Health-related quality of life and anxiety levels among patients under surveillance for intraductal papillary mucinous neoplasm

BACKGROUND

Because of the premalignant nature of intraductal papillary mucinous neoplasms (IPMNs), patients should undergo surveillance as long as they remain fit for surgery. This surveillance, with imaging and laboratory tests every 6 to 12 months, is expensive and may psychologically burden patients. This study aimed to determine the effects of IPMN surveillance on patients´ health-related quality of life (HRQoL) and anxiety levels.

METHODS

We included a random subgroup of all IPMN patients undergoing a follow-up check-up at Helsinki University Hospital (HUH) between August 2017 and November 2018. Patients were asked to complete the 15D HRQoL and state-trait anxiety inventory (STAI) questionnaires just before and three months after an IPMN control.

RESULTS

Among 899 patients in IPMN follow-up, 232 participated. The 15D HRQoL results showed differences in some IPMN patients' 15 analyzed dimensions compared to a sex- and age-standardized general population cohort, but the clinical relevance of these differences appear doubtful. We detected no significant difference in the anxiety levels determined using the STAI questionnaires before or three months after the IPMN control.

CONCLUSION

Surveillance should be less harmful than the risk of disease. Among our patients, the recommended IPMN follow-up carried minimal negative impact on patients' HRQoL or anxiety levels. This result is important, because the number of patients under IPMN surveillance is rapidly increasing and the cancer risk among the majority of these patients remains small.

TRIAL REGISTRATION

The Surgical Ethics Committee of Helsinki University Hospital approved this study (Dnro HUS 475/2017) and it was registered at ClinicalTrials.gov (NCT03131076) before patient enrollment began.

A retrospective study of intraductal papillary neoplasia of the pancreas (IPMN) under surveillance

BACKGROUND AND OBJECTIVE

The growing number of identified intraductal papillary mucinous neoplasm (IPMN) patients places greater pressure on healthcare systems. Only a minority of patients have IPMN-related symptoms. Thus, more precise surveillance is required.

METHODS

In this retrospective single-center cross-sectional study, patients with an active diagnosis of branch duct IPMN (BD-IPMN) and >6 months of surveillance were classified as follows: presence/absence of worrisome features (WF) or high-risk stigmata (HRS), newly developed WF/HRS, under/over 15 mm cyst, growing/not growing <15 mm cyst, and elevated serum carbohydrate antigen 19-9 (CA 19-9).

RESULTS

In all, 377 patients with BD-IPMN were followed for a median of 5.4 years, 28% with WF at diagnosis, and 14% who developed WF/HRS during surveillance. Half had a <15 mm primary cyst, 40% of which did not grow during surveillance. CA 19-9 was elevated in 12%. None of the patients with normal CA 19-9 levels developed cancer or high-grade dysplasia (HGD).

CONCLUSIONS

No carcinomas or HGDs appeared with normal CA 19-9 levels. Patients with <15 mm cysts that do not grow and have no WF/HRS could undergo imaging less frequently.

Treatment response of colorectal cancer liver metastases to neoadjuvant or conversion therapy: a prospective multicentre follow-up study using MRI, diffusion-weighted imaging and 1H-MR spectroscopy compared with histology (subgroup in the RAXO trial)

BACKGROUND

Colorectal cancer liver metastases respond to chemotherapy and targeted agents not only by shrinking, but also by morphologic and metabolic changes. The aim of this study was to evaluate the value of advanced magnetic resonance imaging (MRI) methods in predicting treatment response and survival.

PATIENTS AND METHODS

We investigated contrast-enhanced MRI, apparent diffusion coefficient (ADC) in diffusion-weighted imaging and 1H-magnetic resonance spectroscopy (1H-MRS) in detecting early morphologic and metabolic changes in borderline or resectable liver metastases, as a response to first-line neoadjuvant or conversion therapy in a prospective substudy of the RAXO trial (NCT01531621, EudraCT2011-003158-24). MRI findings were compared with histology of resected liver metastases and Kaplan-Meier estimates of overall survival (OS).

RESULTS

In 2012-2018, 52 patients at four Finnish university hospitals were recruited. Forty-seven patients received neoadjuvant or conversion chemotherapy and 40 liver resections were carried out. Low ADC values (below median) of the representative liver metastases, at baseline and after systemic therapy, were associated with partial response according to RECIST criteria, but not with morphologic MRI changes or histology. Decreasing ADC values following systemic therapy were associated with improved OS compared to unchanged or increasing ADC, both in the liver resected subgroup (5-year OS rate 100% and 34%, respectively, P = 0.022) and systemic therapy subgroup (5-year OS rate 62% and 23%, P = 0.049). 1H-MRS revealed steatohepatosis induced by systemic therapy.

CONCLUSIONS

Low ADC values at baseline or during systemic therapy were associated with treatment response by RECIST but not with histology, morphologic or detectable metabolic changes. A decreasing ADC during systemic therapy is associated with improved OS both in all patients receiving systemic therapy and in the resected subgroup.

