required in order to (modem agriculture, industrial development, gain knowledge on the fine structure of these etc.). The latter are called pollutants. Hence, macromolecules. Radiol lugosl 1990; 24: 303-5 Huljev D. Humic acids -model molecules for monitoring the degree of environmental pollutlon Because of organic molecules present in its basic structure, and specific makeup, HAs can bind and exchange identical organic compounds from its environment. Distinction should be made between organic compounds due to the normal decomposition of live matter (natural resources), and those due to environmental pollution pro­duced by human activity (artifical resources). Hence the interest in total HA molecule hyd­rolysis in terr;ns of compound groups. Of course, HAs isolated from both clean and polluted sites (soils) have to be analyzed for the purpose. Table 1 warrants the conclusion that the soil (HAs) in the Zagreb and Karlovac areas is more polluted by heavy metals than in the Varaždin and Banja Luka areas. The Cs and Co levels in the former areas were found to be 10-30 and 7-20, respectively, as high as in the letter. The soil (HAs) samples found in the areas of Banja Luka and Varaždin contains 9-10 times much Se as the samples from Zagreb and Karlovac (inten­sively fertilized soils). The data listed in Table 2 allow for the assumption that the Zagreb and Banja Luka areas are more polluted by organic industrial waste than the areas of Karlovac and Varaždin. Phenol is the marker of such pollution. the phenol level was found to be 2-4 times as high in the Zagreb and Banja Luka areas, as compared with Karlovac and Varaždin. Sažetak HUMUSNE KISELINE -MODEL ZA PRIKAZ STUPNJA ZAGAOENOSTI OKOLINE Humusne kiseline (HKs) izolirane su iz tla vrlo razlicitog stupnja zagadenosti. Nacinjena je totalna hidroliza HKs. Metodom neutronske aktivacijske ana­lize (NM) odredeni su metali prisutni u HKs i njezinim hidrolizatima. Rezultati eksperimenata pokazuju da HKs iz tla koje se intenzivno obraduje umjetnim gnoji­vima i koi se nalaze u blizini velikih naselja sadrže u svojim molekulama signifikantno povišene koncentra­cije Cs i Co (Se je snižen). Takoder HKs izolirane iz kontaminiranih zemljišta sadrže u svojim hidrolizatima veci postotak fenola. Glavne komponente HKs su: aminokiseline, aromati, fenoli i šeceri. Analize pokazuju da HKs izoirane iz kontaminiranih tla sadrže povišene koncentracije metala (osim Se) i organskih frakcija (fenola) koje spadaju u kontaminate. Zbog toga HKs mogu poslužiti kao markeri zagadenja našeg okoliša leškim metalima i organskim spojevima. References 1. Rashid MA, King LH. Major oxygen-containing functional groups presen! in humic and fulvic acid fractions isolated from contrasting marine environ­ments. Geochim Cosmochim Acta 1970; 34:193-201. 2. Fritz JS, Tateda A. Studies of the anion ex­change behaviour of carboxylic acids and phenols. Anal Chem 1968; 40:2115-9. 3. Huljev O, Strohal P. Physico--chemical proces­ses of humic acid-trace element interaction. Mar Biol 1983; 73 :243-6. 4. Cheshire MV, Cranwell PA, Falshaw CP, FloydAJ, Haworth RD. Humic acid-I1. Structure of humic acid. Tetrahedron 1967; 23:1669-82. 5. Huljev D. Trace metals in humic acids and theirhydrolysis products. Environ Res 1986 6 39 :258-64. 6. Huljev D. The interaction of 2 3Hg in aquaticmedium with humic acids. Radiol lugosl 1989; 23:379­81. 7. Huljev D, Strohal P. lnvestigation of some !raceelements in the bay of Lim. Mar Biol 1983; 73 :239-42. Author's address: Dr. Damir Huljev, Central lnsti­tule for Tumors and Allied Diseases, llica 197, 41 000 Zagreb, Yugoslavia Radiol lugosl 1990; 24: 303-5 KLJUC KOJIM OTVARATE VRATA SVJETSKOG TRŽIŠTA JUGAt'3k-!.IJA 51000 RIJEKA, Obala .90sl•ftftske mo,ru,rice 16 Poiwnski pretinac 379 Te.•: 24 218 yu juline Te!,efon: (051) 21l 111 T.tetu: t051) 211 309 T. .. gram: Jugo-linija· Riiek• REDOVITE LINIJE Kontejnerski servis JADRAN -SJEVERNA AMERIKA-SREDNJI ISTOK JADRAN -SREDNJI ISTOK (ukljucujuci i RO/RO servis) JADRAN -BLISKI ISTOK ( ukljucujuci i RO / RO servis) Konvencionalni servis JADRAN -SJEVERNA EVROPA JADRAN -JUŽNA AMERIKA, Atlantska obala JADRAN -JUŽNA AMERIKA, Centralna i Pacificka obala JADRAN -BLISKI ISTOK JADRAN -SREDNJI ISTOK JADRAN-BENGALSKIZALJEV/SRI LANKA JADRAN -NR KINA JADRAN -DALEKI ISTOK BRODOVI U SLOBODNOJ PLOVIDBI PREVOZE TERETE U SVE LUKE SVIJETA. Iz prakse za praksu IZ PRAKSE ZA PRAKSU KVIZ Br.2 Od govor: Pheochromocytoma Komentar : Na diagnozu upucuje anamnesticki podatci: Groznica i drhtavica (kot temperature 37,5) Hipertenzija Veoma cesti jaki glavoboli, »da gubi savest od »Preskakivanje« srca, ako jih povežemo sa nala­zom CT i kavografije. Pretraga kataholamina, bi nesumljivo razjasnila bolest Kod retroperitonealnih tumora u predelu bubrega neobhodno je misliti na hormonsko aktivne tu­more nadbubrežne žleze. Adresa autora: prim. dr. Jurij Us, Onkološki inštitut Ljubljana, Zaloška 2, 61 000 Ljubljana ZAVOD ZA NUKLEARNU MEDICINU MEDICINSKOG FAKULTETA I KLINICKOG BOLNICKOG CENTRA ZAGREB Spec,jalizirani tecaj: MEDICINSKI POSTUPCI U SLUCAJU Zagreb, 19 -23. 