Systematische Übersichtsarbeit: medikamentöse Therapie des Mammakarzinoms in der Schwangerschaft mit Fokus auf die embryofetale Fruchtschädigung

Das Mammakarzinom gehört zu den am häufigsten in der Schwangerschaft auftretenden Malignomen. Da Frauen zunehmend erst in fortgeschrittenem Alter gebären, ist anzunehmen, dass die Inzidenz schwangerschaftsassoziierter Mammakarzinome zukünftig weiter steigen wird. Aufgrund schwangerschaftsbedingter Veränderungen und zurückhaltender Diagnostik kommt es häufig dazu, dass diese Karzinome erst in fortgeschrittenen Stadien detektiert werden und somit meist einer systemischen adjuvanten Therapie bedürfen. Diesbezüglich verfügbare Daten sind derzeitig jedoch begrenzt. Ziel dieser Übersichtsarbeit ist es daher, die aktuell verfügbare Literatur zur Systemtherapie des Mammakarzinoms in der Schwangerschaft systematisch zusammenzufassen und diese unter pharmakologischen bzw. pharmakokinetischen Gesichtspunkten zu analysieren. Dazu wurde die medizinische Datenbank PubMed für den Zeitraum von 1970 bis 2017 mithilfe eines hierfür generierten Suchterms nach relevanten Publikationen durchsucht. Diese Ergebnisse wurden dann um zusätzliche Treffer, welche die Suche über die multidisziplinäre Web of Science Core Collection ergab, ergänzt. Zusätzlich wurden Referenzen relevanter Artikel berücksichtigt. Redundante Patientenkollektive wurden identifiziert und ausgeschlossen. Zum Einsatz von Anthrazyklinen besteht derzeit die meiste Evidenz. Daten zum Gebrauch anderer Chemotherapeutika wie Taxanen oder Vincaalkaloiden in der Schwangerschaft sind begrenz. Deshalb kann die Anwendung dieser hinsichtlich ihrer Sicherheitsprofils vielversprechend erscheinenden Wirkstoffe derzeit noch nicht uneingeschränkt empfohlen werden. Auf Methotrexat sollte zugunsten sichererer Alternativen in der Schwangerschaft verzichtet werden. Auch antihormonelle Therapien sollten erst nach der Entbindung eingesetzt werden. Target-Agents wie Trastuzumab oder Lapatinib sind heutzutage aus der Tumortherapie nicht mehr wegzudenkende Wirkstoffe, jedoch sollten diese aufgrund auftretender Schwangerschaftskomplikationen nach Möglichkeit erst postpartal gegeben werden. Es werden ständig neue Therapeutika, wie beispielsweise die Gruppe der PARP-Hemmer entwickelt, zu denen aber bezüglich ihrer Anwendbarkeit in der Schwangerschaft noch keine Aussagen getroffen werden können. Die Auswertung der Studien zeigt, dass die Durchführung einer Chemotherapie innerhalb des ersten Trimenons mit erhöhten Raten an Fehlbildungen sowie Spontanaborten einhergeht, eine chemotherapeutische Behandlung im zweiten und dritten Trimenon hingegen hinsichtlich teratogener Effekte als relativ sicher für das ungeborene Kind angesehen werden kann. In diesen späteren Phasen der Schwangerschaft steht hingegen ein gehäuftes Auftreten von intrauterinen Wachstumsrestriktionen, Frühgeburtlichkeit, niedrigem Geburtsgewicht sowie ein erhöhtes Risiko für die Entwicklung neonataler Komplikationen im Vordergrund. Das Management schwangerschaftsassoziierter Mammakarzinome ist komplex und verlangt demnach eine interdisziplinäre Herangehensweise. Ein Team aus Experten muss unter Berücksichtigung individueller Patientenwünsche Nutzen und Risiken einer antineoplastischen Therapie für Mutter und Kind abwägen. Ethische Fragestellungen spielen hierbei eine nicht zu vernachlässigende Rolle, da die applizierten Zytostatika einerseits die embryofetale Entwicklung negativ beeinflussen können, ein Therapieaufschub hingegen andererseits das mütterliche Leben gefährden kann. Aktuell verfügbare Daten suggerieren, vor allem hinsichtlich der neurokognitiven Entwicklung, keine negativen Langzeitauswirkungen für in utero gegenüber Chemotherapeutika exponierte Kinder. Da jedoch die derzeitig verfügbaren Informationen hauptsächlich aus Fallberichten oder kleineren retrospektiven Kohortenstudien stammen, sind zukünftig vor allem prospektiv erhobene Daten mit ausreichend langen Follow-Up Zeiträumen notwendig, um die Sicherheit einer Systemtherapie schwangerschaftsassoziierter Mammakarzinome für Betroffene und deren Kinder weiter verbessern zu können. Bezüglich der Auswertung solcher Daten ist es erforderlich, pharmakologische sowie pharmakokinetische Eigenschaften der Wirkstoffe, transplazentare Transportmechanismen sowie schwangerschaftsbedingte Besonderheiten zu beachten. Übergeordnetes Ziel dieser Bemühungen sollte es sein, langfristig evidenzbasierte Empfehlungen bezüglich der Systemtherapie des schwangerschaftsassoziierten Mammakarzinoms veröffentlichen zu können

