In-bore MR prostate biopsy - initial experience.

INTRODUCTION: The introduction of multiparametric MRI (mpMRI) has been a breakthrough in the diagnosis of noninvasive clinically significant prostate cancer. Currently, MR-guided prostate biopsy (in-bore biopsy) is the only biopsy method that uses real-time MRI in patients with suspected prostate cancer. The aim of the study was a retrospective analysis of the correlation between MRI results and histological findings of prostate samples suspected of malignancy, which were taken during MRI-guided biopsy. MATERIAL AND METHODS: Thirty-nine patients with 57 lesion biopsies were enrolled in the study. Patients were aged 48-84 years (mean age 67.2 ± 9.4 years). RESULTS: Cancer was histologically confirmed in 24 lesions, including primary cancer in 14 lesions and local recurrence in 10 lesions. Cancer was not detected in the remaining lesions (n = 33). Malignancy was confirmed in 90% of lesions previously reported as PI-RADS 5. Only one Prostate Imaging and Reporting and Data System (PI-RADS 5) lesion was histologically negative (prostatitis). Cancer was detected in 50% of lesions defined as PI-RADS 4. Cancer cells were not found in any of 23 lesions defined as PI-RADS 3 (53.5%). Most of the lesions assessed as PI-RADS 3 were located in the transitional zone (n = 19). Only four PI-RADS 3 lesions were found in the peripheral zone. Large lesions or lesions feasible for cognitive TRUS biopsy were not referred for MRI biopsy, which resulted in a higher proportion of lesions assessed as PI-RADS 3. Fourteen lesions suspected of local recurrence were assessed in our study. Cancer was found in approximately 72% of the lesions. CONCLUSIONS: Performing prostate biopsy under the guidance of real-time MRI allows precise collection of material for histological examination (even from a very small lesion). As a result, both primary cancer and local recurrence after previous radiotherapy of prostate cancer can be confirmed.

Anaplastic transformation of low-grade gliomas (WHO II) on magnetic resonance imaging.

INTRODUCTION: Malignant transformation among gliomas WHO II ranges between 35% and 89%. However, according to some reports, all gliomas WHO II undergo such transformation over time. The aim of the study was to analyse MRI parameters indicating anaplastic transformation of gliomas WHO II. MATERIAL AND METHODS: Forty-six consecutive patients were enrolled in the study (20 females and 26 males; range of age 36 ± 9 years) with supratentorial glioma WHO II. Multiparametric MR examination included morphological imaging, perfusion-weighted imaging, diffusion-weighted imaging and proton magnetic resonance spectroscopy. Group division depended on the course of disease (ST - stable group, AT - anaplastic transformation group). RESULTS: Subtotal tumour resection was achieved in the whole AT group, whereas in the ST group, total tumour resection was achieved in 10/29 (34%) patients. The size of the residual tumour after surgery was statistically significantly higher in the AT group compared to the ST group (AT: 51.5 cm³ ± 37.7 vs. ST: 29.0 cm³ ± 37.9; p = 0.011). Contrast enhancement in the AT group occurred in 5/11 (45%) of tumours and in none of the patients' areas of contrast enhancement were resected during surgery/biopsy. However, the initial MR showed contrast enhancement in 10/29 (34%) of patients in the ST group. The areas of contrast enhancement were totally resected in all patients. Compared to the ST group tumours that underwent anaplastic transformation had statistically significantly higher values of mean nrCBV and max nrCBV on the initial MR, the follow-up and final MR examinations. However, statistically significant differences between the groups in ADC values were observed on the follow-up and final MR whereas mean Cho/Cr and mean Cho/NAA were observed as late as on the final MR examination. CONCLUSIONS: Multiparametric MR examination allows the detection of LGGs with high probability of rapid anaplastic transformation and the detection of transformation prior to the occurrence of contrast enhancement. The value of nrCBV is the most useful in the diagnosis of anaplastic transformation. The resection of contrast enhancement area of the tumour significantly increases time to anaplastic transformation of LGGs.

