Extensor carpi ulnaris tendon pathology and ulnar styloid bone marrow edema as diagnostic markers of peripheral triangular fibrocartilage complex tears on wrist MRI: a case-control study.

OBJECTIVES: To evaluate extensor carpi ulnaris (ECU) tendon pathology and ulnar styloid process bone marrow edema (BME) as diagnostic MRI markers for peripheral triangular fibrocartilage complex (TFCC) tears. METHODS: One hundred thirty-three patients (age range 21-75, 68 females) with wrist 1.5-T MRI and arthroscopy were included in this retrospective case-control study. The presence of TFCC tears (no tear, central perforation, or peripheral tear), ECU pathology (tenosynovitis, tendinosis, tear or subluxation), and BME at the ulnar styloid process were determined on MRI and correlated with arthroscopy. Cross-tabulation with chi-square tests, binary logistic regression with odds ratios (OR), and sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were used to describe diagnostic efficacy. RESULTS: On arthroscopy, 46 cases with no TFCC tear, 34 cases with central perforations, and 53 cases with peripheral TFCC tears were identified. ECU pathology was seen in 19.6% (9/46) of patients with no TFCC tears, in 11.8% (4/34) with central perforations and in 84.9% (45/53) with peripheral TFCC tears (p < 0.001); the respective numbers for BME were 21.7% (10/46), 23.5% (8/34), and 88.7% (47/53) (p < 0.001). Binary regression analysis showed additional value from ECU pathology and BME in predicting peripheral TFCC tears. The combined approach with direct MRI evaluation and both ECU pathology and BME yielded a 100% positive predictive value for peripheral TFCC tear as compared to 89% with direct evaluation alone. CONCLUSIONS: ECU pathology and ulnar styloid BME are highly associated with peripheral TFCC tears and can be used as secondary signs to diagnose tears. KEY POINTS: • ECU pathology and ulnar styloid BME are highly associated with peripheral TFCC tears and can be used as secondary signs to confirm the presence of TFCC tears. • If there is a peripheral TFCC tear on direct MRI evaluation and in addition both ECU pathology and BME on MRI, the positive predictive value is 100% that there will be a tear on arthroscopy compared to 89% with direct evaluation alone. • If there is no peripheral TFCC tear on direct evaluation and neither ECU pathology nor BME on MRI, the negative predictive value is 98% that there will be no tear on arthroscopy compared to 94% with direct evaluation alone.

Postoperative MR Imaging of the Pubic Symphysis and Athletic Pubalgia.

MR imaging evaluation can be valuable in patients with prior surgery for athletic pubalgia presenting with new, recurrent, or persistent groin pain. The clinical and interventional history as well as comparison with preoperative imaging is essential for imaging interpretation. Imagers should be aware of expected and unexpected postoperative findings. MR imaging findings concerning for infection, new injury, contralateral injury, or concomitant sources of symptoms (such as hip pathology) should be reported when present.

Spotty Bone Marrow: A Frequent MRI Finding in the Feet of Ballet Dancers.

INTRODUCTION: Bone marrow signal abnormalities on magnetic resonance imaging (MRI) are common in athletes. However, few studies evaluate the MRI appearance of bone marrow in the feet of ballet dancers. Our study aims to describe the "spotty bone marrow" (SBM) pattern in the tarsal bones of a cohort of ballet dancers, establishing its prevalence, distribution, potential associations, and evolution.
Methods: Eighty-six MRIs of 68 ankles in 56 ballet dancers were retrospectively reviewed for mar- row signal alterations, which were classified as focal or SBM (defined as patchy fluid-sensitive signal hyperintensity spanning more than one location or tarsal bone). When SBM involved the talus, its anatomic distribution in the bone and morphologic pattern were recorded. Additional osseous and soft tissue findings were documented. For subjects with more than one MRI of the same ankle, the SBM's evolution was monitored.
Results: Spotty bone marrow was identified in 44 ankles (65%). Spotty bone marrow was isolated to the talus (44%), present in all tarsal bones (25%), or distributed between the talus and one to three other tarsal bones (31%). In the talus, The SBM involved the entire bone (65%), the neck and body (31%), or the head and neck (4%). The SBM most commonly showed a random morphologic pattern (87%) but occasionally showed a peripheral predominance (13%). There was no statistically significant difference in the prevalence of other pathologies in ankles with and without SBM. In eight ankles with a follow-up MRI, the SBM worsened in one, remained stable in two, and improved in five ankles. None progressed to a stress fracture.
Conclusion: Spotty bone marrow is an MRI finding frequently encountered in ballet dancers. It is usually self-limiting and should not be misinterpreted as a more aggressive pathology.

