Search

To identify predictors of biopsy success and complications in CT-guided pancreas transplant (PTX) core biopsy. We retrospectively identified all CT fluoroscopy-guided PTX biopsies performed at our institution (2000-2017) and included 187 biopsies in 99 patients. Potential predictors related to patient characteristics (age, gender, body mass index (BMI), PTX age, PTX volume) and procedure characteristics (biopsy depth, needle size, access path, number of samples, interventionalist's experience) were correlated with biopsy success (sufficient tissue for histologic diagnosis) and the occurrence of complications. Biopsy success (72.2%) was more likely to be obtained in men [+25.3% (10.9, 39.7)] and when the intervention was performed by an experienced interventionalist [+27.2% (8.1, 46.2)]. Complications (5.9%) occurred more frequently in patients with higher PTX age [OR: 1.014 (1.002, 1.026)] and when many (3-4) tissue samples were obtained [+8.7% (-2.3, 19.7)]. Multivariable regression analysis confirmed male gender [OR: 3.741 (1.736, 8.059)] and high experience [OR: 2.923 (1.255, 6.808)] (biopsy success) as well as older PTX age [OR: 1.019 (1.002, 1.035)] and obtaining many samples [OR: 4.880 (1.240, 19.203)] (complications) as independent predictors. Our results suggest that CT-guided PTX biopsy should be performed by an experienced interventionalist to achieve higher success rates, and not more than two tissue samples should be obtained to reduce complications. Caution is in order in patients with older transplants because of higher complication rates., (© 2021 The Authors. Transplant International published by John Wiley & Sons Ltd on behalf of Steunstichting ESOT.)

Purpose: This study was designed to investigate the clinical outcome of patients with irresectable, intrahepatic cholangiocarcinoma (IHC) treated with computed tomography (CT)-guided HDR-brachytherapy (CT-HDRBT) for local tumor ablation., Method: Fifteen consecutive patients with histologically proven cholangiocarcinoma were selected for this retrospective study. Patients were treated by high-dose-rate internal brachytherapy (HDRBT) using an Iridium-192 source in afterloading technique through CT-guided percutaneous placed catheters. A total of 27 brachytherapy treatments were performed in these patients between 2006 and 2009. Median tumor enclosing target dose was 20 Gy, and mean target volume of the radiated tumors was 131 (±90) ml (range, 10-257 ml). Follow-up consisted of clinical visits and magnetic resonance imaging of the liver every third month. Statistical evaluation included survival analysis using the Kaplan-Meier method., Results: After a median follow-up of 18 (range, 1-27) months after local ablation, 6 of the 15 patients are still alive; 4 of them did not get further chemotherapy and are regarded as disease-free. The reached median local tumor control was 10 months; median local tumor control, including repetitive local ablation, was 11 months. Median survival after local ablation was 14 months and after primary diagnosis 21 months., Conclusion: In view of current clinical data on the clinical outcome of cholangiocarcinoma, locally ablative treatment with CT-HDRBT represents a promising and safe technique for patients who are not eligible for tumor resection.

Purpose: To determine the safety and efficacy of computed tomography (CT)-guided brachytherapy in hepatocellular carcinoma (HCC)., Methods and Materials: A total of 83 patients were recruited, presenting with 140 HCC- lesions. Treatment was performed by CT-guided high-dose-rate (HDR) brachytherapy with an iridium-192 source. The primary endpoint was time to progression; secondary endpoints included local tumor control and overall survival (OS). A matched-pair analysis with patients not receiving brachytherapy was performed. Match criteria included the Cancer of the Liver Italian Program (CLIP) score, alpha-fetoprotein, presence, and extent of multifocal disease. For statistical analysis, Kaplan-Meier and Cox regression were performed., Results: Mean and median cumulative TTP for all patients (n = 75) were 17.7 and 10.4 months. Five local recurrences were observed. The OS after inclusion reached median times of 19.4 months (all patients), 46.3 months (CLIP score, 0), 20.6 months (CLIP score, 1) 12.7 months, (CLIP score, 2), and 8.3 months (CLIP score, >or=3). The 1- and 3-year OS were 94% and 65% (CLIP score, 0), 69% and 12% (CLIP score, 1), and 48% and 19% (CLIP score, 2), respectively. Nine complications requiring intervention were encountered in 124 interventions. Matched-pair analysis revealed a significantly longer OS for patients undergoing CT-guided brachytherapy., Conclusion: Based on our results the study treatment could be safely performed. The study treatment had a beneficial effect on OS in patients with advanced HCC, with respect to (and depending on) the CLIP score and compared with OS in a historical control group. A high rate of local control was also observed, regardless of applied dose in a range of 15 to 25 Gy., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

For evaluation of triple-phase multislice computed tomography (CT) for assessment of hepatocellular carcinoma (HCC) before liver transplantation. All HCC patients who underwent liver transplantation at our institution between 2001 and 2006 and had contrast-enhanced abdominal 4-/16-slice CT [unenhanced, arterial (20 s delay), portal venous (40 s), and venous (80 s) scan] within 100 days before transplantation were enrolled retrospectively. CT data were reviewed by two observers. Results were correlated to histopathologic findings by means of a lesion-by-lesion evaluation. Thirty-two patients with 76 HCC-lesions were included. The lesion-based sensitivity of observer 1 and 2 was 78% (59/76) and 83% (63/76) (false positives, n = 6 and n = 10). The sensitivity of observer 1/2 was 89%/95% for lesions >20 mm (n = 37), 94% for lesions 11-20 mm (n = 18), and 43%/53% for lesions <10 mm (n = 21). The mean detection rates of unenhanced, arterial, portal venous, and venous phase scans were 30%, 74%, 59%, and 40%. All detected lesions were visible on arterial and/or portal venous scans (arterial only, 24%; portal venous only, 9%). Arterial and portal venous phase scans are the strongest contributors to the high detection rate of triple-phase multislice-CT in HCC. However, the detection of small HCC measuring <10 mm and false positive findings remains a challenge.

Aims: Liver resection represents a curative treatment approach in patients suffering from liver metastases from gastric cancer. However, its value in the treatment of these patients remains controversial. This study was conducted to evaluate the safety and effectiveness of liver resection in these conditions and to identify criteria for the selection of suitable patients., Methods: From January 1988 to December 2002, 24 patients underwent liver resection for metastatic gastric cancer. The outcome of these 24 patients was retrospectively reviewed using a prospective database. Patient, tumour and operative parameters were analyzed for their influence on long-term survival., Results: One patient died and four patients (17%) developed complications during the postoperative course. The overall one-, three- and five-year survival was 38%, 16% and 10%, respectively. After curative resection (n=17), the one-, three- and five-year survival rate was 53%, 22% and 15%, respectively, and patients with metachronous metastases restricted to the liver (n=5) had a one-, three- and five-year survival of 80%, 40% and 40%, respectively. In the univariate analysis, extrahepatic manifestation showed in tendency (p=0.069) and resection margins statistically significant (p=0.005) influence on survival. The multivariate analysis revealed only resection margins as an independent prognostic factor for survival., Conclusions: Long-term survival can be achieved by liver resection in well selected patients and may be considered in the multidisciplinary treatment approach of metastatic gastric cancer. Patients with metastatic disease restricted to the liver in whom a curative resection can be achieved seem to be most suitable for liver resection.

Background and Purpose: CT-guided interstitial brachytherapy of primary lung malignancies and pulmonary metastases represents a novel interventional technique, combining conventional high-dose-rate (HDR) iridium-192 ((192)Ir) brachytherapy with modern CT guidance for applicator positioning and computer-aided 3-D radiation treatment planning. The purpose of this study was to assess safety and efficacy of this technique., Patients and Methods: 30 patients with 83 primary or secondary lung malignancies were recruited in a prospective nonrandomized trial (Table 1). After catheter positioning under CT fluoroscopy, a spiral CT was acquired for treatment planning (Figure 1). All but two patients received a defined single dose (coverage > 99%) of at least 20 Gy from a (192)Ir source in HDR technique., Results: Adverse effects were nausea (n = 3, 6%), minor (n = 6, 12%) and one major pneumothorax (2%). Post intervention, no changes of vital capacity and forced expiratory volume could be detected. The median follow-up period was 9 months (1-21 months) with a local tumor control of 91% at 12 months (Figure 2)., Conclusion: CT-guided interstitial brachytherapy proved to be safe and effective for the treatment of primary and secondary lung malignancies.

