Embolisation of hypervascular bone tumours: A pictorial essay with literature review

Bone tumours, either primary or secondary, can present in various debilitating manners, including pain and pathological fracture. The situation is particularly problematic when the tumours are hypervascular, and located in regions where a high risk of neurological compromise is anticipated during operation, such as in the spine or sacrum. In such situations, bone tumour embolisation is a useful and effective adjunctive treatment for reducing intra‐operative blood loss. This is particularly relevant in primary bone tumours such as giant cell tumours and metastatic renal cell and thyroid tumours. With a proper pre‐embolisation angiogram and knowledge of anatomy, careful selective cannulation of the arterial supplies and experience in using embolic agents, the risks of non‐target embolisation can be kept to minimum and the best result achieved.     

Malignant chondroid syringoma of the skin: Magnetic resonance imaging features

Skin tumours are usually divided into melanoma and non‐melanoma types. Malignancies of the adnexal structures, of which sweat gland tumours are an example, are characterized under the non‐melanoma types. Sweat gland malignancies are rare tumours that are usually associated with a poor prognosis. Given the rarity of these tumours, MRI findings of such tumours have not been described previously in the literature. We present a case report of an unusual malignant tumour of sweat gland origin known as a malignant chondroid syringoma of the skin with described MRI features. The MRI features are non‐specific depicting intermediate signal intensity, changes on the proton density sequence and increased signal on the T2 and STIR‐weighted sequences. Although these imaging features are characteristic of most soft tissue masses MRI can, in most cases, accurately depict the anatomic extent and identify tissue of origin, depth of invasion and relation to adjacent structures, such as muscles and bones. Thus high‐resolution MRI of the skin in the future can be extremely helpful in characterizing and staging dermal neoplasms.     

Musculoskeletal desmoid tumours: Pre‐ and post‐treatment radiological appearances

This study was aimed to illustrate the pre‐ and post‐treatment imaging findings of musculoskeletal desmoid tumours and describe current treatment methods. Imaging of histologically proven cases of desmoid tumours at St. Vincent's Hospital, Melbourne, were obtained via picture archiving communication system (PACS) and then assessed by two musculoskeletal radiologists. Suitable imaging both pre‐ and post‐treatment were then obtained from PACS. All imaging chosen were de‐identified. Ninety‐two patients were found to have histologically proven cases of desmoid tumours between January 2000 and December 2013. Six patients with extra‐abdominal tumours were selected, where pre‐ and post‐treatment imaging was available. Desmoid tumours can occur in many areas of the body. Treatment of desmoids are varied. Although wide‐margin surgery has been the traditional form of treatment, it still cannot guarantee absence of tumour recurrence despite microscopically tumour‐free margins. Other forms of treatment such as non‐steroidal anti‐inflammatory drugs, radiotherapy, chemotherapy, tyrosine kinase inhibitors and also the conservative ‘watch and wait’ approach have been suggested, which show varying results.     

Histological subtypes of ovarian cancer associated with parity and breastfeeding in the prospective Million Women Study

Ovarian cancer risk is known to be reduced amongst women who have had children, but reported associations with breastfeeding are varied. Few studies have had sufficient power to explore reliably these associations by tumour histotype. In a prospective study of 1.1 million UK women, 8719 developed ovarian cancer during follow‐up. Cox regression yielded adjusted relative risks (RRs) overall and by tumour histotype amongst women with different childbearing patterns. Nulliparous women had a 24% greater ovarian cancer risk than women with one child, with significant heterogeneity by histotype (p = 0.01). There was no significant increase in serous tumours, a modest increase in mucinous tumours, but a substantial increase in endometrioid (RR = 1.49, 95% CI: 1.18‐1.89) and clear‐cell tumours (RR = 1.68, 1.29‐2.20). Among parous women, each additional birth was associated with an overall 6% reduction in ovarian cancer risk; this association also varied by histotype (p = 0.0006), with the largest reduction in risk for clear‐cell tumours (RR per birth = 0.75, 0.65‐0.85, p < 0.001) and weak, if any, effect for endometrioid, high‐grade serous, or mucinous tumours. We found little association with age at first or last birth. There was about a 10% risk reduction per 12‐months breastfeeding (RR = 0.89, 0.84‐0.94, p < 0.001), with no significant heterogeneity by histotype, but statistical power was limited. In this large prospective study, ovarian cancer risk associated with parity varied substantially by tumour histotype. Nulliparity was associated with a substantially greater overall risk than expected from the effect of a single birth, especially for clear cell and endometrioid tumours, perhaps suggesting that infertility is associated with these histotypes.     

