[Incidental and leave me alone findings of abdominal organs-part 2 : Spleen, kidneys and adrenal glands and efferent urinary tracts]. / Inzidentelle und Leave-me-alone-Befunde der abdominellen Organe ­ Teil 2 : Milz, Niere und Nebennieren sowie ableitende Harnwege.

For masses of the spleen, which are mostly benign, accessory spleens, cysts and hemangiomas should be radiologically described; however, if confirmed further follow-up control is unnecessary. In the case of disseminated small masses, chronic inflammation and granulomatous diseases, such as tuberculosis and sarcoidosis should be considered in the differential diagnostics. Solid masses in the kidneys should always be further clarified, with the exception of a fat-rich angiomyolipoma. For cystic masses of the kidneys, the modified Bosniak classification for computed tomography or magnetic resonance imaging should be used. Masses of the adrenal glands greater than 10mm in size should be clarified further as well as those where fat is not detected, independent of the size and evidence of malignancy.

[Incidental and "leave me alone" findings of abdominal organs-part 1 : Liver, gall ducts and pancreas]. / Inzidentelle und Leave-me-alone-Befunde der abdominellen Organe ­ Teil 1 : Leber, Gallenwege und Pankreas.

Incidentalomas of the parenchymal organs of the abdomen, i.e. radiological findings in these organs that are not the primary focus of the clinical question, are frequent in this region of the body. In particular, findings presumed to be unimportant, such as cystic masses in the liver, the bile duct system or the pancreas, initially appear to be irrelevant in the diagnosis. For the liver we define the mostly clearly diagnosable simple cysts and hemangiomas as leave me alone lesions. Otherwise, we recommend a classification of incidentalomas into the three major categories (<0.5 cm, 0.5-1.5 cm and >1.5 cm) as well as an assessment with respect to clearly benign and suspect imaging characteristics in the context of a classification of patients into three different risk groups.

[Diagnostic Imaging of pancreatic carcinoma-Update of the new guideline]. / Diagnostik beim Pankreaskarzinom ­ Update in der neuen Leitlinie.

The new German S3 guidelines on ductal pancreatic adenocarcinoma were published for the first time on the homepage of the Association of the Scientific Medical Societies in Germany (AWMF) in December 2021 as a new update and thus the second update (first update 2013) and contain a large number of innovations in terms of diagnostics and treatment. The guidelines were organized and led by the German Society for Digestive and Metabolic Diseases (DGVS). In this article we would like to present the central content and innovations related to the radiological diagnostics of ductal pancreatic adenocarcinoma. The most important innovations are the highest recommendation strength in favor of computed tomography (CT) when assessing tumor spread as well as the adaptation of the European guidelines for cystic tumors by magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP) as the method of first choice. A further innovation is the implementation of a structured reporting of CT findings for describing the anatomical tumor resectability on the basis of the publication presented by the Abdominal Imaging Working Group and the Oncological Imaging Working Group of the German Radiological Society. There is no evidence for the implementation of radiological imaging in the field of aftercare or in the field of screening.

Icing the Pain-Ultrasound-Guided Cryoablation of Symptomatic Post-Amputation Stump Neuroma.

PURPOSE: To assess the feasibility and outcome of ultrasound-guided cryoablation in patients with a sensitized stump neuroma after limb amputation. MATERIAL AND METHODS: Seven patients (3 females, 4 males; mean age 42 years) were included in this retrospective study. Ultrasound-guided cryoablation of a previously identified painful stump neuroma was performed. Pain was assessed on the visual analogue scale (VAS) and compared before and after cryoablation (Wilcoxon Test). The degree of pain alleviation was correlated with patient age, duration of pain before ablation and time interval between amputation and ablation (Spearman correlation). A p-value less than 0.05 was deemed statistically significant. RESULTS: Nine cryoablations were performed for 8 neuromas. Technical success was 100%, there were no major complications. Mean follow-up was 27 months. There was a statistically significant decrease of pain from mean 8.3 / 10 (baseline) to 4 /10 (on day one), 2.1 / 10 (at one week) and 3 / 10 (at last follow-up) (p < 0.05). Patient satisfaction with cryoablation treatment was very high (median score 70 / 100). CONCLUSION: In our small population observational study, ultrasound-guided cryoablation of a sensitized stump neuroma was effective and safe for pain alleviation with very good long-term results. LEVEL OF EVIDENCE: Level 2, Observational study with dramatic effect.

