Pleural effusion detected at CT prior to primary cytoreduction for stage III or IV ovarian carcinoma: effect on survival.

PURPOSE: To determine the prognostic importance of pleural effusions on preoperative computed tomographic (CT) images in patients with advanced epithelial ovarian cancer. MATERIALS AND METHODS: The institutional review board waived informed consent for this HIPAA-compliant study of 203 patients with International Federation of Obstetrics and Gynecology stage III (n = 172) or IV (n = 31) epithelial ovarian cancer who underwent CT before primary cytoreductive surgery between 1997 and 2004 (mean age, 61 years; range, 37-96 years). Two radiologists retrospectively evaluated chest and/or abdominal CT images for pleural malignancy and the presence, size, and laterality of pleural effusions. To evaluate survival, Kaplan-Meier methods were used, with log-rank P values for comparisons. Multivariate analyses were conducted by using Cox proportional hazards regression. κ Statistics were calculated for interreader agreement. RESULTS: Median survival was 50 months (95% confidence interval [CI]: 45, 55 months) for patients with stage III disease and 41 months (95% CI: 27, 58 months) for patients with stage IV disease. Readers 1 and 2 found pleural effusions in 40 and 41 stage III and 20 and 21 stage IV patients, respectively. At multivariate analysis, after controlling for stage, age at surgery, preoperative serum CA-125 level, debulking status, and ascites, moderate-to-large pleural effusion on CT images was significantly associated with worse overall survival (reader 1: hazard ratio = 2.27 [95% CI: 1.31, 3.92], P < .01; reader 2: hazard ratio = 2.25 [95% CI: 1.26, 4.01], P = .02). Preoperative CA-125 level, debulking status, and ascites were also significant survival predictors (P ≤ .03 for all for both readers). Readers agreed substantially in distinguishing small from moderate-to-large effusions (κ = 0.764). CONCLUSION: Moderate-to-large pleural effusion on preoperative CT images in patients with stage III or IV epithelial ovarian cancer was independently associated with poorer overall survival after controlling for age, preoperative CA-125 level, surgical stage, ascites, and cytoreductive status.

Diagnostic usefulness of water-to-fat ratio and choline concentration in malignant and benign breast lesions and normal breast parenchyma: an in vivo (1) H MRS study.

PURPOSE: To compare total choline concentrations ([Cho]) and water-to-fat (W/F) ratios of subtypes of malignant lesions, benign lesions, and normal breast parenchyma and determine their usefulness in breast cancer diagnosis. Reference standard was histology. MATERIALS AND METHODS: In this HIPPA compliant study, proton MRS was performed on 93 patients with suspicious lesions (>1 cm) who underwent MRI-guided interventional procedures, and on 27 prospectively accrued women enrolled for screening MRI. (W/F) and [Cho] values were calculated using MRS data. RESULTS: Among 88 MRS-evaluable histologically-confirmed lesions, 40 invasive ductal carcinoma (IDC); 10 invasive lobular carcinoma (ILC); 4 ductal carcinoma in situ (DCIS); 3 invasive mammary carcinoma (IMC); 31 benign. No significant difference observed in (W/F) between benign lesions and normal breast tissue. The area under curve (AUC) of receiver operating characteristic (ROC) curves for discriminating the malignant group from the benign group were 0.97, 0.72, and 0.99 using [Cho], (W/F) and their combination as biomarkers, respectively. (W/F) performs significantly (P < 0.0001;AUC = 0.96) better than [Cho] (AUC = 0.52) in differentiating IDC and ILC lesions. CONCLUSION: Although [Cho] and (W/F) are good biomarkers for differentiating malignancy, [Cho] is a better marker. Combining both can further improve diagnostic accuracy. IDC and ILC lesions have similar [Cho] levels but are discriminated using (W/F) values.

Geographic access and the use of screening mammography.

BACKGROUND: Screening mammography rates vary geographically and have recently declined. Inadequate mammography resources in some areas may impair access to this technology. We assessed the relationship between availability of mammography machines and the use of screening. METHODS: The location and number of all mammography machines in the United States were identified from US Food and Drug Administration records of certified facilities. Inadequate capacity was defined as <1.2 mammography machines per 10,000 women age 40 or older, the threshold required to meet the Healthy People 2010 target screening rate. The impact of capacity on utilization was evaluated in 2 cohorts: female respondents age 40 or older to the 2006 Behavioral Risk Factor Surveillance System survey (BRFSS) and a 5% nationwide sample of female Medicare beneficiaries age 65 or older in 2004-2005. RESULTS: About 9% of women in the BRFSS cohort and 13% of women in the Medicare cohort lived in counties with <1.2 mammography machines per 10,000 women age 40 or older. In both cohorts, residence in a county with inadequate mammography capacity was associated with lower odds of a recent mammogram (adjusted odds ratio in BRFSS: 0.89, 95% CI: 0.80-0.98, P < 0.05; adjusted odds ratio in Medicare: 0.86, 95% CI: 0.85-0.87, P < 0.05), controlling for demographic and health care characteristics. CONCLUSION: In counties with few or no mammography machines, limited availability of imaging resources may be a barrier to screening. Efforts to increase the number of machines in low-capacity areas may improve mammography rates and reduce geographic disparities in breast cancer screening.

