CLINICAL/METHODICAL ISSUE:Inflammatory orbital processes on imaging are often misinterpreted as tumors. STANDARD RADIOLOGICAL METHODS:Imaging comprises computed tomography (CT) and magnetic resonance imaging (MRI). ACHIEVEMENTS:Clinical and laboratory data play a crucial role in diagnosing many inflammatory orbital diseases. Radiological imaging provides a supporting but relevant role. PRACTICAL RECOMMENDATIONS:Clinical examination, including specialized ophthalmological examinations, laboratory diagnostics, and MRI are important in the diagnosis of inflammatory orbital diseases.

Bildmorphologisch werden entzündliche Erkrankungen der Orbita häufig als Tumoren fehlinterpretiert. Die Bildgebungsverfahren umfassen die Computertomographie (CT) und die Magnetresonanztomographie (MRT). Klinik und Labordaten spielen bei vielen entzündlichen Orbitaerkrankungen eine entscheidende Rolle zur Diagnosefindung. Der radiologischen Bildgebung kommt eine unterstützende, aber relevante Rolle zu. Für die Diagnostik der entzündlichen Orbitaerkrankungen spielen die Klinik einschließlich spezialisierter ophthalmologischer Untersuchungen, die Labordiagnostik sowie die MRT die Hauptrollen.

Zusammenfassung Klinisches Problem Tumoren der hinteren Schädelgrube machen etwa 50–55 % der kindlichen Hirntumoren aus. Diagnostik Zu den häufigsten Tumorentitäten zählen Medulloblastome, pilozytische Astrozytome, Ependymome, diffuse Mittelliniengliome und atypisch teratoid-rhabdoide Tumoren (ATRT). Der neuroradiologischen Differenzialdiagnostik mittels Magnetresonanztomographie (MRT) kommt eine erhebliche Bedeutung zu, sowohl für die präoperative Planung als auch für die Planung der Anschlusstherapie. Leistungsfähigkeit Wichtige Merkmale für die Differenzialdiagnostik sind die genaue Tumorlokalisation, das Patientenalter und die intratumorale scheinbare Diffusion, die mittels diffusionsgewichteter Bildgebung quantifiziert werden kann. Bewertung Fortschrittliche MR-Techniken, wie MR-Perfusion und MR-Spektroskopie, können sowohl für die initiale Diagnostik als auch für die Beurteilung des Tumorverlaufs hilfreich sein, allerdings sollten Ausnahmeverhalten bestimmter Tumorentitäten bekannt sein. Empfehlung für die Praxis Konventionelle MRT-Sequenzen inklusive Diffusionswichtung sind die wichtigsten diagnostischen Tools zur Evaluation pädiatrischer Tumoren der hinteren Schädelgrube. Fortschrittliche MR-Techniken können helfen, sollten allerdings nicht isoliert von den konventionellen MRT-Sequenzen interpretiert werden.

Kavernöse Malformationen oder Kavernome gehören zu den Angiodysplasien. Sie können sporadisch oder familiär auftreten und trotz fehlendem Links-Rechts-Shunt Symptome (Epilepsie) verursachen. Neben der intrakraniellen Lokalisation finden sich auch spinale Kavernome. In der Diagnostik kommen die Magnetresonanztomographie (MRT) und Computertomographie (CT) zum Einsatz. Die MRT ist, abgesehen von akut oder subakut eingebluteten Kavernomen, beim Läsionsnachweis der CT überlegen. Die CT ist der Akutdiagnostik vorbehalten. Die MRT, insbesondere suszeptibilitätsempfindliche Gradientenechosequenzen, kann auch Kavernome ohne (sub)akute Einblutung oder Verkalkungen nachweisen. Die MRT ist auch für die Unterscheidung familiäre vs. sporadische Form geeignet. Die digitale Subtraktionsangiographie (DSA) dient in seltenen Fällen der Differenzialdiagnose, da Kavernome hier kein Korrelat zeigen.

