Ivan Platzek

Comparison of systematic transrectal biopsy to transperineal magnetic resonance imaging/ultrasound-fusion biopsy for the diagnosis of prostate cancer

To compare targeted, transperineal magnetic resonance imaging (MRI)/ultrasound (US)‐fusion biopsy to systematic transrectal biopsy in patients with previous negative or first prostate biopsy and to evaluate the gain in diagnostic information with systematic biopsies in addition to targeted MRI/US‐fusion biopsies.

Transarterial Chemoembolization of Child-A hepatocellular carcinoma: Drug-eluting bead TACE (DEB TACE) vs. TACE with Cisplatin/Lipiodol (cTACE)

BACKGROUND This study is an outcome evaluation of the Drug-Eluting-Bead-Chemoembolization (DEB TACE) compared to conventional TACE (cTACE) with Cisplation and Lipiodol in patients with hepatocellular carcinoma (HCC) and Child-Pugh A Cirrhosis. MATERIAL/METHODS A comparison of interventional therapy with either cTACE or DEB-TACE of 22 patients each with unresectable HCC and Child-Pugh A Cirrhosis was carried out. A comparison of therapy-associated complications, tumour response rates and mean survival was performed. Tumour response was evaluated in accordance with the European Association for the Study of the Liver (EASL) response criteria by two radiologists in consensus reading. RESULTS The choice of TACE procedure (DEB TACE/cTACE) had no significant impact on therapy-associated complications. Objective Response (OR, complete response + partial response) for DEB-TACE was 22.7%; a further 68.2% was stable disease (SD). The respective response rates for the cTACE were OR 22.7 and SD 31.8%. Thus disease control was not significantly increased for DEB TACE (p=0.066). After DEB-TACE mean survival was significantly prolonged with 651 ± 76 days vs. 414 ± 43 days for cTACE (p=0.01). CONCLUSIONS Associated with a similar safety profile and an at least comparable tumour response, the DEB-TACE is a method of treatment for HCC that has the potential to improve mean survival compared to cTACE with Cisplatin/Lipiodol.

FDG PET/MR for lymph node staging in head and neck cancer

OBJECTIVE To assess the diagnostic value of PET/MR (positron emission tomography/magnetic resonance imaging) with FDG (18F-fluorodeoxyglucose) for lymph node staging in head and neck cancer. MATERIALS AND METHODS This prospective study was approved by the local ethics committee; all patients signed informed consent. Thirty-eight patients with squamous cell carcinoma of the head and neck region underwent a PET scan on a conventional scanner and a subsequent PET/MR on a whole-body hybrid system after a single intravenous injection of FDG. The accuracy of PET, MR and PET/MR for lymph node metastases were compared using receiver operating characteristic (ROC) analysis. Histology served as the reference standard. RESULTS Metastatic disease was confirmed in 16 (42.1%) of 38 patients and 38 (9.7%) of 391 dissected lymph node levels. There were no significant differences between PET/MR, MR and PET and MR (p>0.05) regarding accuracy for cervical metastatic disease. Based on lymph node levels, sensitivity and specificity for metastatic involvement were 65.8% and 97.2% for MR, 86.8% and 97.0% for PET and 89.5% and 95.2% for PET/MR. CONCLUSIONS In head and neck cancer, FDG PET/MR does not significantly improve accuracy for cervical lymph node metastases in comparison to MR or PET.

Added value of Gd-EOB-DTPA-enhanced Hepatobiliary phase MR imaging in evaluation of focal solid hepatic lesions

BackgroundCorrect characterization of focal solid hepatic lesions has always been a challenge and is of great diagnostic and therapeutic relevance. The purpose of this study was to determine the added value of hepatobiliary phase images in Gd-EOB-DTPA-enhanced magnetic resonance imaging (MRI) for differentiating focal solid hepatic lesions.MethodsIn this retrospective trial 84 consecutive patients underwent Gd-EOB-DTPA-enhanced MR examinations. MRI was conducted for 64 patients with malignant focal hepatic lesions (34 hepatocellular carcinoma (HCC), 30 metastases) and for 20 patients with benign hepatic lesions (14 focal nodular hyperplasia (FNH), 3 adenoma, 3 hemangioma). Five radiologists independently reviewed three sets of MR images by means of a 5-point confidence scale from score 1 (definitely benign) to score 5 (definitely malignant): set 1: unenhanced images; set 2: unenhanced and Gd-EOB-DTPA-enhanced dynamic images; set 3: hepatobiliary phase images in addition to set 2. Accuracy was assessed by the alternative free-response receiver operating characteristic curve (Az) and the index of diagnostic performance was calculated.ResultsDiagnostic accuracy was significantly improved by the addition of Gd-EOB-DTPA-enhanced dynamic images: Az in set 1 was 0.708 and 0.833 in set 2 (P = 0.0002). The addition of hepatobiliary phase images increased the Az value to 0.941 in set 3 (set 3 vs set 2, P < 0.0001; set 3 vs set 1, P < 0.0001). The index of diagnostic performance was lowest in set 1 (45%), improved in set 2 (71%), and highest in set 3 (94%).ConclusionsHepatobiliary phase images obtained after Gd-EOB-DTPA-enhanced dynamic MRI improve the differentiation of focal solid hepatic lesions.

