The treatment landscape in metastatic renal cell carcinoma has changed fundamentally over the last decade by the development of antiangiogenic agents, mammalian target of rapamycin inhibitors and ...immunotherapy. Outside of the context of a clinical trial, the treatments are used sequentially. We describe results under real‐life conditions of a sequential treatment strategy, before the era of immunotherapy. All patients were treated according to their prognostic score (either Memorial Sloan Kettering Cancer Center or International Metastatic Renal Cell Carcinoma Database Consortium) for advanced renal cell carcinoma. A treatment strategy involving 1 to 4 lines was determined including a rechallenge criterion for the repeat use of a treatment class. Three hundred forty‐four patients were included over 3 years. Overall survival was 57 months in patients with good or intermediate prognosis and 19 months in patients with poor prognosis. In the former group, the proportions of patients treated with 2 to 4 treatment lines were 70%, 38% and 16%, respectively. The best objective response rates for lines 1 to 4 were 46%, 36%, 16% and 17%, respectively. Grade III/IV toxicity did not appear to be cumulative. The recommended strategy was followed in 68% of patients. A large proportion of patients with good or intermediate prognosis who progress after two lines of treatment still have a performance status good enough to receive a systemic treatment, which justifies such a strategy. Overall survival of patients with good and intermediate prognosis was long, suggesting a benefit from the applied approach. These results might be used as selection criterion for the treatment of patients in the era of immune checkpoint inhibitors.
What's new?
Metastatic renal cancer is a notoriously relapsing disease that can be treated with anti‐angiogenic treatments, tyrosine kinase inhibitors, inhibitors of the mammalian Target of Rapamycin or immune checkpoint inhibitors. The authors performed a “real‐life” study testing a sequential strategy of the first three treatments applied to 344 patients with relapsing metastatic renal cancer before the era of immunotherapy. They found that the overall survival of patients with good and intermediate prognosis was long, almost 5 years, and plan a new study including immunotherapy in the future.
To evaluate the accuracy and source of errors using a two-dimensional (2D)/three-dimensional (3D) fusion road map for endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm.
A rigid 2D/3D ...road map was tested in 16 patients undergoing EVAR. After 3D/3D manual registration of preoperative multidetector computed tomography (CT) and cone beam CT, abdominal aortic aneurysm outlines were overlaid on live fluoroscopy/digital subtraction angiography (DSA). Patient motion was evaluated using bone landmarks. The misregistration of renal and internal iliac arteries were estimated by 3 readers along head-feet and right-left coordinates (z-axis and x-axis, respectively) before and after bone and DSA corrections centered on the lowest renal artery. Iliac deformation was evaluated by comparing centerlines before and during intervention. A score of clinical added value was estimated as high (z-axis < 3 mm), good (3 mm ≤ z-axis ≤ 5 mm), and low (z-axis > 5 mm). Interobserver reproducibility was calculated by the intraclass correlation coefficient.
The lowest renal artery misregistration was estimated at x-axis = 10.6 mm ± 11.1 and z-axis = 7.4 mm ± 5.3 before correction and at x-axis = 3.5 mm ± 2.5 and z-axis = 4.6 mm ± 3.7 after bone correction (P = .08), and at 0 after DSA correction (P < .001). After DSA correction, residual misregistration on the contralateral renal artery was estimated at x-axis = 2.4 mm ± 2.0 and z-axis = 2.2 mm ± 2.0. Score of clinical added value was low (n = 11), good (n= 0), and high (n= 5) before correction and low (n = 5), good (n = 4), and high (n = 7) after bone correction. Interobserver intraclass correlation coefficient for misregistration measurements was estimated at 0.99. Patient motion before stent graft delivery was estimated at x-axis = 8 mm ± 5.8 and z-axis = 3.0 mm ± 2.7. The internal iliac artery misregistration measurements were estimated at x-axis = 6.1 mm ± 3.5 and z-axis = 5.6 mm ± 4.0, and iliac centerline deformation was estimated at 38.3 mm ± 15.6.
