Post-interventional infectious complications in percutaneous transabdominal lymphatic interventions: an observational study.

The purpose of this retrospective study was to evaluate the occurrence of infectious complications and inflammatory reactions after transabdominal lymphatic-interventions. 63 lymphatic-interventions were performed in 60 patients (male/female: 35/25; mean age 56 [9-85] years) [chylothorax n = 48, chylous ascites n = 7, combined chylothorax/chylous ascites n = 5]. Post-interventional clinical course and laboratory findings were analyzed in the whole cohort as well as subgroups without (group A; n = 35) and with peri-interventional antibiotics (group B; n = 25) (pneumonia n = 16, drainage-catheter inflammation n = 5, colitis n = 1, cystitis n = 1, transcolonic-access n = 2). No septic complications associated with the intervention occurred. Leucocytes increased significantly, peaking on post-interventional day-1 (8.6 ± 3.9 × 106 cells/mL vs. 9.8 ± 4.7 × 106 cells/mL; p = 0.009) and decreased thereafter (day-10: 7.3 ± 2.7 × 106 cells/mL, p = 0.005). CRP-values were pathological in 89.5% of patients already at baseline (40.1 ± 63.9 mg/L) and increased significant on day-3 (77.0 ± 78.8 mg/L, p < 0.001). Values decreased thereafter (day-15: 25.3 ± 34.4 mg/L, p = 0.04). In subgroup B, 13/25 patients had febrile episodes post-interventionally (pneumonia n = 11, cystitis n = 1, drainage-catheter inflammation n = 1). One patient developed biliary peritonitis despite continued antibiotics and underwent cholecystectomy. Baseline leucocytes and CRP-levels were higher in group B than A, but with comparable post-interventional profiles. Clinically relevant infectious complications associated with transabdominal lymphatic-interventions are rare irrespective of peri-interventional antibiotic use. Post-interventional elevation of leucocytes and CRP are observed with normalization over 10-15 days.

Long-Term Clinical Outcome of Abdomino-Thoracic Lymphatic Interventions of Traumatic and Non-Traumatic Lymphatic Leakage in Adults.

The aim of this study was to retrospectively evaluate the long-term results of lymphatic interventions in adults with abdomino-thoracic lymphatic pathologies. Management of abdomino-thoracic chylous effusions in adults undergoing X-ray-lymphangiography with or without lymph-vessel embolization (LVE) from 2010-2018 was reviewed. Patients underwent lymphangiography alone when imaging showed normal findings or lymphatic obstruction without leakage or reflux; otherwise, LVE was performed (leakage, reflux, obstruction with leakage or reflux, lymphatic masses). Technical and clinical success, complications, and long-term outcomes were assessed. 78 patients (47 male, median age 56.3 years) were treated for chylous effusions (60.3% traumatic, 39.7% non-traumatic). Lymphangiography showed leakage (48.7%), reflux (14.1%), obstruction (28.2%), lymphatic masses (5.1%), and normal findings (3.8%). Embolization was performed in 49/78 (62.8%) cases. Overall, treatment was clinically successful in 74.4% (mean follow-up of 28 months), with significant differences between LVE and lymphangiography (91.8% vs. 44.8%; p < 0.001), traumatic and non-traumatic etiologies (89.4% vs. 51.6%; p < 0.001), and leakage locations (p = 0.003). The clinical success of LVE did not differ between leakage etiologies or locations. Complications occurred in 5 patients (2/5 needed treatment). Patients survived significantly longer after successful treatment (2679 vs. 927 days; p = 0.044) and without malignancy (3214 vs. 1550 days; p = 0.043). Lymphatic interventions are safe and effective. LVE should be attempted whenever feasible, as success is high (>90%). Successful intervention has a positive effect on patient survival.

MR-lymphangiography identifies lymphatic pathologies in patients with idiopathic recurrent cervical swelling.

Background: Idiopathic recurrent cervical swelling may be caused by lymphatic abnormalities. Methods: Ten patients (9 females, mean age 51.2 ± 7) with idiopathic recurrent cervical swelling underwent MR-lymphangiography (MRL). MR-lymphangiograms were evaluated regarding lymphatic anatomy and flow. Individualized treatment was recommended according to MRL-findings. Results: 8/10 patients presented with left-sided, 2/10 with right-sided swelling. Pathological lymph-flow was identified in all cases: thoracic duct dilatation in patients with left-sided and right lymphatic duct dilatation in right-sided swelling, accessory thoracic lymphatics in 7/10 and reflux in 8/10 cases. In two cases, a lymphatic thrombus was identified.After treatment, symptoms resolved completely in 6/10 cases and partially in 1/10 cases. The remaining three patients have intermittent swellings but have no treatment wish. Conclusion: Idiopathic recurrent cervical swelling can be caused by lymphatic anomalies. MRL displays impaired lymphatic drainage, lymphatic vessel dilatation, and chylolymphatic reflux as hallmarks of this condition and may aid in targeted treatment planning.

