Causes of Hypoxemia in COVID-19 Acute Respiratory Distress Syndrome: A Combined Multiple Inert Gas Elimination Technique and Dual-energy Computed Tomography Study.

BACKGROUND: Despite the fervent scientific effort, a state-of-the art assessment of the different causes of hypoxemia (shunt, ventilation-perfusion mismatch, and diffusion limitation) in COVID-19 acute respiratory distress syndrome (ARDS) is currently lacking. In this study, the authors hypothesized a multifactorial genesis of hypoxemia and aimed to measure the relative contribution of each of the different mechanism and their relationship with the distribution of tissue and blood within the lung. METHODS: In this cross-sectional study, the authors prospectively enrolled 10 patients with COVID-19 ARDS who had been intubated for less than 7 days. The multiple inert gas elimination technique (MIGET) and a dual-energy computed tomography (DECT) were performed and quantitatively analyzed for both tissue and blood volume. Variables related to the respiratory mechanics and invasive hemodynamics (PiCCO [Getinge, Sweden]) were also recorded. RESULTS: The sample (51 ± 15 yr; Pao2/Fio2, 172 ± 86 mmHg) had a mortality of 50%. The MIGET showed a shunt of 25 ± 16% and a dead space of 53 ± 11%. Ventilation and perfusion were mismatched (LogSD, Q, 0.86 ± 0.33). Unexpectedly, evidence of diffusion limitation or postpulmonary shunting was also found. In the well aerated regions, the blood volume was in excess compared to the tissue, while the opposite happened in the atelectasis. Shunt was proportional to the blood volume of the atelectasis (R2 = 0.70, P = 0.003). V˙A/Q˙T mismatch was correlated with the blood volume of the poorly aerated tissue (R2 = 0.54, P = 0.016). The overperfusion coefficient was related to Pao2/Fio2 (R2 = 0.66, P = 0.002), excess tissue mass (R2 = 0.84, P < 0.001), and Etco2/Paco2 (R2 = 0.63, P = 0.004). CONCLUSIONS: These data support the hypothesis of a highly multifactorial genesis of hypoxemia. Moreover, recent evidence from post-mortem studies (i.e., opening of intrapulmonary bronchopulmonary anastomosis) may explain the findings regarding the postpulmonary shunting. The hyperperfusion might be related to the disease severity.

Radiomics and machine learning for renal tumor subtype assessment using multiphase computed tomography in a multicenter setting.

OBJECTIVES: To distinguish histological subtypes of renal tumors using radiomic features and machine learning (ML) based on multiphase computed tomography (CT). MATERIAL AND METHODS: Patients who underwent surgical treatment for renal tumors at two tertiary centers from 2012 to 2022 were included retrospectively. Preoperative arterial (corticomedullary) and venous (nephrogenic) phase CT scans from these centers, as well as from external imaging facilities, were manually segmented, and standardized radiomic features were extracted. Following preprocessing and addressing the class imbalance, a ML algorithm based on extreme gradient boosting trees (XGB) was employed to predict renal tumor subtypes using 10-fold cross-validation. The evaluation was conducted using the multiclass area under the receiver operating characteristic curve (AUC). Algorithms were trained on data from one center and independently tested on data from the other center. RESULTS: The training cohort comprised n = 297 patients (64.3% clear cell renal cell cancer [RCC], 13.5% papillary renal cell carcinoma (pRCC), 7.4% chromophobe RCC, 9.4% oncocytomas, and 5.4% angiomyolipomas (AML)), and the testing cohort n = 121 patients (56.2%/16.5%/3.3%/21.5%/2.5%). The XGB algorithm demonstrated a diagnostic performance of AUC = 0.81/0.64/0.8 for venous/arterial/combined contrast phase CT in the training cohort, and AUC = 0.75/0.67/0.75 in the independent testing cohort. In pairwise comparisons, the lowest diagnostic accuracy was evident for the identification of oncocytomas (AUC = 0.57-0.69), and the highest for the identification of AMLs (AUC = 0.9-0.94) CONCLUSION: Radiomic feature analyses can distinguish renal tumor subtypes on routinely acquired CTs, with oncocytomas being the hardest subtype to identify. CLINICAL RELEVANCE STATEMENT: Radiomic feature analyses yield robust results for renal tumor assessment on routine CTs. Although radiologists routinely rely on arterial phase CT for renal tumor assessment and operative planning, radiomic features derived from arterial phase did not improve the accuracy of renal tumor subtype identification in our cohort.

Renal tumor segmentation, visualization, and segmentation confidence using ensembles of neural networks in patients undergoing surgical resection.

