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Fernandes MC, Charbel C, Romesser PB, Ucpinar BA, Homsi ME, Yildirim O, Fuqua JL, Rodriguez LA, Zheng J, Capanu M, Gollub MJ, Horvat N. Accuracy and Clinical Impact of Persistent Disease Diagnosed on Diffusion-Weighted Imaging and Accuracy of Pelvic Nodal Assessment on Magnetic Resonance Imaging for Squamous Cell Carcinoma of the Anus in the 6-Month Interval Post Chemoradiotherapy. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00380-8. [PMID: 38462017 DOI: 10.1016/j.ijrobp.2024.02.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 01/30/2024] [Accepted: 02/28/2024] [Indexed: 03/12/2024]
Abstract
PURPOSE To evaluate the diagnostic performance of diffusion-weighted imaging (DWI) in the 6-month interval post chemoradiation therapy (CRT) in determining persistent disease and whether persistent diffusion restriction on DWI at 6 months is associated with overall survival; and secondarily, to investigate the accuracy of pelvic lymph node assessment on T2-weighted imaging and DWI in the 6-month interval post CRT, in patients with squamous cell carcinoma of the anus. METHODS AND MATERIALS This retrospective study included patients with squamous cell carcinoma of the anus who underwent CRT followed by restaging rectal MRI from January 2010 to April 2020, with ≥1 year of follow-up after CRT. DW images were qualitatively evaluated by 2 junior and 2 senior abdominal radiologists to determine anal persistent disease. The reference standard for anal persistent disease was digital rectal examination/endoscopy and histopathology. Diagnostic performance was estimated using sensitivity, specificity, negative predictive value, and positive predictive value. Survival outcomes were evaluated via Kaplan-Meier analysis, and associations between survival outcomes and DWI status were tested for significance using the log-rank test. Additionally, DW and T2-weighted images were evaluated to determine lymph node status. RESULTS Among 84 patients (mean age, 63 ± 10.2 years; 64/84 [76%] female), 14 of 84 (17%) had confirmed persistent disease. Interreader agreement on DWI between all 4 radiologists was moderate (Light's κ = 0.553). Overall, DWI had a sensitivity of 71.4%, specificity of 72.1%, positive predictive value of 34.5%, and negative predictive value of 92.5%. Patients with a negative DWI showed better survival than patients with a positive DWI (3-year overall survival of 92% vs 79% and 5-year overall survival of 87% vs 74%), although the difference did not reach statistical significance (P = .063). All patients with suspicious lymph nodes (14/14, 100%) showed negative pathology or decreased size during follow-up. CONCLUSIONS At 6 months post CRT, DWI showed value in excluding anal persistent disease. Persistent diffusion restriction on DWI was not significantly associated with overall survival. Pelvic nodal assessment on DWI and T2-weighted imaging was limited in predicting persistent nodal metastases.
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Affiliation(s)
| | - Charlotte Charbel
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paul B Romesser
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Maria El Homsi
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Onur Yildirim
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - James L Fuqua
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lee A Rodriguez
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Junting Zheng
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marinela Capanu
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Natally Horvat
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York.
