Imaging of Ganglioneuroma: A Literature Review and a Rare Case of Cystic Presentation in an Adolescent Girl.

Retroperitoneal ganglioneuroma is a rare neuroectodermal tumor with a benign nature. We performed a literature review among 338 studies. We included 9 studies, whose patients underwent CT and/or MRI to characterize a retroperitoneal mass, which was confirmed to be a ganglioneuroma by histologic exam. The most common features of ganglioneuroma are considered to be a solid nature, oval/lobulated shape, and regular margins. The ganglioneuroma shows a progressive late enhancement on CT. On MRI it appears as a hypointense mass in T1W images and with a heterogeneous high-intensity in T2W. The MRI-"whorled sign" is described in the reviewed studies in about 80% of patients. The MRI characterization of a primitive retroperitoneal cystic mass should not exclude a cystic evolution from solid masses, and in the case of paravertebral location, the differential diagnosis algorithm should include the hypothesis of ganglioneuroma. In our case, the MRI features could have oriented towards a neurogenic nature, however, the predominantly cystic-fluid aspect and the considerable longitudinal non-invasive extension between retroperitoneal structures, misled us to a lymphatic malformation. In the literature, it is reported that the cystic presentation can be due to a degeneration of a well-known solid form while maintaining a benign character: the distinguishing malignity character is the revelation of immature cells on histological examination.

Pretreatment MRI Radiomics Based Response Prediction Model in Locally Advanced Cervical Cancer.

The aim of this study was to create a radiomics model for Locally Advanced Cervical Cancer (LACC) patients to predict pathological complete response (pCR) after neoadjuvant chemoradiotherapy (NACRT) analysing T2-weighted 1.5 T magnetic resonance imaging (MRI) acquired before treatment start. Patients with LACC and an International Federation of Gynecology and Obstetrics stage from IB2 to IVA at diagnosis were retrospectively enrolled for this study. All patients underwent NACRT, followed by radical surgery; pCR-assessed on surgical specimen-was defined as absence of any residual tumour. Finally, 1889 features were extracted from MR images; features showing statistical significance in predicting pCR at the univariate analysis were selected following an iterative method, which was ad-hoc developed for this study. Based on this method, 15 different classifiers were trained considering the most significant features selected. Model selection was carried out using the area under the receiver operating characteristic curve (AUC) as target metrics. One hundred eighty-three patients from two institutions were analysed. The model, showing the highest performance with an AUC of 0.80, was the random forest method initialised with default parameters. Radiomics appeared to be a reliable tool in pCR prediction for LACC patients undergoing NACRT, supporting the identification of patient risk groups, which paves treatment pathways tailored according to the predicted outcome.

Stereobody radiotherapy for nodal recurrences in oligometastatic patients: a pooled analysis from two phase I clinical trials.

Stereotactic body radiotherapy (SBRT) has been shown to achieve high local control rates in limited metastatic burden of disease. Few papers reported on the efficacy of SBRT in nodal oligometastases. The primary aim of the present paper was to analyze the treatment outcome in this setting. Data from DESTROY-1 and SRS-DESTROY-2 phase I clinical trials were reviewed and analyzed. These trials were based on a 5 fractions and a single fraction regimens, respectively. End-points of this analysis were toxicity rates, overall response rate (ORR), and local control (LC). Patients treated between December 2003 and January 2018, with any metastatic site, and primary tumor type and histology were included. One hundred-eighty-one patients (M/F: 93/88; median age: 67, range 37-88) treated with SBRT on 253 nodal lesions were analyzed. Initially, the used technique was 3D-CRT (20.9%), while subsequently treatments were delivered by VMAT (79.1%). The total dose to the PTV ranged between 12 Gy/single fraction to 50 Gy/5 fractions. With a median follow-up of 21 months (2-124), no grade 3 acute or late toxicity was recorded. ORR based on functional imaging was 92.5% with a complete response rate of 76%. Two- and three-year actuarial LC were 81.6% and 76.0%, respectively. Our large pooled analysis confirms the efficacy and safety of SBRT/SRS in patients with nodal metastases and identifies clinical and treatment variables able to predict complete response and local control rate.

