[Standardized and quality-assured predictive PD-L1 testing in the upper gastrointestinal tract. German version]

As a result of the high approval dynamics and the growing number of immuno-oncological therapy concepts, the complexity of therapy decisions and control in the area of carcinomas of the esophagus, gastroesophageal junction and stomach is constantly increasing. Since the treatment indication for PD‑1 inhibitors that are currently approved in the European Union is often linked to the expression of PD-L1 (programmed cell death-ligand 1), the evaluation of tissue-based predictive markers by the pathologist is of crucial importance for treatment stratification. Even though the immunohistochemical analysis of the PD-L1 expression status is one of the best studied, therapy-relevant biomarkers for an immuno-oncological treatment, due to the high heterogeneity of carcinomas of the upper gastrointestinal tract, there are challenges in daily clinical diagnostic work with regard to implementation, standardization and interpretation of testing. An interdisciplinary group of experts from Germany has taken a position on relevant questions from daily pathological and clinical practice, which concern the starting material, quality-assured testing and the interpretation of pathological findings, and has developed recommendations for structured reporting.

Standardized and quality-assured predictive PD-L1 testing in the upper gastrointestinal tract

As a result of the high approval dynamics and the growing number of immuno-oncological concepts, the complexity of treatment decisions and control in the area of cancers of the esophagus, gastroesophageal junction and stomach is constantly increasing. Since the treatment indication for PD-1 inhibitors that are currently approved in the European Union is often linked to the expression of PD-L1 (programmed cell death-ligand 1), the evaluation of tissue-based predictive markers by the pathologist is of crucial importance for treatment stratification. Even though the immunohistochemical analysis of the PD-L1 expression status is one of the best studied, therapy-relevant biomarkers for an immuno-oncological treatment, due to the high heterogeneity of carcinomas of the upper gastrointestinal tract, there are challenges in daily clinical diagnostic work with regard to implementation, standardization and interpretation of testing. An interdisciplinary group of experts from Germany has taken a position on relevant questions from daily pathological and clinical practice, which concern the starting material, quality-assured testing and the interpretation of pathological findings, and has developed recommendations for structured reporting.

Fibrosis inhibits ablation lesion formation in muscle tissue

Introduction

Myocardial fibrosis is a trigger for both atrial and ventricular arrhythmia. Ventricular fibrosis correlates with ventricular tachycardia, ventricular fibrillation, and sudden death. Besides medical therapy, radiofrequency (RF) ablation is an important therapeutical option to treat ventricular arrhythmia. Our study gains insights into effectivity of RF ablation depending on the degree of fibrosis.

Methods

Using a wet lab, we created with radiofrequency (RF) ablation lesions in parts of restructured beef with a defined, homogenous content of 0, 10, 20 and 50% fiber. We calculated the volume of ablation zones (called lesion volume below). Both common ablation modes low-power long-duration (LPLD: 30 W, 30 s) and high-power short-duration (HPSD: 70 W, 10 s) were tested. Lesion volumes of fibrotic beef were compared to lesion volumes of fibrotic-free beef using an ordinary ANOVA. The effect and interaction of fibrosis and ablation mode to the lesion volume was tested by a two-way ANOVA.

Results

Higher degrees of fibrosis create smaller lesion volumes (M = mean volume ablation zone): M (0%) = 322 mm3 (SD 187 mm3), M (10%) = 226 mm3 (SD 94.8), M (20%) = 217 mm3 (SD 103 mm3) and M (50%) = 186 mm3 (SD 92.7 mm2). Lesion volumes in fibrotic tissue differ significantly from lesion volumes in fibrotic-free tissue (F(3,124) = 6.94, p<0.001). There is a significant difference in lesion volumes for all degrees of fibrosis compared to fibrosis-free tissue (MD = mean difference of ablation zone volumes between 0% fibrosis and 10, 20 and 50% fibrosis): MD (0, 10%) = 95.6 mm3 (95% confidence interval (20.8–170), p=0.008), MD (0, 20%) = 105 mm3 (95% confidence interval (30.4–180), p=0.003) and MD (0, 50%) = 135 mm3 (95% confidence interval (60.7–210), p<0.001). We also found a significant difference in lesion volumes related to the content of fiber in a comparison of all groups (F(3,120) = 7,49, p≪0.001). There is no significant difference in lesion volumes related to the used ablation mode (F(1,120) = 2.89, p=0.09). There is also no significant difference in lesion volumes related to the interaction between the content of fiber and the ablation mode (F(3,120) = 1.23, p=0.3).

Conclusion

Lesions created by RF ablation are influenced by fibrosis. A higher content of fibrosis is associated with smaller lesion volumes. Neither LPLD nor HPSD ablation mode shows an advantage in fibrotic tissue.

Funding Acknowledgement

Type of funding sources: None.

Renal Contrast-Enhanced Sonography Findings in a Model of Acute Cellular Allograft Rejection

Noninvasive methods to diagnose and differentiate acute cellular rejection from acute tubular necrosis or acute calcineurin inhibitor toxicity are still missing. Because T lymphocytes play a decisive role in early states of rejection, we investigated the suitability and feasibility of antibody-mediated contrast-enhanced ultrasound by using microbubbles targeted to CD3(+) , CD4(+) , or CD8(+) T cells in different models of renal disease. In an established rat renal transplantation model, CD3-mediated ultrasound allows the detection of acute rejection as early as on postoperative day 2. Ultrasound signal intensities increased with the severity of inflammation. Further, an early response to therapy could be monitored by using contrast-enhanced sonography. Notably, acute tubular necrosis occurring after ischemia-reperfusion injury as well as acute calcineurin inhibitor toxicity could easily be differentiated. Finally, the quantified ultrasound signal correlated significantly with the number of infiltrating T cells obtained by histology and with CD3 mRNA levels, as well as with chemokine CXCL9, CXCL11, and CCL19 mRNA but not with KIM-1 mRNA expression, thereby representing the severity of graft inflammation but not the degree of kidney injury. In summary, we demonstrate that antibody-mediated contrast-enhanced ultrasound targeting T lymphocytes could be a promising tool for an easy and reproducible assessment of acute rejection after renal transplantation.

