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Coronary CT angiography (cCTA) is a class 1 recommendation in the current guidelines by the European Society of Cardiology (ESC) for excluding significant coronary artery stenosis. To achieve optimal image quality at a low radiation dose, the imaging physician may choose different acquisition modes. Therefore, the consensus guidelines by the Society of Cardiovascular Computed Tomography (SCCT) provide helpful guidance for this procedure.The article provides practical recommendations for the application and acquisition of cCTA based on the current literature and our own experience.According to current ESC guidelines, cCTA is recommended in symptomatic patients with a low or intermediate clinical likelihood for coronary artery disease. We recommend premedication with beta blockers and nitrates prior to CT acquisition under certain conditions even with the latest CT scanner generations. The most current CT scanners offer three possible scan modes for cCTA acquisition. Heart rate is the main factor for selecting the scan mode. Other factors may be coronary calcifications and body mass index (BMI).· CCTA is a valid method to exclude coronary artery disease in patients with a low to intermediate clinical likelihood.. · Even with the latest generation CT scanners, premedication with beta blockers and nitrates can improve image quality at low radiation exposure.. · Current CT scanners usually provide retrospective ECG gating and prospective ECG triggering. Dual-source scanners additionally provide a "high pitch" scan mode to scan the whole heart during one heartbeat, which may also be achieved using single-source scanners with broad detectors in some cases.. · Besides the available scanner technology, the choice of scan mode primarily depends on heart rate and heart rate variability (e. g., arrhythmia)..· Soschynski M, Hagar MT, Taron J et al. Update for the Performance of CT Coronary Angiography. Fortschr Röntgenstr 2022; 194: 613 - 624.Die computertomografische Koronarangiografie (cCTA) hat in den aktuellen Leitlinien der European Society of Cardiology (ESC) einen hohen Stellenwert für den Ausschluss signifikanter Koronarstenosen. Für eine optimale Bildqualität bei niedriger Strahlenexposition stehen dem Untersucher verschiedene Scanverfahren zur Verfügung. Aktuelle Konsensusempfehlungen der Society of Cardiovascular Computed Tomography (SCCT) geben Hinweise für die Durchführung.Der Artikel gibt praktische Empfehlungen zum leitliniengerechten Einsatz und zur Durchführung der cCTA basierend auf der aktuellen Literatur und eigenen Erfahrungswerten.Gemäß den aktuellen Leitlinien der ESC wird die cCTA vor allem bei symptomatischen Patienten mit niedriger und intermediärer klinischer Wahrscheinlichkeit für eine koronare Herzkrankheit (KHK) empfohlen. Vor der Untersuchung empfehlen wir selbst an den modernsten Scannern weiterhin eine Prämedikation mit Beta-Blockern und Nitraten. Für die Akquisition stehen an aktuell verwendeten CT-Scannern 3 Scan-Modi zur Verfügung. Hauptfaktor für die Protokollauswahl ist die Herzfrequenz, Nebenfaktoren können Koronarkalk und Body-Mass-Index (BMI) sein.· Die cCTA kann zunehmend breit bei niedriger und intermediärer klinischer Wahrscheinlichkeit für eine KHK eingesetzt werden.. · Selbst an modernsten CT-Scannern kann die Verwendung von Beta-Blockern und Nitraten eine Verbesserung der Bildqualität bei Protokollen mit niedriger Strahlendosis bewirken.. · Aktuell verwendete CT-Scanner ermöglichen in der Regel ein retrospektives EKG-Gating sowie einen prospektiv EKG-getriggerten Scan. An Dual Source-Scannern besteht zusätzlich die Möglichkeit mit einem „High pitch“-Modus das gesamte Herz innerhalb eines Herzschlages abzubilden, bei Single-Source-Scannern mit breitem Detektor gelingt dies z. T. mit einem „Single-heart-beat“-Modus ebenfalls.. · Neben der verfügbaren CT-Scanner-Technologie ist die Wahl des Scan-Modus primär von der Herzfrequenz sowie der Herzfrequenzvariabilität bzw. dem Vorliegen von Arrhythmien abhängig..· Soschynski M, Hagar MT, Taron J et al. Update for the Performance of CT Coronary Angiography. Fortschr Röntgenstr 2022; 194: 613 – 624.

Background/Aim: To investigate whether quantitative analysis of diffusion weighted images allows for improved risk stratification of transition zone lesions in prostate magnetic resonance imaging (MRI) evaluated according to PI-RADSv2.1 [Prostate Imaging Reporting and Data System, target variable: clinically significant prostate cancer (csPCa)]. Patients and Methods: Consecutive patients with transition zone lesions in 3T prostate MRI were enrolled in the study. All lesions on MRI were histopathologically verified by transperineal MRI-TRUS fusion biopsy. Two blinded radiologists re-evaluated all lesions according to PI-RADSv2.1. A consensus reading was performed after reading of all cases. Additionally, mean apparent diffusion coefficient values (mADC) were derived from blinded lesion segmentation. ROC analysis was performed for PI-RADS categories and PI-RADS categories with separate subcategories and diffusion coefficient values (ADC). Data were examined for optimal mADC cut-off values that improve stratification of csPCa and benign lesions. Results: Among 85 patients (mean age=66.2 years), 98 transition zone lesions were detected. Biopsy confirmed csPCa in 24/98 cases. Area under the curve (AUC) was 0.89/0.90 for reader 1, 0.92/0.91 for reader 2 and 0.92/0.91 for the consensus reading (5 category analysis/analysis with subcategories separately). Inter-reader agreement was substantial, with lower PI-RADS categories assigned by the more experienced reader (p

Objectives: To examine if calcium scoring CT (CAS-CT) reduces the whole-examination radiation dose of prospectively ECG-triggered coronary CT-angiography (CCTA). Methods In this retrospective study, patients underwent CAS-CT and prospectively ECG-triggered CCTA on a 2nd generation Dual-Source CT scanner. CCTA was planned on CAS-CT images. We further simulated CCTA-planning on scout-view. Therefore, the scan length of the scout-view-derived CCTA was set equal to the CAS-CT scan length. Effective doses were compared for the following scenarios: (1) CAS-CT-derived CCTA + CAS-CT and (2) scout-view-derived CCTA without CAS-CT. Dose differences between the scenarios were additionally examined with respect to scan mode and body-mass-index. Results Among 182 patients (58±12 years, 47% females), planning cCTA on CAS-CT resulted in a shorter scan length than planning on scout-view (114.3 ± 9.7 mm vs 133.7 ± 13.2 mm, pConclusions Planning prospectively ECG-triggered CCTA on CAS-CT reduces the overall radiation dose of the examination compared to a scout-view planning approach where no CAS-CT is acquired. Only for high-pitch spiral CCTA a slightly opposite effect was observed.

