Morphological response and tumor shrinkage as predictive factors in metastatic colorectal cancer treated with first-line capecitabine, oxaliplatin, and bevacizumab.

BACKGROUND: Morphologic response (MR) is a novel chemotherapeutic efficacy predictor of solid tumors, especially those treated with anti-vascular endothelial growth factor antibodies. Nevertheless, the importance of systemic chemotherapy MR for colorectal liver metastases (CLM) remains unclear. We aimed to evaluate the usefulness of MR as a factor associated with the therapeutic effects of chemotherapy plus bevacizumab for initially unresectable CLM cases. METHODS: We retrospectively evaluated the associations between MR and/or Response Evaluation Criteria in Solid Tumors (RECIST), progression-free survival (PFS), and overall survival (OS) in patients who received first-line capecitabine, oxaliplatin, and bevacizumab treatment for initially unresectable CLM using multivariate analysis. Patients who showed a complete or partial response based on the RECIST, or an optimal response based on MR, were defined as "responders." RESULTS: Ninety-two patients were examined, including 31 (33%) patients who responded optimally. PFS and OS estimates were comparable in MR responders and non-responders (13.6 vs. 11.6 months, p = 0.47; 26.6 vs. 24.6 months, p = 0.21, respectively). RECIST responders showed better PFS and OS than non-responders (14.8 vs. 8.6 months, p < 0.01; 30.7 vs. 17.8 months, p < 0.01, respectively). The median PFS and OS estimates of MR and RECIST responders were better than those of single responders or non-responders (p < 0.01). Histological type and RECIST response were independently associated with PFS and OS. CONCLUSION: MR predicts neither PFS nor OS; nevertheless, it may be useful when combined with the RECIST. The Ethics Committee of The Cancer Institute Hospital of JFCR approved this study in 2017 (No. 2017-GA-1123): retrospectively registered.

S100-negative epithelioid malignant peripheral nerve sheath tumor with possible perineurial differentiation.

Epithelioid malignant peripheral nerve sheath tumor (MPNST) is a rare subtype of MPNST composed of epithelioid cells with abundant cytoplasm. Currently, strong and diffuse immunostaining for S100 protein and SOX10 is generally regarded as a characteristic feature of epithelioid MPNST. However, malignant tumors with epithelioid morphology that arise from a peripheral nerve or a pre-existing benign nerve sheath tumor should be regarded as epithelioid MPNSTs when they do not show characteristic features that definitively lead to other specific diagnoses. Here, we describe 3 cases of epithelioid MPNST in the peripheral nerve or schwannoma that was negative for S100 protein and SOX10 expression. Instead, these tumors were positive for EMA, GLUT1, claudin 1, and cytokeratin to varying degrees, while all of them retained SMARCB1 and H3K27me3 by immunohistochemistry. EMA, GLUT1, and claudin 1 are known markers of perineurial cell differentiation; thus, they could possibly represent epithelioid MPNST with perineurial cell differentiation.

Rapidly growing giant cell tumor of bone in a skeletally immature girl.

Giant cell tumor of bone (GCTB) in skeletally immature patients is rare, and little is known regarding how fast GCTB can grow. We report a case of a 10-year-old skeletally immature girl with pathologically proven GCTB with obvious growth plate invasion that showed surprisingly rapid growth over only 14 days. A radiograph of the left knee revealed well-circumscribed, geographic bone destruction at the distal metaphysis of the femur with a focal cortical defect, suggesting a pathologic fracture. No abnormal mineralization or periosteal reaction was seen. A CT without contrast and an MRI demonstrated a homogeneous lesion with cortical disruption posteriorly and laterally with a slight soft tissue extension. Biopsy showed numerous multinucleated giant cells and spindle-shaped mononuclear cells without any sign of malignancy, suggesting GCTB. However, rapid lesion enlargement and destruction of the surrounding cortex were noted 14 days after biopsy. Considering the amount of bone destruction, traditional treatment of curettage and bone cement would not suffice to sustain structural strength. In addition, considering the patient's age, the tumor location, and the aggressive course, a malignant tumor, especially a giant cell-rich osteosarcoma, could not be excluded. Therefore, en bloc resection, including the growth plate and prosthetic replacement, were performed. Confirmation of GCTB was made from a pathologic evaluation, and a breach to the growth plate was identified. Since very little inflammatory reaction, degenerative change, or aneurysmal, bone, cyst-like change was found, the growth plate invasion was confirmed as due to GCTB extension, not due to the preoperative biopsy.

