MRI prediction of pathological response in locally advanced rectal cancer: when apparent diffusion coefficient radiomics meets conventional volumetry.

AIM: To investigate the role of diffusion-weighted imaging (DWI), T2-weighted (W) imaging, and apparent diffusion coefficient (ADC) histogram analysis before, during, and after neoadjuvant chemoradiotherapy (CRT) in the prediction of pathological response in patients with locally advanced rectal cancer (LARC). MATERIALS AND METHODS: Magnetic resonance imaging (MRI) at 1.5 T was performed in 43 patients with LARC before, during, and after CRT. Tumour volume was measured on both T2-weighted (VT2W) and on DWI at b=1,000 images (Vb,1,000) at each time point, hence the tumour volume reduction rate (ΔVT2W and ΔVb,1,000) was calculated. Whole-lesion (three-dimensional [3D]) first-order texture analysis of the ADC map was performed. Imaging parameters were compared to the pathological tumour regression grade (TRG). The diagnostic performance of each parameter in the identification of complete responders (CR; TRG4), partial responders (PR; TRG3) and non-responders (NR; TRG0-2) was evaluated by multinomial regression analysis and receiver operating characteristics curves. RESULTS: After surgery, 11 patients were CR, 22 PR, and 10 NR. Before CRT, predictions of CR resulted in an ADC value of the 75th percentile and median, with good accuracy (74% and 86%, respectively) and sensitivity (73% and 82%, respectively). During CRT, the best predictor of CR was ΔVT2W (-58.3%) with good accuracy (81%) and excellent sensitivity (91%). After CRT, the best predictors of CR were ΔVT2W (-82.8%) and ΔVb, 1,000 (-86.8%), with 84% accuracy in both cases and 82% and 91% sensitivity, respectively. CONCLUSIONS: The median ADC value at pre-treatment MRI and ΔVT2W (from pre-to-during CRT MRI) may have a role in early and accurate prediction of response to treatment. Both ΔVT2W and ΔVb,1,000 (from pre-to-post CRT) can help in the identification of CR after CRT.

Could perfusion heterogeneity at dynamic contrast-enhanced MRI be used to predict rectal cancer sensitivity to chemoradiotherapy?

AIM: To evaluate whether perfusion heterogeneity of rectal cancer prior to chemoradiotherapy (CRT) using histogram analysis of dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) quantitative parameters can predict response to treatment. MATERIALS AND METHODS: Twenty-one patients with histologically proven rectal adenocarcinoma were enrolled prospectively. All patients underwent 1.5 T DCE-MRI before CRT. Tumour volumes were drawn on Ktrans and Ve maps, using T2-weighted (W) images as reference, and the following first-order texture parameters of Ve and Ktrans values were extracted: 25th, 50th, 75th percentile, mean, standard deviation, skewness, and kurtosis. After CRT, patients underwent surgery and according with Rödel's tumour regression grade (TRG), they were classified as poor responders "non-GR" (TRG 0-2) and good responders "GR" (TRG 3-4). Differences between GR and non-GR in DCE-MRI first-order texture parameters were evaluated using the Mann-Whitney test, and their role in the prediction of response was investigated using receiver operating characteristic (ROC) curve analysis. RESULTS: Sixteen (76%) patients were classified as GR and five (24%) were non-GR. Skewness and kurtosis of Ve was significantly higher in non-GR (4.886±1.320 and 36.402±24.486, respectively) than in GR patients (1.809±1.280, p=0.003 and 6.268±8.130, p= 0.011). Ve skewness <3.635 was able to predict GR with an area under the ROC curve (AUC) of 0.988, sensitivity 93.8%, specificity 80%, and accuracy 90.5%. Ve kurtosis <21.095 was able to predict response with an AUC of 0.963, sensitivity 93.8%, specificity 80%, and accuracy 90.5%. Other parameters were not different between groups or predictors of response. CONCLUSION: Ve skewness and kurtosis seem to be promising in the prediction of response to CRT in rectal cancer patients.

Could early tumour volume changes assessed on morphological MRI predict the response to chemoradiation therapy in locally-advanced rectal cancer?

