Nova generacija cepiv HEPAGERIX B® injekcije cepivo proti hepatitisu B, izdelano z genetskim inženiringom • metoda genetskega inženiringa .izkljucuje prisotnost cloveške krvi • popolnoma varno in široko preizkušeno cepivo • visoko ucinkovito cepivo, ki varuje pred vsemi znanimi podvrstami hepatitisa B in pred hepatitisom D • dosega skoraj 100 % serokon_verzijo • lahko ga dajemo v vseh starostnih obdobjih • vsi ga dobro prenašajo Bazicno cepljenje opravimo s 3 intramuskularnimi dozami po eni izmed . shern (O, 1, 6) ali (O, 1, 2): a) osebe, ki so izpostavljene manjšemu ali zmernemu tveganju infekcije: prva doza: dan po izbiri (O) druga doza: mesec dni po prvi dozi (1) tretja doza: 6 mesecev po prvi dozi (6) b) osebe, ki potrebujejo hitro zašcito ali so pogosteje izpostavljene infekciji: prva doza: dan po izbiri (O) druga doza: mesec dni po prvi dozi (1) tretja doza: 2 meseca po prvi dozi (2) Odrasli in otroci starejši od 1 O let: 20 µ,g proteina površinskega antigena v 1 ml suspenzije. Novorojencki in otroci do 1 O let :.10 µ,g proteina površinskega antigena v 0,5 ml suspenzije. Podrobnejše informacije in literaturo dobite pri proizvajalcu. ... KRK. tovarna zdravil, p. o., Novo mesto 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 Marija Auersperg Andrija Hebrang Branko Palcic Ljubljana, Slovenia Zagreb, Croatia Vancouver, Canada Matija Bistrovic Durila Horvat Jurica Papa Zagreb, Croatia Zagreb, Croatia Zagreb, Croatia Haris Boko Berta Jereb Dušan Pavcnik Zagreb, Croatia Ljubljana, Slovenia Ljubljana, Slovenia Malte Clausen Vladimir Jevtic Stojan Plesnicar Kiel, Germany Ljubljana, Slovenia Ljubljana, Slovenia Christoph Clemm H. Dieter Kogelnik Ervin B. Podgoršak Miinchen, Germany Salzburg, Austria Montreal, Canada Christian Dittrich Ivan Lovasic Miran Porenta Vienna, Austria Rijeka, Croatia Ljubljana, Slovenia Ivan Drinkovic Marijan Lovrencic Jan C. Roos Zagreb, Croatia Zagreb, Croatia Amsterdam, The Netherlands Bela Fornet Luka Milas Slavko Šimunic Budapest, Hungary Houston, USA Zagreb, Croatia Tullio Giraldi Maja Osmak Andrea V ero nesi Udine, ltaly Zagreb, Croatia Gorizia, ltaly Publishers Slovenian Medica/ Society ­ Section oj Radiology, Croatian Medica/ Association ­ Croatian Society oj Radiology Correspondence address Radiology and Oncology · Institute of Oncology Vrazov tr{F4 61000 Ljubljana Slo·venia Phone: + 38 61 314 970 Fax: + 38 61 329 177 Reader for English language _ 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 50101 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 Slovenian Ministry of Information, 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 PUBLISHING DIV/SION TABLE OF CONTENTS DIAGNOSTIC RADIOLOGY: . Radiological aspect o{ peptic ukus relapse following vagotomy and pyloroplasty Dujmovic M, Lovasic I, Prica M, Radie M 279 The radiological symptomatology of congenital duodenal atresia Zamberlin R, Smolcic S, Krolo I, Bedek D 287 Algorithm of radiological examinations. in the diagnostics of colonic atresia Frkovic M, Mandic A, Bradic I, Župancic B, Batinica S 291 Resolving of mammographically visible though clinically undetectable Iesions suspicious for breast cancer ĽJ . COMPUTERIZED TOMOGRAPHY ANO ULTRASOUND Computerized tomography of the orbit Cerk M Evaluation of metastatic invasion in the wall of main neck vessels. Conventional versus color-coded ultrasonography Juretic M, Šustic A, Fuckar Ž, Car M Colonic sonography Ivaniš N, Rubinic M, Peric R, Banic D, Kraus I 301 304 308 CLINICAL ONCOLOGY The role of radiation in the treatment of childhood malignancies Jereb B 312 lnflammatory breast cancer. Five-year survival of patients with inflammatory breast cancer treated in the period 1986-1987 at the Institute of Oncology in Ljubljana Lindtner J 320 HISTORY OF NUCLEAR MEDICINE -The history of nuclear medicine in the Republic of Slovenia II -spread of the new , medica) speciality into peripheral hospitals from 1960 to 1974 Šuštaršic J . 326 REPORTS The 37th meeting of EORTC group for radiotherapy Jancar B 333 Course of scientific and medica! illustrations Benulic T 338 NOTICES 340 AUTHOR INDEX and SUBJECT INDEX, 1992 Radio/ Oncol 1992; 26: 279-86. Radiological aspect of peptic ulcus relapse f ollowing vagotomy and pyloroplasty Milivoj Dujmovic, Ivan Lovasic, Milan Prica, Milan Radie Clinical Hospital Center Rijeka, Institute of Radiology, Clinic of Interna! Medicine Health Center Krk, Croatia Changed anatomic relations in pylorobulbar area with altered contour appearances and unusual course of folds are the causes of pseudocicatricial changes and the ulcer niches and craters, conditioning great difficulties in discovering of peptic ulcus relapse. lndirect relapse signs are of much greater significance during radiological examinations. The finding of stenosis, especially accompanied by other indirect relapse signs and clinical symptoms, represents a reliable sign of the repeated appearance of peptic ulcer. In our group of examined patients relapses were found by radiological method in 3. 74 % of cases and by endoscopic method in 7.35 % of cases. The preference has been given to the endoscopic examination, especially at ulcus discovered in a deformed pylorobulbar area. Conversely, radiological examination is ·indispelisable in evalution of stomach emptying, and the presentation of the site, leve! and length of stenosis. Radiological examination offers us better possibilities in verifying of complicated ulcus relapse than the endoscopic examination. Key words: peptic ulcer-radiology; vagotomy; pylorus-surgery; recurrence lntroduction Changed anatomic relations in pylorobulbar area are the cause of great difficulties in radio­logical interpretation of a peptic ulcus relapse. Data about the relapse frequency cited in lite­ra!ure vary very much, depending onthe kind . of -vagotomy, · the drainage .ethod and the • ·· _postoperative tirne. Proximal selective vagotomy (PSV) with drai­nage operation or without it should be followe,d Correspondence to: Doc. dr. se. Dujmovic Milivoj, Klinicko bolnicki centar Rijeka, Zayod za radiologiju, 51000 Rijeka, Krešimirova 42, Croatja. UDC: 616.33-002.44-089.85-06:616.33-002.44• by the least number of relapses.1-3 Various percentage of relapses concerning the total po­sterior vagotomy combined with the selective anterior vagotomy, partially tirne dependent as well, have been reported_ in literature, ranging from 2.4 % to 10 % . The percentage of relapse exceeds 20 % at bilateral to tal vagotomy. 4-S Various relapse percentages are also reported in literature with reference to particular types of drainage operations, ranging from 20-27 % at vagotomy and gastroanastomosis to 22.5 % at vagotomy combined with Heineke-Mikulicz pyloroplasty, and 1_0;9.% after Finney's pyloro­ 3 69 plasty .2' , • Clinical data referring to the same group of examined patients, being the topic of our study but during a much earlier treatment phase, speak about 2.4 % of relapses at Hei­ Dujmovic M et al. neke-Mikulicz pyloroplasty and no relapses af­ 5 ter Finney's pyloroplasty.4· According to literature, relapse occurrences are most frequently expressed during the first postoperative year (80 % ). Their number in­creases up to the tenth year following sur­gery. 4, 5, 7 The purpose of this paper is to establish the real place of radiological diagnostics in peptic ulcus verification following vagotomy and pylo­roplasty, with special emphasis on the endosco­pic method of examination. We tried to eva­luate particular radiological relapse symptoms and to draw a parallel between the relapse frequency and literature quotations based on a long-term follow-up of the patients. Patients and methods Because of ulcus disease, from January 1st 1965 to the end of 1984 1358 patients underwent vagotomy using one of drainage methods. An­terior selective vagotomy (VSA) and total po­sterior vagotomy (VTP) were performed as a rule. Urgent and adipose older patients under­went bilateral total vagotomy (VTA and 5, 7, 10, 11 VTP).4, Of drainage operations, sec. Finney was applied 1230 times (90 % ) and sec. Heineke-Mi­kulicz (in the earliest phase) 104 times 5, 7, 10, 11 (8 % ).4, VSA and VTP were most frequently perfor­med in combination with Finney's pyloroplasty -991 times (74%), whereas VTA and VTP combination with sec. Finney took the second place by being used 249 times (18 % ). VTA and VTP with Heineke-Mikulicz pyloroplasty was carried out 96 times (7 % ) at the initial use of the method. The number of male operated patients amounted to 1154 (85 % ) , vs. 204 (15 % ) in females. Most of the operated males were in the fourth and fifth and females in the fifth and sixth life decade. The sequence of indications for surgery in our group of patients were: chronic duodenal ulcus with severe discomforts (29 % ) , perforat­ ed duodenal ulcus (23 % ), chronic duodenal -ulcus and bulbostenosis (22 % ) and bleeding duodenal ulcus (16%).4· 5• 7• 10-12 Preoperative radiological examinations were routinely carried out in ali the patients except those operated urgently. The first (early) post­ operative follow-up examination was obligato­ rily performed in ali the operated between the eighth and the tenth day following surgery, after the nasogastric probe had been removed, in order to check gastric evacuation. For patient examination we used 200 ccm of barium suspension of various producers and without a special preparation. Gastrografin was only exceptionally used for check-up for fear of postoperative complications. Late follow-up examinations were carried out from the sixth month following surgery, but only in those patients who came because of some disturban­ ces and suspected relapse. Checkups covered the subjects from our group of examined patients during the tirne span of 25 years, i. e. five years after the last operated case. Based on reports of other authors and our own experience, in radiological treatment of patients we always tried to establish ali the direct and indirect signs of peptic ulcus relap­ se.1-3, 10 Proved ulcer craters or niches, dis­ played stenosis with more or less expressed aggravated gastric emptying and repeated mor­ phological findings of suspected lesions during a shorter tirne period were counted among · direct radilogical signs of relapse, whereas more or less aggravated gastric emptying, spastic nar­rowing of the antrum lumen and plastic pyloro­bulbar area, mucous membrane oedema of the pylorobulbar area, local sensibility at dosed compression and duodenogastric reflux were among the indirect radiological signs. However, we always tried to establish the efficiency of pyloroplasty by analysing the ap­ pearance of the former area of the pylorus and . bulbus. Retained symmetric or asymmetric bul­bar base with displayed even slightly dilated pylorus has been regarded as a sign of ineffect­ual pyloroplasty. 2• 3· 8• 10 Radiologica/ aspect of peptic ulcus relapse following vagotomy and pyloroplasty 281. Figure 2b. Relapse of d. uodenal ulcus and face-on view showing an oval crater. Dujmovic M et al. Figure 4b. Narrowing of the whole py Ioroplastic area. _ Radiological aspect of peptic ulcus relapse following vagotomy and pyloroplasty Results Ventricular ulcer relapse has been established twenty-one times, being localized along the lesser curvature (Figure la) up to the very border against the duodenum. Ulcer niche find­ing was accompanied by aggravated gastric em­ptying in thirteen patients and was conclusive of ulcer retention (Figure lb). No signs of aggravated evacuation were expressed in eight other patients, whereas typical signs for pene­tration were observed in three subjects (Figure le). We had severa! retention findings without discomforts and without relapses. In our opi­nion, it was a question of candidates for relapse. Pylorobulbar area ulcer relapse has been established eighteen times, but only four pa­tients developed aggravated gastric emptying. Some of indirect radiological symptoms have always been found. Ulcer was more frequently displayed in the form of niche (Figure 2a), and less often as a crater of various form and size (Figure 2b). Relapses were mainly localized at the side of the lesser curvature. Of ali the eighteen findings two revealed penetrating ul­cers (Figure 3a), while two patients developed perforatio tecta (Figure 3b). Ali the four find­ings of complicated duodenal ulcers were cha­racterized by the extension from the side of the lesser curvature towards the area of the lesser omentum. Stenosis of the pylorobulbar area with signs of aggravated evacuation were also established. Stenosis as a symptom of ulcer relapse with­out corresponding direct signs of ulceration was found ten times. It has been found as an accompanying symptom in ali the patients with complicated ulcer relapse together with signs of aggravated gastric content evacuation. Accord­ing to the site we found stenosis five times in front of the plastic area (Figure 4a), twice in plastic pylorobulbar area (Figure 4b) and three times aborally from the plastic part (Figure 4c). Special attention was paid to the tirne of gastric emptying in the case of indirect signs. The average tirne value of the initial evacuation amounted to 6 seconds and the complete emp­tying was 23 minutes within our group of radio­logically examined patients. The examined con­trol groups without ulcer showed the average initial evacuation of 33 seconds and the com­plete emptying tiine of 1 hour and two minutes under the same conditions.10 More than one hour till complete emptying, established in our group of the examined subjects, was considered as prolonged. Based on this criterion, retarded evacuation was recorded twenty-five times; thirteen times with ventricular ulcer relapse; four times with duodenal ulcer relapse and eight times without verified relapse. Of these eight findings a dece­lerated emptying was observed in five patients in the standing position--only. Contrast medium just poured over into the aboral part of duode­num in the right hip lying position. Such finding was recorded only in the case of hook-shaped postoperative stomach with expressed signs of adhesion in the pylorobulbar area. One case developed decelerated evacuation because of spasm and oedema of the antral mucous mem­ . 284 Dujmovic M et al. Table l. Time of relapse occurrence. Discussion and conclusion Postoperative years Number of relapses Relapse percentage · following vagotomy and O-1 3 pyloroplasty cited in literature varies very 1-3 much, ranging from 2 % to 40 % . The results 3-6 28 6-10 10 are not always comparable since they relate to 10-20 10 various types of vagotomy and pyloroplasty and different intervals of tirne after surgery. Z-4, 7 For example, Franciškovic and co-authors reported brane and the pylorobulbar area. The sigris of 1.8 % of relapses in 1967 and 2.5 % of them in spasm and oedema withdrew after a drug ulcer 1972, i. e. 3.5 years following surgery, for our therapy and the evacuation tirne shortened to group of examined patients. Šepic (1974) gave average values. No organic changes that would the figure of 3.l % and Dujmovic (1985) 3,7%. be the cause of retarded emptying were record­We reported the average percentage of 3.9 % s, 7, 10 ed in two patients. 