Quantitative imaging of tumour blood flow by contrast-enhanced magnetic resonance imaging

Eco-evolutionary causes and consequences of temporal changes in intratumoural blood flow

Temporal changes in blood flow are commonly observed in malignant tumours, but the evolutionary causes and consequences are rarely considered. We propose that stochastic temporal variations in blood flow and microenvironmental conditions arise from the eco-evolutionary dynamics of tumour angiogenesis in which cancer cells, as individual units of selection, can influence and respond only to local environmental conditions. This leads to new vessels arising from the closest available vascular structure regardless of the size or capacity of this parental vessel. These dynamics produce unstable vascular networks with unpredictable spatial and temporal variations in blood flow and microenvironmental conditions. Adaptations of evolving populations to temporally varying environments in nature include increased diversity, greater motility and invasiveness, and highly plastic phenotypes, allowing for broad metabolic adaptability and rapid shifts to high rates of proliferation and profound quiescence. These adaptive strategies, when adopted in cancer cells, promote many commonly observed phenotypic properties including those found in the stem phenotype and in epithelial-to-mesenchymal transition. Temporal variations in intratumoural blood flow, which occur through the promotion of cancer cell phenotypes that facilitate both metastatic spread and resistance to therapy, may have substantial clinical consequences.

The role of perfusion effects in monitoring of chemoradiotherapy of rectal carcinoma using diffusion-weighted imaging

PURPOSE

The aim of this study was to characterize and understand the therapy-induced changes in diffusion parameters in rectal carcinoma under chemoradiotherapy (CRT). The current literature shows conflicting results in this regard. We applied the intravoxel incoherent motion model, which allows for the differentiation between diffusion (D) and perfusion (f) effects, to further elucidate potential underlying causes for these divergent reports.

MATERIALS AND METHODS

Eighteen patients with primary rectal carcinoma undergoing preoperative CRT were examined before, during, and after neoadjuvant CRT using diffusion-weighted imaging. Using the intravoxel incoherent motion approach, f and D were extracted and compared with postoperative tumor downstaging and volume.

RESULTS

Initial diffusion-derived parameters were within a narrow range (D1 = 0.94 ± 0.12 × 10(-3) mm(2)/s). At follow-up, D rose significantly (D2 = 1.18 ± 0.13 × 10(-3) mm(2)/s; P < 0.0001) and continued to increase significantly after CRT (D3 = 1.24 ± 0.14 × 10(-3) mm(2)/s; P < 0.0001). The perfusion fraction f did not change significantly (f1 = 9.4 ± 2.0%, f2 = 9.4 ± 1.7%, f3 = 9.5 ± 2.7%). Mean volume (V) decreased significantly (V1 = 16,992 ± 13,083 mm(3); V2 = 12,793 ± 8317 mm(3), V3 = 9718 ± 6154 mm(3)). T-downstaging (10:18 patients) showed no significant correlation with diffusion-derived parameters.

CONCLUSIONS

Conflicting results in the literature considering apparent diffusion coefficient (ADC) changes in rectal carcinoma under CRT for patients showing T-downstaging are unlikely to be due to perfusion effects. Our data support the view that under effective therapy, an increase in D/ADC can be observed.

Diffusion-weighted imaging in rectal carcinoma patients without and after chemoradiotherapy: a comparative study with histology

