Sara Kammerer

Comparative analysis of ERCP, IDUS, EUS and CT in predicting malignant bile duct strictures

AIM To compare endoscopic retrograde cholangio-pancreatography (ERCP), intraductal ultrasound (IDUS), endosonography (EUS), endoscopic transpapillary forceps biopsies (ETP) and computed tomography (CT) with respect to diagnosing malignant bile duct strictures. METHODS A patient cohort with bile duct strictures of unknown etiology was examined by ERCP and IDUS, ETP, EUS, and CT. The sensitivity, specificity, and accuracy rates of the diagnostic procedures were calculated based on the definite diagnoses proved by histopathology or long-term follow-up in those patients who did not undergo surgery. For each of the diagnostic measures, the sensitivity, specificity, and accuracy rates were calculated. In all cases, the gold standard was the histopathologic staging of specimens or long-term follow-up of at least 12 mo. A comparison of the accuracy rates between the localization of strictures was performed by using the Mann-Whitney U-test and the χ(2) test as appropriate. A comparison of the accuracy rates between the diagnostic procedures was performed by using the McNemars test. Differences were considered statistically significant if P < 0.05. RESULTS A total of 234 patients (127 males, 107 females, median age 64, range 20-90 years) with indeterminate bile duct strictures were included. A total of 161 patients underwent operative exploration; thus, a surgical histopathological correlation was available for those patients. A total of 113 patients had malignant disease proven by surgery; in 48 patients, benign disease was surgically found. In these patients, the decision for surgical exploration was made due to the suspicion of malignant disease in multimodal diagnostics (ERCP, CT, or EUS). Fifty patients had a benign diagnosis and were followed by a surveillance protocol with a follow-up of at least 12 mo; the median follow-up was 34 mo. Twenty-three patients had extended malignant disease, and thus were considered palliative. A comparison of the different diagnostic tools for detecting bile duct malignancy resulted in accuracy rates of 91% (ERCP/IDUS), 59% (ETP), 92% (IDUS + ETP), 74% (EUS), and 73% (CT), respectively. In the subgroup analysis, the accuracy rates (%, ERCP + IDUS/ETP/IDUS + ETP; EUS; CT) for each tumor entity were as follows: cholangiocellular carcinoma: 92%/74%/92%/70%/79%; pancreatic carcinoma: 90%/68%/90%/81%/76%; and ampullary carcinoma: 88%/90%/90%/76%/76%. The detection rate of malignancy by ERCP/IDUS was superior to ETP (91% vs 59%, P < 0.0001), EUS (91% vs 74%, P < 0.0001) and CT (91% vs 73%, P < 0.0001); EUS was comparable to CT (74% vs 73%, P = 0.649). When analyzing accuracy rates with regard to localization of the bile duct stenosis, the accuracy rate of EUS for proximal vs distal stenosis was significantly higher for distal stenosis (79% vs 57%, P < 0.0001). CONCLUSION ERCP/IDUS is superior to EUS and CT in providing accurate diagnoses of bile duct strictures of uncertain etiology. Multimodal diagnostics is recommended.

Preoperative prediction of curative surgery of perihilar cholangiocarcinoma by combination of endoscopic ultrasound and computed tomography

Background Perihilar cholangiocarcinomas are often considered incurable. Late diagnosis is common. Advanced disease therefore frequently causes questioning of curative surgical outcome. Aim This study aimed to develop a prediction model of curative surgery in patients suffering from perihilar cholangiocarcinomas based on preoperative endosonography and computer tomography. Methods A cohort of 81 patients (median age 67 (54–75) years, 62% male) with perihilar cholangiocarcinoma was retrospectively analyzed. Multivariate logistic regression analysis of staging variables taken from the European Staging System was performed and applied to ROC analysis. Results The correlation of predicted rates of eligibility for surgery with actual rates reached AUC values between 0.652 and 0.758 for endosonography and computer tomography (p < 0.05 each). Best prediction for curative surgical option was achieved by combining endosonography and computer tomography (AUC: 0.787; 95% CI 0.680–0.893, p < 0.0001). A predictive model (pSurg) was developed using multivariate analysis. Conclusions Our predictive web-based model pSurg with inclusion of T, N, M, B, PV, HA and V stage of the recently published European Staging System for perihilar cholangiocarcinoma results in highly significant predictability for curative surgery when combining preoperative endosonography and computer tomography, thus allowing for better patient selection in terms of possibility of curative surgery.

The role of multislice computed tomography (MSCT) angiography in the diagnosis and therapy of non-occlusive mesenteric ischemia (NOMI): Could MSCT replace DSA in diagnosis?

