Irreversible electroporation of hepatocellular carcinoma: preliminary report on the diagnostic accuracy of magnetic resonance, computer tomography, and contrast-enhanced ultrasound in evaluation of the ablated area.

OBJECTIVE: Irreversible electroporation (IRE) is a new ablation modality. Our purpose was to describe the effectiveness and the safety of the treatment and to evaluate the magnetic resonance imaging (MRI), computed tomography (CT) and contrast-enhanced ultrasound (CEUS) diagnostic accuracy in HCC patients treated with IRE at 1-, 3-, and 6-month follow-up. MATERIALS AND METHODS: In an 18-month period, we treated 24 HCC lesions in 20 patients unfit for surgery. MRI, CT and CEUS were performed before and one, 3 and 6 month after IRE. We employed the liver-specific contrast medium Primovist (gadolinium ethoxybenzyl dimeglumine) in MRI. After IRE the lesions were classified as responders or non-responders to the treatment according to the mRECIST and the complications were recorded. We evaluated the size, shape, signal intensity (T1-W, T2-W, and DWI) in MRI, dynamic contrast enhancement pattern for CEUS, CT and MRI and signal behavior during the liver-specific phase for MRI. RESULTS: According to mRECIST, at 1 month MRI and CEUS showed a complete response (CR) in 91.7% of cases (22/24) tumors, while there was partial response (PR) in the remaining 2/24 (8.3%) treated nodules; in CT study all ablated zone appeared as necrotic (CR 100%). The residual viable tumor in MRI and in CEUS study had similar diameter (10 mm). No new HCC were identified from MRI, CT or CEUS. At 3 months MRI and CEUS showed the same results seen after 1 month from the treatment. Twenty-two necrotic lesions, and 2 residual tumors were found (CR = 91.7% and PD = 8.3%). In MRI study the two cases of residual tumor tissue had a diameter of 11 and 12 mm each. At CEUS the diameter of residual HCC was similar to the diameter at 1 month. CT showed 23 necrotic areas and one residual viable tissue in the treated zone, with a diameter of 10 mm (CR = 95.3% and PD = 4.7%). No new foci of HCC were identified from all imaging studies. At 6 months MRI, CEUS, and CT showed 22 necrotic lesions and 2 residual tumors in ablated zone (CR = 91.7% and PD = 8.3%). At MRI the diameters of the two residual viable HCCs were 12 and 14 mm, at CEUS the diameters were 11 and 12 mm, while at CT the diameters were 10 and 10 mm. No statistical difference was evaluated between CR, PR, PD percentage values for MRI, CT and CEUS (p value > 0.05 at Chi-square test). No major vascular complication was recorded after IRE. Six out of 20 patients (30%) showed a transient hepatic intensity difference (THID) area within the normal liver parenchyma adjacent to the treated lesions. Two of the 20 patients (10%) showed an absent concentration of liver-specific contrast medium around the ablation zone. Two patients developed complications, consisting in a peripheral arteriovenous shunt and a segmental dilation of the intrahepatic biliary ducts. We found no statistically significant difference in morphology, size (variation in the largest diameter), signal intensity in T1-weighted images, in T2-weighted images, in DWI and in the related map of the apparent diffusion coefficient (ADC), presence or absence of contrast enhanced during the arterial, portal, and late phase in MRI, CT, and CEUS, and signal characteristic during the liver-specific phase in MRI of the ablation zone at 1, 3, and 6 months. CONCLUSION: IRE is a feasible, safe and efficient modality in the treatment of patients with non-resectable HCC. We had no major complication, even when the ablated lesion was adjacent to major branches of the portal vein. All images techniques showed similar accuracy during the follow-up at 1, 3, and 6 months in the assessment ablated zone.

The dynamic optical breast imaging in the preoperative workflow of women with suspicious or malignant breast lesions: development of a new comprehensive score.

Purpose. To determine the diagnostic accuracy of DOBIComfortScan in patients with Breast Imaging Reporting suspect breast lesions (BI-RADS) 4-5 breast lesions. Materials and Methods. One-hundred and thirteen patients underwent DOBIComfortScan examination before surgery. Twelve parameters were taken into consideration to define DOBI findings. Results. Twenty-seven radical mastectomies, 47 quadrantectomies and 39 wide excisions, were performed. Overall, 65 invasive cancer, 9 in situ carcinoma and 39 nonmalignant lesions, were observed. Ten out of 12 considered parameters resulted significantly in association with histology at discriminant analysis. A summation score of 30.5 resulted to be the best cut off at ROC analysis, giving a sensitivity and specificity of 80% and 87%, respectively, and a positive predictive value of 92.2%. Finally the following DOBI-BI-RADS model was developed: malignant B5 ≥ 38 score); possibly malignant (B4 = 25 - 37 score); benign but the possibility of malignancy cannot be excluded (B3 = 20 - 24 score); benign (B2 < 20 score). Conclusion. definition of other parameters permits to improve the accuracy of this procedure. Further studies are warranted to define the potential role of DOBIComfortScan in breast cancer imaging.

