GI and GU fluoroscopy in common post-op oncologic surgeries: what you need to know about this leaky business!

Over the past several years, there has been a trend of decreasing screening or diagnostic fluoroscopic examinations ordered by clinical teams, particularly double contrast gastrointestinal studies. The underlying reason is due to increasing number of endoscopic procedures performed by Gastroenterology and Urology and usage of other imaging modalities, which are either more sensitive and/or offer the ability to obtain tissue for confirmation. Many fluoroscopic studies are now tailored toward patients who have undergone gastrointestinal or genitourinary oncologic surgeries, providing both functional and anatomic information, which are important tools for patient management. Some of these surgeries are very complex and an understanding of the postoperative anatomy and potential pitfalls is important to accurately evaluate for complications. The purpose of this article is to describe techniques and indications for common post-operative fluoroscopic procedures in gastrointestinal and genitourinary oncology while reviewing normal appearances. Complications, with emphasis on postoperative leaks, will be highlighted. Familiarity with the various types of gastrointestinal surgeries and urinary diversion techniques and knowledge of the expected postsurgical appearance is essential for achieving an accurate and prompt diagnosis of complications to allow for adequate treatment and management.

Gender Differences in a Mouse Model of Hepatocellular Carcinoma Revealed Using Multi-Modal Imaging.

The worldwide incidence of hepatocellular carcinoma (HCC) continues to rise, in part due to poor diet, limited exercise, and alcohol abuse. Numerous studies have suggested that the loss or mutation of PTEN plays a critical role in HCC tumorigenesis through the activation of the PI3K/Akt signaling axis. The homozygous knockout of PTEN in the livers of mice results in the accumulation of fat (steatosis), inflammation, fibrosis, and eventually progression to HCC. This phenotype bears a striking similarity to non-alcoholic steatohepatitis (NASH) which is thought to occupy an intermediate stage between non-alcoholic fatty liver disease (NAFLD), fibrosis, and HCC. The molecular and physiological phenotypes that manifest during the transition to HCC suggest that molecular imaging could provide a non-invasive screening platform to identify the hallmarks of HCC initiation prior to the presentation of clinical disease. We have carried out longitudinal imaging studies on the liver-specific PTEN knockout mouse model using CT, MRI, and multi-tracer PET to interrogate liver size, steatosis, inflammation, and apoptosis. In male PTEN knockout mice, significant steatosis was observed as early as 3 months using both magnetic resonance spectroscopy (MRS) and computed tomography (CT). Enhanced uptake of the apoptosis tracer 18F-TBD was also observed in the livers of male PTEN homozygous knockout mice between 3 and 4 months of age relative to heterozygous knockout controls. Liver uptake of the inflammation tracer [18F]4FN remained relatively low and constant over 7 months in male PTEN homozygous knockout mice, suggesting the suppression of high-energy ROS/RNS with PTEN deletion relative to heterozygous males where the [18F]4FN liver uptake was elevated at early and late time points. All male PTEN homozygous mice developed HCC lesions by month 10. In contrast to the male cohort, only 20% (2 out of 10) of female PTEN homozygous knockout mice developed HCC lesions by month 10. Steatosis was significantly less pronounced in the female PTEN homozygous knockout mice relative to males and could not accurately predict the eventual occurrence of HCC. As with the males, the [18F]4FN uptake in female PTEN homozygous knockout mice was low and constant throughout the time course. The liver uptake of 18F-TBD at 3 and 4.5 months was higher in the two female PTEN knockout mice that would eventually develop HCC and was the most predictive imaging biomarker for HCC in the female cohort. These studies demonstrate the diagnostic and prognostic role of multi-modal imaging in HCC mouse models and provide compelling evidence that disease progression in the PTEN knockout model is highly dependent on gender.

Neoadjuvant relatlimab and nivolumab in resectable melanoma.

