Paolo Marra

Gastric cancer: texture analysis from multidetector computed tomography as a potential preoperative prognostic biomarker

ObjectivesTo investigate the association between preoperative texture analysis from multidetector computed tomography (MDCT) and overall survival in patients with gastric cancer.MethodsInstitutional review board approval and informed consent were obtained. Fifty-six patients with biopsy-proved gastric cancer were examined by MDCT and treated with surgery. Image features from texture analysis were quantified, with and without filters for fine to coarse textures. The association with survival time was assessed using Kaplan–Meier and Cox analysis.ResultsThe following parameters were significantly associated with a negative prognosis, according to different thresholds: energy [no filter] – Logarithm of relative risk (Log RR): 3.25; p = 0.046; entropy [no filter] (Log RR: 5.96; p = 0.002); entropy [filter 1.5] (Log RR: 3.54; p = 0.027); maximum Hounsfield unit value [filter 1.5] (Log RR: 3.44; p = 0.027); skewness [filter 2] (Log RR: 5.83; p = 0.004); root mean square [filter 1] (Log RR: - 2.66; p = 0.024) and mean absolute deviation [filter 2] (Log RR: - 4.22; p = 0.007).ConclusionsTexture analysis could increase the performance of a multivariate prognostic model for risk stratification in gastric cancer. Further evaluations are warranted to clarify the clinical role of texture analysis from MDCT.Key points• Textural analysis from computed tomography can be applied in gastric cancer.• Preoperative non-invasive texture features are related to prognosis in gastric cancer.• Texture analysis could help to evaluate the aggressiveness of this tumour.

CMR in the assessment of cardiac masses: primary malignant tumors.

CARDIAC MAGNETIC RESONANCE (CMR) PLAYS AN IMPORTANT ROLE IN THE ASSESSMENT OF CARDIAC tumors, because it combines high contrast and spatial resolution with a panoramic view of the heart and surrounding structures and an unmatched ability to characterize tissues. So, CMR assessment is frequently

Pre-treatment MDCT-based texture analysis for therapy response prediction in gastric cancer: Comparison with tumour regression grade at final histology

PURPOSE An accurate prediction of tumour response to therapy is fundamental in oncology, so as to prompt personalised treatment options if needed. The aim of this study was to investigate the ability of preoperative texture analysis from multi-detector computed tomography (MDCT) in the prediction of the response rate to neo-adjuvant therapy in patients with gastric cancer. MATERIAL AND METHODS Thirty-four patients with biopsy-proven gastric cancer were examined by MDCT before neo-adjuvant therapy, and treated with radical surgery after treatment completion. Tumour regression grade (TRG) at final histology was also assessed. Image features from texture analysis were quantified, with and without filters for fine to coarse textures. Patients with TRG 1-3 were considered responders while TRG 4-5 as non- responders. The response rate to neo-adjuvant therapy was assessed both at univariate and multivariate analysis. RESULTS Fourteen parameters were significantly different between the two subgroups at univariate analysis; in particular, entropy and compactness (higher in responders) and uniformity (lower in responders). According to our model, the following parameters could identify non-responders at multivariate analysis: entropy (≤6.86 with a logarithm of Odds Ratio - Log OR -: 4.11; p=0.003); range (>158.72; Log OR: 3.67; p=0.010) and root mean square (≤3.71; Log OR: 4.57; p=0.005). Entropy and three-dimensional volume were not significantly correlated (r=0.06; p=0.735). CONCLUSION Pre-treatment texture analysis can potentially provide important information regarding the response rate to neo-adjuvant therapy for gastric cancer, improving risk stratification.

IFNα gene/cell therapy curbs colorectal cancer colonization of the liver by acting on the hepatic microenvironment.

Colorectal cancer (CRC) metastatic dissemination to the liver is one of the most life‐threatening malignancies in humans and represents the leading cause of CRC‐related mortality. Herein, we adopted a gene transfer strategy into mouse hematopoietic stem/progenitor cells to generate immune‐competent mice in which TEMs—a subset of Tie2+ monocytes/macrophages found at peritumoral sites—express interferon‐alpha (IFNα), a pleiotropic cytokine with anti‐tumor effects. Utilizing this strategy in mouse models of CRC liver metastasis, we show that TEMs accumulate in the proximity of hepatic metastatic areas and that TEM‐mediated delivery of IFNα inhibits tumor growth when administered prior to metastasis challenge as well as on established hepatic lesions, improving overall survival. Further analyses unveiled that local delivery of IFNα does not inhibit homing but limits the early phases of hepatic CRC cell expansion by acting on the radio‐resistant hepatic microenvironment. TEM‐mediated IFNα expression was not associated with systemic side effects, hematopoietic toxicity, or inability to respond to a virus challenge. Along with the notion that TEMs were detected in the proximity of CRC metastases in human livers, these results raise the possibility to employ similar gene/cell therapies as tumor site‐specific drug‐delivery strategies in patients with CRC.

