Breast and Prostate Cancer Risks for Male BRCA1 and BRCA2 Pathogenic Variant Carriers Using Polygenic Risk Scores

BACKGROUND

Recent population-based female breast cancer and prostate cancer polygenic risk scores (PRS) have been developed. We assessed the associations of these PRS with breast and prostate cancer risks for male BRCA1 and BRCA2 pathogenic variant carriers.

METHODS

483 BRCA1 and 1318 BRCA2 European ancestry male carriers were available from the Consortium of Investigators of Modifiers of BRCA1/2 (CIMBA). A 147-single nucleotide polymorphism (SNP) prostate cancer PRS (PRSPC) and a 313-SNP breast cancer PRS were evaluated. There were 3 versions of the breast cancer PRS, optimized to predict overall (PRSBC), estrogen receptor (ER)-negative (PRSER-), or ER-positive (PRSER+) breast cancer risk.

RESULTS

PRSER+ yielded the strongest association with breast cancer risk. The odds ratios (ORs) per PRSER+ standard deviation estimates were 1.40 (95% confidence interval [CI] =1.07 to 1.83) for BRCA1 and 1.33 (95% CI = 1.16 to 1.52) for BRCA2 carriers. PRSPC was associated with prostate cancer risk for BRCA1 (OR = 1.73, 95% CI = 1.28 to 2.33) and BRCA2 (OR = 1.60, 95% CI = 1.34 to 1.91) carriers. The estimated breast cancer odds ratios were larger after adjusting for female relative breast cancer family history. By age 85 years, for BRCA2 carriers, the breast cancer risk varied from 7.7% to 18.4% and prostate cancer risk from 34.1% to 87.6% between the 5th and 95th percentiles of the PRS distributions.

CONCLUSIONS

Population-based prostate and female breast cancer PRS are associated with a wide range of absolute breast and prostate cancer risks for male BRCA1 and BRCA2 carriers. These findings warrant further investigation aimed at providing personalized cancer risks for male carriers and informing clinical management.

Transcriptome-wide association study of breast cancer risk by estrogen-receptor status

Previous transcriptome-wide association studies (TWAS) have identified breast cancer risk genes by integrating data from expression quantitative loci and genome-wide association studies (GWAS), but analyses of breast cancer subtype-specific associations have been limited. In this study, we conducted a TWAS using gene expression data from GTEx and summary statistics from the hitherto largest GWAS meta-analysis conducted for breast cancer overall, and by estrogen receptor subtypes (ER+ and ER-). We further compared associations with ER+ and ER- subtypes, using a case-only TWAS approach. We also conducted multigene conditional analyses in regions with multiple TWAS associations. Two genes, STXBP4 and HIST2H2BA, were specifically associated with ER+ but not with ER- breast cancer. We further identified 30 TWAS-significant genes associated with overall breast cancer risk, including four that were not identified in previous studies. Conditional analyses identified single independent breast-cancer gene in three of six regions harboring multiple TWAS-significant genes. Our study provides new information on breast cancer genetics and biology, particularly about genomic differences between ER+ and ER- breast cancer.

Genome-wide association study identifies 32 novel breast cancer susceptibility loci from overall and subtype-specific analyses

Breast cancer susceptibility variants frequently show heterogeneity in associations by tumor subtype1-3. To identify novel loci, we performed a genome-wide association study including 133,384 breast cancer cases and 113,789 controls, plus 18,908 BRCA1 mutation carriers (9,414 with breast cancer) of European ancestry, using both standard and novel methodologies that account for underlying tumor heterogeneity by estrogen receptor, progesterone receptor and human epidermal growth factor receptor 2 status and tumor grade. We identified 32 novel susceptibility loci (P < 5.0 × 10-8), 15 of which showed evidence for associations with at least one tumor feature (false discovery rate < 0.05). Five loci showed associations (P < 0.05) in opposite directions between luminal and non-luminal subtypes. In silico analyses showed that these five loci contained cell-specific enhancers that differed between normal luminal and basal mammary cells. The genetic correlations between five intrinsic-like subtypes ranged from 0.35 to 0.80. The proportion of genome-wide chip heritability explained by all known susceptibility loci was 54.2% for luminal A-like disease and 37.6% for triple-negative disease. The odds ratios of polygenic risk scores, which included 330 variants, for the highest 1% of quantiles compared with middle quantiles were 5.63 and 3.02 for luminal A-like and triple-negative disease, respectively. These findings provide an improved understanding of genetic predisposition to breast cancer subtypes and will inform the development of subtype-specific polygenic risk scores.

