Radiologe最新文献

Background: Chest X‑ray is one of the most frequent examinations in radiology and its interpretation is considered part of the basic knowledge of every radiologist.

Objectives: The purpose of this article is to recognize common signs and patterns of pneumonias and pseudonodules in chest X‑rays and to provide a diagnostic guideline for young radiologists.

Materials and methods: Recent studies and data are analyzed and an overview of the most common signs and patterns in chest X‑ray is provided.

Results: Knowledge about common signs and patterns in chest X‑ray is helpful in the diagnosis of pneumonias and can be indicative for the cause of an infection. However, those signs are often unspecific and should, therefore, be set in clinical content. Computed tomography is becoming increasingly important in the primary diagnosis of pulmonary lesions because of its much higher sensitivity.

Conclusion: Chest X‑ray is still the first-line modality in the diagnosis of pneumonia and pulmonary nodules; however, radiologists should be aware of its limitations.

Clinical issue: Chest x‑ray is a projection technique which reduces a three-dimensional body to a two-dimensional image. Inevitably, this leads to loss of information. Hence, it is much more difficult to determine anatomy and pathology in chest ray than in computed tomography.

Performance: The so-called "lines and stripes" are prominent landmarks. Knowledge of these lines and stripes eases interpretation of chest x‑rays.

Achievements: This review describes anatomy and normal morphology of all relevant lines and stripes and gives differential diagnoses in case of pathologic morphology.

Background: Imaging plays a pivotal role in the management of multiple myeloma (MM). Besides morphological imaging methods, such as whole-body X‑ray, computed tomography (CT) and magnetic resonance imaging (MRI), the hybrid modality positron emission tomography/CT (PET/CT) using the glucose analogue ¹⁸F‑fluorodeoxyglucose (¹⁸F‑FDG) as radiotracer is increasingly used.

Objectives: Aim of this review article is to outline the major applications of PET/CT in the diagnosis and management of MM, and to provide hints on the reading and interpretation.

Materials and methods: Background knowledge and guideline recommendations on imaging of MM are outlined and complemented by recent study results.

Results: Although ¹⁸F‑FDG PET/CT is not currently considered a standard method for the diagnosis of MM, it is a very powerful diagnostic tool for the detection of medullary and extramedullary disease, a reliable predictor of survival and the most robust modality for treatment response evaluation. Moreover, it plays a significant role in minimal residual disease (MRD) assessment. On the other hand, practical considerations on local availability and costs limit the widespread use of PET/CT. In addition, false-negative and the seldom false-positive results and the heterogeneity of MM presentation inevitably make interpretation of PET/CT images challenging.

Conclusions: PET/CT has a high value in the diagnosis, prognosis, and assessment of treatment response in patients with MM. Therefore, the role of the modality in the management of the disease is expected to increase in the near future.

Clinical issue: Multiple myeloma is a clonal B‑lymphocyte neoplasm of terminally differentiated plasma cells and accounts for approximately 10% of all hematologic malignancies. Reduction of bone mass, seen on computed tomography (CT) as focal osteolysis, or general osteopenia is mainly caused by tumor-induced resorption of bone.

Standard radiological methods: Imaging methods are used in multiple myeloma to record the extent of various dimensions of the disease manifestations (damage to bone substance, bone marrow infiltration, extramedullary involvement) and the disease course. The aim of this review article is to summarize and outline the recommendations of the S3 guideline "Diagnostics, therapy and follow-up care for patients with monoclonal gammopathy of unclear significance (MGUS) or multiple myeloma" in terms of radiographic imaging.

Appraisal and practical recommendations: The use of the conventional X‑ray skeletal status (Paris scheme) is obsolete. When a patient with symptomatic multiple myeloma is initially diagnosed, a whole-body CT should be performed to determine the extent of skeletal damage. The S3 guideline also regards CT as the first imaging modality in relapse and progression.

Clinical issue: Multiple myeloma (MM) is a malignancy of hematopoetic system and is associated with destruction of bone, suppressed bone marrow function and renal failure. It is characterized by strong proliferation of malignant plasma cells.

Standard treatment: Classic therapies contained an alkylating agent and a glucocorticoid. In the 1990s, treatments were supplemented with transplantation of peripheral blood stem cells.

Treatment innovations: During the 2000s, new therapies emerged, combining an immunomodulator (thalidomide, lenalidomide or pomalidomide), a proteasome inhibitor (bortezomib, carfilzomib or ixazomib), and a monoclonal antibody against CD38. Currently, antibodies against BCMA (B-cell maturation antigen), bispecific antibodies, and CAR T‑cell (chimeric antigen receptor T cells) therapies are being investigated in clinical trials.