Diffusion-weighted imaging (DWI) can be used to quantitatively assess functional parameters in rectal carcinoma that are relevant for prognosis and treatment response assessment. However, there is no consensus on the histopathological background underlying the findings derived from DWI. The aim of this study was to perform a comparison of DWI and histologic parameters in two groups of rectal carcinoma patients without (n=12) and after (n=9) neoadjuvant chemoradiotherapy (CRT). The intravoxel incoherent motion (IVIM) model was used to calculate the diffusion coefficient D and the perfusion fraction f in rectal carcinoma, the adjacent rectum and fat in the two patient groups. Immunohistological analysis was performed to assess the cellularity, vascular area fraction and vessel diameter for comparison and correlation. Out of 36 correlations between parameters from DWI and histology, four were found to be significant. In rectal carcinoma of patients without CRT, the diffusion D and the perfusion f correlated with the vascular area fraction, respectively, which could not be found in the group of patients who received CRT. Further correlations were found for the rectum and fat. Histological evaluation revealed significant differences between the tissues on the microscopic level concerning the cellular and vascular environment that influence diffusion and perfusion. In conclusion, DWI produces valuable biomarkers for diffusion and perfusion in rectal carcinoma and adjacent tissues that are highly dependent of the underlying cellular microenvironment influenced by structural and functional changes as well as the administered treatment, and consequently can be beyond histological ascertainability.

Physical determinants of vascular network remodeling during tumor growth

The process in which a growing tumor transforms a hierarchically organized arterio-venous blood vessel network into a tumor specific vasculature is analyzed with a theoretical model. The physical determinants of this remodeling involve the morphological and hydrodynamic properties of the initial network, generation of new vessels (sprouting angiogenesis), vessel dilation (circumferential growth), vessel regression, tumor cell proliferation and death, and the interdependence of these processes via spatio-temporal changes of blood flow parameters, oxygen/nutrient supply and growth factor concentration fields. The emerging tumor vasculature is non-hierarchical, compartmentalized into well-characterized zones, displays a complex geometry with necrotic zones and "hot spots" of increased vascular density and blood flow of varying size, and transports drug injections efficiently. Implications for current theoretical views on tumor-induced angiogenesis are discussed.

Whole tumour quantitative measurement of first-pass perfusion of oesophageal squamous cell carcinoma using 64-row multidetector computed tomography: correlation with microvessel density

PURPOSE

To assess correlations between whole tumour first-pass perfusion parameters obtained with 64-row multidetector computed tomography (MDCT), and microvessel density (MVD) in oesophageal squamous cell carcinoma.

MATERIALS AND METHODS

Thirty-one consecutive patients with surgically confirmed oesophageal squamous cell carcinomas were enrolled into our study. All the patients underwent whole tumour first-pass perfusion scan with 64-row MDCT. Perfusion parameters, including perfusion (PF), peak enhanced density (PED), blood volume (BV), and time to peak (TTP) were measured using Philips perfusion software. Postoperative tumour specimens were assessed for MVD. Pearson correlation coefficient tests were performed to determine correlations between each perfusion parameter and MVD.

RESULTS

Mean values for PF, PED, BV and TTP of the whole tumour were 28.85 ± 20.29 ml/min/ml, 23.16 ± 8.09 HU, 12.13 ± 5.21 ml/100g, and 35.05 ± 13.85 s, respectively. Mean MVD in whole tumour at magnification (×200) was 15.75 ± 4.34 microvessel/tumour sample (vessels/0.723 mm(2)). PED and BV were correlated with MVD (r=0.651 and r=0.977, respectively, all p<0.05). However, PF and TTP were not correlated with MVD (r=0.070 and r=0.100, respectively, all p>0.05).

CONCLUSION

The BV value of first-pass perfusion CT could reflect MVD in oesophageal squamous cell carcinoma, and can be an indicator for evaluating the tumour angiogenesis.

Vascular remodelling of an arterio-venous blood vessel network during solid tumour growth

We formulate a theoretical model to analyze the vascular remodelling process of an arterio-venous vessel network during solid tumour growth. The model incorporates a hierarchically organized initial vasculature comprising arteries, veins and capillaries, and involves sprouting angiogenesis, vessel cooption, dilation and regression as well as tumour cell proliferation and death. The emerging tumour vasculature is non-hierarchical, compartmentalized into well-characterized zones and transports efficiently an injected drug-bolus. It displays a complex geometry with necrotic zones and "hot spots" of increased vascular density and blood flow of varying size. The corresponding cluster size distribution is algebraic, reminiscent of a self-organized critical state. The intra-tumour vascular-density fluctuations correlate with pressure drops in the initial vasculature suggesting a physical mechanism underlying hot spot formation.

