A multicentric study of radiomics and artificial intelligence analysis on contrast-enhanced mammography to identify different histotypes of breast cancer

OBJECTIVE

To evaluate the performance of radiomic analysis on contrast-enhanced mammography images to identify different histotypes of breast cancer mainly in order to predict grading, to identify hormone receptors, to discriminate human epidermal growth factor receptor 2 (HER2) and to identify luminal histotype of the breast cancer.

METHODS

From four Italian centers were recruited 180 malignant lesions and 68 benign lesions. However, only the malignant lesions were considered for the analysis. All patients underwent contrast-enhanced mammography in cranium caudal (CC) and medium lateral oblique (MLO) view. Considering histological findings as the ground truth, four outcomes were considered: (1) G1 + G2 vs. G3; (2) HER2 + vs. HER2 - ; (3) HR + vs. HR - ; and (4) non-luminal vs. luminal A or HR + /HER2-  and luminal B or HR + /HER2 + . For multivariate analysis feature selection, balancing techniques and patter recognition approaches were considered.

RESULTS

The univariate findings showed that the diagnostic performance is low for each outcome, while the results of the multivariate analysis showed that better performances can be obtained. In the HER2 + detection, the best performance (73% of accuracy and AUC = 0.77) was obtained using a linear regression model (LRM) with 12 features extracted by MLO view. In the HR + detection, the best performance (77% of accuracy and AUC = 0.80) was obtained using a LRM with 14 features extracted by MLO view. In grading classification, the best performance was obtained by a decision tree trained with three predictors extracted by MLO view reaching an accuracy of 82% on validation set. In the luminal versus non-luminal histotype classification, the best performance was obtained by a bagged tree trained with 15 predictors extracted by CC view reaching an accuracy of 94% on validation set.

CONCLUSIONS

The results suggest that radiomics analysis can be effectively applied to design a tool to support physician decision making in breast cancer classification. In particular, the classification of luminal versus non-luminal histotypes can be performed with high accuracy.

An Informative Review of Radiomics Studies on Cancer Imaging: The Main Findings, Challenges and Limitations of the Methodologies

The aim of this informative review was to investigate the application of radiomics in cancer imaging and to summarize the results of recent studies to support oncological imaging with particular attention to breast cancer, rectal cancer and primitive and secondary liver cancer. This review also aims to provide the main findings, challenges and limitations of the current methodologies. Clinical studies published in the last four years (2019-2022) were included in this review. Among the 19 studies analyzed, none assessed the differences between scanners and vendor-dependent characteristics, collected images of individuals at additional points in time, performed calibration statistics, represented a prospective study performed and registered in a study database, conducted a cost-effectiveness analysis, reported on the cost-effectiveness of the clinical application, or performed multivariable analysis with also non-radiomics features. Seven studies reached a high radiomic quality score (RQS), and seventeen earned additional points by using validation steps considering two datasets from two distinct institutes and open science and data domains (radiomics features calculated on a set of representative ROIs are open source). The potential of radiomics is increasingly establishing itself, even if there are still several aspects to be evaluated before the passage of radiomics into routine clinical practice. There are several challenges, including the need for standardization across all stages of the workflow and the potential for cross-site validation using real-world heterogeneous datasets. Moreover, multiple centers and prospective radiomics studies with more samples that add inter-scanner differences and vendor-dependent characteristics will be needed in the future, as well as the collecting of images of individuals at additional time points, the reporting of calibration statistics and the performing of prospective studies registered in a study database.

Artificial Intelligence and COVID-19 Using Chest CT Scan and Chest X-ray Images: Machine Learning and Deep Learning Approaches for Diagnosis and Treatment

OBJECTIVE

To report an overview and update on Artificial Intelligence (AI) and COVID-19 using chest Computed Tomography (CT) scan and chest X-ray images (CXR). Machine Learning and Deep Learning Approaches for Diagnosis and Treatment were identified.

METHODS

Several electronic datasets were analyzed. The search covered the years from January 2019 to June 2021. The inclusion criteria were studied evaluating the use of AI methods in COVID-19 disease reporting performance results in terms of accuracy or precision or area under Receiver Operating Characteristic (ROC) curve (AUC).

RESULTS

Twenty-two studies met the inclusion criteria: 13 papers were based on AI in CXR and 10 based on AI in CT. The summarized mean value of the accuracy and precision of CXR in COVID-19 disease were 93.7% ± 10.0% of standard deviation (range 68.4-99.9%) and 95.7% ± 7.1% of standard deviation (range 83.0-100.0%), respectively. The summarized mean value of the accuracy and specificity of CT in COVID-19 disease were 89.1% ± 7.3% of standard deviation (range 78.0-99.9%) and 94.5 ± 6.4% of standard deviation (range 86.0-100.0%), respectively. No statistically significant difference in summarized accuracy mean value between CXR and CT was observed using the Chi square test (p value > 0.05).

CONCLUSIONS

Summarized accuracy of the selected papers is high but there was an important variability; however, less in CT studies compared to CXR studies. Nonetheless, AI approaches could be used in the identification of disease clusters, monitoring of cases, prediction of the future outbreaks, mortality risk, COVID-19 diagnosis, and disease management.

Organ Sparing for Locally Advanced Rectal Cancer after Neoadjuvant Treatment Followed by Electrochemotherapy

Simple Summary

This is a Phase II randomized controlled trial conducted with the aim of investigating whether the use of Electrochemotherapy after neoadjuvant therapy (ECT) and before surgery in patients with major clinical response allows for a more conservative surgical approach in patients with Locally Advanced Rectal Cancer (LARC) in comparison with the control group that will not receive ECT. The treatment response, in both the control arm and in the treatment arm, will be assessed using the histopathological tumor regression grade on tissue specimens after local excision.

Abstract

Background: Currently, 45–55% of rectal cancer patients receive preoperative chemo- radio-therapy for Locally Advanced Rectal Cancer (LARC). The idea of our study is to use Electrochemotherapy (ECT) before surgery, in patients with major clinical response after neoadjuvant therapy, to allow for a more conservative surgical approach. Objective: To evaluate the increase of the complete response rate after neoadjuvant treatment in LARC and to spare organ function due to total mesorectal excision (TME). Patients and Methods: This is a Phase II randomized controlled trial enrolling 70 patients that will be developed in two stages. In the first step, 28 patients will be enrolled: 14 of these will receive ECT for four weeks after neo-adjuvant treatment and then local excision (treatment group) and 14 patients will receive neo-adjuvant treatment and then local excision (control group). If an increase of response rate is observed in the first stage, and/or feasibility/safety is demonstrated, the second stage of the trial will be performed, enrolling an additional 42 patients. The treatment response. in both the control arm and the treatment arm, will be assessed using the histopathological tumor regression grade on tissue specimens after local excision.

