[Diagnostics and therapy for neuroendocrine neoplasia of an unknown primary - a plea for open exploration]. / Diagnostik und Therapie bei neuroendokrinen Neoplasien mit unklarem Primarius - ein Plädoyer für die offene Exploration.

BACKGROUND: Neuroendocrine neoplasia (NEN) are a rare and heterogenous tumour entity. The subgroup with unknown primary tumour (N-CUP) seems to have a worse prognosis as resection of the primary is necessary for cure. The diagnostics and therapeutic algorithms for N-CUP in a German single centre are presented. PATIENTS/METHODS: Analysis of the surgical databank showed 35 cases of N-CUP in 261 cases with NEN from gastroenteropancreatic and lung origin over 2 decades (03/1990-03/2011). Three groups were built: K1 - primary detection after operative exploration (n = 10), K2 - unknown primary after operative exploration (n = 10) and K3 - no operative exploration for various reasons (n = 13). RESULTS: Initially 13.4 % (35/261) of patients presented as N-CUP, after intensified diagnostics 12.7 % (33/261) and after operative exploration 8.8 % (23/261) remained with unknown primary tumour. The sex ratio was 1 : 1, the median age is significantly higher in N-CUP [63.8 years (y) vs. 55.9 y, p = 0.004), the 5-year-survival is lower (58 vs. 72 %, n. s.). compared to NEN with known primary. Operative exploration was performed in 60.6 % (20/33), 30 % (6/20) of them were found to have inoperable situations, in 20 % (4/20) single site metastases were removed completely and in 50 % (10/20) a primary tumour was detected (8 × midgut, 2 × pancreas) intraoperatively. In these cases 70 % (7/10) got complete tumour resection (R0) and in 30 % (3/10) primary tumour resection with debulking of liver metastasis was done. In K3 (39.4 %, 13/33) most patients [69.2 % (9/13)] were treated with chemotherapy. The median age in K1 was significantly lower than in K3 (54.9 y vs. 68.3 y, p = 0.028), male dominance was seen in K3 (3,3 : 1, n. s.). The average Ki-67 index was 4.3, 23.8 and 53 % in K1, K2 and K3 (p < 0.0001 for K1 and K3 and p = 0.035 for K2 and K3), respectively. The death rate was 20, 30 and 76.9 % in K1, K2 and K3, respectively. CONCLUSION: Primary tumours of the midgut and pancreas are often found in the subset of well differentiated neuroendocrine CUP syndrome after open surgical exploration. A high rate of complete tumour resection and cure can be achieved in these cases. After common diagnostic tools (CT, MRI and somatostatin receptor scintigraphy), immunhistochemistry can give important hints (CDX-2 for midgut, TTF-1 for lung and thyroid) for a primary lesion. Also in single site metastasis without primary tumour detection a good clinical outcome is seen after complete resection.

[Diagnosis of and therapy for hepatocellular carcinoma]. / Diagnostik und Therapie des hepatozellulären Karzinoms.

The interdisciplinary guidelines at the S3 level on the diagnosis of and therapy for hepatocellular carcinoma (HCC) constitute an evidence- and consensus-based instrument that is aimed at improving the diagnosis of and therapy for HCC since these are very challenging tasks. The purpose of the guidelines is to offer the patient (with suspected or confirmed HCC) adequate, scientifically based and up-to-date procedures in diagnosis, therapy and rehabilitation. This holds not only for locally limited or focally advanced disease but also for the existence of recurrences or distant metastases. Besides making a contribution to an appropriate health-care service, the guidelines should also provide the foundation for an individually adapted, high-quality therapy. The explanatory background texts should also enable non-specialist but responsible colleagues to give sound advice to their patients concerning specialist procedures, side effects and results. In the medium and long-term this should reduce the morbidity and mortality of patients with HCC and improve their quality of life.

[A comparison of the use of electrochemical treatment and radio frequency ablation in porcine liver]. / Intrahepatische Ablation: Radiofrequenzablation versus Elektrochemische Lyse.

