Performance of multiparametric magnetic resonance imaging in the evaluation and management of clinically low-risk prostate cancer

OBJECTIVE

The purpose of this article is to review the multiparametric magnetic resonance imaging (mMRI) of the prostate and MR-guided prostate biopsy, and their role in the evaluation and management of men with low-risk prostate cancer.

METHODS

We performed a literature review based on the MEDLINE database search for publications on the role of mMRI (a) in detection and localization of prostate cancer, prediction of tumor aggressiveness and progression and (b) in guiding targeted prostate biopsy.

RESULTS

The mMRI, particularly diffusion-weighted imaging with T2-weighted imaging, is a useful tool for tumor localization in low-risk prostate cancer as it can detect lesions that are more likely missed on extended biopsy schemes and can identify clinically significant disease requiring definitive treatment. The MR-guided biopsy of the most suspicious lesions enables more accurate and safer approach to guide enrollment into the active surveillance program. However, the MR-guided biopsy is complex. The fusion of MRI data with transrectal ultrasound for the purpose of biopsy provides a more feasible technique with documented accurate sampling.

CONCLUSION

Although the mMRI is not routinely used for risk stratification and prognostic assessment in prostate cancer, it can provide valuable information to guide management of men with low-risk disease. Incorporation of mMRI into the workup and monitoring of patients with low-risk prostate cancer can help discriminate clinically significant disease from indolent disease. Targeted biopsy of MR-suspicious lesions enables accurate sampling of potentially aggressive tumors that may affect outcomes.

Clinical role of contrast-enhanced harmonic endoscopic ultrasound in differentiating solid lesions of the pancreas: a single-center experience in Korea

Background/Aims

The differential diagnosis of pancreatic solid lesions remains challenging. The aim of this study was to investigate the accuracy of contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) in differentiating pancreatic cancer from benign lesions.

Methods

We prospectively evaluated 37 patients with pancreatic solid lesions. After intravenous injection of a contrast agent (SonoVue), CEH-EUS was performed using a radial echoendoscope. Pancreatic solid lesions were classified into three vascular patterns (hyperintense, isointense, and hypointense) on the basis of CEH-EUS imaging, and these patterns were compared to the histological diagnosis.

Results

The lesions were hypervascular (n=6), isovascular (n=3), or hypovascular (n=28). Histological diagnosis was confirmed by EUS-FNA in 26 patients (22 adenocarcinomas, two focal pancreatitis, one pancreatic neuroendocrine tumor [NET], and one pancreatic tuberculosis); by surgery in 10 patients (four adenocarcinomas, three pancreatic NETs, two invasive intraductal papillary mucinous neoplasms, and one acinar cell carcinoma); and by both methods in one patient. Among pancreatic carcinomas, 28 out of 30 lesions (93%) had persistent hypovascular signals in the early and late phase, which indicates a sensitivity and diagnostic accuracy of 93% and 92%, respectively for the diagnosis of pancreatic cancer.

Conclusions

CEH-EUS was useful for characterization of pancreatic solid masses with high sensitivity and accuracy.

Stress-induced cardiomyopathy complicating a stroke caused by an air embolism

Systemic air embolism is a very rare (<0.1%) complication of computed tomography-guided transthoracic needle aspiration and can result in serious neurological and/or cardiac sequelae. Stroke and stress cardiomyopathy can have a variety of etiologies; however, an association of Takotsubo cardiomyopathy with cerebrovascular events precipitated by an air embolus has not been reported. We report a patient with stress-induced cardiomyopathy after an air embolus-induced stroke. The patient was managed with hyperbaric oxygenation and her cardiomyopathy was initially treated as per the acute coronary syndrome protocol until coronary angiography confirmed patent arteries. We review the pathophysiology and management recommendations for both events. Prompt recognition of air embolism-induced cerebrovascular events and stress cardiomyopathy by clinicians is imperative to the timely initiation of appropriate management and a successful treatment outcome.

Serum vascular endothelial growth factor-C levels: A possible diagnostic marker for lymph node metastasis in patients with primary non-small cell lung cancer

Accurate tumor staging is essential for selecting the appropriate treatment strategy for lung cancer. Computed tomography (CT), or positron emission tomography (PET), is the most commonly used non-invasive staging method of lymph node (LN) metastases (LNM), but this method remains unsatisfactory. The present study measured vascular endothelial growth factor (VEGF)-C levels in serum, tumor tissue and LNs to determine the correlation between serum VEGF-C and LNM, and also assessed the usefulness of serum VEGF-C as an additional diagnostic marker for identifying LNM. A total of 66 patients with non-small cell lung carcinoma (NSCLC) or benign tumors of the lung were included in this study, and circulating VEGF-C levels were assessed with enzyme-linked immunosorbent assays. RNA fractions extracted from the tumor tissues and LNs were subjected to quantitative polymerase chain reaction (qPCR) to assess the mRNA levels of VEGF-C. The VEGF-C levels in serum, tumor tissue and LNM were significantly higher compared with the control group (P<0.05). The VEGF-C levels of patients with LNM were significantly higher compared with those without LNM (P<0.05). The VEGF-C levels in the serum, tumor tissue and LNM were significantly correlated (P<0.05). With regard to the diagnosis of LNM using VEGF-C levels, the serum levels of VEGF-C reached a sensitivity of 65.0% and a specificity of 72.2% when a cutoff value of 655.65 pg/ml was applied. Serum VEGF-C levels may provide additional information for distinguishing between the absence and presence of LNM in patients with lung carcinoma. The evaluation of serum VEGF-C is complementary to accurate LN staging in NSCLC.