Central nervous system (CNS) tumors are the most common solid malignancies in children and adolescents and young adults (C-AYAs). Craniospinal irradiation (CSI) is an essential treatment component for some malignancies, but it can also lead to important toxicity. Pencil beam scanning proton therapy (PBSPT) allows for a minimization of dose delivered to organs at risk and, thus, potentially reduced acute and late toxicity. This study aims to report the clinical outcomes and toxicity rates after CSI for C-AYAs treated with PBSPT. Seventy-one C-AYAs (median age: 7.4 years) with CNS tumors were treated with CSI between 2004 and 2021. Medulloblastoma (n=42: 59%) and ependymoma (n=8; 11%) were the most common histologies. Median prescribed total PBSPT dose was 54 GyRBE (range: 18-60.4), and median prescribed craniospinal dose was 24 GyRBE (range: 18-36.8). Acute and late toxicities were coded according to Common Terminology Criteria for Adverse Events. After a median follow-up of 24.5 months, the estimated 2-year local control, distant control, and overall survival were 86.3%, 80.5%, and 84.7%, respectively. Late grade >= 3 toxicity-free rate was 92.6% at 2 years. Recurrent and metastatic tumors were associated with worse outcome. In conclusion, excellent tumor control with low toxicity rates was observed in C-AYAs with brain tumors treated with CSI using PBSPT.

Zusammenfassung Klinisches/methodisches Problem Technische Fortschritte auf dem Gebiet der spinalen interventionellen Neuroradiologie ermöglichen es, eine breite Palette an gezielten, minimal-invasiven Behandlungsoptionen einschließlich der spinalen Ozontherapie beim Rückenschmerz anzuwenden. Dieser Beitrag gibt eine Übersicht der biochemischen, molekularen, immunologischen und pharmazeutischen Mechanismen sowie Applikationstechniken der gezielten Ozontherapie. Radiologische Standardverfahren Zum Einsatz kommen die Computertomographie (CT) sowie konventionelle Röntgenaufnahmen (Durchleuchtung). Leistungsfähigkeit Die CT-gesteuerten Interventionen (epidural, periradikuläre, Facettengelenk und intradiskal) haben den höchsten Stellenwert und haben sich historisch durchgesetzt. Durchleuchtungsgesteuerte Verfahren können ebenfalls eingesetzt werden. Schlussfolgerung Die Ozontherapie liefert vielversprechende Ergebnisse. Der Beitrag soll dazu dienen, Informationen über die Grundlagen dieser Technik(en) zu vermitteln.

Zusammenfassung Klinisches/methodisches Problem Die Spondylodiszitis ist eine Entzündung der intervertebralen Bandscheibe, die beim Erwachsenen aufgrund der Vaskularisation in der Regel mit einer Spondylitis der angrenzenden Wirbelkörper einhergeht und klinisch häufig nur unspezifische Symptome wie Rücken- oder Nackenschmerzen zeigt. Sie kann erregerassoziiert von verschiedenen Pathogenen, v. a. Bakterien, verursacht werden. Dabei können ein oder mehrere Bewegungssegmente betroffen sein. Die Infektion kann epidurale Abszedierungen verursachen und sich auch auf umliegende Kompartimente ausbreiten. Die Radiologie, und hier insbesondere die Magnetresonanztomographie (MRT), spielt eine wichtige Rolle bei der Primärdiagnostik und im Rahmen von Verlaufsbeurteilungen zur Überprüfung des Therapieansprechens. Die Therapie beruht auf konservativen (Antibiotika) und invasiven Ansätzen, einschließlich einer Operation. Die interventionelle Punktion und Drainage ist v. a. in frühen Stadien der Abszessbildung eine vielversprechende Alternative. Radiologische Standardverfahren Magnetresonanztomographie (MRT), Computertomographie (CT), nuklearmedizinische Verfahren, konventionelles Röntgen. Leistungsfähigkeit Die MRT hat den höchsten Stellenwert. CT und nuklearmedizinische Verfahren können ergänzend und im Fall bestehender Kontraindikationen zur MRT eingesetzt werden. Schlussfolgerung Bei adäquater Diagnostik und Therapie hat die Spondylodiszitis eine gute Prognose. Neben der gezielten bzw. kalkulierten medikamentösen Therapie steht beim epiduralen Abszess die invasive Therapie im Vordergrund. Die interventionell-radiologische Punktion und Drainage (auch zur Keimidentifikation für die gezielte Antibiotikatherapie) können frühzeitig eine schonende Alternative zur chirurgischen Sanierung darstellen.

