Giorgio Benea

Effect of Angiosonography to Monitor Response During Imatinib Treatment in Patients with Metastatic Gastrointestinal Stromal Tumors

Purpose: Gastrointestinal stromal tumor (GIST) metastases are typically intra-abdominal and hypervascular. We assessed the effect of angiosonography with a second-generation contrast agent to monitor response during imatinib treatment in patients with metastatic KIT+ GIST. Experimental Design: Ten consecutive patients with known advanced KIT+ GIST were investigated with angiosonography and computerized tomography (CT). We also monitored the serum levels of the major angiogenic growth factor, vascular endothelial growth factor. Results: Angiosonography showed a reduction in tumor vascularization of liver metastases during imatinib treatment in all cases. We observed a reduction in tumor vascularization before a reduction in tumor size. The tumor perfusion appeared reduced in the central part of the liver metastases. With a median follow-up of 18 months (range 3-33), a reduction in tumor vascularization was initially observed in all patients, but progressive disease was documented in four patients following imatinib treatment. CT documented tumor response according to standardized criteria in six patients, stable disease in four, and progressive disease according to angiosonography. The reduction of tumor perfusion at angiosonography correlated with the pseudocystic appearance at CT. The “nodule(s) within a mass” pattern of recurrence occurred in two patients with no difference observed between angiosonography and CT. Early decreasing serum vascular endothelial growth factor levels were observed in the two cases with higher pretreatment levels. Conclusions: Imatinib could induce antiangiogenic and/or antivascular effects in GIST, and this effect could be easily monitored with angiosonography. Angiosonography might be a useful complement for monitoring the therapeutic effect of imatinib in these patients.

Renal Artery Stenosis Evaluation: Diagnostic Performance of Gadobenate Dimeglumine–enhanced MR Angiography—Comparison with DSA

PURPOSE To prospectively determine diagnostic performance and safety of contrast material-enhanced (CE) magnetic resonance (MR) angiography with 0.1 mmol per kilogram of body weight gadobenate dimeglumine for depiction of significant steno-occlusive disease (> or =51% stenosis) of renal arteries, with digital subtraction angiography (DSA) as reference standard. MATERIALS AND METHODS This multicenter study was approved by local institutional review boards; all patients provided written informed consent. Patient enrollment and examination at centers in the United States complied with HIPAA. Two hundred ninety-three patients (154 men, 139 women; mean age, 61.0 years) with severe hypertension (82.2%), progressive renal failure (11.3%), and suspected renal artery stenosis (6.5%) underwent CE MR angiography with three-dimensional spoiled gradient-echo sequences after administration of 0.1 mmol/kg gadobenate dimeglumine at 2 mL/sec. Anteroposterior and oblique DSA was performed in 268 (91.5%) patients. Three independent blinded reviewers evaluated CE MR angiographic images. Sensitivity, specificity, and accuracy of CE MR angiography for detection of significant steno-occlusive disease (> or =51% vessel lumen narrowing) were determined at segment (main renal artery) and patient levels. Positive and negative predictive values and positive and negative likelihood ratios were determined. Interobserver agreement was analyzed with generalized kappa statistics. A safety evaluation (clinical examination, electrocardiogram, blood and urine analysis, monitoring for adverse events) was performed. RESULTS Of 268 patients, 178 who were evaluated with MR angiography and DSA had significant steno-occlusive disease of renal arteries at DSA. Sensitivity, specificity, and accuracy of CE MR angiography for detection of 51% or greater stenosis or occlusion were 60.1%-84.1%, 89.4%-94.7%, and 80.4%-86.9%, respectively, at segment level. Similar values were obtained for predictive values and for patient-level analyses. Few CE MR angiographic examinations (1.9%-2.8%) were technically inadequate. Interobserver agreement for detection of significant steno-occlusive disease was good (79.9% agreement; kappa = 0.69). No safety concerns were noted. CONCLUSION CE MR angiography performed with 0.1 mmol/kg gadobenate dimeglumine, compared with DSA, is safe and provides good sensitivity, specificity, and accuracy for detection of significant renal artery steno-occlusive disease.

Low-dose unenhanced CT protocols according to individual body size for evaluating suspected renal colic: cumulative radiation exposures

