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OBJECTIVE: To review the congenital anomalies of the pancreas with their main clinical manifestations and key imaging findings on CT and MRI. BACKGROUND AND CLINICAL SIGNIFICANCE: Anomalies of pancreatic development are frequent and generally asymptomatic, but can mimic and predispose individuals to pancreatic or peripancreatic pathologies, such as pancreatitis or malignancy. Their correct diagnosis may help avoid unnecessary further investigations and procedures, or establish adequate treatment when they manifest clinically. Differentiating pancreatic congenital anomalies from their main radiological mimics constitutes a challenge for the radiologist and requires familiarity with key imaging findings. CONCLUSION: The imaging findings of CT and MRI are essential for the correct diagnosis of congenital pancreatic anomalies.
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Imageamento por Ressonância Magnética , Pâncreas , Pancreatopatias , Tomografia Computadorizada por Raios X , Humanos , Pâncreas/diagnóstico por imagem , Pâncreas/anormalidades , Imageamento por Ressonância Magnética/métodos , Tomografia Computadorizada por Raios X/métodos , Diagnóstico Diferencial , Pancreatopatias/diagnóstico por imagemRESUMO
Watch-and-wait has emerged as a new strategy for the management of rectal cancer when a complete clinical response is achieved after neoadjuvant therapy. In an attempt to standardize this new clinical approach, initiated by the Spanish Cooperative Group for the Treatment of Digestive Tumors (TTD), and with the participation of the Spanish Association of Coloproctology (AECP), the Spanish Society of Pathology (SEAP), the Spanish Society of Gastrointestinal Endoscopy (SEED), the Spanish Society of Radiation Oncology (SEOR), and the Spanish Society of Medical Radiology (SERAM), we present herein a consensus on a watch-and-wait approach for the management of rectal cancer. We have focused on patient selection, the treatment schemes evaluated, the optimal timing for evaluating the clinical complete response, the oncologic outcomes after the implementation of this strategy, and a protocol for surveillance of these patients.
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Neoplasias Retais , Conduta Expectante , Humanos , Consenso , Recidiva Local de Neoplasia/tratamento farmacológico , Neoplasias Retais/patologia , Terapia Neoadjuvante/métodos , Quimiorradioterapia/métodos , Resposta Patológica Completa , Resultado do TratamentoRESUMO
Three percent of patients with pancreatic ductal adenocarcinoma (PDAC) present a germline pathogenic variant (GPV) associated with an increased risk of this tumor, CDKN2A being one of the genes associated with the highest risk. There is no clear consensus on the recommendations for surveillance in CDKN2A GPV carriers, although the latest guidelines from the International Cancer of the Pancreas Screening Consortium recommend annual endoscopic ultrasound (EUS) or magnetic resonance imaging (MRI) regardless of family history. Our aim is to describe the findings of the PDAC surveillance program in a cohort of healthy CDKN2A GPV heterozygotes. This is an observational analysis of prospectively collected data from all CDKN2A carriers who underwent screening for PDAC at the high-risk digestive cancer clinic of the "Hospital Clínic de Barcelona" between 2013 and 2021. A total of 78 subjects were included. EUS or MRI was performed annually with a median follow-up of 66 months. Up to 17 pancreatic findings were described in 16 (20.5%) individuals under surveillance, although most of them were benign. No significant precursor lesions were identified, but an early PDAC was detected and treated. While better preventive strategies are developed, we believe that annual surveillance with EUS and/or MRI in CDKN2A GPV heterozygotes may be beneficial.
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BACKGROUND: Immune check-point blockade (ICB) has shown clinical benefit in mismatch repair-deficient/microsatellite instability high metastatic colorectal cancer (mCRC) but not in mismatch repair-proficient/microsatellite stable patients. Cancer vaccines with autologous dendritic cells (ADC) could be a complementary therapeutic approach to ICB as this combination has the potential to achieve synergistic effects. METHODS: This was a Phase I/II multicentric study with translational sub-studies, to evaluate the safety, pharmacodynamics and anti-tumor effects of Avelumab plus ADC vaccine in heavily pre-treated MSS mCRC patients. Primary objective was to determine the maximum tolerated dose and the efficacy of the combination. The primary end-point was 40% progression-free survival at 6 months with a 2 Simon Stage. RESULTS: A total of 28 patients were screened and 19 pts were included. Combined therapy was safe and well tolerated. An interim analysis (Simon design first-stage) recommended early termination because only 2/19 (11%) patients were disease free at 6 months. Median PFS was 3.1 months [2.1-5.3 months] and overall survival was 12.2 months [3.2-23.2 months]. Stimulation of immune system was observed in vitro but not clinically. The evaluation of basal RNA-seq noted significant changes between pre and post-therapy liver biopsies related to lipid metabolism and transport, inflammation and oxidative stress pathways. CONCLUSIONS: The combination of Avelumab plus ADC vaccine is safe and well tolerated but exhibited modest clinical activity. Our study describes, for the first-time, a de novo post-therapy metabolic rewiring, that could represent novel immunotherapy-induced tumor vulnerabilities.
