[Radiologically guided interventional therapies for the treatment of neuroendocrine tumors]. / Radiologisch-interventionelle Möglichkeiten zur Behandlung von neuroendokrinen Tumoren.

BACKGROUND: The majority of patients with neuroendocrine tumors (NET) develop liver metastases during the course of the disease, significantly impacting prognosis and quality of life. CLINICAL ISSUE: Radiologically guided interventional therapies, such as thermal ablation, transarterial embolization (TAE)/chemoembolization (TACE), and selective internal radiotherapy (TARE), can play a crucial role in the treatment of metastatic NET. DATA: Due to the rarity of the disease, the majority of evidence is based on retrospective studies. For thermal ablation, the complete response rates ranging from 31.6 to 95.3% depending on the study. No significant differences in outcomes were found between TAE, TACE, and TARE. In several studies, all intra-arterial procedures led to a reduction of tumor-related symptoms and achieved disease control. CONCLUSION: Thermal ablation can be used as a curative therapy in oligometastatic patients with nonresectable liver metastases from NETs. In cases of disseminated liver metastases, intra-arterial therapy using TAE, TACE, or TARE can be employed.

[Lesions of the paravertebral mediastinum]. / Läsionen des paravertebralen Mediastinums.

BACKGROUND: Lesions of the paravertebral mediastinum are rare, and knowledge of possible differential diagnoses is essential for clinical practice. OBJECTIVE/METHODS: To review common lesions of the paravertebral mediastinum. RESULTS: The paravertebral mediastinum mainly includes fatty tissue and neurogenic structures. Imaging is commonly performed using computed tomography (CT) and magnetic resonance imaging (MRI). Neurogenic tumors are the most common lesions of the paravertebral mediastinum. Other pathologies include extramedullary hematopoiesis, lipomatous, lymphogenic, inflammatory, and cystic lesions. Moreover, also diaphragmatic hernias, vascular and esophageal pathologies may be found in the paravertebral mediastinum.

[Covered endovascular reconstruction of aortic bifurcation (CERAB)]. / Gecoverte endovaskuläre Rekonstruktion der Aortenbifurkation (CERAB).

BACKGROUND: Aortoiliac stenosis is common cause of peripheral arterial disease (PAD), which is particularly prevalent in older age (> 60 years) with a prevalence of 20%. In early stages (TASC [Trans-Atlantic Inter-Society Consensus] II A/B), these stenoses can be successfully treated by endovascular procedures. For more complex aortoiliac stenoses (TASC II C/D), open surgical treatment was the primary treatment in the past. CLINICAL ISSUE: Because of the advanced age and multiple comorbidities of PAD patients with complex aortoiliac stenoses, open surgical treatment is usually associated with high risk, and therefore endovascular procedures are an alternative despite their poorer outcome. Covered endovascular reconstruction of the aortic bifurcation (CERAB) aims to improve the primary patency rate compared with the usual endovascular implantation of kissing stents. DATA: With regard to the primary patency rate, open surgical treatment remains superior to both endovascular procedures; however, the CERAB technique shows a better 5­year outcome than the kissing stent technique. No differences are found in the secondary patency rate for any of the three procedures. The morbidity and mortality of the CERAB and kissing stent techniques are comparably low, and both procedures are superior to open surgical treatment. CONCLUSION: Because of the better long-term outcome of the CERAB versus the kissing stent technique, it should be used in patients with complex aortoiliac stenoses with increased risk of complications expected with open surgical treatment.

[Preoperative diagnostics and typing of abdominal soft tissue sarcomas]. / Präoperative Diagnostik und Typisierung abdomineller Weichteilsarkome.

