Absolute CT perfusion parameter values after the neoadjuvant chemoradiotherapy of the squamous cell esophageal carcinoma correlate with the histopathologic tumor regression grade.

PURPOSE: To analyze value of the computed tomography (CT) perfusion imaging in response evaluation of the esophageal carcinoma to neoadjuvant chemoradiotherapy (nCRT) using the histopathology as reference standard. METHODS: Forty patients with the squamous cell esophageal carcinoma were re-evaluated after the nCRT by CT examination, which included low-dose CT perfusion study that was analyzed using the deconvolution-based CT perfusion software (Perfusion 3.0, GE). Histopathologic assessment of tumor regression grade (TRG) according to Mandard's criteria served as reference standard of response evaluation. Statistical analysis was performed using Spearman's rank correlation coefficient (r(S)) and Kruskal-Wallis's test. RESULTS: The perfusion CT parameter values, measured after the nCRT in the segment of the esophagus that had been affected by neoplasm prior to therapy, significantly correlated with the TRG: blood flow (BF) (r(S)=0.851; p<0.001), blood volume (BV) (r(S)=0.732; p<0.001) and mean transit time (MTT) (r(S)=-0.386; p=0.014). Median values of BF and BV significantly differed among TRG 1-4 groups (p<0.001), while maximal esophageal wall thickness did not (p=0.102). Median BF and BV were gradually rose and MTT decreased as TRG increased, from 21.4 ml/min/100 g (BF), 1.6 ml/100 g (BV) and 8.6 s (MTT) in TRG 1 group, to 37.3 ml/min/100 g, 3.5 ml/100 g and 7.5 s in TRG 2 group, 81.4 ml/min/100 g, 4.1 ml/100 g and 3.8 s in TRG 3 group, and 121.1 ml/min/100 g, 4.9 ml/100 g and 3.7 s in TRG 4 group. In all 15 patients who achieved complete histopathologic regression (TRG 1), BF was <30.0 ml/min/100 g. CONCLUSIONS: CT perfusion could improve the accuracy in response evaluation of the esophageal carcinoma to nCRT.

Standardized perfusion value of the esophageal carcinoma and its correlation with quantitative CT perfusion parameter values.

PURPOSE: Standardized perfusion value (SPV) is a universal indicator of tissue perfusion, normalized to the whole-body perfusion, which was proposed to simplify, unify and allow the interchangeability among the perfusion measurements and comparison between the tumor perfusion and metabolism. The aims of our study were to assess the standardized perfusion value (SPV) of the esophageal carcinoma, and its correlation with quantitative CT perfusion measurements: blood flow (BF), blood volume (BV), mean transit time (MTT) and permeability surface area product (PS) of the same tumor volume samples, which were obtained by deconvolution-based CT perfusion analysis. METHODS: Forty CT perfusion studies of the esophageal cancer were analyzed, using the commercial deconvolution-based CT perfusion software (Perfusion 3.0, GE Healthcare). The SPV of the esophageal tumor and neighboring skeletal muscle were correlated with the corresponding mean tumor and muscle quantitative CT perfusion parameter values, using Spearman's rank correlation coefficient (rS). RESULTS: Median SPV of the esophageal carcinoma (7.1; range: 2.8-13.4) significantly differed from the SPV of the skeletal muscle (median: 1.0; range: 0.4-2.4), (Z=-5.511, p<0.001). The cut-off value of the SPV of 2.5 enabled discrimination of esophageal cancer from the skeletal muscle with sensitivity and specificity of 100%. SPV of the esophageal carcinoma significantly correlated with corresponding tumor BF (rS=0.484, p=0.002), BV (rS=0.637, p<0.001) and PS (rS=0.432, p=0.005), and SPV of the skeletal muscle significantly correlated with corresponding muscle BF (rS=0.573, p<0.001), BV (rS=0.849, p<0.001) and PS (rS=0.761, p<0.001). CONCLUSIONS: We presented a database of the SPV for the esophageal cancer and proved that SPV of the esophageal neoplasm significantly differs from the SPV of the skeletal muscle, which represented a sample of healthy tissue. The SPV was validated against quantitative CT perfusion measurements and statistically significant correlation was proved.

Comparison between the deconvolution and maximum slope 64-MDCT perfusion analysis of the esophageal cancer: is conversion possible?