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Vacinas Anticâncer , Neoplasias do Colo , Neoplasias Colorretais , Neoplasias Retais , Humanos , Vacinas Anticâncer/uso terapêutico , Reparo de Erro de Pareamento de DNA , Neoplasias do Colo/tratamento farmacológico , Neoplasias Retais/tratamento farmacológico , Células Dendríticas , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêuticoRESUMO
BACKGROUND: The aim of the study was to analyze the association between the liver uptake of Gadolinium-ethoxybenzyl-diethylenetriamine penta-acetic acid (Gd-EOB-DTPA) in the hepatobiliary phase (HBP) in cirrhotic patients and the presence of clinically significant portal hypertension (CSPH), and how these features impact on hepatocellular carcinoma (HCC) detection in the HBP. PATIENTS AND METHODS: Post-hoc analysis of a prospective cohort of 62 cirrhotic patients with newly US-detected nodule between 1-2 cm (study group). Twenty healthy subjects were used as control group. Qualitative and quantitative analysis of the liver contrast uptake in the HBP assessed by Relative Liver-Enhancement (RLE), Liver-Spleen (LSCR), Liver-Muscle (LMCR), and Liver-Kidney Contrast-Ratio (LKCR), Contrast Enhancement Index (CEI), and Hepatic Uptake (HUI), and biliary excretion, were registered. CSPH was confirmed invasively (HVPG > 10 mmHg) or by indirect parameters. The appearance of HCC at the HBP was analyzed. RESULTS: Nineteen patients (30.6%) did not have CSPH. In 41 patients (66.1%) the final diagnosis was HCC. All indices were significantly higher in the control group, indicating a more intense HBP liver signal intensity compared to patients with cirrhosis, even if the comparison was restricted to patients with no CSPH. CSPH was associated to a lower rate of HCC hypointensity in the HBP (51.9% vs. 85.7% without CSPH, p = 0.004). CONCLUSIONS: Liver uptake of Gd-EOB-DTPA at the HBP is decreased in cirrhosis even if the liver function is minimally impaired and it falls down significantly in patients with CSPH compromising the recognition of hypointense lesions. This fact may represent a limitation for the detection of small HCC in patients with cirrhosis and CSPH.
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Carcinoma Hepatocelular , Hipertensão Portal , Neoplasias Hepáticas , Carcinoma Hepatocelular/diagnóstico por imagem , Carcinoma Hepatocelular/patologia , Meios de Contraste , Gadolínio DTPA , Humanos , Hipertensão Portal/diagnóstico por imagem , Hipertensão Portal/etiologia , Cirrose Hepática/complicações , Cirrose Hepática/diagnóstico por imagem , Cirrose Hepática/patologia , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/patologia , Imageamento por Ressonância Magnética , Estudos ProspectivosRESUMO
Chronic pancreatitis is a chronic fibroinflammatory disease of the pancreas with prevalence around 50 cases per 100,000 inhabitants. It appears to originate from diverse and yet mixed etiological factors. It shows highly variable presenting features, complication types and disease progression rates. Treatment options are as wide as the multiple personalized scenarios the disease might exhibit at a given time point. Some medical societies have developed guidelines for diagnosis and treatment based on scientific evidence. Although these efforts are to be acknowledged, the gathered level of evidence for any topic is usually low and, therefore, recommendations tend to be vague or weak. In the present series of position papers on chronic pancreatitis from the Societat Catalana de Digestologia and the Societat Catalana de Pàncrees we aimed at providing defined position statements for the clinician based on updated review of published literature and on interdisciplinary expert agreement. The final goal is to propose the use of common terminology and rational diagnostic/therapeutic circuits based on current knowledge. To this end 51 sections related to chronic pancreatitis were reviewed by 21 specialists from 6 different fields to generate 88 statements altogether. Statements were designed to harmonize concepts or delineate recommendations. Part 1 of this paper series discusses topics on aetiology and diagnosis of chronic pancreatitis. Main clinical features are abdominal pain, exocrine and endocrine insufficiency and symptoms derived from complications. Some patients remain symptom-free. Diagnosis (definitive, probable or uncertain) should be based on objective data obtained from imaging, histology, or functional tests.
