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BACKGROUND: Whole-body positron emission tomography/magnetic resonance imaging (WB-PET/MRI) is increasingly used in oncology. However, chest staging remains challenging. PURPOSE: To compare the diagnostic performance of a free-breathing 3D-T1-GRE stack-of-stars volume interpolated breath-hold examination (StarVIBE) with that of a 3D-T1-GRE volume interpolated breath-hold examination (VIBE) during WB-PET/MRI for chest staging. STUDY TYPE: Retrospective, cohort study. POPULATION: One hundred and twenty-three patients were referred for initial staging of solid cancer, 46 of whom had pulmonary nodules and 14 had pulmonary metastasis. FIELD STRENGTH/SEQUENCE: Free-breathing 3D-T1-GRE stack-of-stars (StarVIBE) and Cartesian 3D-T1-GRE VIBE at 3.0 T. ASSESSMENT: Image quality was assessed using a 4-point scale and using the signal-to-noise ratio (SNR) of lung parenchyma and contrast-to-noise ratio (CNR) of pulmonary nodules. Diagnostic performances of both sequences were determined by three independent radiologists for detection of pulmonary nodules, lymph node involvement, and bone metastases using chest CT, pathology, and follow-up as reference standards. STATISTICAL TESTS: Paired Student's t-test; chi-squared; Fisher's exact test. A P value <0.05 was considered statistically significant. RESULTS: StarVIBE quality was judged as better in 34% of cases and at least equivalent to VIBE in 89% of cases, with significantly higher quality scores (4 [4-4] vs. 3 [3-4], respectively). SNR and CNR values were significantly higher with StarVIBE (8 ± 1.3 and 9.7 ± 4.6, respectively) than with VIBE (1.8 ± 0.2 and 5.5 ± 3.3, respectively). Compared to VIBE, StarVIBE showed significantly higher sensitivity (73% [95% CI 62-82] vs. 44% [95% CI 33-55], respectively) and specificity (95% [95% CI 88-99] vs. 67% [95% CI 56-77]) for pulmonary nodules detection and significantly higher sensitivity (100% [95% CI 89-100] vs. 67% [95% CI 48-82], respectively) for detection of lymph node involvement. Sensitivities for bone metastases detection were not significantly different (100% [95% CI 88-100] vs. 82% [95% CI 63-94], P = 0.054). DATA CONCLUSION: Owing to improved SNR and CNR and spatial resolution, a free-breathing 3D stack-of-stars T1-GRE sequence improves chest staging in comparison with standard 3D-T1-GRE VIBE and may be integrated in WB-PET/MRI acquisitions for initial staging of solid cancer. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY: Stage 2.
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Suspensão da Respiração , Neoplasias Pulmonares , Estudos de Coortes , Humanos , Imageamento Tridimensional/métodos , Neoplasias Pulmonares/diagnóstico por imagem , Imageamento por Ressonância Magnética/métodos , Tomografia por Emissão de Pósitrons , Estudos RetrospectivosRESUMO
Background The recently described "macrotrabecular-massive" (MTM) histologic subtype of hepatocellular carcinoma (HCC) (MTM-HCC) represents an aggressive form of HCC and is associated with poor survival. Purpose To investigate whether preoperative MRI can help identify MTM-HCCs in patients with HCC. Materials and Methods This retrospective study included patients with HCC treated with surgical resection between January 2008 and February 2018 and who underwent preoperative multiphase contrast material-enhanced MRI. Least absolute shrinkage and selection operator (LASSO)-penalized and multivariable logistic regression analyses were performed to identify clinical, biologic, and imaging features associated with the MTM-HCC subtype. Early recurrence (within 2 years) and overall recurrence were evaluated by using Kaplan-Meier analysis. Multivariable Cox regression analysis was performed to determine predictors of early and overall recurrence. Results One hundred fifty-two patients (median age, 64 years; interquartile range, 56-72 years; 126 men) with 152 HCCs were evaluated. Twenty-six of the 152 HCCs (17%) were MTM-HCCs. LASSO-penalized logistic regression analysis identified substantial necrosis, high serum α-fetoprotein (AFP) level (>100 ng/mL), and Barcelona Clinic Liver Cancer (BCLC) stage B or C as independent features associated with MTM-HCCs. At multivariable analysis, substantial necrosis (odds ratio = 32; 95% confidence interval [CI] = 8.9, 114; P < .001), high serum AFP level (odds ratio = 4.4; 95% CI = 1.3, 16; P = .02), and BCLC stage B or C (odds ratio = 4.2; 95% CI = 1.2, 15; P = .03) were independent predictors of MTM-HCC subtype. Substantial necrosis helped identify 65% (17 of 26; 95% CI: 44%, 83%) of MTM-HCCs (sensitivity) with a specificity of 93% (117 of 126; 95% CI: 87%, 97%). In adjusted models, only the presence of satellite nodules was independently associated with both early (hazard ratio = 3.7; 95% CI: 1.5, 9.4; P = .006) and overall (hazard ratio = 3.0; 95% CI: 1.3, 7.2; P = .01) tumor recurrence. Conclusion At multiphase contrast-enhanced MRI, substantial necrosis helped identify macrotrabecular-massive hepatocellular carcinoma subtype with high specificity. © RSNA, 2020.
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Carcinoma Hepatocelular/diagnóstico por imagem , Neoplasias Hepáticas/diagnóstico por imagem , Imageamento por Ressonância Magnética/métodos , Idoso , Carcinoma Hepatocelular/classificação , Carcinoma Hepatocelular/patologia , Feminino , Humanos , Aumento da Imagem/métodos , Processamento de Imagem Assistida por Computador/métodos , Estimativa de Kaplan-Meier , Fígado/diagnóstico por imagem , Fígado/patologia , Neoplasias Hepáticas/classificação , Neoplasias Hepáticas/patologia , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/classificação , Recidiva Local de Neoplasia/diagnóstico por imagem , Recidiva Local de Neoplasia/patologia , Prognóstico , Estudos Retrospectivos , Sensibilidade e EspecificidadeRESUMO
OBJECTIVES: To compare the performance of the quantitative analysis of the hepatobiliary phase (HBP) tumor enhancement in gadobenate dimeglumine (Gd-BOPTA)-enhanced MRI and of dual-tracer 18F-FDG and 18F-fluorocholine (FCH) PET/CT for the prediction of tumor aggressiveness and recurrence-free survival (RFS) in resectable hepatocellular carcinoma (HCC). METHODS: This retrospective, IRB approved study included 32 patients with 35 surgically proven HCCs. All patients underwent Gd-BOPTA-enhanced MRI including delayed HBP images, 18F-FDG PET/CT, and (for 29/32 patients) 18F-FCH PET/CT during the 2 months prior to surgery. For each lesion, the lesion-to-liver contrast enhancement ratio (LLCER) on MRI HBP images and the SUVmax tumor-to-liver ratio (SUVT/L) for both tracers were calculated. Their predictive value for aggressive pathological features-including the histological grade and microvascular invasion (MVI)-and RFS were analyzed and compared using area under receiver operating characteristic (AUROC) curves and Cox regression models, respectively. RESULTS: The AUROCs for the identification of aggressive HCCs on pathology with LLCER, 18F-FDG SUVT/L, and 18F-FCH SUVT/L were 0.92 (95% CI 0.78, 0.98), 0.89 (95% CI 0.74, 0.97; p = 0.70), and 0.64 (95% CI 0.45, 0.80; p = 0.035). At multivariate Cox regression analysis, LLCER was identified as an independent predictor of RFS (HR (95% CI) = 0.91 (0.84, 0.99), p = 0.022). LLCER - 4.72% or less also accurately predicted moderate-poor differentiation grade (Se = 100%, Sp = 92.9%) and MVI (Se = 93.3%, Sp = 60%) and identified patients with poor RFS after surgical resection (p = 0.030). CONCLUSIONS: HBP tumor enhancement after Gd-BOPTA injection may help identify aggressive HCC pathological features, and patients with reduced recurrence-free survival after surgical resection. KEY POINTS: ⢠In patients with resectable HCC, the quantitative analysis of the HBP tumor enhancement in Gd-BOPTA-enhanced MRI (LLCER) accurately identifies moderately-poorly differentiated and/or MVI-positive HCCs. ⢠After surgical resection for HCC, patients with LLCER - 4.72% or less had significantly poorer recurrence-free survival than patients with LLCER superior to - 4.72%. ⢠Gd-BOPTA-enhanced MRI with delayed HBP images may be suggested as part of pre-surgery workup in patients with resectable HCC.
