False-positive Findings Research Articles

PD27-02 99m TC-PSMA RADIOGUIDED SURGERY USING A DROP-IN GAMMA PROBE IN RADICAL PROSTATECTOMY: INITIAL RESULTS

You have accessJournal of UrologyCME1 Apr 2023PD27-02 99mTC-PSMA RADIOGUIDED SURGERY USING A DROP-IN GAMMA PROBE IN RADICAL PROSTATECTOMY: INITIAL RESULTS Nina Harke, Christian Fuhrmann, Thorsten Derlin, Desiree Weiberg, Olga Katzendorn, Christoph Czerner, Frank Rudolf, Tobias Ross, Hossein Tezval, and Markus A. Kuczyk Nina HarkeNina Harke More articles by this author , Christian FuhrmannChristian Fuhrmann More articles by this author , Thorsten DerlinThorsten Derlin More articles by this author , Desiree WeibergDesiree Weiberg More articles by this author , Olga KatzendornOlga Katzendorn More articles by this author , Christoph CzernerChristoph Czerner More articles by this author , Frank RudolfFrank Rudolf More articles by this author , Tobias RossTobias Ross More articles by this author , Hossein TezvalHossein Tezval More articles by this author , and Markus A. KuczykMarkus A. Kuczyk More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003305.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In the recent years, PSMA-based diagnostics and therapy has become increasingly established with the addition of radioguided surgery (RGS) and the intraoperative detection of radioactively labeled lymph nodes. We present the first results of a new robotic drop-in gamma probe (SENSEI®; Lightpoint Medical) for the detection of 99mTc-PSMA in robot-assisted radical prostatectomy (RARP). METHODS: The data of nine patients with prostate cancer undergoing RGS were evaluated retrospectively. After preoperative administration of 99mTc-PSMA, a SPECT-CT was conducted and a robotic radical prostatectomy was performed the following day including intraoperative measurement of the lymph node stations using SENSEI®. This was followed by a robotic extended pelvic lymph node dissection with ex vivo control measurement using SENSEI® and a conventional gamma probe. RESULTS: With a mean PSA value of 12.2 ng/ml, seven patients had high-risk and two patients had intermediate-risk prostate cancer. The SPECT-CT examination carried out preoperatively showed no findings suspicious for metastases in eight patients. The in- and ex-vivo lymph node measurements did not show a count rate that was significantly higher than the background. In one patient, intra- and postoperative measurement confirmed the positive signal found on SPECT-CT with lymph node metastases in the final histopathology results. Overall, a mean of 22 lymph nodes were dissected. No postoperative complications related to 99mTc-PSMA RGS or extended pelvic lymph node dissection occurred. CONCLUSIONS: 99mTc-PSMA RGS with SENSEI® allows for safe and easy lymph node measurements during surgery with no false-negative nor false-positive findings so far. Data from further patients will have to confirm these initial results. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e741 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nina Harke More articles by this author Christian Fuhrmann More articles by this author Thorsten Derlin More articles by this author Desiree Weiberg More articles by this author Olga Katzendorn More articles by this author Christoph Czerner More articles by this author Frank Rudolf More articles by this author Tobias Ross More articles by this author Hossein Tezval More articles by this author Markus A. Kuczyk More articles by this author Expand All Advertisement PDF downloadLoading ...

PD39-09 IMPACT OF PROSTATE IMAGING QUALITY (PI-QUAL) SCORE ON THE DETECTION OF CLINICALLY SIGNIFICANT PROSTATE CANCER IN MEN UNDERGOING MRI-TARGETED BIOPSY

PD39-09 IMPACT OF PROSTATE IMAGING QUALITY (PI-QUAL) SCORE ON THE DETECTION OF CLINICALLY SIGNIFICANT PROSTATE CANCER IN MEN UNDERGOING MRI-TARGETED BIOPSY

Mammography in combination with breast ultrasonography versus mammography for breast cancer screening in women at average risk.