Gallbladder metastasis: spectrum of imaging findings.

The objective of this study is to report the diagnostic features of hematogenous gallbladder metastasis using various imaging modalities. We carried out a single-center retrospective analysis of 13 patients with gallbladder metastasis. The primary malignancy was cutaneous melanoma (11 cases), hepatocellular carcinoma (1 case), and non-Hodgkin lymphoma (1 case). All patients underwent sonography (US), with color-power-Doppler assessment in 11 cases. Contrast-enhanced US (CEUS) was performed in 8 patients, MDCT in 8, and MR imaging in 1. Four subjects studied by whole-body PET. The gallbladder lesions were first detected with US in 9 cases and with MDCT in 3 cases. The remaining patient was investigated because of hepatic fluorodeoxyglucose uptake at PET; CEUS failed to detect any liver metastasis in this subject but identified a gallbladder lesion. Typical findings included multiplicity of gallbladder vegetations, broad base, limited mural thickening, presence of contrast enhancement, absence of gallstones and gallbladder bed infiltration, presence of combined lesions within other organs. Only two patients presented an isolated location in the gallbladder and were successfully treated with surgery. Gallbladder metastasis is a rare but possible occurrence. Knowledge of the typical imaging features and careful evaluation of the gallbladder may avoid an incorrect or false negative diagnosis.

FEZ1/LZTS1 protein expression in ovarian cancer.

The FEZ1/LZTS1 (FEZ1) gene maps to chromosome 8p22 and is frequently altered in human cancer. FEZ1 has been proposed as a candidate tumour suppressor gene and its loss may contribute to tumour progression. We have analysed the expression of FEZ1 protein in tissues from ovarian carcinomas in relation to clinico-pathological variables, response to chemotherapy and disease-free and overall survival. FEZ1 status was assessed by immunohistochemistry. Cytoplasmic staining for FEZ1 protein was absent or drastically reduced in 38% of tumours. FEZ1 protein expression was not related to tumour grade, histotype, disease-free survival, or overall survival. On the contrary, it was significantly correlated with age and with FIGO stage of disease. This finding indicates that FEZ1 is involved in ovarian carcinogenesis. Moreover, loss of FEZ1 protein significantly predicted a complete treatment response in patients who received taxane-based chemotherapy. In conclusion, the reduction or loss of FEZ1 protein could be an aid to the clinical management of patients affected by ovarian carcinoma.

HMGA1 protein expression in familial breast carcinoma patients.

HMGA protein overexpression is associated with a highly malignant phenotype and it is also causally related to neoplastic cell transformation. Our previous results have shown that HMGA1 was not expressed in normal breast tissue whereas HMGA1 staining was intense in 25% of hyperplastic lesions with cellular atypia and in 60% of sporadic ductal carcinomas. Moreover, HMGA1 protein levels were significantly correlated with c-Erb-B2 expression. These results suggested HMGA1 expression as a novel prognostic factor in breast ductal carcinomas. In order to investigate whether the HMGA1 detection might have a prognostic role also for inherited breast carcinomas we have analysed the expression of the HMGA1 proteins in 116 breast familial carcinomas associated with BRCA1 or BRCA2 or negative for mutations in both genes (BRCAX). HMGA1 expression was weakly positive in 23 (20%), moderately positive in 34 (29%) and strongly positive in 20 (17%) breast carcinomas, and was not detected in 39 of them (34%). Statistical analysis of the immunostaining data showed that HMGA1 was significantly overexpressed, with a more intense staining, in BRCA2 (p=0.0009) and BRCAX (p=0.0134) patients compared to BRCA1 ones. Furthermore, in BRCA2 positive patients, the expression of HMGA1 seems to correlate with a favourable prognosis with a median overall survival of 65 months and a 5-year survival rate of 80% for HMGA1-negative patients, while median overall survival in the HMGA1-positive subsets was not reached with 5-year survival rates ranging from 84% to 100% of patients (p=0.0198). Conversely, no correlation was found between HMGA1 expression and overall survival in patients carrying inherited mutations in the BRCA1 and in BRCAX patients.

Ultrasound contrast media in the study of salivary gland tumors.

