Inconclusive Cases Research Articles

Refining the role of presurgical PET/4D-CT in a large series of patients with primary hyperparathyroidism undergoing [18F]Fluorocholine PET/CT.

4D-CT has garnered attention as complementary imaging for patients with primary hyperparathyroidism (pHPT). Herein we evaluated a diagnostic strategy using [18F]Fluorocholine Positron Emission Tomography/Computed Tomography (PET/CT), followed by 4D-CT integrated into PET/4D-CT after negative/inconclusive PET/CT results in a single-center retrospective cohort of 166 pHPT patients who underwent parathyroidectomy after [18F]Fluorocholine PET/4D-CT. PET/CT and 4D-CT images were interpreted by three nuclear medicine physicians and one expert radiologist. Pathological findings were documented, and concordance rates were assessed. PET/CT results were categorized as positive/negative, with positive cases rated on a 3-level certitude scale: low, moderate, high. Inconclusive cases included low/moderate positivity. The added value of PET/4D-CT was assessed for negative/inconclusive cases through joint reading. PET/CT lesion-based analysis showed almost perfect interobserver concordance (Cohen's kappa >.8). Across the cohort, PET/CT had a sensitivity of 83%, specificity of 97%, PPV of 90% and NPV of 94%. For 4D-CT, these values were sensitivity: 53%, specificity: 84%, PPV: 56% and NPV: 82%. PET/CT was significantly more accurate than 4D-CT. Among 44 patients with negative/inconclusive results, PET/CT had sensitivity: 60%, specificity: 91%, PPV: 71% and NPV: 86%. In the same patients, sensitivity and specificity of the sequential diagnostic algorithm increased to 80% and 97%, showing significantly better global accuracy (92% vs. 83%) than standard PET/CT. We support a personalized imaging algorithm for pHPT, placing [18F]Fluorocholine PET/CT at the forefront, followed by 4D-CT integrated into PET/4D-CT in the same imaging session for negative/inconclusive results. When PET/CT results are clearly positive, the additional sensitivity benefit of 4D-CT is minimal.

Golden-angle radial sparse parallel (GRASP) magnetic resonance angiography (MRA) for endoleak evaluation after endovascular repair of the aorta: a prospective comparison to conventional time-resolved MRA.

Time-resolved angiography with interleaved stochastic trajectories (TWIST) magnetic resonance angiography (MRA) may obscure smaller vessels and is highly susceptibility to motion artifacts, potentially reducing endoleak detection accuracy after endovascular aortic repair (EVAR). The novel golden-angle radial sparse parallel (GRASP) sequence enhances spatial and temporal resolution with continuous, motion-robust datasets, showing promise for accurate endoleak detection post-EVAR. This study aimed to compare the diagnostic effectiveness of contrast-enhanced compressed-sensing radial GRASP-volume interpolated breath-hold examination (VIBE) sequence with standard contrast-enhanced dynamic TWIST-VIBE sequence in patients with inconclusive computed tomography angiography (CTA) findings regarding endoleak after EVAR. This single-center prospective study consecutively enrolled adults with inconclusive findings regarding the presence or type of endoleak in multiphasic CTA following EVAR for abdominal aortic aneurysms. Participants underwent contrast-enhanced MRA, acquiring dynamic TWIST-VIBE and GRASP-VIBE sequences. Two independent radiologists assessed the datasets for image quality, diagnostic confidence, and the presence and type of endoleak. Additionally, quantitative assessments with signal-to-noise ratios (SNR) and contrast-to-noise ratios (CNR) were performed. Statistical analyses included interrater and intermethod agreement, and diagnostic performance testing. Twenty participants (mean age, 72±9 years; 13 males) were included. GRASP-VIBE demonstrated superior image quality over TWIST-VIBE sequence with predominantly absent motion artifacts and increased diagnostic confidence (all P<0.001). Diagnostic performance significantly improved for detecting type II endoleaks in GRASP-VIBE compared to TWIST-VIBE scans [area under the curve (AUC): 0.96 vs. 0.73; P=0.04]. Diagnostic accuracy improved with GRASP-VIBE for overall (AUC: 0.94 vs. 0.79) and endoleak type I detection (AUC: 1.0 vs. 0.90), however, not significantly (P≥0.05). TWIST-VIBE sequences demonstrated significantly higher SNR for measurements in the clotted aneurysm sac (P=0.01). No significant differences were observed in CNR for the aorta and any aneurysm sacs across the compared imaging sequences. Compressed-sensing dynamic GRASP-VIBE sequence, with its superior image quality, diagnostic confidence, and performance, may be preferred over standard TWIST-VIBE sequence in inconclusive endoleak cases.

