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PURPOSE: Survival in stage I seminoma is almost 100%. Computed tomography (CT) surveillance is an international standard of care, avoiding adjuvant therapy. In this young population, minimizing irradiation is vital. The Trial of Imaging and Surveillance in Seminoma Testis (TRISST) assessed whether magnetic resonance images (MRIs) or a reduced scan schedule could be used without an unacceptable increase in advanced relapses. METHODS: A phase III, noninferiority, factorial trial. Eligible participants had undergone orchiectomy for stage I seminoma with no adjuvant therapy planned. Random assignment was to seven CTs (6, 12, 18, 24, 36, 48, and 60 months); seven MRIs (same schedule); three CTs (6, 18, and 36 months); or three MRIs. The primary outcome was 6-year incidence of Royal Marsden Hospital stage ≥ IIC relapse (> 5 cm), aiming to exclude increases ≥ 5.7% (from 5.7% to 11.4%) with MRI (v CT) or three scans (v 7); target N = 660, all contributing to both comparisons. Secondary outcomes include relapse ≥ 3 cm, disease-free survival, and overall survival. Intention-to-treat and per-protocol analyses were performed. RESULTS: Six hundred sixty-nine patients enrolled (35 UK centers, 2008-2014); mean tumor size was 2.9 cm, and 358 (54%) were low risk (< 4 cm, no rete testis invasion). With a median follow-up of 72 months, 82 (12%) relapsed. Stage ≥ IIC relapse was rare (10 events). Although statistically noninferior, more events occurred with three scans (nine, 2.8%) versus seven scans (one, 0.3%): 2.5% absolute increase, 90% CI (1.0 to 4.1). Only 4/9 could have potentially been detected earlier with seven scans. Noninferiority of MRI versus CT was also shown; fewer events occurred with MRI (two [0.6%] v eight [2.6%]), 1.9% decrease (-3.5 to -0.3). Per-protocol analyses confirmed noninferiority. Five-year survival was 99%, with no tumor-related deaths. CONCLUSION: Surveillance is a safe management approach-advanced relapse is rare, salvage treatment successful, and outcomes excellent, regardless of imaging frequency or modality. MRI can be recommended to reduce irradiation; and no adverse impact on long-term outcomes was seen with a reduced schedule.
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Seminoma , Neoplasias Testiculares , Quimioterapia Adjuvante , Seguimentos , Humanos , Masculino , Recidiva Local de Neoplasia/tratamento farmacológico , Estadiamento de Neoplasias , Orquiectomia , Seminoma/tratamento farmacológico , Seminoma/terapia , Neoplasias Testiculares/diagnóstico por imagem , Neoplasias Testiculares/cirurgiaRESUMO
This article reviews the role of imaging in malignant neoplasms of the uterine corpus. Endometrial cancer is the most common uterine malignancy, and diagnosis is made by histology. Staging of these tumors remain surgical-pathologic on the 2009 International Federation of Gynecology and Obstetrics staging system. However, imaging is important in treatment planning, with magnetic resonance imaging providing the best staging for the primary tumor; more advanced disease may be evaluated with computed tomography or positron emission tomography-computed tomography. Uterine sarcomas are uncommon and heterogeneous group of malignancies. International Federation of Gynecology and Obstetrics have introduced a new staging system for uterine sarcoma that is also surgical-pathologic. Imaging is used in evaluating these tumors and in defining the extent of disease. Other malignant tumors involving the uterus and discussed here include lymphoma and metastases.
