Detection of noncalcified pulmonary nodules on low-dose MDCT: comparison of the sensitivity of two CAD systems by using a double reference standard.

PURPOSE: This study compared the sensitivity of two commercial computer-aided detection (CAD) systems in identifying noncalcified pulmonary nodules on low-dose multidetector computed tomography (MDCT) scans by using a double reference standard. MATERIALS AND METHODS: Three chest low-dose MDCT scans of patients who had undergone lung cancer screening were retrospectively analysed using two distinct commercial CAD systems: LungCAD VC10A, Siemens Medical Solutions (CAD1) and LungVCAR, GE Healthcare (CAD2). The exact location of each finding suggested by each system was recorded by an independent reader according to spatial coordinates (x, y, z). Two panels of experienced thoracic radiologists from two different institutions independently established two reference standards (RS1, RS2) by identifying the true positive findings with spatial coordinates without using CAD. Sensitivity of the two CAD systems, defined by lesionlevel analysis, was tested and sensitivities compared. RESULTS: RS1 identified 34 noncalcified pulmonary nodules, whereas RS2 identified 54. The total number of findings detected by the two CAD systems was 684. CAD1 correctly identified 13/34 nodules (sensitivity 38%) for RS1 and 17/54 (sensitivity 30%) for RS2, whereas CAD2 correctly identified 11/34 nodules (sensitivity 35%) for RS1 and 13/54 (sensitivity 23%) for RS2. Comparison between the two CAD systems did not show a statistically significant difference in terms of sensitivity (p<0.05) for both RS1 (p=0.42) and RS2 (p=0.33). CONCLUSIONS: The two commercial CAD systems had similar sensitivity in detecting noncalcified pulmonary nodules on low-dose MDCT of the chest.

The breast dynamic contrast enhanced MRI: preliminary results of a quantitative analysis.

The objective of our study was to apply a quantitative analysis to the dynamic contrast enhanced MR imaging of the breast. Automated criteria increase the objectivity and reproducibility of the diagnostic interpretation of the imaging for differentiating benign and malignant lesions. The validation of this applied method was evaluated by analysing the time- signal intensity curves and the performance of the extracted enhancement parameters. The performance of some extracted parameters was evaluated by ROC (Receiver Operating Characteristic) analysis. These parameters were found to be particularly accurate in differentiating lesions.

Oral cavity and base of the tongue tumors. Correlation between clinical, MRI and pathological staging of primary tumor.

The diagnosis of oral cavity and oropharyngeal tumors can be obtained through clinical examination and biopsy. CT and MRI can then be used to define the extension of the disease. The aim of this study was to define the accuracy of clinical and MRI T staging of oral cavity and base of the tongue tumors and correlate the results with pathological data. Mandibular involvement, in a subgroup of patients, was determined and sensitivity, specificity, accuracy and positive and negative predictive values were evaluated. Fifty-nine patients affected by squamous cell carcinoma and 1 case of adenoido-cystic carcinoma were examined by means of a superconductive MR unit, using SE T1, and fat-suppressed T2 weighted sequences before contrast medium infusion. SE T1 and T1 fat-suppressed sequences after gadolinium-DTPA infusion were used. T stage accuracy of both clinical examination and MRI were found to be respectively 62% (k 0.459) and 82% (k 0.775). The sensitivity, specificity and accuracy of MRI in the detection of mandibular involvement were 94.1%, 60% and 81.5%, while the positive and negative predictive values were 80% and 85.7%, respectively. The sensitivity, specificity and accuracy of clinical examination in the detection of mandibular involvement were 100%, 30% and 74.1%, while the positive and negative predictive values were 70.8% and 100%. In the present study, MRI was seen to be an adequate technique for the assessment of oral cavity malignancies, in the evaluation of depth invasion, presence and extension of mandibular involvement.

Early post-operative MRI: correlation with progression-free survival and overall survival time in malignant gliomas.

