Body oncologic imaging subspecialty training a curriculum based on the experience in a tertiary cancer center

PURPOSE

To describe the structure of a dedicated body oncologic imaging fellowship program. To summarize the numbers and types of cross-sectional imaging examinations reported by fellows.

METHODS

The curriculum, training methods, and assessment measures utilized in the program were reviewed and described. An educational retrospective analysis was conducted. Data on the number of examinations interpreted by fellows, breakdown of modalities, and examinations by disease management team (DMT) were collected.

RESULTS

A total of 38 fellows completed the fellowship program during the study period. The median number of examinations reported per fellow was 2296 [interquartile range: 2148 - 2534], encompassing all oncology-relevant imaging modalities: CT 721 [646-786], MRI 1158 [1016-1309], ultrasound 256 [209-320] and PET/CT 176 [130-202]. The breakdown of examinations by DMT revealed variations in imaging patterns, with MRIs most frequently interpreted for genitourinary, musculoskeletal, and hepatobiliary cancers, and CTs most commonly for general staging or assessment of nonspecific symptoms.

CONCLUSION

This descriptive analysis may serve as a foundation for the development of similar fellowship programs and the advancement of body oncologic imaging. The volume and diversity of examinations reported by fellows highlights the comprehensive nature of body oncologic imaging.

Imaging Follow-Up of Nonsurgical Therapies for Lung Cancer: AJR Expert Panel Narrative Review

Lung cancer continues to be the most common cause of cancer-related death worldwide. In the past decade, with the implementation of lung cancer screening programs and advances in surgical and nonsurgical therapies, the survival of patients with lung cancer has increased, as has the number of imaging studies that these patients undergo. However, most patients with lung cancer do not undergo surgical re-section, because they have comorbid disease or lung cancer in an advanced stage at diagnosis. Nonsurgical therapies have continued to evolve with a growing range of systemic and targeted therapies, and there has been an associated evolution in the imaging findings encountered at follow-up examinations after such therapies (e.g., with respect to posttreatment changes, treatment complications, and recurrent tumor). This AJR Expert Panel Narrative Review describes the current status of nonsurgical therapies for lung cancer and their expected and unexpected imaging manifestations. The goal is to provide guidance to radiologists regarding imaging assessment after such therapies, focusing mainly on non-small cell lung cancer. Covered therapies include systemic therapy (conventional chemotherapy, targeted therapy, and immunotherapy), radiotherapy, and thermal ablation.

Complications of Cancer Therapy in Children: A Comprehensive Review of Body Imaging Findings

ABSTRACT

Complications of cancer therapy in children can result in a spectrum of toxicities that can affect any organ system and result in a range of morbidity. Complications may occur at the initiation of therapy or years following treatment. Although childhood cancer remains rare, increasing survival rates means more children are living longer following their treatment. Radiologists often play an important role in the diagnosis and evaluation of these complications, and thus, awareness of their imaging findings is essential to guide management and avoid misdiagnosis. This second part of a 2-part review aims to illustrate the typical body imaging findings of cancer therapy-related toxicities, including both early and late treatment effects. The article also discusses the differential diagnosis of imaging findings, highlighting pearls and pitfalls in making the appropriate diagnosis.

Anticancer pan-ErbB inhibitors reduce inflammation and tissue injury and exert broad-spectrum antiviral effects

Targeting host factors exploited by multiple viruses could offer broad-spectrum solutions for pandemic preparedness. Seventeen candidates targeting diverse functions emerged in a screen of 4,413 compounds for SARS-CoV-2 inhibitors. We demonstrated that lapatinib and other approved inhibitors of the ErbB family receptor tyrosine kinases suppress replication of SARS-CoV-2, Venezuelan equine encephalitis virus (VEEV), and other emerging viruses with a high barrier to resistance. Lapatinib suppressed SARS-CoV-2 entry and later stages of the viral life cycle and showed synergistic effect with the direct-acting antiviral nirmatrelvir. We discovered that ErbB1, 2 and 4 bind SARS-CoV-2 S1 protein and regulate viral and ACE2 internalization, and they are required for VEEV infection. In human lung organoids, lapatinib protected from SARS-CoV-2-induced activation of ErbB-regulated pathways implicated in non-infectious lung injury, pro-inflammatory cytokine production, and epithelial barrier injury. Lapatinib suppressed VEEV replication, cytokine production and disruption of the blood-brain barrier integrity in microfluidic-based human neurovascular units, and reduced mortality in a lethal infection murine model. We validated lapatinib-mediated inhibition of ErbB activity as an important mechanism of antiviral action. These findings reveal regulation of viral replication, inflammation, and tissue injury via ErbBs and establish a proof-of-principle for a repurposed, ErbB-targeted approach to combat emerging viruses.

Image-Guided Precision Treatments

Chemotherapy, radiotherapy, and surgery are traditional cancer treatments, which usually produce unpredictable side effects and potential risks to normal healthy organs/tissues. Thus, safe and reliable treatment strategies are urgently required for maximized therapeutic efficiency to lesions and minimized risks to healthy regions. To this end, molecular imaging is responsible to undertake a specific targeting therapy. Besides that, the image guidance as a precision visualized approach for real-time in situ evaluations as well as an intraoperational navigation approach has earned attractive attention in the past decade. Along with the rapid development of multifunctional micro-/nanobiomaterials, versatile cutting-edge and advanced therapy strategies (e.g., thermal therapy, dynamic therapy, gas therapy, etc.) have been achieved and greatly contributed to the image-guided precision treatments in every aspect. Therefore, this chapter aims to discuss about both traditional and advanced cancer treatments and especially to elucidate the important roles that visualized medicine has been playing in the image-guided precision treatments.

