Unnecessary Invasive Procedures Research Articles

The clinical value of artificial intelligence in assisting junior radiologists in thyroid ultrasound: a multicenter prospective study from real clinical practice

BackgroundThis study is to propose a clinically applicable 2-echelon (2e) diagnostic criteria for the analysis of thyroid nodules such that low-risk nodules are screened off while only suspicious or indeterminate ones are further examined by histopathology, and to explore whether artificial intelligence (AI) can provide precise assistance for clinical decision-making in the real-world prospective scenario.MethodsIn this prospective study, we enrolled 1036 patients with a total of 2296 thyroid nodules from three medical centers. The diagnostic performance of the AI system, radiologists with different levels of experience, and AI-assisted radiologists with different levels of experience in diagnosing thyroid nodules were evaluated against our proposed 2e diagnostic criteria, with the first being an arbitration committee consisting of 3 senior specialists and the second being cyto- or histopathology.ResultsAccording to the 2e diagnostic criteria, 1543 nodules were classified by the arbitration committee, and the benign and malignant nature of 753 nodules was determined by pathological examinations. Taking pathological results as the evaluation standard, the sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve (AUC) of the AI systems were 0.826, 0.815, 0.821, and 0.821. For those cases where diagnosis by the Arbitration Committee were taken as the evaluation standard, the sensitivity, specificity, accuracy, and AUC of the AI system were 0.946, 0.966, 0.964, and 0.956. Taking the global 2e diagnostic criteria as the gold standard, the sensitivity, specificity, accuracy, and AUC of the AI system were 0.868, 0.934, 0.917, and 0.901, respectively. Under different criteria, AI was comparable to the diagnostic performance of senior radiologists and outperformed junior radiologists (all P < 0.05). Furthermore, AI assistance significantly improved the performance of junior radiologists in the diagnosis of thyroid nodules, and their diagnostic performance was comparable to that of senior radiologists when pathological results were taken as the gold standard (all p > 0.05).ConclusionsThe proposed 2e diagnostic criteria are consistent with real-world clinical evaluations and affirm the applicability of the AI system. Under the 2e criteria, the diagnostic performance of the AI system is comparable to that of senior radiologists and significantly improves the diagnostic capabilities of junior radiologists. This has the potential to reduce unnecessary invasive diagnostic procedures in real-world clinical practice.

Diagnostic accuracy of the Clear Cell Likelihood Score and selected MRI parameters in the characterization of indeterminate renal masses - a single-institution study.

We aimed to assess the diagnostic accuracy of the clear cell likelihood score (ccLS) and value of other selected magnetic resonance imaging (MRI) features in the characterization of indeterminate small renal masses (SRMs). Fifty patients with indeterminate SRMs discovered on MRI between 2012 and 2023 were included. The ccLS for the characterization of clear cell renal cell carcinoma (ccRCC) was calculated and compared to the final diagnosis (ccRCC vs. 'all other' masses). The ccLS = 5 had a satisfactory accuracy of 64.0% and a very high specificity of 96.3%; however, its sensitivity of 26.1% was relatively low. Receiver operating curve (ROC) analysis revealed that from the selected MRI features, only T1 ratio and arterial to delayed enhancement (ADER) were good discriminators between ccRCC and other types of renal masses (area under curve, AUC = 0.707, p = 0.01; AUC = 0.673, p = 0.03; respectively). The cut-off points determined in ROC analysis using the Youden index were 0.73 (p = 0.01) for T1 ratio and 0.99 for ADER (p = 0.03). The logistic regression model demonstrated that ccLS = 5 and T1 ratio (OR = 15.5 [1.1-218.72], p = 0.04; OR = 0.002 [0.00-0.81], p = 0.04) were significant predictors of ccRCC. The ccLS algorithm offers an encouraging method for the standardization of imaging protocols to aid in the diagnosis and management of SRMs in daily clinical practice by enhancing detectability of ccRCC and reducing the number of unnecessary invasive procedures for benign or indolent lesions. However, its diagnostic performance needs multi-center large cohort studies to validate it before it can be incorporated as a diagnostic algorithm and will guide future iterations of clinical guidelines. The retrospective nature of our study and small patient population confined to a single clinical center may impact the generalizability of the results; thus, future studies are required to define whether employment of the T1 ratio or ADER parameter may strengthen the diagnostic accuracy of ccRCC diagnosis.