The purpose of the study was to establish a diagnostic approach to the preparation of patients with colorectal liver metastases considered for transarterial radioembolization (RE). Twenty-two patients sequentially underwent computed tomography (CT; thorax/abdomen), magnetic resonance imaging (MRI; liver; hepatocyte-specific contrast), positron emission tomography (PET/PET-CT; F18-fluoro-desoxy-glucose), and angiography with perfusion scintigraphy [planar imaging; tomography with integrated CT (SPECT-CT)]. The algorithm was continued when no contraindication or alternative treatment option was found. The impact of each test on the therapy decision and RE management was recorded. Patient evaluation using CT revealed contraindications for RE in 4/22 patients (18%). Of the remaining 18 patients, 2 were excluded and 3 were assigned to locally ablative treatment based on MRI and PET results (28%). The remaining 13 patients entered the planning algorithm: SPECT-CT revealed gastrointestinal tracer accumulations in 4 (31%) patients [SPECT, 2 (15%)], making a modified application necessary. In five patients (38%), planar scintigraphy revealed relevant hepatopulmonary shunting. Therapy was finally administered to all 13 patients without therapy-related pulmonary or gastrointestinal morbidity. Each part of the diagnostic algorithm showed a relevant impact on patient management. The sequential approach appears to be suitable and keeps the number of unnecessary treatments and therapy risks to a minimum.

Background: The significance of pancreatic resection for pancreatic metastatic lesions has not yet been sufficiently investigated. A retrospective analysis of patients undergoing pancreatic resections for pancreatic metastases was conducted., Material and Methods: Twenty patients were resected due to metastatic lesions to the pancreas. Histopathological findings were: renal cell carcinoma (n=9), colon carcinoma (n=1), malignant schwannoma (n=2), leiomyosarcoma (n=2), teratocarcinoma (n=1), adenocarcinoma of the oesophagus (n=1), gallbladder carcinoma (n=1), malignant melanoma (n=1), gastrointestinal stromal tumor (n=1), and spindle cell tumor (n=1). Operative procedures were standard pancreaticoduodenectomy (n=6), pylorus-preserving pancreaticoduodenectomy (n=6), and distal pancreatectomy (n=8)., Result: The overall 5-year survival rate was 61%, for patients with renal cell carcinoma 100%., Conclusion: Pancreatic metastasectomy is a reasonable therapeutic option in suited patients. Patients with pancreatic metastases of renal cell carcinoma achieved excellent prognoses after radical resection.

In the therapy of hilar cholangiocarcinoma, the most favorable survival rates over the long-term are achieved by a surgical concept involving a no-touch-technique, en-bloc-resection and wide tumor-free margins. Currently, these goals can be best achieved by our strategy to combine extended right hepatic resections and principle portal vein resection. In spite of extending resectability to patients with locally advanced tumors, formally curative resections could be performed in 80% of the patients. The 5-year survival rate in these patients is 61%. Liver transplantation had been abandoned by most centers in the 1980s due to poor overall results. Recently, a neoadjuvant strategy involving radiochemotherapy has been reported to result in excellent survival figures at least in a subset of patients suffering from cholangiocellular carcinoma arising in a primary sclerosing cholangitis (PSC). This protocol has been mainly proposed by the Mayo Clinic group and reached 5-year survival rates of 80% in those patients in whom it had been applicable. A substantial drop out rate from this neoadjuvant regimen due to tumor progression or treatment related complications is still a problem.

Objective: To assess the preoperative disease characteristics as well as the rate of postoperative complications, patient survival, and course of symptoms after liver resection or orthotopic liver transplantation (OLT) for Caroli disease (CD) or syndrome (CS)., Summary Background Data: The clinical course of monolobar or diffuse CD or CS is often characterized by multiple conservative treatment attempts and interventions with recurrent episodes of cholangitis and a serious reduction in quality of life. The role and effectiveness of surgical treatment is still not well defined., Patients and Methods: Between June 1989 and December 2002, we treated 44 consecutive patients with CD or CS who had failure of conservative treatment before and were referred for surgical intervention. Demographic and clinical data, operative procedures and related morbidity, course of symptoms, and long-term follow-up were reviewed. Four patients with palliative resection for cholangiocarcinoma and incidental diagnosis of CD were excluded from the analysis., Results: Twenty-two women and 18 men had a median period of 26.5 months from onset of symptoms to surgical therapy. Their median age at therapy was 49 years and 80% of the patients had monolobar disease with a left-right ratio of 2.6 to 1. Thirty-three (82.5%) patients underwent liver resection, while 4 (10%) patients received OLT for diffuse disease. Biliodigestive anastomosis alone was performed in 3 (7.5%) patients with contraindications to OLT. Patients (37.5%) had minor postoperative complications, which were treated conservatively, while 2 (5%) transplanted patients had a reoperation due to intraperitoneal bleeding. After a median follow-up of 86.5 months, we observed a favorable patient and graft survival. Three deaths during follow-up were not related to treatment or disease complications. Follow-up of disease-related symptoms, biliary complications, and antibiotic treatment revealed a significant improvement., Conclusion: Our data show that liver resection for monolobar CD or CS and OLT for diffuse manifestations can achieve excellent long-term patient survival with marked symptom relief. Because of life-threatening long-term complications such as biliary sepsis and development of cholangiocarcinoma, timely indication for surgical treatment is crucial.

Brachytherapy for the treatment of liver metastases is a novel approach. In this procedure, techniques of locally ablative treatment in interventional radiology and radiation therapy are combined. After computed tomography (CT)-guided percutaneous implantation of catheters into the hepatic tumor, the irradiation is performed in an afterloading technique. This minimally invasive procedure offers circumscriptive high-dose rate irradiation of the lesion to treat in a single session, irrespective of breathing motion or potential cooling effects of neighboring vessels. Good local control rates have been achieved in several tumor entities, including both secondary and primary malignancies of the liver. This article gives an overview of the application technique, possible adverse events, and outcome with special attention to the pancreatic cancer scenario.

Background and Objectives: The value of liver resection for metastases from breast cancer is still controversial. This study was conducted to clarify safety and effectiveness of hepatectomy in this conditions and to identify selection criteria for patients suitable for liver resection., Methods: From January 1988 to December 2006, 39 patients underwent liver resection for metastases from breast cancer. The outcome of these 39 patients was retrospectively reviewed using a prospective database. Prognostic factors for patient survival were determined by univariate and multivariate analysis., Results: None of the patients died perioperatively and the morbidity rate was 13% (n = 5). The overall 1-, 3-, and 5-year survival rates were 77%, 50%, and 42%, respectively. In the univariate analysis, metastatic manifestation prior to hepatectomy, vascular invasion and resection margin revealed statistically significant influence on survival. The multivariate analysis identified only resection margin as an independent prognostic factor for survival., Conclusions: Liver resection should be considered in the multimodal treatment approach of patients with metastatic breast cancer. Hepatic resection can be performed with low risk and offers a chance of long-term survival. Achievement of a curative resection and less important absence of previous metastatic manifestation represent suitable criteria to select patients for liver resection., ((c) 2007 Wiley-Liss, Inc.)

Background and Aims: The surgical strategy for treatment of synchronous liver metastases from colorectal cancer remains controversial. This retrospective analysis was conducted to compare the postoperative outcome and survival of patients receiving simultaneous resection of liver metastases and primary colorectal cancer to those receiving staged resection., Materials and Methods: Between January 1988 and September 2005, 219 patients underwent liver resection for synchronous colorectal liver metastases, of whom, 40 patients received simultaneous resection of liver metastases and primary colorectal cancer, and 179 patients staged resections. Patients were identified from a prospective database, and records were retrospectively reviewed. Patient, tumor, and operative parameters were analyzed for their influence on postoperative morbidity and mortality as well as on long-term survival., Results: Simultaneous liver resections tend to be performed for colon primaries rather than for rectal cancer (p = 0.004) and used less extensive liver resections (p < 0.001). The postoperative morbidity was comparable between both groups, whereas the mortality was significantly higher in patients with simultaneous liver resection (p = 0.012). The mortality after simultaneous liver resection (n = 4) occurred after major hepatectomies, and three of these four patients were 70 years of age or older. There was no significant difference in long-term survival after formally curative simultaneous and staged liver resection., Conclusion: Simultaneous liver and colorectal resection is as efficient as staged resections in the treatment of patients with colorectal cancer and synchronous liver metastases. To perform simultaneous resections safely a careful patient selection is necessary. The most important criteria to select patients for simultaneous liver resection are age of the patient and extent of liver resection.

