Ultrasound-guided aspiration of ovarian cysts:results in ultrasonically benign cysts

Ultrasound-guided ovarian cyst aspiration is an increasingly important means of diagnosingand treating ovarean cysts.We report the results of 140 ultrasound-guided ovarian cyst aspirations in112 symptomatic patients,with an age range of 19-87 years(mean 38).Cysts had benign character-istics and ranged from 4 to 20 cm in diameter.The majority of cysts were aspirated once.In 20 casescysts were aspirated twice,in five cases three times and in one case four times.The cyst aspirate wesexamined cytologically and correlated with histology where available.The only complication was an o-varian abscess,giving a eomplieation rate of 0.7%.Cytology was not found to be useful in excludingneoplastic lesions(sensitivity 46.6%.)The aspirate type was more useful.A serous aspirate was asso-ciated with a cure rate of 73.7%(45 of 61);28%(17 of 61)eventually had surgery;at surgery 9(14.75%)neoplastic lesions were found,all were benign.A haemorrhagic aspirate with no histo~ ofendometriosis was associated with a cure rate of 70.6% (12 of 17);there were 4(24%)neoplastic cystsat surgery,1 of these was malignant.Endometriotic cysts had a recurrence rate of 90%(19 of 21).Withmutinous aspirates 75%(3 of 4)were mueinous neoplasms.Aspiration was performed in 14 post-menopausal patients.Two neoplasms were found in this group and one of these was a malignant neoplasm,which had yielded a haemorrhagic aspirate.The majority of cysts even in the postmenopausal patientswere innocuous.Uetrasound-guided cyst aspiration is safe and useful in the management of ovarian cysts with benigncharacteristics.The finding of a haemorrhagic aspirate is more likely to indicate a neoplastic lesion,andespecially in the postmenopausal patient should be viewed with caution.The risk of missing a malignantlesion in non-haemorrhagie cysts with benign eharacteristies on ultrasound is negligible.     

Revision of anterior cruciate ligament reconstruction with allografts in patients younger than 40 years old: a 2 to 4 year results

Purpose

The purpose of this study is first to report the outcomes, at 4 years follow-up, in revision ACL surgery using allografts in patients younger than 40 years old, and then compared soft tissue allografts to bone tendon allografts.

Methods

This retrospective study included 47 patients who underwent ACL revision surgery with fresh-frozen allografts. Patellar tendon allograft or tibialis anterior allograft was used. Twenty-seven patients undergoing ACL revision with patellar tendon allograft were compared retrospectively with twenty-two patients undergoing the same procedure with soft tissue tibialis anterior allograft. Lysholm, IKDC, and KT-1000 values were obtained preoperatively and postoperatively.

Results

The average patient follow-up was 4.6 years (±2.5). The mean age at time of the revision was 34 years old (±6.3). Overall, patients reported the overall condition of their knee as excellent or good in 85 % of the patients (10 excellent, 33 good). Based on their experience, 85 % would have the surgery again if they had the same problem in the other knee. Both subgroups experienced significant improvement in Lysholm, IKDC, and KT-1000 values, with no difference found between groups at final follow-up.

Conclusion

Revision ACL with allografts has excellent and good results in 85 % of patients younger than 40 years old. No statistical difference was seen between soft tissue (tibialis anterior) and patellar tendon allograft.

Level of evidence

IV.     

Pattern approach to MR imaging in patients with end-stage hepatic failure: a proposal for a new disease entity “hepatic encephalopathy continuum”

INTRODUCTION: The purpose of this study was to evaluate the clinical features and the characteristics of MR images of patients with end-stage hepatic failure. METHODS: We reviewed the MR findings and clinical features of 31 consecutive patients (20 men, 11 women=31, mean age 58.7 years) who had been diagnosed with clinical hepatic encephalopathy. Associations between the lesion locations on each MR sequence were analyzed using a binominal test. The clinical and MR findings were compared in relation to the etiology and clinical status. RESULTS: The most frequently involved site, seen as high signal intensity on T2-W images, was the corpus callosum (20 patients), followed by the dentate nucleus (16 patients) and the globus pallidus (13 patients). Significant associations were seen between the pallidus and the crus cerebri, between the crus cerebri and the red nucleus, between the crus cerebri and the dentate nucleus, and between the red nucleus and the dentate nucleus on the T2-W and DW images (P < 0.004). The crus cerebri, red nucleus, and dentate nucleus were involved concurrently with the corpus callosum more frequently in hepatic encephalopathy grades 3 and 4. CONCLUSION: Concurrent involvement of the globus pallidus-crus cerebri-red nucleus-dentate nucleus axis was the main MR pattern in end-stage hepatic encephalopathy, which connected with various areas of the brain. We hypothesize that these overlapping MR features could be regarded as an entity denoted as the "hepatic encephalopathy continuum".     

