Hallmarks of Cancer in the Reading Room: A Guide for Radiologists.

OBJECTIVE: The hallmarks of cancer are mechanisms that cells develop to undergo malignant transformation. The targeting of these hallmarks by newer cancer therapies results in new mechanisms of response, toxicity, and resistance. The purpose of this article is to review these hallmarks, their associated targeted therapies, imaging features of responses, and toxicities. CONCLUSION: Ten hallmarks, among them proliferative signaling, angiogenesis, immune response, and genome instability, are reviewed. Molecular targeted therapies, including antiangiogenic factors and immune checkpoint inhibitors, target these hallmarks.

Can the synthetic C view images be used in isolation for diagnosing breast malignancy without reviewing the entire digital breast tomosynthesis data set?

AIMS AND OBJECTIVES: The aim of this study was to determine if the synthetic C view acquired at digital breast tomosynthesis (DBT) would give adequate information to confirm a malignancy and could obviate the need to review all the tomosynthesis image data set. METHODS: All patients with biopsy-proven breast cancer recalled from screening mammograms between May and September 2016 were included for review. For each patient, the screening 2D mammogram, the synthetic C view, and the DBT images were reviewed by three breast radiologists and each assigned a BIRADS code. Any discrepancies were reviewed and resolved by consensus. RESULTS: A total of 92 patients were diagnosed with breast cancer in this time period. Fourteen were excluded because they did not have DBT performed. Five women were recalled for evaluation of two lesions. In total, 83 lesions were assessed. In 27 cases, the BIRADS code remained unchanged in the three modalities. In 16 cases, the lesions appeared more concerning on C view and DBT that on the original mammogram but were not definitive for malignancy (BIRADS 4). In 29 cases, a BIRADS 5 code was assigned on C view and tomosynthesis but not on 2D. For 11 lesions, a BIRADS 5 code was assigned only on DBT. Four women had BIRADS 5 lesions seen on both the C view and DBT that were not seen on the screening 2D mammogram. One was multifocal. CONCLUSION: While the synthetic C view gives additional information when compared to a screening 2D mammogram, the full DBT tomosynthesis data set needs to be reviewed to diagnose a breast malignancy.

Hepatobiliary phase MRI: impact on planning image-guided liver tumor ablations.

PURPOSE: To assess the impact of hepatobiliary phase images obtained during intravenous gadoxetate disodium-enhanced liver MRI in the planning of image-guided liver tumor ablations. METHODS: This institutional review board-approved retrospective study included 34 patients (21 men, 13 women, ages 25-80) who underwent 36 liver MRI examinations with gadoxetate disodium within 12 weeks prior to image-guided thermal ablation of 62 liver tumors during 36 procedures. Visibility of bile ducts, subdivided by branch order, on hepatobiliary phase images was compared to standard MRI sequence images by an attending abdominal radiologist and fellow. Interventional decision making (whether or not to ablate and technical plan) using hepatobiliary phase images was compared with standard MRI sequences by the ablationists. The technical success and adverse events of ablation procedures were noted. RESULTS: Bile duct visibility was significantly increased by at least one branch order in 18/36 (50%) examinations (p < 0.0001). Interventional decisions were significantly impacted in 15 (41.7%) of 36 ablation procedures (p < 0.0001), including changes to the technical plan in six (16.7%) of these procedures (p = 0.005). Technical success was achieved for 60/62 (97%) of tumors. Mild (grade 1) adverse events occurred in 4/36 (11%) procedures; no biliary complications occurred. CONCLUSIONS: Use of hepatobiliary phase images obtained during gadoxetate disodium-enhanced liver MRI impacted both when and how to perform image-guided liver tumor ablations in our practice.

Evolving Cancer Classification in the Era of Personalized Medicine: A Primer for Radiologists.

