[CEUS-diagnosis of solid renal tumors]. / CEUS ­ Diagnostik solider Nierentumoren.

CLINICAL ISSUE: Renal lesions are detected earlier, often as a result of ultrasound examinations. However, the imaging-based differential diagnosis of different tumour entities remains challenging STANDARD RADIOLOGICAL METHODS: All renal tumours >1 cm should be evaluated for malignancy by computed tomography (CT) or magnetic resonance imaging (MRI). If an angiomyolipoma diagnosis cannot be established with imaging, further diagnostics are appropriate or if malignant progression is suspected, then multidisciplinary discussion for TNM-staging based uro-oncologic therapy is usual. METHODICAL INNOVATIONS: Contrast-enhanced ultrasound (CEUS) gives clear information about the microperfusion of renal tumours. PERFORMANCE: CEUS is helpful for the differentiation of renal cysts and especially papillary renal cell carcinomas. Moreover, CEUS advances renal tumour detection compared to B­mode and Doppler ultrasound per se. Cortical pseudolesions may be confidently ruled out using CEUS. ACHIEVEMENTS: Clear differentiation of benign and malignant renal lesions >1 cm remains challenging, and only in rare cases is it possible with CEUS alone. Nevertheless CEUS is, in combination with other ultrasound techniques, eminently suitable for diagnosing focal pyelonephritis, renal abscesses and suspected renal lymphoma and supports the planning of ultrasound-assisted tumour biopsies. PRACTICAL RECOMMENDATIONS: Combining different imaging techniques is essential to accurately diagnose renal tumors. These imaging results (including the ultrasound/CEUS clips) should be viewed by the multidisciplinary cancer tumour board to facilitate individual treatment concepts for each patient.

[Retrieval of a migrated plastic stent in a 51-year-old man]. / Bergung eines migrierten Doppel-Pigtail-Stents bei einem 51-jährigen Patienten.

BACKGROUND: Endosonographically guided transgastric drainage is the first-line interventional therapy of walled-off necrosis and symptomatic pancreatic pseudocysts in necrotizing pancreatitis. Plastic stents or lumen apposing metal stents are commonly used. A possible complication of endoscopic therapy is stent migration. CASE REPORT: We report upon a 51-year-old man who presented with acute necrotizing pancreatitis. Transgastric necrosectomy was performed and 5 transmural double-pigtail stents (DPS) were left in situ to drain the residual retroperitoneal cavity. The patient recovered and 4 stents were endoscopically removed 5 weeks later on an outpatient basis, whereas the fifth stent was suspected to have passed spontaneously via the natural route. The asymptomatic patient presented 3 months later for follow-up computed tomography. The necrosis had healed but one DPS was seen beyond the gastric wall near the kidney. Transmural access to the stent could be achieved by an endosonographically guided puncture toward the proximal portion of the stent followed by placement of a hydrophilic guidewire alongside the stent. A new gastrostomy was created by using a 6F cystotome followed by wire-guided dilation with a 12 mm balloon. The stent could then be grasped with transmurally inserted rat-tooth forceps and repositioned across the gastrostomy site. The patient was given prophylactic antibiotics. After removal of the stent, the patient could be discharged. CONCLUSION: Herein, we present the successful endosonographically guided transmural removal of a retroperitoneally migrated plastic stent. Of note, in our patient we had to rely completely on endosonography and radiography for localization and targeting of the stent, since the former necrotic cavity had meanwhile completely healed.

A Review of Scientific Topics and Literature in Abdominal Radiology in Germany - Part 1: Gastrointestinal Tract.