Radiation exposure and risk–benefit analysis in cancer screening using FDG-PET: results of a Japanese nationwide survey

Objective

The aim of this study was to estimate radiation exposure and evaluate the risks and benefits of 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) in cancer screening.

Methods

A nationwide survey of FDG-PET cancer screening was conducted in 2006, and the results were analyzed with a common index, “extension/shortening of the average life expectancy.”

Results

The average estimated effective dose was 4.4 mSv (male 4.7 mSv; female 4.0 mSv) for dedicated PET and 13.5 mSv (male 14.2 mSv; female 12.8 mSv) for PET/computed tomography (CT). The risk–benefit break-even age from the viewpoint of radiation exposure was in the 40s for men and 30s for women for dedicated PET and in the 50s for men and 50s (variable injection dose) or 60s (constant injection dose) for women for PET/CT.

Conclusions

FDG-PET cancer screening is beneficial for examinees above the break-even ages. The risks and benefits should be explained to examinees because of the larger radiation used in cancer FDG-PET screening compared with other X-ray tests.     

FLAIR imaging in the follow-up of low-grade gliomas: time to dispense with the dual-echo?

Fluid-attenuated inversion-recovery (FLAIR) imaging has established its utility in neuroimaging. We propose this imaging sequence as a replacement for proton density (PD) and T2-weighted spin-echo sequences in the follow-up of low-grade glioma. 26 MRI examinations of 18 patients with such tumours were reviewed by three neuroradiologists and a neurosurgeon. FLAIR was found to be superior for appreciation of the lesion (91% of studies) and for demonstration of its margin (92%). FLAIR was also better at showing different tumour components, particularly in regions difficult to demonstrate in some planes, such as the vertex in axial imaging. The sequence also defines the postoperative cavity, shows the least amount of susceptibility effect associated with surgical clips, and demonstrates local spread (to white matter tracts, subependymal and capsular) more distinctly. We conclude that FLAIR can replace PD and T2-weighted spin-echo imaging in radiological follow-up of low-grade glioma.     

Comparable outcomes after total knee arthroplasty in patients under 55 years than in older patients: a matched prospective study with minimum follow-up of 10 years

Purpose

To compare outcomes after TKA for osteoarthritis between patients younger than 55 years and older patients.

Methods

A cohort of 61 patients aged 55 years or younger was prospectively matched for gender, body mass index and knee function with patients with median age of 66 (range 60–70) years. Clinical evaluation was performed by the Knee Society scores (KSS), reduced Western Ontario and McMasters Universities (WOMAC) and Short-Form 12 (SF12) questionnaires. Radiological evaluation was also performed.

Results

The median follow-up was 12 (range 10–14) years. Survival at 14 years was 96.7% (95% CI 92–100%) in the younger group and 98.2% (95% CI 95–100%) in the older group (n.s.). There was no deep infection or loosening of femoral or patellar component in either group. In the younger group, 2 patients required revision (aseptic tibial loosening at 8 years, and polyethylene wear at 10 years). In the older group, there was 1 revision (aseptic tibial loosening). Revision rate was not significantly different (n.s.). Multivariate analysis showed no significant relationship between revision and age, gender or BMI. At 5-year follow-up, there were no significant differences between groups in KSS knee or function, WOMAC pain or function, or SF12 physical or mental, but in the last evaluation there were better results in younger patients for KSS-function (p = 0.018), WOMAC-function (p = 0.028), SF12-physical (p = 0.001) and SF12-mental (p = 0.035), although these differences were not clinically relevant. A significant decline was noted for KSS-function in either group from 5-year to at last follow-up.

