Magnetic seed versus skin tattoo localization of non-palpable breast lesions: a single institution cohort study.

OBJECTIVE: The objective of this retrospective study was to investigate the accuracy and feasibility of magnetic seed compared to skin tattoo in preoperative localization of impalpable breast lesions in terms of accuracy of placement, re-excision and positive margins rates, and breast/surgical specimen volume ratio. METHODS: We retrospectively analyzed 77 patients who underwent breast conservative surgery in our center from November 2020 to November 2021, with previous localization with skin tattoo or magnetic seed. RESULTS: Thirty-seven magnetic seeds were placed in 36 patients (48.6%) and 40 skin tattoos were performed in the remaining cases (51.4%). The seeds were placed correctly at the two-view mammogram acquired after the insertion in 97.6% (36/37) of cases. With both methods, 100% of the index lesions were completely removed and found in the surgical specimen. The reported re-excision rate was 0% for both groups. A significant difference was observed in the volume of breast parenchyma removed between the two groups, inferior in the seed group (p = 0.046), especially in case of voluminous breasts (p = 0.003) and small lesions (dimension < 8 mm, p = 0.019). CONCLUSIONS: Magnetic seed is a non-radioactive localization technique, feasible to place, recommended in case of non-palpable breast lesions, saving the breast parenchyma removed compared with skin tattoo, without reducing the accuracy. CLINICAL RELEVANCE STATEMENT: Our findings contribute to the current evidence on preoperative localization techniques for non-palpable breast lesions, highlighting the efficacy of magnetic seed localization for deep and small lesions. KEY POINTS: • Magnetic seed is a non-radioactive technique for the preoperative localization of non-palpable breast lesions studied in comparison with skin tattoo. • Magnetic seed is feasible to place in terms of post-placement migration and distance from the target lesion. • Magnetic seed is recommended in case of non-palpable breast lesions, saving the breast parenchyma removed without reducing the accuracy.

The value of MRI in quantification of parametrial invasion and association with prognosis in locally advanced cervical cancer: the "PLACE" study.

OBJECTIVE: This retrospective observational study aims to evaluate the association between the extent of parametrial invasion (PMI) and disease-free survival (DFS) and cancer-specific survival (CSS) in patients with locally advanced cervical cancer (LACC). MATERIALS AND METHODS: This study included patients with LACC showing parametrial invasion at Magnetic Resonance Imaging (MRI). They were treated with neoadjuvant chemo-radiotherapy (CT/RT) before undergoing radical hysterectomy. The staging MRIs were reviewed retrospectively. Measurements of maximum PMI (PMImax) and parametrial length were taken bilaterally. After that, PMIratio was calculated by dividing PMImax by parametrial length. Analysis was conducted on homogeneous subsets of patients, grouped based on their pathological lymph nodal evaluation (N- and N+). Correlations between PMImax and PMIratio with DFS and CSS were evaluated in both the N- and N+ groups, employing univariable Cox regression analysis. RESULTS: Out of 221 patients, 126 (57%) had non-metastatic lymph nodes (N-), while 95 (43%) had metastatic lymph nodes (N+). The median observation period for all these patients was 73 months (95% confidence interval [CI]: 66-77). The 5-year DFS and CSS probability rates were 75% and 85.7%, respectively, for the N- group and 54.3% and 73.6%, respectively, for the N+ group. A higher PMImax (hazard ratio [HR] = 1.09) and PMIratio (HR = 1.04) correlated with worse overall survival in patients in the N- group (p = 0.025 and p = 0.042). These parameters did not show a significant statistical association in the N+ group. CONCLUSIONS: The degree of PMI evaluated on MRI affects outcome in N- patients with LACC. CLINICAL RELEVANCE STATEMENT: The degree of MRI parametrial invasion affects disease-free survival and cancer-specific survival in patients with the International Federation of Gynecology and Obstetrics (FIGO) stage IIB cervical cancer. This MRI finding can be easily incorporated into routine clinical practice. KEY POINTS: • Visual assessment of parametrial invasion on MRI was not significantly associated with prognosis in locally advanced cervical cancer (LACC). • A greater degree of parametrial invasion is associated with poorer disease-free survival and cancer-specific survival in patients with LACC without metastatic lymph node involvement. • The degree of parametrial invasion at MRI has no correlation with prognosis in LACC with metastatic lymph nodes.

Fetal MRI prior to intrauterine surgery of open neural tube defects: What does the radiologist need to know.

