[Implementation of BIRADSTM together with an organization of percutaneous breast biopsies: experiences, reactions]. / Implementierung der BIRADSTM-Klassifikation in Kombination mit einer Organisation der perkutanen Nadelbiopsie von Brustläsionen: Erfahrungen, Reaktionen.

PURPOSE: To record the acceptance and reactions of radiologists and physicians who recommend patients for mammography after simultaneous establishment of BIRADS TM and a registration of the results of percutaneous breast biopsies. MATERIALS AND METHODS: To improve clarity of mammographic reports and to provide guidance concerning any necessary percutaneous breast biopsies the Breast Imaging Data And Reporting System (BIRADS TM) has been introduced regionally together with a registration of percutaneous breast biopsies. Using a questionnaire, 25 radiologists and 230 referring physicians were asked on acceptance and reactions concerning the established system. RESULTS: Of the 15 answering radiologists, 93 % considered BIRADS TM a worthwhile effort and 87 % found the biopsy guidelines to be useful. They regarded the acceptance of the referring physicians and patients as high (80 %). Up to 69 % of the 52 participating physicians stated a better understanding of the mammographic reports, an easier comprehension of the dignity classification of a mammographic lesion and the feeling of an improvement in their work. Preoperative assessment of histology was found to be valuable by 94 % of the referring physicians. They believe that more than half of the patients benefit from the biopsy guidelines and that the majority of patients accept this approach. CONCLUSION: BIRADS TM is useful to standardize and improve mammographic reports. It is advantageous to link BIRADS TM with guidelines for percutaneous breast biopsies.

[Practical usage of a quality management system according to ISO 9001 : 2000 focusing on the double contrast (barium) enema]. / Praktische Anwendung eines Qualitätsmanagementsystems nach ISO 9001:2000 am Beispiel von Qualitätsverbesserungsmassnahmen beim Kolon-Kontrastmitteleinlauf, Germany.

PURPOSE: We describe the implementation of quality improvement measures in a quality management system. METHODS: With questionnaires for radiologists and patients, we investigated the relations between patient preparation and diagnostic quality serving the main purpose, to improve diagnostic quality with the help of more detailed patient information (e.g., changing preparation sheets and handling out "peri-med" information sheets to the patients). Furthermore, a comparative data ascertainment at other institutes was integrated. RESULTS: For the group of outpatients, increasing process quality (patient information) and outcome (diagnostic quality) could be achieved. Taking aspects of quality costs into consideration, a decrease in costs due to failures was achieved. CONCLUSION: More detailed patient information has positive effects on diagnostic quality of the double contrast (barium) enema.

[Advanced breast biopsy instrumentation (ABBI) experiences and critical comments]. / Advanced Breast Biopsy Instrumentation (ABBI) Erfahrungen und kritische Bemerkungen.

UNLABELLED: Advanced breast biopsy instrumentation (ABBI) experiences and critical comments. PURPOSE: To describe our three-years' experience with advanced breast biopsy instrumentation (ABBI). MATERIALS AND METHODS: Considering lesion size, type and location as well as patient specific criteria 89 patients were selected for an ABBI. The documented data like duration, complication and change of the procedure, size of the lesions and biopsy cannulas, histologic outcome and further treatment were analysed retrospectively. RESULTS: ABBI was successful in 63 of 89 patients. Cancer was found in 18 patients (29 %) with a surgical re-excision to achieve tumour-free margins in 89 %. 45 patients had benign lesions (71 %) with a benign to malignant ratio of 2.5 : 1. ABBI was unsuccessful or had to be replaced by other biopsy techniques in 26 patients (29 %). In four of these patients the localization needle was already placed. Analysing the three-year period ABBI frequency dropped each year with an overall reduction of 63 %. Despite a good benign to malignant ratio the surgical re-excision rate in cancer patients is disappointing. Although using precise selection criteria for ABBI the rate of failed biopsies and changeover to another biopsy procedure was too high. The reduction of ABBI procedures during the three-year period is assumed to be an expression of the negative experiences with the method but also a refusal of the assigning colleagues to use ABBI. CONCLUSION: For the evaluation of suspected breast lesions ABBI is too invasive and too expensive. On the other hand ABBI is too ineffective as a therapeutic tool to remove suspected lesions. Therefore it is not warranted to use ABBI instead of other concurrent biopsy techniques.

Heart luxation through a right-sided traumatic pericardial defect.

A traumatic defect of the pericardium is a rarely diagnosed entity. We present a patient with a right-sided luxation of the heart which was incidentally diagnosed during a thoracic CT performed for other reasons. Despite of the threatening strangulation of the great vessels, the patient had a stable circulation until surgical repair of the pericardial defect.

Acetabular ossicles: normal variant or disease entity?

