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To analyze possible differences in the inter-reader variability between PI-RADS version 2 (v2) and version 2.1 (v2.1) for the classification of prostate lesions using multiparametric MRI (mpMRI) of the prostate.In this retrospective and randomized study, 239 annotated and histopathologically correlated prostate lesions (104 positive and 135 negative for prostate cancer) were rated twice by three experienced uroradiologists using PI-RADS v2 and v2.1 with an interval of at least two months between readings. Results were tabulated across readers and reading timepoints and inter-reader variability was determined using Fleiss' kappa (κ). Thereafter, an additional analysis of the data was performed in which PI-RADS scores 1 and 2 were combined, as they have the same clinical consequences.PI-PI-RADS v2.1 showed better inter-reader agreement in the peripheral zone (PZ), but poorer inter-reader agreement in the transition zone (TZ) (PZ: κ = 0.63 vs. κ = 0.58; TZ: κ = 0.47 vs. κ = 0.57). When PI-RADS scores 1 and 2 were combined, the use of PI-RADS v2.1 resulted in almost perfect inter-reader agreement in the PZ and substantial agreement in the TZ (PZ: κ = 0.81; TZ: κ = 0.80).PI-RADS v2.1 improves inter-reader agreement in the PZ. New differences in inter-reader agreement were mainly the result of the assignment of PI-RADS v2.1 scores 1 and 2 to lesions in the TZ. Combining scores 1 and 2 improved inter-reader agreement both in the TZ and in the PZ, indicating that refined definitions may be warranted for these PI-RADS scores.· PI-RADSv2.1 improves inter-reader agreement in the PZ but not in the TZ.. · New differences derived from PI-RADSv2.1 scores 1 and 2 in the TZ.. · Combined PI-RADSv2.1 scores of 1 and 2 yielded better inter-reader agreement.. · PI-RADSv2.1 appears to provide more precise description of lesions in the PZ.. · Improved inter-reader agreement in the PZ stresses the importance of appropriate lexicon description..· Beetz N, Haas M, Baur A et al. Inter-Reader Variability Using PI-RADS v2 Versus PI-RADS v2.1: Most New Disagreement Stems from Scores 1 and 2. Fortschr Röntgenstr 2022; 194: 852 - 861.ZIEL: Analyse der möglichen Differenzen in der Interrater-Reliabilität zwischen PI-RADS Version 2 (v2) und Version 2.1 (v2.1) für die Klassifizierung von Prostata-Läsionen in der multiparametrischen MRT (mpMRT) der Prostata.In dieser retrospektiven und randomisierten Studie wurden 239 bereits annotierte und histopathologisch korrelierte Läsionen der Prostata (104 positiv und 135 negativ für Prostatakrebs) zweimal von radiologisch-fachärztlichen Experten für uroradiologische Bildgebung bewertet: zuerst nach PI-RADS v2 und nach einem zeitlichen Intervall von mindestens 2 Monaten anhand der aktualisierten Version PI-RADS v2.1. Die Ergebnisse der Bewerter und Bewertungszeitpunkte wurden kreuztabelliert und die Interrater-Reliabilität wurde mittels Fleiss’ kappa (κ) berechnet. In einer weiteren Analyse wurden die beiden Wertungen mit derselben klinischen Konsequenz PI-RADS-Score 1 und 2 kombiniert und deren Interrater-Reliabilität erneut getestet.PI-RADS v2.1 zeigte eine bessere Interrater-Reliabilität in der peripheren Zone (PZ), aber eine schlechtere Interrater-Reliabilität in der Transitionszone (TZ) (PZ: κ = 0,63 vs. κ = 0,58; TZ: κ = 0,47 vs. κ = 0,57). Die Kombination der PI-RADS-Bewertungen 1 und 2 bei PI-RADS v2.1 resultierte in einer nahezu perfekten Interrater-Reliabilität in der PZ und in einer substantiellen Interrater-Reliabilität in der TZ (PZ: κ = 0,81; TZ: κ = 0,80).PI-RADS v2.1 verbessert die Interrater-Reliabilität in der PZ. Neue Differenzen in der Interrater-Reliabilität bei PI-RADS v2.1 entsprangen hauptsächlich den Läsionen in der TZ, die mit einem Score von 1 oder 2 bewertet wurden. Durch die Kombination der klinisch gleichwertigen PI-RADS-Bewertungen 1 und 2 wird die Interrater-Reliabilität sowohl in der TZ als auch PZ verbessert, sodass eine verbesserte Definition für diese Bewertungen angebracht sein könnte.· PI-RADS v2.1 verbessert Interrater-Reliabilität in der PZ, aber nicht in der TZ.. · Neue Unterschiede entspringen den PI-RADS v2.1-Bewertungen 1 und 2 in der TZ.. · Die Kombination der PI-RADS v2.1-Bewertungen 1 und 2 verbessert die Interrater-Reliabilität.. · PI-RADS v2.1 ermöglicht offenbar eine präzisere Deskription von Läsionen in der PZ.. · Verbesserung der Interrater-Reliabilität in der PZ betont die Bedeutung von geeigneten Deskriptoren..