PHoenix score: development and validation of a novel approach to decrease the number of inconclusive GERD diagnoses

BackgroundThe Johnson–DeMeester composite score (DMS) is the historical gold standard for diagnosing gastroesophageal reflux disease (GERD). The Lyon Consensus outlines criteria for diagnosing GERD by pH monitoring, defining normal acid exposure time (AET) as < 4% and pathological as > 6%, presenting diagnostic uncertainty from 4 to 6%. We aimed to (i) calculate the proportion of borderline studies defined by total AET alone that are reclassified as normal or pathological by the DMS, (ii) determine the importance of supine AET for reclassification, and (iii) propose a new classification system using a composite score that considers positional changes.MethodsThis single-center, retrospective, observational study analyzed data from patients with an overall total AET from 2 to 6% on 48-h pH monitoring (Bravo pH capsule). Preselected predictors (supine and upright AET) were included in a model to create a composite score (i.e., pHoenix score) using the regression coefficients. The model was internally validated, and discriminative ability was tested against the DMS and compared to the total AET.ResultsWe identified 114 patients (80 [70.2%] women; median age, 55 years). Using the total AET, 26 (22.8%) were classified as normal and 88 (77.2%) as borderline; however, using the DMS, 45 (39.5%) were classified as normal and 69 (60.5%) as pathological. The new pHoenix score demonstrated strong discriminative ability (AUC: 0.957 [95% CI 0.917, 0.998]) with high sensitivity and specificity (lower threshold, 94.4% and 79.2%; upper threshold, 87 and 95.8%). Compared to the total AET alone, the pHoenix score significantly decreased the proportion of inconclusive cases (77.2% vs. 13.2%, p < 0.001).ConclusionTotal AET has low sensitivity to identify pathological reflux as it disregards supine versus upright reflux. The pHoenix score improves the distinction between normal and pathological cases and reduces ambiguity, offering an alternative approach to diagnosing GERD that addresses the limitations of using total AET alone or the DMS.Graphical abstract

Diagnostic performance of ultrasound reporting systems in evaluation of adnexal masses: A prospective observational study

Objective(s)To evaluate and compare diagnostic performance of ultrasound-based reporting systems IOTA SR, ADNEX, GIRADS, ORADS for discrimination between benign and malignant adnexal masses. Study designA prospective observational study in a tertiary care hospital’s Obstetrics and Gynaecology department evaluated pre-operative ultrasound imaging for adnexal masses in 80 cases, comparing various reporting systems’ sensitivity and specificity against histopathology as gold standard using STATA version 17.0 for data analysis. ResultsAmong the 80 masses, 55 % (44/80) were confirmed as benign on histopathology, while 45 % were identified as malignant. The sensitivity and specificity of SR was 100 % (95 %CI: 90.0–100) and 97.1 % (95 %CI: 84.7–99.9) respectively. Eleven masses (13.8 %) were inconclusive, reducing specificity to 75 % (95 %CI:59.7–86.8).In ADNEX optimal cut-off for risk of malignancy was 34.1 % with sensitivity of 86.1 % (95 % CI: 70.5–95.3) and specificity of 90.9 % (95 % CI: 78.3–97.5). Considering GIRADS 4–5 and risk threshold of ≥10 % (ORADS 4–5) as predictors of malignancy sensitivity was 100 % (95 %CI: 90.3–100) and specificity was 70.5 % (95 %CI: 54.8–83.2) for GIRADS and ORADS. All reporting systems were comparable (p = 0.7). ADNEX identified 72.7 % (8/11) of inconclusive cases, outperforming GIRADS/ORADS which correctly classified 27.2 % (3/11) cases. When applied to misclassified GIRADS/ORADS 4–5 category, ADNEX demonstrated superior performance by correctly classifying 76.9 % (10/13) masses, while SR achieved correct classification in only 38.5 % (5/13) masses. Conclusion(s)All classification systems showed comparable accuracy in malignancy risk identification on imaging. GIRADS/ORADS tended to overestimate malignancy risk. The present study recommends a two-step strategy, leveraging higher specificity of ADNEX model for improved stratification of adnexal masses.

