Differentiation of uterine low-grade endometrial stromal sarcoma from rare leiomyoma variants by magnetic resonance imaging.

The purpose of this study is to evaluate utility of MRI in differentiation of uterine low-grade endometrial stromal sarcoma (LGESS) from rare leiomyoma variants. This multi-center retrospective study included consecutive 25 patients with uterine LGESS and 42 patients with rare leiomyoma variants who had pretreatment MRI. Two radiologists (R1/R2) independently evaluated MRI features, which were analyzed statistically using Fisher's exact test or Student's t-test. Subsequently, using a five-point Likert scale, the two radiologists evaluated the diagnostic performance of a pre-defined MRI system using features reported as characteristics of LGESS in previous case series: uterine tumor with high signal intensity (SI) on diffusion-weighted images and with either worm-like nodular extension, intra-tumoral low SI bands, or low SI rim on T2-weighted images. Area under the receiver operating characteristic curve (AUC), sensitivity, and specificity of the two readers' Likert scales were analyzed. Intra-tumoral low SI bands (p < 0.001), cystic/necrotic change (p ≤ 0.02), absence of speckled appearance (p < 0.001) on T2-weighted images, and a low apparent diffusion coefficient value (p ≤ 0.02) were significantly associated with LGESS. The pre-defined MRI system showed very good diagnostic performance: AUC 0.86/0.89, sensitivity 0.95/0.95, and specificity 0.67/0.69 for R1/R2. MRI can be useful to differentiate uterine LGESS from rare leiomyoma variants.

High signal intensity on diffusion-weighted magnetic resonance images is a useful finding for detecting early-stage pancreatic cancer.

PURPOSE: Early detection of pancreatic ductal adenocarcinoma (PDAC) may improve the prognosis. We evaluated novel imaging findings that may contribute to early detection. METHODS: This single-center, retrospective study enrolled 37 patients with a localized main pancreatic duct (MPD) stricture and no obvious pancreatic mass. All patients underwent endoscopic retrograde cholangiopancreatography and brush sampling with cytology and serial pancreatic juice aspiration cytologic examination via endoscopic naso-pancreatic drainage. Patients with cytology-confirmed malignancy underwent surgical resection. The remaining patients were followed by contrast-enhanced computed tomography (CECT), magnetic resonance imaging (MRI), and endoscopic retrograde cholangiopancreatography. RESULTS: Twenty patients had confirmed malignancy (cancer group) and 17 did not (non-cancer group). Age, MPD stricture location, and PDAC risk factors were similar, but the sex predominance and symptom rate differed between the two groups. In the cancer group, 17 patients were diagnosed by cytology and three by clinical symptoms. CECT, MRI, and endoscopic ultrasonography (EUS) revealed no solid tumors in either group. CECT revealed no significant differences between groups. Diffusion-weighted MRI revealed significant differences in the signal intensity between groups. EUS detected indistinct and small hypoechoic areas in 70% and 41.2% of patients in the cancer and non-cancer groups, respectively. In the cancer group, 11 were diagnosed with cancer at the first indication, and nine were diagnosed at follow-up; the prognosis did not differ between these two subgroups.ss CONCLUSIONS: High signal intensity in diffusion-weighted MRI may be useful for detecting early-stage PDAC and may be an indication for surgical resection even without pathologic confirmation. CLINICAL TRIAL REGISTRATION: The study was a registered at the University Hospital Medical Information Network (UMIN000039623).

A review of factors that affect artifact from metallic hardware on multi-row detector computed tomography.

Artifact arising from metallic hardware can present a major obstacle to computed tomographic imaging of bone and soft tissue and can preclude its use for answering a variety of important clinical questions. The advent of multirow detector computed tomography offers new opportunities to address the challenge of imaging in the presence of metallic hardware. This pictorial essay highlights current strategies for reducing metallic hardware artifacts and presents some illustrative clinical cases.

HER2YVMA drives rapid development of adenosquamous lung tumors in mice that are sensitive to BIBW2992 and rapamycin combination therapy.

