[18F]FDG-PET/CT-based risk stratification in women with locally advanced uterine cervical cancer.

BACKGROUND: [18F]FDG-PET/CT is used for staging and treatment planning in patients with locally advanced cervical cancer (LACC). We studied if a PET-based prediction model could provide additional risk stratification beyond International Federation of Gynaecology and Obstetrics (FIGO) staging in our population with LACC to aid treatment decision making. METHODS: In total, 183 patients with LACC treated with chemoradiation between 2013 and 2018 were included. Patients were treated according to FIGO 2009 and retrospectively reclassified according to FIGO 2018 staging system. After validation of an existing PET-based prediction model, the predicted recurrent free survival (RFS), disease specific survival (DSS) and overall survival (OS) at 1, 3, and 5 years, based on metabolic tumor volume (MTV), maximum standardized uptake value (SUVmax) and highest level of [18F]FDG-positive node was calculated. Then the observed survival was compared to the predicted survival. An area under the curve (AUC) close to or higher than 0.7 was considered adequate for accurate prediction. The Youden (J) index defined survival chance cutoff values for low and high risk groups. RESULTS: All AUC values for the comparison between predicted and observed outcomes were > 0.7 except for 5-year RFS and for 5-year OS which were close to 0.7 (0.684 and 0.650 respectively). Cutoff values for low and high risk survival chance were 0.44 for the 3-year RFS and 0.47 for the 5-year OS. The FIGO 2009 system could not differentiate between the risk profiles. After reclassification according to FIGO 2018, all patients with stage IIIC2 and IVB fell in the high risk and almost all patients with stages IB2-IIIB and IVA in the low risk group. In patients with stage IIIC1 disease the FIGO stage cannot discriminate between the risk profiles. CONCLUSIONS: Low and high risk patients with LACC can be identified with the PET-based prediction model. In particular patients with stage IIIC1 need additional risk stratification besides the FIGO 2018 staging. The Kidd model could be a useful tool to aid treatment decision making in these patients. Our results also support the choice of [18F]FDG-PET/CT imaging in patients with LACC.

Whole-body magnetic resonance imaging for detection of skeletal metastases in children and young people with primary solid tumors - systematic review.

BACKGROUND: Many solid neoplasms have a propensity for osteomedullary metastases of which detection is important for staging and subsequent treatment. Whole-body magnetic resonance imaging (WB-MRI) has been shown to accurately detect osteomedullary metastases in adults, but these findings cannot be unconditionally extrapolated to staging of children with malignant solid tumors. OBJECTIVE: To conduct a literature review on the sensitivity of WB-MRI for detecting skeletal metastases in children with solid tumors. MATERIALS AND METHODS: Searches in MEDLINE and EMBASE databases up to 15 May 2017 were performed to identify studies on the diagnostic value of WB-MRI. Inclusion criteria were children and adolescents (age <21 years) with a primary solid tumor who were evaluated for skeletal metastases by WB-MRI and compared to any type of reference standard. The number of included patients had to be at least five and data on true positives, true negatives, false-positives and false-negatives had to be extractable. RESULTS: Five studies including 132 patients (96 patients with solid tumors) were eligible. Patient groups and used reference tests were heterogeneous, producing unclear or high risk of bias. Sensitivity of WB-MRI ranged between 82% and 100%. The positive predictive value of WB-MRI was variable among the studies and influenced by the used reference standard. CONCLUSION: Although WB-MRI may seem a promising radiation-free technique for the detection of skeletal metastases in children with solid tumors, published studies are small and too heterogeneous to provide conclusive evidence that WB-MRI can be an alternative to currently used imaging techniques.

Diagnostic performance of imaging modalities in chronic pancreatitis: a systematic review and meta-analysis.

