Diagnosis of sarcopenia on thoracic computed tomography and its association with postoperative survival after anatomic lung cancer resection

Computer tomography-derived skeletal muscle index normalized for height in conjunction with muscle density enables single modality-based sarcopenia assessment that accounts for all diagnostic criteria and cutoff recommendations as per the widely accepted European consensus. Yet, the standard approach to quantify skeletal musculature at the third lumbar vertebra is limited for certain patient groups, such as lung cancer patients who receive chest CT for tumor staging that does not encompass this lumbar level. As an alternative, this retrospective study assessed sarcopenia in lung cancer patients treated with curative intent at the tenth thoracic vertebral level using appropriate cutoffs. We showed that skeletal muscle index and radiation attenuation at level T10 correlate well with those at level L3 (Pearson's R = 0.82 and 0.66, p < 0.001). During a median follow-up period of 55.7 months, sarcopenia was independently associated with worse overall (hazard ratio (HR) = 2.11, 95%-confidence interval (95%-CI) = 1.38-3.23, p < 0.001) and cancer-specific survival (HR = 2.00, 95%-CI = 1.19-3.36, p = 0.009) of lung cancer patients following anatomic resection. This study highlights feasibility to diagnose sarcopenia solely by thoracic CT in accordance with the European consensus recommendations. The straightforward methodology offers easy translation into routine clinical care and potential to improve preoperative risk stratification of lung cancer patients scheduled for surgery.

[Acceptance of medical apps and e‑books among German radiologists]

PURPOSE

Smartphones, tablet PCs, mobile applications (apps) and electronic book files (e-books) affect our lives in private and job-related settings. The aim of this study was to analyze the behavior of radiologists on smartphones, tablet PCs and e‑books and to investigate its effect on their daily work.

MATERIALS AND METHODS

An online survey containing of 23 questions was conducted using Survey Monkey© ( www.surveymonkey.com ). The invitation to the survey was done using the newsletter of the German Radiological Society (DRG). The acquired data was automatically stored by the software and then analyzed using descriptive statistics.

RESULTS

In total, 104 radiologists (29% female) participated in the online survey. Of these, 93% and 96.5% owned a smartphone or a tablet PC, respectively, and 72% and 67% used medical apps and e‑books, respectively. Through their use, 31% found moderate and 41% found enormous improvement in their daily work. A majority of participating radiologists would be willing to pay an increased user fee for optimized apps or e‑books.

CONCLUSION

With currently only moderate individual benefit of mobile medical apps and e‑books, there is a widespread need for optimally configured apps and e‑books with a correspondingly high market potential.

KEY POINTS

(1) Radiologists use smartphones (93%) or tablet PCs (96.5%); (2) 72% of radiologists use a smartphone or tablet PC for medical material; (3) 53% of radiologists report significant assistance from or a high value of the mobile medical applications used; (4) There is a willingness to pay a license fee for optimized mobile applications or e‑books.

Long-term survival after percutaneous irreversible electroporation of inoperable colorectal liver metastases

Background

For colorectal liver metastases (CRLM) that are not amenable to surgery or thermal ablation, irreversible electroporation (IRE) is a novel local treatment modality and additional option.

Methods

This study is a retrospective long-term follow-up of patients with CRLM who underwent IRE as salvage treatment.

Results

Of the 24 included patients, 18 (75.0%) were male, and the median age was 57 (range: 28-75) years. The mean time elapsed from diagnosis to IRE was 37.9±37.3 months. Mean overall survival was 26.5 months after IRE (range: 2.5-69.2 months) and 58.1 months after diagnosis (range: 14.8-180.1 months). One-, three-, and five-year survival rates after initial diagnosis were 100.0%, 79.2%, and 41.2%; after IRE, the respective survival rates were 79.1%, 25.0%, and 8.3%. There were no statistically significant differences detected in survival after IRE with respect to gender, age, T- or N-stage at the time of diagnosis, size of metastases subject to IRE, number of hepatic lesions, or time elapsed between IRE and diagnosis.

Conclusion

For nonresectable CRLM, long-term survival data emphasize the value of IRE as a new minimally invasive local therapeutic approach in multimodal palliative treatment, which is currently limited to systemic or regional therapies in this setting.

Low Tube Voltage Liver MDCT with Sinogram-Affirmed Iterative Reconstructions for the Detection of Hepatocellular Carcinoma

Aim of this study was to compare low tube voltage computed tomography (80 kV) of the liver using iterative image reconstruction (SAFIRE) with standard computed tomography (120 kV) using filtered back-projection (FBP) for the detection of hepatocellular carcinoma (HCC). 46 patients (43 men) with 93 HCC confirmed by 3 T MRI with Gd-EOB-DPTA, in inconclusive cases combined with contrast-enhanced ultrasound, underwent dual-energy CT. The raw data of the 80 kV tube was reconstructed using the iterative reconstruction algorithm SAFIRE with two strengths (I3 and I5). The virtual 120 kV image data set was reconstructed using FBP. The CT images were reviewed to determine the lesion-to-liver contrast (LLC), the lesion contrast-to-noise ratio (CNR) and the sensitivity. The LLC (57.1/54.3 [I3/I5] vs. 34.9 [FBP]; p ≤ 0.01), CNR (3.67/4.45 [I3/I5] vs. 2.48 [FBP]; p < 0.01) and sensitivity (91.4%/88.2% [I3/I5] vs. 72.0% [FBP]; p ≤ 0.01) were significantly higher in the low-voltage protocol using SAFIRE. Therefore, low tube voltage CT using SAFIRE results in an increased lesion-to-liver contrast as well as an improved lesion contrast-to-noise ratio compared to FBP at 120 kV which results in a higher sensitivity for the detection of HCC.