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Pancreatite Crônica/diagnóstico , Pancreatite Crônica/etiologia , Diagnóstico Diferencial , Humanos , Cirrose Hepática/diagnóstico , Imageamento por Ressonância Magnética , Medição da Dor/métodos , Testes de Função Pancreática/métodos , Neoplasias Pancreáticas/diagnóstico , Pseudocisto Pancreático/diagnóstico , Pancreatite Crônica/patologia , Fatores de Risco , Sociedades Médicas , Espanha , Tomografia Computadorizada por Raios X , UltrassonografiaRESUMO
Chronic pancreatitis is associated with impaired quality of life, high incidence of comorbidities, serious complications and mortality. Healthcare costs are exorbitant. Some medical societies have developed guidelines for treatment based on scientific evidence, but the gathered level of evidence for any individual topic is usually low and, therefore, recommendations tend to be vague or weak. In the present position papers on chronic pancreatitis from the Societat Catalana de Digestologia and the Societat Catalana de Pàncrees we aimed at providing defined position statements for the clinician based on updated review of published literature and on multidisciplinary expert agreement. The final goal is to propose the use of common terminology and rational diagnostic/therapeutic circuits based on current knowledge. To this end 51 sections related to chronic pancreatitis were reviewed by 21 specialists from 6 different fields to generate 88 statements altogether. Statements were designed to harmonize concepts or delineate recommendations. Part 2 of these paper series discuss topics on treatment and follow-up. The therapeutic approach should include assessment of etiological factors, clinical manifestations and complications. The complexity of these patients advocates for detailed evaluation in multidisciplinary committees where conservative, endoscopic, interventional radiology or surgical options are weighed. Specialized multidisciplinary units of Pancreatology should be constituted. Indications for surgery are refractory pain, local complications, and suspicion of malignancy. Enzyme replacement therapy is indicated if evidence of exocrine insufficiency or after pancreatic surgery. Response should be evaluated by nutritional parameters and assessment of symptoms. A follow-up program should be planned for every patient with chronic pancreatitis.
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Pancreatite Crônica , Qualidade de Vida , Seguimentos , Humanos , Pancreatite Crônica/complicações , Pancreatite Crônica/diagnóstico , Pancreatite Crônica/terapia , Sociedades MédicasRESUMO
INTRODUCTION: The NCCN classification of resectability in pancreatic head cancer does not consider preoperative radiological tumour ≤ 180° contact with portal vein/superior mesenteric vein (PV/SMV) as a negative prognostic feature. The aim of this study is to evaluate whether this factor is associated with higher rate of incomplete resection and poorer survival. METHODS: All patients considered for pancreatic resection between 2012 and 2017 at two Spanish referral centres were included. Patients with borderline and locally advanced pancreatic ductal adenocarcinoma (PDAC) according to NCCN classification were excluded. Preoperative CT scans were reviewed by dedicated radiologists to identify radiologic tumour contact with PV/SMV. RESULTS: Out of 302, 71 patients were finally included in this study. Twenty-two (31%) patients showed tumour-PV/SMV contact (group 1) and 49 (69%) did not show any contact (group 2). Patients in group 1 showed a statistically significantly higher rate of R1 and R1-direct margins compared with group 2 (95 vs 28% and 77 vs 10%) and lower median survival (24 vs 41 months, p = 0.02). Preoperative contact with PV/SMV, lymph node metastases, R1-direct margin and NO adjuvant chemotherapy were significantly associated with disease-specific survival at multivariate analysis. CONCLUSION: Preoperative radiological tumour contact with PV/SMV in patients with NCCN resectable PDAC is associated with high rate of pathologic positive margins following surgery and poorer survival.