OBJECTIVES: Obtain summary estimates of sensitivity and specificity for imaging modalities for chronic pancreatitis (CP) assessment. METHODS: A systematic search was performed in Cochrane Library, MEDLINE, Embase and CINAHL databases for studies evaluating imaging modalities for the diagnosis of CP up to September 2016. A bivariate random-effects modeling was used to obtain summary estimates of sensitivity and specificity. RESULTS: We included 43 studies evaluating 3460 patients. Sensitivity of endoscopic retrograde cholangiopancreatography (ERCP) (82%; 95%CI: 76%-87%) was significant higher than that of abdominal ultrasonography (US) (67%; 95%CI: 53%-78%; P=0.018). The sensitivity estimates of endoscopic ultrasonography (EUS), magnetic resonance imaging (MRI), and computed tomography (CT) were 81% (95%CI: 70%-89%), 78% (95%CI: 69%-85%), and 75% (95%CI: 66%-83%), respectively, and did not differ significantly from each other. Estimates of specificity were comparable for EUS (90%; 95%CI: 82%-95%), ERCP (94%; 95%CI: 87%-98%), CT (91%; 95% CI: 81%-96%), MRI (96%; 95%CI: 90%-98%), and US (98%; 95%CI: 89%-100%). CONCLUSIONS: EUS, ERCP, MRI and CT all have comparable high diagnostic accuracy in the initial diagnosis of CP. EUS and ERCP are outperformers and US has the lowest accuracy. The choice of imaging modality can therefore be made based on invasiveness, local availability, experience and costs. KEY POINTS: • EUS, ERCP, MRI and CT have high diagnostic sensitivity for chronic pancreatitis • Diagnostic specificity is comparable for all imaging modalities • EUS and ERCP are outperformers and US has the lowest accuracy • The choice of imaging can be made based on clinical considerations.

Clinimetric Evaluation of the Vascular Quality of Life Questionnaire in Patients with Lower Limb Ischaemia.

OBJECTIVES: Although commonly used to measure health related quality of life in patients with lower limb ischaemia, the measurement properties of the VascuQol and its assumed underlying health dimensions have not been studied in depth. The objective of this study was therefore to evaluate aspects of reliability and validity of the Dutch version of the VascuQol in patients with intermittent claudication (IC) and critical limb ischaemia (CLI). METHODS: Two datasets containing 195 patients with IC and 150 patients with CLI were used. Face validity of the VascuQol was examined in interviews with patients and a survey among health professionals. Homogeneity and structural validity of the VascuQol were assessed using Cronbach's α coefficients and explanatory factor analysis. Furthermore, convergent validity and known group validity were assessed. RESULTS: During the face validity interviews, three items were indicated as less relevant. Homogeneity analysis showed that the α coefficient of the VascuQol was .93, while the symptoms and social domains had α coefficients below the threshold of .70. The original five domains of the VascuQol could not be reproduced. Instead, factor analysis yielded a three factor solution. Moderate correlations were found for the activities, social and emotional VascuQol domains and matching health domains of other patient reported outcome measures (PROMs). Lower convergent correlations were observed for the pain domain and the sumscore of the VascuQol. The VascuQol was able to distinguish between patients' level of HRQL in relation to their disease severity (IC versus CLI patients). CONCLUSIONS: There is room for improvement of the VascuQol questionnaire. Further clinimetric studies should be performed to strengthen clinically relevant findings based on this instrument.

Determining the Minimally Important Difference for the VascuQol Sumscore and Its Domains in Patients with Intermittent Claudication.

OBJECTIVES: The VascuQol is a questionnaire for health related quality of life (HRQL) in patients with intermittent claudication (IC), and is frequently used to evaluate treatment effects. Yet, the interpretation of change in score on a questionnaire is not always obvious. The minimally important difference (MID) represents the smallest change in score on a questionnaire that is considered relevant by patients. This study aims to determine the MID for the VascuQol sumscore and its different domains for patients with IC. METHODS: A total of 118 participants were recruited from the SUPER study, a multicenter randomized controlled trial comparing angioplasty with supervised exercise therapy for alleviation of IC due to an iliac artery stenosis or occlusion. All patients completed the VascuQol and the Short Form 36 (SF-36) questionnaires at baseline and after 12 months of follow up. Two anchor based methods for MID calculation were applied. Two anchors were used: six global rating of change questions aimed at the VascuQol sumscore and subscales and the health transition item of the SF-36, both recorded at 12 months of follow up. RESULTS: The MID for the VascuQol sumscore ranged between 1.19 and 1.66 for improvement and 0.08 and 0.41 for deterioration. For the pain domain, MID values ranged from 1.48 to 1.91 for improvement and 0.19 to 0.34 for deterioration. Finally, for the activities domain MID values ranging from 1.55 to 2.2 and from 0.12 to 0.26 for improvement and deterioration were found, respectively. Since the correlations between the anchors and the symptom, social and emotional subscales were below the threshold of 0.3, the MID was not calculated for these subscales. CONCLUSIONS: The range of MID values found in this study is an indication of the smallest change score on the VascuQol questionnaire score that is considered relevant by patients with IC. They may help to better interpret trial results and set treatment goals.

