Complications of central venous port systems: a pictorial review.

Central venous port devices are indicated for patients, who need long-term intravenous therapy. Oncologic patients may require intermittent administration of chemotherapy, parenteral nutrition, infusions, or blood transfusions. A venous port system is composed of a port chamber attached to a central catheter, which is implanted into the central venous system. The subcutaneous location of the catheter chamber improves the patients' quality of life and the infection rate is lower than in non-totally implantable central venous devices. However, proper implantation, use, and care of a port system are important to prevent short- and long-term complications. Most common early complications (< 30 days) include venous malpositioning of catheter and perforation with arterial injury, pneumothorax, hemothorax, thoracic duct injury, or even cardiac tamponade. Delayed complications include infection, catheter thrombosis, vessel thrombosis and stenosis, catheter fracture with extravasation, or fracture with migration or embolization of catheter material. Radiologic imaging has become highly relevant in intra-procedural assessment and postoperative follow-up, for detection of possible complications and to plan intervention, e.g., in case of catheter migration. This pictorial review presents the normal imaging appearance of central venous port systems and demonstrates imaging features of short- and long-term complications.

Outcome after radiofrequency ablation of sarcoma lung metastases.

PURPOSE: Resection is the mainstay of management in patients with sarcoma lung metastases, but there is a limit to how many resections can be performed. Some patients with inoperable disease have small-volume lung metastases that are amenable to thermal ablation. We report our results after radiofrequency ablation (RFA). METHODS: This is a retrospective study of patients treated from 2007 to 2012 in whom the intention was to treat all sites of disease and who had a minimum CT follow-up of 4 months. Treatment was performed under general anesthesia/conscious sedation using cool-tip RFA. Follow-up CT scans were analyzed for local control. Primary tumor type, location, grade, disease-free interval, prior resection/chemotherapy, number and size of lung tumors, uni- or bilateral disease, complications, and overall and progression-free survival were recorded. RESULTS: Twenty-two patients [15 women; median age 48 (range 10-78) years] with 55 lung metastases were treated in 30 sessions. Mean and median tumor size and initial number were 0.9 cm and 0.7 (range 0.5-2) cm, and 2.5 and 1 (1-7) respectively. Median CT and clinical follow-up were 12 (4-54) and 20 (8-63) months, respectively. Primary local control rate was 52 of 55 (95 %). There were 2 of 30 (6.6 %) Common Terminology Criteria grade 3 complications with no long-term sequelae. Mean (median not reached) and 2- and 3-year overall survival were 51 months, and 94 and 85 %. Median and 1- and 2-year progression-free survival were 12 months, and 53 and 23 %. Prior disease-free interval was the only significant factor to affect overall survival. CONCLUSION: RFA is a safe and effective treatment for patients with small-volume sarcoma metastases.

Atypical idiopathic inflammatory demyelinating lesions (IIDL): conventional and diffusion-weighted MR imaging (DWI) findings in 42 cases.

INTRODUCTION: The purpose of this study was to evaluate MR imaging characteristics with conventional and advanced MR imaging techniques in patients with IIDL. METHODS: MR images of the brain in 42 patients (20 male, 22 female) with suspected or known multiple sclerosis (MS) from four institutions were retrospectively analyzed. Lesions were classified into five different subtypes: (1) ring-like lesions; (2) Balo-like lesions; (3) diffuse infiltrating lesions; (4) megacystic lesions; and (5) unclassified lesions. The location, size, margins, and signal intensities on T1WI, T2WI, and diffusion-weighted images (DWI), and the ADC values/ratios for all lesions, as well as the contrast enhancement pattern, and the presence of edema, were recorded. RESULTS: There were 30 ring-like, 10 Balo-like, 3 megacystic-like and 16 diffuse infiltrating-like lesions were detected. Three lesions were categorized as unclassified lesions. Of the 30 ring-like lesions, 23 were hypointense centrally with a hyperintense rim. The mean ADC, measured centrally, was 1.50 ± 0.41 × 10(-3) mm(2)/s. The mean ADC in the non-enhancing layers of the Balo-like lesions was 2.29 ± 0.17 × 10(-3) mm(2)/s, and the mean ADC in enhancing layers was 1.03 ± 0.30 × 10(-3) mm(2)/s. Megacystic lesions had a mean ADC of 2.14 ± 0.26 × 10(-3)mm(2)/s. Peripheral strong enhancement with high signal on DWI was present in all diffuse infiltrating lesions. Unclassified lesions showed a mean ADC of 1.43 ± 0.13 mm(2)/s. CONCLUSION: Restriction of diffusion will be seen in the outer layers of active inflammation/demyelination in Balo-like lesions, in the enhancing part of ring-like lesions, and at the periphery of infiltrative-type lesions.

