Is liver lesion characterisation by simplified IVIM DWI also feasible at 3.0 T?

OBJECTIVE: To evaluate simplified intravoxel incoherent motion (IVIM) diffusion-weighted imaging (DWI) for liver lesion characterisation at 3.0 T and to compare it with 1.5 T. METHODS: 3.0-T DWI data from a respiratory-gated MRI sequence with b = 0, 50, 250, and 800 s/mm2 were analysed in 116 lesions (78 patients) and 27 healthy livers. Apparent diffusion coefficient ADC = ADC(0,800) and IVIM-based parameters D1' = ADC(50,800), D2' = ADC(250,800), f1' = f(0,50,800), f2' = f(0,250,800), D*' = D*(0,50,250,800), ADClow = ADC(0,50), and ADCdiff = ADClow-D2' were calculated voxel-wise and analysed on per-patient basis. Results were compared with those of 173 lesions (110 patients) and 40 healthy livers at 1.5 T. RESULTS: Focal nodular hyperplasias were best discriminated from all other lesions by f1' and haemangiomas by D1' with an area under the curve (AUC) of 0.993 and 1.000, respectively. For discrimination between malignant and benign lesions, ADC was best suited (AUC of 0.968). The combination of D1' and f1' correctly identified more lesions as malignant or benign than the ADC (99.1% vs 88.8%). Discriminatory power for differentiating malignant from benign lesions tended to be higher at 3.0 T than at 1.5 T. CONCLUSION: Simplified IVIM is suitable for lesion characterisation at 3.0 T with a trend of superior diagnostic accuracy for discriminating malignant from benign lesions compared with 1.5 T. KEY POINTS: • Simplified IVIM is also suitable for liver lesion characterisation at 3.0 T. • Excellent accuracy was reached for discriminating malignant from benign lesions. • The acquisition of only three b-values (0, 50, 800 s/mm 2 ) is required.

Correction to: Is liver lesion characterisation by simplified IVIM DWI also feasible at 3.0 T?

The original version of this article, published on 08 April 2019, unfortunately contained a mistake. The following correction has therefore been made in the original: The caption of Fig. 2 is wrong. The corrected version is given below.

Surgical therapy of adrenal tumors: guidelines from the German Association of Endocrine Surgeons (CAEK).

BACKGROUND AND AIMS: Previous guidelines addressing surgery of adrenal tumors required actualization in adaption of developments in the area. The present guideline aims to provide practical and qualified recommendations on an evidence-based level reviewing the prevalent literature for the surgical therapy of adrenal tumors referring to patients of all age groups in operative medicine who require adrenal surgery. It primarily addresses general and visceral surgeons but offers information for all medical doctors related to conservative, ambulatory or inpatient care, rehabilitation, and general practice as well as pediatrics. It extends to interested patients to improve the knowledge and participation in the decision-making process regarding indications and methods of management of adrenal tumors. Furthermore, it provides effective medical options for the surgical treatment of adrenal lesions and balances positive and negative effects. Specific clinical questions addressed refer to indication, diagnostic procedures, effective therapeutic alternatives to surgery, type and extent of surgery, and postoperative management and follow-up regime. METHODS: A PubMed research using specific key words identified literature to be considered and was evaluated for evidence previous to a formal Delphi decision process that finalized consented recommendations in a multidisciplinary setting. RESULTS: Overall, 12 general and 52 specific recommendations regarding surgery for adrenal tumors were generated and complementary comments provided. CONCLUSION: Effective and balanced medical options for the surgical treatment of adrenal tumors are provided on evidence-base. Specific clinical questions regarding indication, diagnostic procedures, alternatives to and type as well as extent of surgery for adrenal tumors including postoperative management are addressed.

Accurate IVIM model-based liver lesion characterisation can be achieved with only three b-value DWI.