Association of Genomic Domains in BRCA1 and BRCA2 with Prostate Cancer Risk and Aggressiveness

Pathogenic sequence variants (PSV) in BRCA1 or BRCA2 (BRCA1/2) are associated with increased risk and severity of prostate cancer. We evaluated whether PSVs in BRCA1/2 were associated with risk of overall prostate cancer or high grade (Gleason 8+) prostate cancer using an international sample of 65 BRCA1 and 171 BRCA2 male PSV carriers with prostate cancer, and 3,388 BRCA1 and 2,880 BRCA2 male PSV carriers without prostate cancer. PSVs in the 3' region of BRCA2 (c.7914+) were significantly associated with elevated risk of prostate cancer compared with reference bin c.1001-c.7913 [HR = 1.78; 95% confidence interval (CI), 1.25-2.52; P = 0.001], as well as elevated risk of Gleason 8+ prostate cancer (HR = 3.11; 95% CI, 1.63-5.95; P = 0.001). c.756-c.1000 was also associated with elevated prostate cancer risk (HR = 2.83; 95% CI, 1.71-4.68; P = 0.00004) and elevated risk of Gleason 8+ prostate cancer (HR = 4.95; 95% CI, 2.12-11.54; P = 0.0002). No genotype-phenotype associations were detected for PSVs in BRCA1. These results demonstrate that specific BRCA2 PSVs may be associated with elevated risk of developing aggressive prostate cancer. SIGNIFICANCE: Aggressive prostate cancer risk in BRCA2 mutation carriers may vary according to the specific BRCA2 mutation inherited by the at-risk individual.

Large scale multifactorial likelihood quantitative analysis of BRCA1 and BRCA2 variants: An ENIGMA resource to support clinical variant classification

The multifactorial likelihood analysis method has demonstrated utility for quantitative assessment of variant pathogenicity for multiple cancer syndrome genes. Independent data types currently incorporated in the model for assessing BRCA1 and BRCA2 variants include clinically calibrated prior probability of pathogenicity based on variant location and bioinformatic prediction of variant effect, co-segregation, family cancer history profile, co-occurrence with a pathogenic variant in the same gene, breast tumor pathology, and case-control information. Research and clinical data for multifactorial likelihood analysis were collated for 1,395 BRCA1/2 predominantly intronic and missense variants, enabling classification based on posterior probability of pathogenicity for 734 variants: 447 variants were classified as (likely) benign, and 94 as (likely) pathogenic; and 248 classifications were new or considerably altered relative to ClinVar submissions. Classifications were compared with information not yet included in the likelihood model, and evidence strengths aligned to those recommended for ACMG/AMP classification codes. Altered mRNA splicing or function relative to known nonpathogenic variant controls were moderately to strongly predictive of variant pathogenicity. Variant absence in population datasets provided supporting evidence for variant pathogenicity. These findings have direct relevance for BRCA1 and BRCA2 variant evaluation, and justify the need for gene-specific calibration of evidence types used for variant classification.

240 Hepatocellular Carcinomas: Ultrasound Features, Tumor Size, Cytologic and Histologic Patterns, Serum Alpha-Fetoprotein and HBs Ag

Two hundred and forty cases of hepatocellular carcinomas (HCC), diagnosed by ultrasonography and fine needle biopsy, were studied. The following parameters were investigated: 1. echo features (240 cases) – hypoechoic, 54; hyperechoic, 56; complex, 112; isoechoic with halo, 18; 2. tumor size (240 cases) – single tumor under 4.5 cm, 30; single tumor over 4.5 cm, 74; multiple masses or diffuse, 136; 3. cytologic pattern (240 cases) – well and medium differentiated, 144; pleomorphic, 43; poorly differentiated, 28; unclassified, 25; 4. histologic pattern (157 cases) – trabecular, 74; solid, 42; acinar, 1; mixed, 2; unclassified, 38; 5. alpha-fetoprotein (AFP) level (185 cases) – under 20 ng/ml, 79; between 20 and 320 ng/ml, 40; over 320 ng/ml, 66; 6. HBs Ag (208 cases) – present in 56 cases; 7. cirrhosis (102 cases) –present in 79 cases. Some of the above parameters were correlated with one another. There was: 1. a highly significant frequency of the hypoechoic feature among small HCC; 2. a percentage of AFP-producing tumors increasing with tumor size; 3. no relationship between AFP production and cytologic or histologic pattern; 4. no relationship between tumor size and cytologic or histologic pattern. However, among the small HCC, all the 9 HCC with a diameter of less than 3 cm showed a trabecular pattern and well-differentiated cells. Cirrhosis was present in every patient with a small HCC. Since the discovery of a small HCC is an incidental ultrasonographic finding in the context of severe liver disease, ultrasonographic monitoring of cirrhotic patients is the best available strategy to screen for small HCC.

Fine Needle Percutaneous Intratumoral Chemotherapy under Ultrasound Guidance: A Feasibility Study

To test the feasibility of fine needle (22 gauge) percutaneous intratumoral chemotherapy (PIC) under ultrasound guidance, a trial was conducted on 12 selected neoplastic patients with tumors not responsive to conventional treatments (5 adenocarcinomas of the pancreas, 1 hepatocellular carcinoma, 1 squamous cell carcinoma of the lung, 1 leiomyosarcoma of the hepatic hilum, 1 malignant fibrous histiocytoma of the ischiatic region, 2 liver and 1 peritoneal metastases). The drugs used were 5-fluorouracil, methotrexate and cyclophosphamide, according to the histotype. The doses given never exceeded the routine intravenous doses; 119 sessions of PIC were administered. There have been no significant local complications due to needle injury and drug toxicity or biochemical changes attributable to general toxicity. Partial or total pain control and stable disease or response to 60% was observed. This research has not been described previously to our knowledge.