Early evaluation of the therapeutic effect of denosumab on tartrate-resistant acid phosphatase 5b expression in a giant cell tumor of bone: a case report.

BACKGROUND: Giant cell tumor of bone is an osteolytic, usually benign, tumor characterized by the infiltration of osteoclast-like giant cells. The receptor activator of nuclear factor kappa-B ligand pathway has been shown to play a key role in the pathogenesis of giant cell tumor. Treatment for refractory, recurrent, or metastatic giant cell tumor remains challenging. A monoclonal antibody to receptor activator of nuclear factor kappa-B ligand, denosumab, offers promise in these patients. Tartrate-resistant acid phosphatase 5b, a bone resorption marker, is secreted from osteoclasts and this marker is reported to be high in patients with giant cell tumor of bone. We investigated the effects of denosumab and the usefulness of a tartrate-resistant acid phosphatase 5b as a monitoring marker in the management of a refractory giant cell tumor of bone. CASE PRESENTATION: A 41-year-old Japanese male with right ischiac pain was diagnosed with a giant cell tumor in his right ischium. Since the tumor extended to the acetabulum, there was a possibility that en bloc resection might significantly impair function of the hip joint and curettage could cause massive bleeding. Therefore, denosumab therapy (120 mg, administered 3 times every 4 weeks) was performed before radical surgery. The giant cell tumor of bone was treated with denosumab successfully. No adverse reaction was noted. Tartrate-resistant acid phosphatase 5b secretion was measured in the patient's serum to monitor the response to denosumab, and a rapid normalization of the marker was observed after the first denosumab administration. CONCLUSION: This case suggests that denosumab therapy might be an option for treating refractory giant cell tumor of bone, and that tartrate-resistant acid phosphatase 5b might be an early marker with which to monitor the efficacy of denosumab therapy for refractory giant cell tumor.

Study of surgical indication for knee arthroplasty by cartilage analysis in three compartments using data from Osteoarthritis Initiative (OAI).

BACKGROUND: Bicompartmental or unicompartmental knee arthroplasty (BKA, UKA) is currently advocated as an alternative solution to conventional total knee arthroplasty (TKA) in order to preserve bone stock and ligaments for limited osteoarthritis (OA) with intact anterior and posterior cruciate ligaments (ACL, PCL). However, the actual rate of UKA or BKA compared to TKA procedures in OA patients has not been reported. In this study, we retrospectively analyzed preoperative MRI of the knee in subjects who underwent knee arthroplasty and assessed the potential for UKA or BKA as an alternative treatment. METHODS: Data were extracted from the Osteoarthritis Initiative (OAI) public use data set, which included 4,796 subjects, ages 45-79. 3.0 Tesla MRI scanners were dedicated to imaging the knees of OAI participants annually from February 2004 to March 2010. Extensive quantitative measurements of the knee MRI were performed on 87 patients who underwent knee arthroplasty during follow-up visits. We assessed the cartilage thickness and defect size in the medial femorotibial joint (FTJ), lateral FTJ, and patellofemoral joint (PFJ) as well as ligamentous injury, bone marrow edema, and subchondral cyst size from 2D coronal turbo spin echo (TSE), 2D sagittal TSE, 3D coronal T1-weighted water-excitation fast low angle shot (FLASH), and 3D sagittal water-excitation double echo steady-state (DESS) with axial and coronal reformat images. RESULTS: Eighty-five subjects (97.7%) were subjected to TKA, while only 2 subjects (2.3%) received UKA from the OAI database. Based on the preoperative MRI findings criteria, 51 of 87 subjects (58.6%) met the indication for TKA including the 2 UKA subjects above. This rate was significantly lower (p<0.001) than the actual TKA rate received. Among 85 subjects who actually underwent TKA, 31 subjects (36.5%) and 5 subjects (5.9%) met the indication for BKA and UKA, respectively. CONCLUSIONS: Many medial or lateral compartmental OA subjects, with or without patellar compartment defects have undergone TKA. The results of this study suggest the indication for partial arthroplasty, such as UKA or BKA, may increase when cartilage in each compartment, as well as ligaments and subchondral bone status are comprehensively evaluated.

