Martina Scharitzer

Gadobenate Dimeglumine–enhanced 3.0-T MR Imaging versus Multiphasic 64–Detector Row CT: Prospective Evaluation in Patients Suspected of Having Pancreatic Cancer

PURPOSE To compare the diagnostic performance (detection, local staging) of multiphasic 64-detector row computed tomography (CT) with that of gadobenate dimeglumine-enhanced 3.0-T magnetic resonance (MR) imaging in patients suspected of having pancreatic cancer. MATERIALS AND METHODS The institutional review board approved this prospective study, and all patients provided written informed consent. Multidetector CT and MR imaging were performed in 89 patients (48 women aged 46-89 years [mean, 65.6 years] and 41 men aged 46-86 years [mean, 65.3 years]) suspected of having pancreatic cancer on the basis of findings from clinical examination or previous imaging studies. Two readers independently assessed the images to characterize lesions and determine the presence of focal masses, vascular invasion, distant metastases, and resectability. Findings from surgery, biopsy, endosonography, or follow-up imaging were used as the standard of reference. Logistic regression, the McNemar test, and κ values were used for statistical analysis. RESULTS Focal pancreatic masses were present in 63 patients; 43 patients had adenocarcinoma. For reader 1, the sensitivities and specificities in the detection of pancreatic adenocarcinoma were 98% (42 of 43 patients) and 96% (44 of 46 patients), respectively, for CT and 98% (42 of 43 patients) and 96% (44 of 46 patients) for MR imaging. For reader 2, the sensitivities and specificities were 93% (40 of 43 patients) and 96% (44 of 46 patients), respectively, for CT and 95% (41 of 43 patients) and 96% (44 of 46 patients) for MR imaging. Vessel infiltration was determined in 22 patients who underwent surgery, and reader 1 obtained sensitivities and specificities of 90% (nine of 10 vessels) and 98% (119 of 122 vessels), respectively, for CT and 80% (eight of 10 vessels) and 96% (117 of 122 vessels) for MR imaging; for reader 2, those values were 70% (seven of 10 vessels) and 98% (120 of 122 vessels) for CT and 50% (five of 10 vessels) and 98% (120 of 122 vessels) for MR imaging. Both readers correctly assessed resectability in 87% (13 of 15 patients) of cases with CT and 93% (14 of 15 patients) of cases with MR imaging. Nonresectability was assessed correctly with CT in 75% (six of eight patients) of cases by reader 1 and 63% (five of eight patients) of cases by reader 2; nonresectability was correctly assessed with MR imaging in 75% (six of eight patients) of cases by reader 1 and 50% (four of eight patients) of cases by reader 2. None of the differences between modalities and readers were statistically significant (P > .05). CONCLUSION Both CT and MR imaging are equally suited for detecting and staging pancreatic cancer. SUPPLEMENTAL MATERIAL http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.11101189/-/DC1.

State-of-the-art magnetic resonance imaging of pancreatic cancer.

Technical advances of magnetic resonance imaging (MRI), including ultrahigh-field magnetic resonance at 3.0 T, parallel imaging techniques, and multichannel receive coils of the abdomen, have promoted MRI of the pancreas. For adenocarcinoma, which is the most common malignant pancreatic tumor, helical CT has been most often used for detection and staging, but it has limitations in the detection of small cancers 2 cm in diameter or less (sensitivity, 63%). Moreover, it is not very accurate in determining nonresectability, because small liver metastases, peritoneal carcinomatosis, and subtle signs of vascular infiltration may be missed. At ultrahigh field at 3.0 T, gadolinium-enhanced MRI using volume-interpolated 3-dimensional gradient-recalled echo pulse sequences with near-isotropic voxels are very useful for detection of subtle abnormalities. Mangafodipir-enhanced MRI reveals a very high tumor-pancreas contrast, which helps to diagnose small cancers. Contrast-enhanced MRI is a problem-solving tool in case of equivocal CT: it helps to differentiate between cancer and focal pancreatitis. Neuroendocrine carcinoma may present with a spectrum of appearances at MRI, but the primary tumor and liver metastases are hypervascular in approximately 70%. In this article, pancreas imaging protocols for 1.5 and 3.0 T are explained. We present the imaging features of pancreatic cancer and the important questions in staging, which should be addressed by the radiologist.

Characterization of hepatocellular tumors: value of mangafodipir-enhanced magnetic resonance imaging.