BACKGROUND: Abdominal sarcomas are a heterogeneous group of rare soft tissue tumors and can be localized intraperitoneally or retroperitoneally. A pretherapeutic differentiated subtyping is essential for planning an individual, multimodal treatment concept in an interdisciplinary team of experts. OBJECTIVE: The central aspects of histology acquisition, imaging diagnostics and (molecular) pathological subtyping of abdominal soft tissue sarcomas are described in detail. MATERIAL AND METHODS: Imaging and pathological diagnostics are depicted based on the German S3 guidelines on adult soft tissue sarcomas, a current literature search and personal experiences at the Sarcoma Center at the National Center for Tumor Diseases in Dresden (NCT/UCC). RESULTS: Preoperative imaging and (molecular) pathological subtyping of abdominal soft tissue sarcomas place high demands on surgeons, radiologists and pathologists. Genome analyses of sarcomas have the potential to identify points of attack for individualized treatment options. The limitations of resectability can only be assessed by experienced sarcoma surgeons at specialized centers. CONCLUSION: The treatment of abdominal soft tissue sarcomas at an experienced center is associated with a better prognosis. Even at the first suspicion of an abdominal sarcoma, a referral to an experienced center should be made in order to guarantee optimal expertise in diagnostics and treatment.

Long-term outcome of incidental cystic liver tumors in the general population.

Aim of this study was to investigate frequency, incidence and risk factors of liver cysts in the general population in a longitudinal survey. Cyst frequency was investigated in 607 adult volunteers (288 women, 319 men, mean age 55 years) using strong T2-weighted magnetic resonance imaging. Risk factors were investigated for occurrence, frequency and size of cystic lesions at baseline. Incidence and physiological growing of the lesions were observed in a 5-years follow-up. At baseline, 431 volunteers had 1,479 cysts (71.0%). The mean number of cysts per person was 3.4 ± 9.0. The mean size of cysts was 13.1 ± 11.7 mm. Women had a higher number of cysts than men (p = 0.026). Older and male volunteers demonstrated a higher cyst frequency (p = 0.002 and p = 0.025). Per one-year increase in age the chance for a liver cyst increased by 2%. Four-hundred seventeen volunteers had cysts in the follow-up, in 24.6% new lesions had occurred. Lesion size significantly increased in follow-up (p < 0.001). Age and male sex were associated with the occurrence of at least one liver cyst. Women had a higher average number of cysts. Cystic lesion progression is a physiological phenomenon in the long-term follow-up.

Comparison of sequential and high-pitch-spiral coronary CT-angiography: image quality and radiation exposure.

New protocols for coronary computed tomography angiography (CCTA) could lower the radiation dose for patients but influence the image quality. To compare image quality and radiation exposure in step-and-shoot CCTA and high-pitch spiral CCTA. Fifty-nine pairs of patients matched for weight, height, sex and heart rate were included in this study (74 m, 44 f, average age 60 years, age range 29-94 years). Step-and-shoot CCTA and high-pitch spiral CCTA was performed on a third generation dual-source CT in equally sized patient groups. The signal-to-noise ratio (SNR) in the ascending aorta and the coronary arteries were determined for each dataset. Image quality was rated using a five-point scale. We used the t-test for paired samples to compare SNR and effective dose, and the Wilcoxon test to compare image quality scores. Mean effective dose for the step-and-shoot protocol (4.15 ± 3.07 mSv) was significantly higher in comparison to the high-pitch spiral protocol (1.2 ± 0.69 mSv; p < 0.0001). Mean SNR was higher with the step-and-shoot protocol compared to the high-pitch spiral protocol in the aorta, in the left main and peripheral coronary arteries (p < 0.01), in the proximal right coronary artery (p = 0.027). Image quality scores were significantly better for the step-and-shoot protocol (p = 0.0003). Step-and-shoot CCTA has significantly better SNR and overall image quality compared to high-pitch spiral CCTA, but with a mean effective dose more than thrice as high.

[Percutaneous biliary and gallbladder interventions]. / Perkutane Intervention der Gallenwege und der Gallenblase.

CLINICAL ISSUE: Percutaneous transhepatic biliary and gall bladder interventions play an important role in the diagnosis and therapy of biliary tract diseases. PERFORMANCE: With technical success rates up to 99% as well as complications rates up to a maximum of 26% they showed good results. Indications were opacification of the biliary tree as well as treatment of biliary system pathologies, such as drainage and stents. ACHIEVEMENTS: Interventions were used if endoscopic approaches are not possible or exploited. We describe the current state of knowledge and the range for percutaneous biliary/gall bladder interventions and give an overview of technical approaches for fundamental interventional procedures, including percutaneous transhepatic biliary drainage. PRACTICAL RECOMMENDATIONS: Percutaneous transhepatic biliary and gall bladder interventions are safe and effective treatments for benign and malignant stenosis, postoperative complications and risk patients with cholecystitis.

