Use Of Preoperative MRI Research Articles

Use of Preoperative MRI to Predict Vestibular Schwannoma Intraoperative Consistency and Facial Nerve Outcome

Introduction: Vestibular schwannoma firmness can be a factor in resectability. We sought to identify if preoperative tumor MRI T1 and T2 intensities might predict intraoperative consistency. We then determined whether intraoperative consistency correlated with facial nerve outcomes.

Use of Pre-operative MRI in DCIS of the Breast

Use of Pre-operative MRI in DCIS of the Breast

Multivariate analysis of predictors of positive or close margins in breast-conserving therapy.

105 Background: Local recurrence rates after breast-conserving therapy (BCT) are increased with positive or close margin lumpectomy. This group of patients usually requires a re-excision lumpectomy or a completion mastectomy, causing delays in systemic therapy, and a less desirable cosmetic outcome. The objectives of this study were to identify any predictive risk factors that might be associated with positive or close lumpectomy margins (<1mm), and thus have implications for the planning of appropriate primary surgical excision. Methods: This was a retrospective cohort study of 195 consecutive patients from a prospectively collected, single-institution database. Patients who underwent primary lumpectomy for ductal carcinoma in situ (DCIS), invasive ductal carcinoma, and invasive lobular carcinoma from October 2007 to July 2010 were reviewed. Statistical analysis of the data was performed using Chi-squared analyses, multivariate logistic regression and Student’s t-test to identify significant predictors of a close or positive margin following lumpectomy. Results: In this study, 53.8% had positive or close margins. Ninety-two percent of this group underwent re-excision (86.5%) and total mastectomy (13.5%). We also observed that 53.1% of patients who underwent second operation had no residual disease. Factors significantly associated with positive or close margins include a family history of breast cancer (OR=2.3, p=0.01), a non-palpable mass (OR=2.4, p=0.01), or an excisional biopsy (OR=6.02, p=0.022). Age, race, use of hormone replacement therapy, menopausal status, use of preoperative MRI or US, BIRAD, use of neoadjuvant chemotherapy, tumor size, staging, waiting time, histology, receptor status, and axillary status were not significantly correlated with positive or close margins. Conclusions: For patients who were recommended to have a lumpectomy, an increased risk of a positive or close margin was significantly associated with a family history of breast cancer, a nonpalpable mass, or an excisional biopsy. These predictors should be weighed in the decision for attempting lumpectomy with the goal of a negative margin versus the ability to obtain a satisfactory cosmetic outcome.

Response to: Prognostic indicators of hearing after complete resection of cholesteatoma causing a labyrinthine fistula by Stephenson MF and saliba I. Eur Arch Otorhinolaryngol 2011 Mar 9 [epub ahead of print

Recently, Stephenson and Saliba [1] reported their data on preoperative CT-scanning in cholesteatoma patients with labyrinthine fistula in the article ‘‘Prognostic indicators of hearing after complete resection of cholesteatoma causing a labyrinthine fistula’’. The authors state that high-resolution preoperative CT-scan is very precise in diagnosing labyrinthine fistulas and that its radiologic size helps to predict the type of the fistula. This study is generally well designed and well reported, but we have several comments. The authors mention: ‘‘a further study is needed to identify if a diffusion-weighted sequence for magnetic resonance imaging of labyrinthine cholesteatomatous fistula can predict the effect of the depth on the postoperative hearing outcome after a complete removal of the cholesteatoma’’. Although we consider non-echo-planar diffusion-weighted MRI as an essential tool in the preoperative work-up (and postoperative follow-up) of the cholesteatoma patient, its usefulness for the work-up of labyrinthine fistula in the cholesteatoma patient is limited [2]. Indeed, this sequence does not allow for discrimination of both cholesteatoma and other tissues, such as bone. However, other MRI sequences can be useful. Earlier studies on T1and T2-weighted imaging, gadolinium-enhanced spin-echo, three-dimensional Fourier transformation constructive interference in steady state (3DFT-CISS), and fluid-attenuated inversion recovery (FLAIR) were reported, respectively by Casselman et al. [3], Smadja et al. [4], and Sone et al [5]. In our department, we routinely perform preoperative temporal bone cone-beam CT-scans combined with a full MRI protocol (including non-echo-planar diffusion-weighted MRI) in the cholesteatoma patient [2]. In case of a lateral canal fistula, as diagnosed on CT, we use T2-weighted imaging to evaluate the presence of the labyrinthine fluid. If the labyrinthine fluid in the part of the lateral semicircular canal adjacent to the cholesteatoma is absent (no signal on T2 MRI), this will probably be due to reactive fibrosis. In such cases, the risk for perioperative sensorineural hearing loss is lower because the matrix and perimatrix of the cholesteatoma are not directly in contact with the membranous labyrinth. In case the fluid is still present (high signal on T2 MRI), the risk for a perioperative sensorineural hearing loss is higher because the matrix and perimatrix of the cholesteatoma can be in direct contact with the fluid contents of the membranous labyrinth, depending on the extent of the fistula. Our preoperative counseling of the patient is based on this policy [6]. A further study on the use of preoperative MRI in lateral canal fistula is definitely feasible and should, in our opinion, focus on T2-weighted imaging instead of diffusionweighted imaging. Additionally, the role of the cone-beam CT-scan should be further studied because of the increased spatial resolution and the significant decrease in radiation dosage. V. Van Rompaey E. Offeciers (&) University Department of Otorhinolaryngology and Head and Neck Surgery, Sint Augustinus Hospital, Oosterveldlaan 24, Wilrijk, 2610 Antwerp, Belgium e-mail: erwin.offeciers@gza.be

