Coherent Structural and Functional Network Changes after Thalamic Lesions in Essential Tremor.

BACKGROUND: Magnetic resonance-guided focused ultrasound of the ventral intermediate nucleus is a novel incisionless ablative treatment for essential tremor (ET). OBJECTIVE: The aim was to study the structural and functional network changes induced by unilateral sonication of the ventral intermediate nucleus in ET. METHODS: Fifteen essential tremor patients (66.2 ± 15.4 years) underwent probabilistic tractography and functional magnetic resonance imaging (MRI) during unilateral postural tremor-eliciting tasks using 3-T MRI before, 1 month (N = 15), and 6 months (N = 10) post unilateral sonication. RESULTS: Tractography identified tract-specific alterations within the dentato-thalamo-cortical tract (DTCT) affected by the unilateral lesion after sonication. Relative to the treated hand, task-evoked activation was significantly reduced in contralateral primary sensorimotor cortex and ipsilateral cerebellar lobules IV/V and VI, and vermis. Dynamic causal modeling revealed a significant decrease in excitatory drive from the cerebellum to the contralateral sensorimotor cortex. CONCLUSIONS: Thalamic lesions induced by sonication induce specific functional network changes within the DTCT, notably reducing excitatory input to ipsilateral sensorimotor cortex in ET. ©[2022] International Parkinson and Movement Disorder Society. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Improving quality of life in pancreatic cancer patients following high-intensity focused ultrasound (HIFU) in two European centers.

OBJECTIVES: Pancreatic cancer patients often have a high symptom burden, significantly impairing patients' quality of life (QOL). Nevertheless, there are hardly any reports on the impact of high-intensity focused ultrasound (HIFU) on the QOL of treated patients. For the first time, this study evaluated the effect of HIFU on QOL and compared these results in two European centers. METHODS: Eighty patients with advanced pancreatic cancer underwent HIFU (50 in Germany, 30 in Bulgaria). Clinical assessment included evaluation of QOL and symptoms using the EORTC QLQ-C30 questionnaire at baseline and 1, 3, and 6 months after HIFU. Pain intensity was additionally evaluated with the numerical rating score (NRS). RESULTS: Compared to baseline, global health significantly improved 3 and 6 months after HIFU treatment (p = 0.02). Functional subscales including physical, emotional, and social functioning were considerably improved at 6 months (p = 0.02, p = 0.01, and p = 0.01, respectively) as were leading symptom pain (p = 0.04 at 6 months), fatigue (p = 0.03 at 3 and p = 0.01 at 6 months), and appetite loss (p = 0.01 at 6 months). Moreover, pain intensity measured by NRS revealed effective and strong pain relief at all time points (p < 0.001). Reported effects were independent of tumor stage, metastatic status, and country of treatment. CONCLUSIONS: This study showed that HIFU represents an effective treatment option of advanced pancreatic cancer improving QOL by increasing global health and mitigation of physical complaints with a low rate of side effects, independent of the examiner. Therefore, HIFU is a worthwhile additional treatment besides systemic palliative chemotherapy or best supportive care in management of this aggressive disease. KEY POINTS: • In a prospective two-center study, it was shown that HIFU represents an effective treatment option of advanced pancreatic cancer improving QOL. • HIFU in pancreatic cancer patients is associated with a low rate of side effects, independent of the performer. • HIFU is a worthwhile additional treatment besides systemic palliative chemotherapy or best supportive care in management of this aggressive disease.

Contrast-enhanced Interstitial Transpedal MR Lymphangiography for Thoracic Chylous Effusions.