The aim of this paper is to evaluate the diagnostic image quality of spectral dual-source photon-counting detector coronary computed tomography angiography (PCD-CCTA) for coronary artery disease in a multicenter study. The image quality (IQ), assessability, contrast-to-noise ratio (CNR), Agatston score, and radiation exposure were measured. Stenoses were quantified and compared with invasive coronary angiography, if available. A total of 92 subjects (65% male, age 58 ± 14 years) were analyzed. The prevalence of significant coronary artery disease (CAD) (stenosis ≥ 50%) was 17% of all patients, the range of the Agatston score was 0–2965 (interquartile range (IQR) 0–135). The IQ was very good (one, IQR one–two), the CNR was very high (20 ± 10), and 5% of the segments were rated non-diagnostic. The IQ and assessability were higher in proximal coronary segments (p < 0.001). Agatston scores up to 600 did not significantly affect the assessability of the coronary segments (p = 0.3). Heart rate influenced assessability only at a high-pitch mode (p = 0.009). For the invasive coronary angiography (ICA) subgroup (n = nine), the diagnostic performance for CAD per segment was high (sensitivity 92%, specificity 96%), although the limited number of patients who underwent both diagnostic modalities limits the generalization of this finding at this stage. PCD-CCTA provides good image quality for low and moderate levels of coronary calcifications.

Cardiac diseases are the leading cause of death. Many diseases can be specifically treated once a valid diagnosis is established. Cardiac magnetic resonance imaging (MRI) plays a central role in the workup of many cardiac pathologies. However, image acquisition as well as interpretation and related secondary image evaluation are time-consuming and complex.Cardiac MRI is becoming increasingly established in international guidelines for the evaluation of cardiac function and differential diagnosis of a wide variety of cardiac diseases.Cardiac MRI has limited reproducibility due to the acquisition technique and interpretation of findings with complex secondary measurements. Artificial intelligence techniques and radiomics offer the potential to improve the acquisition, interpretation, and reproducibility of cardiac MRI.Research suggests that artificial intelligence and radiomic analysis can improve cardiac MRI in terms of image acquisition and also diagnostic and prognostic value. Furthermore, the implementation of artificial intelligence and radiomics may result in the identification of new biomarkers.The implementation of artificial intelligence in cardiac MRI has great potential. However, the current level of evidence is still limited in some aspects; in particular there are too few prospective and large multicenter studies available. As a result, the algorithms developed are often not sufficiently validated scientifically and are not yet applied in clinical routine.KLINISCHES/METHODISCHES PROBLEM: Kardiale Erkrankungen sind weltweit die führende Todesursache. Viele Erkrankungen können gezielt behandelt werden, sobald eine valide Diagnose gestellt wurde. Die kardiale Magnetresonanztomographie (MRT) hat in der Abklärung zahlreicher kardialer Pathologien einen hohen Stellenwert. Jedoch sind sowohl die Bildakquisition als auch die Befundung und damit zusammenhängende sekundäre Bildauswertungen zeitaufwändig und komplex.In den internationalen Leitlinien etabliert sich die kardiale MRT zunehmend in der Evaluation der Herzfunktion und der Differenzialdiagnostik verschiedenster kardialer Erkrankungen.Die kardiale MRT besitzt aufgrund der Aufnahmetechnik und der Befundung mit aufwändigen Sekundärmessungen eine eingeschränkte Reproduzierbarkeit. Techniken künstlicher Intelligenz (KI) und Radiomics bieten das Potenzial, die Akquisition, Befundung und Reproduzierbarkeit der kardialen MRT zu verbessern. LEISTUNGSFäHIGKEIT: Studien zeigen, dass KI und Radiomics-Analysen die kardiale MRT hinsichtlich Bildakquisition, diagnostischer und prognostischer Wertigkeit verbessern können. Zudem konnten mit dieser Herangehensweise neue Biomarker identifiziert werden. BEWERTUNG UND EMPFEHLUNG FüR DIE PRAXIS: In der Anwendung von KI in der kardialen MRT liegt großes Potenzial. Die aktuelle Datenlage ist in einigen Aspekten noch zu gering, vor allem liegen zu wenige prospektive und große multizentrische Studien vor. Dadurch sind die entwickelten Algorithmen häufig wissenschaftlich nicht ausreichend validiert und finden in der klinischen Routine noch keine Anwendung.

The optimal treatment strategy for patients with small non-functioning VHL-related incidentalomas is unclear. We searched the Freiburg VHL registry for patients with radiologic evidence of pheochromocytoma/paraganglioma (PHEO/PGL). In total, 176 patients with single, multiple, and recurrent tumours were identified (1.84 tumours/patient, range 1–8). Mean age at diagnosis was 32 ± 16 years. Seventy-four percent of tumours were localised to the adrenals. Mean tumour diameter was 2.42 ± 2.27 cm, 46% were P < 0.025) and before surgery (4.89 ± 3.47 cm vs 1.36 ± 0.43 cm; P < 0.02). Disease was stable in 67% of 21 patients with evaluable tumours ≤1.5 cm according to RECIST and progressed in 7. Time till surgery in these patients was 29.5 ± 20.0 months. A total of 155 patients underwent surgery. PHEO/PGL was histologically excluded in 4 and proven in 151. Of these, one had additional metastatic disease, one harboured another tumour of a different type, and in 2 a second surgery for suspected disease recurrence did not confirm PHEO/PGL. Logistic regression analysis revealed 50% probability for a positive/negative biochemical test result at 1.8 cm tumour diameter. Values of a novel symptom score were positively correlated with tumour size (Rs = 0.46, P < 0.0001) and together with a positive biochemistry a linear size predictor (P < 0.01). Results support standardised clinical assessment and measurement of tumour size and metanephrines in VHL patients with non-functioning incidentalomas

Introduction Hemangioblastomas are rare, histologically benign, highly vascularized tumors of the brain, the spinal cord, and the retina, occurring sporadically or associated with the autosomal dominant inherited von Hippel-Lindau (VHL) disease. Children or adults with VHL disease have one of > 300 known germline mutations of the VHL gene located on chromosome 3. They are prone to develop hemangioblastomas, extremely rarely starting at age 6, rarely at age 12–18, and, typically and almost all, as adults. There is a plethora of VHL-associated tumors and cysts, mainly in the kidney, pancreas, adrenals, reproductive organs, and central nervous system. Due to a lack of causal treatment, alleviation of symptoms and prevention of permanent neurological deficits as well as malignant transformation are the main task. Paucity of data and the nonlinear course of tumor progression make management of pediatric VHL patients with hemangioblastomas challenging. Methods The Freiburg surveillance protocol was developed by combining data from the literature and our experience of examinations of > 300 VHL patients per year at our university VHL center. Results Key recommendations are to start screening of patients at risk by funduscopy with dilated pupils for retinal tumors with admission to school and with MRI of the brain and spinal cord at age 14, then continue biannually until age 18, with emergency MRI in case of neurological symptoms. Indication for surgery remains personalized and should be approved by an experienced VHL board, but we regard neurological symptoms, rapid tumor growth, or critically large tumor/cyst sizes as the key indications to remove hemangioblastomas. Since repeated surgery on hemangioblastomas in VHL patients is not rare, modern neurosurgical techniques should encompass microsurgery, neuronavigation, intraoperative neuromonitoring, fluorescein dye-based intraoperative angiography, intraoperative ultrasound, and minimally invasive approaches, preceded in selected cases by endovascular embolization. Highly specialized neurosurgeons are able to achieve a very low risk of permanent morbidity for the removal of hemangioblastomas from the cerebellum and spinal cord. Small retinal tumors of the peripheral retina can be treated by laser coagulation, larger tumors by cryocoagulation or brachytherapy. Conclusion We consider management at experienced VHL centers mandatory and careful surveillance and monitoring of asymptomatic lesions are required to prevent unnecessary operations and minimize morbidity.

