Role of whole-body 64-slice multidetector computed tomography in treatment planning for multiple myeloma

Oncologist perspective: role of imaging in myeloma

With major advancements in treatments for multiple myeloma (MM), it is critical that we evaluate our methods for both diagnosing MM and monitoring its progression over time. Imaging methods, such as conventional skeletal x-ray, low-dose whole-body CT, MRI, and PET-CT, provide valuable information that influences our clinical decision-making. In this review, we will evaluate the role of these imaging techniques throughout the MM disease course, from diagnosis to follow-up after therapy, and also provide appropriate recommendations.

Correlations between apparent diffusion coefficient values of WB-DWI and clinical parameters in multiple myeloma

Background

Whole-body diffusion-weighted imaging (WB-DWI) is a method for evaluating bone marrow infiltration in multiple myeloma (MM). This study seeks to elucidate the correlation between the apparent diffusion coefficient (ADC) value and some selected clinical parameters.

Methods

A total of 101 Chinese patients with MM who had undergone WB-DWI from May 2017 to May 2019 were enrolled in this study. The ADC values of the MM lesions and the clinical parameters were quantified at the first (baseline) visit and after four-course induction chemotherapy. Multiple linear regression and logistic analyses were carried out to find the implicit inherent relationships within the patients’ data.

Results

The paired Wilcoxon test showed that the ADC values at the baseline visit (ADC₀) were significantly lower than the values after four-course induction chemotherapy (ADC_{4 c}) (p < 0.001), including different therapeutic responses. The Revised International Staging System (RISS) stage, type of MM, and β2-microglobulin (β2-MG) were predictors of clinically significant increases or decreases in the ADC values (p < 0.05). Multiple linear regression showed that the ADC₀ was negatively associated with β2-MG (p < 0.001) and immunoglobulin heavy chain gene rearrangement (p = 0.012), while the RISS Stage III (p = 0.001), type IgG λ (p = 0.005), and albumin were negatively associated with ADC_{4 c} (p = 0.010). The impacts of the therapeutic response were associated with ADC₀ and immunoglobulin heavy chain gene rearrangement (p < 0.001).

Conclusion

The ADC values of WB-DWI may be associated with clinical parameters of MM including the fluorescence in situ hybridization result, and may be useful in the prognosis of patients with MM.

Trial Registration: ChiCTR2000029587

The most stable pinning configurations in transverse supracondylar humerus fracture fixation in children: A novel three-dimensional finite element analysis of a pediatric bone model

PURPOSE

This study aimed at finding out the effect of exit height, trajectory and number of pins on the stability of cross and divergent-lateral pins used in the fixation of extension-type, transverse supracondylar humerus fracture (SHF) in children, based on finite element analysis.

METHODS

Distal humerus model consisting of the ossific nucleus of the capitellum (ONC) and distal cartilage of a 6-year-old boy was developed via three-dimensional finite modeling. Various cross and divergent-lateral pinning models with either two or three pins were simulated on an extension-type, transverse SHF and tested in six loading directions.

RESULTS

Two-cross pins and 2-divergent-lateral pins were more stable against torsional and translation forces respectively, while 3-cross pins were the most stable against all forces. The cross pins exiting at the upper border of the distal metaphyseal-diaphyseal junction (MDJ) had the best stiffness among the 2-cross pins, while the lateral pins with a middle third ONC distal pin provided the best stiffness among the 2-lateral pins. A third olecranon fossa pin greatly enhanced stability of the 2-lateral pins.

CONCLUSION

For typical transverse fractures, 2-cross pins are found to be superior to 2-divergent lateral pins only against torsional forces. Pins exiting at the upper border of the MDJ provides the best mechanical stability with 2-cross pins. Two-divergent-lateral pins with a distal pin going through the middle third of the ONC provides the best mechanical stability against translation forces for these transverse fractures. Three-cross pins however offer the best mechanical stability against both translation and torsional forces. This study offers important clues in the preoperative evaluation and management of extension-type supracondylar fractures in children.

Radiological middle turbinate variations and their relation to nasal septum deviation in asymptomatic adult

Background

Middle turbinate (MT) is one of the important anatomical and physiological structures of the nasal cavity. After the widespread use of nasal endoscope and paranasal sinus computed tomography (CT), many MT variations have been described. This study aimed to determine the incidence of MT variations by computed tomography (CT) in asymptomatic adult, their relation to each other, and to deviated septum (DS).

Results

In the included 86 subjects (172 MTs), pneumatized MT was the most common MT variation followed by paradoxical MT (PMT). Septal deviation did not appear to affect occurrence of pneumatized or PMT. Fifty-nine percent of the reported bilateral PMT were associated with pneumatized MT, while 35.7% of unilateral PMT were associated with pneumatized MT with non-significant difference.