Objectives Evaluation of multislice-CT (MSCT) during diagnosis and therapeutic decision-making in patients with suspected non-occlusive mesenteric ischemia (NOMI). Methods Retrospective, institutional review board-approved study of 30 patients (20 men, 10 women, mean age 64.6±14.2 years, range 24–87 years) undergoing biphasic abdominal MSCT followed by digital subtraction angiography (DSA) due to suspected NOMI. MSCT and DSA were qualitatively and quantitatively evaluated independently by two radiologists with respect to the possible diagnosis of NOMI. MSCT analysis included quantitative measurements, qualitative evaluation of contrast enhancement and assessment of secondary findings (bowel wall thickening, hypo-enhancement, intestinal pneumatosis). MSCT diagnosis and secondary findings were compared against DSA diagnosis. Results NOMI was diagnosed in a total of n = 28 patients. No differences were found when comparing the R1-rated MSCT diagnosis (p = 0.09) to the “gold standard”, while MSCT diagnosis was slightly inferior with R2 (p = 0.02). With R1, vessel-associated parameters revealed the best correlation, i.e. qualitative vessel width (r = -0.39;p = 0.03) and vessel contrast (r = 0.45;p = 0.01). Moderate correlations were found for quantitative vessel diameters in the middle segments (r = -0.48,p = 0.01), increasing to almost high correlations in the distal (r = -0.66;p<0.00001) superior mesenteric artery (SMA) segments. No significant correlation was apparent from secondary findings. Conclusions MSCT is an appropriate non-invasive method for diagnosing NOMI and leads to adequate and immediate therapeutic stratification.

Stereotactic biopsy of cerebellar lesions: straight versus oblique frame positioning

Abstract Objective: Biospies of brain lesions with unknown entity are an everyday procedure among many neurosurgical departments. Biopsies can be performed frame-guided or frameless. However, cerebellar lesions are a special entity with a more complex approach. All biopsies in this study were performed stereotactically frame guided. Therefore, only biopsies of cerebellar lesions were included in this study. We compared whether the frame was attached straight versus oblique and we focused on diagnostic yield and complication rate. Methods: We evaluated 20 patients who underwent the procedure between 2009 and 2017. Median age was 56.5 years. 12 (60%) Patients showed a left sided lesion, 6 (30%) showed a lesion in the right cerebellum and 2 (10%) patients showed a midline lesion. Results: The stereotactic frame was mounted oblique in 12 (60%) patients and straight in 8 (40%) patients. Postoperative CT scan showed small, clinically silent blood collection in two (10%) of the patients, one (5%) patient showed haemorrhage, which caused a hydrocephalus. He received an external ventricular drain. In both patients with small haemorrhage the frame was positioned straight, while in the patient who showed a larger haemorrhage the frame was mounted oblique. In all patients a final histopathological diagnosis was established. Conclusion: Cerebellar lesions of unknown entity can be accessed transcerebellar either with the stereotactic frame mounted straight or oblique. Also for cerebellar lesions the procedure shows a high diagnostic yield with a low rate of severe complications, which need further treatment.

Response Evaluation of Malignant Liver Lesions After TACE/SIRT: Comparison of Manual and Semi-Automatic Measurement of Different Response Criteria in Multislice CT

Purpose To compare measurement precision and interobserver variability in the evaluation of hepatocellular carcinoma (HCC) and liver metastases in MSCT before and after transarterial local ablative therapies. Materials and Methods Retrospective study of 72 patients with malignant liver lesions (42 metastases; 30 HCCs) before and after therapy (43 SIRT procedures; 29 TACE procedures). Established (LAD; SAD; WHO) and vitality-based parameters (mRECIST; mLAD; mSAD; EASL) were assessed manually and semi-automatically by two readers. The relative interobserver difference (RID) and intraclass correlation coefficient (ICC) were calculated. Results The median RID for vitality-based parameters was lower from semi-automatic than from manual measurement of mLAD (manual 12.5 %; semi-automatic 3.4 %), mSAD (manual 12.7 %; semi-automatic 5.7 %) and EASL (manual 10.4 %; semi-automatic 1.8 %). The difference in established parameters was not statistically noticeable (p > 0.05). The ICCs of LAD (manual 0.984; semi-automatic 0.982), SAD (manual 0.975; semi-automatic 0.958) and WHO (manual 0.984; semi-automatic 0.978) are high, both in manual and semi-automatic measurements. The ICCs of manual measurements of mLAD (0.897), mSAD (0.844) and EASL (0.875) are lower. This decrease cannot be found in semi-automatic measurements of mLAD (0.997), mSAD (0.992) and EASL (0.998). Conclusion Vitality-based tumor measurements of HCC and metastases after transarterial local therapies should be performed semi-automatically due to greater measurement precision, thus increasing the reproducibility and in turn the reliability of therapeutic decisions. Key points  · Liver lesion measurements according to EASL and mRECIST are more precise when performed semi-automatically.. · The higher reproducibility may facilitate a more reliable classification of therapy response.. · Measurements according to RECIST and WHO offer equivalent precision semi-automatically and manually.. Citation Format · Höink AJ, Schülke C, Koch R et al. Response Evaluation of Malignant Liver Lesions After TACE/SIRT: Comparison of Manual and Semi-Automatic Measurement of Different Response Criteria in Multislice CT. Fortschr Röntgenstr 2017; 189: 1067 - 1075.