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Conditions that lead to small bowel mural thickening fall into a broad spectrum of diseases, including inflammatory, infectious, vascular or neoplastic. Computed tomography (CT) and Magnetic Resonance Imaging (MRI), especially CT-enterography and MR-enterography, permit evaluation of both entire small bowel and extraluminal structures. In CT/MR-enterography, the main prerequisite for the correct evaluation of small bowel is to obtain optimal intestinal distension. In fact, most errors are related to poor intestinal distension of the bowel which can lead to interpret as pathological a small bowel segment that is not very distended (false positive), or not to recognize presence of pathology in a collapsed segment (false negative). Once the examination has been performed, the images are analyzed in order to identify the presence of small bowel pathology. Pathology of the small bowel can manifest as endoluminal alteration and/or intestinal wall thickening. Once bowel wall thickening has been identified, the radiologist's first objective is trying to define benign or malignant nature of the alteration, using also patient's history and clinical features. Once the suspicion of benign or malignant pathology has been raised, the radiologist must try to formulate a diagnosis of nature. In this pictorial review we describe how the radiologist must reason for a correct diagnosis by answering a pattern of sequential questions in a patient with suspected small bowel disease studied by CT or MRI. (c) 2023 Published by Elsevier Inc.

Simple Summary Early prediction of response to cancer therapies is critical for treatment personalisation. In patients with locally advanced rectal cancer (LARC) undergoing neoadjuvant chemoradiation therapy (nCRT), delta radiomics applied to mesorectal features could potentially lead to the development of predictive models of treatment response. Pre- and post-treatment MRIs of patients treated at a single institution were analysed. Radiomic features of the mesorectum and GTV were extracted and predictive models of pathological complete response (pCR) and two-year disease-free survival (2yDFS) were developed. In 203 patients with LARC, a total of 565 variables were evaluated; the best performing 2yDFS prediction model was based on one GTV and two mesorectal features with an AUC of 0.79 in the training set and 0.70 in the validation set. The mesorectum may contain important radiomics information for predicting response to nCRT treatment in LARC patients. Background: The aim of this study is to evaluate the delta radiomics approach based on mesorectal radiomic features to develop a model for predicting pathological complete response (pCR) and 2-year disease-free survival (2yDFS) in locally advanced rectal cancer (LARC) patients undergoing neoadjuvant chemoradiotherapy (nCRT). Methods: Pre- and post-nCRT MRIs of LARC patients treated at a single institution from May 2008 to November 2016 were retrospectively collected. Radiomic features were extracted from the GTV and mesorectum. The Wilcoxon-Mann-Whitney test and area under the receiver operating characteristic curve (AUC) were used to evaluate the performance of the features in predicting pCR and 2yDFS. Results: Out of 203 LARC patients, a total of 565 variables were evaluated. The best performing pCR prediction model was based on two GTV features with an AUC of 0.80 in the training set and 0.69 in the validation set. The best performing 2yDFS prediction model was based on one GTV and two mesorectal features with an

Conditions that lead to small bowel mural thickening fall into a broad spectrum of diseases, including inflammatory, infectious, vascular or neoplastic. Computed tomography (CT) and Magnetic Resonance Imaging (MRI), especially CT-enterography and MR-enterography, permit evaluation of both entire small bowel and extraluminal structures. In CT/MR-enterography, the main prerequisite for the correct evaluation of small bowel is to obtain optimal intestinal distension. In fact, most errors are related to poor intestinal distension of the bowel which can lead to interpret as pathological a small bowel segment that is not very distended (false positive), or not to recognize presence of pathology in a collapsed segment (false negative). Once the examination has been performed, the images are analyzed in order to identify the presence of small bowel pathology. Pathology of the small bowel can manifest as endoluminal alteration and/or intestinal wall thickening. Once bowel wall thickening has been identified, the radiologist's first objective is trying to define benign or malignant nature of the alteration, using also patient's history and clinical features. Once the suspicion of benign or malignant pathology has been raised, the radiologist must try to formulate a diagnosis of nature. In this pictorial review we describe how the radiologist must reason for a correct diagnosis by answering a pattern of sequential questions in a patient with suspected small bowel disease studied by CT or MRI. (c) 2023 Published by Elsevier Inc.

Design: Neoadjuvant chemoradiotherapy (nCRT) followed by surgery is the standard of care for locally advanced rectal cancer (LARC). Several studies have shown a correlation between a longer interval between the end of nCRT and surgery (surgical interval -SI) and an increased pathological complete response (pCR) rate, with a maximum obtained between 10 and 13 weeks. The primary endpoint of this multicenter, 2-arm randomised trial is to investigate SI lengthening, evaluating the difference in terms of complete response (CR) and Tumor Regression Grade (TRG)1 rate in the two arms. Secondly, the impact of SI lengthening on survival outcomes and quality of life (QoL) will be investigated. Methods: Intermediate-risk LARC patients undergoing nCRT will be prospectively included in the study. nCRT will be administered with a total dose of 55 Gy in 25 fractions on Gross Tumor Volume (GTV) plus the corresponding mesorectum of 45 Gy in 25 fractions on the whole pelvis. Chemotherapy with oral capecitabine will be administered continuously. The patients achieving a clinical major or complete response assessed at clinical-instrumental re-evaluation at 7-8 weeks after treatment completion, will be randomized into two groups, to undergo surgery or local excision at 9-11 weeks (control arm) or at 13-16 weeks (experimental arm). Pathological response will be assessed on the surgical specimen using the AJCC TNM v.7 and the TRG according to Mandard. Patients will be followed up to evaluate toxicity and QoL. The promoter center of the trial will conduct the randomization process through an automated procedure to prevent any possible bias. For sample size calculation, using CR difference of 20% as endpoint, 74 patients per arm will be enrolled. Conclusions: The results of this study may prospectively provide a new time frame for the clinical re-evaluation for complete/major responders patients in order to increase the CR rate to nCRT. Trial registration: ClinicalTrials.gov Identifier: NCT0

Intraductal biliary lesions can involve the main hepatic confluence. Assessment of the extension of pedunculated biliary lesions during per-oral cholangioscopy (POCS) can optimize and personalize the surgical strategy. Four consecutive cases of pedunculated biliary lesions were analysed. Cholangioscopy was performed with a disposable single-operator cholangioscope. POSC was successfully performed in four patients (three female, mean age 50 years), showing involvement of the main biliary confluence in three of four pedunculated biliary lesions; direct biopsy sampling was diagnostic in two of three cases (in one patient, biopsy were not performed due to the smooth appearance of the intrabiliary lesion). No adverse events occurred after POCS. Surgery required excision of the main hepatic confluence in two of three cases (one patient was not resectable). POCS can diagnose intrabiliary extension of protruding biliary lesions, providing important information to plan the surgical intervention.

