Development and multicenter validation of deep convolutional neural network-based detection of colorectal cancer on abdominal CT.

OBJECTIVES: This study aims to develop computer-aided detection (CAD) for colorectal cancer (CRC) using abdominal CT based on a deep convolutional neural network. METHODS: This retrospective study included consecutive patients with colorectal adenocarcinoma who underwent abdominal CT before CRC resection surgery (training set = 379, test set = 103). We customized the 3D U-Net of nnU-Net (CUNET) for CRC detection, which was trained with fivefold cross-validation using annotated CT images. CUNET was validated using datasets covering various clinical situations and institutions: an internal test set (n = 103), internal patients with CRC first determined by CT (n = 54) and asymptomatic CRC (n = 51), and an external validation set from two institutions (n = 60). During each validation, data from the healthy population were added (internal = 60; external = 130). CUNET was compared with other deep CNNs: residual U-Net and EfficientDet. The CAD performances were evaluated using per-CRC sensitivity (true positive/all CRCs), free-response receiver operating characteristic (FROC), and jackknife alternative FROC (JAFROC) curves. RESULTS: CUNET showed a higher maximum per-CRC sensitivity than residual U-Net and EfficientDet (internal test set 91.3% vs. 61.2%, and 64.1%). The per-CRC sensitivity of CUNET at false-positive rates of 3.0 was as follows: internal CRC determined by CT, 89.3%; internal asymptomatic CRC, 87.3%; and external validation, 89.6%. CUNET detected 69.2% (9/13) of CRCs missed by radiologists and 89.7% (252/281) of CRCs from all validation sets. CONCLUSIONS: CUNET can detect CRC on abdominal CT in patients with various clinical situations and from external institutions. KEY POINTS: • Customized 3D U-Net of nnU-Net (CUNET) can be applied to the opportunistic detection of colorectal cancer (CRC) in abdominal CT, helping radiologists detect unexpected CRC. • CUNET showed the best performance at false-positive rates ≥ 3.0, and 30.1% of false-positives were in the colorectum. CUNET detected 69.2% (9/13) of CRCs missed by radiologists and 87.3% (48/55) of asymptomatic CRCs. • CUNET detected CRCs in multiple validation sets composed of varying clinical situations and from different institutions, and CUNET detected 89.7% (252/281) of CRCs from all validation sets.

Development and validation of CT­based radiomics model of PET-negative residual CT masses: a potential biomarker for predicting relapse­free survival in non-Hodgkin lymphoma patients showing complete metabolic response.

PURPOSE: PET-negative residual CT masses (PnRCMs) are usually dismissed as nonviable post-treatment lesions in non-Hodgkin lymphoma (NHL) patients showing complete metabolic response (CMR). We aimed to develop and validate computed tomography (CT)-based radiomics model of PET-negative residual CT mass (PnRCM) for predicting relapse-free survival (RFS) in NHL patients showing CMR. METHODS: A total of 224 patients who showed CMR after completing first-line chemotherapy for PET-avid NHL were recruited for model development. Patients with PnRCM were selected in accordance with the Lugano classification. Three-dimensional segmentation was done by two readers. Radiomic scores (RS) were constructed using features extracted using the Least-absolute shrinkage and selection operator analysis among radiomics features of PnRCMs showing more than substantial interobserver agreement (> 0.6). Cox regression analysis was performed with clinical and radiologic features. The performance of the model was evaluated using area under the curve (AUC). For validation, 153 patients from an outside hospital were recruited and analyzed in the same way. RESULTS: In the model development cohort, 68 (30.4%) patients had PnRCM. Kaplan-Meier analysis showed that patients with PnRCM had significantly (p = 0.005) shorter RFS than those without PnRCM. In Kaplan-Meier analysis, the high RS group showed significantly (p = 0.038) shorter RFS than the low-scoring group. Multivariate Cox regression analysis showed that high IPI score [hazard ratio (HR) 2.46; p = 0.02], treatment without rituximab (HR 3.821; p = 0.019) were factors associated with shorter RFS. In estimating RFS, combined model in both development and validation cohort showed AUC values of 0.81. CONCLUSION: The combined model that incorporated both clinical parameters and CT-based RS showed good performance in predicting relapse in NHL patients with PnRCM.

