Navoban® The 5-HT3 antagonist developed with the patient in_mind. Navoban.t,opisetron) Always once a day. Always 5 mg. A SANDO.Z Sandoz Pharma Ltd, Pharma Basle Operations, Marketing & Sales, CH 4002 Basle/Switzerland RADIOLOGY AND ONCOLOGY Established in 1964 as Radiologia Iugoslavica in Ljubljana, Slovenia. Radiology and Oncology is a journal devoted to publication of original contributions in diagnostic and interventional radiology, computerized tomography, ultrasound, magnetic resonance, nuclear medicine, radiotherapy, clinical and experimental oncology, radiophysics and radiation protection. Editor in chief Tomaž Benulic Ljubljana, Slovenia Associate editors Gregor Serša Ljubljana, Slovenia Viljem Kovac Ljubljana, Slovenia Editorial board Bela Pomet Budapest, Hungary Marija Auersperg Tullio Giraldi Ljubljana, Slovenia Udine, Italy Andrija Hebrang Matija Bistrovic Zagreb, Croatia Zagreb, Croatia Durtla Horvat Haris Boko Zagreb, Croatia Zagreb, Croatia Berta Jereb Malte Clausen Ljubljana, Slovenia Kiel, Germany Vladimir Jevtic Ljubljana, Slovenia Christoph Clemm MUnchen, Germany H. Dieter Kogelnik Salzburg, Austria Mario Corsi Udine, Italy Ivan Lovasic Rijeka, Croatia Christian Dittrich Marijan Lovrencic Vienna, Austria Zagreb, Croatia Ivan Drinkovic Luka Milas Zagreb, Croatia Houston, USA Gillian Duchesne Maja Osmak London, Great Britain Zagreb, Croatia Branko Palcic Vancouver, Canada Jurica Papa Zagreb, Croatia Dušan Pavcnik Ljubljana, Slovenia Stojan Plesnicar Ljubljana, Slovenia Ervin B. Podgoršak Montreal, Canada Miran Porenta Ljubljana, Slovenia Jan C. Roos Amsterdam, The Netherlands Horst Sack Essen, Germany Slavko Šimunic Zagreb, Croatia Lojze Šmid Ljubljana, Slovenia Andrea V ero nesi Gorizia, Italy Publishers Slovenian Medica[ Society -Section of Radiology, Croatian Medica/ Association -Croatian Society oj Radiology Affiliated with Societas Radiologorum Hungarorum Friuli-Venezia Giulia regional groups of S.I.R.M. (Italian Society of Medica! Radiology) Correspondence address Radiology and Oncology Institute of Oncology Vrazov trg 4 61000 Ljubljana Slovenia Phone: + 386 611320 068 Fax: +386 61 1314 180 Reader for English Olga Shrestha Design Monika Fink-Serša Key words und UDC Eva Klemencic Secretaries Milica Harisch Betka Savski Printed by Tiskarna Tone Tomšic, Ljubljana, Slovenia Published quarterly Bank account number 501 OJ 678 48454 Foreign currency account number 50100-620-133-27620-5130/6 LB -Ljubljanska banka d. d. -Ljubljana Subscription fee for institutions 100 USD, individuals 50 USD. Single issue for institutions 30 USD, individuals 20 USD. According to the opinion of the Government of the Republic of Slovenia, Puhlic Relation and Media Office, the journal RADIOLOGY AND ONCOLOGY is a publication of informative value, and as such subject to taxation by 5 % sales tax. lndexed and abstracted by . BIOMEDICINA SLOVENICA CHEMICAL ABSTRACTS EXCERPTA MEDICAIELECTRONIC PUBLISHJNG DIVISfON · C.lNTJ.S DIAGNosi;.<;: AND INTERVENTIONAL RADIOLOGY Radiological presrntation of pulmonary hamartomas 11 '' 1 S6ljbtic H, l-{erceg Z, Slobodnjak Z 5 Side -eft'ects an. complications of percutaneous transluminal angioplasty of the subclavian 1 11 1 • artery: A'.nalys1s o. 55 cases ' ' Heb.a'ng A, Nffiškovic J, Drinkovic I 10 1 The scimitar syndn:pne and partial anomalous pulmonary venous drainage to the azygos ' 1' "I V.lh ' Borkovic Z, Ko1vacevic F, Raos V, Strozzi M, Radanovic B 15 Ultrasonogram of gallj>Iadder perforation 1 lvaniš N,' Kraus "-. Sever-Prebilic M, Brncic-Dabo N, Peric R, Vcev A 19 \ Calcaneal fracture and eroneal tendons injuries: CT analysis -Case report 1._ Cavka K, Cereda lf, Jmburgia L, Taddei L 23 ONCOLOGY Prognosis of patients wit!) non-Hodgkin's lymphoma (NUL), the influence of Kiel classification on survival Jereb B, Stare J, Petri{-Grabnar G, Jancar J 26 Epidemiological features o' cervical carcinoma in young women of Slovenia Pompe Kirn V, Volk N 34 Risk factors connected wit\ the appearance of chronical diseases and cancer in the Republic of Slovenia ' Pokorn D 40 RADIOPHYSICS The characteristic angle-beta concept in electron are therapy Pia M, Podgoršak EB, Pia C 1s an single film-dosimeter enough for monitoring radiation dose to the interventional radiologist? K6nya A, Vigvdry Z 49 58 BOOK REVIEW Imaging of bone tumors Jancar B 63 ANNIVERSARY On the 70th birthday of professor Dr. Ludvik Tabor 64 NOTICES 67 The publication of the journal is subsidized by the Ministry of Science and Technology of the Republic Slovenia. Contributions of Institutions: Inštitut za diagnosticno in intervencijsko radiologijo, KC Ljubljana; Klinika za otorinolaringologijo in maksilofacialno kirurgijo, KC Ljubljana; Klinicki zavod za dijagnosticku interventnu radiologiju, KBC Rebro, Zagreb; Onkološki inštitut, Ljubljana Radio/ Oncol 1994; 28: 5-9. Radiological presentation of pulmonary hamartomas Hrvojka Soljacic,1 Zlata Herceg2 and Zoran Slobodnjak3 1 Clinic for Lung Diseases Jordanovac, Zagreb, Croatia, 2 Clinic for Lung Diseases Jordanovac, Zagreb, Croatia; Clinical Institute for Thoracic Radiology Clinic for Thoracic Surgery, 3 Clinic for Lung Diseases Jordanovac, Zagreb, Croatia A review of thirty-seven cases of pulmonary hamartomas, relatively rare benign tumors of the lung, is presented. In all cases hamartomas were discovered radiologically and confirmed cytologically and pathohistologically before and!or after surgery. The prevalence of hamartoma was established in male patients (males vs. females, 2:1) and in older age group. There were no sex and age related differences with respect to the size or location of tumor. Key words: lungs neoplasms-radiography; hamartoma; human Introduction Hamartomas are benign tumors of the lung. These tumors usually consist of all histologic elements that are present in normal mature pulmonal tissue. They are composed of hyaline, cartilage (sometimes with calcifications), lipo­matous and fibrous tissue with cleft-like spaces lined with low columnar epithelium. The tumors are often surrounded by a layer of compressed alveolar tissue. 1 The etiology of hamartomas is stili unknown. There are opinions that these tumors are conge­nital by origin, or are a result of hyperplasia of normal structures with resultant tumor for­mation. Pulmonary hamartomas are very rare, and most series in the literature involve small num- Correspondence to: Hrvojka Soljacic, MD, Clinic for Lung Diseases Jordanovac, Jordanovac 104, 41000 Zagreb, Croatia. bers of patients seen over a period of years or decades. E. g., McDonald et al.2 found only 20 cases in 7970 necropsies; Rubin and Berck­man 3 reported 28 cases in the total of 8000 postmortem examinations; Blair and McElvein reported 25 patients with pulmonary hamar­toma during 36-year period. The same authors also mentioned that in all English medica] lite­rature up to 1963, a total od 200 hamartomas were reported. Toomes et al.5 reviewed 74 cases in ten year period; Deodato et al.6 obser­ved 11 cases of these pulmonary tumors during the last ten years; Hansen et al.7 diagnosed 89 cases during 25 years. According to most previously citated authors, hamartoma in the lung occurs principally in the pulmonary parenchyma in the bronchi or epi­pleurally. 8 The majority of hamartomas are asymptoma­ tic and are found incidentally on chest X-ray examination, with typical coin lesion appearan­ UDC: 616.24-006-073.75 ce. These are typical solitary pulmonary nodules Soljacic H et al. that appear like a single opacity in the Jung on radiography, with margins that are distinct enough to permit the measurement of diameter. The main problem is to distinguish hamarto­ mas from other coin Iesions of the Jung, spe­ cially those of malignant origin. Recently, the rapid progress of radiological diagnosis by trans­ thoracic needle-biopsy has improved the possi­ bility of correct diagnosis of hamartoma.7• 9 This is of great help to a surgeon. Namely, even where a Jung nodule has been identified as a hamartoma, surgery is the treatment of choice far two reasons: Firstly, because of the possibility of nodular growth,8 and secondly, because of possible, although rare, malignant alteration.10• 11 The purpose of this study was to point out the diagnostic value of hamartoma detection by radiological methods, as well as the possibility of diagnostic verification by percutaneous needle biopsies. Major characteristics of hamar­ tomas are also presented. Material and methods The medica! records and radiographs of ali patients with pulmonary hamartomas, diagno-. sed at the Clinic far Lung Diseases Jordanovac from the beginning of 1983 to the end of 1992, were reviewied. There were in tata! thirty-seven of those patients, with age range from 18 do 68 years. Diagnosis of hamartoma was based on radio­ logic examinations. Ali patients were submitted to radiography in two projections and to tomo­ graphy of the lungs, both in upright position. Special attention was paid to the form, size, localization and structure of the tumor, as well as to its relation to the surrounding structures. By means of radiography in two projections it was possible to establish the form, size and localization of the tumor. In addition, the con­ tours of the tumor in contrast to the surround­ ing structures as well as the shape of the tumor were presented by tomography. In our own series, ali hamartomas were dis­ tinctly delineated from the surrounding structu­ res. Owing to the distinct border of the hamar­tomas in relation to its surrounding structures, primary pulmonal neoplasmas can be excluded. However, this remarkable property stili allows far some other lesions, such as tuberculomas, echinococcal cysts, metastatic tumors and some other benign tumors in differential diagnosis. The calcifications within tumors, which were found in some of our cases were centrally Iocated. This localization does not imply the precise diagnosis of hamartoma, but significant­ly differs from irregularly arranged crumbly calcifications that are usually found within tu­berculomas. Therefore, after determining the precise loca­lization of a solid, well circumscribed coin Iesion with or without central calcification, the percu­taneous needle biopsy was performed to esta­blish a precise diagnosis of hamartoma. Al patients were operated and the post­operative pathohistological examinations of re­section specimens were done. Results are presented as mean ± s.e.m. Results Pulmonary hamartomas were found in 24 ( 65 % ) male ( age range 21-65), and 13 (35 % ) female (age range 18-68) patients. As evident from Figure 1, hamartomas are more common in males and in older age groups. The location and the size of hamartomas were identified on the basis of chest X-ray images. The majority of our patients' tumors were located in the pulmonary parenchyma, with no predilection far any one lobe. There were 9 hamartomas located in the right upper i'Zl o 'i' o' .. Figure l. Age and sex distribution of pulmonary hamartomas in 37 patients. Radiological presentation of pulmonary hamartomas lobe. 2 in the right middle lobe, 9 in the right lower lobe, 7 in the left upper lobe, 9 in the left lowcr lobe. ancl in one patient hamartoma wus s1jread in the right upper and the right middle lohes. Figure 2. A PA chest view. Hamartoma of the right lung. (Arrow) On X-ray films, a hamartoma is usually ima­ged as a sharply demarcated coin lesion of ovoid shape (Figure 2 and 3). In hamartomas with non-homogeneous struc­ture calcifications are characteristic (Figure 4 and 5). Soljacic H et al. Of two diameters, transverse diameter was taken into account, as is usual in literature. From the results shown on Table 1, there was no correlation between the size of tumor and patients' age. Table l. The size (x ± s.e.m.) of pulmonary hamarto­mas in 37 patients in relation to age. Age No. of patients Tumor diameter (mm) up to 19 2 (5.40%) 51.00±31.00 20-29 3 (8.11 %) 22.66±4.81 30-39 3 (8.11 %) 16.67±3.28 40-49 7 (18.92 %) 21.14±2.17 50-59 17(45.95%) 25.05±3.41 60-69 5 (13.51 %) 26.60±9.62 As shown on Table 2, the most hamartomas were 10-29 mm in diameter. The vast majority of hamartomas were remo­ved by enucleation, and only in two cases lobectomies were done. Discussion In our own series pulmonary hamartomas were mainly diagnosed in patients between the fourth and seventh decades (Figure 1). These data are in accordance with many others.6• 7 · 12 As in our study, only few cases were reported in younger persons. 