External Beam Radiotherapy in the Treatment of Male Breast Carcinoma: Patterns of Failure in a Single Institute Experience

Aims and background

We analyzed our own results in the treatment of male breast cancer patients with respect to local control, overall survival and possible prognostic factors for local and distant control.

Methods

Thirty-one patients with 32 carcinomas of the male breast were treated with radiotherapy. Twenty-five patients received radiotherapy to the chest wall including or not regional lymphatics after initial mastectomy (n = 23) or after surgery for local recurrence (n = 2). Median total dose was 60 Gy to the chest wall and 46 Gy to regional lymphatics. Seven patients with metastatic disease were referred for palliative radiotherapy.

Results

Overall survival after postoperative radiotherapy was 40% after a median follow-up of 4.3 years. Actuarial 3-, 5- and 10-year survival was 82.6%, 56.5% and 43.5%, respectively. Five-year progression-free survival was 62.5%. Survival was significantly affected by the presence of lymph node metastases ( P <0.001). Local recurrence was seen in one patient after 29 months.

Conclusions

Postoperative radiotherapy is important in the management of male breast cancer to improve local control and progression-free survival, resulting in one local failure in our analysis. The presence of lymph node metastases significantly impairs survival.

Arteriosclerosis in Dialysis Patients

Arteriosclerosis is a constant problem in long-term hemodialysis patients. Computer tomography of the abdominal aorta allows a well-defined and reproducible evaluation of aortosclerosis. In the cross-sectional study, aortosclerosis was significantly accelerated in 84 chronic hemodialysis patients and was comparable to the results found in 20-year older control patients without renal disease. The increase of aortosclerosis correlated significantly with age of the patient, smoking, and duration of dialysis therapy. Furthermore, increased VLDL cholesterol and decreased HDL cholesterol seem to enhance aortosclerosis in our dialysis patients. In the longitudinal study (two CT scans with a time interval of 87 ± 62.7 months) in 36 dialysis patients, progressed aortosclerosis correlated significantly with the long duration of hypertriglyceridemia, VLDL cholesterol, uric acid, and calcium phosphate products. Progression of aortosclerosis was reduced in parathyroidectomized patients. The study suggests that premature aortosclerosis is found in dialysis patients. In addition to the common risk factor of aortosclerosis, disturbed calcium phosphate and parathyroid hormone metabolism seem to enhance aortosclerosis in patients under maintenance hemodialysis.

A Phase II Study of the Central European Society of Anticancer-Drug Research (CESAR) Group: Results of an Open-Label Study of Gemcitabine plus Cisplatin with or without Concomitant or Sequential Gefitinib in Patients with Advanced or Metastatic Transitional Cell Carcinoma of the Urothelium

INTRODUCTION

This phase II trial evaluated the efficacy and safety of the epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor, gefitinib, in combination with first-line chemotherapy in advanced urothelial cancer.

METHODS

Chemotherapy-naïve patients with advanced or metastatic urothelial carcinoma were randomized 1:1:1 to receive six cycles of chemotherapy (gemcitabine 1,250 mg/m2 on days 1 and 8, and cisplatin 70 mg/m2 on day 1 of every cycle) concomitantly with gefitinib 250 mg/day (arm A); or with sequential gefitinib (arm B); or alone (arm C). The primary endpoint was the time to progression (TTP).

RESULTS

A total of 105 patients received study treatment. Median TTP for arms A, B, and C were 6.1, 6.3, and 7.8 months, respectively. There were no significant differences between treatment arms for any outcomes measured. The most common adverse events were nausea and vomiting.

CONCLUSION

Gefitinib in combination with chemotherapy did not improve efficacy in advanced urothelial cancer.

Final results from the prospective phase III WSG-ARA trial: impact of adjuvant darbepoetin alfa on event-free survival in early breast cancer

BACKGROUND

WSG-ARA plus trial evaluated the effect of adjuvant darbepoetin alfa (DA) on outcome in node positive primary breast cancer (BC).

PATIENTS AND METHODS

One thousand two hundred thirty-four patients were randomized to chemotherapy either with DA (DA+; n = 615) or without DA (DA-; n = 619). DA (500 µg q3w) was started at hemoglobin (Hb) levels <13.0 g/dl (<12 g/dl after DA label amendment) and stopped at Hb levels ≥14.0 g/dl (12 g/dl after label amendment). Primary efficacy end point was event-free survival (EFS); secondary end points were toxicity, quality of life (QoL) and overall survival (OS).

RESULTS

Venous thrombosis (DA+: 3.0%, DA-: 1.0%; P = 0.013) was significantly higher for DA+, but not pulmonary embolism (0.3% in both arms). Median Hb levels were stable in DA+ (12.6 g/dl) and decreased in DA- (11.7 g/dl). Hb levels >15 g/dl were reported in 0.8% of cycles. QoL parameters did not significantly differ between arms. At 39 months, DA had no significant impact on EFS (DA+: 89.3%, DA-: 87.5%; Plog-rank = 0.55) or OS (DA+: 95.5%, DA-: 95.4%; Plog-rank = 0.77).

CONCLUSIONS

DA treatment did not impact EFS or OS in routine adjuvant BC treatment.

Impact and safety of adjuvant chemotherapy on pulmonary function in early stage non-small cell lung cancer

BACKGROUND

Pulmonary function may decline after induction chemotherapy and predict perioperative complications in non-small cell lung cancer (NSCLC). The influence of adjuvant chemotherapy is largely indeterminate.

OBJECTIVE

To assess whether adjuvant chemotherapy alters pulmonary function and impacts on treatment-related adverse events.

METHODS

In a trial on adjuvant chemotherapy (the TREAT trial), 132 patients with R0-resected NSCLC were randomised to 4 cycles of cisplatin-vinorelbine (CVb, n = 65) or cisplatin-pemetrexed (CPx, n = 67). Pulmonary function tests (forced expiratory volume in 1 s, FEV1, forced vital capacity, FVC, total lung capacity, TLC, diffusing capacity for carbon monoxide, DLCO, and blood gas analyses, BGA) were analysed before and 30 days after the last chemotherapy, and changes were calculated (Δ = mean differences).

RESULTS

Overall, FVC increased significantly (Δ +290 ml, n = 76; p < 0.0001), while TLC did not change (Δ +220 ml, n = 41; p = 0.174). For CPx, FEV1 increased significantly (Δ +150 ml, n = 47; p = 0.0017), but not for CVb (Δ +30 ml, n = 30). DLCO decreased only for CVb (-8%, n = 6) but not for CPx (-0.39%, n = 17; p = 0.58). BGA did not change (p = 0.99). In a Cox regression analysis, baseline pulmonary function did not influence treatment failure.

CONCLUSIONS

Adjuvant chemotherapy seems not to result in a decrease of pulmonary function parameters. A significant FVC increase was probably due to ongoing postoperative improvement. Decline of DLCO was noted with CVb but not with CPx. Pulmonary function does not impact on treatment failure.

Randomized phase 2 trial on refinement of early-stage NSCLC adjuvant chemotherapy with cisplatin and pemetrexed versus cisplatin and vinorelbine: the TREAT study

BACKGROUND

Adjuvant chemotherapy is beneficial in non-small-cell lung cancer (NSCLC). However, balancing toxicity and efficacy mandates improvement.