Since the introduction of diagnosis-related groups (DRGs) many surgical departments report inappropriate reimbursement for complex cases and a shift in costly cases. To evaluate this situation, the German Society for Visceral Surgery inaugurated the present cost calculation project. In three university hospitals for 50 cases each, we depicted possible cost separators and utilized the complete cost calculation data (so-called Paragraph 21 data set) to test these separators. We identified "admission from another hospital", "severe surgically relevant concomitant disease", and "reoperation during the same hospital admission". The last was considered the economically most significant and medically most valid factor and was submitted as a possible modification to the german DRG system. The proposed cost separator "reoperation during the same hospital admission" was introduced into the DRG system after validation and leads to better allocation of reimbursements to complex and costly cases.

This study was an analysis of the correlation between pulmonary embolism (PE) and patient survival. Among 694 consecutive patients referred to our institution with clinical suspicion of acute PE who underwent CT pulmonary angiography, 188 patients comprised the study group: 87 women (46.3%, median age: 60.7; age range: 19-88 years) and 101 men (53.7%, median age: 66.9; age range: 21-97 years). PE was assessed by two radiologist who were blinded to the results from the follow-up. A PE index was derived for each set of images on the basis of the embolus size and location. Results were analyzed using logistic regression, and correlation with risk factors and patient outcome (survival or death) was calculated. We observed no significant correlation between the CTPE index and patient outcome (p = 0.703). The test of logistic regression with the sum of heart and liver disease or presence of cancer was significantly (p< 0.05) correlated with PE and overall patient outcome. Interobserver agreement showed a significant correlation rate for the assessment of the PE index (0.993; p< 0.001). In our study the CT PE index did not translate into patient outcome. Prospective larger scale studies are needed to confirm the predictive value of the index and refine the index criteria.

Purpose: To evaluate the feasibility and safety of minimally invasive, percutaneous techniques in metachronous recurrent renal cell cancers (RCCs) in solitary kidneys., Methods: In 4 patients, recurrent RCC was treated by radiofrequency ablation (RFA) (RITA, StarBurst) alone, and in 2 patients by RFA in combination with superselective transarterial particle-lipiodol embolization using 3 Fr microcatheters. RFA was guided by computed tomography in 5 patients, and by magnetic resonance imaging in 1 patient. Mean tumor diameter was 26.7 mm (range 10-45 mm). All interventions were technically successful; during follow-up 1 patient developed recurrent RCC, which was retreated by RFA after embolization., Results: No major peri- or postprocedural complications occurred. Changes in creatinine (pre- vs. post-intervention, 122 vs. 127 micromol/l) and calculated creatinine clearance (pre- vs. post-intervention, 78 vs. 73 ml/min) after ablation were minimal., Conclusion: In single kidneys, percutaneous, minimally invasive techniques are safe and feasible. In large tumors, or where there are adjacent critical structures, we prefer a combination of embolization and thermal ablation (RFA).

Background: A 12-year-old girl presenting with intermittent epigastric pains and diarrhea was referred to our clinic. Diagnostic workup revealed nonfunctional bilateral adrenal pheochromocytomas as well as a neuroendocrine tumor of the pancreatic head. This is the first report on the combination of a neuroendocrine pancreatic tumor with adrenal pheochromocytoma in a pediatric patient with von Hippel-Lindau (VHL) disease., Methods: von Hippel-Lindau disease was confirmed by molecular genetic analysis of peripheral blood lymphocytes, which revealed the mutation VHL c. 695 G > A. The family history showed also VHL disease in the mother who carried the same mutation., Results and Conclusion: Open laparotomy, organ-sparing enucleation of pheochromocytoma, and pylorus-preserving resection of the pancreatic head tumor were successfully performed. After an uneventful postoperative course, the child fully recovered. She was free of further manifestations of VHL disease 30 months after surgery.

Background: This study was conducted to evaluate the safety and efficacy of liver resection in patients with hepatic metastases from renal cell carcinoma and to identify selection criteria for patients suitable for resection., Methods: Between January 1988 and March 2006, 31 patients underwent liver resection for metastases from renal cell carcinoma. Patients were identified from a prospective database and retrospectively reviewed. Patient, tumor, and operative parameters were analyzed for their influence on long-term survival., Results: The overall 1-, 3- and 5-year survival rates were 82.2%, 54.3%, and 38.9%, respectively. One patient was deceased and 4 developed complications during the postoperative course. In the univariate analysis, site of the primary tumor (P = 0.013), disease-free interval (P = 0.012), and resection margins (P = 0.008) showed significant influence on long-term survival. In the multivariate analysis, only the resection margins were identified as an independent prognostic factor after liver resection., Conclusions: Liver resection is effective and safe in the treatment of patients with hepatic metastases from renal cell carcinoma and offers the chance of long-term survival and cure. Achieving a margin-negative resection is the most important criterion in the selection of suitable patients for liver resection. However, the number of patients in the present study was small, and investigations of larger series may provide further prognostic parameters in these patients.

Aims: Numerous patients suffer from recurrence after resection of liver metastases from colorectal cancer. Recurrence is frequently restricted to the liver and repeat liver resection may offer a curative option in these patients. This study was conducted to clarify safety and effectiveness of this treatment and to identify prognostic factors of a favourable outcome after repeat hepatectomy., Methods: Between January 1988 and March 2006 in our institution 811 patients underwent 841 liver resections for metastases from colorectal cancer. Among these, 94 patients underwent a repeat hepatectomy. Patients were identified from a prospective database and retrospectively reviewed. Results of different time periods were assessed and prognostic factors for a favourable outcome were determined., Results: The perioperative morbidity and mortality was 24% (23 of 94) and 3% (3 of 94), respectively. The one-, three-, five- and ten-year survival for all patients in this series was 89%, 55%, 38% and 23%, respectively. In the univariate analysis, pT-stage of the primary, diameter of the largest metastases, surgical radicality, period of resection and distribution of metastases showed statistically significant influence on survival. The multivariate analysis revealed only pT-stage of the primary tumour, surgical radicality and period of resection as independent prognostic factors., Conclusions: Repeat hepatectomy is a safe and effective treatment for recurrent liver metastases from colorectal cancer. Perioperative risk and long-term survival were similar when compared to the results obtained during the initial resection. Achieving a curative resection is the most relevant prognostic factor for a favourable prognosis after repeat liver resection.

Background: Ultrasound is known to be useful in imaging radiofrequency ablation (RFA) lesions intra- and postoperatively. The presented study intends to prove the value of ultrasound examination as a means of screening RFA-treated patients for local tumor recurrence., Patients and Methods: During a period of 47 months, 91 RFA treatments were performed in 61 patients in a single institution. Indications for RFA were hepatocellular carcinoma (74%), colorectal metastases (18%), recurrent cholangiocellular carcinoma (5%) and one neuroendocrine tumor metastasis as well as one metastasis of pancreatic cancer (1.5% each). RFA was only considered in non-resectable liver cancer. All applications were conducted under sonographic guidance following preoperative evaluation. Postoperative screening included sonographic examinations at intervals of 3, 6 and 12 months postoperatively, and further annual follow-up examinations. Mean follow-up period was 11.8 months., Results: Within the first 12 months after treatment, the lesions become more and more inhomogenous with mixed echogeneity. Occasionally, this evolves as a misleading finding, mimicking early tumor recurrence. To clarify suspicious cases (31%), magnetic resonance imaging (20%) or computed tomography (10%) was engaged. Ultrasound led to the detection of local tumor recurrence in 78% of recurrent HCC (13 patients), but only in 67% of metastatic diseases (3 patients). Overall local recurrence rate was 18%., Conclusion: Ultrasound screening as a follow-up of primary hepatic malignancies is, due to its sensitivity, capable of detecting early local recurrence despite its low specifity. Appropriate application of particular criteria of local recurrence allows B-mode ultrasound to play a major role in screening RFA-treated patients.

