[Interdisciplinary tumor boards in the radiological routine : Current situation based on an online survey in Germany]. / Interdisziplinäre Tumorkonferenzen in der radiologischen Routine : Statuserhebung basierend auf einer Online-Befragung in Deutschland.

PURPOSE: Interdisciplinary tumor boards are periodical conferences, where optimal individual therapy plans are developed among medical experts with different specializations. The presence of a board-certified radiologist is medically indispensable in almost all relevant boards. In order to systematically evaluate the current workload for radiologists caused by these boards, we evaluated the current situation within German radiology to obtain numbers for future personnel planning. MATERIALS AND METHODS: We performed an online survey. We invited all 33 German university chairmen and 50 randomly selected head physicians of radiology at level 3 hospitals to participate. RESULTS: We had a participation rate of 79% (26/33) at university hospitals and 56% (28/50) at of level 3 non-university hospitals. The average total number of tumor boards was 3.3/day or 16.7/week at university hospitals and 2.6/day or 13/week at level 3 non-university hospitals. We calculated an average time considering preparation and execution as well as the average number of boards of 33.1 h/week for university hospitals and 18.2 h/week for level 3 hospitals. This results in a 78.8% workload for a board-certified radiologist at a university hospital (regular weekly work time 42 h) and 45.5% work load for level 3 hospitals (regular weekly work time 40 h). CONCLUSION: "Speaking radiology" as in interdisciplinary tumor boards represents a fundamental matter of course in radiology. The active participation in boards accomplished by radiologists improves evidence-based patient care. However, given the prevailing scarcity of resources in medicine, the data collected here regarding personnel costs for clinical radiology for participation in tumor boards must be taken into account in future discussions on personnel compensation.

[When are contrast agents really needed? : Cross-sectional imaging with computed tomography and magnetic resonance imaging]. / Wann ist Kontrastmittel wirklich nötig? : Schnittbildgebung mit Computer- und Magnetresonanztomographie.

CLINICAL ISSUE: The intravenous administration of contrast agents increases the contrast between diverse tissues and vessels against their surroundings in both computed tomography (CT) and magnetic resonance imaging (MRI) scans and has been generously used for years. There are only a few scientific publications that have systematically evaluated the impact of this contrast-enhancing technique over noncontrast enhancing techniques. RADIOLOGICAL STANDARD: According to these publications and our clinical experiences, there are far more indications to use non-contrast-enhancing techniques as they are used in clinical practice. The most important requirement to renounce the use of a contrast agent is sufficient clinical information and differentiated justified indication. The present review shows useful non-contrast-enhanced examination techniques for neuroradiology, musculoskeletal system, lymphatic system, and thorax, including the hearth, abdomen and breasts. CLINICAL RECOMMENDATIONS: Good indications for non-contrast imaging are generally follow-ups. In cerebral related questions, like in traumatic or atraumatic emergencies, transient ischemic attacks, minor stroke diagnostic, dementia and in follow-ups of multiple sclerosis, there is usually no need for contrast agent. Examinations of the musculoskeletal systems and follow-up examinations of the lymphatic system can generally be done without a contrast agent. There is no major loss of value in CT and MRI scans of the thorax by examining without contrast. The value of using a contrast agent in the abdomen is far less than expected. Up to now use of a contrast agent is essential in evaluating questions related to vessels or angiomatous tissue and in breast MRI.

[Image-based screening]. / Screening mit bildgebenden Verfahren.

Screening is a special issue in medical questions concerning disease prevention. Preconditions for screening are clearly defined by the World Health Organization. High prevalence, effectiveness of therapy, availability of accepted test procedure and consensus concerning the economic concerns are necessary for successful implementation of a screening program. Preventive diagnostic studies can only be understood if one is familiar with the statistical terms sensitivity, specificity, prevalence, incidence and bias (especially overdiagnosis and lead time bias). Aspects of radiation protection are especially important in asymptomatic volunteers. The new radiation protection law in Germany also gives the opportunity to define new screening procedures even with use of radiation exposure in individual prevention programs. Potential diseases for radiological secondary prevention with high mortality are malignant tumors (especially breast cancer, lung cancer, colorectal cancer) and cardiovascular diseases (coronary heart disease, stroke or aortic aneurysm).

