Pierpaolo Mainenti

Combined evaluation of rest-redistribution thallium-201 tomography and low-dose dobutamine echocardiography enhances the identification of viable myocardium in patients with chronic coronary artery disease

Abstract. The purpose of this study was to evaluate whether combined evaluation by discriminant analysis of rest-redistribution thallium-201 tomography and low-dose dobutamine echocardiography enhances the accuracy in identifying viable myocardium in patients with chronic coronary artery disease. Rest-redistribution 201Tl has high sensitivity but low specificity in identifying viable myocardium, while the opposite is true for low-dose dobutamine echocardiography. Forty-six patients underwent low-dose dobutamine echocardiography and rest-redistribution 201Tl tomography on the same day. Rest echocardiography was repeated at least 30 days (mean 40±20) after myocardial revascularization. Discriminant analysis was applied to the results of 201Tl tomography and dobutamine echocardiography to classify a/dyskinetic segments as viable or non-viable. In 92 a/dyskinetic segments that were revascularized, rest-redistribution 201Tl tomography yielded an accuracy of 75%, while the accuracy of dobutamine echocardiography was 70% (P<0.05). When discriminant analysis was used, the combined evaluation gave an accuracy of 83% (P<0.05 vs both tests). These findings demonstrate that low-dose dobutamine echocardiography and 201Tl imaging are useful and complementary techniques for identifying viable myocardium in patients with chronic coronary artery disease. Combined evaluation by discriminant analysis significantly improves accuracy, although the cost-effectiveness of such an approach remains to be determined.

Cross-sectional evaluation of transmural healing in patients with Crohn’s disease on maintenance treatment with anti-TNF alpha agents

BACKGROUND Transmural healing (TH) of Crohns disease (CD) is a still unexplored and interesting outcome correlated to concept of deep remission. AIM To assess the rate of TH in CD patients treated with anti-TNF alpha agents using two cross-sectional procedures: bowel sonography (BS) and magnetic resonance enterography (MRE). METHODS We performed a 2-year observational longitudinal study, evaluating steroid-free clinical remission (CR), mucosal healing (MH), and TH in CD patients who would complete a 2-year treatment period with anti-TNFs. All patients underwent endoscopy, BS, and MRE before and after 2 years of treatment. RESULTS Forty out of 80 CD patients were treated with anti-TNFs for 2 years. CR was achieved in 24 patients (60%) while MH in 14 (35%). Using BS, TH was observed in 10 patients (25%), while using MRE, TH was observed in 9 patients (23%) (k=0.90; P<0.01). A good agreement was observed between MH and TH, both using BS (k=0.63; P<0.01) and MRE (k=0.64; P<0.01). A poor agreement was found between CR and TH, with both BS and MRE (k=0.27 and 0.29, respectively; P<0.01); even though all patients with TH had achieved CR. CONCLUSIONS TH can be achieved in about 25% of CD patients treated with anti-TNFs, as shown by BS and MRE. BS could be used as the first cross-sectional procedure to detect TH.

Bowel Damage in Crohnʼs Disease: Direct Comparison of Ultrasonography-based and Magnetic Resonance-based Lemann Index

Background: The Lémann index (LI), calculated by magnetic resonance (MR) or computed tomography enterography in association with endoscopy, was developed to assess bowel damage (BD) in Crohns disease (CD). Our aim was to investigate the concordance between ultrasonography-based Lèmann index (US-LI) and magnetic resonance–based Lèmann index (MR-LI). Methods: We prospectively evaluated all consecutive patients with CD referred to our IBD Unit. All patients had undergone endoscopy, US and MR within 1 month. US-LI and MR-LI were calculated by scoring previous surgery, location, extension, and intestinal complications. Furthermore, we evaluated the association between LI and: CD duration, Harvey–Bradshaw index, and other relevant clinical features. In accordance with recent literature, an LI >4.8 was considered indicative of BD. Results: Seventy-one patients with CD were examined. About CD location, 36% showed ileal disease (L1), 10% showed colonic CD (L2), whereas 54% had an ileocolonic disease (L3). Moreover, 27% of patients presented a noncomplicated behavior (B1), 45% had almost one stricture (B2), whereas 28% showed penetrating CD (B3). Perianal CD was observed in 16% of subjects, whereas 40% had undergone previous surgery. MR-LI and US-LI were 6.62 (95% confidence interval, 4.2–9.7) and 6.04 (95% confidence interval, 3.6–9.2), respectively (r = 0.90; P < 0.001), with 35 patients (49%) showing an LI indicative of BD. No significant correlation was evident between LI and Harvey–Bradshaw index (P = 0.9), whereas a significant correlation was found between both US-LI/MR-LI and CD duration (P = 0.01). Conclusions: US-LI shows high concordance with MR-LI and could be considered a good option for assessing BD in CD by using a highly available and relatively inexpensive procedure.

