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Objective To establish optimised diffusion weightings (‘b-values’) for acquisition of whole-body diffusion-weighted MRI (WB-DWI) for estimation of the apparent diffusion coefficient (ADC) in patients with metastatic melanoma (MM). Existing recommendations for WB-DWI have not been optimised for the tumour properties in MM; therefore, evaluation of acquisition parameters is essential before embarking on larger studies. Methods Retrospective clinical data and phantom experiments were used. Clinical data comprised 125 lesions from 14 examinations in 11 patients with multifocal MM, imaged before and/or after treatment with immunotherapy at a single institution. ADC estimates from these data were applied to a model to estimate the optimum b-value. A large non-diffusing phantom was used to assess eddy current–induced geometric distortion. Results Considering all tumour sites from pre- and post-treatment examinations together, metastases exhibited a large range of mean ADC values, [0.67–1.49] × 10−3 mm2/s, and the optimum high b-value (bhigh) for ADC estimation was 1100 (10th–90th percentile: 740–1790) s/mm2. At higher b-values, geometric distortion increased, and longer echo times were required, leading to reduced signal. Conclusions Theoretical optimisation gave an optimum bhigh of 1100 (10th–90th percentile: 740–1790) s/mm2 for ADC estimation in MM, with the large range of optimum b-values reflecting the wide range of ADC values in these tumours. Geometric distortion and minimum echo time increase at higher b-values and are not included in the theoretical optimisation; bhigh in the range 750–1100 s/mm2 should be adopted to maintain acceptable image quality but performance should be evaluated for a specific scanner. Key Points • Theoretical optimisation gave an optimum high b-value of 1100 (10th–90th percentile: 740–1790) s/mm2for ADC estimation in metastatic melanoma. • Considering geometric distortion and minimum echo time (TE), a b-value in the range 750–1100 s/mm2is recommended. • Sites should evaluate the performance of specific scanners to assess the effect of geometric distortion and minimum TE.

Background Gallbladder cancer has a poor prognosis and imaging can have variable diagnostic accuracy. We assessed the ability of preoperative 18F-fluorodeoxyglucose positron emission tomography computed tomography (18F-FDG-PET/CT) imaging to predict a postoperative histological diagnosis of gallbladder cancer. Method A retrospective analysis was undertaken in a cohort of patients, who had suspected gallbladder cancer on cross-sectional imaging and that underwent preoperative FDG-PET/CT scan. The discriminatory power of FDG-PET/CT was determined in receiver operator characteristic (ROC) analysis and diagnostic accuracy parameters were estimated at different thresholds of maximum standard unit value (SUVmax). Results Twenty-two patients were included in the study; 7 had malignant and 15 benign diagnoses. There was no statistically significant difference between the measured SUVmax between the two groups (p = 0.71). With an area under the curve of 0.486, the ROC curve did not indicate any discriminatory power of FDG-PET/CT at any potential threshold of SUVmax. Conclusion This study indicates that the diagnosis of primary gallbladder cancer cannot be accurately confirmed with FDG PET/CT scanning.

OBJECTIVE. The objective of our study was to compare an abbreviated liver MRI protocol with a standard liver MRI protocol for the posttreatment follow-up of colorectal metastases in assessing disease presence, segmental involvement, and response to chemotherapy and for surgical planning. MATERIALS AND METHODS. This retrospective single-center study reviewed consecutive chemotherapy-naive patients with colorectal liver metastases (April 1, 2011-August 31, 2017) who underwent gadoxetate disodium-enhanced MRI on a 1.5-T unit before and 8-12 weeks after chemotherapy. Two radiologists blinded to outcomes independently reviewed images obtained using standard MRI sequences at baseline and after treatment. The standard MRI sequences were the following: axial T1-weighted, axial T2-weighted, axial DWI (b values = 0-750 s/mm2), axial multiphase contrast-enhanced T1-weighted, and axial and coronal hepatobiliary phase (HBP) T1-weighted sequences. The standard sequences obtained at baseline and the abbreviated protocol sequences (i.e., HBP gadoxetate disodium-enhanced T1-weighted and DWI sequences) obtained after treatment were reviewed. For each image set, reviewers assessed disease presence and segmental involvement; in addition, for images obtained after therapy, treatment response according to RECIST 1.1 was recorded. RESULTS. One hundred thirteen patients (73 men and 40 women; mean age, 61.6 years) were evaluated. The total number of metastases showed high agreement between the standard protocol and abbreviated protocol (intraclass correlation coefficient = 0.97). There was good agreement between the protocols for segmental involvement (weighted κ = 0.73-0.85), and the weighted kappa was 0.82 for all segments. Discrepancies in segmental involvement did not alter potential surgical planning. Categorization of RECIST 1.1 treatment response using the abbreviated protocol versus the standard protocol showed excellent agreement (weighted κ = 0.92). CONCLUSION. An abbreviated liver MRI protocol (i.e., HBP gadoxetate disodium-enhanced T1-weighted and DWI sequences) allows assessment after chemotherapy similar to a standard liver MRI protocol. Use of the abbreviated protocol can reduce imaging time without sacrificing diagnostic performance for the follow-up of colorectal liver metastases.

Diagnosis of patients suspected of multiple myeloma requires a combination of serological and biochemical tests, bone marrow aspirate (BMA) and/or bone marrow trephine (BMT) biopsies as well as complementary information provided by whole-body cross-sectional imaging studies. However, given the heterogeneous nature of multiple myeloma, discrepancies can arise between disease burden on trephine and extent of disease within the marrow on whole-body magnetic resonance imaging (WB-MRI). Here, for the first time, we report on a series of symptomatic multiple myeloma patients for whom there was substantial discordance between disease burden on trephine and WB-MRI.

Objectives Percutaneous liver biopsy (PLB) poses specific challenges in oncological patients such as bleeding and tumour seeding. This study’s aim was to compare a coaxial (C-PLB) and non-coaxial (NC-PLB) biopsy technique in terms of diagnostic yield, safety and seeding risk of image-guided PLB techniques in an oncological setting. Methods Local research committee approval was obtained for this single-site retrospective study. Patients who underwent a PLB between November 2011 and December 2017 were consecutively included. Medical records were reviewed to determine diagnostic yield and complications. Follow-up imaging was re-reviewed for seeding, defined as visible tumour deposits along the PLB track. Mann-Whitney U and chi-squared tests were performed to investigate differences between biopsy techniques in sample number, complications and seeding rate. Results In total, 741 patients (62 ± 13 years, 378 women) underwent 932 PLB (C-PLB 72.9% (679/932); NC-PLB 27.1% (253/932)). More tissue cores (p p = 0.940). Complication rate (9.3%; 87/932) using C-PLB (8.2% (56/679)) was lower compared with NC-PLB (12.3% (31/253); p = 0.024). Major complications were uncommon (C-PLB 2.7% (18/679); NC-PLB 2.8% (7/253)); bleeding developed in 1.2% (11/932; C-PLB 1.2% (8/679); NC-PLB 1.2% (3/253)). Seeding was a rare event, occurring significantly less in C-PLB cases (C-PLB 1.3% (7/544); NC-PLB 3.1% (6/197); p = 0.021). Conclusions C-PLB allows for high diagnostic tissue yield with a lower complication and seeding rate than a NC-PLB and should be the preferred method in an oncological setting. Key Points • A coaxial percutaneous liver biopsy achieves a significant higher number of cores and fewer complications than a non-coaxial biopsy technique. • The risk of tumour seeding is very low and is significantly lower using the coaxial biopsy technique. • In this study, a larger number of cores (median = 4) could be safely acquired using the coaxial technique, providing sufficient material for advanced molecular analysis.

