Diffusion-weighted MRI assessment of the peritoneal cancer index before cytoreductive surgery

BACKGROUND

Patients with limited peritoneal metastases from colorectal cancer may be candidates for an aggressive surgical approach including cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). Selection is based on surgical inspection during laparoscopy or laparotomy. The aim of this study was to investigate whether diffusion-weighted MRI (DW-MRI) can be used to select patients for CRS-HIPEC.

METHODS

This was a prospective study at a tertiary referral centre. Patients with confirmed or suspected colorectal peritoneal metastases scheduled for exploratory laparotomy or laparoscopy were eligible. Two radiologists assessed the peritoneal cancer index (PCI) on CT (CT-PCI) and DW-MRI (MRI-PCI). The reference standard was PCI at surgery. Radiologists were blinded to the surgical PCI and to each other's findings. The main outcome was the accuracy of DW-MRI in predicting whether patients had resectable disease (PCI less than 21) or not.

RESULTS

Fifty-six patients were included in the study, of whom 49 could be evaluated. The mean(s.d.) PCI at surgery was 11·27(7·53). The mean MRI-PCI was 10·18(7·07) for reader 1 and 8·59(7·08) for reader 2. Readers 1 and 2 correctly staged 47 of 49 and 44 of 49 patients respectively (accuracy 96 and 90 per cent). Both readers detected all patients with resectable disease with a PCI below 21 at surgery (sensitivity 100 per cent). No patient was overstaged. The intraclass correlation (ICC) between readers was excellent (ICC 0·91, 95 per cent c.i. 0·77 to 0·96). MRI-PCI had a stronger correlation with surgical PCI (ICC 0·83-0·88) than did CT-PCI (ICC 0·39-0·44).

CONCLUSION

DW-MRI is a promising non-invasive tool to guide treatment selection in patients with peritoneal metastases from colorectal cancer.

Preoperative image-guided identification of response to neoadjuvant chemoradiotherapy in esophageal cancer (PRIDE): a multicenter observational study

BACKGROUND

Nearly one third of patients undergoing neoadjuvant chemoradiotherapy (nCRT) for locally advanced esophageal cancer have a pathologic complete response (pCR) of the primary tumor upon histopathological evaluation of the resection specimen. The primary aim of this study is to develop a model that predicts the probability of pCR to nCRT in esophageal cancer, based on diffusion-weighted magnetic resonance imaging (DW-MRI), dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and ¹⁸F-fluorodeoxyglucose positron emission tomography with computed tomography (¹⁸F-FDG PET-CT). Accurate response prediction could lead to a patient-tailored approach with omission of surgery in the future in case of predicted pCR or additional neoadjuvant treatment in case of non-pCR.

METHODS

The PRIDE study is a prospective, single arm, observational multicenter study designed to develop a multimodal prediction model for histopathological response to nCRT for esophageal cancer. A total of 200 patients with locally advanced esophageal cancer - of which at least 130 patients with adenocarcinoma and at least 61 patients with squamous cell carcinoma - scheduled to receive nCRT followed by esophagectomy will be included. The primary modalities to be incorporated in the prediction model are quantitative parameters derived from MRI and ¹⁸F-FDG PET-CT scans, which will be acquired at fixed intervals before, during and after nCRT. Secondary modalities include blood samples for analysis of the presence of circulating tumor DNA (ctDNA) at 3 time-points (before, during and after nCRT), and an endoscopy with (random) bite-on-bite biopsies of the primary tumor site and other suspected lesions in the esophagus as well as an endoscopic ultrasonography (EUS) with fine needle aspiration of suspected lymph nodes after finishing nCRT. The main study endpoint is the performance of the model for pCR prediction. Secondary endpoints include progression-free and overall survival.

DISCUSSION

If the multimodal PRIDE concept provides high predictive performance for pCR, the results of this study will play an important role in accurate identification of esophageal cancer patients with a pCR to nCRT. These patients might benefit from a patient-tailored approach with omission of surgery in the future. Vice versa, patients with non-pCR might benefit from additional neoadjuvant treatment, or ineffective therapy could be stopped.

TRIAL REGISTRATION

The article reports on a health care intervention on human participants and was prospectively registered on March 22, 2018 under ClinicalTrials.gov Identifier: NCT03474341 .

