Imaging in Gastric Cancer: Current Practice and Future Perspectives.

Gastric cancer represents one of the most common oncological causes of death worldwide. In order to treat patients in the best possible way, the staging of gastric cancer should be accurate. In this regard, endoscopy ultrasound (EUS) has been considered the reference standard for tumor (T) and nodal (N) statuses in recent decades. However, thanks to technological improvements, computed tomography (CT) has gained an important role, not only in the assessment of distant metastases (M status) but also in T and N staging. In addition, magnetic resonance imaging (MRI) can contribute to the detection and staging of primary gastric tumors thanks to its excellent soft tissue contrast and multiple imaging sequences without radiation-related risks. In addition, MRI can help with the detection of liver metastases, especially small lesions. Finally, positron emission tomography (PET) is still considered a useful diagnostic tool for the staging of gastric cancer patients, with a focus on nodal metastases and peritoneal carcinomatosis. In addition, it may play a role in the treatment of gastric cancer in the coming years thanks to the introduction of new labeling peptides. This review aims to summarize the most common advantages and pitfalls of EUS, CT, MRI and PET in the TNM staging of gastric cancer patients.

The Role of Core Biopsy versus Vacuum-Assisted Breast Biopsy In Primary Breast Angiosarcoma.

We report the case of a 45-year-old woman with a slow-growing palpable nodule on the left breast, confirmed as a well-defined opacity on mammography, corresponding to a 5 cm hyperechoic lesion on ultrasound, and considered, on the basis of clinical examination and radiological findings, to be consistent with a lipoma. One year later, the patient represented with an enlarged left breast mass and underwent further imaging investigation with subsequent diagnosis of primary breast angiosarcoma obtained via a Vacuum-Assisted Breast Biopsy. The patient developed metastatic disease and succumbed to the disease one year after definitive diagnosis. Primary breast angiosarcoma is a rare malignant vascular neoplasia, characterized by aggressive patterns, poor prognosis, and absence of pathognomonic radiological features. Currently, there are no evidence-based guidelines regarding treatment, even though wide surgical resection followed by chemo- and radiotherapy appears to improve survival.

Computed Tomography Angiography Combined With Knowledge-Based Iterative Algorithm for Transcatheter Aortic Valve Implantation Planning: Image Quality and Radiation Dose Exposure With Low-kV and Low-Contrast-Medium Protocol.

OBJECTIVE: To evaluate image quality and radiation dose exposure of low-kV setting and low-volume contrast medium (CM) computed tomography angiography (CTA) protocol for transcatheter aortic valve implantation (TAVI) planning in comparison with standard CTA protocol. METHODS: Sixty-patients were examined with 256-row MDCT for TAVI planning: 32 patients (study group) were evaluated using 80-kV electrocardiogram-gated protocol with 60 mL of CM and IMR reconstruction; 28 patients underwent a standard electrocardiogram-gated CTA study (100 kV; 80 mL of CM; iDose4 reconstruction). Subjective and objective image quality was evaluated in each patient at different aortic levels. Finally, we collected radiation dose exposure data (CT dose index and dose-length product) of both groups. RESULTS: In study protocol, significant higher mean attenuation values were achieved in all measurements compared with the standard protocol. There were no significant differences in the subjective image quality evaluation in both groups. Mean dose-length product of study group was 56% lower than in the control one (P < 0.0001). CONCLUSION: Low-kV and low-CM volume CTA, combined with IMR, allows to correctly performing TAVI planning with high-quality images and significant radiation dose reduction compared with standard CTA protocol.

Treatment of hepatocellular carcinoma beyond the Milan criteria. A weighted comparative study of surgical resection versus chemoembolization.