Education for sustainable development at "Schulen im Aufbruch". Looking for new pathways

Konsumverhalten, und damit verbundene Ernährungs- Verbraucher- und Gesundheitsbildung, sind wesentliche Elemente einer Bildung für nachhaltige Entwicklung (BNE). Es wurden die Implementierung und Umsetzung einer BNE an Schulen untersucht, die der Initiative „Schule im Aufbruch“ (SiA) angehören, um die dort gewonnenen Erfahrungen für andere Standorte nutzbar zu machen. (DIPF/Orig.)Consumer behavior and education in nutrition, consumption and health are essential elements of “Education for Sustainable Development” (ESD). The implementation and realisation of ESD at schools which are members of the initiative “Schule im Aufbruch” were examined in order to make the experiences gained there usable for other locations. (DIPF/Orig.

Femoral anteversion change is associated with ischiofemoral impingement after total hip arthroplasty: a retrospective CT evaluation

OBJECTIVES We evaluated the relationship between femoral anteversion (FA), FA change, and ischiofemoral impingement (IFI) and the relationship between FA, femoral offset (FO), and greater trochanteric pain syndrome (GTPS) after total hip arthroplasty (THA). MATERIALS AND METHODS In this retrospective study, two readers assessed FA and FO on CT images of 197 patients following primary THA with an anterior surgical approach between 2014 and 2021. FA change was calculated relative to preoperative CT, while FO change was calculated relative to preoperative radiographs and classified as decreased (≥-5 mm), increased (≥ + 5 mm), or restored (± 5 mm). Clinical and imaging data were analyzed for IFI and GTPS after surgery. Group differences were evaluated using Student's t-test, chi-square analysis, and receiver operating characteristic (ROC) analysis. RESULTS The change in FA was 3.6 ± 3.3° to a postoperative FA of 22.5 ± 6.8°, while FO increased by 1.7 ± 3.5 mm to a postoperative FO of 42.9 ± 7.1 mm. FA and FA change were higher in patients with IFI (p ≤ 0.006), while no significant difference was observed for patients with and without GTPS (p ≥ 0.122). IFI was more common in females (p = 0.023). In the ROC analysis, an AUC of 0.859 was observed for FA change to predict IFI, whereas the AUC value was 0.726 for FA alone. No significant difference was found for FO change in patients with and without IFI or GTPS (p ≥ 0.187). CONCLUSION Postoperative FA, FA change, and female sex were associated with IFI after anterior-approached THA. The change in FA was a better predictor of IFI than absolute postoperative FA alone. CLINICAL RELEVANCE STATEMENT The findings of this study suggest that preservation of the preoperative femoral anteversion may reduce postoperative ischiofemoral impingement in patients undergoing total hip arthroplasty. KEY POINTS • Higher postoperative femoral anteversion and anteversion change were associated with ischiofemoral impingement. • Femoral anteversion change was a better predictor of impingement than absolute postoperative anteversion. • No significant association was found between femoral offset and postoperative hip pain

Hydroxyapatite deposition disease of the wrist with intraosseous migration to the lunate bone