Exercise-Induced Complete Atrioventricular Block Resulting in Cardiac Arrest: A Case Report and Review of Diagnostic Strategies

Abstract Background Exercise-induced complete atrioventricular block (EIAVB) is a rare cardiac conduction abnormality presenting challenges in diagnosis due to non-specific symptoms such as exertional dyspnea, dizziness, and syncope. Case Summary We present a case of a 76-year-old female with recurrent exercise-associated syncope. Non-invasive exercise testing played a crucial role in diagnosing her condition, revealing EIAVB and underscoring its importance in patients with cardiovascular risk factors. Discussion This case provides insight into the pathophysiology of EIAVB, including altered atrioventricular nodal refractoriness and exercise-induced ischemic imbalances. It highlights the need for heightened clinical vigilance in diagnosing exercise-related syncope, especially in pre-existing cardiovascular conditions. Conclusion This case underscores the critical importance of non-invasive testing for diagnosing EIAVB, highlighting the necessity of thorough evaluation in patients presenting with ambiguous symptoms and cardiovascular risks. Consequently, it advocates for adherence to guidelines to enhance outcomes and reduce the need for unnecessary invasive procedures.

Machine Learning and External Validation of the IDENTIFY Risk Calculator for Patients with Haematuria Referred to Secondary Care for Suspected Urinary Tract Cancer

BackgroundThe IDENTIFY study developed a model to predict urinary tract cancer using patient characteristics from a large multicentre, international cohort of patients referred with haematuria. In addition to calculating an individual’s cancer risk, it proposes thresholds to stratify them into very-low-risk (<1%), low-risk (1–<5%), intermediate-risk (5–<20%), and high-risk (≥20%) groups. ObjectiveTo externally validate the IDENTIFY haematuria risk calculator and compare traditional regression with machine learning algorithms. Design, setting, and participantsProspective data were collected on patients referred to secondary care with new haematuria. Data were collected for patient variables included in the IDENTIFY risk calculator, cancer outcome, and TNM staging. Machine learning methods were used to evaluate whether better models than those developed with traditional regression methods existed. Outcome measurements and statistical analysisThe area under the receiver operating characteristic curve (AUC) for the detection of urinary tract cancer, calibration coefficient, calibration in the large (CITL), and Brier score were determined. Results and limitationsThere were 3582 patients in the validation cohort. The development and validation cohorts were well matched. The AUC of the IDENTIFY risk calculator on the validation cohort was 0.78. This improved to 0.80 on a subanalysis of urothelial cancer prevalent countries alone, with a calibration slope of 1.04, CITL of 0.24, and Brier score of 0.14. The best machine learning model was Random Forest, which achieved an AUC of 0.76 on the validation cohort. There were no cancers stratified to the very-low-risk group in the validation cohort. Most cancers were stratified to the intermediate- and high-risk groups, with more aggressive cancers in higher-risk groups. ConclusionsThe IDENTIFY risk calculator performed well at predicting cancer in patients referred with haematuria on external validation. This tool can be used by urologists to better counsel patients on their cancer risks, to prioritise diagnostic resources on appropriate patients, and to avoid unnecessary invasive procedures in those with a very low risk of cancer. Patient summaryWe previously developed a calculator that predicts patients’ risk of cancer when they have blood in their urine, based on their personal characteristics. We have validated this risk calculator, by testing it on a separate group of patients to ensure that it works as expected. Most patients found to have cancer tended to be in the higher-risk groups and had more aggressive types of cancer with a higher risk. This tool can be used by clinicians to fast-track high-risk patients based on the calculator and investigate them more thoroughly.

Use of a diagnostic Puumala virus real-time RT-PCR in an orthohantavirus endemic region in the Netherlands.

The addition of a real-time reverse transcription polymerase chain reaction test to routine orthohantavirus diagnostics may better aid clinical decision making than the use of standard serology tests alone. Awareness by clinicians and clinical microbiologists of this advantage may ultimately lead to a reduction in over-hospitalization and unnecessary invasive diagnostic procedures.