Current status on response to treatment in locally advanced rectal cancer: what the radiologist should know

The assessment of tumor response, after neoadjuvant radiochemotherapy (nCRT), allows stratifying the patient in order to consider the proper therapeutical management. Histopathology analysis of the surgical specimen is considered the gold standard to assess tumour response and the definition of a complete cancer response is related to the clinical and endoscopic features, by direct evaluation of the rectal wall. However, imaging studies, especially Magnetic Resonance Imaging (MRI) have provided additional parameters, as the evaluation of nodal or mesorectal status. MRI provides a radiological tumour regression grade (mrTRG) that is correlated with the pathologic tumor regression grade (pTRG). Functional MRI parameters have additional impending in early prediction of the efficacy of therapy and can be valuable in drug development processes. Some of functional methodologies are already part of clinical practice: diffusion-weighted MRI (DW-MRI) and perfusion imaging (dynamic contrast enhanced MRI [DCE-MRI]). Other technologies, such as radiomics with MRI are still in the experimental phase. An adequate radiological report describing the restaging of rectal cancer after nCRT should be a "structured report" to improve communication in a multidisciplinary team.

Diffusion and perfusion MR parameters to assess preoperative short-course radiotherapy response in locally advanced rectal cancer: a comparative explorative study among Standardized Index of Shape by DCE-MRI, intravoxel incoherent motion- and diffusion kurtosis imaging-derived parameters

PURPOSE

To assess preoperative short-course radiotherapy (SCR) tumor response in locally advanced rectal cancer (LARC) by means of Standardized Index of Shape (SIS) by dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI), apparent diffusion coefficient (ADC), intravoxel incoherent motion (IVIM) and diffusion kurtosis imaging (DKI) parameters derived from diffusion-weighted MRI (DW-MRI).

MATERIALS AND METHODS

Thirty-four patients with LARC who underwent MRI scans before and after SCR followed by delayed surgery, retrospectively, were enrolled. SIS, ADC, IVIM parameters [tissue diffusion (D_t), pseudo-diffusion (D_p), perfusion fraction (f_p)] and DKI parameters [mean diffusivity (MD), mean of diffusional kurtosis (MK)] were calculated for each patient. IVIM parameters were estimated using two methods, namely conventional biexponential fitting (CBFM) and variable projection (VARPRO). After surgery, the pathological TNM and tumor regression grade (TRG) were estimated. For each parameter, percentage changes between before and after SCR were evaluated. Furthermore, an artificial neural network was trained for outcome prediction. Nonparametric sample tests and receiver operating characteristic curve (ROC) analysis were performed.

RESULTS

Fifteen patients were classified as responders (TRG ≤ 2) and 19 as not responders (TRG > 3). Seven patients had TRG 1 (pathological complete response, pCR). Mean and standard deviation values of pre-treatment CBFM D_p and mean value of VARPRO D_p pre-treatment showed statistically significant differences to predict pCR. (p value at Mann-Whitney test was 0.05, 0.03 and 0.008, respectively.) Exclusively SIS percentage change showed significant differences between responder and non-responder patients after SCR (p value << 0.001) and to assess pCR after SCR (p value << 0.001). The best results to predict pCR were obtained by VARPRO Fp mean value pre-treatment with area under ROC of 0.84, a sensitivity of 96.4%, a specificity of 71.4%, a positive predictive value (PPV) of 92.9%, a negative predictive value (NPV) of 83.3% and an accuracy of 91.2%. The best results to assess after treatment complete pathological response were obtained by SIS with an area under ROC of 0.89, a sensitivity of 85.7%, a specificity of 92.6%, a PPV of 75.0%, a NPV of 96.1% and an accuracy of 91.2%. Moreover, the best results to differentiate after treatment responders vs. non-responders were obtained by SIS with an area under ROC of 0.94, a sensitivity of 93.3%, a specificity of 84.2%, a PPV of 82.4%, a NPV of 94.1% and an accuracy of 88.2%. Promising initial results were obtained using a decision tree tested with all ADC, IVIM and DKI extracted parameter: we reached high accuracy to assess pathological complete response after SCR in LARC (an accuracy of 85.3% to assess pathological complete response after SCR using VARPRO D_p mean value post-treatment, ADC standard deviation value pre-treatment, MD standard deviation value post-treatment).

CONCLUSION

SIS is a hopeful DCE-MRI angiogenic biomarker to assess preoperative treatment response after SCR with delayed surgery. Furthermore, an important prognostic role was obtained by VARPRO F_p mean value pre-treatment and by a decision tree composed by diffusion parameters derived by DWI and DKI to assess pathological complete response.

18F-FDG PET/CT Is an Early Predictor of Pathologic Tumor Response and Survival After Preoperative Radiochemotherapy with Bevacizumab in High-Risk Locally Advanced Rectal Cancer

There is an unmet need for predictive biomarkers of the clinical benefit of antiangiogenic drugs. The aim of the present study was to prospectively evaluate the value of ¹⁸F-FDG PET/CT performed during and after preoperative chemoradiotherapy with bevacizumab for the prediction of complete pathologic tumor regression and survival in patients with MRI-defined high-risk locally advanced rectal cancer. Methods: Sixty-one patients treated in a nonrandomized phase II study (BRANCH) with concomitant or sequential (4 d before chemoradiotherapy) administration of bevacizumab with preoperative chemoradiotherapy were included. ¹⁸F-FDG PET/CT was performed at baseline, 11 d after the beginning of chemoradiotherapy (early), and before surgery (late). Metabolic changes were compared with pathologic complete tumor regression (TRG1) versus incomplete tumor regression (TRG2-TRG5), progression-free survival, cancer-specific survival, and overall survival. Receiver-operating-characteristic curves were calculated for those ¹⁸F-FDG PET/CT parameters that significantly correlated with TRG1. Results: Early total-lesion glycolysis and its percentage change compared with baseline (ΔTLG-early) could discriminate TRG1 from TRG2-TRG5. Only receiver-operating-characteristic analysis of ΔTLG-early showed an area under the curve greater than 0.7 (0.76), with an optimal cutoff at 59.5% (80% sensitivity, 71.4% specificity), for identifying TRG1. Late metabolic assessment could not discriminate between the 2 groups. After a median follow-up of 98 mo (range, 77-132 mo), metabolic responders (ΔTLG-early ≥ 59.5%) demonstrated a significantly higher 10-y progression-free survival (89.3% vs. 63.6%, P = 0.02) and cancer-specific survival (92.9% vs. 72.6%, P = 0.04) than incomplete metabolic responders. Conclusion: Our results suggest that early metabolic response can act as a surrogate marker of the benefit of antiangiogenic therapy. The findings provide further support for the use of early ¹⁸F-FDG PET/CT evaluation to predict pathologic response and survival in the preoperative treatment of patients with locally advanced rectal cancer. ΔTLG-early showed the best accuracy in predicting tumor regression and may be particularly useful in guiding treatment-modifying decisions during preoperative chemoradiotherapy based on expected response.

