UDC 616-006(05)(497.1) CODEN RDIUA 4 YU ISSN 0485-893X RADIOLOGIA IUGOSLAVICA ANNO 24 1990 FASC 2 PROPRIETARII IDEMOUE EDITORES: SOCIETAS RADIOLOGORUM IUGOSLAVIAE AC SOCIETAS MEDICINAE NUCLEARIS IN FOEDERATIONE SOCIALISTICA REI PUBLICAE IUGOSLAVIAE LJUBLJANA Radio! lugosl. April-June, 1990 ;24 :113-202 Nov.a generacija cepiv HEPAGERIX B® injekcije cepivo proti hepatitisu 8, izdelano z genetskim inženiringom • metoda genetskega inženiringa .izkljucuje prisotnost cloveške krvi • popolnoma varno in široko preskušeno cepivo • visoko ucinkovito cepivo, ki varuje pred vsemi znanimi podvrstami hepatitisa B in pred hepatitisom O • dosega skoraj 100 % serokonverzijo • lahko ga dajemo v vseh starostnih obdobjih • vsi ga dobro prenašajo Bazicno cepljenje opravimo s 3 intramuskularnimi dozami po eni izmed shem (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 10 let: 10 µ,g proteina površinskega antigena v 0,5 ml suspenzije. Podrobnejše informacije in literaturo dobite pri proizvajalcu t (. lgy SCIENTIFIC PROGRAM ME: -EPIDEMIOLOGY AND VIROLOGY OF BURKITT-LIKE L YM­PHOMA -PATHOLOGY AND IMMUNOLOGY OF BURKITT-LIKE LYM­PHOMA -SYMPTOMATOLOGY AND DIAGNOSTICS OF BURKITT-LIKE LYPHOMA -SPECIAL LECTURE: IMMUNITY IN MALIGNANCIES -POSTER PRESENTATIONS AND A SERIES OF SHORT LECTU­ RES FROM INSTITUTIONS, CLINICS AND WORKING GROUPS WITH EXPERIENCE IN DIAGNOSTICS AND TREATMENT OF BUR­KITT-LIKE L YMPHOMA -CLOSING LECTURE: PRESENT STATUS AND TREATMENT OF BURKITT LIKE L YMPHOMA lnformation and registration: BLL Organizing Committee, Ms. Olga Shrestha, Institute of Oncology, Zaloška 2, 61000 Ljubljana, Yugosla­via. Tei 061-327 955 Sodelavcem ! V letu 1991 bo pricel izhajati 25. letnik naše revije. Z željo da bi jubilejni letnik predstavili najširšemu številu strokovnjakov v svetu, srno v uredništvu sklenili, da izdamo posebno jubilejno številko, ki bo v celoti pisana v anglešcini ali o drugem svetovnem jeziku. V njej naj bi naši in povabljeni tuji strokovnjaki s podrocij, ki jih objavlja revija, predstavili svoje dosežke v obliki originalnih znanstvenih prispevkov ali preglednih clankov. Vse, ki so pripravljeni sodelovati, vljudno naprošamo, da nam to sporocijo do 30. septembra 1990. 25. letnik revije RADIOLOGIA IUGOSLAVICA Priimek in ime avtorja Naslov Predviden naslov prispevka ...................... . ' št. strani ................... . »RADIOLOGIA IUGOSLAVICA« Uredništvo Onkološki inštitut Ljubljana Vrazov trg 4 -61000 Ljubljana Saradnicima ! U godini 1991 štampat ce se 25-godišnjak revije. U želji da jubilejni godišnjak predstavimo najširem broju strucnjaka u svetu, zakljucili smo da se štampa vanredan jubilejni broj koji ce biti u celosti pisan na engleskom ili drugom svetskom jeziku. U tom broju neka bi naši i pozvani strani strucnjaci iz podrucja koja objavljiva revija, predstavili svoja dostignuca u obliku originalnih naucnih ili preglednih clanaka. Sve, koji su spremni saradivati, uctivo molimo da nam to jave do 30. septembra 1990. 25. godišnjak revije »RADIOLOGIA IUGOSLAVICA« Prezime i ime autora Naslov Predvideni naslov clanka ....... . Broj stranica ................... . »RADIOLOGIA IUGOSLAVICA« Uredništvo Onkološki inštitut Ljubljana Vrazov trg 4 -61000 Ljubljana UNIVERZITETSKO MEDICINSKI CENTAR INSTITUT ZA RADIOLOGIJU I ONKOLOGIJU, SARAJEVO KOMPJUTERIZIRANA TOMOGRAFIJA (CT) TORAKALNIH ORGANA U DIJAGNOSTICI EHINOKOKA CHEST CT IN HYDATID DISEASE Dalagija F, Bešlic š Abstract -Chest CT findings in 77 patients with pulmonary hydatid disease were analysed retrospectively and compared with similar data of plain radiography and surgery. Out of the total 89 (100%) operated pulmonary hydatid cysts, 58 (65%) were intact or simple, and 31 (35%) ruptured or complicated hydatid cysts. CT improved preoperative diagnosis of pulmonary, as well as the echinococcus of upper abdominal organs. It proved to be superior to conventional radiologic diagnostic methods in the diagnosis of simple and complicated hydatid cysts, associated with difficulties in differential diagnosis in particular kinds of complicated cysts. UDC: 616.24-002.951.21-073.75 Key words: echinococcosis pulmonary, tomography x-ray computed Orig sci paper Radiol lugosl 1990; 24: 117-20 Uvod -Poznate je da Jugoslavija kao medi­teranska zemlja spada medu desetak zemalja u svijetu s najvecom ucestalošcu zaraženostil pasa i oboljevanja stoke i ljudi. Tocnije, ona je na sedmem mjestu u svijetu po ucestalosti ove parazitoze uzrokovane formam larve Echinococ­cus granulosus. Zbog prave epidemije oboljenja kadriovaskularnog sistema, malignoma i mirno­dopskog traumatizma, smatra se da je ehinoko­koza kao zdravstveni problem potisnuta, pa i zenemarena. Tok bolesti je dugotrajan sa oskudnim i neka­rakteristicnim simptomima, pa se bolest cesto otkriva slucajno, a veliki broj bolesnika ostaje i neotkriven, izležen opasnosti nagle smrti. Pošto je vrijeme eradikacije još daleko, preporuceno je permanentno izucavanje dijagnostike i terapije ehinokoka (1 ). Uz konvencionalne radiološke i druge diiag­nosticko-laboratorijske metode, u našoj ustanovi se u dijagnostici ehinokoka od 1979. godine koristi i kompjuterizirana tomografija (CT). · Osnovni cilj ovog rada je bio da se na pesto- jecem klinickom rnaterijalu iz svakodnevne prakse analiziraju mogucnosti CT i procjeni njen doprinos dijagnostici intratorakalnog ehinokoka. Materija! i metode -Retrospektivnem meto­dom obradeni su nalazi CT torakalnih organa 77 klinickih pacijenata sa intratorakalnim ehinoko­kom, kod kojih je ova pretraga i izvršena u našoj ustanovi u toku posljednjih deset godina, uz operativnu potvrdu nalaza. Od ukupno 77 (100%) pacijenata, 43 (56%) su bili muškog, a 34 (44%) ženskog pola, u životnoj dobi od 4 do 77 godina, prosjecno 34 godine. Pored CT torakalnih organa, kod svih 77 pacijenata predhodno je ucinjena standardna radiografija torakalnih organa (posteroanteriorna i profilna projekcija), a kod nekolicine radioskopi- •ja, konvencionaln,a tomografija, bronhografija, angiografija i bronhoskopija. CT jetre, odnosno gornjeg abdomena, klinicko-laboratorijske pre­trage i operativni zahvat, ucinjeni su, takode, kod svih 77 pacijenata. CT pregledi su izvršeni apara­tom Somatom SF ili DRH u supinacionom polo­žaju pacijenata, sa transverzalnim presjecirna toraksa od nivoa. apeksa do stražnjih freniko-ko­ stalnih sinusa. CT presjeci su najcešce bili od po 8, a rjede i 4 mm, samo nalivno ili i nakon aplikacije kontrastnog sredstva (infuzija i/ili »bo­ lus«). Received: February 2, 1990 -Accepted: March 24, 1990 Dalagija F, Beslic š: Kompjuterizirana tomografija (CT) torakalnih organa u dijagnostici ehinokoka Rezultati -Od ukupno 77 (100%) pacijenata, Od ukupno 89 (100%) operisanih intratora­kod 64 (83%) utvrdena je jednostrana intratora­kalnih ehinokoknih cista (ne ubrajajuci multiple kalna ehinokokoza i to kod 59 u plucnom paren­obostrane ciste pluca kod tri pacijenta), 58 (65%) himu, kod dva u medijastinumu i kod tri sekun­su bile jednostavne ili intaktne, a 31 (35%) darno na pleuri. Kod 59 pacijenata utvrdena je komplicirane ili rupturirane ciste. jednostrana solitarna cista (desno kod 32 paci­jenta i to kod 12 u gornjim i kod 20 u donjim Diskusija -Ehinokokoza ili hidatidna bolest, partijama, a lijevo kod 26 pacijenata, kod 12 u koja je rasprostranjena u mnogim dijelovima gornjim i kod 14 u donjim partijama). Kod pet svijeta, a u koje spada i Jugoslavija, kod covjeka pacijenata utvrdene su po dve ciste jednostrano se manifestuje u formi ciste. Ove ciste se mogu (desno kod tri i lijevo kod dva pacijenta), te kod razviti u svim organima ljudskog tijela, ali prema jednog pacijenta multiple ciste desno (Tabela 1 ). vecini statistika najcešce u jetri, kod 60% i Tabela 1 -Distribucija prema lokalizaciji cista u toraksu Table 1 -Distribution according to the site of cysts in the torax JEDNOSTRANO UNILATERAL 64 (83% po 1 cista by one cyst 58 po 2ciste by two cysts 5 multiple multiple 1 desno right lijevo left desno right lijevo left desno right 26 3 2 1 dole gore dole gore dole gore dole gore dole gore up down up down up down down up down 12 20 12 14 3 Kod 13 (17%) pacijenata utvrdena je obo­strana intratorakalna ehinokokoza, kod deset pa­cijenata po jedna cista obostrano i kod tri paci­jenta multiple ciste obostrano. Kod 21 (27%) pacijenata, poreci intratorakalne, utvrdena je i ehinokokoza organa gornjeg abdomena (kod 19 pacijenata u jetri, kod jednog u jetri, bubregu i periloneumu, te kod jednog u bubregu) (Tabela 2.). 3 o 4 o 1 plucima, kod 30% u svim ostalim organima (slezena, bubrezi, rjede mišici, mozak, kosti itd.), kod 10% slucajeva (1, 2). Utvrdeno -je da se najcešce srece solitarna ehinokokna cista u jed­nom plucnom krilu, ali su moguce i multiple ciste, jednostrano ili obostrano. Ciste su nešto cešce u desnom plucnom krilu, periferno i u bazalnim partijama (1, 2, 3, 4, 5). Isto je potvrdeno i u ovom radu, vidljivo iz Tabela 2 -Distribucija prema lokalizaciji cista u toraksu i gornjem abdomenu Table 2 -Distribution according to the localization of cysts in the torax and upper abdomen OBOSTRANO BILATERAL 13 (17%) po 1 ista by one cyst 10 multiple multiple 3 U GORNJEM ABDOMENU IN THE UPPER ABDOMEN 21 (27%) ujetri u jetri, bubregu, peritoneumu u bubregu liver liver, kidnney, peritoneum kidney 1 19 1 P.c.d;ol lugosl 1990; 24: 117-20. Dalagija F, Beslic š: Kompjuterizirana tomografija (CT) torakalnih organa u dijagnostici ehinokoka tabele 1 i tabele 2, gdje je izležena distribucija cista prema lokalizaciji. Konvencionalne radiološke dijagnosticke me­tode, standardna radiografija i radioskopija, pred­stavljaju i danas osnovne metode u dijagnostici intratorakalne ehinokokoze. Kao što je vec naprijed nevedeno, jedno­stavna ili nekomplicirana ehinokokna cista ima oligosimptomatski tok pa se cesto otkriva slucaj­no. Radiološki se obicno prezentira kao okrugla, oštro ocrtana, homogena, mekotkivna sjena. U diferenciranju od oslidnih tumora koristan je po­znati Escudero Nemen-ov znak, kod manjih i srednjih cista. U toku radioskopije, okrugla sjena ciste u inspiriju dobiva ovalnu formu, ali negati­van nalaz ne iskljucuje cistu. Kod kompliciranih ehinokoknih cista poznati su brojni radiografski znaci (Zehbe, Kamalota, Escudern-Tobias, Gumb. lvanissevich, lessentisseur) od kojih su neki patognomicni za ehinokok (1, 2, 3, 6). Uz pomenute konvencionalne radiološke di­jagnosticke metode u posljednjih desetak godina u dijagnostici ehinokoka koristi se i kompjuterizi­rana komografija (CT). Za razliku od hepaticne ehinokokoze, o CT dijagnostici intratorakalne, u literaturi je znatno manje radova (2, 7). Kao što je poznate, CT je superiorna nad konvencional­nim radiološkim metodama, jer je zahvaljujuci prvenstveno sposobnosti diferenciranja manjih razlilka u apsorbciji X-zraka, odredivanjem ste­pena gustoce lezije, daje dijagnosticke informa­cije koje se ne mogu dobiti konvencionalnim metodama. Stoga se CT, izmedu ostalog, potv­rdila veoma korisnom i u dijagnostici cisticnih lezija, diferencirajuci ih od masa stepena gustoce solidnog ili masnog tkiva (1, 2, 4, 5, 7, 8, 9, 10). Slika 2 -Ehinokokna cista sa »depicem« zraka u zadebljanom zidu kao znak prijetece rupture endociste Fig. 2 -Hydatid cyst with a pocket of air in the thickened wall as a sign of menacing endocyst rupture CT se pokazala najkorisnijom u dijagnostici jednostavnih ili nekompliciranih ehinokonih cista, što je potvrdeno i u ovom radu (CT nalazi su bili podudarni sa operativnim kod preko 90% sluca­jeva sa nekompliciranim cistama.) Ona daje ja­san prikaz okrugle, oštro ocrtane, homogene formacije, stepena gustoce tecnosti (u ovom radu isti se kretao od +3 do+ 19, a prosjecno + 1 O Haunsfildovih jedinica). Poreci prikaza tocne lo­kalizacije, forme, velicine, kontura, stepena gu­stoce i broja cista, CT i kod ovih lezija daje i znatno bolji prikaz odnosa prema okolnim struk­turama-torakalnom zidu. odnosno pleuri, krvnim žilama, perikardu itd. (slika 1 i 2). Medutim, a što je istaknuto i u literaturi, ove ciste nije moguce sa sigurnošcu diferencirati od plucnih cista gustoce tecnosti druge etiologije na osnovu samo CT izgleda (2). lpak, kod CT nalaza cisticne formacije (prema vlastitom zapa­žanju, osobito onih sa intenzivnom prstenastom rubnom zonom, koja odgovara pericisti) u en­demskim krajevima, u koje spada i naša zemlja, treba prvenstveno misliti na ehinokok (1, 2). Smatra se da je CT korisna i u dijagnostici kompliciranih ili rupturiranih ehinokoknih cista. Utvrdeno je da ona, u odnosuc na standardnu radiografiju, može bolje vizualizirati karakteri­sticne detalje kao što su odvojene ili kolabirane endocisticne membrane, kolabirane membrane ciste kcerke i intaktne ciste kcerke, unutar preo­stale hidatidne tecnosti (slika 3 i 4). Rupturirane ciste bez tih karakteristika teško se diferenciraju od tumora, jer zbog potpunog nedosatka tecnosti, kolabirana cista i membralne iste kcerki se ne diterenciraju, pa dobivaju CT gustocu solidnog tkiva. Takode i hronicno infici­rane ciste, odnosno hidatidni apscesi u formi Dalagija F, Beslic š: Kompjuterizira.a tomografija (CT) torakalnih organa u dijagnostici ehinokoka Slika 3 -Jednostavna ehinokona cista sa cistama kcerkama poput septirane ciste Fig. 3 -Simple hydatid cyst with daughter cysts as a septate cyst CT je superiorna nad konvencionalnim radio­loškim dijagnostickim metodama u dijagnostici jednostavnih, a i kompliciranih ehinokoknih cista uz diferencijalno-dijagnosticke teškoce kod odre­denih vrsta kompliciranih cista. Sažetak Nalazi CT torakalnih organa 77 pacijenata sa intrato­rakalnim ehinokokom analizirani su retrospektivno komparirani sa naiazima standardne radiografije i hirur­gije. Od ukupno 89 (100%) operisanih intratorakalnih cista, 58 (68%) su bile intaktne ili jednostavne, a 31 (35%) rupturirane ili komplikovane. CT je korisna i znatno je unaprijedila preoperativnu dijagnostiku intratorakalnog, kao i ehinokoka organa gornjeg abdomena. Ona je superiorna nad konvencio­nalnim radiološkim dijagnostickim metodama u dijagno­stici jednostavnih, a i kompliciranih ehinokoknih cista uz odredene diferencijalno-dijagnosticke teškoce kod pojedinih vrsta kompliciranih cista. Slika 4 -Sekundarna ehinokokoza pleure sa cistama kcerkama Fig. 4 -Secondary hydatid pleural disease with daug­hter cysts šupljine zadebljalog zida periciste sa zracno-tec­nim nivoom, ne mogu se diferencirati od pravog ili piogenog apscesa ni pomocu CT-a (2). Zakljucak -Na osnovu naprijed iznesenog, može se reci da je CT korisna i da je znatno unaprijedila preoperativnu dijagnostiku intratora­kalne, kao i ehinokokoze organa gornjeg abdo­mena. Li teratura 1. L'.ivkovic K. Ehinokokoza covjeka. Šibenik: ŠIRO »Štampa«, 1983. 2. Saksouk FA, Fahl MH, Rizk GK. Computed tomo­graphy of pulmonary hydatid disease. J Comput Assist Tomogr 1986; 1 O :226-32. 3. Balikian JP, Mudarris FF. Hydatid disease of the lungs. A roentgenologic study of 50 cases. Am J Roentgenol Radium Ther Nucl Med, 1974; 122 (4) :692­707. 4. Gonzales LR et al. Radiologic aspects of hepatic echinococcis. Value of the intravenous viscerogram and computed tomography. Radiology 1979; 130:21-7. 5.Scherer U et al. Computed tomography in hydatid disease of the liver. A report of 13 cases. J Comput Assist Tomogr 1978; 2:612-17. 6. Reeder MM. Hydatid cyst of the lung. RPC of the month from the AFIP. Radiology 1970; 95:429-37. 7. Opperman HC et al. Mediastinal hydatid disease in childhood: CT documentation of response to treat­ment with Mebendazole. J Comput Assist Tomogr 1982; 6:175-6. 8. Heitzman ER. CT of the thorax: current perspecti­ves. AJR 1981; 136:2-12. 9. lsmail MA et al. The use of computerized axial tomography (CAT) in the diagnosis of hydatid cysts. Ciin Radiol 1980; 31 :287-90. 1 O. Munro JC. CT of the thorax. Radiogra[)hy 1982; 48:95-101. Adresa autora: Dalagija F, UMC Sarajevo, Institut za radiologiju i onkologiju Radiol lugosl 1990; 24: 117-20. DOM ZDRAVLJA, RUMA KABINET ZA RADIOLOGIJU UL TRAZVUK I KLASICNA GRUDNA RENDGENOLOŠKA DIJAGNOSTIKA ULTRASOUND ANO CLASSIC CHEST X-RAY DIAGNOSTICS Jovanovic G Abstract -Two-dimensional real tirne ultrasonography can be a very helpful additional method to the classic chest x-ray diagnostics in indicated and selected cases, in the first line tor pleural effusions (encapsulated, atypical or free). There are other conditions such as pleural tumors, and tumors of the lungs and mediastinum that are in immediate contact with the thoracic wall or diaphragm, which can also be investigated by this technique. Despite the modest number of evaluated cases, our first results point out the efficacy of the method. UDC: 616.24/.25-073. 75 :534-8 Key words: thoracic radiography, ultrasonic diagnosis Profess paper Radiol lugosl 1990; 24: 121-5. Uvod -Prakticna primena real-tirne dvodimen­zione ultrasonografije u grudnoj dijagnostici (sem ehokardiografije i ehomamografije) je slabo raši­rena, a i podaci o torne iz strucne literature su relativno oskudni. Ultrasonografija može da bude vrlo zahvalna dopunska metoda klasicnoj grudnoj rendgenolo­škoj dijagnostici u odredenim slucajevima, i cilj ovog clanka, koji je baziran skoro iskljucivo na svakodnevnoj praksi u našoj (vanbolnickoj) zdravstvenoj ustanovi, je da to prikaže, argumen­tuje i preporuci. Materija! i metode -U pocetku smo razmatrali samo pleuralne izlive uglavnom pronadene uz­ Slika 1 -Pleuralni izliv desno gred pri ultrasonografskom pregledu gornjeg ab­Fig. 1 -Right pleural effusion domena koji je i osnovna oblast našeg ultrasono­grafskog rada (1, 2, 3); (slika 1 ). U periodu od godinu dana (1989. g.) pregledali Zainteresovani za mogucnost primene real smo ukupno 45 9draslih pacijenata oba pola sa tirne ultrasonografije u grudnoj dijagnostici, prešli sonografski registrabilnim manifestacijama grud­smo zatim na biranje slucajeva koji ce se posle nog oboljenja. Od toga, jedna trecina pacijenata klinicke i rendgenske obrade pacijenta evaluirati nam je upucivana na ultrasonografski pregled i ovom metodam, pri cemu je razvijena saradnja gornjeg abdomena (sa razlicitim uputnim dijagno­sa Dispanzerom za pulmologiju našeg Doma zama ili bez njih), pri cemu je patološki proces u zdravlja (4, 5). grudnom košu ·pronaden uzgred. Druga, veca Received: December 26, 1989 -Accepted: March 21, 1990 JovanoviC G: Ultrazvuk i klasicna grudna rendgenološka dijagnostika grupa paciljenata nam je upucivana ciljano, od strane kolega-pulmologa iz Dispanzera za plucne bolesti, koji su prethodno upoznati sa mogucno­stima i ogranicenjima ultrazvucne dijagnostike. Ovde se uglavnom radilo o pacijentima kod kojih klinicki i rendgenski pregled daju dvojben dijag­nosticki rezultat, pa se od ultrazvuka ocekuje da odgovori na neko od sledecih pitanja: -ima li pleuralnog izliva ili ne? -radi li se o izlivu ili o adheziji? da nije u pitanju atipican izliv? -možda se radi o parakostalnom izlivu, a možda o tumoru pleure ili pluca koji je u nepo­srednem kontaktu sa zidom grudnog koša? -da li je dijafragma stvarno ili prividno podig­nuta? Kakve je debljine i pokretljivosti? -postaji li perikardijalni izliv, i sl. Pregled obavljamo interkostalnim, transabdo­ minalnim (transdijatragmalnim) ili supraklaviku­ larnim pristupom grud noj duplji: mehanicka sek­ torska sonda pendularnog tipa od 3,5 MHz našeg aparata (Combison 320 »Kretz«) sa malom kon­ taktnom površinam omogucava dobijanje slike kroz uske »prozore«, pa je vrlo pogodna. Male slobodne tecne kolekcije u frenikokostal­ nom sinusu se najlakše prikažu u stojecem polo­ žaju pacijenta oko zadnje aksilarne linije, pri cemu podignuta ruka olakšava interkostalni pri­ stup toj strani. Sondiranje u pojedinim slucajevima vršimo ci­ ljano, prema klinickom i/ili rendgenskom nalazu, uz moguce pramene položaja pacijenta. Rezultati i diskusija 1. SI obodni p I e ura In i iz I i vi (28 razma­tranih slucajeva) Ovde smo stekli srazmerno najviše iskustva; radilo se o izlivima razlicite etiologije (zapaljen­ske, posttraumatske, neoplasticne ili kardijalne) i razlicitog obima, vecina ih je bila jednostrana, manje je bilo obostranih. Prakticno su svi paci­jenti obradeni i rendgenskim metodama, i to vecina pre, a manji deo nakon ultrasonografskog pregleda. Uverili smo se da je ultrazvucni pregled osetlji­viji za registraciju male kolicine slobodnog pleu­ralnog izliva u dijafragmalnoj ili dijafragmalno-pa­rakostalnoj fazi od rendgenskih metoda (kod tri pacijenta sa malim pleuralnim izlivima nadenim prvo ultrasonografski, rendgenskim metodama odmah potom radenih cak nismo mogli da ih pronademo), šlo potvrduju i nalazi drugih autora (5). Ovim naravno ne želimo da proglasi!mo ultrasonografiju za metodu izbora u ovoj oblasti! 1 desno i levo se izliv može pronaci sa istom lakocom, lakše se nego rendgenski diferencira od adhezije (izliv se može uvek sa sigurnošcu iskljuciti), a stice se i uvid u kolicinu izlivene tecnosti (tu smo cesto bili iznenadeni neznatnim rendgenskim manifestacijama ultrasonografski pronadenih izliva). Smatramo da je u dijagnostici kolateralnog pankreatiticnog pleuralnog izliva kod ležecih pa­cijenata ultrazvuk bez sumnje metoda izbora, zbog teškoca oko organizovanja standardnog snimanja pluca (imali smo pacijenta sa obilnim levostranim pleuralnim izlivom tog porekla koji je otpušten iz bolnicke ustanove a da izliv uopšte nije verifikovan). 2. Atipicni izlivi i ucaureni pluralni iz I i vi dostupnih lokalizacija (5 slucajeva) Ovde ultrasonografiju naglašavamo kao po­sebno korisnu metodu, jer objašnjava dvojbeni rendgenski na laz: prakticno se može dokazati svaka kolekcija tecnosti koja je dostupna ultra­zvucnom snopu. Tu pre svega dolaze u obzir parakostalni izlivi (prednji, lateralni ili zadnji), prednji paramedijastinalni i dijafragmalni; rend­genska dijagnoza ovakvih izliva se inace potvr­divala tek punkcijama, a u navije vreme uz pomoc kompjuterizovane tomografije. Razmatrali smo svega tri ucaurena parako­stalna izliva: lateralni, koji se na standardnem rendgenskom P-A snimku manifestovao jasno ogranicenom vretenastom senkom uz unutrašnji zid grudnog koša, drugi, slican -lateroposterior­ni, i treci, veliki, posteriorni, koji je imitirao tumor (slika 2). Kod sva tri ova slucaja, ciljani interko- Slika 2 -Veliki zadnji parakostalni izliv Fig. 2 -Large posterior paracostal effusion Radiol lugosl 1990; 24: 121-5. JovanoviC G: Ultrazvuk i klasicna grudna rendgenološka dijagnostika stalni ultrasonografski sken je lako pokazao da se radi o tecnim kolekcijama, a ne o solidnim promenama (pleuralni tumor, debela švarta i sl.). U jednom smo se slucaju ultrasonografski uverili da je slika prividno podignute hemidija­fragme (uz slobodan freniko-kostalni sinus) poti­cala od subpulmonalnog izliva. Drugom smo prilikom potvrdili dijagnozu lokali­zovanog pleuralnog izliva u donjoj polovini velike incizure desnog pluca: pod pretpostavkom da tecnost takvog izliva bar delom dodiruje parije­talnu pleuru održavajuci se tamo fizickim silama, planski je sondiran lateralni torakalni zid a u projekciji donje polovine velike incizure, pa je tu na malom, ogranicenom mestu tecnost zaista i registrovana, dok se njeno prisustvo (kako smo i ocekivali) nije moglo dokazati ni u okolini, ni u freniko-kostalnom sinusu, niti supradijafragmal­no. Nakon desetak dana kardiotonicne terapije, povukli su se rendgenski znaci ovog izliva. Nažalost, nismo u mogucnosti da uporedimo ove nalaze sa rezultatima drugih autora, jer smo naišli na malo podataka u strucnoj literaturi koja nam je dostupna. 3. Uvid u stanje parijetalne i visce­ralne pleure Sonografska determinacija debljine zida grud­ nog koša prikazom parijetalne pleure je u praktic­ noj primeni u planiranju radioterapije (6). U tri slucaja duže postojecih zapaljenskih izli­ va, vidali smo fibrinske naslage na pleuri, pone­ kad u vidu lelujavih traka ili mostova koji povezuju dva pleuralna lista (slika 3). Posttraumatski hematotoraks se može manife­stovati slojem sedimenta ispod bistre tecnosti, što smo jasno prikazali kod jednog pacijenta nekoliko dana nakon serijskog preloma rebara (isti pacijent je vracen iz bolnicke ustanove bez verifikacije izliva). Kod cetiri pacijenta sa izlivima malignog pore­kla vidali smo pleuralna zadebljanja i neopla­sticne cvoraste i krestaste depozite na pleuri. Slicne nalaze pominju i drugi autori (5). 