Androgen deprivation results in time‐dependent hypoxia in LNCaP prostate tumours: Informed scheduling of the bioreductive drug AQ4N improves treatment response

Androgen withdrawal induces hypoxia in androgen‐sensitive tissue; this is important as in the tumour microenvironment, hypoxia is known to drive malignant progression. Our study examined the time‐dependent effect of androgen deprivation therapy (ADT) on tumour oxygenation and investigated the role of ADT‐induced hypoxia on malignant progression in prostate tumours. LNCaP xenografted tumours were treated with anti‐androgens and tumour oxygenation measured. Dorsal skin fold (DSF) chambers were used to image tumour vasculature in vivo. Quantitative PCR (QPCR) identified differential gene expression following treatment with bicalutamide. Bicalutamide‐treated and vehicle‐only‐treated tumours were re‐established in vitro, and invasion and sensitivity to docetaxel were measured. Tumour growth delay was calculated following treatment with bicalutamide combined with the bioreductive drug AQ4N. Tumour oxygenation measurements showed a precipitate decrease following initiation of ADT. A clinically relevant dose of bicalutamide (2 mg/kg/day) decreased tumour oxygenation by 45% within 24 hr, reaching a nadir of 0.09% oxygen (0.67 ± 0.06 mmHg) by Day 7; this persisted until Day 14 when it increased up to Day 28. Using DSF chambers, LNCaP tumours treated with bicalutamide showed loss of small vessels at Days 7 and 14 with revascularisation occurring by Day 21. QPCR showed changes in gene expression consistent with the vascular changes and malignant progression. Cells from bicalutamide‐treated tumours were more malignant than vehicle‐treated controls. Combining bicalutamide with AQ4N (50 mg/kg, single dose) caused greater tumour growth delay than bicalutamide alone. Our study shows that bicalutamide‐induced hypoxia selects for cells that show malignant progression; targeting hypoxic cells may provide greater clinical benefit.     

Prognosis of early breast cancer by immunohistochemistry defined intrinsic sub‐types in patients treated with adjuvant chemotherapy in the NEAT/BR9601 trial

Breast cancer can be classified into molecular sub‐types that have distinct survival patterns. We evaluated the prognostic significance of breast cancer sub‐types in a cohort of women taking part in the NEAT and BR9601 clinical trials comparing cyclophosphamide, methotrexate and fluorouracil (CMF) with ECMF (epirubicin and CMF). Furthermore, we evaluated whether the sub‐types were predictive of the added benefit of epirubicin in these trials. Tumour tissue microarrays were stained and scored for ER, PR, HER2, EGFR and CK5/6. These were used to classify the tumours into six intrinsic sub‐types. We used Cox regression to compare overall survival (OS), breast cancer‐specific survival (BCSS) and relapse‐free survival (RFS) in the different sub‐groups. We also compared the effect of ECMF with CMF by sub‐group. Immunohistochemistry data were available for 1,725 cases of whom 805 were luminal 1‐basal negative. Median follow‐up time was 7 years. The luminal 1‐basal negative tumours were associated with the best prognosis in five years after surgery and the HER2‐like tumours were associated with the poorest prognosis. There was little evidence for significant heterogeneity of this effect by tumour sub‐type (OS p = 0.40, BCSS p = 0.53 RFS p = 0.50) – the largest additional benefit of epirubicin was in women with tumours of the 5‐negative phenotype (OS HR = 0.39 95% CI: 0.21–0.73) and the smallest was in Luminal 1‐basal negative tumours (OS HR = 0.86 95% CI: 0.64–1.16). We confirmed that breast cancer sub‐types show distinct behaviour with differences in short‐ and long‐term survival. The benefit of ECMF over CMF was statistically similar in all disease sub‐types.     

