Radiologische Frühdiagnostik der rheumatoiden Arthritis

CLINICAL/METHODICAL ISSUE: For optimal therapy management of patients with rheumatoid arthritis (RA) specific and sensitive diagnostic methods are essential for assessment of disease activity. STANDARD RADIOLOGICAL METHODS: In addition to projection radiography, imaging techniques, in particular magnetic resonance imaging (MRI) and ultrasound (US) are becoming increasingly more important for the early diagnosis of RA. PRACTICAL RECOMMENDATIONS: The MRI and US techniques play a key role in the early imaging diagnostics of RA. Measurement of inflammation activity represents the basis of therapeutic decision-making and can be quantitatively and qualitatively determined with MRI and US. Synovitis and bone marrow edema are predictors of erosion.     

Multiparametrische MRT der Prostata zum Therapiemonitoring nach Strahlentherapie

CLINICAL/METHODICAL ISSUE: Radiation therapy is a therapeutic option with curative intent for patients with prostate cancer. Monitoring of prostate-specific antigen (PSA) values is the current standard of care in the follow-up. Imaging is recommended only for symptomatic patients and/or for further therapeutic options. STANDARD RADIOLOGICAL METHODS: For detection of local recurrence magnetic resonance imaging (MRI) of the prostate is acknowledged as the method of choice. PERFORMANCE: Good results for primary diagnosis were found especially in combination with functional techniques, whereas in recurrent prostate cancer only few studies with heterogeneous study design are available for prostate MRI. Furthermore, changes in different MRI modalities due to radiation therapy have been insufficiently investigated to date. PRACTICAL RECOMMENDATIONS: As the initial results were promising prostate MRI and available therapeutic options for detection of local recurrence should be considered in patients with increased PSA.     

Steatosis hepatis – eine Herausforderung?

CLINICAL/METHODICAL ISSUE: With the increasing use of cross-sectional imaging techniques both diffuse and focal fat accumulations in the liver are frequent incidental findings. Focal fatty changes in particular, such as localized distribution disorders in steatohepatitis or focal fat deposition of the liver, can lead to difficulties in the correct diagnosis of patients with a history of malignant disease. STANDARD RADIOLOGICAL METHODS: Ultrasound is used as the first imaging modality in most cases but has a relatively low sensitivity and specificity. In most cases a further diagnosis of diffuse fatty liver accumulations is possible with non-contrast computed tomography (CT) scanning and chemical shift imaging in magnetic resonance imaging (MRI) enabling an even further differential diagnostic distinction of fatty disorders of the liver. PERFORMANCE: For the detection of generalized fatty liver disease ultrasound has a sensitivity and specificity of 60-100% and 77-95%, respectively. Non-contrast CT of the liver attains a sensitivity of between 43% and 95% with a specificity of 90%. Sensitivity and specificity for chemical shift imaging of MRI are 81% and 100%, respectively. PRACTICAL RECOMMENDATIONS: For advanced differential diagnostic distinction of the different forms of fatty liver disorders and for the correct diagnosis of benign and malignant liver lesions the leading imaging modality is chemical shift imaging of MRI (in-phase and opposed-phase).     

Pitfalls in der CT bei diffusen Lebererkrankungen

CLINICAL/METHODICAL ISSUE: Misinterpretations in liver diagnostics could result in a false diagnosis, such as a parenchymatous damage or a false focal lesion. STANDARD RADIOLOGICAL METHODS: Computed tomography is a widely used diagnostic tool to visualize liver diseases. METHODICAL INNOVATIONS: Magnetic resonance imaging (MRI) is often used as a second diagnostic test to answer specific questions. PERFORMANCE: The more the condition of changes in liver parenchyma appearance in cross-sectional imaging is known the fewer mistakes will be made in the interpretation. Knowledge of these pitfalls helps to increase diagnostic accuracy. ACHIEVEMENTS: Magnetic resonance imaging could help to depict most of the pitfalls. PRACTICAL RECOMMENDATIONS: By looking at diffuse or focal liver diseases radiologists should be aware of perfusion patterns and structural changes of the liver parenchyma to make a correct diagnosis.     

