Diagnostics and prognostic evaluation in renal cell tumors: the German S3 guidelines recommendations.

The German guidelines on renal cell carcinoma (RCC) have been developed at highest level of evidence based on systematic literature review. In this paper, we are presenting the current recommendations on diagnostics including preoperative imaging and imaging for stage evaluation as well as histopathological classification. The role of tumor biopsy is further discussed. In addition, different prognostic scores and the status of biomarkers in RCC are critically evaluated.

Comparison of the determination of the local tumor extent of primary endometrial cancer using clinical examination and 3 Tesla magnetic resonance imaging compared to histopathology.

PURPOSE: The aim of this study is to analyze the correct staging of primary endometrial cancer (EC) using clinical examination and 3 Tesla (T) magnetic resonance imaging (MRI) results compared to histopathology. METHODS: In this prospective, non-randomized, single-center study, 26 women with biopsy-proven EC were evaluated. All women underwent clinical examination including transvaginal ultrasound (CE/US) and 3T MRI (T2-weighted, diffusion-weighted and dynamic contrast-enhanced sequences) prior to surgery. Spearman's correlation coefficient was employed to analyze the correlation between both staging methods and histopathology and generalized estimation equation analysis to compare their staging results. Main outcome measures are determinations of local tumor extent for EC on CE/US and 3T MRI compared to histopathology (gold standard). RESULTS: Sixteen women had an early-stage pT1a tumor, 10 a locally advanced ≥ pT1b tumor. The early stage was correctly diagnosed at CE/US in 100%, by MRI in 81%. Spearman's correlation coefficient was r = 1.0 (p < 0.001) for correlation of CE/US and histopathology, r = 0.93 (p < 0.001) for correlation of MRI and pathology. A locally advanced tumor stage was exactly diagnosed by MRI in 70% and at CE/US in 50%. CONCLUSIONS: CE/US is sufficient for staging T1a endometrial cancer, while MRI provides higher sensitivity in detecting locally advanced tumors. Based on our results, combining CE/US and 3T MRI in patients with at least suspected deep myometrial invasion offers a more reliable workflow for individual treatment planning.

Five-year outcome after pelvic floor reconstructive surgery: evaluation using dynamic magnetic resonance imaging compared to clinical examination and quality-of-life questionnaire.

Background Dynamic magnetic resonance imaging (dMRI) captures the entire pelvis during Valsalva maneuver and helps diagnosing pelvic floor changes after reconstructive surgery. Purpose To evaluate therapeutic outcome five years after reconstructive surgery using clinical examination, dMRI, and quality-of-life (QOL) questionnaire. Material and Methods Clinical examination, dMRI, and QOL questionnaire were conducted before surgery and in the follow-ups at 12 weeks, one year, and five years in women with pelvic organ prolapse (POP) stage ≥2. dMRI was performed at 1.5-T using a predefined protocol including sagittal T2-weighted (T2W) sequence at rest and sagittal T2W true-FISP sequence at maximum strain for metric POP measurements (reference points = bladder, cervix, pouch, rectum). Pelvic organ mobility (POM) was defined as the difference of the metric measurement at maximum strain and at rest. Results Twenty-six women with 104 MRI examinations were available for analysis. dMRI results mostly differ to clinical examination regarding the overall five-year outcome and the posterior compartment in particular. dMRI diagnosed substantially more patients with recurrent or de novo POP in the posterior compartment (n = 17) compared to clinical examination (n = 4). POM after five years aligns to preoperative status except for the bladder. POM reflects best the QOL results regarding defecation disorders. Conclusion A tendency for recurrent and de novo POP was seen in all diagnostic modalities applied. dMRI objectively visualizes the interaction of the pelvic organs and the pelvic floor after reconstructive surgery and POM correlated best with the women's personal impression on pelvic floor complaints.

Effective downsizing but enhanced intratumoral heterogeneity following neoadjuvant sorafenib in patients with non-metastatic renal cell carcinoma.

