Search

Clinical trials in chronic myeloid leukemia (CML) are usually carried out in specialized centers whereas primary care for patients (pts) with CML is mainly provided by local oncology practices. The aim of this study was to assess treatment practices in pts with CML in the setting of private oncology practices in Germany. We collected data of 819 pts with a confirmed diagnosis (dx) of CML in 2013 or later from 43 practices. At dx, 84.2% (n=690) and 9.4% (n=77) of pts were in chronic or accelerated phase, 0.7% (n=6) had a blast crisis. Molecular monitoring was provided by EUTOS certified laboratories in 87.7% of pts. Typical BCR::ABL1 transcripts were detected in 86.6% (n=709). Molecular response was assessed after 2.8, 6.0, 9.4 and 12.9 m (mean) after start of treatment. Of the pts with available data, 11.1% did not achieve early molecular response and at 18 m, 83.7% had at least a major molecular response. 288 (35.2%) of pts switched to 2 nd line (2L) treatment after a mean of 21.0 months. Reasons for 2L treatment were side effects in 43.4% and suboptimal response or failure in 31.4% of pts. 106 pts went on to third line (3L) treatment. 36.8 % of pts switched to and 92.8 % of pts still on 3L treatment achieved BCR::ABL1 IS ≤1% at 12 m. In conclusion, in Germany pts with CML are routinely monitored by qPCR and good responses are achieved in the majority. Treatment changes are mainly due to adverse events rather than suboptimal responses., (© 2024. The Author(s).)

Ruxolitinib (RUX) is a Janus kinase 1/2 inhibitor (JAKi) approved in the EU for treating disease‑related splenomegaly or symptoms in adults patients with myelofibrosis (MF). This is an interim analysis of JAKoMo, a prospective, non‑interventional, phase IV study in MF. Between 2012-2019 (cutoff March 2021), 928 patients (JAKi-naïve and -pretreated) enrolled from 122 German centers. This analysis focuses on JAKi-naïve patients. RUX was administered according to the Summary of Product Characteristics. Compared to the COMFORT-I, -II, and JUMP trials, patients in JAKoMo were older (median 73 years), had poorer Eastern Cooperative Oncology Group (ECOG) performance statuses (16.5% had ECOG ≥ 2), and were more transfusion dependent (48.5%). JAKoMo represents the more challenging patients with MF encountered outside of interventional studies. However, patients with low-risk International Prognostic Scoring System (IPSS) scores or without palpable splenomegaly were also included. Following RUX treatment, 82.5% of patients experienced rapid (≤ 1 month), significant decreases in palpable spleen size, which remained durable for 24 months (60% patients). Symptom assessment scores improved significantly in Month 1 (median -5.2) up to Month 12 (-6.2). Common adverse events (AEs) were anemia (31.2%) and thrombocytopenia (28.6%). At cutoff, 54.3% of patients had terminated the study due to, death, AEs, or deterioration of health. No new safety signals were observed. Interim analysis of the JAKoMo study confirms RUX safety and efficacy in a representative cohort of real-world, elderly, JAKi-naïve patients with MF. Risk scores were used in less than half of the patients to initiate RUX treatment.Trial registration: NCT05044026; September 14, 2021., (© 2023. The Author(s).)

Background: The fascia thoracolumbalis (FTL) is an important component for stabilization and motion control of the lumbar spine. It coordinates the traction forces of the autochthonous muscles of the back (AM) and connects them to the muscles of the abdominal wall, shoulder, and buttocks., Objectives: The aim of our study was to describe the assessment of the normal FTL and epimysium of the AM in MRI and to identify patterns associated with pathological changes in the lumbar spine., Material and Methods: A total of 33 patients were retrospectively evaluated: 15 patients had no pathology at the lumbar spine; six patients had previous hemilaminectomy, three had spondylodesis, two had ventrolisthesis, and seven had scoliosis. The thickness of the FTL and EM was measured, and the adhesion of both structures was assessed., Results: The fascial thickness at the levels of the lumbar vertebral bodies LVB 3 was 1.8, of LVB 4 it was 2.0, of LVB 5 it was 2.1, and at the sacral vertebra SVB 1 it was 1.8 mm. Fascial adhesions together with thickening of the EM occurred at the level of LVB 4 in 36% of the cases independently of the underlying disorder. Only thickening of the EM was seen in 48% of cases at the level of SVB 1. By contrast, adhesion of the FTL without epimysial changes occurred in 36% of cases at the level of LVB 3., Conclusion: Thickening and adhesions at the EM and FTL occurred both postoperatively and in the case of scoliosis. Furthermore, lipomatous and muscular herniation could be detected in the FTL postoperatively. Epimysial and fascial alterations may be imaging manifestations of chronic myofascial back pain and should be included in radiological assessments., (© 2021. The Author(s).)

More than 100 years ago Max von Laue in Munich discovered that X‑rays can be interpreted not only as X‑ray quanta in a particle picture, but also show a wave character. This property has been used for a long time in basic research (e.g. in crystallography for determining the structure of proteins), but so far has had no application in medical imaging. In the last 10 years, however, very impressive technological progress could be made in preclinical research, which also makes the utilization of the wave character of X‑ray light possible for medical imaging. These novel radiography procedures, so-called phase-contrast and dark-field imaging, have a great potential for a pronounced improvement in X‑ray imaging and therefore, also the diagnosis of important diseases. This article describes the basic principles of these novel procedures, summarizes the preclinical research results already achieved exemplified by various organs and shows the potential for future clinical utilization in radiography and computed tomography.