Assessing response to neo-adjuvant therapy in locally advanced rectal cancer using Intra-voxel Incoherent Motion modelling by DWI data and Standardized Index of Shape from DCE-MRI

Background:

Our aim was to investigate preoperative chemoradiation therapy (pCRT) response in locally advanced rectal cancer (LARC) comparing standardized index of shape (SIS) obtained from dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) with intravoxel-incoherent-motion-modelling-derived parameters by diffusion-weighted imaging (DWI).

Materials and methods:

Eighty-eight patients with LARC were subjected to MRI before and after pCRT. Apparent diffusion coefficient (ADC), tissue diffusion (D_t), pseudodiffusion (D_p) and perfusion fraction (f) were calculated and percentage changes ∆ADC, ∆D_t, ∆D_p, ∆f were computed. SIS was derived comparing DCE-MRI pre- and post-pCRT. Nonparametric tests and receiver operating characteristic (ROC) curves were performed.

Results:

A total of 52 patients were classified as responders (tumour regression grade; TRG ⩽ 2) and 36 as not-responders (TRG > 3). Mann–Whitney U test showed statistically significant differences in SIS, ∆ADC and ∆D_t between responders and not-responders and between complete responders (19 patients with TRG = 1) versus incomplete responders. The best parameters to discriminate responders by nonresponders were SIS and ∆ADC, with an accuracy of 91% and 82% (cutoffs of −5.2% and 18.7%, respectively); the best parameters to detect pathological complete responders were SIS, ∆f and ∆D_p with an accuracy of 78% (cutoffs of 38.5%, 60.0% and 83.0%, respectively). No increase of performance was observed by combining linearly each possible couple of parameters or combining all parameters.

Conclusion:

SIS allows assessment of preoperative treatment response with high accuracy guiding the surgeon versus more or less conservative treatment. DWI-derived parameters reached less accuracy compared with SIS and combining linearly DCE- and DWI-derived parameters; no increase of accuracy was obtained.

Standardized Index of Shape (DCE-MRI) and Standardized Uptake Value (PET/CT): Two quantitative approaches to discriminate chemo-radiotherapy locally advanced rectal cancer responders under a functional profile

Purpose

To investigate dynamic contrast enhanced-MRI (DCE-MRI) in the preoperative chemo-radiotherapy (CRT) assessment for locally advanced rectal cancer (LARC) compared to¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT).

Methods

75 consecutive patients with LARC were enrolled in a prospective study. DCE-MRI analysis was performed measuring SIS: linear combination of percentage change (Δ) of maximum signal difference (MSD) and wash-out slope (WOS). ¹⁸F-FDG PET/CT analysis was performed using SUV maximum (SUV_max). Tumor regression grade (TRG) were estimated after surgery. Non-parametric tests, receiver operating characteristic were evaluated.

Results

55 patients (TRG1-2) were classified as responders while 20 subjects as non responders. ΔSIS reached sensitivity of 93%, specificity of 80% and accuracy of 89% (cut-off 6%) to differentiate responders by non responders, sensitivity of 93%, specificity of 69% and accuracy of 79% (cut-off 30%) to identify pathological complete response (pCR). Therapy assessment via ΔSUV_max reached sensitivity of 67%, specificity of 75% and accuracy of 70% (cut-off 60%) to differentiate responders by non responders and sensitivity of 80%, specificity of 31% and accuracy of 51% (cut-off 44%) to identify pCR.

Conclusions

CRT response assessment by DCE-MRI analysis shows a higher predictive ability than ¹⁸F-FDG PET/CT in LARC patients allowing to better discriminate significant and pCR.

Synergistic antitumor interaction between valproic acid, capecitabine and radiotherapy in colorectal cancer: critical role of p53

Background

Recurrence with distant metastases has become the predominant pattern of failure in locally advanced rectal cancer (LARC), thus the integration of new antineoplastic agents into preoperative fluoropyrimidine-based chemo-radiotherapy represents a clinical challenge to implement an intensified therapeutic strategy.

The present study examined the combination of the histone deacetylase inhibitor (HDACi) valproic acid (VPA) with fluoropyrimidine-based chemo-radiotherapy on colorectal cancer (CRC) cells.

Methods

HCT-116 (p53-wild type), HCT-116 p53^−/− (p53-null), SW620 and HT29 (p53-mutant) CRC cell lines were used to assess the antitumor interaction between VPA and capecitabine metabolite 5′-deoxy-5-fluorouridine (5′-DFUR) in combination with radiotherapy and to evaluate the role of p53 in the combination treatment. Effects on proliferation, clonogenicity and apoptosis were evaluated, along with γH2AX foci formation as an indicator for DNA damage.

Results

Combined treatment with equipotent doses of VPA and 5′-DFUR resulted in synergistic effects in CRC lines expressing p53 (wild-type or mutant). In HCT-116 p53^−/− cells we observed antagonist effects. Radiotherapy further potentiated the antiproliferative, pro-apoptotic and DNA damage effects induced by 5′-DFUR/VPA combination in p53 expressing cells.

Conclusions

These results highlighted the role of VPA as valuable candidate to be added to preoperative chemo-radiotherapy in LARC. On these bases we launched the ongoing phase I/II study of VPA and short-course radiotherapy plus capecitabine as preoperative treatment in low-moderate risk rectal cancer (V-shoRT-R3).

Electronic supplementary material

The online version of this article (10.1186/s13046-017-0647-5) contains supplementary material, which is available to authorized users.