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Veias Mesentéricas , Neoplasias Pancreáticas , Humanos , Veias Mesentéricas/diagnóstico por imagem , Veias Mesentéricas/cirurgia , Invasividade Neoplásica , Neoplasias Pancreáticas/diagnóstico por imagem , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia , Veia Porta/diagnóstico por imagem , Veia Porta/cirurgia , Estudos RetrospectivosRESUMO
BACKGROUND: Colon capsule endoscopy (CCE) and CT colonography (CTC) are minimally invasive techniques for colorectal cancer (CRC) screening. Our objective is to compare CCE and CTC for the identification of patients with colorectal neoplasia among participants in a CRC screening programme with positive faecal immunochemical test (FIT). Primary outcome was to compare the performance of CCE and CTC in detecting patients with neoplastic lesions. METHODS: The VICOCA study is a prospective, single-centre, randomised trial conducted from March 2014 to May 2016; 662 individuals were invited and 349 were randomised to CCE or CTC before colonoscopy. Endoscopists were blinded to the results of CCE and CTC. RESULTS: Three hundred forty-nine individuals were included: 173 in the CCE group and 176 in the CTC group. Two hundred ninety individuals agreed to participate: 147 in the CCE group and 143 in the CTC group. In the intention-to-screen analysis, sensitivity, specificity and positive and negative predictive values for the identification of individuals with colorectal neoplasia were 98.1%, 76.6%, 93.7% and 92.0% in the CCE group and 64.9%, 95.7%, 96.8% and 57.7% in the CTC group. In terms of detecting significant neoplastic lesions, the sensitivity of CCE and CTC was 96.1% and 79.3%, respectively. Detection rate for advanced colorectal neoplasm was higher in the CCE group than in the CTC group (100% and 93.1%, respectively; RR = 1.07; p = 0.08). Both CCE and CTC identified all patients with cancer. CCE detected more patients with any lesion than CTC (98.6% and 81.0%, respectively; RR = 1.22; p = 0.002). CONCLUSION: Although both techniques seem to be similar in detecting patients with advanced colorectal neoplasms, CCE is more sensitive for the detection of any neoplastic lesion. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02081742 . Registered: September 16, 2013.
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Endoscopia por Cápsula/métodos , Colonografia Tomográfica Computadorizada/métodos , Neoplasias Colorretais/diagnóstico por imagem , Neoplasias Colorretais/diagnóstico , Detecção Precoce de Câncer/métodos , Programas de Rastreamento/métodos , Neoplasias Colorretais/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
Background: The prospective phase IV AVAMET study was undertaken to correlate response evaluation criteria in solid tumors (RECIST)-defined response rates with computed tomography-based morphological criteria (CTMC) and pathological response after liver resection of colorectal cancer metastases. Methods: Eligible patients were aged ≥18 years, with Eastern Cooperative Oncology Group (ECOG) performance status 0/1 and histologically-confirmed colon or rectal adenocarcinoma with measurable liver metastases. Preoperative treatment was bevacizumab (7.5 mg on day 1) + XELOX (oxaliplatin 130 mg/m2, capecitabine 1000 mg/m2 bid on days 1-14 q3w). After three cycles, response was evaluated by a multidisciplinary team. Patients who were progression-free and metastasectomy candidates received one cycle of XELOX before undergoing surgery 3-5 weeks later, followed by four cycles of bevacizumab + XELOX. Results: A total of 83 patients entered the study; 68 were eligible for RECIST, 67 for CTMC, and 51 for pathological response evaluation. Of these patients, 49% had a complete or partial RECIST response, 91% had an optimal or incomplete CTMC response, and 81% had a complete or major pathological response. CTMC response predicted 37 of 41 pathological responses versus 23 of 41 responses predicted using RECIST (p = 0.008). Kappa coefficients indicated a lack of correlation between the results of RECIST and morphological responses and between morphological and pathological response rates. Conclusion: CTMC may represent a better marker of pathological response to bevacizumab + XELOX than RECIST in patients with potentially-resectable CRC liver metastases.
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BACKGROUND: Neoadjuvant therapy (NAT) for pancreatic adenocarcinoma (PDAC) patients has shown promising results in non-randomized trials. This is a multi-institutional phase II trial of NAT in resectable PDAC patients. METHODS: Patients with confirmed resectable PDAC after agreement by two expert radiologists were eligible. Patients received three cycles of GEM (1000 mg/m2/week) plus daily erlotinib (ERL) (100 mg/day). After re-staging, patients without progressive disease underwent 5 weeks of therapy with GEM (300 mg/m2/week), ERL 100 mg/day and concomitant radiotherapy (45 Gy). Efficacy was assessed using tumor regression grade (TRG) and resection margin status. Using a single-arm Simon's design, considering the therapy not useful if R0 < 40% and useful if the R0 > 70% (alpha 5%, beta 10%), 24 patients needed to be recruited. This trial was registered at ClinicalTrials.gov, number NCT01389440. RESULTS: Twenty-five patients were enrolled. Adverse effects of NAT were mainly mild gastrointestinal disorders. Resectability rate was 76%, with a R0 rate of 63.1% among the resected patients. Median overall survival (OS) and disease-free survival (DFS) were 23.8 (95% CI 11.4-36.2) and 12.8 months (95% CI 8.6-17.1), respectively. R0 resection patients had better median OS, compared with patients with R1 resection or not resected (65.5 months vs. 15.5 months, p = 0.01). N0 rate among the resected patients was 63.1%, and showed a longer median OS (65.5 vs. 15.2 months, p = 0.009). CONCLUSION: The results of this study confirm promising oncologic results with NAT for patients with resectable PDAC. Therefore, the present trial supports the development of phase II randomized trials comparing NAT vs. upfront surgery in resectable pancreatic cancer.
