Tomosynthesis-guided vacuum-assisted breast biopsy: A feasibility study.

PURPOSE: Evaluation of feasibility and clinical performance of a tomosynthesis-guided vacuum-assisted breast biopsy (TVAB) system compared to Stereotaxy (SVAB). MATERIALS AND METHODS: All biopsies were performed on consecutive patients: 148 TVAB biopsies and 86 biopsies on different patients using SVAB. Evaluation criteria for each biopsy were technical feasibility, histopathology, procedure time, and complications. RESULTS: All 148 TVAB biopsies were technically successful, and gained the targeted groups of microcalcifications (100 %). In 1 of 86 SVAB procedures, it was not possible to gain the targeted microcalcifications (1 %), in 3 of 86 the needle had to be adjusted (4 %). All TVAB biopsies were performed without clinically relevant complications. Distortions were biopsied exclusively by TVAB, mean size 0.9 cm, p < 0.0001. Of the 24 distortions, 13 were cancer, 11 Radial Scars/ CSL. The mean procedure time for TVAB was 15.4 minutes (range 7-28 min), for SVAB 23 minutes (range 11-46 min), p < 0.0001. CONCLUSIONS: TVAB is able to biopsy small architectural distortions with high accuracy. TVAB is easily feasible and appears to have the same degree of clinical performance for diagnosing microcalcifications. The increased number of biopsied distortions by TVAB is presumably due to increased use of tomosynthesis and its diagnostic potential. KEY POINTS: • TVAB is easily feasible. • TVAB is able to target architectural distortions with high accuracy. • TVAB diagnoses microcalcifications with the same clinical performance as SVAB.

Value of one-view breast tomosynthesis versus two-view mammography in diagnostic workup of women with clinical signs and symptoms and in women recalled from screening.

OBJECTIVE: The purpose of this study is to compare the diagnostic value of one-view digital breast tomosynthesis versus two-view full-field digital mammography (FFDM) alone, and versus a combined reading of both modalities. MATERIALS AND METHODS: The datasets of one-view digital breast tomosynthesis and two-view FFDM of abnormal mammograms in 144 consecutive women admitted for diagnostic workup with clinical signs and symptoms (n = 78) or recalled from screening (n = 66) were read alone and in a combined setting. The malignant or benign nature of the lesions was established by histologic analysis of biopsied lesions or by 12-16-month follow-up. RESULTS: Eighty-six of the 144 patients were found to have breast cancer. The BI-RADS categories for one-view digital breast tomosynthesis were significantly better than those for two-view FFDM (p < 0.001) and were equal to those of the combined reading in both women admitted for diagnostic workup and women recalled from screening. The sensitivity and negative predictive values of digital breast tomosynthesis were superior to those of FFDM in fatty and dense breasts overall and in women admitted for diagnostic workup and in women recalled from screening. Only 11% of digital breast tomosynthesis examinations required additional imaging, compared with 23% of FFDMs. CONCLUSION: In patients with abnormal mammograms, one-view digital breast tomosynthesis had better sensitivity and negative predictive value than did FFDM in patients with fatty and dense breasts. They also suggest that digital breast tomosynthesis would likely increase the predictive values if incorporated in routine screening.

MR motility imaging in Crohn's disease improves lesion detection compared with standard MR imaging.

OBJECTIVE: To evaluate retrospectively in patients with Crohn's disease (CD) if magnetic resonance (MR) motility alterations correlate with CD typical lesions leading to an increased detection rate. METHODS: Forty patients with histologically proven CD underwent MR enterography (MRE), including coronal cine sequences (cine MRE), in addition to the standard CD MR protocol. Two blinded readings were performed with and without cine MRE. Locations presenting motility alterations on the cine sequences were analysed on standard MRE for CD-related lesions. This was compared with a second reading using the standard clinical MRE protocol alone. RESULTS: The number of lesions localised by cine MRE and identified on standard MRE compared with standard MRE alone were 35/24 for wall thickening (p = 0.002), 24/20 for stenoses (p = 0.05), 17/11 for wall layering (p = 0.02), 5/3 for mucosal ulcers (p = 0.02) and 21/17 for the comb sign (p = 0.05). Overall, cine MRE detected 35 more CD-specific findings than standard MRE alone (124/89; p = 0.007) and significantly more patients with CD-relevant MR findings (34/28; p = 0.03). CONCLUSION: CD lesions seem to be associated with motility changes and this leads to an increased lesion detection rate compared with standard-MRE imaging alone.

