Marco Calandri

The role of radiology in the evaluation of the immunotherapy efficacy

In the last years, a great interest has arisen on immunotherapy for the treatment of advanced non-small cell lung cancer (NSCLC). Check-point inhibitor drugs are now considered clinical practice standard in different settings and their use is expected to increase significantly in the near future. As treatment options for lung cancer advance and vary, the different patterns of radiological response increase in number and heterogeneity. To correctly evaluate the radiological findings after and during these treatments is of paramount importance, both in the clinical and sperimental setting. In consideration of their peculiar mechanism, immunotherapies can determine unusual response patterns on imaging, that cannot be correctly evaluated with the traditional response criteria such as World Health Organization (WHO) and Response Evaluation Criteria in Solid Tumours (RECIST). Therefore, during these years, several response criteria [immune-related response criteria (irRC), irRECIST and iRECIST] were proposed and applied in clinical trials on immunotherapies. The aim of this review is to describe the radiological findings after immunotherapy, to critically discuss the different response criteria and the imaging of immune-related adverse events.

Ablation of colorectal liver metastasis: Interaction of ablation margins and RAS mutation profiling on local tumour progression-free survival.

ObjectivesTo investigate effects of ablation margins on local tumour progression-free survival (LTPFS) according to RAS status in patients with colorectal liver metastases (CLM).MethodsThis two-institution retrospective study from 2005–2016 included 136 patients (91 male, median age 60 years) with 218 ablated CLM. LTPFS was performed using the Kaplan–Meier method and evaluated with the log-rank test. Uni/multivariate analyses were performed using Cox-regression models.ResultsThree-year LTPFS rates for CLM with minimal ablation margin ≤10 mm were significantly worse than those with >10 mm in both mutant-RAS (29% vs. 48%, p=0.038) and wild-type RAS (70% vs. 94%, p=0.039) subgroups. Three-year LTPFS rates of mutant-RAS were significantly worse than wild-type RAS in both CLM subgroups with minimal ablation margin ≤10 mm (29% vs. 70%, p<0.001) and >10 mm (48% vs. 94%, p=0.006). Predictors of worse LTPFS were ablation margins ≤10 mm (HR: 2.17, 95% CI 1.2–4.1, p=0.007), CLM size ≥2 cm (1.80, 1.1–2.8, p=0.017) and mutant-RAS (2.85, 1.7–4.6, p<0.001).ConclusionsMinimal ablation margin and RAS status interact as independent predictors of LTPFS following CLM ablation. While minimal ablation margins >10 mm should be always the procedural goal, this becomes especially critical for mutant-RAS CLM.Key Points• RAS and ablation margins are predictors of local tumour progression-free survival.• Ablation margin >10 mm, always desirable, is crucial for mutant RAS metastases.• Interventional radiologists should be aware of RAS status to optimize LTPFS.

Radiofrequency Ablation for Renal Cancer in Von Hippel–Lindau Syndrome Patients: A Prospective Cohort Analysis

Introduction Management of renal‐cell carcinoma (RCC) in patients with Von Hippel–Lindau syndrome (VHL) represents a clinical dilemma: the oncologic outcomes must be weighed against preservation of renal function. Radiofrequency ablation (RFA) is currently used in selected cases for treatment of small‐size RCC. The aim of this study was to evaluate the safety, complications, and functional and oncologic outcomes of RFA in the treatment of RCC in VHL patients. Patients and Methods RCCs were treated with ultrasound‐guided RFA or with laparoscopic RFA. Clinical and radiologic response, disease recurrence, and survival outcomes were evaluated during follow‐up. Early and late complications were recorded and graded. Results Nine RCC patients underwent RFA. The median number of RCCs per patient was 3 (interquartile range, 2‐4). Among these 9 patients, a total of 20 RCCs were treated by RFA (19 ultrasound‐guided RFA and 1 laparoscopic procedure). Median RCC size was 2.5 cm (interquartile range, 2.0‐3.0). RFA did not impair renal function (P = .35). In 2 cases disease persisted, and in 1 case disease recurred after 18 months. These patients were retreated with ultrasound‐guided RFA with complete response and no renal function impairment. RFA treatment was overall well tolerated and safe. No complications were recorded. Postoperative stay was no longer than 1 day. Conclusion RCC occurred in about two‐thirds of VHL patients, who had young age at presentation; it was frequently multifocal and recurrent. The use of RFA, with extended indications, could represent a tailored treatment for VHL patients, reducing the risk of renal failure and resulting in satisfying oncologic results. Micro‐Abstract Management of renal‐cell carcinoma (RCC) in Von Hippel–Lindau syndrome (VHL) patients represents a clinical challenge. Radiofrequency ablation (RFA) is currently used in selected cases for treatment of small‐size RCC. The aim of this study was to evaluate the safety and complication rate of RFA in treating RCC in VHL patients. The treatment did not impair renal function and resulted in complete oncologic control.

Treatment of multiple synchronous misdiagnosed renal cell cancers in a young patient affected by a “de novo” Von Hippel-Lindau syndrome

Introduction Von Hippel-Lindau (VHL) disease is an autosomal dominant inherited syndrome occurring in one out of 36,000 live births. Diagnosis could be a challenge in patients with no familial VHL history. Renal cancer (RCC) represents one of the most important manifestations. RCC is usually recurrent and multifocal. Actually treating RCC in VHL patients represent a clinical dilemma: the oncological outcomes must be balanced against renal function preservation. Case Presentation A young man with a negative familial history was referred to our department with seven misdiagnosed renal masses. VHL disease was determined through genetic test. The multiple RCCs were treated by surgery and percutaneous thermal ablation by radiofrequency ablation (RFA) with complete control of RCC and no impairment of renal function. Conclusions This case history confirms that VHL disease has to be suspected in young patients with evidence of synchronous multiple renal masses and in presence of specific clinical criteria. RFA appears to be safe in terms of oncological radicalism and in renal function preservation. In hereditary RCC, we should purpose, whenever it is possible, minimally invasive treatment in terms of low hospital stay and a minimal loss of renal tissue.