Effects of high hydrostatic pressure processing and of glucose oxidase-catalase addition on the color stability and sensorial score of grape juice / Efectos del tratamiento con altas presiones y de la adición de glucosa oxidasa-catalasa en la estabilidad del color y en la evaluación sensorial del zumo de uva

The effects of high hydrostatic pressure treatment (HHP) and the use of glucose oxidase-catalase enzymes on the color stability of a white grape juice were studied. The cold-prepared grape juice was stored for three weeks at 5 °C and evaluated for color and non-flavonoid phenolic content. The HHP treatments at 600 and 900 MPa slowed the degradation of non-flavonoid phenolics and reduced the rate of the browning during storage. No significant effect on the color was observed using 300 MPa. Further color stabilization was obtained using glucose oxidase-catalase enzymes and by setting the initial temperature of water inside the pressure vessel at 50 °C prior to HHP treatment. The sensory analyses indicated that enzymes and HHP improved the aroma and taste of juices; by contrast, oper ating the HHP process at an initial temperature of 50 °C showed no significant effect.

Male breast cancer in BRCA1 and BRCA2 mutation carriers: pathology data from the Consortium of Investigators of Modifiers of BRCA1/2

BACKGROUND

BRCA1 and, more commonly, BRCA2 mutations are associated with increased risk of male breast cancer (MBC). However, only a paucity of data exists on the pathology of breast cancers (BCs) in men with BRCA1/2 mutations. Using the largest available dataset, we determined whether MBCs arising in BRCA1/2 mutation carriers display specific pathologic features and whether these features differ from those of BRCA1/2 female BCs (FBCs).

METHODS

We characterised the pathologic features of 419 BRCA1/2 MBCs and, using logistic regression analysis, contrasted those with data from 9675 BRCA1/2 FBCs and with population-based data from 6351 MBCs in the Surveillance, Epidemiology, and End Results (SEER) database.

RESULTS

Among BRCA2 MBCs, grade significantly decreased with increasing age at diagnosis (P = 0.005). Compared with BRCA2 FBCs, BRCA2 MBCs were of significantly higher stage (P for trend = 2 × 10(-5)) and higher grade (P for trend = 0.005) and were more likely to be oestrogen receptor-positive [odds ratio (OR) 10.59; 95 % confidence interval (CI) 5.15-21.80] and progesterone receptor-positive (OR 5.04; 95 % CI 3.17-8.04). With the exception of grade, similar patterns of associations emerged when we compared BRCA1 MBCs and FBCs. BRCA2 MBCs also presented with higher grade than MBCs from the SEER database (P for trend = 4 × 10(-12)).

CONCLUSIONS

On the basis of the largest series analysed to date, our results show that BRCA1/2 MBCs display distinct pathologic characteristics compared with BRCA1/2 FBCs, and we identified a specific BRCA2-associated MBC phenotype characterised by a variable suggesting greater biological aggressiveness (i.e., high histologic grade). These findings could lead to the development of gender-specific risk prediction models and guide clinical strategies appropriate for MBC management.

FANCM c.5791C>T nonsense mutation (rs144567652) induces exon skipping, affects DNA repair activity and is a familial breast cancer risk factor

Numerous genetic factors that influence breast cancer risk are known. However, approximately two-thirds of the overall familial risk remain unexplained. To determine whether some of the missing heritability is due to rare variants conferring high to moderate risk, we tested for an association between the c.5791C>T nonsense mutation (p.Arg1931*; rs144567652) in exon 22 of FANCM gene and breast cancer. An analysis of genotyping data from 8635 familial breast cancer cases and 6625 controls from different countries yielded an association between the c.5791C>T mutation and breast cancer risk [odds ratio (OR) = 3.93 (95% confidence interval (CI) = 1.28-12.11; P = 0.017)]. Moreover, we performed two meta-analyses of studies from countries with carriers in both cases and controls and of all available data. These analyses showed breast cancer associations with OR = 3.67 (95% CI = 1.04-12.87; P = 0.043) and OR = 3.33 (95% CI = 1.09-13.62; P = 0.032), respectively. Based on information theory-based prediction, we established that the mutation caused an out-of-frame deletion of exon 22, due to the creation of a binding site for the pre-mRNA processing protein hnRNP A1. Furthermore, genetic complementation analyses showed that the mutation influenced the DNA repair activity of the FANCM protein. In summary, we provide evidence for the first time showing that the common p.Arg1931* loss-of-function variant in FANCM is a risk factor for familial breast cancer.

