Davide Prezzi

Perfusion CT imaging of treatment response in oncology

Perfusion CT was first described in the 1970s but has become accepted as a clinical technique in recent years. In oncological practice Perfusion CT allows the downstream effects of therapies on the tumour vasculature to be monitored. From the dynamic changes in tumour and vascular enhancement following intravenous iodinated contrast agent administration, qualitative and quantitative parameters may be derived that reflect tumour perfusion, blood volume, and microcirculatory changes with treatment. This review outlines the mechanisms of action of available therapies and state-of-the-art imaging practice.

Magnetic resonance imaging-quantified small bowel motility is a sensitive marker of response to medical therapy in Crohn's disease

Magnetic resonance enterography (MRE) can measure small bowel motility, reduction in which reflects inflammatory burden in Crohns Disease (CD). However, it is unknown if motility improves with successful treatment.

Changes in dynamic contrast-enhanced pharmacokinetic and diffusion-weighted imaging parameters reflect response to anti-TNF therapy in Crohn's disease

OBJECTIVE To investigate the effect of tumour necrosis factor (TNF)-α antagonists on MRI dynamic contrast-enhanced (DCE) and diffusion-weighted imaging (DWI) parameters in Crohns disease (CD). METHODS 42 patients with CD (median age 24 years; 22 females) commencing anti-TNF-α therapy with baseline and follow-up (median 51 weeks) 1.5-T MR enterography (MRE) were retrospectively identified. MRE included DCE (n = 20) and/or multi-b-value DWI (n = 17). Slope of enhancement (SoE), maximum enhancement (ME), area under the time-intensity curve (AUC), Ktrans (transfer constant), ve (fractional volume of the extravascular-extracellular space), apparent diffusion coefficient (ADC) and ADCfast/slow were derived from the most inflamed bowel segments. A physician global assessment of disease activity (remission, mild, moderate and severe) at the time of MRE was assigned, and the cohort was divided into responders and non-responders. Data were compared using Mann-Whitney U test and analysis of variance. RESULTS Follow-up Ktrans, ME, SoE, AUC and ADCME changed significantly in clinical responders but not in non-responders, baseline {[median [interquartile range (IQR)]: 0.42 (0.38), 1.24 (0.52), 0.18 (0.17), 17.68 (4.70) and 1.56 mm(2) s(-1) (0.39 mm(2) s(-1)) vs follow-up [median (IQR): 0.15 (0.22), 0.50 (0.54), 0.07 (0.1), 14.73 (2.06) and 2.14 mm(2) s(-1) (0.62 mm(2) s(-1)), for responders, respectively, p = 0.006 to p = 0.037}. SoE was higher and ME and AUC lower for patients in remission than for those with severe activity [mean (standard deviation): 0.55 (0.46), 0.49 (0.28), 14.32 (1.32)] vs [0.32 (0.37), 2.21 (2.43) and 23.05 (13.66), respectively p = 0.017 to 0.033]. ADC was significantly higher for patients in remission [2.34 mm(2) s(-1) (0.67 mm(2) s(-1))] than for those with moderate [1.59 mm(2) s(-1) (0.26 mm(2) s(-1))] (p = 0.005) and severe disease [1.63 mm(2) s(-1) (0.21 mm(2) s(-1))] (p = 0.038). CONCLUSION DCE and DWI parameters change significantly in responders to TNF-α antagonists and are significantly different according to clinically defined disease activity status. ADVANCES IN KNOWLEDGE DCE and DWI parameters change significantly in responders to TNF-α antagonists in CD, suggesting an effect on bowel wall vascularity.