Transarterial chemoembolization (TACE) with degradable starch microspheres (DSM) in hepatocellular carcinoma (HCC): multi-center results on safety and efficacy

BACKGROUND

Hepatocellular carcinoma (HCC) is the 3rd leading cause of cancer-related death worldwide. The majority of HCCs are diagnosed in a stage that is not eligible for curative resection. For intermediate stage HCC, transarterial chemoembolization (TACE) is the recommended treatment. We evaluated the safety and efficacy of DSM (degradable starch microspheres) as embolic agent in transarterial chemoembolization (TACE) for the treatment of intermediate stage, non-resectable hepatocellular carcinoma (HCC).

METHODS AND FINDINGS

A national, multi-center observational study on the safety and efficacy of DSM-TACE for the treatment of intermediate HCC was conducted. The recruitment period for the study was from January 2010 to June 2014. The primary endpoints were safety and treatment response according to the mRECIST criteria. A total of 179 DSM-TACE procedures in 50 patients were included in the analysis. The therapeutic efficacy assessed with mRECIST was as follows: complete response (n=1; 2 %), 21 partial response (42 %), 13 stable disease (26 %), 9 progressive disease (18 %), and 6 incomplete data (12 %). Thus, the objective response rate was 44% (n=22) and disease control rate was 70% (n=35). A total of 76 immediate adverse events (AE) and 2 severe adverse events (SAE) were recorded. Forty-eight percent of patients (n=24) did not encounter any immediate AE/SAE. Between treatments, a total of 66 AE and one SAE were recorded. Twenty-four patients (48 %) did not encounter any AE/SAE in between treatments.

CONCLUSION

The use of DSM as a TACE embolic agent appears to be safe for the treatment of HCC and has promising efficacy.

Percutaneous Irreversible Electroporation: Long-term survival analysis of 71 patients with inoperable malignant hepatic tumors

Aim of this retrospective analysis was to evaluate the survival times after percutaneous irreversible electroporation (IRE) in inoperable liver tumors not amenable to thermal ablation. 71 patients (14 females, 57 males, median age 63.5 ± 10.8 years) with 103 liver tumors were treated in 83 interventions using IRE (NanoKnife® system). The median tumor short-axis diameter was 1.9 cm (minimum 0.4 cm, maximum 4.5 cm). 35 patients had primary liver tumors and 36 patients had liver metastases. The Kaplan-Meier method was employed to calculate the survival rates, and the different groups were compared using multivariate log-rank and Wilcoxon tests. The overall median survival time was 26.3 months; the median survival of patients with primary land secondary liver cancer did not significantly differ (26.8 vs. 19.9 months; p = 0.41). Patients with a tumor diameter >3 cm (p < 0.001) or more than 2 lesions (p < 0.005) died significantly earlier than patients with smaller or fewer tumors. Patients with hepatocellular carcinoma and Child-Pugh class B or C cirrhosis died significantly earlier than patients with Child-Pugh class A (p < 0.05). Patients with very early stage HCC survived significantly longer than patients with early stage HCC with a median survival of 22.3 vs. 13.7 months (p < 0.05).

Impact of Different Embolic Agents for Transarterial Chemoembolization (TACE) Procedures on Systemic Vascular Endothelial Growth Factor (VEGF) Levels

Background and Aims: Intermediate stage hepatocellular carcinoma (HCC) can be treated by transarterial chemoembolization (TACE). However, there appear to be side effects, such as induction of proangiogenic factors, e.g. vascular endothelial growth factor (VEGF), which have been shown to be associated with a poor prognosis. This prospective study was designed to compare serum VEGF level response after TACE with different embolic agents in patients with HCC. Methods: Patients were assigned to one of three different TACE regimens: degradable starch microspheres (DSM) TACE, drug-eluting bead (DEBDOX) TACE or Lipiodol TACE (cTACE). All patients received 50 mg doxorubicin/m² body surface area (BSA) during TACE. Serum VEGF levels were assessed before TACE treatment, 24 h post-treatment and 4 weeks later. Results: Twenty-two patients with 30 TACE treatments were enrolled. Compared to baseline VEGF levels, a marked increase was observed for 24 h post-TACE (164% of baseline level) and during the 4-week follow-up (170% of baseline level) only for the cTACE arm (p < 0.05). In contrast, the increase of serum VEGF levels were only 114% and 123% for DEBDOX and 121% and 124% for DSM, respectively. Conclusions: Conventional TACE using Lipiodol shows marked increase in blood levels of the proangiogenic factor VEGF, while DEBDOX and DSM TACE induce only a moderate VEGF response.