90Y Resin Microspheres Radioembolization for Colon Cancer Liver Metastases Using Full-Strength Contrast Material

OBJECTIVES

To assess safety and efficacy of ⁹⁰Y resin microspheres administration using undiluted non-ionic contrast material (UDCM) {100% Omnipaque-300 (Iohexol)} in both the "B" and "D" lines.

MATERIALS AND METHODS

We reviewed all colorectal cancer liver metastases patients treated with ⁹⁰Y resin microspheres radioembolization (RAE) from 2009 to 2017. As of April 2013, two experienced operators started using UDCM (study group) instead of standard sandwich infusion (control group). Occurrence of myelosuppression (leukopenia, neutropenia, erythrocytopenia or/and thrombocytopenia), stasis, nontarget delivery (NTD), median fluoroscopy radiation dose (FRD), median infusion time (IT), liver progression-free (LPFS) and overall survivals (OS) was evaluated. Complications within 6 months post-RAE were reported according to CTCAE v3.0 criteria.

RESULTS

Study and control groups comprised 23(28%) and 58(72%) patients, respectively. Median follow-up was 9.1 months. There was no statistically significant difference in myelosuppression incidence within 6 months post-RAE between groups. Median FRD and IT for study and control groups were 44.6 vs. 97.35 Gy/cm² (p = 0.048) and 31 vs. 39 min (p = 0.006), respectively. A 38% lower stasis incidence in study group was not significant (p = 0.34). NTD occurred in 1/27(4%) study vs. 5/73(7%) control group procedures (p = 1). Grade 1-2 and grade 3-4 toxicities between study and control group patients were 36%(8/22) vs. 45%(26/58), p = 0.61 and 9%(2/22) vs. 16%(9/58), p = 0.72, respectively. There was no difference in LPFS and OS between groups.

CONCLUSION

Administration of ⁹⁰Y resin microspheres using UDCM in both lines is safe and effective, resulting in lower fluoroscopy radiation dose and shorter infusion time, without evidence of myelosuppression or increased stasis incidence.

Whole-volume vs. segmental CT texture analysis of the liver to assess metachronous colorectal liver metastases

PURPOSE

It is unclear whether changes in liver texture in patients with colorectal cancer are caused by diffuse (e.g., perfusional) changes throughout the liver or rather based on focal changes (e.g., presence of occult metastases). The aim of this study is to compare a whole-liver approach to a segmental (Couinaud) approach for measuring the CT texture at the time of primary staging in patients who later develop metachronous metastases and evaluate whether assessing CT texture on a segmental level is of added benefit.

METHODS

46 Patients were included: 27 patients without metastases (follow-up >2 years) and 19 patients who developed metachronous metastases within 24 months after diagnosis. Volumes of interest covering the whole liver were drawn on primary staging portal-phase CT. In addition, each liver segment was delineated separately. Mean gray-level intensity, entropy (E), and uniformity (U) were derived with different filters (σ0.5-2.5). Patients/segments without metastases and patients/segments that later developed metachronous metastases were compared using independent samples t tests.

RESULTS

Absolute differences in entropy and uniformity between the group without metastases and the group with metachronous metastases group were consistently smaller for the segmental approach compared to the whole-liver approach. No statistically significant differences were found in the texture measurements between both groups.

CONCLUSIONS

In this small patient cohort, we could not demonstrate a clear predictive value to identify patients at risk of developing metachronous metastases within 2 years. Segmental CT texture analysis of the liver probably has no additional benefit over whole-liver texture analysis.

TNM classification and the need for revision of pN3a breast cancer

BACKGROUND

According to the seventh edition of tumour-node-metastasis (TNM) classification, pN3a status in breast cancer patients consists of presence of an infraclavicular lymph node metastasis (LNM) and/or presence of ≥10 axillary LNMs. The aim of this study was to determine whether prognosis of pN3a based on at least an infraclavicular LNM differs from ≥10 axillary LNMs.

METHODS

Data were obtained from the Netherlands Cancer Registry. All patients were diagnosed between 2005 and 2008 with primary invasive epithelial breast cancer and pN2a or pN3a status as pathologic result. Patients with pN3a were subdivided in pN3a based on at least an infraclavicular LNM or ≥10 axillary LNMs. Disease-free survival (DFS) included any local, regional or contralateral recurrence, distant metastasis or death within 5 years. Kaplan-Meier curves provided information on 5-year DFS and 8-year overall survival (OS). In addition, Cox proportional hazards model was used to measure the effect of relevant clinicopathological variables on DFS and OS.

