Interventional treatment of refractory non-traumatic chylous effusions in patients with lymphoproliferative disorders

To report results of interventional treatment of refractory non-traumatic abdomino-thoracic chylous effusions in patients with lymphoproliferative disorders. 17 patients (10 male; mean age 66.7 years) with lymphoproliferative disorders suffered from non-traumatic chylous effusions (chylothorax n = 11, chylous ascites n = 3, combined abdomino-thoracic effusion n = 3) refractory to chemotherapy and conservative therapy. All underwent x-ray lymphangiography with iodized-oil to evaluate for and at the same time treat lymphatic abnormalities (leakage, chylo-lymphatic reflux with/without obstruction of central drainage). In patients with identifiable active leakage additional lymph-vessel embolization was performed. Resolution of effusions was deemed as clinical success. Lymphangiography showed reflux in 8/17 (47%), leakage in 2/17 (11.8%), combined leakage and reflux in 3/17 (17.6%), lymphatic obstruction in 2/17 (11.8%) and normal findings in 2/17 cases (11.8%). 12/17 patients (70.6%) were treated by lymphangiography alone; 5/17 (29.4%) with leakage received additional embolization (all technically successful). Effusions resolved in 15/17 cases (88.2%); 10/12 (83.3%) resolved after lymphangiography alone and in 5/5 patients (100%) after embolization. Time-to-resolution of leakage was significantly shorter after embolization (within one day in all cases) than lymphangiography (median 9 [range 4-30] days; p = 0.001). There was no recurrence of symptoms or post-interventional complications during follow-up (median 445 [40-1555] days). Interventional-radiological treatment of refractory, non-traumatic lymphoma-induced chylous effusions is safe and effective. Lymphangiography identifies lymphatic abnormalities in the majority of patients and leads to resolution of effusions in > 80% of cases. Active leakage is found in only a third of patients and can be managed by additional embolization.

Outcome of transarterial radioembolization in patients with hepatocellular carcinoma as a first-line interventional therapy and after a previous transarterial chemoembolization

Purpose

Due to a lack of data, there is an ongoing debate regarding the optimal frontline interventional therapy for unresectable hepatocellular carcinoma (HCC). The aim of the study is to compare the results of transarterial radioembolization (TARE) as the first-line therapy and as a subsequent therapy following prior transarterial chemoembolization (TACE) in these patients.

Methods

A total of 83 patients were evaluated, with 38 patients having undergone at least one TACE session prior to TARE [27 male; mean age 67.2 years; 68.4% stage Barcelona clinic liver cancer (BCLC) B, 31.6% BCLC C]; 45 patients underwent primary TARE (33 male; mean age 69.9 years; 40% BCLC B, 58% BCLC C). Clinical [age, gender, BCLC stage, activity in gigabecquerel (GBq), Child-Pugh status, portal vein thrombosis, tumor volume] and procedural [overall survival (OS), local tumor control (LTC), and progression-free survival (PFS)] data were compared. A regression analysis was performed to evaluate OS, LTC, and PFS.

Results

No differences were found in OS (95% CI: 1.12, P = 0.289), LTC (95% CI: 0.003, P = 0.95), and PFS (95% CI: 0.4, P = 0.525). The regression analysis revealed a relationship between Child-Pugh score (P = 0.005), size of HCC lesions (>10 cm) (P = 0.022), and OS; neither prior TACE (Child-Pugh B patients; 95% CI: 0.120, P = 0.729) nor number of lesions (>10; 95% CI: 2.930, P = 0.087) correlated with OS.

Conclusion

Prior TACE does not affect the outcome of TARE in unresectable HCC.

MRI proton density fat fraction for estimation of tumor grade in steatotic hepatocellular carcinoma

OBJECTIVES

Image-based detection of intralesional fat in focal liver lesions has been established in diagnostic guidelines as a feature indicative of hepatocellular carcinoma (HCC) and associated with a favorable prognosis. Given recent advances in MRI-based fat quantification techniques, we investigated a possible relationship between intralesional fat content and histologic tumor grade in steatotic HCCs.

METHODS

Patients with histopathologically confirmed HCC and prior MRI with proton density fat fraction (PDFF) mapping were retrospectively identified. Intralesional fat of HCCs was assessed using an ROI-based analysis and the median fat fraction of steatotic HCCs was compared between tumor grades G1-3 with non-parametric testing. ROC analysis was performed in case of statistically significant differences (p < 0.05). Subgroup analyses were conducted for patients with/without liver steatosis and with/without liver cirrhosis.

RESULTS

A total of 57 patients with steatotic HCCs (62 lesions) were eligible for analysis. The median fat fraction was significantly higher for G1 lesions (median [interquartile range], 7.9% [6.0─10.7%]) than for G2 (4.4% [3.2─6.6%]; p = .001) and G3 lesions (4.7% [2.8─7.8%]; p = .036). PDFF was a good discriminator between G1 and G2/3 lesions (AUC .81; cut-off 5.8%, sensitivity 83%, specificity 68%) with comparable results in patients with liver cirrhosis. In patients with liver steatosis, intralesional fat content was higher than in the overall sample, with PDFF performing better in distinguishing between G1 and G2/3 lesions (AUC .92; cut-off 8.8%, sensitivity 83%, specificity 91%).

CONCLUSIONS

Quantification of intralesional fat using MRI PDFF mapping allows distinction between well- and less-differentiated steatotic HCCs.

CLINICAL RELEVANCE

PDFF mapping may help optimize precision medicine as a tool for tumor grade assessment in steatotic HCCs. Further investigation of intratumoral fat content as a potential prognostic indicator of treatment response is encouraged.

KEY POINTS

• MRI proton density fat fraction mapping enables distinction between well- (G1) and less- (G2 and G3) differentiated steatotic hepatocellular carcinomas. • In a retrospective single-center study with 62 histologically proven steatotic hepatocellular carcinomas, G1 tumors showed a higher intralesional fat content than G2 and G3 tumors (7.9% vs. 4.4% and 4.7%; p = .004). • In liver steatosis, MRI proton density fat fraction mapping was an even better discriminator between G1 and G2/G3 steatotic hepatocellular carcinomas.

[Dynamic magnetic resonance imaging of the pelvic floor: clinical application]

BACKGROUND

Dynamic magnetic resonance imaging (MRI) of the pelvic floor plays a key role in imaging complex pelvic floor dysfunction. The simultaneous detection of multiple findings in a complex anatomic setting renders correct analysis and clinical interpretation challenging.

OBJECTIVES

The most important aspects (anatomy of the pelvic floor, three compartment model, morphological and functional analysis, reporting) for a successful clinical use of dynamic MRI of the pelvic floor are summarized.

MATERIALS AND METHODS

Review of the scientific literature on dynamic pelvic MR imaging with special consideration of the joint recommendations provided by the expert panel of ESUR/ESGAR in 2016.

RESULTS

The pelvic floor is a complex anatomic structure, mainly formed by the levator ani muscle, the urethral support system and the endopelvic fascia. Firstly, morphological changes of these structures are analysed on the static sequences. Secondly, the functional analysis using the three compartment model is performed on the dynamic sequences during squeezing, straining and defecation. Pelvic organ mobility, pelvic organ prolapse, the anorectal angle and pelvic floor relaxation are measured and graded. The diagnosis of cystoceles, enteroceles, rectoceles, the uterovaginal as well as anorectal decent, intussusceptions and dyssynergic defecation should be reported using a structured report form.

CONCLUSIONS

A comprehensive analysis of all morphological and functional findings during dynamic MRI of the pelvic floor can provide information missed by other imaging modalities and hence alter therapeutic strategies.

[Dynamic magnetic resonance imaging of the pelvic floor: Technical aspects]

BACKGROUND

Dynamic magnetic resonance imaging (MRI) of the pelvic floor plays a key role in imaging complex pelvic floor dysfunction. High-quality examination is crucial for diagnostic benefit but can be technically challenging.

OBJECTIVES

The most important technical aspects (patient selection, patient preparation, MRI technology, MRI scan protocol, success control) for obtaining a state-of-the-art dynamic MRI of the pelvic floor are summarized.

MATERIALS AND METHODS

Review of the scientific literature on dynamic pelvic MR imaging with special consideration of the joint recommendations provided by the expert panels of European Society of Urogenital Radiology/European Society of Gastrointestinal and Abdominal Radiology (ESUR/ESGAR) in 2016 and Society of Abdominal Radiology (SAR) in 2019.