Mammography in combination with breast ultrasonography versus mammography for breast cancer screening in women at average risk.

“A 2 YEAR PROSPECTIVE STUDY EVALUATING DIAGNOSTIC ACCURACY OF MAGNETIC RESONANCE IMAGING (MRI) IN DETECTION OF RAMP LESIONS OF MEDIAL MENISCUS”

The purpose of this study is to Correlate the characteristic pattern of lesions affecting posterior horn of medial meniscus in MRI with Arthroscopic findings and calculate sensitivity, specificity and accuracy in diagnosis of ramp lesions. Methodology:It is a 2-year prospective study conducted in department of orthopedics, Rajarajeswari Medical college and Hospital, Banglore. Patients who were diagnosed with meniscal injuries were posted for arthroscopy surgery after obtaining the informed consent. In this study we compared MRI findings with arthroscopic findings of medial meniscal ramp lesions of knee. The data is prepared and sensitivity, specificity, accuracy of MRI were calculated. Results:A total of 112 patients of knee injuries were evaluated in which the Medial meniscus was injured in 64.96% of cases. The MM tear with ramp lesion was present in 26(65%) cases, of which 5 (12.5%) cases had grade I tear, 8 (20%) cases had grade II tear and 13 (32.5%) cases had grade III tear. The sensitivity, specificity, PPV and NPV were calculated and we found Sensitivity 88.89%, Specificity 84.62%, Positive predictive value 92.31%, Negative predictive value 78.57%, Accuracy 87.50%. Conclusions:The Meniscal Ramp lesions need to evaluation of the knee injuries accurately is very crucial for the proper management and outcome. MRI shows moderate sensitivity, specificity and accuracy in the diagnosis of ramp lesions in posterior horn of medial meniscus with more false positives and false negative values. Common causes of false positive findings in MRI is due to misinterpretation of intra meniscal signal changes (grade II signal changes) or normal anatomy as tears. The arthroscopic evaluation of ramp lesions was done using a postero-medial and trans-notch view and other accessory portals.

Multiplex Digital PCR Assay to Detect Multiple KRAS and GNAS Mutations Associated with Pancreatic Carcinogenesis from Minimal Specimen Amounts

Digital PCR (dPCR) allows for highly sensitive quantification of low-frequency mutations and facilitates early detection of cancer. However, low-throughput targeting of single hotspots in dPCR hinders variant specification when multiple probes are used. We developed a dPCR method to simultaneously identify major variants related to pancreatic carcinogenesis. Using a two-dimensional plot of droplet fluorescence under the optimized concentration of two fluorescent probe pools, the absolute quantification of different KRAS and GNAS variants was determined. Successful detection of the multiple driver mutations was verified in 24 surgically resected tumor samples from 19 patients and 22 fine-needle aspiration samples from patients with pancreatic ductal adenocarcinoma. Precise quantification of the variant allele frequency was optimized by using template DNA at a concentration as low as 1 to 10 ng. Furthermore, amplicons targeting multiple hotspots were successfully enriched with fewer false-positive findings using high-fidelity polymerase, allowing for the detection of various KRAS and GNAS mutations with high probability in small amount of cell/tissue specimens. Using this target enrichment, mutations at a rate of 90% in small residual tissues, such as the fine-needle aspiration needle flush and microscopic lesions in resected specimens, were successfully identified. The proposed method allows for low-cost, accurate detection of driver mutations to diagnose cancers, even with minimal tissue collection.

Digital Tomosynthesis as a Problem-Solving Technique to Confirm or Exclude Pulmonary Lesions in Hidden Areas of the Chest.