Cirse Quality Assurance Document and Standards for Classification of Complications: The Cirse Classification System.

Interventional radiology provides a wide variety of vascular, nonvascular, musculoskeletal, and oncologic minimally invasive techniques aimed at therapy or palliation of a broad spectrum of pathologic conditions. Outcome data for these techniques are globally evaluated by hospitals, insurance companies, and government agencies targeting in a high-quality health care policy, including reimbursement strategies. To analyze effectively the outcome of a technique, accurate reporting of complications is necessary. Throughout the literature, numerous classification systems for complications grading and classification have been reported. Until now, there has been no method for uniform reporting of complications both in terms of definition and grading. The purpose of this CIRSE guideline is to provide a classification system of complications based on combining outcome and severity of sequelae. The ultimate challenge will be the adoption of this system by practitioners in different countries and health economies within the European Union and beyond.

[Liver metastases of colorectal cancer]. / Lebermetastasen kolorektaler Karzinome.

Liver metastases are the most common cause of death in colorectal cancer patients. Nowadays, complete resection is considered to be the only curative treatment but only approximately 25% of patients are suitable candidates for surgery; therefore, many different interventional oncology techniques have been developed in recent years for the treatment of secondary liver metastases. The aim of interventional oncological procedures is either to provide a potentially curative treatment option for locally limited metastases with local ablative techniques, to enable nonresectable tumors to become accessible to surgical or local ablative techniques using transarterial procedures or to achieve improved survival in a palliative setting. These interventional therapies include transarterial approaches, such as chemoembolization and radioembolization as well as a multitude of different ablative techniques, such as radiofrequency and microwave ablation as well as irreversible electroporation (IRE). This article describes the indications for the various procedures and the clinical results of each of these techniques are reviewed based on the currently available literature.

Automatic path proposal computation for CT-guided percutaneous liver biopsy.

PURPOSE: To evaluate feasibility of automatic software-based path proposals for CT-guided percutaneous biopsies. METHODS: Thirty-three patients (60 [Formula: see text] 12 years) referred for CT-guided biopsy of focal liver lesions were consecutively included. Pre-interventional CT and dedicated software (FraunhoferMeVis Pathfinder) were used for (semi)automatic segmentation of relevant structures. The software subsequently generated three path proposals in downward quality for CT-guided biopsy. Proposed needle paths were compared with consensus proposal of two experts (comparable, less suitable, not feasible). In case of comparable results, equivalent approach to software-based path proposal was used. Quality of segmentation process was evaluated (Likert scale, 1 [Formula: see text] best, 6 [Formula: see text] worst), and time for processing was registered. RESULTS: All biopsies were performed successfully without complications. In 91 % one of the three automatic path proposals was rated comparable to experts' proposal. None of the first proposals was rated not feasible, and 76 % were rated comparable to the experts' proposal. 7 % automatic path proposals were rated not feasible, all being second choice ([Formula: see text]) or third choice ([Formula: see text]). In 79 %, segmentation at least was good. Average total time for establishing automatic path proposal was 42 [Formula: see text] 9 s. CONCLUSION: Automatic software-based path proposal for CT-guided liver biopsies in the majority provides path proposals that are easy to establish and comparable to experts' insertion trajectories.

[Thermoablative therapy of hepatocellular carcinoma. Indications, technique and results]. / Thermoablative Therapie des hepatozellulären Karzinoms. Indikation, Technik und Ergebnisse.

Hepatocellular carcinoma (HCC) is one of the most frequent malignancies worldwide. Besides liver transplantation, which is only feasible in few patients and surgical resection, the scope of potential treatment options has considerably expanded in recent years. Thermoablative therapies are now well established in early HCC due to the low rate of complications and short hospital stay. The disadvantage of higher relapse rates compared to surgical resection will be further diminished through technical advances regarding radiofrequency ablation and microwave ablation, as well as growing experience of users and thorough multidisciplinary selection of potential candidates for thermoablative therapy.

