Holger Strunk

Diagnostic Performance of Whole Body Dual Modality 18F-FDG PET/CT Imaging for N- and M-Staging of Malignant Melanoma: Experience With 250 Consecutive Patients

Purpose To assess the diagnostic performance of positron emission tomography/computed tomography (PET/CT) using 18F-fluorodeoxyglucose (FDG) for N- and M-staging of cutaneous melanoma. Patients and Methods This is a retrospective and blinded study of 250 consecutive patients (105 women, 145 men; age 58 ± 16 years) who underwent FDG-PET/CT for staging of cutaneous melanoma at different time points in the course of disease. Whole-body FDG-PET/CT was performed 101 ± 21 minutes postinjection of 371 ± 41 MBq FDG. Diagnostic accuracy for N- and M-staging was determined for CT alone, PET alone, and PET/CT. Results PET/CT detected significantly more visceral and nonvisceral metastases than PET alone and CT alone (98.7%, 88.8%, and 69.7%, respectively). PET/CT imaging thus provided significantly more accurate interpretations regarding overall N- and M-staging than PET alone and CT alone. Overall N- and M-stage was correctly determined by PET/CT in 243 of 250 patients (97.2%; 95% CI, 95.2% to 99.4%) compared with 2...

Pulmonary contusion: CT vs plain radiograms.

In experimentally induced pulmonary contusions, CT (n = 27) and chest X-ray (n = 24) findings were compared with the findings at autopsy. Twenty-seven of 27 (100%) pulmonary contusions were visible by CT immediately after trauma compared with 9 of 24 (37.5%) in the chest X-ray. After 30 min follow-up, 18 of 24 (75%) lesions were seen on the plain film. Five of 24 (21%) contusions escaped detection on conventional radiographs. Computed tomography underestimated lesion size in 5 of 60 (8%) measurements, conventional radiographs in 21 of 36 (58%) measurements. Pathological examination never revealed a pulmonary contusion that was not demonstrated by CT. Therefore, pulmonary contusion seems unlikely in a trauma patient with normal pulmonary CT.

Transjugular intrahepatic portosystemic stent-shunt for hepatorenal syndrome

According to a consensus recommendation, six patients had severe (type-I: serum creatinine >220 μmol/L or creatinine clearance 130 μmol/L or creatinine clearance <40 mL/min). Three of the six type-I patients required haemodialysis. In all patients, we measured renal function indices, urine volume, and sodium excretion before the intervention and 1, 2, 4, 8, 12, and 26 weeks after TIPS. Survival was analysed by Kaplan-Meier. Within 2 weeks of TIPS insertion there was a striking reduction in serum urea and creatinine together with a doubling in creatinine clearance (figure). Baseline sodium excretion increased spontaneously about 1 week after TIPS and was stimulated 2 weeks after TIPS by diuretics (100–200 mg of spironolactone and 40–80 mg frusemide per day). Glomerular filtration rate gradually improved over the next 6–8 weeks and creatinine clearance averaged around 60 mL/min 3 months after TIPS. Haemodialysis could be withdrawn in two patients (on days 12 and 18). Five patients died from progressive liver disease (at weeks 3, 4, 6, 13, 45) and two patients died from non-liver related events (at week 22 from cancer and at week 45 from sepsis). 3-month survival rate was 75% and the estimates of a six-month and a 1-year survival were 68% and 56% with little difference between type-I and type-II hepatorenal syndrome. While the majority of patients (81%) showed a rapid and sustained improvement, all three non-responders (unchanged GFR and severe ascites) died within 6 weeks after TIPS. Beneficial results even in patients already requiring haemodialysis but without subsequent transplant rescue may be due to improved filling of the central venous system decreasing neurohumoral vasoconstrictive activities (eg, plasma renin or noradrenalin), and a reduced sinusoidal pressure can relieve sodium retention by decreasing the direct symphathetic nervous effects on the proximal tubule. The observed 3-month and estimated 6-month and 1-year survival of our high-risk patients was substantially better than with medical management alone.

Limitations and pitfalls of Couinaud's segmentation of the liver in transaxial Imaging.

The segmental anatomy of the human liver has become a matter of increasing interest to the radiologist, especially in view of the need for an accurate preoperative localization of focal hepatic lesions. In this review article first an overview of the different classical concepts for delineating segmental and subsegmental anatomy on US, transaxial CT, and MR images is given. Essentially, these procedures are based on Couinauds concept of three vertical planes that divide the liver into four segments and of a transverse scissura that further subdivides the segments into two subsegments each. In a second part, the limitations of these methods are delineated and discussed with the conclusion that if exact preoperative localization of hepatic lesions is needed, tumor must be located relative to the avascular planes between the different portal territories.