Mutations in the HER2 kinase domain have been identified in human clinical lung cancer specimens. Here we demonstrate that inducible expression of the most common HER2 mutant (HER2(YVMA)) in mouse lung epithelium causes invasive adenosquamous carcinomas restricted to proximal and distal bronchioles. Continuous expression of HER2(YVMA) is essential for tumor maintenance, suggesting a key role for HER2 in lung adenosquamous tumorigenesis. Preclinical studies assessing the in vivo effect of erlotinib, trastuzumab, BIBW2992, and/or rapamycin on HER2(YVMA) transgenic mice or H1781 xenografts with documented tumor burden revealed that the combination of BIBW2992 and rapamycin is the most effective treatment paradigm causing significant tumor shrinkage. Immunohistochemical analysis of lung tumors treated with BIBW2992 and rapamycin combination revealed decreased phosphorylation levels for proteins in both upstream and downstream arms of MAPK and Akt/mTOR signaling axes, indicating inhibition of these pathways. Based on these findings, clinical testing of the BIBW2992/rapamycin combination in non-small cell lung cancer patients with tumors expressing HER2 mutations is warranted.

Hsp90 inhibition suppresses mutant EGFR-T790M signaling and overcomes kinase inhibitor resistance.

The epidermal growth factor receptor (EGFR) secondary kinase domain T790M non-small cell lung cancer (NSCLC) mutation enhances receptor catalytic activity and confers resistance to the reversible tyrosine kinase inhibitors gefitinib and erlotinib. Currently, irreversible inhibitors represent the primary approach in clinical use to circumvent resistance. We show that higher concentrations of the irreversible EGFR inhibitor CL-387,785 are required to inhibit EGFR phosphorylation in T790M-expressing cells compared with EGFR mutant NSCLC cells without T790M. Additionally, CL-387,785 does not fully suppress phosphorylation of other activated receptor tyrosine kinases (RTK) in T790M-expressing cells. These deficiencies result in residual Akt and mammalian target of rapamycin (mTOR) activities. Full suppression of EGFR-mediated signaling in T790M-expressing cells requires the combination of CL-387,785 and rapamycin. In contrast, Hsp90 inhibition overcomes these limitations in vitro and depletes cells of EGFR, other RTKs, and phospho-Akt and inhibits mTOR signaling whether or not T790M is present. EGFR-T790M-expressing cells rendered resistant to CL-387,785 by a kinase switch mechanism retain sensitivity to Hsp90 inhibition. Finally, Hsp90 inhibition causes regression in murine lung adenocarcinomas driven by mutant EGFR (L858R) with or without T790M. However, efficacy in the L858R-T790M model requires a more intense treatment schedule and responses were transient. Nonetheless, these findings suggest that Hsp90 inhibitors may be effective in T790M-expressing cells and offer an alternative therapeutic strategy for this subset of lung cancers.

MRI assessment of lung parenchymal motion in normal mice and transgenic mice with sickle cell disease.

PURPOSE: To test the feasibility of a method to quantify regional pulmonary parenchymal motion via nonrigid registration algorithm at small animal scales. MATERIALS AND METHODS: Voxel-wise displacement vector field maps were generated between end-inspiratory and end-expiratory coronal thoracic MR images on normal mice (N = 5) to analyze the magnitude and direction of parenchymal motion in the segmented regions. The analysis was repeated before and after short-term exposure to hypoxia to demonstrate the effect of hypoxia on the respiratory motion in transgenic (Tg) mice with sickle cell disease (SCD) (N = 4). RESULTS: Normal mice revealed that the right and left lungs moved symmetrically but that there was greater movement in the lower regions than in the upper regions. Calculated strain was uniform in the entire lung. In the Tg mice, the pulmonary motion before hypoxia was similar to that observed in the normal mice. Upon exposure to hypoxia, the displacement magnitude reduced and the direction of motion in some areas became distorted. CONCLUSION: MR quantification of pulmonary motion was feasible in mice and the principle that the method could detect mechanical abnormalities due to pathologic changes was proven. Quantification of pulmonary motion has the potential to lead to earlier disease diagnosis and better monitoring of disease treatments.

