Diagnosis, Therapy and Follow-up of Cervical Cancer. Guideline of the DGGG, DKG and DKH (S3-Level, AWMF Registry No. 032/033OL, May 2021) – Part 1 with Recommendations on Epidemiology, Screening, Diagnostics and Therapy

Aim This update of the interdisciplinary S3 guideline on the Diagnosis, Therapy and Follow-up of Cervical Cancer (AWMF Registry No. 032/033OL) was published in March 2021. This updated guideline was funded by German Cancer Aid (Deutsche Krebshilfe) as part of the German Guideline Program in Oncology. The guideline was coordinated by the German Society of Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe, DGGG) and the Working Group on Gynecological Oncology (Arbeitsgemeinschaft Gynäkologische Onkologie, AGO) of the German Cancer Society (Deutsche Krebsgesellschaft, DKG).

Method The process of updating the S3 guideline dating from 2014 was based on an appraisal of the available evidence using the criteria of evidence-based medicine, adaptations of existing evidence-based national and international guidelines or – if evidence was lacking – on a consensus of the specialists involved in compiling the update. After an initial review of the current literature was carried out according to a prescribed algorithm, several areas were identified which, in contrast to the predecessor version from September 2014, required new recommendations or statements which took account of more recently published literature and the appraisal of the new evidence.

Recommendations The short version of this guideline consists of recommendations and statements on the epidemiology, screening, diagnostic workup and therapy of patients with cervical cancer. The most important new aspects included in this updated guideline include the newly published FIGO classification of 2018, the radical open surgery approach for cervical cancers up to FIGO stage IB1, and use of the sentinel lymph node technique for tumors ≤ 2 cm. Other changes include the use of PET-CT, new options in radiotherapy (e.g., intensity-modulated radiotherapy, image-guided adaptive brachytherapy), and drug therapies to treat recurrence or metastasis.

Diagnosis, Therapy and Follow-up of Cervical Cancer. Guideline of the DGGG, DKG and DKH (S3-Level, AWMF Registry No. 032/033OL, May 2021) – Part 2 with Recommendations on Psycho-oncology, Rehabilitation, Follow-up, Recurrence, Palliative Therapy and Healthcare Facilities

Aim This is an update of the interdisciplinary S3-guideline on the Diagnosis, Therapy and Follow-up of Cervical Cancer (AWMF Registry No. 032/033OL), published in March 2021. The work on the updated guideline was funded by German Cancer Aid (Deutsche Krebshilfe) as part of the German Guideline Program in Oncology. The guideline was coordinated by the German Society of Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe, DGGG) and the Working Group on Gynecological Oncology (Arbeitsgemeinschaft Gynäkologische Onkologie, AGO) of the German Cancer Society (Deutsche Krebsgesellschaft, DKG).

Method The process used to update the 2014 S3-guideline was based on an appraisal of the available evidence using the criteria of evidence-based medicine, adaptations of existing evidence-based national and international guidelines or – if evidence was lacking – on the consensus of the specialists involved in compiling the update. After an initial review of the current literature was carried out according to a prescribed algorithm, several areas were identified which, in contrast to the predecessor version from September 2014, required new recommendations or statements which would take account of more recently published literature and the recent appraisal of new evidence.

Recommendations The short version of this guideline consists of recommendations and statements on palliative therapy and follow-up of patients with cervical cancer. The most important aspects included in this updated guideline are the new FIGO classification published in 2018, the radical open surgery approach used to treat cervical cancer up to FIGO stage IB1, and the use of the sentinel lymph node technique for tumors ≤ 2 cm. Other changes include the use of PET-CT, new options in radiotherapy (e.g., intensity-modulated radiotherapy, image-guided adaptive brachytherapy), and drug therapies to treat recurrence or metastasis.

Structured Reporting of Solid and Cystic Pancreatic Lesions in CT and MRI: Consensus-Based Structured Report Templates of the German Society of Radiology (DRG)

BACKGROUND

 Radiological reports of pancreatic lesions are currently widely formulated as free texts. However, for optimal characterization, staging and operation planning, a wide range of information is required but is sometimes not captured comprehensively. Structured reporting offers the potential for improvement in terms of completeness, reproducibility and clarity of interdisciplinary communication.

METHOD

 Interdisciplinary consensus finding of structured report templates for solid and cystic pancreatic tumors in computed tomography (CT) and magnetic resonance imaging (MRI) with representatives of the German Society of Radiology (DRG), German Society for General and Visceral Surgery (DGAV), working group Oncological Imaging (ABO) of the German Cancer Society (DKG) and other radiologists, oncologists and surgeons.

RESULTS

 Among experts in the field of pancreatic imaging, oncology and pancreatic surgery, as well as in a public online survey, structured report templates were developed by consensus. These templates are available on the DRG homepage under www.befundung.drg.de and will be regularly revised to the current state of scientific knowledge by the participating specialist societies and responsible working groups.