Noninvasive Imaging of Acute Renal Allograft Rejection by Ultrasound Detection of Microbubbles Targeted to T-lymphocytes in Rats

PURPOSE

We propose CD3-antibody-mediated contrast-enhanced ultrasonography using human T-lymphocytes for image-based diagnosis of acute allograft rejection (AR) established in a rat renal transplantation model.

MATERIALS AND METHODS

15 minutes after tail vein injection of 30 × 10(6) human T-lymphocytes, contrast media/microbubbles conjugated with an anti-human CD3 antibody was applied to uni-nephrectomized 10-week-old allogeneically transplanted male rats (Lewis-Brown Norway (LBN) to Lewis, aTX) and ultrasound was performed to investigate the transplanted kidney as well as the native kidney. In vivo results were confirmed via immunohistochemical stainings of CD3 after post mortem dissection. Syngeneically transplanted rats (LBN to LBN, sTX), rats with ischemia/reperfusion injury (IRI, 45 min. warm ischemia), and rats subjected to acute cyclosporin A toxicity (CSA) (cyclosporine 50 mg/kg BW for 2 days i. p.) served as controls.

RESULTS

Accumulation of human T-lymphocytes was clearly detected by antibody-mediated sonography und was significantly increased in allografts undergoing AR (5.41 ± 1.32 A. U.) when compared to native control kidneys (0.70 ± 0.08 A. U.). CD3 signal intensity was low in native kidneys, sTX (0.99 ± 0.30 A. U.), CSA (0.10 ± 0.02 A. U.) and kidneys with IRI (0.46 ± 0.29 A. U.). Quantification of the ultrasound signal correlated significantly with the T-cell numbers obtained by immunohistochemical analysis (R2 = 0.57).

CONCLUSION

Contrast-enhanced sonography using CD3-antibodies is an option for quick and highly specific assessment of AR in a rat model of renal transplantation.

Nachweis der verschiedenen Phasen und Phasenübergänge des Systems Fe-Ga im Konzentrationsbereich 25,7 bis 28,3 At-% Ga bei Temperaturen von 20 °C bis 720 °C mit Hilfe des Mössbauer- Effekts

Fe-Ga-absorbers, bcc-unordered at 20 °C, with 25.7, 27.0, and 28.3 at-% Ga were analyzed up to 720 °C with the Mössbauer effect in order to clear disagreements of former experiments of us with the then known phase diagrams. We found proofs for an ordering transition A2 -DO3 between 180 and 260 °C, a transition DO3 -Ll2 between 280 and 380 °C, a transition Ll2 -DO19 in a small temperature interval at 610 °C, and a further one DO19 - DO3 (or DO19-B2) at 630 °C. The temperature dependence of the magnetically induced Ll2-field gradient q was analyzed. Probably q is negative, while the direction of the magnetic field is parallel [1, 0, 0] in agreement with other experiments at low temperatures. Above 630 °C there seems to exist a further so far unknown ordered phase, which is probably non-cubic with at least two different Fe-sites. Our results are in considerable agreement with recently published phase diagrams, though some of our spectra allow different interpretations.

Exercise-induced adaptations of cardiac redox homeostasis and remodeling in heterozygous SOD2-knockout mice

A reduced expression of the manganese-dependent superoxide dismutase (SOD2) is characterized by increased cardiac oxidative stress. Oxidative stress has also been described in situations of physical exercise. We investigated the influence of physical exercise (EX; treadmill 1 h/day at 15 m/min, 5 days/wk, at an angle of 5° for a duration of 8 wk) on cardiac function [heart frequency (HF), echocardiography, morphometry], oxidative stress [reactive oxygen species (ROS)], and antioxidative defence capacity (peroxiredoxin 1–6) in male SOD2-knockout (SOD2_EX) and wild-type mice (WT_EX) compared with untrained age-matched animals (WT_CON; SOD2_CON). In SOD2_CON, heart weight, cardiomyocyte diameter, and cardiac ROS were significantly larger and peroxiredoxin isoforms 4–6 lower than in WT_CON. The vessel-to-cardiomyocyte ratio, cardiac VEGF-concentration, and cardiac function were similar in SOD2_CON and WT_CON. Both groups tolerated the exercise protocol well. In WT, exercise significantly increased vessel-to-cardiomyocyte ratio and ROS-generation and downregulated peroxiredoxin isoforms 4–6 and VEGF generation. The vessel-to-cardiomyocyte ratio, cardiac VEGF concentration, and cardiac ROS were not altered in SOD2_EX compared with SOD2_CON, but a significant upregulation of cardiac peroxiredoxin 1 and 4 was observed. Similar to the result observed in WT_EX, peroxiredoxin 3 was upregulated in SOD2_EX. Chronic exercise shifted the (mal)adaptive hypertrophic into a compensated dilated cardiac phenotype in SOD2_EX. In conclusion, downregulation of SOD2 induces a maladaptive cardiac hypertrophy. In this situation, physical exercise results in a further deterioration of cardiac remodeling despite an upregulation of the antioxidative defense system.

Responsiveness of adjacent ductal carcinoma in situ and changes in HER2 status after neoadjuvant chemotherapy/trastuzumab treatment in early breast cancer: Results from the GeparQuattro study (GBG 40)

6

Background: Adjacent ductal carcinoma in situ (DCIS) is in found in approximately 45% of invasive ductal carcinomas (IDC) of the breast. Pure DCIS overexpresses HER2 in approximately 45%. There is uncertainty whether adjacent DCIS impacts on the response to neoadjuvant chemotherapy and trastuzumab as well as whether HER2 expression in IDC component or adjacent DCIS changes throughout treatment.