OBJECTIVE: The objective of this study was to evaluate a simplified intravoxel incoherent motion (IVIM) approach of diffusion-weighted imaging (DWI) with four b-values for liver lesion characterisation at 1.5 T. METHODS: DWI data from a respiratory-gated MRI sequence with b = 0, 50, 250, 800 s/mm2 were retrospectively analysed in 173 lesions and 40 healthy livers. The apparent diffusion coefficient ADC = ADC(0,800) and IVIM-based parameters D1' = ADC(50,800), D2' =ADC(250,800), f1', f2', D*', ADClow = ADC(0,50), and ADCdiff=ADClow-D2' were calculated voxel-wise without fitting procedures. Differences between lesion groups were investigated. RESULTS: Focal nodular hyperplasias were best discriminated from all other lesions by f1' with an area under the curve (AUC) of 0.989. Haemangiomas were best discriminated by D1' (AUC of 0.994). For discrimination between malignant and benign lesions, ADC(0,800) and D1' were best suited (AUC of 0.915 and 0.858, respectively). Discriminatory power was further increased by using a combination of D1' and f1'. CONCLUSION: IVIM parameters D and f approximated from three b-values provided more discriminatory power between liver lesions than ADC determined from two b-values. The use of b = 0, 50, 800 s/mm2 was superior to that of b = 0, 250, 800 s/mm2. The acquisition of four instead of three b-values has no further benefit for lesion characterisation. KEY POINTS: • Diffusion and perfusion characteristics are assessable with only three b-values. • Association of b = 0, 50, 800 s/mm2is superior to b = 0, 250, 800 s/mm2. • A fourth acquired b-value has no benefit for differential diagnosis. • For liver lesion characterisation, simplified IVIM analysis is superior to ADC determination. • Simplified IVIM approach guarantees numerically stable, voxel-wise results and short acquisition times.

The role of muscle strength on tendon adaptability in old age.

PURPOSE: The purpose of the study was to determine: (1) the relationship between ankle plantarflexor muscle strength and Achilles tendon (AT) biomechanical properties in older female adults, and (2) whether muscle strength asymmetries between the individually dominant and non-dominant legs in the above subject group were accompanied by inter-limb AT size differences. METHODS: The maximal generated AT force, AT stiffness, AT Young's modulus, and AT cross-sectional area (CSA) along its length were determined for both legs in 30 women (65 ± 7 years) using dynamometry, ultrasonography, and magnetic resonance imaging. RESULTS: No between-leg differences in triceps surae muscle strength were identified between dominant (2798 ± 566 N) and non-dominant limb (2667 ± 512 N). The AT CSA increased gradually in the proximo-distal direction, with no differences between the legs. There was a significant correlation (P < 0.05) of maximal AT force with AT stiffness (r = 0.500) and Young's modulus (r = 0.414), but only a tendency with the mean AT CSA. However, region-specific analysis revealed a significant relationship between maximal AT force and the proximal part of the AT, indicating that this region is more likely to display morphological adaptations following an increase in muscle strength in older adults. CONCLUSIONS: These findings demonstrate that maximal force-generation capabilities play a more important role in the variation of AT stiffness and material properties than in tendon CSA, suggesting that exercise-induced increases in muscle strength in older adults may lead to changes in tendon stiffness foremost due to alterations in material rather than in its size.

[Benign mesenchymal tumors of the abdomen]. / Benigne mesenchymale Tumoren des Abdomens.

BACKGROUND: Benign mesenchymal tumors of the abdomen are-except for hemangiomas-rare neoplasms that are associated with potentially life-threatening complications. Thus, awareness of the most important entities and knowledge of their imaging characteristics is fundamental for the radiologist. OBJECTIVES: An overview of the most frequent benign abdominal soft tissue tumors and their common imaging features is given. Furthermore, other facts concerning the individual entities that are relevant to radiologic practice are outlined. MATERIALS AND METHODS: A literature search and evaluation of the institutional image database were performed. RESULTS: Hemangiomas, desmoid tumors, lipomas and lipoma variants are presented. Typical characteristics and radiological signs (e. g., iris diaphragm sign, band sign, India ink artifact) are elucidated and illustrated by image examples. CONCLUSION: Despite the lack of distinctive imaging features, there are a few radiological characteristics suggestive for each of the entities that in many cases allow for correct diagnosis. In cases of doubt, biopsy or surgery is necessary to distinguish them from malignancies.

[A 59-year-old woman with upper abdominal pain and fever]. / 59-jährige Patientin mit Oberbauchschmerzen und Fieber.

A 59-year-old woman suffered from fever and upper abdominal pain. The computed tomography (CT) scan revealed a liver lesion. Conventional imaging techniques (CT, magnetic resonance imaging, contrast-enhanced ultrasonography) did not allow for a consistent diagnosis. Fine needle biopsy of the liver lesion was performed. Histologically, fibrotic inflammation was found and an inflammatory pseudotumor (IPT) diagnosed. Despite treatment with steroids and antibiotics, the size of the IPT increased; thus, surgical resection was necessary. In case of fever of unknown origin, IPT should be considered as a potential diagnosis.

Intravoxel incoherent motion model-based liver lesion characterisation from three b-value diffusion-weighted MRI.