Task difficulty affects both gaze behavior and hand movements. Therefore, the present study aimed to investigate how task difficulty modulates gaze behaviour with respect to the balance between visually monitoring the ongoing action and prospectively collecting visual information about the future course of the ongoing action. For this, we examined sequences of reach and transport movements of water glasses that differed in task difficulty using glasses filled to different levels. Participants had to grasp water glasses with different filling levels (100, 94, 88, 82, and 76%) and transport them to a target. Subsequently, they had to grasp the next water glass and transport it to a target on the opposite side. Results showed significant differences in both gaze and movement kinematics for higher filling levels. However, there were no relevant differences between the 88, 82, and 76% filling levels. Results revealed a significant influence of task difficulty on the interaction between gaze and kinematics during transport and a strong influence of task difficulty on gaze during the release phase between different grasp-to-place movements. In summary, we found a movement and gaze pattern revealing an influence of task difficulty that was especially evident for the later phases of transport and release.

Clinical/methodical Issue: Focal liver lesions are common incidental findings in abdominal ultrasound diagnostics., Standard Radiological Methods: Characterization of focal liver lesions solely based on b‑mode and color duplex is not feasible in all cases., Methodical Innovations: Using contrast-enhanced ultrasound (CEUS) it is possible to dynamically visualize the vascularization of focal liver lesions, which enables the characterization of benign and malignant liver tumors. The advantages of CEUS are that ultrasound contrast media do not show renal, hepatic or cardiac toxicity and do not influence the thyroid gland. The approach by fusion of CEUS and contrast-enhanced cross-sectional imaging combines the advantages of both imaging modalities., Performance: Using CEUS focal liver lesions can be characterized with a diagnostic accuracy greater than 90%., Achievements: The use of CEUS has become an important imaging modality to evaluate unclear liver lesions., Practical Recommendations: The use of CEUS provides vital information as a supplement to cross-sectional imaging and it has become an important tool in therapy planning, control and monitoring of malignant liver lesions.

Clinical Issue: In the daily clinical routine characterization of focal lesions using native B‑mode classical ultrasound and color Doppler can be difficult or insufficient; therefore, additional diagnostic information must be taken into consideration., Standard Radiological Methods: Standard radiological methods in the daily clinical routine include native B‑mode ultrasound and color Doppler ultrasound., Methodical Innovations: Using sonoelastography it is possible to evaluate and characterize tissue properties and focal lesions regarding their stiffness to acquire additional information on a noninvasive basis., Performance: Sonoelastography enables the differentiation between benign and malignant lesions especially in organs that can be easily evaluated using ultrasound. This particularly includes the liver, the thyroid gland, the breasts and the testicles. Regarding the liver, sonoelastography techniques can also be used for evaluation of the tissue flexibility in the diagnostics of fibrosis and cirrhosis., Achievements: Nowadays, elastography is implemented into every modern ultrasound system and has been established as a supplementary examination technique to the conventional ultrasound techniques., Practical Recommendations: Sonoelastography should be used in cases with unclear findings as an additional noninvasive tool for the differentiation between benign and malignant lesions.

Background: In hospitals, the radiological services provided to non-privately insured in-house patients are mostly distributed to requesting disciplines through internal cost allocation (ICA). In many institutions, computed tomography (CT) is the modality with the largest amount of allocation credits., Objectives: The aim of this work is to compare the ICA to respective DRG (Diagnosis Related Groups) shares for diagnostic CT services in a university hospital setting., Materials and Methods: The data from four CT scanners in a large university hospital were processed for the 2012 fiscal year. For each of the 50 DRG groups with the most case-mix points, all diagnostic CT services were documented including their respective amount of GOÄ allocation credits and invoiced ICA value. As the German Institute for Reimbursement of Hospitals (InEK) database groups the radiation disciplines (radiology, nuclear medicine and radiation therapy) together and also lacks any modality differentiation, the determination of the diagnostic CT component was based on the existing institutional distribution of ICA allocations., Results: Within the included 24,854 cases, 63,062,060 GOÄ-based performance credits were counted. The ICA relieved these diagnostic CT services by € 819,029 (single credit value of 1.30 Eurocent), whereas accounting by using DRG shares would have resulted in € 1,127,591 (single credit value of 1.79 Eurocent). The GOÄ single credit value is 5.62 Eurocent., Conclusions: The diagnostic CT service was basically rendered as relatively inexpensive. In addition to a better financial result, changing the current ICA to DRG shares might also mean a chance for real revenues. However, the attractiveness considerably depends on how the DRG shares are distributed to the different radiation disciplines of one institution.

