Prognostic relevance of serial endoscopic ultrasound after chemoradiation in esophageal cancer.

The objective of this study is the feasibility of sequential endoscopic and endosonographic measurement of locoregional tumor load for the prediction of tumor recurrence in patients after neoadjuvant or definitive chemoradiotherapy, treated in curative intent for locally advanced esophageal carcinoma. In 67 patients with esophageal cancer, serial endoscopic ultrasound was performed before and after neoadjuvant (25) or definitive (42) chemoradiotherapy. Rate of complete endoscopic and endosonographic tumor response, reduction in tumor length or circumferential tumorous extension, maximal tumor thickness, lymph node size, and endosonographic uT- and uN-stage shift was measured. Results were correlated with tumor recurrence rate. After chemoradiotherapy, endosonography revealed a complete response of the primary tumor in 27 patients, and complete resolution of suspicious lymph nodes in 24 patients. According to uTN-stage, 43 patients showed a therapeutic response, with stage shift to a lower tumor stage. In patients with macroscopic residual disease, mean tumor thickness decreased from 13 to 9 mm, with nine patients presenting with a decrease of >50%. Mean tumor length decreased from 5.6 to 4.6 cm, with 10 patients showing a decrease of >50%. Mean lymph node size decreased from 14.5 to 12 mm, with four patients having a reduction in size of >50%. Tumor response was generally more pronounced after definitive than after neoadjuvant chemoradiotherapy. During follow-up, 33 patients developed a tumor recurrence. None of the endoscopic and endosonographic parameter analyzed was predictive for patient's prognosis, irrespective of the kind of chemoradiotherapy (neoadjuvant or definitive). Sequential measurement of locoregional tumor load with endoscopic ultrasound before and after chemoradiotherapy is not suitable for the prediction of tumor recurrence risk.

Improvement in advanced pancreatic cancer survival with novel chemotherapeutic strategies - experience of a community based hospital.

Background: New chemotherapeutic strategies for locally advanced or metastatic pancreatic ductal adenocarcinoma (PDAC) have been shown to improve survival in randomized clinical trials. Little is known about the use of such chemotherapies and their benefit in community-based hospitals. This retrospective study analyzes the overall survival of these patients under "real life conditions" before and after the introduction of FOLFIRINOX in 2011. Methods: We retrospectively identified consecutive patients with PDAC who were treated at our hospital from 2011 to June 2014 (2011+ cohort) and 2004 to 2010 (historical cohort). Patients were included if PDAC was diagnosed in a locally advanced or metastatic state and at least 1 cycle of chemotherapy was given. Survival was assessed until April 2016. Patients with FOLFIRINOX were further analyzed regarding drug administration and side effects. Results: 128 patients met the inclusion criteria. Of the 74 patients in the historical cohort, 62 patients received Gemcitabine. Of the 54 patients diagnosed between 2011 and June 2014, 28 patients received FOLFIRINOX and 22 Gemcitabine as the first-line chemotherapy. Only 34 % of the patients in the historical cohort received a second-line chemotherapy in comparison to 69 % in the 2011+ cohort. Median overall survival (OS) showed a survival of 13.1 months (95 % CI; 11.6 - 14.5) for the 2011+ cohort compared to 9.6 months (95 % CI; 6.1 - 13.1) in the historical group. Conclusion: This study shows a marked improvement in survival of patients diagnosed with locally advanced or metastatic PDAC in a community-based hospital during the past 4 years. The most likely reasons are the use of new polychemotherapies like FOLFIRINOX and the use of second-line chemotherapy.

Ultrasound in radioembolization induced liver disease (REILD).