4. lntratorakalni tu mori i ciste u nepo­srednom kontaktu sa zidom grudnog koša ili dijafragmom (4 pacijenta) Ni ovde ne raspolažemo nikakvim podacima iz dostupne literature, ali sledeci zamisao da poku­šamo da uitrasonografski prikažemo i takve lezi­je, uverili smo se da je to izvodljivo, pa smatramo da je realno moguce ovom metodom pregledati pleuralne tumore, tumore i ciste pluca, kao i tumore i ciste medijastinuma, uz uslov da su u neposrednom kontaktu sa zidom grudnog koša ili dijafragmom; ovde dolazi do izražaja poznata osobina ultrazvuka u lakom diferenciranju solid­nih od cisticnih lezija: -ogroman tumor levog pluca u starijeg paci­jenta, smešten izmedu srca i levog torakalnog zida, u celini je prikazan lateralnim interkostalnim pristupom; radilo se o jasno ogranicenom okru­glom tumoru heterogene ehostrukture; -okrugao tumor promera od nepunih 40 mm, lokalizovan u levom plucnom vrhu mlade ženske osobe pregledali smo ultrasonografskim skeno­vanjem supraklavikularne jame i jasno ga prika­zali (sika 4); Slika 3 -Izliv levo -pleuralna librinska traka (strelica) Slika 4 -Tumor levog vrha pljuca Fig. 3 -Left effusion: pleural fibrinous strip (arrow) Fig. 4 -Tumor of the left pulmonal apex Radio\ \ugosi 1990: 24: 121-5. Jovanovic G: Ultrazvuk i klasicna grudna rendgenološka dijagnostika -oveci tumor pluca druge pacijentkinje (ispo­stavilo se da je u pitanju fibrosarkom) lokalizovan u prednjem delu desnog freniko-kardijalnog ugla, prikazan je kosim desnim subksifoidnim skenom (slika 5). Slika 5 -Tumor plu6a smešten u prednjem desnom kardiofrenicnom uglu (strelica) Fig. 5 -Tumor of the lung situated in the right anterior cardiophrenic angle (arrow) Sve napred pomenute pramene smo tražili ciljano, prema rendgenskom nalazu. Lokalizovanu tecnu kolekciju koja bi odgova­rala perikardijalnoj cisti ili ucaurenom prednjem donjem levom paramedijastinalnom izlivu, regi­strovali smo uz vrh srca šezdesetogodišnjeg pacijenta (slika 6). Pramena je nadena prvo sonografski, a analiza aktuelnih i ranijih radiografija pluca istog paci­jenta je pokazivala vrlo diskretan, dotle zanema­rivan nalaz zasencenja parakardijalno levo, ma­skiranog vrhom srca. 5. Uvid u stanje hemidijafragme (6 slucajeva) Poznato je da se ultrasonografskim pregledom abdomena stice uvid i u stanje dijafragme (1, 3, 7). Desna hemidijafragma je pogodnija za pre­gled, ali se može dobiti dobar uvid i u izgled, debljinu i pokretljivost i leve. Parcijalna relaksacija desne hemidijafragme sa hernijacijom jetrenog parenhima može se lako dokazati transabdominalnim skenovima; ovakve promene mogu da lice na tumore pluca ili dijafragme, perikardijalne ciste, a i fokalne jetrene lezije. Arbiter elegancije americke rend­genologije B. Felson opisuje u svom cuvenom udžbeniku (9) hepaticnu herniju u cijoj je dijagno­ stickoj proceduri korišcen pneumoperitoneum a i scintigrafija jetre: danas, u eri ultrazvuka, ovo bi se svakako izbeglo, a upravo smo i imali dva takva slucaja, gde je jasno prikazano izbocenje jetrenog parenhima u relaksirani deo hemidija­fragme. Kod tri pacijenta u odmaklim fazama (operisa­nih) malignoma želuca vidali smo ekstenzivnu infiltraciju dijafragme neoplasticnim masama, sa njenom delimicnom ili potpunom imobilnošcu. U jednog pacijenta smo istom metodam isklju­cenjem subpulmonalnog izliva ili druge pramene potvrdili relaksaciju cele hemidijafragme. 6. P e r i kar d i j a I n i iz I i v (2 slucaja) Pominjemo ih samo uzgred, jer su u užem domenu ehokardiografije. Zakljucak -Svakodnevna praksa pokazuje višestruku korist primene ultrasonografije kao dopunske a jednostavne i neškodljive metode klasicnoj radiološkoj dijagnostici nekih grudnih oboljenja i stanja (3, 5, 7, 8). Ako vec imamo na rapsolaganju ultrazvucnu tehnologiju, imperativ je da je tamo gde ce koristiti pacijentu i primenjujemo, pa ovo zato ne treba shvatiti kao pomodnu egzibiciju. Naravno, mogucnosti ultrazvuka ne treba precenjivati, ali ovde, u grudnoj dijagnostici, uz pravilnu indikaciju on ce cesto zameniti dopunski jonizujuci dijagno­sticki postupak i dati korisnu informaciju, jer -da se ne zaboravi: » ... radilolog je prvi pozvan da traži nove dijagnosticke metode, koje sa sobom nose manje hazarda od rendgenskog zracenja« (1 O). Radio! lugosl 1990; 24: 121-5. Jovanovic G: Ultrazvuk i klasicna grudna rendgenološka diiagnostika Sažetak Dvodimenziona real tirne ultrasonografija može da bude vrlo korisna dopunska metoda klasicnoj grudnoj rendgen-dijagnostici u indikovanim i odabranim slucaje­vima, u prvom redu za pleuralne izlive (ucaurene, atipicne ili slobodne), ali takode i druga stanja: pleu­ralne !umore i tumore pluca i medijastinuma koji su u neposrednom kontaktu sa zidom grudnog koša ili dija­fragmom, koja se takoder može pregledati ovom tehni­kom. Uprkos skromnom broju razmatranih slucajeva, naši prvi rezultati uveravaju u efikasnost metoda. Literatura 1 . Weill FS. Ultraschalldiagnostik in der Gastroente­rologie. Berlin -Heidelberg: Springer Verlag, 1987. 2. Holm HH, Kristensen JK, Rasmussen SN, Peder­sen JF, Hanche S, Jensen F, Gammelgaard J, Smith EH. Abdominale Ultraschalldiagnostik. Darmstadt: Steinkopff Verlag, 1983: 174, 218. 3. Bouvier M, Frech M, Vivier G, Benoit JP. lnversion diaphragmatique droite lars des epanchements pleu­raux abondantis. Etude echotomographique. J Radiol 1979; 60(12) :739-42. 4. Pumik O. Rentgen dijagnostika pleuralnih izliva. Zajecar: Institut za tuberkulozu i bolesti pluca SR Srbije, 1979 :55-64. 5. Fazlagic 1, Putnik B, Savic ž. Ultrazvucna dijagno­stika oboljenja frenikokostalnog sinusa. U: Zbornik rezimea XIII. kongresa radiologa Jugoslavije. Ohrid: 1988:23. 6. Dakic D, Dobrosavljev M, Živanovic A, Bokorov B. Real-tirne sonografska tehnika u determinaciji deb­ljine zida grudnog koša. Radiol lugosl 1989; 23:131-3. 7. Haber K, Asher M, Freimaris A K. Echographic evaluation of diaphragmatic motion in intra-abdominal diseases. Radiology 1975; 46-325-8. 8. Lewandowski BJ, Winsberg F. Sonographic de­monstration of the right paramediastinal pleural space. Radiology 1982; 145:127-31. 9. Felson B. Chest Roentgenology. Philadelphia ­London: W. B. Saunders, 1973 :425-28. 1 O. Demšar M, Obrez l. Strategija upotrebe ultra­zvucne tehnologije u radiološkim institucijama. Radiol lugosl 1987; 21 (3) :231-4. Adresa autora: Dr Gradimir Jovanovic, Kabinet za radiologiju, Dom Zgravlja »Ruma«, 22400 Ruma EiRLUEi LJUBLJANA p.. 61000 LJUBLJANA, MAŠERA-SPASICEVA ul. 10 Telefoni: n.c. (061) 371 744 -direktor: 371 689 prodaja: 374 436, 374 809, 374 981, 372 219 O SKRB UJE 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® IN ALLIVIT PLUS® Kapsule cesna z dodatkom zdravilnih zelišc. Prodajna in dostavna služba posluje vsak dan neprekinjeno od 7. do 16. ure, razen sobote. Radiol lugosl 1990; 24: 121-5. SRPSKO LEKAR SKO DRUŠT VO Poštovani kolega-ce, lzveštavam Vas da su Predsedništvo i Skupština Sekcije za radio/oglju Srpskog lekarskog društva na sednicama od 22. marta 1990. godine doneli od/uku o održavanju S/MPOZ/JUMA RADIOLOGA SRBIJE. Predsedništvo Sekcije za radio/oglju SLD-a izražava uverenje da ce Simpozijum radiologa Srbije, uz ucešce radiologa Jugoslavije, biti znacajan doprinos savremenoj radiološkoj teoriji i praksi. April 1990. CLAN PREDSEDN/$TVA SEKCIJE Kragujevac ZA RADIOLOG/JU SLD-a Mr sci med dr Željka Markovic PRVI SIMOZIJUM RADIOLOGA SRBIJE PRELIM INAR NO OBA VEŠT ENJ E OR GANIZATOR!: -SEKCIJA ZA RADIOLOGIJU SLD-a -ZAVOD ZA RADIOLOGIJU UKC KRAGUJEVAC -MEDI CINSKI FAKULTET KRAGUJEVAC PREDSEDNIK ORGANIZACIONOG ODBORA Prof dr Branislav Goldner KLINICKI BOLNICKI CENTAR RIJEKA KLINIKA ZA PEDIJATRIJU1 KIRURŠKA KLINIKA2 ZAVOD ZA RADIOLOGIJU3 INTERNA KLINIKA4 KONGENITALNI NEDOSTATAK ŽUCNOG MJEHURA-PRIKAZ BOLESNIKA CO NGENITAL ABSENCE OF THE GALLBLADDER -CASE REPOR T Peršic M 1, Fuckar 22, Šaina G 3, Lekovic A 3, Rubinic M4, Roganovic-0ordevic J 1 Abstract -The authors presen! a 14-and a half year old girl with congenital absence of the galibladder. This is a case of a very rare anomaly which is generally diagnosed in mature age by surgery with simptoms of cholelithyasis. Our patient presented with abdominal pain and the diagnosis was made by u It ras on o grap h y of the abdomen and by intravenous cholangiography. Skeleta! malformation of the thorax was a concomitant anomaly. UDC: 616.366-007.21 Key words: gallbladder-abnormalities Case report Radiol lugosl 1990; 24: 127-9. Uvod -Kongenitalni nedostatak žucnog mje­hura (u daljnjem tekstu KNŽM) veoma je rijetka malformacija hepatobilijarnog sistema. lako se radi o kongenitalnoj anomaliji, otkriva se naj­cešce u odrasloj dobi sa simptomima koledokole­litijaza ili kolangitisa (1, 2, 3), ili autopsijom kao slucajan nalaz. Za dijagnozu je najcešce neop­hodna laparatomija (4). Rendgenske ili/i scinti­grafske pretrage bilijarnog trakta ne mogu sa sigurnošcu dijagnosticirati KNŽM zbog niza lažno negativnih nalaza (1, 5, 6). Noviji radovi (7) ukazuju na znacajnu ulogu ultrazvuka abdomena u dijagnostici KNŽM. Naš rad opisuje dijagnostiku ageneze žucnog mjehura u djecjoj dobi na osnovi neinvazivnih dijagnostickih metoda; intravenozne kolangiogra­fije i ultrazvuka abdomena. U domacoj literaturi postaje opisi ove anomalije u odrasloj dobi (6), ali u djece ovo je prvi prikaz. Prikaz bolesnice -l. A., MB: 1921 /86, cet­rnaest godišnja djevojcica dolazi u bolnicu zbog bolova u trbuhu koji se povremeno javljaju zad­njih mjesec dana. Bolovi se javljaju nakon uzima­nja hrane, najcešce navecer u predjelu žlicice sa širenjem pod desni rebrani luk. Cešci i jaceg intenziteta su nakon uzimanja masne hrane. Afebrilna, bez drugih smetnji. Premorbidna anamneza uredna, osim što je u dobi od cetiri godine uocen deformitet desne strane grudnog koša zbog cega je u više navrata lijecena. Kod prijema za dob slabije uhranjena i razvije­na, gracilne grade. Težinom odgovara dobi od jedanaest godina, a visinom dobi od trinaest godina. Afebrilna, pri svijesti, dobrog opceg sta­nja. Grudni koš kraci u odnosu na ostali dio tijela uz izraženu asimetriju. S prednje strane grudnog koša desno u podrucju hvatišta rebara za ster­num vidi se grebenasto izbocenje velicine šake. Ostali status uredan. Laboratorijski nalazi: kompletna krvna slika, hepatogram s transaminazama, dijastaze se­ruma i urina, proteinogram, imunoglobulini seru­ma, urin i pretrage stolica urednog su nalaza. Intravenozna urografija i rendgenska pasaža že­luca i duodenuma urednog nalaza. U It raz v uk abdomen a : uredan je sonografski prikaz jetre, pankreasa i obaju bubrega. Prikazao se i zajed­nicki žucni vod (AP promjer 0,9 cm), no koleciste se nije vidjelo niti u jednom presjeku (slika 1 ). Received: February 2, 1990 -Accepted: March 9, 1990 Peršic M. et al. Kongenitalni nedostatak žucnog mjehura -Prikaz bolesnika " ILl•lm HUICII mm lll!KA o •• m 12 o fl. ij(llal ·.-.._.,;)1'.· Wi.tJh., ·d ' • . · KS11uis·iul' . . JClt HCll UD> : . CIUPftl . . :. +tt IMCII ··-.·.:. . ..., ___ ,., . , . --.-.--..N!JIE :·'.· .. : .. _,_ ..... .Jfflfflllt .. . ' . :,ir,,.4'"'·'':. , .. . . .illi \?\ Slika 1. Ultrazvuk jetre i zajednickog žucnog voda Figure 1. Ultrasonography of the liver and ductus choledocus Slika 2. Intravenozna kolangiografija a) proširen zajednicki žucni vod Figure 2. lntravenous cholangiography a) Enlarged ductus choledocus 1 n traven o zna k o I a n g i o g rafija: hepati­kokoledokus se prikazuje vec nakan 30 minuta od davanja kontrasta. Širina koledokusa je u najširem dijelu od 0,9 do 1 cm (umjereno prošire­nje). Ni na jednoj od ucinjenih snimki nije prika­zan žucni mjerhur (slika 2). Endoskopska retro­gradna kolangiopankreatografija nije uspjela. Ezofagogastroduodenoskopija: niz duguljastih erozija u podrucju antruma. Na osnovi ucinjenih nalaza i akutnih želucanih erozija, zapoceta je dijeta uz terapiju antacidima. Smetnje brzo nestaju. Vjerojatni je uzrok bio akutni erozivni gastritis, ali se i smetnje koje se opisuju kod nedostatka žucnog mjehura ne mogu iskljuciti. Djevojka je bez smetnji slijedece dvije godine. Rasprava -Kongenitalni nedostatak žucnog mjehura veoma je rijetka malformacija koja se otkriva tek u odrasloj dobi, a iznimno u djece. Ovu je anomaliju prvi opisao Lemery 1701. go­dine (9). Vanderpool sa suradnicima (10) ukazuje da je vec Aristotel poznavao ovu anomaliju u covjeka i u nekih životinja. Životinje s tim nedo­statkom smatrao je biljožderima, a one sa žucnim mjehurom primarnim mesožderima. lncidencija KNŽM iznosi oko 1 :3400 do 1 :7500 (8, 11 ). Sma­tra se da je i viša s obzirom da vecina ljudi s ovom anomalijam nema nikakvih smetnji. Asim­ptomatski slucajevi su 2 puta cešci i otkrivaju se kao slucajni nalaz autopsijom (11 ). U bolesnika ukojih je KNŽM otkrivena za života 33% do 60% ih je bilo bez simptoma, a 25% do 50% imalo jesimptome koledokoletijaze (1, 2, 3). Ova anoma­lija dijagnosticirana autopsijom, dakle asimpto­matska, jednako je zastupana u oba spola (11 ), dok su simptomatski slucajevi cešci u žena u odnosu 3:1 (1, 9). KNŽM se cesto susrece uz neke druge malfor­macije gastrointestinalnog, kardiovaskularnog i genitourinarnog sistema, te uz anomalije skeleta i lica (1, 2, 8). U šestine bolesnika s bilijarnom atrezijam postaji i KNŽM (12). Prisutna je i u VATER asocijaciji (13) i uz trizomiju 18 (8). Spominje se mogucnost nasljedivanja KNŽM kao autozomno dominantno sa slabom penetracijam (14), ili spolno vezana recesivno u sklopu tzv. G sindroma (15). Ocita je povezanost s nizom razlicitih malformacija. Nacin nasljedivanja, i dali postaji, još je uvijek nepoznanica. Stoga se preporuca uciniti ultrazvuk žucnog mjehura u prvih srodnika bolesnika, kako bi se na taj nacin otkrio moguci nasljedni faktor (1 ). U cnaše bole­snice uz KNŽM nalazimo defekt skeleta u vidu deformiteta grudnog koša. Radiol lugosl 1990; 24: 127·9. Peršic M. et al. Kongenitalni nedostatak žucnog mjehura -Prikaz bolesnika Simptomatologija KNL'.M odgovara simpto­mima kronicnog kolangitisa odnosno koledokoliti­jaze (1, 4, 5, 6, 7). Najcešce je prisutno i proširenje koledokusa, što je nadeno i u naše bolesnice (2, 3, 4, 5, 6). 48% do 58% svih bolesnika ima ikterus, a 26% do 50% ih ima kamenac u zajednickom žucnom vodu (5). Pan­kreatitis kao posljedica koledokolitijaze javlja se u 6% bolesnika s KNŽM (16). lnteresantan ali i nejasan je uzrok ovih smetnji u bolesnika koji nemaju holedokolelitijazu (5). To je bilo i u naše bolesnice, iako se u nje bolovi mogu objasniti i pojavom akutnih erozija želuca. Moguci uzrok smetnjama koju bolesnici s KNL'.M osjecaju jest i smanjena sekrecija žucnih kiselina uocena u ovih bolesnika (1 ). Dijagnostika KNŽM do nedavno je bila moguca jedino operativnim putem, laparatomijom (4, 5, 6). Peroralna kolecistografija, intravenozna ko­langiografija kao ni scintigrafski prikaz žucnog mjehura i žucnih puteva nisu zbog mogucih lažno pozitivnih i lažno negativnih nalaza od odlucujuceg znacaja za postavljanje dijagnoze (11, 17). Ultrazvuk žucnog mjehura i žucnih puteva ima prednost pred navedenim pretra­gama jer daje sigurnije podatke. Ovom pretra­gom moguca je dijagnoza KNŽM i bez laparoto­mije (4, 7). Dijagnostika KNŽM je važna da se ne ucini operacija zbog »lažnih simptoma kolelitija­ze« (1, 4). Na ovu anomaliju treba pomisliti i u nizu drugih malformacija koje smo ranije naveli (5, 8, 12, 14, 15). U njih je ona najcešce »nijema« malformacija do odrasle dobi, ali nas može izne­naditi simptomima kolelitijaze. Sažetak Prikazali smo cetrnaestgodišnju djevojcicu s konge­nitalnim nedostatkom žucnog mjehura. Radi se o rijet­koj anomaliji koja se najcešce dijagnosticira operativ­nim putem u odrasloj dobi zbog simptoma koledokoleli­tijaze. U naše je bolesnice prezentirajuci simptom bio bol u trbuhu, a dijagnoza je postavljena na osnovi ultrazvuka abdomena i intravenozne kolangiografije. Od pratecih malformacija u naše je bolesnice prisutna skeletna deformacija grudnog koša. Literatura 1. Wilson JE, Deitrick JE. Agenesis of the gallblad­der: Case report and familial investigation. Surgery 1986; 99:106-9. 2. Gerwig WH, Countigman LK, Gomey Ac. Conge­nital absence of the gallbladder and cystic duet: Report of six cases. Ann Surg 1961; 153:113. 3. Pines B, Grayzel DM. Congenital absence of the gallbladder and cystic duet. Arch Surg 1958; 77: 17 4-4. 4. O'Sullivan J, O'Brien T, McFeely L, Wholton MJ. Congenital absence of the gallbladder -non operative diagnosis. Gastroenterology 1986; 90:1575. 5. Dickinson CZ, Powers TA, Sandler MP, Partain CL. Congenital absence of the gallbladder: Another cause of false-positive hepatobiliary image. J Nucl Med 1984; 25 :70-2. 6. Gustincic J, Grgurevic Z, Franulovic B. Ageneza žucnog mjehura -prikaz slucaja. Medicina 1982; 18:35-7. \ 7. Pinch' LW. Agenesis of the gallbladder. Surgery 1986; 100 :942. 8. Beckwitt Turke! S, Swanson V, Chandrasoma P. Malformations associated with coingenital absence of the gall bladder. J. Med Genet 1983; 20:445-9. 9. Lemery. Observation VIII: Historie de l'Acad Roy des sciences. Annee 1701, p 54. 1 O. Vanderpool D, Klingensmith W, Oles P. Congenital Absence of the gallbladder. Amer Surg 1964; 30:324­30. 11. Raju SG. Agenesis of the gallbladder in two adults and brief review of the literature. Am J Gastroen­terol 1972; 57 :55-62. 12. Rabinovitch J, Rabinovitch P, Rosenblatt P, Pines B. Rare anomalies of the extrahepatic bile ducts. Ann Surg 1958; 148:161-8. 13. Quan L, Smith DW, The VATER association: vertebral defects, anal atresia, T-E fistula with esopha­geal atresia, radial and renal displasia: a spectrum of associated defects. J Pediatr 1973; 85 :345-9. 14. Nadeau LA, Cloutier WA, Konecki JT et al. Hereditary gall gladder agenesis 12 cases in one family. J Maine Med Assoc 1972; 63:1-6. 15. Opitz JM, Frias JL, Gutenberger JE, Pellett JR. The G syndrome of multiple anomalies. Birth Defects 1969; 5:95-101. 16. Dixon CF, Lichtman AL. Congenital absence of gallbladder. Surgery 1945; 17:11-21. 17. Kalff V, Froelich JW, Lloyd R et al. predictive value of an abnormal hepatobiliary scan in patients with severe intercurrent illness. Radiology 1983; 146:191-4. Adresa autora: Mr. se. dr. Mladen Peršic, Klinika za pedijatriju KBC Rijeka, Bratstva i jedinstva 61, 51000 Rijeka Radiol lugosl 1990; 24: 127-9. SIEMENS .l .a, Der neue NIR-Standard. Magnetom SP Magnetom 42 SP, das Hoch­leistungs-MR-System fur Bildgebung oder Magnetom 63 SP, das Hoch­leistungs-MR-System fur Bildgebung und Spektro­ skopie. • Bildrekonstruktion unter 1 Sekunde • lntegrierte 3 D Bildakqui­sition, inklusive aller 3 O Bildrekonstruktions­moglichkeiten • Vollig neuartige, klinisch optimierte Benutzerober­flache mit Maus-oder Trackball-Bedienung. Siemens AG Medica! Engineering Group HenkestraBe 127, 0-8520 Erlangen Banex Trg Sportova 11, Poštanski fah 48 YU-41000 Zagreb Tel. (041) 3133 34 Jurija Gagarina 216, Blok 61 YU-1107 0 Beograd Tel. (011) 1500 65 Banex-Meditehna Novi Skopski Sajam, Belasica bb, Rayon 40 YU-91000 Skopje Tel. (091)2030 73 UNIVERSITY CLINICAL CENTER, UNIVERSITY PEDIATRIC HOSPITAL LJUBLJANA COMPLICATIONS IN CARDIAC CATHETERIZATION AND ANGIOCARDIOGRAPHY IN INFANTS AND CHILDREN -PROSPECTIVE STUDY Robida A Abstract -Prospective study of complications in cardiac catheterization and angiocardiography comprised 411 infants and children consecutively entered into the study protocol in the period from January 1, 1987 to October 30, 1989. The patients were observed tor 48 hours after an invasive procedure and complications were recorded for each patient. There were 46 complications noted in 40 patients. Overall complication rale was 11.2%. However, if only diagnostic procedures were examined their overall rale was 7.5% which compared favorably with other studies. Major complications were more frequent in high-risk group Ihan in low-risk group of patients (P < 0.01). There were 3 deaths (0.78%), bul only one death could be attributed directly to catheterization procedure. The most frequent complications were arrhythmias (58.6% of ali complications); these were encountered more often in infants Ihan in older children (P 3 0.01 ). Each laboratory should keep a continuous record of their activities and complication rates because the introduction of newer procedures, especially in the field of interventional catheterization, might increase the complications and alert the physician to change, improve or even abandon the procedure. UDC: 616.12-089.819.1-061-053.2 Key words: heart catheterization-adverse effects, angiocardiography-adverse effects, child Orig sci paper Radiol lugosl 1990: 24: 131-5. lntroduction -Retrospective review of tne complicatipns in 107 4 infants and children cathe­terized in our hospital from January 1, 1981 to December 31, 1985 revealed the overall compli­cation rate of 5.2% (1 ). The major drawback of that retrospective study might be inaccurate data collection and even possible loss of some cases. The aim of the present report is to present data of the cardiac investigation with the advantage of more exact data collection. Materials and methods -In the period of January 1, 1987 to November 30, 1989 we performed 411 cardiac catheterizations. The in­fants were sedated with the mixture of chlorpro­mazine, promethazine, and pethidine. Ketamine was used in older children as reported in a previous paper (1 ). Percutaneous technique of catheter entry into the femoral vein was used in 315 cases, cul down of great saphenous vein was performed in 66 cases, of femoral vein in 13 cases, and of cubital vein in 4. The umbilical vein was entered in 5 infants. The Femoral artery was punctured in 74 patients, and the axillary artery in 4. The way of entry was chosen by preference of different the investigator, but cut down was also sometimes performed if puncture of the vein failed. 100 U/kg of heparin was administered intravenously immediately after the introduction of sheath or catheter into the artery. AII patients received solution of heparin 5 U/ml of of 5% glucose for flushing the catheter. The modification of classification of the severity of illness described by Stanger and associates was used in the same way as in the retrospective study (2): A. Asymptomatic patients -without distress, cyanosis, hypoxemia, and congestive heart failu­re. B. Slightly ill patients -without distress, non­cyanotic, mildly hypoxemic (pO2 > mmHg), or with controlled heart faillure. C. Moderately ill patients -hypoxemic (pO2 < 25 mmHg), bul without acidosis, or with severe congestive heart failure that is only partly control­led with digitalis and diuretics. D. Critically ill patients -with one or more of the following: ventilatory assistance -acidemia -poor peripheral perfusion and cardiogenic shock. Apart from this classification, high and low risk groups were identified prior to catheterization according to previous experience with the rale of Received: December 20, 1989 -Accepted: February 17, 1990. Robida A: Complications in cardiac catheterization and angiocardiography in infants and children -Prospective study complicat1ons in the retrospective study (1 ). Pa­tients were aliocated to high-risk group if younger than 4 months and/or moderately or criticaliy ill. Ali the infants and children were observed for the complications during the invasive procedure and were routinely examined immediately, 1, 4-6, 24 and 48 hours after the procedure. Detailed data on each invasive procedure were entered into the patient file. Partiuclar attention was paid to age, clinical status prior to catheteri­zation, medications, site of entry of the catheter, type and size of the catheter, route of the cathe­ter, and volume, rate, and site of injection of contrast medium. Fina! diagnosis was recorded after reviewing of ali the noninvasive and invasive data. The nature, tirne of appearance, clinical outcome and therapy employed were described for each complication. Table 1 shows age distri­bution and clinical status of patients prior to catheterization. was 11.2%. Table 2 shows major and minor complications. Percantage of ali complications related to cardiac diagnosis is presented in Table 3. lnterventional procedures were performed in 37 infants and children which represented 9% of ali the invasive investigations which represented a major increase in comparison with the retro­grade study where only 1.5% of such procedures were performed. It was interesting to note that 32% of ali complications occurred during the interventional procedures, and thus their rate was significantly higher than in diagnostic cathe­terizations (P < 0.01 ). lf only complications in diagnostic procedures were examined their rale was e 7.5%. Almost ali complications related to the proce­dure itself occurred during the invasive investiga­tion and the prolongation of observation to 48 hours did not increase the number of complica­tions. Table 1 -Age distribution ancf clinical status of patients Age groups Number of patients Total A B C D < 1 week 3 10 o 14 1 weekto 1 month 2 2 8 8 9 9 3 3 22 22 1 month to 2months 2 4 2 o 8 2months to 4 months 6 8 2 o 16 4 month to 1 year 75 22 4 3 104 1 year to 4 years 99 10 o o 109 4 years to 15 years 116 7 o o 123 > 15 years 14 o o 15 Total 317 70 18 6 411 A = asymptomatic, B = mildly ill, C = moderately ill, D = critically ill For the sake of comparison, major and minor complications were divided in categories used by Stanger and associates (2), Cohn and associates (3), and in the retrospective study (1 ). Chi -square test was used to test the diffe­rence between the age groups, high and low risk groups, and diagnostic and interventional cathe­terizations. Results -Among 411 patients 40 suffered from 46 complications. Overall complication rate Major complications -60.9% of ali complica­tions. The rate of major complications was hig­hest in the age group 1 week 1 month (Table 4). It dropped sharply after 4 months of age (P < 0.01 ). They were also more frequent in the high risk group (P < 0.05). Death within 48 hours of catheterization occur­red in 3 patients (0.73%). The first patient was an 11-month-old gir! with compiet0 form of atrio­ventricular septal defect and pulmonmy hyper­ Haa;,•1 luqosl 1990; 24: 131-5. Robida A: Complications in cardiac catheterization and angiocardiography in infants and children -Prospective study Table 2 -Major and minor complications Major complications Minor complications 1. Death within 48 hours -3 1. Arrhythmias not 2. Arrhythmias: any arrhythmia requiring treatment reguiring treatment or or