Immune checkpoint inhibitors: Assessment of the performance and the agreement of iRECIST, irRC, and irRECIST.

INTRODUCTION: Immunotherapy has become more widely accepted and used by medical oncologists. Radiologists face challenges in assessing tumor response and becoming more involved in the management of treatment. We aimed to assess the agreement between immune-related response criteria (irRC), immune-related RECIST (irRECIST), and immune RECIST (iRECIST) to correlate the response measured by them with overall survival (OS), and to determine the confirmation rate of progressive disease (PD). METHODS: A total of 43 patients (28 men, 15 women; average age = 54.6 ± 15.7 years) treated with immunotherapy were included in this study. Pairwise agreements between iRECIST, irRC, and irRECIST were calculated using Cohen's kappa statistics. The correlation of the criteria-based response and OS was evaluated using the Kaplan-Meier method and log-rank test. A confirmation rate with 95% confidence intervals (CI) was calculated in patients with PD. RESULTS: The kappa values between iRECIST and irRC, iRECIST and irRECIST, and irRC and irRECIST were 0.961 (almost perfect; P < 0.001), 0.961 (almost perfect; P < 0.001), and 0.922 (almost perfect; P < 0.001), respectively. The Kaplan-Meier method and log-rank test showed for each criterion a statistically significant correlation with OS (P < 0.05). The confirmation rates of PD for irRC, irRECIST, and iRECIST were 95% (19/20; 95% CI = 76.4-99.1%), 90% (18/20; 95% CI = 69.9-97.2%), and 90.5% (19/21; 95% CI = 71.1-97.4%), respectively. CONCLUSION: There was an almost perfect and statistically significant agreement between iRECIST, irRC, and irRECIST. The measurements performed with them significantly correlated with the OS; their confirmation rates were similar. iRECIST and irRECIST might be favored over irRC because of their relative ease of use.

Abbreviated and Standard Breast MRI in Neoadjuvant Chemotherapy Response Evaluation: A Comparative Study.

OBJECTIVES: This study aims to investigate the efficacy of abbreviated breast magnetic resonance imaging (MRI) in neoadjuvant chemotherapy (NAC) response evaluation. METHODS: MR images of 50 locally advanced breast cancer patients who underwent standard protocol (SP) breast MRI before and after NAC were re-evaluated retrospectively. Abbreviated protocol (AP) was obtained by extracting images from SP and then evaluating them in a separate session. Protocols were compared with the histological findings after surgery as the reference standard. RESULTS: A statistically significant difference was found between the two protocols in response evaluation by the McNemar test (p=0.018). However, the Kappa value was 0.62 (p<0.001), which indicates substantial agreement. No statistically significant differences were found between the two protocols (AP and SP) and pathological results in the McNemar test (p=0.12, p=0.60, respectively). Kappa values were 0.48 (p<0.001) and 0.60 (p<0.001), respectively, which indicates moderate agreement for both protocols with higher values by SP evaluation. The residual maximum median diameters were smaller than the pathology, with both protocols (p<0.001). CONCLUSION: Despite the statistical differences, there was a significant correlation in response evaluation between the two protocols. The pathological results were moderately correlated with both protocols, with SP slightly higher. However, the residual maximum median diameters were smaller than the pathology with both protocols. These results may limit the use of AP in evaluating the local extent of the tumor, especially in patients who will undergo breast-conserving surgery.

Extrapulmonary Tuberculosis Mimics Diffuse Metastatic Disease: A Case Report.

Background Extrapulmonary tuberculosis (TB) is associated with major diagnostic difficulties as it has many atypical symptoms and its imaging findings are similar to those of many other diseases. Case Report We present the case of a 50-year-old woman with a complex cystic mass in her pelvis and a 2-month history of pain. Thoracoabdominal computed tomography (CT) revealed the following: (1) multiple supraclavicular, axillary, mediastinal, and abdominal pathologic lymph nodes with central hypoattenuation; (2) sternal and dorsal vertebral bone destruction with a soft tissue mass; and (3) multiple hypoattenuating masses in the liver. 18 F-fludeoxyglucose positron emission tomography/computed tomography ( 18 F-FDG PET/CT) revealed pathologic uptake in the defined areas, which were similar to metastases. Chest X-ray was normal. Diffuse metastatic disease was suspected clinically, but careful analysis of the imaging findings and the final pathologic results revealed multisystemic extrapulmonary TB. Clinical and radiological recovery was significant after anti-TB treatment at the 6-month follow-up. Conclusion Extrapulmonary TB without pulmonary involvement is associated with major diagnostic difficulties, especially with PET-CT. However, recognition and understanding of the CT or MR imaging spectrum can aid in the correct diagnosis and management of the disease.

