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Thorsten Lichtenstein,1 Kamal Mammadov,2 Karin Rau,1 Nils Große Hokamp,1 Thuy D Do,3 David Maintz,1 De-Hua Chang1,3 1Department of Radiology, University Hospital of Cologne, Cologne, Germany; 2Department of Radiology, Klinikum Aschaffenburg, Aschaffenburg, Germany; 3Department of Diagnostic and Interventional Radiology, University Medical Center Heidelberg, Heidelberg, GermanyCorrespondence: Thorsten LichtensteinInstitut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Köln (AöR), Kerpener Str. 62, Cologne 50937, GermanyTel +49 221 478-82035Email thorsten.lichtenstein@uk-koeln.dePurpose: This retrospective study examined the incidence, progression, and clinical relevance of catheter-related thrombosis (CRT) and/or fibrin sheaths presenting as incidental findings on routine staging computed tomography (CT) scans performed in cancer patients.Patients and Methods: Patients who underwent central venous port catheter (CVC) placement in a tertiary care hospital between September 2010 and August 2013 were followed up for up to five years. Two radiologists assessed the presence of fibrin sheath and thrombosis in consensus in staging CT scan. Patient demographics, type of cancer, preoperative comorbidities, date of CVC placement and CTs, preexisting anticoagulation, as well as the type and treatment of catheter-related complications were determined from the electronic medical record.Results: A total of 194 patients with 530 CT scans and a mean follow-up time of 394 days were included. Fibrin sheaths and thromboses were seen on 46 scans (8.7%) in 30 patients and 80 scans (15.1%) in 35 patients. The incidence of fibrin sheaths and thromboses was found to be 15.5% and 18%, respectively. The comparison to initial CT reports results indicated that fibrin sheaths or thromboses were missed in 106 examinations (20%). Catheter-associated complications were reported in 14 patients (21.5%) without specific therapy.Conclusion: Fibrin sheaths and CRTs are often overlooked on routine CT scans when patients are asymptomatic. The subsequent high complication rate demonstrates the clinical relevance of the initial incidental finding on CT scan. Further studies should elucidate the effect of thrombolytic agents and interventional radiologic treatment in asymptomatic patients.Keywords: catheter-related complications, central venous catheters, port-a-cath, imaging, staging

Tilman Hickethier,1,* Kamal Mammadov,1,* Bettina Baeßler,1 Thorsten Lichtenstein,1 Jochen Hinkelbein,2 Lucy Smith,3 Patrick Sven Plum,4 Seung-Hun Chon,4 David Maintz,1 De-Hua Chang1 1Department of Radiology, University Hospital of Cologne, Cologne, Germany; 2Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany; 3Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Canada; 4Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Cologne, Germany *These authors contributed equally to this work Background: The study was conducted to compare examination time and artifact vulnerability of whole-body computed tomographies (wbCTs) for trauma patients using conventional or optimized patient positioning. Patients and methods: Examination time was measured in 100 patients scanned with conventional protocol (Group A: arms positioned alongside the body for head and neck imaging and over the head for trunk imaging) and 100 patients scanned with optimized protocol (Group B: arms flexed on a chest pillow without repositioning). Additionally, influence of two different scanning protocols on image quality in the most relevant body regions was assessed by two blinded readers. Results: Total wbCT duration was about 35% or 3:46 min shorter in B than in A. Artifacts in aorta (27 vs 6%), liver (40 vs 8%) and spleen (27 vs 5%) occurred significantly more often in B than in A. No incident of non-diagnostic image quality was reported, and no significant differences for lungs and spine were found. Conclusion: An optimized wbCT positioning protocol for trauma patients allows a significant reduction of examination time while still maintaining diagnostic image quality. Keywords: CT scan, polytrauma, acute care, time requirement, positioning

