Regional radiotherapy in high-risk breast cancer: is the issue solved?

Adjuvant radiotherapy is the treatment standard for breast cancer with lymph node metastases after breast-conserving surgery or mastectomy. The inclusion of regional lymph nodes into the treatment volumes has been a question in recent clinical trials. Their impact on treatment standards and open questions is discussed.Radiotherapy plays an essential role in adjuvant treatment of breast cancer after breast-conserving surgery and in high-risk patients after mastectomy. However, the indications for inclusion of regional lymph nodes into radiotherapy treatment volumes have changed and are currently not homogeneously applied between countries and often not even between institutions in the same country. This commentary will focus on the indication for radiotherapy in patients with 1–3 lymph node metastases and on the use of regional radiotherapy, including parasternal irradiation in high-risk patients.Whereas the inclusion of the supra-/infraclavicular and upper axillary regions in high-risk patients with four or more involved lymph nodes is a treatment standard worldwide, the indications for local or locoregional radiotherapy in intermediate-risk patients with 1–3 lymph node metastases has long been a matter of discussion. In previous years, increasing evidence was provided support that post-mastectomy radiotherapy in this patient group is an advantage. In a subgroup analysis of randomized trials of the Danish Breast Cancer Group (DBCG82b/c) on 1152 node-positive patients with at least 8 lymph nodes removed by axillary dissection, radiotherapy to the chest wall, periclavicular, axillary and parasternal lymph nodes significantly reduced the rate of locoregional recurrences in both patients with 1–3 or with >3 involved lymph nodes compared with those with no radiotherapy. More important, the 15-year survival was also significantly improved in both patient groups.¹ This has been confirmed by a recent meta-analysis of the Early Breast Cancer Trialists'' Collaborative Group on the value of post-mastectomy radiotherapy of the chest wall, periclavicular, axillary and parasternal lymph nodes, which included 8135 females treated within 22 randomized trials. This analysis demonstrated that post-mastectomy radiotherapy leads to the same relative benefit in terms of locoregional tumour control as well as overall survival in the patient groups with 1–3 involved nodes as for patients with >3 lymph node metastases.² While these data provide a clear basis for the routine clinical use of post-mastectomy radiotherapy in the group of patients with 1–3 lymph node metastases, they did not answer the question whether local or locoregional radiotherapy should be applied.This latter question was addressed within the Canadian NCIC-CTG MA20 randomized trial, where 1832 patients with high-risk factors (of those 85% with lymph node metastases) after breast-conserving surgery received radiotherapy to the breast with or without additional regional radiotherapy to level III axillary, periclavicular and parasternal lymph nodes. Preliminary data showed a small but significant improvement of locoregional disease-free and overall survival by approximately 2% (from 94.5% to 96.8% and from 90.7% to 92.3%, respectively). Interestingly, metastases-free survival was significantly improved by the addition of regional radiotherapy from 87.0% to 92.4%.³ Similar results were obtained within the European Organisation for Research and Treatment of Cancer (EORTC) trial including 4004 patients randomized between inclusion or exclusion of the parasternal and medial supraclavicular nodes into locoregional radiotherapy.⁴The DBCG IMN study on 3072 patients applied locoregional radiotherapy, including parasternal lymph nodes only in right-sided and without parasternal lymph nodes in patients with left-sided breast cancer after mastectomy or breast-conserving radiotherapy.⁵ Inclusion of parasternal lymph nodes into the treatment volume again significantly improved the overall survival (75% vs 78%). For patients treated in the DBCG IMN study, it was estimated that the number needed to treat with IMN RT to avoid 1 death at 7 years was 33 patients, whilst in the “worst-case” scenario, the number of patients with no heart disease treated at an age of 50 years to cause 1 cardiac death at 10 years after parasternal radiotherapy was 3333.⁶ Only the smallest trial reported so far, the French multicentre randomized trial including 1334 patients failed to show a survival benefit after addition of parasternal radiotherapy to radiotherapy of the chest wall, axilla and supraclavicular nodes.⁷ In none of the trials was increased cardiac mortality reported after parasternal irradiation after average follow-up times of 10 years, however, final conclusions still need longer follow-up.In light of the overall conclusive results from the trials performed to date, the indication for adjuvant radiotherapy after mastectomy for patients with 1–3 involved lymph nodes should no longer be a matter of discussion. For the issue of inclusion of regional nodes, specifically parasternal nodes into the treatment volume, of patients with high-risk factors, it has to be concluded that this extension of the radiotherapy treatment volume leads to a small but significant improvement of survival for the average of the patient population, obviously by decreased distant metastases. Some countries (e.g. Denmark) considered this evidence by defining locoregional radiotherapy including parasternal radiotherapy as a treatment standard in all patients with lymph node metastases as well as in patients with pT3 tumours. Other countries (e.g. Germany) are still more ambiguous and recommend leaving the indication for the inclusion of parasternal lymph nodes to individual decision.⁸ Independent of such national differences in guidelines, the comparably small survival benefit after complete regional radiotherapy (including parasternal irradiation) can easily be outweighted in individual patients if, for example, cardiac sparing is not sufficiently considered. To take advantage of such small benefit, the use of radiotherapy techniques that optimize cardiac sparing is warranted and individual specific anatomical situations that hinder sufficient cardiac sparing should lead to a discussion of omission of parasternal radiotherapy in these patients. Whether longer follow-up or further subgroup analyses of the randomized trials will help to potentially define patients who benefit more from parasternal radiotherapy needs to be awaited.Another issue is the opposite treatment strategy, that is, treatment de-escalation, for patients with clinically negative but sentinel-node-positive axillary lymph nodes. These patients have been treated with similar success by axillary dissection or by locoregional radiotherapy of the remaining breast or thoracic wall and the axillary and parasternal lymphnodes⁹ or by local radiotherapy of the breast or thoracic wall alone.^10,11 Specifically, the patient cohorts of the Z0011 trial¹⁰ and the AMAROS trial⁹ show substantial overlap with those who received complete locoregional radiotherapy after surgical axillary treatment within the above-mentioned studies. As the results of these three trials do not contradict each other, it can currently only be concluded that axillary surgery may be omitted in specific groups of patients and that at least some of these patients likely benefit from regional radiotherapy.For future translational studies, the evaluation of molecular markers or genetic profiling of breast cancer to stratify patients for potential treatment decisions for or against regional radiotherapy will be of utmost importance. On a mid-term scale, such individualized strategies should not only include risk factors given by the tumour disease but also patient-related dose–volume-related risk factors for the development of toxicities.     

