IDENTIFICAZIONE DELLE LESIONI POLMONARI IN RM CON UNA SEQUENZA VIBE MODIFICATA E CON UNA SEQUENZA VIBE STANDARD: UN CONFRONTO CON LA TC.

Scopo valutare l\u2019accuratezza della RM a 3 Tesla nell\u2019individuazione di lesioni polmonari con una sequenza VIBE modificata e con una sequenza VIBE standard, usando la TC come riferimento. Materiale e metodi abbiamo rivalutato retrospettivamente 37 pazienti oncologici (11 pediatrici e 26 adulti; 19 F) sottoposti a TC e PET/RM da 3T il cui protocollo prevedeva una sequenza VIBE acquisita a respiro trattenuto con echo time (TE) di 0.89 ms e flip angle (FA) di 3\ub0. Le VIBE sono state valutate da tre osservatori per l'identificazione di noduli >5mm o =5mm. Un quarto osservatore ha valutato delle sequenze VIBE standard (TE di 1.2 ms e FA di 10\ub0), anch\u2019esse incluse nel protocollo, ed infine un quinto lettore ha analizzato le immagini TC (considerate come standard di riferimento).Sia per paziente che per singola lesione sono state calcolate sensibilit\ue0 e specificit\ue0 per le due categorie di noduli ed il coefficiente di correlazione intraclasse (ICC) per i lettori delle VIBE modificate. Risultati analisi per paziente (positivit\ue0=1 lesione): sensibilit\ue0 84.6% e specificit\ue0 di 100% per noduli>5mm (VIBE standard 69.2% e 100%) e 44.4% e 100% per noduli=5mm (VIBE standard 33.3% e 100%). Analisi per lesione (presenza/assenza): sensibilit\ue0 di 83.9% per noduli>5mm (VIBE standard 67.74%) e 37.5% per noduli=5mm (VIBE standard 18.7%). L\u2019ICC nell\u2019analisi per paziente era 0.911 per noduli>5mm e 0.902 per noduli=5mm; nell\u2019analisi per lesione 0.866 per noduli>5mm e 0.699 per noduli=5mm. Conclusioni la sequenza VIBE modificata \ue8 riproducibile ed accurata per l\u2019individuazione di noduli >5mm, mentre l\u2019accuratezza risulta meno soddisfacente per i noduli=5mm. L\u2019utilizzo della sequenza modificata nei protocolli RM sembra ragionevole per migliorare la visualizzazione del polmone

[18F]FDG PET/MRI in rectal cancer

We conducted a systematic literature review on the use of [18F]FDG PET/MRI for staging/restaging rectal cancer patients with PubMed, Scopus, and Web of Science, based on the PRISMA criteria. Three authors screened all titles and abstracts and examined the full texts of all the identified\ua0relevant articles. Studies containing aggregated or duplicated data, review articles, case reports, editorials, and letters were excluded. Ten reports met the inclusion criteria. Four studies examined T staging and one focused on local recurrences after surgery; the reported sensitivity (94\u2013100%), specificity (73\u201394%), and accuracy (92\u2013100%) varied only slightly from one study to another. The sensitivity, specificity, and accuracy of [18F]FDG PET/MRI for N staging were 90\u201393%, 92\u201394%, and 42\u201392%. [18F]FDG PET/MRI detected malignant nodes better than MRI, resulting in treatment change. For M staging, [18F]FDG PET/MRI outperformed [18F]FDG PET/CT and CT in detecting liver metastases, whereas it performed worse for lung metastases. The results of this review suggest that [18F]FDG PET/MRI should be used for rectal cancer restaging after chemoradiotherapy and to select patients for rectum-sparing approaches thanks to its accuracy in T and N staging. For M staging, it should be associated at least with a chest CT scan to rule out lung metastases

Rectal cancer staging: An up-to-date pictorial review

Colorectal cancer is the third most common malignancy worldwide, and rectal cancer (RC) accounts for 29% of all cases. Local staging of RC is crucial for the purposes of addressing patients appropriately to surgery alone or to preoperative chemoradiotherapy (pCRT) followed by total mesorectal excision (TME). Combined pCRT and TME may negatively affect rectal function, so rectum-sparing approaches such as transanal local excision have been proposed as an alternative to TME for patients showing a major or complete clinical response on restaging after pCRT. Magnetic resonance imaging (MRI) has a fundamental role in the local staging and restaging of RC, with or without positron emission tomography (PET). PET/MRI enables a multiplanar high-resolution morphological study of the pelvis, providing important information on cell density and metabolic activity with diffusion-weighted imaging (DWI) and 18F fluorodeoxyglucose uptake respectively. This article offers a pictorial review of the MRI anatomy of the ano-rectal region and an update on local RC staging with a hybrid 18F-FDG PET/MRI scan