Direct comparison of multiparametric magnetic resonance imaging (MRI) results with final histopathology in patients with proven prostate cancer in MRI/ultrasonography‐fusion biopsy

To compare multiparametric magnetic resonance imaging (mpMRI) of the prostate and histological findings of both targeted MRI/ultrasonography‐fusion prostate biopsy (PBx) and systematic PBx with final histology of the radical prostatectomy (RP) specimen.

FDG PET/MR for the assessment of lymph node involvement in lymphoma: initial results and role of diffusion-weighted MR.

RATIONALE AND OBJECTIVES The purpose of this study was to evaluate the sensitivity and specificity of positron emission tomography/magnetic resonance imaging (PET/MR) with 18F-fluorodeoxyglucose (FDG) for nodal involvement in malignant lymphoma. MATERIALS AND METHODS Twenty-seven patients with malignant lymphoma (16 men and 11 women; mean age, 45 years) were included in this retrospective study. The patients underwent FDG PET/MR after intravenous injection of FDG (176-357 MBq FDG, 282 MBq on average). Follow-up imaging and histology served as the standard of reference. RESULTS One-hundred and twenty-seven (18.1%) of 702 lymph node stations were rated as having lymphoma involvement based on the standard of reference. One-hundred and twenty-four (17.7%) of 702 lymph node stations were rated as positive by FDG PET/MR. The sensitivity and specificity of FDG PET/MR for lymph node station involvement were 93.8% and 99.4%. CONCLUSIONS FDG PET/MR is feasible for lymphoma staging and has a high sensitivity and specificity for nodal involvement in lymphoma. Comparison with PET/CT is necessary to determine whether FDG PET/MR can replace PET/CT for lymphoma staging.

Use of targeted therapy for refractory ALK-positive anaplastic large cell lymphoma as a bridging strategy prior to allogeneic transplantation

Dear Editor, Anaplastic lymphoma kinase (ALK)-positive anaplastic large cell lymphoma (ALCL) that is refractory following salvage therapy has a poor prognosis. Crizotinib is an ALK-specific tyrosine kinase inhibitor that was recently approved by the Food and Drug Administration (FDA) for the treatment of lung cancer associated with ALK gene rearrangements. Impressive response rates were reported using Crizotinib in lung cancer patients with ALK gene rearrangements as well as patients with ALK-positive anaplastic large cell lymphoma [1–3]. Brentuximab Vedotin (SGN-35) is a CD-30 specific monoclonal antibody attached to the antitubulin agent monomethyl auristatin E. Brentuximab is FDA approved for the treatment of relapsed or refractory Hodgkin’s lymphoma and systemic anaplastic large cell lymphoma, inducing tumor regression in a considerable proportion of patients [4]. Immunotherapy using allogeneic stem cell transplantation is also a promising treatment option for patients with lymphoma that has failed first-line therapy [5]. A 29-year-old man with anaplastic large cell lymphoma received six cycles of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP-21) and reached only a partial response for 1 month. Despite treatment with standard salvage combination chemotherapy regimens (DHAP, Dexa-BEAM) the patient continued to show signs of disease progression—B symptoms, increasing LDH levels, and adenopathy. Positron emission tomography–magnetic resonance imaging (PETMRI) revealed infiltration of cervical, para-aortic and iliac nodes (Fig. 1A). Due to his deteriorating clinical condition and signs of respiratory failure the patient was transferred to intensive care and mechanical ventilation was initiated. A CT scan revealed pulmonary manifestations of lymphoma. Based on the findings of GambacortiPasserini et al. [1] and the lack of further treatment options, our patient was started on Crizotinib as part of a compassionate use program via nasogastric feeding tube. The rapid improvement in clinical status of the patient after started tyrosine kinase inhibitor therapy was impressive. No steroids or other antineoplastic drugs were given at this time. The patient’s B symptoms improved and respiratory function returned within 7 days, accompanied by a significantly improved CTscan. The patient was discharged after 14 days and Crizotinib treatment was continued. R. Ordemann (*) : J. Stöhlmacher : F. Kroschinsky : J. M. Middeke :U. Platzbecker :M. Bornhäuser :G. Ehninger Medical Clinic and Policlinic I, University Hospital, Fetscherstrasse 74, 01307 Dresden, Germany e-mail: rainer.ordemann@uniklinikum-dresden.de