Relatlimab and nivolumab combination immunotherapy improves progression-free survival over nivolumab monotherapy in patients with unresectable advanced melanoma1. We investigated this regimen in patients with resectable clinical stage III or oligometastatic stage IV melanoma (NCT02519322). Patients received two neoadjuvant doses (nivolumab 480 mg and relatlimab 160 mg intravenously every 4 weeks) followed by surgery, and then ten doses of adjuvant combination therapy. The primary end point was pathologic complete response (pCR) rate2. The combination resulted in 57% pCR rate and 70% overall pathologic response rate among 30 patients treated. The radiographic response rate using Response Evaluation Criteria in Solid Tumors 1.1 was 57%. No grade 3-4 immune-related adverse events were observed in the neoadjuvant setting. The 1- and 2-year recurrence-free survival rate was 100% and 92% for patients with any pathologic response, compared to 88% and 55% for patients who did not have a pathologic response (P = 0.005). Increased immune cell infiltration at baseline, and decrease in M2 macrophages during treatment, were associated with pathologic response. Our results indicate that neoadjuvant relatlimab and nivolumab induces a high pCR rate. Safety during neoadjuvant therapy is favourable compared to other combination immunotherapy regimens. These data, in combination with the results of the RELATIVITY-047 trial1, provide further confirmation of the efficacy and safety of this new immunotherapy regimen.

Multimodality Imaging and Genetics of Primary Mucosal Melanomas and Response to Treatment.

Mucosal melanomas (MMs) are rare and aggressive tumors that arise from melanocytes in the mucosal tissues that line the respiratory, gastrointestinal, and urogenital tracts. Most MMs occur during the 6th and 7th decades of life. MMs may be asymptomatic but may also cause bleeding, pain, and itching, depending on the site of origin. Because of their asymptomatic or oligosymptomatic nature and the difficulty of visualizing them in some cases, they are often advanced tumors at patient presentation. MM staging varies depending on the site of the primary tumor. A simplified staging system allows classification of clinically localized disease as stage I, regional nodal involvement as stage II, and distant metastasis as stage III. MM differs genetically from its cutaneous counterparts. Common drivers in cutaneous melanoma such as B-raf proto-oncogene serine/threonine kinase (BRAF) have a lower mutation rate in MM, whereas mutations of other genes including the KIT proto-oncogene, receptor tyrosine kinase (KIT) and splicing factor 3b subunit 1 gene (SF3B1) are more common in MM. Complete resection is the best curative option. However, surgical intervention with wide local excision and negative margins may be difficult to attain because of the local anatomy and the extent of disease. In addition, despite aggressive surgical resection, most patients develop local recurrence and metastatic disease. Recent advances in the treatment of melanoma include immunotherapy and targeted therapy. Unfortunately, MMs have a relatively poor prognosis, with an overall 5-year survival rate of 25%. Online supplemental material is available for this article. ©RSNA, 2021.

Influence of Baseline Positron Emission Tomography in Metastatic Gastroesophageal Cancer on Survival and Response to Therapy.

BACKGROUND: The value of baseline fluorodeoxyglucose-positron emission tomography-computed tomography (PET-CT) remains uncertain once gastroesophageal cancer is metastatic. We hypothesized that assessment of detailed PET-CT parameters (maximum standardized uptake value [SUVmax] and/or total lesion glycolysis [TLG]), and the extent of metastatic burden could aid prediction of probability of response or prognosticate. METHODS: We retrospectively analyzed treatment-naive patients with stage 4 gastroesophageal cancer (December 2002-August 2017) who had initial PET-CT for cancer staging at MD Anderson Cancer Center. SUVmax and TLG were compared with treatment outcomes for the full cohort and subgroups based on metastatic burden (≤2 or >2 metastatic sites). RESULTS: We identified 129 patients with metastatic gastroesophageal cancer who underwent PET-CT before first-line therapy. The median follow-up time was 61 months. The median overall survival (OS) was 18.5 months; the first progression-free survival (PFS) was 5.5 months. SUVmax or TLG of the primary tumor or of all metastases combined had no influence on OS or PFS, whether the number of metastases was ≤2 or >2. Overall response rates (ORRs) to first-line therapy were 48% and 45% for patients with ≤2 and >2 metastases, respectively (nonsignificant). ORR did not differ based on low or high values of SUVmax or TLG. CONCLUSIONS: This is the first assessment of a unique set of PET-CT data and its association with outcomes in metastatic gastroesophageal cancer. In our large cohort of patients, detailed analyses of PET-CT (by SUVmax and/or TLG) did not discriminate any parameters examined. Thus, baseline PET-CT in untreated metastatic gastroesophageal cancer patients has limited or no utility.