Background: Despite enormous technical progress the results of endovascular treatment of the femoropopliteal vasculature are unsatisfactory and its role is still controversially discussed. In the past decade numerous new stent designs have come onto the market but it is unclear whether they have benefits with respect to patency rates., Objectives: Comparison of published data on patency rates and target lesion revascularization rates after use of different stent designs in the femoropopliteal vasculature., Material and Methods: Analysis of 25 published studies and registries from 2006 to 2015 for classical open-cell stents, interwoven stents and partially or fully covered stents., Results and Conclusion: The published data are heterogeneous and comparative studies for different stent designs are completely missing. Over the past decade the patency rates after femoropopliteal stenting could be improved. According to available data stenting of short lesions < 5 cm does not show any benefit compared to isolated balloon angioplasty. Primary stenting is now recommended for intermediate and longer lesions > 6.4 cm. Due to the heterogeneity of published data a clear benefit for a specific stent design is not obvious; however, data for interwoven stents are promising and show a tendency towards improved patency, at least for certain lesions. Randomized controlled comparative trials are needed to confirm this result.

Purpose: To evaluate the safety of radioembolization (RE) with (90)Yttrium ((90)Y) resin microspheres depending on coiling or no-coiling of aberrant/high-risk vessels., Materials and Methods: Early and late toxicity after 566 RE procedures were analyzed retrospectively in accordance with the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE v3.0). For optimal safety, aberrant vessels were either coil embolized (n = 240/566, coiling group) or a more peripheral position of the catheter tip was chosen to treat right or left liver lobes (n = 326/566, no-coiling group)., Results: Clinically relevant late toxicities (≥ Grade 3) were observed in 1% of our overall cohort. The no-coiling group had significantly less "any" (P = 0.0001) or "clinically relevant" (P = 0.0003) early toxicity. There was no significant difference (P > 0.05) in delayed toxicity in the coiling versus the no-coiling group. No RE-induced liver disease was noted after all 566 procedures., Conclusion: RE with (90)Y resin microspheres is a safe and effective treatment option. Performing RE without coil embolization of aberrant vessels prior to treatment could be an alternative for experienced centers.

Objectives: This article discusses the morphological criteria for the differentiation between acute osteoporotic and metastatic vertebral body fractures and new imaging methods, such as diffusion-weighted and chemical shift magnetic resonance imaging (MRI) are presented., Background: The differential diagnostics of osteoporotic and metastatic vertebral body fractures can be difficult in some cases. Both entities normally occur without adequate trauma and predominantly in elderly patients., Imaging: Conventional X-ray examination is the initial imaging method of choice but is not able to reliably differentiate between the osteoporotic or metastatic etiology of a fracture. Computed tomography (CT) clearly depicts osseous destruction in metastatic fractures but lacks specificity. Magnetic resonance imaging (MRI) shows a higher sensitivity and specificity in differentiating osteoporotic and metastatic fractures., Differential Diagnostics: The combination CT and MRI allows an accurate diagnosis with respect to an osteoprorotic or metastatic etiology in most of cases but bone marrow edema in acute fractures sometimes leads to ambiguous results and differential diagnostic problems.

Clinical/methodical Issue: Gastroenteropancreatic neuroendocrine tumors (GEP-NET) are a rare, heterogeneous group of neoplasms. Only 2% of gastrointestinal tumors belong to the group of neuroendocrine neoplasms., Standard Radiological Methods: A wide spectrum of diagnostic imaging modalities is available: apart from ultrasound not only computed tomography (CT) but also magnetic resonance imaging (MRI) and positron emission tomography CT (PET-CT) play an important role in detection and staging of GEP-NETs., Methodical Innovations: The PET-CT technique with somatostatin analogues is used for staging as well as for evaluation and monitoring of treatment with peptide radionuclide radiation therapy., Performance: According to the literature NETs of the small bowel with a size over 3 cm can be detected with a sensitivity of 84.7% and a specificity of 96.6% using CT enteroclysis and MR enteroclysis provides the detection of NETs of the small bowel in 93.3% of cases. 'The sensitivity of MRI in detection of pancreatic NETs is between 74% and 100% and is, therefore, higher than CT. Detection of small primary tumors is carried out using PET-CT and seems to be the most sensitive imaging modality to identify the exact location. On the other hand MRI has to be regarded as the best imaging modality for detection of liver metastases compared to CT and PET-CT., Achievements: The role of diagnostic imaging is to identify the exact location of the primary tumor and possible metastases, to define an appropriate therapy and to monitor treatment effects; however, the choice of the most appropriate diagnostic imaging modality varies depending on the location and type of the primary tumor., Practical Recommendations: The GEP-NETs are predominantly well-vascularized; therefore, dual-phase CT/MR imaging with the arterial and venous phases after contrast media injection is mandatory for detection and localization of primary tumors and metastases. For whole body staging CT and PET-CT should be performed.