OBJECTIVES: To evaluate the safety and feasibility of sorafenib prior to surgery for downsizing tumors in patients with non-metastatic cT1-3 renal tumors together with a characterization of functional intratumoral heterogeneity (ITH). MATERIALS AND METHODS: The effects of 4-week sorafenib prior to curative surgery were assessed in a prospective, single-center, randomized, placebo-controlled, double-blinded, pilot trial in patients with T1-3N0M0 renal cell carcinoma (RCC). Patients received sorafenib or placebo for 28 days prior to surgery. MRI was performed at baseline and prior to surgery to calculate tumor volume. The clinical responses were further characterized on the molecular level by immunohistochemical stainings for Ki-67, cleaved caspase-3, and CD31. RESULTS: After enrolling 20 patients into the study, 14 patients were randomized, of which 12 patients were available for analysis. While no significant change in tumor volume was seen for placebo (range = -24.2-0.2%) a reduction of 29.0% (range = -4.9-61.1%) was detected for sorafenib (p < 0.05). Primary renal tumor diameter changed from 10.6 cm (range = 6.5-10.8) to 10.7 cm (range = 6.7-11.1) in the placebo group, and from 5.4 cm (range = 4.3-7.3) to 4.4 cm (range = 3.5-6.8) for the sorafenib group, at baseline vs. 28 days of treatment. Correlative assessment of proliferation, apoptosis, and microvessel density revealed an enhanced degree of functional ITH in treated patients suggesting adaptive and/or regenerative processes with potential relevance for the development of drug resistance. CONCLUSIONS: Sorafenib in standard dosage, given preoperatively for 28 days, was clinically active in downsizing tumors in patients with locally confined, non-metastatic RCC together but led to an enhanced functional ITH in the residual tumor tissue.

One-year dynamic MRI follow-up after vaginal mesh repair: evaluation of clinical, radiological, and quality-of-life results.

BACKGROUND: Pelvic organ prolapse (POP) is a common disorder in elderly women often surgically repaired with alloplastic meshes; yet knowledge of the pelvic floor behavior and multi-compartment defects postoperatively is scarce. PURPOSE: To evaluate the 1-year outcome after mesh repair in patients with POP using clinical examination (CE), dynamic magnetic resonance imaging (dMRI), and the prolapse quality-of-life (P-QOL) questionnaire. MATERIAL AND METHODS: A prospective observational study was conducted of 69 women undergoing pelvic mesh surgery. Clinical examination, dMRI, and the P-QOL questionnaire were applied before and after surgery to evaluate POP. Mean outcome measures were POP outcome as determined on clinical and dMRI examinations and its impact on quality of life. Statistical results were obtained with SPSS version 15.0. ANOVA was used to compare pre-/postsurgical quality of life data. RESULTS: Sixty-nine women (mean age, 64.75 years; BMI, 26.75 kg/m(2); postmenopausal, 89.2%) were recruited and treated with Seratom® or Perigee™ mesh implants. A significant improvement in the position of bladder neck, vaginal vault/uterus, pouch of Douglas, and rectum was found 12 weeks and 1 year after surgery using POP-Q scale and dMRI. Advanced cystoceles and enteroceles seem underestimated by CE using the POP-Q system compared to dMRI results (P = 0.003 and P < 0.001), vice versa dMRI overestimated POP compared to CE. Sixty-four women completed the P-QOL questionnaire, presenting reduced quality of life before surgery which improves postsurgically. Prolapse impact and physical, social, and role limitations correlated strongest with a low quality of life (P < 0.001). CONCLUSION: The 1-year follow-up after mesh repair showed statistical and clinical improvement for all tools employed. dMRI seems a reliable tool for simultaneous assessment of defects in all three compartments, but tends to overestimate POP compared to clinical examination.

Interdisciplinary counseling service for renal malignancies: a patient-centered approach to raise guideline adherence.