OBJECTIVES: To develop an automatic segmentation model for solid renal tumors on contrast-enhanced CTs and to visualize segmentation with associated confidence to promote clinical applicability. MATERIALS AND METHODS: The training dataset included solid renal tumor patients from two tertiary centers undergoing surgical resection and receiving CT in the corticomedullary or nephrogenic contrast media (CM) phase. Manual tumor segmentation was performed on all axial CT slices serving as reference standard for automatic segmentations. Independent testing was performed on the publicly available KiTS 2019 dataset. Ensembles of neural networks (ENN, DeepLabV3) were used for automatic renal tumor segmentation, and their performance was quantified with DICE score. ENN average foreground entropy measured segmentation confidence (binary: successful segmentation with DICE score > 0.8 versus inadequate segmentation ≤ 0.8). RESULTS: N = 639/n = 210 patients were included in the training and independent test dataset. Datasets were comparable regarding age and sex (p > 0.05), while renal tumors in the training dataset were larger and more frequently benign (p < 0.01). In the internal test dataset, the ENN model yielded a median DICE score = 0.84 (IQR: 0.62-0.97, corticomedullary) and 0.86 (IQR: 0.77-0.96, nephrogenic CM phase), and the segmentation confidence an AUC = 0.89 (sensitivity = 0.86; specificity = 0.77). In the independent test dataset, the ENN model achieved a median DICE score = 0.84 (IQR: 0.71-0.97, corticomedullary CM phase); and segmentation confidence an accuracy = 0.84 (sensitivity = 0.86 and specificity = 0.81). ENN segmentations were visualized with color-coded voxelwise tumor probabilities and thresholds superimposed on clinical CT images. CONCLUSIONS: ENN-based renal tumor segmentation robustly performs in external test data and might aid in renal tumor classification and treatment planning. CLINICAL RELEVANCE STATEMENT: Ensembles of neural networks (ENN) models could automatically segment renal tumors on routine CTs, enabling and standardizing downstream image analyses and treatment planning. Providing confidence measures and segmentation overlays on images can lower the threshold for clinical ENN implementation. KEY POINTS: Ensembles of neural networks (ENN) segmentation is visualized by color-coded voxelwise tumor probabilities and thresholds. ENN provided a high segmentation accuracy in internal testing and in an independent external test dataset. ENN models provide measures of segmentation confidence which can robustly discriminate between successful and inadequate segmentations.

[Staging and Diagnostics of Rectal Cancer]. / Modalitäten des Stagings und der Diagnostik bei Rektumkarzinom.

The review titled "Staging and Diagnostics of Rectal Cancer" aims to provide insight to imaging techniques in patients with rectal cancer.Rectal cancer is among the most common malignancies, with one of the highest mortality rates worldwide. Timely diagnosis and therapy of this cancer therefore has important socio-economic implications.Radiological imaging plays a major role in the planning of subsequent therapy. Modern tomographic imaging is used not only for initial diagnosis, but also for staging.The individual role of different imaging techniques in diagnosis of rectal cancer will be explained in detail, and their function in general. Furthermore, we will present relevant radiological research related.The increasing role of MRI-based local staging will be presented in detail in this review. Defined diagnostic criteria, based on common recommendations, will be explained. We will show how MRI-based local staging can support the initial diagnosis and follow-up examinations in collaboration with other medical specialties in therapeutic planning. In particular, we describe how MRI is capable of substantially influencing the determination of surgical procedures in rectal cancer.

[Management of Injuries to the Parenchymal Abdominal Organs]. / Management von Verletzungen parenchymatöser Abdominalorgane.

The most common organs affected by abdominal trauma are the spleen and the liver, often in combination. Pancreatic injuries are rare. In the case of blunt abdominal trauma, which is much more common, a clinical and laboratory examination as well as sonography should be performed. In the initial assessment, the circulatory situation must be screened. If there is haemodynamic instability and presentation of free fluid, an emergency laparotomy is indicated. If the situation is stable or stabilised and a pathological sonography is present, it is essential to perform triphasic contrast enhanced computed tomography, which is also mandatory in polytraumatised patients. If a renal injury is suspected, a late venous phase should be attached. In addition to the classification of the injury, attention should be paid to possible vascular injury or active bleeding. In this case, angiography with the possibility of intervention should be performed. Endoscopic treatment is possible for injuries of the pancreatic duct. If the imaging does not reveal any intervention target and a circulation is stable, a conservative approach is possible with continuous monitoring using clinical, laboratory and sonographic controls. Most injuries can be successfully treated by non-operative management (NOM).There are various surgical options for treating the injury, such as local and resecting procedures. There is also the option of "damage control surgery" with acute bleeding control and second look. Complex surgical procedures should be performed at centres. Postoperative complications arise out of elective surgery.In the less common case of penetrating abdominal trauma, the actual extent of the injury cannot be estimated from the visible wound. Here again, the circulatory situation determines the next steps. An emergency laparotomy should be carried out in case of instability. If the condition is stable, further diagnostics should be performed using contrast enhanced computed tomography. If penetration through the peritoneum cannot be clearly excluded, diagnostic laparoscopy should be performed.

