Morphologic perfusion patterns and PI-RADSv2.1 in transition zone prostate cancer.

PURPOSE: To evaluate morphologic perfusion patterns in transition zone prostate cancer in multiparametric MRI controlled by in-bore MRI-guided prostate biopsy. METHODS: Two experienced radiologists evaluated MRI perfusion patterns in consensus from 321 biopsy cores from the transition zone in 141 patients. Transition zone cancer was present in 77 cores in 36 patients. Single early-phase perfusion images were evaluated separately for the presence of a transition zone prostate cancer (consensus tumor early perfusion). The proposed criteria for the perfusion pattern (asymmetry, signal strength, and homogeneity) were rated in consensus for each biopsy position in the presence of the T2w images including the markers of the biopsy trace. We analyzed receiver operating characteristic curves for the PI-RADSv2.1 score and the proposed perfusion pattern. RESULTS: A logistic regression model with PI-RADSv2.1 and perfusion patterns in early perfusion imaging improved the model fit significantly compared to a model containing only PI-RADSv2.1 (Likelihood Ratio Test, LR = 14.5, p < .001). The AUC was 0.96 for the multiple regression model compared to 0.92 for the PI-RADSv2.1 alone. The evaluation of homogeneity in single early-enhancement images is not inferior compared to the conventional DCE parameter of PI-RADSv2.1 (AUC 0.84 versus 0.83). CONCLUSION: Morphologic perfusion patterns significantly improve the diagnostic performance of PI-RADSv2.1 in TZ prostate cancer.

Diffusion-weighted MRI and PET-CT in the follow up of chronic periaortitis.

Aim of the present study is to compare magnetic resonance imaging (MRI) and positron emission tomography (PET) parameters in the follow up of chronic periaortitis (CP), with a focus on changes in the apparent diffusion coefficient (ADC) and standardized uptake values (SUV). 127 patients with CP were treated in our urology between 2007 and 2017. We identified 14 patients with parallel abdominal MRI and PET-CT examinations before therapy and in the follow up resulting in a total of 56 examinations. Relative contrast uptake and diffusion-weighted MRI parameters were compared to SUV in the corresponding PET-CT examinationsand laboratory infection markers. All examined MRI and PET-CT parameters showed significant changes between basis and follow-up examinations. Median ADC values increased significantly (p < 0.001) in the follow up. SUVmax and the other MR parameter (contrast uptake, DWI-signal) declined significantly. We observed a strong negative correlation between ADC and SUVmax (rho: - 0.61; p < 0.001). In addition, we found an inverse correlation of ADC with the inflammation markers ESR (rho: - 0.64; p < 0.001) and CRP (rho: - 0.54; p = 0.001). MRI and PET-CT showed comparable results in the individual follow up of CP and compared to laboratory inflammation markers. Our data support MRI as first imaging modality due to absent radiation and the necessity of repetitive follow-up examinations in patients with CP.

[Percutaneous access for endovascular therapy of PAOD. Femoral, popliteal and pedal]. / Perkutane Zugänge zur endovaskulären PAVK-Therapie. Femoral, popliteal, pedal.

BACKGROUND: Percutaneous interventions in patients with peripheral arterial occlusive disease (PAOD) are usually performed from an antegrade or retrograde transfemoral arterial access; however, sometimes chronic femoropopliteal and crural occlusions cannot be negotiated via this route with traditional standard methods. OBJECTIVES: Description and evaluation of transfemoral, transpopliteal and transpedal vascular approaches for the treatment of advanced PAOD. MATERIAL AND METHODS: A literature review of available studies on endovascular interventions with distal retrograde access was carried out. RESULTS: Most complex arterial occlusions can be treated by employing modern subintimal procedures and/or additional retrograde approaches. The success rate also depends on the expertise with the appropriate technique and materials used. CONCLUSION: The transfemoral access remains the first choice for the treatment of patients with PAOD. Additional retrograde approaches from a more distal access constitute an alternative after failure of antegrade intervention attempts.

