Publications by authors named "Matthias F Froelich"

44 Publications

Additional MRI for initial M-staging in pancreatic cancer: a cost-effectiveness analysis.

Eur Radiol 2021 Nov 27. Epub 2021 Nov 27.

Department of Radiology and Nuclear Medicine, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.

Objective: Pancreatic cancer is portrayed to become the second leading cause of cancer-related death within the next years. Potentially complicating surgical resection emphasizes the importance of an accurate TNM classification. In particular, the failure to detect features for non-resectability has profound consequences on patient outcomes and economic costs due to incorrect indication for resection. In the detection of liver metastases, contrast-enhanced MRI showed high sensitivity and specificity; however, the cost-effectiveness compared to the standard of care imaging remains unclear. The aim of this study was to analyze whether additional MRI of the liver is a cost-effective approach compared to routinely acquired contrast-enhanced computed tomography (CE-CT) in the initial staging of pancreatic cancer.

Methods: A decision model based on Markov simulation was developed to estimate the quality-adjusted life-years (QALYs) and lifetime costs of the diagnostic modalities. Model input parameters were assessed based on evidence from recent literature. The willingness-to-pay (WTP) was set to $100,000/QALY. To evaluate model uncertainty, deterministic and probabilistic sensitivity analyses were performed.

Results: In the base-case analysis, the model yielded a total cost of $185,597 and an effectiveness of 2.347 QALYs for CE-MR/CT and $187,601 and 2.337 QALYs for CE-CT respectively. With a net monetary benefit (NMB) of $49,133, CE-MR/CT is shown to be dominant over CE-CT with a NMB of $46,117. Deterministic and probabilistic survival analysis showed model robustness for varying input parameters.

Conclusion: Based on our results, combined CE-MR/CT can be regarded as a cost-effective imaging strategy for the staging of pancreatic cancer.

Key Points: • Additional MRI of the liver for initial staging of pancreatic cancer results in lower total costs and higher effectiveness. • The economic model showed high robustness for varying input parameters.
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http://dx.doi.org/10.1007/s00330-021-08356-0DOI Listing
November 2021

Automated Screening for Abdominal Aortic Aneurysm in CT Scans under Clinical Conditions Using Deep Learning.

Diagnostics (Basel) 2021 Nov 17;11(11). Epub 2021 Nov 17.

Department of Radiology and Nuclear Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim, Germany.

Abdominal aortic aneurysms (AAA) may remain clinically silent until they enlarge and patients present with a potentially lethal rupture. This necessitates early detection and elective treatment. The goal of this study was to develop an easy-to-train algorithm which is capable of automated AAA screening in CT scans and can be applied to an intra-hospital environment. Three deep convolutional neural networks (ResNet, VGG-16 and AlexNet) were adapted for 3D classification and applied to a dataset consisting of 187 heterogenous CT scans. The 3D ResNet outperformed both other networks. Across the five folds of the first training dataset it achieved an accuracy of 0.856 and an area under the curve (AUC) of 0.926. Subsequently, the algorithms performance was verified on a second data set containing 106 scans, where it ran fully automated and resulted in an accuracy of 0.953 and an AUC of 0.971. A layer-wise relevance propagation (LRP) made the decision process interpretable and showed that the network correctly focused on the aortic lumen. In conclusion, the deep learning-based screening proved to be robust and showed high performance even on a heterogeneous multi-center data set. Integration into hospital workflow and its effect on aneurysm management would be an exciting topic of future research.
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http://dx.doi.org/10.3390/diagnostics11112131DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8621263PMC
November 2021

Prediction of cardiac events with non-contrast magnetic resonance feature tracking in patients with ischaemic cardiomyopathy.

ESC Heart Fail 2021 Nov 24. Epub 2021 Nov 24.

1st Department of Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, Heidelberg, D-68167, Germany.

Aims: The aim of this study was to evaluate the prognostic value of feature tracking (FT) derived cardiac magnetic resonance (CMR) strain parameters of the left ventricle (LV)/right ventricle (RV) in ischaemic cardiomyopathy (ICM) patients treated with an implantable cardioverter-defibrillator (ICD). Current guidelines suggest a LV-ejection fraction ≤35% as major criterion for ICD implantation in ICM, but this is a poor predictor for arrhythmic events. Supplementary parameters are missing.

Methods And Results: Ischaemic cardiomyopathy patients (n = 242), who underwent CMR imaging prior to primary and secondary implantation of ICD, were classified depending on EF ≤ 35% (n = 188) or >35% (n = 54). FT parameters were derived from steady-state free precession cine views using dedicated software. The primary endpoint was a composite of cardiovascular mortality (CVM) and/or appropriate ICD therapy. There were no significant differences in FT-function or LV-/RV-function parameters in patients with an EF ≤ 35% correlating to the primary endpoint. In patients with EF > 35%, standard CMR functional parameters, such as LV-EF, did not reveal significant differences. However, significant differences in most FT parameters correlating to the primary endpoint were observed in this subgroup. LV-GLS (left ventricular-global longitudinal strain) and RV-GRS (right ventricular-global radial strain) revealed the best diagnostic performance in ROC curve analysis. The combination of LV-GLS and RV-GRS showed a sensitivity of 85% and a specificity of 76% for the prediction of future events.

Conclusions: The impact of FT derived measurements in the risk stratification of patients with ICM depends on LV function. The combination of LV-GLS/RV-GRS seems to be a predictor of cardiovascular mortality and/or appropriate ICD therapy in patients with EF > 35%.
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http://dx.doi.org/10.1002/ehf2.13712DOI Listing
November 2021

ENT Residents Benefit from a Structured Operation Planning Approach in the Training of Functional Endoscopic Sinus Surgery.

Medicina (Kaunas) 2021 Oct 4;57(10). Epub 2021 Oct 4.

Department of Otorhinolaryngology, University Medical Center Bonn, 53127 Bonn, Germany.

: Preoperative planning utilizing computed tomographies (CT) is of utmost importance in functional endoscopic sinus surgery (FESS). Frequently, no uniform documentation and planning structures are available to residents in training. Consequently, overall completeness and quality of operation planning may vary greatly. The objective of the present study was to evaluate the impact of a structured operation planning (SOP) approach on the report quality and user convenience during a 4-day sinus surgery course. : Fifteen participant were requested to plan a FESS procedure based on a CT scan of the paranasal sinuses that exhibited common pathological features, in a conventional manner, using a free text. Afterwards, the participants reevaluated the same scans by means of a specifically designed structured reporting template. Two experienced ENT surgeons assessed the collected conventional operation planning (COP) and SOP methods independently with regard to time requirements, overall quality, and legibility. User convenience data were collected by utilizing visual analogue scales. : A significantly greater time expenditure was associated with SOPs (183 s vs. 297 s, = 0.0003). Yet, legibility (100% vs. 72%, < 0.0001) and overall completeness (61.3% vs. 22.7%, < 0.0001) of SOPs was significantly superior to COPs. Additionally, description of highly relevant variants in anatomy and pathologies were outlined in greater detail. User convenience data delineated a significant preference for SOPs (VAS 7.9 vs. 6.9, = 0.0185). : CT-based planning of FESS procedures by residents in training using a structured approach is more time-consuming while producing a superior report quality in terms of detailedness and readability. Consequently, SOP can be considered as a valuable tool in the process of preoperative evaluations, especially within residency.
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http://dx.doi.org/10.3390/medicina57101062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8541081PMC
October 2021

End-to-end automated body composition analyses with integrated quality control for opportunistic assessment of sarcopenia in CT.