Protein kinase CK2 potentiates translation efficiency by phosphorylating eIF3j at Ser127

In eukaryotic protein synthesis the translation initiation factor 3 (eIF3) is a key player in the recruitment and assembly of the translation initiation machinery. Mammalian eIF3 consists of 13 subunits, including the loosely associated eIF3j subunit that plays a stabilizing role in the eIF3 complex formation and interaction with the 40S ribosomal subunit. By means of both co-immunoprecipitation and mass spectrometry analyses we demonstrate that the protein kinase CK2 interacts with and phosphorylates eIF3j at Ser127. Inhibition of CK2 activity by CX-4945 or down-regulation of the expression of CK2 catalytic subunit by siRNA cause the dissociation of j-subunit from the eIF3 complex as judged from glycerol gradient sedimentation. This finding proves that CK2-phosphorylation of eIF3j is a prerequisite for its association with the eIF3 complex. Expression of Ser127Ala-eIF3j mutant impairs both the interaction of mutated j-subunit with the other eIF3 subunits and the overall protein synthesis. Taken together our data demonstrate that CK2-phosphorylation of eIF3j at Ser127 promotes the assembly of the eIF3 complex, a crucial step in the activation of the translation initiation machinery.

Candidate genetic modifiers for breast and ovarian cancer risk in BRCA1 and BRCA2 mutation carriers

BACKGROUND

BRCA1 and BRCA2 mutation carriers are at substantially increased risk for developing breast and ovarian cancer. The incomplete penetrance coupled with the variable age at diagnosis in carriers of the same mutation suggests the existence of genetic and nongenetic modifying factors. In this study, we evaluated the putative role of variants in many candidate modifier genes.

METHODS

Genotyping data from 15,252 BRCA1 and 8,211 BRCA2 mutation carriers, for known variants (n = 3,248) located within or around 445 candidate genes, were available through the iCOGS custom-designed array. Breast and ovarian cancer association analysis was performed within a retrospective cohort approach.

RESULTS

The observed P values of association ranged between 0.005 and 1.000. None of the variants was significantly associated with breast or ovarian cancer risk in either BRCA1 or BRCA2 mutation carriers, after multiple testing adjustments.

CONCLUSION

There is little evidence that any of the evaluated candidate variants act as modifiers of breast and/or ovarian cancer risk in BRCA1 or BRCA2 mutation carriers.

IMPACT

Genome-wide association studies have been more successful at identifying genetic modifiers of BRCA1/2 penetrance than candidate gene studies.

Genetic instability of the tumor suppressor gene FHIT in normal human cells

Common fragile sites are hotspots for chromosome instability and co-localize to cancer genomic rearrangements. Whether these loci may be considered stable in human subjects under physiological conditions remains an open question. Here we show by molecular combing that a small but significant percentage of normal human cells carry an abnormal sequence pattern within the tumor suppressor gene FHIT (3p14.2) at FRA3B. Each sequence variation represents a unique pattern within a normal cell population, and therefore it would remain undetected or not interpreted by genome-wide analyses. Remarkably, the region is the same as in FHIT rearrangements described in tumors. By analyses on several normal cell lines (proliferating and resting primary lymphocytes, primary fibroblasts, lymphoblastoid cells including clonal cell cultures) we verified that: (a) each cell type displays altered sequence patterns at FHIT; (b) the presence of abnormal sequence patterns is specific for the FHIT locus; and (c) FHIT instability occurs de novo during cell proliferation, and heterogeneous sequence variants progressively accumulate in the cell populations. FHIT has been widely investigated in cancer cells, but to our knowledge this is the first direct evidence of spontaneous and recurrent occurrence of genomic instability at this gene in human subjects, at the same region involved in cancer rearrangements. Our results suggest that common fragile site activity is not restricted to in vitro cell culture and that genomic instability may pre-exist in normal cells in the absence of exogenous replication stress.

Replication dynamics at common fragile site FRA6E

The replication dynamics at common fragile site FRA6E has been evaluated by molecular combing and interphase fluorescent in situ hybridisation (FISH) in primary human lymphocytes cultured under normal or aphidicolin-induced stress conditions. FRA6E is one of the most frequently expressed common fragile sites of the human genome. It harbours several genes, PARK2 being regarded as the most relevant one. According to the results obtained from interphase FISH analysis, FRA6E can be considered a mid-late-replicating sequence characterised by heterogeneous replication timing. Molecular combing did not reveal specific replication parameters at the fragile site: fork rates were highly comparable to those detected at an early replicating locus (LMNB2) used as control and in very good agreement with the whole-genome data obtained in parallel. The same indication applied to the density of initiation zones, the inter-origin distances from adjacent ongoing forks, the frequencies of unidirectional forks, fork arrest events and asynchronous forks. Interestingly, PARK2 appeared embedded in an early/late replication transition zone, corresponding to intron 8 (162 kb) and to the fragility core of FRA6E. In cells exposed to aphidicolin, few forks progressing at a rather slow rate were observed, the majority of them being unidirectional, but again a specific response of the fragile site was not observed. In summary, at FRA6E the replication process is not impaired per se, but chromosome breakages occur preferentially at an early/late replication transition zone. Aphidicolin might increase the occurrence of breakage events at FRA6E by prolonging the time interval separating the replication of early and late replication domains. These results may be of general significance to address the problem of fragile site instability.