Completion of hand-written surgical consent forms is frequently suboptimal and could be improved by using electronically generated, procedure-specific forms.

INTRODUCTION: Completion of hand-written consent forms for surgical procedures may suffer from missing or inaccurate information, poor legibility and high variability. We audited the completion of hand-written consent forms and trialled a web-based application to generate modifiable, procedure-specific consent forms. METHODS: The investigation comprised two phases at separate UK hospitals. In phase one, the completion of individual responses in hand-written consent forms for a variety of procedures were prospectively audited. Responses were categorised into three domains (patient details, procedure details and patient sign-off) that were considered "failed" if a contained element was not correct and legible. Phase two was confined to a breast surgical unit where hand-written consent forms were assessed as for phase one and interrogated for missing complications by two independent experts. An electronic consent platform was introduced and electronically-produced consent forms assessed. RESULTS: In phase one, 99 hand-written consent forms were assessed and the domain failure rates were: patient details 10%; procedure details 30%; and patient sign-off 27%. Laparoscopic cholecystectomy was the most common procedure (7/99) but there was significant variability in the documentation of complications: 12 in total, a median of 6 and a range of 2-9. In phase two, 44% (27/61) of hand-written forms were missing essential complications. There were no domain failures amongst 29 electronically-produced consent forms and no variability in the documentation of potential complications. CONCLUSION: Completion of hand-written consent forms suffers from wide variation and is frequently suboptimal. Electronically-produced, procedure-specific consent forms can improve the quality and consistency of consent documentation.

[The new law on radiation protection as a consequence of the EU safety standard of 2013]. / Das neue Strahlenschutzgesetz als Auswirkung der EU-Grundnormen von 2013.

The transformation of a European guideline (2013/59/Euratom) from 2013 into national law requires adaptation of the national statutory regulations. This year, all areas of protection from ionizing radiation will be subject to the new radiation protection law (StrlSchG). Through this, the German X­ray and Radiation Protection Acts will be combined to form a higher level of authority. The main parts of the StrlSchG will receive a new classification and will be organized according to the exposure scenario: radiation protection in planned exposure scenarios, radiation protection in emergency exposure scenarios, radiation protection in existing exposure scenarios, and the regulation of overall exposure scenarios. The most important or modified regulated points for radiology are concerned with early recognition, where the application of X­ray or nuclear radiation is permitted in principle under certain conditions; the consultation of medical physics experts in all diagnostic investigative procedures involving radiation and applications for radiological intervention that are linked to high doses in the person under investigation; teleradiology, another special case of the application of X­rays in humans that requires approval, now with the "required" technical qualification in radiation protection, formerly with the "full" technical qualification, in addition to research, the simplified approval procedure being substituted with a notification procedure.Furthermore, in contrast to previous regulations, those tasked with radiation protection can contact the regulators directly in the case of conflict, which indicates considerable reinforcement of their authority.The only dose limit that will be considerably reduced is the organ-specific equivalent dose of the eye lens, where the highest value will be reduced from 150 to 20 mSv per year in those who are exposed to radiation professionally.

One Step Nucleic Acid Amplification (OSNA) positive micrometastases and additional histopathological NSLN metastases: Results from a single institution over 53 months.