PATIENTS AND METHODS

Patients with completely resected stages IB-pT3N1 NSCLC were randomly assigned to either four cycles cisplatin (C: 50 mg/m(2) day (d)1 + 8) and vinorelbine (V: 25 mg/m(2) d1, 8, 15, 22) q4 weeks or four cycles cisplatin (75 mg/m(2) d1) and pemetrexed (Px: 500 mg/m(2) d1) q3 weeks. Primary objective was the clinical feasibility rate (no grade (G)4 neutropenia/thrombocytopenia or thrombocytopenia with bleeding, no G3/4 febrile neutropenia or non-hematological toxicity; no premature withdrawal/death). Secondary objectives were drug delivery and efficacy.

RESULTS

One hundred and thirty two patients were randomized (stages: 38% IB, 10% IIA, 47% IIB, 5% pT3pN1; histology: 43% squamous, 57% non-squamous). The feasibility rates were 95.5% (cisplatin and pemetrexed, CPx) and 75.4% (cisplatin and vinorelbine, CVb) (P = 0.001); hematological G3/4 toxic effects were 10% (CPx) and 74% (CVb) (P < 0.001), non-hematological toxic effects were comparable (33% and 31%, P = 0.798). Delivery of total mean doses was 90% of planned with CPx, but 66% (cisplatin) and 64% (vinorelbine) with CVb (P < 0.0001). The median number of cycles [treatment time (weeks)] was 4 for CPx (11.2) and 3 for CVb (9.9). Time to withdrawal from therapy differed significantly between arms favoring CPx (P < 0.001).

CONCLUSION

Adjuvant chemotherapy with CPx is safe and feasible with less toxicity and superior dose delivery compared with CVb.

PD07-06: Adjuvant Chemotherapy with or without Darbepoetin alpha in Node-Positive Breast Cancer: Survival and Quality of Life Analysis from the Prospective Randomized WSG ARA Plus Trial

Background: Darbepoetin alpha (ARA) is currently used to reduce chemotherapy-associated anemia (CAA) rates in various solid tumors. A possible negative impact of ARA on patient survival has been suggested in some clinical trials. The objective of the prospective randomized phase III ARA Plus trial is to compare the survival effect of darbepoetin alpha use (ARA+/ARA-) in combination with modern standard adjuvant chemotherapy targeting guideline-recommended Hb-levels in high-risk breast cancer (BC).

Methods: ARA Plus compared 6 cycles T75A50C500 q3w or 6 cycles F500E100C500 q3w (at discretion of each center) in patients with node positive BC (aged 18–65 years). Patients were randomized to darbepoetin (ARA+) 500 μg q3w until completion of radiotherapy or to standard supportive care (ARA-). ARA was started at Hb-levels ≤13 g/dL (amendment 01/2008: Hb ≤12 g/dL) and stopped at &gt;14 g/dL (&gt;12 g/dL). Primary endpoint is event-free survival (EFS: relapses, death without disease evidence, second malignancy). Overall survival (OS), toxicity, Hb-levels and quality of life are secondary endpoints. Survival analysis was planned after 7 years of study duration. EFS was tested using χ2-test (α=0.05) with a statistical power of β=80% and log-rank test. Quality of life was measured using FACT questionnaires at beginning of therapy, mid, end of therapy, and at 1 year afterwards.

Results: 1234 pts (616 ARA+/618 ARA-) from 70 centres in Germany were randomized between 01/04 and 06/08. 1198 intent to treat patients (ITT) were analysed (1096 TAC; 102 CEF). Baseline characteristics were well balanced in ARA+ and ARA- arms: median age 53/53 years; tumor size 2.4/2.4cm; number of + LN 3/3; HR+ 80%/ 83.5%, G3 40.7%/36.7%. Toxicity data have been reported earlier (SABCS 2008).

At median follow up of 40 months, 168 events (81 ARA+, 83 ARA-) and 134 relapses (65 ARA+, 69 ARA-) were reported. There was no significant difference in 3-year EFS between ARA+ and ARA- arms (89.2% vs. 87.6%, p=0.97, χ2-test). 37 deaths were reported in the ARA- and 36 in the ARA+ arm. 3-year OS was 95.4% and 95.1% for ARA+ and ARA-, respectively (p=0.85). Only nodal involvement (≥4 vs. 1–3), negative HR, tumor size &gt;2 cm and G3 were significant survival predictors by multivariate analysis. Unplanned retrospective analysis revealed better EFS for ARA+ vs. ARA- in HR- (p=0.05), and no difference in HR+ group (p=0.6). In ARA+ patients, Hb-levels were stable over the whole treatment period with rare overstimulation. In ARA- patients, Hb-levels decreased during therapy (median of all cycles ARA+/ARA-: 12.5/11.6 g/dL). There was no correlation between mean Hb-levels and survival in either study arm.

There were no significant differences in mean FACT scores changes (general, anemia, cognitive) from begin to end of therapy in either study arm. More detailed analyses are ongoing.

Conclusions: To date, the WSG ARA plus trial is the only prospectively randomized trial in early high-risk BC exclusively focusing on the impact of adjuvant ARA on patient outcome. Supportive administration of ARA appears to be safe and to have no significant survival effect when used in combination with TAC or CEF according to current guidelines.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD07-06.

P5-18-03: First Interim Toxicity Analysis of the Randomized Phase III WSG Plan B Trial Comparing 4xEC-4xDoc Versus 6xTC in Breast Cancer Patients with HER2 Negative Breast Cancer (BC)

Background: Anthracycline-taxane based adjuvant chemotherapy (cht) is considered standard in node-positive and high-risk node-negative BC. However, retrospective analyses suggest that in HER2−BC, benefit from anthracyclines may not outweigh acute and long term toxicities. Recurrence Score (RS) identifies patients who are not candidates for cht based on their low relapse risk, as well as minimal, if any, benefit of cht. The WSG Plan B trial investigates anthracycline-free cht in HER2− BC and is the first trial in Europe prospectively incorporating RS for decision making regarding adjuvant cht in both N0 and N+ BC.

Methods: Plan B trial randomizes HER2− BC patients with high-risk N0 (at least one risk factor: ≥pT2; negative HR status; G2-3; age ≤35 years old; high uPA/PAI-1) or N+ disease to 6xTC (Docetaxel 75Cyclophosphomide600) vs. 4xEC (Epirubicin90Cyclophosphomide600)-4xDocetaxel100 G-CSF prophylaxis is recommended according to current ASCO guidelines. The statistical design previews n=2.448 randomized to cht; patients with HR+ BC, N0-3 and a RS ≤11 receive endocrine therapy only.

Results: From April 2009 to June 2011, 3037 patients have been recruited and 2296 randomized (TC/EC-Doc: 1146/1150; age &lt;65 years old: 900/911; ≥65 years old: 246/239). From the patients with HR+ disease (n=2368) 18% had a RS 0–11, 61% a RS 12–25 and 21% a RS ≥ 25. In patients with 0–3 positive LN and RS of 0–11 (n=329) who opted for no cht 257 are in the observational arm. In the group with an intermediate risk (RS 12–25) 14% drop outs before start of cht have been reported. In 1172 fully monitored patients 22 toxicity-related therapy stops have been reported in the TC and 34 in the EC-Doc arm (p=0.12). 614 serious adverse events (SAE) have been reported (299 TC vs. 315 EC-Doc). There is no difference in patients &lt;65 years old (TC vs. EC-Doc: 218/218), but slightly more SAE's in patients ≥65 years old treated by EC-Doc (97 vs. 81, p=0.13).