The objective was the evaluation of minimum intensity projections (MinIP) of 16-channel multidetector computed tomography (MDCT) data for the visualization of biliary ducts with magnetic resonance cholangiopancreatography (MRCP) as reference method. Twenty-five patients with biliary obstruction who received MDCT of the abdomen and MRCP without subsequent interventions were analysed. Coronal and axial MinIP were reconstructed from the MDCT-data. The evaluation of image quality and the quantitative comparison to MRCP was performed by two observers in consensus. The additional diagnostic value of MinIP compared with conventionally visualised MDCT was assessed by three independent observers. With MRCP as the reference method, MinIP was superior to conventional MDCT concerning the visualization of the extent of bile duct dilatation (r, 1.000 vs 0.699) and the correlation of diameter measurement (r, 0.979 vs 0.942). Subsidiary to conventional MDCT, MinIP revealed an improvement of visualization of the biliary system in 73% of cases. Concerning the additional diagnostic value, MinIP allowed for a better definition of the obstruction site in 13% of patients, and in one patient a change of diagnosis was observed. Thus, MinIP can improve the diagnostic assessment of biliary obstructions in MDCT imaging.

Purpose: To characterize cystic pancreatic lesions and tumors with magnetic resonance imaging (MRI), and to assess the value of morphological criteria in differentiating pseudocysts versus cystic tumors and benign versus malignant cystic tumors., Material and Methods: Twenty-three patients with cystic pancreatic tumors or lesions underwent plain and contrast-material-enhanced MRI, including magnetic resonance cholangiopancreatography (MRCP). The MR findings were characterized and analyzed by two readers, and the role of various imaging criteria and combinations thereof for final lesion assignment were assessed. Final diagnoses were obtained from the results of open surgery (n = 19) and/or biopsy (n = 4)., Results: Final diagnoses included cystic tumors (n = 11) and pseudocysts (n = 12). The lesions were located in the head (56%) and body or tail (44%). Lesion diameters ranged from 7 to 50 mm. Various lesion contrast enhancement patterns were observed for both benign and malignant lesions. Serous cystadenomas were located in the head, they were lobulated, and had wall diameters < or = 2 mm; with the combination of these characteristics all patients with serous cystadenoma could be identified, whereas in no other patient was this constellation observed., Conclusion: MRI facilitated the diagnosis of serous cystadenomas, although no definite morphologic criterion for the differentiation between pseudocysts and mucinous cystadenomas was identified. In consideration of the substantial therapeutic consequences, either diagnostics in unclear cystic pancreatic lesions should comprise cyst fluid analysis if necessary, or eligible patients should be referred for surgical resection.

Background: This study assessed the value of image fusion with (18)F-fluorodeoxyglucose-positron emission tomography (FDG-PET) and magnetic resonance imaging (MRI) in patients suspected of having pancreatic cancer., Methods: 32 patients (12 women, 20 men; age 24-79 years; mean 56.6 years) were included. All patients underwent whole-body FDG-PET examinations and contrast-enhanced MRI. Image fusion used a semiautomatic voxel-based algorithm. Separate reading, side-by-side analysis and evaluation of fused PET/MRI images were performed. Results were correlated to histopathology (n = 30), or clinical follow-up (n = 2)., Results: 15/32 patients had pancreas cancer and 17/32 patients benign disease. The sensitivity and specificity for cancer detection by FDG-PET were 93 and 41% for visual and 86 and 58% for semiquantitative analysis whereas MRI achieved 100 and 76% respectively. Topographical assignment of PET foci by image fusion was superior to side-by-side analysis in 11/39 (28%) foci (in 8/32 patients). However, a true impact on therapeutic strategy was observed only in 1/8 patients as the presence of multiple metastases, irresectable primaries or medical reasons for inoperability prevented a curative setting., Conclusion: Compared to side-by-side analysis, PET/MRI image fusion improves the anatomical assignment and interpretation of FDG foci. The therapeutic benefit for the patient however is limited in patients with multiple lesions or incurable primaries., (Copyright 2006 S. Karger AG, Basel and IAP.)

Background: Malignant epithelioid hemangioendothelioma is a rare vascular tumor described mostly in soft tissue, lungs, or liver. The outcome after a wide variety of therapeutic measures, ranging from extended surgical therapy to no therapy, is reported to be variable. Therefore, we reviewed our experience with resective therapy for this rare liver tumor, including orthotopic liver transplantation., Material and Methods: During a period of 5 years, seven patients with the histological diagnosis of hepatic epithelia hemangioendothelioma were seen. In five of them, the liver pathology was detected at random, and all patients were prospectively followed. The therapeutic measures and course of disease are given as case reports., Results: Three patients received formal liver resection and two received liver grafts, one partial and one whole. One further patient is scheduled for transplantation and one is undergoing alternative therapy, with the tumor remaining stable. All resected patients recovered quickly and are alive and well 2 months to 4 years later without signs of tumor recidivism., Conclusion: Anatomic liver resection, or in the case of diffuse tumor spread, orthotopic liver transplantation, show favorable long-term results for the treatment of hepatic epithelioid hemangioendothelioma. Therefore, surgical therapy is proposed as the treatment of choice for this entity.

Biliary complications such as ischemic (type) biliary lesions frequently develop following liver transplantation, requiring costly medical and endoscopic treatment. If conservative approaches fail, re-transplantation is most often an inevitable sequel. Because of an increasing donor organ shortage and unfavorable outcomes in hepatic re-transplantation, efforts to prolong graft survival become of particular interest. From a series of 1685 liver transplants, we herein report on three patients who underwent partial hepatic graft resection for (ischemic type) biliary lesions. In all cases, left hepatectomy (Couinaud's segments II, III and IV) was performed without Pringle maneuver or mobilization of the right liver. All patients fully recovered postoperatively, but biliary leakage required surgical revision twice in one patient. At last follow-up, two patients presented alive and well. The other patient with persistent hepatic artery thrombosis (HAT), however, demonstrated progression of disease in the right liver remnant and required re-transplantation 13 months after hepatic graft resection. Including our own patients, review of the literature identified 24 adult patients who underwent hepatic graft resection. In conclusion, partial graft hepatectomy can be considered a safe and beneficial procedure in selected liver transplant recipients with anatomical limited biliary injury, thereby, preserving scarce donor organs.

Purpose: To investigate whether a combined examination with MRI enteroclysis and MRI colonography is practicable and would provide additional findings in the regions seen with ileo-colonoscopy in the work-up of patients with Crohn's disease., Material and Methods: Twenty-five consecutive patients with Crohn's disease (CD) (age range 19 to 42 years, mean age 29.2 years, gender ratio male:female 8:17) were retrospectively studied. All patients underwent conventional ileo-colonoscopy as a standard of reference followed by a combined examination of MRI enteroclysis and MRI colonography at 1.5T within 15 days. Two blinded radiologists evaluated the MRI examinations and compared them with the colonoscopic results., Results: The MRI examination detected 31 inflamed bowel segments in 25 patients. In comparison to colonoscopy, 5 additional, endoscopically inaccessible lesions were found by MRI and only 2 lesions were missed by MRI. Compared to colonoscopy, MRI found 7 of 10 fistulas detected by colonoscopy, and 3 otherwise indiscernible abscesses. The detection of inflamed bowel segments by means of MRI (endoscopy) revealed a sensitivity of 88.8 % (100 %), specificity of 80 % (100 %) and an overall accuracy of 96 % (100 %)., Conclusion: This study provides strong evidence that the combination of MRI enteroclysis and MRI colonography is practicable and supplies additional results regarding the regions which are not seen with ileo-colonoscopy in the work-up of patients with Crohn's disease.