Conclusions

The TKA survival in younger patients was comparable to older active patients, without increased complications or revisions at a minimum follow-up of 10 years. Primary hybrid TKA can provide successful pain relief, function and quality of life in younger patients than 55 years with osteoarthritis. TKA is a suitable option for these young patients with appropriate surgical indications.

Level of evidence

II.

     

Comparison of manual and semi-automatic measuring techniques in MSCT scans of patients with lymphoma: a multicentre study

Objectives

Multicentre evaluation of the precision of semi-automatic 2D/3D measurements in comparison to manual, linear measurements of lymph nodes regarding their inter-observer variability in multi-slice CT (MSCT) of patients with lymphoma.

Methods

MSCT data of 63 patients were interpreted before and after chemotherapy by one/tworadiologists in five university hospitals. In 307 lymph nodes, short (SAD)/long (LAD) axis diameter and WHO area were determined manually and semi-automatically. Volume was solely calculated semi-automatically. To determine the precision of the individual parameters, a mean was calculated for every lymph node/parameter. Deviation of the measured parameters from this mean was evaluated separately. Statistical analysis entailed intraclass correlation coefficients (ICC) and Kruskal–Wallis tests.

Results

Median relative deviations of semi-automatic parameters were smaller than deviations of manually assessed parameters, e.g. semi-automatic SAD 5.3 vs. manual 6.5 %. Median variations among different study sites were smaller if the measurement was conducted semi-automatically, e. g. manual LAD 5.7/4.2 % vs. semi-automatic 3.4/3.4 %. Semi-automatic volumetry was superior to the other parameters (2.8 %).

Conclusions

Semi-automatic determination of different lymph node parameters is (compared to manually assessed parameters) associated with a slightly greater precision and a marginally lower inter-observer variability. These results are with regard to the increasing mobility of patients among different medical centres and in relation to the quality management of multicentre trials of importance.

Key Points

? In a multicentre setting, semi-automatic measurements are more accurate than manual assessments. ? Lymph node volumetry outperforms all other semi-automaticallyand manually performed measurements. ? Use of semi-automatic lymph node analyses can reduce the inter-observer variability.     

MR-guided vacuum-assisted breast biopsy with a handheld biopsy system: clinical experience and results in postinterventional MR mammography after 24 h

This prospective study evaluates the feasibility of the magnetic resonance (MR)-guided vacuum-assisted breast biopsy with a handheld vacuum-biopsy system and documents the biopsy results with MR mammography 24 h after the procedure. MR-guided biopsy was undertaken in 33 patients with 34 lesions on dynamic MR mammography. The interventions were performed with the handheld 10-gauge Vacora vacuum-biopsy system. In all cases, dynamic MR mammography was performed 24 h after the procedure to determine the extent of the lesion removal and to identify the lesions that were missed. In 5/34 (14.7%) lesions, biopsy was not performed because no suspicious lesion was identified on the day of biopsy. In 25/29 (86.2%) lesions, the biopsy was successfully performed with a complete removal in 4/29 (13.8%) and a partial removal of 21/29 (72.4%) lesions. In 4/29 (13.8%) interventions the lesion was missed with the biopsy. In one case, histopathology after surgical excision revealed ductal carcinoma in situ. Histopathology revealed 9/29 (31%) malignant and 20/29 (68.9%) benign lesions. MR-guided vacuum-assisted breast biopsy with the handheld Vacora vacuum-biopsy system is technically feasible in most cases. MR mammography 24 h after the biopsy should be performed in those cases in which the biopsy success is unclear immediately after the procedure.     

Metachronous pancreatic metastases from renal cell carcinoma: Role of imaging in a review of 17 cases with surgical correlation

Purpose

To describe the imaging features of pancreatic metastases from renal cell carcinoma.

Patients and methods

Retrospective study of 17 patients with isolated metachronous pancreatic metastases from renal cell carcinoma with surgical and pathological correlation.

Results

The preoperative diagnosis was made on ultrasound in 13 cases. Contrast-enhanced CT showed intense tumor enhancement at the arterial phase, mostly homogeneous but sometimes heterogeneous. There were multiple lesions in six cases. Following complete surgical resection, survival was fairly good.

Conclusion

Long-term follow-up with CT obtained in the arterial and portal venous phases is mandatory. The arterial phase acquisition is essential for the diagnosis of pancreatic metastases from renal cell carcinoma.     