[Metastasis or sarcoidosis - a diagnostic pitfall in metastatic rectal carcinoma]. / Metastase oder Sarkoidose ­ eine diagnostische Herausforderung beim metastasierten Rektumkarzinom.

BACKGROUND: Granulomatous diseases as sarcoidosis can impair the staging of metastatic diseases since metastasis are hard to distinguish from granulomas in standard imaging. This case report describes the diagnostic workup and therapy in a patient with simultaneous sarcoidosis and rectal cancer with hepatic metastasis and how a curative stadium was achieved. CASE DESCRIPTION: A 71-year old male patient was diagnosed with an adenocarcinoma of the rectum after presenting with involuntary weight loss and anemia. Further diagnostics raised strong suspicion of hepatic, pulmonary and splenic metastasis. Histology after bronchoscopy surprisingly discovered non-caseating granulomas, leading to the diagnosis of sarcoidosis. Due to an obstructive tumor, a rectum resection was performed. Due to a high suspicion of splenic metastasis during surgery, the spleen was removed. Histology revealed no metastasis in the spleen but multiple granulomas due to sarcoidosis. After surgery, biopsy of a suspicious lesion in the liver revealed both metastasis and sarcoidosis in the same sample. The patient was treated with a pseudo(neo)adjuvant chemotherapy with 5-Fluorouracil, Leukovorin, Oxaliplatin (FOLFOX) and Panitumumab (Anti-EGF-antibody). After treatment, CT scan revealed two hepatic lesions decreasing in size, while all other lesions were metrically stable. A right hemihepatectomy followed and histology revealed both sarcoidosis and metastasis. The curated patient was sent to aftercare and there is no suspicion for a relapse (13 month after last surgery). DISCUSSION: The simultaneous appearance of metastatic tumors and sarcoidosis creates a diagnostic dilemma since both manifestations can barely be distinguished in regular imaging technologies. This case report demonstrates that the histological work-up of affected organs with consecutive resections can cure a patient of a metastatic tumor disease, even in the context of simultaneous sarcoidosis.

Impact of Endoscopic Vacuum Therapy with Low Negative Pressure for Esophageal Perforations and Postoperative Anastomotic Esophageal Leaks.

INTRODUCTION: Management of esophageal anastomotic leaks (AL) and esophageal perforations (EP) remains difficult and often requires an interdisciplinary treatment modality. For primary endoscopic management, self-expanding metallic stent (SEMS) placement is often considered first-line therapy. Recently, endoscopic vacuum therapy (EVT) has emerged as an alternative or adjunct for management of these conditions. So far, data for EVT in the upper gastrointestinal-tract is restricted to single centre, non-randomized trials. No studies on optimal negative pressure application during EVT exist. The aim of our study is to describe our centre's experience with low negative pressure (LNP) EVT for these indications over the past 5-years. PATIENTS AND METHODS: Between January 2014 and December 2018, 30 patients were endoscopically treated for AL (n = 23) or EP (n = 7). All patients were primarily treated with EVT and LNP between -20 and -50 mm Hg. Additional endoscopic treatment was added when EVT failed. Procedural and peri-procedural data, as well as clinical outcomes including morbidity and mortality, were analysed. RESULTS: Clinical successful endoscopic treatment of EP and AL was achieved in 83.3% (n = 25/30), with 73.3% success using EVT alone (n = 22/30). Mean treatment duration until leak closure was 16.1 days (range 2-58 days). Additional treatment modalities for complete leak resolution was necessary in 10% (n = 3/30), including SEMS placement and fibrin glue injection. Mean hospital stay for patients with EP was shorter with 33.7 days compared to AL with 54.4 days (p = 0.08). Estimated preoperative 10-year overall survival (Charlson comorbidity score) was 39.4% in patients with AL and 59.9% in patients with EP (p = 0.26). A mean of 5.1 EVT changes (range 1-12) was needed in EP and 3.6 changes (range 1-13) in AL to achieve complete closure, switch to other treatment modality, or reach endoscopic failure (p = 0.38). CONCLUSION: LNP EVT enables effective minimally - invasive endoluminal leak closure from anastomotic esophageal leaks and EP in high-morbid patients. In this study, EVT was combined with other endoscopic treatment options such as SEMS placement or fibrin glue injection in order to achieve leak or perforation closure in the vast majority of patients (83.3%). Low aspiration pressures led to slower but still sufficient clinical results.

Future liver remnant growth after various portal vein embolization regimens: a quantitative comparison.