Are histopathological features of prostate cancer lesions associated with identification of extracapsular extension on magnetic resonance imaging?

OBJECTIVE: To assess the effect of histopathological lesion characteristics on the sensitivity of magnetic resonance imaging (MRI) for per-lesion identification of extracapsular extension (ECE) of prostate cancer. PATIENTS AND METHODS: The study included 176 patients (median age 58.9 years, range 38-77) who underwent endorectal MRI before radical prostatectomy between January 2001 and July 2004, had no previous treatment and had whole-mount step-section pathological specimens showing at least one capsule-abutting lesion. The likelihood of ECE of capsule-abutting lesions was retrospectively scored from 1 to 5 based on radiologists' prospective MRI interpretations. Generalized estimating equation regression models were used to determine the effect of the following histological variables on the sensitivity of MRI for identifying ECE of capsule-abutting lesions: maximum diameter, largest perpendicular diameter (LPD), bi-dimensional diameter product, Gleason grade, and zonal extent. RESULTS: On histopathology, 339 capsule-abutting lesions were found, including 54 with ECE. MRI correctly identified ECE in 36/54 capsule-abutting lesions, including nine of 18 with focal ECE and 27/36 with established ECE, giving sensitivities (95% confidence interval) of 67 (53-78)%, 50 (27-73)% and 75 (58-87)%, respectively. MRI incorrectly identified ECE in 27/285 (9%) capsule-abutting lesions without ECE. MRI sensitivity for per-lesion ECE identification was significantly associated only with histopathological LPD (P = 0.009). Fifty-one patients (29%) had ECE. MRI had a sensitivity (95% confidence interval) of 69 (54-81)% and specificity of 90 (83-94)% for per-patient ECE identification. CONCLUSIONS: The sensitivity of MRI in per-lesion identification of prostate cancer ECE is significantly associated with the lesion LPD at histopathology.

Interactive dedicated training curriculum improves accuracy in the interpretation of MR imaging of prostate cancer.

OBJECTIVE: To assess the effect of interactive dedicated training on radiology fellows' accuracy in assessing prostate cancer on MRI. METHODS: Eleven radiology fellows, blinded to clinical and pathological data, independently interpreted preoperative prostate MRI studies, scoring the likelihood of tumour in the peripheral and transition zones and extracapsular extension. Each fellow interpreted 15 studies before dedicated training (to supply baseline interpretation accuracy) and 200 studies (10/week) after attending didactic lectures. Expert radiologists led weekly interactive tutorials comparing fellows' interpretations to pathological tumour maps. To assess interpretation accuracy, receiver operating characteristic (ROC) analysis was conducted, using pathological findings as the reference standard. RESULTS: In identifying peripheral zone tumour, fellows' average area under the ROC curve (AUC) increased from 0.52 to 0.66 (after didactic lectures; p<0.0001) and remained at 0.66 (end of training; p<0.0001); in the transition zone, their average AUC increased from 0.49 to 0.64 (after didactic lectures; p=0.01) and to 0.68 (end of training; p=0.001). In detecting extracapsular extension, their average AUC increased from 0.50 to 0.67 (after didactic lectures; p=0.003) and to 0.81 (end of training; p<0.0001). CONCLUSION: Interactive dedicated training significantly improved accuracy in tumour localization and especially in detecting extracapsular extension on prostate MRI.

Correlation of MR imaging and MR spectroscopic imaging findings with Ki-67, phospho-Akt, and androgen receptor expression in prostate cancer.