Sequential PET/CT with [18F]-FDG Predicts Pathological Tumor Response to Preoperative Short Course Radiotherapy with Delayed Surgery in Patients with Locally Advanced Rectal Cancer Using Logistic Regression Analysis

Previous studies indicate that FDG PET/CT may predict pathological response in patients undergoing neoadjuvant chemo-radiotherapy for locally advanced rectal cancer (LARC). Aim of the current study is evaluate if pathological response can be similarly predicted in LARC patients after short course radiation therapy alone. Methods: Thirty-three patients with cT2-3, N0-2, M0 rectal adenocarcinoma treated with hypo fractionated short course neoadjuvant RT (5x5 Gy) with delayed surgery (SCRTDS) were prospectively studied. All patients underwent 3 PET/CT studies at baseline, 10 days from RT end (early), and 53 days from RT end (delayed). Maximal standardized uptake value (SUVmax), mean standardized uptake value (SUVmean) and total lesion glycolysis (TLG) of the primary tumor were measured and recorded at each PET/CT study. We use logistic regression analysis to aggregate different measures of metabolic response to predict the pathological response in the course of SCRTDS. Results: We provide straightforward formulas to classify response and estimate the probability of being a major responder (TRG1-2) or a complete responder (TRG1) for each individual. The formulas are based on the level of TLG at the early PET and on the overall proportional reduction of TLG between baseline and delayed PET studies. Conclusions: This study demonstrates that in the course of SCRTDS it is possible to estimate the probabilities of pathological tumor responses on the basis of PET/CT with FDG. Our formulas make it possible to assess the risks associated to LARC borne by a patient in the course of SCRTDS. These risk assessments can be balanced against other health risks associated with further treatments and can therefore be used to make informed therapy adjustments during SCRTDS.

Evaluation of Tumor Response after Short-Course Radiotherapy and Delayed Surgery for Rectal Cancer

Purpose

Neoadjuvant therapy is able to reduce local recurrence in rectal cancer. Immediate surgery after short course radiotherapy allows only for minimal downstaging. We investigated the effect of delayed surgery after short-course radiotherapy at different time intervals before surgery, in patients affected by rectal cancer.

Methods

From January 2003 to December 2013 sixty-seven patients with the following characteristics have been selected: clinical (c) stage T3N0 ≤ 12 cm from the anal verge and with circumferential resection margin > 5 mm (by magnetic resonance imaging); cT2, any N, < 5 cm from anal verge; and patients facing tumors with enlarged nodes and/or CRM+ve who resulted unfit for chemo-radiation, were also included. Patients underwent preoperative short-course radiotherapy with different interval to surgery were divided in three groups: A (within 6 weeks), B (between 6 and 8 weeks) and C (after more than 8 weeks). Hystopatolgical response to radiotherapy was measured by Mandard’s modified tumor regression grade (TRG).

Results

All patients completed the scheduled treatment. Sixty-six patients underwent surgery. Fifty-three of which (80.3%) received a sphincter saving procedure. Downstaging occurred in 41 cases (62.1%). The analysis of subgroups showed an increasing prevalence of TRG 1–2 prolonging the interval to surgery (group A—16.7%, group B—36.8% and 54.3% in group C; p value 0.023).

Conclusions

Preoperative short-course radiotherapy is able to downstage rectal cancer if surgery is delayed. A higher rate of TRG 1–2 can be obtained if interval to surgery is prolonged to more than 8 weeks.

Critical role of bevacizumab scheduling in combination with pre-surgical chemo-radiotherapy in MRI-defined high-risk locally advanced rectal cancer: Results of the BRANCH trial

BACKGROUND

We have previously shown that an intensified preoperative regimen including oxaliplatin plus raltitrexed and 5-fluorouracil/folinic acid (OXATOM/FUFA) during preoperative pelvic radiotherapy produced promising results in locally advanced rectal cancer (LARC). Preclinical evidence suggests that the scheduling of bevacizumab may be crucial to optimize its combination with chemo-radiotherapy.

PATIENTS AND METHODS

This non-randomized, non-comparative, phase II study was conducted in MRI-defined high-risk LARC. Patients received three biweekly cycles of OXATOM/FUFA during RT. Bevacizumab was given 2 weeks before the start of chemo-radiotherapy, and on the same day of chemotherapy for 3 cycles (concomitant-schedule A) or 4 days prior to the first and second cycle of chemotherapy (sequential-schedule B). Primary end point was pathological complete tumor regression (TRG1) rate.

RESULTS

The accrual for the concomitant-schedule was early terminated because the number of TRG1 (2 out of 16 patients) was statistically inconsistent with the hypothesis of activity (30%) to be tested. Conversely, the endpoint was reached with the sequential-schedule and the final TRG1 rate among 46 enrolled patients was 50% (95% CI 35%-65%). Neutropenia was the most common grade ≥ 3 toxicity with both schedules, but it was less pronounced with the sequential than concomitant-schedule (30% vs. 44%). Postoperative complications occurred in 8/15 (53%) and 13/46 (28%) patients in schedule A and B, respectively. At 5 year follow-up the probability of PFS and OS was 80% (95%CI, 66%-89%) and 85% (95%CI, 69%-93%), respectively, for the sequential-schedule.

CONCLUSIONS

These results highlights the relevance of bevacizumab scheduling to optimize its combination with preoperative chemo-radiotherapy in the management of LARC.

A randomized phase 3 study on the optimization of the combination of bevacizumab with FOLFOX/OXXEL in the treatment of patients with metastatic colorectal cancer-OBELICS (Optimization of BEvacizumab scheduLIng within Chemotherapy Scheme)

BACKGROUND

Despite the improvements in diagnosis and treatment, colorectal cancer (CRC) is the second cause of cancer deaths in both sexes. Therefore, research in this field remains of great interest. The approval of bevacizumab, a humanized anti-vascular endothelial growth factor (VEGF) monoclonal antibody, in combination with a fluoropyrimidine-based chemotherapy in the treatment of metastatic CRC has changed the oncology practice in this disease. However, the efficacy of bevacizumab-based treatment, has thus far been rather modest. Efforts are ongoing to understand the better way to combine bevacizumab and chemotherapy, and to identify valid predictive biomarkers of benefit to avoid unnecessary and costly therapy to nonresponder patients. The BRANCH study in high-risk locally advanced rectal cancer patients showed that varying bevacizumab schedule may impact on the feasibility and efficacy of chemo-radiotherapy.

METHODS/DESIGN

OBELICS is a multicentre, open-label, randomised phase 3 trial comparing in mCRC patients two treatment arms (1:1): standard concomitant administration of bevacizumab with chemotherapy (mFOLFOX/OXXEL regimen) vs experimental sequential bevacizumab given 4 days before chemotherapy, as first or second treatment line. Primary end point is the objective response rate (ORR) measured according to RECIST criteria. A sample size of 230 patients was calculated allowing reliable assessment in all plausible first-second line case-mix conditions, with a 80% statistical power and 2-sided alpha error of 0.05. Secondary endpoints are progression free-survival (PFS), overall survival (OS), toxicity and quality of life. The evaluation of the potential predictive role of several circulating biomarkers (circulating endothelial cells and progenitors, VEGF and VEGF-R SNPs, cytokines, microRNAs, free circulating DNA) as well as the value of the early [(18)F]-Fluorodeoxyglucose positron emission tomography (FDG-PET) response, are the objectives of the traslational project.