Predictors of pulmonary metastases on chest computed tomography in children and adolescents with osteosarcoma—tips for qualifying patients for thoracotomy

BackgroundOsteosarcoma is the most common primary malignant bone tumour in children and adolescents. Lungs are the most frequent and often the only site of metastatic disease. The presence of pulmonary metastases is a significant unfavourable prognostic factor. Thoracotomy is strongly recommended in these patients, while computed tomography (CT) remains the gold imaging standard. The purpose of our study was to create tools for the CT-based qualification for thoracotomy in osteosarcoma patients in order to reduce the rate of useless thoracotomies.MethodsSixty-four osteosarcoma paediatric patients suspected of lung metastases on CT and their first-time thoracotomies (n = 100) were included in this retrospective analysis. All CT scans were analysed using a compartmental evaluation method based on the number and size of nodules. Calcification and location of lung lesions were also analysed. Inter-observer reliability between two experienced radiologists was assessed. The CT findings were then correlated with the histopathological results of thoracotomies. Various multivariate predictive models (logistic regression, classification tree and random forest) were built and predictors of lung metastases were identified.ResultsAll applied models proved that calcified nodules on the preoperative CT scan best predict the presence of pulmonary metastases. The rating of the operated lung on the preoperative CT scan, dependent on the number and size of nodules, and the total number of nodules on this scan were also found to be important predictors. All three models achieved a relatively high sensitivity (72–92%), positive predictive value (81–90%) and accuracy (74–79%). The positive predictive value of each model was higher than of the qualification for thoracotomy performed at the time of treatment. Inter-observer reliability was at least substantial for qualitative variables and excellent for quantitative variables.ConclusionsThe multivariate models built and tested in our study may be useful in the qualification of osteosarcoma patients for metastasectomy through thoracotomy and may contribute to reducing the rate of unnecessary invasive procedures in the future.

A puzzle unravelled: pancytopenia and hepatosplenomegaly in juvenile autoimmune hypothyroidism

Autoimmune thyroiditis is a common cause of hypothyroidism in adolescent females. While normocytic normochromic anemia is a recognized association with hypothyroidism, pancytopenia is seldom reported. This case report discusses a young adolescent girl with autoimmune hypothyroidism presenting with severe pancytopenia and hepatosplenomegaly. After extensive evaluation, hypoproliferative marrow with extramedullary hematopoiesis secondary to uncontrolled hypothyroidism was considered to be the most likely cause. Swift recovery following appropriate levothyroxine replacement further supports this hypothesis. Thus, hypothyroidism can be a potential cause of pancytopenia with hepatosplenomegaly. Early recognition and appropriate management can lead to prompt resolution and prevent unnecessary invasive procedures.

MRI-based Texture Analysis in Differentiation of Benign and Malignant Vertebral Compression Fractures.

The diagnosis and characterization of vertebral compression fractures are very important for clinical management. In this evaluation, which is usually performed with diagnostic (conventional) imaging, the findings are not always typical or diagnostic. Therefore, it is important to have new information to support imaging findings. Texture analysis is a method that can evaluate information contained in diagnostic images and is not visually noticeable. This study aimed to evaluate the magnetic resonance images of cases diagnosed with vertebral compression fractures by the texture analysis method, compare them with histopathological data, and investigate the effectiveness of this method in the differentiation of benign and malignant vertebral compression fractures. Fifty-five patients with a total of 56 vertebral compression fractures were included in the study. Magnetic resonance images were examined and segmented using Local Image Feature Extraction (LIFEx) software, which is an open-source program for texture analysis. The results were compared with the histopathological diagnosis. The application of the Decision Tree algorithm to the dataset yielded impressively accurate predictions (≈95% in accuracy, precision, and recall). Interpreting tissue analysis parameters together with conventional magnetic resonance imaging findings can improve the abilities of radiologists, lead to accurate diagnoses, and prevent unnecessary invasive procedures. Further prospective trials in larger populations are needed to verify the role and performance of texture analysis in patients with vertebral compression fractures.