Eur Radiol 2021 Sep 30. Epub 2021 Sep 30.

Department of Diagnostic and Interventional Radiology, Quantitative Imaging Lab Bonn (QILaB), University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.

Objectives: To develop a pipeline for automated body composition analysis and skeletal muscle assessment with integrated quality control for large-scale application in opportunistic imaging.

Methods: First, a convolutional neural network for extraction of a single slice at the L3/L4 lumbar level was developed on CT scans of 240 patients applying the nnU-Net framework. Second, a 2D competitive dense fully convolutional U-Net for segmentation of visceral and subcutaneous adipose tissue (VAT, SAT), skeletal muscle (SM), and subsequent determination of fatty muscle fraction (FMF) was developed on single CT slices of 1143 patients. For both steps, automated quality control was integrated by a logistic regression model classifying the presence of L3/L4 and a linear regression model predicting the segmentation quality in terms of Dice score. To evaluate the performance of the entire pipeline end-to-end, body composition metrics, and FMF were compared to manual analyses including 364 patients from two centers.

Results: Excellent results were observed for slice extraction (z-deviation = 2.46 ± 6.20 mm) and segmentation (Dice score for SM = 0.95 ± 0.04, VAT = 0.98 ± 0.02, SAT = 0.97 ± 0.04) on the dual-center test set excluding cases with artifacts due to metallic implants. No data were excluded for end-to-end performance analyses. With a restrictive setting of the integrated segmentation quality control, 39 of 364 patients were excluded containing 8 cases with metallic implants. This setting ensured a high agreement between manual and fully automated analyses with mean relative area deviations of ΔSM = 3.3 ± 4.1%, ΔVAT = 3.0 ± 4.7%, ΔSAT = 2.7 ± 4.3%, and ΔFMF = 4.3 ± 4.4%.

Conclusions: This study presents an end-to-end automated deep learning pipeline for large-scale opportunistic assessment of body composition metrics and sarcopenia biomarkers in clinical routine.

Key Points: • Body composition metrics and skeletal muscle quality can be opportunistically determined from routine abdominal CT scans. • A pipeline consisting of two convolutional neural networks allows an end-to-end automated analysis. • Machine-learning-based quality control ensures high agreement between manual and automatic analysis.
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http://dx.doi.org/10.1007/s00330-021-08313-xDOI Listing
September 2021

Detectability of Lung Nodules in Ultra-low Dose CT.

Anticancer Res 2021 Oct;41(10):5053-5058

Department of Radiology and Nuclear Medicine, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany

Background/aim: Investigation of the influence of different ultra-low dose computed tomography (ULDCT) protocols on the detection of solid and subsolid nodules in a phantom study.

Patients And Methods: A chest phantom with pulmonary nodules was scanned with different CT protocols ranging from ultra-low dose settings with spectral shaping to a standard low dose lung cancer screening protocol. Image analysis was performed with different reconstruction algorithms and dedicated computer aided detection (CAD), which was compared to manual readout.

Results: The highest sensitivity rates (83%) were achieved for the 90 mAs and 120 mAs protocols when reconstructed with ADMIRE 3 or 5 and manual readout. The only statistically significant difference was found for subsolid nodules with preference of manual readout compared to CAD (p<0.05). Dose levels for the mAs settings ranged from 0.029 to 0.2 mSv.

Conclusion: Reliable detectability rates for solid nodules were achieved; CAD software did not prove reliable for subsolid nodules.
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http://dx.doi.org/10.21873/anticanres.15320DOI Listing
October 2021

Diagnostic Value of Contrast-Enhanced Ultrasound for Evaluation of Transjugular Intrahepatic Portosystemic Shunt Perfusion.

Diagnostics (Basel) 2021 Sep 1;11(9). Epub 2021 Sep 1.

Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany.

Background: In patients with liver cirrhosis, transjugular intrahepatic portosystemic shunt (TIPS) displays an effective method for treating portal hypertension. Main indications include refractory ascites and secondary prevention of esophageal bleeding. Color Doppler ultrasound (CDUS) plays a leading role in the follow-up management, whereas contrast-enhanced ultrasound (CEUS) is not routinely considered. We compared the efficacy of CEUS to CDUS and highlighted differences compared to findings of corresponding computed tomography (CT) and magnetic resonance imaging (MRI). (2) Methods: On a retrospective basis, 106 patients with CEUS examination after TIPS were included. The enrollment period was 12 years (between 2008 and 2020) and the age group ranged from 23.3 to 82.1 years. In addition, 92 CDUS, 43 CT and 58 MRI scans were evaluated for intermodal comparison. (3) Results: Intermodal analysis and comparison revealed a high level of concordance between CDUS, CT and MRI in the vast majority of cases. In comparison to CDUS, the correlation of the relevant findings was 92.5%, 95.3% for CT and 87.9% for MRI. In some cases, however, additional information was provided by CEUS (4) Conclusions: CEUS depicts a safe and effective imaging modality for follow-up after TIPS. In addition to CDUS, CEUS enables specific assessment of stent pathologies and stent dysfunction due to its capacity to dynamically visualize single microbubbles at high spatial and temporal resolution. Due to the low number of adverse events regarding the application of contrast agents, CEUS can be administered to a very broad patient population, thus avoiding additional radiation exposure compared to CT angiography in cases with divergent findings during follow-up.
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http://dx.doi.org/10.3390/diagnostics11091593DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8472159PMC
September 2021

Cost-Effectiveness of MR-Mammography in Breast Cancer Screening of Women With Extremely Dense Breasts After Two Rounds of Screening.

Front Oncol 2021 9;11:724543. Epub 2021 Sep 9.

Department of Radiology and Nuclear Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim-University of Heidelberg, Mannheim, Germany.

Objectives: To evaluate the cost-effectiveness of MR-mammography (MRM) vs. x-ray based mammography (XM) in two-yearly screening women of intermediate risk for breast cancer in the light of recent literature.

Methods: Decision analysis and Markov modelling were used to compare cumulative costs (in US-$) and outcomes (in QALYs) of MRM vs. XM over the model runtime of 20 years. The perspective of the U.S. healthcare system was selected. Incremental cost-effectiveness ratios (ICER) were calculated and related to a willingness to pay-threshold of $ 100,000 per QALY in order to evaluate the cost-effectiveness. Deterministic and probabilistic sensitivity analyses were conducted to test the impact of variations of the input parameters. In particular, variations of the rate of false positive findings beyond the first screening round and their impact on cost-effectiveness were assessed.