Ossicles located in the acetabular fossa may confuse diagnostic and therapeutic work-up. An accessory ossification centre may persist unfused as an os acetabuli centrale which is surrounded by intact hyaline cartilage representing an anatomic variant. Bone islands located in the pillars of the acetabulum can project into the acetabular fossa simulating acetabular ossicles. Osteochondrosis dissecans, posttraumatic articular bodies, degenerative disease and other rare lesions may be responsible for clinical symptoms and are of similar appearance than anatomic variants. Plain film radiography, X-ray tomography, CT and MRI are used to categorize these lesions. MRI is very valuable to assess cartilage integrity in a noninvasive way, but arthro-CT or arthro-MRI have to be used in unclear cases. Therefore the purpose of this presentation is to discuss the appearance, the possible etiology and the differential diagnosis of acetabular ossicles and how they can be evaluated to avoid an unnecessary arthrotomy.

[Implementation of the quality management system ISO/CD2 9001-2000 in a radiology institute]. / Uber die Implementierung des Qualitätsmanagementsystems ISO/CD2 9001-2000 in einem radiologischen Institut.

Quality assurance in health care, a relatively new discipline, has developed rapidly over the last years and is now required by law. The Quality Management System (QMS) ISO 9001 aims at the definition of requirements necessary in order to achieve perfect products and continuous quality improvement. Implementation of this QMS necessitates the analysis and written documentation of all working processes and modes of operation. Furthermore, potential improvement possibilities are defined to guarantee highly qualified, generally applicable and standardised procedures. Time-consuming data assessment is an instrument to enable disclosure and analysis of existing errors as well as to show possibilities of optimization, thus forming the basis for continuous improvement. The new ISO NORM 9001-2000 is process-orientated with an organisational structure strongly recommendable for service institutions and therefore also for a department of radiology.

[Contrast-enhanced subtraction MRT in the spin-echo technic]. / Kontrastverstärkte Subtraktions-MRT in Spin-Echo-Technik.

PURPOSE: The aim of the retrospective study was to determine whether subtraction of spin-echo images is useful for estimating intensity and extension of contrast enhancement when practised in daily routine diagnostic work. METHODS: 348 patients with different diseases of the musculoskeletal and neuro system were examined with MRI using a T1-weighted spin-echo sequence before and after application of 0.1 mmol/kg Gd-DTPA with subsequent subtraction of both measurements. Usefulness of the source images, pictorial quality of subtracted images and intensity of contrast enhancement were assessed subjectively. RESULTS: Subtracted images were of sufficient quality in 85% of the cases, whereas source images were always usable except in 9 patients. It was easier to visualise the extent of contrast enhancement in subtracted than in non-subtracted images in examinations of the musculoskeletal system, whereas there was no difference in the neuro system. Contrast enhancement could definitely be excluded in 15% of the patients and was stated to be of low, medium and high intensity in 21%, 45% and 19%, respectively. In comparison with subtracted images lesions were stated to appear larger in 62% and 87%, smaller in 25% and 13%, and of the same size in 13% and 0% for T2-weighted and fat-suppressed images, respectively. CONCLUSION: Subtraction of spin-echo images before and after application of contrast media is useful for estimating intensity and extension of contrast enhancement without essentially increasing time and costs of the examination. Extension of contrast enhancement in musculoskeletal lesions rarely correlates with the extension of signal changes in T2-weighted and fat-suppressed images.

Postsurgical reduction of serum lipoproteins: interleukin-6 and the acute-phase response.

In a previous retrospective study, we reported a significant reduction in serum cholesterol levels following major surgery, and speculated on the possible role of cytokines in this reduction. The purpose of this article is to report a prospective study of the association of cytokines with postoperative changes in serum lipoprotein levels. Serum samples were obtained from 11 male patients before and at intervals for up to 10 days after surgery, and were assayed for total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), cortisol, tumor necrosis factor-alpha (TNF-alpha), interleukin-1beta (IL-1beta), interleukin-6 (IL-6), and interferon-gamma (IFN-gamma). LDL-C was calculated. The TC showed a 27.9% decrease, from a mean of 4.27 mmol/L to 3.08 mmol/L (p < 0.001) after surgery, reaching a nadir at 24 hours and returning to preoperative values in 7 to 10 days. A similar decrease was noted in the HDL-C and LDL-C levels. IL-6 levels increased from a mean baseline value of 6 pg/ml to a peak of 143 pg/ml at 24 hours (p < 0.0006). There was an inverse relationship between TC and IL-6 levels, with r = -0.51 for the entire curve and r = -0.90 for the cholesterol nadir with the IL-6 peak. The other cytokines did not show significant changes. We conclude that TC and its fractions decrease to a nadir and that IL-6 increases to a peak approximately 24 hours after major surgery. There is a significant inverse correlation between TC and IL-6, suggesting a possible role of IL-6 in postoperative changes in serum lipoproteins.

