Goffredo Serra

Whole-Tumor Perfusion CT in Patients with Advanced Lung Adenocarcinoma Treated with Conventional and Antiangiogenetic Chemotherapy: Initial Experience

PURPOSE To determine whether wide-volume perfusion computed tomography (CT) performed with a new generation scanner can allow evaluation of the effects of chemotherapy combined with antiangiogenetic treatment on the whole tumor mass in patients with locally advanced lung adenocarcinoma and to determine if changes in CT numbers correlate with the response to therapy as assessed by conventional response evaluation criteria in solid tumors (RECIST). MATERIALS AND METHODS Forty-five patients with unresectable lung adenocarcinoma underwent perfusion CT before and 40 and 90 days after chemotherapy and antiangiogenetic treatment. RECIST measurements and calculations of blood flow, blood volume, time to peak, and permeability were performed by two independent blinded radiologists. Pearson correlation coefficient was used to assess the correlation between baseline CT numbers. Baseline and follow-up perfusion parameters of the neoplastic lesions were tested overall for statistically significant differences by using the repeated-measures analysis of variance and then were also compared on the basis of the therapy response assessed according to the RECIST criteria. RESULTS Pearson correlation coefficient showed a significant correlation between baseline values of blood flow and blood volume (ρ = 0.48; P = .001), time to peak and permeability (ρ = 0.31; P = .04), time to peak and blood flow (ρ = -0.66; P < .001), and time to peak and blood volume (ρ = -0.39; P = .007). Blood flow, blood volume, and permeability values were higher in responding patients than in the other patients, with a significant difference at second follow-up for blood flow (P = .0001), blood volume (P = .02), and permeability (P = .0001); time to peak was higher in nonresponding patients (P = .012). CONCLUSION Perfusion CT imaging may allow evaluation of lung cancer angiogenesis demonstrating alterations in vascularity following treatment.

Whole-tumour CT-perfusion of unresectable lung cancer for the monitoring of anti-angiogenetic chemotherapy effects

OBJECTIVE To determine whether CT-perfusion (CT-p) can be used to evaluate the effects of chemotherapy and anti-angiogenic treatment in patients with non-small-cell lung carcinoma (NSCLC) and whether CT-p and standard therapeutic response assessment (RECIST) data obtained before and after therapy correlate. METHODS 55 patients with unresectable NSCLC underwent CT-p before the beginning of therapy and 50 of them repeated CT-p 90 days after it. Therapeutic protocol included platinum-based doublets plus bevacizumab for non-squamous carcinoma and platinum-based doublets for squamous carcinoma. RECIST measurements and calculations of blood flow (BF), blood volume (BV), time to peak (TTP) and permeability surface (PS) were performed, and baseline and post-treatment measurements were tested for statistically significant differences. Baseline and follow-up perfusion parameters were also compared based on histopathological subclassification (2004 World Health Organization Classification of Tumours) and therapy response assessed by RECIST. RESULTS Tumour histology was consistent with large cell carcinoma in 14/50 (28%) cases, adenocarcinoma in 22/50 (44%) cases and squamous cell carcinoma in the remaining 14/50 (28%) cases. BF and PS differences for all tumours between baseline and post-therapy measurements were significant (p=0.001); no significant changes were found for BV (p=0.3) and TTP (p=0.1). The highest increase of BV was demonstrated in adenocarcinoma (5.2±34.1%), whereas the highest increase of TTP was shown in large cell carcinoma (6.9±22.4%), and the highest decrease of PS was shown in squamous cell carcinoma (-21.5±18.5%). A significant difference between the three histological subtypes was demonstrated only for BV (p<0.007). On the basis of RECIST criteria, 8 (16%) patients were classified as partial response (PR), 2 (4%) as progressive disease (PD) and the remaining 40 (80%) as stable disease (SD). Among PR, a decrease of both BF (18±9.6%) and BV (12.6±9.2%) were observed; TTP increased in 3 (37.5%) cases, and PS decreased in 6 (75%) cases. SD patients showed an increase of BF, BV, TTP and PS in 6 (15%), 21 (52.5%), 23 (57.5%) and 2 (5%) cases, respectively. PD patients demonstrated an increase of BF (26±0.2%), BV (2.7±0.1%) and TTP (3.1±0.8%) while only PS decreased (23±0.2%). CONCLUSION CT-p can adequately evaluate therapy-induced alterations in NSCLC, and perfusion parameters correlate with therapy response assessment performed with RECIST criteria. ADVANCES IN KNOWLEDGE Evaluating perfusional parameters, CT-p can demonstrate therapy-induced changes in patients with different types of lung cancer and identify response to treatment with excellent agreement to RECIST measurements.

