Brachytherapy of liver metastases.

Brachytherapy for the treatment of liver metastases is a novel approach. In this procedure, techniques of locally ablative treatment in interventional radiology and radiation therapy are combined. After computed tomography (CT)-guided percutaneous implantation of catheters into the hepatic tumor, the irradiation is performed in an afterloading technique. This minimally invasive procedure offers circumscriptive high-dose rate irradiation of the lesion to treat in a single session, irrespective of breathing motion or potential cooling effects of neighboring vessels. Good local control rates have been achieved in several tumor entities, including both secondary and primary malignancies of the liver. This article gives an overview of the application technique, possible adverse events, and outcome with special attention to the pancreatic cancer scenario.

[Metastatic lesions to the pancreas. When is resection reasonable?]. / Metastasen im Pankreas. Wann ist eine Resektion sinnvoll?

BACKGROUND: The significance of pancreatic resection for pancreatic metastatic lesions has not yet been sufficiently investigated. A retrospective analysis of patients undergoing pancreatic resections for pancreatic metastases was conducted. MATERIAL AND METHODS: Twenty patients were resected due to metastatic lesions to the pancreas. Histopathological findings were: renal cell carcinoma (n=9), colon carcinoma (n=1), malignant schwannoma (n=2), leiomyosarcoma (n=2), teratocarcinoma (n=1), adenocarcinoma of the oesophagus (n=1), gallbladder carcinoma (n=1), malignant melanoma (n=1), gastrointestinal stromal tumor (n=1), and spindle cell tumor (n=1). Operative procedures were standard pancreaticoduodenectomy (n=6), pylorus-preserving pancreaticoduodenectomy (n=6), and distal pancreatectomy (n=8). RESULT: The overall 5-year survival rate was 61%, for patients with renal cell carcinoma 100%. CONCLUSION: Pancreatic metastasectomy is a reasonable therapeutic option in suited patients. Patients with pancreatic metastases of renal cell carcinoma achieved excellent prognoses after radical resection.

Repeat liver resection for recurrent liver metastases from colorectal cancer.

AIMS: Numerous patients suffer from recurrence after resection of liver metastases from colorectal cancer. Recurrence is frequently restricted to the liver and repeat liver resection may offer a curative option in these patients. This study was conducted to clarify safety and effectiveness of this treatment and to identify prognostic factors of a favourable outcome after repeat hepatectomy. METHODS: Between January 1988 and March 2006 in our institution 811 patients underwent 841 liver resections for metastases from colorectal cancer. Among these, 94 patients underwent a repeat hepatectomy. Patients were identified from a prospective database and retrospectively reviewed. Results of different time periods were assessed and prognostic factors for a favourable outcome were determined. RESULTS: The perioperative morbidity and mortality was 24% (23 of 94) and 3% (3 of 94), respectively. The one-, three-, five- and ten-year survival for all patients in this series was 89%, 55%, 38% and 23%, respectively. In the univariate analysis, pT-stage of the primary, diameter of the largest metastases, surgical radicality, period of resection and distribution of metastases showed statistically significant influence on survival. The multivariate analysis revealed only pT-stage of the primary tumour, surgical radicality and period of resection as independent prognostic factors. CONCLUSIONS: Repeat hepatectomy is a safe and effective treatment for recurrent liver metastases from colorectal cancer. Perioperative risk and long-term survival were similar when compared to the results obtained during the initial resection. Achieving a curative resection is the most relevant prognostic factor for a favourable prognosis after repeat liver resection.

[A method for reassessment of cost-intensive cases in visceral surgery. Results of project by the German Society for Visceral Surgery]. / Methode zur Abbildung kostenintensiver Fälle in der Viszeralchirurgie. Ergebnisse des DRG-Projekts der Deutschen Gesellschaft für Viszeralchirurgie.