MR microscopy of the lung in small rodents.

Understanding how the mammalian respiratory system works and how it changes in disease states and under the influence of drugs is frequently pursued in model systems such as small rodents. These have many advantages, including being easily obtained in large numbers as purebred strains. Studies in small rodents are valuable for proof of concept studies and for increasing our knowledge about disease mechanisms. Since the recent developments in the generation of genetically designed animal models of disease, one needs the ability to assess morphology and function in in vivo systems. In this article, we first review previous reports regarding thoracic imaging. We then discuss approaches to take in making use of small rodents to increase MR microscopic sensitivity for these studies and to establish MR methods for clinically relevant lung imaging.

Unwarranted administration of acetylcholinesterase inhibitors can impair genioglossus and diaphragm muscle function.

BACKGROUND: It is standard practice to administer a cholinesterase inhibitor (e.g., neostigmine) at the end of a surgical case to reverse suspected effects of neuromuscular blocking agents regardless of whether such residual effects are present. The authors hypothesized that cholinesterase inhibition when given the in absence of neuromuscular blockade (NB) would decrease upper airway dilatory muscle activity and consequently upper airway volume. METHODS: The authors measured genioglossus and diaphragm electromyograms during spontaneous ventilation in anesthetized, tracheostomized rats before and after administration of neostigmine (0.03, 0.06, or 0.12 mg/kg), after recovery of the train-of-four ratio (quadriceps femoris muscle) to unity after NB (n = 18). For comparison, the authors made the same measurements in rats that had no previous NB (n = 27). In intact anesthetized rats, the authors measured upper airway volume and end-expiratory lung volume by magnetic resonance imaging before and after 0.12 mg/kg neostigmine (n = 9). RESULTS: Neostigmine treatment in rats that had fully recovered from NB based on the train-of-four ratio caused dose-dependent decreases in genioglossus electromyogram (to 70.3 +/- 7.6, 49.2 +/- 3.2, and 39.7 +/- 2.3% of control, respectively), decreases in diaphragm electromyogram (to 103.1 +/- 6.5, 83.1 +/- 4.7, and 68.7 +/- 7.3% of control), and decreases in minute ventilation to a nadir value of 79.6 +/- 6% of preneostigmine baseline. Genioglossus electromyogram effects were the same when neostigmine was given with no previous NB. Neostigmine caused a decrease in upper airway volume to 83 +/- 3% of control, whereas end-expiratory lung volume remained constant. CONCLUSIONS: The cholinesterase inhibitor neostigmine markedly impairs upper airway dilator volume, genioglossus muscle function, diaphragmatic function, and breathing when given after recovery from vecuronium-induced neuromuscular block.

Bronchial and peripheral murine lung carcinomas induced by T790M-L858R mutant EGFR respond to HKI-272 and rapamycin combination therapy.

The EGFR T790M mutation has been identified in tumors from lung cancer patients that eventually develop resistance to erlotinib. In this study, we generated a mouse model with doxycycline-inducible expression of a mutant EGFR containing both L858R, an erlotinib-sensitizing mutation, and the T790M resistance mutation (EGFR TL). Expression of EGFR TL led to development of peripheral adenocarcinomas with bronchioloalveolar features in alveoli as well as papillary adenocarcinomas in bronchioles. Treatment with an irreversible EGFR tyrosine kinase inhibitor (TKI), HKI-272, shrunk only peripheral tumors but not bronchial tumors. However, the combination of HKI-272 and rapamycin resulted in significant regression of both types of lung tumors. This combination therapy may potentially benefit lung cancer patients with the EGFR T790M mutation.

Multidetector-row computed tomographic angiography of thoracic and abdominal aortic aneurysms: comparison of arterial enhancement with 3 different doses of contrast material.