CAD (computed-aided detection) and CADx (computer aided diagnosis) systems in identifying and characterising lung nodules on chest CT: overview of research, developments and new prospects.

Computer-aided detection (CAD) systems allow the automatic identification of lung nodules on chest computed tomography (CT), providing a second opinion to the radiologist’s judgement and a volumetric evaluation of lesions — a very important aspect in oncological patients. The natural evolution of these systems has led to the introduction of computer-aided diagnosis (CADx) systems, which are able not only to identify nodules but also to characterise them by determining a likelihood of malignancy or benignity. The aim of this article is to describe the main technical principles of CAD and CADx systems, their applicability and influence in clinical practice and new prospects for their future development.RiassuntoI sistemi computed aided detection (CAD) applicati alla tomografia computerizzata (TC) del torace, permettono l’identificazione automatica dei noduli polmonari, fornendo una seconda lettura al giudizio del radiologo e la valutazione volumetrica automatizzata delle lesioni, estremamente importante soprattutto in campo oncologico. La nuova frontiera nello sviluppo di questi sistemi è rappresentata dall’introduzione dei sistemi CAD di diagnosi (computed aided diagnosis) in grado non solo di effettuare l’identificazione dei noduli, ma anche una loro caratterizzazione, con l’elaborazione di un indice della probabilità di malignità o benignità della lesione. Lo scopo di questo articolo è quello di esporre i principi tecnici generali che regolano il funzionamento dei sistemi CAD, la loro applicabilità e influenza nella pratica clinica, e le nuove prospettive per il loro sviluppo nel panorama radiologico odierno in continua evoluzione.

Lung Magnetic Resonance Imaging with Diffusion Weighted Imaging Provides Regional Structural as well as Functional Information Without Radiation Exposure in Primary Antibody Deficiencies

PurposePrimary antibody deficiency patients suffer from infectious and non-infectious pulmonary complications leading over time to chronic lung disease. The complexity of this pulmonary involvement poses significant challenge in differential diagnosis in patients with long life disease and increased radio sensitivity. We planned to verify the utility of chest Magnetic Resolution Imaging with Diffusion-Weighted Imaging as a radiation free technique.MethodsProspective evaluation of 18 patients with Common Variable Immunodeficiency and X-linked Agammaglobulinemia. On the same day, patients underwent Magnetic Resonance Imaging with Diffusion Weighted Imaging sequences, High Resolution Computerized Tomography and Pulmonary Function Tests, including diffusing capacity factor for carbon monoxide. Images were scored using a modified version of the Bhalla scoring system.ResultsMagnetic Resonance Imaging was non-inferior to High Resolution Computerized Tomography in the capacity to identify bronchial and parenchymal abnormalities. HRCT had a higher capacity to identify peripheral airways abnormalities, defined as an involvement of bronchial generation up to the fifth and distal (scores 2–3). Bronchial scores negatively related to pulmonary function tests. One third of consolidations and nodules had Diffusion Weighted Imaging restrictions associated with systemic granulomatous disease and systemic lymphadenopathy. Lung Magnetic Resolution Imaging detected an improvement of bronchial and parenchymal abnormalities, in recently diagnosed patients soon after starting Ig replacement.ConclusionsMagnetic Resonance Imaging with Diffusion Weighted Imaging was a reliable technique to detect lung alterations in patients with Primary Antibody Deficiencies.