PURPOSE: To retrospectively assess whether magnetic resonance (MR) imaging and MR spectroscopic imaging and selected molecular markers correlate with each other and with clinically insignificant and significant prostate cancer (PCa), as defined at surgical pathologic analysis. MATERIALS AND METHODS: The institutional review board approved this HIPAA-compliant study and waived informed consent. Eighty-nine men (mean age, 63 years; range, 46-79 years) with biopsy-proved PCa underwent combined endorectal MR imaging and MR spectroscopic imaging before radical prostatectomy. Suspicion of clinically insignificant PCa was retrospectively and separately recorded for MR imaging and combined MR imaging and MR spectroscopic imaging by using a scale of 0-3. Clinically insignificant PCa was pathologically defined as organ-confined cancer of 0.5 cm(3) or less without poorly differentiated elements. Prostatectomy specimens underwent immunohistochemical analysis for three molecular markers: Ki-67, phospho-Akt (pAkt), and androgen receptor (AR). To examine differences in marker levels for clinically insignificant and significant cancer, a Wilcoxon rank sum test was used. To examine correlations between marker levels and MR imaging or combined MR imaging and MR spectroscopic imaging scores, the Spearman correlation was used. RESULTS: Twenty-one (24%) patients had clinically insignificant and 68 (76%) had clinically significant PCa at surgical pathologic review. All markers were significantly correlated with MR imaging and combined MR imaging and MR spectroscopic imaging findings (all correlation coefficients >0.5). In differentiating clinically insignificant from clinically significant PCa, areas under the receiver operating characteristic curves for Ki-67, AR, pAkt, MR imaging, and combined MR imaging and MR spectroscopic imaging were 0.75, 0.78, 0.80, 0.85, and 0.91, respectively. CONCLUSION: The use of pretreatment MR imaging or combined MR imaging and MR spectroscopic imaging and molecular marker analyses of biopsy samples could facilitate better treatment selection. SUPPLEMENTAL MATERIAL: http://radiology.rsnajnls.org/cgi/content/full/250/3/803/DC1.

Clinical stage T1c prostate cancer: evaluation with endorectal MR imaging and MR spectroscopic imaging.

PURPOSE: To assess the diagnostic accuracy of endorectal magnetic resonance (MR) imaging and MR spectroscopic imaging for prediction of the pathologic stage of prostate cancer and the presence of clinically nonimportant disease in patients with clinical stage T1c prostate cancer. MATERIALS AND METHODS: The institutional review board approved-and waived the informed patient consent requirement for-this HIPAA-compliant study involving 158 patients (median age, 58 years; age range, 40-76 years) who had clinical stage T1c prostate cancer, had not been treated preoperatively, and underwent combined 1.5-T endorectal MR imaging-MR spectroscopic imaging between January 2003 and March 2004 before undergoing radical prostatectomy. On the MR images and combined endorectal MR-MR spectroscopic images, two radiologists retrospectively and independently rated the likelihood of cancer in 12 prostate regions and the likelihoods of extracapsular extension (ECE), seminal vesicle invasion (SVI), and adjacent organ invasion by using a five-point scale, and they determined the probability of clinically nonimportant prostate cancer by using a four-point scale. Whole-mount step-section pathology maps were used for imaging-pathologic analysis correlation. Receiver operating characteristic curves were constructed and areas under the curves (AUCs) were estimated nonparametrically for assessment of reader accuracy. RESULTS: At surgical-pathologic analysis, one (0.6%) patient had no cancer; 124 (78%) patients, organ-confined (stage pT2) disease; 29 (18%) patients, ECE (stage pT3a); two (1%) patients, SVI (stage pT3b); and two (1%) patients, bladder neck invasion (stage pT4). Forty-six (29%) patients had a total tumor volume of less than 0.5 cm(3). With combined MR imaging-MR spectroscopic imaging, the two readers achieved 80% accuracy in disease staging and AUCs of 0.62 and 0.71 for the prediction of clinically nonimportant cancer. CONCLUSION: Clinical stage T1c prostate cancers are heterogeneous in pathologic stage and volume. MR imaging may help to stratify patients with clinical stage T1c disease for appropriate clinical management.

Prostate tumor volume measurement with combined T2-weighted imaging and diffusion-weighted MR: correlation with pathologic tumor volume.

PURPOSE: To retrospectively determine the accuracy of diffusion-weighted (DW) magnetic resonance (MR) imaging for identifying cancer in the prostate peripheral zone (PZ) and to assess the accuracy of tumor volume measurements made with T2-weighted imaging and combined T2-weighted and DW MR imaging by using surgical pathologic examination as the reference standard. MATERIALS AND METHODS: The institutional review board issued a waiver of informed consent for this HIPAA-compliant study. Forty-two patients underwent endorectal MR at 1.5 T before undergoing radical prostatectomy for prostate cancer and had at least one PZ tumor larger than 0.1 cm(3) at surgical pathologic examination. On T2-weighted images, an experienced radiologist outlined suspected PZ tumors. Two apparent diffusion coefficient (ADC) cutoff values were identified by using the Youden index and published literature. Image cluster analysis was performed on voxels within the suspected tumor regions. Associations between volume measurements from imaging and from pathologic examination were assessed by using concordance correlation coefficients (CCCs). The sensitivity and specificity of ADCs for identifying malignant PZ voxels were calculated. RESULTS: In identifying malignant voxels, respective ADC cutoff values of 0.0014 and 0.0016 mm(2)/sec yielded sensitivity of 82% and 95% and specificity of 85% and 65%, respectively. Sixty PZ cancer lesions larger than 0.1 cm(3) were found at pathologic examination; 43 were detected by the radiologist. CCCs between imaging and pathologic tumor volume measurements were 0.36 for T2-weighted imaging, and 0.46 and 0.60 for combined T2-weighted and DW MR imaging with ADC cutoffs of 0.0014 and 0.0016 mm(2)/sec, respectively; the CCC of combined T2-weighted and DW MR imaging (ADC cutoff, 0.0016 mm(2)/sec) was significantly higher (P = .006) than that of T2-weighted imaging alone. CONCLUSION: Adding DW MR to T2-weighted imaging can significantly improve the accuracy of prostate PZ tumor volume measurement. SUPPLEMENTAL MATERIAL: http://radiology.rsnajnls.org/cgi/content/full/252/2/449/DC1.

