Gastrointestinal stromal tumors: relationship between preoperative CT features and pathologic risk stratification

OBJECTIVE

To investigate a relationship between contrast-enhanced computed tomography (CECT) features of gastrointestinal stromal tumors (GISTs) and risk of relapse according to Miettinen stratified risk classifications.

METHODS

After ethical committee approval, a retrospective analysis was conducted on the preoperative CECT of patients with pathologically proven GIST undergoing surgery between June 2009 and December 2019. Chi-square analysis was used to evaluate the correlation between Miettinen stratified risk categories and the following imaging features: tumor size and location, growth pattern, margins, type and degree of contrast enhancement, presence of calcifications, necrosis, signs of ulceration/fistulation, internal hemorrhagic foci, enlarged feeding or draining vessels (EFDV), ascites, peritoneal implants, lymphadenopathy, or metastasis.

RESULTS

A total of 54 patients (mean age 65 ± 11, 29 men) were included in the study with a total of 56 GISTs. Necrosis, ulceration/fistulation, hemorrhage, margins, enlarged vessels, type of contrast enhancement, and metastasis turned out to be associated with Miettinen risk categories (p < 0.005). Logistic regression analysis identified the presence of necrosis and EFDV as predictors of pathologic risk of relapse (overall accuracy of 89.3%).

CONCLUSION

Preoperative CECT may be helpful in predicting pathologic risk categories of GISTs, as determined by the Miettinen classification system.

Atlantoaxial rotatory subluxation/fixation and Grisel's syndrome in children: clinical and radiological prognostic factors

Atlantoaxial rotatory subluxation/fixation (AARS/F) is a rare cause of torticollis in children. The aim of our study is to investigate all possible clinical and radiological prognostic factors in children with AARS/F. We retrospectively reviewed all cervical spine CT scans of children with AARS/F treated in our Hospital over the last 15 years. AARS/F was classified according to Fielding and Hawkins classification and C1-C2 rotation-degree was calculated. Moreover, two orthopedic surgeons reviewed all clinical reports of these children. All patients were conservatively treated (cervical traction/neck collar). An early recovery was considered in patients with complete clinical/radiological healing at 3 months follow-up, while a late recovery was considered in patients with disease persistence or relapse at 3 months follow-up or earlier. Fifty-five patients with diagnosis of AARS/F were included in the study (mean age = 8.5 years old - 25F, 30M). In 9/55 subjects (16.4%), a late recovery was observed. The presence of a concomitant infection or inflammation in the head and neck region (Grisel's syndrome) was significantly associated with a late recovery (p < .001). Also, the type of AARS/F (p = .019), according to the Fielding and Hawkins classification, and C1-C2 rotation-degree (p = .027) were significantly correlated with the recovery time.Conclusion: In patients with AARS/F, the presence of a concomitant infection/inflammation in the head and neck region is the most important prognostic factor and it is associated with a late recovery. The Fielding and Hawkins classification and C1-C2 rotation-degree well correlate with patients' recovery time. What is Known: • Atlantoaxial rotatory subluxation/fixation (AARS/F) is a rare cause of torticollis in children and CT is the most useful imaging tool for diagnosis and classification of AARS/F. • Conservative treatments are effective in the majority of pediatric patients with AARS/F. What is New: • The presence of a concomitant infection/inflammation in the head and neck region associated with AARS/F (Grisel's syndrome) is the most important prognostic factor and it is associated with a late recovery. • C1-C2 rotation-degrees, as well as Fielding and Hawkins classification system, well correlate with patients' recovery time.

