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Aim Defining sensitivity, specificity, diagnostic accuracy for detection of colorectal liver metastases in imaging compared to intraoperative assessment. Defining a cutoff, where accuracy of detection is impaired. Methods Prospective single-institution clinical trial (clinicaltrials.gov: NCT01522209). Patients underwent CEUS, MDCT, and 3 Tesla EOB-MRI within 2 weeks preoperatively. Intraoperative palpation, IOUS, and CEIOUS were performed. A patient and lesion-based database was analyzed for accuracy of detection of CEUS, CT, MRI, and Palp/IOUS/CEIOUS combined read. Histology was standard of reference. Results Forty-seven high tumor load (mean 5, 4 lesions) patients were analyzed. Histopathology confirmed 264 lesions (245 malignant: 19 benign). Accuracy for detection of all lesions: CEUS 63%, CT 71%, MRI 92%, and PALP/IOUS/CEIOUS 98%. ROC analysis for lesion size showed severe impairment of accuracy in lesion detection smaller than 5mm. Intraoperative imaging was not impaired by lesion size. Patient-based analysis revealed a change of resection plan after IOUS/CEIOUS in 35% of patients. Conclusion At 5-mm lesion size, preoperative imaging shows a drop in accuracy of detection. In patients with multiple lesions, addition of MRI to MDCT seems useful. Accuracy of intraoperative ultrasound is not impacted by lesion size and should be mandatory. CEIOUS can improve intraoperative decision-making. Trial Registration Study registered with clinicaltrials.gov : NCT01522209

Background To assess the value of diffusion weighted imaging (DWI) as an early surrogate parameter for treatment response of colorectal liver metastases to image-guided single-fraction 192 Ir-high-dose-rate brachytherapy (HDR-BT). Methods Thirty patients with a total of 43 metastases underwent CT- or MRI-guided HDR-BT. In 13 of these patients a total of 15 additional lesions were identified, which were not treated at the initial session and served for comparison. Magnetic resonance imaging (MRI) including breathhold echoplanar DWI sequences was performed prior to therapy (baseline MRI), 2 days after HDR-BT (early MRI) as well as after 3 months (follow-up MRI). Tumor volume (TV) and intratumoral apparent diffusion coefficient (ADC) were measured independently by two radiologists. Statistical analysis was performed using univariate comparison, ANOVA and paired t test as well as Pearson's correlation. Results At early MRI no changes of TV and ADC were found for non-treated colorectal liver metastases. In contrast, mean TV of liver lesions treated with HDR-BT increased by 8.8% ( p = 0.054) while mean tumor ADC decreased significantly by 11.4% ( p < 0.001). At follow-up MRI mean TV of non-treated metastases increased by 50.8% ( p = 0.027) without significant change of mean ADC values. In contrast, mean TV of treated lesions decreased by 47.0% ( p = 0.026) while the mean ADC increased inversely by 28.6% compared to baseline values ( p < 0.001; Pearson's correlation coefficient of r = -0.257; p < 0.001). Conclusions DWI is a promising imaging biomarker for early prediction of tumor response in patients with colorectal liver metastases treated with HDR-BT, yet the optimal interval between therapy and early follow-up needs to be elucidated.

PurposeTo explore whether a computed tomography angiography (CTA) of the pelvis prior to prostatic artery embolization (PAE) is a beneficial preprocedural planning tool regarding the technical success.Materials and MethodsEighty patients with lower urinary tract symptoms treated with PAE were analyzed retrospectively. Forty of these patients received a CTA of the pelvis prior to the procedure (Group A) and were compared to 40 patients who were treated with PAE without prior CT imaging (Group B). Technical success rate, rate of complications, fluoroscopy time (FT), and mean dose area product (DAP) were assessed and compared. All operators performed at least 50 PAE prior to this study. When needed, cone-beam CT (CBCT) was available during intervention.ResultsMean age was 68.43 ± 8.30 years in Group A and 70.42 ± 7.11 years in Group B (p = 0.252). Mean body mass index was 26.78 ± 3.73 in Group A and 26.85 ± 3.5 in Group B (p = 0.319). Overall technical success was 96.3%. Bilateral PAE was achieved in 60 patients (75.0%) while unilateral PAE was performed in 17 patients (21.3%). Technical failure (no embolization) occurred in two patients of Group A and one patient of Group B. No statistical significance was seen between groups for technical success rate (p = 1.0). Mean DAP was 10,164 × cm2 ± 3944 cGy × cm2 in Group A and 10,039 × cm2 ± 3761 cGy × cm2 in Group B (p = 0.885). Mean FT was 49.27 ± 22.97 min in Group A and 44.32 ± 17.82 min in Group B (p = 0.285). No intervention-related complications during PAE were reported.ConclusionWith experienced interventionalists and CBCT available during PAE, preprocedural CTA has no additional benefit for technical outcome.