Machine Learning-Based Magnetic Resonance Radiomics Analysis for Predicting Low- and High-Grade Clear Cell Renal Cell Carcinoma.

PURPOSE: To explore whether high- and low-grade clear cell renal cell carcinomas (ccRCC) can be distinguished using radiomics features extracted from magnetic resonance imaging. METHODS: In this retrospective study, 154 patients with pathologically proven clear ccRCC underwent contrast-enhanced 3 T magnetic resonance imaging and were assigned to the development (n = 122) and test (n = 32) cohorts in a temporal-split setup. A total of 834 radiomics features were extracted from whole-tumor volumes using 3 sequences: T2-weighted imaging (T2WI), diffusion-weighted imaging, and contrast-enhanced T1-weighted imaging. A random forest regressor was used to extract important radiomics features that were subsequently used for model development using the random forest algorithm. Tumor size, apparent diffusion coefficient value, and percentage of tumor-to-renal parenchymal signal intensity drop in the tumors were recorded by 2 radiologists for quantitative analysis. The area under the receiver operating characteristic curve (AUC) was generated to predict ccRCC grade. RESULTS: In the development cohort, the T2WI-based radiomics model demonstrated the highest performance (AUC, 0.82). The T2WI-based radiomics and radiologic feature hybrid model showed AUCs of 0.79 and 0.83, respectively. In the test cohort, the T2WI-based radiomics model achieved an AUC of 0.82. The range of AUCs of the hybrid model of T2WI-based radiomics and radiologic features was 0.73 to 0.80. CONCLUSION: Magnetic resonance imaging-based classifier models using radiomics features and machine learning showed satisfactory diagnostic performance in distinguishing between high- and low-grade ccRCC, thereby serving as a helpful noninvasive tool for predicting ccRCC grade.

Hepatocellular carcinoma pathologic grade prediction using radiomics and machine learning models of gadoxetic acid-enhanced MRI: a two-center study.

PURPOSE: To develop a radiomics-based hepatocellular carcinoma (HCC) grade classifier model based on data from gadoxetic acid-enhanced MRI. METHODS: This retrospective study included 137 patients who underwent hepatectomy for a single HCC and gadoxetic acid-enhanced MRI within 60 days before surgery. HCC grade was categorized as low or high (modified Edmondson-Steiner grade I-II vs. III-IV). We used the hepatobiliary phase (HBP), portal venous phase, T2-weighted image(T2WI), and T1-weighted image(T1WI). From the volume of interest in HCC, 833 radiomic features were extracted. Radiomic and clinical features were selected using a random forest regressor, and the classification model was trained and validated using a random forest classifier and tenfold stratified cross-validation. Eight models were developed using the radiomic features alone or by combining the radiomic and clinical features. Models were validated with internal enrolled data (internal validation) and a dataset (28 patients) at a separate institution (external validation). The area under the curve (AUC) of the validation results was compared using the DeLong test. RESULTS: In internal and external validation, the HBP radiomics-only model showed the highest AUC (internal 0.80 ± 0.09, external 0.70 ± 0.09). In external validation, all models showed lower AUC than those for internal validation, while the T2WI and T1WI models failed to predict the HCC grade (AUC 0.30-0.58) in contrast to the internal validation results (AUC 0.67-0.78). CONCLUSION: The radiomics-based machine learning model from gadoxetic acid-enhanced liver MRI could distinguish between low- and high-grade HCCs. The radiomics-only HBP model showed the best AUC among the eight models, good performance in internal validation, and fair performance in external validation.

Radiomics Analysis of Magnetic Resonance Proton Density Fat Fraction for the Diagnosis of Hepatic Steatosis in Patients With Suspected Non-Alcoholic Fatty Liver Disease.