Adverse effects of irreversible electroporation of malignant liver tumors under CT fluoroscopic guidance: a single-center experience

PURPOSE

We aimed to describe the frequency of adverse events after computed tomography (CT) fluoroscopy-guided irreversible electroporation (IRE) of malignant hepatic tumors and their risk factors.

METHODS

We retrospectively analyzed 85 IRE ablation procedures of 114 malignant liver tumors (52 primary and 62 secondary) not suitable for resection or thermal ablation in 56 patients (42 men and 14 women; median age, 61 years) with regard to mortality and treatment-related complications. Complications were evaluated according to the standardized grading system of the Society of Interventional Radiology. Factors influencing the occurrence of major and minor complications were investigated.

RESULTS

No IRE-related death occurred. Major complications occurred in 7.1% of IRE procedures (6/85), while minor complications occurred in 18.8% (16/85). The most frequent major complication was postablative abscess (4.7%, 4/85) which affected patients with bilioenteric anastomosis significantly more often than patients without this condition (43% vs. 1.3%, P = 0.010). Bilioenteric anastomosis was additionally identified as a risk factor for major complications in general (P = 0.002). Minor complications mainly consisted of hemorrhage and portal vein branch thrombosis.

CONCLUSION

The current study suggests that CT fluoroscopy-guided IRE ablation of malignant liver tumors may be a relatively low-risk procedure. However, patients with bilioenteric anastomosis seem to have an increased risk of postablative abscess formation.

Bile Duct Injury after Irreversible Electroporation of Hepatic Malignancies: Evaluation of MR Imaging Findings and Laboratory Values

PURPOSE

To evaluate biliary complications after irreversible electroporation (IRE) of hepatic malignancies.

MATERIALS AND METHODS

In 24 patients (17 men; mean age, 59.3 y), bile ducts were located within a 1.0-cm radius of the ablation zone at subacute follow-up (ie, 1–3 d) after percutaneous IRE of 53 hepatic tumors (primary hepatic tumors, n = 14). MR imaging, conducted with a hepatocyte-specific contrast agent before and after treatment, was examined for evidence of bile duct injury. Serum bilirubin and alkaline phosphatase levels measured at subacute and short-term follow-up (ie, 1–2 mo after IRE) were analyzed for evidence of biliary injury. Correlations between bile duct injury and characteristics of patients, lesions, and ablation procedures were assessed by generalized linear models.

RESULTS

Fifty-five bile ducts were located within 1.0 cm of an ablation defect. Locations relative to the ablation area were as follows: 33 were encased, 14 were abutting, and 8 were located within a radius of 0.1–1.0 cm of the ablation zone. Subacute follow-up MR images showed 15 bile duct injuries (narrowing, n = 8; dilation, n = 7). At subacute follow-up, three patients showed transient abnormalities of laboratory values (bilirubin, 1.6–5.2 mg/dL). Short-term laboratory values were abnormal in one patient (increase in alkaline phosphatase of 533 U/L vs baseline) as a result of local tumor recurrence. Patient age (continuous, P = .026; < 65 y vs ≥ 65 y, P = .001) was independently associated with post-IRE bile duct injury.

CONCLUSIONS

Bile ducts adjacent to an IRE ablation area remain largely unaffected by this procedure.

Evaluation of a robotic system for irreversible electroporation (IRE) of malignant liver tumors: initial results

OBJECTIVE

Comparison of conventional CT-guided manual irreversible electroporation (IRE) of malignant liver tumors and a robot-assisted approach regarding procedural accuracy, intervention time, dose, complications, and treatment success.

METHODS

A retrospective single-center analysis of 40 cases of irreversible electroporation of malignant liver tumors in 35 patients (6 females, 29 males, average age 60.3 years). Nineteen of these ablation procedures were performed manually and 21 with robotic assistance. A follow-up (ultrasound, CT, and MRI) was performed after 6 weeks in all patients.

RESULTS

The time from the planning CT scan to the start of the ablation as well as the dose-length product were significantly lower under robotic assistance (63.5 vs. 87.4 min, [Formula: see text]; 2132 vs. 4714 mGy cm, [Formula: see text]). The procedural accuracy, measured as the deviation of the IRE probes with respect to a defined reference probe, was significantly higher using robotic guidance (2.2 vs. 3.1 mm, [Formula: see text]). There were no complications. There was one incomplete ablation in the manual group.

CONCLUSION

Robotic assistance for IRE of liver tumors allows for faster procedure times with higher accuracy while reducing radiation dose as compared to the manual placement of IRE probes.

Evaluation of a Robotic Assistance-System For Percutaneous Computed Tomography-Guided (CT-Guided) Facet Joint Injection: A Phantom Study

Background

The aim of this study was to compare robotic assisted and freehand facet joint puncture on a phantom model in regards to time requirements and puncture accuracy.

