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Background and Aims Since there are no accurate methods for fibrosis identification or quantification, the purpose is to investigate the utility of magnetization transfer (MT) MRI and texture analysis (TA) of T2-weighted MR images for intestinal fibrosis assessment in a mouse model of gut fibrosis. Methods Chronic colitis was obtained in 16 C57BL/6 mice by cyclic administration of dextran sodium sulphate (DSS) inducing early phase inflammation and progressive bowel fibrosis. Mice underwent 7.0 T MR imaging at various timepoints. MT ratio (MTR) in the bowel wall was calculated. Textural features (skewness, kurtosis, entropy) were extracted by a filtration histogram technique. Resected colonic tissue was scored for inflammation and fibrosis. Performance of MT-MRI and TA was validated in a consecutive experiment in mice using antifibrotic therapy. Finally, a retrospective study was conducted in five CD patients who underwent bowel surgery. Results MTR and texture entropy both correlated with histopathological fibrosis (r = .85 and .81, respectively). Entropy was superior to MTR for monitoring bowel fibrosis in presence of coexisting inflammation (linear regression R² = .93 versus R2 = .01). Furthermore, texture entropy was able to assess antifibrotic therapy response (placebo mice versus treated mice at endpoint scan; Δ mean = 0.128, p < .0001). An increase in entropy was indicative of fibrosis accumulation in human CD strictures (1.29 in inflammation; 1.40 and 1.48 in mixed strictures; 1.73 and 1.90 in fibrosis). Conclusion Texture analysis of T2-weighted MR images outperforms magnetization transfer imaging in detecting the fibrotic component in mixed inflammatory-fibrotic bowel tissue and can be used for monitoring antifibrotic treatment response.

Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.The initial STOMP and ORIOLE trial reports suggested that metastasis-directed therapy (MDT) in oligometastatic castration-sensitive prostate cancer (omCSPC) was associated with improved treatment outcomes. Here, we present long-term outcomes of MDT in omCSPC by pooling STOMP and ORIOLE and assess the ability of a high-risk mutational signature to risk stratify outcomes after MDT. The primary end point was progression-free survival (PFS) calculated using the Kaplan-Meier method. High-risk mutations were defined as pathogenic somatic mutations within ATM, BRCA1/2, Rb1, or TP53. The median follow-up for the whole group was 52.5 months. Median PFS was prolonged with MDT compared with observation (pooled hazard ratio [HR], 0.44; 95% CI, 0.29 to 0.66; P value < .001), with the largest benefit of MDT in patients with a high-risk mutation (HR high-risk, 0.05; HR no high-risk, 0.42; P value for interaction: .12). Within the MDT cohort, the PFS was 13.4 months in those without a high-risk mutation, compared with 7.5 months in those with a high-risk mutation (HR, 0.53; 95% CI, 0.25 to 1.11; P = .09). Long-term outcomes from the only two randomized trials in omCSPC suggest a sustained clinical benefit to MDT over observation. A high-risk mutational signature may help risk stratify treatment outcomes after MDT. ispartof: JOURNAL OF CLINICAL ONCOLOGY vol:40 issue:29 pages:3377-+ ispartof: location:United States status: published

A common and untreatable complication of Crohn’s disease (CD) is the development of intestinal fibrosis for which no adequate noninvasive tools for fibrosis progression monitoring exist. For this purpose, we assessed the performance of magnetization transfer (MT) magnetic resonance imaging (MRI) and texture analysis (TA) on T2-weighted images by correlating them with histology in a fibrosis mouse model. MT-MRI and TA performance was validated during antifibrotic therapy in mice and on MR enterography images of CD patients undergoing bowel surgery. The MT-MRI and TA entropy correlated with histological fibrosis (r = .85 and .81, respectively). However, TA entropy was superior to MT-MRI for quantifying fibrosis progression during coexisting inflammation (linear regression R² = .93). TA entropy could efficiently monitor anti-fibrotic therapy efficacy and correlated with the grade of intestinal fibrosis in CD. In conclusion, MT-MRI and TA entropy are highly promising surrogate markers of intestinal fibrosis, but TA entropy performed better in the presence of concomitant inflammation.

In this study, we evaluated the impact ofIn this prospective observational study, 60 prostate cancer patients (9 primary staging, 51 biochemical recurrence) were imaged withThe patient-based detection rate was 82% and a management change was seen in 52% of the cases. The heterogeneous characteristics of the included patients resulted in a widely varying treatment change, mostly originating from an increase of disease extent on

Sacroiliac joint (SIJ) biomechanics have been described in both in vitro and in vivo studies. A standard for joint coordinate systems has been created by the International Society of Biomechanics for most of the joints in the human body. However, a standardized joint coordinate system for sacroiliac joint motion analysis is currently still lacking. This impedes the comparison across studies and hinders communication among scientists and clinicians. As SIJ motion is reported to be quite limited, a proper standardization and reproducibility of this procedure is essential for the interpretation of future biomechanical SIJ studies. This paper proposes a joint coordinate system for the analysis of sacroiliac joint motion, based on the procedure developed by Grood and Suntay, using semi-automated anatomical landmarks on 3D joint surfaces. This coordinate system offers high inter-rater reliability and aspires to a more intuitive representation of biomechanical data, as it is aligned with SIJ articular surfaces. This study aims to encourage further reflection and debate on biomechanical data representation, in order to facilitate interpretation of SIJ biomechanics and improve communication between researchers and clinicians. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