PurposeThe aim of this study was to assess the radiation dose of dose-reduced unenhanced abdominal multidetector computed tomography (MDCT) scan protocols for suspected renal colic in patients within normal weight range and overweight-obese patients and to record the cumulative dose of repeated examinations.Materials and methodsOver a 2-year period, we performed 1,026 unenhanced CT examinations for urolithiasis; among these, 675 were performed on 636 patients referred from the emergency department. Patients were divided into two groups on the basis of body mass index (BMI): normal weight (BMI <25 kg/m2 group 1); overweight and obese (BMI >25 kg/m2 group 2). For patients in group 1 and group 2, the protocols of our 64-row scanner prescribe tube current settings at 70 mAs and 150 mAs, respectively. The dose-length product (DLP) estimated by using the manufacturer’s software was converted into effective dose (ED).ResultsMean DLP and ED were 177 and 345 mGy/cm and 2.4 and 4.8 mSv for group 1 and group 2, respectively. A subset of 25 patients (3.7%) underwent two or more examinations, with estimated ED ranging from 4.8 to 19.2 mSv.ConclusionsAlthough radiation dose is nearly double in overweight-obese patients undergoing MDCT, it remains lower than that delivered by a standard-dose protocol. Patients with flank pain, who are often young, are at increased risk for serial CT examinations. Use of a low-dose protocol is mandatory in both normal-weight and obese patients to minimise radiation exposure.RiassuntoObiettivoScopo dello studio è misurare la dose efficace della TC addominale diretta con protocolli a bassa dose dedicati per pazienti di corporatura normale e pazienti obesi con sospetta urolitiasi, registrando inoltre l’esposizione derivante da indagini TC ripetute.Materiali e metodiDurante un periodo di due anni abbiamo eseguito 1026 indagini TC per urolitiasi; tra queste, 675 TC sono state eseguite in 636 pazienti provenienti dal Pronto Soccorso (PS). Per ogni paziente è stato calcolato l’indice di massa corporea (BMI) dividendo i pazienti in due gruppi: pazienti di taglia normale (BMI<25 kg/m2, gruppo 1) e sovrappeso-obesi (BMI>25 kg/m2, gruppo 2). Per il gruppo 1 ed il gruppo 2 i protocolli del nostro apparecchio TC 64 strati sono stati impostati rispettivamente a 70 mAs e 150 mAs. I valori di DLP forniti dal software dell’apparecchio sono stati convertiti in dose efficace.RisultatiLa DLP media e la dose efficace media sono risultate di 177 e 345 mGy·cm e 2,4 e 4,8 mSv rispettivamente per il gruppo 1 ed il gruppo 2. Una sottopopolazione di 25 pazienti (3,7%) é stata sottoposta a 2 o più indagini con una dose efficace stimata in un range compreso tra 4,8–19,2 mSv.ConclusioniLa dose efficace media è doppia nel paziente obeso, tuttavia inferiore rispetto a quella somministrata con un protocollo standard. I pazienti con colica renale, spesso giovani, hanno alta probabilità di essere sottoposti a ripetute indagini TC. L’impiego di un protocollo a bassa dose dedicato sia al paziente normale che al paziente obeso è fondamentale per minimizzare l’esposizione.

High-resolution MRI of carotid plaque with a neurovascular coil and contrast-enhanced MR angiography: one-stop shopping for the comprehensive assessment of carotid atherosclerosis.

OBJECTIVE The objective of our study was to assess a protocol of study of carotid atherosclerosis coupling vascular wall imaging and luminal imaging in the same examination and to evaluate the accuracy of high-resolution MRI with a neurovascular coil in carotid plaque characterization. SUBJECTS AND METHODS Thirty-two consecutive patients with 34 carotid artery stenoses were prospectively enrolled. MRI was performed on a 1.5-T unit. Plaque assessment was performed starting with a diffusion-weighted sequence and followed by a fat-suppressed T1-weighted sequence; after contrast-enhanced MR angiography (CE-MRA), all patients were evaluated with a T1-weighted 3D high-resolution sequence. Carotid plaques were classified as type A, having a large lipid-necrotic core; type B, being a complex fibrotic-calcified plaque with soft content (mixed plaque); or type C, being a fibrotic-calcified plaque (hard). Additional features indicative of vulnerable plaque such as intraplaque hemorrhage (IPH), ulceration, and severe stenosis were registered. MR findings were compared with surgical specimens. RESULTS MRI correctly identified 11 of 13 type A, eight of 11 type B, and eight of 10 type C plaques (sensitivity, 84.6%, 72.7%, and 80%, respectively). In the identification of lipid-necrotic core plaque, MRI showed a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 84.6%, 100%, 100%, and 91.3%, respectively (κ = 0.87). For reordering all plaques in two groups (i.e., soft vs nonsoft) in the identification of soft plaques, MRI had a sensitivity, specificity, PPV, and NPV of 83.3%, 80%, 90.9%, and 66.7%, respectively (κ = 0.59). IPH, ulcers, and severe stenosis were detected in eight of eight, 11 of 13, and 25 of 25 cases, respectively. CONCLUSION In patients with carotid atherosclerosis, ongoing CE-MRA with a neurovascular coil for the simultaneous detection of unstable plaques is feasible. Our MR protocol accurately identifies the major features of vulnerable plaque.

