A Vismodegib Experience in Elderly Patients with Basal Cell Carcinoma: Case Reports and Review of the Literature.

Cutaneous basal cell carcinoma (BCC) is the most common type of human tumor, and its incidence rate is increasing worldwide. Up until a few years ago, therapeutic options have been limited for patients with advanced BCC (including metastatic and locally-advanced BCC). Over the last few years, promising systemic therapies have been investigated for the treatment of advanced BCC. In particular, the Hedgehog signaling inhibition has shown remarkable results for this population. Hedgehog inhibitors, represented by vismodegib and sonidegib, have been approved by the Food and Drug Administration and the European Medicines Agency for the treatment of both locally advanced and metastatic BCC, with, generally, a good safety profile. Notwithstanding the late onset of BCC in the global population, associated with life expectancy increase, only a few clinical trials have evaluated the efficacy and safety profile of Hedgehog inhibitors in this complex and neglected population. Herein, we review the major mechanisms implicated in the pathogenesis of BCC focusing on the Hedgehog signaling pathway and its therapeutic role in the elderly population. Finally, we report two case reports of BCC elderly patients in order to demonstrate both efficacy and safety of the Hedgehog inhibitors.

Percutaneous Computed Tomography-Guided Lung Biopsies using a Virtual Navigation Guidance: Our Experience.

OBJECTIVE: To evaluate the effectiveness of a virtual CT-guided navigation system (Sirio-MASMEC Biomed) in performing lung biopsies, with greater attention to lesions smaller than 1 cm, compared to the traditional procedure. METHODS: This study was approved by the Ethics Committee of our Institute. Two hundred patients were prospectively selected. Of these, 100 were subjected to percutaneous procedure with the use of Sirio and 100 to traditional CT-guided percutaneous procedure. The two methods were compared in terms of absorbed dose, procedure time, complications, and number of non-diagnostic specimens (diagnostic success). RESULTS: Sirio has shown a significant reduction in the absorbed dose and procedure times (p < 0.05), with a lower incidence of complications compared to the traditional procedure. Sirio has also allowed to carry out biopsies of lesions' diameter ≤10 mm, obtaining fewer non diagnostic specimens thus resulting more effective in terms of diagnostic success. CONCLUSIONS: The use of Sirio in sampling biopsy showed a statistically significant reduction in terms of performed scans and procedural time with lower incidence of post-procedural complications compared to the traditional percutaneous procedure, especially for lesions ≤10 mm. The best diagnostic result, the reduction of the dose absorbed and procedural complications makes the procedures more reliable, safety and less invasive. In addition, the reduction of execution time will increase the number of daily interventional procedures improving clinical management.

Magnetic Resonance Imaging in the Pre-Surgical Staging of Breast Cancer: Our Experience.

PURPOSE: To investigate the clinical impact of magnetic resonance imaging (MRI) in the detection of multifocal-multicentric breast cancers, already identified by mammography and ultrasound, and analyzed histologically, to evaluate its role in preoperative staging. MATERIALS AND METHODS: From January 2012 to February 2014, 188 patients, aged 28 to 74 years, newly diagnosed with breast cancer on conventional imaging (mammography and ultrasound) were enrolled. They underwent preoperative contrast-enhanced 3T MRI. Patients underwent surgery according to international guidelines. Results of all diagnostic procedures were compared. RESULTS: Among the 188 patients, 163 (87%) had a unilateral and unifocal tumor at both conventional imaging; MRI diagnosed 22/22 (100%) of multifocal and multicentric tumors, the combination of mammography and ultrasound diagnosed 12/22 (54%), and mammography alone diagnosed 8/22 (36%) multifocal and multicentric tumors. MRI prompted a change in surgical strategy in 10/188 (5%) patients. This change comprised mastectomy instead of conservative surgery (n = 7) and more extensive conservative surgery (n = 3). CONCLUSIONS: MRI was confirmed to show higher sensitivity than conventional imaging in detecting multifocal and multicentric breast cancers.

Can Diffusion-Weighted Imaging and Related Apparent Diffusion Coefficient be a Prognostic Value in Women With Breast Cancer?

PURPOSE: To analyze diffusion-weighted imaging (DWI) and the related apparent diffusion coefficient (ADC) in women with breast cancer, correlating these values with the presence at 3 years of distant metastases, and to demonstrate that DWI-Magnetic Resonance Imaging (MRI) and related ADC values may represent a prognostic value in the study of women with breast cancer. MATERIALS AND METHODS: Sixty women (aged 45-73 years) affected with breast cancer with a follow-up in 3 years were enrolled. On DWI, we obtained the ADC values, and these were correlated with the clinical condition of patients at 3 years. Moreover, tumour size, lymph node status, and molecular markers, including estrogens receptor, progesterone receptor, Ki-67 index, and human growth factor receptor 2 protein, were correlated with ADC values. This study was approved by the Scientific Committee of our institution. RESULTS: We considered patients with metastasis at 3 years (12 patients - 20%) and without metastasis (48 patients - 80%). The mean ADC value in patients with no metastases at 3 years was 1.06 ± 0.38, while for patients with metastases it was 0.74 ± 0.34 (p = .011). The receiver-operator curve analysis identified a value of 0.75 (<0.75 with risk to develop metastasis) as the best predictive cutoff for ADC values, with the highest sensitivity (81.25%) and higher specificity (66.67%). After regression analysis, ADC value, positivity to estrogen-progestin receptors, and presence of lymph nodes were the only prognostic factors found to be statistically significant. CONCLUSIONS: DWI-MRI and related ADC values may represent a prognostic value in women with breast cancer.