Since the introduction of diagnosis-related groups (DRGs) many surgical departments report inappropriate reimbursement for complex cases and a shift in costly cases. To evaluate this situation, the German Society for Visceral Surgery inaugurated the present cost calculation project. In three university hospitals for 50 cases each, we depicted possible cost separators and utilized the complete cost calculation data (so-called Paragraph 21 data set) to test these separators. We identified "admission from another hospital", "severe surgically relevant concomitant disease", and "reoperation during the same hospital admission". The last was considered the economically most significant and medically most valid factor and was submitted as a possible modification to the german DRG system. The proposed cost separator "reoperation during the same hospital admission" was introduced into the DRG system after validation and leads to better allocation of reimbursements to complex and costly cases.

Multiinstitutional home-therapy trial of recombinant human interleukin-2 and interferon alfa-2 in progressive metastatic renal cell carcinoma.

PURPOSE: In a phase II multiinstitutional outpatient trial, patients with progressive metastatic renal cell carcinoma were treated with a combination of subcutaneous (SC) recombinant interleukin-2 (rIL-2) and recombinant interferon alfa-2 (rIFN alpha 2). PATIENTS AND METHODS: One hundred fifty-two patients with metastatic renal cell carcinoma were treated. Treatment courses consisted of SC rIL-2 at 20 x 10(6) IU/m2 three times per week in weeks 1 and 4, and at 5 x 10(6) IU/m2 three times per week in weeks 2, 3, 5, and 6. Additionally, patients received SC rIFN alpha 2 6 x 10(6) U/m2 once per week in weeks 1 and 4, and three times per week in weeks 2, 3, 5, and 6. RESULTS: There were nine (6%) complete responses (CRs) and 29 (19%) partial responses (PRs), for an overall response rate of 25% (95% confidence interval, 19% to 32%). The median duration of responses for CRs and PRs was 16+ and 9 months, respectively. Additionally, 55 patients (36%) had stable disease (SD). Fifty-nine patients (39%) had continued disease progression (PD) despite treatment, or went off study after less than 4 weeks of therapy. The majority of patients treated experienced fever, chills, malaise, nausea, vomiting, and anorexia, side effects that were mostly limited to World Health Organization (WHO) grade 1 and 2. However, one patient developed grade 4 CNS toxicity with extended somnolence. On cessation of therapy, the neurologic symptoms in this patient were fully reversible, with no neurologic deficiency. CONCLUSION: In summary, this multiinstitutional home-therapy setting of SC rIL-2 and SC rIFN alpha 2 in patients with progressive metastatic renal cell carcinoma demonstrated drastically reduced systemic toxicity, while it confirmed the therapeutic efficacy of the low-dose SC immunotherapy combination schedule.

[Combination of dynamic MR enteroclysis (Sellink) and MR colonography to diagnose Crohn's disease]. / Kombination von dynamischem MR-Sellink und MR-Kolonographie zur Diagnostik des Morbus Crohn.

PURPOSE: To investigate whether a combined examination with MRI enteroclysis and MRI colonography is practicable and would provide additional findings in the regions seen with ileo-colonoscopy in the work-up of patients with Crohn's disease. MATERIAL AND METHODS: Twenty-five consecutive patients with Crohn's disease (CD) (age range 19 to 42 years, mean age 29.2 years, gender ratio male:female 8:17) were retrospectively studied. All patients underwent conventional ileo-colonoscopy as a standard of reference followed by a combined examination of MRI enteroclysis and MRI colonography at 1.5T within 15 days. Two blinded radiologists evaluated the MRI examinations and compared them with the colonoscopic results. RESULTS: The MRI examination detected 31 inflamed bowel segments in 25 patients. In comparison to colonoscopy, 5 additional, endoscopically inaccessible lesions were found by MRI and only 2 lesions were missed by MRI. Compared to colonoscopy, MRI found 7 of 10 fistulas detected by colonoscopy, and 3 otherwise indiscernible abscesses. The detection of inflamed bowel segments by means of MRI (endoscopy) revealed a sensitivity of 88.8 % (100 %), specificity of 80 % (100 %) and an overall accuracy of 96 % (100 %). CONCLUSION: This study provides strong evidence that the combination of MRI enteroclysis and MRI colonography is practicable and supplies additional results regarding the regions which are not seen with ileo-colonoscopy in the work-up of patients with Crohn's disease.