Forty-seven patients with Glioblastoma (42) and Anaplastic Astrocytoma (5) were studied with MR 24 hrs after surgery. In order to evaluate the role of early MR in defining the extent of surgical resection and its relation with the prognosis of malignant glioma patients, three categories of surgical resection were considered: gross total, sub-total and partial resection. The results were correlated with progression-free survival (PFS) and overall survival (ST). As demonstrated by early-MR, gross total resection was performed in 17 patients, sub-total and partial resection in 19 and 11 patients, respectively. The PFS was 6 months in gross total resection, 6 and 3 months in sub-total and in partial resection, respectively. The median survival time was 16 months in total resection patients, 13 months and 7 months in sub-total resection and partial resection patients, respectively. The study confirms that early-MR has to be considered an accurate technique for monitoring the extension of malignant glioma surgical resection and shows a good correlation between early-MR findings, PFS and ST.

Correlation between tumor necrosis factor-alpha and D-dimer levels in non-small cell lung cancer patients.

The present study was designed to investigate whether a correlation exists between IL-6, TNF-alpha and coagulation (Thrombin-antithrombin, TATc) or fibrinolysis (D-dimer) activation in non-small cell lung cancer (NSCLC) patients. One hundred thirty patients with NSCLC (n=65, 53 males, mean age 65 +/- 8, adenocarcinoma n=32, squamous cancer n=33) or chronic obstructive pulmonary disease (COPD) (n=65, 51 males, mean age 67 +/- 9) were studied. As control group 65 healthy donors (51 males, mean age 61 +/- 14) were also evaluated. The results obtained showed that median D-dimer levels were higher in NSCLC patients (3.0 microg/ml) compared either to COPD patients (1.1 microg/ml, P<0.05) or controls (0.3 microg/ml, P<0.0001). Positive TNF-alpha levels (>10 pg/ml) were found in 26% of NSCLC compared to 3% of COPD (P<0.002) and 5% of controls (P<0.0005). On the other hand, positive (>8.5 pg/ml) IL-6 levels were found in 53% of NSCLC and 21% of COPD patients, compared to 5% of control subjects (P<0.001). Median TATc levels were elevated in either NSCLC (6.9 microg/l) or COPD (5.7 microg/l) patients compared to controls (1.8 microg/l, P<0.0001). Elevated D-dimer levels were significantly associated to positive TNF-alpha levels in patients without distant metastasis (F=4.3, P<0.05). Moreover, TNF-alpha levels (P<0.01) were independently related to the presence of positive D-dimer levels in patients with non-metastatic NSCLC. These results suggest that increased levels of TNF-alpha might be responsible for an activation of fibrinolysis in patients with NSCLC.

T stages of tumors of the tongue and floor of the mouth: correlation between MR with gadopentetate dimeglumine and pathologic data.

PURPOSE: To define MR accuracy in the evaluation of the T stages of tumors of the tongue and floor of the mouth. METHODS: Fifty-two patients affected by squamous cell carcinoma were studied with a superconductive system at 1.5 T. The study was performed with spin-echo T1- and T2-weighted images before contrast and short spin-echo T1-weighted and gradient-echo sequences after gadopentetate dimeglumine administration. The results obtained with MR were compared with pathologic data. RESULTS: Good correlation of T stages (TNM system) was obtained in 45 of 52 cases. MR did not show four superficial lesions. In one case, infiltration of the cortical bone of the mandible was not demonstrated (MR, T2; pathologic, T4), and in another the lesion was classified as T2 instead of T3, as it was pathologically. One lesion was classified as T4 on MR because of infiltration of the alveolar ridge but was classified as T2 at surgery. In 46 patients who underwent surgery, the accuracy of MR was excellent for predicting the relationship of tumor to midline and oral floor musculature. The results obtained with gadopentetate dimeglumine were better than those obtained in noncontrast studies in 32 (62%) of 53 cases. CONCLUSION: MR showed high accuracy in the study of tumors of the tongue and floor of the mouth.

Retromolar trigone tumors: evaluation by magnetic resonance imaging and correlation with pathological data.