Mineralizing microangiopathy: radiological features of a "not uncommon" complication of chemoradiotherapy in pediatric cancer patients

Background

Mineralizing microangiopathy represents one of the delayed complications of radiotherapy and chemotherapy. We reviewed clinical and radiological data of pediatric cancer patients who presented with mineralizing microangiopathy. This is a retrospective analysis of the medical records of 37 cancer children treated with chemoradiotherapy presented with imaging criteria suspected of mineralizing microangiopathy admitted to our hospital during the period 2015–2020. The CT was reviewed for distribution of calcification and MRI for signal criteria.

This study aims to raise awareness among radiologists about radiological features of mineralizing microangiopathy during the sequential routine follow-up brain scans of pediatric cancer patients who received chemo, radio, or combined chemoradiotherapy and to identify changes as a long-term delayed complication of therapy and avoid misdiagnosis.

Results

Thirty-seven pediatric cancer patients (17 female and 20 males, aged 1.5–18 years) who had mineralizing microangiopathy were thoroughly investigated. Most of them (32 patients) had brain tumors and 5 patients had leukemia. Cranial radiotherapy and systemic chemotherapy were given to 33 patients, while nine patients received intrathecal chemotherapy. The interval needed to develop mineralizing microangiopathy ranged from 1 to 10 years after the end of treatment. CT detected calcification in the basal ganglia, being the most common location (32 cases), followed by cerebral gray–white matter interface in 26 patients, cerebellum (18), brain stem (13), thalamus (5), and caudate nucleus (4), while dural calcifications were found in only one patient. MRI was considered “positive” when T1 hyperintensity was noted in the anatomical location of CT detected calcification; it was positive in 29 cases.

Conclusion

Mineralizing microangiopathy is one of the delayed complications of chemoradiotherapy among pediatric cancer patients. The awareness of its radiological criteria is essential to avoid misdiagnosis. Early detection can alert pediatric oncologists to monitor neurotoxicity and help prevent long-term neurological sequels.

Tumor pH-functionalized and charge-tunable nanoparticles for the nucleus/cytoplasm-directed delivery of oxaliplatin and miRNA in the treatment of head and neck cancer

Prospective tumor pH-responsive and charge-convertible nanoparticles have been utilized to reduce side effects and improve the active tumor-targeting ability and nuclear/cytoplasmic localization of chemo- and gene therapeutics for the treatment of head and neck cancer (HNC). Oxaliplatin (Oxa) is a third-generation platinum compound that prevents DNA replication. miR-320 may regulate cancer cell apoptosis, resistance, and progression. Innovative nanoparticles incorporating miR-320 and Oxa were modified with a ligand, cell-penetrating peptide, and nucleus-targeted peptide. The nanoparticles were coated with a charge/size-tunable shield to prevent peptide degradation and decoated at acidic tumor sites to expose peptides for active targeting. Results indicated that the designed nanoparticles exhibited a uniform size and satisfactory drug encapsulation efficiency. The nanoparticles displayed the pH-responsive release and uptake of Oxa and miR-320 into human tongue squamous carcinoma SAS cells. The nanoparticles successfully delivered Oxa and miR-320 to the nucleus and cytoplasm, respectively. This work is the first to demonstrate the concurrent intracellular modulation of the NRP1/Rac1, PI3K/Akt/mTOR, GSK-3β/FOXM1/β-catenin, P-gp/MRPs, KRAS/Erk/Oct4/Yap1, and N-cadherin/Vimentin/Slug pathways to inhibit the growth, progression, and multidrug resistance of cancer cells. In SAS-bearing mice, co-treatment with Oxa- and miR-320-loaded nanoparticles exhibited superior antitumor efficacy and remarkably decreased Oxa-associated toxicities. The nucleus/cytoplasm-localized nanoparticles with a tumor pH-sensitive and size/charge-adjustable coating may be a useful combinatorial spatiotemporal nanoplatform for nucleic acids and chemotherapeutics to achieve maximum therapeutic safety and efficacy against HNC. STATEMENT OF SIGNIFICANCE: Innovative nanoparticles incorporating miR-320 and oxaliplatin were modified with a ligand, cell-penetrating peptide, and nucleus-targeted peptide. The tumor pH-sensitive and charge/size-adjustable shield of polyglutamic acid-PEG protected against peptide degradation during systemic circulation. This work represents the first example of the concurrent intracellular modulation of the NRP1/Rac1, PI3K/Akt/mTOR, GSK-3β/FOXM1/β-catenin, P-gp/MRPs, KRAS/Erk/Oct4/Yap1, and N-cadherin/Vimentin/Slug pathways to inhibit cancer cell growth, cancer cell progression, and multidrug resistance simultaneously. The versatile nanoparticles with a tumor pH-functionalized coating could deliver chemotherapeutics and miRNA to the nucleus/cytoplasm. The nanoparticles successfully reduced chemotherapy-associated toxicities and maximized the antitumor efficacy of combinatorial therapy against head and neck cancer.

Urgent and unexpected findings in oncology and hematology patients: A practical approach to imaging

Urgent and unexpected findings are very common in oncology and haematology patients. This article reviews the most important points included in the European Society of Radiology's guidelines and proposes a practical approach to reporting and communicating these findings more efficiently. This approach is explained with illustrative examples. Radiologists can provide added value in the management of these findings by helping referring clinicians reach the best decisions. To this end, it is essential to know the imaging manifestations of the most common findings that must be reported urgently, such as the specific toxicity of different treatments, the complications of tumours and catheters, infections, and thrombosis. Moreover, it is crucial to consider the individual patient's treatment, risk factors, clinical situation, and immune status.