Coronary CT angiography (cCTA) has a high negative predictive value for ruling out significant coronary stenoses. However, it is limited in determining hemodynamic significance of a stenosis and hence to prove the indication for therapy.When and how is cCTA used according to current guidelines? Which functional CT techniques are available to test for hemodynamic significance of coronary stenoses?The value of cCTA is explained on the basis of current guidelines by the European Society of Cardiology (ESC) for the diagnosis of chronic coronary syndromes. Functional CT techniques which test for hemodynamic significance of coronary stenoses are myocardial CT-perfusion (CT‑P) and CT-based fractional flow reserve (CT-FFR).The new ESC guidelines classify cCTA as a class 1 recommendation for diagnosing coronary artery disease in symptomatic patients with low clinical likelihood. If clinical likelihood is high or an at least moderate stenosis is detected with cCTA, noninvasive functional (stress) imaging is preferred. There is a large body of evidence for CT‑P and CT-FFR as functional tests.In the current guidelines, cCTA is highly recommended for the diagnosis of coronary artery disease. The functional CT techniques CT‑P and CT-FFR have shown high diagnostic accuracy for myocardial ischemia of coronary stenoses in many clinical studies. However, these methods are not part of current guidelines yet and clinical adoption is still low.

Aim: The present study analyzes in depth the impact of different calcification patterns on disturbances of the conduction system in transcatheter aortic valve replacement (TAVR) patients. Methods and Results: A total of 169 preprocedural TAVR multislice computed tomography scans from consecutive transfemoral (TF) TAVRs performed between 2014 and 2017 using either Edwards SAPIEN or Medtronic Evolut R valves were retrospectively evaluated. The volume, distribution, and orientation of annular and valvular aortic valve calcification were measured and their impact on postoperative conduction disturbances was determined using linear and logistic regression analyses. The total volume of calcification and distribution at the aortic annulus or valve did not influence the conduction system. Oval calcification of the left aortic cusp was independently associated with an elevated risk for an increase in atrioventricular block degree (+0.6, p = 0.03). Moreover, orthogonal calcifications at the level of the aortic annulus were associated with an increased risk for QRS prolongation (+26 ms, p = 0.004) and an increased risk for permanent pacemaker implantation (OR 4.3, p = 0.03) after TF TAVR. This was more pronounced in patients undergoing TF TAVR using a balloon-expandable Edwards SAPIEN 3 valve (QRS +38.195 ms, p < 0.001; OR permanent pacemaker 15.48, p = 0.013). Conclusion: Orthogonal annular calcification confers an increased risk for conduction disturbances after TAVR. This is even more pronounced after implantation of balloon-expandable valves.

Pancreatic neuroendocrine tumors (PanNETs) are rare in von Hippel–Lindau disease (VHL) but cause serious morbidity and mortality. Management guidelines for VHL-PanNETs continue to be based on limited evidence, and survival data to guide surgical management are lacking. We established the European-American-Asian-VHL-PanNET-Registry to assess data for risks for metastases, survival and long-term outcomes to provide best management recommendations. Of 2330 VHL patients, 273 had a total of 484 PanNETs. Median age at diagnosis of PanNET was 35 years (range 10–75). Fifty-five (20%) patients had metastatic PanNETs. Metastatic PanNETs were significantly larger (median size 5 vs 2 cm; P P = 0.001). All metastatic tumors were ≥2.8 cm. Codons 161 and 167 were hotspots for VHL germline mutations with enhanced risk for metastatic PanNETs. Multivariate prediction modeling disclosed maximum tumor diameter and TVDT as significant predictors for metastatic disease (positive and negative predictive values of 51% and 100% for diameter cut-off ≥2.8 cm, 44% and 91% for TVDT cut-off of ≤24 months). In 117 of 273 patients, PanNETs >1.5 cm in diameter were operated. Ten-year survival was significantly longer in operated vs non-operated patients, in particular for PanNETs P = 0.020; 80% vs 50% at 10 years; P = 0.030). This study demonstrates that patients with PanNET approaching the cut-off diameter of 2.8 cm should be operated. Mutations in exon 3, especially of codons 161/167 are at enhanced risk for metastatic PanNETs. Survival is significantly longer in operated non-metastatic VHL-PanNETs.

To validate the risk stratification algorithm of the Prostate Imaging Reporting and Data System (PI-RADSv2) for intermediary risk lesions (PI-RADSv2 category 3) in the peripheral zone based on focal contrast enhancement and to compare cancer rates in category 3, upgraded category 4 and category 4 based on markedly low ADC value.We retrospectively analyze 172 consecutive patients undergoing prostate MRI with 315 histopathologically verified lesions. We select all lesions either assigned category 3 or category 4 in the peripheral zone for further analysis. We compare cancer rates with the two-sided chi-squared test. To determine inter-observer agreement about contrast enhancement two blinded radiologists evaluate the subset of category 3 lesions based on the diffusion weighted sequence.The frequency of peripheral PI-RADS 3, upgraded PI-RADS 4 and PI-RADS 4 lesions based on markedly low ADC value is 10.8%, 10.8% and 20.3%, respectively. Cancer rates (significant cancer only) in these subgroups are 8.8% (3/34), 23.5% (8/34) and 40.6% (26/64), P 0.01. Inter-observer agreement is moderate for evaluation of contrast enhancement with kappa values between 0.46 and 0.5.We demonstrate a trend of increasing cancer rate from PI-RADSv2 category 3 to upgraded category 4 to category 4 based on markedly low ADC value. Peripheral lesions of intermediary risk in the diffusion weighted sequence account for 21.6% of all prostate lesions encountered. Since it is likely that patient management recommendations will be linked to assessment categories in future versions of PI-RADS, cancer rates in upgraded category 4 and category 4 based on markedly low ADC values should be in a similar range. We conclude that in future studies of PI-RADSv2 upgraded category 4 and category 4 based on markedly low ADC value should be reported separately to generate a database for meta-analysis of cancer rates.

