Histological Grade and Immunohistochemical Biomarkers of Breast Cancer: Correlation to Ultrasound Features.

OBJECTIVES: The purpose of this study is to correlate various features of breast cancers on ultrasound to their histological grade and immunohistochemical biomarkers. METHODS: Seventy-three patients with 77 invasive breast cancers, diagnosed between August 2011 and December 2014, were included in this prospective analysis. Margin, posterior features, shape, and vascularity were determined from ultrasound and classified according to the Breast Imaging Reporting and Data System lexicon. Histological grade, estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) status (positive [+] or negative [-]) were determined from surgical pathology reports. The cancers were categorized into low grade (grades 1 or 2) and high grade (grade 3). Correlation of ultrasound features of the cancers to their histological grade and receptor status was performed. RESULTS: There were 47 low-grade and 29 high-grade cancers. There was a significant difference in margin and posterior features between the low and high grade, ER + and ER-, and PR + and PR- (all P < .05), but not between HER2 + and HER2- cancers (both P > .05). There was no significant difference in shape and vascularity among the different subtypes (all P > .05). Spiculated margin was significantly associated with low-grade, ER+, PR + status; angular margin with high grade; microlobulated margin with ER- status; shadowing with PR + status; and enhancement with high grade, ER- status (all P < .05, all odds ratios ≥ 3.94). CONCLUSIONS: There was significant association of margin and posterior features of breast cancers with their histological grade and receptor status.

FDG PET/CT Response Assessment Criteria for Patients with Hodgkin's and Non-Hodgkin's Lymphoma at End of Therapy: A Multiparametric Approach.

PURPOSE: Based on the International Harmonization Project (IHP) criteria, positron emission tomography (PET) response assessment of residual nodal masses in patients with lymphoma after completion of therapy is performed visually using mediastinal blood pool as the reference. The primary objective of this study was to define the optimal reference for PET response assessment. Secondary aim was to assess if morphological criteria on computed tomography (CT) may improve performance of PET. METHODS: This institutional review board approved retrospective study included 137 patients, with Hodgkin's (n = 43) or non-Hodgkin's lymphoma (n = 94) assessed for residual masses (n = 180) after completion of therapy with pathology and clinical and imaging surveillance data (mean, 19 months) as the standard of reference. Two readers independently assessed response by IHP and Deauville criteria. The addition of morphological parameters on CT was assessed in relation to therapy response. RESULTS: Based on the standard of reference, 36 patients (26.3 %) had residual lymphoma. For IHP and Deauville criteria, sensitivity, specificity and accuracy were 97.2 %, 97.2 % (p = 1); 79.2 %, 92.1 % (p < 0.001); and 83.9 %, 93.4 % (p = 0.001), respectively. Of the morphological parameters assessed, only change in size over course of therapy was significant (p < 0.003) and improved specificity for IHP-based interpretation to 90.4 % (p = 0.008). CONCLUSIONS: Using liver as the visual reference to determine PET positivity for lymphoma patients being assessed for residual masses at the end of therapy improves specificity, yet maintains the high sensitivity of PET in identifying residual disease. The addition of change in size after therapy improves specificity of PET when using IHP-based but not Deauville-based interpretation.

A prospective pilot study of analysis of surgical margins of breast cancers using high-resolution sonography.

To investigate the role of high-resolution specimen sonography (SS) to determine the precise location of the targeted lesion in relation to the six surgical margins; the specimen digital radiography isocenter and the correlation with the rate of re-excision and residual tumour. Freshly excised surgical specimens were scanned by a breast radiologist using a high-frequency linear transducer in a cohort of 25 consecutive women undergoing breast conservation. Sonographic measurements of radial distances from all six margins (superior, inferior, lateral, medial, anterior and posterior) were obtained. Sonographic positive margin status was defined as targeted mass identified <5 mm from the tissue edge. The paired t test was used for statistical comparisons between sonographic and pathological measurements. The median cancer size was 15 mm (range 3.80-42 mm; 95 % CI 9.8-18) on sonography and 16 mm (range 2-60 mm; 95 % CI 15-20) on surgical pathology. SS showed 100 % sensitivity and 59 % specificity in the evaluation of surgical pathology margins. 20 % (5 of 25) patients had positive margins where 60 % were in situ carcinoma. The likelihood of carcinoma at the initial surgical margins was significantly higher in dense breasts (3/6 = 50 % vs 1/17 = 5.8 %; p = 0.04). The deviation of the isocenter of the specimens was found not significant. SS is a valuable tool for identify the cancer within the specimen, and better asses the margins. It is of significant importance in patients with dense breasts where specimen radiography is of limited value.