Assessment of biologic aggressiveness of prostate cancer: correlation of MR signal intensity with Gleason grade after radical prostatectomy.

PURPOSE: To retrospectively investigate whether the signal intensity (SI) of prostate cancer on T2-weighted magnetic resonance (MR) images correlates with the Gleason grade at whole-mount step-section pathologic evaluation after radical prostatectomy. MATERIALS AND METHODS: The institutional review board approved and issued a waiver of informed consent for this HIPAA-compliant study of 74 patients (median age, 57.5 years; range, 32-72 years) who underwent endorectal MR imaging before radical prostatectomy, with subsequent whole-mount step-section pathologic evaluation, between January 2001 and July 2004. Inclusion criteria were that they had: no prior treatment; at least one lesion of uniform Gleason grade 3 or 4 or with Gleason grade 5 components, with a bidimensional diameter product of 20 mm2 or greater; no high SI on T1-weighted MR images indicative of postbiopsy changes; and an interval of more than 4 weeks between biopsy and MR imaging. SI of prostate tumors, nontumor prostatic tissue, and internal obturator muscles was measured on uncorrected and corrected T2-weighted MR images. Correlations between Gleason grades and SI ratios were assessed by using generalized estimating equations. SI ratios in peripheral zone (PZ) and transition zone (TZ) lesions of the same Gleason grade were compared with an unpaired t test. RESULTS: Seventy-nine Gleason grade 3, eight Gleason grade 4, and four mixed Gleason grades 4 and 5 lesions identified at pathologic evaluation were analyzed. Gleason grade correlated significantly with tumor-muscle SI ratio for PZ tumors on corrected and uncorrected images (P = .006 and <.001, respectively). Higher Gleason grades were associated with lower tumor-muscle SI ratios. Nontumor-muscle SI ratios did not correlate with patients' Gleason grades. Tumor-muscle SI ratios were lower in TZ than in PZ tumors (P < .001). CONCLUSION: Higher Gleason grades were associated with lower tumor-muscle SI ratios on T2-weighted MR images. SI evaluation on T2-weighted MR images may facilitate noninvasive assessment of prostate cancer aggressiveness.

Renal masses: characterization with diffusion-weighted MR imaging--a preliminary experience.

PURPOSE: To retrospectively assess the usefulness of apparent diffusion coefficients (ADCs) for characterizing renal masses (ie, viable solid tumors, necrotic or cystic tumor areas, and benign cysts). MATERIALS AND METHODS: The institutional review board waived the requirement for informed consent for this retrospective HIPAA-compliant study. The data of 25 consecutive patients (15 men, 10 women; age range, 39-75 years) who underwent renal magnetic resonance (MR) imaging, including diffusion-weighted imaging, before nephrectomy were included. Renal MR examinations were performed by using transverse T1-weighted dual-echo in-phase and out-of-phase sequences and transverse and coronal T2-weighted single-shot fast spin-echo sequences. Three-dimensional fat-saturated T1-weighted dynamic gadopentetate dimeglumine-enhanced sequences also were performed. Precontrast single-shot spin-echo echo-planar diffusion-weighted images were obtained with b values of 0, 500, and 1000 sec/mm(2) at 1.5 T. Regions of interest were placed on renal lesions to measure the ADC of whole lesions, enhancing viable soft tissue, and nonenhancing necrotic or cystic areas. The T1 signal characteristics of the renal lesions and necrotic or cystic areas were recorded. The Wilcoxon rank sum test was used to compare the median ADC values of the various types of lesions and areas. RESULTS: Twenty-six renal tumors were found in the 25 patients. Eight patients were found to have 11 benign cysts. Renal tumors had significantly lower ADCs (median, 189.3 x 10(-5) mm(2)/sec; range, [102.0-262.0] x 10(-5) mm(2)/sec) compared with benign cysts (median, 322.8 x 10(-5) mm(2)/sec; range, [217.0-421.0] x 10(-5) mm(2)/sec; P < .001). Solid enhancing tumors had significantly lower ADCs (median, 162.3 x 10(-5) mm(2)/sec; range, [102.0-284.0] x 10(-5) mm(2)/sec) compared with nonenhancing necrotic or cystic regions (median, 247.7 x 10(-5) mm(2)/sec; range, [85.2-310.0] x 10(-5) mm(2)/sec; P = .007) [corrected]. T1 hyperintense lesions had lower ADCs compared with their hypointense counterparts. CONCLUSION: The T1 signal characteristics of a renal lesion appear to be related to the ADC of the lesion. ADC may be helpful in characterizing and differentiating renal masses.