INTRODUCTION: The role of sentinel lymph node micrometastases on histopathological analysis is controversial in axillary staging and management in clinically node negative breast cancer. Long-term studies addressing the clinical relevance of occult breast cancer in sentinel lymph nodes based on molecular analysis are lacking. One Step Nucleic Acid Amplification (OSNA), a highly sensitive assay of cytokeratin 19 mRNA, is used intra-operatively for the detection of lymph node macro- and micrometastases in breast cancer. AIM: The aim of this study is to review the rate of micrometastases and further histopathological NSLN metastases, in our unit following the introduction of OSNA in Guildford. METHODS: Data was collected prospectively from the period of introduction 01/12/2008 to 31/05/2013. All patients eligible for sentinel lymph node biopsy were offered OSNA and operations were performed by the consultant breast surgeons. Presence or absence of micro-metastases depends on the agreed cut-off point on the amplification curve. On detection of micrometastases (+) and positive but inhibited (i+) metastases, a level 1 axillary clearance (ANC) was performed and for a macrometastasis (++), a level 3 ANC was carried out. RESULTS: 66% of the patients had negative SLN (n = 672) and 34% (n = 336) had positive sentinel lymph nodes who had further axillary surgery. Of these, 45% (n = 152/336) had macrometastases, 40% (n = 136/336) had micrometastases and 15% (48/336) had positive but inhibited results. There was no difference in the patient demographics and tumour characteristics in the various positive SLN groups. In patients with micrometastases, 15% (20/136) had further positive NLSNs and a further 6% (8/136) had >4 overall positive nodes (SLN + NSLN) thus requiring adjuvant supraclavicular/chest wall radiotherapy (p < 0.05). 25% of node positive patients had further NLSN metastases (85/336) and in these patients, the ratio of positive SLN/harvested SLN (+SLN/SLN) is constant at 1:1. This shows the likelihood of further positive NSLNs if all the harvested lymph nodes are positive. This linear trend is present in both micro-and macrometastases, thus correlating with the size and number of NSLN metastases. CONCLUSION: Our study reflects the tumour burden of NSLNs based on the molecular analysis of the SLN. OSNA has the potential to accurately identify axillary micrometastases. Micro-metastases are important as some of the patients with micrometastases had overall four positive nodes [SLN + NSLN] (criteria for radiotherapy in the absence of other adverse clinicopathological features). Also, our study highlights certain factors that predict the NSLN metastases, pending validation by further prospective long-term data. This will allow accurate calculation of the axillary tumour burden, particularly in patients with micro-metastases.

Results of a national training programme in sentinel lymph node biopsy for breast cancer.

BACKGROUND: New Start, a structured, validated, multidisciplinary training programme in sentinel lymph node biopsy (SLNB), was established to allow the introduction and rapid transfer of appropriate knowledge and technical skills to ensure safe and competent practice across the UK. METHODS: Multidisciplinary teams attended a theory/skills laboratory course, following which they performed 30 consecutive SLNBs, either concurrently with their standard axillary staging procedure (training model A) or as stand-alone SLNB (training model B). SLNB was performed according to a standard protocol using the combined technique of isotope ((99m) Tc-labelled albumin colloid) and blue dye. An accredited New Start trainer mentored the first five procedures in the participant's hospital, or all 30 if stand-alone. Validation standards for model A and B were a localization rate of at least 90 per cent. In addition, for model A only, in which a minimum of ten patients were required to be node-positive, a false-negative rate (FNR) of 10 per cent or less was required. RESULTS: From October 2004 to December 2008, 210 SLNB-naive surgeons, in 103 centres, performed 6685 SLNB procedures. The overall sentinel lymph node (SLN) localization rate was 98·9 (95 per cent confidence interval 98·6 to 99·1) per cent (6610 of 6685) and the FNR 9·1 (7·9 to 10·5) per cent (160 of 1757). The FNR was related to nodal yield, ranging from 14·8 per cent for one node and declining to 9·7, 6·6, 4·7 and 4·1 per cent for two, three, four and more than four SLNs respectively. No learning curve was identified for localization or FNR. CONCLUSION: The programme successfully trained a wide range of UK breast teams to perform safe SLNB and suggested that a standard injection protocol and structured multidisciplinary training can abolish learning curves.

[Screening for colorectal cancer: even with virtual colography?]. / Screening des Kolonkarzinoms: Auch mit virtueller Kolographie?