Adrenal venous sampling in primary hyperaldosteronism: correlation of hormone indices and collimated C-arm CT findings.

PURPOSE: To evaluate the feasibility and effect of an approach to adrenal venous sampling (AVS) analysis by combining established selective cortisol and aldosterone indices with the acquisition of a collimated C-arm CT(CACTColl). METHODS: Overall, 107 consecutive patients (45f,62 m; 54 ± 10 years) undergoing 111 AVS procedures without hormonal stimulation from 7/13 to 2/20 in a single institution were retrospectively analysed. Hormone levels were measured in sequential samples of the suspected adrenal veins and right iliac vein, and selectivity indices (SI) computed. Stand-alone SICortisol and/or SIAldosterone ≥ 2.0 as well as SICortisol and/or SIAldosterone ≥ 1.1 combined with positive right-sided CACTColl of the adrenals (n = 80; opacified right adrenal vein) were defined as a successful AVS procedure. Radiation exposure of CACT was measured via dose area product (DAP) and weighed against an age-/weight-matched cohort (n = 66). RESULTS: Preliminary success rates (SICortisol and/or SIAldosterone ≥ 2.0) were 99.1% (left) and 72.1% (right). These could be significantly increased to a 90.1% success rate on the right, by combining an adjusted SI of 1.1 with a positive CACTColl proving the correct sampling position. Sensitivity for stand-alone collimated CACT (CACTColl) was 0.93, with 74/80 acquired CACTColl confirming selective cannulation by adrenal vein enhancement. Mean DAPColl_CACT measured 2414 ± 958 µGyxm2, while mean DAPFull-FOV_CACT in the matched cohort measured 8766 ± 1956 µGyxm2 (p < 0.001). CONCLUSION: Collimated CACT in AVS procedures is feasible and leads to a significant increase in success rates of (right-sided) selective cannulation and may in combination with adapted hormone indices, offer a successful alternative to previously published AVS analysis algorithms with lower radiation exposure compared to a full-FOV CACT.

Electromagnetic Navigation System-Guided Microwave Ablation of Hepatic Tumors: A Matched Cohort Study.

PURPOSE: To assess the accuracy and applicability of an electromagnetic navigation system (EMNS) for CT-guided microwave ablation (MWA) of hepatic tumors in comparison with conventional CT-guidance. MATERIALS AND METHODS: 34 patients (m = 20/f = 14, mean age 34 y) with 34 liver tumors (primary = 22, metastases = 14, mean size 20 mm) referred for CT-guided MWA were included in this IRB-approved study. Interventions were performed prospectively using an EMNS in 17 patients (navigation group), and results were compared to a matched historic cohort of 17 patients using conventional CT-guidance (control group, t-test, p < 0.05 deemed significant). Primary outcome measurement: accuracy of antenna placement (deviation). Secondary outcome measurements: setup time, number of control scans, duration and radiation exposure for antenna placement. RESULTS: Ablations were performed using a single or a double-angulated approach. Application of the EMNS was feasible in 14 cases (82%). Mean total deviation of the antenna feed point in the navigation and control group was 2.4 mm (range 0.2-4.8 mm) and 3.9 mm (range 0.4-7.8 mm), p < 0.05. Mean setup time for the EMNS was 6.75 ± 3.9 min (range 3-12 min). Mean number of control scans in the navigation and control group was 3 ± 0.9 (range 1-4) and 6 ± 1.3 (range 4-8), p < 0.0001; mean time for antenna placement was 9 ± 7.3 min (range 1.4-25.9 min) and 11.45 ± 6.1 min (range 3.9-27.4 min), p = 0.3164. Radiation exposure was significantly less in the navigation group. CONCLUSION: Our experience in a limited number of patients suggests that EMNS enables intuitive CT-guided MWA of liver tumors with higher accuracy when compared to ablations performed without navigation and with fewer control scans needed.

[State of the art in the diagnostics of hepatocellular carcinoma and current treatment options]. / State-of-the-art in der Diagnostik des hepatozellulären Karzinoms und aktuelle therapeutische Optionen.