[Malignant epithelioid hemangioendothelioma of the liver. Results of surgical treatment strategies]. / Malignes epitheloides Hämangioendotheliom der Leber. Ergebnisse der chirurgischen Behandlung.

BACKGROUND: Malignant epithelioid hemangioendothelioma is a rare vascular tumor described mostly in soft tissue, lungs, or liver. The outcome after a wide variety of therapeutic measures, ranging from extended surgical therapy to no therapy, is reported to be variable. Therefore, we reviewed our experience with resective therapy for this rare liver tumor, including orthotopic liver transplantation. MATERIAL AND METHODS: During a period of 5 years, seven patients with the histological diagnosis of hepatic epithelia hemangioendothelioma were seen. In five of them, the liver pathology was detected at random, and all patients were prospectively followed. The therapeutic measures and course of disease are given as case reports. RESULTS: Three patients received formal liver resection and two received liver grafts, one partial and one whole. One further patient is scheduled for transplantation and one is undergoing alternative therapy, with the tumor remaining stable. All resected patients recovered quickly and are alive and well 2 months to 4 years later without signs of tumor recidivism. CONCLUSION: Anatomic liver resection, or in the case of diffuse tumor spread, orthotopic liver transplantation, show favorable long-term results for the treatment of hepatic epithelioid hemangioendothelioma. Therefore, surgical therapy is proposed as the treatment of choice for this entity.

Chemoimmunotherapy of advanced malignant melanoma: sequential administration of subcutaneous interleukin-2 and interferon-alpha after intravenous dacarbazine and carboplatin or intravenous dacarbazine, cisplatin, carmustine and tamoxifen.

Both chemotherapy and interleukin-2 and/or interferon-alpha produce objective responses in a proportion of advanced malignant melanoma patients. While duration of response to chemotherapy is short, i.e. usually below 4 months, immunotherapy has resulted in a small number of long-lasting remissions in patients with metastatic melanoma. In two consecutive phase II trials in a total of 67 patients, we assessed the potential synergism between both modalities, i.e. chemo- and immunotherapy. Treatment consisted of intravenous (i.v.) carboplatin (CBDCA, 400 mg/m2) and dacarbazine (DTIC, 750 mg/m2) given twice (i.v. bolus over 30 min) at 3-week intervals, or 4 cycles of DTIC (220 mg/m2 i.v. 3 days), cisplatin (DDP, 35 mg/m2 i.v. 3 days), carmustine (BCNU, 150 mg/m2 i.v. cycles 1 and 3) and tamoxifen (TAM, 20 mg oral/daily) at 3-week intervals. Chemotherapy was followed by immunotherapy with combined subcutaneous (s.c.) interleukin-2 (rIL-2) and SC interferon-alpha 2 (rIFN-alpha). Among 40 patients who received a full cycle of chemotherapy with CBDCA/DTIC and sequential immunotherapy, there were 3 (7.5%) complete remissions (CRs) with a median duration of 19 months (range 13-26+). Partial remissions (PRs) were noted in 11 (27.5%) patients with a median response duration of 8 (range 5-14) months. Among 27 patients who received DTIC/DDP/BCNU/TAM and rIL-2/rIFN-alpha, there were 3 (11%) complete remissions and 12 (44.5%) partial remissions. Duration of complete and partial remissions ranged from 9+ to 13+ (median, 11+), and 5 to 15+ (median, 7+) months, respectively. Chemotherapy produced mostly moderate toxicity. Thrombocytopenia was common with the nadir after a median time of 18 days following start of CBDCA/DTIC and DTIC/DDP/BCNU, respectively. 10 patients required transfusion of thrombocytes. Nausea and vomiting due to chemotherapy were well tolerated using concomitant ondansetrone (8 mg i.v.). Immunotherapy was self-administered at home with mild to moderate side effects; malaise, fever, chills, nausea/vomiting, diarrhoea, anorexia and arthralgias were most frequent, but were spontaneously reversible after ending rIL-2/IFN-alpha. A mean 87 and 88% of the projected doses of rIL-2 and rIFN-alpha were administered on either protocol. There were no life-threatening complications and no treatment-related deaths. The sequential combination of chemotherapy and rIL-2 plus rIFN-alpha had at least additive therapeutic activity against metastatic malignant melanoma. The schedules produced long-lasting remissions and were tolerated well overall. These trials substantiate a potential role for low to intermediate dose immunotherapy in maintaining and consolidating therapeutic effects of chemotherapy in metastatic melanoma.