Purpose: To prospectively assess a dose-response relationship for small volumes of liver parenchyma after single-fraction irradiation., Methods and Materials: Twenty-five liver metastases were treated by computed tomography (CT)-guided interstitial brachytherapy. Magnetic resonance imaging was performed 1 day before and 3 days and 6, 12, and 24 weeks after therapy. MR sequences included T1-w gradient echo (GRE) enhanced by hepatocyte-targeted gadobenate dimeglumine. All MRI data sets were merged with 3D dosimetry data and evaluated by two radiologists. The reviewers indicated the border of hyperintensity on T2-w images (edema) or hypointensity on T1-w images (loss of hepatocyte function). Based on the total 3D data, a dose-volume histogram was calculated. We estimated the threshold dose for either edema or function loss as the D(90), i.e., the dose achieved in at least 90% of the pseudolesion volume., Results: Between 3 days and 6 weeks, the extension of the edema increased significantly from the 12.9 Gy isosurface to 9.9 Gy (standard deviation [SD], 3.3 and 2.6). No significant change was detected between 6 and 12 weeks. After 24 weeks, the edematous tissue had shrunk significantly to 14.7 Gy (SD, 4.2). Three days postbrachytherapy, the D(90) for hepatocyte function loss reached the 14.9 Gy isosurface (SD, 3.9). At 6 weeks, the respective zone had increased significantly to 9.9 Gy (SD, 2.3). After 12 and 24 weeks, the dysfunction volume had decreased significantly to the 11.9 Gy and 15.2 Gy isosurface, respectively (SD, 3 and 4.1)., Conclusions: The 95% interval from 7.6 to 12.2 Gy found as the minimal hepatocyte tolerance after 6 weeks accounts for the radiobiologic variations found in CT-guided brachytherapy, including heterogeneous dose rates by variable catheter arrays.

Purposes: To assess the safety of CT-guided brachytherapy of lung malignancies and to evaluate the initial therapeutic response., Patients and Methods: Fifteen patients with 30 lung malignancies were included in this prospective phase I trial (metastases, 28; non-small cell lung cancers, 2). Pre-interventionally two patients had a vital capacity of < 80% (39% and 63%). These two patients, and one other, had FEV1 values of < 80% predicted (17%, 48%, and 64%). Tumors with a maximum diameter of 4 cm were treated with a single brachytherapy catheter that was positioned under CT-fluoroscopy. In two tumors with tumor diameters of 5.5 and 6.5 cm, two applicators were used. In one patient with an 11-cm irregularly shaped tumor, nine catheters were inserted. Treatment planning for 192Ir brachytherapy was performed using three-dimensional CT data that were acquired after percutaneous applicator positioning. All procedures were performed under local anesthesia. A follow-up CT was performed 6 weeks later and every 3 months pos-tintervention., Results: The mean diameter of the 30 lung tumors was 2 cm (range, 0.6 to 11 cm; median diameter, 1.5 cm). The minimal dose within the tumor margin was 20 Gy in all 30 tumors treated. Except for nausea in one patient and focal hemorrhage detected on CT in two patients, no acute adverse events were recorded. One patient developed an abscess at the previous tumor location 9 months after treatment, which proved to be a local tumor recurrence. The median follow-up period was 5+ months with a local tumor control of 97%., Conclusion: The novel technique of CT-guided interstitial brachytherapy was safe for the treatment of lung tumors and yielded a very low complication rate. The initial data on therapeutic response are promising.

Objective: To determine the value of fluorine-18-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) for the detection of recurrent pancreatic cancer in comparison to computed tomography (CT) and magnetic resonance imaging (MRI)., Methods: Thirty-one patients with suspected recurrence after surgery were included. Inclusion criteria were sudden weight loss, pain or increased CA 19-9 levels. FDG-PET was performed in all patients. After visual analysis, maximal standardized uptake values (SUVmax) were determined by placing regions of interest on the pancreas bed. Additionally, all patients underwent contrast-enhanced multidetector CT (n = 14) or MR (n = 17) imaging. Positive findings at FDG-PET or CT/MRI were compared to follow-up., Results: All patients relapsed. Of 25 patients with local recurrences upon follow-up, initial imaging suggested relapse in 23 patients. Of these, FDG-PET detected 96% (22/23) and CT/MRI 39% (9/23). Local SUVmax ranged from 2.26 to 16.9 (mean, 6.06). Among 12 liver metastases, FDG-PET detected 42% (5/12). CT/MRI detected 92% (11/12) correctly. Moreover, 7/9 abdominal lesions were malignant upon follow-up of which FDG-PET detected 7/7 and CT/MR detected none. Additionally, FDG-PET detected extra-abdominal metastases in 2 patients., Conclusion: In patients suspected of pancreatic cancer relapse; FDG-PET reliably detected local recurrences, whereas CT/MRI was more sensitive for the detection of hepatic metastases. Furthermore, FDG-PET proved to be advantageous for the detection of nonlocoregional and extra-abdominal recurrences.

Purpose: To evaluate the diagnostic value of radial reformatting of axial multislice CT (MS-CT) data sets in the presumptive diagnosis of pulmonary embolism., Materials and Methods: In 126 cases with the presumptive diagnosis of an acute pulmonary embolism, 4- and 8-slice axial MS-CT data sets were radially reformatted. The pulmonary vessels were evaluated by five experienced radiologists who determined the number of thrombi at the level of the segmental and subsegmental arteries. A pulmonary artery was considered as thrombosed if it showed at least one unambiguous filling defect on two consecutive sections. It was determined whether the artery was uniformly opacified without filling defects, contained thrombotic material or was completely occluded by a blood clot. Pulmonary vessels that could not be evaluated because of moving artifacts or inadequate opacification were classified as negative. Finally, all experts gave a subjective estimate concerning the simplicity of the diagnosis for both reconstructions., Results: The diagnosis of thromboembolism at a subsegmental level was significantly different for axial sections and radial reconstruction: at 4-slice CT, 77 subsegmental thromboembolisms were found in axial sections vs. 98.6 in radial reconstructions; at 8-slice CT, 23.6 in axial sections vs. 31.2 in radial reconstructions; and using the combined evaluation, 103.2 in axial sections vs. 130.6 in radial reconstructions, with a significance of p = 0.043. The five judges did not find any significant differences in the number of the blood clots in each pulmonary segment. Concerning the simplicity of the diagnosis, the subjective judgment classified the radial reconstructions as better in 49.7 % and the axial sections as better in 22 %. The radial reconstructions of the 4-slice CT were classified as better in 45.7 % vs. 25 % and the 8-slice CT as better in 66 % vs. 16 %., Conclusion: Using radial multiplanar reformatting of the MS-CT data sets improves significantly the recognition of subsegmental pulmonary embolism.

Purpose: To assess the outcome of interventional hepatic arterial port placement in a prospective phase II trial., Materials and Methods: One-hundred five consecutive patients were included in this study. Primary endpoint was port patency; secondary endpoints were complications, toxicity, response, and progression free and overall survival. Seventy-eight patients presented with liver metastasis only, 6 patients had additional minor extrahepatic disease, and 21 patients had no evidence of disease after liver resection, laser-induced thermotherapy, or computed tomography (CT)-guided interstitial brachytherapy of liver metastasis. Exclusive access route was the femoral artery. Subgroup analysis compared either 4-F catheters (n = 58) to 2.2-F (n = 33) and 2.7-F (n = 20) microcatheters or different strategies in anatomic variants of the celiac branch: neglect (n = 10) or embolization of minor hepatic feeders (n = 11), splenic arterial port (n = 8), double port (n = 7)., Results: Technical success was 99%. Assisted port patency after 6 months was 93%. Complications demanding port revisions were significantly lower in patients receiving 4-F versus 2.2-F and 2.7-F systems (P <.001), with disconnection as the major problem with use of microcatheters. Hepatic artery thrombosis occurred in 10 patients (9%), with successful lysis in two patients. With use of 4-F and 2.2-F catheters, there was no difference with respect to catheter occlusion or hepatic thrombosis. No differences were noted in complications or outcome applying four different strategies in celiac branch variants. In a subgroup of patients receiving folinic acid/5-fluorouracil (170 mg/600 mg; 10% dose escalation per cycle) for 5 days every 4 weeks only 15% experienced Grade 3 toxicity. Patients with liver metastasis and salvage therapy demonstrated progression-free survival of 63% after 6 months and a median survival of 16 months., Conclusion: Interventional placement of hepatic arterial port systems may overcome frequent hepatic arterial chemotherapy failures as encountered in all published major trials on hepatic arterial infusion.