Material/Methods

Forty facet joints were punctured, 20 using a robotic guidance system and 20 using a freehand procedure. Side and height of the facet joints were randomized and identical for both groups. Procedural accuracy, defined as axial and sagittal deviation, as well as the number of corrections were assessed. Procedure times for each step were documented and time requirements for pre-positioning, reconstruction, planning, and total intervention were calculated.

Results

Total procedure time for robotic guidance was 259±111 seconds versus 119±77 seconds for freehand procedure (p=1.0). Procedural accuracy for robotic guidance was significantly higher with 0 corrections versus 1.3 corrections for freehand procedure (p=0.02). Needle deviation in the robotics arm was 0.35±1.1 mm in the axial and 2.15±1.2 mm in the sagittal reconstruction.

Conclusions

Robotic assisted puncture of the facet joint allowed accurate positioning of the needle with a lower number of needle readjustments. Higher procedural accuracy was marginally offset by a slightly longer intervention time.

Percutaneous irreversible electroporation (IRE) of prostate cancer: Contrast-enhanced ultrasound (CEUS) findings

PURPOSE

To evaluate the use of contrast-enhanced ultrasound (CEUS) after irreversible electroporation (IRE) of prostatic cancer tissue to assess the ablation status by depicting microvascularisation in the ablation area.

MATERIALS AND METHODS

Retrospective evaluation of CEUS of 13 patients (mean age: 61.4 ± 7.5 years) with histologically confirmed prostatic cancer who underwent percutaneous IRE. In the course of clinical routine, the tumor lesions were documented before, immediately after, and 1 day after the ablationusing color-coded transabdominal and transrectal CEUS. The obtained image data (DICOM loops and images) were subsequently evaluated by 2 experienced radiologists and assessed with regard to micro vascularisation by means of a 5-point scale.

RESULTS

CEUS images showed significantly reduced microcirculation of the lesions (mean 0.9 ± 0.6 cm (0.5-1.5 cm) after IRE. Microcirculation was reduced from 2.15 ± 0.56 prior to ablation to 0.65 ± 0.63 (p <  0.001) immediately after the ablation and to 0.27 ± 0.44 one day after IRE (p <  0.001).

CONCLUSION

This study showed rapid and significant reduction of the microcirculation in the ablation area afterpercutaneous IRE of prostatic cancer tissue.

Percutaneous Ablation of Hepatic Tumors Using Irreversible Electroporation: A Prospective Safety and Midterm Efficacy Study in 34 Patients

PURPOSE

To evaluate the safety and efficacy of percutaneous irreversible electroporation (IRE) of primary and secondary liver cancer unsuitable for resection or thermal ablation.

MATERIALS AND METHODS

In this prospective, single-center study, 65 malignant liver tumors (hepatocellular carcinoma, n = 33; cholangiocellular carcinoma, n = 5; colorectal cancer metastasis, n = 22; neuroendocrine cancer metastasis, n = 3; testicular cancer metastasis, n = 2) in 34 patients (27 men, 7 women; mean age, 59.4 y ± 11.2) were treated. Local recurrence-free survival (LRFS) according to the Kaplan-Meier method was evaluated after a median follow-up of 13.9 months.

RESULTS

Median tumor diameter was 2.4 cm ± 1.4 (range, 0.2-7.1 cm). Of 65 tumors, 12 (18.5%) required retreatment because of incomplete ablation (n = 3) or early local recurrence (n = 9). LRFS at 3, 6, and 12 months was 87.4%, 79.8%, and 74.8%. The median time to progressive disease according to modified Response Evaluation Criteria In Solid Tumors was 15.6 months. Overall complication rate was 27.5% with six major complications and eight minor complications. Major complications included diffuse intraperitonal bleeding (n = 1), partial thrombosis of the portal vein (n = 1), and liver abscesses (n = 4). Minor complications were liver hematomas (n = 6) and clinically inapparent pneumothoraces (n = 2).

CONCLUSIONS

IRE showed promising results regarding therapeutic efficacy for the percutaneous treatment of liver tumors; however, significant concerns remain regarding its safety.

Robot-assisted microwave thermoablation of liver tumors: a single-center experience

PURPOSE

To evaluate and compare the needle placement accuracy, patient dose, procedural time, complication rate and ablation success of microwave thermoablation using a novel robotic guidance approach and a manual approach.

METHODS

We performed a retrospective single-center evaluation of 64 microwave thermoablations of liver tumors in 46 patients (10 female, 36 male, mean age 66 years) between June 2014 and February 2015. Thirty ablations were carried out with manual guidance, while 34 ablations were performed using robotic guidance. A 6-week follow-up (ultrasound, computed tomography and MRI) was performed on all patients.

RESULTS

The total procedure time and dose-length product were significantly reduced under robotic guidance (18.3 vs. 21.7 min, [Formula: see text]; 2216 vs. 2881 mGy[Formula: see text]cm, [Formula: see text]). The position of the percutaneous needle was more accurate using robotic guidance (needle deviation 1.6 vs. 3.3 mm, [Formula: see text]). There was no significant difference between both groups regarding the complication rate and the ablation success.