A clinical review of treatment outcomes in glioblastoma multiforme—the validation in a non-trial population of the results of a randomised Phase III clinical trial: has a more radical approach improved survival?

Objective

Glioblastoma multiforme (GBM) accounts for up to 60% of all malignant primary brain tumours in adults, occurring in 2–3 cases per 100 000 in Europe and North America. In 2005, a Phase III clinical trial demonstrated a significant improvement in survival over 2, and subsequently 5, years with the addition of concurrent and adjuvant temozolomide (TMZ) to radical radiotherapy (RT). The aim of this study was to investigate if the demonstrated improved survival in the literature translated to clinical practice.

Methods

This was a retrospective study including all patients with histologically proven GBM diagnosed from 1999 to 2008 and treated with adjuvant RT at our institution. A total of 273 patients were identified. Statistical analysis was carried out using SPSS® v.18 (SPSS, Chicago, IL).

Results

The median survival for the whole group (n=273) over the 10-year period was 7.6 months (95% confidence interval 6.7–8.4 months). Overall, the cumulative probability of survival at 1 and 2 years was 31.5% and 9.4%, respectively. In total, 146 patients received radical RT. 103 patients were treated with radical RT and TMZ and 43 patients received radical RT alone. The median survival for patients receiving radical RT with TMZ was 13.4 months (95% CI 10.9–15.8 months) vs 8.8 months for radical RT alone (95% CI 6.9–10.7 months, p=0.006). 2-year survival figures were 21.2% vs 4.7%, respectively. On multivariate analysis, independent predictors of survival included Karnofsky Performance Status, RT dose, TMZ and extent of surgery. The strongest predictors of poorer outcome based on the hazard ratio were palliative RT, followed by not receiving TMZ chemotherapy, then KPS <90 and a biopsy only surgical approach.

Conclusion

This paper demonstrates improved survival outcomes consistent with those published in the literature for the addition of concurrent and adjuvant TMZ to radical RT for the treatment of GBM. Although 63% of patients seen in the clinic were suitable for a combined modality approach, the prognosis for the lower Radiation Therapy Oncology Group classes still remains poor.Glioblastoma multiforme (GBM) accounts for up to 60% of all malignant primary brain tumours in adults [1], occurring in 2–3 cases per 100 000 in Europe and North America. Overall survival figures in the literature are poor. In 2005, Stupp et al [2] demonstrated significant improvements in 2-year survival figures with the addition of concurrent and adjuvant temozolomide (TMZ) to radical radiotherapy (RT).The optimal management of patients with GBM provides a challenge owing to the diverse nature of this cohort in clinical practice. The aims of this study were to investigate whether or not the improved survival figures demonstrated in a Phase III randomised trial [3] translated to routine clinical practice with the introduction of protocol-driven standard of care and to analyse factors associated with improved outcome.Corresponding to the publication of the Stupp protocol [2], we introduced a formalised consensus-based treatment approach for GBM at our institution, a designated national neuro-oncology centre. We designed a retrospective study evaluating the overall survival among patients receiving RT for treatment of GBM with or without TMZ. The treatment approach and outcome of patients diagnosed with GBM prior to and after the publication of the Stupp et al [2] results and the introduction of a formalised treatment approach were compared. The utilisation of Radiation Therapy Oncology Group (RTOG) classes allowed comparison over homogeneous subsets of patients.     

Gd-EOB-DTPA-enhanced MRI T1 mapping for assessment of liver function in rabbit fibrosis model: comparison of hepatobiliary phase images obtained at 10 and 20 min

Objectives

To compare hepatobiliary phase (HBP) images obtained at 10 and 20 min after Gd-EOB-DTPA-enhanced MRI for assessment of liver function in rabbit fibrosis model on 3.0 T MR imaging.

Methods

34 animals were separated into three groups: 5 for a control group, 14 for a mild fibrosis group, and 15 for a severe fibrosis group based on pathological proof. T1 relaxation times (T1rt) were measured on T1 mapping and reduction rates of T1rt (rrT1rt) were calculated. HBP images were obtained at 10 and 20 min after Gd-EOB-DTPA enhancement. Indocyanine green retention rates at 15 min (ICG R15) were performed for all animals.