13 A greater prevalence in male patients shown in our material (males vs. females, 2: 1) was also reported by others,4• 7· 14 with a varia­tion in preponderance from 2 : 1 to 3 : l. It is not known whether this difference is real or due to a higher frequency of pulmonary diseases in males, with a discovery of hamartoma being incidental.7 The usual size of hamartomas ran­ged between 20 and 40mm,6• 7 rarely exceeding 8 100 mm.6• According to our data, the smallest lesion was 3 mm, the largest 82 mm, while the most usual size was about 10-30mm (Table 2). 8 Although benign, hamartomas may grow, but the growth of tumor is usually slow. Hansen et al.7 recorded growth in 48 % of follow up cases. Although in our cases a correlation between the age and size of tumor was not recorded (Table 1), a positive correlation between these two parameters has been shown by Hansen et al.7 Studying some differences between benign and malign lesions of the lung, Zwirewitz et al.9 reported that the mean diameter of malig­nant lesions is usually significantly greater than that of benign nodules. So, large cell carcino­mas showed the greatest overall mean size (57 mm ± 23) and hamartomas the smallest (17mm ± 11). Localization of tumor in our patients mainly in pulmonary parenchyma corresponds to that observed by severa) authors.5 • 7· 15 While Too­mes et al.5 mentioned that the right upper lobe was the most frequent site of involvement, in our patients hamartomas were seen in all parts of the Jung, with no predilection for any lobe. The asymptomatic nature of these tumors, as registered in our patients, was not surprising because -owing to their localization and size -they could rarely produce a compression of vita! structures to give any symptoms. The preoperative differentiation of hamarto­mas from the nodules of malignant origin is an important task for a radiologist. The rapid progress of radiological diagnosis in combina­tion with transthoracic needle biopsy has impro­ved the possibility of proper diagnosis of hamar­toma.7 In the past decades thoracic needle · 16 aspiration biopsy, as a specific and highly sen­sitive procedure, has been considered a method of choice for confirming the diagnosis of hamar­toma. The accuracy of this method according to Hansen et al.7 was 85 percent, while in our own material it was about 80 percent in patients with peripheral localization of hamartoma. As Table 2. The incidence of pulmonary hamartoma according to tumor size. Transverse diameter 0-9 10-19 20-29 30-39 40-49 50-59 60 or more (mm) No. of patients 1 15 11 6 o 2 2 % 2.69 40.54 29.73 16.22 o 5.41 5.41 Radiological presentation of pulmonary hamartomas mentioned above, the diagnosis of hamartoma in ali our cases was proved by postoperative histological analysis. A precise preoperative radiological diagnosis with microscopic verification enables the sur­geon to choose an adequate type of resection. If the tumor is well circumscribed, the surgeon will attempt to use local resection or excision. This approach was mainly used in our patients. However, if that was not the case, the method of choice would be lobectomy (Figure 4 and 5). According to some opinions, hamartoma, al­though benign tumor, must be operated immediately after radiologist's diagnosis to re­duce tirne delay and diagnostic errors to mini­mum .17 Another reason is to minimize the possibility of tumor growth or its malignant 5• 10• 18 alteration. On the contrary, according to Hansen et al., 7 since most hamartoma can be diagnosed radio­logically with high accuracy, surgery is required only in the cases of continuous expansion of the tumor, pulmonary symptoms and when malignancy cannot be excluded. If no tumor growth has been observed, surgical treatment of hamartoma is not necessary, although there is a need for continuous follow up of those patients. References l. Robbins SL. Neoplazme. In: Patologijske osnove bolesti. Zagreb: Školska knjiga, 1987: 118-61. 2. McDonald JR, Harrington SW, Clagett OT. Ha­martoma (often called chondroma) of the lungs. 1 Thorac Surg 1945; 14: 128-43. 3. Rubin M, Berckman J. Chondromatous hamar­toma of the lung. 1 Thorac Surg 1952; 23: 393. 4. Blair TC, McElvein RB. Hamartoma of the lung. Dis Chest 1963; 44: 296-303. 5. Toomes H, Delphendahl A, Manke HG, Vogt­Moykopf l. The coin lesions of the lung. Cancer 1983; 51: 534--37. 6. Deodato G, Messina S, Chisari A, Nicolasi M, Piccirillo P, Compagnone S, Tornambene F, Torre T. Hamartochondroma of the lung. Apropos 11 cases. Minerva Chir 1991; 46 (19): 1019-25. 7. Hansen PC, Holtveg H, Francis D, Rasch L, Bertelsen S. Pulmonary hamartoma. .l Thorac Cardiovasc Surg 1992; 104: 674--8. 8. Stulz P, Dalquen P. Unusual localization of a pulmonary hamartoma. Case Report. Thorac car­diovasc Surgeon 1991; 39: 55-7. 9. Zwirewich CV, Veda! S, Miller R, Muller LN. Solitary pulmonary nodule: High resolution CT and radiologic-pathologic correlation. Radiology 1991; 179: 469-76. 10. Hayward RH, Carabasi J. Malignant hamartoma of the lung. 1 Thorac Cardiovasc Surg 1967; 51: 457--66. 11. Cavin E, Masters JH, Moody J. Hamartoma of the lung. 1 Thorac Surg 1958; 35: 816-20. 12. Bateson EM. So-called hamartoma of the lung: a true neoplasm of fibrous connective tissue of the bronchi. Cancer 1973; 31: 1458--67. 13. Oldham HN, Young WG, Sealy WC. Hamartoma of the lung . .l Thorac Cardiovasc Surg 1967; 53: 735-49. 14. Koutras P, Urschel HC, Paulson DL. Hamartoma of the lung . .l Thorac Cardiovasc Surg 1971; 61: 768-76. 15. Fudge TL, Ochsner JL, Mills NL. Clinical spec­trum of pulmonary hamartomas. Ann Thorac Surg 1980; 30: 36-9. 16. Hamper UM, Khouri NF, Stitik FP, Siegelman SS. Pulmonary hamartoma: diagnosis by transtho­racic needle-aspiration biopsy. Radiology 1985; 155: 15-8. 17. Vraneš N, Slobodnjak Z. Kirurško lijecenje ha­martoma pluca. Lijec Vjesn 1989; 111: 461-2. 18. Karasik A, Modan M, Jacob CO. lncreased risk of lung cancer in patients with chondromatous hamartoma . .l Thorac Cardiovasc Surg 1980; 80: 217-20. Radio! Oncol \994: 28: 10-4. Sld."'-'effett8 alid tornplicntions of percutaneous tr.nnslum1md angioplasty of the subclavian artery. Analysis of 55 cases Andrija Hebrang. 1 Josip Maškovir, 2 Ivan Otinkovic1 1 Cliuical /-losf)itnl ,,Mc/·/rnr«, Zhgrl?h, O·oatiat 2 Cliuical /-lvspital Split, 5iplit, Croatia j i/1 ,1 /'1/,1/ 1/1/1·/r•', The complications {//fll side-cffet'ls vj" perc't//1111t!tJi1.hra/i.1•/i11/1hl11l m1gipla.'ll,Y ( /?TA) of th. su/Jclaviu11 artery are presented. /11 thc g1·011J1 of' 55 pali'e11tN· 46 '(t'i3.6 %) /u{(/ .1·teno.vi,t a,ul 1ti11e (16.4 'ľJ) had lhe obliteratio11 of the .rnhclavian arte,y. 7'1111 /){(ffw/ogicu/ changes were C'c\"/(//1/ished by clinical elami11a1io11 and a11giography of' thc' s11;n-actUrtt1I i1e,\·,1'e/,v. The 1mtie111,1· ,vere 38-68 )'l!llr.\· oh/ (111ea11 dge 57 years). The jirst grouJJ cOirlfJf'i.\'ing 30 /?atie11t.'I did not ret·eive hep11ri11, while the other 25 pa/ienls receil'ed 5.000 1111it.1· of heparin hy c'dlhi!ti!r im111ediutely before dilatation. The procedure wa.1· .(·iiccess/ii/ in 48 ou/ of' 55 /Hllients (87.3 %). The complications and side-effects were regis1ered 'ii1 'i'J prltienls (30.9%). Among the most common were: transient thoracic pain (6 patients, 10.CJ"lo), ,,.;;1sito1/ ischemia of' the .finger.,· in 3 (5.5 %), and one groin hematoma (1.8 %). The symptoms of' tra11sitory vertebrohasilar i11sujfitie11cy were registered in seven patients (12.8 %), in four of them vel'llgo and in three headache. There were no signifficant differences in the number of complications bet1veen the gro11p treated with heparin (7 patients, 28 %) and the group without heparin treatment '(!O patien,ts, 33,4%). We cnnclude tha1 the complications and sideeffects of PTA of the subclavian artery are less common then in the operative treatment, and point out PTA as the method of choice in tire trcatment of the .1·11bcla11 ian artery stenosis or obliteration. The use of heparin does not influence lhe incidence of complications. Key wonls: Subclavian artery; angioplasty, PTA; complications, balloon -adverse effects; heparin usc Introduction Percutaneous transluminal angioplasty (PT A) of the subclavian artery is established as a Correspondence to: Prof. Andrija Hebrang, MD, PhD, Department of Radiology, Clinical Hospital »Merkur«, Zajceva 19, 41000 Zagreb, Croatia. UDC: 616.134--007.271-089 method of choice for the treatment of stenoses proximal or distal to the origin of the vertebral artery. Among other authors, we have reported on very good long-term results during a period of 6 to 48 months in 52 patients. 1 Until now, many details about the technique have been published.2-4 Meanwhile, the risk of complica­tions during the dilating of stenoses near the Pe)·cU·r'l!IHeou.\· lr11)1.,/ui1i/Ht!i tuigivp/a.l'/)1 nf lhe su/Jcf1ll'ia11 arlery \' ' Ol"i)iil\ •tlf llie,.Verh:bnll (ll·bcl,y .xl.t.. 1Altlurngii the p1ubl.l'r\1 (-)f ci'-cls!ling ,ihe til•igi11 ,of the ve1·tt?­b1·.il a1·M'y 1 -by ,1 I.M(lool"\, .,1th'€-te1· IH\s· · b0e11 dest:1·,ililutl,' th€11v1J1t12bt,.I ,11-t€1·y c,111 ht: olilst1·Lll;:­ted .a11d ,H./€ .yI11.pt1Jl'liii .r.vei-tebrtlbuailn,1; it1SLtf­fid@oy ctm npp,u1i-.. Ahm, thti:-dtlototim1 of prox11mily 1!;it-.xl .)lll4llt>c.,,CU11 \-it) 'l.i. S(i)Ultlt! ,()f distal .mbol..m • .iuoluding 1th. elt\l1Cllls111,of t,he brain tl11tiugh i\11:lt·tetwul t11·teI'y", -riiere t11·e ,i;o analyseli of' comµlict\itions i.11 gt·eot l'lltt,ili'S 11.1iJ0t·­ted in the lit.1-utute, Ht)re we,prcrnetit nli amnJy­sis of the 1id,f etfo\11. m1d, can;plit\1tiot1:i-,1t1ftet' ,PTA of the subelavitm ai-tei-y in 55 pntie11ts, 1, it :,p,1 nt I)• Materi11I nnd methods 1 , 1 \. " l \ l For this study we n11tdy,e.PPP.1 CDf subola,vian artery in 55 patients, 1perfo.nned,i,1. t..o ltliffure:tat centers. In ali cases the s,u.... indi.)atiou:;, touh• nique and follow-up proµedure 1';.iqre, use.,-The patients were 38-68 years okl (mean age, .7 ' years). 1 , . , , , ·. · li The indication for P'f;A. ;w.1s. stenosis pf.th-0 subclavian artery in 46 pu.tients,(183.6%), i111d an occlusion in nine putients (16.4.%). The main symptom registered before treatment was . brachial ischemia in ali .patients. Tl.ilftynine :· patients (70.9 % ) had symptoms of the. verne­brobasilar insufficiency like di;;tziness, ,ataxia, blurred vision or a combinat.ion of these 1 sym­ptoms. Clinical investi gatiorn;1 included ,blood pressure measurement ,on, both ar-ius, Doppler sonography and/or osci).()gJ"i,lfhY. iP.s ,1 ,Jqfinit.ve diagnostic method angiw;\rpph'{ of :lJ1. ,si1praaor-· tic vessel was perfo.1iljll,t;:.. · r/w :p,1\iWJ,lis ,w11.,11 ·'/l''i11i,-.,"'n present t e mtracrama h 1 ClfCU 1atmn an l1e ro e , of a stenosed subclavian art'c1\r'id'h/·ili/i1 \r\1igf1 t1on. cceptmg t e ru e t at un v t 1c vcrtc )r;i \1.i1'i\'" via1. at·tMy ot ni'lt11' iv1,mellt':11 tnigln t1ncl ol1lite­1;ttUiIDrli df th., cb1H1'mlt1ternl vd1·tebr1t1· ahe1·1 were e1'cluded tro111 fu1·NwI· pt·o.durn, '1-n tht tllrnly­z.ll group, •thc 9ttl11Clflis of thl'l .L1b\llavian ortei-y W,ls IOt;ated p1·oxlm11lly tCl thc origin of 1he , vet·t.l.ntl 111·teI·y ind27 pntients ( 49, l % ), CHLJ.il\g th€ .ubclnvian '!;tcal, sy1;tlrn1t1e with r'etrdg1'Htle hlood flow in th.: il[l.ilt1te1·al vertcbtal attcry. St1vno.es1 in ll110N1c1· l 9 ptltient. (:\4.5 % ) wete .locuted1 distally to thcl origii'1 of the vettebtul tll'tery . .l'{etrograde' verr.bral, flow was fouild in 1111 11ine p,lticnt with obliteration of the subcla­vi.n a11tery, · · ·nWic •utielt tl1e PT A techhique destribed in thcn,litoruttlre,q.-1 111 52 our of'.'i5 patie-nt tlie t1·,1hs­liemorul ,lppr(Jhdi was pe·,lformcd. In three pu•nti en!s with .cduded •femoral arteries PT A \Vasnl.!ondtwted via1 thc uxi!lury atrery. Ahei-pas:;ing-the stenC-lsis or occlusion with ·a 160-centimeternlong qui'de wire', the-b11l10011 carheter was intro­duced: The witlth of.ilhe balloon,· rn11ged bet­,,voen .8 and 1U 1n1illimetcrn, depencli11g on thediameter,of the non-affected part of the subcla•vian artury. The lehgth of the bnlloon was1 <2• tontl,!Q;entimeters an'd the pressure of 5 to :711alntp.s0 pheres wa. used. A l60•centimeter c/tti'de 'wrte)Nas·l