To evaluate the capability of digital tomosynthesis (DTS) to characterize suspected pulmonary lesions in the so-called hidden areas at chest X-ray (CXR). Among 726 patients with suspected pulmonary lesions at CXR who underwent DTS, 353 patients (201 males, 152 females; age 71.5 ± 10.4 years) revealed suspected pulmonary lesions in the apical, hilar, retrocardiac, or paradiaphragmatic lung zones and were retrospectively included. Two readers analyzed CXR and DTS images and provided a confidence score: 1 or 2 = definitely or probably benign pulmonary or extra-pulmonary lesion, or pulmonary pseudo-lesion deserving no further diagnostic work-up; 3 = indeterminate lesion; 4 or 5 = probably or definitely pulmonary lesion deserving further diagnostic work-up by CT. The nature of DTS findings was proven by CT (n = 108) or CXR during follow-up (n = 245). In 62/353 patients the suspected lung lesions were located in the lung apex, in 92/353 in the hilar region, in 59/353 in the retrocardiac region, and in 140/353 in the paradiaphragmatic region. DTS correctly characterized the CXR findings as benign pulmonary or extrapulmonary lesion (score 1 or 2) in 43/62 patients (69%) in the lung apex region, in 56/92 (61%) in the pulmonary hilar region, in 40/59 (67%) in the retrocardiac region, and in 106/140 (76%) in the paradiaphragmatic region, while correctly recommending CT in the remaining cases due to the presence of true solid pulmonary lesion, with the exception of 22 false negative findings (60 false positive findings). DTS showed a significantly (p < 0.05) increased sensitivity, specificity, and overall diagnostic accuracy and area under ROC curve compared to CXR alone. DTS allowed confirmation or exclusion of the presence of true pulmonary lesions in the hidden areas of the chest.

Abstract P2-14-21: NiToNo Study. Evaluation in terms of quality of life and upper extremity functionality after Targeted Axillary Dissection versus lymphadenectomy

Abstract Introduction: Targeted Axillary Dissection (TAD) is the combination of the sentinel lymph node biopsy (SLNB) and retrieval of the clipped node that was proved positive before neoadjuvant treatment (NAT). Previous studies have demonstrated that this approach has a low false-negative rate in patients with cN+ before NAT. Current guidelines recommend axillary radiotherapy in cN+ despite a complete pathological response reported after NAT. Aim: To evaluate if TAD improves the quality of life and arm functionality compared to axillary lymph node dissection (ALND) in patients with cN+ before NAT. Methods: Prospective observational study. The study started in 2017 and ended in 2021. We included patients with one to three suspected lymph nodes and at least one confirmed by fine-needle aspiration. Suspicious lymph nodes were clipped before NAT. After NAT if a complete radiological response was achieved by axillary ultrasound, TAD was performed. During surgery, we used ultrasound-guided marked lymph node dissection and dual tracer SLNB. Clipped and SLN were assessed with intraoperative frozen section H&amp;E, standard H&amp;E, and IHC with CKAE1/AE3. After surgery, the breast tumor board analyzes the pathological findings and the surgical performance. When ITC, micro-metastases, or macro-metastases were found in the nodes, or when surgical performance is considered suboptimal, we proceed to ALND. We assessed QoL with standard forms and upper extremity mobility and lymphedema by physical examination. Results: We analyzed 44 women. Median age 53.9 years old. ALND was performed on 28 patients and TAD on 16 patients. Age and other confounding factors such as (BMI, type of surgery, and type of NAT) were similar in both groups. Median follow-up time: 24 months (5-60). No regional relapse in both groups. The axillary staging is shown in table 1. The surgical procedure and indications for ALND are shown in Table 2. Any patient with a Luminal-A-like profile had an axillary response to NAT and subsequent ALND was performed in all 4 patients. By contrast, patients with HER2 overexpression or triple negatives had better axillary responsiveness and 12/21 were stratified only with TAD. Two patients had a false positive finding on the post-NAT axillary ultrasound (one patient with LuminalB-Her2 positive tumor and one patient with HER2 positive not luminal) and ALND was performed, complete pathological response with only fibrosis was observed. Indications of ALND are shown in table 1. On the questionnaires, health status perception (84.9 TAD vs 65.77 ALND, p=0.02), QoL (83.33 TAD vs 64.29 ALND p=0.03), upped extremity symptoms (8.33% TAD vs 30.16% ALND, p&amp;lt; 0.01) and breast symptoms (14.06% TAD vs 31.25% ALND, p=0.03) are better on TAD than in ALND patients. On physical examination, 11 patients of the ALND group had some alteration in functionality (8 patients had limitation of abduction and 7 patients had lymphedema). By contrast, any alteration was found in the patients staged only with TAD. Conclusions: Targeted axillary dissection reduces posttreatment symptomatology and allows a better quality of life with no axillary relapses though follow-up is short. Patients with Luminal-A-like cancer probably are not good candidates for TAD because of a lack of responsiveness and perhaps another approach must be considered. Table 1: Axillary staging after NAT Table 2: Surgical procedure and indications for lymphadennectomy Citation Format: Laia Vila Homs, MAria Lourdes Carrillo-Guivernau, Catalina Sampol, Gabriel Matheu Capo, Pau CAMARASA, Catalina Serra, Monica Mariño, Angela Tarongí, Octavi Cordoba, Antonia Perelló. NiToNo Study. Evaluation in terms of quality of life and upper extremity functionality after Targeted Axillary Dissection versus lymphadenectomy [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-14-21.