CONCLUSION

 This article presents structured report templates for solid and cystic pancreatic tumors to improve clinical staging (cTNM, ycTNM) in everyday radiology.

KEY POINTS

  · Structured report templates offer the potential of optimized radiological reporting with regard to completeness, reproducibility and differential diagnosis.. · This article presents consensus-based, structured reports for solid and cystic pancreatic lesions in CT and MRI.. · These structured reports are available open source on the homepage of the German Society of Radiology (DRG) under www.befundung.drg.de..

CITATION FORMAT

· Persigehl T, Baumhauer M, Baeßler B et al. Structured Reporting of Solid and Cystic Pancreatic Lesions in CT and MRI: Consensus-Based Structured Report Templates of the German Society of Radiology (DRG). Fortschr Röntgenstr 2020; 192: 641 - 655.

Mesenchymal Hamartoma of the Liver and DICER1 Syndrome

Mesenchymal hamartoma of the liver (MHL) is a benign tumor affecting children that is characterized by a primitive myxoid stroma with cystically dilated bile ducts. Alterations involving chromosome 19q13 are a recurrent underlying cause of MHL; these alterations activate the chromosome 19 microRNA cluster (C19MC). Other cases remain unexplained. We describe two children with MHLs that harbored germline DICER1 pathogenic variants. Analysis of tumor tissue from one of the children revealed two DICER1 "hits." Mutations in DICER1 dysregulate microRNAs, mimicking the effect of the activation of C19MC. Our data suggest that MHL is a new phenotype of DICER1 syndrome. (Funded by the Canadian Institutes of Health Research and others.).

Interdisciplinary Diagnosis, Therapy and Follow-up of Patients with Endometrial Cancer. Guideline (S3-Level, AWMF Registry Number 032/034-OL, April 2018) - Part 2 with Recommendations on the Therapy and Follow-up of Endometrial Cancer, Palliative Care, Psycho-oncological/Psychosocial Care/Rehabilitation/Patient Information and Healthcare Facilities

Summary The first German interdisciplinary S3-guideline on the diagnosis, therapy and follow-up of patients with endometrial cancer was published in April 2018. Funded by German Cancer Aid as part of an Oncology Guidelines Program, the lead coordinators of the guideline were the German Society of Gynecology and Obstetrics (DGGG) and the Gynecological Oncology Working Group (AGO) of the German Cancer Society (DKG). Purpose Using evidence-based, risk-adapted therapy to treat low-risk women with endometrial cancer avoids unnecessarily radical surgery and non-useful adjuvant radiotherapy and/or chemotherapy. This can significantly reduce therapy-induced morbidity and improve the patient's quality of life as well as avoiding unnecessary costs. For women with endometrial cancer and a high risk of recurrence, the guideline defines the optimal extent of surgical radicality together with the appropriate chemotherapy and/or adjuvant radiotherapy if required. An evidence-based optimal use of different therapeutic modalities should improve the survival rates and quality of life of these patients. This S3-guideline on endometrial cancer is intended as a basis for certified gynecological cancer centers. The aim is that the quality indicators established in this guideline will be incorporated in the certification processes of these centers. Methods The guideline was compiled in accordance with the requirements for S3-level guidelines. This includes, in the first instance, the adaptation of source guidelines selected using the DELBI instrument for appraising guidelines. Other consulted sources included reviews of evidence, which were compiled from literature selected during systematic searches of literature databases using the PICO scheme. In addition, an external biostatistics institute was commissioned to carry out a systematic search and assessment of the literature for one part of the guideline. Identified materials were used by the interdisciplinary working groups to develop suggestions for Recommendations and Statements, which were then subsequently modified during structured consensus conferences and/or additionally amended online using the DELPHI method, with consent between members achieved online. The guideline report is freely available online. Recommendations Part 2 of this short version of the guideline presents recommendations for the therapy of endometrial cancer including precancers and early endometrial cancer as well as recommendations on palliative medicine, psycho-oncology, rehabilitation, patient information and healthcare facilities to treat endometrial cancer. The management of precancers of early endometrial precancerous conditions including fertility-preserving strategies is presented. The concept used for surgical primary therapy of endometrial cancer is described. Radiotherapy and adjuvant medical therapy to treat endometrial cancer and uterine carcinosarcomas are described. Recommendations are given for the follow-up care of endometrial cancer, recurrence and metastasis. Palliative medicine, psycho-oncology including psychosocial care, and patient information and rehabilitation are presented. Finally, the care algorithm and quality assurance steps for the diagnosis, therapy and follow-up of patients with endometrial cancer are outlined.