RESULTS

Examination with at least 1.5 T and a surface coil after rectal instillation of ultrasound gel is clinical standard. Dynamic MRI in a closed magnet with the patient in supine position is the most widespread technique. No clinically significant pathologies of the pelvic floor are missed compared to the sitting position in an open magnet. The minimum scan protocol should encompass static, high-resolution T2-imaging (i.e., T2-TSE) in three planes and dynamic sequences with high temporal resolution in sagittal (and possibly axial) plane (i.e., steady-state or balanced steady-state free precession) during squeezing, straining and evacuation. Detailed patient instruction and practicing prior to the scan improve patients' compliance and hence diagnostic quality.

CONCLUSIONS

A technically flawless dynamic MRI of the pelvic floor according to these standards can provide information missed by other imaging modalities and hence alter therapeutic strategies.

Post-interventional infectious complications in percutaneous transabdominal lymphatic interventions: an observational study

The purpose of this retrospective study was to evaluate the occurrence of infectious complications and inflammatory reactions after transabdominal lymphatic-interventions. 63 lymphatic-interventions were performed in 60 patients (male/female: 35/25; mean age 56 [9-85] years) [chylothorax n = 48, chylous ascites n = 7, combined chylothorax/chylous ascites n = 5]. Post-interventional clinical course and laboratory findings were analyzed in the whole cohort as well as subgroups without (group A; n = 35) and with peri-interventional antibiotics (group B; n = 25) (pneumonia n = 16, drainage-catheter inflammation n = 5, colitis n = 1, cystitis n = 1, transcolonic-access n = 2). No septic complications associated with the intervention occurred. Leucocytes increased significantly, peaking on post-interventional day-1 (8.6 ± 3.9 × 106 cells/mL vs. 9.8 ± 4.7 × 106 cells/mL; p = 0.009) and decreased thereafter (day-10: 7.3 ± 2.7 × 106 cells/mL, p = 0.005). CRP-values were pathological in 89.5% of patients already at baseline (40.1 ± 63.9 mg/L) and increased significant on day-3 (77.0 ± 78.8 mg/L, p < 0.001). Values decreased thereafter (day-15: 25.3 ± 34.4 mg/L, p = 0.04). In subgroup B, 13/25 patients had febrile episodes post-interventionally (pneumonia n = 11, cystitis n = 1, drainage-catheter inflammation n = 1). One patient developed biliary peritonitis despite continued antibiotics and underwent cholecystectomy. Baseline leucocytes and CRP-levels were higher in group B than A, but with comparable post-interventional profiles. Clinically relevant infectious complications associated with transabdominal lymphatic-interventions are rare irrespective of peri-interventional antibiotic use. Post-interventional elevation of leucocytes and CRP are observed with normalization over 10-15 days.

A novel and simple cardiac magnetic resonance score (PE2RT) predicts outcome in takotsubo syndrome

OBJECTIVES

To find simple imaging-based features on cardiac magnetic resonance (CMR) that are associated with major adverse cardiovascular events (MACE) in takotsubo syndrome (TTS).

METHODS

Patients with TTS referred for CMR between 2007 and 2021 were retrospectively evaluated. Besides standard CMR analysis, commonly known complications of TTS based on expert knowledge were assessed and summarised via a newly developed PE2RT score (one point each for pleural effusion, pericardial effusion, right ventricular involvement, and ventricular thrombus). Clinical follow-up data was reviewed up to three years after discharge. The relationship between PE2RT features and the occurrence of MACE (cardiovascular death or new hospitalisation due to acute myocardial injury, arrhythmia, or chronic heart failure) was examined using Cox regression analysis and Kaplan-Meier estimator.

RESULTS

Seventy-nine patients (mean age, 68 ± 14 years; 72 women) with TTS were included. CMR was performed in a median of 4 days (IQR, 2-6) after symptom onset. Over a median follow-up of 13.3 months (IQR, 0.4-36.0), MACE occurred in 14/79 (18%) patients: re-hospitalisation due to acute symptoms (9/79, 11%) or chronic heart failure symptoms (4/79, 5%), and cardiac death (1/79, 1%). Patients with MACE had a higher PE2RT score (median [IQR], 2 [2-3] vs 1 [0-1]; p < 0.001). PE2RT score was associated with MACE on Cox regression analysis (hazard ratio per PE2RT feature, 2.44; 95%CI: 1.62-3.68; p < 0.001). Two or more PE2RT complications were strongly associated with the occurrence of MACE (log-rank p < 0.001).

CONCLUSIONS

The introduced PE2RT complication score might enable an easy-to-assess outcome evaluation of TTS patients by CMR.

KEY POINTS

• Complications like pericardial effusion, pleural effusion, right ventricular involvement, and ventricular thrombus (summarised as PE2RT features) are relatively common in takotsubo syndrome. • The proposed PE2RT score (one point per complication) was associated with the occurrence of major adverse cardiac events on follow-up. • Complications easily detected by cardiac magnetic resonance imaging can help clinicians derive long-term prognostic information on patients with takotsubo syndrome.

MR ‐lymphangiography identifies lymphatic pathologies in patients with idiopathic recurrent cervical swelling

Background

Idiopathic recurrent cervical swelling may be caused by lymphatic abnormalities.

Methods

Ten patients (9 females, mean age 51.2 ± 7) with idiopathic recurrent cervical swelling underwent MR‐lymphangiography (MRL). MR‐lymphangiograms were evaluated regarding lymphatic anatomy and flow. Individualized treatment was recommended according to MRL‐findings.

Results

8/10 patients presented with left‐sided, 2/10 with right‐sided swelling. Pathological lymph‐flow was identified in all cases: thoracic duct dilatation in patients with left‐sided and right lymphatic duct dilatation in right‐sided swelling, accessory thoracic lymphatics in 7/10 and reflux in 8/10 cases. In two cases, a lymphatic thrombus was identified.

After treatment, symptoms resolved completely in 6/10 cases and partially in 1/10 cases. The remaining three patients have intermittent swellings but have no treatment wish.

Conclusion

Idiopathic recurrent cervical swelling can be caused by lymphatic anomalies. MRL displays impaired lymphatic drainage, lymphatic vessel dilatation, and chylolymphatic reflux as hallmarks of this condition and may aid in targeted treatment planning.

Transcranial high-intensity Magnetic Resonance-guided focused ultrasound (tcMRgFUS) - safety and impacts on tremor severity and quality of life

INTRODUCTION

Transcranial high-intensity Magnetic Resonance-guided Focused Ultrasound (tcMRgFUS) is a technique for treatment of severe, medication-refractory Essential Tremor (ET). We summarize 1-year follow-up results focusing on clinical and safety parameters and impacts on quality of life.

METHODS

A total of 45 patients with severe, medication-refractory ET were treated with tcMRgFUS thalamotomy. 37 patients completed the clinical follow-up of 12 months. Tremor severity, disability and quality of life were measured using the Clinical Rating Scale for Tremor (CRST), surface electromyography, the Quality of Life in Essential Tremor Questionnaire (QUEST) and the Short-Form-36 questionnaire (SF-36). Depressive symptoms and cognitive function were assessed using standardized questionnaires. Electrophysiological measurements were conducted to evaluate possible effects on central motor and sensory pathways.

RESULTS

1 year after tcMRgFUS the mean tremor improvement on a hand-specific subscore of the CRST was 82%. The QUEST and SF-36 revealed an improvement of mental quality of life, especially in activities of daily living and psychosocial function; depressive symptoms decreased significantly. There was no worsening of cognitive function overt within the self-rating questionnaire; no prolongation of sensory evoked potentials or central motor conduction time occurred. Side effects were mostly classified as mild (78%) and transient (62%).

CONCLUSIONS

TcMRgFUS for severe tremor has a distinct impact on quality of life and neuropsychological symptoms. Self-assessments of cognitive function revealed stable outcomes 1 year after tcMRgFUS. No prolongation of sensory or motor conduction time were found in neurophysiology measures. Side effects occurred in 78% of treated patients but were mostly transient and mild.

Cardiac MRI in Suspected Acute Myocarditis After COVID-19 mRNA Vaccination

PURPOSE

 To evaluate cardiac MRI characteristics in patients with suspected hypersensitivity myocarditis following mRNA COVID-19 vaccination.

MATERIALS AND METHODS

 Patients clinically suspected of acute myocarditis after COVID-19 vaccination were retrospectively analyzed and compared against a healthy control group. Cardiac MRI protocol included parameters such as T1 and T2 relaxation times, extracellular volume (ECV), T2 signal intensity ratio, and late gadolinium enhancement (LGE). Lymph node size was assessed in the patient group on the injection side. Student t-test, analyses of variance (ANOVA) with Tukey post-hoc test, and χ² test were used for statistical analysis.