Extreme complications related to bevacizumab use in the treatment of ovarian cancer: a case series from a III level referral centre and review of the literature.

In patients undergoing debulking surgery for ovarian cancer (OC), bevacizumab-combined chemotherapy has been reported to be associated with an increased incidence of adverse events (AEs). Reports in the literature have noted the overall morbidity of bevacizumab to be between 3.7% and 9%. The aim of this study is to report uncommon and unusual manifestations of morbidity in surgical cases performed at our third level referral centers for gynecologic oncology. Additionally, we review the rare and severe bevacizumab-related complications that have been described in the literature. We defined as "extreme", the particularly rare and/or severe complications up to determining a life-threatening condition or death, which are related to the use of bevacizumab. A case-series of extreme complications registered at our institutions were reported. In addition, a literature search of the PubMed, MEDLINE and EMBASE electronic databases was performed for this review. The studies collected included: 8 randomized controlled trials (RCT) and 5 prospective observational, 1 prospective phase-IV, 10 prospective phase-II, 2 prospective phase-I, and 20 retrospective studies, as well as 9 case reports. Bevacizumab was administered as primary treatment in adjuvant and neo-adjuvant setting in 16 and 5 studies respectively, as treatment for recurrence in 36 trials, and for secondary cytoreductive surgery (SCS) in 3 studies. The overall population administered with bevacizumab numbered 7,096 women. Extreme complications were observed in 591 patients, with a morbidity rate of the 8.3%. Overall, central nervous system (CNS), cardiovascular, gastrointestinal (GI) and primary infectious complications were seen in 22 patients (0.3%), 261 patients (3.7%), 159 patients (2.2%), and 8 patients (0.13%), respectively. Hemorrhagic and wound complications occurred in 18 women (0.25%), and 112 women (1.6%), respectively. Extreme complications related to the use of bevacizumab are rare, and often go unrecognized. The recognition and immediate management of such rare and life-threatening complications in patients treated at third level referral centers could significantly improve patient survival.

Colitis cystica profunda of the rectum with adenomatous dysplastic features: Radiologic-pathologic correlation.

Colitis cystica profunda is a rare nonneoplastic condition characterized by the presence of mucus-containing cysts in the submucosa of the right colon and rectum. The etiology is unclear, with a few cases reported in the literature. The presenting symptoms and signs may mimic colorectal adenocarcinoma. We report a case of colitis cystica profunda localized in the rectum, investigated by colonoscopy, CT, MRI, and subsequently surgically treated.

An atlas for clinical target volume definition, including elective nodal irradiation in definitive radiotherapy of biliary cancer.

Radiotherapy (RT) is a treatment option for advanced biliary tract cancer (BTC), often combined with sequential and/or concurrent chemotherapy. The use of modern RT techniques requires accurate clinical target volume (CTV) definition and delineation. However, guidelines for CTV delineation in BTC are lacking. Therefore, the aim of this study was to propose a computer tomography (CT) atlas for CTV definition of BTC. We previously proposed guidelines to define the nodal CTV (CTV-N) in BTC. In this study, based on a literature analysis, we defined the margins to be added to the gross tumor volume (GTV; subclinical and microscopic disease) to define the primary tumor CTV (CTV-T). An abdominal contrast enhanced planning CT scan was performed on three different patients with unresectable intrahepatic cholangiocarcinoma (CC), extrahepatic CC and gallbladder cancer. The GTV and anatomical reference structures were outlined on CT images. Then, based on our guidelines, the CTV-T and CTV-N were delineated and merged to define the final CTV in the three patients. An atlas, showing the defined CTV, was generated from the reference CT images to illustrate the CTV for intra-hepatic CC, extra-hepatic CC and gallbladder cancer. This atlas can be used as an aid for CTV definition in patients with BTC treated with modern RT techniques.

