Endometriose - eine Stammzellerkrankung?

Endometriosis is an estrogen-dependent and chronic disease with an unknown etiology and pathogenesis. It is however likely and well accepted that retrograde menstruation of endometrial cells into the pelvic cavity is the origin of this disease in many cases. Here we discuss a model in which retrogradely menstruated endometrial cells have different inherent developmental properties because they represent in fact a mixture of different developmental cell stages. These stages can be distinguished in part by the expression of marker proteins such as cytokeratin (intermediate filament protein of epithelial cells) or E-cadherin (intercellular adhesion protein of epithelial cells and metastasis suppressor molecule). Cytokeratin-positive E-cadherin negative cells, for example, would be less differentiated epithelial cells than cytokeratin-positive E-cadherin positive cells. In analogy to findings in other cell systems we assume that the cells which are undifferentiated or not fully differentiated still have the potential to give rise to differentiated daughter cells and, on the other hand, could be maintained as a pool of rather undifferentiated cells and capable of self renewal. This feature would be similar to stem cells (SC) and cells with plasticity. Interestingly we find epithelial cells of different developmental stages in deep infiltrating (e. g. of colon) or peritoneal endometriotic lesions. Therefore we conclude that less differentiated cells in retrogradely menstruated endometrial cell populations possibly representing SC features or plasticity might be the cellular source of primary endometriotic lesions and those present in lesions may contribute to the persistence of the disease by detaching and forming secondary lesions.

Selective anterior fusion of thoracolumbar/lumbar curves in adolescents: when can the associated thoracic curve be left unfused?

STUDY DESIGN

A retrospective multicenter study was conducted to investigate patients with a major thoracolumbar/lumbar adolescent idiopathic scoliosis and an associated minor thoracic curve treated with an anterior instrumentation and fusion of the lower curve.

OBJECTIVE

To establish criteria for determining when such curves can be successfully treated by an anterior only procedure of the lower curve with acceptable spinal balance and residual thoracic curve.

SUMMARY OF BACKGROUND DATA

Anterior spinal instrumentation techniques have been proved effective for the management of isolated thoracolumbar/lumbar scoliosis with small compensatory thoracic curves. The success of a selective anterior fusion when the associated thoracic curve had some structural changes in a small preliminary study was variable and was the stimulus for this study.

METHODS

A multicenter study involved 49 adolescent patients with a major thoracolumbar/lumbar curve in which the associated minor thoracic curve measured between 30 degrees and 55 degrees. In all the patients, the apical vertebra of the lower curve lay outside the midsacral line, and the thoracic apical vertebra fell outside a line dropped from the center of C7. Multiple radiographic parameters were evaluated. The Risser sign, height, weight, onset of menses, and closure of the triradiate cartilages were studied to access the patients' maturity. All the patients were observed at least 2 years. Patients were considered to have a satisfactory result if the thoracic curve at the final follow-up assessment measured 40 degrees or less, if balance and sagittal alignment were reasonable, and if additional procedures were not required.

RESULTS

At final follow-up assessment, two groups emerged. Group 1 (n = 43) had satisfactory results. The preoperative thoracic curve in this group averaged 40 degrees and 26 degrees after surgery. The lumbar curve averaged 56 degrees before surgery and 22 degrees after surgery. Group 2 (n = 6) had unsatisfactory results. The average thoracic curve was 49 degrees before surgery 54 degrees after surgery, whereas the lumbar curve averaged 59 degrees before surgery and 27 degrees after surgery. Three of these patients underwent posterior thoracic instrumentation and fusion.

CONCLUSIONS

Statistical analysis showed that a successful surgical outcome was dependent on both the structural changes in the thoracic curve and the patient's maturity. The thoracolumbar/lumbar-thoracic (TL/L:T) Cobb ratio in combination with the degree of the thoracic curve on lateral bending was the best predictor among the structural indexes. Of 44 patients with a TL/L:T Cobb ratio of 1.25 or greater and/or a thoracic curve, which bent out to 20 degrees or less, 42 had a satisfactory result. The best predictor among the maturity indexes was closure of the triradiate cartilages. Of 43 patients in whom the triradiate cartilages were closed, 42 had satisfactory results. When this data is combined, the outcome for the thoracic curve can be reasonably predicted.

