Radiomics for residual tumour detection and prognosis in newly diagnosed glioblastoma based on postoperative [11C] methionine PET and T1c-w MRI

Personalized treatment strategies based on non-invasive biomarkers have potential to improve patient management in patients with newly diagnosed glioblastoma (GBM). The residual tumour burden after surgery in GBM patients is a prognostic imaging biomarker. However, in clinical patient management, its assessment is a manual and time-consuming process that is at risk of inter-rater variability. Furthermore, the prediction of patient outcome prior to radiotherapy may identify patient subgroups that could benefit from escalated radiotherapy doses. Therefore, in this study, we investigate the capabilities of traditional radiomics and 3D convolutional neural networks for automatic detection of the residual tumour status and to prognosticate time-to-recurrence (TTR) and overall survival (OS) in GBM using postoperative [11C] methionine positron emission tomography (MET-PET) and gadolinium-enhanced T1-w magnetic resonance imaging (MRI). On the independent test data, the 3D-DenseNet model based on MET-PET achieved the best performance for residual tumour detection, while the logistic regression model with conventional radiomics features performed best for T1c-w MRI (AUC: MET-PET 0.95, T1c-w MRI 0.78). For the prognosis of TTR and OS, the 3D-DenseNet model based on MET-PET integrated with age and MGMT status achieved the best performance (Concordance-Index: TTR 0.68, OS 0.65). In conclusion, we showed that both deep-learning and conventional radiomics have potential value for supporting image-based assessment and prognosis in GBM. After prospective validation, these models may be considered for treatment personalization.

Dynamic contrast-enhanced magnetic resonance imaging assessment of residual tumor angiogenesis after insufficient microwave ablation and donafenib adjuvant therapy

To analyze the correlation between dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) permeability parameters and serum vascular endothelial growth factor (VEGF) levels in a rabbit VX2 liver cancer model with insufficient microwave ablation (MWA), to observe the dynamic changes in residual tumor angiogenesis in the short term after MWA, and to assess the effectiveness of donafenib as adjuvant therapy. Forty rabbits with VX2 liver tumors were randomly divided into three groups: an insufficient MWA group (n = 15), a combined treatment group (n = 15) and a control group (n = 10). The dynamic changes in VEGF expression after MWA and the effectiveness of donafenib as adjuvant therapy were evaluated by DCE-MRI and serum VEGF levels before surgery and 1, 3, 7, and 14 days after surgery. The correlation between the volume translate constant (Ktrans) of DCE-MRI parameters and serum VEGF levels fluctuated after ablation, but the coefficient was always positive (all p < 0.001). Repeated-measures ANOVA revealed significant changes in the serum VEGF concentration (F = 40.905, p < 0.001; partial η2 = 0.689), Ktrans (F = 13.388, p < 0.001; partial η2 = 0.420), and tumor diameter in each group (F = 34.065, p < 0.001; partial η2 = 0.648) at all five time points. Pairwise comparisons showed that the serum VEGF level, Ktrans value and tumor diameter in the insufficient MWA group and combined treatment group were significantly lower at 1 d than in the control group, but these values gradually increased over time (all p < 0.05). Ktrans and tumor diameter were significantly greater in the insufficient MWA group than in the control group at 14 days (all p < 0.05). The serum VEGF concentration, Ktrans, and tumor diameter were significantly lower in the combined treatment group than in the other two groups at 3, 7, and 14 days (all p < 0.05). Ktrans is positively correlated with the serum VEGF concentration. Ktrans and the serum VEGF concentration changed significantly after treatment with insufficient ablation or in combination with donafenib, and Ktrans may change faster. Insufficient MWA promotes the progression of residual tumors. Adjuvant treatment with donafenib is effective.

Deep Learning-Based Segmentation of Locally Advanced Breast Cancer on MRI in Relation to Residual Cancer Burden: A Multi-Institutional Cohort Study

BACKGROUND

While several methods have been proposed for automated assessment of breast-cancer response to neoadjuvant chemotherapy on breast MRI, limited information is available about their performance across multiple institutions.

PURPOSE

To assess the value and robustness of deep learning-derived volumes of locally advanced breast cancer (LABC) on MRI to infer the presence of residual disease after neoadjuvant chemotherapy.

STUDY TYPE

Retrospective.

SUBJECTS

Training cohort: 102 consecutive female patients with LABC scheduled for neoadjuvant chemotherapy (NAC) from a single institution (age: 25-73 years). Independent testing cohort: 55 consecutive female patients with LABC from four institutions (age: 25-72 years).

FIELD STRENGTH/SEQUENCE

Training cohort: single vendor 1.5 T or 3.0 T. Testing cohort: multivendor 3.0 T. Gradient echo dynamic contrast-enhanced sequences.

ASSESSMENT

A convolutional neural network (nnU-Net) was trained to segment LABC. Based on resulting tumor volumes, an extremely randomized tree model was trained to assess residual cancer burden (RCB)-0/I vs. RCB-II/III. An independent model was developed using functional tumor volume (FTV). Models were tested on an independent testing cohort and response assessment performance and robustness across multiple institutions were assessed.

STATISTICAL TESTS

The receiver operating characteristic (ROC) was used to calculate the area under the ROC curve (AUC). DeLong's method was used to compare AUCs. Correlations were calculated using Pearson's method. P values <0.05 were considered significant.

RESULTS

Automated segmentation resulted in a median (interquartile range [IQR]) Dice score of 0.87 (0.62-0.93), with similar volumetric measurements (R = 0.95, P < 0.05). Automated volumetric measurements were significantly correlated with FTV (R = 0.80). Tumor volume-derived from deep learning of DCE-MRI was associated with RCB, yielding an AUC of 0.76 to discriminate between RCB-0/I and RCB-II/III, performing similar to the FTV-based model (AUC = 0.77, P = 0.66). Performance was comparable across institutions (IQR AUC: 0.71-0.84).

DATA CONCLUSION

Deep learning-based segmentation estimates changes in tumor load on DCE-MRI that are associated with RCB after NAC and is robust against variations between institutions.

EVIDENCE LEVEL

2.

TECHNICAL EFFICACY

Stage 4.

How to evaluate extent of resection in diffuse gliomas: from standards to new methods

PURPOSE OF REVIEW

Maximal safe tumor resection represents the current standard of care for patients with newly diagnosed diffuse gliomas. Recent efforts have highlighted the prognostic value of extent of resection measured as residual tumor volume in patients with isocitrate dehydrogenase (IDH)-wildtype and -mutant gliomas. Accurate assessment of such information therefore appears essential in the context of clinical trials as well as patient management.

RECENT FINDINGS

Current recommendations for evaluation of extent of resection rest upon standardized postoperative MRI including contrast-enhanced T1-weighted sequences, T2-weighted/fluid-attenuated-inversion-recovery sequences, and diffusion-weighted imaging to differentiate postoperative tumor volumes from ischemia and nonspecific imaging findings. In this context, correct timing of postoperative imaging within the postoperative period is of utmost importance. Advanced MRI techniques including perfusion-weighted MRI and MR-spectroscopy may add further insight when evaluating residual tumor remnants. Positron emission tomography (PET) using amino acid tracers proves beneficial in identifying metabolically active tumor beyond anatomical findings on conventional MRI.

SUMMARY

Future efforts will have to refine recommendations on postoperative assessment of residual tumor burden in respect to differences between IDH-wildtype and -mutant gliomas, and incorporate the emerging role of advanced imaging modalities like amino acid PET.

Detecting residual soft tissue sarcoma after unplanned excision; model-free analysis of dynamic contrast-enhanced MRI at short-term follow-up

OBJECTIVES

To evaluate diagnostic utility of additional DCE-MRI for detecting residual soft tissue sarcomas (STS) after unplanned excision (UPE).

METHODS

We retrospectively evaluated 32 patients with UPE of STS, followed by conventional MRI with DCE-MRI and wide excision (WE), between November 2019 and January 2022. Residual tumors on conventional MRI were categorized into three groups: Lesion-type-0, no abnormal enhancement, Lesion-type-1, an indeterminate lesion, and Lesion-type-2, a definite enhancing nodule. On DCE-MRI, ROIs were manually placed on enhancing areas of suspected residual tumor. The mean and 95th percentile values of AUC of time-intensity curve were calculated at 60, 90, and 120 s of Enhancement-cycle-1 and -2. Optimal DCE parameters were identified by ROC analysis. Diagnostic performance of conventional MRI and DCE-MRI was compared using McNemar's test.

RESULTS

On WE, residual tumor was present in 23 (71.9%) of 32 patients. On MRI, Lesion-type-1 was found in 16/32 (50%) patients and Lesion-type-2 in 16/32 (50%). The optimal DCE parameter was the 95th percentile value of AUC at 120s of Enhancement-cycle-2. The sensitivity, specificity, and AUC were as follows: 65.2% (95% CI, 45.8-85.7%), 88.9% (CI, 68.4-100%), and 0.77 (CI, 0.62-0.92) for conventional MRI, and 100%, 55.6% (CI, 23.1-88.0%), and 0.78 (CI, 0.61-0.95) for combined conventional and DCE-MRI.

CONCLUSIONS

Additional DCE-MRI aided in detecting residual STS after UPE, particularly in cases without definite soft tissue nodular enhancement.

ADVANCES IN KNOWLEDGE

Close follow up may be suggested for patients showing abnormality in DCE-MRI, with more suspicion of residual tumor.

Segmentation of glioblastomas in early post-operative multi-modal MRI with deep neural networks

Extent of resection after surgery is one of the main prognostic factors for patients diagnosed with glioblastoma. To achieve this, accurate segmentation and classification of residual tumor from post-operative MR images is essential. The current standard method for estimating it is subject to high inter- and intra-rater variability, and an automated method for segmentation of residual tumor in early post-operative MRI could lead to a more accurate estimation of extent of resection. In this study, two state-of-the-art neural network architectures for pre-operative segmentation were trained for the task. The models were extensively validated on a multicenter dataset with nearly 1000 patients, from 12 hospitals in Europe and the United States. The best performance achieved was a 61% Dice score, and the best classification performance was about 80% balanced accuracy, with a demonstrated ability to generalize across hospitals. In addition, the segmentation performance of the best models was on par with human expert raters. The predicted segmentations can be used to accurately classify the patients into those with residual tumor, and those with gross total resection.