Interventional management of hypervascular osseous metastasis: role of embolotherapy before orthopedic tumor resection and bone stabilization.

OBJECTIVE: The purpose of this study was to evaluate, in relation to intraoperative estimated blood loss (EBL), the effectiveness of preoperative transcatheter arterial embolization of hypervascular osseous metastatic lesions before orthopedic resection and stabilization. MATERIALS AND METHODS: Between June 1987 and November 2007, 22 patients underwent transcatheter arterial embolization of tumors of the long bone, hip, or vertebrae before resection and stabilization. Osseous metastatic lesions from renal cell carcinoma, malignant melanoma, leiomyosarcoma, and prostate cancer were embolized. All patients were treated with a coaxial catheter technique with polyvinyl alcohol (PVA) particles alone or a combination of PVA particles and coils. After embolization, each tumor was angiographically graded according to devascularization (grades 1-3) based on tumor blush after contrast injection into the main tumor-feeding arteries. RESULTS: In patients with complete devascularization (grade 1), mean EBL was calculated to be 1,119 mL, whereas in patients with partial embolization (grades 2 and 3) EBL was 1,788 mL and 2,500 mL. With respect to intraoperative EBL, no significant difference between devascularization grades was found (p > 0.05). Moderate correlation (r = 0.51, p = 0.019) was observed between intraoperative EBL and tumor size before embolization. Only low correlation (r = 0.44, p = 0.046) was found between intraoperative EBL and operating time. Major complications included transient palsy of the sciatic nerve and gluteal abscess in one patient. CONCLUSION: The results of this study support the concept that there is no statistically significant difference among amounts of intraoperative EBL with varying degrees of embolization.

Intra- and retroperitoneal irrigation liquid after arthroscopy of the hip joint.

The case of intra- and retroperitoneal irrigation solution after hip arthroscopy of a 15-year-old girl is presented. She underwent hip arthroscopy for intra-articular adhesiolysis after previous surgical dislocation of the hip for the treatment of femoroacetabular impingement. Arthroscopy was performed in the lateral decubitus position without traction to debride the peripheral joint compartment. The irrigation pressure was set at 40 mm Hg. There were no intraoperative complications. By the end of surgery, the anesthesiologist reported a drop in the patient's body temperature from 36.3 degrees to 34.5 degrees C. Postoperatively, she complained about abdominal swelling and discomfort. Abdominal sonography revealed approximately 2 to 3 L of intra- and retroperitoneal liquid, which was considered to be irrigation fluid. The irrigation fluid was absorbed within 16 hours without further treatment. The only possible way the irrigation fluid could have flown was a retroperitoneal course along the iliopsoas muscle and the iliac vessels with intraperitoneal perforation along their course. We observed at arthroscopies that irrigation pressure incidentally can rise to 140 mm Hg when leaking of fluid through the portals occurs. Intra-abdominal fluid is a potentially devastating complication. A sudden drop of body temperature has to raise suspicion for intra-abdominal leaking of irrigation fluid.

Targeted radionuclide therapy with 90Y-DOTATOC in patients with neuroendocrine tumors.

BACKGROUND: The aim of this study was to assess the efficacy and safety of targeted radionuclide therapy with [90Y-DOTA0, Tyr3]-octreotide (90Y-DOTATOC) in patients with metastatic neuroendocrine tumors. PATIENTS AND METHODS: One hundred and sixteen patients with metastatic neuroendocrine tumors were included. All patients were pre-therapeutically staged with morphological imaging procedures and with somatostatin receptor scintigraphy. The scintigraphy was positive in all cases. The patients were treated with 162-200 mCi/m2 body surface. In 57 patients, the quality of life was assessed with the National Cancer Institute grading criteria (NCI-CTC). Restaging was performed 8-12 weeks after the last treatment cycle. Blood samples were drawn every 2 weeks after the treatment to evaluate toxicity. RESULTS: Complete remissions were found in 4%, partial remissions in 23%, stabilization in 62% and progressive disease in 11%. A significant reduction of symptoms was found in 83%. No serious adverse event occurred and the toxicity was acceptable. CONCLUSION: 90Y-DOTATOC is a safe and effective treatment for patients with metastatic neuroendocrine tumors.