Chemotherapy-Induced Toxicities: An Imaging Primer

The Coronavirus Disease of 2019 (COVID-19) pandemic has caused significant delays in the delivery of cancer treatments in Canada. As cancer treatment and imaging volumes return to normal, radiologists will encounter more cases of chemotherapy-induced toxicities. These toxicities have varied appearances on imaging, and can affect multiple organ systems. The purpose of this review is to offer a unified resource for general radiologists regarding the imaging appearances of chemotherapy-induced toxicities.

One stone, many birds: Recent advances in functional nanogels for cancer nanotheranostics

Inspired by the development of nanomedicine and nanotechnology, more and more possibilities in cancer theranostic have been provided in the last few years. Emerging therapeutic modalities like starvation therapy, chemodynamic therapy, and tumor oxygenation have been integrated with diagnosis, giving a plethora of theranostic nanoagents. Among all of them, nanogels (NGs) show superiority benefiting from their unique attributes: high stability, high water-absorption, large specific surface area, mechanical strength, controlled responsiveness, and high encapsulation capacity. There have been a vast number of investigations supporting various NGs combining drug delivery and multiple bioimaging techniques, encompassing photothermal imaging, photoacoustic imaging, fluorescent imaging, ultrasound imaging, magnetic resonance imaging, and computed tomography. This review summarizes recent advances in functional NGs for theranostic nanomedicine and discusses the challenges and future perspectives of this fast-growing field. This article is categorized under: Therapeutic Approaches and Drug Discovery > Emerging Technologies Therapeutic Approaches and Drug Discovery > Nanomedicine for Oncologic Disease Nanotechnology Approaches to Biology > Nanoscale Systems in Biology Diagnostic Tools > In Vivo Nanodiagnostics and Imaging.

Drug-induced bowel complications and toxicities: imaging findings and pearls

The use of diverse types of drugs can result in a variety of acute and chronic complications that affect almost any organ. The bowel is one of the organs impacted by the side effects of medications. Imaging frequently plays a crucial role in the detection and characterization of complications occurring in the bowel. They include pseudomembranous colitis or antibiotic-associated colitis; angioedema induced by angiotensin-converting enzyme inhibitors; nonsteroidal anti-inflammatory drug-induced enteropathy; cocaine toxicity; clozapine-induced hypomobility; and bowel toxicity induced by chemotherapeutic agents. It is imperative that radiologists are fully aware of these complications and toxicities as well as the relevant findings. In this way, proper treatment can be implemented immediately. The treatment will involve discontinuation of a drug or a change in regimen.

Emerging Trends and their Impacts on Peptic Ulcer Diseases: Treatments and Techniques

Background:

Peptic ulcer disease (PUD) is prevalent in almost all parts of the world. PUD complications are creating a major source of preventable health care expenses. The major factors responsible for the incidence of PUD and its complication have changed over the past few decades after the identification of non-steroidal inflammatory drugs (NSAIDs) and Helicobacter pylori bacterial infection along with a marked increase in the use of proton-pump inhibitors (PPIs) as drug therapy. The management of PUD has become more complex and challenging due to antimicrobial resistance.

Objective:

The objective of the study was to highlight current therapy and novel techniques used in the treatment of peptic ulcer diseases.

Methods:

An exhaustive literature search has been conducted across PubMed, Google, Scopus and Web of Science as an electronic database to add the crucial information from the relevant literature.

Results:

In the present review, we have discussed PUD and its pathophysiology. The recent trends in PUD and possible treatments with novel techniques have also been discussed. The type and presence of ulcers cannot be predicted accurately based on symptoms. The available treatment approaches for peptic ulcers based on their clinical presentation and etiology are anti-secretary therapy, endoscopy to reveal ulcers followed by drug therapy, and triple therapy for H pylori infection.

Conclusion:

Thus, the popular and effective methods are very beneficial in controlling PUD. The treatment based on diagnosis is the foremost requirement for ameliorating any disorder. In this article, the emerging techniques and development in the treatment and diagnosis of PUD have been reviewed.

Chemotherapy Side-Effects: Not All DNA Damage Is Equal

Recent advances have increased survival rates of children and adults suffering from cancer thanks to effective anti-cancer therapy, such as chemotherapy. However, during treatment and later in life they are frequently confronted with the severe negative side-effects of their life-saving treatment. The occurrence of numerous features of accelerated aging, seriously affecting quality of life, has now become one of the most pressing problems associated with (pediatric) cancer treatment. Chemotherapies frequently target and damage the DNA, causing mutations or genome instability, a major hallmark of both cancer and aging. However, there are numerous types of chemotherapeutic drugs that are genotoxic and interfere with DNA metabolism in different ways, each with their own biodistribution, kinetics, and biological fate. Depending on the type of DNA lesion produced (e.g., interference with DNA replication or RNA transcription), the organ or cell type inflicted (e.g., cell cycle or differentiation status, metabolic state, activity of clearance and detoxification mechanisms, the cellular condition or micro-environment), and the degree of exposure, outcomes of cancer treatment can largely differ. These considerations provide a conceptual framework in which different classes of chemotherapeutics contribute to the development of toxicities and accelerated aging of different organ systems. Here, we summarize frequently observed side-effects in (pediatric) ex-cancer patients and discuss which types of DNA damage might be responsible.