PURPOSE: To compare disease detection of myeloma using contemporary whole-body (WB) MRI and fluorine 18 ((18)F) fluorodeoxyglucose (FDG) PET/CT protocols and to correlate imaging with laboratory estimates of disease burden, including molecular characteristics. MATERIALS AND METHODS: In this observational, prospective study, participants were recruited from November 2015 to March 2018 who had a diagnosis of myeloma, who were planned to undergo chemotherapy and autologous stem cell transplantation, and who underwent baseline WB-MRI and FDG PET/CT (ClinicalTrials.gov identifier NCT02403102). Baseline clinical data, including genetics, were collected. Paired methods were used to compare burden and patterns of disease. RESULTS: Sixty participants (mean age, 60 years ± 9 [standard deviation]; 35 men) underwent baseline WB-MRI and FDG PET/CT. WB-MRI showed significantly higher detection for focal lesions at all anatomic sites (except ribs, scapulae, and clavicles) and for diffuse disease at all sites. Two participants presented with two or more focal lesions smaller than 5 mm only at WB-MRI but not FDG PET/CT. Participants with diffuse disease at MRI had higher plasma cell infiltration (percentage of nucleated cells: median, 60% [interquartile range {IQR}, 50%–61%] vs 15% [IQR, 4%–50%]; P = .03) and paraprotein levels (median, 32.0 g/L [IQR, 24.0–48.0 g/L] vs 20.0 g/L [IQR, 12.0–22.6 g/L]; P = .02) compared with those without diffuse disease. All genetically high-risk tumors showed diffuse infiltration at WB-MRI. CONCLUSION: WB-MRI helped detect a higher number of myeloma lesions than FDG PET/CT, and diffuse disease detected at WB-MRI correlated with laboratory measures of disease burden and molecular markers of risk. Keywords: MR-Imaging, Skeletal-Appendicular, Skeletal-Axial, Bone Marrow, Hematologic Diseases, Oncology Clinical trial registration no. NCT02403102. Supplemental material is available for this article. © RSNA, 2021

Objectives Whole-body MRI (WB-MRI) is recommended by the International Myeloma Working Group for all patients with asymptomatic myeloma and solitary plasmacytoma and by the UK NICE guidance for all patients with suspected myeloma. Some centres unable to offer WB-MRI offer low-dose whole-body CT (WB-CT). There are no studies comparing interobserver agreement and disease detection of contemporary WB-MRI (anatomical imaging and DWI) versus WB-CT. Our primary aim is to compare the interobserver agreement between WB-CT and WB-MRI in the diagnosis of myeloma. Methods Consecutive patients with newly diagnosed myeloma imaged with WB-MRI and WB-CT were prospectively reviewed. For each body region and modality, two experienced and two junior radiologists scored disease burden with final scores by consensus. Intraclass correlation coefficients (ICC), median scores, Wilcoxon signed-rank test and Spearman’s correlation coefficients were calculated. Results There was no significant difference in overall observer scores between WB-MRI and WB-CT (p = 0.87). For experienced observers, interobserver agreement for WB-MRI was superior to WB-CT overall and for each region, without overlap in whole-skeleton confidence intervals (ICC 0.98 versus 0.77, 95%CI 0.96–0.99 versus 0.45–0.91). For inexperienced observers, although there is a trend for a better interobserver score for the whole skeleton on WB-MRI (ICC 0.95, 95%CI 0.72–0.98) than on WB-CT (ICC 0.72, 95%CI 0.34–0.88), the confidence intervals overlap. Conclusions WB-MRI offers excellent interobserver agreement which is superior to WB-CT for experienced observers. Although the overall burden was similar across both modalities, patients with lower disease burdens where MRI could be advantageous are not included in this series. Key Points • Whole-body MRI is recommended by the International Myeloma Working Group for patients with multiple myeloma and solitary plasmacytoma and by the NICE guidance for those with suspected multiple myeloma. • Some centres unable to offer whole-body MRI (WB-MRI) offer low-dose whole-body CT (WB-CT). • This prospective study demonstrates that contemporary WB-MRI (with anatomical sequences and DWI) provides better interobserver agreement in assessing myeloma disease burden for the whole skeleton and across any individual body region in myeloma patients when compared with low-dose whole-body CT. Electronic supplementary material The online version of this article (10.1007/s00330-019-06281-x) contains supplementary material, which is available to authorized users.

The European SocieTy for Radiation and Oncology -Advisory Committee on Radiation Oncology Practice (ESTRO-ACROP) endorsed a project to provide guidelines (GL) for the identification and delineation of clinically negative lymph-nodal stations (LNs) involved in upper gastrointestinal clinical scenarios. The presented GL is focused on preoperative (or definitive) setting. The project aim is to improve the consistency of clinical target volume (CTV) delineation by providing: a description of the anatomical boundaries of the LNs; a radiological computed tomography-based atlas depicting the LNs areas; a free, web-based, interactive example case for independent training of radiation oncologists on LNs delineation according to the presented GL, by both qualitative and quantitative analysis (through the FALCON EduCase platform). This project was carried out with the intention to facilitate and improve uniformity of future upper gastrointestinal guidelines on nodal CTV delineation. We report methodology and results from the collaboration of a working group panel selected by the ESTRO-ACROP. ispartof: RADIOTHERAPY AND ONCOLOGY vol:164 pages:92-97 ispartof: location:Ireland status: published

Objectives: In accordance with initial guidance from the Royal College of Surgeons and Royal College of Radiologists, we evaluated the utility of CT of the chest in the exclusion of asymptomatic COVID-19 infection prior to elective cancer surgery on self-isolating patients during the pandemic. Methods: All surgical referrals without symptoms of COVID-19 infection in April and May 2020 were included. Patient records were retrospectively reviewed. Screening included CT chest for major thoracic and abdominal surgery. CTs were reported according to British Society of Thoracic Imaging guidelines and correlated with reverse transcriptase polymerase chain reaction (RT-PCR) and surgical outcomes. Results: The prevalence of RT-PCR confirmed COVID-19 infection in our screened population was 0.7% (5/681). 240 pre-operative CTs were performed. 3.8% (9/240) of CTs were reported as abnormal, only one of which was RT-PCR positive. 2% (5/240) of cases had surgery postponed based on CT results. All nine patients with CTs reported as abnormal have had surgery, all without complication. Conclusion: The prevalence of asymptomatic COVID-19 infection in our screened population was low. The pre-test probability of CT chest in asymptomatic, self-isolating patients is consequently low. CT can produce false positives in this setting, introducing unnecessary delay in surgery for a small proportion of cases. Advances in knowledge: Self-isolation, clinical assessment and RT-PCR are effective at minimising COVID-19 related surgical risk. The addition of CT chest is unhelpful. Our data have particular relevance during the second wave of infection and in the recovery phase.

