Targeted axillary dissection reduces residual nodal disease in clinically node- positive breast cancer after neoadjuvant chemotherapy.

BACKGROUND: Any advantage of performing targeted axillary dissection (TAD) compared to sentinel lymph node (SLN) biopsy (SLNB) is under debate in clinically node-positive (cN+) patients diagnosed with breast cancer. Our objective was to assess the feasibility of the removal of the clipped node (RCN) with TAD or without imaging-guided localisation by SLNB to reduce the residual axillary disease in completion axillary lymph node dissection (cALND) in cN+ breast cancer. METHODS: A combined analysis of two prospective cohorts, including 253 patients who underwent SLNB with/without TAD and with/without ALND following NAC, was performed. Finally, 222 patients (cT1-3N1/ycN0M0) with a clipped lymph node that was radiologically visible were analyzed. RESULTS: Overall, the clipped node was successfully identified in 246 patients (97.2%) by imaging. Of 222 patients, the clipped lymph nodes were non-SLNs in 44 patients (19.8%). Of patients in cohort B (n=129) with TAD, the clipped node was successfully removed by preoperative image-guided localisation, or the clipped lymph node was removed as the SLN as detected on preoperative SPECT-CT. Among patients with ypSLN(+) (n=109), no significant difference was found in non-SLN positivity at cALND between patients with TAD and RCN (41.7% vs. 46.9%, p=0.581). In the subgroup with TAD with axillary lymph node dissection (ALND; n=60), however, patients with a lymph node (LN) ratio (LNR) less than 50% and one metastatic LN in the TAD specimen were found to have significantly decreased non-SLN positivity compared to others (27.6% vs. 54.8%, p=0.032, and 22.2% vs. 50%, p=0.046). CONCLUSIONS: TAD by imaging-guided localisation is feasible with excellent identification rates of the clipped node. This approach has also been found to reduce the additional non-SLN positivity rate to encourage omitting ALND in patients with a low metastatic burden undergoing TAD.

Immune checkpoint inhibitors: Assessment of the performance and the agreement of iRECIST, irRC, and irRECIST.

INTRODUCTION: Immunotherapy has become more widely accepted and used by medical oncologists. Radiologists face challenges in assessing tumor response and becoming more involved in the management of treatment. We aimed to assess the agreement between immune-related response criteria (irRC), immune-related RECIST (irRECIST), and immune RECIST (iRECIST) to correlate the response measured by them with overall survival (OS), and to determine the confirmation rate of progressive disease (PD). METHODS: A total of 43 patients (28 men, 15 women; average age = 54.6 ± 15.7 years) treated with immunotherapy were included in this study. Pairwise agreements between iRECIST, irRC, and irRECIST were calculated using Cohen's kappa statistics. The correlation of the criteria-based response and OS was evaluated using the Kaplan-Meier method and log-rank test. A confirmation rate with 95% confidence intervals (CI) was calculated in patients with PD. RESULTS: The kappa values between iRECIST and irRC, iRECIST and irRECIST, and irRC and irRECIST were 0.961 (almost perfect; P < 0.001), 0.961 (almost perfect; P < 0.001), and 0.922 (almost perfect; P < 0.001), respectively. The Kaplan-Meier method and log-rank test showed for each criterion a statistically significant correlation with OS (P < 0.05). The confirmation rates of PD for irRC, irRECIST, and iRECIST were 95% (19/20; 95% CI = 76.4-99.1%), 90% (18/20; 95% CI = 69.9-97.2%), and 90.5% (19/21; 95% CI = 71.1-97.4%), respectively. CONCLUSION: There was an almost perfect and statistically significant agreement between iRECIST, irRC, and irRECIST. The measurements performed with them significantly correlated with the OS; their confirmation rates were similar. iRECIST and irRECIST might be favored over irRC because of their relative ease of use.

The Significance of Preoperative Computed Tomography Features in the Prediction of Overall Survival in Gastric Cancer: A Retrospective Analysis.