BACKGROUND: REILD (radioembolization-induced liver disease) is a rare complication after SIRT (selective internal radiotherapy) of the liver. The diagnosis is based on a combination of clinical signs and symptoms, laboratory values, and MRT findings. Data about sonographic signs associated with REILD are lacking. In this report, we describe sonographic changes in two female patients with REILD. CASE REPORTS: Patient 1: a 34-year-old woman with colorectal carcinoma liver metastasis. Two weeks after SIRT, the patient developed histology-proven REILD. Abdominal ultrasound revealed pronounced hepatomegaly, with inhomogeneous, slightly hyperechoic parenchyma without attenuation. The well-known metastasis could not be delineated easily. Liver veins were compressed, with ill defined borders, and flattened biphasic blood flow in duplex sonography. Signs of portal hypertension with ascites, and splenomegaly were present. A therapy with diuretics, heparin, steroids, and ursodesoxycholic acid was introduced, and the patient recovered. After seven weeks, the ascites had resolved, and the liver parenchyma returned to normal echogenicity. Furthermore, the metastases in both lobes were clearly visible again. The liver veins were well delineated, normal sized, with regular triphasic blood flow in duplex sonography, but splenomegaly persisted. Patient 2: a 58-year-old women with recurrent multifocal peripheral cholangiocarcioma. Abdominal ultrasound 5 weeks after SIRT revealed a slightly increased echogenicity of the liver. Liver veins showed slightly irregular borders with biphasic flow pattern. In contrast to patient no.1, liver metastases could still be delineated easily. Ascites or splenomegaly were not present. Laboratory parameters and MRT findings were consistent with a diagnosis of mild REILD. Liver biopsy was not performed. No specific therapy was introduced. Five weeks later, the liver parenchyma became more homogeneous again, and the liver veins normalized with smooth vessel borders, but still flattened biphasic flow pattern. CONCLUSION: Transient hepatomegaly, with inhomogeneous hyperechoic parenchyma without attenuation, and compressed, ill delineated liver veins, with monophasic or flattened biphasic blood flow, are typical sonographic findings in REILD. In addition, common signs of portal hypertension can be present. Liver alterations and ascites resolve parallel with clinical improvement. Splenomegaly can persist.

Incidence of bleeding in 8172 percutaneous ultrasound-guided intraabdominal diagnostic and therapeutic interventions - results of the prospective multicenter DEGUM interventional ultrasound study (PIUS study).

PURPOSE: To analyse the incidence of bleeding after percutaneous ultrasound guided diagnostic and therapeutic intraabdominal interventions in a prospective multicentre study (DEGUM percutaneous interventional ultrasound study). MATERIALS AND METHODS: Within a time period of 2 years diagnostic and therapeutic intraabdominal interventions (with the exclusion of ascites paracentesis) performed percutaneously under continuous ultrasound (US) guidance were prospectively assessed using a pseudonymized standardized web site entry form. Number and type of intervention, operator experience, patient characteristics, medication, lab data as well as technical aspects of the procedure and bleeding complications were analysed according to the interventional radiology standards. RESULTS: 8172 US-guided intraabdominal interventions (liver n = 5903; pancreas n = 501, kidney n = 434, lymph node = 272, biliary system n = 153, spleen n = 63, other abdominal organs and extra-organic targets n = 999) were analysed in 30 hospitals. The majority were diagnostic biopsies including 1780 liver parenchyma, 3400 focal liver lesions and 404 pancreatic lesions. 7525 interventions (92.1 %) were performed in hospitalized patients (mean age 62.6 years). Most operators were highly experienced in US-guided interventions (> 500 interventions prior to the study n = 5729; 70.1 %). Sedation was administered in 1131 patients (13.8 %). Needle diameter was ≥ 1 mm in 7162 punctures (87.9 %) with main focus on core needle biopsies (18 G, n = 4185). Clinically relevant bleeding complications with need of transfusion (0.4 %), surgical bleeding control (0.1 %) and radiological coiling (0.05 %) were very rare. Bleeding complications with fatal outcome occurred in four patients (0.05 %). The frequency of major bleeding complications was significantly higher in patients with an INR > 1.5 (p < 0.001) and patients taking a medication potentially interfering with platelet function or plasmatic coagulation (p < 0.0333). CONCLUSION: This prospective multicentre study confirms the broad spectrum of percutaneous US-guided intraabdominal interventions. However diagnostic liver biopsies dominate with the use of core needle biopsies (18 G). Percutaneous US-guided interventions performed by experienced sonographers are associated with a low bleeding risk. Major bleeding complications are very rare. A pre-interventional INR < 1.5 and individual medication risk assessment are recommended.

Mediastinitis after EUS-FNA in a patient with sarcoidosis - case report with endosonographic features and review of the literature.