12.5 years following surgery in 1990.4• Duodenogastric reflux could be presented in As for the tiine occurrence, relapses in our the best way in the right anterior lying position group, for the difference from citations of other when the prepyloric part of the stomach was authors, are represented by a small number filled with air. It occurred much more frequent­during the first year postoperatively. Relapses ly in operated than inoperated patients, but no are mostly found in the second and the third more frequently in those with proved relapse . year (45 % approximately). They suddenly de­ Other indirect signs could be easily radiologi­crease after the tenth year, which is in agree­. cally verified, being useful as an additional ment with quotations from literature (Table 1). argument for suspected relapse confirmation. Stenosis in pylorobulbar area is a frequent The tirne of relapse occurrence has been symptom. We consider very expressed stenosis, shown in Table 1 ranging from four months to together with clinical signs, to be a reliable sign fifteen years. Most relapses were found in the of relapse. Therefore, this radiological symptom second and the third year following surgery, has been counted among direct signs of peptic with a sudden decrease after the tenth year. ulcus relapse. The site of stenosis, and the The same group of patients underwent endo­extent and length of the narrowed area need scopic examination also, and the parallel fin­to be verified for surgical indication. Sapou­ 23 dings were numarically presented in Tabie 2. nov· also reports stenosis as a reliable sign of Endoscopic findings were considered to be clo­relapse. The standpoint taking stenosis as a ser to a real situation and 7.35 % of relapses, secondary consequence of already primarily oc­including stenosis, as a real fact. curred relapse is only partially acceptable. We Table 2. Comparative numerical presentation of peptic ulcus relapses verified by endoscopic and radiological method. Endoscopic examination Radiological examination No. of of these No. of of these found % ulcus perf. found % ulcus perf. ulcera penetr. tecta ulcera penetr. tecta Relapse of ventricular 26 1.91 1 o 21 1.54 2 o ulcer Relapse of duodenal 3.97 o o 18 1.32 2 2 ulcer Stenosis 20 1.47 o o 12 0.88 o o Tota! 100 1 o 51 4 2 Radiological aspect of peptic ulcus relapse following vagotomy and pyloroplasty believe that a part of stenoses appear indepen­dently of relapse occurrence, as a consequence of cicatricial changes in the operated area. So developed stenosis can secondarily generate ag­gravated gastric evacuation and provide favour­able conditions for relapse appearance. Direct evidence of an ulcer crater or niche of the contrast in morphologically altered pylo­robulbar area represents the main problem in the verification of relapse. Plastic technique, formed cicatrices, adhesions and pockets are very likely to produce radiological pictures re­sembling ulcus craters and niches. An ulcer displayed as a crater represents a special pro­blem. Therefore, most of our relapses are shown as ulcus niches. Changing of their forms during examination indicates that ulcers are out of question. Whether there is a typical fold convergence against the crater or not is of no practical significance because of markedly chan­ged appearance of the pylorobulbar area as a whole, and the fold extension at the site of pyloroplasty. Additional difficulties are caused by fold superposition of the anterior and post­erior wall crossing in various directions follo­wing pyloroplasty. Much greater importance should be attribut­ed to the indirect relapse signs than during the examination of inoperated patients. At any rate, ali these patients are to be subjected to· endoscopic examinations. The tirne of gastric evacuation is of special interest. Decelerated emptying is most fre­quently accompanied by ventricular and duode­nal ulcus relapse. Slowed down evacuation was verified in standing position only in one fifth of these patients where relapses _have not been found. Gastric content is easily evacuated through usually wide pylorobulbar area in the right hip lying position. These findings are interesting from the relapse-preventing point of view, being most probably a consequence of adhesive changes around the pylorobulbar area and weaker gastric wall tonus. Evacuation con­trol is thought to be indispensable in such cases in lying position also. Comparison of radiological and endoscopic findings is of great importance for the assess­ment of peptic ulcus relapse after vagotomy and pyloroplasty. According to our opinion, the preference should be given to the endosco­pic examination, especially with ulceration dis­covered in a deformed pylorobulbar area. This is well evident from Table 2 since the lesser difference of positive findings at verification of ventricular ulcus and stenosis is obvious. A greater number of complicated ulcer relapses associated with radiological examination are worth mentioning here. Regardless of greater efficacy of relapse de­ 2• 3, 13, 14 tection by endoscopic method, radiolo­gical examination is especially important and indispensable for the evaluation of gastric emp­tying, imaging of the site, extent and length of stenosis and verification of complicated relap­sing ulcers. Disregarding the advantage of en­doscopic examination, the use of both methods should be supported supplement since they are complementary to each other. References l. Jamakoski B, Novak J. Peev A, Serafimov K, Ivanov A. Rendgenološki, morfološki i funkcio­nalni karakteristiki na gastroduodenumot posle proksimalna gastricna vagotomija. In: Zbornik radova l. naucnog sastanka, Yagotomija u lijece­nju gastroduodenalnog ulkusa, 1978; 297-305. 2. Sapounov S, _Soehendra N, Rehner M. Zur Diag­nostik des Ruckfallgeschwurs nach Pyloromyopla­stik. Fortschr Rontgenstr 1973; 118: 32-7. 3. Sapounov s, ·Krause D. Die radiologische Diag­nose des Rezidivgeschwtires nach Drainageopera­tionen. Fortschr Rontgenstr 1975; 122: 547-50. 4. Franciškovic V, Budisavljevic B, Šepic A. Vagoto­mija i piloroplastika u lijecenju duodenalnog ulku­sa. Acta Fac Med Finuminensis 1967; 1: 161-9. 5. Franciškovic V, Šepic A, Budisavljevic B. Rane i kasne komplikacije specificne za vagotomiju. In: Zbornik na trudovite, XII Kongres na jugoslaven­skite hirurzi, 1972; 217-20. 6. Bryan WM, Klein D, Griffen WO. The role of Yagotomy in Duodenal Ulcer. Surgery 1967; 61: 864-9. 7. Šepic A. Yrijednost vagotomije i piloroplastike u lijecenju perforiranog duodenalnog ulkusa. Dok­torska dizertacija, Medicinski fakultet Rijeka, 1974. 8. Mass R, Vogel H. Die Rontgenmorphologie des Magenausgangs nach Pyloroplastikoperationen. Fortschr Rontgenstr 1982; 137 (4): 428-33. Dujmovic M et al. 9. Zamberlin R, Smolcic S, Krolo l. Radiological appearance of the gastroduodenum following mo­dem surgical treatment of duodenal ulcer. Radio/ Oncol 1992; 26: 9-13. 10. Dujmovic M. Prilog poznavanju radiološke slike želuca i dvanaesnika poslije vagotomije i piloropla­stike. Doktorska dizertacija, Medicinski fakultet Rijeka, 1988. 11. Zaninovic N, Švalba N, Komljenovic B, Gudovic A, Zelic M, Franciškovic V. Analiza i rezultati vagotomije i piloroplastike u lijecenju ulkusne bolesti. In: Zbornik radova I. naucnog sastanka, Vagotomija u lijecenju gastroduodenalnog ulkusa, 1978; 31-9. 12. Dobrila F, Longhino A. Indikacije za transtora­kalnu trunkalnu vagotomiju. In: Zbornik radova l. naucnog sastanka, Vagotomija u lijecenju ga­stroduodenalnog ulkusa, 1978; 271-4. 13. Gašparov A. I rendgenološka i endoskopska dijag­nostika ulkusa. Lijec Vjesn 1977; 99: 577-8. 14. Prica M, Švalba-Novak V. Endoskopski nalazi u bolesnika s vagotomijom i piloroplastikom. In: Zbornik radova I. naucnog sastanka, Vagotomija u lijecenju gastroduodenalnog ulkusa, 1978; 307­11. Radio/ Oncol 1992; 26: 287-90. The radiological symptomatology of congenital duodenal atresia Ratko Zamberlin, Silvestra Smolcic, Ivo Krolo, Darko Bedek Clinical Hospital "Sestre Milosrdnice", Zagreb Radiological and Oncological Institute Atresia duodeni is a rare disease of the gastrointestinal tract due to disturbed development of the embryo. Over an 8 year period deliveries were observed for the detection of this congenital anomaly in infants in The Obstetrics Department. Out of 12 000 infants observed, three were diagnozed at our Institute as having congenital atresia duodeni. Only two cases are presented in this paper. The water soluble iodine contrast medium plus plain film of the abdomen were employed as radiological diagnostic techniques. An accurate and early diagnosis of this anomaly is of a paramount importance since the infant's life depends on timely surgery. The radiological symptomatology, materials, examination methodology and the differential diagnoses are presented in the paper. Key words: duodenal obstruction-congenital; intestinal atresia-radiography Introduction Among congenital malformations of the ga­strointestinal tract atresias are the most uncom­mon ones. Although atresias may occur in any part of the gastrointestinal tract, they extremely rarely occur in the duodenum. When they do, it is mostly in the second portion of the duode­num (pars descendens duodeni) but they can 2• 3 . also occur in the third and other portions.1• This anomaly is in 60 % of cases associated with other congenital malformations. One third of infants affected by this disease are mongo­loids. 4· 5 Correspondence to: Zamberlin Ratko MD, Radiologi­cal and Oncological Institute, Clinical Hospital "Sestre Milosrdnice", Vinogradska 29, 41000 Zagreb, Croatia. UDC: 616.342-007.271-073.75 Materials and methods Over an 8 year period observation of the deli­veries at The Obstetrics Department, 32 out of 12 000 bom infants were examined because they had symptoms of an obstruction or stenosis in the upper gastrointestinal tract. Twenty in­fants were males and twelve females. As radiological diagnostic techniques we em­ployed a plain film of the abdomen and the examination of the upper gastrointestinal tract, using water soluble iodine contrast medium (Gastrografin). Radiological appearance and discussion Since this congenital anomaly is incompatible with infant's life, timely radiological diagnosis 1• 6 is extremely important for successful surgery . Possible methods for obtaining an accurate diagnosis are plain films of the abdomen and Zamberlin R et al. Figure la. Atresia of the second segment of the duodenum. Plain film of the abdomen showing "dou­ble bubble". the water soluble iodine contrast medium exa­mination. If after these examinations it is yet not possible to make a conclusive radiological diagnosis, the examination of the duodenum using water soluble contrast medium along with some drugs (Glukagon, Reglan) i.e. hypotonic duodenography, might be performed. Sometimes a plain film of the abdomen may be diagnostic. The plain film of the abdomen shows two large air collections, in the upper 4 part of the abdomen "double bubble" . 1• One air collection is seen paravertebrally under the left diaphragm and presents · the stomach fun­dus. The other air collection is seen paraverte­brally on the right, somewhat lower than the former one and presents the distended portion of the duodenum immediatelly above the obs­truction. The lack of air in the lower segments of the small intestine also shows that the obs­truction is complete. Figure lb. The same case examined with water soluble iodine contrast medium (Gastrografin). Over the period observed we examined 32 infants with symptoms of complete obstruction or stenosis of the upper gastrointestinal tract and found three cases of congenital duodenal atresia. Twenty infants were males and twelve females. The X-ray findings of only two cases are presented. In the first case atresia occurred in the second segment of the duodenum and was associated with mongoloism. The patient was operated on at the Surgery Department in The Children's Hospital Zagreb, but the opera­tion was unsuccessful and the patient died (Fi­gures la and lb ). In the second case the ob­struction was found in the third segment of the duodenum. The operation performed was suc­cessful (Figures 2a and 2b). In the first case differential diagnosis might consider another congenital duodenal anomaly i.e. pancreas anulare and in the second case radix mesenterii. However, the complete Jack The radiological symptomatology of congenital duodenal atresia Figure 2a. Atresia of the third segment of the duode­num. Plain film of the abdomen. of air in the lower segments of the small inte­stine confirms the diagnosis of complete ob­struction or duodenal atresia. The data found in literature suggest that the incidence of this congenital anomaly is 1 in 6000 of infants or 0.017 % . In the 8 year period from 1984 through 1992, there were three cases of this extremely uncom­mon anomaly of the gastrointestinal tract iden­tified at our Institute, the incidence ratio being 1 in 4266 or 0.023 % . Thus, our data show a slightly higher inci­dence than that reported in literature. Conclusion In conclusion, it might be said that the timely radiological diagnosis of this congenital ano­maly of the gastrointestinal tract is of a para­mount importance for adequate surgical treat­ment since this is the only efficient way of saving the child's life. Zamberlin R et al. References l. Vaugham VC. Nelson's Text Book of Pediatrics. Philadelphia: Saunders, 1979. 2. Frankoni G, Wallgren A. Pedijatrija. Zagreb: Me­dicinska knjiga, 1975. 3. Oberiter V, Petrovcic F. Atrezija jednjaka. Lijec vjesn 1956; 78: 233-39. 4. Sutton D. Text Book of Radiology. London, New York: Churchill Livingstone, 1987 .. 5. flavšic B. Radiologija probavnog kanala. Zagreb: Skolska knjiga, 1979. 6. Štulhofer M. Digestivna kirurgija. Zagreb: GZH/ JAZU, 1985. Radio/. Oncol 1992; 26: 291-5. Algorithm of radiological examinations in the diagnostics of colonic atresia Marija Frkovic, 1 Ante Mandic, 1 Ivo Bradic, 2 Božidar Župancic, 2 and Stipe Batinica2 Clinical Hospital Center "Rebro" 1 Department of radiology, 2 Department of pediatric surgery Colonic atresia is a rare form of intestinal atresia. During the period 1986---1991, three newborns with atresia of the transverse colon, type 111, were diagnosed, and treated surgically. The authors suggest the algorithm of examinations and discuss radiological methods in preoperative treatment of patients and in postoperative course as well as possible complications. Key words: colon-abnormalities; intestinal atresia-radiology Introduction Colonic atresia is a rare congenital anomaly with the incidence of 3-15 % in ali intestinal 1• 23• 4 atresias. · It is considered that the occlusion of the mesenteric blood vessels during the 6th-7th week of fetal development is the primary etiological 5, 6 cause of these anomalies.1· 2· 3, Colonic atresias can often be found associated with other intestina12 · 4• 7• 8• 9• 10 and extraintesti­nal anomalies.7• 9• 10 They can be located from 11 12 the cecum to rectum• · 13 in the form of a diaphragm-type I, as atresia with the fibrous cord between the blind ends without fissura in the mesentery-type II, and in the form of Iarger or smaller fissura in the mesentery-type III . 1 • 3, 14 Correspondence to: Marija Frkovic, MD, 1 Clinical Hospital Center "Rebro", Department of Radiology, Kišpaticeva 12, 41000 Zagreb, Croatia. UDC: 616.348-007.271-073.75 Martin and Zerella9 have classified multiple intestinal atresias as type IV, and Grosfeid15 has classified multiple "apple peel" small bowel atresias as type IIlb. There are various sugge­stions about predisposing iocalizations of cer­ 12 13 tain types of colonic atresias.11• · Patients with colonic atresia are characterized by clinical and radiological symptoms of low ileus. Clinical symptoms of the colonic atresia are failure of evacuation of the meconium during the first 24 hours after birth, the abdominal distension and bilious vomiting. The exact diagnosis of the etiological cause and the leve! of obstruction is based on radio­Iogical analysis. Plain radiograph of the abdo­men in supine and upright position is useful for the localization of the leve! of obstruction. 