Long-Term Follow-Up in Patients Undergoing Renal Mass Biopsy: Seeding is not Anecdotal

INTRODUCTION

Renal biopsy is recommended if the outcome might alter therapeutic decisions for patients who present with renal masses of unclear etiology. However, little is known about long-term risks related to this procedure.

PATIENTS AND METHODS

We performed a retrospective analysis of an institutional database maintained by a tertiary referral center that included patients who underwent renal biopsies between 2003 and 2005 with a follow-up of at least 15 years. Renal biopsies were taken percutaneously with a coaxial technique according to guideline recommendations and included off-line ultrasound guidance.

RESULTS

We identified 106 patients who underwent biopsies for a renal mass of unclear etiology. The median age was 58.7 years (43.7-66.2). A median of 4.2 (3-6) biopsies were collected from each patient. Tumor seeding leading to local growth was identified in 6 patients (5,7%) after a median follow-up of 8.2 years. Four of these lesions that were resected exhibited the same histology as the original biopsy result; these patients experienced no further recurrence. In 45 patients (42%), the biopsy results led to a therapy other than surgery (n = 28 lymphoma, n = 6 metastasis from other malignancies, n = 11 oncocytoma). The remaining 61 patients (58%) were diagnosed with renal cell carcinoma treated either surgically or with ablation. None of the patients developed metastatic spread related to tumor seeding.

CONCLUSION

Tumor seeding after renal mass biopsy is a rare, but relevant risk associated with this procedure. As indications for renal mass biopsy increase, longer-term follow-up and improved biopsy techniques should be considered to address this complication.

Surgical Trends and Complications in Partial and Radical Nephrectomy: Results from the GRAND Study

BACKGROUND

We aimed to evaluate the current trends in renal cancer surgery, as well as to compare the perioperative outcomes of partial versus radical nephrectomy.

METHODS

We used the GeRmAn Nationwide inpatient Data (GRAND), provided by the Research Data Center of the Federal Bureau of Statistics (2005-2021). We report the largest study in the field, with 317,843 patients and multiple patient-level analyses.

RESULTS

Overall, 123,924 (39%) patients underwent partial and 193,919 (61%) underwent radical nephrectomy in Germany from 2005 to 2021. Of them, 57,308 (18%) were operated on in low-, 142,702 (45%) in intermediate-, and 117,833 (37%) in high-volume centers. A total of 249,333 (78%) patients underwent open, 44,994 (14%) laparoscopic, and 23,516 (8%) robotic nephrectomy. The number of patients undergoing renal surgery remained relatively stable from 2005 to 2021. Over the study period, the utilization of partial nephrectomy increased threefold, while radical nephrectomy decreased by about 40%. After adjusting for major risk factors in the multivariate regression analysis, radical nephrectomy was associated with 3.2-fold higher odds (95% CI: 3.2 to 3.9, p < 0.001) of 30-day mortality, longer hospitalization by 1.9 days (95% CI: 1.9 to 2, p < 0.001), and higher inpatient costs by EUR 1778 (95% CI: 1694 to 1862, p < 0.001) compared to partial nephrectomy. Furthermore, radical nephrectomy had a higher risk of in-hospital transfusion (p < 0.001), sepsis (p < 0.001), acute respiratory failure (p < 0.001), acute kidney disease (p < 0.001), acute thromboembolism (p < 0.001), surgical wound infection (p < 0.001), ileus (p < 0.001), intensive care unit admission (p < 0.001), and pancreatitis (p < 0.001).

CONCLUSIONS

More patients are offered partial nephrectomy in Germany. Patients undergoing radical nephrectomy present with a higher rate of concomitant risk factors and have increased perioperative morbidity and mortality, prolonged hospitalization, and increased in-hospital costs.

Gender-specific outcomes in immune checkpoint inhibitor therapy for advanced or metastatic urothelial cancer: a systematic review and meta-analysis

PURPOSE

To analyze gender-specific differences in survival parameters in advanced or metastatic urothelial cancer patients undergoing immune checkpoint inhibition.

METHODS

The primary aim of this systematic review and meta-analysis was to evaluate gender-specific differences in disease-free (DFS), progression-free (PFS), cancer-specific survival (CSS), event-free survival (EFS), overall survival (OS) and objective response rate (ORR). The sources MEDLINE, Embase and Cochrane Library were systematically searched from January 2010 to June 2022. No restrictions were made concerning language, study region or publication type. A comparison of gender-specific differences in survival parameters was performed using a random-effects meta-analysis. A risk of bias assessment was done using the ROBINS-I tool.