Congenital absence of portal vein with nodular regenerative hyperplasia of the liver

Congenital absence of the portal vein is a very rare anomaly. The intestinal and splenic venous drainage bypasses the liver and drain into the inferior vena cava (IVC). Two cases of such anomaly are described. Both cases were investigated by US coupled with echo-colour Doppler examination, CT and MR imaging, followed by digital subtraction angiography (DSA) and liver biopsy. In the first case the splenic and superior mesenteric vein formed a venous trunk which emptied directly into the IVC; in the second case, the splanchnic blood flowed into a dilated hepatofugal inferior mesenteric vein which connected to the left internal iliac vein. In both cases nodular regenerative hyperplasia of the liver was present, presumably due to an abnormal hepatic cell response to the absent portal flow. The particular contribution of MR imaging to the diagnosis of both vascular abnormalities and liver parenchyma derangement and its advantages over the other diagnostic techniques is emphasized. The clinical and radiological features of 17 previously reported cases are reviewed.

Asymptomatic giant gastric lipoma: What to do?

Gastrointestinal (GI) lipomas are benign, usually single, slowly growing tumors. Their occurrence in the GI tract is most common in the colon, but they can be found also in the small bowel and very rarely in the stomach, where they account for 5% of all GI lipomas. Although most gastric lipomas (GL) are usually detected incidentally, they can cause severe symptoms such as obstruction, invagination, and life-threatening hemorrhages. To date, only three cases of GL have been reported in childhood. We describe the case of an 11-yr-old girl with asymptomatic giant GL, who has not received any treatment until now. New diagnostic insights, therapeutic options, and indications for treatment in asymptomatic patients are discussed.

Treatment of extrahepatic portal hypertension in children by mesenteric-to-left portal vein bypass: a new physiological procedure

OBJECTIVE

To achieve hepatic portal revascularisation and decompression of extrahepatic portal hypertension in children with cavernoma and obstruction caused by idiopathic portal vein thrombosis.

DESIGN

Selected cases.

SETTING

Teaching hospitals. Belgium and Italy.

SUBJECTS

11 children who weighed between 5.9 and 54 kg (2 emergencies) with symptomatic extrahepatic portal hypertension.

INTERVENTION

Interposition of venous autograft between the superior mesenteric vein and the distal (umbilical) portion of the left portal vein.

MAIN OUTCOME MEASURES

Improvements in symptoms and endoscopic appearance after operation.

RESULTS

2 bypasses had to be redone because they stenosed; all 11 were patent at the time of writing (median follow-up 6 months, range 1-32 months).

CONCLUSION

The bypass effectively relieved symptoms of extrahepatic portal hypertension by restoring normal hepatic portal blood flow.

Ultrasound evaluation of hepatic lymph nodes in patients with anti-hepatitis C virus antibody reactivity

BACKGROUND

Portal lymphadenopathy is frequently found in inflammatory liver diseases. However, the mechanisms underlying portal lymphadenopathy are unknown.

AIMS

To evaluate the prevalence of portal lymphadenopathy in patients with serum anti-hepatitis C Virus antibody reactivity and its relationship to clinical parameters.

PATIENTS AND METHODS

The presence of portal lymphadenopathy was evaluated by upper abdominal Ultrasound by the same examiner in 114 patients with anti-hepatitis C Virus reactivity: 56 patients with normal liver enzyme activity and 58 randomly selected patients with increased liver enzyme activity undergoing liver biopsy. Laboratory tests were then performed in all patients the following day.

RESULTS

Portal lymph nodes were found in a significantly higher percentage of patients with increased liver enzymes (74%) than in patients with persistently normal liver enzymes (29%: p < 0.01). Aminotransferases, gamma glutamyl transpeptidase levels and the percentage of patients with HCVRNA in serum and histological scores for piecemeal and lobular necrosis were significantly higher in patients showing hepatic lymph nodes. Multivariate analysis showed that only alanine aminotransferase and lobular necrosis were independently related to the presence of hepatic lymph nodes. A significant correlation was found between lymph node size, aminotransferase activity and lobular necrosis.

CONCLUSION

Ultrasound-proven portal lymph node enlargement is an indirect sign of hepatocellular damage in patients with positive serum anti-hepatitis C Virus antibodies.

The pseudocapsule in hepatocellular carcinoma: correlation between dynamic MR imaging and pathology

Nodular hepatocellular carcinoma (HCC) is characterized by the presence of a pseudocapsule (constructed usually from connective fibrous tissue) that appears hypointense on T1- and T2-weighted spin-echo (SE) and gradient-echo (GE) MR imaging sequences without a contrast medium. The presence of vascular structures inside the tumor, which are verified by histological exam, affects enhancement of the PC after administrating the contrast medium: The impregnation is more evident in the dynamic study but also persists on the delayed T1-weighted SE images. The accuracy of MR in detecting the pseudocapsule of HCC and contrast enhancement of the pseudocapsule during dynamic studies were evaluated and related to pathological findings. Thirty-seven HCC were examined in 33 patients and afterwards resected. In capsulated nodules, besides usual hematoxylin, eosin, and trichrome stainings, histochemical and immunohistochemical methods were performed. On a 1.5-T MR unit, T1- and T2-weighted SE and GE FLASH 2D sequences after intravenous injection of Gd-DTPA (dynamic study) were used. In a later phase, T1-weighted SE sequences were repeated. Histologically, the pseudocapsule (thickness 0.2-6 mm) was present in 26 of 37 nodules (70%). The dynamic study was the most suitable technique to show the pseudocapsule, which was recognized in 80.7% (21 of 26 nodules). In 5 of 26 cases, the pseudocapsule, not demonstrated by MR, was thinner than 0.4 mm. In 16 of 21 cases, in the early portal phase (30-60 s), the pseudocapsule had an early enhancement, which was more evident later; in 5 of 21 cases the enhancement was observed only in the late portal phase (1-2 min). At histological examination, 14 of 16 pseudocapsules with early enhancement showed a more prominent vasculature than those with enhancement in the equilibrium phase. Magnetic resonance was a reliable tool in demonstrating the pseudocapsule of HCC. The histological examination demonstrated a good correlation between the enhancement behavior and the vessel number of the pseudocapsule.