The management of myelomeningocele study trial showed significant prognostic improvement in fetal repair before 26 weeks of gestation. Hence, surgery in utero represents the best treatment option for open-neural tube defects (NTDs). Fetal surgery of open-NTDs has specific inclusion and exclusion criteria, which can be adequately studied with fetal MRI. The main concern: the spine (spinal defects other than Myelomeningocele and Myeloschisis, the level of the lesion higher than T1 or lower than S1 and the degree of kyphosis ≥ 30°), the skull/brain (no cerebellum herniation and Chiari II malformation and the presence of any intracranial abnormality unrelated to open NTDs), the uterus (cervix length less than 2 cm, multiple gestations and placental and uterine abnormalities) and any other fetal abnormality not attributed to spinal defect. In this review, we describe the fundamental role of fetal MRI in supporting therapeutic decisions in pre-surgery intrauterine planning through the accurate and comprehensive description of findings, providing a proposal of a structured report. In addition, we describe how post-surgical MRI is important in investigating the effectiveness of surgery and detecting repairing complications.

THUNDER 2: THeragnostic Utilities for Neoplastic DisEases of the Rectum by MRI guided radiotherapy.

BACKGROUND: Neoadjuvant chemoradiation therapy (nCRT) is the standard treatment modality in locally advanced rectal cancer (LARC). Since response to radiotherapy (RT) is dose dependent in rectal cancer, dose escalation may lead to higher complete response rates. The possibility to predict patients who will achieve complete response (CR) is fundamental. Recently, an early tumour regression index (ERI) was introduced to predict pathological CR (pCR) after nCRT in LARC patients. The primary endpoints will be the increase of CR rate and the evaluation of feasibility of delta radiomics-based predictive MRI guided Radiotherapy (MRgRT) model. METHODS: Patients affected by LARC cT2-3, N0-2 or cT4 for anal sphincter involvement N0-2a, M0 without high risk features will be enrolled in the trial. Neoadjuvant CRT will be administered using MRgRT. The initial RT treatment will consist in delivering 55 Gy in 25 fractions on Gross Tumor Volume (GTV) plus the corresponding mesorectum and 45 Gy in 25 fractions on the drainage nodes. Chemotherapy with 5-fluoracil (5-FU) or oral capecitabine will be administered continuously. A 0.35 Tesla MRI will be acquired at simulation and every day during MRgRT. At fraction 10, ERI will be calculated: if ERI will be inferior than 13.1, the patient will continue the original treatment; if ERI will be higher than 13.1 the treatment plan will be reoptimized, intensifying the dose to the residual tumor at the 11th fraction to reach 60.1 Gy. At the end of nCRT instrumental examinations are to be performed in order to restage patients. In case of stable disease or progression, the patient will undergo surgery. In case of major or complete clinical response, conservative approaches may be chosen. Patients will be followed up to evaluate toxicity and quality of life. The number of cases to be enrolled will be 63: all the patients will be treated at Fondazione Policlinico Universitario A. Gemelli IRCCS in Rome. DISCUSSION: This clinical trial investigates the impact of RT dose escalation in poor responder LARC patients identified using ERI, with the aim of increasing the probability of CR and consequently an organ preservation benefit in this group of patients. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04815694 (25/03/2021).

Radiomics-based prediction of two-year clinical outcome in locally advanced cervical cancer patients undergoing neoadjuvant chemoradiotherapy.

PURPOSE: The aim of this study is to determine if radiomics features extracted from staging magnetic resonance (MR) images could predict 2-year long-term clinical outcome in patients with locally advanced cervical cancer (LACC) after neoadjuvant chemoradiotherapy (NACRT). MATERIALS AND METHODS: We retrospectively enrolled patients with LACC diagnosis who underwent NACRT followed by radical surgery in two different institutions. Radiomics features were extracted from pre-treatment 1.5 T T2w MR images. The predictive performance of each feature was quantified in terms of Wilcoxon-Mann-Whitney test. Among the significant features, Pearson correlation coefficient (PCC) was calculated to quantify the correlation among the different predictors. A logistic regression model was calculated considering the two most significant features at the univariate analysis showing the lowest PCC value. The predictive performance of the model created was quantified out using the area under the receiver operating characteristic curve (AUC). RESULTS: A total of 175 patients were retrospectively enrolled (142 for the training cohort and 33 for the validation one). 1896 radiomic feature were extracted, 91 of which showed significance (p < 0.05) at the univariate analysis. The radiomic model showing the highest predictive value combined the features calculated starting from the gray level co-occurrence-based features. This model achieved an AUC of 0.73 in the training set and 0.91 in the validation set. CONCLUSIONS: The proposed radiomic model showed promising performances in predicting 2-year overall survival before NACRT. Nevertheless, the observed results should be tested in larger studies with consistent external validation cohorts, to confirm their potential clinical use.