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Carcinoma Hepatocelular/diagnóstico por imagem , Carcinoma Hepatocelular/patologia , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/patologia , Imageamento por Ressonância Magnética/métodos , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma Hepatocelular/mortalidade , Carcinoma Hepatocelular/cirurgia , Colina/análogos & derivados , Meios de Contraste , Intervalo Livre de Doença , Feminino , Radioisótopos de Flúor , Fluordesoxiglucose F18 , Humanos , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/cirurgia , Masculino , Meglumina/análogos & derivados , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Compostos Organometálicos , Compostos Radiofarmacêuticos , Recidiva , Estudos RetrospectivosRESUMO
Medicine is evolving toward personalized care and this development entails the integration, amalgamation, and synchronized analysis of data from multiple sources. Multimodality fusion imaging refers to the simultaneous visualization of spatially aligned and juxtaposed medical images obtained by two or more image modalities. PET/MRI scanners and MMFI platforms are able to improve the diagnostic workflow in oncologic patients and provide exquisite images that aid physicians in the molecular profiling and characterization of tissues. Advanced navigation platforms involving real-time ultrasound are promising tools for guiding personalized and tailored mini-invasive interventional procedures on technically challenging targets. The main objective of the present essay was to describe the current applications and future perspectives of multimodality fusion imaging for both diagnostic and interventional purposes in the field of abdominal and pelvic malignancies. We also outlined the technical differences between fusion imaging achieved by means of simultaneous bimodal acquisition (i.e., integrated PET/MRI scanners), retrospective co-registration, and multimodality fusion imaging involving ultrafast or real-time imaging modalities.
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Neoplasias Abdominais/diagnóstico , Neoplasias Abdominais/terapia , Imagem Multimodal , Neoplasias Pélvicas/diagnóstico , Neoplasias Pélvicas/terapia , Humanos , Imagem Multimodal/métodosRESUMO
BACKGROUND: Current guidelines do not indicate any comprehensive management of hepatic hypervascular incidentalomas (HVIs) discovered in hepatocellular carcinoma (HCC) patients during intra-arterial therapies (IATs). This study aims to evaluate the prognostic value of HVIs detected on per-interventional cone beam computed tomography (CBCT) during IAT for HCC in patients waiting for liver transplantation (LT). MATERIAL AND METHODS: In this retrospective single-institutional study, all liver-transplanted HCC patients between January 2014 and December 2018 who received transarterial chemoembolization (TACE) or radioembolization (TARE) before LT were included. The number of ≥10 mm HCCs diagnosed on contrast-enhanced pre-interventional imaging (PII) was compared with that detected on per-interventional CBCT with a nonparametric Wilcoxon test. The correlation between the presence of an HVI and histopathological criteria associated with poor prognosis (HPP) on liver explants was investigated using the chi-square test. Tumor recurrence (TR) and TR-related mortality were investigated using the chi-square test. Recurrence-free survival (RFS), TR-related survival (TRRS), and overall survival (OS) were assessed according to the presence of HVI using Kaplan-Meier analysis. RESULTS: Among 63 included patients (average age: 59 ± 7 years, H/F = 50/13), 36 presented HVIs on per-interventional CBCT. The overall nodule detection rate of per-interventional CBCT was superior to that of PII (median at 3 [Q1:2, Q3:5] vs. 2 [Q1:1, Q3:3], respectively, p < 0.001). No significant correlation was shown between the presence of HVI and HPP (p = 0.34), TR (p = 0.095), and TR-related mortality (0.22). Kaplan-Meier analysis did not show a significant impact of the presence of HVI on RFS (p = 0.07), TRRS (0.48), or OS (p = 0.14). CONCLUSIONS: These results may indicate that the treatment plan during IAT should not be impacted or modified in response to HVI detection.