Catheter-related infection in patients on home parenteral nutrition: results of a prospective survey

BACKGROUND & AIMS

Central venous catheter (CVC) infection is the most frequent complication during home parenteral nutrition (HPN). We prospectively assessed incidence and catheter-related sepsis (CRS)-associated factors in the 42 adult patients enrolled in our HPN centre since its opening.

METHODS

Age, frequency of infusions, CVC type, autonomy or nurse/family aid, underlying disease, involved infectious organism(s), hospital stay, efficacy of antibiotic-lock and other infectious complications, were studied.

RESULTS

CRS occurred 39 times (3/1000 days of HPN). In 37/39 cases, it was proven by both peripheral and central blood cultures. In 56% of patients, clinical signs were discrete, delaying diagnosis. Individual factors like learning potency, underlying disease (especially chronic intestinal obstruction with bacterial overgrowth), and length of remaining colon and small intestine, were slightly associated with higher CRS incidence. Usually, one organism (S. epidermidis; 51%) was detected. A total of 14 CVC were immediately removed. In the others, antibiotic-lock was more effective in patients having tunnelled catheters (TC, 50%) than implanted devices (25%; P<0.05). Mean hospital stay was 22+/-15 days, which was influenced by 3 patients presenting associated osteomyelitis.

CONCLUSIONS

CRS incidence was 3/1000 days of HPN. Clinical symptoms were often discrete, suggesting importance of rigorous survey. Individual apprenticeship and risk for higher bacterial translocation seem associated to higher CRS incidence. CVC sterilization was more frequent in patients with TC.

In search of pathogenic mechanisms in endometriosis: the challenge for molecular cell biology

Endometriosis, defined histologically as the presence of endometrium-like glands and stroma outside the uterus, is a chronic, invasive and metastasising disease. It shares features with malignant tumours (invasion and metastasis) but is not neoplastic. Despite the fact that endometriosis is one of the most frequent gynaecological diseases, it is under researched, puzzling and highly debated. The aetiology and pathogenesis is little understood although it is agreed that implantation, at least in many cases, is responsible for endometriosis. This theory advocates retrograde menstruation as the underlying phenomenon, where cells of the menstrual efflux provide the cellular source for endometriotic lesion formation. Causative therapy and non-invasive diagnostics of endometriosis do not exist. Thus, there is a substantial but unmet need for molecular and cellular research to unravel the pathogenic mechanisms of endometriosis as a basis for developing novel diagnostic and therapeutic concepts. In this review, we specifically focus on the cellular basis of lesion formation, the possible modulation of this by cytokines and other factors and the characteristics of endometriotic cells in terms of invasion and metastasis. Considering available experimental information, we concentrate on arguments and ideas in favour of an endometriotic founder cell population exhibiting substantial plasticity for differentiation and self-renewal. Perhaps present in the menstrual efflux or arising by metaplasia (a complementary theory to implantation), this cell type might respond to stimuli present in the ectopic host environment and establish the endometriotic phenotype.

Identification of an invasive, N-cadherin-expressing epithelial cell type in endometriosis using a new cell culture model

Studies of molecular, cellular, and pathophysiological parameters in endometriosis are primarily hampered by a lack of in vitro model systems, such as endometriotic cell lines. To overcome this we successfully established cell lines from peritoneal endometriotic biopsies and characterized them at the molecular and cellular level. Two types of cells could be transformed: one exhibiting stromal cell features (cytokeratin/E-cadherin-negative), the other epithelial-like (cytokeratin-positive/E-cadherin-negative, invasive in vitro). Using a Matrigel assay the epithelial-like cell lines proved as invasive as metastatic carcinoma cells, possibly through the influence of N-cadherin implicated as a path-finding cadherin allowing cellular invasion and migration in both normal and pathophysiological processes. Our results support the idea that endometriosis, although not neoplastic, shares features with malignant cells and that metastasis in endometriosis may include mechanisms proposed for micrometastasis in cancer. Thus our cell lines will not only be useful tools for analyzing molecular and cellular events relating to endometriosis, but may also represent a paradigm for invasion and metastasis in general.