A machine learning tool to improve prediction of mediastinal lymph node metastases in non-small cell lung cancer using routinely obtainable [18F]FDG-PET/CT parameters

BackgroundIn patients with non-small cell lung cancer (NSCLC), accuracy of [18F]FDG-PET/CT for pretherapeutic lymph node (LN) staging is limited by false positive findings. Our aim was to evaluate machine learning with routinely obtainable variables to improve accuracy over standard visual image assessment.MethodsMonocentric retrospective analysis of pretherapeutic [18F]FDG-PET/CT in 491 consecutive patients with NSCLC using an analog PET/CT scanner (training + test cohort, n = 385) or digital scanner (validation, n = 106). Forty clinical variables, tumor characteristics, and image variables (e.g., primary tumor and LN SUVmax and size) were collected. Different combinations of machine learning methods for feature selection and classification of N0/1 vs. N2/3 disease were compared. Ten-fold nested cross-validation was used to derive the mean area under the ROC curve of the ten test folds (“test AUC”) and AUC in the validation cohort. Reference standard was the final N stage from interdisciplinary consensus (histological results for N2/3 LNs in 96%).ResultsN2/3 disease was present in 190 patients (39%; training + test, 37%; validation, 46%; p = 0.09). A gradient boosting classifier (GBM) with 10 features was selected as the final model based on test AUC of 0.91 (95% confidence interval, 0.87–0.94). Validation AUC was 0.94 (0.89–0.98). At a target sensitivity of approx. 90%, test/validation accuracy of the GBM was 0.78/0.87. This was significantly higher than the accuracy based on “mediastinal LN uptake > mediastinum” (0.7/0.75; each p < 0.05) or combined PET/CT criteria (PET positive and/or LN short axis diameter > 10 mm; 0.68/0.75; each p < 0.001). Harmonization of PET images between the two scanners affected SUVmax and visual assessment of the LNs but did not diminish the AUC of the GBM.ConclusionsA machine learning model based on routinely available variables from [18F]FDG-PET/CT improved accuracy in mediastinal LN staging compared to established visual assessment criteria. A web application implementing this model was made available.

