Natural history of histologically benign PIRADS 4-5 lesions in multiparametric MRI: Real-life experience in an academic center.

INTRODUCTION: The follow-up findings of patients who underwent prostate biopsy for prostate image reporting and data system (PIRADS) 4 or 5 multiparametric magnetic resonance imaging (mpMRI) findings and had benign histology were retrospectively reviewed. METHODS: There were 190 biopsy-naive patients. Patients with at least 12 months of follow-up between 2012 and 2023 were evaluated. All MRIs were interpreted by two very experienced uroradiologists. Of the patients, 125 had either cognitive or software fusion MR-targeted biopsies with 4 + 8/10 cores. The remaining 65 patients had in-bore biopsies with 4-5 cores. Prostate-specific antigen (PSA) levels below 4 ng/mL were defined as PSA regression following biopsy. PIRADS 1-3 lesions on new MRI images were classified as MRI regression. RESULTS: Median patient age and PSA were 62 (39-82) years and six (0.4-33) ng/mL, respectively, at the initial work-up. During a median follow-up period of 44 months, 37 (19.4%) patients were lost to follow-up. Of the remaining 153 patients, 82 (53.6%) had persistently high PSA. Among them, 72 (87.8%) had repeat mpMRI within 6-24 months which showed regressive findings (PIRADS 1-3) in 53 patients (73.6%) and PIRADS 4-5 index lesion persistence in 19 cases (26.4%). The latter group was recommended to have rebiopsy. Of these 19 patients, 16 underwent MRI-targeted rebiopsy. Prostate cancer was diagnosed in six (37.5%) patients and of these four (25%) were clinically significant (>Grade Group 1). Totally, clinically significant prostate cancer was detected in 4/153 (2.6%) patients followed up. CONCLUSION: Patients should be warned against the relative relaxing effect of a negative biopsy after identification of PIRADS 4-5 index lesion. While PSA decrease was observed in many patients during follow-up, persistent MRI findings were present in nearly a quarter of patients with persistently high PSA. A rebiopsy is warranted in these patients, with significant prostate cancer diagnosed in a quarter of patients with rebiopsy.

The role of PSMA PET/CT in predicting downgrading in patients with Gleason score 4+4 prostate cancer in prostate biopsy.

BACKGROUND: To investigate the predictable parameters associated with downgrading in patients with a Gleason score (GS) 8 (4+4) in prostate biopsy after radical prostatectomy. METHODS: We retrospectively analyzed 62 patients with a GS of 4+4 on prostate biopsy who underwent robotic radical prostatectomy between 2017 and 2022. RESULTS: 38 of 62 (61.2%) were downgraded. In multivariable logistic regression model, Ga-68 prostate-specific membrane antigen (PSMA) positron-emission tomography (PET)/computed tomography (CT) SUV max was independent predictor of downgrading (OR 0.904; p = 0.011) and a Logistic Regression model was constructed using the following formula: Y = 1.465-0.95 (PSMA PET/CT SUV max). The model using this variable correctly predicted the downgrading in 72.6% of patients. The AUC for PSMA PET/CT SUV max was 0.709 the cut off being 8.8. A subgroup analysis was performed in 37 patients who had no other European Association of Urology (EAU) high risk features. 25 out of 37 (67.5%) were downgraded, and 21 of these 25 had organ confined disease. Low PSMA SUV max (<8.1) and percentage of GS 4+4 biopsy cores to cancer bearing cores (45.0%) were independently associated with downgrading to GS 7. CONCLUSION: PSMA PET/CT can be used to predict downgrading in patients with GS 4+4 PCa. Patients with GS 4+4 disease, but no other EAU high risk features, low percentage of GS 4+4 biopsy cores to cancer bearing cores, and a low PSMA PET/CT SUV max are associated with a high likelihood of the cancer reclassification to intermediate risk group.

Primary angiosarcoma of the Pancreas - A case Report and review of the literature.