11. 1990. SAi.JR:Ž:AJ Tecaj ce obuhvatiti medicinske aspekte organizacije pripramosti u slucaJu nuklear­nog akcidenta te dijagnosticke postupke i lijecenje prekomjerno ozracenih i kontaminiranih osoba. Za pojedine teme, osim prezentacije u obliku predavanja. organizirat ce se prakticne VJežbe i prikazati nastavni lilmovi koje preporucuju IAEA i REACfTS Oak Ridge. U sklopu tecaja predviden je poiudnevni posjet Nuklearnoj elektrani Krško. Poželjno je da u toku tecaja ucesnici iznesu eventualna svoja iskustva u zbirnjavanju prekomjerno ozracenih, šlo c':e im biti omoguceno organizacijom tecaja. KOME JE TECAJ NAMIJENJEN? Tecaj je namijenjen lijecnicima, tizicarima, kemicarima i drugom osoblju visoke strucne spreme koJe rnože biti zainteresirano za tu tematiku. TROŠKOVI TECAJA: Din 1000 po ucesniku. -Podliježe revalorizaciji u slucaju vece inflacije ili devalvacije dinara. ORGANIZACIJSKI ODBOR TECAJA N.A. Zavod za nuklearnu medicinu -Rebro Kišpaticeva 12 41000 Zagreb UPUTSTV A AUTORIMA Revija Radiologia lugoslavica obavlja origi­ nalne naucne radove, strucne radove, pre­ gledne clanke, prikaze slucajeva i drugo (pre­ glede, kratke informacije, strucne informacije itd.) sa podrucja radiologije, onkologije, nu­ klearne medicine radiofizike, radiobiologije, za­ šiite od radiacije i drugih slicnih podrucja. Slanjem rukopisa redakciji, podrazumevamo da rad nije bio objavljen niti primljen za objavu u nekoj drugoj reviji; autori su odgovorni za sve tvrdnje i izjave u njihovom clanku. Primljeni radovi ne smeju biti objavljeni u drugim revi­ jama bez ovlašcenja redakcije. Radove napisane na engleskom (originalni naucili radovi obavezno na engleskom) ili na nekom od jugoslovenskih jezika, slati na adresu redakcije: Radiologia lugoslavica, On­ kološki inštitut, Zaloška c. 2, 61105 Ljubljana, Jugoslavija. Svi radovi su podvrgnuti urednickom pre­ gledu i pregledu dva recenzenta izabrana od strane redakcije. Radovi koji ne udovoljavaju tehnickim zahtevima revije, bice vraceni auto­ rima na popravak pre nego šlo se pošalju na pregled recenzentima. Odbijeni radovi (radovi koji nisu primljeni za štampanje) se vracaju autorima i revija ne snosi nikakvu odgovornost u vezi sa njima (u slucaju da budu izgubljeni). Redakcija zadržava pravo da pozove autore, da naprave gramaticke i stilske popravke, kao i promene u sadržaju u odnosu na primedbe recenzenata, kada je to neophodno. Dodatne troškove štampanja rada i separata po želji autora, snose autori. Opšta uputstva Rad treba kucati sa duplim razmakom, 4 cm od gornjeg i levog ruba papira formata A4; tekst mora biti gramaticki i stilisticki ispravan. Prilikom upotrebe skracenica, nužno je podati njihovo obrazloženje. Tehnicki podaci u ruko­pisu moraju biti u skladu sa SI sistemom. Rukopis, ukljucujuci i pregled literature, ne sme imati više od 8 kucanih stranica, dok broj slika i tabela ne sme biti veci od 4. Preporucu­jemo da rukopisi sadržavaju: Uvod, Material i metode, Rezultati, Diskusija, Sažetak. lznimno, rezultati i diskusija mogu bili zajedno. Svaka od gore navedenih poglavlja moraju poceti na posebnom listu papira oznacenom arapskim brojem. Prva stranica -ime institucije; prvo ime institucije, a zatim ime odeljenja za svakog autora -naslov rada neka bude kratak i jasan bez skracenica -naslov rada napisati na jednom od j1 1go­slovenskih jezika, a prevod na engleskom, ispod njega (za radove napisane u celini na engleskom jeziku, naslov rada napisati samo na engleskom) -navesti prezimena i inicijale imena svih autora -u sažetku ne sme biti više od 200 l'eci sa kojima se obuhvata sadržina rada i najznacaj­ niji rezultati u radu. Pored sažetka (Abstract-a) na engleskom jeziku, potreban je i prevod na jednom od jugoslovanskih jezika, na posebnom listu pa­ pira koji sledi za diskusijom. Uvod je kratko i sažeto poglavlje u kojeni je