RESULTS

A total of 3400 patients with pN2a and 1788 patients with pN3a were included. In 83 patients, pN3a was based on at least an infraclavicular LNM (4.6%) and in 1705 patients because of ≥10 axillary LNMs (95.4%). After multivariable analyses, DFS and OS were inferior in patients with pN3a based on ≥10 axillary LNMs compared to infraclavicular LNM (DFS 48.8% versus 63.8%, hazard ratio [HR] 1.59, p = 0.036; OS 46.6% versus 63.9%, HR 1.46, p = 0.042). Furthermore, pN2a and pN3a based on infraclavicular LNM had comparable DFS and OS.

CONCLUSION

PN3a status based on an at least an infraclavicular LNM is rare, yet its prognosis is superior to ≥10 axillary LNMs. Reclassification of infraclavicular LNM in the next TNM should therefore be considered into pN2a.

The diagnostic performance of sentinel lymph node biopsy in pathologically confirmed node positive breast cancer patients after neoadjuvant systemic therapy: A systematic review and meta-analysis

PURPOSE

To provide a systematic review and meta-analysis of studies investigating sentinel lymph node biopsy after neoadjuvant systemic therapy in pathologically confirmed node positive breast cancer patients.

METHODS

Pubmed and Embase databases were searched until June 19th, 2015. All abstracts were read and data extraction was performed by two independent readers. A random-effects model was used to pool the proportion for identification rate, false-negative rate (FNR) and axillary pCR with 95% confidence intervals. Subgroup analyses affirmed potential confounders for identification rate and FNR.

RESULTS

A total of 997 abstracts were identified and eventually eight studies were included. Pooled estimates were 92.3% (90.8-93.7%) for identification rate, 15.1% (12.7-17.6%) for FNR and 36.8% (34.2-39.5%) for axillary pCR. After subgroup analysis, FNR is significantly worse if one sentinel node was removed compared to two or more sentinel nodes (23.9% versus 10.4%, p = 0.026) and if studies contained clinically nodal stage 1-3, compared to studies with clinically nodal stage 1-2 patients (21.4 versus 13.1%, p = 0.049). Other factors, including single tracer mapping and the definition of axillary pCR, were not significantly different.

CONCLUSION

Based on current evidence it seems not justified to omit further axillary treatment in every clinically node positive breast cancer patients with a negative sentinel lymph node biopsy after neoadjuvant systemic therapy.

The role of MRI in axillary lymph node imaging in breast cancer patients: a systematic review

Objectives

To assess whether MRI can exclude axillary lymph node metastasis, potentially replacing sentinel lymph node biopsy (SLNB), and consequently eliminating the risk of SLNB-associated morbidity.

Methods

PubMed, Cochrane, Medline and Embase databases were searched for relevant publications up to July 2014. Studies were selected based on predefined inclusion and exclusion criteria and independently assessed by two reviewers using a standardised extraction form.

Results

Sixteen eligible studies were selected from 1,372 publications identified by the search. A dedicated axillary protocol [sensitivity 84.7 %, negative predictive value (NPV) 95.0 %] was superior to a standard protocol covering both the breast and axilla simultaneously (sensitivity 82.0 %, NPV 82.6 %). Dynamic, contrast-enhanced MRI had a lower median sensitivity (60.0 %) and NPV (80.0 %) compared to non-enhanced T1w/T2w sequences (88.4, 94.7 %), diffusion-weighted imaging (84.2, 90.6 %) and ultrasmall superparamagnetic iron oxide (USPIO)- enhanced T2*w sequences (83.0, 95.9 %). The most promising results seem to be achievable when using non-enhanced T1w/T2w and USPIO-enhanced T2*w sequences in combination with a dedicated axillary protocol (sensitivity 84.7 % and NPV 95.0 %).

Conclusions

The diagnostic performance of some MRI protocols for excluding axillary lymph node metastases approaches the NPV needed to replace SLNB. However, current observations are based on studies with heterogeneous study designs and limited populations.

Main Messages

• Some axillary MRI protocols approach the NPV of an SLNB procedure.

• Dedicated axillary MRI is more accurate than protocols also covering the breast.