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Hanekamp BA, Viktil E, Slørdahl KS, Dormagen JB, Kløw NE, Malinen E, Brunborg C, Guren MG, Schulz A. Magnetic resonance imaging of anal cancer: tumor characteristics and early prediction of treatment outcome. Strahlenther Onkol 2024; 200:19-27. [PMID: 37429949 PMCID: PMC10784345 DOI: 10.1007/s00066-023-02114-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 06/18/2023] [Indexed: 07/12/2023]
Abstract
PURPOSE To analyze tumor characteristics derived from pelvic magnetic resonance imaging (MRI) of patients with squamous cell carcinoma of the anus (SCCA) before and during chemoradiotherapy (CRT), and to compare the changes in these characteristics between scans of responders vs. nonresponders to CRT. METHODS We included 52 patients with a pelvic 3T MRI scan prior to CRT (baseline scan); 39 of these patients received an additional scan during week 2 of CRT (second scan). Volume, diameter, extramural tumor depth (EMTD), and external anal sphincter infiltration (EASI) of the tumor were assessed. Mean, kurtosis, skewness, standard deviation (SD), and entropy values were extracted from apparent diffusion coefficient (ADC) histograms. The main outcome was locoregional treatment failure. Correlations were evaluated with Wilcoxon's signed rank-sum test and Pearson's correlation coefficient, quantile regression, univariate logistic regression, and area under the ROC curve (AUC) analyses. RESULTS In isolated analyses of the baseline and second MRI scans, none of the characteristics were associated with outcome. Comparison between the scans showed significant changes in several characteristics: volume, diameter, EMTD, and ADC skewness decreased in the second scan, although the mean ADC increased. Small decreases in volume and diameter were associated with treatment failure, and these variables had the highest AUC values (0.73 and 0.76, respectively) among the analyzed characteristics. CONCLUSION Changes in tumor volume and diameter in an early scan during CRT could represent easily assessable imaging-based biomarkers to eliminate the need for analysis of more complex MRI characteristics.
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Affiliation(s)
- Bettina A Hanekamp
- Department of Radiology, Oslo University Hospital Ullevål, Oslo, Norway.
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Ellen Viktil
- Department of Radiology, Oslo University Hospital Ullevål, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kathinka S Slørdahl
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Oncology, Oslo University Hospital Ullevål, Oslo, Norway
| | | | - Nils E Kløw
- Department of Radiology, Oslo University Hospital Ullevål, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Eirik Malinen
- Department of Physics, University of Oslo, Oslo, Norway
- Department of Medical Physics, Oslo University Hospital, Oslo, Norway
| | - Cathrine Brunborg
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Marianne G Guren
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Oncology, Oslo University Hospital Ullevål, Oslo, Norway
| | - Anselm Schulz
- Department of Radiology, Oslo University Hospital Ullevål, Oslo, Norway
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Prezzi D, Muthuswamy K, Amlani A, Owczarczyk K, Elowaidy A, Mistry T, Bassett P, Goh V. Diffusion-weighted imaging complements T2-weighted MRI for tumour response assessment in squamous anal carcinoma. Eur Radiol 2023; 33:7575-7584. [PMID: 37462820 PMCID: PMC10598114 DOI: 10.1007/s00330-023-09942-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
OBJECTIVES A published tumour regression grade (TRG) score for squamous anal carcinoma treated with definitive chemoradiotherapy based on T2-weighted MRI yields a high proportion of indeterminate responses (TRG-3). We investigate whether the addition of diffusion-weighted imaging (DWI) improves tumour response assessment in the early post treatment period. MATERIALS AND METHODS This retrospective observational study included squamous anal carcinoma patients undergoing MRI before and within 3 months of completing chemoradiotherapy from 2009 to 2020. Four independent radiologists (1-20 years' experience) scored MRI studies using a 5-point TRG system (1 = complete response; 5 = no response) based on T2-weighted sequences alone, and then after a 12-week washout period, using a 5-point DWI-TRG system based on T2-weighted and DWI. Scoring confidence was recorded on a 5-point scale (1 = low; 5 = high) for each reading and compared using the Wilcoxon test. Indeterminate scores (TRG-3) from each reading session were compared using the McNemar test. Interobserver agreement was assessed using kappa statistics. RESULTS Eighty-five patients were included (mean age, 59 years ± 12 [SD]; 55 women). T2-weighted TRG-3 scores from all readers combined halved from 24% (82/340) to 12% (41/340) with DWI (p < 0.001). TRG-3 scores changed most frequently (41%, 34/82) to DWI-TRG-2 (excellent response). Complete tumour response was recorded clinically in 77/85 patients (91%). Scoring confidence increased using DWI (p < 0.001), with scores of 4 or 5 in 84% (287/340). Interobserver agreement remained fair to moderate (kappa range, 0.28-0.58). CONCLUSION DWI complements T2-weighted MRI by reducing the number of indeterminate tumour responses (TRG-3). DWI increases radiologist's scoring confidence. CLINICAL RELEVANCE STATEMENT Diffusion-weighted imaging improves T2-weighted tumour response assessment in squamous anal cancer, halving the number of indeterminate responses in the early post treatment period, and increases radiologists' confidence. KEY POINTS Tumour response based on T2-weighted MRI is often indeterminate in squamous anal carcinoma. Diffusion-weighted imaging alongside T2-weighted MRI halved indeterminate tumour regression grade scores assigned by four radiologists from 24 to 12%. Scoring confidence of expert and non-expert radiologists increased with the inclusion of diffusion-weighted imaging.