Methods: Core biopsies and surgical tissue from participants of the GeparQuattro study with HER2-positive IDC were centrally examined for the area of invasive ductal component and adjacent DCIS before and after receiving neoadjuvant anthracycline-taxane-trastuzumab containing chemotherapy. HER2 overexpression in IDC and adjacent DCIS was quantified separately by immunohistochemistry using the Ventana automated staining system. Pathological complete response (pCR) was defined as no residual invasive or non-invasive tumor tissue.

Results: Fifty nine (37.3%) of 158 IDCs presented with adjacent DCIS at diagnosis. These tumors showed lower regression grades than pure IDC (p=0.033). Presence of adjacent DCIS was an independent negative predictor of pCR (odds ratio 0.42 [95% CI 0.2-0.9], p=0.027). Adjacent DCIS area decreased from pre-treatment to surgery (r=0.205) with 30 (50.8%) IDCs with adjacent DCIS showing complete eradication of adjacent DCIS. HER2 status of adjacent DCIS was highly correlated with HER2 status of IDC component before (r=0.892) and after treatment (r=0.676). Degree of HER2 overexpression of the IDC component decreased in 16 (33.3%) out of 49 patients without a pCR. These 16 IDCs showed lower RGs compared to the 33 IDCs with unchanged HER2 expression (p=0.055).

Conclusions: HER2-positive IDCs with adjacent DCIS is less responsive to neoadjuvant chemotherapy and trastuzumab compared to pure IDC. However, complete eradication of adjacent DCIS is frequently observed. HER2-overexpression of the invasive ductal component decreases in a subset of tumors, which showed less tumor regression.

Epstein-Barr virus-associated diffuse large B-cell lymphoma of the hypopharynx

PROBLEMS/OBJECTIVES

Epstein-Barr virus (EBV) is commonly associated with nasopharyngeal carcinoma and Burkitt's lymphoma, but association with hypopharyngeal and laryngeal tumours is rare. To the best of our knowledge, this is the first case report of an EBV-associated diffuse large B-cell lymphoma (DLBCL) of the hypopharynx.

METHODOLOGY

A 63-year-old male patient suffering from chronic lymphocytic leukemia presented with swallowing disorders and a sore throat. Panendoscopy with laser surgical resection of tissue specimens was performed.

RESULTS

Immunohistochemical and molecular genetic diagnostics, including EBV-encoded small RNA in situ hybridization, confirmed the diagnosis of an EBV-associated DLBCL of the hypopharynx. Ten weeks after the diagnosis, the patient died of disease related to multiple complications.

CONCLUSIONS

We hypothesize that the EBV infection was triggered by long-term immunosuppressive therapy that led secondarily to the development of a DLBCL. Otorhinolaryngologists should keep in mind that lymphomas might develop in the entire pharynx.

Total beta-adrenoceptor deficiency results in cardiac hypotrophy and negative inotropy

The present study investigated cardiac function in hearts of mice with total deficiency of the beta1-, beta2- and beta3-adrenoceptors (TKO) in comparison to wildtype mice (WT). We investigated cardiac morphology and echocardiographic function, measured protein expression of Ca2+-regulatory proteins, SERCA 2a activity, myofibrillar function, and performed running wheel tests. Heart weight and heart-to-body weight ratio were significantly smaller in TKO as compared to WT. This was accompanied by a decrease in the size of the cardiomyocytes in TKO. Heart rate and ejection fraction were significantly diminished in TKO as compared to WT. Protein expressions of SERCA 2a, ryanodine receptor and Na+/Ca2)-exchanger were similar in TKO and WT mice, but phospholamban protein expression was increased. PKA-dependent phosphorylation of phospholamban at serine 16 was absent and CaMKII-dependent phosphorylation at threonine 17 was decreased in TKO. All alterations were paralleled by a decrease in SERCA 2a-activity. A similar maximal calcium-dependent tension but an increased myofibrillar calcium-sensitivity was measured in TKO as compared to WT. We did not observe relevant functional impairments of TKO in running wheel tests. In the absence of beta-agonistic stimulation, SERCA 2a activity is mainly regulated by alterations of phospholamban expression and phosphorylation. The decreased SERCA 2a activity following beta-adrenoceptor deficiency may be partly compensated by an increased myofibrillar calcium-sensitivity.

eNOS phosphorylation and translocation are altered in male but not female mice by increased activation of the Gαq protein

Little is known about sex-dependent physiological and pathophysiological differences in cardiac endothelial nitric oxide synthase (eNOS) expression and activation. Therefore, we investigated cardiac morphology and eNOS protein expression, including its translocation-dependent activation and phosphorylation, in cardiac tissue of male and female wild-type mice and transgenic heart-failure mice having a cardiac-specific, 5-fold overexpression of the Gαq protein. In addition, we measured calcineurin protein expression. Heart-to-body weight ratio was increased in Gαq mice. Female wild-type mice showed higher eNOS protein expression and activation (translocation and phosphorylation) than did wild-type males. In cardiac tissue of Gαq mice, these sex-dependent differences remained or were enhanced. Protein expression of the catalytic subunit calcineurin A, which has been shown to dephosphorylate eNOS, was higher in wild-type males than in wild-type females. These differences were increased in the Gαq mice model. We conclude that sex differences exist in cardiac eNOS protein expression and phosphorylation. Increased activation of the Gαq protein appears to alter eNOS protein expression and phosphorylation only in males.

Resolution of refractory ascites after transcoronary septal ablation for hypertrophic obstructive cardiomyopathy in a cirrhotic patient

This report presents the first case of complete resolution of ascites after transcoronary ablation of septal hypertrophy (TASH) in a cirrhotic patient with concomitant hypertrophic cardiomyopathy (HOCM). A 52-years-old woman with decompensated alcoholic liver cirrhosis was referred to our department for placement of a transjugular intrahepatic portosystemic stent shunt (TIPS) to treat her refractory ascites. The initial treatment with furosemide and spironolactone had to be discontinued because of severe hyponatriemia and an increase of creatinine levels. During further evaluation, HOCM was diagnosed by echocardiography and cardiac catheterization. We performed TASH in order to relieve the dynamic obstruction of the ventricular outflow tract, and the ascites completely resolved without further interventions.