Colorectal cancer (CRC) is responsible for 27,000 deaths and 65,000 new cancers in Germany each year, although this should be unnecessary as CRC is preventable because it is possible to remove the precursors, harmless polyps and adenomas. However, only 2.5 % of people in health insurance make use of screening colonoscopy annually so that it becomes necessary to check out other screening tests. The most commonly used test is the Guaiak-based test for fecal occult blood (gFOBT) which is highly specific but not very sensitive (only approximately 10 %). New immunological stool tests are more sensitive but the specificity is reduced from 90 % to approximately 80 %. Virtual colonoscopy based on computed tomography (CT) or magnetic resonance imaging (MRI) is comparable to endoscopy for diagnostics with overall accuracy rates of approximately 80-90 % for polyps larger than 5 mm but for radiation protection reasons CT is not usable in Germany and MRI is internationally not adequately established by large study trials. For the future there is much hope in molecular blood tests. It is of great importance that every physician is aware of the different tests, their strengths and weaknesses and advises all patients to use the different screening possibilities.

Multicentre evaluation of intraoperative molecular analysis of sentinel lymph nodes in breast carcinoma.

BACKGROUND: Ideally, intraoperative sentinel lymph node (SLN) analysis in breast cancer should be automated, have high concordance with extensive histopathology, and be applicable in any hospital setting. A prospective multicentre evaluation of the one-step nucleic acid amplification (OSNA) automated molecular diagnostic system of SLN analysis was undertaken. METHODS: Intraoperative examination of SLNs from 204 patients with breast cancer was performed by OSNA at four sites in the UK. Half of each SLN was assessed by OSNA (for cytokeratin 19 mRNA) and the remaining half was paraffin embedded for intensive histological examination at ten levels. Discordant cases were reanalysed by further molecular biological techniques and by additional histological examination of all remaining nodal material to ascertain whether the discordance was due to an uneven distribution of metastases, known as tissue allocation bias (TAB). RESULTS: After exclusion of samples affected by TAB, the overall concordance rate for OSNA versus histopathology was 96.0 per cent, with a sensitivity of 91.7 per cent and a specificity of 96·9 per cent. The median time to process a single SLN was 32 (range 22-97) min, and that for two nodes 42 (30-73) min. CONCLUSION: OSNA enables accurate automated intraoperative diagnosis and can be used successfully in different UK hospitals. When the SLN is shown to be positive, the patient can undergo immediate axillary clearance under the same anaesthetic rather than having a delayed second procedure.

Melanoma sentinel node biopsy and prediction models for relapse and overall survival.

BACKGROUND: To optimise predictive models for sentinal node biopsy (SNB) positivity, relapse and survival, using clinico-pathological characteristics and osteopontin gene expression in primary melanomas. METHODS: A comparison of the clinico-pathological characteristics of SNB positive and negative cases was carried out in 561 melanoma patients. In 199 patients, gene expression in formalin-fixed primary tumours was studied using Illumina's DASL assay. A cross validation approach was used to test prognostic predictive models and receiver operating characteristic curves were produced. RESULTS: Independent predictors of SNB positivity were Breslow thickness, mitotic count and tumour site. Osteopontin expression best predicted SNB positivity (P=2.4 × 10⁻7), remaining significant in multivariable analysis. Osteopontin expression, combined with thickness, mitotic count and site, gave the best area under the curve (AUC) to predict SNB positivity (72.6%). Independent predictors of relapse-free survival were SNB status, thickness, site, ulceration and vessel invasion, whereas only SNB status and thickness predicted overall survival. Using clinico-pathological features (thickness, mitotic count, ulceration, vessel invasion, site, age and sex) gave a better AUC to predict relapse (71.0%) and survival (70.0%) than SNB status alone (57.0, 55.0%). In patients with gene expression data, the SNB status combined with the clinico-pathological features produced the best prediction of relapse (72.7%) and survival (69.0%), which was not increased further with osteopontin expression (72.7, 68.0%). CONCLUSION: Use of these models should be tested in other data sets in order to improve predictive and prognostic data for patients.

Current concepts in gynaecomastia.

