Magnetic resonance imaging of anal cancer: tumor characteristics and early prediction of treatment outcome.

PURPOSE: To analyze tumor characteristics derived from pelvic magnetic resonance imaging (MRI) of patients with squamous cell carcinoma of the anus (SCCA) before and during chemoradiotherapy (CRT), and to compare the changes in these characteristics between scans of responders vs. nonresponders to CRT. METHODS: We included 52 patients with a pelvic 3T MRI scan prior to CRT (baseline scan); 39 of these patients received an additional scan during week 2 of CRT (second scan). Volume, diameter, extramural tumor depth (EMTD), and external anal sphincter infiltration (EASI) of the tumor were assessed. Mean, kurtosis, skewness, standard deviation (SD), and entropy values were extracted from apparent diffusion coefficient (ADC) histograms. The main outcome was locoregional treatment failure. Correlations were evaluated with Wilcoxon's signed rank-sum test and Pearson's correlation coefficient, quantile regression, univariate logistic regression, and area under the ROC curve (AUC) analyses. RESULTS: In isolated analyses of the baseline and second MRI scans, none of the characteristics were associated with outcome. Comparison between the scans showed significant changes in several characteristics: volume, diameter, EMTD, and ADC skewness decreased in the second scan, although the mean ADC increased. Small decreases in volume and diameter were associated with treatment failure, and these variables had the highest AUC values (0.73 and 0.76, respectively) among the analyzed characteristics. CONCLUSION: Changes in tumor volume and diameter in an early scan during CRT could represent easily assessable imaging-based biomarkers to eliminate the need for analysis of more complex MRI characteristics.

Do we really need the arterial phase on CT in pelvic trauma patients?

PURPOSE: To evaluate whether an arterial phase scan improves the diagnostic performance of computed tomography to identify pelvic trauma patients who received angiographic intervention on demand of the trauma surgeon. METHODS: This retrospective single-center study was performed at an academic Scandinavian trauma center with approximately 2000 trauma admissions annually. Pelvic trauma patients with arterial and portal venous phase CT from 2009 to 2015 were included. The patients were identified from the institutional trauma registry. Images were interpreted by two radiologists with more than 10 years of trauma radiology experience. Positive findings for extravasation on portal venous phase alone or on both arterial and portal venous phase were compared, with angiographic intervention as clinical outcome. RESULTS: One hundred fifty-seven patients (54 females, 103 males) with a median age of 45 years were enrolled. Sixteen patients received angiographic intervention. Positive CT findings on portal venous phase only had a sensitivity and specificity of 62% and 86%, vs. 56% and 93% for simultaneous findings on arterial and portal venous phase. Specificity was significantly higher for positive findings in both phases compared with portal venous phase only. Applying a threshold > 0.9 cm of extravasation diameter to portal venous phase only resulted in sensitivity and specificity identical to those of both phases. CONCLUSION: Arterial phase scan in addition to portal venous phase scan did not improve patient selection for angiography. Portal venous phase extravasation size alone may be used as an imaging-based biomarker of the need for angiographic intervention.

Texture analysis on diffusion tensor imaging: discriminating glioblastoma from single brain metastasis.

BACKGROUND: Texture analysis has been done on several radiological modalities to stage, differentiate, and predict prognosis in many oncologic tumors. PURPOSE: To determine the diagnostic accuracy of discriminating glioblastoma (GBM) from single brain metastasis (MET) by assessing the heterogeneity of both the solid tumor and the peritumoral edema with magnetic resonance imaging (MRI) texture analysis (MRTA). MATERIAL AND METHODS: Preoperative MRI examinations done on a 3-T scanner of 43 patients were included: 22 GBM and 21 MET. MRTA was performed on diffusion tensor imaging (DTI) in a representative region of interest (ROI). The MRTA was assessed using a commercially available research software program (TexRAD) which applies a filtration histogram technique for characterizing tumor and peritumoral heterogeneity. The filtration step selectively filters and extracts texture features at different anatomical scales varying from 2 mm (fine) to 6 mm (coarse). Heterogeneity quantification was obtained by the statistical parameter entropy. A threshold value to differentiate GBM from MET with sensitivity and specificity was calculated by receiver operating characteristic (ROC) analysis. RESULTS: Quantifying the heterogeneity of the solid part of the tumor showed no significant difference between GBM and MET. However, the heterogeneity of the GBMs peritumoral edema was significantly higher than the edema surrounding MET, differentiating them with a sensitivity of 80% and specificity of 90%. CONCLUSION: Assessing the peritumoral heterogeneity can increase the radiological diagnostic accuracy when discriminating GBM and MET. This will facilitate the medical staging and optimize the planning for surgical resection of the tumor and postoperative management.