termination of termination of catheterization -18 catheterization -9 a. Cardiac standstill -O a. Supraventricular b. Ventricular fibrilation -1 tachycardia -4 c. Ventricular tachycardia -O b. Sinus bradycardia -3 d. Supraventricular tachycardia -4 C. 3 AV block-2 e. Atrial fibrilation or flutter -2 2. Burst of Rashkind f. Sinus bradycardia -7 balloon catheter -3 g. 2AV block-0 3. Arterial problem s -1 h. 3 AV block-4 4. Allergic urticaria -1 3. Profound hypotension -O 5. Myocardial staining -1 4. Arterial problems -1 6. Bleeding without 5. Perforation of the heart or vessel -1 transfusion -2 6. Catheter problems -O 7. Burst of balloon 7. Serious infection -O during dilation of 8. Serious allergic reaction -O aortic recoarctation -1 9. Embolism -O 10. Cardiac complications Total 18 a. Myocardial infarction -O b. Pulmonary edema -o c. Hypoxic spells requiring morphine, · bicarbonate or oxygen -1 11. Serious bleeding -3 a. Surgical intervention -1 b. Transfusion -2 12. Pneumothorax -O 13. Other-0 a. Respiratory arrest-1 Total-30 2 AV = second degree atrioventricular block; 3 AV = third degree atrioventricular block Table 3 -Major and minor complications Age groups Number of % of % of patients major minor < 1 week 14 21.4 28.5 1 week to 1 month 22 40.9 4.5 1 month to 2 months 8 12.4 37.4 2 months to 4 months 16 18.6 6.3 4 months to 1 year 104 7.7 2.9 1 year to 4 years 109 0.9 2.7 4 years to 15 years 123 2.4 1.6 > 15 years 15 O.O 6.7 tension. At the tirne of catheterization the right failure and he was in severe acidosis prior to iliac artery was perforated with the wire and dilator. Signs of hypovolemic shock developed due to bleeding which was confirmed by ultra­sound examination of the abdomen. Surgical reconstruction of the iliac artery failed and the infant died 1 O hours after catheterization. The second death occurred in a 1-month-old infant with transposition of the great arteries and pulmo­nary stenosis, who was referred to our hospital in critical condition. There were signs of heart catheterization. During the attempt to pass Ras­hkind atrioseptostomy catheter into the left atrium complete atrioventricular block developed which reverted spontaneously into the sinus rhythm. The atrioseptostomy failed because the catheter could not be introduced into the left atrium. Surgical septectomy was planned but the child died 12 hours after the invasive procedure. This death was considered to be the consequence of the disease itself and of the failure to do Ras- Radiol lugosl 1990; 24: 131-5. Table 4 -Percantage of complications and cardiac diagnosis Robida A: Complicalions in cardiac catheterization and angiocardiography in infants and children -Prospective study Diagnosis Number of % patients Ventricular septal defect 70 4.2 Tetralogy of Fallot 53 11.3 Atrial septal defect 27 3.7 Coarctation of the aorta 26 15.3 Transposiltion of the great arteries 49 36.7 Patent ductus arteriosus 15 O.O Pulmonary stenosis 21 0.9 Aortic stenosis 31 0.6 Univentricular heart 17 0.5 Atrioventricular septal derect 29 10.3 L-tranposition of the great arteries 5 o.o Tricuspid atresia 10 1.0 Pulmonary atresia 5 O.O Double outlet right ventrticle 12 0.8 Normal children 1 O.O Postoperative catheterization 14 0.7 Aortopulmonary window 2 50.0 Total anomalous pulmonary drainage 4 25.0 Miscellaneous 20 0.5 hkind atrioseptostomy. The last death occurred in a 9-month-old infant 48 hours after the invasive procedure. The infant was in heart failure and had severe valvular aortic stenosis and mitral regurgitation. The death and the invasive proce­dure were probably not directly interconnected. Perforation of the heart during an attempt of balloon valvuloplasty of critical pulmonary valvu­lar stenosis in a 19-day-old infant was without serious consequence, and valvuloplasty was successfully accomplished a week later (4). Hypoxic speli in an infant with tetralogy of Fallot resolved after administration of bicarbo­nate and morphine. Serious bleeding from the femoral vein when cut down technique was used required blood transfusion in 2 infants with transposition of the great arteries. A newborn infant 12 days of age with transpo­sition of the great arteries and ventricular septal defect suffered from apnea immediately after intravenous injection of diazepam. He was intu­bated and ventilated and cardiac catheterization was than performed without further complica­tions. Arrhylhmias were the most common complica- Table 5 - tions (table 5) and they represented 58.6% of ali complications. 75% of ali arrhythmias occurred in infants, their number being significantly higher than in older children (P < 0.01 ). Therapy was necessary in 63% of arrhythmias and was always successful. Minor complications -39.1 % -As in major complications, also here arrhythmias were en­countered most frequently (table 5). There was a loss of arterial pulsation for 6 hours in a 11-month-old girl weighing 7 kg after introduction of F5 pig-tail catheter into the right femoral vein. Rupture of Rashking atrioseptostomy balioon catheter was noticed 3 times without emboliza­tion. In a 4-year-old boy with coarctation of the aorta the balioon of dilation catheter burst in a attempt of relieving the coarctation. The event entailed no consequences. Two minor bleeding episodes from femoral vein cut down occurred not requiring blood tran­sfusion. Only one aliergic reaction to contrast medium in the form of mild urticaria was noted. lnjection of contrast medium into the myocar­dium of the right ventricle with F6 NIH catheter in Arrhythmias Type Number Supraventricular tachycardia 8 Sinus bradycardia 10 Atrioventricular block 3 rd degrec 6 Atrial flutter 2 Ventricular fibrillation 1 f'lgrjiol lugosl 1990; 24: 131-5. Robida A: Complications in cardiac catheterization and angiocardiography in infants and children -Prospective study a child with tetralogy of Fallot occurred and resolved after 5 minutes. Discussion -At the tirne of this study the average number of catheterizations per year was f140 cases in comparison to 215 at the tirne of the retrospective study, which represented 35% reduction. This decrease was a consequence of the introduction of better echocardiographic equipment, and acceptance of some simple ca­ses of congenital heart defects by a surgeon to operate on without prior invasive investigation. The complication rates of major and minor com­plications int his prospective study was hither Ihan in the retrospective one (P < 0.01 ), bul lower Ihan in the report of Stanger and associa­tes (1, 2). However, if only the rale of complica­tions in diagnostic procedures were taken into account, their rates were comparable to the reports of others (2, 3, 5, 6). The reason for higher overall complication rates was thus a higher proportion of interventional procedures in the presen! study. This inctease could be ascri­bed the earlier referral of newborns with transpo­sition of the great arteries for Rashkind atriosep­tostomy, and the introduction of new techniques such as balloon pulmonary valvuloplasty, dilation of recoarctation of the aorta and Blalock-Taussig anastomosi, closure of Blalock-Taussig anasto­mosis and major acirtopulmonary collateral arte­ries. As in the retrospective study, higher rate was noted in high risk group. The arrhythmias again prevailed among the complications and they were more frequent in infants. The arrhythmias were quickly reverted to sinus rhythm by rather simple therapeutic interventions. Three deaths occurred, but only one death with perforation of the external iliac artery could be attributed to the catheterization procedure itself. Both other infants died because of the severity of cardiac anomaly and the cases could be judged as pseudocomplications (7). Conclusion -Complication rates of diagnostic catheterization procedures compare favorably with previous reports. However, the introduction of therapeutic procedures has increased the overall rate of complications. Standards for indivi­ dual cathetrerization laboratory need to be conti­ nuously re-evaluated. The new procedures must be taken into account. The evaluation should focus on the type of procedure performed and the age and clinical status of patients. Acknowledgment -1 wish to thank Dr D. Fettich and Dr D. Bartenjev for performing some of the invasive diagnostics. This study was partly supported by the Re­search Community of Slovenia. Izvlecek ZAPLETI SRCNE KATETERIZACIJE IN ANGIOKARDIOGRAFIJE PRI NOVOROJENCKIH, DOJENCKIH IN OTROCIH ­PROSPEKTIVNA ŠTUDIJA Pri 411 bolnikih smo opazovali pojav zapletov pri srcni kateterizaciji in angiokardiografiji s prospektivno študijo v casu od 1. 1. 1987 do 30. 11. 1989. Opazovali smo jih 48 ur in zaplete vpisovali za vsakega otroka. Naleteli smo na 46 zapletov pri 40 otrocih. Vseh zapletov je bilo 11.2%. Ce smo upoštevali! le diagno­sticne kateterizacije je bilo zapletov 7.5%, kar se dobro sklada z drugimi študijami. Vecjih zapletov je bilo vec pri visoko rizicni kot pri nizko rizicni skupini (P < 0.01 ). Trije otroci so umrli (0.78%), vendar bi le eno smrt lahko neposredno pripisali sami kateterizaciji. Najpogo­stejši zapleti so bile aritmije (58.6% vseh zapletov). Nanje smo naleteli pogosteje pri dojenckih kot pri vecjih otrocih (P < 0.01 ). Vsak kateterizacijski laboratorij naj bi stalno spremljal število zapletov, ker uvedba novih preiskav posebno še na podrocju intervencijskih kateterizacij, lahko poveca število zapletov. To lahko opozori zdravnika, da spre­meni, izboljša ali celo opusti kakšno preiskavo. References 1. Robida A. Complications in cardiac catheterization and angiocardiography in infants and children. Radiol lugosl 1987; 21:111-5. 2. Stanger P, Heyman MA, Tarnoff H, Hoffman JIE, Rudolph MA. Complications of cardiac catheterization in neonates, infants and children. Circulation 1974; 50:595-608. 3. Cohn H, Freed MD, Hellebrand VF, Fyler DC. Complications and mortality associated with cardiac catheterization in ifants under one year: a prospective study. Pediatr Cardiol 1985; 6:123-31. 4. Robida A, Pavcnik D. Perforation of the heart in a newborn with critical valvar pulmonary stenosis during balloon valvoplasty. lnt J Cardiol (in press) 1990. 5. Fellows KE. Therapeutic catheter procedures in congenital heart disease: current status and future prospects. Cardiovasc lntervent Radiol 1984; 7:"170-7. 6. Wyman RM, Safian RD, Portway V et al. Current complications of diagnostic and therapeutic cardiac catheterization. J Am Coli Cardiol 1988; 12:-,400-6. 7. Hildner FJ, Javier RP, Tolentino A, Same! P. Pseudo Complications of cardiac catheterization: upda­te. Cath Cardiovasc. Diag 1872; 8:43-7. Author's address: Andrej Robida, M D, University Clinical Center Ljubljana, University Pediatric Hospital, Vrazov trg 1, 61000 Ljubljana Radiol lugosl 1990; 24: 131-5. danes najboljši kinolonski preparat Cenin ® -Ciprobay ® širokospektralni kemoterapevtik • hitro baktericidno delovanje na gram negativne in gram pozitivne mikroorganizme kakor tudi na problemske klice • hiter terapevtski uspeh zaradi visoke ucinkovitosti • dobra prenosljivost • najvec dvakratna dnevna uporaba, kar pomeni veliko olajšanje v klinicni in splošni praksi • prednost zaradi oralnega zdravljenja Kontraindikacije: preobcutljivost za ciprofloksacin; otroci in mladi v dobi rasti; nosecnost, dojenje; previdnost pri starejših bolnikih in poškodbah osrednjega živcevja. Bayer-Pharma Jugoslavija Ljubljana INSTITUTE OF RENTGENOLOGY, UNIVERSITY MEDICAL CENTER LJUBLJANA, YUGOSLAVIA INSTITUTE FOR CLINICAL ANO EXPERIMENTAL MEDICINE, PRAGUE, CZECHOSLOVAKIA SCIENTIFIC CENTRE OF SURGERY, ACADEMY OF MEDICAL SCIENCES, MOSCOW, SOVIET UNION MUNICIPAL HOSPITAL FRIEDRICHSHEIN, DEPARTMENT OF CARDIOVASCULAR DIAGNOSIS, BERLIN, GERMAN DEMOCRATIC REPUBLIC GLINIC OF RADIOLOGY, PESC, HUNGARY INSTITUTE OF CARDIOVASCULAR SURGERY OF A. N. BAKULEV, MOSCOW, SOVIET UNION PERCUTANEOUS TRANSLUMINAL RENAL ANGIOPLASTY -A MUL TICENTRE STUDY OF THE LONG TERM RESUL TS Belan A, Pavcnik D, Petrosijan A, Horvath L, Rabkin 1, Muller AH, šurlan M, Klancar J, Knific J, Berden P, Vidmar D, Cesar R, Kocijancic 1, Pavlovcic-Kaplan S Abstract -To assess the long-term clinical effect of percutaneous transluminal angioplasty of the renal artery (PTRA), patients with clinical examinations and laboratory tests performed before PTRA and within a minimum of 3 months following the investigation were considered eligible for inclusion. Patients with fibromuscular disease of the main and/or branch renal arteries were the most suitable candidates tor PTRA, because two thirds of them showed a blood pressure benefit at 5-year follow up. These results are similar to those achieved in the group of patients with atheromatous disease. Authors discuss the clinical and laboratory characteristics and radioclogic aspects of PTRA, the technical standard of the procedure, complications and number of redilatations. UDC: 616.136.7.272-089.844 Key words: renal artery obstruction, angioplasty transluminal Orig sci paper Radlol lugosl 1990; 24: 137-45. lntroduction -Percutaneous renal angiopla­sty (PTRA) has become an established interven­tional method used in the treatment of renal artery stenosis. While in stenoses caused by fibromuscular dysplasia, it is the method of first choice, there has not been unanimity redgarding its superiority in cases of stenoses of atheroscle­rotic origin. Substantial improvement of renovas­cular hypertension following PTRA has been reported in fibromuscular stenoses rather than in atherosclerotic stenoses. Doubtless, any further piece of experience, espe­cially that gained in a large group of patinets followed up for a rather long period of tirne after PTRA, helps to build the body of hard evidence available. It was for this reason that we decided to conduct a multicentre study designed to as­sess retrospectively the long-term effect of PTRA on blood pressure in atherosclerotic, fibromuscu­lar and other types of lesions, and to suggest whether the long-term effect can be predicted on the basis of the angiographic finding obtained immediately after PTRA. Patients and methods -The project was joined by the following centres: 1 . Department of Radiology; Institute for Clini­cal and Experimental Medicine (A. Selan), Pra­gue, Czechoslovakia 2. Ali-Union Scientific Centre of Surgery; Aca­demy of Medica! Sciences (l. Kh. Rabkin), Mos­cow, Soviet Union 3. Institute of Rentgenology University Medi­ca! Center (D. Pavcnik), Ljubljana, Yugoslavia 4. Municipal Hospital Friedrichshein, Depar­tment of Cardiovascular Diagnosis (J. H. A. Muller), Berlin, German Democratic Republic 5. Glinic of Radiology (L. Horvath), Pecs, Hun­gary 6. Institute of Cardiovascular Surgery of A. N. Bakulev (l. Petrosyan), Moscow, Soviet Union The study was coordinated by the Department of Radiology of the Institute for Clinical and Experimental medicine in Prague where a que­stionnaire for retrospective data collection was drawn and distributed to each participating cen­tre. The questionnaire was to be filled for each patient undergoing PTRA before 31 December, 1987. The contribution of each centre to the basic group of patients is shown in Table 1. Twenty-three patients after PTA of the renal graft artery were excluded from the study in order to be assesed separately. The remaining Received: March 3, 1990 -Accepted: April 1 O, 1990 Belan A. et al. Percutaneous transluminal renal angioplasty -A multicentre study of the long term r11sults Table 1 -Contribution of each centre to the basic group No. of all pts after PT A Percentage of the No. of pts after PT A of the renal artery entire group of the renal grafi artery 1. Prague 134 30.5 18 2. Moscow R. 118 26.9 1 3. Ljubljana 91 20.7 3 4. Berlin 34 7.7 1 5. Pecs 32 7.3 o 6. Moscow P. 30 6.8 o To tal 23 416 patients were divided into three groups by In some cases, the etiology of stenosis was the etiology of the stenosis: established by histological examination of the artery after its surgical reconstruction, nephrecto­ l. ATHERO (atherosclerosis), n = 261, my, orat autopsy. II. FMD (fibromuscular dysplasia), n = 109, The clinical and laboratory characteristics of III. OTHERS (mostly vascular lesions in arteri­ the patient group before PTRA are shown in tis and other systemic diseases), n = 46. Table 2. Table 2 -Clinico-laboratory characteristics of the group of patients before PTRA l. ATHERO I1.FMD III. OTHERS n=261 n=109 n=46 Mean age n=260 n= 107 n=45 (years) 50.4±7.5 34.5±9.9 32.7±11.3 Sex male 196 75.1% 38 34.9% 28 60.9% temale 65 24.9% 71 65.1% 18 39.1% Extrarenal manifestations of atherosclerosis 131 50% 10 10% 5 11% Primary renal disease 38 14.5% 19 18% 7 15.5% Systemic disease (incl. diabetes mellitus) 19 7% 2 2% 5 11% WHO class of hypertension 1 27 10.8% 32 29.6% 32% II 192 77.1% 68 63% 29 64% III 30 12% 8 7.4% 2 4% Plasma creatinine n=199 n=94 n=27 (umol/I) 127.2±75.6 91.8±26.0 110.6±20.1 (40-764) (46-198) (88-190) Blood pressure n=255 n=108 n=45 (mmHg) systole 197±31 182±30 190±29 diastole 114±17 113±15 114±16 mean 142±20 136±19 140±18 Antihypertensive therapy -none 11 4.4% 4 3.8% 5 11.1% -1-3 hypotensives 202 80.8% 92 86.8% 36 80.0% -> 3 hypotensives 37 14.8% 10 9.4% 4 8.9% lndications tor PIRA -hypertension 223 87.7% 99 94.3% 41 89.1% -hypertension with 31 12.2% 6 5.7% 5 10.9% deteriorated function Radiol lugosl 1990; 24: 137-45. Belan A. et al. Percutaneous transl.minal renal angioplasty -A multicentre study of the long term results As expected, the mean age was markedly higher in Group 1 (ATHERO), with men prevailing and extrarenal complications (ischemic heart di­sease, atherosclerosis of the lower extremities, stroke) present more often than in the other groups. In Group II (FMD), women prevailed and the mean age was lower. There was no diffe­rence between the groups as to other parameters (presence of primary renal disease, systemic disease, WHO classification of hypertension, pla­sma creatinine level, blood pressure before PTRA and the number of hypotensive drugs used). The higher incidence of systemic diseases in Group I was due to the more frequent inci­dence of diabetes. The radiologic characteristics are given in Ta­ble 3. Complications requinng surgery were found in 12 patients. Nephrectomy had to be performed in three cases and aortorenal bypass in nine. The angiographic finding of the renal artery immediately after PTA was assessed as »norma­lized« in disappeared stenoses, »improved« in cases of stenoses smaller than before the proce­dure, and »not improved« in persisting stenoses of the same extent. Fram the basic group (n = 416), a total of 154 patients (37%) undergoing successful PTRA wit­hout redilatation, with clinical examination and laboratory tests done before PTRA and followed up tor a minimum of 90 days since dilatation, were selected to evaluate the effect of PTRA on blood pressure and renal function. The following criteria were chosen: Table 3 -Radiologic characteristics of the group l. ATHERO II. FMD II1. OTHERS n=261 n=109 n=46 Side of stenosis 33.9 22 47.8 12 26.1 * right * left 90 34.4 61 125 47.9 37 * right + left 46 17.6 11 10.1 12 26.1 Number of dilated arteries one 207 79.6 96 89.7 32 69.6 two 50 19.2 10 9.3 14 30.4 three 3 1.2 1 1.0 o Technical failure 16 6.1 9 8.2 10 21.7 Complications of PTRA 23 8.8 17 15.6 5 10.9 Angiographic finding after PTRA * normalization 127 48.8 42 38.5 21 46.7 * improved 119 45.8 56 51.4 18 40.0 * unchanged 14 11 10.1 6 13.3 Number of redilations 27 10.3 Patients in Groups I and III showed more frequent bilateral stenosis. The number of dilated arteries in the ATHERO and OTHERS groups is likewise higher Ihan in that with FMD stenoses. In atherosclerotic stenoses neither information on the type of st.nosis nor records on the angiographic finding of the peripheral arterial bed are available. Post-PTRA complications, regardless the etio­logy of stenosis, were observed in 10.8% of patients. Half of them were minor complications, i.e., renal artery spasm, and complications at the puncture site, with the remaining 50% of compli­cations made up by dissections, embolization, perforation or rupture of the artery, occllusions and an immedia\e decrease in renal function. 12 11.0 1 2.2 Renal function was regarded as unchanged if plasma creatinine level had been within normal limits (i.e., up to 125 umol/I) also before PTRA, or when the chailge, in patients with initial levels over 125 umol/I, di_d not exceed 20% of the initial value after PTRA. Our definition of functional deterioration included cases with normal ilnitial creatinine levels and follow-up levels exceeding 125 umol/I, or a rise from values over 125 umol/I by more than 20%. An improvement in function was registered if creatinine decreased from le­vels over 125 umol/I to below 125 umol/I, or by more Ihan 20% from levels initially higher than 125 umol/1. Blood pressure was considered normal if the value of systolic pressure was lower than 165 Radio! !ugasi 1990; 24: 137-45. Belan A. et ,il. Percutaneous transluminal renal angioplasty -A multicentre study of the long term results mmHg, that of diastolic pressure lower than 95 of 90 days following PTRA in our group of 154 mmHg, and the value of mean pressure below patients are shown in Table 4. 11 O mmHg. -Our definition of improvement was a Changes · in renal function before and after decrease of elevated values to normal level, or a PTRA were assessed by changes in plasma decrease of elevated values by at least 15% of creatinine levels. In Group 1 (ATHERO) improve­the initial value. ment and deterioration were noted in five cases each. There was no change in the remaining Results -The values of plasma creatinine patients. lmprovement and deterioration were and blood pressure before and after a minimum obser ved in one case each in Group II (FMD) Table 4 -Plasma creatinine and blood pressure values in a group of 154 patients examined before PTRA and after a minimum od 90 days later l. ATHERO I1.FMD III. OTHERS n=97 n=44 n=13 before after before after before af ter n=64 n=39 n=6 6 Pl asm a creatinine 121.9 123.3 93.9 91.8 129.1 106.2 (umol/I) ± 52.8 62.9 27.1 25.5 35.0 14.2 Blood pressure n=94 n=44 n= 11 systole 190.6 151.6 177.8 143.7 177.7 136.1 ± 33.4 19.8 33.9 15.6 38.3 41.4 diastole 110.1 93.3 108.9 91.7 107.5 92.7 ± 16.4 10.1 15.5 16.0 14.9 mean 136.9 113.0 131.9 109.0 133.0 110.6 ± 20.7 12.0 20.6 10.4 20.2 21.4 Table 5 1. Follow-up > months after PTRA (n = 149) Mean BP lmproved Not improved ATHERO n % 67 71.3 27 27.7 FMD n 28 16 % 63.6 36.4 OTHERS n % 9 81.8 2 18.2 TOTAL n % 104 67.8 45 30.2 Tot al 94 11 149 2. Follow up > 12 months after PTRA (n = 99) Mean BP lmproved Not improved ATHERO n % 51 75.0 17 25.0 FMD n 13 12 % 52.0 48.0 OTHERS n % 6 100.0 o o TOTAL n % 70 70.1 29 29.3 Tot al 68 25 6 99 3. Followup > months after PTRA (n = 66) Mean BP lmproved Not improved ATHERO n % 30 69.8 13 30.2 FMD n 9 8 % 53.0 47.0 OTHERS n % 6 100.0 o o TOTAL n % 45 68 2 21 31.8 Tot al 43 17 6 66 4. Followup > 60 months !3-fter PTRA (n = 23) Mean BP lmproved Not improved ATHERO n % 14 82.4 3 17.6 FMD n 3 1 % 75.0 25.0 OTHERS n % 2 100.0 o o TOTAL n % 19 82.6 4 17.4 Tot al 17 4 2 23 140 Radiol lugosl 1990; 24: 137-45. Belan A. et al. Percutaneous transluminal renal angioplasty -A multicentre study of the long term results patients. Since plasma creatinine was determi­ned in six patients of Group III (OTHERS) only, the changes were not assessed. The long-term effect of PTRA on blood pres­sure was evaluated at three months (n = 149), at 12 months (n = 99), at 24 months (n= 66) and at 60 months (n = 23). The mean follow-up .. 100 IIO IO 70 IO liO 40 :!O 20 10 o ,····-·-­ ' ... ··-........ ........................ ··-­ ' ' '·• · o -----..0.. . ·-.._ .... _ period (n = 154) was 31 ± 26.8 months (range, 3.3 -92.8 months). lmprovement of mean blood pressure is shown in Table 5 . The cumulative curves of improvement of blood pressure after PTRA according to the etiology of stenosis do not differ statistically over a five-year follow-up period (Fig. 1 ). • ---e.... NormMlnd -.,_ n • 14 -.......... ,. ...... ---.