The aim of this study was to evaluate the diagnostic accuracy of magnetic resonance (MR) images to establish both the T stage and the relationships between the tumors and the surrounding structures in retromolar trigone tumors. Twenty-two patients with squamous cell carcinoma of the retromolar trigone were examined by MR with a superconductive scanner operating at 1.5T. The study was performed with spin-echo (SE) T1 and T2 and short SE T1 sequences (TR 180 ms, TE 15 ms) after the administration of 0.2 mmol/kg of gadolinium-DTPA (Gd-DTPA). The mandible was studied with SE T1 weighted sequences and GE sequences. The results were compared with the pathological data on the T stage (TNM classification) and the involvement of the surrounding structures. A positive correlation was found in 19 of the 22 patients with an accuracy of 86%. In one patient, the lesion was classified as T1 by MR which, at surgery, resulted being T4, given the infiltration of the cortical mandible (this infiltration was too limited). In another, the MR showed a T4 lesion because of the presence of low signal intensity in the mandibular marrow with enhancement after the Gd-DTPA injection without cortical erosion, while pathological data revealed a T2 lesion (this signal intensity was secondary to inflammation). In another case, the lesion was classified as T1 by MR which, at surgery, proved to be a T2 lesion. In assessing the involvement of the surrounding structures. MR showed a high accuracy, specificity and sensitivity (> 90%). Five false positive cases were observed: in two because of infiltration of the masseter muscle and in the other three, because of infiltration to the pterigoid muscle, mandible and tonsillar bed, respectively, due to the close contact between the tumors and the surrounding structures. Only one false negative case was observed with infiltration of the mandibular marrow. In evaluating the low signal intensity of the mandibular marrow, the accuracy of MR was 87% the specificity 77% and the sensitivity 100%. In one case, perineural spread along the mandibular nerve was found. In conclusion, MR proved to be highly accurate to study the T stage and examine the relationships between the surrounding structures in cases of retromolar trigone tumors.

Somatostatin receptors in meningiomas: a scintigraphic study using 111In-DTPA-D-Phe-1-octreotide.

111In-octreotide (Octreoscan) planar scintigraphy was performed in 12 patients with suspected meningioma. The scan was positive in 10 patients with meningioma and negative in two patients with acoustic neurinoma assisting in the differential diagnosis. Good quality images were obtained as early as 2 h after injection and there was no increase in diagnostic quality at 24 h. No adverse effects were observed to radiopharmaceutical administration. The following conclusions are drawn: 111In-octreotide is a safe and fast test which can increase the specificity of traditional neuroimaging procedures.

Somatostatin receptor imaging in CNS tumours using 111In-octreotide.

This study evaluates the in vivo visualization of somatostatin (SS) receptors in central nervous system (CNS) tumours using 111In-octreotide imaging and discusses the clinical implications. Ninety-five patients with histologically confirmed diagnosis of CNS tumours were imaged 2-4 and 24 h after the intravenous injection of 111-185 MBq of 111In-octreotide. An uptake index was computed using tumour/non-tumour ratios evaluated using a standard region-of-interest method. Semi-quantitative immunohistochemical studies of SS binding sites were performed on frozen tumour sections. All meningiomas, most pituitary adenomas and many glial tumours showed a positive scan, whereas all neurinomas, craniopharingiomas and ependymomas had negative receptor scans. Radio-octreotide uptake varied among the SS receptor positive CNS tumours: very intense in meningioma, intermediate in pituitary adenoma and of a low grade in glioma. The results of immunohistochemical studies confirmed the scintigraphic findings in all cases. We believe 111In-octreotide is a suitable radiopharmaceutical for characterizing CNS tumours in vivo as SS receptor positive or negative. This new neuronuclear imaging technique may be useful for differential diagnosis in selected cases, for post-surgical follow-up and in the assessment of differentiation in glial tumours.

Evaluation of hepatic metastases from colorectal carcinoma with MR-superparamagnetic iron oxide.

The purpose of this study was to compare the results obtained with superparamagnetic iron oxide-enhanced and unenhanced Magnetic Resonance at 1.5 T with that of spiral-computed tomography (CT) in order to select those patients suitable for liver resection; the intraoperative US (IOUS) comprised the gold standard. Thirty five candidates for liver resection with known colorectal neoplasm were studied; 26 patients underwent surgery, one patient underwent RF ablation and 8 of them were submitted to follow-up. MR examination was performed using a 1.5 T superconductive instrument, CT examination was performed on a Somatom-Plus (Siemens) scanner. Dimensions and number of the lesions were defined in all patients as well as the sensitivity of spiral CT and MR imaging, using either the plain technique or after Ferumoxides c.m.. In those patients submitted to surgery, results have been correlated to those of IOUS. From 26 patients, a total of 48 lesions were removed surgically. With CT, 34 lesions with 3 false positive cases were detected; 32 with plain MR imaging, while MR imaging with Ferumoxides detected 41 lesions. In the patients not submitted to surgery, MR iron-oxide imaging identified 15 lesions, while both plain MR imaging and CT showed 8 lesions. The smallest lesion was 6 mm. as shown by MR imaging with Ferumoxides. In the cases submitted to surgery, the CT sensitivity was 71%, plain MR imaging 66% and MR imaging with Ferumoxides 85%. In our experience, Ferumoxides-enhanced MR imaging of the liver shows increased sensitivity compared to plain and spiral-CT in the evaluation of hepatic metastases. We think that MR superparamagnetic iron oxide should be used in all patients selected for liver resection.

