Tc-99m DTPA Perfusion Scintigraphy and Color Coded Duplex Sonography in the Evaluation of Minimal Renal Allograft Perfusion

Aim: The clinical impact of perfusion scintigraphy versus color coded Duplex sonography was evaluated, with respect to their potential in assessing minimal allograft perfusion in vitally threatened kidney transplants, i.e. oligoanuric allografts suspected to have either severe rejection or thrombosis of the renal vein or artery. Methods: From July 1990 to August 1994 the grafts of 15 out of a total of 315 patients were vitally threatened. Technetium-99m DTPA scintigraphy and color coded Duplex sonography were performed in all patients. For scintigraphic evaluation of transplant perfusion analog scans up to 60 min postinjection, and time-activity curves over the first 60 sec after injection of 370-440 MBq Tc-99m diethylenetriaminepentaacetate acid (DTPA) were used and classified by a perfusion score, the time between renal and iliac artery peaks (TDiff) and the washout of the renogram curve. Additionally, evaluation of excretion function and assessment of vascular or urinary leaks were performed. By color coded Duplex sonography the perfusion in all sections of the graft as well as the vascular anastomoses were examined and the maximal blood flow velocity (Vmax) and the resistive index (Rl) in the renal artery were determined by means of the pulsed Doppler device. Pathologic-anatomical diagnosis was achieved by either biopsy or post-explant histology in all grafts. Results: Scintigraphy and color coded Duplex sonography could reliably differentiate minimal (8/15) and not perfused (7/15) renal allografts. The results were confirmed either by angiography in digital subtraction technique (DSA) or the clinical follow up. Conclusion: In summary, perfusion scintigraphy and color coded Duplex sonography are comparable modalities to assess kidney graft perfusion. In clinical practice scintigraphy and color-coded Doppler sonography can replace digital subtraction angiography in the evaluation of minimal allograft perfusion.

Accuracy of endoscopic ultrasound in preoperative staging of esophageal cancer: results from a referral center for early esophageal cancer

BACKGROUND AND STUDY AIM

Endoscopic ultrasound (EUS) has been regarded as the most accurate staging tool in esophageal cancer. Staging results have a strong impact on the decision as to whether a patient should undergo endoscopic treatment, surgery alone, or neoadjuvant therapy. This retrospective study was conducted to analyze the accuracy of esophageal cancer staging using EUS.

METHODS

All patients who received EUS for staging of esophageal cancer before esophagectomy from February 2003 to December 2007 at a high volume academic tertiary care center were included.

RESULTS

179 consecutive patients (mean age 64.4 +/- 9.5 years; 142 men) underwent esophageal resection for Barrett's adenocarcinoma (n = 134) and squamous cell cancer (n = 45). Postoperatively, 99 patients were staged as having T1 cancers (55 %), 30 patients T2 (17%), 46 patients T3 (26%), and four patients T4 (2%). The sensitivity and specificity of EUS relative to the T stage were 82% and 91%, respectively, for T1; 43% and 85% for T2; and 83% and 86% for T3. The overall accuracy for EUS in identifying the correct T stage was 74% (95%CI 66-80). Positive lymph nodes were diagnosed histologically in 68 patients (38%). The sensitivity, specificity and accuracy of EUS for the diagnosis of N1 were 71%, 74% and 73% (95%CI 65-79), respectively.

CONCLUSIONS

The diagnostic accuracy of EUS in patients with esophageal cancer is still unsatisfactory. T2 cancers in particular are frequently overstaged, with a significant effect on the subsequent treatment strategy.

Value of high-frequency miniprobes and conventional radial endoscopic ultrasound in the staging of early Barrett's carcinoma

BACKGROUND AND AIMS

High-frequency miniprobes (HFPs) and conventional radial endoscopic ultrasonography (crEUS) are considered valuable tools in the staging of early Barrett's cancer. However, there is some controversy on whether HFPs are superior in the T staging of Barrett's cancer or whether the same level of accuracy can be achieved by the sole use of crEUS.