5025 Background: Prospective reports suggest metastasis directed therapy (MDT) in oligometastatic castration sensitive prostate cancer (omCSPC) is associated with improved treatment outcomes. Here we present long term outcomes of the phase II STOMP and ORIOLE trials and assess the ability of a high-risk (HiRi) mutational signature to provide prognostic and predictive information regarding MDT response. Methods: Patients with omCSPC (< 3 lesions) enrolled on STOMP (n = 62) and ORIOLE (n = 54) randomized to MDT or observation were pooled. The primary endpoint was progression-free survival (PFS) defined as either PSA or radiographic progression, initiation of androgen deprivation, or death. Secondary endpoint was radiographic PFS (rPFS) defined as radiographic progression or death. Both were calculated using the Kaplan-Meier method and stratified by treatment group. Next generation sequencing (NGS) was performed to identify a HiRi mutational signature defined as pathogenic mutations within ATM, BRCA1/2, Rb1, or TP53. Cox proportional hazards regressions were fit to calculate hazard ratios (HR) and assess the prognostic and predictive values of HiRi mutational status. Results: Median follow-up was 52.5 months. Median PFS was prolonged with MDT (11.9 months) compared to observation (5.9 months) with a pooled HR of 0.44 (95% CI, 0.29 – 0.66, p-value < 0.001). MDT was associated with PSA decrease in a majority of patients (84%) as compared to the observation group (41%). On NGS, the incidence of a pathogenic mutation in a HiRi gene was 24.3%. HiRi mutation was prognostic for PFS -- in those without a HiRi mutation median PFS was 11.9 months compared to 5.9 months in those with a HiRi mutation (HR of 1.74, p = 0.06). HiRi mutation was also prognostic for rPFS -- those without a high-risk mutation experienced median rPFS of 22.6 months compared to 10.0 months in those with a high-risk mutation (HR 2.62, p < 0.01). Tumors without a HiRi mutation treated with MDT experienced the longest PFS (13.4 months) while those with a HiRi randomized to observation experienced the shortest PFS (2.8 months). Stratifying by both treatment arms and HiRi status appeared to show a differential benefit to MDT, with those with HiRi mutations experiencing a larger relative magnitude of benefit to treatment: (HiRi mutation: HR of 0.05, p < 0.01; no HiRi mutation: HR of 0.42, p = 0.01; p interaction, 0.12) suggesting a HiRi mutational status can provide information regarding differential response to treatment. Conclusions: Long-term outcomes from the only two randomized trials in omCSPC suggest a sustained benefit to MDT over observation. A HiRi mutational signature appears prognostic for outcomes in omCSPC and those with HiRi might have a relatively larger magnitude of response to MDT. Future studies are needed to optimize patient selection. Clinical trial information: NCT02680587.

Purpose Retrospective studies suggest that metastasis-directed therapy (MDT) for oligorecurrent prostate cancer (PCa) improves progression-free survival. We aimed to assess the benefit of MDT in a randomized phase II trial. Patients and Methods In this multicenter, randomized, phase II study, patients with asymptomatic PCa were eligible if they had had a biochemical recurrence after primary PCa treatment with curative intent, three or fewer extracranial metastatic lesions on choline positron emission tomography–computed tomography, and serum testosterone levels > 50 ng/mL. Patients were randomly assigned (1:1) to either surveillance or MDT of all detected lesions (surgery or stereotactic body radiotherapy). Surveillance was performed with prostate-specific antigen (PSA) follow-up every 3 months, with repeated imaging at PSA progression or clinical suspicion for progression. Random assignment was balanced dynamically on the basis of two factors: PSA doubling time (≤ 3 v > 3 months) and nodal versus non-nodal metastases. The primary end point was androgen deprivation therapy (ADT)–free survival. ADT was started at symptomatic progression, progression to more than three metastases, or local progression of known metastases. Results Between August 2012 and August 2015, 62 patients were enrolled. At a median follow-up time of 3 years (interquartile range, 2.3-3.75 years), the median ADT-free survival was 13 months (80% CI, 12 to 17 months) for the surveillance group and 21 months (80% CI, 14 to 29 months) for the MDT group (hazard ratio, 0.60 [80% CI, 0.40 to 0.90]; log-rank P = .11). Quality of life was similar between arms at baseline and remained comparable at 3-month and 1-year follow-up. Six patients developed grade 1 toxicity in the MDT arm. No grade 2 to 5 toxicity was observed. Conclusion ADT-free survival was longer with MDT than with surveillance alone for oligorecurrent PCa, suggesting that MDT should be explored further in phase III trials.

Objectives To describe the anatomical patterns of PCa recurrence following primary therapy and investigate if patients with low-volume disease have a better prognosis as compared to their counterparts. Material and methods Patients eligible for a F18-choline PET-CT were entered in a prospective cohort study. Eligible patients had an asymptomatic biochemical recurrence following primary PCa treatment and testosterone levels >50 ng/ml. The number of lesions were counted per scan. Patients with an isolated local recurrence or with up to 3 metastases (+/- local recurrence) were considered “low-volume” and patients with >3 metastases as high-volume. Descriptive statistics were used to report recurrences. Cox-regression analysis investigated the influence of prognostic variables on the time to developing castration resistant PCa (CRPC). Results In 208 patients, 625 sites of recurrence were detected in the lymph nodes (N1/M1a: 30%), the bone (18%), the prostate (bed) (11%), viscera (4%) or a combination of any of the previous (37%). In total, 153 patients (74%) had a low-volume recurrence and 55 patients (26%) had a high-volume recurrence. The 3-year CRPC-free survival for the whole cohort was 79% (95% CI: 43 – 55%) and 88% for low-volume recurrences and 50% for high-volume recurrences, respectively (p

BACKGROUND: In patients with prostate cancer (PCa) with histopathologically proven pelvic lymph node (LN) metastasis (pN1) after extended pelvic lymph node dissection (ePLND), multimodality treatment consisting of treatment of the primary tumor and whole pelvic radiotherapy (WPRT) combined with androgen deprivation therapy (ADT) offers promising results, leading to better cause-specific survival rates compared with ADT alone. However, in case more than one pelvic LN is invaded by the tumor, approximately 40% of the patients relapse biochemically and clinically. Clinical relapse is present in the para-aortic LNs (M1a disease) in up to 77% of the relapsing cases. OBJECTIVE: We hypothesize that, based on the evidence that positive LNs represent the door to hematogenous dissemination, elective para-aortic irradiation will reduce the development of both retroperitoneal nodal (M1a) and distant metastasis (M1b or M1c disease), postpone the need for palliative ADT, and prolong the time to castration-refractory disease. METHODS: To test this hypothesis, we will conduct a prospective, nonrandomized phase II trial to study the efficacy of additional elective para-aortic radiotherapy (PART) in pN1 patients compared with those who were historically treated with adjuvant WPRT alone. We aim to include 137 patients with PCa and presence of pN1 disease after ePLND. With this number of patients, an improvement of 15% in the 5-year clinical relapse-free survival can be detected with a power of 80%. RESULTS: Recruitment of patients for this trial started in 2017 and will be completed approximately by March 2020. CONCLUSIONS: This is the first phase II trial to investigate the benefits of an elective PART in patients with PCa. The results of this trial will potentially serve as a sound base for a later randomized phase III trial. All participants are given a PART information sheet and required to give written informed consent. Results are expected to be published in a peer-reviewed journal. TRIAL REGISTRATION: ClinicalTrials.gov NCT03079323; https://clinicaltrials.gov/ct2/show/NCT03079323 (Archived by WebCite at http://www.webcitation.org/73ELimv1d). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/11256. ispartof: JMIR RESEARCH PROTOCOLS vol:7 issue:12 ispartof: location:Canada status: published