Centralized repeated resectability assessment of patients with colorectal liver metastases during first-line treatment: prospective study

BACKGROUND

Metastasectomy is probably underused in metastatic colorectal cancer. The aim of this study was to investigate the effect of centralized repeated assessment on resectability rate of liver metastases.

METHODS

The prospective RAXO study was a nationwide study in Finland. Patients with treatable metastatic colorectal cancer at any site were eligible. This planned substudy included patients with baseline liver metastases between 2012 and 2018. Resectability was reassessed by the multidisciplinary team at Helsinki tertiary referral centre upfront and twice during first-line systemic therapy. Outcomes were resectability rates, management changes, and survival.

RESULTS

Of 812 patients included, 301 (37.1 per cent) had liver-only metastases. Of these, tumours were categorized as upfront resectable in 161 (53.5 per cent), and became amenable to surgery during systemic treatment in 63 (20.9 per cent). Some 207 patients (68.7 per cent) eventually underwent liver resection or ablation. At baseline, a discrepancy in resectability between central and local judgement was noted for 102 patients (33.9 per cent). Median disease-free survival (DFS) after first resection was 20 months and overall survival (OS) 79 months. Median OS after diagnosis of metastatic colorectal cancer was 80, 32, and 21 months in R0-1 resection, R2/ablation, and non-resected groups, and 5-year OS rates were 68, 37, and 9 per cent, respectively. Liver and extrahepatic metastases were present in 511 patients. Of these, tumours in 72 patients (14.1 per cent) were categorized as upfront resectable, and 53 patients (10.4 per cent) became eligible for surgery. Eventually 110 patients (21.5 per cent) underwent liver resection or ablation. At baseline, a discrepancy between local and central resectability was noted for 116 patients (22.7 per cent). Median DFS from first resection was 7 months and median OS 55 months. Median OS after diagnosis of metastatic colorectal cancer was 79, 42, and 17 months in R0-1 resection, R2/ablation, and non-resected groups, with 5-year OS rates of 65, 39, and 2 per cent, respectively.

CONCLUSION

Repeated centralized resectability assessment in patients with colorectal liver metastases improved resection and survival rates.

Repeated centralized multidisciplinary team assessment of resectability, clinical behavior, and outcomes in 1086 Finnish metastatic colorectal cancer patients (RAXO): A nationwide prospective intervention study

Background

Resection of colorectal cancer (CRC) metastases provides good survival but is probably underused in real-world practice.

Methods

A prospective Finnish nationwide study enrolled treatable metastatic CRC patients. The intervention was the assessment of resectability upfront and twice during first-line therapy by the multidisciplinary team (MDT) at Helsinki tertiary referral centre. The primary outcome was resection rates and survival.

Findings

In 2012–2018, 1086 patients were included. Median follow-up was 58 months. Multiple metastatic sites were present in 500 (46%) patients at baseline and in 820 (76%) during disease trajectory. In MDT assessments, 447 (41%) were classified as resectable, 310 (29%) upfront and 137 (18%) after conversion therapy. Six-hundred and ninety curative intent resections or local ablative therapies (LAT) were performed in 399 patients (89% of 447 resectable). Multiple metastasectomies for multisite or later developing metastases were performed in 148 (37%) patients. Overall, 414 liver, 112 lung, 57 peritoneal, and 107 other metastasectomies were performed. Median OS was 80·4 months in R0/1-resected (HR 0·15; CI_95% 0·12–0·19), 39·1 months in R2-resected/LAT (0·39; 0·29–0·53) patients, and 20·8 months in patients treated with “systemic therapy alone” (reference), with 5-year OS rates of 66%, 40%, and 6%, respectively.

Interpretation

Repeated centralized MDT assessment in real-world metastatic CRC patients generates high resectability (41%) and resection rates (37%) with impressive survival, even when multisite metastases are present or develop later.

Funding

The funders had no role in the study design, analysis, and interpretation of the data or writing of this report.

Functional imaging with 11C-metomidate PET for subtype diagnosis in primary aldosteronism

OBJECTIVE

Endocrine Society guidelines recommend adrenal venous sampling (AVS) in primary aldosteronism (PA) if adrenalectomy is considered. We tested whether functional imaging of adrenal cortex with 11C-metomidate (11C-MTO) could offer a noninvasive alternative to AVS in the subtype classification of PA.

DESIGN

We prospectively recruited 58 patients with confirmed PA who were eligible for adrenal surgery.

METHODS

Subjects underwent AVS and 11C-MTO-PET without dexamethasone pretreatment in random order. The lateralization of 11C-MTO-PET and adrenal CT were compared with AVS in all subjects and in a prespecified adrenalectomy subgroup in which the diagnosis was confirmed with immunohistochemical staining for CYP11B2.