Fetal magnetic resonance imaging of lymphangiomas.

OBJECTIVES: To evaluate the fetal magnetic resonance imaging findings of lymphangiomas. METHODS: The magnetic resonance scans of eight fetuses with lymphangiomas were evaluated. Magnetic resonance evaluation included: number; size; signal intensities of the lesions; thickness of the septae; configuration of the margins; presence of blood breakdown products; change in size or signal intensity (in four patients with multiple examinations); exact expansion of the lesions to the adjacent anatomical structures; and concomitant pathological findings. Results were compared with postpartum clinical assessment and imaging in seven patients and with autopsy in one patient. RESULTS: Two retroperitoneal, three thoracic, and three cervical lymphangiomas (diameters between 3.3 and 15.6 cm) were included. All lesions consisted of macrocysts, and additional microcystic parts were found in three lymphangiomas. Blood breakdown products were found in one lesion. Agreement with postpartum imaging was excellent. One patient received intrauterine drainage for chylothorax, and one pregnancy was terminated. CONCLUSIONS: Fetal lymphangiomas display the same magnetic resonance imaging features as postnatal lymphangiomas. Intrauterine magnetic resonance characterization of lymphangiomas provides the exact delineation, detection of associated and/or concomitant pathologies, and differential diagnosis among other cystic pathologies. Patient management may be altered with respect to the type and/or time of treatment, and with regard to the continuation or termination of pregnancy.

Segmental and lobar administration of drug-eluting beads delivering irinotecan leads to tumour destruction: a case-control series.

BACKGROUND: Irinotecan-loaded drug-eluting beads represent a novel drug delivery method that allows for the locoregional delivery of irinotecan to colorectal liver metastases (CRLM). The method has shown impressive response rates. However, the pathological response to this treatment has not previously been demonstrated. METHODS: Patients with easily resectable CRLM were treated with drug-eluting beads delivering irinotecan (DEBIRI) 4 weeks prior to resection. Pathological tumour response was graded using a validated system. The intraoperative detection of previously unidentified disease allowed for the assessment of pathological responses directly attributable to bead treatment. RESULTS: In Patient 1, segmental embolization of the target lesion in segment VIII resulted in 100% necrosis (0% viability). An untreated lesion in segment IV was found to be 30% viable. In Patient 2, subsegmental embolization of the target lesion in segment VI resulted in 60% necrosis and 40% fibrosis (0% viability). An untreated lesion in segment VI remained 60% viable. In Patient 3, lobar embolization of the target lesion in segment II resulted in 0% viability. Two further lesions within the treated hemiliver, both with 0% viability, and one lesion in the untreated hemiliver with 45% viability were discovered at laparotomy. CONCLUSIONS: This series demonstrates the effectiveness of DEBIRI in the treatment of CRLM. High rates of tumour destruction are possible, even with the proximal lobar administration of DEBIRI. Lobar administration appears to be an appropriate method of delivery for integration into future therapeutic regimens.

C-arm CT during hepatic arteriography tumour-to-liver contrast: intraindividual comparison of three different contrast media application protocols.