prevenr the balloon frorrldnoo­vingi•Tlie first gro'up of 30 patients dicl not 1,\ 1 receive heparin. The othcr 25 patients weren given ,S:000 units of Ht!ptirin throught angi6i'>l°,.­ 1 1, 1 · .ty catheter»b€fore clilatation. Aftel'clilatationn J')rncedurel and1 balloon emptying, Hle cathet.rn was withd'rHwnland followaup ane.iC1gt-\iphy per­ 1 l.•ll'.lilli:d1.,·/\llls•i·d'-·-cfT,·, l:, ,md ut11iq,U1 t1lin11'. 1\,·1,· rcgi,lcr,;d duri,'1µ. 2-1 11,>111·. ,ili1·1 111nced111<· Rc.ult. " 1 1 '' 1 1 ,· li!li<."' ,; ', Technical .uccc.,, i1rn,,11rc• ·Jiatd.1 -.,hr ! 'j'>11 1l1cuure '\ '' 1,_·..._J:1!111 ll 1! \ w,as estahlishcd hy lt1llo_w-1i1t• 11r1_1•.11)graphy and 1'\ j\ 1 1· (\1-'1•l!l 1 11 1• hy lhc 11JL'Jsure11w11t ol, h!o,.1 J pressure on the ' a\ltcicd-.iJ. ,111;/ ;111n1 11::: contralateral hand. An ' hi/;;;aI p..'.u). g.adient between both arms ! l !'d, '! ,{ ti , 1 u % was considered as a good res uit.n LI '11? Thc 'tollow up angiography of successfully dila­ 1 artery should not be obliter,ltdl.· h}1 i'l'.1 . . i'. ! :1, i.i,!_ 1;1 catheter, one patlent w1th stenosts of 1 h,. subcl;1-ted arteries immediately after the dilatation ' • · .i Hebrang A et al. Figure la. Significant stenosis of the left subclavin artery proximal to the vertebral origin. showed the normal lumen or the remaining narrowing not greater tban 30 % of the lumen (Figure la, b). Using these criteria, we found satisfactory technical result in 43 out of 46 patients with stenosed (93.5 % ) and in five out of nine patients with occluded subclavian arte­ries (55.6%). Side-effects and complications in the exami­ned group were registered in 17 out of 55 patients (30.9 % ). Seven out of seventeen side- Figure lb. After PTA normal lumen of the subclavian artery is presented. effects and complications occurred in the pa­tients treated with heparin and ten in the pa­tients without this treatment (Table 1). Severa! different side-effects and complica­tions are presented in our results. Local pain in the site of stenosis during dilatation occurred in six patients (10.9 % ). The pain was of short duration and did not require therapy. A transi­tory headache and vertigo occurred in three and four patients, respectively. The distal brac- Table l. Types and number of side-effects and complications in heparin treated and untreated groups during PT A of the subclavian artery. Heparin treated Heparin untreated Side-effects & (25 patients) (30 patients) Tota! complications N % N % N % Thoracic pain 2 8.0% 4 13.3% 6 10.9% Headache 1 4.0% 2 6.7% 3 5.5% Vertigo 2 8.0% 2 6.7% 4 7.3% Hand Ischemia 1 4.0% 2 6.7% 3 5.5% Groin Hematoma 1 4.0% o l 1.8% Tota! 7 28.0% 10 33.4% 17 30.9% Percutaneous transluminal angioplasty of the subclavian artery hial ischemia in three of our cases appeared as transitory pain in the fingers ( duration half to one hour). The pain disappeared without treat­ment. One groin hematoma was registered 24 hours after treatment in a patient who received heparin during PTA procedure. The hematoma had eight centimeters in diameter. After sym­ptomatic therapy, hematoma disappeared in ten days. In total, 17 out of 55 patients showed one of the side effects or complications ali of which were transitory. Taking in to account ali compolications, there were no significant diffe­rences between the heparin-treated and untrea­ted groups of patients (p< 0.001). Discussion PT A of the subclavian artery is a well establis­hed procedure which carries a low risk of 6-S complications in comparison with surgery. The incidence of complications during and after surgical treatment of subclavian stenosis inclu­des pneumothorax, thrombosis, chylothorax, pleural effusion or infection in 23 % of pa­tients. 9 In the recent history the complications of PTA has not been clearly defined. For a long time the radiologists have been hesitant to use PTA to treat the great supraaortal arteries for the fear of possible embolisation of the brain and cerebral ischemia during balloon in­flation.3· 4 Especially the risk associated with the treatment of Jesions proximal to the verte­bral artery origin has been pointed out. Ip the beginning indications for PTA included stenoses of the subclavian artery located distally to the vertebral artery, or stenoses in patients with reverse blood flow in the vertebral artery, which prevents distal vertebral embolisation. Later reports indicated that after PT A of the subcla­vian stenosis antegrade flow in vertebral artery is delayed for severa! seconds to severa! minu­tes, which functions as a protective mechanism against distal embolisation in proximal situated subclavian stenoses. 10 The next problem was transitory occlusion of the vertebral artery du­ring balloon inflation. Vitek showed that such occlusion had no influence on the vertebral circulation. 5 Our results show three kinds of complica­tions. The first one, transitory thoracic pain in the dilatation site is well known during the treatment of other arteries. The second group of complications included headache and vertigo as the sings of transitory vertebrobasilar ische­mia. These symptoms occurred in seven pa­tients, and ali of them had stenoses near the vertebral origin. Probably, the symptoms were caused by the inflated balloon over the verte­bral origin during the procedure. Although the symptoms of vertebrobasilar insufficiency were transient, we emphasize the importance of an­giographic analysis of ali supraaortal vessels before therapeutic angioplasty. The obliteration of the opposite vertebral artery may cause significant vertebral ischemia due to temporary occlusion of the only vertebral artery. The possible damage of the plaque near the verte­bral origin, or rupture of the wessel, must be avoided by the long guide sited deeply in the axilar artery during the dilatation procedure (Figure 2). The third group of complications included distal ischemia of the fingers and groin hemato­ma. The general opinion is that the embolisa­tion of distal arteries can be avoided using a systemic heparinisation. On the other hand, heparin can cause a higher incidence of groin hematoma. Taking into account the possible risks of systemic anticoagulation, especially in patients with !iver disease and thrombocytope- Figure 2. During catheterisation a long safety quide is introduced deeply into the axillary aftery. ffrbraiig !\ ffl al. nir, 11 some <1uthors did not use hep.m-in.n4• 12 Our results show no diffl'lrencf:l \:1etWP!:ll1 the grou.p · of 1 heparin tre;:1ted <1nd tlw group .{n.1ntr6<1ted' potients. Tile only side-effec. rela.ed to 'the 4sd of hepm-i11 w.s <1 case o. .r9.n hern<1torn<1. ' {n counclusion, we sugges.t .fTA ot ..e ..-.­cl;:1vi;:1ri . 4ftery <1s <1 met\10,\:l of c.w,\c. for .J;ie tre'.\.,.ateQ r,rox\ma\jy, OJ rtffi.llt Of stenoses c\ist.l1y fo the origin of tpe vertebrn\ artery. recc1use of tbe transjtory sigqs of the vertebr()­frsi\er insuffi./ency, the cir.ul.tiqp il. <1\l s.­pr.4'ortal arteries h<1s to be an.!Y..tj p,.fore <1ngiop!asty. We did l)Ot pave il/1Y p.tieqt. :-vjfh steooses located in the orig/p of the veffeqrat artery, b11t s,01n.e quth9rs shqwed t11at tlw· fr.c­,t.ure of th,,e jn tpqt site /IlqY C.... e pJaqt,1me ob)iteration of the yertebral art,ery .13 finaifr, the .e:verity qr .dence of complic<1ti()ns in the gT'Nf? of q,ep,af/TT treated and the g.oup of \W9'.e\l;teq p11tiel)ts ar,enaccwding ,to our 1esults, ,..inci­ ,,the same. Refei:ences l. 1-lebrang A. Maškovic J, and Tomi!c .B. ,Percuta­neous transluminal angiopli!.W ,\:Jf \.e -.\l.qlavian arteries: Long-term resu1ts 1n 52 pa\ients. AIR 1991; 156: 1091-4. . , ,,. 1 " ',,. 2. Mot<1rjame A, Keifer JW, and Zuska AJ. Percu­taneous trai;i.\µminal angiopl.&ty of the brachio­cephalic arte.ies. AJR 1982; 138: 457-62. 3. Gordon RL, Haskell L, Hirsch M, Shifrin E,Weinman E, and Rom,tnoff H. Transluminal dila­ ta,non o. t.e sul;>.l,nn artery. Cardiovasc Jnter­.i...avia ,. 1 veryt, 1f!',1!o(, 1..7; .: 14-9,­ . 4 .. Vi.e1' 1,J,, J,epar,/,Kr.J.ent of R,_adwl-ms. 1 -4 During tpe e.wnin.t,ion the mentioned ano­maly coulg b,e st;1spected after careful inspection of chest -'\-\-.. an, q the completion of clinical and laboraJoi;y results. The CT sc;anning of the chest is very helpful in comple.iog the work-up. A defioitive diagno­sis and tl;le most useful clinical information are obtained by means of digital subtraction angio­graphy and catheterisatioo with blood gas ana­lysis. Case report A 31-year old male was admitted to hospital for pains in the stomach, retrosternal opprts­ Borkovic Z et al. Figure l. Anomalous venous drainage of the right lung (arrows). sion and tachyarrhythmia until now healthy. The disturbances began with generalized weak­ness, retrosternal sensations, feeling of sickness, and pains in the epigastric region. Cardiac techyarrhythmia is objectivised. The laboratory findings were normal. ECG: Atrial fibrillation with absolute arrhyt­hmia 137 BMP, incomplete right fascicular block. After intravenous administration of 280 mg of Propafenon (Rytmonorm) a stabile conver­sion to sinus rhythm is achieved. Chest x-ray: Asymmetrical chest due to smal­ler right side and with narrowing of the interco­stal spaces of the same side. The right hilus is smaller. The pulmonary vascular ramification is rarified and irregular in the lower half of the right lung. A vascular shadow originating in the middle pulmonary field on the right side direc­ted medially and distally reaches the diaphragm. Normal finding in the left lung. The configura­tion of the heart and aorta is also normal (Figure 1). Cardiac echosonography: Normal valvular configuration, and right pulmonary regurgita­tion. The contractility and thickness of the myocard and the measures of cardiac cavities were normal. Paracardially on the right, a vas­cular structure was identified, indicative of a possible pathological communication. No signs of possible intracardial shunt. DSA: By means of digital subtraction angio­graphy the pulmonary artery is visualized inclu­ding its tributaries with normal arborisation on the left. Right pulmonary artery hypoplasia is found with a few irregular intrapulmonary tribu­taries, with accentuation in the proximal part (Figure 2). In the venous phase on the left, a normal pulmonary vein inflow into the left atrium is seen. On the right side a wide abnormal vein draining the middle and inferior lung portions into subdiaphragmatic part on the inferior v. cava is seen (Figure 3). CT: An altered pulmonary structure and an abnormal pulmonary lobation are found on the right. The right hilum is small in size. An anomalous pulmonary venous inflow into azy­gos vein is seen on the right side. A wide anomalous pulmonary veins is seen passing between upper and lower pulmonary lobe extrapleuraly, and is directed medially to the inferior v. cava. The structure of the leaf lung is normal (Figure 4). Right cardiac catheterisation: The pressures in the pulmonary circulaare within normal li­mits. Scimitar syndrome and partial venous flow - t':"·JRM-:'i :t: 1 Discussion Figure 3. DSA of the Jung -venous phase -Anoma­lous pulmonary venous drainage into the inferior v. cava (arrow). Oxymetry: Elevation of the blood oxygen saturation in the inferior v. cava of 1,56 vol % which persists, although slightly decreased, in the right ventricle and atrium and in the pulmo­naty artery. Systemic blood volume per minute was 8,600 L, pulmonary blood per minute was 13.5 L -a surplus of 4.9 L of blood per minute can be deduced, i. e. a relation of 1.5 + 1 in benefit to pulmonary v. systemic circulation is established. Scimitar syndrome is a congenital anornaly of the pulmonary venous circulation in which an anornalous pulmonary vein drains to tbe inferior caval vein below the diaphragrn. This malformation is accompanied by right pulrnonary arterial hypoplasia including its in­trapulmonary tributaries, with anornalous pul­monary structure and lobation, including the alterations of bronchial arborisation. 