MIBG molecular imaging for evaluating response to chemotherapy in patients with malignant pheochromocytoma: preliminary results.

Abstract Malignant pheochromocytomas respond to chemotherapy with a reduction in tumor size and catecholamine secretion. We investigated the usefulness of molecular imaging with meta-iodobenzylguanidine (MIBG) for evaluating the effects of chemotherapy in patients with malignant pheochromocytoma. Six patients were studied before and after 6 ± 4 months of combination chemotherapy with cyclophosphamide, vincristine, and dacarbazine. Urinary catecholamines, metanephrines, and vanillylmandelic acid (VMA) levels were measured before and after chemotherapy. [131I]MIBG uptake was calculated for each tumor lesion on images before and after chemotherapy. An intensity ratio (IR) of abnormal to normal tissue count density was used to evaluate the change in lesion activity with therapy. Urinary catecholamines, metanephrines, and VMA significantly decreased with chemotherapy. MIBG uptake decreased in most lesions and the reduction in overall IR correlated with the reduction in urinary VMA. However, the change in individual lesions was variable and MIBG IR did not change or increased in a number of lesions. In conclusion, MIBG imaging is useful in the evaluation of patients with malignant pheochromocytoma who are receiving chemotherapy. It can provide not only a measure of overall effectiveness of treatment but also allows a lesion-by-lesion evaluation of the heterogeneity of response to chemotherapy.

Therapeutic Strategies in HCC: Radiation Modalities

Patients with hepatocellular carcinoma (HCC) comply with an advanced disease and are not eligible for radical therapy. In this distressed scenario new treatment options hold great promise; among them transarterial chemoembolization (TACE) and transarterial metabolic radiotherapy (TAMR) have shown efficacy in terms of both tumor shrinking and survival. External radiation therapy (RTx) by using novel three-dimensional conformal radiotherapy has also been used for HCC patients with encouraging results while its role had been limited in the past for the low tolerance of surrounding healthy liver. The rationale of TAMR derives from the idea of delivering exceptional radiation dose locally to the tumor, with cell killing intent, while preserving normal liver from undue exposition and minimizing systemic irradiation. Since the therapeutic efficacy of TACE is being continuously disputed, the TAMR with 131I Lipiodol or 90Y microspheres has gained consideration providing adequate therapeutic responses regardless of few toxicities. The implementation of novel radioisotopes and technological innovations in the field of RTx constitutes an intriguing field of research with important translational aspects. Moreover, the combination of different therapeutic approaches including chemotherapy offers captivating perspectives. We present the role of the radiation-based therapies in hepatocellular carcinoma patients who are not entitled for radical treatment.

Diagnostic Accuracy of Gd-EOB-DTPA for Detection Hepatocellular Carcinoma (HCC): A Comparative Study with Dynamic Contrast Enhanced Magnetic Resonance Imaging (MRI) and Dynamic Contrast Enhanced Computed Tomography (CT)

Summary Background To compare the diagnostic accuracy of hepato-biliary (HB) phase with gadolinium-ethoxybenzyl-diethylenetriamine-pentaacetic acid (Gd-EOB-DTPA) with dynamic contrast-enhanced MR imaging (DCEMRI) and contrast-enhanced CT (DCECT) for hepatocellular carcinoma (HCC) detection. Material/Methods 73 patients underwent DCECT and Gd-EOB-DTPA-3T-MR. Lesions were classified using a five-point confidence scale. Reference standard was a combination of pathological evidence and tumor growth at follow-up CT/MR at 12 months. Receiver Operating Characteristic (ROC) curves were obtained. Results A total of 125 lesions were confirmed in 73 patients. As many as 74 were HCCs and 51 were benign. Area under the curve (AUC) was 0.984 for DCEMRI+HB phase vs. 0.934 for DCEMRI (p<0.68) and 0.852 for DCECT (p<0.001). For lesions >20 mm (n.40), AUC was 0.984 for DCEMRI+HB phase, 0.999 for DCEMRI, and 0.913 for DCECT, (p=n.s.). For lesions <20 mm (n.85) AUC was 0.982 for DCEMRI+HB phase vs. 0.910 for DCEMRI (p<0.01) and 0.828 for DCECT (p<0.001). Conclusions The addition of HB phase to DCEMRI provides an incremental accuracy of 4.5% compared to DCEMRI and DCECT for HCC detection. The accuracy of Gd-EOB-DTPA-3T-MR significantly improves for lesions <20 mm. No significant improvement is observed for lesions >20 mm and patients with Child-Pugh class B or C.