Purpose: To assess the value of mangafodipir trisodium-enhanced MR imaging for characterization of hepatocellular lesions. Materials and Methods: Magnetic resonance images of 41 patients with 48 histopathologically proven hepatocellular lesions (20 cases of focal nodular hyperplasia [FNH], 4 adenomas, 15 hepatocellular carcinomas [HCCs], 7 regenerative nodules, and 2 others) were retrospectively studied. Magnetic resonance imaging was performed on a 1.5-T unit (Vision, Siemens, Erlangen, Germany; ACS-NT, Philips, Best, The Netherlands) using T2-weighted, fat-saturation, turbo spin echo imaging and T1-weighted gradient echo imaging before and 20 minutes after infusion of 5 μmol/kg mangafodipir (Amersham Health, Oslo, Norway). Qualitative analysis by 4 blinded independent readers included assessment of unenhanced images and, in a second step, assessment of unenhanced and contrast-enhanced images together. Lesions were classified as benign or malignant using a 5-point scale, and readers made a specific diagnosis. Results: For characterization of hepatocellular lesions, mangafodipir-enhanced imaging was significantly superior to unenhanced imaging (P < 0.05). On receiver operating characteristic analysis, the area under the curve was 0.768 (95% confidence interval: 0.633-0.903) for unenhanced images and 0.866 (95% confidence interval: 0.767-0.966) for evaluation of unenhanced and contrast-enhanced images together (P < 0.05). Analysis of enhancement patterns aided in characterization and classification of tumors. Conclusion: Administration of mangafodipir improves the differentiation between adenoma or HCC and “nonsurgical” lesions (FNH or regenerative nodules). The accuracy for arriving at a specific diagnosis is higher when unenhanced and mangafodipir-enhanced images are considered together than for unenhanced MR images alone.

Uveitis and neurologic diseases: an often overlooked relationship

ZusammenfassungZIEL: Auge und Gehirn haben embryologisch gemeinsame Wurzeln und unterliegen einem Immunprivileg, um die Organintegrität und damit die Funktionalität bestmöglich zu schützen. Dass eine Reihe immunsystem-mediierter Erkrankungen an beiden Organen manifest werden kann erscheint plausibel, dennoch wird während der Abklärung der Patienten selten daran gedacht. Ziel dieser Studie war es, auf die Ko-Manifestation entzündlicher Erkrankungen des Auges und Gehirns aufmerksam zu machen und das Vorkommen dieser neurologischen Erkrankungen bei Uveitispatienten zu erheben. PATIENTEN UND METHODIK: Es wurde eine Datenbank von Patienten analysiert, die zwischen 2000 und 2004 an der Uveitisambulanz des AKH (Medizinische Universität Wien) vorstellig geworden waren. Patienten mit neurologischen Manifestationen im Rahmen immunsystem-mediierter Erkrankungen wurden ausgewählt. ERGEBNISSE: Von insgesamt 1973 Patienten wiesen 52 (2,6 %) neurologische Erkrankungen auf, die mit der Uveitis ursächlich in Zusammenhang gebracht werden konnten. Die häufigsten neurologischen Erkrankungen waren Multiple Sklerose, Vogt-Koyanagi-Harada Syndrom, Neurobehcet, ZNS-Lymphom, Neurosyphilis und Neurosarkoidose. Seltener wurde eine Uveitis im Rahmen von infektiöser Meningoenzephalitis (Neuroborreliose, Mumps, Masern), Takayasu-Arteriitis, Guillain-Barre-Syndrom und orbitalem Pseudotumor beobachtet. SCHLUSSFOLGERUNG: Bestimmte immun-mediierte Erkrankungen können sowohl als intraokuläre Inflammationen (Uveitis) als auch als Entzündungen im Zentralnervensystem manifestieren. Aus augenärztlicher Sicht sollte daher beim Vorliegen bestimmter Augenbefunde eine gezielte neurologische Abklärung initiiert werden. Aber auch Neurologen sollten bei Diagnosestellung entzündlicher neurologischer Erkrankungen eine Abklärung über den Ophthalmologen veranlassen. Die oft typischen Augenveränderungen können dabei hilfreiche Hinweise liefern.SummaryAIM: Eye and brain are linked by development, and immune privileges preserve the integrity of these delicate organs thereby preventing irreversible defects in function. Manifestation of inflammatory or immune-mediated diseases in both systems seems perspicuous, yet during check-up of patients with uveitis they are rarely considered. In this study we aimed to determine the frequency of neurologic diseases in our uveitis patients and to describe the characteristics of ophthalmologic findings. METHODS: We analyzed the database of 1973 consecutive patients seen between 2000 and 2004 at the uveitis clinic at the hospital of the Medical University of Vienna. All cases of uveitis associated with neurologic co-manifestations of immune-mediated diseases were selected. RESULTS: Of 1973 patients with uveitis, 52 (2.6 %) had neurologic diseases that were considered to be related to the eye inflammation. The most frequent entities were multiple sclerosis, Vogt-Koyanagi-Haradas disease, neurobehcet, central nervous system lymphoma, neurosyphilis and neurosarcoidosis. Uveitis was only rarely seen with infectious meningoencephalitis (neuroborreliosis, mumps, measles), Takayasu arteritis, Guillain-Barre syndrome or orbital pseudotumor. CONCLUSIONS: Several diseases can cause both ocular and/or central nervous system inflammation. This should prompt ophthalmologists and neurologists in the presence of one to rule out the other. In uveitis patients without evident neurological symptoms, specific ocular pathologies can help the treating ophthalmologist to tailor the work-up, whereas neurologists should always screen their patients, even when they are asymptomatic for ocular disease. Early diagnosis in both cases can help to initiate adequate treatment, thereby modulating the course of the disease and preventing complications.