Grading of Crohn's disease activity using CT, MRI, US and scintigraphy: a meta-analysis.

PURPOSE: To assess the grading of Crohn's disease activity using CT, MRI, US and scintigraphy. MATERIALS AND METHODS: MEDLINE, EMBASE and Cochrane databases were searched (January 1983-March 2014) for studies evaluating CT, MRI, US and scintigraphy in grading Crohn's disease activity compared to endoscopy, biopsies or intraoperative findings. Two independent reviewers assessed the data. Three-by-three tables (none, mild, frank disease) were constructed for all studies, and estimates of accurate, over- and under-grading were calculated/summarized by fixed or random effects models. RESULTS: Our search yielded 9356 articles, 19 of which were included. Per-patient data showed accurate grading values for CT, MRI, US and scintigraphy of 86% (95% CI: 75-93%), 84% (95% CI: 67-93%), 44% (95% CI: 28-61%) and 40% (95% CI: 16-70%), respectively. In the per-patient analysis, CT and MRI showed similar accurate grading estimates (P = 0.8). Per-segment data showed accurate grading values for CT and scintigraphy of 87% (95% CI: 77-93%) and 86% (95% CI: 80-91%), respectively. MRI and US showed grading accuracies of 67-82% and 56-75%, respectively. CONCLUSIONS: CT and MRI showed comparable high accurate grading estimates in the per-patient analysis. Results for US and scintigraphy were inconsistent, and limited data were available. KEY POINTS: • CT and MRI have comparable high accuracy in grading Crohn's disease. • Data on US and scintigraphy is inconsistent and limited. • MRI is preferable over CT as it lacks ionizing radiation exposure.

Test-retest Reliability and Measurement Error Are Excellent for the Dutch Version of the VascuQol Questionnaire in Patients with Intermittent Claudication.

OBJECTIVES: Although the Vascular Quality of Life Questionnaire (VascuQol) is a widely used instrument to assess quality of life in patients with peripheral arterial disease (PAD), data on its reliability are scarce and its measurement error is unknown. The aim of this study was to determine test-retest reliability and measurement error of the Dutch version of the VascuQol in patients with intermittent claudication (IC). METHODS: Patients with intermittent claudication due to PAD presenting between October 2013 and April 2014 completed the VascuQol twice, with a 1 week interval. Test-retest reliability was expressed as the intraclass correlation coefficient (ICC) with 95% confidence interval (CI), and measurement error as a standard error of measurement (SEM). RESULTS: Sixty-one patients completed two VascuQol questionnaires sufficiently. The ICC for the VascuQol sumscore was 0.91 (95% CI 0.86-0.95). The ICC for the different VascuQol domains ranged between 0.77 (95% CI 0.64-0.86) and 0.87 (95% CI 0.79-0.92). The SEM of the sumscore was 0.34 and ranged between 0.44 and 0.76 for the different VascuQol domains. CONCLUSIONS: The test-retest reliability of the Dutch version of the VascuQol is excellent, both for the sumscore and for its different domains. The VascuQol has a measurement error that is sufficiently small to allow detection of clinically relevant changes.

Randomized trials for endovascular treatment of infrainguinal arterial disease: systematic review and meta-analysis (Part 1: Above the knee).