Coherent Structural and Functional Network Changes after Thalamic Lesions in Essential Tremor.

BACKGROUND: Magnetic resonance-guided focused ultrasound of the ventral intermediate nucleus is a novel incisionless ablative treatment for essential tremor (ET). OBJECTIVE: The aim was to study the structural and functional network changes induced by unilateral sonication of the ventral intermediate nucleus in ET. METHODS: Fifteen essential tremor patients (66.2 ± 15.4 years) underwent probabilistic tractography and functional magnetic resonance imaging (MRI) during unilateral postural tremor-eliciting tasks using 3-T MRI before, 1 month (N = 15), and 6 months (N = 10) post unilateral sonication. RESULTS: Tractography identified tract-specific alterations within the dentato-thalamo-cortical tract (DTCT) affected by the unilateral lesion after sonication. Relative to the treated hand, task-evoked activation was significantly reduced in contralateral primary sensorimotor cortex and ipsilateral cerebellar lobules IV/V and VI, and vermis. Dynamic causal modeling revealed a significant decrease in excitatory drive from the cerebellum to the contralateral sensorimotor cortex. CONCLUSIONS: Thalamic lesions induced by sonication induce specific functional network changes within the DTCT, notably reducing excitatory input to ipsilateral sensorimotor cortex in ET. ©[2022] International Parkinson and Movement Disorder Society. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Improving quality of life in pancreatic cancer patients following high-intensity focused ultrasound (HIFU) in two European centers.

OBJECTIVES: Pancreatic cancer patients often have a high symptom burden, significantly impairing patients' quality of life (QOL). Nevertheless, there are hardly any reports on the impact of high-intensity focused ultrasound (HIFU) on the QOL of treated patients. For the first time, this study evaluated the effect of HIFU on QOL and compared these results in two European centers. METHODS: Eighty patients with advanced pancreatic cancer underwent HIFU (50 in Germany, 30 in Bulgaria). Clinical assessment included evaluation of QOL and symptoms using the EORTC QLQ-C30 questionnaire at baseline and 1, 3, and 6 months after HIFU. Pain intensity was additionally evaluated with the numerical rating score (NRS). RESULTS: Compared to baseline, global health significantly improved 3 and 6 months after HIFU treatment (p = 0.02). Functional subscales including physical, emotional, and social functioning were considerably improved at 6 months (p = 0.02, p = 0.01, and p = 0.01, respectively) as were leading symptom pain (p = 0.04 at 6 months), fatigue (p = 0.03 at 3 and p = 0.01 at 6 months), and appetite loss (p = 0.01 at 6 months). Moreover, pain intensity measured by NRS revealed effective and strong pain relief at all time points (p < 0.001). Reported effects were independent of tumor stage, metastatic status, and country of treatment. CONCLUSIONS: This study showed that HIFU represents an effective treatment option of advanced pancreatic cancer improving QOL by increasing global health and mitigation of physical complaints with a low rate of side effects, independent of the examiner. Therefore, HIFU is a worthwhile additional treatment besides systemic palliative chemotherapy or best supportive care in management of this aggressive disease. KEY POINTS: • In a prospective two-center study, it was shown that HIFU represents an effective treatment option of advanced pancreatic cancer improving QOL. • HIFU in pancreatic cancer patients is associated with a low rate of side effects, independent of the performer. • HIFU is a worthwhile additional treatment besides systemic palliative chemotherapy or best supportive care in management of this aggressive disease.

Myocardial Mapping in Systemic Sarcoidosis: A Comparison of Two Measurement Approaches.