Reliability of a radiological grading system for dermal backflow in lymphoscintigraphy imaging

RATIONALE AND OBJECTIVES

Lymphoscintigraphy may be used for diagnosing secondary lymphedema. Dermal backflow, the presence of radiotracer in dermal lymphatics, is a key clinical feature. Although often reported as present or absent, a scale that assesses the severity of dermal backflow has been previously developed. The aim of this study was to determine the reliability of these two methods of assessment.

MATERIALS AND METHODS

Sixteen experienced nuclear medicine physicians assessed the quantity of dermal backflow of 57 lymphoscintigraphy scans using a 4-point descriptive scale that was dichotomized for secondary analysis. Each scan included images from four time points for women previously diagnosed with secondary lymphedema (n = 47) and controls (n = 5); five scans were presented twice to examine intraobserver reliability. This was further investigated as 13 physicians viewed the scans again on an Apple iPad2. The physicians rated their confidence in their scoring. Readers were blinded to clinical history.

RESULTS

Although both the 2- and 4-point scale had moderate interobserver reliability, the reliability of the 2-point scale was slightly higher (4-point: Fleiss κ = .418, standard error [SE] = .008); 2-point: Fleiss κ = .574, SE = .013). Low interobserver reliability was found when only control subjects were considered (Fleiss κ = 0.055, SE = 0.034). Intraobserver reliability of the five repeated images varied from poor to perfect (Cohen κ = .063 to 1.00), whereas moderate to substantial intraobserver reliability (Cohen's κ = .342 to .752) was found when comparing devices. The readers were highly confident of their scores.

CONCLUSIONS

Overall, moderate intraobserver and interobserver reliability was found for quantifying dermal backflow with both the 2- and 4-point scale.

Abdominal wall endometrioma: ultrasonographic features and correlation with clinical findings

BACKGROUND

The diagnosis of abdominal wall endometrioma (AWE) is often confused with other surgical conditions. Certain factors relating to knowledge of the clinical history of the disease make correct diagnosis and treatment difficult.

AIMS

To present the clinical findings and ultrasonographic (US) features of AWE with special emphasis on size-related features.

STUDY DESIGN

This study reviewed abdominal wall endometriomas during a 2-year period in the Radiology Department of Sifa University Hospital, Izmir.

METHODS

Eleven women (mean age 32.6 years) with 12 scar endometriomas (mean diameter 29.2 mm) were consecutively evaluated by US and Colour Doppler examination (CDUS) prior to surgery. Lesions were grouped into large (≥3 cm) and small nodules. Vascularisation was classified as location (central, peripheral and mixed) and severity (absent, moderately vascular and hypervascular). In each patient, the nature of pain (absent, cyclic: associated with menstruation and continuous), historical and clinical data were documented. Four patients underwent Magnetic Resonance Imaging and their findings were presented. Fisher's exact test, χ(2) test for categorical data and the unpaired T-test for continuous variables were used for statistical analysis.

RESULTS

In all the women, US of the AWE showed the presence of a solid hypoechoic mass (less echogenic than the surrounding hyperechoic fat) within the abdominal wall. There was a significant correlation between AWE sizes with repeated caesareans and the mean time between the last operation and admission to hospital (p<0.05). Large endometriomas showed increased central vascularity (p<0.05). Cyclic pain was more frequent in small lesions, whereas continuous pain was more commonly found in patients with larger lesions (p<0.05).

CONCLUSION

AWE is often misdiagnosed clinically because endometriosis may occur years after the caesarean section, the pain is often non-cyclic in nature, and there is not always a palpable tender mass. The sonographic and Doppler findings, along with proper correlation with clinical data, may substantially contribute to the correct diagnosis of endometrioma.

Pre-liver transplant biopsy in hepatocellular carcinoma: a potential criterion for exclusion from transplantation?

BACKGROUND

In cirrhotic patients with hepatocellular carcinoma (HCC), poor differentiation in pre-liver transplantation (LT) biopsy of the largest tumour is used as a criterion for exclusion from LT in some centres. The potential role of pre-LT biopsy at one centre was explored.

METHODS

A prospective database of patients undergoing orthotopic LT for radiologically diagnosed HCC at St James's University Hospital, Leeds during 2006-2011 was analysed.

RESULTS

A total of 60 predominantly male (85.0%) patients with viral hepatitis were identified. There were discrepancies between radiological and histopathological findings with respect to the number of tumours identified (in 27 patients, 45.0%) and their size (in 63 tumours, 64.3%). In four (6.7%) patients, the largest lesion, which would theoretically have been targeted for biopsy, was not the largest in the explant. Nine (31.0%) patients with multifocal HCC had tumours of differing grades. In two (6.9%) patients, the largest tumour was well differentiated, but smaller tumours in the explant were poorly differentiated. In one patient, the largest lesion was benign and smaller invasive tumours were confirmed histologically.

CONCLUSIONS

The need to optimize selection for LT in HCC remains. In the present series, the largest tumour was not always representative of overall tumour burden or biological aggression and its potential use to exclude patients from LT is questionable.

Unilocular anterior mandibular swelling

PURPOSE

To report a rare case of chondromyxoid fibroma, presenting as an unilocular anterior mandibular swelling, which is one of the least common tumours of bone comprising less than 1% of bone tumours and to review the differential diagnosis and literature for a better understanding of this disease as well as addressing the controversies in respect with its treatment.

