MRI in addition to CT in patients scheduled for local therapy of colorectal liver metastases (CAMINO): an international, multicentre, prospective, diagnostic accuracy trial.

BACKGROUND: Guidelines are inconclusive on whether contrast-enhanced MRI using gadoxetic acid and diffusion-weighted imaging should be added routinely to CT in the investigation of patients with colorectal liver metastases who are scheduled for curative liver resection or thermal ablation, or both. Although contrast-enhanced MRI is reportedly superior than contrast-enhanced CT in the detection and characterisation of colorectal liver metastases, its effect on clinical patient management is unknown. We aimed to assess the clinical effect of an additional liver contrast-enhanced MRI on local treatment plan in patients with colorectal liver metastases amenable to local treatment, based on contrast-enhanced CT. METHODS: We did an international, multicentre, prospective, incremental diagnostic accuracy trial in 14 liver surgery centres in the Netherlands, Belgium, Norway, and Italy. Participants were aged 18 years or older with histological proof of colorectal cancer, a WHO performance status score of 0-4, and primary or recurrent colorectal liver metastases, who were scheduled for local therapy based on contrast-enhanced CT. All patients had contrast-enhanced CT and liver contrast-enhanced MRI including diffusion-weighted imaging and gadoxetic acid as a contrast agent before undergoing local therapy. The primary outcome was change in the local clinical treatment plan (decided by the individual clinics) on the basis of liver contrast-enhanced MRI findings, analysed in the intention-to-image population. The minimal clinically important difference in the proportion of patients who would have change in their local treatment plan due to an additional liver contrast-enhanced MRI was 10%. This study is closed and registered in the Netherlands Trial Register, NL8039. FINDINGS: Between Dec 17, 2019, and July 31, 2021, 325 patients with colorectal liver metastases were assessed for eligibility. 298 patients were enrolled and included in the intention-to-treat population, including 177 males (59%) and 121 females (41%) with planned local therapy based on contrast-enhanced CT. A change in the local treatment plan based on liver contrast-enhanced MRI findings was observed in 92 (31%; 95% CI 26-36) of 298 patients. Changes were made for 40 patients (13%) requiring more extensive local therapy, 11 patients (4%) requiring less extensive local therapy, and 34 patients (11%) in whom the indication for curative-intent local therapy was revoked, including 26 patients (9%) with too extensive disease and eight patients (3%) with benign lesions on liver contrast-enhanced MRI (confirmed by a median follow-up of 21·0 months [IQR 17·5-24·0]). INTERPRETATION: Liver contrast-enhanced MRI should be considered in all patients scheduled for local treatment for colorectal liver metastases on the basis of contrast-enhanced CT imaging. FUNDING: The Dutch Cancer Society and Bayer AG - Pharmaceuticals.

MRI-based guidelines for selective neoadjuvant treatment in rectal cancer: Does MRI adequately predict the indication for radiotherapy in daily practice in a large teaching hospital.

OBJECTIVES: According to new Dutch guidelines for rectal cancer, MRI-defined tumour stage determines whether preoperative radiotherapy is indicated. Therefore, we sought to evaluate if preoperative MRI accurately predicts the indication for neoadjuvant treatment in rectal cancer cases in daily practice according to the new Dutch guidelines. METHODS: Data for all rectal cancer patients who underwent mesorectal excision in our hospital, between January 2011 and January 2018 were collected retrospectively. We compared histopathologic outcome with tumour staging on preoperative MRI for patients who received no radiotherapy prior to resection or short-course radiotherapy directly followed by resection. RESULTS: Of 223 patients treated according to the old guidelines, 94% received neoadjuvant therapy. Of 301 patients treated according to the new guidelines, only 49% did. Under the old guidelines, MRI predicted lymph node metastases with a sensitivity of 74.2% and a specificity of 52.6%. With the new guidelines, sensitivity was 47.5% and specificity was 77.3%. The new guidelines resulted in 45% more patients not being exposed to disadvantages of radiotherapy, but 13% of all patients were undertreated. CONCLUSIONS: Concordance between clinical lymph node staging on preoperative MRI and histopathologic staging is limited, resulting in many rectal cancer patients not receiving adequate neoadjuvant therapy.

Improving the Quality of MRI Reports of Preoperative Patients With Rectal Cancer: Effect of National Guidelines and Structured Reporting.