Radiological insertion of Denver peritoneovenous shunts for malignant refractory ascites: a retrospective multicenter study (JIVROSG-0809).

PURPOSE: Peritoneal venous shunts (PVSs) are widely used for palliating symptoms of refractory malignant ascites and are recognized as one of the practical methods. However, reliable clinical data are insufficient because most previous reports have been small studies from single centers. We conducted a retrospective, multicenter study to evaluate the safety and efficacy of radiologically placed PVSs in patients with malignant refractory ascites. METHODS: A total of 133 patients with malignant ascites refractory to medical therapies were evaluated for patient characteristics, technical success, efficacy, survival times, adverse events, and changes in laboratory data. RESULTS: PVSs were successfully placed in all patients and were effective (i.e., improvement of ascites symptoms lasting 7 days or more) in 110 (82.7%). The median duration of symptom palliation was 26 days and median survival time was 41 days. The most frequent adverse event was PVS dysfunction, which occurred in 60 (45.1%) patients, among whom function was recovered with an additional minimally invasive procedure in 9. Abnormalities in coagulation (subclinical disseminated intravascular coagulation) occurred in 37 (27.8%) patients, although only 7 (5.3%) developed clinical disseminated intravascular coagulation. Other major adverse events were gastrointestinal bleeding (9.8%), sepsis (3.8%), and acute heart failure (3.0%). PVS was least effective in patients with elevated serum creatinine, bloody ascites, or gynecologic tumor. CONCLUSIONS: Radiological PVS is a technically feasible and effective method for palliating the symptoms from refractory malignant ascites, but preoperative evaluation and monitoring the postprocedural complications are mandatory to preclude severe adverse events after PVS.

Study of ulnar variance with high-resolution MRI: correlation with triangular fibrocartilage complex and cartilage of ulnar side of wrist.

PURPOSE: To investigate correlations with ulnar variance and the triangular fibrocartilage complex (TFCC) or cartilage of ulnar side of the wrist on high-resolution MRI with a microscopy coil. MATERIALS AND METHODS: We reviewed ulnar variance, TFCC, and cartilage of the ulnar side of the wrist in 93 subjects (29 asymptomatic volunteers and 64 patients with suspected TFCC injury) with high-resolution MRI using a 47-mm microscopy surface coil. All MR images were obtained with a 1.5 T scanner. Coronal 2D gradient recalled echo T(2)*-weighted images were used for analysis. For qualitative analysis we measured ulnar variance, TFCC angle, thickness in the central portion of TFCC disc proper, and cartilage thickness of the lunate and the ulnar head on MRI and calculated the correlation coefficient between measured values. We also examined the relationship between ulnar variance and age or sex. RESULTS: High-resolution MR images clearly demonstrated TFCC and cartilage of the wrist and ulnar variance. The mean ulnar variance on MRI was +0.26 mm (range, -4.59 to +3.71 mm). The mean TFCC angle and TFCC thickness were 23.9 degrees (range, -4.6 to +54.1 degrees ) and 1.11 mm (range, 0.4 to 3.22 mm), respectively. Ulnar variance and TFCC angle were positively correlated (r = 0.84), and ulnar variance and TFCC thickness were negatively correlated (r = -0.71). However, ulnar variance and lunate or ulnar head cartilage thickness were not significantly correlated. CONCLUSION: High-resolution MRI with a microscopy coil is a useful tool for evaluating the relationship between ulnar variance and ulnar side structures.

