An updated review of the TNM classification system for cancer of the oesophagus and its complications.

Cancer of the esophagus is an aggressive cancer with high mortality. Because of the esophagus's lack of serosa and its peculiar lymphatic drainage, esophageal cancer is diagnosed in advanced stages. The eighth edition of the TNM (2017) aims to standardize care for esophageal cancer throughout the world; it includes not only patients treated with esophagectomy alone, but also those receiving neoadjuvant chemotherapy and/or radiotherapy. One new development in the eighth edition is that it establishes separate classifications for different time periods, with pathologic stage groups for prior to treatment (cTNM), after esophagectomy (pTNM), and after neoadjuvant therapy (ypTNM). The combined use of endoscopic ultrasound, CT, PET-CT, and MRI provides the greatest accuracy in determining the clinical stage, and these techniques are essential for planning treatment and for evaluating the response to neoadjuvant treatment. Esophagectomy continues to be the main treatment; it is also the elective gastrointestinal surgery that has the highest mortality, and it carries the risk of multiple complications, including anastomotic leaks, pulmonary complications, technical complications, and functional complications.

Efectos adversos de las terapias dirigidas contra el cáncer: lo que el radiólogo debe saber / Adverse events of targeted anticancer therapies: what radiologists need to know

El tratamiento del cáncer ha avanzado drásticamente en las últimas décadas. Un mayor conocimiento de la biología tumoral ha propiciado el desarrollo de nuevos fármacos anticancerígenos, llamados "terapias dirigidas". Estos fármacos tienen como diana vías de señalización específicas necesarias para el desarrollo del cáncer. Más novedosa es aún la inmunoterapia. Estos nuevos agentes se pueden clasificar en diferentes grupos, principalmente según su mecanismo de acción: inhibidores de VEGF o antiangiogénicos, inhibidores de EGFR, inhibidores de mTOR, inhibidores de CTLA-4, inhibidores de PD-1/PD-L1, etc. Todas estas nuevas terapias traen consigo nuevos efectos adversos que el radiólogo debe conocer. Entender el mecanismo molecular de las terapias dirigidas y reconocer sus efectos adversos es esencial para una correcta valoración radiológica y para proporcionar un tratamiento apropiado

The treatment of cancer has improved drastically in recent decades. Better understanding of tumor biology has enabled the development of new treatments, called targeted therapy. These drugs target specific signaling pathways that are necessary for the development of cancer. Immunotherapy is even more novel. These new agents can be classified into different groups, mainly according to their mechanism of action: VEGF inhibitors or anti-angiogenic agents, EGFR inhibitors, mTOR inhibitors, CTLA-4 inhibitors, or PD-1/PD-L1 inhibitors, etc. All these new treatments are accompanied by new adverse effects that radiologists need to know. Understanding the molecular mechanisms of targeted therapies and knowing their adverse effects are vital to imaging assessment and ensuring appropriate treatment

Adverse events of targeted anticancer therapies: what radiologists need to know. / Efectos adversos de las terapias dirigidas contra el cáncer: lo que el radiólogo debe saber.

The treatment of cancer has improved drastically in recent decades. Better understanding of tumor biology has enabled the development of new treatments, called targeted therapy. These drugs target specific signaling pathways that are necessary for the development of cancer. Immunotherapy is even more novel. These new agents can be classified into different groups, mainly according to their mechanism of action: VEGF inhibitors or anti-angiogenic agents, EGFR inhibitors, mTOR inhibitors, CTLA-4 inhibitors, or PD-1/PD-L1 inhibitors, etc. All these new treatments are accompanied by new adverse effects that radiologists need to know. Understanding the molecular mechanisms of targeted therapies and knowing their adverse effects are vital to imaging assessment and ensuring appropriate treatment.

Hipointensidad cortical en secuencias eco de gradiente T2 en la leucoencefalopatía multifocal progresiva / Cortical hypointensity in T2-weighted gradient-echo sequences in patients with progressive multifocal leukoencephalopathy