RESULTS

 20 patients with clinically suspected post-vaccine myocarditis (28 ± 12 years; 12 men) and 40 controls (31 ± 11 years; 25 men) were evaluated. According to the 2018 Lake Louise criteria (LLC), patients with clinically suspected myocarditis were further subdivided into an LLC-positive group (n = 9) and an LLC-negative group (n = 11). The mean time of symptom onset after vaccination was 1.1 ± 1.2 days (LLC-positive) and 6.5 ± 9.2 days (LLC-negative). Group differences in inflammatory variables between myocarditis patients and control subjects were more pronounced in the LLC-positive group (e. g., T1 relaxation time: 1041 ± 61 ms [LLC positive] vs. 1008 ± 79 ms [LLC-negative] vs. 970 ± 25 ms [control]; p <.001; or T2 signal intensity ratio 2.0 ± 0.3 vs. 1.6 ± 0.3 [LLC-negative] and vs. 1.6 ± 0.3 [control], p = .012). LLC-positive patients were significantly faster in receiving an MRI after initial symptom onset (8.8 ± 6.1 days vs. 52.7 ± 33.4 days; p = .001) and had higher troponin T levels (3938 ± 5850 ng/l vs. 9 ± 11 ng/l; p <.001). LGE lesions were predominantly located at the subepicardium of the lateral wall. Axillary lymphadenopathy was more frequent in the LLC-positive group compared to the LLC-negative group (8/9 [89 %] vs. 0/11 [0 %], p < 0.001).

CONCLUSION

 Vaccine-induced myocarditis should be considered in patients with acute symptom onset after mRNA vaccination, especially if elevated serum troponin T is observed. Imaging findings of vaccine-induced myocarditis are similar to virus-induced myocarditis, allowing for the use of the Lake Louise Criteria for diagnostic purposes.

KEY POINTS

  · Vaccine-induced hypersensitivity myocarditis can be confirmed with cardiac MRI. · Especially patients with sudden onset of symptoms and elevated serum troponin T had positive cardiac MRI findings. · Cardiac MRI characteristics of vaccine-induced myocarditis are similar to those in virus-induced myocarditis.

CITATION FORMAT

· Kravchenko D, Isaak A, Mesropyan N et al. Cardiac MRI in Suspected Acute Myocarditis After COVID-19 mRNA Vaccination. Fortschr Röntgenstr 2022; DOI: 10.1055/a-1752-0951.

1.5 vs 3 Tesla Magnetic Resonance Imaging: A Review of Favorite Clinical Applications for Both Field Strengths-Part 1

ABSTRACT

Whole-body magnetic resonance imaging (MRI) systems with a field strength of 3 T have been offered by all leading manufacturers for approximately 2 decades and are increasingly used in clinical diagnostics despite higher costs. Technologically, MRI systems operating at 3 T have reached a high standard in recent years, as well as the 1.5-T devices that have been in use for a longer time. For modern MRI systems with 3 T, more complexity is required, especially for the magnet and the radiofrequency (RF) system (with multichannel transmission). Many clinical applications benefit greatly from the higher field strength due to the higher signal yield (eg, imaging of the brain or extremities), but there are also applications where the disadvantages of 3 T might outweigh the advantages (eg, lung imaging or examinations in the presence of implants). This review describes some technical features of modern 1.5-T and 3-T whole-body MRI systems, and reports on the experience of using both types of devices in different clinical settings, with all sections written by specialist radiologists in the respective fields.This first part of the review includes an overview of the general physicotechnical aspects of both field strengths and elaborates the special conditions of diffusion imaging. Many relevant aspects in the application areas of musculoskeletal imaging, abdominal imaging, and prostate diagnostics are discussed.

Lesions of the cerebello-thalamic tract rather than the ventral intermediate nucleus determine the outcome of focused ultrasound therapy in essential tremor: A 3T and 7T MRI-study

INTRODUCTION

The ventral intermediate nucleus of the thalamus (VIM) is an important relay station receiving cerebellar and pallidal fiber tracts. Data on structural visualization of the VIM however is limited and uncertainty prevails to what extent lesional approaches to treat tremor affect the VIM itself or passing tracts. The aim of the study was to analyze the localization of individual lesions with respect to the VIM and the cerebello-thalamic tract (CTT).

METHODS

We employed ultrahigh resolution (7 Tesla) MRI to delineate the VIM and performed 3 T-DTI-imaging pre- and post-interventional in seven ET patients undergoing transcranial magnetic resonance guided focused ultrasound (tcMRgFUS). Tremor improvement was measured using a modified subscore of the Clinical Rating Scale for Tremor.

RESULTS

All subjects showed substantial tremor improvement (88.5%, range 80.7%-94,8%) after tcMRgFUS. We found only a minor overlap of the lesions with the VIM (4%, range 1%-7%) but a larger overlap with the CTT (43%, range 23%-60%) in all subjects.

CONCLUSIONS

Lesions within the CTT rather than the VIM seem to drive the tremorlytic response and clinical improvement in tcMRgFUS.

Unusual Left Periclavicular Cutaneous Lymphatic Fistula After Port Explantation Without Lymph Vessel Injury: Imaging and Interventional Treatment

Complex oncological treatment can be associated with lymphatic vascular injury that is burdened by considerable morbidity. Lymphatic imaging and interventional techniques offer new minimally invasive treatment options. We report the case of a 59-year-old woman with an unusual lympho-veno-cutaneous fistula, diagnosed by magnetic resonance lymphangiography and treated by minimally invasive embolization therapy and venous recanalization.

Radiological management of postoperative lymphorrhea

PURPOSE

Postoperative lymphorrhea can occur after different surgical procedures and may prolong the hospital stay due to the need for specific treatment. In this work, the therapeutic significance of the radiological management of postoperative lymphorrhea was assessed and illustrated.

METHOD

A standardized search of the literature was performed in PubMed applying the Medical Subject Headings (MeSH) term "lymphangiography." For the review, the inclusion criterion was "studies with original data on Lipiodol-based Conventional Lymphangiography (CL) with subsequent Percutaneous Lymphatic Intervention (PLI)." Different exclusion criteria were defined (e.g., studies with <15 patients). The collected data comprised of clinical background and indications, procedural aspects and types of PLI, and outcomes. In the form of a pictorial essay, each author illustrated a clinical case with CL and/or PLI.

RESULTS

Seven studies (corresponding to evidence level 4 [Oxford Centre for Evidence-Based Medicine]) accounting for 196 patients were included in the synthesis and analysis of data. Preceding surgery resulting in postoperative lymphorrhea included different surgical procedures such as extended oncologic surgery or vascular surgery. Central (e.g., chylothorax) and peripheral (e.g., lymphocele) types of postoperative lymphorrhea with a drainage volume of 100-4000 ml/day underwent CL with subsequent PLI. The intervals between "preceding surgery and CL" and between "CL and PLI" were 2-330 days and 0-5 days, respectively. CL was performed before PLI to visualize the lymphatic pathology (e.g., leakage point or inflow lymph ducts), applying fluoroscopy, radiography, and/or computed tomography (CT). In total, seven different types of PLI were identified: (1) thoracic duct (or thoracic inflow lymph duct) embolization, (2) thoracic duct (or thoracic inflow lymph duct) maceration, (3) leakage point direct embolization, (4) inflow lymph node interstitial embolization, (5) inflow lymph duct (other than thoracic) embolization, (6) inflow lymph duct (other than thoracic) maceration, and (7) transvenous retrograde lymph duct embolization. CL-associated and PLI-associated technical success rates were 97-100% and 89-100%, respectively. The clinical success rate of CL and PLI was 73-95%. CL-associated and PLI-associated major complication rates were 0-3% and 0-5%, respectively. The combined CL- and PLI-associated 30-day mortality rate was 0%, and the overall mortality rate was 3% (corresponding to six patients). In the pictorial essay, the spectrum of CL and/or PLI was illustrated.

CONCLUSION

The radiological management of postoperative lymphorrhea is feasible, safe, and effective. Standardized radiological treatments embedded in an interdisciplinary concept are a step towards improving outcomes.