Does visceral adiposity have an effect on the survival outcomes of the patients with endometrial cancer?

AIM: Endometrial cancer is the most common cancer of the female reproductive tract in the developed countries. There are many risk factors defined for the development of endometrial cancer, including obesity. We aimed to evaluate the significance of adiposity on the survival outcomes of the patients with endometrial cancer. METHODS: The patients diagnosed with endometrial cancer and underwent surgery between April 2009 and October 2017 were retrospectively reviewed. The visceral adipose tissue and subcutaneous adipose tissue volumes were measured at the level of umbilicus on single-slice magnetic resonance imaging. Visceral adiposity index was calculated. Patients were compared regarding their clinical, demographical, pathologic and survival characteristics. Patients divided into low visceral adiposity (≤0.265, group 1) and high visceral adiposity (>0.265, group 2). RESULTS: A total of 186 patients were included in this retrospective study. There was no significant difference in terms of the demographical, clinical and tumor characteristics of the patients, except age, menopausal status, subcutaneous adipose tissue and visceral adipose tissue. Although no significant difference in progression-free survival and disease-specific survival was noted between groups (P = 0.181), more patients in group 2 died because of endometrial cancer as statistically significant (P = 0.024). Disease-specific survival showed a significant difference between groups according to the log-rank test. CONCLUSION: Visceral adiposity tissue is a significant and reliable prognostic indicator for endometrial cancer prognosis. Women diagnosed with endometrial cancer should be informed about the deleterious effects of visceral adiposity on disease-specific survival.

Improved False-Negative Rates with Intraoperative Identification of Clipped Nodes in Patients Undergoing Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy.

BACKGROUND: Identification and resection of a clipped node was shown to decrease the false-negative rate (FNR) of sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NAC) for patients presenting with initially node-positive breast cancer. METHODS: Between March 2014 and March 2016, a prospective trial analyzed 98 patients with axilla-positive locally advanced breast cancer (T1-4, N1-3) to assess the feasibility and efficacy of placing clips into most suspicious biopsy-proven node. The study considered blue, radioisotope active, and suspiciously palpable nodes as sentinel lymph nodes (SLNs). RESULTS: The SLN identification rate was 87.8%. The median age of the patients with an SLNB (n = 86) was 44 years (range 28-66 years). Of these patients, 77 (88.4%) had cT1-3 disease, and 10 (11.6%) had cT4 disease. The majority of the patients (n = 66, 76.7%) had cN1, whereas 21 patients (23.3%) had cN2 and cN3. A combined method was used for 37 patients (43%), whereas blue dye alone was used for the remaining patients (57%). The clipped node was the SLN in 70 patients (81.4%). For the patients with cN1 before NAC, the FNR was found to be 4.2% (1/24) when the clipped node was identified as an SLN. However, the FNR was estimated to be as high as 16.7% (1/6) for the patients with cN1 before NAC when the clipped node was found to be a non-SLN. CONCLUSIONS: The study results also suggest that axillary dissection could be omitted for patients presenting initially with N1 disease and with a negative clipped node as the SLN after NAC due to the low FNR.

Imatinib response of gastrointestinal stromal tumor patients with germline mutation on KIT exon 13: A family report.