Hepatocellular carcinoma (HCC) is the most frequent primary hepatic malignancy and arises most often based on liver cirrhosis. Of the HCC 80-85% demonstrate a typical contrast medium behavior in imaging, characterized by arterial hypervascularization followed by wash-out in the portal or late venous phase. This specific contrast behavior is diagnostic for HCC in patients at risk. The use of liver-specific contrast agents increases the sensitivity for diagnosis of HCC and can facilitate the differentiation from other liver lesions. At initial diagnosis approximately 50% of HCC are solitary, 40% multifocal and 10% diffuse. Depending on the tumor extent and stage, therapeutic options in patients with HCC include local treatment (resection, ablation, radiation, liver transplantation), locoregional measures (transarterial chemoembolization, selective internal radiotherapy) or systemic therapy (including immunotherapy), either as a stand-alone procedure or in various combinations.

[Severe epigastric pain in a 59-year-old patient]. / Massivste epigastrische Schmerzen bei einem 59-jährigen Patienten.

Abdominal pain is a frequent cause of consultation to doctors' offices and emergency rooms. The most common differential diagnoses can be confirmed with readily available, cost-effective, and low-risk diagnostic tools such as laboratory tests, ultrasound, or gastroscopy. Additional diagnostic tests are required to exclude rare causes such as small, solid, or hematological malignancies, metabolic disorders, or polyneuropathies of varying origin. In the following, we present the case of a patient with severe epigastric pain due to neuroborreliosis, and recapitulate the diagnostic steps for clarifying abdominal pain using this example.

[Computed tomography and/or magnetic resonance imaging of the liver : How, why, what for?] / Computertomographie und/oder Magnetresonanztomographie der Leber : Wie(so), weshalb, warum?

CLINICAL PROBLEM: Colorectal metastases are the most common malignant liver lesions. Imaging of the liver in patients with colorectal carcinoma is performed for early detection of liver metastases (CRLM) at the time of initial tumor diagnosis, for monitoring and follow-up in order to exclude or diagnose metachronous metastases. STANDARD RADIOLOGICAL METHODS: Radiological imaging includes primarily multislice computed tomography (CT) and magnetic resonance imaging (MRI), which play an important role regarding therapeutic management and assessment of prognosis. PERFORMANCE, ACHIEVEMENTS: Contrast-enhanced CT is broadly available and allows for rapid image acquisition including the possibility for complete tumor staging. MRI, on the other hand, is characterized by very good soft tissue contrast and has-especially with the use of diffusion-weighted imaging and administration of liver-specific contrast agents-the highest sensitivity for detection of metastases smaller than 1 cm. PRACTICAL RECOMMENDATIONS: The choice of imaging in daily routine is often dependent on availability and clinical question. Frequently, e.g. for assessment of resectability (extent of metastases, anatomic relation of lesions to critical structures), both modalities may be implemented in combination.

[Diseases and diagnosis of the biliary system : When does the gastroenterologist need the radiologist?] / Erkrankungen und Diagnostik der Gallenwege : Wann braucht der Gastroenterologe den Radiologen?

CLINICAL ISSUE: Biliary diseases require fast and rational use of diagnostic tests by both gastroenterologists and radiologists. STANDARD TREATMENT: Standard diagnostic workup includes transabdominal ultrasound, endoscopic retrograde cholangiography (ERC), endoscopic ultrasound, direct cholangioscopy, magnetic resonance cholangiopancreatography (MRI/MRCP), and computed tomography (CT). TREATMENT INNOVATIONS: Modular cholangioscopy is a novel diagnostic method. DIAGNOSTIC WORK-UP: The goal of diagnostic examinations is the determination of the location of obstructions and differentiation of benign from malignant lesions. ACHIEVEMENTS: Transabdominal ultrasound is risk-free and can show the gallbladder in great detail providing high diagnostic accuracy in most conditions. Endoscopic ultrasound, ERC and/or cholangioscopy are powerful tools to investigate the large bile ducts but are associated with inherent procedural risks. PRACTICAL RECOMMENDATIONS: Gall bladder diseases can often be diagnosed with transabdominal ultrasound alone. Bile duct disease often requires the use of endoscopic ultrasound, ERC and/or cholangioscopy.

Modified ante situm liver resection without use of cold perfusion nor veno-venous bypass for treatment of hepatic lesions infiltrating the hepatocaval confluence.