18F-fluorodeoxyglucose positron emission tomography ([18F]-FDG PET)/MRI in locally advanced rectal cancer after preoperative chemo-radiotherapy: a comparison with conventional imaging

Purpose: To assess the accuracy of restaging after preoperative chemoradiotherapy (pCRT) with whole-body PET/MRI, pelvic T2-weighted (T2W) plus diffusion-weighted imaging (DWI) MRI (pelvic-MRI), pelvic T2W MRI (standard- MRI) and thoracoabdominal CT when predicting histopathologic TNM stage in locally advanced rectal cancer (LARC). Material and methods: 26 patients with LARC underwent PET/MRI and CT before and after pCRT for TNM staging. 21 were treated with total mesorectal excision and 5 with transanal local excision. Histopathologic findings or a follow-up of at least 1-year were the reference standards. One radiologist evaluated pelvic MRI and CT. A second radiologist evaluated standard MRI. A third radiologist and a nuclear medicine physician assessed PET/MRI. T staging results were grouped in T0 and residual disease (T 651). N stage was classified on a per-patient basis as positive or negative using MRI dimensional criteria ( 655mm per node), MRI lymph node global size reduction rate criteria (reduction<70%) and PET/MRI dimensional criteria and/or nodal FDG uptake. Results: Sensitivity and specificity for ypT0 were 100%-85.7% for PET/MRI, 94.7%-85.7% for pelvic-MRI and 94.7%-57.1% for standard-MRI. For ypN+ with dimensional criteria, sensitivity and specificity were 100%-88.9% for PET/ MRI and 75%-88.89% for pelvic-MRI. The values for pelvic-MRI changed to 87.5% and 72.2% using lymph node global size reduction rate criteria. PET/ MRI correctly diagnosed two liver and one distant nodal metastases while missed a lung metastasis. Conclusion: PET/MRI improves the accuracy of ycTN staging compared to MRI, but performs worse than CT in ycM staging. Initial results are promising; however, a larger cHelveticaNeueLT StdHelveticaNeueLT Stdohort of patients should be examined introducing sequences for lung and gadolinium for liver metastases

Assessing FDG-PET/3-T MRI after Preoperative Chemoradiotherapy for Rectal Cancer

PURPOSE To assess the accuracy of pelvic 3-T MRI and combined FDG-PET/3-T MRI (PET/MRI) in predicting pathological tumor and node (ypTN) stages, and to compare the accuracy of whole-body PET/MRI with thoraco-abdominal CT (CT) in predicting metastases (ypM) stage. METHOD AND MATERIALS This prospective study concerned 17 patients (16 male) with locally advanced rectal cancer who underwent preoperative chemoradiotherapy, PET/MRI and CT for staging purposes. PET/MRI included T2 and diffusion weighted images. Total mesorectal excision was the treatment of choice for 13 patients; the remainders were MRI node negative and underwent transanal local excision with at least 1-year endoscopic and pelvic MRI follow-up. Concurrent distant metastases were confirmed by surgery/biopsy or followed up with CT. One radiologist assessed pelvic MRI and CT images. Another radiologist and a nuclear medicine physician jointly assessed PET/MRI findings. All three were blinded to all other imaging and pathology results. RESULTS ypT was T0 in 4 patients, T1 in 3, T2 in 1, T3 in 7, and T4 in 2. ypN was positive in 5/17 cases, and metastases were detected in 3/17 patients. MRI and PET/MRI findings for ypT were concordant and correct in 11/17 patients (64.7%), concordant and incorrect in 2/17 (11.8%), and discordant in 4/17 (23.5%), PET/MRI staging being correct in 2 cases. As for ypN staging, MRI and PET/MRI were concordant and correct in 14/17 patients (82.3%) and discordant in 3/17 (17.7%), with PET/MRI staging predicting ypN status in 2 cases. Two patients with metastases were diagnosed correctly, while PET/MRI misdiagnosed one case of a small lung metastasis. CONCLUSION Integrated whole-body PET/MRI improves the accuracy of ypTN staging, but is less accurate than CT in ypM staging. Further studies are needed, including efforts to refine PET/MRI by using specific sequences for the lung and intravenous gadolinium, to examine the role of this technique in monitoring distal cancer spread. If successful, it would be possible to combine local and distant rectal cancer staging in a single examination. CLINICAL RELEVANCE/APPLICATION FDG-PET/3-T MRI can be a useful tool for the whole-body staging (TNM) of patients with advanced rectal cancer after chemoradiotherapy

