Shaunagh McDermott

FOLFIRINOX in Locally Advanced Pancreatic Cancer: The Massachusetts General Hospital Cancer Center Experience

The objective of our retrospective institutional experience is to report the overall response rate, R0 resection rate, progression-free survival, and safety/toxicity of neoadjuvant FOLFIRINOX (5-fluorouracil [5-FU], oxaliplatin, irinotecan, and leucovorin) and chemoradiation in patients with locally advanced pancreatic cancer (LAPC). Patients with LAPC treated with FOLFIRINOX were identified via the Massachusetts General Hospital Cancer Center pharmacy database. Demographic information, clinical characteristics, and safety/tolerability data were compiled. Formal radiographic review was performed to determine overall response rates (ORRs). Twenty-two patients with LAPC began treatment with FOLFIRINOX between July 2010 and February 2012. The ORR was 27.3%, and the median progression-free survival was 11.7 months. Five of 22 patients were able to undergo R0 resections following neoadjuvant FOLFIRINOX and chemoradiation. Three of the five patients have experienced distant recurrence within 5 months. Thirty-two percent of patients required at least one emergency department visit or hospitalization while being treated with FOLFIRINOX. FOLFIRINOX possesses substantial activity in patients with LAPC. The use of FOLFIRINOX was associated with conversion to resectability in >20% of patients. However, the recurrences following R0 resection in three of five patients and the toxicities observed with the use of this regimen raise important questions about how to best treat patients with LAPC.

Pulmonary Embolism in Pregnancy: Comparison of Pulmonary CT Angiography and Lung Scintigraphy

OBJECTIVE The purpose of this study was to retrospectively compare the diagnostic adequacy of lung scintigraphy with that of pulmonary CT angiography (CTA) in the care of pregnant patients with suspected pulmonary embolism. MATERIALS AND METHODS Patient characteristics, radiology report content, additional imaging performed, final diagnosis, and diagnostic adequacy were recorded for pregnant patients consecutively referred for lung scintigraphy or pulmonary CTA according to physician preference. Measurements of pulmonary arterial enhancement were performed on all pulmonary CTA images of pregnant patients. Lung scintigraphy and pulmonary CTA studies deemed inadequate for diagnosis at the time of image acquisition were further assessed, and the cause of diagnostic inadequacy was determined. The relative contribution of the inferior vena cava to the right side of the heart was measured on nondiagnostic CTA images and compared with that on CTA images of age-matched nonpregnant women, who were the controls. RESULTS Twenty-eight pulmonary CTA examinations were performed on 25 pregnant patients, and 25 lung scintigraphic studies were performed on 25 pregnant patients. Lung scintigraphy was more frequently adequate for diagnosis than was pulmonary CTA (4% vs 35.7%) (p = 0.0058). Pulmonary CTA had a higher diagnostic inadequacy rate among pregnant than nonpregnant women (35.7% vs 2.1%) (p < 0.001). Transient interruption of contrast material by unopacified blood from the inferior vena cava was identified in eight of 10 nondiagnostic pulmonary CTA studies. CONCLUSION We found that lung scintigraphy was more reliable than pulmonary CTA in pregnant patients. Transient interruption of contrast material by unopacified blood from the inferior vena cava is a common finding at pulmonary CTA of pregnant patients.

MR Imaging of Malignancies Arising in Endometriomas and Extraovarian Endometriosis

Cancers that arise in ovarian or extraovarian endometriosis are a distinct disease category with a histologic profile different from that of the more common epithelial ovarian cancers and with a better prognosis. Because the malignant transformation of endometriomas is rarely associated with lymphadenopathy or peritoneal carcinomatosis, a high index of suspicion on the part of the radiologist is necessary to establish a timely diagnosis of endometriosis-related ovarian cancers and allow appropriate oncologic management. Although imaging is not currently performed for surveillance of endometriosis, magnetic resonance (MR) imaging is often performed when surgical treatment is under consideration. An optimal MR imaging protocol for the detection of cancer arising in an endometrioma includes a review of subtraction images derived from unenhanced and contrast material-enhanced T1-weighted datasets. Subtraction images provide improved conspicuity of enhancing mural nodules--which are the most sensitive MR imaging sign of malignancy in ovarian endometriosis--against the background of the high-signal-intensity endometriotic cyst. Cancers arising in extraovarian endometriosis typically manifest as solid lesions with intermediate signal intensity on T1- and T2-weighted images, enhancement after the intravenous administration of a gadolinium-based contrast material, and restricted diffusion on diffusion-weighted images and apparent diffusion coefficient (ADC) maps. The signal intensity of myometrium, or, if the uterus is absent, that of the small bowel wall, is used as an internal reference standard for lesion signal intensity. Lesions are considered to have restricted diffusion if they show signal hyperintensity relative to the reference structure on diffusion-weighted images and hypointensity or isointensity relative to that structure on ADC maps. For definitive diagnosis, histopathologic analysis is required.