Factors contributing to delays in breast cancer management.

6070 Background: Patients with breast cancer (BC) often face delays in diagnosis, surgery, and onset of systemic or loco-regional treatment. While there is considerable literature on this third component, especially regarding delays in onset of radiation therapy, it is relevant to examine the entire continuum. We set out to quantify each component for both adjuvant and neoadjuvant patients, including potential factors for delay: hospital class, availability of prognostic markers, and the use of pre-operative MRI. Methods: We conducted a retrospective review of 949 BC patients referred to The Ottawa Hospital Cancer Centre (TOHCC) in 2008, of which 794 of which were included in this analysis. Dates of screening procedures (S), biopsies (B), marker reports (M), MRI scans, surgeries (Sx), and treatment initiation (chemotherapy [CT], radiation therapy [RT], and hormone therapy [HT]) were obtained and time intervals were calculated for all patients where data was available. Patients were stratified by referring hospital class (academic, nonacademic, or peripheral) and use of preoperative MRI. Analysis was carried out using chi-squared tests, and confirmed with ANOVA, Wilcoxon-Mann-Whitney, and Kruskal-Wallis tests, where appropriate. Results: The results are shown in the Table. Wait time intervals were compared between academic, nonacademic, and peripheral referring hospitals, and were significantly different. Approximately 35 percent of patients had a preoperative MRI. Impact of MRI was highly significant in terms of the number of mastectomies performed: 46.1% with MRI, 53.9% without (p=0.000), as well as the length of time to surgery: 54 days with MRI, 43 days without (p=0.000). Conclusions: Diagnostic and therapeutic delays have been identified in the care of women with early BC. The effect of these delays on outcome has not been determined but need to be considered in the overall management of these patients. S to B B to M B to MRI B to CT B to HT B to Sx Sx to M Sx to CT Sx to RT Sx to HT CT/HT to Sx Neoadjuvant Median 11 35 23 29 48 180 80th %ile 16 54 38 42 129 193 Adjuvant Median 18 48 24 55 74 58 80th %ile 32 67 34 68 95 97 No significant financial relationships to disclose.

Pre-operative MRI for women with newly diagnosed breast cancer: Perspectives on clinician and patient decision-making when evidence is uncertain

The routine use of pre-operative MRI in women with newly diagnosed breast cancer highlights the complexities of the use of new technology when evidence of benefit is uncertain. There are both potential harms and benefits. In the short term patients may desire and feel reassured by further testing and the use of new diagnostic techniques. However, they may also experience greater anxiety and distress from further tests and related follow-up procedures such as biopsy. In the long term MRI may result in more radical treatment decisions which are associated with poorer quality of life for women. Both patients and clinicians often (wrongly) assume that more information via testing leads to better outcomes (information bias). So how should pre-operative MRI be integrated into breast cancer care? First women need to be made aware of the uncertain evidence surrounding MRI. However whether it is appropriate to burden women with complex information and yet another decision at a time of high vulnerability and emotional distress should be considered. One potential solution is to use a Community Informed Consent approach in which a representative sample of patients and healthy women are educated about the benefits and harms and give their informed opinion about whether pre-operative MRI should be offered. Another approach is to provide patients with an evidence based decision aid to support individual informed choice. Either or a combination of both approaches would be acceptable and should be investigated. At present women are poorly informed about pre operative MRI and it is likely that they assume outcomes are be improved as a result. Clear communication about the limits of MRI to patients is needed alongside randomised trials to provide the evidence that benefit indeed outweighs the harms so that all parties involved may be comprehensively informed.

The Effect of Preoperative MRI on Mastectomy Rates in Breast Cancer Patients.

