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Background: In neuroendocrine tumor (NET), complete surgery could better the prognosis. Radioguided surgery (RGS) with β−-radioisotopes is a novel approach focused on developing a new probe that, d...

Introduction: Cystic brain lesions represented a rare finding in cancer patients, even more uncommon in rare disease as neuroendocrine neoplasms. Patient Presentation: We presented a case of a patient with neurologic symptoms as first and only presentation of a neuroendocrine tumor of the lung. Management and Outcome: First of all, the patient underwent neuroradiologic assessment with the finding of cystic brain lesions. A chest and abdomen CT scan detected a pulmonary lesion; a biopsy of this mass revealed an atypical carcinoid of the lung. Considering the absence of other symptoms, in order to clarify the nature of the cystic brain lesions, a right frontal craniotomy was performed, and a cyst was completely excised. Pathology confirmed the metastatic nature of the brain lesions. Unfortunately, the conditions of the patient quickly worsened, and he passed away before the start of the treatment. Conclusion: Due to the low awareness about neuroendocrine tumors and their clinical and radiological presentations, multidisciplinary approach can represent the cornerstone to provide an accurate and timely diagnosis.

Objective: To review the therapeutic strategy in Merkel cell carcinoma (MCC) treated with radiotherapy (RT) discussed in a multidisciplinary tumour board. Methods: Clinical records of patients with a diagnosis of MCC and with an indication to undergo RT at the European Institute of Oncology between 2003 and 2018 were reviewed retrospectively. Results: Twenty-six patients were included in the analysis (median age 65 years, range 42–87). Nineteen received adjuvant RT, 4 exclusive RT, and the remainder palliative RT. Intensity-modulated RT was used in 13 cases, a 3D conformal technique in 11 cases, and stereotactic RT in 2 cases. No major toxicities were recorded. The median relapse-free survival (RFS) after adjuvant RT was 20.5 months, while for unknown primary MCC, it was 23 months. In the adjuvant setting, median polyomavirus-positive RFS was 21.5 months (range 1–49) and median polyomavirus-negative RFS was only 14 months (range 4–45). Overall, RFS of polyomavirus-positive and polyomavirus-negative patients was 10.5 and 8 months, respectively. After adjuvant RT, only 1 out of 10 patients had a recurrence in the RT field. At the time of data collection, 16 patients were alive with no evidence of disease, 1 patient was alive with advanced status of disease, 8 patients died of disease progression, and 1 patient died of other causes. Conclusions: The management of unknown primary and polyomavirus-positive cases, which had a better prognosis in our series, may benefit from a multidisciplinary approach, given the limited data available regarding optimal treatment.

This paper provides a first insight of the potential of the β - Radio Guided Surgery ( β - -RGS) in a complex surgical environment like the abdomen, where multiple sources of background concur to the signal at the tumor site. This case is well reproduced by ex-vivo samples of 90 Y -marked Gastro-Entero-Pancreatic Neuroendocrine Tumors (GEP NET) in the bowel. These specimens indeed include at least three wide independent sources of background associated to three anatomical districts (mesentery, intestine, mucose). The study is based on the analysis of 37 lesions found on 5 samples belonging to 5 different patients. We show that the use of electrons, a short range particle, instead of γ particles, allows to limit counts read on a lesion to the sum of the tumor signal plus the background generated by the sole hosting district. The background on adjacent districts in the same specimen/patient is found to differ up to a factor 4, showing how the specificity and sensitivity of the β - -RGS technique can be fully exploited only upon a correct measurement of the contributing background. This locality has been used to set a site-specific cut-off algorithm to discriminate tumor and healthy tissue with a specificity of 100% and a sensitivity, on this test data sample, close to 100%. Factors influencing the sensitivity are also discussed. One of the specimens set allowed us evaluate the volume of the lesions, thus concluding that the probe was able to detect lesions as small as 0.04 mL in that particular case.

