DIAGNOSTIC IMAGING

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<ul><li> 1. DIAGNOSTIC IMAGING &amp; RADIOTHERAPY </li></ul><p> 2. DIAGNOSTIC IMAGING &amp; RADIOTHERAPY 169 DIRECTOR OF DEPARTMENT HEADS OF DIVISION AND UNITEmilio Bombardieri, MD Daniele Vergnaghi, MD phone number: +39 02 2390 2220 Radiology and Diagnostic Imaging 1 &amp;e-mail: emilio.bombardieri@istitutotumori.mi.it Magnetic Resonance UnitThe Department of Diagnostic Imaging and Radiotherapy is made up of sevenAlfonso Marchian, MDRadiology and Diagnostic Imaging 2 &amp; Divisions and a number special units have been established within these Divisions: theComputed Tomography Unit Magnetic Resonance Unit in Diagnostic Radiology 1, the Computed Tomography Unit and the Intralesional Treatment Unit in Diagnostic Radiology 2, the Breast Imaging UnitFrancesco Garbagnati, MD and the Diagnostic and Interventional Gastroenterology Unit in Diagnostic Radiology 3, Intralesional Treatment Unitthe Clinical PET Unit and the Radiometabolic Therapy and Silvana Bergonzi, MD Endocrinology Unit in Nuclear Medicine. The technologies inRadiology and Diagnostic Imaging 3 &amp; the area of diagnostic imaging (diagnostic radiology and nuclear Breast Imaging Unit medicine) provide not only morphologic information but alsoGuido Cozzi, MD functional parameters. The daily activity related to cancerDiagnostic and Interventional patients is structured in different steps: diagnosis of primaryGastroenterology Unit cancer, characterization, staging and restaging, treatmentEmilio Bombardieri, MD monitoring, and posttreatment follow-up. Besides diagnosticNuclear Medicine procedures, a large part of the activity of the Department is dedicated to cancer treatment. MRI research is carried out inEttore Seregni, MDNuclear Medicine Therapy and different fields: monitoring response to therapy, investigatingEndocrinology Unit patients with a high genetic risk of cancer, and developing software for imaging elaboration and quantitation. Flavio Crippa, MDClinical PET Unit Interventional radiology is an essential component of the scientific culture of INT and several trials are dedicated toPatrizia Olmi, MD central venous catheter placement, embolization and chemoembolization for regional Radiotherapy 1 cancer treatment, and new approaches with radiofrequency ablation. A multi-Carlo Fallai, MD institutional lung cancer screening program with low-dose spiral CT has involved Radiotherapy 2 Diagnostic Radiology Division. The Breast Imaging Unit is conducting studies on the surveillance of young women who previously underwent radiation therapy and on theRenato Marchesini, Physics DMedical Physics early diagnosis of breast cancer in women with a genetic predisposition. New diagnostic modalities such as elastosonography, a novel noninvasive technique, are under evaluation. The Interventional Gastroenterology Unit performs procedures such as percutaneous gastrojejunostomy, transluminal drainage of fluid collection, balloon 3. 170 SCIENTIFIC REPORT 2008 dilatation of stenoses, and palliative stenting. The Nuclear Medicine Division contributes to research activity with high technology modalities like PET/CT to image and better characterize cancer and develop new radiopharmaceuticals (positron- emitting products and radiolabeled peptides and antibodies). These radiopharmaceuticals are selective for tumor targeting and also for delivering killer radiation energy to the tumor mass by the administration of high activities of specific radioactive bullets. Dosimetric studies are of major interest in this area since the final goal of these efforts is to provide physicians with quantitative data about the absorbed dose to healthy organs (dose sparing) and tumor lesions (dose optimization to the target). External beam radiation therapy is focused on organ and function preservation, with the aim to deliver a higher total dose to the tumor and spare normal tissues as much as possible. In the Radiation Therapy Division this is obtained by techniques like 3D-conformal stereotactic intensity-modulated radiation therapy (IMRT), image-guided radiation therapy (IGRT), and brachytherapy with low and high dose rates. The newly acquired linear accelerators permit both online and offline treatment verification, which is especially needed for sophisticated techniques like IMRT and IGRT. High dose rate brachytherapy is also used in uterine cancer, biliary tract cancer and breast cancer. Several trials are addressing pediatric tumors. Research is ongoing on patients with bone metastases and solid tumors (thyroid cancer, rectal cancer, prostate cancer, soft tissue sarcomas, head and neck cancer). The Medical Physics group carries out studies on natural fluorescence spectroscopy of human blood plasma for cancer detection, and simulation of skin and melanocytic lesions with a melanoma-like phantom, mimicking the clinical decision-making related to pigmented skin lesions and implementation of the brachytherapy facility. This summary demonstrates that multidisciplinary interests continue to stimulate clinical studies and basic research, and this is due to the heterogeneity and interaction of the many components of the Department. 