PURPOSE: To estimate if CT perfusion parameter values of the esophageal cancer, which were obtained with the deconvolution-based software and maximum slope algorithm are in agreement, or at least interchangeable. METHODS: 278 esophageal tumor ROIs, derived from 35 CT perfusion studies that were performed with a 64-MDCT, were analyzed. "Slice-by-slice" and average "whole-covered-tumor-volume" analysis was performed. Tumor blood flow and blood volume were manually calculated from the arterial tumor-time-density graphs, according to the maximum slope methodology (BF(ms) and BV(ms)), and compared with the corresponding perfusion values, which were automatically computed by commercial deconvolution-based software (BF(deconvolution) and BV(deconvolution)), for the same tumor ROIs. Statistical analysis was performed using Wilcoxon matched-pairs test, paired-samples t-test, Spearman and Pearson correlation coefficients, and Bland-Altman agreement plots. RESULTS: BF(deconvolution) (median: 74.75 ml/min/100g, range, 18.00-230.5) significantly exceeded the BF(ms) (25.39 ml/min/100g, range, 7.13-96.41) (Z=-14.390, p<0.001), while BV(deconvolution) (median: 5.70 ml/100g, range: 2.10-15.90) descended the BV(ms) (9.37 ml/100g, range: 3.44-19.40) (Z=-13.868, p<0.001). Both pairs of perfusion measurements significantly correlated with each other: BF(deconvolution), versus BF(ms) (rS=0.585, p<0.001), and BV(deconvolution), versus BV(ms) (rS=0.602, p<0.001). Geometric mean BF(deconvolution)/BF(ms) ratio was 2.8 (range, 1.1-6.8), while geometric mean BV(deconvolution)/BV(ms) ratio was 0.6 (range, 0.3-1.1), within 95% limits of agreement. CONCLUSIONS: Significantly different CT perfusion values of the esophageal cancer blood flow and blood volume were obtained by deconvolution-based and maximum slope-based algorithms, although they correlated significantly with each other. Two perfusion-measuring algorithms are not interchangeable because too wide ranges of the conversion factors were found.

Ultrasonographic evaluation of visceral and subcutaneous abdominal fat tissue before and after bariatric surgery.

Visceral fat is considered a key factor in the development of metabolic syndrome and other pathological conditions and diseases associated with obesity. Therefore, analysis of the dynamics of reducing the amount of abdominal visceral fat is important for evaluating the therapeutic effects of different modalities of obesity treatment, including bariatric surgery. In 53 obese patients visceral and subcutaneous abdominal adipose tissue was measured by ultrasonography (US) before and after bariatric surgery, in the period of 1, 3, 6 months. At the same time, standard anthropometric parameters were assessed: body mass (m), BMI, waist circumference (WC), and hip circumference (HC). Five diameters of the visceral abdominal fat (VAF) were measured: IAFT (Intraabdominal Fat Thickness), LV (Lienal Vein), VF (Visceral Fat), MES sum (Mesenterial leafs) and Max PFT (Maximal Preperitoneal Fat Thickness), and three diameters of the subcutaneous abdominal adipose tissue (SCAF): Min SFT (Minimal Subcutaneous Fat), and MaxSFTa and MaxSFTb (Maximal Subcutaneous Fat Thickness a and b). Statistically significant decrease in all anthropometric parameters, except HC was registered 1, 3 and 6 months after the surgery. We registered the decline of almost all US diameters of abdominal adipose tissue in the follow-up period, but statistically significant decrease were found only in the diameters of visceral adipose tissue: IAFT after 1 and 3 months (p = 0.031 and p = 0.027); VF after 1 month (p = 0.031), LV after 6 months (p = 0.011), and MESsum after 3 and 6 months (p = 0.001 and p = 0.028), as well as MaxSFTb, at 1 month follow-up (p = 0.015). In the short-term follow-up period after the bariatric surgery, there was a significant decrease in body mass, BMI and WC, and ultrasonography revealed a significant reduction in the diameters of the visceral abdominal fat.

[Solving of complications arising during and after application self-expandible metallic stents in palliation of malignant dysphagia].