Impact of transjugular intrahepatic portosystemic shunt creation on the central lymphatic system in liver cirrhosis

The puropse of this study was to evaluate associations of cisterna chyli (CCh) diameter with portal hemodynamics and the influence of TIPS-creation in cirrhotic patients. 93 cirrhotic patients (57 male, mean age 59 years) received CT prior to TIPS-creation. 38/93 additionally underwent post-interventional CT. CCh-diameter was measured. After categorization into patients with and without large venous collaterals (i.e. > 6 mm), data were analyzed regarding associations between CCh-diameter, clinical and portal-hemodynamic parameters and diameter-changes after TIPS-creation. Patient survival post-TIPS was analyzed. Median portosystemic pressure-gradient decreased from 20 to 9 mmHg after TIPS-creation. Large venous collaterals were observed in 59 patients. In 69/93 patients (74.2%) the CCh was detectable. Mean pre-interventional diameter was 9.4 ± 2.7 mm (large collaterals: 8.7 ± 2.0 mm, no large collaterals: 10.7 ± 3.2 mm, p = 0.003). CCh-diameter correlated strongly with pre-TIPS portal-pressure (Rs = 0.685, p = 0.0001), moderately with portosystemic-gradient (Rs = 0.524, p = 0.006), liver shear-wave-elastography (Rs = 0.597, p = 0.004) and spleen size (Rs = 0.501, p = 0.01) in patients without large collaterals, but not in patients with large collaterals. Post-TIPS CCh-diameter decreased significantly from 10.2 ± 2.8 mm to 8.3 ± 3.0 mm (p < 0.001). Patients without a detectable CCh on CT survived significantly shorter. The diameter of the CCh is associated with portal-pressure and decreases after TIPS-creation in cirrhotic patients, reflecting a portal decompression mechanism via the lymphatic system. Lack of larger central lymphatics detectable on CT may be associated with shorter survival.

Evaluation of malignant effusions using MR-based T1 mapping

Our aim was to investigate the diagnostic yield of rapid T1-mapping for the differentiation of malignant and non-malignant effusions in an ex-vivo set up. T1-mapping was performed with a fast modified Look-Locker inversion-recovery (MOLLI) acquisition and a combined turbo spin-echo and inversion-recovery sequence (TMIX) as reference. A total of 13 titrated albumin-solutions as well as 48 samples (29 ascites/pleural effusions from patients with malignancy; 19 from patients without malignancy) were examined. Samples were classified as malignant-positive histology, malignant-negative histology and non-malignant negative histology. In phantom analysis both mapping techniques correlated with albumin-content (MOLLI: r = − 0.97, TMIX: r = − 0.98). MOLLI T1 relaxation times were shorter in malignancy-positive histology fluids (2237 ± 137 ms) than in malignancy-negative histology fluids (2423 ± 357 ms) as well as than in non-malignant-negative histology fluids (2651 ± 139 ms); post hoc test for all intergroup comparisons: < 0.05. ROC analysis for differentiation between malignant and non-malignant effusions (malignant positive histology vs. all other) showed an (AUC) of 0.89 (95% CI 0.77–0.96). T1 mapping allows for non-invasive differentiation of malignant and non-malignant effusions in an ex-vivo set up.

Techniken und klinische Anwendungen der MR-Lymphangiografie in Diagnostik und Therapie von Lymphgefäßerkrankungen

Neue Methoden der Lymphgefäßbildgebung werden zunehmend in Diagnostik und Therapie von Lymphgefäßerkrankungen eingesetzt. Die Magnetresonanz-Lymphangiografie nimmt dabei als strahlungsfreies und non- bzw. minimalinvasives Verfahren eine zentrale Rolle ein. Es stehen verschiedene Techniken zur Verfügung, die Informationen sowohl über Anatomie als auch Funktion des peripheren und zentralen Lymphgefäßsystems liefern können. Damit trägt die Magnetresonanz-Lymphangiografie insbesondere in der Differenzialdiagnostik und in der Therapieplanung von Patienten mit Lymphödemen, Lymphgefäßleckagen und komplexen Lymphgefäßanomalien zur Ermöglichung einer zielgerichteten, minimalinvasiven und insbesondere individualisierten Therapie betroffener Patienten bei. Im Folgenden soll ein Überblick über den aktuellen Stand der MR-Lymphangiografie als neue Methode zur Untersuchung von Patienten mit Lymphgefäßerkrankungen gegeben werden, diese in das Spektrum anderer verfügbarer Bildgebungsmethoden eingeordnet und mögliche klinische Indikationen aufgezeigt werden.

Nodal and Pedal MR Lymphangiography of the Central Lymphatic System: Techniques and Applications

Novel lymphatic imaging and interventional techniques are increasingly used in the diagnostic workup and treatment of pathologies of the central lymphatic system and have opened a new field of interventional radiology. The mainstay of lymphatic imaging today is magnetic resonance lymphangiography (MRL). It provides information on the anatomy of the central lymphatic system, lymphatic flow, as well as lymphatic pathologies and therefore is a valuable tool for treatment planning. There are two techniques to perform contrast-enhanced MRL: nodal dynamic contrast-enhanced MRL (nodal DCE-MRL) and interstitial transpedal MRL (tMRL). Nodal DCE-MRL yields superior information on lymphatic flow dynamics and is therefore best suited for suspected lymphatic flow pathologies and lymphatic malformations. tMRL is a technically simpler alternative for central lymphatic visualization without the need for sonographically guided lymph node cannulation. This review article describes current MRL techniques with a focus on contrast-enhanced MRL, their specific advantages, and possible clinical applications in patients suffering from pathologies of the central lymphatic system.

Where Have All the Punctures Gone? An Analysis of Thoracic Duct Embolizations

PURPOSE

To determine how frequently and how severely intra-abdominal structures are affected by transabdominal thoracic duct embolization (TDE).

MATERIALS AND METHODS

Thirty-five TDE procedures in 35 patients (22 male; mean age, 57 y; age range, 10-79 y) with therapy-refractory chylous effusions were evaluated in which radiopaque embolization material outlined the access route on postinterventional CT. CT data were analyzed by 2 TDE-experienced radiologists. Abdominal structures and organs transgressed by the access route were recorded, and findings were correlated with clinical postinterventional course with follow-up of at least 44 days.

RESULTS

Intra-abdominal structures/organs transgressed most often by the access route were the liver (n = 28), crus of the diaphragm (n = 25), pancreas (n = 14), portal vein (n = 10), duodenum (n = 7), inferior vena cava (n = 5), colon (n = 3), left renal vein (n = 2), pleura (n = 2), pericardium (n = 2), and gastric sleeve (n = 2). Pancreatitis was observed in 1 of 14 patients after pancreatic transgression. One case of clinically occult pulmonary glue migration occurred on catheter pullback through the left renal vein. Biliary peritonitis was observed after gallbladder puncture, necessitating cholecystectomy in 1 of 2 transbiliary punctures. No other relevant procedure-related complications such as hemorrhages or infectious complications were observed.

CONCLUSIONS

Despite transgression of intra-abdominal structures, puncture- and access-related complications of TDE are rare. Transpancreatic manipulations are reasonably well tolerated.

Ex Vivo Evaluation of the ArtVentive EOS Occlusion Device for the Management of Biliary Leaks

PURPOSE

 Percutaneous treatment of biliary leaks is frequently required, yet technically challenging and limited to smaller fistulas. This study sought to evaluate the off-the-shelf use of the ArtVentive EOS device for the occlusion of biliary or cystic stump leaks.

MATERIALS AND METHODS

 ePTFE-covered ArtVentive EOS devices were used to perform biliary leak embolization in 5 explanted porcine livers and in 3 explanted bovine livers. After establishing standard percutaneous transhepatic biliary drainage access, artificially created biliary leaks were occluded using 5 & 8 mm EOS devices. Using the 5 mm device, peripheral (n = 3), central (n = 1) and cystic duct leaks (n = 1) were occluded. Using the 8 mm device, peripheral (n = 1), central (n = 1), main (n = 1) and cystic duct leaks (n = 2) were occluded. Total leak occlusion was controlled by cholangiography.

RESULTS

 Selective deployment and occlusion of central biliary leaks (3/3) and cystic stump leaks (3/3) was successful in all cases. Peripheral leaks could not be selectively catheterized in 3 out of 4 cases, making device deployment several millimeters proximal to the leaks necessary.

CONCLUSION

 Selective occlusion of the cystic stump, central biliary, and larger peripheral biliary leaks using the EOS device is technically feasible ex-vivo in a single setting.

KEY POINTS

  · Due to the impermeable ePTFE membrane, one EOS suffices to completely occlude biliary leaks.. · The EOS enables selective occlusion of central and larger peripheral biliary leaks.. · Smaller biliary leaks cannot be treated selectively with the EOS..

CITATION FORMAT

· Kuetting D, Schild HH, Pieper CC. Ex Vivo Evaluation of the ArtVentive EOS Occlusion Device for the Management of Biliary Leaks. Fortschr Röntgenstr 2019; 191: 553 - 559.

Short-Term Measurement Repeatability of a Simplified Intravoxel Incoherent Motion (IVIM) Analysis for Routine Clinical Diffusion-Weighted Imaging in Malignant Liver Lesions and Liver Parenchyma at 1.5 T

OBJECTIVES

 To evaluate measurement repeatability of parameters derived from simplified intravoxel incoherent motion (IVIM) analysis of diffusion-weighted imaging (DWI) using 3 b-values.