CT-guided periradicular infiltration of the cervical spine is an effective symptomatic treatment in patients with radiculopathy-associated pain syndromes. This study evaluates the robustness and safety of a low-dose protocol on a CT scanner with iterative reconstruction software. A total of 183 patients who underwent periradicular infiltration therapy of the cervical spine were included in this study. 82 interventions were performed on a new CT scanner with a new intervention protocol using an iterative reconstruction algorithm. Spot scanning was implemented for planning and a basic low-dose setup of 80 kVp and 5 mAs was established during intermittent fluoroscopy. The comparison group included 101 prior interventions on a scanner without iterative reconstruction. The dose-length product (DLP), number of acquisitions, pain reduction on a numeric analog scale, and protocol changes to achieve a safe intervention were recorded. The median DLP for the whole intervention was 24.3 mGy*cm in the comparison group and 1.8 mGy*cm in the study group. The median pain reduction was -3 in the study group and -2 in the comparison group. A 5 mAs increase in the tube current-time product was required in 5 patients of the study group. Implementation of a new scanner and intervention protocol resulted in a 92.6 % dose reduction without a compromise in safety and pain relief. The dose needed here is more than 75 % lower than doses used for similar interventions in published studies. An increase of the tube current-time product was needed in only 6 % of interventions. · The presented ultra-low-dose protocol allows for a significant dose reduction without compromising outcome.. · The protocol includes spot scanning for planning purposes and a basic setup of 80 kVp and 5 mAs.. · The iterative reconstruction algorithm is activated during fluoroscopy..· Elsholtz FH, Kamp JE, Vahldiek JL et al. Periradicular Infiltration of the Cervical Spine: How New CT Scanner Techniques and Protocol Modifications Contribute to the Achievement of Low-Dose Interventions. Fortschr Röntgenstr 2019; 191: 54 - 61.ZIEL: Die CT-gestützte periradikuläre Infiltrationstherapie der Halswirbelsäule stellt eine effektive symptomatische Behandlungsmethode bei Patienten mit Radikulopathie-bedingtem Schmerzsyndrom dar. Diese Studie evaluiert die Robustheit und Sicherheit eines low-dose-Protokolls bei einem CT Scanner mit iterativer Rekonstruktionssoftware. 183 Patienten nach periradikulärer Infiltrationstherapie der Halswirbelsäule wurden in diese Studie eingeschlossen. 82 Interventionen wurden auf einem neuem CT Scanner mit neuem Protokoll und Einsatz eines iterativen Rekonstruktionsalgorithmus durchgeführt. Spot Scanning wurde zur Planung eingesetzt und während der Fluoroskopie ein Basis-Setup von 80 kVp und 5 mAs verwendet. Die Vergleichsgruppe umfasste 101 zuvor durchgeführte Interventionen mit einem CT Scanner ohne iterative Rekonstruktionssoftware. Das Dosis-Längen-Produkt, die Anzahl der Akquisitionen, die Schmerzreduktion anhand einer numerischen Analogskala und eventuelle Protokolländerungen zur sicheren Durchführung der Intervention wurden registriert. Das mediane DLP für die gesamte Intervention betrug 24,3 mGy*cm in der Vergleichsgruppe und 1,8 mGy*cm in der Studiengruppe. Die mediane Schmerzreduktion betrug –3 in der Studiengruppe und –2 in der Vergleichsgruppe. Eine Erhöhung des Röhrenstrom-Zeit-Produktes um 5 mAs war bei 5 Patienten der Studiengruppe erforderlich. Die Einführung eines neuen CT Scanners mit einem neuen Interventionsprotokoll führte zur einer Dosisreduktion um 92,6 % ohne Einbußen in Sicherheit und Schmerzreduktion. Die benötigte Dosis liegt mehr als 75 % unter den benötigten Dosen vergleichbarer Interventionen, die in bisherigen Studien veröffentlicht wurden. Eine Erhöhung des Röhrenstrom-Zeit-Produktes war in nur 6 % der Interventionen notwendig. · Das vorgestellte Ultra-low-dose-Protokoll ermöglicht eine signifikante Dosisreduktion ohne Minderung des Therapieerfolges.. · Das Protokoll beinhaltet Spot Scanning zur Interventionsplanung und ein Basis Setup von 80 kVp und 5 mAs.. · Während der Fluoroskopie ist ein iterativer Rekonstruktionsalgorithmus aktiviert..