Background Abnormalities of the central lymphatic system (CLS) are increasingly treated by interventional radiology approaches. Planning of these procedures, however, is challenging because of the lack of clinical imaging tools. Purpose To evaluate the clinical usefulness of contrast agent-enhanced interstitial transpedal MR lymphangiography in the preinterventional workup of lymphatic interventions in patients with thoracic chylous effusions. Materials and Methods Patients with chylous effusions evaluated from January 2014 and December 2017 were included in this retrospective analysis of transpedal MR lymphangiography. Indications were chylothorax (n = 19; 76%), cervical lymphatic fistula (n = 2; 8%), and combined chylothorax and chylous ascites (n = 4; 16%). Patients underwent transpedal MR lymphangiography at 1.5 T with T1-weighted imaging after interstitial pedal of gadolinium-based contrast medium under local anesthesia. Contrast-enhanced MRI was evaluated for technical success, depiction of pathologic abnormalities of the CLS, and access site for lymphatic interventions (ie, clinically useful examination). Reader agreement for image quality and overall degree of visualization was assessed with weighted κ. Interrelations between overall image quality and degree of visualization of CLS structures were assessed by Spearman ρ. Efficacy of transpedal MR lymphangiography was calculated by using radiographic lymphangiography as the reference standard. Results Twenty-five patients (mean age, 54 years ± 18 [standard deviation]; 13 men) were evaluated. Eight percent (two of 25) of examinations failed (lymphoma in one patient and technical failure in one patient). Contrast agent injection was well tolerated without complications. Interrater agreement of image quality was excellent (κ = 0.96). The degree of CLS visualization correlated with overall image quality (ρ = 0.71; P < .001). Retroperitoneal lymphatics, cisterna chyli, and thoracic duct were viewed with an accuracy of 23 of 25 (92%), 24 of 25 (96%), and 23 of 25 (92%), respectively. Anatomic variations, a lymphatic pathologic abnormality, and interventional access routes were identified with an accuracy of 22 of 25 (88%), 23 of 25 (92%), and 24 of 25 (96%), respectively. Overall, 23 of 25 (92%) transpedal MR lymphangiograms provided clinically useful information. Conclusion Transpedal interstitial MR lymphangiography was well tolerated by the patient and identified specific pathologic abnormalities causing thoracic chylous leakages before lymphatic intervention. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Maki and Itkin in this issue.

Where Have All the Punctures Gone? An Analysis of Thoracic Duct Embolizations.

PURPOSE: To determine how frequently and how severely intra-abdominal structures are affected by transabdominal thoracic duct embolization (TDE). MATERIALS AND METHODS: Thirty-five TDE procedures in 35 patients (22 male; mean age, 57 y; age range, 10-79 y) with therapy-refractory chylous effusions were evaluated in which radiopaque embolization material outlined the access route on postinterventional CT. CT data were analyzed by 2 TDE-experienced radiologists. Abdominal structures and organs transgressed by the access route were recorded, and findings were correlated with clinical postinterventional course with follow-up of at least 44 days. RESULTS: Intra-abdominal structures/organs transgressed most often by the access route were the liver (n = 28), crus of the diaphragm (n = 25), pancreas (n = 14), portal vein (n = 10), duodenum (n = 7), inferior vena cava (n = 5), colon (n = 3), left renal vein (n = 2), pleura (n = 2), pericardium (n = 2), and gastric sleeve (n = 2). Pancreatitis was observed in 1 of 14 patients after pancreatic transgression. One case of clinically occult pulmonary glue migration occurred on catheter pullback through the left renal vein. Biliary peritonitis was observed after gallbladder puncture, necessitating cholecystectomy in 1 of 2 transbiliary punctures. No other relevant procedure-related complications such as hemorrhages or infectious complications were observed. CONCLUSIONS: Despite transgression of intra-abdominal structures, puncture- and access-related complications of TDE are rare. Transpancreatic manipulations are reasonably well tolerated.

MRI follow-up after magnetic resonance-guided focused ultrasound for non-invasive thalamotomy: the neuroradiologist's perspective.

PURPOSE: Magnetic resonance-guided focused ultrasound (MRgFUS) systems are increasingly used to non-invasively treat tremor; consensus on imaging follow-up is poor in these patients. This study aims to elucidate how MRgFUS lesions evolve for a radiological readership with regard to clinical outcome. METHODS: MRgFUS-induced lesions and oedema were retrospectively evaluated based on DWI, SWI, T2-weighted and T1-weighted 3-T MRI data acquired 30 min and 3, 30 and 180 days after MRgFUS (n = 9 essential tremor, n = 1 Parkinson's patients). Lesions were assessed volumetrically, visually and by ADC measurements and compared with clinical effects using non-parametric testing. RESULTS: Thirty minutes after treatment, all lesions could be identified on T2-weighted images. Immediate oedema was rare (n = 1). Lesion volume as well as oedema reached a maximum on day 3 with a mean lesion size of 0.4 ± 0.2 cm3 and an oedema volume 3.7 ± 1.2 times the lesion volume. On day 3, a distinct diffusion-restricted rim was noted that corresponded well with SWI. Lesion shrinkage after day 3 was observed in all sequences. Lesions were no longer detectable on DWI in n = 7/10, on T2-weighted images in n = 4/10 and on T1-weighted images in n = 4/10 on day 180. No infarcts or haemorrhage were observed. There was no correlation between lesion size and initial motor skill improvement (p = 0.99). Tremor reduction dynamics correlated strongly with lesion shrinkage between days 3 and 180 (p = 0.01, R = 0.76). CONCLUSION: In conclusion, cerebral MRgFUS lesions variably shrink over months. SWI is the sequence of choice to identify lesions after 6 months. Lesion volume is arguably associated with intermediate-term outcome.