IntroductionThe aim of this study was to create a radiomic model able to calculate the probability of 5-year disease-free survival (5yDFS) when oxaliplatin (OXA) is or not administered in patients with locally advanced rectal cancer (LARC) and treated with neoadjuvant chemoradiotherapy (nCRT), allowing physicians to choose the best chemotherapy (CT) regimen. MethodsLARC patients with cT3-4 cN0 or cT1-4 cN1-2 were treated according to an nCRT protocol that included concomitant CT schedules with or without OXA and radiotherapy dose of 55 Gy in 25 fractions. Radiomic analysis was performed on the T2-weighted (T2-w) MR images acquired during the initial tumor staging. Statistical analysis was performed separately for the cohort of patients treated with and without OXA. The ability of every single radiomic feature in predicting 5yDFS as a univariate analysis was assessed using the Wilcoxon-Mann-Whitney (WMW) test or t-test. Two logistic models (one for each cohort) were calculated, and their performance was assessed using the area under the receiver operating characteristic (ROC) curve (AUC). ResultsA total of 176 image features belonging to four families (morphological, statistical, textural, and fractal) were calculated for each patient. At the univariate analysis, the only feature showing significance in predicting 5yDFS was the maximum fractal dimension of the subpopulation identified considering 30% and 50% as threshold levels (maxFD(30-50)). Once the models were developed using this feature, an AUC of 0.67 (0.57-0.77) and 0.75 (0.56-0.95) was obtained for patients treated with and without OXA, respectively. A maxFD(30-50) >1.6 was correlated to a higher 5yDFS probability in patients treated with OXA. ConclusionThis study suggests that radiomic analysis of MR T2-w images can be used to define the optimal concomitant CT regimen for stage III LARC cancer patients. In particular, by providing an indication of the gross tumor volume (GTV) spatial heterogeneity at ini

Background: Neoadjuvant chemoradiation therapy (nCRT) is the standard treatment modality in locally advanced rectal cancer (LARC). Since response to radiotherapy (RT) is dose dependent in rectal cancer, dose escalation may lead to higher complete response rates. The possibility to predict patients who will achieve complete response (CR) is fundamental. Recently, an early tumour regression index (ERI) was introduced to predict pathological CR (pCR) after nCRT in LARC patients. The primary endpoints will be the increase of CR rate and the evaluation of feasibility of delta radiomics-based predictive MRI guided Radiotherapy (MRgRT) model. Methods: Patients affected by LARC cT2-3, N0-2 or cT4 for anal sphincter involvement N0-2a, M0 without high risk features will be enrolled in the trial. Neoadjuvant CRT will be administered using MRgRT. The initial RT treatment will consist in delivering 55 Gy in 25 fractions on Gross Tumor Volume (GTV) plus the corresponding mesorectum and 45 Gy in 25 fractions on the drainage nodes. Chemotherapy with 5-fluoracil (5-FU) or oral capecitabine will be administered continuously. A 0.35 Tesla MRI will be acquired at simulation and every day during MRgRT. At fraction 10, ERI will be calculated: if ERI will be inferior than 13.1, the patient will continue the original treatment; if ERI will be higher than 13.1 the treatment plan will be reoptimized, intensifying the dose to the residual tumor at the 11th fraction to reach 60.1 Gy. At the end of nCRT instrumental examinations are to be performed in order to restage patients. In case of stable disease or progression, the patient will undergo surgery. In case of major or complete clinical response, conservative approaches may be chosen. Patients will be followed up to evaluate toxicity and quality of life. The number of cases to be enrolled will be 63: all the patients will be treated at Fondazione Policlinico Universitario A. Gemelli IRCCS in Rome. Discussion: This clinical tri

Background: Sarcopenia is considered a predictor of poor postoperative and long-term results following liver resection for intrahepatic cholangiocarcinoma (ICC). The aim of our study was to assess the incidence of sarcopenia in patients resected for ICC and its relation to preoperative clinical factors. Methods: Patients resected for ICC in our unit, with available preoperative CT scans within one month before operation, were enrolled in the study. Skeletal muscle index (SMI) and skeletal muscle radiodensity (SMD) were assessed for each patient. Results: Thirty patients matched all inclusion criteria. Low SMI values were documented in 15 patients (50.0%), and low SMD values were documented in 10 patients (33.3%). SMI was significantly greater in males (p < 0.001). In patients who were underweight, the incidence of low SMI was significantly higher than that of high SMI (p = 0.031). In patients who were overweight/obese, the incidence of high SMI was significantly higher than that of low SMI (p = 0.003) and the incidence of low SMD was significantly higher than that of high SMD (p = 0.038). In the univariate analysis, no preoperative factors (clinical and tumor-related factors), in particular BMI, were found to be independent predictors of low SMI. Conclusions: The incidence of sarcopenia was 50.0% in patients selected for liver resection for ICC and was not related to the preoperative clinical factors. A multidisciplinary evaluation of the nutritional status is fundamental before liver resection in patients.

Purpose: Our study investigated the contribution that the application of radiomics analysis on post-treatment magnetic resonance imaging can add to the assessments performed by an experienced disease-specific multidisciplinary tumor board (MTB) for the prediction of pathological complete response (pCR) after neoadjuvant chemoradiotherapy (nCRT) in locally advanced rectal cancer (LARC). Materials and methods: This analysis included consecutively retrospective LARC patients who obtained a complete or near-complete response after nCRT and/or a pCR after surgery between January 2010 and September 2019. A three-step radiomics features selection was performed and three models were generated: a radiomics model (rRM), a multidisciplinary tumor board model (yMTB) and a combined model (CM). The predictive performance of models was quantified using the receiver operating characteristic (ROC) curve, evaluating the area under curve (AUC). Results: The analysis involved 144 LARC patients; a total of 232 radiomics features were extracted from the MR images acquired post-nCRT. The yMTB, rRM and CM predicted pCR with an AUC of 0.82, 0.73 and 0.84, respectively. ROC comparison was not significant (p = 0.6) between yMTB and CM. Conclusion: Radiomics analysis showed good performance in identifying complete responders, which increased when combined with standard clinical evaluation; this increase was not statistically significant but did improve the prediction of clinical response.

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Concerns still exist regarding the role of early routine upper gastrointestinal contrast study (UGI) after bariatric procedures for detection of early complications. We reviewed our database to identify patients who underwent laparoscopic primary or redo surgery (previously placement of adjustable gastric banding), between January 2012 and December 2017. All the patients underwent UGI within 48 h after surgery. Among 1094 patients, early UGI was abnormal in 5 patients: in 4 cases a leak (one false positive) and in one case stenosis (one true positive) were suspected. In this clinical setting, five leaks were observed and required surgical re-exploration: 3 correctly identified and 2 not detected at UGI. Overall, 3 patients developed anastomotic stenosis. Our data suggest that early routine UGI after bariatric procedures has limited utility.