DISCUSSION

Overall this study could optimize bevacizumab scheduling in combination with chemotherapy in mCRC patients. Moreover, correlative studies could improve the knowledge of the mechanisms by which bevacizumab enhance chemotherapy effect and could identify early predictors of response. EudraCT Number: 2011-004997-27 TRIAL REGISTRATION: ClinicalTrials.gove number, NCT01718873.

Abstract 2569: Synergistic antitumor interaction between valproic acid, capecitabine and radiotherapy in colorectal cancer as a rationale for the innovative V-shoRT-R3 trial in locally advanced rectal cancer patients

We have recently demonstrated that the histone deacetylase-inhibitor (HDACi) vorinostat induces synergistic antitumour effects in combination with capecitabine by up-regulating, in vitro and in vivo, in colorectal cancer cells but not in ex vivo treated peripheral blood lymphocytes, the mRNA and protein expression of thymidine phosphorylase (TP), the key enzyme converting capecitabine to 5-FU (Di Gennaro, Brit J Cancer 2010). We confirmed a time and dose-dependent induction of TP mRNA and protein expression by several other HDACi, including valproic acid (VPA). We investigated potential antitumor interaction between capecitabine metabolite 5′-deoxy-5-fluorouridine (5′-DFUR) and several HDACi showing synergistic/additive antiproliferative and pro-apoptotic effects in all cancer cells tested, with good results with VPA. Interestingly, TP protein induction is achieved also at low doses of VPA (0.5-1 mM), corresponding to a plasma level between 50 and 100 μg/ml, easily reached in patients with normal anticonvulsant doses. Although at these doses VPA did not induce growth inhibition as single agents, a significant synergistic antitumor effect was still demonstrated in combination with 5′-DFUR, suggesting a specific mechanism of interaction. TP knockdown experiments confirmed a crucial role of TP protein modulation in the observed synergism. Radiotherapy further potentiated in colorectal cancer cells the antiproliferative, pro-apoptotic and DNA damage effects induced by 5′-DFUR/VPA combination, as demonstrated by clonogenic assay, Caspase-3 cleavage and γH2AX foci formation, respectively. On these bases we launched a phase I/II clinical study (V-ShoRT-R3 trial) to explore whether the addition of both VPA and capecitabine to short-course radiotherapy (SCRT) before optimal radical surgery, might increase the pathologic complete tumor regression rate in low-moderate risk rectal cancer patients (ClinicalTrials.gov number NCT01898104). Several biomarkers will be evaluated comparing normal mucosa with tumor and on blood samples. Tumor metabolism will be measured by 18FDG-PET at baseline and 11 days after the beginning of SCRT. Currently phase I clinical study is ongoing. We have also optimized a protocol to evaluate histones and proteins acetylation in peripheral blood mononuclear cells of recruited patients by flow cytometry, as pharmacodynamic/predictive specific marker of VPA HDACi activity and preliminary results will be presented.

Citation Format: Manuela Terranova Barberio, Biagio Pecori, Serena Imbimbo, Alessandra Leone, Francesca Bruzzese, Maria Carmela Piccirillo, Paolo Delrio, Franco Bianco, Luigi Aloj, Antonio Sorrentino, Fabiana Tatangelo, Antonella Petrillo, Secondo Lastoria, Paolo Muto, Francesco Perrone, Antonio Avallone, Alfredo Budillon, Elena Di Gennaro. Synergistic antitumor interaction between valproic acid, capecitabine and radiotherapy in colorectal cancer as a rationale for the innovative V-shoRT-R3 trial in locally advanced rectal cancer patients. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 2569. doi:10.1158/1538-7445.AM2015-2569

Phase 1/2 study of valproic acid and short-course radiotherapy plus capecitabine as preoperative treatment in low-moderate risk rectal cancer-V-shoRT-R3 (Valproic acid--short Radiotherapy--rectum 3rd trial)

BACKGROUND

Locally advanced rectal cancer (LARC) is a heterogeneous group of tumors where a risk-adapted therapeutic strategy is needed. Short-course radiotherapy (SCRT) is a more convenient option for LARC patients than preoperative long-course RT plus capecitabine. Histone-deacetylase inhibitors (HDACi) have shown activity in combination with RT and chemotherapy in the treatment of solid tumors. Valproic acid (VPA) is an anti-epileptic drug with HDACi and anticancer activity. In preclinical studies, our group showed that the addition of HDACi, including VPA, to capecitabine produces synergistic antitumour effects by up-regulating thymidine phosphorylase (TP), the key enzyme converting capecitabine to 5-FU, and by downregulating thymidylate synthase (TS), the 5-FU target.

METHODS/DESIGN

Two parallel phase-1 studies will assess the safety of preoperative SCRT (5 fractions each of 5 Gy, on days 1 to 5) combined with (a) capecitabine alone (increasing dose levels: 500-825 mg/m2/bid), on days 1-21, or (b) capecitabine as above plus VPA (oral daily day -14 to 21, with an intra-patient titration for a target serum level of 50-100 microg/ml) followed by surgery 8 weeks after the end of SCRT, in low-moderate risk RC patients. Also, a randomized phase-2 study will be performed to explore whether the addition of VPA and/or capecitabine to preoperative SCRT might increase pathologic complete tumor regression (TRG1) rate. A sample size of 86 patients (21-22/arm) was calculated under the hypothesis that the addition of capecitabine or VPA to SCRT can improve the TRG1 rate from 5% to 20%, with one-sided alpha = 0.10 and 80% power.Several biomarkers will be evaluated comparing normal mucosa with tumor (TP, TS, VEGF, RAD51, XRCC1, Histones/proteins acetylation, HDAC isoforms) and on blood samples (polymorphisms of DPD, TS, XRCC1, GSTP1, RAD51 and XRCC3, circulating endothelial and progenitors cells; PBMCs-Histones/proteins acetylation). Tumor metabolism will be measured by 18FDG-PET at baseline and 15 days after the beginning of SCRT.

DISCUSSION

This project aims to improve the efficacy of preoperative treatment of LARC and to decrease the inconvenience and the cost of standard long-course RT. Correlative studies could identify both prognostic and predictive biomarkers and could add new insight in the mechanism of interaction between VPA, capecitabine and RT.EudraCT Number: 2012-002831-28.