Insights into the pathogenesis of catastrophic antiphospholipid syndrome. A case report of relapsing catastrophic antiphospholipid syndrome and review of the literature on ischemic colitis

We present the case of a woman with a severe clinical history of antiphospholipid syndrome and persistent positivity for lupus anticoagulant, IgG anticardiolipin and IgG anti-\u3b22Glycoprotein I antibodies. An acute clinical onset characterized by severe abdominal pain immediately followed by circulatory shock and histological colonic small vessel thrombosis pattern pointed to a diagnosis of ischemic colitis. The subsequent rapid onset of pulmonary alveolitis and heart failure associated to subendocardial hypoperfusion led to a diagnosis of definite catastrophic antiphospholipid syndrome (CAPS). Conventional triple therapy together with a broad-spectrum preventive antibiotic therapy were quickly initiated, and the outcome was favorable. We evaluated the patients with ischemic colitis in CAPS described in the literature between 1992 and May 2019 and our CAPS case. In accordance with the \u201ctwo-hit\u201d hypothesis and on the basis of the patients\u2019 data, we would like to speculate that the colonic wall necrosis related to ischemic colitis damaged the intestinal barrier causing loss of resistance to bacteria and leading to endotoxemia and bacteremia with bacteria translocation through the circulatory stream to the lungs and heart. The bacteria acted as the priming factor which favored the binding of \u3b22Glycoprotein I to the endothelium vessels in the colon, lungs, and heart following activation of anti-\u3b22Glycoprotein I antibodies which attached to the domain I of \u3b22Glycoprotein I. This was followed by complement activation which triggered the thrombotic and cytokine storm. If further clinical studies confirm this hypothesis, the treatment of CAPS could be more targeted and effective

Prediction of N0 Irradiated Rectal Cancer Comparing MRI Before and After Preoperative Chemoradiotherapy

BACKGROUND: The prediction of lymph node status using MRI has an impact on the management of rectal cancer, both before and after preoperative chemoradiotherapy. OBJECTIVE: To maximize the negative predictive value and sensitivity of mesorectal lymph node imaging after chemoradiotherapy because post-chemoradiation nodenegative patients may be treated with rectum-sparing approaches. DESIGN: Retrospective study. SETTINGS: The study was conducted at a tertiary-care hospital. PATIENTS: Sixty-four patients with locally advanced rectal cancer who underwent preoperative chemoradiotherapy and MRI for staging and the assessment of response were evaluated. MAIN OUTCOME MEASURES: The sums of the sizes of all mesorectal lymph nodes in each patient on both pre- and post-chemoradiotherapy imaging datasets were calculated to determine the lymph node global size reduction rates, taking these to be the outcomes of the histopathologic findings. Other included measures were interobserver agreement regarding the prediction of node status based on morphologic criteria and the diagnostic performance of contrast-enhanced images. RESULTS: Using a cutoff value of a 70% lymph node global size reduction rate with only 15 node-positive patients on histopathology, the sensitivity in the prediction of nodal status and negative predictive value were 93% (95%CI: 70.2-98.8) and 97% (95%CI: 82.9-99.8) for Observer 1, and 100% (95%CI: 79.6-100) and 100 % (95%CI:62.9-100) for Observer 2. The areas under the receiver operating characteristic curves for the two observers were 0.90 (95%CI: 0.82-0.98, p<0.0001) for Observer 1 and 0.65 (95%CI: 0.50-0.79, p=0.08) for Observer 2. The efficacy of the morphologic criteria and contrast-enhanced images in predicting node status was limited after chemoradiotherapy. LIMITATIONS: This study is limited by its small sample size and retrospective nature. CONCLUSIONS: Assessing the lymph node global size reduction rate value reduces the risk of undetected nodal metastases and may be helpful in better identifying suitable candidates for the local excision of early-stage rectal cancer