Assessment of contralateral mammary gland dose in the treatment of breast cancer using accelerated hypofractionated radiotherapy

AIM: To measure the dose distribution, related to the treatment planning calculations, in the contralateral mammary gland of breast cancer patients treated with accelerated hypofractionated 3-dimensional conformal radiotherapy.

METHODS: Thirty-four prospectively selected female patients with right breast cancer (pN0, negative surgical margins) were treated with breast-conserving surgery. A total dose of 42.5 Gy (2.66 Gy/fraction) was prescribed; it was requested that planning target volumes be covered by the 95% isodose line. The contralateral mammary gland was defined on CT simulation. The dose received was evaluated by dose volume histograms.

RESULTS: The measured contralateral breast doses were: (1) Dose maximum: 290-448 cGy [Equivalent (Eq) 337-522 cGy]; (2) Mean dose: 45-70 cGy (Eq 524-815 cGy); and (3) Median dose: 29-47 cGy (337-547 cGy) for total primary breast dose of 42.5 Gy in 16 equal fractions. The spearman rho correlation showed statistical significance between the contralateral breast volume and maximum dose (P = 0.0292), as well as mean dose (P = 0.0025) and median dose (P = 0.046) to the breast.

CONCLUSION: Minimizing the dose to the contralateral breast has to be one of the priorities of the radiation oncologist when using short schedules because of the radiosensitivity of this organ at risk. Further study is necessary to assess the long-term clinical impact of this schedule.

A careful evaluation of scout CT lateral radiograph may prevent unreported vertebral fractures

OBJECTIVES

Our purpose was to review scout CT lateral radiographs to reveal osteoporotic vertebral fractures unreported by radiologists and to explore scout CT as a potential diagnostic tool in the detection of vertebral fractures.

METHODS

We considered 500 patients (303 males, 197 females, age 64.6±13.5 year-old). Our investigation was firstly focused on scout CT lateral images to detect vertebral fractures with a combined semiquantitative and quantitative diagnostic approach. Findings addressed to vertebral fracture were subsequently confirmed by multiplanar sagittal CT reconstructions. Whenever a vertebral fracture was discovered the radiologist report was read and a collection of patient anamnesis followed to understand whether fractures were already known.

RESULTS

In 44/500 patients (8.8%) the evaluation on scout CT was incomplete or limited for patient/technical-based conditions, and 15 were excluded from the analysis. In 67/485 patients (13.8%) 99 vertebral fractures were detected. Among 67 fractured patients only 18 (26.9%) were previously diagnosed by radiologists. However, in the clinical history of 32 patients vertebral fractures were already known.

CONCLUSIONS

The perception and sensibility to vertebral fractures among radiologists are still poor when the assessment of the spine is not the aim of the examination. Short time spent for the evaluation of scout CT lateral radiographs could improve our accuracy.

Radiofrequency ablation for the treatment of hepatocellular carcinoma with decompensated cirrhosis

BACKGROUND

Radiofrequency ablation (RFA) is used to treat early-stage hepatocellular carcinoma (HCC), but is sometimes avoided in patients with decompensated liver cirrhosis because of the possible side effect of deterioration of liver function.

AIMS

In this study, we report the safety and effects of RFA for treating HCC patients with Child-Pugh B/C liver cirrhosis.

METHODS

Sixty-six consecutive HCC patients with Child-Pugh B/C cirrhosis, who were treated by RFA, were enrolled in this study. We analyzed patient outcomes, the complications of RFA, and changes in liver function and tumor markers.

RESULTS

Fifty-six patients were classified as Child-Pugh class B, and 10 were classified as class C. The overall survival rates in patients with Child-Pugh B and C cirrhosis were 82 and 83% at 1 year and 47 and 31% at 3 years, respectively. Serum total bilirubin (T.Bil), albumin, prothrombin time, ascites, and encephalopathy were unchanged at 1, 3, and 6 months after RFA in patients with Child-Pugh B cirrhosis; however, serum T.Bil levels increased significantly at 6 months after RFA in 6/10 (60%) patients with Child-Pugh C cirrhosis. Hemothorax and rupture of esophageal varices were observed in 2 patients; however, there were no complications related to poor liver function.

CONCLUSION

RFA is a useful modality for treating HCC in patients with poor liver function such as Child-Pugh B and C, but careful monitoring after RFA must be needed.

EUS for diagnosis of malignant biliary stricture: an analysis of 13 cases

AIM: To compare the clinical value of endoscopic ultrasonography (EUS), endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance cholangiopancreatography (MRCP) in the diagnosis of malignant biliary stricture.

METHODS: The imaging data for 76 patients with malignant biliary stricture who underwent EUS, ERCP or MRCP from January 2008 to May 2010 were retrospectively analyzed. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of each test were compared.

RESULTS: EUS had significantly higher sensitivity (94.2% vs 78.5%), specificity (84.6% vs 57.1%), positive predictive value (89.1% vs 64.5%), negative predictive value (73.3% vs 41.3%) and accuracy (91.6% vs 71.6%) than MRCP in the diagnosis of malignant biliary stricture. EUS had significantly higher sensitivity (94.2% vs 80.5%), specificity (84.6% vs 68.4%) and accuracy (91.6% vs 71.6%) than ERCP in the diagnosis of malignant biliary stricture.

CONCLUSION: EUS has higher sensitivity, specificity and accuracy than MRCP and ERCP in the diagnosis of malignant biliary stricture.