OBJECTIVE: To evaluate intravoxel incoherent motion (IVIM) model-based liver lesion characterisation from three b-value diffusion-weighted imaging (DWI). METHODS: The 1.5-T DWI data from a respiratory gated spin-echo echo-planar magnetic resonance imaging sequence (b = 0, 50, 800 s/mm(2)) were retrospectively analysed in 38 patients with different liver lesions. Conventional apparent diffusion coefficient ADC = ADC(0,800) as well as IVIM-based parameters D' = ADC(50,800), ADC_low = ADC(0,50), and f' were calculated voxel-wise. Sixty-one regions of interest in hepatocellular carcinomas (HCCs, n = 24), haemangiomas (HEMs, n = 11), focal nodular hyperplasias (FNHs, n = 11), and healthy liver tissue (REFs, n = 15) were analysed. Group differences were investigated using Student's t-test and receiver-operating characteristic (ROC) analysis. RESULTS: Mean values ± standard deviations of ADC, D', ADC_low (in 10(-5) mm(2)/s), and f' (in %) for REFs/FNHs/HEMs/HCCs were 130 ± 11/143 ± 27/168 ± 16/113 ± 25, 104 ± 12/123 ± 25/162 ± 18/102 ± 23, 518 ± 66/437 ± 97/268 ± 69/283 ± 120, and 18 ± 3/14 ± 4/6 ± 3/9 ± 5, respectively. Differences between lesions and REFs were more significant for IVIM-based parameters than for conventional ADC. ROC analysis showed the best discriminability between HCCs and FNHs for ADC_low and f' and between HEMs and FNHs or HCCs for D'. CONCLUSION: Three instead of two b-value DWI enables a numerically stable and voxel-wise IVIM-based analysis for improved liver lesion characterisation with tolerable acquisition time. KEY POINTS: • Quantitative analysis of diffusion-weighted MRI helps liver lesion characterisation. • Analysis of intravoxel incoherent motion is superior to apparent diffusion coefficient determination. • Only three b-values enable separation of diffusion and microcirculation effects. • The method presented is numerically stable, with voxel-wise results and short acquisition times.

Clinical Use of High-Intensity Focused Ultrasound (HIFU) for Tumor and Pain Reduction in Advanced Pancreatic Cancer.

PURPOSE: Evaluation of ultrasound-guided high-intensity focused ultrasound (HIFU) used for the first time in Germany in patients with inoperable pancreatic cancer for reduction of tumor volume and relief of tumor-associated pain. MATERIALS AND METHODS: 15 patients with locally advanced inoperable pancreatic cancer and tumor-related pain symptoms were treated by HIFU (n = 6 UICC stage III, n = 9 UICC stage IV). 13 patients underwent simultaneous standard chemotherapy. Ablation was performed using the JC HIFU system (Chongqing, China HAIFU Company) with an ultrasonic device for real-time imaging. Imaging follow-up (US, CT, MRI) and clinical assessment using validated questionnaires (NRS, BPI) was performed before and up to 15 months after HIFU. RESULTS: Despite biliary or duodenal stents (4/15) and encasement of visceral vessels (15/15), HIFU treatment was performed successfully in all patients. Treatment time and sonication time were 111 min and 1103 s, respectively. The applied total energy was 386 768 J. After HIFU ablation, contrast-enhanced imaging showed devascularization of treated tumor regions with a significant average volume reduction of 63.8 % after 3 months. Considerable pain relief was achieved in 12 patients after HIFU (complete or partial pain reduction in 6 patients). CONCLUSION: US-guided HIFU with a suitable acoustic pathway can be used for local tumor control and relief of tumor-associated pain in patients with locally advanced pancreatic cancer. KEY POINTS: • US-guided HIFU allows an additive treatment of unresectable pancreatic cancer.• HIFU can be used for tumor volume reduction.• Using HIFU, a significant reduction of cancer-related pain was achieved.• HIFU provides clinical benefit in patients with pancreatic cancer. Citation Format: • Strunk HM, Henseler J, Rauch M et al. Clinical Use of High-Intensity Focused Ultrasound (HIFU) for Tumor and Pain Reduction in Advanced Pancreatic Cancer. Fortschr Röntgenstr 2016; 188: 662 - 670.

Three-Dimensional Isotropic Fat-Suppressed Proton Density-Weighted MRI at 3 Tesla Using a T/R-Coil Can Replace Multiple Plane Two-Dimensional Sequences in Knee Imaging.