Preoperative contrast-enhanced MRI of the parathyroid glands in hyperparathyroidism.

RATIONALE AND OBJECTIVES: To evaluate the sensitivity of contrast-enhanced MRI in the preoperative detection of abnormal parathyroid glands in patients with clinical evidence of hyperparathyroidism. METHODS: Twenty-eight patients with biochemical evidence of hyperparathyroidism underwent contrast-enhanced preoperative MRI of the parathyroid glands. Two blinded readers assessed the MR images by consensus, and MR results were subsequently correlated with those from surgery (location, diameter, weight) and histopathology. RESULTS: MRI depicted 32 of 39 surgically proved abnormal parathyroid glands (sensitivity 82%; 95% confidence interval, 66%-92%), and 1 of 114 (0.9%) was incorrectly considered abnormal. All ectopic glands were correctly identified (2 mediastinal, 1 submandibular). Sensitivity was superior for adenomas but less for hyperplasia (adenomas 87%; 95% confidence interval, 67%-97%; hyperplasia 75%; 95% confidence interval, 47%-92%). Among all lesions, atypical signal characteristics on MRI were observed in 34% of lesions (9% hyperintense signals on T2- and T1-weighted images; 25% isointense signals on T2- and T1-weighted images), with improved lesion detection after contrast administration in 17% of lesions. CONCLUSIONS: MRI of the parathyroid glands presented a sensitive imaging modality, thus demonstrating its high potential to preoperatively detect abnormal glands. Moreover, in a minor proportion of patients with atypical parathyroid lesion characteristics, contrast administration may increase lesion detectability.

Wavelet versus JPEG (Joint Photographic Expert Group) and fractal compression. Impact on the detection of low-contrast details in computed radiographs.

RATIONALE AND OBJECTIVES: The aim of this study was to evaluate different lossy image compression algorithms in direct comparison. METHODS: Computed radiographs were reviewed after compression with Wavelet, Fractal, and Joint Photographic Expert Group (JPEG) algorithms. For receiver operating characteristic (ROC) analysis, 54 thoracic computed radiographs (31 showing pulmonary nodules) were compressed with a ratio of 1:60. Five images of a test-phantom were coded at 1:13. All images were reviewed on a PC. Uncompressed images were reviewed at a PC and at a radiologic workstation (with image processing). RESULTS: For thorax images, decrease of diagnostic accuracy was significant with Wavelets. Fractal performed worse than Wavelets. No ROC curve was observed for JPEG due to poor image quality. No diagnostic loss was noted comparing PC and Workstation review. For low-contrast details of the phantom, results of Wavelet compression were equal to uncompressed images. Fewer true positives and increased true negatives were noted with Wavelets though. Wavelets were superior to JPEG, and JPEG images were superior to Fractal. Workstation review was superior to PC review. CONCLUSIONS: Only Wavelets provided accurate review of low-contrast details at a compression of 1:13. Frequency filtering of Wavelets affects contrast even at a low compression ratio. JPEG performed better than Fractal at low and worse at high compression ratio.

Biphasic spiral computed tomography for detection of hepatocellular carcinoma before resection or orthotopic liver transplantation.