Conclusion

MT variations in adults are common mainly pneumatized MT then PMT with no apparent relation to septum deviation.

Craniocerebral metastases from a supraglottic squamous cell carcinoma: A case report and literature review

Craniocerebral metastases as the initial spread of supraglottic squamous cell carcinoma (SCC) are exceptional. The presence of several months' history of dysphagia, dyspnea, cachexia, tobacco/alcohol abuse, and seizure(s) is suspicious of craniocerebral metastases from an advanced-stage supraglottic SCC. Physicians should be aware since early diagnosis and treatment may increase patient survival.

Supratubal recess and sinus tympani: CT analysis of middle ear hidden areas

Background

High-resolution computed tomography (HRCT) magnifies the role of preoperative imaging for detailed middle ear anatomy particularly its hidden area. The purpose of the current study was to assess the sinus tympani (ST) and supratubal recess (STR) by HRCT, to create CT classification of the STR depth, and to study the relationship between ST types and the new STR grades.

Results

In HRCT of non-pathological temporal bones of 100 subjects (200 ears), measurements of the STR and ST were calculated, registered, and analyzed. The depth of the STR was classified into grade 1 with depth less than 3 mm, grade 2 with depth ranged between 3 and 5 mm, and grade 3 with depth more than 5 mm. The mean STR length, width, and height were 4.17 ± 0.86, 3.55 ± 0.65, and 3.64 ± 0.7 mm, respectively, while the ST mean length and width of were 2.52 ± 0.5 and 1.82 ± 0.78 mm, respectively, without significant differences between either sexes or sided. The ST types were found to be type A in 56 ears (28%), type B in 142 ears (71%), and type C in 2 ears (1%). The STR grading was grade 1 in 12 ears (6%), grade 2 in 160 ears (80%), and grade 3 in 28 ears (14%) without significant relationship between ST types and STR grading (P = 0.3).

Conclusion

The current study provided reliable and applicable methods of CT assessment of STR and ST that can help to predict the degree of surgical visibility of the ST and STR during ear surgery.

Thoracoscopic segmentectomy assisted by three-dimensional computed tomography bronchography and angiography for lung cancer in a patient living with situs inversus totalis: A case report

BACKGROUND

Situs inversus totalis (SIT) is a rare congenital condition that is characterized by a complete mirror image of the typical arrangement of the thoracic and abdominal viscera. Performing thoracoscopic segmentectomy for a patient with lung cancer and SIT is an extremely skilled and challenging surgical procedure.

CASE SUMMARY

A 41-year old woman with a medical history of dextrocardia since childhood was admitted to our hospital with a mixed ground-glass opacity (mGGO) in her left lung field, discovered by computed tomography during her health checkup. In order to facilitate surgical orientation, three-dimensional computed tomography bronchography and angiography (3D-CTBA) was preoperatively carried out. The result of 3D-CTBA was consistent with the diagnosis of SIT and an mGGO in the posterior segment of the left upper lobe (LS²). Surgery was conducted in accordance with preoperative 3D-CTBA and designed surgical procedure, combined with intraoperative navigation. Final pathological examination revealed in situ adenocarcinoma. The patient’s postoperative condition was uneventful and no complications were observed.

CONCLUSION

We present the first case of lung cancer in a patient with SIT who successfully underwent thoracoscopic segmentectomy assisted by 3D-CTBA. This is a new technique that covers precise confirmation and dissection of targeted structures and intersegmental demarcation, and can help achieve a meticulous anatomical segmentectomy.

Whole-body diffusion-weighted imaging with background body signal suppression in the detection of osseous and extra-osseous metastases

Purpose

To assess the reproducibility of detection of osseous and extra-osseous metastases in cancer patients using whole-body diffusion-weighted imaging with background body signal suppression (WB-DWIBS).

Material and methods

A prospective study was conducted on 39 consecutive patients (21 females, 18 males; mean age 48 years) with metastases, who underwent WB-DWIBS on a 1.5-T MR scanner. Image analysis was performed independently by two blinded observers. Inter-observer agreement was assessed for the detection of osseous (spinal, appendicular) and extra-osseous (hepatic, pulmonary, nodal, and peritoneal) metastases.

Results

The overall inter-observer agreement of WB-DWIBS in the detection of osseous and extra-osseous metastases was excellent (κ = 0.887, agreement = 94.44%, p = 0.001). There was excellent inter-observer agreement of both observers for the detection of osseous spinal (κ = 0.846, agreement = 92.3%), osseous appendicular (κ = 0.898, agreement = 94.8 %), hepatic (κ = 0.847, agreement = 92.3%), pulmonary (κ = 0.938, agreement = 97.4%), nodal metastases (κ = 0.856, agreement = 94.9%), and peritoneal metastasis (κ = 0.772, agreement = 94.9%).