BACKGROUND: Angiosarcomas are malignant neoplasms that originate from endothelial cells. The symptoms exhibit a non-specific nature, and achieving a preoperative diagnosis is frequently challenging. They are seldom encountered in the abdomen, and their occurrence in the pancreas is even rarer. METHODS: Here we document a 67-year-old man with pancreatic angiosarcoma and analyse the literature to outline the clinicopathologic characteristics of this rare phenomenon. RESULTS: This patient with family history of pancreas cancer presented with abdominal pain, and the CT-scan revealed a 4 cm mass at the neck of the pancreas but CA19-9 was normal. Radiologic findings were unusual for ordinary pancreas cancer. Fine-needle aspiration biopsy through endoscopic ultrasound revealed "undifferentiated malignant cells for which the diagnosis of "carcinoma" was favoured. Total pancreatectomy, splenectomy and portal vein reconstruction were performed and epithelioid angiosarcoma were diagnosed. Despite an uneventful postoperative period, discharge on postoperative day 8 without any complications, as well as diligent post-discharge clinical care, the patient died 65 days postoperatively, attributed to the presence of extensive metastasis. A comprehensive literature search has identified a limited number of documented cases of primary pancreatic angiosarcoma, with only ten cases reported to date. CONCLUSIONS: Pancreatic angiosarcomas are very rare and prone to misdiagnosis. The formation of a more demarcated but high-grade tumour with necrosis is a feature that distinguishes angiosarcomas from ordinary carcinomas of this organ. Pathologic diagnosis is also highly challenging closely resembling undifferentiated carcinomas. Angiosarcomas are highly aggressive when they occur in the pancreas. Prompt diagnosis at an early stage is crucial as surgery with curative intent serves as the primary treatment approach.

Surgery with curative intent is the mainstay treatment for pancreatic angiosarcoma when diagnosed at an early stage.Oncological treatment options should be taken into consideration according to the follow-up data.Why does this paper matter?This article is important in that it is the most comprehensive review of the literature on pancreatic angiosarcoma, which is a very rare pathology, from the perspective of radiology, pathology and surgery.

Multisocietal European consensus on the terminology, diagnosis, and management of patients with synchronous colorectal cancer and liver metastases: an E-AHPBA consensus in partnership with ESSO, ESCP, ESGAR, and CIRSE.

BACKGROUND: Contemporary management of patients with synchronous colorectal cancer and liver metastases is complex. The aim of this project was to provide a practical framework for care of patients with synchronous colorectal cancer and liver metastases, with a focus on terminology, diagnosis, and management. METHODS: This project was a multiorganizational, multidisciplinary consensus. The consensus group produced statements which focused on terminology, diagnosis, and management. Statements were refined during an online Delphi process, and those with 70 per cent agreement or above were reviewed at a final meeting. Iterations of the report were shared by electronic mail to arrive at a final agreed document comprising 12 key statements. RESULTS: Synchronous liver metastases are those detected at the time of presentation of the primary tumour. The term 'early metachronous metastases' applies to those absent at presentation but detected within 12 months of diagnosis of the primary tumour, the term 'late metachronous metastases' applies to those detected after 12 months. 'Disappearing metastases' applies to lesions that are no longer detectable on MRI after systemic chemotherapy. Guidance was provided on the recommended composition of tumour boards, and clinical assessment in emergency and elective settings. The consensus focused on treatment pathways, including systemic chemotherapy, synchronous surgery, and the staged approach with either colorectal or liver-directed surgery as first step. Management of pulmonary metastases and the role of minimally invasive surgery was discussed. CONCLUSION: The recommendations of this contemporary consensus provide information of practical value to clinicians managing patients with synchronous colorectal cancer and liver metastases.

Multimodal assessment after total neoadjuvant therapy versus standard neoadjuvant chemoradiotherapy in locally advanced rectal cancer accurately predicts complete responders.