Invasive Procedures Associated With Lung Cancer Screening in Clinical Practice

The harm associated with imaging abnormalities related to lung cancer screening (LCS) is not well documented, especially outside the clinical trial and academic setting. What is the frequency of invasive procedures and complications associated with a community based LCS program, including procedures for false-positive and benign, but clinically important, incidental findings? We performed a single-center retrospective study of an LCS program at a nonuniversity teaching hospital from 2016 through 2019 to identify invasive procedures prompted by LCS results, including their indication and complications. Among 2,003 LCS participants, 58 patients (2.9%) received a diagnosis of lung cancer and 71 patients (3.5%) received a diagnosis of any malignancy. Invasive procedures were performed 160 times in 103 participants (5.1%), including 1.7%of those without malignancy. Eight invasive procedures (0.4%of participants), including four surgeries (12%of diagnostic lung resections), were performed for false-positive lung nodules. Only 1%of Lung Imaging Reporting and Data System category 4A nodules that proved benign were subject to an invasive procedure. Among those without malignancy, an invasive procedure was performed in eight participants for extrapulmonary false-positive findings (0.4%) and in 19 participants (0.9%) to evaluate incidental findings considered benign but clinically important. Procedures for the latter indication resulted in treatment, change in management, or diagnosis in 79%of individuals. Invasive procedures in those without malignancy resulted in three complications (0.15%). Seventy nonsurgical procedures (6%complication rate) and 48 thoracic surgeries (4%major complication rate) were performed in those with malignancy. The use of invasive procedures to resolve false-positive findings was uncommon in the clinical practice of a nonuniversity LCS program that adhered to a nodule management algorithm and used a multidisciplinary approach. Incidental findings considered benign but clinically important resulted in invasive procedure rates that were similar to those for false-positive findings and frequently had clinical value.

Are Computed Tomography Scans Necessary for the Diagnosis of Peritonsillar Abscess?

Background Peritonsillar abscess is one of the most common deep-space infections of the head and neck, accounting for significant healthcare costs in the United States. Contributing to this expenditure is the trend of increased usage of computed tomography (CT), particularly in the emergency department. However, CT can be falsely positive for peritonsillar abscess, prompting unnecessary drainage attempts that yield no purulence. The false positive findings question the accuracy of CT in diagnosing peritonsillar abscess. Objectives The objective of the study was to compare the accuracy of CT with clinical exam to assess if CT is warranted in peritonsillar abscess diagnosis. Methods A retrospective study was performed of patients presenting to eight Orlando emergency departments with throat pain from January 1, 2013, to April 30, 2013. Patients with clinical diagnoses of peritonsillar abscesses were reviewed. A note was made whether CT was performed and if peritonsillar abscess was seen. The reads were compared to the results of procedural intervention for abscess drainage to assess the accuracy of CT in diagnosing peritonsillar abscess. Results There were 116 patients diagnosed with peritonsillar abscess, of which 99 underwent CT scans to aid in diagnosis. Among these 99 patients, 23 received procedural intervention, with 16 having a return of purulence (69.6%), and seven remaining without purulence (30.4%). Conclusion This study highlights the potential inaccuracies of CT scan in diagnosing peritonsillar abscess, as 30.4% of scans interpreted as abscess lacked purulence on intervention. Given these findings, clinicians could serve as better fiscal stewards by using history and exam to guide management in the majority cases with infectious processes of the oropharynx.

Cartilage grafts mimicking cholesteatoma recurrence on diffusion-weighted magnetic resonance imaging: a case series.

Cholesteatomas present a high risk for residual and recurrent disease, and the surveillance of post-operative patients can be challenging. Diffusion-weighted magnetic resonance imaging is becoming the preferred method for investigating recidivism; however, false positive imaging findings increase the risk of patients undergoing unnecessary second look surgery. This study reports two patients with false positive diffusion restriction associated with cartilage grafts that mimicked cholesteatoma and resulted in second look surgery with no disease found at operation. This study also discusses the related medical literature, including potential causes of abnormal diffusion restriction and methods to negate this. Caution should be exercised when considering second look surgery in the presence of a cartilage graft and a high confidence of disease clearance. A multi-disciplinary approach is recommended for the operating surgeon to review the images with a radiologist.

Impact of Preoperative Extramammary Findings in Patients with Newly Diagnosed Breast Cancer.