Reoperations of patients with low-grade gliomas in eloquent or near eloquent brain areas.

BACKGROUND AND PURPOSE: Reoperations of patients with recurrent low-grade gliomas (LGG) are not always recommended due to a higher risk of neurological deficits when compared to initial surgery. The purpose of the present study was to evaluate surgical outcomes of patients operated on for recurrent LGG. MATERIAL AND METHODS: Sixteen patients who had surgery for recurrent LGG out of 68 LGG patients who underwent surgery at the Department of Neurosurgery in Sosnowiec, Poland between 2005 and 2011 were enrolled in the study. RESULTS: A large tumour volume prior to the initial surgery was the most significant parameter influencing LGG progression (96.6 cm³ vs. 47.9 cm3, p = 0.01). Increased incidence of epileptic seizures and decreased mental ability according to Karnofsky score were the most common symptoms associated with tumour recurrence. In the group of patients with malignant transformation, the relative cerebral blood volume (rCBV) was considerably increased (1.21 vs. 2.41, p < 0.01). No statistically significant difference was found in terms of the extent of resection between initial surgery and reoperation. Similarly, no significant difference was found in the number of patients with a permanent neurological deficit after initial surgery and reoperation. CONCLUSIONS: Reoperations of the patients with recurrent LGG are not burdened with a higher risk of neurological sequelae when compared to initial surgery. The extent of resection during the surgery for LGG recurrence is comparable to initial surgery. The increase of rCBV seems to be a significant biomarker that indicates malignant transformation.

The assessment of prognostic factors in surgical treatment of low-grade gliomas: a prospective study.

OBJECTIVE: A prospective volumetric analysis of extent of resection (EOR) was carried out to assess surgical outcomes in adults diagnosed with hemispheric low grade gliomas (LGGs). MATERIALS AND METHODS: 68 consecutive patients diagnosed with LGGs were enrolled in the study. Pre- and post-operative tumor volumes and EOR were measured based on FLAIR MRI. Dynamic susceptibility contrast perfusion magnetic resonance imaging (DSC MRI) was used for the assessment of relative cerebral blood volume (rCBV). Three outcome measures were assessed: overall survival (OS), progression-free survival (PFS), and malignant degeneration-free survival (MFS). RESULTS: In 6 (9%) patients permanent neurologic deficits were observed. No statistically significant dependence between the EOR and the occurrence of permanent deficits was found. The eloquent or close to the eloquent location was statistically connected with lower EOR (p=0.023). The preoperative volume of tumors treated with gross total resection was significantly smaller than the volume of tumors in subtotal or partial resection groups (p=0.020, p<0.001, respectively). OS was predicted by age at diagnosis (p=0.032), and rCBV (p=0.002). Progression and malignant transformation occurred in 22 (32%) and 11 (16%) out of 68 patients. PFS was predicted by preoperative tumor volume (p=0.005), postoperative tumor volume (p=0.008), the EOR (p=0.001), and by the rCBV (p=0.033). MFS was predicted by preoperative tumor volume (p=0.034), the EOR (pp=0.020), and by rCBV (p=0.022). Postoperative tumor volume was associated with a trend of improved MFS (p=0.072). The univariate analysis shows the statistical trend for the relationship between histological subtype and PFS and MFS (p=0.079, p=0.078, respectively). Multivariate analysis selected preoperative tumor volume and rCBV as independently associated with PFS (p=0.009, p=0.019, respectively) and MFS (p=0.023, p=0.035, respectively). EOR was associated with a trend of improved PFS, and MFS (p=0.069, p=0.094, respectively). CONCLUSIONS: Tumor resection of LGG with the use of intraoperative monitoring and neuronavigation is associated with a low risk of new permanent deficits, but EOR significantly decreases with the size of the tumor and/or its location in/close to the eloquent areas. Smaller preoperative tumor volume and greater EOR are significantly associated with longer OS, PFS and MFS. Preoperative rCBV is one of the important prognostic factors significantly connected with survival. Prognosis in LGGs is still under discussion. Other factors such as age, histopathological subtype and KPS should not be underestimated.