Endovascular Treatment of Visceral Artery Aneurysms and Pseudoaneurysms in 100 Patients: Covered Stenting vs Transcatheter Embolization:

Purpose: To retrospectively report a large single-center experience of visceral artery aneurysms (VAAs) and pseudoaneurysms (VAPAs) treated with covered stenting (CS) as the first therapeutic option vs transcatheter embolization (TE). Methods: One hundred patients (mean age 59±14 years; 58 men) underwent 59 elective and 41 emergent endovascular procedures to treat 51 VAAs and 49 VAPAs. Seventy patients had TE and 30 received CS (27 Viabahn and 3 coronary stent grafts). Both TE and CS were performed in 10 cases. Results: Technical success was 96% (97% CS, 96% TE), and 30-day clinical success was 83% (87% CS, 81.4% TE). Four major complications occurred; 30-day mortality was 7%, mainly due to septic shock following pancreatic surgery. The midterm follow-up was 20.8 months in the total population and 32.8 months in the CS group. More than 6 months after CS all aneurysms remained excluded; stent patency was achieved in 88%. Twelve CS patients with >3 years’ follow-up had maintained stent patency. Conclusion: In endovascular treatment of visceral aneurysms, covered stenting was feasible in 30%. CS showed a slightly better efficacy than TE and good midterm patency. The Viabahn covered stent seems to be suitable for endovascular repair of tortuous visceral arteries affected by true or false aneurysms.

Embolization of superior rectal arteries for transfusion dependent haemorrhoidal bleeding in severely cardiopathic patients: a new field of application of the “emborrhoid” technique

Hemorrhoids are one of the most common anorectal diseases, with a prevalence of 4–86% [1]. One of the main symptoms is recurrent painless anorectal bleeding during defecation, which, if overlooked, can cause anemia. Embolization of the superior rectal arteries (“emborrhoid technique”) with coils was recently proposed by Vidal et al. [2] as a less invasive alternative to well-known conventional surgical treatments for hemorrhoids causing significant complication. This technique has been shown to be effective, safe, and well tolerated in patients with hemorrhoidal bleeding unsuitable or unwilling to undergo surgical treatment [3]. Anticoagulant and antiplatelet therapy is crucial in many patients with chronic heart disease to avoid lifethreatening thrombotic complications after cardiac surgery, coronary artery stenting, or left ventricular assist devices (LVAD) implantation, in patients experiencing heart failure. Treatment of severe hemorrhoidal bleeding in this group of “high-risk” surgical patients may be challenging, and they may benefit from non-surgical dearterialization. Technique Two patients, with severe heart disease and bleeding hemorrhoids causing severe anemia requiring blood transfusion, were both treated with the “emborrhoid technique”. Written informed consent was obtained from both patients. The first patient was a 71-year-old man with acute coronary syndrome, previously treated with multiple stent implantation and dual antiplatelet therapy (acetylsalicylic acid and clopidogrel), admitted to the intensive care department for anorectal bleeding and anemia (hemoglobin level 9 g/dL) despite iron supplementation and blood transfusions. A conventional hemorrhoidectomy was not recommended due to the high bleeding risk and the high risk of stopping antiplatelet therapy. The second patient was a 70-year-old man with severe dilated cardiomyopathy and with a heart mate II® (Thoratec Corp, Pleasanton, CA, USA) LVAD implant, as a bridge to heart transplantation; the patient was on long term warfarin therapy with international normal ratio (INR) of 2.5, also admitted to the intensive care department. He suffered severe hemorrhoidal bleeding requiring daily blood transfusions and was also admitted to the intensive care department. Both patients were treated with coil embolization of the terminal branches of the superior rectal arteries. After trans-femoral placement of a 4-F introducer and subsequent catheterization of the inferior mesenteric artery with a 4-F Simmons catheter (Cordis/Johnson and Johnson, Warren, NJ, USA), a preliminary diagnostic angiography was performed to visualize the superior rectal arteries and to identify the possible sources of bleeding (Fig. 1). The terminal branches of both superior rectal arteries were easily catheterized with a coaxial microcatheter (Renegade high flow, Boston Scientific, Marlborough, MA, USA) and then embolized (Fig. 2) using 0.025′′, 3-mm-diameter, 3-cmlong pushable coils (Cook, Bloomington, IN, USA). The post embolization angiogram showed the lack of opacification of the terminal branches of the superior rectal arteries and cessation of bleeding (Fig. 3). At the end of the procedure, prolonged manual compression (30–45 min) was performed after the removal of the femoral introducer. The * P. De Nardi denardi.paola@hsr.it