Percutaneous radiofrequency ablation of lung tumors: evaluation of the literature using evidence-based techniques.

Purpose The aim of this study was to evaluate the literature for articles assessing radiofrequency ablation (RFA) for pulmonary malignancy. Materials and Methods The “bottom-up” approach to evidence-based practice was applied by 2 reviewers to the retrieval and appraisal of original research articles published on pulmonary RFA between 2002 and 2009. Primary lung cancer and pulmonary metastases data were analyzed separately. The relationship between the percentage of local recurrence rate and lesion size, patient age, follow-up duration, and time to local recurrence was assessed using Spearmans rank correlation. Discrete time series were used to evaluate time trends. Results Secondary evidence yielded 1 review of 26 observational studies. Primary evidence yielded 46 studies that seemed suitable for detailed appraisal. A total of 2905 ablations were performed in 1584 patients. Eight studies evaluated primary lung cancers alone, 11 evaluated pulmonary metastases alone, 25 evaluated both, and 2 did not specify the histology. Results revealed trends toward increasing use of conscious sedation over general anesthesia, increasing use of multitined probes, decreasing size of nodule selection, and use of positron emission tomography/computed tomography as the optimal follow-up tool. Mean morbidity was 24.6%. The most prevalent side effects included pneumothorax (28.3%), pleural effusions (14.8%), and pain (14.1%). Procedure-related mortality ranged from 0 to 5.6, with an overall procedure-related mortality rate of 0.21%. There were 282 (12.2%) local recurrences occurring at a mean of 13 months. The mean overall survival rate was 59.4%, and the cancer-specific survival rate was 82.6%. Conclusions This evidence-based practice review of pulmonary RFA shows it to be a promising treatment for pulmonary malignancy in carefully selected patient populations. Studies with higher levels of evidence, including case-control, prospective nonrandomized and randomized trials, that compare RFA with alternative contemporary local treatments are urgently needed.

Is Early Colonoscopy Beneficial in Patients With CT-Diagnosed Diverticulitis?

OBJECTIVE The purpose of this study was to establish CT criteria as an indication for colonoscopy in patients with acute diverticulitis. MATERIALS AND METHODS The study was composed of patients diagnosed with acute diverticulitis on contrast-enhanced CT (CECT) from January 2000 to December 2004. Patients without subsequent colonoscopy were excluded. Findings on CT were correlated with patient outcomes over follow-up. Sensitivity, specificity, and predictive values of the imaging parameters for prediction of colon cancer were calculated. Outcomes were also compared between men and women. RESULTS Of 1034 patients with a CT diagnosis of diverticulitis, 402 (235 women and 167 men; mean age, 63.3 years) had available endoscopic colonic evaluation after CECT. The mean follow-up was 5.3 years. Seventy-eight patients had polyps (71% adenomatous) and nine patients (2.2%) were diagnosed with colon cancer (seven women, two men). The odds ratio for diagnosis of colon cancer was 23.35 in patients with mesenteric or retroperitoneal lymphnodes, 4.67 for abscess, and 24.43 in patients with obstruction and localized mass reported on CT. A significant correlation was found between the location of diverticulitis and cancer (p < 0.001). The diagnosis of cancer was made within 6 months from the date of CECT in eight patients. The odds of cancer were 2.5 times higher in women. CONCLUSION On the basis of the significant correlation of complicated diverticulitis or presence of lymph nodes with new diagnoses of colon cancer, we recommend early colonoscopy in patients with wall thickness more than 6 mm, abscess, obstruction, or lymph nodes seen on CECT.

Radiologic Percutaneous Gastrostomy: Review of Potential Complications and Approach to Managing the Unexpected Outcome

OBJECTIVE Radiologic percutaneous gastrostomy tube placement is a widely accepted method of enteral access for patients requiring long-term nutritional support for a variety of conditions. Although the safety of this procedure is well documented, complications do occur. The purpose of this article is to review the major and minor complications associated with gastrostomy tube placement and to present appropriate and effective management strategies. CONCLUSION Familiarity with the potential complications, techniques for their prevention, and strategies for treatment will help practicing interventional radiologists successfully manage all possible outcomes.