Objectives: Computed tomography (CT) is a frequently used modality for staging in the preoperative evaluation of gastric cancer (GC). Our aim was to interpret the importance of preoperative CT features in predicting overall survival (OS) in patients operated for GC. Methods: One hundred and one patients with GC (33 women, 68 men; range of age: 29-82 years, median age: 61 years) who had abdominal CT prior to surgical resection were included in the study retrospectively. Two radiologists evaluated CT scans to record the longest dimension of the tumor, the localization of the lesion, the attenuation values of the tumor in the arterial and venous phases (Hounsfield units), invasion depth of the lesion (T stage), and the number of pathological lymph nodes (LNs) (N stage). Postoperative pathological results including resection (R0, R1), T stage, N stage, grade, and histopathological subtype were documented. All CT-provided results and clinicopathological features associated with OS were analyzed by univariate, multivariate, and receiver operator characteristic analysis. Results: Multivariate analysis revealed that none of the CT features were associated with the OS. After resection, the survival ratio was poor for the R1 and high-grade groups than for the R0 and low-grade groups (p=0.001 and p=0.005, respectively). N stage and the longest dimension of the tumor on CT imaging truly estimated R1 resection status (AUC, 0.697; sensitivity, 63%; and specificity, 88%, and AUC, 0.734; sensitivity, 18%; and specificity, 76%, respectively). Conclusion: R1 resection status is associated with poor OS in GC. CT features, including the tumor's longest dimension and the number of pathological LNs, can predict R1 resection status.

Abbreviated and Standard Breast MRI in Neoadjuvant Chemotherapy Response Evaluation: A Comparative Study.

OBJECTIVES: This study aims to investigate the efficacy of abbreviated breast magnetic resonance imaging (MRI) in neoadjuvant chemotherapy (NAC) response evaluation. METHODS: MR images of 50 locally advanced breast cancer patients who underwent standard protocol (SP) breast MRI before and after NAC were re-evaluated retrospectively. Abbreviated protocol (AP) was obtained by extracting images from SP and then evaluating them in a separate session. Protocols were compared with the histological findings after surgery as the reference standard. RESULTS: A statistically significant difference was found between the two protocols in response evaluation by the McNemar test (p=0.018). However, the Kappa value was 0.62 (p<0.001), which indicates substantial agreement. No statistically significant differences were found between the two protocols (AP and SP) and pathological results in the McNemar test (p=0.12, p=0.60, respectively). Kappa values were 0.48 (p<0.001) and 0.60 (p<0.001), respectively, which indicates moderate agreement for both protocols with higher values by SP evaluation. The residual maximum median diameters were smaller than the pathology, with both protocols (p<0.001). CONCLUSION: Despite the statistical differences, there was a significant correlation in response evaluation between the two protocols. The pathological results were moderately correlated with both protocols, with SP slightly higher. However, the residual maximum median diameters were smaller than the pathology with both protocols. These results may limit the use of AP in evaluating the local extent of the tumor, especially in patients who will undergo breast-conserving surgery.

A rare case of ruptured liver metastases from a laryngeal cancer.

Rupture of a metastatic liver tumor associated with laryngeal cancer is a very rare complication with no previous case in the literature. We present a case of ruptured liver metastases which was treated conservatively. Dynamic contrast-enhanced computed tomography demonstrated active extravasation and discontinuity of liver capsule. When the patient came to our hospital from the external medical center, we did not see active extravasation on control computed tomography. This case highlights the role of radiologic imaging in the diagnosis and follow-up of ruptured hepatic metastases.

Are radiologists ready to evaluate true response to immunotherapy?

BACKGROUND: Standardized response criteria for evaluating patients radiological imaging have an essential role in oncological management. Immunotherapy, using immune checkpoint inhibitors (ICIs), including drugs targeting cytotoxic T-lymphocyte-associated antigen 4 and programmed cell death protein 1 or its ligand, promise a new role that has demonstrated improvement management in cancers resistant to chemotherapy. This article reviews the literature to understand the most useful response evaluation criteria for optimal patient management under immunotherapy treatment. Areas that warrant further research are described. CONCLUSION: In conclusion, ICIs have become more widely accepted and used by medical oncologists. Radiologists face challenges in assessing tumor response and becoming more involved in the management of treatment. The latest published immune-RECIST criteria can be used in response assessment, but further prospective evaluation is needed with registration clinical trials to be definitively validated.