razložena svrha i ciljevi rada. U uvodu autor navodi rezultate objavljenih radova drugih au­ tora u vezi sa istom problematikom. Uvod nije mesto za davanje preopširnog pregleda litera­ ture. Material i metode ukljucuju dovoljnu kolicinu podataka neophodnih da se eksperiment pono­ vi. Rezultate je potrebno napisati kratko i jasno, bez ponavljanja podataka koji su obuhvaceni slikama i tabelama. W Diskusiji r1e ponavljati rezultate, nego ih objasniti i izvuci zakljucke. Rezultate i zakljucke autor uporeduje sa rezultatima i zakljuccima u drugim objavljenim radovima. Graficki materijal (slike, tabele). Slike i tabele je potrebno poslati u tri primerka: original i dve kopije. Uzimacemo u obzir za objavu samo jasne, ciste materijale. Podvlacenja, gra­fikoni i crteži, moraju biti uradeni tušem. Oznake na grafickom materijalu moraju biti dovoljno velike, da posle smanjivanja na veli­cinu stupca, ostanu citljive. Na fotografijama je potrebno prikrili identitet bolesnika. Slike je potrebno oznaciti na poledini sa imenom auto­ra, prvih nekoliko reci naslova rada i brojem slike. Pored toga, potrebno je strelicom orienti­sati položaj slike. Oznacivanje vršiti obicnom olovkom i vrlo blago. Propratni tekst kao i legende za slike napisati na posebnom listu papira. Tabele otkucati i to bez vertikalnih linija. Popratni tekst za tabele napisati uvek iznad tabele. Tabele obeležiti na njihovoj pole­dini (kao gore navedeno za slike). Propratni tekstovi slika i tabela, kao i sam tekst u tabeli, moraju biti prevedeni na engleskom. Literatura mora biti napisana u skladu sa Vancouver-skim odredbama, sa duplim razma­kom, na posebnom listu papira. Redni brojevi clanaka u pregledu literature moraju odgovarati redosledu citiranja clanaka u tekstu. Za _ime­nima autora napisati naslov rada, naslov revije u skladu sa lndex Medicus-om. Primeri za navodenje clanaka, knjiga ili poglavlja iz knjiga: 1. Deni RG, Cole P. In vitro maturation of monocytes in squamous carcinoma of the lung. Br J Cancer 1981; 43: 486-95. 2. Chapman S, Nakielny R. A guide to radio­logical procedures. London: Bailiere Tindall, 1986. 3. Evans R, Alexander P. Mechanisms of extracellular killir.g of nucleated mammalian cells by macrophages U: Nelson OS ed. lmmu­nobiology of macrophage. New York: Acade­mic Press, 1976; 45-74. lspod literature napisati adresu prvog autora. 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.) pertinant 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 tor publication elsewhe­ re: the authors are responsible for alt state­ ments in their papers. Accepted articles be­ come the property ot the journal and therefore cannot be published elsewhere without written permission from the Editorial Board. Manuscripts written either in English should be sen! to the.Editorial Office, Radiologia lugo­ slavica, Institute of Oncology, Zaloška c. 2, 61105 Ljubljana, Yugoslavia. 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The manuscript, indluding reterences may not exceed 8 typewritten pages, and the number of tigures and tables is limited to 4. It appropriate, organize the text so that it includes: lntroduc­tion, Material and Methods, Results and Dis­cussion. Exceptionally, the results 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 tor each author -a briet and specific title avoiding abbrevia­tions and colloquialisms -family name and initials ot ali authors -in the abstract of not more Ihan 200 words cover the main tactual 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 absttact, 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. Discussion should explain the results, and not simply repeat them, interpret their sigQifi­cance and draw conclusions. Graphic material (figures, tables). Each item should be sen! in triplicate, one of them marked original tor publication. Only high-con­trast glossy prints will be accepted. Line dra­wings, graphs and charts chould be done protessionaly in indian ink. All 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. Orni! 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 tollowed 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 monocytes in squamous carcinoma ot 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 Reterences. 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 JUGOSLAVIJA Kucna centrala -Switchboard: 214-444 Brzojavi -Cables: J A D R O A G E N T Telex: YU JADRAG 24153, 24189, 14354. 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