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Background Cardiophrenic lymph nodes (CPLN) define FIGO stage IVB disease. We evaluate the pattern of CPLN metastases, their prognostic impact and the potential role of CPLN resection in patients with epithelial ovarian cancer (EOC). Methods Analysis of 595 consecutive patients with EOC treated in the period 01/2011–05/2016. CT scans were re-reviewed by two radiologists. Positive CPLN were defined as ≥5 mm in the short-axis diameter. The role of CPLN resection was evaluated in a case-control matched-pair analysis. Results Of 595 patients 458 had FIGO stage IIIB-IV disease. We excluded patients undergoing interval surgery (n = 54), without debulking surgery (n = 32) and without sufficient pre-operative imaging (n = 22), resulting in a study cohort of 350 patients. Of these, 133 (37.9%) had negative CPLN and 217 (62.0%) had radiologically positive CPLN. In patients with postoperative residual tumor, enlarged CPLN had no impact on survival. In patients with complete resection (n = 223), 98 (44.0%) had negative CPLN and a 5-year OS of 69% and a 5-year PFS of 41%; in contrast, in the 125 patients (56.0%) with positive CPLN, 5-year OS was 30% and 5-year PFS was 13%. In 52 patients we resected CPLN. The matched-pair case-control analysis did not demonstrate any significant impact on survival of CPLN resection. Conclusion CPLN metastases are associated with impaired PFS and OS in patients with macroscopically completely resected tumor. Intraabdominal residual tumor has a greater prognostic impact than positive CPLN. The impact of the resection of CPLN remains unclear.

Background Predictive models based on radiomics features are novel, highly promising approaches for gynaecological oncology. Here, we wish to assess the prognostic value of the newly discovered Radiomic Prognostic Vector (RPV) in an independent cohort of high-grade serous ovarian cancer (HGSOC) patients, treated within a Centre of Excellence, thus avoiding any bias in treatment quality. Methods RPV was calculated using standardised algorithms following segmentation of routine preoperative imaging of patients (n = 323) who underwent upfront debulking surgery (01/2011-07/2018). RPV was correlated with operability, survival and adjusted for well-established prognostic factors (age, postoperative residual disease, stage), and compared to previous validation models. Results The distribution of low, medium and high RPV scores was 54.2% (n = 175), 33.4% (n = 108) and 12.4% (n = 40) across the cohort, respectively. High RPV scores independently associated with significantly worse progression-free survival (PFS) (HR = 1.69; 95% CI:1.06–2.71; P = 0.038), even after adjusting for stage, age, performance status and residual disease. Moreover, lower RPV was significantly associated with total macroscopic tumour clearance (OR = 2.02; 95% CI:1.56–2.62; P = 0.00647). Conclusions RPV was validated to independently identify those HGSOC patients who will not be operated tumour-free in an optimal setting, and those who will relapse early despite complete tumour clearance upfront. Further prospective, multicentre trials with a translational aspect are warranted for the incorporation of this radiomics approach into clinical routine.

Sarcopenia was reported as a prognostic factor in cancer patients. Using computed tomography (CT), we analyzed the impact of sarcopenia on overall survival (OS) in patients with advanced epithelial ovarian cancer (EOC) after primary debulking surgery (PDS). Preoperative CT scans of consecutive EOC patients (n = 323) were retrospectively assessed for skeletal muscle index (SMI) and muscle attenuation (MA; Hounsfield units [HU]). The optimal cut-off point for MA (32 HU) was calculated using the Martingale residuals method, and previously reported cut-offs for SMI were used. Logistic regression was used to determine univariate and multivariate factors associated with OS. Sarcopenia defined as SMI 0 (13.2 vs. 3.1%), comorbidity (age-adjusted Charlson Comorbidity Index [ACCI] ≥ 4; 36.8 vs. 13.3%), median body mass index (BMI; 27 vs. 24 kg/m2), International Federation of Gynecology and Obstetrics (FIGO) stage, histology (high-grade serous 95.6 vs. 84.7%), and complete resection (38.2 vs. 68.2%). MA