Atypical pulmonary presentation of Strongyloides stercoralis hyperinfection in a patient with philadelphia chromosome-positive acute lymphoblastic leukemia: Case report

Strongyloides stercoralis is a soil-transmitted helminth endemic to tropical and subtropical regions and can be acquired due to parasite penetration through the skin. It can remain dormant in the gastrointestinal system for decades after the primary infection. In immunocompromised patients, this parasite can cause autoinfection with progression to hyperinfection syndrome. Here we report a unique case of pulmonary strongyloidiasis in a 32-year-old female, originally from Guatemala, with a significant clinical history of Philadelphia chromosome-positive B-cell acute lymphoblastic leukemia diagnosed in 2019. The patient is status post chemotherapy with tyrosine kinase inhibitor plus hyper-CVAD regimen (Cyclophosphamide, Vincristine sulfate, Doxorubicin hydrochloride (Adriamycin), and Dexamethasone). History of drug-induced hyperglycemia and obesity was also noted. Her current chief complaint included dyspnea, tachycardia, and chest pain. Chest computerized tomography (CT) scan showed diffuse interstitial pulmonary edema with septal thickening, scattered ground-glass opacities, and small pericardial effusion. Due to normal ejection fraction, the differential diagnosis included non-cardiogenic pulmonary edema, pneumonitis secondary to chemotoxicity, and infection. She rapidly progressed to acute hypoxic respiratory failure, and a bronchoalveolar lavage study revealed numerous larvae consistent with Strongyloides hyperinfection. Further workup revealed eosinophilia with negative Strongyloides IgG antibody. Given the rarity of this infection in the United States and the patient's place of birth, acquired latent Strongyloides infection is favored as the initial source of infection. The reactivation of the infection process was most likely secondary to her chemotherapy treatment. Strongyloides hyperinfection diagnosis can be challenging to establish and entails a high level of suspicion. Cytology evaluation is an essential factor for diagnosis.

Chemotherapy-related neurotoxicity in pediatric cancer patients: magnetic resonance imaging and clinical correlation

Background

Cancer is the second most common cause of death among children aged 1–14 years in the USA. Pediatric malignancies have elevated morbidity and mortality in the absence of proper treatment. Intensive treatment regimens have resulted in a significant increase in the number of survivors but also have been associated with the risk of developing neurotoxicity. The purpose of this study is to emphasize the role of advanced MRI techniques in the early detection of different chemotherapy neurotoxicities and make radiologists aware of them providing early management to prevent permanent damage.

Results

We evaluated 63 patients (43 males and 20 females), and their ages ranged from (2 to 17 years) with suspected chemotherapy-related neurotoxicity. MR examinations were performed with 1.5-T Philips systems. Clinical data were correlated with magnetic resonance imaging (MRI), and different treatment complications were diagnosed. All of our 63 patients were receiving chemotherapy treatment, and they developed different neurological symptoms. Patients diagnosed as posterior reversible encephalopathy syndrome were 41 with 8 patients had typical and 33 had atypical criteria, 16 patients diagnosed as cerebral venous sinus thrombosis with magnetic resonance venography (MRV) are the most important sequence that successfully diagnosed them, and finally, 6 patients diagnosed as methotrexate neurotoxicity with diffusion-weighted images (DWI) are the most important sequence for early diagnosis.

Conclusion

Chemotherapy is associated with certain neurotoxicities, conventional MRI can detect them, but by the use of advanced MRI techniques including MRV and DWI early detection of these neurotoxicities can occur. Therefore, the combination of conventional MRI together with advanced techniques improves the diagnostic efficacy of MRI in the early diagnosis of neurotoxicity.

Medication-induced Pulmonary Injury: A Scenario- and Pattern-based Approach to a Perplexing Problem

Medication-induced pulmonary injury (MIPI) is a complex medical condition that has become increasingly common yet remains stubbornly difficult to diagnose. Diagnosis can be aided by combining knowledge of the most common imaging patterns caused by MIPI with awareness of which medications a patient may be exposed to in specific clinical settings. The authors describe six imaging patterns commonly associated with MIPI: sarcoidosis-like, diffuse ground-glass opacities, organizing pneumonia, centrilobular ground-glass nodules, linear-septal, and fibrotic. Subsequently, the occurrence of these patterns is discussed in the context of five different clinical scenarios and the medications and medication classes typically used in those scenarios. These scenarios and medication classes include the rheumatology or gastrointestinal clinic (disease-modifying antirheumatic agents), cardiology clinic (antiarrhythmics), hematology clinic (cytotoxic agents, tyrosine kinase inhibitors, retinoids), oncology clinic (immune modulators, tyrosine kinase inhibitors, monoclonal antibodies), and inpatient service (antibiotics, blood products). Additionally, the article draws comparisons between the appearance of MIPI and the alternative causes of lung disease typically seen in those clinical scenarios (eg, connective tissue disease-related interstitial lung disease in the rheumatology clinic and hydrostatic pulmonary edema in the cardiology clinic). Familiarity with the most common imaging patterns associated with frequently administered medications can help insert MIPI into the differential diagnosis of acquired lung disease in these scenarios. However, confident diagnosis is often thwarted by absence of specific diagnostic tests for MIPI. Instead, a working diagnosis typically relies on multidisciplinary consensus. ^©RSNA, 2021.

Diagnostic approach to small-bowel wall thickening: Beyond Crohn's disease and cancer

Although small-bowel wall thickening is a common manifestation of Crohn's disease and tumors, many other entities can give rise to similar imaging findings. The small bowel is difficult to access by endoscopy, so radiologic imaging tests play an essential role in the diagnosis of conditions involving the small bowel. The main objectives of this paper are to explain the definition of small-bowel wall thickening, analyze the patterns of involvement seen in multidetector computed tomography (MDCT) with intravenous contrast administration, and provide an image-based review of the different causes of small-bowel wall thickening. The differential diagnosis must include many entities because wall thickening can result from immune-mediated, infectious, or vascular causes, as well as from toxicity and other lesser-known entities. As the imaging appearance of many of these conditions overlap, clinical and laboratory findings are necessary to support the imaging diagnosis.

