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Hall WA, Mathison AJ, DeVoe E, Tschannen M, Wendt-Andrae J, Straza M, Awan M, Puckett LL, Lawton CAF, Schultz C, Urrutia R, Kerns S, Torres-Roca JF, Li XA, Erickson B, Nevalainen MT, Zimmermann MT, Paulson E. Changes in Daily Apparent Diffusion Coefficient on Fully Quantitative Magnetic Resonance Imaging Correlate With Established Genomic Pathways of Radiation Sensitivity and Reveal Novel Biologic Associations. Int J Radiat Oncol Biol Phys 2024; 120:570-578. [PMID: 38819340 DOI: 10.1016/j.ijrobp.2024.03.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 03/21/2024] [Accepted: 03/27/2024] [Indexed: 06/01/2024]
Abstract
PURPOSE Changes in quantitative magnetic resonance imaging (qMRI) are frequently observed during chemotherapy or radiation therapy (RT). It is hypothesized that qMRI features are reflective of underlying tissue responses. It's unknown what underlying genomic characteristics underly qMRI changes. We hypothesized that qMRI changes may correlate with DNA damage response (DDR) capacity within human tumors. Therefore, we designed the current study to correlate qMRI changes from daily RT treatment with underlying tumor transcriptomic profiles. METHODS AND MATERIALS Study participants were prospectively enrolled (National Clinical Trial 03500081). RNA expression levels for 757 genes from pretreatment biopsies were obtained using a custom panel that included signatures of radiation sensitivity and DDR. Daily qMRI data were obtained from a 1.5 Tesla MR linear accelerator. Using these images, d-slow, d-star, perfusion, and apparent diffusion coefficient-mean values in tumors were plotted per-fraction, over time, and associated with genomic pathways. RESULTS A total of 1022 qMRIs were obtained from 39 patients and both genomic data and qMRI data from 27 total patients. For 20 of those patients, we also generated normal tissue transcriptomic data. Radio sensitivity index values most closely associated with tissue of origin. Multiple genomic pathways including DNA repair, peroxisome, late estrogen receptor responses, KRAS signaling, and UV response were significantly associated with qMRI feature changes (P < .001). CONCLUSIONS Genomic pathway associations across metabolic, RT sensitivity, and DDR pathways indicate common tumor biology that may correlate with qMRI changes during a course of treatment. Such data provide hypothesis-generating novel mechanistic insight into the biologic meaning of qMRI changes during treatment and enable optimal selection of imaging biomarkers for biologically MR-guided RT.
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Affiliation(s)
- William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Angela J Mathison
- Linda T. and John A. Mellowes Center for Genomic Sciences and Precision Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Surgery, Division of Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Elias DeVoe
- Linda T. and John A. Mellowes Center for Genomic Sciences and Precision Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael Tschannen
- Linda T. and John A. Mellowes Center for Genomic Sciences and Precision Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jaime Wendt-Andrae
- Linda T. and John A. Mellowes Center for Genomic Sciences and Precision Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael Straza
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Musaddiq Awan
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lindsay L Puckett
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Colleen A F Lawton
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Christopher Schultz
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Raul Urrutia
- Linda T. and John A. Mellowes Center for Genomic Sciences and Precision Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Surgery, Division of Research, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Biochemistry, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sarah Kerns
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Javier F Torres-Roca
- Department of Radiation Oncology and Bioinformatics, Moffitt Cancer Center, Tampa, Florida
| | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Beth Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Marja T Nevalainen
- Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael T Zimmermann
- Linda T. and John A. Mellowes Center for Genomic Sciences and Precision Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Biochemistry, Medical College of Wisconsin, Milwaukee, Wisconsin; Clinical and Translational Sciences Institute, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Eric Paulson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Curcean S, Curcean A, Martin D, Fekete Z, Irimie A, Muntean AS, Caraiani C. The Role of Predictive and Prognostic MRI-Based Biomarkers in the Era of Total Neoadjuvant Treatment in Rectal Cancer. Cancers (Basel) 2024; 16:3111. [PMID: 39272969 PMCID: PMC11394290 DOI: 10.3390/cancers16173111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2024] [Revised: 09/02/2024] [Accepted: 09/06/2024] [Indexed: 09/15/2024] Open
Abstract
The role of magnetic resonance imaging (MRI) in rectal cancer management has significantly increased over the last decade, in line with more personalized treatment approaches. Total neoadjuvant treatment (TNT) plays a pivotal role in the shift from traditional surgical approach to non-surgical approaches such as 'watch-and-wait'. MRI plays a central role in this evolving landscape, providing essential morphological and functional data that support clinical decision-making. Key MRI-based biomarkers, including circumferential resection margin (CRM), extramural venous invasion (EMVI), tumour deposits, diffusion-weighted imaging (DWI), and MRI tumour regression grade (mrTRG), have proven valuable for staging, response assessment, and patient prognosis. Functional imaging techniques, such as dynamic contrast-enhanced MRI (DCE-MRI), alongside emerging biomarkers derived from radiomics and artificial intelligence (AI) have the potential to transform rectal cancer management offering data that enhance T and N staging, histopathological characterization, prediction of treatment response, recurrence detection, and identification of genomic features. This review outlines validated morphological and functional MRI-derived biomarkers with both prognostic and predictive significance, while also exploring the potential of radiomics and artificial intelligence in rectal cancer management. Furthermore, we discuss the role of rectal MRI in the 'watch-and-wait' approach, highlighting important practical aspects in selecting patients for non-surgical management.
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Affiliation(s)
- Sebastian Curcean
- Department of Radiation Oncology, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania
- Department of Radiation Oncology, 'Prof. Dr. Ion Chiricuta' Oncology Institute, 34-36 Republicii Street, 400015 Cluj-Napoca, Romania
| | - Andra Curcean
- Department of Imaging, Affidea Center, 15c Ciresilor Street, 400487 Cluj-Napoca, Romania
| | - Daniela Martin
- Department of Radiation Oncology, 'Prof. Dr. Ion Chiricuta' Oncology Institute, 34-36 Republicii Street, 400015 Cluj-Napoca, Romania
| | - Zsolt Fekete
- Department of Radiation Oncology, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania
- Department of Radiation Oncology, 'Prof. Dr. Ion Chiricuta' Oncology Institute, 34-36 Republicii Street, 400015 Cluj-Napoca, Romania
| | - Alexandru Irimie
- Department of Oncological Surgery and Gynecological Oncology, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania
- Department of Oncological Surgery, 'Prof. Dr. Ion Chiricuta' Oncology Institute, 34-36 Republicii Street, 400015 Cluj-Napoca, Romania
| | - Alina-Simona Muntean
- Department of Radiation Oncology, 'Prof. Dr. Ion Chiricuta' Oncology Institute, 34-36 Republicii Street, 400015 Cluj-Napoca, Romania
| | - Cosmin Caraiani
- Department of Medical Imaging and Nuclear Medicine, Iuliu Hațieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
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Qadir A, Singh N, Moe AAK, Cahoon G, Lye J, Chao M, Foroudi F, Uribe S. Potential of MRI in Assessing Treatment Response After Neoadjuvant Radiation Therapy Treatment in Breast Cancer Patients: A Scoping Review. Clin Breast Cancer 2024:S1526-8209(24)00136-8. [PMID: 38906720 DOI: 10.1016/j.clbc.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 05/07/2024] [Accepted: 05/26/2024] [Indexed: 06/23/2024]
Abstract
The objective of this scoping review is to evaluate the potential of Magnetic Resonance Imaging (MRI) and to determine which of the available MRI techniques reported in the literature are the most promising for assessing treatment response in breast cancer patients following neoadjuvant radiotherapy (NRT). Ovid Medline, Embase, CINAHL, and Cochrane databases were searched to identify relevant studies published from inception until March 13, 2023. After primary selection, 2 reviewers evaluated each study using a standardized data extraction template, guided by set inclusion and exclusion criteria. A total of 5 eligible studies were selected. The positive and negative predictive values for MRI predicting pathological complete response across the studies were 67% to 88% and 76% to 85%, respectively. MRI's potential in assessing postradiotherapy tumor sizes was greater for volume measurements than uni-dimensional longest diameter measurements; however, overestimation in surgical tumor sizes was observed. Apparent diffusion coefficient (ADC) values and Time to Enhance (TTE) was seen to increase post-NRT, with a notable difference between responders and nonresponders at 6 months, indicating a potential role in assessing treatment response. In conclusion, this review highlights tumor volume measurements, ADC, and TTE as promising MRI metrics for assessing treatment response post-NRT in breast cancer. However, further research with larger cohorts is needed to confirm their utility. If MRI can accurately identify responders from nonresponders to NRT, it could enable a more personalized and tailored treatment approach, potentially minimizing radiation therapy related toxicity and enhancing cosmetic outcomes.
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Affiliation(s)
- Ayyaz Qadir
- Department of Medical Imaging and Radiation Sciences, School of Primary and Allied Health Care, Monash University, Melbourne, Australia.
| | - Nabita Singh
- Department of Medical Imaging and Radiation Sciences, School of Primary and Allied Health Care, Monash University, Melbourne, Australia
| | - Aung Aung Kywe Moe
- Department of Medical Imaging and Radiation Sciences, School of Primary and Allied Health Care, Monash University, Melbourne, Australia
| | - Glenn Cahoon
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness and Research Centre, Austin Health, Heidelberg, Victoria, Australia
| | - Jessica Lye
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness and Research Centre, Austin Health, Heidelberg, Victoria, Australia
| | - Michael Chao
- Department of Medical Imaging and Radiation Sciences, School of Primary and Allied Health Care, Monash University, Melbourne, Australia; Department of Radiation Oncology, Olivia Newton-John Cancer Wellness and Research Centre, Austin Health, Heidelberg, Victoria, Australia
| | - Farshad Foroudi
- Department of Medical Imaging and Radiation Sciences, School of Primary and Allied Health Care, Monash University, Melbourne, Australia; Department of Radiation Oncology, Olivia Newton-John Cancer Wellness and Research Centre, Austin Health, Heidelberg, Victoria, Australia
| | - Sergio Uribe
- Department of Medical Imaging and Radiation Sciences, School of Primary and Allied Health Care, Monash University, Melbourne, Australia
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Granata V, Fusco R, Setola SV, Cozzi D, Rega D, Petrillo A. Diffusion and Perfusion Imaging in Rectal Cancer Restaging. Semin Ultrasound CT MR 2023; 44:117-125. [PMID: 37245878 DOI: 10.1053/j.sult.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
The assessment of tumor response, after neoadjuvant radiochemotherapy (n-CRT), permits the stratification of patients for the proper therapeutical management. Although histopathology analysis of the surgical speciemen is considered the gold standard for assessing tumor response, magnetic resonance imaging (MRI), with its significant developments in technical imaging, have allowed an increase in accuracy for the evaluation of response. MRI provides a radiological tumor regression grade (mrTRG) that is correlated with the pathologic tumor regression grade (pTRG). Functional MRI parameters have additional impending in early prediction of the efficacy of therapy. Some of functional methodologies are already part of clinical practice: diffusion-weighted MRI (DW-MRI) and perfusion imaging (dynamic contrast enhanced MRI [DCE-MRI]).
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Affiliation(s)
- Vincenza Granata
- Division of Radiology, "Istituto Nazionale Tumori IRCCS Fondazione Pascale - IRCCS di Napoli", Naples, Italy
| | | | - Sergio Venazio Setola
- Division of Radiology, "Istituto Nazionale Tumori IRCCS Fondazione Pascale - IRCCS di Napoli", Naples, Italy
| | - Diletta Cozzi
- Department of Radiology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, Milan, Italy
| | - Daniela Rega
- Division of Gastrointestinal Surgical Oncology, "Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale", Naples, Italy
| | - Antonella Petrillo
- Division of Radiology, "Istituto Nazionale Tumori IRCCS Fondazione Pascale - IRCCS di Napoli", Naples, Italy
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Yang T, Li Y, Ye Z, Yao S, Li Q, Yuan Y, Song B. Diffusion Weighted Imaging of the Abdomen and Pelvis: Recent Technical Advances and Clinical Applications. Acad Radiol 2023; 30:470-482. [PMID: 36038417 DOI: 10.1016/j.acra.2022.07.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/20/2022] [Accepted: 07/23/2022] [Indexed: 01/25/2023]
Abstract
Diffusion weighted imaging (DWI) serves as one of the most important functional magnetic resonance imaging techniques in abdominal and pelvic imaging. It is designed to reflect the diffusion of water molecules and is particularly sensitive to the malignancies. Yet, the limitations of image distortion and artifacts in single-shot DWI may hamper its widespread use in clinical practice. With recent technical advances in DWI, such as simultaneous multi-slice excitation, computed or reduced field-of-view techniques, as well as advanced shimming methods, it is possible to achieve shorter acquisition time, better image quality, and higher robustness in abdominopelvic DWI. This review discussed the recent advances of each DWI approach, and highlighted its future perspectives in abdominal and pelvic imaging, hoping to familiarize physicians and radiologists with the technical improvements in this field and provide future research directions.
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Affiliation(s)
- Ting Yang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Ying Li
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Zheng Ye
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Shan Yao
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Qing Li
- MR Collaborations, Siemens Healthcare, Shanghai, China
| | - Yuan Yuan
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Bin Song
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China; Department of Radiology, Sanya People's Hospital, Sanya, Hainan, China.
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Gao PF, Lu N, Liu W. MRI VS. FDG-PET for diagnosis of response to neoadjuvant therapy in patients with locally advanced rectal cancer. Front Oncol 2023; 13:1031581. [PMID: 36741013 PMCID: PMC9890074 DOI: 10.3389/fonc.2023.1031581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/02/2023] [Indexed: 01/19/2023] Open
Abstract
Aim In this study, we aimed to compare the diagnostic values of MRI and FDG-PET for the prediction of the response to neoadjuvant chemoradiotherapy (NACT) of patients with locally advanced Rectal cancer (RC). Methods Electronic databases, including PubMed, Embase, and the Cochrane library, were systematically searched through December 2021 for studies that investigated the diagnostic value of MRI and FDG-PET in the prediction of the response of patients with locally advanced RC to NACT. The quality of the included studies was assessed using QUADAS. The pooled sensitivity, specificity, positive and negative likelihood ratio (PLR and NLR), and the area under the ROC (AUC) of MRI and FDG-PET were calculated using a bivariate generalized linear mixed model, random-effects model, and hierarchical regression. Results A total number of 74 studies with recruited 4,105 locally advanced RC patients were included in this analysis. The pooled sensitivity, specificity, PLR, NLR, and AUC for MRI were 0.83 (95% CI: 0.77-0.88), 0.85 (95% CI: 0.79-0.89), 5.50 (95% CI: 4.11-7.35), 0.20 (95% CI: 0.14-0.27), and 0.91 (95% CI: 0.88-0.93), respectively. The summary sensitivity, specificity, PLR, NLR and AUC for FDG-PET were 0.81 (95% CI: 0.77-0.85), 0.75 (95% CI: 0.70-0.80), 3.29 (95% CI: 2.64-4.10), 0.25 (95% CI: 0.20-0.31), and 0.85 (95% CI: 0.82-0.88), respectively. Moreover, there were no significant differences between MRI and FDG-PET in sensitivity (P = 0.565), and NLR (P = 0.268), while the specificity (P = 0.006), PLR (P = 0.006), and AUC (P = 0.003) of MRI was higher than FDG-PET. Conclusions MRI might superior than FGD-PET for the prediction of the response of patients with locally advanced RC to NACT.
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Affiliation(s)
- Peng Fei Gao
- Department of Traditional Chinese medicine, Jinshan Hospital, Fudan University, Shanghai, China
| | - Na Lu
- Department of Radiology, Huashan Hospital North, Fudan University, Shanghai, China
| | - Wen Liu
- Department of Radiology, Jinshan Hospital, Fudan University, Shanghai, China,*Correspondence: Wen Liu,
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Pham TT, Lim S, Lin M. Predicting neoadjuvant chemoradiotherapy response with functional imaging and liquid biomarkers in locally advanced rectal cancer. Expert Rev Anticancer Ther 2022; 22:1081-1098. [PMID: 35993178 DOI: 10.1080/14737140.2022.2114457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Non-invasive predictive quantitative biomarkers are required to guide treatment individualization in patients with locally advanced rectal cancer (LARC) in order to maximise therapeutic outcomes and minimise treatment toxicity. Magnetic resonance imaging (MRI), positron emission tomography (PET) and blood biomarkers have the potential to predict chemoradiotherapy (CRT) response in LARC. AREAS COVERED This review examines the value of functional imaging (MRI and PET) and liquid biomarkers (circulating tumor cells (CTCs) and circulating tumor nucleic acid (ctNA)) in the prediction of CRT response in LARC. Selected imaging and liquid biomarker studies are presented and the current status of the most promising imaging (apparent diffusion co-efficient (ADC), Ktrans, SUVmax, metabolic tumor volume (MTV) and total lesion glycolysis (TLG) and liquid biomarkers (circulating tumor cells (CTCs), circulating tumor nucleic acid (ctNA)) is discussed. The potential applications of imaging and liquid biomarkers for treatment stratification and a pathway to clinical translation are presented. EXPERT OPINION Functional imaging and liquid biomarkers provide novel ways of predicting CRT response. The clinical and technical validation of the most promising imaging and liquid biopsy biomarkers in multi-centre studies with harmonised acquisition techniques is required. This will enable clinical trials to investigate treatment escalation or de-escalation pathways in rectal cancer.