ObjectivesCholangiocarcinoma is the second most common primary liver tumour with a poor overall prognosis. Percutaneous hepatic perfusion (PHP) is a directed therapy for primary and secondary liver malignancies, and its efficacy and safety have been shown in different entities. The purpose of this study was to prove the safety and efficacy of PHP in patients with unresectable intrahepatic cholangiocarcinoma (iCCA).Patients and methodsWe retrospectively reviewed data from 15 patients with unresectable iCCA treated with PHP in nine different hospitals throughout Europe. Overall response rates (ORR) were assessed according to response evaluation criteria in solid tumours (RECIST1.1). Overall survival (OS), progression-free survival (PFS) and hepatic PFS (hPFS) were analysed using the Kaplan-Meier estimation. Adverse events (AEs) and toxicity were evaluated.ResultsFifteen patients were treated with 26 PHPs. ORR was 20%, disease control was achieved in 53% after the first PHP. Median OS was 26.9 months from initial diagnosis and 7.6 months from first PHP. Median PFS and hPFS were 122 and 131 days, respectively. Patients with liver-only disease had a significantly longer median OS compared to patients with locoregional lymph node metastases (12.9 vs. 4.8 months, respectively; p < 0.01). Haematological toxicity was common, but manageable. No AEs of grade 3 or 4 occurred during the procedures.DiscussionPHP is a standardised and safe procedure that provides promising response rates and survival data in patients with iCCA, especially in non-metastatic disease.Key Points• Percutaneous hepatic perfusion (PHP) offers an additional locoregional therapy strategy for the treatment of unresectable primary or secondary intrahepatic malignancies.• PHP is a standardised and safe procedure that provides promising response rates and survival data in patients with intrahepatic cholangiocarcinoma (iCCA), especially in non-metastatic disease.• Side effects seem to be tolerable and comparable to other systemic or local treatment strategies.

Purpose Percutaneous isolated hepatic perfusion (PIHP) with Melphalan has been developed as a treatment for patients with isolated hepatic metastases of uveal melanoma. We discuss patient outcome and safety in a retrospective multi-centre study. Materials and Methods Between 2012 and 2016 18 patients with un-resectable isolated hepatic metastases of uveal melanoma received single or repeated PIHP with Melphalan ( n  = 35) at seven sites. Progression-free time, overall survival time (OS) and tumour response by means of RECIST 1.1 criteria were evaluated. Peri- and post-procedural adverse events (AE) were registered. Patients’ life quality was assessed using four-point scale questionnaires. Results Of 18 patients, initial PIHP treatment resulted in partial response (PR) in eight, stable disease (SD) in seven and progressive disease (PD) in three cases. Nine patients underwent second PIHP with PR in eight cases and PD in one case. Six patients were evaluated after third PIHP with PR in five patients and SD in one patient. Two patients received fourth PIHP with PD in both cases. Median OS was 9.6 months (range 1.6–41.0 months). Median progression-free survival time was 12.4 months (range 0.9–41.0 months) with 1-year survival of 44%. Most common post-procedural AE grade 3 and 4 were temporary leukopenia ( n  = 11) and thrombocytopenia ( n  = 8). Patients’ self-assessments showed good ratings for overall health and quality of life with only slight changes after PIHP, and a high degree of satisfaction with PIHP treatment. Conclusion PIHP with Melphalan proved to be a relatively safe, minimal-invasive and repeatable treatment for patients with non-resectable hepatic metastases of uveal melanoma.

PurposeTo asses angiographic and computed tomographic success criteria during and after transcatheter arterial drug-eluting bead chemoembolization (DEB-TACE) in patients with hepatocellular carcinoma (HCC) and its impact on progression-free survival (PFS) and overall survival (OS).MethodsIn this retrospective single-center study, 50 patients with unresectable HCC having undergone DEB-TACE from January 2010 to July 2015 were assessed. The angiographic endpoint was classified by Subjective Angiographic Chemoembolization Endpoint (SACE) scale. Relative tumor density in arterial (DArt) and portal venous phase (DPV) computed tomography post- versus pre-DEB-TACE were calculated, respectively. Tumor response according to modified Response Criteria in Solid Tumors (mRECIST) was assessed. Univariate Kaplan–Meier and Cox regression analysis were carried out.ResultsSACE scores I, II, III, and IV were found in 1 (2%), 20 (40%), 15 (30%), and 14 (28%) patients, respectively. Median OS and PFS were 14.2 and 5.5 months, respectively. Death rates at 6 months, 1 year and 2 years were 24%, 38%, and 52%, respectively. SACE score during DEB-TACE significantly correlated with local and overall mRECIST results (local: p < 0.001, r = 0.49, overall: p = 0.042, r = 0.29) and inversely correlated with DPV (p = 0.005, r = − 0.40). In univariate analysis, progressive disease (PD) according to mRECIST and increase of DArt and DPV were associated with significantly shorter PFS. Modified RECIST independently predicted OS (hazard ratio for complete remission vs. PD = 0.15, 95% confidence interval 0.03–0.68, p = 0.014).ConclusionsA direct impact of SACE on PFS or OS could not be shown. However, SACE significantly correlated with local and overall mRECIST tumor response that again significantly predicted OS. We therefore postulate an indirect impact of SACE on OS. Consequently, complete embolization should be attempted.