RESULTS

Five studies were included. In a random-effect meta-analysis of the studies, PCD4989g and IMvigor 211 with both using atezolizumab, females were more likely to have better objective response rate (ORR) than men (OR 2.24; 95% CI 1.20-4.16; p = 0.0110). In addition, females had a comparable median OS to men (MD 1.16; 95% CI - 3.15-5.46; p = 0.598). In summary, comparing all results, a tendency was seen toward better response rates and survival parameters in female patients. The risk of bias assessment yielded an overall low risk of bias.

CONCLUSIONS

There is a tendency toward better outcomes in women for immunotherapy in advanced or metastatic urothelial cancer, but only for the antibody atezolizumab women have a significantly better ORR. Unfortunately, many studies fail to report gender-specific outcomes. Therefore, further research is essential when aiming for individualized medicine. This research should address immunological confounders.

Single‐fraction image‐guided robotic radiosurgery efficiently controls local prostate cancer recurrence after radical prostatectomy

Purpose

To assess the therapeutic potential of single‐fraction robotic stereotactic ablative body radiotherapy (SABR) in patients with locally recurrent prostate cancer (PC) after radical prostatectomy (RP).

Materials and methods

We included 35 patients with biochemical failure after RP with single‐site local recurrence in the prostate bed diagnosed by PSMA PET/CT. About 20/35 pts had previously received post‐surgical adjuvant radiation therapy.

High‐resolution multiparametric magnetic resonance imaging (mpMRI) for exact visualization of tumor tissue was performed at 1.5 (n = 23; Siemens Magnetom Aera) or 3 Tesla (n = 12; Siemens Magnetom VIDA, Siemens Healthineers, Erlangen, Germany). Using the MRI and PET/CT dataset for planning, SABR was carried out after ultrasound‐guided placement of a single gold fiducial marker at the site of tumor recurrence using a CyberKnife M6 unit (Accuray Inc., Sunnyvale, USA). Due to the high diagnostic accuracy of PSMA PET/CT and mpMRI, pre‐SABR biopsy of tumor tissue was not deemed necessary. PSMA PET/CT performed in median 88 days before SABR confirmed the absence of distant metastases. MpMRI was performed at a median of 22 days prior to the intervention. SABR was performed in a single fraction with a dose of 20 (5/35), 21 (27/35) or 22 (3/35) Gy. Follow‐up serum PSA was measured every 3 months thereafter.

Results

Median patient age was 72 years (57‐80 years) and median time from RP to SABR was 96.8 months (IQR, 69.3‐160.2). Median serum PSA before SABR was 1.38 ng/mL (IQR 0.75‐2.72). At 3 months, median PSA had dropped significantly in 27/35 patients to a median of 0.35 ng/mL (IQR 0.25‐0.68). At 6 months, 30/35 patients showed biochemical response to SABR, while five patients were progressing: three had systemic disease on PSMA PET/CT, while two patients had rising PSA values without a visible correlate on PET/CT. The median follow‐up time was 16 months. Grade 1 genitourinary (GU) toxicity was reported in 3/35 patients (9%) and grade 1 gastrointestinal (GI) toxicity in 2/35 patients (6%), respectively.

Conclusion

SABR is an efficient new treatment option in the management of single‐site local recurrent PC without the evidence of systemic disease; due to its very low toxicity, it is an alternative to surgical re‐treatment or other focal therapies. It can significantly delay the onset of androgen deprivation therapy (ADT) in biochemical failure after radical prostatectomy.

Safety, efficacy and prognostic impact of immune checkpoint inhibitors in older patients with genitourinary cancers

INTRODUCTION

Immunosenescence might impact immunotherapy (IT) in patients with advanced age. However, pivotal studies were not powered for this clinical question. Our aim is to explore toxicity (primary objective) and activity (secondary objective) of immune checkpoint inhibitors (ICIs) in patients with renal cell (RCC) and urothelial carcinoma (UC) older than 75 years compared to the younger population.