Triple-split-bolus versus single-bolus CT in abdominal trauma patients: a comparative study.

Background Split-bolus computed tomography (CT) is a recent development in trauma imaging. Instead of multiple scans in different contrast phases after a single contrast bolus, split-bolus protocols consist of one single scan of the thorax and abdomen after two or three contrast injections at different points of time. Purpose To evaluate and compare image quality and injury findings of a new triple-split-bolus CT (TS-CT) protocol of thorax and abdomen with those of a portal venous phase CT (PV-CT) in the same patient group. Material and Methods Trauma patients in 2009-2012 who underwent both the TS-CT initially and a PV-CT during the next six weeks were included. The TS-CT examination was performed as one CT run after application of three contrast boluses (total 175 mL) to enhance renal pelvis and urinary tract, the abdominal organs, and the large arterial vessels. The PV-CT had a fixed delay of 85 s. We measured attenuation in Hounsfield units (HU), evaluated possible organ injury and assessed image quality on a 5-point scale. Results Thirty-five patients were included. Attenuation measurements of major abdominal vessels, organs, and renal pelvis were significantly higher with the TS-CT protocol. Performance in organ injury diagnosis and image quality was equal in both protocols. Conclusion The overall performance of the TS-CT protocol is similar to the standard PV-CT. Excellent visualization of the arterial tree and the collecting system may eliminate the need for separate scans.

Diagnostic performance of CT, MRI and PET/CT in patients with suspected colorectal liver metastases: the superiority of MRI.

BACKGROUND: Meticulous imaging of colorectal liver metastases (CRLM) is mandatory to optimize outcome after liver resection. However, the detection of CRLM is still challenging. PURPOSE: To evaluate prospectively if magnetic resonance imaging (MRI) with diffusion-weighted and Gd-EOB-DTPA-enhanced sequences had a better diagnostic performance for CRLM compared to computed tomography (CT) and fluorine-18 fluorodeoxyglucose positron emission tomography (PET/CT). MATERIAL AND METHODS: Forty-six patients scheduled for resection of suspected CRLM were evaluated prospectively from September 2011 to January 2013. None of the patients had undergone previous treatment for their CRLM. Multiphase CT, liver MRI with diffusion-weighted and dynamic Gd-EOB-DTPA-enhanced sequences and low-dose PET/CT were performed. Two independent, blinded readers evaluated the examinations. The reference standard was histopathological confirmation (81/140 CRLM) or follow-up. RESULTS: A total of 140 CRLM and 196 benign lesions were identified. On a per-lesion basis, MRI had the significantly highest sensitivity overall and for CRLM < 10 mm (P < 0.001). Overall sensitivity/specificity and PPV/NPV were 68%/94% and 89%/81% for CT, 90%/87% and 82%/93% for MRI, and 61%/99% and 97%/78% for PET/CT. For CRLM < 10 mm it was 16%/96% and 54%/80% for CT, 74%/88% and 64%/93% for MRI, and 9%/98% and 57%/79% for PET/CT. CONCLUSION: MRI had the significantly highest sensitivity compared with CT and PET/CT, particularly for CRLM < 10 mm. Therefore, detection of CRLM should be based on MRI.

Standardized cine-loop documentation in abdominal ultrasound facilitates offline image interpretation.