Purpose This overview sums up the Classification of Diverticular Disease (CDD) with regard to its application in computed tomographic diagnosis and briefly recapitulates its targeted advantages over preliminary systems. Primarily, application of the CDD in computed tomography diagnostics is described. Differences with respect to the categories of the older systems are pointed out on the level of each CDD type using imaging examples. Materials and Methods The presented images are derived from our institute according to the S2k criteria. Literature was researched on PubMed. Results The CDD constitutes an improvement compared to older systems for categorizing the stages of diverticular disease. It provides more discriminatory power on the descriptive-morphological level and defines as well as differentiates more courses of the disease. Furthermore, the categories translate more directly into state-of-the-art decision-making concerning hospitalization and therapy. Conclusion The CDD should be applied routinely in the computed tomographic diagnosis of diverticular disease. Typical imaging patterns are presented. Key points Citation Format

Irreversible electroporation (IRE) is the latest in the series of image-guided locoregional tumor ablation therapies. IRE is performed in a nearly non-thermal fashion that circumvents the „heat sink effect“ and allows for IRE application in proximity to critical structures such as bile ducts or neurovascular bundles, where other techniques are unsuitable. IRE appears generally feasible and initial reported results for tumor ablation in the liver, pancreas and prostate are promising. Additionally, IRE demonstrates a favorable safety profile. However, site-specific complications include bile leaking or vein thrombosis and may be more severe after pancreatic IRE compared to liver or prostate ablation. There is limited clinical evidence in support of the use of IRE in the kidney. In contrast, pulmonary IRE has so far failed to demonstrate efficacy due to practicability limitations. Hence, this review will provide a state-of-the-art update on available clinical evidence of IRE regarding feasibility, safety and oncologic efficacy. The future role of IRE in the minimally invasive treatment of solid tumors will be discussed. Key points: • Preclinical findings of IRE have been successfully translated into clinical settings. • Non-thermal ablation is able to prevent the "heat sink effect" and collateral damage. • IRE should primarily be applied to tumors adjacent to sensitive structures (e. g. bile ducts). IRE efficacy appears promising in the liver, pancreas and prostate with tolerable morbidity. • In contrast, there are no evidential benefits of IRE in the lung parenchyma. Citation Format: • Savic LJ, Chapiro J, Hamm B et al. Irreversible Electroporation in Interventional Oncology: Where We Stand and Where We Go. Fortschr Rontgenstr 2016; 188: 735 – 745