Purpose: Aim of this study was to develop a generalised radiomics model for predicting pathological complete response after neoadjuvant chemo-radiotherapy in locally advanced rectal cancer patients using pre-CRT T2-weighted images acquired at a 1.5 T and a 3 T scanner. Methods: In two institutions, 195 patients were scanned: 136 patients were scanned on a 1.5 T MR scanner, 59 patients on a 3 T MR scanner. Gross tumour volumes were delineated on the MR images and 496 radiomic features were extracted, applying the intensity-based (IB) filter. Features were standardised with Z-score normalisation and an initial feature selection was carried out using Wilcoxon–Mann–Whitney test: The most significant features at 1.5 T and 3 T were selected as main features. Several logistic regression models combining the main features with a third one selected by those resulting significant were elaborated and evaluated in terms of area under curve (AUC). A tenfold cross-validation was repeated 300 times to evaluate the model robustness. Results: Three features were selected: maximum fractal dimension with IB = 0–50, energy and grey-level non-uniformity calculated on the run-length matrix with IB = 0–50. The AUC of the model applied to the whole dataset after cross-validation was 0.72, while values of 0.70 and 0.83 were obtained when 1.5 T and 3 T patients were considered, respectively. Conclusions: The model elaborated showed good performance, even when data from patients scanned on 1.5 T and 3 T were merged. This shows that magnetic field intensity variability can be overcome by means of selecting appropriate image features.

Background: Conservative approach has emerged as an option for the management of rectal cancer (RC) patients with a near or complete clinical response after neoadjuvant chemoradiotherapy (nCRT). The aim of this study is to assess the impact of the conservative approach by comparing patients’ survival outcomes and quality of life with those who had surgical resection. Methods: A single-institution and retrospective study including RC patients who reached a near complete or complete clinical response after nCRT from January 2010 to September 2019. Conservative approaches included local excision or watch and wait strategy; surgery approaches included anterior resection or abdominal-perineal resection. Local regrowth (LR), overall survival, disease free survival, metastasis free survival and colostomy free survival were evaluated through Kaplan-Meier curves and compared trough log-rank tests. Quality of life was measured by the following validated questionnaires: EORTC QLC30, EORTC QLQ – CR29 and Fecal Incontinence Quality of Life scale. Results: Overall 157 patients were analyzed: 105 (66,9%) underwent radical surgery and 52 (33,1%) had a conservative approach. With a median follow-up of 51 months, 2 patients in the surgical group had a local recurrence and 8 in the conservative group had a LR, respectively. Distance metastasis occurred in 7 and 1 patients of surgical and conservative group, respectively. No differences were detected in terms of survival outcomes except for colostomy free survival (p: 0,01). The conservative group showed better intestinal (p < 0.01) and sexual (p: 0,04) function and emotional status (p: 0,02). Conclusions: Conservative approach seems to be safe in terms of survival outcomes with a significant advantage on quality of life in RC patients who achieved clinical complete response after nCRT.

PURPOSE: The aim of this study is to evaluate the long term survival of the addition of gefitinib to chemoradiotherapy (CRT) in locally advanced rectal cancer (LARC). METHODS AND MATERIALS: This previously published multicentre, open-label, phase I-II study, enrolled patients (pts) with LARC to receive CRT with concurrent 5-fluorouracil continuous intravenous infusion and a dose escalation of orally administered gefitinib, followed 6-8 weeks later by surgery. An intra-operative radiotherapy boost of 10 Gy was planned. Adjuvant chemotherapy was administrated in ypN1-2 pts. After a median f/u of >10 years, we analyzed Local Control (LC), Metastasis Free Survival (MFS), Disease Free Survival (DFS), Disease Specific Survival (DSS) and Overall Survival (OS). Predictive endpoints of clinical outcomes were tested by univariate and multivariate analysis. Variables analyzed included: age, gefitinib dose and interruptions, adjuvant CT, surgery type, ypT, ypN, and TRG grade. We have also analyzed late toxicity according to CTCAEv4. RESULTS: Of the 41 initially enrolled pts, 39 were evaluable (27M, 12F). With a median f/u of 133 months, LC, MFS, DFS, OS and DSS at 5 years were 84%; 71%; 64%; 87% and 92%, respectively. The OS and DSS at 10 years were 61,5% and 76%, respectively. Grade 3-4 late toxicity occurred in 38% of pts: sexual (28,2%) and gastrointestinal toxicities (10,2%). CONCLUSION: Long term outcomes and late toxicity were similar to previously reported series. The addition of gefitinib did not improve outcomes in LARC. Gefitinib is not recommended for rectal cancer patients who received 5-FU based preoperative CRT. Further studies may identify if gefitinib is beneficial in selected group of patients.

Purpose: Tumor control probability (TCP)-based early regression index (ERITCP) is a radiobiological parameter that showed promising results in predicting pathologic complete response (pCR) on T2-weighted 1.5 T magnetic resonance (MR) images of patients with locally advanced rectal cancer. This study aims to validate the ERITCP in the context of low-tesla MR-guided radiation therapy, using images acquired with different magnetic field strength (0.35 T) and image contrast (T2/T1). Furthermore, the optimal timing for pCR prediction was estimated, calculating the ERI index at different biologically effective dose (BED) levels. Methods and Materials: Fifty-two patients with locally advanced rectal cancer treated with neoadjuvant chemoradiation therapy were enrolled in this multi-institutional retrospective study. For each patient, a 0.35 T T2/T1-weighted MR image was acquired during simulation and on each treatment day. Gross tumor volume was contoured according to International Commission on Radiation Units Report 83 guidelines. According to the original definition, ERITCP was calculated considering the residual tumor volume at BED = 25 Gy. ERI was also calculated in correspondence with several BED levels: 13, 21, 32, 40, 46, 54, 59, and 67. The predictive performance of the different ERI indices were evaluated in terms of receiver operating characteristic curve. The robustness of ERITCP with respect to the interobserver variability was also evaluated considering 2 operators and calculating the intraclass correlation index. Results: Fourteen patients showed pCR. ERITCP correctly 47 of 52 cases (accuracy = 90%), showing good results in terms of sensitivity (86%), specificity (92%), negative predictive value (95%), and positive predictive value (80%). The analysis at different BED levels shows that the best predictive performance is obtained when this parameter is calculated at BED = 25 Gy (area under the curve = 0.93). ERITCP results are robust with respect to interobser