BACKGROUND: One of the main disadvantages of conventional ultrasound is its operator dependency, which might impede the reproducibility of the sonographic findings. A new approach with cine-loops and standardized scan protocols can overcome this drawback. PURPOSE: To compare abdominal ultrasound findings of immediate bedside reading by performing radiologist with offline reading by a non-performing radiologist, using standardized cine-loop sequences. MATERIAL AND METHODS: Over a 6-month period, three radiologists performed 140 dynamic ultrasound organ-based examinations in 43 consecutive outpatients. Examination protocols were standardized and included predefined probe position and sequences of short cine-loops of the liver, gallbladder, pancreas, kidneys, and urine bladder, covering the organs completely in two planes. After bedside examinations, the studies were reviewed and read out immediately by the performing radiologist. Image quality was registered from 1 (no diagnostic value) to 5 (excellent cine-loop quality). Offline reading was performed blinded by a radiologist who had not performed the examination. Bedside and offline reading were compared with each other and with consensus results. RESULTS: In 140 examinations, consensus reading revealed 21 cases with renal disorders, 17 cases with liver and bile pathology, and four cases with bladder pathology. Overall inter-observer agreement was 0.73 (95% CI 0.61-0.91), with lowest agreement for findings of the urine bladder (0.36) and highest agreement in liver examinations (0.90). Disagreements between the two readings were seen in nine kidneys, three bladder examinations, one pancreas and bile system examinations each, and in one liver, giving a total number of mismatches of 11%. Nearly all cases of mismatch were of minor clinical significance. The median image quality was 3 (range, 2-5) with most examinations deemed a quality of 3. Compared to consensus reading, overall accuracy was 96% for bedside reading and 94% for offline reading. CONCLUSION: Standardized cine-loop documentation enables accurate offline reading in abdominal ultrasound and shows high agreement with immediate bedside reading.

Standardized cine-loop documentation in renal ultrasound facilitates skill-mix between radiographer and radiologist.

BACKGROUND: The radiographers' role in ultrasound (US) has been debated due to the operator-dependent aspect of diagnostic US. With standardized cine-loop ultrasound (SCUS) a reliable diagnosis can be achieved by reading SCUS independently from performing the procedure. PURPOSE: To study the correlation between sonographic findings when SCUS is performed and read by a radiologist and when SCUS is performed by a radiographer and read by a radiologist, and to assess the radiologists' confidence when reading SCUS examinations performed by a radiographer. MATERIAL AND METHODS: Thirty-four patients (64 kidneys) who underwent SCUS of the kidneys were included in this study. All patients underwent two consecutive SCUS examinations, one performed by an experienced radiologist reading his own examination (online), and one performed by a SCUS-trained radiographer, read by an experienced radiologist who was not involved in the examination of the patient (offline). Study reports were made using a structured report form designed for this study. Confidence was measured on a visual analog scale ranging from 0 (no confidence) to 100 (extremely confident). The final diagnosis (the reference standard) was defined as the consensus between two US-experienced radiologists. All personnel were blinded to each other's results. RESULTS: We found discordance between image findings for online and offline in eight out of 64 kidneys. There was no systematic difference between online and offline reading. There was a good correlation between online and offline, kappa 0.75 (95% CI 0.60-0.90, P < 0.001). Kappa correlation for online and offline compared to reference standard was 0.94 (95% CI 0.86-1.00, P < 0.001) and 0.81 (95% CI 0.66-0.96, P < 0.001), respectively. Radiologists reported a confidence level of 88 (range, 74-94) and 85 (range, 67-92) in the online and offline group, respectively (P = 0.005). CONCLUSION: There is a high degree of correlation between reported findings in radiologist and radiographer performed SCUS examinations.

Early rectal cancer: The diagnostic performance of MRI supplemented with a rectal micro-enema and a modified staging system to identify tumors eligible for local excision.