RATIONALE AND OBJECTIVES: The authors correlate computed tomography (CT) findings in biphasic spiral technique with histopathology in patients with hepatocellular carcinoma (HCC) who had undergone liver resection (LR) or orthotopic liver transplantation (OLT). METHODS: Preoperative biphasic spiral CT findings in 33 consecutive patients (23 men, 10 women, aged 43-74 years; LR group: n = 17; OLT group; n = 16) with liver cirrhosis and HCC were reviewed retrospectively by consensus of two radiologists and correlated with pathology from liver specimens. RESULTS: Of the 16 patients in the OLT group with 1 to 5 confirmed HCC lesions (total lesions: 29; mean lesion diameter: 2 cm; range: 0.6-5.0 cm), CT before OLT depicted 22 lesions in 15 patients (sensitivity for lesions with a diameter of 0.5-1.0 cm, 20%; for lesions 1.1-2.0 cm, 82%; and for lesions 2.1-3.0 cm and > 3.0 cm, 86% and 100%, respectively). Among the 17 patients in the LR group (total lesions: 21; mean lesion diameter: 5.4 cm; range: 1.0-11.0 cm), CT detected 18 lesions. Lesion-by-lesion sensitivity, as correlated with pathology, was calculated at 76% and 86% in the OLT and LR groups, respectively (overall sensitivity, 80%). The diameter of CT detected lesions, compared with liver specimens, corresponded in 90% of lesions (maximum deviation, 15%). Characteristic CT findings of HCC included unenhanced hypoattenuating focal liver lesions (32 lesions), with hyperattenuation (38 lesions) in the arterial phase of contrast material administration. CONCLUSIONS: Biphasic spiral CT for preoperative HCC detection correlated with pathology in 80%, thus proving this technique to represent a sensitive imaging modality for pretherapeutic evaluation of HCC.

Hepatic and serologic toxicity of systemic interleukin-2 and/or interferon-alpha. Evidence of a risk-benefit advantage of subcutaneous therapy.

A total of 107 cancer patients were treated with 148 cycles of subcutaneous (SC) immunotherapy employing interleukin-2 (rIL-2) and/or interferon-alpha (rIFN-alpha). The systemic toxicities of SC cytokine therapy were retrospectively evaluated with regard to hepatic and metabolic adverse effects, and compared to adverse effects previously reported upon high- or intermediate-dose intravenous (IV) rIL-2 therapy. Our study cohorts consisted of 15 patients who received SC rIL-2 at doses of 4.8-14.4 million IU/m2/day on 5 days per week for a total of 8 weeks, 20 patients who received rIFN-alpha 2b at 3.0-6.0 million U/m2/day thrice weekly for a total of 6 weeks, and 72 patients who were given SC rIFN-alpha 2b at 6.0 million U/m2/day thrice weekly plus SC rIL-2 at 14.4-18.0 million IU/m2/day on days 1 and 2, followed by 4.8 million IU/m2/day, 5 days per week for 6 consecutive weeks. These treatment regimens were well tolerated in the outpatient setting; no toxic deaths occurred, and none of the patients developed life-threatening toxicity. Upon SC rIL-2/rIFN-alpha combination therapy, we observed mild decreases in plasma protein and albumin levels (mean nadir +/- standard deviation, 67 +/- 5 g/L and 38.8 +/- 3.9 g/L, respectively), minor albeit significant increases in serum total bilirubin levels (mean peak +/- standard deviation, 7.8 +/- 3.1 mumol/L), serum aspartate aminotransferase (25.9 +/- 9.9 U/L), alanine aminotransferase (42.0 +/- 45.9 U/L), alkaline phosphatase (301 +/- 255 U/L), lactate dehydrogenase (230 +/- 64 U/L), gamma-glutamyl transpeptidase (147 +/- 141 U/L) activities and triacylglyceride (2.6 +/- 0.9 mmol/L) concentrations. Cholinesterase activities (mean nadir +/- standard deviation, 42.6 +/- 13.7 kU/L), and serum cholesterol levels (4.4 +/- 0.9 mmol/L) decreased upon SC rIL-2/rIFN-alpha combination therapy. These mild clinical side effects and laboratory changes were in marked contrast to a multitude of dose-limiting and life-threatening adverse reactions described upon IV rIL-2 therapy. It is concluded that low-to intermediate-dose SC rIL-2/rIFN-alpha combination therapy as used in this study, can be given in the outpatient setting with good practicability and excellent safety.