Background: The standard approach for locally advanced rectal cancer (LARC) is neoadjuvant chemoradiotherapy (nCRT) followed by total mesorectal excision (TME). After nCRT 20% of patients achieve a clinical complete response (pCR) and could be treated with a non-operative management (NOM). Methods: The panel of the Italian Association of Medical Oncology (AIOM) Guidelines on rectal cancer applied the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach addressing the following question: Should NOM vs. TME be used for patients with rectal cancer with clinical complete response after nCRT? Five outcomes were identified: disease-free survival (DFS), mortality, local recurrence, colostomy rate, and functional outcomes. Results: Nine studies were included in the analysis. A higher risk of disease recurrence was observed in the NOM group compared to the TME group (RR = 1.69, 95% CI 1.08, 2.64) on the other hand, we observed a slightly positive but not significant effect on mortality of NOM (RR = 0.82, 95% CI 0.46, 1.45). Patients in the NOM group were more likely to experience local recurrence (RR = 5.37, 95% CI 2.56, 11.27) and patients in the TME group were more likely to have a permanent colostomy (RR = 0.15, 95% CI 0.08, 0.29). Only one study evaluated functional outcomes. The overall certainty of evidence was rated as very low. Conclusions: NOM was found to correlate with a higher risk of local recurrence which did not translate in worse OS and a lower colostomy rate. Due to the paucity of evidences, no recommendations are possible. NOM remains an experimental treatment; thus, patients managed with NOM should be enrolled in clinical trials with a dedicated follow-up schedule.

Purpose: Distant metastases are currently the main cause of treatment failure in locally advanced rectal cancer (LARC) patients. The aim of this research is to investigate a correlation between the variation of radiomics features using pre- and post-neoadjuvant chemoradiation (nCRT) magnetic resonance imaging (MRI) with 2 years distant metastasis (2yDM) rate in LARC patients. Methods and Materials: Diagnostic pre- and post- nCRT MRI of LARC patients, treated in a single institution from May 2008 to June 2015 with an adequate follow-up time, were retrospectively collected. Gross tumor volumes (GTV) were contoured by an abdominal radiologist and blindly reviewed by a radiation oncologist expert in rectal cancer. The dataset was firstly randomly split into 90% training data, for features selection, and 10% testing data, for the validation. The final set of features after the selection was used to train 15 different classifiers using accuracy as target metric. The models’ performance was then assessed on the testing data and the best performing classifier was then selected, maximising the confusion matrix balanced accuracy (BA). Results: Data regarding 213 LARC patients (36% female, 64% male) were collected. Overall 2yDM was 17%. A total of 2,606 features extracted from the pre- and post- nCRT GTV were tested and 4 features were selected after features selection process. Among the 15 tested classifiers, logistic regression proved to be the best performing one with a testing set BA, sensitivity and specificity of 78.5%, 71.4% and 85.7%, respectively. Conclusions: This study supports a possible role of delta radiomics in predicting following occurrence of distant metastasis. Further studies including a consistent external validation are needed to confirm these results and allows to translate radiomics model in clinical practice. Future integration with clinical and molecular data will be mandatory to fully personalized treatment and follow-up approaches.

Objective: To correlate imaging parameters from baseline MRI diffusion-weighted imaging (DWI) and fludeoxyglucose (FDG) positron emission tomography (PET)-CT with synchronous and metachronous metastases in mucinous carcinoma (MC) and non-mucinous carcinoma (NMC) rectal cancer.Methods: 111 patients with extraperitoneal locally advanced rectal cancer, who underwent pelvic MRI, DWI and FDG PET-CT, were stratified into MC (n = 23) and NMC (n = 88). We correlated adverse morphologic features on MRI [mT4, mesorectal fascia involvement, extramural venous invasion (mEMVI), mN2] and quantitative imaging parameters [ minimum apparent diffusion coefficient (ADC(min)), maximum standardized uptake value, total lesion glycolysis, metabolic tumour volume, T-2 weighted and DWI tumour volumes] with the presence of metastatic disease. All patients underwent preoperative chemoradiation therapy (CRT); 100/111 patients underwent surgery after CRT and were classified as pathological complete response (PCR) and no PCR [tumour regression grade (TRG) vs TRG2-5] and as ypN0 and ypN1-2. Median follow-up time was 48 months. Metastases were confirmed on FDG PET-CT and contrast enhanced multidetector CT.Results: The percentage of mucin measured by MRI correlates with that quantified by histology. On multivariate analysis, the synchronous metastases were correlated with mEMVI [odds ratio(OR) = 21.48, p < 0.01] and low ADC(min) (OR = 0.04, p = 0.038) in NMC. The difference of metachronous recurrence between the MC group (10-90% mucin) and NMC group was significant (p < 0.01) (OR = 21.67, 95% confidence interval 3.8-120.5). Metachronous metastases were correlated with ypN2 (OR = 8.24, p = 0.01) in MC and in NMC. In NMC, mEMVI correlated with no PCR ( p = 0.018) and ypN2 (p < 0.01).Conclusion: mEMVI could identify patients with NMC, who are at high risk of synchronous metastases. The MC group is at a high risk of developing metachronous metastases.Advances in knowledge: Patients at high ris

Objective: To correlate imaging parameters from baseline MRI diffusion-weighted imaging (DWI) and fludeoxyglucose (FDG) positron emission tomography (PET)-CT with synchronous and metachronous metastases in mucinous carcinoma (MC) and non-mucinous carcinoma (NMC) rectal cancer. Methods: 111 patients with extraperitoneal locally advanced rectal cancer, who underwent pelvic MRI, DWI and FDG PET-CT, were stratified into MC (n523) and NMC (n588). We correlated adverse morphologic features on MRI [mT4, mesorectal fascia involvement, extramural venous invasion (mEMVI), mN2] and quantitative imaging parameters [minimum apparent diffusion coefficient (ADCmin), maximum standardized uptake value, total lesion glycolysis, metabolic tumour volume, T2 weighted and DWI tumour volumes] with the presence of metastatic disease. All patients underwent preoperative chemoradiation therapy (CRT); 100/111 patients underwent surgery after CRT and were classified as pathological complete response (PCR) and no PCR [tumour regression grade (TRG)1 vs TRG2-5] and as ypN0 and ypN1-2. Median follow-up time was 48 months. Metastases were confirmed on FDG PET-CT and contrastenhanced multidetector CT. Results: The percentage of mucin measured by MRI correlates with that quantified by histology. On multivariate analysis, the synchronous metastases were correlated with mEMVI [odds ratio (OR) 5 21.48, p,0.01] and low ADCmin (OR50.04, p50.038) in NMC. The difference of metachronous recurrence between the MC group (10-90% mucin) and NMC group was significant (p,0.01) (OR521.67, 95% confidence interval 3.8-120.5). Metachronous metastases were correlated with ypN2 (OR58.24, p50.01) in MC and in NMC. In NMC, mEMVI correlated with no PCR (p50.018) and ypN2 (p,0.01). Conclusion: mEMVI could identify patients with NMC, who are at high risk of synchronous metastases. The MC group is at a high risk of developing metachronous metastases. Advances in knowledge: Patients at high risk of metastases are more likely t

