ADIOLOGY ,.,.11 NCOLOGY December 2005 Vol. 39 No. 4 Ljubljana ISSN 1318-2099 Editorial office RadiologtJ and OncologiJ Decenber 2005 Institute oj Oncology Vol. 39 No. 4 Zaloška 2 Pages 23 7-296 SI-1000 Ljubljana ISSN 1318-2099 Slovenia UDC 616-006 Phone: +386 1 5879 369 CODEN: RONCEM Phone/Fax: +386 1 5879 434 E-mail: gsersa@onko-i.si Aims and scope Radiologi; and Oncology is a joumal devoted to publication oj original contributions in diagnostic and interventional radiology, computerized tomography, ultrasound, magnetic resonance, nuclear medicine, radiotherapy, clinical and experimental oncology, radiobiology, radiophysics and radiation protection. 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Indexed and abstracted by: BIOMEDICINA SLOVENICA CHEMICAL ABSTRACTS EMBASE / Excerpta Medica Sci Base Scopus This journal is printed on acid-free paper Radiology and Oncology is available on the internet at: http://www.onko-i.sz/radioloncol ISSN 1581-3207 Ljubljana, Slovenia ISSN 1318-2099 December 2005 UDC 616-006 Vol. 39 No. 4 CODEN: RONCEM CONTENTS DIAGNOSTIC RADIOLOGY ANO SONOGRAPHY Imaging of small amounts of pleural fluid. Part one -small pleural effusions Kocijancic I 237 Ultrasonography of gallbladder in surgical patients with a prolonged stay (> 14 days) in the intensive care unit Šustic A, Miletic D, Cicvaric T 243 The usefulness of transrectal endosonography in differentiating an anal abscess from a rectal carcinoma. A case report Kolodziejczak M, Sudol -Szopinska I 249 ONCOLOGY New marker of angiogenesis CD105 (endoglin): diagnostic, prognostic and therapeutic role Legan M MHC class II molecules and tumour immunotherapy Oven I Quantitative analysis of fine needle aspiration biopsy samples 253 261 Rajer M, Kmet M Correlation of clinical target vohune and the margins to define planning target volume with beam arrangements for three-dimensional conformal radiation therapy delivery for prostate cancer Erkal H$, Serin M SLOVENIAN ABSTRACTS 273 279 NOTICES 287 AUTHORS INDEX 2005 SUBJECT INDEX 2005 Radiology and Oncology is covered in Biomedicina Slovenica, Chemical Abstracts, EMBASE / Excerpta Medica, Sci Base and Scopus Imaging of small amounts of pleural fluid. Part one – small pleural effusions Igor Kocijancic Department of Radiology, Institute of Oncology, Ljubljana, Slovenia Background. Small pleural effusions are not readily identified on conventional radiographic views of the chest, but may be an important finding, sometimes leading, via thoracocentesis, to a definitive diagnosis of pleural carcinomatosis, infection or transudate. A small meniscus sign and a medial displacement of the costophrenic angle are the only subtle signs of small accumulations of fluid on posteroanterior chest X-rays. On lateral views the finding of a small meniscus sign in the posterior costophrenic angle is the sign of small pleural effusion. Conclusions. Lateral decubitus chest radiographs were used for many years for the diagnosis of small ple­ural effusions. In last decades ultrasonography of pleural space becomes a leading real-time method for de­monstrating small pleural effusions. Key words: pleural effusion; thoracic radiography Introduction Small amount of fluid (5-20 ml) is often pre­sent in the pleural space of healthy individu­als.1 The data on the smallest amount of ple­ural fluid detectable by imaging methods vary considerably, but they are essentially within the same broad range whether computed to­mography, sonography or X-ray examination are used.2-10 With the advent of sonography it was shown that very small amounts of pleu­ral fluid can be demonstrated on this way.3-8 Received 15 September 2005 Accepted 25 September 2005 Correspondence to: Assist. Prof. Igor Kocijancic, MD, PhD, Department of Radiology, Institute of Oncology, Zaloška 2, SI - 1000 Ljubljana; Slovenia; Phone: + 386 1 587 9 505; Fax.: + 386 1 587 9 400; E-mail: ikocijan­cic(onko-i.si In the literature there are only a few arti­cles comparing the thickness of the pleural effusion as seen on sonography with X-ray and the amount of aspirated fluid. In additi­on, there is no clear consensus definition of a small pleural effusion on sonography. So, our term of small pleural effusions includes clini­cally silent effusions, which are usually unex­pected findings on x-ray and/or ultrasonogra­phic (US) examinations undertaken for diffe­rent reasons. Conventional chest radiography a) Erect posteroanteror (PA) views The term small pleural effusion cannot be used for the pleural fluid clearly visible on PA chest films, since it is known that the amo­unts of 175 to 500 ml could be hidden in the pleural space on such views.11 In the early stage with the patient in the upright position, the fluid tends to accumulate in the infrapul­monary position if the pleural space is free of adhesions and the lung is healthy, forming subpulmonary effusion. In general, it is agre­ed that gravity is probably the main factor of the location of fluid although some investiga­tors implicated the elasticity of the lung, basal atelectasis and surface tensions as well.12,13 Nearly simultaneously with the infrapulmo-nic accumulation, the pleural fluid will appe­ar in the costophrenic sulcuses and can be seen as a medial displacement of the costo­phrenic angle first and with blunting of the diaphragm afterwards.12 Davis et al.14 has shown that the upper li­mit of a free pleural effusion is horizontal and is located about the level of the apex of the meniscus shaped density. The x-ray beam tra­verses a greater depth of the fluid in the peri­phery of the thorax where the fluid is tangen­tial to the beam.15 We proposed that a small meniscus sign (Fi­gures 1a, 1b) and a medial displacement of the costophrenic angle (Figures 2a, 2b) are the only subtle signs of small accumulations of fluid on PA views. In these cases 200-300 ml of flu­id can be evacuated from the pleural spa­ce13,16 and that there is probably some residu­al fluid after thoracocentesis as well. We disa­gree with the authors who claim that a meni­scus sign with blunting of one half of the he- Figure 2a. Only medial displacement of costophrenic angle on erect chest X-ray. Figure 2b. About one cm thick fluid layer (approxima­tley 200 mm of fluid) on the the left lateral decubitus view. Radiol Oncol 2005; 39(4): 237-42. Figure 3. The patient’s position during chest X-ray examination in left lateral decubitus position. After leaning 5 min with elevated hip in slight Trendellenburg position, the exposure with central X-ray beam aimed to the late­ral thoracic wall was done. mi diaphragm is the sign of small pleural ef­fusion.17,18 b) Erect lateral views In the study on roentgen pathology models Collins11 showed that as little as 25 ml of ple­ural fluid (injected saline) on lateral erect chest radiograms could be detected as a sub-pulmonic accumulation of fluid in posterior costophrenic sulcus, but only with the pre­sence of coexisting pneumoperitoneum. This is less reliable in practice, so we proposed the finding of a small meniscus sign in the posteri­or costophrenic angle as the sign of small ple­ural effusion on lateral views. Some authors13,19 also suggested that the junction of the major fissure with the dia­phragm may commonly be the site of small amounts of small pleural effusions on lateral erect chest radiograms. The sign is described as a straight triangular shadow at the anterior diaphragmatic contour. We claim that it is difficult to interpret the sign without previo­us lateral chest x-rays and in the cases of su­perimposing fat in anterior mediastinum. c) Lateral decubitus views Lateral decubitus chest radiographs were used for many years for the diagnosis of small pleural effusions. This position was first men­tioned in the work of Rigler.20 Other investi­gators19,21 have developed the technique and, using cadaveric studies,2 have shown that vo­lumes of pleural fluid as little as 5 ml may be detected. Rigler20 did not use exposure in ex­piration, however, nor did he expose with central beam aimed at the lateral chest wall, parallel to the expected fluid level. The latter technical improvement was introduced by Hessen19 together with the elevation of the patient’s hip (Figure 3), while the exposure in expiration is mentioned in the work of Müller and Löfstedt,21 but apparently without gai­ning wider acceptance. Radiol Oncol 2005; 39(4): 237-42. The amounts of pleural fluid detected this way have been assessed in cadaveric experi­ments2 to as little as 5 ml in experimental con­ditions. This is probably less reliable in practice, due to the inexact results of thoracocentesis. In the lateral decubitus position, the crite­ria for small pleural effusions is a density of at least 3 mm (but not exceeding 15 mm) thick, with horizontal level at lateral dependent chest wall (Figure 4). The study of Kocijancic et al.22 showed that lateral decubitus views taken in expiration contributed essentially to the diagnostic sen­sitivity of radiological examination as the flu­id layer thickness changed during inspirati­on-expiration. The improved technique tends to facilitate the diagnosis of small pleural ef­fusions (Figures 5a, 5b) and increased the abi­lity to recognize artefacts such as skin folds, sheets and subcutaneous fat. Chest ultrasonography In last decades ultrasonography (US) of pleural space becomes a leading real-time method for demonstrating small pleural effusions.23-26 US criteria determining pleural effusions are: at least 3 mm thick anechogenic zone between the parietal and the visceral pleura and/or changing of fluid layer thickness between expira­tion and inspiration as well as changing with dif­ferent positions of the patient.23-26 As US is a real-time method it is very important that all sonographic measurements with the probe perpendicular to the thoracic wall should be done. Comparing chest US with expiratory late­ral decubitus radiography, Kocijancic et al.27 showed that both seem to be efficient me­thods for demonstrating small pleural effusi­ons but US appears to assess the thickness of fluid layer more accurately than radiography does. It is interesting that in this study the main sign, allowing the demonstration of the smallest effusions, was similar in both moda­lities: the changing of the fluid layer during inspiration – expiration (Figure 6). The fluid layer thickness between 3-15 mm was found with both examination modalities. On erect chest radiograms only a medial displacement of costophrenic angle and a small meniscus sign were detected in 40% of patients. Radiol Oncol 2005; 39(4): 237-42. They have introduced a method of the US examination in the so called “elbow positi­on”.27 The examination begins with the pati­ent placed in the lateral decubitus position for 5 minutes first (similar to lateral decubitus chest radiography) and than the US examina­tion performed with the patient leaning on the elbow (Figure 7). This manoeuvre allows the detection of small subpulmonic effusions, since the fluid tends to accumulate within the diaphragmatic pleurae in the erect position. In the work of Wu et al.28 so-called “fluid colour” sign was described as a useful indica-tor for discrimination between pleural thicke­nings and pleural effusion and a diagnostic aid to grey scale US for minimal or loculated pleural effusions. Our opinion is that this sign is not a useful diagnostic marker when the amount of fluid is very small. Conclusions Both US and “classical” radiography seem to be efficient methods for demonstrating small pleural effusions. For satisfactory results, the meticulous adherence to the techniques de­scribed (exact position of the patient during lateral decubitus radiography and during chest US examinations, perpendicular US measurements) is probably the most impor­tant. References 1. Noppen M, De Waele M, Li R, Gucht KV, D’Hae­se J, Gerlo E, et al. Volume and cellular content of normal pleural fluid in humans examinated by pleural lavage. Am J Crit Care Med 2000; 162: 1023­6. 2. Moskowitz H, Platt RT, Schachar R, Mellus H. Ro­entgen visualization of minute pleural effusion. Radiology 1973; 109: 33-5. 3. Lipscomb DJ, Flower CDR. Ultrasound in the dia­gnosis and management of pleural disease. Br J Dis Chest 1980; 74: 353-61. 4. Von Eibenberger K, Dock W, Metz V, Weinstabl C, Haslinger B. Grabenwöger F. Wertigkeit der thorax bettaufnahmen zur diagnostik und quanti­fizierung von pleuraergüssen - überprüfung mit-tels sonographie. Fortschr Rontgenstr 1991; 155: 323-6. 5. Lorenz J, Börner N, Nikolaus HP. Sonographische volumetrie von pleuraergüssen. Ultraschall 1988; 9: 212-5. 6. Mathis G. Lungen und pleurasonographie. Berlin: Springer-Verlag; 1992. p. 11. 7. Mc Loud TC, Flower CDR. Imaging of the pleura: sonography, CT and MR imaging. AJR 1991; 156: 1145 -53. Radiol Oncol 2005; 39(4): 237-42. 8. Mikloweit P, Zachgo W, Lörcher U, Meier-Sydow J. Pleuranage Lungenprozesse: Diagnostische wer­tigkeit sonographie versus CT. Bildgebung 1991; 58: 127-31. 9. Leung AN, Muller NL, Miller RR. CT in the diffe­rential diagnosis of pleural disease. AJR 1990; 154: 487-92. 10. Maffesanti M, Tommasi M, Pellegrini P. Compu­ted tomography of free pleural effusions. Europ J Radiol 1987; 7: 87-90. 11. Collins JD, Burwell D, Furmanski S, Lorber P, Stec­kel RJ. Minimal detectable pleural effusions. a ro­entgen pathology model. Radiology 1972; 105: 51-3. 12. Rudikoff JC. Early detection of pleural fluid. Chest 1980; 77: 109-11. 13. Petersen JA. Recognition of infrapulmonary pleu­ral effusion. Radiology 1960; 74: 34-41. 14. Davis S, Gardner F, Qvist G. The shape of a pleu­ral effusion. Brit Med J 1963; 1: 436-7. 15. Raasch BN, Carsky EW, Lane EJ, O’Callaghan JP, Heitzman ER. Pleural effusion: explanation of so­me typical appearances. AJR Am J Roentgenol 1982; 139: 899-904. 16. Anzbock W, Stellamor K, Braun U, Hruby W. Die sonographie der lunge und pleura. Fortschr Rontgenstr 1990; 153: 278-82. 17. Kohan JM, Poe RH, Israel RH, Kennedy JD, Benaz­zi RB, Kallay MC, et al. Value of chest ultrasono­graphy versus decubitis roentgenography for tho-racentesis. Am Rev Respir Dis 1986; 133: 1124-6. 18. Wu RG, Yuan A, Liaw YS, Chang DB, Yu CJ, Wu HD, et al. Image comparison of real-time gray-sca­le ultrasound and color doppler ultrasound for use in diagnosis of minimal pleural effusion. Am J Res-pir Crit Care Med 1994; 150: 510-4. 19. Hessen I. Roentgen examination of pleural fluid. A study of the localisation of free effusions, the potentialities of diagnosing minimal quantities of fluid and its existence under physiological conditi­ons. Acta Radiol 1951; 86(Suppl): 1-80. 20. Rigler LG. Roentgen diagnosis of small pleural ef­fusions. JAMA 1931; 96: 104 - 8. 21. Müller R, Löfstedt S. Reaction of pleura in primary tuberculosis of the lungs. Acta Med Scand 1945; 122: 105-33. 22. Kocijancic I, Tercelj M, Vidmar K, Jereb M. The Value of inspiratory-expiratory lateral decubitus views in the diagnosis of small pleural effusions. Clin Radiol 1999; 54: 595-7. 23. Mathis G. Thoraxsonography - part I: chest wall and pleura. Ultrasound Med Biol 1997; 23: 1131-9. 24. Kocijancic I. The accuracy of chest sonography in the diagnosis of small pleural effusion. Radiol On-col 2003; 37: 13-6. 25. Eibenberger KL, Dock W, Metz V, Weinstabl C, Haslinger B. Grabenwöger F. Ranking of supine chest radiographs for diagnosis and quantification of pleural effusions – checking via sonography. Fortschr Rontgenstr 1991; 155: 323-6. 26. Marks WM, Filly RA, Callen PW. Real-time evalu­ation of pleural lesions: new observations regar­ding the probability of obtaining free fluid. Radio­logy 1982; 142: 163-4. 27. Kocijancic I, Vidmar K, Ivanovi-Herceg Z. Chest sonography versus lateral decubitus radiography in the diagnosis of small pleural effusions. J Clin Ultrasound 2003; 31: 69-74. 28. Wu RG, Yang PC, Kuo SH, Luh KT. “Fluid color” sign: a useful indicator for discriminatrion betwe­en pleural thickening and pleural effusion. J Ultra­sound Med 1995; 14: 767-9. Radiol Oncol 2005; 39(4): 237-42. Ultrasonography of gallbladder in surgical patients with a prolonged stay (> 14 days) in the intensive care unit Alan Šustic1, Damir Miletic2, Tedi Cicvaric3 1Department of Anesthesiology and ICU, University Hospital Rijeka, Rijeka, Croatia 2Department of Radiology, University Hospital Rijeka, Rijeka, Croatia 3Department of Surgery, University Hospital Rijeka, Rijeka, Croatia Background. The aim of this study was to establish the incidence of abnormal ultrasonographic (US) fin­dings of gallbladder (GB) in surgical patients with the prolonged stay in the intensive care unit (ICU) and to correlate these findings with the severity of illness. Methods. In the prospective study fifty-seven (57) adult surgical patients (male 66%; age 49±18 yr.) with the prolonged stay in ICU (>14 days) were analyzed. In all patients the US examination was performed on the 15th day of their stay in ICU. The presence of the following US findings was analyzed: GB wall thickening (?4 mm), biliary sludge, GB hydrops, striated GB wall and pericholecystitic fluid. The severity of illness was also evaluated on the 15th day of the stay in ICU using Simplified Acute Physiology Score (SAPS II). Results. At least one abnormal US finding was found in 36 (63%), patients with GB wall thickening in 32 (56%), biliary sludge in 23 (40%), pericholecystitic fluid in 9 (16%), hydrops of GB in 7 (12%), and striated GB wall in 4 (7%) cases, respectively. Two to five US findings were found in 20 (35%) patients, three to fi­ve in 12 (21%), four to five in 10 (18%), while all five US findings were present in 4 (7%) cases. The pati­ents with one and more US findings had significantly higher SAPS II than the patients who presented regu­lar US findings of the GB (36±9 vs. 28±7; p < 0.01). The patients with two and more US findings had hig­her SAPS II than those with one or none US criteria (40±8 vs. 29±6; p < 0.001), while the patients with three and more had higher SAPS II than those with two, one or none (41±8 vs. 31±9; p < 0.001). The patients with four or five US findings had higher SAPS II than those with three or less (42±11 vs. 31±6; p < 0.001) whi­le the patients with all five had higher SAPS II than all others (45±10 vs. 32±9; p < 0.001). A significant po­sitive correlation between the number of US findings and SAPS II was present (r = 0.57; p < 0.001). Conclusions. More than half of all surgical patients with the prolonged stay in ICU have GB abnormaliti­es seen by ultrasonography; and it is in direct correlation with the severity of illness. Key words: gallbladder diseases ; ultrasonography; postoperative complications; intensive care units Received 21 September 2005 Accepted 5 October 2005 Correspondence to: Alan Šustic, MD, PhD, Dept. of Anesthesiology and ICU, University Hospital Rijeka, T.Strieica 3, Rijeka 51 000, Croatia, Europe; Pho-ne/fax: +385 51 21 84 07; E-mail: alan.sustic@medri.hr Introduction Acute acalculous cholecystitis (AAC) is a seri­ous complication in the treatment of critically ill patients. The incidence, published up to now varies from 0.2% up to 18% in patients treated in intensive care unit (ICU).1-3 Such variability is due to different incidences of AAC in different patients but also due to dis­similar criteria for the diagnosis of AAC. Ul­trasonography (US) remains the method of choice for the diagnosis of AAC because it is a non-invasive, relatively inexpensive and transportable technique.1-4 However, some recently published studies suggest that in cri­tically ill patients it is not an optimal diagno­stic method due to the low sensitivity and the high percentage of abnormal US findings of gallbladder (GB).5,6 The patients with the prolonged stay (>14 days) in ICU represent a specific group of cri­tically ill patients with much higher incidence of complications and worse outcome but with a significantly more expensive treatment vs. other ICU patients.7,8 On the other hand, tho­se patients have many risk factors for abnor­mal US findings of GB as for example: total parentereal nutrition, hypoalbuminaemia, splanchnic ischemia/reperfusion injury, anal-gosedation, mechanical ventilation, infection, shock, sepsis, multiorgan failure, etc.1,2 The main aim of this study was to establish the incidence of abnormal US findings of GB in surgical patients with the prolonged stay (> 14 days) in ICU. The second point of this study is to correlate US findings of GB with the se­verity of illness in these patients at the time of the US examination. Patients and methods In the prospective study 60 consecutive adult surgical patients who stayed more than two weeks (14 days) in ICU were included. All we­re admitted in ICU after the urgent (36 cases) or elective major surgery (24 cases). Before we started the study we excluded patients un­der 18 years of age, neurosurgery or cardiac surgery patients, these with earlier cholec­ystectomy as well as the patients who at pre­sent hospitalization underwent pancreatobili­ary surgery. During the study three cases of gallbladder calculosis, verified by the US exa­mination were excluded. Finally, 57 surgical ICU patients (male 66%; age 49±18 yr.) were analyzed. Gallbladder US was performed in all patients on the 15th day of the stay in ICU. The patients were estimated by real-time ul­trasound scan using a 3.5-5 MHz curved transducer (Hitachi 515 EUB; Tokyo, Japan). All examinations were performed by the sa­me investigator (A.