Achievement incentives in sports are assumed to trigger achievement motivation, which in turn increases performance. We used a within-subject-design to test achievement motive arousal (using an A-B-A design) using video clips. We hypothesized that an ACH-video clip arouses the achievement motive (PSE) stronger, leads to better performance in a skipping task and elicits stronger perceived effort and commitment for the task than the NEUTRAL- and NO-video conditions. We investigated gender differences. 184 students (92 women, age: M = 27.66 years, SD = 9.72) participated in a three-part web-survey. Neither main nor interaction effects of Video-Condition and Gender were found on motive arousal and skipping frequency. Significant interaction effects on skipping slope and perceived effort, however, showed that women are more engaged after the ACH-video than after the NEUTRAL-video and NO-video and here even outperformed men. Results are discussed in terms of why external “motivators” (e.g., videos) affect men and women differently.

Transcatheter aortic valve implantation (TAVI) has evolved into an alternative procedure to surgical valve replacement for high-risk patients with aortic valve stenosis. Despite technical innovations, there is still a risk of complications during and after the intervention. After a TAVI procedure, ECG-gated multidetector computed tomography (MDCT) plays an important role in the early diagnosis of local complications. In this article, we explain for the first time how the technical acquisition of MDCT in the region of the aortic root is performed as post-interventional control of the TAVI prosthesis. In the second part normal post-interventional findings of different prosthetic valves as well as classic and uncommon complications in the implant area will be illustrated in several case studies. In this review the current literature from PubMed about ECG-gated MDCT after TAVI is summarized and structured. It is supplemented by several case studies from our institution. Using retrospectively ECG-gated MDCT, an aortic valve prosthesis after TAVI can be visualized with high spatial resolution in several phases of the cardiac cycle. Images of the implanted aortic valve at all time points of the cardiac cycle enable a functional analysis of prosthetic leaflets similar to echocardiography. MDCT is superior to transthoracic echocardiography with respect to the direct detection of prosthetic leaflet thrombosis. The position of the device in relation to the coronary ostia and correct unfolding of the stent frame need to be evaluated. There are different types of stents carrying the valve leaflets with distinct ideal positions. Any stent should cover the left ventricular outflow tract (LVOT) along its whole circumference. Life-threatening complications in the implant area, such as annulus rupture, can be diagnosed reliably with CT. · ECG-gated multidetector CT (MDCT) after transcatheter aortic valve implantation (TAVI) can provide early detection of postinterventional complications of the prosthetic valve and the aortic root.. · MDCT is superior to echocardiography with respect to the direct detection of prosthetic leaflet thrombosis.. · MDCT can also reveal hypokinesia of the thrombotic valve leaflets.. · Correct position of the device und unfolding of the stent frame differ according to the type of prosthesis.. · The integrity of the native aortic root should be carefully assessed..· Soschynski M, Capilli F, Ruile P et al. Post-TAVI Follow-Up with MDCT of the Valve Prosthesis: Technical Application, Regular Findings and Typical Local Post-Interventional Complications. Fortschr Röntgenstr 2018; 190: 521 - 530. Die Transkatheter-Aortenklappen-Implantation (TAVI) hat sich als Alternative zum chirurgischen Klappenersatz für Patienten mit hohem Operationsrisiko etabliert. Trotz technischer Optimierungen besteht immer noch ein Risiko für Komplikationen während und nach dem Eingriff. Für die postinterventionelle Kontrolle der stentgetragenen Klappenprothese spielt die EKG-getriggerte Multidetektor-Computertomografie (MDCT) eine wichtige Rolle in der frühzeitigen Diagnostik von lokalen Komplikationen. In diesem Artikel gehen wir zunächst auf die technische Durchführung der MDCT im Bereich der Aortenwurzel zur Kontrolle der TAVI-Klappenprothese ein. Im zweiten Schritt werden anhand mehrerer Fallbeispiele postinterventionelle Normalbefunde verschiedener Klappentypen sowie klassische und seltene Komplikationen im Implantationsgebiet illustriert. Die Übersichtsarbeit fasst die Literatur in PubMed zum Thema EKG-getriggerte MDCT nach TAVI strukturiert zusammen und wird um eine Fallsammlung aus unserem Institut ergänzt. Mittels retrospektiv EKG-getriggerter MDCT kann die Aortenklappenprothese nach TAVI räumlich hochaufgelöst in mehreren Phasen des Herzzyklus darstellt werden. Die Darstellung der Klappenprothese über den gesamten Herzzyklus erlaubt eine Funktionsanalyse der bewegten Klappe ähnlich der Echokardiografie. Die MDCT ist der transthorakalen Echokardiografie im direkten Nachweis einer Klappenthrombose überlegen. Bei der Befundung muss die Lage der stentgetragenen Klappe in Bezug zu den Koronargefäßen und die Stententfaltung evaluiert werden. Je nach Klappentyp bestehen unterschiedliche Stentformen und ideale Positionen. Jeder Stent sollte mit der gesamten Zirkumferenz dem linksventrikulären Ausflusstrakt anliegen. Lebensbedrohliche Komplikationen im Implantationsgebiet wie eine Annulusruptur können im CT sicher diagnostiziert werden. · Mit der EKG-getriggerten Multidetektor-CT (MDCT) nach Transkatheter-Aortenklappen-Implantation (TAVI) können postinterventionelle Komplikationen an der Klappenprothese und der Aortenwurzel frühzeitig erkannt werden.. · Die MDCT ist der Echokardiografie im direkten Nachweis einer Klappenthrombose überlegen.. · Das Erkennen einer Hypokinesie bei Klappenthrombose ist ebenfalls mittels MDCT möglich.. · Die korrekte Stentlage und die Stententfaltung unterscheiden sich je nach Klappentyp.. · Auf die Integrität der Aortenwurzel ist gesondert zu achten..· Soschynski M, Capilli F, Ruile P et al. Post-TAVI Follow-Up with MDCT of the Valve Prosthesis: Technical Application, Regular Findings and Typical Local Post-Interventional Complications. Fortschr Röntgenstr 2018; 190: 521 – 530.

