Evaluation of circulating cell-free DNA as a molecular monitoring tool in patients with metastatic cancer.

The clinical decisions made when treating patients with metastatic cancer require knowledge of the current tumor extent and response to therapy. For the majority of solid tumors, a response assessment, which is based on imaging, is used to guide these decisions. However, measuring serum protein biomarkers (i.e. tumor markers) may be of additional use. Furthermore, tumor markers exhibit variable specificity and sensitivity and cannot therefore be solely relied upon when making decisions regarding cancer treatment. Therefore, there is a clinical requirement for the identification of specific, sensitive and quantitative biomarkers. In recent years, circulating cell-free DNA (cfDNA) and mutation-specific circulating cell-free tumor DNA (cftDNA) have been identified as novel potential biomarkers. In the current study, cfDNA and cftDNA were compared using imaging-based staging and current tumor markers in 15 patients with metastatic colorectal, pancreatic or breast cancer. These patients were treated at the Third Medical Department of Paracelsus Medical University Salzburg (Austria). The results of the current study demonstrated a statistically significant correlation between the concentration changes of cfDNA and cftDNA and response to treatment, which was assessed by imaging. A correlation was not indicated with current clinically used tumor markers, including carcinoembryonic antigen, carcinoma antigen 15-3 and carcinoma antigen 19-9. The present study also indicated a correlation between cfDNA and cftDNA and the tumor volume of metastatic lesions, which was not observed with the current clinically used tumor markers. In conclusion, cfDNA and cftDNA exhibit the potential to become novel biomarkers for the response assessment following cancer treatment, and may serve as a tool for the estimation of tumor volume. The current study further supports the increasingly important role of cfDNA and cftDNA as new monitoring tools for use during cancer therapy.

Radiologic complete response (rCR) in contrast-enhanced magnetic resonance imaging (CE-MRI) after neoadjuvant chemotherapy for early breast cancer predicts recurrence-free survival but not pathologic complete response (pCR).

BACKGROUND: Patients with early breast cancer (EBC) achieving pathologic complete response (pCR) after neoadjuvant chemotherapy (NACT) have a favorable prognosis. Breast surgery might be avoided in patients in whom the presence of residual tumor can be ruled out with high confidence. Here, we investigated the diagnostic accuracy of contrast-enhanced MRI (CE-MRI) in predicting pCR and long-term outcome after NACT. METHODS: Patients with EBC, including patients with locally advanced disease, who had undergone CE-MRI after NACT, were retrospectively analyzed (n = 246). Three radiologists, blinded to clinicopathologic data, reevaluated all MRI scans regarding to the absence (radiologic complete remission; rCR) or presence (no-rCR) of residual contrast enhancement. Clinical and pathologic responses were compared categorically using Cohen's kappa statistic. The Kaplan-Meier method was used to estimate recurrence-free survival (RFS) and overall survival (OS). RESULTS: Overall rCR and pCR (no invasive tumor in the breast and axilla (ypT0/is N0)) rates were 45% (111/246) and 29% (71/246), respectively. Only 48% (53/111; 95% CI 38-57%) of rCR corresponded to a pCR (= positive predictive value - PPV). Conversely, in 87% (117/135; 95% CI 79-92%) of patients, residual tumor observed on MRI was pathologically confirmed (= negative predictive value - NPV). Sensitivity to detect a pCR was 75% (53/71; 95% CI 63-84%), while specificity to detect residual tumor and accuracy were 67% (117/175; 95% CI 59-74%) and 69% (170/246; 95% CI 63-75%), respectively. The PPV was significantly lower in hormone-receptor (HR)-positive compared to HR-negative tumors (17/52 = 33% vs. 36/59 = 61%; P = 0.004). The concordance between rCR and pCR was low (Cohen's kappa - 0.1), however in multivariate analysis both assessments were significantly associated with RFS (rCR P = 0.037; pCR P = 0.033) and OS (rCR P = 0.033; pCR P = 0.043). CONCLUSION: Preoperative CE-MRI did not accurately predict pCR after NACT for EBC, especially not in HR-positive tumors. However, rCR was strongly associated with favorable RFS and OS.

Comparison of prone vs. supine unenhanced CT imaging in patients with clinically suspected ureterolithiasis.