Š.). Standard subcostal cross-section was used, and the following US abnormality (i.e. criteria for AAC) were evalu- ated:2-6, 9-12 1. Gallbladder wall thickening. GB wall thic­kening was defined as thickening of GB wall in transverse diameter = 4 mm. 2. Increase of GB volume (hydrops). Increase of GB volume was defined as distension of GB in the longest diameter of = 10 cm or when measured volume of GB was = 100 ccm (ellipsoid formula was used for GB volume measurement).13 3. Biliary sludge. Biliary sludge was defined as an echogenic intraluminal sedimentation and gravity-dependence formation in GB. 4. Layering or target phenomenon of GB. La­yering or target phenomenon of GB was defi­ned as a linear hypoechogenic »halo« within the wall structure (»striated GB wall«). 5. Pericholecystitic fluid. Pericholecystitic fluid was defined as an anechogenic layer around the GB. The severity of illness was estimated in all patients on the 15th day of their stay in ICU, using Simplified Acute Physiology Score II (SAPS II).14 The mean simplified acute physi­ology score II (SAPS II) was 33±10. Statistical analysis All values are presented as number and per­centages or mean value ±standard deviation. A statistical analysis was done with software Statistica 6.0 (StatSoft. inc.), using Mann-Whitney U for comparisons of quantitative Radiol Oncol 2005; 39(4): 243-7. Table 1. The incidence of ultrasonography (US) crite­ria of acute acalculous cholecystitis (AAC) in 57 surgi­cal ICU patients Yes No At least 1 US criteria for AAC 36 (63%) 21 (37%) At least 2 US criteria for AAC 20 (35%) 37 (65%) At least 3 US criteria for AAC 12 (21%) 45 (79%) At least 4 US criteria for AAC 10 (18%) 47 (82%) 5 US criteria for AAC 4 (7%) 53 (93%) variables of unpaired samples and Pearsonís moment for the estimation of correlation co­efficients. Results The results are presented on tables 1, 2 and 3. At least one abnormal US finding of the GB was found in 36 (63%) patients, with GB wall thickening in 32 (56%), biliary sludge in 23 (40%), pericholecystitic fluid/oedema in 9 (16%), hydrops of GB in 7 (12%), and striated GB wall in 4 (7%) patients, respectively. Two to five US criteria of AAC were found in 20 (35%) patients, three to five in 12 (21%), four to five in 10 (18%), while all five US criteria were present in 4 (7%) cases. The patients with one and more US findings of AAC have had significantly higher SAPS II than the pa­tients who presented regular US findings of the GB (36±9 vs. 28±7; p < 0.01). The patients with two and more US findings of AAC have had higher SAPS II than those with one or no­ne criteria of AAC (40±8 vs. 29±6; p < 0.001), while the patients with three and more had higher SAPS II than those with two, one or none criteria (41±8 vs. 31±9; p < 0.001). The patients with four or five US criteria had hig­her SAPS II than those with three or less cri­teria (42±11 vs. 31±6; p < 0.001) while the pa­tients with five had higher SAPS II than all others (45±10 vs. 32±9; p < 0.001). A signifi­cant positive correlation between the number of US criteria of AAC and SAPS II was pre­sent (r = 0.57; p < 0.001) (Figure 1). Table 2. The frequency of abnormal ultrasonographic (US) findings of gallbladder (GB) in 57 surgical ICU patients Abnormal US findings Yes No GB wall thickening (%) 32 (56%) 25 (44%) Biliary sludge (%) 23 (40%) 34 (60%) Hydrops (distension) of GB (%) 7 (12%) 50 (88%) Pericholecistitic fluid (%) 9 (16%) 48 (84%) Striated GB wall (%) 4 (7%) 53 (93%) Discussion Acute acalculous cholecystitis is highly dan­gerous, often lethal complication during the intensive treatment of critically ill surgical pa­tients.1-3 Ultrasonography, as a noninvasive, simple, inexpensive and transportable me­thod represents initial and most often used diagnostic option in the evaluation of criti­cally ill patients with suspect AAC in ICU set­ting.2-4 In many publications during the last 25 years US criteria for AAC are clearly defi­ned: GB thickening, hydrops of GB, biliary sludge, striated GB wall and pericholecystitic fluid.2-6, 9-12 Examining those criteria, one by one or summing them up, the majority of au­thors stressed the overall security of US. Hen­ce, this bedside imaging method is nowadays accepted in many ICU as a basic diagnostic modality when evaluating critically ill pati­ents with suspect AAC. 2-4, 9-12 Nevertheless, in majority of this studies the incidence of one or more abnormal US findings of GB we­re much higher than the expected incidence Table 3. The relationship between ultrasonography criteria (US) of acute acalculous cholecystitis (AAC) and severity of illness (SAPS II) in 57 surgical ICU pa­tients SAPS II P value No Yes = 1 US criteria for AAC 28±7 36±9 < 0.01 = 2 US criteria for AAC 29±6 40±8 < 0.001 = 3 US criteria for AAC 31±9 41±8 < 0.001 = 4 US criteria for AAC 31±6 42±11 < 0.001 = 5 US criteria for AAC 32±9 45±10 < 0.001 Radiol Oncol 2005; 39(4): 243-7. of AAC. For example, in the study of Molenat et al 50% of patients presented at least one from three major US criteria for AAC (GB thickening, hydrops of GB and biliary sludge was considered as major criteria); in the study of Imhof et al 80% of patients, while Helbich et al registered 90% of patients who had at least one US criteria for AAC.9-11 Re­cently published investigations of Boland et al and Puc et al completely confirmed those re­sults but with somewhat different conclusi­ons.5,6 Boland et al found in a heterogenic gro­up of 44 critically ill patients 84% with one positive US criteria for AAC, 57% with three positive and 14% with all five positive US cri­teria.5 The authors assume that many of fin­dings are false positive and because of that conclude that US has a very limited value in diagnosing AAC in ICU patients.5 On the oth­er hand, Puc et al in the retrospective analysis of 62 critically ill injured patients found the very low sensitivity of US diagnostics of so­lely 30% (6/20) concluding that US has insuf­ficient sensitivity to justify its use in diagno­sing AAC in ICU patients.6 The patients with the prolonged stay (> 14 days) in ICU have many risk factors for abnormal US findings of gallbladder (GB), for example total parentereal nutrition, hypoal­buminaemia, splanchnic ischemia/reperfusi-on injury, analgosedation, mechanical venti­lation, infection, shock, sepsis, multiorgan fa­ilure, etc.5,9-12 To our knowledge this is the first study which analyses the incidence of abnormal US findings of GB in critically ill surgical patients with the prolonged ICU stay (> 14 days). Our results are similar to previo­usly mentioned results. We also had over 60% of patients with at least one US criteria for AAC, 21% with three criteria and 5% with all five criteria. If we correlate these results with the expected incidence of AAC, which is ap­proximately 1%,1,2 we can conclude that on one patient with a true positive result (i.e. all five criteria) there are minimally four patients with false positive US findings. Thus, our re­search on a group of surgical patients with a prolonged ICU stay, confirms the conclusions of Puc et al that US has the unsatisfactory sen­sitivity in diagnosing AAC in ICU setting.6 In the presented study we have correlated US findings with the severity of the illness at time of the US examination (i.e. 15th day of stay in surgical ICU). The mean value of SAPS II in our patients was 33±10 with 63% of abnormal US findings. In the previously mentioned study published by Molenat et al the average SAPS I of patients was 13±3 (which corresponds to the approximate value of SAPS II about 35)14 with 50% abnormal US findings.9 In recent investigations of Mariot et al SAPS II of patients included in study was 36±11 (the criteria for inclusion in the study were positive clinical and laboratory symp­toms of AAC) with even 85% of cases with abnormal US findings of GB while the sensi­tivity of US diagnostics was about 50%, res­pectively.15 Summing up the results of our and these studies we may assume that at least 50% of patients staying in ICU with SAPS II over 35 will have abnormal US findings of GB independently of real AAC incidence. Moreo­ver, in our study we found a statistically rele­vant positive correlation between positive US findings and the severity of illness, meaning that the patients with more positive US crite­ria for AAC had on average higher values of SAPS II. This result shows that the severity of illness is one of predictors for abnormal US findings of GB. Similar results were previo- Radiol Oncol 2005; 39(4): 243-7. usly published by Pelinka et al who found the severity of illness as an independent predic­tor for abnormal US findings of GB in selecti­ve group of trauma patients.16 Therefore, we can assume that abnormal US findings of GB will be more often possible, indeed more pro­bable in patients who are more severely ill. However, this thesis should be adequately in­vestigated and confirmed on various groups of ICU patients. Summing up, more than half of all surgical patients with the prolonged stay in ICU have GB abnormalities seen by US, and these abnormalities are in a direct correlation with the severity of illness. At the end we can con­clude that due to a great number of false po­sitive results and low sensitivity US is gene­rally of little benefit for the diagnosis of AAC in critically ill patients with the prolonged stay (>14 days) in ICU. References 1. Shapiro MJ, Luchtefeld WB, Kurzweil S, Kaminski DL, Durham RM, Mazuski JE. Acute acalculous cholecystitis in the critically ill. Am Surg 1994; 60: 335-9. 2. Kalliafas S, Ziegler DW, Flancbaum L, Choban PS. Acute acalculous cholecystitis: incidence, risk fac­tors, diagnosis, and outcome. Am Surg 1998; 64: 471-5. 3. Raunest J, Imhof M, Rauen U, Ohmann CH, Thon KP, BLrrig KF. Acute cholecystitis: a complication in severely injured intensive care patients. J Trau­ma 1992; 32: 433-40. 4. Jeffrey RB, Sommer GF. Follow-up sonography in suspected acalculous cholecystitis: preliminary cli­nical experience. J Ultrasound Med 1993; 19: 183-7. 5. Boland GW, Slater G, Lu DS, Eisenberg P, Lee MJ, Mueller PR. Prevalence and significance of gal­lbladder abnormalities seen on sonography in in­tensive care unit patients. Am J Roentgenol 2000; 174: 973-7. 6. Puc MM, Tran HS, Wry PW, Ross SE. Ultrasound is not a useful screening tool for acute acalculous cholecystitis in critically ill trauma patients. Am Surg 2002; 68: 65-9. 7. Heyland DK, Konopad E, Noseworthy TW, Jo­hnston R, Gafni A. Is it »worthwhile« to continue treating patients with a prolonged stay (> 14 days) in ICU? Chest 1998; 114: 192-8. 8. Wong DT, Gomez M, McGuire GP, Kavanagh B. Utilization of intensive care unit days in a Canadi­an medical-surgical intensive care unit. Crit Care Med 1999; 27: 1319-24. 9. Molenat F, Boussuges A, Valantin V, Sainty JM. Gallbladder abnormalities in medical ICU pati­ents: an ultrasonographic study. Intensive Care Med 1996; 22: 356-8. 10. Imhof M, Raunest J, Ohmann CH, Ršoher HD. Acute acalculous cholecystitis complicating trau­ma: a prospective sonographic study. World J Surg 1992; 16: 1160-6. 11. Helbich TH, Mallek R, Madl C, Wunderbaldinger P, Breitenseher M, Tscholakoff D, et al. Sonomor­phology of the gallbladder in critically ill patients. Value of a scoring system and follow up examina­tions. Acta Radiol 1997; 38: 129-34. 12. Jennings WC, Drabek GA, Miller KA. Significance of sludge and thickened wall in ultrasound evalu­ation of the gallbladder. Surg Gynecol Obstet 1992; 174: 394-8. 13. Wedmann B, Schmidt G, Wagener M, Coenen C, Ricken D, Droge C. Sonographic evaluation of gal­lbladder kinetics: In vitro and in vivo comparison of different methods to assess gallbladder emp­tying. J Clin Ultrasound 1991; 19: 341-9. 14. Le Gall JR, Lemeshow S, Saulnier F. A new simpli­fied acute physiology score (SAPS II) based on a European/North American multicenter study. JA­MA 1993; 270: 2957-63. 15. Mariat G, Mahul P, Prevot N, De Filippis JP, Cuil­leron M, Dubois F, et al. Contribution of ultraso­nography and cholescintigraphy to the diagnosis of acute acalculous cholecystitis in intensive care unit patients. Intensive Care Med 2000; 26: 1658-63. 16. Pelinka LE, Schmidhammer R, Hamid L, Mauritz W, Redl H. Acute calculous cholecystitis after trau­ma: a prospective study. J Trauma 2003: 55: 323-9. Radiol Oncol 2005; 39(4): 243-7. case report The usefulness of transrectal endosonography in differentiating an anal abscess from a rectal carcinoma. A case report Malgorzata Kolodziejczak1, Iwona Sudol - Szopinska2 1Proctology, Sub-Department of General Surgery, City Traumatic Hospital, Warsaw, Poland 2Central Institute for Labour Protection – National Research Institute, Warsaw and Department of Imaging Diagnostics, Second Faculty, Medical School, Warsaw, Poland Background. The high anal abscess might have not a typical, chronic clinical course, and its diagnosis may be difficult. Case report. The authors describe a case of a patient with the initial diagnosis of rectal cancer. Because of non-specific clinical symptoms suggesting a high anal abscess with atypical, chronic course of the disease, additional investigations were suggested. The final diagnosis was high, submucous-intersphincteric abscess. Conclusions. In the described case the most important ones turned out to be an exact finger per rectum exa­mination, clinical proctologic assessment, and the transrectal ultrasound. Key words: anus diseases; abscess; rectal neoplasms; endosonography; diagnosis, differential Introduction The high anal abscess might have not a typi­cal, chronic clinical course, and its diagnosis may be difficult. In the diagnostics of anal ab­scesses one of the most crucial things is early diagnosis, followed by its incision, without waiting for evident clinical symptoms. The longer the process last the greater is the risk of creation of the complex fistula. The treatment for such a fistula carries the risk of anal sphincters trauma. Another important thing is Received 31 August 2005 Accepted 15 September 2005 Correspondence to: Assist. Prof. Iwona Sudol-Szopin-ska, MD, PhD, CIOP-PIB, ul. Czerniakowska 16, 00­701 Warsaw, Poland; Fax +48 2232 65991; E-mail: iw-sud@ciop.pl an exact definition of the type of anal abscess in order to plan the surgical approach.1,2 Case report Half a year ago, a 46-year old woman was hospitalized at the Neurosurgical Depar­tment due to the dystaesthesia and numbness sensation in the lower limbs. The contrast examination led to the suspicion of a tumour in the right curvature of the colon. Colono­scopy did not, however, confirmed that dia­gnosis and it did not find any pathology. A few months ago she was again admitted to the hospital, to the Oncological Depar­tment by her gynaecologist who on palpation confirmed the presence of a rectal mass. The contrast examination and colonoscopy were repeated and have again not found any signs of rectal carcinoma. Because she also had discrete symptoms of periodical discharge of puss from the anus, feeling of pressure against the walls of the anal canal, without neither pain nor fever, she was admitted to the Proctologic Depar­tment with the suspicion of a high abscess of the anal canal. The general examination of the patient did not show any abnormalities. During a proctologic assessment, a hard mass covered by mobile mucous was palpa­ted, about 3 cm from the anal verge, on the right side of the rectum. The lower margin of the mass was reaching level of the dentate li­ne. Little discomfort was felt by the patient during palpation. In the place corresponding to the painful area rectoscopy showed a bulg of mucosa, but the mucosa itself looked normal. No other abnormalities were found. Rectoscopy did not show any lesion within 10 cm of the co­lon, and a normal mucosa was seen covering all walls of the colon. Biopsy specimens were taken from the pa­inful and palpated lesion. The histopatological assessment confirmed the presence of normal fragments of the mucous membrane of the co­lon with small infiltrations of lymphocytes in­to the mucosa and submucosa. Fiberosigmoidoscopy was performed next and the rectum and distal sigmoid colon were assessed. Bulbing of the rectal wall was again seen 5-6 cm from the anal verge, covered by swollen and congested mucous membrane. Bi­opsy specimens were taken. During the exami­nation a leakage of puss content from the ou­tlet was visualized 3 cm above sphincters. No other changes within the colon were found. Computer tomography (layers 10 mm thick) confirmed the presence of a tumour lo­calized just above the anal sphincters. Images were, however, not conclusive. Transrectal ultrasound (TRUS) was perfor­med on the BK Medical unit 3535 with 7 MHz endorectal mechanical probe. It showed the submucosal-intersphincteric abscess with di­ameters reaching 41x17x25 mm on the anteri-or-right anal wall 5-6 cm from anal verge (Fi­gure 1a). From its distal part a channel of an anal fi­stula crossing the internal anal sphincter at the level of puborectal muscle was origina­ting. The internal fistulous opening was loca­ted between high and middle parts of the anal canal, on the right wall (Figure 1b). The ima- Radiol Oncol 2005; 39(4): 249-52. ge was typical for high