CT following US for possible appendicitis: anatomic coverage.

OBJECTIVE: To determine superior-inferior anatomic borders for CT following inconclusive/nondiagnostic US for possible appendicitis. METHODS: Ninety-nine patients with possible appendicitis and inconclusive/nondiagnostic US followed by CT were included in this retrospective study. Two radiologists reviewed CT images and determined superior-inferior anatomic borders required to diagnose or exclude appendicitis and diagnose alternative causes. This "targeted" coverage was used to estimate potential reduction in anatomic coverage compared to standard abdominal/pelvic CT. RESULTS: The study group included 83 women and 16 men; mean age 32 (median, 29; range 18-73) years. Final diagnoses were: nonspecific abdominal pain 50/99 (51%), appendicitis 26/99 (26%), gynaecological 12/99 (12%), gastrointestinal 9/99 (10%), and musculoskeletal 2/99 (2%). Median dose-length product for standard CT was 890.0 (range, 306.3 - 2493.9) mGy.cm. To confidently diagnose/exclude appendicitis or identify alternative diagnoses, maximum superior-inferior anatomic CT coverage was the superior border of L2-superior border of pubic symphysis, for both reviewers. Targeted CT would reduce anatomic coverage by 30-55% (mean 39%, median 40%) compared to standard CT. CONCLUSIONS: When CT is performed for appendicitis following inconclusive/nondiagnostic US, targeted CT from the superior border of L2-superior border of pubic symphysis can be used resulting in significant reduction in exposure to ionizing radiation compared to standard CT. KEY POINTS: • When CT is used following inconclusive/ nondiagnostic ultrasound, anatomic coverage can be reduced. • CT from L2 to pubic symphysis can be used to diagnose/exclude appendicitis. • Reduced anatomic coverage for CT results in reduced exposure to ionizing radiation.

Breast Background Parenchymal Enhancement on Screening Magnetic Resonance Imaging in Women Who Received Chest Radiotherapy for Childhood Hodgkin's Lymphoma.

RATIONALE AND OBJECTIVES: Breast magnetic resonance imaging (MRI) is recommended for the screening of women with a history of chest radiotherapy and consequent increased breast cancer risk. The purpose of this study was to evaluate the impact of prior chest radiotherapy on breast tissue background parenchymal enhancement (BPE) at screening breast MRI. MATERIALS AND METHODS: A departmental database was reviewed to identify asymptomatic women with either a history of chest radiotherapy for Hodgkin's lymphoma or age-matched controls who underwent screening breast MRI between 2009 and 2013. MRI studies were analyzed on an automated breast MRI viewing platform to calculate breast BPE and breast density. RESULTS: A total of 61 cases (mean age 41.6 ± 6.75 years) and 61 controls (mean age 40.8 ± 6.99 years) were included. The age of patients at the time of chest radiotherapy was 22.6 ± 8.17 years. Screening MRI was performed 19.0 ± 7.43 years after chest radiotherapy. BPE was significantly higher in patients who received chest radiotherapy (50% vs. 37%, P <0.01). A weak to moderate positive correlation (r > 0.3; P < 0.03) was found between BPE and number of years post radiotherapy. There was a trend toward significant difference between the two groups in the correlation of BPE and age (P = 0.05). Breast density was not significantly different between the two groups. CONCLUSIONS: BPE is significantly greater in women who receive chest radiotherapy for childhood Hodgkin's lymphoma, and unexpectedly, it positively correlates with the number of years passed after radiation therapy. Long-term biological effects of radiation therapy on breast parenchyma need further research.

Impact of Acquisition Method and Region of Interest Placement on Inter-observer Agreement and Measurement of Tumor Response to Targeted Therapy Using Dynamic Contrast-Enhanced Ultrasound.

This study evaluated the impact of different acquisition methods, user-directed region of interest placement and post-processing steps on the quantification of dynamic contrast-enhanced ultrasound measurements of blood volume in 29 patients with renal cancer, pre- and post-treatment. Specifically, we compared tumor quantification using multiple planes versus a single plane, breathhold versus free breathing and large region of interest versus a region targeting the area of highest vascularity. Performance was evaluated using area under the receiver operating characteristic curves to identify the method that best predicts progression-free survival. The intra-class correlation coefficient was also used to investigate how the same parameters affect inter-observer agreement. Of the different methods used to quantify blood volume in this study, the combination that had the highest level of inter-observer agreement (intra-class correlation coefficient = 0.8-0.97) and was the best predictor of progression-free survival was the change in blood volume measured (area under receiver operating characteristic curve = 0.77, p = 0.04) by a multiplane average, acquired during quiet breathing, quantified using a region of interest that encompassed the entire tumor.