MATERIALS AND METHODS

Previous reports about this lesion in literature were reviewed wherein data was recorded about the age, sex, race, location of pathology, presenting signs and symptoms, duration of pathology, size, radiographic findings, treatment and any recurrence on follow-up.

RESULTS

25 cases were studied and data compiled. Multisectional histopathological examination is advocated to differentiate it from osteosarcoma. Enucleation with or without curettage with long-term follow-up has been considered to be a satisfactory treatment modality.

CONCLUSION

The rarity of the lesion, limited data on the clinical presentation, histological dilemma and treatment options replete with controversies make it a tough predicament. A thorough understanding of the disease and treatment options is indispensable to treat such a case.

Human immunodeficiency virus-associated lung malignancies

This review of lung malignancies in human immunodeficiency virus (HIV) briefly highlights key epidemiologic and clinical features in the pulmonary involvement of AIDS-defining malignancies of Kaposi sarcoma and non-Hodgkin lymphoma. Then, focusing on non-AIDS defining lung cancer, the epidemiology and mechanisms, clinical presentation, pathology, treatment and outcomes, and prevention of HIV-associated lung cancer are discussed. Finally, the important knowledge gaps and future directions for research related to HIV-associated lung malignancies are highlighted.

Sonographic findings of nasopharyngeal carcinoma and its involvement in the parapharyngeal space

OBJECTIVES

The purpose of this study was to determine the sonographic performance in pathologically proven cases of nasopharyngeal carcinoma and its involvement in the parapharyngeal space.

METHODS

The study included 58 patients being treated for suspected nasopharyngeal carcinoma detected by routine nasopharyngoscopy who underwent pathologic biopsy. Sonography was performed immediately thereafter with a convex array transducer in both the B-mode and color mode. Forty-five of the 58 patients (90 parapharyngeal spaces) in whom nasopharyngeal carcinoma was proved by both sonography and pathologic biopsy underwent preradiotherapy magnetic resonance imaging (MRI). The sonographic findings were compared to the pathologic findings. The sonographic findings of parapharyngeal space involvement were correlated with the MRI findings.

RESULTS

The normal anatomy of the nasopharynx and parapharyngeal space, nasopharyngeal carcinoma, and its relationship with the parapharyngeal space were well shown on sonography. The sensitivity of sonography for detection of nasopharyngeal carcinoma was 97.8%, and the specificity was 41.7%. The sonographic findings of parapharyngeal space involvement had a high degree of agreement with MRI (κ = 0.757; P < .001).

CONCLUSIONS

These promising initial data indicate that sonography may be a useful tool for diagnosing nasopharyngeal carcinoma and defining the relationship between the tumor and the parapharyngeal space.

Application of contrast-enhanced ultrasound in the diagnosis of solid pancreatic lesions--a comparison of conventional ultrasound and contrast-enhanced CT

OBJECTIVE

To explore the diagnostic value of contrast-enhanced ultrasound (CEUS) by comparison with conventional ultrasound (US) and contrast-enhanced CT (CECT) in solid pancreatic lesions.

METHOD

Ninety patients with solid pancreatic focal lesions were enrolled, including 36 cases of pancreatic carcinoma, 28 cases of pancreatitis, 6 cases of pancreatic neuroendocrine tumor, 12 cases of solid pseudopapillary tumor of the pancreas, 6 cases of pancreatic metastases, 1 case of cavernous hemolymphangioma and 1 case of lymphoma. US and CEUS were applied respectively for the diagnosis of a total of 90 cases of solid pancreatic lesions. The diagnostic results were scored on a 5-point scale. Results of CEUS were compared with CECT.

RESULTS

(1) 3-score cases (undetermined) diagnosed by CEUS were obviously fewer than that of US, while the number of 1-score (definitely benign) and 5-score (definitely malignant) cases diagnosed by CEUS was significantly more than that of US. There was a significant difference in the distribution of final scores using the two methods (p<0.001). The overall diagnostic accuracies of the 90 cases for CEUS and US were 83.33% and 44.44%, respectively, which indicated an obvious advantage for CEUS (p<0.001). (2) The diagnostic consistency among three ultrasound doctors: the kappa values calculated for US were 0.537, 0.444 and 0.525, compared with 0.748, 0.645 and 0.795 for CEUS. The interobserver agreement for CEUS was higher than that for US. (3) The sensitivity, specificity and accuracy of the diagnosis of pancreatic carcinoma with CEUS and CECT were 91.7% and 97.2%, 87.0% and 88.9%, and 88.9% and 92.2%, respectively, while for the diagnosis of pancreatitis, the corresponding indices were 82.1% and 67.9%, 91.9% and 100%, and 88.9% and 90%, respectively, showing no significant differences (p>0.05).

CONCLUSION

CEUS has obvious superiority over conventional US in the general diagnostic accuracy of solid pancreatic lesions and in the diagnostic consistency among doctors. The performances of CEUS are similar to that of CECT in the diagnosis of pancreatic carcinoma and focal pancreatitis.

Mitral annular caseous calcification: a rare variant of a common echocardiographic finding discovered with advanced imaging techniques

We present the case of a 90-year-old diabetic male and medically managed three-vessel coronary artery disease with evidence of an oval, nonmobile echo-density located on the posterior mitral valve annulus measuring two centimeters in diameter without significant impingement of the mitral valve on initial screening echocardiogram which was initially thought to be prominent mitral annular calcification which was later confirmed to be a rare case of caseoma as confirmed by both cardiac magnetic resonance (CMR) as well as coronary computed tomographic angiography (CCTA).