[Young Women - Problematic Patients in Vascular Surgery]. / Junge Frauen - Problempatientinnen in der Gefäßchirurgie.

The treatment of peripheral arterial disease (PAD) in young women between 40 and 60 years of age represents a difficult challenge for the vascular surgeon. Excessive smoking, an early menopause and the unfavourable anatomic proportions of thinner arterial vessels or vein grafts during peripheral bypass-surgery lead to a higher rate of complications or re-occlusion following invasive therapy in comparison to male patients. A special anatomic manifestation appearing nearly only in women around the 6th decade is the so-called aortoiliac hypoplastic syndrome with a high rate of re-occlusion after balloon-dilatation or local thrombendarteriectomy and bypass grafting, respectively. Variabilities in coagulation and the undertreatment of classical risk factors of PAD by medical drugs lead to poorer results in the treatment of PAD in young women. Therefore a conservative therapy - whenever feasible - should be the first choice for treating PAD in young women.

[Subcutaneous mass as initial manifestation of an osteolytic metastasis]. / Subkutane Weichteilschwellung als Erstmanifestation einer osteolytischen Knochenmetastase.

HISTORY AND CLINICAL FINDINGS: A 69-year-old woman was admitted for evaluation of a left occipital subcutaneous tumour which had grown during the preceding eight weeks from 2 × 2 cm to 4 × 4 cm. INVESTIGATIONS: Sonography revealed a pressure-sensitive subcutaneous mass with osteolytic destruction in the occipital bone. Cranial magnetic resonance imaging confirmed the osteolytic lesion. Thoracic computed tomography showed a lesion in the upper left lobe of the lung with metastases in the hilar lymph nodes. DIAGNOSIS, TREATMENT AND COURSE: Transbronchial biopsy revealed a bronchial carcinoma. After resection of the osteolytic lesion its histology was confirmed to be an osseous metastasis of the carcinoma. Palliative chemotherapy and cranial irradiation were initiated. CONCLUSION: Solitary osteolytic lesions of the skull occur in the context of osseous metastases. Other possible causes include solitary plasmocytoma and eosinophilic granuloma.

MR evaluation of retroperitoneal fibrosis.

PURPOSE: Retroperitoneal fibrosis (RPF) is a rare fibrosing process. The relation of contrast enhancement within the fibrosis and the psoas muscle was suggested for the evaluation of disease activity and response to treatment, but no standardized method for the quantification of the disease activity is currently available. We introduce an MR parameter for the evaluation of RPF. MATERIALS AND METHODS: 29 patients with untreated idiopathic RPF were examined before medical therapy and after three months of treatment. MR analyses included quotients of T 1 and T 2-signal intensities between the RPF and the psoas muscle. Furthermore, we examined the dynamic contrast enhancement of the fibrous tissue. The respective data were compared with the extent of the RPF after 3 months. RESULTS: In the follow-up examinations we observed a significant regression in 37.9 % (n = 11) of cases, a mild regression in 48.3 % (n = 14) and a stable extent in 13.8 % (n = 4). Patients with a significantly reduced extent showed the highest mean values for the applied MR quotients in the initial examination. The lowest mean values for the respective parameters were found for the group with a stable extent. Only dynamic enhancement quotients showed statistically significant differences (p = 0.011) between the groups of response. CONCLUSION: We observed a significant reduction in the fibrous tissue after pharmacological treatment in patients with an elevated dynamic enhancement quotient in the initial examination.

Associated findings and complications of retroperitoneal fibrosis in 204 patients: results of a urological registry.