Performance of baseline FDG-PET/CT radiomics for prediction of bone marrow minimal residual disease status in the LyMa-101 trial

The prognostic value of 18F-Fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) at baseline or the predictive value of minimal residual disease (MRD) detection appear as potential tools to improve mantle cell lymphoma (MCL) patients' management. The LyMa-101, a phase 2 trial of the LYSA group (ClinicalTrials.gov:NCT02896582) reported induction therapy with obinutuzumab, a CD20 monoclonal antibody. Herein, we investigated the added prognostic value of radiomic features (RF) derived from FDG-PET/CT at diagnosis for MRD value prediction. FDG-PET/CT of 59 MCL patients included in the LyMa-101 trial have been independently, blindly and centrally reviewed. RF were extracted from the disease area with the highest uptake and from the total metabolic tumor volume (TMTV). Two models of machine learning were used to compare several combinations for prediction of MRD before autologous stem cell transplant consolidation (ASCT). Each algorithm was generated with or without constrained feature selections for clinical and laboratory parameters. Both algorithms showed better discrimination performances for negative vs positive MRD in the lesion with the highest uptake than in the TMTV. The constrained use of clinical and biological features showed a clear loss in sensitivity for the prediction of MRD status before ASCT, regardless of the machine learning model. These data plead for the importance of FDG-PET/CT RF compared to clinical and laboratory parameters and also reinforced the previously made hypothesis that the prognosis of the disease in MCL patients is linked to the most aggressive contingent, within the lesion with the highest uptake.

Accuracy of Preoperative Contrast-enhanced Cone Beam Breast CT in Assessment of Residual Tumor after Neoadjuvant Chemotherapy: A Comparative Study with Breast MRI

RATIONALE AND OBJECTIVES

To compare the accuracy of preoperative contrast-enhanced cone beam breast CT (CE-CBBCT) and MRI in assessment of residual tumor after neoadjuvant chemotherapy (NAC).

MATERIALS AND METHODS

Residual tumor assessments in 91 female patients were performed on preoperative CE-CBBCT and MRI images after NAC. The agreements of tumor size between imaging and pathology were tested by Intraclass Correlation Coefficient (ICC). Subgroup analyses were set according to ductal carcinoma in situ (DCIS), calcifications and molecular subtypes. Correlated-samples Wilcoxon Signed-rank test was used to analyze the difference between imaging and pathology in total and subgroups. AUC, sensitivity, specificity, PPV, and NPV were calculated to compare the performance of CE-CBBCT and MRI in predicting pathological complete response (pCR).

RESULTS

Comparing with pathology, the agreement on CE-CBBCT was good (ICC = 0.64, 95% CI, 0.35-0.78), whereas on MRI was moderate (ICC = 0.59, 95% CI, 0.36-0.77), and overestimation on CE-CBBCT was less than that on MRI (median (interquartile range, IQR): 0.24 [0.00, 1.31] cm vs. 0.67 [0.00, 1.81] cm; p = 0.000). In subgroup analysis, CE-CBBCT showed superior accuracy than MRI when residual DCIS (p = 0.000) and calcifications (p = 0.000) contained, as well as luminal A (p = 0.043) and luminal B (p = 0.009) breast cancer. CE-CBBCT and MRI performed comparable in predicting pCR, AUCs were 0.749 and 0.733 respectively (p > 0.05).

CONCLUSION

CE-CBBCT showed superior accuracy in assessment of residual tumor compared with MRI, especially when residual DCIS or calcifications contained and luminal subtype. The performance of preoperative CE-CBBCT in predicting pCR was comparable to MRI. CE-CBBCT could be an alternative method used for preoperative assessment after NAC.

Quantitative analysis with multiphase contrast-enhanced computed tomography to evaluate residual tumor activity of hepatocellular carcinoma after DEB-TACE

Most hepatocellular carcinomas (HCC) treated by transcatheter arterial chemoembolization with drug-eluting beads (DEB-TACE) are characterized by coagulation necrosis; therefore, it is often difficult to distinguish enhancement in the arterial phase that would lead to false negative evaluation. This study aimed to evaluate the specificity and sensitivity of the difference value of multiphase contrast-enhanced computed tomography (CECT) in predicting residual tumor activity in HCC lesions after DEB-TACE. This retrospective diagnostic study analyzed CECT images of 73 HCC lesions in 57 patients 20 to 40 days (average 28 days) after DEB-TACE treatment at our Hospital from January to December 2019. Postoperative pathology or digital subtraction angiography images were used as references. Residual tumor activity after the first intervention was determined based on the presence of tumor staining in digital subtraction angiography or the postoperative pathological discovery of HCC tumor cells. A significant difference was observed between the active and inactive residual groups in ∆ HU difference between CT values of arterial phase and non-contrast scans (AN, P = .000), difference between CT values of venous phase and non-contrast scans (VN, P = .000), difference between CT values of delay phase and non-contrast scans (DN, P = .000), (difference between CT values of venous and arterial phase scans, P = .001), and (difference between CT values of delay and arterial phase scans, P = .005). No statistically significant difference was observed between the delayed and venous phases (difference between CT values of delay and venous phase scans, P = .361). The area under the curve (AUC) of the ROC curve showed that the diagnostic efficacies in difference in CT value of AN (AUC = 0.976), VN (AUC = 0.927), and DN (AUC = 0.924) were higher, and their cutoff values were 4.86, 12.065, 20.19 HU with their sensitivities of 93.3%, 84.4%, 77.8% and specificities of 100%, 96.4%, and 100%, respectively. difference in CT value values of AN, VN, DN, difference between CT values of venous and arterial phase scans and difference between CT values of delay and arterial phase scans can sensitively detect residual tumor activity 20-40 days after DEB-TACE. Thus, more sensitive active residual foci were detected using all 3 enhanced phases rather than only the arterial phase. Quantitative analysis of multiphase CECT can detect residual tumor activity in an early and noninvasive manner, which can provide time for patients to receive early follow-up treatment.

Role of MRI in predicting response to neo-adjuvant systemic therapy (NAST) in breast cancer

BACKGROUND AND OBJECTIVES

MRI is generally performed to assess response to Neo-adjuvant systemic therapy (NAST) in breast cancer.

OBJECTIVE

To assess role of MRI in determining the probability of having residual disease in patients undergoing NAST. We also evaluated synchronous cancers diagnosed following MRI.

METHODS

This is a retrospective study which included all patients who had pre-and post-NAST MRI between June 2014 and December 2019. Data on demographics, tumour characteristics and pathology were collected and analysed. Pre- and post-MRI probability were calculated and depicted on nomograms.

RESULTS

The study included 205 patients. Overall pre-MRI probability of having residual disease was 55% (OR:1.2). The post-MRI probability was 78% (95% CI 72-83%; OR:3.5) if MRI showed residual disease and 23% (95% CI 16-31%, OR:0.3) if imaging showed complete response. The absolute benefit was higher in TNBC and HR-HER2. Additional cancers were identified in 8.78% of patients.

CONCLUSION

MRI is beneficial in evaluating response to NAST specifically in TNBC and HR-HER2 cancers. Pre- and post-MRI probabilities of residual disease depicted on nomograms are a useful tool for clinicians. MRI can potentially impact the treatment decisions by identification of synchronous cancers.

Assessing Rectal Cancer Treatment Response Using Coregistered Endorectal Photoacoustic and US Imaging Paired with Deep Learning

Background Conventional radiologic modalities perform poorly in the radiated rectum and are often unable to differentiate residual cancer from treatment scarring. Purpose To report the development and initial patient study of an imaging system comprising an endorectal coregistered photoacoustic (PA) microscopy (PAM) and US system paired with a convolution neural network (CNN) to assess the rectal cancer treatment response. Materials and Methods In this prospective study (ClinicalTrials.gov identifier NCT04339374), participants completed radiation and chemotherapy from September 2019 to September 2020 and images were obtained with the PAM/US system prior to surgery. Another group's colorectal specimens were studied ex vivo. The PAM/US system consisted of an endorectal imaging probe, a 1064-nm laser, and one US ring transducer. The PAM CNN and US CNN models were trained and validated to distinguish normal from malignant colorectal tissue using ex vivo and in vivo patient data. The PAM CNN and US CNN were then tested using additional in vivo patient data that had not been seen by the CNNs during training and validation. Results Twenty-two patients' ex vivo specimens and five patients' in vivo images (a total of 2693 US regions of interest [ROIs] and 2208 PA ROIs) were used for CNN training and validation. Data from five additional patients were used for testing. A total of 32 participants (mean age, 60 years; range, 35-89 years) were evaluated. Unique PAM imaging markers of the complete tumor response were found, specifically including recovery of normal submucosal vascular architecture within the treated tumor bed. The PAM CNN model captured this recovery process and correctly differentiated these changes from the residual tumor. The imaging system remained highly capable of differentiating tumor from normal tissue, achieving an area under the receiver operating characteristic curve of 0.98 (95% CI: 0.98, 0.99) for data from five participants. By comparison, the US CNN had an area under the receiver operating characteristic curve of 0.71 (95% CI: 0.70, 0.73). Conclusion An endorectal coregistered photoacoustic microscopy/US system paired with a convolutional neural network model showed high diagnostic performance in assessing the rectal cancer treatment response and demonstrated potential for optimizing posttreatment management. © RSNA, 2021 Supplemental material is available for this article. See also the editorial by Klibanov in this issue.

Clinical Utility of Radiologic Disease Reassessment in the Management of Pediatric B-Cell Non-Hodgkin Lymphoma

Although outcomes for children with B-cell non-Hodgkin lymphoma are excellent, between 20% and 40% demonstrate residual radiologic abnormalities at disease assessment during consolidation therapy, the significance of which remains uncertain. The authors report the outcomes for all children treated for B-cell non-Hodgkin lymphoma at our center over an 11-year period. Twenty-four of 64 (38%) children had residual radiologic abnormalities at disease remission assessment. Seven (29%) underwent histologic biopsies that were normal. No children with residual radiologic abnormalities experienced disease relapse or death, suggesting that imaging at this time point creates clinical uncertainty without indicating residual disease or predicting relapse.