RESULTS

In the whole study population, the concordance of AVS and 11C-MTO-PET was 51% and did not differ from that of AVS and adrenal CT (53%). The concordance of AVS and 11C-MTO-PET was 55% in unilateral and 44% in bilateral PA. In receiver operating characteristics analysis, the maximum standardized uptake value ratio of 1.16 in 11C-MTO-PET had an AUC of 0.507 (P = n.s.) to predict allocation to adrenalectomy or medical therapy with sensitivity of 55% and specificity of 44%. In the prespecified adrenalectomy subgroup, AVS and 11C-MTO-PET were concordant in 10 of 19 subjects with CYP11B2-positive adenoma and in 6 of 10 with CYP11B2-positivity without an adenoma.

CONCLUSIONS

The concordance of 11C-MTO-PET with AVS was clinically suboptimal, and did not outperform adrenal CT. In a subgroup with CYP11B2-positive adenoma, 11C-MTO-PET identified 53% of cases. 11C-MTO-PET appeared to be inferior to AVS for subtype classification of PA.

Prognostic role of radiological peritoneal cancer index in malignant peritoneal mesothelioma: national cohort study

Malignant peritoneal mesothelioma (MPeM) is a rare cancer of the mesothelial cells of the peritoneum. Computed tomography (CT) is considered the standard for first-line imaging of MPeM, diagnosis and risk stratification remains challenging. Peritoneal cancer index (PCI), as assessed by CT, is utilized in the prognostic assessment of other malignant intra-abdominal conditions; however, there is limited data concerning the utility of PCI in the diagnosis and workup of MPeM. We studied a retrospective cohort of all patients diagnosed with MPeM from 2000 to 2012 in Finland. CT and magnetic resonance imaging (MRI) were reviewed and scored by an experienced and blinded, board-certified abdominal radiologist. Additional clinical data and outcomes were obtained from Finnish Cancer Registry (FCR), the Workers' Compensations Center (WCC), and Statistics Finland (SF). Abdominal CT or MRI was available for 53 of 90 patients. The median radiographic PCI was 25. PCI score was correlated with overall survival (p = 0.004, Exp(B) = 1.064, 95% CI 1.020-1.110). PCI score ≥ 30 was associated with worse survival (p = 0.002), while PCI ≤ 19 was associated with improved overall survival (p = 0.001). Our study indicates that radiological PCI is prognostic in MPeM and should be assessed during radiographic workup and integrated into clinical decision-making.

Repeated centralized MDT resectability assessment during first-line treatment in 1086 Finnish metastatic colorectal cancer (mCRC) patients nationwide (prospective RAXO study)

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Background: Resection of oligometastatic mCRC is curable in up to half and is probably underused in real-life oncology practice. In 2011, a prospective nationwide centralized evaluation of resectability was initiated to assess upfront and conversion to resectability. Methods: The RAXO-study included 1086 mCRCs referred for oncological treatments at all 21 Finnish oncology units (40% of eligible mCRCs in Finland). The MDT at Helsinki tertiary referral center (TRC) assessed resectability of liver, lung and other metastases upfront and twice during first-line therapy. Resectability evaluation was provided online and resections were performed according to clinical praxis, with major resections at TRCs. Results: Median age was 66.5 (range 24-90) yrs, 60% males, ECOG was 0 in 295 (27%), 1 in 600 (55%) and 2-3 in 191 (18%). Tumor was right-sided in 310 (29%), left in 769 (72%) and multiple in 7 (.6%). In the MDT assessment, 435 (40%) were considered resectable, 28% upfront and 12% after conversion. Resections or local ablative therapy were performed in 396 (91% of resectable, R0-1 in 74% and R2 in 17%), with 368 liver-, 91 lung- and 96 other operations. One metastatic site (n = 407), 2 (n = 369) and 3-6 (n = 310) were or became resectable in 65, 33 and 15%, respectively, and R0-1 resected in 54, 30 and 6%, respectively (P < 0.001). In multivariate analysis age < 66.5 (OR 1.51), ECOG 0 (OR 2.40); left-sided primary (OR 1.55), metachronous metastases (OR 1.49), 1-2 metastatic sites (OR 1.86) increased R0-1 resection rates; whereas primary/relapse in situ (OR 0.49), metastases in lung (OR 0.22), peritoneum (OR 0.30) or lymph nodes (OR 0.23) decreased R0-1 rates (P < 0.05). In univariate analyses BRAF wt (OR 0.34), normal CEA (OR 0.31) or normal Ca19-9 (OR 0.45) associated with R0-1 rates. Median OS was 2.4 yrs (CI95% 2.3-2.6) in all, 6.7 yrs in R0-1 (HR 0.15; CI95% 0.11-0.19), 2.8 yrs in R2 (0.50; 0.36-0.68) and 1.7 yrs in non-resected (reference group). Median PFS was 1.1 yrs (1.0-1.1) in all patients, 2.4 yrs in R0-1 (0.24; 0.20-0.28), 1.4 yrs in R2 (0.55; 0.42-0.71) and 0.8 yrs in non-resected patients. P < 0.001 for all comparisons. Conclusions: Repeated centralized MDTs in real-life mCRC patients show high resectability (40%) and resection rates (36%), even if multiple metastatic sites are present. Curative resection associates with good survival. Clinical trial information: NCT01531621.