Traditionally tumors were classified based on anatomic location but now specific genetic mutations in cancers are leading to treatment of tumors with molecular targeted therapies. This has led to a paradigm shift in the classification and treatment of cancer. Tumors treated with molecular targeted therapies often show morphological changes rather than change in size and are associated with class specific and drug specific toxicities, different from those encountered with conventional chemotherapeutic agents. It is important for the radiologists to be familiar with the new cancer classification and the various treatment strategies employed, in order to effectively communicate and participate in the multi-disciplinary care. In this paper we will focus on lung cancer as a prototype of the new molecular classification.

Patterns and Prognostic Importance of Hepatic Involvement in Patients with Serous Ovarian Cancer: A Single-Institution Experience with 244 Patients.

Purpose To evaluate the frequency, patterns, and prognostic importance of metastatic hepatic involvement in serous ovarian cancer. Materials and Methods This institutional review board-approved retrospective study, with waived informed consent, included 244 patients with pathologically proven serous ovarian cancer (mean age ± standard deviation, 59 years ± 10.7; range 19-93 years). Electronic medical records and all available imaging studies over a median follow-up of 44 months (interquartile range [IQR], 27-70) were reviewed to identify the frequency of liver parenchymal invasion (LPI) from perihepatic peritoneal metastasis and hematogenous liver metastases. The associations and prognostic importance of LPI and hematogenous metastases were studied by using univariate and multivariate Cox proportional analysis. Results Eighty-four of 244 patients (34%) developed perihepatic metastases, of whom 55 (23%) developed LPI after median of 43 months (IQR, 25-63). Hematogenous hepatic metastases developed in 38 of 244 patients (16%) after median of 42 months (IQR, 26-64). At multivariate analysis, age (P = .008; hazard ratio [HR]: 1.03; 95% confidence interval [CI]: 1.009, 1.07) and suboptimal cytoreduction (P = .03; HR, 2.13; 95% CI: 1.12, 4.07) were associated with LPI. Increasing age (P = .01; HR, 1.04; 95% CI: 1.008, 1.08), high-grade tumor (P = .01; HR, 6.75; 95% CI: 1.44, 120.5), and advanced stage (P = .03; HR, 3.16; 95% CI: 1.94, 4.56) were associated with hematogenous metastases. Overall survival with and without LPI was similar (median, 80 months; IQR, 50-not reached vs 123 months; IQR, 49-279; P = .6). Hematogenous metastases were associated with significantly shorter survival at univariate (median 63 months, IQR 43-139 vs 145 months, IQR 50-not reached; P = .006) and multivariate analyses (P = .03; HR, 1.88; 95% CI: 1.14, 3.28). Conclusion Differentiating hematogenous metastases and LPI is important for radiologists; hematogenous metastases are associated with shorter survival, while LPI does not adversely affect survival and prognostically behaves like peritoneal disease. © RSNA, 2016.

Metastatic Patterns of Solitary Fibrous Tumors: A Single-Institution Experience.

OBJECTIVE: The objective of our study was to evaluate the metastatic patterns and imaging features of solitary fibrous tumors (SFTs). MATERIALS AND METHODS: This retrospective study included 139 patients with pathologically proven SFT, 49 of whom developed metastases. Electronic medical records and all available images were reviewed to record the pattern and imaging appearances of metastatic disease, and comparisons of thoracic SFTs and extrathoracic SFTs were also performed. Associations of metastatic spread were studied using univariate and multivariate Cox regression analyses. RESULTS: A total of 49 (35%) patients developed metastases at a median of 124 months (interquartile range [IQR], 66-195 months) after SFT diagnosis; 11 patients (8%) had metastases at presentation. Of these 49 patients, 40 patients died at a mean of 183 months after diagnosis. The associations with metastatic disease on univariate analysis were tumor size ≥ 10 cm (p = 0.01) and malignant pathology or mitotic count ≥ 4 per 10 high-power fields (HPF) (p < 0.001). Malignant pathology and a mitotic count of ≥ 4 per 10 HPF were also associated with metastatic disease on multivariate analysis (p = 0.01; hazard ratio, 0.22; 95% CI, 0.05-0.73). The most common sites of metastasis were the lungs (30/49, 61%) followed by the pleura (24/49, 49%) and then the liver (20/49, 41%), bones (20/49, 41%), and peritoneum (20/49, 41%). A significantly higher proportion of patients with extrathoracic SFT had metastatic disease (37/139, 27%) compared with those with thoracic SFT (12/139, 9%) (p = 0.003). The overall metastasis-free survival was a median of 117 months (IQR, 33-169 months) in patients with extrathoracic SFT and a median of 120 months (IQR, 82-169 months) in patients with thoracic SFT (p = 0.01). CONCLUSION: A mitotic count of ≥ 4 per 10 HPF or malignant pathology was significantly associated with metastatic disease on both univariate and multivariate analyses. The sites of metastatic disease differed depending on the site of the primary SFT but were most commonly the lung and pleura. Patients with extrathoracic SFT were statistically more likely to develop metastatic disease than those with thoracic SFT.