PATIENTS AND METHODS

Patients referred for endoscopic treatment for Barrett's cancer were included in this prospective crossover trial and were randomly assigned to either HFPs or crEUS as the initial diagnostic method. Afterwards, all of the patients were re-examined with the alternative procedure. The staging results obtained with each method were documented prospectively.

RESULTS

A total of 43 patients (median age 66 years [interquartile range: 58 - 73]; 34-male) were included. A total of 23 mucosal and 16 submucosal Barrett's cancers were confirmed at histology. Histological confirmation was not possible in four patients. Assessment of the T category was not possible with HFPs in 7 % of patients, compared with 33 % with crEUS ( P < 0.0001) due to positioning problems. T category was correctly assessed with HFP in 64 % of patients and with crEUS in 49 %.

CONCLUSIONS

HFPs are significantly superior to crEUS for local staging of Barrett's cancer. However, the accuracy of assessment of the T category was unsatisfactory with both techniques.

Invisible gastric carcinoma detected by random biopsy: long-term results after photodynamic therapy

BACKGROUND AND STUDY AIMS

Gastric cancer diagnosed from routine gastric biopsies without any evidence of a visible lesion and negative repeated biopsies is an infrequent but serious clinical problem for which gastrectomy has usually been recommended, even if operative specimens do not show cancer either. We report on a series of 22 such patients undergoing long-term follow-up after attempted treatment with photodynamic therapy (PDT).

PATIENTS AND METHODS

22 patients with invisible gastric cancer (IGC) who presented during a 10-year period (10 men, mean age 56 +/- 15 years) were prospectively included. Initial histopathological findings confirmed by second opinion included 10 well-differentiated adenocarcinomas and 12 signet ring cell carcinomas. After two negative state-of-the art endoscopic reassessments, a single session of PDT using 5-delta-aminolevulinic acid (ALA) was performed in the area from which the biopsy was taken, and patients were followed up regularly.

RESULTS

After a mean follow-up period of 56.2 +/- 27.6 months, three patients had died of causes unrelated to gastric cancer, four had developed mucosal cancer that was successfully treated endoscopically after 4 - 38 months, and the remaining 15 patients remained without evidence of recurrent gastric cancer, lymph-node involvement, or metastases during a follow-up period of 54 +/- 26 months.

CONCLUSIONS

Our results suggest that gastrectomy may not be the only option for IGC, which might follow an uneventful natural course provided careful follow-up is scheduled. The role of PDT in this setting remains unclear and should be studied further.

Severe paraneoplastic gastroparesis associated with anti-Hu antibodies preceding the manifestation of small-cell lung cancer

Gastroparesis is a common but challenging disorder which can be idiopathic or induced by a variety of underlying diseases, most frequently by diabetes, or post-surgical conditions of the upper abdomen. Clinicians must also consider rare causes of gastric motor dysfunction, such as collagen vascular disorders and paraneoplastic syndromes. Here we present the case of a patient with severe gastroparesis, who was admitted to our hospital for vomiting and weight loss of 25 kg within four months. Endoscopy showed a dilated fluid-filled stomach without peristalsis but no obstruction. High titres of anti-Hu antibodies were detected in patient's serum, supporting the diagnosis of severe paraneoplastic gastroparesis with chronic intestinal pseudo-obstruction. Fine-needle aspiration of suspicious mediastinal lymph nodes guided by endoscopic ultrasound revealed lymphatic metastases of a small-cell lung carcinoma. Jejunal tube feeding and chemotherapy with carboplatin and etoposide were initiated. Paraneoplastic gastrointestinal dysmotility is rare, however, clinicians should consider this differential diagnosis in otherwise unexplained gastrointestinal motor dysfunction. The pathophysiology of paraneoplastic gastroparesis, the diagnostic relevance of anti-Hu antibodies as well as therapeutic options are discussed.

