Adaptive radiation therapy: When, how and what are the benefits that literature provides?

PURPOSE: To identify from the current literature when is the right time to replan and to assign thresholds for the optimum process of replanning. Nowadays, adaptive radiotherapy (ART) for head and neck cancer plays an exceptional role consisting of an evaluation procedure of the prominent anatomical and dosimetric variations. By performing complex radiotherapy methods, the credibility of the therapeutic result is crucial. Image guided radiotherapy (IGRT) was developed to ensure locoregional control and thus changes that might occur during radiotherapy be dealt with. MATERIALS AND METHODS: An electronic research of articles published in PubMed/MEDLINE and Science Direct databases from January 2004 to October 2020 was performed. Among a total of 127 studies assessed for eligibility, 85 articles were ultimately retained for the review. RESULTS: The most noticeable changes have been reported in the middle fraction of the treatment. Therefore, the suggested optimal time to replan is between the third and the fourth week. Anatomical deviations>1cm in the external contour, average weight loss>10%, violation in the dose coverage of the targets>5%, and violation in the dose of the peripherals were some of the thresholds that are currently used, and which lead to replanning. CONCLUSION: ART may decrease toxicity and improve local-control. Whether it is beneficial or not, depends ultimately on each patient. However, more investigation of the changes should be performed in future prospective studies to obtain more accurate results.

[Spinal tumors]. / Spinale Tumoren.

Spinal tumors are often classified into three anatomical compartments on the basis of their relationship to the dural space and myelon. The most common primary spinal neoplasms are glial tumors (ependymoma, astrocytoma), nerve sheath tumors (schwannoma, neurofibroma) and meningioma. Metastases represent another common tumor entity and can occur in every spinal compartment. Magnetic resonance imaging (MRI) is the most important noninvasive method for spinal tumor imaging.

Whole-body computed tomography versus conventional skeletal survey in patients with multiple myeloma: a study of the International Myeloma Working Group.

For decades, conventional skeletal survey (CSS) has been the standard imaging technique for multiple myeloma (MM). However, recently whole-body computed tomography (WBCT) has been implemented into the diagnostic criteria of MM. This analysis compares sensitivity and prognostic significance of WBCT and CSS in patients with smoldering MM (SMM) and MM. Fifty-four of 212 patients (25.5%) had a negative CSS and a positive WBCT for osteolytic lesions (P<0.0001). Of 66 patients with SMM based on CSS, 12 (22.2%) had osteolytic lesions on WBCT. In comparison, WBCT failed to detect some bone destructions in the appendicular skeleton possibly due to limitations of the field of view. Presence of lytic bone lesions in WBCT was of borderline prognostic significance (P=0.051) for SMM patients, with a median time to progression of 38 versus 82 months for those without bone destructions. In conclusion, WBCT identifies significantly more sites of bone destruction than CSS. More than 20% of patients with SMM according to CSS have in fact active MM detectable with WBCT. On the basis of this and other studies, WBCT (either computed tomography (CT) alone or as part of a positron emission tomography-CT protocol) should be considered the current standard for the detection of osteolytic lesions in MM.

MR imaging of endometriosis: Spectrum of disease.

Endometriosis is a common gynecological disorder defined by the presence of endometrial tissue outside the uterus. It is the most common cause of chronic pelvic pain and typically affects the ovaries, uterine ligaments, peritoneum, tubes, rectovaginal septum and bladder. It may, however, be found at various extrapelvic sites, including the perineum, liver, pancreas, lung or even the central nervous system, and in such cases, diagnosis may be quite challenging. Even though definitive diagnosis requires laparoscopy, preoperative identification of endometriosis is important not only to differentiate it from other diseases with similar clinical presentations but also, for accurate presurgical mapping, since complete removal of all endometriotic foci is critical for the effective treatment of the patient's symptoms. Ultrasound is performed initially, but magnetic resonance imaging (MRI) is increasingly being used, particularly when sonographic findings are unclear, when deep pelvic endometriosis is suspected or when surgery is planned, as it provides better contrast resolution and a larger field of view compared to ultrasound. In this article, we will discuss distinctive MRI appearances of endometriotic foci and we will review common and uncommon locations of endometriosis within the body, in an attempt to familiarize radiologists with its wide spectrum of manifestations.