De-Hua Chang,1,* Sebastian Brinkmann,2,* Lucy Smith,3 Ingrid Becker,4 Wolfgang Schroeder,2 Arnulf H Hoelscher,5 Stefan Haneder,1 David Maintz,1 Judith Eva Spiro6 1Department of Radiology, University Hospital of Cologne, Cologne, Germany; 2Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Cologne, Germany; 3Faculty of Medicine, Memorial University of Newfoundland, St John’s, Canada; 4Institute of Medical Statistics and Computational Biology, University of Cologne, Cologne, Germany; 5Agaplesion Markus Hospital, Frankfurt am Main, Germany; 6Department of Radiology, University Hospital, LMU Munich, Munich, Germany *These authors contributed equally to this work Purpose: Anastomotic leakage is a major surgical complication following esophagectomy and gastric pull-up. Specific risk factors such as celiac trunk (TC) stenosis and high calcification score of the aorta have been identified, but no data are available on their relative prognostic values. This retrospective study aimed to compare and evaluate calcification score versus stenosis quantification with regards to prognostic impact on anastomotic leakage.Patients and methods: Preoperative contrast-enhanced computed tomography scans of 164 consecutive patients with primary esophageal cancer were evaluated by two radiologists to apply a calcification score (0–3 scale) assessing the aorta, the celiac axis and the right and left postceliac arteries. Concurrently, the presence and degree of stenosis of TC and superior mesenteric artery were recorded for stenosis quantification.Results: Anastomotic leakage was noted in 14/164 patients and 12/14 showed stenosis of TC (n=11). The presence of TC stenosis was found to have a significant impact on anastomotic healing (p=0.004). The odds ratio for the prediction of anastomotic leakage by the degree of stenosis was 1.04 (95% CI, 1.02–1.07). Ten of 14 patients had aortic calcification scores of 1 or 2, but calcification scores of the aorta, the celiac axis and the right and left postceliac arteries did not correlate with the corresponding TC stenosis values and showed no influence on patient outcome as defined by the occurrence of anastomotic insufficiency (p=0.565, 0.855, 0.518 and 1.000, respectively). Inter-reader reliability of computed tomography analysis and absolute agreement on calcium scoring was mostly over 90%. No significant differences in preoperative comorbidities and patient characteristics were found between those with and without anastomotic leakage.Conclusion: Measurement of TC stenosis in preoperative contrast-enhanced computed tomography scans proved to be more reliable than calcification scores in predicting anastomotic leakage and should, therefore, be used in the risk assessment of patients undergoing esophagectomy and gastric pull-up. Keywords: TC stenosis, calcification score, anastomotic leakage, stenosis quantification, Ivor Lewis esophagectomy, graft perfusion

De-Hua Chang,1 Kamal Mammadov,1 Tilman Hickethier,1 Jan Borggrefe,1 Martin Hellmich,2 David Maintz,1 Christoph Kabbasch1 1Department of Diagnostic and Interventional Radiology, University Hospital of Cologne, NRW, Germany; 2Institute of Medical Statistics, Informatics and Epidemiology, University Hospital of Cologne, NRW, Germany Purpose: Evaluation of the efficacy of single-shot, low-dose urokinase administration for the treatment of port catheter-associated fibrin sheaths. Methods: Forty-six patients were retrospectively evaluated for 54 episodes of port catheter dysfunction. The presence of a fibrin sheath was detected by angiographic contrast examinations. On an outpatient basis, patients subsequently received thrombolysis consisting of a single injection of urokinase (15.000 IU in 1.5 mL normal saline) through the port system. A second attempt was made in cases of treatment failure. Patients were followed up for technical success, complications and long-term outcome. Results: Port dysfunction occurred at a median of 117 days after implantation (range: 7–825 days). The technical success after first port dysfunction by thrombolysis was 87% (40/46); thereof, initial thrombolysis was effective in 78% (36/46). Nine patients (20%) received a second dose of urokinase after previous treatment failure. Follow-up was available for 26 of 40 patients after successful thrombolysis. In 8 of these, rethrombosis occurred after a median of 98 days (range: 21–354 days), whereby rethrombolysis was effective in 5 of 7 (63%) patients. The overall success of all thrombolyses performed was 70% (45/64). No procedure-related technical or clinical complications occurred. After first favorable thrombolysis, a Kaplan–Meier analysis yielded a 30-, 90- and 180-day probability of patency of 96%, 87% and 81%. Conclusion: Thrombolytic therapy on an outpatient basis appears to be a safe and efficient. Three-month patency rates are comparable to more invasive treatment options, including catheter exchange over a guide wire and percutaneous fibrin sheath stripping. Keywords: central venous port catheter, thrombolysis, urokinase, angiography, port dysfunction, catheter occlusion