Segment 4 (the quadrate lobe): a barometer of cirrhotic liver disease at US

PURPOSE

To evaluate the dimensions of segment 4 of the liver in patients with cirrhosis by using ultrasonography (US).

MATERIALS AND METHODS

The transverse diameter of segment 4 was measured in 125 control subjects without liver disease and 167 patients with cirrhosis. The size of segment 4 was measured on oblique subcostal US scans obtained between the left wall of the gallbladder (or the main fissure after cholecystectomy) and the ascending or umbilical portion of the left portal vein at the point where it gives rise to the branch to segment 4.

RESULTS

In the control subject group, the mean diameter of segment 4 was 43 mm +/- 8 (standard deviation). In the patient group, the mean diameter of segment 4 was 28 mm +/- 9. The cause or severity of cirrhosis had no influence on the size of segment 4.

CONCLUSION

A decreased diameter of segment 4 may be a helpful adjunct sign of cirrhosis in the US investigation of chronic liver disease.

[Diagnostic imaging and interventional therapy in hepatocarcinoma. Multicenter study of 290 cases]

We report the results of a multicenter study on the diagnosis and interventional therapy of hepatocellular carcinoma (HCC). The first aim--diagnosis--was to evaluate the sensitivity of 4 imaging techniques, namely ultrasonography (US), Computed Tomography (CT), digital arteriography (DSA) and Lipiodol CT (LCT), in HCC detection. The accuracy of these techniques was also investigated in tumor staging, which is important for treatment planning. Two hundred ninety patients underwent this imaging protocol. The patients were classified by tumor spread into three groups, namely group 1 (single HCCs < 5 cm), group 2 (multifocal HCCs with max. 3 nodules or tumor volume < 80 cc), group 3 (multifocal HCCs with more than 3 nodules and/or tumor volume > 80 cc). US and CT diagnosed more cases as group 1 and fewer cases as group 3 than DSA and LCT; the latter two techniques gave a similar classification. With LCT as the gold standard, US and CT understaged 27.9% and 26.5% of cases, respectively. Even though LCT is known to have 53% sensitivity, it is currently the most sensitive preoperative investigation and therefore the best tool for treatment planning. In surgical patients, however, intraoperative US, with its nearly 100% sensitivity, is suggested. The second aim--treatment--consisted in assessing the therapeutic efficacy of intraarterial chemoembolization (CEAT) versus percutaneous ethanol injection (PEI) in non advanced HCC and of CEAT versus no treatment (NT) in advanced HCC. Treatment efficacy was evaluated with the following randomized protocols: PEI versus CEAT in group 1, PEI versus CEAT in group 2 and CEAT versus NT in group 3. The data were analyzed relative to 215 patients for 6 to 30 months. The Kaplan-Meier method was used to calculate survival rates, which were, at 24 and 30 months, 72% and 72% for PEI and 72% and 52% for CEAT in group 1, 52% and 28% for PEI and 70% and 50% for CEAT in group 2 and finally 30% and 20% for NT and 45% and 30% for CEAT in group 3. In group 1, PEI appeared markedly superior to CEAT. In group 2, the difference between PEI and CEAT was not statistically significant; the results in this group indicate that CEAT should be considered when three nodules are present because of PEI invasiveness in these cases. In group 3, CEAT results were definitely better in the first two years, but there was no difference with NT patients at the end of the third year. Therefore, CEAT is indicated in advanced HCC because it improves the survival rate in the first 24 months. After this period, the survival time is not modified by treatment.

Arterial chemoembolization in hepatocellular carcinoma suitable for resective surgery

BACKGROUND/AIMS

Authors examined transcatheter arterial embolization (TAE) reliability in modifying diagnosis, staging, choice of treatment after a common instrumental evaluation and in increasing results in patients with hepatocarcinoma(s) potentially suitable for surgery; this value was compared to TAE-related mortality and morbidity.

MATERIALS AND METHODS

Thirty-nine patients underwent TAE. Diagnostic value, reduction in tumor size and necrosis' percentage after treatment were computed. Immediate and long term results were compared to those obtained by primary liver resection in 62 patients.

RESULTS

TAE showed more lesions than any other diagnostic tool, thus excluding 4 patients (10.2%) from surgery. TAE-related mortality (1 patient) and severe morbidity (11 patients) excluded 4 more patients. Complications were correlated to Gelfoam embolization (p < 0.01). After TAE tumor size reduction was sporadic; tumor necrosis > 70% was present in 13/29 resected tumors. Intraoperatively 16/25 patients had TAE-related anatomical alterations; a choledochus' wall necrosis and a tumor' explosion must be mentioned. TAE and intraoperative echography had an equivalent diagnostic value. Immediate and long term results were comparable to those obtained by primary liver resection.