Comparison of performance of various tumor response criteria in assessment of sunitinib activity in advanced gastrointestinal stromal tumors.

PURPOSE: To compare the performance of various tumor response criteria (TRC) in the assessment of patients with advanced gastrointestinal stromal tumor (GIST) treated with sunitinib after failure of imatinib. METHODS: Sixty-two participants with advanced GIST in two clinical trials received oral sunitinib after prior failure of imatinib (median duration 24 weeks; interquartile range 14-56) and were followed with contrast-enhanced computed tomography at baseline and thereafter at median intervals of 6 weeks (IRQ 6-9). Tumor response was prospectively determined using Response Evaluation Criteria in Solid Tumors (RECIST) 1.0, and retrospectively reassessed for comparison using RECIST 1.1, Choi criteria, and modified Choi (mChoi) criteria using the original target lesions. For mChoi criteria, progressive disease was defined as 20% increase in sum of the longest dimension, similar to RECIST 1.1. Clinical benefit rate (CBR; complete response, partial response, or stable disease ≥12 weeks) and progression-free survival were compared between various TRCs using kappa statistics. RESULTS: While partial response as the best response was more frequent by Choi and mChoi criteria (50% each) than RECIST 1.1 (15%) and RECIST 1.0 (13%), CBR was similar between various TRCs (overall CBR 60%-77%, 77%-94% agreement between all TRC pairs). Time to best response was shorter for Choi and mChoi criteria (median 11 weeks each) compared to RECIST 1.1 and RECIST 1.0 (median 25 and 24 weeks, respectively). PFS was similar for RECIST 1.1, RECIST 1.0, and mChoi (median 35 weeks each), and shortest for Choi criteria (median 23 weeks). CONCLUSIONS: CBR was similar among the various TRCs, although Choi criteria led to earlier determination of disease progression. Therefore, RECIST 1.1 and mChoi criteria may be preferred for response assessment in patients with advanced GIST.

Anastomosing hemangiomas: locations of occurrence, imaging features, and diagnosis with percutaneous biopsy.

