Diffusion-weighted imaging for evaluation of uterine arterial embolization of fibroids.

PURPOSE: To determine whether diffusion-weighted imaging (DWI) characteristics could predict the effectiveness of uterine arterial embolization in treatment of fibroids. METHODS: This retrospective study included 17 women (27 fibroids) who underwent uterine arterial embolization for fibroids. MR imaging (1.5 T) was performed before, 1 week and 6 months after uterine arterial embolization. The volume, T2 signal, T1 signal, enhancement after contrast media injection, DWI signal (b = 500 s/mm(2) ) and apparent diffusion coefficient (ADC) were assessed for fibroids. RESULTS: DWI signal or ADC, whether before or 1 week after the procedure, did not show a statistical relationship to success of uterine arterial embolization. On the 1-week follow-up, 22% of fibroids enhanced vs. 85% on baseline, P < 0.0001 and DW signal intensity increased. ADC values in fibroids decreased between baseline and 1-week (1.61 vs. 1.53 × 10(-3) mm(2) /s, P = 0.13). On 6-months, ADC continued to decrease compared with baseline (1.27 × 10(-3) mm(2) /s, P = 0.002), but with a lower signal on DWI. No changes were observed in myometrium ADC at any time point. CONCLUSION: Our study demonstrated that DWI and ADC reflected early and delayed changes in fibroids after embolization; however, we were not able to demonstrate a statistically significant relationship with outcome.

Double pancreatic and gastric adenocarcinomas: a rare association.

Synchronous gastric and pancreatic cancers represent a very rare association. The role of tomodensitometry, endoscopic ultrasound and histology is primordial to differentiate between double tumors, local extension or metastasis. We report in our paper two cases of synchronous gastric and pancreatic cancers treated with Folforinox. Then, we discuss the risk factors, the diagnostic methods, the treatment modalities and the prognosis of these rare double cancers.

Optimisation of the tumour response threshold in patients treated with everolimus for metastatic renal cell carcinoma: analysis of response and progression-free survival in the RECORD-1 study.

BACKGROUND AND OBJECTIVES: Objective response as determined by Response Evaluation Criteria in Solid Tumors (RECIST) is low among patients with metastatic renal cell carcinoma (mRCC) treated with targeted agents, despite significantly improved progression-free survival (PFS). A modified response threshold may be more clinically meaningful than RECIST for identifying patients who may derive a PFS benefit from targeted therapy. PATIENTS AND METHODS: We performed a retrospective analysis of data from the phase III RECORD-1 trial of everolimus versus placebo in patients with mRCC who had failed sunitinib or sorafenib (ClinicalTrials.gov identifier: NCT00410124). A series of tumour response thresholds, defined by the best change in the sum of the longest tumour diameters (ΔSLD) of target lesions, was evaluated to distinguish 'responders' from 'non-responders' with respect to significant improvement in PFS. RESULTS: The optimal threshold for determining a response to everolimus was -5% ΔSLD. At this threshold, median PFS was 8.4 months in responders and 5.0 months in non-responders (hazard ratio [HR] 2.4, 95% confidence interval [CI] 1.6-3.7). CONCLUSION: In patients who have failed vascular endothelial growth factor receptor-tyrosine kinase inhibitor (VEGFr-TKI) therapy, everolimus affords superior PFS to placebo, regardless of change in tumour burden. However, a ≥ 5% reduction in SLD is a better predictor of PFS benefit than the classical ≥ 30% reduction used with RECIST.

Quantitative dynamic contrast-enhanced MR imaging analysis of complex adnexal masses: a preliminary study.