Update of renal imaging

Significant technical improvements have allowed the use of radiological techniques to play a growing role in the imaging of renal diseases. Noninvasive ultrasound methods (ie, sonography and Doppler) are now positioned as first-line methods for the evaluation of renovascular diseases. Multidetector computed tomography is able to provide high spatial resolution images of the kidneys and renal arterial vessels. Magnetic resonance imaging, which provides higher signal-to-noise ratio and higher spatial and/or temporal resolution, can display both morphological information about renal parenchyma and vessels and functional data, including perfusion, filtration, diffusion, or oxygenation. In renovascular diseases, these techniques have the potential to drive new strategies, including Doppler sonography as a first-line method, followed by computed tomography angiography or magnetic resonance angiography, depending mainly on renal function. Imaging of parenchymal renal diseases is developing toward more quantitative (volumetric and functional measurements) and more specific (through in vivo cell targeting) acquisitions for obtaining the adequate information on tissue characteristics relevant either for diagnosis or for prognosis or treatment follow-up.     

Sakroiliitis oder Pseudosakroiliitis?

CLINICAL/METHODICAL ISSUE: When the presence of seronegative spondyloarthropathy is unrecognized there can be a delay in achieving an accurate diagnosis, as the typical inflammatory low back pain is similar to that found in degenerative diseases of the lumbosacral spine and the sacroiliac joints. Thus, seronegative spondyloarthropathy is often misinterpreted as a degenerative disease. The initial radiography of the sacroiliac joints is often normal which results in a delay in diagnosis of sacroiliitis of approximately 3-7 years. STANDARD RADIOLOGICAL METHODS: This illustrates the significance of an adequate imaging method for the early detection of sacroliliitis. METHODICAL INNOVATIONS: Contrast medium administration for magnetic resonance imaging (MRI) enables a differentiation between synovitis, capsulitis, enthesitis and effusion. PERFORMANCE: Sensitivity and specificity for detection of active inflammation by MRI is about 83-85%. Early active inflammation can be detected by MRI 3-7 years before structural changes are obvious by x-ray examination. PRACTICAL RECOMMENDATIONS: Pseudosacroiliitis can be differentiated from inflammatory sacroiliitis by the patient history, laboratory data, osteoproliferative and osteodestructive changes and the typical distribution pattern of bone marrow edema.     

Bedeutung der Ganzk?rper-MRT beim Staging des kolorektalen Karzinoms

CLINICAL/METHODICAL ISSUE: Staging and follow-up of colorectal cancer are usually performed with multimodal imaging strategies. These can be time-intensive and potentially lead to examiner-dependent bias. Alternatively, whole body magnetic resonance imaging (WB-MRI) provides oncologic imaging with a systemic approach. STANDARD RADIOLOGICAL METHODS: Ultrasound, multislice computed tomography (MSCT), dedicated MRI and positron emission tomography/CT (PET/CT). METHODICAL INNOVATIONS: High-resolution WB-MRI with focused examination of various organs, such as the pelvis and abdomen, lungs, brain and skeletal system, using different sequence and contrast techniques. PERFORMANCE: Detection of colorectal tumor recurrence with WB-MRI provides 83% accuracy (lymph node metastases 80%, organ metastases 86%). ACHIEVEMENTS: Potential cost reduction through decreased examination time and personnel costs. PRACTICAL RECOMMENDATIONS: Whole body MRI is a radiation-free alternative to standard sequential algorithms of staging and follow-up of colorectal cancer.     

Ultrasound of the small joints of the hands and feet: current status

The aim of this article was to review the current status of ultrasound imaging of patients with rheumatological disorders of the hands and feet. Ultrasound machines with high-resolution surface probes are readily available in most radiology departments and can be used to address important clinical questions posed by the rheumatologist and sports and rehabilitation physician. There is increasing evidence that ultrasound detects synovitis that is silent to clinical examination. Detection and classification of synovitis and the early detection of bone erosions are important in clinical decision making. Ultrasound has many advantages over other imaging techniques with which it is compared, particularly magnetic resonance. The ability to carry out a rapid assessment of many widely spaced joints, coupled with clinical correlation, the ability to move and stress musculoskeletal structures and the use of ultrasound to guide therapy accurately are principal amongst these. The use of colour flow Doppler studies provides a measure of neovascularisation within the synovial lining of joints and tendons, and within tendons themselves, that is not available with other imaging techniques. Disadvantages compared to MRI include small field of view, poor image presentation, and difficulty in demonstrating cartilage and deep joints in their entirety. Contrast-enhanced magnetic resonance provides a better measure of capillary permeability and extracellular fluid than does ultrasound. The ability to image simultaneously multiple small joints in the hands and feet and their enhancement characteristics cannot be matched with ultrasound, though future developments in 3-D ultrasound may narrow this gap. Magnetic resonance provides a more uniform and reproducible image for long-term follow-up studies.     