PATIENTS AND METHODS

Patients treated at our tertiary care Uro-oncology Department with atezolizumab, pembrolizumab, nivolumab or ipilimumab were retrospectively analyzed. Immune-related adverse events (irAEs) were determined and graded using the Common Terminology Criteria for Adverse Events (CTCAE v.4.0). Disease Control rate (DCR) was assessed according to Response Evaluation Criteria in Solid Tumors (RECIST v1.1). IrAEs and DCR were compared between patients ≥75 vs. <75 years, chi-squared test. Impact of age and other key clinical parameters on irAEs and DCR were tested in a binary logistic regression employing a backward selection. Impact of irAEs on oncological prognosis was assessed in log-rank and Cox regression analyses.

RESULTS

We included 99 patients treated between 11/2015 and 01/2019. Frequency of irAEs (36.4% vs. 39.4%) and DCR (59.4% vs. 41.0%) was comparable between patients ≥75 vs. <75 years. Advanced age was not associated with irAEs or worse DCR. IrAEs occurrence correlated with better disease-specific survival in the univariate and multivariate analyses. IrAEs could be successfully treated with corticosteroids in 78.9% of cases.

CONCLUSIONS

ICIs seem to be both safe and efficacious in an aging population with metastatic RCC or UC. Occurrence of irAEs predicted better prognosis.

Dual energy CT allows for improved characterization of response to antiangiogenic treatment in patients with metastatic renal cell cancer

OBJECTIVES

To evaluate the potential role of dual energy CT (DECT) to visualize antiangiogenic treatment effects in patients with metastatic renal cell cancer (mRCC) while treated with tyrosine-kinase inhibitors (TKI).

METHODS

26 patients with mRCC underwent baseline and follow-up single-phase abdominal contrast enhanced DECT scans. Scans were performed immediately before and 10 weeks after start of treatment with TKI. Virtual non-enhanced (VNE) and colour coded iodine images were generated. 44 metastases were measured at the two time points. Hounsfield unit (HU) values for VNE and iodine density (ID) as well as iodine content (IC) in mg/ml of tissue were derived. These values were compared to the venous phase DECT density (CTD) of the lesions. Values before and after treatment were compared using a paired Student's t test.

RESULTS

Between baseline and follow up, mean CTD and DECT-derived ID both showed a significant reduction (p < 0.005). The relative reduction measured in percent was significantly greater for ID than for CTD (49.8 ± 36,3 % vs. 29.5 ± 20.8 %, p < 0.005). IC was also significantly reduced under antiangiogenic treatment (p < 0.0001).

CONCLUSIONS

Dual energy CT-based quantification of iodine content of mRCC metastases allows for significantly more sensitive and reproducible detection of antiangiogenic treatment effects.

KEY POINTS

• A sign of tumour response to antiangiogenic treatment is reduced tumour perfusion. • DECT allows visualizing iodine uptake, which serves as a marker for vascularization. • More sensitive detection of antiangiogenic treatment effects in mRCC is possible.

Renal Pseudoaneurysms and Arteriovenous Fistulas as a Complication of Nephron-Sparing Partial Nephrectomy: Technical and Functional Outcomes of Patients Treated With Selective Microcoil Embolization During a Ten-Year Period

PURPOSE

The aim of this study was to evaluate the clinical and functional outcomes in patients who underwent selective interventional embolization of renal pseudoaneurysms or arteriovenous fistulas at our center.

MATERIALS AND METHODS

Our retrospective analysis included all consecutive patients who received selective transcatheter embolization of renal pseudoaneurysms or arteriovenous fistulas after partial nephrectomy in our department from January, 2003 to September, 2013. The technical and clinical success rate and functional outcome of every procedure was collected and analyzed. Furthermore, the change in renal parenchymal volume before and after embolization was determined in a subgroup.

RESULTS

A total of 1425 patients underwent partial nephrectomy at our hospital. Of these, 39 (2.7 %) were identified with a pseudoaneurysm or an arteriovenous fistula after partial nephrectomy. The diagnosis of the vascular lesions was made by means of biphasic CT or CEUS. Technical success by means of selective microcoil embolization was achieved in all 39 patients (100 %). Clinical success, defined as no need for further operation or nephrectomy during follow-up, was achieved in 35 of 39 patients (85.7 %). Renal function, as measured by eGFR before and after the intervention, did not change significantly. However, a mean loss of parenchymal volume of 25.2 % was observed in a subgroup. No major or minor complications were attributable to the embolization procedure.