AIM: To investigate the potential role of an additional magnetic resonance imaging (MRI) examination performed during neoadjuvant chemoradiation therapy (CRT) in the prediction of pathological response in locally advanced rectal cancer (LARC). MATERIAL AND METHODS: Forty-eight consecutive patients with LARC underwent neoadjuvant CRT. MRI studies at 1.5 T, including high-resolution T2-weighted sequences that were acquired parallel and perpendicular to the main axis of the tumour were performed before (preMRI), during (midMRI), and 6-8 weeks after the end of CRT (postMRI). Cancer volumes (Vpre, Vmid, Vpost) were drawn manually and the reduction rate calculated (ΔVmid, ΔVpost). According to Rödel's pathological tumour regression grade (TRG), patients were considered non-responders (NR; TRG0-2), partial responders (PR; TRG3), and complete responders (CR; TRG4). Multivariate regression analysis was performed to identify the best MRI predictors of NR, PR, and CR. RESULTS: Twenty-five patients were considered PR (52%), 13 CR (27%), and 10 NR (22%). Tumour shrinkage mainly occurred shortly after CRT (ΔVmid: CR: 80±10% versus PR: 56±19% versus NR: 28±22%, p=2.2×10-16). Vmid, Vpost, ΔVmid, and ΔVpost correlated with TRG (p<0.001). At multivariate analysis, the combined assessment of Vmid and ΔVmid was selected as the best predictor of response to CRT, in that it distinguishes CR, PR, and NR early and accurately (81.5%). CONCLUSION: MidMRI allows final response assessment to neoadjuvant CRT earlier and better than the MRI performed after the end of CRT. MRI findings at midMRI may be useful to tailor patient treatment.

Coagulation indicators in chronic stable effort angina and unstable angina: relationship with acute phase reactants and clinical outcome.

The aim of the study was to evaluate which pattern of coagulation indicators characterizes unstable angina and, particularly, its relationship with short-term prognosis. Forty patients with unstable angina (UA Group) at admission in the intensive care unit, 40 patients with chronic stable effort angina (SEA Group), and 20 age- and sex-matched healthy controls were studied. Blood coagulation indicators were fibrinogen, prothrombin fragment F1 + 2 (F1 + 2), thrombus precursor protein (TpP), and D-dimer. C reactive protein (CRP) and cardiac Troponin I (cTnI) have also been determined and compared. Patients in the UA Group were followed for in-hospital adverse events (sudden death, acute myocardial infarction and angina refractory to medical therapy). CRP, D-dimer and cTnI plasma levels were significantly lower in the SEA Group than in the UA Group; the same trend was found for fibrinogen and F1 + 2 plasma levels, although not statistically significant. The TpP was similar in all groups. The control group showed the lowest levels for all indicators. Within the UA Group, 17 patients developed adverse events during hospitalization; F1 + 2, D-dimer, cTnI and CRP plasma levels were higher in these patients than in those with good outcome. Relative risks for adverse events associated with the highest tertile of D-dimer, cTnI, and CRP plasma levels were 8.4 (95% confidence interval, 1.5-48.9), 6.7 (95% confidence interval, 1.1-38.6) and 5.2 (95% confidence interval, 1.1-25.2), respectively. D-Dimer is significantly increased in patients with unstable angina and, in particular, in those who develop an adverse event.

Feasibility and clinical value of "intelligent" compression and digital storage of transthoracic echocardiograms in day-to-day practice.