\ p <0,01 1 1mp,_ ....:i3 y1.,. Fig. 1 -The cumulative curves of improvement of blood pressure after PTRA accordin9 to the etiology of the stenosis. Three and more months after PTRA, mean Both in the ATHERO and FMD groups, while blood pressure was improved in 104 patients the mean pressure of most patients was within (67.8%). The proportion of »improvement« in normal values, they had to continue receiving each group by the etiology of stenosis is shown hypotensives. The difference was Group II which in Table 6. comprised a substantially higher proportion of Table 6 -lmprovement of hypertension after PTRA Blood pressure improvement > months after PTRA ATHERO FMD OTHERS n=67 n=28 n=9 lmprovement but mean BP > 11 O mmHg thereafter 23 34.3% 3 10.7% 2 22.2% Mean BP > mmHg with hypotensives 29 43.3% 14 50.0% 3 33.3% Mean BP > 110 mmHg without hypotensives 22.4% 11 39.3% 4 44.5% Radio! lugosl 1990; 24: 137-45. Selan A. et al. Percutaneous transluminal renal angioplasty -A multicentre study of the long term results normotensives not taking hypotensive drugs (39.3% vs. 22.4%) and, on the contrary, the percentage of those remaining hypertensive fol­lowing PTRA was considerably lower (10.7% vs. 34.3%). Group III could not be evaluated be­cause of the small number of followed patients. Comparison of patients who, while not taking hypotensive drugs, were normotensive at three months after PTRA (n = 30) with other patients on follow-up (n = 124) revealed that ali the former had significantly lower mean blood pres­sure before PTRA (127 ± 1 O vs. 137 ± 22 mmHG), and the WHO classification of their hypertension was likewise lower (Stage I hyper­tension in 57%, Stage III hypertension in 0%). The therapeutic protocol in patients whose pressure remained unchanged three months af­ter PTRA (n = 45, i.e., 30.2%) did not differ before and after PTRA, i. e., they received the same number of hypotensive drugs. The correlation between the post -PTRA angiographic finding and the effect of the proce­dure is shown in Table 7. The options listed in the questionnaire regarding the post -PTRA angiographic finding on the renal artery compri­sed »normalized«, »improved« nnd »unchan­ged«. The number of patinets with prolonged blood pressure improvement is substantially higher in the group with a »normalized« angiographic fin­ding Ihan in the group whose finding was »impro­ved« only. The group with an »unchanged« angiographic finding was not evaluated owing to the small number of patients. The cumulative curves of blood pressure im­provement according to the post -PTRA angio­graphic finding of the artery irrespective of the etiology is shown in Fig. 2. The difference in the effect on blood pressure in normalized vs. impro­ved findings is statistically significant. Table 7 1. Follow-up at :s 3 months after PTRA (n = 149) Angiographic finding on the reanl artery after PTRA Normalized lmproved Not improved n=64 43.0% n=83 55.7% n=1 0.7% Mean BP improved 54 84.5 59.0 50.0 Mean BP not improved 10 15.5 34 41.0 50.0 2. Follow-up at > 12 months after PTRA (n = 99) Angiographic finding on the renal artery after PTRA Normalized lmproved Not improved n=42 42.4% n=56 56.6% n=1 1.0% Mean BP improved 35 83.5 34 60.7 1 100.0 Mean BP not improved 7 16.5 22 39.3 o O.O 3. Follow-up at > 24 months after PTRA (n = 66) Angiographic finding on the renal artery after PTRA Normalized lmproved Not improved n=27 40.9% n=38 57.6% n=1 1.5% Mean BP improved 23 85.2 21 55.3 1 100.0 Mean BP not improved 4 14.8 17 44.7 o 0.8 4. Follow-up at > 60 months after PTRA (n = 23) Angiographic finding on the renal artery after PTRA Normalized lmproved Not improved n=14 60.9% n=8 34.8% n=1 23.0% Mean BP improved 13 92.9 5 62.5 1 100.0 Mean BP not improved 1 7.1 3 37.5 o o.o Radiol lugosl 1990; 24: 137-45. Selan A. et a/. Percutaneous transluminal renal angioplasty -A mu/ticentre study of the /ong term results 100 ., '.:.--------.,, u. 111 Alhoro ' ·, ,_ ., '-., "--..... ­' ·,. ·,,-0," "· IO 4D -----t. fll. ., 211 10 ---.----·-r 2 S • ­ Fig. 2 -Cumulative curves of blood pressure improve­ment according to post-PTRA angiographe finding of the artery. The long-term effect of redilatations could not be assessed in our group. Out of a total of 40 redilatation procedures, no data on blood pres­sure are available in 19 procedures and technical failures, i.e. renal graft recipient or an extremely short follow-up period, were involved in eight more cases. Of the remaining 13 redilatation procedures assessed at 3 months since the intervention, blood pressure was improved in six patients (all to normotension, one without the need for hypotensive drugs), and remained unal­tered in seven subjects. Discussion -Retrospective evaluation of PTRA and its long-term effect, especially if desig­ned as a multicentric study, usually involves some pitfalls. The participating centres have different criteria for patient selection, a different technique of the procedure, assessment of com­plications and different regimens and methods of subsequent treatment and follow-up. Regarding the clinical characteristics of our group (Table 2), we believe it is consistent with those reported in recent literature (1-7,8). Some data important for the evalulation of the long-term effect of PTRA, e.g., duration of hypertension before radiological procedure, more detailed spe­cification and comparison of hypotensive therapy before and after PTRA, etc., are also missing in our case. It is a pity that as little as 37% of patients remained on long-term follow-up. Radiological determination of the etiology of the stenosis may be likewise difficult. Conside­ring the fact that the patient group was set up over a period of several years in six centres, it could not be assumed that the technique of PTRA in all patients was identical. That is why the initial success rale, which, in turn, as shown later, may play a major role in the evaluation of the long-term success rate, could not be analy­sed (1, 9). lf we compare the initial success rale of PTRA (regardless the etiology) in our group with the summary published recently by Becker et al. (10), our group shows a very good initial technical success rate. Also the number of com­plications (approx. 10%), half of which repre­sents minor complications, is consistent with dala reported by other authors (3, 11, 12). The indication tor PTRA was hypertension in most of the patients enrolled into our study. Only a small proportion of Group 1 (ATHERO) patients (n = 31, i.e., 12.2%) and six patients (57%) in Group II (FMD) were considered for PTRA be­cause of impaired renal function. One could not make any authoritative conclusions as to whether the cause of decreased renal function was inva­riably renal artery stenosis alone, or whether other factors were also involved (13). Moreover, the levels of plasma cratinine at the required intervals were not always available in this small Radio! /ugasi 1990; 24: 137-45. Belan A. et al. Percutaneous transluminal renal angioplasty -A multicentre study of the long term results group either. The mean values of plasma creati­ nine before PTRA and at three months after PTRA were within normal limits in ali three groups and did not change during follow-up. Today, there is no doubt that PTRA has be­come an established technique for the treatment of renovascular hypertension and its results are comparable with those of surgical treatment (8, 14, 15, 16). The technique of PTRA and techno­logy are being constantly refined (1, 17). Long term improvement of blood pressure and the percentage of cured patients (normotensives not requiring hypotensive therapy) are reportedly hig­her in Group II (FMD) (2-4, 6, 7, 8, 12, 14) Ihan in group 1 (ATHERO). Significant imrpovement of systolic, diastolic and mean pressure after PTRA irrespective of the etiology of stenosis was found in 68% of our patients on long-term follow-up. Provided our criterion of clinical effect was a 15% decrease in mean blood pressure, or a decrease in mean blood pressure below 11 O mmHg, the percentage of improved patients was higher in Group 1 (ATHERO), but the cumulative curves of improvement did not differ statistically (Table 5, Graph 1 ). However, the number of Group II (FMD) patients with pressure normaliza­tion was twice as high as that in Group I and, compared with Group 1 (ATHERO), only a third of FMD and, compared with Group 1 (ATHERO), only a third of FMD patients remained hypertensi­ve, even though improved if assessed by our criteria (Table 6). We are not the first to make such an observation. Kuhlman et. al. (5) reported improvement in blood pressure at 21.6 months after PTRA in 48% of patients with atherosclero­tic stenosis, and in as little as 32% of patients with fibromuscular stenosis, even though the percentage of normalized patients was higher in the FMD Ihan in the ATHERO group (50.0 vs. 29.0%). It is implied that the etiology of stenosis, as established by angiography, is not neccessa­rily the basic factor determining the long-term effect of PTRA. Moreover, we are unable to make any conclusions regarding the duration of hypertension before PTRA, nor any other factors that might possibly play a major role. The results of ·our multicentric study in the ATHERO group were primarily attributable to the extremely good dala obtained from the centres headed by Prof. Rabkin from Moscow and Dr. Horvat from Pecs. The angiographic finding after PTRA has tur­ned out to be a significant factor for the prediction of the long-term clinical effect of the procedure. Whereas in the case without residual stenosis (and a pressure gradient no longer persisted) the finding was assessed as »normalized«, patients with residual stenoses and residual pressure gradient were considered »improved«. Regar­dless the etiology of stenosis, the group with a »normalized« finding of the renal artery showed an effect »improved« finding, and the effect persisted for a long period of tirne (Table 7). The cumulative curve of blood pressure improvement is significantly better in the group of »normalized« stenoses (Fig. 2). Since no angiographic follow­up in patients after PTRA has been performed, we are unable to provide dala on the incidence of restenoses neither can we assess the potentiar value of subsequent antiaggregation or anticoa­gulation therapy. PTRA is an effective method for the treatment of renovascular hypertension. It is associated with a high technical success rate and a low rate of serious complications. While, almost as a rule, the improvement of blood pressure in atherosclerotic stenoses is only partial and it is usually necessary to continue hypotensive therapy, in fibromuscular stenoses, normotension is rather often attained without further drug administration. A decrease in blood pressure found at three months after PTRA suggests permanent improvement in most cases. The etiology of the stenosis, as established by angiography is not necessarily the main factor determining the long-term clinical effect. Another important predictor of long-term improvement seems to be the angiographic finding of the renal artery immediately after angioplasty. Povzetek MULTICENTIRICNA ŠTUDIJA PERKUTANE TRANSLUMINALNE ANGIOPLASTIKE Da bi ovrednotili dolgotrajne klinicne ucinke PT A renalnih arterij, smo pri bolnikih opravili klinicni pregled in laboratorijske preiskave pred PTA in tekom (najmanj) treh mesecev po posegu. Najprimernejši bolniki za PTRA so tisti s fibromuskularno boleznijo glavne in katere od vej renalne arterije, saj je bil pri dveh tretjinah bolnikov, 5 let po posegu, ucinek na krvni pritisk dober. Podobno velja tudi za bolnike z arterioskleroticno zoži­tvijo renalne arterije kot tudi za radiološke vidike PT A, tehnicne standarde posega, komplikacije ter število ponovnih dilatacij. References 1. Martin LG, Casarella WJ, Alspaugh JP, Chuang VP. Renal Artery Angioplasty: lncreased Technical Success and Decreased Complications in the Second 100 Patients. Radiology 1986; 159 :631-4. 2. Sos TA, Pickering TG, Sniderman K, Saddekni S, Case DB, Silane MF, Vaugham ED Jr, Laragh JH. Percutaneous Transluminal Renal Angioplasty in Reno- Aadiol lugosl 1990; 24: 137-45. Selan A. et al. Percutaneous transluminal renal angioplasty -A multicentre study of the long term results vascular Hypertension Due to Atheroma of Fibromus­cular Dysplasia. N Engl J Med 1983; 309:274-9. 3. Puylaet CBAJ, Klinge J, Mali WPTM, Geyskes GG, Becking WB, Feldberg MAM. Percutaneous Tran­sluminal Rena! Angioplasty: lnitial and Long-Term Re­sults. Radiology 1989; 1711501-6. 5. Kuhlmann U, Greminger P, Gruentzig A, Schnei­der E, Pouliadis G, Luescher T, Steurer J, Siegenthaler W, Vetter W. Long-Term Experience in Percutaneous Transluminal Dilatation of Rena! Artery Stenosis. Am J Med 1985; 79 :692-8. 6. Tegtmeyer CJ, Kellum CD, Ayers C. Percuta­neous Transluminal Angioplasty of the Renal Artery. Radiology 1984; 153:77-84. 7. Loehr E, Weihert HC, Hartjes H, Schrivjers A. Percutaneous Transluminal Angioplasty of Renal Arte­ries: Therapeutic Principle -Case Repo rt of 128 Patients with Renovascular Hypertension in: Dotter CT et al. Percutaneous Transluminal Angioplasty. Berlin; Springer 1983; 281-5. 8. Grim CE, Yune HY, Donohue JP, Weinberg MH, Dilley R, Klatte EC. Renal Vascular Hypertension: Surgery vs. Dilatation Nephron 1986; 44(1) :96-100. 9. Sos TA, Saddekini S, Pickering TG, Laragh JH. Technical Aspects of Percutaneous Transluminal An­gioplasty in Renovascular Disease. Nephron 1986; 44(1) :45-50. 10. Becker GJ, Katzen BT, Dake MD. NoncoronaryAngioplasty. Radiology 1989; 170:921-40. 11. Maher F, Triller J, Weidmann P, Nachbur b. Complications in Percutaneous Dilatation of Rena! Arteries. Nephron 1986; 44(1) :60-3. 12. Obrez 1, Šimunic S, šurlan M, Gurtl R, Klenkar M, Kaplan-Pavlovcic S, Fuduric-Winter l. Percutaneous Transluminal Renal Angioplasty: Clinical and Angio­graphic Follow-up Results. Radiol Today 1983; (2) :126­30. 13. Martin LG, Casarella WJ, Gaylord GM. Azotemia Caused by Renal Artery Stenosis: Treatment by Percu­taneous Angioplasty. AJR 1988: 150 :839-44. 14. Leuscher TF, Keller HM, lmhof HM, GremingerP, Kuhlmann U, Largiader F, Schneider J, Vetter W. Fibromuscular Hyperplasia: Extension of the Disease and Therapeutic Outcome. Nephron 1986; 44(1):109­14. 15. Zech P, Finaz de Villaine J, Pozet N, Sassard J, Vincent M, Labeeuw M, Collard M, Had-Aissa A. Surgical Versus Medica! Treatment in Renovascular Hypertension. Nephron 1986; 44(1) :105-18. 16. Dean AH. Comparison of Medica! and Surgical Treatment of Renovascular Hypertension. Nephron 1986; 44(1):101-4. 17. Rose BD. Renovascular Hypertension. In: Pat­hophysiology of Renal Disease. 18. Tegtmeyer CJ, Sos TA. Techniques of RenalAngioplasty. Radiology 1986; 161 :577-86. Author's address: Doc. dr. Dušan Pavcnik. dr. med., Inštitut za rentgenologijo Univerzitetnega klinicnega centra Zaloška 7, 61000 Ljubljana Radiol lugosl 1990; 24: 137-45. (ii o\o\les ao \ ._. s . ef \of , o . eo\ \0 o,ago• oS\ s '-'ora\ot'l oe\0 (1\lfla ­ (\ ---1 \J'J e o-"---!-!---­ n \J and o\ne\ b ,ne \\\o\\ovi\n9 , \f\ones \ no(Qfl o Radioimmunoassay FSH RIA TSH -RIA tor the determination of Follitropin Radioimmunoassay tor the determination of Thyrotropin Radioimmunoassay for the determination of Human Growth Hormone Radioimmunoassay for the determination of total Trllodthyronlne Radioimmunoassay tor the determination ot total Thyroxin Radioimmunoassay tor the determlnation of Lutropin HGH -RIA T 3 -RIA T 4 -RIA LH -RIA R I A Radiolmmunoassay PROLACTIN tor the determlnation of Prolactln Radioimmunoassay (3-HCG -RIA for the determination of Chorlonlc R I A Radiolmmunoassay - E S T R A O I O L tor the determlnation of Estradiol Radiolmmunoassay INSULIN -RIA tor the determlnation of lnsulin Radioimmunoassay DIGOXIN -RIA for the determlnatlon of Digoxln VE AuBen-und Binnenhandelsbetrieb Robert-Ri:issle-StraBe 10 Berlin DDR-1115 German Democratic Republic Sisocommerz INSTITUTE OF RENTGENOLOGY UNIVERSITY MEDICAL CENTER LJUBLJANA SELF EXPANDING METALLIC STENTS Pavcnik D, Šurlan M Abstract -Between September and December 1989 four patients with stenosis of the tracheobronchial tree and obstruction of vena cava superior were treated with seli expanding metallic steni. Stents were successfully placed in each patient. Alle are clasified as cured. For venography before and after stent placement lohexol 350 was used. UDC: 616.23-007.271-089.819.5 Key words: tracheal stenosis, superior vena cava syndrome, metallic stents Case report Radiol lugosl 1990; 24: 147-50. lntroduction -In 1969, Charles Dotter first publiched data demonstrating long term patency of intravascular stents in dogs (1, 2). Since Dotter's initial success, others have reported long term patency without significant luminal narrowing in a variety of stents placed in severa! tubular structures (3, 4, 5, 6, 8, 9, 1 O, 11, 12). In our patients we used the expandable metallic steni created by one of the pioneers of lnterven­tional Radiology, Cesare Gianturco. His devices have been responsible for opening the door to lnterventional Radiology. Among his inventions are the embolic coils, the self-expanding stain­less steel stents, the bird's nest vena cava filters, the U-inverted-U balloon assisted stents, patent ductus occluders and septal defect occluders. Materials and methods -In three patients with stenosis of the tracheobronchial tree and in one patients with vena cava superior (VCS) obstruction due to sarcoidosis Gianturco stents were placed. The procedure was performed per­cutaneously in patients with vena cava superior obstruction and transendoscopically in other pa­tients. In ali four cases stenosis was first dilated with a PT A balloon catheter to allow passage of Received: March 3, 1990 -Accepted: March 26, 1990 the guiding sheath. The stents opened the stric­ture segment in ali cases. The expandable metallic stent is constructed of stainless steel wire bent in a zig-zag pattern and encircled to form a cylilnder (5). The stent is compressed and introduced through a Teflon catheter of 10-12 F caliber. The stent is advanced until it reaches the tip of the catheter by using a pusher catheter. It is released from the catheter by withdrawing the catheter while holding the pusher catheter against the stent. Upon release, the stent expands or attempts to expand to its original diameter creating the expansile force to allow the expansion of the vessel against the extrinsic, stenotic force (12). Results -Clinical trials of the Gianturco ex­pandable metallic stent have been conducted also in our institution in Ljubljana. The stent has been evaluated in the tracheobronchial tree and vena cava. To date, the stents opened stenosis in ali cases and after at least 3 months, they have remained patent without migration or other complications. Pavcnik D, šurlan M. Self expanding metallic stents Case report (1) -A 41-year old patient deve­loped superior vena cava obstruction secondary to compression by fibrosis due to sarcoidosis. Clinical findings were facial swelling, distention of the veins of the neck and headache. On phlebography, a contrast medium (lohexol 350) injection into the vena cava superior led to immediate filling of the vena azygos with rever­sed flow direction. Flebogram showed the supe­rior vena cava obstruction (Fig. 1 ). The procedure Fig. 1 -Vena cava superior obstruction (arrows) was performed percutaneously through the right femoral vein. First an introducer sheath was inserted into the femoral vein. For crosing the tight stenosis of vena cava superior we used 0,035 inch. movable core straight guidewire and straight 5 F catheter. Once the diagnostic cathe­ter had crossed the obstruction, the catheter was exchanged for dilatation balloon catheter (6 mm diameter). Before PT A, 5000 units of Heparin was injec­ted through the sheath side arm. After PTA, the balloon catheter was wtihdrawn while the guide­wire was kept in place. Then a longer 20 mm balloon was introduced, and after the second inflation the result was satisfactory. A double stent was placed (Fig. 2) and immediate clinical Fig. 2 -Double self expandable steni in vena cava superior improvement was accomplished. Aspirin and per­santine have been given for three months. To date, stent provides good patency of ves (Fig. 3). Case report (2) -A 58-year old patient deve­loped stenosios of the right bronchus which resulted from fibrosis due to surgery. To over­come this problem we used PT A balloon catheter and two self-expanding stents. This patient has been followed for 4 months. Follow up exams indicate that stents conform to the luminal surfa­ce, are stable, and remain patent. The patient is asymptomatic and this indicates !hat stent can effectively dilate the brbnchus. R.d;01 lugosl 1990: 24: 147-50. Pavcni. D, šurlan M. Self expanding metallic stents Fig. 3 -Patent stent in vena cava superior Disscusion -Gianturco self expandable me­tallic stent has been evaluated in severa! tubular structures including the arteries and aorta (12), the veins and vena cava, the tracheobranchial tree (11 ), the bile ducts (5), and the ureter (4). In the blood vessels, local expansion with neointi­mal proliferation covering the stents was obser­ved. The stent was incorporated in the wall of the blood vessel. In stenotic veins and vena cava, the stents dilated the vessels and decreased the pressure gradient across the stenoses (3). The steni was also placed in the intrahepatic segment of the vena cava inferior in a patient with Budd­Chiarri syndrome (4). When placed in the trac­heobronchial three the steni created focal dilata­tion and inflammation with mucosal secretion covering the stent. There was no obstruction or peforation of the trachea (11 ). Percutaneous biliar drainage is the usual form of biliary decompression in patients with obstruc­tive jaundice secondary to neoplastic involve­ment of the bile ducts. However, there are many comlications associated with currently used de­compression techniques. Catheter drainage sy- Radiol lugosl 1990; 24: 147-50. stem whether external or internal-external may migrate, be associated with infection, or become blocked. The use of indwelling endoprosthesis has not overcome ali the problems, and removal of malfunctioning prostheses may be impossible. Self expandable stents placed in common bile duet opened the strictured segment and remai­ned patent without migration or other complica­tions up to one year (4, 5). Placement of the stent in the ureter resulted in mucosol proliferation which caused obstruction of the ureter in some cases. Conclusion -lnterventional radiology has pro­vided a promising nonsurgical treatment of vas­cular and bronchotracheal strictures with Gian­turco self expandable metallic stents. The work of many investigators (3, 5, 6, 11, 12) as well as our own results demonstrate that these newly developed self expandable stents will improve the treatment of strictures in several tubular · structures. Povzetek SAMORAZTEGLJIVE KOVINSKE PROTEZE V casu od septembra do decembra 1989 smo zdravili štiri bolnike, ki so imeli zožitev traheobronhialnega vejevja in obstrukcijo vene cave sup, s samorazteglji­ vim kovinskim stentom. Pri vseh bolnikih je bila vstavi­ tev uspešna. Vse bolnike smo opredelili kot ozdravljene. pri veno­ grafiji, opravljeni pred in po vstavitvi stenta smo uporabili lohexol 350. References 1. Dotter CT. Transluminally placed coilspring en­darterial tube grafts: long term patency in canine popliteal artery. lnvest Radiol 1969; 4:329. 2. Dotter CT et al. Transluminal expandable nitinol coil stent grafting: preliminary report. Radiology 1983; 147:259-60. 3. Charnsangavej C, Carrasco CH, Wallace S et al. Stenosis of the vena cava, Preliminary assesment of treatment with expandable metallic stents. Radiology 1986; 161 :295-8. 4. Charnsangavej C. Gianturco expandable metallic stent. XIII. Meeting on lnterventional Radiology, Orlan­do; 1988:172-4. 5. Carrasco CH, Wallace S, Charnsangavej C et al. Expandable biliary endoprosthesis: An experimental study. AJR 1985; 145:1279-81. 6. Duprat G Jr, Wright KC, Charnsangavej C et al. Flexible balloon-expanded stent for small vessels. Work in progress. Radiology 1987; 162:276-8. 7. Duprat G Jr, Wright KC, Charnsangavej C et al. Selfexpanding metallic stents for small vessels: an experimental evaluation. Radiology 1987; 162:469-72. 8. Palmaz JC, Sibbit RR, Reuter R, Tio FO, Rice WJ. Expandable intraluminal graft: preliminary study. Work in progress. Radiology 1985; 156 :73-7. Pavcnik O, šurlan M. $elf expanding metallic stents NYCOMED . Contrast Media Mijelografija OMNIPAQUErM joheksol gotovo za upotrebu f""4.GLAVNE PREDNOSTI OMNIPAQUEA _,;:t · - neionsko kontrastno sredstvo . 1 U MIJELOGRAFIJI • vrlo niska neurotoksicnost • nikakvi ili klinicki beznacajni ucinci na EEG, kardiovaskularne parametre i rezultate labora­torijskih pretraga cerebrospinalnog likvora • vrlo mala ucestalost i slab intenzitet subjektiv­ nih reakcija bolesnika • odsustvo neocekivanih ili ireverzibilnih reakcija • vrlo mala vjerojatnost kasnih upalnih reakcija :,. ­ ( arahnoiditis) • visokokvalitetni mijelogrami IZ NYCOMEDA-INOVATORA U PODRUCJU KONTRASTNIH SREDSTAVA Omnipaque je zašticeno ime SIGURNIJE KONTRASTNO LECLERC & CO. Schaffhausen/Švicarska. -. t' C>MN1PN SREDSTVO U DIJAGNOSTICKOJ RADIOLOGIJI <>MN1PAG1e ...;.,. . 1 .· .. , , .__. Proizvodac Nycomed A/S Oslo, Norveška !skljuciva prava prodaje u Jugoslaviji ima firma /' -. '.;· m ?.•.• ,..!,._! .,J . . ,_ ,_ . • 1!· liiii1 --. Zastupstvo za Jugoslaviju ima: REPLEK-MAKEDONIJA, 9. Rousseau H, Puel J, Joffre F, Sigwart U, Dobouc­her C, lmbert C, Knight C, Knopi L, Wallsten H. Self-expanding endovascular prosthesis: an experi­mental study. Radiology 1987; 164:709-14. 10. Strecker EP, Berg G, Weber H, Bohi M, Schnei­der B. Experimentelle Untersuchungen mit einer neuen perkutan einfuhrbaren und aufdehnbaren Gefassendo­prothese. Fortschritte Rontgenstrahlen 1987; 147:669­72. 11. Wallace MJ, Charnsangavej C, Ogawa K et al. Tracheobrachial tree: Expandable metallic stents used in experimental and clinical applications. Radiology 1986; 158:309-12. 12. Wright KC, Wallace S, Charnsangavej C et al. Percutaneous endovascular stents: an experimental evaluation. Radiology 1985; 156:69-72. Author's address: Doc. dr. Dušan Pavcnik, dr. med., Institut of Rentgenology, University Medical Center, Zaloška 7, 61000 Ljubljana. ·. 