Differences in Prognostic Factors and Recurrence Patterns After Curative-Intent Resection of Perihilar and Distal Cholangiocarcinomas

BACKGROUND

Perihilar cholangiocarcinoma and distal cholangiocarcinoma arise from the same tissue but require different surgical treatment methods. It remains unclear whether these cholangiocarcinoma types have different outcomes, prognostic factors, and/or recurrence patterns.

METHODS

This retrospective study evaluated patients who underwent curative-intent resection for perihilar cholangiocarcinoma or distal cholangiocarcinoma at a tertiary academic hospital during 2000-2015. Survival and prognostic factors were identified using Kaplan-Meier and Cox regression analyses.

RESULTS

The 90-day mortality rates were 0% for perihilar cholangiocarcinoma (36 patients) and 4% for distal cholangiocarcinoma (47 patients). There were no significant differences between perihilar cholangiocarcinoma or distal cholangiocarcinoma in median overall survival (30.9 vs 40.4 months) or median disease-free survival (14.2 vs 21.4 months). Among perihilar cholangiocarcinoma patients, age > 65 years was an independent predictor of poorer overall survival (hazard ratio: 2.45, 95% confidence interval: 1.07-5.64), while requiring bile duct re-resection was an independent predictor of disease-free survival (hazard ratio: 2.76, 95% confidence interval: 1.01-7.51). Among distal cholangiocarcinoma patients, a pN1 category independently predicted poorer overall survival (hazard ratio: 3.40, 95% confidence interval: 1.14-10.11), while preoperative CA19-9 levels >30 U/mL (hazard ratio: 2.51, 95% confidence interval: 1.09-5.79) and pN1 category (hazard ratio: 2.51, 95% confidence interval: 1.09-5.79) predicted a shorter disease-free survival. Local recurrence was more common with perihilar cholangiocarcinoma (50% of recurrences), while multiple synchronous sites were more common for distal cholangiocarcinoma (41% of recurrences).

CONCLUSION

Perihilar cholangiocarcinoma and distal cholangiocarcinoma patients have similar survival outcomes. However, local control appears to be more prognostic for perihilar cholangiocarcinoma patients, while positive lymph nodes are critical prognostic factor for distal cholangiocarcinoma patients.

The role of magnetic resonance imaging and endoscopic retrograde cholangiography in the evaluation of disease activity and severity in primary sclerosing cholangitis

BACKGROUND & AIMS

Endoscopic retrograde cholangiography (ERCP) has been considered the gold standard for the diagnosis and follow-up of primary sclerosing cholangitis, but it has been replaced by less invasive magnetic resonance imaging and cholangiopancreatography (MRI-MRCP). However, the role of these two techniques in the evaluation of disease activity and severity needs to be elucidated.

METHODS

Patients with primary sclerosing cholangitis (n: 48, male 31, median age: 35.7; 28.0-44.2) who underwent ERCP and MRI-MRCP within ±3 months for diagnosis or follow-up, were reviewed. ERCP and MRI-MRCP images were scored using the modified Amsterdam score. Serum and biliary cytology markers of disease activity and severity were related to the imaging findings. Agreement on the assessment of the ERCP/MRCP score was calculated by kappa-statistics. Spearman's ρ was calculated when appropriate.

RESULTS

The agreement between ERCP and MRCP in scoring bile duct changes for disease severity was only moderate (weighted kappa: 0.437; 95% CI: 0.211-0.644 for intra- and 0.512; 95% CI: 0.303-0.720 for extra-hepatic bile ducts). ERCP and MRCP intra-hepatic scores were associated to the surrogate marker alkaline phosphatase (P = .02 for both). A weak correlation between MRCP score for extra-hepatic bile ducts and liver transplantation/death was found (Spearman's ρ = .362, 95% CI: 0.080-0.590, P = .022). A weak correlation between intra- (Spearman's ρ = .322, 95% CI: 0.048-0.551, P = .022) and extra-hepatic (Spearman`s ρ = .319, 95% CI: 0.045-0.549, P = .025) peribiliary enhancement on contrast-enhanced MRI and severity of biliary cytologic classification was found.

CONCLUSIONS

The overall agreement between ERCP and MRI-MRCP in assessing disease severity was moderate for intra- and extra-hepatic bile ducts. MRI-MRCP seems to have a minor role as surrogate marker of disease activity and progression in PSC.

Can carcinoembryonic antigen replace computed tomography in response evaluation of metastatic colorectal cancer?