OBJECTIVES: Tumor boards have become an integral part of high-quality cancer care, but in general, patients are not directly involved. To overcome this weakness, we established an interdisciplinary counseling service for renal malignancies where 4 specialists talked to the patient at once. We evaluated this approach from the patients' and physicians' perspective. MATERIALS AND METHODS: For 3 months, we assessed organizational and clinical data. Within a standardized telephone interview lasting for 14 ± 8 minutes, we explored the patients' view 1 week after counseling. A focus group contributed the physicians' perspective. Costs and revenues were calculated from the hospital's perspective. RESULTS: We included 52 consecutive patients aged 62 ± 10 years. Patients' initiative for a "second opinion" triggered 37% of all appointments. Patients had localized (52%) and systemic (48%) disease presenting with primary diagnosis (48%), relapse (27%), or under continuous therapy (25%). The treatment strategy was changed significantly in 16 of 30 (53%) patients reporting a specific external opinion. The most frequent changes in recommendation were nephron-sparing surgery instead of radical nephrectomy in 8 cases and divergent judgments on restaging causing changes in systemic treatment in 6 cases. We successfully interviewed 43 of 52 patients. Overall, patients rated the consultation as very positive and only 1 patient (2%) was dissatisfied. Patients rated the quality of interpersonal interaction as very positive and said they would recommend the consultation service to others. Disease state was not associated with ratings. Physicians expressed a very positive opinion, highlighting the patients' benefit and very constructive case discussions. Nevertheless, they report remarkable efforts concerning time investment and effective coordination of medical experts. We estimated a deficit of 39 Euro per patient given the German health care system. There might be relevant secondary positive economic effects for the hospital such as recommendations from one patient to another leading to acquisition of additional patients. CONCLUSIONS: Patient involvement in multidisciplinary tumor boards is feasible and well regarded by patients and physicians likewise. By stimulating interdisciplinary collaboration, the interdisciplinary counseling service improves patient satisfaction and clinical decision making. The interdisciplinary counseling service corrected half of the external treatment plans for better guideline adherence. These positive effects come at the price of higher resource utilization. (www.germanctr.de, number DRKS00003279).

Magnetic resonance-visible polypropylene mesh for pelvic organ prolapse repair.

AIM: To develop a magnetic resonance (MR)-visible mesh using iron oxides and prove visibility. METHODS: In a phantom study, a suitable iron oxide, Fe3O4 [iron(II,III) oxide] and FeOOH [iron(III) oxide-hydroxide], concentration was determined using relaxometric MR measurements of the transverse relaxation rates R2 and R2*. Next, a nonabsorbable mesh was designed from the MR-visible threads woven into a polypropylene mesh. The mesh was implanted into a fresh female cadaver via the transobturator route, and MR visibility was assessed with various MR pulse sequences in a clinical 3-tesla system. RESULTS: Optimal contrast was achieved with Fe3O4 at 0.2 weight-% in all imaging sequences, and the optimal contrast was achieved in a 3D spoiled gradient-echo (fast low-angle shot) acquisition. In this concentration range the apparent transverse relaxation rate R2* is below 10 ms. The mesh was visible in the cadaver on T1-weighted 3D spoiled gradient-echo images and T1-weighted fast spin-echo images. CONCLUSION: Mesh materials can be manufactured to be visible on MR with a negative contrast. Fe3O4 meshes could simplify follow-up examinations and help diagnose origins of postsurgical lesions after urogynecological procedures with mesh material.

Magnetic resonance imaging of cervical carcinoma using an endorectal surface coil.