BACKGROUND: Optimal treatment of hepatocellular carcinoma (HCC) beyond the Milan criteria (MC) is debated. The aim of the study was to assess overall-survival (OS) and disease-free-survival (DFS) for HCC beyond MC when treated by trans-arterial-chemoembolization (TACE) or surgical resection (SR). METHOD: between 2005 and 2015, all patients with a first diagnosis of HCC beyond MC(1 nodule>5 cm, or 3 nodules>3 cm without macrovascular invasion) were evaluated. Analyses were carried out through Kaplan-Meier, Cox models and the inverse probability weighting (IPW) method to reduce allocation bias. Sub-analyses have been performed for multinodular and single large tumors compared with a MC-IN cohort. RESULTS: 226 consecutive patients were evaluated: 118 in SR group and 108 in TACE group. After IPW, the two pseudo-populations were comparable for tumor burden and liver function. In the SR group, 1-5 years OS rates were 72.3% and 35% respectively and 92.7% and 39.3% for TACE (p = 0.500). The median DFS was 8 months (95%CI:8-9) for TACE, and 11 months (95%CI:9-12) for SR (p < 0.001). TACE was an independent predictor for recurrence (HR 1.5; 95%CI: 1.1-2.1; p = 0.015). Solitary tumors > 5 cm and multinodular disease had comparable OS and DFS as Milan-IN group (p > 0.05). CONCLUSION: Surgery allowed a better control than TACE in patient bearing HCC beyond MC. This translated into a significant benefit in terms of DFS but not OS.

Virtual Guidance of Percutaneous Transthoracic Needle Biopsy with C-Arm Cone-Beam CT: Diagnostic Accuracy, Risk Factors and Effective Radiation Dose.

PURPOSE: C-arm cone-beam computed tomography-guided transthoracic lung core needle biopsy (CBCT-CNB) is a safe and accurate procedure for the evaluation of patients with pulmonary nodules. The purpose of our study was to evaluate the diagnostic performance, complication rates and effective radiation dose of CBCT-CNB with virtual guidance. MATERIALS AND METHODS: We retrospectively collected data regarding 375 CBCT-CNBs performed with virtual guidance (XperGuide-Philips Healthcare, Best, The Netherlands) from January 2010 to June 2015 on 355 patients (mean age, 68.1 years ± 11.8; age range, 31-88 years). Patients were divided into groups and compared based on the diagnostic failure and lesion size (15 mm cutoff). Diagnostic performance, complication rate and effective radiation dose were investigated. Variables influencing diagnostic performance and complications were assessed using Student's T test and Pearson's χ2 test. RESULTS: The sensitivity, specificity, positive and negative predictive value and accuracy for patients subjected to CNBs were 96.8%, 100%, 100%, 100% and 97.2%, respectively. Considering risk factors for pneumothorax, no significant differences were found regarding patient and lesion characteristics. Perilesional hemorrhage occurred more frequently in older patients (p = 0.046) and in smaller lesions (p = 0.001). Hemoptysis was significantly more frequent in patients with perilesional hemorrhage (p = 0.01). Mean effective radiation dose in CBCT-CNB was 7.12 ± 8.78 mSv. CONCLUSIONS: CBCT-CNB combined with virtual guidance is a reliable and accurate technique that allows exact localization of pulmonary lesions, effective preprocedural planning and real-time fluoroscopy altogether.

Evaluation of image quality and radiation dose saving comparing knowledge model-based iterative reconstruction on 80-kV CT pulmonary angiography (CTPA) with hybrid iterative reconstruction on 100-kV CT.

OBJECTIVES: To evaluate dose reduction and image quality of 80-kV CT pulmonary angiography (CTPA) reconstructed with knowledge model-based iterative reconstruction (IMR), and compared with 100-kV CTPA with hybrid iterative reconstruction (iDose4). MATERIALS AND METHODS: One hundred and fifty-one patients were prospectively investigated for pulmonary embolism; a study group of 76 patients underwent low-kV setting (80 kV, automated mAs) CTPA study, while a control group of 75 patients underwent standard CTPA protocol (100 kV; automated mAs); all patients were examined on 256 MDCT scanner (Philips iCTelite). Study group images were reconstructed using IMR while the control group ones with iDose4. CTDIvol, DLP, and ED were evaluated. Region of interests placed in the main pulmonary vessels evaluated vascular enhancement (HU); signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated. RESULTS: Compared to iDose4-CTPA, low-kV IMR-CTPA presented lower CTDIvol (6.41 ± 0.84 vs 9.68 ± 3.5 mGy) and DLP (248.24 ± 3.2 vs 352.4 ± 3.59 mGy × cm), with ED of 3.48 ± 1.2 vs 4.93 ± 1.8 mSv. Moreover, IMR-CTPA showed higher values of attenuation (670.91 ± 9.09 HU vs 292.61 ± 15.5 HU) and a significantly higher SNR (p < 0.0001) and CNR (p < 0.0001).The subjective image quality of low-kV IMR-CTPA was also higher compared with iDose4-CTPA (p < 0.0001). CONCLUSIONS: Low-dose CTPA (80 kV and automated mAs modulation) reconstructed with IMR represents a feasible protocol for the diagnosis of pulmonary embolism in the emergency setting, achieving high image quality with low noise, and a significant dose reduction within adequate reconstruction times(≤ 120 s).