TRIAL REGISTRATION

ClinicalTrials.gov number, NCT01898104.

A prognostic model comprising pT stage, N status, and the chemokine receptors CXCR4 and CXCR7 powerfully predicts outcome in neoadjuvant resistant rectal cancer patients

Despite the optimization of the local treatment of advanced rectal cancer (LARC), combination of preoperative chemoradiotherapy (CRT) and surgery, approximately one third of patients will develop distant metastases. Since the chemokine receptor CXCR4 has been implicated in metastasis development and prognosis in colorectal cancer, the role of the entire axis CXCR4-CXCL12-CXCR7 was evaluated to identify high relapse risk rectal cancer patients. Tumor specimens of 68 LARC patients undergoing surgery after neoadjuvant-CRT were evaluated for CXCR4, CXCR7, and CXCL12 expression through immunohistochemistry. Multivariable prognostic model was developed using classical prognostic factors along with chemokine receptor expression profiles. High CXCR4 correlated with a shorter relapse-free survival (RFS) (p = 0.0006) and cancer specific survival (CSS) (p = 0.0004). Concomitant high CXCR4-negative/low CXCR7 or high CXCR4-negative/low CXCL12 significantly impaired RFS (p = 0.0003 and p = 0.0043) and CSS (p = 0.0485 and p = 0.0026). High CXCR4/N+ identified the worst prognostic category for RFS (p < 0.0001) and CSS (p = 0.0003). The optimal multivariable predictive model for RFS was a five-variable model consisting of gender, pT stage, N status, CXCR4, and CXCR7 (AUC = 0.92, 95% CI = 0.77-0.98). The model is informative and supportive for adjuvant treatment and identifies CXCR4 as a new therapeutic target in rectal cancer.

Multidisciplinary approach to rectal cancer: are we ready for selective treatment strategies?

With optimized local treatment, achieved in the last years by TME surgery and the shift from a postoperative to a preoperative treatment approach, distant metastases have become the predominant mode of failure in rectal cancer. Therefore, the intensification of chemotherapy seems essential to improve distant control and survival in rectal cancer. The integration of newer generation chemotherapeutics and target agents into fluoropyrimidines-based chemoradiotherapy (CRT) has been the more actively pursued intensification strategy. However, early results from randomized phase III trials, evaluating the addition of oxaliplatin to preoperative fluoropyrimidines-based CRT, did not show a significant impact on early pathological response with the addition of oxaliplatin, with the exception of the German CAO/ARO/AIO-04 study. Moreover, the integration of target agents into preoperative CRT, although attractive in principle, has yielded low rates of pathologic complete responses when combined with cetuximab and some concerns on surgical morbidity following preoperative treatment with bevacizumab have been raised. Several novel strategies with different sequence of multimodal treatment components have been developed. However, the evidence that rectal cancers are a widely heterogeneous group of tumors with different prognostic implications, has indicated that the careful assessment of the risk of recurrence is a critical issue. In the era of the preoperative approach, staging with MRI, for its ability to predict the involvement of the mesorectal fascia, should be mandatory for all patients with rectal cancer, to refine the selection of patients for different treatment strategies. Moreover, considering that response to preoperative treatment is not uniformly obtained in all patients and post-operative chemotherapy is generally met with poor adherence, a risk-adapted strategy should be pursued in the postoperative setting as well. The selection of patients for different multidisciplinary treatment strategies based on clinico-pathological features, rather than the current "one size fits all" approach, will allow minimizing therapy and maximizing outcome for rectal cancer patients.

Abstract 4695: Predictive role of FDG PET-CT in monitoring locally advanced rectal cancer (LARC) during preoperative radiochemotherapy with an experimental bevacizumab schedule

Objectives : We have shown that pathological regression of LARC and relapse free survival can be predicted by early changes in FDG uptake during preoperative radiochemotherapy. We have attempted to improve efficacy of our neo-adjuvant treatment by adding an experimental bevacizumab (BEV) schedule. FDG PETCT was utilized to monitor response and correlate with pathological outcome.

Methods : Forty six patients with poor prognosis LARC received 3 biweekly courses of oxaliplatin/ raltitrexed (day 1) and FU/ folinic acid (day 2) during pelvic RT (45 Gy). BEV (5 mg/kg) was administered on day -4 for the first 2 courses. PET-CT was performed at baseline, on day 12 and prior to surgery and lesion TLG (mean SUV x volume) values determined. Pathologic response was defined using a modified Mandard tumor regression grade (TRG) scale. Responders were defined as TRG1-2, non-responders as TRG3-4.

Results : Thirty-seven patients (80%) showed pathologic response (65% with previous scheme). Eight patients (17%, previously 35%) were non-responders. Responders showed significantly higher TLG reduction on day 12 PET-CT (median -72% range -90%+31%) compared to non-responders (TRG3-4, median -38%, range -45% +25%, p &lt; 0.05), confirming previous findings. Preoperative PET-CT studies, on the other hand, were not predictive of pathologic response (responders TLG change median -92%, range -100% +4%, non-responders median 86%, range -94%-76%, p = ns). Ongoing studies to define a correlation between FDG uptake and biomarkers of angiogenesis such as Circulating endothelial cells (CEC) will be presented.

Conclusions : Our findings indicate that the current scheme significantly increases pathologic response. PET-CT confirms to be a powerful early surrogate marker of treatment efficacy. PET-CT may be used to tailor more aggressive treatment for non-responsive patient

Citation Format: Antonio Avallone, Paolo Delrio, Biagio Pecori, Fabiana Tatangelo, Elena Di Gennaro, Antonella Petrillo, Vincenzo Rosario Iaffaioli, Alessandra Leone, Corradina caracò, Alfredo Budillon, Secondo Lastoria, Luigi Aloj. Predictive role of FDG PET-CT in monitoring locally advanced rectal cancer (LARC) during preoperative radiochemotherapy with an experimental bevacizumab schedule. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 4695. doi:10.1158/1538-7445.AM2013-4695

Abstract 1145: CXCR4-CXCL12-CXCR7 axis predicts prognosis in locally advanced-Chemo Radiotherapy (CRT) treated rectal cancer patients