INTRODUCTION: The objective of this trial is to investigate the diagnostic value of magnetic resonance imaging (MRI) with an endorectal surface coil for precise local staging of patients with histologically proven cervical cancer by comparing the radiological, clinical, and histological results. MATERIALS AND METHODS: Women with cervical cancer were recruited for this trial between February 2007, and September 2010. All the patients were clinically staged according to the FIGO classification and underwent radiological staging by MRI that employed an endorectal surface coil. The staging results after surgery were compared to histopathology in all the operable patients. RESULTS: A total of 74 consecutive patients were included in the trial. Forty-four (59.5%) patients underwent primary surgery, whereas 30 (40.5%) patients were inoperable according to FIGO and underwent primary radiochemotherapy. The mean age of the patients was 50.6 years. In 11 out of the 44 patients concordant staging results were obtained by all three staging modalities. Thirty-two of the 44 patients were concordantly staged by FIGO and histopathological examination, while only 16 were concordantly staged by eMRI and histopathological examination. eMRI overstaged tumors in 14 cases and understaged them in 7 cases. CONCLUSIONS: eMRI is applicable in patients with cervical cancer, yet of no benefit than staging with FIGO or standard pelvic MRI. The most precise preoperative staging procedure still appears to be the clinical examination.

Does a venous tumor thrombus exclude renal transitional cell carcinoma? Implications for neo-adjuvant treatment strategies.

BACKGROUND: A venous tumor thrombus (VTT) is well-known in renal cell carcinoma, but we experienced a series of five patients with VTT due to renal transitional cell carcinoma (TCC). Our study aimed to determine the incidence and clinical relevance of this entity. PATIENTS AND METHODS: From our prospectively-maintained tumor database, we identified 102 patients with renal TCC according to postoperative histology and analyzed the incidence of VTT in renal TCC from 1990 to 2010. RESULTS: Five out of 102 patients with TCC (5%) had a VTT. None of these five patients experienced gross haematuria and we presumed correct diagnosis preoperatively in one out of five patients. Univariate analysis revealed that TNM stage and resection status were inferior in the VTT group. All five patients from the VTT group died from their disease, with a median survival of 8.9 months. With regard to all diagnosed VTT, the effective incidence of vena cava involvement in RCC was 48-fold higher than in renal TCC. CONCLUSION: A VTT is very suggestive of renal cell carcinoma. However, before neo-adjuvant treatment, the diagnosis should be assured whenever there is doubt.

Preoperative decision making for renal cell carcinoma: cystic morphology in cross-sectional imaging might predict lower malignant potential.

OBJECTIVES: Several histologic studies showed more favorable oncologic outcome for renal cell carcinoma (RCC) with cystic change. However, there is no prognostic tool to judge on cystic RCC preoperatively. We hypothesized, that cystic morphology in cross-sectional imaging predicts lower malignant potential. MATERIALS AND METHODS: From our prospectively conducted oncologic database, we identified 825 patients who underwent surgery for malignant renal tumors between 2001 and 2010. In 348 cases (42%), adequate imaging was available for an independent review by 2 radiologists. We excluded recurrent and synchronous bilateral RCC, familial syndromes, collecting duct carcinoma, and metastases of other origin. For the resulting 319 patients, we compared clinical, pathologic, and survival outcomes. RESULTS: Median age was 63 (19-88) years and 220 (69%) patients were male. Median follow-up was 1.7 (0-9.8) years. Of 319 renal masses, 277 (86.8%) were solid and 42 (13.2%) were cystic. In cystic RCC, median tumor diameter was lower (3 cm vs. 4 cm, P = 0.002) and nephron-sparing surgery was more frequent (69% vs. 41.5%, P = 0.002). None of the patients with cystic RCC and 56 (20.2%) with solid RCC had synchronous systemic disease (P = 0.001). The nuclear grade of cystic RCC was more favorable (P = 0.002). Patients with cystic RCC showed better overall (P = 0.049) and cancer-specific survival (P = 0.027). In a multivariate model, only synchronous metastases, positive R status, and greater tumor diameter were independent risk factors (P ≤ 0.03). CONCLUSIONS: We report the first study to show that cystic morphology in cross-sectional imaging might predict RCC with a lower malignant potential. This insight could allow less invasive treatment strategies in selected patients.

MRI findings before and after prolapse surgery.