PURPOSE: This study aimed to compare local regrowth rates after total neoadjuvant therapy (TNT) versus standard neoadjuvant chemoradiotherapy (SNCRT) in locally advanced rectal cancer (LARC) patients that were strictly selected and assessed with a multimodal approach. Secondary outcomes were 4-year disease-free (DFS) and overall survival (OS) rates. METHODS: Locally advanced rectal cancer patients without distant metastases treated at Koç Healthcare Group between January 2014 and January 2021 were included. Patients were assessed for complete response with a combination of digital rectal exam, endoscopy, and magnetic resonance imaging with a dedicated rectum protocol. The systemic evaluation was performed with an upper abdomen MRI using intravenous hepatobiliary contrast agent and a thorax CT. RESULTS: Of the 270 patients with LARC, 182 fulfilled the inclusion criteria. Ninety-seven (53.3%) underwent TNT, while 85 (46.7%) underwent SNCRT. A cumulative combination of pathological and sustained clinical complete response was significantly higher in the TNT group than in the SNCRT (45.4% vs. 20.0%, p < 0.0001). After a median follow-up of 48 months, seven patients in the W&W group had regrowth [TNT: 4 (10.8%) vs. SNCRT: 3 (23.1%), p = 0.357]. Based on pathological examination, complete/near complete mesorectum rates (p = 1.000) and circumferential resection margin positivity rates (p = 1.000) were similar between the groups. The 4-year DFS and OS rates were comparable. The patients with clinical or pathological complete response had significantly longer overall survival (p = 0.017) regardless of the type of neoadjuvant treatment. CONCLUSIONS: Multimodal assessment after TNT effectively detects complete responders, resulting in low local recurrence and increased cumulative complete response rates. However, these outcomes did not translate into a survival advantage.

The multi-societal European consensus on the terminology, diagnosis and management of patients with synchronous colorectal cancer and liver metastases: an E-AHPBA consensus in partnership with ESSO, ESCP, ESGAR, and CIRSE.

BACKGROUND: Contemporary management of patients with synchronous colorectal cancer and liver metastases is complex. The aim of this project was to provide a practical framework for care of patients with synchronous colorectal cancer and liver metastases with a focus on terminology, diagnosis and management. METHODS: This project was a multi-organisational, multidisciplinary consensus. The consensus group produced statements which focused on terminology, diagnosis and management. Statements were refined during an online Delphi process and those with 70% agreement or above were reviewed at a final meeting. Iterations of the report were shared by electronic mail to arrive at a final agreed document comprising twelve key statements. RESULTS: Synchronous liver metastases are those detected at the time of presentation of the primary tumour. The term "early metachronous metastases" applies to those absent at presentation but detected within 12 months of diagnosis of the primary tumour with "late metachronous metastases" applied to those detected after 12 months. Disappearing metastases applies to lesions which are no longer detectable on MR scan after systemic chemotherapy. Guidance was provided on the recommended composition of tumour boards and clinical assessment in emergency and elective settings. The consensus focused on treatment pathways including systemic chemotherapy, synchronous surgery and the staged approach with either colorectal or liver-directed surgery as first step. Management of pulmonary metastases and the role of minimally invasive surgery was discussed. CONCLUSIONS: The recommendations of this contemporary consensus provide information of practical value to clinicians managing patients with synchronous colorectal cancer and liver metastases.

Conventional vs invert-grayscale X-ray for diagnosis of pneumothorax in the emergency setting.

INTRODUCTION: Pneumothorax is a pathologic condition in which air is accumulated between the visceral and parietal pleura. After clinical suspicion, in order to diagnose the severity of the condition, imaging is necessary. By using the help of Picture Archiving and Communication Systems (PACS) direct conventional X-rays are converted to gray-scale and this has become a preferred method among many physicians. METHODS: Our study design was a case-control study with cross-over design study. Posterior-anterior chest X-rays of patients were evaluated for pneumothorax by 10 expert physicians with at least 3years of experience and who have used inverted gray-scale posterior anterior chest X-ray for diagnosing pneumothorax. RESULTS: The study included posterior anterior chest X-ray images of 268 patients of which 106 were diagnosed with spontaneous pneumothorax and 162 patients used as a control group. The sensitivity of Digital-conventional X-rays was found to be higher than that of inverted gray-scale images (95% CI (2,08-5,04), p<0,01). There was no statistically significant difference between the gold standard and digital-conventional images (95% CI (0,45-2,17), p=0,20), while the evaluations of the gray-scale images were found to be less sensitive for diagnosis (95% CI (3,16-5,67) p<0,01). CONCLUSION: Inverted gray-scale imaging is not a superior imaging modality over digital-conventional X-ray for the diagnosis of pneumothorax. Prospective studies should be performed where diagnostic potency of inverted gray-scale radiograms is tested against gold standard chest CT. Further research should compare inverted grayscale to lung ultrasound to assess them as alternatives prior to CT.