Tracheomalacia in Adults with Cystic Fibrosis: Determination of Prevalence and Severity with Dynamic Cine CT.

PURPOSE To determine the prevalence and severity of tracheomalacia in adults with cystic fibrosis (CF) by using dynamic cine multidetector computed tomography (CT) and to correlate these findings with pulmonary function test (PFT) results and the severity of parenchymal lung disease. MATERIALS AND METHODS In this institutional review board-approved HIPAA-compliant study, 40 patients with CF (22 men, 18 women; mean age, 28 years +/- 8 [standard deviation]; age range, 18-54 years) prospectively underwent PFTs, standard thin-section CT, and two dynamic cine multidetector CT acquisitions. Ten control subjects underwent dynamic cine multidetector CT. After standard thin-section CT was completed, dynamic cine multidetector CT was performed during a forced expiratory maneuver and during coughing. Dynamic cine multidetector CT images in nine patients were excluded. Maximal inspiratory, dynamic expiratory, and end-expiratory tracheal luminal areas were compared (Student t test) and correlated (Spearman rank) with PFT results and severity of parenchymal lung disease. RESULTS Mean predicted forced expiratory volume in 1 second (FEV(1)) was 70.6% +/- 20.7, and mean Bhalla CT score was 41.8% +/- 13.6. In patients with CF, dynamic cine mean tracheal cross-sectional area reduction was 51.7% +/- 18.4 (range, 9%-89%) for forced expiratory maneuvers and 68.8% +/- 11.7 (range, 18%-88%) for coughing (P = .001). Tracheomalacia was demonstrated in 24 (69%) patients and no control subjects during forced expiratory maneuvers (P = .001) and in 10 (29%) patients and one (10%) control subject during coughing. For end-expiration images, mean tracheal luminal reduction was 16.1% +/- 14.0% (range, 0.0%-53.0%), with one patient demonstrating tracheal luminal reduction of more than 50%. There was no correlation between tracheal cross-sectional luminal reduction and either predicted FEV(1) or CT Bhalla score. CONCLUSION Tracheomalacia depicted at dynamic cine multidetector CT is a highly prevalent finding in adults with CF. SUPPLEMENTAL MATERIAL http://radiology.rsnajnls.org/cgi/content/full/2522081956/DC1.

Radiofrequency Ablation of Liver Tumors

Radiofrequency ablation (RFA) is an alternative therapy for hepatocellular carcinoma and liver metastases when resection cannot be performed or, in the case of hepatocellular carcinoma, when transplant cannot be performed in a timely enough manner to avoid the risk of dropping off the transplant list. RFA has the advantage of being a relatively low-risk minimally invasive procedure used in the treatment of focal liver tumors. This review article discusses the current evidence supporting RFA of liver tumors, as well as the indications, complications, and follow-up algorithms used after RFA.

May-Thurner syndrome: can it be diagnosed by a single MR venography study?

PURPOSE We aimed to evaluate the longitudinal stability of left common iliac vein (LCIV) compression by the right common iliac artery on magnetic resonance venography (MRV). MATERIALS AND METHODS This retrospective study included 214 patients diagnosed with May-Thurner syndrome by MRV. We identified a subset of patients who underwent contrast-enhanced cross-sectional imaging of the pelvis six months before or anytime after the MRV and did not undergo any interventional venous procedures between the two studies; 36 patients met these criteria. The degree of venous compression was calculated in both the index and comparison study. RESULTS On the index MRV, the mean compression of the LCIV was 62%. However, on the comparison study in the same patients, the mean compression was 39%. The mean change in degree of compression between the two studies was 23% (P < 0.0001), ranging from a 12% increase to 69% decrease in degree of compression on the comparison study. CONCLUSION The compressed LCIV on a single MRV study was not stable over time and thus may be insufficient to diagnose May-Thurner syndrome.

Whole body imaging in the abdominal cancer patient: pitfalls of PET-CT

Proper interpretation of PET-CT images requires knowledge of the normal physiological distribution of the tracer, frequently encountered physiological variants, and benign pathological causes of FDG uptake that can be confused with a malignant neoplasm. In addition, not all malignant processes are associated with avid tracer uptake. A basic knowledge of the technique of image acquisition is also required to avoid pitfalls such as misregistration of anatomical and scintigraphic data. This article reviews these potential pitfalls as they apply to the abdomen and pelvis of patients with cancer.