High levels of periostin correlate with increased fracture rate, diffuse MRI pattern, abnormal bone remodeling and advanced disease stage in patients with newly diagnosed symptomatic multiple myeloma.

Periostin is an extracellular matrix protein that is implicated in the biology of normal bone remodeling and in different cancer cell growth and metastasis. However, there is no information on the role of periostin in multiple myeloma (MM). Thus, we evaluated periostin in six myeloma cell lines in vitro; in the bone marrow plasma and serum of 105 newly diagnosed symptomatic MM (NDMM) patients and in the serum of 23 monoclonal gammopathy of undetermined significance (MGUS), 33 smoldering MM (SMM) patients, 30 patients at the plateau phase post-first-line therapy, 30 patients at first relapse and 30 healthy controls. We found high levels of periostin in the supernatants of myeloma cell lines compared with ovarian cancer cell lines that were not influenced by the incubation with the stromal cell line HS5. In NDMM patients the bone marrow plasma periostin was almost fourfold higher compared with the serum levels of periostin and correlated with the presence of fractures and of diffuse magnetic resonance imaging pattern of marrow infiltration. Serum periostin was elevated in NDMM patients compared with healthy controls, MGUS and SMM patients and correlated with advanced disease stage, high lactate dehydrogenase, increased activin-A, increased bone resorption and reduced bone formation. Patients at first relapse had also elevated periostin compared with healthy controls, MGUS and SMM patients, while even patients at the plateau phase had elevated serum periostin compared with healthy controls. These results support an important role of periostin in the biology of myeloma and reveal periostin as a possible target for the development of antimyeloma drugs.

MRI findings before and after abdominal radical trachelectomy (ART) for cervical cancer: a prospective study and review of the literature.

AIM: To report the authors' experience with dedicated pelvic magnetic resonance imaging (MRI) in young women with early-stage cervical cancer treated with abdominal radical trachelectomy (ART). MATERIALS AND METHODS: During a 5-year period, 21 patients, with biopsy-confirmed cervical carcinoma, International Federation of Gynaecology and Obstetrics (FIGO) stage ≤IB1, were considered for trachelectomy. All patients underwent pelvic MRI within 30 days prior to surgery. Tumour size, endocervical extension, extrauterine spread, and nodal status were noted. Postoperative MRI findings were reviewed in 16 patients. RESULTS: Nineteen of the 21 patients were treated with ART. In two patients, trachelectomy was aborted intraoperatively and radical hysterectomy was performed; preoperative MRI findings were consistent with surgicopathological examination in both patients. MRI correctly assessed tumour size in 18/21 patients, coming within 5 mm of the surgical specimen. Tumour size was underestimated in two cases because of circumferential growth (n = 1) or technical difficulties (n = 1). False-positive MRI result was due to post-biopsy inflammation (n = 1). MRI accurately identified absence of internal os involvement in 17/19 ART patients; false-positive MRI for internal os involvement were due to endocervical polyp (n = 1) and coexisting Nabothian cysts (n = 1). No trachelectomy patient had extrauterine disease or malignant nodes at MRI or final histology. Post-trachelectomy complications included hydrosalpinges (n = 3), lymphocysts (n = 2), isthmic stenosis (n = 1), and tumour relapse (n = 2). CONCLUSIONS: Dedicated pelvic MRI is helpful in assessing tumour size and endocervical extension in young women, candidates for ART. Hydrosalpinx may occur after ART and it may influence fertility potential.

International myeloma working group consensus statement and guidelines regarding the current role of imaging techniques in the diagnosis and monitoring of multiple Myeloma.