[MRI findings delay the diagnosis of nasopharyngeal carcinoma]

This report concerns a 55-year-old female patient who presented with headache, dry right eye and dry nose on the right side. After 5 months magnetic resonance imaging (MRI) was carried out but no pathological findings were diagnosed. Right-sided facial pain appeared 6 months later and a second MRI was carried out but only fluid retention in the right mastoid was diagnosed. After a further 8 months paresis of the right abducent nerve occurred and a computed tomography (CT) scan of the petrous bone showed extensive destruction of the apex of the petrous pyramid. Subsequently a third MRI revealed a tumor of about 5 cm in diameter in the right pterygopalatine fossa which was also retrospectively visible in the first MRI with a size of approximately 3 cm and in the second MRI with 4 cm in diameter. The histological examination after biopsy resulted in the diagnosis of a nasopharyngeal carcinoma and radiochemotherapy was initiated. The patient died 9 months later. The relatives of the patient applied to the arbitration board for medical liability which requested expert opinions in neuroradiology and otorhinolaryngology. The board came to the conclusion that the claims for damages against the radiologist who had made the three MRIs were well-founded and recommended an extrajudicial settlement.

Effect of SonoVue on the synovial membrane in rabbit knees

OBJECTIVES

The purpose of this study was to evaluate the effect of intra-articular injection of SonoVue (sulfur hexafluoride with a phospholipid shell; Bracco SpA, Milan, Italy) on the synovial membrane in an animal model.

METHODS

Twenty-one New Zealand White rabbits (42 knees) were used in this study. We injected the knees with normal saline (saline group; n = 21) and SonoVue (SonoVue group; n = 21). A histologic examination of the knees was performed out at 3 and 12 hours and 3, 7, 15, 30, and 45 days after injection. Four histologic parameters (synovial hyperplasia, synovial stroma, vascular dilatation, and inflammatory infiltrates) were graded separately.

RESULTS

We found no significant differences in this study for synovial hyperplasia, vascular dilatation, or inflammatory infiltrates between the saline and SonoVue groups. A significant difference was only observed for synovial stroma (P < .05), and most of the histologic changes were mild in the saline group and moderate in the SonoVue group. The histologic changes observed in this study are considered transitory and reversible.

CONCLUSIONS

The results suggest that intra-articular injection of SonoVue is a safe procedure.

Poul Erik Andersen's radiological work on Osteochondrodysplasias and interventional radiology

Poul Erik Andersen is a Professor and Interventional Radiologist at the University of Southern Denmark, Odense and Odense University Hospital, Denmark. His innovative and expertise is primarily in vascular interventions where he has introduced and developed many procedures at Odense University Hospital. His significant experience and extensive scientific work has led to many posts in the Danish Society of Interventional Radiology, the European Society of Radiology and the Cardiovascular and Interventional Radiological Society of Europe, where he is a fellow and has passed the European Board of Interventional Radiology - The European qualification in Interventional Radiology.

[Malignant focal liver lesions]

Focal liver lesions are a very common occurrence. The detection and differentiation of such lesions is particularly important for the management of oncology patients and is a core task for radiology. The early and conclusive detection of malignant liver processes in a cost-efficient manner and with a low radiation dose for the patient requires systematic and skillful use of the various radiological methods. This review explains the application of current radiological methods for the detection and differentiation of malignant liver lesions and the typical appearance of the most commonly found liver malignancies.

A steroid-conjugated magnetic resonance probe enhances contrast in progesterone receptor expressing organs and tumors in vivo

Progesterone receptor (PR) is a significant biomarker in diseases such as endometriosis and breast, ovarian, and uterine cancers that is associated with disease prognosis and therapeutic efficacy. While receptor status is currently determined by immunohistochemistry assays, the development of noninvasive PR imaging agents could improve molecular characterization, treatment decisions, and disease monitoring. ProGlo, a progesterone-conjugated magnetic resonance imaging (MRI) contrast agent, was evaluated in vivo to determine whether it targets and enhances signal intensity in organs and tumors that express high PR levels. A tissue distribution study indicated that ProGlo accumulates in the PR-rich uterus, which was confirmed by in vivo imaging studies. Ex vivo images of these organs revealed that ProGlo was distributed in the substructures that express high PR levels. In xenograft tumor models, ProGlo was taken up to a greater extent than the nonfunctionalized Gd-DO3A in tumors, particularly in PR(+) tumors. The ability to accumulate and enhance signal intensity in PR(+) organs and tumors suggests that ProGlo may be a promising MRI probe for PR(+) diseases.

Assessment and characterisation of common renal masses with CT and MRI

Objective

Owing to the widespread use of abdominal imaging studies the detection rate of solid renal masses has increased, and an accurate characterisation of imaging features of renal masses has become more essential for case management.

Method and results

MR imaging (MRI) and computed tomography (CT) are frequently used modalities for detection and differentiation of renal masses. This article gives a review of imaging characteristics of benign and malignant renal masses, discussing their appearance in CT and MR imaging. Advanced MR techniques like diffusion-weighted imaging and apparent diffusion coefficient (ADC) mapping, which have shown promising results in the differentiation between benign and malignant renal lesions, will be introduced.

Conclusion

MRI and CT are useful in the characterisation and estimation of the prognosis for renal masses.