Evaluation of Imaging-Guided Peritoneal Biopsy in Diagnosis of Ascites of Unknown Origin

AbstractAscites is a common clinical problem, which can be a result of liver cirrhosis, neoplasm, tuberculous or pyogenic peritonitis, heart failure, nephrosis, and pancreatic disorders. This study aimed to evaluate the role of imaging-guided peritoneal biopsy in the diagnosis of ascites of unknown origin (ascites of local cause). Sixty-three patients with ascites of unknown etiology were included. Abdominal ultrasonography (US) with colored Duplex was performed, followed by laboratory investigations such as, ascitic fluid samples, magnetic resonance imaging, multislice computed tomography (CT), or PET/CT scan (if indicated). Imaging-guided peritoneal biopsy such as US-guided or CT-guided percutaneous peritoneal biopsy (in cases of failure of US-guided technique) of omentum or extravisceral masses was performed. Cytological and histopathological examinations of the tissue specimens were done by a single experienced pathologist. Other more invasive procedures (e.g., laparoscopy) were needed when the imaging-guided biopsy was not diagnostic. Fifty-four patients underwent US-guided biopsies, 48 patients were successfully diagnosed, and other 9 patients underwent CT-guided biopsies (not accessible by US-guided modality); laparoscopy was needed only in 6 patients. Malignant peritoneal pathology was found in 48 patients, while tuberculous peritonitis was diagnosed in 14 patients. Imaging-guided biopsies had perfect sensitivity (100%) and negative predictive value (100%) in differentiating neoplastic lesions. Percutaneous imaging-guided biopsy (US/CT guided) of the peritoneum, omenta, and mesentery has been established as a safe, simple, noninvasive, and well-tolerated procedure with high diagnostic accuracy. It can minimize further unnecessary invasive procedures such as laparoscopy.

The suffering is expensive: comparison of therapeutic costs between palliative care and dysthanasia patient

Objectives: Several studies highlight benefits of palliative care for patients with lifethreatening illnesses, especially in terms of pain control and improving life quality. However, there is still research gap, particularly in the Brazilian context, regarding its ability to reduce costs associated with unnecessary invasive tests and procedures often invested in dysthanasia patients, thereby relieving the burden on the healthcare system. Given this scenario, the objective was to determine whether there is a significant difference in healthcare costs between cancer patients receiving palliative care and those in dysthanasia. Method: Documentary research, analyzing 94 medical records of patients who died from cancer in a hospital, divided into two groups: 47 in palliative care and 47 in dysthanasia. The groups had their average costs compared by surveying all tests and procedures recorded in the last 30 days of each patient’s life, with values scored based on the price table of the Unified Health System (Sistema Único de Saúde). Results: Patients receiving curative care in dysthanasia incurred an average cost of 2,316.92 Brazilian Reais (SD = 3,146.60) for tests and procedures in the last 30 days of life. Patients in palliative care had an average cost of 945.40 Brazilian Reais (SD = 2,508.01). There is a statistically significant difference in the invested values between patients in palliative care and those in dysthanasia (U = 620.00; Z = -4.334; p &lt; 0.001). Conclusions: Implementing palliative care can be considered an effective strategy for reducing hospital costs, leading to significant savings within the healthcare system.

Navigating cholestasis: identifying inborn errors of bile acid metabolism for precision diagnosis.

Inborn errors of bile acid metabolism (IEBAM) cause cholestasis during the neonatal period, and 8 types of IEBAM have been reported to date. IEBAM accounts for approximately 2% of cases of cholestasis of unknown cause. As only 10 patients have been identified in Japan, IEBAM presents diagnostic challenges due to the similarity of clinical symptoms with biliary atresia, thus necessitating precise differentiation to avoid unnecessary invasive procedures. Laboratory tests in IEBAM are characterized by normal γ-glutamyltransferase (GGT) and serum total bile acid (STBA) levels despite the presence of cholestasis; therefore, measuring STBA and GGT is essential to distinguishing biliary atresia from IEBAM. With suspected IEBAM, liquid chromatography-mass spectrometry (LC/MS) analysis of urinary bile acids is needed to optimize diagnostic and therapeutic efficacy and avoid open cholangiography and initiate treatment for primary bile acids such as cholic acid or chenodeoxycholic acid. This prospective report aims to increase awareness of IEBAM by highlighting the characteristics of general blood test and bile acid profiles from LC/MS analyses of blood, urine, and stool samples.