Background: In staging early rectal cancers (ERC), submucosal tumor depth is one of the most important features determining the possibility of local excision (LE). The micro-enema (Bisacodyl) induces submucosal edema and may hypothetically improve the visualization of tumor depth. Purpose: To test the diagnostic performance of MRI to identify ERC suitable for LE when adding a pre-procedural micro-enema and concurrent use of a modified classification system. Material and Methods: In this prospective study, we consecutively included 73 patients with newly diagnosed rectal tumors. Two experienced radiologists independently interpreted the MRI examinations, and diagnostic performance was calculated for local tumors eligible for LE (Tis-T1sm2, n = 43) and non-local tumors too advanced for LE (T1sm3-T3b, n = 30). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were registered for each reader. Inter- and intra-reader agreements were assessed by kappa statistics. Lymph node status was derived from the clinical MRI reports. Results: Reader1/reader2 achieved sensitivities of 93%/86%, specificities of 90%/83%, PPV of 93%/88%, and NPV of 90%/81%, respectively, for identifying tumors eligible for LE. Rates of overstaging of local tumors were 7% and 14% for the two readers, and kappa values for the inter- and intra-reader agreement were 0.69 and 0.80, respectively. For tumors ≤T2, all metastatic lymph nodes were smaller than 3 mm on histopathology. Conclusion: MRI after a rectal micro-enema and concurrent use of a modified staging system achieved good diagnostic performance to identify tumors suitable for LE. The rate of overstaging of local tumors was comparable to results reported in previous endorectal ultrasound (ERUS) studies.

Impact of contrast-enhanced intraoperative ultrasound on operation strategy in case of colorectal liver metastasis.

BACKGROUND: Surgical treatment is the only option for long-term survival in patients with colorectal liver metastasis (CRLM). Contrast-enhanced CT and MRI are usually used for preoperative liver imaging. The initial surgical strategy for liver resection is based upon these findings. Further optimization of the surgical strategy by contrast-enhanced intraoperative ultrasound (CE-IOUS) might further improve the surgical outcome. PURPOSE: To evaluate the current impact of CE-IOUS with SonoVue(®) on the initial surgical strategy for CRLM. MATERIAL AND METHODS: Eighty-six consecutive patients undergoing open liver resection for CRLM were evaluated retrospectively over a 2.5-year period. The patients underwent 97 operations. Preoperative staging was performed with contrast-enhanced CT in all patients and MRI was available in 66 of 86 patients. CE-IOUS was performed in all patients according to a standardized examination technique. Curved array and linear transducers were used. CRLM were identified in venous phase as hypovascular lesions. CE-IOUS findings were compared with preoperative staging. RESULTS: Combined CT/MRI identified preoperatively 328 CRLM (mean 3.4, range 0-14). Seventy-two additional lesions (18%) were identified in 38 patients during the operation. Intraoperatively 41 additional CRLM in 20 patients were identified by inspection, palpation, and CE-IOUS (10%), and another 31 CRLM in 17 patients were identified by CE-IOUS alone (8%). All additional CRLM detected by CE-IOUS were confirmed by histology if resection was performed. CE-IOUS changed planned operation strategy in 29.9% of operations. A larger resection was necessary in 13.4% of the cases, reduced liver resection was found sufficient in 11.3%, and 5.2% were found inoperable. For patients diagnosed preoperatively with solitary lesions CE-IOUS changed operation strategy in 19% and radical tumor resection would have failed in 4.8% without CE-IOUS. CONCLUSION: CE-IOUS is essential to ensure optimal and complete tumor resection both in patient with solitary CRLM and multiple metastases.

Is there need for routine CT colonography after CT-verified uncomplicated diverticulitis of the sigmoid colon?

BACKGROUND: Following an episode of acute diverticulitis, surgical guidelines commonly advise routine colonic follow-up to rule out underlying malignancy. However, as a CT of the abdomen is frequently performed during clinical work-up, the routine need for colonic follow-up has become debated. PURPOSE: To evaluate the need for routine CT colonography after an episode of CT-verified uncomplicated sigmoid diverticulitis to rule out underlying colorectal malignancy. MATERIAL AND METHODS: This study retrospectively evaluated 312 patients routinely referred to colonic evaluation by CT colonography following an episode of acute diverticulitis. Patients were excluded if lacking diagnostic CT of the abdomen at time of diagnosis, if presenting with atypical colonic involvement, or if CT findings were suggestive of complicated disease (e.g., abscess or perforation). CT colonography exams were routinely reviewed by experienced abdominal radiology consultants on the day of the procedure. If significant polyps were detected, or if colorectal malignancy could not be excluded, patients were referred to same-day optical colonoscopy. For these patients, medical records were reviewed for optical colonoscopy results and histology reports if applicable. RESULTS: Among 223 patients with CT-verified uncomplicated sigmoid diverticulitis, no patients were found to have underlying colorectal malignancy. 27 patients were referred to optical colonoscopy based on CT colonography findings. 18 patients consequently underwent polypectomy, all with either hyperplastic or adenomatous histology. CONCLUSIONS: This study indicates that routine colonic evaluation by CT colonography following an episode of CT-verified uncomplicated sigmoid diverticulitis may be unwarranted, and should arguably be reserved for patients with protracted or atypical clinical course.

