Thermal Ablation is Effective in the Treatment of NSCLC

According to a study published in Radiology researchers found that thermal ablation (TA) and stereotactic radiotherapy (STR) delivered comparable two and five-year outcomes in the treatment of early-stage non-small cell lung cancer (NSCLC)

This retrospective study included 28 834 patients (TA, 1102 patients; SRT, 27 732 patients) were identified in the 2004–2013 National Cancer Database.

There was no statistically significant difference in overall survival between TA and SRT at a mean follow-up of 52 months. Overall survival rates of TA and SRT were 85.4% vs. 86.3% in 1 year, 65.2% vs. 64.5% in 2 years,47.8% vs. 45.9% in 3 yearsand 24.6% vs. 26.1% in 5 years.  Unplanned hospital readmission rates were higher (3.7 vs. 0.2%) for patients who underwent TA versus those who underwent SRT.

Thermal ablation has an advantage of enabling physicians to collect biopsy samples during the procedure, while the one-time treatment offers lower direct costs for patients and insurance providers alike.

The authors concluded that TA has equally good results to STR in the treatment of stage 1 non–small cell lung cancer in patients who are deemed inoperable.

Carotid artery wall thickness measured by MRI better in predicting CVC than Ultrasound

A study by Zhang et al published in Radiology found magnetic resonance imaging (MRI) wall thickness measurements of carotid arteries enhances the quality of cardiovascular disease (CVC) risk assessment. 

The researchers enrolled 698 patients from the Multi-Ethnic Study of Atherosclerosis (MESA) from July 2000 to December 2013. Their average age was 63 years old and had no known history of cardiovascular disease. Patients underwent ultrasound and MRI between 2000 and 2004 to compare carotid artery wall thickness. 

The researchers found the association between wall thickness and cardiovascular events was stronger with contrast and non-contrast-enhanced MRI than it was for the ultrasound-based carotid intima-media thickness test. When included in the same model, MRI wall thickness, but not intima-media thickness, remained associated with the outcomes.

Breast MRI Improves depiction of DCIS Components

A study by Kuhl et al published in Radiology found magnetic resonance imaging (MRI) of the breast improves depiction of ductal carcinoma in situ (DCIS) components of invasive breast cancers prior to surgery.

The authors performed a prospective two-center study of 593 patients with biopsy proven invasive breast cancer that underwent breast MRI in addition to conventional imaging. 

The outcomes showed surgical-pathologic evaluation demonstrated DCIS components in 139 (23%) women. MRI had significantly higher sensitivity in the diagnosis of DCIS components pre-operatively in (84%; 118 women out of 139) than that of conventional imaging, which detected (36%; 51 of the 139 women). More than 50 percent of DCIS components were detected with MRI alone. 

The researchers also found the sensitivity benefits of MR imaging over conventional imaging improved with increasing relative size, and with increasing nuclear grade of DCIS components. Positive margin rates were generally low and did not diverge significantly between the 139 women with DCIS components versus the 454 women who lacked them.

The authors concluded that breast MRI improves depiction of DCIS components of invasive breast cancers before surgery.

Breast MRI Without Contrast Detects Cancer.

According to a study published in Radiology a radiomics technique that is based on diffusion weighted imaging with an adapted kurtosis model reduces false-positive results in both malignant and benign breast lesions when compared with x-ray mammography.

This institutional study included 222 women at two study sites (site 1: training set of 95 patients; mean age of 58.6 years; with 61 malignant and 34 benign lesions; and site 2: independent set of 127 patients; mean age, 58.2 years with 61 malignant with 66 benign lesions). 

Among all 222 patients, histopathology results confirmed malignant lesions in 122 women (55%); invasive ductal carcinoma was the most common finding, in 90 patients (74%). Benign lesions were found in the remaining 100 women (45%); fibrosis (21 patients, 21%) and fibroadenoma (20 patients, 20%) were the most common abnormalities.

All women presented with findings suspicious for cancer at x-ray mammography (BI-RADS 4 or 5) and an indication for biopsy. Before biopsy, diffusion-weighted MR imaging (b values, 0–1500 sec/mm²) was performed by using 1.5-T imagers from different MR imaging vendors. Lesions were segmented and voxel-based kurtosis fitting adapted to account for fat signal contamination was performed. Conventional interpretations of MR imaging were also assessed for comparison.

The kurtosis radiomics model reduced false-positive results from 66 to 20 (specificity 70.0% [46 of 66]) at the predefined sensitivity of greater than 98.0% [60 of 61] in the independent test set, with BI-RADS 4a and 4b lesions benefiting from the analysis (specificity 74.0%, [37 of 50]; 60.0% [nine of 15]) and BI-RADS 5 lesions showing no added benefit. The model significantly improved specificity compared with the median apparent diffusion coefficient (P < .001) and apparent kurtosis coefficient (P = .02) alone. Conventional reading of dynamic contrast material–enhanced MR imaging provided sensitivity of 91.8% (56 of 61) and a specificity of 74.2% (49 of 66). Accounting for fat signal intensity during fitting significantly improved the area under the curve of the model (P = .001).