PURPOSE: We studied the frequency of associated findings and complications of retroperitoneal fibrosis in a large clinical collective of urological patients. MATERIALS AND METHODS: All urology departments in Germany were invited to participate in a registry of patients with retroperitoneal fibrosis, for which a data sheet with more than 200 questions was developed. RESULTS: As of March 2010 a total of 204 patients were registered. The male-to-female ratio was 2.1:1 and the average age at onset was 55.6 years. In 123 cases (60.3%) the diagnosis was confirmed by histopathology. Coexisting autoimmune diseases were found in 9.8% of patients, consisting mainly of thyroid disorders. Coexisting fibrosis was detected in 3.4% of the patients and 73.9% of those queried were active smokers. Of 176 patients for whom data on therapy were available 123 received monotherapy and 41 received combination therapy for a mean of 12.1 months (12 received none), while 87 underwent a total of 103 operative procedures. Hydronephrosis was the most frequent complication in 95.6% of patients. Atrophic kidney from undetected hydronephrosis appeared in 46 patients (22.5%) and in 4 bilateral damage necessitated dialysis. Complications from vascular obstruction were observed in 27.5% of patients. Large bowel obstruction requiring colostomy occurred in 4 patients (2.0%). CONCLUSIONS: Patients with retroperitoneal fibrosis often first present to urology departments upon referral for hydronephrosis. In this series at least 1 kidney appeared to be irreversibly damaged in more than 20% of patients. Urologists should be mindful of the role of smoking role as a risk factor, complications arising from vascular and large bowel obstructions, and the possible association of retroperitoneal fibrosis with autoimmune disease.

[Chylous ascites after laparoscopic nephroureterectomy]. / Chylöser Aszites nach laparoskopischer Nephroureterektomie.

A 65-year-old man underwent a laparoscopic nephroureterectomy with a radical retroperitoneal lymphadenectomy for transitional cell carcinoma in the pyelon of the left kidney associated with a paraaortal lymphadenopathy. Four weeks later the patient presented with weight loss, a distended abdomen and a swelling of the left hemiscrotum. With increasing complaints and the suspicion of a large lymphocele an exploratory laparoscopy with the possibility of a fenestration was performed. Intraoperatively the laparoscopy revealed a chylous ascites but failed to detect an injury to the lymph system and a localised leak. The ascites eventually resolved under a strict dietary regimen with a medium-chain triglyceride-based diet and repeated long-term drainage. We report this case to encourage a multimodal approach in this potentially fatal complication.

[Venous interventions. Part 2: Thromboses of the upper torso and mesenteric veins]. / Venöse Interventionen. Teil 2: Thrombosen der oberen Körperhälfte und der mesenterialen Venen.

This article focuses on the percutaneous treatment options of venous thromboses and occlusions. Interventional therapy modalities for mediastinal, brachial, axillar, cerebral, and mesenteric thromboses are reviewed. Stenoses of the superior vena cava are most often caused by mediastinal malignomas. Balloon angioplasty together with stent implantation is an effective method for revascularisation in cases of upper venous congestion. Benign central venous stenoses are common in dialysis patients for whom interventional therapy using balloon angioplasty has proven excellent results. In the treatment of insufficient dialysis access, percutaneous techniques represent the first-choice option. Regarding cerebral and mesenteric thrombosis, interventional therapy is restricted to selected individual cases.

Radiological central vein treatment in vascular access.

In the last decades, the percutaneous interventional approach for the treatment of central venous obstructions (CVO) has become increasingly popular as the treatment of first choice because of its minimal invasiveness and reported success rates. CVOs are caused by a diverse spectrum of diseases which can be broadly categorized into two principal eliciting genera, either benign or malignant obstructions. The large group of benign venous obstructions includes the increasing number of end-stage renal disease patients with vascular access related complications. Due to the invasiveness and complexity of thoracic surgery for benign CVOs, the less invasive percutaneous interventional therapy can generally be considered the preferred treatment option. Initially, the radiological intervention consisted of balloon angioplasty alone, subsequently additional stent placement was applied. This was advocated as either primary placement or secondary in cases of elastic recoil or residual stenosis after percutaneous transluminal angioplasty (PTA). The efficacy of angioplasty of CVO in patients with vascular accesses, either with or without stenting, has been addressed by various studies. Overall, reports indicate an initial technical and clinical success rate above 95% and satisfactory patency rates. However, systematic follow-up and frequent re-interventions are necessary to maintain vascular patency to achieve long-term success.