CONCLUSION

Robotic assistance for liver tumor ablation reduces patient dose and allows for fast positioning of the microwave applicator with high accuracy. The complication rate and ablation success of percutaneous microwave thermoablation of malignant liver tumors using either CT fluoroscopy or robotic guidance for needle positioning showed no significant differences in the 6-week follow-up.

Irreversible Electroporation of Malignant Hepatic Tumors--Alterations in Venous Structures at Subacute Follow-Up and Evolution at Mid-Term Follow-Up

Purpose

To evaluate risk factors associated with alterations in venous structures adjacent to an ablation zone after percutaneous irreversible electroporation (IRE) of hepatic malignancies at subacute follow-up (1 to 3 days after IRE) and to describe evolution of these alterations at mid-term follow-up.

Materials and Methods

43 patients (men/women, 32/11; mean age, 60.3 years) were identified in whom venous structures were located within a perimeter of 1.0 cm of the ablation zone at subacute follow-up after IRE of 84 hepatic lesions (primary/secondary hepatic tumors, 31/53). These vessels were retrospectively evaluated by means of pre-interventional and post-interventional contrast-enhanced magnetic resonance imaging or computed tomography or both. Any vascular changes in flow, patency, and diameter were documented. Correlations between vascular change (yes/no) and characteristics of patients, lesions, and ablation procedures were assessed by generalized linear models.

Results

191 venous structures were located within a perimeter of 1.0 cm of the ablation zone: 55 (29%) were encased by the ablation zone, 78 (41%) abutted the ablation zone, and 58 (30%) were located between 0.1 and 1.0 cm from the border of the ablation zone. At subacute follow-up, vascular changes were found in 19 of the 191 vessels (9.9%), with partial portal vein thrombosis in 2, complete portal vein thrombosis in 3, and lumen narrowing in 14 of 19. At follow-up of patients with subacute vessel alterations (mean, 5.7 months; range, 0 to 14 months) thrombosis had resolved in 2 of 5 cases; vessel narrowing had completely resolved in 8 of 14 cases, and partly resolved in 1 of 14 cases. The encasement of a vessel by ablation zone (OR = 6.36, p<0.001), ablation zone being adjacent to a portal vein (OR = 8.94, p<0.001), and the usage of more than 3 IRE probes (OR = 3.60, p = 0.035) were independently associated with post-IRE vessel alterations.

Conclusion

Venous structures located in close proximity to an IRE ablation zone remain largely unaffected by this procedure, and thrombosis is rare.

Magnetic resonance imaging of the sacroiliac joints in patients with suspected spondyloarthritis--comparison of turbo spin-echo and gradient-echo sequences for the detection of structural alterations

PURPOSE

Magnetic resonance imaging (MRI) is the method of choice for the evaluation of spondyloarthritis (SpA). According to the guidelines of the Assessment of Spondyloarthritis International Society (ASAS) and Outcome Measures in Rheumatology (OMERACT), MRI findings in SpA of the spine and the sacroiliac joints (SIJ) are classified as inflammatory and structural alterations. Modern gradient-echo sequences (GRE) are recommended for optimized detection of structural alterations of the SIJ. We assess the benefit of GRE in the detection of structural alterations of the SIJ in comparison to conventional turbo spin-echo sequences (TSE).

MATERIAL AND METHODS

Retrospective study of 114 patients who received MRI of the SIJ for the evaluation of SpA. Structural alterations of the SIJ were assessed by two blinded readers separately for T1 TSE and T2* GRE. The findings were classified according to a previously published chronicity score separately for both sides and sequences. Interobserver reliability was calculated with Cohen's Kappa, and the significance of findings was assessed with the Wilcoxon test. P-values <0.05 were required for statistical significance.

RESULTS

68 of 114 (60%) patients showed SpA-typical findings of the SIJ. The average chronicity score for GRE (score 3.3) was significantly higher than for TSE (score 2.6), p=0.001. The Kappa-values for the interobserver reliability were 0.86-0.90 without any statistically significant differences between both sides and sequences.

CONCLUSION

Both T1 TSE and T2* GRE showed a high interobserver reliability in the detection of structural alterations in patients with SpA. However, T2* GRE detected significantly more structural alterations than T1 TSE and should be an integral part of a modern MRI protocol for the diagnostic workup of patients with suspected SpA.

KEY POINTS

T2* gradient-echo sequences are superior to T1 turbo spin-echo sequences in the detection of structural SI-joint alterations.

Factors associated with short-term local recurrence of liver cancer after percutaneous ablation using irreversible electroporation: a prospective single-center study

PURPOSE

To evaluate the risk factors associated with short-term local recurrence of malignant liver lesions after irreversible electroporation (IRE).