Purpose: To compare the efficacy of right portal vein embolization using ethylene vinyl alcohol (EVOH-PVE) compared to other embolic agents and surgical right portal vein ligation (PVL).Material and methods: Patients with right sided liver malignancies scheduled for extensive surgery and receiving induction of liver hypertrophy via right portal vein embolization/ligature between 2010-2016 were retrospectively evaluated. Treatments included were ethylene vinyl alcohol copolymer (Onyx®, EVOH-PVE), ethiodized oil (Lipiodol®, Lipiodol/PVA-PVE), polyvinyl alcohol (PVA-PVE) or surgical ligature (PVL). Liver segments S2/3 were used to assess hypertrophy. Primary outcome was future liver remnant growth in ml/day.Results: Forty-one patients were included (EVOH-PVE n = 11; Lipiodol/PVA-PVE n = 10; PVA-PVE n = 8; PVL n = 12), the majority presenting with cholangiocarcinoma and colorectal metastases (n = 11; n = 27). Pre-interventional liver volumes were comparable (p = .095). Liver hypertrophy was successfully induced in all but one patient receiving Lipiodol/PVA-PVE. Liver segment S2/3 growth was largest for EVOH-PVE (5.38 ml/d) followed by PVA-PVE (2.5 ml/d), with significantly higher growth rates than PVL (1.24 ml/d; p < .001; p = .007). No significant difference was evident for Lipiodol/PVA-PVE (1.43 ml/d, p = .809).Conclusions: Portal vein embolization using EVOH demonstrates fastest S2/3 growth rates compared to other embolic agents and PVL, potentially due to its permanent portal vein embolization and induction of hepatic inflammation.

Pre- and post-contrast versus post-contrast cone-beam breast CT: can we reduce radiation exposure while maintaining diagnostic accuracy?

OBJECTIVES: To evaluate whether post-contrast cone-beam breast CT (CBBCT) alone is comparable to the current standard of combined pre- and post-contrast CBBCT regarding diagnostic accuracy and superior regarding radiation exposure. MATERIAL AND METHODS: This study included 49 women (61 breasts) with median age 57.9 years and BI-RADS 4/5 lesions diagnosed on mammography/ultrasound in density type c/d breasts. Two radiologists rated post-contrast CBBCT and pre- and post-contrast CBBCT with subtraction images on the BI-RADS scale separately for calculation of inter- and intra-observer agreement and in consensus for diagnostic accuracy assessment. Sensitivity, specificity, and area under the curve (AUC) were compared via McNemar test and DeLong method, respectively. Subtraction imaging misregistration were measured from 1 (no artifacts) to 4 (artifacts with width > 4 mm). RESULTS: A total of 100 lesion (51 malignant; 6 high risk; 43 benign) were included. AUC, sensitivity, and specificity showed no significant differences comparing post-contrast CBBCT alone versus pre- and post-contrast CBBCT (AUC 0.84 vs. 0.83, p = 0.643; sensitivity 0.89 vs. 0.85, p = 0.158; specificity 0.73 vs. 0.76, p = 0.655). Inter- and intra-observer agreement was excellent (intra-class correlation coefficient ICC = 0.76, ICC = 0.83, respectively). Radiation dose was significantly lower for post-contrast CBBCT alone versus pre- and post-contrast CBBCT (median average glandular radiation dose 5.9 mGy vs. 11.7 mGy, p < 0.001). High-degree misregistrations were evident in the majority of subtraction images (level 1/2/3/4 16.9%/27.1%/16.9%/39%), in particular for bilateral exams (3.2%/29.2%/8.3%/58.3%). CONCLUSION: Diagnostic accuracy of post-contrast CBBCT alone is comparable to pre- and post-contrast CBBCT in type c/d breasts, while yielding a significant twofold radiation dose reduction. KEY POINTS: • The diagnostic accuracy of post-contrast CBBCT alone is comparable to dual acquisition of pre- and post-contrast CBBCT. • Acquisition of the post-contrast CBBCT scan alone reduces radiation exposure compared to pre- and post-contrast CBBCT, thus countering one of the main limitations of CBBCT. • High-degree misregistration artifacts limit the interpretation of subtraction images from pre- and post-contrast CBBCT studies.

Diagnostic accuracy of cone-beam breast computed tomography: a systematic review and diagnostic meta-analysis.