Abstract Background: Currently, there are two primary surgical options for the treatment of early stage breast cancer: modified radical mastectomy and breast conserving surgery (BCS) with post-surgical radiation. Numerous studies have shown that there is no survival difference between the two surgical treatments, however, in recent years, there is data to suggest that mastectomy rates have been on the rise. While many factors undoubtedly influence surgical management decisions in breast cancer patients, the effect of routine use of preoperative breast MRI may be a contributor to the rise in mastectomy rates. Methods: Breast cancer patients who were treated surgically and received a preoperative MRI were identified using a database from the University of Chicago Department of Radiology, which contains information on over 4200 patients who have received breast MRI since 2002. These patients were cross-referenced with data from the University of Chicago Cancer Registry, which contains information regarding type of surgical treatment, surgeon, stage of cancer at time of diagnosis and surgical stage for all breast cancer patients treated at the University of Chicago Hospitals from 2000-2007. Annual mastectomy rates from 2000-2007 were calculated and compared using Pearson's Chi Square test. Annual mastectomy rates were stratified by mean age at diagnosis and stage of disease. Mastectomy rates prior to routine use of preoperative MRI (2000-2002) and after routine use of preoperative MRI (2005-2007) were calculated for breast cancer patients under 45 and over 45 years of age and rates were compared using Fisher's exact test. Results: A total of 1,404 patients received surgical treatment for a new diagnosis of breast cancer between 2000 and 2007 at the University of Chicago Hospitals. Results to date indicate that mastectomy rates across all years are not significantly different (p = 0.315). Results also indicate that the mean age at diagnosis of patients who receive mastectomy as the initial surgical treatment for their breast cancer is higher than those who receive BCS from 2000-2002, but is lower than those who receive BCS from 2003-2007. In addition, breast cancer patients under the age of 45 have higher rates of mastectomy since the routine use of preoperative MRI which trends toward statistical significance (p = 0.0598). Conclusion: These preliminary results indicate that overall mastectomy rates at the University of Chicago Hospitals are not increasing in concordance with the increased use of preoperative MRI testing, but that younger breast cancer patients may have higher rates of mastectomy in the MRI era. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4019.

Cement Leakage During Vertebroplasty Can Be Predicted on Preoperative MRI

Previous studies have shown that cement leakage into an adjacent disk space is a risk factor for new fracture after vertebroplasty. The purpose of this study was to investigate the use of preoperative MRI for predicting such cement leakage. Our institutional review board approved this retrospective study and waived the requirement of informed consent. We studied preoperative MRI of 46 vertebroplasty patients (107 vertebral bodies). Endplate cortical defect, abnormal T2 hyperintensity in adjacent disk space, intravertebral cleft, degree of compression, and wedge angle were correlated to the incidence of cement leakage into the adjacent disk. Patient age, sex, and location of treated vertebral body were also evaluated. We used logistic regression analysis and Fisher's exact probability test to analyze the association between cement leakage and these observations. Cortical defect in the endplate of the treated vertebral body, abnormal T2 hyperintensity in the adjacent intervertebral disk, and absence of intravertebral cleft were associated with cement leakage into the disk space (p < 0.05). There was no statistically significant association between cement leakage into the disk and degree of compression, wedge angle, location of treated vertebral body, patient age, or sex (p > 0.05). Cement leakage into an adjacent disk is more common when there is a cortical defect in the endplate and increased T2 signal in the adjacent disk and is less common if there is an intravertebral cleft.

Posterior cervical laminoforaminotomy for the treatment of cervical radiculopathy

v P urgical intervention for cervical radiculopathy was developed in the early 1900’s by ioneers such as Krause and Stookey, who decribed posterior cervical nerve root decompresion by a posterior approach.1 Early papers reorted good results for the treatment of radicular ain by laminoforaminotomy.1,2,3,4,5,6,7 However, it ecame apparent that patients with central pahology were less adequately treated than paients with laterally located pathology.8,9 The advent of an anterior cervical diskectomy ith fusion by Smith and Robinson in 1955 draatically altered the surgical treatment of cervial radiculopathy.8,10 Although it required an aproach traversing the sensitive structures of the nterior neck, the new anterior approach proided excellent exposure of midline pathology nd acceptable access to more laterally situated athology. In an era before modern imaging, the dvantage of being able to adequately treat both idline and lateral pathology made anterior cerical diskectomy with or without fusion the aproach of choice for the next four decades. Durng this time, anterior cervical diskectomy with usion became a highly refined, popular, and sucessful treatment for cervical radiculopathy. owever, there appeared to be a subgroup of ervical radiculopathy patients with lateral pahology for whom posterior laminoforaminotomy ight be more appropriate.3,5,6,7,8,11,12,13,14 Recent advances in patient screening and perative techniques have led many to believe hat anterior cervical diskectomy and fusion and osterior laminoforaminotomy should be viewed s complementary surgical techniques. The curent widespread use of preoperative MRI for cerical radiculopathy now allows precise localizaion and definition of the origin of nerve root ompression. Patients presenting with radiculopthy with midline or bilateral pathology, with oexisting myelopathy or root compression by a ulging annulus or osteophyte, appear to be beter candidates for anterior cervical diskectomy nd fusion. However, patients with soft lateral isk disease have been reported to have at least

Usefulness of Preoperative MRI in Recurrent Anorectal Fistula

Usefulness of Preoperative MRI in Recurrent Anorectal Fistula