1-7 In our case, we found scimitar syndrorne associated with abnormal venous drainage of the right upper pulrnonary lobe into the azygos vein. The lower pulmonary lobe is drained into the inferior v. cava. This anornaly features 0.4­ 3 0.7 % of ali congenital heart anomalies.1­ The anornaly is usually discovered inciden­tally on routine chest x-rays; in patients with dyspnoic symptomatology it is discovered du­ring diagnostic work-up. Definitive diagnosis is estabilished by means of chest x-ray and CT. An angiographic exami­nation with presentation of thoracic arteries and veins with a typical finding of right pulmo­nary artery hypoplasia also including its tributa­ries, and the presentation of an anomalous vein definitely confirms the diagnosis. Surgical correction of this anomaly which corresponds to an ASD with left-to-right shunt is usually not neccessary. In case of more prominent shunting, the anomalous vein is sur­gicaly implanted in the left atrium. In our case, the consulting heart surgeon declined the neccessity of surgical correction of the anomaly, and suggested further periodical follow-up examinations. Surgical correction should be reestimated in the case of worsenned findings. References l. Godvin JD, Tarver RD. Scimitar syndrome: Four new cases examined with CT. Radiology 1986; 159: 15-20. 2. Olson MA, Becker GJ. The scimitar syndrome: CT findings in partial anomalous pulmonary venous return. Radiology 1986; 159: 25-6. Borkovic Z et al. 3. Schatz SL, Ryvicker MJ, Deutsch AM, Cohen HR. 5. Julsrud P, Fellows KE. Anomalous pulmonary ve­ Partial anomalous pulmonary venous drainage of nous connection. In: Abrams HL ed. Abrams HL the right lover lobe shown by CT seans. Radiology ed. Abrams angiography: vascular and interventio­ 1986; 159: 21-2. nal radiology. 3ed. Boston: Little Brown, 1983: 869-94. 4. Pennes DR, Ellis JH. Anomalous pulmonary ve­ nous drainage of the left upper lobe shown by CT 6. Thorsen MK, Erickson SJ, Mewissen MW, Youker seans. Radiology 1986; 159: 23-4. JE. CT and MR imaging of partial anomalous pulmonary venous return to the azygos vain. J Comput Assist Tomogr 1990; 14: 1007-9. Radio/ Oncol 1994; 28: 19-22. Ultrasonogram of gallbladder perf oration Nikola Ivaniš, Ivica Kraus, Mira Sever-Prebili<\ Nada Brncic-Dabo, Relja Peric, Aleksandar Vcev Department of Interna! Medicine, University of Rijeka, Croatia During the hospitalization of a Jemale patient suffering from acute calculous cholecystitis the diagnosis of gallbladder perforation had been established. The perforation was suspected on the basis of clinical observation and laboratory tests, and the diagnosis established by conventional ultrasound examination. Emergency surgery confirmed the diagnosis of gallbladder perforation. Eight days after surgery, the patient was discharged from the hospital. Six months later, she was found to be symptom free. The conventional ultrasound proved to be an excellent method for following the course of severe acute calculous cholecystitis, which also enables early diagnosis of perforation. "Hale sign" in the gallbladder wall is important sign of perforation. Key words: cholelithiasis -complications; gallbladder-ultrasonography; perforation; gallbladder perforation-gallstone-ultrasonic "hole sign" lntroduction Acute and chronic cholecystitis are distinguish­able both clinically and by the use of ultrasono­graphy. Acute cholecystitis is a disease of middle-aged and elderly individuals. Obese persons and dia­betics are especially prone to contract the disea­se. It is a disease of very frequent occurrence, and under certain conditions and accompanied by the risk factors of lithogenesis it is on the increase, so that today it represents 10 % of ali gallbladder diseases. In 90 % of the patients it occurs in connection and as a consequence of gallstones, only in whereas 10 % of the patients the inflammation is not associated with gall­stones. Correspondence to: Nikola lvaniš, MD, V. M. Lenca 48, 51000 Rijeka, Croatia. Chronic cholecystitis is etiologically (in more than 60% of the patients) most frequently associated with gallstones. It only seldom occurs as a progression of the acute into the chronic form. A frequent cause of the acalculous form of chronic inflammation is sepsis, cholesterolosis, adenomyomatosis and congenital anomaly of the gallbladder. The sonographic signs of acute cholecystitis are: sonographic Murphy's sign, thickened gall­bladder wall, and intraluminal echoes. Other signs, although less dependable, are: distended gallbladder, sonolucency of the wall, and irregu­larities of the outer margin of the gallbladder. The calculous cholecystitis is characterized, besides other ultrasound signs, by solitary or multiple stones with an acoustic shadow, for­ming -with other changes -the characteristic UDC: 616.366-003.217 .7-06:616.366-007.43 WES trias (wall, echo, shadow). 1 Jvaniš N et al. An important ultrasonographic sign of the gallbladder perforation is the pericholecystic fluid accumulation.2·7 This finding, bowever, is not specific.3· 5 In recent times the so-called "bole sign" in the gallbadder wall of tbe patient with gallbladder perforation has been descri­bed. 8· 9 "Hole sign" is sonographic finding of a bole in gallbladder wall. Case rnport This is a report on a 58-year-old female diabetic hospitalized at out Medica! Clinic with right upper quadrant pains, nausea, vomiting, fits of sbivering and fever up to 39 °C. Tbe complaints had begun two to three days prior to hospitali­ zation, after a meal of ricb food. Tbe patient had a two-year history of gallstone disease. The night after admission sbe experienced pain in the right shoulder, and on the following mor­ning signs of Iocalized peritoneal irritation in tbe right upper quadrant appeared, with febri­Iity up to 39.6 °C. Laboratory tests sbowed accelerated SE 62/90, leukocytosis of 16.9 with deflection to the Ieft, and blood sugar 8.2. Ali otber findings were normal. On the emergency ultrasonogram of the abdomen a small quantity of free fluid was seen along tbe rigbt lateral cavity. Ali this was interpreted as an acute cholecystitis with Iocal peritoneal irritation. Du­ring the following three days the patient conti- Figure 2. Site of gallbladder perforation (left), and unrestricted bile in the right lateral cavity (right). nued to feel pain in the right upper quadrant with febrility. An emergency scan of the perito­neal cavity was made. Intensive antibiotic tbe­rapy was applied. On the eighth day of hospi­talization the patient suffered sudden intensive pain in the right upper quadrant and right shoulder with evident local rigidity, but this tirne also accompanied by pain in the right lower abdomen, and very poor peristalsis. Per­foration of the gallbladder was suspected. An emergency ultrasonogram of tbe abdo­men was made, which revealed free fluid along the right lateral cavity. Tbe gallbladder was sbown witb thickened walls and stones, and a "hole sign" in the wall of the gallbladder corres­ponding to gallbladder perforation. In this way the ultrasound examination revealed tbe perfo­ration of tbe gallbladder which required emer­gency surgery. On opening the peritoneum, about two litres of bile mixed with fibrin platelets were remo­ved. A bole disrupting the fundus of tbe gall­bladder was found, from wich bile was leaking. In the gallbladder concrements were palpable, and the wall was extremely thickened. After preparation, antegrade cholecystectomy was performed. Tbe content subdiapbragmatically right and paracollically right was evacuated, lavage of tbe peritoneal cavity made, drainage implanted and abdomen closed. Ultrasonogram of gallbladder pe,foration 1, 1: 11 ! ' Figure 3. Unrestricted bile in the right lateral cavity. The pathohistological finding was: gallblad­der size 10 X 7 cm, wall thickness 1.5 cm, necro­tic mucous mambranes, with one fistula seen at the fundus. The postoperative course under the protect­ion of antibiotics was uneventful, and the pa­tient was discharged on the eighth day. Discussion In gastroenterology acute cholecystitis is a com­mon disease. In most cases an adequate therapy will be sufficient to cure the disease without any complications. In some instances complica­tions such as perforation of the gallbladder, pericholecystitic abscess and fistula in adjacent organs may develop. Ali these complications are the consequence of ischemia and necrosis of the gallbladder will. The perforation of the gallbladder may be localized or unconfined. Localized perforation is confined by the omentum or adhesion resul­ting from previous inflammations. Unconfined perforation is not so common, but accompanied by a mortality of up to 30 % . The hypovascula­rity of the gallbladder fundus makes it the most likely site of perforation. The acute perforation is usually the cause of generalized peritonitis. A usual consequence of the subacute gallblad­der perforation is the pericholecystitic abscess separated from the peritoneal cavity by adhe­sion. The chronic perforation into adjacent or­gans results in the creation of an interna! biliary fistula. Fistulation occurs as a consequence of the spread of the inflammation to the adjacent tissue and organs. The most frequent is the fistula of the gallbladder with the duodenum, and less frequently with the hepatal flexure of the colon, stomach, jejunum, and the frontal gastric wall. With 5 % of the patients a clinically asymptomatic biliodigestive fistula can be found on cholecystectomy in the case of chronic in­flammation of the gallbladder. Ileus is the consequence of the migration of concrements through the duodenum or through the fistula into the duodenum. The impaction usually occurs at the ileocaecal valvula. Through the routine use of ultrasound in detecting the etiology of pains in the right upper quadrant, it is possible in particular cases, to detect the complications of acute cholecysti­tis. As stated in the introduction, the ultrasound finding of pericholecystitic fluid is an important · sign in the diagnosis of gallbladder perfora­tion. 2-7 This sign, however, is not specific enough.3• 5 The most important sign is the "hole sign" in the gallbladder wall. 8• 9 When nonpulsatile, anechois tubular lesions are seen along the perforated gallbladder, diffe­rential diagnostics will suggest the consideration of a cyst, abscess, ascites and haematoma. The abscess will usually have fine irregular margins with some interna! echoes. 10 The cyst, ascites and haematoma will have no connection with the gallbladder and adjacent organs. A standard sign of a· biliary-enteric fistula is usually pneu­mobilia. The echogenicity of the fistula can be identified because of its reflexive lumen or content. The diagnosis of the gallbladder perforation may present some difficulty as its symptoms and signs are hardly distinguishable from those of the acute cholecystitis without perforation. There are no Iaboratory findings indicating gall­bladder perforation. The methods of conventional radiology sel­dom yield valuable data on gallbladder perfora­tion. In recent years ultrasonography has pro­ Ivaniš N et al. ved very useful in the preoperative diagnosis of gallbladder perforation. 8 Helpful signs have been found to be the 7 accummulation of pericholecystic fluid,2-and the most useful "hole sign" which is very spe­cific.11 The presence of the pericholecystic fluid alone is not specific enough, as it may accom­pany also the inflammation of adjacent organs such as the peptic ulcer, pancreatitis, abscess 5 and peritonitis. 