One Step Nucleic Acid Amplification (OSNA) for intra-operative detection of lymph node metastases in breast cancer patients

21053

Background: Sentinel lymph node metastasis in breast cancer patients has conventionally been determined by intra- operative histopathological examination of frozen sections followed by definitive post-operative examination of permanent sections. The purpose of this study is to evaluate a more efficient method for intra-operative detection of lymph node metastasis in a clinical setting. Therefore, a new rapid method of detection of CK19 mRNA by One Step Nucleic Acid Amplification (OSNA) and Reverse Transcription Loop Mediated Isothermal Amplification (RT-LAMP) was tested against standard histological techniques. Methods: The clinical study was conducted at two facilities using 188 lymph nodes (46 patients). Lymph nodes from axillary dissected patients with breast cancer were divided into four slices. Alternate slices were used for the new method of CK19 mRNA detection (OSNA) and histopathological examination by hematoxylin & eosin and cytokeratin staining. For the analysis of concordance between both methods, the slices for histopathology were cut in 4 μm sections. For the OSNA method the other 2 slices were homogenised in a short sample preparation step. Afterwards CK19 mRNA was directly amplified from the tissue lysate within 16 minutes. Results: In the clinical study, an overall concordance rate between the OSNA assay and histopathology was 92%. Several discordant results are explainable with the expected uneven distribution of metastases within the lymph nodes. Conclusions: The study indicates that OSNA is a reliable and fast diagnostic tool for the detection of lymph node metastases in breast cancer patients. This method could be beneficial to avoid diagnostic delay for the patient or second surgery based on a post-operatively diagnosed positive lymph node.

No significant financial relationships to disclose.

Biliary metal stents and air embolism: a note of caution

Metal stents are a valuable treatment modality for patients with biliary obstruction. However, we present here two patients whose cases may serve as a warning about an unusual complication associated with these stents. We encountered this complication after endoscopic retrograde cholangiography for obstructed metal biliary stents. The first patient, an 87-year-old man with a benign biliary stricture, failed to regain consciousness after clearing of his stent using a Dormia basket and balloon catheter. Cerebral air embolism was diagnosed on cerebral computed tomography, and transesophageal echocardiography revealed a patent foramen ovale as a precipitating factor for paradoxical air embolism. He survived and was discharged with a residual hemiparesis. In the second patient, a 54-year-old man who had a history of a Billroth II operation and chronic pancreatitis and who had a portal cavernoma with biliary obstruction due to collateral veins, electromechanical dissociation complicated the balloon-catheter stent revision. Echocardiography performed during cardiopulmonary resuscitation showed major air embolism to the right heart. The patient died. These cases demonstrate that air may gain access to the venous system during therapeutic endoscopic procedures of this type. It is likely that the large diameter of metal stents and the potential for these stents to lacerate venous structures facilitate the entry of air into the venous circulation, an event which may have life-threatening consequences.

Ruptured sinus of Valsalva aneurysm in two patients with subarterial ventricular septal defect

Rupture of a sinus of Valsalva aneurysm (SVA) is a rare, but life-threatening, event and requires immediate recognition and intervention. We present two previously healthy and physically active patients who were 12 and 33 years of age when rupture of a right coronary SVA into the right ventricle occurred. A subarterial ventricular septal defect (VSD) was detectable in both patients. Cardiac surgery involved VSD closure as well as reconstruction of the aortic valve. Considering complications of subarterial VSD, such as aortic cusp prolapse, aortic insufficiency or SVA, we suggest close follow-up and surgical closure of the VSD in case of any aortic valve deformity.

[Long-term fate of left atrial thrombi and incidence of cerebral embolism under continuous anticoagulation therapy]

PURPOSE

Patients (pts.) with atrial fibrillation (AF) and atrial thrombi are known to have an increased risk for cerebral embolism. However, little is known about the clinical course of atrial thrombi and the incidence of cerebral embolism in those patients during anticoagulation therapy. The high sensitivity of MR imaging (MRI) including diffusion-weighted imaging (DWI) suggests that this technique could provide an improved estimate of cerebral embolism associated with the presence of left atrial thrombi. The aims of this prospective study were to evaluate 1) the prevalence of clinically silent and apparent cerebral embolism in pts. with newly diagnosed AF and atrial thrombi using MRI/DWI, 2) the long-term fate of atrial thrombi under continues anticoagulation therapy and 3) the incidence of cerebral embolism during a follow-up period of 12 months with continuous anticoagulation therapy.

MATERIALS AND METHODS

The study group consisted of 32 pts. with 1) newly diagnosed AF and evidence of left atrial (LA) thrombi detected by TEE and 2) a new start of anticoagulation therapy [International Normalized Ratio (INR) 2.0 - 3.0]. 19 pts. with 1) newly diagnosed AF and no evidence of atrial thrombi and 2) an equivalent anticoagulation regimen served as the control group. In both groups a) MRI/DWI studies of the brain (weeks 0, 4, 8, 12, 20, 28, 36, 44, and 52), b) transesophageal echocardiographic studies (TEE) for assessment of LA-Thrombi (weeks 0 and 52) and c) clinical neurological assessments (weeks 0, 20 and 52) were performed.