Aim: Minimally invasive resection of hyperfunctional parathyroid glands is an alternative to open surgery. However, it requires a precise preoperative localization. This study evaluated the diagnostic use of magnetic resonance (MR) imaging, parathyroid scintigraphy, and consecutive image fusion., Patients, Methods: 17 patients (9 women, 8 men; age: 29-72 years; mean: 51.2 years) with primary hyperparathyroidism were included. Examination by MRI used unenhanced T1- and T2-weighted sequences as well as contrast-enhanced T1-weighted sequences. (99m)Tc-MIBI scintigraphy consisted of planar and SPECT (single photon emission tomography) imaging techniques. In order to improve the anatomical localization of a scintigraphic focus, SPECT-data were fused with the corresponding MR-data using a modified version of the Express 5.0 software (Advanced Visual Systems, Waltham, MA). Results of image fusion were then compared to histopathology., Results: In 14/17 patients, a single parathyroid adenoma was found. There were 3 cases with hyperplastic glands. MRI detected 10 (71%), scintigraphy 12 (86%) adenomas. Both modalities detected 1/3 patients with hyperplasia. Image fusion improved the anatomical assignment of the 13 scintigraphic foci in five patients and was helpful in the interpretation of inconclusive MR-findings in two patients., Conclusions: Both MRI and (99m)Tc-MIBI scintigraphy sensitively detect parathyroid adenomas but are less reliable in case of hyperplastic glands. In case of a scintigraphic focus, image fusion considerably improves its topographic assignment. Furthermore, it facilitates the evaluation of inconclusive MRI findings.

Purpose: To assess safety and efficacy of CT-guided brachytherapy of liver malignancies., Patients and Methods: 21 patients with 21 liver malignancies (19 metastases, two primary liver tumors) were treated with interstitial CT-guided brachytherapy applying a (192)Ir source. In all patients, the use of image-guided thermal tumor ablation such as by radiofrequency or laser-induced thermotherapy (LITT) was impeded either by tumor size > or = 5 cm in seven, adjacent portal or hepatic vein in ten, or adjacent bile duct bifurcation in four patients. Dosimetry was performed using three-dimensional CT data sets acquired after CT-guided positioning of the brachytherapy catheters., Results: The mean tumor diameter was 4.6 cm (2.5-11 cm). The mean minimal tumor dose inside the tumor margin amounted to 17 Gy (12-20 Gy). The proportion of the liver parenchyma exposed to > 5 Gy was 18% (5-39%) of total liver parenchyma minus tumor volume. Nausea and vomiting were observed in six patients after brachytherapy (28%). One patient demonstrated obstructive jaundice due to tumor edema after irradiation of a metastasis adjacent to the bile duct bifurcation. We commonly encountered asymptomatic increases of liver enzymes. Local control rates after 6 and 12 months were 87% and 70%, respectively., Conclusion: CT-guided brachytherapy is safe and effective. This technique displays broader indications compared to image-guided thermal ablation by radiofrequency or LITT with respect to tumor size or localization.

This study evaluated the use of image fusion in the preoperative staging of neuroendocrine tumors (NET) of the pancreas and the gastrointestinal tract (GIT). Thirty-eight patients suffering from a metastasized NET with location of the primary in the pancreas ( n=15) or the GIT ( n=23) were examined by somatostatin receptor scintigraphy (SRS) and computed tomography (CT). Consecutive image registration and fusion were performed using custom-built software integrated in AVS/Express (Advanced Visual Systems, Waltham, MA, USA). Registration was performed by a voxel-based algorithm based on normalized mutual information. Image fusion was feasible in 36/38 patients. A total of 87 foci were assigned to anatomical regions (e.g. gut, pancreas, liver, lymph node or others) by two independent observers in both SRS and SRS/CT fusion images. The assignments used a binary ranking system (1="definite", 0="not definite"). These results were then retrospectively compared to the classification of the foci, based on postoperative histology or clinical follow-up. Imaging by SRS allowed a definite anatomical assignment in 57% (50/87) and 61% (53/87) of all lesions in the case of observers A and B, respectively. Image fusion improved the topographic assignment to 91% (79/87) and to 93% (81/87). The number classified as "definite" by both observers increased from 54% (47/87) to 86% (77/87). The increase in definite assignments was highly significant for both observers ( P<0.0001 for each). In the case of foci classified as liver metastases, image fusion allowed improved assignment to the corresponding liver segment from 45% (18/40) to 98% (39/40) and from 58% (23/40) to 100% (40/40) by observers A and B, respectively. Furthermore, the improved assignment of foci classified as lesions by image fusion was relevant for therapy in 7/36 patients (19%). Therefore, the image fusion technique presented herein appears to be a very useful method for clinical routine.

Background: Surgical resection provides the only chance of cure for patients suffering from hilar cholangiocarcinoma. Although appropriate procedures are not agreed upon, an increase in radicality has been observed during the past 20 years., Methods: The literature as well as our own experience after 133 resections of hilar cholangiocarcinomas were reviewed., Results: Tumor-free margins represent the most important prognostic parameter. Hilar resections as least radical resective procedure will generate rates of formally curative resections of less than 50%. Even after these formally curative resections, long-term survival cannot be achieved. Only additional liver resections will increase the number of long-term survivors to significant figures. In our series, the best 5-year survival rate of 72% was achieved after right trisegmentectomy with concomitant resection of the portal vein bifurcation., Conclusion: Right trisegmentectomy and combined portal vein resection represent the best way to comply with basic rules of surgical oncology for hilar cholangiocarcinoma. This procedure will provide the most pronounced benefit among various types of liver resection, whereas local resections of the extrahepatic bile duct must be considered as an oncologically inefficient procedure.

Purpose: To prospectively assess accuracy of magnetic resonance (MR) imaging, MR cholangiopancreatography (MRCP), and MR angiography in patients suspected of having pancreatic tumors., Materials and Methods: Sixty-six patients suspected of having pancreatic tumors underwent MR imaging (unenhanced and contrast material-enhanced MR, MRCP, and contrast-enhanced MR angiography). Two blinded readers prospectively analyzed the images by consensus, and results were correlated with surgery, biopsy, or follow-up findings. Results were tabulated in two-by-two tables., Results: MR assessment of pancreatic lesion status (differentiation of benign vs malignant) resulted in 60 correct diagnoses (accuracy, 91%), and six (10%) false diagnoses. Among histologically proved malignant tumors, MR imaging yielded correct diagnoses in 42 of 44 patients (sensitivity, 95%; 95% CI: 85%, 99%), whereas 18 of 22 patients with benign findings were classified correctly. At MR imaging, findings in four patients with chronic pancreatitis were wrongly categorized as malignant tumors (specificity, 82%; 95% CI: 60%, 95%), and in one patient, a distal common bile duct carcinoma was not detected. In no patient with pancreatic adenocarcinoma was this tumor misdiagnosed as benign. In patients with malignant tumors who underwent resection, local-regional tumor growth and vascular infiltration were accurately classified in 89% and 94%, respectively. MR imaging depicted histologically proved synchronous hepatic metastases in 82%. The positive and negative predictive values for cancer nonresectability were 90% and 83%, respectively, and the accuracy, sensitivity, and specificity were 85%, 69%, and 95%, respectively., Conclusion: Unenhanced and contrast-enhanced MR imaging with MRCP and MR angiography offers potential as a noninvasive tool for assessment of patients suspected of having pancreatic tumors.

The results of end-to-end cavocavostomy during adult liver transplantation were analyzed with special regard to caval complications. In a series of 1000 liver transplants, we observed 17 patients who suffered from postoperative caval obstruction (6 patients) or caval stenosis (11 patients), for an incidence of 1.7%. Surgical therapy was performed in 10 patients (58.8%), and 5 patients required retransplantation (29.4%). Four patients died during the later postoperative course. Two fatalities were related to caval complications, resulting in a mortality rate of 11.8%. Our results indicate that end-to-end cavocavostomy is a safe technique for cavocaval anastomosis. For only a few exceptions, such as pediatric transplantation, reduced size livers, or size mismatch between donor and recipient, should alternative techniques such as end-to-side or side-to-side cavocavostomy be performed.

