Soft Reconstruction Kernels Improve HCC Imaging on a Photon-Counting Detector CT

RATIONALE AND OBJECTIVES

Hepatocellular carcinoma (HCC) is the only tumor entity that allows non-invasive diagnosis based on imaging without further histological proof. Therefore, excellent image quality is of utmost importance for HCC diagnosis. Novel photon-counting detector (PCD) CT improves image quality via noise reduction and higher spatial resolution, inherently providing spectral information. The aim of this study was to investigate these improvements for HCC imaging with triple-phase liver PCD-CT in a phantom and patient population study focusing on identification of the optimal reconstruction kernel.

MATERIALS AND METHODS

Phantom experiments were performed to analyze objective quality characteristics of the regular body and quantitative reconstruction kernels, each with four sharpness levels (36-40-44-48). For 24 patients with viable HCC lesions on PCD-CT, virtual monoenergetic images at 50 keV were reconstructed using these kernels. Quantitative image analysis included contrast-to-noise ratio (CNR) and edge sharpness. Three raters performed qualitative analyses evaluating noise, contrast, lesion conspicuity, and overall image quality.

RESULTS

In all contrast phases, the CNR was highest using the kernels with a sharpness level of 36 (all p < 0.05), with no significant influence on lesion sharpness. Softer reconstruction kernels were also rated better regarding noise and image quality (all p < 0.05). No significant differences were found in image contrast and lesion conspicuity. Comparing body and quantitative kernels with equal sharpness levels, there was no difference in image quality criteria, neither regarding in vitro nor in vivo analysis.

CONCLUSION

Soft reconstruction kernels yield the best overall quality for the evaluation of HCC in PCD-CT. As the image quality of quantitative kernels with potential for spectral post-processing is not restricted compared to regular body kernels, they should be preferred.

A multicentre, randomised, double-blind, phase II study to evaluate the tolerability of an induction dose escalation of everolimus in patients with metastatic breast cancer (DESIREE)

BACKGROUND

Stomatitis is one of the main reasons to discontinue everolimus in patients with hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2-) metastatic breast cancer (mBC). To decrease stomatitis and subsequently early treatment discontinuations or dose reductions, the DESIREE trial investigated the use of a stepwise dose-escalation schedule of everolimus (EVE esc).

PATIENTS AND METHODS

DESIREE is a phase II, multicentre, randomised, double-blind, placebo-controlled trial in patients with HR+/HER2- mBC and progression/relapse after nonsteroidal aromatase inhibitor treatment. Patients were randomised to EVE esc (2.5 mg/day, week 1; 5 mg/day, week 2; 7.5 mg/day, week 3; 10 mg/day, weeks 4-24) or everolimus 10 mg/day (EVE 10mg) for 24 weeks plus exemestane. The primary endpoint was the incidence of stomatitis episodes grade ≥2 within 12 weeks of treatment. The secondary endpoints included toxicity, relative total dose intensity (RTDI) and quality of life (QoL).

RESULTS

A total of 160 patients were randomised and 156 started treatment (EVE esc: 80; EVE 10mg: 76). The median age of patients was 64 years (range 33-85), 56.3% patients in the EVE esc arm versus 42.1% in the EVE 10mg arm had liver metastasis (P = 0.081) and 62.5% versus 51.3% received over one metastatic therapy line (P = 0.196). Within 12 weeks, the incidence of stomatitis episodes grade ≥2 was significantly lower in the EVE esc arm compared with the EVE 10mg arm (28.8% versus 46.1%; odds ratio 0.47, 95% confidence interval 0.24-0.92; P = 0.026). Toxicity was in line with the known safety profile without new safety concerns. The median RTDI was 91.1% in the EVE esc arm versus 80.0% in the EVE 10mg arm (P = 0.329). Discontinuation rate in the first 3 weeks was 6.3% versus 15.8%, respectively (P = 0.073). QoL was comparable between the two treatment arms.

CONCLUSIONS

A dose-escalation schema of everolimus over 3 weeks can be successfully used to reduce the incidence of high-grade stomatitis in the first 12 weeks of treatment in patients with HR+/HER2- mBC.