MATERIALS AND METHODS

Thirty-nine consecutive patients (79 malignant liver lesions) were treated with IRE, of whom 14 were excluded from the analysis (including 12 without 6 mo of follow-up and two with incomplete ablation). The remaining 25 patients (aged 59.4 y ± 11.2) had 48 malignant liver lesions, including 22 hepatocellular carcinomas (HCCs), six cholangiocellular carcinomas, and 20 metastatic liver cancers. Multivariate analyses were used to evaluate the associations of risk factors with early recurrence. The characteristics of patients, lesions, and IRE procedures were assessed by logistic regression.

RESULTS

Fourteen of the 48 treated lesions (29.2%) showed early local recurrence after 6 months. Tumor volume (< 5 cm(3) vs ≥ 5 cm(3); P = .022) and underlying disease type (HCC, cholangiocellular carcinoma, or metastatic disease; P = .023) were independently associated with early local recurrence. However, distances to the surrounding portal veins (< 0.5 cm vs ≥ 0.5 cm; P = .810), hepatic veins (P = .170), hepatic arteries (P = .761), and bile ducts (P = .226) were not significantly associated with local recurrence.

CONCLUSIONS

Because short distances to the surrounding vessels were not associated with early local recurrence, percutaneous IRE might provide an alternative treatment option for perivascular tumors. However, patients with larger tumor volumes appeared to be poor candidates for percutaneous IRE. Regarding the different types of treated lesions, patients with HCC had significantly better outcomes.

S3 guideline for chronic pancreatitis - diagnosis, classification and therapy for the radiologist

Chronic pancreatitis shows an increasing prevalence and incidence mainly in the Western Hemisphere. Early diagnosis and therapy are frequently delayed because of non-specific symptoms as well as non-specific blood values. The German Society of Digestive and Metabolic Diseases (DGVS) organized the preparation and publication of an interdisciplinary S3 level guideline with the support of the German Radiological Society (DRG) as 1 of 11 contributing societies. In this article we present and discuss the main topics of the guideline regarding the diagnosis, differential diagnosis and therapy of complications of this complex chronic disease with a focus on clinical and scientific radiologists.

KEY POINTS

• Ultarsound represents the perfect first line imaging modality • For further diagnostic werk up MRI with MRCP are recommended for the differential diagnosis of pancreatic cancer • For clinical studies the modified (CT, MRI) Cambridge classification is recommended.

Added value of Gd-EOB-DTPA-enhanced Hepatobiliary phase MR imaging in evaluation of focal solid hepatic lesions

Background

Correct characterization of focal solid hepatic lesions has always been a challenge and is of great diagnostic and therapeutic relevance. The purpose of this study was to determine the added value of hepatobiliary phase images in Gd-EOB-DTPA-enhanced magnetic resonance imaging (MRI) for differentiating focal solid hepatic lesions.

Methods

In this retrospective trial 84 consecutive patients underwent Gd-EOB-DTPA-enhanced MR examinations. MRI was conducted for 64 patients with malignant focal hepatic lesions (34 hepatocellular carcinoma (HCC), 30 metastases) and for 20 patients with benign hepatic lesions (14 focal nodular hyperplasia (FNH), 3 adenoma, 3 hemangioma). Five radiologists independently reviewed three sets of MR images by means of a 5-point confidence scale from score 1 (definitely benign) to score 5 (definitely malignant): set 1: unenhanced images; set 2: unenhanced and Gd-EOB-DTPA-enhanced dynamic images; set 3: hepatobiliary phase images in addition to set 2. Accuracy was assessed by the alternative free-response receiver operating characteristic curve (A_z) and the index of diagnostic performance was calculated.

Results

Diagnostic accuracy was significantly improved by the addition of Gd-EOB-DTPA-enhanced dynamic images: A_z in set 1 was 0.708 and 0.833 in set 2 (P = 0.0002). The addition of hepatobiliary phase images increased the A_z value to 0.941 in set 3 (set 3 vs set 2, P < 0.0001; set 3 vs set 1, P < 0.0001). The index of diagnostic performance was lowest in set 1 (45%), improved in set 2 (71%), and highest in set 3 (94%).

Conclusions

Hepatobiliary phase images obtained after Gd-EOB-DTPA-enhanced dynamic MRI improve the differentiation of focal solid hepatic lesions.

Degradable starch microspheres versus ethiodol and doxorubicin in transarterial chemoembolization of hepatocellular carcinoma

PURPOSE

To compare outcomes of transarterial chemoembolization with degradable starch microspheres (DSMs) and conventional transarterial chemoembolization with doxorubicin and Ethiodol in patients with unresectable intermediate-stage hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

A total of 69 patients underwent 169 chemoembolization procedures with Ethiodol (n = 35) or DSMs (n = 34) as the embolic agent. The same chemotherapeutic agent was used for all patients (50 mg doxorubicin). The primary endpoint was patient survival, and secondary endpoints were local tumor response and incidence of therapy-associated complications with conventional or DSM chemoembolization. Tumor response was evaluated by consensus reading by two radiologists in accordance with modified Response Evaluation Criteria In Solid Tumors. Mean survival was calculated according to Kaplan-Meier analysis, and differences in survival curves were assessed by univariate log-rank test. The statistical significance of quantitative variables was determined by parameter-free Wilcoxon-Mann-Whitney U test.

