Abhishek R. Keraliya

Radiographic Profiling of Immune-related Adverse Events in Advanced Melanoma Patients Treated With Ipilimumab

As more melanoma patients are treated with CTLA-4 antibodies, immune-related adverse effects (irAEs) need elucidation. Radiographic imaging identified irAEs in 31% of patients, with colitis being most common. Most irAEs developed within 3 months of therapy. Ipilimumab is a promising novel immunotherapy agent and is associated with a variety of immune-related adverse events (irAE). The purpose of this study was to investigate the manifestations of irAEs on body imaging in patients with advanced melanoma treated with ipilimumab. One-hundred forty-seven patients with advanced melanoma (59 women, 88 men; median age, 64.5 years) treated with ipilimumab were studied. All patients had the baseline and at least one follow-up chest/abdomen/pelvis CT or PET/CT during therapy, which were reviewed by a consensus of two radiologists blinded to the clinical data. Findings indicative of individual types of irAEs were assessed, including thyroiditis, sarcoid-like lymphadenopathy, pneumonitis, hepatitis, pancreatitis, and colitis. Among the 147 patients, 46 (31%) had radiologically identified irAEs. The time interval from the initiation of therapy to the development of irAEs was less than 3 months in 76% (35 of 46) of the patients (range, 0.2–9.1 months). Clinical characteristics did not differ between patients with and without irAEs (P > 0.18). Among the individual types of irAEs, colitis was most common (n = 28; 19%), followed by sarcoid-like lymphadenopathy (n = 8; 5%) and pneumonitis (n = 8; 5%). Hepatitis (n = 3), thyroiditis (n = 2), and pancreatitis (n = 1) were less common. The resolution of irAEs was noted in 32 of 36 patients (89%) with further follow-up scans, with a median time of 2.3 months after the detection of irAE. In conclusion, irAEs were noted on body imaging in 31% of patients with melanoma treated with ipilimumab. Colitis was the most common, followed by sarcoid-like lymphadenopathy and pneumonitis. The results call for an increased awareness of irAEs, given the expanding role of cancer immunotherapy. Cancer Immunol Res; 3(10); 1185–92. ©2015 AACR.

Role of Imaging in Management of Desmoid-type Fibromatosis: A Primer for Radiologists

Desmoid-type fibromatosis (DF) is a locally aggressive fibroblastic neoplasm that has variable clinical and biologic behaviors ranging from indolent tumors that can undergo spontaneous regression to aggressive tumors with a tendency toward local invasion and recurrence. The management of DF has evolved considerably in the last decade from aggressive first-line surgery and radiation therapy to systemic treatment (chemotherapy, hormonal therapy, and targeted therapy) and symptomatic local control (surgery and radiation therapy). Imaging plays an important role in each of these treatment settings. In surgical candidates, computed tomography (CT) and magnetic resonance (MR) imaging are the modalities of choice for assessing resectability and surgical planning. For evaluating recurrence, MR imaging is the modality of choice for extra-abdominal recurrence, whereas CT is the preferred modality for intra-abdominal recurrence. Signal intensity changes at MR imaging can be used to monitor the biologic behavior of certain DFs chosen for expectant management. Response to systemic treatment with anti-inflammatory agents, hormonal therapy (eg, tamoxifen), cytotoxic chemotherapy (eg, doxorubicin, vinblastine, methotrexate), and targeted therapy (eg, sorafenib), as well as to radiation therapy, can be assessed at CT by monitoring size and attenuation changes or at MR imaging by monitoring size, T2 signal intensity, and degree of enhancement. Several patterns of response can be seen at imaging. Imaging also helps in detecting complications associated with systemic therapy and radiation therapy. (©)RSNA, 2016.

Recent developments in the use of computed tomography scanners in coronary artery imaging

ABSTRACT Introduction: Within the past decade, substantial evolution of Coronary CT Angiography (CCTA) has affected evaluation and management of coronary artery disease. In particular, technical advancement of hardware technology and image reconstruction of CT scanners have played an important role in this context making it possible to acquire abundant data with excellent temporal and spatial resolution within a shorter scan time. In addition, a concern related to the high radiation exposure in the initial noninvasive coronary artery imaging has triggered improvement in dose reduction techniques. Areas covered: In this review article, we have focused on recent technological developments in CT scanners and the impact of these developments on CCTA parameters. Expert Commentary: CCTA plays an important role in coronary artery disease management, and technical development of the CT scanners can be expected to address and remedy technical limitations.