TRIAL REGISTRATION

ClinicalTrials.govNCT02387099; https://clinicaltrials.gov/ct2/show/NCT02387099.

Photon-counting detector CT improves quality of arterial phase abdominal scans: A head-to-head comparison with energy-integrating CT

PURPOSE

Photon-counting detector (PCD)-CT is expected to have a substantial impact on oncologic abdominal imaging. We compared subjective and objective image quality between PCD-CT and conventional energy-integrating detector (EID-)CT arterial phase abdominal scans.

METHODS

This study included 84 patients undergoing both types of abdominal CT. EID-CT scans were acquired with a tube voltage of 100 kVp. With PCD-CT, acquired with 120-kVp, we reconstructed polychromatic T3D images and virtual monoenergetic images (VMIs) in 10-keV intervals from 40 to 90 keV. Quantitative image analysis included noise and contrast-to-noise ratio (CNR) of hepatic vessels, kidney cortex, and hypervascular liver lesions to liver parenchyma. Three raters used a 5-point Likert scale for qualitative image analysis of image noise and contrast, lesion conspicuity, and overall image quality. Radiation dose exposure (CT dose index) was compared between the two CT types.

RESULTS

Mean CT dose index and effective dose were respectively 18 % and 26 % lower with PCD-CT versus EID-CT. Compared with EID-CT, CNRs of kidney cortex and vessel to liver parenchyma were significantly higher in PCD-CT VMIs at energies ≤ 60 keV and in polychromatic T3D images (p < 0.004). Overall image quality of PCD-CT VMIs at 50 and 60 keV was rated as significantly better (p < 0.01) than the EID-CT images (inter-reader agreement alpha = 0.80). Lesion conspicuity was significantly better in low-keV VMIs (p < 0.03) and worse in > 70-keV VMIs.

CONCLUSIONS

With low-keV VMI, PCD-CT yields significantly improved objective and subjective quality of arterial phase oncological imaging compared with EID-CT. This advantage may translate into higher diagnostic confidence and lower radiation dose protocols.

Study protocol of the FIRE-8 (AIO-KRK/YMO-0519) trial: a prospective, randomized, open-label, multicenter phase II trial investigating the efficacy of trifluridine/tipiracil plus panitumumab versus trifluridine/tipiracil plus bevacizumab as first-line treatment in patients with metastatic colorectal cancer

Background

Initial systemic therapy for patients with metastatic colorectal cancer (mCRC) is usually based on two- or three-drug chemotherapy regimens with fluoropyrimidine (5-fluorouracil (5-FU) or capecitabine), oxaliplatin and/or irinotecan, combined with either anti-VEGF (bevacizumab) or, for RAS wild-type (WT) tumors, anti-EGFR antibodies (panitumumab or cetuximab). Recommendations for patients who are not eligible for intensive combination therapies are limited and include fluoropyrimidine plus bevacizumab or single agent anti-EGFR antibody treatment. The use of a monochemotherapy concept of trifluridine/ tipiracil in combination with monoclonal antibodies is not approved for first-line therapy, yet. Results from the phase II TASCO trial evaluating trifluridine/ tipiracil plus bevacicumab in first-line treatment of mCRC patients and from the phase I/II APOLLON trial investigating trifluridine/ tipiracil plus panitumumab in pre-treated mCRC patients suggest favourable activity and tolerability of these new therapeutic approaches.

Methods

FIRE-8 (NCT05007132) is a prospective, randomized, open-label, multicenter phase II study which aims to evaluate the efficacy of first-line treatment with trifluridine/tipiracil (35 mg/m² body surface area (BSA), orally twice daily on days 1–5 and 8–12, q28 days) plus either the anti-EGFR antibody panitumumab (6 mg/kg body weight, intravenously on day 1 and 15, q28 days) [arm A] or (as control arm) the anti-VEGF antibody bevacizumab (5 mg/kg body weight, intravenously on day 1 and 15, q28 days) [arm B] in RAS WT mCRC patients. The primary objective is to demonstrate an improved objective response rate (ORR) according to RECIST 1.1 from 30% (control arm) to 55% with panitumumab. With a power of 80% and a two-sided significance level of 0.05, 138 evaluable patients are needed. Given an estimated drop-out rate of 10%, 153 patients will be enrolled.