Rigid registration is feasible and fairly accurate. Only a partial reduction of vascular misregistration was observed after bone correction; minimal DSA acquisition is still required.
Objective To identify geometric indices of abdominal aortic aneurysms (AAAs) on computed tomography that are associated with higher risk of rupture. Methods This retrospective case-control, ...institutional review board-approved study involved 63 cases with ruptured or symptomatic AAA and 94 controls with asymptomatic AAA. Three-dimensional models were generated from computed tomography segmentation and used for the calculation of 27 geometric indices. On the basis of the results of univariate analysis and multivariable sequential logistic regression analyses with a forward stepwise model selection based on likelihood ratios, a traditional model based on gender and maximal diameter (Dmax) was compared with a model that also incorporated geometric indices while adjusting for gender and Dmax. Receiver operating characteristic (ROC) curves were calculated for these two models to evaluate their classification accuracy. Results Univariate analysis revealed that gender ( P = .024), Dmax ( P = .001), and 14 other geometric indices were associated with AAA rupture at P < .05. In the multivariable analysis, adjusting for gender and Dmax, the AAA with a higher bulge location ( P = .020) and lower mean averaged area ( P = .005) were associated with AAA rupture. With these two geometric indices, the area under the ROC curve showed an improvement from 0.67 (95% confidence interval, 0.58-0.77) to 0.75 (95% confidence interval, 0.67-0.83; P < .001). Our predictive model showed comparable sensitivity (64% vs 60%) and specificity (79% vs 77%) with current treatment criteria based on gender and diameter at the point optimizing the Youden index (sensitivity + specificity − 1) on the ROC curve. Conclusions Two geometric indices derived from AAA three-dimensional modeling were independently associated with AAA rupture. The addition of these indices in a predictive model based on current treatment criteria modestly improved the accuracy to detect aneurysm rupture.
Objective The objective of this study was to evaluate the safety and efficacy of external beam radiation (EBR) in preventing restenosis after superficial femoral artery (SFA) stenting in comparison ...with a control group treated with SFA stenting only. Methods In this Institutional Review Board-approved study, patients who provided written informed consent were randomly assigned to 0 Gy or 14 Gy of EBR to the stent site 24 hours after SFA stenting. The primary end point was the angiographic binary restenosis rate 2 years after stenting. Categorical and continuous end points were respectively analyzed using logistic regression models and Wilcoxon tests. End points expressed as time to event were analyzed using a log-rank test. Results The study included 155 patients, 46 women and 109 men (mean age, 66 years; range, 45-85 years). In the 0 and 14 Gy groups, binary restenosis was present, respectively, in 44% (34/77) and 68% (52/76; P = .003) 2 years after stenting. Stent thrombosis occurred in 13% (10/78) of the 0 Gy group and in 33% (25/77) of the 14 Gy group ( P = .003). Target lesion revascularization at 2 years was 26% (25/78) in the 0 Gy group and 30% (23/77) in the 14 Gy group ( P = .56). There were no significant differences in total walking distances change from baseline to 2 years (46 ± 100 and 26 ± 79 m, respectively, in the 0 Gy and 14 Gy group; P = .25). There were no procedure-related deaths and no major amputations. Conclusions A single 14 Gy dose of EBR to the SFA stenting site did not prevent in-stent restenosis.
Purpose
To assess the impact of contrast injection and stent-graft implantation on feasibility, accuracy, and reproducibility of abdominal aortic aneurysm (AAA) volume and maximal diameter (D-max) ...measurements using segmentation software.
Materials and methods
CT images of 80 subjects presenting AAA were divided into four equal groups: with or without contrast enhancement, and with or without stent-graft implantation. Semiautomated software was used to segment the aortic wall, once by an expert and twice by three readers. Volume and D-max reproducibility was estimated by intraclass correlation coefficients (ICC), and accuracy was estimated between the expert and the readers by mean relative errors.