MRI in staging advanced gastric cancer: is it useful compared with spiral CT?

PURPOSE: During the last decade, rapid progress has been made in MR technology. Our objective was to evaluate the role of MRI in staging advanced gastric cancer (AGC; gastric cancer invading the muscularis propria) and to compare it with that of spiral CT. METHOD: We prospectively performed both MR and CT examinations on 26 patients with AGC proven by endoscopic biopsy. Contrast-enhanced CT and nonenhanced MRI with a 1.0 T scanner using FLASH, HASTE, and true-FISP sequences were obtained in each patient after injection of antiperistaltic drug and ingestion of 1 L of tap water. Fifty-two sets of CT and MR images were analyzed by two radiologists in consensus without any information from other images. T and N staging of AGC was determined according to the TNM classification. All patients underwent surgery within 1 week after both examinations. Diagnostic accuracy of each staging of AGC on CT or MRI was evaluated by comparison with the pathologic results. RESULTS: MRI was slightly superior to CT in T staging (81 vs. 73%, respectively; p < 0.05). Although MRI had a tendency to overstage the pathologic T2 cancer, positive predictability of T2 stage and sensitivity of T3 stage were high (100%, respectively). Regarding the N staging, CT was slightly superior to MRI (73 vs. 65%; p > 0.05). However, both CT and MRI demonstrated the tendency of understaging in N staging. CONCLUSION: Although MRI was superior to spiral CT in T staging, MRI cannot completely replace spiral CT in staging AGC because of its limitation in N staging.     

Three-dimensional conformal versus intensity modulated radiotherapy in breast cancer treatment: is necessary a medical reversal?

