Patient centered radiology: investigating 3 Tesla whole body MRI acceptance in cancer patients.

INTRODUCTION: Whole body magnetic resonance imaging (WB-MRI) is a promising emerging imaging technology for detecting bone and soft tissue pathology, especially in the onco-hematological field. This study aims to evaluate cancer patients' experience of WB-MRI performed on a 3T scanner compared to other diagnostic total body examinations. MATERIAL AND METHOD: In this prospective committee-approved study, patients completed a questionnaire in person (n = 134) after undergoing a WB-MRI scan to collect data on their physical and psychological reactions during the scan, the global satisfaction level, and preference for other types of MRI or computed tomography (CT), or positron emission tomography (PET/CT). Of all patients who had performed a CT or PET/CT the previous year, 61.9% had already undergone an MRI. The most common symptoms reported were: 38.1% perceived a localized increase in temperature and 34.4% numbness and tingling of the limbs. The scan time averaged 45 min and was well tolerated by most patients (112, 85.5%). Overall, WB-MRI was appreciated by the majority (121/134-90.3%) of patients who said they would probably undergo the procedure again. Patients preferred the WB-MRI in 68.7% of cases (92/134), followed by CT in 15.7% of cases (21/134) and by PET/CT in 7.4% (10/134), with 8.4% (11/134) of patients without any preference. The preference for imaging modalities was age-dependent (p = 0.011), while (p > 0.05) was independent of sex and a primary cancer site. CONCLUSION: These results demonstrate a high degree of WB-MRI acceptance from a patient's point of view.

Diagnostic and Prognostic Potential of 18F-FET PET in the Differential Diagnosis of Glioma Recurrence and Treatment-Induced Changes After Chemoradiation Therapy.

BACKGROUND: MRI-based differential diagnosis of glioma recurrence (GR) and treatment-induced changes (TICs) remain elusive in up to 30% of treated glioma patients. We aimed to determine 18F-FET PET diagnostic performance in this clinical scenario, its outcome dependency on established prognostic factors, optimal 18F-FET semi-quantitative thresholds, and whether 18F-FET parameters may instantly predict progression-free survival (PFS) and overall survival (OS). METHODS: We retrospectively analyzed 45 glioma patients treated with chemoradiation therapy (32 males; mean age: 51 years, glioma grade: n=26 WHO4; n=15 WHO3; n=4 WHO2) who underwent 18F-FET PET to resolve differential diagnosis of GR and TICs raised by MRI performed in the preceding 2 weeks and depicting any of the following changes in their radiation field: volumetric increase of contrast-enhancing lesions; new contrast-enhancing lesion; significant increase in T2/FLAIR non-enhancing lesion without reducing corticosteroids. 18F-FET PET outcome relied on evaluation of maximum tumor-to-brain ratio (TBRmax), time-to-peak (TTP), and time-activity curve pattern (TAC). Metabolic tumor volume (MTV) and total tumor metabolism (TTM) were calculated for prognostic purposes. Standard of reference was repeat MRI performed 4-6 weeks after the previous MRI. Non-parametric statistics tested 18F-FET-based parameters for dependency on established prognostic markers. ROC curve analysis determined optimal cutoff values for 18F-FET semi-quantitative parameters. 18F-FET parameters and prognostic factors were evaluated for PFS and OS by Kaplan-Meier, univariate, and multivariate analyses. RESULTS: 18F-FET PET sensitivity, specificity, positive predictive value, negative predictive value were 86.2, 81.3, 89.3, 76.5%, respectively; higher diagnostic accuracy was yielded in IDH-wild-type glioma patients compared to IDH-mutant glioma patients (sensitivity: 81.8 versus 88.9%; specificity: 80.8 versus 81.8%). KPS was the only prognostic factor differing according to 18F-FET PET outcome (negative versus positive). Optimal 18F-FET cutoff values for GR were TBRmax ≥ 2.1, SUVmax ≥ 3.5, and TTP ≤ 29 min. PFS differed based on 18F-FET outcome and related metrics and according to KPS; a different OS was observed according to KPS only. On multivariate analysis, 18F-FET PET outcome was the only significant PFS factor; KPS and age the only significant OS factors. CONCLUSION: 18F-FET PET demonstrated good diagnostic performance. 18F-FET PET outcome and metrics were significantly predictive only for PFS.

