| Part ?.Optimizing CT Diagnosis for Primary SacrococcygealChordoma1.Clinical Application of Multiplanar Reconstruction and CT Angiography Based on Thin-section Volume CTE Imaging for Preoperative Assessment of Primary Sacrococcygeal ChordomaPurpose To evaluate the clinical application of multiplanar reconstruction(MPR)and computed tomography angiography(CTA)combined with semi-automatic tumor volume-rendering reconstruction(VR)based on thin-section volume CT enhancement(CTE)imaging for preoperative assessment of primary sacrococcygeal chordoma(PSC).Methods Preoperative thin-section computed tomography(CT)and CTE imaging,surgical and pathological data of 84 PSC patients were reviewed retrospectively.To display the relationships among tumor and supply arteries,and pelvic bones,CTA combined with tumor VR was executed by one experienced radiologist.Tumor location,size and adjacent structures were assessed directly by two experienced radiologists on workstation.According to the boundary between the tumor and the adjacent muscle confirmed by postoperative diagnosis,the 84 cases were divided into two groups: Group A with intact adjacent muscle,and Group B with the adjacent muscle involvement.Reliability analysis statistics,diagnostic test,receiver operating characteristic(ROC)analysis,Independent-samples T-test,Paired-samples T-test and one-way ANOVA were used.Results The relationships among the tumor and its supply arteries,and the pelvic bones are displayed vividly,intuitively and clearly on semi-automatic CTA images.The diagnostic accuracy of MPR in detecting tumor location and sacroiliac joint was 96.4%and 100% respectively.The accuracy,sensitivity and specificity of MPR were 96.2%,93.8% and 97.8% in detecting the adjacent muscles;92.1%,91.6% and 92.6% in detecting the sacral nerves respectively.The specificity of MPR in detecting retrorectal space involvement was 90.8%.The overall tumor size in Group B was significantly bigger than that in Group A(p=0.000).The diagnostic thresholds of the anteroposterior,transverse and superoinferior diameters for muscles involved were 62.5mm,92 mm and102.5mm,respectively.The accuracy,sensitivity and specificity of MPR combined with CTA in detecting the supply artery were 93.1%,91.7% and 94.9%,respectively.Conclusions A combination of CTA and MPR can help detecting the supply arteries and display the whole tumor appearance and adjacent structures in PSC more intuitively and clearly.2.A Noninvasive Quantitative Method to Predict S100 Expression for Primary Sacrococcygeal Chordoma Using CT-Based RadiomicsObjective S100 expression can reflect the grade of malignancy of the primary sacrococcygeal chordoma(PSC).Our purpose is to predict the S100 expression of PSC by using the computed tomography(CT)radiomics based on a 3D non-contrast CT and a 3D CT-enhanced(CTE)image data.Methods Seventy-seven PSC patients who were confirmed pathologically were enrolled for this study.According to the S100 expression results of the immunohistochemical(IHC)research,all cases were divided into two groups: the positive(+)of 59 patients(76.6%)and the negative(-)of 18(23.4%).Independent-samples T-test,Chi-square test and Mann-Whitney rank-sum test were performed to compare the differences in clinical characteristics and Ki67 indices between the two groups.Tumors were manually delineated on CT and CTE images,and the abundant radiomics features were then extracted from the delineated image of some noteworthy three-dimensional volume.Wilcoxon rank-sum test was implemented for the extracted radiomics features to evaluate their effectiveness for discriminating different expressions of S100.Ada Boost was subsequently used to mirror the performance of the combination of radiomics for predicting individualized S100 expression.Results Statistical analyses showed that there were no significant differences in terms of age,sex and Ki67 index in two groups.However,as for radiomics,21 feature descriptors derived from CT images,and 11 feature descriptors derived from CTE images could reflect the significant differences between the two groups(p<0.05).S100 expression was related to the tumor heterogeneity reflected by the image intensity.The AUC of radiomics features from CT,CTE,CT combined with CTE for predicting the individualized S100 expressions were 0.789,0.795 and 0.810,respectively.Conclusions Our study demonstrated that S100 expression was related to the tumor intensity of CT-based radiomics.CT radiomics can distinguish tumor behavior in term of different S100 expressions in PSC by a noninvasive quantitative approach,which provides a potential opportunity to improve decision support in PSC treatment at low cost.The combined injection of CT and CTE radiomics to the Ada Boost classifier contributes to a better performance than using the two separately.Part ?.CT or MRI Characteristics,Clinical Manifestationsand Pathological Features of Primary SacrococcygealChordoma1.CT Characteristics,Clinical Manifestations and Pathological Features of Primary Sacrococcygeal ChordomaObjective To improve diagnostic accuracy and raise awareness of computed tomography(CT)image characteristics combined with clinical manifestations and pathological features in patients with primary sacrococcygeal chordoma(PSC).Methods Pretreatment CT image and demographic of 98 cases,dated from December 2011 to April 2019 and confirmed with a pathological diagnosis of