Interdisciplinary Diagnosis, Therapy and Follow-up of Patients with Endometrial Cancer. Guideline (S3-Level, AWMF Registry Nummer 032/034-OL, April 2018) - Part 1 with Recommendations on the Epidemiology, Screening, Diagnosis and Hereditary Factors of Endometrial Cancer

Summary The first German interdisciplinary S3-guideline on the diagnosis, therapy and follow-up of patients with endometrial cancer was published in April 2018. Funded by German Cancer Aid as part of an Oncology Guidelines Program, the lead coordinators of the guideline were the German Society of Gynecology and Obstetrics (DGGG) and the Gynecological Oncology Working Group (AGO) of the German Cancer Society (DKG).

Purpose The use of evidence-based, risk-adapted therapy to treat low-risk women with endometrial cancer avoids unnecessarily radical surgery and non-useful adjuvant radiotherapy and/or chemotherapy. This can significantly reduce therapy-induced morbidity and improve the patientʼs quality of life as well as avoiding unnecessary costs. For women with endometrial cancer and a high risk of recurrence, the guideline defines the optimal surgical radicality together with the appropriate chemotherapy and/or adjuvant radiotherapy where required. The evidence-based optimal use of different therapeutic modalities should improve survival rates and the quality of life of these patients. The S3-guideline on endometrial cancer is intended as a basis for certified gynecological cancer centers. The aim is that the quality indicators established in this guideline will be incorporated in the certification processes of these centers.

Methods The guideline was compiled in accordance with the requirements for S3-level guidelines. This includes, in the first instance, the adaptation of source guidelines selected using the DELBI instrument for appraising guidelines. Other consulted sources include reviews of evidence which were compiled from literature selected during systematic searches of literature databases using the PICO scheme. In addition, an external biostatistics institute was commissioned to carry out a systematic search and assessment of the literature for one area of the guideline. The identified materials were used by the interdisciplinary working groups to develop suggestions for Recommendations and Statements, which were then modified during structured consensus conferences and/or additionally amended online using the DELPHI method with consent being reached online. The guideline report is freely available online.

Recommendations Part 1 of this short version of the guideline presents recommendations on epidemiology, screening, diagnosis and hereditary factors, The epidemiology of endometrial cancer and the risk factors for developing endomentrial cancer are presented. The options for screening and the methods used to diagnose endometrial cancer including the pathology of the cancer are outlined. Recommendations are given for the prevention, diagnosis, and therapy of hereditary forms of endometrial cancer.

Screening of extravascular findings in pulmonary embolism computer tomography: 397 patients with 1950 non-pulmonary artery findings

Objectives

The aim of this study was to investigate the possible benefits from computed tomography scans of patients with a suspected pulmonary artery embolism with a focus on relevant extravascular findings.

Methods

A total of 400 consecutive computed tomography pulmonary angiographies were evaluated. Computed tomography scans were analyzed in detail for the presence of pulmonary artery embolisms, as well as any other findings. Extra-artery discoveries were classified into none-relevant (Group A), intermediate (Group B), or relevant (Group C) findings.

Results

Aggregated computed tomography pulmonary angiographies detected other diagnosis than pulmonary artery embolism in 236 patients (59%). There were 1950 non-pulmonary artery embolism findings (4.9 per patient; n = 397). In the pulmonary artery embolism group, there were 447 extra-pulmonary artery embolism findings (5.2 per patient; n = 86) and in the non-pulmonary artery embolism group, 1503 findings (4.8 per patient; n = 311). Patients with pulmonary artery embolism had a significantly higher rate of pro-coagulate risk factors ( p < 0.001).

Conclusions

Computed tomography pulmonary angiographies may help to identify further diagnoses. This study represents a retrospective review of a single center experience for incidental computed tomography findings during pulmonary artery embolism work-up and emphasizes the importance of analyzing the whole field-of-view.

Extra-vascular findings in patients undergoing magnetic resonance angiography of the abdomen, pelvis and lower extremities: A retrospective study of 352 patients

Background

The aim of this study was to assess the prevalence and clinical significance of extra-vascular findings in patients undergoing magnetic resonance angiography of the abdomen, pelvis and lower extremities.

Materials and methods

Three hundred fifty-two patients underwent abdominal, pelvic and lower extremity 1.5 T magnetic resonance angiography. Clinically relevant vascular and extra-vascular findings were identified. Relevant vascular findings were classified as stenosis, occlusion, aneurysm, sclerosis, dissection or vasculitis. Relevant extra-vascular findings were categorized as ‘safe’ (Group A), intermediate – requiring additional investigation – (Group B) and malignant/endangering – requiring change of therapy (Group C).