BACKGROUND: Therapeutical outcome after prolapse surgery is evaluated using a standardized grading system based on maximum prolapse extent, which might not provide the full picture of the patient's subjective outcome. We therefore applied an evaluation method, which is detached from a grading system. PURPOSE: To evaluate the impact of pelvic organ mobility in dynamic magnetic resonance imaging (MRI) before and after mesh-repair surgery in patients with symptomatic pelvic organ prolapse. MATERIAL AND METHODS: To obtain measurements, we performed parasagittal T2-weighted turbo spin echo sequence at rest (TR, 3460 ms; TE, 85 ms; matrix, 512; slice thickness [ST], 5 mm), parasagittal T2-weighted true fast imaging with steady-state precession (TrueFISP) single-shot sequence during straining (TR, 397.4 ms; TE, 1.5 ms; matrix, 256; ST, 8 mm), and parasagittal T2-weighted TrueFISP sequence at maximum strain (TR, 4.3 ms; TE, 2.15 ms; matrix, 256; ST, 5 mm) at 1.5 T MRI. Pelvic organ prolapse (anatomical landmarks: bladder, cervix, pouch, rectum) was measured perpendicularly with reference to the pubococcygeal and the midpubic line. Pelvic organ mobility was defined as the difference between the measured distance at rest and at maximum strain for each anatomical landmark. All patients underwent mesh-repair procedure. Eighty patients could be included in this short-term follow-up study. Due to the physical diagnosis of pelvic organ prolapse, 51 underwent anterior mesh repair, 16 underwent posterior mesh repair, and 13 underwent total mesh repair. Surgery was performed by one surgeon, using mesh implants from several manufacturers. RESULTS: Median values of maximum organ prolapse for bladder, cervix, pouch, and rectum preoperatively were 2.54 cm, 0.33 cm, 2.47 cm, and 0.32 cm, respectively, and 12 weeks postoperatively 0.87 cm, -1.79 cm, 1.49 cm, and 0.49 cm, respectively. Highly significant improvement (P < 0.001) of pelvic organ mobility was observed in the treated compartment at 4- and 12-week follow-up. Physical evaluation 12 weeks after mesh-repair showed an asymptomatic POP-Q stage I, if any. CONCLUSION: Dynamic MRI is useful in visualizing the maximum extent of pelvic organ prolapse, as the evaluation of pelvic organ mobility documents the intraindividual therapeutic outcome detached from a grading system based on maximal prolapse values.

Endometrial cancer: results of clinical and histopathological staging compared to magnetic resonance imaging using an endorectal surface coil.

PURPOSE: The aim of this study was to evaluate the staging accuracy of magnetic resonance imaging (MRI) with an endorectal surface coil on patients with endometrial cancer compared to results obtained using the International Federation of Gynecology and Obstetrics (FIGO) classification and histopathology. METHODS: In this prospective study, patients with biopsy-proven endometrial cancer were staged clinically using the FIGO classification before undergoing 1.5 T MRI with an endorectal surface coil (eMRI). The staging results from the FIGO classification and from eMRI were compared with the histopathological results after surgery. Furthermore, each patient was given a questionnaire designed by the authors to evaluate the patients' opinions on eMRI. The responses were examined using the methods of descriptive analysis. RESULTS: A total of 33 consecutive patients were recruited and clinically staged before undergoing eMRI. Subsequently, 21 patients underwent primary surgery and 12 patients primary radiochemotherapy. The FIGO stages were identical to the histopathological results in 17 (81 %) cases, and those of eMRI were identical in 15 (71 %). In 13 (62 %) cases, FIGO and eMRI staged identically. In 12 (57 %) of the 21 cases, all three staging modalities diagnosed the same tumor stage. eMRI overstaged the tumor in four patients and understaged it in two. All T1a tumors were staged correctly by eMRI. Eighteen patients answered the questionnaire, of whom 11 (61 %) patients stated that their experience with eMRI was overall positive. CONCLUSIONS: It seems feasible in principle to employ eMRI for diagnosing patients with endometrial cancer stage T1a. Yet, the results of eMRI for our study population were not better than the results obtained using the FIGO classification or than those from using MRI without an endorectal surface coil. eMRI thus does not meet the expectations based on its use in other pelvic tumor entities.