Radioembolization with Yttrium-90 microspheres (SIRT) in pancreatic cancer patients with liver metastases: efficacy, safety and prognostic factors.

OBJECTIVE: To analyze the clinical efficacy of (90)Y radioembolization in liver metastases from pancreatic cancer, to describe treatment toxicities and to identify biomarkers as predictors of outcome. METHODS: Data from 19 pancreatic cancer patients (9 females/10 males) who had received (90)Y radioembolization for metastatic liver disease between 06/2004 and 01/2011 were analyzed retrospectively. RESULTS: The median age at (90)Y radioembolization was 63 years (range 43-77). In 16 patients, previous palliative gemcitabine-based chemotherapy was given for metastatic disease. Objective response in the liver after (90)Y radioembolization was 47%. Median local progression-free survival in the liver was 3.4 months (range 0.9-45.0). Median overall survival (OS) was 9.0 months (range 0.9-53.0) and 1-year survival was 24%. Cox regression models for baseline biomarkers at (90)Y radioembolization revealed correlations of increased carbohydrate antigen 19-9 (p = 0.02) and C-reactive protein (p = 0.03) with shorter OS. Short-term adverse events (nausea, vomiting, fatigue, fever and abdominal pain) did not exceed grade 3. As long-term adverse events, liver abscesses, gastroduodenal ulceration, cholestasis and cholangitis, ascites and spleen infarction were observed. CONCLUSION: (90)Y radioembolization is able to induce an encouraging local response rate of liver metastases of pancreatic cancer patients. Most short-term toxicities are manageable; however, patients should be followed up carefully for severe long-term toxicities.

[Computed tomographic morphological evaluation of neoadjuvant chemotherapy. Effectiveness of the therapy for colorectal liver metastases]. / CT-morphologische Evaluation neoadjuvanter Chemotherapie. Effektivität der Therapie bei kolorektalen Lebermetastasen.

BACKGROUND: For patients with non-resectable liver metastases a response to chemotherapy is necessary in order to be able to achieve resection. Studies have shown that the response rate during neoadjuvant conversion chemotherapy is closely correlated with the frequency of resection of metastases. METHODS: Assessment of the response in clinical studies is based on the RECIST criteria. These criteria are supplemented by questions on the prognosis, tumor symptoms and toxicity for decisions on therapy. For assessment of resectability, the functional residual liver tissue and prognostic factors are important. RESULTS AND DISCUSSION: Regular imaging controls are necessary for guiding therapy in order to avoid a continuation of chemotherapy in cases of tumor progression. Chemotherapy is normally terminated when resectability has been achieved in order to avoid additional (liver) toxicity. Morphological criteria for response to therapy (e.g. mRECIST) can be more sensitive for assessing the effects of individual therapeutic procedures but are not established for guiding systemic therapy or for comparison with other therapeutic procedures.

[Diagnosis of and therapy for hepatocellular carcinoma]. / Diagnostik und Therapie des hepatozellulären Karzinoms.

The interdisciplinary guidelines at the S3 level on the diagnosis of and therapy for hepatocellular carcinoma (HCC) constitute an evidence- and consensus-based instrument that is aimed at improving the diagnosis of and therapy for HCC since these are very challenging tasks. The purpose of the guidelines is to offer the patient (with suspected or confirmed HCC) adequate, scientifically based and up-to-date procedures in diagnosis, therapy and rehabilitation. This holds not only for locally limited or focally advanced disease but also for the existence of recurrences or distant metastases. Besides making a contribution to an appropriate health-care service, the guidelines should also provide the foundation for an individually adapted, high-quality therapy. The explanatory background texts should also enable non-specialist but responsible colleagues to give sound advice to their patients concerning specialist procedures, side effects and results. In the medium and long-term this should reduce the morbidity and mortality of patients with HCC and improve their quality of life.

[Endovascular treatment of thoracic aneurisms: indications, techniques and results]. / Endovaskuläre Therapie des thorakalen Aortenaneurysmas: Indikationen, Technik und Ergebnisse.