Gastric and esophageal tumors have a poor prognosis; approximately 15% of patients are alive at 10 years following diagnosis. Surgical resection plus adjunctive chemotherapy or chemoradiotherapy is curative in approximately 50% of patients with operable disease, but is also associated with significant morbidity. Therefore, accurate preoperative staging is required to spare patients unnecessary toxicity and futile surgery. This review evaluates the sensitivity and specificities of the modalities used to stage patients with gastroesophageal cancer. Staging techniques reviewed include CT, PET, MRI, EUS, and laparoscopy. The article concludes with suggestions on appropriate staging tools according to site and stage of disease.

Background Diagnosis of lymph node (LN) metastasis in melanoma with non-invasive methods is challenging. The aim of this study was to evaluate the diagnostic accuracy of six LN characteristics on CT in detecting melanoma-positive ilioinguinal LN metastases, and to determine whether inguinal LN characteristics can predict pelvic LN involvement. Methods This was a single-centre retrospective study of patients with melanoma LN metastases at a tertiary cancer centre between 2008 and 2016. Patients who had preoperative contrast-enhanced CT assessment and ilioinguinal LN dissection were included. CT scans containing significant artefacts obscuring the pelvis were excluded. CT scans were reanalysed for six LN characteristics (extracapsular spread (ECS), minimum axis (MA), absence of fatty hilum (FH), asymmetrical cortical nodule (CAN), abnormal contrast enhancement (ACE) and rounded morphology (RM)) and compared with postoperative histopathological findings. Results A total of 90 patients were included. Median age was 58 (range 23–85) years. Eighty-eight patients (98 per cent) had pathology-positive inguinal disease and, of these, 45 (51 per cent) had concurrent pelvic disease. The most common CT characteristics found in pathology-positive inguinal LNs were MA greater than 10 mm (97 per cent), ACE (80 per cent), ECS (38 per cent) and absence of RM (38 per cent). In multivariable analysis, inguinal LN characteristics on CT indicative of pelvic disease were RM (odds ratio (OR) 3.3, 95 per cent c.i. 1.2 to 8.7) and ECS (OR 4.2, 1.6 to 11.3). Cloquet’s node is known to be a poor predictor of pelvic spread. Pelvic LN disease was present in 50 per cent patients, but only 7 per cent had a pathology-positive Cloquet’s node. Conclusion Additional CT radiological characteristics, especially ECS and RM, may improve diagnostic accuracy and aid clinical decisions regarding the need for inguinal or ilioinguinal dissection., The use of non-invasive imaging to detect melanoma lymph node metastases is challenging. This study showed that the use of additional CT morphological characteristics may improve diagnostic accuracy. Additional features of importance

Contains fulltext : 207090.pdf (Publisher’s version ) (Closed access) Multimodal primary treatment of localised adenocarcinoma of the stomach, the oesophagus and the oesophagogastric junction (AEG) was reviewed by a multidisciplinary expert panel in a moderated consensus session. Here, we report the key points of the discussion and the resulting recommendations. The exact definition of the tumour location and extent by white light endoscopy in conjunction with computed tomography scans is the backbone for any treatment decision. Their value is limited with respect to the infiltration depth, lymph node involvement and peritoneal involvement. Additional endoscopic ultrasound was recommended mainly for tumours of the lower oesophagogastric junction (i.e. AEG type II and III according to Siewert) and in early cancers before endoscopic resection. Laparoscopy to diagnose peritoneal involvement was thought to be necessary before the start of neoadjuvant treatment in all gastric cancers and in AEG type II and III. In general, perioperative multimodal treatment was suggested for all locally advanced oesophageal tumours and for gastric cancers with a clinical stage above T1N0. There was consensus that the combination of fluorouracil, folinic acid, oxaliplatin and docetaxel is now a new standard chemotherapy (CTx) regimen for fit patients. In contrast, the optimal choice of perioperative CTx versus neoadjuvant radiochemotherapy (neoRCTx), especially for AEG, was identified as an open question. Expert treatment recommendations depend on the tumour location, biology, the risk of incomplete (R1) resection, response to treatment, local or systemic recurrence risks, the predicted perioperative morbidity and patients' comorbidities. In summary, any treatment decision requires an interdisciplinary discussion in a comprehensive multidisciplinary setting.

Objective: Current therapies for multiple myeloma, which include corticosteroids, increase risk of avascular necrosis. The aim of this study was to assess incidental detection of femoral head avascular necrosis on routine whole body MRI including diffusion weighted MRI. Methods: All whole body MRI studies, performed on patients with known multiple myeloma between 1 January 2010 to 1 May 2017 were assessed for features of avascular necrosis. Results: 650 whole body MR scans were analysed. 15 patients (6.6%) had typical MR features of avascular necrosis: 2/15 (13.3%) had femoral head collapse, 4/15 (26.7%) had bilateral avascular necrosis and 9/15 (60%) were asymptomatic. Conclusion: This is the first report of avascular necrosis detected on routine whole body MRI in patients with multiple myeloma. Targeted review of femoral heads in multiple myeloma patients undergoing whole body MR is recommended, including in patients without symptoms. Advances in knowledge: Whole body MR which includes diffusion-weighted MRI is extremely sensitive for evaluation of bone marrow. Although whole body MRI is primarily used for evaluation of multiple myeloma disease burden, it also presents an unique opportunity to evaluate the femoral heads for signs of avascular necrosis which can predate symptoms.

8012 Background: Early and sensitive detection of bone marrow disease and stratified patient management according to clinical risk can confer survival advantages in multiple myeloma (MM). Whole body MRI (WB MRI) and Fluorodeoxyglucose (FDG) PET/CT are included in international guidelines for imaging in patients with a suspected diagnosis of MM. However prospective studies comparing detection of MM by contemporary WB MRI as per recent MY-RADS consensus against FDG PET/CT are lacking. We report here protocol-defined endpoints from the prospective iTIMM (NCT02403102) study, comparing WB MRI and PET/CT, their relationship with serum and bone marrow estimates of disease burden, as well as molecular tumor characteristics. Methods: Patients with newly diagnosed MM or at first relapse planned to receive chemotherapy and autologous stem cell transplantation were enrolled in iTIMM. Matched baseline WB MRI and FDG PET/CT were performed and baseline clinical data including tumor genetics collected. Scans were double reported for presence of focal and diffuse disease by expert MRI and PET/CT radiologists, blinded to each other’s assessment. Paired methods were used to compare burden and patterns of disease on WB MRI compared to FDG PET/CT at baseline. Primary and secondary trial endpoints include relationship between post-treatment WB MRI response and progression-free survival, for which follow-up is ongoing. Exploratory endpoints include comparison of baseline WB MRI and PET/CT and their correlation with laboratory parameters, for which data is complete and reported here. Results: From May 2015 to March 2018, sixty patients (35 male; mean age 60 years) underwent baseline WB MRI as per MY-RADS consensus and FDG PET/CT. At least one focal lesion was detected in 50/60 patients (83.3%) by WB MRI and in 36/60 patients (60%) by PET/CT. WB MRI was more sensitive ( P< 0.05) across anatomical regions except for ribs and cervical spine. Four patients in our study showed two or more focal lesions ≥5 mm only on WB MRI but not PET/CT. All lesions detected by WB MRI but not PET/CT resolved in follow-up scans after treatment, excluding false positives. In 49/60 (81.7%) patients, diffuse disease was detected by WB MRI, compared to 10/60 (16.7%) by PET-CT; WB MRI was more sensitive across all anatomical areas ( P< 0.05). Plasma cell infiltration and paraprotein levels were significantly higher for patients with diffuse disease on WB MRI, but not on PET/CT. All genetically high-risk tumours, defined by t(4;14), t(14;16), del(1p), gain(1q) or del(17p), showed diffuse infiltration on WB MRI. Conclusions: WB MRI increases detection of focal and diffuse disease compared with FDG PET/CT, including improved detection of focal lesions meeting criteria for active disease as per International Myeloma Working Group diagnostic criteria, proposing it as a gold standard for tumor imaging in MM. Clinical trial information: NCT02403102.