Ultrasound-guided Procedures Allow Delay of Definitive Treatment for Core Muscle Injuries.

INTRODUCTION: Core muscle injuries (CMI) are common in every sport. To minimize lost playing time, providers apply various nonsurgical treatments, including platelet-rich plasma, corticosteroids, ultrasound (US)-guided percutaneous tenotomy, and prolotherapy. Limited data exist with regard to their effectiveness. We chose to review a cohort of consecutive professional and collegiate athletes who sustained CMI at various points within their seasons and underwent a combination of US-guided percutaneous needle "tenotomy" and corticosteroid injections to complete the remainder of their seasons. METHODS: Twenty-five consecutive collegiate or professional athletes with CMI involving the rectus abdominis-adductor aponeurotic plate were included in this retrospective study. Athletes with concomitant symptomatic hip femoroacetabular impingement were included in the study. The primary outcome measure was whether athletes completed their seasons. Secondary measures were weeks played after the procedures (delay until surgery), need for repeat procedures, and outcomes after eventual surgery. Postoperative performance was assessed via interviews at 6 wk and 6 months postoperatively. RESULTS: Twenty-one of 25 (84%) athletes completed their seasons. On average, athletes returned to play 3 d (range, 1-9 d) after the procedures. Surgical repair was delayed a mean of 18 wk (range, 2-44 wk). Seven athletes had concomitant symptomatic femoroacetabular impingement and six underwent combined hip arthroscopy and core muscle repairs. Among 17 patients who eventually had core muscle surgery alone (no hip surgery), 82% (14 of 17) reported performing at their preinjury level at 6 wk. At 6 months, 96% of postop athletes (22 of 23) reported performing at their preinjury level. CONCLUSIONS: Temporizing CMI with US-guided percutaneous tenotomy and corticosteroid injections is effective in allowing continued sport participation among high-level athletes and does not negatively affect postoperative outcomes.

Predicting osteomyelitis in patients whose initial MRI demonstrated bone marrow edema without corresponding T1 signal marrow replacement.

PURPOSE: We endeavored to determine which characteristics of diabetic ulcers portend the strongest risk for osteomyelitis in patients whose initial T1-weighted imaging was normal. By determining which features have a greater risk for osteomyelitis, clinicians can treat patients more aggressively to reduce the sequela of inadequately treated osteomyelitis. MATERIALS AND METHODS: We performed a retrospective analysis of MR imaging from 60 pedal ulcers with suspected osteomyelitis. Ulcer dimensions and depth were measured. Ratios of marrow ROI/joint fluid ROI on T2/STIR sequences were obtained. Progression to osteomyelitis on subsequent MRI was characterized by loss of normal marrow signal on T1-weighted images. Statistical analysis was performed with a two-sample t test and Cox proportional hazard model. A p value < 0.05 was used as the threshold for statistical significance. RESULTS: Sixty MR exams were identified. Thirty-four progressed to osteomyelitis. Marrow ROI/joint fluid ratios averaged 65% in the osteomyelitis group, and 45% in the non-osteomyelitis group, p < 0.001. ROI ratios > 53% had a 6.5-fold increased risk of osteomyelitis, p < 0.001. Proximity to bone averaged 6 mm in the osteomyelitis group and 9 mm in the non-osteomyelitis group, p = 0.02. Ulcer size averaged 4 cm2 in the osteomyelitis group versus 2.4 cm2 in the non-osteomyelitis group, p = 0.07. Ulcers greater than 3 cm2 has a 2-fold increase in the risk of osteomyelitis, p = 0.04. CONCLUSION: Increasing bone marrow ROI signal/joint fluid ratios on T2/STIR images were the strongest risk factors for developing osteomyelitis, while ulcer size and depth are weaker predictors.

Second opinions in orthopedic oncology imaging: can fellowship training reduce clinically significant discrepancies?