Clinical/methodical Issue: Diagnostic imaging of complex multiple trauma remains a challenge for any department providing modern emergency radiology (ER) service. An early and comprehensive approach for ER imaging is crucial for a priority-oriented and timely therapy concept with the aim of identifying potentially life-threatening injuries early and initiating appropriate treatment., Standard Radiological Methods: The basic diagnostic approach still consists of focused ultrasound using focused assessment with sonography for trauma (FAST) and conventional radiography (CR), usually limited to a single supine chest x-ray for triaging patients undergoing immediate operations., Methodical Innovations: Multidetector computed tomography (MDCT) has become established as early whole body CT (WBCT) as the undisputable diagnostic method. The detection rate of injuries by WBCT is outstanding and it improves the probability of survival by 20-25% compared with all other previous methods. At the same time, the spatial and temporal resolution of MDCT was improved resulting in considerably shortened examination times but WBCT is still associated with a significant radiation exposure, even in the acute single use setting. Using modern scanner and dose reduction technology, including iterative reconstruction, a dose reduction of up to 40% could be achieved. The substantial number of images in WBCT is another challenge; images must be processed priority-oriented, read and transferred to the picture archiving and communications system (PACS). For rapid diagnosis, volume image reading (VIR) offers additional options to keep the diagnostic process on time., Achievements/practical Recommendations: Modern WBCT after multiple trauma is performed early, comprehensively and personalized so that WBCT improves the probability of survival by 20-25%.

Clinical/methodical Issue: Robust and reliable imaging methods are required to estimate the skeletal tumor load in multiple myeloma, as well as for the diagnosis of extraskeletal manifestations. Imaging also plays an essential role in the assessment of fracture risk and of vertebral fractures., Standard Radiological Methods: The conventional skeletal survey has been the gold standard in the imaging of multiple myeloma for many years., Methodical Innovations: Other modalities which have been investigated and are in use are whole-body computed tomography (WBCT), 18F-fluorodeoxyglucose positron emission tomography computed tomography (FDG PET-CT) and whole-body magnetic resonance imaging (WBMRI). These techniques are able to depict both mineralized bone and the bone marrow with a high sensitivity for myeloma lesions., Performance: Several studies have shown that cross-sectional imaging is superior to the skeletal survey in the detection of myeloma lesions and WBMRI has been shown to be significantly more sensitive than WBCT for the detection of focal myeloma lesions as well as for diffuse infiltration. The FDG PET-CT technique has a sensitivity comparable to WBMRI., Achievements: Due to the higher sensitivity in the detection of myeloma lesions WBCT and WBMRI should replace the skeletal survey., Practical Recommendations: A WBCT should be performed if there is suspicion of multiple myeloma. If no focal lesions are found WBMRI or at least MRI of the spine and pelvis should be additionally performed if available. If WBMRI has been initially performed and focal lesions are present, an additional WBCT may be performed to assess the extent of bone destruction and fracture risk. In cases of monoclonal gammopathy of undetermined significance (MGUS), solitary and smoldering myeloma, a WBMRI, if available, should be performed in addition to WBCT.

Clinical/methodical Issue: Imaging plays an essential role in the therapeutic management of cancer of unknown primary (CUP) patients for localizing the primary tumor, for the identification of tumor entities for which a dedicated therapy regimen is available and for the characterization of clinicopathological subentities that direct the subsequent diagnostic and therapeutic strategy., Standard Radiological Methods: Modalities include conventional x-ray, computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound as well as positron emission tomography (PET)-CT and MRI-PET., Performance: In whole body imaging CT has a high sensitivity for tumor entities which frequently present as a metastasized cancer illness. According to the current literature CT is diagnostic in 86% of patients with pancreatic carcinoma, in 36% of patients with colon carcinoma and in 74% of patients with lung carcinoma. Additionally a meta-analysis showed that for patients with squamous cell carcinoma and cervical lymph node metastases a positive diagnosis was possible in 22% of the cases using CT, in 36% using MRI and in 28-57% using 18F-fluorodeoxyglucose PET-CT ((18)F-FDG PET-CT). In addition, MRI plays an important role in the localization of primary occult tumors (e.g. breast and prostate) because of its high soft tissue contrast and options for functional imaging., Achievements: At the beginning of the diagnostic algorithm stands the search for a possible primary tumor and CT of the neck, thorax and abdomen is most frequently used for whole body staging. Subsequent organ-specific imaging examinations follow, e.g. mammography in women with axillary lymphadenopathy. For histological and immunohistochemical characterization of tumor tissue, imaging is also applied to identify the most accessible and representative tumor manifestation for biopsy. Tumor biopsy may be guided by CT, MRI or ultrasound and MRI also plays a central role in the localization of primary occult tumors because of superior soft tissue contrast and options for functional imaging (perfusion, diffusion), e.g. investigation of breast carcinoma or prostate carcinoma., Practical Recommendations: Whole body staging stands at the beginning of the diagnostic algorithm in CUP syndrome to localize a potential primary tumor. Clinically, contrast-enhanced CT of the neck, thorax and abdomen is frequently applied; however, many studies have demonstrated augmented sensitivity of (18)F-FDG PET-CT for the detection of primary tumors and metastatic tumor manifestations.

Introduction: To evaluate the kinetic amplitude and direction of the long head of the biceps tendon (LHB) within the pulley and the proximal bicipital groove, we performed a 3T-magnetic resonance-throwing motion analysis., Materials and Methods: This prospective study was performed on a 3T-MRI scanner. A T2-weighted-3D sequence in three specific positions of throwing motion of the dominant shoulder was performed under isometric 5 N loading conditions or without loading, respectively. Measurements were performed in high (140°) abduction/external rotation, medium (110°) abduction/external rotation and low (45°) adduction-flexion/internal rotation. Multiplanar rotational reconstructions along the LHB in the bicipital groove allowed for the localization of the LHB including the degree of motion in the three most proximal slices., Results: 12 healthy volunteers (age 22–34 years) were enrolled. Adduction led to an anterior deviation of the LHB within the bicipital groove. Loading conditions in medium (110°) elevation/external rotation furthermore led to a significant anterior deviation of the LHB. Conclusion Our findings support the thesis that pulley lesions result from movements of the LHB especially in extreme positions during throwing/overhead activities. Load application in the medium (110°) elevation/external rotation position might enable a better evaluation of patients with dedicated pulley lesions. These results need further evaluation in larger study cohorts and in patients with dedicated rotator cuff lesions, which will be the focus of ongoing studies.

