Pearls and Pitfalls of Imaging Small Bowel Obstruction

Small bowel obstruction (SBO) is a common condition encountered by radiologists in the evaluation of patients with abdominal pain, and is an important diagnosis to be comfortable with given substantial associated morbidity and mortality. In this review, we summarize an imaging approach to evaluating patients with suspected SBO, discuss the role of certain imaging modalities such as radiography and small bowel follow through, CT, and MRI, as well as review some common and also less common causes of SBO such as internal hernia. We will also discuss tailoring the imaging approach to address specific clinical questions and special patient populations such as imaging the pregnant patient with suspected SBO, and the inflammatory bowel disease patient.

Systemic Chemotherapies Retain Antitumor Activity in Desmoid Tumors Independent of Specific Mutations in CTNNB1 or APC: A Multi-institutional Retrospective Study

PURPOSE

Determine whether specific CTNNB1 or APC mutations in patients with desmoid tumor were associated with differences in clinical responses to systemic treatments.

EXPERIMENTAL DESIGN

We established a multi-institutional dataset of previously treated patients with desmoid tumor across four U.S. sarcoma centers, including demographic and clinicopathologic characteristics, treatment regimens, and clinical and radiographic responses. CTNNB1 or APC mutation status was determined from prior pathology records, or archival tissue was requested and analyzed by Sanger sequencing and/or next-generation sequencing. Evaluable patients with mutation results were analyzed to determine clinical progression-free survival (cPFS), RECIST 1.1 PFS (rPFS), time to next treatment (TTNT), and overall survival (OS). Kaplan-Meier analysis and Cox proportional hazards regression were performed to identify differences in cPFS, rPFS, TTNT, and OS by mutation subtype, desmoid tumor location, and treatment regimen.

RESULTS

A total of 259 evaluable patients were analyzed for at least one of the survival outcomes, with 177 patients having mutation data. First- and second-line cPFS, rPFS, and TTNT were not significantly affected by mutation subtype; however, APC-mutant desmoid tumors demonstrated nonstatistically significant inferior outcomes. Extremity/trunk desmoid tumor location and treatment with doxorubicin-based, methotrexate/vinca alkaloids and sorafenib regimens were associated with better clinical outcomes compared with surgery or "other" therapies, including estrogen-receptor blockade and imatinib. OS was significantly worse with APC or CTNNB1 negative/other mutations.

CONCLUSIONS

Mutation subtype did not affect responses to specific systemic therapies. APC mutations and nonextremity desmoid tumor locations remain prognostic for worse outcomes, and earlier initiation of systemic therapy for these higher-risk desmoid tumors should be prospectively evaluated. See related commentary by Greene and Van Tine, p. 3911.

MRI Volumetrics and Image Texture Analysis in Assessing Systemic Treatment Response in Extra-Abdominal Desmoid Fibromatosis

Purpose To determine whether MRI volumetric and image texture analysis correlates with treatment-induced biologic changes in desmoid fibromatosis (DF) earlier than conventional response criteria. Materials and Methods This retrospective study included 27 patients with histologically proven extra-abdominal DF who were managed with active surveillance or systemic therapy (from 2004 to 2016). MRI volumetric and image texture parameters were derived from manual tumor segmentations, and tumor signal intensity was normalized to muscle. Results were compared with objective response rates based on Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1, World Health Organization (WHO) lesion response, volumetrics, and MRI-modified Choi criteria. Correlation coefficients (r) between image texture features and maximum tumor diameters were obtained by using a meta-analysis approach. Results The 27 included patients (mean age, 39 years; 74% women) were followed for an average of 4 years, comprising 207 distinct time-point assessments. The mean baseline tumor maximum diameter was 7.9 cm (range, 3.4-15.2 cm). Partial response (PR) rates as best response were 37%, 44%, 70%, and 81% by RECIST, WHO, volumetrics, and MRI-modified Choi criteria, respectively. Among the 10 tumors showing RECIST PR, a preceding MRI-modified Choi PR was observed in 70% (seven of 10), on average 1.3 years earlier. Multiple image texture parameters showed associations with objective measurements of tumor diameter including mean tumor-to-muscle signal ratio (r = 0.51; P = .004), median tumor-to-muscle signal ratio (r = 0.52; P = .003), energy (r = 0.48; P < .001), run entropy (r = 0.32, P = .04), and gray-level nonuniformity (r = 0.54; P ≤ .001). Conclusion Volumetric signal and image texture assessment allows more comprehensive analysis of DF biologic change and may permit early prediction of DF behavior and therapeutic response. Keywords: MR Imaging, Soft Tissues/Skin, Neoplasms-Primary © RSNA, 2021.