INTRODUCTION

Response Evaluation Criteria in Solid Tumours (RECISTs 1.1) define computed tomography (CT) as the gold standard in response evaluation of patients with metastatic colorectal cancer (mCRC) who are undergoing chemotherapy. The aim of this study was to evaluate whether carcinoembryonic antigen (CEA), which is cheaper and easier to perform, can replace repeated CT.

MATERIAL AND METHODS

The study included 66 patients with non-resectable mCRC participating in a phase I-II study. CEA values were determined, and CT images were taken every 2 months. CT images were externally and retrospectively reviewed according to the RECIST 1.1 criteria. Different cut-off values for CEA change in percent (DeltaCEA%) compared with baseline or nadir value underwent testing to find patients with disease control (that is stable disease, partial or complete response) at 2, 4, 6 and 8 months, in order to identify those who could have continued with chemotherapy based on CEA values alone. CT verification is needed in progressive disease (PD), and therefore identifying PD patients was our secondary endpoint.

RESULTS

The results showed that by using a cut-off value of 0 for DeltaCEA%, disease control was seen in all patients at all measuring points (negative predictive value (NPV) = 1.0). Secondarily, increasing CEA was able to identify all PD patients (sensitivity (Se) = 1.0) and in 50-74% of the patients increasing CEA provided a lead time to PD on upcoming CT. It was possible to replace CT with CEA in all patients with decreasing CEA, meaning that 23-47% of CT scans could have been avoided at any given time point.

CONCLUSION

When the CEA level at a certain measuring point is the same or lower than CEA at baseline or at nadir (the measuring point with the lowest CEA value) during treatment, CEA can replace CT.

Biliary Anomalies in Patients With HNF1B Diabetes

CONTEXT

The clinical spectrum of organogenetic anomalies associated with HNF1B mutations is heterogeneous. Besides cystic kidney disease, diabetes, and various other manifestations, odd cases of mainly neonatal and posttransplantation cholestasis have been described. The biliary phenotype is incompletely defined.

OBJECTIVE

To systematically characterize HNF1B-related anomalies in the bile ducts by imaging with magnetic resonance imaging (MRI) or magnetic resonance cholangiopancreatography (MRCP).

SETTING AND PATIENTS

Fourteen patients with HNF1B mutations in the catchment area of the Helsinki University Hospital were evaluated with upper abdominal MRI and MRCP. Blood samples and clinical history provided supplemental data on the individual phenotype.

MAIN OUTCOME MEASURE(S)

Structural anomalies in the biliary system, medical history of cholestasis, other findings in abdominal organs, diabetes and antihyperglycemic treatment, hypomagnesemia, and hyperuricemia.

RESULTS

Structural anomalies of the bile ducts were found in seven of 14 patients (50%). Six patients had choledochal cysts, which are generally considered premalignant.

CONCLUSIONS

Structural anomalies of the biliary system were common in HNF1B mutation carriers. The malignant potential of HNF1B-associated choledochal cysts warrants further studies.

Frequency and locations of systemic metastases in Merkel cell carcinoma by imaging

Background

The primary neuroendocrine skin cancer, Merkel cell carcinoma (MCC), has a well-known predilection to metastasize systemically. However, the experience of systemic metastases in MCC is mainly disseminated through case reports due to the rarity of MCC.

Purpose

To elucidate the frequency and locations of systemic metastasis in MCC by reviewing the imaging of patients with metastatic MCC in a national cohort.

Material and Methods

Patients with diagnosed metastatic MCC by imaging studies in Finland during 1999–2012 were included in this study. We reviewed their imaging studies to evaluate the most frequent sites for systemic metastasis and determined the latency between the primary tumor diagnosis and systemic metastasis. The material includes 30 MCC patients with complete imaging series and 187 examinations, of which 102 (54%) were CT images.

Results

The mean latency from the primary tumor diagnosis to systemic metastasis was 2.1 years and the mean latency between the radiologic diagnosis of the metastases and death was 299 days. Metastases were recorded in several organ systems in most of the cases, and at least two separate metastatic sites in 63% of the cases. Metastatic spread was noted in 60% of the cases in distant lymph nodes. Liver and lungs were the most affected solid organs.

Conclusion

Systemic metastasis in MCC has no predilection site, basically every organ system can be involved. Most of the systemic metastases were recorded during the first two years after the MCC diagnosis.

Performance of imaging studies in patients with suspected appendicitis after stratification with adult appendicitis score

Background

Diagnostic scoring is used to stratify patients with suspected appendicitis into three groups: high, intermediate, and low probability of appendicitis. The stratification can be used for selective imaging to avoid the harms of radiation without compromising diagnostic accuracy.

The aim was to study how stratification by Adult Appendicitis Score affects diagnostic performance of imaging studies.

Methods

Analysis of 822 patients who underwent diagnostic imaging for suspected appendicitis was made. Adult Appendicitis Score was used to stratify patients into groups of high, intermediate, and low probability of appendicitis. Diagnostic performance of computed tomography (CT) and ultrasound (US) was compared between these patient groups.