Genome and RNA sequencing were essential to reveal cryptic intronic variants associated to defective ATP6AP1 mRNA processing

The diagnosis of Mendelian disorders has notably advanced with integration of whole exome and genome sequencing (WES and WGS) in clinical practice. However, challenges in variant interpretation and uncovered variants by WES still leave a substantial percentage of patients undiagnosed. In this context, integrating RNA sequencing (RNA-seq) improves diagnostic workflows, particularly for WES inconclusive cases. Additionally, functional studies are often necessary to elucidate the impact of prioritized variants on gene expression and protein function.Our study focused on three unrelated male patients (P1-P3) with ATP6AP1-CDG (congenital disorder of glycosylation), presenting with intellectual disability and varying degrees of hepatopathy, glycosylation defects, and an initially inconclusive diagnosis through WES. Subsequent RNA-seq was pivotal in identifying the underlying genetic causes in P1 and P2, detecting ATP6AP1 underexpression and aberrant splicing. Molecular studies in fibroblasts confirmed these findings and identified the rare intronic variants c.289-233C > T and c.289-289G > A in P1 and P2, respectively. Trio-WGS also revealed the variant c.289-289G > A in P3, which was a de novo change in both patients. Functional assays expressing the mutant alleles in HAP1 cells demonstrated the pathogenic impact of these variants by reproducing the splicing alterations observed in patients.Our study underscores the role of RNA-seq and WGS in enhancing diagnostic rates for genetic diseases such as CDG, providing new insights into ATP6AP1-CDG molecular bases by identifying the first two deep intronic variants in this X-linked gene. Additionally, our study highlights the need to integrate RNA-seq and WGS, followed by functional validation, in routine diagnostics for a comprehensive evaluation of patients with an unidentified molecular etiology.

Immunohistochemical and histopathological analyses of cutaneous innervation to improve the diagnostic efficacy in hansen disease skin lesion

Abstract Background The diagnosis of Hansen disease (HD) can be difficult when acid-fast bacilli are not detected in the patient's skin sample. Objective To demonstrate that detailed morphological analysis of nonspecific inflammatory and/or noninflammatory alterations in dermal nerves as well as skin adnexa in leprosy-suspected biopsy samples could improve the efficacy of histopathological diagnosis. Methods Patients with one to five skin lesions were enrolled in the study and classified into three groups by skin histopathology findings: Hansen disease (HD, n = 13), other diseases (OD, n = 11), and inconclusive cases (INC, n = 11). We quantified dermal nerve damage via the nerve lesion index (NLI) and PGP9.5-immunoreactive axon quantitative index in dermal nerves (AQI). We also measured inflammatory involvement of adnexa in cutaneous samples as indirect evidence of HD. Results We observed a higher median endoneurial inflammatory infiltrate NLI (HD = 0.5; INC = 0; OD = 0; p &lt; 0.001) and more frequent inflammatory involvement of skin adnexa in samples of the HD group compared with those of the INC and OD groups (HD = 7; INC = 1; OD = 0). However, samples from the INC and OD groups also showed inflammatory and noninflammatory damage of dermal nerves, with 2 or more kinds of alterations in nerves in the same sample (respectively: INC = in 1 and 2 samples; OD = in 3 and 5 respectively). The quantification of PGP9.5-immunoreactive axons in dermal nerves revealed no difference between the groups. Conclusion A detailed morphological analysis of cutaneous nerves in lesions with a suspicion of HD enabled us to select patients with nonspecific inflammatory or non-inflammatory lesions in the dermal nerves in the INC and OD groups, so they may be clinically monitored aiming at a possible future diagnosis of the disease. These INC and OD patients cannot have the HD diagnosis definitely excluded, and HD may coexist with another disease as a comorbidity.

A rare case of atypical intradural extramedullary glioblastoma diagnosed utilizing next-generation sequencing and methylation profiling: illustrative case.

Primary spinal cord tumors, especially primary spinal cord glioblastoma multiforme (PSC-GBM), are exceptionally rare, accounting for less than 1.5% of all spinal tumors. Their infrequency and aggressive yet atypical presentation make diagnosis challenging. In uncertain cases, a surgical approach for tissue diagnosis is often optimal. A 76-year-old male presented with a rapidly progressing clinical history marked by worsening extremity weakness, urinary retention, and periodic fecal incontinence alongside diffuse changes on neuraxis imaging. The patient, in whom subacute polyneuropathy was initially diagnosed, received multiple rounds of steroids and intravenous immunoglobulin without clinical improvement. Histopathological review of the biopsy tissue yielded an initial diagnosis of spindle cell neoplasm. Next-generation sequencing (NGS) is done routinely on all neuropathology specimens at the authors' institution, and methylation profiling is pursued in difficult cases. Ultimately, NGS and methylation profiling results were essential to an integrated final diagnosis of GBM. PSC-GBM is a rare but highly aggressive occurrence of this tumor. Prolonged back pain, rapid neurological decline, and imaging changes warrant the consideration of lesional biopsy for precise disease characterization. In inconclusive cases, NGS has proved invaluable for clinical clarification and diagnosis, underscoring its importance for integrated diagnoses in guiding appropriate treatment strategies.