Abstract 3448: A novel liquid biopsy lung cancer detection method using a coverage and fragment end motif machine learning analysis

Abstract Lung cancer remains the leading cause of cancer death in the United States. One reason for this high mortality is that &amp;gt;40% of cases are diagnosed at a late stage, where the 5-year survival rate is low. Liquid biopsy molecular testing has transformed lung cancer care through the identification of driver mutations when tissue is inaccessible. It also has promise as a tool in early detection and diagnosis, thereby reducing mortality. The existing paradigm for lung cancer screening and diagnosis includes low dose CT (LDCT) scans and tissue biopsy. LDCT scans yield a visualization of lung abnormalities. However, many of these abnormalities are difficult to characterize and next steps are often unclear to physicians. One option is to continue to monitor the patient, which may risk a delay in cancer treatment. Up to 15% of all individuals who are put on a monitoring regime will ultimately be diagnosed with lung cancer. A second option is to biopsy the nodule, which risks unnecessary invasive procedures and expenses to patients. 42-62% of indeterminate nodules detected by LDCT are found to be benign after biopsy. Furthermore, 15% of transthoracic needle biopsies result in complications. Genece Health aims to decrease uncertainty in cancer diagnosis and improve patient outcomes through a minimally invasive liquid biopsy assay that detects the presence of lung cancer. The technology utilizes a proprietary algorithm that leverages machine learning models to detect lung cancer signals in low-pass whole genome sequencing (LP-WGS) of patient cfDNA isolated from plasma. To establish assay performance, 50 clinical lung cancer samples from a commercial biobank, and 100 presumed normal samples were collected in Streck cfDNA BCT Devices. Following cfDNA extraction from plasma, LP-WGS was performed. Sequencing data was then processed to generate fragment end-motif and size (FEMS) and fragment coverage data that was input into Genece Health’s proprietary machine learning classifier to generate a final cancer prediction score. In addition, a limit of detection was determined using three late-stage lung cancer samples, with tumor fractions estimated using whole exome sequencing and ichorCNA scores. Our results show &amp;gt;80% specificity, &amp;gt;90% sensitivity, and a limit of detection of &amp;lt;1% tumor fraction. Through this testing, we demonstrate the assay’s ability to detect lung cancer across various lung cancer stages, including early stage disease, and histologies. Genece has developed a highly sensitive and specific lung cancer detection liquid biopsy assay. We present this assay as a cost-effective approach to discriminate between benign and malignant nodules identified by LDCT. In addition, this assay has the potential to be applied across the cancer care continuum. For example, future work will involve characterizing the assay’s ability to be applied in early cancer screening. Citation Format: Bryan Leatham, Michael Salmans, Molly Smith, Mengchi Wang, Andrew Carson, Kristin Fathe, Byung In Lee. A novel liquid biopsy lung cancer detection method using a coverage and fragment end motif machine learning analysis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3448.

Abstract 3747: Bronchial washing fluid sequencing is useful in the diagnosis of lung cancer with necrotic tumor