RESULTS

The study groups were similar with regard to demographic data and disease stage. For the DSM chemoembolization group, the objective response rate (ie, complete or partial response) was 44.1%, and the rate of stable disease was 38.2%. The respective rates for the conventional chemoembolization group were 48.6% and 31.4%. Mean survival (P = .337) and complications did not significantly differ between groups (P = .907; P = 1.000).

CONCLUSIONS

DSM chemoembolization represents an alternative method of HCC treatment with a safety profile similar to that of conventional transarterial chemoembolization. Regarding local tumor response and overall survival, results of DSM chemoembolization were similar to those of conventional chemoembolization.

Single-phase percutaneous recanalization of malignant bile duct obstructions with a covered stent graft

PURPOSE

The aim of this study was to evaluate the benefit of a percutaneous transhepatic biliary drainage (PTCD) endoprothesis in the case of patients with malignant occlusion of the common bile duct (CBD).

MATERIALS AND METHODS

32 patients (mean age 72 ± 13 years) were treated with an endoprosthesis (VIABIL; M. L. GORE & ASSOCIATES, INC., USA) due to failed attempts of endoscopic retrograde cholangiopancreatography (ERCP) in the case of malignant occlusion of the CBD.

RESULTS

The technical success rate was 96.9 %. In one patient the probing of an intrahepatic bile duct was impossible. Two major complications (bleeding, liver abscess) were successfully treated with appropriate measures. The bilirubin level did not significantly decrease immediately after intervention (13.2 ± 6.5 mg/dl; p > 0.05). However, the follow-up displayed a highly significant decrease of bilirubin to 6.0 ± 7.4 mg/dl; p < 0.05). The endoprosthesis was extended with bare metal NITINOL stents in 9 patients. The mean survival time of the patient group was 64 ± 28 days (range 2 - 250  days).

CONCLUSION

The implantation of an endoprosthesis proved to be an option with high technical success, a low complication rate and good benefit in our patients with malignant bile duct obstruction in palliative therapy situations.

KEY POINTS

• The primary objective in the case of malignant bile duct obstruction is the treatment of jaundice.• After failed endoscopic recanalization of the bile ducts, transhepatic biliary drainage is desirable.• An ePTFE-FEP covered endoprothesis is a good treatment option in palliative situations.• A single-stage procedure shortens hospitalization time.

Irreversible electroporation of a hepatocellular carcinoma lesion adjacent to a transjugular intrahepatic portosystemic shunt stent graft

We report in a 65-year-old man hepatocellular carcinoma adjacent to a transjugular intrahepatic portosystemic shunt stent-graft which was successfully treated with irreversible electroporation (IRE). IRE is a new non-thermal tissue ablation technique which uses electrical pulses to induce cell necrosis by irreversible membrane poration. IRE proved to be more advantageous in the ablation of perivascular tumor with little injury to the surrounding structures.

Degradable starch microspheres transarterial chemoembolisation (DSM-TACE) of HCC: Dynamic Contrast-Enhanced Ultrasonography (DCE-US) based evaluation of therapeutic efficacy using a novel perfusion software

PURPOSE

To evaluate therapeutic efficacy of degradable starch microsphere (DSM)-TACE in hepatocellular carcinoma (HCC) using Dynamic Contrast-Enhanced Ultrasonography (DCE-US) based perfusion analysis.

MATERIALS AND METHODS

A total of 60 DCE-US examinations were performed in 15 selected patients who underwent DSM-TACE with EmboCept®S for the treatment of advanced HCC. DCE-US was performed via i.v. application of ultrasound contrast media before and 24 hours post embolization. In addition DCE-US was performed with i.a. contrast application via the angiographic catheter right before and after the embolization. Microcirculation of embolized HCC lesions was quantified using a dedicated perfusion software by two experienced radiologists in consensus.

RESULTS

Significant reduction of microvascularization (PE, WiAUC and WiR) was seen right after DSM-TACE and during 24 hour follow-up. Mean PE was 342.22 ± 97.80 prior to embolization, 59.28 ± 29.74 post embolization (p = 0.019) and 18.83 ± 7.03 during follow-up (p ≤ 0.01). Mean WiAUC was 1103.21 ± 432.05 prior to embolization 267.69 ± 151.80 post embolization (p = 0.023) and 105.10 ± 44.43 during 24 hour follow-up (p ≤ 0.01). The corresponding values for WiR were 224.91 ± 57.97 prior-, 38.14 ± 18.80 post embolization (p = 0.034) and 6.97 ± 2.68 during follow up (p ≤ 0.01).

CONCLUSION

In this study, therapeutic efficacy of DSM-TACE in HCC using DCE-US based perfusion analysis could be demonstrated.

Percutaneous irreversible electroporation (IRE) of hepatic malignant tumours: contrast-enhanced ultrasound (CEUS) findings

PURPOSE

The aim of this study is to describe the image findings of contrast-enhanced ultrasound (CEUS) after irreversible electroporation (IRE), and to assess its usefulness in relation to the evaluation of the ablation status using a dynamic recording of the microvascularisation.