Development of a compact x-ray particle image velocimetry for measuring opaque flows

A compact x-ray particle image velocimetry (PIV) system employing a medical x-ray tube as a light source was developed to measure quantitative velocity field information of opaque flows. The x-ray PIV system consists of a medical x-ray tube, an x-ray charge coupled device camera, a programmable shutter for a pulse-type x ray, and a synchronization device. Through performance tests, the feasibility of the developed x-ray PIV system as a flow measuring device was verified. To check the feasibility of the developed system, we tested a tube flow at two different mean velocities of 1 and 2 mm/s. The x-ray absorption of tracer particles must be quite different from that of working fluid to have a good contrast in x-ray images. All experiments were performed under atmospheric pressure condition. This system is unique and useful for investigating various opaque flows or flows inside opaque conduits.

Color-coded imaging of splenocyte-pancreatic cancer cell interactions in the tumor microenvironment

In spite of advances in surgical and medical care, pancreatic cancer remains a leading cause of cancer-related death in the United States. An understanding of cancer-cell interactions with host cells is critical to our ability to develop effective antitumor therapeutics for pancreatic cancer. We report here a color-coded model system for imaging cancer cell interactions with host immune cells within the native pancreas. A human pancreatic cancer cell line engineered to express green fluorescent protein (GFP) in the nucleus and red fluorescent protein (RFP) (DsRed2) in the cytoplasm was orthotopically implanted into the pancreas of a nude mouse. After 10-14 days, red or green fluorescent splenocytes from immune-competent transgenic-mouse donors expressing RFP and GFP, respectively, were delivered systemically to the pancreatic cancer-bearing nude mice. Animals were imaged after splenocyte delivery using high-resolution intravital imaging systems. At 1 day after iv injection red- or green-fluorescent spleen cells were found distributed in lung, liver, spleen and pancreas. By 4 days after cell delivery, however, the immune cells could be clearly imaged surrounding the tumor cells within the pancreas as well as collecting within lymphatic tissues such as lymph nodes and spleen. With the high-resolution intravital imaging afforded by the Olympus IV100 and OV100 systems, the interactions of the dual-colored cancer cells and the red- or green-fluorescent spleen cells could be clearly imaged in this orthotopic pancreatic cancer model. This color-coded in vivo imaging technology offers a novel approach to imaging the interactions of cancer and immune cells in the tumor microenvironment (TME).

Dynamic T(1) mapping predicts outcome of chemoradiation therapy in primary rectal carcinoma: sequence implementation and data analysis

PURPOSE

To describe details about the implementation of a dynamic T(1)-mapping technique and a simple data analysis strategy that can be used to predict therapy outcome in primary rectal carcinoma and to investigate the physiologic meaning of the obtained parameter.

MATERIALS AND METHODS

Contrast-enhanced dynamic T(1) mapping was achieved with a snapshot fast low-angle shot (FLASH) T(1) mapping sequence implemented on a 1.5 T MR scanner. This method was applied to 58 patients with primary rectal cancer before onset of chemoradiation therapy. A simple data analysis strategy based on the calculation of the maximum slope of the tissue concentration-time curve divided by the maximum of the arterial input function (AIF) was used as a measure of tumor microcirculation (PI values).

RESULTS

The snapshot FLASH (SFL) T(1)-mapping technique is accurate and sensitive enough to detect inhomogeneous uptake kinetics within tumor tissue. Classifying the patients into two groups according to therapy response showed lower mean PI values for responders as compared to nonresponders. PI was found to combine information about permeability surface area product (PS) and blood volume.

CONCLUSIONS

The described method based on dynamic T(1) mapping has the potential to be a clinical tool for predicting therapy outcome of preoperative chemoradiation in patients with primary rectal carcinoma.