In vivo X-ray computed tomographic imaging of soft tissue with native, intravenous, or oral contrast

X-ray Computed Tomography (CT) is one of the most commonly utilized anatomical imaging modalities for both research and clinical purposes. CT combines high-resolution, three-dimensional data with relatively fast acquisition to provide a solid platform for non-invasive human or specimen imaging. The primary limitation of CT is its inability to distinguish many soft tissues based on native contrast. While bone has high contrast within a CT image due to its material density from calcium phosphate, soft tissue is less dense and many are homogenous in density. This presents a challenge in distinguishing one type of soft tissue from another. A couple exceptions include the lungs as well as fat, both of which have unique densities owing to the presence of air or bulk hydrocarbons, respectively. In order to facilitate X-ray CT imaging of other structures, a range of contrast agents have been developed to selectively identify and visualize the anatomical properties of individual tissues. Most agents incorporate atoms like iodine, gold, or barium because of their ability to absorb X-rays, and thus impart contrast to a given organ system. Here we review the strategies available to visualize lung, fat, brain, kidney, liver, spleen, vasculature, gastrointestinal tract, and liver tissues of living mice using either innate contrast, or commercial injectable or ingestible agents with selective perfusion. Further, we demonstrate how each of these approaches will facilitate the non-invasive, longitudinal, in vivo imaging of pre-clinical disease models at each anatomical site.

SHILO, a novel dual imaging approach for simultaneous HI-/LOw temporal (Low-/Hi-spatial) resolution imaging for vascular dynamic contrast enhanced cardiovascular magnetic resonance: numerical simulations and feasibility in the carotid arteries

BACKGROUND

Dynamic contrast enhanced (DCE) cardiovascular magnetic resonance (CMR) is increasingly used to quantify microvessels and permeability in atherosclerosis. Accurate quantification depends on reliable sampling of both vessel wall (VW) uptake and contrast agent dynamic in the blood plasma (the so called arterial input function, AIF). This poses specific challenges in terms of spatial/temporal resolution and matched dynamic MR signal range, which are suboptimal in current vascular DCE-CMR protocols. In this study we describe a novel dual-imaging approach, which allows acquiring simultaneously AIF and VW images using different spatial/temporal resolution and optimizes imaging parameters for the two compartments. We refer to this new acquisition as SHILO, Simultaneous HI-/LOw-temporal (low-/hi-spatial) resolution DCE-imaging.

METHODS

In SHILO, the acquisition of low spatial resolution single-shot AIF images is interleaved with segments of higher spatial resolution images of the VW. This allows sampling the AIF and VW with different spatial/temporal resolution and acquisition parameters, at independent spatial locations. We show the adequacy of this temporal sampling scheme by using numerical simulations. Following, we validate the MR signal of SHILO against a standard 2D spoiled gradient recalled echo (SPGR) acquisition with in vitro and in vivo experiments. Finally, we show feasibility of using SHILO imaging in subjects with carotid atherosclerosis.

RESULTS

Our simulations confirmed the superiority of the SHILO temporal sampling scheme over conventional strategies that sample AIF and tissue curves at the same time resolution. Both the median relative errors and standard deviation of absolute parameter values were lower for the SHILO than for conventional sampling schemes. We showed equivalency of the SHILO signal and conventional 2D SPGR imaging, using both in vitro phantom experiments (R2 =0.99) and in vivo acquisitions (R2 =0.95). Finally, we showed feasibility of using the newly developed SHILO sequence to acquire DCE-CMR data in subjects with carotid atherosclerosis to calculate plaque perfusion indices.

CONCLUSIONS

We successfully demonstrate the feasibility of using the newly developed SHILO dual-imaging technique for simultaneous AIF and VW imaging in DCE-CMR of atherosclerosis. Our initial results are promising and warrant further investigation of this technique in wider studies measuring kinetic parameters of plaque neovascularization with validation against gold standard techniques.

Feasibility of MR perfusion-weighted imaging by use of a time-spatial labeling inversion pulse

Perfusion-weighted imaging (PWI) by use of arterial spin labeling (ASL) has been introduced to the clinical setting. However, it is not widely available because it requires specialized pulse sequences. Imaging using a time-spatial labeling inversion pulse (time-SLIP), which is a magnetic resonance angiography (MRA) technique that is based on ASL, can be used in various situations. In this study, we examined the feasibility of time-SLIP PWI. Two types of time-SLIP sequences were evaluated: (1) a single inversion recovery (IR) pulse sequence, which is the same as that used in conventional time-SLIP MRA except for the timing of data acquisition, and (2) a dual IR pulse sequence, where a second, non-selective, IR pulse was added during the inflow time to suppress background signals. Subtraction processing is performed between the "on" and "off" settings of the first IR pulse (time-SLIP tag) to obtain PWI. The average signal intensity was measured in a uniform phantom as the residual of the background, and in five healthy subjects as the perfusion signal. The average signal-to-noise ratio (SNR) was also measured in the five subjects. All imaging was performed with a 1.5-T MR scanner. Images using the dual IR method showed lower background signals and higher perfusion signals compared with images using the single IR method. However, the SNR was lower in images with the dual IR method. These results demonstrate that a time-SLIP, which is an MRA method, can be used for obtaining cerebral PWI simply by adjusting the imaging parameters.

The value of "liver windows" settings in the detection of small renal cell carcinomas on unenhanced computed tomography

OBJECTIVE

To assess if "liver window" settings improve the conspicuity of small renal cell carcinomas (RCC).