Hydroxyapatite deposition disease (HADD) is a mostly uniarticular, self-limiting condition caused by deposition of hydroxyapatite (HA) crystals in tendons or in the peritendinous soft tissues. Commonly, the glenohumeral joint is affected. More rarely, the HA depot can be cause of a carpal tunnel syndrome due to an acute inflammatory reaction and space-occupying soft tissue oedema. We report a case of acute HA depot located at the volar site of the right wrist with affection of the deep flexor tendons and intraosseous migration into the lunate bone in a 50-year-old female. There are two main goals of this case report: First, to remind the diagnosis of HADD as a cause of wrist pain and also of carpal tunnel syndrome, as this entity being often misdiagnosed clinically, and second, to report a rare case of intraosseous migration of HA crystals into the lunate bone

Third generation autologous chondrocyte implantation is a good treatment option for athletic persons

PURPOSE Autologous chondrocyte implantation is an established method for the treatment of joint cartilage damage. However, to date it has not been established that autologous chondrocyte implantation is an appropriate procedure for cartilage defects therapy in athletic persons. The aim of this study is to analyze if third-generation autologous chondrocyte implantation is an appropriate treatment for athletic persons with full cartilage defect of the knee joints. METHODS A total of 84 patients were treated with third-generation autologous chondrocyte implantation (NOVOCART® 3D). The mean follow-up time was 8 years (5–14). Sports activity was measured via UCLA Activity Score and Tegner Activity Scale before the onset of knee pain and postoperatively in an annual clinical evaluation. 41 athletic persons and 43 non-athletic persons (UCLA-Cut-off: 7; Tegner Activity Scale-Cut-off: 4) were analyzed. Patient reported outcomes were captured using IKDC subjective, KOOS, Lysholm score and VAS score on movement. RESULTS Patient reported outcomes (IKDC, VAS at rest, VAS on movement) showed significant improvement (p < 0.001) postoperatively. Athletic persons demonstrated significantly better results than non-athletic persons in the analyzed outcome scores (IKDC: p < 0.01, KOOS: p < 0.01, Lysholm score: p < 0.01). 96.4% of the patients were able to return to sport and over 50% returned or surpassed their preinjury sports level. The remaining patients were downgraded by a median of two points on the UCLA- and 2.5 on the Tegner Activity Scale. A shift from high-impact sports to active events and moderate or mild activities was found. Furthermore, it was shown that preoperative UCLA score and Tegner Activity Scale correlated significantly with the patient reported outcome postoperatively. CONCLUSION Autologous chondrocyte implantation is a suitable treatment option for athletic persons with full-thickness cartilage defects in the knee. The return to sports activity is possible, but includes a shift from high-impact sports to less strenuous activities

Three-Dimensional Software- and MR-Imaging-Based Muscle Volumetry Reveals Overestimation of Supraspinatus Muscle Atrophy Using Occupation Ratios in Full-Thickness Tendon Tears

Supraspinatus muscle atrophy is widely determined from oblique-sagittal MRI by calculating the occupation ratio. This ex vivo and clinical study aimed to validate the accuracy of 3D software- and MR-imaging-based muscle volumetry, as well as to assess the influence of the tear pattern on the occupation ratio. Ten porcine muscle specimens were volumetrized using the physical water displacement volumetry as a standard of reference. A total of 149 individuals with intact supraspinatus tendons, partial tears, and full-thickness tears had 3T MRI. Two radiologists independently determined occupation ratio values. An excellent correlation with a Pearson's r of 0.95 for the variables physical volumetry using the water displacement method and MR-imaging-based muscle volumetry using the software was found and formed the standard of reference for the patient study. The inter-reader reliability was 0.92 for occupation ratios. The correlation between occupation ratios and software-based muscle volumes was good in patients with intact tendons (0.84) and partial tears (0.93) but considerably lower in patients with full-thickness tears (0.68). Three-dimensional-software- and MR-imaging-based muscle volumetry is reliable and accurate. Compared to 3D muscle volumetry, the occupation ratio method overestimates supraspinatus muscle atrophy in full-thickness tears, which is most likely due to the medial retraction of the myotendinous unit

Evaluation of patients with respiratory infections during the first pandemic wave in Germany: characteristics of COVID-19 versus non-COVID-19 patients