Evaluation of Apparent Diffusion Coefficient to Predict Grade, Microinvasion, and Invasion in Ductal Carcinoma In Situ of the Breast.

RATIONALE AND OBJECTIVES: To evaluate the role of apparent diffusion coefficient (ADC) in distinguishing ductal carcinoma in situ (DCIS) grades and identifying microinvasive and/or invasive disease in the preoperative evaluation of patients with core biopsy-proven DCIS. MATERIALS AND METHODS: Research Ethics Board-approved study with informed consent from 81 women (age, 36-84 years) scheduled for core-biopsy with results of 82 noninvasive breast carcinomas. All patients were assessed preoperatively by diffusion sequence in addition to contrast magnetic resonance imaging (MRI). Lesion morphology and ADC values were recorded. The Kruskal-Wallis or one-way analysis of variance test and Pearson correlation coefficient were used to study the association between ADC and MRI lesion characteristics. Logistic regression analysis was used to evaluate the ability of ADC to predict the presence of invasion. RESULTS: Surgical pathology demonstrated associated invasive cancer in 26.8%, microinvasion in 14.6%, and pure DCIS in 58.5%. The minimum regions of interest (ROI)-based ADC was significantly different among the following three groups (P < .001, Kruskal-Wallis test): 0.98 × 10(-3) mm(2)/s ± 0.25 for pure DCIS, 0.82 × 10(-3) mm(2)/s ± 0.20 for DCIS with microinvasion, and 0.71 × 10(-3) mm(2)/s ± 0.27 for DCIS with invasive disease. Based on logistic regression analysis, the minimum ROI-based ADC of 0.56 × 10(-3) mm(2)/s was a significant predictor for invasive disease (odds ratio = 0.02, 95% confidence interval [0.002, 0.207], P = .001). Regardless of the field strength (1.5 vs. 3.0 T) ADC values of high-grade and non-high-grade DCIS were not significantly different. CONCLUSIONS: Pure DCIS had the highest "ROI-based" ADC measured using 1.5 T or 3.0 T. The ADC was able to identify microinvasion or invasive cancer in biopsy-proven DCIS lesions but not to distinguish the DCIS grades.

Use of Cardiac Magnetic Resonance Imaging Based Measurements of Inferior Vena Cava Cross-Sectional Area in the Diagnosis of Pericardial Constriction.

PURPOSE: To evaluate the value of cardiac magnetic resonance imaging (MRI)-based measurements of inferior vena cava (IVC) cross-sectional area in the diagnosis of pericardial constriction. METHODS: Patients who had undergone cardiac MRI for evaluation of clinically suspected pericardial constriction were identified retrospectively. The diagnosis of pericardial constriction was established by clinical history, echocardiography, cardiac catheterization, intraoperative findings, and/or histopathology. Cross-sectional areas of the suprahepatic IVC and descending aorta were measured on a single axial steady-state free-precession (SSFP) image at the level of the esophageal hiatus in end-systole. Logistic regression and receiver-operating curve (ROC) analyses were performed. RESULTS: Thirty-six patients were included; 50% (n = 18) had pericardial constriction. Mean age was 53.9 ± 15.3 years, and 72% (n = 26) were male. IVC area, ratio of IVC to aortic area, pericardial thickness, and presence of respirophasic septal shift were all significantly different between patients with constriction and those without (P < .001 for all). IVC to aortic area ratio had the highest odds ratio for the prediction of constriction (1070, 95% confidence interval [8.0-143051], P = .005). ROC analysis illustrated that IVC to aortic area ratio discriminated between those with and without constriction with an area under the curve of 0.96 (95% confidence interval [0.91-1.00]). CONCLUSIONS: In patients referred for cardiac MRI assessment of suspected pericardial constriction, measurement of suprahepatic IVC cross-sectional area may be useful in confirming the diagnosis of constriction when used in combination with other imaging findings, including pericardial thickness and respirophasic septal shift.

Accuracy of Contrast-enhanced US for Differentiating Benign from Malignant Solid Small Renal Masses.