Background: Patients with head and neck squamous cell carcinoma (HNSCC) undergoing radical chemo-radiation (CRT) frequently receive transfusion with packed red cells (PRCT) during radiotherapy on the basis that PRCT increases tumour oxygenation and overcomes hypoxia-induced radio-resistance. This is likely to be a significant oversimplification given the fact that tumour hypoxia is the result of several intrinsic and extrinsic factors, including many that are not directly related to serum haemoglobin (Hb). Therefore, we have studied the effect of PRCT on tumour oxygenation in a prospective cohort of patients who developed low Hb during radical CRT for HNSCC. Methods: This was a prospective study of 20 patients with HNSCC receiving radical CRT undergoing PRCT for Hb

Purpose: To investigate the effects of different time-resolved angiography with stochastic trajectories (TWIST) k-space undersampling schemes on calculated pharmacokinetic dynamic contrast-enhanced (DCE) vascular parameters. Methods: A digital perfusion phantom was employed to simulate effects of TWIST on characteristics of signal changes in DCE. Furthermore, DCE-MRI was acquired without undersampling in a group of patients with head and neck squamous cell carcinoma and used to simulate a range of TWIST schemes. Errors were calculated as differences between reference and TWIST-simulated DCE parameters. Parametrical error maps were used to display the averaged results from all tumors. Results: For a relatively wide range of undersampling schemes, errors in pharmacokinetic parameters due to TWIST were under 10% for the volume transfer constant, K-trans, and total extracellular extravascular space volume, V-e. TWIST induced errors in the total blood plasma volume, V-p, were the largest observed, and these were inversely dependent on the area of the fully sampled k-space. The magnitudes of errors were not correlated with K-trans, V-p and weakly correlated with V-e. Conclusions: The authors demonstrated methods to validate and optimize k-space view-sharing techniques for pharmacokinetic DCE studies using a range of clinically relevant spatial and temporal patient derived data. The authors found a range of undersampling patterns for which the TWIST sequence can be reliably used in pharmacokinetic DCE-MRI. The parameter maps created in the study can help to make a decision between temporal and spatial resolution demands and the quality of enhancement curve characterization. (C) 2016 Author(s).

To assess the optimal timing and predictive value of early intra-treatment changes in multimodality functional and molecular imaging (FMI) parameters as biomarkers for clinical remission in patients receiving chemoradiation for head and neck squamous cell carcinoma (HNSCC).Thirty-five patients with stage III-IVb (AJCC 7th edition) HNSCC prospectively underwentThere were 27 responders and 8 non-responders. Responders showed a greater reduction in PET-derived tumor total lesion glycolysis (TLGEarly intra-treatment changes in FDG-PET, DW and DCE MRI-derived parameters are predictive of ultimate response to chemoradiation in HNSCC. However, the optimal timing for assessment with FDG-PET parameters (week 1) differed from MRI parameters (week 2). This highlighted the importance of scanning time points for the design of FMI risk-stratified interventional studies.

Background 95% of metastatic colorectal cancers (mCRCs) have normal mismatch repair proficient (pMMR) expression and a stable microsatellite phenotype (MSS). As a consequence, checkpoint inhibiting immunotherapy currently plays no role in these tumours. We recently found that RAS/RAF wild type (WT) mCRCs (50% of all CRCs) that first responded to cetuximab and then acquired resistance had converted from an immune-excluded or immune-desert phenotype before treatment to an inflamed phenotype at progression. This progression was characterized by increased CD8+ T cell infiltrates and upregulation of PDL1 and LAG3 immune checkpoints. To assess if the cetuximab induced immune infiltrates can be exploited for therapeutic benefit, the iSCORE trial will treat 25 patients with combined anti-PD1 (nivolumab) and anti-LAG3 (relatlimab) immunotherapy starting ideally within 4 weeks after progression on immunogenic FOLFIRI chemotherapy and cetuximab. Trial design iSCORE is designed to evaluate the efficacy of nivolumab and relatlimab in patients with RAS/RAF WT mCRC who have had radiological response to first line FOLFIRI and cetuximab, but then progressed. Eligible patients will receive nivolumab 480mg and relatlimab 160mg every 4 weeks. The primary endpoint is disease control rate (DCR) at 6 months from treatment initiation. With an A’Hern single stage design for efficacy, 5% significance and a power of 80%, 25 patients would need to be treated and a minimum of 6 would need to be progression free at 6 months in order to support an increase of the DCR at 6 months from Clinical trial identification NCT03867799. Legal entity responsible for the study The Royal Marsden NHS Foundation Trust. Funding The Royal Marsden NHS Foundation Trust, Bristol-Myers Squibb. Disclosure D. Cunningham: Research grant / Funding (institution): AstraZeneca; Research grant / Funding (institution): Celgene; Research grant / Funding (institution): MedImmune; Research grant / Funding (institution): Bayer; Research grant / Funding (institution): 4SC; Research grant / Funding (institution): Clovis; Research grant / Funding (institution): Eli Lilly; Research grant / Funding (institution): Janssen; Research grant / Funding (institution): Merck. I. Chau: Advisory / Consultancy: Eli Lilly; Advisory / Consultancy: BMS; Advisory / Consultancy: MSD; Advisory / Consultancy: Bayer; Advisory / Consultancy: Roche; Advisory / Consultancy: Merck-Serono; Advisory / Consultancy: Five Prime Therapeutics; Advisory / Consultancy: AstraZeneca; Advisory / Consultancy: Oncologie International; Advisory / Consultancy: Pierre Fabre; Research grant / Funding (institution): Eli Lilly; Research grant / Funding (institution): Janssen-Cilag; Research grant / Funding (institution): Sanofi Oncology; Research grant / Funding (institution): Merck-Serono; Honoraria (self): Eli-Lilly. M. Gerlinger: Research grant / Funding (institution): BMS; Research grant / Funding (institution): Merck KG. N. Starling: Research grant / Funding (institution): AstraZeneca; Research grant / Funding (institution): BMS; Research grant / Funding (institution): Pfizer; Travel / Accommodation / Expenses: AstraZeneca; Travel / Accommodation / Expenses: BMS; Travel / Accommodation / Expenses: Eli Lilly; Travel / Accommodation / Expenses: Merck; Travel / Accommodation / Expenses: Roche; Honoraria (self): AstraZeneca; Honoraria (self): Eli Lilly; Honoraria (self): Merck; Honoraria (self): Servier; Advisory / Consultancy: Pfizer; Advisory / Consultancy: AstraZeneca; Advisory / Consultancy: Servier. All other authors have declared no conflicts of interest.