BACKGROUND: The aim of this study was to assess the clinical concordance of expert cardiologists' interpretation of echocardiographic studies recorded on Super-VHS videotape or stored in magneto-optical disk, as well as the feasibility and clinical value of intelligent compression and digital storage of echocardiographic data as cine-loops and still-frames for interpretation of transthoracic echocardiographic images in clinical practice. METHODS: All clinical cardiologists experienced in echocardiography in our department (n = 10) reported on a standardized worksheet checklist the echocardiographic data of 7 consecutive patients (140 reports), and recorded them on videotape or magneto-optical disks to compare the interpretation of videotaped studies, acquired in the usual way, with clinically compressed studies stored to magneto-optical disks using a standard (Italian Society of Echocardiography) image acquisition protocol. RESULTS: The time interval between analog and digital study readings was 50 +/- 15 days. Except for tricuspid valve regurgitation grading (k = 0.28) and for left ventricular global hypokinesia (k = 0.32), the intraobserver agreement in the interpretation of the 3290 cardiovascular morphological and functional findings found on analog and digitally stored images was good (k value ranging from 0.66 to 1.00). The wall motion score index was 1.56 +/- 0.53 when interpreting analog studies, and 1.52 +/- 0.54 on digital studies (p = 0.35). Conversely, the interobserver variability of the wall motion score index (Gini index ranging from 0 to 0.80) was significantly lower when interpreting studies stored digitally than when analog ones were examined (0.48 +/- 0.021 and 0.52 +/- 0.023 respectively, p = 0.006). In comparison to videotape recordings, digital storage of echocardiographic studies significantly shortened the time to image access for study review (327 +/- 62 and 30 +/- 4 s, respectively, p < 0.0001) and the reading time (600 +/- 300 and 540 +/- 300 s respectively, p = 0.034), rendered study accessibility easier (difficult or good: 73 vs 43% of observers, fast or optimal: 27 vs 57% of observers respectively, p = 0.0011) and improved the recorded image quality perception (poor: 25 vs 10% of observers, sufficient or good: 75 vs 90% of observers respectively, p = 0.022), without loss of study completeness (insufficient: 18 vs 17% of observers, adequate or complete: 82 vs 83% of observers, respectively; p = NS). Finally, from September 1, 1999, digital storage has become routine practice for patients admitted to our Department. By December 31, 1999, 411 echo studies had been stored: 7 +/- 3 cine-loop/study, 32 +/- 18 frames/cine-loop, and 3 +/- 2 still-frames/study. The average amount of memory needed for storage was 18.6 +/- 11.9 MB/study. CONCLUSIONS: Clinical compression of echocardiographic studies seems to be an accurate summary of the complete examination recorded to videotape for the assessment of patients admitted in the coronary care unit. In addition, digitally stored studies allow a significant improvement in the interobserver reproducibility of wall motion score assessment.

Dynamic left ventricular outflow tract obstruction: an unusual mechanism mimicking anterior myocardial infarction with cardiogenic shock.

Cardiogenic shock is a frequent and threatening complication in the course of acute myocardial infarction. Besides the well known causes (left ventricular failure, acquired interventricular defect, papillary muscle rupture, free wall rupture) other less frequent mechanisms recognize a functional substrate. The recognition of such mechanisms makes us to revert to the treatments with completely different prognostic implications. In our Coronary Care Unit we encountered, in a period of 12 months, 4 patients who presented clinical, electrocardiographic and/or echographic signs and symptoms of acute myocardial infarction, with different degrees of heart failure up to cardiogenic shock. Only 1 patient showed a severe stenosis of the left anterior descending coronary artery and a significant creatine kinase reduction. Left ventriculography, performed at admission, was unable to disclose the true mechanism of clinical presentation. Only a thorough echographic examination disclosed the presence of a dynamic left ventricular outflow tract obstruction as the cause of heart failure culminating in cardiogenic shock. Once recognized, pathophysiological treatment (administration of beta-blockers and withdrawal of vasodilators, inotropic drugs and intra-aortic balloon pump) led to a dramatic improvement, with an almost complete left ventricular function recovery. Left ventricular outflow tract obstruction is a mechanism that can lead to severe heart failure as a complication of an acute myocardial infarction. Conversely such a mechanism can be precipitated by other causes (hypotension, hypovolemia, especially in hypertensive patients) and can mimic an acute myocardial infarction. Its incidence is not negligible: in our Coronary Care Unit it accounted for about 15% of all cases of myocardial infarction requiring inotropic support. An accurate echocardiographic examination is mandatory even after coronary angiography, and always permits the physician to select the appropriate therapy.

[Digital revolution in the echocardiography laboratory. Current status and future perspectives] . / La rivoluzione digitale nel laboratorio di ecocardiografia. Stato attuale e prospettive future.