91000 Skopje, Jurij Gagarin bb, 091 /237-266, 237-272, 232-222, 232-350 Ur Zastupstvo 091/233-138, Telex 51431 Aadiol \ugo::,i ;S$:); 24· 147-50. KLINICKA BOLNICA »DR MLADEN STOJANOVIC«, ZAGREB KLINIKA ZA NUKLEARNU MEDICINU I ONKOLOGIJU UNIVERSITY HOSPITAL »Dr MLADEN STOJANOVIC«, ZAGREB DEPARTMENT OF NUCLEAR MEDICINE ANO ONCOLOGY TSH RECEPTOR ANTIBODIES IN FOLLOW-UP OF PATIENTS WITH GRAVES' DISEASE DURING ANTITHYROID DRUG THERAPY 0akovi6 N, Kusi6 Z, Lukinac Lj, Lukac J, Ni:ithig-Hus O, Labar 2, Smiciklas-Frani6 N, Spaventi š Abstract: In serum of 35 patients, suffering from Graves'disease, TSH receptor autoantibodies (THYBIA assay) were measured during Methimazole (mercapto -2 -methil -imidasol) therapy. In the group of hyperthyroid patients TSH receptors antibodies were positive (F > 15%) in 27 out of 35 (77%) patients. Out of 27 patients with positive tests who became euthyroid during therapy 24 (89%) of them became THYBIA assay negative. Our results suggest that measurement of antibodies to TSH receptor could be useful parametar in follow-up of patients with Graves'disease during antithyroid drug therapy. UDC: 616.441-008.61-085 Key words: Graves' disease-drug-therapy, methimazole, receptors thyrotropin Orig sci paper Radiol lugosl 1990; 24: 151-2. lntroduction -In Graves'disease, a control of thyroid function by the feedback control system breaks down due to the formation of autoantibo­dies to the TSH RECEPTOR (TRAb -TSH receptor antibodies) (7). The binding of these autoantibodies with an antigen of the thyroid cell membrane (TSH receptor) causes an uncontrol­led stimulation of thyroid hormone synthesis. TSH receptor assay studes indicate that TRAb are essentially found only in the serum of patients with Graves' disease and a proportion of patients with hypothyroidism due to autoimmune thyroi­dits (4, 6). The aim of the study was to evaluate the clinical significance of determination of TSH re­ceptor antibodies in patients with graves' disea­se, during the antithyroid drug therapy. Materials and methods -In serum of 3E, patients, suffering from Grave's disease, TSH receptor autoantibodies were measured by usnig THYBIA assay (Byk Sangtec Diagnostica). The investigation was carried out during therapy with Methymazole (Favistan; mercapto -2 -methil -imidasol). TSH receptor antibodies were measu­red twice: when the patients were hyperthyroid (prior or during Methimazole therapy) and after one to six months, when the patients became euthyroid (during or after Methimazole therapy). Results -In the group of hyperthyroid patients TSH receptor antibodies were positive (F > 15%) in 27 out of 35 (77%) (Table 1 ). Table 1 -Follow-up of TSH receptor antibodies during antithyroid drug therapy (N = 35). HORMONES TSH RECEPTOR ANTIBODIES POSITIVE NEGATIVE TOTAL n % n % n %. INCREASED 27 77 8 23 35 100 NORMAL 3 11 24 89 27 100 Received: December 18, 1989 -Accepted: March 27, 1990 Elakovic N. et al. TSH receptor antibodies in follow-up of patients with graves disease during antithyroid drug therapy Out of 27 patients with positive tests who became euthyroid during therapy 24 (89%) of them became THYBIA assay negative. In three patinets with several measurements the euthy­roid condition was achiaved one to two months betore antibodies became negative. Although in three patients antibodies remained postive, despite euthyroid condition, the titers decreased significantly. Two patinets with a very high titers had severe clinical course of disease, so that radioiodine and surgical treatment was necessary. In one patient with several measurements, thyroid hormones concetrations correlated with levels of antibodies titres. Discussion -In patients suffering from clini­cally overt and untreated Grave's disease, TSH receptor antibodies values were tound ellevated in about 80% of all cases. During antithyroid drug therapy the number of positive titers decrea­sed. The level of thyroid hormones in our study correlated with the TSH receptor antibodies titres in most cases. This observation is in support of the results reported by Paunkovic et al. (5). Our patients with very high titers in untreated thyrotoxicosis had a very severe course of di­sease indicating the early need tor ablative thera­py. This is in agreement with observations of other authors (1, 3). Budihna and Pavlin also found that patients with constantly increased titres of antibodies during antithyroid drug the­rapy had a more severe form of hyperthyroidism (2, 3). Our results suggest that measurement of anti­bodies to the TSH receptor could be useful parametar in the follow-up of patients with Gra­ve's disease during antithyroid drug therapy. Sažetak ANTITIJELA TSH RECEPTORA U PRACENJU LIJE­CENJA BOLESNIKA S GRAVESOVOM BOLESTI Odredivana su antitijela TSH receptora (Thybia as­say) u 35 bolesnika s Gravesovom bolesti tokom lijecenja Favistanom (mercapto -2 -methil -imidasol). Antitijela TSH receptora bila su povišena (F > 15%) u 27 od 35 (77%) bolesnika s povišenim hormonima štitnjace. Od 27 bolesnika u kojih su se hormoni tokom lijecenja normalizirali u 24 (89%) je došlo i do normali­zacije antitijela TSH receptora. Dobiveni rezultati uka­zuju da odredivanje antitijela TSH receptora može poslužiti kao parametar u pracenju bolesnika s Grave­sovom bolesti tokom tireostatske terapije. References 1. Becker W, Reiners C, Borner W: TSH-receptor autoantibody-titers in untreated toxic diffuse goitres ­An early indicator to relapse? Nuc Compact 1984; 15:252-62. 2. Budihna N, Pavlin K: TSH-Receptor Antibodies (TBII) in the Sera of Patients with lmmunogenic Hyper­thyroidism (GRAVES' Disease) During Antithyroid The­rapy. Nucl Med 1986; 25(A):130. 3. Budihna N, Pavlin K, Porenta M: Concetration of TSH-receptor antibodies (TBII) in the sera of patients with immunogenic hyperthyroidism (Grave's disease) receiving antithyroid medication. Radiobiol Radiother 1987; 28:101-6. 4. Kusic Z, Prpic H, Lukinac Lj, Labar L'., Spaventi š: Antitijela TSH receptora u klinickoj praksi. Radiol lugosl 1987; 21 (suppl. IV):47-8. 5. Paunkovic N, Pavlovic O, Miladinovic J: Klinicki znacaj pracenja koncentracije antireceptorskih TSH antitela u toku lecenja hipertireoze. In: Knjiga sažetaka XXIII Jugoslavenskog sastanka za nuklearnu medicinu. Zadar: Udruženje za nuklearnu medicinu Jugoslavije, 1989. 6. Shewring G, Smith BR: An improved radiorecep­tor assay tor TSH receptor antibodies. Ciin Endocrinol 1982; 17:409-17. 7. Smith BR, Hall R: Thyroid-stimulating immunoglo­bulins in Grave's diesease. Lancet 1974; 1 :427-31. Adresa autora: Nikola Elakovic, Klinika za nuklearnu medicinu i onkologiju. Klinicka bolnica »Dr Mladen Stojanovi6«, Vinogradska cesta 29, 41000 Zagreb Radiol lugosl 1990; 24: 151-2. MEDICINSKI FAKULTET NOVI SAD INSTITUT ZA PATOLOŠKU FIZIOLOGIJU I LABORATORIJSKU DIJAGNOSTIKU -ODELENJE ZA NU­ KLEARNU MEDICINU KLINIKA ZA ENDOKRINOLOGIJU I METABOLIZAM SKELETNE PROMENE U POREMECAJIMA ŠTITATSTE ŽLEZDE SKELETAL CHANGES IN THYROID DISORDERS Babic Lj, Curie N, Segedi B, Elilas Lj Abstract -To investigate the pathogenesis of metabolic bone disease in thyroid disorders, we determined values of PTH, bone GLA-protein (ŠGP}, Ca, P, AP, hydroxyproline (Hy-p} along with morphofunctional (scintiqraphic) and morpholoqic studies (bone mineral content) in patients with different thyroid diseases. Our findings sugest that in hyperthyroidism increased bone resorption and bone formation exists due to high level of thyroid hormones. lncreased bone turnover was evaluated with whole body scintigraphic study. Bone mineral content decreased in some of the hyperthyroid patients, in some it was unchanged compared with euthyroid, because of the new balance between resorption and bone formation at the »higher« level. UDC: 616.441-06:616.71-007.15 Key words: thyroid diseases, bone diseases, metabolic Orig sci paper Radiol lugosl 1990; 24: 153-7. Uvod -U održavanju homeostaze kosti sem tri osnovna kalcitropna hormona (PTH, O hormon i kalcitonin) ucestvuju i brojni drugi sistemski hormoni i lokalni cinioci rasla cije medusobno sadejstvo rezultuje krajnjim efektom na metaboli­zam kosti (1, 2, 3). lako su efekti tireoidnih hormona na metabolizam kosti uoceni klinicki i laboratorijski vec duži period vremena, tacan mehanizam delovanja nije još uvek u potpunosti razjašnjen; ostvaruju li oni svoj uticaj direktno ili posredstvom PTH koji je glavni regulatorni cinilac homeostaze kosti (4, 5, 6, 7, 8, 9). Savremene dijagnosticke procedure, metabolicke studije po­mocu radioaktivnog kalcijuma, izucavanje meta­bolizma kolagena, otkrivanje novih pokazatelja osteoblastne aktivnosti (1 O, 11, 12, 13, 14) verifi­kacija distribucije kostne lezije scintigrafijom ske­leta celog tela (15, 16, 17) i egzaktno odredivanje mineralne mase kosti (18, 19, 20) omogucile su i egzaktniju evalulaciju promena metabolizma kosti u razlicitim poremecajima. Cilj rada je da se istovremenim pracenjem hormonskih, biohemijskih pokazatelja metaboli­zma kosti i morfofunkcijskim i morfološkim ispiti­vanjima skeleta u razlicitim poremecajima šiita­ste šlezde utvrdi mehanizam delovanja tireoidnih hormona na metabolizam kosti, medusobne od­nose tireoidnih hormona i PTH, te patofiziološka zbivanja na nivou kosti. Materija! i metode -Obradena je grupa od 59 bolesnika sa razliciti poremecajima štitaste žle­zde. Svi bolesnici su detaljno klinicki i laboratorij­ski obradeni; odredivane su vrednosti tireoidnih hormona T 3 T 4 i tirotropina (TSH IRMA) u bazal­nim uslovima ili u toku RTH testa. Od pokazatelja relevantnih za metabolizam kosti pracene su vrednosti parathormona (PTH), osteokalcina (BGP), kalcija (Ca), fosforja (P), alkalna fosfataza (AP), hidroksiprolina (Hy-p). Vrednosti hormona odredivane su radioimunološkim postupkom pri­menom gotovih pribora firmi »INEP« (T 3, T 4), »Hoechst« (PTH, TSH IRMA), »CIS« (osteokal­cin). Biohemijski pokazatelji odredivani su stan­dardnim biohemijskim procedurama. Scintigrafija skeleta celog tela radena je na gama kameri uz primenu racunara POP 11, 2 h nakon davanja »Teceos« 99 Te. Na ciljanim snimcima lumbalne kicme, karlice, butnih kostiju u odgovarajucim regijama od interesa izracuna­ van je odnos aktiviteta kost/meko tkivo. Regije od interesa (ROi) postavljane su: u lumbalnoj kicmi od L2-L4, za osnovnu aktivnost paralum- Received: February 20, 1990 -Accepted: March 9, 1990 Babic Lj. et al. Skeletne pramene u poremecajima štitaste žlezde balno levo da se izbegnu bubrezi, za sakroili­jacne zglobove u PA poziciji uz isti bekgraund (BG) kao za kicmu, za zglobove kuka u AP poziciji, a ROi za BG lateralno levo i desno uz zglobove, za butne kosti ROi je uziman u donjoj trecini butnih kostiju, a BG unutrašnja strana donje trecine butine obostrano. Mineralni denzitet lumbalne kicme (BMD) odre­divan je dvostrukom fotonskem apsorpciometri­jom primenom aparata BMC Lab 23 (SCAN DETECRONIC) i izražavan kao srednja vrednost od L2, L3 i L4 kicmena pršljena. Statisticka obrada podataka ukljucila je izracu­navanje srednjih vrednosti i SD merenih pokaza­telja. Znacajnost razlika srednjih vrednosti izracu­navana je primenom Student-ovog t testa za nejednak i neparan broj uzoraka. Rezultati rada -Rezultati rada prikazani su na tabelama 1, 2 i 3 i slici br. 1. Utvrdena je znacajna razlika vrednosti PTH izmedu hiper u odnosu na eu-i hipotireoidne bolesnike (p < 0,05). Vrednosti specificnog pokazatelja osteo­blastne aktivnosti, BGP bile su znacajno više u hipertireoidnih osoba u odnosu na eu-i hipoti­reoidne (sve p < 0,01 ), a znacajna razlika posto­jala je u vrednosti ovog pokazatelja u hipotireoid­nih u odnosu na eu-i lecene hipotireoidne bole­snike (U < 0,05). Znacajne razlike u vrednostima alkalne fosfataze nadene izmedu eu-hiper i hipo­tireoidnih osoba (p< 0,01 i < o ·-µ C C 2 -! m o a. > o µ o . z Leta po operaciji Years after qperation Slika 2 -Preživetje bolnikov z malignomi obnosnih votlin primarno operiranih v obdobju 1976 -1985 Fig. 2 -Survival of patients with malignant tumors of the paranasal sinuses primarily treated by surgery in the period 1976 -1985 Rezultati -Od 18 operiranih bolnikov jih je 1 O preživelo brez bolezni najmanj 4 leta po zakljuce­nem zdravljenju, 8 pa jih je umrlo v prvih dveh letih (slika 2). Med preživelimi je bilo 6 od 9 z etmoidalnim malignomom in 4 od 9 z maksilarnim maligomom, torej so bili uspehi zdravljenja pri malignomih etmoida boljšti kot pri tumojrih, ki so izvirali iz maksilarnega sinusa. Od 8 bolnikov, ki jih nismo uspeli ozdraviti, šo 4 umrli zaradi lokalnega recidiva, 2 zaradi odddaljenih metastaz v pljucih in«ali kosteh, eden zaradi podrocnih metastaz, en pacient z obsežnim tumorjem et­ Radio11ugos11990; 24: 167-70. 2:argi M. et al. Operativno zdravljenje raka obnosnih votlin na univerzitetni kliniki za otorinolaringologijo in cervikofacialno kirurgijo v Ljubljani v obdobju 1976-1985 moida pa je umrl deseti dan po operaciji zaradi intrakranialnih zapletov. Tudi radikalnost operativnega posega je bi­stveno vplivala na rezultate zdravljenja. V skupini bolnikov, kjer smo ocenili, da operacija ni bila radikalna, oziroma je bila radikalnost vprašljiva, so bili ozdravljeni le trije od desetih. Nasprotno pa je v skupini radikalno operiranih bolnikov preživelo vec kot 4 leta kar sedem od osmih bolnikov (tabela 2). ter histološke slike, kjer je pri naših bolnikih prevladoval slabo diferenciran oziroma visoko maligen tumor s praviloma difuzno rašco, je razumljivo, da smo na izhodišcno mesto pri nacrtovanju kirurškega zdravljenja postavili mak­silektomijo. Kljub napredku preoperativne diag­nostike -predvsem dolocanja razširjenosti tu­morja, ki ga je prineslka racunalniška tomografija, je bil intraoperativni izvid in dolocanje razsežnosti tumorske rašce s histološko preiskavo ex tem- Tabela 2 -Vpliv radikalnosti operacij na izid zdravljenja bolnikov z malignomi obnosnih votlin primarno operiranih v obdobju 1976 -1985 Table 2 -Influence of radicality of surgical procedures on cure rates in patients with malignant tumors of the paranasal sinuses primarily treated by surgery in the period 1976 -1985 število Lokalizacija število Obseg število bolnikov bolnikov bolnikov No of Site No of Extent No of patients patients patients Operacija neradikalna Operation non radical Preživeli 4 leta Surviving 4 years Operacija radikalna Operation radical Preživeli 4 leta Surviving 4 years maksilarni sinus maxillary sinus 10 < etmoidni sinus 3 ethmoid sinus maksilarni sinus maxillary sinus : etmoidni sinus ethmoid sinus < Razprava -Pri izbiri zdravljenja karcinoma obnosnih votlin je v zadnjih treh desetletjih pre­vla.al kombiniran pristop, to je kirurški z radiote­rapijo, saj zgolj en sam nacin zdravljenja nudi le zelo skromno petletno preživetje, v povprecju do 20% (3). Vloga kemoterapije v sklopu kombinira­nega zdravljenja še ni opredeljena. Zaenkrat lahko recemo, da naj bi bila uporaba kemotera­pije omejena na prospektivne študije pri bolnikih z napredovalimi tumorji (4). Operacija je torej na prvem mestu v sklopu zdravljenja malignomov obnosnih votlin (izjema so limfami). Zaradi veci­noma visokega stadija bolezni ob casu diagnoze 7 T4No 3 širjenje v orbito extension to the orbita širjenje v sfenoidni sinus 2 in/ali intrakranialno extension to the sphenoid sinus and/or intracranially 2 T2No, T1N2b 6 omejen na etmoid limited to the ethmoid širjenje v maksilarni sinus 3 in/ali v nos extension to the maxillary sinus and/or nasal cavity širjenje v orbito 2 extension to the orbit pore še vedno tisto, kar je odlocalo o koncnem obsegu operacije. Za parcialno maksilektomijo vecjega ali manjšega obsega smo se naceloma odlocali, ko je bil tumor omejen na infra in mezostrukturo, oziroma ni segal iznad Ohngre­nove crte (5). Pri karcinomih etmoida in razširje­nih karcinomih etmoidomaksilarnega masiva se bomo morali v bodece vsekakor pogosteje kot doslej odlocati za kombiniran kraniofacialni pri­stop. Najpomembnejša pri odlocanju za tovrstno ekstezivno kirurgijo pa mora vseeno ostati celo­vita presoja razširjenosti in narave tumorja, pri cemer moramo poleg perioperativnega tveganja Radiol lugosl 1990; 24: 167-70. 2argi M. et al. Operativno zdravljenje raka obnosnih votlin na univerzitetni kliniki za otorinolaringologijo in cervikofacialno kirurgijo v Ljubljani v obdobju 1976-1985 in prognoze bolezni upoštevati tudi vse more­bitne za polnika nesprejemljive. posledice take operacije. še posebej je treba poudariti kljucno tocko, kjer smo nekajkrat bolj ali manj zavestno odstopili od radikalnosti operacije, to je socasna izpraznitev oribre. Temu vsekakor ni bil vzrok kirurško-tehnicni problem, temvec še vedno mocno deljena mnenja o indikaicjah za eksente­racijo, predvsem v mejnih primerih, ko tumorska rašca prodre zgolj do periosta orbite ali v njega (6, 7). Pogostnost zasevanja karcinoma obnosnih vo­tlin v podrocne bezgavke je v povprecju do 25% (8), zato smo se pri naših bolnikih odlocali za kurativne disekcije, ne pa za elektivne -v N0 stadiju, saj je den izmed pomembnih dodatnih razlogov za pooperativno obsevanje tudi elek­tivna radioterapija kirurško nedostopnega retrofa­ringalnega bezgavcnega podrocja. Pri vrednotenju rezultatov je bilo zaradi sora­zmerno majhnega števila operiranih bolnikov težko ocenjevati dejavnike, ki so vplivali na izid zidravljenja. To velja tako za histomorfologijo kot tudi za razširjenost tumorja, ceprav se boljše preživetje bolnikov z malignomi v podrocju et­moida v primerjavi s tistimi v maksilarnem sinusu ujema z dejstvom, da je bilo v skupini bolnikov z rakom v etmoidu vec takih z nižjim stadijem bolezni kot pri bolnikih z malignomi v maksilar­nem sinusu. Radikalnost operativnega posega pri zdravlje­ nju malignomov obnosnih votlin je izredno po­ membna (9), kar kažejo tudi naši rezultati. Zaradi redkosti malignomov obnosnih votlin, njihove napredovalosti v casu diagnoze, celovito­ sti diagnosticnega postopka, doslednejšega uva­ janja kombiniranih pristopov (kraniofacialne kiru­ gije), cimprejšnje in dokoncne ne samo prote­ ticne rehabilitacije ter ciljane pooperativne radio­ terapije (ki je možna le ob tesnem sodelovanju med kirurgom in radioterapevtom) bi bila v Slove­ niji smislena in potrebna diagnosticna in terapevt­ ska obravnava teh bolnikov na enem mestu, torej koncentracija teh bolnikov. Le na ta nacin bi lahko cez cas prav ocenili lastne izkušnje na temelju sodobnega kirurškega zdravljenja in, kar je seveda najbolj pomembno, tudi izboljšali zdravljenja. Povzetek Na Univerzitetni otorinolaringološki kliniki v Ljubljani smo od 1976. do vkljucno 1985. leta obravnavali 34 bolnikov z malignomi obnosnih votlin, vecinoma v napredovalem štadiju bolezni. Od 34 bolnikov smo se pri 18 odlocili za operativno zdravljenje, ki mu je v vseh primerih sledilo obsevanje. Ostalih 16 bolnikov je bilo zdravljenih le z obsevanjem. Od 18 operiranih bolnikov jih je 10 preživelo brez bolezni najmanj 4 leta po zakljucenem zdralvjenju (55%), pri cemer je bila radi­kalnost kiruškega posega v pozitivni zvezi z izidom zdravljenja. Literatura 1. American Cancer Society analytical bulletin. New York: The American Cancer Society, 1985: 3-6. 2. Thiel HJ, Rettinger G. Der heutige Stand in der Erkrennung und behandlung maligner Nasen -und Nasennebenhohlen-Tumoren. HNO 1986; 34:91-5. 3. Me Nicoll W, Hopkin N, Dalley VM, Shaw HJ. Cancer of the paranasal sinuses and nasal cavities. Part II. Results of treatment. J Laryngol Otol 1984; 98:707-18 . 4. Auersperg M. lntraarterijska infuzijska kemotera­pija (IAC) tumorjev glave in vratu. Intervencijska radio­logija v onkologiji. Ljubljana: Univerzitetni inštitut za rentgenologijo, 1989; 32-4. 5. Ohngren LG. Malignant tumors of the maxillo­ethmoidal region: a clinical study with special reference to tho treatment with electro-surgery and irradiation. Acta Otolaryngol 1933; 1 :476-89. 6. Pearson BW. Surgical therapy of the nasal cavity and paranasal sinuses. In: Thawley SE, Panje WR. Comprehensive management of head and neck tu­mors. Philadelph.i,a, London: WB Saunders, 1987; 353­ . 67. 7. Rice DH, Stanley BR. Surgical therapy of nasal cavity, ethmoid sinus, and maxillary sinus tumors. In: Thawley SE, Panja WR. Comprehensive management of head and neck tumors. Philadelphia, London: WB Saunders, 1987; 368-89. 8. Pezner RD, Moss WT, Tong D, et al. Cervical lymph node metastases in patients with squamous celi carcinoma of the maxillary antrum: Tile role of elective irradiation of the clinically negative neck. lnt J Radiat Oncol Biol Phys 1979; 5:1977-86. 9. Ketcham AS, Van Buren JM. Tumors of the paranasal sinuses; a therapeutic challenge. Am J Surg 1985; 150:406-13. Naslov avtorja: Doc. dr. Miha 2argi, dr. med., Univer­zitetna klinika za otorinolaringologijo in cervikofacialno kirurgijo, Zaloška 2, 61105 Ljubljana Radiol lugosl 1990; 24: 167-70. THE INSTITUTE OF ONCOLOGY, LJUBLJANA TRIPLE CARCINOMA IN A PATIENT WITH PRIMARY BREAST CANCER Cufer T, Cerar O Abstract -The case of a patient with triple malignoma is reported. On surgery for primary breast carcinoma the pathohistologic examination of the removed axillary lymph nodes revealed the presence of non-Hodgkin lymphoma of low-grade malignancy. Further clinical, laboratory and diagnostic investigations confirmed that, apart from breast cancer, the patient also had a non-Hodgkin lymphoma of KLL type, stage IV A. Two years later, an invasive transilional celi carcinoma of the pyelon of the right kidney was diagnosed as well. The incidence of multiple primary neoplasms in patients with primary breast cancer is discussed. UDC: 618.19-006.6-06 Key words: breast neoplasms, neoplasms multiple primary, lymphoma non-Hodgkin's, kidney neoplasms Case report Radiol lugosl 1990; 24: 171-4 introduction -It has been exactly a hundred years since Billroth in 1889 first described a patient with multilple primary neoplasms (MPN). In 1932, Warren and Gates first reported on a large number of such cases, and proved that cancer patients were at greater risk of developing a second or even a third neoplasm sometime in their life. The authors also set the criteria for MPN diagnosis which have later become gene­rally accepted: 1) each of the tumors must presen! a definite picture of malignancy; 2) each must be distinct; and 3) the probability that one was a metastatic lesion from the other must be excluded. In studying MPN, Moertel distinguis­hed multiple primary neoplasms according to the site of origin, i.e. those appearing multicentrically in one and the same organ, and others origina­ting in different organs (Table 1 ). He was convin­ced that the patients with a particular epithelial neoplasm are at much greater risk of developing a second or even third neplasm ih the same organ or tissue (multiple carcinomas of the aero­digestive and urogenital tracts). As to the appear­nce of MPN in different organs, Moertel was, however, sceptical about their presumably grea­ter incidence in cancer patients (1). In 1977; Schoenberg published his findings on the inci- Table 1 -Classification of Multiple Primary Malignant Neoplasms l. Multiple primary malignant neoplasms of multicentric origin A. The same tissue and organ B. A common contiguous tissue shared by different organs C. The same lissue in bilaterally paired organs II. Multiple primary malignant neoplasms of different tissues or organs III. Multiple primary malignant neoplasms of multicentric origin plus a lesion(s) of a different tissue or organ dence of MPN in Connecticut and Denmark (2) which inequivocally proved that cancer patients were at 31 % increased risk of developing anot­her primary malignoma in the same tissue, whe­reas their risk of developing a second primary malignoma in a different organ was increased by 23%., many studies on MPN in breast cancer patients publiched since the 60's have proved that breast cancer patients run higher risk of developing a second or even third primary malig­noma (3, 4, 5, 6, 7, 8), among these ovarian, uterine and colonic carcinomas are believed to be most frequent. Received: March 26, 1990 -Accepted: April 2, 1990 Cufer T, Cerar O: Tnple carcinoma in a patient with primary breast cancer Case report -A 71-year old housewi!e, who had been free of any major health problems so far, noted a lump in her left breast, which proved to be a breast carcinoma on cytology. Based on the clinical status as well as the findings of examinations tor evaluating the extent of disease (blood count and chemistry indlucing liver tests, chest X-ray and bone scintiscan) a breast cancer in clinical stage T 2N 0M0 was diagnosed. The patient underwent a modified radical mastecto­my. Pathologic examination of breast tissue re­vealed an invasive ductal carcinoma, G II. The axillary lymph nodes were not involved by carci­noma though all the examined lymph node speci­mens contained cells of non-Hodgkin lymphoma of KLL type. No adjuvant treatment tor breast cancer was indicated. Later on, some additional examinations tor staging of NHL were pertormed. Peripheral lymph nodes were not enlarged, and the remaining clinical findings were within normal limits. On CT ot the abdomen, however, enlarged lett iliacal lymph nodes were found. Further biopsy ot the bone marrow revealed the presence on NHL cells in the bone marrow. The findings ot peripheral blood examination were wihtin the limits ot normal values. A NHL ot KLL type, stage IV A was; diagnosed, which