Roles of spectral dual-layer CT, D-dimer concentration, and COVID-19 pneumonia in diagnosis of pulmonary embolism.

Purpose: To demonstrate advantages of spectral dual-layer computed tomography (CT) in diagnosing pulmonary embolism (PE). To compare D-dimer values in patients with PE and concomitant COVID-19 pneumonia to those in patients without PE and COVID-19 pneumonia. To compare D-dimer values in cases of minor versus extensive PE. Methods: A monocentric retrospective study of 1500 CT pulmonary angiographies (CTPAs). Three groups of 500 consecutive examinations: 1) using conventional multidetector CT (CTC), 2) using spectral dual-layer CT (CTS), and 3) of COVID-19 pneumonia patients using spectral dual-layer CT (COV). Only patients with known D-dimer levels were enrolled in the study. Results: Prevalence of inconclusive PE findings differed significantly between CTS and CTC (0.8 % vs. 5.4 %, p < 0.001). In all groups, D-dimer levels were significantly higher in PE positive patients than in patients without PE (CTC, 8.04 vs. 3.05 mg/L; CTS, 6.92 vs. 2.57 mg/L; COV, 10.26 vs. 2.72 mg/L, p < 0.001). There were also statistically significant differences in D-dimer values between minor and extensive PE in the groups negative for COVID-19 (CTC, 5.16 vs. 8.98 mg/L; CTS 3.52 vs. 9.27 mg/L, p < 0.001). The lowest recorded D-dimer value for proven PE in patients with COVID-19 pneumonia was 1.19 mg/L. Conclusion: CTPAs using spectral dual-layer CT reduce the number of inconclusive PE findings. Plasma D-dimer concentration increases with extent of PE. Cut-off value of D-dimer with 100 % sensitivity for patients with COVID-19 pneumonia could be doubled to 1.0 mg/L. This threshold would have saved 110 (22 %) examinations in our cohort.

How to follow the new EU Council recommendation and improve prostate cancer early detection: the Prostaforum 2022 declaration.

An updated Council of the EU recommendation on cancer screening was adopted in December 2022 during the Czech EU presidency. The recommendation included prostate cancer as a suitable target disease for organised screening, and invited countries to proceed with piloting and further research. To support further discussions and actions to promote early detection of prostate cancer, an international conference in November 2022 (Prostaforum 2022) resulted in a joint declaration. Here we describe the EU policy background, summarise the preparation of the declaration and the key underlying evidence and expert recommendations, and report the text of the declaration. The declaration summarises the striking inequalities in prostate cancer burden in Europe and calls on all stakeholders to consider and support concrete steps for advancement of organised early detection of prostate cancer. Our aim is to request endorsement of the text and potential initiation of practical actions by all stakeholders to support the aims of the declaration. Patient summary: Prostate cancer is among the most frequent cancers and is one of the most common causes of cancer death among men. The European Union has recommended new pilot programmes for prostate cancer screening. The Prostaforum 2022 declaration invites all stakeholders to support this new recommendation with specific steps.

Volumetric Analysis of Hepatocellular Carcinoma After Transarterial Chemoembolization and its Impact on Overall Survival.

BACKGROUND/AIM: To evaluate the prognostic value of Response Evaluation Criteria In Solid Tumors (RECIST), modified RECIST and volumetric analysis in patients with hepatocellular carcinoma (HCC) treated by transarterial chemoembolization (TACE). PATIENTS AND METHODS: This single-center prospective cohort study included a total of 61 patients with HCC treated by transarterial chemoembolization (TACE). The response of TACE was evaluated on preprocedural and postprocedural CT by two radiologists using RECIST/mRECIST and volumetric response to treatment. Each response assessment method was used to classify the response as progressive disease, stable disease, partial response and complete response. Kaplan-Meier analysis with log-rank test was performed for each method to evaluate its ability to help predict overall survival and progression free survival. Interobserver variability and reproducibility was determined by the Pearson and Spearman correlation coefficients. RESULTS: The median overall survival was 17.1 months and the median progression-free survival was 11.1 months. Volumetric assessment was proved to be a prognostic factor for overall survival (p<0.01) and progression-free survival (p<0.001), contrasting with RECIST and mRECIST. All three methods featured very small interobserver variability (p<0.001 for Pearson and Spearman correlation coefficients). The patients classified as having stable disease had a 3.8-fold higher risk of death than the patients classified as having a complete/partial response (HR=3.82; 95% Confidence Interval (CI)=1.32-11.02; p=0.013) and a 4.5-fold higher risk of progression (HR=4.46; 95% CI=1.72-11.61; p=0.002). CONCLUSION: The prognostic value of volumetric analysis in patients with HCC treated by TACE appears to be superior to RECIST and mRECIST, with a real impact in everyday practice.

Contrast-Enhanced Ultrasonography for Differential Diagnosis of Benign and Malignant Thyroid Lesions: Single-Institutional Prospective Study of Qualitative and Quantitative CEUS Characteristics.