177Lu-PRRT in advanced gastrointestinal neuroendocrine tumors: 10-year follow-up of the IRST phase II prospective study.

PURPOSE: In March 2014, we reported the activity and safety of 177Lu-DOTA-octreotate peptide receptor radionuclide therapy (Lu-PRRT) at two different dosages (18.5 GBq and 27.5 GBq in 5 cycles) in patients with progressive metastatic gastrointestinal neuroendocrine tumors (GI-NETs). Disease control rate (DCR) and toxicity were addressed. Herein, we report the late toxicity, progression-free survival (PFS), and overall survival (OS) in the same cohort after a 10-year follow-up. METHODS: We conducted an open-label, disease-oriented prospective phase II trial. From March 2008 to June 2011, 43 patients received 3.7 GBq or 5.5 GBq of Lu-PRRT every 6 to 8 weeks, each cycle repeated 5 times. All patients showed 68Gallium-DOTA-peptide PET/Octreoscan® positivity (score 3-4 Rotterdam scale) in known lesions. Tumor burden was estimated radiologically. Time-to-event data (PFS and OS) were described using Kaplan-Meier curves and compared with the log-rank test. RESULTS: Forty-three patients (28 males and 15 females) were evaluable and were monitored for a median period of 118 months (range 12.6-139.6). Median PFS in patients receiving 18.5 GBq was 59.8 months (95% confidence interval [95% CI] 14.3-79.6), identical to that of patients treated with 27.5 GBq (59.8 months, 95% CI 23.4-82.0). Median OS was 71.0 months (95% CI 46.1-107.3) in the group who received 18.5 GBq and 97.6 months (95% CI 64.3-not reached) in the group treated with 27.5 GBq (P = 0.22). Patients with progression limited to lymph nodes showed significantly longer median PFS and OS than those with hepatic lesions (P = 0.02 for PFS and P = 0.04 for OS). Age over 65 years at the time of PRRT was also significant for OS. Of note, no late hematological or renal toxicity was observed in either group. CONCLUSIONS: The long-term follow-up of the IRST phase II study shows that Lu-PRRT is a safe and effective therapy for patients with advanced GI-NET, the most important prognostic factor being tumor burden, hepatic lesions, and age. We believe that Lu-PRRT should be offered to patients with early-stage disease.

Posterior reversible encephalopathy syndrome: A rare neurotoxicity after capecitabine.

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is a condition characterized by seizures, headache, visual disturbances, paresis, nausea and altered mental status. Risk factors include hypertension, eclampsia/pre-eclampsia, infection/sepsis, transplantation (allograft, bone marrow and solid organ) and immunosuppression, especially in association with autoimmune disorders and use of cyclosporine or chemotherapy. CASE REPORT: A few days after starting the first cycle of treatment with capecitabine, a 50-year-old female with metastatic breast cancer experienced serious adverse events consisting of severe hematological, gastrointestinal and neurological toxicity. A brain magnetic resonance imaging, performed because of the severe state of confusion of the patient, confirmed PRES. MANAGEMENT AND OUTCOME: The patient was admitted to the hospital; capecitabine was stopped and treatment was started with antibiotics, growth factor therapy and blood and platelet transfusions. Her clinical conditions slowly improved and the PRES resolved. A dihydropyrimidine dehydrogenase deficiency was identified. DISCUSSION: The patient had previously been treated with another fluoropyrimidine, 5-fluorouracil, but without toxicity. A literature search was performed, and only six cases of PRES associated with capecitabine were found. Our case suggests that capecitabine differs from 5-fluorouracil in its mechanism of action and that at least one of the metabolites of capecitabine has the ability to cross the blood-brain barrier, causing neurotoxicity. We believe that it is useful to test for dihydropyrimidine dehydrogenase deficiency before using fluoropyrimidines and would encourage the reporting of such cases of PRES to gain a better overall picture of its incidence in this setting. NARANJO SCORE: 7.

The emerging role of trans-oral robotic surgery for the detection of the primary tumour site in patients with head-neck unknown primary cancers: A meta-analysis.

