Technical eligibility for treatment of magnetic resonance-guided focused ultrasound surgery

PURPOSE

This study was designed to evaluate the technical eligibility for magnetic resonance-guided focused ultrasound surgery (MRgFUS) treatment of women with symptomatic fibroids.

METHODS

Technical eligibility for MRgFUS treatment without mitigation techniques was evaluated retrospectively in 783 premenopausal women (median age, 44.2 years) with symptomatic fibroids who applied for uterine artery embolization (UAE) at our institution from 2001 to 2012. Technical eligibility for MRgFUS was defined as primary study endpoint. Technical ineligibility was assessed on the basis of MRI criteria, such as bowel interposition/foreign material in the ultrasound beam path, more than five fibroids, distance from fibroid to sacral bone surface, fibroid size/shape, severe concomitant adenomyosis or extensive cutaneous scars in accordance to the US Food and Drug Administration approvals. Secondary study endpoint was defined as evaluation of the most frequent exclusion criteria and differences in technical eligibility for MRgFUS and UAE.

RESULTS

On the basis of MRI, 38.9% of women who applied for UAE were found to be technically eligible for MRgFUS treatment without mitigation techniques. Most frequent reason for ineligibility was bowel interposition in the ultrasound beam path (60.4%). Differences in technical eligibility for MRgFUS (38.9%) and UAE (99.2%) were significant (P < 0.001).

CONCLUSIONS

MRgFUS treatment is technically possible in up to 40% of women with symptomatic fibroids. The most frequent exclusion criterion is the presence of bowel in the ultrasound beam path.

[The balanced scorecard--applications in a radiology department]

The balanced scorecard (BSC) represents a comprehensive management tool for organizations with the aim to focus all activities on a chosen strategy. Targets for various perspectives of the environment such as the customer, financial, process, and potential perspective are linked with concrete measures, and cause-effect relationships between the objectives are analyzed. This article shows that the BSC can also be used for the comprehensive control of a radiology department and thus provides a meaningful contribution in organizing the various diagnostic and treatment services, the management of complex clinical environment and can be of help with the tasks in research and teaching.

[Change in health-related quality of life and change in clinical symptoms after uterine artery embolization in patients with symptomatic adenomyosis uteri - evaluation using a standardized questionnaire]

AIM

To evaluate the clinical response of uterine artery embolization (UAE) in women with symptomatic uterine adenomyosis by comparing health-related quality of life and symptom severity before and after UAE using a standardized questionnaire.

MATERIAL AND METHODS

This longitudinal study at two time points included 17 patients with a median age of 47.1 years with symptomatic uterine adenomyosis (n = 7 pure adenomyosis; n = 10 with concomitant fibroids). The diagnosis was based on clinical symptoms and magnetic resonance imaging (MRI) criteria. Data on health-related quality of life and severity of symptoms before and after UAE were obtained by the standardized "Uterine Fibroid Symptom and Quality of Life" (UFS-QOL) questionnaire and correlated in the following. Treatment failure was defined as the need for a second invasive procedure because of recurrent symptoms or persistent symptoms after UAE.

RESULTS

The median interval between the evaluation of the UFS-QOL questionnaire before and after UAE was 46.0 months. 70.6 % (12/17; 95 % confidence interval 44.0 %  - 88.6 %) of the patients had therapy response with a significant improvement of health-related quality of life and clinical symptoms (p-value = 0.002). The therapy failure rate was 29.4 % (5/17; 95 % confidence interval 11.4 %  - 56.0 %). One patient underwent dilatation and curettage and four patients underwent hysterectomy because of therapy failure.

CONCLUSION

UAE to treat symptomatic adenomyosis uteri can significantly improve the health-related quality of life and clinical symptoms. However, therapy failure is possible in up to one-third of patients.

[Magnetic resonance cholangiographic (MRCP) features of ischemic-type biliary lesions (ITBL): a case-control study]

PURPOSE

To evaluate the spectrum of MR cholangiography (MRCP) features of ischemic-type biliary lesions (ITBL) after orthotopic liver transplantation (OLT).