METHODS

Patients were analysed from our institution's pathology-confirmed RCC database that included the following: (1) stage T1a RCCs, (2) an unenhanced computed tomography (CT) abdomen performed ≤ 6 months before histologic diagnosis, and (3) age ≥ 17 years. Patients with multiple tumours, prior nephrectomy, von Hippel-Lindau disease, and polycystic kidney disease were excluded. The unenhanced CT was analysed, and the tumour locations were confirmed by using corresponding contrast-enhanced CT or magnetic resonance imaging studies. Representative single-slice axial, coronal, and sagittal unenhanced CT images were acquired in "soft tissue windows" (width, 400 Hounsfield unit (HU); level, 40 HU) and liver windows (width, 150 HU; level, 88 HU). In addition, single-slice axial, coronal, and sagittal unenhanced CT images of nontumourous renal tissue (obtained from the same cases) were acquired in soft tissue windows and liver windows. These data sets were randomized, unpaired, and were presented independently to 3 blinded radiologists for analysis. The presence or absence of suspicious findings for tumour was scored on a 5-point confidence scale.

RESULTS

Eighty-three of 415 patients met the study criteria. Receiver operating characteristics (ROC) analysis, t test analysis, and kappa analysis were used. ROC analysis showed statistically superior diagnostic performance for liver windows compared with soft tissue windows (area under the curve of 0.923 vs 0.879; P = .0002). Kappa statistics showed "good" vs "moderate" agreement between readers for liver windows compared with soft tissue windows.

CONCLUSION

Use of liver windows settings improves the detection of small RCCs on the unenhanced CT.

Impact of the adaptive statistical iterative reconstruction technique on image quality in ultra-low-dose CT

AIM

To evaluate the relationship between different noise indices (NIs) and radiation dose and to compare the effect of different reconstruction algorithm applications for ultra-low-dose chest computed tomography (CT) on image quality improvement and the accuracy of volumetric measurement of ground-glass opacity (GGO) nodules using a phantom study.

MATERIALS AND METHODS

A 11 cm thick transverse phantom section with a chest wall, mediastinum, and 14 artificial GGO nodules with known volumes (919.93 ± 64.05 mm(3)) was constructed. The phantom was scanned on a Discovery CT 750HD scanner with five different NIs (NIs = 20, 30, 40, 50, and 60). All data were reconstructed with a 0.625 mm section thickness using the filtered back-projection (FBP), 50% adaptive statistical iterative reconstruction (ASiR), and Veo model-base iterative reconstruction algorithms. Image noise was measured in six regions of interest (ROIs). Nodule volumes were measured using a commercial volumetric software package. The image quality and the volume measurement errors were analysed.

RESULTS

Image noise increased dramatically from 30.7 HU at NI 20 to 122.4 HU at NI 60, with FBP reconstruction. Conversely, Veo reconstruction effectively controlled the noise increase, with an increase from 9.97 HU at NI 20 to only 15.1 HU at NI 60. Image noise at NI 60 with Veo was even lower (50.8%) than that at NI 20 with FBP. The contrast-to-noise ratio (CNR) of Veo at NI 40 was similar to that of FBP at NI 20. All artificial GGO nodules were successfully identified and measured with an average relative volume measurement error with Veo at NI 60 of 4.24%, comparable to a value of 10.41% with FBP at NI 20. At NI 60, the radiation dose was only one-tenth that at NI 20.

CONCLUSION

The Veo reconstruction algorithms very effectively reduced image noise compared with the conventional FBP reconstructions. Using ultra-low-dose CT scanning and Veo reconstruction, GGOs can be detected and quantified with an acceptable accuracy.

Current status of local therapy in malignant gliomas--a clinical review of three selected approaches

Malignant gliomas are the most frequently occurring, devastating primary brain tumors, and are coupled with a poor survival rate. Despite the fact that complete neurosurgical resection of these tumors is impossible in consideration of their infiltrating nature, surgical resection followed by adjuvant therapeutics, including radiation therapy and chemotherapy, is still the current standard therapy. Systemic chemotherapy is restricted by the blood-brain barrier, while methods of local delivery, such as with drug-impregnated wafers, convection-enhanced drug delivery, or direct perilesional injections, present attractive ways to circumvent these barriers. These methods are promising ways for direct delivery of either standard chemotherapeutic or new anti-cancer agents. Several clinical trials showed controversial results relating to the influence of a local delivery of chemotherapy on the survival of patients with both recurrent and newly diagnosed malignant gliomas. Our article will review the development of the drug-impregnated release, as well as convection-enhanced delivery and the direct injection into brain tissue, which has been used predominantly in gene-therapy trials. Further, it will focus on the use of convection-enhanced delivery in the treatment of patients with malignant gliomas, placing special emphasis on potential shortcomings in past clinical trials. Although there is a strong need for new or additional therapeutic strategies in the treatment of malignant gliomas, and although local delivery of chemotherapy in those tumors might be a powerful tool, local therapy is used only sporadically nowadays. Thus, we have to learn from our mistakes in the past and we strongly encourage future developments in this field.

Extracardiac complications in adults with congenital heart disease

With the increasing number of adults living with repaired, or unrepaired, congenital heart disease, there is a growing incidence of extracardiac comorbidities. These comorbidities can affect various organ systems in complex ways, and may have a significant impact on a patient's quality of life and survival. Many of these potential complications may go undiagnosed until there is already a significant bearing on the patient's life. Therefore, it is important for physicians who care for the adult congenital patient to be mindful of these potential extracardiac complications, and actively assess for these complications in their adult congenital practice. Continued research to identify modifiable risk factors is needed so that both preventative and therapeutic management options for these extracardiac complications may be developed.