Monitoring antiproliferative responses to kinase inhibitor therapy in mice with 3'-deoxy-3'-18F-fluorothymidine PET.

UNLABELLED: The aim of this study was to evaluate, whether PET with (18)F-FDG and 3'-deoxy-3'-(18)F-fluorothymidine ((18)F-FLT) may be used to monitor noninvasively the antiproliferative effects of tyrosine kinase inhibitors. METHODS: Using a high-resolution small animal scanner, we measured the effect of the ErbB-selective kinase inhibitor PKI-166 on the (18)F-FDG and (18)F-FLT uptake of ErbB1-overexpressing A431 xenograft tumors. RESULTS: Treatment with PKI-166 markedly lowered tumor (18)F-FLT uptake within 48 h of drug exposure; within 1 wk (18)F-FLT uptake decreased by 79%. (18)F-FLT uptake by the xenografts significantly correlated with the tumor proliferation index as determined by proliferating cell nuclear antigen staining (r = 0.71). Changes in (18)F-FLT uptake did not reflect inhibition of ErbB kinase activity itself but, rather, the effects of kinase inhibition on tumor cell proliferation. Tumor (18)F-FDG uptake generally paralleled the changes seen for (18)F-FLT. However, the baseline signal was significantly lower than that for (18)F-FLT. CONCLUSION: These results indicate that (18)F-FLT PET provides noninvasive, quantitative, and repeatable measurements of tumor cell proliferation during treatment with ErbB kinase inhibitors and provide a rationale for the use this technology in clinical trials of kinase inhibitors.

Synthesis and evaluation of bombesin derivatives on the basis of pan-bombesin peptides labeled with indium-111, lutetium-177, and yttrium-90 for targeting bombesin receptor-expressing tumors.

Bombesin receptors are overexpressed on a variety of human tumors like prostate, breast, and lung cancer. The aim of this study was to develop radiolabeled (Indium-111, Lutetium-177, and Yttrium-90) bombesin analogues with affinity to the three bombesin receptor subtypes for targeted radiotherapy. The following structures were synthesized: diethylenetriaminepentaacetic acid-gamma-aminobutyric acid-[D-Tyr6, beta-Ala11, Thi13, Nle14] bombesin (6-14) (BZH1) and 1,4,7,10-tetraazacyclododecane-N,N',N",N"' -tetraacetic acid-gamma-aminobutyric acid-[D-Tyr6, beta-Ala11, Thi13, Nle14] bombesin (6-14) (BZH2). [111In]-BZH1 and in particular [90Y]-BZH2 were shown to have high affinity to all three human bombesin receptor subtypes with binding affinities in the nanomolar range. In human serum metabolic cleavage was found between beta-Ala11 and His12 with an approximate half-life of 2 hours. The metabolic breakdown was inhibited by EDTA and beta-Ala11-His12 (carnosine) indicating that carnosinase is the active enzyme. Both 111In-labeled peptides were shown to internalize into gastrin-releasing peptide-receptor-positive AR4-2J and PC-3 cells with similar high rates, which were independent of the radiometal. The biodistribution studies of [111In]-BZH1 and [111In]-BZH2 ([177Lu]-BZH2) in AR4-2J tumor-bearing rats showed specific and high uptake in gastrin-releasing peptide-receptor-positive organs and in the AR4-2J tumor. A fast clearance from blood and all of the nontarget organs except the kidneys was found. These radiopeptides were composed of the first pan-bombesin radioligands, which show great promise for the early diagnosis of tumors bearing not only gastrin-releasing peptide-receptors but also the other two bombesin receptor subtypes and may be of use in targeted radiotherapy of these tumors.

