CT urography: definition,indications and techniques. A guideline for clinical practice

The aim was to develop clinical guidelines for multidetector computed tomography urography (CTU) by a group of experts from the European Society of Urogenital Radiology (ESUR). Peer-reviewed papers and reviews were systematically scrutinized. A summary document was produced and discussed at the ESUR 2006 and ECR 2007 meetings with the goal to reach consensus. True evidence-based guidelines could not be formulated, but expert guidelines on indications and CTU examination technique were produced. CTU is justified as a first-line test for patients with macroscopic haematuria, at high-risk for urothelial cancer. Otherwise, CTU may be used as a problem-solving examination. A differential approach using a one-, two- or three-phase protocol is proposed, whereby the clinical indication and the patient population will determine which CTU protocol is employed. Either a combined nephrographic-excretory phase following a split-bolus intravenous injection of contrast medium, or separate nephrographic and excretory phases following a single-bolus injection can be used. Lower dose (CTDIvol 5–6 mGy) is used for benign conditions and normal dose (CTDIvol 9–12 mGy) for potential malignant disease. A low-dose (CTDIvol 2–3 mGy) unenhanced series can be added on indication. The expert-based CTU guidelines provide recommendations to optimize techniques and to unify the radiologist’s approach to CTU. Electronic Supplementary Material The online version of this article (doi:) contains supplementary material, which is available to authorized users. ESUR:     

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.

Predictive value of seven preoperative prognostic scoring systems for spinal metastases

Predicting prognosis is the key factor in selecting the proper treatment modality for patients with spinal metastases. Therefore, various assessment systems have been designed in order to provide a basis for deciding the course of treatment. Such systems have been proposed by Tokuhashi, Sioutos, Tomita, Van der Linden, and Bauer. The scores differ greatly in the kind of parameters assessed. The aim of this study was to evaluate the prognostic value of each score. Eight parameters were assessed for 69 patients (37 male, 32 female): location, general condition, number of extraspinal bone metastases, number of spinal metastases, visceral metastases, primary tumour, severity of spinal cord palsy, and pathological fracture. Scores according to Tokuhashi (original and revised), Sioutos, Tomita, Van der Linden, and Bauer were assessed as well as a modified Bauer score without scoring for pathologic fracture. Nineteen patients were still alive as of September 2006 with a minimum follow-up of 12 months. All other patients died after a mean period of 17 months after operation. The mean overall survival period was only 3 months for lung cancer, followed by prostate (7 months), kidney (23 months), breast (35 months), and multiple myeloma (51 months). At univariate survival analysis, primary tumour and visceral metastases were significant parameters, while Karnofsky score was only significant in the group including myeloma patients. In multivariate analysis of all seven parameters assessed, primary tumour and visceral metastases were the only significant parameters. Of all seven scoring systems, the original Bauer score and a Bauer score without scoring for pathologic fracture had the best association with survival (P < 0.001). The data of the present study emphasize that the original Bauer score and a modified Bauer score without scoring for pathologic fracture seem to be practicable and highly predictive preoperative scoring systems for patients with spinal metastases. However, decision for or against surgery should never be based alone on a prognostic score but should take symptoms like pain or neurological compromise into account. A reviewer’s comment on this original article is available at doi:.     

Occult tumor cells in lymph nodes as a predictor for tumor relapse in pancreatic adenocarcinoma

Background and aims Occurrence of tumor relapse is frequent in patients with pancreatic cancer despite the absence of residual tumor detectable at primary surgery and in histopathological examination. Therefore, it has to be assumed that current tumor staging procedures fail to identify minimal amounts of disseminated tumor cells, which might be precursors of subsequent metastatic relapse. The aim of this study was to assess the prognostic impact of minimal tumor cell spread detected in lymph nodes classified as “tumor-free” in routine histopathologic evaluation. Materials and methods A total of 154 “tumor-free” lymph nodes from 59 patients with pancreatic cancer who underwent intentionally curative tumor resection were examined by immunohistochemistry for disseminated tumor cells. Results Fifty (32.5%) of the “tumor-free” lymph nodes obtained from 36 (61%) patients displayed disseminated tumor cells. Multivariate survival analysis revealed that the presence of disseminated tumor cells in “tumor-free” lymph nodes is an independent prognostic factor for both a significantly reduced relapse-free survival (p = 0.03) and overall survival (p = 0.02). Conclusions The frequent occurrence and prognostic impact of immunohistochemically identifiable disseminated tumor cells in lymph nodes of patients with operable pancreatic cancer supports the need for a refined staging system of excised lymph nodes, which should include immunohistochemical examination.     

Renal N(epsilon)-carboxymethyllysine deposition after kidney transplantation

BACKGROUND: Accumulation of advanced glycation end products, that is, N(epsilon)-carboxymethyllysine (CML), induces oxidative stress and inflammation, and is present in chronic renal failure. Proximal tubular cells (PTCs) take up advanced glycation end products-bound proteins by apical megalin-receptors and degrade them. We hypothesized that renal transplant dysfunction affects renal CML homeostasis. Therefore, tubular and glomerular deposition of CML was investigated in a rat transplantation model, and in human allograft biopsies. METHODS: Fisher 344 kidneys were orthotopically transplanted into Lewis recipients. Recipients were treated with placebo, angiotensin II type 1 receptor blocker (candsartan 5 mg/kg/day), or calcium channel blocker (lacidipine 1 mg/kg/day) more than 28 weeks posttransplantation. Grafts were harvested at 12, 20, and 28 weeks posttransplantation. Sixty-two renal transplant patients underwent graft biopsy because of creatinine increase. Biopsies were graded according to interstitial fibrosis and tubular atrophy. N(epsilon)-carboxymethyllysine and megalin were semiquantitatively investigated in rats and humans using immunohistochemistry. RESULTS: In Fisher grafts, the development of transplant dysfunction was associated with a longitudinal increase in CML deposition in PTCs (week 12: 1.0+/-0.0, week 20: 1.5+/-0.3, week 28: 2.1+/-0.2, P<0.05). No glomerular deposition was present. In human graft biopsies, tubular CML deposition was negatively, and glomerular CML deposition was positively associated with transplant dysfunction (r=-0.29 and r=0.34; P<0.05). Megalin was reduced at advanced grades. CONCLUSION: N(epsilon)-carboxymethyllysine deposition increased in rat PTCs with mild transplant dysfunction. In humans, tubular CML deposition decreased in parallel with the reduction of its cellular uptake mechanism (megalin). Furthermore, glomerular deposition could play a pathophysiological role in chronic allograft injury.     