OBJECTIVE: To evaluate 1 to 36 month follow-up outcomes of different endovascular treatment strategies in above-the-knee (ATK) arterial segments in patients with intermittent claudication (IC) and critical limb ischemia (CLI). METHODS: Studies indexed in Medline and Embase from 1980 to November 2013 of randomized controlled trials comparing balloon angioplasty (PTA) or drug-eluting balloon (DEB) with optional bailout stenting, or primary stenting using a bare stent (BS) or drug-eluting stent (DES) to one another were included. Methodological quality of each trial was assessed using the Cochrane Collaboration tool, and quality of evidence was assessed using the GRADE system. Outcomes assessed were quality of life, walking capacity evaluated by treadmill or questionnaire, change in Rutherford classification, target lesion revascularization (TLR), bypass, binary restenosis, late lumen loss, stenosis grade, amputation, death, major adverse cardiac events, or event-free survival with follow-up periods of at least 1 month. RESULTS: Twenty-three trials including 3314 patients in total were identified. Eighty-five per cent patients had IC and 15% CLI. Fifteen trials showed no systematic benefit of BS over PTA. One trial comparing DES and PTA reported no significant differences in walking capacity or Rutherford classification. Four trials showed a beneficial effect on TLR rate, but not on Rutherford classification of DEB compared with PTA. In four trials DES did not systematically perform better than BS. CONCLUSION: In general, performing PTA with optional bailout stenting for ATK lesions is the preferred strategy in patients with IC. For CLI, more studies are needed for recommending an optimal treatment strategy.

Randomized trials for endovascular treatment of infrainguinal arterial disease: systematic review and meta-analysis (Part 2: Below the knee).

OBJECTIVE: To evaluate 1 to 48 month follow-up outcomes of different endovascular treatment strategies in below-the-knee (BTK) arterial segments in critical limb ischemia (CLI) patients. METHODS: Medline and Embase were searched (last searched on 5 November 2013) for studies of randomized controlled trials comparing either balloon angioplasty (PTA) or drug-eluting balloon (DEB) with optional bailout stenting, or primary stenting using a bare stent (BS) or drug-eluting stent (DES) to one another. Methodological quality of each trial was assessed using a Cochrane Collaboration's tool, and quality of evidence was assessed using the GRADE system. Outcomes assessed were wound healing, quality of life, change in Rutherford classification, amputation, death, target lesion revascularization (TLR), bypass, binary restenosis, late lumen loss, stenosis grade, and event-free survival with follow-up periods of at least 1 month. RESULTS: Twelve trials including 1145 patients were identified, with 90% of patients having CLI. Six BS versus PTA and two DES versus PTA trials showed low-quality evidence of equal efficacy. One trial, comparing DEB with PTA, showed moderate-quality evidence of improved wound healing (RR 1.28; 95% CI: 1.05 to 1.56; p=.01), improvement in Rutherford classification (RR 1.32; 95% CI: 1.08 to 1.60; p=.008), and lower TLR (RR 0.41; 95% CI 0.23 to 0.74; p=.002) and binary restenosis (RR 0.36; 95% CI 0.24 to 0.54; p<.0001) in diabetic patients after 12 months. Amputation and death rate did not differ significantly. For DES versus BS, most trials showed equal efficacy between strategies. CONCLUSION: Based on low- to moderate-quality evidence, PTA with optional bailout stenting using BS should remain the preferred strategy in treating CLI patients with BTK arterial lesions. Before other strategies can be implemented, larger and high-quality RCTs assessing clinically relevant outcomes are needed.

Statistical or clinical improvement? Determining the minimally important difference for the vascular quality of life questionnaire in patients with critical limb ischemia.

OBJECTIVE: Interpreting whether changes in quality of life (Qol) in patients with peripheral arterial disease (PAD) are not only statistically significant but also clinically relevant, may be difficult. This study introduces the concept of the minimally important difference (MID) to vascular surgeons using Qol outcomes of patients treated for chronic critical limb ischemia (CLI). METHODS: The Vascular Quality of Life (VascuQol) questionnaire was recorded at baseline before treatment and after 6 months follow-up in consecutive patients with CLI treated between May 2007 and May 2010. Statistical significance of change in VascuQol score was tested with the Wilcoxon Signed Rank test. The MID for the VascuQol score was determined using a clinical anchor-based method and a distribution-based method. RESULTS: A total of 127 patients with CLI completed the VascuQol after 6 months. The VascuQol sum scores improved from 3.0 (range 1.1-5.9) at baseline to 4.0 (range 1.2-6.7) at 6 months (p < .001). The MID on the VascuQol sumscore indicating a clinically important change determined with the anchor-based method was 0.36, and with the distribution-based method was 0.48. On an individual level, depending on the method of determining the MID, this resulted in 60% to 68% of the patients with an important benefit. CONCLUSIONS: Expression of changes in Qol by means of the MID provides better insight into clinically important changes than statistical significance.