Dynamic Contrast-Enhanced Magnetic Resonance Imaging With Gadolinium Ethoxybenzyl Diethylenetriamine Pentaacetic Acid for Quantitative Assessment of Vascular Effects on Hepatocellular-Carcinoma Lesions Treated by Transarterial Chemoembolization or Radiofrequency Ablation.

PURPOSE: The aim of this study was to investigate the role of dynamic contrast-enhanced magnetic resonance imaging (MRI) in evaluation of blood flow changes related to transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) procedures in patients with hepatocellular carcinoma (HCC) lesions. METHODS: Fifty-four patients, with biopsy-proven HCC, who underwent TACE or RFA, were evaluated, 1 month after treatment, with upper abdominal MRI examination. Multiplanar T2-weighted, T1-weighted, and dynamic contrast-enhanced sequences were acquired. Dedicated perfusion software (T1 Perfusion Package, Viewforum; Philips Medical Systems, The Netherlands) was used to generate color permeability maps. After placing regions of interest in normal hepatic parenchyma, in successfully treated lesions, and in area of recurrence, the following perfusion parameters were calculated and statistically analyzed: relative arterial, venous, and late enhancement; maximum enhancement; maximum relative enhancement, and time to peak. RESULTS: Twenty-one of 54 patients had residual disease, and perfusion parameters values measured within tumor tissue were: relative arterial enhancement median, 42%; relative venous enhancement median, 69%; relative late enhancement median, 57.7%; maximum enhancement median, 749.6%; maximum relative enhancement median, 69%; time to peak median, 81.1 seconds. As for all the evaluated parameters, a significant difference (P < 0.05) was found between residual viable tumor tissue and effective treated lesions. CONCLUSIONS: Dynamic contrast-enhanced MRI represents a complementary noninvasive tool that may offer quantitative and qualitative information about HCC lesions treated with TACE and RFA.

C-arm cone-beam CT-guided transthoracic lung core needle biopsy as a standard diagnostic tool: an observational study.

C-arm cone-beam computed tomography (CT)-guided transthoracic lung core needle biopsy (CNB) is a safe and accurate procedure for the evaluation of patients with pulmonary nodules. This article will focus on the clinical features related to CNB in terms of diagnostic performance and complication rate. Moreover, the concept of categorizing pathological diagnosis into 4 categories, which could be used for clinical management, follow-up, and quality assurance is also introduced. We retrospectively collected data regarding 375 C-arm cone-beam CT-guided CNBs from January 2010 and June 2014. Clinical and radiological variables were evaluated in terms of success or failure rate. Pathological reports were inserted in 4 homogenous groups (nondiagnostic--L1, benign--L2, malignant not otherwise specified--L3, and malignant with specific histotype--L4), defining for each category a hierarchy of suggested actions. The sensitivity, specificity, and positive and negative predictive value and accuracy for patients subjected to CNBs were of 96.8%, 100%, 100%, 100%, and 97.2%, respectively. Roughly 75% of our samples were diagnosed as malignant, with 60% lung adenocarcinoma diagnoses. Molecular analyses were performed on 85 malignant samples to verify applicability of targeted therapy. The rate of "nondiagnostic" samples was 12%. C-arm cone-beam CT-guided transthoracic lung CNB can represent the gold standard for the diagnostic evaluation of pulmonary nodules. A clinical and pathological multidisciplinary evaluation of CNBs was needed in terms of integration of radiological, histological, and oncological data. This approach provided exceptional performances in terms of specificity, positive and negative predictive values; sensitivity in our series was lower compared with other large studies, probably due to the application of strong criteria of adequacy for CNBs (L1 class rate). The satisfactory rate of collected material was evaluated not only in terms of merely diagnostic performances but also for predictive results by molecular analysis.