Dose escalation in extracranial stereotactic ablative radiotherapy (DESTROY-1): A multiarm Phase I trial.

OBJECTIVE:: A multiarm Phase I clinical trial was performed to define the maximum tolerated dose (MTD) of stereotactic body radiotherapy (SBRT) delivered by non-coplanar conformal beams or volumetric modulated arc therapy technique in seven predefined clinical settings. METHODS:: The (a) and (b) arms investigated primary and metastatic lung cancer differentiated by site of onset, arm (c) included primary or metastatic lesions outside the thorax, the (d) and (e) arms were for in-field reirradiation of recurrence, and finally, the (f) and (g) arms were for boost irradiation to the lesions after an adjuvant RT prescribed dose. A 4 months cut-off after previous irradiation course was fixed to distinguish the boost from the retreatment (<4 vs >4 months, respectively). Patients were prospectively enrolled in study arms according to tumor site, clinical stage and previous treatment. The total dose prescribed to the isocenter, ranged from 20 to 50 Gy according to the protocol design and the doses per fraction ranged from 4 to 10 Gy in 5 days. RESULTS:: A total of 281 patients (M/F: 167/114; median age: 69 years) with 376 lesions underwent SBRT. No acute toxicity was reported in 175 patients (62.3%) while 106 (37.7%) experienced only low-grade (G < 2) acute toxicity. Four patients (all previously irradiated in the same site) showed >Grade 2 toxicity within 6 months from SBRT. With a median follow-up of 19 months, 204 patients (72.6%) did not experience late toxicity, and 77 (27.4%) experienced low grade late toxicity. On per-lesion basis, the 12-and 24 months actuarial local control inside the SBRT field were 84.3 and 73.7 %, respectively. CONCLUSIONS:: SBRT delivered in five consecutive fractions up to the doses evaluated is well tolerated. The MTD was reached in four (a, b, c and f) of the seven study arms. Recruitment for (d), (e) and (g) arms is still ongoing. ADVANCES IN KNOWLEDGE:: In a prospective dose-escalation trial, the MTD of 50 Gy/10 Gy fraction and 35 Gy/7 Gy fraction were defined for primary and metastatic lesions and as boost after prior RT dose ≤50 Gy, respectively.

Spontaneous rectus sheath hematoma: The utility of CT angiography.

We described the utility of computed tomography (CT) angiography in detection of bleeding vessels for a rapid percutaneous arterial embolization of the spontaneous rectus sheath hematoma. A 70-year-old woman comes to our attention with acute abdominal pain and a low hemoglobin level. An unenhanced CT was performed demonstrating a large rectus sheath hematoma. A conservative management was initially established. Despite this therapy, the abdominal pain increased together with a further decrease of hemoglobin values. A CT angiography was then performed, demonstrating an active bleeding within the hematoma and addressing the patient to a rapid percutaneous arterial embolization.

Giant angioleiomyoma of uterus: A case report with focus on CT imaging.

We report a rare case of giant angioleiomyoma located in the uterus and detected in a 37-year-old woman. The uterus is an extremely rare location for angioleiomyoma. The definitive diagnosis is usually obtained only after the histopathologic examination because the imaging criteria are challenging for this disease. We focused our attention on the main computed tomography features able to provide a robust preoperative diagnosis of this rare clinical entity.

Sagittal Normal Limits of Lumbosacral Spine in a Large Adult Population: A Quantitative Magnetic Resonance Imaging Analysis.