Persistent inflammation and immune activation contribute to cholestasis in patients receiving home parenteral nutrition

Liver disease is frequent in patients taking home parenteral nutrition (HPN), but its cause remains unclear. Ongoing inflammation was implicated in HPN-associated cholestasis, so we examined the relation between liver-enzyme concentrations and circulating inflammatory and immune markers in these patients. In 17 HPN patients and 10 age- and sex-matched control subjects, we examined erythrocyte sedimentation rate, blood neopterin, soluble interleukin (IL)--2 receptors, circulating tumor necrosis factor-alpha, IL-6, aspartate and alanine aminotransferases, alkaline phosphatases, and gamma-glutamyltranspeptidase (GGT) concentrations. Fourteen of 17 patients had abnormal liver function tests with an increase in alkaline phosphatases (P < 0.001), gamma-glutamyltranspeptidase (P < 0.01), and aspartate aminotransferase (P < 0.01). Alkaline phosphatases were positively correlated to erythrocyte sedimentation rate, neopterin, tumor necrosis factor-alpha, and IL-6. gamma-Glutamyltranspeptidase was positively linked to tumor necrosis factor-alpha and soluble IL-2 receptors. There was no link between aminotransferases and inflammatory parameters. Liver-enzyme concentrations were correlated to the amount of total intravenous calories and calories originating from carbohydrates but not to infused lipids (median infused lipids x kg(-1) body weight x d(-1) = 0.62 g) in contrast to recently published data. Our results confirmed that the number of infused calories contributes to liver toxicity in HPN patients and strongly suggested that sustained inflammation is probably a key factor in worsening HPN-associated cholestasis.

Erythroid carbonic anhydrase and hsp70 expression in chick embryonic development: role of cAMP and hypoxia

In the second half of avian embryonic development cAMP affects major aspects of red blood cell (RBC) function. At day 13/14, progressive developmental hypoxia causes the release of norepinephrine and erythroid beta-adrenergic receptor stimulation initiates the coordinate induction of adaptive key events of erythroid differentiation like carbonic anhydrase (CAII) and 2,3-biphosphoglycerate synthesis. Although cAMP-dependent regulation of CAII protein synthesis has been described in detail, no data exist about the transcriptional regulation in embryonic RBC. Here we report that after day 12 of embryonic development, the caII mRNA is accumulating. Hypoxic incubation at day 10 as well as in vitro incubation of isolated RBC with cAMP-elevating agonists strongly induces erythroid caII expression. The induction of caII occurs fast and does not require new protein synthesis. By screening several late erythroid genes, we could identify hsp70 as another cAMP-induced gene in definitive RBC. Because caII (but not hsp70) is also induced by cAMP in primitive RBC, the signal may regulate key events of late primitive and definitive erythropoiesis.

Application of a new verification technique allowing craniospinal irradiation in supine position

To minimize anaesthesia related risks during craniospinal irradiation in children, treatment in supine position would be preferable. Verification especially of the cervical three-field junction causes problems, because direct visual control is not possible. We present clinical experiences with a new verification technique with all three fields exposed on one single film.

[Splenic thrombosis and celiac disease: a fortuitous association?]

BACKGROUND

Rare cases of venous thrombosis associated with celiac disease have been reported.

CASE REPORT

We report a case of 40-year-old woman with splenic infarction and splenic venous thrombosis associated with celiac disease. This patient was homozygous for the C677T mutation of the methyltetrahydrofolate reductase (MTHFR) gene and had moderately elevated homocysteinemia.

DISCUSSION

We discuss the link between celiac disease and thrombosis as well as the interest and appropriate duration of anticoagulation and hypothesize a mechanism of thrombotic disease in this setting with hyperhomocyseinemia.

Factors associated to hypermanganesemia in patients receiving home parenteral nutrition

BACKGROUND

Home parenteral nutrition (HPN) patients often present hypermanganesamia.

AIM

To examine which factors may be associated to hypermanganesemia in HPN patients.

METHODS

Plasma manganese (Mn), liver function tests, C-reactive protein concentrations, erythrocyte sedimentation rate (ESR), tumor necrosis factor-alpha (TNF- alpha), interleukin-6, soluble receptors of interleukin-2, and blood neopterin concentrations were determined in 21 HPN patients and 10 healthy controls. Brain magnetic resonance imaging (MRI) and careful neurologic clinical examination were performed in 11 patients.

RESULTS

Mn concentration was higher in HPN patients than controls (1.96+/-1.1 vs 0.81+/- 0.4 microg/L;P<0.001) and positively correlated to the amount of parenteral nutrition (PN) supply, transaminases and alkaline phosphatase (r=0.53, P<0.0001) concentrations, as well as to ESR (r=0.61, P<0.0001), TNF- alpha and blood neopterin. The amount of calories provided by PN was positively correlated to inflammatory markers and liver parameters. All patients investigated by MRI showed hyperintense basal ganglia on T1-weighted images suggesting brain Mn deposition. Only one had slight clinical extrapyramidal symptoms.

