Angiomammography: A review of current evidences.

Although mammography is currently the imaging technique of choice for screening and diagnosis, it has some limitations, especially in patients with high-density breasts. The evolution from film screen to full-field digital mammography has recently led to the development of new imaging techniques, which are less expensive and widely available. Contrast-enhanced spectral mammography (CESM) is one of them, coupling X-ray breast imaging to the intravenous administration of an iodinated contrast material. CESM provides both morphological information, similar to mammography, and functional information of tumor perfusion. In this review, the imaging technique, the specificity of interpretation of CESM compared to MRI and the currently available data are presented. The clinical performances of CESM versus those of mammography and MRI and its additional value in preoperative local assessment and screening is discussed. The potential advantages and disadvantages are mentioned and we also discuss how CESM contributes to the detection of lesions and how it can be used in daily clinical workflow.

Long-term survival after aggressive treatment of relapsed serosal or distant pseudomyxoma peritonei.

INTRODUCTION: Complete cytoreductive surgery (CCRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have dramatically changed the prognosis of patients with pseudomyxoma peritonei (PMP). However, recurrences can still occur and no consensus has been reached regarding their optimal treatments. This study aimed to analyze the patterns of recurrence after CCRS plus HIPEC for PMP and potential subsequent treatments of these lesions. PATIENTS AND METHODS: Between 1992 and 2014, patients who had relapsed after treatment of PMP were selected from a prospective database of 251 patients who had undergone CCRS plus HIPEC with a curative intent. RESULTS: After a median follow-up of 85 months, 66 patients (26%) had relapsed with a median free interval of 25 months. The first recurrence was mostly located in the peritoneum, isolated in 50 patients (76%) and associated with extraperitoneal disease in 6 patients. Curatively intended treatment of the relapse, combining surgery and chemotherapy was achievable in 76% of the patients, leading to a 5-year overall survival (OS) rate of 83% from the date of treatment of the first recurrence. In contrast, the 5-year OS rate was only 27% (p < 0.001) for patients treated with non-curative therapy. An isolated peritoneal recurrence was predictive of greater amenability to curative therapy and a better prognosis. CONCLUSION: After CCRS plus HIPEC, serosal recurrences were more common than their distant counterparts. Distant relapses' emergence has raised the question of their optimal treatments. Very long-term survival can be obtained after further treatment of recurrent PMP for patients with limited disease and good general status.

Imaging of neuroendocrine tumors of the pancreas.

Pancreatic neuroendocrine tumors (PNETs) are rare and represent a heterogeneous disease. PNET can be functioning or non-functioning with different clinical presentations and different prognosis based on WHO and pTNM classifications. The role of imaging includes the localization of small functioning tumor, differentiation of these tumors from adenocarcinoma, identification of signs of malignancy and evaluation of extent. PNETs have a broad spectrum of appearance. On CT and MRI, most of functioning PNETs are well defined small tumors with intense and homogeneous enhancement on arterial and portal phases. However, some PNETs with a more fibrous content may have a more delayed enhancement that is best depicted on the delayed phase. Other PNETs can present as purely cystic, complex cystic and solid tumors and calcified tumors. Non-functioning PNETs are larger with less intense and more heterogeneous enhancement. Functional imaging is useful for disease staging, to detect disease recurrence or the primary but also to select patient candidate for peptide receptor radiometabolic treatment. Somatostatin receptor scintigraphy (SRS) (Octreoscan®) is still the most available technique. Gallium 68-SST analogue PET have been demonstrated to be more sensitive than SRS-SPEC and it will be the future of functional imaging for NET. Finally, 18FDG PET/CT is indicated for more aggressive PNET as defined either by negative SRS and huge tumor burden or ki67 above 10% or poorly differentiated PNEC tumors.

Breast pain and imaging.