Background Assessment of Crohn’s disease (CD) activity is important to identify patients with active inflammation for therapy management. Quantitative analysis can provide objective measurement of disease presence. Purpose To evaluate the feasibility of quantitative analysis of contrast-enhanced dual-energy computed tomography (DECT) data in detection of small bowel inflammation in patients with CD with an emphasis on iodine quantification. Material and Methods DECT enterography was prospectively performed in 20 patients with active CD and in 20 healthy individuals, as the control group. Iodine overlay images were created. Wall thickness, attenuation, absolute iodine density, relative iodine density, and fat fraction were measured in the terminal ileum of all patients by two radiologists. Intraclass correlation coefficients were calculated to assess inter-rater agreement. Parameters were compared between patient groups using mixed model analysis. Receiver operating characteristic (ROC) analysis was performed. Results Both absolute and relative iodine density were significantly higher in active disease than in normal small bowel (all P Conclusion DECT with iodine quantification can be used in distinguishing normal small bowel from active inflammatory CD. Further research should investigate the value of iodine quantification in grading CD activity and in monitoring therapeutic response.

Patients with biochemical recurrence following primary prostate cancer (PCa) treatment often experience relapse in the lymph nodes (LNs). Both salvage LN dissection (sLND) and elective nodal radiotherapy (ENRT) are potential treatment options.To describe anatomic patterns of nodal oligorecurrent PCa in relation to different surgical and radiotherapy templates.Patients with biochemical recurrence following primary PCa treatment were eligible forAll LN recurrences were mapped on a reference patient CT, as well as different surgical templates (limited to superextended) and an adapted version of the PIVOTAL ENRT template, blinded for the recurrences. Descriptive statistics were used to report recurrences in relation to the different templates and to compare LN coverage between templates.In total, 158 LN recurrences (N1: 88; M1a: 70) in 82 patients (median age: 67yr; prostate-specific antigen [PSA]: 3.1ng/ml; PSA doubling time of 7.8mo at the time of clinical recurrence) were mapped. In 49% of patients, recurrences were exclusively located in the true pelvis, followed by the common iliac LN (10%), retroperitoneal/inguinal LN (10%), or a combination (31%). There was up to 40% volume overlap between ENRT and the surgical templates. Theoretically, with ENRT more patients are fully covered (p0.02) and the total number of covered lesions is higher (p0.001) when compared to all types of sLND, except for superextended sLND, which is comparable to ENRT (patient-level: p=0.6; lesion-level: p=0.09). With 22% of all 158 lesions located outside all templates (N1: 7%; M1a: 15%), at least 31% of all 82 patients would not be salvaged using any of the templates.More than half of nodal recurrences are located outside the true pelvis. Limited or standard extended sLND is considered insufficient as a salvage treatment approach and is thus not recommended for use. To maximize treatment outcomes for nodal recurrences, ENRT or superextended sLND should be preferred.We compared two possible treatment options, elective nodal radiotherapy and salvage lymph node dissection, for patients with prostate cancer recurrence limited to five or fewer lymph nodes and reported the nodal distrubution. Radiotherapy and surgery cover different areas with possible different outcomes.

BACKGROUND In patients with prostate cancer (PCa) with histopathologically proven pelvic lymph node (LN) metastasis (pN1) after extended pelvic lymph node dissection (ePLND), multimodality treatment consisting of treatment of the primary tumor and whole pelvic radiotherapy (WPRT) combined with androgen deprivation therapy (ADT) offers promising results, leading to better cause-specific survival rates compared with ADT alone. However, in case more than one pelvic LN is invaded by the tumor, approximately 40% of the patients relapse biochemically and clinically. Clinical relapse is present in the para-aortic LNs (M1a disease) in up to 77% of the relapsing cases. OBJECTIVE We hypothesize that, based on the evidence that positive LNs represent the door to hematogenous dissemination, elective para-aortic irradiation will reduce the development of both retroperitoneal nodal (M1a) and distant metastasis (M1b or M1c disease), postpone the need for palliative ADT, and prolong the time to castration-refractory disease. METHODS To test this hypothesis, we will conduct a prospective, nonrandomized phase II trial to study the efficacy of additional elective para-aortic radiotherapy (PART) in pN1 patients compared with those who were historically treated with adjuvant WPRT alone. We aim to include 137 patients with PCa and presence of pN1 disease after ePLND. With this number of patients, an improvement of 15% in the 5-year clinical relapse-free survival can be detected with a power of 80%. RESULTS Recruitment of patients for this trial started in 2017 and will be completed approximately by March 2020. CONCLUSIONS This is the first phase II trial to investigate the benefits of an elective PART in patients with PCa. The results of this trial will potentially serve as a sound base for a later randomized phase III trial. All participants are given a PART information sheet and required to give written informed consent. Results are expected to be published in a peer-reviewed journal. CLINICALTRIAL ClinicalTrials.gov NCT03079323; https://clinicaltrials.gov/ct2/show/NCT03079323 (Archived by WebCite at http://www.webcitation.org/73ELimv1d) INTERNATIONAL REGISTERED REPOR PRR1-10.2196/11256

10 Background: Multiple randomized phase II trials suggest that metastasis-directed therapy (MDT) for oligometastatic prostate cancer (PCa) improves progression-free survival, but the majority of trials lack longer follow-up. We present the updated 5-year results from the STOMP-trial. Methods: In this multicentre, randomised, phase II study, asymptomatic PCa patients were eligible in case of a biochemical recurrence following primary PCa treatment with curative intent and presenting with up to 3 extracranial on choline PET-CT and a serum testosterone levels > 50 ng/ml. Patients were randomly assigned (1:1) to either surveillance or MDT of all detected lesions. Randomisation was balanced dynamically on two factors: PSA doubling time (≤3 vs. > 3 months) and nodal vs non-nodal metastases. The primary endpoint was androgen deprivation therapy (ADT)-free survival. Castrate resistant prostate cancer-free survival (CRPC) was a secondary endpoint. Tests were performed two-sided; p values less than 0.20 were deemed significant. Results: The 5-year ADT-free survival was 8% for the surveillance group and 34% for the MDT group (Figure 1, hazard ratio 0.57 [80% CI: 0.38-0.84], log-rank p = 0.06). There was no significant difference in effect for the different stratification factors (interaction test). The 5-year CRPC-free survival was 53% for the surveillance group and 76% for the MDT group (hazard ratio 0.62 [80% CI: 0.35−1.09]; log−rank p = 0.27). At a median follow for survival of 5.3 years (IQR 4.3-6.3), the 5-year overall survival was 85%, with 6 out of 14 deaths attributed to prostate cancer. Conclusions: The updated STOMP trial outcomes confirm the earlier reported significant difference in ADT free survival in favor of the MDT group compared to surveillance. Prostate-cancer related mortality is low within the first 5 years of diagnosis of oligorecurrent prostate cancer. Clinical trial information: NCT01558427.