Tumour-related neoangiogenesis: functional dynamic perfusion computed tomography for diagnosis and treatment efficacy assessment in hepatocellular carcinoma.

BACKGROUND: Aim of the study was to determine the value of perfusion computed tomography in the quantitative assessment of tumour-related neoangiogenesis for the diagnosis and treatment of hepatocellular carcinoma lesions. METHODS: Overall, 47 consecutive patients with cirrhotic liver disease, with a high risk of hepatocellular carcinoma, and undergoing standard surveillance (six-month intervals) were eligible for inclusion in this prospective study; based on Barcelona Clinic Liver Cancer guidelines, 27 patients were enrolled. Perfusion computed tomography was performed in 29 biopsy-proven hepatocellular carcinoma lesions before and after treatment with transarterial chemoembolization or radiofrequency ablation. The dynamic study was performed with a 256-slice multidetector-computed tomography scanner; the following parameters were measured: hepatic perfusion, arterial perfusion, blood volume, hepatic perfusion index, and time-to-peak in all patients. RESULTS: Hepatocellular carcinoma lesions had the following median perfusion values: perfusion 46.3mL/min/100g; blood volume 20.4mL/100mg; arterial perfusion 42.9mL/min; hepatic perfusion index 92.5%; time to peak 18.7s. Significantly lower perfusion values were obtained in correctly treated lesions or surrounding parenchyma than in viable hepatocellular carcinoma tissue. CONCLUSIONS: In hepatocellular carcinoma, perfusion computed tomography could contribute to a non-invasive quantification of tumour blood supply related to the formation of new arterial structures, and enable the assessment of therapeutic response.

Quantitative evaluation of CT-perfusion map as indicator of tumor response to transarterial chemoembolization and radiofrequency ablation in HCC patients.

PURPOSE: To assess if radiofrequency ablation (RFA) and transarterial chemoembolization (TACE) may influence the evaluation of perfusion parameters obtained with CT-perfusion (CT-p) in HCC treated patients. MATERIALS AND METHODS: Thirty-three consecutive cirrhotic patients with biopsy-proven diagnosis of HCC lesions and candidates to TACE or RFA were included. The CT-p study of hepatic parenchyma and of treated lesions was performed about 1 month after treatment on 16 multidetector CT after injection of 50mL of non ionic contrast agent (350mg I/mL) at a flow rate of 6mL/s acquiring 40 dynamic scans. A dedicated perfusion software which generated a quantitative map of arterial and portal perfusion by means of colour scale was employed.The following perfusion parameters were assessed before and after RFA or TACE treatment: hepatic perfusion (HP), arterial perfusion (AP), blood volume (BV), time to peak (TTP), hepatic perfusion index (HPI). RESULTS: A complete treatment was obtained in 16 cases and incomplete treatment in the 17 remaining cases. The perfusion data of completely treated lesions were: HP 10.2±6.3; AP 10.4±7; BV 4.05±4.8; TTP 38.9±4.2; HPI 9.9±9.2, whereas in partially treated lesions were: HP 43.2±15.1mL/s/100g; AP 38.7±8.8mL/min; BV 20.7±9.5mL/100mg; TTP 24±3.7s; HPI 61.7±7.5%. In adjacent cirrhotic parenchyma, the parameters of all evaluated patients were: HP 13.2±4; AP 12.3±3.4; BV 11.8±2.8; TTP 43.9±2.9; and HPI 17.1±9.8. A significant difference (P<0.001) was found for all parameters between residual viable tumor tissue (P<0.001) compared to successfully treated lesion due to the presence of residual arterial vascular structure in viable portion of treated HCC. CONCLUSION: According to our results, CT-p evaluation is not influenced by TACE or RFA treatments, thus representing a feasible technique that allows a reproducible quantitative evaluation of treatment response in HCC patients.

Use of "Time-Out" checklist in interventional radiology procedures as a tool to enhance patient safety.