The most frequent SAEs were: leucopenia, febrile neutropenia (TC/EC-Doc:37 (3.3%)/31 (2.7%), n.s.), infections and heart/vascular events (TC/EC-Doc 29/40, n.s.). In patients ≥65 years old, there is a trend towards more febrile neutropenia (13 vs. 5; p=0.06) in the TC, and more severe mucositis/diarrhea/nausea (3 vs. 15; p=0.007) and heart/vascular events (5 vs. 14; p=0.06) in the EC-Doc arm. There were 5 therapy related deaths (TC 5 (0.4%)/EC-Doc 0, p=0.03); 3 in patients &lt;65 years, 2 in patients ≥65 years (4 due to sepsis, 1 due to cardiac failure).

Detailed data on relationship between the protocol specified, RS-guided treatment assignment and toxicity, and use of G-CSF support will be updated for the meeting.

Conclusions: The Plan-B trial is one of the largest randomized phase III trials currently evaluating anthracycline-free adjuvant cht in HER2− BC. The cht administered within the study was generally well tolerated, but higher number of treatment-related deaths has been observed within the TC arm. The short term toxicity profile seems be different between both study arms, particularly in patients &gt;65 years old. On the basis of prognosis as determined by RS, cht has been spared after a shared decision process in a substantial group of patients.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-18-03.

Differential effects of CLDR and PDR brachytherapy on cell cycle progression in a syngeneic rat prostate tumour model

PURPOSE

The study consisted of two treatment arms comparing the effects of CLDR (continuous low dose rate) and PDR (pulsed dose rate) brachytherapy on cell cycle progression in a radioresistant rat prostate tumour model.

MATERIALS AND METHODS

Interstitial PDR and CLDR brachytherapy (both 192-Ir, 0.75 Gy/h) were administered to Dunning prostate R3327-AT1 carcinomas transplanted subcutaneously into the thigh of Copenhagen rats. Increasing doses of up to 20 as well as up to 40 Gy were applied. Cell cycle distributions of the aneuploid tumour cell subpopulations were determined at 4 h (3 Gy), 24 h (18 Gy), 48 h (20 and 36 Gy), as well as during the subsequent redistribution period (20 and 40 Gy) at 72, 96, and 120 h. Tumours either implemented with an empty tubing system (n=5) or under undisturbed growth (n=5) served as controls. Three animals were irradiated per time point and exposure condition. At least two flow cytometrical analyses were carried out per animal.

RESULTS

The aneuploid cells possessed a constant DNA-Index of 1.9+/-0.06. In contrast to sham-treated controls, the aneuploid cell fraction with G2/M DNA content was significantly increased (p<0.05) after initiation of both, CLDR and PDR brachytherapy. However, CLDR resulted in an earlier accumulation of tumour cells in G2/M (24 h: 28% CLDR vs. 19% PDR, p<0.05) with a concomitant reduction of cells in G1, whereas PDR yielded delayed, but then more pronounced cell cycle changes, particularly expressed during the redistribution period after both 20 and 40 Gy.

CONCLUSION

CLDR and PDR brachytherapy showed differential effects on cell cycle progression. The induction of a significantly earlier but also less persistent G2/M cell cycle arrest after CLDR compared to PDR brachytherapy implies that a substantially higher fraction of tumour cells are irradiated in G2/M after CLDR.

Second interims analysis of the ARA Plus study: Breast Cancer (BC) adjuvant chemotherapy (CT) with and without darbepoetin- alpha, analysis of serious adverse events

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Background: TAC is one of the most effective regimens. It‘s associated with higher frequency of anemia and chemotherapy-induced neutropenia (CIN). The erythropoiesis stimulating factor (ESF) support of chemotherapy, its complications and survival effect remain unclear. Erythropoetins do prevent chemotherapy-associated anemia (CAA) and subsequent fatigue syndrome but their potential influence on survival is still unclear. One aim of this analysis is to investigate the correlation between CT, growth factor support and toxicity (SAE‘s). Methods: This ARA Plus phase III trial compare chemotherapy ±ARA in breast cancer patients >18 years old, with positive lymph nodes and with M0 disease. Pts get six cycles of of 5-fluoro-uracile 500mg/m2, epirubicine 100mg/m2 and cyclophosphamide 500mg/m2, (FEC, Bonneterre), 3-weekly or six cycles of docetaxcel 75mg/m2, adriamycin 50mg/m2 and cyclophosphamide 500mg/m2, (TAC, BCIRG) and are randomized to ARA 500μg q3w if Hb<13 g/dl or standard support care. Here arte the results. of SAE‘S. Results: A total of 756 pts (373 + ARA/383 -ARA) from 53 sites were enrolled since January 2004, there are 1234 pts. planned up to January 2008. 185 serious adverse events (SAE) are reported. Of these 185 SAE’s 100 (54%) had an ARA-therapy. Most frequent SAE’s were: leucopenia, febrile neutropenia, thrombosis and infections. In 9 (31%) out of the 29 febrile neuropenia SAE’s, ARA was given. 30 thromboses were reported (23+ARA/7-ARA s.) but only 10 at the verty time ARA was given. In 31 severe infections 16 (51,6%; n.s.) were reported in patients receiving ARA Therapy. From 43 patients with intestinal SAE‘s like Diarrhea/Mucositis/Nausea to 30 pts. (69,8 %) ARA eas given. Conclusions: The combination of CT and ARA is safe concerning febrile neutropenia and furthermore appears to be protective factor of this SAE when combined with TAC. There seem to be more SAE‘s concerning thrombosis and intestinal difficulties.These results allow to hypothesize that ARA therapy is associated with higher toxicity concerning thrombosis which could make the use of heparin necessary but on the other side it shows significant reduced neutropenia.

No significant financial relationships to disclose.

Improved overall survival in postmenopausal women with early breast cancer after anastrozole initiated after treatment with tamoxifen compared with continued tamoxifen: the ARNO 95 Study

PURPOSE

In postmenopausal women with estrogen receptor-positive early breast cancer, surgery is usually followed by a 5-year course of tamoxifen. This report presents results of a prospective, open-label, randomized study, designed to evaluate the benefits of switching to anastrozole after 2 years of tamoxifen treatment, compared with continuing on tamoxifen for 5 years.

PATIENTS AND METHODS

After receiving tamoxifen treatment for 2 years, eligible patients (n = 979) were randomly assigned to switch to anastrozole (1 mg/d) or continue tamoxifen (20 or 30 mg/d) for an additional 3 years. Patients were monitored every 6 months during years 1 to 3 and annually thereafter. The primary efficacy variable was disease-free survival, including local or distant recurrence, new contralateral breast cancer, or death. Secondary variables were overall survival and assessment of safety.

RESULTS

Switching to anastrozole resulted in a significant reduction in the risk of disease recurrence (hazard ratio [HR], 0.66; 95% CI, 0.44 to 1.00; P = .049), and improved overall survival (HR, 0.53; 95% CI, 0.28 to 0.99; P = .045) compared with continuing on tamoxifen. Fewer patients who switched to anastrozole reported serious adverse events (22.7% v 30.8%) compared with those who continued on tamoxifen, mainly due to more patients in the tamoxifen group with endometrial events. The overall safety profile for anastrozole was consistent with previous reports and no new safety issues were identified.

CONCLUSION

Postmenopausal women who have taken tamoxifen for 2 years as adjuvant therapy are less likely to experience a recurrence of breast cancer and have improved overall survival if they switch to anastrozole compared with continuing to receive tamoxifen.