Chest MR imaging in the follow-up of pulmonary alterations in paediatric patients with middle lobe syndrome: comparison with chest X-ray

PurposeThe authors evaluated the role of magnetic resonance (MR) imaging of the chest in comparison with chest X-ray in the follow-up of pulmonary abnormalities detected by computed tomography (CT) in paediatric patients with middle lobe syndrome.Materials and methodsSeventeen patients with middle lobe syndrome (mean age 6.2 years) underwent chest CT at the time of diagnosis (100 kV, CARE dose with quality reference of 70 mAs; collimation 24×1.2 mm; rotation time 0.33 s; scan time 5 s); at follow-up after a mean of 15.3 months, all patients were evaluated with chest MR imaging with a respiratory-triggered T2-weighted BLADE sequence (TR 2,000; TE 27 ms; FOV 400 mm; flip angle 150°; slice thickness 5 mm) and chest X-ray. Images from each modality were assessed for the presence of pulmonary consolidations, bronchiectases, bronchial wall thickening and mucous plugging. Hilar and mediastinal lymphadenopathies were assessed on CT and MR images.ResultsBaseline CT detected consolidations in 100% of patients, bronchiectases in 35%, bronchial wall thickening in 53% and mucous plugging in 35%. MR imaging and chest X-ray identified consolidations in 65% and 35%, bronchiectases in 35% and 29%, bronchial wall thickening in 59% and 6% and mucous plugging in 25% and 0%, respectively. Lymphadenopathy was seen in 64% of patients at CT and in 47% at MR imaging.ConclusionsPatients with middle lobe syndrome show a wide range of parenchymal and bronchial abnormalities at diagnosis. Compared with MR imaging, chest X-ray seems to underestimate these changes. Chest MR imaging might represent a feasible and radiation-free option for an overall assessment of the lung in the follow-up of patients with middle lobe syndrome.RiassuntoObiettivoScopo del presente lavoro è valutare il possibile ruolo della risonanza magnetica (RM) del torace, in confronto con l’Rx, nel follow-up delle alterazioni polmonari identificate con esame di tomografia computerizzata (TC) di diagnosi in un gruppo di pazienti pediatrici con sindrome del lobo medio (SLM).Materiali e metodiDiciassette pazienti (età media: 6,2 anni) hanno eseguito un esame TC del torace al momento della diagnosi (100 kV, CARE dose con riferimento di qualità: 70 mAs; collimation: 24×1,2 mm; rotation-time: 0,33 s; scan-time: 5 s); al follow-up (intervallo temporale medio: 15,3 mesi), tutti i pazienti hanno eseguito una RM polmonare [sequenza T2-pesata BLADE con triggeringrespiratorio: tempo di ripetizione (TR): 2000; tempo di eco (TE): 27 ms; campo di vista (FOV): 400 mm; flip-angle: 150°; spessore: 5 mm) ed un esame Rx del torace. La presenza di consolidazioni, bronchiectasie, ispessimento delle pareti bronchiali e mucous plugging (tappi di muco) è stato riportato per ogni modalità d’esame. La presenza di linfoadenopatie ilo-mediastiniche è stata riportata per TC ed RM.RisultatiLa TC di diagnosi ha riportato consolidazioni nel 100% dei pazienti; bronchiectasie: 35%; ispessimento delle pareti bronchiali: 53%; mucous plugging: 35%. RM/Rx hanno riportato, rispettivamente, consolidazioni: 65%/35%; bronchiectasie: 35%/29%; ispessimento delle pareti bronchiali: 59%/6%; mucous-plugging: 25%/0%. Linfoadenopatie sono state riportate nel 64% dei pazienti in TC e 47% in RM.ConclusioniI pazienti con SLM mostrano un ampio corteo di alterazioni polmonari sin dal momento della diagnosi. L’esame Rx sembra sottostimare, in confronto alla RM, la frequenza di tali alterazioni nel corso del follow-up; la RM polmonare può rappresentare una metodica promettente e priva di radiazioni ionizzanti nel follow-up di questi pazienti.