Radiofrequency ablation of hepatocellular carcinoma: Current status

Ablation therapy is one of the best curative treatment options for malignant liver tumors, and can be an alternative to resection. Radiofrequency ablation (RFA) of primary and secondary liver cancers can be performed safely using percutaneous, laparoscopic, or open surgical techniques, and RFA has markedly changed the treatment strategy for small hepatocellular carcinoma (HCC). Percutaneous RFA can achieve the same overall and disease-free survival as surgical resection for patients with small HCC. The use of a laparoscopic or open approach allows repeated placements of RFA electrodes at multiple sites to ablate larger tumors. RFA combined with transcatheter arterial chemoembolization will make the treatment of larger tumors a clinically viable treatment alternative. However, an accurate evaluation of treatment response is very important to secure successful RFA therapy. Since a sufficient safety margin (at least 0.5 cm) can prevent local tumor recurrences, an accurate evaluation of treatment response is very important to secure successful RFA therapy. To minimize complications of RFA, clinicians should be familiar with the imaging features of each type of complication. Appropriate management of complications is essential for successful RFA treatment.

Pathological and MR-DWI study of the acute hepatic injury model after stem cell transplantation

AIM: To investigate apparent diffusion coefficient (ADC) values as an indication of reconditioning of acute hepatic injury (AHI) after allogeneic mononuclear bone marrow cell (MBMC) transplantation.

METHODS: Three groups were used in our study: a cell transplantation group (n = 21), transplantation control group (n = 21) and normal control group (n = 10). AHI model rabbits in the cell transplantation group were injected with 5 mL of MBMC suspension at multiple sites in the liver and the transplantation controls were injected with 5 mL D-Hanks solution. At the end of the 1st, 2nd and 4th wk, 7 rabbits were randomly selected from the cell transplantation group and transplantation control group for magnetic resonance diffusion-weighted imaging (MR-DWI) and measurement of the mean ADC values of injured livers. After MR-DWI examination, the rabbits were sacrificed and the livers subjected to pathological examination. Ten healthy rabbits from the normal control group were used for MR-DWI examination and measurement of the mean ADC value of normal liver.

RESULTS: At all time points, the liver pathological scores from the cell transplantation group were significantly lower than those in the transplantation control group (27.14 ± 1.46 vs 69.29 ± 6.16, 22.29 ± 2.29 vs 57.00 ± 1.53, 19.00 ± 2.31 vs 51.86 ± 6.04, P = 0.000). The mean ADC values of the cell transplantation group were significantly higher than the transplantation control group ((1.07 ± 0.07) × 10^-3 mm²/s vs (0.69 ± 0.05) × 10^-3 mm²/s, (1.41 ± 0.04) × 10^-3 mm²/s vs (0.84 ± 0.06) × 10^-3 mm²/s, (1.68 ± 0.04) × 10^-3 mm²/s vs (0.86 ± 0.04) × 10^-3 mm²/s, P = 0.000). The pathological scores of the cell transplantation group and transplantation control group gradually decreased. However, their mean ADC values gradually increased to near that of the normal control. At the end of the 1st wk, the mean ADC values of the cell transplantation group and transplantation control group were significantly lower than those of the normal control group [(1.07 ± 0.07) × 10^-3 mm²/s vs (1.76 ± 0.03) × 10^-3 mm²/s, (0.69 ± 0.05) × 10^-3 mm²/s vs (1.76 ± 0.03) × 10^-3 mm²/s, P = 0.000]. At any 2 time points, the pathological scores and the mean ADC values of the cell transplantation group were significantly different (P = 0.000). At the end of the 1st wk, the pathological scores and the mean ADC values of the transplantation control group were significantly different from those at the end of the 2nd and 4th wk (P = 0.000). However, there was no significant difference between the 2nd and 4th wk (P = 0.073 and 0.473, respectively). The coefficient of correlation between the pathological score and the mean ADC value in the cell transplantation group was -0.883 (P = 0.000) and -0.762 (P = 0.000) in the transplantation control group.

CONCLUSION: Tracking the longitudinally dynamic change in the mean ADC value of the AHI liver may reflect hepatic injury reconditioning after allogeneic MBMC transplantation.

Recent advances in understanding pancreatic endocrine tumors

Pancreatic endocrine tumors (PETs) are uncommon and have an incidence of approximately 4-5 per 1 000 000 people, accounting for 1%-2% of all pancreatic neoplasms. They usually grow slowly, eventually metastasize and lead to death. PETs can be classified as functioning or non-functioning tumors based on clinical manifestation. The pathogenesis of PETs may involve abnormal expression of CD10, CD44, CD99, p27, COX2, Ki-67, KIT, CK19, ARHI, RUNX1T1, and survivin genes, loss of heterozygosity on chromosomes, hypermethylation of tumor suppressor genes, and overexpression of ghrelin. Chromogranin A (CgA) has long been used as an important broad-spectrum marker for the identification of PETs. KIT and endoglin are new independent prognostic markers for PETs. The diagnosis is based on histopathology demonstrating neuroendocrine features such as positive staining for chromogranin A and specific hormones such as gastrin, proinsulin, vasoactive intestinal peptide (VIP) and glucagon. In addition to standard localization procedures, radiology diagnosis including computed tomography (CT), positron emission tomography and computed tomography (PET/CT), magnetic resonance imaging (MRI), ultrasound (US), endoscopic ultrasound (EUS), laparoscopic ultrasound (LUS), dynamic enhanced spiral CT, selective arterial stimulation and venous sampling (ASVS), and somatostatin receptor scintigraphy (SRS) are performed. Surgery is still one of the cornerstones in the management of PETs. Laparoscopy, and drugs of somatostatin analogs are routinely used. Understanding of the recent advances of PETs has important implications for the early diagnosis and treatment of PETs.