Effectiveness of switching from adjuvant tamoxifen to anastrozole in postmenopausal women with hormone-sensitive early-stage breast cancer: a meta-analysis

BACKGROUND

For more than 20 years, tamoxifen has been the mainstay of adjuvant endocrine therapy for women with hormone-sensitive early-stage breast cancer. However, not only does tamoxifen have potential side-effects such as an increased risk of endometrial cancer and thromboembolic events, but patients can also develop resistance to the drug. We aimed to investigate whether switching treatment of postmenopausal women with such breast cancer to anastrozole after 2-3 years of tamoxifen would be more effective than continuing on tamoxifen for a total of 5 years.

METHODS

We did a meta-analysis of three clinical trials--the Austrian Breast and Colorectal Cancer Study Group (ABCSG 8), Arimidex-Nolvadex (ARNO 95), and the Italian Tamoxifen Anastrozole (ITA) studies--in which postmenopausal women with histologically confirmed, hormone-sensitive early-stage breast cancer were randomised to 1 mg/day anastrozole (n=2009) after 2-3 years of tamoxifen treatment or to continued 20 or 30 mg/day tamoxifen (n=1997). We analysed the data with a stratified Cox proportional hazards model with the covariates of age, tumour size, nodal status, grade, surgery, and chemotherapy.

FINDINGS

Patients who switched to anastrozole had fewer disease recurrences (92 vs 159) and deaths (66 vs 90) than did those who remained on tamoxifen, resulting in significant improvements in disease-free survival (hazard ratio 0.59 [95% CI 0.48-0.74]; p<0.0001), event-free survival (0.55 [0.42-0.71]; p<0.0001), distant recurrence-free survival (0.61 [0.45-0.83]; p=0.002), and overall survival (0.71 [0.52-0.98]; p=0.04).

INTERPRETATION

Our results show that the clinical benefits in terms of event-free survival seen in individual trials for those patients who switched to anastrozole translate into a benefit in overall survival. These findings confirm that clinicians should consider switching postmenopausal women who have taken adjuvant tamoxifen for 2-3 years to anastrozole.

Survival benefit of switching to anastrozole after 2 years’ treatment with tamoxifen versus continued tamoxifen therapy: The ARNO 95 study

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Background: Initial adjuvant treatment with anastrozole has significant efficacy and tolerability advantages over tamoxifen in postmenopausal women with hormone-sensitive early breast cancer (EBC) (ATAC Trialists’ Group. Lancet 2005; 365: 60–62). The ARNO 95 study evaluated prospectively switching to anastrozole from tamoxifen after 2 years, compared with continuing tamoxifen therapy. Here, we present an interim efficacy and safety analysis. Methods: This was a prospective, randomized, open-label study conducted in 54 centers in Germany. Postmenopausal women (≤75 years) with hormone receptor-positive, invasive EBC, who had received 2 years of adjuvant tamoxifen without recurrence, were randomized to switch to anastrozole (1 mg/day) or continue on tamoxifen (20 or 30 mg/day) for a further 3 years. No adjuvant chemotherapy was given. The primary end point was disease-free survival (DFS; time to earliest occurrence of local or distant recurrence, new primary breast cancer, or death from any cause); secondary end points included overall survival (OS), safety, and tolerability. Data were analyzed using a log-rank test; a second analysis used a Cox proportional hazards model with covariates of age, tumor size, nodal status, grade, and type of surgery. Results: Overall, 979 patients (mean age 60 years; 74% node-negative; 97% hormone receptor-positive) were enrolled, 489 were randomized to switch to anastrozole, with 490 continuing on tamoxifen. Median follow-up was 30.1 months. Switching to anastrozole significantly improved DFS and OS compared with continuing on tamoxifen ( Table ). Fewer patients who switched to anastrozole reported serious adverse events (22.7%) compared with those who remained on tamoxifen (30.8%). Conclusions: Switching endocrine treatment improved DFS and OS in this well-defined population. Postmenopausal women with hormone-sensitive EBC who have already received 2 years’ adjuvant tamoxifen therapy should be switched to anastrozole.

[Table: see text]

[Table: see text]

Contrast-enhanced 3D MRI of lung perfusion in children with cystic fibrosis—initial results

This paper is a feasibility study of magnetic resonance imaging (MRI) of lung perfusion in children with cystic fibrosis (CF) using contrast-enhanced 3D MRI. Correlation assessment of perfusion changes with structural abnormalities. Eleven CF patients (9 f, 2 m; median age 16 years) were examined at 1.5 T. Morphology: HASTE coronal, transversal (TR/TE/alpha/ST: 600 ms/28 ms/180 degrees /6 mm), breath-hold 18 s. Perfusion: Time-resolved 3D GRE pulse sequence (FLASH, TE/TR/alpha: 0.8/1.9 ms/40 degrees ), parallel imaging (GRAPPA, PAT 2). Twenty-five data sets were acquired after intravenous injection of 0.1 mmol/kg body weight of gadodiamide, 3-5 ml/s. A total of 198 lung segments were analyzed by two radiologists in consensus and scored for morphological and perfusion changes. Statistical analysis was performed by Mantel-Haenszel chi-square test. Results showed that perfusion defects were observed in all patients and present in 80% of upper, and 39% of lower lobes. Normal lung parenchyma showed homogeneous perfusion (86%, P<0.0001). Severe morphological changes led to perfusion defects (97%, P<0.0001). Segments with moderate morphological changes showed normal (53%) or impaired perfusion (47%). In conclusion, pulmonary perfusion is easy to judge in segments with normal parenchyma or severe changes. In moderately damaged segments, MRI of lung perfusion may help to better assess actual functional impairment. Contrast-enhanced 3D MRI of lung perfusion has the potential for early vascular functional assessment and therapy control in CF patients.

Focal Gene Induction in the Liver of Rats by a Heat-Inducible Promoter Using Focused Ultrasound Hyperthermia

OBJECTIVE

We sought to examine high-intensity focused ultrasound (HIFU)-induced hyperthermia in the liver of a rat model to focally induce green-fluorescent protein (GFP).

MATERIALS AND METHODS

A total of 25 Copenhagen rats were included in this study. Rats were divided into groups treated with an adenovirus coding for green fluorescent protein (GFP) under the control of a hsp70B promoter and a CMV promoter. Ad-CMV-GFP-treated rats served as positive control. Untreated controls only subjected to MRI +/- HIFU-treatment served to find out optimal power of HIFU in the target area of the liver. Temperature was noninvasively monitored by temperature sensitive magnetic resonance imaging (MRI).

RESULTS

Rats treated with Ad-hsp70B-GFP demonstrated localized gene induction within the liver parenchyma, in good correlation with MRI and histology. Applying an acoustic power of 1.92 W a relatively uniform focal temperature up to 42 +/- 5 degrees C within the liver parenchyma could be documented. 3 x 10(9) plaque-forming units proved to account for a very homogeneous liver infection. Number of fluorescent cells in the region of hyperthermia was similar to the control group treated with Ad-CMV-GFP.

CONCLUSION

Using the introduced parameters spatially controlled gene induction within a parenchymal organ such as the liver in rats using HIFU under control of MRI is feasible.

Dynamic contrast-enhanced MRI for assessing the disease activity of multiple myeloma: a comparative study with histology and clinical markers

PURPOSE

To examine whether parameters of dynamic, contrast-enhanced MRI (DCE MRI) reflect the degree of infiltration and vessel density in corresponding bone marrow biopsy specimens.