Clinical/methodological problem Technical advances in the field of spinal interventional neuroradiology allow the application of a wide range of targeted, minimally invasive treatment options including targeted spinal ozone therapy for back pain. This article provides an overview of the biochemical, molecular, immunologic, and pharmaceutical mechanisms and delivery techniques of targeted ozone therapy. Standard radiological methods Computed tomography (CT), conventional X-ray (fluoroscopy). Performance Computed tomography-guided interventions (epidural, periradicular, facet joint, and intradiscal) have the highest place value and have historically prevailed. Fluoroscopy-guided procedures may also be used. Practical recommendations Ozone therapy provides promising results. The article is intended to provide information on the basics of the technique(s).

Background and purposeThis study analyses the dosimetric and dose averaged Linear Energy transfer (LETd) correlation in paediatric craniopharyngioma (CP) patients with and without radiation-induced cerebral vasculopathies (RICVs) treated with pencil beam scanning (PBS) proton therapy (PT).Material and methodsWe reviewed a series of 16 CP patients treated with PT to a median dose of 54 Gy(RBE). Two (12.5%) index patients presented RICVs 14 and 24 months (median, 19) after PT. Organs at risks (OARs) as bilateral internal carotid arteries (ICAs) and circle of Willis were contoured based on CTs and MRIs pre- and post-PT. Dosimetry was reviewed and LETd distributions were calculated; LETd metric for PTVs and OARs were analysed. For a sub-cohort, dosimetric and LETd values robustness due to range uncertainties were computed.ResultsFor the two index patients, no correlation was observed between RICVs and OARs doses. However for those patients mean(maximum) LETd values in the affected OARs were up to 4.0 ± 0.4 (7.8 ± 0.1)keV/μm; those LETd values were significantly higher (p = 0.02) than the mean(maximum) LETd values for the rest of the cohort (mean: 3.1 ± 0.3, maximum: 4.8 ± 1.0 keV/μm). This was due to asymmetric field arrangement, thus resulting in marked asymmetric LETd distributions. For such arrangement, maximum LETd values variations in vascular structures due to range uncertainties were up to 1.2 keV/μm, whilst for the symmetric one they were up to 0.7 keV/μm.ConclusionsFor children with and without RICVs, quantitative analysis showed a significant correlation with LETd average/maximum values in vascular structures, whilst no correlation was found on dosimetric parameters.

Background Skull base chordomas are rare and heterogeneously behaving tumors. Though still classified as benign they can grow rapidly, are locally aggressive, and have the potential to metastasize. To adapt the treatment to the specific needs of patients at higher risk of recurrence, a pre-proton therapy prognostic grading system would be useful. The aim of this retrospective analysis is to assess prognostic factors and the “Sekhar Grading System for Cranial Chordomas” (SGSCC) by evaluating the larger cohort of patients treated at our institution as to determine its reproducibility and ultimately to ensure more risk adapted local treatments for these challenging tumors. Methods We analyzed 142 patients treated for skull base chordomas between 2004 and 2016. We focused the analysis on the 5 criteria proposed for the SGSCC (tumor size, number of anatomic regions and vessels involved, intradural invasion, as well as recurrence after prior treatment) and classified our patients according to their score (based on the above mentioned criteria) into three prognostic groups, low-risk, intermediate-risk and high-risk. The three groups were then analyzed in regards of local control, local recurrence-free survival and overall survival. Results The median follow up was 52 months (range, 3–152). We observed 34 (24%) patients with a local recurrence, resulting in a local control of 75% at 5 years. Overall survival was 83% at 5 years, 12 (9%) patients had died due to local progression. When split into the three prognostic groups according to the SGSCC the observed local control was 90, 72 and 64% ( p = 0.07 ) in the low-, intermediate- and high-risk group, respectively. A similar correlation was observed for local recurrence-free survival with 93, 89 and 66% ( p = 0.05 ) and for overall survival with 89, 83 and 76% (p = 0.65) for the same prognostic groups. Conclusions After splitting our patient cohort into the three SGSCC risk groups, we found a trend towards better outcome for those patients with lower as opposed to higher scores. These results suggest that this prognostic grading system published by Sekhar et al. could be integrated in the management decision-tree for patients with skull base chordoma.