The Italian multi-centre project on evaluation of MRI and other imaging modalities in early detection of breast cancer in subjects at high genetic risk.

This report presents the preliminary results of the first phase (21 months) of a multi-centre, non-randomised, prospective study, aimed at evaluating the effectiveness of contrast-enhanced magnetic resonance imaging (MRI), X-ray mammography (XM) and ultrasound (US) in early diagnosis of breast cancer (BC) in subjects at high genetic risk. This Italian national trial (coordinated by the Istituto Superiore di Sanità, Rome) so far recruited 105 women (mean age 46.0 years; median age 51.0; age range 25-77 years), who were either proven BRCA1 or BRCA2 mutation carriers or had a 1 in 2 probability of being carriers (40/105 with a previous personal history of BC). Eight cases of breast carcinomas were detected in the trial (mean age 55.3 years, median age 52.5; age range 35-70 years; five with previous personal history of BC). All trial-detected BC cases (8/8) were identified by MRI, while XM and US correctly classified only one. MRI had one false positive case, XM and US none. Seven "MRI-only" detected cancers (4 invasive, 3 in situ) occurred in both pre- (n = 2) and post-menopausal (n = 5) women. With respect to the current XM screening programmes addressed to women in the age range 50-69 years, the global incidence of BC in the trial (7.6%) was over ten-fold higher. The cost per "MRI-only" detected cancer in this particular category of subjects at high genetic risk was substantially lower than that of an XM-detected cancer in the general women population. These preliminary results confirmed that MRI is a very useful tool to screen subjects at high genetic risk for breast carcinoma, not only in pre-, but also in post-menopausal age, with a low probability of false positive cases.

[Primary empty sella. Clinico-radiologic considerations in 18 cases]. / La sella vuota primaria. Considerazioni clinico-radiologiche a proposito di 18 casi.

18 patients with "primary empty sella" were reviewed for this study. In 3 of them the sellar enlargement was discovered occasionally by performing skull radiographs for other reasons. The galattorrhea-dismenorrhea or amenorrhea syndrome and obesity were the most common clinical features. Endocrinological tests were normal in ten patients and abnormal in eight. Slight elevation of serum PRL was the most common record. 12 patients had enlarging of the sella turcica; in 4, only the floor was asymmetric and in 2 the sella was quite normal. In 5 patients C.T. without intra-thecal contrast was sufficient to discover the E.S. In 13 patients we performed C.T. cysternography by injecting in the lumbar subarachnoid space 8-10 ml of Iopamidolo 200. This is an excellent and safe technique to perform C.T. cysternography.

[Intracranial meningiomas in the elderly]. / Meningiomi endocranici dell'anziano.