F-18 FDG PET/CT metabolic tumor volume predicts overall survival in patients with disseminated epithelial ovarian cancer

OBJECTIVE We evaluated the prognostic impact of quantitative assessment by maximum standardized uptake value (SUVmax), metabolic tumour volume (MTV) and tumour lesion glycolysis (TLG) on [F-18] FDG PET/CT for patients with peritoneal carcinomatosis from epithelial ovarian cancer (EOC). METHODS Thirty-one patients with EOC underwent PET/CT for an early restaging after cytoreductive surgery, having been diagnosed with carcinomatosis (before chemotherapy). The SUVmax, MTV (cm3; 42% threshold) and TLG (g) were registered on residual peritoneal lesions. The patients were followed up 20±12months thereafter. The PET/CT results were compared to overall survival (OS). RESULTS The Kaplan-Meier survival analysis for the SUVmax did not reveal significant differences in OS (p=0.48). The MTV survival analysis showed a significant higher OS in patients presenting with a higher tumour burden than those with less tumour burden (p=0.01; 26 vs. 14 months), whereas TLG exhibited a similar trend though not significant (p=0.06). Apart from chemo-resistance, the higher the MTV, the better will be the response to chemotherapy. CONCLUSIONS Quantitative assessment by MTV rather than by SUVmax and TLG on PET/CT may be helpful for stratifying patients who present with peritoneal carcinomatosis from EOC, in order to implement the appropriate therapeutic regimen.

Simultaneous non-functioning neuroendocrine carcinoma of the pancreas and extra-hepatic cholangiocarcinoma. A case of early diagnosis and favorable post-surgical outcome.

CONTEXT Thanks to the wide use of diagnostic imaging modalities, multiple primary malignancies are being diagnosed more frequently and different associations of malignancies have been reported in this setting. CASE REPORT In this paper, we describe the case of a patient with non-functioning well-differentiated neuroendocrine carcinoma of the head of the pancreas associated with extra-hepatic cholangiocarcinoma, in which an early diagnosis using magnetic resonance imaging allowed a good outcome. CONCLUSION The simultaneous association of neuroendocrine pancreatic tumors and cholangiocarcinoma has not yet been described; however, this association should be considered and, due to the high contrast of magnetic resonance imaging, this technique is recommended in such patient in order to reach an accurate diagnosis.

P185 Comparison of bowel sonography and entero-MRI for diagnosis of small bowel Crohn's disease

(normal stool frequency and cessation of bleeding; pts’ diaries). Normal stool frequency (UC-DAI stool frequency subscore 0), clinical remission (abbreviated UC-DAI score 0), treatment failure (need for disallowed treatments), and non-bleeding stools (UC-DAI rectal bleeding subscore 0) at week 4 were also analysed. Observed case analyses are shown. Categorical variables were analysed by Cochran-Mantel Haenszel chisquared test and time-to-endpoint variables by Cox survival analysis, all adjusted by country. Results: 206 pts were enrolled and 202 included in intent-totreat analyses (n = 101 per arm). OD 5-ASA was superior to BD for mucosal healing at week 8 (87.5% vs 71.1% respectively; difference 16.4% [CIs 4.5 28.2]; P= 0.007). Median time to remission was significantly shorter with OD vs BD dosing (26 vs 28 days, respectively; P= 0.042). Time to cessation of bleeding was not significantly different (13 vs 21 days, respectively; P= 0.139). At week 4, significantly more pts had normal stool frequency with OD vs BD dosing (P= 0.013); there was no significant difference in rates of clinical remission, treatment failure or non-bleeding stools. Conclusions: 4 g OD 5-ASA was non-inferior to BD dosing. Moreover, significantly more pts with active UC achieved mucosal healing at week 8 and normal stool frequency at week 4 with 4 g 5-ASA OD vs BD, and median time to remission was significantly shorter with OD therapy. Other secondary endpoints were similar with OD and BD dosing at week 4. These data are consistent with those seen for maintenance of remission, and suggest that OD Pentasa® offers potential benefits to pts.

Duodenal Involvement by Breast Cancer

A54-year old woman presented to the emergency department with abdominal pain, intermittent vomiting, and mild jaundice for the past few weeks. Her past medical history included invasive ducto-tubular carcinoma of the right breast treated with wide local excision and axillar node sampling, followed by adjuvant radiation and hormonal therapy. A contrast-enhanced CT scan showed a concentric wall thickening with severe luminal stenosis of the second duodenum, added to thickened ampulla with (a)