Contrast-Enhanced Ultrasound (CEUS) for the characterization of focal liver lesions - prospective comparison in clinical practice: CEUS vs. CT (DEGUM multicenter trial). Parts of this manuscript were presented at the Ultrasound Dreiländertreffen 2008, Davos

AIM

The aim of our study was to evaluate the diagnostic value of Contrast-Enhanced Ultrasound (CEUS) for the characterization of focal liver lesions in a prospective multi-center study in clinical practice. For this purpose CEUS was compared with the spiral-CT (SCT), the standard radiological method.

MATERIAL AND METHODS

1349 patients with unclear liver lesions after fundamental ultrasound diagnostics including color doppler analysis were examined with standardized CEUS (pulse inversion method, mechanical index < 0.4) from May 2004 to December 2006 in 14 hospitals in a prospective study. The enhancement of contrast medium in the liver tumors was analyzed according to known tumor-specific vascular patterns, using standardized documentation and analysis methods for the differentiation of tumor differentiation (malign or benign) and tumor specification (entity). A subcollective of 267 patients was additionally examined by standardized SCT method. Final diagnosis was based on histology, SCT or MRI in typical findings of liver hemangioma and FNH and on proved clinical data and additional follow up.

RESULTS

The subcollective of 267 patients was divided in two subgroups. In 109 of these patients (subgroup A) there was no histological verification, diagnoses based on clear SCT-findings in 79 cases of hemangioma or FNH, as well as in 20 cases with a clear clinical diagnosis. 6 cases (5.5 %) remained unclear. In this subgroup the assessment of tumor differentiation was concordant with CEUS in 90 cases, discordant in 19 cases and the assessment of tumor specification was concordant in 82 and and discordant in 27 cases. In 158 patients (subgroup B) a histological finding was also present, only in 4 cases no definitive tumor diagnosis was achieved. In this subgroup assessment of tumor differentiation with CEUS and SCT was concordant in 124 cases and discordant in 30 cases (CEUS/SCT: sensitivity 94.0 / 90.7 %, specificity 83.0 / 81.5 %, PPV 91.6 / 91.5 %, NPV 87.5 / 80.0 %, accuracy 90.3 / 87.8 %). Tumor specification matched in 103cases and were different in 51 cases (CEUS/SCT: sensitivity 95.3 / 90.6 %, specificity 83.7 / 81.6 %, PPV 92.7 / 91.4 %, NPV 89.1 / 80.0 %, accuracy 91.6 / 87.7 %). A statistically significant difference could not be established. The analysis of particular tumor specification showed a statistically non significant slight advantage in tumor differentiation for CEUS in the case of hemangioma, FNH, HCC and metastases.

CONCLUSION

In a multi-center approach under routine clinical conditions, this prospective study demonstrates CEUS to be of equal rank to the CT-scan in regard to the assessment of tumor differentiation and specification. No statistically significant differences could be established. CEUS should be employed before computed tomography is performed for the differentiation of liver tumors, because radiation exposure and invasive biopsies can be avoided in veritable numbers of cases, when precise clinical evaluation of the findings is implemented.

Contrast-enhanced ultrasound for the characterization of focal liver lesions--diagnostic accuracy in clinical practice (DEGUM multicenter trial)

PURPOSE

To evaluate the diagnostic benefit of contrast-enhanced ultrasound for the differential diagnosis of liver tumors in clinical practice.

MATERIALS AND METHODS

From May 2004 to December 2006 1349 patients (male 677, female 672) with a hepatic tumor lacking a definite diagnosis based on B-mode ultrasound and power Doppler ultrasound were examined at 14 hospitals by contrast-enhanced ultrasound using a standardized protocol (pulse/phase inversion imaging, mechanical index < 0.4). The Tumor status was assessed based on the vascularity pattern and contrast enhancement seen in focal lesions during the arterial, portal, and late phase. The diagnosis established after contrast-enhanced ultrasound was compared to histology (> 75% cases) or in some cases to CT or MRI.

RESULTS

The final diagnosis of hepatic tumors included 573 benign hepatic tumors (hemangiomas n = 242, focal nodular hyperplasia n = 170, hepatocellular adenoma n = 19, other benign lesions n = 142) and 755 malignant hepatic tumors (metastases n = 383, hepatocellular carcinoma n = 279, other malignant lesions n= 93). The overall diagnostic accuracy of contrast-enhanced ultrasound in comparison to the correct final diagnosis based on the combined gold standard was 90.3%. Contrast-enhanced ultrasound was able to correctly assess 723/755 malignant lesions (sensitivity 95.8%) and 476/573 benign lesions (specificity 83.1%). The positive predictive value of contrast-enhanced ultrasound for the diagnosis of a malignant tumor was 95.4% and the negative predictive value of contrast-enhanced ultrasound was 95.7%.

CONCLUSION

Contrast-enhanced ultrasound clearly improves the differential diagnosis of hepatic tumors and is very helpful in clinical practice when B-scan or power Doppler morphological criteria are missing.