Objective: To correlate imaging parameters from baseline MRI diffusion-weighted imaging (DWI) and fludeoxyglucose (FDG) positron emission tomography (PET)-CT with synchronous and metachronous metastases in mucinous carcinoma (MC) and non-mucinous carcinoma (NMC) rectal cancer. Methods: 111 patients with extraperitoneal locally advanced rectal cancer, who underwent pelvic MRI, DWI and FDG PET-CT, were stratified into MC (n523) and NMC (n588). We correlated adverse morphologic features on MRI [mT4, mesorectal fascia involvement, extramural venous invasion (mEMVI), mN2] and quantitative imaging parameters [minimum apparent diffusion coefficient (ADCmin), maximum standardized uptake value, total lesion glycolysis, metabolic tumour volume, T2 weighted and DWI tumour volumes] with the presence of metastatic disease. All patients underwent preoperative chemoradiation therapy (CRT); 100/111 patients underwent surgery after CRT and were classified as pathological complete response (PCR) and no PCR [tumour regression grade (TRG)1 vs TRG2-5] and as ypN0 and ypN1-2. Median follow-up time was 48 months. Metastases were confirmed on FDG PET-CT and contrastenhanced multidetector CT. Results: The percentage of mucin measured by MRI correlates with that quantified by histology. On multivariate analysis, the synchronous metastases were correlated with mEMVI [odds ratio (OR) 5 21.48, p,0.01] and low ADCmin (OR50.04, p50.038) in NMC. The difference of metachronous recurrence between the MC group (10-90% mucin) and NMC group was significant (p,0.01) (OR521.67, 95% confidence interval 3.8-120.5). Metachronous metastases were correlated with ypN2 (OR58.24, p50.01) in MC and in NMC. In NMC, mEMVI correlated with no PCR (p50.018) and ypN2 (p,0.01). Conclusion: mEMVI could identify patients with NMC, who are at high risk of synchronous metastases. The MC group is at a high risk of developing metachronous metastases. Advances in knowledge: Patients at high risk of metastases are more likely t

Acute intramucosal dissection of the esophagus (IED) is a rare complication of eosinophilic esophagitis (EoE). Only few of such IED cases have been described in the literature. We report the case of a 32-year-old man with a 4-months diagnosis of EoE who was referred to the Emergency Department complaining of dysphagia, epigastric pain and fever and who was diagnosed, after an urgent endoscopy, an IED. After careful evaluation and multidisciplinary assessment the patient was managed conservatively, with specific medical therapy—high-dose proton pump inhibitors, swallowed steroid, broad-spectrum antibiotic—and, after a period of absolute fasting, a diet regimen based on “six food elimination diet” with a stepwise increase of food consistency. The patient experienced a rapid and complete relief of symptoms, paralleled by a progressive healing of IED with no recurrence over a 6-month follow-up period. In EoE patients with a high clinical suspicion of an acute IED, we suggest an early execution of chest CT and a contrast esophagography, avoiding potentially dangerous endoscopic procedures in the acute phase that can contribute to enlargement of the dissection, or progression to perforation. Once the diagnosis of IED is confirmed, even in the presence of a contained perforation, a conservative treatment with a multidisciplinary management should always be considered.

Introduction The delineation of Clinical Target Volume (CTV) is a critical step in radiotherapy. Several guidelines suggest different subvolumes and anatomical boundaries in rectal cancer (RC), potentially leading to a misunderstanding in the CTV definition. International consensus guidelines (CG) are needed to improve uniformity in RC CTV delineation. Material and methods The 7 radiation oncologist experts defined a roadmap to produce RC CG. Step 1: revision of the published guidelines. Step 2: selection of RC cases with different clinical stages. Step 3: delineation of cases using Falcon following previously published guidelines. Step 4: meeting in person to discuss the initial delineation outcome, followed by a CTV proposal based on revised and if needed, adapted anatomical boundaries. Step 5: peer review of the agreed consensus. Step 6: peer review meeting to validate the final outcome. Step 7: completion of RC delineation atlases. Results A new ontology of structure sets was defined and the related table of anatomical boundaries was generated. The major modifications were about the lateral lymph nodes and the ischio-rectal fossa delineation. Seven RC cases were made available online as consultation atlases. Conclusion The definition of international CG for RC delineation endorsed by international experts might support a future homogeneous comparison between clinical trial outcomes.

Purpose: The objective of this study is finding an intensity based histogram (IBH) signature to predict pathologic complete response (pCR) probability using only pre-treatment magnetic resonance (MR) and validate it externally in order to create a workflow for the external validation of an MR IBH signature and to apply the model out of the environment where it has been tuned. The impact of pCR and the final predictors on the survival outcome were also evaluated.Methods and Materials: Three centers using different MR scanners were involved in this retrospective study. The first center recruited 162 patients for model training, and the second and third centers provided 34 plus 25 patients for external validation. Patients provided written consent. Accrual period was from May 2008 to December 2014. After surgery pathologic response was defined. T2-weighted MR scans acquired before chemoradiation therapy (CRT) were used for analysis addressed on primary lesions. Images were pre-processed using Laplacian of Gaussian (LoG) filter with multiple s, and first order intensity histogram-based features (kurtosis, skewness, and entropy) were extracted. Features selection was performed using Mann-Whitney test. Tumor staging (cT, cN) was added to build a logistic regression model and predict pCR. Model performance was evaluated with internal and external validation using area under the curve (AUC) of the receiver operator characteristic (ROC) and calibration with Hosmer-Lemeshow test. The linear cross-correlation matrix (Pearson's coefficient) and the variance inflation factor (VIF) were used to check the correlation and the co-linearity among the final predictors. The amount of the information added through the radiomics features was estimated by using the DeLong's test, and the impact of pCR and the final predictors on survival outcomes were evaluated through the Kaplan-Meier curves by using the log-rank test and the multivariate Cox model.Results: Candidate-to