Purpose: To evaluate the diagnostic accuracy, complications, and therapeutic impact of CT-guided percutaneous core biopsies of pulmonary lesions., Material and Methods: Seventy-nine patients underwent diagnostic CT-guided percutaneous core biopsies of pulmonary lesions between July 1995 and March 1999. Evaluation included corresponding clinical data, pathologic results, and therapeutic consequences., Results: There were 29 benign and 50 malignant lesions. Percutaneous core biopsy had an overall diagnostic accuracy of 95%. For malignant lesions, core biopsy was positive in 48 patients (sensitivity 96%), and for benign lesions, in 27 (sensitivity 93%). There were no false-positive findings. Pneumothoraces were observed in 19 patients (24%) and 4 of them required a chest drain (5%). There were no hematothoraces or major bleeding complications; however, postinterventional local hemorrhages were observed in 23 patients (29%). No hemoptysis was noted., Conclusion: Percutaneous core biopsies of pulmonary lesions offer excellent diagnostic accuracy for both benign and malignant pulmonary lesions at a low complication rate.

Rationale and Objectives: To evaluate the sensitivity of contrast-enhanced MRI in the preoperative detection of abnormal parathyroid glands in patients with clinical evidence of hyperparathyroidism., Methods: Twenty-eight patients with biochemical evidence of hyperparathyroidism underwent contrast-enhanced preoperative MRI of the parathyroid glands. Two blinded readers assessed the MR images by consensus, and MR results were subsequently correlated with those from surgery (location, diameter, weight) and histopathology., Results: MRI depicted 32 of 39 surgically proved abnormal parathyroid glands (sensitivity 82%; 95% confidence interval, 66%-92%), and 1 of 114 (0.9%) was incorrectly considered abnormal. All ectopic glands were correctly identified (2 mediastinal, 1 submandibular). Sensitivity was superior for adenomas but less for hyperplasia (adenomas 87%; 95% confidence interval, 67%-97%; hyperplasia 75%; 95% confidence interval, 47%-92%). Among all lesions, atypical signal characteristics on MRI were observed in 34% of lesions (9% hyperintense signals on T2- and T1-weighted images; 25% isointense signals on T2- and T1-weighted images), with improved lesion detection after contrast administration in 17% of lesions., Conclusions: MRI of the parathyroid glands presented a sensitive imaging modality, thus demonstrating its high potential to preoperatively detect abnormal glands. Moreover, in a minor proportion of patients with atypical parathyroid lesion characteristics, contrast administration may increase lesion detectability.

Rationale and Objectives: The aim of this study was to evaluate different lossy image compression algorithms in direct comparison., Methods: Computed radiographs were reviewed after compression with Wavelet, Fractal, and Joint Photographic Expert Group (JPEG) algorithms. For receiver operating characteristic (ROC) analysis, 54 thoracic computed radiographs (31 showing pulmonary nodules) were compressed with a ratio of 1:60. Five images of a test-phantom were coded at 1:13. All images were reviewed on a PC. Uncompressed images were reviewed at a PC and at a radiologic workstation (with image processing)., Results: For thorax images, decrease of diagnostic accuracy was significant with Wavelets. Fractal performed worse than Wavelets. No ROC curve was observed for JPEG due to poor image quality. No diagnostic loss was noted comparing PC and Workstation review. For low-contrast details of the phantom, results of Wavelet compression were equal to uncompressed images. Fewer true positives and increased true negatives were noted with Wavelets though. Wavelets were superior to JPEG, and JPEG images were superior to Fractal. Workstation review was superior to PC review., Conclusions: Only Wavelets provided accurate review of low-contrast details at a compression of 1:13. Frequency filtering of Wavelets affects contrast even at a low compression ratio. JPEG performed better than Fractal at low and worse at high compression ratio.

Rationale and Objectives: The authors correlate computed tomography (CT) findings in biphasic spiral technique with histopathology in patients with hepatocellular carcinoma (HCC) who had undergone liver resection (LR) or orthotopic liver transplantation (OLT)., Methods: Preoperative biphasic spiral CT findings in 33 consecutive patients (23 men, 10 women, aged 43-74 years; LR group: n = 17; OLT group; n = 16) with liver cirrhosis and HCC were reviewed retrospectively by consensus of two radiologists and correlated with pathology from liver specimens., Results: Of the 16 patients in the OLT group with 1 to 5 confirmed HCC lesions (total lesions: 29; mean lesion diameter: 2 cm; range: 0.6-5.0 cm), CT before OLT depicted 22 lesions in 15 patients (sensitivity for lesions with a diameter of 0.5-1.0 cm, 20%; for lesions 1.1-2.0 cm, 82%; and for lesions 2.1-3.0 cm and > 3.0 cm, 86% and 100%, respectively). Among the 17 patients in the LR group (total lesions: 21; mean lesion diameter: 5.4 cm; range: 1.0-11.0 cm), CT detected 18 lesions. Lesion-by-lesion sensitivity, as correlated with pathology, was calculated at 76% and 86% in the OLT and LR groups, respectively (overall sensitivity, 80%). The diameter of CT detected lesions, compared with liver specimens, corresponded in 90% of lesions (maximum deviation, 15%). Characteristic CT findings of HCC included unenhanced hypoattenuating focal liver lesions (32 lesions), with hyperattenuation (38 lesions) in the arterial phase of contrast material administration., Conclusions: Biphasic spiral CT for preoperative HCC detection correlated with pathology in 80%, thus proving this technique to represent a sensitive imaging modality for pretherapeutic evaluation of HCC.

Purpose: To define the value of teleradiographic studies, a comparison was carried out between digitised copies of CT examinations of the skull with the original images. Differences in image quality obtained from a digital scanner and a camera were quantified., Material and Method: 56 CT examinations of the skull, 28 of which had discrete abnormalities, were chosen for ROC analysis. The original films were digitised with a Vidar VXR-12 scanner and Panasonic WV-160 and WV-BP 500 cameras. The images were evaluated by five radiologists after image transfer with Video Conference software to a personal computer., Results: For the analysis of the films the area under the ROC curve was 0.91 +/- 0.04, for the digital scanner it was 0.85 +/- 0.04, for camera WV-BP 500 0.89 +/- 0.06 and for camera WE-160 0.87 +/- 0.09. Comparison with the film findings showed. a minimal p-value of 0.17 which indicated that there was no significant reduction in diagnostic value following digitization., Conclusion: The probable reason for the slight deterioration using the digital scanner was the reduction to 75 dpi compared with 134 dpi on the CT films. The cameras produce image noise comparable to CT with low window settings and reduced local resolution. We expect similar results for CT with soft tissue windows or for MRT of the skull. Conventional radiographs containing high local resolution, wide grey scale and low image noise would presumably make higher demands on methods of digitization.

Numerous medical on-line services have already been established in the world-wide internet. In connection with the Information service TELESCAN, sponsored by the EU, a pilot project has been initiated which offers a radiological "second opinion" via the transmission of radiological findings and images that have been previously rendered anonymous. In addition to a description of the basic implementation, tests of the diagnostic certainty of the transmitted cranial computed tomographs have been performed. The CT images were digitized with a document camera, transmitted over the Internet, and then evaluated on the receiver's monitor. Both the transfer of originally generated digital image files (in ACR-NEMA or DICOM) as well as graphic files after digitization of X-ray films, for example by a document camera, is possible via electronic post (e-mail). Visualization by the receiver requires the use of current proprietary software for special medical image formats, while standard graphic formats such as GIFF or JPEG can be visualized with the usual Internet software. In an ROC analysis, 56 individual images of cranial computed tomographs, half with pathological findings such as space-occupying lesions, infarcts, or brain edema, were tested with regard to the diagnostic certainty after digitization and transmission. In comparison with the original film findings, there was a slight but statistically not significant reduction in diagnostic certainty of the images evaluated on screen after transfer via the Internet. We believe that this result is due to the low local resolution, low dynamic range, the high image noise and of CT arising from the window technique. The same parameters are probably valid for MRI. The result cannot be applied to conventional radiography including mammography because, in comparison to the mentioned image techniques, their local resolution is high and image noise is considerably lower.