False positive 18F-FDG-PET/CT in a patient after talc pleurodesis

A 61-year-old man presented with spontaneous pneumothorax. After diagnosis of emphysemic bullae, the patient underwent talc pleurodesis and had no further complaints. Five years later a routine chest X-ray showed suspicious pleural lesions in addition to the emphysema, which was deemed compatible with the known history of talc pleurodesis. Subsequent chest CT, however, revealed one lesion in the right lung that appeared not typical for this condition in addition to multiple lesions in pleural proximity. FDG-PET/CT demonstrated high glucose uptake in all the lesions. Subsequent needle biopsy of the suspicious intrapulmonary and also of one mediastinal lesion yielded the histopathological diagnosis of talcum granuloma with long-standing calculous fibrotic changes and no evidence of malignancy. This report on PET/CT after talc pleurodesis addresses the potential pitfalls caused by this condition, as chronic granulomatous reactions, like other inflammatory lesions, may account for highly increased FDG uptake which should be interpreted with caution and not simply read as a sign of malignancy. PET/CT offers the opportunity to exactly localize the areas of increased FDG uptake within regions of pleural thickening caused by talc deposition, however, the dilemma of misleading FDG accumulation cannot be solved by this hybrid imaging modality.

Integrated PET/CT in differentiated thyroid cancer: diagnostic accuracy and impact on patient management

The aim of this study was to investigate the diagnostic accuracy and impact on patient management of the new integrated PET/CT modality in patients with suspected iodine-negative, differentiated thyroid carcinoma (DTC).

METHODS

Forty patients with DTC and a suggestion of iodine-negative tumor tissue underwent PET/CT examination (370 MBq (18)F-FDG, coregistered PET/CT whole-body images). As the first step of analysis, PET and CT images were scored blindly and independently by 2 nuclear medicine physicians and 2 radiologists. A 5-point scale was used. The second step consisted of a consensus reading, during which a virtual side-by-side fusion of PET and CT images was initially evaluated and afterward the "real" fusion (i.e., coregistered) PET/CT images were also scored with the same 5-point scale. The imaging results were compared with histopathologic findings and the course of disease during further follow-up examinations.

RESULTS

One hundred twenty-seven lesions in 40 patients were evaluated. Diagnostic accuracy was 93% and 78% for PET/CT and PET, respectively (P = 0.049, per-patient analysis). In 17 (74%) of 23 patients with suspicious (18)F-FDG foci, integrated PET/CT added relevant information to the side-by-side interpretation of PET and CT images by precisely localizing the lesion(s). In tumor-positive PET patients, PET/CT fusion by coregistration led to a change of therapy in 10 (48%) patients. Futile surgery was prevented in an additional 3 patients.

CONCLUSION

Integrated PET/CT is able to improve diagnostic accuracy in a therapeutically relevant way in patients with iodine-negative DTC. By precisely localizing tumor tissue, image fusion by integrated PET/CT is clearly superior to side-by-side interpretation of PET and CT images.

Diagnostic Performance of Whole Body Dual Modality 18F-FDG PET/CT Imaging for N- and M-Staging of Malignant Melanoma: Experience With 250 Consecutive Patients

Purpose

To assess the diagnostic performance of positron emission tomography/computed tomography (PET/CT) using 18F-fluorodeoxyglucose (FDG) for N- and M-staging of cutaneous melanoma.

Patients and Methods

This is a retrospective and blinded study of 250 consecutive patients (105 women, 145 men; age 58 ± 16 years) who underwent FDG-PET/CT for staging of cutaneous melanoma at different time points in the course of disease. Whole-body FDG-PET/CT was performed 101 ± 21 minutes postinjection of 371 ± 41 MBq FDG. Diagnostic accuracy for N- and M-staging was determined for CT alone, PET alone, and PET/CT.

Results

PET/CT detected significantly more visceral and nonvisceral metastases than PET alone and CT alone (98.7%, 88.8%, and 69.7%, respectively). PET/CT imaging thus provided significantly more accurate interpretations regarding overall N- and M-staging than PET alone and CT alone. Overall N- and M-stage was correctly determined by PET/CT in 243 of 250 patients (97.2%; 95% CI, 95.2% to 99.4%) compared with 232 patients (92.8%; 95% CI, 89.6% to 96.0%) by PET, and 197 patients (78.8%; 95% CI, 73.7% to 83.9%) by CT. All differences were significant. Accuracy of PET/CT was significantly higher than that of PET and CT for M-staging (0.98 v 0.93 and 0.84) and significantly higher than that of CT for N-Staging (0.98 v 0.86). Change of treatment according to PET/CT findings occurred in 121 patients (48.4%).

Conclusion

The diagnostic performance of FDG-PET/CT for N- and M-staging of melanoma patients suggests its use for whole-body tumor staging, especially for detection or exclusion of distant metastases.

Telomerase-pulsed dendritic cells: preclinical results and outcome of a clinical phase I/II trial in patients with metastatic renal cell carcinoma

OBJECTIVE

Therapeutic vaccination with dendritic cells (DC) showed promising results in first clinical trials in cases of metastatic renal cell carcinoma (RCC). Human telomerase reverse transcriptase (hTERT) could be a potential target because it is detectable in more than 85% of human tumors including RCC.

DESIGN

10 patients with progressive metastatic RCC were enrolled in a clinical phase I/II trial using DC pulsed with hTERT-peptide. Beside toxicity and feasibility aspects, a complex immune monitoring including in vitro data were evaluated. In addition to detection of tumor-specific effector cells we investigated their functionality like IFN-gamma secretion and cytotoxic activity against tumor cells.