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Affiliation(s)
- Trang Thanh Pham
- South West Sydney Clinical School, Faculty of Medicine and Health, University of New South Wales, Liverpool NSW Australia 2170.,Department of Radiation Oncology, Liverpool Cancer Therapy Centre, Liverpool Hospital, Liverpool NSW Australia 2170.,Ingham Institute for Applied Medical Research, Liverpool NSW Australia 2170
| | - Stephanie Lim
- Ingham Institute for Applied Medical Research, Liverpool NSW Australia 2170.,Department of Medical Oncology, Macarthur Cancer Therapy Centre, Campbelltown Hospital, Campbelltown Australia 2560.,School of Medicine, Western Sydney University, Campbelltown, Sydney 2560
| | - Michael Lin
- South West Sydney Clinical School, Faculty of Medicine and Health, University of New South Wales, Liverpool NSW Australia 2170.,School of Medicine, Western Sydney University, Campbelltown, Sydney 2560.,Department of Nuclear Medicine, Liverpool Hospital, Liverpool NSW Australia 2170
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Shi X, Zhao M, Shi B, Chen G, Yao H, Chen J, Wan D, Gu W, He S. Pretreatment blood biomarkers combined with magnetic resonance imaging predict responses to neoadjuvant chemoradiotherapy in locally advanced rectal cancer. Front Oncol 2022; 12:916840. [PMID: 36016621 PMCID: PMC9396285 DOI: 10.3389/fonc.2022.916840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 07/19/2022] [Indexed: 12/30/2022] Open
Abstract
Aim To investigate the value of pretreatment blood biomarkers combined with magnetic resonance imaging (MRI) in predicting the efficacy of neoadjuvant chemoradiotherapy (NCRT) in patients with locally advanced rectal cancer (LARC). Methods This study involved patients with LARC who received NCRT and subsequently underwent total mesenteric excision from June 2015 to June 2021 at the First Affiliated Hospital of Soochow University. Patients with incomplete courses of neoadjuvant therapy, comorbidities with other malignancies or diseases that affect the study outcome, and those who underwent unplanned surgery were ultimately excluded. Laboratory data such as albumin, CEA, various blood cell levels, and MRI related data such as tumor regression grade assessed by magnetic resonance imaging (mrTRG) were collected from the included patients one week prior to NCRT. MrTRG is a common clinical imaging metric used to assess the degree of tumor regression in rectal cancer, primarily based on morphological assessment of residual tumor. Furthermore, pretreatment blood biomarkers such as neutrophil to lymphocyte ratio (NLR), lymphocyte to monocyte ratio (LMR), albumin to fibrinogen ratio (AFR), and prealbumin to fibrinogen ratio (PFR) were assessed. The independent variables for pathologic complete response (pCR) to NCRT were determined by univariate and multivariate logistic regression analyses. Receiver operating characteristic (ROC) curve analysis was used to examine the performance of MRI with or without pretreatment blood biomarkers in predicting pCR using DeLong’s method. A nomogram was created and confirmed internally. Results Fifty-nine individuals with LARC satisfied the inclusion criteria, among which 23 showed pCR after NCRT. Logistic regression analysis demonstrated that pretreatment CEA (≤ 3 µg/L, OR = 0.151, P = 0.039), NLR (OR = 4.205, P = 0.027), LMR (OR = 0.447, P = 0.034), and PFR (OR = 0.940, P = 0.013) were independent predictors of pCR to NCRT. The AUCs of mrTRG alone and mrTRG plus the above four pretreatment blood biomarkers were 0.721 (P =0.0003) and 0.913 (P <0.0001), respectively. The constructed nomogram showed a C-index of 0.914. Conclusion Pretreatment blood biomarkers combined with MRI can help clinical efforts by better predicting the efficacy of NCRT in patients with locally advanced rectal cancer.
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Affiliation(s)
- Xinyu Shi
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Min Zhao
- Department of Nuclear Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Bo Shi
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Guoliang Chen
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Huihui Yao
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Junjie Chen
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Daiwei Wan
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Wen Gu
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Songbing He
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
- *Correspondence: Songbing He,
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Wichtmann BD, Albert S, Zhao W, Maurer A, Rödel C, Hofheinz RD, Hesser J, Zöllner FG, Attenberger UI. Are We There Yet? The Value of Deep Learning in a Multicenter Setting for Response Prediction of Locally Advanced Rectal Cancer to Neoadjuvant Chemoradiotherapy. Diagnostics (Basel) 2022; 12:1601. [PMID: 35885506 PMCID: PMC9317842 DOI: 10.3390/diagnostics12071601] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 06/26/2022] [Accepted: 06/28/2022] [Indexed: 11/17/2022] Open
Abstract
This retrospective study aims to evaluate the generalizability of a promising state-of-the-art multitask deep learning (DL) model for predicting the response of locally advanced rectal cancer (LARC) to neoadjuvant chemoradiotherapy (nCRT) using a multicenter dataset. To this end, we retrained and validated a Siamese network with two U-Nets joined at multiple layers using pre- and post-therapeutic T2-weighted (T2w), diffusion-weighted (DW) images and apparent diffusion coefficient (ADC) maps of 83 LARC patients acquired under study conditions at four different medical centers. To assess the predictive performance of the model, the trained network was then applied to an external clinical routine dataset of 46 LARC patients imaged without study conditions. The training and test datasets differed significantly in terms of their composition, e.g., T-/N-staging, the time interval between initial staging/nCRT/re-staging and surgery, as well as with respect to acquisition parameters, such as resolution, echo/repetition time, flip angle and field strength. We found that even after dedicated data pre-processing, the predictive performance dropped significantly in this multicenter setting compared to a previously published single- or two-center setting. Testing the network on the external clinical routine dataset yielded an area under the receiver operating characteristic curve of 0.54 (95% confidence interval [CI]: 0.41, 0.65), when using only pre- and post-therapeutic T2w images as input, and 0.60 (95% CI: 0.48, 0.71), when using the combination of pre- and post-therapeutic T2w, DW images, and ADC maps as input. Our study highlights the importance of data quality and harmonization in clinical trials using machine learning. Only in a joint, cross-center effort, involving a multidisciplinary team can we generate large enough curated and annotated datasets and develop the necessary pre-processing pipelines for data harmonization to successfully apply DL models clinically.
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Affiliation(s)
- Barbara D. Wichtmann
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, 53127 Bonn, Germany;
| | - Steffen Albert
- Computer Assisted Clinical Medicine, Mannheim Institute for Intelligent Systems in Medicine, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany; (S.A.); (F.G.Z.)
| | - Wenzhao Zhao
- Data Analysis and Modeling, Mannheim Institute for Intelligent Systems in Medicine (MIISM), Medical School Mannheim, Central Institute for Scientific Computing (IWR), Central Institute for Computer Engineering (ZITI), CZS Heidelberg Center for Model-Based AI, Heidelberg University, 69047 Heidelberg, Germany; (W.Z.); (J.H.)
| | - Angelika Maurer
- Clinical Functional Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Bonn, 53127 Bonn, Germany;
| | - Claus Rödel
- Department of Radiotherapy and Oncology, University Hospital Frankfurt, 60596 Frankfurt am Main, Germany;
| | - Ralf-Dieter Hofheinz
- Department of Medicine III, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany;
| | - Jürgen Hesser
- Data Analysis and Modeling, Mannheim Institute for Intelligent Systems in Medicine (MIISM), Medical School Mannheim, Central Institute for Scientific Computing (IWR), Central Institute for Computer Engineering (ZITI), CZS Heidelberg Center for Model-Based AI, Heidelberg University, 69047 Heidelberg, Germany; (W.Z.); (J.H.)
| | - Frank G. Zöllner
- Computer Assisted Clinical Medicine, Mannheim Institute for Intelligent Systems in Medicine, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany; (S.A.); (F.G.Z.)
| | - Ulrike I. Attenberger
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, 53127 Bonn, Germany;
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Dynamic Contrast-enhanced Magnetic Resonance Imaging Evaluation of Whole Tumour Perfusion Heterogeneity Predicts Distant Disease-free Survival in Locally Advanced Rectal Cancer. Clin Oncol (R Coll Radiol) 2022; 34:561-570. [PMID: 35738953 DOI: 10.1016/j.clon.2022.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 04/08/2022] [Accepted: 05/10/2022] [Indexed: 11/21/2022]
Abstract
AIMS To evaluate diffusion-weighted imaging and dynamic contrast-enhanced magnetic resonance imaging for the prediction of disease-free survival (DFS) in patients with locally advanced rectal cancer. MATERIALS AND METHODS Patients with stage II or III rectal adenocarcinoma undergoing neoadjuvant chemoradiotherapy (CRT) and surgery were eligible. Patients underwent multi-parametric magnetic resonance imaging (diffusion-weighted imaging and dynamic contrast-enhanced) before CRT, during CRT (week 3) and after CRT (1 week prior to surgery). Whole tumour apparent diffusion coefficient (ADC) and Ktrans histogram quantiles (10th, 25th, 50th, 75th, 90th) were extracted for analysis. The associations between ADC and Ktrans at three timepoints with time to relapse were analysed as a continuous variable using a Cox proportional hazard model. RESULTS Thirty-three patients were included in this analysis. The median follow-up was 4.4 years. No patient had locoregional relapse. Nine patients developed distant metastases. The hazard ratios for after CRT Ktrans 10th (P = 0.035), 25th (P = 0.048), 50th (P = 0.046) and 75th (P = 0.045) quantiles were statistically significant for DFS. The best Ktrans cut-off point after CRT for predicting relapse was 28 × 10-3 mL/g/min (10th quantile), with a higher Ktrans value predicting distant relapse. The 4-year DFS probability was 0.93 for patients with after CRT Ktrans value ≤28 × 10-3 mL/g/min versus 0.45 for patients with after CRT Ktrans value >28 × 10-3 mL/g/min. ADC was not able to predict DFS. CONCLUSIONS Patients with higher Ktrans values after CRT (before surgery) in a histogram analysis of whole tumour heterogeneity had a significantly lower 4-year distant DFS and could be considered for more intense systemic therapy.
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Xiong Z, Geng Z, Lian S, Yin S, Xu G, Zhang Y, Dai Y, Zhao J, Ma L, Liu X, Zheng H, Zou C, Xie C. Discriminating rectal cancer grades using restriction spectrum imaging. Abdom Radiol (NY) 2022; 47:2014-2022. [PMID: 35368206 DOI: 10.1007/s00261-022-03500-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/14/2022] [Accepted: 03/15/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE Restriction spectrum imaging (RSI) is a novel diffusion MRI model that separates water diffusion into several microscopic compartments. The restricted compartment correlating to the tumor cellularity is expected to be a potential indicator of rectal cancer aggressiveness. Our aim was to assess the ability of RSI model for rectal tumor grading. METHODS Fifty-eight patients with different rectal cancer grading confirmed by biopsy were involved in this study. DWI acquisitions were performed using single-shot echo-planar imaging (SS-EPI) with multi-b-values at 3 T. We applied a three-compartment RSI model, along with ADC model and diffusion kurtosis imaging (DKI) model, to DWI images of 58 patients. ROC and AUC were used to compare the performance of the three models in differentiating the low grade (G1 + G2) and high grade (G3). Mean ± standard deviation, ANOVA, ROC analysis, and correlation analysis were used in this study. RESULTS The volume fraction of restricted compartment C1 from RSI was significantly correlated with grades (r = 0.403, P = 0.002). It showed significant difference between G1 and G3 (P = 0.008) and between G2 and G3 (P = 0.01). As for the low-grade and high-grade discrimination, significant difference was found in C1 (P < 0.001). The AUC of C1 for differentiation between low-grade and high-grade groups was 0.753 with a sensitivity of 72.0% and a specificity of 70.0%. CONCLUSION The three-compartment RSI model was able to discriminate the rectal cancer of low and high grades. The results outperform the traditional ADC model and DKI model in rectal cancer grading.
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Affiliation(s)
- Zhongyan Xiong
- Paul C. Lauterbur Centre for Biomedical Imaging, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Zhijun Geng
- State Key Laboratory of Oncology in Southern China, Department of Radiology, Sun Yat-Sen University Cancer Center, No. 651 Dongfeng East Road, Guangzhou, 510060, China
| | - Shanshan Lian
- State Key Laboratory of Oncology in Southern China, Department of Radiology, Sun Yat-Sen University Cancer Center, No. 651 Dongfeng East Road, Guangzhou, 510060, China
| | - Shaohan Yin
- State Key Laboratory of Oncology in Southern China, Department of Radiology, Sun Yat-Sen University Cancer Center, No. 651 Dongfeng East Road, Guangzhou, 510060, China
| | - Guixiao Xu
- State Key Laboratory of Oncology in Southern China, Department of Radiology, Sun Yat-Sen University Cancer Center, No. 651 Dongfeng East Road, Guangzhou, 510060, China
| | - Yunfei Zhang
- Central Research Institute, United Imaging Healthcare, Shanghai, 201807, China
| | - Yongming Dai
- Central Research Institute, United Imaging Healthcare, Shanghai, 201807, China
| | - Jing Zhao
- State Key Laboratory of Oncology in Southern China, Department of Radiology, Sun Yat-Sen University Cancer Center, No. 651 Dongfeng East Road, Guangzhou, 510060, China
| | - Lidi Ma
- State Key Laboratory of Oncology in Southern China, Department of Radiology, Sun Yat-Sen University Cancer Center, No. 651 Dongfeng East Road, Guangzhou, 510060, China
| | - Xin Liu
- Paul C. Lauterbur Centre for Biomedical Imaging, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
- Key Laboratory for Magnetic Resonance and Multimodality Imaging of Guangdong Province, Shenzhen, 518000, China
| | - Hairong Zheng
- Paul C. Lauterbur Centre for Biomedical Imaging, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Chao Zou
- Paul C. Lauterbur Centre for Biomedical Imaging, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China.
- Key Laboratory for Magnetic Resonance and Multimodality Imaging of Guangdong Province, Shenzhen, 518000, China.
| | - Chuanmiao Xie
- State Key Laboratory of Oncology in Southern China, Department of Radiology, Sun Yat-Sen University Cancer Center, No. 651 Dongfeng East Road, Guangzhou, 510060, China.
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Boldrini L, Lenkowicz J, Orlandini LC, Yin G, Cusumano D, Chiloiro G, Dinapoli N, Peng Q, Casà C, Gambacorta MA, Valentini V, Lang J. Applicability of a pathological complete response magnetic resonance-based radiomics model for locally advanced rectal cancer in intercontinental cohort. Radiat Oncol 2022; 17:78. [PMID: 35428267 PMCID: PMC9013126 DOI: 10.1186/s13014-022-02048-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 04/04/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Predicting pathological complete response (pCR) in patients affected by locally advanced rectal cancer (LARC) who undergo neoadjuvant chemoradiotherapy (nCRT) is a challenging field of investigation, but many of the published models are burdened by a lack of reliable external validation. Aim of this study was to evaluate the applicability of a magnetic resonance imaging (MRI) radiomic-based pCR model developed and validated in Europe, to a different cohort of patients from an intercontinental cancer center. METHODS The original model was based on two clinical and two radiomics features extracted from T2-weighted 1.5 T MRI of 161 LARC patients acquired before nCRT, considered as training set. Such model is here validated using the T2-w 1.5 and 3 T staging MRI of 59 LARC patients with different clinical characteristics consecutively treated in mainland Chinese cancer center from March 2017 to January 2018. Model performance were evaluated in terms of area under the receiver operator characteristics curve (AUC) and relative parameters, such as accuracy, specificity, negative and positive predictive value (NPV and PPV). RESULTS An AUC of 0.83 (CI 95%, 0.71-0.96) was achieved for the intercontinental cohort versus a value of 0.75 (CI 95%, 0.61-0.88) at the external validation step reported in the original experience. Considering the best cut-off threshold identified in the first experience (0.26), the following predictive performance were obtained: 0.65 as accuracy, 0.64 as specificity, 0.70 as sensitivity, 0.91 as NPV and 0.28 as PPV. CONCLUSIONS Despite the introduction of significant different factors, the proposed model appeared to be replicable on a real-world data extra-European patients' cohort, achieving a TRIPOD 4 level.