Familial gastrointestinal stromal tumor (GIST) is a rare autosomal dominant disorder associated with mutations in the KIT gene in the majority of cases. Although, exon 11 appears to be the hot spot region for approximately 95% of germline mutations, pathogenic variations have also been identified in exon 8, 13 and 17. Exon 13 germline mutations are extremely rare amongst familial GISTs and seven families with a germline mutation have been reported to date. Moreover, the role of imatinib mesylate in this rare familiar settings is not completely known so far. We describe here clinical, imaging, pathological and genetic findings of a family with four affected members; grandmother, his son and two grand-sons having a germline gain-of-function mutation of KIT in exon 13 and discuss the imatinib mesylate treatment surveillance outcomes towards disease management.

Magnetic resonance imaging for diagnosis and neoadjuvant treatment evaluation in locally advanced rectal cancer: A pictorial review.

High-resolution pelvic magnetic resonance imaging (MRI) is the primary method for staging rectal cancer. MRI is highly accurate in the primary staging of rectal cancer; however, it has not proven to be effective in re-staging, especially in complete response evaluation after neoadjuvant therapy. Neoadjuvant chemoradiotherapy produces many changes in rectal tumors and on adjacent area, as a result, local tumor extent may not be accurately determined. However, adding diffusion-weighted sequences to the standard approach can improve diagnostic accuracy. In this pictorial review, an overview of the situation of MRI in the staging and re-staging of rectal cancer is exhibited as a pictorial assay. An experience- and literature-based discussion of limitations and difficulties in interpretation are also presented.

Hematological aftermath of the radiation accident in Istanbul.

PURPOSE: The effects of radiation exposure are long-lasting. Long-term monitoring is imperative to diagnose late effects and improve our far-sightedness about possible events in the future. A radiation accident occurred in Istanbul in 1998 that resulted in mild to moderate acute radiation syndrome (ARS). In this study we aimed to investigate the changes in hematological parameters at the long-term follow-up of ARS patients. METHODS: Ten adults were hospitalized after exposure to a 60Co source. Seven were diagnosed as having ARS and had severe and symptomatic pancytopenia. All of the exposed people recovered following intensive treatment. Treatment was supportive with transfusion, granulocyte-colony stimulating factor, and anti- infective management covering antifungal agents. Patients were closely monitored. Nine years after the accident, the initial and follow-up complete blood count examinations and peripheral blood smears (PBS) were comparatively evaluated by an experienced hematologist. The hematological laboratory values of the patients on admission, after treatment, and nine years after the accident were documented and compared. RESULTS: Biodosimetric analysis revealed that whole-body doses ranged from 1-1.9 Gy. All subjects have shown complete recovery of the hematological laboratory values after treatment. All but one of the subjects showed complete blood cell recovery. The improvement of the blood cell count of the excepted patient stalled at a mildly reduced level and his bone marrow was still hypocellular nine years after the accident; however, no malignant changes were detected. Values at admission were significantly different compared with post treatment and present values of all patients. Post treatment and follow-up values were similar. One of the patients died of lung cancer. None of the patients developed hematological malignancy. CONCLUSIONS: In this study, the recovery from ARS was complete after treatment. The small population, short follow-up period, and the relatively small doses resulted in no long-term adverse effects, as would be predicted.

Neoadjuvant hyperfractionated-accelerated radiotherapy with concomitant chemotherapy in esophageal cancer: phase II study.

PURPOSE: Concomitant use of chemotherapy and a radiation dose schedule that is more efficient compared to conventional radiotherapy may provide better outcomes in patients with esophageal cancer. This study aimed to assess the efficacy and tolerability of neoadjuvant cisplatin-based chemotherapy and hyperfractionated accelerated radiotherapy regimen in this group of patients. METHODS AND MATERIALS: A total of 20 newly diagnosed treatment-naïve esophageal cancer patients were included in the study. Neoadjuvant cisplatin and 5-FU were given with 28-day intervals in a total of three courses. Along with the third course of chemotherapy, hyperfractionated accelerated radiotherapy (HART) was given with the following dose schedule: 5760 cGy/36 fr/16 day. RESULTS: All patients could receive the planned RT dose of 5760 cGy. Odynophagia was the most frequent grade III acute toxicity (50%). None of the acute toxicity reactions required treatment discontinuation. Grade III or higher subacute/late toxicity occurred in 10 patients (75%) including 5 deaths, mostly esophageal. Radiologically, 8 patients (40%) had complete response, 8 (40%) had partial response, and 3 (15%) had stable disease, with only 1 patient (5%) having progressive disease. Seven patients underwent surgery. Overall, 8 patients (40%) had local control. The 5 years overall survival rate was 38.1%. CONCLUSIONS: Neoadjuvant hyperfractionated accelerated radiotherapy plus chemotherapy may help to target local disease control and increase survival in patients with esophageal cancer. Further studies to improve neoadjuvant and radical chemoradiotherapy dose schedules are warranted for maximum tumor control rates with minimal toxicity.