PURPOSE: To test the hypothesis that qualitative and quantitative features of contrast material-enhanced ultrasonography (US) can be used to differentiate benign from malignant small renal masses. MATERIALS AND METHODS: This is an institutional review board approved, HIPAA-compliant prospective study with written informed consent. Patients with histologically characterized solid small renal masses, excluding lipid-rich angiomyolipomas, underwent qualitative contrast-enhanced US with a combination of three different US machines. A subgroup of patients underwent quantitative contrast-enhanced US. Patients received a bolus injection of 0.2 mL of contrast material for qualitative and quantitative evaluations and were followed for 3 minutes. Two radiologists independently reviewed videotaped qualitative contrast-enhanced US examinations and were blinded to the final diagnoses. Features that were evaluated included lesion vascularity relative to the adjacent cortex in the arterial phase, the presence of a capsule, homogeneity, the pattern of vascularity, and washout. One radiologist separately reviewed a subset of contrast-enhanced US examinations that were performed with all three machines. Parameters of a first-pass time intensity curve were calculated for quantitative analysis. The Mann-Whitney test was used for quantitative parameters, the χ(2) or Fisher exact test was used for qualitative parameters, and κ statistics and Fleiss methodology were used to determine interobserver and intermachine agreement. RESULTS: The study population consisted of 91 patients (35 women and 56 men) with 94 lesions. The mean age was 62 years ± 14 (range, 21-91). Three patients had two lesions each, which were evaluated at two different sessions. There were 26 benign small renal masses (including 18 oncocytomas, seven lipid-poor angiomyolipomas, and one hemangioblastoma) and 68 malignant masses (including 41 clear cell, 20 papillary, and seven chromophobe renal cell carcinomas [RCCs[) that were 1.1-4.0 cm in diameter (mean, 2.7 cm ± 0.9). All patients underwent contrast-enhanced US on the same one machine, and 68 patients were imaged on all three machines. Vascularity was present in all lesions (n = 94) at contrast-enhanced US. Lesion hypovascularity relative to the adjacent cortex in the arterial phase was seen in only malignant lesions by both reviewers; reviewer 1 saw hypovascularity in 24 of 94 lesions (P = .0001), and reviewer 2 saw hypovascularity in 21 of 94 lesions (P = .0006), for a specificity of 100% (95% confidence interval [CI]: 84, 100). This feature had κ values of 0.91 (95%CI: 0.82, 1.00) between the two reviewers and 0.85 (95% CI: 0.72, 0.99) between the three machines. Eighteen of 20 papillary RCCs were hypovascular. Quantitative parameters of area under the receiver operating characteristics curve, peak intensity, wash-in slope of 10%-90% and 5%-45%, and washout slope of 100%-10% and 50%-10% were significantly higher in malignant renal masses (P = .018, P = .002, P = .036, P = .016, P = .001, and P = .005, respectively) than in benign lesions. CONCLUSION: Excluding lipid-rich angiomyolipoma, hypovascularity-which has high interobserver and intermachine agreement-of solid small renal masses relative to the cortex in the arterial phase has 100% specificity (95% CI: 84, 100) for detecting malignancy, most often papillary RCC.

Quantitative shear wave elastography: correlation with prognostic histologic features and immunohistochemical biomarkers of breast cancer.

RATIONALE AND OBJECTIVES: To correlate prognostic histologic features and immunohistochemical biomarkers of breast cancer with quantitative shear wave elastography (SWE) parameters. MATERIALS AND METHODS: B-mode ultrasound (US) and SWE were performed before core biopsy on 72 cancers in 68 patients. Mean cancer size was determined from US. Histologic grade, lymph node status, lymphovascular invasion (LVI), histologic type, and immunohistochemical biomarkers (estrogen receptor, progesterone receptor, human epidermal growth factor receptor 2 [HER2]) were determined from surgical pathology reports. Correlation between these features and quantitative SWE parameters (mean elasticity [E mean], maximum elasticity [E max], and elasticity ratio [E ratio]) was made. RESULTS: There was significant correlation of mean cancer size with E mean, E max, and E ratio (correlation, 0.492, 0.500, and 0.435, respectively; all P < .001). Lymph node involvement was associated with significantly higher E max (P = .040). LVI was associated with significantly higher E mean, E max, and E ratio (P = .002, .004, and .042, respectively). There was no significant correlation of histologic grade with SWE parameters. HER2+ cancers were associated with significantly higher E ratio (P = .030). In multivariate analysis, only mean cancer size was significantly correlated with E mean and E max (P < .001). CONCLUSIONS: There was significant correlation of cancer size with SWE parameters. There was significant correlation of lymph node status and LVI with SWE, but only on univariate analysis. SWE has the potential to provide prognostic information of breast cancer in a noninvasive manner, but further study is required.

Endovascular first strategy for de novo TransAtlantic Inter-Society Consensus C and D femoro-popliteal disease: mid-term outcomes from a single tertiary referral center.