Comparison between high-resolution MRI with a microscopy coil and arthroscopy in triangular fibrocartilage complex injury.

PURPOSE: To determine whether high-resolution magnetic resonance imaging (MRI) could detect injuries to the triangular fibrocartilage complex (TFCC). METHODS: Eleven patients who showed both a positive sign during the ulnocarpal stress test and tenderness at the distal end of the ulna had a high-resolution MRI using a 47-mm diameter microscopy coil. Six regions of the TFCC were investigated for injury: the radial attachment, disc, ulnar attachment of the triangular fibrocartilage (TFC), ulnotriquetral ligament, palmar radioulnar ligament (PRUL), and dorsal radioulnar ligament (DRUL). Arthroscopy was performed subsequently on each patient. RESULTS: For injuries to the radial attachment or the disc of the TFC, a high-resolution MRI showed 100% sensitivity and 100% specificity compared with arthroscopy. In 3 cases in which injury to the ulnar attachment of the TFC was detected with MRI and examination showed a positive piano-key sign and distal radioulnar joint instability, only 1 injury was confirmed with arthrotomy. For MRI diagnosis of an ulnotriquetral ulnolunate attachment injury, the sensitivity was 100% and the specificity was 70%; however, 3 cases had false-positive results. Finally MRI had 100% sensitivity for detecting DRUL and PRUL injuries, although specificities were 75% and 83%, respectively. With MRI there were 2 false-positive DRUL injury diagnoses and 1 false-positive PRUL injury diagnosis. CONCLUSIONS: High-resolution MRI using a microscopy surface coil allowed assessment of each TFCC component and showed a higher accuracy for diagnosing injuries to the radial attachment and the disc of the TFC compared with previous studies. High-resolution MRI, however, was not able to diagnose DRUL, PRUL, or ulnolunate ligament injuries accurately. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

High-resolution MR imaging of the proximal zone of the lunotriquetral ligament with a microscopy coil.

OBJECTIVE: To evaluate high-resolution MRI of the proximal zone of the lunotriquetral ligament (LTL) using a microscopy surface coil with a 1.5 T scanner. DESIGN AND SUBJECTS: The proximal zone of the LTL was reviewed in 90 subjects (23 asymptomatic normal volunteers and 67 patients with suspicion of triangular fibrocartilage complex injury) with high-resolution MRI using a 47-mm microscopy surface coil. High-resolution MR images were obtained with gradient recalled echo (GRE) T2*-weighted sequence and short tau inversion recovery imaging, with a 1- to 1.5-mm slice thickness, a 50-mm field of view, an imaging matrix of 140-224x512 using zero fill interpolation, and 3-4 excitations. As a qualitative analysis, the LTL was classified in shape and signal intensity. RESULTS: The triangle-shaped low-signal-intensity LTL was identified in 77 of 90 subjects (85.6%) on GRE images. The triangle was classified as regular (41.1%), broad-based (20.0%), narrow-based (6.7%), or asymmetrical (17.8%). The bar-shaped ligament was seen in one patient, and unclassified ligaments were seen in 12 patients. All volunteers showed triangle-shaped LTL. The MR signal intensity of the proximal zone in the LTL was characterized as homogeneously low intensity (type 1; 33.8%), linear intermediate or high signal intensity traversing the distal surface of the LTL (type 2; 45.5%), and linear intermediate or high intensity traversing both distal and proximal surfaces of LTL (type 3; 20.8%). CONCLUSION: The proximal zone of the LTL showed a broad spectrum of normal variations in shape and signal intensity on high-resolution MR images with a microscopy coil.