Performance of CT in the locoregional staging of colon cancer: detailed radiology-pathology correlation with special emphasis on tumor deposits, extramural venous invasion and T staging.

PURPOSE: To investigate the performance of computed tomography (CT) in the local staging of colon cancer in different segments, with emphasis on parameters that have been found to be significant for rectal cancer, namely, extramural venous invasion (EMVI) and tumor deposits (TDs). METHODS: CT and pathology data from 137 patients were independently reviewed by radiology and pathology teams. The performance of CT in categorizing a given patient into good, versus poor prognostic groups was assessed for each segment, as well as the presence of lymph nodes (LNs), TDs and EMVIs. Discordant cases were re-evaluated to determine potential sources of error. Elastic stain was applied for EMVI discordance. RESULTS: The T staging accuracy was 80.2%. For T stage stratification, CT performed slightly better in the left colon, and the lowest accuracy was in the transverse colon. Under-staging was more common (in 12.4%), and most of the mis-staged cases were in sigmoid colon. According to the first comprehensive correlative analysis, the sensitivity, specificity, and accuracy of CT for detecting TDs were found to be 57.9%, 92.4%, 87.6%, respectively. These figures were 44.7%, 72.7%, and 63.5% for LN, and 58.5%, 82.1% and 73% for EMVI. The detection rate was better for multifocal EMVI. The detection rate was also comparable (although substantially underestimated) for LNs, with the half of the LNs missed by CT being < 5 mm. Four patients that were classified as TD by CT, disclosed to be LNs by pathology. Correlative analysis led to refinement of the pathology criteria, with subsequent modifications of the initial reports in 13 (9.5%) patients. CONCLUSION: Overall, CT performed well in the evaluation of colon cancer, as did TD and EMVI. It is advisable to include these parameters in CT-based staging. Radiologists should be aware of the pitfalls that occur more commonly in different segments.

Kidney and liver fat accumulation: from imaging to clinical consequences.

BACKGROUND: Recent studies indicate that accumulation of adipose tissue in various organs such as liver and kidney may contribute to the pathophysiology of metabolic syndrome. We aim to investigate the association between kidney and liver adipose tissue accumulation, assessed by the magnetic resonance imaging (MRI) proton density fat fraction technique, along with its relation to clinical and biochemical parameters. METHODS: We included 51 volunteers with phenotypical features of metabolic syndrome (mean age = 34 years, mean body-mass index = 26.4 kg/m2) in our study in which liver and kidney adipose tissue accumulation was assessed via MRI-proton density fat fraction along with multiple other clinical and biochemical parameters such as estimated glomerular filtration rate (eGFR), urine albumin-to-creatinine ratio, serum lipid profile, liver function tests and body-mass index (BMI). RESULTS: Our results from the univariate linear regression analysis indicate that both the kidney and liver scores were positively correlated with markers such as BMI, urine albumin-to-creatinine ratio, triglycerides (p < 0.001) and negatively correlated with eGFR (p < 0.05). In multivariate analysis, urine albumin-to-creatinine ratio (p < 0.05), triglycerides (p < 0.01), eGFR (p < 0.05) and BMI (p < 0.001) were found to be independently associated with kidney and liver fat accumulation, respectively (R2 = 0.64; R2 = 0.89). There was also a positive correlation between kidney and liver fat accumulation. CONCLUSION: We have found a significant association between adipose tissue accumulation in liver and kidney and the parameters of metabolic syndrome. Moreover, the presence of a strong association between kidney and liver fat accumulation and kidney function parameters such as urine albumin-to-creatinine ratio and eGFR may be an indicator of the clinical significance of parenchymal fat accumulation.

Intra-ampullary Papillary Tubular Neoplasm (IAPN): Clinicopathologic Analysis of 72 Cases Highlights the Distinctive Characteristics of a Poorly Recognized Entity.