Preoperatively Treated Diffuse-Type Gastric Adenocarcinoma: Glucose vs. Other Energy Sources Substantially Influence Prognosis and Therapy Response.

Diffuse type of gastric adenocarcinoma (dGAC) generally confers a poor prognosis compared to intestinal type. Some dGACs are not avid on fluorine-18 fluoro-2-deoxy-D-glucose PET (FDG-PET) while others seem to consume glucose avidly. We analyzed the outcomes based on the avidity (high with standardized uptake value (SUV) > 3.5 or low with SUV ≤ 3.5) of the primary on baseline FDG-PET. We retrospectively selected 111 localized dGAC patients who had baseline FDG-PET (all were treated with preoperative chemotherapy and chemoradiation). FDG-PET avidity was compared with overall survival (OS) and response to therapy. The mean age was 59.4 years and with many females (47.7%). The high-SUV group (58 (52.3%) patients) and the low-SUV group (53 (47.7%) patients) were equally divided. While the median OS for all patients was 49.5 months (95% CI: 38.5-98.8 months), it was 98.0 months (95% CI: 49.5-NE months) for the low-SUV group and 36.0 months for the high-SUV (p = 0.003). While the median DFS for all patients was 38.2 months (95%CI: 27.7-97.6 months), it was 98.0 (95% CI: 36.9-NE months) months for the low-SUV group was and only 27.0 months (95% CI: 15.2-63.2 months) for the high-SUV group (p = 0.005). Clinical responses before surgery were more common in the low-SUV group but overall we observed only 4 pathologic complete responses in 111 patients. Our unique data suggest that if dGACs used glucose as an energy source then the prognosis was very poor while non-glucose sources improved prognosis. Multi-platform (including metabolomics) profiling of dGACs would yield useful biologic understanding.

Low metabolic activity in primary gastric adenocarcinoma is associated with resistance to chemoradiation and the presence of signet ring cells.

PURPOSES: Preoperative chemoradiation is a potential treatment option for localized gastric adenocarcinoma (GAC). Currently, the response to chemoradiation cannot be predicted. We analyzed the pretreatment maximum standardized uptake value (SUVmax) and total lesion glycolysis (TLG) on positron emission tomography/computed tomography as potential predictors of the response to chemoradiation. METHODS: We analyzed the SUVmax and TLG data from 59 GAC patients who received preoperative chemoradiation. We used logistic regression models to predict a pathologic complete response (pCR) and Kaplan-Meier curves to determine overall survival among patients with high and low SUVmax or TLG. RESULTS: Twenty-nine patients (49%) had Siewert type III adenocarcinoma and 30 (51%) had tumors located in the lower stomach. Forty-one patients had poorly differentiated GAC, and 26 had signet ring cells. The median SUVmax was 7.3 (0-28.2) and the median TLG was 56.6 (0-1881.5). Patients with signet ring cells had a low pCR rate, as well as a low SUVmax and TLG. In the multivariable logistic regression model, high SUVmax was a predictor of pCR (odds ratio = 11.1, 95% confidence interval = 2.12-50.0, p = 0.004). Overall survival was not associated with the SUVmax (log-rank p = 0.69) or TLG (log-rank p = 0.85) CONCLUSION: A high SUVmax was associated with sensitivity to chemoradiation and pCR in GAC, and signet ring cells seemed to confer resistance.

Intestinal and diffuse gastric cancer: a retrospective study comparing primary sites.