Objectives: To extend and revise the diagnostic value of contrast-enhanced ultrasonography (CEUS) for differentiation between malignant and benign thyroid nodules. Methods: This single-institution prospective study aims to compare CEUS qualitative and objective quantitative parameters in benign and malignant thyroid nodules. Consecutive cohort of 100 patients was examined by CEUS, 68 out of them were further analysed in detail. All included patients underwent cytological and/or histopathological verification of the diagnosis. Results: Fifty-five (81%) thyroid nodules were benign, and 13 (19%) were malignant. Ring enhancement pattern was strongly associated with a benign aetiology (positive predictive value 100%) and heterogeneous enhancement pattern with malignant aetiology (positive predictive value 72.7%). The shape of the TIC (time-intensity curve) was more often identical in the benign lesion (98.2%) than in malignant lesions (69.2%), p=0.004. Conclusions: This study indicates that CEUS enhancement patterns were significantly different in benign and malignant lesions. Ring enhancement was a very strong indicator of benign lesions, whereas heterogeneous enhancement was valuable to detect malignant lesions.

Percutaneous Endoluminal Radiofrequency Ablation of Occluded Biliary Metal Stent in Malignancy Using Monopolar Technique: A Feasibility Study.

PURPOSE: To prove feasibility and safety of percutaneous endoluminal radiofrequency ablation (eRFA) using a monopolar approach in treatment of occluded biliary stent in malignancy. MATERIALS AND METHODS: The study included 11 patients with occluded biliary metal stent that had been implanted due to malignant biliary obstruction. All underwent metal stent recanalization by percutaneous eRFA in monopolar setting. Sixteen eRFA procedures were performed under fluoroscopic guidance with an EndoHPB 8F radiofrequency ablation catheter. The effect of stent recanalization was assessed based upon change from pre- to post-procedural diameter of the patent lumen of the metal stent (Wilcoxon test), primary and secondary stent patency (compared by log-rank test), catheter-free period, and overall survival. Adverse events were evaluated according to Common Terminology Criteria for Adverse Events (CTCEA) 4.0. RESULTS: Recanalization of the metal stent by monopolar radiofrequency ablation was successful in all 11 patients. Diameter of the patent lumen of the stent significantly widened after the eRFA inside the stent (median 2 vs. 7 mm, p = 0.003). Grade 1 complications were observed in one-third of procedures. Median stent patency after recanalization by eRFA was non-inferior to primary metal stent patency (154 vs. 161 days, p = 0.27). Median catheter-free survival and overall survival after stent recanalization were 149 and 210 days, respectively. CONCLUSION: Endoluminal radiofrequency ablation in monopolar setting was shown to be a feasible and safe method for recanalization of occluded biliary metal stents. LEVEL OF EVIDENCE: Level 4, Case Series.

The combination of endoluminal radiofrequency ablation and metal stent implantation for the treatment of malignant biliary stenosis - Randomized study.

PURPOSE: To analyse whether endobiliary radiofrequency ablation prior metal stent insertion in malignant biliary stenosis show improved survival or stent patency. METHODS: 76 patients with histologically proven malignant biliary stenosis have been enrolled in a prospective, randomized study. In control arm, 40 patients underwent self-expandable metal stent insertion. In experimental arm, the endoluminal ablation with a bipolar radiofrequency catheter was performed immediately before stent insertion. A subgroup analysis of cholangiocarcinoma was performed (22 vs 21 patients). The objective of the study was to determine the rate of complications, duration of the stent patency and the survival of patients (Kaplan-Meier analysis). RESULTS: No major complications related to the stent insertion and the endoluminal ablation were found. The mean primary stent patency was 5.2 (95% CI 0.7-12.8) vs 4.8 months (95% CI 0.8-18.2) months (p = 0.79) in control and experimental group, respectively, in the subgroup analysis with cholangiocarcinoma 4.5 (95% CI 0.8-10.3) and 9.6 (95% CI 5.2-11.2) months (p = 0.029). The median survival since the insertion of the stent was 6.8 (95 %CI 3.0-10.6) vs 5.2 (95 %CI 2.4-7.9) months (p = 0.495) and since the initial drainage 9.8 (95 %CI 6.9-12.7) vs 9.1 (95 %CI 5.4-12.7) months (p = 0.720) in the control and experimental arm. CONCLUSION: Endobiliary radiofrequency ablation prior metal stent insertion showed increased patency rate only in patients with cholangiocarcinoma, on the other hand, no improvement in survival was demonstrated in this randomized clinical study.

Retrospective analysis of the incidence of pulmonary embolism in CT images in patients with a positive value of D-dimers.

