Colorectal cancer (CRC) monitoring by 6-monthly 18FDG-PET/CT: an open-label multicentre randomised trial.

Background: [18F]2-fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography (18FDG-PET/CT) has high sensitivity for detecting recurrences of colorectal cancer (CRC). Our objective was to determine whether adding routine 6-monthly 18FDG-PET/CT to our usual monitoring strategy improved patient outcomes and to assess the effect on costs. Patients and methods: In this open-label multicentre trial, patients in remission of CRC (stage II perforated, stage III, or stage IV) after curative surgery were randomly assigned (1 : 1) to usual monitoring alone (3-monthly physical and tumour marker assays, 6-monthly liver ultrasound and chest radiograph, and 6-monthly whole-body computed tomography) or with 6-monthly 18FDG-PET/CT, for 3 years. A multidisciplinary committee reviewed each patient's data every 3 months and classified the recurrence status as yes/no/doubtful. Recurrences were treated with curative surgery alone if feasible and with chemotherapy otherwise. The primary end point was treatment failure defined as unresectable recurrence or death. Relative risks were estimated, and survival was analysed using the Kaplan-Meier method, log-rank test, and Cox models. Direct costs were compared. Results: Of the 239 enrolled patients, 120 were in the intervention arm and 119 in the control arm. The failure rate was 29.2% (31 unresectable recurrences and 4 deaths) in the intervention group and 23.7% (27 unresectable recurrences and 1 death) in the control group (relative risk = 1.23; 95% confidence interval, 0.80-1.88; P = 0.34). The multivariate analysis also showed no significant difference (hazards ratio, 1.33; 95% confidence interval, 0.8-2.19; P = 0.27). Median time to diagnosis of unresectable recurrence (months) was significantly shorter in the intervention group [7 (3-20) versus 14.3 (7.3-27), P = 0.016]. Mean cost/patient was higher in the intervention group (18 192 ± 27 679 € versus 11 131 ± 13 €, P < 0.033). Conclusion: 18FDG-PET/CT, when added every 6 months, increased costs without decreasing treatment failure rates in patients in remission of CRC. The control group had very close follow-up, and any additional improvement (if present) would be small and hard to detect. ClinicalTrials.gov identifier: NCT00624260.

[Can the degree of renal artery stenosis be automatically quantified?]. / Peut-on quantifier automatiquement le degré de sténose des artères rénales?

The objective of the reported study is to validate a computer system, QUASAR, dedicated to the quantification of renal artery stenoses. This system estimates automatically the reference diameter and calculates the minimum diameter to compute a degree of stenosis. A hundred and eighty images of atheromatous stenoses between 10% and 80% were collected from two French independent protocols. For the 49 images of the EMMA protocol, the results from QUASAR were compared with the visual estimation of an initial investigator and with the results from a reference method based on a panel of fixe experienced experts. For the 131 images of the ASTARTE protocol, the results from QUASAR were compared with those from a semi-automatic quantification system and with those from a system based on densitometric analysis. The present work validates QUASAR in a population of narrow atheromatous stenoses (> 50%). In the context of the EMMA protocol, QUASAR is not significantly different from the mean of the fixe experts. It is unbiased and more precise than the estimation of a single investigator. In the context of the ASTARTE protocol, there is no significant difference between the three methods for the stenoses higher than 50%, however, globally, QUASAR surestimates significantly (up to 10%) the degree of stenosis.

Interobserver variability in the interpretation of renal digital subtraction angiography.

OBJECTIVE: Our purpose was to analyze interobserver variability in the interpretation of renal digital subtraction angiography and to describe the main factors associated with observer discrepancies. MATERIALS AND METHODS: Forty-nine cases of unilateral atheromatous renal artery stenosis of more than 60% were quantified first by local investigators in a multicenter study and then by five other radiologists. Differences between radiologists for the minimum diameter (Dmin), the reference diameter (Dref), and the percentage of stenosis of the renal arteries were analyzed. Interpretations by the local investigators were then compared with the gold standard, defined as the mean for the five radiologists. RESULTS: The average SD for estimation of all renal artery stenoses by all radiologists was 7% for stenosis percentage, 0.5 mm for Dmin, and 0.7 mm for Dref. Main discrepancies occurred more frequently in cases of weakly opacified renal artery stenosis and poststenotic dilatation. The observations of local investigators disagreed by more than two SDs (14%) with the gold standard for 11 of 49 cases (22%). CONCLUSION: The accuracy of digital subtraction angiography in renal artery interpretations is poor because of variations in evaluating both Dmin and Dref. Precise and reproducible methods for quantification of renal artery stenosis are required.