 The authors concluded the radiomics model based on kurtosis diffusion-weighted imaging allowed for reliable differentiation between malignant and benign breast lesions.

Rotational Angiography in the study of Congenital Cardiac Anomalies in Children

A study by Parini et al published in Pediatric Cardiology. reports on the use of Rotational angiography (RA) for evaluating congenital heart disease (CHD) in the cardiac cath lab, permits acquisition of 3D datasets with superior spatial resolution.  The authors describe five cases on whom they created 3D-printed hearts in patients with CHD.

Diagnoses included coronary artery aneurysm, Glenn shunt, coarctation of the aorta, tetralogy of Fallot with major aortopulmonary collateral arteries (MAPCAs), and pulmonary artery stenosis. There was no significant measurement difference between RA and the printed model (r = 0.990, p < 0.01). There was also no significant inter-observer variability. 

The authors concluded that RA could generate highly accurate 3D models in congenital heart disease.  These models can be useful in patient evaluation and management.

Abbreviated Prostatic MRI

Kuhl et published in Radiology findings of their study in which they explored the accuracy of an abbreviated MRI of the prostate.  Multi-parametric contrast-enhanced MR imaging was performed in men with elevated PSA who after negative transrectal US-guided biopsy underwent state-of-the-art, full multiparametric contrast-enhanced MR imaging at 3.0-T that included high-spatial-resolution structural imaging in several planes, diffusion-weighted imaging at 0, 800, 1000, and 1400 mm²/sec, and dynamic contrast-enhanced MR imaging, obtained without endorectal coil within 34 minutes 19 seconds.

One of four radiologists first reviewed only two sequences of the study

 consisting of single-plane (axial) structural imaging (T2-weighted turbo spin-echo and diffusion-weighted imaging), acquired within 8 minutes 45 seconds (referred to as bi-parametric MR imaging), and established a diagnosis; only thereafter, the remaining full multiparametric contrast-enhanced MR images were read. Men with PI-RADS categories 3–5 underwent MR-guided targeted biopsy. Men with PI-RADS categories 1–2 remained in urologic follow-up for at least 2 years, with rebiopsy (transrectal US-guided or transperineal) when appropriate. 

A total of 542 men, aged 65 years with median PSA of 7 ng/mL, were included. Bi-parametric MR imaging helped detect clinically significant prostate cancer in 138 men. Full multi-parametric contrast-enhanced MR imaging allowed detection of one additional clinically significant prostate cancer (a stage pT2a, intermediate-risk cancer with a Gleason score of 3+4) and caused 11 additional false-positive diagnoses. Diagnostic accuracy for detection of clinically significant cancer of bi-parametric MR imaging was 89.1% (483 of 542) was similar to that of full multi-parametric contrast-enhanced MR imaging 87.2% (473 of 542). 

The authors concluded that bi-parametric MR imaging which can be done with two sequences and without contrast injection in less that 9 minutes allows for detection of clinically significant prostate cancer with a rate equivalent to conventional full multi-parametric contrast-enhanced MR imaging protocols.

CT Angiography is Accurate in Diagnosis of Small Cerebral Aneurysms

A study published by Yang et al in Radiology assessed the accuracy of computed tomographic (CT) angiography for diagnosis of cerebral aneurysms 5 mm or smaller.

A total of 1366 patients who underwent cerebral CT angiography followed by DSA were included in the study.

Of 1366 patients in their study, 579 patients had 711 small aneurysms at DSA. By using DSA as the reference standard, the respective sensitivity, specificity, and accuracy of CT angiography was analyzed for two readers.  The sensitivity of CT angiography was lower for detection of aneurysms smaller than 3 mm that had not ruptured compared with aneurysms that were 3–5 mm and had ruptured (P < .001). No difference existed for the sensitivities of CT angiography for diagnosis of aneurysms in the anterior versus posterior circulation (P > .0167). Excellent or good inter-reader agreement was found for detection of intracranial aneurysms on a per-patient (κ = 0.982) and per-aneurysm (κ = 0.748) basis.

The authors concluded that CT angiography has high accuracy for detection of small cerebral aneurysms.

Radiation Segmentectomy (RS) in Hepatocellular Carcinoma

Research by Lewandowski et al published in Radiology suggests that patients with small hepatocellular carcinomas (HCC) respond favorably to intra-arterial treatment with yttrium-90.

The authors reported outcomes from a retrospective analysis of 70 patients with HCC that were less or equal to 5 cm.  The patients received a radiation dose of more than 190 Gy.

Sixty-three patients (90%) showed response by using European Association for the Study of the Liver  (EASL) criteria, of which 41 (59%) showed complete response. Fifty patients (71%) achieved response by using World Health Organization (WHO) criteria, of which 11 (16%) achieved complete response. Response rates at 6 months were 86% and 49% by using EASL and WHO criteria, respectively. Median overall survival was 6.7 years; survival probability at 1, 3, and 5 years was 98%, 66%, and 57%, respectively. Overall survival probability at 1, 3, and 5 years was 100%, 82%, and 75%, respectively, in patients with baseline tumor size less than or equal to 3 cm (n = 45) and was significantly longer than in patients with tumors greater than 3 cm (P = .026).