The guidelines recently recognized the intra-ampullary papillary tubular neoplasm (IAPN) as a distinct tumor entity. However, the data on IAPN and its distinction from other ampullary tumors remain limited. A detailed clinicopathologic analysis of 72 previously unpublished IAPNs was performed. The patients were: male/female=1.8; mean age=67 years (range: 42 to 86 y); mean size=2.3 cm. Gross-microscopic correlation was crucial. From the duodenal perspective, the ampulla was typically raised symmetrically, with a patulous orifice, and was otherwise covered by stretched normal duodenal mucosa. However, in 6 cases, the protrusion of the intra-ampullary tumor to the duodenal surface gave the impression of an "ampullary-duodenal tumor," with the accurate diagnosis of IAPN established only by microscopic correlation illustrating the abrupt ending of the lesion at the edge of the ampulla. Microscopically, the preinvasive component often revealed mixed phenotypes (44.4% predominantly nonintestinal). The invasion was common (94%), typically small (mean=1.2 cm), primarily pancreatobiliary-type (75%), and showed aggressive features (lymphovascular invasion in 66%, perineural invasion in 41%, high budding in 30%). In 6 cases, the preinvasive component was pure intestinal, but the invasive component was pancreatobiliary. LN metastasis was identified in 42% (32% in ≤1 cm IAPNs). The prognosis was significantly better than ampullary-ductal carcinomas (median: 69 vs. 41 months; 3-year: 68% vs. 55%; and 5-year: 51% vs. 35%, P=0.047). Unlike ampullary-duodenal carcinomas, IAPNs are often (44.4%) predominantly nonintestinal and commonly (94%) invasive, displaying aggressive features and LN metastasis even when minimally invasive, all of which render them less amenable to ampullectomy. However, their prognosis is still better than that of the "ampullary-ductal" carcinomas, with which IAPNs are currently grouped in CAP protocols (while IAPNs are kindreds of intraductal tumors of the pancreatobiliary tract, the latter represents the ampullary counterpart of pancreatic adenocarcinoma/cholangiocarcinoma).

Dynamic power Doppler ultrasonography of anterior abdominal wall hernias: confirmation of incarceration.

PURPOSE: Power Doppler ultrasonography (PD-US) is a motion-sensitive modality that can display flow characteristics regardless of the direction. This increased motion sensitivity can be used as a parameter to show the tissue motion on artificially generated fremitus images. This study aimed to confirm any signs of incarceration in abdominal wall hernias proven by herniorrhaphy by examination with dynamic PD-US (during manual compression-decompression maneuvers). METHODS: Twenty-seven patients with anterior abdominal wall hernia with a narrow neck (<1 cm in diameter) were examined firstly with gray-scale ultrasonography (GS-US), and then with dynamic PD-US. Two independent radiologists, who were blinded to the real-time images showing the orientation and motion of the hernia neck, completed the examinations. These images were evaluated for any signs of incarceration, as well as the orientation of the hernia neck. RESULTS: Orientations of the hernia neck were not described on GS-US images in 13 lesions and on dynamic PD-US images in 3 lesions. While the GS-US examination revealed incarcerated hernia in four of the patients, the dynamic PD-US examination revealed an additional seven patients with symptoms associated with incarceration. CONCLUSION: Dynamic PD-US may show the orientation of the hernia neck and any sign of incarceration more accurately and clearly than conventional GS-US. Being informed about these features preoperatively is of utmost importance. Thus, anterior abdominal wall hernias should be examined by dynamic PD-US.

The value of ultrasound elastography-guided fine-needle aspiration biopsy of thyroid nodules in reducing nondiagnostic results.