BACKGROUND: Radiofrequency ablation (RFA) and electrochemical treatment (ECT) are competing methods of intrahepatic ablation. We compared RFA and ECT in a perfusion model and in vivo in pigs. MATERIAL AND METHODS: Twenty-seven fresh porcine livers were obtained from a slaughterhouse and placed ex vivo into a perfusion model. RFA or ECT electrodes were inserted under ultrasound guidance in perivascular locations at a distance of 10 mm from a portal vessel. A total of 83 areas of ablation were created. In vivo ablations were performed at perivascular sites in 10 laparotomised pigs. Four areas of ablation were created per liver using RFA or ECL. Inflammatory parameters, liver values and cytokine levels were determined before and after surgery and on days 1, 3 and 7 after surgery. On day 7, the livers were harvested and specimens were analysed histo-logically by independent experts. RESULTS: In 29% of 59 ex vivo RFA ablations, the target temperature was not reached and the procedure was discontinued. Intact hepatocytes were detected in close proximity to 70 % of the vessels within necrotic areas. In 24 ECT applications, treatment time depended on the charge delivered and ranged between 50 min at 150 coulombs (C) and 200 min at 600 C. The pH level was 0.9 at the anode and 12.2 at the cathode. ECT always led to complete perivascular necrosis and vessel wall destruction. The animals had an in vivo -median weight of 39.5 kg. Neither RFA nor ECT caused major complications such as bleeding, bile leaks or abscesses. Treatment time was 67 min (200 C) for ECT and 12.4 min for RFA. In 73% of the cases, RFA led to incomplete perivascular areas of necrosis. ECT induced complete perivascular necrosis and vessel wall destruction. On day 1 after surgery, both ECT and RFA were associated with a significant increase in monocyte, C-reactive protein and aspartate aminotransferase levels. Leukocyte counts were elevated only after ECT, bilirubin levels only after RFA. There were no significant differences in interleukin-6 (IL-6), tumour necrosis factor-α (TNF-α) and IL-1ß. CONCLUSION: Both RFA and ECL are safe methods of intrahepatic ablation. As a result of a heat sink effect of blood flow in nearby vessels, RFA leads to incomplete necrosis in perivascular sites both ex vivo and in vivo. ECT has the disadvantage of long treatment times but the advantage of lower costs since the platinum electrodes are reusable. Without a reduction in liver perfusion, the central application of RFA in close proximity to vessels should be considered problematic.

[Progress in diagnostics of anorectal disorders. Part II: radiology]. / Fortschritte in der Diagnostik anorektaler Erkrankungen. Teil II: Radiologische Verfahren.

Diagnostics and therapy of anorectal disorders remain a surgical question. In close cooperation between different departments (radiology and gastroenterology, urology and gynecology, dermatology and psychology), the role of radiologic imaging is of growing importance. Exact knowledge of functional anatomy and precise clinical examination constitute the basis of the according therapeutic strategies. In this context radiology has contributed decisively. Developments in imaging techniques, e.g. dynamic MRI, highly contributed to better understanding of complex functional pelvic floor disorders. The combination of nanotechnology and high-resolution imaging allows precise staging, especially in rectal cancer. Furthermore, advances in virtual colonoscopy could lead to widely acceptable and patient-friendly screening for colorectal malignancies.

[Update on chemoinfusion and chemoembolization treatments]. / Update Chemoperfusion und -embolisation.

In the last two decades image-guided interventional catheterizations and percutaneous ablative regional treatment procedures have revolutionized the therapy of nonresectable primary and secondary liver tumours. A distinction is made between chemoablative procedures and thermo- and radioablative procedures. The main chemoablative interventions are transarterial infusion chemotherapy (HAIC; hepatic arterial infusion chemotherapy) and transarterial (chemo-)embolization (TACE/TAE). The object of the transarterial treatment procedures is to deliver the highest possible concentration of a chemotherapy agent or combination of chemotherapy agents directly into the tumour by way of the blood vessels supplying it, while at the same time keeping the systemic effects of the drugs as small as possible. Transarterial chemoperfusion to the liver can be applied in the treatment of all primary and secondary hepatic tumours, but the main indications are hepatocellular carcinoma (HCC) and metastases from colorectal primary tumours.

[Value of multislice CT for the work-up of pulmonary embolism]. / Stellenwert der Multislice-CT bei der Diagnostik der Lungenembolie.