Balanced Steady-State Free Precession Techniques Improve Detection of Residual Germ Cell Tumor for Treatment Planning

BACKGROUND AND PURPOSE

Identification of a partial/complete chemotherapy response in pediatric patients with intracranial germ cell tumors is clinically important for radiation treatment and management. Partial/complete response is conventionally determined on postcontrast MR imaging sequences. The purpose of this study was to assess the diagnostic utility of a balanced steady-state free precession sequence as an adjunct to standard MR imaging sequences for the detection of residual tumor in pediatric patients on postchemoreduction pre-radiation planning MR imaging.

MATERIALS AND METHODS

This was a retrospective study of pediatric patients with intracranial germ cell tumors undergoing postchemotherapy, preradiotherapy MR imaging. Patients underwent 1.5T or 3T MR imaging with pre- and postcontrast T1WIs, T2WIs, and a balanced steady-state free precession sequence. Two neuroradiologists independently reviewed standard MR imaging sequences without the balanced steady-state free precession sequence, then with the balanced steady-state free precession sequence 1 week later. Assessment for partial/complete response was determined using Response Assessment in Neuro-Oncology criteria. A 5-point Likert scale scored the diagnostic confidence of the neuroradiologist rating each study without/with the balanced steady-state free precession sequence. Rates of residual disease concordance and diagnostic confidence levels without/with the balanced steady-state free precession sequence were calculated.

RESULTS

Thirty-nine patients were included with 31 males and 8 females (mean age, 14.15 ± 4.26 years). Thirty-one patients had single-site disease; 8 patients had multisynchronous disease (47 sites in total). Compared to review of the standard MR sequences alone, the addition of the balanced steady state free precession sequence resulted in higher rates of tumor partial response categorization and greater diagnostic confidence levels (P < .001, P < .001).

CONCLUSIONS

The balanced steady-state free precession sequence improves detection of residual chemotherapy-reduced intracranial germ cell tumors and increases diagnostic confidence of the neuroradiologist. The balanced steady-state free precession sequence may be an important adjunct to the standard MR imaging protocol for radiation planning.

Accuracy of the neurosurgeons estimation of extent of resection in glioblastoma

BACKGROUND

The surgeons' estimate of the extent of resection (EOR) shows little accuracy in previous literature. Considering the developments in surgical techniques of glioblastoma (GBM) treatment, we hypothesize an improvement in this estimation. This study aims to compare the EOR estimated by the neurosurgeon with the EOR determined using volumetric analysis on the post-operative MR scan.

METHODS

Pre- and post-operative tumor volumes were calculated through semi-automatic volumetric assessment by three observers. Interobserver agreement was measured using intraclass correlation coefficient (ICC). A univariate general linear model was used to study the factors influencing the accuracy of estimation of resection percentage.

RESULTS

ICC was high for all three measurements: pre-operative tumor volume was 0.980 (0.969-0.987), post-operative tumor volume 0.974 (0.961-0.984), and EOR 0.947 (0.917-0.967). Estimation of EOR by the surgeon showed moderate accuracy and agreement. Multivariable analysis showed a statistically significant effect of operating neurosurgeon (p = 0.01), use of fluorescence (p < 0.001), and resection percentage (p < 0.001) on the accuracy of the EOR estimation.

CONCLUSION

All measurements through semi-automatic volumetric analysis show a high interobserver agreement, suggesting this to be a reliable assessment of EOR. We found a moderate reliability of the surgeons' estimate of EOR. Therefore, (early) post-operative MRI scanning for evaluation of EOR remains paramount.

Measuring the density of iodine depositions: Detecting an invisible residual tumor after conventional transarterial chemoembolization

Purpose

The purpose of this study is to evaluate the use of density measurements in the diagnosis of an underlying residual tumor beyond iodine depositions after Lipiodol-based conventional transarterial chemoembolization (cTACE).

Method and materials

Thirty follow-up CT scans of 20 patients 6–12 weeks after Lipiodol-based cTACE, receiving a digital subtraction angiography at the same time, were analyzed. Reference for the detection of a residual tumor was the angiography, and a visible contrast enhancement was categorized as a residual tumor (n = 16 with residual tumor; n = 14 without residual tumor). The density of the iodine depositions was measured in all containing slices in non-contrast-, arterial- and portal venous-phase CT scans, with a slice thickness of 5.00 mm. The mean density of the iodine deposition during the portal venous phase was subtracted from the mean density of the arterial phase to calculate the density changes (a positive enhancement score represents washout in the portal venous phase). In addition, a quotient relating to the non-contrast measurement was evaluated.

Results

Patients with a residual tumor displayed significantly higher enhancement scores in favor of density reduction between the arterial and portal venous phases, compared to patients without a residual tumor (1.41 ± 3.59, n = 14 vs. -13.97 ± 2.88, n = 16; p-value < 0.01). Furthermore, 87.75% of patients with an enhancement score higher than -1.00 (n = 9) had a residual tumor, whereas 100.00% of patients with an enhancement score lower than -20.00 (n = 6) were shown to be tumor-free. The enhancement score quotient resulted in similar findings.

Conclusion

After cTACE in patients with hepatocellular carcinoma (HCC), the presence of a viable tumor correlated with enhancement scores based on the density measurements of iodine depositions in different phases of the CT scan. Low enhancement scores were associated with completely treated tumors and can aid the decision process to avoid possibly unnecessary angiographies.

Rare clinical presentations of pleomorphic xanthoastrocytoma with a high proliferative index: Two case reports

INTRODUCTION

Pleomorphic xanthoastrocytomas (PXA) are rare, typically benign, slow-growing tumors that commonly occur in the cerebral hemispheres. We describe two cases of clinically aggressive PXA with uncommon locations; one was in the tectal plate, and the other had simultaneous multicentric lesions.

PATIENT CONCERNS

The both cases presented with severe headache with no significant past medical history.

DIAGNOSIS

PXA World Health Organization grade II were histopathologically diagnosed from surgically resected specimens, and immunohistochemical and sequence analysis revealed a high Ki-67 proliferative index and BRAF V600E mutation in both the cases.

INTERVENTIONS

The first case presented with multicentric lesions and underwent partial resection, whereas the second case presented with a tectal plate tumor that was managed by gross total surgical resection. Strong 5-aminolevulinic acid (5-ALA)-induced fluorescence was observed in both the lesions. Postoperative radiotherapy plus concomitant and adjuvant temozolomide was administered to both the patients.

OUTCOMES

Despite completing adjuvant chemo-radiotherapy, both the patients had local tumor recurrence at 2 and 5 months after the operation, respectively.

CONCLUSION

The progressive clinical courses in our cases suggest that additional postoperative therapy should be considered during the treatment of PXA with a high Ki67 index, and that temozolomide with radiotherapy, followed by temozolomide maintenance therapy, may not prevent recurrence in such tumors. Importantly, our experience implies that unlike other subtypes of low grade gliomas, 5-ALA fluorescence is useful for intraoperative visualization of PXA.

Positron Emission Tomography (PET) Radiopharmaceuticals in Multiple Myeloma

Multiple myeloma (MM) is a plasma cell disorder, characterized by clonal proliferation of malignant plasma cells in the bone marrow. Bone disease is the most frequent feature and an end-organ defining indicator of MM. In this context, imaging plays a pivotal role in the management of the malignancy. For several decades whole-body X-ray survey (WBXR) has been applied for the diagnosis and staging of bone disease in MM. However, the serious drawbacks of WBXR have led to its gradual replacement from novel imaging modalities, such as computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography/computed tomography (PET/CT). PET/CT, with the tracer ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG), is now considered a powerful diagnostic tool for the detection of medullary and extramedullary disease at the time of diagnosis, a reliable predictor of survival as well as the most robust modality for treatment response evaluation in MM. On the other hand, ¹⁸F-FDG carries its own limitations as a radiopharmaceutical, including a rather poor sensitivity for the detection of diffuse bone marrow infiltration, a relatively low specificity, and the lack of widely applied, established criteria for image interpretation. This has led to the development of several alternative PET tracers, some of which with promising results regarding MM detection. The aim of this review article is to outline the major applications of PET/CT with different radiopharmaceuticals in the clinical practice of MM.

What to do with minimal residual disease testing in myeloma

The role and use of minimal residual disease (MRD) testing has changed significantly over the past few years as it has become part of the routine care for response assessment in multiple myeloma. The most widely used standardized methods to assess MRD in myeloma in the bone marrow are multicolor flow cytometry and next-generation sequencing. Importantly, the depth of MRD negativity in the bone marrow correlates with improved progression-free survival and overall survival in myeloma. Whole-body position emission tomography-computed tomography and magnetic resonance imaging are also used to evaluate patchy and extramedullary disease, which may not be readily visible through bone marrow assessment. This article reviews a clinical case in which MRD testing, both in bone marrow and in functional imaging, is part of the standard of care. It also reviews the different modalities of MRD testing and current practice guidelines. Finally, patients with myeloma may be tested for MRD after treatment because this is part of the routine response assessment according to International Myeloma Working Group criteria and correlates with clinical outcomes. Important questions such as when to stop therapy for sustained MRD-negative patients or whether to change treatments for patients who go from MRD negative to positive without other evidence of disease relapse are being evaluated in clinical trials and remain controversial.

The Value of IVIM DWI in Combination with Conventional MRI in Identifying the Residual Tumor After Cone Biopsy for Early Cervical Carcinoma

RATIONALE AND OBJECTIVES

To investigate the value of intravoxel incoherent motion (IVIM) diffusion-weighted imaging (DWI) in combination with conventional MRI in identifying the residual tumor after biopsy for early cervical carcinoma.

MATERIALS AND METHODS

Eighty patients with histologically proven early cervical carcinoma were enrolled into this study. MRI sequences included two sets of MRI sequences including conventional MRI (T1WI, T2WI, and dynamic contrast-enhanced MRI) and IVIM DWI/conventional MRI combinations. The patients were classified into residual tumor and nonresidual tumor group after biopsy. IVIM parameters were quantitatively analyzed and compared between two groups. The diagnostic ability of two sets of MRI sequences were calculated and compared.