Evaluation of How Integrative Oncology Services Are Valued between Hematology/Oncology Patients and Hematologists/Oncologists at a Tertiary Care Center

Evidence regarding opinions on integrative modalities by patients and physicians is lacking. Methods. A survey study was conducted assessing how integrative modalities were valued among hematology/oncology patients and hematologists and oncologists at a major tertiary medical center. Results. 1008 patients and 55 physicians were surveyed. With the exception of support groups, patients valued nutrition services, exercise therapy, spiritual/religious counseling, supplement/herbal advice, support groups, music therapy, and other complimentary medicine services significantly more than physicians (P ≤ 0.05). Conclusion. With the exception of support groups, patients value integrative modalities more than physicians. Perhaps with increasing education, awareness, and acceptance by providers and traditional institutions, integrative modalities could be equally valued between patients and providers. It is possible that increased availability and utilization of integrative oncology modalities at tertiary hospital sites could improve patient satisfaction, quality of life, and other clinical endpoints.

Abstract B36: Compassionate use of an oncolytic adenovirus in a Stage IV treatment-refractory ovarian cancer patient

Ovarian cancer remains the most common cause of death due to gynecologic cancers, and due to its ambiguous symptomatology, diagnosis often occurs at late stages, and prognosis is poor. This case report describes the compassionate use of an oncolytic adenovirus, ONCOS-102, in a 46-year-old female with Stage IV treatment-refractory serous ovarian cancer presenting with metastases to the groin and left breast, peritoneal carcinomatosis, and pleural carcinomatosis. The patient was initially diagnosed in 2007 with a low-grade serous adenocarcinoma of the ovary (pT3, pN1, pMx, G1), c-kit-positive, ER-positive, HER2/EGFR-negative, BRAF -negative and KRAS mutation-negative. Since then, the patient had received multimodal chemotherapy followed by multiple courses of maintenance therapy, with treatments including Bevacizumab (Avastin), Diflunisal/ASA, PAS/ASA, Abraxane, Tamoxifen, Alimta, Gemcitabine, and Topotecan. The patient had also received abandoned radiotherapy and dendritic cell vaccine immunization. Oncos Therapeutics provided ONCOS-102 for compassionate use, based on the rationale that there was no satisfactory alternative treatment, and she was unable to obtain the drug under another IND or clinical trial protocol. ONCOS-102 (Ad5/3-D24-GMCSF) is an oncolytic adenovirus that, due to a 24-bp deletion in its E1A gene, selectively replicates in cancer cells with a defective Rb pathway, and its Ad5 fiber knob protein is replaced with that of Ad3 to facilitate entry into tumor cells. In addition, the virus is armed with a transgene encoding granulocyte/macrophage colony-stimulating factor (GM-CSF). Thus, ONCOS-102 is hypothesized to mediate therapeutic benefit through multiple mechanisms, including direct oncolysis of tumor cells, triggering necrosis/apoptosis via vascular disruption, and activation of innate and adaptive immunity, leading to the induction of a systemic anti-tumor response. Thus, oncolytic virotherapy can be viewed as a form of in situ vaccination, and to further potentiate its effects, our single-patient compassionate use protocol further incorporated a low priming dose of cyclophosphamide (250 mg/m2 IV bolus) for Treg depletion, and a dual checkpoint inhibitor treatment regimen with ipilimumab (3 mg/kg) and nivolumab (1 mg/kg). Approval for the use of this protocol in this patient was obtained from the FDA, as well as the University of Miami's local Institutional Review Board (IRB) and Institutional Biosafety Committee (IBC). The patient passed pre-treatment evaluations and informed consent was obtained for administration of the virus, which was performed following the cyclophosphamide “priming” regimen at a virus dose of 3 x 10^11 VP by intralesional injection into accessible tumors. No product-related adverse events have been observed, and further clinical results will be presented.

Citation Format: Katharina Feister, Sara Collins, Noriyuki Kasahara, Brian Slomovitz. Compassionate use of an oncolytic adenovirus in a Stage IV treatment-refractory ovarian cancer patient. [abstract]. In: Proceedings of the AACR Precision Medicine Series: Targeting the Vulnerabilities of Cancer; May 16-19, 2016; Miami, FL. Philadelphia (PA): AACR; Clin Cancer Res 2017;23(1_Suppl):Abstract nr B36.