[Transesophageal ultrasonography for mediastinum diagnostics]

Along with endosonographic fine needle aspiration, transoesophageal ultrasonography is now well established for staging gastrointestinal tumors. It is especially well suited to assessing mediastinal structures due to its transoesophageal approach and its high local definition. The mediastinum can be viewed all the way from the tracheal bifurcation to the diaphragm. This technique is already in regular use for pulmonary problems and especially for staging pulmonary carcinomas.

[Early duodenal adenocarcinoma arising in gastric metaplasia treated by endoscopic resection]

Early duodenal carcinoma is a rare entity. Most duodenal carcinomas are diagnosed at a more advanced stage. This report describes the case of a 59-year-old lady with an early duodenal adenocarcinoma diagnosed at check-up gastroduodenoscopy in an outpatient clinic who was referred to us for further investigation and management. The initial upper endoscopy at our department revealed a type IIa+c lesion in the proximal duodenum (10 - 12 mm diameter, flat elevated lesion with central depression). Using chromoendoscopy and magnification endoscopy the lesion could be well demarcated and neoplastic changes in the architecture of the intestinal villi could be detected. After submucosal epinephrine-saline injection, the lesion was removed by endoscopic resection without complications. Histopathological examination revealed the rare entity of an early duodenal carcinoma arising from incomplete-type gastric metaplasia in the duodenum. In summary, the presented paper describes a case of successful endoscopic treatment of an early duodenal carcinoma arising from incomplete gastric metaplasia.

Curative treatment for high-grade intraepithelial neoplasia in Barrett's esophagus

BACKGROUND AND STUDY AIMS

The incidence of premalignant and malignant lesions in specialized intestinal metaplasia of the esophagus has increased dramatically in the industrialized world in recent years. This report evaluates the efficacy and safety of local endoscopic therapy for high-grade intraepithelial neoplasia (HGIN) in Barrett's esophagus.

PATIENTS AND METHODS

Over a 5-year period between October 1996 and September 2001, a total of 379 patients were referred with a suspicion of early Barrett's cancer. In a prospective study, 44 patients with HGIN in Barrett's esophagus were selected for local endoscopic treatment. Endoscopic resection was carried out in 14 patients in whom the HGIN was re-detectable, and 27 patients in whom the HGIN was not re-detectable underwent photodynamic therapy (PDT). Endoscopic resection and PDT were combined in three patients.

RESULTS

Complete remission was achieved in 43 of the 44 patients (97.7 %). No major complications occurred. A mean of 1 session was needed to achieve complete local remission. During a mean follow-up period of 36 months (range 7 - 61 months), recurrent or metachronous lesions were observed in six patients (17.1 %), all of whom received a second successful endoscopic treatment.

CONCLUSIONS

Endoscopic therapy is a safe alternative treatment regimen for HGIN in Barrett's esophagus, providing a middle way between the widely promulgated options of a "watch-and-wait" policy and radical esophagectomy.

Accuracy of staging in early oesophageal cancer using high resolution endoscopy and high resolution endosonography: a comparative, prospective, and blinded trial

BACKGROUND AND AIMS

The increasing use of endoscopic resection for curative treatment of early oesophageal cancers requires accurate staging before therapy. In a prospective blinded trial, we compared staging of early oesophageal carcinoma using high resolution endoscopy (HR-E) with staging using high resolution endosonography (HR-EUS).

PATIENTS AND METHODS

A total of 100 patients (89 men, 11 women; mean age 63.9 (10.8) years (range 31-91)) with a suspicion of early oesophageal adenocarcinoma (n = 81) or squamous cell carcinoma (n = 19) were enrolled in the study. After endoscopic staging with high resolution video endoscopy by two experienced endoscopists, HR-EUS was performed by an experienced endosonographer who was blinded to the endoscopic assessment. Results of the staging examinations were correlated with the histology of the resected tumours.