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Linfoma/diagnóstico , Imageamento por Ressonância Magnética/métodos , Tomografia por Emissão de Pósitrons/métodos , Sarcoma/diagnóstico , Tomografia Computadorizada por Raios X/métodos , Neoplasias Uterinas/diagnóstico , Neoplasias do Endométrio/diagnóstico , Feminino , Humanos , Histerossalpingografia/métodos , Estadiamento de Neoplasias , Neoplasias Uterinas/patologia , Neoplasias Uterinas/secundário , Útero/diagnóstico por imagem , Útero/patologiaRESUMO
Dissemination of tumor to lymph nodes is one of the principal routes of metastatic disease. The presence or absence of nodal disease is an important prognostic factor in gynecologic malignancies; thus, nodal staging is an integral part of the pretreatment assessment. It is vital that pretreatment nodal staging be accurate and reliable. Current imaging techniques such as computed tomography and magnetic resonance (MR) imaging have limitations because they rely almost exclusively on size criteria. MR lymphography uses a lymph node-specific contrast agent (ferumoxtran-10) composed of ultrasmall superparamagnetic iron oxide particles. The contrast agent is taken up by macrophages within benign lymph nodes and allows differentiation from malignant nodes on the basis of alterations in signal intensity. This technique has been shown to increase the sensitivity and specificity of detection of lymph node metastases independent of nodal size. However, as with any technique, there are pitfalls that the radiologist must be aware of to avoid interpretative errors.
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Dextranos , Erros de Diagnóstico/prevenção & controle , Óxido Ferroso-Férrico , Neoplasias dos Genitais Femininos/diagnóstico , Aumento da Imagem/métodos , Linfonodos/patologia , Imageamento por Ressonância Magnética/métodos , Meios de Contraste , Feminino , Humanos , Metástase Linfática , Nanopartículas de MagnetitaRESUMO
PURPOSE: Lymph node metastases affect management and prognosis of patients with gynecologic malignancies. Preoperative nodal assessment with computed tomography or magnetic resonance imaging (MRI) is inaccurate. A new lymph node-specific contrast agent, ferumoxtran-10, composed of ultrasmall particles of iron oxide (USPIO), may enhance the detection of lymph node metastases independent of node size. Our aim was to compare the diagnostic performance of MRI with USPIO against standard size criteria. METHODS: Forty-four patients with endometrial (n = 15) or cervical (n = 29) cancer were included. MRI was performed before and after administration of USPIO. Two independent observers viewed the MR images before lymph node sampling. Lymph node metastases were predicted using size criteria and USPIO criteria. Lymph node sampling was performed in all patients. RESULTS: Lymph node sampling provided 768 pelvic or para-aortic nodes for pathology, of which 335 were correlated on MRI; 17 malignant nodes were found in 11 of 44 patients (25%). On a node-by-node basis, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) by size criteria were 29%*, 99%, 56%, and 96%, and by USPIO criteria (reader 1/reader 2) were 93%/82%* (*P = .008/.004), 97%/97%, 61%/59%, and 100%/99%, respectively (where [*] indicates the statistical difference of P = x/x between the two results marked by the asterisk). On a patient-by-patient basis, sensitivity, specificity, PPV, and NPV by size criteria were 27%*, 94%, 60%, and 79%, and by USPIO criteria (reader 1/reader 2) were 100%/91%* (*P = .031/.06), 94%/87%, 82%/71%, and 100%/96%, respectively. The kappa statistic was 0.93. CONCLUSION: Lymph node characterization with USPIO increases the sensitivity of MRI in the prediction of lymph node metastases, with no loss of specificity. This may greatly improve preoperative treatment planning.