PURPOSE: To investigate if T1 and T2 mapping is able to differentiate between diseased and healthy myocardium in patients with systemic sarcoidosis, and to compare the standard mapping measurement (measurement within the whole myocardium of the midventricular short axis slice, SAX) to a more standardized method measuring relaxation times within the midventricular septum (ConSept). MATERIALS AND METHODS: 24 patients with biopsy-proven extracardiac sarcoidosis and 17 healthy control subjects were prospectively enrolled in this study and underwent CMR imaging at 1.5 T including native T1 and T2 mapping. Patients were divided into patients with (LGE+) and without (LGE-) cardiac sarcoidosis. T1 and T2 relaxation times were compared between patients and controls. Furthermore, the SAX and the ConSept approach were compared regarding differentiation between healthy and diseased myocardium. RESULTS: T1 and T2 relaxation times were significantly longer in all patients compared with controls using both the SAX and the ConSept approach (p < 0.05). However, LGE+ and LGE- patients showed no significant differences in T1 and T2 relaxation times regardless of the measurement approach used (ConSept/SAX) (p > 0.05). Direct comparison of ConSept and SAX T1 mapping showed high conformity in the discrimination between healthy and diseased myocardium (Kappa = 0.844). CONCLUSION: T1 and T2 mapping may not only enable noninvasive recognition of cardiac involvement in patients with systemic sarcoidosis but may also serve as a marker for early cardiac involvement of the disease allowing for timely treatment. ConSept T1 mapping represents an equivalent method for tissue characterization in this population compared to the SAX approach. Further studies including follow-up examinations are necessary to confirm these preliminary results. KEY POINTS: · Mapping may enable noninvasive recognition of cardiac involvement in patients with systemic sarcoidosis. · Mapping may serve as a marker for early cardiac involvement in patients with systemic sarcoidosis. · The ConSept approach can be used as an alternative measuring method in sarcoidosis patients. CITATION FORMAT: · Dabir D, Luetkens J, Kuetting D et al. Myocardial Mapping in Systemic Sarcoidosis: A Comparison of Two Measurement Approaches. Fortschr Röntgenstr 2021; 193: 68 - 76.

MRI follow-up after magnetic resonance-guided focused ultrasound for non-invasive thalamotomy: the neuroradiologist's perspective.

PURPOSE: Magnetic resonance-guided focused ultrasound (MRgFUS) systems are increasingly used to non-invasively treat tremor; consensus on imaging follow-up is poor in these patients. This study aims to elucidate how MRgFUS lesions evolve for a radiological readership with regard to clinical outcome. METHODS: MRgFUS-induced lesions and oedema were retrospectively evaluated based on DWI, SWI, T2-weighted and T1-weighted 3-T MRI data acquired 30 min and 3, 30 and 180 days after MRgFUS (n = 9 essential tremor, n = 1 Parkinson's patients). Lesions were assessed volumetrically, visually and by ADC measurements and compared with clinical effects using non-parametric testing. RESULTS: Thirty minutes after treatment, all lesions could be identified on T2-weighted images. Immediate oedema was rare (n = 1). Lesion volume as well as oedema reached a maximum on day 3 with a mean lesion size of 0.4 ± 0.2 cm3 and an oedema volume 3.7 ± 1.2 times the lesion volume. On day 3, a distinct diffusion-restricted rim was noted that corresponded well with SWI. Lesion shrinkage after day 3 was observed in all sequences. Lesions were no longer detectable on DWI in n = 7/10, on T2-weighted images in n = 4/10 and on T1-weighted images in n = 4/10 on day 180. No infarcts or haemorrhage were observed. There was no correlation between lesion size and initial motor skill improvement (p = 0.99). Tremor reduction dynamics correlated strongly with lesion shrinkage between days 3 and 180 (p = 0.01, R = 0.76). CONCLUSION: In conclusion, cerebral MRgFUS lesions variably shrink over months. SWI is the sequence of choice to identify lesions after 6 months. Lesion volume is arguably associated with intermediate-term outcome.

The Entorhinal Cortex Atrophy Score Is Diagnostic and Prognostic in Mild Cognitive Impairment.