submucosal-inters­phincteric abscess and fistula, and there were no suspected signs of rectal cancer. The patient was classified for a surgical in­tervention. During surgery the submucosal compartment of the abscess was opened and its intersphincteric part was then visible. The incision was prolonged in the direction of the anal verge and the intersphincteric space was opened. Open wound was left to healing. The solid, hard fragments of circumferential tissues were taken to the histopathologic investigation. The result of histopathologic investigation was following: fragments of mucous membra­ne of large intestine with signs of unspecific inflammation. The postsurgical period was not complica­ted. The patient was sent home the third day after the operation. Discussion The presented case exemplifies a rare case of high abscess of anal canal about chronic, many months’ course. The chronic inflamma­tory state caused the swelling and the indura­tion of the circumferential tissues which were responsible for diagnostic difficulties to diffe­rentiate it from neoplastic tumour. The ab­scess of anus is in majority of the cases a di­sease about sharp course with main symp­toms such as pain and temperature. In the presented case the clinical presentation was not, however, characteristic because the ab­scess was located above the dentate line. In this area there are no nerves responsible for pain sensation so the patient did not compla­in on pain, and only on periodical feeling of »dilating« in rectum.3 The lack of other typi­cal symptoms like fluctuation and redness of the perianal skin were other reasons which made the diagnosis more difficult. Although it should also be bear in mind that patients with Crohn’s diseases have asymptomatic ab­scesses in 62% of the cases,4 this patient did not, however, suffer from non-specific in­flammatory bowel disease. In many cases an anal fistula is the first symptom of an anal abscess. According to Choen et al5 and Deen et al6 these two disea­ses coexist in 50% and 45% of the patients, respectively. At the time of surgery for the anal abscess such a fistula remains unreco­gnized in the clinical examination in 18-95% of the cases, which leads to the recurrence of the abscess or fistula in 48-62% of the cases.7 The presence of discharge from anus might have helped here because it is often the first symptom of an intersphincteric abscess, but only under the condition that it spontane­ously pierces through the anal crypt. In the presented case only occasionally the abscess emptied itself to the anal crypt, which was noted by the patient as the periodical leakage of pus from the anus, but it has never been accompanied by a high fever. Anoscopy revealed an internal opening with puss sipping from it. TRUS is currently the most commonly used for the diagnostics of the anal canal diseases.8-10 However, in the presented case, the detailed history of the di­sease and the exact proctologic assessment pointed to the inflammatory disease, atypical symptoms suggested initially a rectal cancer. TRUS immediately and easily helped with the differentiation of these two diseases, saving time and costs of further diagnostics. It also showed an excellent agreement with surgery in regard to defining anatomy of abscess and anal fistula, and helped planning the surgical approach. Simple drainage of the diagnosed abscess would be mostly insufficient and that is why the surgeons, relying on TRUS, broa­dened the cryptal outlet. Conclusions Transrectal ultrasound is an useful examina­tion enabling the differentiation of rectal car­cinoma from an abscess of the anal canal. Radiol Oncol 2005; 39(4): 249-52. Aknowledgement The authors thank Professor Anna K. Panor-ska, for help in drafting of this paper. References 1. Eisenhammer S. The final evaluation and classifi­cation of the surgical treatment of the primary anorectal cryptoglandular intermuscular (inters­phincteric) fistulous abscess and fistula. Dis Colon Rectum 1978; 4: 237-43. 2. Marks CG, Ritchie JK. Anal fistulas at St Mark’s Hospital. Br J Surg 1997; 64: 84-91. 3. Kolodziejczak M. The ropnie and the archosyrinx. Warszawa: Borgis; 2003. p. 22-4. 4. van Outryve MJ, Pelckmans PA, Michielsen PP, Van Maercke YM. Value of transrectal ultrasono­graphy in Crohn’s disease. Gastroenterology 1991; 101: 1171-7. 5. Choen S, Nicholls RJ. Anal fistula. Br J Surg 1992; 79: 197-205. 6. Deen KI, Williams JG, Hutchinson R, Keighley MRB, Kumar D. Fistulas in ano: endoanal ultraso­nographic assessment assists decision making for surgery. Gut 1994; 35: 391-4. 7. Bartram CI, DeLancey JOL. Imaging pelvic floor di­sorders. Berlin: Springer Verlag; 2003. 8. Bartram CI, Frudinger A. Handbook of anal endoso­nography. Petersfield: Wrightson Biomedical Publi­shig LTD; 1997. 9. Sudol-Szopinska I,Szczepkowski M, Jakubowski W. Anal ulztrasound in the diagnosis of anal car­cinoma. Case report. Radiol Oncol 2001; 35: 273-6. 10. Kolodziejczak M, Grochowicz M, Sudol-Szopinska I, Kosim A, Stefanski R. Diagnostics and operative treatment of retrorectal cysts – description of five cases. Radiol Oncol 2005; 39: 177-80. Radiol Oncol 2005; 39(4): 249-52. review New marker of angiogenesis CD105 (endoglin): diagnostic, prognostic and therapeutic role Mateja Legan Institute of Histology and Embryology, Medical Faculty University of Ljubljana, Ljubljana, Slovenia Background. The well established notion that malignant tumours depend on angiogenesis to grow and me­tastasize focused the investigators’ ‘interest on tumour vasculature’ into visualization and validation. Pan-endothelial markers (CD31, CD34, F8) and CD105 are differentially expressed in angiogenic and normal vessel endothelial cells. Since the former are excellent markers for the normal vasculature, CD105 (endo­glin) is more suitable for identifying tumour angiogenesis. Endoglin is a transforming growth factor (TGF) ­beta binding receptor, preferentially expressed on endothelial cells of angiogenic tissues, essential for angio-genesis and vascular development. Conclusions. Tumour microvessel density expressed by CD105 immunohistochemical staining in paraffin-embedded tissue sections correlates significantly with tumour aggressiveness and prognosis in many solid tumours. Also, targeting of tumour neovasculature specific antigens offers the possibility of future therape­utic approaches. Key words: neoplasms – blood supply; neovascularisation, pathologic; angiogenesis factor; prognosis Importance of tumour angiogenesis In 1971, Folkman proposed that tumour growth is dependent on angiogenesis.1 Angi­ogenesis is an essential process in the pro­gression of malignant tumours because solid tumours cannot grow beyond 1-2 mm in dia­meter without angiogenesis.2 Tumour neova- Received 7 November 2005 Accepted 5 December 2005 Correspondence to: Mateja Legan, MD, PhD, Institute of Histology & Embryology, Medical Faculty, Univer­sity of Ljubljana, Korytkova 2, SI-1000 Ljubljana, Slo­venia; Phone: +386 1 543 7375; Fax: +386 1 543 7361; E-mail: mateja.legan@mf.uni-lj.si scularization promotes growth because the new vessels allow the exchange of nutrients, oxygen and waste products by a crowded cell population for which the simple diffusion is no longer adequate.3 Next to perfusion effect, endothelial cells of vessels release important paracrine growth factors for tumour cells (li­ke insulin growth factor-2, basic fibroblast growth factor, platelet-derived growth fac­tors). By releasing collagenases, urokinases and plasminogen activators they facilitate spread of tumour into the adjacent fibrin-gel matrix and connective tissue stroma.4,5 Tumour neovasculature has structural and functional abnormalities, increasing the op­portunity for tumour cells to enter the circu­lation.6 They have the abnormal vessel wall: incomplete or missing endothelial lining, in­terrupted or absent basement membrane, lack of pericytes, pharmacological and physiologi­cal receptors. Abnormal vascular architecture with contour irregularities, tortuosity, elonga­tion of vessels, as well as loss of hierarchy is found in tumour vasculature, plenty of arteri­ovenous shunts and abnormal vascular den­sity (chaotic network). Altered morphology re­sults in functional abnormalities: shunt perfu­sion, absence of vasomotion, unstable blood circulation, obstruction of microvessels by le­ucocytes and tumour cells. Changed tumour perfusion results in platelet aggregation, mi­cro- and macrothrombosis and in the increase of viscous resistance. Consequences of increa­sed vascular permeability are hemoconcentra­tion, interstitial bulk flow, extravasation of blood cells and hemorrhages.6 Neoangiogenesis is often a significant in­dependent prognostic indicator for both the overall and the disease-free survival. Intratu­moural microvessel density (MVD) - com­monly measured with a histomorphometric method on tissue sections - is a widely regar­ded predictor of tumour growth, metastasis and patient’s survival. Many studies have shown that MVD correlates with tumour ag­gressiveness of many different tumour types.4,7,8 Meta-analysis by Uzzan and cowor­kers9 of 88 published studies on MVD as a prognostic factor in women with breast can­cer showed that high MVD significantly pre­dicted the poor survival. Validating tumour angiogenesis The most important question in validating tu­mour angiogenesis is what proportion of tu­mour vascular network is due to pre-existing parent tissue vessels or newly formed vessels. We know plenty of pan-endothelial markers, such as CD34 - a cell surface sialomucin-like glycoprotein expressed by endothelial cells, CD31 - platelet-endothelial cell adhesion mo­lecule and von Willebrand factor - also known as F8.10 These markers detect both, tu­mour and parenteral vessels, but the former not to the same degree. Assessing tumour mi-crovessel density with immunohistochemi­stry by antibodies against CD31, CD34 and von Willebrand factor may not be accurate, since these markers are expressed also in nor­mal vessels, and on the other hand, they are not always expressed in all tumour ves­sels.11,12 Besides, they are generally better ex­pressed in larger vessels than in microves­sels.13 In summary, because endothelial cells are heterogeneous, the markers of normal endo­thelial cells are apparently unfit for the studi­es of angiogenesis in tumour tissues. The growth of tumours includes not only the in­crease of blood vessels in number, but also the change of protein molecules in structure of endothelial cells. An ideal marker for angi­ogenesis should detect the newborn vessel quality as well as its quantity.14 In last years, imaging of tumour neovascu­lature by targeting a proliferation-associated endothelial marker CD105, called also endo­glin, gave fruitful results.15 CD105 is a new kind of cell adhesion molecules, first found in a human pre-B cell line.16 It is a receptor that is strongly up-regulated in proliferating endo­thelial cells, and - as such - an optimal indica­tor of proliferation of endothelial cells also in tumour neovasculature. In contrast to pan-en­dothelial markers, CD105 is preferentially ex­pressed on endothelial cells of all angiogenic tissues, including tumours, but weakly or not at all with those of normal tissues,17-20 giving the superiority of CD105 as a marker of tumo­ur angiogenesis. CD105 (endoglin) is a disulfide-linked ho-modimeric cell membrane glycoprotein of 180 kDa. It is a transmembrane phosphorylated glycoprotein, a component of the receptor com­plex of transforming growth factor (TGF)-ß, which is a pleiotropic cytokine that modulates Radiol Oncol 2005; 39(4): 253-9. angiogenesis by the regulation of different cel­lular functions, including proliferation, diffe­rentiation and migration.19 CD105 binds seve­ral components of the TGF-ß superfamily, in particular TGF-ß1 and TGF-ß2. The overex­pression of CD105 antagonizes several cellu­lar responses to TGF-ß1, while down-regulati­on of CD105 potentiates cellular responses to TGF-ß1.18 Endoglin is essential for angioge­nesis and vascular development.21-23 The inhi­bition of CD105 expression on human umbili­cal vein endothelial cells (HUVEC) by an anti-sense approach, enhanced the ability of TGF­ß1 to suppress their growth, migration and ca­pacity to form capillary tubes. Much evidence supports an important role of endoglin in car­diovascular development and vascular remo­delling in humans and chicken.24,25 Endoglin is highly expressed at the endocardial cushion during heart septation by mesenchimal cells24 and it is up-regulated in response to tissue in­jury and atherosclerosis.26-28 The gene of CD105 is located on 9q34.20 The loss of func­tion in the human endoglin gene causes here­ditary hemorrhagic teleangiectasia Type 1.23,29 The detection of CD105 with immunohi­stochemical staining using anti-endoglin mo­noclonal antibody shows that CD 105 is al­most exclusively expressed on endothelial cells of both peri- and intratumoural blood vessels.18 Staining is very selective for the blood vessel endothelium and reacts specifi­cally with endothelial cells without the signi­ficant cross-reactivity of inflammatory or stromal cells within the neoplasm.30,31 Endo­glin staining reduces false-positive staining of blood vessels compared with other com­monly used panendothelial markers. It can be readily performed on formalin-fixed, paraf­fin-embedded tissues. It is a good illuminator of tumour vasculature in solid malignancies (Figure 1).17-19 CD105 is also expressed on non-endothelial cells including haemopoetic progenitor cells, fibroblasts, follicular dendri-tic cells, melanocytes, vascular smooth mu­scle cells, macrophages and mesangial cells, however, this expression is very weak.18,19 Since CD105 is expressed on the most imma­ture cellular subtypes in acute leukaemias, it can also be used in diagnozing haemopoietic tumours.16,19 The experience shows that, in many types of cancer, MVD counted by CD105 is a better estimator of tumour prognosis and survival than MDV counted by pan-endothelial mar­kers. In colorectal cancer CD105 demonstra­ted significantly more proliferating neoplastic microvessels than CD31 and was a more spe­cific and sensitive marker for tumour angio-genesis than commonly used panendothelial markers.31 Also CD105, but not other mar­kers, correlated significantly with liver meta­stases and lymph node invasion. Akagi et al32 quantified MVD detected using monoclonal antibodies CD34 and CD105 in 54 cases of co-lorectal adenoma and in 20 cases of carcino­mas. A significant increment of MVD detec­ted by anti CD105 was found from low-grade to high-grade dysplasia and from high-grade dysplasia to carcinoma. In contrast, no signi­ficant difference of MVD assessed by anti CD34 was observed in the colorectal adeno-ma-carcinoma sequence. Microvessels positi­ve for CD105 were preferentially observed on the surface area of adenomas (whereas CD34 staining was distributed uniformly in the sec­tions), suggesting that angiogenesis mainly took place in this area. The similar findings were shown in pati­ents with head and neck squamous cell carci-nomas,33 where patients with high CD105­MVD had a significantly shorter disease-free interval and overall survival; but CD34-MVD was not associated with the survival. The eva­luation of angiogenesis in non-small cell lung cancer,34 determined with CD105 as well as CD34 immunostaining, also proved CD105 expression superior in the evaluation of angi­ogenesis. Five- year survival rate was signifi­cantly lower in patients with high CD105 ex­pression regarding patients with a low CD105 expression. The difference in the longevity of Radiol Oncol 2005; 39(4): 253-9. survival between patients with high CD34 ex­pression and low CD34 expression was, ho­wever, the same, but statistically insignifi­cant. The hypothesis that the use of CD105 antibody should reduce the incidence of fal­se-positive staining of normal blood vessels entrapped within a tumour and those located within the close vicinity of a cancerous mass was confirmed in the study of Kumar et al35, who reported that vascular density determi­ned using CD105 antibody correlates with the tumour prognosis in breast carcinoma. However, not in all types of tumours MVD correlated with the prognosis. There was also a lot of discrepancies between different studi­es due to the diversity of technical approa­ches, variation in tissue pre-treatment proto­cols and non-standardized counting me­thods.35,36 There is a trend to standardise the procedures so that results from different stu­dies would be comparable. In clear cell renal carcinoma,37 there was the inverse relation­ship between MVD and patient’s survival: tu­mours with higher vascular density were as­sociated with a greater post-operative 5-year survival rate than tumours with lower vascu­lar density. Decreased MVD was associated with tumour fibrosis (which has morphologi­cal effect of decreasing MVD in a given tumo­ur) and the development of large diameter va­scular channels. It was concluded that the as­sociation between tumour microvessel den­sity and the prognosis is not identical for all forms of malignancy but may be modified by architectural remodelling during tumour evo­lution. Besides, lower scores of MVD-CD105 were found in larger sized and more aggressi­ve hepatocellular carcinomas,38 however, the study did not provide significant any progno­stic information. But active angiogenesis as highlighted by diffuse CD105 staining micro-vessels in the adjacent non-tumorous liver tis­sues was predictive for the early recurrence in this study. Clinical potential of CD105 in human malignancies As angiogenesis is crucial for tumour develo­pment and progression, the antiangiogenic therapy represents a promising approach for the cancer treatment. CD105 therapeutic tar­geting was investigated in vitro39 and in ani­mal models.14,40,41 She et al42 investigated the mechanisms by which anti-endoglin monoclonal antibodies (mAbs) - termed SN6 series mAbs, suppress the growth of proliferating endothelial cells. They found that four SN6 series mAbs sup­pressed the growth of human umbilical vein endothelial cells (HUVECs) in a dose-depen­dent manner. Matsuno and co-workers39 in­duced a long-lasting complete regression of distinct solid tumours in immunodeficient mice with the intravenous administration of antiendoglin conjugates, but not with the control conjugate. The same in vivo evidence was shown in a canine mammary carcinoma model.40 In fact this study40 was the first in vi­vo evidence that targeting of CD105 could re­present an effective strategy to image solid malignancies. The antiangiogenic therapy of the mouse chimeras bearing established hu­man skin tumours using various anti-endo­glin monoclonal antibodies SN6, was effecti- Radiol Oncol 2005; 39(4): 253-9. ve in the suppression of tumours. The effi­cacy was enhanced by combining a chemo­therapeutic drug (cyclophosphamide).43 No­wadays, next to systemic intravenous drug approach, a transcriptional targeting of con­ditionally replicating adenovirus with drug-substance to dividing endothelial cells is pos­sible. Savontaus et al41 utilized the regulatory elements of endoglin genes to construct two conditionally replicating adenoviruses (CRAD). In vitro studies it was demonstrated that both CRADs controlling the endoglin promoter, inhibited by 83-91% the capillary network for­mation in an in vitro angiogenesis assay in HUVECs, compared with the non-replicating control virus. This principle may be incorpo­rated into novel therapeutic agents to develop anti-angiogenic treatment for cancer. Endoglin has been detected also in the cir­culation of cancer patients, next to some other angiogenic growth factors. Increased CD105 in the circulation of patients with cancer results from angiogenesis both within and the imme­diate vicinity of the tumour mass. The main question was whether soluble CD105 levels as­sociate with the disease progression. Li et al44 demonstrated in 92 breast cancer patients that serum CD105 might be a valuable novel angio-genetic marker for identifying high risk breast cancer patients, since plasma levels of soluble CD105 (measured with indirect ELISA assay) correlated with metastasis. In 2001, Takahashi et al45 reported about the association of serum endoglin with metastasis in patients with colo-rectal, breast and other solid tumours. In addi­tion, they showed that chemotherapy exerts a suppressive effect on the serum endoglin. They suggested that serum endoglin may be a useful marker for monitoring early signs of metastasis and cancer relapse in a long-term follow-up of solid tumour patients. In 2003, Li and his group36 compared the expression of CD105 in vasculature of resected colorectal cancer by MVD assessment and CD105 levels in the blood of the patients. CD105-MVD was an independent prognostic parameter for the survival of patients with colorectal cancer, and the plasma levels of CD105 were useful para­meter for assessing the disease progression (serum-CD105 positively correlated with Du­kes’ stage). Conclusions It is likely that evaluating tumour angioge­nesis will become an integral part of more consistent tumour staging system and routine prognostic evaluation. CD105 (endoglin) is proliferation-associated endothelial cell adhe­sion molecule, showed as an optimal indica­tor of tumour neovasculature. Moreover, tar­geting of tumour neovasculature specific anti­gens (like CD105) offers the possibility of fu­ture therapeutic approaches. References 1. Folkman J. Tumor angiogenesis: therapeutic impli­cations. N Engl J Med 1971; 285: 1182-6. 