Results

A total of 2152 clinically relevant vascular findings was identified (6.1/patient). The most frequent vascular finding was femoral artery stenosis (10.6%). Four hundred fifty-one extra-vascular findings were observed (1.3/patient) and classified into Group A (78%), Group B (19.5%) and Group C findings (2.4%). The most frequent malignant findings were lung cancer, lymphoma, osteosarcoma, hepatocellular carcinoma and renal cell carcinoma (7/352 patients).

Conclusions

Extravascular findings are frequently encountered in magnetic resonance angiography performed for vascular indications. Clinically relevant findings are seen in a substantial part of patients and should prompt further diagnostic work-up.

Incidental findings in cardiac magnetic resonance imaging: superiority of bSSFP over T1w-HASTE for extra-cardiac findings assessment

Incidental findings are frequent in radiological examinations and may have an impact on further patient management. The aim of this retrospective study was to analyze, which of two thoracic scout sequences is more suitable for detecting incidental extra-cardiac findings at cardiac magnetic resonance imaging (CMRI) with stress perfusion. During a 14-month period clinically indicated stress perfusion CMRI was performed in 97 consecutive patients. For anatomical orientation ECG-triggered (electrocardiography) T1w-Half-fourier acquisition single-shot turbo spin-echo (HASTE) and balanced steady state free precession (bSSFP) sequences were performed for planning the standard cardiac sequences. Two radiologists independently studied incidental extra-cardiac findings with both sequences and rated the diagnostic confidence of the sequences for this assessment using a multinomial model. Furthermore, the interobserver agreement between the observers was assessed by weighted kappa statistics. Eight patients without incidental findings were excluded. In the other 89 patients a total of 153 incidental extra-cardiac findings were observed. Overall, 47.1% of findings were seen with better diagnostic confidence at bSSFP as opposed to 20.6% at T1w-HASTE. 32.4% of findings were equally well seen with both sequences. Consequently the bSSFP sequence was significantly better in terms of diagnostic confidence for detecting the majority of extra-cardiac incidental findings (P < 0.01), whereas a minority of findings was better visible by the HASTE sequence. The weighted kappa statistics was 0.85, indicating good interobserver agreement. Compared with T1w-HASTE, the bSSFP sequence improved the visibility of incidental extra-cardiac findings at stress perfusion CMRI. While all findings were seen on both sequences, bSSFP resulted in improved diagnostic confidence, and the T1w-HASTE sequence provided complementary diagnostic information in only a minority of patients.

Effects of positive blood alcohol concentration on outcome and systemic interleukin-6 in major trauma patients

BACKGROUND

The influence of alcohol on the outcome after major trauma remains controversial. In several recent studies, alcohol has been associated with neuroprotective effects in head injuries, while others reported negative or no effects on survival and/or the in-hospital stay in major trauma patients (TP). The purpose of this study was to examine the relationship of alcohol with injury characteristics and outcome as well as to analyze possible anti-inflammatory properties in major TP.

PATIENTS/METHODS

184 severely injured TP with an Injury Severity Score (ISS) ≥16 were successively enrolled. All patients had measured blood alcohol concentration (BAC). Patients were grouped according to their positive BAC (>0.5‰, BAC) vs. <0.5‰ alcohol (no BAC) upon arrival at the emergency department (ED). Injury characteristics, physiologic parameters and outcome with respect to organ or multiple organ failure (MOF), SIRS, sepsis, pneumonia, ARDS or mortality were assessed. Systemic levels of interleukin (IL)-6 at ED were determined.

RESULTS

Forty-nine TP had positive BAC without chronic alcohol abuse history and 135 patients had BAC levels below 0.5‰. Overall injury severity and age were comparable in both groups. No BAC TP received significantly higher numbers of packed red blood cells and fresh frozen plasma (transfused within the initial 24h or in total) compared to BAC TP. Organ failure, MOF, SIRS, sepsis, pneumonia, ARDS and the in-hospital mortality were not different between both groups. Trauma patients with positive BAC had significantly decreased leukocyte numbers and systemic IL-6 levels compared to no BAC group. There was a significant positive correlation between leukocyte counts and IL-6 as well as BAC and leukocytes. BAC levels did not correlate with IL-6.

CONCLUSIONS

Positive BAC is associated with reduced leukocyte numbers and lowered systemic IL-6 levels at admittance indicating immune-suppressive effects of alcohol in major trauma patients.

Bayesian bivariate meta-analysis of sensitivity and specificity: summary of quantitative findings in 50 meta-analyses

RATIONALE, AIMS AND OBJECTIVES

Meta-analyses of diagnostic test accuracy are important elements in evidence-based medicine. However, currently there is no overview of related quantitative findings that were obtained in a large number of real meta-analyses. This study aimed at providing such empirical summary.