BACKGROUND: This study aimed to assess the diagnostic feasibility of radiomics analysis based on magnetic resonance (MR)-proton density fat fraction (PDFF) for grading hepatic steatosis in patients with suspected non-alcoholic fatty liver disease (NAFLD). METHODS: This retrospective study included 106 patients with suspected NAFLD who underwent a hepatic parenchymal biopsy. MR-PDFF and MR spectroscopy were performed on all patients using a 3.0-T scanner. Following whole-volume segmentation of the MR-PDFF images, 833 radiomic features were analyzed using a commercial program. Radiologic features were analyzed, including median and mean values of the multiple regions of interest and variable clinical features. A random forest regressor was used to extract the important radiomic, radiologic, and clinical features. The model was trained using 20 repeated 10-fold cross-validations to classify the NAFLD steatosis grade. The area under the receiver operating characteristic curve (AUROC) was evaluated using a classifier to diagnose steatosis grades. RESULTS: The levels of pathological hepatic steatosis were classified as low-grade steatosis (grade, 0-1; n = 82) and high-grade steatosis (grade, 2-3; n = 24). Fifteen important features were extracted from the radiomic analysis, with the three most important being wavelet-LLL neighboring gray tone difference matrix coarseness, original first-order mean, and 90th percentile. The MR spectroscopy mean value was extracted as a more important feature than the MR-PDFF mean or median in radiologic measures. Alanine aminotransferase has been identified as the most important clinical feature. The AUROC of the classifier using radiomics was comparable to that of radiologic measures (0.94 ± 0.09 and 0.96 ± 0.08, respectively). CONCLUSION: MR-PDFF-derived radiomics may provide a comparable alternative for grading hepatic steatosis in patients with suspected NAFLD.

Dual-Layer Spectral CT of Pancreas Ductal Adenocarcinoma: Can Virtual Monoenergetic Images of the Portal Venous Phase Be an Alternative to the Pancreatic-Phase Scan?

Objectives: To determine the performance of virtual monoenergetic images (VMIs) of the portal venous phase (PVP) compared with the pancreatic-phase image for pancreatic ductal adenocarcinoma (PDAC) evaluation. Materials and methods: This retrospective study enrolled 64 patients with PDAC who underwent pancreatic CT with dual-layer spectral CT between February 2018 and January 2020. A polychromatic pancreatic-phase image and VMIs at 40 (VMI40), 55 (VMI55), and 70 keV (VMI70) of the PVP were generated. The tumor-to-pancreas contrast-to-noise ratio (CNR), attenuation difference, peripancreatic vascular signal-to-noise ratio (SNR), and CNR were compared among the four images. Subjective image analysis was performed for tumor conspicuity, heterogeneity, size, and arterial invasion. Results: VMI40 and VMI55 demonstrated higher tumor-to-pancreas CNR, attenuation difference, and higher peripancreatic vascular CNR and SNR than the pancreatic-phase image and VMI70 (p < .001). On subjective analysis, VMI55 showed the best tumor conspicuity. Moreover, the inter-reader agreement for arterial invasion in VMIs from the PVP was not inferior to that in the pancreatic-phase image. Conclusion: For evaluating PDAC, the VMI55 of the PVP was superior to the pancreatic-phase image in terms of tumor conspicuity and peripancreatic vascular enhancement. Therefore, the VMI55 of the PVP could be an alternative to the pancreatic-phase scan in patients suspicious of PDAC.

Metastatic Renal Cell Carcinoma Manifesting as a Gastric Polyp on CT: A Case Report and Literature Review.

Gastric metastasis from renal cell carcinoma (RCC) is extremely rare, occurring in 0.2% of all RCC cases. Owing to its low prevalence, metachronous gastric metastasis from RCC may be underdiagnosed, and the imaging findings have not been well-established. Herein we present a case of metastatic RCC manifesting as a gastric polyp in a 70-year-old female along with a literature review on the imaging findings of gastric metastases from RCC. In patients presenting with gastric hyper-enhancing polypoid masses, metastasis from RCC should be considered as a differential diagnosis.