Purpose The exact detection and delineation of the intraprostatic tumour burden is crucial for treatment planning in primary prostate cancer (PCa). We compared 68Ga-HBED-CC-PSMA PET/CT with multiparametric MRI (mpMRI) for diagnosis and tumour delineation in patients with primary PCa based on slice by slice correlation with histopathological reference material. Methodology Seven patients with histopathologically proven primary PCa underwent 68Ga-HBED-CC-PSMA PET/CT and MRI followed by radical prostatectomy. Resected prostates were scanned by ex-vivo CT in a special localizer and prepared for histopathology. Invasive PCa was delineated on a HE stained histologic tissue slide and matched to ex-vivo CT to obtain gross tumor volume (GTV-)histo. Ex-vivo CT including GTV-histo and MRI data were matched to in-vivo CT(PET). Consensus contours based on MRI (GTV-MRI), PSMA PET (GTV-PET) or the combination of both (GTV-union/-intersection) were created. In each in-vivo CT slice the prostate was separated into 4 equal segments and sensitivity and specificity for PSMA PET and mpMRI were assessed by comparison with histological reference material. Furthermore, the spatial overlap between GTV-histo and GTV-PET/-MRI and the Sorensen-Dice coefficient (DSC) were calculated. In the case of multifocal PCa (4/7 patients), SUV values (PSMA PET) and ADC-values (diffusion weighted MRI) were obtained for each lesion. Results PSMA PET and mpMRI detected PCa in all patients. GTV-histo was detected in 225 of 340 segments (66.2%). Sensitivity and specificity for GTV-PET, GTV-MRI, GTV-union and GTV-intersection were 75% and 87%, 70% and 82%, 82% and 67%, 55% and 99%, respectively. GTV-histo had on average the highest overlap with GTV-union (57±22%), which was significantly higher than overlap with GTV-MRI (p=0.016) and GTV-PET (p=0.016), respectively. The mean DSC for GTV-union, GTV-PET and GTV-MRI was 0.51 (±0.18), 0.45 (±0.17) and 0.48 (±0.19), respectively. In every patient with multifocal PCa there was one lesion which had both the highest SUV and the lowest ADC-value (mean and max). Conclusion In a slice by slice analysis with histopathology, 68Ga-HBED-CC-PSMA PET/CT and mpMRI showed high sensitivity and specificity in detection of primary PCa. A combination of both methods performed even better in terms of sensitivity (GTV-union) and specificity (GTV-intersection). A moderate to good spatial overlap with GTV-histo was observed for PSMA PET/CT and mpMRI alone which was significantly improved by GTV-union. Further studies are warranted to analyse the impact of these preliminary findings for diagnostic (multimodal guided TRUS biopsy) and therapeutic (focal therapy) strategies in primary PCa.

Purpose PET/CT directed extended salvage radiotherapy (esRT) of involved lymph-node (LN) regions may be a salvage strategy for patients with nodal recurrent prostate cancer (PCa) after primary therapy or after previous prostate fossa salvage RT. The aim of the study was to determine the time until prostate-specific antigen (PSA) progression, pattern of failure and toxicity after esRT. Material and methods 25 patients with nodal or nodal + local recurrent PCa confirmed by Choline-PET/CT and Magnetic Resonance Imaging (MRI) were treated with esRT at the sites of recurrence. Acute and late toxicity was recorded. In case of subsequent PSA progression, imaging was performed to confirm next relapse. Mean follow-up was 2.9 years. Results According to Choline-PET/CT and MRI findings, 84% (21/25) of esRT were treatment of pelvic only, 12% (3/25) of retroperitoneal only and 4% (1/25) of both pelvic and retroperitoneal regions. 40% (10/25) received concomitant irradiation of the prostatic fossa (after primary radical prostatectomy). Median time to PSA progression of the whole cohort was 19.6 months. Median time to PSA progression for patients with 1–2 PET-positive LN ( n = 15) was 34.9 months versus median 12.7 months for patients with PET-positive LN ≥ 3 ( n = 10), p -value: 0.0476. Acute and late toxicity was mild to moderate, no grade-3 adverse events were observed. Conclusion PET/CT and MRI directed esRT of nodal recurrent PCa with or without local recurrence is feasible with low acute and late toxicity. Patients with only one or two PET-positive LN treated by esRT achieved prolonged complete biochemical remission.

Objective. In this study, we compared prostate cancer detection rates between MRI-TRUS fusion targeted and systematic biopsies using a robot-guided, software based transperineal approach. Methods and Patients. 52 patients received a MRIT/TRUS fusion followed by a systematic volume adapted biopsy using the same robot-guided transperineal approach. The primary outcome was the detection rate of clinically significant disease (Gleason grade ≥ 4). Secondary outcomes were detection rate of all cancers, sampling efficiency and utility, and serious adverse event rate. Patients received no antibiotic prophylaxis. Results. From 52 patients, 519 targeted biopsies from 135 lesions and 1561 random biopsies were generated (total n=2080). Overall detection rate of clinically significant PCa was 44.2% (23/52) and 50.0% (26/52) for target and random biopsy, respectively. Sampling efficiency as the median number of cores needed to detect clinically significant prostate cancer was 9 for target (IQR: 6–14.0) and 32 (IQR: 24–32) for random biopsy. The utility as the number of additionally detected clinically significant PCa cases by either strategy was 0% (0/52) for target and 3.9% (2/52) for random biopsy. Conclusions. MRI/TRUS fusion based target biopsy did not show an advantage in the overall detection rate of clinically significant prostate cancer.

Objectives To evaluate a systolic ECG-gated high-pitch aortoiliac computed tomography (CT) angiography for planning transcatheter aortic valve implantation (TAVI). Methods Patients referred for TAVI underwent a combined CT imaging with retrospective, multiphasic ECG-gating of the heart and systolic ECG-gated high-pitch aortoiliac CT angiography. Consecutive patients were retrospectively included in this study group. Heart rate (HR) and heart rate variability (HRV) were assessed during the high-pitch ECG prediction phase. Aortic annulus area (AAA) was planimetrically quantified on both datasets. While only one moment of cardiac cycle was available for measurements in the high-pitch CT, the point of time in the multiphasic CT was chosen, where AAA yielded maximum size. Hypothetical prosthesis sizing was compared between multiphasic vs. high-pitch CT. Results Among 61 patients (44.2 % men, mean age: 83.3 ± 5.5 years) average heart rate and HRV were 71.0 ± 13.4 bpm and 7.3 ± 8.5 bpm. 20 patients (32.7 %) had atrial fibrillation at the time of image acquisition. There was a strong correlation of AAA as derived from multiphasic vs. the high-pitch CT (r = 0.98). The difference in AAA was 10.5 ± 17.1mm2 (455.1 ± 83.0 mm2 for multiphasic vs. 444.5 ± 87.2 mm2 for high-pitch CT) and did not reach statistical significance (p = 0.08). Hypothetical prosthesis sizing showed an agreement in 55 of 61 patients (90.2 %). A sizing based on the high-pitch CT resulted in smaller prosthesis choice in 6 patients, all of them suffering from atrial fibrillation. Mean effective radiation dose was 10.9 ± 6.1 mSv for cardiac CTA and 4.1 ± 1.0 mSv for high-pitch CTA. Conclusion For patients with sinus rhythm, systolic high-pitch aortoiliac CTA provides adequate prosthesis size selection as compared with multiphasic ECG-gated cardiac CTA and may result in significantly reduced radiation exposition.