OBJECTIVE: Since the implementation of new guidelines for rectal cancer in The Netherlands in April 2014, clinical stage as seen at preoperative MRI indicates whether neoadjuvant therapy is necessary before rectal cancer surgery. Therefore, the importance of correct MRI interpretation has increased. The aim of this study was to evaluate the completeness of MRI reports of rectal cancer and the effect of implementation of the new guidelines and standardized reporting on the completeness of these reports. MATERIALS AND METHODS: Data were collected from all patients who consecutively underwent rectal cancer surgery at one hospital between January 2011 and July 2017. Data were extracted from electronic patient records. RESULTS: The study included 492 MRI examinations. Before implementation of the new guidelines, a median of 4 of 10 items (interquartile range [IQR], 3-6 items) were described in each MRI report. After implementation of the new guidelines, the number of items described improved significantly (median, 7 items; IQR, 6-8 items; p < 0.001). Implementation of a standardized report led to further significant improvement (median, 9 items; IQR, 9-10 items; p < 0.001). The items scored most frequently were distance between the tumor and the anal verge (85.6%) and length of the tumor (87.6%). The items scored least were presence or absence of extramural venous invasion (21.1%) and morphologic features of the tumor (24.6%). CONCLUSION: Implementation of a standardized protocol and a standardized reporting system for MRI in preoperative staging of rectal cancer results in a more complete MRI report.

Diffusion-weighted MRI to assess response to chemoradiotherapy in rectal cancer: main interpretation pitfalls and their use for teaching.

OBJECTIVES: To establish the most common image interpretation pitfalls for non-expert readers using diffusion-weighted imaging (DWI) to assess response to chemoradiotherapy in patients with rectal cancer and to explore the use of these pitfalls in an expert teaching setting. METHODS: Two independent non-expert readers (R1 and R2) scored the restaging DW MRI scans (b1,000 DWI, in conjunction with ADC maps and T2-W MRI scans for anatomical reference) in 100 patients for the likelihood of a complete response versus residual tumour using a five-point confidence score. The readers received expert feedback and the final response outcome for each case. The supervising expert documented any potential interpretation errors/pitfalls discussed for each case to identify the most common pitfalls. RESULTS: The most common pitfalls were the interpretation of low signal on the ADC map, small susceptibility artefacts, T2 shine-through effects, suboptimal sequence angulation and collapsed rectal wall. Diagnostic performance (area under the ROC curve) was 0.78 (R1) and 0.77 (R2) in the first 50 patients and 0.85 (R1) and 0.85 (R2) in the final 50 patients. CONCLUSIONS: Five main image interpretation pitfalls were identified and used for teaching and feedback. Both readers achieved a good diagnostic performance with an AUC of 0.85. KEY POINTS: • Fibrosis appears hypointense on an ADC map and should not be mistaken for tumour. • Susceptibility artefacts on rectal DWI are an important potential pitfall. • T2 shine-through on rectal DWI is an important potential pitfall. • These pitfalls are useful to teach non-experts how to interpret rectal DWI.

Iodine 125 Seed for Localization in Primary Hyperparathyroidism.

Background Preoperative localization of the parathyroid gland prior to a minimally invasive parathyroidectomy (MIP) is important because of varying locations of the parathyroid gland. Several methods have been described to localize the affected gland. One novel technique is the use of an iodine 125 (I-125) seed as a marker. The aim of this study is to evaluate the feasibility of using an I-125 seed in localizing the diseased parathyroid gland prior to MIP. Materials and methods This is a pilot study of 10 patients performed in the Amphia Hospital, the Netherlands. Patients in whom primary hyperparathyroidism (PHPT) was diagnosed in combination with 1 enlarged parathyroid gland on ultrasound (US) and scintigraphy and who were eligible for MIP were included in this study. These patients underwent a preoperative US-guided I-125 seed placement in the affected parathyroid gland. The main study parameters were the feasibility of the placement, intraoperative localization of the diseased gland and complications. Results A total of 10 patients were included. The US-guided I-125 placement in the affected parathyroid gland was technically feasible in the majority of cases. Because of the anatomical location of the gland, the placement was difficult in 2 patients, resulting in suboptimal position and possible misplacement of the marker. MIP was uncomplicated in most cases. Complications during surgery were mainly intraoperative bleeding. Conclusions The use of an I-125 seed for preoperative localization in PHPT is a relatively safe technique in parathyroid surgery. More research is needed to compare this technique with other preoperative localization techniques.

Loss of skeletal muscle index and survival in patients with metastatic colorectal cancer: Secondary analysis of the phase 3 CAIRO3 trial.