CONCLUSION

Transcatheter embolization is a promising method for treating vascular complications which may occur after partial nephrectomy. We confirm the high success rate of this technique while discussing renal functional outcomes and potential safety aspects.

KEY POINTS

Arterial pseudoaneurysms and arteriovenous fistulas are rare but severe complications after partial nephrectomy. Selective microcoil embolization is a safe and effective kidney-preserving procedure for treating these complications. Embolization leads to a significant loss of renal parenchymal volume but not to a loss of renal function.

Dual energy can accurately differentiate uric acid-containing urinary calculi from calcium stones

PURPOSE

To retrospectively evaluate the accuracy of dual-energy CT (DECT) in the detection of the chemical composition of urinary calculi in correlation with infrared spectroscopic stone analysis.

METHODS

We reviewed the CT scans of 255 patients who underwent DECT due to a clinical suspicion of urolithiasis. Out of this group, we included 64 patients with clinically symptomatic urolithiasis requiring stone removal. After surgical removal of the stone by ureterorenoscopy, chemical composition was analyzed with infrared spectroscopy. We correlated DECT stone characterization results with chemical stone composition based on dual-energy indices (DEI). A total of 213 renal and ureteral stones could be removed and chemically analyzed.

RESULTS

A total of 213 calculi were evaluated. Thirty eight out of sixty four (59 %) patients had >1 stone. DECT was used to differentiate stones by using DEI. Stones harboring calcium (CA) were color-coded in blue, while stones containing uric acid (UA) were colored red. Median DEI in UA-containing stones were 0.001. Non-UA-containing stones had a DEI between 0.073 for pure CA stones and 0.077 containing CA and other substances (p = 0.001; p = 0.03, respectively). Sensitivity of DECT was 98.4 % for differentiation of UA from non-UA-containing calculi. Specificity was 98.1 %. Mean effective radiation dose of DECT was 4.18 mSv (0.44-14.27 mSv), thus comparable to conventional CT scans of the abdomen. Conventional measurement of Hounsfield units did not correlate with stone composition.

CONCLUSION

DECT with image post-processing reliably discriminates UA-containing calculi from all other stones, but the study offered limitations. Discrimination within the non-UA stones cannot be reliably achieved but is clinically insignificant.

Rhinovirus inhibits IL-17A and the downstream immune responses in allergic asthma

The proinflammatory cytokine interleukin-17A (IL-17A) is known to mediate antimicrobial activity, but its role during rhinovirus (RV) infections and in asthma needs further investigation. Therefore, we addressed the role of IL-17A during allergic asthma and antiviral immune response in human and murine immunocompetent cells. In this study we found that asthmatic children with a RV infection in their upper airways have upregulated mRNA levels of the antiviral cytokine interferon type I (IFN)-β and the transcription factor T-box 21 (TBX21) and reduced levels of IL-17A protein in their peripheral blood mononuclear cells (PBMCs). We also found that IL-17A inhibited RV1b replication in infected human lung epithelial cells A549. Furthermore, by using gene array analysis we discovered that targeted deletion of Il17a in murine lung CD4(+) T cells impaired Oas1g mRNA downstream of Ifnβ, independently from RV infection. Additionally, in PBMCs of children with a RV infection in their nasalpharyngeal fluid OAS1 gene expression was found downregulated. Finally RV1b inhibited IL-17A production in lung CD4(+) T cells in a setting of experimental asthma. These results indicate that the RV1b inhibits IL-17A in T helper type 17 cells and IL-17A clears RV1b infection in epithelial cells. In both cases IL-17A contributes to fend off RV1b infection by inducing genes downstream of interferon type I pathway.

Right-sided diaphragmatic rupture after repair of a large Morgagni hernia

We present a case of a combination of primary and secondary diaphragmatic hernia in a 63-year male patient. For progressive dyspnea and palpitations caused by a large and symptomatic Morgagni hernia resulting in a right-sided enterothorax, an open tension-free mesh repair was performed. The postoperative course was complicated by a secondary hepatothorax through a spontaneous rupture of the right diaphragm. Primary mesh repair of the Morgagni hernia, however, proved to be sufficient. This recurrent herniation might be a consequence of (1) preexisting atrophy of the right diaphragm caused by disposition and/or long-term diaphragmatic dysfunction due to the large hernia, combined with (2) further thinning out of the diaphragm by intraoperative hernia sac resection, and (3) postoperative increase of intra-abdominal pressure.