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Purpose: The aim of this study was to report the safety and tumor response rate of combined transarterial radioembolization (TARE) through the intrahepatic arteries and transarterial chemoembolization (TACE) through the extrahepatic feeding arteries (EHFA) in patients with hepatocellular carcinoma (HCC). Methods: Patients with HCC, who had both intrahepatic and extrahepatic arterial supply visible on preinterventional multiphase CT and were treated between 2016 and 2021 with a combination of TACE and TARE on the same nodule, were retrospectively included. Epidemiological, clinical, biological, and radiological characteristics were recorded. Safety and tumor response were assessed at 6 months. Results: Nine patients (8 men, median age 62 years [IQR: 54-72 years]) were included. Seven patients had previous treatments on the target nodule (TARE: 5; TACE: 2). The median longest axis (LA) of the lesion was 70 mm (IQR: 60-79 mm). Three patients had portal vein invasion (VP3). The EHFA originated from the right diaphragmatic artery (n = 6), the right adrenal artery (n = 2), and the left gastric artery (n = 1). The LA of the tumor portion treated with TACE was 47 mm (range: 35-64 mm). The ratio between the LA of the entire lesion and the LA treated with TACE was 1.44 (range: 1.27-1.7). One major complication occurred: acute on chronic liver failure. Median follow-up was 23 months (range: 16-29 months). Seven patients underwent further treatment: on the same lesion (n = 2), on newly appeared nodules (n = 2), and systemic treatment (n = 3). At 6-month follow-up, seven patients showed a local objective response. Time-to-progression was 13 (3.5-19) months. Conclusion: The combination of TARE and extrahepatic TACE for HCC with both intrahepatic and extrahepatic arterial supplies seems feasible and safe. Further studies are needed to validate the effectiveness of these preliminary results.
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BACKGROUND: Clinical outcomes of colorectal cancer (CRC) patients after an incomplete microscopic (R1) resection of liver metastases may not differ from those following a microscopically margin negative (R0) resection, when the latest is not feasible because of anatomic issues. We aimed at comparing the clinical outcomes of CRC patients with an intentional R1 or with a R0 resection of liver metastases. METHODS: All patients with advanced in CRC and liver metastases consecutively treated by liver resection between February 2005 and January 2019 at in the department of Digestive and Hepatobiliary Surgery of Henri Mondor University Hospital (Créteil, France) were included in this retrospective case-control study. Overall survival (OS) and event-free survival (EFS) were compared between patients who underwent an intentional (pre-operative decision) R1 resection (iR1) to those who had a R0 resection of liver metastases. To account for confounding, comparison between the 2 groups was performed after adjustment using propensity score analysis. RESULTS: Twenty-six CRC patients treated by iR1 resection of liver metastases were compared to 98 patients treated by R0 resection. Median OS reached 39 months [95% confidence interval (CI): 25-67] and 63 months [95% CI: 52-76] in the iR1 and R0 groups, respectively. After adjustment by inverse probability of treatment weighting, patients' OS and EFS did not differ significantly between the iR1 and R0 groups (hazard ratio (HR): 1.19 [0.54-2.62] and 1.67 [0.93-3.03]), respectively. CONCLUSION: iR1 resection of liver metastases in advanced CRC patients is an acceptable therapeutic strategy, when R0 resection is not feasible.