OBJECTIVE: To evaluate the ability of quantitative dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) to differentiate malignant from benign adnexal tumours. METHODS: Fifty-six women with 38 malignant and 18 benign tumours underwent MR imaging before surgery for complex adnexal masses. Microvascular parameters were extracted from high temporal resolution DCE-MRI series, using a pharmacokinetic model in the solid tissue of adnexal tumours. These parameters were tissue blood flow (F(T)), blood volume fraction (Vb), permeability-surface area product (PS), interstitial volume fraction (Ve), lag time (Dt) and area under the enhancing curve (rAUC). Area under the receiver operating curve (AUROC) was calculated as a descriptive tool to assess the overall discrimination of parameters. RESULTS: Malignant tumours displayed higher F(T), Vb, rAUC and lower Ve than benign tumours (P < 0.0001, P = 0.0006, P = 0.04 and P = 0.0002, respectively). F(T) was the most relevant factor for discriminating malignant from benign tumours (AUROC = 0.86). Primary ovarian invasive tumours displayed higher F(T) and shorter Dt than borderline tumours. Malignant adnexal tumours with associated peritoneal carcinomatosis at surgery displayed a shorter Dt than those without peritoneal carcinomatosis at surgery (P = 0.01). CONCLUSION: Quantitative DCE-MRI is a feasible and accurate technique to differentiate malignant from benign adnexal tumours and could potentially help oncologists with management decisions. KEY POINTS: Quantitative DCE MR imaging allows accurate differentiation between malignant and benign tumours. Quantitative DCE MRI may help predict peritoneal carcinomatosis associated with ovarian tumors. Quantitative DCE MRI helps distinguish between invasive and borderline primary ovarian tumours.

Characterization of complex adnexal masses: value of adding perfusion- and diffusion-weighted MR imaging to conventional MR imaging.

PURPOSE: To retrospectively determine the value of adding perfusion-weighted (PW) and diffusion-weighted (DW) sequences to a conventional magnetic resonance (MR) imaging protocol to differentiate benign from malignant tumors. MATERIALS AND METHODS: The institutional ethics committee approved this retrospective study and waived the requirement to obtain informed consent. MR images in 87 women (age range, 25-87 years) who underwent imaging before surgery for complex adnexal masses-excluding endometriomas and cystic teratomas-were analyzed. Conventional morphologic, perfusion, and diffusion MR criteria of malignancy were recorded. Three independent observers reviewed images in four steps: conventional MR images alone, conventional MR images and PW images combined, conventional MR images and DW images combined, and conventional, PW, and DW MR images combined. Receiver operating characteristic curve analysis was performed to compare the results of the readings. A recursive partitioning model was built to establish a multivariate decision tree. RESULTS: There was almost perfect agreement for lesion characterization regardless of the reader experiment or step considered (κ = 0.811-0.929). Area under the receiver operating characteristic curve values were higher for conventional and DW images combined, conventional and PW images combined, and conventional, DW, and PW images combined compared with conventional MR images alone (P < .05). For all readers, the accuracy of conventional, PW, and DW imaging combined was higher than that of conventional MR imaging alone for benign masses (P < .01) but not for malignant masses (P = .24). The addition of both PW and DW images led to a correct change in the diagnosis in 19% (11 of 57 patients), 23% (13 of 57 patients), and 24% (14 of 57 patients) of cases for readers 1, 2, and 3, respectively, with no incorrect changes. Conventional, PW, and DW MR imaging criteria were combined to generate a decision tree giving an accuracy of 95%. CONCLUSION: The addition of PW and DW sequences to a conventional MR imaging protocol improved the diagnostic accuracy in the characterization of complex adnexal masses.

Metastatic renal carcinoma: evaluation of antiangiogenic therapy with dynamic contrast-enhanced CT.

PURPOSE: To determine whether tumor perfusion parameters assessed by using dynamic contrast material-enhanced computed tomography (CT) could help predict and detect response in patients receiving antiangiogenic therapy for metastatic renal cell carcinoma. MATERIALS AND METHODS: Institutional ethics committee approval and informed consent were obtained. In two phase-III trials involving 51 patients with metastatic renal cell carcinoma (38 men, 13 women; age range, 30-80 years) receiving antiangiogenic drugs (sorafenib [n = 10], sunitinib [n = 22]), a placebo (n = 12), or interferon alfa (n = 7), serial dynamic contrast-enhanced CT was performed, during 90 seconds before and after injection of 80 mL of iobitridol. Perfusion parameters of a target metastatic tumor (tumor blood flow [TBF], tumor blood volume [TBV], mean transit time, and vascular permeability-surface area product) were calculated. Values before and after treatment were compared by using a Wilcoxon signed rank test, and relative changes in groups were compared by using the Wilcoxon rank sum test. Results were compared with Response Evaluation Criteria in Solid Tumors response and with progression-free and overall survival by using Kaplan-Meier curves. RESULTS: Among patients receiving antiangiogenic drugs, baseline perfusion parameters were higher in responders than in stable patients (TBF = 245.3 vs 119.5 mL/min/100 mL, P = .04; TBV = 15.5 vs 8.2 mL/100 mL, P = .02) but were not significantly predictive of survival. After the first cycle of treatment, there was a significant decrease in TBF (162.5 vs 76.7 mL/min/100 mL, P = .0002) and TBV (9.1 vs 3.9 mL/100 mL, P < .0001) in patients receiving antiangiogenic treatment. CONCLUSION: Renal carcinoma perfusion parameters determined with dynamic contrast-enhanced CT can help predict biologic response to antiangiogenic drugs before beginning therapy and help detect an effect after a single cycle of treatment.