Diagnostic performance of computed tomography angiography in peripheral arterial injury due to trauma: a systematic review and meta-analysis.

OBJECTIVES: To evaluate the diagnostic accuracy of computed tomography angiography (CTA) in detecting arterial lesions in patients with suspected arterial injury of the upper or lower extremity due to trauma. METHODS: A systematic review and meta-analysis was carried out. Medline and Embase were searched on August 13, 2012, for studies comparing CTA with surgery, digital subtraction angiography (DSA), or follow-up, which allowed extraction of data into two-by-two tables. The methodological quality of included studies was assessed using the QUADAS tool. Summary estimates of sensitivity and specificity of CTA in identifying or excluding arterial lesions were obtained using a bivariate model. RESULTS: This review included 11 studies making up a total of 891 trauma patients. The included studies were of moderate methodological quality and at risk of misclassification and verification bias. Some 4.2% of all CTA studies were non-diagnostic. The summary estimates of sensitivity and specificity of CTA were 96.2% (95% CI 93.5-97.8%) and 99.2% (95% CI 96.8-99.8%), respectively. CONCLUSION: Despite methodological flaws, the excellent estimates of sensitivity and specificity indicate that CTA is an accurate modality for evaluating arterial lesions in patients with extremity trauma and can replace DSA.

Systematic review of exercise training or percutaneous transluminal angioplasty for intermittent claudication.

BACKGROUND: The aim was to summarize the results of all randomized clinical trials (RCTs) comparing percutaneous transluminal angioplasty (PTA) with (supervised) exercise therapy ((S)ET) in patients with intermittent claudication (IC) to obtain the best estimates of their relative effectiveness. METHODS: A systematic review was performed of relevant RCTs identified from the MEDLINE, Embase and Cochrane Library databases. Eligible RCTs compared PTA with (S)ET, included patients with IC due to suspected or known aortoiliac and/or femoropopliteal artery disease, and compared their effectiveness in terms of functional outcome and/or quality of life (QoL). RESULTS: Eleven of 258 articles identified (reporting data on eight randomized clinical trials) met the inclusion criteria. One trial included patients with isolated aortoiliac artery obstruction, three trials studied those with femoropopliteal artery obstruction and five included those with combined lesions. Two trials compared PTA with advice on ET, four PTA with SET, two PTA plus SET with SET and two PTA plus SET with PTA. Although the endpoints in most trials comprised walking distances and QoL, pooling of data was impossible owing to heterogeneity. Generally, the effectiveness of PTA and (S)ET was equivalent, although PTA plus (S)ET improved walking distance and some domains of QoL scales compared with (S)ET or PTA alone. CONCLUSION: As IC is a common healthcare problem, defining the optimal treatment strategy is important. A combination of PTA and exercise (SET or ET advice) may be superior to exercise or PTA alone, but this needs to be confirmed.

Evaluation of the female pelvic floor in pelvic organ prolapse using 3.0-Tesla diffusion tensor imaging and fibre tractography.