Abstract Lung cancers identified with low-dose CT are typically early stage without endobronchial lesions, and most require a pathological diagnosis using invasive procedures. We conducted a study analyzing bronchial washing (BW) fluid using targeted panel sequencing to evaluate its diagnostic performance. And we aimed to elucidate the characteristics of patients group in which this method could be effectively applied. We prospectively enrolled patients with an incidental lung lesion suspected of early-stage lung cancer on chest CT and no visible endobronchial lesion on bronchoscopy from June 2017 to March 2018 at two independent hospitals. Lung cancer was histologically diagnosed using a diagnostic work-up including surgical lung biopsy, percutaneous needle biopsy, endobronchial ultrasound, and other biopsies. BW was performed on each patient in the subsegmental bronchus where the lung lesion was suspected to be located. Among shared genes between the panels for each cohort, we selected 8 genes that are frequently mutated known oncogenes/tumor suppressor genes in lung cancer not to consider passenger mutations for diagnosis. In addition, several filtering criteria were considered to differentiate cancer. Since criterion d considered definitive somatic mutations [known hotspot mutations or loss of function mutations with variant allele fraction (VAF) ≥ 2%] with criterion c (≥ 2 COSMIC11 variants with VAF ≥ 1%), the sensitivity was increased without loss of precision and the sensitivity of sequencing was higher than BW cytology. In total, 164 subjects (114 with lung cancer and 50 with benign) were enrolled. Of lung cancer patients, necrosis was observed on chest CT in 44 (38.6%) patients and malignant cells were identified upon BW cytological examination in 33 (28.9%) patients. Of total, 33 (20.1%) patients had complications related to invasive diagnostic test. By the panel with the criterion d, 42 patients (25.6%) were classified as cancer. The panel showed 100% of specificity, 100% of positive predictive value for diagnosing cancer whereas it had relatively low sensitivity. Twenty patients who were classified as cancer by sequencing despite of negative cytology. In the group with necrosis, the proportion of patients with positive for sequencing only was significantly higher than that of patients with positive for cytology only. In addition, the sensitivity of BW sequencing reached 75% in patients with necrotic tumors. The prevalence of necrotic tumors was significantly higher in SQC than in ADC. The significant proportion (66.7%) of primary tumors with positive for sequencing only and located in outer area had necrosis. This study demonstrated that BW sequencing could be applied for diagnosis in patients with necrotic lung lesion suspected of early-stage lung cancer in chest CT. It would be possible to reduce the frequency of unnecessary invasive procedures and subsequent complications. Citation Format: Jun Hyeok Lim, Hyun-Tae Shin, Sunmin Park, Woo Kyung Ryu, Lucia Kim, Kyung-Hee Lee, Sung Min Ko, Seung Jae Lee, Jung Soo Kim, Jeong-Seon Ryu. Bronchial washing fluid sequencing is useful in the diagnosis of lung cancer with necrotic tumor [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3747.

Musculoskeletal Pitfalls on Molecular Imaging Studies of Oncologic Patients: How to Stay Out of Trouble.

An increasing amount of molecular imaging studies are ordered each year for an oncologic population that continues to expand and increase in age. The importance of these studies in dictating further care for oncologic patients underscores the necessity of differentiating benign from malignant findings, particularly for a population in whom incidental findings are common. The aim of this review is to provide pictorial examples of benign musculoskeletal pathologies which may be found on molecular imaging and which may be mistaken for malignant processes. Imaging examples are provided in the form of radiographs, bone scintigraphy, computed tomography, and fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) scans. Special attention is paid to specific features that help narrow the differential diagnosis and distinguish benign from malignant processes, with the goal of avoiding unnecessary invasive procedures.

Challenging Axillary Lymph Nodes on PET/CT in Cancer Patients throughout COVID-19 Vaccination Era.

The unexpected detection of axillary lymphadenopathy (AxL) in cancer patients (pts) represents a real concern during the COVID-19 vaccination era. Benign reactions may take place after vaccine inoculation, which can mislead image interpretation in patients undergoing F-18-FDG, F-18-Choline, and Ga-68-DOTATOC PET/CT. They may also mimic loco-regional metastases or disease. We assessed PET/CT findings after COVID-19 first dose vaccination in cancer patients and the impact on their disease course management. We evaluated 333 patients undergoing PET/CT (257 F-18-FDG, 54 F-18-Choline, and 23 Ga-68 DOTATOC) scans after the first vaccination with mRNA vaccine (Pfizer-BioNTech) (study group; SG). The uptake index (SUVmax) of suspected AxL was defined as significant when the ratio was > 1.5 as compared to the contralateral lymph nodes. Besides, co-registered CT (Co-CT) features of target lymph nodes were evaluated. Nodes with aggregate imaging positivity were further investigated. Overall, the prevalence of apparently positive lymph nodes on PET scans was 17.1% during the vaccination period. 107 pts of the same setting, who had undergone PET/CT before the COVID-19 pandemic, represented the control group (CG). Only 3 patients of CG showed reactive lymph nodes with a prevalence of 2.8% (p < 0.001 as compared to the vaccination period). 84.2% of SG patients exhibited benign characteristics on co-CT images and only 9 pts needed thorough appraisal. The correct interpretation of images is crucial to avoid unnecessary treatments and invasive procedures in vaccinated cancer pts. A detailed anamnestic interview and the analysis of lymph nodes' CT characteristics, after performing PET/CT, may help to clear any misleading diagnosis.