Results
All segmentations were technically successful. The mean AAA volume was 167.0 ± 82.8 mL and the mean D-max 55.0 ± 10.6 mm. Inter- and intraobserver ICCs for volume and D-max measurements were greater than 0.99. Mean relative errors between readers varied between −1.8 ± 4.6 and 0.0 ± 3.6 mL. Mean relative errors in volume and D-max measurements between readers showed no significant difference between the four groups (
P
≥ 0.2).
Conclusion
The feasibility, accuracy, and reproducibility of AAA volume and D-max measurements using segmentation software were not affected by the absence of contrast injection or the presence of stent-graft.
Key points
•
AAA volumetry by semiautomated segmentation is accurate on CT following endovascular repair
.
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AAA volumetry by semiautomated segmentation is accurate on unenhanced CT
.
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Standardization of the segmentation technique maximizes the reproducibility of volume measurements
.
Abstract Purpose To validate the reproducibility and accuracy of a software dedicated to measure abdominal aortic aneurysm (AAA) diameter, volume and growth over time. Materials and methods A ...software enabling AAA segmentation, diameter and volume measurement on computed tomography angiography (CTA) was tested. Validation was conducted in 28 patients with an AAA having 2 consecutive CTA examinations. The segmentation was performed twice by a senior radiologist and once by 3 medical students on all 56 CTAs. Intra and inter-observer reproducibility of D -max and volumes values were calculated by intraclass correlation coefficient (ICC). Systematic errors were evaluated by Bland–Altman analysis. Differences in D -max and volume growth were compared with paired Student's t -tests. Results Mean D -max and volume were 49.6 ± 6.2 mm and 117.2 ± 36.2 ml for baseline and 53.6 ± 7.9 mm and 139.6 ± 56.3 ml for follow-up studies. Volume growth (17.3%) was higher than D -max progression (8.0%) between baseline and follow-up examinations ( p < .0001). For the senior radiologist, intra-observer ICC of D -max and volume measurements were respectively estimated at 0.997 (≥0.991) and 1.000 (≥0.999). Overall inter-observer ICC of D -max and volume measurements were respectively estimated at 0.995 (0.990–0.997) and 0.999 (>0.999). Bland–Altman analysis showed excellent inter-reader agreement with a repeatability coefficient <3 mm for D -max, <7% for relative D -max growth, <6 ml for volume and <6% for relative volume growth. Conclusion Software AAA volume measurements were more sensitive than AAA D -max to detect AAA growth while providing an equivalent and high reproducibility.
To compare automated measurements of maximal diameter (D
) of abdominal aortic aneurysm (AAA) orthogonal to luminal or outer wall envelope centerline for endovascular repair (EVAR) follow-up.
...Eighty-three consecutive patients with AAA treated by EVAR who had at least 1 computed tomography (CT) scan before and 2 CT scans after EVAR with at least 5 months' interval were included. Three-dimensional reconstruction of the AAA was achieved with dedicated segmentation software. Performances of automated calculation algorithms of D
perpendicular to lumen or outer wall envelope centerlines were then compared to manual measurement of D
on double-oblique multiplanar reconstruction (gold standard). Accuracy of automated D
measurements at baseline, follow-up, and progression over time was evaluated by calculation of mean error, Bland-Altman plot, and regression models.
Disagreement in D
measurements between outer wall envelope algorithm and manual method was insignificant (mean error: baseline, -0.07 ± 1.66 mm, P = .7; first follow-up, 0.24 ± 1.69 mm, P = .2; last follow-up, -0.41 ± 2.74 mm, P = .17); whereas significant discrepancies were found between the luminal algorithm and the manual method (mean error: baseline, -1.24 ± 2.01 mm, P < .01; first follow-up, -1.49 ± 3.30 mm, P < .01; last follow-up, -1.78 ± 3.60 mm, P < .01). D
progression results were more accurate with AAA outer wall envelope algorithm compared to luminal method (P = .2).
