Effect of Positron Emission Tomography Imaging in Women With Locally Advanced Cervical Cancer: A Randomized Clinical Trial.

Importance: In women with locally advanced cancer of the cervix (LACC), staging defines disease extent and guides therapy. Currently, undetected disease outside the radiation field can result in undertreatment or, if disease is disseminated, overtreatment. Objective: To determine whether adding fludeoxyglucose F 18 positron emission tomography-computed tomography (PET-CT) to conventional staging with CT of the abdomen and pelvis affects therapy received in women with LACC. Design, Setting, and Participants: A randomized clinical trial was conducted. Women with newly diagnosed histologically confirmed International Federation of Gynecology and Obstetrics stage IB to IVA carcinoma of the cervix who were candidates for chemotherapy and radiation therapy (CRT) were allocated 2:1 to PET-CT plus CT of the abdomen and pelvis or CT alone. Enrollment occurred between April 2010 and June 2014 at 6 regional cancer centers in Ontario, Canada. The PET-CT scanners were at 6 associated academic institutions. The median follow-up at the time of the analysis was 3 years. The analysis was conducted on March 30, 2017. Interventions: Patients received either PET-CT plus CT of the abdomen and pelvis or CT of the abdomen and pelvis. Main Outcomes and Measures: Treatment delivered, defined as standard pelvic CRT vs more extensive CRT, ie, extended field radiotherapy or therapy with palliative intent. Results: One hundred seventy-one patients were allocated to PET-CT (n = 113) or CT (n = 58). The trial stopped early before the planned target of 288 was reached because of low recruitment. Mean (SD) age was 48.1 (11.2) years in the PET-CT group vs 48.9 (12.7) years in the CT group. In the 112 patients who received PET-CT, 68 (60.7%) received standard pelvic CRT, 38 (33.9%) more extensive CRT, and 6 (5.4%) palliative treatment. The corresponding data for the 56 patients who received CT alone were 42 (75.0%), 11 (19.6%), and 3 (5.4%). Overall, 44 patients (39.3%) in the PET-CT group received more extensive CRT or palliative treatment compared with 14 patients (25.0%) in the CT group (odds ratio, 2.05; 95% CI, 0.96-4.37; P = .06). Twenty-four patients in the PET-CT group (21.4%) received extended field radiotherapy to para-aortic nodes and 14 (12.5%) to common iliac nodes compared with 8 (14.3%) and 3 (5.4%), respectively, in the CT group (odds ratio, 1.64; 95% CI, 0.68-3.92; P = .27). Conclusions and Relevance: There was a trend for more extensive CRT with PET-CT, but the difference was not significant because the trial was underpowered. This trial provides information on the utility of PET-CT for staging in LACC. Trial Registration: ClinicalTrials.gov Identifier: NCT00895349.

A Retrospective Study Evaluating the Impact of Preoperative Breast MRI on Surgical Decision-Making in Young Patients (≤50 Years) with Invasive Breast Cancer.

INTRODUCTION: Breast magnetic resonance imaging (MRI) is considered a more sensitive diagnostic test for detecting invasive breast cancer than mammography or breast ultrasound. Breast MRI may be particularly useful in younger premenopausal women with higher density breast tissue for differentiating between dense fibroglandular breast tissue and breast malignancies. The main objective of this study was to determine the impact of preoperative breast MRI on surgical decision-making in young women with breast cancer. METHODS: A retrospective review of patients with newly diagnosed invasive breast cancer and age of ≤50 years was performed. All patients underwent physical examination, preoperative mammogram, breast ultrasound, and bilateral breast MRI. Two breast cancer surgeons reviewed the preoperative mammogram report, breast ultrasound report, and physical examination summary and were asked if they would recommend a lumpectomy, a quandrantectomy, or a mastectomy. A few weeks later, the two surgeons were shown the same information with the breast MRI report and were asked what type of surgery they would now recommend. In each case, MRI was classified by two adjudicators as having affected the surgical outcome in a positive, negative, or neutral fashion. A positive impact was defined as the situation where breast MRI detected additional disease that was not found on physical examination, mammogram, or breast ultrasound and led to an appropriate change in surgical management. A negative impact was defined as the situation where breast MRI led the surgeon to recommend more extensive surgery, with less extensive disease actually found at pathology. No impact was defined as the situation where MRI findings did not alter surgical recommendations or outcomes. RESULTS: Of 37 patients whose charts were reviewed, five patients were deemed to be ineligible due to having received neoadjuvant chemotherapy, having previous breast implants, or having had their tumor fully excised during biopsy. In total, 32 patients met the inclusion criteria of this study and were appropriate for analysis. The median age of our study patient population was 42 years. The pathologic diagnosis was invasive ductal carcinoma in 91% (29/32) of patients and invasive lobular carcinoma in 9% (3/32) of patients. For surgeon A, clinical management was altered in 21/32 (66%) patients, and for surgeon B, management was altered in 13/32 (41%) patients. The most common change in surgical decision-making after breast MRI was from breast-conserving surgery to a mastectomy. Mastectomy rates were similar between both surgeons after breast MRI. After reviewing the pathology results and comparing them with the breast MRI results, it was determined that breast MRI led to a positive outcome in 13/32 (41%) patients. Breast MRI led to no change in surgical management in 15/32 (47%) patients and resulted in a negative change in surgical management in 4/32 (13%) patients. Bilateral breast MRI detected a contralateral breast cancer in 2/32 (6%) patients. CONCLUSIONS: Preoperative breast MRI alters surgical management in a significant proportion of younger women diagnosed with breast cancer. Prospective studies are needed to confirm these findings and to help determine if this change in surgical decision-making will result in improved local control.