3• The case presented is a female patient whose gallbladder perforation had been detected by means of the ultrasonographic examination alone in the course of an acute calculous chole­cystitis; the diagnosis was confirmed by conse­quent surgery. Ultrasound examination is considered very useful in the cases of suspected gallbladder perforation. Especially the "hole sign" is the most helpful ultrasonographic sign, because in combination with other ultrasound signs of acute cholecystitis it indicates subacute and chronic gallbladder perforation. References l. MacDonald FR, Cooperberg PL, Cohen MM. The "WES" triade specific sonographis sign in gallstones. Gastrointestinal Radiology 1981; 6: 39­41. 2. Berman AB, Neiman HL, Kraut B. Ultrasono­graphic evaluation of pericholecystic abscess. American Journal of Radiology 1979; 132: 201-4. 3. Crade M, Taylor KJN, Rosenfield AT et al. Ultrasonic imaging of pericholecystic inflamma­tion. JAMA 1980; 244: 708-10. 4. Deitch EA, Engel JM. Ultrasonic detection of acute cholecystitis with pericholecystic abscess. Am Surg 1981; 47: 211-4. 5. Madrazo BL, Francis L, Hricak H et al. Sonogra­phic findings in perforatio of the gallbladder. American Iournal of Radiology 1982; 139: 491-5. 6. Sty JR, Starshak RJ, Gorenstein L. Gallbladder perforation in a case of Kawasaki disease: Image correlation. J Ciin Ultrasound 1983; 11: 381-5. 7. Takada T, Yasuda H, Uchiyma K. Pericholecystic abscess: Classification of US findings to determine the proper therapy. Radiology 1989; 172: 693-5. 8. Chau WK, Na AT, Feng TI et al. Ultrasound diagnosis of perforation of the gallbladder: Real tirne application and the demonstration of a new sonographic sign. J Ciin Ultrasound 1988; 16: 358-60. 9. Chen JJ, Lin HH, Chiu CT et al. Gallbladder perforation with intrahepatic abscess formation. J Ciin Ultrasound 1990; 18: 43-5. 10. Doust BD, Quiroz F, Stewart JM. Ultrasonic distinction of abscesses from other intraabdominal fluid collections. Radiology 1977; 125: 213-5. 11. Chau WK, Wong KB, Chan SC, Na AT, Chan S, Wang JS, Wong CM. Ultrasonic "Hole Sign": A Reliable Sign of Perforation of the Gallbladder. I Ciin Ultrasound 1992; 20: 294-9. Radio/ Oncol 1994; 28: 23-5. Calcaneal fracture and peroneal tendons injuries: CT analysis ­case report Krešimir Cavka, 1 Walter Cereda, 1 Lorenzo Imburgia, 1 Luigi Taddei2 1 2 Department of radiology, Department of surgery, Regional Hospital Beata Vergine, Mendrisio, Switzerland A case of a 57 year old patient with tabor accident is presented. CT examination of the foot was done immediatly after routine radiographs. CT showed fractures of the calcaneus with lateral subluxation of the left peroneal tendons. The findings were confirmed by surgery. Key words: tomography, calcaneus, fracture, peroneal tendons, luxation, ankle, injuries Introduction Fractures of the talus and calcaneus may be difficult to evaluate using conventional imaging modalities. Since 1980, computed tomography (CT) has been increasingly used for examination of the musculoskeletal system. 1-4 CT of the ankle is introduced as an effective technique in the evaluation of calcaneal fractures. CT provided more information on acutely injured patients, and improved preoperative planning, postoperative follow-up, and detailed analysis of causes for chronic residual pain. CT further identified significant soft tissue injuries such as peroneal tendons displacement which 67 cannot be delineated on plain films. 5, , Correspondence to: Krešimir Cavka, MD, PhD, Ospe­dale Regionale Beata Vergine, Department of Radio­logy, Via Turconi 23, 6850 Mendrisio, Switzerland. UDC: 616.718.726-001.516-073.756.8 Case report A 57 year old patient was admitted following a la bor accident. He teli from the height of 5 m. Routine radiographs showed subluxation of the calcaneocuboid articulation and fracture of the calcaneus (Figure 1). Cavka K et al. CT examination of the foot was done imme­diatly after routine radiographs. The patient was studied on a GE-PACE scanner using a 512 x 512 matrix. The examination was done in supine position of the patient. The scanning plane was parallel to the plantar ankle to the plantar fat pad, with 4mm spacing. The CT examination of the left foot evaluated the complete luxation of the talocalcaneal arti­culation with fracture of the sustentaculum (Fi­gure 2a). More caudal section showed subluxa­tion of the calcaneocuboid articulation (Figure 2b ). In addition, the suspicion of subluxation of the peroneal tendons (Figure 3) was made. The findings were confirmed by surgery. Du­ring the operation the surgeon found that the peroneal tendons had been completly dislocated anteriorly of the laterni malleolus. Reconstruction of the calcaneocuboid and talocalcaneal joints have been done (Figure 4). The peroneal tendons were fixated on the po­sterior part of the laterni maleollus. Discussion The foot and ankle are highly complex anatomic structures: there are at least 26 bones and 38 articulations in each foot.8 Figure 3. Most cranial section shows the lateral sublu­xation of the left peroneal tenclons (arrowheacls). It is not always possible with conventional radiogrnphic techniques to show foot pathology in the best way. The main advantages of CT for planning a surgical intervention are a clear assesment of: a) the size and number of fragments b) the size and displacement of the sustenta­cular fragment Calcaneal fracture and peroneal tendons injuries c) the presence of step and diastasis in the posterior facet.9 Injury of the peroneal tendons is one of the major complications of intraarticular calcaneal fractures, and bas been difficult to diagnose by conventional radiography. In their retrospective review of 24 intraarticular calcaneal fractures, Rosenberg et al. have found acute peroneal tendon abnormalities in 22 cases (92 % ) . 7 References l. Genant HK, Wilson JS, Bovill EG, Brunelle FO, Muray WR, Rodrigo JJ. Computed tomography of the musculosceletal system. J Bone Joint Surg (Am) 1980; 62: 1088-101. 2. Heger L, Wulff K. Computed tomography of the calcaneus: normal anatomy. AJR 1985; 145: 123-29. 3. Hubbard LF, McDermott JH, Garett G. Computed axial tomography in musculosceletal trauma. J Trauma 1982; 22: 388-94. 4. Solomon MA, Gilula LA, Oloff LM, Oloff J, Compton T. CT scanning of the foot and ankle: normal anatomy. AJR 1986; 146: 1192-203. 5. Bradley SA, Davies AM. Computed tomographic assessment of soft tissue abnormalities following calcaneal fractures. BR J Radiol 1992; 65: 105-11. 6. Rosenberg ZS, Feldman F, Singson RD, Price GJ. Peroneal tendon injury associated with calcaneal fractures: CT analysis. Radiology 1986; 161: 743­48. 7. Rosenberg ZS, Feldman F, Singson RD, Price GJ. Peroneal tendon injury associated with calcaneal fractures: CT findings. AJR 1987; 149: 125-29. 8. Solomon MA, Gilula LA, Oloff LM, Oloff J. CT scanning of the foot and ankle: 2. clinical applica­tions and review of the literature. AJR 1986; 146: 1204-14. 9. Heger L, Wulff K, Seddiqi MSA. Computed tomo­graphy of calcaneal fractures. AJR 1985; 145: 131­7. Radio/ Oncol 1994; 28: 26-33. Prognosis of patients with non-Hodgkin's Iymphoma (NHL), the influence of Kiel classification on survival Berta Jereb1 , Janez Stare2 , Gabrijela Petric-Grabnar1 , Janez Jancar1 1 The Institute of Oncology, Ljubljana, 2 The Institute for Biomedical Information, Medica! Faculty, University of Ljubljana, Slovenia The effect of treatment modalities on the survival of patients with NHL and the prognostic impact of Rappaport's and Kiel classifications was analysed with the multivariate Cox model. Between 1978 and 1986, 482 adult patients received their first treatment for non Hodgkin's lymphoma at the Institute of Oncology in Ljubljana. We compared a group of 317 patients classified according to both Rappaport and Kiel classification (Group K) with a group of 165 patients classified according the Rappaport classification alone (Group R). Group K was divided into subgroups of high grade or low grade lymphomas, which again were analysed separately. The Kiel group patients had 1.5 times better chances far cure than the R-group. Stage was significant for the predicting of outcome. Chemotherapy and radiation significantly improve the survival in the high-grade (K) group but do not seem to have any bearing on the outcome in the low-grade (K) group of patients. Key words. iymphoma, non-Hodkins; prognosis; Kiel classification Introduction In recent decades, considerable progress has been achieved in the management of patients with non Hodgkin's lymphoma (NHL). The biology of this disease with its multitude of biologic variations has become better under­stooa.1-10 New chemotherapeutic regimens have been introduced, enabling the treatment to be Correspondence to: Berta Jereb, Ph. D., M.D., Insti­tute of Oncology, Ljubljana, Zaloška 2, Slovenia. Tel.: ( + 386 61) 323-063 (ext. 37-17). Fax: ( + 386 61) 1314 180. more "individualized"11-18, i.e. adjusted to the aggressiveness of the disease.19-26 As a result, the survival has improved, mainly in the group of patients with highly malignant lymphomas.17 A number of new prognostic factors have been recognized. While the significance of some of these is undisputed ( extent of the disease, pri­mary site), there is stili some diversity of opi­nions concerning others: age, sex, histology of the tumor, its cellular proliferation and DNA 28 content.27• In an earlier report, we analysed patients with NHL by means of a multivariate model and have found sex, age, stage and some treat­ UDC: 61.6-006.441-036 ment methods to be of significance for the Prognosis of patients with non-Hodgkin's lymphoma outcome. We could also show the survival to have significantly improved during the long period of tirne under investigation. In that analysis, however, neither the primary site nor the histological type of the tumor were included among the variables.29 In this paper we report on the results of our analysis of a more recent group of patients, with these two variables included in the multivariate model. We aimed to find out whether Kiel classification serves us better in daily work with these patients. There­fore, no reclassification was attempted. We also tried to establish the effect of treatment methods on the survival in different groups of patients. The prognostic impact of Rappa­port's30 as well as Kiel classification31 has been evaluated separately. Material and methods Between 1978 and 1986, 482 adult patients had their first treatment for NHL at the Institute of Oncology in Ljubljana. Patients younger than 15 years, those with chronic lymphocytic leukemia (CLL) and those admitted for recur­rent disease were not included in the study. The extent of disease was assessed by clinical examination, biochemistry and blood status, chest X-ray, bone marrow aspiration of the iliac crest, and radionuclide scanning of the !iver and spleen. After 1980, the investigations also included an abdominal sonogram, or CT and bone marrow biopsy. For histological classifica­tion the Rappaport system was used before 1980, and an updated Kiel classification after 1980. The treatment approaches used during these two periods were different: in the earlier period, one drug or a COP combination (Cyc­lophosphamide, Vincristine, Prednison) was, as a rule, complemented by radiation to the bulky lesions. After 1980, CHOP (including also Adriamycin) combination was most often used for high grade NHL. Patients with low grade histology and stages I and II were treated by radiation, whereas those with advanced stages were often only observed and treated only if bulky lesions, and surgery for gastrointestinal tumors was more favoured after 1980 than before. Ann Arbor system was used for clinical staging throughout. 