Although ultrasound and magnetic resonance imaging are competitive imaging modalities for the guidance of needle-based interventions, computed tomography (CT) is the only modality suitable for image-guided interventions in all regions of the body, including the lungs and bone. The ongoing technical development of CT involves accelerated image acquisition, significantly improved spatial resolution, CT scanners with an extended gantry diameter, acceleration of the procedure through joystick control of relevant functions of interventional CT by the interventional radiologist and tube current modulation to protect the hands of the examiner and radiosensitive organs of the patient. CT fluoroscopy can be used as a real-time method (the intervention is monitored under continuous CT fluoroscopy) or as a quick check method (repeated acquisitions of individual CT fluoroscopic images after each change of needle or table position). For the two approaches, multislice CT fluoroscopy (MSCTF) technique with wide detectors is particularly useful because even in the case of needle deviation from the center slice the needle tip is simultaneously visualised in the neighboring slices. With the aid of this technique a precise placement of interventional devices is possible even in angled access routes and in the presence of pronounced respiratory organ movements. As the reduction of CT fluoroscopy time significantly reduces radiation exposure for the patient and staff, the combination of a quick check technique and a low milliampere technique with multislice CT fluoroscopy devices is advantageous.

With respect to monitoring of high intensity focused ultrasound (HIFU), synonym focused ultrasound (FUS) treatment, magnetic resonance imaging (MRI) is characterized by several advantageous properties: the precise definition and morphological characterization of the target area (before and after the intervention), the real-time visualization of the treatment effect by thermal imaging (during the intervention) and in the sense of a stereotactic system, the 3-dimensional localization of the target lesion, planning of the target volume and assessment of the achieved ablation volume (before and during the intervention). Non-enhanced T2-weighted multislice MR images are acquired for planning of the intervention. For temperature monitoring (comprising thermometry and thermodosimetry), the temperature-dependent shift of proton resonance frequency (PRFS) is most frequently employed. This method is independent of the treated tissue type or thermally induced tissue changes and facilitates a relative measurement of the temperature change based on a reference value. Future MRI applications include diffusion-weighted MRI (DWI-MRI; for the intrainterventional estimation of treatment efficacy), dynamic contrast-enhanced MRI (DCE-MRI, for the prediction of the potential and assessment of the treatment effect achieved) and motion-corrected temperature monitoring (referenceless and multibaseline thermometry).

Oncologic imaging and reporting are an important part of clinical trials and have to be performed according to standardized criteria that clearly define how certain changes in the size and number of tumorous lesions have to be rated. Knowledge of these criteria is not only crucial when interpreting cases for a clinical trial but may also be used as guidelines for everyday clinical reporting as they aid decision making and can increase the validity of radiologic reporting.This article summarizes the most important and frequently used criteria: the response evaluation criteria in solid tumors (RECIST) criteria which are only used in solid malignancies, the Choi criteria that have been designed for the assessment of gastrointestinal stroma tumors (GIST), and the Cheson criteria that are applied to malignant lymphomas. The compilation of these criteria is designed to be used as a repetitorium for experts and can also serve as training guidelines for junior radiologists who want to become involved in clinical trial reporting.

Clinical/methodical Issue: Access site complications after endovascular catheterization sometimes require open surgery and negatively impair safety, patient comfort and reimbursement. Increasing numbers of procedures and patients with multiple anticoagulants as well as cost pressure explain the demand for an immediate and stable access site closure., Standard Radiological Methods: Manual compression followed by compression bandage and bed rest for 4-24 h is still the gold standard but is unable to prevent access site complications in all cases., Methodical Innovations: Arterial vascular closure devices allow immediate and stable closure of the puncture channel either by suture or by implantation of occluding foreign bodies or gluing fluids., Performance: The safety has been proven in several clinical trials. The main advantage lies in closing large lumen access sites without surgery and in patients treated with multiple anticoagulants as well as in outpatient procedures., Achievements: They have become a valuable supplement to the interventional arsenal., Practical Recommendations: The physician, however, has to decide between different systems and mechanisms with respect to patient constitution, selected access vessel and level of calcification and diameter. Furthermore, all systems require a defined training prior the first use.

Standard Radiological Methods: High-intensity focused ultrasound (synonyms FUS and HIFU) under magnetic resonance imaging (MRI) guidance (synonyms MRgFUS and MR-HIFU) is a completely non-invasive technology for accurate thermal ablation of a target tissue while neighboring tissues and organs are preserved., Methodical Innovations: The combination of FUS with MRI for planning, (near) real-time monitoring and outcome assessment of treatment markedly enhances the safety of the procedure., Achievements: The MRgFUS procedure is clinically established in particular for the treatment of symptomatic uterine fibroids, followed by palliative ablation of painful bone metastases. Furthermore, promising results have been shown for the treatment of adenomyosis, malignant tumors of the prostate, breast and liver and for various intracranial applications, such as thermal ablation of brain tumors, functional neurosurgery and transient disruption of the blood-brain barrier.