Does restaging MRI radiomics analysis improve pathological complete response prediction in rectal cancer patients? A prognostic model development.

PURPOSE: Our study investigated the contribution that the application of radiomics analysis on post-treatment magnetic resonance imaging can add to the assessments performed by an experienced disease-specific multidisciplinary tumor board (MTB) for the prediction of pathological complete response (pCR) after neoadjuvant chemoradiotherapy (nCRT) in locally advanced rectal cancer (LARC). MATERIALS AND METHODS: This analysis included consecutively retrospective LARC patients who obtained a complete or near-complete response after nCRT and/or a pCR after surgery between January 2010 and September 2019. A three-step radiomics features selection was performed and three models were generated: a radiomics model (rRM), a multidisciplinary tumor board model (yMTB) and a combined model (CM). The predictive performance of models was quantified using the receiver operating characteristic (ROC) curve, evaluating the area under curve (AUC). RESULTS: The analysis involved 144 LARC patients; a total of 232 radiomics features were extracted from the MR images acquired post-nCRT. The yMTB, rRM and CM predicted pCR with an AUC of 0.82, 0.73 and 0.84, respectively. ROC comparison was not significant (p = 0.6) between yMTB and CM. CONCLUSION: Radiomics analysis showed good performance in identifying complete responders, which increased when combined with standard clinical evaluation; this increase was not statistically significant but did improve the prediction of clinical response.

The role of apparent diffusion coefficient (ADC) in the evaluation of lymph node status in patients with locally advanced cervical cancer: our experience and a review.

Purpose: To evaluate the role of apparent diffusion coefficient (ADC) value measurement in the diagnosis of meta-static lymph nodes (LNs) in patients with locally advanced cervical cancer (LACC) and to present a systematic review of the literature. Material and methods: Magnetic resonance imaging (MRI) exams of patients with LACC were retrospectively eva-luated. Mean ADC, relative ADC (rADC), and correct ADC (cADC) values of enlarged LNs were measured and compared between positron emission tomography (PET)-positive and PET-negative LNs. Comparisons were made using the Mann-Whitney U-test and Student's t-test. ROC curves were generated for each parameter to identify the optimal cut-off value for differentiation of the LNs. A systematic search in the literature was performed, exploring several databases, including PubMed, Scopus, the Cochrane library, and Embase. Results: A total of 105 LNs in 34 patients were analysed. The median ADC value of PET-positive LNs (0.907 × 10-3 mm2/s [0.780-1.080]) was lower than that in PET-negative LNs (1.275 × 10-3 mm2/s [1.063-1.525]) (p < 0.05). rADC and cADC values were lower in PET-positive LNs (rADC: 0.120 × 10-3 mm2/s [-0.060-0.270]; cADC: 1.130 [0.980-1.420]) than in PET-negative LNs (rADC: 0.435 × 10-3 mm2/s [0.225-0.673]; cADC: 1.615 [1.210-1.993]) LNs (p < 0.05). ADC showed the highest area under the curve (AUC 0.808). Conclusions: Mean ADC, rADC, and cADC were significantly lower in the PET-positive group than in the PET-negative group. The ADC cut-off value of 1.149 × 10-3 mm2/s showed the highest sensitivity. These results confirm the usefulness of ADC in differentiating metastatic from non-metastatic LNs in LACC.

Liver enhancement during hepatobiliary phase after Gd-BOPTA administration: correlation with liver and renal function.