Multiple myeloma treatment response assessment with whole-body dynamic contrast-enhanced MR imaging.

PURPOSE: To compare posttreatment bone marrow changes at whole-body dynamic contrast material-enhanced magnetic resonance (MR) imaging with clinical response in patients with multiple myeloma (MM) and to determine if this technique can be used to assess treatment response in patients with MM. MATERIALS AND METHODS: This study was approved by an institutional review board; all patients gave informed written consent. Thirty patients (21 men, nine women; mean age, 58 years +/- 10 [standard deviation]) underwent whole-body dynamic contrast-enhanced MR imaging before treatment, after induction chemotherapy (n = 30), and after autologous stem cell transplantation (ASCT) (n = 20). Maximal percentages of bone marrow (BME(max)) and focal lesion (FLE(max)) enhancement were assessed at each MR imaging examination. Clinical responses were determined on the basis of international uniform response criteria. Posttreatment changes in BME(max)and FLE(max)were compared with clinical response to therapy by using the Mann-Whitney U test. Receiver operating characteristic (ROC) analysis of posttreatment BME(max)was used to identify poor responders. RESULTS: Eleven of 30 patients were good responders to induction chemotherapy; 16 of 20 patients were good responders to ASCT. After induction chemotherapy, mean BME(max)differed between good and poor responders (94.3% vs 138.4%, respectively; P = .02). With the exclusion of results from six examinations with focal lesions in which a poor clinical response was classified but BME(max)had normalized, a posttreatment BME(max)of more than 96.8% had 100% sensitivity for the identification of poor responders (specificity, 76.9%; area under the ROC curve, 0.90; P = .0001). Mean FLE(max)after induction chemotherapy did not differ between good and poor responders. Mean timing (ie, the number of postcontrast dynamic acquisitions where FLE(max)was observed) was significantly delayed in good responders compared with poor responders (4.7 vs 2.9, P < .0001). Post-ASCT MR imaging results correctly depicted all four clinically good responders whose disease subsequently progressed. CONCLUSION: With quantitative analysis of BME(max)and the timing of FLE(max), whole-body dynamic contrast-enhanced MR imaging can be used to assess treatment response in patients with MM.

Contribution of diffusion-weighted MR imaging for predicting benignity of complex adnexal masses.

The purpose of this study was to prospectively assess the contribution of diffusion-weighted MR imaging (DWI) for characterizing complex adnexal masses. Seventy-seven women (22-87 years old) with complex adnexal masses (30 benign and 47 malignant) underwent MR imaging including DWI before surgery. Conventional morphological MR imaging criteria were recorded in addition to b(1,000) signal intensity and apparent diffusion coefficient (ADC) measurements of cystic and solid components. Positive likelihood ratios (PLR) were calculated for predicting benignity and malignancy. The most significant criteria for predicting benignity were low b(1,000) signal intensity within the solid component (PLR = 10.9), low T2 signal intensity within the solid component (PLR = 5.7), absence of solid portion (PLR = 3.1), absence of ascites or peritoneal implants (PLR = 2.3) and absence of papillary projections (PLR = 2.3). ADC measurements did not contribute to differentiating benign from malignant adnexal masses. All masses that displayed simultaneously low signal intensity within the solid component on T2-weighted and on b(1,000) diffusion-weighted images were benign. Alternatively, the presence of a solid component with intermediate T2 signal and high b(1,000) signal intensity was associated with a PLR of 4.5 for a malignant adnexal tumour. DWI signal intensity is an accurate tool for predicting benignity of complex adnexal masses.

Mapping the zonal organization of tumor perfusion and permeability in a rat glioma model by using dynamic contrast-enhanced synchrotron radiation CT.