2. Folkman J, Watson K, Ingiber D, Hanahan D. In­duction of angiogenesis during the transition from hyperplasia to neoplasia. Nature 1989; 339: 58-61. 3. Weidner N. Intratumor microvessel density as a prognostic factor in cancer. Am J Pathol 1995; 147: 9-19. 4. Weidner N. The importance of tumor angiogene-sis: the evidence continues to grow. Am J Clin Pa-thol 2004; 122(5): 675-7. 5. Bergers G, Benjamin LE. Tumorigenesis and the angiogenic switch. Nat Rev Cancer 2003; 3(6): 401­10. 6. Vaupel P, Kallinowski F, Okunieff P. Blood flow, oxygen and nutrient supply, and metabolic micro-environment of human tumors: a review. Cancer Res 1989; 49(23): 6449-65. 7. Khan AW, Dhillon AP, Hutchins R, Abraham A, Shah SR, Snooks S, et al. Prognostic significance of intratumoural microvessel density (IMD) in re-sected pancreatic and ampullary cancers to stan­dard histopathological variables and survival. Eu J Surg Oncol 2002; 28(6): 637-44. Radiol Oncol 2005; 39(4): 253-9. 8. Mineo TC, Ambrogi V, Baldi A, Rabitti P, Bollero P, Vincenzi B, et al. Prognostic impact of VEGF, CD31, CD34, and CD105 expression and tumour vessel invasion after radical surgery for IB-IIA non-small cell lung cancer. J Clin Pathol 2004; 57(6): 591-7. 9. Uzzan B, Nicolas P, Cucherat M, Perrret GY. Mi-crovessel density as a prognostic factor in women with breast cancer: a systematic review of the lite­rature and meta-analysis. Cancer Res 2004; 64: 2941-55. 10. Middleton J, Americh L, Gayon R, Julien D, Man-sat M, Mansat P, et al. A comparative stuady of en­dothelial cell markers expressed in chronically in­flamed human tissues: MECA-79, Duffy antigen receptor for chemokines, von Willebrand factor, CD31, CD34, CD105 and CD146. J Pathol 2005; 206(3): 260-8. 11. Wang JM, Kumar S, Pye D, Haboubi N, al-Nakib L. Breast carcinoma: comparative study of tumor vasculature using two endothelial cell markers. J Natl Cancer Inst 1994; 86(5): 386-8. 12. Parums DV, Cordell JL, Micklem K, Heryet AR, Gatter KC, Mason DY. JC70: a new monoclonal antibody that detects vascular endothelium associ­ated antigen on routinely processed tissue secti­ons. J Clin Pathol 1990; 43(9): 752-7. 13. Akagi K, Ikeda Y, Sumiyoshi Y, Kimura Y, Kino­shita J, Miyazaki M, et al. Estimation of angiogene-sis with anti-CD105 immunostaining in the pro­cess of colorectal cancer development. Surgery 2002; 131(1 Suppl): S109-13. 14. Yu JX, Zhang Xt, Liao YQ, Zhang QY, Chen H, Lin M, et al. Relationship between expression of CD105 and growth factors in malignant tumors of gastrointestinal tract and its significance. World J Gastroenterol 2003; 9(12): 2866-9. 15. Bredow S, Lewin M, Hofmann B, Marecos E, We-issleder R. Imaging of tumour neovasculature by targeting the TGF-beta binding receptor endoglin. Eur J Cancer 2000; 36(5): 675-81. 16. Gougos A, Letarte M. Indentification of human endothelial cell antigen with monoclonal antibody 44G4 produced against a pre-B leukemic cell line. J Immunol 1988; 141(6): 1925-33. 17. Fonsatti E, Del Vecchio L, Altomonte M, Sigalotti L, Nicotra MR, Coral S, et al. Endoglin: An acces­sory component of the TGF-beta-binding receptor - complex with diagnostic, prognostic, and bioim­munotherapeutic potential in human malignanci­es. J Cell Physiol 2001; 188(1): 1-7. 18. Fonsatti E, Altomonte M, Nicotra MR, Natali PG, Maio M. Endoglin (CD105) : a powerful therapeu­tic target on tumor-associated angiogenetic blood vessels. Oncogene 2003; 22(42): 6557-63. 19. Fonsatti E, Maio M. Highlights on endoglin (CD105): from basic findings towards clinical ap­plications in human cancer. J Transl Med 2004; 2: 18. 20. Sharma S, Sharma MC, Sarkar C. Morphology of angiogenesis in human cancer: a conceptual over­view, histoprognostic perspective and significance of neoangiogenesis. Histopathology 2005; 46(5): 481-9. 21. Li DY, Sorensen LK, Brooke BS, Urness LD, Davis EC, Taylor DG, et al. Defective angiogenesis in mice lacking endoglin. Science 1999; 284(5419): 1534-7. 22. Arthur HM, Ure J, Smith AJ, Renforth G, Wilson DI, Torsney E, et al. Endoglin, an ancillary TGFbe­ta receptor, is required for extraembryonic angio-genesis and plays a key role in heart development. Dev Biol 2000; 217(1): 42-53. 23. Mc Allister KA, Grogg KM, Johnson DW, Gallione CJ, Baldwin MA, Jackson CE, et al. Endoglin, a TGF-ß binding protein of endothelial cells, is the gene for hereditary hemorrhagic teleangiectasia type 1. Nat Genet 1994; 8: 345-51. 24. Qu R, Silver MM, Letarte M. Distribution of endo­glin in early human development reveals high le­vels on endocardial cushion tissue mesenchyme during valve formation. Cell Tissue Res 1998; 292(2): 333-43. 25. Vincent EB, Runyan RB, Weeks DL. Production of the transforming growth factor-beta binding pro­tein endoglin is regulated during chick heart deve­lopment. Dev Dyn 1998; 213(3): 237-47. 26. Torsney E, Charlton R, Parums D, Collis M, Arthur HM. Inducible expression of human endoglin du­ring inflammation and wound healing in vivo. In-flamm Res 2002; 51(9): 464-70. 27. Conley BA, Smith JD, Guerrero-Esteo M, Bernabeu C, Vary CP. Endoglin, a TGF-beta receptor-associ­ated protein, is expressed by smooth muscle cells in human atherosclerotic plaques. Atherosclerosis 2000; 153(2): 323-35. 28. Botella LM, Sanz-Rodriguez F, Sanchez-Elsner T, Langa C, Ramirez JR, Vary C, et al. Lumican is down-regulated in cells expressing endoglin. Evi­dence for an inverse correlationship between En-doglin and Lumican expression. Matrix Biol 2004; 22(7): 561-72. Radiol Oncol 2005; 39(4): 253-9. 29. Brouillard P, Vikkula M. Vascular malformations: localized defects in vascular morphogenesis. Clin Genet 2003; 63(5): 340-51. 30. Brewer CA, Setterdahl JJ, Li MJ, Johnston JM, Mann JL, McAsey ME. Endoglin expression as a measure of microvessel density in cervical cancer. Obstet Gynecol 2000; 96(2): 224-8. 31. Saad RS, Liu Yl, Nathan G, Celebrezze J, Medich D, Silverman JF. Endoglin (CD105) and vascular endothelial growth factor as prognostic markers in colorectal cancer. Mod Pathol 2004; 17(2): 197-203. 32. Akagi K, Ikeda Y, Sumiyoshi Y, Kimura Y, Kino­shita J, Miyazaki M, et al. Estimation of angiogene-sis with anti-CD105 immunostaining in the pro­cess of colorectal cancer development. Surgery 2002; 131(1 Suppl): S109-13. 33. Martone T, Rosso P, Albera R, Migliaretti G, Frai-re F, Pignataro L, et al. Prognostic relevance of CD105+ microvessel density in HNSCC patient outcome. Oral Oncol 2005; 41(2): 147-55. 34. Tanaka F, Otake Y, Yanagihara K, Kawano Y, Mi-yahara R, Li M, et al. Evaluation of angiogenesis in non-small cell lung cancer: comparison between anti-CD34 antibody and anti-CD105 antibody. Clin Cancer Res 2001; 7(11): 3410-5. 35. Kumar S, Ghellal A, Li C, Byrne G, Haboubi N, Wang JM, et al. Breast carcinoma: vascular density determined using CD105 antibody correlates with tumor prognosis. Cancer Res 1999; 59(4): 856-61. 36. Li C, Gardy R, Seon BK, Duff SE, Abdalla S, Rene-han A, et al. Both high intratumoral microvessel density determined using CD105 antibody and elevated plasma levels of CD105 in colorectal can­cer patients correlate with poor prognosis. Br J Cancer 2003; 88(9): 1424-31. 37. Delahunt B, Bethwaite PB, Thornton A. Prognostic significance of microscopic vascularity for clear cell renal cell carcinoma. Br J Urol 1997; 80(3): 401-4. 38. Ho JW, Poon RT, Sun CK, Xue WC, Fan ST. Clini­copathological and prognostic implications of en-doglin (CD105) expression in hepatocellular carci­noma and its adjacent non-tumorous liver. World J Gastroenterol 2005; 11(2): 176-81. 39. Matsuno F, Haruta Y, Kondo M, Tsai H, Barcos M, Seon BK. Induction of lasting complete regression of preformed distinct solid tumors by targeting the tumor vasculature using two new anti-endoglin monoclonal antibodies. Clin Cancer Res 1999; 5(2): 371-82. 40. Fonsatti E, Jekunen AP, Kairemo KJA, Coral S, Snellman M, Nicotra MR, et al. Endoglin is a sui­table target for efficient imaging of solid tumors: in vivo evidence in a canine mammary carcinoma model. Clin Cancer Res 2000; 6(5): 2037-43. 41. Savontaus MJ, Sauter BV, Huang TG, Woo SL. Transcriptional targeting of conditionally replica­ting adenovirus to dividing endothelial cells. Gene Ther 2002; 9(14): 972-9. 42. She X, Matsuno F, Harada N, Tsai H, Seon BK. Synergy between anti-endoglin (CD105) monoclo­nal antibodies and TGF-beta in supression of growth of human endothelial cells. Int J Cancer 2004; 108(2): 251-7. 43. Takahashi N, Haba A, Matsuno F, Seon BK. Anti-angiogenic therapy of established tumors in hu­man skin/severe combined immunodeficiency mouse chimeras by anti-endoglin (CD105) mono­clonal antibodies, and synergy between anti-endo­glin antibody and cyclophosphamide. Cancer Res 2001; 61(21): 7846-54. 44. Li C, Guo B, Wilson PB, Stewart A, Bryne G, Bun-dred N, et al. Plasma levels of soluble CD105 cor­relate with metastasis in patients with breast can­cer. Int J Cancer 2000; 89(2): 122-6. 45. Takahashi N, Kawanishi-Tabata R, Haba A, Taba­ta M, Haruta Y, Tsai H, et al. Association of serum endoglin with metastasis in patients with colorec­tal, breast, and other solid tumors, and supressive effect of chemotherapy on the serum endoglin. Clin Cancer Res 2001; 7(3): 524-32. Radiol Oncol 2005; 39(4): 253-9. review MHC class II molecules and tumour immunotherapy Irena Oven University of Ljubljana, Biotechnical Faculty, Department of Animal Science, Domžale, Slovenia Background. Tumour immunotherapy attempts to use the specificity and capability of the immune system to kill malignant cells with a minimum damage to normal tissue. Increasing knowledge of the identity of tu­mour antigens should help us design more effective therapeutic vaccines. Increasing evidence has demon­strated that MHC class II molecules and CD4+ T cells play important roles in generating and maintaining antitumour immune responses in animal models. These data suggest that it may be necessary to involve both CD4+ and CD8+ T cells for more effective antitumour therapy. Novel strategies have been developed for en­hancing T cell responses against cancer by prolonging antigen presentation of dendritic cells to T cells, by the inclusion of MHC class II-restricted tumour antigens and by genetically modifying tumour cells to pre­sent antigen to T lymphocytes directly. Conclusions. Vaccines against cancers aim to induce tumour-specific effector T cells that can reduce tumo­ur mass and induce development of tumour-specific T cell memory, that can control tumour relapse. Key words: neoplasms; immunotherapy, adoptive; CD4 – positive T – lymphocytes; T – lymphocytes, helper – inducer; cancer vaccines Introduction Immunotherapy denotes a strategy for mani­pulating a patient’s immune response. In can­cer or infectious disease the approach is desi­gned to boost the patient’s response to tumo­ur antigens or pathogens.1 Many strategies for enhancement of the immune response to autologous tumours have recently been deve- Received 5 October 2005 Accepted 11 October 2005 Correspondence to: Irena Oven, University of Ljublja­na, Biotechnical Faculty, Department of Animal Scien­ce, Groblje 3, SI-1230 Domzale, Slovenia; Phone: +386 1 7217 916; E-mail address: irena.oven@bfro.uni-lj.si loped. These strategies use tumour cells trans-fected with genes encoding molecules that enhance immune responses.2 Tumour speci­fic immunity is mediated by T lymphocytes. T cells play a major role in the antitumour im­mune response and surveillance and repre­sent an important basis for the development of cancer immunotherapy.3 Identification of immunogenic tumour antigens has signifi­cantly advanced our understanding of tumo­ur immunity and provides opportunity for the development of effective antigen-specific cancer therapy.4 Since most cancers do not express major histocompatibility complex (MHC) class II molecules on their surface and CD8+ cytotoxic T lymphocytes (CTLs) are able to induce lysis of tumour cells upon recogni­tion of tumour antigen derived peptides, pre­sented by the tumour’s MHC class I molecu­les, the research has been focused mainly on modulation and use of MHC class I antigen presenting pathway for tumour immunothe­rapy. However, clinical trials using MHC class I restricted antigens have elicited only modest and transient immune responses in most immunized patients. A possible reason for this failure is the lack of tumour specific CD4+ T cell responses5, so recently a lot of progress has been made in acknowledging the importance of MHC class II molecules in mediating antitumour immune response.6-8 MHC class I and MHC class II antigen presentation pathways The MHC is a large multigene family that en­codes cell surface glycoproteins involved in binding and presentation of antigenic pepti­des to T lymphocytes. MHC class I molecules, which are expressed on most nucleated cells, present peptides to CD8+ cytolytic T lymp­hocytes (CTLs). In contrast, the constitutive expression of MHC class II molecules, which are essential for antigen presentation to CD4+ T helper (TH) cells, is restricted to antigen pre­senting cells, such as dendritic cells, B cells, monocytes, macrophages and thymic epithe­lial cells. Expression of MHC class II molecu­les can however be induced by interferon-. (IFN-.) on most other cell types.9 Class II mo­lecules usually present exogenously synthesi­zed peptides, which are acquired in the cellu­lar compartment for peptide loading, whereas class I molecules usually present endogeno­usly synthesized self-peptides.10 Endogenous antigens are degraded by proteasome into short peptides. These peptides are transpor­ted into the endoplasmic reticulum (ER) by TAP complex. Here the newly synthesized MHC class I heavy chains assemble with the light chain and peptide and this complex is transported to the cell surface for presentati­on to CD8+ CTLs. MHC class II molecule is usually unable to bind endogenous peptides, because the peptide antigen binding groove is occupied by invariant chain (Ii) molecules in the ER. This assembly stabilizes the MHC II complexes and its CLIP region prevents the binding of endogenous antigen peptides pre­sent in the ER. Ii also contains two sorting si­gnals in its cytoplasmic tail, which are res­ponsible for the transport of the MHC/Ii com­plexes into endosomal and lysosomal com­partments, where Ii is degraded by cathe­psins and only CLIP peptide is left in the bin­ding groove. HLA-DM then catalyses the rele­ase of CLIP, allowing the groove to bind the antigen-derived peptides, which come from the lysosome (Figure 1).5,11,12 Figure 1. MHC class I and class II antigen processing and presentation pathways. (a) Proteasome degrades endogenous antigens into peptides, which are trans­ported into the ER by TAP complex. Here the newly synthesized MHC class I molecules assemble with peptide and the MHC-peptide complex is transported through the Golgi to the cell surface for presentation to CD8+ T cells. (b) Exogenous antigens are taken in by endocytosis and processed by proteases in an endoso-me into short peptides. The alpha and beta chains of MHC class II, along with an invariant chain, are synthesized, assembled in the endoplasmic reticulum, and transported through the Golgi apparatus to reach the endosome, where the invariant chain is digested, and the peptide fragments from the exogenous prote­in are able to associate with the MHC class II molecu­les, which are finally transported to the cell surface for presentation to CD4+ T cells. Radiol Oncol 2005; 39(4): 261-8. The role of CD4+ T cells in immunity CD4+ T lymphocytes play a central role in the onset and maintenance of adaptive immu­nity. CD4+ T cells help antibody responses and also help the activation and expansion of CD8+ T cells and are essential in maintaining the CD8+ T cell memory and long-lasting anti-tumour immune response (Figure 2).5,13 CD4+ T cells can be divided into two main subsets: TH1 and TH2, depending on the cyto-kines they produce in response to antigen ac­tivation. TH2 produce IL-4 and IL-5. IL-4 acti­vates B cells to become antibody secreting plasma cells. IL-5 is a growth and activation factor for eosinophils. It has been reported that a significant cytotoxicity against tumour cells can be mediated by eosinophils after IL-5-mediated in vivo activation and that eosino­phils may be involved in the antitumour res­ponse in vivo.14 TH1 cells produce IL-2, IL-12 and IFN-., which are important for cellular immunity. IL-2 has been used in several stu­dies in which its administration facilitates tu­mour eradication.13,15 IL-12 plays an essential role in the interaction between the innate and Figure 2. The role of CD4+ T cells in immune respon­se against cancer. TH cells play a crucial role in regula­ting the host immune response. They help B cells to produce antibodies, they release cytokines, which sti­mulate other varieties of immune cells to kill the inva­ding tumour cell. They provide help in stimulating CD8+ CTL, which directly kill tumour cells. Finally, TH cells are also involved in the inhibition of tumour growth in the absence of CD8+ T cells. adaptive immunity. IL-12 