Computer-aided hepatocellular carcinoma detection on the hepatobiliary phase of gadoxetic acid-enhanced magnetic resonance imaging using a convolutional neural network: Feasibility evaluation with multi-sequence data.

BACKGROUND AND OBJECTIVES: Diagnosis of hepatocellular carcinoma (HCC) on liver MRI needs analysis of multi-sequence images. However, developing computer-aided detection (CAD) for every single sequence requires considerable time and labor for image segmentation. Therefore, we developed CAD for HCC on the hepatobiliary phase (HBP) of gadoxetic acid-enhanced magnetic resonance imaging (MRI) using a convolutional neural network (CNN) and evaluated its feasibility on multi-sequence, multi-unit, and multi-center data. METHODS: Patients who underwent gadoxetic acid-enhanced MRI and surgery for HCC in Korea University Anam Hospital (KUAH) and Korea University Guro Hospital (KUGH) were reviewed. Finally, 170 nodules from 155 consecutive patients from KUAH and 28 nodules from 28 patients randomly selected from KUGH were included. Regions of interests were drawn on the whole HCC volume on HBP, T1-weighted (T1WI), T2-weighted (T2WI), and portal venous phase (PVP) images. The CAD was developed from the HBP images of KUAH using customized-nnUNet and post-processed for false-positive reduction. Internal and external validation of the CAD was performed with HBP, T1WI, T2WI, and PVP of KUAH and KUGH. RESULTS: The figure of merit and recall of the jackknife alternative free-response receiver operating characteristic of the CAD for HBP, T1WI, T2WI, and PVP at false-positive rate 0.5 were (0.87 and 87.0), (0.73 and 73.3), (0.13 and 13.3), and (0.67 and 66.7) in KUAH and (0.86 and 86.0), (0.61 and 53.6), (0.07 and 0.07), and (0.57 and 53.6) in KUGH, respectively. CONCLUSIONS: The CAD for HCC on gadoxetic acid-enhanced MRI developed by CNN from HBP detected HCCs feasibly on HBP, T1WI, and PVP of gadoxetic acid-enhanced MRI obtained from multiple units and centers. This result imply that the CAD developed using single MRI sequence may be applied to other similar sequences and this will reduce labor and time for CAD development in multi-sequence MRI.

Diagnostic Feasibility of Magnetic Resonance Elastography Radiomics Analysis for the Assessment of Hepatic Fibrosis in Patients With Nonalcoholic Fatty Liver Disease.

OBJECTIVE: The aim of the study was to investigate the diagnostic feasibility of radiomics analysis using magnetic resonance elastography (MRE) to assess hepatic fibrosis in patients with nonalcoholic fatty liver disease (NAFLD). METHODS: One hundred patients with suspected NAFLD were retrospectively enrolled. All patients underwent a liver parenchymal biopsy. Magnetic resonance elastography was performed using a 3.0-T scanner. After multislice segmentation of MRE images, 834 radiomic features were analyzed using a commercial program. Radiologic features, such as median and mean values of the regions of interest and variable clinical features, were analyzed. A random forest regressor was used to extract important radiomic, radiological, and clinical features. A random forest classifier model was trained to use these features to classify the fibrosis stage. The area under the receiver operating characteristic curve was evaluated using a classifier for fibrosis stage diagnosis. RESULTS: The pathological hepatic fibrosis stage was classified as low-grade fibrosis (stages F0-F1, n = 82) or clinically significant fibrosis (stages F2-F4, n = 18). Eight important features were extracted from radiomics analysis, with the 2 most important being wavelet-high high low gray level dependence matrix dependence nonuniformity-normalized and wavelet-high high low gray level dependence matrix dependence entropy. The median value of the multiple small regions of interest was identified as the most important radiologic feature. Platelet count has been identified as an important clinical feature. The area under the receiver operating characteristic curve of the classifier using radiomics was comparable with that of radiologic measures (0.97 ± 0.07 and 0.96 ± 0.06, respectively). CONCLUSIONS: Magnetic resonance elastography radiomics analysis provides diagnostic performance comparable with conventional MRE analysis for the assessment of clinically significant hepatic fibrosis in patients with NAFLD.