UNLABELLED: The working group for abdominal and gastrointestinal diagnosis is a group of the German Radiological Society (DRG) focusing clinically and scientifically on the diagnosis and treatment of the gastrointestinal tract with all parenchymatous abdominal organs. In addition to the clinical and scientific further development of abdominal radiology, the education of radiologists within this core discipline of radiology is one of the major aims. In this article we give an up-to-date literature review of scientific radiological topics especially covered by German radiologists. This manuscript focuses on the most recent literature on the diagnosis of the stomach, small bowel, colon and rectum. The review with a focus on the most recent studies published by German radiologists concludes with a synopsis of mesenterial bleeding and ischemia followed by a critical appraisal of the current literature on conventional abdominal radiography. KEY POINTS: Based on recent literature and guidelines there is a change of paradigms regarding the diagnosis of esophagus and gastric cancer towards CT, which is considered equally to endosonography. For small bowel imaging in Crohn's disease ultrasound as well as MRI with a new focus on DWI are the most important imaging modalities scientifically. For colonic diagnosis virtual colonoscopy has replaced the conventional radiological methods. For staging of rectal carcinoma as well as for therapeutic stratification a high resolution MRI of the pelvis is of paramount interest. Multislice CT is considered the most important modality to assess mesenteric ischemia or bleeding.

[Omitted spinal X-ray examination after a fall from a height of 3 m]. / Keine Röntgenuntersuchung der Wirbelsäule nach Sturz aus 3 m Höhe.

A 59-year-old patient with right-sided chest pains after a fall from a height of 3 m was referred to hospital by an emergency physician. The chest x-rays showed fractures of the third and seventh ribs on the right side. Inpatient analgesic therapy was initiated and after 3 days the patient was discharged from hospital for further outpatient treatment. As the pain persisted the patient consulted a surgeon 5 weeks later and the first X-ray examination of the spine was carried out which revealed the formation of several wedge-shaped thoracolumbar vertebral bodies. Further magnetic resonance imaging (MRI) diagnostics also revealed alterations to T10, T12, L1 and L3 as well as radiological signs of Scheuermann's disease; however, a definite statement differentiating these findings from older spinal fractures as a result of the accident was no longer possible. The patient claimed that the hospital failed to perform spinal X-ray investigations leading to prolonged pain and limitations in the quality of life. An external expert stated that the distracting injury of the ribs and the pain medication might have veiled the additional vertebral fractures. Thus, an earlier diagnosis of the apparently stable vertebral fractures would not have changed the conservative therapy approach. The decision of the arbitration board differed from the expert opinion as additional imaging techniques of the spine should have been initially performed due to the mechanism of injury. Although no irreversible damage to health resulted an earlier targeted treatment could have reduced the overall length of therapy.

A Review of Scientific Topics and Literature in Abdominal Radiology in Germany--Part 2: Abdominal Parenchymal Organs.

UNLABELLED: The working group for abdominal and gastrointestinal diagnosis is a group of the German Radiological Society (DRG) focusing clinically and scientifically on the diagnosis and treatment of the gastrointestinal tract as well as the parenchymal abdominal organs. In this article we give an up-to-date literature review of scientific radiological topics especially covered by German radiologists. The working group experts cover the most recent relevant studies concerning liver-specific contrast media with an emphasis on a new classification system for liver adenomas. Additionally studies regarding selective internal radiotherapy (SIRT) are reviewed. For the pancreas the most important tumors are described followed by an introduction to the most recently introduced functional imaging techniques. The manuscript concludes with some remarks on recent studies and concerning chronic pancreatitis as well as autoimmune pancreatitis. KEY POINTS: • Different subtypes of liver adenomas with different therapeutic consequences can be differentiated by MRI • Most recently published studies focus on liver imaging with extracellular liver specific contrast media as well as diffusion weighted imaging. They consider this new method having a high diagnostic potential. • For pancreatic neoplasm diagnosis diffusion--as well as perfusion--imaging is considered as a highly promising method.

[Grisel's syndrome after otoplasty]. / Grisel-Syndrom nach Anthelixplastik.

Grisel's syndrome is known as a very rare complication of ENT surgery. It is described as non-traumatic atlantoaxial rotatory subluxation, often seen after tonsillectomy or adenoidectomy in children. Therapy is staged according to the Fielding classification. We report the case of a 9-year-old female patient with Grisel's syndrome after otoplasty. The diagnosis was confirmed by CT scan. Manual reposition was performed under general anaesthesia, followed by temporary immobilization with a Minerva orthesis.