acts on T cells and NK cells by inducing proliferation and pro­duction of cytokines, especially IFN-.. IL-12 is also the major cytokine responsible for the differentiation of TH1 cells, which are potent producers of IFN-.. In experimental tumour models, recombinant IL-12 treatment has a dramatic anti-tumour effect on transplantable tumours, on chemically induced tumours, and in tumours arising spontaneously in ge­netically modified mice.16 IFN-. also plays an important role in tumour rejection. IFN-. co­uld have direct effects on tumour cells by (a) cytotoxic activity on tumour cells, mediated by production of oxygen derivatives and ni­tric oxide, (b) up-regulation of MHC class II molecules expression, thus increasing tumo­ur cell recognition and elimination, (c) altera­tion of the endogenous antigen-processing machinery, and (d) induction of inhibitors of angiogenesis in the cells.13,17 The importance of CD4+ T cells in respon­se to tumours and protection against tumour growth is now widely recognized. Strategies have evolved to generate tumour cells that can directly present tumour peptides and specifically activate tumour-specific CD4+ TH cells. This approach is based on the assump­tion that the effectiveness of CD8+ T cells is dependent on sufficient help from tumour-ac­tivated CD4+ T cells, and that optimal immu­nological memory can be generated if both CD4+ and CD8+ T cells are stimulated.18 Tumour immunotherapy by modulating MHC class II gene expression in tumour cells Down regulation of MHC class I or class II ex­pression is one way for tumours to escape im­munosurveillance. Whereas some tumours do express variable levels of MHC class II mo­lecules, they often up-regulate expression of the Ii protein and thus prevent MHC class II presentation of endogenous tumour antigens. Radiol Oncol 2005; 39(4): 261-8. Tumour cells that co-express class II and Ii molecules, such as B-lymphomas, are not ca­pable of directly presenting tumour peptides and are thus no more immunogenic than class II negative tumour cells.19 Melanoma tu­mours also express MHC class II molecules, which can present tumour antigens. Howe­ver, as these tumours lack co-stimulatory mo­lecules that are necessary to activate naďve CD4+ T cells, such as B7 ligand, this may re­sult in tumour antigen presentation and the induction of tumour antigen-specific CD4+ T lymphocyte anergy. Through these mecha­nisms the MHC class II molecules may parti­cipate in melanoma progression and immune escape.20,21 In contrast, high levels of MHC class II expression in gastrointestinal and bre­ast cancers are often associated with better prognosis, showing the involvement of CD4+ T cells in protective immune response against the tumour.22,23 In fact several groups have published to successfully treat MHC class II negative tumours by converting them into MHC class II positive and thus making them APCs.7,24 MHC class II gene expression is regulated mainly on the transcriptional level. One of the most important factors is the class II tran­sactivator (CIITA), which acts as coactivator by virtue of its ability to interact with other components of the MHC class II enhanceoso-me, which are present on MHC class II pro­moters. CIITA is a non-DNA binding protein and controls constitutive and inducible MHC class II gene activation. Coinciding with MHC class II expression, the constitutive expressi­on of CIITA is confined to APCs only, and CI­ITA expression can be induced by IFN-. in va­rious other cell types. The transcriptional re­gulation of human CIITA is controlled by at least three independent promoter units (CII­TA-PI, -PIII and -PIV), each transcribing a uni­que first exon. These isoforms of the protein are cell type specific. CIITA-PI and CIITA-PIII are used for constitutive expression in den-dritic cells and B cells, respectively. CIITA­PIV has been the promoter shown to be pre­dominantly IFN-. inducible.25 The first demonstration that lack of IFN-. mediated induction of MHC class II antigens was caused by the absence of expression of CIITA was made in foetal trophoblast-derived tumour cell lines. Expression of CIITA follo­wing gene transfer resulted in the induction and subsequent cell surface expression of all isotypes of MHC class II molecules.9,26 A variety of mouse tumours have been transfected with syngeneic MHC class II ge­nes, and the resulting transfectants are very effective vaccines against subsequent chal­lenge with the wild type class II-negative tu­ mors.10,27 Interestingly, the expression of other ge­nes whose products are involved in the MHC class II antigen presentation pathway, such as invariant chain and HLA-DM molecules, al­though not absolutely depending upon CII­TA, is strongly increased in the presence of CIITA. Some studies show that coexpression of Ii is required for expression of functional MHC class II molecules28, while others show, that class II are functional in the absence of Ii29,30 and that coexpression of MHC class II and Ii correlates with poor tumour progno­sis.31 Meazza et al show, that by modifying the murine mammary adenocarcinoma TS/A cell line by CIITA gene transfer, CIITA+ tumour cells express surface MHC class II molecules. Even though these cells also up-regulate the invariant chain mRNA and corresponding protein, CIITA+ tumour cells were rejected in syngeneic recipients and the capacity to be rejected correlated with the amount of CIITA-mediated MHC class II expression. Tumour rejecting mice also became resistant to the re-challenge with the wild type tumour. This re­jection required both CD4+ and CD8+ cells.7 Other groups however show, that up-regulati­on of Ii chain expression converts an immu­nogenic tumour to non-immunogenic, that is highly malignant in autologous mice.32,33 Radiol Oncol 2005; 39(4): 261-8. In vivo studies demonstrate that MHC class II+ /Ii-tumour cells, and not host derived cells, were the predominant antigen-presen­ting cells for MHC class II-restricted nuclear antigens.34 Due to allele heterogenicity, the transfection of genes for autologous MHC class II molecules is not practical clinically. Alternative approaches inducing expression of MHC class II molecules with transfection of CIITA or IFN-. stimulation of CIITA ex­pression and suppression of Ii protein by an-tisense methods using short oligonucleotides have been used successfully in several types of tumours. The cytotoxic effect can be en­hanced by co-injecting the cells with IL-2 ge­ne expressing plasmid, since IL-2 promotes T cell infiltration and activation against tumour antigens.35 Intra-tumoural gene therapy can also be aided by radiation of tumours to en­hance the therapeutic efficacy of intra-tumou­ral gene therapy for in situ induction of tumo­ur-specific immune response.36 There are se­veral possible mechanisms for radiation en­hancement of gene therapy, which include (a) slowing of the tumour growth, so that immu­notherapy has time to develop, (b) radiation induced tissue damage mobilizes inflamma­tory cells in the tumour vicinity, (c) radiation limits suppressive immunoregulatory T cells and (d) radiation increases gene transduction efficiency and duration of expression of sur­viving tumour cells. The advantage of the methods that include converting tumour cells into antigen presen­ting cells is not only killing of the cells di­rectly contacted by tumour therapy, but also eliciting of an immune response which in turn eradicates tumour cells and deposits at both locoregional and distant sites.36 Dendritic cells as tumour-antigen presenting cells Dendritic cells (DCs) are the most potent an-tigen-presenting cells. They can present tu­ mour antigens to immunologic effector cells. MHC II molecules on DC surfaces play an im­portant role in priming effector cells against tumour cells and their antigens, so they may be used to overcome tumour escape. DCs capture and process antigens in periphery, express lymphocyte co-stimulatory molecu­les, migrate to lymphoid organs, and secrete mediators to initiate immune responses.37 DCs present peptides to naďve T cells and in­duce a cellular immune response that invol­ves both CD4+ TH1 cells and cytolytic CD8+ T cells. They can also stimulate humoral immu­nity by activating naďve and memory B cells.38 Effective cancer vaccines will need to elicit both CD4+ IFN-. producing and CD8+ cytoto­xic T cell responses. Successful antitumour immunity will therefore depend on receipt by DC of maturation signals, which drive diffe­rentiation of naďve CD4+ and CD8+ T cells in­to TH1/TC1 effector cells.1 Thus DCs repre­sent a powerful tool for vaccination against tumour cells,38,39 but one has to consider, that immature DCs can induce tolerance and only mature DCs, which express co-stimulatory molecules on surface and produce inflamma­tory cytokines, induce effective antitumour immunity.1 Marten et al demonstrate the transfection of CIITA gene into DCs, which strongly incre­ases MHC class II expression. Transfection of the DCs with CIITA leads to an increase in antitumoural immunostimulatory capacity and therefore suggests the use of DCs in tre­atment of cancer cells.39 DCs pulsed with tumour antigens have al­so been used in several studies. Such DCs ha­ve been successfully used in raising specific CD8+ T cells. Similarly this approach is also used to raise specific CD4+ T cells by loading them with MHC class II restricted anti­gens.38,40 Even though more and more tumo-ur-restricted antigens are being identified, unfortunately most tumours still have no de­fined tumour antigens,39 so this method has only limited applicability in clinical therapy. Radiol Oncol 2005; 39(4): 261-8. Zhao et al show that short incubation of mR-NA-transfected DCs with antisense oligonu­cleotides directed against the Ii chain enhan­ces the presentation of mRNA-encoded class II epitopes and activation of CD4+ T-cell res­ponses in vitro and in vivo. Immunization of mice with the antisense oligonucleotide-trea­ted DCs stimulates a more potent and longer lasting CD8+ CTL response and enhances the antitumour efficacy of DC-based tumour vac­cination protocols. Since vaccination with tu­mour mRNA-transfected DCs does not requi­re the identification of the effective tumour antigens in each patient with cancer and is not limited by tumour tissue availability, this approach could represent a broadly useful method to augment antitumour T cell immu­nity alongside CD8+ T-cell immunity.31 Conclusions Our current understanding of molecular me­chanisms of cancer and tumour-specific im­mune responses has greatly benefited from the advances in molecular genetics and immu­nology. At the same time, the advances in re­combinant DNA technologies have been ma­de, that enable development of immunothe­rapy for the disease. Different immunothe­rapy strategies have proven to be very effecti­ve in animal models; however patients in most clinical trials conducted so far have elici­ted only weak and transient immune respon­se. Therefore combination of different trea­tment strategies, such as gene therapy combi­ned with cytokine treatment, radiation and/or chemotherapy will have to be considered. The identification of MHC class I and class II-restricted tumour antigens has enabled de­velopment of methods for the targeting of ei­ther defined epitopes or whole antigens into the MHC pathway. Tumour cells can be gene­tically engineered to function as APCs, the­reby facilitating the generation of tumour-specific immunity. The advantage of this me­thod is that prior identification of tumour an­tigens is not necessary. By inducing a potent antitumour immune response, tumour cells throughout the body that are left behind after surgery or radiotherapy could be eradicated. By enabling induction of a potent CD4+ and CD8+ T cell antitumour immune response, the clinical outcomes in patients with cancer should be greatly improved. DCs are also an attractive target for thera­peutic manipulation of the immune system in cancer. By loading them with combined MHC class I and class II peptides, they can be used to immunize patients. The combined use of MHC class I and class II-restricted tumour antigens, co-stimu­latory molecules and cytokines that can be used to enhance immune responses represent an unprecedented opportunity for the develo­pment of new generation of effective cancer vaccines. References 1. Faith A, Hawrylowicz CM. Targeting the dendritic cell: the key to immunotherapy in cancer? Clin Exp Immunol 2005; 139: 395-7. 2. Armstrong TD, Pulaski BA, Ostrand-Rosenberg S. Tumor antigen presentation: changing the rules. Cancer Immunol Immunother 1998; 46: 70-4. 3. Rosenberg SA. Progress in human tumour immu­nology and immunotherapy. Nature 2001; 411: 380-4. 4. Wang RF. Enhancing antitumor immune respon­ses: intracellular peptide delivery and identificati­on of MHC class II-restricted tumor antigens. Im­munol Rev 2002; 188: 65-80. 5. Bonehill A, Heirman C, Thielemans K. Genetic ap­proaches for the induction of a CD4+ T cell respon­se in cancer immunotherapy. J Gene Med 2005; 7: 686-95. 6. Armstrong TD, Clements VK, Martin BK, Ting JP, Ostrand-Rosenberg S. Major histocompatibility complex class II-transfected tumor cells present endogenous antigen and are potent inducers of tu­mor-specific immunity. Proc Natl Acad Sci U S A 1997; 94: 6886-91. Radiol Oncol 2005; 39(4): 261-8. 7. Meazza R, Comes A, Orengo AM, Ferrini S, Accol-la RS. Tumor rejection by gene transfer of the MHC class II transactivator in murine mammary adeno-carcinoma cells. Eur J Immunol 2003; 33: 1183-92. 8. Walter W, Lingnau K, Schmitt E, Loos M, Maeurer MJ. MHC class II antigen presentation pathway in murine tumours: tumour evasion from immuno-surveillance? Br J Cancer 2000; 83: 1192-201. 9. van den Elsen PJ, van der Stoep N, Yazawa T. Class II Transactivator (CIITA) Deficiency in tu­mor cells: complicated mechanisms or not? Am J Pathol 2003; 163: 373-6. 10. Ostrand-Rosenberg S. Tumor immunotherapy: the tumor cell as an antigen-presenting cell. Curr Opin Immunol 1994; 6: 722-7. 11. Pieters J. MHC class II-restricted antigen processing and presentation. Adv Immunol 2000; 75: 159-208. 12. Van Kaer L. Major histocompatibility complex class I-restricted antigen processing and presenta­tion. Tissue Antigens 2002; 60: 1-9. 13. Gerloni M, Zanetti M. CD4 T cells in tumor immu­nity. Springer Semin Immunopathol 2005; 27: 37-48. 14. Kataoka S, Konishi Y, Nishio Y, Fujikawa-Adachi K,Tominaga A. Antitumor activity of eosinophils activated by IL-5 and eotaxin against hepatocellu­lar carcinoma. DNA Cell Biol 2004; 23: 549-60. 15. Atkins MB, Lotze MT, Dutcher JP, Fisher RI, We­iss G, Margolin K, et al. High-dose recombinant in­terleukin 2 therapy for patients with metastatic melanoma: analysis of 270 patients treated betwe­en 1985 and 1993. J Clin Oncol 1999; 17: 2105-16. 16. Colombo MP, Trinchieri G. Interleukin-12 in anti-tumor immunity and immunotherapy. Cytokine Growth Factor Rev 2002; 13: 155-68. 17. Dighe AS, Richards E, Old LJ, Schreiber RD. En­hanced in vivo growth and resistance to rejection of tumor cells expressing dominant negative IFN gamma receptors. Immunity 1994; 1: 447-56. 18. Kern DE, Klarnet JP, Jensen MC, Greenberg PD. Requirement for recognition of class II molecules and processed tumor antigen for optimal generati­on of syngeneic tumor-specific class I-restricted CTL. J Immunol 1986; 136: 4303-10. 19. Koch N, Harris AW. Differential expression of the invariant chain in mouse tumor cells: relationship to B lymphoid development. J Immunol 1984; 132: 12-5. 20. Baton F, Deruyffelaere C, Chaplin M, Prod’homme T, Charron D, Al-Daccak R, et al. Class II transac­tivator (CIITA) isoform expression and activity in melanoma. Melanoma Res 2004; 14: 453-61. 21. Egorov IK. Mouse models of efficient and ineffici­ent anti-tumor immunity, with emphasis on mini­mal residual disease and tumor escape. Cancer Im­munol Immunother 2005; 10: 1-22. 22. Satoh A, Toyota M, Ikeda H, Morimoto Y, Akino K, Mita H, et al. Epigenetic inactivation of class II transactivator (CIITA) is associated with the ab­sence of interferon-gamma-induced HLA-DR ex­pression in colorectal and gastric cancer cells. On­cogene 2004; 23: 8876-86. 23. Sheen-Chen SM, Chou FF, Eng HL, Chen WJ. An evaluation of the prognostic significance of HLA­DR expression in axillary-node-negative breast cancer. Surgery 1994; 116: 510-5. 24. Armstrong TD, Clements VK, Ostrand-Rosenberg S. Class II-transfected tumor cells directly present endogenous antigen to CD4+ T cells in vitro and are APCs for tumor-encoded antigens in vivo. J Im­munother 1998; 21: 218-24. 25. Harton JA, Ting JP. Class II transactivator: maste­ring the art of major histocompatibility complex expression. Mol Cell Biol 2000; 20: 6185-94. 26. Murphy SP, Tomasi TB. Absence of MHC class II antigen expression in trophoblast cells results from a lack of class II transactivator (CIITA) gene expression. Mol Reprod Dev 1998; 51: 1-12. 27. James RF, Edwards S, Hui KM, Bassett PD, Grosveld F. The effect of class II gene transfection on the tu­mourigenicity of the H-2K-negative mouse leukae­mia cell line K36.16. Immunology 1991; 72: 213-8. 28. Elliott EA, Drake JR, Amigorena S, Elsemore J, Webster P, Mellman I, et al. The invariant chain is required for intracellular transport and function of major histocompatibility complex class II molecu­les. J Exp Med 1994; 179: 681-94. 29. Busch R, Cloutier I, Sekaly RP, Hammerling GJ. Invariant chain protects class II histocompatibility antigens from binding intact polypeptides in the endoplasmic reticulum. Embo J 1996; 15: 418-28. 30. Miller J, Germain RN. Efficient cell surface expres­sion of class II MHC molecules in the absence of associated invariant chain. J Exp Med 1986; 164: 1478-89. 31. Zhao Y, Boczkowski D, Nair SK, Gilboa E. Inhibi­tion of invariant chain expression in dendritic cells presenting endogenous antigens stimulates CD4+ T-cell responses and tumor immunity. Blood 2003; 102: 4137-42. 32. Martin BK, Frelinger JG, Ting JP. Combination ge­ne therapy with CD86 and the MHC class II tran­sactivator in the control of lung tumor growth. J Immunol 1999; 162: 6663-70. Radiol Oncol 2005; 39(4): 261-8. 33. Clements VK, Baskar S, Armstrong TD, Ostrand-Rosenberg S. Invariant chain alters the malignant phenotype of MHC class II+ tumor cells. J Immunol 1992; 149: 2391-6. 34. Qi L, Rojas JM, Ostrand-Rosenberg S. Tumor cells present MHC class II-restricted nuclear and mito­chondrial antigens and are the predominant anti­gen presenting cells in vivo. J Immunol 2000; 165: 5451-61. 35. Overwijk WW, Theoret MR, Restifo NP. The futu­re of interleukin-2: enhancing therapeutic antican­cer vaccines. Cancer J Sci Am 2000; 6(Suppl 1): S76­80. 36. Hillman GG, Kallinteris NL, Lu X, Wang Y, Wright LJ, Li Y, et al. Turning tumor cells in situ into T-helper cell-stimulating, MHC class II tumor epitope-presenters: immuno-curing and immuno-consolidation. Cancer Treat Rev 2004; 30: 281-90. 37. Banchereau J, Steinman RM. Dendritic cells and the control of immunity. Nature 1998; 392: 245-52. 38. Banchereau J, Palucka AK. Dendritic cells as thera­peutic vaccines against cancer. Nat Rev Immunol 2005; 5: 296-306. 39. Marten A, Ziske C, Schottker B, Weineck S, Re-noth S, Buttgereit P, et al. Transfection of dendri-tic cells (DCs) with the CIITA gene: increase in im­munostimulatory activity of DCs. Cancer Gene Ther 2001; 8: 211-9. 