Fibre integrity and diffusivity of the pyramidal tract and motor cortex within and adjacent to brain tumour in patients with or without neurological deficits.

BACKGROUND: Assessment of the relationship between preoperative neurological deficits and diffusion tensor imaging (DTI) parameters in patients with brain tumour within/adjacent to pyramidal tract and motor cortex. Evaluation of the difference in fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values in patients with low and high grade gliomas. MATERIAL AND METHODS: 20 patients with supratentorial brain tumours were divided into two groups: I with preoperative neurological deficits and II without preoperative neurological deficits. 8/20 tumours were classified as low grade gliomas, 10/20 as high grade gliomas and 2/10 as metastases. All MR examinations were performed on a 3T scanner. FA and ADC values were calculated for a precentral gyrus (PCG), a posterior limb of the internal capsule (PLIC) and a pyramidal tract (PT) ipsilateral and contralateral to the tumour side. These values were compared between patients with and without preoperative neurological deficits, with low and high grade gliomas. RESULTS: A statistical analysis revealed significant differences between patients with and without preoperative neurological deficits in PCGs and PTs ipsilateral to the tumour side. Separate analysis conducted in the group with preoperative neurological deficits showed significant statistical differences only in terms of FA values comparing ipsilateral and contralateral tumour side. No statistically significant difference was observed comparing FA and ADC values ipsilateral and contralateral to the tumour side in the group without preoperative neurological deficits and between patients with low and high grade gliomas. CONCLUSIONS: There is a relation between FA and ADC values and preoperative deficits in patients with brain tumour adjacent/within the main white matter tracts. Tumour relation to the white matter tracts is more important than the glioma WHO grade.

Measurement of glycine in a brain and brain tumors by means of 1H MRS.

AIM: Evaluation of a peak at 3.55 ppm in a long echo time (TE) recognized as glycine (Gly) in the WHO grade II gliomas and central neurocytomas by means of 1H MRS. MATERIAL AND METHODS: Retrospective analysis of 19 patients with histopathologically confirmed WHO grade II glioma and 2 patients with central neurocytoma was conducted. 1H MRS (TE = 135 ms and TE = 144 ms) was performed with 1.5 T and 3.0 T scanners. Gly/Cr, Gly/Cho and Gly/NAA ratios were compared between the analysed groups. Additional analysis of a brain of 61 healthy volunteers was conducted. RESULTS: Glycine was distinguished in 12 out of 19 (63%) WHO grade II gliomas. Among those 12 WHO grade II gliomas only in 26% of a spectra Gly was recognized. In both central neurocytomas Gly was distinguished and in 43% of the spectra Gly was recognized. The ratio of Gly/Cr in central neurocytomas was higher than in WHO grade II gliomas (mean(CNC) 0.62 ± 0.18 vs. mean(WHO II) 0.37 ± 0.10; p < 0.001) but the ratio of Gly/Cho was lower (mean(CNC) 0.18 ± 0.04 vs. mean(WHO II) 0.24 ± 0.07; p < 0.001). There was no difference between analysed groups in terms of Gly/NAA ratio (mean(CNC) 0.36 ± 0.09 vs. mean(WHO II) 0.36 ± 0.14; p = NS). Only in 0.3% of the spectra of normal brain Gly was distinguished. CONCLUSIONS: Glycine is found in WHO II grade gliomas as well as in central neurocytomas, but only in a part of a tumor volume. It is necessary to perform 1H MRS of the whole tumor volume to confirm/exclude the presence of glycine. Glycine in a normal brain can not be identified by means of conventional 1H MRS performed by means of 1.5 T or 3.0 T scanners.

Differentiation between brain tumor recurrence and radiation injury using perfusion, diffusion-weighted imaging and MR spectroscopy.