Gynaecomastia is a common breast condition. Each case merits a careful and complete history, with thorough examination and investigations being required in selected patients with progressive disease or suspected sinister pathology. Treatment is usually indicated for any underlying cause, associated symptoms and the gynaecomastia itself. Treatment may be either medical or surgical but must be individualised. Medical treatment may be especially advocated in the symptomatic group. The indications for surgery include failure of medical treatment, intolerable side-effects of necessary drugs, malignancy, small lesions which cause significant distress and patients with large and ptotic gynaecomastia. A careful programme of counselling, pre-operatively in particular, may help to minimise litigation.

[Screening of colorectal neoplasm]. / Screening des kolorektalen Karzinoms.

In Germany approximately 29,000 people died of colorectal carcinoma (CRC) in 2002; the risk of getting CRC is 4-6% in Germany, rising with age from the 50th year of life. About one third of all people over 50 years of age have polyps with the potential for malignant transformation in the colorectum, which is a sufficiently high prevalence rate to justify screening. In contrast to most other cancer diseases, in the case of CRC it is possible to prevent the cancer and not only to detect it at an early stage. Application of the test for occult blood in persons between their 45th and 80th years can reduce the mortality of CRC by 14%. We can assume that already regular sigmoidoscopies with consistent performance of polypectomy when needed could reduce the incidence of CRC by 50-70%. There is no doubt that coloscopy is the technique of choice for secondary prevention, as it unites the possibility of complete diagnosis and treatment with a justifiably low level of risk. The economic advantages of an avoidance strategy compared with the treatment of CRC, which is certainly expensive, have been documented. On the basis of all the data reported, in the case of CRC preventive strategies can be emphatically recommended.

Chemoocclusion vs chemoperfusion for treatment of advanced hepatocellular carcinoma: a randomised trial.

AIMS: Transarterial chemoembolization (TACE) can be associated with considerable toxicity and treatment-associated mortality. Transient transarterial chemoocclusion (TACO) using degradable starch microspheres (DSM) has been proposed as a potentially safer alternative while maintaining anti-tumour efficiency. In a randomised phase II trial TACO was compared to transarterial chemoperfusion without DSM (TACP). METHODS: Seventy-four patients with advanced HCC were randomised to two treatment arms: (i) TACO (600-1200 mg DSM) and (ii) TACP. In both arms regional chemotherapy consisted of cisplatin (100 mg/m2) and doxorubicin (60 mg/m2). Both arms were corresponding in terms of age, gender, liver performance state, and tumour-stage. A maximum of six treatment cycles was applied in monthly intervals. Follow-up was performed in terms of tumour response, time to progression, survival and quality of life. RESULTS: Tumour response rates did not differ significantly between the two treatment arms, however, there was a tendency towards higher response rates in the TACO arm (TACO vs TACP): partial response: 26 vs 9%, stable disease: 41 vs 55%, progressive disease: 33 vs 36%. Time to tumour progression (32 vs 27 weeks), and overall survival (60 vs 69 weeks) were not significantly different. Grade 4 adverse events were rare in both arms and treatment-associated mortality was not observed. In addition, there was no significant difference in terms of quality of life under therapy (EORTC). CONCLUSION: TACO with DSM did not improve response or survival significantly compared to TACP in advanced non-resectable HCC.

An investigation into the effect of axillary surgery on ipsilateral axillary sweating--a pleasing 'complication' or a potential treatment for hyperhidrosis?

Although there had not been complaints of excessive sweating pre-operatively, it was noticed incidentally that a large proportion of patients who had undergone axillary lymph node sampling or clearance for breast carcinoma seemed to report ipsilateral sweat loss as a pleasing 'complication'. We interviewed 65 consecutive patients who had all had axillary dissections performed by the same surgeon's technique; the interviews were held 2-102 months after their operations. In 36 cases, patients reported no change in axillary sweating (mean 35 months), whereas 29 patients reported a decrease (mean 50 months). This result was statistically significant at the 95% confidence interval (p=0.022).

Hepatic resection for breast cancer metastases.