PSC,including CT characteristics,clinical manifestations and pathological features,were analyzed retrospectively.Independent samples T-test,chi-square test and one-way ANOVA were analyzed for different study purpose and data type.All statistical tests were two-sided,and p values of <0.05 were considered statistically significant.Bonfferroni T-test was adopted to compared the intersection of multiple samples,and p values of<0.05/n was considered statistically significant.Results Of the 98 cases,patients who came for their treatment were at the age of29-78(58.38±11.46)years,with a predilection for 50 to 68 year.The men-women-ratio was 2.2:1,and the age for diagnosis is of no difference in statistics(p=0.616).The occurrence rates of sacrococcygeal pain,bowel dysfunction,bladder dysfunction and lower extremity dysfunction were 87.8%,67.4%,48.0% and 41.8%,respectively.The course of disease was from 6 days to 360 months,the median course of disease was 6months,and the modal courses of disease were 6,12 and 24 months.The subtypes of the conventional,dedifferentiated,chondroid and sarcomatoid were 94(96.0%),2(2.0%),1(1.0%)and 1(1.0%),respectively.The positive expressions rate of CK,vimentin,EMA and S100 were 99.0%,96.9%,94.9% and 80.6%,respectively.Ki67 indexes were 0-46,the mediam was 3.0,and the modal was 5.0.The irregular appearance,lobulated margin and osteolytic bony destruction were displayed in all tumors.84(85.7%)cases located in the middle line zone of the sacrococcygeal area.The sacral segaments above S2/3 were involved in 49(50.0%)cases.Three or more than three vertebrates were destroyed in 89(90.8%)cases.“sandwich biscuit sign”,“rat gnawing sugarcane”,“anti-quote sign”,“floating bone fragments” and intratumoral calcification were observed in cases of 81(82.7%),79(80.6%),69(70.4%),48(49.0%)and 52(53.0%),respectively.Osteosclerosis was observed in 5(5.1%)cases.We found 403(1-8,4.43±1.93)of S1-4 sacral nerves were involved in 91(92.9%)cases and 159(1-8,29.4±1.62)adjacent muscles were encroached in 54(55.1%)cases.And the retrorectal space,sacroiliac joint and iliac were involved in 36(36.7%),14(14.3%)and 5(5.1%),respectively.Bonfferroni T-test showed that the maximal diameter by anteroposterior view was significantly shorter than it was by superoinferior and/or transverse view(p<0.0167),hence the values of housefield(Hu)among the lowest intensity of CT image,the highest intensity of CT image and CTE image were significantly different in statistics(p<0.01).Independent samples test showed that the overall tumor size was significantly larger in PSC with intratumoral calcification,adjacent muscle involvement and bladder dysfuntction than those without(p<0.05).S2 sacral nerve involvement was related to bladder dysfuntction(p<0.05).There was no significant relationship among pathological features,CT image characteristics and clinical manifestations(p>0.05).Conclusions Most of the cases were conventional PSC and occurred in men of 50-68 years old.The sacrococcygeal pain and the bowel and bladder dysfunction were common symptoms in PSC.Tumor heterogeneity was presented on CT images,including tumor size,intensity,shape and the adjacent structures involvement.The tumor growth was limited in anterior-posterior direction.The common CT characteristics,including:irregular appearance and lobulated margin,located in the middle line zone of the sacrococcygeal area,and osteolytic bony destruction,multiple vertebrae involvement,“sandwich biscuit sign”,“rat gnawing sugarcane”,“floating bone fragments” and sacral nerves involvement.Intratumoral calcification,“anti-quote sign” and adjacent muscle involvement were occurred in about half of the cases.The retrorectal space was involved in around one third of all cases.Tumor seldom encroached on sacroiliac joint space and iliac bone.Intratumoral calcification and adjacent muscle involvement were related to tumor size.Bladder dysfuntction was related to S2 nerve involvement,the anteroposterior and superoinferior diameters.2.Clinical Manifestations,Pathological Features and MRI Characteristics of Primary Sacrococcygeal ChordomaObjective To investigate the clinical manifestations,immunopathological features and MRI characteristics of the primary sacrococcygeal chordoma(PSC).Methods Clinical records,pathological reports and MRI data of 80 patients with PSC were retrospectively reviewed and relationships among them were analyzed statistically.Results The course of disease was from 6 days to 30 years.The cases of sacrococcygeal pain,bowel dysfunction,bladder dysfunction and lower extremity dysfunction were 70,56,35 and 35,respectively.The conventional and dedifferentiated chordoma of pathological subtypes were 79 and 1,respectively.The positive expressions cases of CK,vimentin,EMA and S100 were 78,75,78 and 65,respectively;Ki67 indexes were 0-30%.MRI showed that 69 cases located in the midline;S2 or above were involved by the tumor in 46 cases;the sacroiliac joints of 68 cases were intact.the cystic and solid-cystic tumors presented in 17 and 63 cases respectively;The maximal superoinferior and transverse diameters were lager than the maximal anteroposterior diameter significantly(p<0.05).The bladder dysfunction was related to S2 nerve involvement.Conclusion The course of disease in patients with PSC was variable.The sacrococcygeal pain and bowel dysfunction were common symptoms in PSC.Most of the cases were conventional