Results

T1rt on pre-enhancement imaging showed no significant difference (p > 0.05) among all groups. T1rt on 10 min HBP and 20 min HBP showed significant difference (p < 0.05) among all groups. T1rt and rrT1rt in three groups showed no-significant difference (p > 0.05) between 10 min HBP and 20 min HBP. T1rt on both 10 and 20 min HBP showed significant correlation with ICG R15 (p < 0.05); rrT1rt on both 10 min HBP and 20 min HBP showed significant inverse correlation with ICG R15 (p < 0.05).

Conclusions

Comparing 10 min HBP and 20 min HBP T1 mapping after Gd-EOB-DTPA enhancement, our results suggest that 10 min HBP T1 mapping is feasible for quantitatively assessing liver function.

     

Comparison of 1.0 M gadobutrol and 0.5 M gadopentate dimeglumine-enhanced MRI in 471 patients with known or suspected renal lesions: results of a multicenter, single-blind, interindividual, randomized clinical phase III trial

The purpose of this phase III clinical trial was to compare two different extracellular contrast agents, 1.0 M gadobutrol and 0.5 M gadopentate dimeglumine, for magnetic resonance imaging (MRI) in patients with known or suspected focal renal lesions. Using a multicenter, single-blind, interindividual, randomized study design, both contrast agents were compared in a total of 471 patients regarding their diagnostic accuracy, sensitivity, and specificity to correctly classify focal lesions of the kidney. To test for noninferiority the diagnostic accuracy rates for both contrast agents were compared with CT results based on a blinded reading. The average diagnostic accuracy across the three blinded readers (‘average reader’) was 83.7% for gadobutrol and 87.3% for gadopentate dimeglumine. The increase in accuracy from precontrast to combined precontrast and postcontrast MRI was 8.0% for gadobutrol and 6.9% for gadopentate dimeglumine. Sensitivity of the average reader was 85.2% for gadobutrol and 88.7% for gadopentate dimeglumine. Specificity of the average reader was 82.1% for gadobutrol and 86.1% for gadopentate dimeglumine. In conclusion, this study documents evidence for the noninferiority of a single i.v. bolus injection of 1.0 M gadobutrol compared with 0.5 M gadopentate dimeglumine in the diagnostic assessment of renal lesions with CE-MRI.

Selective anteromedial bundle reconstruction in partial ACL tears: a series of 36 patients with mean 24 months follow-up

The purpose of this study was to describe an original technique of reconstruction of the anteromedial bundle preserving the posterolateral bundle and to report the results of a consecutive 36 patients series with mean 24 months follow-up. Our hypothesis is that this selective reconstruction of ACL partial tears could restore knee stability and function. In a consecutive series of 256, ACL reconstructions, 36 patients in which intact ACL fibers remained in the location corresponding to the posterolateral bundle were perioperatively diagnosed. These patients (21 women and 15 men) underwent isolated reconstruction of the anteromedial bundle while keeping the remaining fibers intact. AM bundle reconstructions were performed by the same surgeon using an outside-in technique. A quadrupled hamstring graft was used in 20 patients and a doubled semitendinosus graft in 16 patients. The mean age of the patients at the time of surgery was 32 years (min 15, max 53). The delay between injury and surgery was 6.6 months (min 2, max 35). Patients were assessed with the IKDC ligament evaluation form. Instrumented knee testing was performed with the Rolimeter arthrometer. Statistical analysis was performed to compare the preoperative and postoperative objective evaluation. Eleven concomitant meniscal lesions at the time of reconstruction were found. One patient who underwent a traumatic graft rupture at 4 months post surgery and two patients with previous contralateral ACL reconstruction were excluded, leaving 33 patients for final evaluation. Three reoperations were performed, including two arthrolysis for cyclops syndrome and one revision for a traumatic graft rupture. At last follow-up, 24 (73%) patients were graded A, 8 (24%) graded B and 1 C (3%) at IKDC objective evaluation. Mean side to side instrumented laxity was 4.8 mm (min 3, max 6) preoperatively and 0.8 mm (min 0, max 2) postoperatively. AM bundle reconstruction with an outside-in technique remains simple and reproducible. The preliminary results are encouraging with excellent side to side laxity. Graft size should probably be adapted to limit cyclops syndrome occurrence.     