1• 9 The etiological cause of obstruction can be defined on the basis of barium enema stud­ 4 ies.1· · 9· 16· 17 However, with this examination it is not possible to determine either the type of Frkovic M et al. lesion or the size of the atretic segment. The Patients and methods proximal, preatretic colon is often filled with dense meconium, and in most cases the at­. tetnpts to define its size using air or perorally : given contrast medium remain without result. Recently, attempts have been made to de­_monstrate the preatretic segment using ultraso­ ·--nograp_hy (US) . 18• 19 These examinations are, in some cases, limited by distended proximal loops of the iritestines. The th.rapy of this anomaly is surgical. Va­rious surgical treatments performed in two, or more .rarely in one stage, from colostomy to direct anastomosis, with or without extensive rese˝don of the dilated pre11tretic segment of 7, 15 the colon, have been suggested.2• 5, In the last 5 years (1986-1991) we have diagno­sed, surgically treated and clinically followed up 3 newborns with congenital atresia of the colon, Type III (Table 1). Ali 3 infants were bom at term, after uncomplicated pregnancies. D. N., a female, and P. N., a male newborn, were transferred from Maternity Hospital to our Surgical department. They were of the same age, and presented with identical sympto­matology -absence of me.conium, distended, tense abdomen and bilious vomiting. Their ge­neral condition allowed adequate preoperative treatment. US finding showed marked distension of the intestines. Plain radiography of the abdomen in Table l. Demonstration of applied diagnostical methods and findings in our patients with colonic atresia. Name Sex Age {hours) Applied rtg methods Rtg ffiagnosis Surgical diagnosis Schematic presentation of anomalies D.·N. f 48 Preoperative -plain radio­graphs of the abdomen ileus colonic atresia -US type III colonic -barium enema atresia Postoperative -barium enema normal finding P.N. m 40 Preoperative -plain radio­ ileus graph of the abdomen colonic atresia -US type III -barium enema colonic atresia Postoperative -barium enema normal finding G.D. m 96 Preoperative -plain radio-. graph of the abdomen Postoperative I -plain radio­graph of the abdomen -US -CT -barium enema Postoperative II -barium enema pneumo­perito­neum dehiscen­ce, para­colic abscess normal finding perforation, (p) peritonitis, colonic atresia type III dehiscence, paracolic abscess Algorithm of radiological examinations in the diagnostics of colonic atresia Figure l. Atresia of the transverse colon. The post­atretic segment of the colon with concave-convex proximal contour demonstrated by means of barium enema. The colon is narrow, without meconium. supine and upright position showed signs of low ileus. In patient D. N. on barium enema examina­tion, the rectum, sigmoid and the descending colon down to the left flexure were demonstra­ted (Figure 1). In patient P. N. the colon was demonstrated up to the middle third of the transverse colon. Aboral parts of the colon had narrow lumen, about 1 cm wide, without meco­nium, with concave-convex proximal ending. Radiological diagnosis of intestinal atresia was surgically confirmed. In patient D. N. the atretic segment was in aboral, whereas in pa­tient P. N. in proximal half of the transverse col on with wide fissura in the mesentery, type III. The proximal preatretic segment of the colon was dilated and measured 10 cm. During surgery, t.e preatretic dilated colon was remodelled by resection of an antimesente­ric part in a conically shaped cylirider about 1.5 cm wide at its aboral part. By termino-ter­minal anastomosis the preatretic and postatretic segment of the colon were connected. The Bauchini valve was preserved. Apendectomy was also performed. Postoperative recovery was without complications. Third patient, G. D., a male newborn was 4 days old when he was transferred from Mater­nity Hospital to our Surgical department. On admission he was in a state of prostration, vitally threatened. On native supine and upright radiographs of the abdomen, signs of pneumo-· peritoneum were found. Surgery was indicated without further radiological examinations. At surgery, atresia of the proximal segment of the transverse colon, type III, was found. The postatretic segment was 1 cm wide. The preatre­tic segment was approximately 8 cm wide and on its aboral part, about 10 cm from the Bau­chini valve, a perforated orifice about· 2 cm wide, was seen. In the peritoneal cavity a larger mass of meconium was found. At first surgical intervention the orifice was closed, the lavage of the abdominal cavity and anus preter on proximal preatretic segment of the colon were done, and antibiotics and paren­teral feeding were ordered. After recovery, during second surgical inter­vention, remodelling of the proximal preatretic segment of the colon, termino-terminal anasto­mosis with distal postatretic segment of the colon, and closing of anus preter were done. On the 3th postoperative day complications with sepsis occurred. On plain roentgenograms of the abdomen, in the upper medial abdomen, beside gas in the intestines, aeroliquid levels which were identified to be paracolic abscesses, were seen. There were no signs of ileu.. ·. US and CT have not confirmed the diagnosis of abscess. Barium enema was indicated. Using barium water mixture, aboral part of the colon was demonstrated. Close to the anastomosis, the lumen of the colon was reduced to a narrow track of contrast medium which filled the irre­gular cavity of paracolic abscess towards the 294 Frkovic M et al. Figure 2. Postoperative complication, dehiscence of termino-terminal anastomosis and paracolic abscess (-) caudal contour of partly dehiscented suture (Figure 2). The child was reoperated. The postoperative course with intensive antibiotic therapy was without complications. Discussion The aim of our study was to assess the possibi­lities and limitations of radiological methods because prognosis of the patients with colonic atresia depends on correct and early diagnosis. The diagnosis of low ileus was established on the basis of plain abdominal roentgenograms, and the etiological cause of ileus was found using barium enema examination. "Hook sign" ,16 "cul-de-sac", 12 or concave-convex pro­ximal contours of postatretic segment of the colon demonstrated by use of contrast medium, are important signs in the diagnostics of this pathologic condition. However, on the basis of these examinations, neither the type of atresia nor the size of the atretic segment can be diagnosed. At surgery, in ali 3 patients, atresia of the transverse colon, type III, was found. It is the usual predisposing site of this type of atresia.11• 12 The possibilities of US and er in the preope­ rative diagnostics are limited by large quantities of gas present in the proximal bowel Ioops. 18• 19 The therapy of these anomalies is surgical. Its aim is to restore the continuity of the intestines. The type of the surgical intervention depends on the location of atresias, their num­ber, associated anomalies and physical status of 457 patient.3• • • • 9• 12 Our two patients underwent only one surgery, whereas the third patient G. D. underwent three surgeries due to the compli­cations described above. Despite the advanced surgical techniques, the mortality rate of children with this anomaly is very high, especially if the diagnosis and indication for surgical treatment is prolonged which can cause the perforation of the intesti­ 9, 10, 20, 21, 22 nes. 6, The possibility of development of functional obstruction in the postoperative treatment after restoration of intestinal continuity, which can also lead to lethal outcome, is discussed in literature. 23 In our opinion, in our patient G. D. the association of all previously mentioned parame­ters has contributed to the complicated course of illness, but fortunately, without lethal ·outco­me. On the basis of plain roentgenograms and barium enema studies the status of colon, ana­stomosis, postatretic segment of the colon after surgery, as well as possible complications can be diagnosed. US and er examination in this period of illness are inadequate. In summary, on the basis of our own and other authors' experience, we suggest the follo­wing algorithm of examinations in the cases suspective of colonic atresia: Algorithm of radiological examinations in the diagnostics of colonic atresia l. US is a method of limited possibilities in the diagnostics of this pathology. We recom­mend it as a screening method in less complica­ted cases. 2. Plain roentgenograms of the abdomen in supine and upright position are useful in the diagnostics of the level of the obstruction. 3. Barium enema is a necessary diagnostic method in defining the level and the etiological cause of the obstruction. 4. Barium meal examination or any other radiological method (CT) with regard to its harmfulness and usefulness is not justified in the diagnostics of this pathology. The postoperative follow-up of the morpholo­gical and functional status of the colon requires barium enema examination. Due to the possible preoperative or postoperative complications, the clinical status of a patient can modify the algorithm of examinations. References l. Harbor MJ, Altman DH and Gilbert M. Congeni­tal Atresia of the Colon. Radiology 1966; 84: 19-23. 2. Meradji M und Molenar JC. Kongenitale Atresie des Kolon. Z Kinderchir 1976; 18: 170-80. 3. Rickham PP. Intestinal atresia and Stenosis exclu­ding the duodenum. In: Rickham PP and Johnston JH. Neonatal Surgery. Butterworth, London 1978; 316-35. 4. Schiller M, Aviad I, Freund H. Congenital Colo­nic Atresia and stenosis. Am 1 Surg 1979; 138: 721-4. 5. Howard ER and Otherson HBJr. Proximal Jejuno­plasty in the Treatment of Jejunal Atresia. 1 Pediatr Surg 1973; 8: 685-90. 6. Louw JH. Investigations into Etiology of Congeni­tal Atresia of the Colon. Dis Colon Rectum 1964; 7: 471-8. 7. Boles ET, Vassa LE, Ralston M. Atresia of the Colon. 1 Pediatr Surg 1976; 11: 69-74. 8. Guttman FM, Braun P, Garance PH, Blanchard H, Collin PP, Dallaire L, Desjardins JG and Perrault G. Multiple Atresias and a New Syn­drome of Hereditary Multiple Atresias Involving the Gastrointestinal Track from Stomach to Rec­tum. 1 Pediatr Surg 1973; 8: 633-40. 9. Menardi G. Congenital Colonic Atresias. Z Kin­derchir 1987; 42: 31-5. 10. Sacher P und Stauffer UG. Langzeitresultate bei Patienten mit Atresien und Stenosen des Dtinn­darmes distal des Ligaments von Treitz und des Kolons. Z Kinderchir 1981; 32: 230-6. 11. Sturim HS, Ternberg JL. Congenital atresia of the colon. Surgery 1966; 59: 458-61. 12. Canavese F, Cavallaro S, Freni G, Bardini T. Atresia of the Colon. Z Kinderchir 1981; 33: 316-20. 13. Peck DA, Lyn HB and Harris LE. Congenital Atresia and Stenosis of the Colon. Are Surg 1963; 87: 428-39. 14. Swischuk LE. Radiology of the Newborn and 2nd Young Jnfant. Ed Williams and Wilkins, Bal­timore/London 1980; 458-9. 15. Grosfeld JL, Ballantine TVN, Shoemaker R. Ope­ratic management of intestinal atresia and stenosis based on pathological findings. J Pediatr Surg 1979; 14: 368-75. 16. Selke ACJr and Jona JZ. The hook sign in type 3 congenital colonic atresia. A.lR 1978; 131: 350-1. 17. Bley WR and Franken EAJr. Roentgenology of Colon Atresia. Pediatr Radio/ 1973; 1: 105-8. 18. Pasto ME, Deiling JM O'Hara AE, Rifkin MD, Goldberg BB. Neonatal colonic atresia: ultra­sound findings. Pediatr Radio! 1984; 14: 346-8. 19. McHugh K and Daneman A. Multiple gastrointe­stinal atresias: sonography of associated biliary abnormalities. Pediatr Radio/ 1991; 21: 355-7. 20. Hecker WCh. Kongenitale Kolonatresie, ein kli­nischer Beitrag zum Ileus in der Neugebornenpe­riode. Chirurg 1960; 9: 405-7. 21. Staple TW and McAlister WH. Perforation of an Atretic Colon During Barium Enema Examina­tion. AJR 1967; 101: 325-8. 22. Wilson BJ, Nelson A, Hershberger M. Congenital atresia of the colon. Surg Gynec Obstet 1954; 99: 34-41. 23. De Lorimier AA, Norman DA, Gooding CA and Preger L. A Model for the Cinefluoroscopic and Manometric Study of Chronic Intestinal Obstruct­ ion. 1 Pediatr Surg 1973; 8: 785-91. Radio/ Oncol 1992; 26: 296-300. Resolving of mammographically visible though clinically undetectable lesions suspicious for breast cancer Jurij Us Institute of Oncology, Department of Diagnostic Radiology, Ljubljana, Slovenia The results of active screening for breast cancer are presented. The study included 60 women with mammographically detected breast lesions which were clinically not palpable, though their mammo-· ·graphical findings were suspicious for breast cancer. In alf 60 women, localization of the breast lesion was performed by means of a wire according to the Franken's method. Breast cancer was established in 16 patients (26.6%), 7 of which (43.7%) had non-invasive and 9 (56.3%) invasive cancer, whereas benign dysplasia was found in 44 women (73.4 %). Key words: breast neoplasms-diagnosis; mammography Introduction Nowadays, breast cancer detection is based on two essential diagnostic methods: 1) clinical examination (CE) and X-ray imaging of the breast, i.e. mammography (MG). The findings of both examinations require additional micro­scopic verification. Clinically detectable (palpa­ble) breast lesions can be best explained by fine needle aspiration biopsy (FNB). According to the recommendations of the European Breast Cancer Study Group (EBCSG), active screen­ing for early breast cancer should be carried out in women without symptoms of breast can­cer. Thus, asymptomatic women over 50 years of age should be subjected to regular mammo­graphic examinations in 2-3 year intervals. Such Correspondence: Prim. Jurij Us, MD, Department of Diagnostic Radiology, Institute of Oncology, Zaloška 2, 61105 Ljubljana, Slovenia. UDC: 618.19-006.6-073.75 an approach is expected to contribute to a significant decrease in breast cancer mortality .1 Regardless the fact that mammography is a method that can detect breast cancer at a stage when it is not assessable by any other available method, the diagnosis is regarded incomplete without a clinical examination. Up to 63 % rate of false negative mammographic findings in women under 35 years of age reported in the literature can be attributed to the density of parenchyma in young women, whereas in wo­men over 35 years of age mammography fails to discover up to 15 % of clinically detectable tumors.2 Mammographically detected changes suspi­cious for breast cancer require further explana­tion. According to the recommendations of EBCSG, such changes should be marked by radiologist to facilitate their exact positioning at surgery. Surgically removed part of the breast is then again X-rayed in order to make sure that the suspicious tissue has been actually removed; at the same tirne the lesion is marked Mammography in lesions suspicious far breast cancer for better and more effective histopathologic examination. 3• 4• 5 The lesion can be easily marked by means of a thin stainless-steel wire with a hooked tip.6 In this-way both the change and the mark can be e asily· imaged on mammography, thus facili­ _ tating the interpretation of mammographical finding and positioning of-t.e Iesion on surgery. The surgeon orientates_ the removed b_reast tissue by marking-its front_ and upper edge and sends it to the radiologist for X-ray examination (FigureJ. During the procedure the tissue sam­ple is placed on a Petri dish filled with paraffin. The dish with the .specimen is placed into a special device whjch .nables marking of the -suspicious lesion for fast and accurate histologic ex;mination. 