Era of diagnostic and interventional ultrasound

It is an era of diagnostic and interventional ultrasound (US). Various new techniques such as three-dimensional US (3D US), interventional US, and contrast-enhanced US (CEUS) have been introduced into clinical practice. Dr. Xu and his colleagues have taken advantage of these techniques and carried out a series of relevant studies. Their use of 3D US in the liver, gallbladder, liver tumor volumetry, guidance for ablation, and 3D CEUS has widened the application of 3D US in the clinic. They found that prognosis in patients with hepatocellular carcinoma (HCC) after thermal ablation with curative intent was determined by treatment response to ablation, pretreatment serum AFP, and liver function reserve. Tumor response to treatment was the most predictive factor for long-term survival. They compared the use of percutaneous microwave ablation and radiofrequency ablation for the treatment of HCC and found that both are effective methods in treating HCCs. The local tumor control, complications related to treatment, and long-term survival were equivalent for the two modalities. They first compared the enhancement patterns of HCC and intrahepatic cholangiocarcinoma (ICC) and proposed the diagnostic clues for ICC, liver angiomyolipoma (AML), gallbladder cancer, renal carcinoma, and renal AML, which have greatly enhanced the role of CEUS in the clinic. They also evaluated the diagnostic performance of CEUS in characterizing complex cystic focal liver lesions and the agreement between two investigators with different experience levels; and found that CEUS is especially useful for the young investigator. They assessed the effect of anti-angiogenic gene therapy for HCC treated by microbubble-enhanced US exposure and concluded that gene therapy mediated by US exposure enhanced by a microbubble contrast agent may become a new treatment option for HCC.

Whole brain radiotherapy: prognostic factors and results of a radiation boost delivered through a conventional linear accelerator

PURPOSE

Assess prognostic factors for overall survival and the potential benefit of a boost in patients treated with whole brain radiation therapy (WBRT).

METHODS AND MATERIALS

From 2002 to 2006, a retrospective analysis was made from 250 unselected consecutive patients with secondary brain metastases from lung cancer, breast cancer and melanoma. Eighteen patients received surgery and were excluded from analysis. Four potential prognostic factors have been studied: primary tumor type, gender, number of metastases and improvement of neurological symptoms after radiation therapy. A subgroup analysis was performed to determine whether an additional boost could potentially improve outcome in patients who presented with less than three metastases, performance status <2, and no surgical resection of their metastasis.

RESULTS

Average follow-up was 10.3 months. Median overall survival was 5.6 months and survival rates at 1 and 2 years were 22.7% and 10%, respectively. Age less than 65 (p<0.01), neurological improvement after WBRT (p<0.01), and presence of less than three metastases were significant factors for overall survival in multivariate analysis. When focusing on the selected subgroup (120 assessable patients), median overall survival was 4.0 months in patients with no radiation boost, versus 8.9 months in patients with radiation boost (p=0.0024).

CONCLUSIONS

Survival and prognostic factors were similar to those found in the literature. Boost delivered after WBRT by a conventional particle accelerator could provide a benefit in selected patients, especially for centers that do not have radiotherapy techniques in stereotactic conditions. This warrants further prospective assessment.

Impact of contrast enhanced MRI on lymphocyte DNA damage and serum visfatin level

OBJECTIVES

Nephrogenic systemic fibrosis is a novel clinical entity encountered in subjects undergoing contrast enhanced magnetic resonance imaging (MRI). The aim of the present study is to evaluate the impact of contrast enhanced MRI exposure on lymphocyte DNA damage and serum levels of visfatin.

DESIGN AND METHODS

Twenty-eight subjects undergoing contrast enhanced hypophysial MRI with omniscan were included in the study. Blood samples were drawn before MRI, after non-contrast MRI and after contrast enhanced MRI from each subject. Lymphocyte DNA damage was analyzed by the alkaline comet assay, whereas serum visfatin level was assessed with enzyme immuno assay.

RESULTS

Both lymphocyte DNA damage and serum visfatin levels were statistically significantly increased in samples withdrawn after contrast enhanced MRI compared to samples withdrawn after non-contrast enhanced MRI and baseline samples (ANOVA p<0.001, for both).

CONCLUSIONS

Findings of the present study revealed that the contrast enhanced MRI is associated with increased lymphocyte DNA damage and increased serum visfatin level.

Minimally invasive techniques for head and neck malignancies: current indications, outcomes and future directions

The trend toward minimally invasive surgery, appropriately applied, has evolved over the past three decades to encompass all fields of surgery, including curative intent cancer surgery of the head and neck. Proper patient and tumor selection are fundamental to optimizing oncological and functional outcomes in such a personalized approach to cancer treatment. Training, experience, and appropriate technological equipment are prerequisites for any type of minimally invasive surgery. The aim of this review was to provide an overview of currently available techniques and the evidence justifying their use. Much evidence is in favor of routine use of transoral laser resection, transoral robot-assisted surgery, transnasal endoscopic resection, sentinel node biopsy, and endoscopic neck surgery for selected malignant tumors, by experienced surgical teams. Technological advances will enhance the scope of this type of surgery in the future and physicians need to be aware of the current applications and trends.

Refractory gastroesophageal variceal bleeding secondary to neuroendocrine carcinoma in the pancreatic tail

The main cause of gastroesophageal variceal bleeding (GEVB) is portal hypertension (PH) due to liver cirrhosis. Here, we report a case of regional PH and refractory GEVB secondary to neuroendocrine carcinoma (NC) in the pancreatic tail. This condition was treated using a pancreatic tail resection, splenectomy, and portal azygous devascularization. Regional PH caused by a pancreatic NC is rare and is usually presented as isolated gastric varices. This case report of regional PH details simultaneous esophageal and gastric varices that were caused by a pancreatic NC, which is a rare occurrence. Therefore, after excluding liver cirrhosis, unusual causes should be considered in cases of refractory GEVB with PH. and IAP.