Primary Rectal Cancer: Repeatability of Global and Local-Regional MR Imaging Texture Features

Purpose To assess the day-to-day repeatability of global and local-regional magnetic resonance (MR) imaging texture features derived from primary rectal cancer. Materials and Methods After ethical approval and patient informed consent were obtained, two pretreatment T2-weighted axial MR imaging studies performed prospectively with the same imaging unit on 2 consecutive days in 14 patients with rectal cancer (11 men [mean age, 61.7 years], three women [mean age, 70.0 years]) were analyzed to extract (a) global first-order statistical histogram and model-based fractal features reflecting the whole-tumor voxel intensity histogram distribution and repeating patterns, respectively, without spatial information and (b) local-regional second-order and high-order statistical texture features reflecting the intensity and spatial interrelationships between adjacent in-plane or multiplanar voxels or regions, respectively. Repeatability was assessed for 46 texture features, and mean difference, 95% limits of agreement, within-subject coefficient of variation (wCV), and repeatability coefficient (r) were recorded. Results Repeatability was better for global parameters than for most local-regional parameters. In particular, histogram mean, median, and entropy, fractal dimension mean and standard deviation, and second-order entropy, homogeneity, difference entropy, and inverse difference moment demonstrated good repeatability, with narrow limits of agreement and wCVs of 10% or lower. Repeatability was poorest for the following high-order gray-level run-length (GLRL) gray-level zone size matrix (GLZSM) and neighborhood gray-tone difference matrix (NGTDM) parameters: GLRL intensity variability, GLZSM short-zone emphasis, GLZSM intensity nonuniformity, GLZSM intensity variability, GLZSM size zone variability, and NGTDM complexity, demonstrating wider agreement limits and wCVs of 50% or greater. Conclusion MR imaging repeatability is better for global texture parameters than for local-regional texture parameters, indicating that global texture parameters should be sufficiently robust for clinical practice. Online supplemental material is available for this article.

Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) - Multidisciplinary Management.

*North Wales Cancer Treatment Centre, Glan Clwyd, UK, †Basingstoke & North Hampshire Hospital, Basingstoke,UK, ‡Cardiff University and Velindre Cancer Centre, Cardiff, UK, §John Radcliffe Hospital, Oxford, UK, ¶University of Birmingham and Queen Elizabeth Hospital,Birmingham, UK, **Clatterbridge Hospital, Wirral, UK, ††University of Manchester and Christie Hospital, Manchester, UK, ‡‡King’s College and Guy’s & St Thomas’ Hospital, London, UK, §§Guy’s & St Thomas’ Hospital, London, UK, ¶¶Birmingham Heartlands Hospital, Birmingham, UK, ***University of Sheffield, Sheffield, UK, and †††Queen Elizabeth Hospital, Birmingham, UK

Rectal Cancer Magnetic Resonance Imaging: Imaging Beyond Morphology

Magnetic resonance imaging (MRI) has in recent years progressively established itself as one of the most valuable modalities for the diagnosis, staging and response assessment of rectal cancer and its use has largely focused on accurate morphological assessment. The potential of MRI, however, extends beyond detailed anatomical depiction: aspects of tissue physiology, such as perfusion, oxygenation and water molecule diffusivity, can be assessed indirectly. Functional MRI is rapidly evolving as a promising non-invasive assessment tool for tumour phenotyping and assessment of response to new therapeutic agents. In spite of promising experimental data, the evidence base for the application of functional MRI techniques in rectal cancer remains modest, reflecting the relatively poor agreement on technical protocols, image processing techniques and quantitative methodology to date, hampering routine integration into clinical management. This overview outlines the established strengths and the critical limitations of anatomical MRI in rectal cancer; it then introduces some of the functional MRI techniques and quantitative analysis methods that are currently available, describing their applicability in rectal cancer and reviewing the relevant literature; finally, it introduces the concept of a multi-parametric quantitative approach to rectal cancer.

Adaptive statistical iterative reconstruction improves image quality without affecting perfusion CT quantitation in primary colorectal cancer

Highlights • Quantitative Perfusion CT parameters are not affected substantially by increasing ASIR levels.• ASIR improves image noise and CNR at a reduced peak kilovoltage of 100 kV.• Peak tumour CNR is greater than 1.5 with 60% ASIR and above.