Intravoxel incoherent motion model-based liver lesion characterisation from three b-value diffusion-weighted MRI

OBJECTIVE

To evaluate intravoxel incoherent motion (IVIM) model-based liver lesion characterisation from three b-value diffusion-weighted imaging (DWI).

METHODS

The 1.5-T DWI data from a respiratory gated spin-echo echo-planar magnetic resonance imaging sequence (b = 0, 50, 800 s/mm(2)) were retrospectively analysed in 38 patients with different liver lesions. Conventional apparent diffusion coefficient ADC = ADC(0,800) as well as IVIM-based parameters D' = ADC(50,800), ADC_low = ADC(0,50), and f' were calculated voxel-wise. Sixty-one regions of interest in hepatocellular carcinomas (HCCs, n = 24), haemangiomas (HEMs, n = 11), focal nodular hyperplasias (FNHs, n = 11), and healthy liver tissue (REFs, n = 15) were analysed. Group differences were investigated using Student's t-test and receiver-operating characteristic (ROC) analysis.

RESULTS

Mean values ± standard deviations of ADC, D', ADC_low (in 10(-5) mm(2)/s), and f' (in %) for REFs/FNHs/HEMs/HCCs were 130 ± 11/143 ± 27/168 ± 16/113 ± 25, 104 ± 12/123 ± 25/162 ± 18/102 ± 23, 518 ± 66/437 ± 97/268 ± 69/283 ± 120, and 18 ± 3/14 ± 4/6 ± 3/9 ± 5, respectively. Differences between lesions and REFs were more significant for IVIM-based parameters than for conventional ADC. ROC analysis showed the best discriminability between HCCs and FNHs for ADC_low and f' and between HEMs and FNHs or HCCs for D'.

CONCLUSION

Three instead of two b-value DWI enables a numerically stable and voxel-wise IVIM-based analysis for improved liver lesion characterisation with tolerable acquisition time.

KEY POINTS

• Quantitative analysis of diffusion-weighted MRI helps liver lesion characterisation. • Analysis of intravoxel incoherent motion is superior to apparent diffusion coefficient determination. • Only three b-values enable separation of diffusion and microcirculation effects. • The method presented is numerically stable, with voxel-wise results and short acquisition times.

Efficacy and safety of radiofrequency ablation for hepatocellular carcinoma in the caudate lobe of the liver

AIM

Radiofrequency ablation (RFA) is a promising alternative to hepatic resection for the treatment of hepatocellular carcinoma (HCC) located in the caudate lobe. We evaluated the therapeutic efficacy and safety of RFA for HCC located in the caudate lobe compared with HCC located elsewhere in the liver.

METHODS

Overall, 555 consecutive patients treated by RFA for a single HCC tumor of less than 3 cm diameter, were enrolled in this study, including 20 patients with HCC located in the caudate lobe. Among these 20 patients, HCC was located in the Spiegel lobe in eight patients, in the paracaval portion in another 10 and in the caudate process in two. We evaluated differences in the local recurrence rate and the incidence of complications associated with RFA between the caudate and the non-caudate groups.

RESULTS

The 4-year cumulative local recurrence rate after RFA in the caudate group and the non-caudate group was 22.3% and 4.5%, respectively (P < 0.001). Multivariate analysis of factors affecting local recurrence demonstrated that tumor size and tumor location (caudate or non-caudate) were independent significant factors. No postoperative complications were observed in the caudate group, whereas 15 patients (2.8%) in the non-caudate group experienced complications related to RFA.

CONCLUSION

We were able to safely treat HCC located in the caudate lobe by RFA. However, there was a high incidence of local recurrence, presumably because of the heat sink effect of the inferior vena cava and the restricted puncture approach. We should pursue a revised method to reduce local recurrence.

Clinical usefulness of plasma chromogranin a in pancreatic neuroendocrine neoplasm

Chromogranin A (CgA) is widely used as an immunohistochemical marker of neuroendocrine neoplasms and has been measurable in plasma of patients. We assessed the clinical role of plasma CgA in diagnosing pancreatic neuroendocrine neoplasm (PNEN). CgA was checked in 44 patients with pancreatic mass who underwent surgical resection from 2009 through 2011. The cutoff value for diagnosing PNEN and the relationships between CgA and clinicopathologic variables were analyzed. Twenty-six patients were PNENs and 18 patients were other pancreatic disorders. ROC analysis showed a cutoff of 60.7 ng/mL with 77% sensitivity and 56% specificity, and the area under the curve (AUC) was 0.679. Among PNEN group, the sensitivity and specificity of diagnosing metastasis were 100% and 90% respectively when CgA cutoff was 156.5 ng/mL. The AUC was 0.958. High Ki-67 index (160.8 vs 62.1 ng/mL, P = 0.001) and mitotic count (173.5 vs 74.6 ng/mL, P = 0.044) were significantly correlated with plasma CgA, but the tumor size was not. In conclusion, CgA has a little value in diagnosing PNEN. However, the high level of CgA (more than 156.5 ng/mL) can predict the metastasis. Also, plasma CgA level correlates with Ki-67 index and mitotic count which represents prognosis of PNENs.