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Adenocarcinoma/cirurgia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Desoxicitidina/análogos & derivados , Cloridrato de Erlotinib/uso terapêutico , Terapia Neoadjuvante/métodos , Neoplasias Pancreáticas/cirurgia , Adenocarcinoma/tratamento farmacológico , Adenocarcinoma/mortalidade , Adenocarcinoma/radioterapia , Idoso , Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Desoxicitidina/administração & dosagem , Desoxicitidina/uso terapêutico , Esquema de Medicação , Cloridrato de Erlotinib/administração & dosagem , Feminino , Humanos , Masculino , Pancreatectomia , Neoplasias Pancreáticas/tratamento farmacológico , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/radioterapia , Radioterapia Adjuvante , Análise de Sobrevida , GencitabinaRESUMO
OBJECTIVE: The objective of this study was to analyse the safety, feasibility and survival outcomes of our treatment of perihilar cholangiocarcinoma (PHC) since the introduction of more aggressive approaches (en bloc, vascular and extended liver resections) in 2007. PATIENTS AND METHODS: From July 2007 to December 2014, 32 consecutive patients with PHC underwent surgery with curative intent. Surgery with resection and reconstruction of the portal vein bifurcation and right hepatic artery was performed if necessary for a complete removal of the tumour. Perioperative data and postoperative histological findings, tumour recurrence rates and survival rates were recorded. Seventeen (53%) of the patients presented with stage IIIb or IV according to the UICC classification system. RESULTS: The 5-year survival rate in our series was 45%, and this percentage increased to 65% when patients with advanced stage cancer (stage IIIb or higher) were excluded. We performed 3 arterials and 23 portal vein reconstruction. Twelve patients underwent extended hemihepatectomy. We achieved cancer-free margins in 19 patients (60%). Tumour stage and nodal involvement were the most important prognostic factors. The perioperative morbidity and mortality rates of this cohort were 72% (23) and 15.6% (5), respectively; these results were similar to data published by other groups. CONCLUSIONS: An aggressive approach involving en bloc or extended liver resection combined with vascular reconstruction provides acceptable morbidity and mortality and increases the 5-year survival rate of PHC.
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Neoplasias dos Ductos Biliares/cirurgia , Ductos Biliares Intra-Hepáticos , Hepatectomia , Tumor de Klatskin/cirurgia , Veia Porta/cirurgia , Idoso , Neoplasias dos Ductos Biliares/mortalidade , Neoplasias dos Ductos Biliares/patologia , Estudos de Viabilidade , Feminino , Humanos , Tumor de Klatskin/mortalidade , Tumor de Klatskin/patologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND AND OBJECTIVE: Clinical management of adenocarcinoma of the pancreas is complex, and requires a multidisciplinary approach. The same applies for the premalignant lesions that are increasingly being diagnosed. The current document is an update on the diagnosis and management of premalignant lesions and adenocarcinoma of the pancreas. PATIENTS AND METHODS: A conference to establish the basis of the literature review and manuscript redaction was organized by the Grupo Español Multidisciplinar en Cáncer Digestivo. Experts in the field from different specialties (Gastroenterology, Surgery, Radiology, Pathology, Medical Oncology and Radiation Oncology) met to prepare the present document. RESULTS: The current literature was reviewed and discussed, with subsequent deliberation on the evidence. CONCLUSIONS: Final recommendations were established in view of all the above.