OBJECTIVE: To determine factors that lead to significant discrepancies in second-opinion consultation of orthopedic oncology patients, and particularly if musculoskeletal fellowship training can decrease clinically significant discrepancies. METHODS: A PACS database was queried for secondary reads on outside cross-sectional imaging studies, as requested by orthopedic oncology from 2014 to 2017. Comparison of original and secondary reports was performed using a published seven-point scale that defines clinically significant discrepancies. An online search was performed for each original radiologist to record if a fellowship in musculoskeletal imaging was completed. Additionally, years of post-residency experience, number of Medicare part B patients billed per year (marker of practice volume), and average hierarchical condition category for each radiologist (marker of practice complexity) was recorded. RESULTS: A total of 571 patients met the inclusion criteria, with 184 cases initially interpreted by an outside fellowship trained musculoskeletal (MSK) radiologist and 387 cases initially interpreted by a non-MSK trained radiologist. The rate of clinically significant discrepancy was 9.2% when initially interpreted by MSK radiologists compared with 27.9% when initially performed by non-MSK radiologists (p < 0.05). After adjustment by both patient characteristics and radiologist characteristics, the likelihood of clinically significant discrepancies was greater for initial interpretations by non-MSK radiologists compared with MSK radiologists (OR = 1.36; 95% CI = 1.23-2.49). CONCLUSION: In orthopedic oncology patients, the rate of clinically significant discrepancies was significantly higher when initially interpreted by non-MSK radiologists compared with MSK radiologists. The lower rate of clinically significant discrepancies demonstrates that subspecialty training may direct more appropriate diagnosis and treatment.

Lumbosacral transitional vertebrae: significance of local bone marrow edema at the transverse processes.

OBJECTIVE: To evaluate the association between low back pain and bone marrow edema in lumbosacral transitional vertebra (LSTV) transverse processes, and to assess the prevalence of LSTV in a physically active population. MATERIALS AND METHODS: Individuals with LSTV on coronal MRI studies were identified in a retrospective review by keyword search from PACS. In total, 140 cases were reviewed by two fellowship-trained musculoskeletal radiologists. Data on associated low back pain were collected from patient records at the time of the imaging. RESULTS: Bone marrow edema was observed in 44% of the cases, but no correlation with low back pain was found. On coronal MRI, the prevalence of LSTV was 2.6%, with type II LSTV being the most common subtype. CONCLUSIONS: No correlation with bone marrow edema at the transverse processes of the LSTV and low back pain was observed. In our selected study population, the prevalence of LSTV was low.

Analysis of a Steerable Needle for Fine Needle Aspiration and Biopsy: Efficiency and Radiation Dose Compared With a Conventional Straight Needle.

PURPOSE: Percutaneous computed tomography (CT)-guided needle biopsy has proven to be an efficacious method for sampling of many soft tissue lesions, especially deep-seated masses in the abdomen and pelvis. This study sought to test the potential for a novel steerable needle to improve localization and to reduce procedure duration and radiation dose compared with a conventional straight needle. MATERIAL AND METHODS: A fresh, raw meat sample (lean bovine flank) was imbedded with cylindrical radiopaque and radiolucent obstacles designed to simulate vessels (radiolucent objects) and bones (radiopaque objects) on CT. A pit-containing olive (partially radiopaque) was imbedded beyond the obstacles to represent the target. Two sites on the surface of the meat were selected and marked to determine initial needle placement. Two radiologists with different levels of experience proceeded to position a straight needle and the steerable needle from each skin site to the target using CT guidance as efficiently as possible, avoiding the obstacles. The total positioning time, the number of CT scans required for positioning, and the number of repositioning events (partial withdrawal followed by advancement) were tracked for the straight and steerable needles. RESULTS: For the straight needle, total time to reach the target was 499 to 667 seconds (mean, 592 seconds); for the steerable needle, total time to reach the target was 281 to 343 seconds (mean, 309 seconds), on average, 48% lower. The number of CT scans needed for needle positioning averaged 6.25 for the straight needle and 3.5 for the steerable needle, which is 44% lower. Repositioning events (withdrawing and readvancing the needle) ranged from 3 to 10 for the straight needle (mean, 6.5) and 0 for the steerable needle. CONCLUSIONS: Using an in vitro model embedded with obstacles, the steerable needle performed better than a straight needle with regard to procedure time, needle repositioning events, and CT scans required for placement.

Clinical Impact of Second-Opinion Musculoskeletal Subspecialty Interpretations During a Multidisciplinary Orthopedic Oncology Conference.