Results: Breast cancer screening with MRM resulted in increased costs and superior effectiveness. Cumulative average costs of $ 6,081 per woman and cumulative effects of 15.12 QALYs were determined for MRM, whereas screening with XM resulted in costs of $ 5,810 and 15.10 QALYs, resulting in an ICER of $ 13,493 per QALY gained. When the specificity of MRM in the second and subsequent screening rounds was varied from 92% to 99%, the ICER resulted in a range from $ 38,849 to $ 5,062 per QALY.

Conclusions: Based on most recent data on the diagnostic performance beyond the first screening round, MRM may remain the economically preferable alternative in screening women of intermediate risk for breast cancer due to their dense breast tissue.
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http://dx.doi.org/10.3389/fonc.2021.724543DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8458937PMC
September 2021

Safety assessment and diagnostic evaluation of patients undergoing contrast-enhanced urosonography in the setting of vesicoureteral reflux confirmation.

Clin Hemorheol Microcirc 2021 ;79(1):65-72

Department of Radiology, Ludwig-Maximilians-University Munich, Munich, Germany.

Background: Vesicoureteral reflux (VUR) represents a common pediatric anomaly in children with an upper urinary tract infection (UTI) and is defined as a retrograde flow of urine from the bladder into the upper urinary tract. There are many diagnostic options available, including voiding cystourethrography (VCUG) and contrasted-enhanced urosonography (ceVUS). ceVUS combines a diagnostic tool with a high sensitivity and specificity which, according to previous study results, was even shown to be superior to VCUG. Nevertheless, despite the recommendation of the EFSUMB, the ceVUS has not found a widespread use in clinical diagnostics in Europe yet.

Materials And Methods: Between 2016 and 2020, 49 patients with a marked female dominance (n = 37) were included. The youngest patient had an age of 5 months, the oldest patient 60 years. The contrast agent used in ceVUS was SonoVue®, a second-generation blood-pool agent. All examinations were performed and interpreted by a single experienced radiologist (EFSUMB Level 3).

Results: The 49 patients included in the study showed no adverse effects. 51% of patients (n = 26) were referred with the initial diagnosis of suspected VUR, while 49% of patients (n = 23) came for follow-up examination or to rule out recurrence of VUR. The vast majority had at least one febrile urinary tract infection in their recent medical history (n = 45; 91,8%).

Conclusion: ceVUS is an examination method with a low risk profile which represents with its high sensitivity and specificity an excellent diagnostic tool in the evaluation of vesicoureteral reflux, especially in consideration of a generally very young patient cohort.
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http://dx.doi.org/10.3233/CH-219110DOI Listing
November 2021

Cost-effectiveness of short-protocol emergency brain MRI after negative non-contrast CT for minor stroke detection.

Eur Radiol 2021 Aug 28. Epub 2021 Aug 28.

Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.

Objectives: To investigate the cost-effectiveness of supplemental short-protocol brain MRI after negative non-contrast CT for the detection of minor strokes in emergency patients with mild and unspecific neurological symptoms.

Methods: The economic evaluation was centered around a prospective single-center diagnostic accuracy study validating the use of short-protocol brain MRI in the emergency setting. A decision-analytic Markov model distinguished the strategies "no additional imaging" and "additional short-protocol MRI" for evaluation. Minor stroke was assumed to be missed in the initial evaluation in 40% of patients without short-protocol MRI. Specialized post-stroke care with immediate secondary prophylaxis was assumed for patients with detected minor stroke. Utilities and quality-of-life measures were estimated as quality-adjusted life years (QALYs). Input parameters were obtained from the literature. The Markov model simulated a follow-up period of up to 30 years. Willingness to pay was set to $100,000 per QALY. Cost-effectiveness was calculated and deterministic and probabilistic sensitivity analysis was performed.

Results: Additional short-protocol MRI was the dominant strategy with overall costs of $26,304 (CT only: $27,109). Cumulative calculated effectiveness in the CT-only group was 14.25 QALYs (short-protocol MRI group: 14.31 QALYs). In the deterministic sensitivity analysis, additional short-protocol MRI remained the dominant strategy in all investigated ranges. Probabilistic sensitivity analysis results from the base case analysis were confirmed, and additional short-protocol MRI resulted in lower costs and higher effectiveness.

Conclusion: Additional short-protocol MRI in emergency patients with mild and unspecific neurological symptoms enables timely secondary prophylaxis through detection of minor strokes, resulting in lower costs and higher cumulative QALYs.

Key Points: • Short-protocol brain MRI after negative head CT in selected emergency patients with mild and unspecific neurological symptoms allows for timely detection of minor strokes. • This strategy supports clinical decision-making with regard to immediate initiation of secondary prophylactic treatment, potentially preventing subsequent major strokes with associated high costs and reduced QALY. • According to the Markov model, additional short-protocol MRI remained the dominant strategy over wide variations of input parameters, even when assuming disproportionally high costs of the supplemental MRI scan.
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http://dx.doi.org/10.1007/s00330-021-08222-zDOI Listing
August 2021

Cost-Effectiveness Analysis of Local Treatment in Oligometastatic Disease.

Front Oncol 2021 15;11:667993. Epub 2021 Jun 15.

Department of Radiology, University Hospital, LMU Munich, Munich, Germany.

Background: In certain malignancies, patients with oligometastatic disease benefit from radical ablative or surgical treatment. The SABR-COMET trial demonstrated a survival benefit for oligometastatic patients randomized to local stereotactic ablative radiation (SABR) compared to patients receiving standard care (SC) alone. Our aim was to determine the cost-effectiveness of SABR.

Materials And Methods: A decision model based on partitioned survival simulations estimated costs and quality-adjusted life years (QALY) associated with both strategies in a United States setting from a health care perspective. Analyses were performed over the trial duration of six years as well as a long-term horizon of 16 years. Model input parameters were based on the SABR-COMET trial data as well as best available and most recent data provided in the published literature. An annual discount of 3% for costs was implemented in the analysis. All costs were adjusted to 2019 US Dollars according to the United States Consumer Price Index. SABR costs were reported with an average of $11,700 per treatment. Deterministic and probabilistic sensitivity analyses were performed. Incremental costs, effectiveness, and cost-effectiveness ratios (ICER) were calculated. The willingness-to-pay (WTP) threshold was set to $100,000/QALY.

Results: Based on increased overall and progression-free survival, the SABR group showed 0.78 incremental QALYs over the trial duration and 1.34 incremental QALYs over the long-term analysis. Treatment with SABR led to a marginal increase in costs compared to SC alone (SABR: $304,656; SC: $303,523 for 6 years; ICER $1,446/QALY and SABR: $402,888; SC: $350,708 for long-term analysis; ICER $38,874/QALY). Therapy with SABR remained cost-effective until treatment costs of $88,969 over the trial duration (i.e. 7.6 times the average cost). Sensitivity analysis identified a strong model impact for ongoing annual costs of oligo- and polymetastatic disease states.

Conclusion: Our analysis suggests that local treatment with SABR adds QALYs for patients with certain oligometastatic cancers and represents an intermediate- and long-term cost-effective treatment strategy.
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http://dx.doi.org/10.3389/fonc.2021.667993DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8239286PMC
June 2021

Cost-effectiveness analysis in radiology: methods, results and implications.