[The diagnostic value of radial multiplanar reformatting (MPR) in the CT-diagnosis of pulmonary embolism]. / Stellenwert radiärer Reformatierungen in der CT-Diagnostik der Lungenarterienembolie.

PURPOSE: To evaluate the diagnostic value of radial reformatting of axial multislice CT (MS-CT) data sets in the presumptive diagnosis of pulmonary embolism. MATERIALS AND METHODS: In 126 cases with the presumptive diagnosis of an acute pulmonary embolism, 4- and 8-slice axial MS-CT data sets were radially reformatted. The pulmonary vessels were evaluated by five experienced radiologists who determined the number of thrombi at the level of the segmental and subsegmental arteries. A pulmonary artery was considered as thrombosed if it showed at least one unambiguous filling defect on two consecutive sections. It was determined whether the artery was uniformly opacified without filling defects, contained thrombotic material or was completely occluded by a blood clot. Pulmonary vessels that could not be evaluated because of moving artifacts or inadequate opacification were classified as negative. Finally, all experts gave a subjective estimate concerning the simplicity of the diagnosis for both reconstructions. RESULTS: The diagnosis of thromboembolism at a subsegmental level was significantly different for axial sections and radial reconstruction: at 4-slice CT, 77 subsegmental thromboembolisms were found in axial sections vs. 98.6 in radial reconstructions; at 8-slice CT, 23.6 in axial sections vs. 31.2 in radial reconstructions; and using the combined evaluation, 103.2 in axial sections vs. 130.6 in radial reconstructions, with a significance of p = 0.043. The five judges did not find any significant differences in the number of the blood clots in each pulmonary segment. Concerning the simplicity of the diagnosis, the subjective judgment classified the radial reconstructions as better in 49.7 % and the axial sections as better in 22 %. The radial reconstructions of the 4-slice CT were classified as better in 45.7 % vs. 25 % and the 8-slice CT as better in 66 % vs. 16 %. CONCLUSION: Using radial multiplanar reformatting of the MS-CT data sets improves significantly the recognition of subsegmental pulmonary embolism.

[How certain is teleradiological telediagnosis for the tomographic procedure?]. / Wie sicher ist die teleradiologische Ferndiagnose für Schnittbildverfahren?

PURPOSE: To define the value of teleradiographic studies, a comparison was carried out between digitised copies of CT examinations of the skull with the original images. Differences in image quality obtained from a digital scanner and a camera were quantified. MATERIAL AND METHOD: 56 CT examinations of the skull, 28 of which had discrete abnormalities, were chosen for ROC analysis. The original films were digitised with a Vidar VXR-12 scanner and Panasonic WV-160 and WV-BP 500 cameras. The images were evaluated by five radiologists after image transfer with Video Conference software to a personal computer. RESULTS: For the analysis of the films the area under the ROC curve was 0.91 +/- 0.04, for the digital scanner it was 0.85 +/- 0.04, for camera WV-BP 500 0.89 +/- 0.06 and for camera WE-160 0.87 +/- 0.09. Comparison with the film findings showed. a minimal p-value of 0.17 which indicated that there was no significant reduction in diagnostic value following digitization. CONCLUSION: The probable reason for the slight deterioration using the digital scanner was the reduction to 75 dpi compared with 134 dpi on the CT films. The cameras produce image noise comparable to CT with low window settings and reduced local resolution. We expect similar results for CT with soft tissue windows or for MRT of the skull. Conventional radiographs containing high local resolution, wide grey scale and low image noise would presumably make higher demands on methods of digitization.

Preoperative localization of parathyroid glands. Use of MRI, scintigraphy, and image fusion.