PURPOSE: To describe a series of anastomosing hemangiomas and report its locations, imaging features, and the use of image-guided percutaneous biopsy to establish the diagnosis. METHODS: In this institutional review board-approved, HIPAA compliant, retrospective study, an electronic pathology database was searched for all cases of anastomosing hemangioma from January 2009 to January 2015, yielding 32 cases (18 men, mean age 62 years). Tumor locations were recorded, and in a subgroup of patients with imaging, image characteristics (contour, attenuation, enhancement after intravenous contrast injection, the presence of hemorrhage or fat attenuation, and non-enhancing component) were evaluated. The number of cases diagnosed using percutaneous biopsy specimen was determined, and in a subgroup of these patients, biopsy technique and complications were assessed. RESULTS: Anastomosing hemangioma occurred in different locations, more commonly in the retroperitoneum (15/32, 47%), including the kidney (7/32, 22%), and more rarely in the ovary (4/32, 13%) and liver (2/32, 6%). Of the 5 cases with imaging available, four anastomosing hemangiomas were in the retroperitoneum (one in retroperitoneal fat, one para-aortic, one renal and one adrenal) and the fifth was mesenteric. Most tumors were well circumscribed (4/5, 80%), and on non-contrast CT, they appeared as mildly hyperdense (4/5, 80%) with avid contrast enhancement and heterogeneous attenuation (4/5, 80%) due to the presence of fat (2/5, 40%) or non-enhancing components (2/5, 40%). Diagnosis was rendered solely based on percutaneous biopsy in 7/32 (22%), all of which were core biopsy specimens. Fine-needle aspiration biopsy was performed in 1 case, which was non-diagnostic. CONCLUSIONS: Anastomosing hemangioma, a rare benign vascular tumor, is most commonly seen in the retroperitoneal fat and kidneys. On imaging, they are usually circumscribed, hyperdense, and heterogeneous due to fatty or non-enhancing hypodense areas and show avid post-contrast enhancement. Percutaneous biopsy can yield the diagnosis, potentially avoiding surgery.

Accuracy and feasibility of estimated tumour volumetry in primary gastric gastrointestinal stromal tumours: validation using semiautomated technique in 127 patients.

OBJECTIVES: To validate estimated tumour volumetry in primary gastric gastrointestinal stromal tumours (GISTs) using semiautomated volumetry. METHODS: In this IRB-approved retrospective study, we measured the three longest diameters in x, y, z axes on CTs of primary gastric GISTs in 127 consecutive patients (52 women, 75 men, mean age 61 years) at our institute between 2000 and 2013. Segmented volumes (Vsegmented) were obtained using commercial software by two radiologists. Estimate volumes (V1-V6) were obtained using formulae for spheres and ellipsoids. Intra- and interobserver agreement of Vsegmented and agreement of V1-6 with Vsegmented were analysed with concordance correlation coefficients (CCC) and Bland-Altman plots. RESULTS: Median Vsegmented and V1-V6 were 75.9, 124.9, 111.6, 94.0, 94.4, 61.7 and 80.3 cm(3), respectively. There was strong intra- and interobserver agreement for Vsegmented. Agreement with Vsegmented was highest for V6 (scalene ellipsoid, x ≠ y ≠ z), with CCC of 0.96 [95 % CI 0.95-0.97]. Mean relative difference was smallest for V6 (0.6 %), while it was -19.1 % for V5, +14.5 % for V4, +17.9 % for V3, +32.6 % for V2 and +47 % for V1. CONCLUSION: Ellipsoidal approximations of volume using three measured axes may be used to closely estimate Vsegmented when semiautomated techniques are unavailable. KEY POINTS: Estimation of tumour volume in primary GIST using mathematical formulae is feasible. Gastric GISTs are rarely spherical. Segmented volumes are highly concordant with three axis-based scalene ellipsoid volumes. Ellipsoid volume can be used as an alternative for automated tumour volumetry.

Advanced High-Grade Serous Ovarian Cancer: Frequency and Timing of Thoracic Metastases and the Implications for Chest Imaging Follow-up.

PURPOSE: To study the frequency, timing, and associations of thoracic metastases in advanced (stage III and IV) high-grade serous ovarian cancer (HGSC) to help optimize the use of cross-sectional chest imaging. MATERIALS AND METHODS: This institutional review board-approved retrospective study with waived informed consent included 186 consecutive patients with pathologically proven advanced HGSC after primary cytoreduction (mean age ± standard deviation, 60 years ± 9.7) who underwent imaging at our tertiary cancer institution from January 2012 to December 2012 with at least 1 year of follow-up, unless there was thoracic metastasis or death. Electronic medical records and all available imaging studies were reviewed to record patient and tumor characteristics, frequency and timing of abdominal and thoracic metastases, and visibility of the first thoracoabdominal metastasis on abdominal images. Patient and tumor characteristics associated with thoracic metastases were studied by using univariate and multivariate Cox proportional analysis. RESULTS: After median follow-up of 57 months (interquartile range [IQR], 38-93), 175 patients (94%) developed metastatic disease; each had abdominal disease, and 76 (41%) had thoracic metastases. The first thoracoabdominal metastasis was visible on abdominal images in all 175 patients. The thoracic metastasis-free interval was longer than the abdominal disease-free interval (median, 85 months [IQR, 28-131] vs 14 months [IQR, 7-27], respectively; P < .0001). Presence of disease on abdominal images (hazard ratio, 2.56; 95% confidence interval: 1.35, 4.76) was the only factor independently associated with thoracic metastases. CONCLUSION: Thoracic metastases in advanced HGSC rarely occur before abdominal disease, and first thoracoabdominal metastases are invariably visible on abdominal images. Therefore, cross-sectional chest imaging may be deferred until development of abdominal disease, with minimal risk of missing thoracic metastases.