Objectives: Written radiological report remains the most important means of communication between radiologist and referring medical/surgical doctor, even though CT reports are frequently just descriptive, unclear, and unstructured. The Italian Society of Medical and Interventional Radiology (SIRM) and the Italian Research Group for Gastric Cancer (GIRCG) promoted a critical shared discussion between 10 skilled radiologists and 10 surgical oncologists, by means of multi-round consensus-building Delphi survey, to develop a structured reporting template for CT of GC patients. Methods: Twenty-four items were organized according to the broad categories of a structured report as suggested by the European Society of Radiology (clinical referral, technique, findings, conclusion, and advice) and grouped into three “CT report sections” depending on the diagnostic phase of the radiological assessment for the oncologic patient (staging, restaging, and follow-up). Results: In the final round, 23 out of 24 items obtained agreement (≥ 8) and consensus (≤ 2) and 19 out 24 items obtained a good stability (p > 0.05). Conclusions: The structured report obtained, shared by surgical and medical oncologists and radiologists, allows an appropriate, clearer, and focused CT report essential to high-quality patient care in GC, avoiding the exclusion of key radiological information useful for multidisciplinary decision-making. Key Points: • Imaging represents the cornerstone for tailored treatment in GC patients. • CT-structured radiology report in GC patients is useful for multidisciplinary decision making.

Objective The aim of this case series is to describe our experience in diagnosis and management of oncological asymptomatic patients with COVID-19 who underwent 18F-FDG PET/CT. Methods From March 9 to March 31, 2020, we identified 5 patients who had PET/CT findings suspicious for COVID-19, but no symptom of infection. Results The first three patients were administered an SARS-CoV-2 test in a COVID-dedicated center, while the fourth and fifth were tested in our institution, in accordance with a new internal procedure. The SARS-CoV-2 test yielded positive results in all five patients. Conclusion In this COVID-19 emergency, our task as radiologists and nuclear medicine physicians is to be able to identify imaging findings suggestive of the disease and to manage patients without overloading the hospital system.

Primary neuroendocrine tumors of the thymus are extremely rare. In patients with advanced disease, tumor growth control, and sometimes also syndrome control are the main goals of systemic therapy. Unfortunately, no standard therapies are available in clinical practice; therefore, clinical studies are strongly recommended. Axitinib (AXI) is a tyrosine kinase inhibitor, currently under investigation in an international phase II/III trial including thymic neuroendocrine tumors. Over the past 5 months, the entire world has been facing a devastating medical emergency brought about by a pandemic due to a novel coronavirus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which emerged in Wuhan, China, in late 2019. Since then, health professionals have been expending all their efforts on trying to provide the best available treatments for patients involved. Patients with cancer, especially those with thoracic involvement, are at higher risk of coronavirus disease 19 (COVID-19) and its complications because of their immunosuppressive status caused by the cancer and the anticancer therapies. As it remains unclear how to optimally manage such patients, we wished to report our experience with a patient with a metastatic neuroendocrine tumor of the thymus infected with SARS-CoV-2 in the hope that it may provide some insights and reflections on the management of cancer patients during this challenging time in our history.

The sternum is an uncommon site for neoplastic lesion and so sternectomy for oncologic indications is rare (1,2). Primary tumors of the sternum represent 0.5% of all primary bone neoplasms, being chondrosarcoma the most frequent, occurring mainly in young male patients (3). The sternum can be the site of isolated bone metastasis from non-bone primary tumors and sternectomy can be indicated in very selected case.

Well-established criteria for evaluating the response to treatment and the appropriate followup of individual patients are critical in clinical oncology. The current evidence-based data on these issues in terms of the management of gastroenteropancreatic (GEP) neuroendocrine neoplasms (NEN) are unfortunately limited. This document by the Italian Association of Clinical Endocrinologists (AME) on the criteria for the follow-up of GEP-NEN patients is aimed at providing comprehensive recommendations for everyday clinical practice based on both the best available evidence and the combined opinion of an interdisciplinary panel of experts. The initial risk stratification of patients with NENs should be performed according to the grading, staging and functional status of the neoplasm and the presence of an inherited syndrome. The evaluation of response to the initial treatment, and to the subsequent therapies for disease progression or recurrence, should be based on a cost-effective, risk-effective and timely use of the appropriate diagnostic resources. A multidisciplinary evaluation of the response to the treatment is strongly recommended and, at every step in the follow-up, it is mandatory to assess the disease state and the patient performance status, comorbidities, and recent clinical evolution. Local expertise, available technical resources and the patient preferences should always be evaluated while planning the individual clinical management of GEP-NENs.