BACKGROUND. In non-castrate prostate cancer (PCa), the prognostic value of the number of metastases on prostate cancer-specific survival (PCSS) is not well studied. METHODS. We retrospectively analyzed the medical records of 1,206 patients, referred for radiotherapy of the prostate (bed) following diagnosis of PCa. Distant metastases (nodal, skeletal, and/or visceral) developed in 121 patients following curative treatment, of which 80 with complete records were not castrated at time of metastasis. The treatment at time of metastases was androgen deprivation therapy (ADT; n ¼22), active surveillance (n ¼10) or metastasis-directed therapy (MDT; n ¼48). Cox-regression analyses were used to examine the influence of different variables on PCSS. RESULTS. The median follow-up from primary PCa treatment was 6.9 years with a median interval from diagnosis to first metastatic event of 4.1 year (range: 0.2–15 years). The primary site of metastases was limited to lymph nodes (48%), bone (39%), and viscera (1%) or a combination (12%). Median PCSS from diagnosis of noncastrate metastases was 6.6 years (95% confidence interval [CI], 5.6–7.7 years). A longer premetastatic PSA doubling time (DT) (hazard ratio [HR] 0.73; 95% CI: 0.57–0.92), a lower number of metastases at first presentation (HR 1.07; 95% CI: 1.02–1.12) and pattern of metastatic spread (HR 3.6; 95% CI: 1.13–11.8 for extensive vs. minimal) were associated with improved PCSS. CONCLUSION. A longer PSA DT, involvement of nodes or axial skeleton and a lower number of metastases are associated with an improved PCSS in non-castrated patients developing metastases. Prostate # 2013 Wiley Periodicals, Inc.

Pseudomyxoma peritonei (PMP) is a rare clinical syndrome characterized by mucinous peritoneal disease arising from disseminated peritoneal adenomucinosis. Primary treatment involves a combination of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC). There is no consensus on the proper treatment of recurrent PMP. In selected patients, repeated cytoreductive surgery with or without HIPEC might improve outcome. However, every repeated debulking procedure becomes less effective with increased morbidity. We present a case of a patient with intestinal obstruction caused by recurrent pseudomyxoma peritonei. We treated the patient with whole abdominopelvic radiotherapy (WAPRT) using intensity-modulated arc therapy (IMAT) to a total dose of 33 Gy, delivered in 22 daily fractions. The treatment was well tolerated and resulted in resolution of the obstruction for a period of 24 months. To the best of our knowledge, we present the first case report showing the possibility of resolving intestinal obstruction with WAPRT in a patient with recurrent PMP. It is our opinion that WAPRT delivered by IMAT, in analogy with ovarian cancer, should be considered as a palliative treatment option in managing patients with recurrent PMP especially in case of obstruction.

IntroductionSince the addition of chemotherapy to radiotherapy, the survival rates of locally advanced cervical cancer (LACC) have improved but are still disappointing. Therefore, the idea of surgery after chemoradiation in case of LACC or bulky disease was adopted. One of the concerns regarding surgery following chemoradiotherapy is surgery-related morbidity.AimThe objectives of this study were to investigate the feasibility of surgery after advanced radiotherapy techniques such as intensity-modulated arc therapy (IMAT) and to describe the morbidity.MethodsThis was a prospective study of primary inoperable LACC patients primary treated with IMAT, in most cases combined with weekly cisplatin. Then the resectability was reevaluated. If resectable patients were treated with Wertheim type 2 surgery ± pelvic lymphadenectomy (on positron emission tomography–computed tomography indication). If tumor is not resectable, patients were treated with brachytherapy.ResultsSince 2006, 41 consecutive patients were included. After neoadjuvant IMAT, 34 were considered resectable and underwent surgery, whereas 7 proceeded with brachytherapy. The operative mortality rate was nil. There were no major perioperative complications. No ureter, bladder, or bowel injuries occurred. No postoperative urinary/digestive fistulae or stenoses were noted. Eleven patients had postoperatively urinary retention problems. At the time of discharge, 5 patients still needed self-catheterization. All problems resolved within 3 months. In 4 cases, we saw significant lymphoceles. In all patients intended to treat, overall survival and disease-free survival at 3 years were 63% and 74%. In the Wertheim group, overall survival and disease-free survival at 3 years were 81% and 91%.ConclusionsCompleting surgery after chemoradiation therapy (with IMAT) for LACC or bulky disease is feasible, and complication rates are comparable with those of primary surgery for cervical cancer.

Background We investigated whether repeated stereotactic body radiotherapy (SBRT) of oligometastatic disease is able to defer the initiation of palliative androgen deprivation therapy (ADT) in patients with low-volume bone and lymph node metastases. Patients and Methods Patients with up to 3 synchronous metastases (bone and/or lymph nodes) diagnosed on positron emission tomography, following biochemical recurrence after local curative treatment, were treated with (repeated) SBRT to a dose of 50 Gy in 10 fractions. Androgen deprivation therapy-free survival (ADT-FS) defined as the time interval between the first day of SBRT and the initiation of ADT was the primary end point. ADT was initiated if more than 3 metastases were detected during follow-up even when patients were still asymptomatic or in case of a prostate specific antigen elevation above 50 ng/mL in the absence of metastases. Secondary end points were local control, clinical progression-free survival, and toxicity. Toxicity was scored using the Common Terminology Criteria for Adverse Events. Results We treated 24 patients with a median follow-up of 24 months. Ten patients started with ADT resulting in a median ADT-FS of 38 months. The 2-year local control and clinical progression-free survival was 100% and 42%, respectively. Eleven and 3 patients, respectively, required a second and third salvage treatment for metachronous low-volume metastatic disease. No grade 3 toxicity was observed. Conclusion Repeated salvage SBRT is feasible, well tolerated and defers palliative ADT with a median of 38 months in patients with limited bone or lymph node PCa metastases.