Breast pain is a common reason for consultation and a source of anxiety for patients. Cyclical breast pain can be distinguished from non-cyclical pain and breast pain with other symptoms. Many causes, usually benign are possible and the clinical enquiry and physical examination are essential to establish predisposing factors. Although imaging is not always needed for isolated breast pain, it is still useful for the diagnosis of specific causes such as tension cysts, giant adenofibromas or Mondor's thrombophlebitis. Ultrasound is the first line investigation before mammography, MRI or biopsy, which may be indicated for suspicious abnormalities. Some cancers may be associated with pain, which implies that radiologists and physicians should always take breast pain seriously.

Liver, lung and peritoneal metastases in colorectal cancers: is the patient still curable? What should the radiologist know.

Regardless of the advances in chemotherapy, the only curative treatment for colorectal metastases is surgery, which must be complete and excise all of the metastatic sites of disease. Thanks to advances in neoadjuvant chemotherapy and also to alternative techniques, such as radiofrequency ablation, however, surgical treatments have become available to a larger number of patients and have improved patient survival. The aim of this article is to describe the different treatment strategies for colorectal metastases and to examine the role of imaging in defining the resect ability of these metastases. The key factors in the radiological report in the initial and post-chemotherapy assessments are described.

Whole body MRI in paediatric oncology.

Whole body MRI provides excellent contrast resolution imaging and is an interesting alternative to nuclear medicine examinations in paediatric oncology because it does not involve exposure to radiation. This technique, now feasible in clinical practice, helps to evaluate metastatic spread and response to treatment, which are of great prognostic interest. Numerous studies have demonstrated the non-inferiority of this technique when compared to nuclear medicine examinations. However, there is still a need to standardize indications in each type of cancer and at every stage of it. This article first discusses the technical principles of whole body MRI, then reviews current clinical applications for the modality in children, and finally, discusses future useful developments for paediatric oncology.

Contrast-enhanced spectral mammography versus MRI: Initial results in the detection of breast cancer and assessment of tumour size.

OBJECTIVES: To compare mammography (MG), contrast-enhanced spectral mammography (CESM), and magnetic resonance imaging (MRI) in the detection and size estimation of histologically proven breast cancers using postoperative histology as the gold standard. METHODS: After ethical approval, 80 women with newly diagnosed breast cancer underwent MG, CESM, and MRI examinations. CESM was reviewed by an independent experienced radiologist, and the maximum dimension of suspicious lesions was measured. For MG and MRI, routine clinical reports of breast specialists, with judgment based on the BI-RADS lexicon, were used. Results of each imaging technique were correlated to define the index cancer. Fifty-nine cases could be compared to postoperative histology for size estimation. RESULTS: Breast cancer was visible in 66/80 MG, 80/80 CESM, and 77/79 MRI examinations. Average lesion largest dimension was 27.31 mm (SD 22.18) in MG, 31.62 mm (SD 24.41) in CESM, and 27.72 mm (SD 21.51) in MRI versus 32.51 mm (SD 29.03) in postoperative histology. No significant difference was found between lesion size measurement on MRI and CESM compared with histopathology. CONCLUSION: Our initial results show a better sensitivity of CESM and MRI in breast cancer detection than MG and a good correlation with postoperative histology in size assessment. KEY POINTS: • Contrast-enhanced spectral mammography (CESM) is slowly being introduced into clinical practice. • Access to breast MRI is limited by availability and lack of reimbursement. • Initial results show a better sensitivity of CESM and MRI than conventional mammography. • CESM showed a good correlation with postoperative histology in size assessment. • Contrast-enhanced spectral mammography offers promise, seemingly providing information comparable to MRI.

Prognostic significance of visible cardiophrenic angle lymph nodes in the presence of peritoneal metastases from colorectal cancers.