Dilated cardiomyopathy (DCM) is the most common type of cardiomyopathy with a prevalence of 1 out of 2,500 in adults. Due to mild clinical symptoms in the early phase of the disease, the true prevalence is probably even much higher. Patients present with variable clinical symptoms ranging from mild systolic impairment of left ventricular function to congestive heart failure. Even sudden cardiac death may be the first clinical symptom of DCM. The severity of the disease is defined by the degree of impairment of global left ventricular function. Arrhythmias, such as ventricular or supraventricular tachycardia, atrioventricular (AV) block, ventricular extrasystole and atrial fibrillation are common cardiac manifestations of DCM. Magnetic resonance imaging (MRI) plays an important role in the exact quantification of functional impairment of both ventricles and in the evaluation of regional wall motion abnormalities. With its excellent ability for the assessment of myocardial structure, it is becoming increasingly more important for risk stratification and therapy guidance.

Hypertrophic cardiomyopathy (HCM) has a prevalence of approximately 0.2% and is clinically asymptomatic in many patients or presents with unspecific symptoms. This explains the importance of imaging for the diagnosis of HCM as well as for the assessment of the clinical course. The definitive finding in HCM is myocardial hypertrophy with thickening of the ventricular wall ≥ 15 mm. While echocardiography is an excellent screening tool magnetic resonance imaging (MRI) allows a comprehensive analysis of the heart in HCM. This includes a detailed analysis of the distribution and extent of myocardial hypertrophy, a thorough evaluation of systolic and diastolic cardiac function, the assessment of the presence and extent of dynamic outflow tract obstruction as well as the description of the systolic anterior motion (SAM) phenomenon of the mitral valve with secondary mitral insufficiency. When contrast material is administered, additional information about myocardial perfusion as well as the presence and extent of myocardial fibrosis can be obtained. This study compared systolic functional parameters as well as end systolic and end diastolic wall thickness of patients with and without diastolic dysfunction.

1D09C3 is a human monoclonal IgG4-type antibody against human leukocyte antigen-DR (HLA-DR) which has demonstrated pro-apoptotic activity against lymphoid tumors in vitro and in vivo. We report results from a phase I dose-escalation study which aimed to identify tolerated dosing, and the pharmacokinetic and pharmacodynamic profile of 1D09C3. Fourteen patients with relapsed/refractory B cell type leukemia/lymphoma were treated and followed after up to 4 weekly infusions of 1D09C3, administered in 6 dose levels at 0.25-8 mg/kg/day. Treatment was tolerated well with mostly mild side effects. The most common grade III-IV toxicities were hematological events observed in 4 patients. In one patient, treated at 8.0 mg/kg/day, a dose limiting toxicity occurred, identified as an invasive catheter-related infection. Adverse events resolved completely without long-term sequelae. 1D09C3 reduced peripheral blood B cells and monocytes by a median of 73-81 % in all patients, with a nadir reached 30-60 min after infusion and sustained for <96 h. Granulocytes and natural killer cells predominantly increased with variable time courses. Pharmacokinetic assessments showed detectable drug concentrations at doses 4-8 mg/kg/day and a terminal half-life of 0.7-7.9 h. Effective saturation of HLA-DR on peripheral blood B cells/monocytes was achieved, varying consistently with available serum concentrations and the cell-reducing activity of 1D09C3. In summary, 1D09C3 could be administered safely in patients with advanced B cell malignancies. Pharmacodynamic studies demonstrated a strong dose dependent but transient reduction of peripheral blood B cells and monocytes, consistent with a short drug serum availability.

In most patients, mantle cell lymphoma (MCL) shows an aggressive clinical course with a continuous relapse pattern and a median survival of only 3-5 years. In the current study generation of the European MCL Network, the addition of high-dose Ara-C to R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone)-like regimen followed by myeloablative consolidation achieved a significant improvement of progression-free survival in younger patients. In elderly patients, rituximab maintenance led to a marked prolongation of remission duration. Emerging strategies include mammalian target of rapamycin (mTOR) inhibitors, proteasome inhibitors, immune modulatory drugs, Bruton's tyrosine kinase inhibitors and others, all based on the dysregulated control of cell cycle machinery and impairment of several apoptotic pathways. Combination strategies are currently being investigated in numerous trials, but their introduction into clinical practice and current treatment algorithms remains a challenge. In the current survey, the application of the molecular targeted compounds were collected and evaluated by a representative national network of 14 haematological institutions. Optimised strategies are recommended for clinical routine. Future studies will apply individualised approaches according to the molecular risk profile of the patient.