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Affiliation(s)
- Luca Boldrini
- grid.414603.4Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Jacopo Lenkowicz
- grid.414603.4Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Lucia Clara Orlandini
- grid.54549.390000 0004 0369 4060Department of Radiation Oncology, Sichuan Cancer Hospital and Institute, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Gang Yin
- grid.54549.390000 0004 0369 4060Department of Radiation Oncology, Sichuan Cancer Hospital and Institute, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Davide Cusumano
- grid.414603.4Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Giuditta Chiloiro
- grid.414603.4Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Nicola Dinapoli
- grid.414603.4Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Qian Peng
- grid.54549.390000 0004 0369 4060Department of Radiation Oncology, Sichuan Cancer Hospital and Institute, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Calogero Casà
- grid.414603.4Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Maria Antonietta Gambacorta
- grid.414603.4Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Vincenzo Valentini
- grid.414603.4Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Jinyi Lang
- grid.54549.390000 0004 0369 4060Department of Radiation Oncology, Sichuan Cancer Hospital and Institute, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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13
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Munk NE, Bondeven P, Pedersen BG. Diagnostic performance of MRI and endoscopy for assessing complete response in rectal cancer after neoadjuvant chemoradiotherapy: a systematic review of the literature. Acta Radiol 2021; 64:20-31. [PMID: 34928715 DOI: 10.1177/02841851211065925] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The diagnostic performance of magnetic resonance imaging (MRI) modalities and/or endoscopy for assessing complete response in rectal cancer after neoadjuvant chemoradiotherapy (nCRT) is unclear. PURPOSE To summarize existing evidence on the diagnostic performance of diffusion-weighted MRI, perfusion-weighted MRI, T2-weighted MR tumor regression grade, and/or endoscopy for assessing complete tumor response after nCRT. MATERIAL AND METHODS MEDLINE and Embase databases were searched. The PRISMA guidelines were followed. Sensitivity, specificity, negative predictive, and positive predictive values were retrieved from included studies. RESULTS In total, 81 studies were eligible for inclusion. Evidence suggests that combined use of MRI and endoscopy tends to improve the diagnostic performance compared to single imaging modality. The positive predictive value of a complete response varies substantially between studies. There is considerable heterogeneity between studies. CONCLUSION Combined re-staging tends to improve diagnostic performance compared to single imaging modality, but the vast majority of studies fail to offer true clinical value due to the study heterogeneity.
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Affiliation(s)
| | - Peter Bondeven
- Department of Surgery, Regional Hospital Randers, Randers, Denmark
| | - Bodil Ginnerup Pedersen
- Department of Radiology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
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14
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Deidda S, Elmore U, Rosati R, De Nardi P, Vignali A, Puccetti F, Spolverato G, Capelli G, Zuin M, Muratore A, Danna R, Calabrò M, Guerrieri M, Ortenzi M, Ghiselli R, Scabini S, Aprile A, Pertile D, Sammarco G, Gallo G, Sena G, Coco C, Rizzo G, Pafundi DP, Belluco C, Innocente R, Degiuli M, Reddavid R, Puca L, Delrio P, Rega D, Conti P, Pastorino A, Zorcolo L, Pucciarelli S, Aschele C, Restivo A. Association of Delayed Surgery With Oncologic Long-term Outcomes in Patients With Locally Advanced Rectal Cancer Not Responding to Preoperative Chemoradiation. JAMA Surg 2021; 156:1141-1149. [PMID: 34586340 DOI: 10.1001/jamasurg.2021.4566] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Extending the interval between the end of neoadjuvant chemoradiotherapy (CRT) and surgery may enhance tumor response in patients with locally advanced rectal cancer. However, data on the association of delaying surgery with long-term outcome in patients who had a minor or poor response are lacking. Objective To assess a large series of patients who had minor or no tumor response to CRT and the association of shorter or longer waiting times between CRT and surgery with short- and long-term outcomes. Design, Setting, and Participants This is a multicenter retrospective cohort study. Data from 1701 consecutive patients with rectal cancer treated in 12 Italian referral centers were analyzed for colorectal surgery between January 2000 and December 2014. Patients with a minor or null tumor response (ypT stage of 2 to 3 or ypN positive) stage greater than 0 to neoadjuvant CRT were selected for the study. The data were analyzed between March and July 2020. Exposures Patients who had a minor or null tumor response were divided into 2 groups according to the wait time between neoadjuvant therapy end and surgery. Differences in surgical and oncological outcomes between these 2 groups were explored. Main Outcomes and Measures The primary outcomes were overall and disease-free survival between the 2 groups. Results Of a total of 1064 patients, 654 (61.5%) were male, and the median (IQR) age was 64 (55-71) years. A total of 579 patients (54.4%) had a shorter wait time (8 weeks or less) 485 patients (45.6%) had a longer wait time (greater than 8 weeks). A longer waiting time before surgery was associated with worse 5- and 10-year overall survival rates (67.6% [95% CI, 63.1%-71.7%] vs 80.3% [95% CI, 76.5%-83.6%] at 5 years; 40.1% [95% CI, 33.5%-46.5%] vs 57.8% [95% CI, 52.1%-63.0%] at 10 years; P < .001). Also, delayed surgery was associated with worse 5- and 10-year disease-free survival (59.6% [95% CI, 54.9%-63.9%] vs 72.0% [95% CI, 67.9%-75.7%] at 5 years; 36.2% [95% CI, 29.9%-42.4%] vs 53.9% [95% CI, 48.5%-59.1%] at 10 years; P < .001). At multivariate analysis, a longer waiting time was associated with an augmented risk of death (hazard ratio, 1.84; 95% CI, 1.50-2.26; P < .001) and death/recurrence (hazard ratio, 1.69; 95% CI, 1.39-2.04; P < .001). Conclusions and Relevance In this cohort study, a longer interval before surgery after completing neoadjuvant CRT was associated with worse overall and disease-free survival in tumors with a poor pathological response to preoperative CRT. Based on these findings, patients who do not respond well to CRT should be identified early after the end of CRT and undergo surgery without delay.
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Affiliation(s)
- Simona Deidda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Ugo Elmore
- Division of Gastrointestinal Surgery, San Raffaele Hospital, Milan, Italy
| | - Riccardo Rosati
- Division of Gastrointestinal Surgery, San Raffaele Hospital, Milan, Italy
| | - Paola De Nardi
- Division of Gastrointestinal Surgery, San Raffaele Hospital, Milan, Italy
| | - Andrea Vignali
- Division of Gastrointestinal Surgery, San Raffaele Hospital, Milan, Italy
| | - Francesco Puccetti
- Division of Gastrointestinal Surgery, San Raffaele Hospital, Milan, Italy
| | - Gaya Spolverato
- Department of Surgical, Oncological, and Gastroenterological Sciences, University of Padova, Padua, Italy
| | - Giulia Capelli
- Department of Surgical, Oncological, and Gastroenterological Sciences, University of Padova, Padua, Italy
| | - Matteo Zuin
- Department of Surgical, Oncological, and Gastroenterological Sciences, University of Padova, Padua, Italy
| | - Andrea Muratore
- Division of General Surgery, E. Agnelli Hospital, Pinerolo, Italy
| | - Riccardo Danna
- Division of General Surgery, E. Agnelli Hospital, Pinerolo, Italy
| | - Marcello Calabrò
- Division of General Surgery, E. Agnelli Hospital, Pinerolo, Italy
| | - Mario Guerrieri
- Department of General Surgery, Polytechnic University of Marche, Ancona, Italy
| | - Monica Ortenzi
- Department of General Surgery, Polytechnic University of Marche, Ancona, Italy
| | - Roberto Ghiselli
- Department of General Surgery, Polytechnic University of Marche, Ancona, Italy
| | - Stefano Scabini
- Oncologic Surgical Unit, Policlinico San Martino Genova, Genoa, Italy
| | - Alessandra Aprile
- Oncologic Surgical Unit, Policlinico San Martino Genova, Genoa, Italy
| | - Davide Pertile
- Oncologic Surgical Unit, Policlinico San Martino Genova, Genoa, Italy
| | - Giuseppe Sammarco
- Department of Health Sciences, Operative Unit of General Surgery, University of Catanzaro, Catanzaro, Italy
| | - Gaetano Gallo
- Department of Medical and Surgical Sciences, Operative Unit of General Surgery, University of Catanzaro, Catanzaro, Italy
| | - Giuseppe Sena
- Department of Medical and Surgical Sciences, Operative Unit of General Surgery, University of Catanzaro, Catanzaro, Italy
| | - Claudio Coco
- Division of General Surgery 2, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianluca Rizzo
- Division of General Surgery 2, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Donato Paolo Pafundi
- Division of General Surgery 2, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Claudio Belluco
- Department of Surgical Oncology, CRO Aviano National Cancer Institute IRCCS, Aviano, Italy
| | - Roberto Innocente
- Division of Radiotherapy, CRO Aviano National Cancer Institute IRCCS, Aviano, Italy
| | - Maurizio Degiuli
- University of Torino, School of Medicine, Department of Oncology, Digestive Surgery and Surgical Oncology, San Luigi University Hospital, Orbassano, Torino, Italy
| | - Rossella Reddavid
- University of Torino, School of Medicine, Department of Oncology, Digestive Surgery and Surgical Oncology, San Luigi University Hospital, Orbassano, Torino, Italy
| | - Lucia Puca
- University of Torino, School of Medicine, Department of Oncology, Digestive Surgery and Surgical Oncology, San Luigi University Hospital, Orbassano, Torino, Italy
| | - Paolo Delrio
- Colorectal Surgical Oncology, National Cancer Institute, IRCCS, G. Pascale Foundation, Napoli, Italy
| | - Daniela Rega
- Colorectal Surgical Oncology, National Cancer Institute, IRCCS, G. Pascale Foundation, Napoli, Italy
| | - Pietro Conti
- Division of General Surgery, Civil Hospital of Lentini, Siracusa, Italy
| | - Alessandro Pastorino
- Medical Oncology Unit, Department of Oncology, Ospedale Sant'Andrea, La Spezia, Italy
| | - Luigi Zorcolo
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Salvatore Pucciarelli
- Department of Surgical, Oncological, and Gastroenterological Sciences, University of Padova, Padua, Italy
| | - Carlo Aschele
- Medical Oncology Unit, Department of Oncology, Ospedale Sant'Andrea, La Spezia, Italy
| | - Angelo Restivo
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
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Pham TT, Liney G, Wong K, Henderson C, Rai R, Graham PL, Borok N, Truong MX, Lee M, Shin JS, Hudson M, Barton MB. Multi-parametric magnetic resonance imaging assessment of whole tumour heterogeneity for chemoradiotherapy response prediction in rectal cancer. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2021; 18:26-33. [PMID: 34258404 PMCID: PMC8254202 DOI: 10.1016/j.phro.2021.03.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/03/2021] [Accepted: 03/18/2021] [Indexed: 12/30/2022]
Abstract
Background and purpose Prediction of chemoradiotherapy response (CRT) in locally advanced rectal cancer would enable stratification of management. The purpose was to prospectively evaluate multi-parametric magnetic resonance imaging (MRI) assessment of tumour heterogeneity combining diffusion weighted imaging (DWI) and dynamic contrast enhanced (DCE) MRI for the prediction of CRT response in locally advanced rectal cancer. Materials and methods Patients with Stage II or III rectal adenocarcinoma undergoing neoadjuvant CRT and surgery underwent MRI (DWI and DCE) before, during (week 3), and after CRT (1 week before surgery). Patients with histopathology tumour regression grade (TRG) 0-1 were classified as responders, and TRG 2-3 were classified as non-responders. A whole tumour voxel-wise technique was used to produce apparent diffusion coefficient (ADC) and Ktrans (Tofts model) histograms derived from DWI and DCE-MRI, respectively. Logistic regression was used to predict response status for ADC and Ktrans quantiles. Results Thirty-three patients were included in this analysis; 16 responders, and 17 non-responders. On heterogeneity analysis, odds of being a responder were significantly higher after CRT (before surgery) for higher ADC 75th (p = 0.049) and ADC 90th (p = 0.034) percentile values. The Ktrans quantiles were lower in non-responders than responders before and during CRT, and higher after CRT although no significant association with response status was observed (p ≥ 0.10). Conclusions DWI-MRI after CRT (before surgery) incorporating a histogram analysis of whole tumour heterogeneity was predictive of CRT response in patients with locally advanced rectal cancer. DCE-MRI did not add value in response prediction. Clinical trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) number ACTRN12616001690448.
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Affiliation(s)
- Trang Thanh Pham
- Ingham Institute for Applied Medical Research, South West Sydney Clinical School, Faculty of Medicine, University of New South Wales, Sydney, PO Box 3151, Liverpool, NSW 2170, Australia.,Department of Radiation Oncology, Liverpool Cancer Therapy Centre, Liverpool Hospital, Sydney, Locked Bag 7103, Liverpool BC, NSW 1871, Australia
| | - Gary Liney
- Ingham Institute for Applied Medical Research, South West Sydney Clinical School, Faculty of Medicine, University of New South Wales, Sydney, PO Box 3151, Liverpool, NSW 2170, Australia
| | - Karen Wong
- Department of Radiation Oncology, Liverpool Cancer Therapy Centre, Liverpool Hospital, Sydney, Locked Bag 7103, Liverpool BC, NSW 1871, Australia
| | - Christopher Henderson
- Department of Anatomical Pathology, Liverpool Hospital, Sydney, Locked Bag 7103, Liverpool BC, NSW, 1871, Australia
| | - Robba Rai
- Department of Radiation Oncology, Liverpool Cancer Therapy Centre, Liverpool Hospital, Sydney, Locked Bag 7103, Liverpool BC, NSW 1871, Australia
| | - Petra L Graham
- Centre for Economic Impacts of Genomic Medicine, Macquarie Business School and Department of Mathematics and Statistics, Faculty of Science and Engineering, Macquarie University, Sydney, Macquarie University, NSW 2109, Australia
| | - Nira Borok
- Department of Radiology, Liverpool Hospital, Sydney, Locked Bag 7103, Liverpool BC, NSW 1871, Australia
| | - Minh Xuan Truong
- Department of Radiology, Liverpool Hospital, Sydney, Locked Bag 7103, Liverpool BC, NSW 1871, Australia
| | - Mark Lee
- Department of Radiation Oncology, Liverpool Cancer Therapy Centre, Liverpool Hospital, Sydney, Locked Bag 7103, Liverpool BC, NSW 1871, Australia
| | - Joo-Shik Shin
- Department of Anatomical Pathology, Liverpool Hospital, Sydney, Locked Bag 7103, Liverpool BC, NSW, 1871, Australia.,School of Medicine, Western Sydney University, Sydney, Locked Bag 1797, Penrith, NSW 2751, Australia
| | - Malcolm Hudson
- NHMRC Clinical Trials Centre, Sydney, Locked Bag 77, Camperdown, NSW 1450, Australia
| | - Michael B Barton
- Ingham Institute for Applied Medical Research, South West Sydney Clinical School, Faculty of Medicine, University of New South Wales, Sydney, PO Box 3151, Liverpool, NSW 2170, Australia
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van Houdt PJ, Yang Y, van der Heide UA. Quantitative Magnetic Resonance Imaging for Biological Image-Guided Adaptive Radiotherapy. Front Oncol 2021; 10:615643. [PMID: 33585242 PMCID: PMC7878523 DOI: 10.3389/fonc.2020.615643] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/08/2020] [Indexed: 12/20/2022] Open
Abstract
MRI-guided radiotherapy systems have the potential to bring two important concepts in modern radiotherapy together: adaptive radiotherapy and biological targeting. Based on frequent anatomical and functional imaging, monitoring the changes that occur in volume, shape as well as biological characteristics, a treatment plan can be updated regularly to accommodate the observed treatment response. For this purpose, quantitative imaging biomarkers need to be identified that show changes early during treatment and predict treatment outcome. This review provides an overview of the current evidence on quantitative MRI measurements during radiotherapy and their potential as an imaging biomarker on MRI-guided radiotherapy systems.
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Affiliation(s)
- Petra J van Houdt
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Yingli Yang
- Department of Radiation Oncology, University of California, Los Angeles, CA, United States
| | - Uulke A van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
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17
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Zhao M, Zhao L, Yang H, Duan Y, Li G. Apparent diffusion coefficient for the prediction of tumor response to neoadjuvant chemo-radiotherapy in locally advanced rectal cancer. Radiat Oncol 2021; 16:17. [PMID: 33472660 PMCID: PMC7819172 DOI: 10.1186/s13014-020-01738-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 12/26/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Patients with locally advanced rectal cancer generally have different response rates to preoperative neoadjuvant chemo-radiotherapy. This study investigated the value of the apparent diffusion coefficient (ADC) as a predictor to forecast the response to neoadjuvant chemo-radiotherapy in patients with locally advanced rectal cancer. METHODS Ninety-one locally advanced rectal cancer patients who underwent neoadjuvant chemo-radiotherapy between 2015 and 2018 were enrolled. Diffusion-weighted magnetic resonance imaging was performed before treatment and within 4 weeks after the completion of neoadjuvant chemo-radiotherapy. Mean ADC values of regions of interest were evaluated by two radiologists. The tumor response was evaluated according to RESCIST 1.1. The cut-off value for the mean ADC and increasing percentage (ΔADC%) after neoadjuvant chemo-radiotherapy was calculated using the receiver operating characteristic curve. The response rate of pre-ADC and ΔADC% above/below the cut-off values was determined using the chi-square test, respectively. Primary tumor progression-free survival (PFS) was analyzed using the Kaplan-Meier method, based on the pre-ADC and ΔADC% cut-off values. RESULTS The cut-off value of mean pre-ADC and ΔADC% was 0.94 × 10-3 mm2/s (80.36% sensitivity, 74.29% specificity) and 26.0% (73.21% sensitivity, 77.14% specificity), respectively. Lower mean pre-ADC values were related to a better response rate (83.3% vs 29.7%, P < 0.001) and PFS (26.12 vs 17.70 months, P = 0.004). ΔADC% above the cut-off value was also related to a better response rate (83.7% vs 35.7%, P < 0.001) and PFS (26.93 vs 15.65 months, P = 0.034). CONCLUSIONS The mean ADC pre-treatment value and ΔADC% were potential predictors for the tumor response in locally advanced rectal cancer patients treated with neoadjuvant chemo-radiotherapy.