INTRODUCCIÓN: La leucoencefalopatía multifocal progresiva (LMP) es una enfermedad desmielinizante del sistema nervioso central causada por la reactivación del virus JC. Esta encefalopatía oportunista se asocia mayormente a pacientes inmunodeprimidos con VIH en estadio III, y en los últimos años se ha asociado a tratamientos inmunosupresores como el natalizumab. La resonancia magnética (RM) tiene un papel importante tanto en el diagnóstico precoz como en el seguimiento de esta enfermedad. Recientemente, se han descrito en las secuencias eco de gradiente T2 (EGT2) y secuencias de susceptibilidad magnética (SWI) hipointensidades en las fibras-U y en la corteza adyacente a las lesiones de sustancia blanca características de la enfermedad. OBJETIVO: Nuestro objetivo es analizar la presencia y utilidad del signo de la hipointensidad cortical en secuencias EGT2 en relación con el diagnóstico de LMP, así como realizar una revisión bibliográfica sobre el tema. MATERIAL Y MÉTODOS: En este trabajo se analizan tres casos de LMP vistos en nuestro centro en 3 pacientes diferentes con inmunosupresión de distinto origen: uno con enfermedad por VIH en estadio III, otro con esclerosis múltiple en tratamiento con natalizumab y otro con artritis reumatoide en tratamiento con rituximab. RESULTADOS: En los tres casos se observa en la RM el hallazgo de hipointensidad cortical adyacente a la lesión de la sustancia blanca en la secuencia EGT2. En la paciente con esclerosis múltiple, este signo fue más precoz que la alteración de señal en la sustancia blanca. El paciente en tratamiento con rituximab fue diagnosticado post mortem y se presenta una correlación radiopatológica. CONCLUSIÓN: La hipointensidad cortical descrita en el EGT2 en los estudios de RM parece ser un hallazgo que apoyaría el diagnóstico de la LMP, independientemente del tipo de inmunosupresión, lo que nos hace plantear su inclusión de forma rutinaria entre los hallazgos a evaluar en RM en los pacientes con sospecha de LMP

INTRODUCTION: Progressive multifocal leukoencephalopathy is a demyelinating disease of the central nervous system caused by the reactivation of the JC virus. This opportunistic encephalopathy mainly affects immunodepressed patients with stage III HIV infection, although in recent years it has also been found in association with treatment with immunosuppressors such as natalizumab. MRI plays an important role in both the early diagnosis and follow-up of this disease. Recently, it has been reported that hypointensities in U-fibers and cortex adjacent to white-matter lesions characteristic of the disease can be identified on T2-weighted gradient-echo and susceptibility-weighted sequences in patients with progressive multifocal leukoencephalopathy. OBJECTIVE: We aimed to analyze the presence and usefulness of cortical hypointensity on T2-weighted gradient-echo sequences in relation to the diagnosis of progressive multifocal leukoencephalopathy and to review the literature on the topic. MATERIAL AND METHODS: We analyze three cases of progressive multifocal leukoencephalopathy seen at our center in three patients with immunosuppression of different origins: one with stage III HIV infection, one with multiple sclerosis being treated with natalizumab, and one with rheumatoid arthritis being treated with rituximab. RESULTS: In all three cases MRI showed the cortical hypointensity adjacent to the white-matter lesion in the T2-weighted gradient-echo sequence. In the patient with multiple sclerosis, this sign appeared earlier than the abnormal signal in the white matter. The patient being treated with rituximab was diagnosed postmortem and the pathology findings correlated with the MRI findings. CONCLUSION: The finding of cortical hypointensity on T2-weighted gradient-echo MRI sequences seems to support the diagnosis of progressive multifocal leukoencephalopathy, regardless of the type of immunosuppression, so this finding should routinely assessed in patients suspected of having this disease

Cortical hypointensity in T2-weighted gradient-echo sequences in patients with progressive multifocal leukoencephalopathy. / Hipointensidad cortical en secuencias eco de gradiente T2 en la leucoencefalopatía multifocal progresiva.

INTRODUCTION: Progressive multifocal leukoencephalopathy is a demyelinating disease of the central nervous system caused by the reactivation of the JC virus. This opportunistic encephalopathy mainly affects immunodepressed patients with stage III HIV infection, although in recent years it has also been found in association with treatment with immunosuppressors such as natalizumab. MRI plays an important role in both the early diagnosis and follow-up of this disease. Recently, it has been reported that hypointensities in U-fibers and cortex adjacent to white-matter lesions characteristic of the disease can be identified on T2-weighted gradient-echo and susceptibility-weighted sequences in patients with progressive multifocal leukoencephalopathy. OBJECTIVE: We aimed to analyze the presence and usefulness of cortical hypointensity on T2-weighted gradient-echo sequences in relation to the diagnosis of progressive multifocal leukoencephalopathy and to review the literature on the topic. MATERIAL AND METHODS: We analyze three cases of progressive multifocal leukoencephalopathy seen at our center in three patients with immunosuppression of different origins: one with stage III HIV infection, one with multiple sclerosis being treated with natalizumab, and one with rheumatoid arthritis being treated with rituximab. RESULTS: In all three cases MRI showed the cortical hypointensity adjacent to the white-matter lesion in the T2-weighted gradient-echo sequence. In the patient with multiple sclerosis, this sign appeared earlier than the abnormal signal in the white matter. The patient being treated with rituximab was diagnosed postmortem and the pathology findings correlated with the MRI findings. CONCLUSION: The finding of cortical hypointensity on T2-weighted gradient-echo MRI sequences seems to support the diagnosis of progressive multifocal leukoencephalopathy, regardless of the type of immunosuppression, so this finding should routinely assessed in patients suspected of having this disease.