MATERIALS AND METHODS

 24 patients (16 male, 8 female, mean age: 67 years) with hepatic malignancy (HCC: 10, metastases: 14) underwent 29 liver MRI examinations at 1.5 T. Respiratory-triggered DWI (b = 0, 50, 800 s/mm²) was acquired twice. Parameter maps of the apparent diffusion coefficient ADC(0,800), estimated diffusion coefficient D' and perfusion fraction f' were calculated. Measurement repeatability for a region of interest (ROI) placed in one lesion and liver parenchyma per lobe was assessed by intra-session variation coefficients (CV).

RESULTS

 86 ROIs (43 lesions, 43 parenchymas) were analyzed. Parameters did not significantly differ between measurements. Repeatability was excellent for ADC(0,800) and D' and good for f' in parenchyma (CVs: 7.3 %, 9.8 %, 13.0 %) and lesions (CVs: 7.5 %, 8.5 %, 11.0 %). Differences in CV-values between liver and lesions were not significant. Repeatability was better for the right than for the left lobe by tendency, for parenchyma (CVs: 6.4 % vs 8.4 %, 8.8 % vs 10.9 %, 10.5 % vs 16.0 %) and for lesions (CVs: 6.9 % vs 8.1 %, 7.5 % vs 9.5 %, 9.5 % vs 12.7 %).

CONCLUSION

 Measurement repeatability is excellent for ADC(0,800) and D' values and good for f' values using the simplified IVIM approach, both in lesions and liver parenchyma. Repeatability was better for lesions in the right compared to the left liver lobe.

KEY POINTS

  · Repeatability obtained by a simplified IVIM analysis approach is good to excellent.. · Repeatability is better for the right than for the left liver lobe.. · The simplified approach may be helpful in diagnosing and monitoring liver malignancies..

CITATION FORMAT

· Pieper CC, Sprinkart AM, Kukuk GM et al. Short-Term Measurement Repeatability of a Simplified Intravoxel Incoherent Motion (IVIM) Analysis for Routine Clinical Diffusion-Weighted Imaging in Malignant Liver Lesions and Liver Parenchyma at 1.5T. Fortschr Röntgenstr 2019; 191: 199 - 208.

Percutaneous Treatment Options of Lower Urinary Tract Fistulas and Leakages

BACKGROUND

Lower urinary tract fistulas are currently a rather rare, but severe condition associated with considerable morbidity. Treatment is challenging, especially in fistulas caused by pelvic malignancy or radiation therapy. Surgical treatment attempts fail in a considerable number of patients, especially in those with pelvic malignancies/prior radiation therapy or are precluded altogether due to severe comorbidity. For such patients percutaneous approaches can provide alternative treatment.

METHOD

This review is based on case studies and case reports dealing with percutaneous treatment options of lower urinary tract fistulas and leakages from the past four decades (1979 - 2017). The included techniques were ureteral fulguration, tissue adhesive-based embolization, non-detachable and detachable balloon occlusion, ureteral coiling, ureteral clipping, silicone or nylon plug as well as modified vascular plug embolization.

RESULTS AND CONCLUSION

Percutaneous treatment options of lower urinary tract fistulas and leakages allow for either permanent or temporary, instant ureteral occlusion. In general, transrenal ureteral occlusion is a safe and reliable alternative to surgical treatment of ureteral fistulas and leakages. So far, no technique has been proven to be superior to the others. Depending on the underlying disease, the optimal percutaneous technique may vary and should be chosen according to the individual needs of the patients.

KEY POINTS

· Patients with therapy-refractory urerteral fistulas may benefit from transrenal ureteral occlusion.. · Transrenal ureteral occlusion allows for long-term symptom relief.. · Ureteral occlusion should be in the armamentarium of interventional radiologists..

CITATION FORMAT

· Kuetting D, Pieper CC . Percutaneous Treatment Options of Lower Urinary Tract Fistulas and Leakages. Fortschr Röntgenstr 2018; 190: 692 - 700.

Accurate IVIM model-based liver lesion characterisation can be achieved with only three b-value DWI

OBJECTIVE

The objective of this study was to evaluate a simplified intravoxel incoherent motion (IVIM) approach of diffusion-weighted imaging (DWI) with four b-values for liver lesion characterisation at 1.5 T.

METHODS

DWI data from a respiratory-gated MRI sequence with b = 0, 50, 250, 800 s/mm² were retrospectively analysed in 173 lesions and 40 healthy livers. The apparent diffusion coefficient ADC = ADC(0,800) and IVIM-based parameters D₁' = ADC(50,800), D₂' =ADC(250,800), f₁', f₂', D*', ADC_low = ADC(0,50), and ADC_diff=ADC_low-D₂' were calculated voxel-wise without fitting procedures. Differences between lesion groups were investigated.

RESULTS

Focal nodular hyperplasias were best discriminated from all other lesions by f₁' with an area under the curve (AUC) of 0.989. Haemangiomas were best discriminated by D₁' (AUC of 0.994). For discrimination between malignant and benign lesions, ADC(0,800) and D₁' were best suited (AUC of 0.915 and 0.858, respectively). Discriminatory power was further increased by using a combination of D₁' and f₁'.

CONCLUSION

IVIM parameters D and f approximated from three b-values provided more discriminatory power between liver lesions than ADC determined from two b-values. The use of b = 0, 50, 800 s/mm² was superior to that of b = 0, 250, 800 s/mm². The acquisition of four instead of three b-values has no further benefit for lesion characterisation.

KEY POINTS

• Diffusion and perfusion characteristics are assessable with only three b-values. • Association of b = 0, 50, 800 s/mm²is superior to b = 0, 250, 800 s/mm². • A fourth acquired b-value has no benefit for differential diagnosis. • For liver lesion characterisation, simplified IVIM analysis is superior to ADC determination. • Simplified IVIM approach guarantees numerically stable, voxel-wise results and short acquisition times.

Interstitial Transpedal MR-Lymphangiography of Central Lymphatics Using a Standard MR Contrast Agent: Feasibility and Initial Results in Patients with Chylous Effusions

PURPOSE

To describe a novel technique for transpedal magnetic resonance lymphangiography (tMRL) with interstitial injection of a standard gadolinium-based contrast agent, and to assess its ability to visualize the central lymphatic system (CLS) in patients with chylous effusions.

MATERIALS AND METHODS

Experiences with tMRL were retrospectively reviewed in seven patients with chylous effusions. High-resolution three-dimensional multi-echo (mDIXON) images of the entire torso were obtained before and after interstitial injection of an extracellular gadolinium-based contrast agent. MR examinations were assessed qualitatively by two radiologists with respect to visualization of central lymphatics, delineation of their anatomy and presence of a lymphatic pathology (chylolymphatic leakage or reflux).

RESULTS

Examination was technically successful in 6/7 patients. tMRL confirmed the location of chylolymphatic leakage in 3/7, demonstrated a lymphatic malformation in 1/7, chylolymphatic reflux in 1/7, and confirmed normal chylolymphatic flow in the central lymphatics in 1/7 patients. In one patient neither CLS enhancement nor leakage were detectable. tMRL findings were considered helpful in all technically successful cases, and considerably influenced further treatment in four patients. All examinations were well tolerated without complications. No general anesthesia or conscious sedation was necessary.

CONCLUSION

Transpedal MR-lymphangiography with interstitial injection of a standard extracellular gadolinium-based contrast agent is feasible in clinical routine without general anesthesia and allows for assessment of pathologic conditions of central lymphatics.

KEY POINTS

· Transpedal MR-lymphangiography of central lymphatics is technically feasible.. · A standard extracellular gadolinium-based contrast agent can be used for tMRL.. · tMRL allows for evaluation of anatomy and pathologies of central lymphatics.. · tMRL is a useful tool for treatment planning in chylous effusions..

CITATION FORMAT

· Pieper CC, Schild HH. Interstitial Transpedal MR-Lymphangiography of Central Lymphatics Using a Standard MR Contrast Agent: Feasibility and Initial Results in Patients with Chylous Effusions. Fortschr Röntgenstr 2018; 190: 938 - 945.

Yttrium-90 radioembolization of unresectable hepatocellular carcinoma - a single center experience

PURPOSE

To determine the value of radioembolization (RE) for treatment of unresectable hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

Records of patients undergoing RE for unresectable HCC were retrospectively reviewed. Biochemical and clinical toxicities, imaging response (according to modified Response Evaluation Criteria In Solid Tumors), time-to-progression (TTP) and overall survival (OS) were analyzed. Data were stratified according to clinical and procedural parameters. Univariate and multivariate analyses were performed.