OBJECTIVES: To assess the influence of liver and renal function on liver relative enhancement during hepatobiliary phase MRI after Gd-BOPTA administration. METHODS: In this IRB-approved retrospective cohort study, we included 326 patients who underwent Gd-BOPTA-enhanced 1.5T liver MRI, including hepatobiliary phase (HBP) acquired 90-150 min after injection, in two centres between Jan 2016 and Dec 2019. Liver signal intensity was measured on native and HBP phases and normalized to paraspinal muscles. Liver normalized relative enhancement (NRE) in HBP was calculated and compared with eGFR, total serum bilirubin and HBP acquisition delay by means of Spearman r correlation test and Mann-Whitney U test. RESULTS: 221/326 patients received 0.05 mmol/Kg Gd-BOPTA (group A), whereas 105/326 received 0.1 mmol/Kg (group B). Liver NRE in HBP was significantly higher in group B than in group A (0.55vs.0.33, p < 0.0001). In both groups, liver NRE in HBP had a negative correlation with total serum bilirubin level (r = - 0.32, p < 0.0001, group A; r = - 0.36, p = 0.0002, group B). Patients with total bilirubin > 1.2 mg/dl showed significantly lower NRE in HBP compared with those with total bilirubin ≤ 1.2 mg/dl (p < 0.0001, group A; p = 0.04, group B). Patients with impaired liver function in group B showed a NRE during HBP comparable with those with normal liver function in group A. No statistically significant correlation between liver NRE and eGFR or acquisition delay was observed. CONCLUSIONS: The degree of liver enhancement during HBP is not correlated with eGFR or acquisition delay, but it is significantly reduced in patients with impaired liver function. 0.1 mmol/kg Gd-BOPTA dose might be useful in patients with total serum bilirubin > 1.2 mg/dl. KEY POINTS: • The degree of liver enhancement during hepatobiliary phase after Gd-BOPTA administration has a negative correlation with total serum bilirubin level (r = - 0.32, p < 0.0001). • The degree of liver enhancement during HBP after Gd-BOPTA administration is not significantly correlated with renal function and acquisition delay (comprised between 90 and 150 min after contrast injection). • 0.1 mmol/Kg Gd-BOPTA dose might be preferable in patients with increased total serum bilirubin levels.

Standardizing percutaneous Microwave Ablation in the treatment of Lung Tumors: a prospective multicenter trial (MALT study).

OBJECTIVES: To prospectively assess reproducibility, safety, and efficacy of microwave ablation (MWA) in the treatment of unresectable primary and secondary pulmonary tumors. METHODS: Patients with unresectable primary and metastatic lung tumors up to 4 cm were enrolled in a multicenter prospective clinical trial and underwent CT-guided MWA. Treatments were delivered using pre-defined MW power and duration settings, based on target tumor size and histology classifications. Patients were followed for up to 24 months. Treatment safety, efficacy, and reproducibility were assessed. Ablation volumes were measured at CT scan and compared with ablation volumes obtained on ex vivo bovine liver using equal treatment settings. RESULTS: From September 2015 to September 2017, 69 MWAs were performed in 54 patients, achieving technical success in all cases and treatment completion without deviations from the standardized protocol in 61 procedures (88.4%). Immediate post-MWA CT scans showed ablation dimensions smaller by about 25% than in the ex vivo model; however, a remarkable volumetric increase (40%) of the treated area was observed at 1 month post-ablation. No treatment-related deaths nor complications were recorded. Treatments of equal power and duration yielded fairly reproducible ablation dimensions at 48-h post-MWA scans. In comparison with the ex vivo liver model, in vivo ablation sizes were systematically smaller, by about 25%. Overall LPR was 24.7%, with an average TLP of 8.1 months. OS rates at 12 and 24 months were 98.0% and 71.3%, respectively. CONCLUSIONS: Percutaneous CT-guided MWA is a reproducible, safe, and effective treatment for malignant lung tumors up to 4 cm in size. KEY POINTS: • Percutaneous MWA treatment of primary and secondary lung tumors is a repeatable, safe, and effective therapeutic option. • It provides a fairly reproducible performance on both the long and short axis of the ablation zone. • When using pre-defined treatment duration and power settings according to tumor histology and size, LPR does not increase with increasing tumor size (up to 4 cm) for both primary and metastatic tumors.

Secretin-Enhanced MRCP: How and Why-AJR Expert Panel Narrative Review.