Prostate cancer: identification with combined diffusion-weighted MR imaging and 3D 1H MR spectroscopic imaging--correlation with pathologic findings.

PURPOSE: To retrospectively measure the mean apparent diffusion coefficient (ADC) with diffusion-weighted magnetic resonance (MR) imaging and the mean metabolic ratio (MET) with three-dimensional (3D) hydrogen 1 ((1)H) MR spectroscopic imaging in regions of interest (ROIs) drawn over benign and malignant peripheral zone (PZ) prostatic tissue and to assess ADC, MET, and combined ADC and MET for identifying malignant ROIs, with whole-mount histopathologic examination as the reference standard. MATERIALS AND METHODS: The institutional review board approved this HIPAA-compliant retrospective study and issued a waiver of informed consent. From among 61 consecutive patients with prostate cancer, 38 men (median age, 61 years; range, 42-72 years) who underwent 1.5-T endorectal MR imaging before radical prostatectomy and who fulfilled all inclusion criteria of no prior hormonal or radiation treatment and at least one PZ lesion (volume, >0.1 cm(3)) at whole-mount pathologic examination were included. ADC maps were generated from diffusion-weighted MR imaging data, and MET maps of (choline plus polyamine plus creatine)/citrate were calculated from 3D (1)H MR spectroscopic imaging data. ROIs in the PZ identified by matching pathologic slides with T2-weighted images were overlaid on MET and ADC maps. Areas under the receiver operating characteristic curves (AUCs) were used to evaluate accuracy. RESULTS: The mean ADC +/- standard deviation, (1.39 +/- 0.23) x 10(-3) mm(2)/sec, and mean MET (0.92 +/- 0.32) for malignant ROIs differed significantly from the mean ADC, (1.69 +/- 0.24) x 10(-3) mm(2)/sec, and mean MET (0.73 +/- 0.18) for benign ROIs (P < .001 for both). In distinguishing malignant ROIs, combined ADC and MET (AUC = 0.85) performed significantly better than MET alone (AUC = 0.74; P = .005) and was also better than ADC alone (AUC = 0.81), although the difference was not statistically significant (P = .09). CONCLUSION: The combination of ADC and MET performs significantly better than MET for differentiating between benign and malignant ROIs in the PZ.

Perihepatic lymph node micrometastases impact outcome after partial hepatectomy for colorectal metastases.

BACKGROUND: Hepatectomy for resectable colorectal liver metastases provides a survival advantage but is usually reserved for patients without extrahepatic disease. Metastases to perihepatic lymph nodes (LN) occur with controversial significance. This study uses standard pathologic analysis and immunohistochemistry (IHC) to determine the impact of occult metastatic disease to perihepatic LN in patients with colorectal cancer undergoing hepatectomy. METHODS: Fifty-nine patients with liver metastases from colon or rectal primary cancer were studied prospectively. Perihepatic LN were sampled from the portocaval, pancreaticoduodenal, and common hepatic artery regions. All LN were analyzed using hematoxylin and eosin (H&E), and those negative by H&E were analyzed using IHC for cytokeratin. Recurrence and survival were compared amongst LN groups. RESULTS: Median follow-up was 42 months for survivors. There were eight patients with metastatic disease to at least one perihepatic LN identified by H&E and fourteen patients with metastases identified by IHC only. Forty-one patients (70%) recurred after resection, and patients with LN metastases, regardless of detection method, had a shorter recurrence-free survival compared to node negative patients. However, patterns of recurrence differed by LN group. Compared to H&E-positive patients, IHC-positive patients had a better overall survival and were more likely to recur at a single site amenable to salvage resection. CONCLUSIONS: In patients with hepatic colorectal metastases, IHC analysis of perihepatic LN adds prognostic value regarding the timing and burden of recurrence after resection. Routine IHC assessment of perihepatic LN is reasonable since the information garnered would potentially influence postresection chemotherapy recommendations.

Characterization of adnexal masses using feature analysis at contrast-enhanced helical computed tomography.