The authors concluded that RS provides tumor control, and survival outcomes comparable to curative-intent treatments for patients with early-stage HCC who have preserved liver function.

FDA requires a warning on Gadolinium Contrast Agents

The U.S. Food and Drug Administration (FDA) has issued a new advisory requiring a new class warning and other safety measures for all gadolinium-based contrast agents (GBCAs) for magnetic resonance imaging (MRI) regarding gadolinium remaining in patients’ bodies, including the brain, for months to years after receiving these drugs which may be linked to renal harm.   These agents have been associated with nephrogenic systemic fibrosis in patients with pre-existing renal failure.  Although this complication is rare, it is serious enough to justify the advisory to all professionals and patients.

Although the benefit of all approved GBCAs continues to outweigh any potential risks the FDA now requires several actions to alert health care professionals and patients about gadolinium retention after an MRI using a GBCA, including actions that can minimize problems.  Health care professionals should consider the retention characteristics of each agent when choosing a GBCA for patients who may be at higher risk for gadolinium. These patients include those requiring multiple lifetime doses, pregnant women, children, and patients with inflammatory conditions. FDA suggests fewer repeated GBCA imaging studies when possible, particularly closely spaced MRI studies. However, physicians are advised to not avoid or defer necessary GBCA MRI scans.

Patients, parents, and caregivers should carefully read the new patient Medication Guide that will be given to him before receiving a GBCA. The Medication Guide explains the risks associated with GBCAs.  It also asks the patient to inform health care professional about medical conditions, such as: pregnancy, date of last MRI and number of prior MRI with gadolinium and kidney problems.

All new patients will be provided with the Medical Guide that provides educational information that every patient will be asked to read before receiving a GBCA. FDA will also require manufacturers of GBCAs to conduct human and animal studies to further assess the safety of these contrast agents.

Thrombectomy 6 to 16 Hours After Ictus Is Beneficial

A paper by Albers et al published in the NEJM suggests that many more stroke victims can be saved from disability or death if they undergo removal of thrombi obstructing their internal carotid or proximal middle cerebral artery.

182 stroke patients with clots in major vessels were enrolled in the study.  They were last known to be well between 6 and 16 hours earlier and had diffusion and perfusion MRI scans upon admission to Emergency Room. Patients with proximal middle-cerebral-artery or internal-carotid-artery occlusion, and an initial infarct size of less than 70 ml, and a ratio of the volume of ischemic tissue on perfusion imaging to infarct volume of 1.8 or more were randomly assigned to endovascular therapy plus standard medical therapy or standard medical therapy alone. The primary outcome was the score on the modified Rankin scale (range, 0 to 6, with higher scores indicating greater disability) at day 90.  Ninety-two of these patients had clots removed, while the remaining 90 did not. 

The study found that the 90-day death rate was lower for patients who had a thrombectomy vs. those who did not – 14 percent vs. 26 percent.   The data also indicated that more pronounced was the rate of functional independence among the thrombectomy patients – 45 percent vs. 17 percent at 90 days after the procedure.

Endovascular thrombectomy for ischemic stroke plus standard medical therapy resulted in better functional outcomes than standard medical therapy alone among patients with proximal middle-cerebral-artery or internal-carotid-artery occlusion and a region of tissue that was ischemic but not yet infarcted.

MRI safe for most patients with Pacemakers or Defibrillators

A study by Russo et al published in the NEJM found that MRI scans for patients with older not FDA approved pacemakers and implantable cardioverter-defibrillators (ICD) are safe even if the scan focuses on the chest area.

The researchers performed 1000 MRI in which patients had a pacemaker and in 500 MRI in which patients had an ICD in a 1.5T MRI scanner. No deaths, lead failures, losses of capture, or ventricular arrhythmias occurred during MRI. One ICD generator could not be interrogated after MRI and required immediate replacement; the device had not been appropriately programmed per protocol before the MRI.  Nine of the implants were disrupted but reset themselves to backup mode.  In all but one instance the effect was temporary.

Neither MRI performed on chest or in other parts of the body produced significant complications.   The concerns of potential magnetic field–induced cardiac lead heating, which could result in myocardial thermal injury and/or disrupt pacing properties of the devices were noted in this study.

The authors concluded that in their study, device or lead failure did not occur in any patient who was appropriately screened, and had the device reprogrammed in accordance with the pre-specified protocol.

Top Three

In the past four years I uploaded 113 posts in Radiology Weekly.  The top three in order of viewing frequency were:

Risk of Stroke due to Intracranial Atherosclerosis

http://radiologyweekly.blogspot.com/2014/05/risk-of-stroke-due-to-intracranial.html

iPad is Accurate in the Diagnosis of Bone Fractures

http://radiologyweekly.blogspot.com/2014/08/ipad-is-accurate-in-diagnosis-of-bone.html

Circulating Tumor Cells Culture Promises Individualized Testing and Treatment 

http://radiologyweekly.blogspot.com/2014/07/circulating-tumor-cells-culture.html

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