Secretin-enhanced MRCP (S-MRCP) has advantages over standard MRCP for imaging of the pancreaticobiliary tree. Through the use of secretin to induce fluid production from the pancreas and leveraging of fluid-sensitive MRCP sequences, S-MRCP facilitates visualization of ductal anatomy, and the findings provide insight into pancreatic function, allowing radiologists to provide additional insight into a range of pancreatic conditions. This narrative review provides detailed information on the practical implementation of S-MRCP, including patient preparation, logistics of secretin administration, and dynamic secretin-enhanced MRCP acquisition. Also discussed are radiologists' interpretation and reporting of S-MRCP examinations, including assessments of dynamic compliance of the main pancreatic duct and of duodenal fluid volume. Established indications for S-MRCP include pancreas divisum, anomalous pancreaticobiliary junction, Santorinicele, Wirsungocele, chronic pancreatitis, main pancreatic duct stenosis, and assessment of complex postoperative anatomy. Equivocal or controversial indications are also described along with an approach to such indications. These indications include acute and recurrent acute pancreatitis, pancreatic exocrine function, sphincter of Oddi dysfunction, and pancreatic neoplasms.

The role of imaging in acute pancreatitis.

Acute pancreatitis is one of the most commonly encountered etiologies in the emergency setting, with a broad spectrum of findings that varies in severity from mild interstitial pancreas to severe forms with significant local and systemic complications that are associated with a substantial degree of morbidity and mortality. In this article the radiological aspect of the terminology and classification of acute pancreatitis are reviewed. The roles of ultrasound, computed tomography, and magnetic resonance imaging in the diagnosis and evaluation of acute pancreatitis and its complications are discussed. The authors present a practical image-rich guide, applying the revised Atlanta classification system, with the goal of facilitating radiologists to write a correct report, and reinforcing the radiologist's role as a key member of a multidisciplinary team in treating patients with acute pancreatitis. Computed tomography is the most performed imaging test for acute pancreatitis. Nevertheless, MRI is useful in many specific situations, due to its superiority soft tissue contrast resolution and better assessment of biliary and pancreatic duct, for example in the ductal disconnection. The purpose if this article is to review recent advances in imaging acquisition and analytic techniques in the evaluation of AP.

Automated breast volume scanner (ABVS) compared to handheld ultrasound (HHUS) and contrast-enhanced magnetic resonance imaging (CE-MRI) in the early assessment of breast cancer during neoadjuvant chemotherapy: an emerging role to monitoring tumor response?

OBJECTIVES: To investigate the role of automated breast volume scanner (ABVS) compared to handheld ultrasound (HHUS) and contrast-enhanced magnetic resonance imaging (CE-MRI) in the early detection of patients with locally advanced breast cancer who are more likely to reach a complete pathological response (pCR) during neoadjuvant chemotherapy (NAC). METHODS: A single-institution prospective study was performed in patients with histological diagnosis of invasive breast cancer, eligible for NAC, and who were to undergo surgery in our Hospital. Imaging examinations with ABVS, HHUS and CE-MRI were performed at diagnosis (basal time) and after 3 months of chemotherapy (middle time). The tumor size of each lesion was measured at the basal and middle times, and the dimensional variation was reported. Based on this, patients were divided dichotomously by the median value, obtaining "good responders" (goodR) versus "poor responders" (poorR). The results were correlated with the histological assessment (pCR versus No-pCR) with the use of the intergroup comparison of categorical data (Fisher's exact test). RESULT: A total of 21 patients were included; 5 obtained a pCR (23%). Both the ABVS and the CE-MRI found all 5 patients with pCR in the group of goodR (10 patients), while none of the poorR (11 patients) obtained a pCR [correlation was statistically significant (p 0.01)]. In the HHUS, goodR (10 patients) 1 obtained a pCR while in the poorR (11 patients) 4 obtained a pCR [correlation not statistically significant (p 0.31)]. CONCLUSIONS: ABVS could be a useful tool, appearing to be more reliable than HHUS, and as accurate as CE-MRI, in early detection of patients who could reach a pCR after NAC.

Radial Scar: a management dilemma.

Radial scar (RS) or complex sclerosing lesions (CSL) if > 10 mm is a benign lesion with an increasing incidence of diagnosis (ranging from 0.6 to 3.7%) and represents a challenge both for radiologists and for pathologists. The digital mammography and digital breast tomosynthesis appearances of RS are well documented, according to the literature. On ultrasound, variable aspects can be detected. Magnetic resonance imaging contribution to differential diagnosis with carcinoma is growing. As for the management, a vacuum-assisted biopsy (VAB) with large core is recommended after a percutaneous diagnosis of RS due to potential sampling error. According to the recent International Consensus Conference, a RS/CSL lesion, which is visible on imaging, should undergo therapeutic excision with VAB. Thereafter, surveillance is justified. The aim of this review is to provide a practical guide for the recognition of RS on imaging, illustrating radiological findings according to the most recent literature, and to delineate the management strategies that follow.