Hermansky-pudlak syndrome complicated by pulmonary fibrosis: radiologic-pathologic correlation and review of pulmonary complications.

Hermansky-Pudlak syndrome (HPS) is a rare autosomal recessive disorder characterized by oculocutaneous hypopigmentation, platelet dysfunction, and in many cases, life-threatening pulmonary fibrosis. We report the clinical course, imaging, and postmortem findings of a 38-year-old female with HPS-related progressive pulmonary fibrosis, highlighting the role of imaging in assessment of disease severity and prognosis.

"EcoRadiology"--pulling the plug on wasted energy in the radiology department.

RATIONALE AND OBJECTIVES: We sought to evaluate the power consumption of various devices around the radiology department, audit our use of recycling, and review efforts by vendors to reduce the environmental impact of their products. MATERIALS AND METHODS: Using a readily available power monitor, we calculated the power consumption of different devices around our department. In particular, we calculated the financial and environmental cost of leaving equipment on overnight and/or at weekends. When it was not possible to measure energy usage directly, we obtained and reviewed relevant technical manuals. We contacted vendors directly to document how the environmental impact of new technology and decommissioning aging technology is being tackled. RESULTS: We found that 29 of 43 desktop computers and 25 of 27 picture archiving and communications system (PACS) reporting stations were left on needlessly overnight and/or at weekends, resulting in estimated electrical running costs while not in use of approximately $7253 per year, and CO2 emissions equivalent to the annual emissions of over 10 passenger cars. We discovered that none of our PACS reporting stations supported energy-saving modes such as "sleep" or "hibernate." Despite encouraging staff to turn off computers when not in use, a reaudit found no improvement in results. CONCLUSIONS: Simple steps such as turning off computers and air-conditioning units can produce very significant financial and environmental savings. Radiology can lead the way in making hospitals more energy efficient.

Practical tips and tricks for assessing prosthetic valves and detecting paravalvular regurgitation using cardiac CT.

Paravalvular leaks are an uncommon but serious complication of prosthetic valves. Transthoracic echocardiography is used in the assessment of prosthetic valves but can be limited by acoustic shadowing from the prosthesis and poor acoustic windowing. Small case series have previously shown cardiac CT to have promising results in detecting paravalvular leaks. We assessed 32 valves in our institution on cardiac CT using echocardiography results as standard and developed methods for improved evaluation of prosthetic valves. These include optimizing prescan drug therapy for heart rate control, optimum window and center adjustments, and carefully selected image planes to best demonstrate the valve ring and valve annulus. Recognition of surgical material is also important to recognize. In this review, we provide a detailed description of these techniques with imaging examples of prosthetic valve evaluation using cardiac CT.

Thyroid lymphoma on a background of Hashimoto's thyroiditis: PET/CT appearances.

Primary thyroid lymphoma is a rare thyroid tumor accounting for only 5% of all thyroid malignancies. It is more common in patients with a background history of chronic thyroiditis. PET/CT is helpful in the initial staging and for follow up to assess treatment response.

Magnetic resonance imaging appearances in primary and secondary angiosarcoma of the breast.