OBJECTIVE: To compare tumour-to-liver contrast (TLC) of C-arm CT during hepatic arteriography (CACTHA) acquired using three protocols in patients with HCC. METHODS: This prospective study was IRB approved and informed consent was obtained from each patient. Twenty-nine patients (mean age, 68 ± 7 years; 27 men) with 55 HCCs (mean diameter, 2.6 ± 1.5 cm) underwent three different CACTHA protocols in random order before chemoembolisation. Contrast medium (100 mg iodine/ml) was injected into the common hepatic artery (flow rate 4 ml/s). The imaging delay for the start of the CACTHA examination was 4 s (protocol A), 8 s (protocol B) and 12 s (protocol C) (total amount of injected contrast medium: 48 ml, 64 ml, 80 ml). TLC was measured by placing regions of interest (ROIs) in the HCC and liver parenchyma. Mixed model ANOVAs and Bonferroni corrected post hoc tests were used for statistical analysis. RESULTS: Mean values for TLC were 132 ± 3.3 HU, 186 ± 5.8 HU and 168 ± 2.8 HU for protocols A, B and C. Protocol B provided significantly higher TLC than protocols A and C (p < 0.001). CONCLUSION: TLC was significantly higher using an imaging delay of 8 s compared with a delay of 4 or 12 s.

Hepatic steatosis assessment with 1H-spectroscopy and chemical shift imaging at 3.0 T before hepatic surgery: reliable enough for making clinical decisions?

PURPOSE: To compare the accuracy of liver fat quantification using chemical shift imaging (CSI) and H1 MR-spectroscopy (MRS) at 3.0 T in patients undergoing liver resection. METHODS: Totally 35 patients were included in this prospective IRB approved study. The histopathologically assessed liver fat was compared to the hepatic fat fractions calculated with CSI (with and without spleen correction) and MRS. Spearman's rank correlation and Fisher z-test were used for correlation analysis. Sensitivity and specificity regarding the detection of marked steatosis were calculated for the different modalities and compared using the McNemar test. RESULTS: MRS (r=.85) and CSI with spleen correction (r=.85) showed a significantly better correlation (p=.03) with histology compared to CSI without spleen correction (r=.67). Sensitivity and specificity for the detection of marked steatosis was 100% (12/12) and 87% (20/23) for MRS and 92% (11/12) and 83% (19/23) for CSI with spleen correction (p>.12). CONCLUSION: For the assessment of hepatic steatosis both CSI with spleen correction and MRS at 3.0 T, show a good correlation with histology. CSI without spleen correction should not be used. Sensitivity and specificity for the detection of marked steatosis are high with both modalities. However, results that are scattered around the cut-off values are not reliable enough for clinical decisions.

Quantification of the subcutaneous fat layer with MRI in fetuses of healthy mothers with no underlying metabolic disease vs. fetuses of diabetic and obese mothers.

OBJECTIVE: To assess the age-dependent fetal subcutaneous fat layer (SCFL) of non-diabetic, normal-weight mothers and fetuses of mothers with gestational diabetes (GDM) and normal body weight or obesity. METHODS: In a prospective study, we evaluated 115 MRI examinations of fetuses with no history of (maternal) metabolic disease [gestational week (GW) 29 to 39/40] and 50 examinations of mothers with GDM and normal body weight or obesity. The SCFL was measured at predetermined anatomical landmarks. Measurements were correlated with the maternal body mass index (BMI) and glycated hemoglobin A1c (HbA1c)-values in diabetic mothers. RESULTS: In fetuses of non-diabetic, normal-weight mothers, measurements showed high consistency within the respective GW and ranged from 2 mm at GW 29 at all measured points, up to 4.5 mm at the trunk and 6.0 mm at the extremities at GW 39/40. In 47/50 fetuses of mothers with GDM, the SCFL was within the range of fetuses of mothers with no metabolic disease. In three patients with GDM and BMI<30, the SCFL-thickness was decreased. No fetuses showed an increased SCFL-thickness. CONCLUSION: The SCFL of normally developed fetuses is easily detectable from GW 29 on T1-weighted images (T1-W), and increases with gestational age. The presented data provide physiological benchmarks to evaluate developmental status and may help in the prenatal diagnosis of abnormal growth and macrosomia. In pregnant women with well-controlled GDM, an increase of the SCFL is not expected.