K-ras mutation detected by peptide nucleic acid-clamping polymerase chain reaction, Ki-67, S100P, and SMAD4 expression can improve the diagnostic accuracy of inconclusive pancreatic EUS-FNB specimens

ObjectivesWe aimed to assess the diagnostic utility of an immunohistochemical panel including calcium-binding protein P, p53, Ki-67, and SMAD family member 4 and K-ras mutation for diagnosing pancreatic solid lesion specimens obtained by endoscopic ultrasound-guided fine-needle biopsy and to confirm their usefulness in histologically inconclusive cases. MethodsImmunohistochemistry and peptide nucleic acid-clamping polymerase chain reaction for K-ras mutation were performed on 96 endoscopic ultrasound-guided fine-needle biopsy specimens. The diagnostic efficacy of each marker and the combination of markers was calculated. The diagnostic performances of these markers were evaluated in 27 endoscopic ultrasound-guided fine-needle biopsy specimens with histologically inconclusive diagnoses. A classification tree was constructed. ResultsK-ras mutation showed the highest accuracy and consistency. Positivity in more than two or three of the five markers showed high diagnostic accuracy (94.6 % and 93.6 %, respectively), and positivity for more than three markers showed the highest accuracy for inconclusive cases (92.0 %). A classification tree using K-ras mutation, Ki-67, S100P, and SMAD4 showed high diagnostic performance, with only two misclassifications in inconclusive cases. ConclusionsK-ras mutation detection via peptide nucleic acid-clamping polymerase chain reaction is a stable and accurate method for distinguishing between pancreatic ductal adenocarcinoma and non-pancreatic ductal adenocarcinoma lesions. A classification tree using K-ras mutation, Ki-67, S100P, and SMAD4 helps increase the diagnostic accuracy of cases that are histologically difficult to diagnose.

An Observational Study to Correlate the Histopathological and Dermoscopic Features in Leprosy Patients in a Tertiary Care Hospital.

Leprosy is a chronic granulomatous infection with varied clinical presentations. Dermoscopy is a noninvasive technique widely used in the diagnosis of various skin diseases. To see the correlation between the clinical and dermoscopic features with the histopathological findings in leprosy. A prospective observational study was conducted on clinically suspected leprosy patients attending the dermatology outpatient department (OPD) for 18 months. Representative lesions were observed by dermoscopy, and a biopsy was performed, followed by histopathology for final diagnosis. Patients were categorized by Ridley-Jopling classification. A total of 70 clinically suspected leprosy patients were included in the study. Amongst 70 cases, 56 cases were diagnosed as leprosy by dermoscopy, and 53 cases were confirmed as leprosy by histopathology (hematoxylin and eosin [H and E] staining and Fite-Faraco staining). The other six cases were diagnosed as other nonspecific dermatitis by histopathological findings. Eleven cases that were dermoscopically negative were also confirmed by histopathology to be truly negative. There are three inconclusive cases of dermoscopic findings, which were diagnosed as mid-borderline leprosy by histopathology. Dermoscopic and histopathological correlation was found above 87% in all types of leprosy except mid-borderline leprosy, which showed only a 25% correlation. Dermoscopy is a useful noninvasive tool to assess lesions of leprosy, requires less time for diagnosis, skin features are magnified several times and may become evident before clinical presentation. It definitely helps to reduce the number of biopsies in case of diagnosis of leprosy. However, in doubtful cases, histopathology is required for definitive diagnosis as it is the gold standard to date.

The Diagnostic Characteristic and Reproducibility of Bone Scintigraphy Single-Photon Emission Computed Tomography/Computed Tomography for Diagnosing Aseptic Loosening of Uncemented Total Knee Arthroplasty