RESULTS

In the study group (AF and LA-Thrombi) 11 out of 32 pts. (34 %) displayed signs of acute (n = 8) or chronic (n = 3) cerebral embolism in the initial MRI studies. In 4 out of 32 pts. (13 %), MRI/DWI depicted new or additional cerebral emboli (n = 12) during the follow-up period despite continuous anticoagulation therapy. 2 (n = 2/4; 50 %) of these patients had clinically apparent neurological deficits. In the control group 1 out of 19 pts. (5 %) showed evidence of chronic cerebral embolism as assessed by MRI/DWI at the beginning of the study (week 0). No embolic cerebral lesions were detected during the 12-month follow-up. Within 12 months only 63 % (n = 20/32) of LA thrombi in the study group resolved completely under anticoagulation.

CONCLUSION

1. The incidence of clinically inapparent cerebral emboli in pts. with newly diagnosed AF and atrial thrombi is much higher than the incidence of clinically apparent emboli and has been underestimated in the past. 2. New cerebral embolism may occur even with continued effective anticoagulation therapy in 13 % of pts. 3. Only 63 % of atrial thrombi resolve completely within 12 months under anticoagulation therapy.

3D motion adapted gating (3D MAG): a new navigator technique for accelerated acquisition of free breathing navigator gated 3D coronary MR-angiography

This study aimed to evaluate the influence of a new navigator technique (3D MAG) on navigator efficiency, total acquisition time, image quality and diagnostic accuracy. Fifty-six patients with suspected coronary artery disease underwent free breathing navigator gated coronary MRA (Intera, Philips Medical Systems, 1.5 T, spatial resolution 0.9x0.9x3 mm3) with and without 3D MAG. Evaluation of both sequences included: 1) navigator scan efficiency, 2) total acquisition time, 3) assessment of image quality and 4) detection of stenoses >50%. Average navigator efficiencies of the LCA and RCA were 43+/-12% and 42+/-12% with and 36+/-16% and 35+/-16% without 3D MAG (P<0.01). Scan time was reduced from 12 min 7 s without to 8 min 55 s with 3D MAG for the LCA and from 12 min 19 s to 9 min 7 s with 3D MAG for the RCA (P<0.01). The average scores of image quality of the coronary MRAs with and without 3D MAG were 3.5+/-0.79 and 3.46+/-0.84 (P>0.05). There was no significant difference in the sensitivity and specificity in the detection of coronary artery stenoses between coronary MRAs with and without 3D MAG (P>0.05). 3D MAG provides accelerated acquisition of navigator gated coronary MRA by about 19% while maintaining image quality and diagnostic accuracy.

3D Motion Adapted Gating: Eine neue Navigatortechnik zur Verkürzung der Messzeit bei der MR-Koronarangiographie

PURPOSE

A major problem of free breathing coronary MR angiography (MRA) with respiratory navigator gating is low navigator efficiency and prolonged scan time due to irregular breathing patterns. 3D motion adapted gating (MAG) is a new adaptive navigator technique, which adapts in real time to changes of the end-expiratory position of diaphragm. This study evaluates the influence of 3D MAG on coronary MRA.

METHODS AND MATERIALS

In 3D MAG, two additional gating windows are grouped around the conventional window. Additionally, each gating window is divided into three bands assigned to different portions of the k-space. The scan is terminated when three consecutive bands are filled and one complete image data set is collected. Free breathing navigator-gated coronary MRA was performed on 48 patients with suspected coronary artery disease. In random order, each patient underwent an ECG-gated, a 3D segmented k-space gradient echo sequence using 3D MAG and a conventional navigator technique. The coronary MRA was evaluated and compared using the following parameters: 1. navigator efficiency and scan time; 2. visualized coronary artery length; 3. qualitative assessment of image quality; and 4. detection of stenoses > 50 % in comparison with catheter angiography.

RESULTS

Coronary MRA with 3D MAG had a significant increase in the average navigator efficiency (46 % +/- 12 % vs. 38 % +/- 12 %, p < 0.05), resulting in a significantly shorter scan time (mean: 18 % +/- 4 %, p < 0.05) for coronary MRA with 3D MAG compared to conventional navigator technique. Scans with and without 3D MAG had no significant differences in the continuously visualized vessel lengths, in the assessed image quality and in the sensitivity and specificity (83 % and 89 % vs. 83 % and 88 %, p > 0.05) of detecting coronary artery stenoses > 50 %.

CONCLUSION

The 3D MAG technique improves the navigator efficiency and significantly (p < 0.05) shortens the scan time of navigator gated coronary MRA while maintaining image quality and diagnostic accuracy in the detection of coronary artery stenoses.

Wert der Applikation von Nitroglycerin bei der 3D-MR-Koronarangiographie mit Echtzeit-Navigatortechnik

PURPOSE

Nitroglycerin administration results in dilation of epicardial coronary vessels and in an increase in coronary blood flow, and has been suggested to improve MR coronary angiography. This study evaluates systematically whether administration of nitroglycerin improves the visualization of coronary arteries and, as a result, the detection of coronary artery stenosis during free breathing 3D coronary MR angiography.

MATERIALS AND METHODS

Coronary MR angiography was performed in 44 patients with suspected coronary artery disease at a 1.5 Tesla System (Intera, Philips Medical Systems) (a) with and (b) without continuous administration of intravenous nitroglycerin at a dose rate of 2.5 mg/h, using an ECG gated gradient echo sequence with real-time navigator correction (turbo field echo, in-plane resolution 0.70 x 0.79 mm(2), acquisition window 80 ms). Equivalent segments of the coronary arteries in the sequences with and without nitroglycerin were evaluated for visualized vessel length and diameter, qualitative assessment of visualization using a four point grading scale and detection of stenoses > 50 %. Catheter coronary angiography was used as a gold-standard.

RESULTS

No significant differences were found between scans with and without nitroglycerin as to average length of the contiguously visualized vessel length (p > 0.05) and diameter (p > 0.05). There was also no significant difference in the coronary MR angiography with and without nitroglycerin in the average qualitative assessment score of the visualization of LM, proximal LAD, proximal CX, and proximal and distal RCA (2.1 +/- 0.8 and 2.2 +/- 0.7; p > 0.05). Sensitivity (77 % [17/22] vs. 82 % [18/22] p > 0.05) and specificity (72 % [13/18] vs. 72 % [13/18] p > 0.05) for the detection of coronary artery stenosis also did not differ significantly between scans with and without intravenous administration of nitroglycerin.