Endoscopic vs open saphenous vein harvest for coronary artery bypass grafting: a prospective randomized trial

OBJECTIVE: Endoscopic saphenous vein harvesting (EVH) for coronary artery bypass grafting (CABG) has been developed to reduce leg wound morbidity and improve patient satisfaction. Choosing between EVH of a short vein segment from the thigh and open venous harvesting (OVH) of a short segment from the calf represents a clinical dilemma as EVH is easiest to perform from the thigh and OVH is easiest to perform from the calf. The purpose of this study was to investigate whether leg wound morbidity was reduced after EVH of a short vein segment from the thigh compared with OVH from the calf. Secondly we investigated whether EVH would reduce length of hospital stay and improve cosmetic results. METHODS: From April 2004 to June 2007, 132 patients undergoing elective isolated CABG were randomized to have a short segment of saphenous vein harvested either by the EVH or OVH technique. Clinical follow-up was scheduled at day 5 and at 1 month. Primary end-points included wound morbidity. Secondary end-points included harvest time, length of hospital stay, cosmetic results and need for additional wound care after discharge. RESULTS: The groups were preoperative similar. Three patients in the OVH group were excluded from the study as it became apparent that it was necessary to extend the incision beyond the knee. Harvest time was longer for the EVH group, but these patients suffered from significantly fewer cases of infectious and non-infective wound complications, with a substantial reduction in the need for post-discharge leg wound care. The purulent infection rates in the EVH and OVH groups were 0% and 11%, respectively. The overall leg wound morbidity rates regarding cellulitis, purulent infection, dehiscence and skin necrosis were 3% and 27% in the EVH and OVH groups, respectively (p<0.001). The length of hospital stay was similar. The conversion rate from EVH to OVH was 14%. The EVH group experienced less pain and better cosmetic results. CONCLUSIONS: EVH of a short vein segment from the thigh results in less wound morbidity and better cosmetic results compared with OVH of a short vein segment from the calf.     

Storage (irritative) and voiding (obstructive) symptoms as predictors of benign prostatic hyperplasia progression and related outcomes

OBJECTIVES: To assess the utility of voiding and filling symptom subscores in predicting features of benign prostatic hyperplasia (BPH) progression, including acute urinary retention (AUR) and prostate surgery. METHODS: The Proscar Long-term Efficacy and Safety Study (PLESS) was a 4-year study designed to evaluate the effects of finasteride versus placebo in men with lower urinary tract symptoms (LUTS), clinical evidence of BPH, and no evidence of prostate cancer. A self-administered questionnaire was employed to quantify LUTS at baseline. Receiver operating characteristics (ROC) curves were used to assess baseline characteristics from patients treated with placebo as predictors of outcomes. The characteristics assessed included the overall symptom score (Quasi-AUA SI), separate voiding and filling subscores, prostate volume (PV) and serum prostate-specific antigen (PSA) levels. RESULTS: PV and PSA were superior to the symptom scores at predicting episodes of spontaneous AUR and all types of AUR. The Quasi-AUA SI and the filling and voiding subscores were effective at predicting progression to surgery; however, PSA was more effective at predicting this outcome. To better evaluate symptoms as predictors of surgery, patients who experienced a preceding episode of AUR were excluded from the surgery analysis. In the absence of preceding AUR, the best predictors of future surgery were the Quasi-AUA SI and the filling subscore. CONCLUSIONS: Among men with LUTS, clinical BPH and no history of AUR, the overall symptom score and storage subscore are useful parameters to aid clinicians in identifying patients at risk for future prostate surgery. PV and PSA were the best predictors of AUR, while PSA was the best predictor of prostate surgery (for all indications).     

Modic changes following lumbar disc herniation

Only a small proportion (20%) of patients with LBP can be diagnosed based on a patho-anatomical entity. Therefore, the identification of relevant subgroups, preferably on a patoanatomical basis, is strongly needed. Modic changes have been described by several authors as being closely linked with LBP. The aims of this study were to describe the prevalence of Modic changes, their development as well as their association to LBP, previous disc contour, and surgery in patients with previous severe sciatica. This is a longitudinal cohort study where the patients were recruited from an RCT comparing two active conservative treatments, the 181 patients, who at baseline had radicular pain in or below the knee; all underwent a physical examination and MRI. MRI’s, pain history and physical examination of 166 patients were obtained at follow-up 14 months later. The prevalence of Modic changes type 1 increased from 9% at baseline to 29% at follow-up. At that time, a strong association between Modic changes and non-specific LBP was noted. Apparently, Modic changes type 1 was more strongly associated with non-specific lumbar pain than Modic changes type 2. The development of new Modic changes was closely related to the level of a previous disc herniation. A lumbar disc herniation is a strong risk factor for developing Modic changes (especially type 1) during the following year. Furthermore, Modic changes are strongly associated with LBP.