Can diffusion-weighted MRI determine complete responders after neoadjuvant chemoradiation for locally advanced rectal cancer?

PURPOSE: We aimed to prospectively determine if analyzing pre- and post-chemoradiotheraphy (CRT) changes in the signal intensity (SI) and apperent diffusion coefficient (ADC) values from diffusion-weighted magnetic resonance imaging (DW-MRI) can accurately predict complete responders for locally advanced rectal cancer. MATERIALS AND METHODS: Thirty patients (mean age, 54.3 years) with locally advanced rectal cancer who underwent neoadjuvant CRT and subsequent surgery were included in this study. All patients were evaluated pre- and post-CRT by standardized turbo spin echo and DW-MRI. Pre- and post-CRT tumor and normal rectal wall SI (which were gradually scored as very high, high, intermediate, low, and no signal) and ADC values were recorded. RESULTS: Tumor SIs were decreased in all of the patients that had a therapy response. However, complete tumor SI loss was only seen in two (22.2%) of nine patients with a pathological complete response, while it regressed to low and/or intermediate SI levels in the remaining seven patients (77.8%). Post-CRT ADC values of rectal tumors were significantly higher from the preCRT ADC values (P < 0.0001; Z=-9.39). However, post-CRT ADC values from the complete and partial/no response patient groups were not significantly different (P = 0.071; Z=-1.99). CONCLUSION: In re-staging of rectal tumors by DW-MRI, an increase in ADC values and decrease in SIs can predict therapy response but cannot unequivocally determine a complete response.

Transrectal US-guided seminal vesicle aspiration in the diagnosis of partial ejaculatory duct obstruction.

There has been recent interest in techniques for diagnosing ejaculatory duct obstruction (EDO), especially when the partial form of the disease is suspected clinically. Currently, there is no gold standard technique for diagnosing EDO. Transrectal ultrasonography (TRUS), which is the technique used most widely, can overdiagnose EDO. As adjunctive diagnostic techniques, duct chromotubation and seminal vesiculography cannot distinguish patients with partial obstruction from those without EDO. TRUS-guided seminal vesicle aspiration can be used in conjunction with TRUS to confirm the diagnosis pre-operatively, especially in patients with seminal vesicle dilation and a prostatic midline/ejaculatory duct cyst on TRUS. In patients with findings of chronic inflammation, such as ejaculatory duct calcifications and seminal vesicle atrophy/ hypoplasia on TRUS, proximal vasal obstruction or functional EDO should be excluded.

Correlation of clinical and MRI staging in cervical carcinoma treated with radiation therapy: a single-center experience.

PURPOSE: To correlate clinical and MRI findings in patients with cervical carcinoma treated with radiation therapy (RT). MATERIALS AND METHODS: Forty-two patients with pretreatment IB-IVA cervical carcinoma were included in this retrospective study. Pre- and post-treatment MRI findings of the patients were reevaluated and compared with clinical staging. Six-month, one-year, and two-year follow-up imaging by MR was performed for 36, 20, and 7 patients, respectively. The correlation between clinical and MRI findings was assessed by a Spearman's rho (rank correlation) test. Univariate analyses were performed to identify the prognostic significance of the tumor volume and lymph node status. RESULTS: Pre-treatment correlations between MRI and clinical findings for diagnoses without parametrial invasion, with parametrial invasion, and with pelvic sidewall invasion were 71.0%, 64.7%, and 15.8%, respectively. According to the Spearman's rho (rank correlation) test, the parametrial invasion correlation was poor (r = 0.410, P < 0.01). The correlation of clinical and MRI findings at 6 months was 88.9% (r = 0.674, P < 0.0001). CONCLUSION: In advanced cervical cancer, the correlation of clinical and MRI staging prior to neoadjuvant RT was low despite a high correspondence in the assessment of local response after RT.