Quantifying stenosis in renal arteriograms: a fuzzy syntactic analysis.

The introduction of fuzzy logic improves a system for the automatic quantification of renal artery lesions seen in digital subtraction angiograms. A two-step approach has been followed. An earlier system based on non-fuzzy syntactic analysis provided a clear symbolic description of the stenotic lesions. Although this system worked correctly, it did not take into account the variability and uncertainty inherent to image processing and to knowledge on the reference diameter. This system has been improved by the introduction of fuzzy logic in the representation of the reference diameter. It provides a description of the stenosis in terms of fuzzy quantities. To illustrate the benefits of the fuzzy approach, the results of the two systems have been compared by plotting the differences of an index of variability. It appears that the differences are statistically different when using a two-tailed paired t-test (t = 2.37; p = 0.025). The result shows that the fuzzy approach is better than a non-fuzzy approach in the sense that the index of variability is reduced significantly.

A fuzzy classification system to predict renal artery restenosis after angioplasty.

Percutaneous transluminal angioplasty (PTRA) has emerged as a promising treatment for patients with renovascular hypertension. However, the benefit of this procedure is hampered by restenosis that frequently occurs within around 6 months after a successful angioplasty. This paper presents a fuzzy classification system based on a fuzzy pattern matching model that is being developed to evaluate the risk of short-term restenosis. First, identified classes are represented by fuzzy prototypes that take into account the imprecision of the criteria. Second, the system is applied to angiographic features of given stenoses and provides the membership degree of these stenosis to the two classes "short term restenosis" or "no restenosis". The fuzzy classifier's performances have been tested on twenty two patients who underwent balloon angioplasty in the context of a French multicenter randomized trial EMMA. With the fuzzy classifier, restenosis were predicted prospectively with 100% while its sensitivity is about 73%. The fuzzy classification system is expected to become a reliable tool to predict PTRA outcomes.

Automatic stenosis detection and quantification in renal arteriography.

Visual assessment of the degree of renal artery stenosis on renal arteriography has a large inter- and intraobserver variability. This degree is usually estimated by the ratio between the most narrowed portion of the artery and the reference diameter. The latter is a priori unknown information and thus operator dependent. The objective of the present work was to test the performances of a computer system that was designed to analyze and quantify lesions on 2D renal arteriograms. The main hypothesis was to consider that the most frequent diameter computed along the artery was a good candidate to approximate the reference diameter. Forty nine patient images were collected from the EMMA randomized trial, a multicenter study comparing two treatment strategies in unilateral atheromatous renal artery stenosis of at least 60%. For each image, the degree of stenosis was evaluated by five independent experts and the mean value was used to represent the gold standard for the computer system. The system is based on a fuzzy automaton and performs a syntactic analysis of the arterial segment providing automatic and reproducible quantification of lesions. Both the radiologist caring for the patient and the system were compared to the gold standard. Compared to individual radiologists, the computer system gave a more precise estimation of percent stenosis and did not over or under estimate the severity of the lesion.

Fuzzy classification of renal artery lesions from angiograms in the context of angioplasty.

This paper describes a system that automatically classifies renal artery lesions from arteriograms in the context of Percutaneous Transluminal Renal Angioplasty (PTRA). PTRA outcomes have been categorized into type A (success) or type B (failure) according to morphological features. The morphological features are naturally represented by fuzzy sets. The classification process is based on a fuzzy pattern matching procedure between fuzzy prototypes of lesions in the classes A and B and fuzzy quantified assessments of lesions in angiograms. The system provides a meaningful membership degree to the class rather than an abrupt yes or no answer. The system is expected to be a good framework to study the technical results of PTRA according to the anatomy of the lesion.