CONCLUSION

In HPN patients, sustained inflammation may facilitate hypermanganesemia through 1. cholestatic liver disease and thereby decreased Mn biliary excretion, 2. high nutritional requirements (responsible for increased Mn supply), and/or 3. modified Mn metabolism or body distribution. Neurologic complications appeared marginal whereas Mn brain deposition seems frequent.

Vitamins and trace elements in home parenteral nutrition patients

AIMS

to study the micronutrient status in home parenteral nutrition (HPN) patients and its relationship to inflammatory markers, and clinical outcome.

METHODS

Vitamins (A, 25OH D3, E, B12), serum folic acid, as well as trace elements (selenium, zinc, copper, iron and manganese) were measured in 22 adult HPN patients and 14 controls. They were compared to serum malondialdehyde (MDA) concentration (as a marker of lipid peroxidation), erythrocyte superoxide dismutase (SOD) and gluthatione peroxidase (GSHPx), inflammatory markers, and clinical outcome.

RESULTS

In HPN patients MDA concentration was increased whereas vitamin E concentrations were decreased, and significantly negatively correlated to MDA. Erythrocyte GSHPx and plasma selenium were decreased in the patients and positively correlated to each other. By contrast, manganese concentration was significantly increased in HPN patients and correlated to inflammatory markers.

CONCLUSIONS

Adult HPN patients showed increased lipid peroxidation. This seems principally the result of low vitamin E status. In addition, these patients presented often a decrease in plasma selenium responsible for low GSHPx activity. These combined antioxidant system deficiencies contribute probably to peroxidative damage in HPN patients. Increased manganese concentrations, in view of their potential neurotoxicity have to be closely surveyed. In HPN patients micronutrient status needs regular monitoring in regard to the possibility of vitamin and/or trace element abnormalities.

Home parenteral nutrition: clinical and laboratory analysis of initial experience (1994-1997). Implications for patient management

BACKGROUND/AIM AND METHOD: Severe malabsorption often necessitates prolonged parenteral nutrition. Home parenteral nutrition (HPN) offers the opportunity for treatment at home. We report clinical and laboratory data of initial 27 HPN patients of one center since its opening in 1994.

RESULTS

Clinical and biological markers of nutritional status were normalized and well maintained in most patients. Except for vitamin E and selenium (lower in HPN patients), the other vitamin and micronutrient levels were normal. There was no obvious essential fatty acid deficiency. Cholestasis was usual, but only 1 patient had a severe hepatic disease. Catheter infection occurred 18 times in 13 patients, but the frequency decreased with time (from 4.2 to 1.7 infections/1,000 days on HPN). No patient died from HPN complications. Social rehabilitation and, in some patients, full professional rehabilitation were constant.

CONCLUSIONS

These data confirm that HPN performed in centers with expertise allowed patients to overcome gut failure and to recover subnormal or normal nutritional status. Satisfactory social rehabilitation was obtained in all patients. HPN complications were rarely life-threatening, and their frequency decreased with experience.

Antioxidant and immune status in active Crohn's disease. A possible relationship

BACKGROUND AND AIMS

As reactive oxygen has been demonstrated to participate in immune genes transcription, the aim of this study was to examine the relationship between systemic concentrations of several antioxidants and markers of inflammatory and immune activation in patients with Crohn's disease (CD).

METHODS

In 26 CD patients and 15 controls we compared plasma selenium and zinc concentrations, erythrocyte glutathione peroxidase (GSHPx) and superoxide dismutase activities, as well as erythrocyte sedimentation rate (ESR), C-reactive protein, tumor necrosis factor-alpha, interleukin-6, blood neopterin and soluble receptors of interleukin-2 (sIL-2R), and examined the link between these parameters.

RESULTS

Selenium concentration and GSHPx activity were decreased in CD patients (54.5 +/- 3.2 vs 79 &plusmn 2.2 microg/l, P<< 0.05; 28 +/- 1.6 vs 38 +/- 2.6 IU/g Hb, P<< 0.05) and positively correlated to each other's (r= 0.59, P<< 0.01). TNF-alpha was significantly increased in patients (18 +/- 2.6 vs 5 +/- 0.6 pg/ml;P<< 0.001), negatively correlated to GSHPx activity (r= -0.56, P<< 0.05) and selenium concentration (r= -0.72, P<< 0.001), and positively to neopterin and sIL-2R concentrations. Selenium showed negative correlation with sIL-2R (r= -0.83, P<< 0.0001) and ESR.