Clinical Issue: Causes and imaging patterns of hydrocephalus differ depending on the age of the patient. Traditionally, hydrocephalus was classified into non-communicating and communicating hydrocephalus but more recent classifications also take the site of occlusion and the etiology into account., Diagnostics: For the diagnostic work-up computed tomography (CT), sonography and magnetic resonance imaging (MRI) are available and MRI is the method of choice for children and adolescents as it allows determination of the cause and location of a possible obstruction. In the first 12-18 months sonography allows evaluation of the lateral ventricles and the third ventricle and CT is usually only chosen in children in emergency situations and/or if no other modality is available., Performance: We retrospectively evaluated a population of 785 children and adolescents (426 males aged 0-17 years) referred for MRI between April 2009 and March 2012 due to headaches, somnolence, concentration difficulties or developmental delay. Among these 80 (49 male) met the MRI criteria for hydrocephalus, 75 (46 male) had non-communicating hydrocephalus and 5 (3 male) communicating hydrocephalus. Of the patients 24 (15 male) had posthemorrhagic aqueductal stenosis, 16 (8 male) intracranial tumors, 9 (6 male) Chiari II malformations, 5 (4 male) other congenital malformations including malformations of the Dandy Walker spectrum, 9 (3 male) idiopathic aqueductal stenosis, 7 (5 male) arachnoidal cysts and 10 (8 male) other disorders, such as post-infections, macrocephaly cutis marmorata telangiectatica congenita (M-CMTC) syndrome, mesencephalic arteriovenous malformation (AVM), Langerhans cell histiocystosis., Practical Recommendations: It is important to take the age of the patient and the imaging pattern into account and to exclude tumors when reporting MR images of children with hydrocephalus.

Clinical Problem: Diffuse liver diseases show an increasing prevalence. The diagnostic gold standard of liver biopsy has several disadvantages. There is a clinical demand for non-invasive imaging-based techniques to qualitatively and quantitatively evaluate the entire liver., Standard Radiological Methods: Ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) are routinely used., Methodical Innovations: Steatosis: chemical shift and frequency selective imaging, MR spectroscopy (MRS). Hemochromatosis: MR-based iron quantification. Fibrosis: MR elastography, diffusion, intravoxel incoherent motion (IVIM) and MR perfusion. PERFORMANCE/ACHIEVEMENTS/PRACTICAL RECOMMENDATIONS: T1-weighted in and opposed phase imaging is the clinically most frequently used MR technique to noninvasively detect and quantify steatosis. New methods for quantification that are not influenced by confounders like iron overload are under investigation. The most sensitive method to measure the fat content of the liver is MRS. As data acquisition and analysis remain complex and there is no whole organ coverage, MRS of the liver is not a routine method. With an optimized protocol incorporating T2* sequences, MRI is the modality of choice to quantify iron overload in hemochromatosis. Standard MR sequences cannot depict early stages of liver fibrosis. Advanced MR techniques (e.g. elastography, diffusion, IVIM and perfusion) for noninvasive assessment of liver fibrosis appear promising but their role has to be further investigated.

The current improvements in modern high resolution ultrasound technology, like Tissue Harmonic Imaging (THI), Speckle Reduction Imaging (SRI), partial color coding of B-mode (Color Coded Imaging), and also the advent of ultrasound based elastography as well as contrast-enhanced ultrasound (CEUS) offer fundamentally new ways to characterize diffuse alterations of the liver parenchyma. Besides metabolic disease, disorders of liver fat distribution, infectious and malignant diseases can cause diffuse alterations of the liver parenchyma. In case of liver fibrosis, only a combination of different ultrasound techniques including CEUS, allows the differentiation between benign dysplastic and malignant lesions. Ultrasound elastography allows assessing the extent of the fibrosis. This article focuses on the different ultrasound based diagnostic possibilities in case of diffuse liver disease.

Clinical/methodical Issue: Hybrid imaging of function and morphology has gained significant importance for lesion detection and treatment monitoring in oncology. In patients with differentiated thyroid carcinoma (DTC) a planar whole body scan is carried out after radioiodine therapy (RIT) for staging. However, due to limited spatial resolution the diagnostic accuracy of this scintigraphy method is impaired. Radioembolization utilizing (90)Yttrium loaded micro-spheres by selective internal radiotherapy (SIRT) allows a minor invasive therapy of primary and secondary liver tumors. In order to avoid side effects of the micro-spheres caused by an outflow into intestines, stomach or lungs, imaging the arteries supplying the liver has to be performed by means of technetium-99m macroaggregated albumin ((99m)Tc-MAA) and scintigraphy. The limited morphological information supplied by scintigraphy is again a challenge in treatment monitoring. STANDARD RADIOLOGICAL/NUCLEAR MEDICAL METHODS: (131)Iodine whole body scanning is used for staging in patients with DTC 3-4 days after ablation. Monitoring of the tumor marker thyroglobulin and selective radioiodine whole body scans are available for patients with a high risk profile in the further follow-up with imaging of the arteries supplying the liver by means of (99m)Tc-MAA scintigraphy in preparation of SIRT., Methodical Innovations: Single photon emission computed tomography/computed tomography (SPECT/CT) of the neck and thorax with a therapeutic activity of radioiodine for staging after ablation. Techniques include imaging of arteries supplying the liver by means of (99m)Tc-MAA SPECT/CT before SIRT and evaluation and quantification of the uptake of liver tumors, especially in comparison to the uptake of liver parenchyma by means of SPECT/CT., Performance: Due to the integration of combined functional and morphological information SPECT/CT can be used to characterize the morphology and iodine uptake of lesions more accurately, resulting in optimized staging in patients with DTC in comparison to whole body iodine scans and SPECT/CT provides more accurate imaging of the arterial supply of the liver and of potential outflows of micro-spheres into other organs. SPECT/CT allows evaluation and quantification of the uptake of liver tumors., Achievements: Improved postablative staging in patients with differentiated thyroid cancer by SPECT/CT in comparison to radioiodine whole body scans can be achieved. Improved planning and monitoring of SIRT therapies utilizing SPECT/CT leads to optimized therapeutic doses within liver lesions., Practical Recommendations: Integration of SPECT/CT into the clinical standard for postablative staging in patients with DTC is recommended as well as utilization of SPECT/CT during the planning process, for dose calculation and treatment monitoring of SIRT therapies.