Objectives

Aim of the present study is to compare three-dimensional conformal RT (3D-CRT) and 4-fields intensity modulated radiation therapy (4f-IMRT) treatment plans, in terms of target dose coverage, integral dose and dose to Organs at risk (OARs) in early breast cancer (BC).

Methods

Twenty consecutive BC patients, after lumpectomy, were selected for the present analysis. A total dose of 50 Gy and a simultaneous dose of 60 Gy in 25 fractions was prescribed to Planning Target Volume of the whole breast (PTV_breast) and of the surgical bed, respectively. For each patient, a 3D-CRT plan and a sliding-window 4f-IMRT plan were generated. Conformity and homogeneity indexes (CI, HI) and various organ specific V_xGy values were analyzed for PTVs, OARs and normal tissue (NT), respectively.

Results

In terms of HI, 4f-IMRT was superior to 3D-CRT for the PTV_breast (p < 0.0001), and a significant difference for CI was observed in favor of 4f-IMRT (p < 0.0001).In terms of dose to OARs, a superiority of 4f-IMRT was shown. For NT, all parameters are in favor of IMRT, except the V _5Gy for which the difference was not statistically significant. The average NT-D_mean was 2.7 ± 0.7 for 3D-CRT and 1.8 ± 0.5 for 4f-IMRT (p < 0.0001).

Conclusions

4f-IMRT technique significantly reduced the dose to OARs and NT, with a better target coverage compared to 3D-CRT.

     

MR arthrography of postoperative knee: for which patients is it useful?

PURPOSE: To assess which postoperative patients benefit most from MR arthrography of the knee. MATERIALS AND METHODS: One hundred consecutive MR arthrograms obtained in patients who had previous knee surgery underwent retrospective review in consensus by three radiologists after prospective reading by one of the three radiologists. Criterion on MR arthrograms for a retear was abnormal tracking of an intraarticular dilute gadolinium-based contrast material and saline mixture into the substance of a meniscus. Patients were separated into three groups: those with more than 25% meniscal resection, those with less than 25% meniscal resection, and those with meniscal repair. All 100 patients had preoperative MR images to review directly in conjunction with the postoperative MR images. Fifty-seven of these 100 patients underwent second-look arthroscopy. RESULTS: Nine patients had MR findings consistent with avascular necrosis. Nineteen patients had marked degenerative arthrosis in the area of previous surgery. Seven patients had chondral defects or injuries. Twenty-nine patients had clear MR evidence of a meniscal retear without any contrast material injected into the joint. In 32 of the 100 patients, intraarticular contrast material was useful in demonstrating a retear. Of these 32 patients, 22 had MR arthrographic evidence of a retear, while 10 had no clear MR arthrographic finding to explain postoperative pain. Four additional patients had no clear MR imaging or MR arthrographic abnormality. All patients with meniscal repair (n = 16) needed MR arthrography to diagnose a residual or recurrent meniscal tear. No patient with less than 25% meniscal resection (n = 23) needed MR arthrography to demonstrate a residual or recurrent meniscal tear. Sixteen of 61 patients with more than 25% meniscal resection needed MR arthrography to demonstrate a residual or recurrent meniscal tear. CONCLUSION: All patients with meniscal repair required MR arthrography. All patients with meniscal resection of more than 25%, who did not have severe degenerative arthrosis, chondral injuries, or avascular necrosis required MR arthrography. Patients with less than 25% meniscal resection did not need MR arthrography.     

How 'hot' is the pathologically positive sentinel lymph node in breast cancer patients?