Echocardiography is changing from an operative modality in which most images are stored in analog fashion on videotape into one with most data stored digitally. This transition is accelerating today, fueled by several factors. First, there is widespread recognition of the value of digital storage of echocardiograms, including random access to studies as well as to images within a study, side-by-side comparison with prior studies, easier quantification, and multiplication and remote transmission of images without degradation. Second, continuous improvement of the cost/performance ratio of modern computers makes routine digital echocardiography both feasible and affordable. Finally, the formulation and acceptance within the industry of the DICOM image formatting standard for echocardiography. The acceptance of this standard allows the echo-labs around the world to be free to choose individual echo-machines on the basis of their individual merits for their laboratories with the assurance that these machines will be able to communicate with each other by an internationally agreed upon standard. Advantages of digital echocardiography are overwhelming and there is little doubt that this approach will be essential for the proper utilization of this technique. The technology will undoubtedly continue to change. Those who are waiting for it to be perfected may be waiting for a long time.

Systolic anterior movement of mitral valve during acute apical myocardial infarction: An unusual mechanism of acute mitral regurgitation.

We describe a singular case of a 75-year-old woman affected by an anterior acute myocardial infarction in the subset of a very recent orthopaedic surgery. She had had severe mitral regurgitation on coronary angiography. A thorough cardiac echocardiographic examination revealed the particular mechanism of mitral incompetence, consisting of a dynamic anterior mitral leaflet displacement caused by a sustained compensatory left ventricle hypercontractility and favored by postsurgical moderate anemia and mild hypertensive hypertrophy. The use of beta-blockers and the avoidance of pure vasodilators permitted complete reversal of such mechanisms during the clinical course.

Signal-averaged electrocardiography and Doppler echocardiographic study in predicting acute rejection in heart transplantation.

BACKGROUND AND METHODS: In a prospective protocol for noninvasive diagnosis of acute cardiac rejection, 83 routine endomyocardial biopsies, followed each time by the analysis of signal-averaged electrocardiography and by a cardiac Doppler echocardiographic study, were performed in 18 heart transplant recipients. The follow-up time was 5 +/- 3.6 months. To detect noninvasively acute cardiac rejection, we compared biopsy findings with the presence of late potentials at signal-averaged electrocardiography and with two diastolic indexes, pressure half-time, and isovolumic relaxation time obtained from Doppler echocardiographic study. RESULTS: Thirteen acute rejection crises requiring modification of immunosuppression were diagnosed by means of endomyocardial biopsy. This clinically relevant acute cardiac rejection was associated with the presence of late potentials in 69% of cases and with the presence of pressure half-time < or = 55 msec and isovolumic relaxation time < or = 60 msec in 69% and 62% of cases, respectively. Sensitivity and specificity were as follows: for late potentials, 69% and 71%; for pressure half-time < or = 55 msec, 69% and 76%; for isovolumic relaxation time < or = 60 msec, 62% and 83%, respectively. The presence in a single patient of at least one abnormal parameter showed a sensitivity of 100% and a specificity of 60% in detecting important rejection. CONCLUSIONS: These data support the use of combined signal-averaged electrocardiography and Doppler echocardiographic study of the left ventricular diastolic function in the screening of acute cardiac rejection. Such results can suggest when endomyocardial biopsy should be performed, with the reliance that a normal noninvasive study highly excludes the presence of acute cardiac rejection requiring intensified immunosuppression.

[Percutaneous closure of congenital and iatrogenic coronary arterial fistulas]. / La chiusura percutanea delle fistole arteriose coronariche congenite e iatrogene.

Coronary arteriovenous fistulas (CAF) are the most common hemodinamically significant congenital coronary anomalies. Surgery has been the only therapeutic option for ages. We describe three cases of percutaneous occlusion of CAF, congenital and iatrogenic, that we treated with different devices, to fit their different anatomic and functional characteristics. Case 1). Male patient (pt) 20 years old, asymptomatic, affected with CAF between the right coronary artery and the right ventricle, with aneurysmatic vessel dilatation and occlusion of the posterolateral branches. CAF has been occluded with a detachable, valvulated latex balloon, wedged into the proximal neck of the aneurysm. Case 2). Female pt 63 years old, who was symptomatic for exertion angina, affected with multiple CAF which originated from proximal and distal circumflex artery, proximal left anterior descending artery (LAD), all of which flowed into the left inferior lobar pulmonary artery. The fistulas have been occluded with steel and tungsten coils. Case 3). Male pt 62 years old, who underwent orthotopic cardiac transplantation in 1990 for dilated cardiomyopathy. Coronary angiogram at one year was normal, but subsequently a multilocular CAF between LAD in the middle portion and the right ventricle became evident. During angiographic follow-up an increase of the size of the fistula was observed, together with a reduction of that of distal LAD. For this reason a percutaneous occlusion with multiple tungsten coil has been performed. The three procedures have had a favorable outcome and we did not observe any acute or late complications; clinical and angiographic follow-up confirmed this satisfactory results at six months. Based on the data of the literature and on this experience, we conclude that percutaneous occlusion is the first line therapy of CAF and that the different devices can be tailored to meet different anatomic and functional characteristics.