METHODS

From the literature 50 meta-analyses were randomly selected that had reported their 2 × 2 count data of sensitivity and specificity. Descriptive statistics, assessment of between-study heterogeneity and bivariate random-effects meta-analysis of sensitivity and specificity were performed with a novel Bayesian program code. The bivariate model parameters were also converted to the parameters of the closely related hierarchical summary receiver operating characteristic (HSROC) model.

RESULTS

Among the 50 meta-analyses, the studies per meta-analysis ranged from 5 to 45 and the disease prevalence from 2.3 to 71%. Significant between-study heterogeneity was found in 43 of 50 meta-analyses, favouring a random-effects model over a fixed-effects model. Empirical distributions of sensitivity and specificity, positive and negative likelihood ratios, and other model results are presented in the full text numerically and graphically.

CONCLUSIONS

Studies of diagnostic test accuracy can be well meta-analysed within a Bayesian framework, and the presented quantitative findings provide an orientation when interpreting the results of the standard bivariate/HSROC model.

Persistent left superior vena cava detected after central venous catheter insertion

Introduction

Persistent left superior vena cava is a rare case with an appearance of 0.3% to 0.5% of individuals in general population. Indication for jugular venous intervention could be different, such as implantable venous catheters for oncological therapy. The present report describes a case of a patient with a persistent left superior vena cava detected after central venous catheter (CVC) installation using computer-assisted tomography (CT).

Case description

In a control chest X-ray the CVC was not in the right superior vena cava as expected to be. A following blood gas analysis revealed venous concentration. The consultation of additional CT diagnostics yielded a persistent left superior vena cava with an outlet to dilated coronary sinus.

Discussion and evaluation

The patient was followed over 1 year with the underlying disease of chronic obstructive pulmonary disease. Cardiac insufficiency, sinus aneurysm and arryhtmias could appear with growing age in patients with persistence left superior vena cava, but most of them are asymptomatic. Knowing the venous anatomy is important for correct position and function of e.g. totally implantable venous catheters, central lines or pacemakers.

Conclusion

The importance of early imaging diagnosis of this anatomical variation could optimize adequate therapy and finally improve living conditions. CT can help adapting correct therapy with correct diagnostics.

Accelerometer and gyroscope based gait analysis using spectral analysis of patients with osteoarthritis of the knee

[Purpose] A wide variety of accelerometer tools are used to estimate human movement, but there are no adequate data relating to gait symmetry parameters in the context of knee osteoarthritis. This study’s purpose was to evaluate a 3D-kinematic system using body-mounted sensors (gyroscopes and accelerometers) on the trunk and limbs. This is the first study to use spectral analysis for data post processing. [Subjects] Twelve patients with unilateral knee osteoarthritis (OA) (10 male) and seven age-matched controls (6 male) were studied. [Methods] Measurements with 3-D accelerometers and gyroscopes were compared to video analysis with marker positions tracked by a six-camera optoelectronic system (VICON 460, Oxford Metrics). Data were recorded using the 3D-kinematic system. [Results] The results of both gait analysis systems were significantly correlated. Five parameters were significantly different between the knee OA and control groups. To overcome time spent in expensive post-processing routines, spectral analysis was performed for fast differentiation between normal gait and pathological gait signals using the 3D-kinematic system. [Conclusions] The 3D-kinematic system is objective, inexpensive, accurate and portable, and allows long-term recordings in clinical, sport as well as ergonomic or functional capacity evaluation (FCE) settings. For fast post-processing, spectral analysis of the recorded data is recommended.

Current role of cardiac and extra-cardiac pathologies in clinically indicated cardiac computed tomography with emphasis on status before pulmonary vein isolation

PURPOSE

The aim of this study was to assess the incidence of cardiac and significant extra-cardiac findings in clinical computed tomography of the heart in patients with atrial fibrillation before pulmonary vein isolation (PVI).

MATERIALS AND METHODS

224 patients (64 ± 10 years; male 63 %) with atrial fibrillation were examined by cardiac 64-slice multidetector CT before PVI. Extra-cardiac findings were classified as "significant" if they were recommended to additional diagnostics or therapy, and otherwise as "non-significant". Additionally, cardiac findings were documented in detail.

RESULTS

A total of 724 cardiac findings were identified in 203 patients (91 % of patients). Additionally, a total of 619 extra-cardiac findings were identified in 179 patients (80 % of patients). Among these extra-cardiac findings 196 (32 %) were "significant", and 423 (68 %) were "non-significant". In 2 patients (1 %) a previously unknown malignancy was detected (esophageal cancer and lung cancer, local stage, no metastasis). 203 additional imaging diagnostics followed to clarify the "significant" findings (124 additional CT, costs 38 314.69 US dollars). Overall, there were 3.2 cardiac and 2.8 extra-cardiac findings per patient. Extra-cardiac findings appear significantly more frequently in patients over 60 years old, in smokers and in patients with a history of cardiac findings (p <0.05).