Accuracy of MRI for predicting anterior peritoneal reflection involvement in locally advanced rectal cancer: a comparison with operative findings.

PURPOSE: To assess the diagnostic accuracy of preoperative rectal MRI for anterior peritoneal reflection (APR) involvement in rectal cancer through comparison with the surgeon's operative findings. METHODS: This retrospective study was approved by the institutional review board; informed consent was waived. We enrolled 55 consecutive patients with suspected locally advanced mid-to-upper rectal cancer. All patients underwent rectal MRI using a 3T system. APR involvement in rectal cancer was assessed radiologically using a 5-point scale by two independent board-certified abdominal radiologists. The surgeon's evaluation during surgery was regarded as the gold standard for APR involvement. The accuracy of rectal MRI in predicting APR involvement was obtained. RESULTS: Rectal MRI showed good APR identification (rater 1, 92.7%; rater 2, 94.7%). On preoperative rectal MRI, rater 1 diagnosed 19 (34.5%) patients as having APR involvement and rater 2 diagnosed 28 (50.9%) as having APR involvement. There was moderate agreement (κ = 0.602, p < 0.001) between the two raters with regard to the evaluation of APR involvement. During surgery, the surgeon confirmed APR involvement in 13 (23.6%) patients. The sensitivity, specificity, PPV, and NPV of preoperative MRI for APR involvement were 69.2%, 76.2%, 47.4%, and 88.9%, respectively. The diagnostic accuracy of MRI for predicting APR involvement was 74.6%. CONCLUSION: Preoperative rectal MRI provides accurate anatomical information regarding APR involvement with high conspicuity. However, MRI has relatively low sensitivity (< 70%) and a low PPV (< 50%) with regard to the assessment of APR involvement in rectal tumors. Both rater 1 and rater 2 evaluated these images as positive involvement of APR. The patient underwent laparoscopic low anterior resection after preoperative evaluation. However, during surgery, the surgeon evaluated APR involvement as negative, and the final pathologic staging was confirmed as T3.

Active Learning for Efficient Segmentation of Liver with Convolutional Neural Network-Corrected Labeling in Magnetic Resonance Imaging-Derived Proton Density Fat Fraction.

This study aimed to propose an efficient method for self-automated segmentation of the liver using magnetic resonance imaging-derived proton density fat fraction (MRI-PDFF) through deep active learning. We developed an active learning framework for liver segmentation using labeled and unlabeled data in MRI-PDFF. A total of 77 liver samples on MRI-PDFF were obtained from patients with nonalcoholic fatty liver disease. For the training, tuning, and testing of the liver segmentation, the ground truth of 71 (internal) and 6 (external) MRI-PDFF scans for training and testing were verified by an expert reviewer. For 100 randomly selected slices, manual and deep learning (DL) segmentations for visual assessments were classified, ranging from very accurate to mostly accurate. The dice similarity coefficients for each step were 0.69 ± 0.21, 0.85 ± 0.12, and 0.94 ± 0.01, respectively (p-value = 0.1389 between the first step and the second step or p-value = 0.0144 between the first step and the third step for paired t-test), indicating that active learning provides superior performance compared with non-active learning. The biases in the Bland-Altman plots for each step were - 24.22% (from - 82.76 to - 2.70), - 21.29% (from - 59.52 to 3.06), and - 0.67% (from - 10.43 to 4.06). Additionally, there was a fivefold reduction in the required annotation time after the application of active learning (2 min with, and 13 min without, active learning in the first step). The number of very accurate slices for DL (46 slices) was greater than that for manual segmentations (6 slices). Deep active learning enables efficient learning for liver segmentation on a limited MRI-PDFF.