RESULTS

The vaccine was well tolerated. Two patients showed a mixed response (MR) and one patient a stable disease (SD). Interestingly, responders showed cytotoxic activity already before start of therapy and there was a significant increase in cytotoxic activity of effector cells from all responders (SD and MR patients) after the first vaccination. In contrast non-responders showed no cytotoxic activity before and during treatment. Therefore, cytotoxic activity might be used as a predictive marker in the future. Tetramer staining detected higher amounts of tumor-specific cytotoxic cells in responding patients compared to non-responders. Also, responders possessed increasing amounts of IFN-gamma producing immunological effector cells.

CONCLUSION

Telomerase-pulsed DC could enhance a tumor-specific immune response against RCC.

Magnetic resonance (MR) imaging and MR angiography for evaluation and follow-up of hepatic artery banding in patients with hepatic involvement of hereditary hemorrhagic telangiectasia

BACKGROUND

We describe findings obtained by magnetic resonance angiography (MRA) and magnetic resonance imaging (MRI) for evaluation and follow-up after hepatic artery banding in patients with hepatic involvement of hereditary hemorrhagic telangiectasia (HHT).

METHODS

Abdominal MRA and liver MRI were performed in three patients with HHT as clinically defined by Curacao criteria. One patient underwent MRA and MRI twice for preinterventional evaluation and follow-up, one patient for preinterventional evaluation, and one patient for postinterventional evaluation. Hepatic vascular involvement of the disease and postinterventional vascular anatomy were evaluated by two radiologists by consensus.

RESULTS

Hepatic vascular involvement with perfusion disorders and arteriosystemic shunts was found in all three patients. MRA and MRI allowed diagnostic characterization of hepatic vascular disease (three of three), preinterventional evaluation of complex vascular anatomy and variants (two of two), and postinterventional follow-up of hepatic artery banding (two of two).

CONCLUSION

In preinterventional evaluation and postinterventional follow-up, MRA and MRI allows characterization of complex hepatic vascular alterations of HHT and, hence, is an alternative to other imaging modalities in the diagnosis, clinical decision making, and follow-up of HHT.

Therapy of hepatocellular carcinoma with iodine-131-lipiodol. Results in a large German cohort

AIM

To evaluate the efficacy and tolerance of iodine-131-lipiodol ((131)I-lipiodol) for hepatocellular carcinoma (HCC) in German long term patients and comparison with medically treated controls.

PATIENTS, METHODS

38 courses of intra-arterial (131)I-lipiodol therapy with a total activity up to 6.7 GBq were performed in 18 patients with HCC (6 with portal vein thrombosis). Liver and tumour volume and lipiodol deposition were measured by computed tomography and (131)I activity by scintigraphy. Therapeutic efficacy was determined by tumour volume change and matched-pairs analysis in comparison to medically (i.e. tamoxifen or medical support) treated patients.

RESULTS

Tumour volume decreased in 20/32 index nodules (63%) after the first course. Repeated therapy frequently resulted in further tumour reduction. Overall response to treatment was partial in 11 nodules, minor response in 4 nodules, and disease was stable in 12 and progressive in 5. Significant response was associated with pretherapeutic nodule volume up to 150 ml (diameter of 6.6 cm). Survival rate after 3, 6, 9, 12, 24 and 36 months was 78, 61, 50, 39, 17, and 6%. Matched-pairs analysis of survival revealed (131)I-lipiodol to be superior to medical treatment. The most important side effect was a pancreatitis-like syndrome whereas overall tolerance was good.

CONCLUSION

The long term results confirm that HCC therapy with (131)I-lipiodol is effective and probably superior to medical treatment. Tumour nodules of up to 6 cm diameter are well suited for this therapy even in the presence of portal vein thrombosis.

Kontrastmittelgestützte „Low-MI-Real-Time”-Sonographie zur Beurteilung der Dignität fokaler Leberläsionen

PURPOSE

Contrast enhanced sonography using phase-inversion harmonic mode is a promising technique to detect and characterize hepatic lesions. Aim of the following study was to evaluate whether this technique can characterize liver tumors.

MATERIAL AND METHODS

During January and December 2004, 46 patients with a solitary liver lesion were examined. The age of the 21 women and 25 men ranged between 37 and 82 years. The tumor size was between 8 mm and 14.5 cm. First conventional B-mode sonography and color-coded sonography were performed, followed by intravenous injection of the contrast agent SonoVue and continuous sonographic examination over 5 minutes using "low MI real-time" phase-inversion mode. The examination was video taped. The enhancement was evaluated qualitatively.

RESULTS

Of the 21 malignant lesions, 20 could be correctly diagnosed as malignant. One of the malignant lesions was classified as benign. Of the 25 benign lesions, 21 could be classified correctly as benign, however, 4 lesions (2 hemangiomas, 1 adenoma, 1 teratoma) showed no enhancement in the portal and late phase and were incorrectly classified as malignant as well.

CONCLUSION

Using pulse-inversion harmonic US with SonoVue, liver lesions showing an isoechoic or hyperechoic enhancement can be classified as probably benign. Further work up is necessary in case of little or no enhancement on delayed phase imaging.

PET recognition of pulmonary metastases on PET/CT imaging: impact of attenuation-corrected and non-attenuation-corrected PET images

PURPOSE

The aims of this study were to assess the performance of FDG PET at PET/CT imaging for the detection of pulmonary metastases and to evaluate differences in lesion detectability on attenuation-corrected (AC) and non-attenuation corrected (NAC) PET images.