Positron emission tomography/magnetic resonance imaging of gastrointestinal cancers

As an integrated system, hybrid positron emission tomography/magnetic resonance imaging (PET/MRI) is able to provide simultaneously complementary high-resolution anatomic, molecular, and functional information, allowing comprehensive cancer phenotyping in a single imaging examination. In addition to an improved patient experience by combining 2 separate imaging examinations and streamlining the patient pathway, the superior soft tissue contrast resolution of MRI and the ability to acquire multiparametric MRI data is advantageous over computed tomography. For gastrointestinal cancers, this would improve tumor staging, assessment of neoadjuvant response, and of the likelihood of a complete (R0) resection in comparison with positron emission tomography or computed tomography.

Imaging for the diagnosis and response assessment of renal tumours

PurposeImaging plays a key role throughout the renal cell carcinoma (RCC) patient pathway, from diagnosis and staging of the disease, to the assessment of response to therapy. This review aims to summarise current knowledge with regard to imaging in the RCC patient pathway, highlighting recent advances and challenges.MethodsA literature review was performed using Medline. Particular focus was paid to RCC imaging in the diagnosis, staging and response assessment following therapy.ResultsCharacterisation of small renal masses (SRM) remains a diagnostic conundrum. Contrast-enhanced ultrasound (CEUS) has been increasingly applied in this field, as have emerging technologies such as multiparametric MRI, radiomics and molecular imaging with 99mtechnetium-sestamibi single photon emission computed tomography/CT. CT remains the first-line modality for staging of locoregional and suspected metastatic disease. Although the staging accuracy of CT is good, limitations in determining nodal status persist. Response assessment following ablative therapies remains challenging, as reduction in tumour size may not occur. The pattern of enhancement on CT may be a more reliable indicator of treatment success. CEUS may also have a role in monitoring response following ablation. Response assessments following anti-angiogenic and immunotherapies in advanced RCC is an evolving field, with a number of alternative response criteria being proposed. Tumour response patterns may vary between different immunotherapy agents and tumour types; thus, future response criteria modifications may be inevitable.ConclusionThe diagnosis and characterisation of SRM and response assessment following targeted therapy for advanced RCC are key challenges which warrant further research.

The impact of MRI sequence on tumour staging and gross tumour volume delineation in squamous cell carcinoma of the anal canal

ObjectivesTo compare maximum tumour diameter (MTD) and gross tumour volume (GTV) measurements between T2-weighted (T2-w) and diffusion-weighted (DWI) MRI in squamous cell carcinoma of the anal canal (SCCA) and assess sequence impact on tumour (T) staging. Second, to evaluate interobserver agreement and reader delineation confidence.MethodsThe staging MRI scans of 45 SCCA patients (25 females) were assessed retrospectively by two independent radiologists (0 and 5 years’ experience of anal cancer MRI). MTD and GTV were delineated on both T2-w and high-b-value DWI images and compared between sequences; T staging was derived from MTD. Interobserver agreement was assessed and delineation confidence scored (1 to 5) by each observer.ResultsGTV and MTD were significantly and systematically lower on DWI versus T2-w sequences by 14.80%/9.98% (MTD) and 29.70%/12.25% (GTV) for each reader, respectively, causing T staging discordances in approximately a quarter of cases. Bland-Altman limits of agreement were narrower and intraclass correlation coefficients higher for DWI. Delineation confidence was greater on DWI: 40/42 cases were scored confidently (4 or 5) by each reader, respectively, versus 31/36 cases based on T2-w images.ConclusionsSequence selection affects SCCA measurements and T stage. DWI yields higher interobserver agreement and greater tumour delineation confidence.Key Points• MTD and GTV measurements are significantly lower on DWI than on T2-w MRI.• Such differences cause T staging discordances in up to a quarter of cases.• DWI results in higher agreement between inexperienced and experienced observers.• DWI offers greater tumour delineation confidence to inexperienced readers.