MATERIALS AND METHODS

The pelvis of 24 patients with multiple myeloma (MM) was examined using contrast-enhanced DCE MRI. Biopsy was obtained from the spina iliaca posterior superior. Using a two-compartment model (assuming one intravascular and one interstitial compartment), the parameters amplitude (A, the maximum, relative signal increase over baseline) and the exchange rate constant (k(ep), describing the redistribution of contrast agent from the interstitial into the intravascular compartment) in the biopsied region were calculated and compared with the histological and clinical data.

RESULTS

DCE MRI parameters were significantly higher in lesions with marked infiltration than with mild or no infiltration (P < 0.05). The amplitude normalized to that in the iliac artery (A(n)), but not k(ep), was higher in lesions with high vessel-density at histology (P = 0.01). Higher k(ep) levels were found in presence of increased serum immunoglobulins.

CONCLUSION

Increased contrast uptake in the bone marrow of MM patients indicates at least moderate tumor involvement. Furthermore, the contrast enhancement correlates with vessel-density and serum markers of disease activity.

Assessment of reproducibility and stability of different breath-hold maneuvres by dynamic MRI: comparison between healthy adults and patients with pulmonary hypertension

To assess the stability and reproducibility of different breath-hold levels in healthy volunteers and patients using dynamic MRI (dMRI). In ten healthy volunteers and ten patients with pulmonary hypertension (PH) and normal lung function craniocaudal intrathoracic distances (CCD) were measured during inspiratory and expiratory breath-hold (15 s) (in healthy volunteers additionally at a self-chosen mid-inspiratory breath-hold) using dMRI (trueFISP, three images/s). To evaluate stability and intraobserver reproducibility of the different breath-hold levels, CCDs, time-distance curves, confidence intervals (CIs), Mann-Witney U test and regression equations were calculated. In healthy volunteers there was a substantial decrease of the CCD during the inspiratory breath-hold in contrast to the expiratory breath-hold. The CI at inspiration was 2.84+/-1.28 in the right and 2.1+/-0.68 in the left hemithorax. At expiration the CI was 2.54+/-1.18 and 2.8+/-1.48. Patients were significantly less able to hold their breath at inspiration than controls (P<0.05). In patients CI was 4.53+/-4.06 and 3.46+/-2.21 at inspiration and 4.45+/-4.23 and 4.76+/-3.73 at expiration. Intraobserver variability showed no significant differences either in patients or in healthy subjects. Reproducibility was significantly lower at a self-chosen breath-hold level of the healthy volunteers. DMRI is able to differentiate stability and reproducibility of different breath-hold levels. Expiratory breath-hold proved to be more stable than inspiratory breath-hold in healthy volunteers and patients.

Computer-assisted quantitative assessment of power Doppler US: effects of microbubble contrast agent in the differentiation of breast tumors

RATIONALE AND OBJECTIVES

To objectively quantify the effects of a microbubble contrast agent to differentiate breast tumors with power doppler ultrasound and to compare these results with color doppler ultrasound (CD US).

METHODS

In 47 patients a microbubble contrast agent was injected intravenously. Computer-assisted quantitative assessment of the color pixel density was performed to evaluate the increase in Doppler signals. Results were compared to previously published results of a color Doppler ultrasound study.

RESULTS

Peak color pixel density at contrast-enhanced power Doppler ultrasound was higher for carcinomas than for benign tumors (P < 0.03). Time to peak enhancement was shorter in carcinomas than in benign tumors (P < 0.01). For both parameters, diagnostic accuracy of power Doppler ultrasound was 69 and 78%, and for color Doppler ultrasound 62 and 76%, respectively.

CONCLUSIONS

Quantitative assessment of contrast-enhanced power Doppler ultrasound showed significant differences in malignant and benign breast tumors. Diagnostic accuracy of contrast-enhanced power Doppler ultrasound was higher compared to color Doppler ultrasound.

Influence of different breathing maneuvers on internal and external organ motion: Use of fiducial markers in dynamic MRI

PURPOSE

To investigate, with dynamic magnetic resonance imaging (dMRI) and a fiducial marker, the influence of different breathing maneuvers on internal organ and external chest wall motion.

METHODS AND MATERIALS

Lung and chest wall motion of 16 healthy subjects (13 male, 3 female) were examined with real-time trueFISP (true fast imaging with steady-state precession) dMRI and a small inductively coupled marker coil on either the abdomen or thorax. Three different breathing maneuvers were performed (predominantly "abdominal breathing," "thoracic breathing," and unspecific "normal breathing"). The craniocaudal (CC), anteroposterior (AP), and mediolateral (ML) lung distances were correlated (linear regression coefficient) with marker coil position during forced and quiet breathing.

RESULTS

Differences of the CC distance between maximum forced inspiration and expiration were significant between abdominal and thoracic breathing (p < 0.05). The correlation between CC distance and coil position was best for forced abdominal breathing and a marker coil in the abdominal position (r = 0.89 +/- 0.04); for AP and ML distance, forced thoracic breathing and a coil in the thoracic position was best (r = 0.84 +/- 0.03 and 0.82 +/- 0.03, respectively). In quiet breathing, a lower correlation was found.

CONCLUSION

A fiducial marker coil external to the thorax in combination with dMRI is a new technique to yield quantitative information on the correlation of internal organ and external chest wall motion. Correlations are highly dependent on the breathing maneuver.

Improved Vascular Opacification in Cerebral Computed Tomography Angiography With 80 kVp

PURPOSE

We sought to intraindividually compare computed tomography angiographies (CTAs) acquired at 80 kVp and 120 kVp with respect to vessel contrast, noise level, and radiation dose.

MATERIAL AND METHODS

CTA was performed on a single-slice CT scanner using tube voltages of 80 kVp and 120 kVp in 29 patients with arteriovenous malformations. Mean Hounsfield Units (HU) were evaluated for different vessels and brain parenchyma. To determine contrast-to-noise ratios (CNRs), noise levels were estimated from phantom measurements.

RESULTS

The calculated effective dose to male/female patients was 0.4/0.5 mSv for 80 kVp and 0.7/0.8 mSv for 120 kVp. CT density in blood vessels was between 297 and 458 HU for 80 kVp and 152 and 229 HU for 120 kVp (P<0.0001). Despite an increased noise level in the low-voltage images, the CNR was 26-59% higher at 80 kVp than at 120 kVp (P<0.05).

CONCLUSION

The use of a reduced tube potential leads to improved CNR in CTA of the cerebral vasculature and a markedly reduced radiation exposure to patients.

Preoperative staging of renal cell carcinoma with inferior vena cava thrombus using multidetector CT and MRI: prospective study with histopathological correlation

OBJECTIVE

To evaluate the accuracy of multidetector computed tomography (CT) and magnetic resonance imaging (MRI) in staging and estimating renal carcinomas with caval thrombus.

METHODS

Initially, 23 patients with suspected caval thrombi were admitted into this prospective study. Triphasic CT imaging was performed using a multidetector CT with a reconstructed slice thickness of 2 mm. 3D CT reconstructions were used to improve surgical planning. MRI protocol included: a transversal T1-weighted GE sequence with and without Gd-DTPA, a transversal T2-weighted respiratory-gated TSE, and a coronal T1-weighted GE sequence with Gd-DTPA and fat saturation. In addition, a multiphase 3D angiography was performed after Gd-DTPA injection. Patients were divided into 3 groups: caval thrombus below the insertion of the hepatic veins, within the intrahepatic vena cava, and intra-atrial extension. The results the tumor thrombus extension and staging results of 2 independent readers were correlated with surgical and histopathological staging.