BACKGROUND: Since the introduction of CT and then MRI in the clinical practice, the number of elderly patients with intracranial meningiomas observed in neurosurgical departments has increased to three/four times. Considering that some patients die because of their meningioma and others die with their meningioma, the neurosurgeon should not only be able to eradicate surgically the lesion, but also to decide if that benign tumor should be treated or not. MATERIALS AND METHODS: Forty-three patients with intracranial meningioma, aged over 65 were operated upon between 1989 and 1995. They constitute about one fourth of all the meningioma-patients operated upon in that period at our Department. Main symptoms were focal deficits, psychorganic syndrome, and seizures. Mean duration of symptoms was 15 months, with 30% of the histories lasting less than 3 months. Associate pathologies were those typical of the elderly population with hypertension and senile cardiopathy at the first places. Two patients had insulin-dependent diabetes, 2 prostatic carcinoma, and 8 were obese. MRI was useful either in depicting the location of the tumor or in helping the surgeon to give a correct operative indication and risk evaluation. MRI criteria for risk evaluation were severe edema and venous vascular infiltration. Forty-five operations were performed. Their duration was not a risk factor by itself, it only reflected the difficulty of the removal, due to the location of the tumor. Dissection of tumor remnants from main arteries or veins was never attempted in this group of patients; total removal was achieved in 75.5% of the cases. RESULTS: Immediate postoperative results were good in 71% of cases. Four patients died (9%). Long term results were evaluated in 29 patients (mean follow-up period: 35 months). Twenty-two patients (76%) had excellent or good results, 5 (17%) fair, and 2 (7%) had severe neurological dysfunctions and needed continuous assistance. CONCLUSIONS: Surgical risk factors typical of this age group were identified: cranio-spinal location, damage to the cortical or deep venous system, severe peritumoral edema, and poor neurological preoperative conditions. Systemic risk factors were insulin-dependent diabetes and obesity.

In-111 octreotide scintigraphy in the diagnostic evaluation of en plaque meningioma. A case report.

A 44-year-old woman had a 13-year history of a small bulge of the left frontal region which had increased in size during the last year. At admission, an orange-sized, hard, fixed left frontal mass was found. Magnetic resonance imaging showed hyperostosis in the left frontal region which was causing a skull deformity and marked focal meningeal enhancement. A hyperostotic plaque meningioma was hypothesized. In-111 octreotide scintigraphy confirmed the diagnosis before surgery. In-111 octreotide scintigraphy allows biologic characterization of neoplasms in vivo.

Thallium-201 scintigraphy and chemotherapeutic response in rhabdomyosarcoma.

Thallium-201 scintigraphy was used to evaluate chemotherapeutic response in a case of rhabdomyosarcoma treated with epirubicin. A scintigraphic semiquantitative index of tumor viability was correlated with MRI and clinical assessment. Both imaging studies were performed before therapy and after treatment involving a cumulative dose of 640 mg/m2 of epirubicin. A very good inverse correlation was observed between Tl-201 uptake and tumor necrosis evaluated by MRI, leading to the conclusion that sequential Tl-201 scintigraphy may have a role not only in delineating the extent of the tumor, but in objectively assessing tumor response to therapeutic interventions. The proposed scintigraphic method is much simpler to perform and less expensive than MRI-derived semiquantitative measurement of tumor necrosis.

[Gemcitabine in peritoneal mesothelioma: a case report]. / Gemcitabina nel mesotelioma peritoneale: presentazione di un caso clinico.

Malignant peritoneal mesothelioma is a rare tumor whose prognosis is poor. We report a case history of a 57-year old woman with large peritoneal masses and ascites refractory to several chemotherapeutic regimens. The patient benefited of a dramatic regression of disease with symptomatic improvement during chemotherapy with gemcitabine. Serum CA-125 values declined consensually to tumor regression. The duration of response was 12 months. The activity of gemcitabine in malignant mesothelioma has been already confirmed in phase II studies. Data are also available suggesting that better results can be obtained combining this agent with cisplatin, and a multicenter phase II study is now exploring the activity of this combination.

[Renal carcinoma: effective modulation of low-dose interferon-alpha and interleukin-2 with medroxyprogesterone acetate and 13-cis retinoic acid]. / Carcinoma renale: efficace modulazione dell'interferone-alpha e dell'interleuchina 2 a basse dosi con medrossiprogesterone acetato e acido 13-cis retinoico.

We report a case history of a patient with clear renal carcinoma. After surgical treatment of primary tumor patient had been treated with medium-high doses IL-2 and alpha IFN for lung metastasis and paraaortic nodes, without significant response. Subsequently, low doses alpha IFN/IL-2 produced a response, and further response have been obtained by the combination of low-doses alpha IFN/IL-2 plus medroxyprogesterone acetate and cis-retinoic acid. We can therefore conclude that in immunogenic tumors, such as renal cancer, various immunologic strategies are justified, also employing in combination drugs not active as single agents, or modifying doses and schedules.