Diffusion-weighted MR Imaging: clinical applications in neuroradiology

Among functional magnetic resonance imaging techniques, diffusion-weighted imaging (DWI) plays an important role in the assessment of a wide variety of brain diseases. DWI provides image contrast that depends on the molecular motion of water and it can be easily added to a standard cranial MR examination, with limited increase in time (imaging time ranges from a few seconds to 2 minutes). DWI is particularly sensitive in the detection of acute ischaemic stroke and in monitoring its evolution (also in the light of new therapeutic strategies for early treatment). Diffusion-weighted MR imaging also provides adjunctive information in the differential diagnosis of other brain diseases including neoplasms, intracranial infections, traumatic brain injury and demyelination some of which may manifest with sudden neurological deficits mimicking acute ischaemic stroke.     

磁共振功能成像在肝细胞癌中的应用

近年来,肝细胞癌的发病率与死亡率在全球范围内逐年上升。随着分子影像学的发展,磁共振功能成像技术在各系统疾病中的应用越来越广泛,其在肝细胞癌诊断、鉴别诊断、术后疗效评估等方面发挥越来越重要的作用。作者就目前常用的几种功能磁共振成像技术在肝细胞癌中的应用现状进行综述。     

Pr?klinische Bildgebung im Tiermodell bei Strahlentherapie

CLINICAL/METHODICAL ISSUE: Modern radiotherapy benefits from precise and targeted diagnostic and pretherapeutic imaging. STANDARD RADIOLOGICAL METHODS: Standard imaging modalities, such as computed tomography (CT) offer high morphological detail but only limited functional information on tumors. METHODICAL INNOVATIONS: Novel functional and molecular imaging modalities provide biological information about tumors in addition to detailed morphological information. PERFORMANCE: Perfusion magnetic resonance imaging (MRI) CT or ultrasound-based perfusion imaging as well as hybrid modalities, such as positron emission tomography (PET) CT or MRI-PET have the potential to identify and precisely delineate viable and/or perfused tumor areas, enabling optimization of targeted radiotherapy. Functional information on tissue microcirculation and/or glucose metabolism allow a more precise definition and treatment of tumors while reducing the radiation dose and sparing the surrounding healthy tissue. ACHIEVEMENTS: In the development of new imaging methods for planning individualized radiotherapy, preclinical imaging and research plays a pivotal role, as the value of multimodality imaging can only be assessed, tested and adequately developed in a preclinical setting, i.e. in animal tumor models. PRACTICAL RECOMMENDATIONS: New functional imaging modalities will play an increasing role for the surveillance of early treatment response during radiation therapy and in the assessment of the potential value of new combination therapies (e.g. combining anti-angiogenic drugs with radiotherapy).     

Childhood arthritis: classification and radiology.

Childhood arthritis has now been reclassified into a single internationally recognized entity of juvenile idiopathic arthritis (JIA). Radiology provides an important role in the management of JIA, in helping in the differential diagnosis, monitoring disease progression and detecting complications. Traditionally, plain radiographs have been the imaging investigation of choice but magnetic resonance imaging (MRI) and ultrasound are now providing a more effective and safer alternative. The appropriate use of sequences in MR imaging is important in the early detection of joint abnormalities in JIA.     