When many lymph nodes are found by using lymphoscintigraphic techniques performed to detect the sentinel lymph nodes (SLNs) in breast cancer, it is usual to find that the 'hottest' SLN is not always the node that is pathologically positive (pN+). Various criteria have been proposed to define which radioactive lymph nodes should be removed. In order to determine the frequency with which the hottest SLN 'fails' to be pN+, and to determine which criteria best define the radioactive lymph node to be removed, we reviewed and analysed our cases in which more than one SLN was detected and where there was also at least one pN+ node. From a series of 181 patients, 40 were selected. In 11 of these 40 cases (27.5%), the hottest SLN was not pN+. Radioactivity levels in the pN+SLN of these 11 patients ranged from 2% to 94% of the activity of the hottest SLN. Twenty-one patients (52.5%) showed only micrometastatic (pN1a) disease in one or more SLNs. In four of these patients (19%) the pN1a SLN was not the hottest node. Two of the patients had radioactivity levels in the pN+SLN which were more than 50% of that of the hottest SLN. In another two of these patients (9.5%), radioactivity levels were lower than 50% of that of the hottest node (respectively, 38% and 2%). However, in these two last cases, the first and hottest SLN removed surgically was found, by the pathologist, to consist of six nodes. Macrometastases (dimensions greater than 2 mm) were found in 19 patients. In 12 of these patients, the hottest SLN was macrometastatic although macrometastases and/or micrometastases were found in other 'cooler' SLNs in four of them. In another seven of these patients (36.8%), macrometastases were found in SLNs with radioactive levels lower than 51% of that of the hottest node. One patient (with three SLNs) out of the 40 (2.5%) had one SLN pN+ with less than 10% of that of the hottest. In fact, it contained only one micrometastasis and its activity was equal to 2%. Upon pathological examination, however, the hottest lymph 'node' was found to consist of six nodes. It is concluded that, with four intra-mammary and peritumoural injections of 99mTc labelled nanosized colloids of Human Serum Albumin (Nanocoll R: Sorin: 74 MBq and 0.05 mg per injection) performed 18-24 h before using a gamma probe to detect the SLNs, the hottest SLN was not the pathologically positive node in 27.5% of patients in our series. By using the activity in the hottest SLN as the reference point, and 10% of this activity as the lower threshold for removing active SLNs, the sensitivity of the technique is 97.5%.     

Postoperative periclavicular radiotherapy in breast cancer patients with 1–3 positive axillary lymph nodes

Purpose

The goal of this work was to examine the possible influence of periclavicular irradiation on outcome of breast cancer patients with 1–3 positive lymph nodes with special emphasis on late toxicity rates.

Patients and methods

Between 1997 and 2000, 235?breast cancer patients (T1–2, 1–3 involved lymph nodes) were treated at our department following breast conservative surgery: 139?patients (59.1%) had one, 62?patients (26.4%) two, and 34?patients (14.5%) three positive lymph nodes. Extracapsular spread (ECS) was described in 72?patients (30.6%). There were 67?patients (28.5%) who received additional radiotherapy to the ipsilateral periclavicular lymph nodes (PCLNI), while 168?patients did not (noPCLNI). Patients were re-examined or contacted by phone with regard to treatment-related late effects.

Results

After a median follow-up of 78?months (range 7–107?months), 22?patients (9.4%) developed local, 9?(3.8%) axillary, 4?periclavicular (1.7%), and 41?distant failure (17.4%). The actuarial 8-year locoregional recurrence-free (LRRFS), disease-free (DFS), and overall survival rates (OS) were 83%, 67%, and 74%, respectively. Survival data for the PCLNI vs. noPCLNI group were 72% vs. 89% (p?=?0.3), 56% vs. 73% (p?=?0.4), and 86% vs. 70% (p?=?0.3), respectively. No higher toxicity rates were reported in the PCLNI group compared to the noPCLNI group.

Conclusion

We could not demonstrate any difference in outcome in breast cancer patients with 1–3 positive axillary lymph node metastases with or without periclavicular lymph node irradiation. In addition, patients with PCLNI did not complain about higher rates of late toxicities. However, patients with ECS, which may predict for locoregional failure, may benefit from adjuvant periclavicular irradiation.     

Does high-dose radiotherapy benefit palliative lung cancer patients?

Background and purpose

The present analysis compares two palliative treatment concepts for lung cancer in terms of overall survival.

Patients and methods

Survival data from 207 patients were used in a retrospective analysis. All patients received palliative treatment comprising either 25 Gy applied in 5 fractions or 50 Gy in 20 fractions. A subgroup analysis was performed to compare patients with a good–fair vs. poor overall condition.