IgG4-Related Disease With Coronary Arteritis

A 53-year-old male patient with chronic renal failure and biopsy-proven Immunoglobulin G4 (IgG4) renal involvement presented with complains of chest pain and syncope. An ECG showed lateral ST segment depressions concerning for myocardial ischemia. The patient underwent coronary catheterization, which revealed multifocal aneurysms and severe stenosis. A cardiac computerized tomographic angiogram was performed to further characterize aneurysms, which showed aneurysms involving left main, proximal left anterior descending artery, and proximal right coronary artery (Figures 1 and 2). Circumferential mural thickening with associated enhancement of the wall of the coronary arteries, particularly at the site of the stenoses, was concerning for vasculitis. A small pulmonary artery aneurysm was seen in the right upper lobe (Figure 3 …

Solitary Fibrous Tumors: 2016 Imaging Update.

Optimal management of solitary fibrous tumor requires a multidisciplinary approach with proper histopathological mapping and use of various imaging modalities for exact delineation of primary tumor and metastatic disease if present. In this article, the authors present a comprehensive review of the spectrum of imaging findings of solitary fibrous tumors involving various organ systems and discuss the role of molecular targeted therapies in the management of metastatic disease.

Diffuse Large B-Cell Lymphoma In The Era Of Precision Oncology: How Imaging is Helpful

Diffuse large B cell lymphoma (DLBCL) is the most common histological subtype of Non-Hodgkins lymphoma. As treatments continues to evolve, so do imaging strategies, and positron emission tomography (PET) has emerged as the most important imaging tool to guide oncologists in the diagnosis, staging, response assessment, relapse/recurrence detection,and therapeutic decision making of DLBCL. Other imaging modalities including magnetic resonance imaging (MRI), computed tomography (CT), ultrasound, and conventional radiography are also used in the evaluation of lymphoma. MRI is useful for nervous system and musculoskeletal system involvement and is emerging as a radiation free alternative to PET/CT. This article provides a comprehensive review of both the functional and morphological imaging modalities, available in the management of DLBCL.

Imaging of Nervous System Involvement in Hematologic Malignancies: What Radiologists Need to Know.

OBJECTIVE The purpose of this article is to provide a comprehensive review of the imaging features of neurologic involvement in hematologic malignancies. CONCLUSION Neurologic involvement can be seen in lymphoma, leukemia, post-transplant lymphoproliferative disorder (PTLD), plasma cell neoplasms, and histiocytic and dendritic neoplasms. Imaging, MRI in particular, plays an important role in the workup of these patients. Familiarity with the imaging features of nervous system involvement in hematologic malignancies can help radiologists suggest the diagnosis and guide management.

Systemic treatment in breast cancer: a primer for radiologists

Cytotoxic chemotherapy, hormonal therapy and molecular targeted therapy are the three major classes of drugs used to treat breast cancer. Imaging modalities such as computed tomography (CT), magnetic resonance imaging (MRI), 18F-FDG positron emission tomography (PET)/CT and bone scintigraphy each have a distinct role in monitoring response and detecting drug toxicities associated with these treatments. The purpose of this article is to elucidate the various systemic therapies used in breast cancer, with an emphasis on the role of imaging in assessing treatment response and detecting treatment-related toxicities.Teaching Points• Cytotoxic chemotherapy is often used in combination with HER2-targeted and endocrine therapies.• Endocrine and HER2-targeted therapies are recommended in hormone-receptor- and HER2-positive cases.• CT is the workhorse for assessment of treatment response in breast cancer metastases.• Alternate treatment response criteria can help in interpreting pseudoprogression in metastasis.• Unique toxicities are associated with cytotoxic chemotherapy and with endocrine and HER2-targeted therapies.

Soft-Tissue Sarcomas: An Update for Radiologists Based on the Revised 2013 World Health Organization Classification

OBJECTIVE Soft-tissue sarcomas are a diverse group of malignancies, and our rapidly improving understanding of their molecular pathogenesis and treatment is leading to better clinical outcomes. The revised 2013 World Health Organization (WHO) classification of soft-tissue sarcomas introduced several important changes. We provide a comprehensive overview of the relevant changes for radiologists. CONCLUSION Rapid advances in the understanding of the pathogenesis and molecular biology of soft-tissue sarcomas led to major revisions in the 2013 WHO classification. To provide optimal multidisciplinary patient care, radiologists must remain up-to-date with the latest developments in the field of soft-tissue sarcomas to best correlate the histologic and imaging features of the various types of tumors and understand the unique patterns of treatment response and disease recurrence.

Regression of Coronary Atherosclerosis with Medical Therapy

A 42-year-old man who had been treated for severe coronary stenosis 4 years earlier presented with atypical chest pain. The imaging findings showed the potential value of medical therapy in treating stenosis.