Predictive Factors for the Survival Outcomes of Preoperative Chemotherapy in Patients with Resectable and Borderline Resectable Colorectal Cancer with Liver Metastasis.

BACKGROUND: Preoperative chemotherapy increases resectability in borderline resectable colorectal liver metastasis (CRLM) patients who undergo curative liver surgery. Most clinical risk scores and other predictive factors for survival have been extensively studied in patients who undergo upfront liver surgery. However, predictive factors of CRLM patients who received preoperative chemotherapy remains controversial. METHODS: CRLM patients who received preoperative systemic therapy followed by curative liver surgery at our institution between 1/2012 and 12/2018 were included. This study aimed to investigate factors that predicted the outcomes of preoperative systemic treatment, optimal dose/duration, and toxicity in patients with CRLM. OUTCOMES: Ninety-eight patients were eligible for analysis. Most patients received oxaliplatin-based chemotherapy (72.7%), while 15.9% received both oxaliplatin and irinotecan. Biologic agents were administered in 48.9% of patients. Overall, chemotherapy-induced liver injury was observed in 38.5%. The median disease-free survival (DFS) and overall survival (OS) were 8.7 months and 3.6 years, respectively. Baseline, pre-surgery, and increased Fong scores after preoperative chemotherapy were significantly associated with DFS and OS. In multivariate analysis, a high Fong score at baseline (p=0.018) was significantly associated with shorter DFS, whereas male sex (p=0.040) and liver surgery (p=0.044) were related to longer OS. CONCLUSION: In our study, Fong clinical risk scores, female sex, and liver surgery as a part of liver-directed therapy were independent prognostic factors for survival in CRLM patients who received preoperative chemotherapy. These clinical factors should be considered as an option to guide physicians' decisions in selecting patients with CRLM who may benefit most from curative liver-directed therapy.

Evaluation and external validation of minor lymphatic pelvic pathway for distant metastases in cervical cancer patients treated with concurrent chemoradiotherapy.

To evaluate and validate the minor lymphatic pathway for distant metastases in cervical cancer. This is a retrospective cohort of cervical cancer patients underwent curative concurrent chemoradiotherapy. We used original dataset from 1 university hospital and validation dataset from 3 university hospitals. Lymphadenopathy status in CT imaging was reviewed by radiologist in either the obturator and external iliac nodes (major pathway) or the internal iliac and presacral nodes (minor pathway). We then used Cox regression to adjust for all potential confounders, including paraaortic nodes, T stage, histology, age, total treatment time, total number of nodes, total short axis of nodes. 397 and 384 patients were in the original and validation datasets (median follow-up period, 59.5 month's). The minor pathway was independent prognostic factor in multivariable analysis [HR=2.64; 95%CI=1.07-6.55; P = 0.036] and [HR=14.84; 95%CI=3.15-70.01; P= 0.001] in original and validation datasets, respectively. Whereas, the major pathway was statistically non-significant. Further validation showed that the minor pathway had the highest HR for distant metastases with both the EMBRACE (HR=6.05; 95% CI=1.30-28.08; P = 0.022) and the FIGO 2018 (HR=7.43; 95% CI=2.94-18.78; P<0.001) in the original dataset. A similar result was found with the validation dataset: EMBRACE, HR=30.91; 95% CI=2.78-343.62; P = 0.005; and FIGO 2018, HR=42.41; 95% CI=8.83-203.60; P<0.001.This is the first clinical study to validate that the minor lymphatic pathway was predominantly associated with distant metastases in cervical cancer. This finding should be validated in larger cohort to further integrate in standard staging for prediction of distant metastases.

Development and validation of a prognostic prediction model including the minor lymphatic pathway for distant metastases in cervical cancer patients.

To develop and validate a prognostic model, including the minor lymphatic pathway (internal iliac and presacral nodes). STUDY DESIGN: Retrospective cohort. PARTICIPANTS: Locally advanced cervical cancer underwent concurrent chemoradiotherapy. SAMPLE SIZE: 397 and 384 patients in the development and validation data set. PREDICTORS: Our new nodal staging system with the minor lymphatic pathway. OUTCOME: Distant metastases. STATISTICAL ANALYSIS: Cox regression; net reclassification improvement (NRI) and decision curve analysis (DCA). Our new nodal system was the strongest predictor. The predictors in the final model were new nodal system, tumor stage, adenocarcinoma, initial hemoglobin, tumor size and age. The nodal system and the pretreatment model had concordance indices of 0.661 and 0.708, respectively, with good calibration curves. Compared to the OUTBACK eligibility criteria, the nodal system showed NRI for both cases (22%) and controls (16%). The pretreatment model showed NRI for cases (31%) and controls (18%). DCA in both models showed threshold probability of 15% and 12%, respectively, when compared with 24% in OUTBACK eligibility criteria. Our new nodal staging system and the pretreatment model could differentiate between high-risk and low-risk patients, thus facilitating decisions to provide more aggressive treatment to prevent distant metastases.

Mass-forming cholangiocarcinoma and adenocarcinoma of unknown primary: can they be distinguished on liver MRI?