INTRODUCTION: Hepatic resection is an established modality of treatment for colorectal cancer metastases. Resection of breast cancer liver metastases remains controversial, but has been shown to be an effective treatment in selected cases. This study reports the outcome of 8 patients with liver metastases from breast cancer. PATIENTS & METHODS: 8 patients with liver metastases from previously treated breast cancer were referred for hepatic resection between September 1996 and December 2002. Six were eligible for liver resection. The mean age was 45.8 years. The resections performed included 1 segmentectomy and 5 hemihepatectomies of which one was an extended hemihepatectomy. One patient had a repeat hepatectomy 44 months after the first resection. RESULTS: There were no postoperative deaths or major morbidity. The resectability rate was 75%. Follow-up periods range from 6 to 70 months with a median survival of 31 months following resection. There have been 2 deaths, one died of recurrence in the residual liver at 6 months and one died disease-free from a stroke. Of the remaining 4 patients, 1 has had a further liver resection at 44 months following which she is alive and 'disease-free' at 70 months. The one patient with peritoneal recurrence is alive 49 months after her liver resection with 2 patients remaining disease-free. CONCLUSION: Hepatic resection for breast cancer liver metastases is a safe procedure with low morbidity and mortality.

S2k Guidlines for Diverticular Disease and Diverticulitis: Diagnosis, Classification, and Therapy for the Radiologist.

UNLABELLED: Diverticular disease and diverticulitis represent an increasingly common disease especially in patients with advanced age. The German Society of Digestive and Metabolic Diseases (DGVS) as well as the German Society of General and Visceral Surgery (DGAV) in collaboration with the German Radiology Society (DRG) created and published S2k guidelines regarding this topic. Knowledge of the diagnosis and therapy of this common disease is extremely important for the radiologist for the daily clinical routine. In this article we review and discuss the most important clinical situations and algorithms of this disease focusing on radiological topics. Additionally, we introduce the new CCD (classification of diverticular disease) system regarding radiology. KEY POINTS: For the diagnosis of a diverticular disease a sectional imaging method should be performed. First choice should be a "qualified ultrasound examination" followed by CT in uncertain situations or complicated disease. Disease classification should be done according the new CCD (Classification of diverticular disease) algorithm. Based on this new CCD patients can be stratified into outpatient, in-house patient and surgical treatment therapy.

Disseminated bone marrow metastases from primary breast cancer: detection and follow-up by radioimmune bone marrow scintigraphy.

Bone scintigraphy of a 40-yr-old patient suffering from primary breast cancer suggested the possibility of diffuse metastases. Bone marrow scintigraphy using 99mTc-labeled monoclonal antibodies (BW 250/183) demonstrated diffuse destruction of bone marrow due to metastatic disease and consecutive bone marrow extension. Bone marrow scintigraphy was highly sensitive in detecting progression of disease in this asymptomatic patient.

Effect of propranolol and depot lanreotide SR on postprandial and circadian portal haemodynamics in cirrhosis.

BACKGROUND: Long-acting somatostatin analogues have been suggested as an alternative to propranolol for the prevention of variceal rebleeding. AIM: To compare the effectiveness of lanreotide SR, a new depot formulation injected once-weekly, and propranolol in reducing circadian portal blood flow (PVF) and meal-stimulated hepatic venous pressure gradient (HVPG) in patients with liver cirrhosis. METHODS: Patients were randomized to receive either lanreotide SR intramuscularly (30 mg once weekly, n=12) or propranolol (n=12) orally. Hemodynamic measurements were performed on day 0 and on day 21 after a 3-week period of drug administration, while patients received three standard oral liquid test meals. On each study day 27 PVF measurements were performed over 24 h and eight measurements of HVPG during the first postprandial period. RESULTS: Propranolol was more effective than lanreotide SR in reducing baseline HVPG (-21.9 vs. -13.6%, P=0.04) and meal-stimulated HVPG (-16.6 vs. -3.8%, P=0.04). Propranolol reduced circadian PVF significantly by 9.3% (P=0.03) but not lanreotide SR. CONCLUSIONS: Long-term treatment with propranolol reduced baseline and postprandial HVPG and circadian PVF, while lanreotide SR did not. The results of our study do not encourage clinical testing of lanreotide SR 30 mg for the prevention of variceal haemorrhage.