AIM: Minimally invasive resection of hyperfunctional parathyroid glands is an alternative to open surgery. However, it requires a precise preoperative localization. This study evaluated the diagnostic use of magnetic resonance (MR) imaging, parathyroid scintigraphy, and consecutive image fusion. PATIENTS, METHODS: 17 patients (9 women, 8 men; age: 29-72 years; mean: 51.2 years) with primary hyperparathyroidism were included. Examination by MRI used unenhanced T1- and T2-weighted sequences as well as contrast-enhanced T1-weighted sequences. (99m)Tc-MIBI scintigraphy consisted of planar and SPECT (single photon emission tomography) imaging techniques. In order to improve the anatomical localization of a scintigraphic focus, SPECT-data were fused with the corresponding MR-data using a modified version of the Express 5.0 software (Advanced Visual Systems, Waltham, MA). Results of image fusion were then compared to histopathology. RESULTS: In 14/17 patients, a single parathyroid adenoma was found. There were 3 cases with hyperplastic glands. MRI detected 10 (71%), scintigraphy 12 (86%) adenomas. Both modalities detected 1/3 patients with hyperplasia. Image fusion improved the anatomical assignment of the 13 scintigraphic foci in five patients and was helpful in the interpretation of inconclusive MR-findings in two patients. CONCLUSIONS: Both MRI and (99m)Tc-MIBI scintigraphy sensitively detect parathyroid adenomas but are less reliable in case of hyperplastic glands. In case of a scintigraphic focus, image fusion considerably improves its topographic assignment. Furthermore, it facilitates the evaluation of inconclusive MRI findings.

Radical surgery for hilar cholangiocarcinoma.

In the therapy of hilar cholangiocarcinoma, the most favorable survival rates over the long-term are achieved by a surgical concept involving a no-touch-technique, en-bloc-resection and wide tumor-free margins. Currently, these goals can be best achieved by our strategy to combine extended right hepatic resections and principle portal vein resection. In spite of extending resectability to patients with locally advanced tumors, formally curative resections could be performed in 80% of the patients. The 5-year survival rate in these patients is 61%. Liver transplantation had been abandoned by most centers in the 1980s due to poor overall results. Recently, a neoadjuvant strategy involving radiochemotherapy has been reported to result in excellent survival figures at least in a subset of patients suffering from cholangiocellular carcinoma arising in a primary sclerosing cholangitis (PSC). This protocol has been mainly proposed by the Mayo Clinic group and reached 5-year survival rates of 80% in those patients in whom it had been applicable. A substantial drop out rate from this neoadjuvant regimen due to tumor progression or treatment related complications is still a problem.

Liver resection for metastatic gastric cancer.

AIMS: Liver resection represents a curative treatment approach in patients suffering from liver metastases from gastric cancer. However, its value in the treatment of these patients remains controversial. This study was conducted to evaluate the safety and effectiveness of liver resection in these conditions and to identify criteria for the selection of suitable patients. METHODS: From January 1988 to December 2002, 24 patients underwent liver resection for metastatic gastric cancer. The outcome of these 24 patients was retrospectively reviewed using a prospective database. Patient, tumour and operative parameters were analyzed for their influence on long-term survival. RESULTS: One patient died and four patients (17%) developed complications during the postoperative course. The overall one-, three- and five-year survival was 38%, 16% and 10%, respectively. After curative resection (n=17), the one-, three- and five-year survival rate was 53%, 22% and 15%, respectively, and patients with metachronous metastases restricted to the liver (n=5) had a one-, three- and five-year survival of 80%, 40% and 40%, respectively. In the univariate analysis, extrahepatic manifestation showed in tendency (p=0.069) and resection margins statistically significant (p=0.005) influence on survival. The multivariate analysis revealed only resection margins as an independent prognostic factor for survival. CONCLUSIONS: Long-term survival can be achieved by liver resection in well selected patients and may be considered in the multidisciplinary treatment approach of metastatic gastric cancer. Patients with metastatic disease restricted to the liver in whom a curative resection can be achieved seem to be most suitable for liver resection.

Liver resection for metastases from renal cell carcinoma.

