BACKGROUND:The purpose of this study was to validate the diagnostic value of direct magnetic resonance imaging (dMRI) arthrography and indirect MRI (iMRI) arthrography concerning intrinsic ligament injuries and tears of the triangular fibrocartilage complex (TFCC). PATIENTS AND METHODS:A randomized prospective trial was conducted with patients who presented with wrist pain potentially due to carpal lesions and 10 patients aged 19-60 years (3 female and 7 male) were included. Between the clinical examination and the diagnostic and therapeutic arthroscopy, dMRI and iMRI arthrography were performed for the diagnostics of injuries of the intrinsic ligaments or the TFCC. The results of dMRI and iMRI arthrography were evaluated by two radiologists blinded to the injuries of the patients and a consensus was reached. The results were compared with the findings obtained by arthroscopy. RESULTS:In the arthroscopy five lesions of the scapholunate ligament (SL), one of the lunotriquetral ligament (LT) and seven of the TFCC were identified. The sensitivity of iMRI and dMRI for carpal ligament lesions (SL and LT) was low (50 %) whereas the specificity was high (93 %). For injuries of the TFCC the sensitivity (up to 100 %) and the specificity (100 %) were both excellent. The area under the curve (AUC) in the receiver operating characteristics (ROC) analysis was high for TFCC lesions in both dMRI and iMRI arthrography. CONCLUSION:Indirect MRI arthrography is a suitable method for detection of injuries of the TFCC and intrinsic ligaments of the wrist with good sensitivity and specificity. Despite the low number of patients the results of this study showed that there were no essential differences between dMRI and iMRI arthrography with respect to the diagnostic value for carpal injuries of the wrist.

Vergleich der diagnostischen Aussagekraft der direkten und der indirekten Magnetresonanz(MR)-Arthrographie hinsichtlich intrinsischer Bandverletzungen und Verletzungen des triangulären fibrokartilaginären Komplexes (TFCC) des Handgelenks.

Evaluation der Sensitivität und Spezifität EKG-getriggerter CINE-Sequenzen hinsichtlich der Detektion der Umgebungsinfiltration durch Thymome.

Ziele: Gd3+-Chelate werden schon lange routinemäßig im MRT als Kontrastmittel eingesetzt. Das Ziel der Studie ist es zu zeigen, dass anorganische NaYF4 Nanopartikel (NPs) mit Gd3+- Ionen beladen ebenfalls einen Effekt auf die T1 bzw. T2 Relaxationszeiten haben und somit potentiell als MRT-Kontrastmittel geeingnet sind. Methode: NaYF4 NPs mit 30mol% Gd3+ (durchschnittlicher Durchmesser von 10nm) wurden synthetisiert. Es wurde eine Verdünnungsreihe in einer NaCl-Lösung mit NPs Konzentrationen von 1.0, 0.8, 0.6, 0.4, 0.2, 0.1, 0.05, 0.02mmol/L hergestellt sowie eine Referenzprobe ohne NPs.

Purpose: Using the BLADE (PROPELLER) technique for T2-weighted MR imaging of the cervical spine has proven to be a reliable tool for reducing artifacts typically for this region. The aim of this study was to evaluate whether the application of BLADE sequences has an impact on the detection of small or low contrast spinal cord and epidural lesions.Materials and Methods: A standard TSE and a BLADE sequence were compared in 33 patients with 46 spinal cord and epidural lesions for T2-weighted sagittal imaging of the cervical spine. Image sharpness, visualization of the dura, reliability of spinal cord depiction as well as lesion contrast were evaluated by two independent readers. Additionally two experienced neuroradiologists selected in consensus the sequence they would prefer for diagnostic purposes. Statistical evaluations were performed using the sign and the chi(2) test.Results: BLADE was significantly superior to TSE regarding image sharpness, visualization of the dura and reliability of spinal cord depiction. Regarding lesion contrast there was a positive trend towards the BLADE sequence. In 17 of 46 lesions, BLADE was judged superior to TSE, while TSE was favored in 10 lesions. In consensus reading both neuroradiologists preferred BLADE for overall image quality in 27 of 33 patients and for lesion contrast in 10 and TSE in 14 of the 33 patients, but 3 TSE sequences were rated as non-diagnostic regarding this criterion.Conclusion: For the detection of even small and low-contrast spinal cord lesions, BLADE is at least equivalent to TSE, yielding better overall image quality and fewer non-diagnostic images.