Multislice computed tomography (MSCT) of the pulmonary arteries has overcome the limitations of single-slice CT and is accepted as the sole reference standard for imaging pulmonary embolism (PE) in many institutions. This technique provides the opportunity of efficient risk stratification to enable adequate differential therapy. With a low or intermediate pretest probability and a negative CT angiography (CTA), relevant PE can be ruled out safely. In >30% further diagnoses other than pulmonary embolism, e.g., pneumonia or aortic aneurysm, can be established on the basis of thoracic CTA. This article discusses the present role of MSCT in diagnostic imaging of PE and provides optimized acquisition protocols as well as practical aspects for secondary image reconstruction. Examples of typical imaging features of PE are shown. Diagnostic algorithms for daily emergency practice are discussed with respect to artifacts and pitfalls in image interpretation.

[CTA and MRA in peripheral arterial disease--is DSA out?]. / CTA und MRA bei PAVK--ist die DSA "out"?

New developments in technique and postprocessing have led to further improvement in diagnosing and evaluating peripheral arterial disease (PAD) by noninvasive computed tomographic angiography (CTA) and magnetic resonance angiography (MRA). Under clinical conditions diagnostic conventional angiography (DSA) will be increasingly replaced by CTA and MRA. The radiologist has to become familiar with the field of indications, the different techniques, postprocessing tools, and effective visualization. In consideration of the current literature some methodological aspects and the role of CTA and MRA in PAD will be discussed.

Percutaneous radiofrequency ablation of pulmonary tumors--is there a difference between treatment under general anaesthesia and under conscious sedation?

OBJECTIVE: This retrospective study aimed to compare feasibility, complication rate and local tumor control after radiofrequency ablation (RFA) of pulmonary tumors under conscious analgo-sedation (AS) versus general anaesthesia (GA). MATERIALS AND METHODS: Within 36 months 21 patients had RFA (36 tumors, 26 treatment sessions). One patient suffered from NSCLC, 20 had metastases (breast (8/20), colorectal (6/20), renal cell (2/20), pharyngeal carcinoma (1/20), malignant melanoma (3/20)). Patients were no surgical candidates due to underlying comorbidities. Eleven of 26 treatments were performed under GA, while in 15 of 26 treatments AS was used. Follow-up was scheduled 24 h, 6 weeks, 3 months, 6 months and then every 6 months after treatment. RESULTS: RFA was feasible in all treatments under GA, while under AS targeting of the lesion was not possible in 2/15. Six adverse events occurred in the GA group (three major, three minor), while seven complications happened in the AS group (three major, four minor) (p=0.57). During follow-up of 3-36 months local recurrence was detected in 3 of 21 tumors in the GA group and in 2 of 15 tumors in the AS group (p=0.79). DISCUSSION: Hospitalization, complication rates and types, and the rate of local tumor control did not differ substantially among both groups. Furthermore, there was no significant difference in technical success and feasibility. CONCLUSION: RFA of pulmonary tumors under GA or AS did not result in different tumor control and complication rates, respectively. Therefore, AS should be used except in anxious or agitated patients.

[Interventions for benign biliary strictures]. / Interventionen bei benignen Gallengangstenosen.

Due to their potential for serious consequences, even including biliary liver cirrhosis, benign biliary strictures pose a considerable diagnostic and therapeutic challenge. In addition to inflammatory disease or an acute liver injury, iatrogenically caused biliary strictures following hepatobiliary surgery represent in 95% of cases the main cause for all benign entities. The diagnosis should be determined noninvasively with magnetic resonance cholangiopancreaticography (MRCP). Invasive techniques such as ERCP or percutaneous transhepatic cholangiography (PTC) should be reserved for unclear cases and first performed before the scheduled intervention. Depending on the site and cause of the stricture, surgical and interventional procedures are employed in the treatment of biliary strictures. The best results are obtained in short-segment strictures of the main bile duct. Interventional methods such as balloon dilation and/or stent application with concomitant drain insertion achieve patency rates of up to 75% after 5 and 55% after 12 years with a total complication rate of 5-8%. Due to the fact that most of the cases involve cicatricial fibroses, predisposition for recurrence of biliary strictures after interventional therapy can be very high, ranging up to 66% depending on the localization.

[Liver tumor ablation]. / Tumorablation der Leber.