[A case of radiation-induced coronary occlusion treated with elective and emergency PTCA]. / Su di un caso con occlusioni coronariche radioindotte trattate con PTCA elettive e d'emergenza.

We describe the case of a patient (pt) treated with radiotherapy for Hodgkin's lymphoma at the age of 17. Two years later he presented an apical AMI and underwent coronary angiography (CA) for postinfarction angina. A 40% stenosis of the left anterior descending (LAD) was found in the proximal portion and the vessel was occluded at the middle level. Septal and diagonal branches supplied collaterals to the distal LAD and left ventricular function was only mildly reduced (EF angio-ventriculographic = 52%). We successfully performed a first PTCA, but the pt was re-admitted to our hospital few days later for a new large anterior myocardial infarction with refractory hypotension and low output condition. An intraaortic balloon catheter was inserted and CA demonstrated proximal LAD occlusion; a new PTCA was then performed and the opening of the vessel was obtained after 90' from symptoms' onset. The subsequent course was uneventful and the pt was discharged after 20 days. The ejection fraction was 39%. Thirty days after, a third PTCA with Palmaz-Schatz stent implantation was necessary for unstable angina due to a restenosis of the proximal LAD. After ten months follow-up the pt is asymptomatic with negative exercise test and an angioscintigraphic EF = 47%. CA and intravascular ultrasound demonstrated nor restenosis or progression of the disease, with a good minimal luminal diameter (MLD). A review of the literature on this topic is presented. Moreover we discuss the mechanism of coronary stenosis and occlusion and the reasons for choosing PTCA in the various settings.

[The usefulness of transesophageal echocardiography in the follow-up of patients operated on for replacement of the ascending aorta with a tubular-valvular prosthesis (Cabrol's intervention)]. / Utilità dell'ecocardiografia transesofagea nel follow-up dei pazienti operati di sostituzione dell'aorta ascendente con protesi tubulo-valvolata (intervento di Cabrol).

OBJECTIVES: The usefulness of transesophageal echocardiography (TEE) in assessing the postoperative results of aortic root replacement (Cabrol's procedure) was evaluated. METHODS: Between 1986 and 1993, 31 patients underwent replacement of the aortic valve and ascending aorta by a composite graft using the Cabrol procedure. Twenty-six patients had annuloaortic ectasia, two type I DeBakey dissection and four type II dissection. Hospital mortality was 9.7%. Studies were performed in 18 patients, two to 70 months (mean 27.5 months) after composite graft replacement. The following features were examined: prosthetic aortic valve function, coronary graft morphology and function, tubular graft and aneurysm wrapped around morphology and dimensions, presence of intimal flap, false lumen and thrombus in the false lumen and persistence of right atrial fistula. RESULTS: Periprosthetic leakage with significant regurgitation was detected by TEE in 3 (16.6%) of 18 patients. In one patient with infected aortic graft a fistula between the periprosthetic space and the right ventricle was detected (confirmed at reoperation). In another patient occlusion of the graft for left coronary artery was noted. In three patients (16.6%) an aneurysm of the periprosthetic space with perivalvular leakage and persistence of the fistula with the right atrium was visualized. In the two patients operated for DeBakey type I dissection an intimal flap persisted distal to the graft and in one patient flow was detected in the false lumen, while it was totally obliterated in the other. CONCLUSIONS: 1) Complications after Cabrol's procedure are not infrequent; although the real importance of some of them (periprosthetic aneurysm, persistence of dissection) is uncertain, a careful follow-up may be essential to improve the long term survival. 2) TEE is a useful and well-tolerated procedure for postoperative follow-up of patients who underwent aortic root replacement with Cabrol's procedure.