With optimized local treatment and the shift from a postoperative to a preoperative treatment approach, distant metastases have become the predominant mode of failure in locally advanced rectal cancer (LARC). Therefore, the intensification of chemotherapy appears today as an essential approach to improve distant control and survival in LARC. However, extensive evidence have indicated that the LARC presents a considerable heterogeneity in terms of prognostic and response to preoperative treatment. Thus a critical issue is the selection of patients for postoperative chemotherapy strongly favoring a risk-adapted strategy rather than “one size fits all” approach. The chemokine receptor CXCR4 is expressed in colorectal cancer (CRC) and correlates with reduced survival and disease-free interval. A novel receptor for CXCL12, CXCR7, was recently identified. Despite the signal transduction of CXCR7 is not defined it certainly regulates the activity of CXCR4. The aim of the present study is to evaluate the possible prognostic role of CXCR4-CXCL12-CXCR7 axis in LARC patients subjected to CRT neoadjuvant treatment and total mesorectal excision. Sixty-eight LARC patients treated with different scheme of CRT and with persistence of pathological tumor were evaluated for the expression of CXCR4, CXCR7, CXCL12 through immunohistochemistry. CXCR4 and CXCR7 were rated as negative (0-50%) CXCL12 was rated as low (50%). At a median follow up of 65 months, high CXCR4 expression (&gt;50%) impacted significantly on 5- years-relapse free survival (RFS) and -cancer specific survival (CSS); high CXCR4 patients had a 5-year RFS of 51,5% versus 93,7% negative-low CXCR4 (HR 0.10; 95% CI, 0.07-0.44) (p = 0.0003), patients with high CXCR4 had a 5-year CSS of 69% versus the 100% of negative-low CXCR4 (HR 0.00; 95% CI, 0.03-0.43) (p = 0.001). The expression of CXCR7 and CXCL12 alone did not correlate with survival; concomitant expression of CXCR4/CXCR7 or CXCR4/CXCL12 improved the prediction of survival. High CXCR4 expression/ neg-low CXCR7 (&lt; 50%) impacted on 5 years- RFS (p = 0.0001) as well as CSS (p = 0.0278); high CXCR4 expression plus neg-low CXCL12 (&lt;50%) affected 5 years-RFS (p = 0.0166) and CSS (p = 0.0145). Interestingly evaluating CXCR4 categories (negative/low and high) versus the lymph nodal status (negative and positive) significantly improved the predictive power of CXCR4 and N status. High CXCR4 expression plus N+ identified patients with a worse 5 years RFS (p= 0.0001). The valuation of the CXCR4-CXCL12-CXCR7 axis is a valuable prognostic tool in rectal cancer patients treated with CRT neoadjuvant. Moreover CXCR4 inhibitors might be considered in the adjuvant treatment of rectal cancer.

Citation Format: Crescenzo D'Alterio, Antonio Avallone, Paolo Delrio, Fabiana Tatangelo, Biagio Pecori, Elena Di Gennaro, Rosario Vincenzo Iaffaioli, Paolo Muto, Gerardo Botti, Stefania Scala. CXCR4-CXCL12-CXCR7 axis predicts prognosis in locally advanced-Chemo Radiotherapy (CRT) treated rectal cancer patients. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 1145. doi:10.1158/1538-7445.AM2013-1145

Evaluation of two different schedules of bevacizumab (BEV) with oxaliplatin (OXA), raltitrexed (TOM), levo-folinic acid (LFA), and 5-fluorouracil (5-FU) during preoperative (preop) pelvic RT in high-risk locally advanced rectal cancer (HR-LARC) patients (pts)

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Background: OXA, RTX, 5FU, and LFA during preop pelvic RT produced a high rate of complete (TRG1) or subtotal (TRG2) tumor regression in HR-LARC. BEV might enhance response to chemoradiotherapy (CH-RT), but scheduling of BEV could be critical. Therefore, we added BEV to CH-RT in two different schedules to evaluate their feasibility and activity. According to the Simon's two-stage design, assuming a hypothesis of a 50% TRG1 (α=0.05, β=0.20), at least 6/16 TRG1 should be obtained to continue pts accrual in every schedule. Methods: Inclusion criteria were: cT4, cN+, cT3(<5 cm from the anal verge and/or +ve CRM), resectable M1. Pts received 3 biweekly courses(c) of OXA (100 mg/m2)/TOM (2.5 mg/m2) on day 1, and 5FU (800 mg/m2)/LFA(250 mg/m2) on day 2 during pelvic RT (45 Gy). BEV (5 mg/kg) was given biweekly from day -14 for 4 c in schedule A, and from day -4 for 2 c in schedule B. Toxicity was graded with NCI-CTCv3. Changes of circulating endothelial cells (CECs)assessed by flow cytometry in 17 (7 A; 10 B) pts, and glucose metabolism evaluated by FDG-PET in 27 (15 A; 12 B) pts after 1st c of CT were used as surrogate markers of tumor response. The Mann-Whitney test assessed the differences in CECs and FDG-PET related to schedules. TME was planned 8 wks after CH- RT. Results: Until now, 28 pts (16 A; 12 B) were treated: M/F=19/9; median age 57 (range, 43–74) yrs. All but one pt (A) completed the planned CH-RT. Grade 3/4 neutropenia was the most common toxicity with schedule A (7 pts, 44%), while it never occurred with schedule B. No treatment-related or postop death occurred. CECs were more decreased by schedule B than by schedule A (median, -78% vs -29%, p< 0.05). Glucose metabolism was also more reduced by schedule B (median, -78% vs -50%, p < 0.05). All but one pt (refusal) of schedule A, and 7 pts of schedule B proceeded to TME. With schedule A, 2 pts obtained a TRG1, 8 pts a TRG2, 3 pts a TRG3 and 2 pts a TRG4. With schedule B, 4 pts obtained a TRG1 and 3 pts a TRG2. Conclusions: These data suggest the relevance of BEV scheduling during preop CT-RT to optimize safety and efficacy of the combination treatment. Updated results on the whole study population will be presented.

No significant financial relationships to disclose.

Combined multistep approach in a locally advanced rectal cancer with sacral invasion: case report

Composite pelvic resection with sacrectomy may provide good local control in case of locally advanced rectal cancer infiltrating the sacral bone. A combined multidisciplinary approach including chemotherapy and radiotherapy is here presented for a case of rectal tumor invading the sacrum.

[The recrudescence of spondylodiscitis due to migratory flows. The role of magnetic resonance as a method of first instance in diagnosis and follow-up]

PURPOSE

We report 15 cases of spondylodiscitis due to infective processes of different etiology and stress the role of MRI in the diagnosis and follow-up of this condition, whose high epidemiologic recrudescence is probably related to an increased westward migratory flow.