Objective: To prospectively evaluate diffusion-weighted imaging (DWI) for early prediction of tumour response in patients with colorectal liver metastases following selective internal radiotherapy (SIRT). Methods: We evaluated 41 metastases in 21 patients, age 62.9 ± 9.9 years. All patients underwent magnetic resonance imaging (MRI) including breath-hold echoplanar DWI sequences. Imaging was performed before therapy (baseline MRI), 2 days after SIRT (early MRI) as well as 6 weeks later (follow-up MRI). Tumour volume (TV) and intratumoural apparent diffusion coefficient (ADC) were measured independently by two radiologists at all time points. Results: Metastases were categorised as responding lesions (RL; n  = 33) or non-responding lesions (NRL; n  = 8) according to changes in TV after 6 weeks. We found an inverse correlation of changes in TV and ADC at follow-up MRI with a Pearson’s correlation coefficient of r  = −0.66 ( p  < 0.0001). On early MRI, no significant changes in TV were found for either RL or NRL. Conversely, ADC decreased significantly in RL by 10.7 ± 8.4% ( p  < 0.0001). ADC increased in NRL by 9.6 ± 20.8%, which was not statistically significant ( p  = 0.40). Conclusion: DWI was capable of predicting therapy effects of SIRT in patients with colorectal hepatic metastases as early as 2 days following treatment.

Die Entwicklung einer in-stentRestenose nach stent-geschutzter Angioplastie der carotis (sPAc) ist eine relativ seltene Komplikation, bei der noch keine einheitliche Empfehlung hinsichtlich des therapeutischen Vorgehens existiert. In einer retrospektiven Analyse unserer Daten von 176 Patienten behandelt mit carotis-stents zwischen 2009 und 2015 wurden in insgesamt 9 Patienten farbduplexsonografisch eine hochgradige Restenose diagnostiziert (mittleres Alter 66.0 Jahre, sD 11.7 Jahre, 6 Frauen und 3 Manner). Die mittels Us detektierten stenosen wurden angiographisch in allen Fallen bestatigt, und mittels drug-eluting balloon (DEb) in der gleichen sitzung behandelt. Ein Patient hatte eine bilaterale Erkrankung, und ein weiterer Patient benotigte eine wiederholte behandlung mittels Deb 19 Monate nach der Erstbehandlung; so dass insgesamt 11 Prozeduren an den 9 Patienten erfolgten. Die mediane Zeit zwischen carotis-stent und erster DEB betrug 9 Monate. In 3 der Prozeduren musste die DEB durch einen weiteren stent unterstutzt werden--in zwei Fallen bei einer Edge-stenose, in einem Fall bei einer Dissektion wahrend der Behandlung mittels DEB. Es traten keine periprozeduralen Komplikationen auf. Das 1 Jahres event-free-survival (EFs) betrug somit 100%, das 2, und 3 Jahres sowie das 5 Jahres EFs 83% hinsichtlich einer Re-stenose nach DEB. Zusammenfassend ist die DEB eine vielversprechende, effektive und sichere Behandlung fur Patienten mit einer hochgradigen Rezidivstenose nach sPAc. Aufgrund der potenziellen Notwendigkeit einer zusatzlichen stentimplantation erscheint eine Behandlung durch erfahrene neuroradiologische Interventionalisten angezeigt.

The purpose was to assess osteoporotic vertebral fractures and other spinal lesions in sagittal reformations obtained from routine multidetector computed tomography (MDCT) studies of the thorax and abdomen, to compare sagittal reformations with axial images in detecting these lesions and to investigate how frequently they were missed in the official radiology report. Routine abdominal or thoracoabdominal MDCT using a standard protocol was performed in 112 postmenopausal women. Axial images and sagittal reformations were analyzed separately by two radiologists in consensus and were compared in order to evaluate how often spinal lesions could be detected. In addition the official radiology reports were assessed to determine how many of those abnormalities were identified. Spine abnormalities were visualized in 101/112 postmenopausal women. In 27 patients osteoporotic vertebral deformities were found; 6 of these were shown in the axial images, but none of these were diagnosed in the official radiology report. Additional abnormalities included degenerative disc disease, osteoarthritis of the facet joints, scoliosis, hemangiomas and bone metastases. In only 9/101 patients spine abnormalities were mentioned in the radiology report. Sagittal reformations of standard MDCT images provide important additional information on spinal abnormalities; in particular, osteoporotic vertebral deformities are substantially better detected.