Several imaging technologies are used for the diagnosis and management of patients with multiple myeloma (MM). Conventional radiography, computed tomography (CT), magnetic resonance imaging (MRI) and nuclear medicine imaging are all used in an attempt to better clarify the extent of bone disease and soft tissue disease in MM. This review summarizes all available data in the literature and provides recommendations for the use of each of the technologies. Conventional radiography still remains the 'gold standard' of the staging procedure of newly diagnosed and relapsed myeloma patients. MRI gives information complementary to skeletal survey and is recommended in MM patients with normal conventional radiography and in all patients with an apparently solitary plasmacytoma of bone. Urgent MRI or CT (if MRI is not available) is the diagnostic procedure of choice to assess suspected cord compression. Bone scintigraphy has no place in the routine staging of myeloma, whereas sequential dual-energy X-ray absorptiometry scans are not recommended. Positron emission tomography/CT or MIBI imaging are also not recommended for routine use in the management of myeloma patients, although both techniques may be useful in selected cases that warrant clarification of previous imaging findings, but such an approach should ideally be made within the context of a clinical trial.

Lung scintigraphy with nonspecific human immunoglobulin G ((99m)Tc-HIG) in the evaluation of pulmonary involvement in connective tissue diseases: correlation with pulmonary function tests (PFTs) and high-resolution computed tomography (HRCT).

PURPOSE: In patients with connective tissue diseases (CTD), the early detection and evaluation of the severity of the pulmonary involvement is mandatory. High-resolution computed tomography (HRCT) and pulmonary function tests (PFTs) are considered to be valuable noninvasive diagnostic modalities. Radiopharmaceuticals have also been used for this purpose. Our aim was the evaluation of technetium-labeled human polyclonal immunoglobulin G (HIG) lung scintigraphy in the early detection and assessment of the severity of the pulmonary involvement in CTD patients. METHODS: Fifty-two nonsmoking CTD patients were studied by PFTs, HRCT, and HIG. According to PFTs, patients were divided in group A (impaired PFTs-abnormal pulmonary function) and group B (normal pulmonary function). Semiquantitative analysis was done on HIG and HRCT and corresponding scores were obtained. RESULTS: Significant difference was found between HIG scores in the two groups (0.6 +/- 0.07 vs 0.51 +/- 0.08, P < 0.001). There was a statistically significant negative correlation between HIG scores and PFTs results and a positive correlation between HIG and HRCT scores. HIG demonstrated similar clinical performance to HRCT. At the best cut-off levels of their score (0.56 and 7, respectively), HIG had a superior sensitivity (77.5 vs 57.5%) with lower specificity (75 vs 91.7%). The combination of the two methods increased the sensitivity of abnormal findings at the expense of specificity. CONCLUSIONS: HIG scintigraphy can be used in the early detection and evaluation of the severity of the pulmonary involvement in CTD, whereas, when used in combination with HRCT, the detection of affected patients can be further improved.

Intramedullary spinal cord and leptomeningeal metastases in a patient with carcinoma of the uterine cervix.

BACKGROUND: : Neoplastic meningitis in patients with carcinoma of the uterine cervix is unusual in the course of their diseases. Even more unusual are intramedullary spinal metastases. CASE: We report the case of a 64-year-old woman who presented with leptomeningeal and intramedullary spinal cord metastases from a grade 2 squamous cell cancer of the uterine cervix. This is just the second case of intramedullary metastases from cervical carcinoma. CONCLUSION: Neoplastic meningitis or intramedullary metastases are extremely rare in the course of uterine cervix carcinoma. Nevertheless, when indicated by symptoms, patients should undergo MRI of the brain and/or spine and have a lumbar puncture performed, for the diagnosis of this devastating complication. Treatment is mainly palliative but may offer symptom relief.

Prognostic significance of magnetic resonance imaging of bone marrow in previously untreated patients with multiple myeloma.

BACKGROUND: Magnetic resonance imaging (MRI) has been a useful technique for the assessment of patients with multiple myeloma (MM). We evaluated the prognostic significance of different MRI patterns in symptomatic patients with MM. PATIENTS AND METHODS: A total of 142 symptomatic MM patients underwent MRI before treatment. MRI patterns of involvement were correlated with known prognostic variables, including the International Staging System (ISS), response to treatment and survival. RESULTS: Focal marrow lesions were identified in 50% of patients, diffuse marrow replacement in 28%, a variegated pattern in 14% and normal pattern in 8%. When patients with the diffuse pattern were compared with patients with the other MRI patterns, they had features of more advanced disease such as higher ISS, anemia, hypercalcemia, elevated lactate dehydrogenase and extensive marrow plasmacytosis. Response rate was similar among patients with different MRI patterns. Median survival was 24 months for patients with the diffuse pattern, 51 months for those with the focal pattern, 52 months for those with the variegated pattern and 56 months for patients with the normal pattern (P = 0.001). The presence or absence of a diffuse MRI pattern separated patients with ISS stages I and II into two subgroups with significantly different survival times of 28 months and 61 months, respectively (P = 0.01). Furthermore, a diffuse MRI pattern predicted inferior outcome regardless of whether or not patients had received high-dose therapy with autologous stem cell transplantation. CONCLUSION: Diffuse marrow replacement on MRI adds to the evaluation of patients with multiple myeloma and their management.