Clostridium difficile colitis: CT findings and differential diagnosis

Clostridium difficile infection (CDI) is a severe and potentially deadly infectious colitis whose incidence is dramatically increasing in the last decades, with more virulent strains. CDI should be suspected in case of unexplained diarrhea and abdominal pain in patients with a recent history of antibiotic use and healthcare exposures; diagnosis is based on a combination of clinical and laboratory findings with demonstration of C. difficile toxins by stool test. The advantages of contrast-enhanced computed tomography (CECT) are the noninvasiveness and the ability to evaluate both the colonic wall and the adjacent soft tissues. Considerable overlap exists between the CECT findings of CDI and those of colitis of other origins, such as typhlitis, ischemic colitis, graft-versus-host disease, radiation colitis and inflammatory bowel diseases; however, some features may help distinguish between these conditions. This paper provides a comprehensive overview of the imaging features of Clostridium difficile colitis and its mimics, with a view to assist the radiologist in reaching the correct diagnosis.

Stereotactic radiotherapy of pancreatic cancer: a systematic review on pain relief

Locally advanced pancreatic carcinoma (LAPC) has a poor prognosis and the purpose of treatment is survival prolongation and symptom palliation. Radiotherapy has been reported to reduce pain in LAPC. Stereotactic RT (SBRT) is considered as an emerging radiotherapy technique able to achieve high local control rates with acceptable toxicity. However, its role in pain palliation is not clear. To review the impact on pain relief with SBRT in LAPC patients, a literature search was performed on PubMed, Scopus, and Embase (January 2000-December 2017) for prospective and retrospective articles published in English. Fourteen studies (479 patients) reporting the effect of SBRT on pain relief were finally included in this analysis. SBRT was delivered with both standard and/or robotic linear accelerators. The median prescribed SBRT doses ranged from 16.5 to 45 Gy (median: 27.8 Gy), and the number of fractions ranged from 1 to 6 (median: 3.5). Twelve of the 14 studies reported the percentage of pain relief (in patients with pain at presentation) with a global overall response rate (complete and partial response) of 84.9% (95% CI, 75.8%-91.5%), with high heterogeneity (Q ² test: P<0.001; I2=83.63%). All studies reported toxicity data. Acute and late toxicity (grade ≥3) rates were 3.3%-18.0% and 6.0%-8.2%, respectively. Reported gastrointestinal side effects were duodenal obstruction/ulcer, small bowel obstruction, duodenal bleeding, hemorrhage, and gastric perforation. SBRT achieves pain relief in most patients with pancreatic cancer with an acceptable gastrointestinal toxicity rate. Further prospective studies are needed to define optimal dose/fractionation and the best systemic therapies modality integration to reduce toxicity and improve the palliative outcome. Finally, the quality of life and, particularly, pain control should be considered as an endpoint in all future trials on this emerging treatment technique.

Definitive Radiotherapy in Invasive Vaginal Carcinoma: A Systematic Review

AIM

This study systematically reviews the recent literature on the role of definitive radiotherapy (RT) in the management of vaginal cancer (VC) and presents comprehensive data on clinical outcomes and toxicity.

METHODS

The authors performed a literature search using PubMed (2007-2016) to identify all prospective and retrospective studies that have been published on RT in invasive VC.

RESULTS

Of the 199 identified studies, 13 met the inclusion criteria. All studies had a retrospective design. Overall, 793 patients (median, 45; range, 26-138) were included. A high heterogeneity was found across studies in terms of RT techniques, assessment criteria, and reported outcomes. The majority of the patients were treated with a combination of external beam RT and brachytherapy (74.2%). Acute and late grade ≥3 toxicity rates ranged from 0.0% to 24.4% (median, 8.7%) and from 0.0% to 22.5% (median, 12.8%), respectively. The 5-year local control rates ranged between 39% and 79%. The 5-year overall survival ranged between 34% and 71.0% (median, 63.5%). Early stage of the disease (International Federation of Gynecology and Obstetrics stages I-II vs. III-IV), small tumor size (<4 cm), previous hysterectomy, high pretreatment/treatment hemoglobin levels (≥12/12.5 mg/dL), and patients' age <70 or <64 years were correlated with better clinical outcomes.

CONCLUSION

Only retrospective studies, in a limited number, have been published on RT in VC in the past decade, with significant heterogeneity in terms of treatment characteristic and evaluation criteria. Clinical results were strongly influenced by tumor stage. Prospective randomized studies are needed to improve patients' outcomes, especially in advanced-stage disease.