Results

Median survival times were 21 weeks (range 6–26 weeks) for patients treated with 25 Gy in 5 fractions and 23 weeks (range 14.5–31.5 weeks) for patients treated with 50 Gy in 20 fractions (95?% confidence interval, CI; p?=?0.334). For patients with a good–fair overall condition, median survival times were 30 weeks (21.8–39.2 weeks) for 25 Gy in 5 fractions and 28 weeks (14.2–41.8 weeks) for 50 Gy in 20 fractions (CI 95?%, p?=?0.694). In patients with a poor overall condition, these values were 18 weeks (14.5–21.5 weeks) and 21 weeks (13.0–29.0 weeks), respectively (CI 95?%, p?=?0.248).

Conclusion

The palliative treatment concept of 25 Gy applied in 5 fractions is sufficient for radiation of lung cancer, given that there was no obvious survival improvement in patients treated with the higher total dose regimen.     

Short-term imaging follow-up of patients with concordant benign breast core needle biopsies: is it really worth it?

PURPOSE

Women with histologically proven concordant benign breast disease are often followed closely after biopsy for a period of two years, and they are considered to be at high-risk for cancer development. Our goal was to evaluate the utility of short-term (six-month) imaging follow-up and determine the incidence of breast cancer development in this population.

METHODS

Retrospective review of concordant benign breast pathology was performed in 558 patients who underwent multi-modality breast core biopsy. A total of 339 patients (60.7%) with 393 biopsies qualified for the study. The six-, 12-, and 24-month incidence rates of breast cancer development were estimated with 95% confidence intervals (CI), using the exact method binomial proportions.

RESULTS

No cancer was detected in 285 of 339 patients (84.1%) returning for the six-month follow-up. No cancer was detected in 271 of 339 patients (79.9%) returning for the 12-month follow-up. Among 207 follow-up exams (61.1%) performed at 24 months, three patients were detected to have cancer in the ipsilateral breast (1.45% [95% CI, 0.30%–4.18%]) and two patients were detected to have cancer in the contralateral breast (0.97% [95% CI, 0.12%–3.45%]). Subsequent patient biopsy rate was 30 of 339 (8.85%, [95% CI, 6.05%–12.39%]). Three ipsilateral biopsies occurred as a sole result of the six-month follow-up of 285 patients (1.05%, [95% CI, 0.22%–3.05%]).

CONCLUSION

Short-term imaging follow-up did not contribute to improved breast cancer detection, as all subsequent cancers were detected on annual mammography. Annual diagnostic mammography after benign breast biopsy may be sufficient.According to the American Cancer Society, an estimated 232 340 new cases of breast cancer are expected to occur in women in the year 2013, making breast cancer the most commonly diagnosed cancer in women (1). A few of the factors which increase a woman’s risk of breast cancer include age, menopausal status, family history, age at first live birth, and history of benign breast disease diagnosed on core needle biopsy or at surgical excisional biopsy (2, 3).Approximately 1.5 million breast biopsies are performed annually (4, 5), and approximately 75% of these biopsies yield benign histology (6). Percutaneous image-guided core needle biopsy is routinely performed as an accurate alternative to surgical biopsy for obtaining a histological diagnosis of breast lesions (7). Many concordant benign lesions on core biopsy are closely followed after biopsy to evaluate for stability and to avoid any delay in diagnosis of a possible false-negative biopsy (7–11). This follow-up incurs additional cost, radiation, and patient anxiety, with questionable added clinical benefit.Follow-up imaging protocols after concordant benign breast biopsy vary by institution, and no standard follow-up imaging guidelines for concordant benign lesions have been established (12, 13). The 2010 and 2013 consensus guidelines published by the National Comprehensive Cancer Network (NCCN) recommend follow-up diagnostic imaging and physical exam every 6–12 months for 1–2 years following a concordant benign core needle biopsy, prior to releasing these women back into the general screening population (14). It remains unclear what the appropriate clinical breast exam/imaging schedule should be during those two years, and more importantly, whether this intensive two-year follow-up protocol is of clinical benefit. The goal of this study was to retrospectively examine the utility of our institutional protocol of six-, 12- and 24-month imaging follow-up after concordant benign breast biopsy. We examined the incidence of interval development of bilateral breast cancer in women with histologically proven, concordant benign breast disease with and without atypia. We also evaluated the number of subsequent benign biopsies performed on these women in either breast during the two-year follow-up period, and those that occurred solely as a result of additional follow-up.     