Discussion

To the best of our knowledge, this is the first phase II trial to evaluate the efficacy of trifluridine/tipiracil plus panitumumab in first-line treatment of RAS WT mCRC patients. The administration of anti-EGFR antibodies rather than anti-VEGF antibodies in combination with trifluridine/tipiracil may result in an increased initial efficacy.

Trial registration

EU Clinical Trials Register (EudraCT) 2019-004223-20. Registered October 22, 2019, ClinicalTrials.govNCT05007132. Registered on August 12, 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09892-8.

OP0079 SYNOVIAL FIBROBLASTS – T CELL INTERACTIONS ARE MAJOR DRIVERS OF INFLAMMATION: A CLOSER LOOK INTO THE JOINT

Background

Rheumatoid Arthritis (RA) is a chronic inflammatory disease, which is characterized by synovial inflammation resulting in bone and cartilage destruction. Crosstalk between activated fibroblast-like synoviocytes (FLS) and immune cells, such as CD4+ T cells, within the synovium might amplify synovial inflammation and joint destruction.

Objectives

To define the interaction profile of activated FLS and CD4+ T cells within an inflammatory setting and to elucidate its consequence on synovial inflammation.

Methods

To screen for factors that activate FLS in RA, isolated FLS were treated with different inflammatory cytokines and transcriptomic changes were measured with RNA-seq. Fluorescence activated cell sorting (FACS) purified naïve CD4+ T-cells from the same patients were co-cultured with the cytokine pre-treated FLS. Automated fluorescence microscopy and downstream bioinformatic image analysis allowed visualization and quantification of cell-cell interactions. After co-culture T-cells were isolated and T-cell activation, proliferation and differentiation was determined by flow cytometry.

Results

To model the in vivo situation, FLS were pre-stimulated with different pro- and anti-inflammatory cytokines. RNA-seq revealed cytokine specific activation patterns of FLS. Correspondingly, we observed distinct CD4+ T cells – FLS interaction profiles depending on the cytokine used for FLS activation. In line with distinct interaction profiles, specific patterns in CD4+ T cells activation, proliferation and differentiation of naïve T cells into CD62Lhigh CD45ROhigh memory T cells could be detected. Signatures of cytokine-stimulated FLS could be identified in transcriptomic data from synovial tissue samples.

Conclusion

Within this study, we describe how cytokine induced CD4+ T cells – FLS interactions impact on T-cell proliferation, activation and differentiation.

References

[1]Zhang F, Wei K, Slowikowski K, Fonseka CY, Rao DA, Kelly S, et al. Defining inflammatory cell states in rheumatoid arthritis joint synovial tissues by integrating single-cell transcriptomics and mass cytometry. Nat Immunol. 2019.

[2]Smolen JS, Aletaha D, Barton A, Burmester GR, Emery P, Firestein GS, et al. Rheumatoid arthritis. Nat Rev Dis Primers. 2018;4:18001.

[3]Smolen JS, Aletaha D, McInnes IB. Rheumatoid arthritis. The Lancet. 2016;388(10055):2023-38.

[4]Bartok B, Firestein GS. Fibroblast-like synoviocytes: key effector cells in rheumatoid arthritis. Immunol Rev. 2010;233(1):233-55.

[5]Zhang F, Wei K, Slowikowski K, Fonseka CY, Rao DA, Kelly S, et al. Defining inflammatory cell states in rheumatoid arthritis joint synovial tissues by integrating single-cell transcriptomics and mass cytometry. Nat Immunol. 2019.

Disclosure of Interests

None declared.

Diagnostic accuracy of wrist MRI in comparison to wrist arthroscopy regarding TFCC lesions in clinical practice

INTRODUCTION

The purpose of this study was to arthroscopically verify MRI diagnostic accuracy for triangular fibrocartilage complex (TFCC) lesions in a regular clinical environment.