40. Zeng G. MHC class II-restricted tumor antigens re­cognized by CD4+ T cells: New strategies for can­cer vaccine design. J Immunother 2001; 24: 195-204. Radiol Oncol 2005; 39(4): 261-8. Quantitative analysis of fine needle aspiration biopsy samples Mirjana Rajer1, Marko Kmet2 1Department of Radiotherapy, Institute of Oncology Ljubljana, Slovenia, 2Department of Internal Medicine, General Hospital Novo mesto, Slovenia Background. The fine needle aspiration biopsy (FNAB) is one of the methods used in tumour evaluation. Since a certain number of tumour cells are needed for a complete diagnostic algorithm, we wanted to test how many cells remain in the needle and syringe after routine stains have been made and which factors in­fluence this number. The remaining cells are used in ancillary diagnostic procedures. Materials and methods. One hundred fifty two FNAB samples of tumours of the breast, thyroid and lymph nodes were included in our study. We counted the cells which were left in the needle and the syringe after the standard smears had been made. Buerker-Tuerk’s chamber was used for this purpose. Results. The number of cells depended on the organ from which the cells had been aspirated, on the type of tumour and, in the case of breast cancer, also on the level of experience of the FNAB performer. The per­centage of samples with too few cells for all modern diagnostic methods (<5x105 ) is lowest in FNAB of lymph nodes (4.9%), followed by breast (16.7%) and thyroid (18%). Conclusions. We concluded that FNAB in the majority of cases grants a sufficient number of cells for the standard microscopic evaluation and also ancillary diagnostic procedures. Key words: neoplasms – pathology; biopsy, needle; cytodiagnosis; cell count Introduction The fine needle aspiration biopsy (FNAB) is a quick, simple, safe, painless and inexpensive method. It is of the utmost importance in the preoperative diagnostics of tumours.1 The di­agnostic reliability of the method is good. It enables us to classify tumours as malignant Received 28 October 2005 Accepted 12 December 2005 Correspondence to: Mirjana Rajer, MD, Department of Radiotherapy, Institute of Oncology Ljubljana, Zaloška 2, 1000 Ljubljana, Slovenia; Phone: + 386 41 26 99 46; Fax.: + 386 1 587 9 400; E-mail: mrajer@onko-i.si or benignant in almost 100% cases and to fur­ther specify the type of the tumour in 80-98% of cases.2 Serious side effects (pneumotho­rax, severe bleeding, infection, pain, vomit­ing etc.) are rare.3 In the process of aspiration the cells are seldom extensively damaged since the small diameter of the needle en­ables it to push aside the tissue rather than tearing it.1,4 New, highly specialized methods of treat­ment require the specification of the tumour lesion to the highest extent. Any additional information about the morphology and cell structure, which determines the prognosis and helps to choose an appropriate treat­ment, is a welcome addition to the standard morphologic analysis. Such analyses are used for example in determining the hormonal re­ceptor status in breast cancer.5 The number of cells in the sample is, however, limited and determines how many additional diagnostic procedures can be made, besides the stan­dard two smears.6 The purpose of our study was two-fold. First of all, to determine the number of cells that remain in the needle and syringe after FNAB had been performed and the standard two smears had been made and secondly, to establish eventual impact of tumour charac­teristics and performer’s previous experience on the results. For our study, we chose tu­mours of the breast, thyroid and lymph nodes as the number of ancillary cytological meth­ods is the greatest in these types of lesions. Materials and methods Data from 152 samples (54 tumours of the breast, 33 of the thyroid and 65 of the lymph nodes) were included in our study. We analysed the cells which were left in the nee­dle and syringe after FNAB and the standard two smears have been made. We rinsed the needle and syringe with a so called »rinsing solution«, composed of 4.5% of bovine serum albumin and 0.45% EDTA in phosphate buffer with 100 I.U. of penicillin in 100 ml of the solution. We processed the sample ac­cording to the Buerker-Tuerk’s protocol for cell counts; this was done in Buerker-Tuerk’s chamber. We counted the cells by using a 100x magnification of the standard light mi­croscope. Cells in four squares of the cham­ber were counted and the average number was calculated. Next, we calculated the number of remain­ing cells. The equation used for this purpose was: x = c x V where x stands for the total number of cells, c for density and V for volume of the re­mainder of the sample with the volume of the rinsing fluid included. The density of the cells was calculated by using the following equation: c = n x 20 x 104 where n stands for the number of counted cells. We had to multiply this number by 20 as the dilution ratio of the cell suspension to Buerker Tuerk’s solution had been 10 µl: 190 µl. The volume of the chamber is 104 ml, hence the last multiplicator.7 Eight cytologists performed the biopsies. They were divided in two groups, based on their previous experience. In the first group there were three cytologists with more than five years of experience each. The rest, with less than one year of experience each, were in group number two. A two-sided t-test was used to calculate the level of the statistical significance of the between-group compari­son. Results The percentage of samples with 500.000 cells in the syringe after the two standard smears were made was 95% in lymph node biopsy, 82% in breast cancer biopsy and 81% in thy­roid cancer biopsy. Radiol Oncol 2005; 39(4): 269-72. Figure 2. Average cell number according to the type of lymph node pathology. Average number of cells regarding the target organ We found that the average number of cells was the highest in samples acquired from lymph nodes, followed by breast samples. The average number was the lowest for thyroid samples. The difference was statistically sig­nificant when comparing averages of lymph node to breast (p = 0.0003) and lymph node to thyroid samples (p = 0.00006). The difference between breast and thyroid samples was not statistically significant (Figure 1). Average number of cells regarding the type and size of the tumour There was a statistically significant difference when comparing different types of tumours. For example, in invasive ductal carcinoma of the breast the number of cells was signifi­cantly higher than in invasive lobular carci­noma (p = 0.01). The results for different lymph node tumours were similar (p values ranging from 0.0002 to 0.05) while there was no statistically significant difference in differ­ent types of tumours of the thyroid (Figure 2). In all three organs there was no significant difference in the number of acquired cells re­garding the tumour size. Average number of cells regarding the performer of FNAB The only statistically significant difference in the number of cells between younger and old- Figure 3. Average number of cells regarding the expe­rience of the FNAB performer in breast samples. er performers was present in FNAB samples of the breast (p = 0.03), while samples of the thyroid and lymph node did not show any significant difference (Figure 3). Discussion The percentage of samples containing enough cells to perform ancillary diagnostic methods (more than 500.000 cells in the syringe after the two standard smears)1 was different ac­cording to the organ from which the sample was taken. Most cells were present in lymph nodes samples, on average 4 millions, fol­lowed by breast samples with 2 million on av­erage and thyroid samples with 1.65 million. This result is not surprising if we consider that the tissues have a different structure. We expected to get more cells from bigger tumours, but this was not the case in our study. The possible explanation for this fact could be that in bigger tumours, there is more tumour regression and necrosis which lowers the number of aspirated cells. Different types of tumours have a different structure and the number of cells obtained from them was different. Cells of malignant lymphoma are connected by fragile nests of stroma and surrounded by a gentle capsule.8 This explains why we can obtain a large num­ber of cells with ABTI by applying only a low pressure to the needle. Even though the absolute average number Radiol Oncol 2005; 39(4): 269-72. of aspirated cells was lower in all three or­gans in the second, younger group of cytolo­gists, we found that the only statistically sig­nificant difference was present in FNAB of the breast. While there is some difference be­tween the two groups it is not so important and proves that FNAB is easy to learn and to perform. All the FNAB-s in our study were done in the same centre and it would be in­teresting to compare different centres. In most of the cases FNAB provides enough cells for basic and advanced diagnos­tic procedures. The number of necessary cells is especially high in breast cancer, because of the number of available diagnostic tests. In the future we expect more new and accurate diagnostic procedures that will enable us to make a clearer picture of the nature of the tu­mour and will thus lead to better treatment decisions. Acknowledgement We thank Prof. Marija Us Krašovec for her guidance in this research. References 1. Us Krašovec M. Aspiracijska biopsija v onkologiji. Onkologija 2001; 5: 11-2. 2. Papparaskeva K, Nagel H, Droese M. Cytologic di­agnosis of medullary carcinoma of the thyroid gland. Dyagn Cytopathol 2000; 22: 351-8. 3. Kline TS, Neal HS. Needle aspiration biopsy: a critical appraisal. JAMA 1987; 239: 36-9. 4. Us Krašovec M, Golouh R, Auesperg M, Pogacnik A. Tissue damage after fine needle aspiration biopsy. Acta Cytol 1992; 36: 456-60. 5. Frable WJ. Fine needle aspiration biopsy: a review. Hum Pathol 1983; 14: 9-27. 6. Kloboves Prevodnik V, Pogacnik A, Us Krašovec M, Petric J, Ihan A, Golouh R, et al. Can ancillary methods improve the reliability of fine needle as­piration biopsy in preoperative diagnosis of non-Hodgkin lymphomas? 10th meeting of European as­sociation for hematopathology. London; 2000. p. 10. 7. Freshney RI. Quantitation and experimental de­sign. In: Freshney RI, editor. Culture of animal cells. New York: Alan R. Liss; 1987. p. 272-82. 8. Koss LG, editor. Diagnostic Cytology and Its 4th Histopathological Bases. edition Philadelphia: Lippincott; 1992. p. 1-11, 126-53, 1268-1315, 1532-71. Radiol Oncol 2005; 39(4): 269-72. Correlation of clinical target volume and the margins to define planning target volume with beam arrangements for three-dimensional conformal radiation therapy delivery for prostate cancer Haldun S¸ükrü Erkal,1,2 Meltem Serin1,2 1Department of Radiation Oncology, Ankara University Faculty of Medicine, Ankara, Turkey 2Department of Radiation Oncology, Inönü University Faculty of Medicine, Malatya, Turkey Background. A conceptual study was undertaken to correlate the clinical target volume and the margins to define the planning target volume with the beam arrangements for a three-dimensional conformal radiation therapy delivery on two patients with prostate cancer having considerably different prostate shapes and vo­lumes. Material and methods. The clinical target volume was defined as prostate and seminal vesicles. Uniform margins of 0.4, 0.8 and 1.2 cm were added around the clinical target volume to define three planning target volumes. Three well-established coplanar beam arrangements were simulated for all planning target volu­mes. Dose-volume histograms were calculated and quantitatively compared. Results. The mean dose (Dm) for PTVs ranged from 98.7 to 99.9%, with standard deviations ranging from 1.5 to 1.7%. Plan I appeared to be the best considering the Dm for the rectum, whereas Plan II appeared to be the best considering V95 (fraction of volume receiving a dose higher than 95% of the isocenter dose for the rectum). Plan III appeared to be the best considering the Dm and V95 for the bladder and also conside­ring the Dm and V50 for the femur. Conclusions. This conceptual study suggested that the differences in shapes and volumes of planning tar­get volume might be taken into consideration in an attempt to individually establish the optimum beam ar­rangements for three-dimensional conformal radiation therapy delivery in prostate cancer. Key words: prostatic neoplasms radiotherapy; radiotherapy, conformal Received 28 November 2005 Accepted 12 December 2005 Correspondence to: Haldun S¸ükrü Erkal, M.D., De­partment of Radiation Oncology, Inönü University Fa­culty of Medicine, TR-44280, Malatya, Turkey; Phone: + 90 422 341 00 45; Fax: + 90 422 341 00 36; E-mail: hserkal@inonu.edu.tr Introduction A three-dimensional conformal radiation the­rapy is characterized by the conformation of the radiation dose to the target volume besides the reduction of the radiation dose to the nor­mal tissues at risk.1 The three-dimensional conformal radiation therapy requires the accu­rate delineation of gross tumor volume (GTV) and meticulous identification of the margins to define the clinical target volume (CTV) and the planning target volume (PTV).2 The design of the beam arrangements for the three-dimensi­onal conformal radiation therapy delivery co­uld be hampered by the variations in the sha­pe and the volume of GTV as well as the vari­ations in the margins to define CTV and PTV. The aim of this conceptual study was to correlate CTV and the margins to define PTV with the beam arrangements for the three-di­mensional conformal radiation therapy deli­very on two descriptive patients with prosta­te cancer having considerably different pro­state shapes and volumes. Material and methods Of two patients with localized prostate cancer investigated in this study, Patient I had a con­cave shaped prostate with a comparatively small CTV of 48.3 cm3 and Patient II had a non-concave shaped prostate with a compara­tively large CTV of 82.1 cm3. The patients we­re positioned supine with a full bladder and immobilized in a molded foam cradle (Redifo-am, Med-Tec Inc., Orange City, United States of America). Following the administration of the contrast material into the bladder and the rectum, transverse computed tomography images of the pelvis were obtained on a dedi­cated scanner (IQ-TC, Picker International, Cleveland, United States of America) with a slice thickness of 0.2 cm (at 0.2 cm steps) thro­ughout the region containing the target volu­me (from the bottom of the sacroiliac joints to the penile urethra) and a slice thickness of 0.5 cm (at 0.5 cm steps) throughout the regions above and below the region containing the tar­get volume. The prostate, the seminal vesicles, the bladder (from the apex to the dome), the rectum (from the anus at the level of the ischi­al tuberosities for a length of 15 cm) and right femur (to the level of the ischial tuberosities) were outlined on a virtual simulation worksta­tion (Acqsim, Picker International, Cleveland, United States of America). With respect to the International Commis­sion on Radiation Units and Measurements (ICRU) Report 50,2 GTV was defined as the prostate and CTV was defined as the prostate and the seminal vesicles. Uniform margins of 0.4 cm (Margin I), 0.8 cm (Margin II) and 1.2 cm (Margin III) were added around CTV thro­ugh the automatic volume expansion to take into account the variations in the shape and the volume of CTV as well as to take into ac­count the uncertainties in patient positioning. Margin I, Margin II and Margin III defined PTV I, PTV II and PTV III, respectively. To de­fine the block edges, a margin of 0.7 cm was added around PTVs to account for the effect of the penumbra. Three well-established coplanar beam ar­rangements were simulated for PTV I, PTV II and PTV III. Plan I had an anteroposterior fi­eld and two lateral 30° wedged fields, Plan II had an anteroposterior field, a posteroanteri-or field and two lateral fields and Plan III had an anteroposterior field, a posteroanterior fi­eld, two anterior oblique fields and two poste­rior oblique fields. Dose distributions for equ­ally weighted fields were calculated for 18 MV photons and normalized at the isocenter on a three-dimensional treatment planning system (Cadplan, Varian-Dosetek Oy, Fin­land). The reference dose was considered as 95% of the isocenter dose. Dose-volume histo­grams (DVHs) for PTV, the bladder, the rec­tum and the femur were calculated. For the quantitative comparison of DVHs, the mean dose (Dm) and the fraction of volume recei­ving a dose higher than 95% of the isocenter dose (V95) were considered for the rectum and the bladder and Dm and the fraction of volume receiving a dose higher than 50% of the isocenter dose (V50) was considered for the femur. Radiol Oncol 2005; 39(4): 273-7. Results The Dm for PTVs ranged from 98.7 to 99.9%, with standard deviations ranging from 1.5 to 1.7%. Considering Dm for the rectum, Plan I ap­peared to be the best and Plan III appeared to be the worst beam arrangement regardless of the shape and the volume of the prostate and regardless of the margin added around CTV. Considering V95 for the rectum, Plan II appe­ared to be the best and Plan III appeared to be the worst beam arrangement for Margin I and Margin II while Plan III appeared to be the best and Plan I appeared to be the worst be­am arrangement for Margin III for Patient I, whereas Plan I appeared to be the best and Plan III appeared to be the worst beam arran­gement regardless of the margin added aro­und CTV for Patient II. Considering Dm for the bladder, Plan III appeared to be the best and Plan II appeared to be the worst beam arrangement regardless of the shape and the volume of the prostate and regardless of the margin added around CTV. Considering V95 for the bladder, Plan III appeared to be the best beam arrangement for Margin I and Plan I appeared to be the best beam arrangement for Margin II and Margin III while Plan II appeared to be the worst beam arrangement regardless of the margin added around CTV for Patient I, whe­reas Plan I appeared to be the best and Plan II appeared to be the worst beam arrangement regardless of the margin added around CTV for Patient II. Considering both Dm and V50 for the fe­mur, Plan III appeared to be the best and Plan I appeared to be the worst beam arrangement regardless of the shape and the volume of the prostate and regardless of the margin added around CTV. Dm and V95 values for the rectum and the bladder and Dm and V50 values for the femur are shown in Table 1 and Table 2, respecti­vely, for Patient I and Patient II. Discussion For patients with prostate cancer treated with the three-dimensional conformal radiation therapy, a wide range of variation has been reported for CTV as dictated by the volume of the prostate. Forman et al. have reported the volume of the prostate to range from 10 to Table 1. Comparisons of Dm and V95 values for the rectum and the bladder and Dm and V50 values for the fe­mur for different PTVs with different beam arrangements for Patient I. Plan I Plan II Plan III PTV* I PTV II PTV III PTV I PTV II PTV III PTV I PTV II PTV III Bladder Dm** 29.39 34.92 37.92 34.41 39.36 42.31 