PURPOSE: To analyze the impact on clinical management when musculoskeletal radiologists render second-opinion consultations during multidisciplinary orthopedic oncology conference. METHODS: A PACS database was searched for secondary interpretations on outside MRI studies reviewed during a multidisciplinary orthopedic oncology conference from January 2014 to December 2016. Reports were compared with the original interpretations, when available. Reports were categorized using a 7-point scale: I (no discrepancy), II (undetected clinically insignificant abnormality), III (clinically insignificant difference in interpretation), IV (difference in imaging follow-up recommendation), V (equivocal initial interpretation with subsequent definitive subspecialty interpretation), VI (clinically significant difference in interpretation), VII (failure to detect a clinically significant abnormality). RESULTS: A total of 409 patients met inclusion criteria, with an average age of 47.9 ± 19.2. There were 91 (22.2%) instances of discrepant interpretations resulting in clinically significant differences in management; 67 (16.4%) were category VI and 24 (5.9%) were category VII. An additional 72 subjects (17.6%) were identified as category IV and 28 (6.8%) as category V, yielding at total of 191 (46.7%) clinically relevant discrepancies. When pathology was available, the secondary consultations were concordant in 57 of 61 cases (93.4%) and the outside interpretations were concordant in 39 of 61 cases (63.9%, P < .05). CONCLUSION: A 22.2% rate of clinically significant difference was observed between primary and secondary interpretations. The substantial rate of clinically relevant discrepancies demonstrates that subspecialty expertise often changed the primary diagnosis. Thus, by participating in a multidisciplinary team, subspecialty radiologists have a unique opportunity to help direct appropriate treatment plans.

Algorithm for Imaging the Hip in Adolescents and Young Adults.

The imager's role in diagnosing prearthritic hip syndromes has increased significantly in the past 10 years. As surgical and nonsurgical treatment algorithms for mechanical syndromes including femoroacetabular impingement and acetabular dysplasia have evolved, clinicians have grown increasingly dependent on radiography, MR imaging, MR arthrography, and even computed tomography to confirm diagnoses and support the need for potential intervention. Musculoskeletal radiologists should help referrers navigate available imaging options and protocols, while using both clinical information and imaging findings to arrive at a diagnosis that adds value to the treatment plan.

Potential Utility of a Combined Approach with US and MR Arthrography to Image Medial Elbow Pain in Baseball Players.

Purpose To evaluate a combined imaging approach with both ultrasonography (US; conventional US and valgus stress US) and magnetic resonance (MR) arthrography in baseball players with medial elbow pain. Materials and Methods Institutional review board approval was obtained and the requirement for informed consent was waived. The study is compliant with HIPAA. Baseball players with medial elbow pain underwent US in addition to MR arthrography. Findings were assessed with each modality alone and both combined in this retrospective investigation. For the evaluation of ulnar collateral ligament (UCL) tears with stress US, the interval gapping of the medial elbow joint was measured between rest and valgus stress both at the injured and at the uninjured (contralateral) elbow. Surgical or arthroscopic correlation was available as the so-called gold standard. McNemar tests compared the accuracies of the imaging modalities. Results In this study, 144 baseball players had 191 findings of medial elbow pain, including 53 UCL tears. With stress US, joint gapping at the injured elbow greater than 1.0 mm compared with the contralateral elbow yielded a sensitivity, specificity, and accuracy of 96%, 81%, and 87%, respectively, for diagnosing UCL tears. With MR arthrography, the sensitivity, specificity, and accuracy for UCL tears were 81%, 91%, and 88%, respectively, and increased to 96% (P = .013, McNemar test), 99% (P = .023), and 98% (P < .001), respectively, when combined with US to a dual modality MR and US approach. For 31 patients with ulnar neuritis, the sensitivity, specificity, and accuracy increased from 74%, 92%, and 88%, respectively, with MR arthrography alone to 90% (P = .07, McNemar test), 100% (P < .001), and 98% (P < .001) combined with US. For the 59 myotendinous and the 48 osteochondral diagnoses, the sensitivity, specificity, and accuracy with MR arthrography alone were 93%, 93%, and 93%, and 94%, 98%, and 97%, respectively, with no additional diagnostic value from US. Conclusion The combined approach with both MR arthrography and US shows higher accuracy than each modality alone for the assessment of medial elbow pain. (©) RSNA, 2016.

