Cost-effectiveness of multimodal imaging in intermediate complex renal cysts

Zur Diagnosestellung und Verlaufsbeobachtung von Nierenzysten stehen mehrere Bildgebungsmodalitäten zur Verfügung. Untersuchungsgegenstand der vorliegenden Studie war die Kosteneffektivität der routinemäßig verwendeten, kontrastmittelverstärkten Modalitäten Computertomographie (CT), Magnetresonanztomographie (MRT) sowie Sonographie (engl. contrast-enhanced ultrasound, CEUS) bei Patientinnen und Patienten mit einer Nierenzyste der Bosniak-Klasse IIF oder III. Die Grundlage einer Simulation bildete ein Markov-Modell, in dem fiktive Patientenkohorten die Zustände keine maligne Läsion, lokale Malignität, metastasiertes Stadium sowie Tod einnehmen konnten. Der Nutzen wurde mittels qualitätskorrigierter Lebensjahre der Patientinnen/Patienten erfasst. Die realen Verfahrenskosten in der Radiologie und Chirurgie wurden mittels der internen Kostenverrechnung der Charité- Universitätsmedizin Berlin ermittelt. Sowohl eine deterministische als auch eine probabilistische Sensitivitätsanalyse wurden durchgeführt. Die Ergebnisse wurden als arithmetisches Mittel pro Patientin/Patient über einen Zeitraum von zehn Jahren angegeben. Alle betrachteten radiologischen Modalitäten zeigten Differenzen in der Effektivität von deutlich unter 1%. Die mittleren Gesamtkosten für Bildgebung und operative Therapie beliefen sich für die CT-, MRT- und CEUS-Kohorten auf 1600 €, 1632 € und 1511 € bei einer Bosniak IIF-Zyste sowie 4499 €, 5174 € und 4256 € bei einer Bosniak IIIZyste. Die deterministische Sensitivitätsanalyse zeigte einen großen Einfluss vor allem der diagnostischen Genauigkeiten und der Kosten auf das Ergebnis. Die probabilistische Sensitivitätsanalyse bestätigte die Ergebnisse des Basisszenarios. Zusammenfassend zeigten die Modalitäten eine vergleichbare Effektivität, wobei sich CEUS als die günstigste und die MRT als die teuerste herausstellte. Insgesamt war 2 CEUS kosteneffektiv gegenüber der CT. Die Ergebnisse müssen vor Übertragung auf Kliniken mit einer anderen Kostenstruktur angepasst werden.Several imaging modalities are available for the diagnosis and monitoring of renal cysts. The object of the study was to compare the cost-effectiveness of contrast enhanced computed tomography (CT), contrast-enhanced magnetic resonance imaging (MRI) and contrast-enhanced ultrasound (CEUS) in patients with a complex renal cyst (Bosniak IIF or III). A Markov model formed the basis of a simulation in which fictitious patient cohorts can assume the states cancer-free, local cancer, metastasized cancer stage and deceased. The benefits in the model were quantified using quality-adjusted life years of the patients. Real-world procedural costs in radiology and surgery were determined with internal cost allocation of Charité-Universitätsmedizin Berlin. Both a deterministic and a probabilistic sensitivity analysis were carried out. The results were reported as arithmetic mean per patient over a course of 10 years. All considered radiological modalities showed a difference in effectiveness of less than 1%. Total costs for imaging and surgery for CT, MRI and CEUS cohorts were € 1600, € 1632 and € 1511 in patients with Bosniak IIF cyst and € 4499, € 5174 and € 4256 in patients with Bosniak III cyst, respectively. The deterministic sensitivity analysis showed a major influence on the result especially for the diagnostic accuracies and the procedural costs. The probabilistic sensitivity analysis validated the results of the base case scenario. In summary, the effectiveness of the modalities considered was consistent, with CEUS being the most inexpensive and MRI the most expensive modality. Thus, CEUS was cost-effective compared to CT. The results need to be adjusted before transferring them to clinics with a different cost structure

Multiparametric ultrasound findings in acute kidney failure due to rare renal cortical necrosis