Breast MRI has been associated with significant rates of false positive findings. We aimed to determine the frequency of extramammary findings (EMFs) in newly diagnosed breast cancer patients on breast MRI with contrast and assess the significance of these findings and need for additional imaging and follow-up. A retrospective review of patients diagnosed with breast cancer from October 2018 to October 2019 was performed. Clinicopathologic features were collected, including type of breast cancer, size, stage, and whether the patients had a breast MRI. Those who had MRI were included, and the MRI was reviewed to determine if EMFs were identified. Further imaging and follow-up were assessed and recorded. Of the 480 patients included in this cohort, 353 (74%) had invasive cancer, and the remainder had ductal carcinoma in situ. Two hundred ninety patients (60%) underwent MRI, and 53 of 290 (18%) had EMFs on MRI. Of these, 28 of 53 (53%) underwent additional imaging to further evaluate findings. Two invasive procedures were performed (fine needle aspiration and thymectomy), and 1 malignancy was identified in the thymus. No metastatic breast cancer was identified in any patient. MRIs are frequently obtained for newly diagnosed breast cancer patients, and additional findings, especially extramammary, can be stressful for patients, and potentially lead to treatment delay if further evaluation is warranted. Our results demonstrate that incidental EMFs discovered via breast MRI are common and often lead to additional imaging studies. However, no metastatic lesions were found, and only 1 separate malignancy was identified, which did not affect breast cancer management. In patients with early-stage breast cancer, EMFs yield a very low rate of malignancy, providing high levels of reassurance and supporting the option of proceeding with surgery or treatment without delay.

Evolution of flash visual evoked potentials to monitor visual pathway integrity during tumor resection: illustrative cases and literature review.

Flash visual evoked potentials (fVEPs) provide a means to interrogate visual system functioning intraoperatively during tumor resection in which the optic pathway is at risk for injury. Due to technical limitations, fVEPs have remained underutilized in the armamentarium of intraoperative neurophysiological monitoring (IONM) techniques. Here we review the evolution of fVEPs as an IONM technique with emphasis on the enabling technological and intraoperative improvements. A combined approach with electroretinography (ERG) has enhanced feasibility of fVEP neuromonitoring as a practical application to increase safety and reduce error during tumor resection near the prechiasmal optic pathway. The major advance has been towards differentiating true cases of damage from false findings. We use two illustrative neurosurgical cases in which fVEPs were monitored with and without ERG to discuss limitations and demonstrate how ERG data can clarify false-positive findings in the operating room. Standardization measures have focused on uniformity of photostimulation parameters for fVEP recordings between neurosurgical groups.

Development and Validation of a Deep Learning Algorithm to Differentiate Colon Carcinoma From Acute Diverticulitis in Computed Tomography Images

Differentiating between malignant and benign etiology in large-bowel wall thickening on computed tomography (CT) images can be a challenging task. Artificial intelligence (AI) support systems can improve the diagnostic accuracy of radiologists, as shown for a variety of imaging tasks. Improvements in diagnostic performance, in particular the reduction of false-negative findings, may be useful in patient care. To develop and evaluate a deep learning algorithm able to differentiate colon carcinoma (CC) and acute diverticulitis (AD) on CT images and analyze the impact of the AI-support system in a reader study. In this diagnostic study, patients who underwent surgery between July 1, 2005, and October 1, 2020, for CC or AD were included. Three-dimensional (3-D) bounding boxes including the diseased bowel segment and surrounding mesentery were manually delineated and used to develop a 3-D convolutional neural network (CNN). A reader study with 10 observers of different experience levels was conducted. Readers were asked to classify the testing cohort under reading room conditions, first without and then with algorithmic support. To evaluate the diagnostic performance, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for all readers and reader groups with and without AI support. Metrics were compared using the McNemar test and relative and absolute predictive value comparisons. A total of 585 patients (AD: n = 267, CC: n = 318; mean [SD] age, 63.2 [13.4] years; 341 men [58.3%]) were included. The 3-D CNN reached a sensitivity of 83.3% (95% CI, 70.0%-96.6%) and specificity of 86.6% (95% CI, 74.5%-98.8%) for the test set, compared with the mean reader sensitivity of 77.6% (95% CI, 72.9%-82.3%) and specificity of 81.6% (95% CI, 77.2%-86.1%). The combined group of readers improved significantly with AI support from a sensitivity of 77.6% to 85.6% (95% CI, 81.3%-89.3%; P < .001) and a specificity of 81.6% to 91.3% (95% CI, 88.1%-94.5%; P < .001). Artificial intelligence support significantly reduced the number of false-negative and false-positive findings (NPV from 78.5% to 86.4% and PPV from 80.9% to 90.8%; P < .001). The findings of this study suggest that a deep learning model able to distinguish CC and AD in CT images as a support system may significantly improve the diagnostic performance of radiologists, which may improve patient care.