BackgroundThe primary objective of this study was to investigate the diagnostic characteristics of bone scintigraphy single-photon emission computed tomography/computed tomography (BS-SPECT/CT) for diagnosing aseptic loosening after uncemented total knee arthroplasty (TKA), and to evaluate the following aspects: how to manage inconclusive results, the interobserver reliability, and the location of tracer uptake between symptomatic cases with and without aseptic loosening. MethodsIn this study, 180 patients who had uncemented TKA and persistent knee pain suspected of aseptic loosening were included. As part of routine medical care, BS-SPECT/CT was used, and its results were compared with the reference standard, which involved revision surgery for aseptic loosening or a 12-month follow-up without revision or imaging. Inconclusive BS-SPECT/CT results were considered either negative (best-case scenario) or positive (worst-case scenario). Sensitivity, specificity, positive/negative likelihood ratios (LRs), and positive/negative predictive values (PPV and NPV) were calculated. Sensitivity analyses were conducted by comparing the diagnostic characteristics between cases with a follow-up of less and more than 2 years of follow-up. The anatomical distribution of tracer uptake and interobserver reliability were also evaluated. ResultsOf the 180 BS-SPECT/CT scans conducted, 22 were determined positive, 113 negative, and 45 inconclusive. The best-case scenario showed a sensitivity of 66.7%, specificity of 93.8%, +LR 10.8, −LR 0.4, PPV 54.6%, and NPV 96.2%. In contrast, the worst-case scenario had a sensitivity of 94.4%, specificity of 69.1%, +LR 3.1, −LR 0.1, PPV 25.4%, and NPV 99.1%. Sensitivity analyses revealed no relevant differences in characteristics between the 2 TKA-interval groups. The interobserver reliability was fair-to-moderate (κ = 0.39; 95% confidence interval 0.18 to 0.60), with an estimated agreement of 79% (95% confidence interval 70 to 87). Four prosthetic zones had a notably higher proportion of cases with tracer uptake in those with aseptic loosening compared to those without. ConclusionsThe test characteristics of BS-SPECT/CT were deemed appropriate in patients who have complaints of uncemented TKA suspected of aseptic loosening. Inconclusive cases were best categorized as negative, especially in patients who have a short interval between TKA and the first BS-SPECT/CT. Increased tracer uptake in 4 prosthetic zones was observed in cases of aseptic loosening, although interobserver reliability was fair to moderate. Level of EvidenceLevel III, Diagnostic Retrospective Cohort Study.

Discovery of a Novel Missense Variant in NLRP3 Causing Atypical Cryopyrin-Associated Periodic Syndromes With Hearing Loss as the Primary Presentation, Responsive to Anti-Interleukin-1 Therapy.

Cryopyrin-associated periodic syndromes (CAPS), also known as NLRP3-associated autoinflammatory diseases, are a spectrum of rare autoinflammatory diseases caused by gain-of-function variants in the NLRP3 gene, resulting in inflammasome hyperactivation and dysregulated release of interleukin-1β (IL-1β). Many patients with CAPS develop progressive sensorineural hearing loss (SNHL) because of cochlear autoinflammation, which may be the sole manifestation in rare cases. This study was undertaken to establish the suspected diagnosis of CAPS in a family presenting with autosomal-dominant progressive/acute SNHL and a novel missense variant in the NLRP3 gene of unknown significance (NM_001079821.3:c.1784G>A p.Ser595Asn). We conducted an ex vivo functional assessment of the NLRP3 inflammasome in heterozygous individuals (n=10) and healthy family members (n=5). The assay revealed hyperactivation of the inflammasome among heterozygous individuals, supporting the hypothesis that this missense variant is a pathogenic gain-of-function variant. Administration of IL-1 receptorantagonist resulted in a substantial clinical improvement among pediatric patients, who exhibited near resolution of hearing impairment within 1 to 3 months of treatment. Our findings highlight the crucial role of early diagnosis and treatment with an anti-IL-1 agent in reversing cochlear damage. Furthermore, our results suggest that high- and ultrahigh-frequency ranges need to be included in the auditory assessment to enable early detection of subclinical SNHL. Finally, incorporating functional inflammasome assessment as part of the clinical evaluation could establish the diagnosis in inconclusive cases.

Genetic ancestry and diagnostic yield of exome sequencing in a diverse population

It has been suggested that diagnostic yield (DY) from Exome Sequencing (ES) may be lower among patients with non-European ancestries than those with European ancestry. We examined the association of DY with estimated continental/subcontinental genetic ancestry in a racially/ethnically diverse pediatric and prenatal clinical cohort. Cases (N = 845) with suspected genetic disorders underwent ES for diagnosis. Continental/subcontinental genetic ancestry proportions were estimated from the ES data. We compared the distribution of genetic ancestries in positive, negative, and inconclusive cases by Kolmogorov–Smirnov tests and linear associations of ancestry with DY by Cochran-Armitage trend tests. We observed no reduction in overall DY associated with any genetic ancestry (African, Native American, East Asian, European, Middle Eastern, South Asian). However, we observed a relative increase in proportion of autosomal recessive homozygous inheritance versus other inheritance patterns associated with Middle Eastern and South Asian ancestry, due to consanguinity. In this empirical study of ES for undiagnosed pediatric and prenatal genetic conditions, genetic ancestry was not associated with the likelihood of a positive diagnosis, supporting the equitable use of ES in diagnosis of previously undiagnosed but potentially Mendelian disorders across all ancestral populations.

Waardenburg Syndrome: The Contribution of Next-Generation Sequencing to the Identification of Novel Causative Variants.