BACKGROUND: Visible cardiophrenic angle lymph nodes (CPALN) (enlarged or not), detected on CT scan are correlated with the presence of peritoneal metastases (PM), and contribute to the diagnosis of PM in colorectal cancer patients. OBJECTIVE: To study whether visible CPALN exert a prognostic impact on survival after complete cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (CCRS + HIPEC) treating PM. PATIENTS AND METHODS: From 1999 to 2010, 114 patients with colorectal cancer and PM were treated with CCRS + HIPEC. CPALN were depicted in 64% of cases. The impact of visible CPALN on survival was investigated retrospectively. RESULTS: The mean peritoneal cancer index (PCI) score was 9.2, 21% of the patients had presented with associated liver metastases, and 71% of the women with ovarian metastases. Median follow-up was 3.9 years. Visible CPALN had no impact on OS nor on DFS, unlike the PCI score which was unequivocably the most potent prognostic factor in the multivariate analysis. CONCLUSION: Although some arguments might suggest that CPALN are malignant, paradoxically, we found that visible CPALN did not exert a positive nor a negative impact on survival after CCRS + HIPEC. SYNOPSIS: Visible cardiophrenic angle lymph nodes (CPALN) on CT-scan are strongly associated with the presence of peritoneal metastases. But this study demonstrates that the presence of CPALN has no prognostic impact after optimal cytoreductive surgery plus HIPEC.

Value of cardiophrenic angle lymph node for the diagnosis of colorectal peritoneal carcinomatosis.

BACKGROUND: Cardiophrenic angle lymph nodes (CPALN) have been reported in patients with abdominopelvic malignancies. We aimed to assess whether the presence of CPALN is associated with peritoneal carcinomatosis (PC) in colorectal cancer. PATIENTS AND METHODS: Between 2007 and 2011, 550 patients with colorectal cancer, including 165 (30%) with PC, had undergone surgery with complete peritoneal exploration. We retrospectively reviewed preoperative CT scans for the presence of CPALN and assessed its association with confirmed PC by univariate and multivariate analyses. RESULTS: CPALN were present in 123 (75%) patients with PC, but absent in 263 (68%) patients without PC (Se: 0.72; Sp: 0.68; PPV: 0.49; NPV: 0.85; [OR], 3.3; p<0.001). PC was the only factor independently associated with CPALN in the multivariate analysis. CPALN was not correlated with the presence of liver metastases. 99 of the 165 patients with PC (62%) had visible signs of PC on CT scan. Among the remaining 66 patients, CPALN were the only potential sign of PC in 41 (62%), (Se 0.62, Sp 0.68, PPV 0.24, and NPV 0.92). CONCLUSION: The detection of CPALN on CT may be of valuable help for the diagnosis of PC in patients with CRC.

Breast elastography: the technical process and its applications.

Breast elastography is being increasingly used to better characterize breast lesions. Published studies have shown that it improved specificity of B mode ultrasound. Two elastography modes are available: free-hand elastography and shear wave elastography. Free-hand elastography is obtained by a mechanic wave induced by the ultrasound probe, deforming the target, either by small movements induced by breathe. An elastogram is obtained and displayed either as a colour map or a size ratio or elasticity ratio measurement. The second mode is shear wave elastography; two methods are available: Shear Wave Elastography (SWE) and ARFI mode (Acoustic Radiation Force Impulse). Shear wave elastography is less operator-dependent than free-hand elastography mode and provides a quantitative approach. A value of over 80kPa (SWE) or velocity results of over 2m/s (ARFI) are considered as suspicious. False negatives may occur in soft breast cancers (mucinous carcinoma, carcinoma with an inflammatory stroma, etc.) and false positives may be seen with poorly deformable benign lesions such as old fibrous adenomas. In practical use, elastography is a useful complementary tool for undetermined breast lesions categorized as BI-RADS 4a or BI-RADS 3, or for cystic lesions but cannot avoid fine needle aspiration or core biopsy if ultrasound features are clearly suspicious.

Computed-aided diagnosis (CAD) in the detection of breast cancer.

Computer-aided detection (CAD) systems have been developed for interpretation to improve mammographic detection of breast cancer at screening by reducing the number of false-negative interpretation that can be caused by subtle findings, radiologist distraction and complex architecture. They use a digitized mammographic image that can be obtained from both screen-film mammography and full field digital mammography. Its performance in breast cancer detection is dependent on the performance of the CAD itself, the population to which it is applied and the radiologists who use it. There is a clear benefit to the use of CAD in less experienced radiologist and in detecting breast carcinomas presenting as microcalcifications. This review gives a detailed description CAD systems used in mammography and their performance in assistance of reading in screening mammography and as an alternative to double reading. Other CAD systems developed for MRI and ultrasound are also presented and discussed.