IMPLICATIONS FOR PRACTICE

This study systematically reviews the recent literature on the role of definitive radiotherapy in the management of vaginal cancer and presents comprehensive data on clinical outcome and toxicity. The prognosis of patients is dismal, with a 5-year overall survival of approximately 50%. Early stage of the disease, small tumor size, previous hysterectomy, high pretreatment/treatment hemoglobin levels, and patients' age were correlated with a better clinical outcome. A brachytherapy boost should be delivered, especially in patients with higher-stage disease. The addition of concurrent weekly cisplatin should be considered in most patients, and transfusion should be used to maintain high hemoglobin levels.

Postoperative Hypofractionated Radiation Therapy in Prostate Carcinoma: A Systematic Review

BACKGROUND/AIM

A systematic review on toxicity, local control (LC), overall survival (OS), and biochemical relapse-free survival (bRFS) after postoperative hypofractionated radiotherapy (HFRT) on prostate cancer (PCa) was performed.

MATERIALS AND METHODS

Based on the PRISMA methodology, studies reporting clinical results after adjuvant or salvage HFRT were included.

RESULTS

A total of 1,208 patients from 17 eligible studies were included. Median follow-up was 30 months. No case of severe acute gastrointestinal (GI) toxicity was recorded. Grade ≥3 acute genitourinary (GU) toxicity ranged between 0% and 3%. Different rates of grade ≥2 late GI (range=0-8.7%) and GU (range=0-66%) toxicity were recorded. Encouraging results on LC, OS, and bRFS were reported.

CONCLUSION

Acute toxicity does not seem to be increased in patients receiving postoperative HFRT, but the results of late-GU toxicity are conflicting. Further prospective studies are needed before including postoperative HFRT in clinical practice.

Quantitative imaging techniques for the assessment of osteoporosis and sarcopenia

Bone and muscle are two deeply interconnected organs and a strong relationship between them exists in their development and maintenance. The peak of both bone and muscle mass is achieved in early adulthood, followed by a progressive decline after the age of 40. The increase in life expectancy in developed countries resulted in an increase of degenerative diseases affecting the musculoskeletal system. Osteoporosis and sarcopenia represent a major cause of morbidity and mortality in the elderly population and are associated with a significant increase in healthcare costs. Several imaging techniques are currently available for the non-invasive investigation of bone and muscle mass and quality. Conventional radiology, dual energy X-ray absorptiometry (DXA), computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound often play a complementary role in the study of osteoporosis and sarcopenia, depicting different aspects of the same pathology. This paper presents the different imaging modalities currently used for the investigation of bone and muscle mass and quality in osteoporosis and sarcopenia with special emphasis on the clinical applications and limitations of each technique and with the intent to provide interesting insights into recent advances in the field of conventional imaging, novel high-resolution techniques and fracture risk.

Imaging of diabetic bone

Diabetes is an important concern in terms of medical and socioeconomic costs; a high risk for low-trauma fractures has been reported in patients with both type 1 and type 2 diabetes. The mechanism involved in the increased fracture risk from diabetes is highly complex and still not entirely understood; obesity could play an important role: recent evidence suggests that the influence of fat on bone is mainly dependent on the pattern of regional fat deposition and that an increased amount of visceral adipose tissue negatively affects skeletal health.Correct and timely individuation of people with high fracture risk is critical for both prevention and treatment: Dual-energy X-ray Absorptiometry (currently the "gold standard" for diagnosis of osteoporosis) underestimates fracture risk in diabetic patients and therefore is not sufficient by itself to investigate bone status. This paper is focused on imaging, covering different modalities involved in the evaluation of skeletal deterioration in diabetes, discussing the limitations of conventional methods and exploring the potential of new tools and recent high-resolution techniques, with the intent to provide interesting insight into pathophysiology and fracture risk.