The identification of the site in head neck unknown primary (HNUP) tumour is of utmost importance to help select best treatment while decreasing treatment-related morbidity and mortality. The primary purpose of this study is to demonstrate that TORS may be a valuable tool in detecting primary tumour. Studies were systematically searched in the PubMed, EMBASE, the Cochrane Library and CENTRAL electronic databases. A total of 12 selected studies (349 patients) were analyzed. The primary tumour detection and positive surgical margins rates were 70.8% and 19.4%, respectively. The rate of HPV-related tumour was 71.3%. The primary tumour was mainly in base of tongue (64%). In conclusion, TORS seems to be an effective surgical approach both in terms of detection of primary tumour site and in terms of therapeutic perspective for HNUP. In particular, a subset of HPV-related tumours might benefits all advantages from this surgical modality.

Aeromonas veronii biovar veronii and sepsis-infrequent complication of biliary drainage placement: A case report.

BACKGROUND: Aeromonas species are uncommon pathogens in biliary sepsis and cause substantial mortality in patients with impaired hepatobiliary function. Asia has the highest incidence of infection from Aeromonas, whereas cases in the west are rare. CASE SUMMARY: We report the case of a 64-year-old woman with advanced pancreatic cancer and jaundice who manifested fever, abdominal pain, severe thrombocytopenia, anemia and kidney failure following the insertion of a percutaneous transhepatic biliary drainage. Blood culture results revealed the presence of Aeromonas veronii biovar veronii (A. veronii biovar veronii). After antibiotic therapy and transfusions, the life-threatening clinical conditions of the patient improved and she was discharged. CONCLUSION: This was a rare case of infection, probably the first to be reported in West countries, caused by A. veronii biovar veronii following biliary drainage. A finding of Aeromonas must alert clinician to the possibility of severe sepsis.

Deep convolutional neural network-based segmentation and classification of difficult to define metastatic spinal lesions in 3D CT data.

This paper aims to address the segmentation and classification of lytic and sclerotic metastatic lesions that are difficult to define by using spinal 3D Computed Tomography (CT) images obtained from highly pathologically affected cases. As the lesions are ill-defined and consequently it is difficult to find relevant image features that would enable detection and classification of lesions by classical methods of texture and shape analysis, the problem is solved by automatic feature extraction provided by a deep Convolutional Neural Network (CNN). Our main contributions are: (i) individual CNN architecture, and pre-processing steps that are dependent on a patient data and a scan protocol - it enables work with different types of CT scans; (ii) medial axis transform (MAT) post-processing for shape simplification of segmented lesion candidates with Random Forest (RF) based meta-analysis; and (iii) usability of the proposed method on whole-spine CTs (cervical, thoracic, lumbar), which is not treated in other published methods (they work with thoracolumbar segments of spine only). Our proposed method has been tested on our own dataset annotated by two mutually independent radiologists and has been compared to other published methods. This work is part of the ongoing complex project dealing with spine analysis and spine lesion longitudinal studies.

Dynamic contrast-enhanced ultrasonography (D-CEUS) for the early prediction of bevacizumab efficacy in patients with metastatic colorectal cancer.

OBJECTIVES: To investigate early changes in tumour perfusion parameters by dynamic contrast-enhanced ultrasonography (D-CEUS) and to identify any correlation with survival and tumour response in patients with metastatic colorectal cancer (CRC) treated with bevacizumab (B). METHODS: Thirty-seven patients randomized to either chemotherapy (C) plus B or C alone were considered for this study. D-CEUS was performed at baseline and after the first treatment cycle (day 15). Four D-CEUS perfusion parameters were considered: derived peak intensity (DPI), area under the curve (AUC), slope of wash-in (A) and time to peak intensity (TPI). RESULTS: In patients treated with C plus B, a ≥22.5 % reduction in DPI, ≥20 % increase in TPI and ≥10 % reduction in AUC were correlated with higher progression-free survival in the C+B arm (p = 0.048, 0.024 and 0.010, respectively) but not in the C arm. None of the evaluated parameter modifications had a correlation with tumour response or overall survival. CONCLUSIONS: D-CEUS could be useful for detecting and quantifying dynamic changes in tumour vascularity as early as 15 days after the start of B-based therapy. Although these changes may be predictive of progression-free survival, no correlation with response or overall survival was found. KEY POINTS: • D-CEUS showed early changes in liver metastasis perfusion in colorectal cancer. • A decrease in tumour perfusion was associated with longer progression-free survival. • The decrease in perfusion was not correlated with higher overall survival.

Metronomic capecitabine in gastroenteropancreatic neuroendrocrine tumors: a suitable regimen and review of the literature.