PURPOSE: To evaluate whether a 3 D proton density-weighted fat-suppressed sequence (PDwFS) of the knee is able to replace multiplanar 2D-PDwFS. MATERIALS AND METHODS: 52 patients (26 men, mean age: 41.9 ±â€Š14.5years) underwent magnetic resonance imaging (MRI) of the knee at 3.0 Tesla using a T/R-coil. The imaging protocol included 3 planes of 2D-PDwFS (acquisition time (AT): 6:40 min; voxel sizes: 0.40 - 0.63 × 0.44 - 0.89 × 3mm³) and a 3D-PDwFS (AT: 6:31 min; voxel size: 0.63 × 0.68 × 0.63mm³). Homogeneity of fat suppression (HFS), artifacts, and image sharpness (IS) were evaluated on a 5-point scale (5[excellent] - 1[non-diagnostic]). The sum served as a measure for the overall image quality (OIQ). Contrast ratios (CR) compared to popliteal muscle were calculated for the meniscus (MEN), anterior (ACL) and posterior cruciate ligaments (PCL). In 13 patients who underwent arthroscopic knee surgery, two radiologists evaluated the presence of meniscal, ligamental and cartilage lesions to estimate the sensitivity and specificity of lesion detection. RESULTS: The CR was higher in the ACL, PCL and MEN in 3D- PDwFS compared to 2D-PDwFS (p < 0.01 for ACL and PCL; p = 0.07 for MEN). Compared to 2 D images, the OIQ was rated higher in 3D-PDwFS images (p < 0.01) due to fewer artifacts and HFS despite the lower IS (p < 0.01). The sensitivity and specificity of lesion detection in 3D- and 2D-PDwFS were similar. CONCLUSION: Compared to standard multiplanar 2D-PDwFS knee imaging, isotropic high spatial resolution 3D-PDwFS of the knee at 3.0 T can be acquired with high image quality in a reasonable scan time. Multiplanar reformations in arbitrary planes may serve as an additional benefit of 3D-PDwFS. KEY POINTS: • 3D-PDwFS of the knee is acquired with high image quality• 3D-PDwFS can be achieved in only one measurement with a reasonable scan time• 3D-PDwFS with the advantage of multiplanar reformation may replace 2D-PD-weighted knee MRI Citation Format: • Homsi R, Gieseke J, Luetkens JA et al. Three-Dimensional Isotropic Fat-Suppressed Proton Density-Weighted MRI at 3 Tesla Using a T/R-Coil Can Replace Multiple Plane Two-Dimensional Sequences in Knee Imaging. Fortschr Röntgenstr 2016; 188: 949 - 956.

Noninvasive evaluation of cerebral arteriovenous malformations by 4D-MRA for preoperative planning and postoperative follow-up in 56 patients: comparison with DSA and intraoperative findings.

BACKGROUND AND PURPOSE: 4D-MRA is a promising technique in the diagnosis and follow-up of cAVMs. The purpose of this study was to compare 4D-MRA in the pre- and postoperative evaluation of cAVMs with DSA or intraoperative findings as the standards of reference regarding qualitative and quantitative parameters. MATERIALS AND METHODS: Fifty-six consecutive patients with cAVMs (30 women) underwent both 4D-MRA and DSA. Preoperative 4D-MRA was excluded from analysis in 1 patient (movement artifacts). Twenty-five patients underwent surgery on cAVMs and underwent both imaging modalities pre- and postoperatively. 4D-MRA was performed with either 0.5-mol/L gadolinium-diethylene-triamine pentaacetic acid (group 1: voxel size, 1.1 × 1.1 × 1.4 mm(3); 608 ms/dynamic frame; 19 patients) or 1.0-mol/L gadobutrol (group 2: voxel size, 1.1 × 1.1 × 1.1 mm(3); 572 ms/dynamic frame; additional alternating view sharing; 37 patients). Two readers independently reviewed 4D-MRA and DSA regarding the Spetzler-Martin classification, arterial feeders, and postoperative residual filling. Vessel sharpness, vessel diameter, and VBC of 4D-MRA were quantified. RESULTS: Preoperative Spetzler-Martin classification 4D-MRA and DSA ratings matched in 55/55 patients (Spetzler-Martin grades: I, 12; II, 22; III, 15; IV, 5; V, 1), and 93/100 arterial feeders were correctly identified by preoperative 4D-MRA (7 additional arterial feeders identified by DSA only: group 1, 3/19; group 2, 4/36). Postoperative 4D-MRA and DSA matched in 25/25 patients (residual filling, 1/25). Vessel sharpness and diameters did not differ substantially between the 2 groups. VBC was significantly higher in group 2 (P < .005). CONCLUSIONS: 4D-MRA is a reliable tool that allows predicting Spetzler-Martin classification and postoperative residual filling; it hence allows substituting DSA in the pre- and postoperative evaluation of patients with cerebral AVMs.

[Diaplacental inhibition of fetal blood coagulation in pregnant sheep (author's transl)]. / Die diaplazentare Hemmung der fetalen Blutgerinnung am trächtigen Schaf.