CONCLUSION

Administration of nitroglycerin does not improve visualization of the coronary arteries and detection of coronary artery stenosis in free breathing 3D coronary MR angiography.

[Determination of the renal blood flow in macro- and microcirculation by means of pulse inversion imaging]

PURPOSE

To evaluate whether real-time and intermittent pulse inversion technology (PI) allows the analysis of blood flow in renal macro- and microcirculation.

MATERIALS AND METHODS

The experiments were performed in a kidney perfusion phantom as an experimental model for the assessment of contrast replenishment in vascular regions of high flow velocity (medulla) and low flow velocity (cortex). During continuous infusion (0.03 ml/min) of Optison, contrast replenishment kinetics were assessed with intermittent PI at high emission power (MI: 1.3, with increasing trigger intervals) and with real-time PI at low emission power (MI: 0.09) at variable renal arterial blood flow (15 - 65 ml/min), using an HDI-5000 ultrasound unit (Philips Medical Systems). Regions of interest were placed in the major arteries of the medulla and the renal cortex to obtain replenishment curves of the macro- and microcirculation. Non-linear curve fitting was performed using the mathematical model y = A (1-e (-beta t)) with A as the parameter describing blood volume and beta as the parameter describing the speed of contrast replenishment.

RESULTS

Replenishment curves could be obtained in all analyzed renal segments. For intermittent and real-time PI a strong linear correlation was found between renal arterial blood flow and A*beta (intermittent PI: cortex: R = 0.97; medulla: R = 0.98; real-time PI: cortex: R = 0.99; medulla: R = 0.96). The differences between the slopes of the regression lines (cortex: high power vs. low power, p = 0.844; medulla: high power vs. low power, p = 0.444) were not significant.

CONCLUSION

Intermittent and real-time PI allows the assessment of renal blood flow in different vessel compartments.

Tumour suppression induced by the macrophage activating lipopeptide MALP-2 in an ultrasound guided pancreatic carcinoma mouse model

BACKGROUND AND AIM

Carcinoma of the exocrine pancreas has a particularly poor prognosis. Therefore, novel therapeutic strategies such as immunotherapy are required. Here we investigated the immunomodulatory capacity of macrophage activating lipopeptide 2 (MALP-2), which binds to toll-like receptors 2 and 6 and induces activation of nuclear factor kappaB in monocytes. This causes the release of early stage leucocyte attracting chemokines and proinflammatory cytokines.

METHODS

MALP-2 was tested in a new orthotopic ultrasound guided pancreatic cancer mouse model. This model is close to the biological situation and avoids the stress and immunostimulation caused by laparotomy. Cells from the syngeneic, highly aggressive, and metastatic cell line Panc 02 were administered orthotopically, by ultrasound guidance, to C57bl/6 mice. MALP-2 was administered intratumorally or intraperitoneally and tumour growth, immune status, and leucocyte infiltration at the tumour site were determined.

RESULTS

We showed a tumour suppressive effect induced by a single injection of MALP-2. Median survival increased from 21 to 30 days (p<0.002). Combining chemotherapy (gemcitabine) with MALP-2 treatment caused further prolonged survival (median survival 27 days with chemotherapy alone v 37 days for combined treatment; p<0.0002). The life prolonging effect was paralleled by a significant increase in cytotoxic T cells, restoration of beta2 integrin expression on lymphocytes, and high expression of CD45RB on T helper cells. Immunohistochemical stains showed strong cytotoxic T lymphocyte and natural killer cell infiltration.

CONCLUSIONS

In conclusion, in a model of orthotopic pancreatic cancer in mice, we induced a tumour suppressive effect by treatment with a synthetic lipopeptide. Treatment with MALP-2 could be an option for immunotherapy in pancreatic cancer.

Transcatheter PFO closure with a prominent Eustachian valve

We report the successful PFO closure in a 57-year old woman with complex atrial anatomy. To avoid the risk of interfering with the occluder device due to a prominent Eustachian valve, a Helex Septal Occluder was implanted. Differential therapeutic considerations and specific device characteristics are outlined.

Do we still need CK-MB in coronary artery bypass grafting surgery?

AIM

The aim of this study was to evaluate the role of cardiac Troponin I (cTnI) and CK-MB for early prediction of outcome of patients undergoing coronary artery bypass grafting (CABG) surgery.

METHODS

In 134 consecutive patients undergoing CABG-surgery blood samples were analyzed for cTnI concentration and CK-MB activity. ECG, hemodynamic parameters and the need for inotropic support, were continuously registered. Patients were divided into group A (uneventful course), group B (ischemia by ECG, hemodynamic stability) and group C (ischemia by ECG and IABP).

RESULTS

After removal of X-clamp an increase cTnI and CK-MB was observed in all patients. Five hrs after stop of CPB group A (8.3+/-4.2 microg/L) had lower cTnI values compared to group B (14.8+/-5.3 microg/L) (p=0.035) and C (54+/-22.8 microg/L) (p=0.023). The cut off value was 14.8 microg/L. Sensitivity and specificity (99%/97%) was higher for cTnI than for CK-MB (90%/30%). The positive predictive value of outcome was better for cTnI (86%) than for CK-MB (33%).

CONCLUSION

CTnI is a specific and sensitive marker for evaluation of perioperative myocardial ischemia (PMI). Additional determination of CK-MB activity does not provide further clinical information. CTnI should be the marker of first choice in CABG surgery.