PURPOSE: Describe outcomes after endovascular intervention of TransAtlantic Inter-Society Consensus C and D femoro-popliteal disease. MATERIALS AND METHODS: Retrospective cohort study. Patient demographics, ankle-brachial indices, and lesion details were analyzed from a prospectively maintained database. In all, 980 limbs treated with percutaneous transluminal angioplasty±stenting of the femoro-popliteal segment between 2005 and 2012 were reviewed. Seventy-six patients representing 83 limbs with de novo TransAtlantic Inter-Society Consensus C and D lesions measuring ≥15 cm continuously were identified (mean age 71.3±12.1 years, 62% male). RESULTS: Twenty-five (30.1%) limbs were treated for severe claudication and 58 (69.9%) for critical limb ischemia. The mean pre-procedural ankle-brachial index was 0.47±0.19. The mean lesion length was 22.9±4.82 cm. Seventy patients representing 77 limbs were available for a mean follow-up length of 19.5 months (range 0-79). The mean post-procedural ankle-brachial index was 0.71±0.28. Primary, assisted-primary, and secondary patency rates were 68.1%, 72.7%, and 83.3% at 6 months, 55.3%, 63.6%, and 58.3% at 12 months, and 38.2%, unavailable, and 10.4% at 24 months, respectively. CONCLUSIONS: Angioplasty-first strategy for TransAtlantic Inter-Society Consensus C and D lesions of the femoro-popliteal artery can be safely performed. However, patency drastically decreases after 12 months suggesting further improvements are required to achieve longer-term clinical benefit.

Cardiac magnetic resonance imaging findings predict major adverse events in apical hypertrophic cardiomyopathy.

PURPOSE: The purpose of this study was to determine the prognostic significance of cardiac magnetic resonance imaging (MRI) findings in patients with apical hypertrophic cardiomyopathy (HCM). MATERIALS AND METHODS: Cardiac MRI studies of 93 consecutive patients with apical HCM were retrospectively evaluated. Quantification of late gadolinium enhancement (LGE) was determined and expressed as a percentage of total left ventricular (LV) myocardial mass (%LGE). Morphologic features including presence of apical aneurysm, right ventricular hypertrophy, and LV thrombus were also assessed. Clinical data were collected during follow-up to assess for occurrence of major adverse events, defined as: heart failure, stroke, appropriate automatic implantable cardioverter defibrillator discharge, sustained ventricular tachycardia, aborted sudden cardiac death, and/or all-cause death. RESULTS: The mean age of the patients was 54.9±13.8 years, and 72.0% (n=67) were male. LGE, right ventricular hypertrophy, apical aneurysm, and LV thrombus were identified in 69.4%, 25.8%, 18.3%, and 4.3%, respectively. Mean %LGE was 10.8%±11.1%. Over 2.4±1.7 years of follow-up, 14 subjects (15.1%) experienced a major adverse event (event rate, 6.3%/y): heart failure (6.5%), stroke (6.5%), appropriate automatic implantable cardioverter defibrillator discharge (2.2%), sustained ventricular tachycardia (2.2%), aborted sudden cardiac death (1.1%), and all-cause death (0.0%). Presence of apical aneurysm and extent of LGE were significant predictors of major adverse events [odds ratio (OR) 4.6, P=0.015; and OR 1.4/5% LGE, P=0.030, respectively]. Patients with both apical aneurysm and >5% LGE were at highest risk for major adverse events (OR 6.7, P=0.004) and had shortest event-free survival (P=0.001). CONCLUSIONS: Within our population of apical HCM patients, the extent of LGE and the presence of an apical aneurysm identified by cardiac MRI were both significant predictors of major adverse clinical events.

Diagnostic performance of quantitative shear wave elastography in the evaluation of solid breast masses: determination of the most discriminatory parameter.