BACKGROUND: The aims of the present study were: to assess standard ultrasound and color-Doppler patterns for the study and characterization of salivary gland tumors; to define the improvement in the color-Doppler ultrasound image after injection of a signal amplifier (Levovist); to compare morphological and vascular aspects of the neoplasm with data obtained during postoperative histopathological analysis. MATERIALS AND METHODS: We used color-Doppler ultrasound before and after injection of the contrast medium to study 56 patients (32 males and 24 females) between the ages of 28 and 77 years old, presenting nodular pathology of the salivary glands. Only patients with less than optimal results of the basic color-Doppler examination (grade of vascularization 0-1) were included in the study. The data were then compared with the final histological results. RESULTS: According to B-mode ultrasonography, all neoplasms were hypoechogenous; 8 showed irregular margins and, of these, 6 were carcinomas. We did not obtain significant data regarding size and echostructure. In 10 cases, we observed the presence of multiple locoregional formations in the lymph nodes. Patients were selected on the basis of unsatisfactory color-Doppler examination results; following injection of the contrast medium, we were able to visualize an increased number of vascular signals in 40 out of 56 patients, compared to the basic examination. This enabled us to better assess the vascular map of the neoplasms, as well as more easily trace the vascular blood flow and perform a better extrapolation of the quantitative and semi-quantitative data. This study demonstrated the importance of the vascular pattern, which is predictive of a malignant lesion when it is high-grade with multiple vascular poles and irregular vascular distribution. Furthermore, certain semi-quantitative parameters proved to be important, particularly the velocity of the systolic peak (SP), the cut-off of which was approximately 25 cm/s. The resistance index (RI) and pulsality index (PI) did not prove significant and showed overlapping values. CONCLUSION: We observed that the contrast medium was useful in characterizing lesions, of the salivary glands by allowing for a more precise vascular map of the lesions, as well as greater diagnostic accuracy in tracing the vascular blood flow and calculating quantitative and semiquantitative data.

Color-doppler using contrast medium in evaluating the response to neoadjuvant treatment in patients with locally advanced breast carcinoma.

BACKGROUND: The aim of our study was to assess the color-Doppler ultrasound (CDU) pattern in the analysis of neoadjuvant preoperative treatment of patients with locally advanced breast carcinoma, improvement after injection of contrast medium (Levovist) and possible correlations between morphological and vascular aspects of the neoplasm and postoperative histopathological findings. MATERIALS AND METHODS: We studied 50 patients affected by locally advanced breast carcinoma (T3a e b-T4), using CDU before and after injection of Levovist, prior to and after neoadjuvant chemotherapeutic treatment. RESULTS: The use of Levovist for ultrasound examinations prior to treatment revealed a higher number of vascular signals in 94% of the lesions compared to the basic color-Doppler examination; in only 3 cases (6%) were no modifications observed after injection of the contrast medium. This finding was also evident after neoadjuvant treatment, as a greater number of vessels in 28 lesions were observed, in addition to residual vascularization in 9 patients in whom the basic color-Doppler examination demonstrated substantial avascularity. Histopathology revealed that this method was more sensitive in disclosing the presence of active neoplastic tissue. CONCLUSION: Color-Doppler ultrasound is the first step in assessing the efficacy of neochemotherapeutic treatment in patients affected by locally advanced breast carcinoma. Levovist increases sensitivity and improves the diagnostic precision, thus allowing for a better image of the vessels, which is an important index of the biological activity of the neoplasm, compared to the basic color-Doppler examination.

Local ablation procedures in primary liver tumors: Levovist US versus spiral CTto evaluate therapeutic results.

BACKGROUND: The objective of this study was to compare Levovist power Doppler ultrasound (Levovist US) with contrast-enhanced spiral computed tomography (spiral CT), in the evaluation of the efficacy of percutaneous local ablation procedures, in patients with hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Forty-six patients with 62 HCC were studied using Levovist US and triphasic spiral CT, after treatment by radiofrequency ablation (RFA) (32), percutaneous ethanol injection (PEI) (24), transarterial chemoembolization (TACE) (4), laser-therapy (LT) (1) and RFA plus TACE (1). RESULTS: Spiral CT scan showed contrast enhancement in 47% of the cases; at basal power Doppler ultrasound only 10% of the nodules showed to be vascular but, after Levovist infusion, 72.5% showed intralesional vascular spots. CONCLUSION: We detected that residual tumor vascularity in HCC, after treatment using percutaneous local ablation procedures, was significantly increased by Levovist. Levovist US could be proposed as a good alternative in patients unfit for CT scanning due to allergies to iodate contrast media, renal failure or cardiovascular disease and, moreover, could help to select those patients requiring a new treatment, without performing spiral CT, thereby reducing the cost of treatment and improving patient tolerance.