Use of hop (Humulus lupulus) agricultural by-products for the reduction of aqueous lead(II) environmental health hazards

The agricultural by-products of the hop plant (Humulus lupulus L.) were investigated to determine their potential for use in the removal of heavy lead(II) ions from contaminated aqueous solutions. Separate batch laboratory experiments were performed to establish the optimal binding pH, time exposures, and capacity of the metal adsorption for lead(II) ions by dried and ground hop leaves and stems biomass. Results from these studies have shown a pH dependent binding trend from pH 2-6, with optimum binding occurring around pH 5.0. Time dependency experiments showed a rapid adsorption of lead(II) ions within the first 5 min of contact. Binding capacity experiments demonstrated that 74.2mg of lead(II) were bound per gram of leaf biomass. Similarly overall capacity was seen for the leaves and stems. Desorption of 99% of the bound lead(II) ions was achieved by exposing the metal laden biomass to 0.5M sodium citrate. Further experiments were performed with silica-immobilized hop tissues to determine the lead(II) binding ability under flow conditions. Comparison studies were performed with ion-exchange resins to evaluate the binding ability and to gain further insight into the metal binding mechanism. X-ray absorption spectroscopy experiments were also utilized to gain further insight into the possible lead(II) binding mechanism by the hop plant tissue. Results from these studies indicate that carboxyl ligands are involved in the binding of lead(II) from aqueous solution. These findings show that the use of hop agricultural waste products may be a viable alternative, for the removal and recovery of aqueous lead(II) ions from contaminated waters.

Subendocardial steal effect seen with real-time perfusion imaging at low emission power during adenosine stress: replenishment M-mode processing allows visualization of vertical steal

We present a patient in whom power pulse inversion imaging clearly demonstrated a subendocardial myocardial perfusion defect during contrast vasodilator stress using adenosine. The defect was best appreciated with M-mode postprocessing of power pulse inversion imaging data.

The impact of emission power on the destruction of echo contrast agents and on the origin of tissue harmonic signals using power pulse-inversion imaging

The purpose of this study was to determine the impact of emission power on ultrasound (US)-induced destruction of echocontrast microbubbles during real-time power pulse inversion imaging (PPI) in myocardial contrast echocardiography (MCE) and to evaluate the magnitude of noncontrast PPI signals arising from myocardial tissue at variable emission power to define the cut-off emission power for optimal MCE using low power technologies. In vitro studies were performed in a flow phantom using Optison, Definity and AFO 150. PPI signal intensity during real-time imaging at 27 Hz was compared with intermittent imaging at 0.1 Hz to evaluate bubble destruction at variable emission power (MI: 0.09 to 1.3). In healthy volunteers, PPI signal intensities during constant infusion of Optison(R) was studied in real-time PPI 22 HZ and during intermittent imaging triggered end-systolic frames every, every 3rd and every 5th cardiac cycle. In addition, the impact of emission power on nonlinear PPI signals from myocardial structures was studied. In vitro, there was a 40% decrease of real-time PPI signal intensity for Optison and AFO 150 at lowest emission power (0.09), whereas no signal loss was observed for Definity. Increase of emission power resulted in a faster decay for Optison(R) and AFO 150 as compared to Definity. In vivo, real-time PPI during continuous infusion of Optison(R) resulted in a 40% decrease of myocardial signal intensity as compared to intermittent imaging every 5th cardiac cycle, even at lowest possible emission power (mechanical index = 0.09). There was a strong positive relationship between MI and noncontrast myocardial PPI signals in all myocardial segments. PPI signal intensity was found to be lower than 1 dB only for extremely low emission power (MI < 0.2). Destruction of microbubbles during real-time imaging by use of PPI at low emission power varies considerably for different echo contrast agents. However, bubble destruction and the onset of tissue harmonic signals focus the use of real-time perfusion imaging to very low emission power.

Continuous-infusion contrast-enhanced US: in vitro studies of infusion techniques with different contrast agents

PURPOSE

To evaluate the infusion properties of three ultrasonographic (US) contrast agents and to compare different infusion techniques for achieving constant signals during harmonic power Doppler US.

MATERIALS AND METHODS

In vitro studies were performed in a flow phantom. SH U 508A, NC100100, or FS069 was continuously infused at clinically usable doses and infusion rates. To assess agent-specific physical properties, these agents were administered by using a vertically fixed infusion pump and varying infusion start times. The contrast agents were administered by also using a horizontally oriented infusion pump that was either fixed or continuously rotated to homogenize the agent in the syringe.

RESULTS

With SH U 508A and NC100100, constant signals were achieved, regardless of the infusion modality used. Compared with conventional infusion, the continuous homogenization of SH U 508A, although not necessary for signal constancy, increased the agent's usefulness (P <.05). With FS069, only continuous homogenization yielded constant signals (P <.001).

CONCLUSION

Continuous infusion of SH U 508A or NC100100 provided constant harmonic power Doppler US signals, regardless of the infusion modality used. Because of the special physical properties of FS069, only homogenization produced constant harmonic power Doppler US signals during continuous infusion of this agent.

Feasibility of the flash-replenishment concept in renal tissue: which parameters affect the assessment of the contrast replenishment?

The purpose of the study was to evaluate whether power pulse inversion (PPI) and pulse inversion (PI) techniques allow the measurement of indices of microcirculatory flow in real-time at low emission power using contrast microbubbles. PPI and PI imaging were performed in a kidney perfusion model during continuous infusion of Definity (0.12 mL/min). At steady state of tissue enhancement, contrast was destroyed by emission of echo bursts at high emission power (MI = 1.3). Consecutively, contrast replenishment was assessed at low emission power (MI = 0.09) in real-time imaging modes (PPI: 12 Hz; PI: 25 Hz). Regions-of-interest (ROI) of variable sizes were placed in the renal cortex and bigger arteries to compare replenishment of macro- and microcirculation. Nonlinear curve fitting was performed using the mathematical model y=s+A(1-e(-betat)), with A as the parameter describing blood volume and beta as a parameter describing the speed of microbubble contrast replenishment. Replenishment curves could be visually appreciated and quantitatively analyzed in all renal segments. A was significantly higher in bigger arteries compared to renal cortex (p < 0.001). beta was found to be significantly higher in the arteries as compared to the cortex (p < 0.001). The SD of beta diminishes with increasing size of the ROI. The acquisition of replenishment curves following ultrasound (US)-induced destruction of contrast microbubbles is feasible at low power using PPI and PI. Assessment of replenishment kinetics allows the differentiation between macro- and microcirculation. Size and position of the ROI have an important impact on the generation of replenishment curves in both imaging modalities, which has to be taken into account.