AAA outer wall envelope segmentation is recommended to enable automated calculation of D
perpendicular to its centerline during EVAR follow-up.
Purpose
To compare different methods measuring abdominal aortic aneurysm (AAA) maximal diameter (Dmax) and its progression on multidetector computed tomography (MDCT) scan.
Materials and Methods
...Forty AAA patients with two MDCT scans acquired at different times (baseline and follow-up) were included. Three observers measured AAA diameters by seven different methods: on axial images (anteroposterior, transverse, maximal, and short-axis views) and on multiplanar reformation (MPR) images (coronal, sagittal, and orthogonal views). Diameter measurement and progression were compared over time for the seven methods. Reproducibility of measurement methods was assessed by intraclass correlation coefficient (ICC) and Bland–Altman analysis.
Results
Dmax, as measured on axial slices at baseline and follow-up (FU) MDCTs, was greater than that measured using the orthogonal method (
p
= 0.046 for baseline and 0.028 for FU), whereas Dmax measured with the orthogonal method was greater those using all other measurement methods (
p
-value range: <0.0001–0.03) but anteroposterior diameter (
p
= 0.18 baseline and 0.10 FU). The greatest interobserver ICCs were obtained for the orthogonal and transverse methods (0.972) at baseline and for the orthogonal and sagittal MPR images at FU (0.973 and 0.977). Interobserver ICC of the orthogonal method to document AAA progression was greater (ICC = 0.833) than measurements taken on axial images (ICC = 0.662–0.780) and single-plane MPR images (0.772–0.817).
Conclusion
AAA Dmax measured on MDCT axial slices overestimates aneurysm size. Diameter as measured by the orthogonal method is more reproducible, especially to document AAA progression.
Limitations of the dog model of orthotopic heart transplantation to study rejection include the need for extracorporeal circulation and transfusions. Heterotopic cervical heart transplantation may ...improve on these limitations. It is not known whether the natural history after heterotopic transplant is similar to that after orthotopic grafting.
Twenty-one dogs underwent cervical heterotopic heart transplantation. Serial echocardiographic studies were performed 1 to 3 hours after surgery, at 24 hours, 48 hours later, and immediately before killing (5 to 7 days).
LV diastolic and systolic areas were elevated immediately after transplantation (4.95 ± 1.49 cm
2 and 3.36 ± 1.18 cm
2 respectively) but decreased at 24 hours (3.93 ± 1.20 cm
2,
p = 0.0003 and 2.44 ± 0.96 cm
2,
p = 0.16). Thereafter, a progressive increase in LV diastolic and systolic areas was observed until sacrifice (5.53 ± 2.20 cm
2 and 4.59 ± 2.14 cm
2,
p < 0.001 vs 24 hours). LV fractional area shortening (FAS) and fractional volume change were depressed immediately after transplantation (28.2 ± 12.8% and 40.4 ± 12.3%, respectively), but increased at 24 hours (35.7 ± 10.0%,
p = 0.11 and 50.3 ± 4.0%,
p = 0.02). FAS decreased at 48 hours to 19.6 ± 11.1% (
p = 0.01 vs 24 hours). The centractility indexes were markedly reduced before killing (FAS = 14.0 ± 8.2% and LVEF = 18.4 ± 1.3%,
p < 0.0005 vs 24 hours). The thickness of the interventricular septum increased from 11.9 ± 2.0 mm at baseline to 14.4 ± 4.2 mm before sacrifice (
p = 0.007).
The evolution of dogs after heterotopic cervical heart transplant is comparable to that after the more standard orthotopic graft. Considering its multiple practical advantages including the easy echocardiographic follow-up, heterotopic transplantation may become a very practical model to use for the study of rejection after heart transplantation.
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