BACKGROUND: Structural magnetic resonance imaging (MRI) is routinely performed in patients with mild cognitive impairment (MCI), but diagnostic accuracy to detect early cerebral atrophy is limited. OBJECTIVE: To validate the visual entorhinal cortex atrophy (ERICA) rating scale regarding diagnosis, biomarker status, neuropsychological profile, and dementia risk in MCI. METHODS: The ERICA score was retrospectively assessed regarding its discrimination of MCI (n = 80) from subjective cognitive decline and Alzheimer's disease (AD) dementia (n = 60, respectively), its prediction of conversion to dementia (median follow-up 28 months) and amyloid/tau biomarker status, and its association with neuropsychological tests. RESULTS: The ERICA score achieved 97% positive predictive value (PPV) for the presence of MCI. Discrimination between MCI and AD dementia (area under the curve: 0.71) was comparable to volumetry, and superior to the medial temporal lobe atrophy (MTA) score (p = 0.006). The PPV of the ERICA score for conversion to dementia was 83%, equivalent to tau status. It achieved 90% PPV for conversion when combined with tau, and 100% negative predictive value with verbal recall. While no measure predicted the predominantly positive amyloid status, the ERICA score was at least comparable to volumetry, and superior to the MTA score in predicting tau positivity (92% PPV for phospho-tau). The ERICA score was associated with verbal learning and memory, and, unlike the MTA score, also with AD-specific deficits in cued verbal recall. CONCLUSION: The ERICA score is a simple and valuable tool to exploit structural MRI for diagnosis and prognosis in MCI and is non-inferior to volumetry.

Contrast-enhanced Interstitial Transpedal MR Lymphangiography for Thoracic Chylous Effusions.

Background Abnormalities of the central lymphatic system (CLS) are increasingly treated by interventional radiology approaches. Planning of these procedures, however, is challenging because of the lack of clinical imaging tools. Purpose To evaluate the clinical usefulness of contrast agent-enhanced interstitial transpedal MR lymphangiography in the preinterventional workup of lymphatic interventions in patients with thoracic chylous effusions. Materials and Methods Patients with chylous effusions evaluated from January 2014 and December 2017 were included in this retrospective analysis of transpedal MR lymphangiography. Indications were chylothorax (n = 19; 76%), cervical lymphatic fistula (n = 2; 8%), and combined chylothorax and chylous ascites (n = 4; 16%). Patients underwent transpedal MR lymphangiography at 1.5 T with T1-weighted imaging after interstitial pedal of gadolinium-based contrast medium under local anesthesia. Contrast-enhanced MRI was evaluated for technical success, depiction of pathologic abnormalities of the CLS, and access site for lymphatic interventions (ie, clinically useful examination). Reader agreement for image quality and overall degree of visualization was assessed with weighted κ. Interrelations between overall image quality and degree of visualization of CLS structures were assessed by Spearman ρ. Efficacy of transpedal MR lymphangiography was calculated by using radiographic lymphangiography as the reference standard. Results Twenty-five patients (mean age, 54 years ± 18 [standard deviation]; 13 men) were evaluated. Eight percent (two of 25) of examinations failed (lymphoma in one patient and technical failure in one patient). Contrast agent injection was well tolerated without complications. Interrater agreement of image quality was excellent (κ = 0.96). The degree of CLS visualization correlated with overall image quality (ρ = 0.71; P < .001). Retroperitoneal lymphatics, cisterna chyli, and thoracic duct were viewed with an accuracy of 23 of 25 (92%), 24 of 25 (96%), and 23 of 25 (92%), respectively. Anatomic variations, a lymphatic pathologic abnormality, and interventional access routes were identified with an accuracy of 22 of 25 (88%), 23 of 25 (92%), and 24 of 25 (96%), respectively. Overall, 23 of 25 (92%) transpedal MR lymphangiograms provided clinically useful information. Conclusion Transpedal interstitial MR lymphangiography was well tolerated by the patient and identified specific pathologic abnormalities causing thoracic chylous leakages before lymphatic intervention. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Maki and Itkin in this issue.

Acute radiation-induced skin toxicity in hypofractionated vs. conventional whole-breast irradiation: An objective, randomized multicenter assessment using spectrophotometry.

PURPOSE: Radiation dermatitis represents one of the most frequent side effects in breast cancer patients undergoing adjuvant whole-breast irradiation (WBI). Whether hypofractionated WBI induces comparable or less acute radiation-induced skin reactions than conventional WBI is still not fully clarified, as randomized evidence and objective assessments are limited. The aim of this study was to objectively determine frequency and severity of acute radiation-induced skin reactions during hypofractionated vs. conventionally fractionated adjuvant WBI. METHODS: In this randomized multicenter study, a total of 140 breast cancer patients underwent either hypofractionated or conventional WBI following breast-preserving surgery. Maximum radiation dermatitis severity was assessed at completion and during follow-up by physician-assessed CTCAE v4.03 and the patient-reported RISRAS scale. Additionally, photospectrometric skin readings were performed to objectify skin color differences between both treatment arms. RESULTS: Radiation dermatitis severity was significantly lower in patients receiving hypofractionation compared with conventional fractionation (mean 1.05 vs. 1.43, p = .024). Grade 0 radiation dermatitis occurred in 21.43% vs. 4.28%, grade ≥2 in 27.14% vs. 42.91% and grade ≥3 in 0% vs. 4.34% of patients following hypofractionated and conventional WBI, respectively. Objective photospectrometric measurements (n = 4200) showed both decreased erythema severity (p = .008) and hyperpigmentation (p = .002) in the hypofractionation arm. Patients allocated to hypofractionated WBI also reported less pain (p = .006), less hyperpigmentation (p = <0.001) and less limitations of day-to-day activities (p = <0.001). CONCLUSION: Physician and patient-assessed toxicity scorings as well as objective photospectrometric skin measurements revealed that hypofractionated WBI yielded lower rates and severity of acute radiation-induced skin toxicity.