Adjuvant chemotherapy for breast cancer in a patient with primary autoimmune neutropenia.

We report an extremely rare and complex case of a 44-year-old woman diagnosed with an early stage triple negative breast cancer in the setting of primary autoimmune neutropenia with a pre-existing severe neutropenia. This case-report demonstrates that adjuvant chemotherapy for breast cancer can be administered in a patient with severe neutropenia. The management is however complicated and requires careful monitoring of side-effects related to both chemotherapy and treatment of autoimmune neutropenia. The role of chemotherapy in the treatment of triple negative breast cancer, the approach to autoimmune neutropenia and potential interactions are reviewed. To our knowledge, this is the first case reporting on the use of chemotherapy in a patient with severe pre-existing primary autoimmune neutropenia.

A review of pneumatosis intestinalis in the setting of systemic cancer treatments, including tyrosine kinase inhibitors.

PURPOSE: Pneumatosis intestinalis is a radiologic diagnosis that manifests in a variety of clinical settings. We report 4 cases of pneumatosis intestinalis in patients undergoing cancer treatments that included cytotoxic agents and/or tyrosine kinase inhibitors. These reports aim to provide insight into the clinical interpretation and pathogenesis of pneumatosis intestinalis in the setting of cancer treatments and demonstrate a potential association with tyrosine kinase inhibitors. METHODS: Radiologists responsible for the interpretation of adult imaging at our tertiary care centre were surveyed to identify cases of pneumatosis intestinalis arising in the midst of cancer treatment. The case histories were reviewed by physicians with expertise in cancer treatment. RESULTS: Four cases of chemotherapy-related pneumatosis intestinalis were identified. The diagnosis was made in 1 patient during investigations undertaken for non-life-threatening abdominal symptoms and incidentally in 2 patients by abdominal imaging used to measure chemotherapy response. A fourth patient presented in a life-threatening manner, and abdominal imaging was symptom guided. Interestingly, 3 of the 4 patients were receiving treatments that included a tyrosine kinase inhibitor, and this agent was the only identifiable potential etiology in 1 patient. CONCLUSIONS: The significance of pneumatosis intestinalis arising during cancer treatments is difficult to interpret because of the complex nature of the diseases and the treatments that often include combinations of cytotoxic agents and/or novel therapies. These reports demonstrate the importance of classifying this radiologic finding according clinical severity rather than etiology and underscore the need for continued observation for unexplained adverse effects when using novel therapies.

Solitary fibrous tumor (SFT) of the pelvis.

Solitary fibrous tumors (SFTs) are well recognized in the pleura, but their occurrence at other sites has only become appreciated in recent years, as a consequence of which extrapleural examples often go unrecognized and misdiagnosed. Because of their rarity, overall experience concerning this tumor has not been significant and reports detailing radiological findings are few. We herein report an unusual case of a large retroperitoneal pelvic SFT with features of high vascularity negating successful surgical resection.

Transvaginal sonography as an adjunct to endorectal sonography in the staging of rectal cancer in women.

OBJECTIVE: The purpose of this study was to evaluate the contribution of transvaginal sonography (TVS) in the staging of rectal cancer in women. MATERIALS AND METHODS: Sixty women with rectal tumors underwent TVS. Forty-five of the 60 women also underwent endorectal sonography. Forty-nine of the women had rectal carcinoma; nine, tubulovillous adenoma; and two, gastrointestinal stromal tumor confirmed at surgical pathologic examination (n = 41) and biopsy before chemoradiation therapy (n = 19). Four of the 49 rectal carcinomas were T1; seven, T2; 35, T3; and three, T4. Images from TVS and endorectal sonography were shown independently to two blinded reviewers, who staged the tumors and assessed examination adequacy for tumor presence, size, and depth and nodal status. Staging results with TVS were compared with those obtained with endorectal sonography and histopathologic examination. RESULTS: All tumors were seen with TVS. In 30 of the 49 rectal carcinomas confirmed at surgical pathologic examination TVS tumor staging was accurate in 25 (83.3%) of the cases. Two (6.7%) of the 30 tumors were understaged, and 3 (10%) were overstaged. All tumors selected for chemoradiation (n = 19) were correctly staged T3. Endorectal sonography was suboptimal for tumors that were stenotic (n = 3), large (n = 2), high at the rectosigmoid junction (n = 4), or low at the anal canal (n = 3). In these 12 cases, TVS successfully depicted the lesion, and the images gave enough information for prediction of stage. In interpretation of the images of 45 patients who underwent both TVS and endorectal sonography, the blinded reviewers had good agreement and comparable accuracy for staging in adequate examinations with each technique. Four of the nine villous adenomas were overstaged as T1 on TVS. Gastrointestinal stromal tumors manifested as intramural vascular masses. CONCLUSION: TVS is an excellent adjunct to endorectal sonography in the staging of rectal cancer in women. It helps resolve the findings after endorectal sonography has been unsuccessful because the tumors are stenotic or in a high or low position.