PURPOSE: Treatment of malignancies invading the hepatic veins/inferior vena cava is a surgical challenge. An ante situm technique allows luxation of the liver in front of the situs to perform tumor resection. Usually, cold perfusion and veno-venous bypass are applied. Our experience with modified ante situm resection relying only on total vascular occlusion is reported. METHODS: Retrospective analysis on an almost 15-year experience with ante situm resection without application of cold perfusion or veno-venous bypass RESULTS: The ante situm technique was applied on eight patients. Five individuals were treated due to intrahepatic cholangiocellular cancer and one case each for mixed cholangio-/hepatocellular carcinoma, colorectal liver metastasis, and pheochromocytoma. Trisectorectomy (n = 4), left hemihepatectomy, right hepatectomy, atypical resection, or mesohepatectomy (each n = 1) were performed, combined with dissection of suprahepatic/retrohepatic vena cava/hepatic veins. Venous reconstruction was achieved by reimplantation of hepatic veins with/without vascular replacement using allogeneic donor veins or PTFE grafts. Median total vascular occlusion of the liver was 23 min. Severe morbidity occurred in three patients (Dindo-Clavien > 3A). R0 status was achieved in six cases with a median overall survival of 33.5 months. CONCLUSIONS: Ante situm liver resection can be applied without cold perfusion nor veno-venous bypass with acceptable morbidity and mortality. However, this procedure remains challenging even for the experienced hepato-pancreato-biliary surgeon.

Use of the liver maximum function capacity test (LiMAx) for the management of liver resection in cirrhosis - A case of hypopharyngeal cancer liver metastasis.

INTRODUCTION: The presence of liver cirrhosis goes along with a higher chance for the need of liver resection. As established laboratory parameters often underestimate the degree of cirrhosis this is associated with an increased risk for postoperative liver failure due to the preoperatively impaired liver function. Known liver function tests are unlikely to be performed in daily use because of high cost or expenditure of time. Liver maximum function capacity test (LiMAx) provides a novel tool for measurement of liver function and references for the safety of liver resection. PRESENTATION OF CASE: A 63-year old patient presented at our hospital with a large, solitary liver metastasis from hypopharyngeal cancer in segments VII/VIII with infiltration of the diaphragm. Liver resection was unsuccessful in a peripheral hospital 10 months before due to considerable macroscopic liver cirrhosis (CHILD B). Upon presentation conventional laboratory parameters revealed sufficient liver function. LiMAx was performed and showed regular liver function (354µg/kg/h; at norm >315µg/kg/h). Consequently, atypical liver resection (R0) was performed resulting in a postoperative LiMAx value of 281µg/h/kg (>150µg/kg/h). The patient was discharged from hospital 37days after surgery without any signs of postoperative liver failure. CONCLUSION: The LiMAx-test enables determination of liver function at a so far unavailable level (metabolism via cytochrome P450 1A2) and hence might provide crucial additional diagnostic information to allow for safe liver resection even in cirrhotic patients.

Thermoablation of Bone Tumors.

UNLABELLED: The aim of this article is to review the significance of percutaneous thermal ablation in the treatment of bone tumors. We describe available ablation techniques as well as advantages and disadvantages in specific settings. In detail, radiofrequency ablation (RFA), microwave ablation (MWA), laser ablation, high intensity focused ultrasound (HIFU) and cryoablation are presented. In the second part of this review curative and palliative indications for the treatment of benign and malignant bone tumors are discussed. This includes especially RFA, laser or cryoablation for the treatment of osteoid osteoma, as well as the palliative treatment of painful bone metastases, for example, by means of MWA or MR-guided HIFU. KEY POINTS: • The various thermoablative techniques demonstrate specific advantages and disadvantages.• Radiofrequency ablation is the evidence-based method of choice for treating osteoid osteoma.• Laser ablation is primarily suited for the treatment of small lesions of the hands and feet.• The intrinsically analgesic effect of cryoablation is advantageous when treating painful lesions.• Palliative treatment of painful bone metastases can for example be performed using MWA or MR-guided HIFU, by itself or combined with cementoplasty. Citation Format: • Ringe KI, Panzica M, von Falck C. Thermoablation of Bone Tumors. Fortschr Röntgenstr 2016; 188: 539 - 550.