MATERIALS AND METHODS

30 patients (16 m, 14 f) with an average age of 52 years (9 - 69 y) were examined in two 1.5 MR units using breath-hold 2D-SS-FSE-sequences and 3D-MRCP sequences. 20 of the 30 patients had an established ITBL, and the remaining 10 patients were post-OLT controls. MRCPs were evaluated independently by two experienced radiologists that were blinded to the clinical history as well as the results of other imaging modalities. All images were analyzed for the presence of 16 different pathological features. Differences between ITBL patients and controls were analyzed using the Mann-Whitney-U Test. Inter-rater variability was tested using the Cohen's Kappa test.

RESULTS

Abnormal findings of bile ducts were seen in all patients. The most common findings were (in percentage for reader 1 / 2) intrahepatic bile duct dilatation (95 % / 95 %) and extrahepatic bile duct stenoses (95 % / 85 %), followed by intrahepatic main duct stenoses (90 % / 95 %) and segmental duct stenoses (85 % / 85 %). Differences between ITBL patients and controls were significant for most of the analyzed features (Mann-Whitney-U test, p < 0.05). For 12 of 16 features, there was substantial or almost perfect agreement (κ = 0.61 - 1.00), for 2 of 16 features moderate agreement (κ = 0.41- 0.60) and for 2 of 16 features fair agreement (κ < 0.40).

CONCLUSION

In patients with ITBL, MR cholangiography reveals characteristic features that may allow differentiation from other biliary complications after liver transplantation.

[Imaging before and after uterine artery embolization]

Percutaneous catheter-based embolization treatment of symptomatic uterine fibroids has evolved into the most widely used alternative therapeutic approach to surgical treatment worldwide. Uterine artery embolization (UAE) induces infarction of leiomyomas, resulting in ischemic necrosis, hyaline degeneration, and size reduction with resolution of associated symptoms. Published experience suggests that UAE is an effective and reliable option for treating uterine fibroids with high patient satisfaction.Magnetic resonance imaging (MRI) is superior to ultrasonography for determining the site, size and number of fibroids, which is important for establishing the indication for UAE. Other potential advantages of MRI include the option of performing MR angiography (MRA) and obtaining contrast-enhanced images for monitoring the outcome of UAE and assessing possible complications after UAE.

[Preoperative imaging in 78 living kidney donors using CE-MRA and DSA]

PURPOSE

To evaluate contrast-enhanced 3D magnetic resonance angiography (CE-MRA) and digital subtraction angiography (DSA) in comparison with the intraoperative findings in living kidney donors.

MATERIALS AND METHODS

A total of 156 kidneys in 78 potential kidney donors were prospectively examined using CE-MRA (0.2 mmol Gd/kg, voxel size 1.3 x 0.8 x 2.0) and DSA. Two experienced radiologists assessed the images in consensus regarding the renal vascular anatomy and variants. The results for the 67 candidates accepted for donation were compared to the intraoperative findings. In the other kidneys not accepted for donor nephrectomy, MRA and DSA were compared with each other.

RESULTS

Nineteen arterial variants were identified intraoperatively, of which 11 (58%) were also detected by preoperative CE-MRA and 10 (53%) by preoperative DSA. Of the 10 venous variants found intraoperatively, CE-MRA detected 8 (80%) and DSA 3 (30%). The agreement (kappa test) between MRI and DSA for all 156 evaluated kidneys was 0.7 for arterial variants (McNemar p=0.12) and 0.3 for venous variants (McNemar p=0.01). The preoperative choice of kidney (right or left) made on the basis of the renal vascular anatomy seen on CE-MRA and DSA differed in 22% of the 78 potential donors (McNemar p=0.3).

CONCLUSION

Our results in a large group of potential living kidney donors suggest that CE-MRA and DSA are comparable for detecting arterial renal variants while CE-MRA is superior for identifying venous variants. The preoperative choice of transplant kidney was not significantly influenced by the different results of CE-MRA and DSA.

[Current state of uterine artery embolization for treating symptomatic leiomyomas of the uterus]

A number of new approaches in treating symptomatic leiomyomas of the Uterus have been introduced in recent years. Only little scientific data is available an percutaneous or laparoscopic myolysis using focussed ultrasound, laser, or coagulation guided by magnetic resonance imaging or an laparoscopic ligation of the uterine vessels by means of bipolar coagulation or clipping. Established therapeutic options are limited by a number of disadvantages, except for total laparoscopic hysterectomy with morcellation. The latter is a minimally invasive procedure that spares important pelvic structures and thereby reduces the risk of prolapse and is associated with rapid recovery of the patients. Another minimally invasive therapeutic approach with preservation of the uterus is transarterial catheter embolization of uterine leiomyomas in which the vessels supplying the leiomyomas, in particular the branches of the uterine artery, are partly occluded by injection of synthetic (polyvinyl) beads. Uterine artery embolization has since developed into a good alternative to other therapeutic options. Studies report cure rates ranging from 77-93 %.