METHODS

The institutional PET/CT database was searched for patients with pulmonary metastases of 3-60 mm in diameter. Ninety-two patients with 438 metastases to the lungs were included in the study. The primary tumours were 33 malignant melanomas, 12 carcinomas of unknown primary, 11 colorectal carcinomas, eight differentiated thyroid carcinomas, seven aggressive non-Hodgkin's lymphomas, six head and neck cancers, three breast cancers, two prostate cancers and ten others. Lesion detectability was visually compared between PET and CT and between AC and NAC PET images using a five-point scale.

RESULTS

Of the 438 pulmonary metastases, 174 were detected with FDG PET (39.7%), six of them on NAC images only (not significant). Visual scores were higher on NAC images in 41.4% and equal in 54.6% of lesions. The sensitivity of FDG PET increased significantly from 0.405 for metastases of 5-7 mm in diameter to 0.784 for lesions of 8-10 mm and to 0.935 for lesions measuring 11-29 mm in diameter. No metastases smaller than 5 mm in diameter were seen on PET images.

CONCLUSION

FDG PET/CT is useful for the assessment of pulmonary metastases. The frequency of lesion detection is similar for AC and NAC PET images. A reduced sensitivity of FDG PET has to be considered for lesions smaller than 11 mm in diameter.

Detection of Klatskin's tumor in extrahepatic bile duct strictures using delayed 18F-FDG PET/CT: preliminary results for 22 patient studies

Detection of cholangiocarcinoma in extrahepatic bile duct strictures is a continuing challenge in clinical practice because brush cytology taken at endoscopic retrograde cholangiography has an average sensitivity of 50%. The aim of this study was to evaluate the effectiveness of dual-modality PET/CT using (18)F-FDG for noninvasive differentiation of extrahepatic bile duct strictures.

METHODS

Twenty-two PET/CT studies were performed on 20 patients (10 women, 10 men; mean age +/- SD, 63 +/- 14 y) with extrahepatic bile duct strictures on endoscopic retrograde cholangiography. PET imaging was started 101 +/- 22 min after injection of 369 +/- 48 MBq of 18F-FDG. Blood glucose was 100 +/- 20 mg/dL. PET images were reconstructed iteratively with attenuation correction based on a rescaling of the CT image. CT was performed within 1 min before the PET study, with the patient in the same position. CT was used to place a volume of interest 5 cm in diameter at the liver hilus for quantitative evaluation of PET images by means of standardized uptake values (SUVs).

RESULTS

Final diagnosis was histologically proven cholangiocarcinoma in 14 cases and benign causes of strictures in 8 cases without evidence of malignancy during a follow-up of 18 +/- 3 mo. All patients with cholangiocarcinoma presented with focal increased uptake in the liver hilus with an SUV of 6.8 +/- 3.3 (range, 3.9-15.8), compared with 2.9 +/- 0.3 (range, 2.5-3.3) in patients with benign causes of strictures (P = 0.003). There was a clear cutoff SUV of 3.6 for detection of malignancy in the liver hilus.

CONCLUSION

18F-FDG PET/CT provided high accuracy for noninvasive detection of perihilar cholangiocarcinoma in extrahepatic bile duct strictures.

Pitfalls in der kontrastverstärkten Lebersonographie: Konsequenzen für die Praxis

Contrast-enhanced sonography performed as phase inversion harmonic imaging is a promising new technique for detection and characterization of hepatic foci. It has been reported that malignant liver tumors can be differentiated from benign entities with almost 100% sensitivity and that diagnosis of the type is possible with an accuracy of over 90%. The following report describes seven of our own cases and then compares the results we obtained with current knowledge, followed by a discussion. In summary, most hepatic lesions can be correctly characterized by supplemental use of enhanced sonography; practitioners should nevertheless be aware of atypical phenomena to be able to critically evaluate the findings.

PET-CT in der Nachsorge des kolorektalen Karzinoms: Einfluss der Bildfusion auf die Staginggenauigkeit

PURPOSE

To evaluate the diagnostic impact of positron emission tomography (PET) with fluorine-18-labeled deoxy-D-glucose (FDG) combined with non-contrast computed tomography (CT) as PET-CT modality in restaging colorectal cancer patients.

MATERIAL AND METHODS

In this retrospective study, 29 consecutive patients with histologically proven colorectal cancer (17 female, 12 male, aged 51-76 years) underwent whole body scans in one session on a dual modality PET-CT system (Siemens Biograph) 90 min. after i.v. administration of 370 MBq 18F-FDG. The CT imaging was performed with 40 mAs, 130 kV, slice-thickness 5 mm and without i.v. contrast administration. PET and CT images were reconstructed with a slice-thickness of 5 mm in coronal, sagittal and transverse planes. During a first step of analysis, PET and CT images were scored blinded and independently by a group of two nuclear medicine physicians and a group of two radiologists, respectively. For this purpose, a five-point-scale was used. The second step of data-analysis consisted of a consensus reading by both groups. During the consensus reading, first a virtual (meaning mental) fusion of PET and CT images and afterwards the "real" fusion (meaning coregistered) PET-CT images were also scored with the same scale. The imaging results were compared with histopathology findings and the course of disease during further follow-up.

RESULTS

The total number of malignant lesions detected with the combined PET/CT were 86. For FDG-PET alone it was n = 68, and for CT alone n = 65. Comparing PET-CT and PET, concordance was found in 81 of 104 lesions. Discrepancies predominantly occurred in the lung, where PET alone often showed true positive results in lymph nodes and soft tissue masses, where CT often was false negative. Comparing mental fusion and "real" co-registered images, concordance was found in 94 of 104 lesions. In 13 lesions or, respectively, in 7 of 29 patients, a relevant information was gathered using fused images.