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Affiliation(s)
- Mengjing Zhao
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Lihao Zhao
- Department of Chemoradiation Oncology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Han Yang
- Department of Chemoradiation Oncology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Yuxia Duan
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China.
| | - Gang Li
- Department of Chemoradiation Oncology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China.
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Di Re AM, Sun Y, Sundaresan P, Hau E, Toh JWT, Gee H, Or M, Haworth A. MRI radiomics in the prediction of therapeutic response to neoadjuvant therapy for locoregionally advanced rectal cancer: a systematic review. Expert Rev Anticancer Ther 2021; 21:425-449. [PMID: 33289435 DOI: 10.1080/14737140.2021.1860762] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Introduction: The standard of care for locoregionally advanced rectal cancer is neoadjuvant therapy (NA CRT) prior to surgery, of which 10-30% experience a complete pathologic response (pCR). There has been interest in using imaging features, also known as radiomics features, to predict pCR and potentially avoid surgery. This systematic review aims to describe the spectrum of MRI studies examining high-performing radiomic features that predict NA CRT response.Areas covered: This article reviews the use of pre-therapy MRI in predicting NA CRT response for patients with locoregionally advanced rectal cancer (T3/T4 and/or N1+). The primary outcome was to identify MRI radiomic studies; secondary outcomes included the power and the frequency of use of radiomic features.Expert opinion: Advanced models incorporating multiple radiomics categories appear to be the most promising. However, there is a need for standardization across studies with regards to; the definition of NA CRT response, imaging protocols, and radiomics features incorporated. Further studies are needed to validate current radiomics models and to fully ascertain the value of MRI radiomics in the response prediction for locoregionally advanced rectal cancer.
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Affiliation(s)
- Angelina Marina Di Re
- Colorectal Department, Westmead Hospital, Cnr Hawkesbury, Westmead, NSW.,School of Physics, University of Sydney, Camperdown, NSW, Australia
| | - Yu Sun
- School of Physics, University of Sydney, Camperdown, NSW, Australia
| | - Purnima Sundaresan
- Radiation Oncology Network, Western Sydney Local Health District, Cnr Hawkesbury, Westmead, NSW, Australia.,Sydney Medical School, University of Sydney, Camperdown, NSW, Australia
| | - Eric Hau
- Radiation Oncology Network, Western Sydney Local Health District, Cnr Hawkesbury, Westmead, NSW, Australia.,Sydney Medical School, University of Sydney, Camperdown, NSW, Australia.,Centre for Cancer Research, Westmead Institute of Medical Research, Westmead, NSW, Australia
| | - James Wei Tatt Toh
- Colorectal Department, Westmead Hospital, Cnr Hawkesbury, Westmead, NSW.,Sydney Medical School, University of Sydney, Camperdown, NSW, Australia.,Centre for Cancer Research, Westmead Institute of Medical Research, Westmead, NSW, Australia
| | - Harriet Gee
- Radiation Oncology Network, Western Sydney Local Health District, Cnr Hawkesbury, Westmead, NSW, Australia.,Sydney Medical School, University of Sydney, Camperdown, NSW, Australia
| | - Michelle Or
- Radiation Oncology Network, Western Sydney Local Health District, Cnr Hawkesbury, Westmead, NSW, Australia
| | - Annette Haworth
- School of Physics, University of Sydney, Camperdown, NSW, Australia
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19
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Intven M, de Mol van Otterloo S, Mook S, Doornaert P, de Groot-van Breugel E, Sikkes G, Willemsen-Bosman M, van Zijp H, Tijssen R. Online adaptive MR-guided radiotherapy for rectal cancer; feasibility of the workflow on a 1.5T MR-linac: clinical implementation and initial experience. Radiother Oncol 2021; 154:172-178. [DOI: 10.1016/j.radonc.2020.09.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 09/13/2020] [Accepted: 09/14/2020] [Indexed: 10/23/2022]
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20
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Sauter AP, Kössinger A, Beck S, Deniffel D, Dapper H, Combs SE, Rummeny EJ, Pfeiffer D. Dual-energy CT parameters in correlation to MRI-based apparent diffusion coefficient: evaluation in rectal cancer after radiochemotherapy. Acta Radiol Open 2020; 9:2058460120945316. [PMID: 32995044 PMCID: PMC7503032 DOI: 10.1177/2058460120945316] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/03/2020] [Indexed: 01/04/2023] Open
Abstract
Background Rectal cancer (RC) is a frequent malignancy for which magnetic resonance imaging (MRI) is the most common and accurate imaging. Iodine concentration (IC) can be quantified with spectral dual-layer computed tomography CT (DL-CT), which could improve imaging of RC, especially for evaluation of response to radiochemotherapy (RCT). Purpose To compare a DL-CT system to MRI as the non-invasive imaging gold standard for imaging of RC to evaluate the possibility of a response evaluation with DL-CT. Material and Methods Eleven patients who received DL-CT as well as MRI before and after RCT of RC were retrospectively included into this study. For each examination, a region of interest (ROI) was placed within the tumor. For MRI, the mean apparent diffusion coefficient (ADC) was assessed. For DL-CT, IC, z-effective, and Hounsfield Units (HU) were measured. IC, z-effective, and HU were normalized to the aorta. ADC was correlated to absolute and relative normalized IC, z-effective, and HU with Spearman’s ρ. Differences before and after treatment were tested with Wilcoxon signed-rank test. Results HU, IC, and Z-effective values in DL-CT images decreased significantly after RCT (P<0.01 for each comparison). The mean ADC increased significantly after RCT. Spearman’s ρ of the absolute IC difference and the absolute ADC (both before and after RCT) is high and significant (ρ = 0.73; P = 0.01), whereas the ρ-value for z-effective (ρ = 0.56) or HU (ρ = 0.45) to ADC was lower and non-significant. Conclusion Response evaluation of RC after RCT could be possible with DL-CT via the measurement of IC.
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Affiliation(s)
- Andreas P Sauter
- Department of Diagnostic and Interventional Radiology, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Antonia Kössinger
- Department of Diagnostic and Interventional Radiology, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Stefanie Beck
- Department of Diagnostic and Interventional Radiology, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Dominik Deniffel
- Department of Diagnostic and Interventional Radiology, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Hendrik Dapper
- Department of Radiation Oncology, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany.,Department of Radiation Sciences (DRS), Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Neuherberg, Germany.,Deutsches Konsortium für Translationale Krebsforschung (dktk), Partner Site Munich, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany.,Department of Radiation Sciences (DRS), Institute of Radiation Medicine (IRM), Helmholtz Zentrum München, Neuherberg, Germany.,Deutsches Konsortium für Translationale Krebsforschung (dktk), Partner Site Munich, Munich, Germany
| | - Ernst J Rummeny
- Department of Diagnostic and Interventional Radiology, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Daniela Pfeiffer
- Department of Diagnostic and Interventional Radiology, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
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Jiménez de los Santos ME, Reyes-Pérez JA, Sandoval-Nava RM, Villalobos-Juárez JL, Villaseñor-Navarro Y, Vela-Sarmiento I, Sollozo-Dupont I. The apparent diffusion coefficient is a useful biomarker in predicting treatment response in patients with locally advanced rectal cancer. Acta Radiol Open 2020; 9:2058460120957295. [PMID: 32974055 PMCID: PMC7495679 DOI: 10.1177/2058460120957295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 08/18/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Apparent diffusion coefficient (ADC) values achieve promising results in treatment response prediction in patients with several types of cancers. PURPOSE To determine whether ADC values predict neoadjuvant chemoradiation treatment (nCRT) response in patients with locally advanced rectal cancer (LARC). MATERIAL AND METHODS Forty-four patients with LARC who underwent magnetic resonance imaging scans before and after nCRT followed by delayed surgery were enrolled retrospectively. The sample was distributed as follows: responders (R), n = 8; and non-responders (Non-R), n = 36. Three markers of treatment response were considered: post-nCRT measures; ΔADC; and Δ%ADC. Statistical analysis included a Wilcoxon test, a Mann-Whitney U test, and a receiver operating characteristic (ROC) analysis in order to evaluate the diagnostic accuracy for each ADC value marker to differentiate between R and Non-R. RESULTS Both minimum and mean ADC values were significantly higher after nCRT in the R group, while non-significant differences between basal and control ADC values were found in the non-R group. In addition, ΔADC and Δ%ADC exhibited increased values after nCRT in R when compared with non-R. ROC analysis revealed the following diagnostic performance parameters: post-nCRT: ADCmin = 1.05 × 10-3 mm2/s (sensitivity 61.1% and specificity 66.7%), ADCmean = 1.50 × 10-3 mm2/s (sensitivity 72.2% and specificity 83.3%), ΔADC: ADCmin = 0.35 (sensitivity 66.7% and specificity 83.3%), ADCmean = 0.50 (sensitivity 72% and specificity 83%); and Δ%ADC: ADCmin = 44% (sensitivity 66.7% and specificity 83.3%) and ADCmean = 60% (sensitivity 83% and specificity 99%). CONCLUSION Our findings suggest that post-treatment rectal tumor ADC values, as well changes between pre- and post-treatment values, may be biomarkers for predicting treatment response in patients with LARC who underwent nCRT.
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22
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Pazdirek F, Minarik M, Benesova L, Halkova T, Belsanova B, Macek M, Stepanek L, Hoch J. Monitoring of Early Changes of Circulating Tumor DNA in the Plasma of Rectal Cancer Patients Receiving Neoadjuvant Concomitant Chemoradiotherapy: Evaluation for Prognosis and Prediction of Therapeutic Response. Front Oncol 2020; 10:1028. [PMID: 32793464 PMCID: PMC7394215 DOI: 10.3389/fonc.2020.01028] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 05/22/2020] [Indexed: 12/13/2022] Open
Abstract
Introduction: Patients with locally advanced rectal cancer (LARC) are undergoing neoadjuvant chemoradiotherapy (NCRT) prior to surgery. Although in some patients the NCRT is known to prevent local recurrence, it is also accompanied by side effects. Accordingly, there is an unmet need to identify predictive markers allowing to identify non-responders to avoid its adverse effects. We monitored circulating tumor DNA (ctDNA) as a potential liquid biopsy-based biomarker. We have investigated ctDNA changes plasma during the early days of NCRT and its relationship to the overall therapy outcome. Methods and Patients: The studied cohort included 36 LARC patients (stage II or III) undergoing NCRT with subsequent surgical treatment. We have detected somatic mutations in tissue biopsies taken during endoscopic examination prior to the therapy. CtDNA was extracted from patient plasma samples prior to therapy and at the end of the first week. In order to optimize the analytical costs of liquid-biopsy testing, we have utilized a two-level approach in which first a low-cost detection method of denaturing capillary electrophoresis was used followed by examination of initially negative samples by a high-sensitivity BEAMING assay. The ctDNA was related to clinical parameters including tumor regression grade (TRG) and TNM tumor staging. Results: We have detected a somatic mutation in 33 out of 36 patients (91.7%). Seven patients (7/33, 21.2%) had ctDNA present prior to therapy. The ctDNA positivity before treatment reduced post-operative disease-free survival and overall survival by an average of 1.47 and 1.41 years, respectively (p = 0.015, and p = 0.010). In all patients, ctDNA was strongly reduced or completely eliminated from plasma by the end of the first week of NCRT, with no correlation to any of the parameters analyzed. Conclusions: The baseline ctDNA presence represented a statistically significant negative prognostic biomarker for the overall patient survival. As ctDNA was reduced indiscriminately from circulation of all patients, dynamics during the first week of NCRT is not suited for predicting the outcome of LARC. However, the general effect of rapid ctDNA disappearance apparently occurring during the initial days of NCRT is noteworthy and should further be studied.
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Affiliation(s)
- Filip Pazdirek
- Department of Surgery, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czechia
| | - Marek Minarik
- Department of Surgery, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czechia.,Elphogene, Prague, Czechia
| | - Lucie Benesova
- Center for Applied Genomics of Solid Tumors (CEGES), Genomac Research Institute, Prague, Czechia
| | - Tereza Halkova
- Center for Applied Genomics of Solid Tumors (CEGES), Genomac Research Institute, Prague, Czechia
| | | | - Milan Macek
- Department of Biology and Medical Genetics, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czechia
| | - Lubomír Stepanek
- Institute of Biophysics and Informatics, 1st Faculty of Medicine, Charles University, Prague, Czechia
| | - Jiri Hoch
- Department of Surgery, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czechia
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23
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Bostel T, Dreher C, Wollschläger D, Mayer A, König F, Bickelhaupt S, Schlemmer HP, Huber PE, Sterzing F, Bäumer P, Debus J, Nicolay NH. Exploring MR regression patterns in rectal cancer during neoadjuvant radiochemotherapy with daily T2- and diffusion-weighted MRI. Radiat Oncol 2020; 15:171. [PMID: 32653003 PMCID: PMC7353746 DOI: 10.1186/s13014-020-01613-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 07/03/2020] [Indexed: 12/15/2022] Open
Abstract
Background To date, only limited magnetic resonance imaging (MRI) data are available concerning tumor regression during neoadjuvant radiochemotherapy (RCT) of rectal cancer patients, which is a prerequisite for adaptive radiotherapy (RT) concepts. This exploratory study prospectively evaluated daily fractional MRI during neoadjuvant treatment to analyze the predictive value of MR biomarkers for treatment response. Methods Locally advanced rectal cancer patients were examined with daily MRI during neoadjuvant RCT. Contouring of the tumor volume was performed for each MRI scan by using T2- and diffusion-weighted-imaging (DWI)-sequences. The daily apparent-diffusion coefficient (ADC) was calculated. Volumetric and functional tumor changes during RCT were analyzed and correlated with the pathological response after surgical resection. Results In total, 171 MRI scans of eight patients were analyzed regarding anatomical and functional dynamics during RCT. Pathological complete response (pCR) could be achieved in four patients, and four patients had a pathological partial response (pPR) following neoadjuvant treatment. T2- and DWI-based volumetry proved to be statistically significant in terms of therapeutic response, and volumetric thresholds at week two and week four during RCT were defined for the prediction of pCR. In contrast, the average tumor ADC values widely overlapped between both response groups during RCT and appeared inadequate to predict treatment response in our patient cohort. Conclusion This prospective exploratory study supports the hypothesis that MRI may be able to predict pCR of rectal cancers early during neoadjuvant RCT. Our data therefore provide a useful template to tailor future MR-guided adaptive treatment concepts.
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Affiliation(s)
- T Bostel
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany. .,Department of Radiation Oncology, University Medical Center Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany.
| | - C Dreher
- Division of Radiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - D Wollschläger
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center Mainz, Obere Zahlbacher Strasse 69, 55131, Mainz, Germany
| | - A Mayer
- Department of Radiation Oncology, University Medical Center Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - F König
- Division of Radiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - S Bickelhaupt
- Division of Medical Imaging and Radiology - Cancer Prevention, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Institute of Radiology, Friedrich-Alexander-University Erlangen-Nürnberg, Maximiliansplatz 2, 91054, Erlangen, Germany
| | - H P Schlemmer
- Division of Radiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - P E Huber
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - F Sterzing
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Radiation Oncology, Kempten Clinic, Robert-Weixler-Strasse 50, 87439, Kempten, Germany
| | - P Bäumer
- Division of Radiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,dia.log, Altoetting Center for Radiology, Vinzenz-von-Paul-Strasse 10, 84503, Altoetting, Germany
| | - J Debus
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - N H Nicolay
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany. .,Department of Radiation Oncology, University of Freiburg Medical Center, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.