7 Material and methods In the years 1986 to 1992, changes suspicious for breast cancer were Iocalized in 60 women in the age of 36---69 years. Mammographically suspicious though clinically undetectable chan­ges were as follows: asymmetrical breast struc­ture, accentuated tissue density, the presence of stellate formations, a cluster of 5 or more microcalcinations appearing alone or associated with the above mentioned changes, and finally, a mammographically evident tumor. The size of localized changes ranged from a hardly perceptible cluster of microcalcinations to a tumor with the diameter of 2 cm. In the case of a mammographically detected suspicious breast Iesion, further diagnostic and therapeutic procedures were agreed upon by both the surgeon and the radiologist. Surgery was performed either on outpatient basis, when no major intervention had been expected, or the patient was admitted to the ward a day before surgery taking into account possible need for radical surgery. Mammography was repeated again prior to surgery and premedication. Approximate posi­tioning of the Iesion was done by means of a special Iocalization plate. The inserted wire was fixed with a piece of adhesive tape and the pu_ncture site protected wfth sterile gauze. The patient was operated on within two hours after the Iocalization procedure. The breast tissue severed on surgery was X-rayed by means of a special device equipped_ with coordination system which helped us to find the removed Iesion; the surgeon was imme. diately informed about the outcome· of the procedure. For the needs of radiologic investi-· gation the removed breast tissue was placed on: a Petri dish filled with paraffin which enaqie-cf Iocalization of the Iesion by means of injection needles. Thus prepared specimen was again X-rayed. The method has been nained "sainple mammography'' (SM). During sample laking procedure, the radiologist assisted the patholo., gist by explaining the SM image in order t0_ -enable him to determine the most suitable site for sample taking. Case 1: Patient M.V., bom 1952, patient record no.· 3105/82, has been referred to our Institute because of the enlarged right axillary lymph nodes. FNAB revealed the presence of light-cell carcinoma. The site of primary tumor could pot be found. The patient underwent mammogra­phy, though the obtained mammograph showed only a dense homogeneous shadow which was diagnostically irrelevant owing to the .patieni's breast type (Wolfe DY). On the other hand, this type of the breast, which is known to b_ec-­rather unyielding to mammography, is as;.cia: ted with the highest incidence of breast cancer. As the radiologist found a suspicious density in. the lower inner quadrant of the breast, a blind biopsy of that site was performed. On patholo­gical examination no evidence of malignoma could be found in the surgical specimen. Taking into account the possibility that formerly dia­gnosed light-cell carcinoma could originate from _ the kidney, intravenous urography was perfor­med as well; the findings, however, were within normal limits. The radiologist who carried out the procedure reviewed previous radiograms, and discoveFed a cluster of microcalcinations suspicious for breast cancer in the outer upper quadrant of the right breast. After consultation 298 Us J with surgeon, he carried out localization of the microcalcinations. Postoperative sample mam­mography confirmed that the changes had been removed. Pathomorphological examination of the removed breast tissue revealed the presence of an infiltrative dueta) light-cell carcinoma; it was moderately differentiated, with strongly expressed fibrous stroma. The tumor was of the same structure as previously discovered lymph node metastases. Subsequently, the patient un­derwent radical mastectomy. Case 2: Patient N.M., bom 1923, pat. record no. 2643/ 86, was asymptomatic. She decided to undergo breast examination because her niece, a medica! nurse, advised her so. She had always been healthy. She got menar­che at the age of 14 and had been postmenopau­sal for 15 years already. She gave birth twice and had one abortion. Clinical examination showed evidence of nor­mal involutive breast. On mammography a small stellate formation suspicious for breast cancer was imaged in the outer upper quadrant of the left breast. Localization was done by means of a wire (Figures 1 and 2). The removed part of the breast was X-rayed (Figure 3) again, and the suspicious lesion in the sample marked. Patho­morphological diagnosis was intraductal infiltra­tive carcinoma of the breast, 7 mm of size; this finding corresponded to the so-called "minimal breast cancer" which is considered curable. Results We have performed 60 localizations of suspi­cious breast lesions. Of these 16 (26.6 % ) tur­ned out to be breast cancer, whereas benign displasias were found in 44 cases (73.4 % ) (Table 1). There were 7 ( 43. 7 % ) noninvasive and 9 (56.3 % ) invasive breast cancers (Table 2). Figure l. Craniocaudal plane. Wire hook is in the immediate vicinity of the lesion. Mammography in lesions suspicious for breast cancer Table l. Suspicious breast lesions. Surgically treated patients n = 60 (100%) Diagnosed breast cancers benign dysplasias n = 16 (22.6%) n = 44 (73 .4 % ) Table 2. Established breast cancers. Diagnosed breast cancers n = 16 (100%) Noninvazive Invazive n = 7 (43.7%) n = 9 (56.3 %) the ducts, whereas another 4 were lobular and one was of mixed type (lobular and dueta!). Discussion Localization of changes in the breast is a simple, fast and reliable method which helps to resolve mammographically evident lesions suspicious for breast cancer. The diagnosis of cancer was confirmed in more than one fourth of our patients. According to the reports from literatu­re, about 20-40 % of cancers in surgically trea­ted patients are discovered by the help of this method. The rate of established cancers vs benign displasias depends on the criteria used by the radiologist when assessing a change as suspicious for breast cancer. Undoubtedly, with respect to a high rate of established breast cancers these criteria must be very strict. A question remains, however, how many initial (noninvazive) breast cancers failed to be detect­ed owing to a too restrictive approach. In our report, almost a half of the established cancers were noninvazive (7/16). This undoubtedly pro­ves that our selection criterium was relatively good. Self-evidently, initial cancer, particularly when situated deep in the breast, is not acces­sible to clinical examination. It seems also justi­fied to question why tumors as large as 2 cm 300 Us J need to be localized. But everyone who is involved in the diagnostics of breast diseases should be aware of the fact that every now and­then enormously large breast can be seen. When, apart from their size, such breasts are also clinically difficult to assess, it seems quite logical that -though exceptionally -even a relatively large tumor can be easily overlooked on clinical examination. Conclusion Mammography of the breast stili remains the method of choice for the detection of very small changes that cannot be evidenced by clinical examination. Both mammographical and clini­cal findings must be microscopically confirmed in order to serve as a basis for treatment selection. Localization of mammographically evident changes suspicious for breast cancer is a fast, ·simple and reliable method which facilitates the surgeon to determine the correct site for sample taking. Surgically removed tissue should be again radiographically examined so that '.the site of bioptic sample taking can be determined. Ali these findings have beei;i. confirmed by the results of our study. References l. European Group for Breast Cance_.r Screening ­ Recommendation for Breast Cancer.Screening. Eur . Gynec Oncol 1990; 11: 6, 498-9Q. 2. Sienko DG, Osuch J, Garlonghousa C, Rakowski V, Given B. The Design and Implementation of a Community Breast Cancer. Screening Project. Ca 1992; 42: 163-76. 3. Screening for Breast Cancer: Recommendations for Training. Lancet 1987; 1 (N ° 8529): 398. 4. Screening for Breast Cancer: Examination and Re­porting of Histopathological Preparations. Lancet 1988; 2 (N ° 8617): 953. 5. Guidelines for Breast Cancer Screening -The European Group for Breast Cancer Screening. Ciin Radio/ 1987; 38 (3): 217. 6. Us J, Jelincic V, Knez D, Gregorcic D, Kokošin S. Lokalizacija klinicno nezaznavnega rakll. dojke s pomocjo lokalizacijske igle TIK Kobarid. Radio/ lugosl 1986; 20: 23-6. 7. Us J. The Role of Radiologist t!} Verification of Mammographically Suspicious Lesions for Breast Carcinoma. Radio/ lugosl 1992; 25: 1-4 . Radio! Oncol 1992; 26: 301-3. Computerized tomography of the orbit Martin Cerk Institute of Diagnostic and Interventional Radiology, University Medica/ Center, Ljubljana, Slovenia -­ The role of computerized tomography in the diagnosis of orbita! diseases is presented. The problems of radiation and protection are particularly pointed out as it is believed that the investigation-related radiation dose may be high enough to produce a cataract. Key words: orbita! diseases; tomography, x-ray computed Introduction Computerized tomography (CT) is a computer­quided X-ray imaging method. Owing to its good resolution, thin sections and short expo­sure tirne CT is suitable for imaging of the orbit as well as of other formations of the skull base. The bony structure of the orbit and its con­tents is examined using axial and coronal (trans­verse) planes.1 An image in other plane can be reconstructed by means of a computer in the same way as e.g. an image in the sagittal or fronta! plane can be reconstructed from axial sections. Apart from the fact that the resolution of such images is generally of a lower quality, also the measurements of absorption values are not sufficiently accurate. Besides, absorption measurements on a CT with poor resolution are also of inferior quality. A better Correspondence to: Martin Cerk, MD, Institute of Diagnostic and Interventional Radiology, University Medica! Center Ljubljana, Zaloška 7, 61000 Ljubljana, Slovenia. reconstruction of images-can be obtained by partly overlapping sections, however, this ap­proach requires a greater number of sections to be done, which resul!s in a higher exposure of the patient to radiation. In order to calculate the volume of e.g. fatty tissue in the orbit a number of sequential parallel sections is nee­ded. Adverse effe<;:ts of x-rays are particularly evident on the eye lens where they may give rise to a cataract. Critical absorption doses able to cause this condition range between 2-15 Gy (Gray),2 depending on tli.e age of the patient (1 Gy is a unit used in dosimetry, denoting absorbed energy per inass unit of matter, i. e. lJ/kg; 1 Gy = 100 rad). Radiation dose per eye lens Radiation dose to the eye lens received by the patient on CT of the orbit is in direct correlation with -number of sections, -thickness of sections -mAs product -direction of sections with respect to the eye UDC: 617.76-073.756.8 lens (Figures 1, 2, 3, 4, 5). 302 Cerk M Figure 5. Retrobulbar tumor between medial and inferior extraocular muscles. Both muscles are chang­ed (coronal projection with magnification). The highest radiation dose to the eye lens is received when the eyeball is in the direct beam of X-rays. Total dose received in an examina­tion of the orbit using a sequence of closely parallel thin axial sections is 20mGy, whereas the dose with coronary sections amounts to 47 mGy. In the section thickness of 2 mm we use 780mAs product, in 4mm 460, and in 8mm 230. Thus the total dose to the eye lens received during examination of the orbit using 4 mm sections is only 20 mGy, whereas with 2 mm sections the dose amounts to 52mGy . Thin sections provide a more accurate information and a better image owing to the elimjnation of data pertinent to the adjoining structures, Computerized tomography of the orbit though in this case a much higher number of sections is needed for imaging of the same 3 structure. Conclusion In CT examination of the orbit as low a number of maximum thin target sections as possible should be made by means of a machine that can produce a good-resolution image in a very short exposure tirne. Nevertheless, magnetic resonance should be used preferably for exami­nation of the orbit, whenever available. In this way the risk of a cataract and associated with that further damage of the eye, which has already been affected by different conditions such as e.g. endocrine ophthalmology, can be significantly reduced. References l. Jacobs L, Weisberg LA, Kinke) WR. Computer Tomography of the Orbit and Se/la Turcica. Raven Press Books, 1980. 2. Neufang KFR, Zanella TE, Ewen K. Radiation Doses to the Eye in Computed Tomography of the Orbit and the Petrous Bone. Europ 1 Radiol 1987; 7: 203-5. 3. Newton TH, Potts DG. Radiology of the Skull and Brain. Technical Aspects of Computed Tomogra­phy, The C. V. Mosby company, 1981; S: 4228-58. Radio/ Oncol 1992; 26: 304-7. Evaluation of metastatic invasion in the wall of main neck vessels. Conventional versus color-coded ultrasonography Mirna Juretic,1 Alan Šustic,2 Željko Fuckar,2 Marijan Car1 0 · 1 Department of Maxillo-facial Surgery 2 Ultrasound Unit, University Hospital, Rijeka, Croatia Conventional ultrasonography and color-coded sonography are used in evaluation of the relationship between metastatic tumor vs the wall of large blood vessels of the neck, i. e. the common carotid artery and its main .branches, as well as the interna! jugu/ar vein in 34 patients with malignant tumors of the maxillo-facial region. The results have not shown any significant difference between the two sonographic methods, as both proved to be highly sensitive (100 % ) and specific (84-86 % ) . Key words: carotid a!tery diseases-ultrasonography; jugular veins-ultrasonography; neoplasm metastasis; Introduction Malignant tumors of the oral cavity and maxillo­facial region metastasize mainly into the lymph nodes of the neck. Modem diagnostics, beside clinical examination includes also »blind« or sonographically guided aspiration biopsy, com­puterized tomography of magnetic resonan­ 3456 ce.1 · 2• • • • Ultrasonography has developed rapidly in the last few years due to swift pro­gress of medica! technology. The construction of high-resolution high-frequency transducers has enabled visualization of very tiny forma­tions, and by the introduction of duplex sono­graphy, especially color-coded flow mapping (CD-sonography) into clinical practice, and ex- Correspondence to: Marjan Car, MD, Ph.D., Depart­ment of Maxillo-facial Surgery, University Hospital Rijeka, Krešimirova 42, 51000 Rijeka, Croatia. UDC: 616.133-033.21:616.145 .2-033.2:534-8 cellent presentation of vascular body-system was achieved.4 From surgical point of view, one of the basic preoperative information is the relation of me­tastatic process to the large blood-vessels, na­mely the common carotid artery and its main branches, as well as v. jugularis interna. As evident from recent literature, CD sono­graphy is an non-invasive method which enables excellent presentation of blood vessels and he­modynamic conditions, and therefore we have decided to correlate this method with conven­tional sonography of the neck. Using our own casuistics, we have tried to assess metastatic invasion toward main vessels of the neck by means of both methods, and later on, intraope­ratively confirm the obtained findings. Patients and methods In the period from September 1, 1991 to Sep­tember 1, 1992, 34 patients with malignant Ultrasonography in evaluation of metastatic invasion tumors of the maxillo-facial region and metasta­tic _involveme,nt of the neck lymph nodes were treated at the Department of Maxillofacial Sur­gery (Univers-ity Hospital Rijeka, Croatia). The age of th. I?'atients ranged between 35-81 whe­ _ reas · t_he.