PURPOSE: To review the published evidence on cone-beam breast computed tomography (CBBCT) and summarize its diagnostic accuracy for breast lesion assessment. MATERIALS AND METHODS: A systematic literature search was conducted using the EMBASE, MEDLINE and CENTRAL libraries. Studies were included if reporting sensitivity and specificity for discrimination of benign and malignant breast lesions via breast CT. Sensitivity and specificity were jointly modeled using a bivariate approach calculating summary areas under the receiver-operating characteristics curve (AUC). All analyses were separately performed for non-contrast and contrast-enhanced CBBCT (NC-CBBCT, CE-CBBCT). RESULTS: A total of 362 studies were screened, of which 6 with 559 patients were included. All studies were conducted between 2015 and 2018 and evaluated female participants. Four of six studies included dense and very dense breasts with a high proportion of microcalcifications. For NC-CBBCT, pooled sensitivity was 0.789 (95% CI: 0.66-0.89) and pooled specificity was 0.697 (95% CI: 0.471-0.851), both showing considerable significant between-study heterogeneity (I2 = 89.4%, I2 = 94.7%, both p < 0.001). Partial AUC for NC-CBBCT was 0.817. For CE-CBBCT, pooled sensitivity was 0.899 (95% CI: 0.785-0.956) and pooled specificity was 0.788 (95% CI: 0.709-0.85), both exhibiting non-significant moderate between-study heterogeneity (I2 = 57.3%, p = 0.0527; I2 = 53.1%, p = 0.0738). Partial AUC for CE-CBBCT was 0.869. CONCLUSION: The evidence available for CBBCT tends to show superior diagnostic performance for CE-CBBCT over NC-CBBCT regarding sensitivity, specificity and partial AUC. Diagnostic accuracy of CE-CBBCT was numerically comparable to that of breast MRI with meta-analyses reporting sensitivity of 0.9 and specificity of 0.72. KEY POINTS: • CE-CBBCT rather than NC-CBBCT should be used for assessment of breast lesions for its higher diagnostic accuracy. • CE-CBBCT diagnostic performance was comparable to published results on breast MRI, thus qualifying CE-CBBCT as a potential imaging alternative for patients with MRI contraindications.

Real-time MRI for the dynamic assessment of fundoplication failure in patients with gastroesophageal reflux disease.

PURPOSE: To assess the diagnostic potential of dynamic real-time MRI for fundoplication failure in patients with persistent or recurrent GERD-like (gastroesophageal reflux disease) complaints. MATERIAL AND METHODS: Twenty-two consecutive patients (male n = 11; female n = 11; median age 59 years) with recurrent or persistent GERD-like symptom after fundoplication were enrolled between 2015 and 2017. Median duration of GERD-like symptoms was 21 months. Real-time MRI (3 Tesla) was performed at 40 ms temporal resolution using undersampled radial fast low-angle shot acquisitions with nonlinear inverse image reconstruction. MRI movies dynamically visualized bolus transit of pineapple juice through the gastroesophageal junction, position of the fundoplication wrap and recurring hernia or reflux during Valsalva maneuver. MRI results were compared to endoscopic findings. RESULTS: Real-time MRI was successfully completed in all patients without adverse events (average examination time 15 min). Morphological correlates for GERD-like symptoms were evident in 20 patients (90.1%) with gastric reflux in 19 cases. Nine patients (40.1%) had wrap disruption and recurrent gastric hernia. Wrap migration or telescoping hernia was detected in nine patients (40.1%). One patient presented with continued reflux despite intact fundoplication wrap. Esophageal dysmotility with delayed bolus passage was observed in one case. On endoscopy, gastric hernia or wrap disruption was diagnosed in seven cases, and esophagitis or Barret's metaplasia in nine cases. CONCLUSION: Real-time MRI is a fast and safe modality for dynamic imaging after fundoplication, without radiation exposure or administration of gadolinium-based contrast media. In a relevant number of cases, real-time MRI reveals correlates for GERD-like symptoms. KEY POINTS: • Real-time MRI reliably visualizes the gastroesophageal junction after fundoplication surgery. • Patients with recurring GERD-like symptoms have a high rate of morphological failure patterns that can be identified by real-time MRI. • Dynamic assessment of gastroesophageal junction by real-time MRI is a perspective diagnostic tool for detection of fundoplication failure.

Hiatal hernias in patients with GERD-like symptoms: evaluation of dynamic real-time MRI vs endoscopy.