Preoperative 18F-FDG-PET/CT imaging and sentinel node biopsy in the detection of regional lymph node metastases in malignant melanoma.

The objective of this study was to evaluate the role of preoperative 18F-fluorodeoxyglucose-positron emission tomography/computed tomography scanning, preoperative lymphoscintigraphy (LS), and sentinel lymph node biopsy in patients with malignant melanoma. Fifty-two patients (36 men: 16 women; mean age 55.0±13.0 years; median age 61 years; range 17–76 years) with malignant melanoma were selected. According to the latest version of the American Joint Committee on Cancer staging system, the disease in the study patients was initially classified as either stage I or II. The other primary tumor characteristics were mean Breslow depth=2.87 mm and median=2 mm; range 1–12.0 mm and Clarks levels III–V. None of the study patients had clinical or radiological evidence of regional lymph node metastatic disease. At least one sentinel node was identified in all patients. Preoperative LS detected a total of 111 sentinel lymph nodes (average 2.13 sentinel lymph node per patient) and demonstrated a single nodal draining basin in 38 (73%) patients and multiple (2–3 draining basins) in the remaining 14 (27%) patients. Fourteen out of the 52 patients (27%) had at least one involved sentinel node. Positron emission tomography was true positive in two patients with a sentinel node greater than 1 cm and false positive in two other patients. In this study, the detection of sentinel lymph node by LS and gamma probe had a sensitivity of 100%. In contrast, 18F-FDG-PET imaging demonstrated very low sensitivity (14.3%; 95% CI, 2.5 to 44%) and positive predictive value (50%; 95% CI, 9 to 90%) for localizing the subclinical nodal metastases. The specificity, net present value, and diagnostic accuracy were 94.7, 75, and 73%, respectively. Preoperative fluorodeoxyglucose-positron emission tomography/computed tomography imaging is not able to substitute LS/sentinel lymph node biopsy in patients at stage I or II.

Prospective evaluation of a clinical score for 60-day mortality after transjugular intrahepatic portosystemic stent-shunt: Bonn TIPSS early mortality analysis.

Objective Transjugular intrahepatic portosystemic stent-shunt (TIPSS) is increasingly used to treat complications of portal hypertension, but proven tools for risk assessment of early mortality are lacking. Design The prospective evaluation of a new 60-day mortality score. Patients and methods In a tertiary medical centre, 30 consecutive TIPSS patients were analysed for early mortality predictors, such as Child–Pugh score, TIPSS urgency (elective:⩾ 36 h or emergency:< 36 h after variceal bleeding), comorbidity (Acute Physiology and Chronic Health Evaluation [APACHE]-II) and clinical data. Main predictors (P< 0.01) in this group (group-1: Child–Pugh score 10A, 10B, 10C) were graded (1, 2 or 3 points representing low, medium and high risk, respectively) and summarized as a Bonn TIPSS early mortality (BOTEM) score. This score was then tested prospectively in the next 73 TIPSS patients (group-2: Child–Pugh score 14A, 42B, 17C). Results Group 1 early mortality (30%) depended primarily on bilirubin (P< 0.005), APACHE-II (P < 0.001) and TIPSS urgency (P< 0.001). Added risk points (1, 2, 3) for bilirubin (< 3 mg/dl, 3–6 mg/dl, > 6 mg/dl, respectively), APACHE-II (< 10, 10–20, > 20 points, respectively) and urgency (elective, emergency, active bleeding, respectively) represented individual BOTEM score points. BOTEM was the best mortality predictor (P< 0.001);⩽/ > 6 score points was the optimal cut-off, with 56% sensitivity, 100% specificity, 100% positive predictive value, 84% negative predictive value and 87% accuracy. In group 2, early mortality (8.2%) was again best predicted by BOTEM (P < 0.01) with the same cut-off and 67% sensitivity, 99% specificity, 80% positive predictive value, 97% negative predictive value and 96% accuracy. Conclusion BOTEM score based on bilirubin, comorbidity and TIPSS-urgency predicts rather reliably post-TIPSS 60-day mortality and might optimize TIPSS treatment.

CXCL9 is a prognostic marker in patients with liver cirrhosis receiving transjugular intrahepatic portosystemic shunt.