Purpose: In 215 consecutive patients with advanced metastatic renal cell carcinoma seen at a single institution the efficacy and tolerance of different subcutaneous recombinant interleukin-2 based home therapies were assessed., Materials and Methods: Treatment consisted of subcutaneous recombinant interleukin-2 alone and subcutaneous recombinant interleukin-2 in combination with recombinant interferon-alpha 2 with or without intravenous 5-fluorouracil., Results: Overall objective response rate in 215 patients was 33% (95% confidence interval 26 to 39%). Among 16 patients receiving recombinant interleukin-2 alone there was 1 partial remission (overall response 6%). In 79 patients receiving recombinant interleukin-2 and interferon-alpha 2 in combination 6 complete and 16 partial remissions occurred (overall response 28%). Of 120 patients receiving a combination of recombinant interleukin-2, recombinant interferon-alpha 2 and 5-fluorouracil 13 achieved a complete and 34 a partial remission (overall response 39%). Of all patients 5% achieved long-lasting remissions and remain disease-free. Multivariate analyses identified pretreatment erythrocyte sedimentation rate greater than 70 mm. per hour and lactic dehydrogenase greater than 280 units per l. as independent prognostic factors of major significance (p < or = 0.0001) in metastatic renal cell carcinoma. Additionally, neutrophil count greater than 6,000/microliters., hemoglobin less than 100 gm./l., extrapulmonary metastases and bone lesions were identified as minor (p < or = 0.006) prognostic variables. Patients were assigned to 1 of 3 risk categories according to cumulative risk score defined as the function of the sum of all 6 independent variables. In 116 intermediate risk patients 2-year survival was 65% (median survival not reached after 32 months) with recombinant interleukin-2, recombinant interferon-alpha 2 and 5-fluorouracil, as opposed to 27% 2-year survival (median survival 15 months) with recombinant interleukin-2 and interferon-alpha 2 (p < 0.0001), and 0% (median survival 4.8 months) with single agent recombinant interleukin-2. In the majority of patients systemic toxicity of subcutaneous recombinant interleukin-2 based protocols was limited to grade 1 or 2 constitutional symptoms, that is fever, chills, malaise and anorexia, which allowed for outpatient therapy., Conclusions: The present outpatient recombinant interleukin-2 triple drug combination protocol was as effective as the most aggressive intravenous recombinant interleukin-2 regimen available. Combination home therapy eliminated the need for inpatient and/or intensive care as required for intravenous cytokine administration and, thereby, it substantially improved the therapeutic index and cost-effectiveness of recombinant interleukin-2 therapy in metastatic renal cell carcinoma stratified for risk.

Both chemotherapy and interleukin-2 and/or interferon-alpha produce objective responses in a proportion of advanced malignant melanoma patients. While duration of response to chemotherapy is short, i.e. usually below 4 months, immunotherapy has resulted in a small number of long-lasting remissions in patients with metastatic melanoma. In two consecutive phase II trials in a total of 67 patients, we assessed the potential synergism between both modalities, i.e. chemo- and immunotherapy. Treatment consisted of intravenous (i.v.) carboplatin (CBDCA, 400 mg/m2) and dacarbazine (DTIC, 750 mg/m2) given twice (i.v. bolus over 30 min) at 3-week intervals, or 4 cycles of DTIC (220 mg/m2 i.v. 3 days), cisplatin (DDP, 35 mg/m2 i.v. 3 days), carmustine (BCNU, 150 mg/m2 i.v. cycles 1 and 3) and tamoxifen (TAM, 20 mg oral/daily) at 3-week intervals. Chemotherapy was followed by immunotherapy with combined subcutaneous (s.c.) interleukin-2 (rIL-2) and SC interferon-alpha 2 (rIFN-alpha). Among 40 patients who received a full cycle of chemotherapy with CBDCA/DTIC and sequential immunotherapy, there were 3 (7.5%) complete remissions (CRs) with a median duration of 19 months (range 13-26+). Partial remissions (PRs) were noted in 11 (27.5%) patients with a median response duration of 8 (range 5-14) months. Among 27 patients who received DTIC/DDP/BCNU/TAM and rIL-2/rIFN-alpha, there were 3 (11%) complete remissions and 12 (44.5%) partial remissions. Duration of complete and partial remissions ranged from 9+ to 13+ (median, 11+), and 5 to 15+ (median, 7+) months, respectively. Chemotherapy produced mostly moderate toxicity. Thrombocytopenia was common with the nadir after a median time of 18 days following start of CBDCA/DTIC and DTIC/DDP/BCNU, respectively. 10 patients required transfusion of thrombocytes. Nausea and vomiting due to chemotherapy were well tolerated using concomitant ondansetrone (8 mg i.v.). Immunotherapy was self-administered at home with mild to moderate side effects; malaise, fever, chills, nausea/vomiting, diarrhoea, anorexia and arthralgias were most frequent, but were spontaneously reversible after ending rIL-2/IFN-alpha. A mean 87 and 88% of the projected doses of rIL-2 and rIFN-alpha were administered on either protocol. There were no life-threatening complications and no treatment-related deaths. The sequential combination of chemotherapy and rIL-2 plus rIFN-alpha had at least additive therapeutic activity against metastatic malignant melanoma. The schedules produced long-lasting remissions and were tolerated well overall. These trials substantiate a potential role for low to intermediate dose immunotherapy in maintaining and consolidating therapeutic effects of chemotherapy in metastatic melanoma.

Purpose: In a phase II multiinstitutional outpatient trial, patients with progressive metastatic renal cell carcinoma were treated with a combination of subcutaneous (SC) recombinant interleukin-2 (rIL-2) and recombinant interferon alfa-2 (rIFN alpha 2)., Patients and Methods: One hundred fifty-two patients with metastatic renal cell carcinoma were treated. Treatment courses consisted of SC rIL-2 at 20 x 10(6) IU/m2 three times per week in weeks 1 and 4, and at 5 x 10(6) IU/m2 three times per week in weeks 2, 3, 5, and 6. Additionally, patients received SC rIFN alpha 2 6 x 10(6) U/m2 once per week in weeks 1 and 4, and three times per week in weeks 2, 3, 5, and 6., Results: There were nine (6%) complete responses (CRs) and 29 (19%) partial responses (PRs), for an overall response rate of 25% (95% confidence interval, 19% to 32%). The median duration of responses for CRs and PRs was 16+ and 9 months, respectively. Additionally, 55 patients (36%) had stable disease (SD). Fifty-nine patients (39%) had continued disease progression (PD) despite treatment, or went off study after less than 4 weeks of therapy. The majority of patients treated experienced fever, chills, malaise, nausea, vomiting, and anorexia, side effects that were mostly limited to World Health Organization (WHO) grade 1 and 2. However, one patient developed grade 4 CNS toxicity with extended somnolence. On cessation of therapy, the neurologic symptoms in this patient were fully reversible, with no neurologic deficiency., Conclusion: In summary, this multiinstitutional home-therapy setting of SC rIL-2 and SC rIFN alpha 2 in patients with progressive metastatic renal cell carcinoma demonstrated drastically reduced systemic toxicity, while it confirmed the therapeutic efficacy of the low-dose SC immunotherapy combination schedule.

We conducted a phase I/II clinical trial evaluating the sequential outpatient combination of S.C. recombinant human interleukin-2 (rIL-2; given at 10 MIU/m2 b.i.d. on days 3-5 weeks 1 and 4 and at 5 MIU/m2 on days 1, 3, and 5 of weeks 2 and 3), s.c. recombinant human alpha-interferon (rIFN-alpha; given at 6 MIU/m2 on day 1 of weeks 1 and 4 and on days 1, 3, and 5 of weeks 2 and 3 and at 9 MIU/m2 on days 1, 3, and 5 of weeks 5-8), i.v. bolus 5-fluorouracil (5-FU; given at 1,000 mg/m2 once weekly during weeks 5-8), and i.v. bolus vinblastine (given at 6 mg/m2 once weekly during weeks 5 and 8) in conjunction with p.o. 13-cis-retinoic acid (13-C-RA; given at 35 mg/m2 daily during weeks 1-8). Therapy was always given in the outpatient setting. Grade 3 constitutional symptoms (malaise, chills, fevers, anorexia) were observed in 4%-8% of treatment cycles and required a 50% reduction in the doses of rIL-2 and rIFN-alpha. None of the patients experienced major 5-FU-related toxicities such as severe diarrhea and/or stomatitis; up to 20% of patients developed vinblastine-associated peripheral polyneuropathy, which was reversible after the cessation of therapy. 13-cis-Retinoic acid produced no significant side effect; no toxic death occurred. Among 24 patients with progressive metastatic disease, there were 4 complete remissions (lung, lymph nodes) and 6 partial remissions (lung, pleura, liver, lymph nodes, and peritoneal carcinosis), for an overall objective response rate of 42% (95% confidence interval, 22%-63%).(ABSTRACT TRUNCATED AT 250 WORDS)