CONCLUSION

Combined PET/CT leads to greater accuracy in the interpretation of data and is a valuable tool for diagnosis and anatomic localization of metastases in colorectal cancer patients.

[Inflammatory myofibroblastic tumour (so-called pseudotumour) of the hepatobiliary system]

The purpose of this report is to describe the ultrasonographic features of hepatic inflammatory myofibroblastic tumour (IMT). This tumour presented as an area of periportal soft-tissue infiltration. Because periportal infiltration is a common feature in both IMT and other malignant tumours of the hepatic portal, histological examination should be considered before final diagnosis and treatment.

Therapy of hepatocellular cancer with iodine-131-Lipiodol

Most patients with hepatocellular carcinoma are not eligible for surgery at the time of primary diagnosis. Portal vein thrombosis is frequent and represents a contraindication for transarterial chemoembolisation. Transarterial therapy with iodine-131-Lipiodol is superior to systemic therapy in tumours up to diameters of 5 cm and may be performed even in cases with portal vein thrombosis. Compared to other intraarterial therapy procedures, iodine-131-Lipiodol shows the same efficacy but less side effects.

Limitations and pitfalls of Couinaud's segmentation of the liver in transaxial Imaging

The segmental anatomy of the human liver has become a matter of increasing interest to the radiologist, especially in view of the need for an accurate preoperative localization of focal hepatic lesions. In this review article first an overview of the different classical concepts for delineating segmental and subsegmental anatomy on US, transaxial CT, and MR images is given. Essentially, these procedures are based on Couinaud's concept of three vertical planes that divide the liver into four segments and of a transverse scissura that further subdivides the segments into two subsegments each. In a second part, the limitations of these methods are delineated and discussed with the conclusion that if exact preoperative localization of hepatic lesions is needed, tumor must be located relative to the avascular planes between the different portal territories.

Changes in TH1/TH2 immunity after endovascular and conventional infrarenal aortic aneurysm repair: its relevance for clinical practice

OBJECTIVE

to evaluate local surgical trauma induced by endovascular (TPEG) and conventional infrarenal aortic aneurysm repair (AAA-C), the inflammatory response and changes in cell-mediated and antibody-mediated immunity as illustrated by the type-1/type-2 T-helper (TH1/TH2) cell balance were investigated.

DESIGN

prospective study.

PATIENTS AND METHODS

sixteen patients were included, eight patients underwent AAA-C and eight TPEG. Venous peripheral blood samples were collected 24h preoperatively and 24, 48, 72h, 5 and 7 days postoperatively. Besides the WBC, intracellular TH1/TH2 cytokines (IFN-gamma/IL-4) and the cell surface markers HLA-DR on monocytes and CD23 on B cells were measured by four colour flow cytometry.

RESULTS

statistically significant higher values in the AAA-C group were demonstrated for neutrophiles. The TH1/TH2 immunobalance (expressed by forming the ratio of IFN-(gamma/IL-4 producing T cells as well as by the ratio of HLA-DR(pos) monocytes/CD23(pos) B-cells) showed a significant shift towards TH2 immunity in the AAA-C group whereas TPEG led to a significant lesser shift 24-72h after surgery (p < 0.05).

CONCLUSIONS

TPEG leads to a minor distortion of the TH1/TH2 immunobalance. This implies that TPEG is a less stressing procedure, that is especially beneficial in patients whose conditions are considered less suitable for AAA-C due to age and serious comorbidity.

Benign hepatic tumours

Benign hepatic tumours include a broad spectrum of regenerative and true neoplastic processes. Due to advances in imaging procedures like MRI, Cf-scan and ultrasound as well as progress in immunohistochemistry, the appropriate diagnosis is made ina high percentage of patients without laparotomy and resection. Most important in clinical practice is the differential diagnosis of focal nodular hyperplasia and hepatocellular adenoma because of the risk of rupture and bleeding in the latter. Cavernous haemangioma, the most common benign hepatic tumour, rarely needs treatment. The diagnosis of nodular regenerative hyperplasia is often missed and patients present with secondary complications and signs of portal hypertension that necessitate treatment. The main problem in angiomyolipoma is to distinguish it from malignant processes which do require treatment. Because of its clinical presentation, inflammatory pseudotumour is also sometimes confused with a malignant tumour. Therapeutic options are drug therapy or surgical resection. Benign haemangioendothelioma of the infant is rare but may cause life-threatening complications. Bile duct adenoma is an incidental finding that is not known to cause any symptoms whereas biliary cystadenoma is often symptomatic and may progress to cystadenocarcinoma and therefore needs resection.

Randomly segmented central k-space ordering in high-spatial-resolution contrast-enhanced MR angiography of the supraaortic arteries: initial experience

Contrast material-enhanced three-dimensional (3D) magnetic resonance (MR) angiography of the supraaortic arteries with randomly segmented central k-space ordering (ie, contrast-enhanced timing-robust angiography [CENTRA]) was performed in 16 patients. CENTRA enabled reliable depiction of the aortic arch up to the circle of Willis at high spatial resolution (true voxel size, 0.81 x 0.81 x 1.0 mm(3)). With CENTRA, the divergent demands of high spatial resolution, wide anatomic coverage, and arterial phase imaging have been reconciled. The random order of central k-space acquisition may minimize artifacts in contrast-enhanced 3D MR angiography caused by unstable contrast material opacification at the initiation of sampling.