Purpose: Paclitaxel-coated balloons (PCB) inhibit neointimal proliferation in arteries. The purpose of this retrospective analysis was to investigate the effect of PCB in in-stent restenosis after transjugular intrahepatic portosystemic shunt (TIPS) in patients with cirrhotic liver disease. Materials and Methods: Six patients (mean age: 65 ± 10 years) with recurrent in-stent restenoses in TIPS (5 bare stents, 1 covered stent) underwent a single percutaneous transluminal angioplasty (PTA) with PCB (3 µg paclitaxel/mm2). Post-interventional outcome and patency were compared with those of prior plain optimal balloon angioplasty (POBA) in the same patients. During a two-year follow-up period, all patients underwent angiographic examinations at 6-month intervals. In-stent minimal lumen diameter (MLD) and late lumen loss (LLL) were assessed. Paclitaxel residues on balloon and sheath surfaces as well as venous plasma concentrations (0 – 24 hours) were analyzed. Results: PCB decreased the need for clinically driven repeat PTA (POBA: 53 % of angiographic examinations; paclitaxel PTA: 19 %; P = 0.014). LLL/diameter stenosis was higher after POBA (2.4 ± 1.5 mm/28 ± 18 %) than after PCB (0.5 ± 0.8 mm/7 ± 11 %, P = 0.029). Residual paclitaxel on balloons was 28 ± 9 % of dose and 0.2 ± 0.1 % on sheath surfaces. Paclitaxel plasma concentrations were below detectable levels throughout the first 24 hours after the interventions in all patients. The procedure was well tolerated and no clinical side effects attributable to paclitaxel were observed. Conclusion: In patients with recurrent in-stent stenoses, a single PTA with PCB resulted in a prolonged secondary patency due to pseudointimahyperplasia without a systemic effect of paclitaxel. Key points: • Intimahyperplasia is a common reason for long-time TIPS dysfunction • First-in-man local paclitaxel application in TIPS patients with recurrent in-stent stenoses • PTA with PCB resulted in a prolonged secondary patency compared to POBA • No systemic effects of Paclitaxel were detected Citation Format: • Marticorena Garcia SR, Langmann M, Schnorr B et al. Use of Paclitaxel-Coated Balloon Catheter Dilation to Reduce In-Stent Restenosis in Transjugular Intrahepatic Portosystemic Shunt (TIPS). Fortschr Rontgenstr 2016; 188: 374 – 380

New technical and clinical developments of sonography and magnetic resonance imaging include improved detection, localization and staging as well as active surveillance of prostate cancer. Multiparametric MRI can best answer these typical clinical questions. However, ultrasound elastography seems to be suitable for the detection of significant prostate cancer as well. The structured reporting system for multiparametric MRI of the prostate according to PI-RADS Version 1 led to improved and reproducible diagnosis of prostate cancer. The new PI-RADS Version 2 aims to minimize the limitations of Version 1 and make PI‐RADS standardization more globally acceptable. Key Points: • The detection, staging, and active monitoring of prostate cancer are common clinical questions. • The best method for answering these questions is multiparametric MRI. • Ultrasound elastography also seems to be suitable for the detection of significant prostate cancer. • The new PI-RADS Version 2 claims to eliminate the limitations of PI-RADS Version 1 and to allow globally recognized standardized diagnostic reporting. Citation Format: • Franiel T, Asbach P, Teichgraber U et al. Bildgebung der Prostata – Ein Update. Fortschr Rontgenstr 2015; 187: 751 – 759

Purpose To survey integrative teaching in radiology at German universities. Materials and methods A questionnaire about radiological education was sent electronically to all 37 chairpersons of university radiology departments in Germany. The questions included the course type, teaching methods, concept, perception, and advantages and disadvantages of integrative teaching. Statistical analysis was performed with nonparametric statistics and chi-square test. Results The survey was considered representative with a return rate of 68 %. Integrative teaching is established at 4/5 of all departments. Integrative teaching is well accepted with an acceptance rate that is significantly higher in so-called "Modellstudiengangen" [model courses of study] (100 %) compared to conventional courses of study (72 %). The advantages of integrative teaching include linking of content (92 %) and preparation for interdisciplinary work (76 %). The disadvantages include high effort (75 %) and time (67 %) for organization. Furthermore, there is a risk that basic radiological facts and knowledge cannot be conveyed and that the visibility of radiology as an independent discipline is lost. Conventional radiological teaching has a similarly high acceptance (84 %) compared to integrative courses (76 %). Conclusion Integrative teaching has a high acceptance among chairpersons in radiology in Germany despite the greater effort. A good interdisciplinary collaboration is essential for integrative teaching and at the same time this can be conveyed to the students. However, the visibility of radiology as a discipline and the possibility to cover basic radiological content must be ensured. Therefore, both conventional courses and integrative teaching seems reasonable, especially in cross-disciplinary subjects such as radiology. Key points Both integrative teaching and conventional radiological teaching are highly accepted. The advantages include the linking of multidisciplinary content and the preparation for interdisciplinary cooperation. The disadvantages include more time and effort for organization and reduced visibility of cross-disciplinary subjects.