Accuracy of unenhanced CT in the diagnosis of cerebral venous sinus thrombosis.

OBJECTIVES: To evaluate the diagnostic performance of unenhanced brain CT (NECT) in identifying patients with cerebral venous sinus thrombosis (CVT). METHODS: Forty-eight consecutive patients with CVT and 48 healthy controls were included in our retrospective study. All patients underwent NECT and CT/MR angiography within 24 h. Two radiologists independently evaluated NECT images for the presence of sinus hyperdensity; discrepancies were solved by consensus. Sinus attenuation was measured in seven sites. The obtained data were compared with the presence of CVT at CT/MR angiography and with patients' hematocrit. RESULTS: Interobserver agreement in sinus hyperdensity detection was good (k = 0.64). The presence of sinus hyperdensity at NECT enabled to detect patients with CVT with 81% sensitivity, 77% specificity, 78% PPV, and 80% NPV. Mean attenuation was significantly higher in sinus segments involved by CVT than in patent ones (62.4 ± 10 versus 55.6 ± 6 HU, p < 0.0001). ROC analysis showed that a cutoff value of 63 HU enables to detect patients with CVT with 52% sensitivity and 88% specificity. Hematocrit values were significantly correlated with patent sinus segments attenuation (r = 0.19). CONCLUSIONS: The presence of sinus hyperdensity at NECT enables to detect patients with CVT with 81% sensitivity and 77% specificity. A sinus attenuation cutoff value of 63 HU can be used in order to increase specificity, but lowering sensitivity.

The role of MRI in cervical cancer > 2 cm (FIGO stage IB2-IIA1) conservatively treated with neoadjuvant chemotherapy followed by conization: a pilot study.

INTRODUCTION: MRI is very accurate in selecting young women with cervical cancer for fertility-sparing surgery (FSS), in particular radical hysterectomy (RH). In order to improve obstetrical outcomes, neoadjuvant chemotherapy (NACT) followed by cold knife conization (CKC) has been proposed as alternative technique. OBJECTIVE: To investigate the role of MRI in evaluation of response to treatment after neoadjuvant chemotherapy (NACT), followed by CKC, in patients with cervical cancer FIGO stage IB2-IIA1 with tumor size 2 - 4 cm, desiring to preserve their fertility. METHODS: 13 young women (23-36 years old) with cervical cancer stage IB2-IIA1 desiring to preserve their fertility were included. Tumor diameter at baseline and after treatment was detected on 1.5 T MRI. Treatment response was assessed according to Response Evaluation Criteria in Solid Tumors (RECIST 1.1) and then compared to histopathology result. RESULTS: MRI correctly assessed 11 out of 13 cases, according to RECIST 1.1, compared to histopathology. Among these 7 patients with partial response (PR), 2 cases of CR, 1 SD and 1 PD with persistence or enlargement of primary tumor. CONCLUSION: Our pilot study supports the usefulness of MRI in assessment of treatment response after NACT, followed by CKC. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov: NCT02323841.

The role of 18F-FDG-PET/CT in predicting the histopathological response in locally advanced cervical carcinoma treated by chemo-radiotherapy followed by radical surgery: a prospective study.

PURPOSE: This prospective study aimed to evaluate whether 18F-FDG-PET/CT performed before, during and after neoadjuvant chemo-radiotherapy (CRT) could predict histopathological response in patients with locally advanced cervical cancer (LACC) treated with CRT followed by radical surgery. METHODS: Between October 2010 and June 2014, 88 patients with LACC were enrolled. For each patient, three 18F-FDG-PET/CT scans (baseline, early and final) were acquired and evaluated by qualitative and quantitative analysis. Maximum standardized uptake value (SUVmax), SUVmean, metabolic tumor volume (MTV) and total lesion glycolysis (TLG) were measured as absolute values and their percentage variation (delta) (early vs. baseline and final vs. baseline). The role of 18F-FDG-PET/CT in predicting lymph node (LN) residual disease was evaluated by qualitative analysis only. Histopathology was the reference standard. RESULTS: At histopathology, 40 patients had complete response (CR, pR0), 48 had partial response (PR: 21 microscopic [pR1] and 27 macroscopic [pR2]). At baseline, SUVmax and SUVmean were significantly higher in pR0 than in pR1-pR2 patients. At early evaluation, MTV and TLG were significantly higher in pR1-pR2 than in pR0 patients. At final evaluation, SUVmax, SUVmean and TLG were significantly higher in pR1-pR2 than in pR0 patients. Delta SUV parameters and delta TLG were significantly lower in PR group both during and after CRT. Delta MTV was significantly lower in patients with PR in the early phase only. In receiver operating characteristic (ROC) curve analysis, baseline SUVmean, early delta TLG, and final delta SUVmax better discriminated PR, providing 83.3%, 67.6% and 85% positive predictive value (PPV) and 60.3%, 90% and 70.8% negative predictive value (NPV), respectively. For LN assessment, high NPV was observed at early and final 18F-FDG-PET/CT (93.5% and 92.3%, respectively). CONCLUSION: In LACC patients treated with CRT followed by surgery, early variations in metabolic parameters effectively discriminate histopathological PR of the primary tumor, suggesting the potential role of 18F-FDG-PET/CT in early personalized treatment. The high NPV of early and final PET/CT could enable "tailored surgery" by avoiding lymphadenectomy in selected patients.