INTRODUCTION: During palliative treatment of malignant disphagia in inoperabile patients various and serious complications may occur and compromite the method of treatment if there were not solved. AIM: Goal is to present the most frequent complications due to esophageal stenting and the way of their solving. MATERIALS AND METHOD: From 1996. to 2009. in 237 patients (164 esophageal carcinoma, 33 carcinoma of the esophagogastric junction, 14 bronchial carcinoma, 7 esophagojejunal anastomosis, 9 esophageal fistulas) 245 stents have been placed (54 uncovered and 191 covered). Mean survival period was 14.7 months (ranged from 1 do 33 months). Esophageal perforation (1), stent migration (9), malignant tissue ingrowth (31) and overgrowth (24) have been revealed by barium contrast study during follow up. Perforation was solved by placing covered stent, migration by removing migrated stent endoscopically or surgically, ingrowth and overgrowth by balon dilating or restenting under the fluoroscopically guidance and control. CONCLUSION: One can expect and recognize complications regarding esophageal stenting because it is the only way for their sucsessfull treatment.

[X-ray and CT presentation of advanced gastric carcinomas of different locations].

We presented the X-ray and CT findings characteristic for gastric cancers of different localizations (localized in different parts of the stomach). Particularly, esophagogastric junction (EGJ) carcinomas and antral carcinomas are singled out, as two localizations of gastric cancer that we usually meet in everyday clinical and radiological practice, and which have completely different radiological presentation. Advanced carcinomas of esophago-gastric junction, whose incidence is on the rise, usually affect the distal segment of the esophagus, cardia, and proximal part of the stomach, in different proportions. Siewert's, and the Japanese classification of these tumors are listed. Due to the involvement of the distal esophagus, scanning region, besides the abdomen, should be expanded to the chest. Advanced cancer of the antral part of the stomach is presented by the X-ray as a fungating, infiltrative, or combined form, often capturing the entire wall circumference. Possible infiltration of the left liver, the body and neck of the pancreas, colon and anterior abdominal wall should be estimated by CT.

[Computerized tomography in postoperative monitoring of patients with the Whipple operation--characteristics of CT findings].

We presented the postoperative CT findings of patients after the Whipple's operation (cephalic pancreaticoduodenectomy), performed for the pancreatic head cancer, or ampullary carcinoma. Technique of the Whipple's operation is described, and normal and pathological postoperative CT findings, which are characteristic for the immediate (early) and delayed (late) follow-up period, are presented. In addition, difficulties in differentiation of afferent jejunal loop from the recurrent tumor by CT are discussed, and references from the literature about the possibilities of successful visualization of the afferent jejunal loop are cited. Possible locations and CT appearances of the tumor recurrences are presented. An overview of the literature is provided.

[Newer techniques in diagnostic imaging of colorectal carcinoma].

A wide spectrum of nowadays availible radiological and imaging methods in the diagnostic evaluation of patients with colorectal cancer enabled not only the improvement of primary colorectal malignancy detection, precise staging, regional involvement and metastatic spread assessment, but also the posttherapeutical estimation and follow-up. Having in mind that the exact diagnostic assessment of colorectal carcinoma by use of different imaging modalities still raises a lots of contradictories, in this report we have tried to present the possibilities of newer imaging techniques in the diagnostic evaluation of the patients with colorectal cancer.

[The future of transcatheter antitumor therapy].

Transcatheter antitumor therapy very quickly accepted during the last decade and their importance in the treatment of oncology patients will be increasing. By improvement of new targeted agents, which can be given intraarterial or systemic, efficiency of transcatheteric therapeutic approaches can be drastically increased. Numerous clinical trials (study phase I / II / III) relating to the synergy of two antitumor therapeutic approaches are already in progress. Preliminary results of these trials are already very encouraging. Further improvement in the development of specific therapeutics antitumor drugs and systemic applications will be a big step in the quest for medication against malignant tumors.

[Transcatether chemoembolization in the treatment of hepatocellular carcinoma].

UNLABELLED: The authors describe their own experience with chemoembolization as a palliation in the treatment of non resectable hepatocellular carcinoma. MATERIAL/METHODS: During period of 64 months procedure was performed in 41 patients with non resectable hepatocellular carcinoma. The combination of Lipiodol and chemotherapeutic agents were applied in a. hepatica propria and its branches via transfemorally placed catheter. Stages of neoplasms were defined by Okuda method. RESULTS: The majority of tumors (30) were classified as Grade I. Liver cirrhosis was present in 36 patients, and abnormal levels of alpha-fetoprotein were found in 68% of cases. Each of twenty nine patients had more than one chemoembolization therapy, therefore, a total of 85 treatments were carried out. CT scanning perfomed one month following the procedure revealed more than 75% of Lipiodol retention in 42% of cases, and over 90% of neoplasm necrosis was recorded in 90% of cases, while all treated patients manifested lower levels of alpha-fetoprotein. All patients survived during three and six months, respectively, while the survival rate was 68% after 18 months. No letal outcome was reported during procedure, and morbidity in relation to total number of interventions was 19%. CONCLUSION: Achieved effects of this relatively safe procedure in our series do not differ significantly from those in the literature.