Purpose: The objective of this study is finding an intensity based histogram (IBH) signature to predict pathologic complete response (pCR) probability using only pre-treatment magnetic resonance (MR) and validate it externally in order to create a workflow for the external validation of an MR IBH signature and to apply the model out of the environment where it has been tuned. The impact of pCR and the final predictors on the survival outcome were also evaluated.Methods and Materials: Three centers using different MR scanners were involved in this retrospective study. The first center recruited 162 patients for model training, and the second and third centers provided 34 plus 25 patients for external validation. Patients provided written consent. Accrual period was from May 2008 to December 2014. After surgery pathologic response was defined. T2-weighted MR scans acquired before chemoradiation therapy (CRT) were used for analysis addressed on primary lesions. Images were pre-processed using Laplacian of Gaussian (LoG) filter with multiple s, and first order intensity histogram-based features (kurtosis, skewness, and entropy) were extracted. Features selection was performed using Mann-Whitney test. Tumor staging (cT, cN) was added to build a logistic regression model and predict pCR. Model performance was evaluated with internal and external validation using area under the curve (AUC) of the receiver operator characteristic (ROC) and calibration with Hosmer-Lemeshow test. The linear cross-correlation matrix (Pearson's coefficient) and the variance inflation factor (VIF) were used to check the correlation and the co-linearity among the final predictors. The amount of the information added through the radiomics features was estimated by using the DeLong's test, and the impact of pCR and the final predictors on survival outcomes were evaluated through the Kaplan-Meier curves by using the log-rank test and the multivariate Cox model.Results: Candidate-to

Objectives: To update the 2012 ESGAR consensus guidelines on the acquisition, interpretation and reporting of magnetic resonance imaging (MRI) for clinical staging and restaging of rectal cancer. Methods: Fourteen abdominal imaging experts from the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) participated in a consensus meeting, organised according to an adaptation of the RAND-UCLA Appropriateness Method. Two independent (non-voting) Chairs facilitated the meeting. 246 items were scored (comprising 229 items from the previous 2012 consensus and 17 additional items) and classified as ‘appropriate’ or ‘inappropriate’ (defined by ≥ 80 % consensus) or uncertain (defined by OpenSPiltSPi 80 % consensus). Results: Consensus was reached for 226 (92 %) of items. From these recommendations regarding hardware, patient preparation, imaging sequences and acquisition, criteria for MR imaging evaluation and reporting structure were constructed. The main additions to the 2012 consensus include recommendations regarding use of diffusion-weighted imaging, criteria for nodal staging and a recommended structured report template. Conclusions: These updated expert consensus recommendations should be used as clinical guidelines for primary staging and restaging of rectal cancer using MRI. Key Points: • These guidelines present recommendations for staging and reporting of rectal cancer. • The guidelines were constructed through consensus amongst 14 pelvic imaging experts. • Consensus was reached by the experts for 92 % of the 246 items discussed. • Practical guidelines for nodal staging are proposed. • A structured reporting template is presented.

To evaluate whether metabolic changes in the primary tumour during and after preoperative radiochemotherapy (RCT) can predict the histopathological response in patients with locally advanced rectal cancer as well as disease-free survival (DFS) and overall survival (OS).

Purpose: The aim of this study is to test a novel multiparametric imaging guided procedure for high-doserate brachytherapy in anal canal cancer, in order to evaluate the feasibility and safety. Material and methods: For this analysis, we considered all consecutive patients who underwent magnetic resonance/computed tomography image adapted brachytherapy (MR/CT-IABT) treated from February 2012 to July 2014. To conduct this project, we formed a working group that established the procedure and identified the indicators and benchmarks to evaluate the feasibility and safety. We considered the procedure acceptable if 90% of the indicators were consistent with the benchmarks. Magnetic resonance imaging with contrast and diffusion weighted imaging were performed with an MRI-compatible dummy applicator in the anus to define the position of the clinical target volume disease and biological information. A pre-implantation treatment planning was created in order to get information on the optimal position of the needles. Afterwards, the patient underwent a simulation CT and the definite post-implantation treatment planning was created. Results: We treated 11 patients (4 men and 7 women) with MR/CT-IABT and we performed a total of 13 procedures. The analysis of indicators for procedure evaluation showed that all indicators were in agreement with the benchmark. The dosimetric analysis resulted in a median of V200, V150, V100, V90, V85, respectively of 24.6%, 53.4%, 93.5%, 97.6%, and 98.7%. The median coverage index (CI) was 0.94, the median dose homogeneity index (DHI) was 0.43, the median dose non-uniformity ratio (DNR) resulted 0.56, the median overdose volume index (ODI) was 0.27. We observed no episodes of common severe acute toxicities. Conclusions: Brachytherapy is a possible option in anal cancer radiotherapy to perform the boost to complete external beam radiotherapy (EBRT). Magnetic resonance can also have biological advantages compared to the US. Our results suggest that

In case of incomplete colonoscopy, several radiologic methods have traditionally been used, but more recently, capsule endoscopy was also shown to be accurate. Aim of this study was to compare colon capsule endoscopy (CCE) and CT colonography (CTC) in a prospective cohort of patients with incomplete colonoscopy.

Background: Presently, few options are available for refractory colorectal cancer (CRC). O6-methyl-guanine-DNA-methyltransferase (MGMT) promoter methylation is a frequent and early event in CRC tumourigenesis. This epigenetic silencing is a predictor of response to the alkylating drug temozolomide in glioblastoma. Preclinical evidences and some case reports showed temozolomide activity in CRC with MGMT silencing, but the available data from clinical trials are inconsistent. Methods: This was a multicentre, phase 2 trial, planned according to a two-stage Simon's optimal design to investigate activity and safety of temozolomide in refractory CRC harbouring MGMT promoter methylation. The primary end point was overall response rate (ORR). Patients who failed two or more prior treatments received temozolomide at a dose of 150-200 mg m -2 per day on days 1-5 every 28 days. Results: From July 2012 to June 2016, 225 patients were screened, 80 showed MGMT promoter methylation and 41 were enrolled. Overall response rate was 10% and disease control rate was 32%. Median progression-free survival and overall survival were 1.9 and 5.1 months, respectively. Conclusions: Temozolomide showed a modest activity in this heavily pretreated population and the study did not meet its primary end point. The role of temozolomide in CRC remains still controversial and further research is warranted.

BACKGROUND: Portal vein embolization (PVE) is an effective procedure to increase the future remnant liver (FRL) before major hepatectomy. A controversial issue is that PVE may stimulate tumor growth and can be associated with poor prognosis after liver resection for colorectal liver metastases (CRLM). The aim of this study was to evaluate the impact of PVE on long-term survival following major hepatectomy for CRLM. METHODS: Between 1998 and 2010, 100 right and extended-right hepatectomies for unilobar, right-sided CRLM were performed. Of the group, 20 patients underwent preoperative PVE (group A). The control patients (group B; 20 patients) were selected by matching with the group A patients. RESULTS: It was found that 25 patients (25/40; 62.5%) had developed tumor recurrence. The rate of global recurrence was not significantly different in groups A and B (65% vs 60%, respectively; P = .744). The specific overall intrahepatic recurrence rate was 42.5% (17 of 40 patients) and was not significantly different in groups A and B (45% vs 40%, respectively; P = .749). The 5-year overall and disease-free survival rates were similar in groups A and B (42.9% and 33.6% vs 42.1% and 27.7%, respectively). The 5-year specific liver-disease-free survival was 45.3% in group A and 53.5% in group B (P = .572). On multivariate analysis of all 100 hepatectomies, R1 resection (P = .013) was found to be the only independent predictor of liver-disease-free survival. CONCLUSION: This study showed that PVE did not affect overall survival and specific liver-disease-free survival in patients undergoing right or right-extended hepatectomy for unilobar, right-sided CRLM.