Image findings of a tailgut cyst. Case report and short review of the literature.

We present a case of retrorectal hamartoma (tailgut cyst). Imaging findings on ultrasound, computed tomography and magnetic resonance imaging, pathologic findings, as well as the diagnostic pitfalls during the patient's management are documented. As it is a rare lesion with a non specific clinical presentation, it is usually misdiagnosed. Our aim is to present image characteristics of these lesions in all modalities and include retrorectal hamartomas in our differential diagnosis in patients with lesions with similar image findings.

Age-related thymic activity in adults following chemotherapy-induced lymphopenia.

BACKGROUND: The potential role of the adult thymus in T-cell homeostasis subsequent to lymphopenia remains the subject of debate. We examined whether thymic activity contributes to reconstitution of the peripheral T-cell pool, a critical process for patients recovering from antineoplastic therapy. METHODS: In selected patients with various neoplastic diseases we assessed peripheral blood lymphocyte subsets by flow-cytometry, including thymus-derived, CD4+ T cells expressing the CD45RA molecule, and thymic size rebound by CT scan before, and 3, 6 and 12 months after completion of cytotoxic therapy. RESULTS: Adult patients (n = 21, mean age of 30 years, range 18-49) had higher baseline numbers of B and lower numbers of NK cells than elderly patients (n = 15, mean age of 79 years, range 70-91), while total T-cell numbers did not differ. Despite the reduction of lymphocyte counts being comparable in the adult (mean of 45%) and elderly (mean of 49%) groups, occurring at, or near, completion of treatment, an enlargement of the previously atrophic thymus was evident in 63% of the adult, but in none of the elderly, subjects. In 22 patients who remained active disease-free during the following year, B cells and NK cells recovered to pretreatment levels as soon as at 3 months, whereas overall T-cell recovery occurred at 6 months post-treatment. Thymic rebound, observed in 11 of 22 patients who were of younger age, correlated significantly with a faster and more complete recovery of CD45RA+ CD4+ (mainly helper-naïve) T cells. CONCLUSION: The adult thymus appears capable of regeneration, at least up to middle age, contributing significantly to the reconstitution of the peripheral T-cell pool following chemotherapy-induced lymphopenia. In advanced age, however, although peripheral homeostatic pathways appear intact, regeneration of the naïve repertoire is incomplete.

The outcome of elderly patients with advanced urothelial carcinoma after platinum-based combination chemotherapy.

BACKGROUND: The majority of patients with advanced urothelial cancer are elderly, but data regarding this specific age group are limited. We compared the tolerability and efficacy of first-line platinum (cisplatin or carboplatin)-based chemotherapy in elderly patients (> or =70 years) with those in younger patients. PATIENTS AND METHODS: A total of 381 patients with advanced urothelial carcinoma received CIMV (cisplatin, ifosphamide, methotrexate, vinblastine) (n=32), MVAC (methotrexate, vinblastine, doxorubicin, cisplatin) (n=105), DC (docetaxel, cisplatin) (n=174), CaG (carboplatin, gemcitabine) (n=64) or other regimes (n=6) and were included in this analysis. RESULTS: A total of 116 patients were > or =70 years. Elderly patients experienced more frequent neutropenia grade 3/4 (55% versus 37%, P=0.087) and renal toxicity (28% versus 10%, P=0.033) among patients treated with CIMV/MVAC, and neutropenic infections (4% versus 0%, P=0.019) among patients treated with DC. Median survival did not differ significantly between elderly and younger patients (9.3 versus 10.5 months, P=0.16). Eastern Cooperative Oncology Group performance status (PS) and haemoglobin were independently associated with prognosis. Patients with PS <2 and haemoglobin > or =10 g/dl had a median survival of 14 months as opposed to 5 months for patients with PS > or =2 or haemoglobin <10 g/dl (P <0.001). CONCLUSION: Elderly patients with advanced urothelial cancer tolerate platinum-based chemotherapy well and derive the same benefit as their younger counterparts.