Hypofractionated Postoperative IMRT in Prostate Carcinoma: A Phase I/II Study

AIM

To report the outcome of hypofractionated radiotherapy after radical prostatectomy (RP) for prostate cancer (PCa) using simultaneous integrated boost-intensity modulated radiation therapy (SIB-IMRT).

PATIENTS AND METHODS

A total of 124 patients with PCa at high risk of relapse after RP or diagnosis of biochemical relapse were included. Patients received 62.5 Gy to the prostate bed and 45 Gy to pelvic nodes in 25 fractions. Androgen-suppressive therapy was prescribed based on National Comprehensive Cancer Network risk categories.

RESULTS

Median follow-up was 30 months. Only two patients (1.6%) developed grade 3 or more acute toxicity: one grade 3 skin toxicity (0.8%) and one grade 4 genitourinary toxicity (0.8%). Grade 2 acute gastrointestinal and genitourinary toxicity was recorded in 24.2% and 17.7% of patients, respectively. Five-year grade 2 or more gastrointestinal and genitourinary toxicity was 1.1% and 7.3%, respectively. Five-year biochemical relapse-free survival was 86.5%.

CONCLUSION

After RP, hypofractionated IMRT-SIB demonstrated a favorable toxicity profile and encouraging results in terms of relapse-free survival.

Electrical Characterization of Ion Imiplanted, Thermally Annealed TiN Films Acting as Diffusion Barriers on Shallow Junction Silicon Devices

TiN films prepared by implantation onto evaporated Ti layers are tested as diffusion barriers in contact with a thick Al overlayer. Both the TiN/Al and TiSi2/TiN/Al contact structures are evaluated, after thermal treatments up to 600 C, on shallow junction diodes and four terminal resistor test patterns for contact resistance measurements. It is shown that, upon annealing at 600 C, the TiSi2/TiN/Al contact system still exhibits excellent electrical performances. The degradation is found to depend on TiSi2 thickness and contact area.

Relationship between anal canal diameter and pressure evaluated simultaneously by endosonography and manometry in normal human subjects

The study investigated the relationship between anal canal size and anal canal pressure measured simultaneously by anal endosonography and an electronic pressure probe. Twelve normal subjects were studied. Anal endosonography was performed using a 7.5-Mhz rotating transducer of 2-5 cm focal length covered with a sylastic balloon filled with degassed water (25 ml). During anal endosonography an electronic manometric probe was passed along the side of the probe and positioned in the anal canal. The ultrasonic image was frozen when maximal anal pressure was seen at basal, squeeze, and minimal pressure during straining. An image was also obtained at maximal anal relaxation after rectal distension with a balloon filled with 150 ml air. The results showed that anal canal pressure was significantly and linearly correlated with anal canal diameter (P < 0.001).

Valutazione combinata ecourodinamica clinica e neurofisiologica per la predizione di efficacia riabilitativa in soggetti con incontinenza urinaria: Echourodynamic and neurophysiological screening in patients with urinary incontinence for the evaluation of rehabilitative prognosis

The rationale for the present work was to evaluate both neurophysiological and urological parameters and to predict the outcome of rehabilitative therapy. In this study 300 patients with various urological and neurological problems, all presenting altered micturition, were evaluated. In all patients a complete neurophysiological screening was carried out. A parallel urological screening was performed that included morphological and dynamic sonography and urodynamic tests. All the patients underwent rehabilitative therapy. In 91% of the treated patients we have obtained a satisfactory functionality. As expected the patients with stress incontinence, sensitivity urgency sindrome and neurophysiological alterations had less functional recovery. Our results show that combination of neurophysiological screening with traditional urological tests, represents a suitable tool to predict the prognosis in case of micturition disturbances.