Successful localization is mandatory for focused parathyroidectomy. If ultrasound and sestamibi scan are negative, bilateral neck exploration is necessary. We examined the contribution of complementary computed tomography (CT) scan to identify the affected parathyroid gland. Between November 1999 and April 2014, 25 patients (20 females and 5 males; mean age 67 ± 11 years) with negative or dubious standard imaging (ultrasound and sestamibi scan) underwent CT scan prior to parathyroidectomy and were included in this study. Fifteen patients had had previous neck surgery for parathyroidectomy (n = 11) or thyroidectomy (n = 4). Thin-slice CT (n = 9) or four-dimensional (4D) CT imaging (n = 16) was used. Cure was defined as >50 % post-excision fall of intraoperatively measured parathyroid hormone or fall into the normal range, confirmed by normocalcaemia at least 6 months after surgery. Preoperative CT scan provided correct localization in 13 out of 25 patients (52 %) and was false positive once. Parathyroidectomy was performed by a focused approach in 11 of these 13 patients as well as in 1 patient guided by intraoperatively measured parathyroid hormone (ioPTH). Thirteen patients required bilateral neck exploration. The cure rate was 96 % (24/25 patients). One patient has persistent primary hyperparathyroidism (pHPT) and one a recurrent disease. Six patients presented a multiglandular disease. A CT scan identifies about half of abnormal parathyroid glands missed by conventional imaging and allows focused surgery in selected cases.

Among these providers, urologists accounted for the largest number of studies ordered (57.2%), followed by hematologist/oncologists (14.1%) and radiation oncologists (15.1%). The remaining studies were ordered by primary care providers, nurse practitioners, nephrologists, radiologists and general surgeons. The most common indications for ordering a prostate MRI were initial staging/restaging patients who had not undergone treatment and were not on active surveillance (51.1%), rising prostate-specific antigen (PSA) with negative biopsy (18.5%), active surveillance (10.9%) and surveillance following prostatectomy or radiation (7.7%). The MRI results revealed positive findings in 28.6%, negative findings in 23.7% and indeterminate findings in 17.4% of cases. CONCLUSIONS: This study demonstrates a rapidly rising trend in the utilization of prostate MRIs despite the absence of established guidelines to support its use. While there is some evidence to suggest the potential value of MRIs, particularly in detecting prostate cancer in men with elevated PSAs and negative biopsies, most studies were being ordered for prostate cancer staging and surveillance. Additionally, we found a significant number of indeterminate cases. This brings into question whether MRIs are linked to improved clinical outcomes at such high costs to the health care system. In light of these results, it will be important to develop clear guidelines for prostate MRI utilization given the trend in rapid rate of adoption and utilization.

Glycogen storage disease type Ib is an autosomal recessive inherited metabolic disorder resulting from deficiency of the microsomal glucose-6-phosphatase enzyme system. Six patients (three of which were treated with granulocyte colony stimulating factor) suffering from this disease were examined using image guided localized proton magnetic resonance (MR) spectroscopy. The relative signal intensities of water and lipid protons of the lumbar spine were determined. Comparison was made with iliac crest biopsies in the glycogen storage disease type Ib patients and localized proton MR spectroscopic values of the lumbar spine obtained by thirteen healthy volunteers. The data demonstrate for the first time that hypercellularity and myeloid hyperplasia in subjects with glycogen storage disease type Ib due to functionally impaired leucocytes results in a strongly increased water proton signal with a very low or absent lipid signal in localized proton MR spectroscopy. Upon granulocyte colony stimulating factor treatment, the water proton signal in the lumbar spine is not further augmented. J. Magn. Reson. Imaging 2001;14:757–762. © 2001 Wiley-Liss, Inc.

Preexisting renal impairment is an all-encompassing risk factor for radiocontrast-associated nephrotoxicity. Renal impairment appears to be associated with the inadequate production of renal prostaglandins at the critical time of radiocontrast administration and for a variable time period afterward. We prospectively studied 130 patients with chronic renal insufficiency (serum creatinine > or =1.5 mg/dL) who were undergoing radiocontrast administration. Using a double-blind, randomized, prospective technique, patients were assigned to either placebo or one of three prostaglandin E1 (PGE1) treatment groups (10, 20, or 40 ng/kg/min). Infusion was started 60 +/- 30 minutes before the administration of radiocontrast and was continued for a total of 6 hours. In the placebo group, radiocontrast administration resulted in a mean increase (+/- SD) in serum creatinine of 0.72 +/- 1.15 mg/dL at 48 hours. This increase was less in each of the PGE1 treatment groups after 48 hours, with a significant difference between placebo and the 20 ng/kg/min PGE1 group (P = 0.01). Using baseline adjusted means, analysis of covariance with baseline serum creatinine as the covariable demonstrated significant differences between the placebo and 20 ng/kg/min PGE1 group (P = 0.03) and between the placebo and 10 ng/kg/min PGE1 group P = 0.047). In a subgroup analysis of the diabetic patients, the increase in serum creatinine was less pronounced in the three PGE1 groups versus the placebo group, and the 20 ng/kg/min PGE1 group had the most favorable outcome. The parenteral administration of PGE1 immediately before radiocontrast exposure and continued for a period of 5 to 5.5 hours significantly reduced the elevation of serum creatinine poststudy. The most effective of the three PGE1 dosing regimens was 20 ng/kg/min.