PURPOSE: To assess the diagnostic potential of real-time MRI for assessment of hiatal hernias in patients with GERD-like symptoms compared to endoscopy. MATERIAL AND METHODS: One hundred eight patients with GERD-like symptoms were included in this observational cohort study between 2015 and 2017. Real-time MRI was performed at 3.0 Tesla with temporal resolution of 40 ms, dynamically visualizing the esophageal transport of a pineapple juice bolus, its passage through the gastroesophageal junction, and functional responses during Valsalva maneuver. Hernia detection on MRI and endoscopy was calculated using contingency tables with diagnosis of hernia on either modality as reference. RESULTS: Of 108 patients, 107 underwent successful MRI without adverse events; 1 examination was aborted to inability to swallow pineapple juice in supine position. No perforation or acute bleeding occurred during endoscopy. Median examination time was 15 min. Eighty-five patients (79.4%) were diagnosed with hiatal hernia on either real-time MRI or endoscopy. Forty-six hernias were visible on both modalities. Seventeen hernias were evident exclusively on MRI, and 22 exclusively on endoscopy. Sixteen of the 63 MRI-detected hernias (25.4%) were detectable only during Valsalva maneuver, which were smaller compared to hernias at rest (median - 13.5 vs - 33.0 mm, p < 0.001). Diagnostic accuracy for hernia detection was comparable for MRI and endoscopy (sensitivity 74% vs 80%, p = 0.4223; specificity 100% vs 100%, p > 0.99). CONCLUSION: Real-time MRI is a fast and safe modality for assessment of the gastroesophageal junction, without radiation exposure or administration of gadolinium-based contrast media. Although MRI and endoscopy yield comparable diagnostic accuracy, dynamic MRI sequences are able to visualize hiatal hernias that were occult on static MRI sequences or endoscopy in a relevant number of cases. KEY POINTS: • Real-time MRI is a safe and fast imaging modality for examination of the gastroesophageal junction, combining anatomical and functional information for enhanced detection of hiatal hernias. • Real-time MRI and endoscopy yield comparably high diagnostic accuracy: real-time MRI visualizes hiatal hernias that were occult on endoscopy in a relevant number of patients; however, several hiatal hernias detected on endoscopy were occult on real-time MRI. • There is clinical potential of real-time MR imaging in patients with GERD-like symptoms and equivocal findings on endoscopy or pH-metry, for anatomical visualization in patients planned for surgical intervention, or those with suspected fundoplication failures.

Management of Aortoesophageal Fistula in a Palliative Patient with Non-Small-Cell Lung Cancer: A Case Report.

INTRODUCTION: Aortoesophageal fistulas are a rare but life-threatening complication in patients with thoracic malignancies. CASE PRESENTATION: We describe a case of a 55-year-old female patient with metastatic non-small-cell lung cancer. Due to esophageal tumor compression, a fully covered self-expanding metal stent (fcSEMS) had been deployed in the esophagus several months before. The patient was subsequently admitted to the emergency department with massive hematemesis. Endoscopy suggested a fistula between the aorta and the esophagus proximal of the fcSEMS, which was confirmed by computed tomography and led to hemodynamical relevant upper gastrointestinal bleeding. A thoracic endovascular aortic repair was performed to stop the hemorrhage. After the successful intervention, the patient needed long-term antibiotic treatment, and the fcSEMS remained in place. Afterward, the patient continued palliative tumor therapy using pembrolizumab for further 5 months. The patient died 8 months after the initial admission to the emergency department. CONCLUSION: This is to the best of our knowledge the first case of a technically successful interventional therapy of an aortoesophageal fistula which did not only achieve hemostasis but also enabled the patient to continue tumor therapy to regain quality of life.

[Treatment recommendation and care in traumatic rupture of the spleen]. / Therapieempfehlung und Versorgung bei traumatischer Milzruptur.

The spleen is the most frequently affected organ in blunt abdominal trauma. Initial diagnostics include the physical examination, laboratory blood controls and ultrasound. Furthermore, a triphasic dynamic contrast-enhanced computed tomography (CT) scan is indicated. Apart from the imaging-based classification of the injury with consideration of vascular alterations and active bleeding, the hemodynamic condition of the patient is a crucial factor. For patients who are hemodynamically stable or can be stabilized, a nonoperative management with a minimum of 24 h of continuous monitoring, regular blood controls of the hemoglobin level as well as ultrasound follow-up should be given precedence. In cases of active bleeding or pathological vascular alterations, a radiological intervention in the sense of an embolization should be initiated. A hemodynamically unstable patient must immediately undergo surgical treatment, during which a spleen-preserving approach via splenorrhaphy should principally be favored over splenectomy. This also applies to patients where the intervention has failed. To prevent severe infections after splenectomy it is advised to vaccinate against Pneumococcus, Haemophilus influenzae type B and Meningococcus as well as the annual seasonal influenza vaccination according to the Standing Committee on Vaccination (STIKO) recommendations.

T1 mapping of the prostate using Single-Shot T1FLASH and MOLLI MRI Techniques: Comparison of artifact burden and image quality.