BACKGROUND: Differentiation between tumor recurrence/vital tumor tissue and radionecrosis based on conventional diagnostic imaging is impossible because of the likeness of the images. In such circumstances advanced MRI techniques (PWI, DWI, 1HMRS) seem to be helpful. The aim of our study was to evaluate the diagnostic effectiveness of PWI, DWI and 1HMRS in the differentiation of the tumor recurrence from radiation related injury. MATERIAL AND METHODS: The retrospective analysis comprised 11 contrast-enhancing lesions observed in 8 patients treated for gliomas with radiotherapy or radiochemotherapy. 5 out of 11 contrast-enhancing lesions were tumor recurrences whereas 6 out of 11 radiation-related injuries. The MR examinations comprised of conventional MR imaging (T1-SE, T1-MPRAGE with CE, T2-TSE, T2 FLAIR) and PWI, DWI, 1HMRS. Mean and maximum rCBV values of each contrast-enhancing lesion were calculated. These values were normalized to normal appearing white matter. Mean normalized ADC ratio to normal appearing white matter and mean ADC obtained from contrast-enhancing lesions were analysed. In 1HMRS only those voxels which were placed in solid part of the contrast-enhancing lesion were analysed and Cho/Cr, Cho/NAA ratios presented. RESULTS: Mean normalized rCBVmax (2.44 +/- 0.73 for tumor recurrence vs. 0.78 +/- 0.46 for radiation injury; p < 0.001) and mean normalized rCBVmean (1.46 +/- 0.49 for tumor recurrence vs. 0.49 +/- 0.38 for radiation injury; p < 0.005) were significantly higher in the recurrent gliomas group than in the radiation injury one. It was observed that normalized rCBVmax higher than 1.7 and normalized rCBVmean higher than 1.25 is highly indicative for recurrent glioma whereas normalized rCBVmax lower than 1.0 and normalized rCBVmean lower than 0.5 is highly indicative for radiation injury. Results obtained in DWI and 1HMRS were not statistically significant different between two analysed groups. Mean ADCce: 1.06 +/- 0.18 x 10-3 mm2/s for tumor recurrence vs. 1.13 +/- 0.13 x 10-3 mm2/s for radiation injury; p = 0.51. Mean normalized ADC: 1.55 +/- 0.39 x 10-3 mm2/s for tumor recurrence vs. 1.55 +/- 0.18 x 10-3 mm2/s for radiation injury; p = 0.98. Median Cho/Cr ratio: (2.16min/max [1.67-3.15] for tumor recurrence vs. 1.34min/max [1.13-2.37] for radiation injury; p = 0.15), median Cho/NAA ratio (1.9min/max [0.86-2.36] for tumor recurrence vs. 2.11min/max [0.97 vs. 2.87] for radiation injury; p = 0.51). CONCLUSIONS: Among the analyzed advanced neuroimaging methods PWI seems to be most reliable in differentiation between tumor regrowth/recurrence and radiation necrosis. In these results mean rCBV is a better differing factor than max rCBV. Proton MR spectroscopy (1HMRS) and DWI do not differentiate analyzed groups with statistical significance, despite tendency to lower ADC values in recurrence group than in radiation injury one.

Effect of blood glucose levels on prognosis in acute myocardial infarction in patients with and without diabetes, undergoing percutaneous coronary intervention.

BACKGROUND: Diabetes mellitus (DM) is a significant factor regarding poor outcome in patients with myocardial infarction. Recently a new prognostic factor is under consideration - a baseline glucose level on admission. We sought to assess the influence of blood glucose levels on admission on prognosis of patients with acute ST-segment elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI). METHODS AND RESULTS: Consecutive patients treated with PCI for STEMI were analyzed. Presence or absence of DM was the first grouping criterion. The secondary criterion was the blood glucose level on admission [threshold >or= 7.8 mmol/L (140 mg/dL)]. Hyperglycemic and non-hyperglycemic subgroups were selected within both DM and non-DM groups according to the threshold. One-year mortality of diabetics was 16.0%. There was no significant difference in 1-year mortality between hyperglycemic and non-hyperglycemic patients with DM. One-year mortality in the non-DM group was 5.6%. Patients without DM but with hyperglycemia showed a higher 1-year mortality rate than non-hyperglycemic patients (8.51% vs. 3.68%, p = 0.001). Multivariate analysis revealed that in the non-DM group blood glucose level (per 1 mmol/L) on admission was a factor affecting 1-year mortality [HR = 1.09 (1.01-1.17)]. CONCLUSIONS: Elevated blood glucose levels in STEMI affect the prognosis of patients without DM; however, it is not an independent death risk factor of patients with DM treated with PCI.