Clinical application of dual-source CT in the evaluation of patients with lung cancer: correlation with perfusion scintigraphy and pulmonary function tests

PurposeThis study was done to assess the diagnostic potential of dual-source computed tomography (DSCT) in the functional evaluation of lung cancer patients undergoing surgical resection. The CT data were compared with pulmonary perfusion scintigraphy and pulmonary function tests (PFTs).Materials and methodsAll patients were evaluated with DSCT, scintigraphy and PFTs. The DSCT scan protocol was as follows: two tubes (80 and 140 kV; Care Dose protocol); 70 cc of contrast material (5 cc/s); 5- to 6-s scan time; 0.6 mm collimation. After the automatic calculation of lung perfusion with DSCT and quantification of air volumes and emphysema with dedicated software applications, the perfusional CT studies were compared with scintigraphy using a visual score for perfusion defects; CT air volumes and emphysema were compared with PFTs.ResultsThe values of accuracy, sensitivity, specificity and positive (PPV) and negative (NPV) predictive values of DSCT compared with perfusion scintigraphy as the reference standard were: 0.88, 0.84, 0.90, 0.93 and 0.88, respectively. The McNemar test did not identify significant differences either between the two imaging techniques (p=0.07) or between CT and PFTs (p=0.09).ConclusionsDSCT is a robust and promising technique that provides important and accurate information on lung function.RiassuntoObiettivoScopo del nostro studio è stato determinare le potenzialità diagnostiche della tomografia computerizzata dual-source (TC-DS) nella valutazione funzionale polmonare nei pazienti con tumore candidati a chirurgia; i dati ottenuti con la TC sono stati confrontati con la scintigrafia perfusionale e le prove di funzionalità respiratoria (PFTs).Materiali e metodiTutti i pazienti sono stati sottoposti ad una TC-DS, scintigrafia e PFTs. I parametri di acquisizione TC-DS sono stati: doppio tubo radiogeno (80 e 140 kV; protocollo Care Dose); 70 cc di mezzo di contrasto (MdC) (5 cc/s); tempo di scansione 5–6 secondi; collimazione 0,6 mm. Dopo l’elaborazione automatica della perfusione TC e la quantificazione dei volumi aerei e del grado di enfisema mediata da software dedicati, gli studi perfusionali TC-DS sono stati confrontati con la scintigrafia perfusionale con l’utilizzo di uno score visivo per la valutazione dei difetti di perfusione; i dati relativi ai volumi aerei e all’enfisema sono stati confrontati con le PFTs.RisultatiSono stai determinati i valori di accuratezza, sensibilità, specificità, valore predittivo positivo (PPV) e valore predittivo negativo (NPV) della TC-DS in confronto alla scintigrafia perfusionale: 0,88, 0,84, 0,90, 0,93 e 0,88, rispettivamente. Il test di McNemar non ha evidenziato differenze statisticamente significative tra le due metodiche (p=0,07) e tra TC e PFTs (p=0,09).ConclusioniLa TC-DS si presenta accurata e promettente, fornendo importanti informazioni di natura funzionale sul polmone.

J-Net: An Adaptive System for Computer-Aided Diagnosis in Lung Nodule Characterization

The aim of this study is to evaluate the capability of improved artificial adaptive systems and additional novel training methods in order to distinguish between benign and malignant lung nodules in Multi Detector Computed Tomography. A total of 90 nodules belonging to 88 patients are analyzed. A set of adjacent slices representing the lesion selected from the CT Image analysis by the experts are collected and stored in a database. Features extracted by an assembly of adaptive algorithms working in sequence [Active Connection Fusion (ACF): a new set of ANNs for image fusion; J-Net Active Connections Matrix (J-Net): a new ANN for dynamic image segmentation; Population (Pop): a new and fast multidimensional scaling algorithm] are divided into several groups using random or experimental methods to train and test different Artificial Neural Networks. Best results are obtained with Adaptive Learning Quantization (AVQ) and Meta-Consensus, two new supervised ANNs, experts in rapid classification and not sensitive to over fitting. After optimization of the distribution of cases among the training and testing sets the following results are achieved: sensitivity (recognition of malignant nodules) ranging from 93.33% to 100%; specificity (recognition of benign nodules) stable on 95.56% and overall accuracy ranging from 94.44% to 97.78%. These results represent the highest predictive values ever recorded in lung CAD literature. Benchmarking analysis, with advanced mathematical algorithms using simpler approaches, show that complex processing systems, composed of different steps and sub processing systems, are clearly superior and probably needed to reach excellent predictive performances in lung nodule characterization.