NeoGemTax: gemcitabine and docetaxel as neoadjuvant treatment for locally advanced nonmetastasized pancreatic cancer.

BACKGROUND: About 30% of patients with pancreatic cancer suffer from locally advanced nonmetastatic carcinoma at the time of diagnosis. We conducted a prospective phase II clinical trial using neoadjuvant chemotherapy, consisting of gemcitabine and docetaxel, to assess the rate of complete radical resection and overall survival. METHODS: Gemcitabine (900 mg/m2) and docetaxel (35 mg/m2) were given on days 1, 8, and 15 of a 28-day cycle. Two cycles were administered for a preoperative treatment duration of 8 weeks. Patients experiencing tumor regression or stable disease and improved performance status subsequently underwent surgical exploration and pancreatic resection, if feasible. All patients were followed postoperatively to assess long-term survival. RESULTS: A total of 25 patients were eligible and included in the intent-to-treat and evaluable population. Thirteen patients had unresectable disease at inclusion and 12 patients had borderline resectable pancreatic cancer. Finally, 8 of 25 (32%) patients underwent resection after neoadjuvant chemotherapy; 7 (87%) of these patients had R0 resection. The median overall survival of patients who underwent resection was 16 months (95% confidence interval [CI], 8-24 months) compared to 12 months (95% CI, 8-16 months) for those without resection (p=0.276). The median recurrence-free survival rate after resection was 12 months (95% CI, 2-21 months). CONCLUSIONS: NeoGemTax was safe and resection was feasible in a number of patients after systemic neoadjuvant treatment. Further randomized clinical trials are needed to identify novel multimodal regimens that would be able to increase the percentage of patients undergoing curative pancreatic cancer surgery despite advanced tumor stage at the time of diagnosis.

Gadobenate dimeglumine-enhanced 3.0-T MR imaging versus multiphasic 64-detector row CT: prospective evaluation in patients suspected of having pancreatic cancer.

PURPOSE: To compare the diagnostic performance (detection, local staging) of multiphasic 64-detector row computed tomography (CT) with that of gadobenate dimeglumine-enhanced 3.0-T magnetic resonance (MR) imaging in patients suspected of having pancreatic cancer. MATERIALS AND METHODS: The institutional review board approved this prospective study, and all patients provided written informed consent. Multidetector CT and MR imaging were performed in 89 patients (48 women aged 46-89 years [mean, 65.6 years] and 41 men aged 46-86 years [mean, 65.3 years]) suspected of having pancreatic cancer on the basis of findings from clinical examination or previous imaging studies. Two readers independently assessed the images to characterize lesions and determine the presence of focal masses, vascular invasion, distant metastases, and resectability. Findings from surgery, biopsy, endosonography, or follow-up imaging were used as the standard of reference. Logistic regression, the McNemar test, and κ values were used for statistical analysis. RESULTS: Focal pancreatic masses were present in 63 patients; 43 patients had adenocarcinoma. For reader 1, the sensitivities and specificities in the detection of pancreatic adenocarcinoma were 98% (42 of 43 patients) and 96% (44 of 46 patients), respectively, for CT and 98% (42 of 43 patients) and 96% (44 of 46 patients) for MR imaging. For reader 2, the sensitivities and specificities were 93% (40 of 43 patients) and 96% (44 of 46 patients), respectively, for CT and 95% (41 of 43 patients) and 96% (44 of 46 patients) for MR imaging. Vessel infiltration was determined in 22 patients who underwent surgery, and reader 1 obtained sensitivities and specificities of 90% (nine of 10 vessels) and 98% (119 of 122 vessels), respectively, for CT and 80% (eight of 10 vessels) and 96% (117 of 122 vessels) for MR imaging; for reader 2, those values were 70% (seven of 10 vessels) and 98% (120 of 122 vessels) for CT and 50% (five of 10 vessels) and 98% (120 of 122 vessels) for MR imaging. Both readers correctly assessed resectability in 87% (13 of 15 patients) of cases with CT and 93% (14 of 15 patients) of cases with MR imaging. Nonresectability was assessed correctly with CT in 75% (six of eight patients) of cases by reader 1 and 63% (five of eight patients) of cases by reader 2; nonresectability was correctly assessed with MR imaging in 75% (six of eight patients) of cases by reader 1 and 50% (four of eight patients) of cases by reader 2. None of the differences between modalities and readers were statistically significant (P > .05). CONCLUSION: Both CT and MR imaging are equally suited for detecting and staging pancreatic cancer. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.11101189/-/DC1.