Diagnostic work-up: Classic diagnostics were based on end-organ damage, e.g., bone destruction, and estimated tumor load. Since 2014, new criteria for an earlier start of therapy were introduced-concentration of antibody light chains in blood serum, bone marrow lesions and its infiltration by malignant plasma cells. These lesions (clusters of myeloma cells) can be detected by magnetic resonance imaging (MRI) or positron emission tomography/computed tomography (PET/CT). Both methods are also used to monitor therapy response. Traditional X‑ray imaging has been replaced by the more gentle, low-dose CT. The standard diagnostic process is extended by cytogenetic examination of bone marrow samples via imaging fluorescent in situ hybridization (iFiSH) to identify patients at high risk.

Performance: While most MM patients could be treated only palliatively until the 1990s, the prognosis has continuously improved since then. Nowadays, MM can be classified as a chronic disease.

Clinical/methodical issue: Multiple myeloma can affect the complete skeleton, which makes whole-body imaging necessary. With the current assessment of these complex datasets by radiologists, only a small part of the accessible information is assessed and reported.

Standard radiological methods: Depending on the question and availability, computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET) is performed and the results are then visually examined by radiologists.

Methodological innovations: A combination of automatic skeletal segmentation using artificial intelligence and subsequent radiomics analysis of each individual bone have the potential to provide automatic, comprehensive, and objective skeletal analyses.

Performance: A few automatic skeletal segmentation algorithms for CT already show promising results. In addition, first studies indicate correlations between radiomics features of bone and bone marrow with established disease markers and therapy response.

Achievements: Artificial intelligence (AI) and radiomics algorithms for automatic skeletal analysis from whole-body imaging are currently in an early phase of development.

Background: Multiple myeloma (MM) is one of the most common hematological neoplasms and accounts for approximately 1% of human cancers.

Objectives: Description of current diagnostics and classification of MM and related plasma cell neoplasms from the pathology viewpoint.

Materials and methods: Current knowledge regarding pathology and genetics of MM is summarized and tissue-based diagnostics following international consensus classifications and the current S3 guideline are described.

Results: MM and related neoplasms are composed of malignant plasma cells that secrete a monoclonal immunoglobulin, which is an important parameter of disease activity. MM shows a multistage development. Almost all cases are preceded by a clinically inapparent precursor lesion, monoclonal gammopathy of undetermined significance (MGUS), which can progress to smoldering myeloma with a higher tumor burden, but absence of organ damage. Systemic MM needs to be discerned from the localized forms, solitary osseous and primary extramedullary plasmacytoma. MM is genetically very heterogeneous and can be broadly subdivided into two cytogenetic groups, cases with primary IGH translocations and cases with hyperdiploidy. Intratumoral genetic heterogeneity is frequently pronounced and correlates with the size of focal lesions in imaging.

Conclusions: Diagnosis of plasma cell neoplasms is done according to the criteria of the International Myeloma Working Group (IWMG) and requires interdisciplinary evaluation of clinical, serological, pathological and radiological features. In addition to clinical parameters, molecular markers, especially cytogenetic aberrations, are of great prognostic relevance.

Background: Treatment options for patients with solitary plasmacytoma (SP) or multiple myeloma (MM) should be discussed in an interdisciplinary context. This systematic review focuses on the importance of radiotherapy in MM and SP.

Objective: Summary of local radio-oncological treatment options for patients with SP and MM.

Materials and methods: Based on a systematic literature search, the current evidence on the topic was analyzed and summarized.

Results: Patients with SP should be primarily treated with radiotherapy with or without surgery. Irradiation concepts may vary depending on risk factors and manifestation (solitary bone plasmacytoma vs. solitary extramedullary plasmacytoma). Although local control rates are high after radiotherapy, progression to multiple myeloma frequently occurs. In patients with MM, radiation is mainly used in palliative settings for pain relief, prevention of fractures or in patients who suffer from neurological symptoms due to spinal cord compression. Irradiation dose and fractionation should be selected based on treatment indication and general condition of the patient.

Conclusion: Although most patients receive systemic treatment at initial diagnosis, approximately 40% of patients with MM will require radiation during the course of their disease. While radiation is mainly used for palliation in patients with MM, it represents the primary and curative treatment option in patients with SP.