Breast elasticity: principles, technique, results: an update and overview of commercially available software.

Breast ultrasound elasticity evaluation has become a routine tool in addition to diagnostic ultrasound during the last five years. Two elasticity evaluation modes are currently available: free-hand elastography and shear-wave elastography (SWE). Most of the commercially available elastography scanners have specific procedures which must be understood by the users. Free-hand elastography usually displays qualitative imaging such as an elastogram, but most of the companies now use it to quantify the relative stiffness between a lesion and the surrounding breast tissue. SWE is a new mode theoretically independent of the sonographer which displays more quantitative information, and can be useful for characterizing breast lesions. Recent studies on elastography suggest that elasticity imaging can increase B-mode accuracy and specificity in differentiating benign and malignant breast lesions. This functional imaging mode could help reduce the number of biopsies performed for benign breast lesions. This review gives a detailed description of the main commercially available systems and the results of current applications in the evaluation of breast elasticity.

Sequential research-related biopsies in phase I trials: acceptance, feasibility and safety.

BACKGROUND: Sequential tumour biopsies are of potential interest for the rational development of molecular targeted therapies. PATIENTS AND METHODS: From June 2004 to July 2009, 186 patients participated in 14 phase I clinical trials in which sequential tumour biopsies (13 trials) and/or sequential normal skin biopsies (6 trials) were optional. All patients had to sign an independent informed consent for the biopsies. RESULTS: Tumour biopsies were proposed to 155 patients and 130 (84%) signed the consent while normal skin biopsies were proposed to 70 patients and 57 (81%) signed the consent. Tumour biopsies could not be carried out in 41 (31%) of the 130 consenting patients. Tumour biopsies were collected at baseline in 33 patients, at baseline and under treatment in 56 patients. Tumour biopsies were obtained using an 18-gauge needle, under ultrasound or computed tomography guidance. Only nine minor complications were recorded. Most tumour biopsy samples collected were intended for ancillary molecular studies including protein or gene expression analysis, comparative genomic hybridization array or DNA sequencing. According to the results available, 70% of the biopsy samples met the quality criteria of each study and were suitable for ancillary studies. CONCLUSIONS: In our experience, the majority of the patients accepted skin biopsies as well as tumour biopsies. Sequential tumour and skin biopsies are feasible and safe during early-phase clinical trials, even when patients are exposed to anti-angiogenic agents. The real scientific value of such biopsies for dose selection in phase I trials has yet to be established.

Results of systematic second-look surgery plus HIPEC in asymptomatic patients presenting a high risk of developing colorectal peritoneal carcinomatosis.

PURPOSE: To analyze the impact of systematic second-look surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC) performed 1 year after resection of the primary tumor in asymptomatic patients at high risk of developing peritoneal carcinomatosis (PC). PATIENTS AND METHODS: From 1999 to 2009, 41 patients without any sign of recurrence on imaging studies underwent second-look surgery aimed at treating limited PC earlier and more easily. They were selected based on 3 primary tumor-associated criteria: resected minimal synchronous macroscopic PC (n = 25), synchronous ovarian metastases (n = 8), and perforation (n = 8). RESULTS: PC was found and treated with complete surgery plus HIPEC in 23 of the 41 (56%) patients. The other patients underwent complete abdominal exploration plus systematic HIPEC. Median follow-up was 30 (9-109) months. One patient died postoperatively at day 69. Grade 3-4 morbidity was low (9.7%). The 5-year overall survival rate was 90% and the 5-year disease-free survival rate was 44%. Peritoneal recurrences occurred in 7 patients (17%), 6 of whom had macroscopic PC discovered during the second-look (26%), and one patient had no macroscopic PC (6%). In the univariate analysis, the presence of PC at second-look surgery was a significant risk factor for recurrence (P = 0.006). CONCLUSION: Selection criteria for high-risk patients appear to be accurate. In these patients, the second-look strategy treated peritoneal carcinomatosis preventively or at an early stage, yielding promising results. This study has allowed us to design a multicentric randomized trial (comparing the second-look + HIPEC approach versus standard follow-up alone), which is beginning.