Rofo 2021 Jun 17. Epub 2021 Jun 17.

Department of Radiology, University Hospital, LMU Munich, Germany.

Background:  Diagnostic radiological examinations as well as interventional radiological therapies are performed at a steadily increasing rate amidst increasingly limited resources in healthcare systems. Given their potential to contribute decisively to optimized therapy, in most cases associated short-term direct costs can be well justified from a clinical perspective. However, to realize their clinical benefits, they must also succeed in justifying them to payers and policymakers. Therefore, the aim of this work is to present suitable methods for economic analysis of radiological precedures and to elaborate their relevance for radiology.

Methodology:  Methods and metrics of cost-effectiveness analysis are presented and then exemplified using the example cases of MR mammography and interventional treatment of oligometastatic tumor disease of the liver.

Results:  Cost-effectiveness considerations, taking into account long-term gains in lifespan and quality of life, as well as potential savings through improved treatment planning, do often objectively and credibly justify short-term additional costs.

Conclusions:  Cost-effectiveness analyses performed with radiological and health economic expertise can support the establishment of new radiological technologies in diagnostics and therapy.

Key Points:   · When radiological procedures are employed, short-term costs are often offset by significant long-term benefits.. · Radiological examinations and therapies must be justified in the context of limited economic resources.. · Economic methodologies can be used to quantify the quality and cost-effectiveness of radiological methods.. · Such analyses as well as targeted training should be encouraged to provide greater transparency..

Citation Format: · Froelich MF, Kunz WG, Tollens F et al. Cost-effectiveness analysis in radiology: methods, results and implications. Fortschr Röntgenstr 2021; DOI: 10.1055/a-1502-7830.
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http://dx.doi.org/10.1055/a-1502-7830DOI Listing
June 2021

Plasma-based S100B testing for management of traumatic brain injury in emergency setting.

Pract Lab Med 2021 Aug 12;26:e00236. Epub 2021 May 12.

Department of Neuroradiology, University Medicine Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany.

Background: Serum biomarker S100B has been explored for its potential benefit to improve clinical decision-making in the management of patients suffering from traumatic brain injury (TBI), especially as a pre-head computed-tomography screening test for patients with mild TBI. Although being already included into some guidelines, its implementation into standard care is still lacking. This might be explained by a turnaround time (TAT) too long for serum S100B to be used in clinical decision-making in emergency settings.

Methods: S100B concentrations were determined in 136 matching pairs of serum and lithium heparin blood samples. The concordance of the test results was assessed by linear regression, Passing Pablok regression and Bland-Altman analysis. Bias and within- and between-run imprecision were determined by a 5 × 4 model using pooled patient samples. CT scans were performed as clinically indicated.

Results: Overall, S100B levels between both blood constituents correlated very well. The suitability of S100B testing from plasma was verified according to ISO15189 requirements. Using a cut-off of 0.105 ng/ml, a sensitivity and negative predictive value of 100% were obtained for identifying patients with pathologic CT scans. Importantly, plasma-based testing reduced the TAT to 26 min allowing for quicker clinical decision-making. The clinical utility of integrating S100B in TBI management is highlighted by two case reports.

Conclusions: Plasma-based S100B testing compares favorably with serum-based testing, substantially reducing processing times as the prerequisite for integrating S100B level into management of TBI patients. The proposed new clinical decision algorithm for TBI management needs to be validated in further prospective large-scale studies.
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http://dx.doi.org/10.1016/j.plabm.2021.e00236DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8141926PMC
August 2021

Cost-Effectiveness of Digital Breast Tomosynthesis vs. Abbreviated Breast MRI for Screening Women with Intermediate Risk of Breast Cancer-How Low-Cost Must MRI Be?

Cancers (Basel) 2021 Mar 12;13(6). Epub 2021 Mar 12.

Department of Radiology and Nuclear Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.

Background: Digital breast tomosynthesis (DBT) and abbreviated breast MRI (AB-MRI) offer superior diagnostic performance compared to conventional mammography in screening women with intermediate risk of breast cancer due to dense breast tissue. The aim of this model-based economic evaluation was to analyze whether AB-MRI is cost-effective in this cohort compared to DBT.

Methods: Decision analysis and Markov simulations were used to model the cumulative costs and quality-adjusted life-years (QALYs) over a time horizon of 30 years. Model input parameters were adopted from recent literature. Deterministic and probabilistic sensitivity analyses were applied to test the stability of the model.

Results: In the base-case scenario, the costs of an AB-MRI examination were defined to equal the costs of a full protocol acquisition. Two-yearly screening of women with dense breasts resulted in cumulative discounted costs of $8798 and $9505 for DBT and AB-MRI, and cumulative discounted effects of 19.23 and 19.27 QALYs, respectively, with an incremental cost-effectiveness ratio of $20,807 per QALY gained in the base-case scenario. By reducing the cost of an AB-MRI examination below a threshold of $241 in sensitivity analyses, AB-MRI would become cost-saving compared to DBT.

Conclusion: In comparison to DBT, AB-MRI can be considered cost-effective up to a price per examination of $593 in screening patients at intermediate risk of breast cancer.
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http://dx.doi.org/10.3390/cancers13061241DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8000655PMC
March 2021

Cost-Effectiveness Analysis of Local Ablation and Surgery for Liver Metastases of Oligometastatic Colorectal Cancer.

Cancers (Basel) 2021 Mar 25;13(7). Epub 2021 Mar 25.

Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany.

Background: Colorectal cancer is among the most prevalent cancer entities worldwide, with every second patient developing liver metastases during their illness. For local treatment of liver metastases, a surgical approach as well as ablative treatment options, such as microwave ablation (MWA) and radiofrequency ablation (RFA), are available. The aim of this study is to evaluate the cost-effectiveness of RFA, MWA and surgery in the treatment of liver metastases of oligometastatic colorectal cancer (omCRC) that are amenable for all investigated treatment modalities.

Methods: A decision analysis based on a Markov model assessed lifetime costs and quality-adjusted life years (QALY) related to the treatment strategies RFA, MWA and surgical resection. Input parameters were based on the best available and most recent evidence. Probabilistic sensitivity analyses (PSA) were performed with Monte Carlo simulations to evaluate model robustness. The percentage of cost-effective iterations was determined for different willingness-to-pay (WTP) thresholds.

Results: The base-case analysis showed that surgery led to higher long-term costs compared to RFA and MWA (USD 41,848 vs. USD 36,937 vs. USD 35,234), while providing better long-term outcomes than RFA, yet slightly lower than MWA (6.80 vs. 6.30 vs. 6.95 QALYs for surgery, RFA and MWA, respectively). In PSA, MWA was the most cost-effective strategy for all WTP thresholds below USD 80,000 per QALY.