Fine-needle aspiration biopsy (FNAB) is an important tool for diagnosing thyroid nodules; however, nondiagnostic results are a problem with FNAB. We evaluated the optimal targeting area of thyroid nodules for FNAB by using ultrasound elastography (USE) to reduce nondiagnostic results. Between December 2008 and November 2010, 96 consecutive prospective subjects scheduled to undergo FNAB were included in the study. Initially, the dominant nodule was evaluated with ultrasound, after which USE was performed. FNABs were performed from both the red (hard foci) and the green (soft foci) color-coded areas using the same technique according to the USE maps. The cellularity of all the specimens was evaluated cytopathologically. Nondiagnostic results from the red and green color-coded areas were compared by Chi-square test. In the red color-coded regions on USE images, the diagnostic rate was 76.0 % and the nondiagnostic rate was 24.0 %. In the green color-coded regions on USE images, the diagnostic rate was 53.1 % and the nondiagnostic rate was 46.9 %. Seven nodules were malignant and 89 were benign. Nondiagnostic results were significantly fewer in red color-coded regions (P = 0.0001). USE can help to enhance the cellularity of biopsy of thyroid nodules to reduce the nondiagnostic results if the red color-coded (less elastic or hard) areas are preferred.

The Evaluation of Renal Iron Deposition With a 3 Tesla MRI Device in Beta-Thalassemia Major Patients.

Background and objective Beta-thalassemia is the most frequent monogenic disease in the world. In beta-thalassemia major (BTM) patients, blood transfusions for severe anemia usually cause iron overload, leading to increased morbidity and mortality. In this study, we aimed to examine the iron overload in the kidneys of BTM patients with a 3 Tesla (3T) MRI device and assess the relationship between iron overload in the liver and heart as well as serum ferritin levels. Methods This was a retrospective study covering the period between November 2014 and March 2015. MRI was performed on 21 patients with BTM who were receiving blood transfusions and chelation therapy. The control group (n=11) included healthy volunteers. A 3T MRI device (Ingenia, Philips, Best, The Netherlands) using a 16-channel phased array SENSE-compatible torso coil was used. Three-point DIXON (mDIXON) sequence and the relaxometry method were employed to measure iron overload. Both kidneys were analyzed via mDIXON sequence for atrophy or variations. Afterward, the images in which renal parenchyma could be distinguished best were selected. Iron deposition was analyzed via the relaxometry method using a unique software (CMR Tools, London, UK). All data were analyzed using IBM SPSS Statistics v.21 (IBM Corp., Armonk, NY). The Kolmogorov-Smirnov test, independent samples t-test, Mann-Whitney U test, and Pearson's and Spearman's rho correlation coefficient were used. A p-value <0.05 was considered statistically significant. Results There was a statistically significant relationship between beta-thalassemia patients who had cardiac iron deposition and those who did not in terms of T2* time (p=0.02). In contrast, there was no similar relationship for liver iron deposition (p>0.05). Renal T2* values were significantly different between the patient and control groups (p=0.029). T2* times were significantly different between patients who had ferritin levels below 2500 ng/ml and those with ferritin levels above 2500 ng/ml (p=0.042). Conclusion Based on our findings, 3T MRI is a safe and reliable tool for screening iron overload in BTM patients as it makes distinguishing between renal parenchyma and renal sinus much easier and as it is more sensitive to iron deposition.

Intraoperative Frozen Section via Neurosafe During Robotic Radical Prostatectomy in the Era of Preoperative Risk Stratifications and Primary Staging With mpMRI and PSMA-PET CT: Is There a Perfect Candidate?

BACKGROUND: We aimed to analyze the effect of preoperative risk assessment including Ga-68 PSMA PET and multiparametric magnetic resonance imaging (mpMRI) on nerve sparing practices, positive surgical margin (PSM) rates and oncological outcomes based on a comparison between patients underwent RARP with and without Neurosafe (NS). METHODS: Patients underwent RARP with NS (RARP-NS) or without (RARP-only) NS retrospectively evaluated. Suspicion for extracapsular extension on mpMRI and/or Ga-68 PSMA PET was recorded as i(imaging)T3. NS was performed according to the Martini-Klinik technique. PSM at preserved bundle side were called PSM at region of interest (ROI) while the others were elsewhere. RESULTS: A total of 208 patients (90 in RARP-NS, 118 in RARP-only groups) were included. Preoperatively the RARP-only group showed significantly higher mean PSA (p = .01) and PIRADS 5 (p = .002) findings and had more D'Amico high risk (DAHR) patients (p = .08). The overall PSM rates for pT2 versus pT3 disease were 7.5% versus 21.6 and 15.6% versus 55% in RARP-NS and RARP-only groups, respectively. NS resulted in more bilaterally preserved bundles (81.1% vs. 66.3%) and less PSM at the ROI (3.3% vs. 23.4%) than RARP-only group. NS outperformed RARP-only in all clinical settings had its highest differential benefit in more bilateral nerve sparing and less PSM at ROI in patients with both DAHR and iT3 disease. BCR rates were 2.2% and 2.5% for RARP-NS and RARP only groups, respectively (p = .4). One patient in RARP-NS and 9 in RARP-only groups had PSA persistence (p = .02). CONCLUSION: RARP-NS led to more preserved bundles with less PSM. It was especially useful in DAHR patients with preoperative extracapsular extension suspicion in imaging simultaneously.