MATERIAL AND METHOD

In this prospectively designed study, a percutaneous IRE was performed for the treatment of malignant hepatic lesions in a total of 15 patients following the interdisciplinary diagnosis. The lesions were documented using CEUS before, immediately after and 20 minutes after the ablation. The acquired CEUS image data was subsequently independently retrospectively evaluated by 2 experienced radiologists and assessed in relation to microvascularisation using a 5 point scale.

RESULTS

Using CEUS, a significant reduction in the microcirculation of the lesions, both centrally and marginally, could be detected following IRE (p < 0.001 and p < 0.001). The mean evaluation of the central microcirculation was reduced from 3.13 ± 1.38 to 0.47 ± 0.64 (p < 0.01). For the peripheral area of the lesion and the ablation margin, there was a reduction of 3.37 ± 1.13 to 1.57 ± 0.46 (p = 0.001). There was no significant reduction in the macrocirculation.

CONCLUSION

Within the framework of this study, it could be demonstrated that, in the course of IRE, a rapid significant reduction of the microcirculation in the ablation area occurred.

Transarterial chemoembolization - status quo in Germany

PURPOSE

Against the background of the current preparation of the national disease management guideline for the diagnosis and treatment of hepatocellular carcinoma (HCC), the German Society for Interventional Radiology (DEGIR) launched a statewide survey in order to evaluate the current status of transarterial chemoembolization (TACE) in Germany.

MATERIALS AND METHODS

In April 2012 an e-mail questionnaire relating to TACE practices in patients with intermediate-stage HCC was sent to all chief physicians of interventional radiology departments in Germany that were members of DEGIR.

RESULTS

96 questionnaires were completed and evaluated statistically. The most frequent combinations of embolic agents and cytotoxic drugs are drug-eluting beads combined with doxorubicin or epirubicin as well as lipiodol plus doxorubicin, epirubicin or cisplatin. 60 % of the interventionalists prefer superselective chemoembolization. In most cases more than one chemoembolization per patient is performed (95.5 %). The most common (77 %) time interval between two interventions ranges between one and two months.

CONCLUSION

The results of this survey show the often stated criticism in Germany regarding the substantial differences in TACE protocols and highlight the importance of standards of practice for TACE in patients with HCC.

Palliative treatment of presacral recurrence of endometrial cancer using irreversible electroporation: a case report

INTRODUCTION

Irreversible electroporation (IRE) is a new minimally invasive tumor ablation technique which induces irreversible disruption of cell membrane integrity by changing the transmembrane potential resulting in cell death. Irreversible electroporation is currently undergoing clinical investigation as local tumor therapy for malignant liver and lung lesions. This is the first case report to describe the successful palliative ablation of a presacral recurrence of an endometrial cancer to achieve locoregional tumor control and pain relief.

CASE PRESENTATION

A 56-year-old Caucasian woman was referred for interventional treatment of an advanced local recurrence of endometrial cancer (11.9 × 11.6 × 14.9cm) with infiltration of the sacral bone and nerve plexus. Due to the immediate proximity to the sacral plexus, the patient could neither undergo surgical therapy nor a second radiation therapy. Due to its ablation mechanism irreversible electroporation was deemed to be the best therapy option.

CONCLUSION

We showed in this case that a large tumor mass adjacent to a bundle of neural structures, the sacral plexus, can be widely ablated by irreversible electroporation with only minor temporary impairment of the neural function, even though a large infiltrating tissue volume (941cm3) was ablated.

Hepatic steatosis causes induction of the chemokine RANTES in the absence of significant hepatic inflammation

Nonalcoholic fatty liver disease (NAFLD) encompasses a spectrum ranging from simple steatosis to cirrhosis. Hepatocellular lipid accumulation is a hallmark of both nonalcoholic steatosis and steatohepatitis (NASH). The latter develops upon pro-inflammatory cell infiltration and is widely considered as the first relevant pathophysiological step in NAFLD-progression. The chemokine CCL5/RANTES plays an important role in the progression of hepatic inflammation and fibrosis. We here aimed to investigate its expression in NAFLD. Incubation of primary human hepatocytes with palmitic acid induced a dose-dependent lipid accumulation, and corresponding dose-dependent RANTES induction in vitro. Furthermore, we observed significantly elevated hepatic RANTES expression in a dietary model of NAFLD, in which mice were fed a high-fat diet for 12 weeks. This diet induced significant hepatic steatosis but only minimal inflammation. In contrast to the liver, RANTES expression was not induced in visceral adipose tissue of the group fed with high-fat diet. Finally, RANTES serum levels were elevated in patients with ultrasound-diagnosed NAFLD. In conclusion, our data indicate hepatocytes as cellular source of elevated hepatic as well as circulating RANTES levels in response to hepatic steatosis. Noteworthy, upregulation of RANTES in response to lipid accumulation occurs in the absence of relevant inflammation, which further indicates that hepatic steatosis per se has pathophysiological relevance and should not be considered as benign.