PURPOSE: To assess artifact burden and image quality of different MRI T1 mapping techniques of the prostate. METHODS: Participants with suspected prostate cancer (PCa) were prospectively enrolled from June-October 2022 and examined with multiparametric prostate MRI (mpMRI; 3 T scanner; T1wi, T2wi, DWI und DCE). T1 mapping was performed before and after administration of gadolinium-based contrast-agent (GBCA) using (i) a modified Look-Locker inversion (MOLLI) technique and (ii) a novel single-shot T1FLASH inversion recovery technique. T2wi, DWI, T1FLASH and MOLLI sequences were systematically examined regarding prevalence of artifacts and image quality using a 5-point Likert-Scale. RESULTS: A total of n = 100 patients were included (median age: 68 years). T1FLASH maps (pre-and post-GBCA) showed metal artifacts in 7% of cases and susceptibility artifacts in 1%. For MOLLI maps, pre-GBCA metal and susceptibility artifacts were documented in 6.5% of cases each. MOLLI maps post-GBCA showed artifacts in 59% of cases resulting primarily from urinary GBCA excretion and GBCA accumulation at the bladder base (p < 0.01 versus T1FLASH post-GBCA). Image quality for T1FLASH pre-GBCA was rated at a mean 4.9+/-0.4 and for MOLLI at 4.8+/-0.6 (p = 0.14). Post-GBCA image quality was rated at a mean 4.9+/-0.4 for T1FLASH and at 3.7+/-1.1 for MOLLI (p < 0.001). CONCLUSIONS: T1FLASH maps provide a fast and robust method for quantification of T1 relaxation times of the prostate. T1FLASH is suitable for T1 mapping of the prostate following administration of contrast agents, while MOLLI T1 mapping is impaired through GBCA accumulation at the bladder base leading to severe image artifacts and reduced image quality.

Visualization of deglutition and gastroesophageal reflux using real-time MRI: a standardized approach to image acquisition and assessment.

This study aims to develop a standardized algorithm for gastroesophageal image acquisition and diagnostic assessment using real-time MRI. Patients with GERD symptoms undergoing real-time MRI of the esophagus and esophagogastric junction between 2015 and 2018 were included. A 10 ml bolus of pineapple juice served as an oral contrast agent. Patients performed Valsalva maneuver to provoke reflux and hiatal hernia. Systematic MRI assessment included visual presence of achalasia, fundoplication failure in patients with previous surgical fundoplication, gastroesophageal reflux, and hiatal hernia. A total of 184 patients (n = 92 female [50%], mean age 52.7 ± 15.8 years) completed MRI studies without adverse events at a mean examination time of 15 min. Gastroesophageal reflux was evident in n = 117 (63.6%), hiatal hernia in n = 95 (52.5%), and achalasia in 4 patients (2.2%). Hiatal hernia was observed more frequently in patients with reflux at rest (n = 67 vs. n = 6, p < 0.01) and during Valsalva maneuver (n = 87 vs. n = 8, p < 0.01). Real-time MRI visualized a morphologic correlate for recurring GERD symptoms in 20/22 patients (90%) after fundoplication procedure. In a large-scale single-center cohort of patients with GERD symptoms undergoing real-time MRI, visual correlates for clinical symptoms were evident in most cases. The proposed assessment algorithm could aid in wider-spread utilization of real-time MRI and provides a comprehensive approach to this novel imaging modality.

Time to Deliver on Promises: The Role of ERBB2 Alterations as Treatment Options for Colorectal Cancer Patients in the Era of Precision Oncology.

Receptor tyrosine kinase erythroblastic oncogene B2 (ERBB2), also known as human epidermal growth factor receptor 2 (HER2), represents an oncogenic driver and has been effectively targeted in breast and gastric cancer. Recently, next-generation sequencing (NGS) discovered ERBB2 as a promising therapeutic target in metastatic colorectal cancer (mCRC), where it is altered in 3-5% of patients, but no therapies are currently approved for this use. Herein, we present the experience of a single center in diagnosing actionable genetic ERBB2 alterations using NGS and utilizing the latest therapeutic options. Between October 2019 and December 2022, a total of 107 patients with advanced CRC underwent molecular analysis, revealing actionable ERBB2 mutations in two patients and ERBB2 amplifications in two other patients. These findings correlated with immunohistochemical (IHC) staining. Of these four patients, two were treated with trastuzumab-deruxtecan (T-DXd). We present two exemplary cases of patients with actionable ERBB2 alterations to demonstrate the effectiveness of T-DXd in heavily pretreated ERBB2-positive mCRC patients and the need for early molecular profiling. To fully exploit the potential of this promising treatment, earlier molecular profiling and the initiation of targeted therapies are essential.

Kinetics of human leukocyte antigen receptor HLA-DR+ monocytes and T lymphocytes during remission induction therapy in ANCA-associated vasculitis.