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24
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Zimmermann C, Distler M, Jentsch C, Blum S, Folprecht G, Zöphel K, Polster H, Troost EGC, Abolmaali N, Weitz J, Baumann M, Saeger HD, Grützmann R. Evaluation of response using FDG-PET/CT and diffusion weighted MRI after radiochemotherapy of pancreatic cancer: a non-randomized, monocentric phase II clinical trial-PaCa-DD-041 (Eudra-CT 2009-011968-11). Strahlenther Onkol 2020; 197:19-26. [PMID: 32638040 PMCID: PMC7801319 DOI: 10.1007/s00066-020-01654-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 06/02/2020] [Indexed: 02/07/2023]
Abstract
Background Pancreatic cancer is a devastating disease with a 5-year survival rate of 20–25%. As approximately only 20% of patients diagnosed with pancreatic cancer are initially staged as resectable, it is necessary to evaluate new therapeutic approaches. Hence, neoadjuvant (radio)chemotherapy is a promising therapeutic option, especially in patients with a borderline resectable tumor. The aim of this non-randomized, monocentric, prospective, phase II clinical study was to assess the prognostic value of functional imaging techniques, i.e., [18F]2-fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography (FDG-PET/CT) and diffusion weighted magnetic resonance imaging (DW-MRI), prior to and during neoadjuvant radiochemotherapy. Methods Patients with histologically proven resectable, borderline resectable or unresectable non-metastatic pancreatic adenocarcinoma received induction chemotherapy followed by neoadjuvant radiochemotherapy. Patients underwent FDG-PET/CT and DW-MRI including T1- and T2-weighted sequences prior to and after neoadjuvant chemotherapy as well as following induction radiochemotherapy. The primary endpoint was the evaluation of the response as quantified by the standardized uptake value (SUV) measured with FDG-PET. Response to treatment was evaluated by FDG-PET and DW-MRI during and after the neoadjuvant course. Morphologic staging was performed using contrast-enhanced CT and contrast-enhanced MRI to decide inclusion of patients and resectability after neoadjuvant therapy. In those patients undergoing subsequent surgery, imaging findings were correlated with those of the pathologic resection specimen. Results A total of 25 patients were enrolled in the study. The response rate measured by FDG-PET was 85% with a statistically significant decrease of the maximal SUV (SUVmax) during therapy (p < 0.001). Using the mean apparent diffusion coefficient (ADC), response was not detectable with DW-MRI. After neoadjuvant treatment 16 patients underwent surgery. In 12 (48%) patients tumor resection could be performed. The median overall survival of all patients was 25 months (range: 7–38 months). Conclusion Based on these limited patient numbers, it was possible to show that this trial design is feasible and that the neoadjuvant therapy regime was well tolerated. FDG-PET/CT may be a reliable method to evaluate response to the combined therapy. In contrast, when evaluating the response using mean ADC, DW-MRI did not show conclusive results. Electronic supplementary material The online version of this article (10.1007/s00066-020-01654-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Carolin Zimmermann
- Department of General, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany. .,National Center for Tumor Diseases (NCT), Partner Site Dresden, German Cancer Research Center (DKFZ), Heidelberg, Germany. .,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany. .,Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.
| | - Marius Distler
- Department of General, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Christina Jentsch
- National Center for Tumor Diseases (NCT), Partner Site Dresden, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Sophia Blum
- Department of Radiology, Technische Universität Dresden, Dresden, Germany
| | - Gunnar Folprecht
- National Center for Tumor Diseases (NCT), Partner Site Dresden, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.,Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Klaus Zöphel
- Department of Nuclear Medicine, Klinikum Chemnitz gGmbh, Chemnitz, Germany
| | - Heike Polster
- Department of General, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Esther G C Troost
- National Center for Tumor Diseases (NCT), Partner Site Dresden, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,German Cancer Consortium (DKTK) Partner Site Dresden, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Nasreddin Abolmaali
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Department of Radiology, Technische Universität Dresden, Dresden, Germany.,OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,Department of Radiology, Municipal Hospital and Academic Teaching Hospital of the Technical University Dresden, Dresden-Friedrichstadt, Germany
| | - Jürgen Weitz
- Department of General, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany.,National Center for Tumor Diseases (NCT), Partner Site Dresden, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Michael Baumann
- National Center for Tumor Diseases (NCT), Partner Site Dresden, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Association/Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.,German Cancer Research Center (DKFZ) Heidelberg, Heidelberg, Germany
| | - Hans-Detlev Saeger
- Department of General, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Robert Grützmann
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
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Hörberg L, Roth D, Leander P, Månsson S, Fält T, Ekberg O, Zackrisson S. Reproducibility of measurements with a semi-automatic software package for the evaluation of rectal cancer. Acta Radiol 2020; 61:586-594. [PMID: 31510762 DOI: 10.1177/0284185119873118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Staging of rectal cancer with MRI has major impact on treatment choice and may be of importance in new cancer management strategies such as “wait-and-see” policy. Purpose To assess the reproducibility of a software package recently developed at our department to measure volumes, apparent diffusion coefficient, and the skewness of apparent diffusion coefficient in lymph nodes and tumors in rectal cancer patients before and after chemoradiation treatment. Material and Methods This study included 20 consecutive patients with biopsy-verified rectal cancer, in whom MRI staging had been performed both before and after chemoradiation treatment. The diffusion-weighted images were transferred to the software. The volume, apparent diffusion coefficient, and skewness were determined for 93 lymph nodes and 40 tumors. The volumes were compared with manual measurements of the volume of the same lymph nodes and tumors. Results The agreement in semi-automatic measurements of lymph nodes was very good (ICC = 0.99), and in tumors good (ICC = 0.88). The agreement in manual measurements of lymph nodes was very good (ICC = 0.95) when all lymph nodes were included, but low (ICC = 0.52) if three outliers were excluded. Bland–Altman plots showed clear agreement between manual and semi-automatic measurements in the lymph nodes, but not in measurements of tumors. The values of apparent diffusion coefficient and skewness in tumors differed before and after treatment but did not differ in lymph nodes as a group. Conclusion The software package showed a high degree of reproducibility in measurements on lymph nodes but requires further development to improve the reproducibility of tumor measurements.
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Affiliation(s)
- Lisa Hörberg
- Department of Translational Medicine, Diagnostic Radiology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Daniel Roth
- Medical Radiation Physics, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Peter Leander
- Department of Translational Medicine, Diagnostic Radiology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Sven Månsson
- Medical Radiation Physics, Department of Translational Medicine, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Tobias Fält
- Department of Translational Medicine, Diagnostic Radiology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Olle Ekberg
- Department of Translational Medicine, Diagnostic Radiology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Sophia Zackrisson
- Department of Translational Medicine, Diagnostic Radiology, Skåne University Hospital, Lund University, Malmö, Sweden
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Diffusion-weighted magnetic resonance imaging of mucin pools in locally advanced rectal mucinous adenocarcinoma predicts tumor response to neoadjuvant therapy. Eur J Radiol 2020; 125:108890. [DOI: 10.1016/j.ejrad.2020.108890] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 02/05/2020] [Accepted: 02/10/2020] [Indexed: 12/16/2022]
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27
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A prospective, multi-centre trial of multi-parametric MRI as a biomarker in anal carcinoma. Radiother Oncol 2020; 144:7-12. [DOI: 10.1016/j.radonc.2019.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 09/12/2019] [Accepted: 10/01/2019] [Indexed: 11/23/2022]
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Zhang Q, van Houdt PJ, Lambregts DMJ, van Triest B, Kop MPM, Coolen BF, Strijkers GJ, van der Heide UA, Nederveen AJ. Locally advanced rectal cancer: 3D diffusion-prepared stimulated-echo turbo spin-echo versus 2D diffusion-weighted echo-planar imaging. Eur Radiol Exp 2020; 4:9. [PMID: 32030561 PMCID: PMC7005244 DOI: 10.1186/s41747-019-0138-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 11/20/2019] [Indexed: 11/10/2022] Open
Abstract
Background Diffusion-weighted imaging (DWI) has shown great value in rectal cancer imaging. However, traditional DWI with echo-planar imaging (DW-EPI) often suffers from geometrical distortions. We applied a three-dimensional diffusion-prepared stimulated-echo turbo spin-echo sequence (DPsti-TSE), allowing geometrically undistorted rectal DWI. We compared DPsti-TSE with DW-EPI for locally advanced rectal cancer DWI. Methods For 33 prior-to-treatment patients, DWI images of the rectum were acquired with DPsti-TSE and DW-EPI at 3 T using b-values of 200 and 1000 s/mm2. Two radiologists conducted a blinded scoring of the images considering nine aspects of image quality and anatomical quality. Tumour apparent diffusion coefficient (ADC) and distortions were compared quantitatively. Results DPsti-TSE scored significantly better than DW-EPI in rectum distortion (p = 0.005) and signal pileup (p = 0.001). DPsti-TSE had better tumour Dice similarity coefficient compared to DW-EPI (0.84 versus 0.80, p = 0.010). Tumour ADC values were higher for DPsti-TSE compared to DW-EPI (1.47 versus 0.86 × 10-3 mm2/s, p < 0.001). Radiologists scored DPsti-TSE significantly lower than DW-EPI on aspects of overall image quality (p = 0.001), sharpness (p < 0.001), quality of fat suppression (p < 0.001), tumour visibility (p = 0.009), tumour conspicuity (p = 0.010) and rectum wall visibility (p = 0.005). Conclusions DPsti-TSE provided geometrically less distorted rectal cancer diffusion-weighted images. However, the image quality of DW-EPI over DPsti-TSE was referred on the basis of several image quality criteria. A significant bias in tumour ADC values from DPsti-TSE was present. Further improvements of DPsti-TSE are needed until it can replace DW-EPI.
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Affiliation(s)
- Qinwei Zhang
- Amsterdam UMC, Radiology and Nuclear Medicine, University of Amsterdam, Room Z0-178, Meibergdreef 9, 1100 DD, Amsterdam, Netherlands.
| | - Petra J van Houdt
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | - Baukelien van Triest
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Marnix P M Kop
- Amsterdam UMC, Radiology and Nuclear Medicine, University of Amsterdam, Room Z0-178, Meibergdreef 9, 1100 DD, Amsterdam, Netherlands
| | - Bram F Coolen
- Amsterdam UMC, Biomedical Engineering and Physics, University of Amsterdam, Amsterdam, the Netherlands
| | - Gustav J Strijkers
- Amsterdam UMC, Biomedical Engineering and Physics, University of Amsterdam, Amsterdam, the Netherlands
| | - Uulke A van der Heide
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Aart J Nederveen
- Amsterdam UMC, Radiology and Nuclear Medicine, University of Amsterdam, Room Z0-178, Meibergdreef 9, 1100 DD, Amsterdam, Netherlands
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29
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Li Y, Liu W, Pei Q, Zhao L, Güngör C, Zhu H, Song X, Li C, Zhou Z, Xu Y, Wang D, Tan F, Yang P, Pei H. Predicting pathological complete response by comparing MRI-based radiomics pre- and postneoadjuvant radiotherapy for locally advanced rectal cancer. Cancer Med 2019; 8:7244-7252. [PMID: 31642204 PMCID: PMC6885895 DOI: 10.1002/cam4.2636] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 09/01/2019] [Accepted: 10/07/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Total mesorectal excision following neoadjuvant chemoradiotherapy (nCRT) is recommended in the latest treatment of locally advanced rectal cancer (LARC). OBJECTIVE To predict whether patients with LARC can achieve pathologic complete response (pCR), comparing MRI-based radiomics between before and after neoadjuvant radiotherapy (nRT) was performed. METHODS One hundred and sixty-five MRI-based radiomics features in axial T2-weighted images were obtained quantitatively from Imaging Biomarker Explorer Software. The specific features of conventional and developing radiomics were selected with the analysis of least absolute shrinkage and selection operator logistic regression, of which the predictive performance was analyzed with receiver operating curve and calibration curve, and applied to an independent cohort. RESULTS One hundred and thirty-one target patients were enrolled in the present study. A radiomics signature founded on seven radiomics features was generated in the primary cohort. A remarkable difference about Rad-score between pCR and non-pCR group occurred in both of primary (P < .001) or validation cohorts (P < .001). The value of area under the curves was 0.92 (95% CI, 0.86-0.99) and 0.87 (95% CI, 0.74-1.00) in the primary and validation cohorts, respectively. The Rad-score (OR = 23.581; P < .001) from multivariate logistic regression analysis was significant as an independent factor of pCR. CONCLUSION Our predictive model based on radiomics features was an independent predictor for pCR in LARC and could be a candidate in clinical practice.
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Affiliation(s)
- Yuqiang Li
- Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University, Changsha, China.,Department of General Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wenxue Liu
- Department of Rheumatology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,Department of Cardiology, Xiangya Hospital, Central South University, Changsha, China
| | - Qian Pei
- Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Lilan Zhao
- Department of Thoracic surgery, Fujian Provincial Hospital, Fuzhou, China
| | - Cenap Güngör
- Department of General Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hong Zhu
- Department of Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Xiangping Song
- Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Chenglong Li
- Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Zhongyi Zhou
- Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Yang Xu
- Department of General Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dan Wang
- Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Fengbo Tan
- Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Pei Yang
- Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University, Changsha, China.,Department of Oncology, Hunan Cancer Hospital, Changsha, China
| | - Haiping Pei
- Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University, Changsha, China
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30
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Yoo GS, Park HC, Yu JI, Choi DH, Cho WK, Park YS, Park JO, Lim HY, Kang WK, Lee WY, Kim HC, Yun SH, Cho YB, Park YA, Song KD, Kim SH, Ha SY. Carcinoembryonic Antigen Improves the Performance of Magnetic Resonance Imaging in the Prediction of Pathologic Response after Neoadjuvant Chemoradiation for Patients with Rectal Cancer. Cancer Res Treat 2019; 52:446-454. [PMID: 31588705 PMCID: PMC7176967 DOI: 10.4143/crt.2019.261] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 09/24/2019] [Indexed: 02/06/2023] Open
Abstract
PURPOSE The purpose of this study was to investigate the role of carcinoembryonic antigen (CEA) levels in improving the performance of magnetic resonance imaging (MRI) for the prediction of pathologic response after the neoadjuvant chemoradiation (NCRT) for patients with rectal cancer. MATERIALS AND METHODS We retrospectively reviewed the medical records of 524 rectal cancer patients who underwent NCRT and total mesorectal excision between January 2009 and December 2014. The performances of MRI with or without CEA parameters (initial CEA and CEA dynamics) for prediction of pathologic tumor response grade (pTRG) were compared by receiver-operating characteristic analysis with DeLong's method. Cox regression was used to identify the independent factors associated to pTRG and disease-free survival (DFS) after NCRT. RESULTS The median follow-up was 64.0 months (range, 3.0 to 113.0 months). On multivariate analysis, poor tumor regression grade on MRI (mrTRG; p < 0.001), initial CEA (p < 0.001) and the mesorectal fascia involvement on MRI before NCRT (mrMFI; p=0.054) showed association with poor pTRG. The mrTRG plus CEA parameters showed significantly improved performances in the prediction of pTRG than mrTRG alone. All of mrTRG, mrMFI, and initial CEA were also identified as independent factors associated with DFS. The initial CEA further discriminated DFS in the subgroups with good mrTRG or that without mrMFI. CONCLUSION The CEA parameters significantly improved the performance of MRI in the prediction of pTRG after NCRT for patients with rectal cancer. The DFS was further discriminated by initial CEA level in the groups with favorable MRI parameters.
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Affiliation(s)
- Gyu Sang Yoo
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Chul Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Il Yu
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doo Ho Choi
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Kyung Cho
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Suk Park
- Division of Hematology-Oncology, Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joon Oh Park
- Division of Hematology-Oncology, Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ho Yeong Lim
- Division of Hematology-Oncology, Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Ki Kang
- Division of Hematology-Oncology, Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo Yong Lee
- Department of General Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Cheol Kim
- Department of General Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Hyeon Yun
- Department of General Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Beom Cho
- Department of General Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoon Ah Park
- Department of General Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyoung Doo Song
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seok-Hyung Kim
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang Yun Ha
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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31
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Nougaret S, Castan F, de Forges H, Vargas HA, Gallix B, Gourgou S, Rouanet P. Early MRI predictors of disease-free survival in locally advanced rectal cancer from the GRECCAR 4 trial. Br J Surg 2019; 106:1530-1541. [PMID: 31436325 DOI: 10.1002/bjs.11233] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 04/05/2019] [Accepted: 04/14/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Tailored neoadjuvant treatment of locally advanced rectal cancer (LARC) may improve outcomes. The aim of this study was to determine early MRI prognostic parameters with which to stratify neoadjuvant treatment in patients with LARC. METHODS All patients from a prospective, phase II, multicentre randomized study (GRECCAR4; NCT01333709) were included, and underwent rectal MRI before treatment, 4 weeks after induction chemotherapy and after completion of chemoradiotherapy (CRT). Tumour volumetry, MRI tumour regression grade (mrTRG), T and N categories, circumferential resection margin (CRM) status and extramural vascular invasion identified by MRI (mrEMVI) were evaluated. RESULTS A total of 133 randomized patients were analysed. Median follow-up was 41·4 (95 per cent c.i. 36·6 to 45·2) months. Thirty-one patients (23·3 per cent) developed tumour recurrence. In univariable analysis, mrEMVI at baseline was the only prognostic factor associated with poorer outcome (P = 0·015). After induction chemotherapy, a larger tumour volume on MRI (P = 0·019), tumour volume regression of 60 per cent or less (P = 0·002), involvement of the CRM (P = 0·037), mrEMVI (P = 0·026) and a poor mrTRG (P = 0·023) were associated with poor outcome. After completion of CRT, the absence of complete response on MRI (P = 0·004), mrEMVI (P = 0·038) and a poor mrTRG (P = 0·005) were associated with shorter disease-free survival. A final multivariable model including all significant variables (baseline, after induction, after CRT) revealed that Eastern Cooperative Oncology Group performance status (P = 0·011), sphincter involvement (P = 0·009), mrEMVI at baseline (P = 0·002) and early tumour volume regression of 60 per cent or less after induction (P = 0·007) were associated with relapse. CONCLUSION Baseline and early post-treatment MRI parameters are associated with prognosis in LARC. Future preoperative treatment should stratify treatment according to baseline mrEMVI status and early tumour volume regression.