required no treat­ment. Twenty months later the patient presented with pain in the lett shoulder and the left upper extremity. Bone scintiscan revealed a pathologic uptake in the left humerus and the lumbar verte­brae. X-ray ot the affected region showed the presence of osteolitic metastases. No metasta­ses in the sott tissue or viseral organs could be established. Hormona! therapy with tamoxiten and irradiation ot the lett humerus were aplied. This treatment resulted in a partial regression of bone metastases. Three months later the patient presented with massive hematuria. Apart trom the enlarged iliac lymph nodes, the abdominal CT pertormed at that tirne revealed a tumor in the region ot the right kidney, which required nephroureterectomy with lymphadenectomy. On histopathologic examination, the renal tumor was found to be an intiltrative transitional celi carci­noma of the pyelon, G III, whereas the hilar and paraaortic lymph nodes contained NHL infiltrates of KLL type. An additional treatment tor this carcinoma was not indicated. During the tollo­wing two years the patient was receiving conti­nuous hormona! treatment and was subject to regular tollow up. The bone metastases were in remission, but enlarged neck and bilateral ingui­nal lymph nodes appeared. The tindings ot aspi­ration biopsy suggested a NHL-KLL type involve­ment ot the lymph nodes, which, however, did not seem to cause any difticulty to the patient; as the findings of blood examinations were all the tirne within the limits ot normal values, no treat­ment tor NHL was considered necessary. In December 1989, i. e. four years after the diagno­sis of primary brfeast cancer and NHL, 2 years from the appearance of carcinoma of the right renal pyelon, and 30 month after the confirmation of skeleta! metastases, the patient presented with clinically and radiologically evident progress of osteolitic skeletal metastases. CT of the abdo­men, pertormed to explain pain in the lumbar region, showed enlarged iliacal lymph nodes as well as a tumorous mass in the apical part ot the left kidney. Angiography of the lett kidney imaged an irregular vascularization of the apical part ot the left kidney, which was not of hypernephrotic type. Angiographic findings indicated a very high probability of a tumor of the left renal pyelon. Based on the investigations performed so far, in our patient with praven triple malignoma, the appearance of a tourth neoplasm has been suspected, which is most probably another malig­noma of multicentric origin in the uropoietic sy­ stem. Extirpation of the tumor and histologic veritication ot the process in the left kidney were not indicated because of the patients' advanced age and her poor general condition due to the progress ot bone metastases. Encouraged by the favorable effect ot first-line hormona! treat­ ment on skeletal metastases, we introduced a second-line hormona! therapy and palliative irra­ diation tor alleviation ot skeleta! pain as the only treatment. Discussion -Results ot the studies performed on a large number of breast cancer patients during the past tew years have contirmed that breast cancer patients are at an increased risk ot being affected by other neoplasms as well (6, 7, 8). The largest study carried out in Finland comprised 26 000 patients with breast cancer (Table 2). AII the results published so far unifor­mly confirm the exposure ot breast cancer pa­tients to an increased risk ot developing a new primary carcinoma in the contralateral breast (1, 2, 3, 6, 7, 8). As to the appearance of new malignomas in other organs, breast cancer pa­tients are believed to be more frequently attected by carcinoma ot the genital organs, i. e. ovarian, endometrial and cervical carcinomas (3, 4, 7, 8). The studies analysing the appearance of a se­condary malignoma of the genital organs accor­ding to the patient's age at breast cancer diagno­sis have pointed out that younger women, parti- Radiol lugosl 1990: 24: 171-174. Cufer T, Cerar O: Triple carcinoma in a patient with primary breast cancer Table 2 -Subsequent multiple primary malignant tu mors in patients with cancer of the breast (No = 26 617 females) in Finland in 1953-79 Cancer designation Observed SIR Site of first cancer: Breast Site or type of new cancer Any site (excluding breast) 720 1.17* Esophagus 16 0.78 Stomach 107 1.11 Colon 62 1.36* Rectum 33 0.97 Gallbladder, bile ducts 8 0.43* Lung 46 1.67* Cervix uteri 33 0.95 Corpus uteri 62 1.33* Ovary 64 1.73* Bladder 20 1.65* Thyroid gland 22 1.95* Leukemia 36 1.91 * P < 0.05 SIR= ratio of observed to expected number of cases cularly those less than 45 years of age at the tirne of breast cancer diagnosis, are at greater risk of developing a second malignoma in the ovary (6). A secondary malignoma of the uterus more often appears in women older than 60 years at the tirne of breast cancer diagnosis (6, 7). Many studies (7, 8) though not ali (6) give evidence of an increased risk of breast cancer patients for developing a second primary carci­noma in the colon. Some authors claim that in breast cancer patients the observed morbidity for other neoplasms such as carcinoma of the lung, bladder and thyroid as well as soft tissue sarco­mas exceed the expected numbers (7, 8) whe­reas the reports of other authors do not support this belief (6). The risk of developing a second primary neoplasm increases by observation years. The younger the patient at the tirne of breast cancer diagnosis is, the greater the risk she runs of developing a new primary carcinoma. The causes for the appearance of multiple pri­mary neoplasms in a person could be ascribed to environmental and genetic factors which are presumably responsible for the rise of multiple neoplasms of different origin. Thus a simulta­neous appearance of breast carcinoma and en­dometrial carcinoma could be ascribed to exces­sive body weight in these patients as well as to their typical hormona! milieu (9). Familial and hereditary factors are believed to be responsible tor a simultaneous rise of breast cancer and ovarian carcinoma, particularly in young patients. As to the frequently reported simultaneous ap­pearance of breast carcinoma and colonic carci­noma, severa! authors ascribe this phenomenon to particular nutritional habits, as well as to the high socio-economic status of these patients (1 O). Considering the differing results and opinions of severa! prominent authors, it is stili questiona­ble whether the observed number of other pri­mary neoplasms in breast cancer patients is actually greater than expected, or it is just a consequence of a more accurate medica! follow up of these patients, as it has been presumed by Moertel (1 ). Also in our patient the second malig­noma (NHL of KLL type) was diagnosed on the pathohistologic examination of the lymph nodes removed on surgery for breast cancer. More effective treatment methods result in a prolonged overall survival of cancer patients, and so also of breast cancer patients, which on the other hand represents a greater possibility of appearance and detection of a second or even third neoplasm some tirne in their life. According to the results of recent studies (6, 7, 8) it can be concluded that at least certain age groups of breast cancer patients are undoubtedly exposed to a greater risk of being affected by particular malignomas. Thus, women with breast cancer have 3-4 times greater possibility of developing another carci­noma in the contralateral breast. Younger breast cancer patients are more frequently affected by ovarian carcinoma, whereas women having breast cancer detected in their older age are more likely to develop endometrial carcinoma. The mentioned correlations are, at presently known facts, the only ones that could justify preventive diagnostic examinations performed in search of a second malignoma. AII other possible correlations between breast carcinoma and other neoplasms have not been supported by inconte­stable and convincing enough evidence so as to allow tor any preventive diagnostic measures to be taken in this respect. It is of essential impor­tance, however, that the possibility of a new primary malignoma in breast cancer patients is taken into account, and any possible appearance of new tumorous masses is not automatically regarded as a metastatic spread from breast cancer. Particular attention is required with soli­tary tumorous lesions in the organs that do not represent a common site of breast cancer meta­static involvement. In such cases histologic veri­fication of the lesions is recommended in indivi­dual cases the relevant findings can esentially influence the treatment and prognosis of these patients. Apart from severa! epidemiologic stu- Radio! lugosl 1990: 24: 171-4. Cuter T, Cerar O': Triple carcinoma in a patient with primary breast cancer dies which prove and confirm an increased risk of MPN in breast cancer patients, the available literature stili lacks dala on the influence of a second or even third primary malignoma on the treatment and survival of these patients. Conclusion -In comparison with other wo­men, breast cancer patients are at greater risk of acquiring new primary malignomas some tirne in their lite. In breast cancer patients, the incidence of another primary carcinoma in the contralateral breast is five limes greater Ihan in other women. These patients are also more frequently affected by ovarian and endometrial carcinomas. Opinion on other cancer types that are presumed to appear more frequently in breast cancer patients are stili differing. It is important, however, that the possibility of second malignoma in breast cancer is taken into account. The appearance of a new tumorous mass must not invariably be interpreted as a metastasis from the primary malignoma. Histologic verification of the tumorous mass can significantly influence the course of treatment and patient's prognosis. Povzetek TROJNI KARCINOM PRI BOLNICI S PRIMARNIM KARCINOMOM DOJKE V clanku porocava o bolnici s trojnim malignomom. Ob operaciji primarnega karcinoma dojke je bil s patohistološkim pregledom pazdušnih bezgavk odstra­njenih ob operaciji karcinoma dojke ugotovljen ne-Hod­gkinov limfam nizke malignostne stopnje v le teh. Nadaljnje klinicne, laboratorijske in diagnosticne prei­skave so pokazale, da ima bolnica poleg karcinoma dojke še ne-Hodgkinov limfam tipa KLL stadij IVA. Dve leti kasneje je bil pri banici ugotovljen invazivni tranzi­ciocelularni karcilnom pielona desne ledvice. V diskusiji razpravljava o pojavnosti (incidenci) multiplih primarnih neoplazem pri primarnem karcinomu dojke. References 1. Moertel CG. Multilple primary neoplasma. Histori­cal perspectives. Cancer 1977; 40:1786-1792. 2. Boice JO, Curtis RE, Kleinerman RA, Flannery JT, Fraumeni JF. Surnmary of multiple primary cancer in Connecticut and Denmark. NCI Monogr 1985; 68:219-292. 3. Schoenbe,g BS, Greenberg RA, Eisenberg H. Occurence of certain multiple primary cancers in tema­les. J Natl. Cancer lnst 1969; 43: 15-32. 4. Schottenfeld D, Berg J. lncidence of multiple primary cancers. Cancer ot the temale breast and genital organs. J Natl Cancer lnst 1971; 46:161-170. 5. Weis NS, Daling JR, Chow W H. lncidence of cancer ot large bowel in women in relation to reproduc­tive and hormona! tactors. J Natl Cancer lnst 1981 ; 67:57-60. 6. Adami HO, Bergkvist L, Krusemo U, Fersson l. Breast cancer as a risk tactor tor other primary malig­nant diseases. A nationwide cohort study. J Natl cancer lnst 1984; 73:1049-1055. 7. Teppo L, Pukkala E, Saxen E. Multiple primary cancer -an epidemiologic exercise in Finland. J Natl Cancer lnst 1985; 75:207-217. 8. Schwartz AG, Ragheb NE, Swanson GM, Sata­riano WA. Racial and age differences in multiple pri­mary cancer after breast cancer: A population based analysis. Breast Cancer Res Treat 1989; 14:245-254. 9. MacMahon B. Risk factors tor endornetrial cancer. Gynecol Oncol 1974; 2:122-129. 10. Weiss NS, Daling JR, Chaw WH. lncidence ot cancer ot the large bowel in women in relation to reproductive and hormona! tactors. J Natl Cancer lnst 1981; 67:57-60. Acknowledgement -The authors thank Dr. Janez Lamovec tor the revision ot histologic material Author's Address: Tanja Cuter, MD, The Institute ot Oncology, Zaloška 2, 61105 Ljubljana, Yugoslavia Radiol lugosl 1990: 24: 171-4. ONKOLOŠKI INŠTITUT, LJUBLJANA OBSEVALNO ZDRAVLJENJE BOLNIC Z RAKOM DOJKE Z IMPLANTACIJO Pt -1921r Pt-192 1r IRRADIATION THERAPY FOR BREAST CANCER USING Pt-1921r WIRE NET IMPLANTS Kuhelj J Abstract -The technique of radiotherapy with Pt-lr implants in breast cancer patients is described. Pt-lr alloy (lr192) wire with the diameter of 0.2 mm was activated in the nuclear reactor in Podgorica, inserted in plastic tubes and afterwards loaded into 15 cm long needles. These were pierced into the tumor site through two parallel perforated plates with geometrically regular hale distribution. Such implantation technique ensures an optimal dispersion of activity in the tumor. lsodose distribution is calcullated and graphically presented using a special computer program. The treatment was assessed as favourable. In 7-24 month period, neither a local recurrence nor marked esthetic sequellae or metastases could be observed in an of the 5 implanted patients. The method is associated with the following problems: 1) clinical localization of the tumor site in an anatomically alterated breast pressed between two parallel plates, and 2) radiation exposure of the staff during preparation of applicators, manual afterloading and patients care. UDC: 618.19:615.849.5 Key words: breast neoplasms-radiotherapy, brachytherapy, platinum, iridium radioisotopes Orig sci paper Radiol lugosl 1990; 24: 175-7 Uvod -Zdravljenje bolnic z rakom dojke z implantacijo radijskih igel je opisal že Finci (1 ). Na Onkološkem inštitutu v Ljubljani je tak nacin zdravljenja uporabljal obcasno Šavnik. Er­javec je uvedel v implantacijo tumorjev dojke zlata zrna ter trajne in zacasne iridijeve implanta­te. Podobne metode je uporabljal tudi Fras (2, 3, 4). O tehniki implantacije raka dojke s pomocjo posebnih plošc za vodila sta porocala Benulic in Zwitter 1980 (5). Uporaba elektronov v teleterapiji raka dojke in zanemarljivo število radikalno obsevanih bolnic je pri nas zanimanje za implantacijo raka dojk mocno zmanjšalo. Ker pa so se pojavila v litera­turi porocila o dobrih uspehih implantacije dojk, tako pri radikalnem obsevanju kot pri postopera­tivnem obsevanju (6, 7, 8, 9, 10), smo tudil pri nas priceli leta 1987 ponovno z implantacijami tumorjev dojk. V clanku želimo opisati našo tehniko in metodo implantacije ter prikazati zgodnje rezultate zdrav­ljenja tumorja dojk z implantacijo in komplikacije takega zdravljenja. Material in metode -Leta 1987 do 1989 smo zdravili z implantacijo lr žic v tumor s posebnim apliktorjem pet bolnic z rakom dojke (tabela 1 ). Pri eni bolnici smo zdravili recidivo, eno bolnico smo obsevali po tumorektomiji in odstranitvi paz­dušnih bezgavk, pri ostalih pa je bila implanta­cija v sklopu radikalnega obsevalnega zdravljen­ja raka dojke. Tumor je bil pri vseh bolnicah citološko ali histološko potrjen. Pri eni bolnici je bil stadij pT1N1b, pri eni T4bNo, pri dveh T4b,N1b, pri eni bolnici pa je bil stadij T4dNlb · Vse bolnice so bile pred implantacijo tudi perkutano obsevane. Srednja tumorska doza je bila 58 Gy. Pri implantaciji smo uporabljali Pt-lr žice (192 1r. Žice smo kupili pri podjetju Johnson-Matthey, nato smo jih v reaktorju Podgorica aktivirali. Specificna aktivnost žic, primernih za implantaci­jo, je znašala 37 MBq/cm -74 MBq/cm (1 do 2 mCi/cm) žice. Žica je bila debeline 0,2 mm. Aktivno žico smo pred uporabo vstavili v pla­sticno cevko z notranjim premerom 0,5 mm, zunanji premer je znašal 0,9 mm. Kot vodila za tako pripravljene Pt-lr žice smo uporabili kovin­ske igle, dolžine 15 cm, ki so bile na enem koncu stožcasto zašiljene in zaprte, na drugi strani pa so imele odprtino, premera 1,2 mm. Zunanji premer uporabljenilh igel je znašal 1,6 mm. Reccived: March 20, 1990-Accepted: March 27, 1990 Kuhelj J: Obsevalno zdravljenje bolnic z rakom dojke z implantacijo Pt-1921r žic v mreži Tabela 1 -bolnice z rakom dojke, zdravljene tudi z implantacijo Pt-lr žice ( 1 921r) v mreži Table 1 -Breast cancer patients treated with Pt-lr ( 192 1r) wire net implants Stadij Starost Citl./ali histol. Perkutano cas opazov. Oddaljene Stage (leta) verifikacija obsevanje po zacetku metastaze Age Cytol.or/histol. TD(Gy) Implantacija RT (mesec) Distant (yrs) verification Percutane. lmplantation (Follow up metastases tumor bezgavke irrad TD MD ChT HT since RT start Lokalno tumour lymphnodes TD(Gy) (mos) Local p T1N1b T4bNo + + 50 15.2 26.8 CMF - 21 CR + - 64 21.9 45.6 - 10 CR T4bNlb 80 + 48 28 40 Nolvadex 24 CR T4bN1b 55 susp. 42+20 33.6 43 CMF Nolvadex 16 CR T4dN1b 48 + 56+ 10 20 CMF - 7 CR Legenda -Legend: RT -radioterapija radiotherapy Cht -kemoterapija chemotherapy HT -hormonska terapija hormona! therapy TD -tumorska doza tumor dose MD -maksimalna doza maximum dose CMF-ciklofosfamid / cyclophosphamide metotrexat / methotrexate 5-FU CR -popolna remisija complete remission Vodili za igle pa sta bili dve vzporedni perforirani plasticni plošci. Vsaka je imela debelino 1 cm in kvadratno razporejene luknjice -premera 2 mm -v medsebojni odddaljenosti 1 cm. Štiri posebna vodila v vogalih obeh plošc so omogocila vzpo­redno spreminjanje oddaljenosti plošc od O -15 cm, pri cemer smo jih lahko s pomocjo posebnih vijakov ucvrstili v vsaki poljubni oddaljenosti. En rob plošc je bil prilagojen obliki torakalne stene in je bil rahlo konkaven. Pripravo je izdelal TIK Kobarid v sodelovanju s strokovnjaki Onkolo­škega inštituta (slika 1 ). Implantacija je potekala v splošni anesteziji. Med vzporedni plasticni plošci smo zajeli tkivo dojke, v kateri je bil karcinom. Nato smo plošci približali drugo drugi tako, da je bila dojka znotraj plošc stisnjena samo toliko, da se je razmak med plošcami s tkivom dojke enakomerno izpolnil. Tako stisnjeni plošci smo pricvrstili s posebnimi elasticnimi trakovi na torakalno steno, nato pa dolocili podrocje tumorja znotraj dojke, pri cemer smo si pomagali z mamografijo, po potrebi pa smo uporabili tudi radioopacne igle, ki smo jih vnesli v sam tumor. Ko smo imeli prikazano podrocje tumorja, smo priceli! ubadati prej opi­sane igle, ki so predstavljale nosilce za radioak­tivne izvore. Dojko smo stisnili v sagitalni smeri. Igle smo uvajali iz lateralne v medialno smer. Razporedili smo jih tako, da smo pokrili celotno tumorsko podrocje, pri cemer sta vzporedno ležeci plošci z vzporednimi perforacijami omogo­cali tocno razvrstitev igel v 1 cm mreži skozi podrocje tumorja. Pravilni razpored igel znotraj tumorja smo preverili z mamograf.ko sliko. Po potrebi smo ponovno razvrstili ubodene igle. Ko smo se prepricali, da je tumor v celoti zajet v implantat, smo bolnico odpeljali v bolniško sobo, kjer smo naknadno napolnili igle z aktivnim mate­rialom (slika 2). Pred tem smo pripravili razvrsti­tev aktivnega materiala tako, da je bil aktivni del samo v predelu tumorja, ostali del aplikatorja pa je bil napolnjen z neaktivnim materialom, vlože­nim v plasticno cevko. Ta cevka je na enem Radiol lugosl 1990; 24: 175-9. Kuhelj J: Obsevalno zdravljenje bolnic z rakom dojke z implantacijo Pt-192l r žic v mreži Slika 2 -lmplantirana dojka Fig. 2 -lmplanted breast koncu primerno oblikovana za vtikanje v iglo, na drugem koncu pa je zataljena tako, da se lahko vnese v iglo samo na en nacin. Ko so bile vse igle napolnjene z aplikatorji, smo jih fiksirali s pomocjo posebne 0,5 cm debele plasticne ploš­ce, ki smo jo nataknili na štiri že omenjene vzporedne nosilce in z njimi pricvrstili igle in izvire v željeni položaj. Dozo smo definirali z izodozno krivuljo, ki je bila 0,5 cm oddaljena od roba implantata. To smo naredili s pomocjo posebnega racunalni­škega programa (slika 3). Presek, v katerem Izodoz• 0,5). The incidence of complications in patients with the treated volume over or under 16 cm3 did not vary. The frequency varied at the tumour volume 8 cm3. The implantation of tumour volume under 3 8 cm gave 12,5% sequelae, at larger tumour volumes the sequelae were 55,6%. The Chi­square test (with Yates correction), shows p > 0,05, which is also not statistically significant. Discussion -Although the analysis included irradiated patients with a high cumulative irradia­tion dose, we were astonished at the relatively high rate of complications (44%). It should be pointed out, though, that some authors, reporting Radiol lugosl 1990: 24: 181-6. Kovac V, Kuhelj J: Complications at interstitial radiotherapy of gynecological carcinoma low incidence of adverse irradiation side effects, counted as complication from treatment only those injuries where there was no trace of malig­nant lesion and the injury was of a severe character (1, 9). Others, reporting high incidence of complications, scored as a complication of treatment also milder injuries such as cystitis and proctitis -damages recorded by Ulmer and Frischbier {12) in the majority of irradiated pa­tients. Similar to the external beam irradiation of gynecological cancer, where subacute fibroses and complications of the urinary tract occurred as the most frequent post-irridation complications (2), the implantation gave the highest number of cistitis. Hydronephrosis is a frequent complication in gynecological oncology (13). However, only a single case of hydronephrosis as a consequence of the ureteral damage was recorded, since the implantations involved only the distal regions of the genitary tract. Rectal complications were substantially avoi­ded due to the measurement of rectal dose (4, 14). The recommended maximal cumulative rec­tal dose on the anterior surface of the rectum should not exceed 60 Gy. Accordingly, the rectal doses already delivered with the external beam and intracavitary irradiation should be considered in dosimetric measurements in imlantation. Mon­tana and Wesley report a significantly higher occurrence of proctitis in the group of patients with the mean rectal dose higher than 69 Gy, whereas the mean bladder dose for the group of patients with cystitis exceeded 66,6 Gy (15). We intentionally risked a higher cumulative measured rectal dose and calculated bladder in order to attain the cancericidal dose, this being the only possible therapy for the observed pa­tients. Nevertheless we concluded that 4 severe post-therapeutic complications (3 vesicovaginal fistulas, 1 rectovaginal fistula) were a conse­quence of the large tumour volume rather than of the exceeded tolerance dose. According to Flet­cher, at least 90% of fistulas are developed at the invasion of carcinoma into vagina, or due to the bulky tumour lesion, respectively (6). In our case, the incidence of complications was conditioned by the radiation dose at implan­tation and the tumour volume. However, this correlation was not statistically significant. This could be explailned (a) by the small number of patients, (b) by the strong relationship between rectal and bladder doses and the distance bet­ween the implant and both organs and (c) the fact that the sequelae of treatment observed on rectum and bladder also depend on the previous dose rate and previous surgical treatment. Manual application of the implants highly in­creased the exposure to irradiation of the profes­sional staff over that of the machine technique of after-loading the interstitial implant. Although the department staff at our institute is exposed to 5-20 times lower equivalent dose of the yearly recommended dose limit for professional staff, we wish to lower this dose to a minimum with the introduction of the after-loading technique. In our gynecological patients, the implantation is a rather rarely applied therapy. We have a smaller number of patients with residual tumour, a larger number with regional metastasis and the largest number witll local recurrence. We estimate that in the future the trend will be for the application of the implantation technique at the completion of radiation therapy. Similar assessments have been reached by other aut­hors as well (6, 7, 8, 9, 16, 17, 18). Povzetek KOMPLIKACIJE PO INTERSTICIALNI RADIOTERA­PIJI GINEKOLOŠKEGA KARCINOMA 36 bolnic z rakom na rodilih, stadij 1-IV, smo implan­tirali. 18 se jih je zdravilo zaradi raka vratu maternice, 5 zaradi endometricnega raka, 6 zaradi raka v nožnici in 7 zaradi raka na jajcnikih. Pred implantacijo so bile operirane in/ali perkutano obsevane, skoraj polovico od njih pa je prejelo tudi intrakavitarno radioterapijo. Obsevane so bile do tolerancne doze 70 Gy na tocko A. Indikacije za implantacijo so bile: lokalni recidiv (20), regionalne metastaze (15) in reziduum tumorja po primarnem zdravljenju (6). 5 bolnic je imelo dvojno indikacijo. Od 36 inplantacij smo naredili 16 z 198Au zrni in 20 z 192 1r žicami. Referencna doza pri takem obsevanju je bila od 26 do 120 G.; volumen inplantiranega podrocja pa od 3,9 do 70 cm Komplikacije smo ugotovili pri 44% bolnic. Bolj pogo­ste so bile blage in akutne, kot pa težje in kasne. Komplikacije so bile odvisne od višine tumorske doze in velikosti obsevanega volumna pri implantaciji, vendar povezava ni bila statisticno signifikantna, ampak se je le nakazovala. References 1. Comber PF, Daly NJ, Horiot JC et al. Results of radiotherapy alone in 581 patients with stage II carci­noma of the uterine cervix. In! J Radioat Oncol Biol Phys 1985; 11 :463-71. 