Clinical/methodical issue Oral cavity malignancies are the most common tumors in the field of ear, nose and throat medicine or otorhinolaryngology worldwide. It comprises a heterogeneous group of tumors, the knowledge of which is necessary to meet the different requirements of diagnostics and therapy. Standard radiological methods Computed tomography (CT), magnetic resonance imaging (MRI), sonography (US), nuclear medical procedures (NUK). Performance The above-mentioned diagnostics are used in a complementary manner. Achievements Early diagnosis of the tumor improves staging and thus the patient's therapy and prognosis. Practical recommendations The radiologist plays an important role in the interdisciplinary treatment of malignant tumors of the oral cavity. Despite great progress in radiotherapy, oncology and immunotherapy, surgery still plays an important role in the treatment of malignant diseases of the oral cavity.

Zusammenfassung Klinisches/methodisches Problem Mundhöhlenmalignome stellen weltweit die häufigsten Tumoren im Bereich der Hals-Nasen-Ohrenheilkunde bzw. Otorhinolaryngologie dar. Es handelt sich um eine heterogene Gruppe an Tumoren, deren Kenntnis erforderlich ist, um den unterschiedlichen Anforderungen an Diagnostik und Therapie gerecht zu werden. Radiologische Standardverfahren Computertomographie (CT), Magnetresonanztomographie (MRT), Sonographie, nuklearmedizinische Verfahren (NUK). Leistungsfähigkeit Die o. g. Diagnostika werden komplementär eingesetzt. Bewertung Eine frühzeitigere Diagnose des Tumors verbessert das Staging und somit die Therapie und Prognose des Patienten. Schlussfolgerung Dem Radiologen kommt bei der interdisziplinären Behandlung von Malignomen der Mundhöhle eine bedeutende Rolle zu. Trotz großer Fortschritte in der Radiotherapie, Onkologie und Immuntherapie spielt die Chirurgie weiterhin eine wichtige Rolle in der Behandlung maligner Erkrankungen der Mundhöhle.

Case description A 73-year-old male presented with new onset dizziness and a 22-kg weight loss due to antibiotic-induced nausea/vomiting. Due to gaze-evoked nystagmus (GEN), thiamine deficiency was suspected. Within 12 h after replacement, his GEN decreased. Conclusion In patients with nutritional deprivation, new onset GEN should prompt further diagnostics and immediate thiamine supplementation to avoid disease progression.

Skullbase chordomas (sbC) are bone tumors arising from remnants of the notochord, often presenting within the clivus or spinal column, and characterized by significant tissue heterogeneity. Tumor shape is likely determined by proximity to surrounding anatomic barriers, whilst their location, generally closed to very sensitive structures, makes them a typical indication for high-dose adjuvant proton therapy (PT) following partial tumor resection. The aim of this work is to investigate whether shape and/or textural features extracted from pre-surgery and pre-PT MRI acquisitions correlate with clinical outcome. We retrospectively analyzed 60 sbC patients treated using PBS-PT at our institute. A total of 34 shape and texture features have been extracted from T2w- and DWI-MRI images which was correlated with patient's outcome. First, tumor tissues and organs-at-risk (OARs) have been classified using in-house developed software based clustering kmeans algorithm. Secondly, the features dataset has been split (0.3 ratio) to train and test the predictive potential of a sequential deep learning model. Finally, clustering classification and predictive deep learning have been cross-correlated with clinical outcome. Overall the clustering analysis distinctively identified 11 (73.3%) out of 15 recurrences based on shape morphological features. However, due to the small number of recurrences, this result is not statistically significant. We have found significant correlation (correlation coeff.>0.85) among apparently non-correlated features, as in the case of signature-mean vs. compactness and homogeneity vs. contrast features. Significant changes both for shape and texture features occurred in the interval between surgery and PT treatment, but none of them showed potential in predicting treatment outcome. Deep learning prediction reported a precision of 0.78 to predict the absence of recurrences, but only 0.53 in case of recurrence. In contrast, the sensitivity was 0.3 and 0.82 for subject without and with recurrence, respectively. For each feature, we have generally observed a large coefficient of variation (CV>0.4 in most cases). Such large CV, which is defined as the ration between standard deviation and average value of a distribution, reflects the tissue heterogeneity that characterizes sbC. Unfortunately, from analytical perspective, an increment of CV determines a decrease of the robustness of predictive models. Clustering classification can perform tumor classification based on features extracted from MRI image dataset. The large heterogeneity of sbC tissues negatively affects the robustness of classification and predictive approach. Deep learning approach based on shape and texture features has the potential to be used as a predictive model for treatment outcome in sbC. We are currently working to improve the reliability of deep learning and extend our analysis to pediatrics brain tumors.