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Affiliation(s)
- S Nougaret
- Department of Radiology, Institut du Cancer de Montpellier, University of Montpellier, Montpellier, France.,Institut de Recherche en Cancérologie de Montpellier, Institut National de la Santé et de la Recherche Médicale, U1194, Montpellier, France
| | - F Castan
- Biometrics Unit, Institut du Cancer de Montpellier, University of Montpellier, Montpellier, France
| | - H de Forges
- Clinical Research Unit, Institut du Cancer de Montpellier, University of Montpellier, Montpellier, France
| | - H A Vargas
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - B Gallix
- Department of Radiology, Royal Victoria Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - S Gourgou
- Biometrics Unit, Institut du Cancer de Montpellier, University of Montpellier, Montpellier, France
| | - P Rouanet
- Department of Surgical Oncology, Institut du Cancer de Montpellier, University of Montpellier, Montpellier, France
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Pham TT, Stait-Gardner T, Lee CS, Barton M, Graham PL, Liney G, Wong K, Price WS. Correlation of ultra-high field MRI with histopathology for evaluation of rectal cancer heterogeneity. Sci Rep 2019; 9:9311. [PMID: 31249325 PMCID: PMC6597556 DOI: 10.1038/s41598-019-45450-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 06/04/2019] [Indexed: 01/22/2023] Open
Abstract
Current clinical MRI techniques in rectal cancer have limited ability to examine cancer stroma. The differentiation of tumour from desmoplasia or fibrous tissue remains a challenge. Standard MRI cannot differentiate stage T1 from T2 (invasion of muscularis propria) tumours. Diffusion tensor imaging (DTI) can probe tissue structure and organisation (anisotropy). The purpose of this study was to examine DTI-MRI derived imaging markers of rectal cancer stromal heterogeneity and tumour extent ex vivo. DTI-MRI at ultra-high magnetic field (11.7 tesla) was used to examine the stromal microstructure of malignant and normal rectal tissue ex vivo, and the findings were correlated with histopathology. Images obtained from DTI-MRI (A0, apparent diffusion coefficient and fractional anisotropy (FA)) were used to probe rectal cancer stromal heterogeneity. FA provided the best discrimination between cancer and desmoplasia, fibrous tissue and muscularis propria. Cancer had relatively isotropic diffusion (mean FA 0.14), whereas desmoplasia (FA 0.31) and fibrous tissue (FA 0.34) had anisotropic diffusion with significantly higher FA than cancer (p < 0.001). Tumour was distinguished from muscularis propria (FA 0.61) which was highly anisotropic with higher FA than cancer (p < 0.001). This study showed that DTI-MRI can assist in more accurately defining tumour extent in rectal cancer.
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Affiliation(s)
- Trang T Pham
- Department of Radiation Oncology, Liverpool Cancer Therapy Centre, Liverpool Hospital, Sydney, Australia. .,South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia. .,Ingham Institute for Applied Medical Research, Sydney, Australia.
| | - Timothy Stait-Gardner
- Nanoscale Organisation and Dynamics Group, Western Sydney University, Sydney, Australia
| | - Cheok Soon Lee
- South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia.,Ingham Institute for Applied Medical Research, Sydney, Australia.,School of Medicine, Western Sydney University, Sydney, Australia.,Department of Anatomical Pathology, Liverpool Hospital, Sydney, Australia
| | - Michael Barton
- Department of Radiation Oncology, Liverpool Cancer Therapy Centre, Liverpool Hospital, Sydney, Australia.,South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia.,Ingham Institute for Applied Medical Research, Sydney, Australia
| | - Petra L Graham
- Centre for Economic Impacts of Genomic Medicine (GenIMPACT), Macquarie Business School, Macquarie University, Sydney, Australia
| | - Gary Liney
- Department of Radiation Oncology, Liverpool Cancer Therapy Centre, Liverpool Hospital, Sydney, Australia.,South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia.,Ingham Institute for Applied Medical Research, Sydney, Australia
| | - Karen Wong
- Department of Radiation Oncology, Liverpool Cancer Therapy Centre, Liverpool Hospital, Sydney, Australia.,South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia.,Ingham Institute for Applied Medical Research, Sydney, Australia
| | - William S Price
- Department of Radiation Oncology, Liverpool Cancer Therapy Centre, Liverpool Hospital, Sydney, Australia.,Nanoscale Organisation and Dynamics Group, Western Sydney University, Sydney, Australia.,School of Medicine, Western Sydney University, Sydney, Australia
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33
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Yi X, Pei Q, Zhang Y, Zhu H, Wang Z, Chen C, Li Q, Long X, Tan F, Zhou Z, Liu W, Li C, Zhou Y, Song X, Li Y, Liao W, Li X, Sun L, Pei H, Zee C, Chen BT. MRI-Based Radiomics Predicts Tumor Response to Neoadjuvant Chemoradiotherapy in Locally Advanced Rectal Cancer. Front Oncol 2019; 9:552. [PMID: 31293979 PMCID: PMC6606732 DOI: 10.3389/fonc.2019.00552] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 06/06/2019] [Indexed: 12/14/2022] Open
Abstract
Background: Conventional methods for predicting treatment response to neoadjuvant chemoradiotherapy (nCRT) in patients with locally advanced rectal cancer (LARC) are limited. Methods: This study retrospectively recruited 134 LARC patients who underwent standard nCRT followed by total mesorectal excision surgery in our institution. Based on pre-operative axial T2-weighted images, machine learning radiomics was performed. A receiver operating characteristic (ROC) curve was performed to test the efficiencies of the predictive model. Results: Among the 134 patients, 32 (23.9%) achieved pathological complete response (pCR), 69 (51.5%) achieved a good response, and 91 (67.9%) achieved down-staging. For prediction of pCR, good-response, and down-staging, the predictive model demonstrated high classification efficiencies, with an AUC value of 0.91 (95% CI: 0.83–0.98), 0.90 (95% CI: 0.83–0.97), and 0.93 (95% CI: 0.87–0.98), respectively. Conclusion: Our machine learning radiomics model showed promise for predicting response to nCRT in patients with LARC. Our predictive model based on the commonly used T2-weighted images on pelvic Magnetic Resonance Imaging (MRI) scans has the potential to be adapted in clinical practice. Novelty and Impact Statements: Methods for predicting the response of the locally advanced rectal cancer (LARC, T3-4, or N+) to neoadjuvant chemoradiotherapy (nCRT) is lacking. In the present study, we developed a new machine learning radiomics method based on T2-weighted images. As a non-invasive tool, this method facilitates prediction performance effectively. It achieves a satisfactory overall diagnostic accuracy for predicting of pCR, good response, and down-staging show an AUC of 0.908, 0.902, and 0.930 in LARC patients, respectively.
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Affiliation(s)
- Xiaoping Yi
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, China.,Postdoctoral Research Workstation of Pathology and Pathophysiology, Basic Medical Sciences, Xiangya Hospital, Central South University, Changsha, China
| | - Qian Pei
- Department of General surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Youming Zhang
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, China
| | - Hong Zhu
- Department of Radiation Oncology, Xiangya Hospital, Central South University, Changsha, China
| | - Zhongjie Wang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Chen Chen
- Department of Radiology, Zhuzhou 331 Hospital, Zhuzhou, China
| | - Qingling Li
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, China
| | - Xueying Long
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, China
| | - Fengbo Tan
- Department of General surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Zhongyi Zhou
- Department of General surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Wenxue Liu
- Department of Cardiology, Xiangya Hospital, Central South University, Changsha, China
| | - Chenglong Li
- Department of General surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Yuan Zhou
- Department of General surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Xiangping Song
- Department of General surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Yuqiang Li
- Department of General surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Weihua Liao
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, China
| | - Xuejun Li
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Lunquan Sun
- Postdoctoral Research Workstation of Pathology and Pathophysiology, Basic Medical Sciences, Xiangya Hospital, Central South University, Changsha, China
| | - Haiping Pei
- Department of General surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Chishing Zee
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Bihong T Chen
- Department of Diagnostic Radiology, City of Hope National Medical Center, Duarte, CA, United States
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White IM, Scurr E, Wetscherek A, Brown G, Sohaib A, Nill S, Oelfke U, Dearnaley D, Lalondrelle S, Bhide S. Realizing the potential of magnetic resonance image guided radiotherapy in gynaecological and rectal cancer. Br J Radiol 2019; 92:20180670. [PMID: 30933550 PMCID: PMC6592079 DOI: 10.1259/bjr.20180670] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 02/24/2019] [Accepted: 03/21/2019] [Indexed: 12/25/2022] Open
Abstract
CT-based radiotherapy workflow is limited by poor soft tissue definition in the pelvis and reliance on rigid registration methods. Current image-guided radiotherapy and adaptive radiotherapy models therefore have limited ability to improve clinical outcomes. The advent of MRI-guided radiotherapy solutions provides the opportunity to overcome these limitations with the potential to deliver online real-time MRI-based plan adaptation on a daily basis, a true "plan of the day." This review describes the application of MRI guided radiotherapy in two pelvic tumour sites likely to benefit from this approach.
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Affiliation(s)
- Ingrid M White
- Institute of Cancer Research and Royal Marsden National Health Service Foundation Trust, Sutton, Surrey, UK
| | - Erica Scurr
- Institute of Cancer Research and Royal Marsden National Health Service Foundation Trust, Sutton, Surrey, UK
| | - Andreas Wetscherek
- Institute of Cancer Research and Royal Marsden National Health Service Foundation Trust, Sutton, Surrey, UK
| | - Gina Brown
- Institute of Cancer Research and Royal Marsden National Health Service Foundation Trust, Sutton, Surrey, UK
| | - Aslam Sohaib
- Institute of Cancer Research and Royal Marsden National Health Service Foundation Trust, Sutton, Surrey, UK
| | - Simeon Nill
- Institute of Cancer Research and Royal Marsden National Health Service Foundation Trust, Sutton, Surrey, UK
| | - Uwe Oelfke
- Institute of Cancer Research and Royal Marsden National Health Service Foundation Trust, Sutton, Surrey, UK
| | - David Dearnaley
- Institute of Cancer Research and Royal Marsden National Health Service Foundation Trust, Sutton, Surrey, UK
| | - Susan Lalondrelle
- Institute of Cancer Research and Royal Marsden National Health Service Foundation Trust, Sutton, Surrey, UK
| | - Shreerang Bhide
- Institute of Cancer Research and Royal Marsden National Health Service Foundation Trust, Sutton, Surrey, UK
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Schurink NW, Lambregts DMJ, Beets-Tan RGH. Diffusion-weighted imaging in rectal cancer: current applications and future perspectives. Br J Radiol 2019; 92:20180655. [PMID: 30433814 DOI: 10.1259/bjr.20180655] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
This review summarizes current applications and clinical utility of diffusion-weighted imaging (DWI) for rectal cancer and in addition provides a brief overview of more recent developments (including intravoxel incoherent motion imaging, diffusion kurtosis imaging, and novel postprocessing tools) that are still in more early stages of research. More than 140 papers have been published in the last decade, during which period the use of DWI have slowly moved from mainly qualitative (visual) image interpretation to increasingly advanced methods of quantitative analysis. So far, the largest body of evidence exists for assessment of tumour response to neoadjuvant treatment. In this setting, particularly the benefit of DWI for visual assessment of residual tumour in post-radiation fibrosis has been established and is now increasingly adopted in clinics. Quantitative DWI analysis (mainly the apparent diffusion coefficient) has potential, both for response prediction as well as for tumour prognostication, but protocols require standardization and results need to be prospectively confirmed on larger scale. The role of DWI for further clinical tumour and nodal staging is less well-defined, although there could be a benefit for DWI to help detect lymph nodes. Novel methods of DWI analysis and post-processing are still being developed and optimized; the clinical potential of these tools remains to be established in the upcoming years.
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Affiliation(s)
- Niels W Schurink
- 1 Radiology, Netherlands Cancer Institute , Amsterdam , The Netherlands.,2 GROW School for Oncology and Developmental Biology , Maastricht , The Netherlands
| | | | - Regina G H Beets-Tan
- 1 Radiology, Netherlands Cancer Institute , Amsterdam , The Netherlands.,2 GROW School for Oncology and Developmental Biology , Maastricht , The Netherlands
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Lambregts DMJ, Boellaard TN, Beets-Tan RGH. Response evaluation after neoadjuvant treatment for rectal cancer using modern MR imaging: a pictorial review. Insights Imaging 2019; 10:15. [PMID: 30758688 PMCID: PMC6375095 DOI: 10.1186/s13244-019-0706-x] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 10/24/2018] [Indexed: 01/02/2023] Open
Abstract
In recent years, neoadjuvant chemoradiotherapy (CRT) has become the standard of care for patients with locally advanced rectal cancer. Until recently, patients routinely proceeded to surgical resection after CRT, regardless of the response. Nowadays, treatment is tailored depending on the response to chemoradiotherapy. In patients that respond very well to CRT, organ-preserving treatments such as watch-and-wait are increasingly considered as an alternative to surgery. To facilitate such personalized treatment planning, there is now an increased demand for more detailed radiological response evaluation after chemoradiation. MRI is one of the main tools used to assess response, but has difficulties in assessing response within areas of post-radiation fibrosis. Hence, MR sequences such as diffusion-weighted imaging are increasingly adopted in clinical MR protocols to improve the differentiation between tumor and fibrosis. In this pictorial review, we discuss the strengths and weaknesses of modern MR imaging, including functional imaging sequences such as diffusion-weighted MRI, for response evaluation after chemoradiation treatment and provide the main pearls and pitfalls for image interpretation.
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Affiliation(s)
- Doenja M J Lambregts
- Department of Radiology, Antoni van Leeuwenhoek - Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - Thierry N Boellaard
- Department of Radiology, Antoni van Leeuwenhoek - Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Regina G H Beets-Tan
- Department of Radiology, Antoni van Leeuwenhoek - Netherlands Cancer Institute, Amsterdam, The Netherlands.,GROW School for Oncology and Developmental Biology - Maastricht University, Maastricht, The Netherlands
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Valentini V, Gambacorta MA, Cellini F, Aristei C, Coco C, Barbaro B, Alfieri S, D'Ugo D, Persiani R, Deodato F, Crucitti A, Lupattelli M, Mantello G, Navarria F, Belluco C, Buonadonna A, Boso C, Lonardi S, Caravatta L, Barba MC, Vecchio FM, Maranzano E, Genovesi D, Doglietto GB, Morganti AG, La Torre G, Pucciarelli S, De Paoli A. The INTERACT Trial: Long-term results of a randomised trial on preoperative capecitabine-based radiochemotherapy intensified by concomitant boost or oxaliplatin, for cT2 (distal)-cT3 rectal cancer. Radiother Oncol 2019; 134:110-118. [PMID: 31005204 DOI: 10.1016/j.radonc.2018.11.023] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/26/2018] [Accepted: 11/30/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE Capecitabine-based radiochemotherapy (cbRCT) is standard for preoperative long-course radiochemotherapy of locally advanced rectal cancer. This prospective, parallel-group, randomised controlled trial investigated two intensification regimens. cT4 lesions were excluded. PRIMARY OBJECTIVE pathological outcome (TRG 1-2) among arms. MATERIALS AND METHODS Low-located cT2N0-2M0, cT3N0-2M0 (up to 12 cm from anal verge) presentations were treated with cbRCT randomly intensified by either radiotherapy boost (Xelac arm) or multidrug concomitant chemotherapy (Xelox arm). Xelac: concomitant boost to bulky site (45 Gy/1.8 Gy/die, 5 sessions/week to the pelvis, +10 Gy at 1 Gy twice/week to the bulky) plus concurrent capecitabine (1650 mg/mq/die). Xelox: 45 Gy to the pelvis + 5.4 Gy/1.8 Gy/die, 5 sessions/week to the bulky site + concurrent capecitabine (1300 mg/mq/die) and oxaliplatin (130 mg/mq on days 1,19,38). Surgery was planned 7-9 weeks after radiochemotherapy. RESULTS From June 2005 to September 2013, 534 patients were analysed: 280 in Xelac, 254 in Xelox arm. Xelox arm presented higher G ≥ 3 haematologic (p = 0.01) and neurologic toxicity (p < 0.001). Overall, 98.5% patients received curative surgery. The tumour regression grade distribution did not differ between arms (p = 0.102). TRG 1+2 rate significantly differed: Xelac arm 61.7% vs. Xelox 52.3% (p = 0.039). Pathological complete response (ypT0N0) rates were 24.4 and 23.8%, respectively (p non-significant). Median follow-up:5.62 years. Five-year disease-free survival rate were 74.7% (Xelac) and 73.8% (Xelox), respectively (p = 0.444). Five-year overall survival rate were 80.4% (Xelac) and 85.5% (Xelox), respectively (p = 0.155). CONCLUSION Xelac arm significantly obtained higher TRG1-2 rates. No differences were found about clinical outcome. Because of efficacy on TRG, inferior toxicity and good compliance, Xelac schedules or similar radiotherapy dose intensification schemes could be considered as reference treatments for cT3 lesions.