Waardenburg syndrome (WS) is characterized by hearing loss and pigmentary abnormalities of the eyes, hair, and skin. The condition is genetically heterogeneous, and is classified into four clinical types differentiated by the presence of dystopia canthorum in type 1 and its absence in type 2. Additionally, limb musculoskeletal abnormalities and Hirschsprung disease differentiate types 3 and 4, respectively. Genes PAX3, MITF, SOX10, KITLG, EDNRB, and EDN3 are already known to be associated with WS. In WS, a certain degree of molecularly undetected patients remains, especially in type 2. This study aims to pinpoint causative variants using different NGS approaches in a cohort of 26 Brazilian probands with possible/probable diagnosis of WS1 (8) or WS2 (18). DNA from the patients was first analyzed by exome sequencing. Seven of these families were submitted to trio analysis. For inconclusive cases, we applied a targeted NGS panel targeting WS/neurocristopathies genes. Causative variants were detected in 20 of the 26 probands analyzed, these being five in PAX3, eight in MITF, two in SOX10, four in EDNRB, and one in ACTG1 (type 2 Baraitser-Winter syndrome, BWS2). In conclusion, in our cohort of patients, the detection rate of the causative variant was 77%, confirming the superior detection power of NGS in genetically heterogeneous diseases.

Genetic diversity and forensic parameters of autosomal STR markers included Investigator® HDplex panel in the general population of the Russian Federation

Modern STR multiplexes used for parentage and kinship testing typically contain 20–30 informative loci. However, in certain cases, additional markers are necessary to address uncertainties and inconclusive cases. The Investigator® HDplex multiplex includes loci that are often utilized as supplementary markers and are not part of the standard STR identification systems. In our study, we examined a total of 558 unrelated individuals from 76 geographically distinct localities across all eight Federal Districts of the Russian Federation. We present key forensic parameters and allele frequencies obtained from this analysis. We evaluated the intra-population genetic diversity among the Federal District populations and compared the general population of the Russian Federation with populations from various regions around the world. SE33 exhibited the highest level of polymorphism, with 48 detected alleles, while D4S2366 and D6S474 displayed the fewest alleles (7). Heterozygosity values across all loci ranged from 0.7616 for D4S2366 to 0.9337 for SE33. We did not observe any significant deviation from the Hardy-Weinberg Equilibrium for the loci studied. The maximum FST value between the Russian sub-populations was 0.003. Comparison of the general population of the Russian Federation with populations from Europe, Asia, Africa, and South America, largely supported the historical relationship between the studied population and their respective biogeography.

An Observational Study on Evaluation of IOTA Ultrasound Simple Rules to Distinguish Benign and Malignant Ovarian Masses and Histopathological Correlation in a Tertiary Care Hospita

Background: The international ovarian tumor analysis (IOTA) study technique is a specialized method for classifying and identifying adnexal growths. It employs 10 simple ultrasound directions to characterize masses as benign or malignant. Objectives: This study aims to provide pre-operative information to help gynecologists manage ovarian masses, avoiding delays in malignancy treatment and unnecessary surgery for benign lesions.&#x0D; Methods: This was a hospital-based observational study conducted in the radiology department on patients with clinical diagnoses of ovarian masses from August 2020 to March 2022 by prospective randomized sampling method. Patients with suspected ovarian pathology were evaluated using IOTA ultrasound rules and designated benign or malignant. The patients underwent a thorough history and clinical examination. Ultrasound was used to confirm the ovarian origin of the mass and differentiate it as benign or malignant. A transvaginal ultrasound was performed where necessary. Histopathological examination was the gold standard to confirm ultrasound and Doppler findings. Descriptive stats: Frequencies/percentages for categorical data, mean ± SD for normal, median with IQR for non-normal. Uncertainty measured by 95% CI.&#x0D; Results: During the study, 50 women were eligible for the study, and the mean age of the participants was 45.3 years. Of 50 patients who underwent surgery, 38 cases were considered benign based on IOTA USG rules, of which 35 were benign and 3 were malignant histologically. Eight cases were considered malignant based on IOTA USG rules, of which 6 were malignant and 2 were benign. Four cases were considered indeterminate, with two being benign and two being malignant histologically. If inconclusive cases are classified as malignant, the sensitivity and specificity are 75% and 88%, respectively.&#x0D; Conclusions: USG is an easily available imaging tool that can be used as an initial modality in evaluating ovarian masses. IOTA simple ultrasound rules have diagnostic accuracy in distinguishing benign and malignant ovarian masses and help in management.

Follow-Up Findings in Multiple System Atrophy from [123I]Ioflupane Single-Photon Emission Computed Tomography (SPECT): A Prospective Study.