Minimal-invasive techniques for ablation of primary and secondary hepatic tumors gain increasingly clinical importance. This is especially true since surgical resection and classic chemotherapy is successful only in a limited number of patients. Local ablative methods incorporate chemo- (percutaneous alcohol instillation, transarterial chemoembolization), thermo- (radiofrequency-, laser-, microwave-, cryoablation, high intensive focused ultrasound) and radio-ablative techniques (interstitial brachytherapy, selective internal radiotherapy). Regarding their implementation and specific effects these methods are varying widely, nevertheless all of them have a high therapeutical efficacy together with a low complication rate in common-correct application presumed. The knowledge on specific indications and contraindications is crucial to implement these methods into multimodality therapy concepts.

[Long-term results of interventional treatment of large unresectable hepatocellular carcinoma (HCC): significant survival benefit from combined transcatheter arterial chemoembolization (TACE) and percutaneous ethanol injection (PEI) compared to TACE monotherapy]. / Langzeitergebnisse der interventionellen Therapie von grossen, inoperablen hepatozellulären Karzinomen (HCC): signifikanter Uberlebensvorteil von transarterieller Chemoembolisation (TACE) und perkutaner Ethanolinjektion (PEI) gegenüber der TACE-Monotherapie.

PURPOSE: A retrospective analysis of long-term efficacy of combined transcatheter arterial chemoembolization (TACE) and percutaneous ethanol injection (PEI) and TACE monotherapy was conducted in patients with large, non-resectable hepatocellular carcinoma (HCC). METHODS AND MATERIALS: Fifty patients with large, unresectable HCC lesions underwent selective TACE. Liver cirrhosis was present in 42 patients, due to alcohol abuse (n = 22) and viral infection (n = 17). In three patients, the underlying cause for liver cirrhosis remained unclear. Child A cirrhosis was found in 22 and Child B cirrhosis in 20 patients. Repeated and combined TACE and PEI were performed in 22 patients and repeated TACE monotherapy was performed in 28 patients. Survival and complication rates were determined and compared. RESULTS: The 6-,12-, 24- and 36-month survival rates were 61 %, 21 %, 4 %, and 4 % for TACE monotherapy and 77 %, 55 %, 39 % and 22 % for combined TACE and PEI (Kaplan-Meier method). The kind of treatment significantly affected the survival rate (p = 0.002 log-rank test). Severe side effects were present in two patients of the monotherapy group and in three patients of the combination therapy group. CONCLUSION: The combination of TACE and PEI is an effective and safe method in the palliative treatment of large HCC that has the potential of improving long term survival compared to TACE monotherapy.

[Interventional therapy in renal artery dissection due to renal artery PTA. Case report]. / Interventionelles Vorgehen bei Nierenarteriendissektion infolge einer Nierenarterien-PTA. Ein Fallbericht.

Percutaneous angioplasty of a renal artery stenosis may lead to dissection and acute thrombosis that may put the organ at risk. In this case, it should be discussed individually how to treat the patient and the decision on interventional therapy should be based on interdisciplinary consensus. Local fibrinolysis usually allows to recognize the cause of obstruction which then is the basis for further treatments. The case report presented in this article describes how a dissection involving two thirds of the renal artery and leading to significant obstruction may successfully be treated by means of interventional radiology.

[Prospective comparison of hydrosonography, endosonography and specimen sonography for TN staging of gastric carcinoma]. / Prospektiver Vergleich von Hydrosonographie, Endosonographie und Präparatesonographie beim TN-Staging von Magenkarzinomen.

PURPOSE: To compare hydrosonography (HUS), endosonography (EUS) and experimental sonography (PUS) with respect to TN-staging accuracy of gastric carcinoma. MATERIAL AND METHODS: Thirty-six patients with gastric carcinoma underwent EUS (7.5/12 MHz transducer, Olympus GF-UM 20) and HUS (3.75 MHz transducer, Toshiba, Sonolayer SSA-270A) for TN-staging according to the UICC-classification. The resected specimens were reexamined (3.75/7.5 MHz transducer) and again TN-staging was performed. Findings were correlated with histopathological results. RESULTS: T- and N-staging accuracies were as follows: EUS 54 % (19/35) and 79 % (27/34); HUS 41 % (15/37) and 61 % (22/36); and PUS 51 % (19/37) and 72 %(26/36). Sensitivities and specificities for the detection of lymph node metastases were as follows: EUS 87 % and 54 %; HUS 57 % and 69 %; and PUS 83 % and 54 %. CONCLUSIONS: The accuracy of sonographic TN- staging is limited in patients with gastric carcinoma. Nevertheless, EUS may contribute to the preoperative management of patients with gastric carcinoma if indications are well defined. HUS is not suited for TN-staging of gastric carcinoma.