Regionale Wandbewegungsstörungen und Myokardnarben als Funktionsparameter der koronaren Herzkrankheit (KHK) werden in der Kardio-MRT in der Regel getrennt mittels EKG-getriggerter Cine-Sequenzen und Delayed-enhancement-Sequenzen bestimmt. Ziel des vorgestellten Protokolls ist die synchrone Visualisierung von regionaler Wandbewegungsstörung und zugrundeliegender myokardialer Narbe.

Object Neuronavigation with display of intraoperative structures, instrument locations, orientation and relationships to nearby structures can increase anatomic precision while enhancing the surgeon's confidence and his/her perception of safety. Combination of neuronavigation with functional imaging provides multimodal guidance for surgery of cerebral lesions. We evaluated the impact of functional MRI (fMRI) on surgical decision making and outcome.Materials and methods A neuronavigational device (Stealth-Station (tm), Medtronic Inc.) was used as platform to merge fMRI data with anatomic images, and to implement intraoperative multimodal guidance. In a 52-month period, where 977 surgical procedures were performed with the aid of neuronavigation, 88 patients underwent image-guided procedures using multimodal guidance. Patient, surgical and outcome data of this series was prospectively collected.Results Evaluation of 88 procedures on cerebral lesions in complex regions where fMRI data were integrated using the navigation system demonstrated that the additional information was presented in a user-friendly way. Computer assisted fMRI integration was found to be especially helpful in planning the best approach, in assessing alternative approaches, and in defining the extent of the surgical exposure. Furthermore, the surgeons found it more effective to interpret fMRI information when shown in a navigation system as compared to the traditional display on a light board or monitor.Conclusion Multimodal navigation enhanced by fMRI was judged useful for optimization of surgery of cerebral lesions, especially in and around eloquent regions by experienced neurosurgeons.

Zusammenfassung. Der folgende Beitrag stellt eine multimodale Therapie bei aufmerksamkeitsgestörten/hyperaktiven Kindern vor. Die Therapie bestand aus verschiedenen Therapiemodulen (Aufmerksamkeitstraining mit dem Kind, Eltern- und Lehrerberatung, Sozialtraining), von denen jeweils eine bereichsspezifische Wirksamkeit erwartet wurde. Anhand von Einzelfallanalysen (Grundraten-Versuchspläne) wurde überprüft, inwieweit sich das Zielverhalten der Kinder im Alltag verbesserte. Hierzu wurde in den Grundraten, therapiebegleitend sowie 12 Monate nach Ende der Therapie erfasst, inwieweit die Kinder im Alltag wünschenswertes Zielverhalten realisierten. Eltern und Lehrer gaben hierzu an, inwieweit den Kindern charakteristische und alltagstypische Verhaltensweisen gelangen. Die Wirksamkeit der Therapie wurde in Form von Effektstärken berechnet. Bei Therapieende wurde eine durchgängig große Effektstärke festgestellt. In der Katamnese sahen die Eltern das Verhalten der Kinder als dauerhaft gebessert, während die Lehrer nach einem Jahr einen eher mittleren Behandlungseffekt konstatierten. Die Daten zur Wirksamkeit der einzelnen Behandlungsmodule zeigen, dass zur Stabilisierung der Behandlungseffekte in der Schule eine möglichst alltagsnahe Lehrerberatung notwendig ist. Die hier praktizierte Methodik wird als ökonomische Evaluationsmethode gesehen. Es wird dafür plädiert, in der Praxis vor allem positive Evaluationskriterien heran zu ziehen, um das Ausmaß erwünschten Verhaltens zu erfassen.