OBJECTIVE: To compare the quality of multidetector-row computed tomographic angiography in patients with and without aortic aneurysms by 3 different amounts of contrast media (CM). METHODS: A total of 115 patients with aortic aneurysms were divided into 3 groups: group A, 100 mL CM; group B, 75 mL CM with 20 mL saline flush (SF); and group C, 50 mL CM with 20 mL SF. Twenty-five patients without aortic aneurysms were also enrolled (group D, 50 mL CM with 20 mL SF). Quantitative and qualitative analyses were performed by measuring attenuation in thoracoabdominal/aortoiliac lumen, aneurysmal lumen, and superior vena cava. RESULTS: In group C, attenuation was lower in distal than those in proximal and middle areas (P < 0.05). Contrast enhancement in abdominal aneurysmal lumen was more inhomogeneous in group C (P = 0.003). Visual analysis showed contrast enhancement was more nonuniform in group C (P = 0.004), and perivenous artifacts were more conspicuous in group A (P < 0.0001). CONCLUSIONS: Seventy-five milliliters CM followed by 20 mL SF can produce optimal contrast enhancement at systemic multidetector-row computed tomographic angiography in patients with aortic aneurysms.

Difference in myocardial flow reserve between patients with dilated cardiomyopathy and those with dilated phase of hypertrophic cardiomyopathy: evaluation by 15O-water PET.

BACKGROUND: The clinical features of patients with the dilated phase of hypertrophic cardiomyopathy (DHCM) may resemble those of patients with dilated cardiomyopathy (DCM); that is, systolic dysfunction and left ventricular dilatation. Myocardial flow reserve (MFR) is impaired in patients with nonischemic cardiomyopathy, and the reduced MFR may be related to poor prognosis. Several studies report that the mortality rate for patients with DHCM is higher than for DCM, but the difference between these 2 cardiomyopathies is still unclear. The purpose of this study was to assess the MFR of these 2 cardiomyopathies, using (15)O-water positron emission tomography (PET) to elucidate their differences. METHODS AND RESULTS: In total 30 patients were investigated: 23 with DCM (Group A) and 7 with DHCM (Group B). All those who were in a stable condition underwent cardiac catheterization. Myocardial blood flow (MBF) at rest and under ATP infusion was measured by (15)O-water PET, and the MFR was calculated. There were no significant differences in the hemodynamics of the 2 groups. The mean MFR in DHCM was significantly lower than that in DCM (1.49+/-0.31 vs 2.62+/-1.08; p=0.042), whereas MBF at rest did not differ (DCM vs DHCM: 0.66+/-0.20 vs 0.49+/-0.05 ml . min(-1) . g(-1); NS). The MFR in both Group A and B was significantly decreased compared with the normal controls (MFR in normal controls: 5.15+/-1.64, p=0.00015, 0.00013, respectively). CONCLUSIONS: These results suggest that impaired vasodilatation (ie, dysfunction of the microcirculation) is more severe in patients with DHCM than in patients with DCM, even though patients' characteristics and hemodynamics do not differ.

Therapeutic anti-EGFR antibody 806 generates responses in murine de novo EGFR mutant-dependent lung carcinomas.

Activating EGFR mutations occur in human non-small cell lung cancer (NSCLC), with 5% of human lung squamous cell carcinomas having EGFRvIII mutations and approximately 10%-30% of lung adenocarcinomas having EGFR kinase domain mutations. An EGFR-targeting monoclonal antibody, mAb806, recognizes a conformational epitope of WT EGFR as well as the truncated EGFRvIII mutant. To explore the anticancer spectrum of this antibody for EGFR targeted cancer therapy, mAb806 was used to treat genetically engineered mice with lung tumors that were driven by either EGFRvIII or EGFR kinase domain mutations. Our results demonstrate that mAb806 is remarkably effective in blocking EGFRvIII signaling and inducing tumor cell apoptosis, resulting in dramatic tumor regression in the EGFRvIII-driven murine lung cancers. Another EGFR-targeting antibody, cetuximab, failed to show activity in these lung tumors. Furthermore, treatment of murine lung tumors driven by the EGFR kinase domain mutation with mAb806 also induced significant tumor regression, albeit to a less degree than that observed in EGFRvIII-driven tumors. Taken together, these data support the hypothesis that mAb806 may lead to significant advancements in the treatment of the population of NSCLC patients with these 2 classes of EGFR mutations.