-0111ale -fernale ratio was 82-18 % in favor of male patients, respectively. Conventi_onal sonographic examination was perform<:Ji on. the ultrasound apparatus Aloka SSD LS ·230 with a linear transducer of 5 MHz, whereas for CD sonog:raphy a color-coded ap­par.atus Hitachi EUB 515 with a convex trans­duce_r of .5 MHz was used. T.e findings were considered negative when the blood.vessel w.lls were intact, and positive when they ·:Vere invaded by secondary tumor. Ah cast!s were examined by two independent, equally qualified specialists. Hemodynamic pa­rameters obtairied by Doppler analysis are not pres.ented. The malignant nature of secondary deposits was :verified preoperatively by sono­graphically guided fine-needle aspiration biop­sy, and la ter on by postoperative pathohistolo­gical analysis. Results Previously verified metastatic deposits of the neck have been visualized by preoperative con­ventional ultrasonography and CD sonography. Ali findings were later on intraoperatively eva­luated and the results tabulated (Table 1). Correlating conventional vs CD sonography, a minimal statistically insignificant difference has been observed. The sensitivity of both methods is 100 % , whereas specificity for CD technique and conventional sonography is 84 % Table l. The relation of metastatic tumor versus a. carotis (comm., int., ext.). Conventional CD Interventional US sonography finding Negative 29/85 % 28/82 % 31/91 % Positive 5/15 % 6/18% 3/9% Tota! 34/100% 34/100% 34/100% and 86 % respectively. Positive predictive value ranges between 60 % ( conventional ultrasono­graphy) and 50% (CD), whereas negative pre­dictive value for both methods is 100 % (Table 2): Table 2.-The ralation of metastatic tumor versus v. jugularis int. Conventional CD Interventional US sonography finding Negative 21/62 % 21/62 % 25/74% Positive 13/38% 13/38% 9/26% Tota! 34/100% 34/100% 34/100% The results in the group, where the relation between metastatic tumor vs vena jugularis interna was evaltiated, have been identical in both sonographic methods: sensitivity 100 % , specificity 86 % , positive predictive value 69 % and negative predictive value 100 % respecti­vely (Figure 1, 2). 306 Juretic M Figure 2. Destruction of both the interna! jugular vein and common carotid artery ( conventional sonography, 5 MHz). With reference to the presented results it is important to emphasize that the hemodynamic parameters obtained by Doppler analysis (PI, RI, etc.) have not been presented owing to the fact that pathoanatomical substratum of vessel­-wall lesion is not in direct correlation with the degree of hemodynamic perturbations in early stages of the disease. Compression of the vessel lumen certainly alters numerical results obtain­ed by quick Furier's transformation, however, summing up personal experience and data from relevant literature, no direct correlation bet­ween the damage of blood-vessel wall and he­modynamical disorders has been established. Discussion Color-coded sonography is a new non-invazive method which has in many ways improved conventional sonographic diagnostics. The pre­sent prospective study has been undertaken in the belief that this method may also increase preoperative evaluation of blood-vessel wall lesions caused by metastatic processes. Howe­ver, the results have not shown any significant difference between the two sonographic me­thods. Both were found to be highly sensitive, and their specificity was quite adequate (bet­ween 84-66 % ) . Low positive predictive value (50 % , 60 % , 69 % ) should be attributed to a relatively small group of patients. Conclusion Conventional sonography is the method of choice in evaluating metastatic invasion of the 1 z 3 4 blood-vessel wall of neck tumors., , , Its advantages such as low cost, rapidity of investi­gation, no risk of exposure to irradiation and high diagnostic value have been often mention­ed in the relevant literature. 2• 4 In many aspects, the more expensive color-coded sonography represents a certain improvement of the stan­dard ultrasonic diagnostics, but nevertheless, the present study has not been able to demons­trate it. Conventional ultrasonography stili remains the best method for the evaluation of metastatic tumors vs vascular body of the neck. Of course, CD-sonography is recommended for the asse­sment of hemodynamic disorders caused by blood-vessel compression, and also as an adju­vant procedure to the routine neck examination in cases of primary malignant tumors of the maxillo-facial region. References l. Hessling KH, Schmelzeisen R, Reimer P, Milbradt H, Unverfehrt D. Use of sonography in the follow up of preoperatively irradiated efferent lymphatics of the neck in oropharyngeal tumors. J Cranioma­xillofac-Surg 1991; 19 (3); 128-30. 2. Quetz JU, Rohr S, Hoffmann P, Wustrow J, Mer­tens J. B-image sonography in lymph node staging of the head and neck. area. A comparison with palpation, computerized and magnetic resonance tomography. HNO 1991; 39 (2); 61-3. 3. Leicher-Duber A, Bleier R, Duber C, Thelen M. Regional lymph node metastases in malignant tu­mors of the head and neck: value of diagnostic procedures. Laryngorhinootologie 1991; 70 (1); 27-31. Ultrasonography in evaluation of metastatic invasion 4. Stiglich F, Barbonetti C, Di Lorenzo E, Gherardi US-guided fine-needle aspiration cytology. Radio­G, Maspero S, Bottinelli O, Bonoma F, Bottinelli logy 1991; 180 (2); 457-61. G, Campani R. Diagnostic reliability of ultrasono­ 6. Baatenburg de Jong R:f, Rongen RJ, Verwoerd graphy in head and neck neoplasm. Radio/ Med CD, van Overhagen H, Lameris JS, Knegt P. (Torino) 1991; 81 (6); .38-43. Ultrasound-guided fine-needle aspiration biopsy of 5. Vari-der Brekel MW, Castelijus JA, Stel HV; Luth . neck nodes. Arch Otolaryngol Head Neck Surg WJ, Valk J, Van der Waal 1, Snow GB. Occult 1991; :J-17 ( 4); 402-4. metastatic neck ·disease: detection with US a.d Radio/ Oncol 1992; 26: 308-11. Colonic sonography Nikola lvaniš, Milivoj Rubini<:, Relja Peric, Duško Banic, I. Kraus Clinical Hospital Centre Rijeka Clinic of Interna! Medicine and Institute of Radiology The authors' experience in sonography of the colon filled with water is described. This is a relatively new method reported in medica! literature of the recent five years. Our experience so far confirms the great value of this method in the diagnostics of tumours and polyps, as well as of inflammatory diseases (ulcerative colitis and Crohn's Disease) of the colon. Compared with colonoscopy, its results are particularly valuable. Out of thr 53 colonosonographies there were only three false positive findings, as compared with colonoscopy, which confirms the reliability of the former method. The very good results of this method are apparent in the evaluation of the spread of colonic cancer to adjacent structures. Key words: colonic diseases-ultrasonography Introduction The importance of conventional sonography in the diagnostics of colonic diseases is not negli­gible, but is nevertheleses limited by the length of this organ and the fact that it is filled with bowel contents. Hence, there are few reports on the use of sonography in the diagnostics, especially of colonic cancer . 1• 2• 3 Well-known are also the possibilities of en­doscopic sonography, in this case particularly transrectal, the possibilities of which in the diagnostics and evaluation of the spread of rectal cancer are incontestable and quoted by a great number of authors.4-7 Correspondence to: Nikola Ivaniš MD, Clinical Hospi­tal Centre Rijeka, Clinic of Interna! Medicine, B. Kidrica 42, 51000 Rijeka, Croatia. UDC: 616.348-073:534-8 The method presented here is relatively new and has a great practical value in the diagnostics and follow up of the extent and treatment results of bowel diseases. It is equally valuable in case of tumorous as well as inflammatory diseases of the colon.s-13 Material and methods The ultrasound examination of the colon has been adopted by our institution as well as by a great number of other centres practically as an everyday routine procedure. The non-inva­sive character of this method renders it one of the most frequently used techniques in contem­porary diagnostics. But in addition to this me­thod, some more invasive methods are also used routinely, of which the endoscopic ones come first and foremost.14 An essential requirement in colonic sop.o­graphy is as !horough as possible purging of the Colonic sonography patient's bowels. For better relaxation of the colon one of the spasmolytics is administered. By means of a catheter inserted into the rectum the col on is filled with 1500 to 1800 ml of water. The ultrasound examination of the colon is started as soon as water begins to be instilled. It is carried out by means of an ultrasound apparatus and Convex probe of 5 MHz. The average duration of the examination ranges from 25 to 30 minutes. So far 53 colosonogr_aphic examinations have been carried out in our institution during a one-year period. Results In nine cases the findings were normal, whereas in 28 patients colonic carcinoma was found; eight patients had polyps of the colon, five of them with typical signs of Crohn's Disease, and three of ulcerative colitis. With ali of them this method was easy to perform and practically painless. In ali these cases the results were verified by colonoscopy., and in the case of patients with colonic carcinoma the diagnosis was confirmed also by surgery. In our group of 53 patients there were three false positive findings. The first was the case of the remains of the content in the cecum misin­terpreted for a polyp, which was rulled out by colonoscopy. The second case was wrongly diagnosed as a polyp of Valvula Bauchinis; in reality it was the prolapse of the same, confir­med by total colonoscopy, the third case was first explained as a stenosis of the colon, and later on confirmed by s.rgery as an adhesion. Discussion From the above results it can be seen that colonic sonography is the most useful clinical diagnostic procedure. It is non-invasive and easily carried out by means of a real-tirne ultrasound apparatus and a 5 MHz probe. The scan of the colonic wall is reliable, showing pathological changes in the wall and their ex­pansion into the vicinity of the colon, as well Ivani§ N et al. Figure 4. Polyp on a narrow stalk (arrow). Figure 7. Crohn's disease -stenotic section. Figure 5. Polypoid colon carcinoma. Figure 8. Ulcerative colitis -swollen wall. Figure 6. Stenotic colon carcinoma (arrow). Figure 9. Ulcerative colitis -pseudopolyp (arrow)'. Colonic sonography 3ll as the length of the afflicted section of the bowels. From the results obtained so far we can draw the following conclusions: -the sonography scan of the colonic wall is up to 5 mm thick and consists of five layers (Figure 1) -with normal findings, from the lumen of the colon which appears dark (anechoic) small movable hyperechoic lamelliform plates pro­trude (Figure 2) -polyps on stalks or broad bases stand out in the lumen appearing as oval echoic forma­tions; the wall at the base the polyp is of normal structure (Figure 3 and Figure 4) -the colon carcinoma prominent in the lu­men is of irregular surface and does not float in the lumen, has no peristalsis, and at the touch of the probe remains unchanged (Figure 5) -stenotic carcinoma infiltrates the wall, thus narrowing the lumen, is of irregular echo struc­ture with irregular surface of the colonic wall (Figure 6) -part of the colon affected by Crohn's Di­sease is extremely swollen, the lumen is narro­wed, the layers of the wall are not discernible (Figure 7) -parts of the colon affected by ulcerative colitis show hypoechoic moderately swollen wall; the wall is clearly discernible, but there is no haustra and the lumen is not stenotic. These conclusions basically agree with those reported in the available literature.s--14 In the group of patients treated, the sensiti­vity of the method amounts to 94 % , confirming the assertion of the applicability of this method in everyday routine and representing a stimulus for further improvements. Self-evidently, in particular cases it is necessary to use also other supplementary methods such as colonoscopy. It is particularly encouraging that surgical findings have, with the exception of one case, confirmed the colonic sonography findings on the extent of colon carcinoma. References l. Grtin R, Wagner E, Tomsik H et al. Sonographi­sche Diagnostik von Tumoren in Ziikum uncl Colon ascenclcns. Z Gas/roentero/ 1991; 29: 65-7. 2. Ivaniš N, Rubinic M, Peric R et al. Sonographic presentation of aclvancecl stages of colorectal can­cer. Radio/ 1 ugosl ·1991; 25: 125-8. 3. Fuckar Ž. Ultrazvuk trbušne stijenke, intraperito­nealnih kolekcija i crijeva. In: Kurjak A. ecl. Ultrazvuk abdomena i malih organa. Zagreb: Na­prijecl, 1990: 97-106. 4. Ivaniš N, Banic D, Peric R et al. Ultrasouncl examination of Rectal cancer. In: Transvaginal sonography and endosonography -Book of Abs­tracts. Opatija 1990: 23. 5. Takemoto T, Aibe T, Fuji T. Encloscopic ultraso­nography. Ciin Gastroenterol 1986; 15: 306-10. 6. Hilclebranclt U, Feifcl G. Preoperative staging of rectal cancer by intrarectal ultrasouncl. Dis colon. Rectum 1985; 28: 42-8. 7. Wang KY, Kimmey BM, Nyberg DA et al. Colo­rectal neoplasms: Accurary of US in clemostrating the clepth of invasion. Radiology 1987; 1965: 827­32. 8. Limberg B. Diagnostik entztincllicher uncl tu­moriiser Diekdarmveranclerungen durch Kolonso­nographie. Dtsch Med Wschr 1986; 111: 1273-8. 9. Limberg B. Differentialdiagnose akuter entztind­licher Dickclarmerkrankungen durch Kolosono­graphie. Dtsch Med Wschr 1987; 112: 382-6. 10. Limberg B. Diagnosis of aeute ulcerative colitis and colonic Crohn's disease by colonic sono­graphy. J Ciin Ultrasound 1989; 17: 25-9. 11. Worlicek H, Lutz H, Thoma B. Sonographie chronisch entztindlicher Darmerkrankungen -ein prospektive Studie. Ullraschall 1986; 7: 275-80. 12. Limberg B. Diagnose of large bowel tumors by colonic sonography. Lancet 1990; 335: 114-8. 13. Limberg B, Osswalcl B, Hiipker WW. Sono­graphische Diagnostik der normalen und patholo­gisch veranclerten Dickdarmwand. Klin Wschr 1988; 66: 212-6. 14. Ottenjanin R, Weingart J. Encloskopie und Biop­sie cles Dickclarms. In: Ottenjann R, Fahrlancler H eds. Enlzilndliche Erkrankungen des Dick­darms. Berlin-Heidelberg-New York: Springer Yerlag, 1983. Radio/ Oncol 1992; 26: 312-9. The role of radiation in the treatment of childhood malignancies Berta Jereb Institute of Oncology, Ljubljana, Slovenia fmprovement in the cure of childhood malignancies in the last decades has mostly been due to chemotherapy, however, this modalitity alone is unable to cure solid tumors; there, radiation treatment is an essential part of therapy, especially when surgery is not feasible. The treatment of malignant tumors in children is therefore often combined: surgery, radiation and chemotherapy may be used sequentially or simultaneously. At present we are stil! gathering new information about the timing of radiation, the curative tumor doses, the tolerance of normal tissue when radiation is combined with chemotherapy. The late effects of combined treatment remain a major problem, increasing with the tirne of observation. These considerations are crucial in children who are more susceptible to radiation damage and have a longer tirne to develop sequelae and live with them. Regular follow-up with psychosociaal, endocrinological and cytogenetic aspectst have to be evaluated in detail in children treated for malignancies. Key words: neoplasms-radiotherapy; child lntroduction Ionizing radiation has been a part of cancer treatment virtually since its discovery by the Curies and W. C. Roentgen about 90 years ago. In sufficient doses it will kili normal as well as malignant cells and its .clinical effect is based on the generally greater sensitivity of the latter. White it is used in some benign conditions, its beneficial effect in patients with malignant_ t.