Results

After scoring, pre-test probability of appendicitis ranged from 9-16% in low probability group to 75-79% in high probability group in patients who underwent US or CT. Post-test probability of appendicitis after positive CT was 99, 91, and 75% in high probability, intermediate probability and low probability groups, respectively, p < 0.001. After positive US the respective probabilities were 95, 91 and 42%, p < 0.001.

Conclusion

Diagnostic imaging has limited value in patients with low probability of appendicitis according to Adult Appendicitis Score.

Significant inter-observer variation in the diagnosis of extrapancreatic necrosis and type of pancreatic collections in acute pancreatitis - An international multicenter evaluation of the revised Atlanta classification

BACKGROUND

For consistent reporting and better comparison of data in research the revised Atlanta classification (RAC) proposes new computed tomography (CT) criteria to describe the morphology of acute pancreatitis (AP). The aim of this study was to analyse the interobserver agreement among radiologists in evaluating CT morphology by using the new RAC criteria in patients with AP.

METHODS

Patients with a first episode of AP who obtained a CT were identified and consecutively enrolled at six European centres backwards from January 2013 to January 2012. A local radiologist at each center and a central expert radiologist scored the CTs separately using the RAC criteria. Center dependent and independent interobserver agreement was determined using Kappa statistics.

RESULTS

In total, 285 patients with 388 CTs were included. For most CT criteria, interobserver agreement was moderate to substantial. In four categories, the center independent kappa values were fair: extrapancreatic necrosis (EXPN) (0.326), type of pancreatitis (0.370), characteristics of collections (0.408), and appropriate term of collections (0.356). The fair kappa values relate to discrepancies in the identification of extrapancreatic necrotic material. The local radiologists diagnosed EXPN (33% versus 59%, P < 0.0001) and non-homogeneous collections (35% versus 66%, P < 0.0001) significantly less frequent than the central expert. Cases read by the central expert showed superior correlation with clinical outcome.

CONCLUSION

Diagnosis of EXPN and recognition of non-homogeneous collections show only fair agreement potentially resulting in inconsistent reporting of morphologic findings.

A body-sized phantom for evaluation of diffusion-weighted MRI data using conventional, readout-segmented, and zoomed echo-planar sequences

BACKGROUND

Abdominal diffusion-weighted imaging (DWI) has been rapidly increasing during the last few years. For the evaluation of new DWI techniques, the development of suitable phantoms and quality assurance methods is important.

PURPOSE

To construct a body-diameter phantom for abdominal DWI and study the impact of different acquisition options on image quality.

MATERIAL AND METHODS

A phantom with a diameter of 31 cm and a volume of 26 L was constructed, containing four samples representing a clinically relevant range of apparent diffusion coefficient (ADC) values. Measurements were carried out on 1.5T and 3.0T MRI systems using conventional echo-planar imaging (EPI), readout-segmented EPI, and zoomed EPI (3.0T) sequences. The effects of parallel imaging, coil intensity normalization, and patient-specific B1 shim (3.0T) were also examined. ADC values and signal-to-noise ratios of the samples were measured, and the level of artifacts was visually evaluated.

RESULTS

The agreement of ADC values between different acquisition options was generally good, but higher values (by 0.07 × 10(-3) mm(2)/s on the average) with readout-segmented EPI as well as ADC variations of approximately 0.1 × 10(-3) mm(2)/s in slice direction were observed. The image artifacts were reduced by using patient-specific B1 shim, readout-segmented EPI, or zoomed EPI.

CONCLUSION

The body-sized phantom demonstrated well the expected image artifacts in DWI with large field of view. The use of patient-specific B1 shim, readout-segmented EPI, or zoomed EPI improved image quality of DWI in this study.

What to do when I find a focal lesion in the liver?

A focal lesion in a healthy liver of a person not having cancer is almost always benign. Diagnosis is often achieved on the basis of anamnesis and imaging findings. A histologic specimen is required in the case of suspected malignant tumor or hepatocellular adenoma. Magnetic resonance imaging is the primary investigation for an unresolved focal lesion of a cancer patient, and the histologic specimen will, when necessary, be taken only after this. Early detection of metastases of colorectal cancer in particular is important, since metastases that have spread to the liver or lungs may be operable. A focal lesion in a cirrhotic liver is either a regenerative nodule or hepatocellular carcinoma.

[Multidisciplinary tailoring of therapy of metastatic colon cancer]

Treatment of colon cancer requires multidisciplinary team work. The multitude of therapies in metastatic colon cancer have led to longer overall survival with fewer symptoms. Median survival has increased from 5 months with the best supportive care to 30-40 months in randomized studies, even with curative treatment in some patients. Tailoring of the treatment is best done by a multidisciplinary team considering radiotherapy and operation of the primary tumor, resection of liver, lung and peritoneal metastases, medical treatment alternatives, palliative care, ablative methods etc. Without skillful surgeons, oncologists, pathologists, geneticists, radiologists etc. the best treatment opportunities may be missed.