We compared fluor-18 choline positron emission tomography/computed tomography (PET/CT) and axial skeleton magnetic resonance imaging (MRI) prospectively obtained for the detection of bone metastases in non-castrated patients with biochemically recurrent prostate cancer following primary treatment. PET/CT was performed 45 min post-injection of 3-4 MBq/kg F-18 methyl choline. MRI included T1- and fluid sensitive T2-weighted images of the spine and pelvis. Readers were initially blinded from other results and all scans underwent independent double reading. The best valuable comparator (BVC) defined the metastatic status. On the basis of the BVC, 15 out of 64 patients presented with 24 bone metastases. On a patient level, the sensitivity and specificity of MRI and PET were not significantly different. On a lesion level, the sensitivity of MRI was significantly better compared to PET, and the specificity did not differ significantly. In conclusion, axial MRI is an interesting screening tool for the detection of bone metastases because of its low probability of false negative results. However, F-18 choline PET is a valuable addition as it can overrule false positive MRI results and detect non-axial metastases., info:eu-repo/semantics/published

Background The sacroiliac joint and spine are seen on abdominal computed tomography (CT) and may show structural lesions as part of spondyloarthritis. Purpose To determine the prevalence of CT features of spondyloarthritis in patients with Crohn’s disease (CD). Material and Methods A retrospective study of structural lesions of spondyloarthritis on abdominal CT was performed. The sacroiliac joints and spine of 120 patients were studied: study group I consisted of 40 patients with known CD and inflammatory back pain, group II involved 40 patients with CD without inflammatory back pain, and group III consisted of 40 patients without known joint or inflammatory bowel disease. Recorded CT features included sclerosis, erosions or ankylosis of the sacroiliac joint, enthesopathy, spinal syndesmophytes, and costovertebral joint lesions. Results CT showed structural lesions of the sacroiliac joints in 19/40 (48%) patients with CD and inflammatory back pain (sclerosis [n = 14; 35%], erosions [n = 14; 35%], ankylosis [n = 3; 8%]), in 8/40 (8%) patients with CD without inflammatory back pain (sclerosis [n = 3; 8%], erosions [n = 4; 10%], ankylosis [n = 3; 8%]), and in 3/40 (8%) patients without known joint or bowel disease (sclerosis [n = 2; 5%], ankylosis [n = 1; 3%]). Syndesmophytes were exclusively seen in group I (n = 6; 15%). Conclusion CT of the abdomen in patients with CD and inflammatory back pain shows structural lesions of the sacroiliac joint, entheses, or spine in almost half of the patients. Awareness and knowledge of these findings may guide the referring clinician to further clinical evaluation, imaging, and biomarker evaluation of the disease.

To report on toxicity after postoperative intensity-modulated arc therapy (IMAT) for cervical (CC) and endometrial cancer (EC).Twenty-four CC and 41 EC patients were treated with postoperative IMAT. If indicated, para-aortic lymph node irradiation (preventive or when affected, PALN) and/or concomitant cisplatin (40 mg/m(2), weekly) was administered. The prescribed dose for IMAT was 45 Gy (CC, 25 fractions) and 46 Gy (EC, 23 fractions), followed by a brachytherapeutic boost if possible. Radiation-related toxicity was assessed prospectively. The effect of concomitant cisplatin and PALN irradiation was evaluated.Regarding acute toxicity (n = 65), Grade 3 and 2 acute gastrointestinal toxicity was observed in zero and 63% of patients (79% CC, 54% EC), respectively. Grade 3 and 2 acute genitourinary toxicity was observed in 1% and 18% of patients, respectively. Grade 2 (21%) and 3 (12%) hematologic toxicity (n = 41) occurred only in CC patients. Seventeen percent of CC patients and 2% of EC patients experienced Grade 2 fatigue and skin toxicity, respectively. Adding cisplatin led to an increase in Grade2 nausea (57% vs. 9%; p = 0.01), Grade 2 nocturia (24% vs. 4%; p = 0.03), Grade ≥ 2 hematologic toxicity (38% vs. nil, p = 0.003), Grade ≥ 2 leukopenia (33% vs. nil, p = 0.009), and a strong trend toward more fatigue (14% vs. 2%; p = 0.05). Para-aortic lymph node irradiation led to an increase of Grade 2 nocturia (31% vs. 4%, p = 0.008) and a strong trend toward more Grade2 nausea (44% vs. 18%; p = 0.052). Regarding late toxicity (n = 45), no Grade 3 or 4 late toxicity occurred. Grade 2 gastrointestinal toxicity, genitourinary toxicity, and fatigue occurred in 4%, 9%, and 1% of patients. Neither concomitant cisplatin nor PALN irradiation increased late toxicity rates.Postoperative IMAT for EC or CC is associated with low acute and late toxicity. Concomitant chemotherapy and PALN irradiation influences acute but not late toxicity.

Objective To report on the value of magnetic resonance imaging (MRI) and 2-deoxy-2-[18] fluoro-D-glucose positron emission tomography computed tomography (18FDG PET-CT) in predicting resectability and pathological response of primary locally advanced cervical cancer after neoadjuvant intensity-modulated arc therapy (IMAT) with or without cisplatin (C). Methods and Materials Twenty-seven patients with International Federation of Gynecology and Obstetrics stages IB2 to IVA cervical cancer were treated with IMAT-C followed by extrafascial hysterectomy (EH). All patients received MRI and 18FDG PET-CT after IMAT-C. The end points of this study were to: Assess the ability of MRI to predict negative surgical margins (R0). Assess the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of MRI in predicting the following situation at the EH specimen: “no residual disease or minimal microscopically visible residual tumor.” Assess the sensitivity, specificity, PPV, and NPV value of 18FDG PET-CT in predicting “no residual viable tumor cells” at the EH specimen. Results An R0 resection was obtained in all patients. None of the EH specimens contained macroscopically visible tumor. In 13 patients, no viable tumor cells were found and only 14 had residual microscopic disease. Twenty-four of 27 MRIs were able to correctly predict R0 resection. A negative MRI was 100% predictive for the end point “R0 resection.” The specificity and NPV of MRI (end point 2) were 74% and 100%, respectively. No sensitivity or PPV could be calculated. The sensitivity, specificity, PPV, and NPV of 18FDG PET-CT were 29%, 62%, 44%, and 44%, respectively (end point 3). Conclusions A negative MRI after IMAT-C predicts 100% correctly for R0 resection. The role of 18FDG PET-CT in predicting viable tumor cells at EH specimen is at least debatable.