Intraoperative Conversion to ALPPS in a Case of Intrahepatic Cholangiocarcinoma.

Background. Surgical resection remains the best treatment option for intrahepatic cholangiocarcinoma (ICC). Two-stage liver resection combining in situ liver transection with portal vein ligation (ALPPS) has been described as a promising method to increase the resectability of liver tumors also in the case of ICC. Presentation of Case. A 46-year-old male patient presented with an ICC-typical lesion in the right liver. The indication for primary liver resection was set and planed as a right hepatectomy. In contrast to the preoperative CT-scan, the known lesion showed further progression in a macroscopically steatotic liver. Therefore, the decision was made to perform an ALPPS-procedure to avoid an insufficient future liver remnant (FLR). The patient showed an uneventful postoperative course after the first and second step of the ALPPS-procedure, with sufficient increase of the FLR. Unfortunately, already 2.5 months after resection the patient had developed new tumor lesions found by the follow-up CT-scan. Discussion. The presented case demonstrates that an intraoperative conversion to an ALPPS-procedure is safely applicable when the FLR surprisingly seems to be insufficient. Conclusion. ALPPS should also be considered a treatment option in well-selected patients with ICC. However, the experience concerning the outcome of ALPPS in case of ICC remains fairly small.

A case of successful renal transplantation for hydatid disease after surgical treatment of disseminated cysts.

Hydatid disease is a systemic disorder affecting especially the liver and lungs. Although it is not endemic in Europe, it can be seen sporadically, particularly because of travel and immigration. Severe, multiple organ involvement is quite rare. A 39-year-old Kurdish male patient presented with the previous diagnosis of hydatid disease and disseminated cysts in the liver, lung, and left kidney, leading to renal failure and the need for hemodialysis. Following multiple operations, complete eradication of infectious cysts was achieved, and kidney transplantation was performed. After 4 years of follow-up, the patient is in good condition, especially with normal renal function and no sign of recurrent hydatid disease.

Long-lasting tumour response to sorafenib therapy in advanced hepatocellular carcinoma.

The multi-kinase inhibitor sorafenib still remains the only approved agent for advanced HCC. Its benefits typically involve disease stabilisation, whereas an induction of response is rare. We report a series of five cases with extraordinary response to sorafenib. For two patients complete response to sorafenib was reported with a recurrence-free survival of 51 and 21 months. In another HCC patient pretreated with transarterial chemoembolisation (TACE) sorafenib treatment resulted in a complete response with no evidence of disease 18 months after first diagnosis. In patient 4 with unresectable HCC and sorafenib therapy secondary resectability and subsequent liver transplantation was achieved. Patient 5 had stabilised disease for 48 months after TACE and sorafenib treatment. Sorafenib may be very potent in individual patients. Excellent interdisciplinary strategies are required to achieve best results. There is an urgent need of predictive biomarkers to identify HCC patients that will benefit the most.

Liver remnant hypertrophy induction--how often do we really use it in the time of computer assisted surgery?

PURPOSE: To evaluate the significance of the hypertrophy concept in patients requiring extended liver resections for colorectal metastasis in the time of computer assisted surgery. METHODS: Retrospective analysis of patient collective undergoing major liver surgery. 2D CT, 3D CAS with Fraunhofer MeVis Sofware. Portal vein embolisation (PVE) with the Amplazer Plug, portal vein ligation (PVL) as 1. Stage operative procedure. RESULTS: 2D CT data identified 29 patients out of 319 (2002-2009) to be at risk for liver failure after resection. After 3D CAS analysis and virtual operation planning, only 7/29 were at true risk and were submitted to portal vein occlusion (PVO). Another 5 patients were submitted to the hypertrophy concept for intraoperative finding of insufficient parenchyma quality. In total, 12 patients underwent PVO (6 PVE/6 PVL). 9/12 patients went to stage 2 and were successfully operated. There was no difference in future remnant liver volume (FRLV) gain or waiting time to step 2 between the groups, though survival was better in the PVE group. CONCLUSION: PVO is an effective approach if the patient's future remnant liver (FRL) is too small on 2D CT volumetry. 3D CAS has great impact on the analysis of FRL capacity and in augmenting resectability - in our experience only patients with insufficient FRLV on the virtual resection plan have to take the risk of PVO to maintain the chance of liver resection.