RESULTS

Overall rates for accuracy of the endoscopic and endosonographic staging were 83.4% and 79.6%, respectively. Sensitivity for mucosal tumours (n = 68) was more than 90% (EUS 91.2%, endoscopy 94.1%) while sensitivity for submucosal tumours (n = 25) was lower, at 48% for EUS and 56% for endoscopic staging. A combination of the two techniques increased the sensitivity for submucosal tumours to 60%. Submucosal tumours in the tubular oesophagus were significantly better staged with HR-EUS than submucosal tumours close to the oesophagogastric junction (10/11 v 2/14; p<0.001). Tumours infiltrating the second and third submucosal layers were also more correctly diagnosed than tumours with slight infiltration of the first submucosal layer (sm1).

CONCLUSIONS

The overall diagnostic accuracy of both HR-E and HR-EUS with a 20 MHz miniprobe in early oesophageal cancer was high (approximately 80%), with no significant differences between the two techniques. HR-E and HR-EUS provide a high level of diagnostic accuracy for mucosal tumours and submucosal tumours located in the tubular part of the oesophagus. With submucosal tumours located at the oesophagogastric junction or with infiltration of the first third of the submucosa however, the diagnostic accuracy of both techniques is not yet satisfactory.

Endoscopic mucosal resection of early cancer and high-grade dysplasia in Barrett's esophagus

BACKGROUND & AIMS

In view of the mortality and morbidity rates of esophagectomy and the relatively large group of inoperable patients, local therapeutic techniques are required for high-grade dysplasia and early Barrett's cancer.

METHODS

A prospective investigation of endoscopic mucosal resection was conducted in 64 patients (mean age, 65 +/- 10 years) who had early carcinoma (61 patients) or high-grade dysplasia (3 patients) in Barrett's esophagus. Thirty-five patients met the criteria for low risk: macroscopic types I, IIa, IIb, and IIc; lesion diameter up to 20 mm; mucosal lesion; and histological grades G1 and G2 and/or high-grade dysplasia (group A). The remaining 29 patients were included in group B (high risk).

RESULTS

A total of 120 resections were performed, with no technical problems encountered. The mean number of treatment sessions per patient was 1. 3 +/- 0.6 in group A and 2.8 +/- 2.0 in group B (P < 0.0005). Only one major complication occurred, a case of spurting bleeding, which was managed endoscopically. Complete local remission was achieved significantly earlier (P = 0.008) in group A than in group B. In May 1999, complete remission had been achieved in 97% of the patients in group A and in 59% of those in group B; however, 1 patient in group A and 9 in group B are still undergoing treatment or awaiting the first check-up. During a mean follow-up of 12 +/- 8 months, recurrent or metachronous carcinomas were found in 14%.

CONCLUSIONS

Endoscopic mucosal resection of early carcinoma in Barrett's esophagus is associated with promisingly low morbidity and mortality rates. The procedure may offer a new minimally invasive therapeutic alternative to esophagectomy, especially in low-risk situations. Comparisons with surgical results will need to be done when the long-term results of this procedure become available.

Local treatment of early cancer in short Barrett's esophagus by means of argon plasma coagulation: initial experience

In recent years endoscopically controlled local therapeutic methods, such as photodynamic therapy, mucosectomy, or laser therapy, have been used with a curative aim for the destruction of early esophageal or gastric cancers. We report on our experience of treating histologically proven mucosal cancer in Barrett's esophagus with argon plasma coagulation (APC), in three patients. All the mucosal esophageal cancers, with a mean diameter of 4 mm, were successfully destroyed after one or two treatment sessions. Additionally, in two of the three patients the specialized columnar epithelium was replaced by normal squamous cell epithelium when APC treatment was combined with omeprazole. In the third patient with Barrett's esophagus, a partial squamous cell re-epithelialization was induced. No method-related mortality and morbidity were observed. During the mean follow-up of 24.3 +/- 1.1 months (range 23-25 months) one tumor recurrence developed which was successfully treated with photodynamic therapy. In patients with small early Barrett's carcinoma APC might offer an effective, minimally invasive alternative to mucosectomy or photodynamic therapy, as the treatment procedure is less cumbersome and the equipment less expensive.