­mors has been well recognized. Correspondence to: prof. Berta Jereb, MD, Ph. D., Institute of Oncology, Zaloška 2, 61000 Ljubljana, Slovenia. UDC: 616-006.6-053.2:615.849.2 The treatment of malignant tumors in child­ren is often combined: surgery, radiation and chemotherapy may be used sequentially or si­multaneously. Although the dramatic improvement in the cure of childhood malignancies in the last deca­des has mostly been due to chemotherapy, this modality alone is unable to cure solid tumors. Radiaton treatment is an essential part of treat­ment of these, especially when surgery is not feasible (Figure 1). 1 If the choice is radiation treatment with at­tempt to cure, this goal should be pursued vigorously, taking into account some degree of complications, since the issue here is lite. After deciding whether curative or palliative radiation therapy is indicated, the dose, volume, and The role of radiation in the treatment of childhood mali.nancies 100 .----,-----------------______:_, .0.WILM S' Ti DISEASE •HODGKIN' . -f-! /4/ .DGKIN'icoMA (LOCAL) -.STEOGEN.i. 80 . E..N ARHABOOMYO G C, > /" 1 L'' .:.//.BRAIN TUMORS z w I­.--------:::::: .,,_-, ,_____./ ,t; . '/ . 20 / w /1 a.. * 7 .==--====8 (j 0-F-----------::::::::=================------------l . CHEMOTHERAPY RADIOTHERAPY SURGERY > C: / / 1940 1950 1960 1970 1980 Figure l. Improvement of 2-year survival of children with malignant tumors during the decades when surgery, radiation therapy, and chemotherapy were developed asa combined modality therapy (1940-1980) -Hammond 1986. tirne during which it is delivered are determi­ned. Some radiobiological and technical aspects Although radiation affects all parts of the cell, the inhibition of mitotic activity is its most important feature. Rupture of chemical bonds within the DNA molecule strands occurs either by direct absorption of radiation, or indirectly, by ionization of H20 producing active radicales and electrons. Microscopical changes are essentially the sa­me, whether the irradiated cell is normal or malignant. The radiosensitivity of a malignant tumor tends to be in the same range, though usually at least somewhat higher, than that of the tissue from which it arose. Thus, tumors, arising from bone marrow, lymphatic tumors, and seminomas, tend to be very radiosensitive, while those arising from cartilage, bone, con­ .. nective and neural tissues are much more resi­stant to radiotherapy. The radiocurability will depend, among other factors, on the radiosen­sitivity of a tumor and. the tumor site, limiting the dose of radiation tolerated, as well as on the tumor size. In order to increase the selectivity of radia­tion we can: 1) plan such a dose distribution that will result in a low dose (below the tolerance leve]) for normal tissue and a higher dose (tumorici­dal) to the tumor. An adequate image of the treated area, often at several angles, is neces­sary for planning. A CT scan is usually helpful (Figure 2). 2) increase the gap between the effect on tumor cells and normal cells by fractionation 3 (Figures 3a, 3b, and 3c).2• In general, protracted fractionation is used over several weeks, with about 1000 cGy deli­vered each week. Recently, attempts were 314 Jereb B Figure 2. Treatment plan (isodose distribution) for a patient with embryonal rhabdomyosarcoma of the orbit. made to base the fractionation scheme on mo­dem radiobiologic research, using 2 or 3 daily fractions. ldeally, the dose and its distribution should be timed with the individual tumor , growth, but we stili lack the knowledge to achieve this (Figures 4, 5).2 TOT AL OOSE IN r 9000 7000 500 - 400 - - 300 / Skin Necrosi Cure o! Skin Cancer 2000 / Maist Desquamation Dry De squamatio ,/ - Erythem "--­ 1000 f One Treatment 3) moodify the effect of radiation with radio­senzitizers and radioprotectors (Figure 6). Various physical, chemical, and biologic agents can modify the radiation response of the cells. Antimetabolites, such as Methotrexate, 5-fluorouracil, and 6-mercaptopurine, also in­terfere with the DNA synthesis. Cells exposed to these agents become more sensitive to radiat­ion. Clinical aspects of radiotherapy Radiation therapy can be given: locally: -directly to the tumor (radiosensitive), to ino­ perable tumors: e. g. ERMS of the epihpa­ rynx, -postooperatively to the tumor bed e.g. Wilms' tumor, Ewing's sarcoma) -preoperatively, although it has been mostly replaced by chemotherapy it is stili used when the response to chemotherapy is poor e.g. neuroblastoma) or sistemically: -TBI (total body irradiation) and -HBI (hemibody irradiation). It can be given after, before or sandwiched between chemotherapy (e.g. Hodgkin's lym­phoma). - .---­ - - - - - - 5 6 78910 15 20 30 40 Tota! duration in days after the first irradiation Figure 3a. Effect of fractionated radiation on tumor and normal cells -shematic presentation. The role of radiation in the treatment of childhood malignancies Eacht represents a dose of radiation ' i . i-* . ! . . t l '+-Normal cells recovering ., .--< .--< QJ " "" o >, Cell recovery +> ..... impossible .--< :31------------------------~.---l CI) below this •rl level > Tumour cells /disintegrating l ______ ___.___._..._____.____.__.____.__.......___, 20 21 22 23 24 25 2 3 4 5 6 7 8 9 10 -(Time days) ­ Figure 3b. Effect of fractionated radiation on tumor and normal cells -shematic presentation. Figure 3c. Effect of fractionated radiation on tumor and normal cells -shematic presentation. 316 Jereb B The main sources of radiation used in clinical practice are either external beam machines or sealed radioactive sources. External beam ma­chines emanate: photons (X-ray machines, betatrons, linear accelerators), gamma-rays, (Co60 machine, teratron, gam­matron, etc.) electrons: betatrons, Iinear accelerators pro­tons, neutrons are stili only seldom used. The advantages and disadvantages of diffe­ rent sources can be understood by comparison of the absorbtion of radiation in tissue present­ed by the isodose distribution courves (Figure 7). The amount of irradiation prescribed is ex- ENDOF TUMOR TREATMENT 111111111111 many small tu1ctions , ' • repalr ' • rodlstribullon • ropopulation 1 ' • reoxygenatlon , Oose / • repldly cyellng cells tumor regresslng • quloscont cotls • hypoxic cells et><>"""11 / 11HUH EARLY RESPONOING TISSUE tissue soverely depleted pressed in units, i.e., the quantity of energy absorbed by unit of mass (ergs/per gram). Rad is the unit absorbed dose where: 1 rad = 100 ergs/gram A special name for the unit of absorbed dose is Gy where 1 Gy = 100 rad. Radiotherapy treatment planning is a routine procedure, and significant improvements are unlikely to occur in the near future. The diffi­culties, however, are stili on the medico-clinical side, e.g. how to specify the targer volume occupied by the tumor bearing tissue more accurately. MONTHS LATER YEARS LATER ---..._ , , , ' , ' , , ' ' 1 ' , / , ' ----, tumor gone tumor gone r;:ipid repopulatlon • frssue intogrlty inlact Figure 4. The kinetic pattern following irradiation with many small dose fractions. A small dose fraction produces relatively less damage to late-responding that to early--responding tissues because .of their curvy dose-response relationship. The tumor regresses and disappears. The early-responding tissues show a reaction but repopulate by rapid celi division. The late responding tissues show little damage. The role of radiation in the treatment of childhood malignancies ENDOF TUMOR TREATMENT MONTHS LATER YEARS LATER ----.... , ----..... , ' ' ' 1 ' / , ', , lew l¦rge lr¦ctions , 1 • rep¦ir • redlstributlon • repopulatlon 1 @@ 1 I (§/!Y • reoxyg¦nation 1 ' / Do,e ... ____ ..... ........ ___ ,.. / • r¦pldly cycllng cells ' tumor regressing • qulesc¦nt cells . • hypoxlc cetls . . . repopulation - tissuo linuolnt¦ct S¦Yerely deplet¦d • cell$d1e ,., · . 0 • remoYed a1 slow rale . At ·;) ,., slow turnoYer • l¦t¦nt d¦m¦g¦ In • l¦t¦nt damaga in tissue breaks down m¦nyc¦il• manycells • lew r¦moved • lew removed • tlHU¦ lntegrlty lnt¦ct • ti¦su¦ lntegrlty intact Figure 5. The kinetic pattern following irradiation with a few large dose fractions. A large dose fraction produces relatively more damage to late-responding than to early-responding tissues because of the difference in curviness of the dose-response relationship. The tumor regresses and disappears, though there is evidence of a higher recurrence rate after radiotherapy regimens involving a small number of fractions, perhaps because there is less opportunity for reoxygenation. The early-responding tissues show a reaction but repopulate by celi division; this is the same as in Figure 4 and 5. However, the late responding tissues carry a large amount of latent damage which is expressed months or years later when the cells. in these tissues begin to turn over. 100 6 100 "' .::; "" O 80 . /,,,,-:2,,,.--80 . O 60 8 . .'q-,f 1/ h, 1 /.°' 1§ 60 "­ . , l!5"' (.) ... . le" u O -. 1 "' O 40 'l' 20 G . / _,,, oL...ri"""': -,,:, ,_.,.-_,...... o i! t DOSE- o Figure 6. Scheme of therapeutic ratio modification. Rather than in radiotherapy treatment plan­ning, advances are likely to occur in areas such as combination regimens and modification of dose fractionation schemes. Also, as the prog­nosis is related to the extent of disease at the beginning of treatment, an earlier diagnosis is essential together with a better knowledge of the spread, and patterns of failure of different tumors. Chemotherapy is an integral part of treatment in the great majority of tumors in children (Figure 8).4 Knowledge on the effects of such combined treatment has accumulated very rapidly in the last decades; it is likely, however, that in the near future, we shall stili be gathering new information about the timing of radiation, the curative tumor doses, and the tolerance of normal tissue when radiation is combined with chemotherapy. Although the acute radia ti on effects ( even severe when ChT is given concomitantly) on normal tissue may resolve rapidly, the late effects of radiation remain a major problem, increasing with the tirne of observation. These considerations are crucial in children who are more susceptible to radiation damage and have a longer tirne to develop sequelae and live with them (Figure 9). 5 Some late sequelae have not been recognized until recently and some may be more common 318 Jereb B -- - -... -----l9 MV ..._ 60C-o ­ [Ji \ \ \ \ -­ 11.f. 20 \.. 11 6 4 MeV . 25 MeV MeV 16 2 8 12 14 o o DE P T H (cm) Figure 7. Central-axis-depth 2 -treatment -related gastrointestinal compli­ cations grade 3 -hematologic toxicity grade 2 -patient's refusal of therapy The study proQosal is supported by the results of a pilot experiment which has confirmed that a dose of 350mg/m2 5-FU is stili tolerable whereas a dose of 420 mg is not. The main difficulty related to chemotherapy is diarrhea. This tria! has already been approved in France. 2) Study 22922 This is a randomised study on the irradiation of the interna! mammary chain lymph nodes after surgery for breast carcinoma stage 1-111. The proposal has been resubmitted for consi­ deration by the Protocol Review Committee (PRC). New study proposals 1) Study on ARCON The use of ARCON (Accelerated Radiothe­rapy with CarbOxen and Nicotinamide) seems sensible since the inhalation of carbogen redu­ces chronic hypoxia in the tumor while nicotin­amide influences acute hypoxia caused by the cyclic closing of the tumor vessels. Experiments on mice in Gray's Iaboratory have shown that up to 1.9-times enhanced effects of irradiation can be expected by this method. 336 Jancar B According to the clinical data obtained so far, the dose 6 g of nicotinamide per day is quite safe and free of any adverse side effects. The following treatment regimen was suggest­ ed for bronchial carcinoma: irradiation twice daily with 1.5 Gy fractions and a free interval of 8 hours up to the cumulative dose of 60 Gy in 40 fractions, delivered in· 20 days. Accelerated irradiation for head and neck sites should be basically the same as in the study 22851. 2) A randomised study on postoperative treat­ment for ovarian carcinoma stage I and II by irradiation or chemotherapy is being prepared. After surgery, the patients will be randomiz­ ed into two study arms. The first groupe will receive TAi (total abdominal irradiation) as adjuvant therapy in the following schedule: dose 25 Gy, fractions 1.25 Gy/day, without !iver shielding though with protection of the kidneys, followed by irradiation of the pelvis according to the previously described regimen. The second group will receive postoperative chemotherapy with Platino!, 75 mg/m2 every 3 weeks, 4-6 cycles. The treatment is commenced within 6 weeks following surgery. Seventeen institutions have already registered their participation in the study, and the cancer centers from Ljubljana and Zagreb are also going to take part in it. 3) Study proposal for postoperative irradiat­ion of head and neck carcinomas ( oral cavity, oropharynx, hypopharynx, paranasal sinuses). After surgery, the patients would be distri­ buted into two groups, i.e. into a high-risk and low-risk group. The criteria for the "high-risk" classification are as follows: -T3, T4, N2-3 -incomplete resection -carcinoma invasion through the lymph node sapsule. Suggested therapy: a) for low-risk group: the 1st study arm: 54 · Gy in 5.5 weeks the 2nd study arm: 66 Gy in 6.5 weeks b) for high-risk group: 66 Gy in both investi­gation arms, and afterwards randomization into the 1 st arm receiving no additional therapy, and the 2nd arm receiving chemotherapy with Plati­no! 70mg/m2 week, 6 cycles. It was pointed out in the discussion that such a chemotherapy regimen can be very aggressive, but dr. H. Bartelink explained that the feasibi­lity of the suggested therapy was confirmed by the results of a pilot study. New proposals to be discussed 1) Proposal of a study for the evaluation of stereotactic method for irradiation of brain me­ tastases. Patients with 1-3 brain metastases (carcinoma or sarcoma) will be randomized into two study arms: one rece1vmg classical irradiation (10 X 300cGy), and the other with stereotactic approach where a single fraction of 20 Gy will be used with isodose of 80 % covering the whole metastasis. The final proposal will be prepared by the Radiosurgery Committee till the next meeting. 