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis is characterized by small vessel inflammation and the presence of autoantibodies against cytoplasmic proteases, most often proteinase-3 and myeloperoxidase. Peripheral blood monocytes are an important source of local macrophage accumulation within parenchymal organs, as evidenced by their presence in early lesions in ANCA-associated glomerulonephritis. Major histocompatibility complex (MHC) II cell surface receptor human leukocyte antigen receptor (HLA-DR) allows antigen presentation to T cells and is crucial for the initiation of an immune response. We herein report HLA-DR abundance in AAV and the kinetics of HLA-DR+ monocytes and T lymphocytes during remission induction therapy in AAV. Life-threatening AAV with pulmonary hemorrhage and renal involvement was associated with the presence of HLA-DR in a considerable population of peripheral blood monocytes and T lymphocytes, and relapsing disease manifested despite persistent B cell depletion after remission induction with rituximab. Moreover, remission induction in AAV with steroids, plasma exchange and intravenous cyclophosphamide, and improvement of clinical symptoms were associated with a decrease in HLA-DR+ differing between monocytes and T lymphocytes. Particularly, persistent suppression of HLA-DR+ monocytes was observed during remission induction, while an initial decrease in HLA-DR+ T lymphocytes was followed by recovery of this population during the further course. Detailed insights into HLA-DR kinetics could pave the way towards an increased understanding of immunopathology and identify patients that could mostly benefit from distinct remission induction regimens.

Dual-Positive MPO- and PR3-ANCA-Associated Vasculitis Following SARS-CoV-2 mRNA Booster Vaccination: A Case Report and Systematic Review.

As the coronavirus disease 2019 (COVID-19) pandemic is ongoing, and new variants of severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) are emerging, vaccines are needed to protect individuals at high risk of complications and to potentially control disease outbreaks by herd immunity. After SARS-CoV-2 vaccination, antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) presenting with a pulmonary hemorrhage has been described. Previous studies suggested that monocytes upregulate major histocompatibility complex (MHC) II cell surface receptor human leukocyte antigen receptor (HLA-DR) molecules in granulomatosis with polyangiitis (GPA) patients with proteinase 3 (PR3)- and myeloperoxidase (MPO)-ANCA seropositivity. Here, we present a case of new-onset AAV after booster vaccination with the Pfizer-BioNTech SARS-CoV-2 mRNA vaccine. Moreover, we provide evidence that the majority of monocytes express HLA-DR in AAV after SARS-CoV-2 booster vaccination. It is possible that the enhanced immune response after booster vaccination and presence of HLA-DR+ monocytes could be responsible for triggering the production of the observed MPO- and PR3-ANCA autoantibodies. Additionally, we conducted a systematic review of de novo AAV after SARS-CoV-2 vaccination describing their clinical manifestations in temporal association with SARS-CoV-2 vaccination, ANCA subtype, and treatment regimens. In light of a hundred million individuals being booster vaccinated for SARS-CoV-2 worldwide, a potential causal association with AAV may result in a considerable subset of cases with potential severe complications.

Assessment of esophagogastric junction morphology by dynamic real-time MRI: comparison of imaging features to high-resolution manometry.

PURPOSE: To assess the esophagogastric junction (EGJ) on real-time MRI and compare imaging parameters to EGJ morphology on high-resolution manometry (HRM). METHODS: A total of 105 of 117 eligible patients who underwent real-time MRI and high-resolution manometry for GERD-like symptoms between 2015 and 2018 at a single center were retrospectively evaluated (male n = 57; female n = 48; mean age 52.5 ± 15.4 years). Real-time MRI was performed at a median investigation time of 15 min (1 frame/40 ms). On HRM, EGJ morphology was assessed according to the Chicago classification of esophageal motility disorders. Real-time MRI was performed at 3 T using highly undersampled radial fast low-angle shot acquisitions with NLINV image reconstruction. A 10 mL pineapple juice bolus served as oral contrast agent at supine position. Real-time MRI films of the EGJ were acquired during swallowing events and during Valsalva maneuver. Anatomic and functional MRI parameters were compared to EGJ morphology on HRM. RESULTS: On HRM, n = 42 patients presented with EGJ type I (40.0%), n = 33 with EGJ type II (31.4%), and n = 30 with EGJ type III (28.6%). On real-time MRI, hiatal hernia was more common in patients with EGJ type III (66.7%) than in patients with EGJ type I (26.2%) and EGJ type II (30.3%; p < 0.001). Sliding hiatal hernia was more frequent in patients with EGJ type II (33.3%) than in patients with EGJ type III (16.7%) and EGJ type I (7.1%; p = 0.017). The mean esophagus-fundus angle of patients was 85 ± 31° at rest and increased to 101 ± 36° during Valsalva maneuver. CONCLUSION: Real-time MRI is a non-invasive imaging method for assessment of the esophagogastric junction. Real-time MRI can visualize dynamic changes of the EGJ during swallowing events.