• T1w/T2w protocols combined with USPIO-enhanced sequences are the most promising sequences.

Mandatory imaging cuts costs and reduces the rate of unnecessary surgeries in the diagnostic work-up of patients suspected of having appendicitis

OBJECTIVE

To evaluate whether mandatory imaging is an effective strategy in suspected appendicitis for reducing unnecessary surgery and costs.

METHODS

In 2010, guidelines were implemented in The Netherlands recommending the mandatory use of preoperative imaging to confirm/refute clinically suspected appendicitis. This retrospective study included 1,556 consecutive patients with clinically suspected appendicitis in 2008-2009 (756 patients/group I) and 2011-2012 (800 patients/group II). Imaging use (none/US/CT and/or MRI) was recorded. Additional parameters were: complications, medical costs, surgical and histopathological findings. The primary study endpoint was the number of unnecessary surgeries before and after guideline implementation.

RESULTS

After clinical examination by a surgeon, 509/756 patients in group I and 540/800 patients in group II were still suspected of having appendicitis. In group I, 58.5% received preoperative imaging (42% US/12.8% CT/3.7% both), compared with 98.7% after the guidelines (61.6% US/4.4% CT/ 32.6% both). The percentage of unnecessary surgeries before the guidelines was 22.9%. After implementation, it dropped significantly to 6.2% (p<0.001). The surgical complication rate dropped from 19.9% to 14.2%. The average cost-per-patient decreased by 594 <euro> from 2,482 to 1,888 <euro> (CL:-1081; -143).

CONCLUSION

Increased use of imaging in the diagnostic work-up of patients with clinically suspected appendicitis reduced the rate of negative appendectomies, surgical complications and costs.

KEY POINTS

• The 2010 Dutch guidelines recommend mandatory imaging in the work-up of appendicitis. • This led to a considerable increase in the use of preoperative imaging. • Mandatory imaging led to reduction in unnecessary surgeries and surgical complications. • Use of mandatory imaging seems to reduce health care costs.

Diagnostic accuracy of preoperative tests for lymph node status in endometrial cancer: a systematic review

Background: Approximately 72% of endometrial cancers are FIGO stage I at diagnosis and about 10% have lymph node metastases. An ideal diagnostic test for nodal disease would be able to prevent both overtreatment (i.e. unnecessary lymphadenectomy) and undertreatment (i.e. withholding lymphadenectomy or adjuvant postoperative treatment to patients with lymph node metastases). Objectives: In this review we compare the accuracy of preoperative tests (computed tomography, magnetic resonance imaging, positron emission tomography-computed tomography, CA-125 serum levels, and ultrasonography) for the detection of lymph node metastases in endometrial cancers with the final histopathologic diagnosis after complete pelvic and para-aortic lymphadenectomy as the gold standard. Method: A systematic search in MEDLINE (using PubMed), Embase and The Cochrane Library was performed up to 23 July 2012. Results: We found one article that met our inclusion criteria for computed tomography, none for magnetic resonance imaging, 2 for positron emission tomography/computed tomography), 2 for CA-125 and none for ultrasonography. Conclusions: Due to the lack of high-quality articles on a preoperative test for lymph node status in endometrial cancer, no proper comparison between these modalities can be made.

Modern multidisciplinary treatment of rectal cancer based on staging with magnetic resonance imaging leads to excellent local control, but distant control remains a challenge

AIM

The purpose of this multicenter cohort study was to evaluate whether a differentiated treatment of primary rectal cancer based on magnetic resonance imaging (MRI) can reduce the number of incomplete resections and local recurrences and improve recurrence-free and overall survival.

METHODS

From February 2003 until January 2008, 296 patients with rectal cancer underwent preoperative MRI using a lymph node specific contrast agent to predict circumferential resection margin (CRM), T- and N-stage. Based on expert reading of the MRI, patients were stratified in: (a) low risk for local recurrence (CRM>2mm and N0 status), (b) intermediate risk and (c) high risk (close/involved CRM, N2 status or distal tumours). Mainly based on this MRI risk assessment patients were treated with (a) surgery only (TME or local excision), (b) preoperative 5 × 5 Gy+TME and (c) a long course of chemoradiation therapy followed by surgery after a 6-8 week interval.