[CT imaging--towards patient- and indication-specific optimization]

The same CT imaging program should not be applied to all patients, because the required image quality and dose of radiation vary according to the indications and regions. The programs should be optimized on the basis of indication, size of the patient and usage of intravenously administered iodine contrast agent. New technical options are available for reducing the radiation exposure. Additional means of optimization include proper definition of the region being imaged, avoidance of redundant series of images, selection of correct image quality, tube current and voltage, and new methods of calculating images. Patients' radiation exposure and clinical image quality should also be monitored.

[Computed tomographic colonography]

Computed tomographic colonography, i.e. CT colonography has already widely replaced double-contrast colonography as a method of examination of the colon. A prerequisite of successful examination is a well-emptied and distended colon. CT colonography detects cancer with a sensitivity of 96%, which corresponds to the results of colonoscopy. Furthermore, CT colography allows the simultaneous assessment of the extracolonic organs in the abdominal cavity. The risk of bowel perforation is smaller than in conventional colonoscopy, and for the patient the CT examination is more convenient than conventional endoscopy or double-contrast colonography.

Postoperative acute pancreatitis as a major determinant of postoperative delayed gastric emptying after pancreaticoduodenectomy

The aim of this study was to prospectively analyze the possible association of delayed gastric emptying and postoperative pancreatic complications after pancreaticoduodenectomy. Although hospital mortality after pancreaticoduodenectomy is minimal, morbidity is still high; delayed gastric emptying is one of the most frequent complications. Thirty-nine consecutive patients undergoing pancreaticoduodenectomy were included in this study: 14 females and 25 males (median age 65 years; range, 7-82). Delayed gastric emptying was defined as the need for a nasogastric tube or recurrent vomiting that prevented normal feeding on the 10th postoperative day. Blood analysis was performed on postoperative days 4, 6, and 10; Gastrografin examination on day 6; CT scan on days 2 and 5; and drain amylases were measured on day 5. Pancreatitis was defined as pancreatitis changes in CT scan interpreted by an experienced radiologist without knowing other data. Pancreatic fistula was defined according to the recent international recommendations. We had no mortality. Twelve patients (31%) developed delayed gastric emptying. Surgical (9/12 vs. 5/27; P = 0.001) but not medical complications occurred more often in the delayed gastric emptying group. Of the single complications, postoperative CT-detected pancreatitis (6/12 vs. 4/27; P = 0.03) and postoperative pancreatic fistula (5/12 vs. 1/27; P = 0.0007) were significantly associated with delayed gastric emptying compared with the patients without delayed gastric emptying. This pancreatitis was already detected in CT scan on day 2 in most patients (6/10, 60%). In delayed gastric emptying patients, the only parameters in blood analysis that differed significantly from patients without this complication were serum amylase activity (mean +/- SEM, 715 +/- 205 vs. 152 +/- 70 IU/L; P = 0.02), blood leukocyte count (16 +/- 2 vs. 9 +/- 0.6 x 10(9)/L; P = 0.007) and serum C-reactive protein (CRP) concentration (144 +/- 28 vs. 51 +/- 14 mg/L, P = 0.01). Postoperative pancreatic (subclinical) fistula was also associated with postoperative pancreatitis (6/10 vs. 0/29; P = 0.003). Preoperative coronary artery disease (OR = 16; 95% CI, 1.0-241; P = 0.05) and soft pancreatic texture at operation (OR = 9; 95% CI, 1.4-52; P = 0.02) were significant risk factors for the development of postoperative pancreatitis. The diagnosis of delayed gastric emptying after pancreaticoduodenectomy often follows postoperative pancreatitis. Delayed gastric emptying is also associated with postoperative pancreatic fistula, for which this pancreatitis seems to be a risk factor. Preoperative coronary artery disease and soft texture of the pancreas are significant risk factors for postoperative CT-detected pancreatitis.

Investigation of suspected intra-abdominal sepsis: the contribution of nuclear medicine

The diagnosis of abdominal infections and inflammations often presents considerable difficulty, and various imaging techniques may be required to localize them accurately. At present, radiolabelled leucocytes offer the most widely accepted radionuclide method for imaging inflammation. Because of the many advantages of technetium-99m (99mTc) over indium-111 (111In), 99mTc-HMPAO-leucocyte scintigraphy is preferred for the investigation of acute abdominal sepsis and inflammatory bowel disease, and 111In-leucocyte scintigraphy for more chronic infections and renal sepsis. The 99mTc-HMPAO-labelled leucocytes technique is highly accurate within the first few hours postinjection, and is therefore useful also in acutely ill patients. It is sensitive in detecting abdominal abscesses in all locations except the liver and spleen. By whole body imaging, unsuspected sites and types of infection can be found. 99mTc-HMPAO-leucocyte scan is valuable also in the investigation of acute cholecystitis in problematic situations in which ultrasound is known to give misleading results, especially in acute acalculous cholecystitis. In inflammatory bowel disease it can reliably assess disease activity, but a normal scintigraphy does not exclude mild inflammation. Leucocyte scan is useful also in suspected acute appendicitis, acute diverticulitis, pelvic inflammatory disease, aortic graft infection, etc. But infection and inflammation cannot reliably be differentiated, which may cause misinterpretations in the early postoperative period. Radionuclide techniques have an important role to play in the investigation of abdominal sepsis if the nuclear medicine department can offer instant investigations when the clinical problem is acute.