PURPOSE: This study was done to evaluate the feasibility and effectiveness of adopting a safety checklist (SC) in the angiography suite during interventional radiology (IR) procedures to enhance patient safety. MATERIALS AND METHODS: Surgical SC was successfully introduced in 2009 with the aim of drastically reducing the morbidity and mortality caused by human error on patients during their stay in the operating room. Even CIRSE, the Cardiovascular and Interventional Radiological Society of Europe, recently published its own SC recommending its use in IR suites. Since January 2012, in our routine practice in the angiographic unit, we have used a 20-item checklist named "Time-Out" derived from the CIRSE SC. The main items are: in the Time-Out phase, active verbal communication within the team; correct identification of the patient and of the procedure site and side. Additionally, during the preprocedure (Sign-In) and postprocedure (Sign-Out) stages a series of clinical data are collected such as administration of prophylaxis against contrast allergy or contrast-induced nephropathy (CIN), when needed informed consent, discontinuation of anticoagulation therapy, fasting, correct labelling of biological samples, etc. RESULTS: Preliminary educational sessions were held to sensitise all the staff involved in the Time-Out project (physicians, nurses, radiographers) and ensure satisfactory compliance from the outset in consideration of the increased time and paperwork that checklist implementation would involve. CONCLUSIONS: The use of a checklist in IR, named "Time-Out" in our experience was feasible and effective allowing elimination of adverse events in the first year of use and promoting significant involvement and awareness of patient safety among the health-care team. The level of implementation, completeness and acceptability of the SC within the team increased after adequate training had been provided.

Viable residual tumor tissue after radiofrequency ablation treatment in hepatocellular carcinoma: evaluation with CT perfusion.

PURPOSE: To assess the role of CT perfusion technique in detection of blood flow changes related to the therapeutic effects in HCC lesion treated with RFA. METHODS: 14 cirrhotic patients with known HCC underwent a perfusion study about 4 months (range 1-13 months) after RFA on a 16-slice MDCT scanner (Brilliance, Philips). Dynamic CT was performed acquiring 8 dynamic slice/scan, after injection of 50 mL of contrast media. In treated lesion, surrounding parenchyma and hypervascular tissue suspicious for residual disease/recurrence, the following perfusion parameters were analyzed: perfusion (P, mL/100 g min); arterial perfusion (AP, mL/min); blood volume (BV, mL/100 mg); hepatic perfusion index (HPI, %), and time to peak (TTP, s). Univariate Wilcoxon signed rank test was used for statistical analysis. RESULTS: In patients with residual disease (8/14) values of perfusion parameters measured within tumor were: P, median = 45.2; AP, median = 48.2; BV, median = 18.9; HPI, median = 35.8; and TTP, median = 19.4. The values calculated in ablated area were: P, median = 10.9; AP, median = 9.6; BV, median = 5.5; HPI, median = 14.6; TTP, median = 39.6. The parameters calculated in the surrounding parenchyma were: P, median = 15.8; AP, median = 14.2; BV, median = 12.0; HPI, median = 17.9; TTP, median = 43.2. A significant difference (P < 0.05) was observed in mean values of P, AP, and HPI, calculated between treated lesions with residual tumor and those successfully treated. CONCLUSION: Perfusion CT enables assessment of HCC vascularity after RFA treatment, by adding quantitative information about the presence of residual arterial vessels within the viable residual neoplastic tissue.

Hepatocellular carcinoma treated with transarterial chemoembolization: dynamic perfusion-CT in the assessment of residual tumor.