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Neoplasias do Endométrio/patologia , Metástase Linfática/patologia , Imageamento por Ressonância Magnética/métodos , Nanoestruturas , Neoplasias do Colo do Útero/patologia , Adulto , Idoso , Diagnóstico Diferencial , Feminino , Compostos Férricos , Humanos , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Sensibilidade e EspecificidadeRESUMO
AIM: To evaluate the relationship between erectile function and the radiation dose to the penile bulb and other proximal penile structures in men receiving conformal radiotherapy (CFRT) for prostate cancer (PCa). METHODS: The Medical Research Council (MRC) RT01 trial randomised 843 men who had localised PCa to receive either 64 or 74 Gy after 3 - 6 months neoadjuvant hormonal treatment. Fifty-one men were selected who were potent prior to hormonal treatment, having completed both pre-hormone and 2-year post-CFRT Quality of Life assessments, and on whom dose volume data were available for analysis. The men were divided into three groups according to 2-year follow-up: potent, reduced potency, and impotent. The bulb of the penis together with the crura, were outlined on restored treatment plans. Dose - volume histograms were generated and compared between the three groups. An ordered logistic regression model was used to calculate the odds ratio of a range of dose - volume parameters to the penile bulb and effect on erectile dysfunction. The dose to the penile bulb was correlated to the dose received by the crura. RESULTS: Of the 51 patients, 12 remained potent, 22 had reduced potency, and 17 were impotent at 2 years. No differences were seen in mean dose to the penile bulb by allocated treatment (t test = 1.61, p = 0.11). The mean doses to the penile bulb received by the potent, reduced potency, and impotent groups were 45.5 Gy (SD 17.1), 48 Gy (SD 16.1), and 59.2 Gy (SD 13.8), respectively. There was a strong correlation between the mean dose received by the penile bulb and dose to the crura (r = 0.82, p < 0.0001). 83.3% of impotent patients received a D90 > or = 50 Gy to the penile bulb compared with 29.4% of patients who maintained potency at 2 years (p = 0.006). CONCLUSION: There is evidence from this study to suggest a dose volume effect on the penile bulb and erectile dysfunction. A D90 > or = 50 Gy is associated with a significant risk of erectile dysfunction and this should form a basis for selecting dose constraints in future dose escalation studies.
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Adenocarcinoma/radioterapia , Disfunção Erétil/etiologia , Ereção Peniana/efeitos da radiação , Pênis/efeitos da radiação , Neoplasias da Próstata/radioterapia , Idoso , Estudos de Coortes , Relação Dose-Resposta à Radiação , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Qualidade de Vida , Planejamento da Radioterapia Assistida por Computador , Radioterapia ConformacionalRESUMO
BACKGROUND: In active surveillance (AS) for prostate cancer there are few data on long-term outcomes associated with novel imaging markers. OBJECTIVE: To determine long-term outcomes with respect to the apparent diffusion coefficient (ADC) derived from diffusion-weighted magnetic resonance imaging (DW-MRI) in a prospective AS cohort. Early results have already been published; we now present findings with long-term follow-up. DESIGN, SETTING, AND PARTICIPANTS: A subset of patients (n=86) underwent pre-enrolment DW-MRI in a prospective AS study between 2002 and 2006. Inclusion criteria were untreated prostate cancer, clinical T1/T2a/N0M0, Gleason ≤ 3+4, and prostate-specific antigen (PSA) <15 ng/ml. Protocol follow-up was by biopsy at 18-24 mo and then every 24 mo, with regular PSA measurement. INTERVENTION: Men underwent baseline DW-MRI in addition to standard sequences. ADC was measured from the index lesion on T2-weighted images. To avoid influencing treatment decisions, DW-MRI sequence results were not available to the AS study investigators. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Baseline ADC was analysed with respect to time to radical treatment (TRT) and time to adverse histology (TAH). Kaplan-Meier analysis and univariate and multivariate regression analyses were performed. RESULTS AND LIMITATIONS: The median follow-up was 9.5 yr (interquartile range 7.9-10.0 yr). On univariate analysis, ADC below the median was associated with shorter TAH (hazard ratio [HR] 2.13, 95% confidence interval [CI] 1.17-3.89; p<0.014) and TRT (HR 2.54, 95% CI 1.49-4.32; p<0.001). Median TRT was 9.3 yr (95% CI 7.0-11.6 yr) for patients with ADC above the median and only 2.4 yr (95% CI 1.5-6.0 yr) for ADC below the median. For TRT, addition of ADC to a multivariate model of baseline variables resulted in a significant improvement in model fit (HR 1.33, 95% CI 1.14-1.54; p<0.001). Receiver operating characteristic analysis for TRT revealed an area under the curve of 0.80 (95% CI 0.70-0.88). The number of variables included in the multivariate model was limited by sample size. CONCLUSIONS: Long-term follow-up for this study provides strong evidence that ADC is a useful marker when selecting patients for AS. Routine DW-MRI is now being evaluated in our ongoing AS study for initial assessment and as an alternative to repeat biopsy. PATIENT SUMMARY: Before entering a study of close monitoring for the initial management of prostate cancer, patients had a type of magnetic resonance imaging scan that looks at the movement of water within cancers. These scans may help in predicting whether patients should receive close monitoring or whether immediate treatment should be given.