METHODS

A total of 859 patients' data with both preoperative MRI of the wrist and additional wrist arthroscopy were retrospectively reviewed. Two board-certified hand surgeons and one orthopaedic surgeon executed wrist arthroscopy, whereas more than 100 radiologists examined the MRI of the wrist. The accordance of TFCC lesion classification using MRI in comparison to wrist arthroscopy and diagnostic precision of the former depending on technical details were evaluated.

RESULTS

Diagnostic accuracy of MRI for TFCC lesions is poor in comparison to wrist arthroscopy as the reference standard. Technical specifications for MRI of the wrist are heterogeneous among the radiologists. These parameters have not improved accuracy of TFCC evaluation at large.

CONCLUSION

The accuracy of MRI in a regular clinical environment still remains inferior to wrist arthroscopy for detection of TFCC lesions. Development of a standard MRI protocol may be implemented on a regular basis and application of the Palmer classification for TFCC lesion should be sought.

Prognostic relevance of the HER2 status of circulating tumor cells in metastatic breast cancer patients screened for participation in the DETECT study program

BACKGROUND

Circulating tumor cells (CTCs) have been reported to predict clinical outcome in metastatic breast cancer (MBC). Biology of CTCs may differ from that of the primary tumor and HER2-positive CTCs are found in some patients with HER2-negative tumors.

PATIENTS AND METHODS

Patients with HER2-negative MBC were screened for participation in DETECT III and IV trials before the initiation of a new line of therapy. Blood samples were analyzed using CELLSEARCH. CTCs were labeled with an anti-HER2 antibody and classified according to staining intensity (negative, weak, moderate, or strong staining).

RESULTS

Screening blood samples were analyzed in 1933 patients with HER2-negative MBC. As many as 1217 out of the 1933 screened patients (63.0%) had ≥1 CTC per 7.5 ml blood; ≥5 CTCs were detected in 735 patients (38.0%; range 1-35 078 CTCs, median 8 CTCs). HER2 status of CTCs was assessed in 1159 CTC-positive patients; ≥1 CTC with strong HER2 staining was found in 174 (15.0%) patients. The proportion of CTCs with strong HER2 staining among all CTCs of an individual patient ranged between 0.06% and 100% (mean 15.8%). Patients with estrogen receptor (ER)- and progesterone receptor (PR)-positive tumors were more likely to harbor ≥1 CTC with strong HER2 staining. CTC status was significantly associated with overall survival (OS). Detection of ≥1 CTC with strong HER2 staining was associated with shorter OS [9.7 (7.1-12.3) versus 16.5 (14.9-18.1) months in patients with CTCs with negative-to-moderate HER2 staining only, P = 0.013]. In multivariate analysis, age, ER status, PR status, Eastern Cooperative Oncology Group performance status, therapy line, and CTC status independently predicted OS.

CONCLUSION

CTC detection in patients with HER2-negative disease is a strong prognostic factor. Presence of ≥1 CTC with strong HER2 staining was associated with shorter OS, supporting a biological role of HER2 expression on CTCs.

Nutrient pattern analysis in critically ill patients using Omics technology (NAChO) - Study protocol for a prospective observational study

INTRODUCTION

Intensive care unit-acquired weakness (ICU-AW) is often observed in critically ill patients with prolonged intensive care unit (ICU) stay. We hypothesized that evolving metabolic abnormalities during prolonged ICU stay are reflected by changing nutrient patterns in blood, urine and skeletal muscle, and that these patterns differ in patients with/without ICU-AW and between patients with/without sepsis.

METHODS

In a prospective single-center observational trial, we aim to recruit 100 critically ill patients (ICU length of stay ≥ 5 days) with severe sepsis/septic shock ("sepsis group", n = 50) or severe head trauma/intracerebral hemorrhage ("CNS group", n = 50). Patients will be sub-grouped for presence or absence of ICU-AW as determined by the Medical Research Council sum score. Blood and urine samples will be collected and subjected to comprehensive nutrient analysis at different time points by targeted quantitative mass spectrometric methods. In addition, changes in muscular tissue (biopsy, when available), muscular architecture (ultrasound), electrophysiology, body composition analyses (bioimpedance, cerebral magnetic resonance imaging), along with clinical status will be assessed. Patients will be followed-up for 180 and 360 days including assessment of quality of life.