Paclitaxel and epirubicin versus paclitaxel and carboplatin as first-line chemotherapy in patients with advanced breast cancer: a phase III study conducted by the Hellenic Cooperative Oncology Group.

BACKGROUND: To compare survival between patients with advanced breast cancer (ABC) treated with epirubicin/paclitaxel (Taxol) or paclitaxel/carboplatin (Cp) chemotherapy. PATIENTS AND METHODS: From January 1999 to April 2002, 327 eligible patients with ABC were randomized to receive either paclitaxel 175 mg/m(2) in a 3-h infusion followed by epirubicin (EPI) 80 mg/m(2) (group A) or paclitaxel, as in group A, followed by Cp at an AUC of 6 mg x min/ml (group B) every 3 weeks for six cycles. RESULTS: After a median follow-up of 23.5 months, median survival was not significantly different between the two groups (22.4 months versus 27.8 months, P=0.25), whereas median time to treatment failure was significantly longer in patients treated with paclitaxel/Cp (8.1 months in group A versus 10.8 months in group B, P=0.04). Both regimens were well tolerated. In total, 39 patients (24%) in group A and 46 (29%) in group B suffered at least one severe side-effect. Quality-of-life assessment and cost analysis did not reveal any significant differences between the two groups. CONCLUSION: Our study suggests that the paclitaxel/Cp combination is an effective therapeutic alternative for patients with ABC in which anthracycline administration has the potential of being harmful.

A prospective study on lung toxicity in patients treated with gemcitabine and carboplatin: clinical, radiological and functional assessment.

BACKGROUND: Small series and retrospective studies have suggested that treatment with gemcitabine may be associated with pulmonary toxicity. However, a prospective evaluation of cancer patients treated with gemcitabine-based chemotherapy without neoplastic involvement of the thorax and without administration of radiotherapy has not been performed. PATIENTS AND METHODS: To investigate this issue, 41 consecutive patients receiving gemcitabine and carboplatin underwent prospective evaluation of lung function, which included pulmonary symptoms, pulmonary function tests, arterial blood gases and radiographic studies. Assessment was performed before and after completion of chemotherapy in all patients. Patients with a substantial decline in diffusion capacity for carbon monoxide (DLCO), defined as a drop of > or = 20%, were reassessed 2 months later. RESULTS: After chemotherapy, there were no significant changes in forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC ratio, alveolar volume or total lung capacity. In contrast, there was a significant decline in DLCO (73 +/- 22 versus 67 +/- 24% predicted; P = 0.017) and in carbon monoxide transfer coefficient (KCO) (89 +/- 24 versus 80 +/- 24% predicted; P = 0.004). Arterial blood gases did not change following treatment. Ten of the 41 patients (24%) exhibited a substantial decline in DLCO, which, however, recovered within 2 months (DLCO at baseline, immediately after therapy and at 2 months after completion of treatment, 84 +/- 14, 58 +/- 16 and 77 +/- 17% predicted, respectively; P < 0.001; baseline DLCO versus DLCO at 2 months, P > 0.05). Four of the 41 patients (10%) experienced dyspnea, which was self-limiting, with the exception of one patient who developed interstitial lung fibrosis. Among the various risk factors examined, older age, female gender and lower baseline DLCO were associated with more profound changes in DLCO post-treatment. CONCLUSIONS: This prospective analysis showed that the combination of gemcitabine and carboplatin induces a significant, but reversible, decrease in diffusion capacity, which is mostly asymptomatic. Thus, this regimen is safe as regards clinically significant lung toxicity.

Ovarian masses in young adolescents: imaging findings with surgical confirmation.