CONCLUSIONS

In CD patients low selenium concentration may participate in reduced GSHPx activity facilitating inflammatory and immune activation. In these patients, selenium monitoring and, if needed, supplementation may be of therapeutical interest.

Ontogeny of catecholamine and adenosine receptor-mediated cAMP signaling of embryonic red blood cells: role of cGMP-inhibited phosphodiesterase 3 and hemoglobin

We have previously shown that the cAMP signaling pathway controls major aspects of embryonic red blood cell (RBC) function in avian embryos (Glombitza et al, Am J Physiol 271:R973, 1996; and Dragon et al, Am J Physiol 271:R982, 1996) that are important for adaptation of the RBC gas transport properties to the progressive hypercapnia and hypoxia of later stages of avian embryonic development. Data about the ontogeny of receptor-mediated cAMP signaling are lacking. We have analyzed the response of primitive and definitive chick embryo RBC harvested from day 3 to 18 of development towards forskolin, beta-adrenergic, and A2 receptor agonists. The results show a strong response of immature definitive and primitive RBC to adenosine A2 and beta-adrenergic receptor agonists, which is drastically reduced in the last stage of development, coincident with the appearance of mature, transcriptionally inactive RBC. Modulation of cGMP-inhibited phosphodiesterase 3 (PDE3) has a controlling influence on cAMP accumulation in definitive RBC. Under physiological conditions, PDE3 is inhibited due to activation of soluble guanylyl cyclase (sGC). Inhibition of sGC with the specific inhibitor ODQ decreases receptor-mediated stimulation of cAMP production; this effect is reversed by the PDE3 inhibitor milrinone. sGC is acitivated by nitric oxide (NO), but we found no evidence for production of NO by erythrocyte NO-synthase. However, embryonic hemoglobin releases NO in an oxygen-linked manner that may activate guanylyl cyclase.

Effect of high altitude and in vivo adenosine/(β)-adrenergic receptor blockade on ATP and 2,3BPG concentrations in red blood cells of avian embryos

In chick embryos, developmental changes of the blood oxygen tension control hemoglobin (Hb) oxygen affinity via modulation of ATP and 2, 3BPG concentrations in red blood cells. Hypoxia, which is a normal developmental condition for late chick embryos, causes a decrease of the red cell ATP concentration (and increase of red cell oxygen affinity) as well as activation of 2,3BPG synthesis via cyclic AMP-dependent signaling. Adenosine and catecholamines have been implicated as signaling substances in these red cell responses. To assess the extent to which adenosine and catecholamines are involved in vivo in the control of red cell ATP/2,3BPG concentrations, day 13 chick embryos were treated for 24 h with adenosine A(2) and/or (β)-adrenergic receptor blockers and red cell ATP and 2,3BPG levels were determined. The data suggest that adaptive effects later in development in chick embryos induced by adenosine and catecholamines are vital. We have also tested whether avian embryos of the free-living, high-altitude, native white-tailed ptarmigan (Lagopus leucurus) alter their organic phosphate pattern in red cells in response to incubation at different altitudes. Embryos incubated at 3600–4100 m decrease their red cell ATP concentration much more rapidly than embryos of the same clutch incubated at 1600 m. From these data it can be inferred that the oxygen affinity of high altitude embryos will be adjusted to the altitude at which the eggs are incubated.

Management of common bile duct stones in a single operation combining laparoscopic cholecystectomy and perioperative endoscopic sphincterotomy

BACKGROUND

Laparoscopic cholecystectomy (LC) has become the reference treatment for biliary lithiasis, but the management strategy for common bile duct stones (CBDS) remains a subject of controversy in the absence of an established consensus. While conventional surgery remains the reference treatment for CBDS, minimally invasive techniques are becoming more and more popular. These methods consist of the extraction of the common bile duct stones either exclusively by laparoscopy or by sequential treatment with endoscopic sphincterotomy (ES) followed by LC. The aim of this study was to evaluate the treatment of CBDS in a one-stage operation by laparoscopic cholecystectomy (LC) and perioperative endoscopic sphincterotomy.