26.21 31.85 37.08 V95*** 11.09 19.46 30.33 14.57 22.29 35.01 10.76 19.79 32.18 Rectum Dm 25.05 30.74 33.69 28.27 33.19 35.51 29.33 34.75 36.92 V95 18.35 32.12 43.48 18.24 30.48 42.61 20.54 35.72 42.19 Femur Dm 30.25 34.10 37.41 22.68 26.29 37.80 19.48 23.59 26.64 V50**** 76.60 90.21 100.42 59.72 75.47 86.56 18.65 32.00 40.70 *PTV: Planning target volume, **Dm: The mean dose, ***V95: The fraction of volume receiving a dose hig­her than 95% of the isocenter dose, ****V50: The fraction of volume receiving a dose higher than 50% of the isocenter dose. Radiol Oncol 2005; 39(4): 273-7. Table 2. Comparisons of Dm and V95 values for the rectum and the bladder and Dm and V50 values for the fe­mur for different PTVs with different beam arrangements for Patient II. Plan I Plan II Plan III PTV* I PTV II PTV III PTV I PTV II PTV III PTV I PTV II PTV III Bladder Dm** 37.36 42.21 46.56 42.04 46.77 50.40 34.76 39.98 45.54 V95*** 13.18 20.38 36.08 18.42 29.35 44.00 13.37 23.00 39.54 Rectum Dm 42.43 50.35 57.00 50.71 57.03 61.36 51.05 58.32 63.67 V95 2.96 9.68 16.75 5.04 11.97 19.64 5.31 12.04 20.92 Femur Dm 42.65 45.05 47.81 32.21 34.02 36.42 23.45 25.89 28.73 V50**** 130.36 138.55 146.86 120.43 129.22 138.97 6.56 16.20 46.85 *PTV: Planning target volume, **Dm: The mean dose, ***V95: The fraction of volume receiving a dose hig­her than 95% of the isocenter dose, ****V50: The fraction of volume receiving a dose higher than 50% of the isocenter dose. 155 cm3 (median, 52 cm3) in patients with prostate cancer treated with three-dimensio­nal conformal radiation therapy.3 In the inter­vening years since the publication of the ICRU Report 50 in 1993, the acceleration in the clinical application of three-dimensional conformal radiation therapy has necessitated a more accurate definition of PTV. In 1999, the ICRU Report 62 has been published as a supplement to Report 50, addressing the dif­ferent sources of uncertainties to be taken in­to account in delineating PTV.4 The ICRU Report 62 has defined an inter­nal margin (IM) to take into account the un­certainties in the shape and the volume of CTV and a set-up margin (SM) to take into ac­count the uncertainties in patient positioning. While IM has mainly been related to the physiological variations that have been diffi­cult or impossible to control, SM has mainly been related to the technical factors that co­uld have been reduced by the more accurate immobilization and the set-up of the patient, as well as the improved mechanical stability of the treatment machine.4 Tinger et al. have reported margins ranging from 0.7 to 1.1 cm to be added around CTV to encompass the overall uncertainties with a 95% probability and margins ranging from 1.0 to 1.6 cm to be added around CTV to encompass the overall uncertainties with a 99% probability.5 The three-dimensional conformal radiati­on therapy for prostate cancer has traditio­nally been delivered through well-established coplanar three-field, four-field or six-field be­am arrangements.6-8 Although these beam ar­rangements have been compared in terms of dose distributions to the normal tissues at risk through dose-volume histograms, the dif­ferent sources of uncertainties to be taken in­to account in delineating PTV have generally not been appreciated.9,10 Therefore, the con­tributions of the shape and the volume of the prostate and the magnitude of the margin de­fining PTV to the selection of the beam arran­gements for the three-dimensional conformal radiation therapy delivery have not been in­dependently described.11,12 In this conceptual study, the differences in the shapes and the volumes of PTVs for the investigated patients underlined the establi­shment of different beam arrangements as the optimum beam arrangement for different patients. However, the same beam arrange­ments were established as the optimum beam arrangement for a given patient, regardless of the increases in the magnitudes of the mar­gins defining PTVs. These findings suggest Radiol Oncol 2005; 39(4): 273-7. that the inherent characteristics of the pati­ents, such as the shape and the volume of the prostate, might lead to more critical contribu­tions for the establishment of the optimum beam arrangements when compared to the margins typically added around the target vo­lumes based on the established policies of the institutions. Further studies of a larger scale are warranted to confirm that the selection of the beam arrangements for three-dimensio­nal conformal radiation therapy delivery in patients with prostate cancer having conside­rably different prostate shapes and volumes should call for individual rather than class so­lutions. Acknowledgement This study has been presented at the “3rd Ta-kahashi Memorial International Workshop on Three Dimensional Conformal Radiothe­rapy” in Nagoya, Japan in 2001. References 1. Purdy JA. 3-D radiation treatment planning: A new era. Front Radiat Ther Oncol 1996; 29: 1-16. 2. International Commission on Radiation Units and Measurements. Prescribing, recording and reporting photon beam therapy: ICRU Report 50. Bethesda: In­ternational Commission on Radiation Units and Measurements; 1993. 3. Forman JD, Keole S, Bolton S, Tekyi-Mensah S. Association of prostate size with urinary morbi­dity following mixed conformal neutron and pho­ton irradiation. Int J Radiat Oncol Biol Phys 1999; 45: 871-5. 4. International Commission on Radiation Units and Measurements. Prescribing, recording and reporting photon beam therapy (Supplement to ICRU Report 50): ICRU Report 62. Bethesda: International Commis­sion on Radiation Units and Measurements; 1999. 5. Tinger A, Michalski JM, Cheng A, Low DA, Zhu R, Bosch WR, et al. A critical evaluation of the plan­ning target volume for 3-D conformal radiothe­rapy of prostate cancer. Int J Radiat Oncol Biol Phys 1998; 42: 213-21. 6. Bedford JL, Khoo VS, Oldham M, Dearnaley DP, Webb S. A comparison of coplanar four-field te­chniques for conformal radiotherapy of the prosta­te. Radiother Oncol 1999; 51: 225–35. 7. Bedford JL, Khoo VS, Webb S, Dearnaley DP. Op­timization of coplanar six-field techniques for con­formal radiotherapy of the prostate. Int J Radiat Oncol Biol Phys 2000; 46: 231–8. 8. Khoo VS, Bedford JL, Webb S, Dearnaley DP. An evaluation of three-field coplanar plans for confor­mal radiotherapy of prostate cancer. Radiother On-col 2000; 55: 31–40. 9. Fiorino C, Reni M, Cattaneo GM, Bolognesi A, Ca-landrino R. Comparing 3-, 4- and 6-fields techni­ques for conformal irradiation of prostate and se­minal vesicles using dose-volume histograms. Ra-diother Oncol 1997; 44: 251-7. 10. Neal AJ, Oldham M, Dearnaley DP. Comparison of treatment techniques for conformal radiothe­rapy using dose-volume histograms and normal tissue complication probabilities. Radiother Oncol 1995; 37: 29-34. 11. Lennernas B, Rikner G, Letocha H, Nilsson S. Ex­ternal beam radiotherapy of localized prostatic adenocarcinoma: Evaluation of conformal the­rapy, field number and target margins. Acta Oncol 1995; 34: 953-8. 12. Roach M, Pickett B, Rosenthal SA, Verhey L, Phil­lips TL. Defining treatment margins for six field conformal irradiation of localized prostate cancer. Int J Radiat Oncol Biol Phys 1994; 28: 267-75. Radiol Oncol 2005; 39(4): 273-7. Radio/ Onco/ 2005; 39(4): 237-42. Majhna kolicina proste plevralne tekocine. plevralni izliv Kocijancic I Izhodišca. Majhne plevralne izlive obicajni pregledni posnetki prsnih organov redko odkrijejo. Tak izvid pa je pomemben, saj lahko skupaj s probatorno punkcijo vodi do koncne diagnoze kar­cinomatoze, vnetja ali transudata. Majhen rentgentski znak meniskusa in medialni pomik freni­kokostalnega recesusa sta edina, ki nakazujeta možnost manjše kolicine plevralne tekocine na posnetku prsnih organov stoje. Na stranskem posnetku stoje je majhen meniskus v posterior­nem frenikokostalnem recesusu znak majhnega plevralnega izliva. Zakljucki. Že vrsto let uporabljamo za dokazovanje majhnih kolicin proste plevralne tekocine posnetke prsnih organov leže na boku. V zadnjem desetletju pa je vodilna metoda prikazovanja majhnih plevralnih izlivov ultrazvocni pregled plevralnega prostora. Rndiol Oncol 2005; 39(4): 279-85. S/ovellimz abstmcts Radio/ 0Hcol 2005; 39(4): 243-7. Ultrazvocna preiskava žolcnika pri bolnikih s podaljšanim bivanjem (>14 dni) v enoti intenzivnega zdravljenja Šustic A, Miletic D, Cicvaric T Izhodišca. Namen pricujoce raziskave je bil ugotoviti pogostnost nenormalnega ultrazvocnega (UZ) izvida žolcnika pri kirurških bolnikih, ki so bivali v enoti intenzivnega zdravljenja vec kot 14 dni. Prav tako smo želeli primerjati te UZ izvide z resnostjo obolenja. Metode. V prospektivno raziskavo smo zajeli 57 odraslih kirurških bolnikov (66% moških; sta­rost 49±18 let) s podaljšanim bivanjem v enoti intenzivnega zdravljenja. Pri vseh bolnikih smo UZ preiskavo naredili 15. dan bivanja v intenzivni enoti. Ultrazvocno smo ugotavljali: debelino stene žolcnika (24 mm), vsebino žolcnika, brazgotinjenje žolcnikove stene in periholecistiticno tekocino. Isti dan smo ocenjevali tudi resnost obolenja po SAPS II lestvici. Rezultati. Vsaj en UZ znak obolenja žolcnika je imelo 36 (63%) bolnikov, med njimi zadebelje­no steno žolcnika 32 (56%), žolcno usedlino 23 (40%), periholecistiticno tekocino 9 (16%), hidro­picen žolcnik 7 (12%) in zabrazgotinjeno steno žolcnika 4 (7%) bolniki. Od naštetih 5 UZ znakov obolenja žolcnika smo dva in vec ugotovili pri 20 (35%) bolnikih, tri in vec pri 12 (21 %), štiri in vec pri 10 (18%) in vseh pet pri 4 (7%) bolnikih. Bolniki z enim ali vec UZ znakom obolenja žolcnika so imeli statisticno znacilno resnejše obolenje po SAPS II lestvici glede na bolnike z nor­malnim UZ izvidom (36±9 vs. 28±7; p<0,01). Statisticno znacilno resnejša obolenja po SAPS II lestvici smo tudi ugotovili, ko smo primerjali bolnike z dvema UZ znakoma obolenja žolcnika in bolnike z nobenim ali enim (40±8 vs. 29±6; p<0,001), bolnike s tremi znaki in bolniki z dvema ali manj znakoma (41±8 vs. 31±9; p<0,001), bolnike s štirimi in bolnike s tremi ali manj znaki (42±11 vs. 31±6; p<0,001) ter bolnike s petimi zanki in bolnike z manj UZ znaki obolenja žolcni­ka (45±10 vs. 32±9; p<0,001). Tako smo ugotovili statisticno znacilno povezavo med številom UZ znakov obolenja žolcnika in resnostjo obolenja po SAPS II lestvici (r = 0.57; p <0,001). Zakljucki. Vec kot polovica kirurških bolnikov, ki smo jih vec kot 14 dni obravnavali v enoti in­tenzivnega zdravljenja, je imelo nenormalen UZ izvid, ki je bil v neposredni povezavi z resno­stjo obolenja. Radio/ On col 2005; 39( 4): 2 79-85. Radio/ Oncol 2005; 39(4): 249-52. Koristnost transrektalne endoluminalne ultrazvocne preiskave pri locevanju analnega abscesa in rektalnega karcinoma. Prikaz primera Kolodziejczak M, Sudol -Szopinska I Izhodišca. Visoko ležeci analni abscesi imajo lahko neznacilen, kronicni klinicni potek, zato jih je težje diagnosticirati. Prikaz primera. Avtorici opisujeta primer bolnice, pri kateri so sprva sumili, da ima rektalni kar­cinom. Ker so neznacilni klinicni simptomi kazali na možnost visokoležecega abscesa s kro­nicnim potekom bolezni, so naredili dodatne preiskave. Potrdili so, da ima bolnica visokoležeci, submukozni, intersfinkterski absces. Zakljucki. Zgoraj opisani primer bolnice kaže, da sta bili pri ugotavljanju bolezni najvažnejša natancna digitalna interrektalna priskava ter transrektalni endoluminalni ultrazvok. Radio/ Oncol 2005; 39(4): 279-85. Radio/ Oncol 2005; 39(4): 253-9 Novi oznacevalec angiogeneze CD105 (endoglin): diagnosticni, napovedni in terapevtski pomen Legan M Izhodišca. Angiogeneza je kljucna za napredovanje in metastaziranje malignih tumorjev, zato so številne raziskave usmerjene v prikaz in vrednotenje tumorskega žilja ter ugotavljanje poveza­nosti le-tega z napovedjo poteka bolezni. Panendotelijski oznacevalci (CD31, CD34 in F8) ter no­vejši oznacevalec CD105 so razlicno izraženi v endotelijskih celicah nastajajocih (predvsem tu­morskih) žil in endotelijskih celicah normalnega žilja. Prvi so idealni oznacevalci normalnega žil­ja, CD105 (imenovan tudi endoglin) pa je primernejši za prikaz tumorske angiogeneze. Endoglin je receptor za tumorski rastni dejavnik (tumor growth factor -TGF) beta, ki ga najdemo na endo­telijskih celicah angiogenih tkiv. Potreben je pri aktivni angiogenezi v tumorju kot tudi pri ra­zvoju žil pri zarodku. Zakljucki. Gostota tumorskega žilja -prikazana z imunohistokemicnim oznacevanjem CD105 v tkivnih rezinah tumorja in izmerjena s histomorfometricnimi metodami -je znacilno povezana z agresivnostjo tumorja in napovedjo poteka bolezni pri številnih solidnih tumorjih. Ucinkovanje na endoglin, ki je specificni antigen v tumorskem žilju, ima tudi velike terapevtske možnosti. Radio/ Oncol 2005; 39(4): 279-85. Radio! Oncol 2005; 39(4): 261-8. Pomen molekul MHC II pri imunoterapiji tumorjev Oveni Izhodišca. Imunoterapija tumorjev izrablja sposobnost imunskega sistema, da specificno ubija tumorske celice, pri tem pa minimalno poškoduje normalno tkivo. Vedno vecje poznavanje tu­morskih antigenov prispeva k nacrtovanju bolj ucinkovitih terapevtskih cepiv. Študije narejene na živalskih modelih so pokazale, da so poleg molekul MHC I in celic CD8+ T pri nastanku in vzdrževanju imunskega odziva proti tumorjem pomembne tudi molekule MHC II in celice CD4+ T. Rezultati nakazujejo, da bo za ucinkovito protitumorsko cepivo potrebno aktivirati tako celi­ce CD4+ kot tudi CD8+ T. V zadnjem casu so se razvile nove strategije za okrepitev T celicnega odgovora proti raku, ki izrabljajo sposobnost dendriticnih celic, da delujejo kot antigeni. Z vkljucevanjem tumorskih antigenov specificnih za molekule MHC II in z geneticnim spreminja­nem tumorskih celic, da delujejo kot antigeni (antigen-predstavitvene celice), lahko podaljšamo predstavljanje antigenov celicam T preko dendriticnih celic. Zakljucki. Z združitvijo razlicnih pristopov bi lahko naredili ucinkovito protitumorsko cepivo, ki bi vzpodbudilo delovanje za tumor specificnih celic T, te pa bi ubile tumorske celice. S tem bi zmanjšale obseg tumorja, obenem pa bi vzpodbudile tudi nastanek za tumor specificnega ce­licnega spomina T, ki bi omejil ali preprecil ponovni nastanek tumorja. Radio/ Oncol 2005; 39(4): 279-85. Radio/ Oncol 2005; 39(4): 269-72. Kvantitativna analiza vzorcev aspiracijske biopsije Rajer M, Kmet M Izhodišca. Aspiracijska biopsija s tanko iglo (ABTI) je varna, hitra, enostavna, neboleca in poce­ni metoda v preoperativni diagnostiki tumorjev. Za postavitev diagnoze je potrebno z ABTI pri­dobiti doloceno število celic za izdelavo rutinskih celicnih razmazov ter za dodatne, novejše pre­iskave, ki so pomembne za natancnejšo opredelitev prognosticnih dejavnikov in dolocitev ustre­znega zdravljenja. Zanimalo nas je, koliko celic ostane v igli in brizgalki po pripravi rutinskih preparatov in kaj vpliva na to število, kajti ravno na tem delu vzorca opravljamo te dodatne pre­iskave. Material in metode. V prospektivno raziskavo smo vkljucili 152 vzorcev ABTI tumorjev dojke, šcitnice in bezgavke. S pomocjo Buerker-Tuerkove komore smo šteli celice, ki ostanejo v brizgal­ki in igli po pripravi rutinskih preparatov. Rezultati. Po ocenah sodelavcev Onkološkega inštituta je za dodatne preiskave potrebno z AB­TI pridobiti vsaj 500.000 celic poleg tistih, ki smo jih uporabili za dva rutinska razmaza. To smo dosegli pri vzorcih 95% tumorjev bezgavk, 82% tumorjev šcitnice in 81 % tumorjev dojk. Ugoto­vili smo, da je število celic odvisno od organa, ki ga punktiramo. Pri tumorjih dojk in bezgavk je število odvisno tudi od vrste tumorja, velikost tumorja pa na število celic ne vpliva. Ko smo pri­merjali število celic, ki so jih pridobili izkušeni citologi s številom pri manj izkušenih, smo pri ABTI tumorjev dojk dobili statisticno znacilno razliko (p = 0,03), pri ostalih dveh pa razlika ni dosegla statisticne znacilnosti. Zakljucki. ABTI je metoda, ki v vecini primerov zagotovi zadostno število celic za standardno mikroskopsko preiskavo in dodatne analize tumorskih celic. Število celic je odvisno od organa, ki ga punktiramo, lastnosti tumorja in pri ABTI dojke tudi od izvajalca. Radio/ Oncol 2005; 39( 4): 2 79-85. Radio/ Oncol 2005; 39( 4): 2 73-8. Primerjava med klinicnim tarcnim volumnom in varnostnim robom, ki dolocata planirni tarcni volumen ter obliko polj pri tridimenzionalni konf ormni radioterapiji raka prostate Erkal HS, Serin M Izhodišca. Primerjalna študija je bila opravljena na dveh bolnikih z rakom prostate razlicnih ob­lik in volumnov. Želeli smo ugotoviti razmerje med klinicnim tarcnim volumnom in varnostnim robom, ki dolocata planirni tarcni volumen (PTV) ter obliko polj pri tridimenzionalni konformni radioterapiji. Material in metode. Klinicni tarcni volumen je vkljuceval prostato in seminalne vezikule. Varno­stne robove dolžin 0,4 cm, 0,8 cm in 1,2 cm smo enakomerno dodali na klinicni tarcni volumen in tako dolocili tri PTV. Pri vseh PTV smo simulirali tri dobro osnovana istoravninska (koplanar­na) polja. Naredili smo histograme, ki so kazali razmerje med dozo in volumnom ter jih med se­boj kvantitativno primerjali. Rezultati. Povprecna doza za PTV je bila v razponu od 98,7 do 99,9%, s standardno deviacijo med 1,5 in 1,7%. Plan I je bil najboljši glede na povprecno dozo sevanja, ki ga je prejel rektum, medtem ko je bil Plan II najboljši glede na V95 za rektum (delež volumna, ki prejme dozo višjo od 95% doze do­locene v izocentru). Plan III pa je bil najboljši tako glede na povprecno dozo sevanja in V95 za mehur kot tudi glede na povprecno dozo sevanja in VSO za glavice kolkov. Zakljucki. Primerjalna študija kaže, da moramo upoštevati razlike v oblikah in volumnih planir­nih tarcnih volumnov. Takšen pristop nam omogoca individualno dolocevanje optimalnih polj potrebnih za tridimenzionalno konformno radioterapijo v primeru raka prostate. Radio/ Oncol 2005; 39(4): 279-85. Notices Notices submitted far publication should contain a mailing address, phone and/ or fax number and/ or e-mail of a Contact person or department. Thoracic oncology January 13-15, 2006 The "5th Annual UCSF Clinical Cancer Update" will be held in Lake Tahoe, California, USA. Contact University of California, San Francisco, Of­fice of Continuing Medica! Education, Box 0742, 3333 California St., San Francisco, CA 94143; or e-mail CME@ocme.ucsf.edu;or http://www.ucsfcme.com Cellular biology Januan; 25-28, 2006 The cellular biology meeting "Celi Signaling World. Signal Transduction Pathways as therapeutic targets." will take place in Luxembourg. See http://www. transduction-meeting.lu Oncology January 25-28, 2006 The IASLC workshops of British Thoracic Oncology Group will be offered in Dublin, Ireland. E-mail obyrne@st.james.ie Prostate cancer February 12-16, 2006 The ESTRO teaching multisdisplinary course about prostate cancer will take place in Gent, Belgium. Contact ESTRO office, Avenue E. Mounierlaan 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Radiotherapy February 17-19, 2006 The IASLC workshops "Development of a Japane­se-North American Cooperative Clinical Tria! Compa­ring Stereotactic Radiation Therapy with Surgery for Stage I non-small celi lung cancer" will be offered in Maui, Hawaii. Contact Dr. anderson.org; R. Komaki, e-mail rkomaki@md Prostate cancer Febnwn; 24-26, 2006 The ASCO symposium will be held in San Franci­sco, California, USA. Contact E mail: enews@asco.org; or see http:// www/asco.org Molecular Oncology March 4, April 30, 2006 The ESTRO teaching course "Molecular Oncology for the Radiation Oncologists" will take place in Gra­nada, Spain. Contact ESTRO office, Avenue E. Mounierlaan 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Oncology March 8-12, 2006 The 11th NCCN Annual Conference will be held in Hollywood, Florida, USA. See http:// www.nccn.org Radio/ Oncol 2005; 39(4): 287-91. 