Background: Whole-ventricular radiotherapy (WV-RT) followed by a boost to the tumor bed (WV-RT/TB) is recommended for intracranial germ cell tumors (IGCT). As the critical brain areas are mainly in the target volume vicinity, it is unclear if protons indeed substantially spare neurofunctional organs at risk (NOAR). Therefore, a dosimetric comparison study of WV-RT/TB was conducted to assess whether proton or photon radiotherapy achieves better NOAR sparing. Methods: Eleven children with GCT received 24 Gy(RBE) WV-RT and a boost up to 40 Gy(RBE) in 25 fractions of 1.6 Gy(RBE) with pencil beam scanning proton therapy (PBS-PT). Intensity-modulated radiotherapy (IMRT) and volumetric-modulated arc therapy (VMAT) plans were generated for these patients. NOAR were delineated and treatment plans were compared for target volume coverage (TVC), homogeneity index (HI), inhomogeneity coefficient (IC) and (N)OAR sparing. Results: TVC was comparable for all three modalities. Compared to IMRT and VMAT, PBS-PT showed statistically significant optimized IC, as well as dose reduction, among others, in mean and integral dose to the: normal brain (-35.2%, -32.7%; -35.2%, -33.0%, respectively), cerebellum (-53.7%, -33.1%; -53.6%, -32.7%) and right temporal lobe (-14.5%, -31.9%; -14.7%, -29.9%). The Willis' circle was better protected with PBS-PT than IMRT (-7.1%; -7.8%). The left hippocampus sparing was higher with IMRT. Compared to VMAT, the dose to the hippocampi, amygdalae and temporal lobes was significantly decreased in the IMRT plans. Conclusions: Dosimetric comparison of WV-RT/TB in IGCT suggests PBS-PT's advantage over photons in conformality and NOAR sparing, whereas IMRT's superiority over VMAT, thus potentially minimizing long-term sequelae. (C) 2019 The Authors. Published by Elsevier B.V. on behalf of European Society for Radiotherapy and Oncology.

Angefangen von der kleinsten funktionellen Einheit, dem Bewegungssegment mit der zentral gelegenen Bandscheibe, sind Wirbelsäule und Becken mit den Iliosakral- und Hüftgelenken als funktionelle Einheit zu verstehen. Im komplexen Zusammenspiel der diskalen, ossären und ligamentären Strukturen sowie dem angrenzenden Muskelapparat spielen die Bandscheiben eine wichtige Rolle. Diskusveränderungen gehen häufig mit Veränderungen der Abschlussplatten einher und können bereits frühzeitig kernspintomographisch nachgewiesen werden. Der Fokus bei der Diagnostik und Beurteilung der Bandscheibendegeneration sollte auf die klinische Problematik zentriert sein. Grundlage dafür ist eine einheitliche Terminologie zwischen den beteiligten Fachdisziplinen.