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Adenocarcinoma/diagnóstico por imagem , Adenocarcinoma/patologia , Imagem de Difusão por Ressonância Magnética , Neoplasias da Próstata/diagnóstico por imagem , Neoplasias da Próstata/patologia , Conduta Expectante/métodos , Adenocarcinoma/sangue , Adenocarcinoma/terapia , Idoso , Área Sob a Curva , Biópsia , Braquiterapia , Progressão da Doença , Seguimentos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Modelos de Riscos Proporcionais , Estudos Prospectivos , Próstata/diagnóstico por imagem , Próstata/patologia , Antígeno Prostático Específico/sangue , Prostatectomia , Neoplasias da Próstata/sangue , Neoplasias da Próstata/terapia , Curva ROC , Fatores de TempoRESUMO
OBJECTIVES: To determine the impact on survival of symptomatic and asymptomatic venous thromboembolism (VTE) at time of diagnosis of primary ovarian malignancy. MATERIALS AND METHODS: The clinical records of 397 consecutive cases of primary ovarian malignancy were studied. Clinical, pathological and survival data were obtained. RESULTS AND CONCLUSIONS: Of 397 cases, 19 (4.8%) were found to have VTE at diagnosis, of which 63.2% (n=12) were asymptomatic. VTE was significantly associated with reduced overall median survival (28 vs. 45 months, p=0.004). Decreased survival was associated with symptomatic VTE compared to patients with asymptomatic VTE (21 vs. 36 months, p=0.02) whose survival was similar to that of patients without VTE. Decreased survival remained significant in symptomatic patients after controlling for stage of disease at diagnosis, cytoreductive status and adjuvant chemotherapy use. Overall these data suggest for the first time that symptomatic but not asymptomatic VTE prior to primary treatment of ovarian cancer is an independent adverse prognostic factor.
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Doenças Assintomáticas/mortalidade , Neoplasias Ovarianas/diagnóstico , Neoplasias Ovarianas/mortalidade , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/mortalidade , Distribuição por Idade , Idoso , Causalidade , Comorbidade , Intervalo Livre de Doença , Feminino , Humanos , Incidência , Londres/epidemiologia , Pessoa de Meia-Idade , Neoplasias Ovarianas/terapia , Fatores de Risco , Análise de Sobrevida , Taxa de Sobrevida , Avaliação de Sintomas/estatística & dados numéricos , Tromboembolia Venosa/terapiaRESUMO
BACKGROUND: Episiotomy during childbirth, intended to protect the anal sphincter, may fail to do so. Furthermore damage to the anal sphincter complex may occur without complete perineal tear. We hypothesise that these particular injuries may occur due to posterior displacement of the anus leading to distraction of the anal sphincter complex from an anterior attachment to the perineal membrane. However, the anatomical basis for this has not been well defined. OBJECTIVE: To investigate the relationship between the anal sphincter and the perineal membrane. MATERIALS AND METHODS: High-resolution MRI scans of a female cadaver perineum were performed. The imaging findings were correlated with the anatomical structure identified on dissection and histological examination. RESULTS: The perineal membrane was easily identified on MR imaging. Fibres from the perineal membrane could be seen to attach to the anal sphincter complex at the apex of the perineal body This was confirmed on histological examination and was a deeper layer than that of the decussation of the superficial transverse perineal muscle with the superficial part of the external anal sphincter. CONCLUSION: The upper ano-rectal canal and apex of the perineal body have demonstrable attachment to the free margin of the perineal membrane postero-lateral to the lower vagina. This attachment would resist posterior displacement of the anal canal.