Redefining lumbosacral transitional vertebrae (LSTV) classification: integrating the full spectrum of morphological alterations in a biomechanical continuum

In light of advancements in imaging techniques and basic science studies, this study proposes modifications in the existing Castellvi's classification for better clinical and biomechanical correlation of LSTV subtypes. LSTVs are commonly occurring variations of the lower spine. The current system does not include functionally important structural variations of the neural arch components and sacral auricular surfaces induced by LSTV afflictions within the classification. This study is an attempt to integrate vital biomechanical correlates into the proposed modification. Emerging diagnostic and clinical evidence also point out the need of understating subdivisions within LSTV anomalies as distinctly stratified entities to get a better correlation with the biomechanical continuum involved with LSTV associated low back pain. Important neural arch element and sacral auricular surface alterations associated with each LSTV subtypes were studied from a large number of osseous samples and data available from published LSTV related clinical and morphological studies. Sacralisation and lumbarisation were designated separate stratifications in the proposed revision, with arrangement of the LSTV subtypes as members of a LSTV anatomical 'array' extending cranio-caudally at the lumbo-sacral junction. The proposed modification is capable of identifying LSTV associated structural defects (in anterior and posterior elements), their exact level of occurrence and status of facet and auricular surface morphologies. Coding for the inclusion of biomechanically important alterations associated with LSTV types within the proposed new classification would probably be helpful in better clinical correlation of LSTV.

Methodology for improved detection of low concentration metabolites in MRS: optimised combination of signals from multi-element coil arrays

State of the art magnetic resonance imaging (MRI) scanners are generally equipped with multi-element receive coils; 16 or 32 channel coils are common. Their development has been predominant for parallel imaging to enable faster scanning. Less consideration has been given to localized magnetic resonance spectroscopy (MRS). Multinuclear studies, for example (31)P or (13)C MRS, are often conducted with a single element coil located over the region of interest. (1)H MRS studies have generally employed the same multi-element coils used for MRI, but little consideration has been given as to how the spectroscopic data from the different channels are combined. In many cases it is simply co-added with detrimental effect on the signal to noise ratio. In this study, we derive the optimum method for combining multi-coil data, namely weighting with the ratio of signal to the square of the noise. We show that provided that the noise is uncorrelated, this is the theoretical optimal combination. The method is demonstrated for in vivo proton MRS data acquired using a 32 channel receive coil at 7T in four different brain areas; left motor and right motor, occipital cortex and medial frontal cortex.

Asymmetrically hypointense veins on T2*w imaging and susceptibility-weighted imaging in ischemic stroke

AIM: To review the literature on the assessment of venous vessels to estimate the penumbra on T2*w imaging and susceptibility-weighted imaging (SWI).

METHODS: Literature that reported on the assessment of penumbra by T2*w imaging or SWI and used a validation method was included. PubMed and relevant stroke and magnetic resonance imaging (MRI) related conference abstracts were searched. Abstracts that had overlapping content with full text articles were excluded. The retrieved literature was scanned for further relevant references. Only clinical literature published in English was considered, patients with Moya-Moya syndrome were disregarded. Data is given as cumulative absolute and relative values, ranges are given where appropriate.

RESULTS: Forty-three publications including 1145 patients could be identified. T2*w imaging was used in 16 publications (627 patients), SWI in 26 publications (453 patients). Only one publication used both (65 patients). The cumulative presence of hypointense vessel sign was 54% (range 32%-100%) for T2* (668 patients) and 81% (range 34%-100%) for SWI (334 patients). There was rare mentioning of interrater agreement (6 publications, 210 patients) and reliability (1 publication, 20 patients) but the numbers reported ranged from good to excellent. In most publications (n = 22) perfusion MRI was used as a validation method (617 patients). More patients were scanned in the subacute than in the acute phase (596 patients vs 320 patients). Clinical outcome was reported in 13 publications (521 patients) but was not consistent.

CONCLUSION: The low presence of vessels signs on T2*w imaging makes SWI much more promising. More research is needed to obtain formal validation and quantification.

MDCT of right aortic arch with aberrant left subclavian artery associated with kommerell diverticulum and calcified ligamentum arteriosum

We present a case of the right aortic arch with kommerell diverticulum (KD) and aberrant left subclavian artery in a symptomatic 50-year-old patient with a calcification in the presumed attachment site of the ligamentum arteriosum (LA) to the KD. In another 30-year-old male patient, the entire course of a calcified LA was demonstrated using multidetector row computed tomography.

Ultrasound elastography in liver

Conventional imaging techniques cannot provide information about tissue mechanical properties. Many injuries can cause changes in tissue stiffness, especially tumors and fibrosis. In recent years, various non-invasive ultrasound methods have been developed to study tissue elasticity for a large number of applications (breast, thyroid, prostate, kidneys, blood vessels, liver…). For non-invasive assessment of liver diseases, several ultrasound elastography techniques have been investigated: Transient elastography (the most extensively used), Real Time Elastography (RTE), Acoustic Radiation Force Impulse Imaging (ARFI) and more recently Shear Wave Elastography (SWE). Even if evaluation of liver fibrosis in chronic liver disease remains the principal application, there are many others applications for liver: predicting cirrhosis-related complications; monitoring antiviral treatments in chronic viral liver disease; characterizing liver tumors; monitoring local treatments, etc. The aim of this article is to report on the different hepatic ultrasound elastography techniques, their advantages and disadvantages, their diagnostic accuracy, their applications in clinical practice.

Multiparametric magnetic resonance imaging of prostate cancer

In India, prostate cancer has an incidence rate of 3.9 per 100,000 men and is responsible for 9% of cancer-related mortality. It is the only malignancy that is diagnosed with an apparently blind technique, i.e., transrectal sextant biopsy. With increasing numbers of high-Tesla magnetic resonance imaging (MRI) equipment being installed in India, the radiologist needs to be cognizant about endorectal MRI and multiparametric imaging for prostate cancer. In this review article, we aim to highlight the utility of multiparamteric MRI in prostate cancer. It plays a crucial role, mainly in initial staging, restaging, and post-treatment follow-up.