Multiple system atrophy (MSA) is subdivided into two types: MSA-P (parkinsonian) and MSA-C (cerebellar). Brain SPECT allows for the detection of nigrostriatal involvement, even in the early stages. To date, the scientific literature does not show a consensus on how to follow-up MSA, especially MSA-C. Our aim was to analyze the diagnostic effectiveness of repeat [123I]Ioflupane SPECT for the follow-up of MSA. A longitudinal observational study on 22 MSA patients (11 males and 11 females). Significant changes were obtained in the quantitative SPECT assessments in the three Striatum/Occipital indices. The qualitative SPECT diagnosis did not show differences between the initial and evolving SPECT, but the neurologist's clinical suspicion did. Our results showed a brain deterioration of around 31% at 12 months, this being the optimal cut-off for differentiating a diseased subject (capable of solving diagnostic error rate). Previous imaging tests were inconclusive, as they showed less deterioration in the SPECT and quantitative assessments with respect to the group of confirmed patients. Repeated SPECT increased the diagnostic sensitivity (50% vs. 75%) and positive predictive value (72.73% vs. 77%). In addition, repeated SPECT proved decisive in the diagnosis of initial inconclusive cases. Repeat SPECT at 12 months proves useful in the diagnosis and follow-up of MSA.

SAT587 Methylation-based Machine Learning Classifiers Discriminate Sellar Tumors By Lobe Origin Using Liquid Biopsy Or Surgical Specimens

Abstract Disclosure: G.A. Herrgott: None. K.P. Asmaro: None. M. Wells: None. K. Nelson: None. B. Thomas: None. L.A. Hasselbach: None. A. Transou: None. S. Cazacu: None. K.M. Tundo: None. S. Nadimidla: None. L. Scarpace: None. J. Barnholtz-Sloan: None. A.E. Sloan: None. W.R. Selman: None. A.C. deCarvalho: None. A. Mukherjee: None. A.M. Robin: None. I.Y. Lee: None. J. Craig: None. S. Kalkanis: None. J. Snyder: None. T. Walbert: None. J. Rock: None. H. Noushmehr: None. A.B. Castro: None. Background: The differential diagnosis of challenging sellar tumor cases can be inconclusive through imaging features and could benefit from noninvasive diagnostic approaches, such as liquid biopsy (LB). Similar to tissue, LB specimens carry tumor-specific DNA methylation signatures amenable to the construction of accurate machine learning models able to discriminate CNS tumors. We aimed to develop methylation-based classifiers which classify sellar tumors by lobe of origin, using either LB or tumor tissue specimens. Methodology: We analyzed the DNA methylome (EPIC array) of tumor tissue (T) and LB specimens from adult patients with tumors representing each of the three pituitary lobes (Anterior: T=177; LB=37; Intermediate: T= 7; LB: 10 and Posterior: T=44, LB=2 cases). Using the most variably methylated CpG probes derived from the unsupervised variance-based analyses across tumors from different lobes, we applied multi-class linear discriminant analysis to construct machine learning models to classify sellar tumor tissue and/or LB specimens. Results: We generated classifiers based on lobe-specific methylation signatures that were able to discriminate across sellar tumors either using tissue and/or LB specimens (500 and 600 CpGs, respectively) with observed accuracies of ∼99% across independent validation. DISCUSSION/CONCLUSION: Our findings suggest that methylation-based classifiers constitute an accurate diagnostic approach to discriminate sellar tumors according to the lobe origin, either pre-surgically through a blood draw or through surgical tumor specimens. These classifiers are objective approaches that could complement imaging and pathology reports for an accurate diagnosis of inconclusive cases, ultimately leading to optimal management of the patients with these diseases. Presentation: Saturday, June 17, 2023

Development and validation of a vero cell-based suspension method for the detection of Zika virus.

To develop and validate a cell suspension method using Vero 76 cells for culturing Zika virus (ZIKV) based on infection of detached freshly seeded cells. Three different multiplicities of infection of ZIKV were used to develop and compare this novel method to the standard confluent cell monolayer method. In addition, we preliminary validated the cell suspension method using well-characterized ZIKV positive and negative clinical samples. The standard confluent cell monolayer method was used as the reference method, and viral isolation was confirmed by a ZIKV-specific RT-PCR. The sensitivity and its 95% confidence intervals for the cell suspension method were estimated. Also, a technical comparison of the cell suspension method against the cell monolayer method was performed. Our findings suggested that both the viral load and replication of ZIKV were comparable between both monolayer- and suspension-infection methods. Although both methods were suitable for culturing and isolating ZIKV, the cell suspension method was easier, cheaper, and quicker as well as a sensitive isolation technique. The cell suspension method was significantly more sensitive in detecting Zika in inconclusive cases by RT-PCR, with a fourfold increase compared to the confluent cell monolayer method. The cell suspension method has the potential to be an effective method for cultivating and isolating ZIKV and its application is potentially useful in both research and clinical settings.