Three-dimensional magnetic resonance microscopy of pulmonary solitary tumors in transgenic mice.

We attempted to accurately detect pulmonary solitary tumors and other complicated pulmonary disorders in aging inbred transgenic mice by cardiac- and respiratory-gated MR microscopy at 4.7 Tesla. A comparison of in vivo MR images with histological results demonstrated that submillimeter lung tumors and most of the nontumor lesions could be detected by screening with two-dimensional (2D) gradient echo (GRE) imaging. Subsequently performed 2D spin-echo (SE) imaging provided higher image contrast, which distinguished the tumors from the surrounding complications. On the 3D GRE images and the generated maximum intensity projection (MIP) and volume-rendered (VR) images, proper spatial localization of solitary tumors relative to the orientation of the pulmonary vessels was exhibited, and the tumor volume could also be measured. This promising method is noninvasive and has the potential to eventually replace invasive histopathology because it obviates the need to kill groups of animals at multiple time points.

Thoracoabdominal-aortoiliac MDCT angiography using reduced dose of contrast material.

OBJECTIVE: The objective of our study was to compare the image quality of MDCT angiography studies obtained by injection of low doses of contrast medium with saline flush versus conventional doses of contrast medium. MATERIALS AND METHODS: Seventy-one patients with pre- or postoperative aortic aneurysms underwent MDCT angiography throughout the thoracoabdominal-aortoiliac system using an 8-MDCT scanner. In 37 patients, 100 mL of contrast medium was injected at a flow rate of 3.0 mL/s (hereafter referred to as the 100-mL group). In 34 patients, 50 mL of contrast medium followed by a 20-mL saline flush was injected at a flow rate of 2.5 mL/s (the 50-mL group). For each group, quantitative analysis involved calculating the mean aortoiliac enhancement, plateau deviation, and contrast enhancement in the pulmonary trunk and superior vena cava (SVC). Qualitative analysis involved assessing the 3D postprocessing images. RESULTS: Significant differences between the groups in mean aortoiliac enhancement (100-mL group vs 50-mL group, 337 +/- 6 H vs 319 +/- 5 H, p < 0.0001) and mean plateau deviation (51 +/- 4 H vs 58 +/- 4 H, p < 0.0001) were found. However, adequate arterial enhancement (>or= 200 H) was observed in 31 of 34 patients in the 50-mL group and uniform aortoiliac enhancement (< 50 H) was seen in 26 patients. Visual analysis showed no difference in contrast material magnitude and homogeneity between the groups. Furthermore, in the 50-mL group, the thoracic aorta was more clearly visualized because of a reduction in the opacity of the main pulmonary artery and SVC. CONCLUSION: In our experience, administration of 50 mL of contrast medium followed by a 20-mL saline flush produces thoracoabdominal-aortoiliac MDCT angiographic examinations of effective quality in most cases.

Demonstration of cardiac involvement of sarcoidosis by contrast-enhanced multislice computed tomography and delayed-enhanced magnetic resonance imaging.

Delayed-enhanced magnetic resonance (MR) imaging has recently been shown to be effective in detecting cardiac sarcoidosis. Two cases in which contrast-enhanced multislice computed tomography imaging clearly identified the localization and extension of cardiac sarcoidosis as delayed-enhanced MR imaging are presented.

Effectiveness of delayed enhanced MRI for identification of cardiac sarcoidosis: comparison with radionuclide imaging.

OBJECTIVE: The purpose of this study was to evaluate the usefulness of delayed enhanced MRI for detecting cardiac sarcoidosis and to clarify the relationship between the findings of MRI and those of radionuclide imaging. CONCLUSION: Delayed enhanced MRI is considered a useful method for the early identification of cardiac sarcoidosis. Delayed hyperenhancement is frequently associated with a reduction of regional wall motion and thallium-201 perfusion defects.