2) Study proposal on the role of irradiation in the treatment of nonsmall celi bronchus carci­noma (NSCBC). The incidence of Jung cancer takes the first place in Slovenia as well as in Europe, and represents about 25 % of ali cancer-related deaths. The prognosis in patients with bronchus cancer has not improved significantly during. the last 30 years, and less than 10 % of patients are expected to survive 5 years form diagnosis. Small celi bronchus carcinoma represents ap­proximately 20 % of ali bronchus carcinomas. With respect to its early metastasizing and sensitivity to a number of chemotherapeutic agents, chemotherapy is considered the treat­ment of choice. On the other hand, NSCBS is known to be rather chemoresistant. Therefore, radical resection offers the best chances for cure. In localized tumors stage Tl-2, NO, 5-year survival is more than 50 % . Report 337 Of ali newly detected patients with NSCBC, 50 % are found inoperable already on the first clinical examination, additional 20 % on bron­choscopy, and 10 % more on explorative thora­cotomy. Of the remaining 20 % patients, only 30 % of that are alive 5 years after surgery. In patients with localized though technically inoperable NSCBC, who have been treated by radiotherapy, 5-year survival is observed in 20-50 % ; these are generally the patients with stage T-2 and NO, who would have been--ope­rated on, had it not been for their old age, other diseases etc. which overrule the possibility of surgery. They were irradiated with a dose up to 50-70 Gy. A majority of patients with NSCBC present with advanced disease; their median survival is 8-12 months, and 5-year survival less tha 10 % . Treatment in these patients is of palliative na­ture only, and has but a negligible effect on their survival. In Europe as well as in the United States of America, the role of irradiation of these pa­tients depends more or less on individual cen­ters, and even more frequently on individual opinion of the therapist. A number of recent reviews have pointed out very differing ap­proach irradiation so with respect to the doses and fractions used, as well as with respect to the prognosis. There is no uniform opinion on when radiotherapy should be regarded as pallia­tive and when as curative. Also in palliative irradiation the doses are greatly differing, and so are also the indications for therapy. These range from the opinion that radiation is perfor­med merely with a palliative intent to alleviate symptoms such as pain, bleeding and respira­tory distress, to the belief that irradiation should be used as a preventive measure. In a previous study by Bleehan, two irradia­tion regimens were compared in a randomized group of patients. The first group was irradiated with the dose of 17 Gy in two fractions, and with 1 week interval, whereas the second group received 30 Gy in 10 fractions and 2 week interval. There was no difference in the results with regard to patients survival (median 6 months), the improvement of symptoms and the duration of that improvement. According to a new proposal for study of the role of irradiation in the treatment of non-small celi bronchus carcinoma, the patients are distri­bute into 3 groups: A -patients with favourable prognosis, pre­sumably curable by high-dose radiotherapy; B -patients with no practical chance of cure, but in whom the treatment for local tumor control is expected to result in a prolonged survival and an improved quality of Iife; C -patients with poor prognosis and expect­ed survival less than 6 months; a majority of them suffer from disease-related simptoms, and therefore the therapy is directed into alleviating difficulties. Suggested therapy: Group A: not eligible for this study; 1st Group B: RT: 30 Gy/10 fractions 60-65 Gy/30-33 fractions 2nd RT: 30 Gy/10 fractions 10 Gy/1 fraction Group C: 3rd RT: 30 Gy/10 fractions 10 Gy/1 fraction The first group was aimed to established the possibility of cure by means of high-dose iradia­tion, or to answer the question whether such a regimen enables a better local tumor control. In the second group, a possible advantage of fractionated regimen over single-fraction irra­diation, as well as it influence on survival and alleviation of symptoms should be established. The third group was designed with the aim to establish the lowest possiblc dose and the simplest irradiation regimen able to result in alleviation or control of symptoms. Owing to a large number of patients with NSCBC in Europe, we can expect the study to be completed very soon. The results obtained should have a significant influence on the survi­val of these patients which represent a great burden for ali radiotherapy centers. Boris Jancar, MD Institute of Oncolgy, Ljubljana Radio! Oncol 1992; 26: 338-9. Course on scientific and medica) illustratio11s September 2-4, 1992, Krems/D, .ustria IPOKRaTES (International Postgraduate Orga­nisation for Knowledgetransfer, Research and Teaching Excellent Students) is an international organization which has been established with the aim to promote a higher leve! of research projects and their presentation. Within the scope of its activities it organizes various cours­es intended for both the research workers as well as for those who are in on·e way or the other directly involved in the processing of _their investigation results (e. g. reviewers, edi­tors etc). One such course dedicated to the relevance and techniques of scientific and medi­ca] illustration was held in September last year in Krems, Austria. It is an indisputable fact that an illustration offers more direct and easy-to-understand infor­mation than a written or spoken text, and as such it facilitates the exchange of scientific information for both the conveyer and the recipient. It represents an explanation, support and confirmation of the reported scientific re­sult in one. Illustrations differ as to their purpo­se, and can be categorized into three main groups, i. e. 1) for written/printed communica­tions, 2) slide projection and 3) for poster presentation. Whereas the first may comprise a relatively extensive and complex information, those that serve the Iatter two purposes should be as brief as possible, containing only the most essential key data. Drawings often have the advantage over photographs by offering the possibility of simplification, marcation of de­tails, and not requiring a background. Photo­graphs should be of adequate contrast, centred on the presentation of a detail which should be positioned centrally. In sonograms, a conic sec­tor of the ultrasonographic image without late­ral background would generally be sufficient. Today, the design of tables is almost equal in ali publications. A few horizontal lines sepa­rating the title, table head, totals and foot-notes are acceptable, whereas any vertical lines bet­ween columns are considered redundant and cannot be seen frequently. The size and con­tents of the table should be such as to enable the reader to grasp the information without much effort and laborous reading of details, which particularly refers to the units and termi­nology used. By means of graphs we can present numeric data in form of columns, curves of points in order to illustrate e. g. an increase or decrease of values, differences between them, as well as their correalation and trends. Columns being generally vertical, the abscissa (x) in graphs is mostly considered unnecessary. It is important that the value scale on abscissa (x) and ordinate (y) should start with zero (O) value. In the opposite case, the distance should be clearly marked with a set-off or a disruption on both the curve and the axis. Any curve-related marks should best be placed as close to the curve as possible, rather then being written dissociated just anywhere in the graph or even below it. More important curves can be highlighted, whe­reas those presenting different values, though of the same rank of importance, should be marked so as to remain within the same rank. An open graph conveys the message more clearly than a closed one (in form of a rectangle or square). When submitting graphic materials (graphs and photographs) for fina! editing, the size of publication and the width of text columns Report 339 should be taken into account, since any redu­cing may result in poor Iegibility of the figures. General guidelines for poster preparation are usually given by the organizer of the event where the poster is to be presented, but never­theless it· ·should be carefully designed. Considering the short tirne when authors are available to explain their works, a large number of paricipants and posters, and frequently ina­dequate exhibition place, a poster must be as simple as possible, centred on few basic points of the investigation. Should author wish to give more details, he is advised to do so in a written synopsis that can be distributed to interested participants. The course held by Mrs. M. H. Briscoe dealt with a number of problems related to scientific illustration, ali from the initial idea to its fina) materialisation. It was supported by practical use of computer for processing of graphs, as well as by the book "A Researcher's Guide to Scientific and Medica) Illustrations". Rather than passively attending a cycle of lectures ex catedra, the participants were expected to take active part by asking questions and suggesting possible solutions to the posed problems. The most advanced possibilities of graphic presentation of scientific work were shown and discussed. These are governed by own strictly defined regulations, though it may sometimes appear that a figure was created ad hoc, self-evidently depending on the author's endeavours. A valuable research work, impeca­ble as its performance might have been, means nothing but a waste of tirne and money, had it not been properly presented. Tomaž Benulic, MD, MSc Institute of Oncology, Ljubljana Radio! Oncol 1992; 26: 340. Notices Notices submitted far publication should contain a mailing address and phone number of a contact person or department. Genito-urinary tract tumours The ESO training course for Central and Eastern Europe will be held in Grossenzersdorf, Vienna, Aus­tria, .fuly /9-21, 1993. Contact European School of Oncology -Vienna Office, Arztekammer Fuer Wien, Weihburggasse 1­12, 1010 Yienna, Austria; or call + 43 222 51 501 280. Fax: + 43 222 51 501 240. Lung cancer The ESO training course for Central and Eastern Europe will be offered in Grossenzersdorf, Yienna, Austria, September, 1993. Contact European School of Oncology -Yienna Office, Arztekammer Fuer Wien, Weihburggasse 10­12, 1010 Yienna, Austria; or call + 43 222 51 501 280. Fax: + 43 222 51 501 240. Tumour imaging The ESO seminar will take place in Venice, ltaly, September 8-10, 1993. Contact European School of Oncology, Yia Vene­zian, 18 20133 Milan, Italy; or call + 39 2 70635923 or 2364283. Fax: + 39 2 2664662. Medica! physics Medica! Physics 93 & The 9th Spanish medica! physics congress, including a joint EFOMP/ESTRO session on portal imaging, will be held in Puerto de la Cruz, Tenerife, Spain, September 22-24, 1993. Contact the ESTRO Secretariat -University Hospi­tal St. Rafael, Radiotherapy Department, Capucijnen­voer 35, 3000 Leuven, Belgium; or call + 32 16 33-64-13. Fax: + 32 16 33 64 28. Head and neck tumours The ESO training course for Central and Eastern Europe will be offered in Grossenzersdorf, Yienna, Austria, September 30 -October 2, 1993. Contact European School of Oncology -Vienna Office, Arztekammer Fuer Wien, Weihburggasse 10­12, 1010 Vienna, Austria; or call + 43 222 51 501 280. Fax: + 43 222 51 501 240. Oncology The ESO training course for Central and Eastern Europe, titled "Good clinical practice", will take place in Grossenzersdorf, Yienna, Austria, September, 1993. Contact European School of Oncology -Yienna Office, Arztekammer Fuer Wien, Weihburggasse 1­12, 1010 Yienna, Austria; or cal + 43 222 51 501 280. Fax: + 43 222 51 501 240. Oesophageal mucosa The 4th International Polydisciplinary Congress of O.E.S.O. (lnternational Organization for Statistical Studies on Diseases of the Oesophagus) will be held in Paris, France, September 1-4, 1993. Contact Michele Liegeon, O.E.S.O.; 2, Boulevard du Montparnasse, 75015 Paris, France; or call + 33 1 45 66 91 15. Fax: + 33 1 45 66 50 72. Radiation physics The ESTRO teaching course "Radiation Physics for Clinical Radiotherapy", will be held in Leuven, Bel­gium, September 5-9, 1993. Contact the ESTRO Secretariat -University Hospi­tal St. Rafael, Radiotherapy Department, Capucijnen­voer 35, 3000 Leuven, Belgium; or call + 32 16 33-64-13. Fax. + 32 16 33 64 28. Radio! Oncol 1992; 26: 341-2. Author Index 1992 Ahel V: 1/1-3 Banic D: 2/120-4; 4/308-11 Banic S: 3/228-32 Batinica S: 4/291-5 Becher W: 1/37-43 Bedek D: 4/287-90 Benulic T: 3/250; 4/338-9 Bešlic S: 2/125-9; 3/212-7 Bobinac D: 3/193-204 Borkovic Z: 3/209-11 Bradic I: 4/291-5 Car M: 4/304-7 Cerk M: 4/301-3 Dalagija F: 2/125-9; 3/212-7 Debevec M: 1/56-9; 2/167-8 Depolo A: 2/120-4 Dodig D: 1/71-6 Dujmovic M: 3/193-204; 4/279-86 Džajo M: 2/145-9 Eljuga D: 2/140-4 Fischbach W: 1/37-43 Frkovic M: 2/113-9; 4/291-5 Fuckar Ž: 2/120-4; 3/218-22; 4/304-7 Gavric V: 3/205-8 Grivceva-Janoševic N: 1/4-8; 3/233-8; 3/248-9 Grunevski M: 1/4-8 Huljev D: 2/145-9 Ibralic M: 2/125-9; 3/212-7 Ivaniš N: 2/120-4; 3/218-22; 4/308-11 Jancar B: 4/333-7 Jereb B: 4/312-9 Juretic M: 4/304-7 Kasal B: 1/71-6 Kolaric K: 2/169 K6nya A: 2/150-6 Košutic K: 2/145-9 Kraus I: 4/308-11 Kristl V: 2/130-9 Krolo I: 1/9-13; 4/287-90 Kuhelj J: 1/90-1 Kus B: .3/223-7 Ledic S: 1/25-36 Lindtner J: 4/320-5 Lovasic I: 2/165-6; 3/193-204; 4/279-86 Lovrincevic A: 1/16-24; 2/125-9; 3/212-7 Mandic A: 2/113-9; 4/291-5 Merhemic Z: 2/125-9; 3/212-7 Metzger B: 3/239-42 Mikic Ž: 1/16-24 Mossner J: 1/37-43 Nacinovic-Duletic A: 3/218-22 Novakovic S: 3/223-7 Osmak M: 2/140-4 Palcevski G: 1/1-3 Peric R: 2/120-4; 3/218-22; 4/308-11 Prica M: 2/120-4; 4/279-86 Radie M: 4/279-86 Rajkovic-Huljev Z: 2/145-9 Ravnihar B: 1/77-82 Roš-Opaškar T: 1/45-55 Rožmanic V: 1/1-3 Rubinic M: 2/120-4; 3/218-22; 4/308-11 Rudolf Z: 1/45-55 Schwarte B: 1/37-43 Serša G: 3/223-7 Sever-Prebilic M: 3/218-22 Smolcic S: 1/9-13; 4/287-90 342 Author lndex Šepic A: 1/1-3 Škrbec M: 1/56-9 Štalc A: 3/223-7 Šustic A: 4/304-7 Šuštaršic J: 1/83-90; 3/243-7; 4/326-32 Tadžer I: 2/157-64 Tautz M: 1/60-70 Us J: 1/14-5, 1/44; 4/296-300 Vigvary Z: 2/150-6 Vlaisavljevic V: 3/205-8 Zamberlin R: 1/9-13; 4/287-90 Živkovic V: 3/209-11 Župancic B: 4/291-5 Radio/ Oncol 1992; 26: 343-4. Subject lndex 1992 alpha 1-antitrypsin: 1/37-43 angiography: 3/209-11 aplasia: 3/209-11 balloon dilatation: 1/1-3 biliary tract diseases: 2/150-6 bone and bones -radiology: 1/16-24 bone diseases -classification: 1/16-24 brain CT: 1/56-9 brain metastases: 1/56-9 brain neoplasms -secondary: 1/56-9 breast neoplasms -diagnosis: 3/205-8; 4/296-300 breast neoplasms -therapy: 4/320-5 carotid artery diseases -ultrasonography: 4/304-7 celi cultures: 2/140-4 child: 1/1-3, 1/4-8; 4/312-9 chromium radioisotopes: 1/37-43 colon -abnormalities: 4/291-5 colonic diseases -ultrasonography: 4/308-11 dekontamination: 1/71-6 diagnostic approach: 2/130-9 digital subtraction: 3/209-11 drug resistance: 2/140-1 drug therapy: 2/140-1 duodenal obstruction -congenital: 4/287-90 duodenal ulcer -surgery: 1/9-13 duodenum -radiography: 1/9-13 experimental: 3/223-7, 3/228-32 faces -analysis: 1/37-43 gadolinium: 2/130-9 -gadolinium-DTPA: 2/130-9 gastric emptying: 3/193-204 indium radioisotopes: 1/37-43 inflammatory bowel disease: 1/37-43 interventional radiology: 2/150-6 intestinal atresia -radiography: 4/287-90 intestinal atresia -radiology: 4/291-5 jugular veins -ultrasonography: 4/304-7 lumbago: 1/14-5 lumbar vertebra: 1/14-5 lumboiscchialgia: 1/14-5 lung diseases -radiography: 3/212-7 lung neoplasms -radiography: 1/56-9 lymphadenopathia colli: 1/14-5 lymphoma -ultrasonography: 3/218-22 Macedonia: 2/157-64; 3:233-8 magnetic resonance imaging: 2/130-9 mammography: 3/205-8; 4/296-300 melanoma: 1/45-55; 3/223-7 methylcholanthrene: 3/228-32 mice: 3/223-7, 3/228-32 neoplasms: 3/228-32 -neoplasms -history: 4/326-32 -neoplasms -metastasis: 4/304-7 -neoplasms -radiotherapy: 4/312-9 -neoplasms -staging: 3/218-22 nuclear medicine -history: 1/83-90; 4/326-32 nuclear medicine -trends: 2/157-64 nuclear reactor: 1/71-6 orbita! diseases: 4/301-3 organometallic compounds neoplasms -analy­ sis: 2/145-9 pancreatic diseases -radiography: 2/120-4 peptic ulcer -radiology: 4/279-86 phannacokinetics: 3/223-7 physician's role: 3/239-42 pituitary neoplasms -radiology: 1/25-36 primary tumor detection: 1/56-9 prognosis: 1/45-55 pulmonary artery -abnonnalities: 3/209-11 