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Neoplasias Colorretais , Neoplasias Hepáticas , Humanos , Estudos Retrospectivos , Pontuação de Propensão , Estudos de Casos e Controles , Neoplasias Hepáticas/patologia , Hepatectomia , Neoplasias Colorretais/patologia , Taxa de SobrevidaRESUMO
The subject of this narrative review is macrotrabecular-massive hepatocellular carcinoma (MTM-HCC). Despite their rarity, these tumours are of general interest because of their epidemiological and clinical features and for representing a distinct model of the interaction between the angiogenetic system and neoplastic cells. The MTM-HCC subtype is associated with various adverse biological and pathological parameters (the Alfa-foetoprotein (AFP) serum level, tumour size, vascular invasion, and satellite nodules) and is a key determinant of patient prognosis, with a strong and independent predictive value for early and overall tumour recurrence. Gene expression profiling has demonstrated that angiogenesis activation is a hallmark feature of MTM-HCC, with overexpression of both angiopoietin 2 (ANGPT2) and vascular endothelial growth factor A (VEGFA).
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Optimal HCC therapeutic management relies on accurate tumor staging. Our aim was to assess the impact of 18F-FDG-WB-PET/MRI on HCC metastatic staging, compared with the standard of care CT-CAP/liver MRI combination, in patients with HCC referred on a curative intent or before transarterial radioembolization. One hundred and four consecutive patients followed for HCC were retrospectively included. The WB-PET/MRI was compared with the standard of care CT-CAP/liver MRI combination for HCC metastatic staging, with pathology, followup, and multidisciplinary board assessment as a reference standard. Thirty metastases were identified within 14 metastatic sites in 11 patients. The sensitivity of WB-PET/MRI for metastatic sites and metastatic patients was significantly higher than that of the CT-CAP/liver MRI combination (respectively 100% vs. 43%, p = 0.002; and 100% vs. 45%, p = 0.01). Metastatic sites missed by CT-CAP were bone (n = 5) and distant lymph node (n = 3) in BCLC C patients. For the remaining 93 nonmetastatic patients, three BCLC A patients identified as potentially metastatic on the CT-CAP/liver MRI combination were correctly ruled out with the WB-PET/MRI without significant increase in specificity (100% vs. 97%; p = 0.25). The WB-PET/MRI may improve HCC metastatic staging and could be performed as a "one-stop-shop" examination for HCC staging with a significant impact on therapeutic management in about 10% of patients especially in locally advanced HCC.
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Since its introduction about 15 years ago, coronary computed tomography angiography has become today the most accurate clinical instrument for noninvasive assessment of coronary atherosclerosis. Important technical developments have led to a continuous stream of new clinical applications together with a significant reduction in radiation dose exposure. Latest generation computed tomography scanners (≥ 64 slices) allow the possibility of performing static or dynamic perfusion imaging during stress by using coronary vasodilator agents (adenosine, dipyridamole, or regadenoson), combining both functional and anatomical information in the same examination. In this article, the emerging role and state-of-the-art of myocardial computed tomography perfusion imaging are reviewed and are illustrated by clinical cases from our experience with a second-generation dual-source 128-slice scanner (Somatom Definition Flash, Siemens; Erlangen, Germany). Technical aspects, data analysis, diagnostic accuracy, radiation dose and future prospects are reviewed.
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Isquemia Miocárdica/diagnóstico por imagem , Imagem de Perfusão do Miocárdio/métodos , Angiografia por Tomografia Computadorizada/métodos , Angiografia por Tomografia Computadorizada/normas , Teste de Esforço/métodos , Previsões , Humanos , Imagem Multimodal/métodos , Imagem de Perfusão do Miocárdio/normas , Exame Físico/métodos , Sensibilidade e EspecificidadeRESUMO
A 49-year-old man presented with chest pain, dyspnea, and lactic acidosis. Left ventricular hypertrophy and myocardial fibrosis were detected. The sequencing of mitochondrial genome (mtDNA) revealed the presence of A to G mtDNA point mutation at position 3243 (m.3243A>G) in tRNALeu(UUR) gene. Diagnosis of cardiac involvement in a patient with Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-like episodes syndrome (MELAS) was made. Due to increased risk of sudden cardiac death, cardioverter defibrillator was implanted.