Therapy response evaluation of malignant lymphoma in a multicenter study: comparison of manual and semiautomatic measurements in CT

PURPOSE

Comparison of manual one-/bi-dimensional measurements versus semi-automatically derived one-/bi-dimensional and volumetric measurements for therapy response evaluation of malignant lymphoma during CT follow-up examinations in a multicenter setting.

MATERIALS AND METHODS

MSCT data sets of patients with malignant lymphoma were evaluated before (baseline) and after two cycles of chemotherapy (follow-up) at radiological centers of five university hospitals. The long axis diameter (LAD), the short axis diameter (SAD) and the bi-dimensional WHO of 307 target lymph nodes were measured manually and semi-automatically using dedicated software. Lymph node volumetry was performed semi-automatically only. The therapeutic response was evaluated according to lymphoma-adapted RECIST.

RESULTS

Based on a single lymph node, semi-automatically derived multidimensional parameters allowed for significantly more accurate therapy response classification than the manual or the semi-automatic unidimensional parameters. Incorrect classifications were reduced by up to 9.6%. Compared to the manual approach, the influence of the study center on correct therapy classification is significantly less relevant when using semi-automatic measurements.

CONCLUSION

Semi-automatic volumetry and bi-dimensional WHO significantly reduce the number of incorrectly classified lymphoma patients by approximately 9.6% in the multicenter setting in comparison to linear parameters. Semi-automatic quantitative software tools may help to significantly reduce wrong classifications that are associated with the manual assessment approach.

KEY POINTS

► Semi-automatic volumetry and bi-dimensional WHO significantly reduce the number of incorrectly classified lymphoma patients ► Manual lymph node evaluation with uni-dimensional parameters is inferior to semi-automatic analysis in a multicenter setting ► Semi-automatic quantitative software tools should be introduced in clinical study evaluation.

[Modern imaging of kidney tumors]

If a renal mass is suspected on clinical examination or ultrasound the finding has to be confirmed by cross-sectional imaging. Methods that are used include multidetector-row computed tomography (MDCT) and magnetic resonance imaging (MRI). Also contrast-enhanced ultrasound has been successfully implemented in renal imaging and now plays a major role in the differentiation of benign from malignant renal masses. In expert hands it can be used to show very faint vascularization and subtle enhancement. The MDCT technique benefits from the recently introduced dual energy technology that allows superior characterization of renal masses in a single-phase examination, thereby greatly reducing radiation exposure. For young patients and persons allergic to iodine MRI should be used and it provides excellent soft tissue contrast and visualizes contrast enhancement kinetics in multiphase examinations.This article aims at giving a comprehensive overview of these different imaging modalities, their clinical indications and contraindications, as well as a description of imaging findings of various renal masses.

Right-sided diaphragmatic rupture after repair of a large Morgagni hernia

We present a case of a combination of primary and secondary diaphragmatic hernia in a 63-year male patient. For progressive dyspnea and palpitations caused by a large and symptomatic Morgagni hernia resulting in a right-sided enterothorax, an open tension-free mesh repair was performed. The postoperative course was complicated by a secondary hepatothorax through a spontaneous rupture of the right diaphragm. Primary mesh repair of the Morgagni hernia, however, proved to be sufficient. This recurrent herniation might be a consequence of (1) preexisting atrophy of the right diaphragm caused by disposition and/or long-term diaphragmatic dysfunction due to the large hernia, combined with (2) further thinning out of the diaphragm by intraoperative hernia sac resection, and (3) postoperative increase of intra-abdominal pressure.

Dose reduction in oncological staging multidetector CT: effect of iterative reconstruction

OBJECTIVE

To compare radiation exposure and image quality of oncological staging multidetector CT (MDCT) examinations of the chest, abdomen and pelvis with and without iterative reconstruction (IR).

METHODS

40 patients with known malignancy underwent staging CT examinations at two time points. Both CT scans were performed on the same scanner (SOMATOM® Definition Flash, Siemens Healthcare, Forchheim, Germany). For the baseline scan, the tube current-time product was set to 250 mAs [image reconstruction: filtered back projection (FBP)] and for the follow-up scan to 150 mAs [reconstruction: iterative reconstruction (IR)]. Effective radiation doses were estimated based on dose-length products for both baseline and follow-up. Noise measurements in defined regions were compared for FBP and IR. Images were also subjectively evaluated for image quality by three radiologists with different levels of experience.