OBJECTIVE: The purpose of this article is to assess the diagnostic performance of quantitative shear wave elastography in the evaluation of solid breast masses and to determine the most discriminatory parameter. SUBJECTS AND METHODS: B-mode ultrasound and shear wave elastography were performed before core biopsy of 123 masses in 112 women. The diagnostic performance of ultrasound and quantitative shear wave elastography parameters (mean elasticity, maximum elasticity, and elasticity ratio) were compared. The added effect of shear wave elastography on the performance of ultrasound was determined. RESULTS: The mean elasticity, maximum elasticity, and elasticity ratio were 24.8 kPa, 30.3 kPa, and 1.90, respectively, for 79 benign masses and 130.7 kPa, 154.9 kPa, and 11.52, respectively, for 44 malignant masses (p < 0.001). The optimal cutoff value for each parameter was determined to be 42.5 kPa, 46.7 kPa, and 3.56, respectively. The AUC of each shear wave elastography parameter was higher than that of ultrasound (p < 0.001); the AUC value for the elasticity ratio (0.943) was the highest. By adding shear wave elastography parameters to the evaluation of BI-RADS category 4a masses, about 90% of masses could be downgraded to BI-RADS category 3. The numbers of downgraded masses were 40 of 44 (91%) for mean elasticity, 39 of 44 (89%) for maximum elasticity, and 42 of 44 (95%) for elasticity ratio. The numbers of correctly downgraded masses were 39 of 40 (98%) for mean elasticity, 38 of 39 (97%) for maximum elasticity, and 41 of 42 (98%) for elasticity ratio. There was improvement in the diagnostic performance of ultrasound of mass assessment with shear wave elastography parameters added to BI-RADS category 4a masses compared with ultrasound alone. Combined ultrasound and elasticity ratio had the highest improvement, from 35.44% to 87.34% for specificity, from 45.74% to 80.77% for positive predictive value, and from 57.72% to 90.24% for accuracy (p < 0.0001). The AUC of combined ultrasound and elasticity ratio (0.914) was the highest compared with the other combined parameters. CONCLUSION: There was a statistically significant difference in the values of the quantitative shear wave elastography parameters of benign and malignant solid breast masses. By adding shear wave elastography parameters to BI-RADS category 4a masses, we found that about 90% of them could be correctly downgraded to BI-RADS category 3, thereby avoiding biopsy. Elasticity ratio (cutoff, 3.56) appeared to be the most discriminatory parameter.

Cardiovascular CT in the diagnosis of pericardial constriction: predictive value of inferior vena cava cross-sectional area.

BACKGROUND: The diagnosis of pericardial constriction remains challenging. PURPOSE: We sought to evaluate the predictive value of cardiovascular CT-based measurements of inferior vena cava (IVC) parameters in the diagnosis of pericardial constriction. METHODS: Forty-two consecutive patients referred for assessment of pericardial constriction by 64-slice CT were evaluated. The diagnosis of pericardial constriction was confirmed by clinical history, echocardiography, cardiac catheterization, intraoperative findings, histopathology, or a combination. Diameter and cross-sectional area of the suprahepatic IVC and cross-sectional area of the aorta were measured on a single-axial CT image at the level of the esophageal hiatus. Maximum pericardial thickness was measured. Logistic regression and receiver operating curve analyses were performed. RESULTS: Twenty-two patients had pericardial constriction. Mean age of the 42 patients was 57.1 ± 16.4 years, 57.1% were men. IVC diameter, IVC area, the ratio of IVC to aortic area, and pericardial thickness were all significantly greater in patients with constriction than in patients without (P < .05 for all). IVC-to-aortic area ratio had the highest odds ratio (51; 95% CI, 2.8-922) for the prediction of constriction and remained a significant predictor in multivariable analysis. In nested models, IVC-to-aortic area ratio had incremental value over pericardial thickness for the diagnosis of constriction. IVC-to-aortic area ratio discriminated between patients with and without constriction with an area under the curve of 0.88 on receiver operating curve analysis, with a value ≥ 1.6 having a sensitivity and specificity of 95% and 76%, respectively. Interobserver agreement for IVC-to-aortic area ratio was excellent (intraclass correlation coefficient, 0.98). CONCLUSION: Assessment of IVC-to-aortic area ratio on CT aids with the diagnosis of pericardial constriction and has independent and incremental value over pericardial thickness alone.

(18)F-FDG-PET/CT in assessing response to neoadjuvant chemoradiotherapy for potentially resectable locally advanced esophageal cancer.

PURPOSE: To correlate metabolic response to neoadjuvant chemoradiotherapy (NACR) on FDG-PET/CT using PERCIST-based criteria to pathologic and clinical response, and survival in patients with locally advanced esophageal cancer (LAEC). MATERIALS AND METHODS: Forty-five patients with LAEC underwent PET/CT at baseline and after NACR. Tumors were evaluated using PERCIST (PET response criteria in solid tumors)-based criteria including SUL, SUL tumor/liver ratio, % change in SUL. These parameters were compared to pathology regression grade (PRG), clinical response (including residual or new disease beyond the surgical specimen), and overall survival. RESULTS: On surgical pathology, there was complete or near-complete regression of tumor in 51.1 %, partial response in 42.2 %, and lack regression in 4.4 %. One patient (2.2 %) had progression of disease on imaging and did not undergo surgical resection. None of the baseline PET parameters had significant correlation to pathology regression grade or clinical response. On follow-up, a positive correlation was found between post-therapy SUL ratio, %∆ SUL and %∆ SUL ratio and clinical response (p = 0.025, 0.035, 0.030, respectively). A weak correlation was found between post-therapy SUL ratio to PRG (p = 0.049). A strong correlation was found between the metabolic response score and PRG (p = 0.002) as well as between metabolic response and clinical response (p < 0.001). CONCLUSION: PERCIST-based metabolic response assessment to NACR in LAEC may correlate with clinical outcome and survival.

