Evaluation of MRI in the diagnostic accuracy of extrahepatic metastases in neuroendocrine tumors in comparison with the reference standard somatostatin-receptor–PET/CT

PurposeThe aim of this study was to compare the diagnostic performance of different sets of MR sequences in detecting extrahepatic disease of NETs on routine liver magnetic resonance imaging (MRI).MethodOne hundred twenty-seven patients with NETs with and without hepatic and extrahepatic metastases who underwent liver MRI and SSTR-PET/CT were retrospectively analyzed. Two radiologists evaluated in consensus in four sessions: (1) non-contrast T1w+T2w (NC), (2) NC+DWI, (3) NC+ contrast-enhanced T1w (CE), and (4) NC+DWI+CE the presence and number of metastases (lymph nodes, bone, peritoneal surface, lung base, and abdominal organ). Sensitivity, specificity, positive, and negative predictive value for detection of metastases were calculated for each session in a patient-based manner; detection and error rates were calculated for lesion-based analysis. Comparison between the MR-sessions and positron emission tomography–computed tomography (PET/CT) was performed with the McNemar test.ResultsRegarding all 1,094 lesions detected in PET/CT, NC+DWI, and NC, CE+DWI identified most true-positive lesions 779 (71%) and 775 (71%), respectively. Patient-based analysis revealed significantly higher sensitivity by NC+DWI (85%) than NC and NC+CE (p = 0.011 and 0.004, respectively); the highest specificity was reached by NC+CE+DWI (100%). Site-based analysis revealed highest detection rates for lymph node metastases for NC+DWI and NC, CE+DWI (73 and 76%, respectively); error rates were lower for NC, CE+DWI with 5% compared with 17% (NC+DWI). Detection rates for bone metastases were similarly high in NC+DWI and NC, CE+DWI (75 and 74%, respectively), while CE showed no benefit. For peritoneal metastases highest sensitivity was reached by NC+DWI (67%).ConclusionThe combination of NC+DWI showed better sensitivities than the combination of NC+CE. NC+DWI showed similar, sometimes even better sensitivities than NC+CE+DWI, but with lower specificities

Recurrence after pituitary surgery in adult Cushing's disease: a systematic review on diagnosis and treatment

PURPOSE Recurrence after pituitary surgery in Cushing's disease (CD) is a common problem ranging from 5% (minimum) to 50% (maximum) after initially successful surgery, respectively. In this review, we give an overview of the current literature regarding prevalence, diagnosis, and therapeutic options of recurrent CD. METHODS We systematically screened the literature regarding recurrent and persistent Cushing's disease using the MESH term Cushing's disease and recurrence. Of 717 results in PubMed, all manuscripts in English and German published between 1980 and April 2020 were screened. Case reports, comments, publications focusing on pediatric CD or CD in veterinary disciplines or studies with very small sample size (patient number < 10) were excluded. Also, papers on CD in pregnancy were not included in this review. RESULTS AND CONCLUSIONS Because of the high incidence of recurrence in CD, annual clinical and biochemical follow-up is paramount. 50% of recurrences occur during the first 50 months after first surgery. In case of recurrence, treatment options include second surgery, pituitary radiation, targeted medical therapy to control hypercortisolism, and bilateral adrenalectomy. Success rates of all these treatment options vary between 25 (some of the medical therapy) and 100% (bilateral adrenalectomy). All treatment options have specific advantages, limitations, and side effects. Therefore, treatment decisions have to be individualized according to the specific needs of the patient

Diagnostic Workup for Patients with Solid Renal Masses: A Cost-Effectiveness Analysis

Simple Summary There are several benign and malignant types of solid renal masses. For diagnostic and characterization of these masses, a few imaging methods such as magnetic resonance imaging (MRI), computed tomography (CT) or (contrast-enhanced) ultrasound (CEUS) are established in the clinical routine. The aim of our study was to assess the most economical approach for detecting and characterizing these masses. As a result, contrast-enhanced ultrasound turned out to be a cost-effective diagnostic method. Therefore, if available, this method should be considered in the routine. Alternatively, MRI also offers excellent diagnostic accuracy, but it is associated with higher costs. This result may lead to a change in the diagnostic workup of solid renal masses in clinical routine, as contrast-enhanced ultrasound should be considered as an appropriate method for the first analysis compared to CT and MRI. Background: For patients with solid renal masses, a precise differentiation between malignant and benign tumors is crucial for forward treatment management. Even though MRI and CT are often deemed as the gold standard in the diagnosis of solid renal masses, CEUS may also offer very high sensitivity in detection. The aim of this study therefore was to evaluate the effectiveness of CEUS from an economical point of view. Methods: A decision-making model based on a Markov model assessed expenses and utilities (in QALYs) associated with CEUS, MRI and CT. The utilized parameters were acquired from published research. Further, a Monte Carlo simulation-based deterministic sensitivity analysis of utilized variables with 30,000 repetitions was executed. The willingness-to-pay (WTP) is at USD 100,000/QALY. Results: In the baseline, CT caused overall expenses of USD 10,285.58 and an efficacy of 11.95 QALYs, whereas MRI caused overall expenses of USD 7407.70 and an efficacy of 12.25. Further, CEUS caused overall expenses of USD 5539.78, with an efficacy of 12.44. Consequently, CT and MRI were dominated by CEUS, and CEUS remained cost-effective in the sensitivity analyses. Conclusions: CEUS should be considered as a cost-effective imaging strategy for the initial diagnostic workup and assessment of solid renal masses compared to CT and MRI