Conclusions: In omCRC patients with liver metastases, MWA and surgery are estimated to provide comparable efficacy. MWA was identified as the most cost-effective strategy in intermediate resource settings and should be considered as an alternative to surgery in high resource settings.
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http://dx.doi.org/10.3390/cancers13071507DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8037107PMC
March 2021

Supplemental F-FDG-PET/CT for Detection of Malignant Transformation of IPMN-A Model-Based Cost-Effectiveness Analysis.

Cancers (Basel) 2021 Mar 18;13(6). Epub 2021 Mar 18.

Department of Radiology and Nuclear Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim, Germany.

Accurate detection of malignant transformation and risk-stratification of intraductal papillary mucinous neoplasms (IPMN) has remained a diagnostic challenge. Preliminary findings have indicated a promising role of positron emission tomography combined with computed tomography and F-fluorodeoxyglucose (F-FDG-PET/CT) in detecting malignant IPMN. Therefore, the aim of this model-based economic evaluation was to analyze whether supplemental FDG-PET/CT could be cost-effective in patients with IPMN. Decision analysis and Markov modeling were applied to simulate patients' health states across a time frame of 15 years. CT/MRI based imaging was compared to a strategy with supplemental F-FDG-PET/CT. Cumulative costs in US-$ and outcomes in quality-adjusted life years (QALY) were computed based on input parameters extracted from recent literature. The stability of the model was evaluated by deterministic sensitivity analyses. In the base-case scenario, the CT/MRI-strategy resulted in cumulative discounted costs of USD $106,424 and 8.37 QALYs, while the strategy with supplemental FDG-PET/CT resulted in costs of USD $104,842 and a cumulative effectiveness of 8.48 QALYs and hence was cost-saving. A minimum specificity of FDG-PET/CT of 71.5% was required for the model to yield superior net monetary benefits compared to CT/MRI. This model-based economic evaluation indicates that supplemental F-FDG-PET/CT could have a favorable economic value in the management of IPMN and could be cost-saving in the chosen setting. Prospective studies with standardized protocols for FDG-PET/CT could help to better determine the value of FDG-PET/CT.
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http://dx.doi.org/10.3390/cancers13061365DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8002963PMC
March 2021

F FDG PET/MRI with hepatocyte-specific contrast agent for M staging of rectal cancer: a primary economic evaluation.

Eur J Nucl Med Mol Imaging 2021 09 9;48(10):3268-3276. Epub 2021 Mar 9.

Department of Radiology and Nuclear Medicine, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.

Purpose: Rectal cancer is one of the most frequent causes of cancer-related morbidity and mortality in the world. Correct identification of the TNM state in primary staging of rectal cancer has critical implications on patient management. Initial evaluations revealed a high sensitivity and specificity for whole-body PET/MRI in the detection of metastases allowing for metastasis-directed therapy regimens. Nevertheless, its cost-effectiveness compared with that of standard-of-care imaging (SCI) using pelvic MRI + chest and abdominopelvic CT is yet to be investigated. Therefore, the aim of this study was to analyze the cost-effectiveness of whole-body F FDG PET/MRI as an alternative imaging method to standard diagnostic workup for initial staging of rectal cancer.

Methods: For estimation of quality-adjusted life years (QALYs) and lifetime costs of diagnostic modalities, a decision model including whole-body F FDG PET/MRI with a hepatocyte-specific contrast agent and pelvic MRI + chest and abdominopelvic CT was created based on Markov simulations. For obtaining model input parameters, review of recent literature was performed. Willingness to pay (WTP) was set to $100,000/QALY. Deterministic sensitivity analysis of diagnostic parameters and costs was applied, and probabilistic sensitivity was determined using Monte Carlo modeling.

Results: In the base-case scenario, the strategy whole-body F FDG PET/MRI resulted in total costs of $52,186 whereas total costs of SCI were at $51,672. Whole-body F FDG PET/MRI resulted in an expected effectiveness of 3.542 QALYs versus 3.535 QALYs for SCI. This resulted in an incremental cost-effectiveness ratio of $70,291 per QALY for PET/MRI. Thus, from an economic point of view, whole-body F FDG PET/MRI was identified as an adequate diagnostic alternative to SCI with high robustness of results to variation of input parameters.

Conclusion: Based on the results of the analysis, use of whole-body F FDG PET/MRI was identified as a feasible diagnostic strategy for initial staging of rectal cancer from a cost-effectiveness perspective.
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http://dx.doi.org/10.1007/s00259-021-05193-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8426298PMC
September 2021

Structured Reporting in the Characterization of Renal Cysts by Contrast-Enhanced Ultrasound (CEUS) Using the Bosniak Classification System-Improvement of Report Quality and Interdisciplinary Communication.

Diagnostics (Basel) 2021 Feb 15;11(2). Epub 2021 Feb 15.

Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany.

Background: This study aims to evaluate the potential benefits of structured reporting (SR) compared to conventional free-text reporting (FTR) in contrast-enhanced ultrasound (CEUS) of cystic renal lesions, based on the Bosniak classification.

Methods: Fifty patients with cystic renal lesions who underwent CEUS were included in this single-center study. FTR created in clinical routine were compared to SR retrospectively generated by using a structured reporting template. Two experienced urologists evaluated the reports regarding integrity, effort for information extraction, linguistic quality, and overall quality.

Results: The required information could easily be extracted by the reviewers in 100% of SR vs. 82% of FTR ( < 0.001). The reviewers trusted the information given by SR significantly more with a mean of 5.99 vs. 5.52 for FTR ( < 0.001). SR significantly improved the linguistic quality (6.0 for SR vs. 5.68 for FTR ( < 0.001)) and the overall report quality (5.98 for SR vs. 5.58 for FTR ( < 0.001)).

Conclusions: SR significantly increases the quality of radiologic reports in CEUS examinations of cystic renal lesions compared to conventional FTR and represents a promising approach to facilitate interdisciplinary communication in the future.
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http://dx.doi.org/10.3390/diagnostics11020313DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7919270PMC
February 2021

Structured Reporting Using CEUS LI-RADS for the Diagnosis of Hepatocellular Carcinoma (HCC)-Impact and Advantages on Report Integrity, Quality and Interdisciplinary Communication.

Cancers (Basel) 2021 Jan 31;13(3). Epub 2021 Jan 31.

Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany.

Background: Our retrospective single-center study aims to evaluate the impact of structured reporting (SR) using a CEUS LI-RADS template on report quality compared to conventional free-text reporting (FTR) in contrast-enhanced ultrasound (CEUS) for the diagnosis of hepatocellular carcinoma (HCC).

Methods: We included 50 patients who underwent CEUS for HCC staging. FTR created after these examinations were compared to SR retrospectively generated by using template-based online software with clickable decision trees. The reports were evaluated regarding report completeness, information extraction, linguistic quality and overall report quality by two readers specialized in internal medicine and visceral surgery.

Results: SR significantly increased report completeness with at least one key feature missing in 31% of FTR vs. 2% of SR ( < 0.001). Information extraction was considered easy in 98% of SR vs. 86% of FTR ( = 0.004). The trust of referring physicians in the report was significantly increased by SR with a mean of 5.68 for SR vs. 4.96 for FTR ( < 0.001). SR received significantly higher ratings regarding linguistic quality (5.79 for SR vs. 4.83 for FTR ( < 0.001)) and overall report quality (5.75 for SR vs. 5.01 for FTR ( < 0.001)).