Transjugular portal venous stenting in inflammatory extrahepatic portal vein stenosis

We report the case of a 37-year-old man with necrotizing pancreatitis associated with inflammatory extrahepatic portal vein stenosis and progressive ascites. Four months after the acute onset, when no signs of infection were present, portal decompression was performed to treat refractory ascites. Transjugular transhepatic venoplasty failed to dilate the stenosis in the extrahepatic portion of the portal vein sufficiently. Therefore a Wallstent was implanted, resulting in almost normal diameter of the vessel. In follow-up imaging studies the stent and the portal vein were still patent 12 months after the intervention and total resolution of the ascites was observed.

Hemodynamic effects of propranolol and nitrates in cirrhotics with transjugular intrahepatic portosystemic stent-shunt

BACKGROUND

The combination of tailored TIPS with vasoactive drugs might allow reduction of the rate of subsequent shunt-related sequelae.

METHODS

We studied cirrhotic patients 8 weeks (median) after TIPS insertion (8-10 mm) for variceal bleeding. Nitrate (0.1 mg/kg) and propranolol (0.15 mg/kg) alone or combined (same dosages) were infused (I h) sequentially at 1-h intervals (n = 17). Similarly, propranolol was randomly compared to placebo (NaCl, n = 14). We measured mean arterial pressure (MAP, mmHg), heart rate (HR) and portal pressure gradient (PPG: portal minus central venous pressure) prior to and after drugs.

RESULTS

Propranolol reduced PPG (mean +/- s, mmHg) significantly (14.8 +/- 3.7 versus 12.1 +/- 3.7; -21% +/- 10%; P < 0.001), while nitrates alone (14.3 +/- 3.4 versus 13.7 +/- 3.4; -11% +/- 3%; P=0.06) or nitrates plus propranolol (12.9 +/- 4 versus 12.4 +/- 4; -7% +/- 8%; P=0.2) induced only minor additive effects on portal pressure. However, nitrate reduced MAP (P < 0.001) and increased HR (P < 0.01), whereas propranolol reduced only HR (P < 0.001) with unchanged MAP, and the combination decreased MAP (P < 0.001). Compared to placebo (no effect), propranolol decreased PPG (14.4 +/- 5.6 versus 11.1 +/- 5.5; -23% +/- 11%; P < 0.001) and HR (P < 0.001). Overall, most patients (92%) responded to propranolol and 54% showed a marked PPG decrease (>20%).

CONCLUSIONS

Propranolol significantly reduced portal pressure in cirrhotic patients after TIPS, whereas nitrates induced only minor benefit. TIPS-treated patients might therefore profit from additive propranolol therapy allowing limited shunts to be applied initially and/or to reduce the need for TIPS revisions in the case of shunt-dysfunction during follow-up.

Prospective evaluation of a clinical score for 60-day mortality after transjugular intrahepatic portosystemic stent-shunt: Bonn TIPSS early mortality analysis

OBJECTIVE

Transjugular intrahepatic portosystemic stent-shunt (TIPSS) is increasingly used to treat complications of portal hypertension, but proven tools for risk assessment of early mortality are lacking.

DESIGN

The prospective evaluation of a new 60-day mortality score.

PATIENTS AND METHODS

In a tertiary medical centre, 30 consecutive TIPSS patients were analysed for early mortality predictors, such as Child-Pugh score, TIPSS urgency (elective: > or = 36 h or emergency: < 36 h after variceal bleeding), comorbidity (Acute Physiology and Chronic Health Evaluation [APACHE]-II) and clinical data. Main predictors (P< 0.01) in this group (group-1: Child-Pugh score 10A, 10B, 10C) were graded (1, 2 or 3 points representing low, medium and high risk, respectively) and summarized as a Bonn TIPSS early mortality (BOTEM) score. This score was then tested prospectively in the next 73 TIPSS patients (group-2: Child-Pugh score 14A, 42B, 17C).

RESULTS

Group 1 early mortality (30%) depended primarily on bilirubin (P< 0.005), APACHE-II (P < 0.001) and TIPSS urgency (P< 0.001). Added risk points (1, 2, 3) for bilirubin (< 3 mg/dl, 3-6 mg/dl, > 6 mg/dl, respectively), APACHE-II (< 10, 10-20, > 20 points, respectively) and urgency (elective, emergency, active bleeding, respectively) represented individual BOTEM score points. BOTEM was the best mortality predictor (P< 0.001); < or = / > 6 score points was the optimal cut-off, with 56% sensitivity, 100% specificity, 100% positive predictive value, 84% negative predictive value and 87% accuracy. In group 2, early mortality (8.2%) was again best predicted by BOTEM (P < 0.01) with the same cut-off and 67% sensitivity, 99% specificity, 80% positive predictive value, 97% negative predictive value and 96% accuracy.

CONCLUSION

BOTEM score based on bilirubin, comorbidity and TIPSS-urgency predicts rather reliably post-TIPSS 60-day mortality and might optimize TIPSS treatment.