MR and CT anatomy of the axilla.

PURPOSE: To depict the complex anatomy of the axilla with CT and MR imaging. MATERIAL AND METHODS: The axillary regions of 2 cadavers (with arms hyperabducted) were examined by means of CT and MR. In this position the cadavers were frozen and cryosectioned. The anatomical sections documented by the MR and CT images were compared and anatomical structures were designated. To show the reproducibility of the anatomical structures and to find variations, 20 volunteers were also examined by MR, and 20 consecutive patients without axillary symptoms were examined by CT. RESULTS: The complexity of the axilla was excellently shown by both CT and MR, but MR was able to demonstrate more detail in the small vessels and in the brachial plexus. The comparability of the examinations of the different individuals was best in the axial plane. Some differences appeared in the coronal and sagittal planes caused by different positions of the arm. CONCLUSION: Axillary anatomy was demonstrated in detail and was reproducible with CT and MR imaging.

Pitfalls in sonography of the Gamekeeper's thumb.

The gamekeeper's or skier's thumb is a very common injury. Nondisplaced tears of the ulnar collateral ligament of the thumb (UCL) may be treated conservatively. For that reason an accurate diagnosis is mandatory for choosing the correct therapy. Ultrasound is able to depict the position of the torn UCL correctly in approximately 90 % of cases. Sonographic pitfalls can be caused by a dislocation of the palmar joint capsule to the ulnar joint space, by a scalloping of the adductor aponeurosis due to the displaced UCL, and by scar tissue or technical mistakes. It is important to know about those pitfalls because conservative treatment of displaced UCL tears leads to instability. Therefore, the use of MRI is recommended whenever a nondisplaced UCL tear is suspected by US and a conservative therapy is suggested. Splitting the diagnostic pathway between US and MRI and preferring conservative therapy in nondisplaced UCL tears should help to save money in this field.

[Preoperative axillary ultrasound in breast carcinoma: value of the method in routine clinical practice]. / Präoperative axillasonographie beim Mammakarzinom: Wertigkeit der Methode im Routinebetrieb.

AIM: To evaluate the significance of routinely performed preoperative axillary sonography in breast cancer patients. METHOD: 191 patients with surgical treated breast cancer were analysed retrospectively. 74 patients of these had an axillary sonography done by 5 different examiners. RESULTS: For detecting lymph node metastases sensitivity was 68.2% in all T-stages and 50% in T1-stages with a specificity of 100%. Classification of the axillary status (positive or negative for lymph node metastases) is possible in 90.5% for all T-stages and 94.9% for T1-stages. Microscopic and small lymph node metastases are missed by ultrasound. Compared to axillary palpation, sonography is better. CONCLUSION: Preoperative axillary sonography is an useful diagnostic method even when done routinely. If further criteria are considered, axillary dissection could be avoided in some patients.

[Value of preoperative axilla ultrasound in breast carcinoma]. / Wertigkeit der präoperativen Axillasonographie beim Mammakarzinom.

Preoperative axillary sonography is a superior method in predicting axillary lymph node status than clinical examination in patients with breast cancer. However, the results depend on the skills and care of the examiner, metastases less than 3-5 mm are hardly visible.

Effects of iodinated contrast agents in MR imaging.

PURPOSE: To investigate the effects of iodinated contrast agents in MRI. MATERIAL AND METHODS: Twenty patients were examined with MRI immediately, 8 and 24 h after lumbar myelography. Signal intensities and calculated T1- and T2-relaxation times of different iodinated contrast agents, a dilution row of iopamidol, and a mixture of CSF and iotrolan were compared with physiological saline solution using different T1- and T2-weighted sequences. 1H-spectroscopy was performed with several solutions containing iodine or other substances. RESULTS: A fluid-fluid level of the CSF existed in the lumbar dural sac in all patients immediately after lumbar myelography with a non-ionic iodinated contrast agent. Increased signal intensity on T1-weighted and decreased signal intensity on T2-weighted sequences was found for all contrast agents, as well as for the dilution row, compared with physiological saline solution. The structure of the side chains of the contrast agents is responsible for the T1- and T2-shortening effect. CONCLUSION: It is important to be aware of the effect of iodinated contrast agents in MRI. To avoid misinterpretation of atypical findings, MRI of the spine should not be performed earlier than 24 h after myelography.

Ulnar collateral ligament: differentiation of displaced and nondisplaced tears with US and MR imaging.