4. DIAGNOSTIC IMAGING &amp; RADIOTHERAPY 171 RADIOLOGY AND DIAGNOSTIC IMAGING 1THE DIVISION OF DIAGNOSTIC RADIOLOGY 1 (RD1) INCLUDES THE UNIT OF MAGNETIC RESONANCE IMAGING (MRI). THE DIRECTOR OF DIAGNOSTIC RADIOLOGY IS ALSO THE HEAD OF THE MRI UNIT. In 2008 RD1 carried out 10,956 MRI scans and 36,529 conventional radiologicHEAD OF DIVISION examinations (chest, general bone, contrast radiology of kidney and urinary system). Daniele Vergnaghi, MD MRI was used for the diagnosis of primary cancer, tumor staging, treatment STAFF MEMBERS monitoring, and follow-up. The following new methodologies were improved:Alberto Laffranchi, MD; Paolo - DCE-MRI (dynamic contrast-enhancement magnetic imaging)Potepan, MD; Giovanna Trecate, MD;Antonella Messina, MD; Davide - Diffusion technologyScaramuzza, MD - Perfusion technology - Spectroscopy of prostate cancer and of breast cancer RADIOLOGY TECHNICIANS - Magnetic resonance urography and magnetic resonance cholangiopancreatography Valeria Tosi, RT; Carmelina Pannone,RT; Cinzia Fossaceca, RT; Tina and new technologies were established: Mastrostefano; Antonella Laturra, - Total body imaging RT; Nicola Puler, RT; Maurizio - MRI-guided breast biopsy.Zattoni, RT; Annunziata Gaetano, RT;Luca Musumeci, RT The research activity was focused on several institutional projects on: Multicenter surveillance of women with a high genetic or familial risk of breast cancer (in collaboration with the Istituto Superiore Sanit, Rome); Prostate project on the study of patients by means of diffusion and DCE-MRI evaluation and spectroscopy performed with endocoil; DCE-MRI applied to the evaluation of tumor response to specific treatments carried out in some of the clinical Units. RD1 continued its collaboration with the Department of Biomedical Engineering of the Polytechnic of Milan aimed at developing software for image elaboration. In detail, a project to evaluate the accuracy of both DCE-MRI and diffusion MRI for the diagnosis of rectal cancer relapse was developed. The project on prostate DCE-MRI achieved a high level of development. RD1 collaborated with several clinical Units of the Institute in order to integrate diagnostic imaging with clinical information and to monitor the response of primary cancer to traditional and novel treatment strategies. The radiologists worked in close 5. 172 SCIENTIFIC REPORT 2008 cooperation with the physicians of the Soft Tissue Sarcoma Unit, Pediatric Oncology Unit, Colorectal Surgery Unit, and Head and Neck Unit. The most relevant interest of the Division lies in the area of breast disease, with more than 650 breast MRI examinations performed each year. An experience spanning nearly 20 years makes the Division a national reference center for breast cancer. Important results were obtained in patients at high genetic risk for breast cancer and in patients previously submitted to plastic and reconstructive surgery.FIGURE 1Total Body Imaginga) T1 W imageb) T2 W fat satc) Fusion image between T1morfological e diffusion images.Arrows point pathologic tissuedue a myeloma disease. 6. DIAGNOSTIC IMAGING &amp; RADIOTHERAPY 173 RADIOLOGY AND DIAGNOSTIC IMAGING 2WITHIN THE DIVISION OF DIAGNOSTIC RADIOLOGY 2 (RD2), TWO SPECIAL UNITS FOR SPECIFIC ACTIVITIES HAVE BEEN ESTABLISHED: THE UNIT OF COMPUTED TOMOGRAPHY AND THE UNIT OF INTRALESIONAL TREATMENT WITH RADIOFREQUENCY. THE DIRECTOR OF THE RD2 DIVISION ALSO LEADS THE UNIT OF COMPUTED TOMOGRAPHY. RD2 makes use of ultrasonography (US), computed tomography (CT), multifunctionalHEAD OF DIVISION fluoroscopy and digital angiography. Diagnostic oncology and interventionally-orientedAlfonso Marchian, MD radiology represent the daily activity. Inpatients and outpatients with cancer undergo a STAFF MEMBERS diagnostic workup, including the different steps of patient management: primary Francesco Garbagnati, MD; Enrico diagnosis, staging, follow-up and monitoring after surgical, chemotherapeutic and/orCivelli, MD; Giuseppe radiotherapeutic treatment. Di Tolla, MD; Laura F. Frigerio, MD; Rodolfo Lanocita, MD; Carlo Morosi, The interventional radiology activity includes long-term central venous catheterMD; Carlo Spreafico, MD placement, infusion chemotherapy, nutritional support, and infusional support. The selection and follow-up of candidates for liver transplantation are on the way, including CONSULTANTS Bruno Damascelli, MD perioperative standby for emergency diagnostic procedures related to transplant Gianluigi Patelli, MD salvage. All kinds of percutaneous biopsies are currently carried out. During 2008, 1,133 diagnostic vascular procedures, 313 interventional vascularRADIOLOGY TECHNICIANS Pietro Basile; Marilena Barbiero; procedures, about 500 long-term central venous catheter placements, 254 nonvascular Maria Ferrarello; Roberto Gallo; interventional procedures, and a total of 495 