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Affiliation(s)
- Vincenzo Valentini
- Department Radiation Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Maria Antonietta Gambacorta
- Department Radiation Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Francesco Cellini
- Department Radiation Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.
| | - Cynthia Aristei
- Radiation Oncology Section, Department of Surgery and Biomedical Science, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Claudio Coco
- Chirurgia Generale Presidio Columbus, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Brunella Barbaro
- Department of Bioimaging and Radiological Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Sergio Alfieri
- Istituto di Clinica Chirurgica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Domenico D'Ugo
- Abdominal Surgery Area, General Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Roberto Persiani
- Department of Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Francesco Deodato
- Radiotherapy Department, Fondazione Ricerca e Cura Giovanni Paolo II, Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Antonio Crucitti
- Department of Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marco Lupattelli
- Radiation Oncology Centre - S. Maria Misericordia Hospital, Perugia, Italy
| | - Giovanna Mantello
- Radiotherapy Unit, Azienda Ospedaliero Universitaria, Ospedali Riuniti Ancona, Italy
| | - Federico Navarria
- Radiation Oncology Department, Centro di Riferimento Oncologico, IRCCS, Aviano, Italy
| | - Claudio Belluco
- Surgical Oncology Department, Centro di Riferimento Oncologico, IRCCS, Aviano, Italy
| | - Angela Buonadonna
- Medical Oncology Department, Centro di Riferimento Oncologico, IRCCS, Aviano, Italy
| | - Caterina Boso
- Radiotherapy and Nuclear Medicine Unit, IOV-IRCCS, Padova , Italy
| | - Sara Lonardi
- Medical Oncology Unit 1, IOV-IRCCS, Padova, Italy
| | - Luciana Caravatta
- Radiotherapy Unit, SS Annunziata Hospital, G. D'Annunzio University, Chieti, Italy
| | | | - Fabio Maria Vecchio
- Department of Pathology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | | | - Domenico Genovesi
- Radiotherapy Unit, SS Annunziata Hospital, G. D'Annunzio University, Chieti, Italy
| | - Giovanni Battista Doglietto
- Istituto di Clinica Chirurgica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Alessio Giuseppe Morganti
- Radiation Oncology Center, Department of Experimental, Diagnostic and Speciality Medicine, DIMES, University of Bologna, S. Orsola-Malpighi Hospital, Italy
| | - Giuseppe La Torre
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Italy
| | - Salvatore Pucciarelli
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Italy
| | - Antonino De Paoli
- Radiation Oncology Department, Centro di Riferimento Oncologico, IRCCS, Aviano, Italy
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Magnetic resonance imaging in locally advanced rectal cancer: quantitative evaluation of the complete response to neoadjuvant therapy. Pol J Radiol 2018; 83:e600-e609. [PMID: 30800199 PMCID: PMC6384410 DOI: 10.5114/pjr.2018.81156] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 09/13/2018] [Indexed: 02/01/2023] Open
Abstract
Purpose To assess the diagnostic performance of diffusion-weighted imaging (DWI) for the discrimination of complete responder (CR) from the non-complete responder (n-CR) in patients with locally advanced rectal cancer (LARC) undergoing chemotherapy and radiation (CRT). Material and methods Between December 2009 and January 2014, 32 patients (33 lesions: one patient had two synchronous lesions) were enrolled in this retrospective study. All patients underwent a pre- and post-CRT conventional MRI study completed with DWI. For both data sets (T2-weighted and DWI), the pre- and post-CRT tumour volume (VT2; VDWI) and the tumour volume reduction ratio (ΔV%) were determined as well as pre- and post-CRT apparent diffusion coefficient (ADC) and ADC change (ΔADC%). Histopathological findings were the standard of reference. Receiver operating characteristic (ROC) curves were generated to compare performance of T2-weighted and DWI volumetry, as well as ADC. Results The area under the ROC curve (AUC) revealed a good accuracy of pre- and post-CRT values of VT2 (0.86; 0.91) and VDWI (0.82; 1.00) as well as those of ΔVT2% (0.84) and ΔVDWI% (1.00) for the CR assessment, with no statistical difference. The AUC of pre- and post-CRT ADC (0.53; 0.54) and that of ΔADC% (0.58) were significantly lower. Conclusions Both post-CRT VDWI and ΔVDWI% (AUC = 1) are very accurate for the assessment of the CR, in spite of no significant differences in comparison to the conventional post-CRT VT2 (AUC = 0.91) and ΔVT2% (AUC = 0.84). On the contrary, both ADC and ΔADC% values are not reliable.
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Multiple mathematical models of diffusion-weighted magnetic resonance imaging combined with prognostic factors for assessing the response to neoadjuvant chemotherapy and radiation therapy in locally advanced rectal cancer. Eur J Radiol 2018; 110:249-255. [PMID: 30599868 DOI: 10.1016/j.ejrad.2018.12.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/25/2018] [Accepted: 12/04/2018] [Indexed: 12/16/2022]
Abstract
PURPOSE To investigate whether the apparent diffusion coefficient (ADC), intravoxel incoherent motion (IVIM), and stretched exponential model (SEM) based on histogram analyses derived from the whole-tumor volume combined with prognostic factors can be used to assess the response to chemotherapy and radiation therapy (CRT) in locally advanced rectal cancer (LARC). MATERIALS AND METHODS This study included 60 patients with LARC who underwent diffusion-weighted imaging with 9b values (0-1000s/mm2) before CRT. Histograms derived from the whole-tumor volume were used to obtain the ADC, IVIM (Dslow, Dfast, and f), and SEM parameters (distributed diffusion coefficient (DDC) and α). The histogram metrics and prognostic factors before CRT were compared between pathological complete response (pCR) and non-pCR patients. The receiver operating characteristic (ROC) and the area under the ROC curve (AUC) were generated to analyze the histogram metrics and prognostic factors. RESULTS A significant difference was only found in the tumor volume between the pCR and non-pCR groups (p = 0.033, AUC = 0.740). The ADC mean, DDC median, and most of the histogram metrics were significantly lower in the pCR group than the non-pCR group (p = 0.000-0.025), and AUC was highest for the ADC mean (0.890). Only the Dslow median differed significantly between the two groups (p = 0.023, AUC = 0.721). However, the Dfast, f, and α histogram metrics did not differ significantly between the pCR and non-pCR groups. The AUC for the ADC mean combined with the tumor volume was 0.908, with a sensitivity of 100% and specificity of 81%. The inter-observer agreements were good or excellent for the ADC and SEM histogram parameters but generally fair for IVIM. CONCLUSION The whole-tumor ADC mean combined with the tumor volume was highly accurate for predicting pCR. The IVIM models were inferior to ADC and SEM at predicting pCR.
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Hunt A, Hansen VN, Oelfke U, Nill S, Hafeez S. Adaptive Radiotherapy Enabled by MRI Guidance. Clin Oncol (R Coll Radiol) 2018; 30:711-719. [PMID: 30201276 DOI: 10.1016/j.clon.2018.08.001] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 08/10/2018] [Accepted: 08/20/2018] [Indexed: 12/11/2022]
Abstract
Adaptive radiotherapy (ART) strategies systematically monitor variations in target and neighbouring structures to inform treatment-plan modification during radiotherapy. This is necessary because a single plan designed before treatment is insufficient to capture the actual dose delivered to the target and adjacent critical structures during the course of radiotherapy. Magnetic resonance imaging (MRI) provides superior soft-tissue image contrast over current standard X-ray-based technologies without additional radiation exposure. With integrated MRI and radiotherapy platforms permitting motion monitoring during treatment delivery, it is possible that adaption can be informed by real-time anatomical imaging. This allows greater treatment accuracy in terms of dose delivered to target with smaller, individualised treatment margins. The use of functional MRI sequences would permit ART to be informed by imaging biomarkers, so allowing both personalised geometric and biological adaption. In this review, we discuss ART solutions enabled by MRI guidance and its potential gains for our patients across tumour types.
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Affiliation(s)
- A Hunt
- The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK
| | - V N Hansen
- The Institute of Cancer Research, London, UK; Joint Department of Physics, The Royal Marsden NHS Foundation Trust, London, UK
| | - U Oelfke
- The Institute of Cancer Research, London, UK; Joint Department of Physics, The Royal Marsden NHS Foundation Trust, London, UK
| | - S Nill
- The Institute of Cancer Research, London, UK; Joint Department of Physics, The Royal Marsden NHS Foundation Trust, London, UK
| | - S Hafeez
- The Institute of Cancer Research, London, UK; The Royal Marsden NHS Foundation Trust, London, UK.
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MRI-Based Apparent Diffusion Coefficient for Predicting Pathologic Response of Rectal Cancer After Neoadjuvant Therapy: Systematic Review and Meta-Analysis. AJR Am J Roentgenol 2018; 211:W205-W216. [PMID: 30240291 DOI: 10.2214/ajr.17.19135] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The purpose of this study was to assess the use of apparent diffusion coefficient (ADC) during DWI for predicting complete pathologic response of rectal cancer after neoadjuvant therapy. MATERIALS AND METHODS A systematic review of available literature was conducted to retrieve studies focused on the identification of complete pathologic response of locally advanced rectal cancer after neoadjuvant chemoradiation, through the assessment of ADC evaluated before, after, or both before and after treatment, as well as in terms of the difference between pretreatment and posttreatment ADC. Pooled mean pretreatment ADC, posttreatment ADC, and Δ-ADC (calculated as posttreatment ADC minus pretreatment ADC divided by pretreatment ADC and multiplied by 100) in complete responders versus incomplete responders were calculated. For each parameter, we also pooled sensitivity and specificity and calculated the area under the summary ROC curve. RESULTS We found 10 prospective and eight retrospective studies. Overall, pathologic complete response was observed in 22.2% of patients. Pooled mean pretreatment ADC in complete responders was 0.84 × 10-3 mm2/s versus 0.89 × 10-3 mm2/s in incomplete responders (p = 0.33). Posttreatment ADC values were 1.51 × 10-3 mm2/s and 1.29 × 10-3 mm2/s, in complete and incomplete responders, respectively (p = 0.00001). The Δ-ADC percentages were also significantly higher in complete responders than in incomplete responders (59.7% vs 29.7%, respectively, p = 0.016). Pooled sensitivity, specificity, and AUC were 0.743, 0.755, and 0.841 for pretreatment ADC; 0.800, 0.737, and 0.782 for posttreatment ADC; and 0.832, 0.806, and 0.895 for Δ-ADC. CONCLUSION Use of ADC during DWI is a promising technique for assessment of results of neoadjuvant treatment of rectal cancer.
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Delli Pizzi A, Cianci R, Genovesi D, Esposito G, Timpani M, Tavoletta A, Pulsone P, Basilico R, Gabrielli D, Rosa C, Caravatta L, Di Tommaso M, Caulo M, Filippone A. Performance of diffusion-weighted magnetic resonance imaging at 3.0T for early assessment of tumor response in locally advanced rectal cancer treated with preoperative chemoradiation therapy. Abdom Radiol (NY) 2018; 43:2221-2230. [PMID: 29332248 DOI: 10.1007/s00261-018-1457-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
PURPOSE The purpose of the article is to determine whether changes in apparent diffusion coefficient (ADC) values of locally advanced rectal cancer (LARC) obtained 2 weeks after the beginning of chemoradiation therapy (CRT) allow to predict treatment response and whether correlate with tumor histopathologic response. METHODS Forty-three patients receiving CRT for LARC and 3.0T magnetic resonance imaging with diffusion-weighted sequences before treatment, 2 weeks during, and 8 weeks post the completion of CRT were included. ADC values were calculated at each time point and percentage of ADC changes at 2 weeks (ΔADC during) and 8 weeks (ΔADC post) were assessed. Data were correlated to surgical results and histopathologic tumor regression grade (TRG), according to Mandard's classification. ADC values and ΔADCs of complete responders (CR; TRG1) and non-complete responders (non-CR; TRG 2-5) were compared. Receiver-operating characteristic curve (ROC) analysis was used to assess diagnostic accuracy of ΔADC for differentiating CR from non-CR. The correlation with TRG was investigated using Spearman's rank test. RESULTS ΔADC during and ΔADC post were significantly higher in CR (33.9% and 57%, respectively) compared to non-CR (13.5% and 2.2%, respectively) group (p = 0.006 and p < 0.001, respectively). ROC analysis revealed the following diagnostic performances: ΔADC during: AUC 0.78 (0.08), p = 0.004, cut-off 20.6% (sensitivity 75% and specificity 76.5%); ΔADC post: AUC 0.94 (0.04), p ≤ 0.001, cut-off 22% (sensitivity 95% and specificity 82.4%). Significant moderate and good negative correlation was found between ΔADC during and ΔADC post and TRG (r = - 0.418, p = 0.007; r = - 694, p ≤ 0.001, respectively). CONCLUSION ΔADC at 2 weeks after the beginning of CRT is a reliable tool to early assess treatment response.
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Affiliation(s)
- Andrea Delli Pizzi
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio", Chieti, Italy.
- ITAB Institute of Advanced Biomedical Technologies, University "G. d'Annunzio", Via Luigi Polacchi, 11 66100, Chieti, Italy.
| | - Roberta Cianci
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio", Chieti, Italy
| | | | - Gianluigi Esposito
- Ospedale "Pesenti Fenaroli", Via Mazzini, 88 24022, Alzano Lombardo (BG), Italy
| | - Mauro Timpani
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio", Chieti, Italy
| | - Alessandra Tavoletta
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio", Chieti, Italy
| | - Pierluigi Pulsone
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio", Chieti, Italy
| | - Raffaella Basilico
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio", Chieti, Italy
| | - Daniela Gabrielli
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio", Chieti, Italy
| | - Consuelo Rosa
- Radiation Oncology Unit, SS Annunziata Hospital, Chieti, Italy
| | | | | | - Massimo Caulo
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio", Chieti, Italy
- ITAB Institute of Advanced Biomedical Technologies, University "G. d'Annunzio", Via Luigi Polacchi, 11 66100, Chieti, Italy
| | - Antonella Filippone
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio", Chieti, Italy
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Gurdal N, Fayda M, Alishev N, Bakir B, Tastekin D, Aykan F, Gezer U, Balik E, Saglam EK, Oral EN, Gulluoglu M, Kizir A. Neoadjuvant volumetric modulated arc therapy in rectal cancer and the correlation of pathological response with diffusion-weighted MRI and apoptotic markers. TUMORI JOURNAL 2018; 104:266-272. [PMID: 29218690 DOI: 10.5301/tj.5000702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE In this prospective observational study, we aimed to report the applicability and tolerability of neoadjuvant volumetric modulated arc therapy with simultaneous integrated boost (SIB-VMAT) and concurrent chemotherapy in patients with locally advanced rectal cancer (LARC), and to evaluate the correlation of pathological response with apparent diffusion coefficient (ADC) measurements on diffusion-weighted magnetic resonance imaging (DW-MRI) and apoptotic markers. METHODS The study enrolled 30 patients with T3 to T4 and/or N+ rectal cancer who preoperatively received SIB-VMAT and concurrent chemotherapy. Before and after the neoadjuvant treatment, apoptotic markers including the nucleosomes and cell-free DNA fragments in the serum samples were examined; DNA integrity was assessed by amplifying the ACTB gene; and the ADC measurements on the DW-MRI were analyzed. RESULTS No patients had acute or chronic grade III-IV toxicity. Pathologic complete response (pCR) was achieved in 8 patients (27%), while in 10 patients (33%) near-complete pathological response was obtained. Posttreatment ADC was significantly higher in patients with pCR compared with the others (1.28 vs. 1.10, p = 0.017). ROC curve analysis showed that posttreatment ADC values had a sensitivity of 75% and a specificity of 77.3% for distinguishing the patients with pCR from other responders. On the other hand, posttreatment DNA integrity values were revealed lower than the pretreatment values (p = 0.36). Also, the results revealed an insignificant increase in the posttreatment serum level of nucleosomes (p = 0.72). CONCLUSIONS Neoadjuvant SIB-VMAT with concurrent chemotherapy was proved to be a feasible treatment regimen in LARC with tolerable side effects, and improved local control rate and pCR rate.