BACKGROUND: EUS-FNA of lymph nodes is believed to harbour no risk of serious complications. However, recently, a case series of mediastinal abscess formation after EUS-FNA in patients with sarcoidosis has been published. Here, we describe a patient with sarcoidosis and mediastinitis after EUS-FNA. CASE REPORT: Two years before EUS-FNA, the patient with a history of sarcoidosis, was operated because of esophageal adenocarcinoma. Due to progredient mediastinal lymphoma, we performed EUS-FNA to exclude tumor recurrence. 30 hours later, the patient developed general weakness, musculoskeletal pain, non-productive cough, and mild dysphagia. Ten days later, the patient was admitted with fever and thrombocytopenia. A CT scan showed a mediastinal mass without liquid areas, but small deposits of air. Meropenem, steroid, and low-dose heparin were started. The fever resolved after 24 hours, CRP, as well as coagulatory parameters returned to normal levels after 5 days. Endoscopic ultrasound revealed an inhomogeneous, slightly hyperechoic, mediastinal mass. The lymph nodes were partly dislodged, and partly embedded into this mass with a rounded shape and large hyperechoic center. Vascularization was not increased, liquid areas, or inclusions of gas were not present. A follow-up examination 6 weeks later revealed complete resolution of the mass. CONCLUSION: EUS-FNA, but not EBUS-FNA, seems to be associated with an increased infectious risk in patients with sarcoidosis. Endosonographic features include inhomogeneous, mass-forming mediastinal infiltration, and swelling of lymph nodes with hyperechoic central parts. In cases of suspected sarcoidosis, EBUS-FNA should be preferred. EUS-FNA, probably with antibiotic prophylaxis, should only be done after a non-diagnostic bronchoscopic work-up.

[Validity of endoscopic ultrasonography-guided fine needle aspiration of mediastinal and abdominal lymph nodes in daily clinical practice]. / Endosonographisch gesteuerte Feinnadelpunktion bei mediastinalen und abdominellen Lymphknotenvergrößerungen.

BACKGROUND: According to recent clinical trials, EUS-FNA has a high diagnostic yield in case of mediastinal and abdominal lymphadenopathy. However, it is questionable, if the results of centers of excellence can be maintained in daily clinical practice. METHODS: We retrospectively analyzed the results of 141 EUS-FNP in 121 patients (female 25, male 86; mean age 61,5 years, range 22-87) of 119 mediastinal and 22 abdominal lymph nodes, performed under routine conditions in daily clinical practice in a community hospital. Histopathological examination of operative specimens or clinical follow-up served as gold standard. RESULTS: In 124/141 (80 %) of cases, adequate specimens could be obtained, irrespective of lymph node size. During follow-up, the rate of adequate specimens obtained increased from 77 % (2002-2006) to 98 % (2007-2010). Sensitivity and specifity for the diagnosis of malignancy was 77 and 100 % (diagnostic accuracy 92 %). During follow-up, a relevant learning curve could be observed with a significant increase in sensitivity (72 to 80 %). CONCLUSION: In comparison to the results of centers of excellence, our diagnostic accuracy is slightly inferior. However, even in daily routine praxis, EUS-FNP is a safe and accurate method of sampling mediastinal and abdominal lymph nodes.

Contrast-enhanced ultrasound (CEUS) for differentiating between hepatocellular and cholangiocellular carcinoma.

PURPOSE: HCC and CC are the most common primary malignancies of the liver. There is only minimal evidence as to whether these two entities can be reliably differentiated by contrast-enhanced ultrasound. MATERIALS AND METHODS: We retrospectively analyzed the CEUS pattern of 39 patients with HCC, 11 patients with intrahepatic cholangiocarcinoma (ICC), 3 patients with Klatskin tumor, and 4 patients with gallbladder carcinoma. CEUS was performed using a standardized protocol (low MI, SonoVue®) with documentation of the arterial, portal-venous, and late phase. Besides the contrast enhancement compared to the adjacent normal liver tissue in every phase, the specific contrast pattern during the arterial phase (complete filling, incomplete filling of different grade, rim sign) was analyzed. RESULTS: Most HCC and ICC showed hyperenhancement during the arterial phase, with hypoenhancement or isoenhancement in the portal-venous and late phase. Hyperenhancement during the portal-venous phase was only observed in some cases of HCC, but not in ICC. In the case of arterial hyperenhancement, HCC showed complete filling more often than ICC. In the case of incomplete filling, the area of contrast-enhanced tumor in most HCCs was larger than in ICCs. A rim sign was present in only less than half ICCs, but in no HCCs. CONCLUSION: HCC and ICC differ to some extent in their CEUS enhancement pattern. Incomplete arterial hyperenhancement is more often seen in ICC than in HCC. A rim sign seems to be specific for ICC, but is only rarely present. However, in a case-to-case decision, due to overlapping characteristics, a reliable differentiation between the two tumor types by CEUS alone is very often not possible.