CMR based measurement of aortic stiffness, epicardial fat, left ventricular myocardial strain and fibrosis in hypertensive patients.

INTRODUCTION: A combined assessment of different parameters of cardiovascular (CV) risk and prognosis can be supportive and performed with cardiac magnetic resonance (CMR). Aortic stiffness, epicardial fat volume (EFV), left ventricular (LV) strain and fibrosis were evaluated within a single CMR examination and results were related to the presence of hypertension (HTN) and diabetes mellitus (DM). METHODS: 20 healthy controls (57.2 ± 8.2 years(y); 26.2 ± 3.9 kg/m2), 31 hypertensive patients without DM (59.6 ± 6.7 y; 28.4 ± 4.7 kg/m2) and 12 hypertensive patients with DM (58.8 ± 9.9y; 30.7 ± 6.3 kg/m2) were examined at 1.5Tesla. Aortic stiffness was evaluated by calculation of aortic pulse wave velocity (PWV), EFV by a 3D-Dixon sequence. Longitudinal & circumferential systolic myocardial strain (LS; CS) were analyzed and T1-relaxation times (T1) were determined to detect myocardial fibrosis. RESULTS: EFV was highest in hypertensive patients with diabetes (78.4 ± 28.0 ml/m2) followed by only hypertensive patients (64.2 ± 27.3 ml/m2) and lowest in controls (50.3 ± 22.7 ml/m2; p < 0.05). PWV was higher in hypertensive patients with diabetes (9.8 ± 3.3 m/s) compared to only hypertensive patients (8.6 ± 1.7 m/s; p < 0.05) and to controls (8.1 ± 1.9 m/s; p < 0.05). LS&CS were worse in hypertensive patients with diabetes (LS:-20.9 ± 5.1% and CS: -24.4 ± 5.7%) compared to both only hypertensive patients (LS: -24.7 ± 4.6%; CS: -27.1 ± 5.0%; p < 0.05) and to controls (LS: -25.5 ± 3.8; CS: -28.3 ± 4.1%; p < 0.05). Both hypertensive groups with and without DM had higher T1́s (994.0 ± 43.2 ms; 991.6 ± 35.5 ms) than controls (964.6 ± 40.3 ms; p < 0.05). CONCLUSION: CMR revealed increased aortic stiffness and EFV in hypertensive patients, which were even higher in the presence of DM. Also signs of LV myocardial fibrosis and a reduced strain were revealed. These parameters support the assessment of CV risk and prognosis. They can accurately be measured with CMR within a single examination when normally different techniques are needed.

The impact of rheolytic percutaneous mechanical thrombectomy on glomerular filtration rate levels.

OBJECTIVE: Rheolytic percutaneous mechanical thrombectomy (PMT) has been established as an endovascular technique for thrombus removal. Initial studies reporting on postinterventional kidney dysfunction have surfaced. The aim of this study was to investigate glomerular filtration rate (GFR) changes after PMT. METHODS: A total of 45 interventions were included; 21 were performed in the venous system and 24 in the arterial system. Renal function was evaluated through assessment of GFR value changes from baseline to a minimum of two postinterventional values, and RIFLE criteria (Risk, Injury, Failure, Loss of kidney function, End-stage kidney disease) were applied. RESULTS: The univariate analysis of variance revealed a significant association of GFR increase between time points and the type of intervention (arterious or venous; P = .002), whereas there was no significant association of intervention duration (P = .382), quantity of administered contrast medium (P = .544), or use of urokinase (P = .377). Repeated measures analysis of variance revealed a significant difference in GFR values between the four time points for venous interventions (P = .008) but not for arterial interventions (P = .908). In venous interventions, postinterventional GFR values were significantly lower compared with preinterventional values (P = .008) and the two measurements after intervention (P = .017 and P = .014, respectively). According to the RIFLE criteria, 1 of the 21 patients in the venous group had a complete loss of kidney function and 2 patients progressed to the risk group (GFR decreases >25%). CONCLUSIONS: PMT in the venous system has a significant impact on GFR levels, although there is only a low risk for clinically important renal dysfunction. The occurrence of renal impairment should be taken into account in evaluating PMT treatment, especially because of the associated morbidity.