MRI findings of subchondroplasty of the knee: a two-case report.

Bone marrow lesions observed in magnetic resonance imaging (MRI) have been recognized as a source of knee pain. Subchondroplasty was developed to treat these lesions with a percutaneous injection of calcium phosphate bone substitute into the bone. As subchondroplasty may potentially become a more common procedure in the treatment of knee osteoarthritis, it is important for radiologists to recognize the typical MRI findings and not to confuse them with other pathology. Here we report the MRI findings for two patients following subchondroplasty.

Acromial apophysiolysis: superior shoulder pain and acromial nonfusion in the young throwing athlete.

PURPOSE: To describe the frequency of acromial apophysiolysis and its association with incomplete fusion and superior shoulder pain, to determine risk factors of acromial apophysiolysis, and to assess whether acromial apophysiolysis is associated with the development of an os acromiale and rotator cuff tears. MATERIALS AND METHODS: Institutional review board approval was obtained for this HIPAA-compliant study; requirement for informed consent was waived. A retrospective report review of 2372 consecutive patients between 15 and 25 years of age who underwent shoulder magnetic resonance (MR) imaging for shoulder pain was performed. Individuals with edema at the acromial apophyses and no other abnormalities on MR images were included in the study group. Association of acromial edema with incomplete fusion, pitching, and clinical findings was determined in the study group and in an age- and sex-matched control group, with both univariate and multivariate binary logistic regression analyses. Association with the development of an os acromiale and rotator cuff tears later in life was assessed with follow-up imaging after age 25 years. RESULTS: Edema at the acromial apophyses was found in 2.6% (61 of 2372) of patients and was associated with incomplete fusion of the acromial apophyses (χ(2), P < .001) and superior shoulder tenderness (P < .001). The entity was named acromial apophysiolysis. A pitch count of more than 100 pitches per week was shown to be a risk factor for acromial apophysiolysis (odds ratio [ OR odds ratio ] = 6.5, P = .017). Follow-up imaging showed that acromial apophysiolysis was significantly associated with the development of an os acromiale ( OR odds ratio = 138, P < .001) and rotator cuff tears ( OR odds ratio = 5.4, P = .015) after age 25 years. CONCLUSION: Acromial apophysiolysis is characterized by incomplete fusion and edema at the acromial apophyses. It is associated with superior shoulder pain in young patients (< 25 years old), and pitching is a risk factor. It predisposes the patient to the development of an os acromiale and rotator cuff tears after age 25 years.

Prediction of metastatic disease and survival in patients with gastric and gastroesophageal junction tumors: the incremental value of PET-CT over PET and the clinical role of primary tumor volume measurements.

RATIONALE AND OBJECTIVES: To investigate the accuracy of M staging (staging of metastatic disease) in esophageal carcinoma based on a visual interpretation and based on tumor volume measurements on positron emission tomography (PET) computed tomography (CT). MATERIALS AND METHODS: Fifty-nine untreated patients with gastroesophageal junction tumors were enrolled, including 36 subcardial gastric tumors (type III according to Siewert classification) and 23 adenocarcinomas of the cardia (AEG, type II Siewert). Patients were grouped in metastasis free (M0 stage, n = 34) and metastatic stages (M1 stage, n = 25). Tumor volume and mean and maximum standardized uptake value were measured on PET-CT. The accuracy of these quantitative tumor volume parameters in distinguishing metastasis-free tumors (M0 stage) from metastatic stages (M1 stage) was compared to the accuracy of a visual analysis with fused PET-CT. Furthermore, accuracy of PET-CT was compared to PET reviewed side by side with CT in a lesion-based analysis of 84 distant metastatic sites. RESULTS: In the visual interpretation, PET-CT (accuracy 88%, 74/84) was more accurate than PET (accuracy 78%, 66/84; P = .008) in characterizing the 84 potential metastatic sites in the 59 patients. Among the tumor parameters, the PET-CT tumor volume was the most accurate predictor of M1 stage and overall survival. With a threshold of 39 mL, PET-CT volume was able to predict M1 stage disease with a sensitivity of 96% and a specificity of 85%. The accuracy of M-staging was increased further when combining tumor volume measurements with the results from the visual analysis (combined results: sensitivity 96%, specificity 94%). CONCLUSIONS: PET-CT was more accurate than PET (reviewed side by side with CT) in characterizing distant metastatic sites of gastroesophageal junction carcinomas. The highest accuracy for M-staging was obtained when combining the results of the visual analysis with the results from primary tumor volume measurements. Primary tumor volume was shown to be an independent prognostic factor.