OBJECTIVES: To prospectively explore the clinical application of diffusion tensor imaging (DTI) and fibre tractography in evaluating the pelvic floor. METHODS: Ten patients with pelvic organ prolapse, ten with pelvic floor symptoms and ten asymptomatic women were included. A two-dimensional (2D) spin-echo (SE) echo-planar imaging (EPI) sequence of the pelvic floor was acquired. Offline fibre tractography and morphological analysis of pelvic magnetic resonance imaging (MRI) were performed. Inter-rater agreement for quality assessment of fibre tracking results was evaluated using weighted kappa (κ). From agreed tracking results, eigen values (λ1, λ2, λ3), mean diffusivity (MD) and fractional anisotropy (FA) were calculated. MD and FA values were compared using ANOVA. Inter-rater reliability of DTI parameters was interpreted using the intra-class correlation coefficient (ICC). RESULTS: Substantial inter-rater agreement was found (κ = 0.71 [95% CI 0.63-0.78]). Four anatomical structures were reliably identified. Substantial inter-rater agreement was found for MD and FA (ICC 0.60-0.91). No significant differences between groups were observed for anal sphincter, perineal body and puboperineal muscle. A significant difference in FA was found for internal obturator muscle between the prolapse group and the asymptomatic group (0.27 ± 0.05 vs 0.22 ± 0.03; P = 0.015). CONCLUSION: DTI with fibre tractography permits identification of part of the clinically relevant pelvic structures. Overall, no significant differences in DTI parameters were found between groups. KEY POINTS: Diffusion tensor MRI offers new insights into female pelvic floor problems. DTI allows 3D visualisation and quantification of female pelvic floor anatomy. DTI parameters from pelvic floor structures can be reliably determined. No significant differences in DTI parameters between groups with/without prolapse.

SUPERvised exercise therapy or immediate PTA for intermittent claudication in patients with an iliac artery obstruction--a multicentre randomised controlled trial; SUPER study design and rationale.

INTRODUCTION: Treatment of intermittent claudication (IC) due to peripheral arterial disease (PAD) is aimed at improving walking distance and includes secondary prevention of cardiovascular disease. Both supervised exercise therapy (SET) and percutaneous transluminal angioplasty (PTA) have proven to be effective in increasing maximum and pain-free walking distance in IC. However, the optimal treatment strategy in patients with IC due to iliac artery stenosis or occlusion remains unclear. OBJECTIVE: To compare the (cost-) effectiveness of initial PTA versus initial SET in patients with disabling IC due to an iliac artery obstruction. DESIGN: In a multicentre randomised controlled trial 400 consecutive patients with IC will be randomly assigned to PTA (with additional stent placement on indication) or SET. Primary outcomes are maximum walking distance and health-related quality of life measured using the disease-specific VascuQol instrument after 1 year. Secondary outcomes are pain-free walking distance, functional status, generic quality of life, complications related to each of the interventions, additional interventions, treatment failures and costs (cost-effectiveness and cost-utility) after 1 year. CONCLUSION AND IMPLICATIONS: Based on the results of this proposed large study well-founded adjustments of existing guidelines on the treatment of iliac artery occlusive disease can be implemented (Clinical Trials.gov NCT01385774; Nederlands Trial Register NTR2776).

Feasibility of diffusion tensor imaging (DTI) with fibre tractography of the normal female pelvic floor.

OBJECTIVES: To prospectively determine the feasibility of diffusion tensor imaging (DTI) with fibre tractography as a tool for the three-dimensional (3D) visualisation of normal pelvic floor anatomy. METHODS: Five young female nulliparous subjects (mean age 28 ± 3 years) underwent DTI at 3.0T. Two-dimensional diffusion-weighted axial spin-echo echo-planar (SP-EPI) pulse sequence of the pelvic floor was performed, with additional T2-TSE multiplanar sequences for anatomical reference. Fibre tractography for visualisation of predefined pelvic floor and pelvic wall muscles was performed offline by two observers, applying a consensus method. Three eigenvalues (λ1, λ2, λ3), fractional anisotropy (FA) and mean diffusivity (MD) were calculated from the fibre trajectories. RESULTS: In all subjects fibre tractography resulted in a satisfactory anatomical representation of the pubovisceral muscle, perineal body, anal - and urethral sphincter complex and internal obturator muscle. Mean FA values ranged from 0.23 ± 0.02 to 0.30 ± 0.04, MD values from 1.30 ± 0.08 to 1.73 ± 0.12 × 10(-)³ mm²/s. Muscular structures in the superficial layer of the pelvic floor could not be satisfactorily identified. CONCLUSIONS: This study demonstrates the feasibility of visualising the complex three-dimensional pelvic floor architecture using 3T-DTI with fibre tractography. DTI of the deep female pelvic floor may provide new insights into pelvic floor disorders.