Iterative reconstruction improves image quality and reduces radiation dose in trauma protocols; A human cadaver study.

BACKGROUND: Radiation-related cancer risk is an object of concern in CT of trauma patients, as these represent a young population. Different radiation reducing methods, including iterative reconstruction (IR), and spilt bolus techniques have been introduced in the recent years in different large scale trauma centers. PURPOSE: To compare image quality in human cadaver exposed to thoracoabdominal computed tomography using IR and standard filtered back-projection (FBP) at different dose levels. MATERIAL AND METHODS: Ten cadavers were scanned at full dose and a dose reduction in CTDIvol of 5 mGy (low dose 1) and 7.5 mGy (low dose 2) on a Siemens Definition Flash 128-slice computed tomography scanner. Low dose images were reconstructed with FBP and Sinogram affirmed iterative reconstruction (SAFIRE) level 2 and 4. Quantitative image quality was analyzed by comparison of contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR). Qualitative image quality was evaluated by use of visual grading regression (VGR) by four radiologists. RESULTS: Readers preferred SAFIRE reconstructed images over FBP at a dose reduction of 40% (low dose 1) and 56% (low dose 2), with significant difference in overall impression of image quality. CNR and SNR showed significant improvement for images reconstructed with SAFIRE 2 and 4 compared to FBP at both low dose levels. CONCLUSIONS: Iterative image reconstruction, SAFIRE 2 and 4, resulted in equal or improved image quality at a dose reduction of up to 56% compared to full dose FBP and may be used a strong radiation reduction tool in the young trauma population.

Preoperative 18F-FDG PET/computed tomography predicts survival following resection for colorectal liver metastases.

OBJECTIVE: The liver is the most frequent metastatic site from colorectal cancer and about 20% of these patients are treated by surgical resection. However, the 5-year disease-free survival (DFS) following resection is only about 25% and 5-year overall survival (OS) about 38%. The aim of the study was to evaluate the ability of metabolic and volumetric measurements from fluorine-18-fluorodeoxyglucose (F-FDG) PET/computed tomography (CT) prior to resection for colorectal liver metastases (CLM) to predict survival. PATIENTS AND METHODS: Preoperative F-FDG PET/CT examinations were assessed. Metabolic tumor volume (MTV), total lesion glycolysis (TLG), maximum, mean and peak standardized uptake values and tumor to background ratio, were obtained for all CLM. Cutoff values were determined for each of these parameters by using receiver operating characteristic analysis dividing the patients into two groups. DFS, liver recurrence-free survival (LRFS), OS and cancer-specific survival (CSS) for patients over and under the cutoff value were compared by using the Kaplan-Meier method and log-rank test. RESULTS: Twenty-seven patients who underwent F-FDG PET/CT prior to resection for CLM were included. Low values of total MTV and TLG were significantly correlated to improved 5-year LRFS (P = 0.016 and 0.006) and CSS (P = 0.034 and 0.008). Patients who developed liver recurrence had significantly higher total MTV and TLG compared to patients without liver recurrence (P = 0.042 and 0.047). CONCLUSION: Low values of total MTV and TLG were significantly correlated to improved LRFS and CSS and may improve the risk stratification of patients considered for resection for CLM.

Diagnostic performance of texture analysis on MRI in grading cerebral gliomas.