RESULTS

One hundred and fifteen patients (89 male, mean age 69.3 years) underwent 158 REs (119 resin-, 39 glass-based) (Barcelona Clinic Liver Cancer [BCLC]-A: 6.1%, B: 33.9%, C: 60.0%). Median clinical follow-up was 5.9 (0.9-83.5) months. No grade 4 or 5 clinical toxicities were noted. Objective response rate was 35.6%; disease control rate was 76.7%. Median TTP of the treated part of the liver was 4 (0.9-45.4) months. 108/115 patients died during follow-up (median OS 8.4 [0.3-82.8] months after first RE [BCLC-A: 52.8 months, BCLC-B: 12.4 months, BCLC-C: 6.1 months]). On multivariate analysis, baseline Eastern Co-operative Oncology Group status <1, ascites prior to RE and best imaging response were predictors of longer OS. In BCLC-C patients, tumor burden, ascites prior to RE, baseline gamma-glutamyltransferase and Child-Pugh score were predictive of OS.

CONCLUSIONS

RE is safe and effective in carefully selected patients suffering from HCC with a low complication rate. Low baseline Eastern Co-operative Oncology Group status and absence of ascites prior to RE are positive prognostic factors.

[Interventional Radiological Treatment of Intercostal Artery Bleedings - a Retrospective Analysis]

Background Intercostal artery bleedings are potentially fatal injuries. Apart from conservative and surgical treatment options, emergency interventional radiological treatment can also be performed. We report our experience with emergency intercostal artery embolisation. Materials and Methods Patients with acute arterial bleedings from the intercostal artery who were treated interventionally over a period of 7 years were identified retrospectively. Technical and clinical success, clinical and procedural parameters as well as overall survival were analysed. Results Between 2010 and 2017, a total of 27 embolisation procedures was performed in 24 patients (14 male, mean age 65.7 ± 13.9 years). The majority of patients suffered from iatrogenic intercostal artery bleedings (n = 17; 70.1%; especially after thoracocentesis). In five cases, thoracoscopic surgery was attempted prior to intervention but was unsuccessful. Primary technical success was obtained in 25/27 interventions. In two cases, there was re-bleeding via collateral arteries so that re-intervention became necessary (secondary technical success). In 15 cases, secondary surgery after successful interventional treatment was necessary to evacuate the haematoma/haemothorax. Intercostal artery embolisation was clinically successful in 23/24 patients. One patient died despite technically successful embolisation, due to extensive haemothorax. One case of spinal ischaemia was observed as a major complication. Conclusion Intercostal artery embolisation is an effective interventional radiological emergency measure in patients with acute bleeding and is an alternative to surgical treatment even after attempted, unsuccessful surgery. Because of potentially severe complications, the interventional procedure should be performed by an experienced interventionalist.

In Vitro Evaluation of the Occlusive Properties of the ArtVentive Endoluminal Occlusion System Occlusion Device for Transrenal Ureteral Occlusion

PURPOSE

Current techniques for percutaneous ureteral occlusion are either technically difficult or not satisfactory because of frequent ureteral recanalization. The purpose of this in vitro study was to evaluate the occlusive properties of an "off the shelf" solution (Endoluminal Occlusion System [EOS™]; ArtVentive Medical Group, Inc., Carlsbad, CA) for transrenal ureteral occlusion.

MATERIALS AND METHODS

Both 8 and 11 mm expanded polytetrafluoroethylene-covered ArtVentive EOS devices were used in 10 porcine models. Experiments were performed in explanted porcine ureters to simulate physiologic conditions. EOS devices were deployed in a midureteral position using a transrenal approach. Contrast agent (Iopamidol 300) diluted in saline solution was infused into the renal pelvis under continuous fluoroscopic guidance. Intrapelvic pressure measurements were performed until leakage, plug dislocation, or until pelvic blow out occurred.

RESULTS

All EOS devices were deployed effectively and achieved prompt total ureteral occlusion. Ureteral leakage occurred with intraureteral pressures between 60 to 109 cm H₂O (8 mm EOS) and between 65 and 125 cm H₂O (11 mm EOS). Before leakage, tubular reflux was seen in all cases, pelvic blowout occurred in half of the cases.

CONCLUSIONS

The ArtVentive EOS occlusive device is an effective tool for "off the shelf" ureteral occlusion. Both the 8 mm and the 11 mm devices fully occluded ureters at pressure levels that are to be expected in vivo.

Classification of spondylolytic clefts in patients with spondylolysis or isthmic spondylolisthesis using positional MRI

Background Posterior instability is a pathologic movement occurring in the spondylolytic cleft. Purpose To present a new classification system for the evaluation of spondylolytic cleft by positional magnetic resonance imaging (MRI) and determine the prevalence of the different types. Material and Methods A total of 176 segments of the lumbar spine with spondylolysis or isthmic spondylolisthesis were examined using positional MRI. Scans were obtained in neutral sitting, flexion, and extension positions. No visible movement in the cleft was defined as type A, fluid displaced into the cleft as type BI, displacement of the flava ligaments at the level of the cleft as type BII, and intraspinal cysts arising from the spondylolytic cleft as type BIII. The movements were characterized by a radiologist and a neurosurgeon experienced in positional MRI. Clinical findings were correlated with the different types of instability. Results A high agreement was found between the two observers. In total, 131 segments were characterized as type A, six as type BI, 24 as type BII, and 10 as type BIII. In five segments, the type differed between the right and the left side. Two patients had a mixed type BI/II, another two patients had a mixed type BII/III, and one patient had a mixed type BI/III. Patients with type BII and BIII instabilities suffered more often from radicular symptoms compared to patients without any instability. Conclusion The presented classification might help to better understand and study changes encountered in the spondylolytic cleft in patients with spondylolysis and isthmic spondylolisthesis using positional MRI.

Intravoxel Incoherent Motion Diffusion-Weighted MR Imaging for Prediction of Early Arterial Blood Flow Stasis in Radioembolization of Breast Cancer Liver Metastases

PURPOSE

To retrospectively evaluate predictive value of intravoxel incoherent motion (IVIM) diffusion-weighted imaging (DWI) for early arterial blood flow stasis during transarterial radioembolization (TARE) of liver dominant breast metastases (LdBM).

MATERIALS AND METHODS

Preinterventional 1.5T DWI (b0, b1, b2 = 0, 50, 800 s/mm(2)) data for 28 liver lobes of 18 female patients treated by resin-based radioembolization (10 bilobar and 8 unilobar treatments) were analyzed. Apparent diffusion coefficient (ADC) (0, 800) and an estimation of the true diffusion coefficient D' and of the perfusion fraction f' were calculated for the 2 largest metastases. Response rate at 3 months and survival were analyzed. Procedures without full dose application because of early stasis were assigned to group A (n = 15), and procedures with full dose application were assigned to group B (n = 13).

RESULTS

Metastases in group A showed significantly lower f' (0.035 ± 0.018 vs 0.076 ± 0.015, P < .0001) and a trend toward lower ADC(0, 800) with values given in 10(-6) mm(2)/s (1,066 ± 141 vs 1,189 ± 176, P = .051); no group difference was shown for D'. Groups were best discriminated by weighted mean f' values of the 2 largest metastases with accuracy of 100%. Mean tumor diameter before and after TARE was 51 mm ± 18 and 50 mm ± 24 in group A and 47 mm ± 27 and 48 mm ± 32 for group B. Imaging response did not differ between groups (P = .545). Overall survival did not differ significantly between group A (230 d) and B (155 d) (P = .124).

CONCLUSIONS

Perfusion-sensitive IVIM parameter f' may predict early blood flow stasis in patients undergoing TARE for LdBM. Determination of this parameter before intervention may increase awareness of the interventionalist and increase safety of microsphere administration.

The value of intravoxel incoherent motion model-based diffusion-weighted imaging for outcome prediction in resin-based radioembolization of breast cancer liver metastases

Purpose

To evaluate prognostic values of clinical and diffusion-weighted magnetic resonance imaging-derived intravoxel incoherent motion (IVIM) parameters in patients undergoing primary radioembolization for metastatic breast cancer liver metastases.