RESULTS

Of the 23 patients admitted, CT and MR scans of 14/13 patients respectively were correlated with histopathological workup. CT thrombus detection sensitivity and specificity for both readers was 0.93 and 0.8 respectively. MRI sensitivity and specificity for both readers was 1.0/0.85 and 0.75. Readers I and II evaluated the uppermost extension of the cranial tumor thrombus by both CT and MRI. CT and MR accuracy was 78% and 72%, 88% and 76% respectively.

CONCLUSION

In cases of a suspected tumor thrombus, MRI and multidetector CT imaging showed similar staging results. Consequently, these staging modalities can be used to assess the extension of the tumor thrombus.

In vivo chemosensitivity-adapted preoperative chemotherapy in patients with early-stage breast cancer: the GEPARTRIO pilot study

BACKGROUND

Response to the first two cycles of preoperative chemotherapy might differentiate subgroups of breast cancer patients with high or minimal chances for a pathologic complete response (pCR) and may be used as an in vivo chemosensitivity test.

METHODS

Breast cancer patients were treated with two cycles of TAC (docetaxel 75 mg/m(2), doxorubicin 50 mg/m(2), cyclophosphamide 500 mg/m(2) every 21 days). Patients whose tumors showed a response received four more cycles. Patients whose tumors did not respond were randomized to four additional cycles TAC or NX (vinorelbine 25 mg/m(2) days 1 and 8, capecitabine 2000 mg/m(2) days 1-14, every 21 days). The primary end point was pCR at surgery.

RESULTS

Two hundred and eighty-five patients showed a clinical response, in 73.0% after two cycles, in 88.4% at surgery, and a pCR was seen in 17.9%. Breast conservation was possible in 72.2%. Responding patients obtained a pCR in 22.6% whereas non-responding patients reached a pCR in 7.3% and 3.1% with TAC or NX, respectively. Grade III/IV neutropenia and febrile neutropenia were observed during TAC in 70.2% and 13.5%, respectively. Significantly less toxicity were observed with NX.

CONCLUSION

Early response to TAC can reliably identify patients with a high chance of achieving a pCR. New effective treatments need to be explored for patients without an early response.

Measurement of tumor diameter-dependent mobility of lung tumors by dynamic MRI

BACKGROUND AND PURPOSE

To assess the influence of tumor diameter on tumor mobility and motion of the tumor bearing hemithorax during the whole breathing cycle in patients with stage I non-small-cell lung cancer (NSCLC) using dynamic MRI.

PATIENTS AND METHODS

Breathing cycles of thirty-nine patients with solitary NSCLCs were examined using a trueFISP sequence (three images per second). Patients were divided into three groups according to the maximal tumor diameter in the transverse plane (<3, 3-5 and >5 cm). Continuous time-distance curves and deep inspiratory and expiratory positions of the chest wall, the diaphragm and the tumor were measured in three planes. Motion of tumor-bearing and corresponding contralateral non-tumor bearing regions was compared.

RESULTS

Patients with a tumor >3 cm showed a significantly lower diaphragmatic motion of the tumor bearing compared with the non-tumor bearing hemithorax in the craniocaudal (CC) directions (tumors 3-5 cm: 23.4+/-1.2 vs 21.1+/-1.5 cm (P<0.05); tumors >5 cm: 23.4+/-1.2 vs 20.1+/-1.6 cm (P<0.01). Tumors >5 cm in the lower lung region showed a significantly lower mobility compared with tumors <3 cm (1.8+/-1.0 vs 3.8+/-0.7 cm, P<0.01) in the CC directions.

CONCLUSIONS

Dynamic MRI is a simple non-invasive method to differentiate mobility of tumors with different diameters and its influence on the surrounding tissue. Tumor diameter has a significant influence on tumor mobility and this might be taken into account in future radiotherapy planning.

Asbestos-Related Pleural Disease

OBJECTIVES

We sought to compare respiratory-gated high-spatial resolution magnetic resonance imaging (MRI) and radial MRI with ultra-short echo times with computed tomography (CT) in the diagnosis of asbestos-related pleural disease.

METHODS

Twenty-one patients with confirmed long-term asbestos exposure were examined with a CT and a 1.5-T MR unit. High-resolution respiratory-gated T2w turbo-spin-echo (TSE), breath-hold T1w TSE, and contrast-enhanced fat-suppressed breath-hold T1w TSE images with an inplane resolution of less than 1 mm were acquired. To visualize pleural plaques with a short T2* time, a pulse sequence with radial k-space-sampling was used (TE = 0.5 milliseconds) before and after administration of Gd-DTPA. CT and MR images were assessed by 4 readers for the number and calcification of plaques, extension of pleural fibrosis, extrapleural fat, detection of mesothelioma and its infiltration into adjacent tissues, and detection of pleural effusion. Observer agreement was studied with the use of kappa statistics.

RESULTS

The MRI protocol allowed for differentiation between normal pleura and pleura with plaques. Interobserver agreement was comparable for MRI and CT in detecting pleural plaques (median kappa = 0.72 for MRI and 0.73 for CT) and significantly higher with CT than with MRI for detection of plaque calcification (median kappa 0.86 for CT and 0.72 for MRI; P = 0.03). Median sensitivity of MRI was 88% for detection of plaque calcification compared with CT. For assessment of pleural thickening, pleural effusion, and extrapleural fat, interobserver agreement with MRI was significantly higher than with CT (median kappa 0.71 and 0.23 for pleural thickening, 0.87 and 0.62 for pleural effusion, and 0.7 and 0.56 for extrapleural fat, respectively; P < 0.05). For detection of mesothelioma, median kappa was 0.63 for MRI and 0.58 for CT.

CONCLUSION

High-resolution MR sequences and radial MRI achieve a comparable interobserver agreement in detecting pleural plaques and even a higher interobserver agreement in assessing pleural thickening, pleural effusion, and extrapleural fat when compared with CT.

Contrast-enhanced three-dimensional pulmonary perfusion magnetic resonance imaging: intraindividual comparison of 1.0 M gadobutrol and 0.5 M Gd-DTPA at three dose levels

RATIONALE AND OBJECTIVES

To compare 1.0 M gadobutrol and 0.5 M Gd-DTPA for contrast-enhanced three-dimensional pulmonary perfusion magnetic resonance imaging (3D MRI).

MATERIALS AND METHODS

Ten healthy volunteers (3 females; 7 males; median age, 27 years; age range, 18-31 years) were examined with contrast-enhanced dynamic 3D MRI with parallel acquisition technique (FLASH 3D; reconstruction algorithm: generalized autocalibrating partially parallel acquisitions; acceleration factor: 2; TE/TR/alpha: 0.8/1.9 milliseconds/40 degrees; FOV: 500 x 375 mm; matrix: 256 x 86; slab thickness: 180 mm; 36 partitions; voxel size: 4.4 x 2 x 5 mm; TA: 1.48 seconds). Twenty-five consecutive data sets were acquired after intravenous injection of 0.025, 0.05, and 0.1 mmol/kg body weight of gadobutrol and Gd-DTPA. Quantitative measurements of peak signal-to-noise ratios (SNR) of both lungs were performed independently by 3 readers. Bolus transit times through the lungs were assessed from signal intensity time curves.