Evaluation of tumor blood flow in musculoskeletal lesions: dynamic contrast-enhanced MR imaging and its possibility when monitoring the response to preoperative chemotherapy—work in progress

PURPOSE

The objective of this study was to calculate tumor blood flow (TBF) in musculoskeletal lesions and to evaluate the usefulness of this parameter in differentiating malignant from benign lesions and monitoring the treatment response to preoperative chemotherapy.

MATERIALS AND METHODS

Altogether, 33 patients with musculoskeletal lesions underwent a total of 50 dynamic magnetic resonance imaging (MRI) examinations, including 28 on 9 patients undergoing preoperative chemotherapy. TBF was calculated using deconvolution analysis. Steepest slope (SS) was determined from the time-intensity curve during the first pass of contrast medium.

RESULTS

TBF ranged from 2.7 to 178.6 mL/100 mL/min in benign lesions and from 15.4 to 296.3 mL/100 mL/min in malignant lesions. SS ranged from 0.5%/s to 31.8%/s for benign lesions and from 3.1%/s to 64.8%/sec for malignant lesions. TBF and SS did not differ significantly between benign and malignant lesions. Among the nine patients who underwent preoperative chemotherapy, TBF after chemotherapy was lower in good responders (11.7, 11.0, 7.9 mL/100 mL/min) (n = 3, tumor necrosis > or =90%) than in poor responders (23.4-141.5 mL/100 mL/min) (n = 6, tumor necrosis <90%).

CONCLUSION

TBF and SS cannot reliably differentiate malignant from benign lesions. However, they have potential utility in evaluating the preoperative treatment response in patients with malignant musculoskeletal tumors.

Tracer kinetic analysis of signal time series from dynamic contrast-enhanced MR imaging

Rapid magnetic resonance imaging (MRI) makes it possible to detect the fast kinetics of tissue response after intravenous administration of a paramagnetic contrast medium (CM), reflecting the status of tissue microcirculation. In this paper, the basic physical and tracer kinetic principles of dynamic relaxivity and susceptibility contrast-enhanced MRI are reviewed. Quantitative analysis of data acquired is broken up into an MR-specific part, in which the signal variation observed is related to the CM concentration in the tissue, and an MR-independent part, in which the computed concentration time series are analyzed by tracer kinetic modeling to estimate well-defined physiological tissue parameters. The clinical application of dynamic MRI techniques is demonstrated by two representative studies.

Measurement of Tumor Blood Flow Using Dynamic Contrast-enhanced Magnetic Resonance Imaging and Deconvolution Analysis

OBJECTIVE

To measure tumor blood flow (TBF) using dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI).

METHODS

A DCE-MRI was performed using inversion recovery-preparation fast-field echo sequences. Dynamic data were obtained every 3.2 seconds for 2 minutes, immediately after gadolinium injection. In 14 patients with malignant musculoskeletal tumors, TBF maps were generated pixel-by-pixel by deconvolution analysis. For preclinical studies, muscle blood flow in 5 volunteers and signal intensities of different gadolinium concentrations were measured.

RESULTS

There was a good linear relationship between signal intensities and gadolinium concentrations (r = 0.989, P < 0.001, at gadolinium concentrations <or=2 mmol/L). The average value of muscle blood flow in volunteers was 11.1 +/- 2.7 mL.100 mL.min. In 14 patients with musculoskeletal tumors, TBF showed wide variances: the lowest of 9.6 mL.100 mL.min in liposarcoma and the highest of 182.0 mL.100 mL.min in osteosarcoma. After chemotherapy, the TBF values (7.9, 11.0, and 11.7 mL. 100 mL.min) in the good responders were lower than those (26.8, 31.0, and 62.4 mL.100 mL.min) in the poor responders.

CONCLUSIONS

A functional map of TBF generated by DCE-MRI and deconvolution analysis would be a promising tool for evaluating tumor blood flow in vivo.