Upper esophageal sphincter dysfunction: diverticula–globus pharyngeus

The following discussion of upper esophageal sphincter dysfunction includes commentaries on the role of the cricopharyngeus muscle in reflux disease; the etiology and treatment of Zenker diverticulum; the use of videofluoroscopy in patients with dysphagia, suspicion of aspiration, or globus; the role of pH–impedance monitoring in globus evaluation; and treatment for reflux‐associated globus.

Neuogenic and oropharyngeal dysphagia

Oropharyngeal dysphagia (OD) is a swallowing disorder caused by congenital abnormalities and structural damage and disease‐associated damage of the oral cavity, pharynx, and upper esophageal sphincter. Patients with OD lack the protective mechanisms necessary for effective swallowing, exhibiting difficulty controlling food in the mouth and initiating a swallow, leading to choking, coughing, and nasal regurgitation. OD is a major risk factor for malnutrition, dehydration, and aspiration pneumonia. The following on OD includes commentaries on the application of simulation of oropharyngeal transient receptor potential vanilloid 1 (TRPV1) and maneuvers like the Shaker exercise to improve the safety and efficacy of swallow in OD patients; the prevalence of esophageal pathologies in OD patients and the need to evaluate the esophagus, esophagogastric junction, and stomach; and strategies for clinical screening to detect OD and aspiration among high‐risk patients and to improve oral health care, maintain nutrition and hydration, and prevent aspiration pneumonia.

Taking the history in patients with swallowing disorders: an international multidisciplinary survey

PurposeClinical assessment of swallowing disorders (dysphagia) requires accurate and comprehensive medical history-taking to further tailor the diagnostic work-up, but functional health care questionnaires show a large variability and various limitations. The aim of this study was to assess the way in which international swallowing experts from various disciplines asses swallowing problems in order to improve the radiologist´s ability to take a thorough medical history in this specific patient group.MethodsA two-step Delphi method was used to collect swallowing experts’ ways of taking the medical history in patients with swallowing disorders. The questions obtained in a first interview round were pooled and structured by dividing them into general and specific questions, including several subcategories, and these were scored by the experts in a second step based on to their clinical relevance.ResultsEighteen experts provided 25 different questions categorized as general questions and 34 dimension-specific questions (eight attributed to ‘suspicion of aspiration,’ 13 to ‘dysphagia,’ six to ‘globus sensation,’ four to ‘non-cardiac chest pain,’ and three to ‘effect of life.’) In the second interview round, the experts´ average predictive values attributed to those questions showed the varying importance of the presented items. Seven general and 13 specific questions (six of them attributed to ‘effect on life’ and seven ‘others’) were also added.ConclusionsThis collection of questions reflects the fact that a multidisciplinary approach when obtaining the medical history in patients with swallowing disorders may contribute to an improved technique for performing a symptom-oriented medical history-taking for radiologists of all training levels.

Innovative techniques in evaluating the esophagus; imaging of esophageal morphology and function; and drugs for esophageal disease.