Stage at diagnosis is a key explanation of differences in breast cancer survival across Europe

We used multiple regression models to assess the influence of disease stage at diagnosis on the 5‐year relative survival of 4,478 patients diagnosed with breast cancer in 1990–1992. The cases were representative samples from 17 population‐based cancer registries in 6 European countries (Estonia, France, Italy, Netherlands, Spain and UK) that were combined into 9 regional groups based on similar survival. Five‐year relative survival was 79% overall, varying from 98% for early, node‐negative (T1N0M0) tumours; 87% for large, node‐negative (T2‐3N0M0) tumours; 76% for node‐positive (T1‐3N+M0) tumours and 55% for locally advanced (T4NxM0) tumours to 18% for metastatic (M1) tumours and 69% for tumours of unspecified stage. There was considerable variation across Europe in relative survival within each disease stage, but this was least marked for early node‐negative tumours. Overall 5‐year relative survival was highest in the French group of Bas‐Rhin, Côte d'Or, Hérault and Isère (86%), and lowest in Estonia (66%). These geographic groups were characterised by the highest and lowest percentages of women with early stage disease (T1N0M0: 39% and 9%, respectively). The French, Dutch and Italian groups had the highest percentage of operated cases. The number of axillary nodes examined, a factor influencing nodal status, was highest in Italy and Spain. After adjusting for TNM stage and the number of nodes examined, survival differences were greatly reduced, indicating that for these women, diagnosed with breast cancer in Europe during 1990–1992, the survival differences were mainly due to differences in stage at diagnosis. However, in 3 regional groups, the relative risks of death remained high even after these adjustments, suggesting less than optimal treatment. Screening for breast cancer did not seem to affect the survival patterns once stage had been taken into account. © 2003 Wiley‐Liss, Inc.     

Impact of clinicopathological characteristics on the efficacy of neoadjuvant therapy in patients with human epidermal growth factor receptor‐2‐positive breast cancer

Neoadjuvant therapy has become increasingly common in human epidermal growth factor receptor‐2 (HER2)‐positive breast cancer. In this study, we examined the impact of different clinicopathological characteristics on pathological complete response (pCR) in patients treated with anti‐HER2 agents. The PubMed and Embase databases were searched from inception through April 2017 to identify studies that met pre‐specified criteria. The odds ratios (ORs) and 95% confidence intervals (CIs) were extracted directly or were calculated with other available information. Eleven randomized controlled trials (RCTs) that involved 3,269 HER2‐positive women were included in this meta‐analysis. Patients with hormone receptor (HR)‐negative breast cancer benefited more from anti‐HER2 therapy than did patients with HR‐positive tumours (OR, 2.25; 95% CI, 1.93‐2.62). Furthermore, this improvement in pCR was independent of anti‐HER2 agents, phase, combined chemotherapy, neoadjuvant duration, year the trials started and region where the trials were conducted. Patients with small tumours achieved greater benefits than patients with large tumours (OR, 1.25; 95% CI, 1.00‐1.55). Age did not predict an additional benefit from anti‐HER2 neoadjuvant treatment (OR, 1.02; 95% CI, 0.73‐1.45). The impact of nodal status on pCR was dependent on the anti‐HER2 agents. In conclusion, for HER2‐targeted neoadjuvant treatment in breast cancer, greater benefits were achieved in patients with small HR‐negative tumours compared with patients with large HR‐positive tumours. These results may improve drug development and treatment strategies, economic analyses and the design and interpretation of clinical trials.     

An unusual case of extra‐abdominal desmoid tumour

ZAMPIERI N., CECCHETTO M., ZORZI M.G., PIETROBELLI A., OTTOLENGHI A. & CAMOGLIO F. (2010) European Journal of Cancer Care 19 , 410–412
An unusual case of extra‐abdominal desmoid tumour Desmoid tumour is relatively rare and generally non‐metastatisizing lesion of mesenchymal origin composed of fibrous tissue and fitting in the group of aggressive fibromatosis; it is a locally aggressive proliferative soft‐tissue lesion with controversial nature. This tumour accounts for 0.03% of all tumours and 3% of soft‐tissue tumours with annual incidence of two to four cases per million. Although desmoid tumours are more common in persons aged 10–40 years than in others, they do occur in young children and older adults; in children the sex incidence is equal. This is a rare case of extra‐abdominal desmoid tumour in a 14‐year‐old girl affected by spastic tetraparesis. To our knowledge no similar cases are present in literature to date.     