BACKGROUND & AIMS Inflammation, collagen deposition and tissue remodelling are involved in the pathogenesis and complications of cirrhosis with portal hypertension. CXCL9 and other chemokines play an important role in these processes and have been associated with liver injury and complications of liver disease in humans. However, their predictive value in patients with cirrhosis and portal hypertension remains to be established. METHODS 103 patients with liver cirrhosis who had received TIPS (transjugular intrahepatic portosystemic shunt) were included into this study. The TIPS indication was either refractory ascites or recurrent bleeding. Before and after the TIPS procedure portal and hepatic venous blood samples were obtained in 78 patients. In 25 patients blood samples were obtained from the portal vein, hepatic vein, right atrium and cubital vein at TIPS insertion. Serum levels of CXCL9 were measured by cytometric bead array and correlated with clinical parameters and overall outcome. RESULTS Portal venous levels of CXCL9 decreased after TIPS. Child-Pugh score, refractory ascites, renal dysfunction and alcoholic aetiology of cirrhosis were associated with increased CXCL9 levels. Importantly, low levels of CXCL9 in portal and hepatic vein samples were prognostic factors for the survival of patients receiving TIPS during long-time follow-up. CONCLUSIONS The CXCR3 ligand CXCL9 affects the liver and/or is released by the liver and thereby might contribute to hepatic and extrahepatic organ dysfunction. Elevated levels of CXCL9 are associated with shorter survival in cirrhotic patients with severe portal hypertension receiving TIPS. This chemokine should be further evaluated as a novel biomarker for the outcome in patients with cirrhosis and portal hypertension and its modulation as a new therapeutic strategy.

Acute Budd-Chiari syndrome: Treatment with transjugular intrahepatic portosystemic shunt

The case of a 28-year-old man with acute Budd-Chiari syndrome due to veno-occlusive disease is reported. Transjugular intrahepatic portosystemic shunt (TIPS) was performed after upper gastrointestinal endoscopy, duplex sonographic and abdominal computed tomographic examination, inferior cavogram with hepatic venous catheterization, and transvenous biopsy. A 10-mm parenchymal tract was created. The patient did well after the procedure; ascites resolved and liver function improved markedly. The shunt has remained patent up to now for 6 months.

Soluble TNF-Alpha-Receptors I Are Prognostic Markers in TIPS-Treated Patients with Cirrhosis and Portal Hypertension

Background TNFα levels are increased in liver cirrhosis even in the absence of infection, most likely owing to a continuous endotoxin influx into the portal blood. Soluble TNFα receptors (sTNFR type I and II) reflect release of the short-lived TNFα, because they are cleaved from the cells after binding of TNFα. The aims were to investigate the circulating levels of soluble TNFR-I and -II in cirrhotic patients receiving TIPS. Methods Forty-nine patients with liver cirrhosis and portal hypertension (12 viral, 37 alcoholic) received TIPS for prevention of re-bleeding (n = 14), therapy-refractory ascites (n = 20), or both (n = 15). Portal and hepatic venous blood was drawn in these patients during the TIPS procedure and during the control catheterization two weeks later. sTNFR-I and sTNFR-II were measured by ELISA, correlated to clinical and biochemical characteristics. Results Before TIPS insertion, sTNFR-II levels were lower in portal venous blood than in the hepatic venous blood, as well as in portal venous blood after TIPS insertion. No significant differences were measured in sTNFR-I levels. Hepatic venous levels of sTNFR-I above 4.5 ng/mL (p = 0.036) and sTNFR-II above 7 ng/mL (p = 0.05) after TIPS insertion were associated with decreased survival. A multivariate Cox-regression survival analysis identified the hepatic venous levels of sTNFR-I (p = 0.004) two weeks after TIPS, and Child score (p = 0.002) as independent predictors of mortality, while MELD-score was not. Conclusion Hepatic venous levels of sTNFR-I after TIPS insertion may predict mortality in patients with severe portal hypertension.

Second-Generation Amplatzer Vascular Plug (AVP) for the Treatment of Subsequent Subclavian Backflow Type II Endoleak After TEVAR

Since its approval as an occlusive device in the peripheral vasculature in 2004, the first-generation Amplatzer Vascular Plug (AVP; AGA Medical, Golden Valley, MN, USA) has already become a therapeutic alternative to coil embolization in dedicated cases. Here, we present for the first time, a case of type II endoleak from the left subclavian artery after thoracic stent-graft placement successfully treated with a second-generation AVP.