RESULTS

The mean D and f values were significantly lower in residual tumor group than in nonresidual tumor group (p < 0.05). The areas under receiver operating characteristic curves of D and f for discriminating between residual tumor and nonresidual tumor group were 0.848 and 0.767, respectively. The sensitivity and accuracy of conventional MRI/IVIM DWI combinations for the detection of residual tumor were 82.7% and 83.8%, respectively, while the sensitivity and accuracy of conventional MRI were 52.4% and 53.8%, respectively.

CONCLUSION

The addition of IVIM DWI to conventional MRI considerably improves the sensitivity and accuracy of the detection of residual tumor after biopsy for early cervical carcinoma.

Differentiation of postoperative changes and residual tumors in dynamic contrast-enhanced sella MRI after transsphenoidal resection of pituitary adenoma

To establish magnetic resonance imaging (MRI) features that differentiate residual tumors from postoperative surgical changes following the transsphenoidal approach of a pituitary adenoma.We analyzed residual enhancements at the tumor bed in 52 patients who underwent dynamic contrast-enhanced sella MRI within 48 hours after surgery and at 6 to 28 months. Patients were divided into 2 groups defined by either peripheral or nodular enhancement patterns. For each group, we measured the maximum thickness of the residual enhancing portion and compared differences in the residual tumor and postoperative changes.Among the tumors examined in the 52 patients, 19 residual tumors showed nodular (n = 16) and peripheral (n = 3) enhancement patterns, and 33 postoperative changes showed nodular (n = 3) and peripheral (n = 30) enhancement patterns. The mean residual tumor thickness was 7.1 mm (range, 2.9-16.8 mm) and 1.9 mm (range, 1.0-7.4 mm) in the postoperative change. Receiver operating characteristic curve analysis revealed that a 3.9-mm thickness was associated with 89% sensitivity, 97% specificity, and 94% accuracy for diagnosis of residual tumor.On immediate postoperative MRI, residual enhancement with greater than 3.9-mm thickness and nodular pattern suggest residual pituitary adenoma tumor.

Prognostic analysis of gastric mucosal dysplasia after endoscopic resection: A single-center retrospective study

PURPOSE

To analyze the prognostic factors of gastric mucosal dysplasia after endoscopic resection.

METHODS

362 patients with gastric mucosal dysplasia diagnosed by endoscopic biopsy and undergoing endoscopic resection from March 2012 to March 2016 were enrolled. Follow-up was longer than 30 months. Basic characteristics of enrolled patients were recorded, including age, gender, surgical procedures, lesion location, pathological type, lesion size, Helicobacter pylori (HP) infection, operation time and wound area. The relationship between the above factors and postoperative residual lesions and recurrence after endoscopic resection of gastric mucosal dysplasia was analyzed.

RESULTS

Included were 200 males and 162 females, aged 28-78 years, (mean 59.3±11.5). Operation time and wound area were not correlated with postoperative recurrence of gastric mucosal dysplasia resected by endoscopic mucosal resection (EMR) (p>0.05). Operation time in patients undergoing endoscopic submucosal dissection (ESD) was longer compared with those of controls (p=0.032). Additionally, wound area was smaller in patients with postoperative residual disease (p=0.003) and postoperative recurrence (p=0.048) after ESD compared with controls. Intestinal metaplasia was a common risk factor for postoperative residual disease and postoperative recurrence of gastric mucosal dysplasia. Lesion location and complete resection were independent risk factors for postoperative recurrence of gastric mucosal dysplasia. Also, pathological findings and HP infection were independent risk factors for recurrence of gastric mucosal dysplasia after endoscopic resection.

CONCLUSIONS

In patients undergoing ESD of gastric mucosal dysplasia, prolonged operation time may increase the possibility of postoperative residual disease. Complete resection may reduce the possibility for recurrence. Intestinal metaplasia may serve as a common independent risk factor for postoperative residual disease and recurrence of gastric mucosal dysplasia after endoscopic resection.

SERS-based dynamic monitoring of minimal residual disease markers with high sensitivity for clinical applications

Minimal residual disease (MRD) measurement is important for the diagnosis and prognosis of B cell hematological malignancies in the clinic. Thus, a sensitive and accurate method for monitoring the corresponding surface markers is in high demand for early diagnosis and treatment instruction. Herein, we developed a surface enhanced Raman scattering (SERS)-based sandwich-type immunoassay for the simultaneous detection of two surface markers (i.e., CD19 and CD20) in Raji cell lines as well as in clinical blood samples. First, to compare with the results obtained by flow cytometry, we evaluated the sensitivity and reproducibility of the SERS immunoassay for real-time detection of CD19 and CD20 expressions in Raji cells and blood samples. Then, we conducted follow-up tests on 13 B cell hematological malignancy patients for one month and dynamically monitored their CD19 and CD20 expressions by the SERS immunoassay. In addition to the improved sensitivity of the SERS method, good linear correlations between the SERS intensities and flow cytometry results were also observed for both CD19 and CD20, which indicated the accuracy of this SERS-based strategy. Therefore, this SERS-based simultaneous detection approach shows great potential for accurate and early diagnosis of MRD in B cell hematological malignancies.

Radiofrequency ablation in the treatment of atypical cartilaginous tumours in the long bones: lessons learned from our experience

BACKGROUND

Surgery is the cornerstone of treatment of symptomatic cartilaginous neoplasms. We previously studied the application of radiofrequency ablation of atypical cartilaginous tumours in the long bones. The purpose of the present study was to investigate the additional effect of placing multiple needles and a longer procedure duration on the proportion of completely ablated tumours. Post-ablation MRI findings and the occurrence of complications were also assessed.

METHODS

We prospectively included 24 patients with atypical cartilaginous tumours in the long bones. Patients underwent CT-guided radiofrequency ablation followed by curettage with adjuvant phenolisation 3 months later, retrieving material assessed for viable tumour. Before curettage, gadolinium-enhanced MRI was performed to check for residual tumour. The occurrence of complications was noted.

RESULTS

Complete tumour ablation was achieved in 17 out of 24 patients (71%). Complete ablation was achieved in 5 of the 6 cases (83%) when multiple needles were used in tumours ≥30 mm. There was incomplete ablation in 8% of patients. Post-ablation gadolinium-enhanced MRI findings agreed with the histological results in 17 out of 23 cases and there was a negative predictive value of 83%. One patient suffered a fracture after radiofrequency ablation.

CONCLUSION

Radiofrequency ablation could be an alternative to curettage when treating atypical cartilaginous tumours in the long bones. It was shown that multiple needle placement in addition to longer duration of the ablation procedure is an effective measure in achieving complete ablation in tumours ≥30 mm. Gadolinium-enhanced MRI has a negative predictive value of 83% and could guide post-ablation follow-up.

Degrees of Diaphragma Sellae Descent during Transsphenoidal Pituitary Adenoma Resection: Predictive Factors and Effect on Outcome

This study is aimed to classify degrees of diaphragma sellae (DS) descent into sella turcica according to the surgical field block caused by the descent and to construct predictive imaging criteria for the degree of descent, and in addition, to determine whether there is any correlation between the degree of DS descent and the operative outcome (in the form of cerebrospinal fluid leak and/or presence of residual tumor). Totally, 72 patients were enrolled in our study. Their clinical and radiological data as well as the high definition videos of operations were retrospectively reviewed. The degree of DS descent during the operation was classified into five degrees according to surgical field block caused by the descent. We investigated the correlation between these five degrees and the clinical findings, radiological findings as well as the surgical outcomes. We found that the most important determining factors of DS descent degree were the volume and the height of the tumor portion above diaphragma opening. On the other hand, the total tumor volume, the maximum tumor height and the morphological pattern according to Wilson's system (modified from Hardy) had no statistically significant correlation with DS degree of descent. Presence of residual tumor on postoperative magnetic resonance images was significantly correlated with Wilson's classification and with supradiaphragmatic tumor height. On the other hand, cerebrospinal fluid leak showed no statistically significant difference between variable degrees of DS descent. Volumetric data of the tumor portion above the diaphragma opening are more important than morphological data for prediction of surgical field block caused by descended DS. While DS prolapse significantly increases the difficulty of the operative procedure, residual tumor presence is mainly dependent on morphological classification, especially cavernous sinus invasion.

Positron emission tomography (PET) and magnetic resonance imaging (MRI) for assessing tumour resectability in advanced epithelial ovarian/fallopian tube/primary peritoneal cancer

BACKGROUND

Ovarian cancer is the leading cause of death from gynaecological cancer in developed countries. Surgery and chemotherapy are considered its mainstay of treatment and the completeness of surgery is a major prognostic factor for survival in these women. Currently, computed tomography (CT) is used to preoperatively assess tumour resectability. If considered feasible, women will be scheduled for primary debulking surgery (i.e. surgical efforts to remove the bulk of tumour with the aim of leaving no visible (macroscopic) tumour). If primary debulking is not considered feasible (i.e. the tumour load is too extensive), women will receive neoadjuvant chemotherapy to reduce tumour load and subsequently undergo (interval) surgery. However, CT is imperfect in assessing tumour resectability, so additional imaging modalities can be considered to optimise treatment selection.

OBJECTIVES

To assess the diagnostic accuracy of fluorodeoxyglucose-18 (FDG) PET/CT, conventional and diffusion-weighted (DW) MRI as replacement or add-on to abdominal CT, for assessing tumour resectability at primary debulking surgery in women with stage III to IV epithelial ovarian/fallopian tube/primary peritoneal cancer.

SEARCH METHODS

We searched MEDLINE and Embase (OVID) for potential eligible studies (1946 to 23 February 2017). Additionally, ClinicalTrials.gov, WHO-ICTRP and the reference list of all relevant studies were searched.

SELECTION CRITERIA

Diagnostic accuracy studies addressing the accuracy of preoperative FDG-PET/CT, conventional or DW-MRI on assessing tumour resectability in women with advanced stage (III to IV) epithelial ovarian/fallopian tube/primary peritoneal cancer who are scheduled to undergo primary debulking surgery.

DATA COLLECTION AND ANALYSIS

Two authors independently screened titles and abstracts for relevance and inclusion, extracted data and performed methodological quality assessment using QUADAS-2. The limited number of studies did not permit meta-analyses.