Renal cortical necrosis (RCN) is a rare cause of acute kidney failure and is usually diagnosed on the basis of characteristic enhancement patterns on cross-sectional imaging. Contrast-enhanced ultrasound (CEUS) offers benefits in patients with kidney failure in the clinical setting including the use of a nonnephrotoxic intravascular contrast agent and the fact that it can be performed at the bedside in critical cases. Therefore, the aim of this study is to investigate whether CEUS can reliably identify typical imaging features of RCN. We retrospectively analyzed 12 patients with RCN examined in our department and confirmation of the diagnosis by either histopathology, other contrast-enhanced cross-sectional imaging tests, and/or CEUS follow-up. Assessed parameters in conventional US were reduced echogenicity, loss of corticomedullary differentiation, length and width of kidney, hypoechoic rim, resistance index and in CEUS delayed wash-in of contrast agent (>20 s), reverse rim sign, maximum nonenhancing rim and additional renal infarction. Furthermore, imaging features in RCN were compared with the findings in renal vein thrombosis (RVT), among them echogenicity, corticomedullar differentiation, hypoechoic rim, RI value, delayed cortical enhancement, total loss of cortical perfusion and enhancement of renal medulla. All 12 patients showed the reverse rim sign, while a hypoechogenic subcapsular rim was only visible in four patients on B-mode ultrasound. A resistance index (RI) was available in 10 cases and was always less than 1. RI was a strong differentiator in separating RVT from RCN (RI>1 or not measurable due to hypoperfusion as differentiator, p=0.001). CEUS showed total loss of medullary enhancement in all cases of RVT. With its higher temporal resolution, CEUS allows dynamic assessment of renal macro- and microcirculation and identification of the typical imaging findings of RCN with use of a nonnephrotoxic contrast agent

Quality Assessment of CEUS in Individuals with Small Renal Masses—Which Individual Factors Are Associated with High Image Quality?

Obesity and bowel gas are known to impair image quality in abdominal ultrasound (US). The present study aims at identifying individual factors in B-mode US that influence contrast-enhanced US (CEUS) image quality to optimize further imaging workup of incidentally detected focal renal masses. We retrospectively analyzed renal CEUS of focal renal masses <= 4 cm performed at our center in 143 patients between 2016 and 2020. Patient and lesion characteristics were tested for their influence on focal and overall image quality assessed by two experienced radiologists using Likert scales. Effects of significant variables were quantified by receiver operating characteristics (ROC) curve analysis with area under the curve (AUC), and combined effects were assessed by binary logistic regression. Shrunken kidney, kidney depth, lesion depth, lesion size, and exophytic lesion growth were found to influence focal renal lesion image quality, and all factors except lesion size also influenced overall image quality. Combination of all parameters except kidney depth best predicted good CEUS image quality showing an AUC of 0.91 (p < 0.001, 95%-CI 0.863-0.958). The B-mode US parameters investigated can identify patients expected to have good CEUS image quality and thus help select the most suitable contrast-enhanced imaging strategy for workup of renal lesions

Cost‐effectiveness analysis of multiple imaging modalities in diagnosis and follow‐up of intermediate complex cystic renal lesions

Objectives: To compare health-economic aspects of multiple imaging modalities used to monitor renal cysts, the present study evaluates costs and outcomes of patients with Bosniak IIF and III renal cysts detected and followed-up by either contrast-enhanced computed tomography (ceCT), contrast-enhanced magnetic resonance imaging (ceMRI), or contrast-enhanced ultrasonography (CEUS). Patients and methods: A simulation using Markov models was implemented and performed with 10 cycles of 1 year each. Proportionate cohorts were allocated to Markov models by a decision tree processing specific incidences of malignancy and levels of diagnostic performance. Costs of imaging and surgical treatment were investigated using internal data of a European university hospital. Multivariate probabilistic sensitivity analysis was performed to confirm results considering input value uncertainties. Patient outcomes were measured in quality-adjusted life years (QALY), and costs as averages per patient including costs of imaging and surgical treatment. Results: Compared to the 'gold standard' of ceCT, ceMRI was more effective but also more expensive, with a resulting incremental cost-effectiveness ratio (ICER) >€70 000 (Euro) per QALY gained. CEUS was dominant compared to ceCT in both Bosniak IIF and III renal cysts in terms of QALYs and costs. Probabilistic sensitivity analysis confirmed these results in the majority of iterations. Conclusion: Both ceMRI and CEUS can be used as alternatives to ceCT in the diagnosis and follow-up of intermediately complex cystic renal lesions without compromising effectiveness, while CEUS is clearly cost-effective. The economic results apply to a large university hospital and must be adapted for smaller hospitals

Solitary peliosis hepatis mimics a liver metastasis on contrast-enhanced ultrasound

Peliosis hepatis remains a rare focal liver lesion with inconclusive imaging features. The unknown pathogenesis represents a wide possible range of etiologies including the breakdown of the sinusoidal borders, a potential hepatic outflow obstruction or dilatation of the central vein of a hepatic lobule. In histopathology, a blood-filled cystlike appearance with sinusoidal dilatation was reported. On ultrasound, B-mode features are not specific demonstrating a irregular, moreover hypoechogenic focal liver lesions. Postcontrast imaging features on Contrast-Enhanced-Ultrasound may mimic a malignant lesion with irregular contrast inflow and washout during late phase. Our case demonstrates a peliosis hepatis with malignant image features on contrast-enhanced ultrasound, ruled out by PET-CT and core needle biopsy with corresponding histopathological workup

AUV MARUM-SEAL Dive 70: RAW-Data of High Resolution Bathymetry and Backscatter of Chapopote Asphalt Volcano