Angiosarcomas are malignant tumours of endovascular origin. They are rare tumours accounting for 0.04-1% of all breast malignancies. Two different forms are described: primary, occurring in young women, and secondary angiosarcoma, which occurs in older women with a history of breast-conserving surgery and radiation therapy. Imaging findings on mammography and ultrasound are non-specific, but magnetic resonance imaging with dynamic contrast enhancement is more informative. We present two cases - one of primary and one of secondary angiosarcoma - and review the imaging findings.

Staging of gastroenteropancreatic neuroendocrine tumors: how we do it based on an evidence-based approach.

In contrast to other common types of malignant tumors, the vast majority of gastroenteropancreatic neuroendocrine tumors are well differentiated and slowly growing with only a minority showing aggressive behavior. It is important to accurately stage patients radiologically so the correct treatment can be implemented and to improve prognosis. In this article, we critically appraise the current literature in an effort to establish the current role of radiologic imaging in the staging of neuroendocrine tumors. We also discuss our protocol for staging neuroendocrine tumors.

Poststernotomy lymphadenopathy: prevalence, size, and location on chest CT.

PURPOSE: We aimed to determine the prevalence of enlarged lymph nodes (LNs) in chest computed tomography (CT) scans of patients with a history of sternotomy. MATERIALS AND METHODS: The chest CT scans of 271 patients with a history of sternotomy (mean age, 68.3±14.4 years; range, 15-93 years; 178 males) were retrospectively scored in a blind and random manner for the presence, size, and location of enlarged LNs. Scans with known etiologies for enlarged LNs were excluded. Serial scans were available for 15 patients with enlarged LNs. Twenty patients (mean age, 61.2±7.0 years; range, 54-64 years; 15 males) that had cardiac CT data with no cardiac surgery were included as controls. RESULTS: Of the 271 patients, 189 had other identifiable etiologies for enlarged LNs. Of the remaining 82 patients, 36 (44%) demonstrated enlarged LNs. None of the control patients presented with enlarged LNs (n=20). The mean size of the enlarged nodes was 13.0±2.0 mm. Enlargement of the lymph nodes in station 4R was most common (n=18, 50%; size, 13.1±2.0 mm), followed by the enlargement of nodes in station 7 (n=16, 44%; size, 12.3±2.2 mm). The majority of patients had one (n=20, 56%) or two (n=12, 33%) nodal stations that showed enlargement. We did not observe any significant association between the number or types of grafts and enlarged LNs. Serial CT scans did not show any significant changes in LN enlargement for any nodal station. CONCLUSIONS: Enlarged mediastinal and/or hilar LNs are common in patients with a history of previous sternotomy. It is important for radiologists to be aware of this association to avoid misdiagnosis and further unnecessary procedures for nodal sampling.

Thrombosed prosthetic valve in Ebstein's anomaly: Evaluation with echocardiography and 64-slice cardiac computed tomography.

Ebstein's anomaly (EA) is a rare cardiac congenital malformation with displacement of septal and posterior tricuspid leaflets, resulting in atrialization of the right ventricle. We report a case of EA in which the etiology of a malfunctioning prosthetic tricuspid valve is depicted on cardiac computed tomography to be as a result of thrombus lodged in the valve.

Investigation of cardiomyopathy using cardiac magnetic resonance imaging part 2: Rare phenotypes.

Cardiac magnetic resonance imaging (CMRI) has emerged as a useful tertiary imaging tool in the investigation of patients suspected of many different types of cardiomyopathies. CMRI images are now of a sufficiently robust quality to enable high spatial and temporal resolution image acquisition. This has led to CMRI becoming an effective non-invasive imaging tool for many cardiomyopathies. In this two-part review we outline the typical sequences used to image cardiomyopathy and present the imaging spectrum of cardiomyopathy. Part I focused on the current classification of cardiomyopathy, the basic CMRI sequences used in evaluating cardiomyopathy and the imaging spectrum of common phenotypes. Part II illustrates the imaging spectrum of the more rare phenotypes.