Magnetic resonance imaging spectrum of medulloblastoma.

INTRODUCTION: Two medulloblastoma variants were recently added to the WHO classification of CNS tumours. We retrospectively analysed the imaging findings of 37 classic and 27 cases of variant medulloblastomas to identify imaging characteristics that might suggest a particular MB subtype. METHODS: Sixty-four patients from three institutions were included. Location, tumour margins, signal intensities on conventional MRI, enhancement pattern, the presence of haemorrhage, calcifications and hydrocephalus were recorded and analysed. Signal characteristics on diffusion-weighted MR images and MR spectra were evaluated when available. RESULTS: Thirty-seven classic type of MB (CMB), twelve cases of desmoplastic/nodular medulloblastoma (DMB), nine medulloblastomas with extensive nodularity (MB-EN), five cases of anaplastic and one of large-cell medulloblastoma were included. Fifty of 64 tumours were located in the 4th ventricle region. On T2WI, CMB were all hyperintense, whereas DMB and MB-EN showed isointensity in up to 66%. One third of the classic MB showed only subtle marginal or linear enhancement. All medulloblastoma variants showed marked enhancement. CONCLUSION: The results of our study suggest: (a) an age-dependent distribution of MB variants, with DMB and MB-EN more common in younger children; (b) a female predominance in DMB; (c) a more common off-midline location in DMB (50%) and MB-EN (33%) variants.

Continuous systemic corticosteroids do not affect the ongoing regression of metastatic melanoma for more than two years following ipilimumab therapy.

Malignant melanoma is an aggressive skin cancer with no effective therapies currently approved for advanced disease. In the case presented, a 55-year-old female patient diagnosed with widespread disease from amelanotic desmoplastic melanoma was treated with 10 mg/kg ipilimumab as part of a phase II clinical trial (CA184-008). Prior to ipilimumab, three chemotherapeutic regimens had failed. Ipilimumab acts as a T-cell potentiator via blockade of cytotoxic T-lymphocyte antigen-4, a negative regulator of T-cell activation. Response to ipilimumab treatment was rapid, with a substantial drop in tumor volume within 12 weeks of treatment initiation. Based on the appearance of a new subcutaneous lesion, reinduction with ipilimumab was performed at Week 30. Following reinduction, the appearance of another small new lesion made the patient ineligible, as per protocol, for further dosing despite stabilization of her remaining lesions. Ipilimumab-associated immune-related adverse events were manageable with the use of treatment guidelines. It is of remarkable immunotherapeutic importance that no new lesions emerged and gradual tumor regression is still ongoing more than 2 years following the last dose of ipilimumab, despite daily administration of systemic corticosteroids to manage drug-induced AEs. The ongoing clinical response is maintained without any further antineoplastic treatment.

Sinonasal imaging after Caldwell-Luc surgery: MDCT findings of an abandoned procedure in times of functional endoscopic sinus surgery.