Imaging of chemotherapy-induced liver toxicity: an illustrated overview

Chemotherapy is a potential cause of focal and diffuse hepatobiliary lesions. Many of these lesions may be demonstrated on imaging, especially computed tomography and MRI. Some of these lesions, especially those of steatosis and sinusoidal obstruction syndrome, are associated with a worse prognosis and risk of hepatic failure in the context of surgical management. Notably, some chemotherapy-induced hepatic alterations, such as sinusoidal obstruction syndrome, pseudocirrhosis and focal hepatopathies, may be mistakenly interpreted as signs of cancer progression, misguiding the therapeutic planning for patients receiving chemotherapy.

Drug-induced pulmonary toxicity in breast cancer patients treated with systemic therapy: a systematic literature review

INTRODUCTION

Drug-induced pulmonary toxicity (DIPT) associated with breast cancer (BC) therapy has been a major concern in recent times. DIPT may not be attributed to a single type of therapy because of the concomitant use of other anticancer drugs or along with radiotherapy, which is an independent risk factor for pulmonary toxicity.

AREAS COVERED

In this systematic literature review, we evaluated the probable cause and prevalence of DIPT in various systemic therapies used in BC treatment. A literature search was conducted in PubMed, Embase and Cochrane database, up to October 2020. Clinical studies reporting DIPT and related clinical manifestations due to systemic therapy in BC treatment were included. A total of 1749 articles were retrieved, and 193 articles were included.

EXPERT OPINION

: The leading cause of DIPT among patients with BC was targeted therapy followed by chemotherapy containing regimens. A total of 17 studies reported 35 deaths (15 deaths in chemotherapy) due to DIPT. Physicians must take extra precaution while prescribing systemic therapy known to be associated with DIPT and need to be familiar with early diagnosis of DIPT in order to avoid respiratory-related complications during treatment in BC patients.

A Case of Intratumoral and Hepatic Portal Venous Gas in Patient with Gastric Cancer Liver Metastases

BACKGROUND

Hepatic portal venous gas [HPVG] is not a common finding in daily practice. It is usually associated with mesenteric ischemia and bowel necrosis in adults. Combination of intratumoral gas in metastatic liver lesions with HPVG is quite rare and thought to be associated with chemotherapy-induced necrosis and infection of the necrotized metastasis.

OBJECTIVE

Here we present a case of gastric adenocarcinoma with portal venous and intratumoral gas in metastatic liver lesions due to the infected necrosis.

CASE PRESENTATION

The patient was presented to the emergency room with severe abdominal pain and septic condition after the second round of chemotherapy. Hepatic portal venous and intratumoral gas in metastatic liver lesions due to the infected necrosis of liver metastasis was detected in computed tomography images. There were no findings of mesenteric ischemia both clinically and radiologically. Massive intratumoral infected necrosis in metastatic liver lesions and fistulization to the right portal vein branches were detected on abdominopelvic CT. Secondary infection of the necrotic metastases and fistulization to portal vein branches was believed to cause the air in metastatic liver masses and portal venous gas.

CONCLUSION

Infected necrosis of metastatic liver lesions and fistulizations to the portal venous structures is extremely rare. Clinicians and radiologists should be aware of such a rare complication because early detection is crucial for patient management.

Post-chemotherapy and targeted therapy imaging of the chest in lung cancer

Non-small-cell lung cancer (NSCLC) is frequently diagnosed when it is not amenable to local therapies; therefore, systemic agents are the mainstay of therapy for many patients. In recent years, treatment of advanced NSCLC has evolved from a general approach primarily involving chemotherapy to a more personalised strategy in which biomarkers such as the presence of genomic tumour aberrations and the expression of immune proteins such as programmed death-ligand 1 (PD-L1), in combination with other elements of clinical information such as histology and clinical stage, guide management. For instance, pathways resulting in uncontrolled growth and proliferation of tumour cells due to epidermal growth factor receptor (EGFR) mutations and anaplastic lymphoma kinase (ALK) rearrangements may be targeted by tyrosine kinase inhibitors (TKIs). In this article, we review the current state of medical oncology, imaging characteristics of mutations, pitfalls in response assessments and the imaging of complications.

Tissue Adequacy and Safety of Percutaneous Transthoracic Needle Biopsy for Molecular Analysis in Non-Small Cell Lung Cancer: A Systematic Review and Meta-analysis

Objective

We conducted a systematic review and meta-analysis of the tissue adequacy and complication rates of percutaneous transthoracic needle biopsy (PTNB) for molecular analysis in patients with non-small cell lung cancer (NSCLC).

Materials and Methods

We performed a literature search of the OVID-MEDLINE and Embase databases to identify original studies on the tissue adequacy and complication rates of PTNB for molecular analysis in patients with NSCLC published between January 2005 and January 2020. Inverse variance and random-effects models were used to evaluate and acquire meta-analytic estimates of the outcomes. To explore heterogeneity across the studies, univariable and multivariable meta-regression analyses were performed.

Results

A total of 21 studies with 2232 biopsies (initial biopsy, 8 studies; rebiopsy after therapy, 13 studies) were included. The pooled rates of tissue adequacy and complications were 89.3% (95% confidence interval [CI]: 85.6%–92.6%; I² = 0.81) and 17.3% (95% CI: 12.1%–23.1%; I² = 0.89), respectively. These rates were 93.5% and 22.2% for the initial biopsies and 86.2% and 16.8% for the rebiopsies, respectively. Severe complications, including pneumothorax requiring chest tube placement and massive hemoptysis, occurred in 0.7% of the cases (95% CI: 0%–2.2%; I² = 0.67). Multivariable meta-regression analysis showed that the tissue adequacy rate was not significantly lower in studies on rebiopsies (p = 0.058). The complication rate was significantly higher in studies that preferentially included older adults (p = 0.001).