An assessment of radiology resident competency in identifying suppurative retropharyngeal lymphadenitis: an examination using the WIDI SIM platform.

Suppurative retropharyngeal lymphadenitis is a retropharyngeal space infection almost exclusively seen in the young (4-8years old) pediatric population. It can be misdiagnosed as a retropharyngeal abscess, leading to unnecessary invasive treatment procedures. This retrospective study aims to assess radiology residents' ability to independently identify CT imaging findings and make a definitive diagnosis of suppurative retropharyngeal lymphadenitis in a simulated call environment. The Wisdom in Diagnostic Imaging Emergent/Critical Care Radiology Simulation (WIDI SIM) is a computer-aided emergency imaging simulation proven to be a reliable method for assessing resident preparedness for independent radiology call. The simulation included 65 cases across various imaging modalities of varying complexity, including normal studies, with one case specifically targeting suppurative retropharyngeal adenitis identification. Residents' free text responses were manually scored by faculty members using a standardized grading rubric, with errors subsequently classified by type. A total of 543 radiology residents were tested in three separate years on the imaging findings of suppurative retropharyngeal lymphadenitis using the Wisdom in Diagnostic Imaging simulation web-based testing platform. Suppurative retropharyngeal lymphadenitis was consistently underdiagnosed by radiology residents being tested for call readiness irrespective of the numbers of years in training. On average, only 3.5% of radiology residents were able to correctly identify suppurative retropharyngeal lymphadenitis on a contrast-enhanced computed tomography (CT). Our findings underscore a potential gap in radiology residency training related to the accurate identification of suppurative retropharyngeal lymphadenitis, highlighting the potential need for enhanced educational efforts in this area.

Qualitative and quantitative characteristics of CEUS for renal cell carcinoma and angiomyolipoma: a narrative review.

Incidental findings of renal masses are increasing. However, a substantial portion of surgically treated renal masses turn out to be benign on histopathological examination. Thus, there is a clear need for improved pre-surgical assessment to minimize unnecessary invasive procedures. The challenge intensifies when distinguishing between renal cell carcinoma (RCC) and angiomyolipoma (AML) in renal lesions smaller than 4cm with minimal adipose tissue. In such cases, contrast-enhanced ultrasound (CEUS) has emerged as a valuable diagnostic tool, by utilizing both qualitative and quantitative parameters. Quantitative measures offer objectivity, reliability, and reproducibility compared to qualitative parameters, enabling the characterization of RCC subtypes and differentiation from AML. Qualitative features as enhancement pattern, degree, and peak were less helpful in distinguishing triphasic minimal fat AML (TAML) from epithelioid AML (EAML), with the pseudocapsule sign potentially being the only distinguishing qualitative feature. The pseudocapsule sign was more frequently observed in ccRCCs (38.0%) than in AMLs (15.6%). Moreover, it was detected in 40.0% of EAMLs and 34.5% of ccRCCs but not in TAMLs due to similar growth patterns between EAMLs and low-grade ccRCCs. Quantitative measures such as the time-to-peak (TTP) ratio can further enhance diagnostic accuracy and also TOC ratio should be considered, as it was higher in clear cell RCCs (ccRCCs) and in EAMLs compared to TAMLs, indicating behavior similar to ccRCCs. However, CEUS remains an operator-dependent exam.

Assessment of the cardiac output at rest and during exercise stress using real-time cardiovascular magnetic resonance imaging in HFpEF-patients