Cystic lumbar nerve sheath tumours: MRI features in five patients

Intraspinal cystic lumbar nerve sheath tumours constitute an uncommon subset of tumours with distinct clinico‐biological behaviour. The MRI findings in five such cases are presented. Four of these were cystic schwannomas and one was a cystic neurofibroma. The pathology, MRI findings and the differential diagnosis of these rare tumours are analysed.     

Stage IV breast cancer: a population‐based study about prognostic factors according to HER2 and HR status

We aim to describe trends in net survival (NS) and to assess the prognostic factors among women with de novo metastatic breast cancer (MBC) according to human epidermal growth factor receptor 2 (HER2) and hormone receptor (HR) status. Data on women suffering from de novo MBC and diagnosed from 1998 to 2009 were provided by the Côte‐d'Or breast cancer registry. NS was described using the Pohar Perme estimator and prognostic factors were investigated in a generalised linear model. We identified 232 patients (mean age = 64.7). Median NS was 29.2 months, 1‐ and 5‐year NS were 76% and 26% respectively. The survival trend in patients with HER2‐positive tumours who did not receive trastuzumab was similar to that in women with triple‐negative tumours. A higher relative excess risk of death by cancer was observed for high‐grade tumours [RER, relative excess rates = 1.76 (95% CI, confidence intervals: 1.17–2.62) for Scarff Bloom Richardson grade 3 vs. 1 + 2], while a lower risk was observed for luminal tumours [RER = 0.49 (95% CI: 0.27–0.89)] and HER2‐positive tumours treated with trastuzumab [RER = 0.28 (95% CI: 0.14–0.59)], both compared with triple‐negative tumours. Surgery of the primary tumour was associated with better survival [RER = 0.43 (95% CI: 0.28–0.68)]. With half of the women dead before 29 months, stage IV breast cancer still has a bleak outlook. Progress should continue with new target therapies for both HR and HER2 receptors.     

Imaging evaluation of treated benign bone tumours

A number of benign bone tumours can be treated with curettage and packing with either bone cement or graft. It is essential that the radiologist be familiar with both the normal and abnormal post‐operative imaging appearance of these treated tumours. Through the use of numerous imaging examples, we aim to provide a pictorial review of the expected post‐operative appearance of benign bone tumours treated with curettage and packing, as well as the imaging features of recurrence, the most common potential complication.     

Percutaneous radiofrequency ablation for malignant liver tumours in challenging locations

Purpose: To evaluate the treatment results of radiofrequency ablation (RFA) for primary and metastatic malignant liver tumours in challenging locations and also to present the treatment strategy that was used in these cases. Patients and Methods: From January 2007 to January 2010, we performed CT‐guided RFA on 528 lesions in 402 patients (265 men and 137 women; mean age 65.1 years, range 19–82 years) with liver tumours (primary and metastatic) of which 98 lesions in 84 patients (55 men and 29 women; mean age 67.8 years, range 33–82 years) were located in challenging locations, defined as less than 5 mm from a large vessel or an extrahepatic organ (heart, lung, gall bladder, right kidney or gastrointestinal tract). The sizes of the tumours ranged 1.5–6 cm. We used two different RFA systems with an expandable needle electrode (RITA; Rita Medical Systems, Inc, Mountain View, CA, USA and MIRAS; Invatec S.r.l., Roncadelle, Italy).The tumours were considered as ablated completely if no viability was found on dual‐phase dynamic contrast‐enhanced CT at 1 month after RFA. Results: Complete ablation was obtained in 89.7% (88/98) of the high‐risk located lesions, while 10 (10.3%) of the lesions were managed with repeated RFA because of tumour residue. The 1‐, 2‐ and 3‐year survival rates were 82.6, 67.3 and 54.1%, respectively. Minor complications occurred in eight of the 84 patients (9.5%), including small sub‐capsular haematoma in four, small pleural effusion in three and partial liver infarction in one. Local tumour progression rate was 9.2% (9/98). Conclusion: RFA is a safe and effective method of treatment of primary and metastatic liver tumours even located in challenging locations when performed by a well‐trained and experienced interventional radiologist.     