[Evaluation of the T parameter of TNM classification of tumors of the tonsillar region. Correlation of MR and pathological data]. / Valutazione del parametro T della classificazione TNM dei tumori della regione tonsillare. Correlazione tra RM e dati patologici.

The purpose of this study was to define MR accuracy in the evaluation of T Stage of tumors in the tonsillar region. Twenty-two patients with a squamous cell carcinoma of the tonsillar region were studied utilizing a superconductive scanner operating at 1.5 T. The study was performed with SE T1 and T2 images before contrast and short SE T1 after Gd-DPTA infusion. MR results were correlated with pathological data on T Stage (TNM classification) and on the relationships between tumors and surrounding structures. A positive correlation between MR and pathological data was obtained in 19/22 cases, with an MR accuracy of 86%. MR did not show the presence of 2 superficial lesions (MR T0, pathological T1), while one lesion was classified T2 with MR, instead of pathology T1. The accuracy of MR was 95% in the evaluation of the relationships between tumors and the base of the tongue and 100% for body of the tongue, retromolar trigone, valleculae, epiglottis, pre-epiglottis, parapharyngeal and masticator space. MR showed high accuracy in the evaluation of T Stage, above all utilizing Gd-DPTA infusion, with short SE T1 sequences. MR did not show the superficial lesions, but in these cases a deep extension of the disease was excluded.

Quantitative analysis of elastography images in the detection of breast cancer.

PURPOSE: The aim of this study was to develop a quantitative method for breast cancer diagnosis based on elastosonography images in order to reduce whenever possible unnecessary biopsies. The proposed method was validated by correlating the results of quantitative analysis with the diagnosis assessed by histopathologic exam. MATERIAL AND METHODS: 109 images of breast lesions (50 benign and 59 malignant) were acquired with the traditional B-mode technique and with elastographic modality. Images in Digital Imaging and COmmunications in Medicine format (DICOM) were exported into a software, written in Visual Basic, especially developed to perform this study. The lesion was contoured and the mean grey value and softness inside the region of interest (ROI) were calculated. The correlations between variables were investigated and receiver operating characteristic (ROC) curve analysis was performed to assess the diagnostic accuracy of the proposed method. Pathologic results were used as standard reference. RESULTS: Both the mean grey value and the softness inside the ROI resulted statistically different at the t test for the two populations of lesions (i.e., benign versus malignant): p<0.0001. The area under the curve (AUC) was 0.924 (0.834-0.973) and 0.917 (0.826-0.970) for the mean grey value and for the softness respectively. CONCLUSIONS: Quantitative elastosonography is a promising ultrasound technique in the detection of breast cancer but large prospective trials are necessary to determine whether quantitative analysis of images can help to overcome some pitfalls of the methodic.

Weekly gemcitabine in advanced or metastatic solid tumors. A clinical phase I study.

Gemcitabine (GEM) is a novel deoxycytidine analogue which has shown promising antitumor activity in solid tumor models and a broad range of schedule-dependent MTDs (12-4560 mg/m2) in preliminary clinical studies. The present phase I trial evaluated escalating doses of weekly GEM using a 30-min infusion at a starting dose-level of 300 mg/m2/wk x 3 every 28 days. At least 3 patients entered each dose-level step and 3 more cases were treated when significant toxicity was seen. A total of 39 patients with various advanced solid tumors and prior chemotherapy entered this study. Six escalation steps (102 courses) were tested to define the MTD at 1,370 mg/m2/wk. No definite dose-effect relationships were observed for myelosuppression up to 1,095 mg/m2/wk. However, increased severity of leucopenia (dose-limiting) and greater non-hematologic toxicity as well as a higher number of toxic treatment delays, requiring subsequent dose attenuation in 6 out of 12 patients, were observed at 1,370 mg/m2/wk. In all, 6 out of 11 patients experiencing WHO grade > or = 3 toxicity (11/21 events recorded in 11/18 courses) were treated at the MTD. Clinically significant toxicity included (patients with WHO grade 2-3): leucopenia (44%), thrombocytopenia (26%), anemia (23%), fever (69%), emesis (38%) and AST/ALT rise (26%). Mild proteinuria, ankle edema, skin rash, hair loss and mucositis were seen in < or = 5%.(ABSTRACT TRUNCATED AT 250 WORDS)