Triple arterial phase dynamic MRI with sensitivity encoding for hypervascular hepatocellular carcinoma: comparison of the diagnostic accuracy among the early, middle, late, and whole triple arterial phase imaging.

OBJECTIVE: We assessed and compared the diagnostic accuracy of the early, middle, late, and whole triple arterial phase MRI with sensitivity encoding (SENSE) for the detection of hypervascular hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Thirty-one patients with 102 HCCs underwent dynamic MRI with SENSE. The findings of CT examinations, combined with those of visceral angiography or histopathologic examination, were used as the gold standard. After acquisition of T1- and T2-weighted images, gadolinium-enhanced triple arterial, portal, and delayed phase images were obtained. Acquisition of the triple arterial phase imaging was started at the timing of peak aortic enhancement and completed within a single breath-hold. Acquisition time for each phase was 8.4 sec. Four image sets including the early, middle, late, and whole triple arterial phase imaging were interpreted separately by four observers. The mean values of area under alternative-free-response receiver operating characteristic (AFROC) curve and of sensitivity were compared among the four image sets. RESULTS: The mean values of area under AFROC curve were 0.52, 0.66, 0.53, and 0.68 and of sensitivity were 45%, 64%, 48%, and 65% for the image sets with the early, middle, late, and whole triple arterial phase imaging, respectively. Both mean values were significantly higher for the image sets with the middle and whole triple arterial phase imaging than for those with the early and late arterial phase imaging. CONCLUSION: The middle arterial phase imaging with k-space centered at 12.6 sec after the peak aortic enhancement was optimal for detecting HCC and showed diagnostic accuracy equivalent to that of the whole triple arterial phase imaging.

Functioning ovarian tumors: direct and indirect findings at MR imaging.

There are many kinds of ovarian tumors and tumorlike conditions that produce estrogen or androgen. Magnetic resonance imaging can demonstrate not only ovarian tumors but also an enlarged uterus with a thick endometrium, even in cases of a clinically latent excess of estrogen. These clinical and indirect imaging findings can aid in the differential diagnosis of ovarian tumors. Granulosa cell tumor and thecoma are well-known estrogen-producing tumors. In pediatric or postmenopausal patients, they manifest as precocious pseudopuberty or postmenopausal bleeding, respectively. Conversely, Sertoli-Leydig cell tumor is representative of hormone-producing tumors that cause virilization. However, there are other functioning ovarian tumors besides the sex cord-stromal tumors. It is well known that metastatic ovarian tumors often have androgen-producing stroma and that mucinous cystadenoma sometimes produces estrogens. Most other ovarian tumors can produce sexual hormones in their stroma. In addition, some endocrinologic abnormalities (eg, polycystic ovary syndrome) also cause virilization.

High-resolution MR imaging of the elbow using a microscopy surface coil and a clinical 1.5 T MR machine: preliminary results.

OBJECTIVE: To obtain high-resolution MR images of the elbow using a microscopy surface coil with a 1.5 T clinical machine and to evaluate the feasibility of its use for elbow injuries. DESIGN AND PATIENTS: Five asymptomatic normal volunteers and 13 patients with elbow pain were prospectively studied with MR imaging using a microscopy surface coil 47 mm in diameter. High-resolution MR images using a microscopy coil were obtained with fast spin echo (FSE) proton density-weighted sequence, gradient recalled echo (GRE) T2*-weighted sequence, and short tau inversion recovery (STIR) sequence, with a 1-2 mm slice thickness, a 50-70 mm field of view, an imaging matrix of 140-224 x 512 using zero fill interpolation, and 2-6 excitations. RESULTS: High-resolution MR images of normal volunteers using a microscopy coil clearly showed each structure of the medial and lateral collateral ligaments on GRE T2*-weighted images and FSE proton-density weighted images. Partial medial collateral ligament injury, a small avulsion of the medial epicondyle, and osteochondritis dissecans were well demonstrated on high-resolution MR images. CONCLUSION: High-resolution MR imaging of the elbow using a microscopy surface coil with a 1.5 T clinical machine is a promising method for accurately characterizing the normal anatomy of the elbow and depicting its lesions in detail.