PURPOSE: To assess the effect of computer-aided detection (CAD) as a second reader on the sensitivity and specificity of computed tomographic (CT) colonography in detecting 6-9-mm colorectal cancer (CRC) lesions. MATERIALS AND METHODS: Individuals with clinical indications for colonoscopy--either for symptoms or as part of participating in a surveillance program or CRC screening--were prospectively enrolled at one of 10 academic centers between July 2007 and May 2009. Institutional review board approval was obtained at each clinical site, and all participants provided written informed consent. All participants underwent CT colonography and colonoscopy on the same day. Experienced readers interpreted the CT colonography images unassisted and then reviewed all colorectal lesion-like structures pinpointed by the CAD algorithm. Segmental unblinding of CT colonoscopy findings at colonoscopy was utilized. The sensitivity and specificity of unassisted and CAD-assisted reading in identifying individuals with 6-9-mm lesions were calculated and compared by means of pairwise analysis. RESULTS: A total of 618 participants (mean age, 57.9 years; 54.5% male) were included in the final analysis. Of these participants, 464 (75.1%) had no lesions 6 mm or larger, and 52 (8.4%) had 6-9-mm lesions. The sensitivity of CT colonography with unassisted reading and that with CAD-assisted reading in identifying individuals with 6-9-mm lesions was 65.4% (95% confidence interval [CI]: 50.9%, 78.0%) and 76.9% (95% CI: 63.2%, 87.5%; P = .016), respectively. No significant change in specificity was observed: The specificity of CT colonography with unassisted and that with CAD-assisted reading was 91.8% (95% CI: 88.9%, 94.1%) and 90.9% (95% CI: 88.0%, 93.4%; P = .063), respectively. Evaluation of CAD candidates required an additional 1.6 minutes (25th-75th percentile: 1.0 minute to 3.4 minutes). CONCLUSION: The addition of CAD to reading performed by experienced readers resulted in a significant b

OBJECTIVES: To develop guidelines describing a standardised approach regarding the acquisition, interpretation and reporting of magnetic resonance imaging (MRI) for clinical staging and restaging of rectal cancer. METHODS: A consensus meeting of 14 abdominal imaging experts from the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) was conducted following the RAND-UCLA Appropriateness Method. Two independent (non-voting) chairs facilitated the meeting. Two hundred and thirty-six items were scored by participants for appropriateness and classified subsequently as appropriate or inappropriate (defined by ≥ 80 % consensus) or uncertain (defined by < 80 % consensus). Items not reaching 80 % consensus were noted. RESULTS: Consensus was reached for 88 % of items: recommendations regarding hardware, patient preparation, imaging sequences, angulation, criteria for MRI assessment and MRI reporting were constructed from these. CONCLUSIONS: These expert consensus recommendations can be used as clinical guidelines for primary staging and restaging of rectal cancer using MRI.

Inflammatory pseudotumour of the liver is a rare benign condition which may mimic malignant tumours. It is associated with many diseases including Crohn's disease, diabetes and Sjögren's syndrome [1]. Inflammatory pseudotumour of the liver presents a variable appearance on Magnetic Resonance Imaging (MRI), and spontaneous regression at follow-up has been reported [2, 3]. A 37-year-old woman with a history of primary antiphospholipid antibody syndrome with first trimester miscarriage and recurrent pulmonary embolism treated with warfarin, underwent an abdominal ultrasound (US) which revealed on the right liver multiple oval hypoechoic lesions (mean diameter 10–20 mm); after sulphur hexafluoride injection, lesions displayed centripetal arterial enhancement and early wash out. She denied symptoms. Liver function tests were normal, as well as tests for HBsAg, anti-HCV and autoimmune diseases. Erythrocyte sedimentation rate was 73 mm/h and Protein C reactive was 39 mg/L. An MRI showed (Fig. 1) multiple T2-hyperintense lesions that have restricted diffusion on Diffusion-Weighted Imaging. The vascular study demonstrated a peripheral arterial enhancement with delayed central uptake, while the hepatospecific phase showed no enhancement. Liver biopsy showed fibrovascular tissue embedding biliary ducts and infiltrated by lymphocytes, plasma cells and granulocytes. During a quarterly follow-up, MRI revealed that some lesions spontaneously were reduced or even disappeared but other enlarged or appeared. A final diagnosis of an inflammatory pseudotumour of the liver was made. At present, patient continues to be asymptomatic. Here, we report the first case of association of hepatic inflammatory pseudotumour and antiphospholipid syndrome, with a peculiar vanishing-recurrent pattern of liver lesions.

To assess the effectiveness of the potential advantages with 3-dimensional-based treatment planning versus 2-dimensional pelvic bone-based treatment planning in patients with rectal cancer, controlled for clinical stage.

BACKGROUND: Transanal endoscopic microsurgery (TEM) after radiochemotherapy (RCT) has been reported in selected cases of locally advanced rectal cancer as an alternative to traditional radical resection with total mesorectal excision with a curative intent or as diagnostic tool to confirm a pathological complete response of the primary tumor. No study has evaluated functional outcome after TEM in preoperatively irradiated patients. METHODS: This study was designed to evaluate short-term morbidity (according to Clavien's classifications) and establish (by a questionnaire) continence and evacuative function after RCT and TEM, at 1 year from surgery, analyzing the impact of RCT on postoperative outcomes. Patients with locally advanced rectal cancer treated by RCT and TEM (group 1) or with early T1 or adenomas treated only by TEM (group 2) entered this cohort comparative study. RESULTS: Twenty-two patients entered the study as group 1 and 25 as group 2. No postoperative mortality occurred. The morbidity rate was 36.4 % in group 1 vs. 16 % in group 2 (p = 0.114). The rate of suture dehiscence was 22.7 % in group 1 vs. 4 % in group 2 (p = 0.068). No grade III complications, reoperation, or hospital readmission within 30 days was recorded in either group. One year after surgery, continence and evacuative scores in group 1 were 1.05 ± 1.25 and 24.72 ± 2.79, respectively, which were similar to group 2 (p = 0.081 and 0.288, respectively). CONCLUSIONS: TEM after RCT in selected rectal cancer patients has an acceptable morbidity and functional results at 1 year from surgery. Preoperative irradiation could increase postoperative short-term morbidity, but it does not seem to influence evacuative or sphincter function after 1 year from surgery.