Postoperative graft incorporation after aortic reconstruction--comparison between computerised tomography and Tc-99m-HMPAO labelled leucocyte imaging

Aortic graft infection may result in high mortality ranging up to 88%. Therefore, early diagnosis is imperative in the treatment of this serious complication. Computerised tomography (CT) is considered as a sensitive tool in the diagnosis of aortic graft infection. Some findings used as the criteria for infection, such as periprosthetic gas and fluid are, however, normal postoperative findings. The aim of this prospective study was to compare CT-scan and Tc-99m-HMPAO labelled leucocytes in the early diagnosis of aortic graft infection. The present study includes 24 consecutive patients (all men, age 70 +/- 8 years, range 55-85 years), who were operated on for abdominal aortic aneurysm. Prosthetic and suture materials were the same in all operations. Each patient was examined with the aid of CT-scan and imaged with Tc-99m-HMPAO labelled leucocytes 2 weeks and 3, 6 and 12 months after the reconstructive aortic surgery. Two radiologists and two specialists in nuclear medicine examined the data independently without knowing the clinical picture of the results of any other examinations of the patients. Seven patients (7/24; 29%) showed significant accumulation of labelled leucocytes in the first imaging (2 weeks postoperatively) with Tc-99m-HMPAO labelled leucocytes. Three months after the surgery only four patients (4/24; 17%) were positive in this respect. One of these patients had clinically proven aortic graft infection and another positive was a patient with resected and reconstructed mycotic aneurysm. CT-examination in all scans was suggestive for aortic graft infection in two cases (2/24; 8%), but neither of these patients showed any signs of infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Technetium-99m hexamethyl propylene amine oxine leucocytes in the assessment of disease activity in inflammatory bowel disease

The inflammatory activity in 108 bowel segments of 40 patients with suspected or known inflammatory bowel disease was assessed macroscopically by endoscopy, histology and technetium-99m hexamethyl propylene amine oxine (99mTc-HMPAO) leucocytes using a numerical grading system (scores 0-3). A 4-h series of scintigrams showed a significant correlation with both histological and macroscopical assessment of disease activity (rho = 0.850, P less than 0.001 and rho = 0.773, P less than 0.001, respectively). Sensitivity, specificity and accuracy of scintigraphy in detecting active inflammatory segments were 85%, 92% and 89%, respectively. A normal scintigram did not completely exclude mild inflammatory activity, especially in the rectosigmoid area. 99mTc-HMPAO leucocytes offer an accurate and non-invasive alternative for the assessment of disease activity in ulcerative colitis and Crohn's disease.

Accumulation of leucocytes labelled with technetium-99m hexamethylpropylene amine oxime in malignant abdominal tumours

A total of 343 leucocyte scans labelled with technetium-99m hexamethylpropylene amine oxime were reviewed that had been performed in 338 patients suspected of having abdominal infection or inflammation. There was uptake by malignant abdominal tumours in 10 cases (2.9%), which represents 62.5% of known malignancies at the time of the scintigram. Accumulation was seen in 8 patients with adenocarcinoma of the colon associated with a secondary infection in the tumour or pericolic inflammation. A large tumour that had spread beyond the bowel wall was related to a positive scintigram. Accumulation was also found twice in a malignant fibrous histiocytoma in which bleeding and an inflammatory reaction to necrosis were probably responsible for the uptake. The relevant treatment was delayed for 2 weeks-2 months in 4 patients with adenocarcinoma of the colon in whom the positive uptake was regarded as confirmation of the clinically suspected acute diverticulitis.

Scintigraphy with 99mTc-HMPAO labeled leukocytes in acute cholecystitis

99mTc-HMPAO labeled leukocyte scanning was performed on 38 patients with clinically suspected acute cholecystitis (AC) to evaluate its diagnostic value. The typical finding was an increasing accumulation of the tracer in the gallbladder wall in a 4 hour series of scintigrams. Leukocyte scan was positive in 16 of 17 patients with surgically and histologically confirmed AC. There were no false-positive findings. The sensitivity, specificity, and accuracy of scintigraphy were 94, 100, and 96%, respectively. In 2 patients with acute acalculous cholecystitis true-positive findings were observed. Scintigraphy with 99mTc-HMPAO labeled leukocytes is a valuable new imaging method in AC.