Microcirculation of subepithelial gastric tumors using contrast-enhanced ultrasound.

OBJECTIVES: The evaluation of subepithelial tumors of the stomach is normally the domain of gastroscopy and endoscopic ultrasound. We investigated these rare tumors using transabdominal B-mode ultrasound and performed perfusion analysis of these tumors with contrast enhanced ultrasound. METHODS: Patients with gastrointestinal stromal tumors (GIST, n = 3), leiomyoma (n = 1) and schwannoma (n = 1) were routinely examined using conventional B-mode-ultrasound, colour Doppler ultrasound and contrast-enhanced ultrasound (contrast media: Sonovue; ultrasound device: Siemens Acuson Sequoia 512). Gastroscopy, endosonography with puncture of the subepithelial tumor and computed tomography were also performed in all patients. After surgery, the resected stomach tumors were correlated with the preoperative imaging findings. RESULTS: All calculated tumor sizes using any imaging modalities showed a good correlation with the macroscopic tumor sizes ex-vivo. Histologically increased tumor size of the GISTs was correlated with large, central avascular areas. The GISTs and the leiomyoma presented with mixed echogenicity in B-mode-ultrasound. Colour Doppler ultrasound was able to detect some vessels in the periphery of the tumor only. Using contrast-enhanced ultrasound the GISTs and the leiomyoma presented hypervascular. The contrast pattern of these lesions was from the periphery to the centre or diffuse or a progressive centrifugal fill in during the arterial phase. We also registered slowly progressive washout starting at the end of the arterial phase and increasing into the late phase. The contrast media behaviour in the schwannoma was different from that describt above within the GISTs: it was noted to have a diffuse intralesional pattern at the start of the arterial phase followed by an early, rapidly progressing washout-phenomenon. CONCLUSION: In our pilot study B-mode transabdominal ultrasound was able to visualise gastric subepithelial tumors larger than three centimetre. Contrast-enhanced ultrasound is a proven method in clinical practice for the perfusion analysis of gastric subepithelial tumors. It can also be used for the planning of ultrasound-guided biopsies to avoid punctures of necrotic tumor parts.

Diffusion-weighted magnetic resonance imaging in cervical lymphadenopathy: report of three cases of patients with Bartonella henselae infection mimicking malignant disease.

Diffusion-weighted MR imaging is a potential technique for differentiation between benign and malignant lymph nodes. However, lympadenopathy caused by Bartonella henselae infection showes low ADC values in diffusion weighted MRI as typically seen in malignant disease.

[MRI for malignant pancreatic tumors]. / MRT bei malignen Pankreastumoren.

In recent years continuous advancements in software and hardware technology of modern MRI systems have contributed to substantial progress in the field of pancreatic tumor imaging. Despite technical advances in abdominal MRI, multislice CT still remains the preferential diagnostic tool for pancreatic lesions. In the majority of cases the essential clinical questions can thereby be answered with a high degree of accuracy. However, in dilemma cases state-of-the-art MR imaging can provide relevant information for the diagnosis allowing an optimal therapeutic concept. This report gives an overview on possible applications for MRI in the diagnostic evaluation of malignant pancreatic tumors.

[Endothelial adrenal cyst mimicking cystic echinococcosis in a Turkish woman]. / Endotheliale Nebennierenzyste als Differenzialdiagnose zur zystischen Echinokokkose bei einer türkischen Patientin.