Tc-99m DTPA perfusion scintigraphy and color coded duplex sonography in the evaluation of minimal renal allograft perfusion

AIM

The clinical impact of perfusion scintigraphy versus color coded Duplex sonography was evaluated, with respect to their potential in assessing minimal allograft perfusion in vitally threatened kidney transplants, i.e. oligoanuric allografts suspected to have either severe rejection or thrombosis of the renal vein or artery.

METHODS

From July 1990 to August 1994 the grafts of 15 out of a total of 315 patients were vitally threatened. Technetium-99m DTPA scintigraphy and color coded Duplex sonography were performed in all patients. For scintigraphic evaluation of transplant perfusion analog scans up to 60 min postinjection, and time-activity curves over the first 60 sec after injection of 370-440 MBq Tc-99m diethylenetriaminepentaacetate acid (DTPA) were used and classified by a perfusion score, the time between renal and iliac artery peaks (TDiff) and the washout of the renogram curve. Additionally, evaluation of excretion function and assessment of vascular or urinary leaks were performed. By color coded Duplex sonography the perfusion in all sections of the graft as well as the vascular anastomoses were examined and the maximal blood flow velocity (Vmax) and the resistive index (RI) in the renal artery were determined by means of the pulsed Doppler device. Pathologic-anatomical diagnosis was achieved by either biopsy or post-explant histology in all grafts.

RESULTS

Scintigraphy and color coded Duplex sonography could reliably differentiate minimal (8/15) and not perfused (7/15) renal allografts. The results were confirmed either by angiography in digital subtraction technique (DSA) or the clinical follow up.

CONCLUSION

In summary, perfusion scintigraphy and color coded Duplex sonography are comparable modalities to assess kidney graft perfusion. In clinical practice scintigraphy and color-coded Doppler sonography can replace digital subtraction angiography in the evaluation of minimal allograft perfusion.

Thyroid autonomy with color-coded image-directed Doppler sonography: internal hypervascularization for the recognition of autonomous adenomas

In a prospective study, we assessed the possibility of recognizing autonomous adenomas of the thyroid with color-coded image-directed Doppler sonography using internal hypervascularization in thyroid nodules for identification. Fifty-three patients with thyroid nodules underwent additional CCDS examination and nuclear scintigraphy (reference). Of 29 patients having autonomous adenomas, 28 patients presented internal hypervascularization in their nodules resulting in a sensitivity of 96% and a specificity was 75%. Interestingly CCDS detected six adenomas in patients showing normal laboratory data (bTSH, TT3, FT4). CCDS could be used to exclude focal adenomas with a negative predictive value of 94%. The positive predictive value for adenoma was 82%.

Color Doppler imaging versus phlebography in the diagnosis of deep leg and pelvic vein thrombosis

The objective of this prospective study was to evaluate the accuracy of color Doppler imaging in comparison to phlebography in diagnosing phlebothrombosis. Five hundred and twenty-six phlebographies (reference method) were compared with 526 color Doppler sonographic examinations. Thrombosis diagnosed with color Doppler imaging showed a sensitivity of 98.0% (400 of 408). In 91.6% (482 of 526) of all examinations the extent of the thrombosis diagnosed with phlebography could also be seen with color Doppler imaging. When the clinical situation is unclear, color Doppler imaging should precede phlebography. Only when findings with ultrasonography are questionable should phlebography definitely be considered.

[Imaging tumor vascularization of hepatocellular carcinoma with ultrasound angiography]

AIM

With the introduction, in 1994, of Ultrasound Angio (UA), a technical innovation in sonographic colour coded blood-flow detection has become available using angle-independent amplitude signal plotting leading to an enhanced sensitivity in blood flow detection.

METHOD

In a first application study we attempted to verify an improved blood-flow detection in hepatocellular carcinomas (HCC) compared to conventional colour coded duplex sonography.

RESULTS AND CONCLUSION

In all patients with HCC we found a highly improved detection of internal vascularity. In one patient, we could even detect blood flow in the tumour which was not visible with several other conventional highly sensitive colour duplex equipment.