Subjects and methods

A total of 21 females (mean age 54 years, range 43–72 years) with liver-dominant metastatic breast cancer underwent standard liver magnetic resonance imaging (1.5 T, diffusion-weighted imaging with b-values of 0, 50, and 800 s/mm²) before and 4–6 weeks after radioembolization. The IVIM model-derived estimated diffusion coefficient D’ and the perfusion fraction f’ were evaluated by averaging the values of the two largest treated metastases in each patient. Kaplan–Meier and Cox regression analyses for overall survival (OS) were performed. Investigated parameters were changes in f’- and D’-values after therapy, age, sex, Eastern Cooperative Oncology Group (ECOG) status, grading of primary tumor, hepatic tumor burden, presence of extrahepatic disease, baseline bilirubin, previous bevacizumab therapy, early stasis during radioembolization, chemotherapy after radioembolization, repeated radioembolization and Response Evaluation Criteria in Solid Tumors (RECIST) response at 6-week follow-up.

Results

Median OS after radioembolization was 6 (range 1.5–54.9) months. In patients with therapy-induced decreasing or stable f’-values, median OS was significantly longer than in those with increased f’-values (7.6 [range 2.6–54.9] vs 2.6 [range 1.5–17.4] months, P<0.0001). Longer median OS was also seen in patients with increased D’-values (6 [range 1.6–54.9] vs 2.8 [range 1.5–17.4] months, P=0.008). Patients with remission or stable disease (responders) according to RECIST survived longer than nonresponders (7.2 [range 2.6–54.9] vs 2.6 [range 1.5–17.4] months, P<0.0001). An ECOG status ≤1 resulted in longer median OS than >1 (7.6 [range 2.6–54.9] vs 1.7 [range 1.5–4.5] months, P<0.0001). Pretreatment IVIM parameters and the other clinical characteristics were not associated with OS. Classification by f’-value changes and ECOG status remained as independent predictors of OS on multivariate analysis, while RECIST response and D’-value changes did not predict survival.

Conclusion

Following radioembolization of breast cancer liver metastases, early changes in the IVIM model-derived perfusion fraction f’ and baseline ECOG score were predictive of patient outcome, and may thus help to guide treatment strategy.

Transarterial Alcohol-Lipiodol Therapy in Patients with Hepatocellular Carcinoma Using Low Alcohol Concentrations

PURPOSE

To evaluate transarterial alcohol-lipiodol therapy (TAL) with low concentrations of alcohol for the treatment of hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

17 patients (69.3 ± 10.7a, 13 male, 4 female) with previously untreated HCC (tumor diameter: 7.7 ± 5.8 cm), who underwent 20 transarterial alcohol-lipiodol injections, were evaluated retrospectively. 14 patients had HCC with coexistent cirrhosis (Child-A n = 9, Child-B n = 4, Child-C n = 1). 9 patients presented an Okuda stage I, 7 patients an Okuda stage II and 1 patient an Okuda stage III. Infiltration of the portal vein was seen in 3 patients.

RESULTS

15 patients underwent TAL with an alcohol:lipiodol ratio of 1:2, another one with a ratio of 1:3 and yet another one with a ratio of 1:5. The median survival was 23 months, and the 1-year and 2-year survival rates were 62.7 % and 31.4 %, respectively. The median survival of patients with HCC < 7.5 cm (n = 10) was 25 months and significantly (p = 0.009) higher than for patients with HCC ≥ 7.5 cm (n = 7; 3 months). Tumor diameters ≥ 7.5 cm were associated with worse lipiodol-contrasting of HCC. Intrainterventional side effects were only feelings of slight abdominal pressure in 2 of 20 interventions. Postinterventional, mild side effects were observed after 3 interventions (abdominal pain n = 1, thoracic pain n = 1, fever n = 1). Serious complications were not observed, in particular there was no decompensation of liver cirrhosis.

CONCLUSION

TAL with low concentrations of alcohol was a safe and effective treatment in our cohort in spite of extensive tumors and impaired liver function. TAL could be a treatment option for patients who cannot receive other therapies (e. g. TACE, RFA) because of their advanced tumor disease, liver cirrhosis or other contraindications.

KEY POINTS

• TAL can be performed safely in advanced tumor disease and liver cirrhosis Citation Format: • Mohné F, Meyer C, Kuhl CK et al. Transarterial Alcohol-Lipiodol Therapy in Patients with Hepatocellular Carcinoma Using Low Alcohol Concentrations. Fortschr Röntgenstr 2016; 188: 676 - 683.

Evaluation of the delivered activity of yttrium-90 resin microspheres using sterile water and 5 % glucose during administration

BACKGROUND

The purpose of this study is to evaluate the impact of switching from sterile water to 5 % glucose (G5W) for the administration of yttrium-90 ((90)Y)-resin microspheres on the total activity of (90)Y administered (expressed as a proportion of the prescribed/calculated activity), as well as the number of cases of stasis and the reported incidence of discomfort during the selective internal radiation therapy (SIRT) procedure.

METHODS

In December 2013, we switched from sterile water to G5W for the administration of SIRT using (90)Y resin microspheres in all patients. This retrospective observational single-center case series describes our experience in the months preceding and after the switch. Apart from the change in administration medium, the protocol for SIRT was otherwise identical.

RESULTS

One hundred and four SIRT procedures were performed on 78 patients (45 male, mean age: 63 years, range: 31-87 years) with either unresectable hepatocellular carcinoma, cholangiocarcinoma, or chemorefractory liver-dominant metastatic cancer. Compared with sterile water, the whole prescribed activity was administered in significantly more procedures with G5W: 85 vs. 22 %; p < 0.0001. A significantly higher proportion of the calculated activity was administered with G5W: 96.1 ± 11.0 % vs. 77.4 ± 24.3 % (p < 0.0001). G5W procedures were also associated with a significantly lower incidence of stasis (28 vs. 11 % procedures; p = 0.02) and mild-to-moderate upper abdominal pain during the procedure (1.8 vs. 44 % procedures; p < 0.0001).

CONCLUSIONS

Replacing sterile water with isotonic G5W during administration favorably impacts on the safety of SIRT, eliminates and/or minimizes flow reductions and stasis/reflux during administration of (90)Y resin microspheres, improves percentage activity delivered, and reduces peri-procedural pain.

[Imaging of the Lacrimal Gland and the Lacrimal Drainage System]

A large number of different neoplastic, infective and autoimmunologic diseases can affect the lacrimal gland. Thorough imaging examinations can help to characterize lesions to narrow down possible differential diagnoses. Diseases of the lacrimal drainage system, especially obstructions with constant epiphora are often very irritating for the patients. Imaging examinations can assist in selecting the adequate therapy in interdisciplinary consensus. Moreover, interventional-radiological therapy (e. g. balloon-dacryocystoplasty) is an attractive minimally-invasive treatment alternative.

Lymphatic Interventions for Treatment of Chylothorax

PURPOSE

To determine effectiveness of lymphatic interventional procedures for treatment of chylothorax.

MATERIAL AND METHODS

Analysis of interventions performed from 2001 to 2014.

RESULTS

In 21 patients with therapy resistant chylothorax a lymphatic radiological intervention was attempted, which could be performed in 19 cases: 17 thoracic duct embolizations (15 transabdominal, one transzervical and one retrograde transvenous procedure), 2 percutaneous destructions of lymphatic vessels, one CT-guided injection of ethanol next to a duplicated thoracic duct. Fourteen of seventeen (82.3 %) of the technically successful embolizations lead to clinical cure. This encluded three patients with prior unsuccessful surgical thoracic duct ligation. Also the injection of ethanol was clinically effective. Complications were a bile peritonitis requiring operation, and one clinical deterioration of unknown cause.

CONCLUSION

Interventional lymphatic procedures allow for effective treatment in many cases of chylothorax, and should be considered early during treatment.

KEY POINTS

• Thoracic duct embolization is an effective treatment method for chylothorax. • If embolization is impossible, percutaneous lymphatic destruction or injection of sclerosants/tissue adhesive next to the thoracic duct may be tried.

Postinterventional passive expansion of partially dilated transjugular intrahepatic portosystemic shunt stents

PURPOSE

To investigate passive transjugular intrahepatic portosystemic shunt (TIPS) stent expansion in patients with intentional "underdilation" (eg, 10-mm stent, 8-mm balloon) during TIPS creation.

MATERIALS AND METHODS

Custom in-house software was developed for objective quantification of cross-sectional stent area from computed tomography (CT) data. The technique was validated by in vitro experiments. The study included 39 patients (22 men; mean age, 59.2 y) who underwent TIPS creation (VIATORR stent graft [W. L. Gore & Associates, Flagstaff, Arizona]; n = 29; WALLSTENT endoprosthesis [Boston Scientific, Marlborough, Massachusetts], n = 10) with stent underdilation. Follow-up CT data of the patients were used to quantify in vivo stent area changes. Data were analyzed by variance analysis and entered into a general linear model to test for interrelations between stent area changes and clinical (eg, cirrhosis grade) and procedural parameters.