BACKGROUND AND PURPOSE: Today, functional endoscopic sinus surgery (FESS) is performed in most of the patients with sinonasal inflammatory disease. The postoperative imaging findings of FESS in multidetector computed tomography (MDCT) considerably differ from those of historic Caldwell-Luc (CL) maxillary sinus surgery which is an uncommon procedure today. Thus, the postoperative CL imaging findings may lead to diagnostic confusion and misinterpretation. Therefore, this study explicitly presents the MDCT findings of post-CL patients which have not been described previously. METHODS: Twenty-eight patients with clinically suspected sinusitis and documented history of CL-procedure underwent 16 row MDCT (MDCT Mx8000 IDT Philips) with multiplanar reconstructions of the paranasal sinuses in the axial plane. The following parameters were used: 140kV, 50mAs; 16mmx0.75mm detector collimation; 1mm reconstructed slice thickness; 0.5mm increment. The studies were reconstructed with a bone algorithm (W3000/L600; 1mm slice thickness) in axial plane and coronal plane (3mm slice thickness). The images were retrospectively evaluated for the presence of normal surgery-related and pathological findings. RESULTS: Surgery-related imaging characteristics presented as follows: an anterior and a medial bony wall defect and sclerosis and sinus wall thickening were observed in all 28/28 cases (100%). Collaps of the sinus cavity was seen in 26/28 cases (92.9%). Furthermore, inflammatory disease of the operated sinus(es) was found in 23/28 cases (82.1%): 14/28 patients (50%) had inflammatory mucosal thickening of the operated sinus(es) as well as of other sinonasal cavities and 9/28 patients (32.1%) had inflammatory mucosal thickening limited to the operated sinus(es). A postoperative mucocele was depicted in 3/28 cases (10.7%). 2/28 patients (7.1%) showed neither maxillary nor other mucosal swelling. CONCLUSION: MDCT with multiplanar reconstructions is a precise method to evaluate post-CL patients and helps to differentiate normal surgery-related findings, which may mimic pathology, from real pathological findings.

Two K versus 4 K storage phosphor chest radiography: detection performance and image quality.

The purpose of this study was to evaluate the effect of matrix size (4-K versus 2-K) in digital storage phosphor chest radiographs on image quality and on the detection of CT-proven thoracic abnormalities. In 85 patients who underwent a CT of the thorax, we obtained two additional posteroanterior storage phosphor chest radiographs, one with a matrix size of 3,520x4,280 (=4-K) and the other with a matrix size of 1,760x2,140 (=2-K). Acquisition, processing and presentation parameters were identical for all radiographs. Two radiologists evaluated the presence of mediastinal, pleural, and pulmonary abnormalities on hard copies of the radiographs, applying ROC analysis. In addition, four radiologists were asked to subjectively rank differences in image quality and to assess the demarcation of anatomic landmarks comparing the images in a blinded side-by-side manner. These data were analyzed using a two-sided binomial test with a significance level of P<0.05. Both tests, the ROC analysis of the detection performance and the binomial test of the subjective quality ratings, did not reveal significant differences between the two matrix sizes. Compared to 2-K radiographs, 4-K storage phosphor chest radiographs do not provide superior detection performance or image quality when evaluated in identical hard copy formats.

State-of-the-art magnetic resonance imaging of pancreatic cancer.

Technical advances of magnetic resonance imaging (MRI), including ultrahigh-field magnetic resonance at 3.0 T, parallel imaging techniques, and multichannel receive coils of the abdomen, have promoted MRI of the pancreas. For adenocarcinoma, which is the most common malignant pancreatic tumor, helical CT has been most often used for detection and staging, but it has limitations in the detection of small cancers 2 cm in diameter or less (sensitivity, 63%). Moreover, it is not very accurate in determining nonresectability, because small liver metastases, peritoneal carcinomatosis, and subtle signs of vascular infiltration may be missed. At ultrahigh field at 3.0 T, gadolinium-enhanced MRI using volume-interpolated 3-dimensional gradient-recalled echo pulse sequences with near-isotropic voxels are very useful for detection of subtle abnormalities. Mangafodipir-enhanced MRI reveals a very high tumor-pancreas contrast, which helps to diagnose small cancers. Contrast-enhanced MRI is a problem-solving tool in case of equivocal CT: it helps to differentiate between cancer and focal pancreatitis. Neuroendocrine carcinoma may present with a spectrum of appearances at MRI, but the primary tumor and liver metastases are hypervascular in approximately 70%. In this article, pancreas imaging protocols for 1.5 and 3.0 T are explained. We present the imaging features of pancreatic cancer and the important questions in staging, which should be addressed by the radiologist.