[Adrenal tumors: principles of imaging and differential diagnostics]. / Tumoren der Nebennieren : Prinzipien der Bildgebung und Differenzialdiagnosen.

CLINICAL/METHODICAL ISSUE: Adrenal masses are very common and are usually detected incidentally. Less frequently, imaging is performed for the localization of the underlying lesion in the case of endocrine disease. The differentiation between adenomas and non-adenomas is fundamental. METHODICAL INNOVATIONS: Adenomas show a low density on unenhanced computed tomography (CT) and a rapid washout of contrast agents. In magnetic resonance imaging (MRI) adenomas are characterized by a low signal in opposed phase imaging as compared to in phase imaging. PERFORMANCE: According to the literature a density of less than 10 HU in an adrenal mass has a specificity of 98% and a sensitivity of 71% for the presence of an adenoma and MRI is slightly more sensitive. Some adrenal lesions, e.g. cysts or myelolipomas can be diagnosed with high accuracy due to pathognomonic findings. ACHIEVEMENTS: In the majority of cases the synopsis of imaging along with clinical and laboratory findings is necessary for a reliable diagnosis. PRACTICAL RECOMMENDATIONS: For the evaluation of an adrenal mass the CT examination should begin with an unenhanced scan, if necessary followed by a washout examination. In the case of MRI in phase and opposed phase imaging are essential components of the examination.

[CT urography in women with primary or recurrent pelvic tumors : background and initial experiences]. / CT-Urographie bei Frauen mit primären oder rezidivierenden Beckentumoren : Hintergrund und erste Erfahrungen.

Malignant tumors of the female pelvis account for 12-13% of newly diagnosed solid neoplasms among women in the USA and Germany. German guidelines advocate diagnostic imaging for local recurrence and metastasis while there are no recommendations for primary tumors. As excretory urography has been replaced by the excretory phase of computed tomography urography (CTU) in many institutions, two independent observers retrospectively evaluated CTUs of primary or recurrent female pelvic tumors to rule out associations between CTU findings and subsequent urologic measures. Among 31 CTUs of 27 women (age 29-84 years, mean 57 years) with 15 primary and 13 recurrent tumors, 83-100% of unremarkable proximal, middle and distal ureter segments were completely delineated in the excretory phase (delay 6-29 min, mean 16 min). The most common pathological findings included distal ureter obstruction (n=19, 61%), bladder compression (n=13, 42%) and bladder invasion (n=8, 26%). Out of 20 pathologically altered urinary tracts 8 were subsequently subjected to urologic measures (2-tailed Fisher exact test, p=0.0215) but none of the 10 unremarkable urinary tracts were treated. It appears that CTU is a sensible pre-therapeutic test for the urinary tract for primary and recurrent female pelvic tumors.

[Angiographic diagnosis of acral circulatory disorders of the upper extremities]. / Angiographische Diagnostik akraler Durchblutungsstörungen an der oberen Extremität.

Acral ischemic lesions rarely affect the upper extremities. While in the lower limbs atherosclerosis is responsible for the majority of lesions, vasculitis and autoimmune diseases play an important role in the pathogenesis of ischemic lesions of the upper limbs. A considerable number of acral circulatory disorders present with Raynaud's phenomenon and often without associated necrosis. Raynaud's phenomenon is mainly idiopathic but may also be secondary to underlying conditions, such as autoimmune diseases and vasculitis. Because of its high spatial resolution and the often discrete morphological findings digital subtraction angiography (DSA) is still an important diagnostic method in the radiological evaluation of acral circulatory disorders of the hand. Angiographic features of vasculitis are not strictly pathognomonic but certain morphologic DSA findings are very typical and may allow for a radiologic diagnosis. For instance, atherosclerosis results in irregular contours of vessel walls in DSA in contrast to autoimmune diseases and vasculitis, which are usually characterized by smooth vessel walls and optional vasospasm, the latter being especially typical for thromboangiitis obliterans and scleroderma. In thromboangiitis obliterans occlusions of the distal hand arteries, corkscrew collateral vessels and subsequent development of fine collateral networks are typical findings. Abrupt or filiform occlusions of distal finger arteries with sparse collateralization and symmetric affection of both hands are suggestive of scleroderma. Disseminated segmental ectasis and stenosis as well as microaneurysms (63% of all patients) are very common in patients with panarteriitis nodosa.

[Therapy of peripheral vessel stenosis and occlusion in patients with thromboangiitis obliterans]. / Therapie peripherer Gefäßstenosen und -verschlüsse bei Thromboangiitis obliterans.

Vasculitis consists of a group of diseases characterized by an inflammatory process of the vessel wall. There is a wide variation in symptoms and almost any organ or tissue can be affected. Thromboangiitis obliterans (TAO; also known as Buerger's disease) is a special form of vasculitis with recurring inflammation and thrombosis of small and medium size arteries and veins of the hands and feet. To date the etiology still remains unclear but there is a strong association with the use of tobacco products. Ulcerations and gangrene of the extremities are common complications often resulting in the need for amputation of the extremity involved. Treatment of TAO includes both surgical and non-surgical methods but there is still no agreement concerning the optimal treatment strategy. In this contribution the advantages and disadvantages of different treatment options will be addressed and representative cases will be discussed.

Abdominal actinomycosis.

A 59-year-old, healthy Croatian presented with a slowly growing tumor in the left lower abdomen, which was slightly painful on compression. He complained of neither dyspepsia nor fever. There were no pathologic findings in laboratory analysis, particularly no elevation of leukocytes or C-reactive protein. MRI of the abdomen (T1w, fat saturated, and iv-contrast) shows a diffuse contrast enhancing mass of the left abdominal wall (Figure 1a, arrow) with infiltration of the peritoneal cavity (Figure 1b, arrow). Because a malignant process was suspected the patient underwent abdominal surgery and excision of the tumor. Histopathological examination showed chronic-fibrosing and granulocytic, abscess-forming inflammation with Gram- and PAS-positive bacteria, corresponding to the diagnosis of chronic actinomycosis (Figure 1c). Following surgery, the patient was treated 1 month with iv and 6 more months with oral penicillin. The patient remained well 1 year after surgery. Actinomycosis is a rare, chronic granulomatous disease, which affects most commonly the cervicofacial and abdominal area. Actinomycetes are filamentous, gram-positive, anaerobic bacteria and commensal inhabitants of the oral cavity and intestinal tract; however, they acquire pathogenicity through invasion of the breached tissue. Because of its rarity and non-specific symptoms, abdominal actinomycosis is usually diagnosed postoperatively since most patients undergo exploratory laparotomy for a suspected neoplasm.

[Chronic critical ischemia of the lower leg: pretherapeutic imaging and methods for revascularization]. / Die chronische kritische Unterschenkelischämie: prätherapeutische Diagnostik, Methoden der Revaskularisation.

Each year 1-2% of patients with peripheral arterial occlusive disease (pAOD) develop critical limb ischemia (CLI), characterized by rest pain and peripheral ulcer or gangrene. This aggravation of the disease is accompanied by an increase of the 1-year mortality rate up to 25% and a similarly increased frequency of major amputation. We can choose between conservative, endovascular, and surgical procedures for an adequate therapy of the underlying vascular stenoses or occlusions. Yet, clear therapeutic recommendations only exist for suprapopliteal lesions. However, in a number of cases, especially in diabetics, target lesions have an infrapopliteal location. Since endovascular procedures have undergone significant improvement in the last few years, the following review discusses methods for infrapopliteal revascularization taking into consideration the newest publications on this topic.