DISCUSSION

Key objective of this trial is to assess changes in nutrient pattern in blood and urine over time in critically ill patients with/without ICU-AW by using quantitative nutrient analysis techniques. Peer-reviewed published NAChO data will allow for a better understanding of metabolic changes in critically ill patients on standard liquid enteral nutrition and will likely open up new avenues for future therapeutic and nutritional interventions.

Quantitative Determination of Plasminogen

A modification of the caseinolytic assay for plasminogen is described. This assay system is characterized by the following features :

1. Urokinase is used as activator achieving a complete activation of the plasminogen whereas with streptokinase caseinolytically inactive plasminogen-activator complexes are formed.

2. All incubation times are reduced to the minimum which is still compatible with accuracy.

3. Results are expressed in percent of a standard of ten normal plasmas.

4. In this two-stage assay-system (activation of plasminogen to plasmin, digestion of casein by plasmin) both stages proceed simultaneously in the same system, thus the plasmin formed is stabilized “in statu nascendi” by the casein.

5. Several conditions (stability of plasminogen in frozen plasma, use of anticoagulants, reproducibility) are defined.

Freeform characterization based on nanostructured diffraction gratings

The in-line characterization of freeform optical elements during the production cycle is challenging. Recently, we presented a compact sensor setup for the characterization of the wavefront generated by freeform optical elements in transmission. The sensor is based on a common-path interferometer consisting of diffractive components and Fourier filtering being adapted to the subsequent numerical post processing. Additionally, it offers several degrees of freedom for enlarging the measurement range of the wavefront gradients. In this contribution, we propose an advanced sensor setup for the measurement of wavefronts generated by freeform elements in reflection. The main advantage is the uni-axial illumination of the test object and the measuring system without the need for conventional beamsplitters. Due to this uni-axial arrangement, the main challenge is to avoid the effect of stray light and back reflections on the measurement signal-to-noise ratio. This is achieved by implementing a highly absorbing amplitude grating based on nanostructured silicon. We demonstrate the experimentally realized measurement system and compare its performance to a commercial Shack-Hartmann sensor.

Note: Soft X-ray transmission polarizer based on ferromagnetic thin films

A transmission polarizer for producing elliptically polarized soft X-ray radiation from linearly polarized light is presented. The setup is intended for use at synchrotron and free-electron laser beamlines that do not directly offer circularly polarized light for, e.g., X-ray magnetic circular dichroism (XMCD) measurements or holographic imaging. Here, we investigate the degree of ellipticity upon transmission of linearly polarized radiation through a cobalt thin film. The experiment was performed at a photon energy resonant to the Co L₃-edge, i.e., 778 eV, and the polarization of the transmitted radiation was determined using a polarization analyzer that measures the directional dependence of photo electrons emitted from a gas target. Elliptically polarized radiation can be created at any absorption edge showing the XMCD effect by using the respective magnetic element.

Assessment of imatinib as first-line treatment of chronic myeloid leukemia: 10-year survival results of the randomized CML study IV and impact of non-CML determinants

Chronic myeloid leukemia (CML)-study IV was designed to explore whether treatment with imatinib (IM) at 400 mg/day (n=400) could be optimized by doubling the dose (n=420), adding interferon (IFN) (n=430) or cytarabine (n=158) or using IM after IFN-failure (n=128). From July 2002 to March 2012, 1551 newly diagnosed patients in chronic phase were randomized into a 5-arm study. The study was powered to detect a survival difference of 5% at 5 years. After a median observation time of 9.5 years, 10-year overall survival was 82%, 10-year progression-free survival was 80% and 10-year relative survival was 92%. Survival between IM400 mg and any experimental arm was not different. In a multivariate analysis, risk group, major-route chromosomal aberrations, comorbidities, smoking and treatment center (academic vs other) influenced survival significantly, but not any form of treatment optimization. Patients reaching the molecular response milestones at 3, 6 and 12 months had a significant survival advantage. For responders, monotherapy with IM400 mg provides a close to normal life expectancy independent of the time to response. Survival is more determined by patients' and disease factors than by initial treatment selection. Although improvements are also needed for refractory disease, more life-time can currently be gained by carefully addressing non-CML determinants of survival.