There are different methods for obtaining access to quantitative information about the spatial resolution in dosimetric imaging. For polymer dosimetry these methods have mainly been based on comparisons between the dosimetric results of film or pin-point dose visualization to those of MR-based polymer dosimetry (MRPD) the resolution being typically 1 mm. With difference we present a more systematic approach as known from general imaging concepts based on the modulation transfer concept. We investigate periodic dose modulations in photon radiation fields down to spatial structures of a/2 = 280 μm (a: spatial period) using high resolution MR-microimaging at very small voxel sizes (Vs = 199 × 199 × 1000 μm3). The results are compared to those of a film scanner system as used for high resolution relative dosimetry in clinical routine.

Purpose: To analyze the correlation between dose-volume histograms based on organ contour and organ wall delineation for bladder and rectum, and to compare the doses to these organs with the absorbed doses at the ICRU bladder and rectum reference points.Material and methods: Individual MRI based brachytherapy treatment planning was performed in 15 patients as part of a prospective comparative trial. The external contours and the organ walls were delineated for the bladder and rectum in order to compute the corresponding dose-volume histograms. The minimum dose in 2 cm(3), 5 cm(3) and 10 cm(3) volumes receiving the highest dose were referred to as [D2], [D5] and [D10] and compared with the absorbed dose at the ICRU rectum and bladder reference point.Results: The bladder (bext) and rectal (text) doses derived from external contours and computed for volumes of 2 cm 3 [132], provided a good estimate for the doses computed for the organ walls (bw and rw) only (mean ratio [D2]b(ext)/[D2](bw) = 1.1 +/- 0.2 and [D2](rext)/[D2](rw) = 1.2 +/- 0.1, respectively). This correspondence was no longer true when larger volumes were considered (5 and 10 cm 3). The dose at the ICRU rectum reference point did overestimate the dose computed for 2 cm 3 of the rectum wall (mean ratio: 1.5 +/- 0.4). In contrast, the dose at the ICRU bladder reference point did-in the case of inappropriate topographic location of the balloon-underestimate the dose computed for 2 cm 3 of the bladder wall (overall mean ratio: 0.9 +/- 0.4).Conclusion: For clinical applications, when volumes smaller than 5 cm(3) are considered, the dose-volume histograms computed from external organ contours for the bladder and rectum can be used instead of dose-volume histograms computed for the organ walls only. External organ contours are indeed easier to obtain. The dose at the ICRU rectum reference point provides a good estimate of the rectal dose computed for volumes smaller than 2 cm(3) [D2] only for a midline position of the rectum. The ICRU bladder reference point provides a good estimate of the dose computed for the bladder wall [D2] only in cases of appropriate balloon position. (C) 2003 Elsevier Ireland Ltd. All rights reserved.

Purpose: The purpose of this comparative prospective study was to assess the effect of CT and MR based individualisation and adaptation on the dose distribution in the target volume and organs at risk compared to a radiography based procedure.Material and methods: In 15 patients MR scans, in 10 patients additional axial CT-scans with compatible tube-ring applicator in situ were performed and digitally transferred to the PLAT(R) planning system. Considering clinical examination and MR-scan before radiotherapy individual 3-D dose distribution was calculated and adapted based on (1) two orthogonal radiographs; (2) isodoses superimposed on the CT images: and (3) isodoses superimposed on the MR images. Adaptation was strictly limited by the dose level at 2 cm(3) bladder or rectum volume (D-2) to allow comparison of CT and MR plans. All three individualised dose distributions were superimposed on the MR images and cumulative dose-volume histograms were calculated for comparison.Results: 3-D individualisation based on sectional imaging enabled higher dose to the target volume (isodose enclosing 95% of the CTV = CTV95) compared to individualised treatment plans based on orthogonal radiographs by a mean factor of 1.2 (1-1.7). The dose to bladder and/or rectum wall was at the same time not increased beyond the prescribed tolerance level (71% of the prescribed target dose). in a subgroup of 10 patients MRI based treatment plans were superior to CT based treatment plans allowing for a higher dose (138% vs. 124%).Conclusion: Sectional imaging based treatment planning, in particular using MR, was superior to radiography allowing for a clinical meaningful dose escalation without increasing the dose to bladder and rectum beyond the tolerance level. (C) 2003 Elsevier Science Ireland Ltd. All rights reserved.