Purpose: To evaluate and compare the costs of MRI-guided and CT-guided cervical nerve root infiltration for the minimally invasive treatment of radicular neck pain. Materials and Methods: Between September 2009 and April 2012, 22 patients (9 men, 13 women; mean age: 48.2 years) underwent MRI-guided (1.0 Tesla, Panorama HFO, Philips) single-site periradicular cervical nerve root infiltration with 40 mg triamcinolone acetonide. A further 64 patients (34 men, 30 women; mean age: 50.3 years) were treated under CT fluoroscopic guidance (Somatom Definition 64, Siemens). The mean overall costs were calculated as the sum of the prorated costs of equipment use (purchase, depreciation, maintenance, and energy costs), personnel costs and expenditure for disposables that were identified for MRI- and CT-guided procedures. Additionally, the cost of ultrasound guidance was calculated. Results: The mean intervention time was 24.9 min. (range: 12 – 36 min.) for MRI-guided infiltration and 19.7 min. (range: 5 – 54 min.) for CT-guided infiltration. The average total costs per patient were EUR 240 for MRI-guided interventions and EUR 124 for CT-guided interventions. These were (MRI/CT guidance) EUR 150/60 for equipment use, EUR 46/40 for personnel, and EUR 44/25 for disposables. The mean overall cost of ultrasound guidance was EUR 76. Conclusion: Cervical nerve root infiltration using MRI guidance is still about twice as expensive as infiltration using CT guidance. However, since it does not involve radiation exposure for patients and personnel, MRI-guided nerve root infiltration may become a promising alternative to the CT-guided procedure, especially since a further price decrease is expected for MRI devices and MR-compatible disposables. In contrast, ultrasound remains the less expensive method for nerve root infiltration guidance. Citation Format: • Maurer MH, Froeling V, Rottgen R et al. MRI-Guided and CT-Guided Cervical Nerve Root Infiltration Therapy: A Cost Comparison. Fortschr Rontgenstr 2014; 186: 559 – 566

Magnetic resonance imaging (MRI) has evolved into an integral component of the pretherapeutic local staging of cervical cancer. Many recent studies have demonstrated the superiority of MRI for this indication. It is the method of choice for therapeutic decision making and planning, monitoring of the response to radiotherapy, excluding of tumor recurrence, and assessing of patients for tumor or therapy-related complications. The superiority of MRI is mainly due to its high soft-tissue contrast that allows depiction of the abdominal and pelvic organs with excellent image quality. This article provides an overview of the diagnostic potential and limitations of MRI in the primary staging of cervical cancer and supplementary imaging modalities - CT, PET, and PET/CT - on the basis of the current scientific literature. Also included is a discussion of state-of-the-art lymph node staging and the limitations of imaging in lymph node assessment.

PURPOSE: Recent magnetic resonance elastography (MRE) studies have reported the potential of this noninvasive method for diagnosing hepatic fibrosis based on the elastic properties of liver tissue. However, in many cases biological tissue responds to mechanical vibrations as a combined solid-liquid body causing MRE-derived elastic parameters to become functions of the applied vibration frequency. Therefore a multi-frequency MRE study of liver was performed and the potential of the method for separating healthy from fibrotic liver was investigated. The aim of this study was the increase of the accuracy of liver elastography by analyzing multi-frequency MRE examinations using the springpot model. MATERIALS AND METHODS: 18 healthy volunteers and 10 patients were examined by multi-frequency MRE of the liver in a frequency range between 25 Hz and 62.5 Hz. The liver was mechanically excited with four harmonic vibrations simultaneously. The measured dispersion of the complex modulus was analyzed using the springpot model which accounts for both elastic and viscous properties of a material with 2 independent parameters. RESULTS: The mechanical stimulation and the motion encoding according to the multi-frequency approach was implemented successfully. Significant differences (p < 0.05) were found in the hepatic viscoelasticities of normal livers. The separation of healthy volunteers and patients was achieved with a sensitivity and specificity of 80 and 100 %, respectively. CONCLUSION: Using the springpot model, multi-frequency MRE is sensitive to interindividual differences in the hepatic viscoelastic properties of healthy volunteers. The obtained accuracy of the technique in separating healthy from fibrotic livers opens the possibility of applying multi-frequency MRE as a noninvasive method for diagnosing liver fibrosis in the future.