percutaneous biopsies in various body Giuseppina Gentile; Ester districts were performed. A total of 7,500 US examinations were carried out.Mazzarella; Roberto Nioi; Geremia Two CT scanners are available, both with fast multislice scanning capacity. About Porcelli (Radiogy Technicians' Coordinator); Salvatore Romaniello; 22,000 diagnostic examinations per year and a substantial number of interventionalLuciana Tanzini radiologic procedures are carried out. The Division has set up a study on percutaneous cryoablation in selected patients with small renal masses. The initial results in about 20 patients show a very good tolerability of the procedure and excellent preliminary responses. RD2 has developed several protocols dealing with embolization and chemoembolization for regional cancer treatment. The main fields of interest are primary liver cancer, liver metastases, and head and neck cancer. An international 7. 174 SCIENTIFIC REPORT 2008 multicenter study on the treatment of inoperable hepatocellular carcinoma with intraarterial injection of radiolabeled microspheres is ongoing in collaboration with the Divisions of Nuclear Medicine and Gastrointestinal and Hepatopancreatobiliary Surgery &amp; Liver Transplantation. Over 50 patients have been successfully treated with microspheres. Alternative approaches with radiofrequency ablation and intraarterial chemotherapy are proposed for primary and secondary liver cancer when other conventional treatments are not possible. An innovative approach to control recurrence of glioblastoma using intraarterial infusion of liposomal doxorubicin has been approved and launched by INT and the Carlo Besta Neurologic Institute of Milan. A multicenter observational clinical project with retrievable vena cava filters for pulmonary embolism control in cancer patients is ongoing. RD2 staff offers teaching courses and practical demonstrations to medical and nursing staff.FIGURE 2 Improving CT imaging in oncology. A study of central vein high-flow contrast injection through implanted infusional High flow contrast medium devices in cancer patients has been activated. The aim of this clinical study is to exploit injection through implantable the use of implanted central venous catheters or ports (currently used only for infusional devices. Illustrative chemotherapy and intravenous systemic support), thereby improving CT image qualityexample. Right small-cell lung cancer. Superior vena cava for cancer detection and staging, and treatment monitoring. injection at 5 mL/sec through The lung cancer screening program (MILD) with low-dose spiral CT continued in 2008. PowerPort allows 3 dimensional We performed over 5,000 low-dose spiral CT scans and are testing the prerelease of a(3D) volume rendering (VR) reconstruction. commercial system for computer-aided detection (CAD) of pulmonary nodules. We have published a first report in Radiology on the assessment of in vivo precision volumetric analysis and the estimation of the growth rate of small pulmonary nodules. We are going to compare the performance of radiologists with or without the aid of the CAD system for pulmonary nodule detection. A new screening program is planned for the early detection of kidney cancer. Screening will be done with noninvasive techniques such as ultrasonography. People in the 50- to 60-year age group living in the Lombardy region will be enrolled. Intralesional Treatment (Head of Unit: F. Garbagnati)In 1989 we started a research project to evaluate the possibility to treat inoperable liver tumors with minimally invasive thermoablation procedures. To date we have treated about 770 patients, most of whom suffering from inoperable liver tumors and some having kidney, lung or bone neoplasms. 8. DIAGNOSTIC IMAGING &amp; RADIOTHERAPY 175 In 2008 we used intralesional radiofrequency therapy, simple or combined with arterial stop flow, in one treatment session in 70 patients with hepatocellular carinomas with a maximum diameter of 10 cm. We are collaborating with the Universities of Milan and Pavia to evaluate new procedures and new technical possibilities. The combination of intralesional radiofrequency therapy and arterial stop flow in large hepatocellular carcinomas is very effective and in one session it is possible to treat tumors with a 10- cm diameter during a one-day hospitalization (Figure 3). Being part of RD2, the Intralesional Treatment Unit can benefit from the experience of the interventional radiology staff and collaborate with all clinical and surgical Units to treat unresectable tumors in the best way possible. The Intralesional Treatment Unit also has the capacity to evaluate clinical results by means of radiodiagnostic procedures with a highly precise intralesional approach utilizing radiologic guidance. Ultrasound, CT and angiography procedures in association with intralesional thermoablation techniques can significantly improve treatment results. With the Department of Biomedical Physics of the Milan Polytechnic we are evaluating the q...</p>