Purpose Patients hospitalized for infection with SARS-CoV-2 typically present with pneumonia. The respiratory failure is frequently complicated by pulmonary embolism in segmental pulmonary arteries. The distribution of pulmonary embolism in regard to lung parenchymal opacifications has not been investigated yet. Methods All patients with COVID-19 treated at a medical intensive care unit between March 8th and April 15th, 2020 undergoing computed tomography pulmonary angiography (CTPA) were included. All CTPA were assessed by two radiologists independently in respect to parenchymal changes and pulmonary embolism on a lung segment basis. Results Out of 22 patients with severe COVID-19 treated within the observed time period, 16 (age 60.4 ± 10.2 years, 6 female SAPS2 score 49.2 ± 13.9) underwent CT. A total of 288 lung segment were analyzed. Thrombi were detectable in 9/16 (56.3%) patients, with 4.4 ± 2.9 segments occluded per patient and 40/288 (13.9%) segments affected in the whole cohort. Patients with thrombi had significantly worse segmental opacifications in CT (p, Highlights (mandatory) • In COVID-19 respiratory failure, thrombi in segmental pulmonary arteries are common. • All Thrombi detected were localized in opacitated (presumably COVID-19 affected) lung segments. • This might suggest local clot formation.

To determine the value of a radiomics MRI phenotype of the transition zone to explain PSA level in patients with low suspicion for clinically significant cancer to confirm hyperplastic changes.T2 weighted images from 36 consecutive PI-RADS 2 and 3 cases with volume adapted systematic transperineal biopsy as reference standard (all biopsies negative, 34.8 biopsy cores per patient in average, mean PSA level 10.77 ng/mL) are manually segmented to define transition zone (TZ) volume. 54 radiomic features (RF) are derived for each TZ. RF are tested for significant correlation with PSA level, Bonferroni correction is applied. We build regression models to explain PSA level with a) TZ volume b) RF c) TZ volume+RF. We apply all models to a control group with clinically significant transition zone cancer.TZ volume is moderately correlated with PSA level (r = 0.44). 5/54 RF are significantly correlated with PSA level (r: 0.53-0.69, p 0.05). Inclusion of each of these five features into the regression model significantly improves the explanatory value for PSA level (p 0.05). Furthermore, RF alone better explain PSA level compared to TZ volume alone (p 0.01). A systematic and significant trend for positive residuals is observed when regression models are applied to the malignant control group.A radiomics analysis of the transition zone has the potential to improve explanation of corresponding PSA level in patients with low suspicion. This knowledge may reassure radiologists to read prostate MRI cases as unremarkable, despite present hyperplastic changes.

WOS: 000439200100008, PubMed ID: 29794110, Although the authors of the present review have contributed to genetic discoveries in the field of pheochromocytoma research, we can legitimately ask whether these advances have led to improvements in the diagnosis and management of patients with pheochromocytoma. The answer to this question is an emphatic Yes! In the field of molecular genetics, the well-established axiom that familial (genetic) pheochromocytoma represents 10% of all cases has been overturned, with >35% of cases now attributable to germline disease-causing mutations. Furthermore, genetic pheochromocytoma can now be grouped into five different clinical presentation types in the context of the ten known susceptibility genes for pheochromocytoma-associated syndromes. We now have the tools to diagnose patients with genetic pheochromocytoma, identify germline mutation carriers and to offer gene-informed medical management including enhanced surveillance and prevention. Clinically, we now treat an entire family of tumors of the paraganglia, with the exact phenotype varying by specific gene. In terms of detection and classification, simultaneous advances in biochemical detection and imaging localization have taken place, and the histopathology of the paraganglioma tumor family has been revised by immunohistochemical-genetic classification by gene-specific antibody immunohistochemistry. Treatment options have also been substantially enriched by the application of minimally invasive and adrenal-sparing surgery. Finally and most importantly, it is now widely recognized that patients with genetic pheochromocytoma/paraganglioma syndromes should be treated in specialized centers dedicated to the diagnosis, treatment and surveillance of this rare neoplasm.

Background: Adrenalectomy is standard of care for phaeochromocytomas, but for bilateral phaeochromocytoma, the recommendations are inconsistent. However, large studies systematically investigating long-term outcomes for total adrenalectomies compared to those for patients with adrenal-sparing operations are lacking. Methods: A multi-center consortium-based registry was established to study clinical, genetic and surgical data in 623 patients with bilateral phaeochromocytomas. Findings: Of 623 patients, median age at diagnosis was 30 (range 3-79) years and 48% were female. Synchronous bilateral phaeochromocytomas were diagnosed in 396 patients and metachronousphaeochromocytomas in 227 (36%); interval to second operations were up to 40 (median 6) years. In 96% of tested patients germline mutations were detected in the genes RET (56%), VHL (34%), and others (10%). Of 849 operations, 385 (45%) surgeries in 326 patients were planned as adrenal-sparing which was successful in 251. 372 patients became steroid-dependent. Follow-up was up to 53 (median 11) years. Adrenal crises developed in 67 patients (18%) during follow-up, and 49 (13%) had manifestations of iatrogenic Cushing syndrome. Of the steroid-independent patients, 34 (14%) had developed another phaeochromocytoma within the remnant adrenal after up to 27, median 8 years, all treated with removal of the new phaeochromocytoma. Overall survival was mainly influenced by non-phaeochromocytoma comorbidities, whereas only 1% died of metastatic phaeochromocytoma. Cortical-sparing operations did not affect survival. Interpretation: Cortical-sparing operations avert lifelong steroid-dependency without affecting survival. Preoperative genetic testing is recommended even in unilateral phaeochromocytoma presentations to identify patients at heritable risk, to guide surgical approach, and inform for gene-specific extra-adrenal morbidities. Funding Statement: Supported in part by the grant AZV 16-32665A to Sarka Dvorakova and Petr Vlcek, and the Blank Foundation to Charis Eng. Declaration of Interests: None of the authors have relevant conflicts of interest. Ethics Approval Statement: The institutional review boards for human subjects’ protection or ethical committees of all participating centers approved this study. Patients provided written informed consent according to the protocols of respective institutional review boards. In The Netherlands data were collected anonymously, and no further Institutional Review Board approval is required.

Hartmut P.H. Neumann is supported by grants from the Deutsche Krebshilfe (Grant 107995 to H.P.H.N.). Stephane Richard is supported by grants from the Direction Generale de l’Organisation des Soins (French Department of Health), the Institut National du Cancer (INCa; French NCI), and the Ligue Nationale contre le Cancer (Comites du Cher et de l’Indre; French League against Cancer).