Diffusion weighted imaging and apparent diffusion coefficient in 3 tesla magnetic resonance imaging of breast lesions.

OBJECTIVE: To evaluate the utility of diffusion-weighted-imaging (DWI) and apparent-diffusion-coefficient (ADC) in a 3T magnetic-resonance-imaging (MRI) study of breast cancer. In particular, the study aims to classify ADC-values according to histology either for benign or malignant lesions. METHODS: 110 Breast MRI with MRI-DWI sequences and quantitative evaluation of the ADC were retrospectively reviewed. Results obtained with MRI-DWI and with biopsy were analyzed and ADC values were compared to histological results. RESULTS: MRI showed a 95.5% sensitivity and a 83.7% specificity. The mean ADC values of benign and malignant lesions were 2.06 ± 0.19 and 1.03 ± 0.07 mm(2)/s, respectively (p < .05). CONCLUSIONS: DWI and ADC-values could help distinguishing malignant and benign breast masses.

Challenges in the diagnosis and management of tumor-induced osteomalacia: A case report.

The present case report is aimed to highlight the difficulty and the reason for the delayed diagnosis of phosphaturic mesenchymal tumors, emphasizing the need of standardized protocols for diagnosis, surgery and follow-up in high-volume hospitals. The clinical signs and symptoms, diagnostic and therapeutic procedures, immunohistological features were analyzed. Delayed diagnosis of phosphaturic mesenchymal tumor was primarily due to non-specific clinical symptoms such as fatigue, muscular and bone pain, and multiple fractures. This cryptic clinical picture made the diagnosis tricky that led to treatment of patient for non-specific pain and stress fractures before to consider the tumor-induced osteomalacia syndrome. Some well-documented studies were found in the literature in which the history of trauma is a critical trigger of glomus tumors. Extra-subungual tumors most frequently occur in the knee and ankle regions, particularly among young adults, and the diagnosis is typically made approximately 7.2 years after initial symptom onset. The difficult tumor localization represented an additional obstacle to the prompt treatment, leading to delayed curative surgery.

Comparison between Gleason score and apparent diffusion coefficient obtained from diffusion-weighted imaging of prostate cancer patients.

OBJECTIVES: To correlate the apparent diffusion coefficient (ADC) of prostate cancer patients with pathological Gleason scores (GS). METHODS: 40 patients with GS 2 + 3, 3 + 3, 3 + 4, or 4 + 4 were selected. The magnetic resonance imaging (MRI) study was performed adding axial diffusion-weighted imaging (DWI) sequences to the standard MRI protocol. ADC values obtained were correlated with the GS data. RESULTS: Statistically significant differences of ADC (p < .05) were found among GS groups with a trend of decreasing ADC values with increasing GS. CONCLUSIONS: The ADC values may help clinicians to delineate prostate carcinoma, recognizing its high- or low-grade compartments.

Diffusion-weighted magnetic resonance imaging in patients with prostate cancer treated with radiotherapy.

AIMS: To evaluate the utility of a multiparametric 3T magnetic resonance imaging (MRI) study using diffusion-weighted images (DWI) for the assessment of prostate cancer before and after radiotherapy (RT). METHODS: A total of 34 patients, who received a histologic diagnosis of prostate adenocarcinoma, underwent MRI examination before and after local RT for the assessment of response to treatment. Apparent diffusion coefficient (ADC) values were calculated and compared. RESULTS: Before RT, DWI shows pathologic restriction of signal, while after RT pathologic restriction of signal was reduced or disappeared. The ADC values were significantly increased after therapy (p<0.05). CONCLUSIONS: The use of DWI with ADC measurements may be an imaging biomarker in the assessment of prostate cancer.

Comparison between magnetic resonance spectroscopy and diffusion weighted imaging in the evaluation of gliomas response after treatment.

PURPOSE: To compare magnetic resonance spectroscopy (MRS) and diffusion weighted imaging (DWI) in the assessment of progression and regression of brain tumors in order to assess whether there is correlation between MRS and DWI in the monitoring of patients with primary tumors after therapy. METHODS: Magnetic resonance imaging (MRI) has been performed in 80 patients, 48 affected by high grade gliomas (HGG) and 32 affected by low grade gliomas (LGG). The variation of apparent diffusion coefficient (ADC) value and metabolite ratios before and after treatment has been used to test DWI sequences and MRS as predictor to response to therapy. Comparison between post contrast-enhancement sequences, MRS and DWI has been done in terms of accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Moreover statistical correlation of ADC deviations with MRS metabolites variations before and after therapy have been studied. RESULTS: In the case of HGG, MRS shows better sensitivity, specificity, PPV, NPV and accuracy compared to DWI, especially when considering the Choline/N-acetylaspartate (Cho/NAA) ratio. Regarding the LGG, the technique that better evaluates the response to treatment appears to be the DWI. A moderate correlation between ADC deviations and Cho, Lipide (Lip) and Lactate (Lac) has been found in LGG; while NAA revealed to be weakly correlated to ADC variation. Considering HGG, a weak correlation has been found between ADC deviations and MRS metabolites. CONCLUSION: Combination of DWI and MRS can help to characterize different changes related to treatment and to evaluate brain tumor response to treatment.