Tomotherapy in malignant mesothelioma: a planning study to establish dose constraints.

PURPOSE: A planning study was performed for helical tomotherapy treatment. We evaluated the maximum achievable protection of organs at risk (OARs) in patients with malignant pleural mesothelioma after pleurectomy with simultaneous optimal target coverage. MATERIALS AND METHODS: The datasets of 13 patients were included. The applied dose to the planning target volume (PTV) was 50.4 Gy with single doses of 1.8 Gy per fraction. Presuming optimal target coverage, we evaluated the applied dose to the OARs with special regard to the contralateral lung. RESULTS: For left-(lsRT)/right(rsRT)-sided radiotherapy, target coverage for the PTV showed a D98 (mean) of 49.37/49.71 Gy (98.0%/98.6%) and a D2 (mean) of 54.19/54.61 Gy (107.5%/108.3%). The beam-on time was kept below 15 min. The achieved mean dose (D50) to the contralateral lung was kept below 4 Gy for lsRT and rsRT. With regard to the other organs at risk the applied doses were as follows: mean dose (lsRT): ipsilateral kidney (Dmean) 13.03 (5.32-22.18) Gy, contralateral kidney (Dmean) <2.0 Gy, heart (Dmean) 22.23 (13.57-27.72) Gy, spinal cord D1

A matched-pair analysis on survival and response rates between German and non-German cancer patients treated at a Comprehensive Cancer Center.

BACKGROUND: Research shows disparities in cancer outcomes by ethnicity or socio-economic status. Therefore, it is the aim of our study to perform a matched-pair analysis which compares the outcome of German and non-German (in the following described as 'foreign') cancer patients being treated at the Center for Integrated Oncology (CIO) Köln Bonn at the University Hospital of Bonn between January 2010 and June 2016. METHODS: During this time, 6314 well-documented patients received a diagnosis of cancer. Out of these patients, 219 patients with foreign nationality could be matched to German patients based on diagnostic and demographic criteria and were included in the study. All of these 438 patients were well characterized concerning survival data (Overall survival, Progression-free survival and Time to progression) and response to treatment. RESULTS: No significant differences regarding the patients' survival and response rates were seen when all German and foreign patients were compared. A subgroup analysis of German and foreign patients with head and neck cancer revealed a significantly longer progression-free survival for the German patients. Differences in response to treatment could not be found in this subgroup analysis. CONCLUSIONS: In summary, no major differences in survival and response rates of German and foreign cancer patients were revealed in this study. Nevertheless, the differences in progression-free survival, which could be found in the subgroup analysis of patients with head and neck cancer, should lead to further research, especially evaluating the role of infectious diseases like human papillomavirus (HPV) and Epstein-Barr virus (EBV) on carcinogenesis and disease progression.

Effects of a 24-hr-shift-related short-term sleep deprivation on cardiac function: A cardiac magnetic resonance-based study.

Fatigue and sleep deprivation are common phenomena, especially among medical professionals and shift workers. Studies have proven that short episodes of sleep deprivation can lead to sympathetic hyperactivity with an elevation in blood pressure, heart rate, and an increased secretion of stress hormones (e.g. cortisol, noradrenaline, thyroid hormones). In this study investigating cardiac strain in 20 healthy subjects undergoing short-term sleep deprivation, it could be shown for the first time that 24-hr-shift-related short-term sleep deprivation leads to a significant increase in cardiac contractility, blood pressure, heart rate and stress hormone secretion. These findings may help better understand how workload and shift duration affect public health, and lay the foundation for further investigations.