We investigated the effect of the synthetic low-molecular thrombin inhibitor 4-amidinophenyl-pyruvic acid (APPA) on the maternal and fetal coagulation at 10 far advanced in pregnancy sheep. APPA inhibits as well the maternal as by diaplacental passage the fetal hemostasis in dependence on the dosage till the incoagulability. The effect in the fetal organism occurs after a delay of some minutes and wars of a bit earlier.

[Diaplacental influence on the disseminated intravascular coagulation (DIC) in an asphyxia model. I. Influence on the vasal tonus and on the vasal wall (author's transl)]. / Diaplazentare Einwirkung auf die disseminierte intravasale Gerinnung (DIC) im Asphyxiemodell I. Gefässtonus- und Gefässwandbeeinflussung.

With the aid of an asphyxia model in rabbit fetuses the possibility of diaplacental influence on the hypoxic effects of the fetal organism has been investigated. The trial to change the vasotonia during the asphyctic shock by sympathicomimetic or -lytic drugs (Dilatol, Obsidan, Ergocomb, Regitin) remained to be without any effect on the DIC in the fetal organism. Trying to seal the vascular wall by the high-molecular-weight basic polypeptide Aprotinin there seemed rather to be an increase of the intravascular fibrin sedimentation.

[Diaplacental influence on the disseminated intravascular coagulation (DIC) in an asphyxia model. II. Influence on the vessel's content (author's transl)]. / Diaplazentare Einwirkung auf die disseminierte intravasale Gerinnung (DIC) im Asphyxiemodell II. Beeinflussung des Gefässinhaltes.

There is reported on the possibilities of diaplacental influencing on the DIC arising from the hypoxia we provoked with the help of an asphyxia model in rabbit fetuses. We could demonstrate the impossibility of influencing on the fetal vasal content by means of low molecular dextran, heparin or streptokinase. On the contrary, the possibility exists to influence on the fetal hemostasis by low molecular synthetic substances. The antifibrinolytic drug PAMBA causes in case of advanced acidosis diaplacental a definite growth of the intravascular coagulation, as well. But an inhibition of the fibrin sedimentation in the terminal vessels at the asphyctic shock can be achieved by applying the ethyl ester of the 4-amidinophenylpyruvic acid (APPA).

[Animal experiments on direct drug effects on disseminated intravascular coagulation (DIC) in asphyxic shock]. / Tierexperimente zur direkten Beeinflussung der disseminierten intravasalen Gerinnung (DIC) im asphyktischen Schock.

In a total of 41 rabbit fetus it could be demonstrated in an asphyxia model to what extent disseminated intravascular coagulation may be influenced by directly applying drugs in the foetal circulation. Administration of heparin or streptokinase in the umbilical vessels led to a decrease of fibrin sediments in the areas of terminal coagulation, whereas an increase was caused by injecting noradrenalin or PAMBA.

A distinct gene close to the hairless locus on chromosome 8p underlies hereditary Marie Unna type hypotrichosis in a German family.

BACKGROUND: Hypotrichosis of the Marie Unna type (HMU) is a rare autosomal dominant disorder characterized by male-pattern hair loss with childhood onset and anomalies of the hair shaft. OBJECTIVES: We aimed to evaluate a number of chromosomal loci as possible candidate regions for HMU. METHODS: A linkage analysis was performed in a large German family using microsatellite markers spanning candidate regions on chromosomes 8, 12 and 17. RESULTS: We found that the HMU locus maps to chromosomal region 8p21 in a 13.01-cM interval between markers D8S1145 and D8S1771. This interval harbours the hairless gene (HR). Mutational analysis of HR on the genomic and transcript levels revealed no pathogenic mutation. CONCLUSIONS: Our findings, together with a recent report of two unrelated families of Dutch and British origin, provide evidence for a hair growth regulatory gene distinct from HR in chromosomal region 8p21.

A gene for hypotrichosis simplex of the scalp maps to chromosome 6p21.3.

Hypotrichosis simplex of the scalp (HSS) is an autosomal dominant form of isolated alopecia causing almost complete loss of scalp hair, with onset in childhood. After exclusion of candidate regions previously associated with hair-loss disorders, we performed a genomewide linkage analysis in two Danish families and localized the gene to chromosome 6p21.3. This was confirmed in a Spanish family, with a total LOD score of 11.97 for marker D6S1701 in all families. The combined haplotype data identify a critical interval of 14.9 cM between markers D6S276 and D6S1607. Localization of the locus for HSS to 6p21.3 is a first step toward identification of the gene. The gene will give important insights into the molecular and cellular basis of hair growth on the scalp.