Conclusions: Using SR instead of conventional FTR increases the overall quality of reports in CEUS examinations of HCC patients and may represent a valuable tool to facilitate clinical decision-making and improve interdisciplinary communication in the future.
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http://dx.doi.org/10.3390/cancers13030534DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7866827PMC
January 2021

Impact of specificity on cost-effectiveness of screening women at high risk of breast cancer with magnetic resonance imaging, mammography and ultrasound.

Eur J Radiol 2021 Apr 30;137:109576. Epub 2021 Jan 30.

Department of Radiology and Nuclear Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim-University of Heidelberg, Germany.

Purpose: Aim of this study was to analyze the comparative cost-effectiveness of MR-mammography vs conventional imaging in a screening setting for women with high risk of breast cancer, with particular focus on the impact of specificity of MRM.

Method: Decision analytic modelling and Markov Modelling were applied to evaluate cumulative costs of each screening modality and their subsequent treatments as well as cumulative outcomes in quality adjusted life years (QALYs). For the selected time horizon of 30 years, false positive and false negative results were included. Model input parameters for women with high risk of breast cancer were estimated based on published data from a US healthcare system perspective. Major influence factors were identified and evaluated in a deterministic sensitivity analysis. Based on current recommendations for economic evaluations, a probabilistic sensitivity analysis was conducted to test the model stability.

Results: In a base-case analysis, screening with XM vs. MRM and treatment resulted in overall costs of $36,201.57 vs. $39,050.97 and a cumulative effectiveness of 19.53 QALYs vs. 19.59 QALYs. This led to an incremental cost-effectiveness ratio (ICER) of $ 45,373.94 per QALY for MRM. US and XM + US resulted in ICER values higher than the willingness to pay (WTP). In the sensitivity analyses, MRM remained a cost-effective strategy for screening high-risk patients as long as the specificity of MRM did not drop below 86.7 %.

Conclusion: In high-risk breast cancer patients, MRM can be regarded as a cost-effective alternative to XM in a yearly screening setting. Specificity may be an important cost driver in settings with yearly screening intervals.
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http://dx.doi.org/10.1016/j.ejrad.2021.109576DOI Listing
April 2021

Evaluation of the Diagnostic Value of Contrast-Enhanced Voiding Urosonography with Regard to the Further Therapy Regime and Patient Outcome-A Single-Center Experience in an Interdisciplinary Uroradiological Setting.

Medicina (Kaunas) 2021 Jan 9;57(1). Epub 2021 Jan 9.

Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany.

: Vesicoureteral reflux (VUR) describes a common pediatric anomaly in pediatric urology with a prevalence of 1-2%. In diagnostics, in addition to the gold standard of voiding cystourethrography (VCUG), contrast-enhanced urosonography (ceVUS) offers a radiation-free procedure, which, despite its advantages, is not yet widely used. In the present single-center study, subsequent therapeutic procedures and outcomes after ceVUS of 49 patients were investigated. The aim of the study is to investigate the efficacy of ceVUS with the intention of broader clinical implementation. : Between 2016 and 2020, 49 patients were retrospectively included and received a ceVUS to evaluate VUR. With a distribution of 47:2 (95.9%), a clear female predominance was present. The age of the patients varied between 5 months and 60 years at the time of ceVUS. All examinations were all performed and subsequently interpreted by a single experienced radiologist (EFSUMB level 3). : Compared to intraoperative findings, ceVUS shows a sensitivity of 95.7% with a specificity of 100%. Allergic reactions to the contrast medium could not be observed. : With its high sensitivity and intraoperative validation, ceVUS offers an excellent alternative to VCUG, the gold standard in the diagnosis of VUR. In addition, ceVUS is a radiation-free examination method with a low risk profile that offers an exceptional diagnostic tool in the diagnostic clarification of recurrent urinary tract infections with the suspected diagnosis of VUR and should also be included in the consideration of a diagnosis next to the established VCUG, especially in younger children.
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http://dx.doi.org/10.3390/medicina57010056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7826578PMC
January 2021

Contrast-Enhanced Ultrasound for Assessing Abdominal Conditions in Pregnancy.

Medicina (Kaunas) 2020 Dec 8;56(12). Epub 2020 Dec 8.

Department of Radiology, University Hospital LMU, Marchioninistrasse 15, 81377 Munich, Germany.

: Native ultrasound is the most common imaging modality in obstetrics. The use of contrast-enhanced ultrasound (CEUS) during pregnancy has not been officially approved by leading societies for obstetrics and ultrasound. The present study aims to monitor the safety and diagnostic performance of CEUS for assessing abdominal issues in five pregnant women. : Five pregnant patients who underwent a total of 11 CEUS examinations between June 2020 and October 2020 were included (mean age: 34 years; mean time of pregnancy: 21 weeks). All CEUS scans were interpreted by one experienced consultant radiologist (EFSUMB Level 3). : Upon contrast application, no maternal nor fetal adverse effects were observed. Moreover, no fetal contrast enhancement was observed in any patient. CEUS helped to diagnose renal angiomyolipoma, pyelonephritis, necrotic uterine fibroid, gallbladder polyp, and superior mesenteric vein thrombosis. : In our study, off-label use of CEUS showed an excellent safety profile allowing the avoidance of ionizing radiation exposure as well as contrast agents in case of CT or use of gadolinium-based contrast agents in case of MRI. CEUS is a promising diagnostic instrument for facilitating clinical decision-making and improving the management of pregnant women.
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http://dx.doi.org/10.3390/medicina56120675DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7762549PMC
December 2020

The role of structured reporting and structured operation planning in functional endoscopic sinus surgery.

PLoS One 2020 30;15(11):e0242804. Epub 2020 Nov 30.

Department of Radiology and Nuclear Medicine, University Medical Center Mannheim, Mannheim, Baden-Wuerttemberg, Germany.

Computed tomography (CT) scans represent the gold standard in the planning of functional endoscopic sinus surgeries (FESS). Yet, radiologists and otolaryngologists have different perspectives on these scans. In general, residents often struggle with aspects involved in both reporting and operation planning. The aim of this study was to compare the completeness of structured reports (SR) of preoperative CT images and structured operation planning (SOP) to conventional reports (CR) and conventional operation planning (COP) to potentially improve future treatment decisions on an individual level. In total, 30 preoperative CT scans obtained for surgical planning of patients scheduled for FESS were evaluated using SR and CR by radiology residents. Subsequently, otolaryngology residents performed a COP using free texts and a SOP using a specific template. All radiology reports and operation plannings were evaluated by two experienced FESS surgeons regarding their completeness for surgical planning. User satisfaction of otolaryngology residents was assessed by using visual analogue scales. Overall radiology report completeness was significantly higher using SRs regarding surgically important structures compared to CRs (84.4 vs. 22.0%, p<0.001). SOPs produced significantly higher completeness ratings (97% vs. 39.4%, p<0.001) regarding pathologies and anatomical variances. Moreover, time efficiency was not significantly impaired by implementation of SR (148 s vs. 160 s, p = 0.61) and user satisfaction was significantly higher for SOP (VAS 8.1 vs. 4.1, p<0.001). Implementation of SR and SOP results in a significantly increased completeness of radiology reports and operation planning for FESS. Consequently, the combination of both facilitates surgical planning and may decrease potential risks during FESS.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0242804PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7703956PMC
January 2021

Diagnostic Performance of Contrast-Enhanced Ultrasound (CEUS) in the Evaluation of Solid Renal Masses.