32 Our aims were: l. to find out whether the histological classi­fication system did influence the survival and disease free survival presumably owing to better adjustment of treatment methods to the biolo­gical behaviour of disease; 2. to find out whether the independent varia­bles significant for survival were the same in Group K (classified according to Kiel) and Group R (classified according to Rappaport); 3. to find out whether the variables significant for the survival of patients with high grade tumors were the same as for those with low grade tumors. Statistical analysis For each patient the following data were recorded for statistical analysis and used as independent variables: -sex: 245 males, 237 females -age at the tirne of diagnosis: between 16 and 89 years mean 55.6 median 58.0 -stage: stage I -117 stage II -147 stage III -76 stage IV -142 429 were classified as A and 53 had B symp­ toms. -primary site: nodal 250 extranodal 217 unknown 15 -with subgroups: symptomatic. Radiation therapy was applied to peripheral nodes Jereb B et al. mediastinum 26 abdominal 32 head and neck 75 skin 16 bone 10 gastrointestinal tract 88 other extranodal (breast 11, testis 6, spleen 7, soft tissue 6, central spinal 3, and ovary, kidney, uterus , parotis one each) 37 unknown 13 -histology: Rappaport's classification only (R-group): 165 nodular 20 diffuse 95 other 50 Kiel classification (K-group): 317 low grade 163 high grade 124 other 30 There were 174 cases classified according to both systems, and 31 could not be histologically classified. Table l. Treatment, combination of the 3 methods. -methods of treatment: chemotherapy, radiotherapy and surgery. The methods of first treatment are given in Table l. -duration of chemotherapy: < 6 months 6 months -1 year >1 year The data were statistically evaluated by survi­val analysis methods, the tirne from diagnosis until death being the outcome of interest. The survival curves were calculated according to Kaplan-Meier method.33 To reduce the number of potential prognostic variables to a manageable leve], we first did univariate analysis, subdividing the data by prognostic variables and comparing the survival curves by log-rank test. The variables which proved to be significantly associated with survi­val, as well as some other variables considered important by clinicians, were then included in Cox proportional hazards model34 which was used for the following two purposes: 1) to follow other prognostic variables when trying to confirm the connection between survi­val and histological classification, Number of patients Number of patients percent of patients percent of patients Chemotherapy/ Surgery/ /RT none mono MOPP COP CHOP other Tota! /RT none surgery Tota! no RT 20 o 36 40 21 155 136 19 155 72 26 36 32 20 32 <2000cGy 7 4 o 17 30 11 69 50 19 69 5 14 18 19 19 14 13 20 14 199 ;;a2000cGy 97 4 4 43 84 26 258 258 68 100 45 52 60 Tota! 142 28 4 96 154 58 482 385 97 482 Surgery/ChT none 113 24 3 80 121 44 385 80 86 83 76 80 14 97 surgery 29 4 1 16 20 14 25 17 21 24 20 Tota! 142 28 4 96 154 482 Prognosis of patients with non-Hodgkin's lymphoma 29 Table 2. Survival according to histological calssification. STATUS Histological Alive Alive Died Died classification no with of of sympt. disease NHL other causes Died of treatment Died of unknown causes Lost to follow- Tota! Kiel 127 23 112 5 28 9 317 66% 2 NoKiel 12 3 21 4 165 34% Tota! 25 187 5% 39% 25 8 49 13 482 5% 2% 10% 3% 100% 36% 2) to identify important prognostic variables in some subgroups. We did this in order to see if the importance of prognostic variables varied between the subgroups. Results By the end of the study in December 1990, 200 patients were alive, 269 dead and 13 were !ost to follow up (Table 2). The patients who had their tumors classified according to Kiel system (treated more recen­tly) had significantly better chances for survival than those who had their tumors classified according to Rappaport system (Figure 1). On the whole, patients with extranodal primary sites did not fare better than those with primary nodal disease (Figure 2). However, patients with extranodal primary tumors of the bone, skin, head and neck, and gastrointestinal organs did significantly better than those with some rare "other extranodal" tumors and those with the primary site in the lymph nodes. The pa­tients with primary abdominal lymph node in­volvement had the worst prognosis while the prognosis of those with primary bone NHL was the best (Figure 3). Neither age nor sex appea­red to be prognostically significant factors. The results of the multivariate analysis are presented in Tables 3-6; the hazard ratio is the ratio between the hazard of patients in a specific group and the hazard of patients in a reference group; it is of statistical significance according to the log-rang test. The multivariate analysis confirmed the result of the univariate analysis, showing a 1.5 higher hazard ratio (risk value) for Group R than for Group K. The same prognostic variables were than used in the multivariate analysis for Groups K and R separately. Table 3 shows the values for Group K. The stage of disease, which emerged as a highly significant factor, was followed by the mediastinum as the primary nodal site, and 7 8 9 10 11 1:Z 100 90 80 > 50 ·s; .... :::, oo #. 20 o 1 2 3 4-5 6 7 8 years years Figure l. Survival by histologic classification system. Figure 2. Survival by primary site. Jereb Bet al. Table 4. Results of multivariate analysis for R-group patients. Predictors b hazard p 80 70 60 ol 50 " 40 L ... ..---··-··················•· r: 30 '2/2. 201 -•"""'•""'-·75,t, 'p .n.ccla..o-1a$-•· ···--e ::tuti,w,., -2& ·•· log-rank p < 0.0000 fO :=: i .flWt . : ::: Breslow p < 0.0000 o ::=: i .CJo ugal Switzerland cteneva , Trieste arese . \\.11t' Finland, 1 1 1 1, 1 1 1 1 ' 1 ' ' o 0.1 0.2 0.3 0.4 0.5 Cancer lncidence in Five Rate/100 Continents Vol. VI Figure 2. Cumulative cervical cancer incidence rates in young women 0-34, Europe 1983-1987. Pompe Kirn Vand Volk N Polanci, SileBi Germany, forr& 3r G 5 1, ortuia 1 .nm rk TistoRia ova 1a UK, sc'6Wa?la 1 Norwa. 1 lc.an 1 UK, Engl & ales 1 1 Germanv, i8frrland 1 we en 1 lraly 8 ri.te1 SP,ain,. T, .eona Spa1n, arra 1 Itareie 1 Neth., . , .stric t 1 Switi.rlan eneva 1 Neth., i 1 1.n1X.a r 1 o 0.5 1.5 2 2.5 3 Source: Cancer lncidence in Five Rate/100 Continents Vol. VI Figure 3. Cumulative cervical cancer incidence rates 0-74, Europe 1983-1987. The problem of young women does not al­present the incidence in Slovenia, as elsewhere ways reflect the magnitude of the burden of in the world, reflects both exposure to risk this disease in the studied population. In the factors and leve! of screening activity. In whole rank order of cumulative rates 0-74, Slovenia Slovenia an opportunistic screening activity has was in the upper half (Figure 3). The risk of a been going on since the year 1960. 1-4 It was woman in Slovenia to get cervical cancer till started earlier, i. e. in 1953 in three regions her 75th birthday in the studied period was stili only. These screening activities are mainly re­1.4/100. flected in the intraepithelial cervical carcinoma In Figures 4 and 5 tirne trends of crude rates. The crude rates of invasive carcinoma cervical cancer incidence rates for ali women had been decreasing till the year 1979, whereas and age specific rates for the younger ones are the age specific rates for younger women aged plotted. Invasive and intraepithelial cervical 25-34 had been decreasing till the year 1965 carcinoma rates are given together because at only and were relatively stable afterwards. Be­ 100 . -- ------, 80 o o o o o Q) 40 'lil 20 o ' ' ' 1953 58 63 68 73 78 83 88 -lnvasive -lntraepithelial Figure 4. Incidence of invasive and intraepithelial cervical carcinoma, Slovenia 1953-1989. Epidemiological features of cervical carcinoma in young women of Slovenia Figure 5. Incidence of invasive and intraepithelial cervical carcinoma in young women, Slovenia 1953-1989. fore the age of 25 invasive cervical carcinoma has been a very rare phenomenon in Slovenia since 1950; 1 or 2 cases per year have been registered, only. The incidence in young women in last 15 years was analysed in more detail. Besides rather stable invasive carcinoma rates, the in­traepithelial carcinoma rates were greatly va­rying, with a peak in 1980-1982 for ali three age groups 20-24, 25-29, and 30-34yrs. Later a decreasing tendency was noted in ali three age groups (Figure 5). The invasive carcinoma rates were rather stable. At some tirne points only, an increasing tendency was observed. The stage distribution of ali invasive carci­noma cases in the 15 year period with rather stable rates was much more favourable for younger women then for the elderly (Figure 6). Unfortunately, in tirne trends of the stage dis­tribution an unfavourable tendency was noticed in young women in Slovenia ( Figure 7). The percentages of the so called localised stage were slightly decreasing with tirne, the decrease was not statistically significant as the confidence Figure 6. Stage distribution of cervical carcinoma by age, Slovenia 1987-89. Pompe Kirn Vand Volk N N=123 N=114 N=131 Figure 7. Stage distribution of cervical carcinoma in young women, Slovenia 1975-1989. intervals were overlapping. In the analysis of FIGO Stage I distribution into A and B stages (Figure 8) a tendency to a less favourable stage distribution was also noticed in the eighties. Conclusion In 1987-1989 in young women of Slovenia cer­vical carcinoma was still the most common cancer site with an age-specific rate of 11/ N=100 100 80 c 60 Q) Q) o.. 40 20 o 1975-79 100 000 women. The incidence rates have been rather stable over a long tirne period despite the opportunistic screening going on in the whole state since the year 1960. Considering different tirne periods, an obvious increase in the incidence of invasive form could not be confirmed either. The results of a detailed analysis of the last 15 year period: in the 80's a decrease in the intraepithelial carcinoma rates, a tendency to­ N=82 N=95 1980-84 1985-89 1 .A IZZlB .Unknown 1 Figure 8. Distribution of A and B FIGO I. stage of cervical carcinoma in young women, Slovenia 1975-1989. Epidemiological features of cervical carcinoma in young women of Slovenia wards a decline in the percentage of the locali­sed stage as well as of the Figo IA stage are a reason for concern, however. If the described tendency continues, an in­crease in the invasive carcinoma incidence in young women of Slovenia could be expected as well. Considering the last European guidelines for Quality Assesment in Cervical Screening7 the following questions are posed: Is it the opportunistic screening in Slovenia, as it is, the right way? What is the quality of taking and reading cervical smears in Slovenia? Were the registered Stage IB cases the so-cal­led fast growing carcinomas or they occurred to women not assessed by the opportunistic screening practised in Slovenia? In the case they were reached, what was the quality of taking and reading smears? The situation calls for further analysis and action. References l. Kovacic J. An epidemiologic evaluation of cervical cancer screening (in slovene). Ljubljana: University of Ljubljana, 1972 (doctor's thesis). 2. Pompe Kirn V, Ravnihar B. Time trends and geographical distribution of uterine cervix cancer and breast cancer incidence in Slovenia (in slovc­ne). Zdrav. vestn. 1980; 49: 149-52. 3. Pompe Kirn V, Vršcaj Uršic M, Kovacic J, PrimicŽakelj M. Epidemiological evaluation of early de­tection of cervical cancer in Slovenia till 1981. Bur J Gynec Oncol 1986; 7: 147-51. 4. Pompe Kirn V, Kovacic J, Primic Žakelj M. Epide­miological evaluation of cervical cancer screening in Slovenia up to 1986. Bur J Gynaec Oncol 1992; 13: 75-82. 5. Cancer registration: principles and methods. JARC Sci Pubi 1991; 95. 6. Cancer incidence in five continents. Vol 6. JARC Sci Pubi 1992; 120. 