Whole-body diffusion-weighted MRI: a new gold standard for assessing disease burden in patients with multiple myeloma?

To investigate the effects of different time-resolved angiography with stochastic trajectories (TWIST) k-space undersampling schemes on calculated pharmacokinetic dynamic contrast-enhanced (DCE) vascular parameters.A digital perfusion phantom was employed to simulate effects of TWIST on characteristics of signal changes in DCE. Furthermore, DCE-MRI was acquired without undersampling in a group of patients with head and neck squamous cell carcinoma and used to simulate a range of TWIST schemes. Errors were calculated as differences between reference and TWIST-simulated DCE parameters. Parametrical error maps were used to display the averaged results from all tumors.For a relatively wide range of undersampling schemes, errors in pharmacokinetic parameters due to TWIST were under 10% for the volume transfer constant, KThe authors demonstrated methods to validate and optimize k-space view-sharing techniques for pharmacokinetic DCE studies using a range of clinically relevant spatial and temporal patient derived data. The authors found a range of undersampling patterns for which the TWIST sequence can be reliably used in pharmacokinetic DCE-MRI. The parameter maps created in the study can help to make a decision between temporal and spatial resolution demands and the quality of enhancement curve characterization.

The objective of this study was to assess the predictive value of early assessment (after 1 cycle of induction chemotherapy [IC]) with F-18-FDG PET/CT and diffusion-weighted (DW) MRI for subsequent response to radical chemoradiotherapy in locally advanced head and neck squamous cell carcinoma (HNSCC). Methods: Twenty patients with stage III-IVa HNSCC prospectively underwent F-18-FDG PET/CT and DW MRI before and 2 wk after each cycle of IC (first cycle, IC1; second cycle, IC2). Response was assessed 3 mo after completion of chemoradiotherapy with clinical examination, MRI, and F-18-FDG PET/CT. Patients with persistent disease were classed as nonresponders. Changes in functional and molecular imaging parameters after IC1 were compared between responders and nonresponders with the Mann-Whitney U test. The significance threshold was set at a P value of less than 0.05. Results: Responders showed a significantly greater reduction in metabolic tumor volume (P = 0.03) and total lesion glycolysis (P = 0.04) after IC1 than nonresponders. Responders also showed a tendency toward a larger but statistically nonsignificant increase in apparent diffusion coefficient after IC1. There was no significant difference in the changes from baseline between the IC1 and IC2 for all functional and molecular imaging parameters, indicating that most biologic response to IC measured by 18F-FDG PET/CT and DW MRI was observed early after the first cycle of IC. Conclusion: Our preliminary data indicate that the 18F-FDG PET/CT-derived metabolic tumor volume or total lesion glycolysis, acquired after IC1, are early predictive biomarkers for ultimate response to subsequent chemoradiotherapy. These early biomarkers enable identification of patients at risk of treatment failure at an early time point, permitting treatment individualization and consideration of alternative strategies such as radiotherapy dose escalation or surgery.

We describe a case of intra-abdominal fibromatosis, which occurred in a 44-year-old woman who had a previous history of gastrointestinal stromal tumor (GIST) of the sigmoid mesocolon, which was treated with imatinib and resection. A mass was detected at the site of ileocolic anastomosis of the previous small bowel resection and sigmoid colectomy, nearly 3 years later. Clinically, this was suspected to represent recurrent GIST and was excised, but histology and mutational analysis showed desmoid-type fibromatosis with a mutation in codon 41 of exon 3 of the CTNNB1 (β-catenin) gene. The occurrence of fibromatosis at the site of excision of GIST is very rare, but its recognition is important as the treatment of the two neoplasms differs significantly. As imaging cannot reliably distinguish between these 2 entities, histological diagnosis is crucial for correct clinical management.

Oesophageal cancer is the third most common gastrointestinal malignancy worldwide. Over the last 40 years, the UK has seen a rise in prevalence and it is now the 13th most common cancer in adults [1]. It has an incidence of 8,300 new cases each year demonstrating a 2:1 preference for males to females. It is reported that 80 % of new cases are diagnosed in patients over 60 years of age [1]. The distribution of tumour subtype varies according to ethnicity with adenocarcinoma favouring Caucasians and squamous cell carcinomas favouring Asian, South American and African populations [2]. Despite advances in multimodality treatment, oesophageal cancer is still devastatingly aggressive with over 65 % of new cases incurable at time of presentation. The disease maintains a 5-year survival of just 15–20 % [3].

Segmental liver hyperintensity can be observed in malignant biliary obstruction on diffusion weighted MRI (DW-MRI). We describe MRI findings associated with this sign and evaluate whether DW-MRI segmental hyperintensity has any relationship with serum alanine aminotransferase (ALT) levels.The DW-MRI T(1) weighted, T(2) weighted and gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced T(1) weighted images obtained in 21 patients with hepatic malignancy, who demonstrated biliary obstruction and segmental hyperintensity on DW-MRI (b=0-750 s mm(-2)), were retrospectively reviewed by 2 readers blinded to clinical results. DW-MRI hyperintense liver segments were recorded as hypointense, isointense or hyperintense relative to normal liver on T(1)/T(2) weighted imaging. It was also noted whether contrast enhancement was similar to that observed in normal liver or diminished in the hepatocellular phase. The mean apparent diffusion coefficient (ADC) value (×10(-3) s mm(-2)) of DW-MRI hyperintense segments, normal liver and tumour were compared using Student's t-test. The frequency of MRI findings was corroborated with serum ALT levels, which reflect hepatocyte injury.DW-MRI hyperintense segments frequently showed T(1) hyperintensity (10/21), T(2) hyperintensity (19/21) and/or diminished contrast enhancement (15/21). Tumours showed significantly lower mean ADC values than liver (1.23 ± 0.08 vs 1.43 ± 0.05; p=0.013). Segments showing concomitant T(1) hyperintensity had lower mean ADC values than liver (1.30 ± 0.05 vs 1.43 ± 0.05; p=0.023). The patients (8/10) with concomitant T(1) and DW-MRI segmental hyperintensity showed elevated ALT levels (p=0.030, Fisher's exact test).Concomitantly high T(1) weighted and DW-MRI signal in liver segments was associated with lower ADC values and abnormal liver function tests, which could reflect underlying cellular swelling and damage.

TPS4139Background: Peri-operative chemotherapy with 5FU, oxaliplatin and docetaxel (FLOT) is a new standard of care in resectable gastro-oesophageal adenocarcinoma (GOA), however with 3y survival r...