Extramural venous invasion (EMVI) revisited: a detailed analysis of various characteristics of EMVI and their role as a predictive imaging biomarker in the neoadjuvant treatment response in rectal cancer.

PURPOSE: To assess whether size, diameter, and large vein involvement of MR-detected extramural venous invasion (MR-EMVI) have an impact on neoadjuvant therapy response in rectal adenocarcinoma. METHODS: 57 patients with locally advanced rectal adenocarcinoma scanned with MRI before and after neoadjuvant therapy were included. Two abdominal radiologists evaluated the images with special emphasis on EMVI, on initial staging and after neoadjuvant treatment. The sensitivity and specificity of MRI for detection of rest EMVI were determined. The association of various MR-EMVI characteristics including number, size, and main vein involvement with treatment response was investigated. In subjects with discordance of radiology and pathology, elastin stain was performed, and images and slides were re-evaluated on site with a multidisciplinary approach. RESULTS: At initial evaluation, 17 patients were MR-EMVI negative (29.8%) and 40 were MR-EMVI positive (70.2%). Complete/near-complete responders had less number (mean 1.45) and smaller diameter of MR-EMVI (mean 1.8 mm), when compared with partial responders (2.54 and 3.3 mm; p < 0.005). The sensitivity of MRI for rest EMVI detection was high, specificity was moderate, and in one patient elastin stain changed the final decision. In five patients with rest MR-EMVI positivity, carcinoma histopathologically had a distinctive serpiginous perivascular spread, growing along the track of vascular bundle, although it did not appear in intravascular spaces. CONCLUSION: This study demonstrates that not only the presence, but also size and number of EMVI that may be significant clinically and thus these parameters also ought to be incorporated to the MRI evaluation and prognostication of treatment response. From pathology perspective, tumors growing alongside major vessels may also reflect EMVI even if they are not demonstrably "intravascular."

Optimizing the Personalized Care for the Management of Rectal Cancer: A Consensus Statement.

Colorectal cancer is the third most common cancer in Turkey. The current guidelines do not provide sufficient information to cover all aspects of the management of rectal cancer. Although treatment has been standardized in terms of the basic principles of neoadjuvant, surgical, and adjuvant therapy, uncertainties in the management of rectal cancer may lead to significant differences in clinical practice. In order to clarify these uncertainties, a consensus program was constructed with the participation of the physicians from the Acibadem Mehmet Ali Aydinlar and Koç Universities. This program included the physicians from the departments of general surgery, gastroenterology, pathology, radiology, nuclear medicine, medical oncology, radiation oncology, and medical genetics. The gray zones in the management of rectal cancer were determined by reviewing the evidence-based data and current guidelines before the meeting. Topics to be discussed consisted of diagnosis, staging, surgical treatment for the primary disease, use of neoadjuvant and adjuvant treatment, management of recurrent disease, screening, follow-up, and genetic counseling. All those topics were discussed under supervision of a presenter and a chair with active participation of related physicians. The consensus text was structured by centralizing the decisions based on the existing data.

Multiparametric MRI of rectal cancer-repeatability of quantitative data: a feasibility study.