Transarterielle Embolisation bei Uterus myomatosus: klinische Erfolgsrate und kernspintomographische Ergebnisse

PURPOSE

To analyze the clinical success rate and the findings of magnetic resonance imaging (MRI) after uterine artery embolization of symptomatic leiomyomas (fibroids) of the uterus.

MATERIALS AND METHODS

This is a prospective single-center case study of 80 consecutively treated patients, followed for 3 - 6 months (group I), 7 - 12 months, (group II), and 13 - 25 months (group III). MRI was used to determine the uterine volume and size of the dominant leiomyoma. Symptoms and causes requiring repeat interventions were analyzed.

RESULTS

Significant (p < 0.01) volume reduction of the uterus (median: 34.95 % confidence interval [CI]: 30.41 - 41.76 %) and dominant leiomyoma (median: 52.07 %, CI: 47.71 - 61.57 %) was found. The decrease in uterine volume (I-III: 22.68 %, 33.56 %, 47.93 %) and dominant leiomyoma volume (I-III: 41.86 %, 62.16 %, 73.96 %) progressed with the follow-up time. Bleeding resolved significantly (p < 0.0001) in all three follow-up groups (groups I-III: 92.86 %, 95.23 %, 96.67 %). Furthermore, urinary frequency (groups I-III: 70 %, 75 %, 82.35 %) and sensation of pelvic pressure (groups I-III: 42.86 %, 60 %, 93.75 %) improved, which was statistically significant in group III (p < 0.01). The number of leiomyomas correlated (p < 0.05) with improvement of the bleeding and the pelvic pressure. Repeat therapy was necessary for complications in four patients (5 %) and for therapeutic failure in three patients (3.8 %). Permanent amenorrhea was observed in four patients (5 %) of age 45 years or older.

CONCLUSION

Uterine artery embolization of uterine leiomyomas has a high clinical success rate with an acceptable incidence of complications and repeat interventions.

Early Postoperative Ultrasound of Kidney Transplants: Evaluation of Contrast Medium Dynamics Using Time-intensity Curves

OBJECTIVE

To evaluate kidney recipients in the early posttransplant phase by semiquantitative analysis of the arterial arrival of ultrasound (US) contrast medium using time-intensity curves.

PATIENTS AND METHODS

Twenty-two kidney recipients underwent US examination after intravenous bolus administration of 2.4 ml of US contrast medium (SonoVue, Bracco Altana) 5 to 7 days after transplantation. The examinations were performed with the Aplio US system (Toshiba) and a 3.5-MHz wideband transducer using contrast harmonic imaging at a low mechanical index of 0.1. Arterial arrival was documented digitally over 60 sec (image repetition rate: 10 images per sec) for subsequent evaluation of contrast medium kinetics in the main renal artery, interlobar artery, subcapsular area, and renal vein using the system's integrated time-intensity curve (TIC) software. The increase, decrease, and percentage enhancement factor were calculated from the curves. Four patients were excluded from analysis because of perirenal hematoma (n = 3) or a polar perfusion loss demonstrated by power Doppler (n = 1).

RESULTS

Twelve of the remaining 18 patients assigned to the nonrejection group showed an uneventful clinical course. These had uniform TICs with an early and steep increase of similar magnitude in the main renal artery (11.7 +/- 4.5 intensity units/sec), interlobar artery (8.7 +/- 4.6 intensity units/sec), and subcapsular area (8.3 +/- 3.7 intensity units/sec) followed by a washout and subsequent plateau phase. Six patients showed histologically proven acute rejection on day 5 or 6 after transplantation (rejection group). This group had a delayed (time to peak in the subcapsular area: 32.9 +/- 8.3 sec in the rejection group versus 20.9 +/- 4.7 sec in the nonrejection group, p < 0.05) and smaller subcapsular percentage increase (41.2 +/- 21.9 % versus 114.4 +/- 59.8 %, p < 0.05). In the rejection group the subcapsular area (3.8 +/- 2.3 intensity units/sec) showed a less pronounced increase than the main renal artery (7.9 +/- 5.9 intensity units/sec) and interlobar artery (8.7 +/- 3.8 intensity units/sec). The RI in the rejection group was in the normal range at the time of contrast-enhanced US (day 5: 0.78 +/- 0.06) and increased to abnormal levels in the further course (day 7: 0.94 +/- 0.09).