How to accurately measure the distance from the anal verge to rectal cancer on MRI: a prospective study using anal verge markers.

PURPOSE: To determine an accurate method for localizing rectal cancer using the distance from the anal verge on preoperative MRI. METHODS: This prospective study included 50 patients scheduled for MRI evaluation of rectal cancer. After rectal filling with gel, MRI was performed with two markers attached at the anal verge. The distance between the tumor and the anal verge on a sagittal T2-weighted image (T2WI) was measured independently by two radiologists using six methods divided into three groups of similar measurement approaches, and compared to those obtained on rigid sigmoidoscopy. The anal verge location relative to the external anal sphincter was assessed on oblique coronal T2WI in reference to the markers. Correlation analysis was performed using the intraclass correlation coefficient (ICC) for verification, and a paired t test was used to evaluate the mean differences. RESULTS: The highest correlation (ICC 0.797-0.815) and the least mean difference (0.74-0.85 cm) with rigid sigmoidoscopy, and the least standard deviation (3.12-3.17 cm) were obtained in the direct methods group using a straight line from the anal verge to the tumor. The anal verge was localized within a range of - 1.4 to 1.5 cm (mean - 0.31 cm and - 0.22 cm) from the lower end of the external anal sphincter. CONCLUSION: The direct methods group provided the most accurate tumor distance among the groups. Among the direct methods, we recommend the direct mass method for its simplicity. Despite minor differences in location, the lower end of the external anal sphincter was a reliable anatomical landmark for the anal verge.

How Should We Assign Large Infiltrative Hepatocellular Carcinomas for Staging?

Infiltrative gross morphology of hepatocellular carcinoma (HCC) is known to be associated with poor prognosis, but this is not considered for staging. A total of 774 HCC patients who underwent curative liver resection were retrospectively reviewed and the prognostic significance of infiltrative type HCC was assessed using the American Joint Committee on Cancer (AJCC) and Barcelona Clinic Liver Cancer (BCLC) staging systems. Seventy-four patients (9.6%) had infiltrative HCCs with a higher proportion of multifocal tumors, larger tumors, vessel invasion, increased tumor marker levels, and advanced T-stages than those with nodular HCC (all, p < 0.01). Infiltrative morphology was independently associated with lower overall survival (OS), but its impact was significant when the tumor size was ≥ 4 cm (p < 0.001). Under current AJCC and BCLC staging criteria, these large infiltrative HCCs were associated with significantly worse OS in early AJCC T-stages (T1b/T2, p < 0.001) and BCLC stage A/B (both, p < 0.01) but not in late AJCC (T3/T4) and BCLC C. The reassignment of this subtype to T3 and T4 increased the discriminatory ability of AJCC T-staging with lower AIC values (3090 and 3088 vs. 3109) and higher c-index (0.69 and 0.69 vs. 0.67), respectively (both, p < 0.001). Similarly, the reassignment of large infiltrative HCC to BCLC stages B and C also improved the prognostic performance. Large infiltrative HCCs should be assigned to more advanced stages in current staging systems for their prognostic impact.

Efficacy of ZOOMit coronal diffusion-weighted imaging and MR texture analysis for differentiating between benign and malignant distal bile duct strictures.