Longitudinal study of interventional radiology activity in a large metropolitan Italian tertiary care hospital: how the COVID-19 pandemic emergency has changed our activity.

OBJECTIVES: To retrospectively analyze interventional radiology (IR) activity changes in the COVID-19 era and to describe how to safely and effectively reorganize IR activity. METHODS: All IR procedures performed between January 30 and April 8, 2020 (COVID-era group) and the same 2019 period (non-COVID-era group) were retrospectively included and compared. A sub-analysis for the lockdown period (LDP: 11 March-8 April) was also conducted. Demographic, hospitalization, clinical, and procedural data were obtained for both groups and statistically compared with univariable analysis. RESULTS: A total of 1496 procedures (non-COVID era, 825; COVID era, 671) performed in 1226 patients (64.9 ± 15.1 years, 618 women) were included. The number of procedures decreased by 18.6% between 2019 and 2020 (825 vs 671, p < .001), with a reduction by 48.2% in LDP (188 vs 363, p < .0001). In the LDP COVID era, bedside procedures were preferred (p = .013), with an increase in procedures from the intensive care unit compared with the emergency department and outpatients (p = .048), and an increased activity for oncological patients (p = .003). No incidents of cross-infection of non-infected from infected patients and no evidence of COVID-19 infection of healthcare workers in the IR service was registered. CONCLUSIONS: Coronavirus disease outbreak changed the interventional radiology activity with an overall reduction in the number of procedures. However, this study confirms that interventional radiology continuum of care can be safely performed also during the pandemic, following defined measures and protocols, taking care of all patients. KEY POINTS: • Coronavirus disease pandemic determined a reduction of interventional radiology activity as compared to the same period of the previous year. • Interventional radiology procedures for life-threatening conditions and non-deferrable oncologic treatments were prioritized as opposed to elective procedures. • Strict adoption of safe procedures allowed us to have until now no incidents of cross-infection of non-infected from infected patients and no evidence of COVID-19 infection of HCWs in the IR service.

Fusion imaging of ultrasound and MRI in the assessment of locally advanced cervical cancer: a prospective study.

BACKGROUND: Fusion imaging is a new diagnostic method that integrates MRI and ultrasound. It may improve the detection and staging of locally advanced cervical cancer. OBJECTIVE: To evaluate the feasibility and accuracy of fusion imaging in patients with locally advanced cervical cancer. METHODS: Patients with suspicion of locally advanced cervical cancer at clinical examination and/or imaging, who were candidates for neoadjuvant treatment (chemotherapy or chemoradiation) followed by surgery, were prospectively enrolled between March and November 2018. MRI, ultrasound, and fusion images were obtained before and after neoadjuvant treatment. Feasibility, success of the fusion examination, and time needed to perform fusion studies were evaluated. The rates of concordance between MRI and ultrasound before and after performing fusion, using Cohen, Spearman, and McNemar tests were calculated. The agreement between MRI and ultrasound examination, and the agreement between radiologist and gynecologist during the fusion technique in assessing local extension of disease and the presence of residual disease after neoadjuvant therapy, were also analyzed. The rates of concordance between MRI and ultrasound examination before and after performing fusion imaging, using Cohen's kappa and Spearman's rank correlation coefficient were calculated. A McNemar test was used to assess if there were statistical significant differences in the parameters' agreement before and after performing fusion imaging. RESULTS: 40 patients were selected and of these, 33 were analyzed. A total of 52 fusion examinations were performed: 33 (63.5%) of 52 at the time of diagnosis and 19 (36.5%) of 52 after neoadjuvant treatment. Fusion imaging was feasible in 50 (96%) of 52 studies. The median overall time of fusion execution was 13 min (range 6-30) and the time spent in performing a fusion examination decreased from the first to the last examination (20 vs 6 min). The agreement between MRI and ultrasound parameters increased after performing fusion, particularly for parametrial infiltration (74% vs 86%, p=0.014 for the right posterior parametrium; 66% vs 80%, p=0.008 for the left posterior parametrium, 70% vs 82%, p=0.014 for the right lateral parametrium). CONCLUSIONS: Fusion of MRI and ultrasound is feasible in patients with locally advanced cervical cancer and may increase the diagnostic accuracy of the single imaging methods. Fusion provides multiple diagnostic opportunities in gynecological oncology.