Lung neuroendocrine tumors (NETs) comprise typical (TC) and atypical carcinoids (AC). They represent the well differentiated (WD) or low/intermediate grade forms of lung neuroendocrine neoplasms (NENs). Unlike the lung poorly differentiated NENs, that are usually treated with chemotherapy, lung NETs can be managed with several different therapies, making a multidisciplinary interaction a key point. We critically discussed the multimodal clinical management of patients with advanced lung NETs. Provided that no therapeutic algorithm has been validate so far, each clinical case should be discussed within a NEN-dedicated multidisciplinary team. Among the systemic therapies available for metastatic lung NETs everolimus is the only approved drug, on the basis of the results of the phase III RADIANT-4 trial. Another phase III trial, the SPINET, is ongoing comparing lanreotide with placebo. Peptide receptor radionuclide therapy and chemotherapy were not studied within phase III trials for lung NETs, and they have been reported to be active within retrospective or phase II prospective studies. Temozolomide and oxaliplatin are two interesting chemotherapeutic agents in lung NETs. While some European Institutions were certificated as Centers of Excellence for gastroenteropancreatic NENs by the European Neuroendocrine Tumor Society (ENETS), an equivalent ENETS certification for lung NENs does not exist yet. Ideally a lung NEN-dedicated multidisciplinary tumor board should include NEN-dedicated medical oncologists, thoracic medical oncologist, thoracic surgeons, pathologists, interventional radiologists, endocrinologists, radiotherapists, interventional pneumologists, nuclear physician.

Metronomic therapy is characterized by the administration of regular low doses of certain drugs with very low toxicity. There have been numerous debates over the empirical approach of this regimen, but fewest side effects are always something to consider in order to improve patients' quality of life. Neuroendocrine tumors (NETs) are rare malignancies relatively slow-growing; therefore their treatment is often chronic, involving several different therapies for tumor growth control. Knowing that these tumors are highly vascularized, the anti-angiogenic aspect is highly regarded as something to be targeted in all patients harboring NETs. Additionally the metronomic schedule has proved to be effective on an immunological level, rendering this approach as a multi-targeted therapy. Rationalizing that advanced NETs are in many cases a chronic disease, with which patients can live for as long as possible, a systemic therapy with regular low doses and a very low toxicity is in many cases a judicious manner of pursuing stabilization. Metronomic schedule is usually correlated with chemotherapy in oncology, but other therapies, such as radiotherapy and biotherapy can be delivered in a metronomic like manner. This review describes clinical trials and case series involving metronomic therapies alone or in combination in patients with advanced NETs. Nowadays level of evidence about metronomic therapy in NETs is quite low, therefore future prospective clinical studies are needed to validate the metronomic approach in specific clinical settings.

Neuroendocrine tumors (NETs) represent a large and heterogeneous group of malignancies with various biological and clinical characteristics, depending on the site of origin and the grade of tumor proliferation. In NETs, as in other cancer types, molecularly targeted therapies have radically changed the therapeutic landscape. Recently two targeted agents, the mammalian target of rapamycin inhibitor everolimus and the tyrosine kinase inhibitor sunitinib, have both demonstrated significantly prolonged progression free survival in patients with advanced pancreatic NETs. Despite these important therapeutic developments, there are still significant limitations to the use of these agents due to the lack of accurate biomarkers for predicting tumor response and efficacy of therapy. In this review, we provide an overview of the current clinical data for the evaluation of predictive factors of response to/efficacy of everolimus and sunitinib in advanced pancreatic NETs. Surrogate indicators discussed include circulating and tissue markers, as well as non-invasive imaging techniques.

212 Background: The 2016 European Neuroendocrine Tumor Society consensus guidelines update recommends resection of the primary tumor and all mesenteric lymph-nodes for all patients with si-NENs, both with curative and palliative purposes. Current resectability criteria are based on the degree of involvement of the superior mesenteric artery (SMA) by the metastatic lymph nodes. The aim of this work was to test these criteria for the evaluation of our patients; we included as additional criteria the degree of involvement of the superior mesenteric vein (SMV) and peritoneum, two features not covered by current literature. Methods: We retrospectively reviewed the pre-operative CT-scans of all patients with si-NENs operated at IEO (European Institute of Oncology) between 2008 and April 2018. A first analysis classified tumors as “resectable” or “unresectable” according to SMA involvement. A second analysis classified tumors as resectable or unresectable according to SMA involvement, SMV involvement (infiltration of the peripheral or proximal portion) and peritoneal involvement (presence or absence of fibrosis and retraction of the mesentery). We finally reviewed all surgery reports assessing radicality and completeness of the operation. Results: Abdominal CT-scan were available for analysis in 42 out of 47 operated patients. According to the first analysis, all three tumors classified as unresectable underwent incomplete resection, whereas out of the 39 tumors classified as resectable, six received an incomplete resection and 33 were completely resected. According to the second analysis, the nine tumors classified as unresectable underwent an incomplete resection, whereas 33 tumors classified as resectable were completely resected. Conclusions: Our retrospective analysis confirmed that SMA involvement may be useful to evaluate the resectability of the primary tumor and mesenteric lymph nodes. Furthermore, it suggested that the additional evaluation of the SMV and peritoneum involvement can allow to identify further cases of tumors for which complete resection is not possible.