This paper reporting on techniques for esophageal evaluation and imaging and drugs for esophageal disease includes commentaries on endoscopy techniques including dye‐based high‐resolution and dye‐less high‐definition endoscopy; the shift from CT to MRI guidance in tumor delineation for radiation therapy; the role of functional lumen imaging in measuring esophageal distensibility; electrical stimulation of the lower esophageal sphincter (LES) as an alternative to fundoduplication for treatment of gastroesophageal reflux disease (GERD); the morphological findings of reflux esophagitis and esophageal dysmotility on double‐contrast esophagography; the value of videofluoroscopy in assessing protecting mechanisms in patients with chronic reflux or swallowing disorders; targeting visceral hypersensitivity in the treatment of refractory GERD; and the symptoms and treatments of nighttime reflux and nocturnal acid breakthrough (NAB).

Neurogenic [corrected] and oropharyngeal dysphagia.

Oropharyngeal dysphagia (OD) is a swallowing disorder caused by congenital abnormalities and structural damage and disease‐associated damage of the oral cavity, pharynx, and upper esophageal sphincter. Patients with OD lack the protective mechanisms necessary for effective swallowing, exhibiting difficulty controlling food in the mouth and initiating a swallow, leading to choking, coughing, and nasal regurgitation. OD is a major risk factor for malnutrition, dehydration, and aspiration pneumonia. The following on OD includes commentaries on the application of simulation of oropharyngeal transient receptor potential vanilloid 1 (TRPV1) and maneuvers like the Shaker exercise to improve the safety and efficacy of swallow in OD patients; the prevalence of esophageal pathologies in OD patients and the need to evaluate the esophagus, esophagogastric junction, and stomach; and strategies for clinical screening to detect OD and aspiration among high‐risk patients and to improve oral health care, maintain nutrition and hydration, and prevent aspiration pneumonia.

Acute colonic pseudo-obstruction (Ogilvie's-syndrome) and Pneumatosis intestinalis in a kidney recipient patient

ZusammenfassungDie akute Pseudo-Obstruktion des Kolons (Ogilvie’s Syndrom) wird charakterisiert durch eine massive nicht toxische Dilatation des Kolons bei fehlender mechanischer Obstruktion und ist mit einer erhöhten Morbidität und Mortalität beim immunsupprimierten Patienten assoziiert. Wir präsentieren den Fall eines nierentransplantierten Patienten, der ein lebensbedrohliches klinisches Zustandsbild mit akuter Pseudoobstruktion des Kolons und zusätzlich radiologischem Nachweis einer linearen Pneumatosis intestinalis (PI) ausgebildet hatte.Bei der Akutlaparotomie fand sich ein massiv dilatiertes Coecum, Colon ascendens und Colon transversum mit Darmwandnekrosen und multiplen Serosadefekten weswegen eine erweiterte Hemikolektomie rechts durchgeführt wurde. In den Stuhlkulturen und intraoperativen Abstrichen konnte kein Erreger nachgewiesen, weiters fand sich kein Hinweis für eine virale Infektion oder Pilzinfektion. 31 Tage nach der Nierentransplantation konnte der Patient mit normaler Nierenfunktion entlassen werden.Über steroid-induzierten Ileus (Pseudo-Obstruktion) bei transplantierten Patienten als potentiell bedrohliche Frühform von Dysmotilität des Kolons wurde bislang selten berichtet. Die Kenntnis dieser Diagnose und ihre Früherkennung mit rascher Korrektur ursächlicher Faktoren sind für eine erfolgreiche Behandlung entscheidend. Durch eine kolonoskopische Dekompression kann in den meisten Fällen eine Rückbildung der Kolondilatation erreicht werden, jedoch in einzelnen Fällen ist eine prophylaktische Laparotomie indiziert, um die katastrophalen Konsequenzen einer Perforation zu vermeiden.SummaryAcute colonic pseudo-obstruction (Ogilvie’s syndrome) is a clinical entity characterized by massive nontoxic dilatation of the colon in the absence of mechanical obstruction and is associated with increased morbidity and mortality in the immunosuppressed patient.We present a case of a kidney transplant recipient developing a life-threatening condition with acute colonic pseudo-obstruction associated with radiologic findings of a linear pneumatosis intestinalis (PI). Urgent laparotomy and resection of the dilated cecum, colon ascendens and transversum was performed because of bowel necrosis with multiple serosal defects. Stool cultures and special stains for microorganisms were all negative, and there was no evidence for viral or fungal infection. The patient was discharged 31 days after transplantation with normal renal function.In conclusion, this steroid-induced ileus (pseudo-obstruction) is a potentially malignant early form of colonic dysmotility rarely reported in transplant recipients. Awareness and early recognition of the condition are critical for a successful outcome. Colonoscopic decompression can achieve reversal of colonic dilatation in most cases, but in some patients prophylactic laparotomy is indicated for prevention of the catastrophic consequences of perforation.