RESULTS

Dose reduction was 44.4±8.2% for reduced-dose CT scans with IR compared with baseline with FBP. Image noise was not significantly different between images reconstructed with FBP and IR. The subjective quality of standard-dose FBP images and reduced-dose iteratively reconstructed CT images were identical.

CONCLUSION

Our results show the dose-reducing potential of IR of CT image data in oncological patients.

ADVANCES IN KNOWLEDGE

The algorithm tested in the present scientific study allows a >45% dose reduction at maintained image quality.

[Importance of PET/CT for imaging of colorectal cancer]

CLINICAL/METHODICAL ISSUE

Fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) has emerged as a very useful imaging modality in the management of colorectal carcinoma. Data from the literature regarding the role of PET/CT in the initial diagnosis, staging, radiotherapy planning, response monitoring and surveillance of colorectal carcinoma is presented. Future directions and economic aspects are discussed.

STANDARD RADIOLOGICAL METHODS

Computed tomography (CT), magnetic resonance imaging (MRI) and FDG-PET for colorectal cancer and endorectal ultrasound for rectal cancer.

METHODICAL INNOVATIONS

Combined FDG-PET/CT.

PERFORMANCE

While other imaging modalities allow superior visualization of the extent and invasion depth of the primary tumor, PET/CT is most sensitive for the detection of distant metastases of colorectal cancer.

ACHIEVEMENTS

We recommend a targeted use of PET/CT in cases of unclear M staging, prior to metastasectomy and in suspected cases of residual or recurrent colorectal carcinoma with equivocal conventional imaging. The role of PET/CT in radiotherapy planning and response monitoring needs to be determined. Currently there is no evidence to support the routine use of PET/CT for colorectal screening, staging or surveillance.

PRACTICAL RECOMMENDATIONS

To optimally exploit the synergy between morphologic and functional information, FDG-PET should generally be performed as an integrated FDG-PET/CT with a contrast-enhanced CT component in colorectal carcinoma.

[Clinical approach to renal trauma]

Management of kidney injuries is an uncommon challenge to urologists. Therapy has evolved in recent years from mainly surgical to predominantly conservative treatment. Immediate surgical intervention for renal trauma is now only necessary in rare instances. This overview is based on the guidelines of the European Association of Urology and the Societé International d'Urologie as well as clinical experience and is intended to provide practical advice for treatment of renal trauma.

[Indications for and results of CT colonography: from screening to the symptomatic patient]

CT colonography (CTC) is also referred to as virtual colonoscopy and is being used with increasing frequency in radiological practice. While there are still no generally accepted, clear-cut indications for its use in mass colorectal cancer screening, there is evidence that this investigation is useful in patients in whom colonoscopy has not been successful or who have known stenotic lesions in the colon. Recent results of significant comparative studies of CTC and conventional colonoscopy will have some influence on the future place of CTC in screening for cancer of the bowel; they show the great potential of CT-aided bowel examination.

Comparison of CT colonography, colonoscopy, sigmoidoscopy and faecal occult blood tests for the detection of advanced adenoma in an average risk population

BACKGROUND AND AIMS

This prospective trial was designed to compare the performance characteristics of five different screening tests in parallel for the detection of advanced colonic neoplasia: CT colonography (CTC), colonoscopy (OC), flexible sigmoidoscopy (FS), faecal immunochemical stool testing (FIT) and faecal occult blood testing (FOBT).

METHODS

Average risk adults provided stool specimens for FOBT and FIT, and underwent same-day low-dose 64-multidetector row CTC and OC using segmentally unblinded OC as the standard of reference. Sensitivities and specificities were calculated for each single test, and for combinations of FS and stool tests. CTC radiation exposure was measured, and patient comfort levels and preferences were assessed by questionnaire.

RESULTS

221 adenomas were detected in 307 subjects who completed CTC (mean radiation dose, 4.5 mSv) and OC; 269 patients provided stool samples for both FOBT and FIT. Sensitivities of OC, CTC, FS, FIT and FOBT for advanced colonic neoplasia were 100% (95% CI 88.4% to 100%), 96.7% (82.8% to 99.9%), 83.3% (95% CI 65.3% to 94.4%), 32% (95% CI 14.9% to 53.5) and 20% (95% CI 6.8% to 40.7%), respectively. Combination of FS with FOBT or FIT led to no relevant increase in sensitivity. 12 of 45 advanced adenomas were smaller than 10 mm. 46% of patients preferred CTC and 37% preferred OC (p<0.001).