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Affiliation(s)
- Davide Prezzi
- School of Biomedical Engineering and Imaging Sciences, King's College London, King's Health Partners, London, UK.
- Department of Radiology, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | | | - Ashik Amlani
- Department of Radiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Kasia Owczarczyk
- Department of Radiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ahmed Elowaidy
- Department of Radiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Tina Mistry
- Department of Radiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Vicky Goh
- School of Biomedical Engineering and Imaging Sciences, King's College London, King's Health Partners, London, UK
- Department of Radiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Golia Pernicka JS, Rauch GM, Gangai N, Bates DDB, Ernst R, Hope TA, Horvat N, Sheedy SP, Gollub MJ. Imaging of Anal Squamous Cell Carcinoma: Survey Results and Expert Opinion from the Rectal and Anal Cancer Disease-Focused Panel of the Society of Abdominal Radiology. Abdom Radiol (NY) 2023; 48:3022-3032. [PMID: 36932225 PMCID: PMC10929685 DOI: 10.1007/s00261-023-03863-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 03/19/2023]
Abstract
The role and method of image-based staging of anal cancer has evolved with the rapid development of newer imaging modalities and the need to address the rising incidence of this rare cancer. In 2014, the European Society of Medical Oncology mandated pelvic magnetic resonance imaging (MRI) for anal cancer and subsequently other societies such as the National Comprehensive Cancer Network followed suit with similar recommendations. Nevertheless, great variability exists from center to center and even within individual centers. Notably, this is in stark contrast to the imaging of the anatomically nearby rectal cancer. As participating team members for this malignancy, we embarked on a comprehensive literature review of anal cancer imaging to understand the relative merits of these new technologies which developed after computed tomography (CT), e.g., MRI and positron emission tomography/computed tomography (PET/CT). The results of this literature review helped to inform our next stage: questionnaire development regarding the imaging of anal cancer. Next, we distributed the questionnaire to members of the Society of Abdominal Radiology (SAR) Rectal and Anal Disease-Focused Panel, a group of abdominal radiologists with special interest, experience, and expertise in rectal and anal cancer, to provide expert radiologist opinion on the appropriate anal cancer imaging strategy. In our expert opinion survey, experts advocated the use of MRI in general (65% overall and 91-100% for primary staging clinical scenarios) and acknowledged the superiority of PET/CT for nodal assessment (52-56% agreement for using PET/CT in primary staging clinical scenarios compared to 30% for using MRI). We therefore support the use of MRI and PET and suggest further exploration of PET/MRI as an optimal combined evaluation. Our questionnaire responses emphasized the heterogeneity in imaging practice as performed at numerous academic cancer centers across the United States and underscore the need for further reconciliation and establishment of best imaging practice guidelines for optimized patient care in anal cancer.
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Affiliation(s)
- Jennifer S Golia Pernicka
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA.
- , 530 E 74th St, Room 07118, New York, NY, 10021, USA.
| | - Gaiane M Rauch
- Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Natalie Gangai
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - David D B Bates
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Randy Ernst
- Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thomas A Hope
- Departments of Radiology and Biomedical Imaging and Pharmaceutical Chemistry, University of California San Francisco, San Francisco, CA, USA
| | - Natally Horvat
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | | | - Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
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Muirhead R. Image-Guided Radiotherapy – The Unsung Hero of Radiotherapy Development. Clin Oncol (R Coll Radiol) 2020; 32:789-791. [DOI: 10.1016/j.clon.2020.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 09/21/2020] [Accepted: 10/05/2020] [Indexed: 02/06/2023]
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