Conclusion

We concluded that WB-DWIBS is reproducible for detection of osseous and extra-osseous metastases in cancer patients.

Diagnostic value of whole-body MRI in Opsoclonus-myoclonus syndrome: a clinical case series (3 case reports)

Background

Opsoclonus-myoclonus syndrome (OMS) is a rare clinical disorder and typically occurs in association with occult neuroblastic tumor in pediatric patients. I-123 metaiodobenzylguanidine (mIBG) scintigraphy is widely adopted as screening procedure in patients with suspected neuroblastic tumor. Also, contrast-enhanced magnetic resonance imaging (MRI) or computed tomography (CT) are involved in the imaging workup, primarily for the assessment of the primary tumor region. However, the diagnostic value of whole-body MRI (WB-MRI) for the detection of occult neuroblastic tumor in pediatric patients presenting with OMS remains unknown.

Case presentation

We present three cases of patients with OMS, in whom WB-MRI revealed occult neuroblastic tumor masses, whereas scintigraphy was inconclusive:

In a 17 months old girl with OMS, WB-MRI revealed a paravertebral mass. After thoracoscopic resection, histopathology revealed a ganglioneuroblastoma.

A 13 months old boy presenting with OMS WB-MRI detected a tumor of the left adrenal gland; histopathology demonstrated a ganglioneuroblastoma after adrenalectomy.

In a 2 year old boy with OMS, immunoscintigraphy at the time of diagnosis was inconclusive. At the age of 13 years, a WB-MRI was performed due to persistent neurological symptoms, revealing a paravertebral retroperitoneal mass, which was classified as ganglioneuroblastoma.

Conclusion

In OMS, particularly in the setting of inconclusive scintigraphy, WB-MRI may be considered as a valuable alternative in the early phase of diagnostic work-up.

Upregulated delta-like protein 3 expression is a diagnostic and prognostic marker in endometrial cancer: A retrospective study

Upregulated delta-like protein 3 (DLL3) functions as a Notch ligand and has been a target for cancer therapy. The present study assessed DLL3 expression as a tumor marker for endometrial cancer.RNA-Seq expression data and clinicopathologic records from 545 patients with endometrial cancer were downloaded from The Cancer Genome Atlas database. Mann-Whitney U and logistic regression tests were applied to associate the level of DLL3 expression with clinical variables from the patients. Kaplan-Meier curves and log-rank tests were performed to compare overall survival of patients stratified by different levels of DLL3 expression. Multivariate Cox regression tests were used to analyze independent predictors for endometrial cancer. DLL3 expression was upregulated in endometrial cancer tissues compared to para-carcinoma tissues (P = .0003). High DLL3 expression was associated with the age of patients (odds ratio [OR] = 1.74), advanced stages of the International Federation of Gynecology and Obstetrics system (OR = 2.9), grade III/IV (OR = 5.1), myometrial invasion (OR = 2.2), pelvic involvement (OR = 12.9), and para-aortic lymph node metastasis (OR = 9.9) (all P ≤ .001). Furthermore, upregulated DLL3 expression was also associated with a median overall survival of 112 months (HR = 1.85, confidence internal 1.202-2.846, P = .005). The multivariate analysis showed that DLL3 overexpression and advanced tumor stages, grades, and lymph node metastases were all independent prognostic predictors for endometrial cancer.The DLL3 expression could be a potential and novel tumor marker for early diagnosis and an independent predictor of poor survival for patients with endometrial cancer.

Value of virtual monochromatic spectral images with metal artifact reduction algorithm in dual-energy computed tomography-guided microcoil localization of pulmonary nodules

To evaluate the clinical value of virtual monochromatic spectral (VMS) images with metal artifact reduction (MAR) algorithm in dual-energy computed tomography (DECT)-guided microcoil localization of pulmonary nodules.Fifty-one patients underwent DECT after placement of microcoils on small pulmonary nodules before video-assisted thoracoscopic surgery (VATS). Optimal energy level (in keV) was defined as the level at which CT values of nodules were equivalent to those of 120 kVp images and with no serious metal artifacts. VMS images at optimal keV and at 50, 90,110, and 140 keV with and without MAR were reconstructed. Image quality was scored using a 3-point scale: 1 = excellent, minimal artifacts; 2 = good, mild artifacts; and 3 = poor, extensive artifacts. Image quality scores between the VMS-only and VMS + MAR groups were compared;74 keV was found to be the optimal level for VMS images. The image quality of the VMS + MAR images at 74 keV were significantly better than VMS-only images (1.35 ± 0.59 vs 2.11 ± 0.87, P = .005). There was no difference in image quality score among VMS + MAR images at 74 keV and higher energy levels.VMS images from DECT at 74 keV with MAR can reduce artifacts from microcoils and improve image quality for microcoil localization of pulmonary nodules.