Cardiac functional analysis with multi-detector row CT and segmental reconstruction algorithm: comparison with echocardiography, SPECT, and MR imaging.

PURPOSE: To evaluate accuracy of cardiac functional analysis with multi-detector row computed tomography (CT) and segmental reconstruction algorithm over a range of heart rates. MATERIALS AND METHODS: Institutional review board approval was obtained. Informed consent was not required. Multi-detector row CT (500-msec rotation time, 8 x 1-mm detector collimation) and magnetic resonance (MR) imaging were performed in 50 patients (28 men, 22 women; age range, 46-84 years; mean age, 67 years). Two-dimensional echocardiography was performed in 41 patients, and electrocardiographically (ECG)-gated single photon emission computed tomography (SPECT) was performed in 27. End-diastolic volume (EDV), end-systolic volume (ESV), ejection fraction (EF), and left ventricular (LV) mass were estimated with multi-detector row CT and compared with values estimated with MR imaging, which served as the reference standard. Additionally, EF values estimated with multi-detector row CT, echocardiography, and SPECT were compared with those estimated with MR imaging. Systemic error and degree of agreement of global functional parameters measured with MR imaging and other modalities were assessed. In a second analysis, linear regression analysis was added. RESULTS: EF estimated with multi-detector row CT agreed and correlated well with EF estimated with MR imaging (bias +/- standard deviation, -1.2% +/- 4.6; r = 0.96). Agreement and correlation were similar for EDV (-0.35 mL +/- 15.2; r = 0.97), ESV (1.1 mL +/- 8.6; r = 0.99), and LV mass (2.5 mL +/- 15.0; r = 0.96). Standard deviation of EF difference between multi-detector row CT and MR imaging was significantly less than that between echocardiography and MR imaging (P < .001) or that between SPECT and MR imaging (P < .001). CONCLUSION: Various LV functional parameters were measured with multi-detector row CT with a segmental approach, and measurements correlated and agreed with those obtained with MR imaging. Moreover, functional analysis with multi-detector row CT was more accurate than that with two-dimensional echocardiography or ECG-gated SPECT.

Comparison of myocardial blood flow induced by adenosine triphosphate and dipyridamole in patients with coronary artery disease.

Myocardial perfusion imaging with adenosine triphosphate (ATP) has been used increasingly to diagnose coronary artery disease (CAD) and assess risk for this disease. This study compared absolute myocardial blood flow (MBF) and myocardial flow reserve index (MFR) with ATP and dipyridamole (DIP) in patients with CAD. MBF was quantified by 15O-H2O PET in 21 patients with CAD (17 male, 4 female), aged 55 to 81 years. MBF was measured at rest, during intravenous injection of ATP (0.16 mg/kg/min), and again after DIP infusion (0.56 mg/kg). Regions of interest were drawn in nonischemic and ischemic segments based on findings from thallium-201 (201T1) scintigraphy and coronary angiography (CAG). Absolute MBF values and indexes of MFR were calculated in nonischemic and ischemic segments. Intravenous injection of ATP and DIP significantly increased MBF in nonischemic (2.4 +/- 0.9 and 2.1 +/- 0.8 ml/g/min, respectively; p < 0.01, for both) and in ischemic segments (1.3 +/- 0.4 and 1.5 +/- 0.4 ml/g/min, respectively; p < 0.01, for both). There was a significant difference in MBF values between ATP and DIP in nonischemic segments (p < 0.05), which was not observed in ischemic segments. In nonischemic segments, ATP produced higher MFR than DIP (2.1 +/- 0.8 and 1.8 +/- 0.7, respectively; p < 0.05), while no significant difference was observed in ischemic segments (1.5 +/- 0.6 and 1.7 +/- 0.3, respectively). ATP produced a greater hyperemia than DIP between the ischemic and nonischemic myocardium in patients with CAD. ATP is as effective as DIP for the diagnosis of CAD.