Ischaemic colitis--review.

Colonic ischaemia, commonly referred to as ischaemic colitis, is the most common type of intestinal ischaemia. The term "ischaemic colitis" was used by Marston (1966) with three typical patterns of injury described: transient reversible ischaemia, ischaemic ulcers with stricturing, and gangrenous ischaemic colitis. Dominant presenting symptoms were colicky abdominal pain, vomiting, bloody diarrhea, and hematochezia. Patients often have minimal signs on clinical examination. Most patients were diagnosed at colonoscopy. Two regions that are believed to be anatomically vulnerable to ischemic disease are "Griffith's point", at the splenic flexure and "Sudeck's critical point", of the Drummond marginal artery. Clinically, ischaemic colitis is classified as non-gangrenous or gangrenous. Non-gangrenous ischaemic colitis involves the mucosa and submucosa and accounts for 80-85 percent of all cases of ischaemic colitis. Non-gangrenous ischaemic colitis is further subclassified into transient, reversible ischaemic colitis with a less severe form of injury and chronic, non-reversible ischaemic colitis, which includes chronic colitis and stricture and has a more severe form of injury. Gangrenous ischaemic colitis accounts for the remaining 15-20 percent of cases and manifests as the most seve-re form of injury. It includes acute fulminant ischaemia with transmural infarction that may progress to necrosis and death. Specific indications for operation include peritonitis, perforation, recurrent fever or sepsis, clinical deterioration in patients refractory to me-ical management. Relative indications include fulminant colitis, massive hemorrhage, chronic protein losing colopathy, and symptomatic ischemic stricture.

[Algorithm for percutaneous origin of irreversible icterus ].

It is retrospective analysis of all percutaneous billiary dranage typs used in 600 patients with opstructive icterus in last 10 years.The procedure technics is analysed. It had positiv therapeutical result in about 75% cases. The most frequent complication are showed. The most coressponding percutaneous derivation algorithm is discussed. As initial method is suggested the usage of externo-internal derivation which, in dependence of the procedure, continue by internal derivation-catheteral endoprosthesys or matelic stent. The covered metalic stents usage is suggested as method of choise in metalic endoprosthesys application.

[Thoracic manifestations of gastrointestinal diseases].

Variety of gastrointestinal tract (GIT) changes that have their manifestation in thorax, disable their detailed review. Therefore, this article, represents short and overall over-view of these conditions. Standard chest x-ray can reveal esophageal disorders, herniation of abdominal organs into thorax, signs of GIT organs perforation, subphrenic abscess. Numerous diseases of intrabadominal organs of digestive tract can spread to the thorax, either per continuitatem or by lymphogenous or hemaotgenous dissemination. Therefore, chest x-ray is obliged by investigation of abdominal organs. If it is necessary additional diagnostic procedures are performed to confirm or exclude the association of lung or pleura features with GIT disorders. Above mentioned, just confirm that chest x-ray is first in algorithm of diagnostic procedures in these pathologic conditions. If there is any suspicion to conditions that require patients treatment, additional imaging methods like computerized tomography (CT), ultrasonography (US) and barium enema of digestive tract are necessary.

[Diagnosis of pericardial cysts: significance of cardiac magnetic resonance and literature review].

Pericardial cysts are uncommon and caused by an incomplete coalescence of fetal lacunae forming the pericardium. The paper presents two cases of pericardial cyst and literature review. The first is a case of a female patient with progressive dispnoa and spherical mass located in the right cardiophrenic angle on a chest x-ray. A pericardial cyst with low signal intensity was noted on T1w, high signal intensity on T2w in TSE (turbo spin echo) sequence on magnetic resonance images (MRI) which was suggestive of serous content. The patient underwent pericardial puncture and was thereafter free of symptoms. Histologic study of the cyst confirmed hydatid cyst diagnosis. Another patient is with echocardiographic evidence of cystic formation which was confirmed on MRI, with high signal intensity on SSFP (steady state free precession) sequence. The cyst was without septa and without communication with pericardial space. Since there were no significant hemodynamic changes, the patient is on regular follow up.