288 Notices Oncology March 9-12, 2006 The ESO advanced course "Modifying Cancer Res­ponse to Therapy: From Molecular signalling to Can­cer Care" will be offered in Lugano, Switzerland. Contact: Chatrina Melcher, European School of On­cology, ESO Bellinzona Office, IOSI, Ospedale Regio­nale Bellinzona e Valli, CH-6500 Bellinzona, Switzer­land; or cal +41 91 8111 8050; or fax +41 91 811 8051; or e-mail eso2@esoncology.org Oncology March 12-15, 2006 ICTR 2006, the "3rd International Conference on Translation Research and Pre-Clinical Strategies in Radiation Oncology" will be offered in Lugano, Swit­zerland. Contact: ICTR 2006 Secretariat, Department of Ra­dio-Oncology, Oncology Institute of Southern Swit­zerland, CH-6504 Bellinzona, Switzerland; or fax +41 91 811 8678; or http://www.iosi.ch/ictr2006.html Oncology March 15-18, 2006 The 3rd International Croatia Conference in Onco­logy will be offered in Zagreb, Croatia. Contact: Penta d.o.o., Ms. Danijela Curcic, A He­branga 20, 1000 Zagreb, or call +385 1 4553 290; or fax +385 1 4553 284; or e-mail danijela@penta-zagreb.hr; or http://www.penta-zagreb.hr Breast cancer March 21, 2006 The ESTRO pre-meeting workshop on radiotherapy in early breast cancer will take place in Nice, France. Contact ESTRO office, Avenue E. Mounierlaan, 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Experimental and translational oncology March 22-26,2006 The "4th Conference on Experimental and Transla­tional Oncology" will take place in Kranjska gora, Slo­venia. Contact conference secretariat: Helena Koncar, Na­tional Institute of Biology, Vecna pot 111, 1000 Lju­bljana, Slovenia, or call +386 1 241 29 70, fax +386 1 241 29 80, E-mail ceto@nib.si, or see http://www.on­ko-i.si/ceto Radiotherapy March 26-30, 2006 The ESTRO teaching course "Radiotherapy Trea­tment Planning-Principles and Practices" will take pla­ce in Dublin, Ireland. Contact ESTRO office, Avenue E. Mounierlaan 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Brachytherapy March 26-30, 2006 The ESTRO teaching course "Modem Brachythe­rapy Techniques" will take place in Prague, Czech Re­public. Contact ESTRO office, Avenue E. Mounierlaan 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Lung cancer April 19-26, 2006 The "2nd Latin American Conference on Lung Can­cer" will be offered in Cancun, Mexico. Contact E-mail: LungCancerLA@meet-ics.com: or see http:// www.LCLA2006.com Molecular oncology April 30 -May 4, 2006 The ESTRO teaching course "Molecular Oncology for the Radiation Oncologist" will take place in Grana­da, Spain. Contact ESTRO office, Avenue E. Mounierlaan, 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Radio/ Oncol 2005; 39(4): 287-91. Notices 289 Radiotherapy May 7-11, 2006 The ESTRO teaching course "Dose Determination in Radiotherapy: Beam Characterisation, Dose Calcu­ Iation and Dose Verification" will take place in Izmir, Turkey. Contact ESTRO office, Avenue E. Mounierlaan, 83/12, B-1200 Brussels, Belgium; or call + 32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Radiology May 15-17, 2006 The UK radiological congress will be held in Bir­ mingham, UK. Contact UKRC 2006 Organisers, PO Box 2895, Lon­don WlA SRS, UK; or call + 44(0) 207 307 1410/20; or fax +44(0) 207 307 1414; or e mail conferen­ce@ukrc.org.uk / exhibition@ukrc.org.uk; or see http:// www.ukrc.org.uk Ethics in oncology May 18-20, 2006 The ESO course on "Ethics in Oncology" will be held in Bled, Slovenia. Contact course secretariat, Rita de Martini, Europe­an School of Oncology, Via del Bollo 4, 20123 Milan, ltaly, or call +39 02 854 645 27, or fax +39 02 854 645 45; or e-mail rdemartini@esoncology.org Clinical oncology June 2-6, 2006 The 42nd ASCO Meeting will be offered in Atlanta, USA. Contact E mail: enews@asco.org; or see http:// www/asco.org Radiotherapy June 11-15, 2006 The ESTRO teaching course "Imaging for Target Vo­Iume Determination in Radiotherapy" will take place in Athens, Greece. Contact ESTRO office, Avenue E. Mounierlaan, 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Cancer research June 17- 23, 2006 The 8th intensive workshop for European junior cli­ nical oncologists "Methods in Clinical Cancer Rese­ arch" will take place in Flims, Switzerland. Contact Federation of European Cancer Societies (FECS), Avenue E. Mounier, 83, B-1200 Brussels, Bel­ gium; or call +32 2 775 02 06; or fax +32 2 775 02 45; or e-mail workshop@fecs.be; or see http://www. fecs.be Lung cancer June 18-21, 2006 The "10th Central European Lung Cancer Confe­rence" will be offered in Prague, Czech Republic. Contact: +420-608-408-708; or e-mail celcc@confer­ence.cz; or see http://www.conference.cz/celcc2006 Prostate cancer ]une 25-2 7, 2006 The ESTRO teaching course "Brachytherapy for Prostate Cancer" will take place in Barcelona, Spain. Contact ESTRO office, Avenue E. Mounierlaan 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://vvww.estro.be Bronchology Jzme 25-28, 2006 The 14th Word Congress of Bronchology and the 14th Word Congress of Bronchoesophagology will ta­ke place in Buenos Aires, Republic Argentina. Contact: General Secretariat, Ms. Maria Graziani & Asociados with phone +4394 7726 4393 3437; or Fax: +541 439 33436; or E-mail: mg@mariagraziani.com Radiotherapy June 25-29, 2006 The ESTRO teaching course "IMRT and Other Con­formal Techniques in Practice" will take place in Co­penhagen, Denmark. Contact ESTRO office, Avenue E. Mounierlaan 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Radio/ Oncol 2005; 39(4): 287-91. 290 Notices Clinical trial statistics June 28-30, 2006 The EORTC (European Organisation for Research and Treatment of Cancer) course "Clinical Tria! Stati­stics for Non Statisticians" will take place in Brussels, Belgium. Contact Danielle Zimmermann, EORTC Education Office, Avenue E. Mounier 83 B. 11, B-1200 Brussels, Belgium; or call +32 2 774 16 02; or fax +32 2 772 62 33; or e-mail dzi@eortc.be; or see http://www.eortc.be Lung cancer June 30 -July 2, 2006 Inaugural IASLC Australian Lung Cancer Confe­rence on Multidisciplinary Care will be offered in Palm Cove, North Queensland, Australia. E-mail fongk@health.qld.gov.au Cancer research ]uly 1-4, 2006 The "19th Meeting of the European Association for Cancer Research EACR 19" will take place in Buda­pest, Hungary. Contact EACR-19 Secretariat, Federation of Europe­an Cancer Societies, Avenue E. Mounier, 83, B-1200 Brussels, Belgium; or call +32 2 775 02 01; or fax +32 2 775 02 00; or e-mail EACR19@fecs.be; or see http://www.fecs.be Gynaecological malignancies August 31 -September 1, 2006 The ESTRO teaching course "Brachytherapy for Gynaecological malignancies" will take place in Vien­na, Austria. Contact ESTRO office, Avenue E. Mounierlaan 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Radiotherapy September 3-7, 2006 The ESTRO teaching course "Physics for Clinical Radiotherapy" will take place in Innsbruck, Austria. Contact ESTRO office, Avenue E. Mounierlaan, 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax + 32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Radio/ Oncol 2005; 39(4): 287-91. Oncology September 8, 2006 The EORTC (European Organisation for Research and Treatment of Cancer) course "One-Day Introduc­tion to EORTC Trials" will take place in Brussels, Bel­gium. Contact Danielle Zimmermann, EORTC Education Office, Avenue E. Mounier 83 B 11, B-1200 Brussels, Belgium; or call +32 2 774 16 02; or fax +32 2 772 62 33; or e-mail dzi@eortc.be; or see http://www.eortc.be Radiobiology September 17-21, 2006 The ESTRO teaching course "Basic Clinical Radiobi­ology" will take place in Lisbon, Portugal. Contact ESTRO office, Avenue E. Mounierlaan, 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Lung cancer September 25-26, 2006 The "2nd lnternational Workshop Early Invasive Lung Cancer: New Diagnostic Tools & Treatment Stra­tegies" will be held in Turin, Italy. Contact E-mail: a.crippa@congressiefiere.com or see http://www.congressifiere.com Oncology October 8-12, 2006 The ESTRO 25 / ECCO 14 Conference will take pla­ce in Leipzig, Germany. Contact FECS office, Av. E. Mounierlaan, 83/4, B­1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estroweb.org Radiation oncology October 22-2 7, 2006 The ESTRO teaching course "Evidence-Based Radi­ation Oncology: Methodological Basis and Clinical Application" will take place in Giardini Naxos, Italy. Contact ESTRO office, Avenue E. Mounierlaan, 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Notices 291 Lung and head & neck October 26-28, 2006 The "4th Lung & Head and Neck Conference" will be offered in Chicago, Illinois. Contact: Taryn Klocke; call +1 770-984-5113; or e-mail evokes@medicine.bsd.uchicago.edu Lungcancer November 8-12, 2006 The "3rd IASLC/ASCO/ESMO International Confe­rence on Targeted Therapies in Lung Cancer" will be held in Taormina, Sicily, Italy. Contact E-mail: fred.hirsch@UCHSC.edu Radiotherapy November 19-23, 2006 The ESTRO teaching course "IMRT and Other Con­formal Techniques in Practice" will take place in Gli­wice, Poland. Contact ESTRO office, Avenue E. Mounierlaan 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://www.estro.be Surgical oncology November 30 -December 2, 2006 The "13th Congress of the European Society of Sur­gical Oncology ESSO 2006" will take place in Venice, ltaly. Contact Conference Secretariat, ESSO 2006, Fede­ration of European Cancer Societies, Avenue E. Mou­nier, 83, B-1200 Brussels, Belgium; or call +32 2 775 02 01; or fax +32 2 775 02 00; or e-mail ESSO2006@ fecs.be; or see http://www.fecs.be Radiotherapy December 3-7, 2006 The ESTRO teaching course "Image-guided Radio­therapy (IGRT)" will take place in Brussels, Belgium. Contact ESTRO office, Avenue E. Mounierlaan 83/12, B-1200 Brussels, Belgium; or call +32 2 775 93 40; or fax +32 2 779 54 94; or e-mail info@estro.be; or see http://vvww.estro.be Toxicology July 15-19, 2007 The "1 lth International Congress of Toxicology" will be offered in Montreal, Canada. Contact Congress Secretariat, e-mail: ict2007@ nrc-cnrc.gc.ca; or see http://www.ict2007.org Lung cancer September 2-6, 2007 The "12th World Conference on Lung Cancer" will be offered in Seoul, Korea. Contact Conference Secretariat; e-mail WCLC 2007@ncc.re.kr; or see http://www.iaslc.org!uma­ges/12worldconfannounce.pdf Oncology September 23-27, 2007 The "14th European Cancer Conference ECCO 14" will take place in Barcelona, Spain. Contact Conference Secretariat, ECCO 14, The Eu­ropean Cancer Conference, European Cancer Societi­es (FECS), Avenue E. Mounier, 83, B-1200 Brussels, Belgium; or call +32 2 775 02 01; or fax +32 2 775 02 00; or e-mail ECC014@fecs.be; or see http://www. fecs.be Lung cancer August 21-24, 2009 The "13th World Conference on Lung Cancer" will be offered in San Francisco, USA. Contact Conference Secretariat; e-mail WCLC 2007@ncc.re.kr; or see http://www.iaslc.orgiuma­ges/12worldconfannounce.pdf As a service to our readers, notices of meetings or courses will be inserted free oj charge. Please send i11formation to the Editorial office, Radiologi; and Oncology, Zaloška 2, SI-1000 Ljubljana, Slovenia. Radio/ 011col 2005; 39(4): 287-91. Author Index 2005 Agava S: 2/153-158 Aksu G: 1/55-59 Anic P: 1/37-47; 1/37-47 Arslan M: 1/55-59 Barnett E: 1/71-78 Bastic M: 1/1-4 Batinica M: 3/181-184 Bešlic Š: 2/101-114; 3/185-191 Bilic A: 1/9-13 Boric I: 1/1-4; 2/91-94 Brnic Z: 1/37-47 C. Miller R: 2/141-146 Cerar A: 1/61-70 Cicvaric T: 4/243-247 Cigit I: 2/91-94 Dalagija F: 1/15-21; 2/101-114; 3/185-191 Debeljak A: 2/115-121; 2/123-131 Debevec L: 2/115-121 Dede D: 2/95-99 Dizdarevic S: 1/15-21 Durovic V: 2/101-114 Erkal H$: 4/273-278 Eržen J: 2/115-121; 2/123-131 Fallone BG: 1/71-78 G. Gold D: 2/141-146 Gašparov S: 1/37-47 Grabec D: 3/219-224 Grochowicz M: 3/177-180 Giiveli M: 1/55-59 Hadjidekov V: 2/153-158 Hadjidekova V: 2/153-158 Homma S: 1/49-53 Ishikawa H: 1/49-53 Jakubowski W: 3/171-175 Kagohashi K: 1/49-53 Karadeniz AN: 1/55-59 Karadjov G: 2/153-158 Kecelj P: 2/123-131 Kern I: 2/115-121; 2/123-131 Kirova G: 1/23-35 Kmet M: 4/269-272 Kocijancic B: 3/193-196 Kocijancic !: 1/5-8; 4/237-242 Kodre V: 2/133-140 Ko!odziejczak M: 3/171-175; 3/177-180; 4/249-252 Kosim A: 3/177-180 Kovac V: 2/115-121; 2/123-131 Kragelj B: 3/211-217 Krnic A: 1/9-13 Kucan D: 1/37-47 Kurishima K: 1/49-53 Legan M: 4/253-259 Lincender L: 1/15-21 Lozo P: 1/37-47 Lušic M: 3/181-184 MacKenzie M: 1/71-78 Miletic D: 4/243-247 Mrevlje Ž: 3/193-196 Novakovic S: 2/147-152 Oberman B: 3/181-184 Oblak Bicek!: 2/133-140 Ohtsuka M: 1/49-53 Oven I: 4/261-268 Panorska AK: 3/171-175 Panov SZ: 3/197-210 Perše M: 1/61-70 Popova L: 2/153-158 Posaric V: 1/1-4; 2/91-94 Radovic N: 1/37-47 Rajer M: 4/269-272 Ramljak V: 1/37-47 Roic G: 1/1-4; 2/91-94 Rott T: 2/123-131 Satoh H: 1/49-53 Sayin B: 2/95-99 Sefic !: 1/15-21 Sekizawa K: 1/49-53 Senecic-Cala !: 3/181-184 Serin M: 4/273-278 Sever M: 3/193-196 Sjekavica !: 3/181-184 Sok M: 2/123-131 Stanovnik M: 2/123-131 Stefariski R: 3/177-180 Stegel V: 2/147-152 Strojan P: 3/219-224 Sucic Z: 1/9-13; 1/9-13 Sudol-Szopiriska I: 3/171-175; 3/177-180; 4/249-252 Szopinski T: 3/171-175 Radio/ Oncol 2005; 39(4): 293-4. Štern-Padovan R: 3/181-184 Šuštic A: 4/243-247 Traskov D: 2/153-158 Vegar-Zubovic S: 1/15-21 Velenik V: 2/133-140 Vidas Ž: 1/37-47 Vidmar S: 2/123-131 Vrtar Z: 2/91-94 Vucic N: 1/9-13 Vural M: 2/95-99 Yildirim N: 2/95-99 Zeljko Ž: 1/37-47 Župancic B: 1/1-4 Radio/ Oncol 2005; 39(4): 293-4. Subject Index 2005 1,2-dimethylhydrazine: 1/61-70 abscess: 4/249-252 anemia -drug therapy: 2/133-140 angiogenesis factor: 4/253-259 angiography -adverse effects: 2/153-158 anus diseases: 4/249-252 appendicitis-ultrasonography: 1/15-21 axillary artery-injuries-ultrasonography-surgery: 1/9-13 azoxymethane: 1/61-70 biopsy, needle: 1/37-47; 4/269-272 breast neoplasms -genetics: 2/147-152 bulbourethral glands-abnormalities: 1/1-4 calcinosis: 3/185-191 cancer vaccines: 4/261-268 carcinoid tumor: 3/193-196 CD4 -positive T-lymphocytes: 4/261-268 cell count: 4/269-272 child: 1/1-4; 1/15-21 chromosome aberrations: 2/153-158 colorectal neoplasms -chemically induced: 1/61-70 comparative study: 4/273-278 coronary vessels: 3/185-191 cysts: 3/177-180 cytodiagnosis: 4/269-272 diagnosis, differential: 4/249-252 diamond detector, intensity modulated radiotherapy: 1/71-78 disease models, animal: 1/61-70 duodenum-abnormalities: 3/181-184 endoscopy: 3/193-196 endosonography: 3/171-175; 4/249-252 epoetin alfa: 2/133-140 gallbladder diseases -ultrasonography: 4/243-247 genes, BRCAl: 2/147-152 genes, tumor suppressor: 3/197-210 head and neck neoplasms-radiotherapy: 3/219-224 ideal diseases: 2/91-94 immunotherapy, adoptive: 4/261-268 intensitive care units: 4/243-247 intestinal neoplasms-diagnosis: 3/193-196 intussusception: 2/91-94 kidney neoplasms -diagnosis: 1/23-35 lung neoplasms: 1/49-53 lung neoplasms -diagnosis -therapy: 2/115-121 lung neoplasms-genetics: 3/197-210 lymphocytes: 2/153-158 magnetic resonance imaging: 1/23-35 maxillary neoplasms -radiography: 2/95-99 Meckel's diverticulum: 2/91-94 mesothelioma -surgery -drug therapy -radiotherapy: 2/123-131 micronucleus tests: 2/153-158 mutation: 2/147-152 myocardial infarction: 3/185-191 neoplasm metastasis -radiotherapy: 2/141-146 neoplasms: 4/261-268 neoplasms -blood supply: 4/253-259 neoplasms -pathology: 4/269-272 neoplasms invasiveness: 1/55-59 neoplasms staging: 1/23-35 neoplasms, multiple primary: 1/49-53 neovascularisation, pathologic: 4/253-259 osteosarcoma: 2/95-99 parietal bone: 1/55-59 pleural effusion: 4/237-243 pleural neoplasms: 2/123-131 pleura-ultrasonography: 1/5-8 polymerase chain reaction: 2/147-152 postoperative complications: 4/243-247 pregnancy: 1/5-8 preschool: 1/1-4 prognosis: 4/253-259 prostate-specific antigen: 1/37-47 prostatic neoplasms: 3/211-217 prostatic neoplasms -pathology: 1/37-47 prostatic neoplasms -radiotherapy: 4/273-278 pulmonary embolism -diagnosis: 2/101-114 pylorus-abnormalities: 3/181-184 radiotherapy: 1/71-78 radiotherapy dosage: 1/71-78; 3/219-224 radiotherapy planning: 4/273-278 radiotherapy, conformal: 3/211-217; 4/273-278 rats: 1/61-70 rectal disease-ultrasonography-surgery: 3/177-180 rectal fistula-diagnosis: 3/171-175 rectal neoplasms: 4/249-252 rectal neoplasms -radiotherapy -drug therapy: 2/133-140 recurrence: 3/171-175 spina! cord compression: 2/141-146 survival analysis: 2/115-121 sweat gland neoplasms: 1/55-59 Radio/ Oncol 2005; 39(4): 295-6. Subject Index 2005 T -lymphocytes, helper -inducer: 4/261-268 thoracic radiography: 4/237-243 thrombectomy: 1/9-13 thrombosis: 1/9-13 thymoma: 2/141-146 tomography: 3/185-191 X-ray computed: 3/185-191 X-ray computed -methods: 2/101-114 Radio/ On col 2005; 39( 4): 295-6. FONDACIJA "DOCENT DR. J. CHOLEWA" JE NEPROFITNO, NEINSTITUCIONALNO IN NESTRANKARSKO ZDRUŽENJE POSAMEZNIKOV, USTANOV IN ORGANIZACIJ, KI ŽELIJO MATERIALNO SPODBUJATI IN POGLABLJATI RAZISKOVALNO DEJAVNOST V ONKOLOGIJI. MESESNELOVA 9 1000 LJUBLJANA TEL 0 1 51 9 1 2 77 FAKS 01 251 81 13 ŽR: 50100-620-133-05-1 0331 15-214779 Activity of "Dr. J. Cholewa" Foundation for Cancer Research and Education -A Report for the Final Quarter of 2005 The Dr. J. Cholewa Foundation for Cancer Research and Education continues to support activities associated with cancer research and education in Slovenia with dif­ferent grants and other forms of financial support. All the requests are being dealt with by the responsible bodies formed by Foundation members with clinical and can­cer research experience and by members with important experience in finance. The Dr. J. Cholewa Foundation for Cancer Research and Education continues to support the regular publication of "Radiology and Oncology" international scientific journal, which is edited, published and printed in Ljubljana, Slovenia, as it has done over the last couple of years. This support is considered to be one of its more impor­tant and permanent commitments. Among other recipients of grants and other forms of support it is possible to find severa! experts in the field of lung and breast cancer, Slovenian Association of Pathology and Slovenian Cancer Society. It is the policy of the Foundation to lend support to individuals and institutions that participate in cancer research and education in Slovenia. The Dr. J. Cholewa Foundation for Cancer Research and Education therefore respectfully acknowledges the importance of the commitment of various public companies and private individu­als to its cause. Andrej Plesnicar, MD Borut Štabuc, MD, PhD Tomaž Benulic, MD kapsule raztopina za intravensko infundiranje Sestava 1 kapsula vsebuje 50 mg, 100 mg ali 150 mg flukonazola. 1 viala vsebuje 200 mg flukonazola. Indikacije Sistemske kandidoze, mukozne kandidoze, preprecevanje kandidoze, kriptokokoze, vaginalna kandidoza in dermatomikoze. Odmerjanje In nacin uporabe Velikost odmerka je odvisna od indikacije. Odraslim dajemo obicajno 50 do 800 mg flukonazola 1-l