The demand for highly resolved small animal MRI for the purpose of biomedical research has increased constantly. Dedicated small animal MRI scanners working at ultra high field strengths from 4.7 to 7.0 T and even above are MRI at its best. However, using high resolution RF coils in clinical scanners up to 3.0 T, small animal MRI can achieve highly resolved images showing excellent tissue contrast. In fact, in abundant experimental studies, clinical MRI is used for small animal imaging. Mostly clinical RF coils in the single-loop design are applied. In addition, custom-built RF coils and even gradient inserts are used in a clinical scanner. For the reduction of moving artifacts, special MRI-compatible animal ECG und respiration devices are available. In conclusion, clinical devices offer broad availability, are less expense in combination with good imaging performance and provide a translational nature of imaging results.

Magnetic resonance (MR) imaging gains a more and more important role in the diagnostic assessment of the female pelvis. The free selection of the imaging plane is of particular importance for the visualization of the uterus, and the high soft-tissue contrast presently offers the best possibilities for assessment of the zonal anatomy of the uterus. Advances in coil technology and the use of time-saving pulse sequences that, in addition, yield high-resolution images (e.g., fast spin-echo sequences) have made MR imaging a reliable diagnostic modality with a high image quality. There is no doubt that ultrasound continues to be the most widely used imaging modality besides the clinical examination. However, ultrasound is not only limited by high interexaminer variation but also by an insufficient tissue characterization and, above all, the lacking possibility of staging malignancies. Computed tomography has turned out to be inefficient in determining the local tumor stage due to its poor soft-tissue contrast and should thus only be used in advanced tumor stages. MR imaging, on the other hand, excellently depicts the morphologic details of the female pelvis and helps in the assessment of both benign and malignant masses of the uterus and has the highest diagnostic value in staging malignancies. Furthermore, recent studies have shown that MR imaging is also cost-effective as a pretherapeutic modality in cervical cancer.

PURPOSE: To evaluate contrast-enhanced 3D magnetic resonance angiography (CE-MRA) and digital subtraction angiography (DSA) in comparison with the intraoperative findings in living kidney donors. MATERIALS AND METHODS: A total of 156 kidneys in 78 potential kidney donors were prospectively examined using CE-MRA (0.2 mmol Gd/kg, voxel size 1.3 × 0.8 × 2.0) and DSA. Two experienced radiologists assessed the images in consensus regarding the renal vascular anatomy and variants. The results for the 67 candidates accepted for donation were compared to the intraoperative findings. In the other kidneys not accepted for donor nephrectomy, MRA and DSA were compared with each other. RESULTS: Nineteen arterial variants were identified intraoperatively, of which 11 (58 %) were also detected by preoperative CE-MRA and 10 (53 %) by preoperative DSA. Of the 10 venous variants found intraoperatively, CE-MRA detected 8 (80 %) and DSA 3 (30 %). The agreement (kappa test) between MRI and DSA for all 156 evaluated kidneys was 0.7 for arterial variants (McNemar p = 0.12) and 0.3 for venous variants (McNemar p = 0.01). The preoperative choice of kidney (right or left) made on the basis of the renal vascular anatomy seen on CE-MRA and DSA differed in 22 % of the 78 potential donors (McNemar p = 0.3). CONCLUSION: Our results in a large group of potential living kidney donors suggest that CE-MRA and DSA are comparable for detecting arterial renal variants while CE-MRA is superior for identifying venous variants. The preoperative choice of transplant kidney was not significantly influenced by the different results of CE-MRA and DSA.