[MR imaging of gastric wall layers in vitro: correlation to thehistologic wall structure]. / Experimentelle Darstellung der Schichten der Magenwand mittels MRT: Korrelation mit demhistologischen Wandaufbau.

PURPOSE: To correlate gastric wall layers visible of MRI with the anatomical structure of the gastric wall. METHODS: After macroscopic preparation 5 x 5 cm post-mortem tissue sections of the gastric antrum were evaluated using a 2.4 Tesla MR unit (Bruker, Ettlingen, Germany). MR imaging consisted of T2-weighted multi-spinecho sequences in longitudinal and axial directions. The specimens then were stained with hematoxylin-eosin for histological examination. After that histological correlation of the gastric wall layers visible on MRI was performed. RESULTS: In all specimens four gastric wall layers could be clearly identified on MRI. The direct comparison of those layers to the histological findings showed the following correlation: 1) intermediate signal = mucosa, 2) hypointense signal = lamina muscularis mucosae, 3) hyperintense signal = submucosa, 4) intermediate signal = muscularis propria. CONCLUSIONS: Gastric wall layers visible on MRI were successfully correlated to the anatomic layers of the gastric wall. This allows us for the first time to classify invasion of gastric carcinoma using high spatial-resolution MR imaging. However, the subserosa and serosa are excluded from this conclusion, because so far a reliable statement concerning the value of MRI to depict these very variable layers is not possible.

Angiographic and histologic changes in artery, vein and portal vein after placement of bare or covered Z-stent; an experimental study in dogs.

The aim of this study was to examine stenosis in the aorta, portal vein (PV), and inferior vena cava (IVC) after bare and covered Z-stent placement. Eight beagles underwent bare (n=4) or polytetrafluoroethylene (PTFE) covered (n=4) Z-stent placement in the aorta, PV, and IVC. Angiography was performed 1 and 3 weeks later to evaluate stenosis. The animals were sacrificed after 3 weeks for histopathologic examination. Angiographic findings revealed that stenosis in the bare stent group tended to be smaller than in the covered stent group in 3 vessels and stenosis tended to be smaller in the order of the aorta, PV and IVC in either group. In both groups, stenosis in the PV and IVC was mainly caused by organized thrombus. In addition, in the covered stent group, the space between the cover and native vessel wall (subgraft space) was formed and filled with neointima in every vessel. Preventing thrombus formation in the PV and IVC after bare and covered stent placement and reducing the subgraft space in the aorta after covered stent placement are important for minimizing stenosis.

[Carcinoma of the stomach. Role of imaging for primary diagnosis and preoperative tumor staging]. / Das Magenkarzinom. Stellenwert der bildgebenden Verfahren für Primärdiagnose und präoperatives Tumorstaging.

The aim of imaging of gastric carcinoma has to be to diagnose the carcinoma as early as possible and to sort out the tumors that are resectable. At the same time imaging of gastric carcinoma should reduce the number of futile laparotomies in patients with advanced, non-resectable tumors to a minimum. Today, endoscopy is the method of choice to diagnose gastric carcinoma. Endosonography is advantageous if small carcinomas have to be judged for depth of tumor infiltration (early gastric carcinoma vs. advanced gastric carcinoma) because high resolution images of the gastric wall are obtained. Staging of large carcinomas that have grown beyond the gastric wall is best performed by hydro-CT because CT scans most accurately delineate infiltrations of surrounding organs/structures and help to plan surgery. Nowadays MRI is not suited for gastric imaging. MRI, however, has the highest potential to fundamentally improve staging of gastric carcinoma if high resolution imaging of the gastric wall is combined with screening for metastases in one examination.