Hepatic resection is considered to be feasible when all malignant nodules can be technically excised. The goal of the surgical approach is to optimize the oncologic resection (negative margins), sparing the non-cancerous hepatic parenchyma. The outflowing hepatic vein (HV) of that particular liver remnant must be intact in order to preserve its function. The purpose of this article is to familiarize radiologists with anatomy and anatomical variants of HVs, with special emphasis on segmental venous drainage for presurgical planning of hepatic resections. We focus on information which radiologist should give to hepatic surgeon to choose proper surgical approach. Radiologist's familiarity with the anatomy and anatomical variants of HVs is essential for accurate surgical planning to avoid venous congestion as postoperative complication. Any clinically important hepatic vein variation detected on presurgical imaging should be carefully recorded in the radiology report.

To prospectively monitor the response in patients with locally advanced nonmucinous rectal cancer after chemoradiotherapy (CRT) using diffusion-weighted magnetic resonance imaging. The histopathologic finding was the reference standard.

PURPOSE: To prospectively monitor the response in patients with locally advanced nonmucinous rectal cancer after chemoradiotherapy (CRT) using diffusion-weighted magnetic resonance imaging. The histopathologic finding was the reference standard. METHODS AND MATERIALS: The institutional review board approved the present study. A total of 62 patients (43 men and 19 women; mean age, 64 years; range, 28-83) provided informed consent. T(2)- and diffusion-weighted magnetic resonance imaging scans (b value, 0 and 1,000 mm(2)/s) were acquired before, during (mean 12 days), and 6-8 weeks after CRT. We compared the median apparent diffusion coefficients (ADCs) between responders and nonresponders and examined the associations with the Mandard tumor regression grade (TRG). The postoperative nodal status (ypN) was evaluated. The Mann-Whitney/Wilcoxon two-sample test was used to evaluate the relationships among the pretherapy ADCs, extramural vascular invasion, early percentage of increases in ADCs, and preoperative ADCs. RESULTS: Low pretreatment ADCs (<1.0 × 10(-3)mm(2)/s) were correlated with TRG 4 scores (p = .0011) and associated to extramural vascular invasion with ypN+ (85.7% positive predictive value for ypN+). During treatment, the mean percentage of increase in tumor ADC was significantly greater in the responders than in the nonresponders (p < .0001) and a >23% ADC increase had a 96.3% negative predictive value for TRG 4. In 9 of 16 complete responders, CRT-related tumor downsizing prevented ADC evaluations. The preoperative ADCs were significantly different (p = .0012) between the patients with and without downstaging (preoperative ADC ≥1.4 × 10(-3)mm(2)/s showed a positive and negative predictive value of 78.9% and 61.8%, respectively, for response assessment). The TRG 1 and TRG 2-4 groups were not significantly different. CONCLUSION: Diffusion-weighted magnetic resonance imaging seems to be a promising tool for monitoring the response to CRT.

N/A

The prognosis of patients with advanced hepatocellular carcinoma (HCC) is very poor. The outcome of these patients is particularly bleak when the disease is complicated by portal vein tumor thrombosis (PVTT), since the increased portal pressure often causes serious gastrointestinal bleedings. Before the introduction of sorafenib (SOR), a tyrosine kinase inhibitor, no effective treatment was available for patients with advanced disease. SOR is now considered the standard treatment even for patients with tumor thrombosis, although the well-known interference between tyrosine kinase inhibitors and the coagulation pathway calls for caution against their use in this setting. Here, we report the case of a 74-year-old male patient with advanced HCC and PVTT treated with sunitinib (SUN), another multikinase inhibitor. During the third cycle, our patient experienced a life-threatening hematemesis with hemorrhagic shock that required intensive care treatment and SUN discontinuation. However, he completely recovered, and the PET/CT scan performed 1 year after the adverse effect demonstrated no evidence of the tumor together with portal vein recanalization. The short course of SUN causing both tumor response and gastrointestinal bleeding warrants further studies on the effectiveness of SUN in this setting as well as on the duration of treatment with multikinase inhibitors in patients with tumor thrombosis.

Leyomiosarcomas arising from the portal/mesenteric venous system are very rare tumours, and only a few cases have been reported in the global literature. As the other leyomiosarcomas of vascular origin, they are associated with a poor prognosis. The present report describes the case of a 66-year-old woman with a leyomiosarcoma of the inferior mesenteric vein, unexpectedly found during a CT scan performed for another indication. A brief review of the literature is also given. The patient underwent radical surgical excision and enjoys a good health, without radiological signs of recurrence, 24 months after surgery. In this case, an early incidental diagnosis determined an early treatment and, probably, a favourable prognosis. This is the second case of leyomiosarcoma of the inferior mesenteric vein reported in the literature.

Computed tomographic (CT) colonography has been recognized as an alternative for colorectal cancer (CRC) screening in average-risk individuals, but less information is available on its performance in individuals at increased risk of CRC.

Not available

Our objective was evaluate the outcome of primary clinical T4M0 extraperitoneal rectal cancer treated by neoadjuvant radiochemotherapy. Prognosis of clinical T4 rectal cancer is poor. Preoperative chemoradiation therapy may be beneficial. The results obtained are unclear due to lack of objective and strictly applied staging methods. METHODS: Patients with primary, clinical, T4MO, extraperitoneal rectal cancer, defined by transrectal ultrasonography, computed tomography or magnetic resonance imaging, were considered. Intraoperative radiotherapy and adjuvant chemotherapy were employed in some patients after curative resection (R0). Variables influencing the possibility to perform an R0 resection and a sphincter-saving procedure were investigated as predictors of outcome. RESULTS: 100 patients were included. R0 resection was performed in 78 patients. R0 resection rate was greater in females (93% vs 67%) and in responders to neoadjuvant chemoradiation (94% vs 60%). The ability to perform a sphincter-saving procedure was 57%, greater in middle rectal location (85% vs 51%) and in responders to the chemoradiation (70% vs 47%). Median follow-up was 31 months (range, 4-136). Local recurrences were found in 7 patients (10%). Five-year local control in R0 patients was 90% and better in the IORT group (100%). Distant relapse occurred in 24 patients (30%). Five-year overall survival was 59%, and was better after an R0 versus an R1 or R2 resection (68% vs 22%). Overall and disease free survival in R0 patients improved after overall downstaging. Adjuvant chemotherapy given in addition to the neoadjuvant therapy did not appear to offer benefit in improving survival. CONCLUSION: A multimodal approach enabled us to obtain a 5-year overall survival of about 60%. IORT increased local control. The role of adjuvant chemotherapy needs to be further investigated