MAIN RESULTS

Five studies (544 participants) were included in the analysis. All studies performed the index test as replacement of abdominal CT. Two studies (366 participants) addressed the accuracy of FDG-PET/CT for assessing incomplete debulking with residual disease of any size (> 0 cm) with sensitivities of 1.0 (95% CI 0.54 to 1.0) and 0.66 (95% CI 0.60 to 0.73) and specificities of 1.0 (95% CI 0.80 to 1.0) and 0.88 (95% CI 0.80 to 0.93), respectively (low- and moderate-certainty evidence). Three studies (178 participants) investigated MRI for different target conditions, of which two investigated DW-MRI and one conventional MRI. The first study showed that DW-MRI determines incomplete debulking with residual disease of any size with a sensitivity of 0.94 (95% CI 0.83 to 0.99) and a specificity of 0.98 (95% CI 0.88 to 1.00) (low- and moderate-certainty evidence). For abdominal CT, the sensitivity for assessing incomplete debulking was 0.66 (95% CI 0.52 to 0.78) and the specificity 0.77 (95% CI 0.63 to 0.87) (low- and low-certainty evidence). The second study reported a sensitivity of DW-MRI of 0.75 (95% CI 0.35 to 0.97) and a specificity of 0.96 (95% CI 0.80 to 1.00) (very low-certainty evidence) for assessing incomplete debulking with residual disease > 1 cm. In the last study, the sensitivity for assessing incomplete debulking with residual disease of > 2 cm on conventional MRI was 0.91 (95% CI 0.59 to 1.00) and the specificity 0.97 (95% CI 0.87 to 1.00) (very low-certainty evidence). Overall, the certainty of evidence was very low to moderate (according to GRADE), mainly due to small sample sizes and imprecision.

AUTHORS' CONCLUSIONS

Studies suggested a high specificity and moderate sensitivity for FDG-PET/CT and MRI to assess macroscopic incomplete debulking. However, the certainty of the evidence was insufficient to advise routine addition of FDG-PET/CT or MRI to clinical practice..In a research setting, adding an alternative imaging method could be considered for women identified as suitable for primary debulking by abdominal CT, in an attempt to filter out false-negatives (i.e. debulking, feasible based on abdominal CT, unfeasible at actual surgery).

Magnetic Resonance Imaging Combined With Second-look Ultrasonography in Predicting Pathologic Complete Response After Neoadjuvant Chemotherapy in Primary Breast Cancer Patients

BACKGROUND

Magnetic resonance imaging (MRI) or ultrasonography (US) alone is limited in the ability to predict the pathologic complete response (pCR) accurately after neoadjuvant chemotherapy (NAC). The aim of the present study was to predict the pCR using MRI combined with second-look US in primary breast cancer patients.

MATERIALS AND METHODS

A total of 1274 consecutive primary breast cancer patients who were examined by MRI and second-look US before and after NAC and had undergone breast-conserving surgery from 2004 to 2014 were included. The positive predictive value (PPV) of a clinical complete response (cCR) by MRI alone and MRI plus US was assessed. A CR was defined as no residual invasive carcinoma. The presence of a residual in situ component was also assessed (ypTis).

RESULTS

Of the 1274 patients, 333 (26.1%) had a pCR (ypT0/is), and 102 (8.0%) had a residual in situ component (ypTis). A cCR was found in 247 patients (19.4%) using MRI alone and in 182 patients (14.3%) using MRI plus US. The PPV for a cCR using MRI alone was 79.4% and the PPV for MRI plus US was 86.8%. The PPV for a cCR by MRI plus US was the greatest at 98.1% in the estrogen receptor-negative (ER^-)/human epidermal growth factor receptor-positive (HER2⁺) group (86.5% in the ER⁺/HER2⁺, 83.0% in the ER^-/HER2^-, and 64.7% in the ER⁺/HER2^- groups). The PPV for residual in situ component was as low as 72.2%.

CONCLUSION

Our results have shown that MRI combined with second-look US in predicting for a pCR was useful compared with MRI alone, especially for ER^-/HER2⁺. However, it was difficult to predict for the presence of a residual in situ component. Our ongoing prospective multi-institutional study has shown that adding vacuum-assisted biopsy to MRI plus second-look US is warranted to improve the prediction of pCR for omitting breast surgery.

Imaging of IR700DX Labeled Mouse Breast Tumor Using a Custom Angle-Selective Fluorescence Contact Imaging System

Cancer treatment faces the challenge of identifying small clusters of residual tumor cells in the resection cavity after the gross section of tumor is surgically removed. Despite the introduction of targeted fluorescent probes to guide cancer surgeries, large, bulky, optical components restrict the ability of fluorescence imaging devices to detect small clusters of tumor cells in the complex surgical cavity. We have developed a small size-scale contact fluorescence image sensor that incorporates angle-selective gratings and a thin 15 m amorphous silicon optical wavelength filter for detecting residual cancer tissue in vivo. Using a custom fluorescent probe combining a fluorescent dye, IR700DX, with a targeted antibody, Trastuzumab, we label and visualize breast tissue in in vivo mouse models of breast cancer. When imaging tumorbearing mice injected with the probe, HER2+ breast cancer tissue intensity is 3.80.8 times brighter than other tissue. Excised cancer tumors and residual cancer attached to healthy tissue are imaged using the custom image sensor. Residual cancer tissue can be detected in real-time and is imaged with a high SNR of 45 dB using an integration time of only 40 ms.

PRospective Imaging of CErvical cancer and neoadjuvant treatment (PRICE) study: role of ultrasound to assess residual tumor in locally advanced cervical cancer patients undergoing chemoradiation and radical surgery

OBJECTIVE

To determine the diagnostic performance of two-dimensional (2D) ultrasound parameters, three-dimensional (3D) power Doppler and contrast-enhanced indices in detecting residual disease in locally advanced cervical cancer patients triaged to neoadjuvant treatment followed by radical surgery.

METHODS

Between October 2010 and June 2014, we screened 108 women with histologically documented locally advanced cervical cancer Stage IB2-IVA, of whom 88 were included in the final analysis. 2D ultrasound parameters, 3D power Doppler and contrast-ultrasound parameters were assessed 5 weeks after the end of neoadjuvant chemoradiation therapy. The pathological response was defined as complete (absence of any residual tumor after treatment) or partial (including microscopic and/or macroscopic residual tumor at pathology examination). The two response groups were compared and receiver-operating characteristics (ROC) curves generated to determine the best cut-off value of sonographic tumor diameter to predict residual disease. Histology was considered as reference.

RESULTS

Complete pathological response to chemoradiation was observed in 40 (45.5%) patients and partial response in 48 (54.5%). The presence of residual disease, as confirmed at pathology examination, was detected by 2D grayscale ultrasound with a sensitivity of 64.6% and specificity of 65%. Color Doppler examination in the cases with lesions visualized on grayscale imaging detected the presence of residual disease, confirmed at pathology, with a sensitivity of 87.1% and specificity of 21.4%. The best area under the ROC curve (0.817) was for the detection of pathological residual disease of at least 6 mm in diameter, using a cut-off value of 12 mm for the largest tumor diameter assessed using 2D grayscale ultrasound (sensitivity, 95%; specificity, 70.6%). Neither 3D vascular indices nor contrast-ultrasound parameters obtained for lesions suspected at ultrasound following chemoradiation differed significantly between patients with histological complete and those with partial response.

CONCLUSIONS

Our results show that grayscale and color Doppler ultrasound have a low level of diagnostic performance in detecting residual disease after neoadjuvant chemoradiation in patients with locally advanced cervical cancer. The best performance was achieved in detection of macroscopic (≥ 6 mm) residual disease. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Post-operative imaging assessment of non-functioning pituitary adenomas

BACKGROUND

Non-functioning pituitary adenomas (NFAs) are the most common pituitary tumors. There is significant variability in clinical practice in terms of post-operative imaging evaluation. The objective of this manuscript is to provide an exhaustive review of published articles pertaining to the post-operative imaging evaluation of NFAs.

METHODS

The MEDLINE database was queried for studies investigating imaging for the post-operative evaluation of pituitary adenomas. From an initial search of 5589 articles, 37 articles were evaluated in detail and included in this review.

RESULTS

Magnetic resonance imaging (MRI) is the gold standard for post-operative monitoring of NFAs, although functional imaging modalities may improve identification of residual tumor in conjunction with MRI. The residual tumor can be distinguished from post-operative changes by experienced practitioners using high-resolution MRI in the immediate post-operative setting (within 1 week of surgery). However, continued imaging evolution in the appearance of residual tumor or resection cavity is expected up to 3 months post-operatively.

CONCLUSIONS

Post-operative imaging appearance of the pituitary gland, optic apparatus, and pneumocephalus patterns, correlated with the clinical outcomes. Long-term, lifetime follow-up is warranted for NFA patients who underwent surgical resection.

Differentiation of residual/recurrent gliomas from postradiation necrosis with arterial spin labeling and diffusion tensor magnetic resonance imaging-derived metrics

PURPOSE

The aim of this study is to differentiate recurrent/residual gliomas from postradiation changes using arterial spin labeling (ASL) perfusion and diffusion tensor imaging (DTI)-derived metrics.

METHODS

Prospective study was conducted upon 42 patients with high-grade gliomas after radiotherapy only or prior to other therapies that underwent routine MR imaging, ASL, and DTI. The tumor blood flow (TBF), fractional anisotropy (FA), and mean diffusivity (MD) of the enhanced lesion and related edema were calculated. The lesion was categorized as recurrence/residual or postradiation changes.

RESULTS

There was significant differences between residual/recurrent gliomas and postradiation changes of TBF (P = 0.001), FA (P = 0.001 and 0.04), and MD (P = 0.001) of enhanced lesion and related edema respectively. The area under the curve (AUC) of TBF of enhanced lesion and related edema used to differentiate residual/recurrent gliomas from postradiation changes were 0.95 and 0.93 and of MD were 0.95 and 0.81 and of FA were 0.81 and 0.695, respectively. Combined ASL and DTI metrics of the enhanced lesion revealed AUC of 0.98, accuracy of 95%, sensitivity of 93.8%, specificity of 95.8%, positive predictive value (PPV) of 93.8%, and negative predictive value (NPV) of 95.8%. Combined metrics of ASL and DTI of related edema revealed AUC of 0.97, accuracy of 92.5%, sensitivity of 93.8%, specificity of 91.7%, PPV of 88.2%, and NPV of 95.7.