RESULTS

Overall 228 patients underwent treatment with curative intent: 49 with surgery only, 86 with 5 × 5 Gy and surgery and 93 with chemoradiation and surgery. The number of complete resections (margin>1mm) was 218 (95.6%). At a median follow-up of 41 months the three-year local recurrence rate, disease-free survival rate and overall survival rate is 2.2%, 80% and 84.5%, respectively.

CONCLUSION

With a differentiated multimodality treatment based on dedicated preoperative MR imaging, local recurrence is no longer the main problem in rectal cancer treatment. The new challenges are early diagnosis and treatment, reducing morbidity of treatment and preferably prevention of metastatic disease.

Diagnostic accuracy and additional value of diffusion-weighted imaging for discrimination of malignant cervical lymph nodes in head and neck squamous cell carcinoma

INTRODUCTION

The aim was to determine the diagnostic accuracy and additional value of diffusion-weighted imaging for detection of malignant lymph nodes in head and neck squamous cell carcinoma.

METHODS

Two hundred nineteen lymph nodes, predominantly smaller than 10 mm (95.4%), in 16 consecutive patients were evaluated at 1.5 T. Lymph nodes were evaluated for maximum short axial diameter, morphological criteria, and apparent diffusion coefficient (ADC) values (b = 0 and b = 1,000 s/mm(2)). Sensitivity, specificity, positive and negative predictive values as well as diagnostic odds ratios (DORs) and areas under the curves (AUCs) of ROC curves were calculated for the various magnetic resonance imaging (MRI) criteria individually and in combination. Histological examination of lymph nodes in the neck dissection specimen was the gold standard to determine malignant involvement.

RESULTS

The optimal ADC threshold was 1.0 x 10(-3) mm(2)/s. Using this cutoff point, sensitivity and specificity were 92.3% and 83.9%, respectively. When used in combination with size and morphological criteria, ADC value <1.0 x 10(-3) mm(2)/s was the strongest predictor of presence of metastasis (DOR = 97.6). A model which added ADC values to the other MRI criteria performed significantly better than a model without ADC values: AUC = 0.98 versus AUC = 0.91 (p = 0.036).

CONCLUSION

In this study, with predominantly small lymph nodes, the ADC criterion is the strongest independent predictor of presence of metastasis. The use of ADC values in combination with the other MRI criteria significantly improves the discrimination between malignant and benign lymph nodes.

Patterns of local recurrence in rectal cancer: a single-center experience

A cohort of patients operated at the National Cancer Center Hospital in Tokyo for rectal carcinoma, at or below the peritoneal reflection, was reviewed retrospectively. The purpose was to study the risk factors for local relapse and the patterns of local recurrence. Three hundred fifty-one patients operated between 1993 and 2002 for rectal carcinoma, at or below the peritoneal reflection, were analyzed. One hundred forty-five patients, with preoperatively staged T1 or T2 tumors without suspected lymph nodes, underwent total mesorectal excision (TME). Lateral lymph node dissection (LLND) was performed in suspected T3 or T4 disease, or when positive lymph nodes were seen; 73 patients received unilateral LLND and 133 patients received bilateral LLND. Of the 351 patients 6.6% developed local recurrence after 5 years. TME only resulted in 0.8% 5-year local recurrence. In lymph-node-positive patients, 33% of the unilateral LLND group had local relapse, significantly more (p = 0.04) than in the bilateral LLND group with 14% local recurrence. Local recurrence in the lateral, presacral, perineal, and anastomotic subsites was lower in the bilateral LLND group as compared with in the unilateral LLND group. We conclude that, in selected patients, surgery without LLND has a very low local recurrence rate. Bilateral LLND is more effective in reducing the chance of local recurrence than unilateral LLND. Either surgical approach, with or without LLND, requires reliable imaging during work-up.