[Primary percutaneous transluminal coronary angioplasty in acute myocardial infarction: immediate and short-term results. National experience]. / L'angioplastica coronarica transluminale percutanea primaria nell'infarto miocardico acuto: risultati immediati e a breve termine. Esperienza nazionale.

Direct percutaneous transluminal coronary angioplasty (PTCA) in the early phase of acute myocardial infarction (AMI) has till now a relatively limited use, mainly because of logistic problems, in comparison with systemic thrombolysis. The aim of this paper was to discuss the role direct PTCA during AMI, based on the most recent international experience. In brief, the major benefits of direct PTCA are the high percentage of recanalization (90%), optimal recanalization quality, the absence of contraindications in most cases; in patients with cardiogenic shock the mortality is lowered from 80% to 40-45%; absence of haemorrhagic stroke and lower incidence of cardiac ischemic events and urgent coronary artery bypass grafting (CABG) are seen in short-term follow-up. We also present the whole series of 22 Italian centers, all of which has wide experience of PTCA, but not performing it on a routine bases in AMI. It concerns of 721 patients, 389 with single-vessel disease, 198 with double-vessel disease and 105 with triple-vessel disease. Twenty patients presented left main disease and 147 patients were in cardiogenic shock. Palmaz-Schatz stent was implanted in 31 cases; 3 Simpson atherectomy were performed. In 24 cases the PTCA was carried out as a "bridge" to emergency CABG, in the presence of triple-vessel disease. Among the group without cardiogenic shock 400 procedures were direct, 164 were rescue PTCA (within 12 hours). Angiographic success (residual stenosis < or = 50%) was obtained in 92 e 89% of cases respectively. In 147 patients with cardiogenic shock success was 74%. Mortality was 2.8% in patients without shock and 48% in patients with shock.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence and determinants of carotid atherosclerosis in a general population.

BACKGROUND AND PURPOSE: The aim of this study was to assess the prevalence of asymptomatic carotid atherosclerotic lesions and their relation to principal risk factors. The importance of the relation between asymptomatic carotid atherosclerotic lesions, stroke, and coronary atherosclerosis has been widely discussed, but there are few transversal and longitudinal studies on a general population. METHODS: A noninvasive examination was carried out using high-resolution B-mode ultrasonography, which has been shown to be a reliable tool for epidemiological studies. We examined 630 men and 718 women aged 18-99 years (participation rate, 74.9%). RESULTS: The global prevalence of carotid atherosclerosis was 25.4% in men and 26.4% in women. Intimal-medial thickening was found in 9.4% of men and 11.7% of women. Plaque prevalence was 13.3% in men and 13.4% in women; prevalence of stenotic plaques was 2.7% and 1.5%, respectively. Subjects aged < or = 39 years showed a very low prevalence of any asymptomatic carotid atherosclerotic lesions. In the multiple logistic regression, the analysis of subjects aged > or = 40 years showed a positive significant association between the severity of carotid atherosclerotic lesions (plaques and stenosis) and age (p < 0.001), systolic blood pressure (p < 0.01), cigarette smoking (p < 0.0001), and the protective effect of high density lipoprotein cholesterol (p < 0.037). This analysis did not provide evidence of a clear-cut association between risk factors and intimal-medial thickening. CONCLUSIONS: This population study shows the high prevalence of asymptomatic carotid atherosclerotic lesions in a general population (approximately 25% of adults) and its relation with the classic risk factors. It emphasizes the value of ultrasonography in the detection of early atherosclerotic lesions.

[Intravenous pentoxifylline in Fontaine stage II and III peripheral arterial diseases]. / La pentossifillina per via endovenosa nell'arteriopatia periferica al II e III stadio Fontaine.

Thirty patients with lower limb arterial disease (15 Fontaine stage II, 15 stage III) were treated for two weeks with continuous pentoxifylline infusion (1 g daily). In all cases, a significant improvement of the Winsor index was obtained: in stage II from 0.57 +/- 0.11 to 0.67 +/- 0.15 (p less than 0.008), and in stage III from 0.43 +/- 0.20 to 0.58 +/- 0.19 (p less than 0.042). In patients who could be submitted to treadmill exercise, the average distance increased from 216 +/- 88 m to 314 +/- 187 m (p less than 0.05) while distance walked without pain increased from 124 +/- 76 m to 199 +/- 153 (p less than 0.05).