On newborn cuddliness

We discuss the methodological implications of research into the newborn's response to cuddling, that is cuddliness, an item on the Brazelton NBAS scale. After analyzing its dimension as an interaction cycle, we describe an investigation into cuddliness in 52 newborns aged 0 to 3 hours before they had been fed or presented to their mothers. We report on the behavioral changes that proved to be most significant both for postural sequence and for involvement of the partner. These data are correlated with the variations in level of alertness observed during the maneuvers and characterizing the course of the interaction, which started in the quiet awake state (level 3-4) and ended with the transition either to sleepiness or to tension.

[Studies of the expectancy wave (CNV) in patients with interruption of the thalamo-prefrontal interconnnection pathways caused by psychosurgical prefrontal lobotomy operations]

Frontal and vertex CNVs were studied in 8 selected nonschizophrenic patients subjected to unilateral or bilateral extensive prefrontal lobotomy. The dorsomedial thalamo-frontal pathways had been severed and their regeneration must be considered impossible. Standard CNV task (S1-S2-R) was followed in order to elicit CNVs from the frontal areas anterior to the line of sections and at Cz. In 7 out of 8 patients it was quite easy to evoke CNV with almost normal features and equal latencies in each case from all the cortical areas explored. These results show that CNV formation is not grossly altered in the prefrontal areas which have been irreversibly deprived of normal bi-directional mediothalamic-frontocortical connnections. This suggests that the role of the dorsomedial thalamo-frontal pathways are not essential in the genesis of the frontal CNV in humans. These findings would suggest that the CNV is a diffuse electrical event essentially related to a unitary cerebral process mediated fundamentally by nonspecific ascending meso-diencephalic reticular systems. The differences in morphology and polarity of the CNVs detectable in various brain structures are presumably related to their intrinsic anatomo-functional characteristics and to the method commonly utilized in recording the CNV.

[Event-related slow potentials (ERSPs) of the brain in cases of temporal psychomotor and petit mal status]

Two cases have been studied by means of the usual method for eliciting CNV (S-1.5 OR 1 SEC-S-operant response) during and after the end of an episode of prolonged epileptic twilight state with almost continuous strictly unilateral temporal lobe discharge. From the clinical viewpoint in both cases the twilight state, lasting respectively about 12 and 48 hours, was characterized by a slightly clouded consciousness and moderate impairment of awareness and of psychic performances, at times associated with simple and complex psychomotor automatism and hallucinations. The EEG recorded an almost continous left temporal discharge of pseudorhythmic mixed slow waves and sharps. The third case had typical prolonged petit mal states with continuous spike-and-slow-wave activity, impaired intellectual and motor performances (very long reaction time etc.). In this patient for eliciting ERSPs, besides the standard method, we have used a paradigm in which S consisted of a colored slide, with various semantic contents, remaining visible for 5 seconds on a screen. At the trials of the standard paradigm during the epiliptic twilight state, all patients showed they had understood the signal to interrupt (S loud repetitive tone) in the shortest time possible and could clearly distinguish them from the S. The operant response was almost always made with sufficient precision and sometimes with fairly short reaction time, especially by the patients with temporal psychomotor status. During the episodes of prolonged clouded consciosness in all series of trials administered to the patients, no negative slow potential shifts were observed in the averaged EEG recordings obtained from F-T, F-T or F, FCZ and referred to to linked mastoids. On repetition of the examinations some time after the end of the epileptic twilight state, fairly normal ERSPs were obtained in all cases. Taking also into account the results of previous researches, these studies show that the temporal lobe and "centrencephalic" epileptic discharges, under certain conditions, may influence negatively the neurophysiological mechanisms which contribute to the information of complex contingent connections and which also underly the particular attentional, cognitive and sensorimotor functions involved in the inhibiting the appearance of ERSPs probably related to more specific perceptual and integrative functions. Some AA. maintain that negative slow potential shifts express the functional activity of the brain structures, particularly of determined cerebral cortex regions, involved not only in attentional, perceptual, cognitive and psychomotor functioning, but also in information processing (memory recording mechanism). Hence, the negative influence of prolonged temporal lobe or meso-diencephalic epileptic discharges on these structures may explain the almost complete amnesia that patients generally show at the termination of this kind of twilight state.