CONCLUSION

Combined ASL and DTI metrics of enhanced lesion and related edema are valuable noninvasive tools in differentiating residual/recurrent gliomas from postradiation changes.

Current prognostic and predictive factors in follicular lymphoma

Follicular lymphoma (FL) is generally considered an indolent disorder. With modern day treatments, long remissions are often achieved both in the front-line and relapsed setting. However, a subset of patients has a more aggressive course and a worse outcome. Their identification is the main purpose of modern day prognostic tools. In this review, we attempt to summarize the evidence concerning prognostic and predictive factors in FL, including (1) pre-treatment factors, from baseline clinical characteristics and imaging tests to histological grade, the microenvironment and genomic abnormalities; (2) post-treatment factors, i.e., depth of response, measured both by imaging tests and minimal residual disease; (3) factors at relapse and duration of response; and (4) prognostic factors in histological transformation. We conclude that, despite the existence of numerous tools, the availability of some of them is still limited; they generally suffer from notable downsides, and most have unproven predictive value, thus having scarce bearing on the choice of regimen at present. However, with the technological and scientific developments of the last few years, the potential for these prognostic factors is promising, particularly in combination, which will probably, in time, help guide therapeutic decisions.

Early postoperative growth in non-functioning pituitary adenomas; A tool to tailor safe follow-up

PURPOSE

Non-functioning pituitary adenomas are common, and the treatment and follow-up of these patients represent a multidisciplinary challenge. First line treatment is transphenoidal surgery, with debulking or total removal of tumour. A substantial portion of the tumours relapse after surgery, and there is no consensus of how to follow these patients postoperatively. Our aim was to characterize the postoperative growth of non-functioning pituitary adenomas and correlate it to clinical and paraclinical data.

METHODS

We retrospectively registered 52 patients operated for non-functioning pituitary adenomas, with four or more consecutive MR-investigations not interrupted by secondary treatment. Adenoma volumes were estimated by the Cavalieri principle with summation of manually drawn areas multiplied by slice interval. Growth curves were modelled and tumour volume doubling time was calculated for 39 tumours with regrowth after surgery.

RESULTS

A total of 13 tumours showed exponential growth, 10 linear growth and 16 logistic growth after surgery. The remaining 13 did not show regrowth of tumour. Seven of the exponential growing tumours underwent secondary surgery, compared to one and two of linear and logistic growing tumours (p = 0.03), respectively. Initial tumour volume doubling time was significantly lower in logistic growing tumours than in exponential growing tumours (p < 0.01). Men had tumours with lower tumour volume doubling time than women (p = 0.03). None of the tumours demonstrated signs of accelerated growth.

CONCLUSION

Residual tumours following surgery frequently grow. The logistic growing tumours had the fastest initial growth in our cohort. We found no indication of accelerated growth, whereby the tumour volume doubling time might be used to predict a "worst-case" scenario when planning follow-up of these patients.

Do Calcifications Seen on Mammography After Neoadjuvant Chemotherapy for Breast Cancer Always Need to Be Excised?

BACKGROUND

This study aimed to determine the relationship between mammographic calcifications and magnetic resonance imaging (MRI) tumoral enhancement before and after neoadjuvant chemotherapy (NAC) and to assess the impact of these findings on surgical management.

METHODS

This Institutional Review Board-approved, Health Insurance Portability and Accountability Act (HIPAA)-compliant retrospective study involved breast cancer patients who underwent NAC between 2009 and 2015. The study cohort comprised 90 patients with pre- and posttreatment MRI and mammograms demonstrating calcifications within the tumor bed either at presentation or after treatment. The data gathered included pre- and post-NAC imaging findings and post-NAC histopathology, particularly findings associated with calcifications. Comparisons were made using Fisher's exact test, with p values lower than 0.05 considered significant.

RESULTS

Complete resolution of MRI enhancement occurred for 44% of the patients, and a pathologic complete response (pCR) was achieved for 32% of the patients. No statistically significant correlation between changes in mammographic calcifications and MRI enhancement was found (p = 0.12). Resolution of enhancement was strongly correlated with pCR (p < 0.0001). The majority of the patients with pCR demonstrated complete resolution of enhancement (79%, 23/29). No statistically significant relationship was found between changes in calcifications and rates of pCR (p = 0.06). A pCR was achieved most frequently for patients with resolution of enhancement and new, increasing, or unchanged calcifications (p < 0.0001).

CONCLUSIONS

Although calcifications seen on post-NAC mammography may be associated with benign disease, loss of MRI enhancement does not predict the absence of residual tumor with sufficient accuracy to leave calcifications in place. Complete excision of tumor bed calcifications remains standard practice and a substantial limitation to NAC use for downstaging patients to be eligible for breast conservation treatment.

Intraoperative Molecular Imaging of Lung Adenocarcinoma Can Identify Residual Tumor Cells at the Surgical Margins

PURPOSE

During lung surgery, identification of surgical margins is challenging. We hypothesized that molecular imaging with a fluorescent probe to pulmonary adenocarcinomas could enhance residual tumor during resection.

PROCEDURES

Mice with flank tumors received a contrast agent targeting folate receptor alpha. Optimal dose and time of injection was established. Margin detection was compared using traditional methods versus molecular imaging. A pilot study was then performed in three humans with lung adenocarcinoma.

RESULTS

The peak tumor-to-background ratio (TBR) of murine tumors was 3.9. Fluorescence peaked at 2 h and was not improved beyond 0.1 mg/kg. Traditional inspection identified 30% of mice with positive margins. Molecular imaging identified an additional 50% of residual tumor deposits (p < 0.05). The fluorescent probe visually enhanced all human tumors with a mean TBR of 3.5.

CONCLUSIONS

Molecular imaging is an important adjunct to traditional inspection to identify surgical margins after tumor resection.

Imaging prediction of residual hepatocellular carcinoma after locoregional therapy in patients undergoing liver transplantation or partial hepatectomy

PURPOSE

Locoregional therapies for hepatocellular carcinoma (HCC) offer alternatives for patients unable to undergo resection or awaiting transplant. We sought to evaluate the prevalence and interobserver agreement of imaging features suggestive of viable tumor at posttherapy CT/MRI and to determine a size threshold for tumor detection.

METHODS

Patients having undergone liver transplant or hepatectomy between 2012 and 2014 with presurgical embolization or ablation of HCC were identified. Imaging was retrospectively reviewed, and enhancement characteristics of each lesion were noted by two radiologists. Original pathology slides were reviewed, and the size of nodular viable tumor was noted, if present. Cohen's kappa was used to evaluate interobserver agreement.

RESULTS

87 patients with 129 HCCs were reviewed retrospectively following IRB approval. 50% (65/129) of lesions showed viable tumor at pathology. 86 lesions (67%) were imaged with CT and 43 (33%) with MR. Of viable lesions, 25 (38%) showed nodular arterial enhancement and 18 (28%) demonstrated washout. One lesion had capsule appearance. Sensitivity/specificity for nodular enhancement, washout, and capsule were 0.38/0.83, 0.28/0.89, and 0.02/1.00, respectively. Overall detection rate was 41% of <1 cm, 54% of 1-2 cm, and 57% of >2 cm viable lesions.

CONCLUSIONS

Nodular arterial enhancement was most frequently observed, followed by washout. Both showed moderate interobserver agreement. Sensitivity of any imaging feature was less than 50%, though findings were specific for viable disease. There is limited detection of nodules of viable tumor <1 cm and only marginal detection of larger lesions, though MRI outperformed CT for the detection of subcentimeter viable tumor.

Intraoperative diagnostics and elimination of residual microtumours with plasmonic nanobubbles

Failure of cancer surgery to intraoperatively detect and eliminate microscopic residual disease (MRD) causes lethal recurrence and metastases, and the removal of important normal tissues causes excessive morbidity. Here, we show that a plasmonic nanobubble (PNB), a non-stationary laser pulse-activated nanoevent, intraoperatively detects and eliminates MRD in the surgical bed. PNBs were generated in vivo in head and neck cancer cells by systemically targeting tumours with gold colloids and locally applying near-infrared, low-energy short laser pulses, and were simultaneously detected with an acoustic probe. In mouse models, between 3 and 30 residual cancer cells and MRD (undetectable with current methods) were non-invasively detected up to 4 mm deep in the surgical bed within 1 ms. In resectable MRD, PNB-guided surgery prevented local recurrence and delivered 100% tumour-free survival. In unresectable MRD, PNB nanosurgery improved survival twofold compared with standard surgery. Our results show that PNB-guided surgery and nanosurgery can rapidly and precisely detect and remove MRD in simple intraoperative procedures.

Microwave coagulation/ablation in combination with sorafenib suppresses the overgrowth of residual tumor in VX2 liver tumor model

OBJECTIVES

Our study is to evaluate the effect of thermal ablation on residual VX2 tumor tissue and the efficiency of sorafenib as an adjuvant therapy after insufficient microwave coagulation (MWC) on a rabbit VX2 liver tumor model.

METHODS

Thirty-seven rabbits with orthotic VX2 liver tumors were randomly divided into MWC group (n=11), combination treatment group (n=14), and control group (n=12). The therapeutic efficacy was evaluated by contrast enhanced ultrasound (CEUS), magnetic resonance imaging (MRI), pathological and immunohistochemical examinations. Analysis of enhancement characteristics included enhancement level, pattern, and location. The necrotic degree of tumor was analyzed by semi-quantitative classification. The apparent diffusion coefficiency (ADC) was calculated using diffused weighted image (DWI).

RESULTS

The tumor growth was accelerated in MWC group compared with control group and combination treatment group. A low metastasis rate was shown in combination treatment group compared with other two groups. The degree of necrosis in combination treatment group was greater than that in MWC group. The ADC value on DWI was higher compared with that of the control and MWC group, with statistical significance (P<0.05). With adjuvant therapy of sorafenib after insufficient ablation, the microvessel density (MVD) was lower than that of control group, whereas in MWC group the MVD was higher than that of control group, with statistical significance (P<0.05).

CONCLUSION

Insufficient thermal ablation promotes residual tumor progression. While the adjuvant therapy of sorafenib serves as an effective way to suppress the overgrowth and neovascularization of residual tumor after insufficient thermal ablation.