Incidental Findings in Small Field of View Cone-beam Computed Tomography Scans, Part 2: Interpretation with Aid of a Checklist

IntroductionCone-beam computed tomography (CBCT) scans are routinely used by endodontic residents and faculty at Tufts University School of Dental Medicine for diagnostic purposes but are not routinely read for pathologic findings by a radiologist. In a 2017 study by Oser et al (part 1), endodontic residents and a radiologist interpreted CBCT scans taken for endodontic diagnostic purposes, and their findings were compared. The results demonstrated that a radiologist is significantly more likely to report incidental findings in small field of view (FOV) scans. A limitation of this study was that the radiologist used a checklist of common findings to review the scans. The purpose of this study was to examine whether the use of a checklist would improve the sensitivity of the endodontic residents’ reporting of incidental findings in small FOV CBCT scans. MethodsThe 203 small FOV CBCT scans used in part 1 were obtained and reviewed by endodontic residents in a systematic fashion. Radiographic findings were reported using a blank checklist. The results were compared with those previously reported. ResultsThe radiologist reported abnormalities in 176 of the 203 subjects (87%), and the residents reported abnormalities in 184 of the 203 subjects (91%). There was an increase in false positive findings when the residents were using a checklist. ConclusionsThe use of a checklist improved the sensitivity but decreased the specificity of the reporting of incidental findings in small FOV CBCT scans by endodontic residents.

The athlete's ECG : What is normal or abnormal?

The electrocardiogram (ECG) has become amobile and cost-effective routine assessment tool to risk stratify leisure-time and professional athletes during preparticipation screening. A central goal is the reduction of sudden cardiac death in sports through early recognition of the most prevalent underlying cardiac pathologies, e.g., hereditary cardiomyopathies or primary arrhythmias. Continuous evolution of the first ECG criteria for athletes, presented in 2010 by the European Society of Cardiology (ESC), has helped to improve the specificity of the criteria to both detect cardiac pathologies in early stages and differentiate from physiologic adaptation of the athlete's heart. Thus, the risk of false-positive findings and erroneous stigmatizations of athletes has been successfully reduced. This review article intends to trace back the changes of the ECG criteria in the light of agrowing body of scientific evidence over the last 15years, to present the key messages of the current International ECG criteria from 2017 and to identify some of the remaining challenges that wait to be answered by physicians in the field of sports medicine and sports cardiology.

Author's reply: Letter to the Editor: Double counting due to inadequate statistics leads to false-positive findings in "Effects of creatine supplementation on memory in healthy individuals: a systematic review and meta-analysis of randomized controlled trials".

Author's reply: Letter to the Editor: Double counting due to inadequate statistics leads to false-positive findings in "Effects of creatine supplementation on memory in healthy individuals: a systematic review and meta-analysis of randomized controlled trials".