CONCLUSIONS

TAE has a high diagnostic accuracy but the capacity in changing the final judgment after a good instrumental evaluation is low. The specific risk-benefit ratio is not favourable, in particular after mechanical embolization, and clinical benefit is not evident.

[Peripheral intrahepatic cholangiocarcinoma. The role of imaging diagnosis and fine-needle biopsy]

Peripheral intrahepatic cholangiocarcinoma (ICC) is a fairly uncommon type of cancer in Italy which may be misdiagnosed as a metastasis from extrahepatic adenocarcinoma. In all, 22 cases of intrahepatic cholangiocarcinoma were diagnosed at the Radiology Department of the University of Brescia, Italy, from 1989 to 1994. The patients were 15 men and 7 women and their age ranged 30-77 years. Most of them underwent US examinations because of abdominal pain, weight loss or a general malaise and, less frequently, for signs of cholestasis. Hepatic cirrhosis was found in 8 patients. US showed a single nodular lesion with irregular margins in 6 cases and a large nodule with adjacent smaller satellite nodules in 12 cases. In the other 4 subjects, an infiltrative and diffuse lesion with no apparent nodules was observed. US showed hypoechoic lesions in 17 cases and both hypo- and hyperechoic areas in the other patients. The main nodular lesion was 1-3 cm in diameter in 2 cases, 3-10 cm in 15 and over 10 cm in 6 cases. Both hepatic lobes were involved in 14 patients. Twenty-one of 22 patients were submitted to CT and 3 to MR examinations. Both techniques confirmed US findings of an intrahepatic tumor but they did not help locating its origin in the intrahepatic biliary tract. Therefore, every patient was submitted to US-guided fine needle biopsy which allowed the correct diagnosis to be made in 12 cases. The remaining 10 patients had an initial diagnosis of adenocarcinoma metastases and only further studies of the histologic specimens, performed after a series of useless and negative exams (e.g., barium enema and endoscopy), allowed ICC to be correctly diagnosed. Since no typical pattern of this type of cancer can be observed with US, CT or MR examinations, we suggest that US-guided fine needle biopsy be used as the method of choice, which however needs a fruitful cooperation between the radiologist and the pathologist.

[The role of magnetic resonance angiography in the assessment of arterial stenosis in the transplanted kidney]

Artery stenosis in the transplanted kidney is the most frequent vascular complication; hypertension onset or worsening may be associated and, at an end stage, also renal insufficiency. The diagnosis must be early and accurate and provide guidelines for medical, interventional or surgical therapy. To assess the diagnostic reliability or MRA, 27 patients were examined. On the basis of clinical, biochemical, pharmacological (Captopril test) and instrumental (color-Doppler US) examinations, the artery of the transplanted kidney was considered normal in 6 patients and stenotic in 21. In the control group, MRA results were in agreement with color-Doppler findings. On the contrary, in 8 of 21 abnormal conditions, the two techniques were in disagreement. Digital angiography, considered as the gold standard, was performed in any questionable case, confirming a slight overestimation of the stenoses by MRA (3 cases) and 2 false positives by color-Doppler US. The authors believe color-Doppler US to be a reliable technique for screening stenosed arteries in the transplanted kidney. MRA is proposed as a complementary investigation useful to define stenosis type and to provide guidelines for treatment.

[Comparative evaluation of ultrasonography, computerized tomography, angiography and lipiodol CT in defining extent of hepatocarcinoma. A multicenter study]

The authors report the results of a multicentric trial on hepatocellular carcinoma (HCC) patients, whose lesions were confirmed with biopsy or by high (> 400 ng/ml) alpha-fetoprotein levels. The series consisted of 149 patients examined in 8 different centers and submitted to ultrasonography (US), Computed Tomography (CT) before and after contrast agent administration, angiography and Lipiodol CT. According to lesion size and number, the patients were divided with each imaging modality into three groups: a) group 1: unifocal HCC < 5 cm diameter; b) group 2: multifocal HCC with 2-3 nodules and/or tumor mass < 80 ml; c) multifocal HCC with more than 3 nodules (with total tumor mass not exceeding 40% of liver volume) or with total tumor mass > 80 ml. In 77 patients all the examinations were available for comparison. US and CT diagnosed more patients as belonging to group 1 than angiography and Lipiodol CT, while more patients were classified as groups 2 and 3 with angiography and Lipiodol CT, meaning that US and CT may understage some HCC cases (about 15%) because they show a lower number of nodules. This observation was confirmed by the direct comparison between US and Lipiodol CT (in 114 patients), CT and Lipiodol CT (in 103 patients) and angiography and Lipiodol CT (in 116 patients). US and Lipiodol CT were in disagreement in 18 cases, CT and Lipiodol CT in 16 cases and angiography and Lipiodol CT in 13 cases. In most of these cases, Lipiodol CT showed more lesions than the other techniques. The size of the undetected lesions was small, ranging few mm to 2 cm in nearly all cases. To conclude, the results of this multicentric trial show that Lipiodol CT is a fundamental tool to evaluate HCC extent. In contrast, conventional CT appeared not to add any significant piece of information and can therefore be excluded from the diagnostic protocol of HCC.