BACKGROUND: Cystic liver lesions include hepatic echinococcosis as an important differential diagnosis, especially in patients from endemic countries. Serology might be false negative in a relevant percentage of the patients. Thus, modern clinical imaging techniques are the most important non-invasive means for making or excluding the diagnosis of hepatic echinococcosis. CASE REPORT: A 37-year-old Turkish woman was admitted to hospital because of abdominal pressure, lack of appetite and weight loss. The suspected radiological diagnosis of hepatic echinococcosis was made based on a septated, cystic liver process with calcifications seen in an already performed computered tomography. The physical examination and laboratory findings did not show any specific pathology. The serological tests for echinococcosis were negative. The MRI scan of the liver showed a 10 x 7.5 cm large, multi-segmented, cystic lesion between the right kidney and the right liver lobe. The cyst was discussed as possibly having an origin from the right adrenal gland and very unlikely from the liver or kidney. Ultrasonography (Siemens-Acuson Sequoia 512, Mountain View) showed a cystic lesion with septated structures and calcifications between the right kidney and the liver without a typical capsule. Contrast-enhanced ultrasound after fractionated injection of 4.8 mL Sonovue (Bracco, Milano) showed an intensive perfusion of the septa in the cyst. We admitted the patient for surgery. Interoperatively a right adrenalectomy and cystectomy was performed. Histology showed an epithelial adrenal cyst. The patient was asymptomatic twelve months after surgery. CONCLUSION: High-end-ultrasonography with microbubble contrast media of the second generation is the primary diagnostic tool for the differential diagnosis of cystic lesions of the liver and adrenal glands. MRI or CT scans might be additionally indicated in the case of poor ultrasound conditions in a patient or before planned surgery, but can also fail to correct determine the origin of a cyst.

[Contrast-enhanced magnetic resonance cholangiography using gadolinium-EOB-DTPA. Preliminary experience and clinical applications]. / Kontrastverstärkte MR-cholangiographie mit Gadolinium-EOB-DTPA. Erste Erfahrungen und klinische Einsatzmöglichkeiten.

Magnetic resonance cholangiopancreaticography (MRCP) with heavily T2-weighted RARE and HASTE sequences has become an important imaging modality for the morphologic evaluation of intra- and extrahepatic bile ducts. However, for the diagnosis of functional biliary disorders, cholangiopancreaticography (ERCP) and endoscopic manometry, two invasive techniques with considerable morbidity and mortality, remain the standard. Biliary scintigraphy, secretin-stimulated MRCP, and secretin-stimulated endoscopic ultrasound have not proven to be sufficient to replace these techniques as they lack diagnostic accuracy and correlate poorly with manometry results. Contrast-enhanced magnetic resonance cholangiography (CE-MRC) uses hepatocyte-selective contrast agents that are eliminated by the biliary system. Therefore, these substances can serve as biliary contrast agents in T1-weighted MR imaging. This method makes a noninvasive functional evaluation of the hepatobiliary system possible. In the present article, our preliminary experience with Gd-EOB-DTPA-enhanced MRC is summarized and potential clinical applications of this method are discussed. Additionally, the article reviews publications evaluating a possible benefit of CE-MRC with other hepatobiliary contrast agents such as mangafodipir trisodium.

[MSCT for staging and response evaluation of esophageal cancer]. / Staging und Therapiebeurteilung des Osophaguskarzinoms mittels MSCT.

Squamous cell carcinomas and adenocarcinomas account for the majority of cases of esophageal cancer. Esophageal cancer often is diagnosed in advanced stages as clinical symptoms are lacking in early stages. The major aims of imaging in esophageal cancer are to determine local tumor extension (T and N staging), to rule out systemic disease (M staging), and to assess response to neoadjuvant therapy (response evaluation). CT is still inferior to endoscopic ultrasound in differentiating T stages and detecting regional lymph node metastases. However, it plays a central role in determining infiltration into adjacent organs (T4 stage) and in ruling out distant metastases. Multislice-CT (MSCT) offers the possibility of reconstructions, which often help to assess the relationship between tumor and anatomic landmarks like the tracheobronchial tree or the diaphragm. First results of CT volumetry for response evaluation are promising; however, PET and PET/CT with the glucose analogue FDG are the standard methods to evaluate response to neoadjuvant therapy.