Linitis plastica of the rectum secondary to bladder carcinoma: a report of two cases and its MR features

Rectal linitis plastica (RLP) is a circumferentially infiltrating intramural anaplastic carcinoma that results in a rigid constricted rectum with thickened walls. A long delay between the onset of symptoms and the diagnosis often occurs because RLP can mimic a lot of diseases and endoscopy and biopsies are often negative, owing to the fact that the mucosa is frequently unaffected in RLP. RLP secondary to bladder cancer is rarely described in the English literature. We present the first report of the MR features of secondary rectal linitis plastica from a bladder carcinoma. Two patients presented with changed bowel habits. All diagnostic tests were inconclusive. In both patients, pelvic T(2) weighted MR images revealed a double-layered thickening of the rectal wall with an inner isointense circumferential thickening of the submucosa and outer hypointense circumferential thickening of the muscular rectal wall. Based on MRI, further investigations were performed and secondary RLP was diagnosed. It is important to establish the diagnosis of RLP early because of its bad prognosis. The value of MRI in supporting the diagnosis of RLP should not be underestimated. As endoscopy plus biopsy can often be negative, we suggest that, if pelvic MRI shows a concentric double layered thickening of the rectal wall over a long segment, then the diagnosis of RLP should be considered. This should prompt further investigations either to confirm or rule out the diagnosis of RLP by performing endoscopy with deep rectal wall biopsies.

Morphological MRI criteria improve the detection of lymph node metastases in head and neck squamous cell carcinoma: multivariate logistic regression analysis of MRI features of cervical lymph nodes

The aim was to evaluate whether morphological criteria in addition to the size criterion results in better diagnostic performance of MRI for the detection of cervical lymph node metastases in patients with head and neck squamous cell carcinoma (HNSCC). Two radiologists evaluated 44 consecutive patients in which lymph node characteristics were assessed with histopathological correlation as gold standard. Assessed criteria were the short axial diameter and morphological criteria such as border irregularity and homogeneity of signal intensity on T2-weighted and contrast-enhanced T1-weighted images. Multivariate logistic regression analysis was performed: diagnostic odds ratios (DOR) with 95% confidence intervals (95% CI) and areas under the curve (AUCs) of receiver-operating characteristic (ROC) curves were determined. Border irregularity and heterogeneity of signal intensity on T₂-weighted images showed significantly increased DORs. AUCs increased from 0.67 (95% CI: 0.61–0.73) using size only to 0.81 (95% CI: 0.75–0.87) using all four criteria for observer 1 and from 0.68 (95% CI: 0.62–0.74) to 0.96 (95% CI: 0.94–0.98) for observer 2 (p < 0.001). This study demonstrated that the morphological criteria border irregularity and heterogeneity of signal intensity on T2-weighted images in addition to size significantly improved the detection of cervical lymph nodes metastases.

Location of involved mesorectal and extramesorectal lymph nodes in patients with primary rectal cancer: preoperative assessment with MR imaging

AIM

The purpose of this study is to evaluate the location of involved mesorectal and extramesorectal lymph nodes as depicted on preoperative MRI. Preoperative availability of this information might be useful for the surgeon as well as the radiation therapist and medical oncologist for optimal treatment strategy: type and extent of neoadjuvant treatment as well as extent of surgical resection.

METHODS

Forty-one patients with biopsy-proven rectal cancer were included. All patients underwent preoperative MRI using USPIO (lymph node specific contrast agent). Location of all mesorectal and extramesorectal nodes visible on MRI was recorded, as well as USPIO prediction on nodal status. Lesion-by-lesion analysis using histology after surgery was performed for patients who did not receive long course chemoradiation therapy.

RESULTS

There were 438 nodes visible, 94 of which were malignant. Most nodes are located in the laterodorsal part of the mesorectum, with no difference in distribution between positive and negative nodes. In relation to height of tumor, the majority of positive nodes are located at tumor height or above. There were significantly more negative nodes (9.6%) located below tumor height as compared to positive nodes (2.1%). There were 40 extramesorectal nodes, in 16 patients, 5 of which were positive in 4 patients. All patients had distal rectal cancer.

CONCLUSION

In conclusion, positive mesorectal nodes are located in the laterodorsal part of the mesorectum, at tumor height or above. Positive nodes distal to the tumor are rare, and occur in patients with more proximal nodal metastases. Positive extramesorectal nodes mainly occur in patients with distal rectal cancer with nodal metastases in the mesorectum.

Detection of lymph node metastases in head and neck cancer: a meta-analysis comparing US, USgFNAC, CT and MR imaging

PURPOSE

To perform a meta-analysis comparing ultrasonography (US), US guided fine needle aspiration cytology (USgFNAC), computed tomography (CT), and magnetic resonance imaging (MRI) in the detection of lymph node metastases in head and neck cancer.