Low-risk differentiated thyroid cancer and radioiodine remnant ablation: a systematic review of the literature

BACKGROUND

Radioiodine remnant ablation (RRA) has traditionally been one of the cornerstones of differentiated thyroid cancer (DTC) treatment. The decision to use RRA in low-risk (LR) and intermediate-risk (IR) patients is controversial. The aim of this review is to examine the evidence of RRA benefit in the staging, follow-up, and recurrence prevention in LR and IR DTC patients.

METHODS

From a PubMed search, we selected original papers (OPs) using the following inclusion criteria: 1) DTC; 2) LR and IR patients; 3) non-RRA-treated patients or RRA-treated vs non-RRA-treated groups; 4) a report of the outcome of cancer recurrence; and 5) publication since 2008.

RESULTS

Neck ultrasonography is superior to whole-body scan for disease detection in the neck. A rising or declining serum thyroglobulin level over time provides an excellent positive or negative predictive value, respectively, even in non-RRA-treated patients. No OP demonstrating RRA benefit on recurrence in LR patients was found; two OPs found no evidence of benefit. We found 11 OPs that observed some benefit in reducing recurrence rates with RRA in IR patients and 13 OPs that failed to show benefit from RRA in this group.

CONCLUSIONS

Neck ultrasonography and serum thyroglobulin measurement are equivalent or superior in detecting and localizing residual disease compared to post-therapy whole-body scan. There is no evidence of RRA benefit in recurrence prevention for LR patients. There are conflicting data on IR patients and only a few studies with homogenous and properly stratified populations. A careful evaluation of tumor pathological features and patient characteristics and preferences should guide RRA decision making.

[Value of FDG PET-CT associated with pathology in diagnosing residual tumor in patients with nasopharyngeal carcinoma after radiotherapy]

OBJECTIVE

To find a rational way in early detecting the residual tumor in patients with nasopharyngeal carcinoma (NPC) after radiotherapy.

METHODS

A total of 47 NPC patients who were diagnosed residual tumor after radiotherapy and treated in our hospital from Dec 2009 to Aug 2012 were included in this study and their clinicopathological and follow-up data were reviewed and analyzed. The patients were checked by nasopharynx MRI, FDG PET-CT and were examined by biopsy of the residual tumors within two weeks after radiotherapy. The diagnosis of relapses was determined by pathological re-examination.

RESULTS

All the 47 patients were followed up for 10-42 months. Three of them had nasopharynx relapse. The others had not tumor relapse and their residual tumors disappeared completely. The specificity of MRI, FDG PET-CT and pathological tumor response in diagnosing residual tumors were 9.1%, 77.3%, and 95.5% (P<0.001). Their accuracy rates were 14.9%, 78.9%, and 95.7%, respectively (P<0.001). The M of SUVmax in the team who had moderate and severe pathologic tumor response (team A) was 3.05 and that in the team who had mild pathologic tumor response (team B) was 4.68 (P=0.012). None of patients in the team A had nasopharynx relapse. Three patients in the team B who had SUVmax ≥4 had nasopharynx relapses, and in other 2 patients who had SUVmax <4, the residual tumors disappeared during the following-up. The specificity and accuracy in diagnosing residual tumors were increased when mild pathologic tumor response combined with SUVmax4 were used.

CONCLUSION

PET-CT combined with pathologic tumor response is beneficial for early diagnosis of residual nasopharyngeal tumors after radiotherapy.

Tumor volume reduction assessed by planning computed tomography in patients with rectal cancer during preoperative chemoradiation: impact of residual tumor volume on the prediction of pathologic tumor regression

AIMS AND BACKGROUND

To determine whether the residual tumor volume measured using the Eclipse treatment planning system correlates with pathologic tumor regression grade after preoperative chemoradiotherpy for rectal cancer.

MATERIALS AND METHODS

The study included 30 patients with rectal cancer who had undergone preoperative chemoradiotherpy followed by surgery from June 2008 to April 2011 at the Korea University Guro Hospital. The tumor volume was measured using the Eclipse treatment planning system in the initial simulation computed tomography and boost planning computed tomography. The correlation between the residual tumor volume in boost planning computed tomography and the pathologic tumor regression grade was analyzed. Tumor regression grade defined in the American Joint Committee on Cancer 7th edition was used.

RESULTS

The mean and median residual tumor volume was 57.34% ± 20.37% and 52.35% (range, 18.42%-95.79%), respectively. After surgery, pathologic complete response (tumor regression grade 0) occurred in 4 patients (13.33%), moderate response (tumor regression grade 1) in 18 patients (60%), minimal response (tumor regression grade 2) in 4 patients (13.33%), and poor response (tumor regression grade 3) in 4 patients (13.33%). When residual tumor volume was categorized into two groups (<50% and ≥50%), complete or moderate regression (tumor regression grade 0 or 1) was significantly greater for patients with a residual tumor volume <50% ( P <0.05). The mean residual tumor volume of tumor regression grade 0 or 1 was 49.07% ± 18.39% and that of tumor regression grade 2 or 3 was 76.31% ± 16.94% (P <0.05).

CONCLUSIONS

Residual tumor volume measured using routine boost planning computed tomography during preoperative chemoradiotherpy correlated significantly with pathologic tumor regression grade after surgery.

Potential use of contrast-enhanced ultrasound (CEUS) in the detection of metastatic superficial lymph nodes in melanoma patients

PURPOSE

Malignant melanoma represents a significant and growing public health burden worldwide. Ultrasonography is the most useful diagnostic modality for regional lymph nodal staging. Because any focal areas of cortical lobulation or thickening-swelling should also be considered as a sign of metastases, we are going to report the usefulness of contrast-enhanced ultrasonography (CEUS) in the differential diagnosis of benign or malignant lymph nodes in patients with malignant melanoma based on blood stream patterns and investigate the diagnostic capability.

PATIENTS AND METHODS

After the excision of cutaneous melanoma with positive excision margins but with negative sentinel lymph node, 540 patients underwent US of superficial lymph nodes. The inclusion criteria for CEUS consisted of both major signs (absence of the echogenic hilus, round shape, and peripheral capsular vascularity) and minor ones (the presence of focal cortical thickening). The diagnostic capability was evaluated by comparing the cytological findings with the enhancement pattern on CEUS. 

RESULTS

US in combination with CEUS correctly classified 534/540 patients. CEUS applied to lymph nodes with focal cortical thickening on grayscale US confirmed great sensitivity (0.98) and specificity (0.99) but above all, it showed a markedly improved accuracy of 0.99. The likelihood ratios confirmed the good performance of the methods used.

CONCLUSION

CEUS increases the diagnostic accuracy of US in the differential diagnosis of benign and malignant LNs but it also allows us, when possible, to avoid unnecessary invasive operations such as LN FNAC. Moreover, CEUS may guide FNAC in the case of focal cortical thickening on the basis of hypoperfusion, with a reduction in the number of false negatives and much earlier detection of nodal metastatic foci.

[Method of detection of residual tissues in recurrent operations on the thyroid gland]

A search of residual tissues is complicated in recurrent operations on the thyroid gland. The Saint-Petersburg Centre of Surgery of the Endocrine System and Oncology developed the method of detection of residual tissues of the thyroid gland with the aim of preoperative chromothyroidolymphography under control of ultrasound. The method consisted of US performance during 15-20 minutes before the operation and an introduction of 1% sterile water solution of methylene blue in revealed residual tissues of the thyroid gland. The volume of injected coloring agent was 0.5-2 ml in the residual tissue volume smaller than 9 cm3 and 2-3 ml injected in case of more than 9 cm3. The residual tissues of the thyroid gland accurately visualized during the following operation. Described method gives the possibility to detect all regions of residual tissues which should be removed and at the same time it shortens a revision and surgery trauma.

Monitoring during hepatic radiofrequency ablation (RFA): comparison of real-time ultrasound elastography (RTE) and contrast-enhanced ultrasound (CEUS): first clinical results of 25 patients

PURPOSE

To evaluate the reliability of ultrasound elastography for delineating thermal ablation defects post-radiofrequency ablation (RFA) by comparing lesion dimensions determined by real-time elastography (RTE) with the findings of contrast-enhanced ultrasound (CEUS).

MATERIALS AND METHODS

A total of 21 malignant liver tumors were percutaneously ablated using RFA. Color-coded elastography and CEUS were performed by one experienced examiner, using a 1 - 5 MHz multi-frequency convex transducer (LOGIQ E9, GE). Lesions were examined using CEUS and real-time elastography (RTE) to assess ablation defects. Measurements of lesions (long axis, short axis, and area) representing the same image plane used for elastography were taken during CEUS examination and compared to the measurements obtained from the elastograms. All measurements were performed by two independent observers.

RESULTS

A statistically significant correlation in vivo between RTE and CEUS measurements with respect to the lesion's principal axis and area (r = 0.876 long axis, r = 0.842 short axis and r = 0.889 area) was found. Inter-rater reliability assessed with the concordance correlation coefficient was substantial for all measurements (ρc ≥ 0.96) Overall, elastography slightly underestimated the lesion size, as judged by the CEUS images.

CONCLUSION

These results support that RTE could potentially be used for the routine assessment of thermal ablation therapies.

[Microbubbles enhanced HIFU ablation on rabbit hepatic VX2 tumors: detecting residual tumor with contrast-enhanced ultrasound and spiral CT]

OBJECTIVE

To assess the application of gray-scale contrast-enhanced ultrasound (CEUS) and contrast-enhanced spiral computed tomography (CECT) in detection of residual tumor after high intensity focused ultrasound (HIFU) ablation with microbubbles on rabbit hepatic VX2 tumors.

METHODS

Forty rabbits with hepatic VX2 tumors were randomly divided into three groups before ablation. Group I (n=10) served as sham ablation controls, rabbits in group II (n=15) and group III (n=15) were ablated using HIFU under the manipulation of computer. A bolus of 0.2 ml SonoVue solution was injected via ear marginal vein of rabbits in group III before ablation. Tumors were examined with CEUS and CECT before and within 3h after HIFU ablation. Necropsy and histopathological assessment were performed immediately after the completion of images evaluation.