Total body irradiation: Significant dose sparing of lung tissue achievable by helical tomotherapy.

PURPOSE: Total body irradiation (TBI) is an important procedure in the conditioning for bone marrow and hematopoietic stem cell transplantation. Doses up to 12Gy are delivered in hyperfractionated regimes. TBI performed with helical Tomotherapy® (Accuray, Madison, Wisconsin, USA) is an alternative to conventional techniques to deliver dose in extended target volumes with the possibility of simultaneous dose sparing to organs at risk. In this study we focused on maximum dose reduction to the lungs in TBI using helical Tomotherapy®. MATERIAL AND METHODS: Forty treatment plans of patients who received TBI were calculated with TomoH® (Accuray, Madison, Wisconsin, USA, Version 2.0.4) with a dose of 12Gy delivered in six equal fractions (2×2Gy/day). Planning iterations necessary to accomplish ICRU 83 report should be less than 250. Treatment time should be practicable in daily routine (<60min.). Besides the usual contouring of organs at risk special contouring was required for optimization processes which focused on maximum dose sparing in the central lung tissue. Dose constraints (D2, D98, D99) were predefined for target volumes (i.e. PTV TBI D99: 90% of prescribed dose). Homogeneity index <0.15 was defined for acceptability of the treatment plan. RESULTS: For all patients acceptable treatment plan fulfilling the predefined constraints were achievable. An average time of 46min is required for treatment. Thirty-four of forty patients fulfilled D2 in the PTV TBI. Four patients failed D2 due to a high BMI >28 (maximum dose 13.76Gy=114.7%). The D98 in the PTV TBI was not reached by 2/40 patients due to BMI>31 (minimum dose 11.31Gy=dose coverage of 94.2%). Also these two patients failed the homogeneity index <0.15. The mean lung dose over all patients of the right lung was 7.18Gy (range 6.4-9.5Gy). The left lung showed a median (D50) dose of 7.9Gy (range 6.7-9.3Gy). Central lung dose showed a mean dose (D50) of 5.16Gy (range 4.02-7.29Gy). The D80 of the central lung showed an average dose of 3.87Gy. CONCLUSIONS: Total body irradiation using helical Tomotherapy® can be delivered with maximum lung tissue sparing (<6Gy) but without compromise in adjacent PTV TBI structures (i.e. ribs, heart). High conformity and homogeneity in extended radiation volumes can be reached with this technique in an acceptable planning and treatment time. Limitations may occurred in patients with high body mass index.

Where Have All the Punctures Gone? An Analysis of Thoracic Duct Embolizations.

PURPOSE: To determine how frequently and how severely intra-abdominal structures are affected by transabdominal thoracic duct embolization (TDE). MATERIALS AND METHODS: Thirty-five TDE procedures in 35 patients (22 male; mean age, 57 y; age range, 10-79 y) with therapy-refractory chylous effusions were evaluated in which radiopaque embolization material outlined the access route on postinterventional CT. CT data were analyzed by 2 TDE-experienced radiologists. Abdominal structures and organs transgressed by the access route were recorded, and findings were correlated with clinical postinterventional course with follow-up of at least 44 days. RESULTS: Intra-abdominal structures/organs transgressed most often by the access route were the liver (n = 28), crus of the diaphragm (n = 25), pancreas (n = 14), portal vein (n = 10), duodenum (n = 7), inferior vena cava (n = 5), colon (n = 3), left renal vein (n = 2), pleura (n = 2), pericardium (n = 2), and gastric sleeve (n = 2). Pancreatitis was observed in 1 of 14 patients after pancreatic transgression. One case of clinically occult pulmonary glue migration occurred on catheter pullback through the left renal vein. Biliary peritonitis was observed after gallbladder puncture, necessitating cholecystectomy in 1 of 2 transbiliary punctures. No other relevant procedure-related complications such as hemorrhages or infectious complications were observed. CONCLUSIONS: Despite transgression of intra-abdominal structures, puncture- and access-related complications of TDE are rare. Transpancreatic manipulations are reasonably well tolerated.