PATIENTS AND METHODS

Between January 1994 and March 1998, 44 patients, 20 male and 24 female, (sex ratio 1.2) with a median age of 57 years (range 28-84 years) were treated for suspected or confirmed CBDS. The CBDS were uncomplicated in 39 cases (88%) and associated with a complication in 5 cases (12%), namely, cholangitis (2 cases) or acute pancreatitis (3 cases). The perioperative ES was performed immediately after the LC during the same operative time, with perioperative cholangiography being systematically performed (1 failure). In 6 cases, a transcystic drain was left in place (to ensure complete evacuation of the CBDS postoperatively) when there were more than three stones and/or when they were larger than 6 mm. The patient was positioned in the left lateral position in order to perform the ES.

RESULTS

Mean operative time for LC was 60 min, range 40-90 min. The general anesthesia was prolonged by 40 min in order to perform an ES (range 30-60 min). The perioperative ES was unsuccessful in one case (2%), due to the impossibility of catheterizing the papilla, the preoperative MR cholangiogram being normal. Immediate clearance of the CBD was achieved in 95% of the cases (42 p). In 2 cases, residual stone was found in the sixth day after cholangiography and was spontaneously evacuated as shown by 21st-day control. There was no mortality or postoperative complications. The duration of the postoperative hospitalization was 4.6 days (range 3-6).

CONCLUSIONS

We believe that LC combined with perioperative ES is a quick, reliable, and safe technique for the treatment of CBDS during a single operative procedure, although this approach is limited by the proximity and availability of an endoscopic team.

Nitric oxide end products in patients hospitalized for diarrhoea

OBJECTIVE

Increased nitric oxide (NO) has been demonstrated in inflammatory bowel diseases (IBD). Plasma and urinary nitrite and nitrate are usually considered to reflect global NO generation. Recently it has been suggested that plasma nitrate may be a discriminant indicator between infectious enterocolitis (IC) and IBD. To investigate this hypothesis we compared plasma and 24 h urinary nitrite and nitrate in 13 healthy controls, 44 patients with IBD [Crohn's disease (CD) n = 30; ulcerative colitis (UC) n = 14], 16 patients presenting with IC and seven chronic radiation enterocolitis (RE) patients.

RESULTS

Despite a trend towards higher plasma nitrate in IC (54.6+/-11.4 micromol/l) than in the other groups (CD: 38.4+/-4.8, UC: 34.8+/-8.4, RE: 34.7+/-7.5, controls: 31.1+/-5.2), this difference was not statistically significant. Urinary nitrate was higher in IBD, IC and RE than in controls, with no difference between these groups. Nitrite concentrations were not different. Nitrate levels were positively correlated with blood and 24 h urinary neopterin (e.g. plasma nitrate and blood neopterin: r = 0.54, P<0.0001), and in some cases, to C-reactive protein.

CONCLUSIONS

High nitrate (in our case only urinary nitrate) appears to be secondary to the magnitude of the inflammation rather than the aetiology of the diarrhoea. It should therefore more likely be considered as a marker of the severity of the inflammatory response rather than used as a discriminant indicator between IC and IBD patients.

Craniospinal axis irradiation in children. Treatment in supine position including field verification as a prerequisite for anesthesia without intubation

PURPOSE

For craniospinal axis irradiation in young children sometimes anesthesia is required. In order to minimize risks from the anesthesist's point of view supine position would be preferable to standard prone position. In case of irradiation in supine position verification of the 3-field junction in the cervical region causes problems, because there is no direct visual control. For such situations the clinical application of a new technique is presented.

PATIENTS AND METHODS

For treatment planning a modern 3D planning system was necessary. Patient's positioning was done by using a vacuum-form body immobilizer and an integrated head mask. Radiation fields were placed only by table movements being calculated by the planning system in relation to a reference point at the patient's surface. In addition to common verification films specially prepared small films were used for the 3-field junction in the cervical region. These films were placed close to the patient for the whole time of each radiation session being exposed by every radiation field.

RESULTS

Two children (age 3 and 5 years, respectively) were irradiated as described. Twenty-eight of those specially prepared films were exposed. Two films (7%) had to be excluded because of inadequate exposure. An overlap of radiation fields was seen on 1 of the 26 remaining films (4%), whereas an unacceptable gap was not found. Acute skin reactions were comparable to those observed in patients being irradiated in standard prone position.

CONCLUSION

The presented technique for craniospinal axis irradiation in supine position including field verification was not only precise and reproducable, but also comfortable and safe for the patient. We suggest it as a new option for craniospinal axis irradiation in children.