Radiofrequency ablation of liver malignancies: MRI for evaluation of response

Summary The aim of this study was to investigate the role of magnetic resonance imaging (MRI) in the evaluation of response to radiofrequency ablation (RFA) and detect residual or recurrent tumor. After RFA, the target lesion shows a hyperintensive signal without increased T1-weighted, low on T2-weighted, non enhancing in gadolinium-enhanced MRI. In the long term follow-up the successfully treated lesions decrease in size. Signs of recurrence include new enhancement areas, the lesion’s size increase, and development of T1-weighted hypointense and T2 weighted hyperintense areas. The MRI is a reliable method to evaluate the effectiveness of RFA and detect residual tumor.

Hepatic metastases of hemangiopericytoma: contrast-enhanced MRI, contrast-enhanced ultrasonography and angiography findings.

Hemangiopericytoma is a rare and characteristically hypervascular tumour. We report a case of hepatic metastases of hemangiopericytoma for which there was correlative imaging by ultrasonography, ultrasonography with second-generation contrast agent (BR1), computed tomography, gadolinium-enhanced, Gd-BOPTA-enhanced and ferumoxides-enhanced magnetic resonance, and angiography. To our knowledge, this is the first reported case in which all these modalities were used in the diagnostic evaluation.

Long-lasting response with metronomic capecitabine in advanced hepatocellular carcinoma.

Effective and safe systemic treatment for advanced hepatocellular carcinoma (HCC) with severe underlying cirrhosis is not yet available. Sorafenib, an oral multikinase inhibitor, has proved to be effective in the treatment of patients affected by HCC with Child-Pugh class A liver function. For patients with cirrhosis-associated HCC having Child-Pugh class B and C liver function, no systemic treatments of documented efficacy and safety exist. We report a case of metastatic HCC associated with Child-Pugh class B cirrhosis that was treated with low, “metronomic” doses of capecitabine (1000 mg/day continuously). This treatment was effective and well tolerated and the response was maintained for 18 months. Metronomic capecitabine may represent a possible alternative in the treatment of those patients with advanced cirrhosis-associated HCC who cannot be treated with sorafenib. Free full text available at www.tumorionline.it

Coronary artery anomalies presenting with ST-segment elevation myocardial infarction

ST-segment elevation MI (STEMI) is a rare presentation in patients with coronary artery anomalies. In these patients, the identification of the culprit lesion and its treatment may be difficult, particularly in the emergency setting of primary percutaneous coronary intervention (PCI). From January 2008 to April 2011, 1015 STEMI patients received coronary artery angiography and primary PCI in our centre. Of these, 5 (0.4%) patients showed a coronary artery anomaly. In this paper we reported two rare cases: i) the first is a single coronary artery originating from right sinus of Valsalva; ii) the second is a separate origin of 3 coronary arteries originating from the right sinus of Valsalva. In conclusion, coronary artery anomalies presenting with STEMI are really uncommon, but often are a challenge. The integration between traditional coronary artery angiography and multidetector computerized tomography is crucial to optimize the interventional and medical management of these patients.

Polar plot maps by parametric strain echocardiography allow accurate evaluation of non-viable transmural scar tissue in ischaemic heart disease

AIMS Assessment of left ventricular (LV) transmural scar tissue in clinical practice is still challenging because magnetic resonance imaging (MRI) and nuclear techniques have limited access and cannot be performed extensively. The aim of this study was to verify whether parametric two-dimensional speckle-tracking echocardiography (2D-STE) can more accurately localize and quantify LV transmural scar tissue in patients with healed myocardial infarct (MI) in comparison with MRI. METHODS AND RESULTS Thirty-one consecutive patients (age 56 ± 32 years, 29 males) with MRI and echocardiography performed after at least 6 months from an acute MI were studied. Apical LV longitudinal strain images by 2D-STE and short-axis contrast images by MRI were analysed to generate parametric bulls eye maps showing the distribution of the LV transmural scar tissue, whose extension was measured by planimetry and expressed as a percentage of the total myocardial area. Twelve patients also had early 2D-STE and MRI examinations after the acute MI. 2D-STE accurately quantified the extent of transmural scar tissue vs. MRI (r = 0.86; limits of agreement 10.0 and -9.5%). Concordance between 2D-STE and MRI for transmural scar tissue localization was high, with only 3.6% of discordant segments using an LV 16-segment model. Lin coefficients, intra-class correlation coefficients, and Bland-Altman analysis showed very good intra- and inter-observer reproducibility for 2D-STE evaluations. The transmural scar tissue area at 6 months could be predicted by early 2D-STE evaluation. CONCLUSION 2D-STE polar plots of LV longitudinal strain characterize transmural scar tissue accurately compared with MRI and may facilitate its assessment in clinical practice.

Staphylococcus hemolyticus liver abscess as an uncommon presentation of silent colonic cancer: a case report.

To the Editor: Although liver abscess is a common intra-abdominal infection, accounting for about one of every 4,500 to 7,000 hospital admissions,1 the clinical manifestation of colonic cancer as a liver abscess, in the absence of liver metastases, is not frequent.