Gastrointestinal lymphoma: a spectrum of fluoroscopic and CT findings.

Gastrointestinal lymphomas can occur in nodular, polypoid, cavitary, ulcerative or diffuse infiltrating (submucosal) forms. Barium studies and computed tomography (CT) are the most popular imaging techniques used to diagnose these lymphomas. Barium studies are superior to CT in evaluating mild mucosal and submucosal changes. However, CT is the technique of choice because it provides a complete evaluation of the extent of disease dissemination, recent disease development, therapeutic response, and related complications.

Comparison of transrectal ultrasonography and transrectal ultrasonography-guided seminal vesicle aspiration in the diagnosis of the ejaculatory duct obstruction.

OBJECTIVE: To compare transrectal ultrasonography (TRUS) and TRUS-guided seminal vesicle aspiration in the diagnosis of ejaculatory duct obstruction (EDO). DESIGN: A retrospective case-controlled study comparing the findings of TRUS and TRUS-guided seminal vesicle (SV) aspiration. SETTING: Clinics of Urology and Radiology. PATIENT(S): Seventy patients with suspected EDO (complete in 10, partial in 60 patients) on clinical evaluation. INTERVENTION(S): Each SV was punctured transrectally using a 20-gauge Chiba needle within 2 hours after ejaculation. MAIN OUTCOME MEASURE(S): In SV aspirates, greater than three sperm per high-power microscopic field was considered a positive result for EDO. RESULT(S): Fifty-five (78.6%) patients had evidence of EDO on diagnostic TRUS. However, obstruction on TRUS was confirmed in 49.1% (27 of 55) of the patients with SV aspiration. Higher sperm positivity rates were achieved in patients with SV dilation (11 of 13, 84.6%) and prostatic midline/ED cyst (12 of 16, 75.0%). Stepwise logistic regression analysis revealed that the incidence of SV dilation was significantly higher, whereas that of chronic inflammatory findings in the prostate was significantly lower in the positive SV aspirate group. CONCLUSION(S): TRUS alone is not a reliable tool for the diagnosis of EDO. For this reason, SV aspiration should be used as an adjunctive technique in patients with SV dilation or a prostatic midline/ED cyst to confirm the diagnosis before surgery.

Computed tomography enteroclysis in the diagnosis of intestinal diseases.

The role of computed tomography (CT) enteroclysis in the imaging of small bowel diseases is expanded with recent technological advances in multidetector CT system. Computed tomography enteroclysis is the examination of choice for patients with symptoms of intermittent small bowel obstruction, especially when there is a history of prior complex abdominal surgery, abdominal tumor, radiation therapy, and also in high grade obstructions with suspicion of extraintestinal internal fistula. Computed tomography enteroclysis is becoming the first-line modality for the evaluation of advanced and complicated small bowel Crohn disease. Computed tomography enteroclysis can also become an important complementary imaging technique to capsule endoscopy in the assessment of small bowel neoplasms and occult gastrointestinal hemorrhage. In this study, the technique and clinical applications of CT enteroclysis are reviewed; its advantages and limitations compared with the other imaging techniques and capsule endoscopy are discussed.

A gastrointestinal stromal tumor with mesenteric and retroperitoneal invasion.