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Adenocarcinoma , Neoplasias Pancreáticas , Lesões Pré-Cancerosas , Adenocarcinoma/diagnóstico , Adenocarcinoma/patologia , Adenocarcinoma/terapia , Quimioterapia Adjuvante , Humanos , Estadiamento de Neoplasias , Cuidados Paliativos , Pancreatectomia , Neoplasias Pancreáticas/diagnóstico , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/terapia , Lesões Pré-Cancerosas/diagnóstico , Lesões Pré-Cancerosas/patologia , Lesões Pré-Cancerosas/terapia , Radioterapia AdjuvanteRESUMO
BACKGROUND: Autologous tumour lysate dendritic cell vaccine (ADC) has T-cell stimulatory capacity and, therefore, potential antitumour activity. We designed a phase II randomised trial of ADC + best supportive care (BSC) (experimental arm [EA]) compared with BSC (control arm [CA]), in pre-treated metastatic colorectal cancer (mCRC) patients. PATIENTS AND METHODS: Patients with progressive mCRC, at least to two chemotherapy regimens and Eastern Cooperative Oncology Group performance status (ECOG PS) 0-2, were randomised to EA versus CA. Stratification criteria: ECOG PS (0-1 versus 2) and lactate dehydrogenase (
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Vacinas Anticâncer/administração & dosagem , Neoplasias Colorretais/terapia , Células Dendríticas/imunologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Vacinas Anticâncer/imunologia , Linhagem Celular Tumoral , Neoplasias Colorretais/imunologia , Neoplasias Colorretais/patologia , Neoplasias Colorretais/secundário , Feminino , Humanos , Imunoterapia/métodos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Análise de SobrevidaRESUMO
PURPOSE: Sorafenib, an oral inhibitor of B-raf, VEGFR2, and PDGFR2-beta, acts against pancreatic cancer in preclinical models. Due to the radio-sensitization activity of both sorafenib and gemcitabine, we designed a multicenter, phase I trial to evaluate the safety profile and the recommended dose of this combination used with concomitant radiation therapy. METHODS: Patients with biopsy-proven, unresectable pancreatic adenocarcinoma (based on vascular invasion detected by computed tomography) were treated with gemcitabine (300 mg/m2 i.v. weekly ×5 weeks) concurrently with radiation therapy (45 Gy in 25 fractions) and sorafenib (escalated doses in a 3+3 design, from 200 to 800 mg/day). Radiation portals included the primary tumor but not the regional lymph nodes. Patients with planning target volumes (PTV) over 500 cc were excluded. Cases not progressing during chemoradiation were allowed to continue with sorafenib until disease progression. RESULTS: Twelve patients were included. Three patients received 200 mg/day, 6 received 400 mg/day, and 3 received 800 mg/day; PTVs ranged from 105 to 500 cc. No dose-limiting toxicities occurred. The most common grade 2 toxicities were fatigue, neutropenia, nausea, and raised serum transaminases. Treatment was discontinued in one patient because of a reversible posterior leukoencephalopathy. There were no treatment-related deaths. CONCLUSION: The addition of sorafenib to concurrent gemcitabine and radiation therapy showed a favorable safety profile in unresectable pancreatic adenocarcinoma. A dose of 800 mg/day is recommended for phase II evaluation. TRIAL REGISTRATION: EudraCT 2007-003211-31 ClinicalTrials.gov 00789763.
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Adenocarcinoma/tratamento farmacológico , Adenocarcinoma/radioterapia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Desoxicitidina/análogos & derivados , Niacinamida/análogos & derivados , Neoplasias Pancreáticas/tratamento farmacológico , Neoplasias Pancreáticas/radioterapia , Compostos de Fenilureia/uso terapêutico , Adenocarcinoma/diagnóstico por imagem , Adenocarcinoma/cirurgia , Adulto , Idoso , Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Terapia Combinada , Desoxicitidina/administração & dosagem , Desoxicitidina/uso terapêutico , Relação Dose-Resposta a Droga , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Niacinamida/administração & dosagem , Niacinamida/uso terapêutico , Neoplasias Pancreáticas/diagnóstico por imagem , Neoplasias Pancreáticas/cirurgia , Compostos de Fenilureia/administração & dosagem , Tomografia por Emissão de Pósitrons , Sorafenibe , Tomografia Computadorizada por Raios X , GencitabinaRESUMO
PURPOSE: This study was designed to compare the radiation dose in abdominal dual-energy (DE) and single-energy (SE) acquisitions obtained in clinical practice with a second-generation DE computed tomography (DECT) and to analyze the dose variation in comparison with an SE acquisition performed with a 64-row SECT (SECT). METHODS: A total of 130 patients divided into 2 groups underwent precontrast and portal abdominal 128-row CT examination. In group A, DE portal acquisition was performed using a detector configuration of 2 × 40 × 0.6 mm, tube A at 80 kVp and a reference value of 559 mAs, tube B at 140 kVp and a reference value of 216 mAs, pitch 0.6, and online dose modulation; group B underwent SE portal acquisition using a detector configuration of 64 × 0.6 mm, 120 kVp and a reference value of 180 mAs, pitch 0.75, and online dose modulation. Group C consisted of 32 subjects from group A previously studied with 64-row SECT using the following parameters: detector configuration 64 × 0.6 mm, 120 kVp and a reference value of 180 mAs, pitch 0.75, and online dose modulation. In each group, the portal phase dose-length product and radiation dose (mSv) were calculated and normalized for a typical abdominal acquisition of 40 cm. RESULTS: After normalization to standard 40-cm acquisition, a dose-length product of 599.0 ± 133.5 mGy · cm (range, 367.5 ± 1231.2 mGy · cm) in group A, 525.9 ± 139.2 mGy · cm (range, 215.7-882.8 mGy · cm) in group B, and 515.9 ± 111.3 mGy · cm (range, 305.5-687.2 mGy · cm) in group C was calculated for portal phase acquisition.A significant radiation dose increase (P < 0.05) was observed in group A (10.2 ± 2.3 mSv) compared with group B (8.9 ± 2.4) and group C (8.8 ± 1.9 mSv). No significant difference (P > 0.05) was reported between SE 64- and 128-row acquisitions. A significant positive correlation between radiation dose and body mass index was observed in each group (group A, r = 0.59, P < 0.0001; group B, r = 0.35, P < 0.0001; group C, r = 0.20, P = 0.0098). CONCLUSIONS: In clinical practice, abdominal DECT acquisition shows a significant but minimal radiation dose increase, on the order of 1 mSv, compared with 64- and 128-row SE acquisition. The slightly increased radiation dose can be justified if the additional information obtained using a spectral imaging approach directly impacts on patient management or reduce the overall radiation dose with the generation of virtual unenhanced images, which can replace the precontrast acquisition.