CONCLUSION

Cardiac CT scans before PVI should be screened for extracardiac incidental findings that could have important clinical implications for each patient.

Cerebral near-infrared spectroscopy correlates to vital parameters during cardiopulmonary bypass surgery in children

Near-infrared spectroscopy (NIRS) can monitor changes in cerebral regional oxygen saturation (rSO2) and tissue hemoglobin content (HbT). The relation between cerebral NIRS readings and vital parameters has not been analyzed before at a fine temporal scale. This study analyzed this relation during cardiopulmonary bypass (CPB) surgery in 10 children (0-9 years, 1,770 min of data records) by using a novel random-coefficient model. The analysis indicated that a small number of patients is sufficient for obtaining significant results with this model. Changes of vital parameters explained 84.7 % of rSO2 changes and 90.7 % of HbT changes. Cerebral rSO2 correlated positively with perfusion pressure and inversely with body temperature (P < 0.05). Cerebral HbT correlated positively with perfusion pressure, central venous pressure, and temperature and inversely with arterial oxygen saturation (P < 0.05). During hypothermic circulatory arrest, the half-life of the exponential rSO2 decay correlated to the rSO2 reserve (P = 0.016). In conclusion, NIRS readings of cerebral hemoglobin content and tissue oxygen saturation correlate well to vital parameters during CPB surgery in children. NIRS may therefore become a monitoring device for the neuroprotective optimization of those vital parameters.

Always expect the unexpected: lung abscess due to pseudomonas aeruginosa mimicking pulmonary aspergilloma in acute B-cell leukemia

We report on a case of Pseudomonas aeruginosa sepsis and consecutive lung abscess in a 13-year-old patient with acute B-cell leukemia. At first, radiographic findings strongly suggested presence of pulmonary aspergilloma and only microbiological testing of the surgically enucleated mass revealed the correct underlying pathogen and confirmed final diagnosis.

Tuberculous peritonitis with infracarinal mass and elevated CA-125 in a 13-year-old girl

A 13-year-old girl with weight loss and ascites was admitted with suspicion of a malignant disease. Abdominal magnetic resonance imaging indicated extensive peritonitis and showed no evidence of a solid tumor. As a new imaging observation, thoracic computed tomography showed a lymphoma-like infracarinal mass and further enlarged lymph nodes in the pathway of draining lymph ducts. A tuberculin skin test and an interferon-gamma blood test were positive, and the tumor marker CA-125 was elevated. Histology of a peritoneal biopsy showed infectious granulomas with central necrosis, and Mycobacterium tuberculosis could be cultured, leading to the diagnosis of a tuberculous peritonitis. The girl received multi-drug anti-tuberculous treatment and subsequently recovered. At follow-up the peritonitis and the infracarinal mass had vanished. In conclusion, tuberculous peritonitis is a rare but relevant differential diagnosis in peritonitis of unknown origin. Its diagnosis is facilitated by imaging, by tuberculosis skin and blood tests, and by clinical interpretation.

Diagnosing flow residuals in coiled cerebral aneurysms by MR angiography: meta-analysis

This meta-analysis summarizes the accuracy of magnetic resonance angiography (MRA) for diagnosing residuals in coiled cerebral aneurysms by using the threefold Roy classification (residuals: none, neck, or sac). Four databases were searched from 2000 to June 2013 for eligible studies that compared MRA to digital subtraction angiography (DSA) and reported 3 × 3 count data of threefold Roy classification, or a reduced scheme of 2 × 2 count data. Bivariate and trivariate Bayesian random-effects models were used for meta-analysis. Among 27 included studies (2,119 coiled aneurysms in 1,809 patients) the average prevalence of DSA-confirmed sac residuals was 18.2 % (range 0-43 %). The pooled sensitivity was 88.0 % (95 % CI 81.4-94.0) and specificity was 97.2 % (94.6-99.0 %) for assessing sac residuals by MRA. In the trivariate meta-analysis, a "sac residual" finding at MRA had a high positive likelihood ratio of 28.2 (14.0-79.0). A "neck residual" finding had a moderate negative likelihood ratio of 0.246 (0.111-0.426), and the MRA finding of "no residual" had a good negative likelihood ratio of 0.044 (0.013-0.096). Subgroup analyses identified no significant influence of covariates on diagnostic accuracy (P > 0.05). In conclusion, in coiled cerebral aneurysms MRA with application of the threefold Roy classification is well suited for detecting or excluding sac residuals that might require retreatment.

Prevalence and clinical relevance of extracardiac findings at cardiac MRI

PURPOSE

To assess the incidence of extracardiac findings in patients undergoing clinical cardiac magnetic resonance imaging (CMRI) of the heart, and to determine the influence of those findings on patient management.