PURPOSE: To compare the usefulness of ultrasound (US) and magnetic resonance (MR) imaging in the differentiation of displaced and nondisplaced tears of the ulnar collateral ligament (UCL). MATERIALS AND METHODS: Seventeen patients (eight female and nine male, aged 14-70 years) with clinically diagnosed tears underwent examination with US and MR imaging. T1-weighted, spin-echo (SE) and T2-weighted, turbo SE sequences were used. MR and US findings were compared with those of surgery. Normal UCLs in 21 volunteers were also examined with MR imaging. RESULTS: The results of US were correct in 15 patients, but displaced and nondisplaced ruptures were misinterpreted in two patients (sensitivity, 88%; specificity, 83% for displaced, 91% for nondisplaced). Sensitivity and specificity were both 100% for MR imaging. The T2-weighted sequence was more useful because the normal UCL is rarely homogeneously hypointense. CONCLUSION: MR imaging is better than US, but both methods are useful in the evaluation of the torn UCL.

[The normal CT and ultrasonic findings after a laparoscopic inguinal hernia operation]. / CT- und Ultraschallnormalbefunde nach laparoskopischer Leistenhernienoperation.

Common surgery has been revolutionised by minimal invasive surgery in a very short period of time. Laparoscopic operations of inguinal hernias are routinely done by many surgeons. For interpreting correctly postoperative complications with radiological techniques it is necessary to know the sonographical and CT changes of the normal postoperative situs. For evaluating these changes 23 patients without symptoms were examined between the first and third postoperative day. Typical sonographic findings are high echogenicity of the hernial orifice (17x) and echo-lucent thickening of the spermatic cord. The surgical clips and fleece and CO2 bubbles could not be detected by ultrasound. Using CT we found free peritoneal fluid collection (2x), streaky thickenings in the area of operation (20x), oedema at the hernial orifice (19x), residual CO2 bubbles (22x), thickening of the spermatic cord (22x) and visualisation of the surgical clips. The surgical fleece was invisible in all patients.

[Ultrasound pathology of the axilla. Part II]. / Sonopathologie der Axilla. II. Teil.

In comparison with other diagnostic modalities axillary sonography undoubtedly is highly valuable examining unclear palpation findings, in the staging of tumours with lymphatic drainage to the axilla and in posttherapeutic screening of cancer patients. Usually pathologic changes of the axilla are due to diseases of the lymph nodes. Infrequently there are soft tissue tumours, inflammations, diffuse changes of the axillary soft tissue, vascular diseases and pathologic findings of the shoulder joint. Provided the most common sonographic features of morphologic changes of the axillary tissues are known, sonography of the axilla is a very important diagnostic tool and is extremely helpful in deciding on further diagnostic and therapeutic procedures. Part I deals with the pathology of the axillary lymph nodes, whereas in part II pathological changes of the other soft tissues are discussed in detail.

[Sonographic pathology of the axilla. Part I]. / Sonopathologie der Axilla. I. Teil.

In comparison with other diagnostic modalities axillary sonography undoubtedly is highly valuable in when examining unclear palpation findings, in the staging of tumours with lymphatic drainage to the axilla and in post-therapeutic screening of cancer patients. Usually pathologic changes of the axilla are due to diseases of the lymph nodes. Infrequently there are soft tissue tumours, inflammations, diffuse changes of the axillary soft tissue, vascular diseases and pathologic findings of the shoulder joint. Provided the most common sonographic features of morphologic changes of the axillary tissues are known, sonography of the axilla is a very important diagnostic tool and is extremely helpful in deciding on further diagnostic and therapeutic procedures. Part I deals with the pathology of the axillary lymph nodes, whereas in part II pathological changes of the other soft tissues are discussed in detail.

[Sonographic anatomy of the axilla]. / Sonoanatomie der Axilla.

The axilla represents a region of special interest for small-part sonography. It is easy to demonstrate musculocutaneous, osseous, neurovascular and lymphatic structures. Especially in the presence of breast malignomas with lymphatic drainage to the axillary region sonography of the axillary lymphatic tracts and nodes is essential. The examination is performed with a linear 7.5 MHz transducer with the patient in supine position and the arm hyperabducted. The transducer is directed in transversal and sagittal planes and along the axillary vessels. It is of importance to know exactly the complex topographic anatomy of the axilla. The very dominant pectoral muscles serve as guiding structures. In their vicinity one can find some important groups of lymph nodes. The last station of axillary lymph nodes is the apical group situated along the axillary neurovascular bundle. With their typical echo, the head of the humerus and the coracoid-process facilitate the orientation. Ultrasound is now generally available and should always be used as a secondary method of examination, it breast malignomas are present or suspected in mammogramms, since it supplies important clinical information.

Aneurysm of the proper hepatic artery as a rare source of upper gastrointestinal bleeding.

The rare case of the penetration of a partially thrombosed aneurysm into the duodenal bulb causing acute upper gastrointestinal bleeding is described. Besides angiography and CT, ultrasound is the method of choice for early detection. In any case of upper gastrointestinal bleeding of unclear origin the existence of an arteriointestinal fistula should be included in the differential diagnosis.