OBJECTIVES: The objective of this study was to determine, using magnetic resonance imaging (MRI) of the lumbosacral spine from L1 to S1, the values of the normal sagittal diameter of the spinal canal (SCD), sagittal diameter of the dural sac (DSD), and the normal values of dural sac ratio (DSR) in a large nonsymptomatic adult population and to discriminate whether a vertebral canal is pathological or nonpathological for dural ectasia and/or stenosis. MATERIALS AND METHODS: Six hundred and four patients were prospectively enrolled. All measurements were performed on MRI sagittal T1- and T2-weighted images. The 95% confidence interval (95% CI), defined as mean ± 1.96 standard deviation, was determined for each metric. The upper limit of 95% CI was considered the cutoff value for the normal DSR; the lower limit of 95% CI was considered the cutoff value for the normal SCD. RESULTS: SCD cutoff values from L1 to S1 ranged from 14.5-10.1 mm (males) to 15.0-9.9 mm (females). DSD ratios at S1 and L4 level show a significant difference in male and female groups: 11% of S1/L4 values exceeded 1 in male group while only 4% of S1/L4 values exceeded 1 in female group. Mean DSR at each level was significantly higher in female patients than in male patients (P < 0.001), ranging from 0.70 to 0.56 (male) and from 0.82 to 0.63 (female). CONCLUSIONS: We determined the cutoff values for the normal DSR and for the normal SCD. Our findings show the relevant discrepancies with respect to literature data for diagnosis of lumbar stenosis and/or dural ectasia.

Computed tomography angiography of unilateral agenesis of the internal carotid artery: 2 cases report with focus on embryology, collateral pathways, and imaging.

Congenital absence of internal carotid artery (ICA) is a rare anomaly seen in around 0.01% of the population. High incidence of aneurysms is reported in these patients population. Many patients are asymptomatic as the development of a collateral circulation ensures cerebral perfusion. The embryology, the common collateral pathways, and the imaging findings associated with this anomaly are illustrated with 2 new cases. We reported the cases of 2 totally asymptomatic patients at the time of imaging in which ICA agenesis was proved on computed tomography angiography. On imaging, all the most important findings necessary for ICA agenesis diagnosis have been identified and described. Noninvasive imaging techniques are currently the mainstay of ICA agenesis diagnosis.

Incidental Finding of Dual Ectopic Thyroid on Computed Tomography Angiography.

The presence of simultaneous two ectopic foci of thyroid tissue (dual ectopic thyroid) is rare, and few cases have been reported in the literature. The ectopic thyroid tissue is an extremely uncommon embryological aberration due to the alterations occurring during the embryological development with incomplete migration of thyroid precursors. Commonly ectopic thyroid tissue is a midline structures, but the lateral location is possible but very rare. Ectopic thyroid is common in women and can vary in size from a microscopic focus to a few centimeters. The normal process of migration of the thyroid can be interrupted at various levels determining a lingual ectopy, a sublingual ectopic, prelaryngeal ectopy, or mediastinic ectopy. Intrathoracic and subdiaphragmatic organs are other sites where the ectopic thyroid tissue may be present. In most of the cases, ectopic tissue is a lingual thyroid and this condition can be totally asymptomatic, discovered incidentally, or occurs with symptoms such as dysphonia, dysphagia, dyspnea, and hemoptysis. Sublingual or suprahyoid ectopia is rare and even rarer are the cases of two foci of ectopic thyroid tissue simultaneously present. On imaging, the ectopic tissue shows the same characteristics of orthotopic thyroid tissue and similarly can undergo goiterous and cancerous transformation. We report a case of incidental dual ectopic thyroid in lingual and suprahyoid level in a 72-year-old female patient, asymptomatic and with normal thyroid function, who underwent computed tomography (CT) angiography before vascular surgery for the treatment of carotid stenosis. The presence of a lingual thyroid can lead to a difficult and dangerous intubation, with possible fatal consequences. For this reason, the discovery of these abnormalities has totally changed the patient management who has been subjected to endovascular treatment, instead to the classical surgery.

Radiological and clinical results following high-dose intensity-modulated radiotherapy in recurrent craniopharyngioma: A case report.

Craniopharyngiomas (CPs) are rare benign suprasellar tumors. The standard treatment for CP is complete surgical resection or partial resection followed by adjuvant radiotherapy (RT). Adjuvant RT is typically administered at a total dose of 54 Gy with 1.8 Gy/fraction. The current study reported the case of a young patient affected by recurrent craniopharyngioma, who was treated with irradiation subsequent to several surgical resections. Image fusion and intensity-modulated radiation therapy techniques were employed to deliver a high total dose (63 Gy with 2.1 Gy/fraction) with no severe acute toxicities recorded. At the 6-year follow-up, no radiological or clinical signs of disease progression or late sequelae were observed.