Conclusion

PTNB demonstrated an average tissue adequacy rate of 89.3% for molecular analysis in patients with NSCLC, with a complication rate of 17.3%. PTNB is a generally safe and effective diagnostic procedure for obtaining tissue samples for molecular analysis in NSCLC. Rebiopsy may be performed actively with an acceptable risk of complications if clinically required.

Imaging side effects and complications of chemotherapy and radiation therapy: a pictorial review from head to toe

Newer biologic drugs and immunomodulatory agents, as well as more tolerated and effective radiation therapy schemes, have reduced treatment toxicity in oncology patients. However, although imaging assessment of tumor response is adapting to atypical responses like tumor flare, expected changes and complications of chemo/radiotherapy are still routinely encountered in post-treatment imaging examinations. Radiologists must be aware of old and newer therapeutic options and related side effects or complications to avoid a misinterpretation of imaging findings. Further, advancements in oncology research have increased life expectancy of patients as well as the frequency of long-term therapy-related side effects that once could not be observed. This pictorial will help radiologists tasked to detect therapy-related complications and to differentiate expected changes of normal tissues from tumor relapse.

Urgent and unexpected findings in oncology and hematology patients: a practical approach to imaging

Urgent and unexpected findings are very common in oncology and hematology patients. This article reviews the most important points included in the European Society of Radiology's guidelines and proposes a practical approach to reporting and communicating these findings more efficiently. This approach is explained with illustrative examples. Radiologists can provide added value in the management of these findings by helping referring clinicians reach the best decisions. To this end, it is essential to know the imaging manifestations of the most common findings that must be reported urgently, such as the specific toxicity of different treatments, the complications of tumors and catheters, infections, and thrombosis. Moreover, it is crucial to consider the individual patient's treatment, risk factors, clinical situation, and immune status.

Rare pulmonary tumors and carcinoma mimickers; experience from an interventional radiology unit with radiologic-pathologic correlation-A pictoral essay

BACKGROUND

Although imaging findings along with patients' clinical history may give clue for the etiology of a pulmonary lesion, the differentiation of benign pulmonary lesions from lung cancer could be challenging.

OBJECTIVE

The aim of this review article was to increase the awareness of the carcinoma mimicking lung lesions.

METHODS

This paper was designed to illustrate rare pulmonary tumors and carcinoma mimickers with emphasis on radiologic-pathologic correlation. Pitfalls encountered on CT images and also false positivity of PET-CT scans were also presented.

CONCLUSION

Several benign pulmonary lesions may grow in size on follow-up and some may show pathologic FDG (18F-fluorodeoxyglucose) uptake, which makes them indistinguishable from lung carcinoma by imaging. In addition, some slow-growing malignant lesions, such as carcinoid, may be false-negative on PET/CT scans.

Comparison of Chest CT Findings of COVID-19, Influenza, and Organizing Pneumonia: A Multireader Study

Background: Previous studies have compared CT findings of COVID-19 pneumonia with those of other infections; however, to our knowledge, no studies have included non-infectious organizing pneumonia (OP) as a comparison group. Objective: To compare chest CT features of COVID-19, influenza, and OP using a multireader design, and to assess radiologists' performance in distinguishing between these conditions. Methods: This retrospective study included 150 chest CT examinations in 150 patients (mean age 58±16 years) with diagnosis of COVID-19, influenza, or non-infectious OP (50 randomly selected abnormal CT examinations per diagnosis). Six thoracic radiologists independently assessed CT examinations for 14 individual CT findings and Radiologic Society of North America (RSNA) COVID-19 category and recorded a favored diagnosis. CT characteristics of the three diagnoses were compared using random effects models; readers' diagnostic performance was assessed. Results: COVID-19 pneumonia was significantly different (p<.05) from influenza pneumonia for seven of 14 chest CT findings, though different (p<.05) from OP for 4 of 14 findings [central or diffuse distribution in 10% and 7% of COVID-19 vs 20% and 21% of OP; unilateral distribution in 1% of COVID-19 vs 7% of OP; non-tree-in-bud nodules in 32% of COVID-19 vs 53% of OP; tree-in-bud nodules in 6% of COVID-19 vs 14% of OP]. A total of 70% of cases of COVID-19, 33% of influenza, and 47% of OP had an RSNA COVID-19 category of typical (p<.001). Mean percentage of correct favored diagnoses compared to actual diagnoses was 44% for COVID-19, 29% for influenza, and 39% for OP. Mean diagnostic accuracy of favored diagnoses was 70% for COVID-19 pneumonia and 68% for both influenza and OP. Conclusion: CT findings of COVID-19 substantially overlap with influenza and, to a greater extent, with OP. Radiologists' diagnostic accuracy was low in a study sample containing equal proportions of these three types of pneumonia. Clinical Impact: Recognized challenges in diagnosing COVID-19 by CT are furthered by our observed strong overlap between CT appearances of COVID-19 and OP. This challenge may be particularly evident in clinical settings with substantial proportions of patients with potential causes of OP such as ongoing cancer therapy or autoimmune conditions.