PURPOSE:Endovascular brachytherapy (EVBT) has been proven to significantly reduce restenosis after percutaneous transluminal angioplasty (PTA). The object of this analysis was to assess the possible correlation between iridium-192 source non-centering and angiographic-determined restenosis. MATERIALS AND METHODS:A total of 113 patients with long-segment lesions of the superficial femoro-popliteal artery (SFA) were randomized to receive either PTA alone or PTA followed by EVBT in the Vienna-2 study. This analysis was performed on a subgroup of 34 out of 57 patients, who received PTA+EVBT. Angiographic restenosis was defined as lumen reduction of more than 50%. Angiograms taken immediately after PTA (34 patients) and at follow-up (25 patients) were analyzed. The distance between the vessel wall and the actual position of the source at the time of EVBT was measured (in mm) and correlated with the follow-up vessel lumen diameter. Measurements were performed at points at a distance of 10 mm from each other. The dose was determined at the luminal surface and at the reference depth of 2 mm into the vessel wall for different distances from the source. RESULTS:Among the 622 measured points, 62 (10.0%) were within restenotic areas; 560 (90.0%) were in arterial segments without proven angiographic restenosis. As far as source centering is concerned, 7.9% of restenotic points were observed when the maximum distance to the arterial wall was <3 mm and 9.6% for 4 mm, respectively. The percentage of restenotic points increased up to 15.9% when the maximum distance to the arterial wall was 5 mm and reached 22.2% when it was >5 mm. CONCLUSIONS:The proportion of restenotic points significantly increased with source non-centering. This observation was interpreted as being related to a decrease in dose at the target. When the maximum distance between the source and the vessel surface was >5 mm, the dose at the reference depth (2 mm into the vessel wall) decreased to values lower than 5 Gy.

PURPOSE:To perform and assess the effectiveness of local excision of recurrent tumor followed by postoperative pulse dose rate (PDR) brachytherapy.MATERIALS AND METHODS:From 1994 to 2000, 17 patients who had small recurrent breast carcinomas after initially undergoing breast-conserving therapy (BCT), which included postoperative radiation therapy, were treated with local tumor excision and PDR brachytherapy. Recurrences occurred at a median time of 50 months (range, 11-208 months) after primary treatment. Eight patients underwent a combination of PDR brachytherapy (total dose range, 12.5-28.0 Gy) and external-beam radiation therapy (EBT) (total dose range, 12-30 Gy). Nine patients underwent radiation therapy with 40.2-50.0-Gy PDR brachytherapy only. The prescribed radiation dose was 0.5-1.0 Gy per pulse. Patients were examined for local tumor control and treatment-related side effects.RESULTS:Twelve of 17 patients had no local tumor at a median follow-up time of 59 months (range, 20-84 months); two of these patients showed signs of having distant disease. One patient died after a cerebral stroke without evidence of tumor. Four women treated with combined EBT and brachytherapy had secondary local tumor recurrences 4, 8, 8, and 11 months after therapy and had to undergo mastectomy. Despite having undergone radiation therapy previously, patients had side effects limited to moderate (grade 1-2) fibrosis.CONCLUSION:Local tumor excision combined with PDR brachytherapy for small local-regional tumor recurrences after primary BCT is feasible and well tolerated and might obviate mastectomy. Preliminary experiences are encouraging. Further studies are required for appropriate patient selection.