Minimal-dose computed tomography is superior to chest x-ray for the follow-up and treatment of patients with resected lung cancer.

OBJECTIVES: A minimal-dose computed tomography scan of the thorax (MnDCT) delivers a radiation dose comparable with a chest x-ray (CXR). We hypothesized that in patients with completely resected lung cancer, surveillance with MnDCT, when compared with CXR, leads to earlier detection and a higher rate of treatment of new or recurrent lung cancer. METHODS: After lung cancer resection, patients prospectively were enrolled for surveillance with MnDCT and CXR at 3, 6, 12, 18, 24, 36, 48, and 60 months. Images were interpreted by different blinded radiologists. When new or recurrent cancer was suspected, standard-dose CT and/or a tissue biopsy were performed for confirmation. RESULTS: Between 2007 and 2012, 271 patients were included and 1137 pairs of CXR and MnDCT were analyzed. MnDCT was more sensitive (94% vs 21%; P < .0001) and had a higher negative predictive value (99% vs 96%; P = .007) than CXR for the diagnosis of new or recurrent lung cancer. The prevalence of new or recurrent lung cancer was 23.2% (63 of 271), of whom 78% (49 of 63) had asymptomatic disease. The majority of asymptomatic patients (75%; 37 of 49) were treated with curative intent and had a median survival of 69 months. The remainder of patients received palliative treatment (24%; 12 of 49) and had a median survival of 25 months (P < .0001). CONCLUSIONS: After curative resection of lung cancer, MnDCT is superior to CXR for the detection of new or recurrent lung cancer. The majority of new or recurrent cancer was detected by MnDCT at an asymptomatic phase, allowing for curative treatment, leading to a long survival.

Cardiovascular magnetic resonance imaging predictors of pregnancy outcomes in women with coarctation of the aorta.

AIMS: The aim of this study was to determine associations between aortic morphometry evaluated by cardiovascular magnetic resonance (CMR) and pregnancy outcomes in women with aortic coarctation (CoA). METHODS: Consecutive women with CoA seen with CMR within 2 years of delivery were reviewed. Aortic dimensions were measured on CMR angiography. Adverse outcomes (cardiovascular, obstetric, and foetal/neonatal) were documented. RESULTS: We identified 28 women (4 with native and 24 with repaired CoA) who had 30 pregnancies. There were 29 live births (1 stillbirth) at mean gestation 38 ± 2 weeks. Mean maternal ages at first cardiac intervention and pregnancy were 6 ± 8 and 29 ± 6 years, respectively. There were nine cardiovascular events (hypertensive complications in five; stroke in two and arrhythmia in two) occurring in seven pregnancies. Minimum aortic dimensions were smaller in women with cardiovascular events (12.1 vs. 14.3 mm, P = 0.001), specifically in those with hypertensive complications (11.6 vs. 14.4 mm, P < 0.001). From receiver operator curve analysis, optimal discrimination for the development of adverse cardiovascular events occurred at the 12 mm diameter threshold [sensitivity 78%, specificity 91%, area under the curve 0.86 (95% CI: 0.685-1)]. All hypertensive events occurred in conjunction with a minimum aortic diameter of 12 mm (7mm/m(2)) or less. No adverse outcomes occurred if minimum diameter exceeded 15 mm. CONCLUSION: Smaller aortic dimensions relate to increased risk of hypertensive events in pregnant women with CoA. CMR can aid in stratification of risk for women with CoA who are considering pregnancy.

Cystic renal cell carcinomas: do they grow, metastasize, or recur?