Targeted radiotherapy for small cell lung cancer using 90Yttrium-DOTATOC, an Yttrium-labelled somatostatin analogue: a pilot trial.

BACKGROUND: Some small cell lung carcinomas (SCLC) express neuro-endocrine markers, such as somatostatin receptors. Therefore, somatostatin analogues can be radio-labelled with 111Indium (Octreoscan) for diagnostic scintigraphy, or with 90Y-DOTATOC for therapeutic use. This is the first trial to assess the toxicity and efficacy of treatment with 90Y-DOTATOC in patients with Octreoscan positive SCLC. METHODS: Patients with SCLC after > or =first line chemotherapy received an Octreoscan scintigraphy and results were compared to CT scans. Patients with strong somatostatin-receptor expression were treated with 60 mCi/m2 90Y-DOTATOC i.v. every 3 weeks, for a total of three cycles. Major inclusion criteria were measurable tumour lesions, disease progression, normal creatinine clearance, PS < or = 2. RESULTS: Octreoscan scintigraphy identified 70% of all primary tumours, 87% of all mediastinal lesions, but only 26% of all extrathoracic tumour manifestations. Six patients were treated. Median number of 90Y-DOTATOC cycles was 2 (1-3). The only grade 3 toxicity was fatigue (n = 2) and dyspnea (n = 1). There were no severe renal or haematological toxicities. All six patients had tumour progression, median progression free survival (PFS) was 37.5 days (28-52) and median overall (OS) was 103.5 days (28-269). CONCLUSION: This is the first report of somatostatin-receptor targeted radiotherapy for SCLC in the literature. In contrast to well differentiated neuro-endocrine tumours, 90Y-DOTATOC seems to be inactive in SCLC.

Impact of patient weight and emission scan duration on PET/CT image quality and lesion detectability.

UNLABELLED: This study was performed to prospectively evaluate fast PET/CT imaging protocols using lutetium oxyorthosilicate (LSO) detector technology and 3-dimensional (3D) image-acquisition protocols. METHODS: Fifty-seven consecutive patients (30 male, 27 female; mean age, 58.6 +/- 15.7 y) were enrolled in the study. After intravenous injection of 7.77 MBq (0.21 mCi) of (18)F-FDG per kilogram, a standard whole-body CT study (80-110 s) and PET emission scan were acquired for 4 min/bed position in 49 patients and 3 min/bed position in 8 patients. One-minute-per-bed-position data were then extracted from the 3- or 4-min/bed position scans to reconstruct single-minute/bed position scans for each patient. Patients were subgrouped according to weight as follows: <59 kg (<130 lb; n = 15), 59-81 kg (130-179 lb; n = 33), and >or=82 kg (>or=180 lb; n = 9). Three experienced observers recorded numbers and locations of lesion by consensus and independently rated image quality as good, moderate, poor, or nondiagnostic. RESULTS: The observers analyzed 220 reconstructed whole-body PET images from 57 patients. They identified 114 lesions ranging in size from 0.7 to 7.0 cm on the 3- (n = 8) and 4-min/bed position images (n = 49). Of these, only 4 were missed on the 1-min/bed position scans, and all lesions were identified on the corresponding 2-min/bed position images. One- and 2-min/bed position image quality differed significantly from the 4-min/bed position image reference (P < 0.05). CONCLUSION: LSO PET detector technology permits fast 3D imaging protocols whereby weight-based emission scan durations ranging from 1 to 3 min/bed position provide similar lesion detectability when compared with 4-min/bed position images.

Cardiac pacemakers and central venous lines can induce focal artifacts on CT-corrected PET images.