Lung cancer screening with MRI: Evaluation of MRI for lung cancer screening by comparison of LDCT- and MRI-derived Lung-RADS categories in the first two screening rounds.

PURPOSE: To evaluate MRI for lung cancer screening comparing LDCT- and MRI-derived Lung-RADS categories in the first two screening rounds. MATERIALS AND METHODS: 224 participants in a lung cancer screening study were examined with MRI and low-dose CT (LDCT). Acquired MRI sequences were T2, balanced, T1 and DWI. MRI was prospectively analysed regarding nodules. Minimum nodule size was 4 mm. Nodules were assigned a Lung-RADS score based on appearance and size at baseline and after 3, 6 and 12 months. MRI findings were correlated with LDCT. RESULTS: The early recall rate dropped from 13.8% at baseline to 1.9% in the second screening round with biopsy rates of 3.6% in the first round and 0.5% in the second round. Histology revealed lung cancer in 8/9 participants undergoing biopsy/surgery. All eight cancers were accurately depicted by MRI. The following categories were assigned on MRI (results of LDCT in parentheses): 4B/4X in 10 (10) cases, 4A in 16 (15) cases, 3 in 13 (12) cases, 2 in 77 (92) cases and 1 in 140 (126) cases. Lung-RADS scoring correlated significantly between MRI and CT. The score was overestimated by MRI in one case for category 4A, in two cases for category 3 and in five cases for category 2. MRI-based Lung-RADS score was underestimated for category 1 in 20 cases. CONCLUSION: Lung-RADS might be applied for lung cancer screening with MRI, since findings correlated with LDCT. Relevant findings with a Lung-RADS score of 3 and higher were never missed or underestimated by MRI KEY POINTS: • MRI performed comparably to low-dose CT in a lung cancer-screening programme. • Lung-RADS might be applied for lung cancer screening with MRI. • Lung-RADS findings score of 3 and higher were never missed by MRI.

Fat-free muscle area measured by magnetic resonance imaging predicts overall survival of patients undergoing radioembolization of colorectal cancer liver metastases.

OBJECTIVES: To investigate the clinical potential of fat-free muscle area (FFMA) to predict outcome in patients with liver-predominant metastatic colorectal cancer (mCRC) undergoing radioembolization (RE) with 90Yttrium microspheres. METHODS: Patients with mCRC who underwent RE in our center were included in this retrospective study. All patients received liver magnetic resonance imaging including standard T2-weighted images. The total erector spinae muscle area and the intramuscular adipose tissue area were measured at the level of the origin of the superior mesenteric artery and subtracted to calculate FFMA. Cutoff values for definition of low FFMA were 3644 mm2 in men and 2825 mm2 in women. The main outcome was overall survival (OS). For survival analysis, the Kaplan-Meier method and Cox regressions comparing various clinic-oncological parameters which potentially may affect OS were performed. RESULTS: Seventy-seven patients (28 female, mean age 60 ± 11 years) were analyzed. Mean time between MRI and the following RE was 17 ± 31 days. Median OS after RE was 178 days. Patients with low FFMA had significantly shortened OS compared to patients with high FFMA (median OS: 128 vs. 273 days, p = 0.017). On multivariate Cox regression analysis, OS was best predicted by FFMA (hazard ratio (HR) 2.652; p < 0.001). Baseline bilirubin (HR 1.875; p = 0.030), pattern of tumor manifestation (HR 1.679; p = 0.001), and model of endstage liver disease (MELD) score (HR 1.164; p < 0.001) were also significantly associated with OS. CONCLUSIONS: FFMA was associated with OS in patients receiving RE for treatment of mCRC and might be a new prognostic biomarker for survival prognosis. KEY POINTS: • Fat-free muscle area (FFMA) as a measure of lean muscle area predicts survival in metastatic colorectal liver cancer following radioembolization. • FFMA can easily be assessed from routine pre-interventional liver magnetic resonance imaging. • FFMA might be a new promising biomarker for assessment of sarcopenia.

In Vitro Evaluation of the Polymerization Properties of N-Butyl Cyanoacrylate/Iodized Oil Mixtures for Lymphatic Interventions.