Head and neck squamous cell carcinoma is the sixth most common cancer diagnosed worldwide and the eighth most common cause of cancer death. Malignant tumors of the oral cavity, oropharynx, and larynx can be treated by surgical resection or radiotheraphy with or without chemotheraphy and have a profound impact on quality of life functions, including swallowing. When surgery is the chosen treatment modality, the patient may experience swallowing impairment in the oral and pharyngeal phases of deglutition. A videofluoroscopic study of swallow enables the morphodynamics of the pharyngeal-esophageal tract to be accurately examined in patients with prior surgery. These features allow an accurate tracking of the various phases of swallowing in real time, identifying the presence of functional disorders and of complications during the short- and long-term postoperative recovery. The role of imaging is fundamental for the therapist to plan rehabilitation. In this paper, the authors aim to describe the videofluoroscopic study of swallow protocol and related swallowing impairment findings in consideration of different types of surgery.

A low burden of disease represents an independent favorable prognostic factor of response to peptide receptor radionuclide therapy (PRRT) in patients affected by gastro-entero-pancreatic neuroendocrine tumors. However, it is not clear whether this is due to a lower diffusion of the disease or thanks to debulking surgery. From 1996 to 2013 those patients diagnosed with G1–G2 pancreatic neuroendocrine tumor (PNET) and synchronous liver metastases who were not deemed eligible for liver radical surgery but were eligible to receive upfront PRRT were prospectively included in the study. Two groups of comparison were identified: those submitted for primary tumor resection before PRRT and those who were not. The outcome was evaluated as: objective response to PRRT (OR), progression-free survival (PFS), and overall survival (OS). Of the 94 subjects, 31 were previously submitted for primary tumor resection. After propensity score adjustments, patients who underwent surgery before PRRT showed higher stabilization or objective responses after PRRT (p = .006), and this translated into a better median PFS (70 vs. 30 months; p = .002) and OS (112 vs. 65 months; p = .011), for operated versus nonoperated patients, respectively. At multivariate analysis, operated patients showed a statistically significantly improved PFS: HR, 5.11 (95 % CI 1.43–18.3); p = .012, whereas Ki-67 in continuous fashion was correlated significantly with OS: 1.13 (95 % CI 1–1.27); p = .048. Primary tumor resection prior to PRRT can be safely proposed in G1–G2 PNETs with diffuse liver metastases because it seems to enhance response to PRRT and to improve significantly PFS.

Aim To determine the T 2 relaxation time of colorectal hepatic metastases and changes in T 2 relaxation times following chemotherapy. Materials and methods 42 patients with 96 hepatic colorectal metastases underwent baseline MRI. Axial T 1 , T 2 and multi-echo GRASE sequences were acquired. ROIs were drawn on T 2 relaxation maps, obtained from GRASE images, encompassing metastasis and normal liver to record T 2 relaxation time values. In 11 patients with 28 metastases, MRI was repeated using same protocol at 6 weeks following chemotherapy. The median pre-treatment T 2 values of metastases and normal liver were compared using the Mann–Whitney test. The pre- and post-treatment median T 2 values of metastases were compared using the Wilcoxon–Rank test for responding ( n =16) and non-responding ( n =12) lesions defined by RECIST criteria. The change in T 2 values (Δ T 2 ) were compared and correlated with percentage change in lesion size. Results There was no difference in the pre-treatment median T 2 of metastases between responding (67.3±8.6) and non-responding metastases (71.4±16.5). At the end of chemotherapy, there was a decrease in the median T 2 of responding lesions (61.6±12.6) p =0.83, and increase in non-responding lesions (76.2±18.4) p =0.03, but these were not significantly different from the pre-treatment values. There was no significant difference in Δ T 2 of responding and non-responding lesions ( p =0.18) and no correlation was seen between size change and Δ T 2 (coefficient=0.3). Conclusion T 2 relaxation time does not appear to predict response of colorectal liver metastasis to chemotherapy.