Cerebral vasculitis as a complication of pneumococcal meningitis: A cohort study

ObjectiveCerebral vasculitis (CV) is a severe complication of pneumococcal meningitis (PM); whether dexamethasone use can reduce its occurrence remains to be determined. MethodsThis is a retrospective observational bicentric study analyzing all adults with proven PM hospitalized between January 2002 and December 2020 in two tertiary hospitals. Extrapolating from a standardized definition of primary angiitis of the central nervous system, we defined CV as worsened neurological symptoms associated with compatible imaging. All images were analyzed by a radiologist, and two neurologists reviewed all inconclusive cases of suspected CV for adjudication. Factors associated with CV were analyzed, including dexamethasone use. A subgroup analysis was limited to patients with a lumbar puncture at PM diagnosis. ResultsAmong 168 patients with PM, 49 (29.2%) had CV, occurring after a median of 8 days (IQR 5–13) of PM diagnosis. In multivariate analysis (N = 151), initial CRP was associated with CV (OR 1.28 per 50-unit increase, p = 0.003), which was marginally linked with delayed hospital admission more than 48 hours after first symptoms (OR 2.39, p = 0.06) and prior NSAID intake (OR 2.94, p = 0.05). Dexamethasone administration did not impact CV occurrence. In 133 patients having undergone lumbar puncture, CSF protein level > 4.4 g/L (OR 4.50, p = 0.006) was associated with CV. ConclusionsIn our cohort, CV was a frequent and severe complication of PM, often occurring in association with unduly delayed medical care, high CRP at admission, and high levels of protein in CSF.

Diagnostic Performance of Ultrasonography-Based Risk Models in Differentiating Between Benign and Malignant Ovarian Tumors in a US Cohort

Ultrasonography-based risk models can help nonexpert clinicians evaluate adnexal lesions and reduce surgical interventions for benign tumors. Yet, these models have limited uptake in the US, and studies comparing their diagnostic accuracy are lacking. To evaluate, in a US cohort, the diagnostic performance of 3 ultrasonography-based risk models for differentiating between benign and malignant adnexal lesions: International Ovarian Tumor Analysis (IOTA) Simple Rules with inconclusive cases reclassified as malignant or reevaluated by an expert, IOTA Assessment of Different Neoplasias in the Adnexa (ADNEX), and Ovarian-Adnexal Reporting and Data System (O-RADS). This retrospective diagnostic study was conducted at a single US academic medical center and included consecutive patients aged 18 to 89 years with adnexal masses that were managed surgically or conservatively between January 2017 and October 2022. Evaluation of adnexal lesions using the Simple Rules, ADNEX, and O-RADS. The main outcome was diagnostic performance, including area under the receiver operating characteristic (ROC) curve (AUC), sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios. Surgery or follow-up were reference standards. Secondary analyses evaluated the models' performances stratified by menopause status and race. The cohort included 511 female patients with a 15.9% malignant tumor prevalence (81 patients). Mean (SD) ages of patients with benign and malignant adnexal lesions were 44.1 (14.4) and 52.5 (15.2) years, respectively, and 200 (39.1%) were postmenopausal. In the ROC analysis, the AUCs for discriminative performance of the ADNEX and O-RADS models were 0.96 (95% CI, 0.93-0.98) and 0.92 (95% CI, 0.90-0.95), respectively. After converting the ADNEX continuous individualized risk into the discrete ordinal categories of O-RADS, the ADNEX performance was reduced to an AUC of 0.93 (95% CI, 0.90-0.96), which was similar to that for O-RADS. The Simple Rules combined with expert reevaluation had 93.8% sensitivity (95% CI, 86.2%-98.0%) and 91.9% specificity (95% CI, 88.9%-94.3%), and the Simple Rules combined with malignant classification had 93.8% sensitivity (95% CI, 86.2%-98.0%) and 88.1% specificity (95% CI, 84.7%-91.0%). At a 10% risk threshold, ADNEX had 91.4% sensitivity (95% CI, 83.0%-96.5%) and 86.3% specificity (95% CI, 82.7%-89.4%) and O-RADS had 98.8% sensitivity (95% CI, 93.3%-100%) and 74.4% specificity (95% CI, 70.0%-78.5%). The specificities of all models were significantly lower in the postmenopausal group. Subgroup analysis revealed high performances independent of race. In this diagnostic study of a US cohort, the Simple Rules, ADNEX, and O-RADS models performed well in differentiating between benign and malignant adnexal lesions; this outcome has been previously reported primarily in European populations. Risk stratification models can lead to more accurate and consistent evaluations of adnexal masses, especially when used by nonexpert clinicians, and may reduce unnecessary surgeries.