PURPOSE: To depict and analyze in vivo the tumor zone organization of C6 gliomas depicted on quantitative parametric maps obtained with dynamic contrast material-enhanced synchrotron radiation computed tomography (CT) in a tightly controlled data-processing protocol. MATERIALS AND METHODS: Animal use was compliant with official French guidelines and was assessed by the local Internal Evaluation Committee for Animal Welfare and Rights. Fifteen Wistar rats with orthotopically implanted gliomas were studied at monochromatic synchrotron radiation CT after receiving a bolus injection of contrast material. The iodine concentration maps were analyzed by using a compartmental model selected from among a package of models. Choice of model and assessment of the relevance of the model were guided by quality criteria. Tissue blood flow (F(T)), tissue blood volume fraction (V(T)), permeability-surface area product (PS), artery-to-tissue delay (D(A-T)), and vascular mean transit time (MTT) maps were obtained. Parametric map findings were compared with histologic findings. Local regions of interest were selected in the contralateral hemisphere and in several tumor structures to characterize the tumor microvasculature. Differences in parameter values between regions were assessed with the Wilcoxon method. RESULTS: Whole-tumor parameters were expressed as means +/- standard errors of the mean: Mean F(T), V(T), PS, and D(A-T) values and MTT were 61.4 mL/min/100 mL +/- 15.3, 2.4% +/- 0.4, 0.37 mL/min/100 mL +/- 0.11, 0.24 second +/- 0.06; and 3.9 seconds +/- 0.83, respectively. MTT and mean PS were significantly lower (P < .01) in the normal contralateral tissue: 1.10 seconds +/- 0.06 and < or = 10(-5) mL/min/100 mL, respectively. Tumor regions were characterized by significantly different (P < .05) F(T) and V(T) pairs: 108 mL/min/100 mL and 3.66%, respectively, at the periphery; 45.9 mL/min/100 mL and 1.91%, respectively, in the intermediate zone; 5.1 mL/min/100 mL and 0.42%, respectively, in the center; and 210 mL/min/100 mL and 6.82%, respectively, in the maximal value region. CONCLUSION: Fine mapping of the glioma microcirculation is feasible with dynamic contrast-enhanced synchrotron radiation CT performed with well-controlled analytic protocols. SUPPLEMENTAL MATERIAL: http://radiology.rsnajnls.org/cgi/content/full/2501071929/DC1.

Dynamic contrast-enhanced MR imaging of ovarian neoplasms: current status and future perspectives.

MR imaging is useful for characterizing ovarian tumors. Dynamic contrast-enhanced MR imaging is a promising new technique useful for characterizing perfusion and angiogenesis of ovarian masses. This article describes the dynamic contrast-enhanced MR imaging technique examines the current and future applications of this technique in patients with ovarian tumors.

Dynamic contrast-enhanced magnetic resonance imaging: a useful tool for characterizing ovarian epithelial tumors.

PURPOSE: To evaluate the utility of dynamic contrast enhancement (DCE) MRI for distinguishing among benign, borderline and invasive epithelial ovarian tumors. MATERIALS AND METHODS: We analyzed preoperative MRI studies of 37 patients with ovarian epithelial tumors (10 benign, 11 borderline, and 16 invasive). A DCE-MRI sequence was acquired and regions of interest (ROIs) were drawn in the ovarian tumors and adjacent myometrium. A total of three patterns of enhancement were defined. Dynamic data were parameterized using mathematical models that included the enhancement amplitude (EA), the time of half rising (THR), and the maximal slope (MS). Using myometrium as the internal reference, ratios of EA (EAr), THR (THRr), MS (MSr), and initial area under the curve for 60 seconds after injection (IAUC(60) ratio) were determined. RESULTS: Morphological criteria such as septa, papillary projection, solid portion, and T2-weighted MR signal intensity of solid tissue were useful for discriminating invasive from noninvasive ovarian tumors (P = 0.01, P = 0.02, P = 0.002, and P < 0.0001 respectively) but not for discriminating benign from borderline tumors. Curve type 3 was specific for invasive ovarian tumors. EAr, MSr, and IAUC(60) ratio were higher for invasive than for benign (P < 0.0001) and borderline tumors (P = 0.005, P = 0.002, and P = 0.001, respectively). The IAU(60) ratio was the most relevant factor for discriminating benign from borderline and invasive tumors. MSr and IAU(60) ratio could be combined to generate a decision tree with 81% accuracy. CONCLUSION: DCE-MRI is a useful tool for characterizing epithelial ovarian tumors.

Epithelial ovarian tumors: value of dynamic contrast-enhanced MR imaging and correlation with tumor angiogenesis.