MATERIALS AND METHODS

During 40 months, 854 CMRI were performed at 1.5 T. Extracardiac findings were classified as significant (group A), if recommended for additional diagnostics or therapeutic interventions, and as nonsignificant (group B).

RESULTS

The most frequent indication for CMRI was evaluation of cardiac stress ischemia. In all, 631 CMRI (74% of 854) showed no extracardiac pathologies. In the remaining 223 CMRI (26% of 854), a total of 286 extracardiac findings were detected. Among these findings, 49 were considered significant (group A) and 237 nonsignificant (group B). In group A, the most common findings were suspicious pulmonary nodules or masses. In group B, the most frequent findings were hepatic cysts or hemangiomas. Eight malignancies were observed with certainty at CMRI. Seven of them had been incidentally diagnosed on CMRI for the first time, and subsequently changed the patients' management.

CONCLUSION

Extracardiac findings in clinically indicated CMRI are common (about 26%). Radiologists and cardiologists should be aware of relevant extracardiac findings that might require additional diagnostics or treatment.

Bivariate random-effects meta-analysis of sensitivity and specificity with the Bayesian SAS PROC MCMC: methodology and empirical evaluation in 50 meta-analyses

BACKGROUND AND OBJECTIVE

Meta-analysis allows for summarizing the sensitivities and specificities from several primary diagnostic test accuracy studies quantitatively. This article presents and evaluates a full Bayesian method for bivariate random-effects meta-analysis of sensitivity and specificity with SAS PROC MCMC.

METHODS

First, the formula of the bivariate random-effects model is presented. Then its implementation with the Bayesian SAS PROC MCMC is empirically evaluated, using the published 2 × 2 count data of 50 meta-analyses. The convergence of the Markov chains is analyzed visually and qualitatively. The results are compared with a Bayesian WinBUGS approach, using the Bland-Altman analysis for assessing agreement between 2 methods.

RESULTS

The 50 meta-analyses covered broad ranges of pooled sensitivity (17.4% to 98.8%) and specificity (60.0% to 99.7%), and the between-study heterogeneity varied as well. In all meta-analyses, the Markov chains converged well. The meta-analytic results from the SAS PROC MCMC and the WinBUGS random-effects approaches were nearly similar, showing close 95% limits of agreement for the pooled sensitivity (-0.06% to 0.05%) and specificity (-0.05% to 0.05%) without significant differences (P > 0.05). This indicates that the bivariate model is well implemented with both different statistical programs, without systematic differences arising from program attributes.

CONCLUSIONS

As alternative to a WinBUGS approach, the Bayesian SAS PROC MCMC is well suited for bivariate random-effects meta-analysis of sensitivity and specificity.

Head-to-head comparison of prospectively triggered vs retrospectively gated coronary computed tomography angiography: Meta-analysis of diagnostic accuracy, image quality, and radiation dose

BACKGROUND

In coronary computed tomography (CT) angiography (CTA) prospective electrocardiography triggering requires less radiation dose than retrospective electrocardiography gating but provides less cardiac phases for interpretation. This meta-analysis presents a concise and comprehensive head-to-head comparison of image quality, diagnostic accuracy, and radiation dose of prospectively triggered coronary CTA vs retrospectively gated CTA in patients with suspected or known coronary artery disease (CAD).

METHODS

In patients with CAD and without tachyarrhythmia, eligible studies (selected from 4 databases) compared prospectively triggered vs retrospectively gated CTA (performed with ≥64-slice CT or dual-source CT) in 2 groups having approximately similar patient characteristics, scored CTA image quality, and/or assessed how accurately CTA diagnoses ≥50% coronary stenoses compared with catheter angiography and reported the radiation dose. The data were meta-analyzed by random-effects models, with CIs provided in the text.

RESULTS

Among 3,330 patients from 20 included studies, 91.3% of CTAs (segments: 97.8%) had diagnostic quality with prospective triggering and 93.3% of CTAs (segments: 98.4%) with retrospective gating (P > .05). Among 664 patients from 5 studies, the pooled sensitivity/specificity of diagnostic CTAs was 98.7%/91.3% (segment level: 91.3%/97.7%) with prospective triggering and 96.9%/95.8% (segment level: 93.1%/97.6%) with retrospective gating (P > .05). The pooled effective dose was 3.5 mSv with prospective triggering and thus, by a factor of 3.5, lower than the pooled effective dose of retrospective gating, which was 12.3 mSv (P < .01).

CONCLUSIONS

In patients with CAD and without tachyarrhythmia, prospectively triggered coronary CTA provides image quality and diagnostic accuracy comparable with retrospectively gated CTA, but at a much lower radiation dose.