Functional cysts and benign neoplasms are the most common ovarian masses among young adolescents. Ovarian cancer on the other hand, although rare in this age group, is the most common genital tract malignancy. The purpose of this study was to define imaging characteristics of ovarian masses in adolescents between 12 and 21 years old and correlate imaging and surgical findings. Thirty-seven female adolescent patients aged between 12 and 21 years were operated on because of a diagnosed ovarian mass between 1997 and 2002. All patients underwent pelvic ultrasound, five had an abdominal CT scan, two had abdominal MRI, one abdominal X-ray and one intravenous pyelography. Ultrasound was used to define the size of the lesion and to characterize its gross morphologic condition as solid, simple cyst or complex cyst. The records were reviewed for age at presentation, presenting symptoms, diagnostic studies, surgical procedure and pathology findings, which were available for all patients. In our study 32 patients (86.5%) were symptomatic and five asymptomatic (13.5%). The most common presenting symptom was abdominal pain (59.5%). Thirty-four patients (91.1%) had benign lesions, two had malignant tumors (5.4%) and one patient had a borderline lesion (2.7%). The most common ovarian masses detected were germ cell tumors (27.5%) and functional cysts (25%). Twenty patients (54%) underwent operative laparoscopy and 17 patients (46%) exploratory laparotomy. Simple resection of the ovarian mass was achieved in the majority of cases (84%). Bilateral salpingo-oophorectomy was performed in only one case (2.7%).

Reverse of the differential uptake intensity of Tc-99m MIBI and Tc-99m V-DMSA by multiple myeloma lesions in response to therapy.

PURPOSE: The objective of this study was to compare the uptake changes of Tc-99m 2-methoxy isobutyl isonitrile (MIBI) and Tc-99m pentavalent dimercaptosuccinic acid (V-DMSA) in multiple myeloma (MM) lesions in response to high-dose chemotherapy (HDC). MATERIALS AND METHODS: The authors compared Tc-99m MIBI and Tc-99m V-DMSA scans before and after HDC in a patient with focal MM lesions without amyloidosis who had received previous standard chemotherapy as well. RESULTS: HDC had the effect of eliminating all Tc-99m MIBI uptake in the lesions. Tc-99m V-DMSA uptake was increased in lesions presenting significant initial Tc-99m MIBI uptake. In 1 particular lesion that demonstrated this phenomenon, magnetic resonance showed necrosis of the area of MM. CONCLUSION: The authors consider that the effect of increasing Tc-99m V-DMSA uptake in the absence of an increase in viable plasma cells possibly reflects the treatment-generated inflammatory and fibrotic changes and not necessarily viable tumor tissue. Exclusive focal Tc-99m V-DMSA uptake in this clinical setting could be considered as a sign of effectively treated lesions and not a sign of deterioration.

Detection of malignant bone marrow involvement with dynamic contrast-enhanced magnetic resonance imaging.

BACKGROUND: The purpose of this study was to evaluate the role of dynamic contrast-enhanced magnetic resonance imaging (dMRI) in detecting bone marrow involvement in cancer patients. PATIENTS AND METHODS: We studied 50 consecutive patients with histologically confirmed malignant dissemination to the bone marrow, using dMRI of the lumbosacral spine. Time-signal intensity curves were generated from regions of interest (ROIs) obtained from areas of obvious bone marrow disease (group B). In 16 patients from group B with focal disease, ROIs were also placed on areas with apparently normal bone marrow on static magnetic resonance images (group C). Twenty-two patients with no history of malignancy were used as a control group (group A). Wash-in (WIN) and wash-out (WOUT) rates, time to peak (TTPK), time to maximum slope (TMSP) values and WIN/TMSP ratios were calculated for each patient. Mean values for the three groups were compared statistically. Six patients from group B had follow-up dMRI after chemotherapy: four patients achieved a clinical partial response and two had resistant disease. RESULTS: A significant difference was found between groups A and B for all values. Between groups A and C, in spite of the similar static MRI appearance, all values were significantly different. Between groups B and C, a significant difference was found for WIN, WOUT rates and WIN/TMSP ratio. Follow-up dMRI data analysis correlated well with clinical staging. CONCLUSIONS: dMRI can distinguish normal from malignant bone marrow. It may identify malignant bone marrow infiltration in patients with negative static MRI and serve as both a diagnostic and prognostic tool for patients with bone marrow malignancies.