DEGRO practical guidelines: radiotherapy of breast cancer I

Background and purpose

The aim of the present paper is to update the practical guidelines for postoperative adjuvant radiotherapy of breast cancer published in 2007 by the breast cancer expert panel of the German Society for Radiooncology (Deutsche Gesellschaft für Radioonkologie, DEGRO). The present recommendations are based on a revision of the German interdisciplinary S-3 guidelines published in July 2012.

Methods

A comprehensive survey of the literature concerning radiotherapy following breast conserving therapy (BCT) was performed using the search terms “breast cancer”, “radiotherapy”, and “breast conserving therapy”. Data from lately published meta-analyses, recent randomized trials, and guidelines of international breast cancer societies, yielding new aspects compared to 2007, provided the basis for defining recommendations according to the criteria of evidence-based medicine. In addition to the more general statements of the DKG (Deutsche Krebsgesellschaft), this paper addresses indications, target definition, dosage, and technique of radiotherapy of the breast after conservative surgery for invasive breast cancer.

Results

Among numerous reports on the effect of radiotherapy during BCT published since the last recommendations, the recent EBCTCG report builds the largest meta-analysis so far available. In a 15 year follow-up on 10,801 patients, whole breast irradiation (WBI) halves the average annual rate of disease recurrence (RR 0.52, 0.48–0.56) and reduces the annual breast cancer death rate by about one sixth (RR 0.82, 0.75–0.90), with a similar proportional, but different absolute benefit in prognostic subgroups (EBCTCG 2011). Furthermore, there is growing evidence that risk-adapted dose augmentation strategies to the tumor bed as well as the implementation of high precision RT techniques (e.g., intraoperative radiotherapy) contribute substantially to a further reduction of local relapse rates. A main focus of ongoing research lies in partial breast irradiation strategies as well as WBI hypofractionation schedules. The potential of both in replacing normofractionated WBI has not yet been finally clarified.

Conclusion

After breast conserving surgery, no subgroup even in low risk patients has yet been identified for whom radiotherapy can be safely omitted without compromising local control and, hence, cancer-specific survival. In most patients, this translates into an overall survival benefit.     

DEGRO practical guidelines: radiotherapy of breast cancer II

Purpose

To complement and update the 2007 practice guidelines of the breast cancer expert panel of the German Society of Radiation Oncology (DEGRO) for radiotherapy (RT) of breast cancer. Owing to its growing clinical relevance, in the current version, a separate paper is dedicated to non-invasive proliferating epithelial neoplasia of the breast. In addition to the more general statements of the German interdisciplinary S3 guidelines, this paper is especially focused on indication and technique of RT in addition to breast conserving surgery.

Methods

The DEGRO expert panel performed a comprehensive survey of the literature comprising recently published data from clinical controlled trials, systematic reviews as well as meta-analyses, referring to the criteria of evidence-based medicine yielding new aspects compared to 2005 and 2007. The literature search encompassed the period 2008 to September 2012 using databases of PubMed and Guidelines International Network (G-I-N). Search terms were “non invasive breast cancer”, “ductal carcinoma in situ, “dcis”, “borderline breast lesions”, “lobular neoplasia”, “radiotherapy” and “radiation therapy”. In addition to the more general statements of the German interdisciplinary S3 guidelines, this paper is especially focused on indications of RT and decision making of non-invasive neoplasia of the breast after surgery, especially ductal carcinoma in situ.

Results

Among different non-invasive neoplasia of the breast only the subgroup of pure ductal carcinoma in situ (DCIS; synonym ductal intraepithelial neoplasia, DIN) is considered for further recurrence risk reduction treatment modalities after complete excision of DCIS, particularly RT following breast conserving surgery (BCS), in order to avoid a mastectomy. About half of recurrences are invasive cancers. Up to 50?% of all recurrences require salvage mastectomy. Randomized clinical trials and a huge number of mostly observational studies have unanimously demonstrated that RT significantly reduces recurrence risks of ipsilateral DCIS as well as invasive breast cancer independent of patient age in all subgroups. The recommended total dose is 50 Gy administered as whole breast irradiation (WBI) in single fractions of 1.8 or 2.0 Gy given on 5 days weekly. Retrospective data indicate a possible beneficial effect of an additional tumor bed boost for younger patients. Prospective clinical trials of different dose–volume concepts (hypofractionation, accelerated partial breast irradiation, boost radiotherapy) are still ongoing.

