Combined two-stage total pancreatoduodenectomy and esophagectomy for synchronous malignancy of the pancreatic corpus and the esophagus: A surgical case report.

INTRODUCTION: Synchronous visceral malignancy is rare especially for esophagogastric junction adenocarcinoma combined with malignancy in the pancreas. So far only 7 cases of combined partial pancreatoduodenectomy and esophagectomy for synchronous malignancy have been described in the literature and none for combined total pancreatectomy and esophagectomy. PRESENTATION OF CASE: We report the case of a 67-year-old male patient, who underwent multi-modality treatment including two-stage total pancreatoduodenectomy and subsequent Ivor-Lewis esophagectomy for synchronous adenocarcinoma of the distal esophagus and pancreatic multilocal metastases of a renal cell carcinoma after nephrectomy 17 years ago. Pathology revealed R0 resections for both malignancies and there were no postoperative complications. A 12 months follow-up showed no signs of recurrence and a good quality of life. CONCLUSION: Curative-intent, combined oncological two-stage open total pancreatoduodenectomy and esophagectomy with several days interval is safe and feasible in selected cases when performed by an experienced interdisciplinary team in a high-volume surgical center.

Diffusion weighted MRI of osteoid osteomas: Higher ADC values after radiofrequency ablation.

PURPOSE: Feasibility of diffusion weighted MRI (DWI) pre- and post-radiofrequency ablation (RFA) in patients with osteoid osteoma (OO). MATERIAL AND METHODS: Ten patients (1 female, 24±9years) received RFA of OO (mean size 8.7±3.2mm). Two OO recurred, in one of these a second RFA was performed. A 1.5T DWI (b=50, 400, and 800s/mm(2)) and a fat saturated DCE MRI were obtained the day before and after RFA. In DWI, the mean apparent diffusion coefficient (ADC) was recorded. With DCE MRI, signal-to-noise ratio, contrast-to-noise ratio, absolute signal intensity (SI), relative SI, and SI ratio were documented. All parameters were compared pre- and post-RFA using paired Wilcoxon rank test. RESULTS: ADC values were significantly higher post-ablation, 1.6±0.5µm(2)/ms versus 1.3±0.6µm(2)/ms (p<0.05). Perfusion was significantly reduced after ablation [SNR, CNR, SI, %SI, and SI OO/SI muscle]; post-RFA: 55±13, 27±20, 757±534, 102±16, and 1.6±0.2; pre-RFA: 88±37, 65±22, 1038±755, 226±51, and 2.0±0.5 (p<0.05). DISCUSSION: DWI is feasible in OO. ADC values increased and contrast enhancement decreased after RFA of OO. This may be explained by RFA-induced necrosis and devascularization.

IVIM-DWI of transplanted kidneys: reduced diffusion and perfusion dependent on cold ischemia time.

PURPOSE: To evaluate the effect of cold ischemia time (CIT) of renal allografts on diffusion and perfusion using intravoxel incoherent motion (IVIM) derived parameters. MATERIAL AND METHODS: A total of 37 patients with renal allografts (CIT: 27 <15 h, 10 ≥15 h) and 30 individuals with healthy kidneys were examined at 1.5 T using a single-shot echo-planar diffusion-weighted pulse sequence with nine b-values ranging from 0 to 800 s/mm(2). ADC, perfusion fraction f, and the diffusion coefficient D were calculated using the IVIM model. Parameters of allografts stratified by CIT were compared with healthy kidney groups using the Mann-Whitney U test for unpaired data. We computed the Spearman correlation coefficient for correlation with creatinine values. RESULTS: ADC, D, and f of transplanted kidneys were significantly lower than in the healthy controls. The long-CIT group showed significantly lower diffusion parameters compared with the short-CIT group [mean±SD]: ADC: 1.63±0.14 µm(2)/ms, f: 11.90±5.22%, D: 1.55±0.25 µm(2)/ms versus ADC: 1.79±0.13 µm(2)/ms, f: 16.12±3.43%, D: 1.73±0.14 µm(2)/ms, P(ADC), (f), (D)<0.05. CONCLUSION: Our results suggest that diffusion parameters, especially the ADC, depend on the CIT of the kidney allograft. Potentially, this stands for functional changes in renal allografts. Diffusion-weighted imaging could be used for follow-up examinations. Thus, diffusion parameters may help guide therapy in patients with delayed graft function.

Investigation of renal lesions by diffusion-weighted magnetic resonance imaging applying intravoxel incoherent motion-derived parameters--initial experience.

PURPOSE: Usefulness of biexponentially fitted signal attenuation at different b-values for differentiating the histological characteristics of renal tumors. MATERIALS AND METHODS: A total of 26 patients with 28 renal masses (histologically proven: 20 clear cell renal cell carcinomas [ccRCC], three transitional cell carcinomas, two oncocytomas, and one papillary RCC) and 30 volunteers with healthy kidneys were examined at 1.5 Tesla using an echo-planar DWI sequence. Using the IVIM model, we calculated the perfusion fraction f and the diffusion coefficient D. Furthermore, the ADC was obtained. These tumor parameters were compared to healthy renal tissue nonparametrically, and a receiver operating characteristic (ROC) analysis was performed. RESULTS: Healthy renal parenchyma showed higher ADC and D values (p<0.001) than ccRCC (ADC 1.95±0.10 [SD] µm2/ms, f 18.32±2.52%, and D 1.88±0.11 µm2/ms versus ADC 1.45±0.38 µm2/ms, f 18.59±6.16%, and D 1.34±0.38 µm2/ms). When detecting malignancies the area under the curve for D was higher than for ADC. The f values for ccRCC were higher (p<0.001) than for non-ccRCC (ADC 1.52±0.47 µm2/ms, f 8.44±1.24%, and D 1.30±0.18 µm2/ms). Both f and D correlated with ccRCC grading. CONCLUSION: IVIM imaging is able to provide reliable diffusion values in the human kidney and may enhance the accuracy of tumor diagnosis. The D value was the best parameter to distinguish renal tumors from healthy renal tissue. The f value is promising for determining the histological subgroups.