METHODS

MEDLINE, EMBASE and Cochrane databases were searched (January 1990-January 2006) for studies reporting diagnostic performances of US, USgFNAC, CT, and MRI to detect cervical lymph node metastases. Two reviewers screened text and reference lists of potentially eligible articles. Criteria for study inclusion: (1) histopathology was the reference standard, (2) primary tumors and metastases were squamous cell carcinoma and (3) data were available to construct 2 x 2 contingency tables. Meta-analysis of pairs of sensitivity and specificity was performed using bivariate analysis. Summary estimates for diagnostic performance used were sensitivity, specificity, diagnostic odds ratios (DOR) (95% confidence intervals) and summary receiver operating characteristics (SROC) curves.

RESULTS

From seventeen articles, 25 data sets could be retrieved. Eleven articles studied one modality: US (n=4); USgFNAC (n=1); CT (n=3); MRI (n=3). Six articles studied two or more modalities: US and CT (n=2); USgFNAC and CT (n=1); CT and MRI (n=1); MRI and MRI-USPIO (Sinerem) (n=2); US, USgFNAC, CT and MRI (n=1). USgFNAC (AUC=0.98) and US (AUC=0.95) showed the highest areas under the curve (AUC). MRI-USPIO (AUC=0.89) and CT (AUC=0.88) had similar results. MRI showed an AUC=0.79. USgFNAC showed the highest DOR (DOR=260) compared to US (DOR=40), MRI-USPIO (DOR=21), CT (DOR=14) and MRI (DOR=7). Conclusion USgFNAC showed to be the most accurate imaging modality to detect cervical lymph node metastases.

Detection of lymph node metastases in head and neck cancer: a meta-analysis comparing US, USgFNAC, CT and MR imaging

PURPOSE

To perform a meta-analysis comparing ultrasonography (US), US guided fine needle aspiration cytology (USgFNAC), computed tomography (CT), and magnetic resonance imaging (MRI) in the detection of lymph node metastases in head and neck cancer.

METHODS

MEDLINE, EMBASE and Cochrane databases were searched (January 1990-January 2006) for studies reporting diagnostic performances of US, USgFNAC, CT, and MRI to detect cervical lymph node metastases. Two reviewers screened text and reference lists of potentially eligible articles. Criteria for study inclusion: (1) histopathology was the reference standard, (2) primary tumors and metastases were squamous cell carcinoma and (3) data were available to construct 2 x 2 contingency tables. Meta-analysis of pairs of sensitivity and specificity was performed using bivariate analysis. Summary estimates for diagnostic performance used were sensitivity, specificity, diagnostic odds ratios (DOR) (95% confidence intervals) and summary receiver operating characteristics (SROC) curves.

RESULTS

From seventeen articles, 25 data sets could be retrieved. Eleven articles studied one modality: US (n=4); USgFNAC (n=1); CT (n=3); MRI (n=3). Six articles studied two or more modalities: US and CT (n=2); USgFNAC and CT (n=1); CT and MRI (n=1); MRI and MRI-USPIO (Sinerem) (n=2); US, USgFNAC, CT and MRI (n=1). USgFNAC (AUC=0.98) and US (AUC=0.95) showed the highest areas under the curve (AUC). MRI-USPIO (AUC=0.89) and CT (AUC=0.88) had similar results. MRI showed an AUC=0.79. USgFNAC showed the highest DOR (DOR=260) compared to US (DOR=40), MRI-USPIO (DOR=21), CT (DOR=14) and MRI (DOR=7). Conclusion USgFNAC showed to be the most accurate imaging modality to detect cervical lymph node metastases.

Preoperative assessment of the circumferential margin in rectal cancer is more informative in treatment planning than the T stage

Preventing local recurrence in rectal cancer means achieving a free circumferential resection margin (CRM) through an optimal combination of surgery, radiotherapy and chemotherapy. This requires a differentiation between primary resectable and locally advanced cancers. The T staging used, while being a powerful marker of prognosis, has two major downsides. First, accuracy of preoperative predictions of the T stage is unacceptably low. Second, a T3 tumor can be either primary resectable or locally advanced. A review of the literature was performed to establish the value of the CRM as the preferred preoperative staging classification, and to establish the feasibility of predicting the CRM using modern day, high-resolution imaging techniques. We advocate using the CRM as preoperative staging classification. Magnetic resonance imaging and multislice computed tomography offer an accurate pre-operative prediction of the CRM, and staging by means of predicted CRM offers the ideal combination of accuracy and clinical relevance.