Mediastinal lymph node enlargement in idiopathic pulmonary fibrosis: relationships with disease progression and pulmonary function trends.

BACKGROUND AND OBJECTIVES: Evidence of mediastinal Lymph Node Enlargement (LNE) on CT scan is a common finding in idiopathic pulmonary fibrosis (IPF). We sought to investigate whether the involvement of mediastinal lymph nodes is associated with accelerated disease progression, and explored the changes occurring in mediastinal lymph nodes during the radiological follow up of these patients. METHODS: This retrospective study included IPF patients referred to a single ILD centre in Italy. A consensus-based assessment of mediastinal LNE on chest CT scan was performed by two thoracic radiologists. Kaplan-Meier curves and multivariate Cox proportional hazards regression were used to assess hazard ratios for mortality and disease progression (defined as categorical FVC decline ≥10%). The annualized rates of change in functional parameters for each patient were calculated using mixed linear models. RESULTS: The study population consisted of 152 IPF patients, of whom 135 (89%) received antifibrotic treatment for IPF during the study follow up. Patients having evidence of 3 or more enlarged mediastinal lymph nodes on baseline CT scan showed increased rates of mortality (HR 5.03, 95% CI 1.86-13.62, p ≤ 0.001) and significant disease progression (HR 2.99, 95% CI 1.22-7.33, p = 0.17) as compared to patients without LNE, after adjusting for GAP stage. Among 62 patients with LNE who underwent a follow up CT scan of the chest and received antifibrotic treatment, 57 (92%) maintained evidence mediastinal LNE over time. CONCLUSIONS: Diffuse mediastinal lymph node involvement predicts clinically meaningful functional deterioration in patients with IPF.

Exploring technical issues in personalized medicine: NSCLC survival prediction by quantitative image analysis-usefulness of density correction of volumetric CT data.

The aim of this study was to apply density correction method to the quantitative image analysis of non-small cell lung cancer (NSCLC) computed tomography (CT) images, determining its influence on overall survival (OS) prediction of surgically treated patients. Clinicopathological (CP) data and preoperative CT scans, pre- and post-contrast medium (CM) administration, of 57 surgically treated NSCLC patients, were retrospectively collected. After CT volumetric density measurement of primary gross tumour volume (GTV), aorta and tracheal air, density correction was conducted on GTV (reference values: aortic blood and tracheal air). For each resulting data set (combining CM administration and normalization), first-order statistical and textural features were extracted. CP and imaging data were correlated with patients 1-, 3- and 5-year OS, alone and combined (uni-/multivariate logistic regression and Akaike information criterion). Predictive performance was evaluated using the ROC curves and AUC values and compared among non-normalized/normalized data sets (DeLong test). The best predictive values were obtained when combining CP and imaging parameters (AUC values: 1 year 0.72; 3 years 0.82; 5 years 0.78). After normalization resulted an improvement in predicting 1-year OS for some of the grey level size zonebased features (large zone low grey level emphasis) and for the combined CP-imaging model, a worse performance for grey level co-occurrence matrix (cluster prominence and shade) and first-order statistical (range) parameters for 1- and 5-year OS, respectively. The negative performance of cluster prominence in predicting 1-year OS was the only statistically significant result (p value 0.05). Density corrections of volumetric CT data showed an opposite influence on the performance of imaging quantitative features in predicting OS of surgically treated NSCLC patients, even if no statistically significant for almost all predictors.