Diffusion-weighted MRI of metastatic liver lesions: is there a difference between hypervascular and hypovascular metastases?

Background Different perfusion characteristics and histopathologic features of liver metastasis may potentially lead to different diffusion-weighted magnetic resonance imaging (DW-MRI) characteristics which can affect the performance of DW-MRI in their diagnosis. Purpose To compare ADC values of hypervascular and hypovascular metastases and the added value of DW-MRI to T2-weighted (T2-w) images in their detection. Material and Methods In this retrospective study, 46 patients (21 with hypervascular, 25 with hypovascular liver metastases) who had undergone abdominal MRI were included. Two independent observers first reviewed T2-w images only and then T2-w + DW-MR images and recorded number of metastases in each session. Lesion detection rate was compared using McNemar test. ADC of metastases in each patient was measured and compared between hypo- and hypervascular lesions using t-test. Results A total of 153 hypervascular and 187 hypovascular metastases were detected at consensus review. Two observers detected significantly more hypervascular metastases on T2-w + DW-MR image review session compared to T2-w image only review session (reader 1: 148 [96.7%] vs. 129 [84.3%], P = 0.002; reader 2: 125 [81.9%] vs. 113 [73.8%], P = 0.004). Detection rate of hypovascular metastases was similar between two sessions for both observers (reader 1: 180 [96.2%] vs. 184 [98.4%]; reader 2: 176 [94.1%] vs. 180 [96.2%], P > 0.05). The mean ADC value of hypervascular metastases was significantly lower than mean ADC value of hypovascular metastases (1.23+/−0.31 × 10−3 mm2/s vs. 1.49+/−0.19 × 10−3 mm2/s) (P = 0.001). Conclusion Liver metastases are not a homogenous group of lesions with uniform DW-MRI features. Hypervascular metastases demonstrate significantly lower ADC values compared to hypovascular metastases. DW-MRI improved detection of hypervascular metastases compared to T2-w images alone and is a useful adjunct to T2-w images for their detection

Apparent diffusion coefficients (ADC) in response assessment of transarterial radioembolization (TARE) for liver metastases of neuroendocrine tumors (NET): a feasibility study

Background: In patients with hepatic neuroendocrine tumors (NETs) locoregional therapies such as transarterial radioembolization (TARE) are increasingly applied. Response evaluation remains challenging and previous studies assessing response with diffusion-weighted imaging (DWI) have been inconclusive. Purpose: To perform a feasibility study to evaluate if response assessment with quantitative apparent diffusion coefficient (ADC) in patients with liver metastases of NETs after TARE will be possible. Material and Methods: Retrospectively, 43 patients with 120 target lesions who obtained abdominal magnetic resonance imaging (MRI) with DWI 39±28 days before and 74±46 days after TARE were included. Intralesional ADC (ADCmin, ADCmax, and ADCmean) were measured for a maximum number of three lesions per patient on baseline and post-interventional DWI. Tumor response was categorized according to RECIST 1.1 and mRECIST. Results: TARE resulted in partial remission (PR) in 23% (63%), in stable disease (SD) in 73% (23%), in progressive disease (PD) in 5% (7%) and in complete response (CR) in 0% (1%) according to RECIST 1.1 (mRECIST, respectively). ADC values increased significantly (P<0.005) after TARE in the PR group whereas there was no significant change in the PD group. Post-therapeutic ADC values of SD lesions increased significantly when evaluated by RECIST 1.1 but not if evaluated by mRECIST. Percentual changes of ADCmean values were slightly higher for responders compared to non-responders (P<0.05). Conclusion: ADC values seem to represent an additional marker for treatment response evaluation after TARE in patients with secondary hepatic NET. A conclusive study seems feasible though patient-based evaluation and overall survival and progression free survival as alternate primary endpoints should be considered

Suspected recurrence of brain metastases after focused high dose radiotherapy: can [F-18]FET-PET overcome diagnostic uncertainties?