Spectrum of germ cell tumors: from head to toe.

Germ cell tumors (GCTs) occur most frequently in the gonads and are relatively rare in other sites, such as the pineal gland, neurohypophysis, mediastinum, and retroperitoneum. GCTs are thought to originate from primordial germ cells, which migrate to the primitive gonadal glands in the urogenital ridge. Extragonadal GCTs might also originate from these cells when the cells are sequestered during their migration. Pathologic subtypes of GCTs vary, and the prevalence of mixed tumors is high. These factors produce a diversity of radiologic findings and make prospective radiologic diagnosis difficult in many cases. However, similar radiologic findings have been observed in pathologically equivalent tumors in varying sites. Seminomas appear as uniformly solid, lobulated masses with fibrovascular septa that enhance intensely. Nonseminomatous GCTs appear as heterogeneous masses with areas of necrosis, hemorrhage, or cystic degeneration. Fat and calcifications are hallmarks of teratomas, most of which are benign. In immature teratomas, scattered fat and calcification within larger solid components are occasionally seen. These imaging characteristics reflect the pathologic features of each tumor, and histologically similar GCTs at varying sites have similar radiologic features. Knowledge of the pathologic appearances of GCTs and their corresponding radiologic appearances will allow radiologists to diagnose these tumors correctly.

High-resolution MR imaging of triangular fibrocartilage complex (TFCC): comparison of microscopy coils and a conventional small surface coil.

OBJECTIVE: To compare MR images of the triangular fibrocartilage complex (TFCC) using microscopy coils with those using a conventional surface coil qualitatively and quantitatively. DESIGN AND PATIENTS: Proton density-weighted images and T2*-weighted images of the TFCC from ten normal volunteers were obtained with a conventional surface coil (C4 coil; 80 mm in diameter), a 47-mm microscopy surface coil and a 23-mm microscopy surface coil) at 1.5 T. Qualitative image analysis of MR images with three coils was performed by two radiologists who assigned one of five numerical scores (0, nonvisualization; 1, poor; 2, average; 3, good; 4, excellent) for five TFCC components, which were disc proper, triangular ligament, meniscus homologue, ulnotriquetral and ulnolunate ligament. Quantitative analysis included the signal-to-noise ratio (S/N) of the disc proper of TFCC, the lunate cartilage, the lunate bone and the contrast-noise-ratio (C/N) between articular cartilage and disc proper or bone marrow were measured. RESULTS: All structures show higher scores qualitatively on MR with microscopy coils than those with a C4 coil, and the difference was significant with the exception of the ulnolunate ligament. MR with microscopy coils showed significantly higher S/N values than those with a conventional surface coil (P<0.05 to P<0.001). T2*-weighted images using microscopy coils showed significantly higher cartilage-disc proper C/N and cartilage-bone marrow C/N (P<0.01 to P<0.001). On proton density-weighted images, the C/N between cartilage and disc proper with two microscopy coils was significantly higher (P<0.01) than that with a conventional coil. CONCLUSION: High-resolution MR images of the normal wrist using microscopy coils were superior to those using a conventional surface coil qualitatively and quantitatively. High-resolution MR imaging with a microscopy coil would be a promising method to diagnose TFCC lesions.

MR findings of spinal muscular atrophy Type II: sibling cases.

We present magnetic resonance (MR) findings of siblings affected by spinal muscular atrophy (SMA) Type II. MRI of their thighs showed severe muscle atrophy and fatty infiltration. Selective preservation of the adductor longus muscle, the gracilis muscle, and the sartorius muscles was observed, suggesting a characteristic finding of SMA Type II. These findings were more severe in the older patient.