Conclusion

Postoperative radiotherapy permits breast conservation for the majority of women by halving local recurrence as well as reducing progression rates into invasive cancer. New data confirmed this effect in all patient subsets—even in low risk subgroups (LoE 1a).     

Contrast-enhanced power Doppler US: is it useful in the differentiation of gallbladder disease?

Thirteen patients with gallbladder disease underwent power Doppler ultrasound (PDUS) before and after microbubble contrast agent injection. Lesion and liver bed vascularity was evaluated. Pathological diagnoses in nine patients were two acute cholecystitis, four chronic inflammation, one adenoma and two adenocarcinoma. Two cases of cancer were included on clinical and radiological findings. Two cases were excluded because no pathologic diagnosis was available. Liver bed hyperemia was noted only in acute cholecystitis. Contrast-enhanced PDUS was superior to nonenhanced PDUS in the demonstration of vascularity of gallbladder diseases. However, contrast-enhanced PDUS has limited value in the differentiation.     

Monitoring neoadjuvant chemotherapy in breast cancer patients: Improved MR assessment at 3 T?

Purpose:

To investigate possible improvements in predicting the response to neoadjuvant chemotherapy (NAC) at 3 T for locally advanced breast cancer (LABC).

Materials and Methods:

Dynamic contrast‐enhanced magnetic resonance (DCE‐MR) images acquired before and during NAC were retrospectively analyzed in 85 patients. Tumor volume and diameter, three volumes based on the shape of the enhancement curve, relative signal intensity, area under the curve, and the signal‐to‐noise ratio were extracted. Differences between responders and nonresponders at the same and between MR timepoints during treatment were evaluated.

Results:

A higher signal‐to‐noise ratio was observed on 3 T images compared to 1.5 T, and 3 T revealed more significant findings related to response compared to 1.5 T. The DCE‐MRI‐derived volume parameters were the earliest predictors of response at both 1.5 and 3 T.

Conclusion:

Our results show that 3 T provides an improved assessment of the response to NAC in LABC patients, where the MR determined tumor volume reduction before the second cycle of NAC was the strongest and earliest predictor of a response. J. Magn. Reson. Imaging 2011;. © 2011 Wiley‐Liss, Inc.     

Is it essential to use fiducial markers during cone-beam CT-based radiotherapy for prostate cancer patients?

Purpose

To compare soft-tissue cone-beam computed tomography (CBCT-P) and fiducial marker (CBCT-FM)-based image guided radiotherapy in prostate cancer patients.

Materials and methods

Sixteen prostate cancer patients were treated with volumetric modulated arc therapy. Manual alignment using CBCT-P and CBCT-FM was performed for each patient. Couch shifts were calculated and compared between methods in the left–right (x), superior–inferior (y), and anterior–posterior (z) directions.

Results

CBCT-P and CBCT-FM alignments were compared using 252 scans from the 16 patients. Mean displacement from zero was 2.4 ± 1.3, 1.7 ± 1.2, and 1.8 ± 1.1 mm for CBCT-P and 2.3 ± 1.3, 1.7 ± 1.1 and 1.8 ± 1.1 mm for CBCT-FM in the x, y and z directions, respectively. There was no difference in median displacement between CBCT-P and CBCT-FM; however, there was a significant positive correlation between CBCT-P- and CBCT-FM-based displacements in the x (r = 0.881; p < 0.001), y (r = 0.789; p < 0.001) and z (r = 0.856; p < 0.001) directions by linear regression analysis. Systematic deviations within each group were <1 mm; however, random and systematic errors were similar in the x and y directions but larger in the z direction.

Conclusion

Our study demonstrated that CBCT-FM was not superior to CBCT-P for image-guided radiotherapy in prostate cancer patients.