PURPOSE: To retrospectively evaluate whether prone CT scanning is superior to supine scanning for correct localization of distal urinary calculi in patients with acute flank pain. METHODS: Consecutively performed unenhanced CT scans in patients with acute flank pain were retrospectively analyzed in 150 patients in supine and another 150 patients in prone position. Images were reviewed by two radiologists on consensus. Findings in both groups were compared using two-sided Fisher Exact tests and Wilcoxon-Mann-Whitney test. RESULTS: Urinary calculi were found in 67% of patients in each group. In the supine scanning group, there were 16 cases, in which the location of the stone was equivocal being either located intramurally at the ureterovesical junction (UVJ) or having already passed into the bladder. In contrast, in the prone imaging group all distal stones could be allocated accurately, either to the intramural UVJ or the urinary bladder (37 intramural UVJ stones and six bladder stones in prone scanning group vs. 21 intramural UVJ stones and one bladder stone when scanned supine). CONCLUSION: Prone scanning is superior to supine CT scanning for acute flank pain to accurately distinguish intramural UVJ stones from stones that have already passed into the bladder, a distinction which influences patient management.

Recurrence of a Delayed-Onset Posttraumatic Renal Pseudoaneurysm after Initially Successful Transarterial Embolization.

Hemodynamically stable patients with renal injury can be managed conservatively. Anatomy typically leads to physiologic confinement of urinomas or renal hematomas to the interfascial planes of the retroperitoneum. In the presented case there was unusual reperfusion 14 days after a successful embolization of a renal pseudoaneurysm, at this time 28 days after the initiating trauma. This article discusses the evolution, treatment options and possible underlying causes for the reperfusion of this late-onset renal pseudoaneurysm.

First Episode of Spontaneous Pneumothorax: CT-based Scoring to Select Patients for Early Surgery.

BACKGROUND: Although recurrence of primary spontaneous pneumothorax (PSP) is frequent, guidelines do not routinely recommend surgery after first presentation. A CT-based lung dystrophy severity score (DSS) has recently been proposed to predict recurrence following conservative therapy. This study compares the DSS in surgically and conservatively treated patients. METHODS: This is a retrospective analysis of first episode PSP patients, comparing video-assisted thoracic surgery (VATS; group A) to conservative treatment with or without chest drainage (group B). CT scans were reviewed for blebs or bullae, and patients were assigned DSS values and stratified into risk groups (low and high-grade). Primary end point was ipsilateral or contralateral recurrence. RESULTS: Fifty-six patients were included, 33 received VATS and 23 conservative treatment. In total, 37.5 % experienced recurrence, with a 5-year estimated recurrence rate of 40.7 % (group A: 13.3 %; group B: 73.9 %; p < 0.001). In group B, detection of any dystrophic lesions resulted in significantly higher 5-year recurrence rates (86.7 vs. 50.0 %; p = 0.03), there was no significant difference in group A (17.7 vs. 7.7 %; p = 0.50). Greater DSS values correlated with higher 5-year recurrence rates in group B (p = 0.02), but not in group A (p = 0.90). Comparing low- and high-grade patients in group B resulted in a significant 5-year recurrence rate of 53.8 versus 100 % (p = 0.023). CONCLUSIONS: The DSS is useful to indicate VATS after the first episode. For routine application, assigning patients to low- and high-grade groups seems most practical. We recommend CT-evaluation for every PSP patient and early surgery for those with lesions exceeding one bleb. After VATS, the preoperative DSS is not beneficial in predicting recurrence.

CT-Guided Lead Placement for Selective Sacral Neuromodulation to Treat Lower Urinary Tract Dysfunctions.

OBJECTIVE: Selective sacral neuromodulation may fail after fluoroscopically guided lead placement because of malpositioning. We implemented a new technique to attain precise lead placement. CONCLUSION: CT-guided tined lead placement was successful in eight patients after 12-month follow-up. Especially in patients with an altered anatomy in the sacral region, this new technique may prevent treatment failure.

Relative Uptake Factor of Invasive Ductal Breast Cancer in Breast-specific Gamma Imaging as a Surrogate Parameter for Sub-typing.

AIM: The retrospective evaluation of correlations between semi-quantitative breast-specific gamma imaging (BSGI) and invasive ductal breast cancer (IDC) sub-types. MATERIALS AND METHODS: The biopsy specimen of 50 histologically-proven IDCs were retrospectively evaluated concerning receptor status, human epidermal growth factor receptor 2 (HER2/Neu) status, Ki-67 level and classification into IDC sub-types. These results were compared to the relative uptake factor (RUF) in BSGI. Depending on RUF, we described four categories to outline the predictive value of RUF. RESULTS: A total of 50 IDCs with a mean diameter of 20.36 mm were included. RUF differed reliably between luminal-A and non-luminal-A IDCs. RUF exceeding 6.5 pointed to non luminal A-carcinoma, with a specificity and positive predictive value of 100%. RUF of less than 2.6 was unlikely to be associated with a non-luminal A-carcinoma (negative predictive value: 76.5%). Comparable results were calculated for the correlation between RUF and the K-67 level. CONCLUSION: RUF may help classify the sub-type of an IDC in addition to pathology.