Diagnostic performance of various tests and criteria employed in allergic bronchopulmonary aspergillosis: a latent class analysis

Aim

The efficiency of various investigations and diagnostic criteria used in diagnosis of allergic bronchopulmonary aspergillosis (ABPA) remain unknown, primarily because of the lack of a gold standard. Latent class analysis (LCA) can provide estimates of sensitivity and specificity in absence of gold standard. Herein, we report the performance of various investigations and criteria employed in diagnosis of ABPA.

Methods

Consecutive subjects with asthma underwent all the following investigations Aspergillus skin test, IgE levels (total and A.fumigatus specific), Aspergillus precipitins, eosinophil count, chest radiograph, and high-resolution computed tomography (HRCT) of the chest. We used LCA to estimate the performance of various diagnostic tests and criteria in identification of ABPA.

Results

There were 372 asthmatics with a mean age of 35.9 years. The prevalence of Aspergillus sensitization was 53.2%. The sensitivity and specificity of various tests were Aspergillus skin test positivity (94.7%, 79.7%); IgE levels>1000 IU/mL (97.1%, 37.7%); A.fumigatus specific IgE levels>0.35 kUA/L (100%, 69.3%); Aspergillus precipitins (42.7%, 97.1%); eosinophil count>1000 cells/µL (29.5%, 93.1%); chest radiographic opacities (36.1%, 92.5%); bronchiectasis (91.9%, 80.9%); and, high-attenuation mucus (39.7%, 100%). The most accurate criteria was the Patterson criteria using six components followed by the Agarwal criteria. However, there was substantial decline in accuracy of the Patterson criteria if components of the criteria were either increased or decreased from six.

Conclusions

A.fumigatus specific IgE levels and high-attenuation mucus were found to be the most sensitive and specific test respectively in diagnosis of ABPA. The Patterson criteria remain the best diagnostic criteria however they have good veridicality only if six criteria are used.

Future radiation therapy: photons, protons and particles

Radiation therapy plays a critical role in the current management of cancer patients. The most common linear accelerator-based treatment device delivers photons of radiation. In an ever more precise fashion, state-of-the-art technology has recently allowed for both modulation of the radiation beam and imaging for this treatment delivery. This has resulted in better patient outcome with far fewer side effects than were achieved even a decade ago. Recently, a push has begun for proton therapy, which may have clinical advantage in select indications, although significant limitations for these devices have become apparent. In addition, currently, heavy particle therapy has been touted as a potential means to improve cancer patient outcomes. This article will highlight current benefits and drawbacks to modern radiation therapy and speculate on future tools that will likely dramatically improve radiation oncology.

Estimation of the risk of secondary cancer in the thyroid gland and the breast outside the treated volume in patients undergoing brain, mediastinum and breast radiotherapy

The purpose of this study was to measure the peripheral dose which is the absorbed dose in organs located outside the treatment volume such as the thyroid gland and the breast in patients undergoing radiotherapy, utilising the MOSFET dosemeters, as well as to estimate the probability of secondary cancer. The thyroid gland doses, expressed as a percentage of the prescribed dose (%TD), were measured to be 2.0±0.3 %, in whole brain irradiation, 10.0±8.0 % in mediastinum treatment and 8.0±2.0 and 2.0±0.8 % in breast treatment, with and without the supraclavicular irradiation, respectively, with a corresponding risk of 0.2, 2.0, 1.0 and 0.3 %. The dose to the breast was 7.0±2.0 %, in the mediastinum treatment, and 4.0±1.0 and 2.0±0.8 %, in the breast treatment, with and without supraclavicular irradiation, respectively, with a corresponding risk of 4.0, 2.0 and 1.0 %. Although the results indicate that the risk is not negligible, its significance should be considered in conjunction with the existing pathology and age of the patients.

Hepatocellular carcinoma treated with sorafenib: early detection of treatment response and major adverse events by contrast-enhanced US

BACKGROUND & AIMS

Early prediction of tumour response and major adverse events (AEs), especially liver failure, in patients with hepatocellular carcinoma (HCC) is essential for maximizing the clinical benefits of sorafenib. To evaluate the usefulness of dynamic contrast-enhanced ultrasound (DCE-US) for the early prediction of tumour response and major AEs in HCC patients.

METHODS

Thirty-seven HCC patients were started on a reduced dosage of sorafenib, subsequently increased to the standard dosage. Tumour response at 1 month was assessed by CT using the Response Evaluation Criteria in Solid Tumors (RECIST). Major AEs were defined as grade 3 or higher. DCE-US was performed before treatment (day 0) and on days 7, 14 and 28. Changes in perfusion parameters in the tumour and liver parenchyma between day 0 and later time points were compared between treatment responders and nonresponders based on RECIST and between patients who experienced major AEs and those who did not. Tumour results were also compared with progression-free survival (PFS) and overall survival (OS).

RESULTS

Tumour perfusion parameters based on the area under the time-intensity curve (AUC) were statistically significant, with AUC during washin on day 14, the most relevant for tumour response (P = 0.0016) and AUC during washin on day 7, the most relevant for both PFS (P = 0.009) and OS (P = 0.037). A decrease in total AUC between days 0 and 7 in the liver parenchyma was strongly correlated with major AEs (P = 0.0002).

CONCLUSION

DCE-US may be useful for the early prediction of tumour response and major AEs in patients with HCC.