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Carga Corporal (Radioterapia) , Doses de Radiação , Radiografia Abdominal/estatística & dados numéricos , Imagem Radiográfica a Partir de Emissão de Duplo Fóton/estatística & dados numéricos , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Adulto JovemRESUMO
Cholangiocarcinoma (CC) is the most frequent neoplasm of the biliary system. According to its anatomic origin in the biliary tree it is usually classified as intrahepatic, perihilar, or extrahepatic distal CC. Tumors originated in these areas differ in biological behavior and management. The stratification of the patients aligned to therapeutic options and prognosis is a key point in the management of CC. Thus, specific staging systems have been designed for each anatomical location. They are precise for surgical planning, to establish prognosis after surgery, or to compare the benefits of different therapeutic approaches, but they are less accurate to stratify patients into a therapeutic decision algorithm. Imaging tools, mainly multidetector computed tomography and magnetic resonance imaging (MRI), allow full assessment of the diagnosis and extension of the tumor. They are especially useful in establishing the correct diagnosis and determining resectability, which reaches a high negative predictive value, identifying those patients in whom surgery will not be effective. We will discuss the different staging systems for CC, the radiologic characteristics with classical and recently described signs that allow a confident diagnosis of the disease and the criteria for resectability of biliary tract malignancies.
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Neoplasias dos Ductos Biliares/patologia , Ductos Biliares Intra-Hepáticos , Colangiocarcinoma/patologia , Diagnóstico por Imagem , Humanos , Metástase Linfática/patologia , Estadiamento de NeoplasiasRESUMO
PURPOSES: We aimed to analyze the image quality, CT number, artifacts, radiation dose reduction, and coverage in abdominal virtual unenhanced (VU) and conventional unenhanced (CU) data sets obtained with a second-generation dual-energy computed tomography and to compare the sensitivity of VU and CU data sets for liver lesion detection. MATERIALS AND METHODS: One hundred eleven patients underwent triphasic abdominal CT examination that included single-energy CU and dual-energy arterial and portal phases. Virtual unenhanced images were generated from arterial (AVU) and portal (PVU) phases. Two abdominal radiologists independently (a) analyzed the image quality using a 5-point scale, CT number, and noise of the abdominal organs and (b) identified and characterized liver lesions in CU, AVU, and PVU. The triphasic abdominal examination was considered the reference standard for liver lesion detection and characterization. RESULTS: The quality of VU images was mostly excellent but not as good as CU images (P < 0.05). The mean (SD) image quality classified by readers 1 and 2 was 4.9 (0.2; range, 4.7-5.0) and 4.8 (0.5; range, 4.4-4.9) for CU, 4.7 (0.4; range, 4.3-4.9) and 4.6 (0.4; range, 4.2-4.8) for AVU, and 4.7 (0.6; range, 4.1-4.8) and 4.6 (0.4; range, 4.2-4.8) for PVU, respectively. The CT number of the liver, the spleen, the pancreas, the renal cortex and medulla, the aorta, and the retroperitoneal fat was higher in AVU and PVU than in CU images. A total of 270 liver lesions were found in 76 patients. Portal virtual unenhanced data set was more sensitive than AVU and CU were for hypodense lesions smaller than 1 cm. Reader 1 correctly detected 72/144 (50.0%), 61/144 (42.4%), and 55/144 (38.2%) hypodense lesions with PVU, AVU, and CU, respectively; and reader 2 correctly diagnosed 70/144 (48.7%), 62/144 (43.0%), and 53/144 (36.8%) lesions with PVU, AVU, and CU, respectively. Conventional unenhanced data set was more sensitive than AVU or PVU was for small calcified lesions. Reader 1 detected 24/40 (60.0%), 24/40 (60.0%), and 40/40 (100%) with PVU, AVU, and CU, respectively; and reader 2 detected 27/40 (67.5%), (25/40) 62.5%, and 40/40 (100%) with PVU, AVU, and CU, respectively. The dose reduction achieved by omitting the unenhanced acquisition was a mean (SD) of 21.1% (1.2%; P < 0.01). CONCLUSIONS: Second-generation abdominal VU data sets, despite a mostly excellent image quality, still cannot replace CU images in clinical practice because of limitations in material subtraction. ADVANCES IN KNOWLEDGE: 1. Second-generation abdominal VU data sets yield excellent image quality but are still slightly lower than that of CU. 2. More small hypodense liver lesions were detected in VU images than in CU images; however, a significant number of small calcified lesions were not identified in VU images. 3. Second-generation abdominal VU images are still not ready to replace CU images in clinical practice. Implications for Patient Care: 1. Using VU images in abdominal studies makes it possible to reduce the total radiation dose delivered to patients who need multiphasic acquisition by avoiding precontrast scan. 2. Erroneous material subtraction and incomplete abdominal coverage represent a limit in VU data set application in clinical routine.