Dynamic magnetic resonance imaging evaluation of pelvic reconstruction with porcine dermal collagen mesh following extra-levator abdominoperineal excision for primary rectal cancer.

PURPOSE: Extra-levator abdominoperineal excision for rectal cancer includes resection of the levator ani muscle and therefore makes pelvic reconstruction advisable. The aim of our study was to evaluate morphologic and functional long-term results of pelvic floor augmentation with porcine dermal collagen mesh by dynamic magnetic resonance imaging and clinical examination. METHODS: Twenty consecutive patients underwent perineal reconstruction with porcine dermal collagen mesh following extra-levator abdominoperineal excision for primary rectal adenocarcinoma with curative intent between 2009 and 2012. Patient perioperative and postoperative data were collected prospectively. There were one cancer-related and two noncancer-related deaths in the follow-up period, and another three patients refused the dynamic magnetic resonance imaging. RESULTS: Fourteen patients were included in the study. The median time period from surgery to dynamic magnetic resonance imaging and clinical examination was 31 months (range 19-56). Wound infections were observed in 43% (6 of 14) of these patients in the postoperative period, but no mesh had to be removed. No focal mesh defect, no damage on the suture line, and no perineal hernia were detected on dynamic magnetic resonance imaging. Clinical examination revealed no pathological findings in any patient. CONCLUSIONS: The implantation of a porcine dermal collagen mesh is an effective and reliable option for pelvic floor reconstruction after extra-levator abdominoperineal excision. Despite a high incidence of primary wound infections, the healing rate was satisfactory, no mesh had to be removed, and long-term stability could be achieved.

Small mesenteric hematoma following blunt abdominal trauma as early sign in computed tomography of occult small bowel perforation-report of 2 cases.

Blunt abdominal trauma can lead to mesenteric injuries, which are not an uncommon but often underestimated finding on the initial computed tomography (CT) scan. Only small mesenteric hematomas, which are shrinking in short-term follow-up CT examinations, do not require surgery. We present two cases where subtle mesenteric hematoma was one hint on the admission scan for subsequent small bowel perforation. So it can be a relevant finding and should prompt early CT follow-up imaging, even in asymptomatic patients. This will enable early diagnosis and reduction in morbidity and mortality.

Systemic effect of catumaxomab in a patient with metastasized colorectal cancer: a case report.

BACKGROUND: Catumaxomab, the first anti-EpCAM antibody, was approved in 2009 for the treatment of malignant ascites in cancer patients with EpCAM positive tumors. We consider this case of interest as treatment with catumaxomab not only prolonged the puncture-free interval but also showed a systemic effect in a patient with metastasized colorectal cancer by regression of a pulmonary metastasis. CASE PRESENTATION: We describe the case of a 78 year old patient initially diagnosed with locally advanced colon cancer and one synchronous liver metastasis in September 2010 who was treated by hemicolectomy and simultaneous atypical liver resection. During adjuvant chemotherapy the patient developed a peritoneal carcinomatosis with ascites in March 2011. Palliative chemotherapy was not well tolerated and therefore refused by the patient. Because of disease progression in June 2011 with one pulmonary metastasis and clinically predominant ascites an immunotherapy with intraperitoneal catumaxomab was started in December 2011. After treatment with catumaxomab a puncture free survival of 12 months as well as a regression of the pulmonary lesion was achieved until January 2013. CONCLUSION: This case suggests that treatment with catumaxomab does not only improve quality of life by local suppression of malignant ascites but also might have a systemic antitumor effect.

Differentiation of renal clear cell carcinoma and renal papillary carcinoma using quantitative CT enhancement parameters.

OBJECTIVE: The purpose of our study was to evaluate quantitative multiphasic CT enhancement patterns of malignant renal neoplasms to enable lesion differentiation by their enhancement characteristics. We used a new method to standardize enhancement measurement in lesions on multiphasic CT not being influenced by intrinsic factors like cardiac output. CONCLUSION: The new correction method is a simple tool for excluding intrinsic influences on the enhancement of lesions. Quantitative enhancement evaluation with this method of the influence of intrinsic factors enables accurate differentiation between renal clear cell carcinoma and renal papillary carcinoma.