Reducing the oral contrast dose in CT colonography: evaluation of faecal tagging quality and patient acceptance.

AIM: To evaluate the minimal iodine contrast medium load necessary for an optimal computed tomography colonography tagging quality. MATERIALS AND METHODS: Faecal occult blood test positive patients were randomly selected for one of three iodine bowel preparations: (1) 3 × 50 ml meglumine ioxithalamate (45 g iodine), (2) 4 × 25 ml meglumine ioxithalamate (30 g iodine); or (3) 3 × 25 ml (22.5 g iodine) meglumine ioxithalamate. Two experienced readers assessed the tagging quality per colonic segment on a five-point scale and the presence of adherent stool. Also semi-automatic homogeneity measurements were performed. Patient acceptance was assessed with questionnaires. RESULTS: Of 70 eligible patients, 45 patients participated (25 males, mean age 62 years). Each preparation group contained 15 patients. The quality of tagging was insufficient (score 1-2) in 0% of segments in group 1; 4% in group 2 (p<0.01 versus group 1); and 5% in group 3 (p=0.06 versus group 1). In group 1 in 11% of the segments adherent stool was present compared with 49% in group 2 and 41% in group 3 (p<0.01, group 2 and 3 versus group 1). Homogeneity was 85, 102 (p<0.01), and 91 SD HU (p=0.26) in groups 1, 2, and 3, respectively. In group 1 two patients experienced no burden after contrast agent ingestion compared to one patient in group 2 and nine patients in group 3 (p=0.017). CONCLUSION: A dose of 3 × 50 ml meglumine ioxithalamate is advisable for an optimal tagging quality despite beneficial effects on the patient acceptance in patients receiving a lower dose.

CT colonography with minimal bowel preparation: evaluation of tagging quality, patient acceptance and diagnostic accuracy in two iodine-based preparation schemes.

PURPOSE: The aim of this study was to compare a 1-day with a 2-day iodine bowel preparation for CT colonography in a positive faecal occult blood test (FOBT) screening population. MATERIALS AND METHODS: One hundred consecutive patients underwent CT colonography and colonoscopy with segmental unblinding. The first 50 patients (group 1) ingested 7 50 ml iodinated contrast starting 2 days before CT colonography. The latter 50 patients (group 2) ingested 4 50 ml iodinated contrast starting 1 day before CT colonography. Per colonic segment measurements of residual stool attenuation and homogeneity were performed, and a subjective evaluation of tagging quality (grade 1-5) was done. Independently, two reviewers performed polyp and carcinoma detection. RESULTS: The tagging density was 638 and 618 HU (p = 0.458) and homogeneity 91 and 86 HU for groups 1 and 2, respectively (p = 0.145). The tagging quality was graded 5 (excellent) in 90% of all segments in group 1 and 91% in group 2 (p = 0.749). Mean per-polyp sensitivity for lesions >or=10 mm was 86% in group 1 and 97% in group 2 (p = 0.355). Patient burden from diarrhoea significantly decreased for patients in group 2. CONCLUSIONS: One-day preparation with meglumine ioxithalamate results in an improved patient acceptability compared with 2-day preparation and has a comparable, excellent image quality and good diagnostic performance.

[Imaging in the diagnosis of colorectal liver metastases and extrahepatic abnormalities]. / Beeldvormende diagnostiek van colorectale levermetastasen en extrahepatische afwijkingen.

Imaging using ultrasonography, spiral CT, MRI and 18F-fluorodeoxyglucose positron emission tomography (FDG-PET), plays a major role at two situations during the management of patients with colorectal liver metastases: (a) at the time of the diagnosis and treatment of the primary colorectal tumour, and (b) during the follow-up for the detection of liver metastases and assessing the resectability of these metastases. At the time of the diagnosis and the treatment of the primary tumour, imaging comprising spiral CT or MRI to detect and characterize liver lesions is considered to be the modality of choice. Due to their low prevalence, imaging for the evaluation of lung metastases may be limited to conventional chest radiography. For evaluation of the extrahepatic abnormalities, abdominal and chest CT may be performed in combination with CT of the liver; alternatively a FDG-PET may be performed. During the follow-up of patients treated for colorectal carcinoma, ultrasonography is the most important imaging modality. However, if the liver cannot be adequately imaged by ultrasonography, if there is a raised level ofcarcinoembryonic antigen or irresectability cannot be determined, additional CT or MRI examination will result in more information.