RESULTS

In vitro validation of the in-house software showed good agreement and reproducibility without overestimation of stent area. Mean clinical follow-up time in patients was 787 days (range, 7-2,450 d). At the time of intervention, VIATORR stent grafts and WALLSTENT endoprostheses were dilated to an average of 64.4% ± 2.3% and 65.63% ± 8.52% of nominal area, respectively. At the last imaging follow-up evaluation, this value had increased in all stents to a mean of 87.8% ± 7.9% (VIATORR) and 82.34% ± 19.6% (WALLSTENT) in the TIPS tract (P < .05). Multivariate analysis revealed the time after intervention to be the only predictor of stent area in the TIPS tract. There was no significant association between stent expansion and clinical or procedure-related parameters.

CONCLUSIONS

The area of self-expanding stents implanted in the liver for TIPS creation with dilation to less than nominal diameter significantly increases over time. This increase has to be considered as an additional factor influencing the long-term portosystemic gradient.

Efficacy and time-to-hemostasis of antegrade femoral access closure using the ExoSeal vascular closure device: a retrospective single-center study

OBJECTIVE

To retrospectively evaluate the efficacy and time-to-hemostasis of antegrade femoral access closure using the ExoSeal vascular closure device (VCD).

DESIGN

Retrospective, single-center analysis.

MATERIALS AND METHODS

Between September 2010 and February 2013, 148 ExoSeal VCD closures (5-7F) of antegrade femoral accesses were performed in 119 patients (70 males, mean age 71.6 years, range 40-97 years). In all cases initial diagnostic angiography was performed via an 18G/3.8F retrograde femoral access, which was left in place during intervention (in-house standard) and was used to obtain control angiography after successful closure of the antegrade access to determine hemostasis. Technical device success was defined as ExoSeal closure without major VCD-related complications; procedural success as hemostasis within 5 minutes. Statistical analysis was performed using a logistic regression model and correlation analyses.

RESULTS

145/148 (98.0%) ExoSeal closures were technically successful (5F: n = 76; 6F: n = 65; 7F: n = 7). Angiographic control showed closure after 2 minutes in 130/145 cases. In a further 14 cases hemostasis was achieved after an additional 3 minutes MC, so that closure was successful within 5 minutes in 144/148 cases (97.3%). No major complication occurred. One minor complication was recorded in a 6F access case. Pre-interventional activated partial thromboplastin time (aPTT) was the only statistically significant predictor of necessary manual compression (MC) > 2 minutes (p = .01), but with an odds-ratio of only 1.038. The INR showed an odds-ratio of 2.455 for need for 5 minutes MC (NS). Significant correlations were found between the need for 5 minutes MC and medication with acetylsalicylic acid (p = .01), clopidogrel (p < .01), and abciximab (p < .001).

CONCLUSION

ExoSeal vascular closure of antegrade femoral punctures is safe and effective with a low complication rate. Two minutes of MC are sufficient to achieve hemostasis in the majority of cases. However, in patients on antiplatelet therapy, especially after abciximab, the authors advocate prolonging MC to 5 minutes.

In vitro evaluation of the occlusive properties of latex-covered amplatzer vascular plugs for transrenal ureteral occlusion

PURPOSE

To evaluate the occlusive properties of latex-covered Amplatzer Vascular Plugs (AVPs) for transrenal ureteral occlusion in vitro.

MATERIALS AND METHODS

Latex-covered AVPs type I and II (diameter 8, 10, 12, 14, and 16 mm) were used as occlusive devices. Radial force of an AVP was measured using simulated ureteral diameters of 4 to 12 mm. Occlusive properties were examined in a silicone tube (inner diameter 6 mm) with measurement of drainage time of a 40 cm water column. In complete occlusion, the maximum pressure that the plug was able to withstand was determined at different temperature levels. Statistical analysis of drainage time was performed in a general linear model (GLM) and using correlation analyses. Explanted porcine ureters were used to simulate physiologic conditions. Pressure measurements were performed until leakage, plug dislocation, or rupture of the ureter occurred.

RESULTS

Radial force depended on AVP type, size, ureteral diameter, and temperature. The 16-mm AVP II showed the highest radial force of more than 5 N (ureteral diameter 4 mm, body temperature). All AVP I showed water leakage and plug dislocation. Drainage time of the AVP II depended significantly on plug size and temperature and correlated with radial force (r=0.731, P<0.001). In complete occlusion, water leakage occurred at 500 to 1000 cm H2O and dislocation between 500 to more than 2000 cm H2O. In porcine ureters, leakage occurred at room temperature between 19 to 93 cm H2O. At body temperature, all AVP II occluded the ureter completely.

CONCLUSION

Latex-covered AVP II (diameter 8-16 mm) can effectively occlude the ureter, especially considering remodeling of the nitinol at body temperature. Large plug diameters can exert enough radial force even in dilated ureters to allow for successful occlusion. Because deployment of a 16-mm latex-covered AVP II can be technically difficult, we advocate the use of 12- or 14-mm AVP II for transrenal ureteral occlusion. AVP Is are not suitable for ureteral occlusion.

Endovascular repair of an ductus arteriosus aneurysm causing Ortner syndrome

A ductus arteriosus aneurysm (DAA) is a rare but potentially fatal condition in adults. In the past, open surgery was the only available option for treatment. Nowadays, endovascular repair has emerged as a safe and less invasive treatment option for aortic aneurysms. However, there is little experience with DAA and its anatomic location can complicate endovascular repair. Here, we describe the case of a 69-year-old patient who presented with Ortner syndrome caused by DAA, which was successfully treated using a solely endovascular approach and a standard stent graft.

Changes of pituitary gland volume in Kennedy disease

BACKGROUND AND PURPOSE

Kennedy disease is a rare X-linked neurodegenerative disorder caused by a CAG repeat expansion in the first exon of the androgen-receptor gene. Apart from neurologic signs, this mutation can cause a partial androgen insensitivity syndrome with typical alterations of gonadotropic hormones produced by the pituitary gland. The aim of the present study was therefore to evaluate the impact of Kennedy disease on pituitary gland volume under the hypothesis that endocrinologic changes caused by partial androgen insensitivity may lead to morphologic changes (ie, hypertrophy) of the pituitary gland.

MATERIALS AND METHODS

Pituitary gland volume was measured in sagittal sections of 3D T1-weighted 3T-MR imaging data of 8 patients with genetically proven Kennedy disease and compared with 16 healthy age-matched control subjects by use of Multitracer by a blinded, experienced radiologist. The results were analyzed by a univariant ANOVA with total brain volume as a covariant. Furthermore, correlation and linear regression analyses were performed for pituitary volume, patient age, disease duration, and CAG repeat expansion length. Intraobserver reliability was evaluated by means of the Pearson correlation coefficient.

RESULTS

Pituitary volume was significantly larger in patients with Kennedy disease (636 [±90] mm(3)) than in healthy control subjects (534 [±91] mm(3)) (P = .041). There was no significant difference in total brain volume (P = .379). Control subjects showed a significant decrease in volume with age (r = -0.712, P = .002), whereas there was a trend to increasing gland volume in patients with Kennedy disease (r = 0.443, P = .272). Gland volume correlated with CAG repeat expansion length in patients (r = 0.630, P = .047). The correlation coefficient for intraobserver reliability was 0.94 (P < .001).

CONCLUSIONS

Patients with Kennedy disease showed a significantly higher pituitary volume that correlated with the CAG repeat expansion length. This could reflect hypertrophy as the result of elevated gonadotropic hormone secretion caused by the androgen receptor mutation with partial androgen insensitivity.

"Anatomy and imaging": 10 years of experience with an interdisciplinary teaching project in preclinical medical education - from an elective to a curricular course

PURPOSE

Presentation of an interdisciplinary, interactive, tutor-based preclinical teaching project called "Anatomy and Imaging".

MATERIALS AND METHODS

Experience report, analysis of evaluation results and selective literature review.

RESULTS

From 2001 to 2012, 618 students took the basic course (4 periods per week throughout the semester) and 316 took the advanced course (2 periods per week). We reviewed 557 (return rate 90.1 %) and 292 (92.4 %) completed evaluation forms of the basic and the advanced course. Results showed overall high satisfaction with the courses (1.33 and 1.56, respectively, on a 5-point Likert scale). The recognizability of the relevance of the course content for medical training, the promotion of the interest in medicine and the quality of the student tutors were evaluated especially positively.

CONCLUSION

The "Anatomy and Imaging" teaching project is a successful concept for integrating medical imaging into the preclinical stage of medical education. The course was offered as part of the curriculum in 2013 for the first time. "Anatomia in mortuis" and "Anatomia in vivo" are not regarded as rivaling entities in the delivery of knowledge, but as complementary methods.