[Visceral artery aneurysms]

The purpose of this article is to review the etiology, clinical presentation and treatment options of visceral artery aneurysms (VAA) on the basis of our experiences. Visceral artery aneurysms are uncommon lesions with a frequency of 0,1-0,2 % in autopsy statistics. In fact many visceral artery aneurysms still present first with a rupture (22 %) and despite emergency laparotomies the mortality rate is about 8,5 %. The course of disease often is disastrous due to rupture of the aneurysms or thromboembolic complications, emphasizing the importance to be aware of this differential diagnosis of abdominal pain. This article covers 9 patients with VAA. 3 patients each revealed an a. lienalis aneurysm and a. gastrica aneurysm, resp. In the other 3 patients an aneurysm of the a. gastroepiploica, the a. pancreatico-duodenalis and the a. mesenterica superior resp. was proven. In 8 of 9 patients a surgical therapy of the VAA took place. Only 2 patients (22 %) were interventionally treated. 1 patient deceased due to postoperative hemorrhage. Both the surgical and the radiological intervention therapy are available for treatment of the VAA. The decision on the choice of the therapeutic procedure should be made on an individual basis.

[Obstruction of surgical portosystemic shunts in the early postoperative phase: interventional treatment by angioplasty with stent implantation]

PURPOSE

Recurrent variceal bleeding in patients treated with surgical porto-systemic shunting is most often due to shunt stenoses or occlusion. Radiological interventional procedures are a possible method of therapy and our experience herein is described in this report.

PATIENTS AND METHODS

From 1997 to 1999 54 patients with recurrent variceal bleeding were treated with a surgical porto-systemic shunt procedure. Of these early shunt occlusion occurred in 5 patients, which was treated with percutaneous transcatheter techniques.

RESULTS

In only one patient was PTA alone sufficient to reestablish shunt patency, in four patient stent placement was necessary in addition. In the follow-up period 1 patient died 26 month after intervention with (autopsy-proven) patent shunt, in one patient shunt reocclusion occurred after 11 months and in 3 patients the shunt is still patent.

CONCLUSIONS

PTA, if necessary in combination with stent placement, is an attractive alternative method of therapy in case of an early surgical porto-systemic shunt occlusion.

[Diagnosis of intramural bile duct varicose veins ("pseudo-cholangiocarcinoma sign"]

We report the case of a patient with portal hypertension and portal vein thrombosis who was admitted to hospital for evaluation prior to a scheduled portosystemic shunt operation. Ultrasound examination revealed dilatation of intrahepatic bile ducts and echogenic thickening of the walls of both right and left main bile ducts as well as the common bile duct, highly suspicious of a carcinoma. Further evaluation, however, showed a varicosis of the bile duct walls to be the cause of the thickening of the walls, the varicosis resulting from the long-standing cavernous transformation of the portal vein and the portal hypertension. This tumour-like thickening of the walls, caused by numerous tiny varicose veins, is also known as "Pseudo-cholangiocarcinoma sign" in the Anglo-American world.

Infarction and laceration of liver parenchyma caused by wedged CO(2) venography before tips insertion

We describe the fatal outcome of an elective TIPS procedure performed in a 43-year-old man with alcoholic cirrhosis. Wedged hepatic venography with CO(2) was the reason for infarction and laceration of liver parenchyma resulting in a subcapsular hematoma and subsequent intra-abdominal bleeding. This is the first report of this complication after the use of CO(2) in a cirrhotic patient.

Long term outcome after transjugular intrahepatic portosystemic stent-shunt in non-transplant cirrhotics with hepatorenal syndrome: a phase II study

BACKGROUND

Recent small studies on hepatorenal syndrome (HRS) indicate some clinical benefit after transjugular intrahepatic portosystemic stent-shunt (TIPS) but sufficient long term data are lacking.

AIM

We studied prospectively feasibility, safety, and long term survival after TIPS in 41 non-transplantable cirrhotics with HRS (phase II study).

PATIENTS AND METHODS

HRS was diagnosed using current criteria (severe (type I) HRS, n=21; moderate (type II) HRS, n=20). Thirty one patients (14 type I, 17 type II) received TIPS (8-10 mm) while advanced liver failure excluded shunting in 10. During follow up (median 24 months) we analysed renal function and survival (Kaplan-Meier).

RESULTS

TIPS markedly reduced the portal pressure gradient (21 (5) to 13 (4) mm Hg (mean (SD)); p<0.001) with one procedure related death (3.2%). Renal function deteriorated without TIPS but improved (p<0.001) within two weeks after TIPS (creatinine clearance 18 (15) to 48 (42) ml/min; sodium excretion 9 (16) to 77 (78) mmol/24 hours) and stabilised thereafter. Following TIPS, three, six, 12, and 18 month survival rates were 81%, 71%, 48%, and 35%, respectively. As only 10% of non-shunted patients survived three months, total survival rates were 63%, 56%, 39%, and 29%, respectively. Multivariate Cox regression analysis revealed bilirubin (p<0.001) and HRS type (p<0.05) as independent survival predictors after TIPS.

CONCLUSIONS

TIPS provides long term renal function and probably survival benefits in the majority of non-transplantable cirrhotics with HRS. These data warrant controlled trials evaluating TIPS in the management of HRS.

[Tissue harmonic imaging in comparison with conventional sonography: effect on image quality and observer variability in the measurement of the intima-media thickness in the common carotid artery]

OBJECTIVE

The purpose of this study was to determine if tissue harmonic imaging (THI) produced a higher image quality than conventional sonography and if THI reduced the observer availability in the intima media thickness (IMT) measurements of the common carotid artery (ACC).