RESULTS

Before ablation, intense arterial feeding vessels was detected in the tumors (77.5%,31/40 Compared with 52.5%,21/40) or the periphery of the tumors (22.5%,9/40 Compared with 47.5%,19/40) by CEUS and CECT, respectively. The tumors were characterized by quick wash-in and wash-out (high and rapid peak of enhancement in the arterial phase,followed by a fast decrease in enhancement level). The dose parameters used to achieve therapeutic effect in group III were significantly lower than those in group II(P<0.01). There were local residual viable tumor tissues due to incomplete ablation in 60.0% (9/15) of group II and 13.3% (2/15) of group III revealed by histopathology(P<0.05). The concordance rate of CECT and CEUS with histopathology on residual tumor detection was 27.3% and 81.8% (P<0.05), respectively.

CONCLUSION

The administration of microbubble agent enhances the efficacy of HIFU on rabbit hepatic VX2 tumors. CEUS is more sensitive than CECT in detection of residual viable rabbit VX2 tumor after HIFU.

Factors influencing the outcome of microsurgical transsphenoidal surgery for pituitary adenomas: a study on 184 patients

OBJECTIVE

Evaluation of factors influencing the outcome of microsurgical transsphenoidal surgery in patients harbouring pituitary adenomas as well as of the efficacy and safety of this procedure.

DESIGN

A total of 184 consecutive patients with pituitary adenomas, undergoing microsurgical transsphenoidal resection of their lesions from March 2004 to June 2011, were prospectively studied. Extent of tumour resection and disease remission were defined according to recently established radiological and hormonal consensus criteria.

RESULTS

The study included 97 nonfunctioning and 87 functioning adenomas. A gross-total removal, as documented on postoperative imaging, was achieved in 67.4% of all patients. Residual tumour after surgery was detected in 37.1% of patients with nonfunctioning adenomas. The remission rates for patients with functioning adenomas, as documented by the last endocrinological evaluation, were 54.9% for growth hormone-secreting, 69.5% for adrenocorticotropin hormone-secreting, 72.7% for prolactin-secreting and 100% for thyroid-stimulating hormone-secreting, with two recurrences in patients with Cushing's disease. Multivariate analysis showed that factors influencing surgical outcome were cavernous sinus invasion, large tumour diameter (≥25 mm) and reoperation for the nonfunctioning adenomas, and cavernous sinus invasion as well as large tumour diameter (≥25 mm) for the functioning adenomas. In the latter cohort, predictors for endocrinological remission were maximum tumour diameter (≤20 mm) and reoperation. Postoperative complications were present in 3.3% of the cases. One patient developed epistaxis, two hemorrhage at the surgical field, one postoperative rhinorrhea, one postoperative permanent diabetes insipidus and one postoperative panhypopituitarism.

CONCLUSIONS

Microsurgical transsphenoidal surgery is an effective and safe treatment in all patients with pituitary adenomas, except for prolactinomas responsive to medical therapy.

Intraoperative high frequency ultrasound in intracerebral high-grade tumors

PURPOSE

To demonstrate the utility of a new concept of intraoperative use of high frequency ultrasound (hfioUS) in maximizing the extent of resection (EOR) of intracerebral high-grade tumors.

MATERIALS AND METHODS

22 Patients harboring an intracerebral high-grade tumor were retrospectively included in this study (14 primary tumors, 8 metastasis). 14 of them had a perilesional edema equal or greater to lesion volume, 3 had previously received radiotherapy. Following macroscopic tumor debulking, the small (11 × 31 mm) L15 - 7io (Philips, Bothell, USA) high-frequency probe (7 - 15 MHz) was introduced into the resection cavity and its walls were meticulously scanned to search for tumor remnants. Postoperative MR scan was evaluated by a board-certified independent neuroradiologist, who assessed the EOR.

RESULTS

Gross total resection was achieved in 21 patients (95.5 %). One patient had a small tumor remnant (6 × 4 × 3 mm) of a very large (80 × 60 × 74 mm) anaplastic astrocytoma, detected in the postoperative MR scan. A permanent postoperative hemiparesis was diagnosed in one patient with a metastasis in the motor area, while the other patients recovered without permanent neurological deficits from the surgery.

CONCLUSION

The hfioUS probe allowed in this study a precise detection of the tumor and a detailed discrimination between normal, pathological and edematous tissue in all 22 cases.

Successful treatment of duodenal myeloid sarcoma with allogeneic bone marrow transplantation and additional radiotherapy

Myeloid sarcoma (MS) is a tumor consisting of myeloid blasts that occurs at an anatomical site other than the bone marrow. We report the case of a 38-year-old man with duodenal MS who underwent an allogeneic bone marrow transplant in a non-complete remission (CR) state. After the transplant, residual disease was suspected on a fluorodeoxyglucose positron emission tomography (FDG-PET)/CT scan, and additional radiotherapy resulted in CR, which has been maintained for 21 months. FDG-PET/CT scanning is useful for evaluating residual myeloid sarcoma during the peritransplant period.

Standardized FDG uptake as a prognostic variable and as a predictor of incomplete cytoreduction in primary advanced ovarian cancer

INTRODUCTION

In patients with advanced ovarian cancer undergoing preoperative PET/CT, we investigated the prognostic value of SUV in the primary tumor and we evaluated the value of SUV for predicting incomplete primary cytoreduction (macroscopic residual tumor).

MATERIAL AND METHODS

From September 2004 to August 2007, 201 consecutive patients with a pelvic tumor and a Risk of Malignancy Index (RMI) > 150 based on serum CA-125, ultrasound examinations and menopausal state, underwent PET/CT within two weeks prior to standard surgery/debulking of a pelvic tumor. At two-year follow-up (August 15, 2009) the association between SUV and overall survival/cytoreductive result were analyzed in 60 ovarian cancer patients (58 stage III and two stage IV).

RESULTS

At inclusion median age was 62 years (range 35-85 years); 97% (58/60) had a performance status ≤2; 42% (25/60) underwent complete debulking (no macroscopic residual tumor); median SUV(max) was 13.5 (range 2.5-39.0). Median follow-up was 30.2 months. At follow-up 57% (34/60) were alive and 43% (26/60) had died from ovarian cancer. SUV(max) in patients alive was not statistically different from SUV(max) in dead patients (p=0.69), and SUV(max) was not correlated with the amount of residual tumor after surgery (p=0.19). Using univariate Cox regression analysis, residual tumor was a significant prognostic variable (p=0.001); SUV(max) was not a statistically significant prognostic variable (p=0.86).

DISCUSSION

FDG uptake (SUV(max)) in the primary tumor of patients with advanced ovarian cancer was not a prognostic variable and the FDG uptake did not predict complete cytoreduction after primary surgery. Future prospective clinical trials will need to clarify if other PET tracers can serve as prognostic variables in ovarian cancer.

Intraoperative 3-dimensional ultrasound for resection control during brain tumour removal: preliminary results of a prospective randomized study

INTRODUCTION

The amount of resection is closely related to survival in brain tumours. To enhance resection, especially intraoperative magnetic resonance imaging (MRI) has been applied. The aim of this prospective, randomized study was to test if intraoperative 3-D ultrasound likewise can be used for resection control.

METHODS

16 patients, who underwent surgery for intraaxial tumours in non-eloquent brain areas, were initially included into this prospective study. In two patients, the small size of the craniotomy hindered intraoperative ultrasound imaging. In 14 patients, 3-D ultrasound images were obtained before and after opening of the dura, during tumour removal, prior to evaluation by a blinded investigator for identification of tumour remnants, and after dura closure. Seven patients were randomized to complete tumour removal according to the impression of the surgeon (group 1). Seven patients were randomized to incomplete tumour removal (tumour remnant <1cm) (group 2); in these patients, the neurosurgeon intentionally left a tumour remnant prior to evaluation by the blinded investigator. The tumour remnant was then removed. It was tested if 3-D ultrasound can correctly identify complete and incomplete tumour resection. All patients underwent early postoperative MRI.

RESULTS

In two patients (one each of the two groups) the image quality was too poor for a meaningful intraoperative evaluation. In the six patients randomized for incomplete tumour removal, 3-D ultrasound correctly identified tumour remnants in four patients (67%). In six patients randomized for complete tumour removal, 3-D ultrasound confirmed complete tumour resection in three patients. In addition, 3-D ultrasound identified correctly one tumour remnant in a patient randomized for complete tumour removal. Thus, the sensitivity for tumour remnant detection increased to 71% (five of seven patients) and that of confirmation of complete tumour removal was 60 % (three of five patients).

CONCLUSION

The number of investigated patients is still to low to allow definite conclusions. However, the study results suggest, that 3-D ultrasound is especially helpful for detection of overseen brain tumour tissue.

The value of postoperative/preadjuvant chemotherapy computed tomography in the management of patients with ovarian cancer

OBJECTIVE

The objectives of the study were to compare the operative assessment of residual disease with the postoperative computed tomography (CT) findings in patients with ovarian cancer who underwent primary surgical cytoreduction or interval debulking surgery to residual disease 1 cm or less and to assess the effect of potential prognostic factors on patient survival.

METHODS

Patients scheduled for surgery and with an available postoperative CT were eligible for the study. Images were retrospectively analyzed in consensus by 2 radiologists.A 5-point qualitative scoring system was used to evaluate the CT findings (1 = tumor definitely absent, 2 = tumor probably absent, 3 = tumor possibly present, 4 = tumor probably present, 5 = tumor definitely present).

RESULTS

Between September 2005 and December 2008, 206 consecutive patients were enrolled; 51 were eligible. In 30 cases (59%), the postoperative CT findings correlated with the surgeon's assessment of residual disease. For the univariate analyses, the only significant prognostic factors associated with overall survival were no residual disease versus residual disease of less than 1 cm as assessed by the surgeon (hazard ratio [HR], 3.06; 95%confidence interval [CI], 1.29--7.27; P = 0.011) and no residual disease versus residual disease greater than 1 cm on CT (HR, 2.57; 95% CI, 1.02--6.48; P = 0.045). The interaction of surgical residual disease and stage 3 was significant (HR, 3.40; 95% CI, 1.42--8.16;P = 0.006) in the multivariate Cox model.

CONCLUSIONS

There was only 59% correlation between the surgical assessment and post operative CT findings of residual disease in patients reported to have undergone optimal surgery. Stage and residual disease as assessed by the surgeon were significant prognostic factors for overall survival. The value for postoperative CT may lie in those cases with small-volume residual disease (visible but reported as G1 cm) at surgery.