[Perfusion measurement using the T2* contrast media dynamics in neuro-oncology. Physical basics and clinical applications]

Perfusion imaging in the central nervous system (CNS) is mostly performed using the first-pass dynamic susceptibility-weighted contrast-enhanced (DSC) MRI. The first-pass of a contrast bolus in brain tissue is monitored by a series of T2*-weighted MR images. The susceptibility effect of the paramagnetic contrast agent leads to a signal loss that can be converted, using the principles of the indicator dilution theory, into an increase of the contrast agent concentration. From these data, parameter maps of cerebral blood volume (CBV) and flow (CBF) can be derived. Regional CBF and CBV values can be obtained by region-of-interest analysis. This review article describes physical basics of DSC MRI and summarizes the literature of DSC MRI in neurooncological issues.Studies, all with relatively limited patient numbers, report that DSC MRI is useful in the preoperative diagnosis of gliomas, CNS-lymphomas, and solitary metastases, as well as in the differentiation of these neoplastic lesions from infections and tumor-like manifestations of demyelinating disease. Additionally, DSC MRI is suitable for determining glioma grade and regions of active tumor growth which should be the target of stereotactic biopsy. After therapy, DSC MRI helps better assessing the tumor response to therapy, residual tumor after therapy, and possible treatment failure and therapy-related complications, such as radiation necrosis. The preliminary results show that DSC MRI is a diagnostic tool depicting regional variations in microvasculature of normal and diseased brains.

Tumor angiogenesis and dynamic CT in colorectal carcinoma: Radiologic-pathologic correlation

AIM: To investigate the correlation between microvessel density and spiral CT perfusion imaging in colorectal carcinoma.

METHODS: Thirty-seven patients, with histologically proven colorectal carcinoma, underwent water enema spiral CT scan. The largest axial surface of the primary tumor was searched on unenhanced spiral CT images. At this level, the enhanced dynamic scan series was acquired. Time-density curves (TDC) were created from the region of interest drawn over the tumor, target artery by Toshiba Xpress/SX spiral CT with perfusion functional software. Then the perfusion was calculated. Microvessel density (MVD) was evaluated using immunohistochemical staining of surgical specimens with anti-CD34, and then MVD was correlated with perfusion.

RESULTS: MVD of colorectal carcinomas was 33.11-173.44, mean 87.28, and perfusion was 15.60-64.80 mL/min/ 100 g, mean 39.74 mL/min/100 g. MVD and perfusion were not associated with invasive depth, metastasis and disease stage, and they all decreased with increasing Dukes’ stage, but no significant correlation was found between them (r = 0.18, P = 0.29).

CONCLUSION: There is no significant correlation between MVD and perfusion. Neovascularizaton and perfusion are highly presented in early colorectal carcinoma. CT perfusion imaging may be more suited for assessing tumorigenesis in colorectal carcinoma than histological MVD technique.

Comparison of tumor blood perfusion assessed by dynamic contrast-enhanced MRI with tumor blood supply assessed by invasive imaging

PURPOSE

To evaluate the potential of Gd-DTPA-based dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) for providing high-resolution tumor blood perfusion images.

MATERIALS AND METHODS

Xenografted tumors from two amelanotic human melanoma lines (A-07 and R-18) were used as preclinical models of human cancer. DCE-MRI was performed at a voxel size of 0.5 x 0.2 x 2.0 mm(3) with the use of spoiled gradient recalled sequences. We produced tumor images of E . F (where E is the initial extraction fraction, and F is perfusion) by subjecting the DCE-MRI data to Kety analysis, and then compared those images with images of tumor blood supply. We obtained high-resolution tumor blood supply images using the Bioscope silicon strip detector system to measure the uptake of Na(99m)TcO(4) in histological preparations. We assessed the global blood supply by measuring the tumor uptake of three freely diffusible blood flow tracers: (86)RbCl, [(14)C]IAP, and Na(99m)TcO(4).

RESULTS

E . F was found to mirror the blood supply well in A-07 and R-18 tumors. The mean E . F differed between the A-07 and R-18 tumors by a factor of approximately 1.6, and this difference was similar to the difference in the global blood supply. The intratumor heterogeneity in E . F was significant for tumors of both lines, and this heterogeneity was similar to the intratumor heterogeneity in the blood supply. The intratumor heterogeneity in the blood supply differed slightly between the A-07 and R-18 tumors, and even this difference was mirrored by the E . F images.