OBJECTIVE: To determine the computed tomographic imaging features predictive of adnexal malignancy and evaluate the accuracy of contrast-enhanced helical computed tomography (CT) in the characterization of adnexal masses. MATERIALS AND METHODS: The institutional review board waived the informed consent requirement for this retrospective study, which was Health Insurance Portability and Accountability Act compliant. For 143 consecutive patients who underwent preoperative contrast-enhanced CT of the abdomen and pelvis and had adnexal masses found at surgical pathology, preoperative contrast-enhanced computed tomographic scans were retrospectively and independently reviewed by 2 radiologists. Receiver operating characteristic analysis was used to assess the value of contrast-enhanced CT in detecting and characterizing adnexal masses. Feature analysis was performed to select the findings with the highest sensitivities and specificities for predicting malignant lesions. Interobserver variability was assessed using kappa statistics. RESULTS: At surgical pathology, 234 adnexal masses were found (165 were malignant). Readers 1 and 2 detected 215 and 216 (92%) adnexal masses, respectively. For both readers, the features most predictive of malignancy were heterogeneity for a solid lesion, multilocularity (>3 locules), irregular and thickened cystic septations or walls, and the presence of internal vegetations for a cystic lesion. Irregular lesion contour and ancillary findings, including ascites, peritoneal implants, lymphadenopathy, and pleural effusion, were predictive of malignancy in both solid and cystic lesions. In diagnosing malignancy in all patients and in the subgroup without ancillary findings, areas under the receiver operating characteristic curves were 0.88 (95% confidence interval [CI], 0.84-0.93) and 0.89 (95% CI, 0.83-0.96) for reader 1, respectively, and 0.90 (95% CI, 0.86-0.94) and 0.88 (95% CI, 0.80-0.97) for reader 2, respectively. Interobserver agreement (kappa = 0.71) was good. CONCLUSIONS: Contrast-enhanced helical CT is highly accurate in characterizing adnexal masses as malignant. Recognition of the computed tomographic features most often associated with adnexal malignancy will assist in more confident use of this modality and may potentially obviate the need for additional imaging studies before treatment selection.

Incremental value of multiplanar cross-referencing for prostate cancer staging with endorectal MRI.

OBJECTIVE: The purpose of this study was to assess whether use of the PACS cross-referencing tool in 3D MRI improves tumor staging of prostate cancer when pathologic findings are used as the reference standard. MATERIALS AND METHODS: The institutional review board granted a waiver of informed consent for the study. Endorectal MRI at 1.5 T was performed before radical prostatectomy in 255 consecutive patients. Two radiologists unaware of the clinical data retrospectively and independently interpreted MR images without and with cross-referencing to predict the presence of extracapsular extension (ECE) and seminal vesicle invasion (SVI). Histopathologic findings were used as the reference standard. Area under the receiver operating characteristics curve (AUC), sensitivity and specificity, and weighted kappa statistics were calculated. RESULTS: At histologic examination, 68 (27%) of the patients were found to have ECE and 13 (5%) of the patients to have SVI; the latter all had ECE. In detecting ECE, both reviewers had a higher AUC using cross-referencing (p < 0.001 for both). The weighted kappa value was 0.56 for MRI alone and 0.76 for MRI with cross-referencing, indicating fair to good interobserver agreement. Sensitivity and specificity for ECE with MRI alone and with cross-referencing were 43% and 94% and 57% and 100% for reviewer 1 and 40% and 93% and 59% and 98% for reviewer 2, respectively. In detecting SVI, both reviewers had a higher AUC with cross-referencing (p = 0.007 and p = 0.056 for reviewers 1 and 2, respectively). Reviewer 1 benefited much more from cross-referencing than did reviewer 2. The weighted kappa statistic was 0.69 for MRI alone and the same with cross-referencing, indicating good interobserver agreement. Sensitivity and specificity for SVI with MRI alone and with cross-referencing, respectively, were 23% and 83% and 46% and 93% for reviewer 1 and 31% and 91% and 54% and 95% for reviewer 2. CONCLUSION: PACS cross-referencing significantly improves tumor staging of prostate cancer with 3D MRI. Some reviewers benefit more than others from use of this tool.

Second-line chemotherapy for prostate cancer: patient characteristics and survival.