The goal of this work was to evaluate the feasibility and outcome of intensity-modulated arc therapy ± cisplatin (IMAT ± C) followed by hysterectomy for locally advanced cervical cancer.A total of 30 patients were included in the study. The primary tumour and PET-positive lymph node(s) received a simultaneous integrated boost. Four weeks after IMAT ± C treatment, response was evaluated. Resection consisted of hysterectomy with or without lymphadenectomy. Tumour response, acute and late radiation toxicity, postoperative morbidity and outcome were evaluated.All hysterectomy specimens were macroscopically tumour-free with negative resection margins; pathological complete response was 40%. In 2 patients, one resected lymph node was positive. There was no excess in postoperative morbidity. Apart from two grade 3 hematologic toxicities, no grade 3 or 4 acute radiation toxicity was observed. No grade 3, 1 grade 4 (4%) intestinal, and 4 grade 3 (14%) urinary late toxicities were observed. The 2-year local and regional control rates were 96% and 100%, respectively. The 2-year distant control rate was 92%. Actuarial 2-year progression free survival rate was 89%. Actuarial 1- and 2-year overall survival rates were 96% and 91%, while 3-year overall survival was 84%.Surgery after IMAT ± C is feasible with low postoperative morbidity and radiation toxicity. Local, regional, distant control and survival rates are promising.

Background: Multidetector CT is a valuable technique for diagnosis/staging in several pancreatic pathologies. Diagnosis is usually based on tissue density measurements. Recently, newer functional CT techniques have been introduced. The aim of this study was to assess variability in perfusion and dual-energy CT data, and to compare these data with density measurements in the pancreas of a healthy population. Methods: Two groups were included: 20 patients underwent perfusion CT imaging, and 10 patients were scanned using a dual-energy protocol. In both groups, tissue density [Hounsfield units (HU)] was measured in the pancreatic head, body and tail. Functional data were calculated (blood flow/blood volume in the perfusion CT group, iodine concentration in the dual-energy group), and variability was assessed. Results: Density measurements were comparable for the perfusion and dual-energy CT groups, and ranged from 14 to 60 HU. Maximal enhancement differences between the head/body/tail of the pancreas ranged between 2 and 21 HU. Considerable variability was observed, both in density measurements (ranging from 3 to 34%) and in functional parameters (mean variability in perfusion CT parameters blood flow and blood volume was 21.3 and 10% respectively; mean variability in dual-energy iodine-mapping results was 24.4%). Conclusion: This study demonstrated the presence of important intraindividual variability in pancreatic tissue contrast enhancement, regardless of the CT technique used. Considering the variability observed in this study, the use of cut-off values to characterize pancreatic pathologies seems troublesome, and morphologic primary and secondary changes will remain important, even when using novel functional imaging techniques.

Intensive care unit (ICU) patients frequently undergo contrast-enhanced radiographic examinations, which carries a risk for development of contrast-associated acute kidney injury (CA-AKI). Data on this in ICU patients are scarce. The aim of this study was therefore to evaluate the epidemiology and short- and long-term outcomes of CA-AKI in ICU patients.A retrospective single-centre cohort study covering the period 1 March 2004 to 31 December 2008 on ICU patients who underwent a radiography examination with parenteral administration of iodinated radio contrast media was conducted. Data analysis included univariate and multivariate analyses of patients with and without CA-AKI.A total of 787 ICU patients were included in the study. CA-AKI occurred in 128 (16.3%) and was associated with higher need for RRT [30 (4.6%) vs. 21 (16.4%), p 0.001], worse kidney function at discharge, longer length of ICU and hospital stay, and higher 28-day and 1-year mortality [28-day: 86 (13.1%) vs. 46 (35.9%), p 0.001, and 1-year: 158 (24.0%) vs. 71 (55.5%), p 0.001]. Higher serum creatinine, lower mean arterial pressure, and administration of diuretics and vasoactive therapy were associated with development of CA-AKI in multivariate analysis. After correction for confounders we found that CA-AKI was associated with 28-day mortality in this cohort of ICU patients (odds ratio = 2.742, 95% confidence interval 1.374-5.471).CA-AKI occurred in one out of six ICU patients who underwent a contrast-enhanced radiography examination and was associated with both short-and long-term worse outcomes such as need for RRT, worse kidney function at discharge, increased length of stay in the ICU and hospital, and mortality.

Perfusion CT can provide information regarding blood perfusion and permeability in (tumor) tissues in a non-invasive manner. In this study, values of CT perfusion parameters in several pancreas pathologies were determined and compared to a control population. Dynamic 128-slice perfusion CT was performed in patients admitted to the radiology department between June 2010 and March 2011. Included pathologies were pancreatic adenocarcinoma, acute and chronic pancreatitis, neuroendocrine tumors, and (pseudo)cystic lesions. Parametric mappings of blood flow, blood volume, and permeability surface area product were generated. Blood flow and blood volume were significantly lower in acute and chronic pancreatitis compared to the control group. In the center of adenocarcinoma tumors, low blood flow and blood volume was observed, gradually increasing toward the tumor rim; perfusion values in pancreatic parenchyma adjacent to the tumor were not significantly different from the control population. In neuroendocrine tumors, significantly increased perfusion values were observed. Compared to the control population, significant decreases in perfusion values were observed in all pancreatic pathologies under study, except in neuroendocrine tumors. Perfusion CT values can be used as an additional parameter to differentiate pancreatic pathologies.

We evaluated the relationship of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI)-derived pharmacokinetic parameters and contrast agents with different molecular weights (MW) in a pancreatic tumor mouse model.Panc02 tumors were induced in mice at the hind leg. DCE-MRI was performed using Gadolinium (Gd)-based contrast agents with different MW: Gd-DOTA (0.5 kDa), P846 (3.5 kDa), and P792 (6.47 kDa). Quantitative vascular parameters (AUC, K(trans), V(e), and V(p)) were calculated according to a modified Tofts two-compartment model. Values for all contrast groups were compared for tumor and control (muscle) tissues.Values for K(trans) and V(e) were significantly higher in tumor tissue than in muscle tissue. When comparing contrast agents, lowest absolute K(trans) values were observed using P792. The relative increase in K(trans) in tumor tissue compared with normal tissue was highest after the use of P792. In both tumor and normal tissues, K(trans) decreased with increasing molecular weight of the contrast agent used.It was demonstrated that values for the different DCE-MRI vascular (permeability) parameters are highly dependent on the contrast agent used. Due to their potential to better differentiate tumor from muscle tissue, higher molecular weight contrast agents show promise when evaluating tumors using DCE-MRI.