PURPOSE: To evaluate polymerization of N-butyl cyanoacrylate (NBCA)/iodized oil mixtures for lymphatic interventions in vitro. MATERIALS AND METHODS: Polymerization times of different NBCA/iodized oil mixtures (ratios of 1:0-1:7) were investigated in a static and dynamic experimental setup (performed in a lymph flow model in a silicone tube). Eight lymphatic samples with different triglyceride (TG) concentrations (low TGs, < 50 mg/dL; medium TGs, approximately 100-400 mg/dL; high TGs, > 700 mg/dL) were investigated. Morphologic changes during NBCA polymerization were monitored and recorded by video. Statistical analysis was performed with intergroup comparisons (Kruskal-Wallis test) and multiple regression analysis. RESULTS: Static experiments showed increasing polymerization times with increasing concentrations of iodized oil as well as increasing concentrations of TGs. In the low-TG group, polymerization time increased from 14 s at a 1:1 ratio of NBCA to iodized oil to 1,336 s at a 1:7 ratio; times in the medium-TG group increased from 21 s (1:1) to 2,546 s (1:7), and those in the high TG group increased from 168 s (1:1) to 16,530 s (1:7). In dynamic experiments, prolongation of polymerization time was less pronounced. For low- and medium-TG groups, total occlusion of the silicon tube was observed in all cases during the embolization procedure at between 26 seconds (1:1 ratio) and 52 seconds (1:7). In the high-TG group, polymerization took considerably longer (between 43 s [1:1] and 467 s [1:7]) or failed completely. CONCLUSIONS: Polymerization time of NBCA/iodized oil in lymph seems to be prolonged by increasing iodized oil and TG concentrations.

Multiparametric cardiovascular magnetic resonance imaging in acute myocarditis: a comparison of different measurement approaches.

BACKGROUND: Myocardial T1 and T2 mapping are reliable diagnostic markers for the detection and follow up of acute myocarditis. The aim of this study was to compare the diagnostic performance of current mapping measurement approaches to differentiate between myocarditis patients and healthy individuals. METHODS: Fifty patients with clinically defined acute myocarditis and 30 healthy controls underwent cardiovascular magnetic resonance (CMR). Myocardial T1 relaxation times, T2 relaxation times, left ventricular (LV) function, T2 ratio, early gadolinium enhancement ratio, and presence of late gadolinium enhancement (LGE) were analysed. Native T1 and T2 relaxation times, as well as extracellular volume fraction (ECV) were measured for the entire LV myocardium (global), within the midventricular short axis slice (mSAX), within the midventricular septal wall (ConSept), and within the remote myocardium (remote). Receiver operating characteristics analysis was performed to compare diagnostic performance. RESULTS: All measurement approaches revealed significantly higher native T1 and T2 relaxation times as well as ECV values in patients compared to healthy controls (p < 0.05 for all parameters). The global measurement approach showed highest diagnostic performance regarding all mapping parameters (AUCs, native T1: 0.903, T2: 0.847, ECV: 0.731). Direct comparison of the different measurement approaches revealed significant differences in diagnostic performance between the global and the remote approach regarding T1 relaxation times and ECV (p = 0.001 and p = 0.002 respectively). Further, the global measurement approach revealed significantly higher T1 relaxation times compared to the ConSept approach (AUCs: 0.903 vs. 0.783; p = 0.003) and nearly significant differences compared to the mSAX approach (AUC: 0.850; p = 0.051). T2 relaxation times showed no significant differences between all measurement approaches (p > 0.050 for all parameters). CONCLUSIONS: Native T1 and T2 mapping allow for accurate detection of acute myocarditis irrespective of the measurement approach used. Even measurements performed exclusively within remote myocardium allow for reliable detection of acute myocarditis, demonstrating diffuse involvement of disease despite a mostly regional or patchy distribution pattern of visible pathologies. The global measurement approach provides the overall best diagnostic performance in acute myocarditis for both T1 and T2 mapping.

Safety and Feasibility of Magnetic Resonance Imaging of the Brain at 1.5 Tesla in Patients with Temporary Transmyocardial Pacing Leads.