BACKGROUND Characteristics of COVID-19 patients have mainly been reported within confirmed COVID-19 cohorts. By analyzing patients with respiratory infections in the emergency department during the first pandemic wave, we aim to assess differences in the characteristics of COVID-19 vs. Non-COVID-19 patients. This is particularly important regarding the second COVID-19 wave and the approaching influenza season. METHODS We prospectively included 219 patients with suspected COVID-19 who received radiological imaging and RT-PCR for SARS-CoV-2. Demographic, clinical and laboratory parameters as well as RT-PCR results were used for subgroup analysis. Imaging data were reassessed using the following scoring system: 0 - not typical, 1 - possible, 2 - highly suspicious for COVID-19. RESULTS COVID-19 was diagnosed in 72 (32,9%) patients. In three of them (4,2%) the initial RT-PCR was negative while initial CT scan revealed pneumonic findings. 111 (50,7%) patients, 61 of them (55,0%) COVID-19 positive, had evidence of pneumonia. Patients with COVID-19 pneumonia showed higher body temperature (37,7~± 0,1 vs. 37,1~± 0,1 °C; p = 0.0001) and LDH values (386,3~± 27,1 vs. 310,4~± 17,5 U/l; p = 0.012) as well as lower leukocytes (7,6~± 0,5 vs. 10,1~± 0,6G/l; p = 0.0003) than patients with other pneumonia. Among abnormal CT findings in COVID-19 patients, 57 (93,4%) were evaluated as highly suspicious or possible for COVID-19. In patients with negative RT-PCR and pneumonia, another third was evaluated as highly suspicious or possible for COVID-19 (14 out of 50; 28,0%). The sensitivity in the detection of patients requiring isolation was higher with initial chest CT than with initial RT-PCR (90,4% vs. 79,5%). CONCLUSIONS COVID-19 patients show typical clinical, laboratory and imaging parameters which enable a sensitive detection of patients who demand isolation measures due to COVID-19

Hematopoietic islands mimicking osteoblastic metastases within the axial skeleton

Background Hyperplasia of the hematopoietic bone marrow in the appendicular skeleton is common. In contrast, focal hematopoietic islands within the axial skeleton are a rare entity and can confuse with osteoblastic metastases. This study aimed to characterize typical MRI and CT findings of hematopoietic islands in distinction from osteoblastic metastases to help both radiologists and clinicians, on the one hand, not to overdiagnose this entity and, on the other hand, to decide on a reasonable work-up. Methods We retrospectively analyzed the imaging findings of 14 hematopoietic islands of the axial skeleton in ten patients (nine females, median age = 65.5 years [range, 49–74]) who received both MRI and CT at initial diagnosis between 2006 and 2020. CT-guided biopsy was performed in five cases to confirm the diagnosis, while the other five patients received long-term MRI follow-up (median follow-up = 28 months [range, 6–96 months]). Diffusion-weighted imaging was available in three, chemical shift imaging respectively 18 F- fluorodeoxyglucose PET/CT in two, and Technetium 99 m skeletal scintigraphy in one of the patients. Results All lesions were small (mean size = 1.72 cm 2 ) and showed moderate hypointense signals on T1- and T2-weighted MRI sequences. They appeared isointense to slightly hyperintense on STIR images and slightly enhanced after gadolinium administration. To differentiate this entity from osteoblastic metastases, CT provides important additional information, as hematopoietic islands do not show sclerosis. Conclusions Hematopoietic islands within the axial skeleton can occur and mimic osteoblastic metastases. However, the combination of MRI and CT allows for making the correct diagnosis in most cases

Artifact characterization of Nitinol needles in magnetic resonance imaging-guided musculoskeletal interventions at 3.0 tesla: a phantom study

PURPOSETo characterize the artifacts of an 18-gauge coaxial nickel-titanium needle using a balanced steady-state free precession sequence in magnetic resonance imaging-guided interventions at 3.0 tesla.METHODSThe influence of flip angle (FA), bandwidth, matrix, slice thickness (ST), and read-out direction on needle artifact behavior was investigated for different intervention angles (IA). Artifact diameters were rated at predefined positions. Subgroup differences were assessed using Bonferroni-corrected non-parametric tests and correlations between continuous variables were expressed using the Bravais–Pearson coefficient. Interrater reliability was quantified using intraclass correlation coefficients (ICCs), and a contrast-enhanced target lesion to non-enhanced muscle tissue contrast ratio was quantified.RESULTSThe artifact diameters decreased with an increase in FA for all IAs (P 7 mm, and, if possible, an IA of 45°–60°. The visibility of the target lesion and the needle’s artifact behavior must be weighed up against each other when choosing the ST, while higher FAs (40°–60°) and matrices (224 × 224/256 × 256) are associated with low artifacts and sufficient lesion visibility