Drug-Related Pneumonitis in Cancer Treatment during the COVID-19 Era

Interstitial lung disease is recognized as a group of diseases with a different etiopathogenesis characterized by chronic lung inflammation with the accumulation of inflammatory cells, lymphocytes and macrophages, and the consequent release of proinflammatory cytokines. Various degrees of pulmonary fibrosis can be associated with this inflammatory condition. Interstitial lung disease related to oncological drugs is a relevant problem in clinical practice. The etiopathogenetic mechanisms underlying this adverse event are not completely known but can be partly explained by the mechanism of action of the drug involved. Therefore, knowledge of the relevance of this potentially fatal adverse event supported by the reported safety data of pivotal studies becomes fundamental in the management of patients. The prompt diagnosis of drug-related pneumonia and the consequent differential diagnosis with other forms of pneumonia allow a rapid suspension of treatment and the establishment of an immunosuppressive treatment if necessary. In the context of the health emergency related to SARS CoV2 infection and COVID-19-related interstitial lung disease, such knowledge holds decisive relevance in the conscious choice of cancer treatments. Our intent was to describe the oncological drugs most correlated with this adverse event by reporting, where possible, the percentages of insurgency in pivotal studies to provide an overview and therefore promote greater awareness of this important toxicity related to oncological treatment.

Diagnostic approach to small-bowel wall thickening: beyond Crohn's disease and cancer

Although small-bowel wall thickening is a common manifestation of Crohn's disease and tumors, many other entities can give rise to similar imaging findings. The small bowel is difficult to access by endoscopy, so radiologic imaging tests play an essential role in the diagnosis of conditions involving the small bowel. The main objectives of this paper are to explain the definition of small-bowel wall thickening, analyze the patterns of involvement seen in multidetector computed tomography (MDCT) with intravenous contrast administration, and provide an image-based review of the different causes of small-bowel wall thickening. The differential diagnosis must include many entities because wall thickening can result from immune-mediated, infectious, or vascular causes, as well as from toxicity and other lesser-known entities. As the imaging appearance of many of these conditions overlap, clinical and laboratory findings are necessary to support the imaging diagnosis.

Paclitaxel-Induced Bowel Perforation: A Rare Cause of Acute Abdomen

Paclitaxel, a chemotherapeutic agent, is routinely administered for the treatment of various solid organ malignancies. In rare instances, patients receiving infusions of paclitaxel may present with signs of an acute abdomen. Ischemia and necrosis of the bowel wall from chemotherapy-induced neutropenia and direct toxic effects of the drug have been implicated as the cause. We present a case of necrotizing small and large bowel perforation in a patient with breast cancer, 2 weeks after paclitaxel administration.

On the magnetic aggregation of Fe3O4 nanoparticles

Background and objective In-vivo MRI-guided drug delivery concept is a personalized technique towards cancer treatment. A major bottleneck of this method, is the weak magnetic response of nanoparticles. A crucial improvement is the usage of paramagnetic nanoparticles aggregates since they can easier manipulated in human arteries than isolated particles. However its significance, not a comprehensive study to estimate the mean length and time to aggregate exists. Methods The present detailed numerical study includes all major discrete and continues forces and moments of the nanoscale in a global model. The effort is given in summarizing the effects of particle diameter and concentration, and magnetic field magnitude to comprehensive relations. Therefore, several cases with nanoparticles having various diameters and concentrations are simulated as magnetic field increases. Results It is found that aggregations with maximum length equal to 2000nm can be formed. In addition, the increase of the concentration leads to a decrease in the amount of the isolated particles. Consequently, 33% of the particles are isolated for the concentration of 2.25mg/ml while 13% for the concentration of 10mg/ml. Moreover, the increase of the permanent magnetic field and diameter of particles gives rise to an asymptotic behavior in the number of isolated particles. Furthermore, the mean length of aggregates scales linear with diameter and magnetic field, however, concentration increase results in a weaker effect. The larger aggregation that is formed is composed by 21 particles. Smaller time is needed for the completion of the aggregation process with larger particles. Additionally, the increase of the magnitude of the magnetic field leads to a decrease in the aggregation time process. Therefore, 8.5ms are needed for the completion of the aggregation process for particles of 100nm at B₀=0.1T while 7ms at B₀=0.9T. Surprisedly, the mean time to aggregate is of the same order as in microparticles, although, with an opposite trend. Conclusions In this study, the evolution of the mean length of aggregations as well as the completion time of the aggregation process in the nano and micro range is evaluated. The present results could be useful to improve the magnetic nanoparticles assisted drug delivery method in order to minimize the side effects from the convectional cancer treatments like radiation and chemotherapy.

Multimodality Radiological Pictorial Review of Testicular Carcinoma: From Initial Staging to Restaging

With an overall 5-year survival rate >95%, patients with testicular cancer have a great prognosis. Although initial diagnosis is based on clinical examination, imaging does play a significant role in the diagnosis and prognosis of testicular cancer, which are dependent on tumor burden and staging. Successful treatment requires appropriate disease assessment throughout a patient’s treatment: evaluating treatment response, restaging, and monitoring for disease recurrence after treatment completion. Ultrasound is usually the initial screening modality for painless testicular masses, and computedtomography (CT) the most commonly used for staging and restaging. However, with regard to seminomas, positron-emission tomography (PET) combined with CT is slowly taking priority. With regard to nonseminomatous germ-cell tumors, PET-CT has not proven to be completely effective, due to a high number of false-negative results. The purpose of this paper is to provide radiologists with a pictorial review of testicular carcinoma from initial staging through posttreatment follow-up.

Not all that glitters is COVID! Differential diagnosis of FDG-avid interstitial lung disease in low-prevalence regions

Coronavirus disease-19 (COVID-19) is only one of the many possible infectious and non-infectious diseases that may occur with similar imaging features in patients undergoing [¹⁸F]-fluorodeoxyglucose (¹⁸FDG) monitoring, particularly in the most fragile oncologic patients. We briefly summarise some key radiological elements of differential diagnosis of interstitial lung diseases which, in our opinion, could be extremely useful for physicians reporting ¹⁸FDG PET/CT scans, not only during the COVID-19 pandemic, but also for their normal routine activity.