Manual repositioning of intra-atrial kidney cancer tumor thrombus: a technique reducing the need for cardiopulmonary bypass.

OBJECTIVE: To describe a feasible surgical technique for patients with renal cell carcinoma associated with a supradiaphragmatic tumor thrombus that avoids cardiopulmonary bypass procedure. MATERIALS AND METHODS: From 2004 to 2009, 4 patients with a right kidney tumor and tumor thrombus above the diaphragm (pT3c) underwent manual repositioning of the tumor thrombus out of the right atrium into the inferior vena cava on the beating heart. These patients were aged 65.8 years and had a body mass index of 25.5 kg/m(2). Median tumor size was 10.8 cm, and 3 patients had synchronous metastasis. RESULTS: Manual repositioning of the tumor thrombus was safe and feasible in all patients. Mean operating time was 561 minutes (range, 302-613 minutes), and no perioperative death occurred. Auxiliary cardiopulmonary bypass procedure was applied in 1 patient to remove a preoperatively diagnosed pulmonary embolus. Three patients subsequently underwent systemic therapy for metastatic disease. Median survival was 16 months (range, 1.7-26 months). CONCLUSION: Manual repositioning of a vena cava tumor thrombus without cardiopulmonary bypass is a safe and feasible approach. The risk of tumor thrombembolization seems to be low, and cardiopulmonary bypass can be avoided or at least reduced to a minimum time of intervention.

Passive marker tracking via phase-only cross correlation (POCC) for MR-guided needle interventions: initial in vivo experience.

PURPOSE: In this work, a passive tracking sequence employing a phase-only cross correlation (POCC) algorithm was studied with a focus on the in vivo applicability of the technique. Therefore, MR-guided needle interventions were performed in a phantom and two animal experiments. METHODS: The targeting accuracy was quantified in an agarose phantom with 15 fiducials. For each fiducial, the distance between needle trajectory and target point was measured. In a first animal experiment at 3 T, the prostate of a pig was punctured under POCC guidance. Second, POCC-based tracking was performed during a laser-induced thermal therapy procedure in peripheral porcine muscle tissue at 1.5 T. RESULTS: In the phantom experiment, the 15 fiducials were penetrated with a mean accuracy of 1.5 ± 0.9 mm (mean duration for one puncture about 2 min). In the first animal experiment, the center of the pig's right prostatic lobe was accurately punctured within 15 min. In the second, targeting and insertion of the needle could be performed within 5 min and a thermal lesion was successfully created. CONCLUSION: Our initial experience with the POCC-based tracking sequence indicates that this technique has the potential as an accurate and versatile tool for in vivo MR-guided needle interventions.

Accuracy of MRI with an endorectal coil for staging endometrial cancer.

BACKGROUND: The very good results of magnetic resonance imaging (MRI) using an endorectal coil in staging prostate cancer at 1.5T suggested that this imaging technique might be able to be used to stage endometrial cancer, the most common tumor in postmenopausal women. PURPOSE: To evaluate the accuracy of MRI with an endorectal surface coil for staging primary endometrial carcinoma. MATERIAL AND METHODS: A total of 33 consecutive patients with biopsy-proven endometrial cancer underwent 1.5T MRI with an endorectal surface coil (eMRI) using sagittal and axial T2-weighted (T2w) turbo spin echo (TSE), axial T1 gradient echo 2D fat-saturated (fs), sagittal T1 gradient echo 3D with and without contrast enhancement (CE), and axial T1 TSE fs CE sequence. Evaluation of local tumor extension was based on the revised standard TNM classification for endometrial cancer. eMRI staging was compared with the histopathological results after surgery. RESULTS: A total of 33 consecutive patients underwent eMRI for staging endometrial cancer, and 21 of these underwent primary surgery. The histological stages were as follows: T1a (n = 8), T1b (n = 10), T2b (n = 2), and T3a (n = 1). Overall staging accuracy by eMRI was 71% (15 of 21). With regard to depth of myometrial invasion, eMRI correctly diagnosed stage T1a in 75% (6/8) and stage T1b in 80% (8/10). eMRI overstaged the tumor in four patients and understaged it in two. CONCLUSION: eMRI is highly accurate in staging myometrial invasion. However, eMRI at 1.5T does not seem to be significantly more accurate than pelvic MRI without an endorectal coil at 1.5T for staging primary endometrial cancer. eMRI for endometrial carcinoma therefore might not meet expectations compared with the results obtained using eMRI for staging prostate cancer at 1.5T.