CONCLUSIONS

High-resolution and low-dose CTC is feasible for colorectal cancer screening and reaches sensitivities comparable with OC for polyps >5 mm. For patients who refuse full bowel preparation and OC or CTC, FS should be preferred over stool tests. However, in cases where stool tests are performed, FIT should be recommended rather than FOBT.

Value of ultrasound in the diagnosis of aneurysms of the extracranial internal carotid arteries

Aneurysms of the extracranial carotid arteries are a rare abnormalitiy and may represent a diagnostic challenge in examination of the patients. B-flow is a new digital vascular ultrasound technique and is an especially reliable method in the diagnosis of the extracranial portion of the internal carotid arteries as it shows less flow artifacts than color-coded Doppler sonography (CCDS) and power Doppler (PD). This review compares color-coded Doppler sonography, power Doppler and B-flow findings in extracranial ICA and CA aneurysm to emphasize the usefulness of B-flow in this clinical condition.

[Persistent pharyngeocutaneous fistula after transcervical resection of a diverticulum of the hypopharynx]

CASE

A 26-year-old white male patient had undergone resection of a diverticulum of the hypopharynx and myotomy of the cricopharyngeal muscle elsewhere. A transcervical approach had been chosen owing to the presence of an arteria lusoria and the associated risk of vessel injury. The patient had subsequently had recurrent fistulas through the skin incision, which had not resolved despite four further operations. He presented in our department with significant weight loss and persistent retrosternal pain. Esophageal manometry revealed that resting muscle tone in the upper esophageal sphincter was still significantly elevated. Assuming that the earlier myotomy had not been completely successful, we decided to complete this operation as revision surgery. The pharynx was closed with a running suture using the Conley technique. The fistula healed, and there were no further recurrences.

CONCLUSION

Complete and careful dissection of all muscle fibers back to the mucosa is essential, as well as complete removal of the diverticulum if this operation is to be successful when performed by the transcutaneous approach. Recurrent diverticula are not the only possible complication; persistent pharyngeocutaneous fistulas can also arise.

Verletzungen des Nierenbeckens und des Ureters

About 5% of injuries of the urinary tract affect the renal pelvis and ureter and constitute a severe complication. Around 75% of these injuries are iatrogenic and only about 25% are caused by blunt abdominal trauma or perforation. To avoid complications and improve prognosis, immediate diagnosis and therapy are essential. The diagnostic accuracy of preoperative studies is low, therefore frequently injuries are detected during explorative laparotomy. The management of upper urinary tract lesions depends on severity and localization, whereas the ultimate ambition should always be the preservation of the kidney. As a basic rule, ureteral stenting is mostly sufficient for small lesions, and only larger injuries require open reconstructive techniques. Longitudinal studies document a high degree of functional reconstitution if adequate and immediate treatment is carried out.

Computer-aided detection in CT colonography: initial clinical experience using a prototype system

Computer-aided detection (CAD) algorithms help to detect colonic polyps at CT colonography (CTC). The purpose of this study was to evaluate the accuracy of CAD versus an expert reader in CTC. One hundred forty individuals (67 men, 73 women; mean age, 59 years) underwent screening 64-MDCT colonography after full cathartic bowel cleansing without fecal tagging. One expert reader interpreted supine and prone scans using a 3D workstation with integrated CAD used as "second reader." The system's sensitivity for the detection of polyps, the number of false-positive findings, and its running time were evaluated. Polyps were classified as small (< or =5 mm), medium (6-9 mm), and large (> or =10 mm). A total of 118 polyps (small, 85; medium, 19; large, 14) were found in 56 patients. CAD detected 72 polyps (61%) with an average of 2.2 false-positives. Sensitivity was 51% (43/85) for small, 90% (17/19) for medium, and 86% (12/14) for large polyps. For all polyps, per-patient sensitivity was 89% (50/56) for the radiologist and 73% (41/56) for CAD. For large and medium polyps, per-patient sensitivity was 100% for the radiologist, and 96% for CAD. In conclusion, CAD shows high sensitivity in the detection of clinically significant polyps with acceptable false-positive rates.