Medicina (Kaunas) 2020 Nov 19;56(11). Epub 2020 Nov 19.

Department of Radiology, Ludwig-Maximilians-University Munich, 81377 Munich, Germany.

Background: The present study aims to evaluate the diagnostic performance of contrast-enhanced ultrasound (CEUS) for discriminating between benign and malignant solid renal masses.

Methods: 18 patients with histopathologically confirmed benign solid renal masses (11 oncocytomas, seven angiomyolipomas) as well as 96 patients with confirmed renal cell carcinoma (RCC) who underwent CEUS followed by radical or partial nephrectomy were included in this single-center study. CEUS examinations were performed by an experienced radiologist (EFSUMB Level 3) and included the application of a second-generation contrast agent.

Results: Renal angiomyolipomas, oncocytomas, and renal cell carcinomas showed varying sonomorphological characteristics in CEUS. Angiomyolipomas showed heterogeneous echogenicity (57% hypo-, 43% hyperechoic), while all lesions showed rapid contrast-enhancement with two lesions also showing venous wash-out (29%). Notably, 9/11 oncocytomas could be detected in conventional ultrasound (64% hypo-, 9% hyper-, 9% isoechoic) and 2/11 only demarcated upon intravenous application of contrast agent (18%). All oncocytomas showed hyperenhancement in CEUS, venous wash-out was registered in 7/11 lesions (64%).

Conclusions: In line with the current state of knowledge, no specific sonomorphological characteristics allowing for accurate distinction between benign and malignant solid renal masses in CEUS could be detected in our study.
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http://dx.doi.org/10.3390/medicina56110624DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7699268PMC
November 2020

Cost-effectiveness of MR-mammography vs. conventional mammography in screening patients at intermediate risk of breast cancer - A model-based economic evaluation.

Eur J Radiol 2021 Mar 16;136:109355. Epub 2020 Oct 16.

Department of Radiology and Nuclear Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim-University of Heidelberg, Germany.

Purpose: The aim of this study was to analyze the cost-effectiveness of screening patients of intermediate risk of breast cancer with MR-Mammography (MRM) versus conventional mammography (XM).

Method: A decision model for both diagnostic modalities and a subsequent markov model for the simulation of follow-up costs and outcomes was developed. Input parameters were acquired from published literature for this markov modelling study. The expected cumulative costs and outcomes were calculated for both modalities in a 30-year timeframe in US-dollar ($) and quality-adjusted life years (QALYs). A deterministic sensitivity analysis and a probabilistic sensitivity analysis incorporating 30,000 Monte Carlo iterations were performed to investigate the model stability.

Results: In total, XM with its consecutive treatments resulted in total costs of $ 5,492.68 and an average cumulative quality of life of 18.87 QALYs, compared to MRM with costs of $ 5,878.66 and 18.92 QALYs. The corresponding incremental cost-effectiveness ratio (ICER) for MRM was $ 8,797.60 per QALY - distinctly below international willingness-to-pay thresholds for cost-effectiveness. The results were confirmed within the limits of the sensitivity analyses.

Conclusions: In patients with intermediate risk for breast cancer due to their dense breast tissue, two-yearly screening with MRM may be considered as cost-effective.
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http://dx.doi.org/10.1016/j.ejrad.2020.109355DOI Listing
March 2021

Impact of Size and Location of Metastases on Early Tumor Shrinkage and Depth of Response in Patients With Metastatic Colorectal Cancer: Subgroup Findings of the Randomized, Open-Label Phase 3 Trial FIRE-3/AIO KRK-0306.

Clin Colorectal Cancer 2020 12 22;19(4):291-300.e5. Epub 2020 Jun 22.

Department of Medicine III, University Hospital, LMU Munich, Germany; Comprehensive Cancer Center Munich, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich and German Cancer Research Centre (DKFZ), Heidelberg, Germany. Electronic address:

Background: The Response Evaluation Criteria in Solid Tumors (RECIST) are used to define degrees of response to chemotherapy. For accelerated response evaluation, early tumor shrinkage (ETS) of ≥ 20% has been suggested as a predictor for outcome in metastatic colorectal cancer (mCRC). Together with depth of response (DpR), new alternative metrics have been provided, yielding promising outcome parameters. In this analysis, we aimed to further characterize ETS and DpR.

Patients And Methods: This analysis was based on FIRE-3, a randomized phase 3 trial comparing first-line FOLFIRI plus either cetuximab or bevacizumab in KRAS exon 2 wild-type mCRC. ETS and DpR were determined on the basis of RECIST 1.1 in a blinded radiologic review. ETS was evaluated as a categorized (≥ 20% shrinkage) and continuous parameter. The impact of baseline location and size of metastases on ETS and DpR were evaluated by univariate and multivariate analyses.

Results: Of 592 patients, 395 (66.7%) had data available for radiologic review. Median continuous ETS for lung, liver, and suspected lymph node metastases was 20%, 23%, and 30%, respectively. The median DpR was -32%, -44%, and -50%, respectively (all P < .01). In multivariate analysis, lung metastases were significantly associated with inferior DpR (P = .021), whereas hepatic metastases led to higher DpR (P = .024). Large metastases were associated with favorable ETS, whereas small metastases were correlated with higher DpR (P < .001).

Conclusion: ETS and DpR depend on the location and size of metastases in mCRC. These associations may establish the basis for further research to optimize the predictive accuracy of both parameters. This may help basing treatment decisions on ETS and DpR.
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http://dx.doi.org/10.1016/j.clcc.2020.06.005DOI Listing
December 2020

Evaluation of optimal education level to implement structured reporting into ultrasound training.

Med Ultrason 2020 Nov 12;22(4):445-450. Epub 2020 Jul 12.

Department of Otorhinolaryngology, Head and Neck Surgery, University of Tübingen Medical Center, Tübingen, Germany.

Aims: Reporting of head and neck ultrasound (HNU) has been outlined to be a major obstacle during ultrasound training due to a lack of standardized structure, content and terminology. Consequently, overall report quality differs significantly between various examiners posing a severe risk factor for information loss and miscommunication. Therefore, the present study's purpose is to compare the overall quality of free text reports (FTR) and structured reports (SR) of HNU at various stages of training in order to determine the optimal educational level to implement SR.

Material And Methods: Typical pathologies in HNU were reported upon using SR and FTR by medical students, junior residents and senior residents. The reports were assessed for overall quality, time efficiency and readability. Additionally, user satisfaction was determined using a questionnaire.