Whole-body MRI in follow-up of patients with renal cell carcinoma

Background: Recent technological advances have made whole-body MRI feasible within a reasonable time-frame. The clinical utility of whole-body MRI in patients with renal cell carcinoma has not been evaluated yet. Purpose: To compare the diagnostic accuracy of whole-body MRI and computed tomography (CT) in follow-up of patients with renal cell carcinoma. Material and Methods: In 28 patients with primary renal cell carcinoma a multislice CT scan of the thorax, abdomen, and pelvis, and a whole-body MRI were carried out as part of the postoperative follow-up. A combination of subsequent imaging studies and histology served as standard of reference. Results: MRI demonstrated a significantly better diagnostic accuracy regarding musculoskeletal metastases compared with CT (97.7% vs 82%, P<0.001). In contrast, CT was superior in the detection of pulmonary metastases (88.5% vs 71.9%, P<0.001). Both methods had similar diagnostic performance regarding lymph node metastases (CT, accuracy 82.4%; MRI, accuracy 83.4%, P=0.25). The concordance of both modalities regarding N and M stage was excellent (Cohens kappa 1.00). In two patients cerebral metastases were revealed by MRI, which led to a change in therapy. Conclusion: At this stage, whole-body MRI cannot be considered an adequate replacement for CT in the follow-up of patients with renal cell carcinoma. Further significant improvement of lung MR protocols is necessary, as CTs sensitivity for pulmonary nodules is clearly superior. In contrast, the main advantage of whole-body MRI is its high diagnostic accuracy for musculoskeletal metastases.

Treatment of metastatic renal cell cancer with sunitinib during chronic hemodialysis.

OBJECTIVES To report on 2 cases of metastatic renal cell cancer treated with sunitinib during chronic hemodialysis. METHODS Two patients who were receiving chronic hemodialysis were treated with escalating doses of sunitinib with close clinical and laboratory surveillance. RESULTS The treatment toxicities were tolerable even after dose escalation. The first patient had a complete response after 5 treatment cycles and the second patient had stable disease after 13 treatment cycles. CONCLUSIONS Sunitinib treatment is feasible and effective against metastatic renal cell cancer with the patient receiving chronic hemodialysis. Patients with terminal renal failure can be offered sunitinib treatment with close clinical and laboratory monitoring.

Early and late effects of radiochemotherapy on cerebral blood flow in glioblastoma patients measured with non-invasive perfusion MRI.

BACKGROUND AND PURPOSE To provide a systematic measure of changes of brain perfusion in healthy tissue following a fractionated radiotherapy of brain tumors. MATERIALS AND METHODS Perfusion was assessed before and after radiochemotherapy using arterial spin labeling in a group of 24 patients (mean age 54.3 ± 14.1 years) with glioblastoma multiforme. Mean relative perfusion change in gray matter in the hemisphere contralateral to the tumor was obtained for the whole hemisphere and also for six regions created by thresholding the individual dose maps at 10 Gy steps. RESULTS A significant decrease of perfusion of -9.8 ± 20.9% (p=0.032) compared to the pre-treatment baseline was observed 3 months after the end of radiotherapy. The decrease was more pronounced for high-dose regions above 50 Gy (-16.8 ± 21.0%, p=0.0014) than for low-dose regions below 10 Gy (-2.3 ± 20.0%, p=0.54). No further significant decrease compared to the post-treatment baseline was observed 6 months (-0.4 ± 18.4%, p=0.94) and 9 months (2.0 ± 15.4%, p=0.74) after the end of radiotherapy. CONCLUSIONS Perfusion decreased significantly during the course of radiochemotherapy. The decrease was higher in regions receiving a higher dose of radiation. This suggests that the perfusion decrease is at least partly caused by radiotherapy. Our results suggest that the detrimental effects of radiochemotherapy on perfusion occur early rather than later.