Pulmonary ultrasonography in the follow-up of respiratory distress syndrome on preterm newborns. Reduction of X-ray exposure

PURPOSE

Respiratory distress syndrome (RDS) is the most common cause of respiratory failure in preterm neonates, whose lungs are often immature. The diagnosis and follow-up are based on clinical and radiographic findings. Due to the problem of air artifacts, ultrasonography (US) is not used routinely in the diagnosis of lung diseases. However, when the alveolar air content decreases, as it does in RDS, characteristic patterns appear that can be observed during US lung examinations. The aim of this study was to determine whether the use of chest radiographs in neonates with RDS could be reduced by the routine use of chest US for follow-up examinations.

MATERIALS AND METHODS

From April through September 2008, were enrolled all preterm newborns, with very low birth weight (VLBW), consecutive admitted in NICU with clinically and radiologically diagnosed RDS. We performed lung ultrasound examination in this patients. Video-taped US examinations were done every 8-12 h until clinical resolution of the disease was observed. Chest X-rays were performed only in unclear cases. We compared the number of chest radiographs obtained in the NICU during this period and during the preceding six months.

RESULTS

105 serial US lung examinations were performed in 21 preterm infant with clinically and radiologically diagnosed RDS. US lung examinations revealed "comet-tail" artifacts that were compact, diffuse, and symmetrically distributed throughout both lung fields. In 8 cases, the pleural line was also extensively thickened and irregular, and in 7 cases multiple subpleural hypoechoic areas indicative of lung consolidation were observed (mainly on posterior and lateral scans). The mean number of chest radiographs per infant performed in the NICU during the study period was significantly lower than that of the preceding six months (2.6 ± 1 versus 3.8 ± 1.5; p < 0.05).

CONCLUSIONS

Chest ultrasound is a valid alternative for the follow-up of VLBW infants with RDS, which can decrease the need for chest X-rays and reduce patient exposure to ionizing radiation.

Semi-LASER localized dynamic 31P magnetic resonance spectroscopy in exercising muscle at ultra-high magnetic field

Magnetic resonance spectroscopy (MRS) can benefit from increased signal-to-noise ratio (SNR) of high magnetic fields. In this work, the SNR gain of dynamic 31P MRS at 7 T was invested in temporal and spatial resolution. Using conventional slice selective excitation combined with localization by adiabatic selective refocusing (semi-LASER) with short echo time (TE = 23 ms), phosphocreatine quantification in a 38 mL voxel inside a single exercising muscle becomes possible from single acquisitions, with SNR = 42 ± 4 in resting human medial gastrocnemius. The method was used to quantify the phosphocreatine time course during 5 min of plantar flexion exercise and recovery with a temporal resolution of 6 s (the chosen repetition time for moderate T1 saturation). Quantification of inorganic phosphate and pH required accumulation of consecutively acquired spectra when (resting) Pi concentrations were low. The localization performance was excellent while keeping the chemical shift displacement acceptably small. The SNR and spectral line widths with and without localization were compared between 3T and 7 T systems in phantoms and in vivo. The results demonstrate that increased sensitivity of ultra-high field can be used to dynamically acquire metabolic information from a clearly defined region in a single exercising muscle while reaching a temporal resolution previously available with MRS in non-localizing studies only. The method may improve the interpretation of dynamic muscle MRS data.

Comparison of magnetic resonance angiography scans on 1.5, 3, and 7 Tesla units: a quantitative study of 3-dimensional cerebrovasculature

BACKGROUND

Although multiple studies demonstrate benefits of high field imaging of cerebrovasculature, a detailed quantitative analysis of complete cerebrovascular system is unavailable. To compare quality of MR angiography (MRA) acquisitions at various field strengths, we used 3-dimensional (3D) geometric cerebrovascular models extracted from 1.5 T/3 T/7 T scans.

METHODS

The 3D cerebrovascular models were compared in volume, length, and number of branches. A relationship between the vascular length and volume was statistically derived. Acquisition performance was benchmarked against the maximum volume at infinitive length.

RESULTS

The numbers of vessels discernible on 1.5 T/3 T/7 T are 138/363/907. 3T shows 3.3(1.9) and 7 T 1.2(9.1) times more arteries (veins) than 1.5 T. The vascular lengths and volumes at 1.5 T/3 T/7 T are 3.7/12.5/22.7 m and 15.8/26.6/28.0 cm(3). For arteries: 3T-1.5 T gain is very high in length, high in volume; 7 T-3T gain is medium in length, small in volume. For veins: 3 T-1.5 T gain is moderate in length, high in volume; 7 T-3T gain is very high in length, moderate in volume. 1.5 T shows merely half of vascular volume. At 3 T 6%, while at 7 T only 1% of vascular volume is missing.

CONCLUSION

Our approach differs from standard approaches based on visual assessment and signal (contrast)-to-noise ratio. It also measures absolute acquisition performance, provides a unique length-volume relationship, and predicts length/volume for intermediate teslages.