PATIENT AND METHODS

February through December, 1996, fifteen patients with acute spinal pain were submitted to MRI (1.0 T superconductive magnet, Magnetom SP42E, Siemens, Erlangen, Germany). In all cases both the painful spinal tract and the rest of the spine were studied to detect any infiltrative processes elsewhere in the spine. All patients underwent MR follow-up, according to the evolution of subjective symptoms, until complete recovery of the infections.

RESULTS

MRI always permitted the correct diagnosis to be made and the correct evaluation of infection evolution, allowing adequate (medical and/or surgical) treatment to be carried out in the early stage of infections.

DISCUSSION

MRI can be considered the best diagnostic tool study osteomedullary inflammations and, particularly, to diagnose and follow-up spondylodiscitis. This technique permits clear differentiation between the different evolution stages of the infections, as well as the evaluation of bone, disks, epidural spaces and spinal cord involvement. Moreover the MR findings permit adequate treatment choices, which results in much fewer complications and therefore better prognosis.

CONCLUSIONS

The role of MRI in the diagnosis and follow-up of spondylodiscitis has been fully discussed in the literature. Our report is aimed at stressing the important role of MRI as the technique of choice for the diagnosis of suspected spondylodiscitis, especially considering the high recrudescence of this condition in Western populations which is probably related to increased westward migrations.

Diagnostic and prognostic role of 99mTc-Tetrofosmin in breast cancer

99mTc-Tetrofosmin (TF) is a lipophilic diphosphine compound routinely used for myocardial scintigraphy. Extracardiac utilization has occurred in evaluation of patients with malignant neoplasms and in parathyroid adenomas. Although its uptake mechanisms are not completely understood, they appear similar to those of 99mTc Setamibi (MIBI). The importance of flow and the metabolic status of cells with an intracellular uptake depending on mitochondria and the Na+/K+ pump have been hypothesized. It has also been demonstrated that Tetrofosmin shares with MIBI the property of being a substrate for P-glycoprotein (P-gp), a multidrug resistance transporter. In this review the possible clinical role in breast cancer is analysed. First experiences suggest that scintimammography with TF is useful in patients with indeterminate Mammography and to obtain complementary data to avoid surgery and/or biopsy. TF is a reliable tracer for diagnosis of primary cancer, of local recurrence of axillary lymph node metastases. Preliminary data stimulate a possible role in functional imaging of chemoresistance and in differential diagnosis of distant metastases with main reference to the evaluation of single hot lesions at bone scan.

Kinetics of Tc-99m sestamibi and Tc-99m tetrofosmin in a case of parathyroid adenoma

The uptake of Tc-99m tetrofosmin (TF) is reported in a case of parathyroid adenoma. A 65-year-old woman was studied on different days with TF, Tc-99m sestamibi (MIBI) and Tl-201 chloride (Tl). TF and MIBI injections were preceded by oral administration of potassium perchlorate. Clear identification of the adenoma was observed in all scans. No further information was obtained using a subtraction technique with Tc-99m pertechnetate. Regarding the thyroid/parathyroid ratio, different kinetics between TF and MIBI appear to be demonstrated. In particular, thyroid washout was observed with MIBI but not with TF.

Scintimammography with technetium-99m tetrofosmin in the diagnosis of breast cancer and lymph node metastases

The aim of the study was to evaluate the possible role of scintimammography (SMM) with technetium-99m tetrofosmin in breast cancer. Thirty-three patients with breast disease and ten normal controls were included in the study. Planar scintigraphic images in supine anterior, prone lateral and lateral views, with the patient lying in lateral recumbency, were acquired. A qualitative analysis evaluating both breasts and lymph nodes was performed. All breast lesions were verified after surgery and/or by fine-needle aspiration. In 8 of the 33 patients, mammography was inconclusive because of mastectomy or dense breasts. For mammography, a sensitivity of 95.6%, a specificity of 66.7% and an accuracy of 89.6% were obtained. At SMM, 26 out of 28 malignant lesions (average size 2.8 cm, range 0. 4-12 cm), including two recurrences, were detected with a 92.8% sensitivity, a 100% specificity and a 95.1% accuracy. The smallest detectable carcinoma measured 0.6 cm. Two false-negative results on SMM were found in a 0.4-cm intraductal carcinoma and in the only mucinous papillary carcinoma in our series. With regard to lymph node analysis, 11 out of 12 axillary metastases (sensitivity=91.6%) were detected. A false-positive result, yielding a specificity of 92. 3% was also obtained. A metastatic involvement of the internal mammary chain was observed. No uptake was seen in 11 benign mammary lesions or at the level of the breast and axilla when neoplastic involvement was absent. In conclusion, SMM with 99mTc-tetrofosmin is an effective technique for the evaluation of primary breast carcinomas, recurrences and lymph node metastases.

Prostate-specific antigen as a unique routine test in monitoring therapy for inoperable prostate cancer: comparison with radionuclide bone scan and prostatic acid phosphatase

The aim of the present investigation was the evaluation of cost-effectiveness of variables used in monitoring patients with inoperable prostate cancer. Prostate-specific antigen (PSA), prostatic acid phosphatase (PAP), and radionuclide bone scan were considered. The tumor marker positivity was assessed according to dynamic criteria (> 50% increase between consecutive samples). 108 patients entered the study; 72 patients treated with a luteinizing hormone-releasing hormone analogue were followed up for periods ranging from 12 to 64 months. PSA and PAP levels were measured using immunometric assays. Both cutoff-based and dynamic, serial sample-based decision criteria were employed. With respect to a positive bone scan, PSA showed negative predictive values of 82 and 77%, respectively, using 4 and 10 ng/ml as cutoff points. Progression of the disease to the bone occurred in 20 patients: in 17 PSA was the first indicator of progression, in the other 3 PAP anticipated PSA for a very short time (3-4 months), which was not of relevance to clinical decisions. PAP is less specific and sensitive than PSA; PAP may eventually provide information on disease status in a limited percentage of patients with advanced prostate cancer treated with androgen ablation, being differently regulated with respect to PSA. No increasing PSA profile was detected in patients who responded to the therapy. From the results of the present investigation, we draw the following conclusions: (1) PSA can be used reliably as a unique tool in the follow-up of patients for the early detection of progressive disease, and (2) dynamic criteria of evaluation of serial PSA determinations probably provide more effective and earlier clinical information.

[Pathogenetic endocrine aspects of primary osteoporosis]

The pathogenetic endocrine aspects of primary osteoporosis are reviewed on the basis of some physiological remarks. Specifically, postmenopausal and senile osteoporosis represent 2 distinct clinical entities. For both, the last event in the pathogenetic chain is in any case the negative skeletal balance, but the starting point and the development of processes present differently.