7. Anon. The effectiveness of organised screening programmes. Bur J Cancer 1993; 29A (Suppl 4): Sl-S3. Radio/ Oncol 1994; 28: 40-8. Risk factors connected with the appearance of chronical diseases and cancer in the Republic of Slovenia Dražigost Pokorn University of Ljubljana, Medica! Faculty, Institute of Hygiene, Slovenia The article shows the most frequent risk factors in the Republic of Slovenia that the author could gather on the basis of available sources in Slovenia. We could conclude that relatively high incidence and prevalence of chronical and degenerative diseases (cardiovascular diseases and cancer) in the Republic of Slovenia or their permanent increase, if compared with western countries, where it is lower and decreasing already for severa! years, is a consequence of a much too intensive presence of risk factors in the Republic of Slovenia. Only after a change in the policy of nutrition, environmental protection, medica! education and a changed medica! welfare service in general, it will be possible to decrease the incidency of these diseases in the newly established s tate of Slovenia. Key words: neoplasms-epidemiology; chronic disease-epidemiology; risk factors; Slovenia Introduction With their endeavours to prolong the life expec­tancy (Table 1) during the last twenty years the Slovenians stayed considerably behind their neighbouring countries. In Slovenia, the main reasons for premature mortality are the same as in other European countries; undoubtedly Slovenia is one of the countries where its inha­bitants loose their lives because of injuries and suicides. 1 Slovene patients with cardiovascular diseases and cancer, representing 69 .1 % of ali causes of death, are dying earlier as similar patients in the neighbouring countries. Since 1970, mortality from ischaemic heart diseases has been growing in Slo_venia similarly as in other countries of Central and Eastern Europe, while the trend in the developed countries of Northern Europe2 is opposite (Figure 1). Du­ring the last few years a slight decrease in premature mortality from heart-and coronary 3 diseases can be observed (Figure 2). 1• Cancer incidence (1950-1987) is also growing (Figure 3).4 The Slovenians contract these diseases be­cause of worse primary prevention, consequen- Table l. Lifge expectancy in 5 European eountries, 1 1970, 1980, 1988. Country 1970 1980 1988 Men Women Men Women Men Women Corespondence to: Prof. Dražigost Pokorn, PhD, MD, Austria 66.3 73.4 69.0 76.1 72.1 78.7 Instit ute of Hygiene, Medica! Faculty, 61000 Ljubljana, Slovenia. Zaloška 4, Germany Italy Sweden 67.2 73.6 69.6 76.8 72.3 79.1 68.6 74.7 71.0 77.6 72.7 79.2 72.3 77.4 72.8 79.0 74.2 80.4 UDC: 616-006.6-036.2-02 Slovenia 65.0 72.3 67.4 75.2 67.6 76.8 Risk factors in the Republic of Slovenia /C.echoslovakia Finland UK -Bulgaria Slovenia France -Spain 1970 1975 1980 1985 Year Figure l. Premature mortality from ishaemic heart diseases. Standard mortality rate for men and women, 0-64 years of age, per 100 000.1• 2 1985 1986 1987 1988 1989 1990 e ar s Y Figure 2. Premature mortality from cardiovascular (CVD) and ishaemic heart diseases (IHD) in Slovenia. Standard mortality rate for men and women, 35-64 years of age, per 100 000.1• 3 Rate per 100000 tly larger prevalence of risk factors, or these illnesses are discovered later and treated less successfully. The main purpose of this article is to try to show the most frequent risk factors in the Republic of Slovenia on the basis of available sources in Slovenia. The quoted data can serve only as an orien­tation for a survey of risk factors associated with the appearance of chronical diseases in a country that has only started with the preven­tion of cardiovascular diseases and cancer. Material and method The data on dead inhabitants acording to the causes of their death, sex and hospital admis­sions due to the diseases of resident population by international classification of diseases (ICD) are based on the Medical Statistical Annual of Slovenia, 1991, published by the Institute of Health of the Republic of Slovenia, 1 collecting health statistics. From the same source we also took the data on diseases detected in specialized out-patient departments and on gastrointestinal diseases for 1969-1991 and 1977-1989. Data on age-standardized mortality for men and women· (for the age 0-64 years per 100.000 inhabitants) were specialy prepared for this survey by the Institute for Health (Personal Report 1992). We incorporated them into the figure showing mortality from ischaemic heart diseases in Cen­tral, Eastern and North Europae (E. Helsing).2 The data on annual cancer incidence, crude incidence rate per 100.000 inhabitants in the Republic of Slovenia, and on annual incidence rates of stomach cancer were obtained from the Central Cancer Register of Slovenia at the Institute of Oncology in Ljubljana.4 Data on the production, transport and sales of food and on the annual consumption of food and bevera­ges per household member for 1965-1988 and 1970-1990 were derived from the Statistical Annual of the Republic of Slovenia, which is published regularly by the Statistical Office of the Republic of Slovenia.5 The energetic value of an average daily meal and the nutrient ratio: protein, fats, carbohy­ Pokorn D drates and dietary fibers in a meal were calcu­Results with discussion lated on the basis of the data for annual con­ sumption of food and beverages per household member in the Republic of Slovenia according to the inquiry on the consumption in house­holds, performed by the Statistical Office of the Republic of Slovenia for 1965-1988 and 1970­1990 every five years,5 and by the help of plates with nutritional values of the food, Zagreb 1990.6 In 1988 the pattern of a five-year inquiry included 3.250 households: 56 rural, 811 mixed and 2.383 nonrural households, chosen accor­ding to the method of random selection. The Statistical Office of the Republic of Slovenia was also the source of data on the production of cigarettes. Data on the emission of sulphur dioxide into the air by consumers of fuel and raw materials in the Republic of Slove­nia are -on the basis of analyses made by the Institute for Hydrometeorology of the Republic of Slovenia5 -also gathered by the Statistical Office of Slovenia. The analyses of samples of drinking water as to their bacteriological and chemical irreproac­habilty are regularly performed by regional institutes of hygiene and social medicine in the Republic of Slovenia. Data on irreproachability of drinkable water were obtained from the Report ·of these microbiological laboratories.1 The analysis of the magnesium content of drin­kable water in Slovenia in 79 at random chosen water sources ( of open and closed type) was in 1981 and 1982 performed by the Center for Mineral Water Research in Maribor, Republic of Slovenia. 7 The data on individual risk factors (smoking, obesity, hypertension, hypercholesterolemia) were obtained from the !atest epidemiologic reasearches in Slovenia: Berger et al,8 Accetto and Javornik;9 Pokorn;10 Srebot et al;11 Fortic12 and Strgar;13 Gradišek et al;14 Jezeršek et al;15 Radisavljevic et al. 16 The daily nutritional pattern and the content of salt and dietary fibrins in the daily food pattern of the older population was taken from the study of Pokorn et al. 17 It is interesting that although chronical diseases affect different organic systems and differ com­pletely also as to their etiopathogenesis, the risk factors for some of them are very similar. For example: the development of arteriosclero­sis is advanced by numerous factors, the effects of which should not only be added-up, because they intensify each other.18 Therefore it is extre­mly difficult to explain the influence of food on heart and coronary diseases, if important risk factors for the appearance of arteriosclerosis such as physical activity and cigarette smoking of the population are not known. As important risk factors for the appearance of heart and coronary diseases and cancer among the population of Slovenia, we took into account some nutritional factors, alcohol abuse, and polluted environment, which are systemati­cally collected by the state institutions, and also some other available risk factors -smoking, elevated blood pressure, and plasma concentra­tion of cholesterol. Among the risk factors for the appearance of chronical diseases it is food that may be one 20 of the most important risk factors.19• With the average consumption of food and beverages per household member in the Republic of Slo­venia (1965-1988) a rise in the consumption of individual groups of food -with the exception of fats -can be observed. The variability of 371' fat Sat Carbohydrates Protein . D Jl:'2il ccal/ capita/day 1965 2539 1970 2505 1975 2972 1.80 J. 2566 1984 3288 1985 3343 1986 3021 1987 2524 1988 2312 o 10 20 30 40 50 60 110 80 90 100 " J.J8'%, carbohydrate ( 6, 7'f. sucrose) 15'%. protein Figure 4. The proportion of fat, carbohydrates and protein in the total energy supply in Slovenia, 1965­1988. 5 Risk factors in the Republic of Slovenia milk consumption of individual food types is relati­ ----in 100 000 hl '.l 3., 10 . o_ Bo 60 so-, vely large, which could be attributed to diffe­rent and insufficiently accurate methods of hou­seholds inquiring. After 1965 an obvious fall in the food con­sumption can be observed, which can be seen fish also from the average energetic and nutritional 8 1 in lOOOton value of an average daily meal (Figure 4). From 6 1965 to 1985 the energetic value of an average 5 4 daily meal was growing from 2539 to 3343 Kcal. Afterwards it started to fall and in 1988 it ranged at 2312 Kcal/day when an average meal meat of a Slovenian contained more than 35 % of 20 in 1000 ton fats and approximately 15 % of proteins in respect to the energetic value of the consumed food. The ratio between the animal and vegeta­ble fats was decreased (Table 2). The share of eggs in 1000000 Table 2. The proportion of animal and vegetable fat in the total fat supply in Slovenia, 1979-1989.5 pieces Year Animal fat (%) Vegetable fat (%) Olive oil (5) 1979 n n3 0.1 1984 . .8 0.2 1989 M .-8 0.2 olive oil, which is supposed to have also an important protective influence on the appea­rance of arteriosclerosis, 19 is extremly low. A bigger share of vegetable oils in everyday nutri­tion can be partly proved also by the increasing production of this food in the Republic of Slovenia. The increased production of eggs, meat, milk and fish during the last twenty years (Figure 5) caused a rise of the percentage of proteins in the daily nutrition and probably also 40 30 20 10 1970 1975 1980 1985 1990 Y e a r s Figure 5. Production of protein food in Slovenia, 1970-1990.5 The quantity of the consumed fruit and vegetables has been falling since 1979-1989 (Table 3). Because of the low quantity of daily consumed fruit and vegetables and cereal pro­ducts, especially wholegrain cereals, the content Sugar** Rate per capi ta per per year of saturated fats. 100 "'-, ,' / 120 teet 110 100 --.-.._."----­ ' / , ' ­/ The quantity of the consumed table sugar per household member was falling extensively from 21 20 19 18 l'1 / \ 90 sugar . 1975 to 1988, while the quantitative trade with sugar and candy production are both increasing, 17 11' Bo 1 / " 16 V 70 which means that the consumption of sugar products, chocolate, cakes, etc. is on the increa­se. Together with a lower consumption of table sugar there is also a fall in caries incidence (Figure 6). The cause for a lower caries rate in the Republic of Slovenia can not be found only in the lower consumption of table sugar, but also in the improved mouth hygiene and better teeth fluoridation. 21 1965 ffJ 70 75 79 00 84 &S 00 90 Year Figure 6. Treatment* in general dental clinics by HC domicile, Slovenia, 1969-1990 and available supply of 5 sugar in Slovenia, 1965-1988.1• * Teeth filling with and without treatment, surgical treatment ( extracted teeth and other treatment). ** Sugar consumption per persona per year in Slove­nia. Pokorn D 5,2 5,5 5,9 3,8 Table 3. Per capita consumption of fruit, vegetables and dietary fiber in Slovenia, 1979-1989.5 Unit 1979 1984 1989 Vegetables Fruit Dietary fiber kg/day kg/year g/day 31.6 56.8 16.4 16.6 32.7 16.0 15.7 31.2 15.1 of dietary fibers in the daily nutrition has also been decreasing -in the same period it ranged between 16.4 and 15.1 g/day. Together with a low consumption of fruit and vegetable there is also a lower consumption of protective sub­stances and this can be an important risk factor for the appearance of cardio-vascular diseases and cancer. 