Lymph node staging in esophageal adenocarcinoma with PET-CT based on a visual analysis and based on metabolic parameters.

BACKGROUND: In order to investigate the value of FDG positron emission tomography-computed tomography (PET-CT), FDG PET (reviewed side-by-side with CT), and metabolic parameters in the assessment of lymph node status and prognosis. METHODS: Fifty-five subjects with lymph node positive (N1) and 26 subjects with lymph node negative (N0) disease were included. In the slice with the maximum FDG uptake of the tumor, the axial area of the primary tumor, the maximum diameter of the tumor, and the mean and maximum standardized uptake values were measured. RESULTS: Fused PET-CT correctly characterized 289 of 325 lymph node groups (accuracy 89%) compared to 273 of 325 with PET (accuracy 84%). In lymph node staging (N0 vs. N1), PET-CT (accuracy 83%) was more accurate than PET (accuracy 78%). Among the metabolic parameters, the tumor diameter measured on PET-CT was the best predictor of lymph node stage (N0 vs. N1: accuracy 86%; threshold 25.5 mm) and overall survival. However, the highest accuracy of lymph node staging (N0 vs. N1) was achieved with the synergistic combination of visual analysis and primary tumor diameter measurements (accuracy 95%). CONCLUSIONS: PET-CT increases accuracy of lymph node staging in esophageal adenocarcinoma compared to PET. The primary tumor diameter further improves accuracy in lymph node staging and was shown to be an independent predictor of overall survival.

Metabolic tumor width parameters as determined on PET/CT predict disease-free survival and treatment response in squamous cell carcinoma of the esophagus.

MATERIALS AND METHODS: We investigated the utility of metabolic tumor width parameters in predicting response to chemoradiotherapy and in predicting disease-free survival in patients with esophageal cancer. Furthermore, we evaluated the possible confounding effect of therapy-induced esophagitis on the evaluation of treatment response. Forty-nine patients with squamous cell carcinoma, who had undergone positron emission tomography/computed tomography (PET/CT) exams before and after neoadjuvant chemoradiotherapy, were included in the study. In the slice with the maximum 2-deoxy-2-[F-18]fluoro-D: -glucose (FDG) uptake of the tumor, the following metabolic tumor width parameters were measured: Area of the tumor, maximum diameter of the tumor, maximum and mean standardized uptake value (SUV). Furthermore, the "diameter-SUV index" was calculated by multiplying the tumor diameter by the mean SUV. RESULTS: The decrease of the metabolic tumor diameter between pre- and post-treatment PET/CT scans was the single best predictor of treatment response and tumor-free survival. However, the accuracy of predicting response and survival was even higher when using the decrease of the "diameter-SUV index" as the metabolic criterion for treatment response. A decrease by more than 55% of the diameter-SUV index identified pathologic responders (n = 22) with a sensitivity of 91% and a specificity of 93%. Radiation esophagitis was found to have a significant impact on the assessment of treatment response when evaluating therapy response based on the maximum SUV, whereas no confounding effect of radiation esophagitis was seen when evaluating therapy response based on the tumor diameter or the diameter-SUV index. CONCLUSION: The present study shows that tumor width parameters, especially the tumor diameter or the combination of diameter and SUV in the "diameter-SUV index", are valuable for predicting tumor-free survival and treatment response independent from the presence of radiation esophagitis.

Assessment of treatment response and recurrence in esophageal carcinoma based on tumor length and standardized uptake value on positron emission tomography-computed tomography.