The authors sought to evaluate the effect of model-based iterative reconstruction (MBIR) on the sensitivity of ground-glass nodule (GGN) detection at different dose levels.Fifty-four artificial GGN were randomly divided into three sets, each positioned in an anthropomorphic phantom. The three sets were evaluated on standard-dose (SD, 350 mA), low-dose (LD, 35 mA) and ultra-low-dose (ULD, 10 mA) CT scans (100 kV, 64 × 0.625 mm, 0.5 s), and each scan was reconstructed twice with filtered back projection (FBP) and MBIR. Three radiologists independently evaluated the scans for GGN presence and size. SD + FBP was considered the reference standard. A region of interest (ROI) was used to calculate signal-to-noise ratio (SNR) and contrast-to-noise ratio normalised to dose (CNRD). McNemar's test, Bland-Altman analysis and t test were used for statistical assessment (p 0.05).The mean diameter of the 54 GGNs was 9.2 mm (range 3.7-17.3 mm). For the three readers, no statistically significant differences were observed in the sensitivity of GGN detection between LD + MBIR, ULD + MBIR and SD + FBP (p 0.05). Bland-Altman analysis showed a good reader agreement (±1.5 mm) for GGN size between SD + FBP and ULD + MBIR. For low dose and ultra-low dose, the SNR and CNRD were significantly higher with MBIR (p 0.0001). The effective dose was 97.1 % lower with ultra-low dose (0.15 mSv) than standard dose (5.15 mSv).The detection of GGN with MBIR at low-dose and ultra-low-dose CT does not differ significantly from standard-dose CT with FBP in an anthropomorphic phantom.

Lipofilling is a well-established technique in reconstructive plastic surgery. It is used primarily in recontouring of the body and face to correct post-traumatic and congenital defects. The regenerative properties of adipose tissue have allowed the use of the lipofilling technique for the treatment of burn sequelae and irradiated breast to improve tissue quality and elasticity. We report on the case of a patient treated with radiation therapy for a nasopharyngeal carcinoma who presented with severe postradiation dysphagia. The lipofilling technique was successfully used to improve abnormal swallowing. The technical details and functional outcomes are discussed.

Purpose: The diagnosis of peritoneal carcinomatosis secondary to ovarian cancer is a real challenge in the cancer imaging field. In this retrospective study, we evaluate the accuracy of Single Detector Computed Tomography (SDCT), Multi Detector Computed Tomography (MDCT), and Positron Emission Tomography-Computed Tomography with F18-fluorodeoxyglucose ([ 18F]FDG-PET/CT) in the diagnosis of peritoneal seeding and we evaluate the possible applications of MDCT to predict the complete surgical removal of the peritoneal deposits. Methods and materials: A total of 228 scans (91 SDCT, 89 MDCT, and 48 [18F]FDG-PET/CT) of patients with peritoneal carcinomatosis secondary to ovarian cancer proved at laparoscopy and confirmed by histopathology were retrospectively reviewed by two independent groups of Radiologists and Nuclear Medicine Physicians for the evaluation of ascites, peritoneal nodules, and omental cake signs. Results: MDCT showed 81% of true positives, SDCT 72.5%, and [18F]FDG-PET/CT 77%. False negatives were 19% for MDCT, 27.5% for SDCT, and 23% for [18F]FDG-PET/CT. Conclusion: From our results, we concluded that MDCT is the technique of choice in the diagnosis of peritoneal seeding, while [18F]FDG-PET/CT, though showing similar accuracy, remains the most accurate technique for monitoring therapeutic response and disease recurrence. MDCT could play an important role due to its ability to predict the possibility of complete surgical removal of disease thus influencing the treatment plan aimed to improve quality of life. © Springer Science+Business Media, LLC 2009.

The lethality of lung cancer is related to the advanced stage at diagnosis. Initial studies have demonstrated that screening computed tomography (CT) is effective in diagnosing lung cancer at an earlier stage when compared with current clinical practice, however the best clinical approach for screening detected nodules has to be defined. The population to be identified as high risk should be over 50 years of age and should have smoked at least one pack/day for 20 years. CT protocols should use multidetector CT, low dose and a 2.5 reconstruction interval. Diagnostic work-up on detected nodules should be designed according to size and consider CT at 3 or 12 months to evaluate doubling time, CT enhancement, PET/CT and/or FNAB or VATS. The prevalence of lung cancer in the screened population is 1.1%–2.7%, and the incidence is 0.2%–1.1%. Eighty-one percent of cancers are diagnosed in stage I. The percentage of surgery performed for benign lesions ranges from 21% to 55%. In our series, the overall mortality rate was 3.2% in 5 years. The results of randomized clinical studies, when available, will assess the real efficacy of CT in reducing lung cancer related mortality.