[Risk factors for the development of vision disorders in polymyalgia rheumatica with giant cell arteritis]. / Risikofaktoren für die Entwicklung von Sehstörungen bei Polymyalgia rheumatica mit Riesenzellarteriitis.

BACKGROUND AND OBJECTIVE: Visual disorders, even blindness, are serious complications of polymyalgia rheumatica (PMR) associated with temporal arteritis. Their early recognition in patients at high risk is essential to avoid the development of such visual disorders. It was the aim of this study to identify these risk factors. PATIENTS AND METHODS: Clinical and laboratory data and biopsy findings in 131 patients (94 women, 37 men; mean age 74 years) with PMR and concomitant temporal arteritis were analysed retrospectively. RESULTS: Visual disorders occurred in 61 of the 131 patients. Temporal artery biopsy was not sufficient to detect those at high risk. But this was possible by identifying a typical clinical pattern in that most patients with visual disorders had severe cerebral symptoms, while they had only minor forms of PMR and few generalized symptoms. There was no correlation between any of the laboratory tests and high risk. CONCLUSIONS: A typical pattern of clinical manifestations can provide early identification of those patients who have PMR associated with temporal arteritis and are at high risk of developing visual disorders.

[The rare differential diagnosis of a mediastinal space-occupying lesion]. / Seltene Differentialdiagnose einer mediastinalen Raumforderung.

HISTORY AND CLINICAL FINDINGS: Two months before admission a 31-year-old man first noted a painless swelling on the right side of his neck without any associated symptoms. Physical examination revealed a painless right cervical node 4 cm in diameter. INVESTIGATIONS: Magnetic resonance imaging demonstrated a large right-sided cervical tumour which extended into a mediastinal mass 11 cm in diameter. The excised cervical node showed a Hodgkin's lymphoma. Further tests to stage the disease revealed a 1.5 cm tumour in the right testis. Removal of the latter showed a mixed testicular tumour. Mediastinoscopic biopsy confirmed Hodgkin's lymphoma of the mediastinal mass. TREATMENT AND COURSE: Standard chemotherapy of the Hodgkin's lymphoma was undertaken, followed by "extended field" radiation which has so far secured a remission of two years. CONCLUSION: Histological diagnosis is always essential in the case of an unusual tumour location so that a synchronous second tumour may be revealed. If there is a second tumour, exact histological classification with definitive staging of the tumours is necessary to ensure adequate treatment.

[The synchronous occurrence of acute myeloid leukemia and kidney carcinoma]. / Synchrones Auftreten von akuter myeloischer Leukämie und Nierenkarzinom.

HISTORY AND CLINICAL FINDINGS: During the past year a 52-year-old man had developed quarterly bouts of fever, up to 38.5 degrees C, associated with fatigue and arthralgia. The fourth bout continued as undulating periods of fever with markedly impaired general state. Physical examination was unremarkable except for mild generalised lymphadenopathy. INVESTIGATIONS: Extensive imaging and serological studies failed to find an infectious or autoimmunological cause. But computed tomography and angiography revealed a space-occupying lesion in the left kidney, yet the suspected diagnosis of renal carcinoma insufficiently explained the clinical picture. DIAGNOSIS TREATMENT AND COURSE: Haematological tests having shown anaemia (Hb 8.1 g/dl) and blast cells (10%) in the peripheral blood a bone marrow biopsy was performed which indicated acute myeloid leukaemia. Three courses of intensive chemotherapy brought about only partial remission and the patient died 6 months later from a cerebral haemorrhage. An autopsy confirmed both the acute myeloid leukaemia and a renal carcinoma. CONCLUSION: The possibility of synchronous occurrence of two malignancies should always be kept in mind especially if the initially diagnosed tumor cannot explain the clinical symptoms.