AIM: The analysis of the correlation between D-dimer and positive finding of pulmonary embolism on CT-angiography. Determination of the cut-off value of D-dimers, which would lead to a reduction in the number of examinations on CT-angiography. MATERIALS AND METHODS: Patients who had positive D-dimer values in their blood tests and were examined using CT-angiography were included in the analysis. The relationship between the D-dimer value and the finding of pulmonary embolism on CT-angiography was analyzed. The analysis included 91 consecutive patients (46 women, 64,5 ± 18,8 years) examined from December 2019 to January 2020. RESULTS: The mean value of D-dimers in patients with proven pulmonary embolism on CT was statistically significantly higher than in patients without embolism (7,46 vs 2,93 mg/l; p < 0,001). Of the total number of patients examined on CT, pulmonary embolism was confirmed in 21 (23 %). We did not show a statistically significant difference in the incidence of pulmonary embolism in one sex (52 % female vs 48 % male; p = 1,000), nor the relationship between age and the incidence of pulmonary embolism (64,2 vs 64,5 years; p = 0,981). Based on ROC analysis, we determined a high probability of negative CT-angiography at the value of D-dimers up to 1,7 mg/l (negative predictive value 95,7 %). We also determined the value of D-dimers 3,5 mg/l, from which the probability of pulmonary embolism on CT is high (specificity 81,4 %). CONCLUSION: Based on a retrospective analysis of patients with measured values of D-dimers and objectification of the finding of pulmonary embolism on CT-angiography, we demonstrated a very low probability of pulmonary embolism at D-dimer values up to 1,7 mg/l. We also showed that at values above 3,5 mg/l, the probability of pulmonary embolism is high.

Prognostic Survival Factors of Hepatocellular Carcinoma Treated with Transarterial Chemoembolization.

PURPOSE: Identification of prognostic survival factors of hepatocellular carcinoma (HCC) treated with transarterial chemoembolization (TACE) in a single center in 2005-2018. BACKGROUND: Transarterial chemoembolization in hepatocellular carcinoma is indicated in Barcelona Liver Cancer Clinic (BLCC) stage B. This stage includes a very large group of patients unsuitable for curative treatment, who are in a good clinical condition and do not show extra-hepatic spread. The aim of this retrospective analysis is to identify factors influencing patient survival and to divide the patients into subgroups based on these risk factors. MATERIALS AND METHODS: All patients with HCC indicated for TACE in complex oncological center in 2005-2018 were included in the analysis. The survival rates from the 1st TACE were evaluated in relation to HCC on computed tomography/magnetic resonance prior to the 1st TACE (size of the biggest lesion, single/multiple lesions, unilobar/bilobar involvement), presence and severity of liver disease (cirrhosis, Child-Pugh, portal vein thrombosis) and a combination of other invasive treatment (resection, percutaneous ablation) (single and multivariate analysis). The survival of HCC patients was compared according to the year of the dia-gnosis and the year of the 1st TACE (log-rank test). RESULTS: Out of 382 patients, 157 (29 women) of them were treated with TACE (540 TACEs in total, median 3 TACEs per patient). The most important risk factors for survival were the presence of portal vein thrombosis (hazard ratio (HR) = 3.279), bilobar involvement (HR = 2.257), lesion size (HR = 1.125/cm) and Child-Pugh B in chronic liver disease (HR = 1.922). Based on these risk factors, the patients were divided into 3 prognostic groups with different median survival (52.1 vs. 21.5 vs. 9.0 months). CONCLUSION: Based on the retrospective analysis, predictive factors of HCC survival after TACE were identified and the patients were divided into 3 prognostic groups based on these factors.

Prospective evaluation of contrast-enhanced ultrasound of breast BI-RADS 3-5 lesions.

BACKGROUND: To determine the benefit of contrast-enhanced ultrasound (CEUS) in the assessment of breast lesions. METHODS: A standardized contrast-enhanced ultrasound was performed in 230 breast lesions classified as BI-RADS category 3 to 5. All lesions were subjected to qualitative and quantitative analysis. MVI (MicroVascular Imaging) technique was used to derive qualitative analysis parameters; blood perfusion of the lesions was assessed (perfusion homogeneity, type of vascularization, enhancement degree). Quantitative analysis was conducted to estimate perfusion changes in the lesions within drawn regions of interest (ROI); parameters TTP (time to peak), PI (peak intensity), WIS (wash in slope), AUC (area under curve) were obtained from time intensity (TI) curves. Acquired data were statistically analyzed to assess the ability of each parameter to differentiate between malignant and benign lesions. The combination of parameters was also evaluated for the possibility of increasing the overall diagnostic accuracy. Biological nature of the lesions was verified by a pathologist. Benign lesions without histopathological verification (BI-RADS 3) were followed up for at least 24 months. RESULTS: Out of 230 lesions, 146 (64%) were benign, 67 (29%) were malignant, 17 (7%) lesions were eliminated. Malignant tumors showed statistically significantly lower TTP parameters (sensitivity 77.6%, specificity 52.7%) and higher WIS values (sensitivity 74.6%, specificity 66.4%) than benign tumors. Enhancement degree also proved to be statistically well discriminating as 55.2% of malignant lesions had a rich vascularity (sensitivity 89.6% and specificity 48.6%). The combination of quantitative analysis parameters (TTP, WIS) with enhancement degree did not result in higher accuracy in distinguishing between malignant and benign breast lesions. CONCLUSIONS: We have demonstrated that contrast-enhanced breast ultrasound has the potential to distinguish between malignant and benign lesions. In particular, this method could help to differentiate lesions BI-RADS category 3 and 4 and thus reduce the number of core-cut biopsies performed in benign lesions. Qualitative analysis, despite its subjective element, appeared to be more beneficial. A combination of quantitative and qualitative analysis did not increase the predictive capability of CEUS.