Purpose of the cruise M114 At the so-called asphalt volcanoes in the southern Gulf of Mexico heavy oil is seeping at the seafloor where it remains as asphalt deposits. Discovered and preliminarily surveyed during SO174 and M67/2 expeditions, these sites are subject for detail studies during M114 focusing on mapping with autonomous underwater vehicle (AUV MARUM-SEAL), deep-towed sidescan sonar (DTS-1), sediment echosounder (Parasound), multibeam echosounder (EM122), and remotely operated vehicle MARUM-ROV Quest. The overarching objective is to better understand the impact, fate, and decay rates of oil in the deep-sea environment. Heavy oil and gas bubbles are emitted from the 1200 to 2900 m deep seafloor in the hy-drocarbon province Campeche Knolls in the southern Gulf of Mexico. The viscous heavy oil flows across the seafloor, loses volatile compounds, solidifies, and is converted to asphalt with time. Due to the fact that the heavy oil remains at the seafloor, these sites are natural laboratories to study the impact of oil on deep-sea ecosystems, and the time scales of oil and asphalt degradation. These subjects are very timely, and can help understanding effects of deep water oil spills as caused by the 2010 Deepwater Horizon accident in the northern Gulf of Mexico. We propose to study the extent of oil emissions and asphalt deposits using sidescan sonar and to investigate them further employing ROV Quest. A further major topic of the proposed cruise addresses the question whether or not methane can reach the sea surface and may contribute to the pool of greenhouse gases. The fact that seepage of oil-coated gas bubbles leads to oil slicks at the sea surface and enhanced methane concentrations was recently shown in the north-ern Gulf. It can be assumed that similar efficient transport processes for methane exists in the area of the Campeche Knolls, where oil slicks have been observed in association with about ~30 individual seafloor structures

Gridded bathymetry mosaic of Venere mud volcano (MV), based on AUV MARUM-SEAL data acquisition during POS499

Gridded bathymetry and backscatter mosaic of Venere mud volcano (MV), based on AUV MARUM-SEAL data acquisition during the POS499 cruise, conducted between 13.10.2010 and 20.11.2010 in the Calarbrian Arc. / PI: Paul Wintersteller, Gerrit Meinecke, Markus Loher, Jens Renken, Ulli Spiesecke, Till von Wahl & Chief Scientist Gerhard Bohrmann

Gridded backscatter mosaic of Venere mud volcano (MV), based on AUV MARUM-SEAL data acquisition during POS499

Gridded bathymetry and backscatter mosaic of Venere mud volcano (MV), based on AUV MARUM-SEAL data acquisition during the POS499 cruise, conducted between 13.10.2010 and 20.11.2010 in the Calarbrian Arc. / PI: Paul Wintersteller, Gerrit Meinecke, Markus Loher, Jens Renken, Ulli Spiesecke, Till von Wahl & Chief Scientist Gerhard Bohrmann

AUV MARUM-SEAL Dive 70: High Resolution Bathymetry and Backscatter of Chapopote Asphalt Volcano

Abstract & Purpose of the cruise M114 At the so-called asphalt volcanoes in the southern Gulf of Mexico heavy oil is seeping at the seafloor where it remains as asphalt deposits. Discovered and preliminarily surveyed during SO174 and M67/2 expeditions, these sites are subject for detail studies during M114 focusing on mapping with autonomous underwater vehicle (AUV MARUM-SEAL), deep-towed sidescan sonar (DTS-1), sediment echosounder (Parasound), multibeam echosounder (EM122), and remotely operated vehicle MARUM-ROV Quest. The overarching objective is to better understand the impact, fate, and decay rates of oil in the deep-sea environment. Heavy oil and gas bubbles are emitted from the 1200 to 2900 m deep seafloor in the hy-drocarbon province Campeche Knolls in the southern Gulf of Mexico. The viscous heavy oil flows across the seafloor, loses volatile compounds, solidifies, and is converted to asphalt with time. Due to the fact that the heavy oil remains at the seafloor, these sites are natural laboratories to study the impact of oil on deep-sea ecosystems, and the time scales of oil and asphalt degradation. These subjects are very timely, and can help understanding effects of deep water oil spills as caused by the 2010 Deepwater Horizon accident in the northern Gulf of Mexico. We propose to study the extent of oil emissions and asphalt deposits using sidescan sonar and to investigate them further employing ROV Quest. A further major topic of the proposed cruise addresses the question whether or not methane can reach the sea surface and may contribute to the pool of greenhouse gases. The fact that seepage of oil-coated gas bubbles leads to oil slicks at the sea surface and enhanced methane concentrations was recently shown in the north-ern Gulf. It can be assumed that similar efficient transport processes for methane exists in the area of the Campeche Knolls, where oil slicks have been observed in association with about ~30 individual seafloor structures