Does glucose level at hospital discharge predict one-year mortality in patients with diabetes mellitus treated with percutaneous coronary intervention for ST-segment elevation myocardial infarction?

BACKGROUND: It has been shown that diabetes mellitus (DM) is an independent prognostic factor in patients with myocardial infarction (MI). In addition to that fact the prognostic significance of blood glucose (BG) abnormalities in the acute phase of MI has also been suggested. Recently, a new prognostic factor has been evaluated - the glucose level at hospital discharge. AIM: To assess whether the glucose level at hospital discharge is associated with one-year mortality in patients with DM treated with percutaneous coronary intervention (PCI) for ST-segment elevation MI (STEMI), taking into account hypoglycaemic treatment. METHODS: Consecutive patients with STEMI and DM treated with PCI, who survived hospitalisation, were included in the analysis. Patients were assumed to have DM if previous diagnosis of DM or newly diagnosed DM during hospital stay was noted. Criteria of newly diagnosed DM were as follows: fasting BG >or=7 mmol/l at least twice after acute phase of STEMI, BG >or=11.1 mmol/l in a 2-hour glucose tolerance test performed before discharge. Fasting plasma glucose at hospital discharge was used for analysis. RESULTS: Out of 2762 consecutive patients with STEMI, 565 had DM. In-hospital mortality in this group was 9.4% (53 patients), so the final DM group consisted of 512 patients. After discharge 59 (11.5%) patients died during one-year follow-up. The glucose level at discharge was not an independent prognostic factor of one-year mortality in the whole analysed group, however insulin treatment at discharge was (HR 2.61, 95% CI 1.29-5.29; p=0.008). Afterwards, we undertook multivariate analysis separately in the group treated with insulin (253 patients) and in the group treated with oral drugs or diet only (259 patients). This analysis showed that in the group treated with insulin the glucose level at discharge was not an independent prognostic factor of one-year mortality (HR 1.07, 95% CI 0.95-1.22; p=0.27), whereas in patients treated with hypoglycaemic agents or diet it was significantly associated with a one-year mortality (HR 1.30, 95% CI 1.01-1.68; p=0.049). CONCLUSIONS: 1. Patients with STEMI and DM treated with insulin at hospital discharge have higher risk of death, probably because of more advanced DM and more severe complications, than patients treated with oral drugs or diet. 2. Elevated glucose level at hospital discharge predict one-year mortality only in patients with MI and DM treated with oral drugs or diet.

Relationship between blood glucose on admission and prognosis in patients with acute myocardial infarction treated with percutaneous coronary intervention.

