Radiologe最新文献

Clinical/methodical issue: In the new edition of the German S3-guideline published in June 2021, the diagnosis and treatment of cholangiocarcinoma (CCA) and gallbladder carcinoma are addressed for the first time. This article discusses the local and locoregional treatment options for intrahepatic CCA (iCCA).

Standard radiological methods: Mortality is high in iCCA and the incidence is rising. In unresectable patients, treatment options include local and locoregional approaches.

Methodical innovations: Besides recommendations regarding surgery, biliary drainage, intraductal locoregional therapy and radiation therapy, two recommendations regarding interventional radiologic therapies are included in the updated S3-guideline. Percutaneous thermal ablation via radiofrequency or microwave ablation (RFA/MWA) is suggested for unresectable tumors with up to 3 cm in diameter as primary therapy and for recurrent tumors. In advanced, liver dominant iCCA, intra-arterial therapies such as transarterial radioembolization (TARE), transarterial chemoembolization (TACE) or hepatic arterial infusion (HAI) are recommended as single therapy or in combination with other therapies.

Achievements: Due to a lack of randomized controlled studies, the efficacy of locoregional therapies in iCCA is challenging to assess; however, various cohort studies, meta-analyses and review articles confirm their efficiency.

Practical recommendations: Interventional radiological therapies alone or in combination with systemic therapies have the potential to improve the prognosis of patients with iCCA. Due to the various therapeutic options, patients with iCCA should be treated in centers which cover the entire therapeutic spectrum.

Clinical issue: Treatment of hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (iCCA) has markedly improved in recent years.

Standard treatment: Liver resection and, for HCC, liver transplantation are essential components of curative treatment in the nonmetastatic stage.

Treatment innovations: In the current S3 guideline, the role of the interdisciplinary tumor board is strengthened for the individual therapy decision. Overall, liver transplantation offers the best long-term results in terms of survival and relapse rate for selected patients. For liver resection, the use of minimally invasive resection techniques can significantly reduce perioperative morbidity and mortality compared to open liver surgery, so that it can be used both as a curative therapeutic approach and as part of bridging strategies for liver transplantation.

Performance: The 5‑year survival rate after liver transplantation in selected, nonresectable patients who fulfil and also those who do not fulfil the Milan criteria is above 70%, compared with about 30% without liver transplantation under locoregional therapy.

Achievements: The following article reports the status of evidence-based surgical therapy for HCC and iCCA based on the recommendations of the current German S3 guideline.

Practical recommendations: The differentiated local therapy of HCC in cirrhosis is based on many patient- and tumor-specific factors. In addition to surgical resection, liver transplantation plays an important role as a curative therapy for patients with irresectable HCCs regardless of whether they meet the Milan criteria. For resectable iCCA or HCC without cirrhosis in the nonmetastatic stage, surgical resection represents the treatment of choice.

The update of the S3 German guideline for the management of the hepatocellular carcinoma and biliary tract cancer contains a comprehensive revision of the guideline for hepatocellular carcinoma and establishes a new guideline for biliary tract cancer. In recent years several studies have been conducted to improve diagnostic and therapeutic options for liver cancer. Magnetic resonance imaging (MRI) and biopsy are important for the diagnosis of hepatocellular carcinoma or cholangiocarcinoma. This guideline shows the progress in the treatment options for hepatocellular carcinoma, including advances in liver transplantation, bridging and downstaging. For cholangiocarcinoma there is a focus on interventional treatment and resection. This guideline also emphasizes the need of molecular diagnostics and the resulting treatment options in targeted therapy.

Clinical/methodical issue: The diagnosis of hepatocellular carcinoma (HCC)-especially the characterization of small lesions <2 cm-continues to be a radiological challenge.

Standard radiological methods: In the current S3 guideline on diagnosis and therapy of HCC, contrast-enhanced imaging examinations, such as contrast-enhanced ultrasonography (CEUS), computed tomography (CT), and magnetic resonance imaging (MRI), are still the diagnostic standard.

Methodological innovations: HCC in the cirrhotic liver should be diagnosed by its typical contrast-enhanced pattern in the MRI. In addition, the use of quality assurance instruments such as LI-RADS (Liver Imaging Reporting and Data System) contributes to the desired consistency of findings, even with small ambiguous findings.

Performance: Many studies have shown that the LI-RADS classification reflects the likelihood of HCC and other malignant liver lesions.

Achievements: Guidelines and quality assurance instruments contribute to a more precise diagnosis in patients with suspected HCC.

Practical recommendations: A guideline-compliant diagnostic algorithm and the LI-RADS should be used across the board for accurate HCC diagnostics.

The S3 guideline on hepatocellular carcinoma has been expanded to include malignant biliary carcinoma (synonym cholangiocarcinoma [CCA]). Magnetic resonance imaging (MRI) with additional magnetic resonance cholangiopancreatography (MRCP) is the imaging modality of choice to evaluate local findings. Use of gadolinium ethoxybenzyl diethylenetriamine penta-acetic acid (Gd-EOB-DTPA)-based contrast agent increases its diagnostic value. Histologic confirmation is always required when diagnosing intrahepatic CCA (iCCA) because using imaging alone there is a risk of confusion with HCC subtypes.

Since the first version of the S3 guideline for the diagnosis and treatment of hepatocellular carcinoma (HCC) in 2013, a large number of studies have consolidated the data on transarterial radioembolization (TARE) and created a broad evidence base. As a result, TARE was incorporated into the current 2021 S3 guideline with a number of specific recommendations, whereas it was previously only offered under study conditions. TARE is now offered with the other minimally invasive procedures for bridging and downstaging before liver transplantation, but also as an alternative to transarterial chemotherapy (TACE) in intermediate HCC and in locally limited intrahepatic cholangiocarcinoma in second-line therapy for selected patients-albeit with different levels of evidence. Based on the study situation, however, TARE is not recommended for advanced HCC; here, systemic therapy with immunotherapeutic agents is preferred based on current data.

Background: Even after more than 100 years, the chest X‑ray is still an important technique to detect important pathological changes of lungs, heart and vessels in a fast and low-dose manner. For the German-speaking regions, there are only recommendations available published by the "Ständigen Strahlenschutzkommission (SSK)" regarding the indication. These recommendations are not updated on a regular basis and more recent developments are only integrated with delayed.

Methods: The chest division of the German Radiological Society has summarized their expertise for the usage and indication of the chest X‑ray. Especially within the field of oncology the usage of chest X‑ray is evaluated differently to the aforementioned recommendations; here chest computed tomography (CT) is much more sensitive for evaluation of metastasis and local invasion of tumors. Also, within the area of infectious diseases in non-immunocompetent patients, CT is the method of choice. Based on the structure of the current recommendations, many current guidelines and indications are summarized and presented within the context of the usage of chest X‑ray.