CONCLUSION

E . F images of xenografted tumors reflect blood perfusion. This implies that E . F may be a useful parameter for improving cancer diagnostics and individualizing cancer treatment. This possibility deserves to be investigated thoroughly in clinical studies.

Anti-vascular tumor therapy: recent advances, pitfalls and clinical perspectives

Anti-vascular tumor therapy represents a promising new strategy for cancer treatment. Anti-vascular treatment may be divided in anti-angiogenic and vascular targeting therapy. Whereas anti-angiogenic drugs aim on the inhibition of new vessel formation, vascular targeting compounds are designed to selectively destruct preexisting tumor blood vessels leading to secondary tumor cell death. Both anti-angiogenic drugs and vascular targeting agents have proven effective anti-tumoral activity in numerous preclinical studies over the last decade. In vivo, a combination with anti-vascular tumor therapy enhances the effects of other treatment modalities as chemo- and radiotherapy. Phase I clinical studies revealed a number of well-tolerated candidates. As monotherapy, however, anti-angiogenic treatment lacked efficacy in randomized clinical studies so far. In contrast, combination of anti-angiogenic therapy with chemotherapy was highly effective in an encouraging, large randomized phase III trial on metastatic colorectal cancer. This review will outline recent advances in the preclinical and clinical development of anti-vascular therapy with focus on vascular targeting. Conceptual differences between anti-angiogenic and vascular targeting therapies will be discussed with emphasis on specific problems and pitfalls in the conversion into the clinic.

Assessment of tumor blood perfusion by high-resolution dynamic contrast-enhanced MRI: A preclinical study of human melanoma xenografts

A noninvasive method to obtain high-resolution images of tumor blood perfusion is needed for individualized cancer treatments. In this study we investigated the potential usefulness of dynamic contrast-enhanced MRI (DCE-MRI), using human melanoma xenografts as models of human cancer. Gadopentetate dimeglumine (Gd-DTPA) was used as the contrast agent, and DCE-MRI was performed at a voxel size of 0.5 x 0.2 x 2.0 mm3 with spoiled gradient-recalled sequences. We obtained images of E. F (where E is the extraction fraction, and F is perfusion) by subjecting DCE-MR images to Kety analysis. We obtained highly reproducible E. F images, which we verified by imaging heterogeneous tumors twice. We hypothesized that the extraction fraction of Gd-DTPA would be high and would not vary significantly in tumor tissue, implying that E. F should be a well-suited parameter for describing tumor blood perfusion. Observations consistent with this hypothesis were made by comparison of E. F-images with immunostained histological preparations from the imaged sections. The E. F images mirrored the histological appearance of the tumor tissue perfectly. Quantitative studies showed that E. F was highest in nonhypoxic tissue with high microvascular density, second highest in nonhypoxic tissue with low microvascular density, third highest in hypoxic tissue, and lowest in necrotic tissue. Moreover, the radial heterogeneity in E. F was almost identical to that in the blood supply, as assessed by the use of Na99mTcO4 as a perfusion tracer. Taken together, our observations show that high-resolution images reflecting tumor blood perfusion can be obtained by DCE-MRI.

Differential relationship between changes in tumour size and microcirculatory functions induced by therapy with an antivascular drug and with cytotoxic drugs. implications for the evaluation of therapeutic efficacy of AC7700 (AVE8062)