Results: SRs exhibited a significantly superior report quality (93.1% vs. 45.6%, p<0.001) at all training levels. Overall time efficiency was significantly better for SRs, especially at the stages of medical school and early residency (89.4 s vs. 160.2 s., p<0.001). Using structured reporting also increased user satisfaction significantly (VAS 8.6 vs. 3.9, p<0.001).

Conclusions: Implementing structured reporting of HNU results in a superior report quality at all training stages. Greatest benefits for time efficiency are achieved by implementation during medical school. Therefore, structured reporting of HNU should be implemented early on in the training of HNU.
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http://dx.doi.org/10.11152/mu-2530DOI Listing
November 2020

Follow-Up 18F-FDG PET/CT versus Contrast-Enhanced CT after Ablation of Liver Metastases of Colorectal Carcinoma-A Cost-Effectiveness Analysis.

Cancers (Basel) 2020 Aug 27;12(9). Epub 2020 Aug 27.

Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany.

Purpose: After a percutaneous ablation of colorectal liver metastases (CRLM), follow-up investigations to evaluate potential tumor recurrence are necessary. The aim of this study was to analyze whether a combined 18F-Fluordesoxyglucose positron emission tomography-computed tomography (18F-FDG PET/CT) scan is cost-effective compared to a contrast-enhanced computed tomography (CE-CT) scan for detecting local tumor progression.

Materials And Methods: A decision model based on Markov simulations that estimated lifetime costs and quality-adjusted life years (QALYs) was developed. Model input parameters were obtained from the recent literature. Deterministic sensitivity analysis of diagnostic parameters based on a Monte-Carlo simulation with 30,000 iterations was performed. The willingness-to-pay (WTP) was set to $100,000/QALY.

Results: In the base-case scenario, CE-CT resulted in total costs of $28,625.08 and an efficacy of 0.755 QALYs, whereas 18F-FDG PET/CT resulted in total costs of $29,239.97 with an efficacy of 0.767. Therefore, the corresponding incremental cost-effectiveness ratio (ICER) of 18F-FDG PET/CT was $50,338.96 per QALY indicating cost-effectiveness based on the WTP threshold set above. The results were stable in deterministic and probabilistic sensitivity analyses.

Conclusion: Based on our model, 18F-FDG PET/CT can be considered as a cost-effective imaging alternative for follow-up investigations after percutaneous ablation of colorectal liver metastases.
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http://dx.doi.org/10.3390/cancers12092432DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7565889PMC
August 2020

Cost-effectiveness of MR-mammography as a solitary imaging technique in women with dense breasts: an economic evaluation of the prospective TK-Study.

Eur Radiol 2021 Feb 28;31(2):967-974. Epub 2020 Aug 28.

Institute of Clinical Radiology and Nuclear Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim - University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.

Objectives: To evaluate the economic implications of our previous study on the use of MR-mammography (MRM) as a solitary imaging tool in women at intermediate risk due to dense breasts.

Background: In our previous study, we found MRM to be a specific diagnostic tool with high accuracy in patients with dense breasts representing a patient collective at intermediate risk of breast cancer. For this study, we examined whether MRM is an economical alternative.

Methods: For the determination of outcomes and costs, a decision model based on potential diagnostic results of MRM was developed. Quality of life was estimated in a Markov chain model distinguishing between the absence of malignancy, the presence of malignancy, and death. Input parameters were utilized from the prospective TK-Study. To investigate the economic impact of MRM, overall costs in € and outcomes of MRM in quality-adjusted life years (QALYs) were estimated. A deterministic sensitivity analysis was performed.

Results: MRM was associated with expected costs of 1650.48 € in the 5-year period and an expected cumulative outcome of 4.69 QALYs. A true positive diagnosis resulted in significantly lower costs and a higher quality of life when compared to the consequences of a false negative result. In the deterministic sensitivity analysis, treatment costs had more impact on overall costs than the costs of MRM. The total costs per patient remained below 2500 € in the 5-year period.

Conclusion: MRM, as a solitary imaging tool in patients at intermediate risk due to dense breasts, is economically feasible.

Key Points: • In patients with dense breasts (i.e., patients at intermediate risk of breast cancer), the relative cost of MR-mammography examinations only had moderate impact on overall costs. • This is due to cost-savings through the application of a sensitive imaging technique resulting in an optimized staging and therapy planning. • MR-mammography, unaccompanied by mammography or ultrasound in patients with dense breasts, was economically feasible in our analysis.
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http://dx.doi.org/10.1007/s00330-020-07129-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7813739PMC
February 2021

The relevance of CT-based geometric and radiomics analysis of whole liver tumor burden to predict survival of patients with metastatic colorectal cancer.

Eur Radiol 2021 Feb 27;31(2):834-846. Epub 2020 Aug 27.

Department of Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.

Objectives: To investigate the prediction of 1-year survival (1-YS) in patients with metastatic colorectal cancer with use of a systematic comparative analysis of quantitative imaging biomarkers (QIBs) based on the geometric and radiomics analysis of whole liver tumor burden (WLTB) in comparison to predictions based on the tumor burden score (TBS), WLTB volume alone, and a clinical model.

Methods: A total of 103 patients (mean age: 61.0 ± 11.2 years) with colorectal liver metastases were analyzed in this retrospective study. Automatic segmentations of WLTB from baseline contrast-enhanced CT images were used. Established biomarkers as well as a standard radiomics model building were used to derive 3 prognostic models. The benefits of a geometric metastatic spread (GMS) model, the Aerts radiomics prior model of the WLTB, and the performance of TBS and WLTB volume alone were assessed. All models were analyzed in both statistical and predictive machine learning settings in terms of AUC.

Results: TBS showed the best discriminative performance in a statistical setting to discriminate 1-YS (AUC = 0.70, CI: [0.56, 0.90]). For the machine learning-based prediction for unseen patients, both a model of the GMS of WLTB (0.73, CI: [0.60, 0.84]) and the Aerts radiomics prior model (0.76, CI: [0.65, 0.86]) applied on the WLTB showed a numerically higher predictive performance than TBS (0.68, CI: [0.54, 0.79]), radiomics (0.65, CI: [0.55, 0.78]), WLTB volume alone (0.53, CI: [0.40. 0.66]), or the clinical model (0.56, CI: [0.43, 0.67]).

Conclusions: The imaging-based GMS model may be a first step towards a more fine-grained machine learning extension of the TBS concept for risk stratification in mCRC patients without the vulnerability to technical variance of radiomics.

Key Points: • CT-based geometric distribution and radiomics analysis of whole liver tumor burden in metastatic colorectal cancer patients yield prognostic information. • Differences in survival are possibly attributable to the spatial distribution of metastatic lesions and the geometric metastatic spread analysis of all liver metastases may serve as robust imaging biomarker invariant to technical variation. • Imaging-based prediction models outperform clinical models for 1-year survival prediction in metastatic colorectal cancer patients with liver metastases.
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http://dx.doi.org/10.1007/s00330-020-07192-yDOI Listing
February 2021
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