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OBJECTIVES: to compare vascular and parenchymal enhancement in abdominal computed tomography (CT) using two iodine concentrations (370 vs 300mgI/mL) of the same contrast medium (CM) molecule (iopromide), using fixed iodine delivery rate (IDR, 1.2gI/s) and total iodine load (630mgI/kg). METHODS: 144 patients were randomized into two groups: group A receiving iopromide 370 and group B receiving iopromide 300. Attenuation values (AV) were measured in correspondence to key anatomical structures on different phases and compared between groups with parametrical tests. Qualitative analysis was also performed. Peak injection pressure and local discomfort at the site of injection (pain and warmth) were registered. RESULTS: mean AV of abdominal aorta in late arterial phase were 300.32±59.76 for group A and 298.2±59.14 for group B (p=0.8); mean AV of portal vein in portal phase were 190.5±29.92 for group A and 192.91±24.12 for group B (p=0.6). Mean AV of liver parenchyma in portal phase were 124.73±18.22 for group A and 125.11±15.7 for group B (p=0.9); mean AV of liver at equilibrium were 85.11±7.75 for group A and 85.41±8.09 for group B (p=0.8). Qualitative analysis did not show significant differences between groups (p>0.05). Median peak injection pressure was lower in group B (93psi, 76-172) than in group A (115psi, 88-288, p<0.0001), while discomfort at injection site was not significantly different (p>0.05). CONCLUSIONS: with fixed IDR and total iodine load, comparable quantitative and qualitative enhancement can be achieved with different concentrations of the same CM. Peak injection pressure increases using CM with higher iodine concentration.
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Aorta Abdominal/diagnóstico por imagem , Meios de Contraste , Iodo/administração & dosagem , Iodo/sangue , Fígado/diagnóstico por imagem , Veia Porta/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Idoso , Meios de Contraste/administração & dosagem , Meios de Contraste/metabolismo , Relação Dose-Resposta a Droga , Feminino , Humanos , Iohexol/administração & dosagem , Iohexol/análogos & derivados , Iohexol/metabolismo , Masculino , Estudos Prospectivos , Reprodutibilidade dos TestesRESUMO
Tras su introducción hace unos 15 años, la angiografía por tomografía computarizada se ha convertido actualmente en el instrumento clínico más exacto para la evaluación no invasiva de la aterosclerosis coronaria. Los importantes avances técnicos han conducido a un torrente continuo de nuevas aplicaciones clínicas junto con una reducción significativa de la dosis de exposición a la radiación. Los escáneres de tomografía computarizada de última generación (≥ 64 cortes) brindan la posibilidad de obtener imágenes de perfusión estáticas o dinámicas durante la aplicación de estrés mediante vasodilatadores coronarios (adenosina, dipiridamol o regadenosón), combinando la información funcional y anatómica en la misma exploración. En este artículo se examina el papel emergente y el estado actual de las imágenes de perfusión miocárdica con tomografía computarizada, y se ilustra con casos clínicos de la propia experiencia con un escáner de segunda generación de 128 cortes y doble fuente (Somatom Definition Flash, Siemens; Erlangen, Alemania). Se examinan los aspectos técnicos, el análisis de los datos, la exactitud diagnóstica, la dosis de radiación y las perspectivas futuras (AU)
Since its introduction about 15 years ago, coronary computed tomography angiography has become today the most accurate clinical instrument for noninvasive assessment of coronary atherosclerosis. Important technical developments have led to a continuous stream of new clinical applications together with a significant reduction in radiation dose exposure. Latest generation computed tomography scanners (≥ 64 slices) allow the possibility of performing static or dynamic perfusion imaging during stress by using coronary vasodilator agents (adenosine, dipyridamole, or regadenoson), combining both functional and anatomical information in the same examination. In this article, the emerging role and state-of-the-art of myocardial computed tomography perfusion imaging are reviewed and are illustrated by clinical cases from our experience with a second-generation dual-source 128-slice scanner (Somatom Definition Flash, Siemens; Erlangen, Germany). Technical aspects, data analysis, diagnostic accuracy, radiation dose and future prospects are reviewed (AU)