[Possibilities and limits of a new color technique: ultrasound angiography--results of the "Heidelberg Round Table Discussion"]

Sonographic diagnostics has been essentially enlarged by blood flow measurements with the color Doppler technique. Nevertheless, the method has certain limitations, especially when employed to visualize extremely slow blood flow velocities, which occur e.g. in malignant tumors due to neovascularization. Recently, a new technique, the so-called angio-color procedure, has been presented, which is supposed to overcome the above-mentioned limitations. The way of coding the signal differs considerably from that in conventional color Doppler: The amplitude is color coded, not the frequency deviations. Results and first experiences with the new procedure in various domains were discussed at a 'Heidelberg Round Table' and are summarized in the present article. In the obstetrics/gynecology there are clear advantages in the representation of blood flow in the placenta. In eutrophic fetuses a blood flow over the entire placental breadth was detected, in dystrophic fetuses, however, only on the margins of the placenta. Conventional color Doppler could not visualize blood flow in the placenta at all. Blood flow assessment in the fetal organs also provided different results with the two procedures: the angio-color method showed color pixels even in the peripheral areas. In 8 malignant breast tumors the same observation was made, the angio-color procedure seemed to visualize more color pixels. In 4 of 6 benign lesions blood flow could be measured with the traditional color Doppler, but in 5 of 6 patients with the angio-color Doppler. This was also observed in ovarian tumors. Angio-color representation of renal transplants with normal function resulted in blood flow information reaching deep into the renal capsule, whereas in cases of renal transplants with impaired function a clearly reduced perfusion was visualized. These differences were not so evident with the conventional Doppler method. In lymph node diagnosis, too, marked differences between malignant and reactive lymph nodes could be visualized. In the diagnosis of arteriosclerotic plaques, blood flow in the residual lumen could also be detected more exactly with the angio-color technique. Color representation of liver tumors also showed a higher color signal density with ultrasound angiography. In summary, ultrasound angiography can provide additional information in the color representation of vessels with slow flow velocities. However, an obvious problem is the unability to quantify detected low blood flow. The new procedure will not replace but usefully complete the established sonographic techniques.

[Follow-up of vena cava filters with color Doppler ultrasound]

In 49 patients, colour-coded Duplex sonography was performed after implantation of a Greenfield caval filter. A plain film radiograph of the abdomen was taken additionally. The examination could be assessed free of artifacts in the longitudinal and transverse section in a total of 41 patients (84%). The procedure facilitates not only a diagnosis of thrombotic changes in the vena cava but can also display the topographical position of the filter and the venous flow. Caval thrombosis was verified in 5 patients. In 7 cases there was a decentral position of the filter apex with tilting. The penetration of filter struts through the vein wall eluded sonographic diagnosis as did morphological changes to the filter (e.g. filter fracture). In combination with the plain film radiograph, colour-coded Duplex sonography can replace cavography or computed tomography in the investigation of position and venous flow.

[Diagnosis of phlebothrombosis using color-coded duplex sonography. A prospective comparison with phlebography]

In a prospective study the reliability of colour-coded duplex-sonography (CCDS) and phlebography in the diagnosis of deep leg and pelvic vein thrombosis was compared. In 82 consecutive in- or out-patients (42 men, 40 women; mean age 53 [19-86] years) with clinically suspected leg or pelvic vein thrombosis the results of 275 phlebographies (reference method) and 275 CCDS were compared on admission and during follow-up. The two methods were performed less than 6 hours apart. In the diagnosis of thrombosis the sensitivity of CCDS was 99%, specificity 80%. In 88% of all tests, the different thrombosis levels, as diagnosed by phlebography, were also demonstrated by CCDS. These data indicate that, if the clinical picture of suspected deep leg or pelvic vein thrombosis is unclear, CCDS should be done first. Phlebography should be performed only if the results of the former are inconclusive.

Perfusion scintigraphy and color-coded duplex sonography in a minimally perfused renal allograft

Both, 99mTc DTPA perfusion scintigraphy and color-coded duplex sonography are reliable methods to quantitatively and qualitatively assess kidney transplant perfusion. In this case, minimal perfusion could be detected in a kidney allograft with marked vascular rejection by the scintigraphic analogous scan, whereas color-coded duplex sonography failed.