PURPOSE: To retrospectively evaluate the diagnostic performance of dynamic contrast material-enhanced magnetic resonance (MR) imaging for the characterization of ovarian epithelial tumors, by using histologic findings as the reference standard, and to correlate dynamic contrast-enhanced MR imaging findings with angiogenesis biomarkers. MATERIALS AND METHODS: Ethics committee approval was obtained, with waiver of informed consent. Patients consented to having their data used for future retrospective research. Forty-one women (age range, 22-73 years) with 48 epithelial ovarian tumors underwent dynamic contrast-enhanced MR imaging before surgical excision. In case of bilateral tumors (n = 7), only the most complex tumor was analyzed. Thus, 41 tumors (12 benign, 13 borderline, and 16 invasive) were examined with dynamic contrast-enhanced MR imaging and immunohistochemical methods. Dynamic contrast-enhanced MR imaging parameters (enhancement amplitude [EA], time of half rising [T(max)], and maximal slope [MS]) were analyzed according to histopathologic findings, microvessel density, pericyte coverage index (PCI), and vascular endothelial growth factor receptor 2 (VEGFR-2) expression. Statistical analyses were performed by using Kruskal-Wallis, Fisher exact, and Spearman tests and receiver operating curve analysis. RESULTS: EA was higher for invasive tumors than for benign (P < .001) and borderline (P < .05) tumors. T(max) was longer for benign tumors than for borderline (P < .05) and invasive (P < .01) tumors. MS was steeper for invasive tumors than for benign (P < .001) and borderline (P < .001) tumors. PCI was lower in invasive tumors than in borderline (P < .05) and benign (P < .05) tumors. Microvessels showed stronger immunohistochemical VEGFR-2 expression in invasive tumors than in benign or borderline tumors (P < .05). MS correlated with a lower PCI (r = -0.34, P = .04) and stronger VEGFR-2 expression by using both epithelial (r = 0.41, P < .01) and endothelial (r = 0.66, P < .001) cells. CONCLUSION: The early enhancement patterns of ovarian epithelial tumors on dynamic contrast-enhanced MR images can help distinguish among benign, borderline, and invasive tumors and were found to correlate with tumoral angiogenic status.

Glucose-receptor MR imaging of tumors: study in mice with PEGylated paramagnetic niosomes.

PURPOSE: To evaluate a magnetic resonance (MR) imaging contrast agent for tumor detection based on paramagnetic nonionic vesicles (niosomes) bearing polyethylene glycol (PEG) and glucose conjugates for the targeting of overexpressed glucose receptors. MATERIALS AND METHODS: Four gadobenate dimeglumine-loaded niosome preparations including nonconjugated niosomes, niosomes bearing glucose conjugates (N-palmitoyl glucosamine [NPG]), niosomes bearing PEG 4400, and niosomes bearing both PEG and NPG were tested. In vitro cellular uptake was measured at electron paramagnetic resonance (EPR) after incubation with human prostate carcinoma, PC3, cells. In vivo distribution was studied at MR imaging 6, 12, and 24 hours after injection, with assessment of tumor, brain, liver, and muscle signal intensity (SI) in 49 mice bearing PC3 cells. Efficiency of targeted contrast agents was assessed with tumor-to-muscle contrast-to-noise ratio (CNR). Testing for differences was performed with analysis of variance followed by a posteriori Fisher test. RESULTS: In vitro, gadolinium could be detected at EPR only in cell pellets incubated with niosomes bearing glucose conjugates or niosomes bearing both glucose conjugates and PEG (4.9. 10(-15) and 4.5. 10(-15) mol gadolinium per PC3 cell). In vivo, marked predominant tumor enhancement was demonstrated 24 hours after injection of glycosylated PEG niosomes (P <.01); no significant differences were observed following injection of nonconjugated niosomes, glycosylated niosomes, or PEG 4400 niosomes. Twenty-four hours after injection, sole presence of NPG or PEG 4400 on the surface of the niosome led to higher tumor-to-muscle CNR than that observed after injection of nonconjugated niosomes (CNR of 3.3 +/- 0.7 [SD], 3.4 +/- 2.2, and 0 +/- 1.9). Combination of NPG and PEG led to even higher tumor-to-muscle CNR (6.3 +/- 2.2). CONCLUSION: Combination of PEG and glucose conjugates on the surface of niosomes significantly improved tumor targeting of an encapsulated paramagnetic agent assessed with MR imaging in a human carcinoma xenograft model.