BACKGROUND: Low skeletal muscle index (SMI) in metastatic colorectal cancer (mCRC) patients is associated with poor outcomes. The prognostic impact of SMI changes during consecutive palliative systemic treatments is unknown. METHODS: This is a retrospective analysis of the phase 3 CAIRO3 study. The CAIRO3 study randomized 557 patients between maintenance capecitabine + bevacizumab (CAP-B) or observation, after six cycles capecitabine + oxaliplatin + bevacizumab (CAPOX-B). Upon first disease progression (PD1), CAPOX-B was reintroduced until second progression (PD2). SMI was assessed by computed tomography (CT) (total 1355 scans). SMI and body mass index (BMI) changes were analyzed for three time-periods; p1: during initial CAPOX-B, p2: randomization to PD1, and p3: PD1 to PD2. The association between absolute and change in SMI and BMI (both per 1 standard deviation) during p1-p3, with PD1, PD2, and survival was studied by Cox regression models. RESULTS: This analysis included 450 of the 557 patients randomized in the CAIRO3 study. Mean SMI decreased during p1: mean -0.6 SMI units [95% CI -1.07;-0.26] and p3: -2.2 units [-2.7;-1.8], whereas during p2, SMI increased + 1.2 units [0.8-1.6]. BMI changes did not reflect changes in SMI. SMI loss during p2 and p3 was significantly associated with shorter survival (HR 1.19 [1.09-1.35]; 1.54 [1.31-1.79], respectively). Sarcopenia at PD1 was significantly associated with early PD2 (HR 1.40 [1.10-1.70]). BMI loss independent of SMI loss was only associated with shorter overall survival during p3 (HR 1.35 [1.14-1.63]). CONCLUSIONS: In mCRC patients, SMI loss during palliative systemic treatment was related with early disease progression and reduced survival. BMI did not reflect changes in SMI and could not identify patients at risk of poor outcome during early treatment lines.

Early local recurrence and one-year mortality of rectal cancer after restricting the neoadjuvant therapy regime.

INTRODUCTION: To reduce the risk of local recurrence after rectal cancer surgery, neoadjuvant radiotherapy (RT) can be applied. However, as this causes morbidity and increases mortality, new Dutch guidelines withhold RT in low-risk patients. The aim of this study is to investigate if early local recurrence and one-year mortality in rectal cancer patients has changed since this more restricting indication for neoadjuvant RT was introduced in 2014. METHODS: This retrospective study included all consecutive patients treated with a mesorectal excision for primary rectal cancer in the Amphia Hospital, the Netherlands, between January 2011 and July 2016. Data were extracted from the electronic patient records. Survival data were collected from the Municipal Personal Records Database. RESULTS: Between 2011 and July 2016, 407 resections of primary rectal cancer without synchronic metastases were performed, 225 under the old guidelines and 182 under the new guidelines. Significantly fewer patients received neoadjuvant treatment under the new guidelines (89% vs 41%, p < 0.001). Both clinical tumour stage (p = 0.001) and clinical lymph node stage (p < 0.001) were lower in the new group, but no difference in pathologic TN-stage was found. There was no difference in one-year local recurrence (2.2% in both groups, p = 0.987), nor in one-year mortality (5.3% vs 3.8%, p = 0.479). CONCLUSION: Introducing a new guideline and thereby restricting the indication for neoadjuvant RT in rectal cancer patients did not increase the early local recurrence rate or decreased one-year mortality in our hospital.

[Coincidental finding in a man with a painful knee]. / Toevalsbevinding bij een man met een pijnlijke knie.

A 40-year-old man presented to the emergency department with a painful right knee. Conventional radiography and a CT-scan coincidentally found an asymptomatic intraosseous ganglion. The patient was treated conservatively, with success. Intraosseous ganglia are benign lesions of the metaphyseal area of the long bones. Treatment of asymptomatic lesions is not necessarily unless cortical bone is involved.

[Treatment of colorectal liver metastasis at a regional hospital versus a university medical centre]. / Chirurgische behandeling van colorectale levermetastasen in een perifeer en een academisch ziekenhuis.

OBJECTIVE: To evaluate the results of this type of liver surgery performed at a specialised regional hospital in comparison with the operation performed at a university medical centre (UMC). DESIGN: Prospective study at 2 hospitals. METHODS: All patients with colorectal liver metastasis who had undergone a partial liver resection and/or radiofrequency ablation (RFA) at Amphia Hospital or at the Academic Medical Centre - University of Amsterdam (AMC) from January 2005-June 2011 were included. Data on patient characteristics, type of operation, pathology results and (disease-free) survival were collected. The primary outcome measures were surgical complications and survival. RESULTS: A total of 232 patients were included. No difference in patient characteristics between centres was identified. At the AMC, 121 patients (98.4%) had undergone a resection; 6 in combination with RFA. Two patients (1.6%) had only undergone RFA. At Amphia Hospital, 85 patients (78%) had undergone a resection; 30 in combination with RFA. In 24 patients (22%), only RFA was performed. There was significant difference in the type of treatment (p < 0.01). Not significantly different between centres were the average lengths of hospital stays, surgical complications and recurrence rates. After resection, no significant differences in the 1- and 3-year (disease-free) survival rates were found between the centres. At Amphia Hospital, the overall survival at 1, 3 and 5 years was 86, 47 and 29%, respectively. These rates were significantly better at AMC with 91, 78 and 53%, respectively (p < 0.05). The difference in (disease-free) survival for the entire group of patients can be explained by the more frequent performance of RFA at Amphia Hospital. CONCLUSIONS: Postoperative morbidity, mortality and survival rates after liver surgery obtained from a specialised regional hospital are similar to results obtained from a UMC.