A novel combretastatin A-4 derivative, AC7700, which is now in Phase I clinical trials under a new code, AVE8062, has shown strong antitumour effects against solid tumours in rodents because of its powerful and continued stanching of the tumour blood flow (TBF). Despite the strong tumour-suppressing qualities of AC7700, it does not produce an immediate reduction in tumour size. To elucidate the reason for this effect, we investigated the relationship between the change in tumour size in Sato lung carcinoma (SLC) and circulatory functions after therapy with AC7700, doxorubicin (Adriamycin [ADR]), or mitomycin C (MMC). To measure time-lapse changes in TBF with the hydrogen clearance method at the same site after drug administration, we developed a new apparatus for keeping electrodes within a tumour. AC7700 led to the destruction of both cancer cells and tumour vessels by interrupting the supply of nutrients. Intravenous (i.v.) administration of fluorescent dyes after AC7700 treatment revealed no fluorescence within the tumour vessels, which confirmed that the tumour microcirculation had been completely blocked. In contrast, ADR led to the destruction of SLC tumour cells, but did not have the same effect on tumour vessels. Intravenously administered fluorescent dyes immediately reached the tumour, which indicated that the tumour vasculature remained intact, and the TBF remained at the preadministration level, even 6 days after ADR treatment. In addition, although the size of the tumour increased slightly for 2 days with ADR treatment, possibly because of swelling of the cancer cells, thereafter it continued to decrease. MMC had virtually no effect on SLC tumour cells, tumour size or tumour vessels. We conclude that changes in tumour size brought about by cancer chemotherapy depend not only on the sensitivity of the cancer cells to the drug in question, but also on the nature of changes in the microcirculatory functions of the tumour brought about by the therapy. When both tumour cells and the tumour vasculature are destroyed, the effectiveness of therapy can not be determined from changes in tumour size alone.

Tumor microcirculation and diffusion predict therapy outcome for primary rectal carcinoma

PURPOSE

The aim of our study was to correlate perfusion indices and apparent diffusion coefficients with therapy outcome after chemoradiation.

METHODS AND MATERIALS

In 34 patients with primary rectal carcinoma (cT3) undergoing preoperative chemoradiation, pretherapeutic perfusion indices and apparent diffusion coefficients were obtained by dynamic or diffusion-weighted magnetic resonance imaging. Therapy response was defined if the pathologic observation revealed no invasion into the perirectal fat after chemoradiation.

RESULTS

In 18 patients, a response and in 16, no response was observed. Statistically significant differences were found for the mean perfusion index (p < 0.001; 7.5 +/- 1.5 mL/min/100 g vs. 10.7 +/- 2.7 mL/min/100 g) and for the intratumoral cumulative fraction of pixels with perfusion-indices > 12 mL/min/100 g (p < 0.001, 3.7 +/- 4.0% vs. 24.7 +/- 17.9%). A three-way ANOVA resulted in significant effects for therapy responder/nonresponder (p < 0.001) and for apparent diffusion coefficient and the individual patients.

CONCLUSION

Perfusion indices and apparent diffusion coefficients inside the tumor region seem to be of predictive value for therapy outcome of preoperative therapy in patients with primary rectal carcinoma. Higher parameter levels in the nonresponding group could be explained by increased shunt flow or increased angiogenic activity in aggressive tumor cell clusters resulting in reduced nutrients supply and higher fraction of intratumoral necrosis respectively.

Angiogenesis in cutaneous melanoma: pathogenesis and clinical implications

Neovacularization is an essential step in the multistage progression of malignant melanoma. The onset of new blood vessel formation is ushered in by the release of VEGF and numerous other angiogenic molecules by the tumor cells. Human melanoma is unique among neoplasms that both avascular (early horizontal growth phase characterized by very slow progression and 99%, 10-year survival) and vascular (late radial and vertical growth phase associated with rapid growth, metastasis and death in many cases), phases are discernible by the naked eye. Although cell biologists have made great strides in unraveling the mechanisms involved in the laying down of tumor vasculature and the factors that inhibit it, clinicians treating melanoma have been rather slow to realize and utilize the full potential of suppressing the tumor blood flow to the best advantage of the patient. We suggest a consorted endeavor by all the melanoma experts across the globe to establish an "angiogenesis database" wherein they pool the blood flow and vascularity information along with Breslow's thickness, Clark's level of invasion, lymphatic and vascular invasion, regression, and outcome of their patients.