Pre-operative imaging of rectal cancer and its impact on surgical performance and treatment outcome

AIM

To discuss the ability of pre-operative MRI to have a beneficial effect on surgical performance and treatment outcome in patients with rectal cancer.

METHODS

A description on how MRI can be used as a tool so select patients for differentiated neoadjuvant treatment, how it can be used as an anatomical road map for the resection of locally advanced cases, and how it can serve as a tool for quality assurance of both the surgical procedure and overall patient management. As an illustration the proportion of microscopically complete resections of the period 1993-1997, when there was no routine pre-operative imaging, is compared to that of the period 1998-2002, when pre-operative MR imaging was standardized.

RESULTS

The proportion of R0 resections increased from 92.5 to 97% (p=0.08) and the proportion of resections with a lateral tumour free margin of >1mm increased from 84.4 to 92.1% (p=0.03). The incomplete resections in the first period were mainly due to inadequate surgical management of unsuspected advanced or bulky tumours, whereas in the second period insufficient consideration was given to extensive neoadjuvant treatment when the tumour was close to or invading the mesorectal fascia on MR.

CONCLUSIONS

There are good indications that in our setting pre-operative MR imaging, along with other improvements in rectal cancer management, had a beneficial effect on patient outcome. Audit and discussion of the incomplete resections can lead to an improved operative and perioperative management.

Imaging for Predicting the Risk Factors—the Circumferential Resection Margin and Nodal Disease—of Local Recurrence in Rectal Cancer: A Meta-Analysis

The aim of the present study was to conduct a meta-analysis of English literature on the accuracy of preoperative imaging in predicting the two most important risk factors for local recurrence in rectal cancer, the circumferential resection margin (CRM) and the nodal status (N-status). Articles published between 1985 and August 2004 that report on the diagnostic accuracy of endoluminal ultrasound (EUS), computed tomography (CT), or magnetic resonance imaging (MRI) in the evaluation of lymph node involvement were included. A similar search was done for the assessment of the circumferential resection margin in rectal cancer in the period from January 1985 till January 2005. The inclusion criteria were as follows: (1) more than 20 patients with histologically proven rectal cancer were included, (2) histology was used as the gold standard, and (3) results were given in a 2 x 2 contingency table or this table could otherwise be extracted from the article by two independent readers. Based on the results summary receiver operating characteristic (ROC) curves were constructed. Only 7 articles matching inclusion criteria were found concerning the CRM. The meta-analysis shows that MRI is rather accurate in diagnosing a close or involved CRM. For nodal status 84 articles could be included. The diagnostic odds ratio of EUS is estimated at 8.83. For MRI and CT, the diagnostic odds ratio are 6.53 and 5.86, respectively. The results show that EUS is slightly, but not significantly, better than MRI or CT for identification of nodal disease. There is no significant difference between the different modalities with respect to staging nodal status. At present, MRI is the only modality that predicts the circumferential resection margin with good accuracy, making it a good tool to identify high and low risk patients. Predicting the N-status remains a problem for the radiologist for every modality, although considering the new developments in MR imaging, this may change in the near future.

Dynamic contrast-enhanced magnetic resonance imaging at 1.5 Tesla with gadopentetate dimeglumine to assess the angiostatic effects of anginex in mice

The purpose of this study was to evaluate the effects of anginex on tumour angiogenesis assessed by dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) on a clinical 1.5 Tesla MR system and with the clinically available contrast agent gadopentetate dimeglumine. C57BL/6 mice carrying B16F10 melanomas were treated with anginex, TNP-470 or saline. Tumour growth curves and microvessel density (MVD) were recorded to establish the effects of treatment. DCE-MRI was performed on day 16 after tumour inoculation, and the endothelial transfer coefficients of the microvessel permeability surface-area product (K(PS)) were calculated using a two-compartment model. Both anginex and TNP-470 resulted in smaller tumour volumes (P<0.0001) and lower MVD (P <0.05) compared to saline. Treatment with anginex resulted in a 64% reduction (P<0.01) of tumour K(PS) and TNP-470 resulted in a 44% reduction (P=0.17), compared to saline. DCE-MRI with a clinically available, small-molecular contrast agent can therefore be used to evaluate the angiostatic effects of anginex and TNP-470 on tumour angiogenesis.