A Review of the Mechanisms and Clinical Implications of Precision Cancer Therapy-Related Toxicity: A Primer for the Radiologist

OBJECTIVE. The purpose of this review is to elucidate the mechanisms, types, and clinical significance of molecular targeted therapy (MTT) and immune checkpoint inhibitors (ICIs) and their related toxicity, emphasizing the radiologic manifestations. CONCLUSION. The related toxicities of MTT and ICIs can have acute, recurrent, chronic, and delayed presentations. These toxicities may serve as markers of response and survival. By understanding the clinical significance of drug toxicities, radiologists can play an important role in personalized cancer therapy.

Imaging of acute abdomen in cancer patients

The pattern of disease causing acute abdominal pain has changed over last few decades, some of this has been attributed to intraabdominal cancers. The most common acute abdominal complaints in cancer patients are related to the gastrointestinal system. Abdominal emergencies in cancer patients can result from the underlying malignancy itself, cancer therapy and/or result from the standard pathologies causing acute abdomen in otherwise healthy population. Therapy-related or disease-related immunosuppression or high dose analgesics often blunt many of the findings which are usually expected in non-cancer general population. This complicates the clinical picture rendering the clinical exam less reliable in many cancer patients, and resulting in different pathologies which clinicians and the radiologists should remain aware of. This article focuses on imaging illustrations with differential diagnosis for various emergency scenarios related to acute abdomen specifically in oncologic settings.

Evaluation of the Efficacy and Safety of the Herbal Formula PM014 in a Cisplatin- and Paclitaxel-Treated Tumor-Bearing Mouse Model

PM014 (HL301) is a standardized herbal mixture derived from a traditional Korean medicine, Chung-Sang-Bo-Ha-Tang. Previously, we reported that PM014 treatment significantly suppressed pulmonary fibrosis, one of the frequent adverse effects of anticancer therapy in lung cancer. Before the clinical application of PM014 in anticancer therapy, the safety and efficacy of PM014 in combination with conventional anticancer drugs should be addressed to determine whether PM014 can be used in lung cancer. Lewis lung cancer–bearing mice were injected with 10 mg/kg of cisplatin or paclitaxel on day 5. Starting on day 7, the mice were administered 200 mg/kg PM014 every 2 days. On day 15, all mice were assessed by biochemical and histological analyses. PM014 did not block the antitumor activity of cisplatin and paclitaxel. Coadministration of PM014 and antitumor agents did not elevate the aspartate transaminase/alanine transaminase ratio or the blood urea nitrogen/creatinine ratio. Histopathological analysis also showed that PM014 did not induce hepatic or renal injury. Moreover, PM014 had no apparent inhibitory effects on drug metabolizing enzymes, indicating that PM014 did not alter the pharmacokinetics of chemotherapeutic drugs. Overall, these data show the safety and compatibility of combination therapy of PM014 and chemotherapies for the treatment of lung cancer.

Update on Hodgkin lymphoma from a radiologist's perspective

Recent advances in the management of Hodgkin lymphoma, due to new staging and response assessment systems as well as new therapies, have redefined the role of imaging for this disease. The purpose of this article is to provide radiologists with an update on the current role of imaging in Hodgkin lymphoma from diagnosis to assessment of treatment response, in view of the new staging and response assessment system and current treatment strategies.

Development of complex renal cysts: A complication associated with Crizotinib therapy

Crizotinib is a tyrosine kinase inhibitor that has been found to be effective in the treatment of anaplastic lymphoma kinase (ALK) positive non-small cell lung cancer. This targeted cancer therapy agent has been shown to have superior efficacy over standard chemotherapy in this small subset of lung cancer patients. An adverse effect of this drug therapy is the development of complex renal cysts. Here, we present a case of a 68-year-old patient with non-small cell lung cancer on Crizotinib therapy who developed complex bilateral renal cysts. It is important to recognize this drug-related complication in order to avoid mistaking it for disease progression, primary renal malignancy, or renal infection.

Overview of imaging findings associated with systemic therapies in advanced epithelial ovarian cancer

PURPOSE

To provide an overview for radiologists of the systemic agents used in the treatment of advanced epithelial ovarian cancer (EOC) and their associated toxicities.

RESULTS

EOC is a common gynecological malignancy, with the majority of patients presenting with advanced stage disease at the time of diagnosis. Although primary cytoreductive surgery and chemotherapy are the principal treatments for EOC, recurrence rates of disease remain high. As several molecular targeted therapies have been developed in the last decade, various novel agents have shown efficacy in the treatment of advanced EOC. Advanced EOC will be discussed by outlining the relevant radiological features of toxicities.

CONCLUSION

Knowledge of the systemic therapies utilized in the treatment of advanced EOC and their associated radiological features is critical in diagnostic image interpretation.

Sonographic assessment of infectious diseases of the gastrointestinal tract: from scanning to diagnosis

BACKGROUND

Sonography of the gastrointestinal (GI) tract is a practical, safe, inexpensive, and reproducible diagnostic tool for the evaluation, diagnosis, and follow-up of infectious bowel disease. The modality is rapidly gaining prominence among clinicians on a global scale. In the United States, however, ultrasound of the bowel remains underutilized primarily due to insufficient experience among radiologists and sonographers in performing sonographic bowel assessment. This lack of experience and knowledge results in misinterpretations, missed diagnoses, and underutilization of this modality in patients with acute abdomen, with the majority of GI pathology on sonography discovered incidentally.

OBJECTIVES

This article aims to demonstrate the characteristic sonographic findings associated with GI infectious processes as well as provide dedicated ultrasound protocols for evaluation of the GI tract.

CONCLUSION

This article serves a twofold purpose, raising awareness of the utility of this imaging modality within the radiology community and also providing practical teaching points for sonographic evaluation of infectious disorders of the GI tract.