Would you bet on PET? Evaluation of the significance of positive PET scan results post‐microwave ablation for non‐small cell lung cancer

Fluodeoxyglucose‐positron emission tomography (FDG‐PET) imaging is an acknowledged modality for the follow‐up of solid tumours treated with thermal ablation, with persistent or new FDG uptake at the ablation site considered to be a reliable indicator of local recurrence. Several cases of proven false‐positive FDG‐PET scans are illustrated in this pictorial essay with uptake at the site of the ablated tumour, remote from the ablated lesion and in mediastinal and hilar lymph nodes. Positive FDG‐PET scans post‐thermal ablation of lung tumours therefore cannot always reliably predict local tumour recurrence or nodal spread. It is important to be familiar with FDG uptake patterns post‐ablation and their significance. FDG‐PET avid lesions post‐ablation may require histological confirmation before further therapy is planned or management is changed.     

High management impact of Ga-68 DOTATATE (GaTate) PET/CT for imaging neuroendocrine and other somatostatin expressing tumours

Introduction: Ga‐68 DOTATATE (Ga‐octreotate, GaTate) positron emission tomography (PET)/CT has multiple advantages compared with conventional and In‐111 octreotide imaging for neuroendocrine tumours and other somatostatin‐receptor expressing tumours. This study assesses the management impact of incremental diagnostic information obtained from this technique compared with conventional staging. Methods: Fifty‐nine GaTate PET/CT studies were performed over an 18‐month period (52 proven or suspected gastro‐entero‐pancreatic or bronchial neuroendocrine tumours and seven neural crest/mesenchymal tumours). A retrospective blinded review was performed on the number of abnormalities (1, 2–5 or >5) within defined regions with comparison to conventional imaging to assess incremental diagnostic information. Subsequent management impact (high, moderate or low) was determined by clinical review and follow up to assess pre‐PET stage, treatment intent and post‐PET management change. Results: Eighty‐eight percent of GaTate studies were abnormal. Compared with conventional and In‐111 octreotide imaging, additional information was provided by GaTate PET/CT in 68 and 83% of patients, respectively. Management impact was high (inter‐modality change) in 47%, moderate (intra‐modality change) in 10% and low in 41% (not assessable in 2%). High management impact included directing patients to curative surgery by identifying a primary site and directing patients with multiple metastases to systemic therapy. Conclusion: GaTate PET/CT imaging provides additional diagnostic information in a high proportion of patients with consequent high management impact. GaTate PET/CT could replace ¹In‐111 octreotide scintigraphy at centres where it is available given its superior accuracy, faster acquisition and lower radiation exposure. Rapid implementation could be achieved by allowing substitutional funding in the Medicare Benefit Schedule.     

Preoperative embolization of a large vaginal leiomyoma: Report of a case and review of the literature

Leiomyoma of the vagina is a very rare tumour of the lower urogenital tract. These slow‐growing masses may be asymptomatic or present with pain, dyspareunia or urinary symptoms. Rarely, these tumours may present with life‐threatening haemorrhage. These hypervascular tumours are treated by surgical excision. Preoperative embolization therefore may aid in devascularization of these tumours before surgical excision. We present the MRI features of a case of vaginal leiomyoma, which was managed by preoperative embolization and was then excised in toto. To the best of our knowledge, this is the first report where preoperative embolization was performed before excision of a vaginal leiomyoma with minimal peroperative blood loss.     

Ultrasound of soft‐tissue masses: Pitfalls in interpretation

A review of 43 patients with soft‐tissue tumours identified from a tumour registry showed a 23% rate of incorrect initial diagnosis by ultrasound imaging. Seven patients, five with malignant tumours, suffered a delay in diagnosis (ranging up to 6 months) as a result. The most common error was to mistake a solid tumour for a haematoma. Caution is recommended in the interpretation of ultrasound of soft‐tissue masses, particularly with regard to the erroneous diagnosis of haematoma.     

Bladder pheochromocytoma encountered on sonography

Pheochromocytomas of the bladder are rare neoplasms, constituting <0.06% of all vesical tumours. Common presenting features of this tumour include episodes of sweating, hypertension, haematuria and postmicturition syncope. We describe a case of bladder pheochromocytoma in a 66‐year‐old man whose only symptom of macroscopic haematuria was initially assessed with ultrasonography. Clinical presentation highlights the need for a high index of suspicion during sonographic evaluation of bladder neoplasms because such tumours might present without symptoms of adrenergic excess.