PURPOSE: First-line chemotherapy with docetaxel in patients with progressive castrate metastatic prostate cancer has been shown to improve overall survival compared with mitoxantrone-based therapies. The use and outcomes of chemotherapy after first-line antimicrotubule-based therapy have not been well described. PATIENTS AND METHODS: Patients with progressive castrate metastatic prostate cancer enrolled on an antimicrotubule-based protocol for treatment were followed to determine their baseline characteristics and outcomes with second- or third-line systemic therapy. RESULTS: Of 108 patients treated with antimicrotubule-based therapy, 81% received second-line therapy, and 40% received third-line therapies. Corresponding prostate-specific antigen (PSA) decreases > or = 50% were observed in 72%, 15%, and 22% of patients. Median survival times from the start of first-, second-, and third-line therapy were 21 months (95% confidence interval [CI], 18-25 months), 13 months (95% CI, 10-15 months) and 12 months (95% CI, 9-19 months). Significant prognostic indicators for survival in the second-line setting include pretreatment PSA level, alkaline phosphatase level, and performance status. Patients not fit to receive second-line therapy were more symptomatic with first-line therapy, as illustrated by a greater need for narcotic therapy (67% vs. 15%) and palliative radiation therapy after first-line therapy (57% vs. 10%) in lieu of second-line systemic therapy. CONCLUSION: Eighty percent of patients received second-line chemotherapy, with a median survival of 12 months from the start of second-line treatment. Although only 40% received third-line chemotherapy, median survival was similar to that of patients in the second-line setting. Our data show that patients who initiate chemotherapy with symptoms are more likely to require palliative radiation therapy rather than chemotherapy as second-line therapy. A sequential or continuous administration of therapy may optimize the care of this subset of symptomatic patients.

Ethnic differences in bladder cancer survival.

OBJECTIVE: To examine trends in bladder cancer survival among whites, blacks, Hispanics, and Asian/Pacific Islanders in the United States over a 30-year period. Racial disparities in bladder cancer outcomes have been documented with poorer survival observed among blacks. Bladder cancer outcomes in other ethnic minority groups are less well described. METHODS: From the Surveillance, Epidemiology and End Results cancer registry data, we identified patients diagnosed with transitional cell carcinoma of the bladder between 1975 and 2005. This cohort included 163,973 white, 7731 black, 7364 Hispanic, and 5934 Asian/Pacific Islander patients. We assessed the relationship between ethnicity and patient characteristics. Disease-specific 5-year survival was estimated for each ethnic group and for subgroups of stage and grade. RESULTS: Blacks presented with higher-stage disease than whites, Hispanics, and Asian/Pacific Islanders, although a trend toward earlier-stage presentation was observed in all groups over time. Five-year disease-specific survival was consistently worse for blacks than for other ethnic groups, even when stratified by stage and grade. Five-year disease-specific survival was 82.8% in whites compared with 70.2% in blacks, 80.7% in Hispanics, and 81.9% in Asian/Pacific Islanders. There was a persistent disease-specific survival disadvantage in black patients over time that was not seen in the other ethnic groups. CONCLUSION: Ethnic disparities in bladder cancer survival persist between whites and blacks, whereas survival in other ethnic minority groups appears similar to that of whites. Further study of access to care, quality of care, and treatment decision making among black patients is needed to better understand these disparities.

Do characteristics of pulmonary nodules on computed tomography in children with known osteosarcoma help distinguish whether the nodules are malignant or benign?

PURPOSE: To determine if selected computed tomography (CT) characteristics of pulmonary nodules in pediatric patients with osteosarcoma can help distinguish the nodules as benign or malignant. METHODS: The institutional review board approved this HIPAA (Health Insurance Portability and Accountability Act-compliant, retrospective study of 30 pediatric osteosarcoma patients (median age 14 years, range 8-22) who underwent chest CT with resection of 117 pulmonary nodules from January 2001 to December 2006. Two pediatric radiologists and one chest radiologist independently and retrospectively reviewed the CT scans and classified nodules as benign, malignant, or indeterminate on the basis of nodule size, laterality, number, location, growth, density, margin appearance, and calcification. Generalized estimating equations were used to examine which characteristics were independent predictors of nodule malignancy. RESULTS: Of the 117 nodules, 80 (68%) were malignant and 37 (32%) were benign by pathologic review. The readers correctly classified 93% to 94% of the malignant nodules. For benign lesions, the results were not as accurate, with the readers correctly classifying only 11% to 30% of lesions. Most of the benign lesions were classified as indeterminate by the readers (54%-65%). Nodule size (≥5 mm) and the presence of calcifications were associated with an increased probability of malignancy (P b .05). CONCLUSION: On chest CT, nodule size 5 mm or greater and the presence of calcifications are associated with an increased probability of malignant nodule histology in pediatric patients with osteosarcoma. However, nodule characteristics, apart from size and calcification, at chest CT cannot reliably distinguish benign from malignant pulmonary nodules in these patients.

Characteristics and outcomes of breast cancer in women with and without a history of radiation for Hodgkin's lymphoma: a multi-institutional, matched cohort study.