Concerning rates of pulmonary vein (PV) stenosis were reported following PV isolation (PVI) with a circular pulmonary vein ablation catheter (PVAC). As this may depend on intraprocedural imaging, we evaluated the incidence of PV stenosis in patients undergoing PVAC-PVI with continuous surveillance by intracardiac echocardiography (ICE). Multi-slice computed tomography was performed before and 3 months after PVAC-PVI with continuous ICE surveillance in 30 patients (37 % male, 65 ± 9 years). PV areas at two levels (ostial and 1 cm distally) and left atrial (LA) volumes were measured. PV area/LA volume ratio was calculated to correct for reverse LA remodelling. PV stenosis was classified as mild (25–50 %), moderate (50–75 %) and severe (>75 %). One hundred sixteen veins were isolated with PVAC with additional touch-up ablation in one patient. One patient was excluded from analysis for untriggered CT acquisition. Left atrial volume decreased from 109.1 ± 30.9 cm3 before to 98.4 ± 34.4 cm3 after ablation (p

To examine the diagnostic performance of PI-RADSv2 T2w and diffusion weighted imaging (DWI) based lexicon descriptors, inter-observer agreement for descriptor assignment and diagnostic accuracy of the PI-RADSv2 assessment categories for multiparametric prostate MRI.176 lesions in 79 consecutive patients are analyzed, lesions are histopathologically verified by MRI-ultrasound fusion biopsy. All lesions are rated according to the PI-RADSv2 lexicon, descriptors for T2w and DWI sequences and resulting assessment categories are assigned by two independent blinded radiologists. We perform receiver-operating-characteristic analysis using the assessment categories. To analyze inter-observer agreement, we calculate weighted kappa values for assessment category assignment and unweighted kappa values for descriptor assignment.PI-RADSv2 assessment categories yield an area under the curve of 0.76/0.74 (radiologist 1/radiologist 2), P0.05. Weighted kappa for agreement is 0.601 in the peripheral zone and 0.580 in the transition zone. We detect a difference in the cancer rate for PI-RADSv2 category 3 between peripheral zone (32%) and transition zone (12%), P0.05. We obtain moderate agreement at most for descriptor assignment with kappa values ranging from 0.082 (T2w shape in the transition zone) to 0.407 (T2w signal intensity in the peripheral zone) and 0.493 (ADC pattern in the peripheral zone). Our analysis corroborates typical descriptors for benign/malignant lesions, but also reveals insights into potential pitfalls - T2w wedge shaped lesions in the peripheral zone have a considerable cancer rate, despite being labelled category 2 in the lexicon.Agreement for descriptor assignment in the PI-RADSv2 lexicon is at most moderate in our study. Typical descriptors for benign and malignant lesions are validated, whereas the discriminatory power of some descriptors is challenged. The difference in the cancer rate for PI-RADSv2 category 3 between peripheral zone and transition zone should be considered when management recommendations are linked to assessment categories in the future.

Acute transmural myocardial infarction by coronary embolism in a patient with JAK2 V617F-positive essential thrombocythemia

Background. Endolymphatic sac tumors (ELSTs) are, with a prevalence of up to 16%, a component of von Hippel-Lindau (VHL) disease. Data from international registries regarding heritable fraction and characteristics, germline VHL mutation frequency, and prevalence are lacking. Methods. Systematic registration of ELSTs from international centers of otorhinolaryngology and from multidisciplinary VHL centers' registries was performed. Molecular genetic analyses of the VHL gene were offered to all patients. Results. Our population-based registry comprised 93 patients with ELST and 1789 patients with VHL. The prevalence of VHL germline mutations in apparently sporadic ELSTs was 39%. The prevalence of ELSTs in patients with VHL was 3.6%. ELST was the initial manifestation in 32% of patients with VHL-ELST. Conclusion. Prevalence of ELST in VHL disease is much lower compared to the literature. VHL-associated ELSTs can be the first presentation of the syndrome and mimic sporadic tumors, thus emphasizing the need of molecular testing in all presentations of ELST. (C) 2015 Wiley Periodicals, Inc.

AIMS To evaluate the feasibility of a non-contrast three-dimensional (3D)-FLASH magnetic resonance angiography (MRA) protocol for pre-procedural aortic annulus assessment for transcatheter aortic valve replacement (TAVR) in comparison with cardiac dual-source computed tomography angiography (CTA). METHODS AND RESULTS In this prospective study, 69 of 104 consecutive patients (mean age 81.8 ± 5.4 years, 37.7% arrhythmic) with severe aortic stenosis who had undergone pre-TAVR cardiac CTA received a respiratory and ECG-triggered, non-contrast 3D-FLASH MRA at 3 T. Annular area measurements were obtained at mid-diastole for both modalities whereas maximum systolic area was assessed by CTA only. Systolic MRA dimensions were modelled, by adding the relative difference of systolic and diastolic CTA area dimensions as a corrective factor. Hypothetical prosthesis sizing was performed based on systolic CTA, diastolic, and modelled systolic MRA area measurements. MR image quality and degree of annular calcifications were evaluated using 4-point-grading scales. The mean acquisition time was 14 ± 4.2 min. The mean image quality was 3.1 ± 0.9 with only two examinations rated non-diagnostic. The mean degree of calcifications was equal. As assessed by Bland-Altman analysis, there was no relevant systematic difference between area measurements for modelled systolic MRA and systolic CTA [the mean difference -3.1 mm(2) (limits of agreement -44.4 mm(2); 38.2 mm(2))]. Agreement for hypothetical prosthesis sizing was found in 63 of 67 (94%) patients for systolic CTA and modelled systolic MRA. CONCLUSION The employed non-contrast 3D-FLASH MRA protocol allows for reliable assessment of aortic annulus dimensions and calcifications even in the presence of arrhythmias in an all-comers pre-TAVR population. Implementation of this technique appears legitimate in patients at an increased risk for contrast-induced nephropathy.

Purpose: To prospectively investigate computed tomographic (CT) image quality parameters by using different protocols and to calculate radiation dose estimates for noninvasive coronary angiography performed with dual-source CT in the step-and-shoot (SAS) mode. Materials and Methods: This study was local ethics board approved; written informed consent was obtained from all patients. In the preliminary portion of the study, 40 patients underwent CT coronary angiography in the SAS mode: at 100 kV (protocol A) in 22 patients with a body mass index (BMI) of less than 25 kg/m2 and at 120 kV (protocol B) in 18 patients with a BMI of 25–30 kg/m2. Both protocols involved use of an attenuation-based tube current and 1 mL of contrast material per kilogram of body weight. The final portion of the study involved 50 additional patients: 21 patients with a BMI of 25–30 kg/cm2 assigned to protocol B and 29 patients with a BMI of less than 25 kg/cm2 assigned to protocol C, which was performed with 100 kV, an attenuation-b...