Evidence-base guideline on management of colorectal liver metastases in the Netherlands.

A dutch national evidence-based guideline on the diagnosis and treatment of patients with colorectal liver metastases has been developed. The most important recommendations are as follows. For synchronous liver metastases, spiral computed tomography (CT) or magnetic resonance imaging (MRI) should be used as imaging. For evaluation of lung metastases, imaging can be limited to chest radiography. For detection of metachronous liver metastases, ultrasonography could be performed as initial modality if the entire liver is adequately visualised. In doubtful cases or potential candidates for surgery, CT or MRI should be performed as additional imaging. For evaluation of extrahepatic disease, abdominal and chest CT could be performed. Fluorodeoxyglucose positron emission tomography could be valuable in patients selected for surgery based on CT (liver/abdomen/chest), for identifying additional extrahepatic disease. Surgical resection is the treatment of choice with a five-year survival of 30 to 40%. Variation in selection criteria for surgery is caused by inconclusive data in the literature concerning surgical margins.

Imaging and treatment of patients with colorectal liver metastases in the Netherlands: a survey.

BACKGROUND: Clinical experience has highlighted the absence of a uniform approach to the management of patients with colorectal liver metastases in the Netherlands. METHODS: A written survey on the diagnosis and treatment of patients with colorectal liver metastases was sent to all 107 chairmen of oncology committees in each hospital. Questions were asked concerning: specialists involved in decision-making, availability and existence of guidelines and meetings, factors that needed to be improved, information regarding the diagnostic work-up of liver metastases, detailed techniques of ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET), factors influencing resectability, types of surgery performed, the use of (neo)adjuvant chemotherapy, portal vein embolisation performance, considering isolated hepatic perfusion (IHP) or local ablation as treatment options, actual performance of local ablation and the use of systemic as well as regional chemotherapy. RESULTS: Response rate was 68% (73/107). Specialists involved in the management were mostly surgeons (70), medical oncologists (66) and radiologists (42). Factors that needed to be improved, as indicated by responders, were the absence of 1) guidelines; 2) registration of patients and 3) guidelines for radiofrequency ablation (RFA). Diagnostic work-up of synchronous liver metastases occurred in 71 hospitals, (by US in 69 and by CT in 2). For the work-up of metachronous liver metastases, US was used as initial modality in 14, CT in 2 hospitals, and 57 hospitals used one or the other (mainly US). As additional modality, CT was performed (71) and to a lesser extent MRI (38) or PET (22). Diagnostic laparoscopy and biopsy were performed incidentally. The choice for an imaging modality was mostly influenced by the literature, and to a lesser extent by the availability and by costs, personnel and waiting lists. Substantial variation exists in the US, CT, MRI and PET techniques. The absence of extrahepatic disease and the clinical condition were considered as the most important factors influencing resectability. Surgery was performed in 30 hospitals; hemihepatectomy in 25, segment resection in 27, multisegment resection in 23, wedge excision in 27 and combination of resection and RF A in 18 institutions. In 52 hospitals (neo)adjuvant chemotherapy was administrated to improve surgical results, partly (35%) in trials. In nine hospitals portal vein embolisation was performed, with the volume of the remnant liver as the most important factor. Local ablative techniques were considered as a treatment option in 48 hospitals and actually performed in 16 hospitals, without clearly defined indications. Experimental IHP was considered a treatment option by 45 (62%) responders, irrespective whether this treatment was available at their centre. Patients with extensive metastases received systemic chemotherapy in all 73 hospitals and regional chemotherapy in ten hospitals. CONCLUSION: This survey shows substantial variation in the diagnostic and therapeutic work-up of patients with colorectal liver metastases. This variation reflects either under- or over-utilisation of diagnosis and treatment options. Evidence-based guidelines taking into account the available evidence, experience and availability can solve this variation.