PURPOSE Severe peripheral arterial occlusive disease (pAOD) requires adequate diagnostic imagery of poststenotic and postocclusive vascular regions. This study was designed to evaluate the validity of i.a. DSA using fine-needle technique (FNA) especially concerning the vascular area of the lower limb. MATERIAL AND METHODS 206 FNA of the lower limb wer evaluated retrospectively. Besides evaluation of the image quality of the 1119 angiographic image series, main points of interest were the determination of accuracy of the FNA in comparison to the operative findings, the average radiocontrast agent consumption and the rate of complication. RESULTS In all cases the image quality was rated either very good or good in the pelvic, femoral and popliteal vessels. 94% of the image series of the lower leg and foot could be rated as well as very good/good although 75% of all patients demonstrated an advanced stage of pAOD. Accuracy of FNA compared to operative findings came up to 82%. The average radiocontrast consumption amounted to 69 ml per examination. Overall, two major complications were seen. CONCLUSION I.a. DSA of the lower limb using fine-needle-technique is an easily applied angiographic method of low radiocontrast agent consumption and a low complication rate. Essential information can be acquired preoperatively in planning far peripheral bypass anastomoses. Postoperative vascular complications can be safely assessed.

Amongst 1599 patients undergoing surgery for abdominal aortic aneurysm, there were 89 patients (5.6%) who showed typical features of inflammatory aneurysms of the abdominal aorta (IAAA). 37 of the 89 patients had been examined preoperatively by CT. In 73% of the cases (27/37) a correct diagnosis had been made. Localisation, width and extent of the IAAA was correctly diagnosed in all patients. Involvement of the renal arteries by the inflammatory process, the extent of thrombus and of mural calcification were accurately shown. The inflammatory tissues were typically ventral and lateral to the aorta. Frequently, there were adhesions to neighbouring structures. Aortic rupture, aortic dissection and retroperitoneal lymphoma may produce similar CT appearances; nevertheless, CT remains at present the method of choice for the diagnosis of IAAA because of its high sensitivity.

Background Endoscopic adrenalectomy has become the treatment of choice for small benign adrenal tumours but should not be used for malignant lesions. It is debatable whether large and therefore potentially malignant primary adrenal tumours should be removed by minimally invasive techniques. Methods Three hundred and eighty primary adrenal tumours in 368 patients (142 male and 226 female; mean(s.d.) age 48·9(14·4) years) were excised by laparoscopic or retroperitoneoscopic adrenalectomy. Adrenal neoplasias exceeded 6 cm in diameter (range 6–13 cm) in 33 patients (18 male and 15 female; age 42·6(14·2) years). Results There were no deaths. Patients with large tumours had an increased conversion rate (P = 0·039), longer operating time (P < 0·001) and greater intraoperative blood loss (P = 0·007) than those with smaller lesions, but a similar overall morbidity rate (P = 0·207). Six malignant tumours were identified (diameter 4–10 cm; four phaeochromocytomas and two adrenocortical carcinomas). Local recurrence developed in two patients and distant metastasis occurred in all six patients with malignant lesions. Conclusion Endocopic adrenalectomy perfomed by an experienced surgeon should be the treatment of choice for tumours exceeding 6 cm in diameter.

Aim: TACE with Irinotecan loaded drug-eluting beads has shown activity in colorectal liver metastases. A neoangiogenic reaction due to ischemia may be among the factors interfering with its effectiveness. In this study we evaluated the changes in VEGF-A serum level as a potential surrogate for this neoangiogenic reaction in patients treated with TACE. Methods: Patients with predominant and life threatening liver metastases from CRC which were refractory to all drugs approved for metastasized CRC and documented tumor progression during or shortly after the last chemotherapy, were prospectively treated with DEBIRI with a size of 100-300 µm. Therapy was applied by a temporary catheter placed in the liver arteries. Usually each lobe of the liver was treated two times with an interval of 4 weeks. Each treatment of one liver lobe was performed with 1 vial of the DC-Beads loaded with 100 mg Irinotecan. Blood samples to measure the VEGF-A-serum levels were taken before TACE and at days 8, 15 and 22 after first treatment. Results: Complete blood samples to evaluate the VEGF-A-level were taken from 37 patients (24 m/13 f; median age 64 y) from 2/11 to 5/13. 51% of patients had an increase of the VEGF-A-level compared to baseline of median 75 % after 21 days, whereas 49% of patients had a decrease of the VEGF-A-Level of median 34% after 21 days, respectively. The changes of the VEGF-A-level at day 8 were predictive for the following course of the levels. Baseline levels were significantly higher in patients pretreated with Bevacizumab within the last 9 weeks prior to first DEBIRI (p Conclusions: These findings show different behavior of the serum VEGF-A-levels after DEBIRI-TACE, suggesting that the occlusion of blood vessels and subsequent ischemia induces neo-angiogenesis due to VEGF-A in a subset of 51% of these patients. VEGF-A -level decrease in patients with a Bevacizumab therapy within the last 9 weeks prior to first TACE may be due to a neoangiogenesis-pathway other than VEGF-mediated. These results could implicate that drugs targeting the VEGF-pathway might be effective as an additive therapy to chemoembolization in a subset of patients e.g. those with a low baseline VEGF-A-level. Disclosure: S. Pluntke: Consultancy Terumo Germany. All other authors have declared no conflicts of interest.