Objective Bone Morphogenetic Protein-4 (BMP-4) and Extracellular-Signal Regulated Kinases (ERK) play crucial roles in vascular diseases. Here, we demonstrate that BMP-4 not only signals through the classical Smad cascade but also activates ERK phosphorylation as an alternative pathway in human umbilical vein endothelial cells (HUVEC) and that Smad and ERK pathways communicate through signal crosstalk. Methods HUVECs were treated with BMP-4 and/or MEK inhibitors. Smad 6 and constitutively active (ca) MEK1 were overexpressed. Loss of function of Smad 4 and Smad 6 was achieved by specific siRNA transfection. Cell lysates were analyzed by western blotting for Smad and ERK phosphorylation. HUVEC spheroids were generated for angiogenesis quantification. Results Treatment with BMP-4 results in a dose- and time-dependent activation of the MEK–ERK 1/2 pathway in addition to activation of the Smad pathway and is blocked by MEK inhibitors. Quantitative in-gel angiogenesis assays in the presence or absence of MEK inhibitors demonstrate that ERK signals are necessary for BMP-4 induced capillary sprouting. Furthermore sprouting is not blocked by inhibition of the Smad signaling pathway. Overexpression of the inhibitory Smad 6 inhibits ERK phosphorylation and ERK-induced capillary sprouting, whereas loss of function of Smad 4 has no effect. Conclusions We demonstrate that ERK1/2 functions as an alternative pathway in BMP-4 signaling in HUVECs. Capillary sprouting induced by BMP-4 is dependent on ERK phosphorylation. ERK is essential for efficient transduction of BMP signals and serves as a positive feedback mechanism. On the other hand, stimulation of Smad 6 inhibits ERK activation and thus results in a negative feedback loop to fine-tune BMP signaling in HUVECs.

Nodal pelvic/retroperitoneal recurrent prostate cancer (PCa) after primary therapy can be treated with salvage lymph node dissection (salvage-LND) in order to delay disease progression and offer cure for a subset of patients. Whether adjuvant radiotherapy (ART) in affected regions improves the outcome by elimination of residual tumour burden remains unclear. A total of 93 patients with exclusively nodal PCa relapse underwent choline-positron-emission tomography-computed-tomography-directed pelvic/retroperitoneal salvage-LND; 46 patients had surgery only and 47 patients received ART in regions with proven lymph node metastases. In case of subsequent prostate specific antigen (PSA) progression, different imaging modalities were performed to confirm next relapse within or outside the treated region (TR). Mean follow-up was 3.2 years. Lymphatic tumour burden was balanced between the two groups. Additional ART resulted in delayed relapse within TR (5-year relapse-free rate 70.7 %) versus surgery only (5-year relapse-free rate 26.3 %, p

We evaluated the diagnostic accuracy of choline positron emission tomography/computerized tomography for nodal relapse of prostate cancer according to topographical site and tumor infiltration size in lymph nodes.A total of 72 patients with nodal prostate cancer relapse after primary therapy underwent pelvic and/or retroperitoneal salvage lymph node dissection. Salvage was done after whole body positron emission tomography/computerized tomography with (11)C-choline or (18)F-fluoroethylcholine showed positron emission tomography positive lymph nodes but no other detectable metastasis. Diagnostic accuracy was evaluated in 160 dissected lymph node regions (pelvic left/right and retroperitoneal), 498 subregions (common, external and internal iliac, obturator, presacral, aortic bifurcation, aortal, vena caval and interaortocaval) and 2,122 lymph nodes.Lymph node metastasis was present in 32% of resected lymph nodes (681 of 2,122), resulting in 238 positive subregions and 111 positive regions. Positron emission tomography/computerized tomography was positive for 110 regions and 209 subregions. Sensitivity, specificity, positive and negative predictive values, and accuracy were 91.9%, 83.7%, 92.7%, 82.0% and 89.4% (region based), 80.7%, 93.5%, 91.9%, 84.1% and 87.3% (subregion based), and 57.0%, 98.4%, 94.5%, 82.6% and 84.9% (lesion based), respectively. Of 393 positive lymph node metastases detected by this method 278 (70.7%) were in lymph nodes with a less than 10 mm short axis diameter. Imaging sensitivity was 13.3%, 57.4% and 82.8% for a tumor infiltration depth of 2 or greater to less than 3 mm, 5 or greater to less than 6 mm and 10 or greater to less than 11 mm, respectively. Lymph node metastasis site and the radiotracer ((11)C-choline/(18)F-fluoroethylcholine) had no substantial impact on diagnostic accuracy.Choline positron emission tomography/computerized tomography detects affected lymph node regions (pelvic left/right and retroperitoneal) in patients with prostate cancer relapse with high accuracy and it seems helpful for guiding salvage lymph node dissection. Sensitivity decreases with the size of metastatic infiltration in lymph nodes. This technique detects metastasis in a significant fraction of lymph nodes that are not pathologically enlarged on computerized tomography.

Supplemental Digital Content is available in the text, Pancreatic ductal adenocarcinoma (PDAC) is characterized by a strong fibrotic stromal reaction and diffuse growth pattern. Peritumoral fibrosis is often evident during surgery but only distinguishable from tumor by microscopic examination. The aim of this study was to investigate the role of clearance of fibrotic stromal reaction at the mesopancreatic resection margin as a criterion for radical resection and preoperative assessment of resectability. Mesopancreatic stromal clearance status (S-status) was defined as the presence or absence (S+/S0) of fibrotic stromal reaction at the mesopancreatic resection margin. Detailed retrospective clinicopathologic re-evaluation of margin status and preoperative cross-sectional imaging was performed in a cohort of 91 patients operated for pancreatic head PDAC from 2001 to 2011. Conventional margin positive resection (R+, tumor cells directly at the margin) was found in 36%. However, S-status further divided the margin negative (R0) group into patients with median survival of 14 months versus 31 months (S+ versus S0, P = 0.005). Overall rate of S+ was 53%. S-status and lymph node ratio constituted the only independent predictors of survival. Stranding of the superior mesenteric artery fat sheath was the only independent radiologic predictor of S+ resection, and achieved a 71% correct prediction of S-status. Mesopancreatic stromal clearance is a major determinant of curative resection in PDAC, and preoperative prediction by cross-sectional imaging is possible, setting the basis for a new definition of borderline resectability.

Objectives To compare the impact of unenhanced and contrast-enhanced multi-detector computed tomography (MDCT) for the detection of urinary stones and urinary obstruction in patients with suspected renal colic. Methods 95 patients with suspected renal colic underwent a three-phase MDCT for evaluation of the urinary tract. The unenhanced scan and the multiphase examination were reviewed retrospectively by two radiologists for the characterization of urinary stones and signs of obstruction. Results of unenhanced MDCT were compared with those obtained during the second review of the entire multiphase examination. Results Overall diagnosis of urinary stones revealed an accuracy of 97.0% for unenhanced, and 98.9% for multiphase MDCT with a significant difference between both protocols (mixed-effects logistic regression: odds ratio 3.3; p = 0.019). With 3 versus 15 false positive ratings, multiphase MDCT was superior to unenhanced MDCT for the diagnosis of urinary stones. There was no significant difference in detecting signs of obstruction. Inter-reader agreement for overall stone detection was excellent on both unenhanced (kappa 0.84) and multiphase (kappa 0.88) MDCT. Conclusion Contrast-enhanced multiphase MDCT offers distinct advantages compared to an unenhanced approach for the assessment of urinary stone disease, and therefore should be considered as a complementary examination for patients with inconclusive findings.