BACKGROUND: Temporary transmyocardial pacing leads (TTPLs) represent an absolute contraindication to magnetic resonance imaging (MRI). The purpose of this study was to evaluate the safety and feasibility of MRI at 1.5 Tesla (T) using a transmit/receive (T/R) head coil in patients with TTPL. METHODS: TTPLs (220 cm, Osypka TME, Dr. Osypka GmbH, Rheinfelden, Germany) were implanted in a phantom and exposed to conditions of a 1.5 T brain examination using a T/R head coil. Temperature changes at the lead tip were continuously recorded. A total of 28 patients with TTPL and an urgent indication for a brain MRI underwent MRI at 1.5 T with vital sign monitoring. A T/R head coil was used to minimize radiofrequency exposure of the TTPL. Before and immediately after the MRI scan, TTPL lead impedance, pacing capture threshold (PCT), signal slope, and sensing were measured. Serum troponin I was determined before and after MRI to detect thermal myocardial injury. RESULTS: In vitro, the maximum temperature increase from radiofrequency-induced heating of the TTPL tip was < 1°C. In vivo, no complications, such as heating sensations, dizziness, unexpected changes in heart rate or rhythm, or other unusual signs or symptoms were observed. No significant changes in the lead impedance, PCT, signal slope, or sensing were recorded. There were no increases of serum troponin I after the MRI examination. CONCLUSIONS: MRI of the brain may be performed safely at 1.5 T using a T/R head coil in case of an urgent clinical need in patients with TTPL and may be considered a feasible and safe procedure when appropriate precautionary measures are taken.

Lung cancer screening with MRI: characterization of nodules with different non-enhanced MRI sequences.

BACKGROUND: There is increased interest in pulmonary magnetic resonance imaging (MRI) as a radiation-free alternative to computed tomography (CT) for lung cancer screening. PURPOSE: To analyze MRI characteristics of pulmonary nodules with different non-enhanced sequences. MATERIAL AND METHODS: Eighty-two participants of a lung cancer screening were included. MRI datasets of 32 individuals with 46 different nodules ≥ 6 mm were prospectively evaluated together with 50 controls by two readers. Acquired sequences were T2- short tau inversion recovery (STIR), T2, balanced steady-state free precession (bSSFP), 3D-T1, and diffusion-weighted imaging (DWI). Each sequence was randomly and separately viewed blinded to low-dose CT (LDCT). Size, shape, and contrast of nodules were evaluated on each sequence and then correlated with LDCT and histopathology. RESULTS: All eight carcinomas were detected by T2-STIR, T2, and bSSFP, and 7/8 by 3D-T1. Contrast was significantly higher for malignant nodules on all sequences. The highest contrast ratio between malignant and benign nodules was provided by T2-STIR. Of eight carcinomas, seven showed restricted diffusion. Size measurement correlated significantly between MRI and LDCT. Sensitivity/specificity for nodules ≥ 6 mm was 85-89%/92-94% for T2-STIR, 80-87%/93-96% for T2, 65-70%/96-98% for bSSFP, and 63-67%/96-100% for 3D-T1. Seven of eight subsolid nodules were visible on T2-sequences with significantly lower lesion contrast compared to solid nodules. Two of eight subsolid nodules were detected by bSFFP, none by 3D-T1. All three calcified nodules were detected by 3D-T1, one by bSSFP, and none by T2-sequences. CONCLUSION: Malignant as well as calcified and subsolid nodules seem to have distinctive characteristics on different MRI sequences. T2-imaging was most suitable for the detection of nodules ≥ 6 mm.

Clinical Effectiveness and Potential Survival Benefit of US-Guided High-Intensity Focused Ultrasound Therapy in Patients with Advanced-Stage Pancreatic Cancer.

PURPOSE: Pancreatic cancer (PaC) is a life-limiting tumor with a wide range of incapacitating symptoms such as cancer pain in more than 80 % of patients. This prospective interventional study addresses the clinical effectiveness of ultrasound-guided high-intensity focused ultrasound (HIFU) treatment for patients with advanced-stage PaC, including pain perception, tumor size and survival benefit. MATERIALS AND METHODS: 50 patients with late-stage PaC underwent HIFU. Clinical assessment included evaluation of tumor volume by imaging and pain burden (pain severity, pain sensation, interference with daily activities) using the Brief Pain Inventory at baseline and follow-up. Median overall survival, progression-free survival and time to local progression were estimated using Kaplan-Meier analysis. RESULTS: In 84 % of patients, significant early relief of cancer-induced abdominal pain was achieved by HIFU independent of metastatic status; it persisted during follow-up. Tumor volume reduction was 37.8 ±â€Š18.1 % after 6 weeks and 57.9 ± 25.9 % after 6 months. 21 % of HIFU-treated patients had local tumor progression with a median time of 14.4 months from intervention. The median overall survival and progression-free survival were 16.2 and 16.9 months from diagnosis and 8.3 and 6.8 months from intervention. CONCLUSION: In patients with advanced pancreatic cancer and otherwise limited treatment options, HIFU resulted in significant early and long-lasting pain relief and tumor size reduction over time independent of metastatic status. Clinical data suggest an additional potential survival benefit.