Stellenwert der SPECT/CT zur Abkl?rung von Kiefererkrankungen

CLINICAL/METHODICAL ISSUE: Diseases of the jaw, such as osteomyelitis, condylar hyperactivity and tumors need adequate imaging to evaluate the extension and activity for therapy planning. STANDARD RADIOLOGICAL METHODS: Conventional planar scintigraphy, orthopantomography, computed tomography (CT) and magnetic resonance imaging (MRI) can be used for the evaluation of jaw diseases. METHODICAL INNOVATIONS: Single photon emission computed tomography/computed tomography (SPECT/CT) provides metabolic and morphologic information in one imaging step and is becoming increasingly more available in larger hospitals. PERFORMANCE: The SPECT/CT is superior to planar scintigraphy alone, CT and orthopantomography in the evaluation of the extension and activity of osteomyelitis and jaw tumors. ACHIEVEMENTS: In our hospital SPECT/CT has replaced the other imaging modalities in the evaluation of osteomyelitis and condylar hyperactivity. PRACTICAL RECOMMENDATIONS: If available SPECT/CT should be performed for the evaluation of osteomyelitis of the jaw.     

Stellenwert der PET/CT zur Bildgebung des kolorektalen Karzinoms

CLINICAL/METHODICAL ISSUE: Fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) has emerged as a very useful imaging modality in the management of colorectal carcinoma. Data from the literature regarding the role of PET/CT in the initial diagnosis, staging, radiotherapy planning, response monitoring and surveillance of colorectal carcinoma is presented. Future directions and economic aspects are discussed. STANDARD RADIOLOGICAL METHODS: Computed tomography (CT), magnetic resonance imaging (MRI) and FDG-PET for colorectal cancer and endorectal ultrasound for rectal cancer. METHODICAL INNOVATIONS: Combined FDG-PET/CT. PERFORMANCE: While other imaging modalities allow superior visualization of the extent and invasion depth of the primary tumor, PET/CT is most sensitive for the detection of distant metastases of colorectal cancer. ACHIEVEMENTS: We recommend a targeted use of PET/CT in cases of unclear M staging, prior to metastasectomy and in suspected cases of residual or recurrent colorectal carcinoma with equivocal conventional imaging. The role of PET/CT in radiotherapy planning and response monitoring needs to be determined. Currently there is no evidence to support the routine use of PET/CT for colorectal screening, staging or surveillance. PRACTICAL RECOMMENDATIONS: To optimally exploit the synergy between morphologic and functional information, FDG-PET should generally be performed as an integrated FDG-PET/CT with a contrast-enhanced CT component in colorectal carcinoma.     

Value of radiological methods in the diagnosis of biliary diseases

The modern cross-sectional radiological methods of ultrasound, computed tomography, and magnetic resonance imaging provide manifold possibilities for the diagnosis of inflammatory and tumorous diseases of the gallbladder and the bile ducts as well as stone-related diseases. The invasive methods for direct imaging of the bile ducts, such as endoscopic retrograde cholangiopancreatography, are mainly used within therapeutic concepts. According to the literature, ultrasound and magnetic resonance imaging show a sensitivity of up to 100% in the diagnosis of intra- and extrahepatic cholestasis, but concerning the diagnosis of the cause of cholestasis these methods are limited. Therefore, additional MRI sequences or computed tomography are necessary. Computed tomography is particularly efficient for the diagnosis of the biliary system and adjacent anatomical and pathological structures within the pre- and postoperative period.     

Stellenwert der radiologischen Verfahren bei Erkrankungen von Gallenblase und -wegen

The modern cross-sectional radiological methods of ultrasound, computed tomography, and magnetic resonance imaging provide manifold possibilities for the diagnosis of inflammatory and tumorous diseases of the gallbladder and the bile ducts as well as stone-related diseases. The invasive methods for direct imaging of the bile ducts, such as endoscopic retrograde cholangiopancreatography, are mainly used within therapeutic concepts. According to the literature, ultrasound and magnetic resonance imaging show a sensitivity of up to 100% in the diagnosis of intra- and extrahepatic cholestasis, but concerning the diagnosis of the cause of cholestasis these methods are limited. Therefore, additional MRI sequences or computed tomography are necessary. Computed tomography is particularly efficient for the diagnosis of the biliary system and adjacent anatomical and pathological structures within the pre- and postoperative period.     