RESULTS

The peak SNR in the lungs was comparable between gadobutrol and Gd-DTPA at all dose levels (15.7 vs. 15.5 at 0.1 mmol/kg bw; 12.9 vs. 12.5 at 0.05 mmol/kg bw; 7.6 vs. 8.9 at 0.025 mmol/kg bw). A dose of 0.1 mmol/kg achieved the highest peak SNR compared with all other dose levels (P < 0.05). A higher peak SNR was observed in gravity dependent lung (P < 0.05). Despite different injection volumes, transit times of the contrast bolus did not differ between both agents.

CONCLUSION

Higher concentrated gadolinium chelates offer no advantage over standard 0.5 M Gd-DTPA for contrast-enhanced 3D MRI of lung perfusion.

[Fluoroscopy based surgical navitation vs. mechanical guidance system for percutaneous interventions. A controlled prospective study exemplified by distal locking of intramedullary nails]

The aim of this study was to directly compare mechanically based targetting and surgical navigation when applied for percutaneous osteosynthesis. The distal locking procedure of intramedullary nails was used as the clinical model for a controlled prospective study. A total of 50 patients were included in two groups. In group 1, the distal locking was done with a mechanical aiming device while in group 2 this was done using a fluoroscopy based surgical navigation system. The target parameters were the precision attained, the necessary operation and fluoroscopy times as well as the number and severity of intra-operative problems. The drill-bit failed to pass through the interlocking hole in one patient with mechanical guidance and in two patients with surgical navigation. The average procedure time for distal locking with mechanical guidance was 6.9 minutes compared with 37.6 minutes with surgical navigation. An additional 44 minutes were required before skin incision and after skin closure as setup time for the navigation system. There was no significant difference in the fluoroscopy time or in the number of intra-operative technical problems. Surgical navigation increased the demand for resources but failed to improve the precision of distal locking compared with mechanical guidance. Further clinical studies are required to determine to what degree these results, using a special model, relate to other applications.

Diagnostic accuracy of staging renal cell carcinomas using multidetector-row computed tomography and magnetic resonance imaging: a prospective study with histopathologic correlation

OBJECTIVE

The aim of this prospective study is to compare the diagnostic accuracy of multidetector-row computed tomography (CT) and magnetic resonance imaging (MRI) in tumor staging of renal cell carcinomas.

METHODS

In a prospective study, 82 renal cell carcinomas were assessed for tumor staging before surgery using multidetector-row CT and MRI, the results of which were then correlated to histopathologic staging. Triphasic CT (noncontrast, arterial phase, and parenchymal phase) imaging was performed using multidetector-row CT with a reconstructed slice thickness of 2 mm. In MRI, a transverse T1-weighted gradient echo sequence with and without administration of Gd-DTPA, a transverse T2-weighted respiratory-gated turbo spin echo (TSE) sequence, and a coronal T1-weighted gradient echo sequence with Gd-DTPA were used. In addition, multiphasic 3-dimensional angiography after Gd-DTPA injection and a transverse T1-weighted fat-suppression sequence were performed.

RESULTS

With MRI, readers 1 and 2 correctly staged 71 and 64 tumors (overall accuracy of 0.87 and 0.78, respectively) and achieved Mantel-Haenszel chi(2) values of 66 and 63 (P < 0.0001). Computed tomography allowed correct staging of 68 and 66 tumors (readers 1 and 2, overall accuracy of 0.83 and 0.80, respectively) with Mantel-Haenszel chi(2) values of 54 and 54 for CT staging (P < 0.0001). No statistically significant difference between overall accuracy was found in the chi(2) test (P > 0.15).

CONCLUSION

Magnetic resonance imaging and multidetector-row CT with its multiplanar reconstruction capabilities achieve similar accuracy in tumor staging of renal cell carcinomas.

Fluoroscopic guidance versus surgical navigation for distal locking of intramedullary implants. A prospective, controlled clinical study

A prospective controlled clinical study was performed to compare fluoroscopic guidance with fluoroscopy-based surgical navigation for distal locking of intramedullary implants. Forty-two patients with fractures of the lower extremity treated by intramedullary nailing were divided in two groups: distal locking either with fluoroscopic guidance (group I) or with surgical navigation (group II). The average fluoroscopic time to insert one interlocking screw with fluoroscopic guidance was 108 s compared with 7.3s in the navigation group. The average procedure time to insert one interlocking screw in group I was 13.7 min compared with 17.9 min in group II. The drill bit failed to pass through the interlocking hole in one patient from group II. There was no significant difference in the technical reliability between both groups. Fluoroscopic times to achieve equivalent precision are reduced with fluoroscopy-based surgical navigation compared with fluoroscopic guidance. Fluoroscopy-based surgical navigation is recommended for intraoperative guidance in situations where reduction of exposure to radiation is considered advantageous over the increase of procedure time.

Regional lung perfusion: assessment with partially parallel three-dimensional MR imaging

PURPOSE

To evaluate partially parallel three-dimensional (3D) magnetic resonance (MR) imaging for assessment of regional lung perfusion in healthy volunteers and patients suspected of having lung cancer or metastasis.

MATERIALS AND METHODS

Seven healthy volunteers and 20 patients suspected of having lung cancer or metastasis were examined with 3D gradient-echo MR imaging with partially parallel image acquisitions (fast low-angle shot 3D imaging; repetition time msec/echo time msec, 1.9/0.8; flip angle, 40 degrees; acceleration factor, two; number of reference k-space lines for calibration, 24; field of view, 500 x 440 mm; matrix, 256 x 123; slab thickness, 160 mm; number of partitions, 32; voxel size, 3.6 x 2.0 x 5.0 mm(3); acquisition time, 1.5 seconds) after administration of 0.1 mmol/kg of gadobenate dimeglumine. In volunteers, 3D MR perfusion data sets were assessed for topographic and temporal distribution of regional lung perfusion. Sensitivity, specificity, accuracy, and positive and negative predictive values for perfusion MR imaging for detecting perfusion abnormalities in patients were calculated, with conventional radionuclide perfusion scintigraphy as the standard of reference. Interobserver and intermodality agreement was determined by using kappa statistics.

RESULTS

Topographic analysis of lung perfusion in volunteers revealed a significantly higher signal-to-noise ratio (SNR) of up to 327% in gravity-dependent lung areas. Temporal analysis similarly revealed much shorter lag time to peak enhancement in gravity-dependent lung areas. In patients, perfusion MR imaging achieved high sensitivity (88%-94%), specificity (100%), and accuracy (90%-95%) for detection of perfusion abnormalities. Interobserver agreement (kappa = 0.86) was very good and intermodality agreement (kappa = 0.69-0.83) was good to very good for detection of perfusion defects. A significant difference (P <.0001) in SNR was observed between normally perfused lung (14 +/- 7 [SD]) and perfusion defects (7 +/- 4) in patients.

CONCLUSION

Partially parallel MR imaging with high spatial and temporal resolution allows assessment of regional lung perfusion and has high diagnostic accuracy for detecting perfusion abnormalities.

Assessment of Irradiated Brain Metastases by Means of Arterial Spin-Labeling and Dynamic Susceptibility-Weighted Contrast-Enhanced Perfusion MRI

RATIONALE AND OBJECTIVES

To assess if preradiation and early follow-up measurements of relative regional cerebral blood flow (rrCBF) can predict treatment outcome in patients with cerebral metastases and to evaluate rrCBF changes in tumor and normal tissue after stereotactic radiosurgery using arterial spin-labeling (ASL) and first-pass dynamic susceptibility-weighted contrast-enhanced (DSC) perfusion MRI.