Primary gastrointestinal lymphoma

Gastrointestinal tract is the most common extranodal site involved by lymphoma with the majority being non-Hodgkin type. Although lymphoma can involve any part of the gastrointestinal tract, the most frequent sites in order of its occurrence are the stomach followed by small intestine and ileocecal region. Gastrointestinal tract lymphoma is usually secondary to the widespread nodal diseases and primary gastrointestinal tract lymphoma is relatively rare. Gastrointestinal lymphomas are usually not clinically specific and indistinguishable from other benign and malignant conditions. Diffuse large B-cell lymphoma is the most common pathological type of gastrointestinal lymphoma in essentially all sites of the gastrointestinal tract, although recently the frequency of other forms has also increased in certain regions of the world. Although some radiological features such as bulky lymph nodes and maintenance of fat plane are more suggestive of lymphoma, they are not specific, thus mandating histopathological analysis for its definitive diagnosis. There has been a tremendous leap in the diagnosis, staging and management of gastrointestinal lymphoma in the last two decades attributed to a better insight into its etiology and molecular aspect as well as the knowledge about its critical signaling pathways.

Quantitative analyses of pediatric cervical spine ossification patterns using computed tomography

The objective of the present study was to quantify ossification processes of the human pediatric cervical spine. Computed tomography images were obtained from a high resolution scanner according to clinical protocols. Bone window images were used to identify the presence of the primary synchondroses of the atlas, axis, and C3 vertebrae in 101 children. Principles of logistic regression were used to determine probability distributions as a function of subject age for each synchondrosis for each vertebra. The mean and 95% upper and 95% lower confidence intervals are given for each dataset delineating probability curves. Posterior ossifications preceded bilateral anterior closures of the synchondroses in all vertebrae. However, ossifications occurred at different ages. Logistic regression results for closures of different synchondrosis indicated p-values of <0.001 for the atlas, ranging from 0.002 to <0.001 for the axis, and 0.021 to 0.005 for the C3 vertebra. Fifty percent probability of three, two, and one synchondroses occurred at 2.53, 6.97, and 7.57 years of age for the atlas; 3.59, 4.74, and 5.7 years of age for the axis; and 1.28, 2.22, and 3.17 years of age for the third cervical vertebrae, respectively. Ossifications occurring at different ages indicate non-uniform maturations of bone growth/strength. They provide an anatomical rationale to reexamine dummies, scaling processes, and injury metrics for improved understanding of pediatric neck injuries.

Radiofrequency ablation of hepatocellular carcinoma: a literature review

Radiofrequency ablation (RFA) of liver cancers can be performed safely using percutaneous, laparoscopic, or open surgical techniques, and much of the impetus for the use of RFA has come from cohort series that have provided an evidence base for this technique. Here, we give an overview of the current status of radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC), including its physical properties, to assess the characteristics that make this technique applicable in clinical practice. We review the technical development of probe design and summarize current indications and outcomes of reported clinical use. An accurate evaluation of treatment response is very important to secure successful RFA therapy since a sufficient safety margin (at least 0.5 cm) can prevent local tumor recurrences. We also provide a profile of side effects and information on the integration of this technique into the general management of patients with HCC. To minimize complications of RFA, physicians should be familiar with each feature of complication. Appropriate management of complications is essential for successful RFA treatment. Moreover, adjuvant therapy, such as molecular targeted therapies following curative therapy, is expected to further improve survival after RFA.

Missed incidental vertebral compression fractures on computed tomography imaging: More optimism justified

Missed incidental vertebral compression fractures on computed tomography (CT) imaging are a common problem. Although numerous publications are available on this topic, recent publications still show a high percentage of such missed fractures. The rate of such missed fractures in the authors department is much lower than that in the reported literature when routine multiplanar reconstructions are used for reporting CT scans. Therefore, a more optimistic view on this topic seems to be justified.

Contrast-enhanced ultrasound in diagnosis and characterization of focal hepatic lesions

The extensive use of imaging techniques in differential diagnosis of abdominal conditions and screening of hepatocellular carcinoma in patients with chronic hepatic diseases, has led to an important increase in identification of focal liver lesions. The development of contrast-enhanced ultrasound (CEUS) opens a new window in the diagnosis and follow-up of these lesions. This technique offers obvious advantages over the computed tomography and magnetic resonance, without a decrease in its sensitivity and specificity. The new second generation contrast agents, due to their intravascular distribution, allow a continuous evaluation of the enhancement pattern, which is crucial in characterization of liver lesions. The dual blood supply in the liver shows three different phases, namely arterial, portal and late phases. The enhancement during portal and late phases can give important information about the lesion’s behavior. Each liver lesion has a different enhancement pattern that makes possible an accurate approach to their diagnosis. The role of emerging techniques as a contrast-enhanced three-dimensional US is also discussed. In this article, the advantages, indications and technique employed during CEUS and the different enhancement patterns of most benign and malignant focal liver lesions are discussed.

An alternate method of classifying allergic bronchopulmonary aspergillosis based on high-attenuation mucus

Background and Aim

Allergic bronchopulmonary aspergillosis (ABPA) is classified radiologically based on the findings of central bronchiectasis (CB) and other radiologic features (ORF). However, the long-term clinical significance of these classifications remains unknown. We hypothesized that the immunological activity and outcomes of ABPA could be predicted on HRCT chest finding of high-attenuation mucus (HAM), a marker of inflammatory activity. In this study, we evaluate the severity and clinical outcomes of ABPA with different radiological classifications.

Methods

Patients were classified based on CT chest findings as: (a) serologic ABPA (ABPA-S) and ABPA-CB; (b) ABPA-S, ABPA-CB, and ABPA-CB-ORF; and, (c) ABPA-S, ABPA-CB and ABPA-CB-HAM. The clinical, spirometric and serological (total and A fumigatus specific IgE levels, eosinophil count) severity of the disease and clinical outcomes in various classifications were analyzed.