OBJECTIVE: We assessed differences in primary sites and spread patterns of the intestinal and diffuse subtypes of gastric carcinoma. We also compared survival outcomes based on spread patterns. MATERIALS AND METHODS: For this retrospective IRB-approved study, our institutional imaging database was mined for patients with gastric cancer. We included 99 treatment-naïve patients. Patient demographics, pathologic data, tumor classification, primary tumor site, and metastasis sites were recorded. Pearson's chi-squared test was used to correlate tumor pathology with metastatic sites. Kaplan-Meier survival curves were compared between baseline metastatic types. A heat map was created based on the relative frequencies of metastatic sites for each primary tumor site. RESULTS: Of the 99 patients, 66 patients had intestinal and 33 had diffuse gastric carcinoma. The intestinal subtype was significantly associated with hepatic metastases (p < 0.001). Diffuse subtype was associated with peritoneal metastases, including omental metastases (p < 0.006), gastrosplenic ligament involvement (p < 0.004), and mesocolonic implants (p < 0.008). Patients with primary gastric tumors occurring at the greater curvature had longer overall survival than those with primary sites at the antrum, GE junction and lesser curvature (p = 0.0015). Patients with peritoneal metastases had a significantly shorter overall survival than patients without peritoneal metastases (p < 0.001). Patients without mesocolon, gastrohepatic ligament, and gastrosplenic ligament involvement had a better survival (p = 0.005, p = 0.0002, and p = 0.0005, respectively). Presence of hepatic metastases had no effect on survival (p = 0.16). CONCLUSION: Recognizing distinctive spread patterns for intestinal versus diffuse gastric carcinoma can aid radiologists in diagnosis and guide clinical management.

Unravelling Adrenal Oncocytic Neoplasm.

Oncocytic neoplasms are rare tumors arising in the adrenal glands and usually considered as nonfunctional and benign. We report 4 cases of adrenal oncocytic neoplasm. The paucity of literature describing this entity increases the chance for misdiagnosis. Confirmatory diagnosis is by tissue sampling with adrenalectomy as the mainstay of treatment.

Liver Calcifications and Calcified Liver Masses: Pattern Recognition Approach on CT.

OBJECTIVE: Because of the ubiquitous use of radiologic imaging, particularly with CT, the detection of focal hepatic calcifications has increased. Calcifications can be seen in cystic and solid masses associated with both benign and malignant causes, pseudomasses, and miscellaneous pathologic abnormalities. CONCLUSION: These calcifications can manifest in various patterns, recognition of which can increase specificity for various diagnoses. In this article, we review a wide range of calcified hepatic pathologic abnormalities at CT and propose an approach for diagnosis.

Evaluating for Pseudoprogression in Colorectal and Pancreatic Tumors Treated With Immunotherapy.

Pseudoprogression has been observed in patients with various tumor types treated with immunotherapy. However, the frequency of pseudoprogression is unknown in gastrointestinal malignancies. Metastatic colorectal cancer (mCRC) and advanced pancreatic ductal adenocarcinoma (PDAC) patients who progressed on treatment with immunotherapy beyond RECIST version 1.1 criteria were analyzed. Degree of progression, tumor markers, time to progression, overall survival, Eastern Cooperative Oncology Group Performance Status (ECOG PS), and costs were analyzed for patients treated beyond progression (TBP) and not treated beyond progression. Fifty-nine of 159 (37%) patients with mCRC or PDAC were TBP (31 mCRC, 28 PDAC). Fifty-four of 59 (92%) patients were microsatellite stable. Zero of these 59 patients with initial treatment beyond progression demonstrated subsequent radiographic tumor shrinkage at a median 42 days from first scan documenting progression. A pseudoprogression rate of >6% could be excluded with 95% confidence. Compared with baseline, median growth on the first and second scan that showed progression was 29.8% and 43%, respectively. In those not treated beyond progression, median growth at first restaging was 31.2%. The trend in change in tumor size positively correlated with the trend in tumor markers in all patients TBP. Fifteen patients (25%) experienced grade 3/4 adverse events by continuing treatment beyond progression, whereas 19 (32%) experienced deterioration in ECOG PS. Pseudoprogression was not seen in microsatellite stable patients with mCRC or PDAC treated with immunotherapy. Changes in tumor markers correlated with changes in tumor volume. This data may help inform future treatment decisions and/or trial design in patients with mCRC or advanced PDAC treated with immunotherapy.