SUBJECTS AND METHODS

A prospective study was performed on 26 healthy volunteers and IMT was assessed by three experienced sonographers in 52 carotid arteries. A 7.5 MHz transducer was used to measure carotid IMT in both harmonic and fundamental modes. Three measurements of IMT were carried out on the far wall of the ACC along a 1 cm-long section proximal to the bifurcation. Image quality was graded from 1-3 (1 = excellent, 2 = good, 3 = poor). IMT measurements using harmonic and fundamental modes were compared and intra- and inter-observer variability were calculated. Statistical analyses were performed using a kappa analysis, ANOVA and the McNemar/Wilcoxon Test.

RESULTS

In the 52 cases image quality was excellent in 51% using THI in comparison to 32% using conventional sonography. Image quality was graded significantly more frequent as excellent using harmonic sonography as compared to conventional sonography (p = 0.001). A significant difference in IMT was found between the measurements obtained by harmonic imaging in comparison to those obtained by conventional imaging (p < 0.0001). Using the harmonic mode inter-observer variability of the IMT measurements was significantly reduced from 8.1% to 5.2% (p < 0.001).

CONCLUSIONS

THI produced a higher image quality with a better visualisation of carotid IMT and reduced significantly the intra- and inter-observer variability in the IMT measurements.

Detection of thrombosis in the portal venous system: comparison of contrast-enhanced MR angiography with intraarterial digital subtraction angiography

PURPOSE

To determine whether intraarterial digital subtraction angiography (DSA) can be replaced by contrast material-enhanced magnetic resonance (MR) angiography in the assessment of patency or thrombosis of the portal venous system in patients with portal hypertension.

MATERIALS AND METHODS

Thirty-six patients with portal hypertension underwent contrast-enhanced MR angiography and intraarterial DSA for assessment of the portal venous system. The images were evaluated for vessel patency or thrombosis of the portal, splenic, or superior mesenteric vein.

RESULTS

Of the 101 vessels evaluated, 42 were thrombosed. Overall sensitivity, specificity, and accuracy for the detection of thrombosis were 100%, 98%, and 99%, respectively, for MR angiography and 91%, 100%, and 96%, respectively, for DSA; differences between the imaging methods were not statistically significant. Only in four patients with six vessels (6%) were there discordant findings between MR angiography and DSA.

CONCLUSION

Noninvasive contrast-enhanced MR angiography has the potential to replace intraarterial DSA as the standard method to assess the whole portal venous system.

[Locoregional chemoperfusion with mitoxantrone for palliative therapy in bleeding bladder cancer compared with embolization]

PURPOSE

To assess the efficacy of intraarterial chemoperfusion (CP) with mitoxantrone in patients with bleeding bladder cancer; comparison with the results of intraarterial embolization therapy (ET).

MATERIALS AND METHODS

Thirty patients with urinary bladder cancer and intractable bladder hemorrhage were treated with intraarterial (i.a.) CP (15 patients) using Mitoxantron 820 mg/m2/1-2 h) and i.a. ET (15 patients) using Histoacryl or Ethibloc. Bleeding control rate, recurrence of hemorrhage, survival rate and complications were evaluated.

RESULTS

Complete control of the hemorrhage was achieved in 14/15 and 12/15 of the patients with CP and ET, respectively. Hemorrhage stopped in CP patients after an interval of (4 to 15) 10 days, and within 24 hours in ET patients. Recurrence of hemorrhage was observed in 3/14 of CP and 4/13 of ET patients. The survival rate was 4-5 months in both groups. Complications were observed in ET patients only (7/22). Posttherapeutic pain occurred significantly more often in ET patients (20/22) than in CP patients (6/31 versus 20/22).

CONCLUSION

Intra-arterial chemoperfusion using Mitoxantron is an effective therapy in patients with intractable urinary bladder hemorrhage. Due to the delayed effect in CP, ET should be used in patients with life-threatening bleeding.

Intraarterial HCC therapy with I-131-Lipiodol

We report on our 2-year experience with intraarterial liver therapy with I-131-Lipiodol in patients with hepatocellular carcinoma in Germany. 30 therapies with intraarterial delivery of I-131-labeled Lipiodol were performed in 14 patients with hepatocellular carcinoma (HCC) with or without portal vein thrombosis during hepatic angiography. The patients were monitored for 1) distribution of Lipiodol by CT, 2) distribution of applied activity by planar scintigraphy and SPECT, and 3) tumor response by CT, MRT and 18-FDG-PET. In 5 patients the tumor size was reduced after the first treatment (responder). Eight patients, primarily with big tumors (> 7 cm), had stable (4) or progressive disease (4), and 1 patient died because of renal failure. CT and SPECT showed pronounced I-131-lipiodol accumulation in the tumor tissue in all patients with variable distribution patterns. One patient had an acute pancreatitis like syndrome together with elevation of liver enzymes, probably due to arterial spasm. 9 patients had transient and mild symptoms in the upper abdomen, fever to 40 degrees C, and a leukocytosis. Two patients had a transient mild elevation of pancreatic enzymes. All patients had a transient rise in liver enzymes. In conclusion, therapeutic efficacy was dependent on the tumor mass. Side effects due to the radiopharmaceutical were tolerable, and other side effects may result from the angiography procedure related manipulations. These results are encouraging for tumors up to a moderate mass.