BACKGROUND: Previous studies demonstrated that a decrease of the standardized uptake value between pretreatment and posttreatment positron emission tomography (PET) scans can predict histopathologic treatment response in patients with esophageal cancer. METHODS: Forty-seven patients who underwent PET-computed tomography (CT) scans before (scan 1) and after (scan 2) neoadjuvant chemoradiotherapy and during the follow-up period after surgery (scan 3) were included in this study. It was evaluated whether decrease of metabolic tumor length between scan 1 and scan 2 can predict histopathologic response to treatment. Moreover, the value of PET-CT was compared with PET in the assessment of tumor recurrence based on a visual analysis of scan 3. Reference standards for treatment response and recurrence were histopathology results. RESULTS: The reduction of tumor length between before and after chemoradiotherapy scans (between scan 1 and scan 2) was a better predictor of histopathologic response and of time to recurrence than the decrease in standardized uptake value. The most accurate differentiation was achieved when using a cut-off value of 33% reduction of the initial tumor length. Using this threshold to define metabolic response, the sensitivity was 91% (19 of 21) and the specificity was 92% (24 of 26) for predicting histopathologic treatment response. Based on a visual analysis, PET-CT was more accurate than PET in the differentiation of tumor recurrence from posttreatment tissue changes. Integrated PET-CT achieved a sensitivity of 91% (48 of 53) and a specificity of 81% (30 of 37) in identifying sites of tumor recurrence, compared with 83% (44 of 53) and 65% (24 of 37) with PET. CONCLUSIONS: Decrease of tumor length was shown to be a better predictor of treatment response and disease-free survival than decrease of standardized uptake value. Furthermore, PET-CT is more accurate in the evaluation of recurrence than PET.

Adenocarcinomas of the esophagus: response to chemoradiotherapy is associated with decrease of metabolic tumor volume as measured on PET-CT. Comparison to histopathologic and clinical response evaluation.

PURPOSE: We determined whether evaluation of treatment response is feasible by measuring metabolic tumor volume parameters on 18F-FDG (Fluorodeoxyglucose) PET-CT (Positron emission tomography-Computed tomography). We compared the response evaluation based on metabolic tumor volume parameters to a histopathologic and clinical response evaluation (clinical response criteria: RECIST criteria=Response evaluation criteria in solid tumors, and WHO criteria=World health organization). PATIENTS AND METHODS: A total of 51 study subjects with adenocarcinomas (Type I due to Siewert classification) of the esophagus underwent PET-CT scans before and after neoadjuvant chemoradiotherapy. Tumor volume, maximum and mean standardized uptake values (SUV) were assessed before and after chemoradiotherapy. Furthermore, the total lesion glycolysis (TLG) was calculated by multiplying the tumor volume by the mean SUV of the volume. Clinical response evaluation was performed with endoscopic ultrasound and CT using RECIST and WHO criteria. The reference standard for treatment response was the postsurgical histopathology. RESULTS: The decrease of tumor volume between the pre- and post-treatment PET-CT scans was a better predictor of histopathologic response and survival than the decrease of the SUV and of the clinical response evaluation based on RECIST and WHO criteria. The highest accuracy, however, was achieved when using the TLG for the identification of treatment responders. A decrease of the TLG by > 78% between pre- and post-therapy scans predicted histopathologic response with a sensitivity and specificity of 91% and 93%, respectively. CONCLUSIONS: Tumor volume and TLG can be used to assess treatment response and survival in patients with esophageal adenocarcinoma.

Tumour length measured on PET-CT predicts the most appropriate stage-dependent therapeutic approach in oesophageal cancer.

To compare the accuracy of determining the most appropriate treatment approach based on a visual analysis on combined PET-CT, based on a visual analysis on PET (reviewed side-by-side with CT) and based on tumour length measurements (on PET and PET-CT). Tumour length, SUV, and the length-SUV index (length x SUV) were assessed (on PET and PET-CT) in benign oesophageal lesions (reflux oesophagitis; n = 29), in potentially curable stages of oesophageal cancer (Tis; T1-T3NxM0; curable group; n = 52), and in stages of oesophageal cancer best treated with palliative therapy (T4NxMx; TxNxM1; palliative group; n = 30). All lesions were histopathologically proven. Based on a visual analysis, PET-CT (sensitivity: 77%;specificity: 96%) was more accurate than PET (sensitivity: 67%; specificity: 89%) in assessing the appropriate treatment (curative vs. palliative). The length-SUV index was the most accurate quantitative parameter to distinguish palliative from curable stages (sensitivity: 93%; specificity: 90%) and to predict survival. The highest overall accuracy was reached when combining the results of the quantitative (length-SUV index) analysis with those of the qualitative (visual) analysis (sensitivity: 93%; specificity: 96%). Moreover, neither tumour length nor SUV can be used to distinguish reflux oesophagitis from early malignant lesions (T1 stage). Tumour length measured with PET-CT or PET is associated with stage and overall survival of oesophageal cancer and helps to guide the appropriate treatment approach.