2. Kuhelj J, Kavcic M, Habic M et al. Naši pogledi na lijecenje porcije vaginalis uteri. Radiol lugosl 1975; 9:291-4. Radiol lugosl 1990; 24: 181-6. Kovac V, Kuhelj J; Complications at interstitial radiotherapy of gynecological carcinoma 3. Grigsby PW, Kuske RR, Perez GA et al. Medically 13. Ulmer HU, Frischbier HJ. Treatment of advanced inoperable stage I adeno-carcinoma of the endome­cancer of the cervix uteri with external irradiation alone. trium treated with radiotherapy alone. lnt J Radia! lnt J Radia! Oncol Biol Phys 1983; 9:809-12. Oncol Biol Phys 1987; 13 :483-8. 14. Pourquier H, Dubois JB, Delard R. Cancer of the 4. Kuhelj J, Kavcic M. Frequency of subacute com­uterine cervix: dosimetric guidelines tor prevention of plications in the high dose radiation therapy of cancer late rectal and rectosigmoid complications as a result of the uterine cervix. Radiol lugosl 1974; 8:21-7. of radiotherapeutic treatment. lnt J Radia! Oncol Biol 5. O'Sullivan B, Sutcliffe SB. The toxicity of radiothe­Phys 1982; 8:1887-95. rapy. Ciin Oncol 1985; 4 :485-509. 15. Montana GS, Fowler WC. Carcinoma of the 6. Fletcher GH. Textbook of radiotherapy. 3. ed. cervix: analysis of bladder and rectal radiation dose Philadelphia: Lea & Fibeger, 1980. and complications. lnt J Radia! Oncol 19I89; 16 :95-100. 7. Prempree T, Scott RM. Treatment of stage III B 16. Syed AMN, Feder BH. Technique of after-loa­carcinoma of the cervix. Cancer 1978; 42 :1105-13. ding interstitial implants. Radio! Ciin 1977; 46 :458-75. 8. Prempree T. Parametrial implant in stage III B 16. Syed AMN, Feder BH. Technique of after-loa­cancer of the cervix. Cancer 1983; 52:748-50. dilng interstitial implants. Radiol Ciin 1977; 46 :458-75. 9. Gaddis O Jr, Morrow CP, Klement V, Schlaerth 17. Aristizabal SA, Woolfitt B, Valencia A et al. LB, Nalick RH. Treatment of cervical carcinoma em­lnterstitial parametrial implants in carcinoma of the ploying a template for transperineal interstitial lr 192 cervix stage II B. lnt J Radia! Oncol Biol Phys 1987; brachy-therapy. lnt J Radia! Oncol Biol Phys 1983; 13:445-50. 9:819-27. 18. Sewchand W, Prempree T, Patanaphan V et al. 1 O. Henschke UK, Cevc P. Dimension averaging a Radium needles implant in the treatment of extensive simple method for dosimetry of interstitial implants. vagina! involvment from cervical carcinoma. Acta Ra­Radiol Radiother 1968; 9 :287-98. diol Oncol 1984; 23:449-53. 11 . The Ellis nominal single dose concept. Ottawa: Acknowledgement -Our thanks to Assist. Prof. Dr. Atomic Energy of Canada Limited Commercial Pro­P. Cevc for carefully calculated tumour doses, tor ducts, 1973. taking care of radiation material and tor radiation protection. 12. Valente S, Onnis GL. Urologic complications and urodynamics in gynecological oncology. Eur J Author's address: Viljem Kovac, MD, The Institute of Gynaec oncol 1987; 7:174-6. Oncology, Zaloška 2, 61000 Ljubljana ,----------------------------­ RO INSTITUT ZA NUKLEARNE NAUKE »BORIS KIDRIC«, VINCA OOUR INSTITUT ZA RADIOIZOTOPE »RI« 11001 Beograd, p. p. 522 Telefon: (011)438-134 T elex: YU 11563 Telegram: VINCA INSTITUT ACTH-RIA Služi za odredivanje hipofunkcije adrenalnih žljezda (primarna i sekundarna) i hiperfunkcije adrenalnog korteksa (Conn-ov, Cushing-ov i adrenogenitalni sindrom). Uz našu redovnu proizvodnju i snabdevanje korisnika pribora za in vitro ispitivanja: T3-RIA T4-RIA lnsulin -RIA HR-RIA u 1988.godini pustili smo u redovan promet: CEA-RIA Pribor za odredivanje karcinoembrionalnog antigena (CEA) u serumu metodom radioimunološke analize. Radiol lugosl 1990: 24: 181-6. Byk Gulden Pharmazeutika Konstanz/SR Nemacka .r. RENTGENSKA KONTRASTNA SREDSTVA: HEXABRIX -kontrastno sredstvo niskog osmoaliteta, smanjene toksicnosti i gotovo bez­ bolan u primeni. INDIKACIJE: Sva arteriografska ispitivanja, zatim cerebralna angiografija, i flebografija, kao i selektivna koronarografija. PAKOVANJA: Hexabrix amp. (5 amp. X 10 ml) Hexabrix amp. (20 amp. X 20 ml) Hexabrix boc. (2 boc. X 50 ml) Hexabrix boc. (1 boc. X 100 ml) Hexabrix inf. (1 boc. X 200 ml bez pribora za infuziju) DIMER X ampule 5 X 5 ml -kontrast za lumbosakralnu mielografiju TELEBRIX -kontrast za urografije, angiografije, periferne i selektivne arteriografije. PAKOVANJA: Telebrix 300 amp. (20 amp. X 30 ml sa špricom) Telebrix 300 amp. (20 amp. X 30 ml bez šprica) Telebrix 380 amp. (20 amp. X 30 ml sa špricom) Telebrix 380 amp. (20 amp. X 30 ml bez šprica) Telebrix 380 za inf. (2 boc. X 50 ml) Telebrix 300 za inf. (2 boc. X 50 ml) Telebrix 30 za inf. (1 boca X 100 ml) Telebrix 45 za inf. (1 boca X 250 ml) i) FABEG BykGulden 8 lnostrana zastupstva Predstavništvo: Pharmazeutlka Beograd Kosovska 17M Zagreb, Savska cesta 41M Konstanz/SR Nemacka telefoni: 321-440 i 321-791 telefoni: 539-355 i 539-476 SREDIŠNJI INSTITUT ZA TUMORE I SLICNE BOLESTI, ZAGREB LABORATORIJ ZA EKSPERIMENTALNU KANCEROLOGIJU THE IMPORTANCE OF SELENIUM IN ONCOLOGY Huljev D Abstract -Selenium levels in tumorous and congeneric normal human tissues were analyzed by the NAA method. As shown by the results of the experiments, many tumorous tissues contain selenium to a significantly lower extent as compared with identical but normal tissues. The following tumorous to identical normal tissue selenium ratios (dry weight) were obtained in men: larynx 0.07/0.7; cerivcal lymph nodes 0.2/0.8; lung 0.16/0.8; eyelid 0.5/4.0 ug/g (ppm). It there is a selenium surplus or shortage in the body (tissue), either can be a possible cause or consequence of a malignant process. This is why the daily diet should contain a specific quantity of selenium which can approximately be eliminated. UDC: 616-006.6-074:546.23 Key words: neoplasms-analysis, selenium Orig sci paper Radiol lugosl 1990; 24: 187-9 lntroduction -The essential role of selenium in animal nutrition is well established. In humans it has been demonstrated that an endemic car­diomyopathy prevalent in certain areas of China is correlated with selenium deficiency. Selenium also has been claimed to prevent certain types of cancer (1, 2), to enhance immune responses, and to increase fertility in domestic animals. Specific incorporation of selenium in biologi­cally active macromolecules has provided some molecular basis for the nutritional role of sele­nium in mammals and bacteria. Of the eilght selenoenzymes that have been identified to date, seven are of bacterial origin. Glutathione peroxi­dase, which occurs in mammals and birds, has not been reported in prokaryotes. The chemical forms of selenium in the polypeptide chain of several of these enzymes is selenocysteine or, in two instances, selenomethionine. It is well known that NAA can be used to advantage in analyzing trace elements in oncolo­gical cases (3). As shown by many analyses, tumorous tissues contain a significantly higher level of selenium and other trace elements as compared with their normal counterparts (4). Our first specimens produced identical data (5). Some tumorigenic processes can also produce lower concentrations of selenium and other ele­ments in tumorous tissues (6). Studies have also shown that one should distinguish trace element data for women and men because of significant differences (7). lnterestingly enough, tumorous tissue age also affects its trace e.lement composi­tion (8). Experiments on mice have shown that some elements are excreted -during the tumori­genic process -from tumorous tissue into the blood and may be used as growth markers for the tumorigenic process in guestion (5, 9, 1 O). Very important studeis have resulted in the disco­very of isotopes used in detecting tumor microsi­tes (3). Selenium was selected for analysis, being a classic anticancerogenic element (11 ). It is found in an enzyme, glutathione peroxidase, which serves together with vitamin E as an antioxidative barrier in the celi (12, 123, 14, 15). Selenium supplemented diets reduce the inci­dence of cancer in variety of chemically induced experimental tumor systems (16). This study was focused on obtaining data on selenium levels in tumorous tissues and their comparison with results obtained in identical but normal tissues. The principal goal was the use of such data in tumor diagnosis and therapy. Reccived: January 31, 1990 -Accepted: March 30, 1990 Huljev D: The importance of selenium in oncology Material and Methods -Ali the specimens obtained from the clinicians at the institute were pathohistologically analyzed. The same proce­dure was applied to both tumorous and normal tissues. Quartz and polyethylene vessels were used in order to avoid specimen contamination. Selenium was determined by nondestructive NAA in order to prevent additional specimen contamination. The analysis was described in detail on an earlier occasion (3). Results -Table 1 lists only trace element data tor tissues of humans living in a single geographi­cal locality. This has been done in order to avoid the effects of the environment (soil, water and air) on trace element composition in the analyzed tissues. Only trace element data on tissues of persons of the same sex (men) have been comoared. Table 1 -Dala obtained by Se analysis (NAA) in tumorous and normal tissues of people coming from the same geographical locality (Zagreb region) are shown in ug/g (ppm) of dry weight Ratios Tissues tumorous normal p(t-test) tumorous normal Larynx (15+15 camples) 0.07 0.7 0.001 1 : 10 Cervical lymph nodes (20+20 samples) 0.2 0.8 0.001 1 : 4 Eyelid (20+20 samples) 0.5 4.0 0.001 1 : 8 Lung (5+5 samples) 0.16 0.8 0.001 1 : 5 Discussion -Trace element/cancer studies should answer two very important questions: do trace element imbalances cause cancer? Does the tumorigenic process produce differences in tumorous as compared to normal or entirely healthy tissue? We have tried to answer these questions by tests carried out on experimental, genetically identical mice (8). The results showed the following: although the mice infected with tumorous cells lived identically as the control animals, the trace element composition of the tissue in which the tumor grew changed. This shows that the tumorous tissue of infected mice suffered from an imbalance (shortage or surplus) of trace elements although trace element supply was the same tor bolh infected and noninfected animals. It may therefore be assumed that the tumorigenic process in the tissue of mice infected with tumorous cells causes an imbalance in trace element composition. Thus, the imbalance in breast tissue in women is probably due to the tumorigenic process, because of which tumorous tissue accumulates a number of elements as compared with identical, normal breast tissue (17). The excretion of some elements from tumo­rous cells into the blood stream is also due to tumorous celi growth. The excreted elements can serve as markers of tumorigenic process progression. Trace element analysis can be of help in detecting elements (isotopes) which spe­cifically accumulate in the tumorous tissue of a given organ. AII these experiments provide a small contribution to improving detection and localization of the tumorigenic process. Selenium can be considered as a marker of those tumori­genic processes which involve selenium elimina­tion from tissue. Radioactive selenium can be used, in the form of isotopes or chelates, in searching tor tumorigenic process microsites if they are characterized by selenium and selenium compound acumulation. Sažetak Analizirana je koncentracija selena u tumorskim i istovrsnim riormalnim tkivima u ljudi metodam neutron­ske aktivacijske analize (NAA). Rezultati eksperime­nata pokazuju da mnoga tumorska tkiva sadrže signifi­kantno manje selena nego identicna ali normalna tkiva. Za odnos selena u tumorskom prema identicnom nor­malnom tkivu (suha težina) u muškaraca, dobiveni su slijedeci podaci: larinks 0.07/0.7; limfni cvorovi vrata 0.2/0.8; tkivo pluca 0.16/0.8; vjeda oko 0.5/4.0 ug/g (ppm). Ako u organizmu (tkivu) ima višak ili manjak selena, oboje može biti jedan od mogucih uzroka ili posljedica malignog procesa. Zbog toga je važno, da dnevno putem hrane u organizam ude sasvim odre­dena kolicina selena, da bi približno ista mogla biti eliminirana. References 1. lp C. Prophylaxis of mammary neoplasia by sele­nium supplementation in the initiation and promotion phases of chemical carcinogen. Cancer Res 1981 ; 41 :4386-90. 2. lp C, Thompson HJ. New approaches of chemo­prevention with difluoromethylornithine and selenite. J Na! Cancer lnst 1989; 81 :839-43. 3. huljev D, Maricic L, Graf D. Determination of !race elements in oncology by neutron activation analysis. Libri oncol 1981; 10:387-93. 4. Mulay IL, Roy R, Knox BE, Suhr NH, Delaney WE. Trace-metal analysis of cancerous and noncance­rous human tissues. J Na! Cancer lnst 1971 ; 47 :2-11. 5. Huljev D, Metali-markeri tumorskog rasla. Radio! lugosl 1986; 20:177-80. 6. Huljev D, Graf D, Car D. Microelement in cance­rous and noncancerous human eyelid tissue. Radio! lugosl. 1988; 22:145-8. Radiol lugosl 1990; 24: 187-9. Huljev D: The importance of selenium in oncology 7. Graf D. Odredivanje mikroelemenata u biološkim uzorcima metodom neutronske aktivacijske analize. Magistarski rad, Sveucilište u Zagrebu, 1980. 8. Huljev D. Distribution of element in the spleen of mice during progressive syngeneic lymphoma. J Ra­dioanal Nucl Chem 1989; 237-40. 9. Maricic ž. Komparativna istraživanja oligoeleme­nata u tumorskim i normalnim limfnim žlijezdama glave i vrata. Doktorska disertacija, Sveucilište u Zagrebu, 1976. 1 O. Salonen JT, Alfthan G, Huttunen JK, Puska P. Association between serum selenium and the risk of cancer. Am J Epidemiol 1984; 120:342-9. 11. Willett WC, Stampfer MJ. Selenium and cancer Brit Med J 1988; 297 :573-81. 12. Griffin AC. Role of selenium in the chemopreven­tion of cancer. Adv Cancer res 1979; 29 :419-442. 13. Helzlso er KJ. Selenium and caner prevention. Semin Oncol 1983; 3:305-10. 14. Helzlsouer KJ, Comstock GW, Morris JS. Sele­nium, lycopene, alphatocopherol, beta-carotene, retinol and subsequent bladder. Cancer Res 1989; 49 :6144-8. 15. Knekt P, Aromaa A, Maatela J, Alfthan G, Aaran RK, Teppo L, Hakama M. Serum vitamin E, serum selenium and risk of gastrointestinal cancer. lnt J Cancer 1988; 42 :846-50. 16. lp C. Mammary cancer chemoprevention by inorganic and organic s·eIenium: single agent treatment or in combination with vitamin E and their effects on in vitro immune functions. Carcinogenesis 1987; 8:1763­6. 17. Huljev D, Graf D, Draškovic J, Rajkovic-Huljev Z. Comparison between concentration of !race ele­ments in tumorous and normal human breast tissue. Radiol lugosl 1989; 23:165-8. Adresa autora: Dr Damir Huljev, Središnji institut za tumore i slicne bolesti, llica 197, 41000 Zagreb Zahvala -Vrlo mi je drago da mogu zahvaliti prof. dr. Mirku Dikšicu iz UniverzTtetskog neurolo­škog Instituta u Montrealu na vrlo korisnim suge­stijama i primjedbama kod istraživanja mikroele­menata a narocite u biološkem materijalu po­mocu metode NAA. TOSAMA Proizvaja in nudi kvalitetne izdelke: Komprese vseh vrst Gazo sterilno in nesterilno Elasticne ovoje Virfix mrežo Micropore obliže Obliže vseh vrst Gypsona in mavcene ovoje Sanitetno vato PhJ III Zdravniške maske in kape Sanitetne torbice in omarice Avtomobilske apoteke Radiol lugosl 1990; 24: 187-9. THE INSTITUTE OF ONCOLOGY, LJUBLJANA1 UNIVERSITY GLINIC OF GYNECOLOGY, DEPARTMENT OF REPRODUCTION, LJUBLJANA2 THE INFLUENCE OF RADIOTHERAPY ON SPERMATOGENESIS IN PATIENTS WITH TEStlCULAR SEMINOMA IN RELATION TO PROTECTION FROM SCATTERED RADIATION Kovac V1 , Umek 8 1 , Marolt F 1 , Škrk J 1 , Reš P2, Kuhelj J 1 Abstract -In 40 patients with testicular seminoma that had been treated with unilateral orchiectomy and prophilactic irradiation of retroperitoneal lymph nodes, there was established the extent of impaired spermatoge­nesis and measured the gonadal dose during irradiation by means of TLD dosemeters. Before radiotherapy (RT) only 11 patients had adequate results ot semen analysis. After RT in most cases the quality of semen deteriorated. In patients, whose testes were shielded from scattered radiation, the impairment of semen after RT was smaller than in patients that were not shielded, yet the difference was not statistically significant because of the small number of the patients studied. A comparison ot the measured gonadal dose in 4 unprotected and 8 protected patients showed that by the use ot shielding the gonadal dose was lower for about two thirds. UDC: 616.681-006.2 :615.849.2.06 :612.616.2 Key words: testicular neoplasms, seminoma, radiotherapy-adverse effects, semen-analysis, spermatogenesis Orig sci paper Radiol lugosl 1990; 24: 191-4 lntroduction -Contemporary methods of treatment allow a longer disease-free survival or complete recovery for an increasing number of patients. Radiotherapy (RT) (in addition to che­motherapy and some surgical treatment) influen­ces the functions of many organic systems, which may result in an impaired quality of life after a successful treatment (1 ). Negative influence of ionizing radiation upon spermatogenesis in animals and humans has been reported by numerous authors (2, 3, 4). After irradiation there can be seen a decreased state of fertility, which is shown in an altered quality of ejaculate. The impairment depends on the applied dose, the manner of fractionation and upon the primary fertility of the patients (5, 6). • After RT has been completed, the function of te.:,tic: (a) completely recovers, (b) partially reco­v.eh,, or (c) patients remain sterile. The speed and the extent of recovery is influenced by the above factors, therefore it cannot easily be fore­seen. Hence semen cryopreservation before RT is of special importance (7, 8). In clinical practice there are also treated young patients (in reproductive age) with seminoma who want to have children after their recovery. Therefore we were interested in finding out to which extent and for how long RT impaired the spermatogenesis of the remaining testis with respect to the gonadal dose of scattered radiation (9). It was tried to improve the treatment by shiel­ding the testes from scattered radiation, which was evaluated by measuring the gonadal dose and performing the controlling of semen quality. Materials and methods -40 patients with an average age 30 years (from 18 to 48 years) were treated with unilateral orchiectomy and prophilac­tic irradiation of retroperitoneal lymph nodes. Ali patients had a histologically confirmed diagnosis of testicular seminoma. In the period 1981-1983 29 patients were treated without shielding the rerr.Jining testis from scattered radiation (Group /). In 14 of these patients semen analysis was performed before and after RT, whereas in 15 patients it was performed either before or after RT. The gonadal dose was measured in 4 patients. Later, in the years 1988-1989, a special lead shield was constructed to protect the testis from scattered radiation during treatment in supine position (Fig. 1 ). In prone position the testis was Received: March 29, 1990 -Accepted: April 5, 1990 Fig. 1 : Patient with contact gonadal shield during treatment with external beam irradiation stili unshielded. In this manner 11 patinets (Group II) were treated. In all patients the semen analysis before RT was made, whereas in 6 patients the semen analysis after RT was perfor­med as well. The gonadal dose was measured in 8 patients. The impairment of spermatogenesis in relation to the gonadal dose was statistically evaluated with Fisher's exact test and Chi-square test. Both groups of patients were treated with two opposite fields, with 8 MeV X-rays from linear accelerator MEL SL 75/20, the tumour dose being 3000 cGy (20x150 cGy, in four weeks). The dose was measured by TLD dosemeters (LiF rods) that were attachet to the patient's testis. The dosemeters were thermally treated and read out in a TLD reader Toledo 654 (D. A. Pitman lnst.) (1 O). Semen specimens were collected and analy­zed before and after RT at the University Glinic of Gynecology in Ljubljana according to conven­tional methods (11 ). When the patients had their sperm analysed severa! times, the spermato­gram showing the greatest impairment was taken into account except when the analyses were made in the course of the same month. lf the ejaculate before RT was adequate, se­men cryoconservation was performed for possi­ble artifical insemination. Thus, 11 patinets from Group I and 1 O patients from Group 11 gave sperm for cryoconservation at the University Glinic of Gynecology in Ljubljana. Results -The results of measuring the gona­dal dose in patients with shielded and unshielded testis are shown in Table 1. It is evident therefrom that by the use of shielding the gonadal dose Table 1 -Gonadal dose at the end of the treatment Number Median Range %of of dose (cGy) tumour patients (cGy) dose Group 1 unshielded testis 4 127 124-156 4.2 Group II shielded testis 8 45 26-120 1.5 Table 2 -Results of semen analyses before and after RT in patients without gonadal shield during treatment (Group /). Before After RT (in 0-38 months, median RT 10.5 months) OATII OATIII AZOO NECRO WSA NORMAL 7 2 3 OATI 6 2 3 OATII 4 1* 2 1 OATIII 5 2* 1 2 NECRO 2 1* 1 WSA s·· 2 3 TOTAL 29 2 6 10 1 10*** • No evidence of increased impairment •• Semen analysis was only made after RT, the fertility before RT was proven by the partner's pregnancy. ••• Semen analysis was made only before RT, patients declined further analysis or were lost from the follow-up NORMALnormal spermatogram OATI oligoastenoteratozoospermia grade 1 OATII oligoastenoteratozoospermia grade II OATIII oligoastenoteratozoospermia grade III AZOO azoospermia NECRO necrozoospermia WSA without semen analysis was decreased approximately by two thir'ds: The­reby there was achieved a gonadal dose of 1.5% of the applied tumour dose. A semen analysis was made before and after RT. The analysis results in unshielded and shiel­ded patients are shown in Tables 2 and 3. It is evident therefrom that the patients of Group II (with the shield) had lesser impairments of sper­matogenesis Ihan the patients of Group 1 (without the shield). In order to exactly compare the effect of diffe­rent doses upon spermatogenesis only patients with spermatograms before and after RT were considered, i. e. 14 patients from Group I and 6 patients from Group II (Table 4). In Group 1, i.e. Radiol lugosl 1990; 24.1--4. Kovac V. et al. The influence of radiotherapy on spermatogenesis those with unshielded testis, 1 O patients had worse results of spermatoanalysis after RT and 4 patients had equal results, whereas in Group II, where the special gonadal shield was used, this ratio was 2 :4. Because of the small sample we used Fisher's exact test, which shows p = 0.16, which means that the difference between the groups is not statistically significant though such conclusions are suggested. As we wanted to have a more representative sample, Group I was supplemented by 5 patients who had children before RT, i.e. who were primarily fertile though this fertility was not esta­blished by a previous spermatogram. Chi-square (with Yates correction) shows p = 0.11, which is not statistically significant either. Table 3 -Results of semen analyses before and after RT in patients with gonadal stiield during treatment (Group/1) Before After RT (in 0-12 months, RT median 4 months} NORMAL OAT II WSA NORMAL OZI ASZI ATZI OATII OATIII 4 1 1 1 3 1 1· 1 3• 3 TOTAL 11 1 5 5•• • No evidence of increased impairment. •• Semen analysis was made only before RT, patients have not been motivated tor further analysis. NORMAL normal spermatogram OZI oligozoospermia grade 1 ASZ I astenozoospermia grade 1 ATZ I astenoteratozoospermia grade 1 OAT II oligoastenoteratozoospermia grade II OA T 111 oligoastenoteratozoospermia grade 111 WSA without semen analysis Table 4 -Comparison of semen analysis results of patients of bolh groups after RT (patients lacking an analysis either before or after RT have been eliminated) Number of patients with increased without increased Total impairment impairment Group 1 unshielded testis 10 4 14 Group II shielded testis 2 4 6 Total 12 8 20 Discussion -It is evident from Table 1 that the range of the measured gonadal doses was very broad. This can be attributed mostly to the different distances between the testis and the edge of the treatment field, and also to the size of the treatment field. Our results are close to other results in the literature. Smithers et al achieved by their protec­tion that the gonadal dose amounted 1.5 to 2.5% of the nodal dose (12), Schlappack et al achieved 2.0% of the nodal dose (13), Fossa et al achie­ved 1 to 3% of the target dose (5) and Fraass et al reached the gonadal dose of less than 1 % of the dose aplied (14). The majority of seminoma patients already had impaired spermatogenesis before RT. This could be explained (a) by testicular histologic abnormalities that give rise to process of maligni­sation, (b) by surgical stress at orchiectomy, and (c) by anxiety about infertility and the success of the treatment. Our semen analyses and measurements of the gonadal dose confirm the finding that in patients with testicular seminoma scattered ra­diation additionaly impairs spermatogenesis (2, 3, 5, 15). By the contact shield of the testis during exposure to X-rays the gonadal dose was redu­ced from 4.2% to 1.5% of the applied tumour dose, which less impairs the spermatogenesis. A statistically more significant difference has been expected, the number of the patients, however, seems to have been too small for more significant results. A detailed analysis of Tables 2 and 3 shows that the impairments of spermatogenesis in Group I were not only more frequent but also more intensive. Most patients had spermatograms made seve­ral times after RT and it has been possible to establish the reversibility of the impairment in most cases. The exception were the patients who had severely impaired spermatogenesis even before RT. In spite of the reversibility of the impairment, the state after RT cannot be anticipated with certainty, which is due to the above-mentioned different states of spermatogenesis before RT and to different intensiveness of the repair mec­hanism. Since scattered radiation during RT can­not be completely avoided, semen cryoconserva­tion before the beginning of the treatment is stili indicated. It is the aim of our further research to achieve a higher degree of protection than we have reached so far. We also intend to follow up the Radiol lugosl 1990; 24: 191-4. Kovac V. et al. The influence of radiotherapy on spermatogenesis children of our patients that should be born after RT in order to establish any possible effects of scattered radiation upon the offspring and to be able to give advice to patients in the reproductive age. So far our results have been quite encoura­ging. Povzetek VPLIV RADIOTERAPIJE NA SPERMATOGENEZO PRI BOLNIKIH S SEMINOMOM TESTISA Z OZIROM NA ZAŠCITO PRED SIPANIM L'.ARCENJEM 40 bolnikom s seminomom testisa, ki so bili zdravljeni z enostransko orhiektomijo in profilakticnim obseva­njem retroperitonealnih bezgavk, smo ugotavljali stop­njo okvare spermatogeneze in med obsevanjem merili gondadno dozo s TLD dozimetri. Samo 11 bolnikov je imelo pred radioterapijo (RT) normalen spermatogram. Po RT smo ugotovili v vecini primerov poslabšanje rezultatov semenske analize. Pri bolnikih, ki smo jim šcitili testise pred sipanim žarcenjem, je bila okvara speramatogeneze manjša kot pri tistih, kjer posebne zašcite še nismo uporabljali. Zaradi majhnega števila bolnikov razlika med skupinama ni bila statisticno signifikantna, ampak se je le nakazovala. Merjenje gonadne doze 4 bolnikom, ki jim preostalega testisa nismo šcitili in 8 bolnikom z zašcitenim testisom je pokazalo, da smo z uporabo zašcite gonadno dozo zmanjšali za približno dve tretjini. References 1. O'Sullivan B, Sutcliffe SB. The toxicity of radiothe­rapy. Ciin Oncol 1985; 4: 485-509. 