[CT endoscopy in urinary bladder lesions detection].

AIM: To evaluate applicability and efficacy CT virtual cystoscopy in detection of urinary bladder tumors. MATERIAL AND METHODS: During the period of 14 months, 17 patients with suspicion or present of some urinary bladder lesions has undergone CT virtual and conventional cystoscopy. After examination, all data were moved to the workstation for interactive endoluminal navigation. After that, radiologist analyzed transversal and virtual images without results of conventional cystoscopy and made conclusion. RESULTS: Results were divided according to their basic clinical application. By using this method, all lesions over 5 mm in size were revealed. In the group of patients that were followed up for urinary bladder tumors, three patients with carcinomatous lesion were revealed. Two tumors of bladder vault that were missed on transversal scan were visualized by virtual cystoscopy. Useful additional information about tumor spread was given in two patient. One tumor inside the bladder diverticulum was detected, that was not seen by conventional cystoscopy. In two patients, endoluminal origin of mass that could not be confirmed by conventional radiologic methods, was determined. CONCLUSION: CT virtual cystoscopy is useful method and technics that promise a lot, especially in following situations: a) follow up of bladder tumors; b) supplemental estimation of endoscopically hardly accessible regions; c) differential diagnosis between intravesical and exravesical lesions. Optimal estimation offers adequate bladder distension with patient positioned on the back and on the belly and interpretation as well as on transversal and virtual images.

[Recanalization of urethral strictures using a temporary curved biocompatible new generation metal endoprosthesis]].

The male urethral stricture treatment is actual clinical issue with its resolution being increasingly frequently based on application of minimum invasive therapeutic interventional uroradiology methods. Since the methodology is applied over the last two decades, the most reasonable therapeutic algorithm has not been defined yet with respect to the correlation with the contemporary surgical treatment. The results of application of the temporary covered self-expandable nitinol Allium stents, which have been applied for the first time ever at our Institution in October 2003. Over the last 3 years, the method was applied in 40 males, averagely aged 54 years with urethral strictures previously treated by urological methods. In four cases, stent placement was performed after endourethral incision. The most common etiology of the stricture was the posttraumatic (55%), post-inflammatory (32%) and iatrogenic (10%). In all the cases, stents were removed 12-14 months after their insertions. The results are evaluated using uroflowmetry and urethrocystography, revealing in 85% of the cases permanent recanalization free of dysuric complaints. Development of a stricture on the anterior stent end was evidenced in 15% of the cases.

[Radiologic palliation of dysphagia--placement of esophageal stents under radiologic control].

As for the gastrointestinal tract, stents are most commonly applied in the esophagus. Majority of the esophageal stents are implanted for the purpose of palliation of the inoperable malignant dysphagias, however they may also be used, although less frequently, for dilatation of the constricted anastomosis, covering of fistulas and least frequently for dilatation of the benign stenoses. Increasingly frequently the stents are used in the prepyloric gastric region, duodenal and rectosigmoid portion of the colon. The paper describes our own six-year experience in application of the gastrointestinal stents for palliation of dysphagia.

Endoanal ultrasonography in establishing the diagnosis of fecal incontinence.

Visualisation of the rectum, rectoanal junction and adjacent structures is very demanding and challenging both with technical and medical side. Local staging of rectal and anal tumor and perianal neoplasm by conventional and sibgle slice CT or by barium enema study is not so valuable. These methods can not visualise fistulous communication in inflamatory bowel diseases and have not any role in evaluation of fecal incontinence. During last decade, endoscopic ultrasound and magnetic resonance imaging have been recognised as methods of choice in establishing diagnosis of rectal, perirectal, anal and perianal diseases. The aim of this article is to review the possibilities of endoanal ultrasound in evaluation of fecal incontinence.

[Recanalization of uretero-intestinal anastomoses].

The authors present their own experience related to application of the metallic stents in treatment of ureteroenteric strictures. Over the period of approximately 3 years, we have implanted them in 27 patients (28 strictures). Due to the unsatisfactory therapeutic effects of the repeated balloon catheter dilatations and catheter prostheses the further course of treatment included placement of the metallic Strecker stents of 4-8 cm in length and 6-8 mm in diameter. Six months after the procedure, 58% of the procedures were assessed as satisfactory. After one year, 12 out of 28 were clinically efficient at long-term. The achieved effects were significantly better in comparison to older generation interventional radiology methods.