METHODS

In 25 patients with a total of 28 brain metastases, DSC MRI and ASL perfusion MRI using the Q2TIPS sequence were performed with a 1.5-T unit. Measurements were performed prior to and at 6 weeks, 12 weeks, and 24 weeks after stereotactic radiosurgery. Follow-up examinations were completely available in 25 patients for Q2TIPS and 17 patients with 18 metastases for DSC MRI. The rrCBF of the metastases and the normal brain tissue was determined by a region-of-interest analysis. rrCBF values were correlated with the treatment outcome that was classified according to tumor volume changes at 6 months.

RESULTS

The alteration of the rrCBF at the 6-week follow-up was highly predictive for treatment outcome. A decrease of the rrCBF value predicted tumor response correctly in all metastases for Q2TIPS and in 13 of 16 metastases for DSC MRI. The pretherapeutic rrCBF was not able to predict treatment outcome. The rrCBF values in normal brain tissue affected by radiation doses less than 0.5 Gy remained unchanged after therapy.

CONCLUSION

These preliminary results suggest that ASL and DSC MRI techniques determining rrCBF changes in brain metastases after stereotactic radiosurgery allow the prediction of treatment outcome.

Evaluation of Chest Motion and Volumetry During the Breathing Cycle by Dynamic MRI in Healthy Subjects

RATIONALE AND OBJECTIVES

To investigate diaphragm and chest wall motion during the whole breathing cycle using magnetic resonance imaging (MRI) and a volumetric model in correlation with spirometry.

MATERIALS AND METHODS

Breathing cycles of 15 healthy volunteers were examined using a trueFISP sequence (5 slices in 3 planes, 3 images per second). Time-distance curves were calculated and correlated to spirometry. A model for vital capacity (VC), continuous time-dependent vital capacity (tVC), and investigating the influence of horizontal and vertical parameters on tVC was introduced.

RESULTS

Time-distance curves of the breathing cycle using MRI correlated highly significant with spirometry (P < 0.0001). VC calculated by the model was similar to VC measured in spirometry (5.00 L vs. 5.15 L). tVC correlated highly significantly with spirometry (P < 0.0001). Vertical parameters had a more profound influence on tVC change than horizontal parameters.

CONCLUSIONS

Dynamic MRI is a simple noninvasive method to evaluate local chest wall motion and respiratory mechanics. It widens the repertoire of tools for lung examination with a high temporal resolution.

Perfusion CT in patients with advanced bronchial carcinomas: a novel chance for characterization and treatment monitoring?

Advanced bronchial carcinomas by means of perfusion and peak enhancement using dynamic contrast-enhanced multislice CT are characterized. Twenty-four patients with advanced bronchial carcinoma were examined. During breathhold, after injection of a contrast-medium (CM), 25 scans were performed (1 scan/s) at a fixed table position. Density-time curves were evaluated from regions of interest of the whole tumor and high- and low-enhancing tumor areas. Perfusion and peak enhancement were calculated using the maximum-slope method of Miles and compared with size, localization (central or peripheral) and histology. Perfusion of large tumors (> 50 cm3) averaged over both the whole tumor (P = 0.001) and the highest enhancing area (P = 0.003) was significantly lower than that of smaller ones. Independent of size, central carcinomas had a significantly (P = 0.04) lower perfusion (mean 27.9 ml/min/100 g) than peripheral ones (mean 66.5 ml/min/100 g). In contrast, peak enhancement of central and peripheral carcinomas was not significantly different. Between non-small-cell lung cancers and small-cell lung cancers, no significant differences were observed in both parameters. In seven tumors, density increase after CM administration started earlier than in the aorta, indicating considerable blood supply from pulmonary vessels. Tumor perfusion was dependent on tumor size and localization, but not on histology. Furthermore, perfusion CT disclosed blood supply from both pulmonary and/or bronchial vessels in some tumors.

Time-resolved contrast-enhanced three-dimensional pulmonary MR-angiography: 1.0 M gadobutrol vs. 0.5 M gadopentetate dimeglumine

PURPOSE

To compare contrast characteristics and image quality of 1.0 M gadobutrol with 0.5 M Gd-DTPA for time-resolved three-dimensional pulmonary magnetic resonance angiography (MRA).

MATERIALS AND METHODS

Thirty-one patients and five healthy volunteers were examined with a contrast-enhanced time-resolved pulmonary MRA protocol (fast low-angle shot [FLASH] three-dimensional, TR/TE = 2.2/1.0 msec, flip angle: 25 degrees, scan time per three-dimensional data set = 5.6 seconds). Patients were randomized to receive either 0.1 mmol/kg body weight (bw) or 0.2 mmol/kg bw gadobutrol, or 0.2 mmol/kg bw Gd-DTPA. Volunteers were examined three times, twice with 0.2 mmol/kg bw gadobutrol using two different flip angles and once with 0.2 mmol/kg bw Gd-DTPA. All contrast injections were performed at a rate of 5 mL/second. Image analysis included signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) measurements in lung arteries and veins, as well as a subjective analysis of image quality.

RESULTS

In patients, significantly higher SNR and CNR were observed with Gd-DTPA compared to both doses of gadobutrol (SNR: 35-42 vs.17-25; CNR 33-39 vs. 16-23; P < or = 0.05). No relevant differences were observed between 0.1 mmol/kg bw and 0.2 mmol/kg bw gadobutrol. In volunteers, gadobutrol and Gd-DTPA achieved similar SNR and CNR. A significantly higher SNR and CNR was observed for gadobutrol-enhanced MRA with an increased flip angle of 40 degrees. Image quality was rated equal for both contrast agents.

CONCLUSION

No relevant advantages of 1.0 M gadobutrol over 0.5 M Gd-DTPA were observed for time-resolved pulmonary MRA in this study. Potential explanations are T2/T2*-effects caused by the high intravascular concentration when using high injection rates.

Evaluation of therapeutic potential of heavy ion therapy for patients with locally advanced prostate cancer

PURPOSE

To investigate the feasibility of raster scanned heavy charged particle therapy in the treatment of prostate cancer (PCa,) with special regard to the influence of internal organ motion on the dose distribution.

METHODS AND MATERIALS

The CT data of 8 patients with PCa who underwent three-dimensional conformal radiotherapy (RT) were chosen. In addition to the routine treatment planning scan, three to five additional positioning control CT scans were performed. The organs at risk and the target volumes were defined on all CT scans. Primary and boost carbon ion plans were calculated to deliver 66 Gy to the clinical target volume/planning target volume, with an additional 10 Gy to the gross tumor volume (GTV). To estimate the influence of internal organ motion on plan quality, the dose was recalculated on the basis of the control CT scans. The comparative analysis was based on the dose-volume histogram-derived physical parameters.

RESULTS

The average 90% target coverage was 99.1% for the GTV. The maximal dose to the rectum was 71.8 Gy. The average rectal mean dose was 19 Gy. The volume of the rectum receiving 70 and 68 Gy was 0.1 and 0.3 cm3. The average difference in the 90% coverage for the GTV on control CT cubes was 3.6%. The maximal rectal dose increased to 76.2 Gy. The deviation in the mean rectal dose was <1 Gy on average. The rectal volume receiving 70 and 68 Gy increased to 2.5 and 3.3 cm3.

CONCLUSION

The investigation demonstrated the feasibility of raster scanned carbon ions for PCa RT. Excellent coverage of the target volume and optimal sparing of the rectum were acquired. The combination of photon intensity-modulated RT and a carbon ion boost to the GTV is the most rational solution for the gain of clinical experience in heavy ion RT for PCa patients.