Background: After focused high dose radiotherapy of brain metastases, differentiation between tumor recurrence and radiation-induced lesions by conventional MRI is challenging. This study investigates the usefulness of dynamic O-(2-F-18-Fluoroethyl)-L-Tyrosine positron emission tomography (F-18-FET PET) in patients with MRI-based suspicion of tumor recurrence after focused high dose radiotherapy of brain metastases. Methods: Twenty-two patients with 34 brain metastases (median age 61.9 years) were included. Due to follow-up scan evaluations after repeated treatment in a subset of patients, a total of 50 lesions with MRI-based suspicion of tumor recurrence after focused high dose radiotherapy could be evaluated. F-18-FET PET analysis included the assessment of maximum and mean tumor-to-background ratio (TBRmax and TBRmean) and analysis of time-activity-curves (TAC;increasing vs. decreasing) including minimal time-to-peak (TTPmin). PET parameters were correlated with histological findings and radiological-clinical follow-up evaluation. Results: Tumor recurrence was found in 21/50 cases (15/21 verified by histology, 6/21 by radiological-clinical follow-up) and radiation-induced changes in 29/50 cases (5/29 verified by histology, 24/29 by radiological-clinical follow-up). Median clinical-radiological follow-up was 28.3 months (range 4.2-99.1 months). F-18-FET uptake was higher in tumor recurrence compared to radiation-induced changes (TBRmax 2.9 vs. 2.0, p < 0.001;TBRmean 2.2 vs. 1.7, p < 0.001). Receiver-operating-characteristic (ROC) curve analysis revealed optimal cut-off values of 2.15 for TBRmax and 1.95 for TBRmean (sensitivity 86 %, specificity 79 %). Increasing TACs and long TTPmin were associated with radiation-induced changes, decreasing TACs with tumor recurrence (p = 0.01). By combination of TBR and TACs, sensitivity and specificity could be increased to 93 and 84 %. Conclusions: In patients with MRI-suspected tumor recurrence after focused high dose radiotherapy, F-18-FET PET has a high sensitivity and specificity for the differentiation of vital tumor tissue and radiation-induced lesions

Injuries of the isolated larynx-hyoid complex in post-mortem computed tomography (PMCT) and post-mortem fine preparation (PMFP) - a comparison of 54 forensic cases

Objectives!#!To assess the diagnostic accuracy (ACC) of post-mortem computed tomography (PMCT) for fractures of the isolated larynx-hyoid complex (LHC) in comparison to post-mortem fine preparation (PMFP).!##!Methods!#!This monocentric prospective study enclosed 54 LHCs that were extracted during autopsy, fixed in formalin, and underwent a PMCT scan (64-row multidetector CT, helical pitch). Two radiologists independently analyzed the LHC scans for image quality (IQ) and fractures (4-point Likert scales). A specialized forensic preparator dissected the specimens under the stereomicroscope. The PMFP results were standardized documented, and used as the standard of reference for the comparison to PMCT.!##!Results!#!The PMCT-IQ of 95% of the LHC images was rated as good or excellent. IQ was decreased by decay, incisions during autopsy, and separation of the hyoid from the cartilaginous components in 7, 3, and 12 specimens, respectively. PMFP detected 119 fractures in 34 LHCs (63.0%). PMCT identified 91 fractures in 32 specimens (59.3%). PMFP and PMCT significantly agreed concerning the location (Cohen's κ = 0.762; p &amp;lt; 0.001) and the degree of dislocation (κ = 0.689; p &amp;lt; 0.001) of the fractures. Comparing PMCT to PMFP resulted in a sensitivity of 88.2%, a specificity of 90.0%, and an ACC of 88.9% for the LHC. The ACCs for the hyoid, thyroid, and cricoid were 94.4%, 87.0%, and 81.5%, respectively. PMCT procedure was significantly faster than PMFP (28.9 ± 4.1 min vs. 208.2 ± 32.5 min; p &amp;lt; 0,001).!##!Conclusions!#!PMCT can detect distinct injuries of the isolated LHC and may promptly confirm violence against the neck as cause of death. PMFP outmatches PMCT in the detection of decent injuries like tears of the cricoid cartilage.!##!Key points!#!• Post-mortem computed tomography is able to assess fractures of the larynx-hyoid complex. • Prospective monocentric in vitro study showed that post-mortem computed tomography of the larynx-hyoid complex is faster than post-mortem fine preparation. • Post-mortem computed tomography can confirm violence against the neck as cause of death

Quantitative SSTR-PET/CT for predicting response and survival outcomes in patients with pancreatic neuroendocrine tumors receiving CAPTEM

This study aimed to evaluate the predictive and monitoring role of somatostatin receptor (SSTR) positron emission tomography-computed tomography (PET/CT) and clinical parameters in patients with neuroendocrine liver metastases (NELM) from pancreatic neuroendocrine tumors (pNET) receiving capecitabine and temozolomide (CAPTEM)

Role of diffusion-weighted imaging in response prediction and evaluation after high dose rate brachytherapy in patients with colorectal liver metastases

The aim of the study was to assess the role of diffusion-weighted imaging (DWI) to evaluate treatment response in patients with liver metastases of colorectal cancer