AIM: To asses the value of computed tomography (CT)-perfusion in the detection of residual hepatocellular carcinoma (HCC) vascularization after transarterial chemoembolization (TACE). METHODS: Thirty-two consecutive patients were prospectively included in this study. All patients had liver cirrhosis and a confirmed HCC lesion which was treated with TACE. One month after treatment, perfusion measurements of treated lesions were carried out. The CT-perfusion (CT-p) protocol was performed with 16 slice multidetector computed tomography which included the following parameters: 8 dynamic slices/scan per 40 scans after iv injection of 50 mL of iodinated contrast (350 mg/mL) at a flow rate of 6 mL/s. Treated lesions were evaluated using dedicated perfusion software, which generated a quantitative colour map of perfusion. The following parameters were considered: hepatic perfusion (HP), arterial perfusion (AP), blood volume (BV), hepatic perfusion index (HPI), and time to peak (TTP). Perfusion parameters were described with quartile values of their distribution and statistically analyzed. RESULTS: Perfusion parameters of the treated lesions could be quantitatively assessed using CT-p analysis. The presence of residual tumor tissue was observed in 13 of the 32 patients. The values of the perfusion parameters measured within the relapse tissue were: HP (mL/100 g per minute): median = 44.4 (1(st)qt = 31.3, 3(rd)qt = 55.8); BV (mL/100 g): median = 18.7 (1(st)qt = 11.5, 3(rd)qt = 22.5); AP (mL/min): median = 39.0 (1(st)qt = 36.5, 3(rd)qt = 61.3); HPI (%): median = 34.0 (1(st)qt = 30.4, 3(rd)qt = 38.9); TTP (s): median = 17.3 (1(st)qt = 15.8, 3(rd)qt = 26.5). With the use of the univariate paired Wilcoxon signed rank test, HP, AP and HPI were shown to be significantly higher (P < 0.001) in the relapse site than in the primary lesion. The BV and TTP parameters showed a tendency to be greater and lower, respectively, in the relapse site than in the primary lesion. CONCLUSION: In patients with HCC treated with TACE, CT-p provides measurement of flow parameters related to residual arterial structures in viable tumor, thus helping in the assessment of therapeutic response.

Is percutaneous radiofrequency thermal ablation of hepatocellular carcinoma a safe procedure?

AIM: To assess the safety and efficacy of percutaneous radiofrequency thermal ablation (RFA) in the treatment of nonsurgical hepatocellular carcinoma (HCC) in daily practice. METHODS: A total of 63 consecutive patients with HCC (solitary nodule

Pseudoaneurysm after spontaneous rupture of renal angiomyolipoma in tuberous sclerosis: successful treatment with percutaneous thrombin injection.

We report a case of a large perinephric pseudoaneurysm due to spontaneous rupture of renal angiomyolipoma, occluded by percutaneous thrombin injection under ultrasound guidance in a young woman affected by tuberous sclerosis.

[Liver trauma: experience in the management of 252 cases]. / I traumi epatici: esperienza di trattamento di 252 casi.

The treatment of liver traumas has evolved considerably over recent decades with the possibility of non-operative management and arteriographic embolisation for selected patients in haemodynamically stable conditions. The aim of the study was to compare two periods with different approaches to the management of blunt or penetrating liver injuries. From January 1989 to October 2004, 252 patients were admitted to the emergency surgery department of Niguarda Hospital in Milan for liver traumas. Hepatic lesions accounted for 66% of abdominal lesions due to trauma and were classified according to the Organ Injury Scaling system. Abdominal ultrasound and CT scans were used to investigate the injuries. The study consisted of two periods: during the first period (1989-1993) surgery was the only treatment for trauma-induced hepatic lesions of any grade. Damage control surgery was employed for unstable patients undergoing laparotomy. From 1994 on, grade 1-2 injuries in patients with haemodynamically stable conditions were treated by non-operative management and grade 3 injuries by embolisation. In this second period only unstable patients with active bleeding or haemoperitoneum >500 ml with grade 3-5 injuries underwent laparotomy. The overall mortality for liver traumas was 27% (68/252) and was intraoperative in 97% of cases (66/68). Deaths were due to liver haemorrhage in 30 cases and to bleeding from extrahepatic or extra-abdominal injuries in the other 38 cases. Liver trauma was therefore directly responsible for mortality in as many as 12% of cases (30/252). The present study analysed two periods characterised by different approaches to the management of liver trauma. In the first period, laparotomy was the only choice, whereas subsequently non-operative management came to play an important role in haemodynamically stable patients and proved to be a safe method in selected cases. Major liver resections are seldom indicated in liver injuries. Damage control surgery has been practised since the first period and, before any surgical manoeuvres are performed, still represents a valuable tool to guarantee haemodynamic stability, which is the crucial factor for the outcome of liver resections for trauma.