BACKGROUND: Gastrointestinal stromal tumors are rare visceral sarcomas arising in the gastrointestinal tract wall. In this report we present a case of gastrointestinal stromal tumors with mesenteric and retroperitoneal invasion, describe and discuss its computed tomography findings. CASE PRESENTATION: A 57-years-old male patient has been complaining of abdominal distention, weight lose, and hematuria. During physical examination, significant distention and multiple palpable tumor masses were identified on the abdomen. Abdominal computed tomography showed multiple, well-defined, soft tissue masses with homogenous and heterogeneous pattern, in the mesenteric and retroperitoneal areas. Unlike specific features of gastrointestinal stromal tumor, renal obstruction and atypical central calcification without chemotherapy that has not been yet described were seen in this case. Computed tomography did not reveal liver metastases and/or the lymph nodes with pathological size. Ultrasonography-guided true-cut biopsy was made, histopathologic and immunohistochemical analyses demonstrated stromal tumor which, C-KIT (+). The patient underwent left ureterectomy, left nephrectomy and total colectomy. Postoperative histopathological analyses revealed lower grade malignant GISTs. As of 17 months after the surgery, he is alive and free of recurrence. CONCLUSION: When intraabdominal, multiple, large (>5 cm), well-circumscribed, homogenous or heterogeneous mass lesions without ascites, omental caking and lymph nodes metastases were seen, gastrointestinal stromal tumors should be considered in the differential diagnosis.

Cervical cancer: MR imaging findings before, during, and after radiation therapy.

In this study, magnetic resonance (MR) imaging findings of patients with varying stages of cervical carcinoma are reviewed. The appearances of the postirradiation pelvis on MR images are also characterized and correlated with preradiation therapy staging. MR imaging findings of recurrent and metastatic disease are presented and discussed.

Endosonographic imaging of anorectal diseases.

OBJECTIVE: The normal sonographic anatomy of the anorectum, sonographic findings of anorectal diseases, and indications and limitations of endosonography compared with magnetic resonance imaging are reviewed. Methods. Endosonographic imaging was performed with a Siemens (Erlangen, Germany) FI 400 ultrasound scanner with an end-fire 7.5-MHz biplane endorectal probe and a B-K Medical (Sandhoften, Denmark) scanner with an 1850 axial-type side-fire 5.0- to 10.0-MHz rotating endoscopic probe. RESULTS: Rectal carcinoma appears on endorectal sonography as a low-echogenicity lesion that abruptly interrupts the normal sequence of layers. The internal anal sphincter is seen very clearly on endoanal sonography, and it is easy to appreciate atrophy and small tears of this sphincter. Endoanal sonography cannot accurately show thinning of the external anal sphincter. Peroxide-enhanced endoanal sonography is especially useful for patients with recurrent perianal fistulas in whom scarring should be distinguished from recurrent fistulas and detection of the internal opening. However, sonography does not provide an adequate deep and global display of all adjacent pelvic and perineal spaces. CONCLUSIONS: Endosonography can accurately stage primary rectal tumors and assess the internal anal sphincter. Peroxide-enhanced 3-dimensional imaging can increase the utility of endoanal sonography in detection and characterization of perianal fistulas and planning of optimal therapy. However, magnetic resonance imaging can be used a complementary modality to endosonography, especially for evaluation of external anal sphincter atrophy and deep pelvic inflammation.

Imaging findings of intestinal tuberculosis.

Intestinal tuberculosis (TB) has 3 main forms: ulcerative, hypertrophic or ulcerohypertrophic, and fibrous stricturing. In the ulcerative form, barium examination reveals thickened folds, spasticity, and shallow ulcers involving the cecum and terminal ileum. Computerized tomography shows preferential thickening of the ileocecal valve and medial wall of the cecum as well as a few small regional nodes. In the hypertrophic or ulcerohypertrophic form, a hyperplastic reaction is seen in the exophytic masses around the ulcerated lumen on computed tomography. An inflammatory mass that extends into adjacent muscle suggests TB. In the sclerotic form, the main reaction is fibrosis with single or multiple short strictures. The cecum classically becomes amputated, conical, shrunken, and retracted. In comparison, Crohn's disease (CD) has a rather uniform and lesser thickening of the bowel wall. Mural stratification, vascular jejunization or the comb sign, and mesenteric fibrofatty proliferation are seen only in CD. The hypertrophic form may also mimic malignant neoplasms, such as lymphoma or carcinoma. Cecal carcinoma rarely extends beyond the ileocecal valve, however. In lymphoma, it can be seen as a greater degree of wall thickness with aneurysmatic dilation of the intestinal lumen. Single or multiple strictures are also seen as a CD complication. Advanced skip lesions adjacent to the stricture are usually diagnostic for CD.