Successful treatment of stage-IIIB seminoma with single-agent carboplatin therapy.

Single-agent carboplatin chemotherapy has recently been introduced into the therapy of limited seminoma. Because of poor compliance due to Down's syndrome we successfully treated a 32-year-old man with relapsed stage-IIIB seminoma with a dose-modified carboplatin monotherapy schedule leading to complete remission even after a follow-up of 4 years.

Acquired C 1-inhibitor deficiency with angioedema due to pleomorphic immunocytoma in a patient with three malignant tumors: long-term follow-up data and presentation of an additional case.

Two cases of lymphoma-associated acquired C 1-inhibitor deficiency are described. In both patients, C 1-inhibitor deficiency and related symptoms preceded the diagnosis of the underlying neoplasm by several months. C 1-inhibitor deficiency was most likely due to consumption following immunocomplex formation. In both patients, a close relationship between low levels of C 1-inhibitor and tumor relapse was observed during follow-up. These findings indicate that measurement of C 1-inhibitor and complement factor C4 can be used as markers of disease activity in affected patients.

Predominant myocardial sarcoidosis.

Unexpected autopsy findings of a predominantly myocardial sarcoidosis are reported. For a period of two years prior to death, the 42-year-old man suffered from atypical angina pectoris and ventricular arrythmias with episodic ventricular fibrillation. Echocardiography revealed a non-obstructive hypertrophic cardiomyopathia. He succumbed to sudden cardiac arrest. Sarcoidosis granulomas were widespread in the ventricular and atrial myocardium with intensive involvement of the sinus node, atrioventricular node, and the main bundle of His. According to a review of the previous literature on this subject, an obviously deleterious obstructive granulomatous angiitis of the sinus node's central artery was found for the first time.

Thrombendarteriitis pulmonalis carcinomatosa Ceelen: an immunohistological investigation.

A 65-year-old woman died in sudden right heart failure caused by thrombendarteriitis pulmonalis carcinomatosa Ceelen 16 months after resection of a rectal carcinoma. Autopsy disclosed a complex picture of multiple tumour cell emboli in small pulmonary arteries associated with local thrombosis and thrombus-associated vessel wall reaction. This was characterized by movement of medial muscle cells into the thrombus. In addition, affected vessels showed a prominent perivascular tumour-related infiltration by lymphocytes which are identified immunohistochemically as CD3-reactive T-cells.

Effects of acute normovolemic hemodilution on splanchnic oxygenation and on hepatic histology and metabolism in anesthetized pigs.

Perioperative hemodilution (HD) has become an accepted means of reducing transfusion requirements. Therefore, the effects of limited (decrease in hematocrit [Hct] from 30 to 20%, "HD1") and severe (decrease in Hct from 20 to 14%, "HD2") acute normovolemic HD with 6% hydroxyethyl starch on splanchnic blood flows (electromagnetic flow probes), O2 uptakes and deliveries, surface O2 tensions (PO2) (Clark-type electrode), hepatic metabolism (organic acids), and hepatic histology (liver biopsies) were studied in nine pigs anesthetized and paralyzed with ketamine/flunitrazepam and pancuronium. HD1 caused significant (P less than 0.05) increases in cardiac output and all splanchnic flows. Only hepatic arterial blood flow increased twice as much as did cardiac output. Except for hepatic arterial O2 delivery, all splanchnic O2 deliveries decreased. Splanchnic O2 extractions increased, and O2 uptakes remained unchanged. There were no changes in mean surface PO2 values or in surface PO2 histograms of liver and small intestine; in portal or hepatic venous pH; and in hepatic uptake of pyruvate and lactate. In contrast, during HD2 (despite further increases in flows and O2 extractions) portal and hepatic venous pH decreased; mean surface PO2 of liver and small intestine decreased; and the liver surface PO2 histogram showed broadening and a shift to the left. However, hepatic uptake of lactate and pyruvate, and splanchnic O2 uptake remained unchanged, and histologic examination did not reveal significant cell injury. These data indicate that in this experimental model limited acute normovolemic HD was well tolerated by the splanchnic organs. After severe HD, gross liver function remained intact, but there was evidence that compensatory mechanisms (increases in flow and O2 extractions) were no longer fully able to counteract the decrease in splanchnic O2 delivery.