Diagnostic imaging of renal pelvis tumours

— Renal pelvis tumours represent 5–10% of renal neoplasms. 75–80% are malignant and 90% of these are transitional cell tumours. Haematuria is the most common sign It is important that a correct management of diagnostic imaging should be followed. For this reason a retrospective study on 51 patients with carcinoma of the pelvicalices has been carried out. By comparing the association of all three examinations (ultrasonography, urine cytology and urography) a more specific diagnosis can be obtained. A single exam has already proved to be insufficient, and risks being false negative. Retrograde pyelography and CT also proved to be very useful in completing the diagnosis.

[Comparison of ultrasonography, computerized tomography, and magnetic resonance in the study of parotid masses]

One hundred and seven patients were examined to compare advantages and pitfalls of the imaging methods currently used to stage parotid masses. Thirty patients underwent US and CT, 44 were investigated with US and MRI and 33 with US, CT and MRI. The accuracy of the three techniques was analyzed in detecting and assessing the intra-/extraglandular location of the parotid lesions and their benign/malignant nature. The intraglandular lesion spread to superficial/deep lobes was also investigated, together with its relationship to the surrounding structures. The findings were correlated with the cytohistological data from US-guided biopsy or from surgical resection. US was less accurate than CT and MRI, the latter being not statistically superior to the former. Because of the low incidence of pitfalls, US with fine-needle aspiration cytology should be the technique of choice; CT and MRI must be used for lesions > 3 cm or for masses in the deep gland lobes. In conclusion, CT accurately assesses parotid lesions but MRI demonstrates the relationship to adjacent structures better.

[The use of echography and US-guided percutaneous puncture in addition to mammography for the detection of malignant breast tumors]

At present, mammography is the most effective means to detect breast cancers, especially in the early stages. However, it lacks sensitivity and specificity in women with dense breasts. Moreover, indeterminate lesions are often seen on mammograms, which should undergo further examination before surgery. Due to recent improvement in the technique--i.e., the use of high-resolution 10-MHz transducers--US can now detect also nonpalpable breast lesions, about 1 cm phi. Fine-needle biopsy (FNB) under US guidance, which is complementary to US, allows a correct diagnosis of malignancy in a high number of cases. A total of 1821 women with indeterminate lesions at mammography underwent US, and 491 of them underwent US-guided FNB, in the Leno Hospital (Brescia, Italy), in the period 1988-90. Thirty-one breast cancers which had been missed at mammography and clinical examination were found. Three cases were carcinomas in situ, 23 invasive cancers were classified as pathological stage T1, and 15 cases had no axillary lymph node involvement. The routine use of US and FNB in addition to mammography when indeterminate lesions are seen on mammograms and in women with dense breasts may significantly reduce the number of both false-negative cases at mammography and unnecessary biopsies.

[The dynamic magnetic resonance study of focal liver lesions by FLASH sequences with bolus intravenous gadolinium-DTPA]

Thirty-five patients with hepatic hemangioma (n = 12), metastasis (n = 10), hepatocellular carcinoma (HCC) (n = 10) and focal nodular hyperplasia (n = 3) were examined with the fast low-angle shot (FLASH) technique and an intravenous bolus injection of Gd-DTPA. In order to differentiate the lesions, the following criteria were used: a) pre Gd-DTPA intensity of lesions; b) post Gd-DTPA patterns of contrast enhancement. On the basis of these criteria, an unquestionable differential diagnosis could be made. Hemangiomas were characterized by an hypointense mass before Gd-DTPA, by peripheral contrast enhancement and by subsequent continuous hyperintense fill-in; thus, hemangiomas were visualized as hyperintense lesion during the late phase. Before contrast administration hypovascular metastases appeared as hypointense; they were characterized by delayed uptake of contrast agent. HCCs were hyperintense lesions before contrast administrations; then, quick contrast enhancement and rapid decrease in signal intensity were observed with visualization of a hyperintense ring due to the capsule. Finally, focal nodular hyperplasia appeared isointense or hypointense relative to normal liver on precontrast scans; the lesions were enhanced transiently with subsequent quick dismission of contrast agent. This initial experience suggests dynamic contrast-enhanced MR imaging as an effective method to improve the differential diagnosis among hepatic tumors when precontrast T2-weighted images are equivocal.

[The use of echography and echo-guided fine needle biopsy in the preclinical diagnosis of renal neoplasms]

During a 3 year period, 24 cases of renal cell carcinoma by means of ultrasonography have been observed. Seven of the 24 patients presented signs and/or symptoms of renal disease (29.2%); in 6 cases a malignant disease of unknown origin was suspected (25%) and in the other 11 the diagnosis was directed to gastrointestinal diseases (45.8%). The incidental finding of a renal malignant tumor by ultrasound in a high percentage of cases suggested an increasing use of this technique in hospitalized patients.