Background and purpose: During the past 15 years many retrospective studies and prospective randomized trials have been published supporting the use of breast conserving treatment (BCT) including Surgery and radiotherapy. However, there are still many controversies on the necessary amount of resection, the width of the resection margins and the optimal radiation technique, dose and volume, in particular of the boost. In this retrospective study a large cohort of 410 women with early breast cancer treated with BCT including an interstitial brachytherapy (BT) boost is evaluated after a long follow-up period.Material and methods: In order to clarify the impact of the different treatment-related factors on local control, these were carefully discriminated, based on widely accepted classification and reporting systems for surgery as well as for radiotherapy. The surgical approach was classified according to EORTC criteria and a high rate of quadrantectomies (60%) was found. Dose and volume of interstitial BT is reported according to recommendations of ICRU 58, and reveals a significant radiation dose and volume: mimimum target dose, mean central dose (MCD) and '85% of MCD' for low-dose rate (LDR) BT was mean 20, 28 and 24 Gy, for high-dose rate (HDR) BT it was mean '10, 15 and 13 Gy, respectively; the treated volume was 104 cc for LDR BT and 83 cc for HDR BT.Results: The actuarial rates for overall survival, disease-free survival and disease-specific survival were 97, 90 and 98% at 5 years and 85, 79 and 92% at 10 years. There have been only 16 breast recurrences in 410 treated patients resulting in a 5- and 10-year actuarial local recurrence rate of 2 and 3.9%, respectively; six recurrences (1.5%) were in the original quadrant. Except age and menopausal status, all tumour- and patient-related. risk factors had no significant impact on local control.Conclusions: Our data confirm that intensive BCT leads to excellent long-term results in terms of local control, masking classical risk factors. This high-dose and large-volume interstitial BT seems to be superior to classical BCT without BT. (C) 2002 Elsevier Science Ireland Ltd. All rights reserved.

PURPOSE:To evaluate the feasibility and efficacy of MR-guided interstitial brachytherapy of non-resectable liver metastasis.METHODS:Liver metastases (0.8-5.2 cm in diameter) were treated during a prospective phase I/II study using an open 0.2 Tesla MR system (Magnetom Open Viva, Siemens, Erlangen). MR-compatible brachytherapy applicators were placed percutaneously under MR-guidance in an open 0.2 Tesla MR system (Magnetom Open Viva, Siemens, Erlangen) using fast T1-weighted sequences. Pretreatment and follow-up studies were performed using a 1.5 Tesla MR system.RESULTS:Preliminary results of an unpublished prospective study are discussed exemplary on 2 selected patients. The median procedure time was 4.9 h. No major complications were observed and late effects were acceptable. In large symptomatic metastases only a temporary relief of pain was achieved. In smaller metastases (DM 3 cm) a tumor control was observed.CONCLUSION:MR-guided brachytherapy is feasible and has the potential to ablate liver metastases with diameter of less than 3 cm. Further developments are necessary.

PURPOSE: To evaluate the feasibility, safety, and effectiveness of endovascular brachytherapy for the prevention of restenosis after long-segment femoropopliteal percutaneous transluminal angioplasty (PTA) and stent implantation.MATERIALS AND METHODS: Thirty-three patients (23 men, 10 women; mean age, 66 years) with femoropopliteal lesions (mean treated length, 17 cm; range, 4-30 cm) underwent PTA and stent implantation followed by brachytherapy with a centering catheter. A dose of 14 Gy was delivered to the adventitia by using an iridium 192 source. Long-term pharmacotherapy with acetylsalicylic acid was combined with clopidogrel for 1 month. Follow-up examinations included measurement of the ankle-brachial index, color-coded duplex ultrasonography, and angiography.RESULTS: The overall 6-month recurrence rate was 30% (10 of 33 arteries). Seven patients developed sudden late thrombotic occlusion of the segment with the stent 3.5-6 months after stent implantation. Considering the overall results after successful local thrombolysis in six of these seven patients, only four (12%) of 33 arteries with a stent had in-stent restenosis caused by neointimal hyperplasia.CONCLUSION: The study results are promising concerning the possibility of reducing in-stent restenosis by means of brachytherapy after long-segment femoropopliteal placement of stents. The high incidence of late thrombotic occlusion requires optimization of the antithrombotic regimen.