chordoma by pathology confirmed.MRI showed that most of the cases were solid-cystic and located in the midline;the tumor growth was limited in anterior-posterior direction;more than half of cases involved S2 or above;the sacroiliac joint was seldom encroached.The bladder dysfunction was related to S2 nerve involvement.Part ?.The Classification of CT or MRI of PrimarySacrococcygeal Chordoma1.The Classification and Features of Primary Sacrococcygeal Chordoma Based on CT ImageObjective To develop a computed tomography(CT)image classification system and analyze CT image features for pretreatment primary sacrococcygeal chordoma(PSC),and provide evidences for its diagnosis and personalized medicine.Methods Pretreatment CT image of 101 patients with a histopathological diagnosis of PSC were analyzed retrospectively,including tumor location,extent,size,intensity,involvement of adjacent structure.According the tumor location,from upper to lower,PSCs were classified into four types(?-?).Four subtypes(a-d),from small to large,were defined by tumor extent.The ratio of subtype was analyzed by Kruskal-Wallis H-test and pairwise comparison.R × C contingency table of exact probability was compared for the occurrence rate of tumor calcification among different types and subtypes.One-way ANOVA and LSD-T-test were adopted to analyze the tumor size and intensity among different types and subtypes.Results In 101 cases,the ratios of type ?-? were 17.8%,30.7%,36.6% and 14.9%respectively;the ratios of subtype a-d were 9.9%,25.7%,58.4% and 5.9% respectively.Differences of ratio among subtypes had statistical significance(p=0.012).The proportion of subtype c was higher than subtype a(p=0.039),while the proportion of subtype d was lower than subtype a(p=0.036).There were no significantly differences among the other subtypes.For the occurrence rates of tumor calcification,there were no significant differences for those various types(p=0.233),but not for the subtypes(p=0.003).For the occurrence rates of tumor calcification were increasing from subtype a to subtype d.The transverse and vertical dimensions of type ? were larger than type ? to ?(p<0.05).As for the anteroposterior dimensions,there were statistically significant differences for subtypes b to d(p<0.05),but not for subtypes a and b(p=0.102),while the transverse dimensions and vertical dimensions were significantly different in statistics(p<0.05).However,the dimensions were increasing from subtype a to subtype d.Conclusions Type ? and ? were common in pretreatment CT images of the 101 PSCs while the first sacrum was seldom involved.And,subtype a was uncommon,subtype c was the commonest and subtype d was rare.The intensity of tumor was not associated with CT type and the occurrence rate of tumor calcification was related to subtypes.The extent of tumor in type ? was wider than the other types;the tumor dimensions were increasing from subtype a to d;CT imaging classification system was beneficial to judge the extent of a tumor.The diagnosis delay of PSC was obvious,but the distant invasion and metastasis were infrequent.CT imaging can develop a classification system for pretreatment of PSC and provide evidences for its diagnosis and personalized medication.2.MRI Type Predicts Postoperative Recurrence Free Survival in Patients with Primary Sacrococcygeal ChordomaPurpose To build the magnetic resonance imaging(MRI)type by classifying MRI characteristics of primary sacrococcygeal chordoma(PSC),and predict postoperative recurrence free survival(RFS)by MRI type.Methods MRI and clinical data of 80 patients with PSC were retrospectively analyzed.MRI of multiple sequences were executed by 3.0T MRI.MRI characteristics of tumor and adjacent structures were first appraised by two experienced radiologists,and were then classified by a two-step cluster analysis.Subsequently,RFS was predicted by MRI type.The two-step cluster analysis,one-way ANOVA,multinomial logistic regression,Chi-square test and Kaplan-Meier(KM)analysis were adopted in this study.Results Seven MRI characteristics were classified into three types through the two-step cluster.Chi-square test(Monte Carlo)showed that tumor intensity(TIWI,T2 WI,bleeding and enhancement),the involvement of sacroiliac joints and iliac bones were significantly different in statistics(p<0.01)among the three types.The one-way ANOVA analysis showed that the number of adjacent muscles involvement was significantly different in statistics(p<0.01).Multinomial logistic regression showed that MRI was an independent factor for predicting the RFS(p<0.01).The period of RFS was the longest for Type ?,while it was the shortest for Type ?(p<0.01).K-M analysis showed that the RFS among the three MRI types were significantly different in statistics(p<0.01).The proportions of local tumor recurrence in type ?,?,? were 21.4%,39.3%,and 60.0%,respectively.The one-way ANOVA analysis showed that the periods(months)of RFS of type ?,?,? were 39.86±17.27,32.43±16.55 and 17.70±9.76,respectively.Conclusion The tumor intensity,the involvement of sacroiliac joints and iliac bones,the number of adjacent muscles involvement were significantly different among the three MRI types.MRI type can predict local tumor recurrence.From type ? to type ?,the proportions of local tumor recurrence were increasing and the periods of RFS were decreasing gradually. |
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