CONCLUSIONS

Quantitative determination of arterial arrival of an US contrast medium in the early phase after kidney transplantation is possible. This new US procedure might identify acute rejection earlier than conventional techniques.

Technische Erfolgsrate, peri-interventionelle Komplikationen und Strahlenexposition der transarteriellen Embolisation bei Uterus myomatosus

PURPOSE

To analyze the technical success rate, incidence and type of peri-interventional complications, and radiation exposure of uterine artery embolization (UAE) in symptomatic leiomyomas of the uterus.

MATERIALS AND METHODS

This prospective study includes 75 patients consecutively treated with UAE from October 2000 through August 2002, with all interventions performed by the same radiologist. Technical success rate, interventional material, and incidence and type of peri-interventional complications (length of hospitalization) were recorded and categorized according to the definitions of the Society of Interventional Radiology (SIR). Fluoroscopy time (FT), dose-area product (DAP), and effective dose (ED) were determined for each intervention and the influence of the radiologist's experience on the radiation exposure analyzed.

RESULTS

UAE was technically successful in 97.3 % of the cases. Peri-interventional complications occurred in 14.7 %. Four complications (5.3 %) were classified as major class C according to the SIR (post-embolization syndrome requiring prolonged drug treatment and hospitalization [n = 3] perforation of the uterine artery [n = 1]). None of the complications led to discontinuation of the intervention, subsequent surgical intervention, or permanent sequelae. FT decreased significantly (p < 0.05) until the 35th intervention. The median FT decreased from 18.8 min (13.4 - 28 min [25th to 75th percentile]) to 11.8 min (9.7 - 13.3 min [25th to 75th percentile]). The DAP decreased by 25.3 % to a median of 8.547 (6.527 - 11.590 cGy*cm (2) [25th to 75th percentile]). The median ED was 31.5 mSv from the 36th intervention onward.

CONCLUSION

UAE has a high technical success rate with a low rate of peri-interventional complications. The study showed a statistically significant learning effect with a decrease in radiation exposure for the first 35 interventions. The effective dose of UAE is comparable to that of 1 to 2 small bowel enema.

Double contrast MRI of thermally ablated liver metastases

PURPOSE

To investigate the ability of double contrast MRI (enhancement with iron oxide and gadopentetate dimeglumine) to increase the difference in contrast between various tissues after thermal ablation of liver metastases.

MATERIALS AND METHODS

12 patients were imaged after MR-guided laser-induced thermotherapy (LITT). Imaging was performed with a 1.5T MR system. Nonenhanced, iron oxide-enhanced and double contrast images were acquired using T (1)-weighted GRE and T (2)-weighted TSE sequences. Iron oxide imaging was performed 10 min after injection of 1.4 ml ferucarbotran (Resovist(R), Schering AG Berlin, Germany) and double contrast imaging 60 sec after the additional injection of 0.1 mmol/kg body weight gadopentetate dimeglumine (Magnevist(R), Schering AG Berlin, Germany). Qualitative and quantitative assessment was performed on induced necroses, residual or recurrent tumor tissue and metastatic tissue untreated at the time of the study.

RESULTS

Iron oxide-enhanced T (1) GRE images demonstrated the highest contrast between ablated hyperintense tissue and iron accumulating and resultant hypointense liver parenchyma. Due to Gd enhancement, double contrast T (1)-weighted GRE images displayed the highest change in signal intensity in vital tumor tissue compared to ablated tissue and iron oxide accumulating liver parenchyma (p < 0.01).

CONCLUSIONS

First observations indicate that LITT of hepatic metastases can be better followed with double contrast MRI, which displays increased contrast due to Gd enhancement of perfused tumor tissue and signal intensity loss in iron oxide accumulating hepatic parenchyma. Induced necrosis does not change its signal intensity at all after injection of iron oxide and Gd-containing contrast media.

Stellenwert der Magnetresonanztomographie f�r Indikationsstellung, Interventionsplanung und Nachsorge bei transarterieller Embolisationsbehandlung des Uterus myomatosus

AIM

To describe the role of magnetic resonance imaging (MRI) in establishing the indication for, planning, and following up uterine artery embolization (UAE) for treating symptomatic leiomyomas of the uterus on the basis of the current literature and our results.