UNLABELLED: PET/CT imaging can be associated with focal artifactual (18)F-FDG uptake introduced by metallic implants or contrast agents. It is unknown whether cardiac pacemakers or permanent central venous catheters can also result in such artifacts. METHODS: Twenty-seven patients with permanent central venous lines (13 men and 14 women; mean age +/- SD, 53.8 +/- 16.2 y) and 9 patients with pacemakers (7 men and 2 women; mean age +/- SD, 74.8 +/- 5.1 y) who were referred for a variety of oncologic indications were studied with lutetium-oxyorthosilicate-based dual-slice PET/CT after injection of 7.77 MBq/kg of (18)F-FDG. CT-corrected and -uncorrected PET images were reviewed, and (18)F-FDG uptake was graded as absent, mild, moderate, or intense. RESULTS: CT-corrected PET images revealed focally increased uptake of moderate intensity in all patients with cardiac pacemakers and focally increased uptake of mild intensity in 8 of 27 patients (29.6%) with central venous lines. CONCLUSION: Cardiac pacemakers and reservoirs of central venous lines can induce artifactual (18)F-FDG on CT-corrected PET images. Thus, in patients with permanent central lines or pacemakers, both corrected and uncorrected PET images need to be reviewed to avoid false-positive PET findings.

Cigarette smoking and coronary blood flow.

Cigarette smoking is associated with an increased risk for vascular disease. The effects of smoking and nicotine on coronary and peripheral arterial function have been probed with various invasive and noninvasive techniques. The current review provides a brief summary of the available techniques for measuring coronary or peripheral arterial function and discusses the determinants of myocardial blood flow at rest and during stress. Finally, it summarizes research addressing the effects of smoking on coronary and peripheral arterial function. Acute and chronic smoking does not appear to alter substantially endothelium independent coronary vasodilatory capacity. In contrast, active and passive smoking alters coronary and peripheral arterial vasomotion in patients with and individuals without coronary artery disease (CAD). Therefore, the site of the damaging effects of smoking appears to be the coronary endothelium. The smoking history is correlated with the degree of vasomotor abnormalities. Further, the degree of smoking-induced endothelial dysfunction appears to increase with the severity of CAD. Finally, the coronary endothelial and peripheral arterial vasomotor dysfunction observed in active and passive healthy smokers appear to be to some degree reversible.

Tumor response and clinical benefit in neuroendocrine tumors after 7.4 GBq (90)Y-DOTATOC.

UNLABELLED: The aim of this prospective phase II study was to evaluate the tumor response of neuroendocrine tumors to high-dose targeted irradiation with 7.4 GBq/m(2) of the radiolabeled somatostatin analog (90)Y-1,4,7,10-tetra-azacyclododecan-4,7,10-tricarboxy-methyl-1-yl-acetyl-D-Phe-Tyr(3)-octreotide (DOTATOC). In addition, we investigated the clinical benefit of (90)Y-DOTATOC regarding the malignant carcinoid syndrome and tumor-associated pain. METHODS: Thirty-nine patients (mean age, 55 y) with progressive neuroendocrine gastroenteropancreatic and bronchial tumors were included. The treatment consisted of 4 equal intravenous injections of a total of 7.4 GBq/m(2) (90)Y-DOTATOC, administered at intervals of 6 wk. After each treatment cycle, a standardized clinical benefit assessment using the National Cancer Institute grading criteria (NCI-CTC) was performed. RESULTS: The objective response rate according to World Health Organization (WHO) criteria was 23%. For endocrine pancreatic tumors (13 patients), the objective response rate was 38%. Complete remissions were found in 5% (2/39), partial remissions in 18% (7/39), stable disease in 69% (27/39), and progressive disease in 8% (3/39). A significant reduction of clinical symptoms could be found in 83% of patients with diarrhea, in 46% of patients with flush, in 63% of patients with wheezing, and in 75% of patients with pellagra. The overall clinical benefit was 63%. All responses (both clinical benefit and WHO response) were ongoing for the duration of follow-up (median, 6 mo; range, 2-12 mo). Side effects were grade 3 or 4 (NCI-CTC) lymphocytopenia in 23%, grade 3 anemia in 3%, and grade 2 renal insufficiency in 3%. CONCLUSION: High-dose targeted radiotherapy with 7.4 GBq/m(2) (90)Y-DOTATOC is a well-tolerated treatment for neuroendocrine tumors, with remarkable clinical benefit and objective response.