Purpose To retrospectively review our experience with whole abdominopelvic radiotherapy (WAPRT) using intensity-modulated arc therapy in the palliative treatment of chemotherapy-resistant ovarian cancer with bulky peritoneal disease. Methods and Materials Between April 2002 and April 2008, 13 patients were treated with WAPRT using intensity-modulated arc therapy. We prescribed a dose of 33 Gy to be delivered in 22 fractions of 1.5 Gy to the abdomen and pelvis. All patients had International Federation of Gynecology and Obstetrics Stage III or IV ovarian cancer at the initial diagnosis. At referral, the median age was 61 years, and the patients had been heavily pretreated with surgery and chemotherapy. All patients had symptoms from their disease, including gastrointestinal obstruction or subobstruction in 6, minor gastrointestinal symptoms in 2, pain in 4, ascites in 1, and vaginal bleeding in 2. A complete symptom or biochemical response required complete resolution of the patient's symptoms or cancer antigen-125 level. A partial response required ≥50% resolution of these parameters. The actuarial survival was calculated from the start of radiotherapy. Results The median overall survival was 21 weeks, with a 6-month overall survival rate of 45%. The 9 patients who completed treatment obtained a complete symptom response, except for ascites (partial response). The median and mean response duration (all symptoms grouped) was 24 and 37 weeks, respectively. Of the 6 patients presenting with obstruction or subobstruction, 4 obtained a complete symptom response (median duration, 16 weeks). Conclusion WAPRT delivered using intensity-modulated arc therapy offers important palliation in the case of peritoneal metastatic ovarian cancer. WAPRT resolved intestinal obstruction for a substantial period.

A predictive technique in the management of patients with cancer could improve the therapeutic index by allowing better individualization of treatment. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) is a noninvasive technique that can provide anatomical and physiological information on the tumor and its microenvironment. We studied the effect of chemotherapy (gemcitabine), anti-angiogenesis therapy (sunitinib) and radiotherapy on the kinetics of DCE-MRI parameters in a preclinical model of pancreatic cancer using P846, a new low-diffusible contrast agent. Mice underwent DCE-MRI before treatment (MRI1), after 1 week of treatment (MRI2), and after 1 additional week (MRI3). Combined treatment with radiotherapy and sunitinib had a synergistic effect on tumor growth. In radiotherapy/sunitinib-treated mice, a decrease in K(trans) at MRI2 predicted its superior antivascular and antitumor effect at an early time. An increased K(trans) at MRI2, as seen in gemcitabine- and gemcitabine/sunitinib-treated mice, reflects increased permeability for P846 and might predict a smaller therapeutic effect at this early time. This study shows that the kinetics of DCE-MRI parameters depends on the contrast agent used. P846 appears to be a promising low-diffusible agent to monitor therapeutic effects in this preclinical cancer model, but further studies are needed to compare its behavior with Gd-DTPA and macromolecular-weight contrast agents. Sunitinib as a radiosensitizer is promising for future clinical trials in human pancreatic cancer.

Acute pancreatitis (AP) is a common inflammatory disease which can be mild and self-limiting without complications or severe with prolonged hospitalization, high morbidity, and high mortality. Different radiological scoring systems to predict severity and outcome in AP have been developed since the early 1990s. In the meantime, new insights in the pathophysiology of AP and consequently, therapeutic management of these patients have been introduced. The purpose of this review is therefore (1) to describe the current terminology and new concepts in the pathophysiology, (2) to outline the long existing and newly developed radiological scoring systems in prediction of severity and outcome with their respective advantages and limitations, and (3) to define the role of radiological prognostic scoring systems in the new environment of perception of the last decade. Risk stratification in AP requires scoring systems that can be calculated early in the course of disease which allows time for intervention. For that reason, scoring systems based on necrosis are not useful in severity prediction. The recent developed radiological scoring systems based on signs of systemic inflammatory response syndrome and organ dysfunction are promising in prediction of severity early after onset of AP.

To introduce a new scoring system based on signs of systemic inflammation on computed tomography (CT) [ExtraPancreatic Inflammation on CT (EPIC) score] and evaluate this score as an early prognostic tool.Forty patients with acute pancreatitis who received an abdominal CT within 24 h after admission were included in the study. The Balthazar score, the CT Severity Index, and the EPIC score (based on the presence of pleural effusion, ascites, and retroperitoneal fluid collections) were calculated for all patients. The end points were the occurrence of severe acute pancreatitis (local complication or presence of organ failure for more than 48 h) and in hospital mortality. This score was evaluated by calculating receiver operator characteristic (ROC) curves and the area under the ROC curve.Mean age of the patients was 50 (+/-17.7) years, and Ranson score was 3.3. Fourteen (35%) patients developed severe disease; in hospital mortality was 15% (6/40). The mean EPIC score was 3.6 (+/-2.0). The area under the ROC curve for predicting severe disease and mortality was 0.91 (95% confidence interval, 0.83-0.99) and 0.85 (95% confidence interval, 0.71-0.99), respectively. An EPIC score of 4 or more had a 100% sensitivity and 70.8% specificity for predicting severe pancreatitis. The EPIC score was superior to the Balthazar score and CT Severity Index to predict outcome.In patients with acute pancreatitis, extrapancreatic inflammation assessed by abdominal CT scan and quantified with the EPIC score allows accurate estimation of disease severity and mortality within 24 h of admission.