MATERIAL AND METHODS

Retrospective analysis of the MRI findings obtained in 130 patients before and after UAE. Presentation of characteristic MRI features and their relevance in establishing the indication for, performing, and following up of UAE. Discussion of the results in conjunction with published data.

RESULTS

The intermediate results of UAE reported in the literature show a successful improvement of leiomyoma-related symptoms in 82-94% of cases and an average reduction of leiomyoma size by 36-64%. The typical MRI appearance of degenerating leiomyomas is presented together with that of relevant differential diagnoses. MRI findings allow for establishing the indication for UAE by providing reliable information on the location, size, and number of uterine leiomyomas. Analysis of 60 patients of our study population showed solitary leiomyoma in 16% of cases, 2-10 leiomyomas in 47%, and over 10 in 37%. Subserosal, pedunculated leiomyomas cannot be treated by UAE; these were present in 5% of the patients. MR angiography is useful in assessing pelvic vascular anatomy before the intervention and identifies collateral vascular supply to the uterus. Contrast-enhanced imaging is suitable for monitoring successful devascularization following embolization and evaluating complications.

[Uterine fibroid embolization - a new therapeutic option for symptomatic leiomyomata of the uterus]

Uterine fibroid embolization (UFE) is a new minimal-invasive therapy for the treatment of symptomatic leiomyomata of the uterus and a uterine-sparing alternative to surgical procedures. Short-term and mid-term results indicate a high clinical success rate with improvement of fibroid-related bleeding symptoms in 80 - 100 % of cases, improvement of bulk symptoms in 60 - 100 % of cases and reduction in fibroid volume at an average of about 36 - 78 % combined with a low rate of complications and side effects. This review discusses indications and contraindications, technique and pathophysiology, choice of material, results and complications of UFE on the basis of the current literature and our own results.

Multifocal nodular fatty infiltration of the liver mimicking metastatic disease on CT: imaging findings and diagnosis using MR imaging

The aim of this study was to describe the MR appearance of multifocal nodular fatty infiltration of the liver (MNFIL) using T1-weighted in-phase (IP) and opposed-phase (OP) gradient-echo as well as T2-weighted turbo-spin-echo sequences with fat suppression (FSTSE) and without (HASTE). Magnetic resonance imaging examinations at 1.5 T using T1-weighted IP and OP-GRE with fast low angle shot (FLASH) technique, and T2-weighted FSTSE, T2-weighted HASTE of 137 patients undergoing evaluation for focal liver lesions were reviewed. Five patients were identified in whom CT indicated metastatic disease; however, no liver malignancy was finally proven. Diagnosis was confirmed by biopsy (n = 3), additional wedge resection (n = 1) or follow-up MRI 6-12 months later (n = 5). Regarding the identified five patients, the number of focal liver lesions was 2 (n = 2) and more than 20 (n = 3). The MR imaging characteristics were as follows: OP-image: markedly hypointense (n = 5); IP image: isointense (n = 2) or slightly hyperintense (n = 3); T2-weighted FSTSE-image: isointense (n = 5); T2-weighted HASTE image isointense (n = 1); slightly hyperintense (n = 4). On OP images all lesions were sharply demarcated and of almost spherical configuration (n = 5). Further evaluation by histology or follow-up MR imaging did not give evidence of malignancy in any case. Histology revealed fatty infiltration of the liver parenchyma in three patients. Magnetic resonance follow-up showed complete resolution in two patients and no change in three patients. Multifocal nodular fatty infiltration can simulate metastatic disease on both CT and MR imaging. The combination of in-phase (IP) and opposed-phase (OP) gradient-echo imaging can reliably differentiate MNFIL from metastatic disease.

Long-term survival after radical resection of a primary angiosarcoma of the innominate vein

The case updated here demonstrates the longest survival that has been observed so far after radical resection of primary angiosarcoma of the left innominate vein, which is the second case that has ever been reported to date. Radical resection was performed after preoperative radiotherapy. The venous continuity was restored by expanded polytetrafluoroethylene graft interposition. This case underscores that the prognosis of primary venous sarcoma, though fatal in the majority of patients, may be better in individual cases when radical surgery with curative intention is achieved.