PURPOSE: In this study, we aimed to analyze the repeatability of quantitative multiparametric rectal magnetic resonance imaging (MRI) parameters with different measurement techniques. METHODS: All examinations were performed with 3 T MRI system. In addition to routine sequences for rectal cancer imaging protocol, small field-of-view diffusion-weighted imaging and perfusion sequences were acquired in each patient. Apparent diffusion coefficient (ADC) was used for diffusion analysis and ktrans was used for perfusion analysis. Three different methods were used in measurement of these parameters; measurements were performed twice by one radiologist for intraobserver and separately by three radiologists for interobserver variability analysis. ADC was measured by the lowest value, the value at maximum wall thickness, and freehand techniques. Ktrans was measured at the slice with maximum wall thickness, by freehand drawn region of interest (ROI), and at the dark red spot with maximum value. RESULTS: A total of 30 patients with biopsy-proven rectal adenocarcinoma were included in the study. The mean values of the parameters measured by the first radiologist on the first and second measurements were as follows: mean lowest ADC, 721.31±147.18 mm2/s and 718.96±135.71 mm2/s; mean ADC value on the slice with maximum wall thickness, 829.90±144.24 mm2/s and 829.48±149.23 mm2/s; mean ADC value measured by freehand ROI on the slice with maximum wall thickness, 846.56±136.31 mm2/s and 848.23±144.15 mm2/s; mean ktrans value on the slice with maximum wall thickness, 0.219±0.080 and 0.214±0.074; mean ktrans by freehand ROI technique (including as much tumoral tissue as possible), 0.208±0.074 and 0.207±0.069; mean ktrans measured from the dark red foci, 0.308±0.109 and 0.311±0.105. Intraobserver agreement was very good among diffusion and perfusion parameters obtained with all three measurement techniques. Interobserver agreement was very good, except for one of the measurement techniques. As far as interobserver variability is considered, only ADC value measured on the slice with maximum wall thickness differed significantly. CONCLUSION: Multiparametric MRI of rectum, using ADC as the diffusion and ktrans as the perfusion parameter is a repeatable technique. This technique may potentially be used in prediction and evaluation of neoadjuvant treatment response. New studies with larger patient groups are needed to validate the role of multiparametric MRI.

Multiparametric MRI in rectal cancer.

MRI has a pivotal role in both pretreatment staging and posttreatment evaluation of rectal cancer. The accuracy of MRI in pretreatment staging is higher compared with posttreatment evaluation. This occurs due to similar signal intensities of tumoral and posttreatment fibrotic, necrotic, and inflamed tissue. This limitation occurs with conventional MRI of the rectum with morphologic sequences. There is a need towards increasing the accuracy of MRI, especially for posttreatment evaluation. The term multiparametric MRI implies addition of functional sequences, namely, diffusion and perfusion to the routine protocol. This review summarizes the technique, potential implications and previously published studies about multiparametric MRI of rectal cancer.

Dealing with the gray zones in the management of gastric cancer: The consensus statement of the Istanbul Group.

The geographical location and differences in tumor biology significantly change the management of gastric cancer. The prevalence of gastric cancer ranks fifth and sixth among men and women, respectively, in Turkey. The international guidelines from the Eastern and Western countries fail to manage a considerable amount of inconclusive issues in the management of gastric cancer. The uncertainties lead to significant heterogeneities in clinical practice, lack of homogeneous data collection, and subsequently, diverse outcomes. The physicians who are professionally involved in the management of gastric cancer at two institutions in Istanbul, Turkey, organized a consensus meeting to address current problems and plan feasible, logical, measurable, and collective solutions in their clinical practice for this challenging disease. The evidence-based data and current guidelines were reviewed. The gray zones in the management of gastric cancer were determined in the first session of this consensus meeting. The second session was constructed to discuss, vote, and ratify the ultimate decisions. The identification of the T stage, the esophagogastric area, imaging algorithm for proper staging and follow-up, timing and patient selection for neoadjuvant treatment, and management of advanced and metastatic disease have been accepted as the major issues in the management of gastric cancer. The recommendations are presented with the percentage of supporting votes in the results section with related data.

Acute aortic dissection with painless paraplegia: report of 2 cases.

Acute aortic dissection is often a life-threatening event that usually presents as a sudden, severe, exquisitely painful, ripping sensation in the chest or back. There are a few reports of atypical findings or no pain in the literature. We report 2 patients with painless acute aortic dissection who presented to the emergency department (ED) with sudden onset paraplegia.