Methodology. Seventeen patients with prostate-specific antigen (PSA) rise following local treatment for prostate cancer with curative intent underwent open or minimally invasive salvage pelvic lymph node dissection (SLND) for oligometastatic disease (0,2 ng/mL; and after incomplete biochemical response as 2 consecutive PSA rises. Newly found metastasis on imaging defined clinical progression (CP). Palliative androgen deprivation therapy (ADT) was initiated if >3 metastases were detected or if patients became symptomatic. Kaplan-Meier statistics were applied.Results. Clavien-Dindo grade 1, 2, 3a, and 3b complications were seen in 6, 1, 1, and 2 patients, respectively. Median follow-up time was 22 months. Among 13 patients treated for oligometastatic disease, 8 (67%) had a PSA decline, with 3 patients showing cBR. Median PSA progression-free survival (FS) was 4.1 months and median CP-FS 7 months. Three patients started ADT, resulting in a 2-year ADT-FS rate of 79.5%.Conclusion. SLND is feasible, but postoperative complication rate seems higher than that for primary LND. Biochemical and clinical response duration is limited, but as part of an oligometastatic treatment regime it can defer palliative ADT.

Background: Metastases-directed therapy (MDT) with surgery or stereotactic body radiotherapy (SBRT) is emerging as a new treatment option for prostate cancer (PCa) patients with a limited number of metastases (≤3) at recurrence – so called “oligometastases”. One of the goals of this approach is to delay the start of palliative androgen deprivation therapy (ADT), with its negative impact on quality of life. However, the lack of a control group, selection bias and the use of adjuvant androgen deprivation therapy prevent strong conclusions from published studies. The aim of this multicenter randomized phase II trial is to assess the impact of MTD on the start of palliative ADT compared to patients undergoing active surveillance. Methods/Design: Patients with an oligometastatic recurrence, diagnosed on choline PET/CT after local treatment with curative intent, will be randomised in a 1:1 ratio between arm A: active surveillance only and arm B: MTD followed by active surveillance. Patients will be stratified according to the location of metastasis (node vs. bone metastases) and PSA doubling time (≤3 vs. > 3 months). Both surgery and SBRT are allowed as MDT. Active surveillance means 3-monthly PSA testing and re-imaging at PSA progression. The primary endpoint is ADT-free survival. ADT will be started in both arms at time of polymetastatic disease (>3 metastatic lesions), local progression or symptoms. The secondary endpoints include progression-free survival, quality of life, toxicity and prostate-cancer specific survival. Discussion: This is the first randomized phase 2 trial assessing the possibility of deferring palliative ADT with MDT in oligometastatic PCa recurrence. Trial registration: Clinicaltrials.gov identifier: NCT01558427

1A 64-year-old female presented with a three-month history of decreased appetite, nausea and progressive abdominal distension. Physical examination revealed a distended abdomen with a fluid wave and a hard perium bilical bluish swelling (Fig. A). Because intra-abdominal malignancy was suspected, a contrastenhanced computed tomography of the abdomen was performed which showed a pelvic mass originating from the left ovary, omental and peritoneal metastases, ascites, and a lobulated mass through the umbilicus with infiltration of the surrounding subcutaneous fat (Fig. B, C). Diagnostic laparoscopy and histopathological analysis of the obtained ovarian samples confirmed the diagnosis of metastatic ovarian carcinoma. A Sister Mary Joseph nodule (SMJN) is a metastatic umbilical lesion originating from intra-abdominal or pelvic malignant disease. It can be a sign of undiagnosed malignancy or a symptom or sign of disease progression or recurrence in a patient with known disease. Its incidence is low

Imaging results of F-18 fluorodeoxyglucose (FDG) PET/CT scanning and Tc-99m pertechnetate scintigraphy of the thyroid gland are described and compared with pathology in a patient who was followed after left nephrectomy for renal cell carcinoma diagnosed 10 years earlier. On F-18 FDG PET/CT scanning, a multinodular struma with increased localized F-18 FDG uptake in 4 nodules was seen. Two nodules with increased glucose metabolism appeared normal on Tc-99m pertechnetate scintigraphy. Pathology indicated hyperplastic nodules. High focal F-18 FDG uptake was also seen in a lesion that corresponded with a "cold" nodule on Tc-99m pertechnetate scintigraphy, suggesting malignant disease. However, pathology revealed hyperplastic nodules with a background of aspecific lymphocytic thyroiditis. A fourth nodule with increased F-18 FDG uptake appeared mixed ("cold"/"hot") on Tc-99m pertechnetate scintigraphy. On pathology, a well-differentiated follicular carcinoma was found. These findings, in a single patient, illustrate the wide spectrum of matched and mismatched F-18 FDG and Tc-99m pertechnetate thyroid uptake along with their variable pathologic correlates.

In non-castrate prostate cancer (PCa), the prognostic value of the number of metastases on prostate cancer-specific survival (PCSS) is not well studied.We retrospectively analyzed the medical records of 1,206 patients, referred for radiotherapy of the prostate (bed) following diagnosis of PCa. Distant metastases (nodal, skeletal, and/or visceral) developed in 121 patients following curative treatment, of which 80 with complete records were not castrated at time of metastasis. The treatment at time of metastases was androgen deprivation therapy (ADT; n = 22), active surveillance (n = 10) or metastasis-directed therapy (MDT; n = 48). Cox-regression analyses were used to examine the influence of different variables on PCSS.The median follow-up from primary PCa treatment was 6.9 years with a median interval from diagnosis to first metastatic event of 4.1 year (range: 0.2-15 years). The primary site of metastases was limited to lymph nodes (48%), bone (39%), and viscera (1%) or a combination (12%). Median PCSS from diagnosis of noncastrate metastases was 6.6 years (95% confidence interval [CI], 5.6-7.7 years). A longer premetastatic PSA doubling time (DT) (hazard ratio [HR] 0.73; 95% CI: 0.57-0.92), a lower number of metastases at first presentation (HR 1.07; 95% CI: 1.02-1.12) and pattern of metastatic spread (HR 3.6; 95% CI: 1.13-11.8 for extensive vs. minimal) were associated with improved PCSS.A longer PSA DT, involvement of nodes or axial skeleton and a lower number of metastases are associated with an improved PCSS in non-castrated patients developing metastases.

A 63-year-old woman with COPD presented to our hospital with complaints of breathlessness on exertion, productive cough and weight loss. Chest X-ray showed a bright silhouette extending from the aortic knob in the right paratracheal area on the PA-view and a posterior indentation of the tracheal air column on the lateral view. No other abnormalities were observed. Further work-out consisted of a contrast enhanced CT of the chest which revealed bilateral aortic arches, both of which arising from the ascending aorta anterior to the trachea. Each arch gave origin to the common carotid artery and the subclavian artery, and joined the right posterior ward to form the descending aorta. The left arch was the larger of the two arches. The trachea and esophagus were placed in the middle of the aortic ring. No abnormal compression of the trachea or the esophagus was observed.