On the cutting edge of intensity modulated radiotherapy and simultaneous integrated boost (IMRT-SIB): The case of a patient with 8 brain metastases.

BACKGROUND: Patients with multiple brain metastases, especially those with more than 3 lesions, usually undergo to palliative whole brain (WB) radiotherapy (RT). METHODS: A breast cancer patient with 8 brain metastases was treated on the brain by a radical RT regimen. Prescription doses were according to the simultaneous integrated boost-intensity modulated radiation therapy (SIB-IMRT) technique with all lesions as well brain irradiated simultaneously in 20 daily fractions. Doses of 40.0 Gy (2.0 Gy/fraction) and 50.0 Gy (2.5 Gy/fraction) were prescribed to the whole brain and to eight individual metastases, respectively. RESULTS: Mean volume of the eight metastases was 8.1 cc (range: 3.8-10.1 cc). For all lesions, the volume receiving 95% of prescribed dose was 100% and dose homogeneity was within 3%. Moreover, maximum doses were less than 105% of prescribed dose, while average mean dose to lesions was 50.6 Gy (range: 49.7-51.5 Gy). Whole brain mean dose was 45.2 Gy. Maximum doses to brainstem and optic chiasma were limited to 44.5 Gy and 42.9 Gy, respectively, while maximum doses to eyes, lens and optic nerves were limited to 9.2 Gy, 4.9 Gy and 41.0 Gy, respectively. From a clinical point of view, subsequent MRI brain controls showed a complete clinical response. Forty months after treatment the patient is disease free and shows no late brain and skin toxicities. CONCLUSION: This case demonstrates the technical feasibility of a SIB-IMRT treatment in patients with more than 3 brain metastases.

Sclerosing adenosis of the breast: report of two cases and review of the literature.

BACKGROUND: Sclerosing adenosis is a benign, usually asymptomatic lobulocentric proliferative process that involves both the epithelial and the mesenchymal component of the breast. It is commonly an incidental finding in perimenopausal women undergoing screening mammography. CASE REPORT: We reported on two patients with sclerosing adenosis assessed with mammography, ultrasound, and contrast-enhanced magnetic resonance imaging. Case 1 was a 21-year-old woman with a palpable lesion in her right breast that was depicted as an irregular mass on contrast-enhanced magnetic resonance imaging. Case 2 was an asymptomatic 42-year-old woman with suspicious ultrasound findings in her left breast; contrast-enhanced magnetic resonance imaging showed regional non-mass-like enhancement associated with increased vascularity. Both patients underwent ultrasound-guided vacuum-assisted biopsy. Sclerosing adenosis does not have distinctive radiological features and can mimic a malignant growth process, thus requiring a diagnostic biopsy. CONCLUSIONS: SA is a common, benign, generally asymptomatic proliferative lesion of the breast. It is associated with a doubling of the risk of developing breast carcinoma, even though its role in carcinogenesis remains to be elucidated. It does not exhibit distinctive MG, US or even MRI features. Since it may mimic a carcinoma it requires further investigation with a diagnostic biopsy.

Integrated imaging of breast hamartoma: two case reports.

Hamartoma of the breast is an uncommon, benign, slow-growing mass usually diagnosed in women in the fourth and fifth decade of life undergoing mammography (MX). Here we report two cases of hamartoma of the breast assessed by integrated MX, ultrasonography and magnetic resonance imaging (MRI) examination. Case 1 was an asymptomatic 47-year-old woman who had never been screened previously. A 90 mm mass was found in her left breast on MX. Case 2 was a 35-year-old woman with pain in her right breast where a 50 mm mass was found on MX. Both patients underwent MRI examination. Breast MRI is an adjunct to MX that can confirm hamartoma diagnosis and exclude rare malignant transformation.