A matched-pair analysis on survival and response rates between German and non-German cancer patients treated at a Comprehensive Cancer Center.

BACKGROUND: Research shows disparities in cancer outcomes by ethnicity or socio-economic status. Therefore, it is the aim of our study to perform a matched-pair analysis which compares the outcome of German and non-German (in the following described as 'foreign') cancer patients being treated at the Center for Integrated Oncology (CIO) Köln Bonn at the University Hospital of Bonn between January 2010 and June 2016. METHODS: During this time, 6314 well-documented patients received a diagnosis of cancer. Out of these patients, 219 patients with foreign nationality could be matched to German patients based on diagnostic and demographic criteria and were included in the study. All of these 438 patients were well characterized concerning survival data (Overall survival, Progression-free survival and Time to progression) and response to treatment. RESULTS: No significant differences regarding the patients' survival and response rates were seen when all German and foreign patients were compared. A subgroup analysis of German and foreign patients with head and neck cancer revealed a significantly longer progression-free survival for the German patients. Differences in response to treatment could not be found in this subgroup analysis. CONCLUSIONS: In summary, no major differences in survival and response rates of German and foreign cancer patients were revealed in this study. Nevertheless, the differences in progression-free survival, which could be found in the subgroup analysis of patients with head and neck cancer, should lead to further research, especially evaluating the role of infectious diseases like human papillomavirus (HPV) and Epstein-Barr virus (EBV) on carcinogenesis and disease progression.

Multiparametric cardiovascular magnetic resonance imaging in acute myocarditis: a comparison of different measurement approaches.

BACKGROUND: Myocardial T1 and T2 mapping are reliable diagnostic markers for the detection and follow up of acute myocarditis. The aim of this study was to compare the diagnostic performance of current mapping measurement approaches to differentiate between myocarditis patients and healthy individuals. METHODS: Fifty patients with clinically defined acute myocarditis and 30 healthy controls underwent cardiovascular magnetic resonance (CMR). Myocardial T1 relaxation times, T2 relaxation times, left ventricular (LV) function, T2 ratio, early gadolinium enhancement ratio, and presence of late gadolinium enhancement (LGE) were analysed. Native T1 and T2 relaxation times, as well as extracellular volume fraction (ECV) were measured for the entire LV myocardium (global), within the midventricular short axis slice (mSAX), within the midventricular septal wall (ConSept), and within the remote myocardium (remote). Receiver operating characteristics analysis was performed to compare diagnostic performance. RESULTS: All measurement approaches revealed significantly higher native T1 and T2 relaxation times as well as ECV values in patients compared to healthy controls (p < 0.05 for all parameters). The global measurement approach showed highest diagnostic performance regarding all mapping parameters (AUCs, native T1: 0.903, T2: 0.847, ECV: 0.731). Direct comparison of the different measurement approaches revealed significant differences in diagnostic performance between the global and the remote approach regarding T1 relaxation times and ECV (p = 0.001 and p = 0.002 respectively). Further, the global measurement approach revealed significantly higher T1 relaxation times compared to the ConSept approach (AUCs: 0.903 vs. 0.783; p = 0.003) and nearly significant differences compared to the mSAX approach (AUC: 0.850; p = 0.051). T2 relaxation times showed no significant differences between all measurement approaches (p > 0.050 for all parameters). CONCLUSIONS: Native T1 and T2 mapping allow for accurate detection of acute myocarditis irrespective of the measurement approach used. Even measurements performed exclusively within remote myocardium allow for reliable detection of acute myocarditis, demonstrating diffuse involvement of disease despite a mostly regional or patchy distribution pattern of visible pathologies. The global measurement approach provides the overall best diagnostic performance in acute myocarditis for both T1 and T2 mapping.

Cardiac magnetic resonance including parametric mapping in acute Takotsubo syndrome: Preliminary findings.