Quantitative and qualitative characterization of vascularization and hemodynamics in head and neck tumors with a 3D magnetic resonance time-resolved echo-shared angiographic technique (TREAT)—initial results

The purpose of this paper is to characterize and quantify the vascularization and hemodynamic characteristics of head and neck tumors (HNT) with a dynamic 3D time-resolved echo-shared angiographic technique (TREAT) using the regular contrast agent (CA) bolus. Sixteen patients with HNT underwent 3D-TREAT during the CA administration on a 1.5-T magnetic resonance (MR) scanner. Using a parallel imaging acceleration factor of 2, 20 3D data sets at a temporal resolution of 2.3 s/frame were acquired. The quality of tumor delineation, vascularization type, and enhancement pattern were evaluated. Quantitative assessment included measurement of the contrast-to-noise ratio (CNR), determination of signal-intensity-over-time (SIT) curves, time-to-peak enhancement within the carotid arteries and the tumor, and the delay between both. TREAT was compared to conventional digital subtraction angiography (DSA) in six patients. Tumor delineation with TREAT was very good or good in 11/16 patients, and better with TREAT than with DSA in 3/6 cases. The CNR was significantly different for glomus tumors versus hypovascularized malignant tumors with TREAT (p=0.0001), but not on T1-weighted gradient echo (T1w GE) images. Qualitative assessment of tumor vascularization on dynamic TREAT shows good correlation (r=0.75) to quantitative SIT curves. We conclude that TREAT imaging permits the characterization of tumor vascularity and holds promise as a supplementary diagnostic tool in the differential diagnosis of HNT. H.J. Michaely and K.A. Herrmann both contributed equally to this work.     

MRI of the pelvis at 3 T: very high spatial resolution with sensitivity encoding and flip-angle sweep technique in clinically acceptable scan time

Objective The higher signal at 3.0-T allows spatial resolution to be increased without loss in image quality. We evaluated a T2-weighted turbo spin-echo sequence with high spatial resolution (3T-HR) to determine whether this provides clinically useful pelvic MRI. Materials and methods We designed a sequence with high spatial resolution (3T-HR) (0.45×0.46×4 mm) that was combined with parallel imaging and the variable refocusing angle technique (8.06 min). We examined 23 patients with gynecological disorders using 3T-HR and a standard sequence (3T-SP; 4.03 min; equivalent to 1.5 T). Two radiologists analyzed tissue contrast, signal to noise, detail delineation and artifact level. Results Tissue contrasts and signal to noise were rated equal. Motion artifacts occurred more often with 3T-SP despite the longer scanning time of 3T-HR. The higher spatial resolution provided additional information in four patients. In two patients small myomas were detected, in one patient a lymph node metastasis was apparent, and in one patient 3T-HR excluded tumor invasion. Conclusions High spatial resolution pelvic studies with high image quality can be obtained at 3 T in acceptable scan time. The higher spatial resolution that is feasible at 3 T also provides more clinically relevant information.     

Functional and perceived response to intra-articular hyaluronan injection in patients with knee osteoarthritis: persistence of treatment effects over 5 months

Intra-articular injections of hyaluronic acid are currently indicated as a symptom-modifying treatment for knee osteoarthritis to palliate symptoms and improve function. A series of three to five weekly injections are typically delivered once per week and a period of at least 6 months must pass between consecutive injection series. Little is known about why some patients do not respond to this treatment or about its effects on outcome measures recorded during functional activities. In addition to investigating short-term self-report and measured functional changes, the purpose of this study was to evaluate the persistence of treatment effects over the typical time interval between consecutive treatment series. According to the a priori definition for response to treatment, over two-thirds of patients experienced improved knee function during the typical period between series of intra-articular injection of hyaluronic acid while a one-third did not demonstrate a change in self-report scores. Differences in response were similarly seen between groups in functional tests. Many had immediate benefits and although some did not retain their gains, others experienced a delayed response in the following months. Knee flexion range of motion was related to self-report and tested function, and improvements in range of motion were associated with concurrent improvements in other functional measures across the testing period. A short functional test and knee-specific questionnaire may provide an index that provides an indication as to whether or not a particular patient is likely to respond to hyaluronan injections. Such information may provide valuable input when decisions are made regarding which treatment option is recommended to individuals with knee osteoarthritis.