Results

Of the 234 (123 males, 111 females; mean age, 34.1 years) patients, 55 (23.5%) had normal HRCT, 179 (76.5%) had CB, 49 (20.9%) had HAM, and 27 (11.5%) had ORF. All immunological markers were consistently higher in the HAM classification, while in other classifications these findings were inconsistent. On multivariate analysis, the factors predicting frequent relapses were presence of HAM (OR 7.38; 95% CI, 3.21–17.0) and CB (OR 3.93; 95% CI, 1.63–9.48) after adjusting for ORF.

Conclusions

The classification scheme based on HAM most consistently predicts immunological severity in ABPA. Central bronchiectasis and HAM are independent predictors of recurrent relapses in ABPA. Hence, HAM should be employed in the radiological classification of ABPA.

Further developments for improving response and tolerance to irradiation for advanced renal cancer: concurrent (mTOR) inhibitor RAD001 and helical tomotherapy

PURPOSE

Radiotherapy remains marginal in the treatment of renal cell carcinoma (RCC), due to radioresistance and risks of acute toxicity. However, recent data have shown that the m-TOR inhibitors could decrease the tumor resistance to ionizing radiation. At the same time, new highly conformal irradiation modalities may significantly improve the tolerance to radiation.

METHODS

Here, we report the first case of concurrent use of mTOR antagonist, rapamycin and Helical Tomotherapy and its potential in critical organs sparing in a patient with retroperitoneal relapse from a RCC. He was treated with Everolimus, 10 mg/d and concurrent Helical Tomotherapy to the region of the recurrence (45 Gy, 1.8 Gy per fraction).

RESULTS

Helical Tomotherapy allowed very sharp dose distributions around the target volumes, while sparing critical organs from useless radiation. No radiotherapy related acute toxicity was observed. At last follow-up (6 months later), the patient remains in partial remission at the irradiated region.

CONCLUSIONS

While targeted agents might find applications for radiosensitizing purposes, this report highlights the potential of Helical Tomotherapy for reducing the doses delivered to the critical organs, thus improving tolerance to irradiation.

Radiofrequency ablation of hepatocellular carcinoma: Current status

Ablation therapy is one of the best curative treatment options for malignant liver tumors, and can be an alternative to resection. Radiofrequency ablation (RFA) of primary and secondary liver cancers can be performed safely using percutaneous, laparoscopic, or open surgical techniques, and RFA has markedly changed the treatment strategy for small hepatocellular carcinoma (HCC). Percutaneous RFA can achieve the same overall and disease-free survival as surgical resection for patients with small HCC. The use of a laparoscopic or open approach allows repeated placements of RFA electrodes at multiple sites to ablate larger tumors. RFA combined with transcatheter arterial chemoembolization will make the treatment of larger tumors a clinically viable treatment alternative. However, an accurate evaluation of treatment response is very important to secure successful RFA therapy. Since a sufficient safety margin (at least 0.5 cm) can prevent local tumor recurrences, an accurate evaluation of treatment response is very important to secure successful RFA therapy. To minimize complications of RFA, clinicians should be familiar with the imaging features of each type of complication. Appropriate management of complications is essential for successful RFA treatment.

[Active surveillance for prostate cancer: usefulness of endorectal MR at 1.5 Tesla with pelvic phased array coil in detecting significant tumors]

PURPOSE

To describe and assess MRI signs of significant tumor in a series of patients who all underwent radical prostatectomy and also fulfilled criteria to choose active surveillance according to French "SurAcaP" protocol.

PATIENTS AND METHODS

The clinical reports of 681 consecutive patients operated on for prostate cancer between 2002 and 2007 were reviewed retrospectively. All patients had endorectal MR (1.5 Tesla) with pelvic phased array coil. (1.5 T erMR PPA). Sixty-one patients (8.9%) fulfilled "SurAcaP" protocol criteria. Preoperative data (MR+core biopsy) were assessed by comparison to whole-mount step section pathology.

RESULTS

85.3% of the 61 patients entering SurAcaP protocol had significant tumor at pathology. (Non Organ Confined Disease (Non OCD)=8.2%, Gleason sum score>6=39.2%). A new exclusion criterion has been assessed: T3MRI±NPS>1 as a predictor tool of significant tumor. ("T3MRI±NPS>1"=Non OCD at MR±number of positive sextants involved in tumor at MR and/or Core Biopsy > to 1). Sensitivity, specificity, PPV, NPV of the criterion "T3MRI±NPS>1" in predicting significant tumor were, respectively: 77%, 33%, 86%, 20%. Adding this criterion to other criteria of the "SurAcaP" protocol could allow the exclusion of all Non OCD, and a decrease in Gleason sum Score>6 rates (20%).

CONCLUSION

Endorectal MR at 1.5 Tesla with pelvic-phased array coil should be considered when selecting patients for active surveillance in the management of prostate cancer. A criterion based upon MR and core biopsy findings, called "T3MR±NSP>1" may represent an exclusion citeria due to its ability to predict significant tumor.