BACKGROUND: Diabetes mellitus in patients with myocardial infarction affects in-hospital and late mortality. It has been shown that the glucose level on admission can also affect prognosis. This conclusion was based on an analysis performed on a heterogeneous group of patients, treated not only with percutaneous coronary intervention (PCI) but also with fibrinolysis. Moreover, the threshold values hyperglycaemia for the diagnosis of were also variable. AIM: To assess whether glucose level on admission affects in-hospital and one-year prognosis in patients with ST-segment elevation myocardial infarction (STEMI) treated with PCI. METHODS: Consecutive patients with STEMI treated with PCI were included in the analysis. Patients with STEMI complicated by cardiogenic shock were also included. Three groups according to the glucose level on admission were analysed: group I - <7.8 mmol/l (140 mg/dl), group II - 7.8-11.1 mmol/l (140-200 mg/dl), and group III - > or = 11.1 mmol/l (200 mg/dl). RESULTS: The incidence of diabetes mellitus in the total group (1027 patients) was 26.1%, and of cardiogenic shock - 9.2%. Group I consisted of 472 patients, group II - 307 patients, and group III - 248 patients. Compared with normoglycaemic patients, those with elevated glucose level were older, more often female, had more often hypertension, diabetes mellitus, cardiogenic shock, were more often treated with fibrinolysis before PCI but were less often smokers. Multivessel disease and initial patency of the infarct-related artery (TIMI 0-1) were more often observed in patients with higher glucose level. A trend towards a higher incidence of reocclusion was also more often present in patients with increased glucose level. Moreover, mean creatine kinase concentration was the highest and the left ventricular ejection fraction was the lowest in group III. During the in-hospital stay, the complication rate was as follows: stroke (1.1% vs. 1.3% vs. 4.4%), and mortality (2.8 vs. 4.9 vs. 13.3%) in groups I, II, and III, respectively. The same tendency was observed during the one-year follow-up period: stroke (1.3 vs. 2.9 vs. 6.9%), mortality (6.4 vs. 9.1 vs. 22.6%). The 1 mmol/l (18 mg/dl) increase of the baseline glucose level among various risk factors was an independent prognostic factor of higher -year mortality (HR=1.06; 95% CI 1.02-1.09). Diabetes mellitus did not affect prognosis among patients included in the analysis. CONCLUSION: Elevated glucose level on admission is associated with adverse prognosis in patients with STEMI treated with PCI.

Effects of direct stenting on epicardial and myocardial perfusion in patients with acute ST segment elevation myocardial infarction.

BACKGROUND: Results of studies comparing direct stenting (DS) with conventional stenting (CS) after balloon predilatation in patients with acute myocardial infarction (MI) have been reported in the past, however they are conflicting. There are only few randomised studies that aim to answer whether DS improves epicardial and myocardial patency. AIM: To assess the effects of DS on epicardial and myocardial patency in patients with acute MI. METHODS: Consecutive patients with acute MI were randomised either to DS or CS strategy. Clinical exclusion criteria were as follows: clinical and electrocardiographic features of reperfusion, pulmonary oedema, cardiogenic shock, contradictions to coronarography, allergy to aspirin, ticlopidine, clopidogrel, heparin and stainless steel. Angiographic exclusion criteria were as follows: lesion <50% with correct patency in the infarct-related artery (IRA), lesion in the left main coronary artery, previously performed percutaneous coronary intervention in the target vessel, diameter of the IRA <2 mm or >4 mm. We assessed epicardial patency according to the TIMI (thrombolysis in myocardial infarction) scale and myocardial patency according to the TMPG (TIMI myocardial perfusion grade) scale. In addition, we analysed ST segment resolution in 12-lead electrocardiography (ECG). The ECG was performed before and 30 minutes after PCI. RESULTS: We analysed 300 consecutive patients with acute ST segment elevation MI. After exclusion of patients not suitable for the study design, the DS group comprised 110 patients and the CS group - 107 patients. Clinical and angiographic results were similar in both groups. Initial TIMI 0 (48.2% vs. 43.0%), initial TIMI 3 (31.8% vs. 28.0%), initial TMPG 0-1 (77.3% vs. 78.5%), final TIMI 3 (95.5% vs. 93.5%) and final TMPG 2-3 (68.2% vs. 60.8%) were similar in the DS and CS groups, respectively (p=NS). The incidence of no-reflow phenomenon was comparable in both groups (4.5% vs. 6.5%, NS). The inclusive rate of no-reflow phenomenon plus worsening patency in the IRA were 6.4% vs. 10.3% in the DS and CS groups respectively. The ST segment resolution > or = 50% was 58.1% in the DS group and 56.1% in the CS group (NS). CONCLUSIONS: Direct stenting does not significantly improve epicardial and myocardial patency in an unselected group of patients with acute ST segment elevation MI.