BACKGROUND AND PURPOSE: Grading of cerebral gliomas is important both in treatment decision and assessment of prognosis. The purpose of this study was to determine the diagnostic accuracy of grading cerebral gliomas by assessing the tumor heterogeneity using MRI texture analysis (MRTA). MATERIAL AND METHODS: 95 patients with gliomas were included, 27 low grade gliomas (LGG) all grade II and 68 high grade gliomas (HGG) (grade III=34 and grade IV=34). Preoperative MRI examinations were performed using a 3T scanner and MRTA was done on preoperative contrast-enhanced three-dimensional isotropic spoiled gradient echo images in a representative ROI. The MRTA was assessed using a commercially available research software program (TexRAD) that applies a filtration-histogram technique for characterizing tumor heterogeneity. Filtration step selectively filters and extracts texture features at different anatomical scales varying from 2mm (fine features) to 6mm (coarse features), the statistical parameter standard deviation (SD) was obtained. Receiver operating characteristics (ROC) was performed to assess sensitivity and specificity for differentiating between the different grades and calculating a threshold value to quantify the heterogeneity. RESULTS: LGG and HGG was best discriminated using SD at fine texture scale, with a sensitivity and specificity of 93% and 81% (AUC 0.910, p<0.0001). The diagnostic ability for MRTA to differentiate between the different sub-groups (grade II-IV) was slightly lower but still significant. CONCLUSIONS: Measuring heterogeneity in gliomas to discriminate HGG from LGG and between different histological sub-types on already obtained images using MRTA can be a useful tool to augment the diagnostic accuracy in grading cerebral gliomas and potentially hasten treatment decision.

[Treatment of splenic injuries in children]. / Behandling av miltskader hos barn.

BACKGROUND: Most children with blunt splenic trauma are treated non-operatively. Controversy exists regarding the minimal hospital stay, follow-up imaging and length of activity restriction required after discharge. MATERIAL AND METHODS: To evaluate outcome for this group of patients, a review was performed of children (age below 14) with blunt splenic injuries treated between January 2000 and December 2003. RESULTS: Fifteen children were admitted with blunt splenic trauma, all were successfully treated non-operatively. Four patients were excluded from further analysis because of multiple injuries that prolonged their hospital stay or they were transferred to our institution more than six days after the accident. Median age was 8 years (range, 1-12). Median length of stay was 5 days (range, 3-8) including 0 days (range, 0-4) in the intensive care unit. Median numbers of follow-up ultrasound examinations were 2 (range, 0-4) with no influence on treatment. Reduced activity after discharge was advised for a median of 4 weeks (3-6). All patients had an uneventful recovery. INTERPRETATION: Haemodynamically stable children with blunt splenic injuries can be treated non-operatively with short hospital stay and a few weeks of restricted activity after discharge. Routine follow-up imaging seems unnecessary.

[Pseudoaneurysm in splenic injury]. / Pseudoaneurisme ved miltskader.

Blunt splenic injuries are increasingly being managed non-operatively. Consequently, radiological examinations in the follow up of these injuries must aim at detecting lesions like pseudoaneurysms that can cause delayed bleeding. Two patients are presented. They were both diagnosed at a local hospital and treated at the regional trauma centre. In both patients pseudoaneurysms were detected on CT examination with arterial contrast phase. Angiographic embolisation was performed successfully. The cases are discussed with reference to relevant literature. Pseudoaneurysms may not be detected at the initial CT scan and can cause delayed bleeding. Thus it seems wise to perform a CT scan in arterial and venous contrast phase 5-7 days after the injury. Interventional angiography should be offered haemodynamically stable adult patients with serious splenic injury and in the absence of other indications for laparotomy.

Respiratory gated PET/CT of the liver: A novel method and its impact on the detection of colorectal liver metastases.