93 Background: TACE with irinotecan-loaded drug-eluting beads has shown activity in colorectal liver metastases. Among the factors potentially interfering with its effectiveness is a hypothetical neo-angiogenic reaction due to ischemia. Methods: Patients with predominant liver metastases from CRC which were refractory to chemotherapy and documented tumor progression during or shortly after the last chemotherapy, were prospectively treated with irinotecan-loaded drug-eluting beads with a size of 100-300 µm. Therapy was applied by a temporary catheter placed in the liver arteries. Usually each lobe of the liver was according to the recommended DEBIRI treatment algorithm. Each treatment of one liver lobe was performed with 1 vial of the 100-300 µm DC-Beads loaded with 100 mg irinotecan. Blood samples to measure the VEGF serum levels were taken before TACE and at days 7, 14, and 21 after first treatment. Results: Complete blood samples were taken from 15 patients from 2/11 to 2/12. 60% of patients had an increase of the VEGF-A-Level with a median of 107 %, 40% of patients had a decrease of the VEGF-A-Level with a median of – 39% respectively. The relative decrease of the VEGF-A-Levels depends on a prior liver resection (p=0.05), and a significant decrease was found in patients with a prior bevacizumab therapy (p=0.025). A trend to an increase in VEGF-A-Levels was detected in patients with a low count of liver metastases (p=0.087). Conclusions: These findings show different behavior of the VEGF-A-levels after DEBIRI-TACE, suggesting that the occlusion of blood vessels and subsequent ischemia induces neo-angiogenesis due to these growth factors in a subset of 60% of the patients treated with a DEBIRI-TACE. We found a trend for a lower count of liver metastases, prior liver resection and a prior bevacizumab-therapy, respectively influencing the VEGF-A-Level-changes. The trend toward a decrease in patients with a prior bevacizumab therapy may be due to a neoangiogenesis-pathway other than VEGF-mediated. These first results could implicate that antiangiogenic drugs might be effective as an additive therapy to chemoembolization in a subset of patients, e.g., those with no prior bevacizumab therapy.

Introduction Transcatheter arterial chemoembolization (TACE) with Irinotecan loaded drug eluting beads has shown activity in colorectal liver metastases. Among the factors potentially interfering with its effectiveness is a hypothetical nonangiogenic reaction due to ischemia. In this study we evaluated the changes in VEGF serum levels in patients treated with TACE. Methods Patients with predominant and life threatening liver metastases from CRC which were refractory to all drugs approved for metastasized CRC and documented tumor progression during or shortly after the last chemotherapy, were prospectively treated with Irinotecan loaded drug eluting beads with a size of 100-300 µm. All Patients gave written informed consent. Therapy was applied by a temporary catheter placed in the liver arteries. Usually each lobe of the liver was treated two times with an interval of 4 weeks, according to the recommended DEBIRI treatment algorithm. Each treatment of one liver lobe was performed with 1 vial of the 100-300 µm DC-Beads loaded with 100 mg Irinotecan. Blood samples to measure the VEGF serum levels were taken before TACE and at day 7, 14 and 21 after first treatment (Test-Kit: Human VEGF-A Platinum ELISA, Bender MedSystems). Results Complete blood samples to evaluate the VEGF-A-Levels were taken from 15 Patients ( 12 male/ 3 female; median age 61) from 2/11 to 2/12. 66% (10/15) of patients had an increase of the VEGF-Level with a median of 107, 37%, 33 % (5/15) of patient had a decrease of the VEGF-Level with a median of - 38, 94%. Conclusion These first findings show different behavior of the serum VEGF level after the TACE with Irinotecan loaded Drug eluting Beads, suggesting that the occlusion of blood vessels and subsequent ischemia induces neo-angiogenesis due to these growth factors in 66% of Patients and a subset of 33% with a decrease of VEGF Levels. Updated results concerning correlation of changes of the VEGF-Level with tumor necrosis, response rate or time to progression will be presented. These preliminary results could implicate that antiangiogenic drugs might be effective as an additive therapy to chemoembolization in a subset of patients.