PURPOSE: To compare characteristics and outcomes of breast cancer in women with and without a history of radiation therapy (RT) for Hodgkin's lymphoma (HL). PATIENTS AND METHODS: Women with breast cancer diagnosed from 1980 to 2006 after RT for HL were identified from eight North American hospitals and were matched three-to-one with patients with sporadic breast cancer by age, race, and year of breast cancer diagnosis. Information on patient, tumor and treatment characteristics, and clinical outcomes was abstracted from medical records. RESULTS: A total of 253 patients with breast cancer with a history of RT for HL were matched with 741 patients with sporadic breast cancer. Median time from HL to breast cancer diagnosis was 18 years. Median age at breast cancer diagnosis was 42 years. Breast cancer after RT for HL was more likely to be detected by screening, was more likely to be diagnosed at an earlier stage, and was more likely to be bilateral at diagnosis. HL survivors had an increased risk of metachronous contralateral breast cancer (adjusted hazard ratio [HR], 4.3; 95% CI, 1.7 to 11.0) and death as a result of any cause (adjusted HR, 1.9; 95% CI, 1.1 to 3.3). Breast cancer-specific mortality was also elevated, but this difference was not statistically significant (adjusted HR, 1.6; 95% CI, 0.7 to 3.4). CONCLUSION: In women with a history of RT for HL, breast cancer is diagnosed at an earlier stage, but these women are at greater risk for bilateral disease and are more likely to die as a result of causes other than breast cancer. Our findings support close follow-up for contralateral tumors in these patients and ongoing primary care to manage comorbid conditions.

Preliminary results of a phase I trial of prophylactic ethanol-lock administration to prevent mediport catheter-related bloodstream infections.

BACKGROUND: Catheter-related bloodstream infections remain costly with no simple prevention. We report preliminary results of a phase I trial of ethanol-lock administration to prevent mediport catheter-related bloodstream infections in children. METHODS: Twelve patients receiving intravenous antibody treatments for neuroblastoma were enrolled. On 4 days of each 5-day antibody cycle, 70% ethanol was administered instead of heparin to dwell in each patient's mediport overnight. We used clinical monitoring/questionnaires to assess symptoms and measured blood ethanol levels and liver functions. Patients were tracked for positive blood cultures. Time to infection for ethanol-lock-treated patients was compared with historical controls. RESULTS: We administered 123 ethanol-locks. No adverse symptoms attributable to ethanol occurred; one patient's urticaria worsened. Blood ethanol levels averaged 11 mg/dL. The study was voluntarily suspended after 3 patients' catheters became occluded, 1 of which fractured. A positive blood culture occurred in 1 (8%) of 12 patients, but suspension of the study precluded statistical power to detect impact on time to infection. CONCLUSIONS: Although children with mediport catheters exhibited nontoxic blood ethanol levels and a low rate of bloodstream infections following prophylactic ethanol-lock use, there was a high incidence of catheter occlusion. Adjustments are necessary before adopting ethanol-locks for routine prophylaxis against catheter infections in children.

Assessment of therapy responses and prediction of survival in malignant pleural mesothelioma through computer-aided volumetric measurement on computed tomography scans.

PURPOSE: The purposes of this study were (1) to calculate the tumor volume in patients with malignant pleural mesothelioma using computed tomography (CT) scan images and a computer-aided measurement technique and (2) to investigate whether the baseline volume, or volume change after chemotherapy, predicts patient survival. METHODS: We compiled the clinical characteristics and outcome from 30 patients enrolled in two clinical trials at our cancer center in which the patients were treated with induction chemotherapy followed by surgery and radiation. CT scans of 30 patients were obtained at baseline and after two cycles of chemotherapy. Tumor volumes were calculated using a semiautomated computer algorithm. Overall survival was measured using a landmark time at 3 months post-treatment start date such that all patients had already received two cycles of chemotherapy and a follow-up scan. Association of volume changes with overall survival were determined by a Cox Proportional Hazards Model or log-rank test. The relationship between both pre and postoperative clinical stage and baseline tumor volume was analyzed using the rank sum test. RESULTS: The median baseline tumor volume was 473 cm(3) (range, 61 cm(3)-2108 cm(3)). Patients with high preoperative stages (III and IV) had larger baseline tumor volume than those with low preoperative stages (I and II) (p = 0.05). Patients with baseline volumes smaller than 619 cm(3) tended to survive longer than those with baseline volumes larger than or equal to 619 cm(3) (p = 0.07). Percentage change of tumor volume from baseline to first follow-up CT after two cycles of chemotherapy was significantly associated with overall survival (hazard ratio: 1.94 [95% confidence interval, 1.05-3.60], p = 0.04). Whereas the relative change in modified RECIST measurements was not significantly associated with overall survival (hazard ratio: 1.06 [95% confidence interval, 0.96-1.16], p = 0.25). By classifying changes of tumor volumes between two scans into two groups, i.e., "increase" and "decrease," a significant difference in survival was found between those who increased and decreased after two cycles of chemotherapy (p = 0.03). CONCLUSIONS: Changes in tumor volume after two cycles of chemotherapy predicted overall survival in patients with malignant pleural mesothelioma. Tumor volume at baseline was shown to be associated with preoperative clinical stage and survival. Computer-aided volumetric measurements may enable more reliable therapeutic response assessment and could provide additional prognostic information.