Introduction Magnetic resonance imaging (MRI) provides superior diagnostic accuracy over computed tomography (CT) in oropharyngeal tumours. Precise delineation of the gross tumour volume (GTV) is mandatory in radiotherapy planning when a GTV boost is required. CT volume definition in this regard is poor. We studied the feasibility of using flexible surface (flex-L) coils to obtain MR images for MR–CT fusion to assess the benefit of MRI over CT alone in planning base of tongue tumours. Methods Eight patients underwent CT and MRI radiotherapy planning scans with an immobilisation device. Distortion-corrected T1-weighted post-contrast MR scans were fused to contrast-enhanced planning CT scans. GTV, clinical target and planning target volumes (CTV, PTV) and organs at risk (OAR) were delineated on CT, then on MRI with blinding to the CT images. The volumetric and spatial differences between MRI and CT volumes for GTV, CTV, PTV and OAR were compared. MR image distortions due to field inhomogeneity and non-linear gradients were corrected and the need for such correction was evaluated. Results The mean primary GTV was larger on MRI (22.2 vs. 9.5cm 3 , p =0.05) than CT. The mean primary and nodal GTV (i.e. BOT and macroscopic nodes) was significantly larger on MRI (27.2 vs. 14.4cm 3 , p =0.05). The volume overlap index (VOI) between MRI and CT for the primary was 0.34 suggesting that MRI depicts parts of the primary tumour not detected by CT. There was no significant difference in volume delineation between MR and CT for CTV, PTV, nodal CTV and nodal PTV. MRI volumes for brainstem and spinal cord were significantly smaller due to improved organ definition ( p =0.002). Susceptibility and gradient-related distortions were not found to be clinically significant. Conclusion MRI improves the definition of tongue base tumours and neurological structures. The use of MRI is recommended for GTV dose-escalation techniques to provide precise depiction of GTV and improved sparing of spinal cord and brainstem.

Preoperative cisplatin/fluorouracil is used for the treatment of localised oesophageal carcinoma. This phase II study aimed to assess the efficacy and safety of administering preoperative epirubicin/cisplatin/capecitabine (ECX). Patients with stage II or III oesophageal/gastro-oesophageal junctional adenocarcinoma from one institution received 4 cycles of ECX (epirubicin 50 mg m(-2) day 1, cisplatin 60 mg m(-2) day 1, capecitabine 625 mg m(-2) b.i.d. daily) followed by surgery. The primary end point was the pathological complete response (pCR) rate based on a Simon two-stage design. Secondary end points included overall and progression-free survival (OS/PFS). Thirty-four patients were recruited: median age 60 years (range 41-81), 91% male, 97% PS 0/1, 80% T3, 68% N1. Thirty-one patients completed four ECX cycles. Grade 3/4 toxicitiesor=5% included neutropenia (62%), hand-foot syndrome (15%) and nausea/vomiting (9%). Thirteen out of 28 (46%) evaluable patients responded to chemotherapy by EUS (or=30% reduction in maximal tumour thickness). Twenty-six out of 34 (76%) patients underwent resection (R0=73%, R1=27%). Post-operatively, two patients died within 60 days of surgery. The pCR rate was 5.9% (95% CI 0-14%) in the intent-to-treat population. According to the statistical design, this prompted early study termination. However, with a median follow-up of 34 months the median OS and 1- and 2-year survival rates were 17 months, 67 and 39% respectively. Median PFS was 13 months. Of the 14 relapsed patients, 10 presented with distant metastases. Preoperative ECX is feasible and well tolerated. Although associated with a low pCR rate, survival with ECX was comparable with published studies suggesting that pCR may not correlate with satisfactory outcome from preoperative chemotherapy for localised oesophageal adenocarcinoma.

Malignant pleural mesothelioma (MPM) typically demonstrates a non-spherical growth pattern, so it is often difficult to accurately categorize change in tumour burden using size-based tumour response criteria (e.g., WHO (World Health Organisation), RECIST (Response Evaluation Criteria in Solid Tumours) and modified RECIST). Functional imaging techniques are applied to derive quantitative measurements of tumours, which reflect particular aspects of the tumour pathophysiology. By quantifying how these measurements change with treatment, it is possible to observe treatment effects. In this review, we survey the existing roles of CT and MRI for the management of MPM, including the currently applied size measurement criteria for the assessment of treatment response. New functional imaging techniques, such as positron emission tomography (PET), diffusion-weighted MRI (DWI) and dynamic contrast-enhanced MRI (DCE-MRI) that may potentially improve the assessment of treatment response will be highlighted and discussed.

Liver-specific magnetic resonance (MR) contrast agents are increasingly used in evaluation of the liver. They are effective in detection and morphological characterization of lesions, and can be useful for evaluation of biliary tree anatomy and liver function. The typical appearances and imaging pitfalls of various tumours at MR imaging performed with these agents can be understood by the interplay of pharmacokinetics of these contrast agents and transporter expression of the tumour. This review focuses on the applications of these agents in oncological imaging.

BACKGROUND: When induction chemotherapy (IC) is used prior to chemoradiotherapy (CRT) in head and neck cancer (HNC), functional imaging (FI) may inform adaptation of treatment plans with the aim of optimising outcomes. Understanding the impact of IC on FI parameters is, therefore, essential. PURPOSE: To prospectively evaluate the feasibility of acquiring serial FI ((18)F-FDG-PET, diffusion-weighted (DW) and dynamic contrast-enhanced (DCE) MRI) and its role in defining individualised treatment regimens following IC in HNC. METHODS AND MATERIALS: Ten patients with stage III and IV HNC underwent conventional (CT and MRI) and functional (DW, DCE-MRI and (18)F-FDG-PET/CT) imaging at baseline and following two cycles of IC prior to definitive CRT. RESULTS: One patient withdrew due to claustrophobia. Seven out of nine patients had a complete metabolic response to IC on (18)F-FDG-PET imaging. DCE-MRI showed a significant fall in transfer constant (K(trans)) (0.209 vs 0.129 min(-1)P

To compare the diagnostic accuracy of gadolinium-ethoxybenzyl-diethylenetriaminepentaacetic acid (Gd-EOB-DTPA)-enhanced MRI, diffusion-weighted MRI (DW-MRI) and a combination of both techniques for the detection of colorectal hepatic metastases.72 patients with suspected colorectal liver metastases underwent Gd-EOB-DTPA MRI and DW-MRI. Images were retrospectively reviewed with unenhanced T(1) and T(2) weighted images as Gd-EOB-DTPA image set, DW-MRI image set and combined image set by two independent radiologists. Each lesion detected was scored for size, location and likelihood of metastasis, and compared with surgery and follow-up imaging. Diagnostic accuracy was compared using receiver operating characteristics and interobserver agreement by kappa statistics.417 lesions (310 metastases, 107 benign) were found in 72 patients. For both readers, diagnostic accuracy using the combined image set was higher [area under the curve (Az)=0.96, 0.97] than Gd-EOB-DTPA image set (Az=0.86, 0.89) or DW-MRI image set (Az=0.93, 0.92). Using combined image set improved identification of liver metastases compared with Gd-EOB-DTPA image set (p0.001) or DW-MRI image set (p0.001). There was very good interobserver agreement for lesion classification (κ=0.81-0.88).Combining DW-MRI with Gd-EOB-DTPA-enhanced T(1) weighted MRI significantly improved the detection of colorectal liver metastases.