pulmonary valve stenosis -congenital: 1/1-3 Subject lndex 1992 pyloric stenosis -radiography: 2/113-9 pylorus -surgery: 3/193-204; 4/279-86 radiation dosage: 1/60-70; 2/150-6 radiation injuries: 1/71-6 radiation monitoring: 1/71-6 radioactive tracers: 2/145-9 radiography: 1/60-70 radiology: 2/165-6 -radiology -manpower: 3/239-42 -radiology -trends: 3/233-8 radiotherapy: 1/60-70 -radiotherapy -dosage: 4/312-9 -radiotherapy -history: 1/77-82 recurrence: 4/279-86 Rijeka: 2/165-6 sella turcica -radiography: 1/25-36 skin neoplasms: 1/45-55 Slovenia: 1/77-82, 1/83-90; 4/326-32 stomach -radiography: 1/9-13 survival analysis: 4/320-5 thoracic radiography: 2/125-9 tomography: 2/125-9; 3/212-7; 4/301-3 tumor necrosis factor: 3/223-7 ultrasonography: 2/120-4 vagotomy: 3/193-204; 4/279-86 vincristine: 2/140-4 vitamin E: 3/228-32 X-ray: 1/14-5 -X-ray computed: 2/125-9; 3/212-7; 4/301-3 Reviewers in 1992 Benulic T, Ljubljana, Slovenia -Brencic E, Ljubljana, Slovenia -Budja M, Murska Sobota, Slovenia -Demšar F, Ljubljana, Slovenia -Drinkovic I, Zagreb, Croatia -Fajgelj A, Ljubljana, Slovenia -Guna F, Ljubljana, Slovenia -Horvat Dj, Zagreb, Croatia -lvaniš N, Rijeka, Croatia -Jereb B, Ljubljana, Slovenia -Jevtic V, Ljubljana, Slovenia -Kopitar Z, Ljubljana, Slovenia -Kovac V, Ljubljana, Slovenia -Kovacevic D, Zagreb, Croatia -Kristl V, Ljubljana, Slovenia -Kurbus-Verk J, Ljubljana, Slovenia -Lekovic A, Rijeka, Croatia -Pavcnik D, Ljubljana, Slovenia -Pichler E, Zagreb, Croatia . Plesnicar S, Ljubljana, Slovenia -Serša G, Ljubljana, Slovenia -Škrbec-Jamar B, Ljubljana, Slovenia -Škrk J, Ljubljana, Slovenia -Šurlan M, Ljubljana, Slovenia -Šuštaršic J, Ljubljana, Slovenia -Us J, Ljubljana, Slovenia -Vlaisavljevic V, Maribor, Slovenia Editors greatly appreciate the work of the reviewers which significantly contributed to the improved quality of our journal. g....3 •HUNGARY• Annual Meeting and Postgraduate Course Cardiovascular and lnterventional Radiological Society of Europe -CIRSE Budapest, Hungary, June 20-24, 1993 In Association with: The Society of Cardiovascular and lnterventional Radiology (USA) The Japanese Society of Angiography & lnterventional Radiology The Scientific Programe will feature -4 State of the Art Lectures -5 Plenary Sessions on Main Topics -3 Round Tables -10 Oral Poster Presentations (morning: plenary, afternoon: parallel) -6 Workshops (parallel} -1 Work in Progress Session -6 Free Paper Sessions (parallel) Venue Budapest Convention Centre, Jagello ut. 1-3, 1123 Budapest Organizing Office CIRSE 93, P.O. Box 201, CH-8028 Zurich, Tel. +41-1-262 2404. Fax + 41-1-261 0578 Local Congress Office MALEV AIR TOURS, Congrees Department Ms Edit Omaisz Roosvelt ter 2. PF 122 or H-1051 Budapest H-1367 Budapest Phone: + 36-1-266 7836 -Fax + 36-1-266 7359. KEMOFARMACIJA Lekarne, bolnišnice, zdravstveni domovi 1n veterinarske ustanove vecino svojih nakupov opravijo pri nas. Uspeh našega poslovanja temelji na kakovostni ponudbi, ki pokriva vsa podrocja humane medicine in veterine, pa tudi na hitrem in natancnem odzivu na zahteve naših kupcev. KEMOFARMACIJA -VAŠ ZANESLJIVI DOBAVITELJ! I<: KEMOFARMACIJA Veletrgovina za oskrbo zdravstva, p. o. / 61001 Ljubljana, Cesta na Brdo l 00 Telefon: 061 268-145 / Telex: 31334 KEMFAR / Telefax 271-362 Ab a kt a ampoules 400 mg (pefloxacin) A new potent drug against infections • May be given orally and parenterally • Effecive in life-threatening infections caused by nosocomial strains resistant to many drugs • May be given to patients hypersensitive to penicillins and cephalosporins • lts favourable pharmacokinetic properties allow twice-a-day dosage • 1s very well tolerated Contraindications Pefloxacin is contraindicated in patients with known hypersensitivity to quinolones, in preg­nant women, nursing mothers, children under 15 years of age, and patients with inborn glucose-6-phosphate dehydrogenase deficiency. Precautions During pefloxacin therapy exposure to strong sunlight should be avoided because of the risk of photosensitivity reactions. In patients with a severe !iver disorder dosage of pefloxa­ cin should be adjusted. Side effects Gastro-intestinal disturbances, muscle and/ or connective tissue pains, photosensitivity reactions, neurologic disturbances (headache, insomnia), and thrombocytopenia (at doses of 1600 mg daily) may occur. Dosage and administration The average daily dosage tor adults and children over 15 years of age is 800 mg. Oral: 1 tablet twice daily after meals. Parenteral: the content of 1 ampoule 400 mg diluted in 250 ml of 5 % glucose as a slow 1-hour infusion twice daily. The maximum daily dosage is 8 mg of pefloxacin per kg body­weight. In severe hepatic insufficiency pefloxacin is administered only once daily (jaundice), once every 36 hours (ascites), and once every 48 hours (jaundice and ascites). @ lek Pharmaceutical and Chemical Company d.d. Ljubljana Klimicin ® Klimicin is an effective (Clindamycin) It stimulates the action bactericidal or of polymorphonuclear bacteriostatic as leukocytes (PMN) evidenced by the principal factors in MIC/MBC ratio. host immune system. PMN leukocyte. Anaerobes Aerobes Bacteroides spp. (including Bacteroides fragilis) Streptococcus spp. (including Fusobacterium spp. Streptococcus pyogenes), except Propionibacterium Enterococcus Eubacterium Actinomyces spp. Pneumococcus spp. Peptococcus spp. Staphylococcus spp. (including Peptostreptococcus spp. B-lactamase producing strains) Clostridium perfringens Contraindications: In patients hypersensitive to lincomycin and clindamycin. Precautlons: Klimicin should be prescribed with caution to elderly patients and to individuals with a history of gastrointestinal disease, particularly colitis. Side Effects: Gastrointestinal disturbances (abdominal pain, nausea, vomiting, diarrhea). When significant diarrhea occurs, the drug should be discontinued or continued only with close observation of the patient. The posibility of pseudo­membranous colitis must be ruled out. @ lek Pharmaceutical and Chemical Company d.d. Ljubljana © Eastman Kodak Company, 1990 Kodak systems provide dependable performance for advanced diagnostic imaging. Our quality components are made to work together from exposure to viewbox. Kodak X-Omat processors are the most respected in the field. Kodak X-Omatic cassettes are known the world over far unexcelled screen-film contact and dura­bility. Kodak multiloaders have earned an enviable reputation far reliability. The Kodak Ektascan laser printer is changing the look of digital imaging. The list goes on. There are quality Kodak products throughout the imaging chain. Equally important, they are made to work together to achieve remarkable performance and diagnostic quality. Contact your Kodak representative far more information. 1 1 11 1 1 NI lopami,rg® 150 -200 -300 -370 mgl/ml FOR ALL RADIOLOGICAL EXAMINATIONS MYELOGRAPHY ANGIOGRAPHY UROGRAPHY C.T. D.S.A. THE FIRS"Ji WATER SOLUBLE READV TO USE NON-IONIC CONTRAST MEDIUM Manufacturer· Distributer: Bracco s.p.a. Agorest s.r.l. Via E. Folli, 50 Via S. Michele, 334 20134 -Milan -(1) Fax (02) 26410678 Telex 311185 Bracco 1 Phone: (02) 21771 e 34170 -Gorizia -(1) Fax: (0481) 20719 Telex: 460690 AF-GO 1 Phone: (0481) 21711 ondansetron NAJ BO ZDRAVLJENJE MALIGNIH BOLEZNI MANJ NEPRIJETNO Novo zdravilo za preprecevanje bruhanja in slabosti Skrajšano informacijo o preparatu: Indikacije: Slabost in bruhanje povzroceno s kemoterapijo ali z radioterapijo. Dozira.nje: Odrasli, Visokoemetogeno kemoterapijo, Dozo po 8 mg s pocasno iv. injekcijo neposredno pred kemoterapijo in še dve iv dozi po 8 mg v presledku po dve do štiri ure, ali nepretrgano infuzijo l mg/uro do 24 ur. Za zašcito pred zakasnelim bruha­njem, po preteku prvih 24 ur, nadaljujemo z oralnim dajanjem Zofrono po 8 mg 2-krot dnevno do 5 dni po ciklusu zdravljenja. Emetogeno kemoterapijo in radioterapijo: Zofron po 8 mg dajemo v pocasni iv. injekciji neposredno pred ciklusom zdravljenje oli oralno eno do dve uri pred ciklusom in nadaljujemo z oralnim dajanjem po 8 mg vsakih dvanajst ur. Zo zašcito pred zakas­nelim bruhanjem, po preteku prvih 24 ur, nadaljujemo z oralnim dajanjem Zofrono po 8 mg 2-krat dnevno do 5 dni po ciklusL zdravljen jo. Otroci, Otrokom dajemo eno iv. injekcijo po 5mg/m2 neposredno pred kemoterapijo in 12 ur kasneje nadaljujemo z dozo pc 4 mg oralno. Dajanje po 4 mg 2-krat dnevno nadaljujemo do 5 dni po ciklusu zdravljenja. Kontraindikacije: Preobcutljivost za katerokoli sestavino pripravka. Previdnost: Nosecnost in dojenje. Stranski pojavi: Glavobol, obcutek vrocine ali toplote v glavi in epigostriju, zaprtje, prehodno zvišanje ominotronsferoz, zelc redko reakcije preobcutljivosti. Opremo: Zofron za injekcije: ampule po 2 in 4 ml v škatlicah po pet. Zofron tablete (4 mg), zavojcki po 10 in 30 tablet. Zofror tablete (8 mg): zavojcki po 10 in 30 tablet. Podrobnejše informacije dobite pri: Glaxo Export limited Predstavništvo v Ljubljani, T ržoško 132, 61111 Ljubljano tel. (061) 272 570, 272-491,fox (061) 272 569 Your partner in :adiology. Prestilix DRS Advantx AFM Vectra SIEMENS SOMATOM AR.T SIC 212 Ganzkbrper-Computertomograph CT 1111 1· 1 1 1 1111 , 1,1' !':i 1 1 ;1; ! TOSAMA Tovarna sanitetnega materiala p.o. 61230v Domžale p.p. 128 Vir, Saranoviceva 35 telefon: (061) telefax: (061) telex: IZDELUJE: SANITETNI PROGRAM -tkane, rezane, elasticne povoje -mavcne in sadrona povoje -sanitetno mrežo Virfix -konfekcionirano gazo -konfekcionirano vato -celulozno vato in izdelke -obliže -sanitetne torbice, omarice -avtomobilske in motorske apoteke PROGRAM IZDELKOV ZA OSEBNO HIGIENO -higienski vložki VIR -higienski tamponi VIRTAMP -higiensko in cik-cak vato -Jasmin vato -Jasmin blazinice -bebi palcke OTROŠKI PROGRAM -tekstilne plenice -nocne plenice TOSAMA -hlacne plenice SAMO Super -bebi plenicne predloge -povijalne rutice -zašcitne hlacke 714-611 714-660 39-804 PROGRAM MEDICINSKE PLASTIKE -Virkol vrecke -urinske vrecke VIRTEKS PROGRAM -posteljno perilo -zdravniške maske -kape -bolniške, ortopedske, zdravniške -operacijski plašci, halje, predpasniki -prevleke za obuvala -rute za operirance -operacijska pregrinjala INKO PROGRAM -Inko podloge -Inko povijalne rute -Inko hlacke -podloge za bolnike PROGRAM IZDELKOV ZA DOM -vecnamenska krpa Bistrica -polirna vata -vrteks -vrtnarska vlaknovina 5s::I L U 5 LJUBLJANA D. D. 61000 LJUBLJANA, MAŠERA-SPASICEVA ul. 10 Telefoni: n.c. (061) 181-144 -direktor: 182-069 . prodaja: 181-031, 181-130, 182-001, 181-041 -Fax: 181-02 2 OSKRBUJE lekarne, bolnišnice, zdravstvene domove ter druge ustanove in podjetja s farmacevtskimi, medicinskimi in drugimi proizvodi domacih proizvajalcev, s proizvodi tujih proizvajalcev pa s pomocjo lastne zunanjetrgovinske službe. Proizvaja: ALLIVIT PLUS® Kapsule cesna z dodatkom zdravilnih zelišc. Prodajna in dostavna služba posluje vsak dan neprekinjeno od 7. do 16. ure, razen sobote. ll®.IBfi. LESNINA ZDRUŽENA PODJETJA ZA TRGOVINO , INŽENIRING IN PROIZVODNJO n.sub.o. , OSEBNA IZKAZNICA LESNINE JE: -ena najvecjih in najstarejših trgovskih organizacij v lesni stroki z dolgo­letno tradicijo, saj posluje že vec kot štirideset let -organizacija, ki prodaja pohištvo, notranjo opremo ter gradbeni material -organizacija, ki opravlja celoten inženiring v notranji opremi in opremi lesno predelovalnih tovarn doma in v tujini -proizvajalec ekskluzivnega pohištva, pohištva po meri in druge notranje opreme ter proizvodov iz aluminija -organizacija, ki združuje enajst podjetij ter tri družbe -izvaža v štirideset držav po vseh celinah in je tretji najvecji izvoznik pohištva -ima sedem lastnih in mešanih podjetij ter predstavništev v tujini in sedem montažnic pohištva v ZDA -organizacija, ki ima financno poslovanje urejeno v lastni interni banki -organizacija, ki zaposluje 2.100 ljudi. 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, UKC Ljubljana Klinika za otorinolaringologijo in maksilofacialno kirurgijo, UKC Ljubljana Klinicki zavod za dijagnosticku i interventno radiologijo, KBC Rebro, Zagreb Onkološki inštitut, Ljubljana Organizacijski odbor Desetog znanstvenog skopa Hrvatskog društva radiologa (Varaždin, 1992) DONATORS AND ADVERTISERS: AGOREST S.r.l., Gorizia, Italy ANGIOMED Karlsruhe, Germany GENERAL ELECTRIC -CGR Representative Otlice Zagreb, Croatia GLAXO Export Itd. Ljubljana, Slovenia KEMOFARMACIJA Ljubljana p.o. • Ljubljana, Slovenia KRKA p.o. Novo mesto, Slovenia EWOPHARMA AG Schaffhausen, Switzerland LEK d.d. Ljubljana, Slovenia LESNINA, Interna banka d.o.o. Ljubljana, Slovenia MEDITRADE-KODAK, Ljubljana, Sloveilia PLIVA Ljubljana d.o.o. Ljubljana, Slovenia SALUS d.d. Ljubljana, Slovenia SANOLABOR p.o. Ljubljana, Slovenia SIEMENS d.o.o. Ljubljana, Slovenia TOSAMA p.o. Domžale, Slovenia Radio{ Oncol 1992; 26: 362 Instructions to authors The journal Radiology and Oncology publishes ori­ginal scientific papers, professional papers, review ar­ticles, case reports and varia (reviews, short communi­cations, professional information, ect.) pertinent to diagnostic and interventional radiology, computerised tomography, magnetic resonance, nuclear medicine, radiotherapy, clinical and experimental oncology, ra­diobiology, radiophysics and radia ti on protection. Submission of manuscript to Editorial Board implies that the paper has not been published or submitted for publication elsewhere: the authors are responsible for ali statements in their papers. Accepted articles become the property of the journal and therefore cannot be published elsewhere without written permis­sion from the Editorial Board. Manuscripts written in English should be sent to the Editorial Offiee: Radiology and Oncology, Institute of Oncology, Vrazov trg 4, 61000 Ljubljana, Slovenia; Phone; +38 61314 970; Fax: +38 61329 177. Radiology and Oncology will consider manuscripts prepared according to the Vancouver Agreement (N Engl J, Med 1991; 324: 424-8.; BMJ 1991; 302: 6772.). Ali articles are subjected to editorial review and review by two independent referees selected by the Editorial Board. Manuscripts which do not comply with the teehnical requirements stated herc will be returned to the authors for correction before the review of the referees. Rejeeted manuscripts are gene­rally returned to authors, however, the journal cannot be held responsible for their loss. The Editorial Board reserves the right to require from the authors to make appropriate changes in the content as well as gramma­tical and stylistic corrcctions when necessary. The expenses of additional editorial work and requcsts for reprints will be charged to the authors. General instructions: Type the manuscript double spa­ced on one side with a 4cm margin at the top and left hand side of the sheet. Write the paper in grammati­cally and stylistically correct language. Avoid abbrevia­tions unless previously explained. The technical data should confirm to the SI system. The manuscript, including the refcrences may not exceed 15 typewritten pages, and the number of figures and tables is limited to 4. If appropriate, organise the text so that it includes: Introduction, Material and methods, Results and Discussion. Exceptionally, the results and discus­sion can be combined in a single section. Start each section on a new page and number these consecutively with Arabic numerals. Authors are encouraged to submit their contributions besides three typewritten copies also on diskettes ( 5 1/4") in standard ASCII format. First page: -name and family name of ali authors, -a brief and specific title avoiding abbreviations and colloquialisms, -complcte address of institution for each author, -in the abstract of not more than 200 words cover the main factual points of the article, and illustrate them with the most relevant