[Chylothorax: Current Therapeutic Options]. / Chylothorax: eine Übersicht über aktuelle therapeutische Möglichkeiten.

Therapeutic options in management of chylothorax encompass conservative, surgical and also interventional measures. Despite the fact that interventions have been performed in substantial numbers of patients - particularly thoracic duct embolisations - general knowledge about this therapeutic option is still limited. Therefore, this article gives an overview of the state of the art for therapeutic options, also emphasising radiological/interventional procedures. At present, interventional treatment has lower morbidity and mortality, and is especially indicated after failed surgical therapy, or in inoperable patients.

The ERICA Score: An MR Imaging-based Visual Scoring System for the Assessment of Entorhinal Cortex Atrophy in Alzheimer Disease.

Purpose To establish and evaluate a visual score focused on entorhinal cortex atrophy (ERICA), as the entorhinal cortex is one of the first brain structures affected in Alzheimer disease (AD). Materials and Methods In this retrospective study, ERICA was visually evaluated with magnetic resonance imaging (2009-2016). First, a four-point ERICA score was developed by using data in 48 consecutive subjects (20 patients with AD and 28 control subjects). Then, in the main analysis, ERICA and the standard medial temporal lobe atrophy (MTA) scores were determined in an independent cohort of 60 patients suspected of having AD (mean age, 69.4 years; range, 46-86 years) and in 60 age-matched patients with subjective cognitive decline (SCD) (mean age, 72.4 years; range 50-87 years). Score performances were evaluated with κ statistics, receiver operating characteristic analysis, t tests, and analysis of variance according to the Standards for Reporting of Diagnostic Accuracy Studies. Results Patients with AD had higher MTA scores (mean, 2.13) and ERICA scores (mean, 2.05) than patients with SCD (P < .001). An ERICA score of 2 or greater achieved a higher diagnostic accuracy (91%) than the MTA score (74%), with a sensitivity of 83% versus 57% and a specificity of 98% versus 92% in discriminating dementia caused by AD from SCD (P < .001). The ERICA score was correlated with amyloid ß 42/40 ratio (ρ = -0.54, P < .001) and with cerebrospinal fluid tau (ρ = 0.35, P = .001) and p-tau (ρ = 0.31, P = .004). In multivariable linear regression analysis, ERICA was associated with verbal learning and recall (ß = -.40 and -.41), nonverbal recall (ß = -.28), and cued recall (ß = -.41, P ≤ .002 for all). Conclusion An ERICA score of 2 or greater indicates probable AD with high diagnostic accuracy. © RSNA, 2018 Online supplemental material is available for this article.

Quantification of Liver Fibrosis at T1 and T2 Mapping with Extracellular Volume Fraction MRI: Preclinical Results.

Purpose To evaluate MRI T1 and T2 mapping with calculation of extracellular volume (ECV) for diagnosis and grading of liver fibrosis. Materials and Methods Different grades of fibrosis were induced in 60 male Sprague-Dawley rats by bile duct ligation (BDL) and carbon-tetrachloride (CCl4) intoxication. Portal pressure was measured invasively, whereas hepatic fibrosis was quantified by hydroxyproline content, Sirius red staining, and α smooth muscle actin staining. T1 values, T2 values, and ECV were assessed by using quantitative MRI mapping techniques. Results T1 values in animals 4 weeks after BDL were greater than in control animals (718 msec ± 74 vs 578 msec ± 33, respectively; P < .001). T2 values at 4 weeks were also greater in animals that underwent BDL than in control animals (46 msec ± 6 vs 29 msec ± 2, respectively; P < .001). Similar T1 and T2 findings were observed after CCl4 intoxication. ECV was greater in animals 4 weeks after BDL compared with control animals (31.3% ± 1.3 vs 18.2% ± 3.5, respectively; P < .001), with similar results after CCl4 intoxication. High correlations were found between ECV and hepatic hydroxyproline content (BDL: r = 0.68, P < .001; CCl4: r = 0.65, P < .001), Sirius red staining (BDL: r = 0.88, P < .001; CCl4: r = 0.82, P < .001), α smooth muscle actin staining (BDL: r = 0.70, P < .001; CCl4: r = 0.73, P < .001), and portal pressure (BDL: r = 0.54, P = .003; CCl4: r = 0.39, P = .043). Conclusion Elevation of T1 and T2 values and ECV was associated with severity of liver fibrosis and portal hypertension in an experimental animal model.