Letter to the Editor: Double-counting due to inadequate statistics leads to false-positive findings in "Effects of creatine supplementation on memory in healthy individuals: a systematic review and meta-analysis of randomized controlled trials".

Prokopidis et al have conducted a meta-analysis of randomized, placebo-controlled clinical trials to assess the effects of oral creatine supplementation on memory performance of healthy individuals. However, concerns were raised regarding the validity of their statistical analyses, which may have led to misleading conclusions. In this letter, we describe the statistical issue at hand and its potential implications.

Using multiple outcomes in intervention studies: improving power while controlling type I errors.

Background The CONSORT guidelines for clinical trials recommend using a single primary outcome, to guard against excess false positive findings when multiple measures are considered. However, statistical power can be increased while controlling the familywise error rate if multiple outcomes are included. The MEff statistic is well-suited to this purpose, but is not well-known outside genetics. Methods Data were simulated for an intervention study, with a given sample size (N), effect size (E) and correlation matrix for a suite of outcomes ( R). Using the variance of eigenvalues from the correlation matrix, we compute MEff, the effective number of variables that the alpha level should be divided by to control the familywise error rate. Various scenarios are simulated to consider how MEff is affected by the pattern of pairwise correlations within a set of outcomes. The power of the MEff approach is compared to Bonferroni correction, and a principal component analysis (PCA). Results In many situations, power can be increased by inclusion of multiple outcomes. Differences in power between MEff and Bonferroni correction are small if intercorrelations between outcomes are low, but the advantage of MEff is more evident as intercorrelations increase. PCA is superior in cases where the impact on outcomes is fairly uniform, but MEff is applicable when intervention effects are inconsistent across measures. Conclusions The optimal method for correcting for multiple testing depends on the underlying data structure, with PCA being superior if outcomes are all indicators of a common underlying factor. Both Bonferroni correction and MEff can be applied post hoc to evaluate published intervention studies, with MEff being superior when outcomes are moderately or highly correlated. A lookup table is provided to give alpha levels for use with Meff for cases where the correlation between outcome measures can be estimated.

Automated lung cancer assessment on 18F-PET/CT using Retina U-Net and anatomical region segmentation

ObjectivesTo develop and test a Retina U-Net algorithm for the detection of primary lung tumors and associated metastases of all stages on FDG-PET/CT.MethodsA data set consisting of 364 FDG-PET/CTs of patients with histologically confirmed lung cancer was used for algorithm development and internal testing. The data set comprised tumors of all stages. All lung tumors (T), lymphatic metastases (N), and distant metastases (M) were manually segmented as 3D volumes using whole-body PET/CT series. The data set was split into a training (n = 216), validation (n = 74), and internal test data set (n = 74). Detection performance for all lesion types at multiple classifier thresholds was evaluated and false-positive-findings-per-case (FP/c) calculated. Next, detected lesions were assigned to categories T, N, or M using an automated anatomical region segmentation. Furthermore, reasons for FPs were visually assessed and analyzed. Finally, performance was tested on 20 PET/CTs from another institution.ResultsSensitivity for T lesions was 86.2% (95% CI: 77.2–92.7) at a FP/c of 2.0 on the internal test set. The anatomical correlate to most FPs was the physiological activity of bone marrow (16.8%). TNM categorization based on the anatomical region approach was correct in 94.3% of lesions. Performance on the external test set confirmed the good performance of the algorithm (overall detection rate = 88.8% (95% CI: 82.5–93.5%) and FP/c = 2.7).ConclusionsRetina U-Nets are a valuable tool for tumor detection tasks on PET/CT and can form the backbone of reading assistance tools in this field. FPs have anatomical correlates that can lead the way to further algorithm improvements. The code is publicly available.Key Points• Detection of malignant lesions in PET/CT with Retina U-Net is feasible.• All false-positive findings had anatomical correlates, physiological bone marrow activity being the most prevalent.• Retina U-Nets can build the backbone for tools assisting imaging professionals in lung tumor staging.