Background: Cognitive performance depends on intact cortical connectivity. Important for memory processing in the human brain is the connection between posterior cingulate cortex and hippocampus, directly as well as indirectly via the parahippocampal gyrus. These brain areas are involved early in Alzheimer's disease (AD). At the same time, they belong to the default mode network (DMN), a functional network showing high functional connectivity under resting state conditions. In AD, this connectivity in specifically compromised, offering the possibility to investigate the structural basis of functional brain connectivity., Methods: We studied 18 patients with mild to moderate AD, 16 patients with mild cognitive impairment (MCI) and 20 healthy control subjects using diffusion tensor imaging (DTI) and resting state fMRI at 3.0 Tesla. We determined the effect of structural integrity in the posterior cingulate as assessed by DTI on the functional connectivity between posterior cingulate, hippocampus and parahippocampus during resting state in these three groups., Results: Structural integrity was reduced in posterior cingulate fibre tracts in patients with AD in the left hemisphere; however, this effect was partly accounted for by age differences. All three groups showed high functional connectivity between posterior cingulate cortex and hippocampus, via both the direct and the indirect pathways. Determination of effective connectivity yielded a negative fractional anisotropy (FA)-moderated correlation on the direct pathway in AD and MCI for both hemispheres, and in healthy controls for the right hemisphere. The indirect pathway showed a negative FA-moderated correlation in AD for the right hemisphere and in MCI for both hemispheres. Healthy controls showed a positive correlation on the indirect pathway for the left hemisphere., Conclusion: Our data suggest that under healthy conditions, effective connectivity in the DMN between posterior cingulate cortex and hippocampus is mainly maintained by the indirect pathway via the parahippocampal gyrus. Patients with AD and patients with MCI show changes in this connectivity with a partial allocation to the direct pathway, most likely reflecting early parahippocampal lesions. The combination of DTI and fMRI broadens our understanding of human brain connectivity and its pathological changes with AD.

As the incidence of primary and metastatic liver cancer continues to increase, the use of minimally invasive techniques as a treatment option is becoming more common. Radioembolization, a form of intra-arterial brachytherapy, is a technique where particles of glass or resin, impregnated with the isotope 90yttrium (90Y), are infused through a catheter directly into the hepatic arteries. This modality is based on the fact that hepatic malignancies receive their blood supply from the hepatic artery, whereas normal hepatocytes are perfused mostly from the portal circulation, which allows delivery of high doses to the tumor vasculature with relative sparing of normal liver tissue. This has been shown to be effective for both primary and metastatic tumors. A variety of complications may be related to hepatic intra-arterial treatments, especially to the gastroduodenal region. These complications are known to come from inadvertent extrahepatic infusion of 90Y particles, through arteries originating from the hepatic arterial branches such as the falciform artery, cystic artery, arteries from the pancreaticoduodenal arcade, gastroduodenal artery, or right gastric artery. Surgeons and interventional radiologists rely on accurate imaging and assessment of the hepatic arterial supply. It is important to know the common anatomic variations and technical considerations before radioembolization. We recommend an aggressive occlusion of all the above-mentioned arteries; further, clinicians should watch out for any other aberrant branches, and if in doubt, they ought to be coiled.

Clinical/methodical Issue: Fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) has emerged as a very useful imaging modality in the management of colorectal carcinoma. Data from the literature regarding the role of PET/CT in the initial diagnosis, staging, radiotherapy planning, response monitoring and surveillance of colorectal carcinoma is presented. Future directions and economic aspects are discussed., Standard Radiological Methods: Computed tomography (CT), magnetic resonance imaging (MRI) and FDG-PET for colorectal cancer and endorectal ultrasound for rectal cancer., Methodical Innovations: Combined FDG-PET/CT., Performance: While other imaging modalities allow superior visualization of the extent and invasion depth of the primary tumor, PET/CT is most sensitive for the detection of distant metastases of colorectal cancer., Achievements: We recommend a targeted use of PET/CT in cases of unclear M staging, prior to metastasectomy and in suspected cases of residual or recurrent colorectal carcinoma with equivocal conventional imaging. The role of PET/CT in radiotherapy planning and response monitoring needs to be determined. Currently there is no evidence to support the routine use of PET/CT for colorectal screening, staging or surveillance., Practical Recommendations: To optimally exploit the synergy between morphologic and functional information, FDG-PET should generally be performed as an integrated FDG-PET/CT with a contrast-enhanced CT component in colorectal carcinoma.