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Affiliation(s)
- Necla Gurdal
- 1 Department of Radiation Oncology, Institute of Oncology, Istanbul University, Istanbul - Turkey
| | - Merdan Fayda
- 2 Department of Radiation Oncology, Istinye University, Faculty of Medicine, Istanbul - Turkey
| | - Nijat Alishev
- 3 Department of Radiology, Istanbul University, Istanbul Faculty of Medicine, Istanbul - Turkey
| | - Baris Bakir
- 3 Department of Radiology, Istanbul University, Istanbul Faculty of Medicine, Istanbul - Turkey
| | - Didem Tastekin
- 4 Department of Medical Oncology, Institute of Oncology, Istanbul University, Istanbul - Turkey
| | - Faruk Aykan
- 4 Department of Medical Oncology, Institute of Oncology, Istanbul University, Istanbul - Turkey
| | - Ugur Gezer
- 5 Department of Basic Oncology, Institute of Oncology, Istanbul University, Istanbul - Turkey
| | - Emre Balik
- 6 Department of General Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul - Turkey
| | - Esra Kaytan Saglam
- 1 Department of Radiation Oncology, Institute of Oncology, Istanbul University, Istanbul - Turkey
| | - Ethem Nezih Oral
- 1 Department of Radiation Oncology, Institute of Oncology, Istanbul University, Istanbul - Turkey
| | - Mine Gulluoglu
- 7 Deparment of Pathology, Istanbul University, Istanbul Faculty of Medicine, Istanbul - Turkey
| | - Ahmet Kizir
- 1 Department of Radiation Oncology, Institute of Oncology, Istanbul University, Istanbul - Turkey
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Delli Pizzi A, Basilico R, Cianci R, Seccia B, Timpani M, Tavoletta A, Caposiena D, Faricelli B, Gabrielli D, Caulo M. Rectal cancer MRI: protocols, signs and future perspectives radiologists should consider in everyday clinical practice. Insights Imaging 2018; 9:405-412. [PMID: 29675627 PMCID: PMC6108973 DOI: 10.1007/s13244-018-0606-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 01/17/2018] [Accepted: 02/06/2018] [Indexed: 12/18/2022] Open
Abstract
Abstract Magnetic resonance imaging (MRI) allows to non-invasively evaluate rectal cancer staging and to assess the presence of “prognostic signs” such as the distance from the anorectal junction, the mesorectal fascia infiltration and the extramural vascular invasion. Moreover, MRI plays a crucial role in the assessment of treatment response after chemo-radiation therapy, especially considering the growing interest in the new conservative policy (wait and see, minimally invasive surgery). We present a practical overview regarding the state of the art of the MRI protocol, the main signs that radiologists should consider for their reports during their clinical activity and future perspectives. Teaching Points • MRI protocol for rectal cancer staging and re-staging. • MRI findings that radiologists should consider for reports during everyday clinical activity. • Perspectives regarding the development of latest technologies.
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Affiliation(s)
- Andrea Delli Pizzi
- ITAB Institute of Advanced Biomedical Technologies, University "G. d'Annunzio", Via Luigi Polacchi, 11 66100, Chieti, Italy.
| | - Raffaella Basilico
- SS Annunziata Hospital, Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio", 66100, Chieti, Italy
| | - Roberta Cianci
- SS Annunziata Hospital, Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio", 66100, Chieti, Italy
| | - Barbara Seccia
- SS Annunziata Hospital, Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio", 66100, Chieti, Italy
| | - Mauro Timpani
- SS Annunziata Hospital, Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio", 66100, Chieti, Italy
| | - Alessandra Tavoletta
- SS Annunziata Hospital, Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio", 66100, Chieti, Italy
| | - Daniele Caposiena
- SS Annunziata Hospital, Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio", 66100, Chieti, Italy
| | - Barbara Faricelli
- SS Annunziata Hospital, Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio", 66100, Chieti, Italy
| | - Daniela Gabrielli
- SS Annunziata Hospital, Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio", 66100, Chieti, Italy
| | - Massimo Caulo
- ITAB Institute of Advanced Biomedical Technologies, University "G. d'Annunzio", Via Luigi Polacchi, 11 66100, Chieti, Italy
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45
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Monitoring early changes in rectal tumor morphology and volume during 5 weeks of preoperative chemoradiotherapy – An evaluation with sequential MRIs. Radiother Oncol 2018; 126:431-436. [DOI: 10.1016/j.radonc.2017.12.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 12/18/2017] [Accepted: 12/27/2017] [Indexed: 12/18/2022]
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Zhu T, Das S, Wong TZ. Integration of PET/MR Hybrid Imaging into Radiation Therapy Treatment. Magn Reson Imaging Clin N Am 2017; 25:377-430. [PMID: 28390536 DOI: 10.1016/j.mric.2017.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Hybrid PET/MR imaging is in early development for treatment planning. This article briefly reviews research and clinical applications of PET/MR imaging in radiation oncology. With improvements in workflow, more specific tracers, and fast and robust acquisition protocols, PET/MR imaging will play an increasingly important role in better target delineation for treatment planning and have clear advantages in the evaluation of tumor response and in a better understanding of tumor heterogeneity. With advances in treatment delivery and the potential of integrating PET/MR imaging with research on radiomics for radiation oncology, quantitative and physiologic information could lead to more precise and personalized RT.
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Affiliation(s)
- Tong Zhu
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, 101 Manning Drive, Chapel Hill, NC 27599, USA
| | - Shiva Das
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, 101 Manning Drive, Chapel Hill, NC 27599, USA
| | - Terence Z Wong
- Department of Radiology, University of North Carolina at Chapel Hill, 101 Manning Drive, Chapel Hill, NC 27599, USA.
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47
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Lu W, Jing H, Ju-Mei Z, Shao-Lin N, Fang C, Xiao-Ping Y, Qiang L, Biao Z, Su-Yu Z, Ying H. Intravoxel incoherent motion diffusion-weighted imaging for discriminating the pathological response to neoadjuvant chemoradiotherapy in locally advanced rectal cancer. Sci Rep 2017; 7:8496. [PMID: 28819296 PMCID: PMC5561073 DOI: 10.1038/s41598-017-09227-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 07/17/2017] [Indexed: 02/07/2023] Open
Abstract
To investigate the usefulness of intravoxel incoherent motion diffusion-weighted imaging (IVIM-DWI) in discriminating the pathological complete response (pCR) to neoadjuvant chemoradiotherapy (nCRT) in locally advanced rectal cancer (LARC), 42 patients underwent preoperative IVIM-DWI before (pre-nCRT) and after nCRT (post-nCRT). The values of pre-nCRT and post-nCRT IVIM-DWI parameters (ADC, D, D* and f), together with the percentage changes (∆% parametric value) induced by nCRT, were compared between the pCR (tumour regression grade [TRG] 4) and non-pCR (TRG 0, 1, 2 or 3) groups and between the GR (TRG 3 or 4) and PR (TRG 0, 1 or 2) groups based on the Dworak TRG system. After nCRT, the ADC and D values for LARC increased significantly (all P < 0.05). The TRG score revealed a positive correlation with pref (r = 0.357, P = 0.020), postD (r = 0.551, P < 0.001) and Δ%D (r = 0.605, P < 0.001). The pCR group (n = 10) had higher preD*, pref, postD, ∆%ADC and ∆%D values than the non-pCR group (n = 32) (all P < 0.05). The GR group (n = 15) exhibited higher postD, ∆%ADC and ∆%D values than the PR group (n = 27) (all P < 0.05). Based on ROC analysis, ∆%D had a higher area under the curve value than ∆%ADC (P = 0.009) in discriminating the pCR from non-pCR groups. In conclusion, IVIM-DWI may be helpful in identifying the pCR to nCRT for LARC and is more accurate than traditional DWI.
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Affiliation(s)
- Wen Lu
- Department of Diagnostic Radiology, Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine,Central South University, Changsha, 410013, Hunan, P.R. China
| | - Hou Jing
- Department of Diagnostic Radiology, Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine,Central South University, Changsha, 410013, Hunan, P.R. China
| | - Zhou Ju-Mei
- Department of Radiotherapy, Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine,Central South University, Changsha, 410013, Hunan, P.R. China
| | - Nie Shao-Lin
- Department of Colorectal Surgery, Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine,Central South University, Changsha, 410013, Hunan, P.R. China
| | - Cao Fang
- Department of Pathology, Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, 410013, Hunan, P.R. China
| | - Yu Xiao-Ping
- Department of Diagnostic Radiology, Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine,Central South University, Changsha, 410013, Hunan, P.R. China.
| | - Lu Qiang
- Department of Diagnostic Radiology, Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine,Central South University, Changsha, 410013, Hunan, P.R. China
| | - Zeng Biao
- Department of Radiotherapy, Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine,Central South University, Changsha, 410013, Hunan, P.R. China
| | - Zhu Su-Yu
- Department of Radiotherapy, Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine,Central South University, Changsha, 410013, Hunan, P.R. China
| | - Hu Ying
- Department of Radiotherapy, Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine,Central South University, Changsha, 410013, Hunan, P.R. China.
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Barina A, De Paoli A, Delrio P, Guerrieri M, Muratore A, Bianco F, Vespa D, Asteria C, Morpurgo E, Restivo A, Coco C, Pace U, Belluco C, Aschele C, Lonardi S, Valentini V, Mantello G, Maretto I, Del Bianco P, Perin A, Pucciarelli S. Rectal sparing approach after preoperative radio- and/or chemotherapy (RESARCH) in patients with rectal cancer: a multicentre observational study. Tech Coloproctol 2017; 21:633-640. [PMID: 28755256 DOI: 10.1007/s10151-017-1665-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 07/19/2017] [Indexed: 01/12/2023]
Abstract
BACKGROUND Rectum-sparing approaches appear to be appropriate in rectal cancer patients with a major (mCR) or complete clinical response (cCR) after neoadjuvant therapy. The aim of the present study is to evaluate the effectiveness of rectum-sparing approaches at 2 years after the completion of neoadjuvant treatment. STUDY DESIGN Patients with rectal adenocarcinoma eligible to receive neoadjuvant therapy will be prospectively enrolled. Patients will be restaged 7-8 weeks after the completion of neoadjuvant therapy and those with mCR (defined as absence of mass, small mucosal irregularity no more than 2 cm in diameter at endoscopy and no metastatic nodes at MRI) or cCR will be enrolled in the trial. Patients with mCR will undergo local excision, while patients with cCR will either undergo local excision or watch and wait policy. The main end point of the study is to determine the percentage of rectum preservation at 2 years in the enrolled patients. CONCLUSION This protocol is the first prospective trial that investigates the role of both local excision and watch and wait approaches in patients treated with neoadjuvant therapy for rectal cancer. The trial is registered at clinicaltrials.gov (NCT02710812).
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Affiliation(s)
- A Barina
- Department of Surgical, Gastroenterological and Oncological Sciences (DiSCOG), Clinica Chirurgica I, University of Padua, Padua, Italy.
| | - A De Paoli
- Department of Radiation Oncology, Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - P Delrio
- National Cancer Institute, IRCCS Fondazione "G.Pascale", Naples, Italy
| | - M Guerrieri
- Surgery Clinic, Marche Polytechnic University, Ancona, Italy
| | - A Muratore
- E. Agnelli Hospital, Pinerolo, TO, Italy
| | - F Bianco
- Abdominal Surgical Oncology Unit, IRCCS Fondazione "G.Pascale", Naples, Italy
| | - D Vespa
- General Surgery Unit, San Bortolo Hospital, Vicenza, Italy
| | - C Asteria
- Department of Surgery and Orthopaedics, General Surgery Units of Asola, Mantua, Italy
| | - E Morpurgo
- Department of Surgery, Regional Center for Laparoscopic and Robotic Surgery, Camposampiero Hospital, Padua, Italy
| | - A Restivo
- Department of Surgery, Colorectal Surgery Center, University of Cagliari, Cagliari, Italy
| | - C Coco
- Department of Surgical Sciences, Catholic University of Rome, Rome, Italy
| | - U Pace
- National Cancer Institute, IRCCS Fondazione "G.Pascale", Naples, Italy
| | - C Belluco
- Department of Radiation Oncology, Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - C Aschele
- Medical Oncology Unit, S. Andrea Hospital, La Spezia, Italy
| | - S Lonardi
- Medical Oncology Unit 1, Istituto Oncologico Veneto, IRCCS, Padua, Italy
| | - V Valentini
- Institute of Radiotherapy, Catholic University of Rome, Rome, Italy
| | - G Mantello
- Department of Radiotherapy, Ospedali Riuniti, Ancona, Italy
| | - I Maretto
- Department of Surgical, Gastroenterological and Oncological Sciences (DiSCOG), Clinica Chirurgica I, University of Padua, Padua, Italy
| | | | - A Perin
- Department of Surgical, Gastroenterological and Oncological Sciences (DiSCOG), Clinica Chirurgica I, University of Padua, Padua, Italy
| | - S Pucciarelli
- Department of Surgical, Gastroenterological and Oncological Sciences (DiSCOG), Clinica Chirurgica I, University of Padua, Padua, Italy
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Locally advanced rectal cancer: predicting non-responders to neoadjuvant chemoradiotherapy using apparent diffusion coefficient textures. Int J Colorectal Dis 2017; 32:1009-1012. [PMID: 28497403 DOI: 10.1007/s00384-017-2835-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/05/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of the study is to evaluate whether apparent diffusion coefficient (ADC) textures could identify patient with locally advanced rectal cancer (LARC) who would not respond to neoadjuvant chemoradiotherapy (NCRT). METHOD Twenty-six patients who underwent MRI including diffusion-weighted imaging at a 3.0 T system before NCRT were enrolled. Texture analysis of pre-therapy ADC mapping was carried out, and a total of 133 ADC textures as well as routine mean ADC value of the primary tumor were extracted for each patient. Texture parameters and mean ADC were compared between responsive group and non-responsive group. Logistic regression was used to determine the independent predictors for non-responders. Receiver operating characteristic curve (ROC) was performed to evaluate the predictive performance of the significant parameters. RESULTS Eighteen of the 133 texture parameters significantly differed between responsive and non-responsive groups (p < 0.05). Further, energy variance and SdGa47 were identified as independent predictors for non-responders to NCRT; this logistic model achieved an area under the curve (AUC) of 0.908. CONCLUSION Texture analysis based on pre-therapy ADC mapping could potentially be helpful to identify patients with LARC who would not respond to NCRT.
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50
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Bakke KM, Hole KH, Dueland S, Grøholt KK, Flatmark K, Ree AH, Seierstad T, Redalen KR. Diffusion-weighted magnetic resonance imaging of rectal cancer: tumour volume and perfusion fraction predict chemoradiotherapy response and survival. Acta Oncol 2017; 56:813-818. [PMID: 28464745 DOI: 10.1080/0284186x.2017.1287951] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND In locally advanced rectal cancer (LARC), responses to preoperative treatment are highly heterogeneous and more accurate diagnostics are likely to enable more individualised treatment approaches with improved responses. We investigated the potential of diffusion-weighted magnetic resonance imaging (DW MRI), with quantification of the apparent diffusion coefficient (ADC) and perfusion fraction (F), as well as volumetry from T2-weighted (T2W) MRI, for prediction of therapeutic outcome. MATERIAL AND METHODS In 27 LARC patients receiving neoadjuvant chemotherapy (NACT) before chemoradiotherapy (CRT), T2W- and DW MRI were obtained before and after NACT. Tumour volumes were delineated in T2W MRI and ADCs and Fs were estimated from DW MRI using a simplified approach to the intravoxel incoherent motion (IVIM) model. Mean tumour values and histogram analysis of whole-tumour heterogeneity were correlated with histopathologic tumour regression grade (TRG) and 5-year progression-free survival (PFS). RESULTS At baseline, high tumour F predicted good tumour response (TRG1-2) (AUC = 0.79, p = 0.01), with a sensitivity of 69% and a specificity of 100%. The combination of F and tumour volume (Fpre/Vpre) gave the highest prediction of poor tumour response (AUC = 0.93, p < 0.001) with a sensitivity of 88% and a specificity of 91%, and also predicted PFS (p < 0.01). Baseline tumour ADC was not significantly related to therapeutic outcome, whereas a positive change in ADC from baseline to after NACT, ΔADC, significantly predicted good tumour response (AUC = 0.83, p < 0.01, 83% sensitivity, 73% specificity), but not PFS. CONCLUSIONS The MRI parameter F/V at baseline was a remarkably strong predictor of both histopathologic tumour response and 5-year PFS in patients with LARC.
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Affiliation(s)
- Kine Mari Bakke
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway
- Department of Physics, University of Oslo, Oslo, Norway
| | - Knut Håkon Hole
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Svein Dueland
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | | | - Kjersti Flatmark
- Department of Tumor Biology, Institute for Cancer Research, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Gastroenterological Surgery, Oslo University Hospital, Oslo, Norway
| | - Anne Hansen Ree
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Therese Seierstad
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Kathrine Røe Redalen
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway
- Department of Physics, Norwegian University of Science and Technology, Trondheim, Norway
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