Emerging roles for transthoracic ultrasonography in pulmonary diseases

As a result of many advantages such as the absence of radiation exposure, non-invasiveness, low cost, safety, and ready availability, transthoracic ultrasonography (TUS) represents an emerging and useful technique in the management of pleural and pulmonary diseases. In this second part of a comprehensive review that deals with the role of TUS in pleuropulmonary pathology, the normal findings, sonographic artifacts and morphology of the most important and frequent pulmonary diseases are described. In particular, the usefulness of TUS in diagnosing or raising suspicion of pneumonia, pulmonary embolism, atelectasis, diffuse parenchymal diseases, adult and newborn respiratory distress syndrome, lung cancer and lung metastases are discussed, as well as its role in guidance for diagnostic and therapeutic interventional procedures. Moreover, the preliminary data about the role of contrast enhanced ultrasonography in the study of pulmonary pleural-based lesions are also reported. Finally, the limits of TUS when compared with chest computed tomography are described, highlighting the inability of TUS to depict lesions that are not in contact with the pleura or are located under bony structures, poor visualization of the mediastinum, and the need for very experienced examiners to obtain reliable results.

Windows on the human body--in vivo high-field magnetic resonance research and applications in medicine and psychology

Analogous to the evolution of biological sensor-systems, the progress in "medical sensor-systems", i.e., diagnostic procedures, is paradigmatically described. Outstanding highlights of this progress are magnetic resonance imaging (MRI) and spectroscopy (MRS), which enable non-invasive, in vivo acquisition of morphological, functional, and metabolic information from the human body with unsurpassed quality. Recent achievements in high and ultra-high field MR (at 3 and 7 Tesla) are described, and representative research applications in Medicine and Psychology in Austria are discussed. Finally, an overview of current and prospective research in multi-modal imaging, potential clinical applications, as well as current limitations and challenges is given.

MRI estimation of gadolinium and albumin effects on water proton

The longitudinal relaxivity on the protons of water of a Gd-chelate-albumin compound was measured at 7 T as a function of the macromolecular content of a cross-linked matrix. In agreement with previous works, the results demonstrate that the effect of gadolinium on water proton relaxivity is not constant, rising moderately with increase in the concentration of bovine serum albumin (BSA). About 35% variation in relaxivity was observed over a 0%-25% range of BSA concentrations (ℜ = 3.893 + 0.0502 × BSA [%], SE = 0.0119 and 0.1740, t = 4.215 and 22.383, p < 0.014 and 0.001).

The impact of the loco-regional treatment in elderly breast cancer patients: hypo-fractionated exclusive radiotherapy, single institution long-term results

PURPOSE

To assess the efficacy of exclusive hypo-fractionated radiotherapy (HFRT) without previous breast-conserving surgery (BCS) in elderly women.

MATERIALS AND METHODS

From 1995 to 1999, we have treated with breast-conserving treatment 396 patients older than 70 years with early-stage breast cancer (T1,T2 tumours) at the Institut Curie, Paris, France. Seventy-nine consecutive elderly non-metastatic patients treated for early breast cancer have been treated with HFRT. Of them, 50 underwent BCS followed by HFRT of 32.5 Gy/5 fractions/5 weeks, and 29 patients (presented with different co-morbidities, inoperable or patients' refusal, and/or transportation problems) received the same HFRT schedule followed by a 13 Gy boost (two fractions of 6.5 Gy) as exclusive radiotherapy treatment. This population of 29 patients has been studied. In case of hormonal positive status, hormonal therapy was also proposed to the patients.

RESULTS

There was a median follow-up of 93 months (9-140 months). At 7-year follow-up, the cause-specific survival was 96.4% (confidence interval (CI) 95: 89.8.6-100%), the metastasis-free survival rate was 92.4% (CI 95: 82.8-100%) and the loco-regional control rate was 95.8% (CI 95: 88.2-100%).

CONCLUSIONS

This long-term follow-up retrospective study demonstrated acceptable local control and good outcome in elderly patients treated by exclusive HFRT for early breast cancer. However, large-scale prospective randomised trials are needed to confirm these results.

Diagnosis of pancreatic tumors by endoscopic ultrasonography

Pancreatic tumors are highly diverse, as they can be solid or cystic, and benign or malignant. Since their imaging features overlap considerably, it is often difficult to characterize these tumors. In addition, small pancreatic tumors, especially those less than 2 cm in diameter, are difficult to detect and diagnose. For characterizing pancreatic tumors and detecting small pancreatic tumors, endoscopic ultrasonography (EUS) is the most sensitive of the imaging procedures currently available. This technique also provides good results in terms of the preoperative staging of pancreatic tumors. EUS-guided fine needle aspiration (EUS-FNA) has also proved to be a safe and useful method for tissue sampling of pancreatic tumors. Despite these advantages, however, it is still difficult to differentiate between benign and malignant, solid or cystic pancreatic tumors, malignant neoplasms, and chronic pancreatitis using EUS, even when EUS-FNA is performed. Recently, contrast-enhanced EUS with Doppler mode (CE-EUS) employing ultrasound contrast agents, which indicate vascularization in pancreatic lesions, has been found to be useful in the differential diagnosis of pancreatic tumors, especially small pancreatic tumors. However, Doppler ultrasonography with contrast-enhancement has several limitations, including blooming artifacts, poor spatial resolution, and low sensitivity to slow flow. Consequently, an echoendoscope was developed recently that has a broad-band transducer and an imaging mode that was designed specifically for contrast-enhanced harmonic EUS (CEH-EUS) with a second-generation ultrasound contrast agent. The CEH-EUS technique is expected to improve the differential diagnosis of pancreatic disease in the future. This review describes the EUS appearances of common solid and cystic pancreatic masses, the diagnostic accuracy of EUS-FNA, and the relative efficacies and advantages of CE-EUS and CEH-EUS along with their relative advantages and their complementary roles in clinical practice.