Blood flow assessment by ultrasound-induced destruction of echocontrast agents using harmonic power Doppler imaging: which parameters determine contrast replenishment curves?

OBJECTIVE

To evaluate the feasibility of flow determinations by contrast replenishment using harmonic power Doppler imaging (H-PDI).

BACKGROUND

The application of indicator dilution principles on contrast echocardiography is limited by numerous methodical problems. Recently, a new method was introduced that relies on ultrasound-mediated microbubble destruction and evaluation of the contrast replenishment.

METHODS

Definity, a perfluorocarbon-derived contrast agent under development, was continuously infused into a steady flow phantom and H-PDI registrations were performed within a silicone tube (d = 8 mm). Replenishment interval between destruction and imaging frame was varied from 0.04-2 seconds. Nonlinear curve fitting was performed using an exponential mathematical model.

RESULTS

Strong linear correlation between contrast dose and maximum signal intensity as well as between flow and the slope variable beta of the replenishment curve was found for all settings (r > 0.96). Maximum signal intensity and contrast replenishment rate were found to be a function of emission power and were significantly influenced by depth and focus position.

CONCLUSION

The feasibility of flow assessment using replenishment curves obtained by H-PDI was demonstrated. However, in experimental conditions, flow analysis was severely influenced by ultrasound system settings and imaging conditions such as emission power, sound field geometry, and investigation depth. For a clinical use of this promising approach, algorithms that take specific system settings and imaging conditions into account have to be found. Imaging modalities that enable a most homogeneous scan field are best suited for the assessment of contrast replenishment.

[Myocardial contrast echocardiography. Research instrument or already clinical application?]

Increasing interest has been focused on myocardial contrast echocardiography (MCE) since latest imaging technologies allow the detection of echocontrast agents within myocardial structures following intravenous injections. Although numerous studies on different aspects of pre-clinical and clinical applications have been published, MCE has not yet become a standard clinical application. This paper summarises and estimates the clinical value of the recent developments in this evolving field of research, particularly with regard to the new real-time perfusion imaging technologies.

Incidence of left atrial thrombi in patients in sinus rhythm and with a recent neurologic deficit

OBJECTIVES

We sought to determine the incidence of left atrial (LA) thrombi in patients in sinus rhythm (SR) and with a recent neurologic deficit and to analyze the relation between LA thrombi and LA chamber and appendage function in patients in SR.

METHODS

A prospective study was conducted in 869 consecutive patients. The study group consisted of 583 patients in SR (67%). The remaining 286 patients had atrial fibrillation (AF) and served as controls (33%).

RESULTS

The incidence of LA thrombi was significantly higher in patients with AF (n = 39 [14%]) compared with patients in SR (n = 6 [1%]; P <.001). Three of 6 patients with thrombi in SR had mitral stenosis, 1 patient had aortic stenosis, 1 patient had coronary artery disease, and another patient had a cardiomyopathy. Of the patients with detected thrombi, those in SR did not receive anticoagulation, whereas those with AF did in 18 cases. Patients with thrombi in SR and with AF did not significantly differ in LA diameter (5.1 +/- 0.8 cm vs 4.8 +/- 0.7 cm; 95% confidence interval [CI], -0.78 to 0.45), left ventricular ejection fraction (46% +/- 13% vs 42% +/- 15%; 95% CI, -18.7 to 7.4), LA appendage area (5.8 +/- 2.7 cm(2) vs 6.7 +/- 3.2 cm(2); 95% CI, -1.9 to 3.6), peak emptying velocity of the LA appendage (0.19 +/- 0.08 m/s vs 0.17 +/- 0.07 m/s; 95% CI, -0.08 to 0.04), or LA spontaneous echo contrast (3. 5 +/- 0.6 vs 3.9 +/- 0.5; 95% CI, -0.06 to 0.45).

CONCLUSIONS

LA appendage thrombi are an infrequent cause of thromboembolism in patients in SR and are associated either with mitral valve disease or LA chamber and appendage dysfunction. Routine transesophageal echocardiography for the exclusion of LA thrombi is not recommended in patients in SR without underlying heart disease and normal LA function as assessed by transthoracic echocardiography.

[Transthoracic echocardiography in endocarditis: a comparison of conventional and harmonic echocardiography]

BACKGROUND AND OBJECTIVE

Compared with conventional echocardiography (CEC) harmonic imaging (HEC) provides better resolution of the endocardial line and valvular apparatus. This prospective study was undertaken to compare the value of harmonic and conventional transthoracic echocardiography in endocarditis and compare them with standard transoesophageal echocardiography (TOE) and operative findings.

PATIENTS AND METHOD

Conventional and harmonic echocardiographic imaging was compared in 30 patients (aged 58 +/- 17 years; 19 males and 11 females) with endocarditis clinically judged to require surgical intervention. The results of both methods were then compared with those of standard TOE and the intraoperative findings.

RESULTS

Intraoperatively 15 floating structures, 9 abscesses and 5 perforations were demonstrated. Transoesophageal echocardiography was better than the standard method in diagnosing floating structures and detecting abscesses (15 vs. 10 vegetations, p < 0.05; 7 vs. 5 abscesses, p = 0.05). TOE was better than either method in the diagnosis of abscess.

CONCLUSION

Harmonic transthoracic echocardiography is better than the conventional mode in diagnosing complications of endocarditis.