2. Ash P. The influence of radiation on fertility in man. Br J Rad 1980; 53: 271-8. 3. Hahn EW, Feingold SM, Nisce L. Aspermia and recovery of spermatogenesis in cancer patients follo­wing incidental gonadal irradiation durign treatment: A progress repo rt. Radiology 1976; 119: 223-5. 4. Pinon-Lataillade G, Maas J. Continuous gamma­irradiation of rats: dose-rate effect on los and recovery of spermatogenesis. Strahlentherapie 1985; 161 : 421­6. 5. Fossa SO, Almaas B, Jetne V, Bjerkedal T. Paternity after irradiation for testicular cancer. Acta Radiol Oncol 1986; 25: 33-6. 6. Marmor D, Elefant E, Dauchez C, Roux C. Semen analysis in Hodgkin's disease before ·'the unset of treatment. Cancer 1986; 57: 1986-7. 7. Rothman CM. The usefulness of sperm banking. Ca 1980; 30(3): 186-8. 8. Milligan VW, Hughes R, Lindsay KS. Semen cryopreservation in men undergoing cancer chemothe­rapy -a UK survery. Br J Cancer 1989; 60: 966-7. 9. Kinsella T J, Trivette G, Rowland J et al. Lang-term follow-up of testicular function following radiation the­rapy tor early-stage Hodgkin's disease. J Ciin Oncol 1989; 7: 718-24. 1 O. Umek B. Fast preparation of thermoluminiscent LiF dosimeters tor the use. Radiol lugosl 1988; 22: 93-7. 11. Kolbezen-Simoniti M, Ograjenšek Z, Reš P. Rutin­ski pregled semenskega izliva. Novi s, 1980; 7(7) :25­31. 12. Smithers DW, Wallace DM, Austin DE. Fertility after unilateral orchidectomy and radiotherapy tor pa­tients with malignant tumours of the testis. Br Med J 1973; 4: 66-9. 13. Schlappack OK, Kratzik C, Schmidt W, Spona J. Spermiogenese nach Strahlentherapie wegen Semi­noms. In: Schmoll, Weissbach eds. Diagnostik und Therapie von Hodentumoren. Berlin Heidelberg: Sprin­ger Verlag, 1988: 493-500. 14. Fraass BA, Kinsella TJ, Harrington FS, Glatstein E. Peripheral dose to the testes: the design and clinical use of a practical and effective gonadal shield. lnt J Radia! On col Biol Phy 1985; 11 :609-15. 15. Reš P, Ograjenšek Z. Diagnosticni postopki za ugotavljanje vzroka neplodnosti pri moškem. In: Me­den-Vrtovec H et al, eds. Neplodnost. Ljubljana: Can­karjeva založba, 1989: 261-7. Author's address: Viljem Kovac, MD, The Institute of Oncology, Zaloška 2, 61000 Ljubljana Radiol lugosl 1990; 24: 191-4. Gasil presentation with test (answer) FROM PRACTICE FOR PRACTICE Answer: Mammography of the Left Breast Stellate lesion 8 mm in diameter, suspicIous for carcinoma. Marcation with localization wire is required. /Radiol lUgosl 1986; 20 (1): 23-6/. f0 L ', Fig. 3 • t' L Fig. 4 Marcation of the lesion with localization wire. The wire is inserted in the immediate vicinity of the lesion. .. '. ..•. ···-··· Fig. 5 Sample Mammography The sample is fixed in the localization device. The suspicious areas for pathomorphologic sam­ple taking are marked with a needle. Pathomorphologic Findings Frozen section: invasive carcinoma Fina! histologic findings: intraductal and infiltra­ting tubular carcino1T1a of grade I malignancy ­minimal disease; 7 mm diameter. None of the twenty examined lymph nodes shows evidence of metastases Comment: Minimal cancer up to JO mm of size has a fovourable prognosis, and is therefore regarded as curable. The fina! diagnosis of stellate lesions can be made only by histology. High resolution of mammograms is .chieved by cassette technique (cassettes with screens KODAK MinR Fast Screens, and high resolu­tion film KODAK T Mat M II) and MAMMODIAGNOST UM-PHILIPS. Author's address: Jure US, MD, The Institute of oncology, Zaloška 2, 61j000 Ljubljana Radiol lugosl 1990; 24: 195-7. Varia . izveštaj VI JUGOSLAVENSKI SIMPOZIJ O INTERVENTNOJ RADIOLOGIJI U ONKOLOGIJI Ljubljana, 15. -17. juni, 1989. g. Kao što je poznata, interventna radiologija (naziv je uveo Wallace, 1976.) je od procedura koje su u pocetku osporavane od klinicara, po­stala u posljednjih 15 do 20 godina opšte prihva­cena i veoma vrijedna grana radiologije, odnosno medicine. Prema Obrezu l. (1986), decenijama najvaž­nija uloga radiologa -interpretacija radiograma i konsultacija, bitno se promijenila. Zahvaljujuci razvoju interventne radiologije, rješavanje mno­gih klinickih problema prešlo je u potpunu nadlež­nost radiologa u pogledu dijagnoze i terapije. U cilju pracenja svjetskih dostignuca u ovoj oblasti, cije se metode pocinju uvoditi od 1978. godine u Ljubljani, Beogradu i Zagrebu, a 1981. i u Splitu, Sarajevu, Mariboru i Novom Sadu, organizuju se i skupovi ljekara koji se bave interventnem radiologijam. Prvi takav sk-up, informativno-organizacionog karaktera, održan je 1979. u Ljubljani. Slijede celiri skupa u Zagrebu: »Okrugli stol o interven­cijskoj radiologiji« -1980., »Simpozij iz interven­cijske radiologije« -1981., »Simpozij o perkuta­noj transluminalnoj angioplastici perifernih, renal­nih i koronarnih arterija« s medunarodnim uceš­cem, -1983. i »Simpozij intervencijske radiolo­gije -perkutane drenaže organa i organskih sustava«, takode sa medunarodnim ucešcem ­1985. U meduvremenu je 1983. g. u Dubrovniku održan »Joint Meeting and Postgraduate Cour­se«, u organizaciji Evropskog angiološkog koled­ža, Evropskog društva za kardiovaskularnu i interventnu radiologiju i Americkog društva za kardiovaskularnu radiologiju. U Sarajevu su za­lim 1985. i 1986. g. održana dva skupa pod nazivom »lnterventional Radiology and Newer lmaging Modalities« u organizaciji Instituta za radiologiju i onkologiju UMC-a Sarajevo i Depar­tment of Radiology and Division of Continuing Education Medical University of South Carolina, USA. »IV Simpozij o intervencijskoj radiologiji« od­ržan je 1986. u Splitu, a » V Simpozijum o interventnoj radiologiji« 1987. godine u Beogra­du, takode oba sa medunarodnim ucešcem. Pocetak rada Simpozijuma oznacen je podsje­canjem na život i rad nedavno preminulog prof. dr Ive Obreza uz rijeci poštovanja i zahvalnosti za njegov doprinos radiologiji i posebno interven­tnoj radiologiji Slovenije i Jugoslavije. U Uvodu je navedeno da je brzi razvoj inter­ventne radiologije u zadnjoj deceniji doprinio uspješnijem otkrivanju i lijecenju raka, a posebno u palijativnom tretmanu. Pri torne je nužna tijesna saradnja ljekara raznih specijalnosti. Promije­njeni status radiologa koji je sada aktivni ucesnik u procesu lijecenja zahtijeva dodatno klinicko znanje, manuelnu spretnost i osposobljenost za akciju u svakom trenutku. Cilj Simpozijuma je, kao šlo je istaknuto, pred­staviti mjesto interventne radiologije u otkrivanju i lijecenju raka uz kratak pregled drugih nacina u kombinaciji lijecenja. Na Simpozijumu su održana i štampana u Zborniku tri pozvana predavanja (2 iz Ljubljane i 1 iz Zagreba). Od 90 prijavljenih referata (34 iz Ljubljane, 16 iz Sarajeva, 1 O iz Beograda, 9 iz Zagreba, 6 iz Rijeke, 4 iz Kragujevca, 3 iz Splita, 3 iz Hjustona, 2 iz Seca, 1 iz Graca, 1 iz Novog Sada i 1 iz Niša) u Zborniku je štampano 75 referata. Ukupno 90 prijavljenih referata raspore­deno je u slijedece oblasti: Glava i vrat (7), grudni koš i dojka (9), jetra (15), bilijarni sistem (6), uropoetski sistem (1 O), mala zdjelica (1 O), kosti i meka tkiva (14) i slobodne teme (19). Pored radiologa u radu Simpozijuma ucestvo­vali su sa referatima i patolozi, citolozi, onkolozi, hirurzi i internisti. Iznesena su vlastita iskustva i rezultati pri­mjene slijedecih metoda interventne radiologije: -Perkutane citološke (aspiracione) i hostolo­ške biopsije tumora pluca, medijastinuma, jetre, dojke, kostiju, prostate, retroperitor.ualnih limfo­noda, pod kontrolam dijaskopije, ultrazvuka ili CT-a; -Transkateterske embolizacije meningeoma, tumora bubrega, mokracnog mjehura, male zdje­lice, lokomotornog sistema (preoperativna pri­prema ili palijativni tretman hipervaskulariziranih tumora mekih tkiva i kostiju, aneurizmatskih ko­štanih cista, koštanih !umora, metastaza kraljež­nice); Radiol lugosl i.90; 24: 195-7. Varia -izveštaj -lntraarterijska infuzijska kemoterapija tu­mora glave i vrata, male zdjelice, kosti (osteosar­koma), primarnih i sekundarnih tumora jetre (Li­piodol sa kemoterapeutikom pod kontrolom CT­a); -Perkutana intratumorska aplikacija alkohola u terapiji jetrenih metastaza; -Perkutana intraperikardijalna primjena cito­statika kod metastatskog eksudativnog perikardi­tisa; -Bilijarne drenaže i endoproteze u tretmanu maligne 6pstrukcije; -Perkutana nefrostomija kod maligne ops­trukcije urinarnih puteva; -Sklerozacija bubrežnih cista alkoholom, per­kutane drenaže apscesa i tecnih kolekcija, dis­cektomija, litotripsija i -Balon dilatacije suženJa gastrointestinalnog, bilijarnog i uro trakta. Ovaj simpozijum je vjerovatno pokazao ak­tuelne domete i opseg primjene metoda interven­tne radiologije u Jugoslaviji. Kao i ostali do sada i ovaj ce sigurno doprinijeti njihovoj daljnjoj popu­larizaciji. Garancija za to su i izneseni rezultati iz sve veceg broja i manjih centara kao i sve brojnije ucešce mladih radiologa. U tom smislu je i donesena odluka da se slijedeci skup održi u Nišu. Doc. dr. sci. Faruk Dalagija r--·-··­ =f .le1vetius MEDICAL SUPPLIES Dobavitelj ;;_'.{ Radiol lugosl 1990; 24: 195-7. UPUTSTVA AUTORIMA Revija Radiologia lugoslavica obavlja origi­ nalne naucne radove, strucne radove, pre­ gledne clanke, prikaze slucajeva i drugo (pre­ glede, kratke informacije, strucne informacije itd.) sa podrucja radiologije, onkologije, nu­ klearne medicine radiofizike, radiobiologije, za­ šiite od radiacije i drugih slicnih podrucja. Slanjem rukopisa redakciji, podrazumevamo da rad nije bio objavljen niti primljen za objavu u nekoj drugoj reviji; autori su odgovorni za sve tvrdnje i izjave u njihovom clanku. Primljeni radovi ne smeju biti objavljeni u drugim revi­ jama bez ovlašcenja redakcije. Radove napisane na engleskom (originalni naucili radovi obavezno na engleskom) ili na nekom od jugoslovenskih jezika, slati na adresu redakcije: Radiologia lugoslavica, On­ kološki inštitut, Zaloška c. 2, 61105 Ljubljana, Jugoslavija. Svi radovi su podvrgnuti urednickom pre­ gledu i pregledu dva recenzenta izabrana od strane redakcije. Radovi koji ne udovoljavaju tehnickim zahtevima revije, bice vraceni auto­ rima na popravak pre nego što se pošalju na pregled recenzentima. Odbijeni radovi (radovi koji nisu primljeni za štampanje) se vracaju autorima i revija ne snosi nikakvu odgovornost u vezi sa njima (u slucaju da budu izgubljeni). Redakcija zadržava pravo da pozove autore, da naprave gramaticke i stilske popravke, kao i promene u sadržaju u odnosu na primedbe recenzenata, kada je to neophodno. Dodatne troškove štampanja rada i separata po želji autora, snose autori. Opšta uputstva Rad treba kucati sa duplim razmakom, 4 cm od gornjeg i levog ruba papira formata A4; tekst mora biti gramaticki i stilisticki ispravan. Prilikom upotrebe skracenica, nužno je podati njihovo obrazloženje. Tehnicki podaci u ruko­pisu moraju biti u skladu sa SI sistemom. Rukopis, ukljucujuci i pregled literature, ne sme imati više od 8 kucanih stranica, dok broj slika i tabela ne sme biti veci od 4. Preporucu­jemo da rukopisi sadržavaju: Uvod, Material i metode, Rezultati, Diskusija, Sažetak. lznimno, rezultati i diskusija mogu biti zajedno. Svako od gore navedenih poglavlja moraju poceti na posebnom listu papira oznacenom arapskim brojem. Prva stranica -ime institucije; prvo ime institucije, a zalim ime odeljenja za svakog autora -naslov rada neka bude kratak i jasan bez skracenica -naslov rada napisati na jednom od j•igo­slovenskih jezika, a prevod na engleskom, ispod njega (za radove napisane u celini na engleskom jeziku, naslov rada napisati samo na engleskom) -navesti prezimena i inicijale imena svih autora -u sažetku ne sme biti više od 200 reci sa kojima se obuhvata sadržina rada i najznacaj­niji rezultati u radu. Pored sažetka (Abstract-a) na engleskom jeziku, potreban je i prevod na jednom od jugoslovenskih jezika, na posebnom listu pa­pira koji sledi za diskusijom. Uvod je kratko i sažeto poglavlje u kojem je razložena svrha i ciljevi rada. U uvodu autor navodi rezultate objavljenih radova drugih au­tora u vezi sa istom problematikam. Uvod nije mesto za davanje preopširnog pregleda litera­ture. · Material i metode ukljucuju dovoljnu kolicinu podataka neophodnih da se eksperiment pono­ vi. Rezultate je potrebno napisati kratko i jasno, bez ponavljanja podataka koji su obuhvaceni slikama i tabelama. U Diskusiji ne ponavljati rezultate, nego ih objasniti i izvuci zakljucke. Rezultate i zakljucke autor uporeduje sa rezultatima i zakljuccima u drugim objavljenim radovima. Graficki materija! (slike, tabele). Slike i tabele je potrebno poslati utri primerka: original i dve kopije. Uzimacemo u obzir za objavu samo jasne, ciste materijale. Podvlacenja, gra­fikoni i crteži, moraju biti uradeni tušem. Oznake na grafickom materijalu moraju biti dovoljno velike, da posle smanjivanja na veli­cinu stupca, ostariu citljive. Na fotografijama je potrebno prikriti identitet bolesnika. Slike je potrebno oznaciti na poledini sa imenom auto­ra, prvih nekoliko reci naslova rada i brojem slike. Pared toga, potrebno je strelicom orienti­sati položaj slike. Oznacivanje vršiti obicnom olovkom i vrlo blago. Propratni tekst kao i legende za slike napisati na posebnom listu papira. Tabele otkucati i to bez vertikalnih linija. Popratni tekst za tabele napisati uvek iznad tabele. Tabele obeležiti na njihovoj pole­dini (kao gore navedeno za slike). Propratni tekstovi slika i tabela, kao i sam tekst u tabeli, moraju biti prevedeni na engleskom. Literatura mora biti napisana u skladu sa Vancouver-skim odredbama, sa duplim razma­kom, na posebnom listu papira. Redni brojevi clanaka u pregledu literature moraju odgovarati redosledu citiranja clanaka u tekstu. Za _ime­nima autora napisati naslov rada, naslov revije u skladu sa lndex Medicus-om. Primeri za navaden je clanaka, knjiga ili poglavlja iz knjiga: 1. Dent RG, Cole P. In vitro maturation of monocytes in squamous carcinoma of the lung. Br J Cancer 1981; 43: 486-95. 2. Chapman S, Nakielny R. A guide to radio­logical procedures. London: Bailiere Tindall, 1986. 3. Evans R Alexander P. Mechanisms of extracellular killir.g of nucleated mammalian cells by macrophages U: Nelson OS ed. lmmu­nobiology of macrophage. New York: Acade­mic Press, 1976: 45-74. lspod literature napisati adresu prvog autora. INSTRUCTIONS TO AUTHORS The journal RADIOLOGIA IUGOSLAVICA publishes original scientific papers, professio­nal papers, rewiew articles, case reports and varia (reviews, short communications, profes­sional information ect.) pertinent to radiology, radiotherapy, oncology, nuclear medicine, ra­diophysics, radiobilogy, radiation protection and allied subjects. Submission of. manuscript to the Editorial Board implies that the paper has not been published or submitted tor publication elsewhe­re; the authors are responsible tor all 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 either in English should be sen! to the Editorial Office, Radiologia lugo­slavica, Institute of Oncology, Zaloška c. 2, 61105 Ljubljana, Yugoslavia. AII articles are subject to editorial review and review by two independent referees selected by the Editorial Board. Manuscrips which do not comply with the technical requirements stated here will be returned to the authors tor correction before-the review of the referees. Rejected manuscripts are generally returned to authors, however, the journal cannot be held responsible tor their loss. The Editorial Board reseNes the right to require from the authors to make appropriate changes in the content as well as grammatical and stylistic corrections when necessary. The expenses of additional editorial work and requests tor reprints will be charged to the authors. General instructions Type the manuscript double space on one side with a 4 cm margin at the top and left hand sides of the sheet. Write the paper in gramma­tically and stylistically correct language. Avoid abbreviations unless previously explained. The technical data should conform to the SI system. The manuscript, indluding references may not exceed 8 typewritten pages, and the number of figures and tables is limited to 4. II appropriate, organize the text so that it includes: lntroduc­tion, 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. First page -complete address of institution for each author -a brief and specific title avoiding abbrevia­tions and colloquialisms -family name and initials of all authors -in the abstract of not more Ihan 200 words cover the main factual points of the article, and illustrate them with the most relevant data, so that the reader may quickly obtain a general view of the material. Apart from the English abstract, an adequate translation of this including the title into one of the Yugoslav languages should be provided on a separate sheet of paper following the Discus­sion. For foreign writers the translation of the abstract will be provided by the Editorial Board. lntroduction is a brief and concise section, stating the purpose of the article in relation to other already published papers on the same subject. Do not presen! extensive reviews of the literature. Material and methods should provide enough information to enable the experiments to be repeated. Write the Results clearly and concisely and avoid repeating the data in the tables and figures. Discussion should explain the results, and not simply repeat them, interpret their signifi­cance and draw conclusions. Graphic material (figures, tables). Each item should be sent in triplicate, one of them marked original tor publication. Only high-con­trast glossy prints will be accepted. Line dra­wings, graphs and charts chould be done professionaly in indian ink. All lettering must be legible after reduction to column size. In photo­graphs mask the identities of patients. Label the figures in pencil on the back indicating author's name, the first few words of the title and figure number; indicate the top with an arrow. Write legends to figures and illustrations on a separate sheet of paper. Orni! vertical lines in tables and write the text to tables overhead. Label the tables on their reverse side. References should be typed in accordance with Vancouver style, double spaced on a separate sheet of paper. Number the·referen­ces in the order in which they appear in the text and quote thl:!ir corresponding numbers in the text. The authors names are followed by the title of the article and the title of the journal abbreviated according to the style of the lndex Medicus. Following are some examples of references from articles, books and book chap­ters. 1. Deni RG, Cole P. In vitro maturation of monocytes in squamous carcinoma of the lung. Br J Cancer 1981 ; 43: 486--95. 2. Chapman S, Nakielny R. A guide to radio­logical procedures. London: Bailliere Tindall, 1986. 3. Evans R, Alexander P. Mechanisms of extracellular kiling of nucleated mammalian cells by macrophages. In: Nelson OS ed. lm­munobiology of macrophage. New York: Aca­demic Press, 1976; 45-74. Author's address should be written following the References. lzdavanje revije potpomaže Raziskovalna skupnost Slovenije u svoJe ime i u ime istraživackih zajednica svih drugih republika i pokrajina u SFRJ -The publication of the review is subsidized by the Assembly of the Self managing Communities tor Research Work of the Republics and Provinces of Yugoslavia, and the Res.earch Community of Slovenia. Doprinosi ustanova na osnovu samoupravnih dogovora -Contribution on the basis of the self-managing agreements: -Institut za radiologiju, MF u Prištini -Institut za rendgenologiju, UMC-a Sarajevo -Inštitut za rentgenologijo, UKC Ljubljana -Klinicka bolnica »Dr Vukašin Markovic« Titograd -Klinika za nukleano medicino, UKC Ljubljana -Medicinski centar »Zajecar« u Zajecaru -Onkološki inštitut, Ljubljana -OOUR Institut medicinskih službi, Novi Sad; -RJ Institut za patološku fiziologiju i laboratorijsku dijagnostiku u Novom Sadu -RJ Institut za radiologiju u Novom Sadu -RO Institut za nuklearne nauke »Boris Kidric«, Vinca -OOUR Institut za radioizotope »RI«, Beograd -Sekcija za radiologiju Makedonskog lekarskog društva, Skopje. Pomoc reviji i narucnici reklama -Donators and Advertisers -ANGIOMED, Karlsruhe, BRD -BAYER PHARMA JUGOSLAVIJA, Ljubljana -BYK GULDEN, Konstanz, SR Nemacka -zastupstvo FABEG, Beograd -FOTOKEMIKA, Zagreb -F. HOFFMANN -LA ROCHE & CO., Basel, Švica -zastupstvo JUGOMONTANA, Beograd -HELVETIUS, Trst, Italija -ISOCOMMERZ / lnterwerbung, Berlin, DDR -OZEHA, Zagreb -JADROAGENT, Rijeka -JUGOLINIJA, Rijeka -KRKA, Novo mesto -KOMPAS, Ljubljana -MEBLO, Nova Gorica -NYCOMED NS Oslo, Norveška -predstavništvo LECLERC & Co. 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Fax: 213-696 OSNOVNE DJELATNOSTI: -PRIHVAT I OTPREMA BRODOVA U LUKAMA -ZAKLJUCIVANJE VOZARINSKIH UGOVORA (BOOKING) -OPERATIGN KONTEJNERA -MEDUNARODNA ŠPEDICIJA -ZAKLJUCIVANJE BRODARSKIH UGOVORA (CHARTERING) -KUPOPRODAJA BRODOVA -PUTNICKA SLUŽBA P & 1 REPRESENTATIVES LLOYD'S AGENTS Clan: -BIMCO -The Baltic ans lnternational Maritime Conference, Copengahen -FIATA-e, medunarodnog udruženja špeditera, Z0rich -MUL TIPORT Ship Agencies Network, Rotterdam PROIZVODNI PROGRAM ZA MEDICINU Za potrebe MEDICINSKIH SNIMANJA proizvodimo: -medicinski rendgen film: -SANIX RF-90 -HS-90-2 -SANIX M (za mamografiju) -SANIX DENT 20 (zubni) -STATUS O (za panoramska snimanja celjusti) -film za koronarografiju: SANIX COR 17 i SANIX COR 21 -SANIX FNM-1 (za sve metode snirnanja kod kojih se slika dobiva optickim preslikavanjem sa katodne cijevi) Kemikalije za strojnu i rucnu obradu medicinskih filmova. Za potrebe MIKROGRAFIRANJA proizvodimo: -MIKROFILM NEGATIV NF-216mrn i 35mm s kernikalijama za obradu, prikladan za sve mikrofilmske kamere -MIKROFILM N-1 nesenzibilizirani mikrofilm za izradu crno-bijelih diJapozitiva LN_OVO! NOVO! NOVO! SANIX ORTHO -medicinski rendqen film namijenjen snimanju s orthokromatskim foli­jama za pojacavanje. Smanjuje ukupnu dozu zracenja više od 50%. SANIX RENDGEN CASSETTE SANIX ORTHO POJACAVAJUCE FOLIJE FOTOKEMIKA PODUZECE ZA PROIZVODNJU I PROMET FOTOMATERIJALA I OPREME S P.O., ZAGREB, HONDLOVA 2 CI,. avtotehna PHILIPS e . Philips Medical Systems DIAGNOST 92 A univerzalni, diagitalni, slikovni sistem IIII II II II lllll llllllllllllllllllll Sistem za angiografijo na daljinsko upravljanje lllllllllllllllllllllllllllllllllll Generalni zastopnik za Philips medicinsko opremo, diagnosticne in terapijske rentgene, CT, ultrazvok, NMR, Gama-kamere ... 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