Preoperative tumor studies using MRI or CT in patients with clinically suspected insulinoma.

PURPOSE: Insulinomas are rare tumors that originate from the islet cells of the pancreas. The aims of this study were to localize insulinomas preoperatively using CT and/or MRI in correlation with postoperative pathological results. PATIENTS AND METHODS: Between December 2001 and June 2010, 27 consecutive patients with clinically suspected insulinoma were surgically treated in our university hospital. Preoperative CT (14 of 27 patients) and MRI studies (14 of 27 patients, one patient had both MRI and CT), operation reports, intraoperative ultrasonography reports, and pathological diagnoses were analyzed retrospectively. For each lesion, images were analyzed based on the presence of enhancement or the characteristics of signal intensities. Pathologic correlation was available for all the lesions. RESULTS: The female: male ratio was 2.9, with a mean age of 47.5 years (range 12-82) . Preoperative tumor localization was achieved by means of MRI and CT. A focal pancreatic lesion, which was hypointense on T(1)-weighted sequences, was detected on all the MR images (14 of 27 patients; 100%). These lesions were isointense (4 cases) to slightly hyperintense (10 of 14 cases) on T(2)-weighted sequences. In T(1)-weighted fat-suppressed contrast-enhanced sequences, there were two types of enhancement: homogeneously hyperintense lesions (in 10 of 14 cases) or peripherally hyper-, centrally isointense (in 4 of 14 cases). On all the CT images (14 of 27 patients), there was no detectable lesion on precontrast series; on arterial series in 13 of 14 patients (arterial series has not been done in one patient), lesions enhanced hypervascular in contrast to the rest of the pancreas with a mean enhancement of 147 HU (range 113-248) and 95 HU (range 65-141), respectively. On venous series in 13 of 14 patients (venous series has not been done in one patient), there was an enhanced lesion in contrast to the rest of the pancreas with a mean enhancement of 110 HU (range 91-151) and 86 HU (range 65-137), respectively. Intraoperative ultrasonography was performed in 11 of 27 patients to localize the tumor, which correlated with the results of the mentioned preoperative studies. Tumor size ranged from 9 × 11 to 31 × 37 mm. Enucleation was carried out in 14 patients, Whipple in 5, segmental resection in 3 and left distal pancreatectomy in 5 patients. The mortality rate was 0. Pathological findings were insulinoma or neuroendocrine tumors in 26 of 27 cases. One patient had a pathological finding of chronic pancreatic disease with intraepithelial neoplasia (grade 1A). CONCLUSION: We conclude that the preoperative localization of insulinoma in clinically suspected patients can be made on the basis of MRI and/or CT studies. A hallmark lesion is hypointense in T(1)-weighted sequences, homogeneously or peripherally hyperintense in T(1)-weighted fat-suppressed contrast-enhanced sequence using MRI (100% of cases) or/and a hypervascular enhanced lesion on arterial (100% of CT studies) and on venous series using CT (66.7% of CT studies).

Imaging of female pelvic malignancies regarding MRI, CT, and PET/CT: Part 2.