OBJECTIVE: The purpose of this study is to evaluate the interval growth, tumor recurrence, and metastatic disease occurrence of cystic renal cell carcinoma (RCC). MATERIALS AND METHODS: Pre-and posttreatment imaging of 47 histologically proven cystic RCCs, with at least 6 months of pretreatment imaging monitoring or at least 2 years of posttreatment imaging follow-up, or both, was retrospectively reviewed. Tumor morphologic features, preoperative growth, histologic typing and grading, and the incidence of tumor recurrence or metastasis were evaluated. Growth rate of tumors were compared among various histologic subtypes and Fuhrman grades. RESULTS: Of 47 tumors, 27 (57.5%) were clear cell RCCs, 12 (25.5%) were multilocular RCCs, and eight (17%) were papillary cystic RCCs. Overall, 26 (55.3%) tumors were graded as Fuhrman grade 2, 17 (36.1%) were Fuhrman grade 1, and one tumor was Fuhrman grade 3. Of the 26 tumors with a minimum of 6 months of pretreatment imaging monitoring, 19 (73%) did not show a significant increase in tumor size. The differences in mean growth among the Fuhrman grades and different subtypes were not statistically significant. The average duration of posttreatment follow-up was 51 months. There were no local recurrences among the 43 patients who underwent posttreatment imaging, except for one patient who had metastasis at preoperative clinical presentation. CONCLUSION: Cystic RCCs exhibit slow indolent growth, if any, and show no significant metastatic or recurrence potential, with excellent clinical outcomes. We raise the need for revisiting current imaging protocols that may involve frequent pre-and posttreatment imaging in cystic RCCs.

Heterogeneity of myocardial iron distribution in response to chelation therapy in patients with transfusion-dependent anemias.

The purpose of this study is to examine the effect of different iron chelation regimens on the distribution of myocardial iron in patients with transfusion-dependent anemias. Institutional review board approval was obtained. Patients treated with iron chelation therapy who had undergone baseline and 1-year follow-up cardiac T2* MR studies in a four-year period were identified retrospectively. One hundred and eight patients (44 % male, mean age 31.6 ± 9.7 years) were included. The interventricular septum on three short-axis slices (basal, mid and apical) was divided into anterior and inferior regions of interest for T2* analysis. Cardiac iron concentration (CIC) was calculated from T2* values. Statistical analysis included analysis of variance and paired t-test, using Bonferroni adjustment in all pairwise comparisons. At baseline, T2* measurements varied significantly across all six regions (p < 0.001): lowest in the mid anteroseptum (mean 22.3 ± 10.1 ms) and highest in the apical inferoseptum (mean 26.2 ± 12.8 ms). At follow-up, T2* and CIC values improved significantly in all segments [mean change of 3.78 ms (95 % CI (2.93, 4.62), p < 0.001) and 0.23 mg/g (95 % CI (0.16, 0.29), p < 0.001), respectively]. Change in T2* values varied significantly between segments (p < 0.001) with greatest improvement in the apical inferoseptum [4.26 ms, 95 % CI (2.42, 6.11)] and least improvement in the basal anteroseptum [2.95 ms, 95 % CI (1.37, 4.54)]. The largest improvement in T2* values was noted in patients treated with deferiprone [4.96 ms, 95 % CI (2.34, 7.58)]. There was a statistically significant difference in improvement in CIC values between chelation regimens (p = 0.016). This is the first study to report heterogeneity in response to iron chelating drugs with variable segmental changes in T2* values.

Deep basal inferoseptal crypts occur more commonly in patients with hypertrophic cardiomyopathy due to disease-causing myofilament mutations.

PURPOSE: To determine the relationship between deep basal inferoseptal crypts and disease-causing gene mutations in hypertrophic cardiomyopathy (HCM). MATERIALS AND METHODS: Institutional research and ethics board approval was obtained for this retrospective study, and the requirement to obtain informed consent was waived. Two readers, who were blinded to genetic status, independently assessed cardiac magnetic resonance (MR) images obtained in 300 consecutive unrelated genetically tested patients with HCM. Readers documented the morphologic phenotype, the presence of deep basal inferoseptal crypts, and the imaging plane in which crypts were first convincingly visualized. The Student t test, the Fisher exact test, and multivariate logistic regression were used for comparisons and to evaluate the relationship between these crypts and the detection of disease-causing mutations. RESULTS: The frequency of deep basal inferoseptal crypts was significantly higher in patients with disease-causing mutations than in those without disease-causing mutations (36% and 4%, respectively; P < .001). The presence of crypts was a stronger predictor of disease-causing mutations than was reverse septal curvature (P = .025). Patients with these crypts had a higher likelihood of having disease-causing mutations than non-disease-causing mutations (P < .001). Thirty-one of the 34 patients with both deep basal inferoseptal crypts and reverse septal curvature (91%) had disease-causing mutations (sensitivity, 26%; specificity, 98%). The presence of deep basal inferoseptal crypts (odds ratio: 6.64; 95% confidence interval: 2.631, 16.755; P < .001) and reverse septal curvature (odds ratio: 4.8; 95% confidence interval: 2.552, 9.083; P < .001) were predictive of disease-causing mutations. Both observers required additional imaging planes to identify approximately half of all crypts. CONCLUSION: Deep basal inferoseptal crypts occur more commonly in patients with HCM with disease-causing mutations than in those with genotype-negative HCM.