Rektumkarzinom – Lokales Staging und Bildgebung unter neoadjuvanter Therapie

CLINICAL/METHODICAL ISSUE: Rectal cancer restaging after neoadjuvant therapy is based on two principles: an anatomic definition of the tumor allowing surgical planning and prognostic stage grouping. STANDARD RADIOLOGICAL METHODS: Emerging data suggest that reassessment using a combination of different imaging modalities may help to provide valuable prognostic information before definitive surgery. METHODICAL INNOVATIONS: Perfusion computed tomography (CT) may provide special information regarding tumor vascularity. PERFORMANCE: Evaluation of therapy response, especially of the circumferential resection margin (CRM) is necessary for surgical planning. ACHIEVEMENTS: For local staging high-resolution and diffusion-weighted magnetic resonance imaging has proven to be of high diagnostic accuracy. PRACTICAL RECOMMENDATIONS: The M status should be assessed using multidetector computed tomography (MDCT) according to response evaluation criteria in solid tumors (RECIST) while lymph node evaluation requires either magnetic resonance imaging or positron emission tomography/computed tomography scanning.     

Koxarthrose – eine radiologische Ann?herung und Leitfaden

CLINICAL/METHODICAL ISSUE: Coxarthrosis is one of the most frequent indications in radiological practice with a prevalence as high as 8%. STANDARD RADIOLOGICAL METHODS: Radiography, sonography, computed tomography, magnetic resonance imaging. METHODICAL INNOVATIONS: Magnetic resonance arthrography for detection of early stages of labral and chondral pathologies as well as detection of osteonecrosis at an early stage. PERFORMANCE: Czerny C, Hofmann S, Neuhold A et al. (1996) Lesions of the acetabular labrum: accuracy of MR imaging and MR arthrography in detection and staging. Radiology 200(1):225-230. Czerny C, Oschatz E, Neuhold A et al. (2002) [MR arthrography of the hip joint]. Radiologe 42(6):451-456. Kramer J, Breitenseher M, Imhof H et al. (2000) [Diagnostic imaging in femur head necrosis]. Orthopade 29(5):380-388. ACHIEVEMENTS: Is already established in clinical practice. PRACTICAL RECOMMENDATIONS: Each modality has relevant indications.     

Early-stage rheumatoid arthritis: prospective study of the effectiveness of MR imaging for diagnosis

PURPOSE: To assess the effectiveness of magnetic resonance (MR) imaging for the diagnosis of early-stage rheumatoid arthritis (RA). MATERIALS AND METHODS: Fifty subjects (nine men and 41 women) with polyarthralgia who were suspected of having early-stage RA on the basis of clinical and radiographic findings were selected to undergo gadolinium-enhanced MR imaging of the hands. The MR imaging criterion for the diagnosis of early RA was bilateral enhancement in both wrists and/or the metacarpophalangeal and/or proximal interphalangeal joints. Follow-up continued until a final diagnosis was determined. Two patients left the study before the end of follow-up. RESULTS: Final diagnoses were established after a mean follow-up of 776 days: rheumatoid arthritis in 26 patients and nonrheumatoid disease in 22. Use of the MR imaging criterion yielded the correct diagnosis in 25 patients with RA and three false-positive results in three patients without RA. As compared with the traditional format and classification tree criteria of the American Rheumatism Association, the MR imaging criterion allowed detection of seven and six additional patients with true RA, respectively. CONCLUSION: The introduction of MR imaging into the diagnostic criteria for early RA may contribute to more accurate diagnosis in patients suspected of having RA and thus allow an earlier decision to start proper medication.     

Radiologische Differenzialdiagnose der rheumatoiden Arthritis

CLINICAL/METHODICAL ISSUE: Establishing an early and reliable diagnosis of rheumatoid arthritis (RA) is of major importance but can be a great clinical challenge leading to direct therapeutic consequences. No single epidemiological, genetic, clinical, serological or radiological test exists which can exclusively diagnose RA. STANDARD RADIOLOGICAL METHODS: In general diagnosis of RA includes a case history, clinical signs, laboratory abnormalities and radiological examinations, viz. conventional radiography of the joints of the hands and feet. PRACTICAL RECOMMENDATIONS: This review summarizes the most important radiological features of RA and the radiological findings of its closest differential diagnoses.