Patient positioning in head and neck cancer : Setup variations and safety margins in helical tomotherapy.

OBJECTIVE: To evaluate the interfractional variations of patient positioning during intensity-modulated radiotherapy (IMRT) with helical tomotherapy in head and neck cancer and to calculate the required safety margins (sm) for bony landmarks resulting from the necessary table adjustments. MATERIALS AND METHODS: In all, 15 patients with head and neck cancer were irradiated using the Hi-Art II tomotherapy system between April and September 2016. Before therapy sessions, patient position was frequently checked by megavolt computed tomography (MV-CT). Necessary table adjustments (ta) in the right-left (rl), superior-inferior (si) and anterior-posterior (ap) directions were recorded for four anatomical points: second, fourth and sixth cervical vertebral body (CVB), anterior nasal spine (ANS). Based upon these data sm were calculated for non-image-guided radiotherapy, image-guided radiotherapy (IGRT) and image guidance limited to a shortened area (CVB 2). RESULTS: Based upon planning CT the actual treatment required ta from -0.05 ± 1.31 mm for CVB 2 (ap) up to 2.63 ± 2.39 mm for ANS (rl). Considering the performed ta resulting from image control (MV-CT) we detected remaining ta from -0.10 ± 1.09 mm for CVB 4 (rl) up to 1.97 ± 1.64 mm for ANS (si). After theoretical adjustment of patients position to CVB 2 the resulting ta ranged from -0.11 ± 2.44 mm for CVB6 (ap) to 2.37 ± 2.17 mm for ANS (si). These data imply safety margins: uncorrected patient position: 3.63-9.95 mm, corrected positioning based upon the whole target volume (IGRT): 1.85-6.63 mm, corrected positioning based upon CVB 2 (IGRT): 3.13-6.66 mm. CONCLUSIONS: The calculated safety margins differ between anatomic regions. Repetitive and frequent image control of patient positioning is necessary that, however, possibly may be focussed on a limited region.

Flip angle optimization for balanced SSFP: Cardiac cine imaging following the application of standard extracellular contrast agent (gadobutrol).

PURPOSE: To investigate the effect of the flip angle (FA) on the blood-myocardium contrast and to define the FA leading to highest image quality in contrast-enhanced balanced steady-state free precession (bSSFP) images. bSSFP images provide excellent contrast between myocardium and blood with high signal-to-noise and contrast-to-noise ratios (SNR, CNR). In clinical practice, bSSFP images are typically acquired following the injection of extracellular contrast agents (ECAs), although ECAs decrease the blood-myocardium contrast. MATERIALS AND METHODS: First, a theoretical optimization was performed to determine the FA that maximizes CNR in bSSFP imaging 2-20 minutes after application of ECA. Second signal-ratios, contrast, SNR, and CNR were assessed in vivo in 25 patients in bSSFP images at 1.5T acquired before (FA = 50°) and 10-15 minutes after (FAs = 50°, 80°, 90°, 100°) application of a double-dose contrast agent. Image quality was assessed by two readers. RESULTS: Simulations yielded FAs in the range of 85-100° for optimal CNR in contrast-enhanced images. In vivo comparison of conventionally acquired cine images (FA 50°) showed an increase in CNR between blood and myocardium by 57% in diastole and 78% in systole in adapted contrast-enhanced bSSFP images (FA 100°). Contrast-enhanced images with an FA of 100° were rated highest in image quality assessment. CONCLUSION: By means of FA adaptation a similar blood-myocardium contrast can be achieved in contrast-enhanced bSSFP as in unenhanced bSSFP imaging with an increase in CNR. LEVEL OF EVIDENCE: 1 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2018;47:255-261.