AimTo evaluate the tolerability and efficacy of sorafenib in patients with thyroid carcinoma.MethodsPatients with progressive locally advanced/metastatic medullary thyroid carcinoma (MTC), or differentiated thyroid carcinoma (DTC) with non-radioiodine-avid disease, were treated with sorafenib 400 mg twice daily until disease progression. The primary endpoint was the radiological response rate (RR) at 6 months. Secondary endpoints were RR at 3, 9 and 12 months, biochemical responses, toxicity, biomarker analyses and progression free and overall survival (OS).ResultsA total of 34 patients were recruited to the study (15 medullary and 19 differentiated). After 6 months, the RR rate was 15% and a further 74% of patients achieved stable disease in the first 6 months. After 12 months of treatment, the RR was 21%. In the MTC patients, the RR at 12 months was 25% and OS was 100%. In DTC patients corresponding rates were 18 and 79% respectively. Median overall and progression-free survival points were not reached at 19 months. Commonest adverse events included hand–foot syndrome, other skin toxicities, diarrhoea and alopecia. Dose reduction was required in 79% patients. Median time on treatment was 16.5 months.ConclusionThis study demonstrates that sorafenib is tolerable at reduced doses over prolonged periods of time in patients with thyroid cancer. Sorafenib leads to radiological and biochemical stabilisation of disease in the majority of these patients despite dose reductions.

The examination of limited, potentially non-representative fragments of tumour tissue from a core biopsy can be misleading and misdirect subsequent treatment, especially in cases where a primary tumour has not been identified. This case report is of a 65-year-old woman presenting with a destructive sacral mass, diagnosed on radiological imaging and core biopsy as a hindgut neuroendocrine tumour, which on histopathological review of the subsequently resected tumour was found instead to represent a metastasis from an occult hormone-positive breast cancer with neuroendocrine features.

Advances in MRI technology in recent years with the development of surface coils and faster sequence acquisition times now makes it possible to acquire images at high spatial resolution (small voxel size and field of view) with good signal-to-noise ratio. Different techniques are available for imaging the upper GI tract using either an external surface coil or a modified endoscope with a receiver coil mounted on the tip of the scope. The improved spatial resolution enables visualization of the individual layers of the esophageal and stomach wall, which is not possible when using conventional MRI techniques.

To compare the diagnostic accuracy of MnDPDP MR imaging and diffusion-weighted imaging (DWI), alone and in combination, for detecting colorectal liver metastases in patients with suspected metastatic disease. Thirty-three consecutive patients with suspected colorectal liver metastases underwent MR imaging. Three image sets (MnDPDP, DWI and combined MnDPDP and DWI) were reviewed independently by two observers. Lesions were scored on a five-point scale for malignancy and the areas (Az) under the receiver operating characteristic curves were calculated for each observer and image set. The sensitivity and specificity for lesion detection were calculated for each image set and compared. There were 83 metastases, 49 cysts and 1 haemangioma. Using the combined set resulted in the highest diagnostic accuracy for both observers (Az = 0.94 and 0.96), with improved averaged sensitivity of lesion detection compared with the DWI set (p = 0.01), and a trend towards improved sensitivity compared with the MnDPDP set (p = 0.06). There was no difference in the averaged specificity using any of the three image sets (p > 0.5). Combination of MnDPDP MR imaging and DWI resulted in the highest diagnostic accuracy and can increase sensitivity without loss in specificity.

Introduction: Whole body MRI is recommended for all patients suspected of having smouldering myeloma for detection of disease defining lesions (Dimopoulos et al. 2015). The speed, sensitivity and quantitative capabilities of Whole body Diffusion Weighted MRI (WB-DWI) have seen this increasingly used as the MRI sequence of choice for detection and response assessment in myeloma (Messiou and Kaiser 2015). 18-F-fluorodeoxyglucose positron emission tomography-CT (FDG PET-CT) also offers whole body coverage with standard uptake value (SUV) measurements of individual lesions. In previous studies the sensitivity and specificity of conventional MRI superseded FDG PET-CT due to improved detection of small focal lesions and diffuse disease (Zamagni et al. 2007, Shortt et al. 2009). However, WB-DWI and FDG PET-CT comparisons in patients with myeloma have not previously been investigated. We compared the assessment of myeloma using these two modalities and determined the relationship to laboratory estimates of disease burden. Method: Patients who had undergone paired WB-DWI and FDG PET-CT scans for myeloma at our institution were included. Scans were excluded if there was clinical or biochemical evidence of change in disease status between scans. Expert radiologists (WB-DWI = CM, AR; FDG PET-CT = BS, LF) scored disease burden by consensus using a previously described system (Giles et al. 2014) based on the number, size and pattern (diffuse/focal) of disease. Whole body and per region scores were compared. Bone marrow trephine assessments of % plasma cell (PC) infiltration were correlated to the imaging scores and compared to the assessment of disease infiltration at the iliac crests. Results: 20 pairs of scans were performed in 17 patients. Scans took place within a median of 9.5 days (range 0-78), mean 14 days ±18.15. There was a positive correlation between WB-DWI and FDG PET-CT scores (Spearman r = 0.35, 95% C.I. [-0.12,0.69]) but the whole body score for WB-DWI was significantly higher than for FDG PET-CT (WB-DWI mean 17.65±12.24 vs FDG PET-CT mean 8.45±8.70. P=0.0023 Wilcoxon signed rank). In all regions scores for WB-DWI (Table 1) were higher than FDG PET-CT with statistical significance in all except for pelvis and long bones. Diffuse disease was reported in 36% (51/140) of regions on WB-DWI scans compared to only 7% (10/140) on FDG PET-CT. The regions reported as having diffuse disease on WB-DWI were reported on FDG PET-CT as 'no disease' for most (36/51) regions (Figure 1A). Whole body scores were reanalyzed including only focal lesions. The scores for FDG PET-CT and WB-DWI were no longer significantly different (FDG PET-CT mean 6.45±7.06, WB-DWI mean 7.45±10.32, P=0.92) (Figure 1Bi-ii) suggesting the ability of WB-DWI to detect more disease is largely due to the increased ability to detect diffuse marrow involvement. For 10 WB-DWI scans on which there was activity a follow up WB-DWI was available and demonstrated a change in disease burden (e.g. Figure 1B). This supports the presence of active lesions on the initial MRI and indicates the utility of WB-DWI as a response assessment tool. 15/20 pairs had bone marrow trephines with adequate tissue for the calculation of PC % performed close to the FDG PET-CT and WB-DWI scans. The PC % was better correlated to WB-DWI scores than FDG PET-CT. In 93% of patients the trephine PC % was similar to the WB-DWI report of activity at the iliac crests compared with only 67% for FDG PET-CT. Conclusions: In paired scans WB-DWI reports a higher burden of myeloma disease than FDG PET-CT. This is largely due to the increased ability for WB-DWI to detect diffuse marrow disease. WB-DWI also outperforms FDG PET-CT in the assessment of disease infiltration in the iliac bones, essential for good clinical correlation of trephine results. We are in the process of validating these results in a prospective study but our results support guidance that MRI should be the investigation of choice for detection of myeloma marrow infiltration. Table 1. Region ScoreMean (±SD) P value* FDG PET-CT WB-DWI Whole body 8.45 (±8.70) 17.65 (±12.24) 0.002 C spine 0.47 (±1.17) 1.68 (±1.92) 0.016 D spine 1.20 (±1.64) 2.60 (±2.04) 0.011 L spine 1.00 (±1.62) 2.50 (±2.04) 0.007 Pelvis 2.40 (±2.54) 3.30 (±1.95) NS, 0.13 Long bones 1.85 (±2.35) 2.80 (±2.71) NS, 0.19 Skull 0.21 (±0.63) 1.95 (±1.96) 0.004 Ribs/other 1.35 (±1.90) 3.00 (±1.97) 0.006 *Wilcoxon matched-pairs signed rank test Figure 1. Figure 1. Disclosures Pawlyn: Celgene: Honoraria, Other: Travel support; The Institute of Cancer Research: Employment. Off Label Use: vorinostat for treatment of myeloma. Kaiser:Amgen: Consultancy, Honoraria; Janssen: Honoraria; Chugai: Consultancy; BristolMyerSquibb: Consultancy; Celgene: Consultancy, Honoraria, Research Funding. Jones:Celgene: Other: Travel support, Research Funding. Davies:Takeda-Milenium: Honoraria; Celgene: Honoraria; Onyx-Amgen: Honoraria; University of Arkansas for Medical Sciences: Employment. Morgan:Bristol Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees; Takeda-Millennium: Honoraria, Membership on an entity's Board of Directors or advisory committees; CancerNet: Honoraria; Weisman Institute: Honoraria; University of Arkansas for Medical Sciences: Employment; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; MMRF: Honoraria.