[MR imaging patterns of bone marrow]. / Approche didactique de la moelle osseuse en IRM.

The marrow contains a variable amount of yellow or fatty marrow and red or cellular marrow creating the signal intensity observed on MRI. Marrow replacement (by cells not normally present in bone marrow) typically is T1W hypointense. Marrow proliferation (by cells normally present in bone marrow) may be T1W hypointense (pseudo marrow replacement) or show intermediate T1W signal intensity due to red marrow redistribution. Marrow edema (reaction to an external process) show intermediate T1W hypointensity (mixture of water and marrow). Location will allow correct diagnosis. Bone marrow ischemia usually results in a necrotic fragment surrounded by a thin T1W hypointense rim.

Endocrine pancreatic tumours: which are the most useful MRI sequences?

OBJECTIVES: To determine magnetic resonance imaging (MRI) signal and enhancement characteristics of endocrine pancreatic tumours (ETPs) and which MR sequences show them most consistently. METHODS: Fifty-five consecutive patients with 68 ETPs underwent 1.5-T abdominal MRI comprising T2-weighted, unenhanced T1-weighted and dynamic T1-weighted after injection of gadopentetate dimeglumine sequences. Twenty-one patients underwent diffusion-weighted imaging (DWI). Two radiologists identified the number, location, size, signal and enhancement patterns of ETPs, and determined a confidence scale indicating the presence of tumours on DWI. The results were compared with echo-endoscopy (endoscopic ultrasound) findings. RESULTS: The detection sensitivity was 95%, similar to that of echo-endoscopy. T2-weighted and T1-weighted sequences at the arterial phase had the highest contrast-to-noise ratio (CNR) median value. On DWI, the mean sensitivity was 65%. The mean apparent diffusion coefficient (ADC) value of ETP was significantly lower than in the normal parenchyma. CONCLUSION: In suspected ETP, MRI is a sensitive method, similar to echo-endoscopy and could be recommended as the first imaging technique. T2-weighted sequences and T1-weighted sequences in the arterial phase are the optimal pulse sequences. The quantitative assessment of ADC values is a promising tool for the characterisation of pancreatic lesions.

Adrenocortical carcinoma: is the surgical approach a risk factor of peritoneal carcinomatosis?

CONTEXT: Peritoneal carcinomatosis (PC) is a rare site of distant metastases in patients with adrenocortical cancer (ACC). One preliminary study suggests an increased risk of PC after laparoscopic adrenalectomy (LA) for ACC. OBJECTIVE: The objective of the study was to search for risk factors of PC including surgical approach. DESIGN: This was a retrospective cohort study conducted in an institutional practice. PATIENTS: Sixty-four consecutive patients with ACC seen at our institution between 2003 and 2009 were included. Mean tumor size was 132 mm. Patients had stage I disease in 2 cases, stage II disease in 32 cases, stage III disease in 7 cases, stage IV disease in 21 cases, and unknown stage disease in 2 cases. Surgery was open in 58 cases and laparoscopic in 6 cases. MAIN OUTCOME: The main outcome was the risk factors of PC. RESULTS: PC occurred in 18 (28%) patients. It was present at initial diagnosis in three cases and occurred during follow-up in 15 cases. The only risk factor of PC occurring during follow-up was the surgical approach with a 4-year rate of PC of 67% (95% confidence interval (CI), 30-90%) for LA and 27% (95% CI, 15-44%) for open adrenalectomy (P=0.016). Neither tumor size, stage, functional status, completeness of surgery, nor plasma level of op'DDD was associated with the occurrence of PC. CONCLUSION: We found an increased risk of PC after LA for ACC. Whether this is related to an inappropriate surgical approach or to insufficient experience in ACC surgery should be clarified by a prospective program.