Glioma infiltration of the corpus callosum: early signs detected by DTI

The most frequent primary brain tumors, anaplastic astrocytomas (AA) and glioblastomas (GBM): tend to invasion of the surrounding brain. Histopathological studies found malignant cells in macroscopically unsuspicious brain parenchyma remote from the primary tumor, even affecting the contralateral hemisphere. In early stages, diffuse interneural infiltration with changes of the apparent diffusion coefficient (ADC) and fractional anisotropy (FA) is suspected. The purpose of this study was to investigate the value of DTI as a possible instrument of depicting evidence of tumor invasion into the corpus callosum (CC). Preoperatively, 31 patients with high-grade brain tumors (8 AA and 23 GBM) were examined by MRI at 3 T, applying a high-resolution diffusion tensor imaging (DTI) sequence. ADC- and FA-values were analyzed in the tumor-associated area of the CC as identified by fiber tracking, and were compared to matched healthy controls. In (MR-)morphologically normal appearing CC the ADC values were elevated in the tumor patients (n = 22; 0.978 × 10⁻³ mm²/s) compared to matched controls (0.917 × 10⁻³ mm²/s, p < 0.05), and the corresponding relative FA was reduced (rFA: 88 %, p < 0.01). The effect was pronounced in case of affection of the CC visible on MRI (n = 9; 0.978 × 10⁻³ mm²/s, p < 0.05; rFA: 72 %, p < 0.01). Changes in diffusivity and anisotropy in the CC can be interpreted as an indicator of tumor spread into the contralateral hemisphere not visible on conventional MRI.

Peripherally circulating CD4⁺ FOXP3⁺ CXCR3⁺ T regulatory cells correlate with renal allograft function

Peripheral immunoregulation depends on T regulatory cell trafficking into the allograft to modulate the local alloresponse. Little is known about the relevance of trafficking receptors for Tregs after solid organ transplantation in humans. In this study, expression of the peripheral chemokine receptors CXCR3 and CCR5 on CD4⁺ FOXP3⁺ Treg cells was analysed and correlated with allograft function in renal transplant recipients. Flow cytometry analysis of peripheral blood mononuclear cells of 54 renal transplant recipients receiving a calcineurin inhibitor-based immunosuppression was performed for CD4, CD25, FOXP3, CXCR3 and CCR5 within the first 18 months post-transplantation. Correlation analysis of chemokine receptor expression and glomerular filtration rate as calculated by MDRD (eGFR) was performed. Expression of the peripheral homing receptors CXCR3 (r = 0.44, P < 0.05) and CCR5 (r = 0.45, P < 0.05) on FOXP3⁺ Tregs correlated with renal allograft function (eGFR) in patients receiving tacrolimus (n = 28), but not cyclosporine A (CsA) (n = 26). CsA but not tacrolimus reduced surface expression of CXCR3 on FOXP3⁺ Tregs in renal transplant recipients as correlated to trough levels (r = -0.42, P < 0.05). In contrast to CD4⁺ CXCR3⁺ CD25(lo) T cells, flow-sorted CD4⁺ CXCR3⁺ CD25(hi) Tregs isolated from healthy individuals did not produce IFNγ or IL-17 ex vivo and expressed high levels of GARP mRNA both at baseline as well as after TCR activation indicating functional regulatory activity. Expression of the peripheral trafficking receptors CXCR3 and CCR5 on FOXP3⁺ Tregs is associated with renal allograft function. These results suggest that Treg trafficking may also depend on the interaction of CXCR3 or CCR5 and their respective ligands.

Blastomatoid pulmonary carcinosarcoma: report of a case with a review of the literature

BACKGROUND

Pulmonary carcinosarcoma is a biphasic tumour with an unfavourable prognosis. The differential diagnosis includes pulmonary blastoma and is often challenging.

CASE PRESENTATION

We here describe a case of blastomatoid pulmonary carcinosarcoma in a 58-year-old patient, who underwent surgical resection. Histopathological examination revealed immature glandular epithelium resembling high-grade fetal adenocarcinoma expressing epithelial markers and membranous beta-catenin, and blastomatoid spindle cells with partial rhabdomyosarcoma-like differentiation. Both elements expressed p53, MDM2, and cyclin-dependent kinase 4 (CDK4), but not thyroid-transcription factor 1 (TTF-1). Mutation analysis of KRAS, EGFR, and beta-catenin revealed no mutations. Comparative genomic hybridization detected +1q, +6p, +6q24qter, +8q, +11q12q14, +11q23qter, +12q12q21, +12q24qter, +17q, +20q, -5q14q23, -9p13pter, -13q21q21, and amplifications at 12q14q21, 15q24qter, 20q11q12.

CONCLUSION

The observed molecular and cytogenetic findings may provide additional tools for the differential diagnosis of biphasic pulmonary neoplasms. Furthermore, TP53, MDM2, CDK4, and PTPN1 may be involved in tumourigenesis.