PURPOSE: To compose diagnostic standard operating procedures for both clinical and imaging assessment for vulvar and vaginal cancer, for vaginal sarcoma, and for ovarian cancer. METHODS: The literature was reviewed for diagnosing the above mentioned malignancies in the female pelvis. Special focus herein lies in tumor representation in MRI, followed by the evaluation of CT and PET/CT for this topic. CONCLUSION: MRI is a useful additional diagnostic complement but by no means replaces established methods of gynecologic diagnostics and ultrasound. In fact, MRI is only implemented in the guidelines for vulvar cancer. According to the current literature, CT is still the cross-sectional imaging modality of choice for evaluating ovarian cancer. PET/CT appears to have advantages for staging and follow-up in sarcomas and cancers of the ovaries.

Long-term remission in a patient with heavily pretreated, advanced ovarian cancer achieved by bevacizumab and metronomic cyclophosphamide treatment.

Vascular endothelial growth factor seems to be a promoter of tumor progression for epithelial ovarian cancer. New drugs such as bevacizumab, either alone or in combination with metronomic chemotherapy, suppress tumor growth and have proved to be effective in various tumor types. We present a 60-year-old patient with heavily pretreated, recurrent epithelial ovarian cancer, who received bevacizumab (10 mg/m(2)) every 2 weeks in combination with metronomic administered low-dose cyclophosphamide (50 mg/day orally) after failing four explorative laparotomies and multiple chemotherapy regimes. At the time of writing, February 2011, she was being treated with this combination therapy for 24 months and the progression-free survival still continues. Treatment of advanced, refractory epithelial ovarian cancer with bevacizumab in combination with low-dose cyclophosphamide could be a very effective salvage treatment option in heavily pretreated patients.

Imaging of female pelvic malignancies regarding MRI, CT, and PET/CT : part 1.

AIM: The goal of this article is to provide an overview of diagnostic standard operating procedures for both clinical and imaging assessment of cervical and endometrial carcinoma, sarcoma of the uterus, and primary pelvic non-Hodgkin's lymphoma. METHODS: The literature was reviewed for methods used to diagnose malignancies in the female pelvis with a special focus on the role of MRI as the imaging method of choice. Furthermore, CT findings and staging criteria for the mentioned malignancies are also provided. CONCLUSION: Whereas ultrasound still remains the imaging modality of choice in clinical practice for the early diagnosis of female pelvic malignancies, MRI is more frequently recognized as a diagnostic tool for its accuracy in tumor identification. MRI also plays a crucial role in the 3D pretreatment planning for brachytherapy especially in cervical cancer. In the future, PET/CT might achieve an important role for staging lymph nodes or distant metastases as well as tumor recurrence.

Short-range clinical, dynamic magnetic resonance imaging and P-QOL questionnaire results after mesh repair in female pelvic organ prolapse.

OBJECTIVE: To evaluate clinical, quality-of-life (QoL) and dynamic magnetic resonance imaging (dMRI) results in patients with pelvic organ prolapse (POP) preoperatively, and 4 and 12 weeks after anterior and/or posterior mesh repair. STUDY DESIGN: Thirty-six patients (mean age 65 years) with symptomatic pelvic floor descent underwent mesh repair. The prolapse was quantified using the POP-Q system. Before surgery as well as 4 and 12 weeks after surgery, the pelvic organ positions were measured on dynamic magnetic resonance imaging during Valsalva manoeuvre in relation to the pubococcygeal and mid-pubic lines to assess surgery outcome. Patients also completed the P-QOL questionnaire to evaluate subjective changes at each visit. RESULTS: Four and 12 weeks after surgery patients showed improvement of the POP on clinical examination and on dynamic MRI. The latter demonstrated high significance (p<0.001) especially in bladder and vaginal cuff/cervix positions during maximal straining. All quality-of-life domains and some symptom questions of the P-QOL questionnaire significantly improved (p<0.05) 12 weeks after surgery. CONCLUSION: Significant anatomical and quality-of-life improvement was demonstrated after anterior and/or posterior mesh repair for POP using dynamic MRI and the P-QOL questionnaire.