Extent of simultaneous radiation dose and iodine reduction at stable image quality in computed tomography of the chest: A systematic approach using automated tube voltage adaption and iterative reconstructions

BACKGROUND

Aim of this study was to systematically combine tube voltage adaptation and iterative reconstructions for reduction of iodine and radiation dose.

METHODS

Settings for the study protocol were evaluated in ex-ante trials to provide image quality that is comparable to a reference protocol at 120 kV with tube current modulation. Consecutive patients were randomized to undergo computed tomography (CT) of the chest using the study protocol (n = 62) or reference protocol (n = 50). Objective and subjective image quality was assessed and compared.

RESULTS

Tube voltage was decreased to 100 kV in 47 patients and to 80 kV in 15 patients in the study group. The iodine dosage (16.1 vs 10.5 g) and the effective radiation dose (3.6 vs 2.5 mSv) were significantly decreased in the study group (both P < .001). Contrast-to-noise ratio was comparable in the pulmonary trunk and increased in the aorta (P < .01). Subjective image quality was comparable without statistically significance.

CONCLUSIONS

Simultaneous reductions in iodine dosage and radiation dose by one-third are feasible for CT of the chest.

Computed Tomography Assessment of Hepatic Metastases of Breast Cancer with Revised Response Evaluation Criteria in Solid Tumors (RECIST) Criteria (Version 1.1): Inter-Observer Agreement

Background

To assess inter-observer agreement of revised RECIST criteria (version 1.1) for computed tomography assessment of hepatic metastases of breast cancer.

Material/Methods

A prospective study was conducted in 28 female patients with breast cancer and with at least one measurable metastatic lesion in the liver that was treated with 3 cycles of anthracycline-based chemotherapy. All patients underwent computed tomography of the abdomen with 64-row multi- detector CT at baseline and after 3 cycles of chemotherapy for response assessment. Image analysis was performed by 2 observers, based on the RECIST criteria (version 1.1).

Results

Computed tomography revealed partial response of hepatic metastases in 7 patients (25%) by one observer and in 10 patients (35.7%) by the other observer, with good inter-observer agreement (k=0.75, percent agreement of 89.29%). Stable disease was detected in 19 patients (67.8%) by one observer and in 16 patients (57.1%) by the other observer, with good agreement (k=0.774, percent agreement of 89.29%). Progressive disease was detected in 2 patients (7.2%) by both observers, with perfect agreement (k=1, percent agreement of 100%). The overall inter-observer agreement in the CT-based response assessment of hepatic metastasis between the two observers was good (k=0.793, percent agreement of 89.29%).

Conclusions

We concluded that computed tomography is a reliable and reproducible imaging modality for response assessment of hepatic metastases of breast cancer according to the RECIST criteria (version 1.1).

Inter-Observer Agreement of Whole-Body Computed Tomography in Staging and Response Assessment in Lymphoma: The Lugano Classification

Background

To assess inter-observer agreement of whole-body computed tomography (WBCT) in staging and response assessment in lymphoma according to the Lugano classification.

Material/Methods

Retrospective analysis was conducted of 115 consecutive patients with lymphomas (45 females, 70 males; mean age of 46 years). Patients underwent WBCT with a 64 multi-detector CT device for staging and response assessment after a complete course of chemotherapy. Image analysis was performed by 2 reviewers according to the Lugano classification for staging and response assessment.

Results

The overall inter-observer agreement of WBCT in staging of lymphoma was excellent (k=0.90, percent agreement=94.9%). There was an excellent inter-observer agreement for stage I (k=0.93, percent agreement=96.4%), stage II (k=0.90, percent agreement=94.8%), stage III (k=0.89, percent agreement=94.6%) and stage IV (k=0.88, percent agreement=94%). The overall inter-observer agreement in response assessment after a completer course of treatment was excellent (k=0.91, percent agreement=95.8%). There was an excellent inter-observer agreement in progressive disease (k=0.94, percent agreement=97.1%), stable disease (k=0.90, percent agreement=95%), partial response (k=0.96, percent agreement=98.1%) and complete response (k=0.87, Percent agreement=93.3%).

Conclusions

We concluded that WBCT is a reliable and reproducible imaging modality for staging and treatment assessment in lymphoma according to the Lugano classification.