Optimizing the size variation threshold for the CT evaluation of response in metastatic renal cell carcinoma treated with sunitinib.

BACKGROUND: In metastatic renal cell carcinoma (mRCC), antiangiogenic treatments rarely achieve a reduction of -30% in the sum of longest diameters (SLD) of target lesions required by RECIST for an 'objective response', although they objectively improve progression-free survival (PFS). We sought to determine a threshold for the computed tomography evaluation of these patients' best reflecting patient outcome. PATIENTS AND METHODS: In 334 mRCC patients treated with sunitinib, we tested thresholds from -45% to +10%. We classified patients as 'responders' when the best relative variation of the sum of longest diameters (DeltaSLD) reached the tested threshold and as 'nonresponders' otherwise. For each tested threshold, the median PFS of the two groups were compared. Receiver operating characteristic (ROC) analysis was also carried out among the 103 patients that progressed during follow-up. Finally, the 'optimal' threshold was retested on an independent cohort of 39 patients. RESULTS: The DeltaSLD threshold of -10% gave the most significant difference. It divided patients into 256 responders and 78 nonresponders (median PFS 11.1 and 5.6 months). The same -10% threshold was found using the ROC analysis. Results were confirmed on the external validation cohort. CONCLUSION: A variation of -10% in the SLD accurately and rapidly identifies mRCC patients benefiting from sunitinib.

Liposarcoma or lipoma: does genetics change classic imaging criteria?

Differentiating benign from malignant fatty tumours has always been very difficult for both radiologists and pathologists. Cytogenetic and molecular genetic analyses provide complementary tools for differentiating soft tissue tumours. Our objective was to compare imaging criteria of malignancy with a new diagnostic gold standard, namely, pathological analysis combined with cytogenetic and molecular genetic analyses. Nineteen patients with a fatty tumour were included. All had computed tomography and/or magnetic resonance imaging examination before any biopsy or surgery. All had histopathological and cytogenetic and/or molecular genetic analyses. The imaging diagnosis of benign or malignant lesions was accurate in 15 cases, with 4 false positives for malignancy. Erroneous criteria were a large size (4 cases), and a mass that was not purely fatty. In conclusion, the main pitfall for a false positive radiological diagnosis of liposarcoma is certainly a large-sized tumour. Cytogenetic and molecular genetic analyses contribute to the diagnosis and can be performed at the same time with a core biopsy.

Combined liver surgery and RFA for patients with gastroenteropancreatic endocrine tumors presenting with more than 15 metastases to the liver.

AIM: The aim of this study was to report the feasibility and early survival results of liver metastases (LM) resection combining cytoreductive surgery and radiofrequency ablation (RFA) during a one-step procedure, in patients presenting more than 15 bilateral LM from well-differentiated endocrine carcinoma. It is an extensive application of the current guidelines. METHODS: In this retrospective review of a prospectively collected database, we used a combination of hepatectomy to treat large or contiguous LM, and extensively used multiple RFA to treat the remaining LM which were smaller than 2.5 cm. Patients were selected based on a low natural tumor burden slope, and the technical feasibility of treating all the detectable LM. RESULTS: From January 2002 to May 2007, 16 patients with a median of 23 LM per patient (mean number: 25.7 + or -12; range16-89) underwent this procedure. A mean of 15 + or - 9 LM per patient were surgically removed and a mean of 12 + or - 8 (median of 10) LM per patient were RF ablated. No mortality occurred. Morbidity was observed in 11 patients (69%). The 3-year overall survival and disease-free survival rates were similar to those observed in our preliminary series of 47 hepatectomized patients with a median of 7 LM per patient. CONCLUSION: This new one-step combined technique allowed us to apply an "upgraded" therapeutic approach to a selection of patients presenting a median of 23 LM per patient and to improve their prognosis, putting it on par with that obtained by conventional hepatectomy.