Diagnostic accuracy of metastatic axillary lymph nodes in breast MRI.

PURPOSE: The most important prognostic variable for early stage breast cancer is the status of axillary lymph nodes. The aim of this study was to evaluate the diagnostic accuracy of preoperative magnetic resonance imaging (MRI) for metastatic axillary lymph node in breast cancer cases with post-operative sentinel lymph node biopsy (SLNB) results. MATERIALS AND METHODS: Women aged between 21 and 73 years who were diagnosed with malignant mass lesion of the breast between 2013 and 2015 were included in this study. The preoperative MR images of patients with diagnosis of breast cancer was evaluated to determine axillary lymph node status. Axillary lymph node size, long axis to short axis ratio, lymph node contours, cortical thickness to anteroposterior diameter ratio, the presence of a fatty hilum and contrast enhancement patterns (homogenous or heterogenous) was noted. Additionally, the presence of comet tail sign which a tail extending from an enhancing breast lesion into the parenchyma and might represent ductal infiltration on post-contrast series was also noted. All data obtained from this evaluation was compared with postoperative SLNB results. RESULTS: Metastatic nodes were found to have a longer short axis when compared to reactive nodes (p = 0.042; p < 0.05). The long axis to short axis ratio was notably lower in metastatic nodes when compared to reactive nodes. Cortical thickness was higher in metastatic nodes when compared to reactive nodes (p = 0.024; p < 0.05). Comet sign was observed in 15 of metastatic nodes (73.3 %) and in one (5 %) reactive node. This difference was statistically significant (p = 0.001; p < 0.01). While fatty hilum was seen in 40 % of metastatic nodes (n = 6), it was seen in all (n = 20) reactive nodes. This difference was statistically significant (p = 0.001; p < 0.01). CONCLUSIONS: MRI is a non invasive sensitive and specific imaging modality for evaluating the axilla. We have shown that with the help of comet tail sign and status of fatty hilum contrast enhanced MRI has the highest sensitivity of 84.7 % for detecting axillary lymph node metastases (Singletary et al. in Semin Surg Oncol 21(1):53-59, 2003).

Computed tomography imaging findings of craniofacial fibrous dysplasia.

INTRODUCTION: The purpose of this study was to retrospectively describe demographic characteristics and computed tomography (CT) imaging findings of craniofacial fibrous dysplasia (FD). PATIENTS AND METHODS: Between February 2010 and February 2013, we retrospectively studied 64 patients described as FD at CT imaging. Site of involvement and CT imaging findings of craniofacial FD were recorded for each patient. RESULTS: Our patients are described as FD at CT imaging with the following findings: expansion, ground glass density, expansion and sclerosis, expansion with sclerosis and lytic appearance, expansion and lytic appearance, and only sclerosis. Expansion was the main feature which was seen with other findings (85%). The most common finding was ground glass density and the least appearance was expansion with lytic areas and only sclerosis. DISCUSSION: Our study has shown that it is very effective to know about CT findings and localizations of craniofacial FD to reduce unnecessary biopsy rates and increase the true diagnosis.

Liver trauma grading and biochemistry tests.

Among solid organ blunt traumas, the liver and spleen are mostly subject to injury. In addition, the liver is also commonly injured in penetrating traumas because of its size, location, and the ease of injury to the "Glisson Capsule". Several enzymes are known to be elevated following trauma. In our study, we evaluated the correlation between the levels of serum aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, and gamma-glutamyl transpeptidase in 57 patients with blunt trauma to the liver and compared these values to the American Association for the Surgery of Trauma trauma grading system. Additionally, we compared the enzyme level elevations in these patients to the enzyme levels of 29 healthy subjects. As expected, we found significant elevations in enzyme levels of trauma patients compared to the control group. The calculated point estimates were not significantly different between grades 1 and 2 trauma. However, grade 3 trauma group showed a significant increase in enzyme levels.