BACKGROUND: This study was conducted to evaluate the safety and efficacy of liver resection in patients with hepatic metastases from renal cell carcinoma and to identify selection criteria for patients suitable for resection. METHODS: Between January 1988 and March 2006, 31 patients underwent liver resection for metastases from renal cell carcinoma. Patients were identified from a prospective database and retrospectively reviewed. Patient, tumor, and operative parameters were analyzed for their influence on long-term survival. RESULTS: The overall 1-, 3- and 5-year survival rates were 82.2%, 54.3%, and 38.9%, respectively. One patient was deceased and 4 developed complications during the postoperative course. In the univariate analysis, site of the primary tumor (P = 0.013), disease-free interval (P = 0.012), and resection margins (P = 0.008) showed significant influence on long-term survival. In the multivariate analysis, only the resection margins were identified as an independent prognostic factor after liver resection. CONCLUSIONS: Liver resection is effective and safe in the treatment of patients with hepatic metastases from renal cell carcinoma and offers the chance of long-term survival and cure. Achieving a margin-negative resection is the most important criterion in the selection of suitable patients for liver resection. However, the number of patients in the present study was small, and investigations of larger series may provide further prognostic parameters in these patients.

Impact of FDG-PET/MRI image fusion on the detection of pancreatic cancer.

BACKGROUND: This study assessed the value of image fusion with (18)F-fluorodeoxyglucose-positron emission tomography (FDG-PET) and magnetic resonance imaging (MRI) in patients suspected of having pancreatic cancer. METHODS: 32 patients (12 women, 20 men; age 24-79 years; mean 56.6 years) were included. All patients underwent whole-body FDG-PET examinations and contrast-enhanced MRI. Image fusion used a semiautomatic voxel-based algorithm. Separate reading, side-by-side analysis and evaluation of fused PET/MRI images were performed. Results were correlated to histopathology (n = 30), or clinical follow-up (n = 2). RESULTS: 15/32 patients had pancreas cancer and 17/32 patients benign disease. The sensitivity and specificity for cancer detection by FDG-PET were 93 and 41% for visual and 86 and 58% for semiquantitative analysis whereas MRI achieved 100 and 76% respectively. Topographical assignment of PET foci by image fusion was superior to side-by-side analysis in 11/39 (28%) foci (in 8/32 patients). However, a true impact on therapeutic strategy was observed only in 1/8 patients as the presence of multiple metastases, irresectable primaries or medical reasons for inoperability prevented a curative setting. CONCLUSION: Compared to side-by-side analysis, PET/MRI image fusion improves the anatomical assignment and interpretation of FDG foci. The therapeutic benefit for the patient however is limited in patients with multiple lesions or incurable primaries.

Magnetic resonance imaging in the assessment of cystic pancreatic lesions: differentiation of benign and malignant lesion status.

PURPOSE: To characterize cystic pancreatic lesions and tumors with magnetic resonance imaging (MRI), and to assess the value of morphological criteria in differentiating pseudocysts versus cystic tumors and benign versus malignant cystic tumors. MATERIAL AND METHODS: Twenty-three patients with cystic pancreatic tumors or lesions underwent plain and contrast-material-enhanced MRI, including magnetic resonance cholangiopancreatography (MRCP). The MR findings were characterized and analyzed by two readers, and the role of various imaging criteria and combinations thereof for final lesion assignment were assessed. Final diagnoses were obtained from the results of open surgery (n = 19) and/or biopsy (n = 4). RESULTS: Final diagnoses included cystic tumors (n = 11) and pseudocysts (n = 12). The lesions were located in the head (56%) and body or tail (44%). Lesion diameters ranged from 7 to 50 mm. Various lesion contrast enhancement patterns were observed for both benign and malignant lesions. Serous cystadenomas were located in the head, they were lobulated, and had wall diameters < or = 2 mm; with the combination of these characteristics all patients with serous cystadenoma could be identified, whereas in no other patient was this constellation observed. CONCLUSION: MRI facilitated the diagnosis of serous cystadenomas, although no definite morphologic criterion for the differentiation between pseudocysts and mucinous cystadenomas was identified. In consideration of the substantial therapeutic consequences, either diagnostics in unclear cystic pancreatic lesions should comprise cyst fluid analysis if necessary, or eligible patients should be referred for surgical resection.