PURPOSE: To determine MR features suggestive of mass-forming cholangiocarcinoma (CCA) or liver metastases of adenocarcinoma of unknown primary (AUP), and to compare the ability of two experienced radiologists to establish the correct diagnosis. MATERIALS AND METHODS: 61 patients with CCA or AUP, with MRIs were placed into two groups: population 1, 28 patients with certain diagnosis of either CCA or AUP; and population 2, 33 patients with uncertain diagnosis. Using population 1 with known diagnosis, two investigators formulated imaging criteria for CCA or AUP, which represented phase 1 of the study. In phase 2, two independent radiologists categorized the patients in populations 1 and 2 as CCA or AUP using the formulated criteria. This categorization was compared with the patient medical records and pathologist review. Findings were tested for statistical significance. RESULTS: In phase 1, solitary lesion, multifocal lesions with dominant lesion, capsule retraction, and porta hepatis lymphadenopathy were features of CCA; multifocal lesions with similar size, and ring enhancement were features of AUP. The number of lesions, capsule retraction, and early tumor enhancement pattern were observed to be significant features (P < 0.05). In phase 2, agreement between the two radiologists was good (k = 0.663). For population 1, the agreement was good (k = 0.659), and was fair for population 2 (k = 0.293). Concordance between the two radiologists, medical record, and the pathologist was found in 41/61 (67%) patients. CONCLUSION: Distinctive features of CCA and AUP are identifiable on MRI images, which may aid the radiologist to establish the correct diagnosis.

Liver adenomatosis: serial investigation on MRI.

PURPOSE: To describe the natural history of liver adenomatosis (LA), including complications and changes in lesion size over time. MATERIALS AND METHODS: Eighteen patients with clinical diagnosis of LA were included. Clinical and biochemical information were collected. The initial and follow-up MR studies were reviewed retrospectively to determine change in lesion size and imaging features. RESULTS: Seventeen patients were women (94.4%). The mean age of the initial MR study was 37.0 years (18-52 years). The median size of the largest lesion was 6.7 cm (range 3.0-13.5 cm). Intratumoral bleeding was detected on MRI in 9 lesions, in 7 patients (38.8%). The median size for hemorrhagic lesions was 7.6 cm (range 4.1-13.5 cm). During the mean follow-up period of 29.4 (range 4-98) months, 10 patients had stable disease (55.6%), and 8 patients had tumor regression (44.4%). Of 8 patients who were followed without intervention, 3 patients (37.5%) had spontaneous regression. No malignant transformation or lesion progression was occurred. CONCLUSION: During an over 2-year follow-up period, the majority of lesions of LA appeared to remain stable or showed tumor regression. Spontaneous tumor regression can be observed in approximately 37% of individuals in the age range of 28-53 years.

Outcomes of patients with elevated α-fetoprotein level and initial negative findings at MR imaging.

PURPOSE: To evaluate interval cancer diagnosis in patients with elevated α-fetoprotein (AFP) level and initial negative findings at magnetic resonance (MR) imaging. MATERIALS AND METHODS: The institutional review board approved this HIPAA-compliant retrospective study and waived informed consent. Seventeen patients with elevated AFP levels (>300 ng/mL [>300 µg/L]) and initial negative findings at hepatic MR imaging from 2002 to 2011 were identified. MR reports, pathology reports, and medical records were reviewed to determine outcome, including identification of hepatocellular carcinoma (HCC), and track changes in serum AFP level. Initial and follow-up MR images were reviewed to evaluate presence and size of hepatic nodules. Significance of AFP values was tested with repeated-measures analysis of variance. RESULTS: Ten (59%) of 17 patients developed HCCs (13 tumors) after a mean of 138 days (range, 41-247 days). Nine (90%) of 10 patients with HCCs underwent follow-up MR imaging, and one patient (10%) underwent liver transplantation without MR follow-up. Of 12 HCCs in nine patients who underwent follow-up MR imaging, 10 (83%) were noted at follow-up MR imaging and two were found only at surgery. Mean diameter of visualized HCCs was 3.4 cm. Of 10 HCCs detected at follow-up MR imaging, five were identifiable in retrospect at initial MR studies (mean diameter, 1.4 cm). Serum AFP levels in patients with HCCs were significantly higher than those in patients without HCCs and progressively increased over time (P = .012). CONCLUSION: Subsequent HCCs in patients with elevated AFP levels and initial negative findings at MR imaging are relatively common and demonstrable during short follow-up. Close follow-up (serial 3-month studies) is recommended in the setting of a steady increase in AFP level.

Free breathing three-dimensional gradient echo-sequence with radial data sampling (radial 3D-GRE) examination of the pancreas: Comparison with standard 3D-GRE volumetric interpolated breathhold examination (VIBE).

PURPOSE: To evaluate the diagnostic performance of free breathing three-dimensional gradient echo-sequence with radial data sampling (radial 3D-GRE) in MR imaging of the normal and diseased pancreas, using standard 3D-GRE for comparison in cooperative patients, and to perform a preliminary assessment in noncooperative patients. MATERIALS AND METHODS: One hundred and eight consecutive patients underwent 1.5 Tesla MR imaging of the abdomen that included pre- and postcontrast free breathing radial 3D-GRE. The sequences were evaluated by two radiologists retrospectively, independently, and blindly. The results were compared using Wilcoxon-Mann-Whitney test. Kappa statistics were used to measure the extent of agreement between the reviewers. RESULTS: The average scores indicated that the overall images quality of radial 3D-GRE was lower than 3D-GRE-VIBE in both pre- and postcontrast study (P = 0.0172 and 0.0001), however it achieved a rating that approximated good. In all patients, radial 3D-GRE had a mild extent of streak artifact, pulsation, susceptibility, and respiratory artifact. Radial 3D-GRE approximated good results for pancreatic edge sharpness and pancreatic ductal clarity, and did not differ significantly between cooperative and noncooperative patients. Respiratory artifact was worse in cooperative than in noncooperative patients (P = 0.02). Demonstration of pancreatic disease was slightly inferior with radial 3D-VIBE, but quality approximated good. CONCLUSION: Free breathing radial 3D-GRE may be applicable for pancreatic MR imaging in patients who are unable to suspend respiration.