De-Hua Chang,1 Sonja Hiss,1 Lena Herich,2 Ingrid Becker,2 Kamal Mammadov,1 Mareike Franke,1 Anastasios Mpotsaris,1 Robert Kleinert,3 Thorsten Persigehl,1 David Maintz,1 Christopher Bangard1 1Department of Radiology, 2Institute of Medical Statistics, Informatics and Epidemiology, 3Department of Surgery, University Hospital of Cologne, Cologne, Germany Objective: The aim of the study reported here was to evaluate patients’ satisfaction with implantation of venous access devices under local anesthesia (LA) with and without additional oral sedation.Materials and methods: A total of 77 patients were enrolled in the prospective descriptive study over a period of 6 months. Subcutaneous implantable venous access devices through the subclavian vein were routinely implanted under LA. Patients were offered an additional oral sedative (lorazepam) before each procedure. The level of anxiety/tension, the intensity of pain, and patients’ satisfaction were evaluated before and immediately after the procedure using a visual analog scale (ranging from 0 to 10) with a standardized questionnaire.Results: Patients’ satisfaction with the procedure was high (mean: 1.3±2.0) with no significant difference between the group with premedication and the group with LA alone (P=0.54). However, seven out of 30 patients (23.3%) in the group that received premedication would not undergo the same procedure without general anesthesia. There was no significant influence of lorazepam on the intensity of pain (P=0.88). In 12 out of 30 patients (40%) in the premedication group, the level of tension was higher than 5 on the visual analog scale during the procedure. In 21 out of 77 patients (27.3%), the estimate of the level of tension differed between the interventionist and the patient by 3 or more points in 21 out of 77 patients (27.3%).Conclusion: Overall patient satisfaction is high for implantation of venous access devices under LA. A combination of LA with lorazepam administered orally might not be adequate for patients with a high level of anxiety and tension. The level of tension is often underestimated by the interventionist. Pre-procedural standardized questionnaires could be used to identify patients for whom a gradual approach of individualized sedation may be more effective. Keywords: patient satisfaction, pain, supportive care, chemotherapy, central venous port implantation

Background: Osteosarcoma and Ewing's sarcoma in children and adolescents require age-specific interdisciplinary diagnosis and treatment to achieve optimal therapeutic outcomes. Methods: The diagnosis and treatment of malignant bone tumors in childhood and adolescence are presented in the light of publications retrieved by a selective search, pertinent guidelines, and the authors' extensive experience in an interdisciplinary cancer center. Results: Bone sarcomas make up approximately 5% of all malignancies in children and adolescents; the most common types are Ewing's sarcoma and osteosarcoma. Patients are often not referred to a specialized center until long after the onset of symptoms, as they and their physicians rarely consider the possibility of a bone tumor, and the symptoms are often trivialized. Bone pain of unknown origin, swelling, and functional limitations should be investigated with conventional x-rays. Lesions of unclear origin should be biopsied after a meticulous clinical and radiologic evaluation. Multimodal treatment consists of neo - adjuvant chemotherapy, limb-preserving resection if possible, and radiotherapy where indicated. In multicenter studies, patients with osteosarcoma achieve event-free survival in 64% of cases if their disease is localized, and 28% if it is metastatic; the corresponding figures for patients with Ewing's sarcoma are 80% and 27%, respectively. Conclusion: With implementation of the current treatment recommendations, most children and adolescents with malignant bone tumors can be treated successfully with curative intent. These patients should be referred to a sarcoma center for diagnosis and treatment. [ABSTRACT FROM AUTHOR]