22-27 An extremly low value of daily consumed fibers in the daily nutrition of Slovenian popu­lation was established also with the analysis of 56 at random chosen patterns of daily meals in the city of Ljubljana. The value of fibrins ranged between 3.5-21.9 g/day (7.7 + /-3.9 g/day).17 A lot of eggs, fats, sugar, meat and milk products and a low quantity of fruit and vege­table ( dietary fibrins) can also be a risk factor 29 for the appearance of gallstones,28' which is also on the increase (Figure 5). We lack 5.2 mmol/l). %subjects Place of research Men Women No Age groups Zgornja Šcavnica (8) 79.3 76.3 1132 25-64 Brnik (8) 58.6 54.1 743 25-64 Ljubljana (14) 67.0 60.0 1692 25-64 Ljubljana (9) 47.9 67.8 696 60-94 Ljubljana* (10) 17.1 30.7 432 60-101 * institutionalized subjects epidemiologic studies performed in the Repu­blic of Slovenia. The results show that more than a half of the examined subjects have an important and basic risk factor for the develop­ment of atherosclerosis -but these results can­not be generalized for the whole Slovene terri­tory. Six studies, published in Slovenia between 1987 and 1992, which included 8049 examined subjects (Table 5) showed that the population aged between 25 and 70 years had a relatively different prevalence of hypertension, which is also an important factor for the appearance of cardiovascular and cerebrovascular diseases. Such variability of results can also be a conse­quence of different methods for blood-pressure 3941 measurements. In five epidemiological studies which included 7572 subjects aged from 7 to 101 years we could observe excessive body weight and obesity in 9.6 % of the examined men aged between 25 and 64 years, and 22.2-41 % of the examined women. Among children aged between 7 and 15 years there were only 2.8-4.7 % of boys and 4.8-7.7% of girls with excessive body weight (Table 6). Relatively high body weight of the subjects, although their daily energy consump­tion is relatively low, can be a consequence of insufficient physical activity and of too high a 43 content of fats in the daily nutrition.42• Conclusion We could conclude that a relatively high inci­dence and prevalence of chronical and degene­rative diseases in the Republic of Slovenia, or their constant increase, -if compared with western countries where it is lower and has been decreasing for several years already, -is Table 5. Incidence of elevated blood pressure (mm Hg) in Slovenia. % subjects Place of research Men Women Together No Age groups Ljubljan. Šiška (15) - - 18.9 2965 40-70 Zgornja Scavnica (8) 17.6 22.9 1132 25-64 Brnik (8) 17.0 17.1 743 25-64 Ljubljana (14) 47.3 30.9 39.1 1692 25-64 Ljubljana (9) 37.9 51.2 46.1 695 60-94 Ljubljana* (10) 37.1 50.2 47.9 822 60-101 * institutionalized subjects Risk factors in the Republic of Slovenia Table 6. Obesity in men and women in Slovenia. Place of Indices of %* Age research obesity No groups Men Women Ljubljana (14) BMI 49.0 41.0 897 25-64 Ljubljana (9) Q 69.9 61.9 699 60--94 Zgornja Šcavnica (8) RTM 9.6 22.2 1132 25-64 Brnik (8) RTM 19.2 23.0 25-64 Maribor (16) RTM 1033 7 1107 11 RTM 6.3 4.6 RTM 2.8 4.8 928 15 BMI = body mass index (kg/m2); * > 2.7 RTM = relative body mass: (% ); * > 120 Q = Quetelet's index (body mass/body height2 (g/cm2)); * > 2.57 a consequence of a much too intensive presence of risk factors in the Republic of Slovenia. 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Rocella EJ, Bowler AE, Horan M. Epidemiologic considerations in defining hypertension. Med Clin North Amer 1987; 71: 785-802. 42. Lissner L, Levitsky DA, Strupp BJ, Kalkwarf HJ, Rol AD. Dieta-ry fat and regulation of energy intake in human subjects. Am J Clin Nutr 1987; 46: 886-92. 43. Astrad PO.Physical activity and fitness. Am J Clin Nutr 1992: 12318-69. Radio[ Oncol 1994; 28: 49-57. The characteristic angle-B concept in electron are therapy Marina Pia, Ervin B. Podgoršak, and Conrado Pia Department of Medica! Physics, Montreal General Hospital, McGill University, Montreal, Quebec H3G IA4, Canada Eleetron are therapy is a speeial radiotherapeutie teehnique in whieh a rotational eleetron beam is used to treat superficial tumour volumes whieh follow eurved surfaees. While the teehnique is well known and aeeepted as clinieally useful in the treatment of eertain tumours, it is not widely used beeause it is relatively eomplieated and its physieal eharaeteristies are poorly understood. Moreover, the dependenee of dose distributions on a large number of physieal and treatment parameters makes treatment planning in eleetron are therapy very diffieult even far homogeneous media. The exeellent clinieal results aehieved by the few pioneers in this field during the past two deeades have eertainly stimulated an inerfased interest in eleetron are therapy, both far eurative treatments as well as far palliation. In faet, manufaeturers of linaes now offer the eontinuous eleetron are therapy mode as one of the standard treatment options. While this option is usually purehased with a new linae sinee it is relatively inexpensive, it is rarely used clinically beeause of the teehnieal diffieulties involved. However, the number of eentres using or planning to use this treatment modality is growing, making the improved understanding of teehnieal and physieal aspeets of eleetron are therapy highly relevant. The charaeteristie angle-. eoneept provides a useful empirieal approaeh to treatment planning in eleetron are therapy. The eoneept is reviewed and its applieability is expanded from homogeneous to heterogeneous phantoms. It is also shown that for homogeneous phantoms depth dose data at a partieular eleetron beam energy ean be caleulated from a data set measured at some other standard energy. Key words: neoplasms-radiotherapy; eleetron are therapy Introduction The partieular energy loss eharaeteristies of eleetrons as they penetrate into tissue make eleetrons suitable for use in treatment of super­fieial malignant diseases. Stationary eleetron beams are now routinely used in radiotherapy Correspondence to: Marina Pia, M. Se., Department of Medica! Physics, Montreal General Hospital, 1650 avenue O.dar, Montreal, Quebec H3G 1A4. and severa! radiotherapy eentres have during the past two deeades, in addition to stationary eleetron beam teehniques, developed moving eleetron beam teehniques whieh are ussually referred to as eleetron are therapy. Eleetron are therapy is well-suited for treat­ment of large superfieial tumour volumes whieh follow eurved surfaees. The treatment is perfor­med either with a eontinuous beam-on rotation UDC: 616-006.6:615.849 of the eleetron beam (eontinuous are) or with so Pia Metal. a series of overlapping isocentric stationary electron beams (pseudo are). Electron are the­rapy has proved useful in the treatment of patients with recurrent malignant chest wall disease ( e. g., breast cancer) who had failed previous conventional photon beam radiothe­rapy or patients with extensive superficial skin tumours involving large curved surfaces of the body ( e. g., sarcomas, limited mycosis fungo­ides, extensive basal or squamous celi carcino­mas, and limited lymphomas). In our department we have been using elec­tron are therapy clinically since 1986. During this tirne we have treated 43 patients and achie­ved excellent local palliation of the disease in most of them. The clinical experience with our pseudo are electron therapy on 24 patients treated between November 1986 and June 1990 has been described in detail elsewhere1 inclu­ding information on tumour types, tumour loca­tions, tumour control and morbidity. The calculation of dose distributions in elec­tron are therapy is a complicated procedure and usually cannot be performed reliably with algo­rithms used for standard stationary electron beam treatment planning. The dose distribu­tions in electron are therapy depend in a com­plicated and seemingly haphazard way on seve­ra! treatment parameters, such as the electron field width, depth of isocentre, source-axis dis­tance, electron beam energy, surface curvature of the patient, use of secondary and tertiary collimation, field shape as defined by the secon­dary collimator, and number of monitor units either per degree in continuous arcs or per each stationary beam in pseudo arcs. The difficulties in optimization of the treat­ment parameters for a particular patient make electron are therapy very complex and prevent its wider use in standard radiotherapy depart­ments. The few radiotherapy centres which to date have used electron are therapy clinically1-11 have developed their own specific solutions to the technical problems related to the treatment itself and to the calculation of the dose distribu­tions inside and outside the targeted volume. In our centre we have developed an empirical method, referred to as the characteristic angle-. concept, for the calculation of dose distributions in electron are therapy. In this paper we review the angle-. concept and extend it to account for multiple electron energies and tissue hetero­geneities. Materials and methods Experimental apparatus and techniques. An isocentric linear accelerator (Clinac-18, Va­rian Associates, Alto Palo, California), capable of producing electron beams in the energy range between 6 Me V and 18 Me V, has been used as the source of electrons. The virtual source of the stationary electron beam is at 85 cm from the isocenter axis making our nomi­nal source-axis distance in the pseudoarc techni­que equal to 85 cm. The electron beam depth dose distributions for stationary and are therapy beams were measured in cylindrical phantoms with thermoluminescent dosimetry (TLD) tech­niques incorporating a TLD reader (model 2000, Harshaw Chemical Company, Solon, Ohio) and dosimeters in the form of LiF rods (TLD-100, Harshaw Chemical Company, Solon, Ohio) with dimensions of 1 x 1 x 6mm3 . Characteristic angle-. concept. Before introducing the electron are therapy clinically, we initiated a study of the basic physics of electron are therapy and developed the characteristic angle-. concept for an empi­rical, yet general, description of dose distribu­tions in electron are therapy. The angle-. con­cept has been described in detail elsewhere, 12 so that here only a concise description of its main features will be given. For a given electron are treatment geometry a characteristic angle . can be uniquely deter­mined by three treatment parameters: nominal field width w, depth of isocentre di, and virtual source-axis distance f. As shown in Figure 1, the characteristic angle . for an arbitrary point Q on the patient's surface is measured between the central axes of two rotational electron beams positioned in such a way that at point The characteristic angle-(3 concept in electron are therapy Q the frontal edge of one beam crosses the trailing edge of the other beam. The treatment are angle a is of course much larger than the characteristic angle .­ The relationship among the parameters ., di, w, and f is then through straightforward geome­try given by: 2di sin(.) w-1-(7) ,o,(.) (1) and hence one obtains the following quadratic equation for calculating .: ( .. 2 -1) tan2 (.) + 4 (.)tan (.) + (2) +(:J-1)=0 We found experimentally that, for a constant f, electron beams with combinations of di and w which give the same characteristic angle . ,, Figure l. Schematic representation of the electron are therapy geometry ( a = are therapy angle, . = characte­ristic angle, I = isocentre, d; = depth of isocentrc, w = ficld width, f = virtual sourcc-axis distance, Q = point of interest on patient contour). exhibit very similar radia! percantage depth 401 \ tli o "C 20 f (a) \_ lf (b) 113 = sool \ IHDD0I . oor • d1 = 10cm „d1=5cm w =14,1cm w = 8.0cm 0:: 60 • d = \ x d1 = 15cm 1 10cm w =22.3cm w =16.6cm x d1 = 15cm 401 1 w = 25.9cm 20 (c) \_ ll (d) \_._ o 2 4 6 o 2 4 6 De p t h d ( cm) Figure 2. Radia! percentage depth doses in electron are therapy measured in a homogeneous phantom for various combinations of field size w and isocenter depth di giving characteristic angles 13 calculated from Eq. (2). Electron beam energy: 9 MeV. beam the measured radial percentage depth doses for various combination of w and di giving characteristic angles . of ( a) 20 ° , (b) 40 ° , ( c) 80 ° , and ( d) 100 ° . The agreement among the depth