Leiomyoma of the Prostate: Case Report and Review of the Literature.

Leiomyomas can develop in any organ containing smooth muscles. They most commonly occur in the gastrointestinal and the female genital tracts. Leiomyoma of the prostate is a rare, benign tumor. We report 3 cases of rare prostatic leiomyomas. The paucity of literature describing prostatic leiomyoma increases the chance for misdiagnosis. Fewer than 30 cases in the English literature, with none including magnetic resonance imaging, computed tomography (CT), ultrasound, positron emission tomography-CT, and pathological findings together were found. Over the past decade, there has been a shift in the management of prostatic leiomyomas. Prostatectomy was once considered a standard approach for treatment, but now nonsurgical treatment options such as embolization are preferred. Conservative management including surveillance is an option for asymptomatic patients.

[18F]-2-Fluoro-2-Deoxy-D-glucose-PET Assessment of Cervical Cancer.

This article provides an overview of PET in cervical cancer, primarily with regard to the use of 18F-2-fluoro-2-deoxy-d-glucose-PET/computed tomography. A brief discussion of upcoming technologies, such as PET/MR imaging, is presented.

Small Cell Carcinoma of the Ovary, Hypercalcemic Type: Clinical and Imaging Review.

Small Cell Carcinoma of the Ovary, Hypercalcemic Type (SCCOHT) is a rare, aggressive malignancy with a poor prognosis. Its features are difficult to differentiate from other ovarian malignancies. In this article, we discuss recent advances in our understanding of this rare malignancy including tumor genetics. We also describe demographic, clinical and imaging findings, staging, and treatment options.

Metastatic melanoma to the testis.

This case report presents the ultrasound and positron emission tomography-computed tomography (PET-CT) imaging findings related to a patient with metastatic melanoma to the testis. We review this very rare entity and discuss the role of imaging.

Feasibility of Contrast-Enhanced Intraoperative Ultrasound for Detection and Characterization of Renal Mass Undergoing Open Partial Nephrectomy.

OBJECTIVES: To determine the feasibility of obtaining intraoperative contrast-enhanced ultrasound (CEUS) imaging in patients undergoing open partial nephrectomy for renal cancer. We hypothesize that the study was feasible and the addition of CEUS would improve lesion identification and characterization. METHODS: The study population consisted of 10 patients with known renal mass scheduled for intraoperative ultrasound-guided open partial nephrectomy. After dissection and exposure of the kidney by the surgeon, an intraoperative pre- and post-CEUS was performed by the radiologist. Feasibility was defined as successful imaging in 8 of 10 patients with intraoperative CEUS. Image quality, lesion conspicuity/contrast, lesion vascularity, morphology, and size were assessed and graded with pre- and post-contrast images. RESULTS: Intraoperative ultrasound was successfully acquired in 10 of 11 patients for renal mass detection and characterization. One study was canceled intraoperatively as a result of clinical complications related to a difficult surgery. Tumor size ranged from 1.3 to 4.2 cm. All lesions were solid. No additional lesions were found on CEUS compared with baseline imaging. Image quality post-contrast ranged from acceptable to excellent. There were no adverse events recorded for all 10 patients. CONCLUSIONS: In our feasibility study consisting of 10 patients, CEUS for detection and characterization of renal mass undergoing open partial nephrectomy was feasible and safe. Because intraoperative ultrasound during open partial nephrectomy can affect the extent of surgery, CEUS can be used to help detect and characterize renal mass for surgical planning/resection intraoperatively.