INTRODUCTION: T1 and T2 mapping have been shown to be reliable markers of interstitial myocardial fibrosis, edema, and inflammation. The aim of this study was to evaluate myocardial involvement in acute phase Takotsubo syndrome using native and post-contrast T1 mapping, ECV fraction, and T2 mapping. MATERIAL AND METHODS: We investigated 14 patients with acute Takotsubo syndrome and 14 healthy controls. CMR included cine imaging, black-blood STIR imaging, early and late gadolinium enhancement imaging, native and post-contrast T1 mapping, and T2 mapping. Wall motion, T2 ratio, early gadolinium enhancement ratio, extracellular volume fraction, T1 and T2 relaxation times were analyzed. RESULTS: Patients had significantly impaired left ventricular function (46 ± 10%) and acute wall motion abnormalities compared with controls (62 ± 2%). Native T1 and T2 values, T2 ratio, and ECV fraction were significantly higher in patients compared with controls. In patients, native T1 and T2 values as well as T2 ratio were significantly higher in segments with abnormal wall motion compared with normokinetic segments. Native T1 values, T2 relaxation times, T2 ratio, and ECV fraction were significantly higher, post-contrast T1 relaxation times significantly lower in segments with abnormal wall motion compared with segments of controls; except for T2 ratio and post-contrast T1 relaxation times this also held true for patients' segments with normal wall motion. CONCLUSIONS: Native T1 and T2 mapping, as well as ECV fraction, discriminate between visually affected vs. unaffected segments in patients with acute Takotsubo syndrome and reveal significant T1 and T2 tissue changes even in visually unaffected segments. Thus, mapping may allow for better detection in convalescent stages of disease and additionally may have the potential to serve as a marker of disease progress. These preliminary findings warrant further investigation in a larger patient cohort.

Tomotherapy in malignant mesothelioma: a planning study to establish dose constraints.

PURPOSE: A planning study was performed for helical tomotherapy treatment. We evaluated the maximum achievable protection of organs at risk (OARs) in patients with malignant pleural mesothelioma after pleurectomy with simultaneous optimal target coverage. MATERIALS AND METHODS: The datasets of 13 patients were included. The applied dose to the planning target volume (PTV) was 50.4 Gy with single doses of 1.8 Gy per fraction. Presuming optimal target coverage, we evaluated the applied dose to the OARs with special regard to the contralateral lung. RESULTS: For left-(lsRT)/right(rsRT)-sided radiotherapy, target coverage for the PTV showed a D98 (mean) of 49.37/49.71 Gy (98.0%/98.6%) and a D2 (mean) of 54.19/54.61 Gy (107.5%/108.3%). The beam-on time was kept below 15 min. The achieved mean dose (D50) to the contralateral lung was kept below 4 Gy for lsRT and rsRT. With regard to the other organs at risk the applied doses were as follows: mean dose (lsRT): ipsilateral kidney (Dmean) 13.03 (5.32-22.18) Gy, contralateral kidney (Dmean) <2.0 Gy, heart (Dmean) 22.23 (13.57-27.72) Gy, spinal cord D1

Disentangling motor planning and motor execution in unmedicated de novo Parkinson's disease patients: An fMRI study.

Many studies have used functional magnetic resonance imaging to unravel the neuronal underpinnings of motor system abnormalities in Parkinson's disease, indicating functional inhibition at the level of basal ganglia-thalamo-cortical motor networks. The study aim was to extend the characterization of functional motor changes in Parkinson's Disease by dissociating between two phases of action (i.e. motor planning and motor execution) during an automated unilateral finger movement sequence with the left and right hand, separately. In essence, we wished to identify neuronal dysfunction and potential neuronal compensation before (planning) and during (execution) automated sequential motor behavior in unmedicated early stage Parkinson's Disease patients. Twenty-two Parkinson's Disease patients (14 males; 53 ±â€¯11 years; Hoehn and Yahr score 1.4 ±â€¯0.6; UPDRS (part 3) motor score 16 ±â€¯6) and 22 healthy controls (14 males; 49 ±â€¯12 years) performed a pre-learnt four finger sequence (index, ring, middle and little finger, in order), either self-initiated (FREE) or externally triggered (REACT), within an 8-second time window. Findings were most pronounced during FREE with the clinically most affected side, where motor execution revealed significant underactivity of contralateral primary motor cortex, contralateral posterior putamen (sensorimotor territory), ipsilateral anterior cerebellum / cerebellar vermis, along with underactivity in supplementary motor area (based on ROI analyses only), corroborating previous findings in Parkinson's Disease. During motor planning, Parkinson's Disease patients showed a significant relative overactivity in dorsolateral prefrontal cortex (DLPFC), suggesting a compensatory overactivity. To a variable extent this relative overactivity in the DLPFC went along with a relative overactivity in the precuneus and the ipsilateral anterior cerebellum/cerebellar vermis Our study illustrates that a refined view of disturbances in motor function and compensatory processes can be gained from experimental designs that try to dissociate motor planning from motor execution, emphasizing that compensatory mechanisms are triggered in Parkinson's Disease when voluntary movements are conceptualized for action.