Clinical problem. Intracerebral cysts are common findings in imaging of the neurocranium and are not always clinically significant. The pathological spectrum of intracerebral cysts is, however, very broad and in addition to incidental findings includes developmental disorders, malformation tumors, primary and secondary neoplasms and infectious etiologies, such as cerebral abscess formation, cysticercosis or residuals after congenital cytomegalovirus infections. Intracerebral cystic defects may be caused by inflammatory central nervous system (CNS) diseases, such as multiple sclerosis as well as by mitochondriopathies, leukodystrophy, electrolyte disturbances or osmotic demyelination syndrome or brain infarctions, e.g. after lacunar infarctions or as encephalomalacic changes after severe traumatic brain injury. Radiological standard procedures. In addition to the radiological findings of cysts in magnetic resonance imaging (MRI) or in computed tomography (CT), the localization, patient age, patient medical history and laboratory diagnostics are helpful for the differential diagnostics. Methodical innovation. In addition to the morphological assessment, advanced MRI techniques, such as diffusion-weighted imaging for epidermoids or the use of MR spectroscopy, can provide valuable information for the differential diagnosis. Performance/assessment. Intracranial cysts can be subdivided into intraventricular and periventricular cysts, intra-axial cysts and cysts in the external fluid-filled spaces. Associated tumor nodules and the contrast medium behavior of the cyst walls and/or associated soft tissue components as well as the reaction of the adjacent parenchyma are helpful for the diagnosis and assessment.

Whole ventricular irradiation (WV-RT) followed by a boost to the tumor bed (WV-RT/TB) is recommended for localized intracranial germ cell tumors (GCT). As the eloquent brain areas are mainly in direct vicinity of the target volume, it is unknown if proton therapy indeed substantially spares these organs at risk (OAR). Therefore, a dosimetric comparison study of WV-RT/TB was conducted to assess whether protons or modern photon radiotherapy achieve better critical organ sparing. Eleven children with GCT received 24 Gy(RBE) WV-RT and a boost up to 40 Gy(RBE) in 25 fractions of 1.6 Gy(RBE) with pencil beam scanning proton therapy (PBS-PT). Respective intensity-modulated radiation therapy (IMRT) plans were generated for these patients. Additional critical structures for neurocognition (NCS) have been delineated and plans compared for target volume coverage (TVC) (homogeneity index (HI) and inhomogeneity coefficient (IC)), NCS and OAR sparing. TVC was similar for both modalities. Compared to IMRT, PBS-PT showed statistically significant dose reduction (p<0.05) in: maximum (Dmax), mean (Dmean) and integral dose (ID) of the normal brain (2.6%, 35.4%, 35.7%); Dmean of the Willis’ circle (6.7%), and brainstem (7.4%). Likewise, the volume receiving ≥20 Gy (V20Gy) of the right (24.2%) and left (20.9%) temporal lobes was significantly decreased. No significant difference was observed for the dose-metrics/hippocampus. Dosimetric comparison of WV-RT/TB in GCT demonstrates PBS-PT’s advantage over IMRT in critical organ sparing, while keeping TVC the same. PBS-PT may decrease the likelihood of vascular/neurological sequelae, as well as the risk of radio-induced secondary malignancies.

BACKGROUND:Compared with other available injection techniques for lumbar transforaminal epidural steroid injections (LTFESIs), the traditionally performed subpedicular approach is associated with a higher risk of spinal cord infarction, a rare but catastrophic complication.PURPOSE:To assess the short-term efficacy of the retroneural approach for computed tomography (CT)-guided LTFESIs with respect to different needle-tip positions.MATERIAL AND METHODS:This retrospective analysis included 238 patients receiving 286 CT-guided LTFESIs from January 2013 to January 2016. Short-term outcomes in terms of pain relief were assessed using the visual analogue scale (VAS) at baseline and 30 min after. The needle-tip location was categorized as extraforaminal, junctional, or foraminal relative to the neural foramen. Additionally, the distance from the needle tip to the nerve root was measured.RESULTS:A mean pain reduction of 3.22 points (±2.17 points) on the VAS was achieved. The needle-tip location was extraforaminal in 48% (136/286), junctional in 42% (120/286), and foraminal in 10% (28/286) of the cases. The mean distance from the needle tip to the nerve root was 3.83 mm (±3.37 mm). There was no significant correlation between pain relief and needle-tip position in relation to the neural foramen. Therapy success was not dependent on the distance between the needle tip and the nerve root. No major complications were observed.CONCLUSION:In our population treated with LTFESIs, the retroneural approach was shown to be an effective technique, with no significant differences in pain relief following different needle-tip positions.