Covered stenting and transcatheter embolization of splenic artery aneurysms in diabetic patients: A review of endovascular treatment of visceral artery aneurysms in the current era

ABSTRACT Diabetes mellitus is associated with both microvascular and macrovascular complications, which can result in visceral aneurysms as for example splenic artery aneurysms: in their management, an endovascular treatment, less invasive than surgery, is generally preferred. Endovascular treatment of splenic artery aneurysms can be based either on covered stenting (CS) or transcatheter embolization (TE). CS generally allows aneurysm exclusion with vessel preservation, while TE usually determines target artery occlusion with potential risk of distal ischemia. We performed a review of the existing literature on endovascular treatment of visceral artery aneurysms (VAAs) and psudoaneurysms (VAPAs) in the current era.

Allo- and auto-percutaneous intra-portal pancreatic islet transplantation (PIPIT) for diabetes cure and prevention: the role of imaging and interventional radiology

Although the life expectancy of patients with type 1 diabetes mellitus (T1DM) has improved since the introduction of insulin therapy, the acute life-threatening and long-term complications from diabetes mellitus are significant causes of both mortality and morbidity. Percutaneous intra-portal pancreatic islet transplantation (PIPIT) is a minimally invasive, repeatable procedure which allows a β-cell replacement therapy through a liver islet engraftment, leading to insulin release and glycaemic control restoration in patients with diabetes. Allo-PIPIT, in which isolated and purified islets from cadaveric donor are used, does not require major surgery, and is potentially less expensive for the recipient. In case of long-term T1DM, islet-after-kidney (IAK) transplantation can simultaneously cure diabetes and chronic renal failure, while islet-transplant-alone (ITA) is performed in brittle, short-term T1DM, based on the infusion of an adequate islet mass and on a steroid-free immunosuppressive regimen according to the Edmonton protocol. Results of the Collaborative Islet Transplant Registry (CITR) demonstrate that allo-PIPIT reduces episodes of hypoglycemia and diabetic complications, and improves quality of life of diabetic patients. Auto-PIPIT, in which the own patients islets are used, has been investigated as a preventive treatment for pancreatogenic diabetes in patients who undergo extensive pancreatectomy for malignant and non-malignant disease. This Review outlines the role of imaging and interventional radiology in allo- and auto-PIPIT.

Four-class tumor staging for early diagnosis and monitoring of murine pancreatic cancer using magnetic resonance and ultrasound

Background The widely used genetically engineered mouse LSL-KrasG12D/+; LSL-Trp53R172H/+; Pdx-1-Cre, termed KPC, spontaneously develops pancreatic cancer mirroring all phases of the carcinogenesis but in asynchronous manner. Preclinical studies need defined criteria for the enrollment of the KPC sharing the same stage of carcinogenesis. Aim To define a tumor-staging criteria using magnetic resonance (MR) and ultrasound (US) and then to correlate the imaging stage with overall survival of KPC mice. Methods Forty KPC (2- to 5-month-old mice) were imaged by axial fat-saturated T2-weighted sequences at MR and by brightness mode US to establish criteria for tumor staging. Immunohistopathology was used to validate imaging. A second cohort of 25 KPC was used to correlate imaging stage with survival by Kaplan-Meier analysis. Results We defined a four-class tumor staging system ranking from stages 1 to 4. Stage 1 was described as radiologically healthy pancreas; precursor lesions were detectable in histology only. Cystic papillary neoplasms, besides other premalignant alterations, marked stage 2 in the absence of cancer nodules. Stages 3 and 4 identified mice affected by overt pancreatic cancer with size <5 or ≥5 mm, respectively. Regarding the prognosis, this staging system correlated with disease-related mortality whatever may be the KPC age when they staged. Conclusion This imaging-based four-class tumor staging is an effective and safe method to stage pancreatic cancer development in KPC. As a result, regardless of their age, KPC mice can be synchronized based on prognosis or on a specific phase of tumorigenesis, such as the early but already radiologically detectable one (stage 2).

Therapeutic EUS: Biliary drainage - The interventional radiologist's perspective

Up to 75% of patients with pancreatic cancer develop symptomatic biliary obstruction[1] and both the most recent guidelines from the European Society of Medical Oncology (ESMO)[2] and the National Comprehensive Cancer Network (NCCN) strongly recommend the endoscopic approach for the placement of a metallic biliary stent. Although biliary drainage (BD) is strongly recommended as palliation in advanced pancreatic cancer to provide relief of biliary and/or duodenal obstruction, malnutrition, and pain,[2] studies do not recommend presurgical BD.[3,4] However, based on the most recent evidence, including a randomized controlled trial, both the ESMO and NCCN guidelines suggest routine preoperative BD only in selected patients with symptomatic jaundice, cholangitis, or with an expected delay to surgery.[2,5,6]