UNLABELLED: CLINICAL ISSUE OF THORACIC ANEURYSMS: Aneurysms are among the most common diseases affecting the thoracic aorta, with a continuous increase in incidence over the recent decades. The main cause of thoracic aneurysms is atherosclerosis, which, due to the frequent lack of major symptoms and the potentially lethal complications such as ruptured aortic aneurysm, remains a challenge in clinical practice. STANDARD RADIOLOGICAL METHODS: CT angiography remains the imaging method of choice for acute aortic aneurysms, with MR angiography being increasingly used for follow-up imaging. THRESHOLD FOR TREATMENT: In the ascending aorta a diameter larger than 5-5.5 cm (descending aorta 6.5 cm) is regarded as the threshold for treatment. THORACIC ENDOVASCULAR AORTIC REPAIR: The continuous evolution of aortic stent grafting (i.e., thoracic endovascular aortic repair [TEVAR]) since Parodi, Palmaz and Dake has led to a steep rise in stent grafting procedures in recent years. PRACTICAL RECOMMENDATIONS: Particularly in elderly patients with multiple comorbidities, TEVAR is a valuable, less invasive option compared to open surgical repair.

Multimodality treatment for early-stage hepatocellular carcinoma: a bridging therapy for liver transplantation.

PURPOSE: To evaluate the efficiency of a multimodality approach consisting of transcatheter arterial chemoembolization (TACE) and radiofrequency ablation (RFA) as bridging therapy for patients with hepatocellular carcinoma (HCC) awaiting orthotopic liver transplantation (OLT) and to evaluate the histopathological response in explant specimens. MATERIALS AND METHODS: Between April 2001 and November 2011, 36 patients with 50 HCC nodules (1.4-5.0 cm, median 2.8 cm) on the waiting list for liver transplantation were treated by TACE and RFA. The drop-out rate during the follow-up period was recorded. The local efficacy was evaluated by histopathological examination of the explanted livers. RESULTS: During a median follow-up time of 29 (4.0-95.3) months the cumulative drop-out rate for the patients on the waiting list was 0, 2.8, 5.5, 11.0, 13.9 and 16.7% at 3, 6, 12, 24, 36 and 48 months, respectively. 16 patients (with 26 HCC lesions) out of 36 (44.4%) were transplanted by the end of study with a median waiting list time of 13.7 (2.5-37.8) months. The histopathological examination of the explanted specimens revealed a complete necrosis in 20 of 26 HCCs (76.9%), whereas 6 (23.1%) nodules showed viable residual tumor tissue. All transplanted patients are alive at a median time of 29.9 months. Imaging correlation showed 100% specificity and 66.7% sensitivity for the depiction of residual or recurrent tumor. CONCLUSION: We conclude that TACE combined with RFA could provide an effective treatment to decrease the drop-out rate from the OLT waiting list for HCC patients. Furthermore, this combination therapy results in high rates of complete tumor necrosis as evaluated in the histopathological analysis of the explanted livers. Further randomized trials are needed to demonstrate if there is a benefit in comparison with a single-treatment approach.

Practical vascular anatomy in the preparation of radioembolization.

As the incidence of primary and metastatic liver cancer continues to increase, the use of minimally invasive techniques as a treatment option is becoming more common. Radioembolization, a form of intra-arterial brachytherapy, is a technique where particles of glass or resin, impregnated with the isotope 90yttrium (90Y), are infused through a catheter directly into the hepatic arteries. This modality is based on the fact that hepatic malignancies receive their blood supply from the hepatic artery, whereas normal hepatocytes are perfused mostly from the portal circulation, which allows delivery of high doses to the tumor vasculature with relative sparing of normal liver tissue. This has been shown to be effective for both primary and metastatic tumors. A variety of complications may be related to hepatic intra-arterial treatments, especially to the gastroduodenal region. These complications are known to come from inadvertent extrahepatic infusion of 90Y particles, through arteries originating from the hepatic arterial branches such as the falciform artery, cystic artery, arteries from the pancreaticoduodenal arcade, gastroduodenal artery, or right gastric artery. Surgeons and interventional radiologists rely on accurate imaging and assessment of the hepatic arterial supply. It is important to know the common anatomic variations and technical considerations before radioembolization. We recommend an aggressive occlusion of all the above-mentioned arteries; further, clinicians should watch out for any other aberrant branches, and if in doubt, they ought to be coiled.