This methodological study aimed to validate the cardiac output (CO) measured by exercise-stress real-time phase-contrast cardiovascular magnetic resonance imaging (CMR) in patients with heart failure and preserved ejection fraction (HFpEF). 68 patients with dyspnea on exertion (NYHA ≥ II) and echocardiographic signs of diastolic dysfunction underwent rest and exercise stress right heart catheterization (RHC) and CMR within 24 h. Patients were diagnosed as overt HFpEF (pulmonary capillary wedge pressure (PCWP) ≥ 15mmHg at rest), masked HFpEF (PCWP ≥ 25mmHg during exercise stress but < 15mmHg at rest) and non-cardiac dyspnea. CO was calculated using RHC as the reference standard, and in CMR by the volumetric stroke volume, conventional phase-contrast and rest and stress real-time phase-contrast imaging. At rest, the CMR based CO showed good agreement with RHC with an ICC of 0.772 for conventional phase-contrast, and 0.872 for real-time phase-contrast measurements. During exercise stress, the agreement of real-time CMR and RHC was good with an ICC of 0.805. Real-time measurements underestimated the CO at rest (Bias:0.71 L/min) and during exercise stress (Bias:1.4 L/min). Patients with overt HFpEF had a significantly lower cardiac index compared to patients with masked HFpEF and with non-cardiac dyspnea during exercise stress, but not at rest. Real-time phase-contrast CO can be assessed with good agreement with the invasive reference standard at rest and during exercise stress. While moderate underestimation of the CO needs to be considered with non-invasive testing, the CO using real-time CMR provides useful clinical information and could help to avoid unnecessary invasive procedures in HFpEF patients.

A multitask approach for automated detection and segmentation of thyroid nodules in ultrasound images

An increase in the incidence and diagnosis of thyroid nodules and thyroid cancer underscores the need for a better approach to nodule detection and risk stratification in ultrasound (US) images that can reduce healthcare costs, patient discomfort, and unnecessary invasive procedures. However, variability in ultrasound technique and interpretation makes the diagnostic process partially subjective. Therefore, an automated approach that detects and segments nodules could improve performance on downstream tasks, such as risk stratification. Ultrasound studies were acquired from 280 patients at UCLA Health, totaling 9888 images, and annotated by collaborating radiologists. Current deep learning architectures for segmentation are typically semi-automated because they are evaluated solely on images known to have nodules and do not assess ability to identify suspicious images. However, the proposed multitask approach both detects suspicious images and segments potential nodules; this allows for a clinically translatable model that aptly parallels the workflow for thyroid nodule assessment. The multitask approach is centered on an anomaly detection (AD) module that can be integrated with any UNet architecture variant to improve image-level nodule detection. Of the evaluated multitask models, a UNet with a ImageNet pretrained encoder and AD achieved the highest F1 score of 0.839 and image-wide Dice similarity coefficient of 0.808 on the hold-out test set. Furthermore, models were evaluated on two external validations datasets to demonstrate generalizability and robustness to data variability. Ultimately, the proposed architecture is an automated multitask method that expands on previous methods by successfully both detecting and segmenting nodules in ultrasound.

Tips for Transient Perivascular Inflammation of the Carotid Artery Syndrome

BackgroundIdiopathic carotidynia, also known as transient perivascular inflammation of the carotid artery (TIPIC) syndrome, is a rare, self-limited, clinical-radiologic entity. Over the years, the diagnosis of carotidynia has been controversial, but recent pathologic, radiologic, clinical, and laboratory findings support an inflammatory etiology. Case ReportA 61-year-old woman with a history of hypertension, left lower extremity liposarcoma, and right internal jugular port placement 2 weeks prior with initiation of chemotherapy presented to the emergency department with right neck pain and swelling of the lateral neck and lower face for the past 3 days. Computed tomography–neck with IV contrast revealed marked mural thickening of the right common carotid artery, which can be seen with carotidynia (Fay syndrome and TIPIC syndrome) and vasculitis. The patient had elevated inflammatory markers and was treated clinically for carotidynia with ibuprofen, evaluated by vascular surgery, and discharged home. Why Should an Emergency Physician Be Aware of This?The causes of acute neck pain are diverse, ranging from nonemergent to surgically emergent etiologies. As radiologists and emergency physicians, we believe TIPIC syndrome is a rare entity with important clinical impact deserving attention, as it is not typically included in medical training and is usually learned only through years of clinical experience and practice. TIPIC syndrome requires a unique combination of both clinical and radiologic findings to diagnose accurately and appropriately. It is important to be familiar with this diagnosis because treatment is focused on symptomatic relief without the need for invasive procedures. Our goal was to increase awareness of this uncommon diagnosis to improve patient care by preventing unnecessary invasive procedures and aid in timely and accurate diagnosis.