Methods In this retrospective study, 22 patients (15 M: 7F ; mean age =65) with CRLM were evaluated with gadoxetic acid enhanced MRI before and after chemotherapy. Regions of interest were drawn encompassing metastases on T1W images and ADC map by an expert radiologist to record their average signal intensities (SI) normalised to the SI of paravertebral muscle and the average ADC value. We compared the median ADC value; pre-contrast and hepatocellular phase normalised SI and their percentage change in pathologic complete responders and pathologic non complete responders before and after chemotherapy using Mann-Whitney test. Receiver operating curve characteristics (ROC) of these parameters were determined. A p-value of < 0.05 was deemed statistically significant.

surgery occurred in 3(5.6%) and 4(7.4%) patients in the CT group versus 4(7.8%) and 3(5.9%) patients in the CRT group. Conclusions: Part 1 of the TOPGEAR trial demonstrates preoperative CRT to be safe and feasible. With IDSMC recommendation the trial has proceeded to Part 2 where overall survival will be the primary end point. Current accrual is 170 patients recruited from 55 active sites. No conflict of interest.

The purpose of this study was to use high-resolution MRI to evaluate the surgical anatomy of the posterior mediastinum, in particular the esophagus and its relation to the surrounding structures. The aim was to familiarize radiologists with the appearance of structures considered important in planning surgical resection of the esophagus.The thoraces of two cadavers were imaged with a 1.5-T magnet using a high-resolution T2-weighted sequence. Axial cadaveric sections of the posterior mediastinum were cut with a band saw at levels determined from the MR images, and histologic whole-mount sections of the esophagus and surrounding tissue were prepared from the cadaveric sections. The appearance of structures identified on the MR images was compared with the findings on corresponding gross anatomic and histologic whole-mount sections.The MR images depicted the esophagus and structures in close anatomic relation: the pleural reflections and pericardium. The technique enabled visualization of structures to our knowledge not previously described on cross-sectional imaging: the individual layers of the esophageal wall, the thoracic duct, a connective tissue layer attaching the esophagus to the anterior wall of the aorta, and a fascial plane passing between layers of the right and left parietal pleura posterior to the esophagus.High-resolution MRI of the posterior mediastinum provides detailed anatomic information, delineating structures not visible on other forms of cross-sectional imaging. It can provide important information for planning surgical intervention.

This paper describes the development and optimization of an innovative technique using an external surface coil to obtain high resolution, thin section MR images of the oesophagus using volunteers. T2 weighted fast spin echo sequences were performed with and without cardiac gating. The field of view (FOV), matrix size, slice thickness, number of signal averages (NSA), and repetition time (TR)/echo time (TE) were altered to optimize signal to noise ratio (SNR) whilst maintaining spatial resolution. The effect of cardiac gating was also investigated. Workstation images were evaluated on the ability to visualize: individual oesophageal wall layers; perioesophageal fat; the azygos vein and wall of the descending aorta, giving qualitative assessment of image clarity. The optimum sequence enabled the layers of the oesophageal wall and perioesophageal tissues to be demonstrated in an acceptable scan time of 7.07 min. A FOV of less than 250 mm degraded image quality so that individual oesophageal wall layers could not be depicted and noise within the image impaired visualization of posterior mediastinal structures. The results indicate that high resolution imaging of the oesophagus using an external surface coil can depict anatomic structures clearly and that the use of cardiac gating improves image clarity. The technique offers an alternative, non-invasive method of detailed imaging of the oesophagus.

OBJECTIVE. The aim of this pilot study was to assess the feasibility of external surfacecoil MRI as a new method of imaging the esophagus and esophageal cancer.CONCLUSION. The results for the 10 patients investigated indicate that by using a high-resolution axial T2-weighted sequence (small field of view, thin section images), MRI provides detailed imaging of the anatomic layers of the esophageal wall and tumor. Three independent radiologists found good correlation in the morphologic appearance and extent of tumor between MRI and matched histology sections. This study illustrates the potential of the technique as an alternative form of local staging for esophageal cancer.

This paper describes the spectrum of imaging features of oesophageal adenocarcinoma seen using high-resolution T2-weighted (T2W) magnetic resonance imaging (MRI). Thirty-nine patients with biopsy-proven oesophageal adenocarcinoma were scanned using an external surface coil. A sagittal T2W sequence was used to localise the tumour and to plan axial images perpendicular to the tumour. Fast spin-echo (FSE) T2W axial sequence parameters were: TR/TE, 3,300–5,000 ms/120–80 ms; field of view (FOV) 225 mm, matrix 176×512(reconstructed) mm to 256×224 mm, giving an in-plane resolution of between 1.28×0.44 mm and 0.88×1.00 mm, with 3-mm slice thickness. Thirty-three patients underwent resection and the MR images were compared with the histological whole-mount sections. There were four T1, 12 T2, and 17 T3 tumours. The T2W high-resolution MRI sequences produced detailed images of the oesophageal wall and surrounding structures. Analysis of the imaging appearances for different tumour T stages enabled the development of imaging criteria for local staging of oesophageal cancer using high-resolution MRI. Our study illustrates the spectrum of appearances of oesophageal cancer on T2W high-resolution MRI, and using the criteria established in this study, demonstrates the potential of this technique as an alternative non-invasive method for local staging for oesophageal cancer.