[Endoscopic-sonographic control of cystogastric catheter drainage of pancreatogenic fluid collections]

In 1985, Hancke published a report on cystogastrostomy using a double pigtail catheter as an alternative to surgical drainage of pseudocysts. Between 1986 and 1991, with the aim of testing the technique, we carried out a prospective study in 39 patients with 40 pancreatic collections of fluid. The object of the study was to identify those collections of fluid that would be suitable for cystogastric drainage. Among the first 20 patients thus treated, permanent evacuation of the cyst was achieved in eleven. In the other nine patients, the reasons for the failure of cystogastric drainage included to immature a cyst, too small a cyst, prior cyst infection and status after a BII resection. For the patients No. 21 to 40, these conditions were adopted as exclusion criteria, with the result that we were able to increase the percentage of permanent emptying to 75%. This makes cystogastric drainage a genuine alternative to surgical and other drainage procedures. As a minimally invasive intervention, it is a first choice therapeutic procedure in suitable pancreatic pseudocysts. If cystogastric drainage is shown not to be feasible, the possibility of employing percutaneous drainage should be investigated. Surgical drainage procedures are reserved for use in such cases as cannot be treated with catheter drainage.

[Needle tract metastasis following sonographically guided puncture of a mesenteric lymph node metastasis in Pancoast's tumor]

Peripheral bronchial carcinoma with infiltration of the right lateral thoracic wall (Pancoast tumour) was demonstrated in a 60-year-old man with breathing-related pain in the right thoracic wall of two months' duration. As part of tumour staging needle puncture of an intra-abdominal space-occupying lesion was performed, guided by ultrasonography. Histological examination confirmed it as a bronchial carcinoma metastasis. Combined radio- and chemotherapy hardly influenced tumour growth. Three months later a subcutaneous lesion became palpable in the area of the previous needle puncture which on excision proved to be a metastasis. The patient died 10 months later from the bronchial carcinoma. Percutaneous puncture of potentially malignant space-occupying lesions must be strictly indicated. The frequency of needle tract seeding is not exactly known.

[Polypoid lesions of the gallbladder]

Ultrasound examination of the gallbladder was performed in a prospective study (from 1985 to 1988) of 14,841 consecutive patients. Polypoid changes were found in 224 (129 men, 95 women; mean age 54 [18-88] years), sonographically classified as cholesterol polyps in 212, as polypoid lesions of uncertain benignity in 12. Mean observation time of 92 patients with cholesterol polyps was 9 (3-48) months. In six the polyp diameter increased by up to 5 mm: only two of them were operated upon and the diagnosis was confirmed in both. A total of 21 patients suspected of having cholesterol polyps were operated upon, the diagnosis confirmed in 17, chronic cholecystitis in two and, in one case each, thickened wall-adherent bile or wall-adherent concrements as cause of the ultrasound changes. Six of the 12 patients with polypoid lesions of uncertain benignity were operated upon: two had an adenoma, one each had tissue heterotopy, malignant melanoma metastasis, gall-bladder carcinoma and adenomyomatosis.

[Piezoelectric lithotripsy of gallstones. Initial clinical experiences]

Piezoelectric lithotripsy was undertaken on 50 patients with gallbladder stones, none of them requiring anaesthesia, analgetics or sedatives. Stone fragmentation was achieved in all patients during the first treatment. In 44 patients the maximum fragment size was less than 50% of the initial stone diameter. The mean maximum fragment size after the first treatment was 4.3 mm (+/- 3.3 mm). After a follow-up of 0-2 months in 14 of the 50 patients and of 2-4 months in 6 of 13 patients, no more stones could be seen by ultrasonography. After an average period of 8 weeks, 17 of 50 patients were free of stones. Piezoelectric lithotripsy did not have any severe side effects besides a mild pancreatitis in one patient.