Assuntos
Hepatopatias/diagnóstico por imagem , Radiografia Abdominal , Imagem Radiográfica a Partir de Emissão de Duplo Fóton , Adulto , Idoso , Idoso de 80 Anos ou mais , Artefatos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Doses de Radiação , Sensibilidade e Especificidade , Tomografia Computadorizada por Raios X , Adulto JovemRESUMO
PURPOSE: To prospectively assess the accuracy of contrast agent-enhanced (CE) ultrasonography (US) with a second-generation US contrast agent in the detection and classification of endoleaks after endovascular repair of abdominal aortic aneurysms (EVAR), with computed tomographic (CT) angiography as the reference standard. MATERIALS AND METHODS: Institutional review board and written informed consent were obtained. Thirty-five patients who underwent EVAR were enrolled in a prospective study that consisted of CT angiography and CE US studies performed at 1- and 6-month follow-up and performed yearly thereafter. CE US was performed after bolus injection of 2.4 mL of sulfur hexafluoride by using equipment with specific software for contrast studies. Angiography was performed in patients who had type II endoleaks with an increase in aneurysm sac size and in patients with type I or III endoleaks. CE US sensitivity, specificity, positive and negative predictive values, and accuracy were determined for endoleak detection, and Cohen κ statistic was used to assess agreement of CE US and CT angiographic findings for endoleak classification. RESULTS: A total of 126 CT angiographic and CE US studies were performed. CT angiography depicted 34 endoleaks in 16 patients (type IA, n=1; type IB, n=1; type II inferior mesenteric artery, n=2; type II lumbar artery, n=28; type II complex, inferior mesenteric, and lumbar arteries, n=2). CE US depicted 33 endoleaks. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of CE US in endoleak detection were 97%, 100%, 100%, 98%, and 99%, respectively. CE US enabled correct classification of 26 of 33 endoleaks. No clinically important endoleak was missed at CE US. CONCLUSION: CE US yields good sensitivity, specificity, and accuracy in endoleak detection, and it might represent a noninvasive tool that can be used in the follow-up of patients who undergo EVAR.
Assuntos
Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Meios de Contraste , Endoleak/diagnóstico por imagem , Hexafluoreto de Enxofre , Idoso , Idoso de 80 Anos ou mais , Angiografia/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Sensibilidade e Especificidade , Tomografia Computadorizada por Raios X , Resultado do Tratamento , UltrassonografiaRESUMO
BACKGROUND AND OBJECTIVES: Solid pseudopapillary neoplasms (SPNs) are rare tumours of the exocrine pancreas. Although they can develop metastasis, the prognosis is good. The aim of this study was to describe the characteristics of these tumours attended in our hospital. PATIENTS AND METHOD: All cases of SPN in the database of the Pathology Department between 1991 and 2010 were included. Age, sex, symptoms, type of surgery, pathologic and immunohistochemical characteristics, and clinical evolution were analyzed. RESULTS: Six cases were identified; all of them were women with a median age of 27.5 years. One patient presented haemoperitoneum, 2 abdominal pain and 3 were diagnosed incidentally. The most frequent localization was the pancreatic tail (n=4) and the median size was 7.7 cm. Four tumours were benign and 2 carcinomas. One of them had liver and lymph node metastases. Ki-67 proliferation index was low (1-3%). After a median follow-up of 33.5 months, all patients were alive and without evidence of relapse. CONCLUSION: SPNs occur in young women. In most cases surgical resection is curative. A low mitotic index confers a good prognosis and a long survival.