PURPOSE: To evaluate the diagnostic performance of a new method for respiratory gated positron emission tomography (rgPET/CT) for colorectal liver metastases (CRLM), secondly, to assess its additional value to standard PET/CT (PET/CT). MATERIALS AND METHODS: Forty-three patients scheduled for resection of suspected CRLM were prospectively included from September 2011 to January 2013. None of the patients had previously undergone treatment for their CRLM. All patients underwent PET/CT and rgPET/CT in the same session. For rgPET/CT an in-house developed electronic circuit was used which displayed a color-coded countdown for the patient. The patients held their breath according to the countdown and only the data from the inspiration breath-hold period was used for image reconstruction. Two independent and blinded readers evaluated both PET/CT and rgPET/CT separately. The reference standard was histopathological confirmation for 73 out of 131 CRLM and follow-up otherwise. RESULTS: Reference standard identified 131 CRLM in 39/43 patients. Nine patients accounted for 25 mucinous CRLM. The overall per-lesion sensitivity for detection of CRLM was for PET/CT 60.0%, for rgPET/CT 63.1%, and for standard+rgPET/CT 67.7%, respectively. Standard+rgPET/CT was overall significantly more sensitive for CRLM compared to PET/CT (p=0.002) and rgPET/CT (p=0.031). The overall positive predictive value (PPV) for detection of CRLM was for PET/CT 97.5%, for rgPET/CT 95.3%, and for standard+rgPET/CT 93.6%, respectively. CONCLUSION: Combination of PET/CT and rgPET/CT improved the sensitivity significantly for CRLM. However, high patient compliance is mandatory to achieve optimal performance and further improvements are needed to overcome these limitations. The diagnostic performance of the evaluated new method for rgPET/CT was comparable to earlier reported technically more complex and expensive methods.

Preserved splenic function after angioembolisation of high grade injury.

BACKGROUND: After introducing splenic artery embolisation (SAE) in the institutional treatment protocol for splenic injury, we wanted to evaluate the effects of SAE on splenic function and assess the need for immunisation in SAE treated patients. METHODS: 15 SAE patients and 14 splenectomised (SPL) patients were included and 29 healthy blood donors volunteered as controls. Clinical examination, medical history, general blood counts, immunoglobulin quantifications and flowcytometric analysis of lymphocyte phenotypes were performed. Peripheral blood smears from all patients and controls were examined for Howell-Jolly (H-J) bodies. Abdominal doppler, gray scale and contrast enhanced ultrasound (CEUS) were performed on all the SAE patients. RESULTS: Leukocyte and platelet counts were elevated in both SAE and SPL individuals compared to controls. The proportion of memory B-lymphocytes did not differ significantly from controls in either group. In the SAE group total IgA, IgM and IgG levels as well as pneumococcal serotype specific IgG and IgM antibody levels did not differ from the control group. In the SPL group total IgA and IgG Pneumovax(®) (PPV23) antibody levels were significantly increased, and 5 of 12 pneumococcal serotype specific IgGs and IgMs were significantly elevated. H-J bodies were only detected in the SPL group. CEUS confirmed normal sized and well perfused spleens in all SAE patients. CONCLUSION: In our study non-operative management (NOM) of high grade splenic injuries including SAE, was followed by an increase in total leukocyte and platelet counts. Normal levels of immunoglobulins and memory B cells, absence of H-J bodies and preserved splenic size and intraparenchymal blood flow suggest that SAE has only minor impact on splenic function and that immunisation probably is unnecessary.

A protocol for angiographic embolization in exsanguinating pelvic trauma: a report on 31 patients.

BACKGROUND: The indication for acquiring angiographic embolization in the initial treatment of severe pelvic fractures is controversial. We describe the characteristics and outcome of 31 patients with traumatic pelvic bleeding who underwent percutaneous angiography with embolization according to a standardized protocol. PATIENTS AND METHODS: During an 8.5-year period, 1,260 patients were treated for pelvic trauma. We performed a prospective registration of the 46 patients who underwent angiography, and report the 31 patients who had signs of significant arterial injury on angiography, necessitating embolization. RESULTS: The rate of significant arterial injury after pelvic trauma was 2.5%. All patients had been subjected to high-energy injuries and all were severely injured as measured by the Injury Severity Score: 41 (17-66). Pelvic arterial injury was observed with all types of pelvic trauma, including isolated acetabular (4/31) and sacral fractures (3/31). The internal iliac artery or its branches was injured in 28 of 31 patients. Survival rate after embolization was 84%, and correlated inversely with increasing patient age. None of the patients died of bleeding. INTERPRETATION: Our findings show that significant pelvic arterial injuries occur in a minority of patients after pelvic trauma, and predominantly affect patients with multiple high-energy injuries regardless of fracture type. The effect of angiographic embolization was good.