BACKGROUND: We present a retrospective analysis of metronomic capecitabine in metastatic gastroenteropancreatic neuroendrocrine tumors (GEP-NETs). A review of the literature is also presented. METHODS: From January 2007 to December 2013, ten patients with metastatic GEP-NETs (four pancreatic and six ileal) who progressed after treatment with somatostatin analogs and other cytotoxic agents received oral capecitabine 1,500 mg/day continuously. The median patient age was 68 (range 29-82) years. The median treatment duration was 8 months. RESULTS: Five (50%) patients achieved a partial radiographic response, four (40%) showed stable disease, and one (10%) progressed. Median overall survival was 56 months. Three of the four pancreatic patients achieved a partial radiographic response that lasted for a median of 15.5 months; overall survival and progression-free survival in this subgroup was 58 and 6 months, respectively. CONCLUSION: Data in the literature show that capecitabine has only occasionally been used as a single agent, with increased toxicity. Only one study using single-agent capecitabine reported a progression-free survival of 9.9 months and overall survival of 36.5 months, without an objective response or major toxicity. In our experience, metronomic capecitabine was well tolerated, although minor side effects may have been underestimated due to the retrospective nature of our study. This regimen also seems to be feasible in elderly people. Although high response rates and prolonged response duration indicate the potential efficacy of this treatment, our results should be interpreted cautiously because of the small number of patients involved. Capecitabine was most effective in the pancreatic subgroup, which would seem to be more sensitive to chemotherapy.

Single bone metastasis from adenocarcinoma of the lacrimal gland: a case report.

Malignant tumors of the lacrimal gland are rare, and single bone metastases from lacrimal gland carcinoma are an exceptional event. We present the case of a 71-year-old man with a history of lumbar pain and left exophthalmos. Surgical resection of the lacrimal lesion and a bone biopsy gave a final histopathological diagnosis of primary ductal adenocarcinoma of the lacrimal gland with bone metastasis. The pathological tissue from both procedures was positive for androgen receptor expression. The patient underwent embolization and radiotherapy in association with total androgen blockade. After 20 months, the patient is still asymptomatic and has maintained the partial response at L1 with no progression to other sites. Our patient would appear to have a better prognosis and the disease a more indolent clinical course than the other cases of ductal adenocarcinoma of the lacrimal gland reported in the literature.

Acute hiatal hernia: a late complication following gastrectomy.

INTRODUCTION: We describe a case of acute hiatal hernia during chemotherapy, in a female patient previously treated with gastrectomy. CASE PRESENTATION: After gastric resection, the patient underwent chemotherapy, developing important emetic symptoms. A radiograph of the abdomen was performed because of acute epigastrial pain and it showed a marked left diaphragm elevation.A CT scan carried out 24 hours later identified an occlusion with herniation in the left hemi thorax. Subsequent surgical investigation resulted in a diagnosis of hiatal hernia with volvulus. CONCLUSIONS: This case represents a rare, late complication occurring after gastrectomy.

Three-dimensional computed tomography of the orthotopic ileal neobladder reconstruction: normal and abnormal findings.

INTRODUCTION: Our study aimed to assess the usefulness of 3D-CT in patients who have undergone radical cystectomy and orthotopic ileal neobladder. MATERIALS AND METHODS: We performed a CT study with 3D reconstructions in 32 patients 6 months after radical cystectomy and different orthotopic ileal neobladder (8 Studer, group A; 10 Hautmann-Ghoneim, group B; 14 Hautmann with 'double chimney' modification, group C). We evaluated position, shape and volume of neobladder; length of ureters and of afferent limb (in group A), length and diameter of ureteral intramural tunnel (in group B) and length of 'chimney' (in group C); vesico-urethral angle; vesico-ureteral reflux; possible complications. RESULTS: In group A, we observed a renal stone with hydronephrosis, a lateral neobladder and a bilateral vesico-ureteral reflux. In 2 females of group B, neobladder was on the right side and associated in 1 case with a conical shape, hydroureteronephrosis, filling defects and urinary incontinence. In group C, 1 patient had a bilateral vesico-ureteral reflux and 1 had a left hydronephrosis. A pouchocele was detected in 1 patient with vesico-urethral angle less than 120 degrees. CONCLUSIONS: 3D-CT is helpful for better displaying the morphology of a new reno-vesical anatomy, and some features seem to be indicative of a predisposition to develop possible complications. It may be useful for surgeons to plan a reintervention to obviate or prevent complications.