PURPOSE: To investigate the diagnostic efficacy of ZOOMit coronal diffusion-weighted imaging (Z-DWI) and MR texture analysis (MRTA) for differentiating benign from malignant distal bile duct strictures. METHODS: We retrospectively enrolled a total of 71 patients with distal bile duct stricture who underwent magnetic resonance cholangiopancreatography (MRCP). For quantitative analysis, the average apparent diffusion coefficient (ADC) value at suspected stricture sites was assessed on both Z-DWI and conventional DWI (C-DWI). For qualitative analysis, two reviewers independently reviewed two image sets containing different diffusion-weighted images, and receiver operating characteristic (ROC) curve analysis was performed. Several MRTA parameters were extracted from the area of the stricture on the ADC map of the ZOOMit coronal diffusion-weighted images using commercially available software. RESULTS: Among 71 patients, 26 patients were diagnosed with malignant stricture. On quantitative analysis, the average ADC value of the malignant and benign strictures, using Z-DWI, was 1.124 × 10-3 mm2/s and 1.522 × 10-3 mm2/s, respectively (P < 0.001). The average ADC value of the malignant and benign strictures, using C-DWI, was 1.107 × 10-3 mm2/s and 1.519 × 10-3 mm2/s, respectively (P < 0.001). On qualitative analysis, for each reviewer, the area under the ROC curve (AUC) values for differentiating benign from malignant stricture was 0.928 and 0.939, respectively, for the ZOOMit diffusion set and 0.851 and 0.824, respectively, for the conventional diffusion set. Multiple MRTA parameters showed a significantly different distribution for the benign and malignant strictures, including mean, entropy, mean of positive pixels, and kurtosis at spatial filtration values of 0, 5, and 6 mm. CONCLUSION: The addition of Z-DWI to conventional MRCP is helpful in differentiating benign from malignant bile duct strictures, and some MRTA parameters also can be helpful in differentiating benign from malignant distal bile duct strictures.

Predicting cannulation difficulty in endoscopic retrograde cholangiopancreatography using CT image findings: a decision-tree analysis.

BACKGROUND: Difficult cannulation during endoscopic retrograde cholangiopancreatography (ERCP) is associated with increased complications; therefore, its prediction is important. PURPOSE: To identify radiologic risk factors of difficult cannulation during ERCP based on computed tomography (CT) findings and to develop a predictive model for a difficult cannulation. MATERIAL AND METHODS: A total of 171 patients with native papilla who underwent both enhanced CT and ERCP were recruited. Two radiologists independently measured the distal common bile duct (CBD) diameter and choledochoduodenal (CD) angle and analyzed CT images for presence of CBD stone and papilla bulging, size and type of periampullary diverticulum (PAD), and duodenal segment in which major papilla was located. Multivariate logistic regression analysis and decision-tree analysis were performed to identify risk factors for difficult cannulation. RESULTS: Thirty-nine patients underwent a difficult cannulation. The multivariate logistic regression analysis revealed that a smaller CBD diameter, presence of papilla bulging, location of the major papilla other than the descending duodenum, a smaller CD angle, and a higher worrisome PAD score were statistically relevant factors for difficult cannulation (P < 0.049). In the decision-tree analysis, a higher worrisome PAD score was the strongest predictor of difficult cannulation, followed by the presence of papilla bulging, smaller CD angle, and a smaller CBD diameter. The predictive model had an 82.5% overall predictive accuracy. CONCLUSION: The CT findings-based decision-tree analysis model showed a high accuracy in predicting cannulation difficulty and may be helpful for making pre-ERCP strategy.

Survival according to recurrence patterns after resection for transplantable hepatocellular carcinoma in HBV endemic area: Appraisal of liver transplantation strategy.

BACKGROUND AND AIMS: Since there is a shortage of liver donors, we investigated recurrence patterns and outcomes after liver resection (LR) to determine the feasibility of salvage liver transplantation (SLT). METHODS: We analyzed 468 patients with hepatocellular carcinoma (HCC) within the Milan criteria (MC) who were mainly associated with Hepatitis B virus infection (76.3%) and had undergone curative LR as an initial treatment. RESULTS: The overall survival (OS) rates were 86.6% and 67.4% at 5 and 10 years after LR, respectively. During a median follow-up of 59 months, 211 patients experienced recurrences including 175 (37.4%) within MC and 36 (7.7%) beyond MC. Survival was lowest in patients with beyond MC-recurrence followed by within MC- and no-recurrence groups (26.5%, 86.6%, and 94.7% at 5 years, respectively, P<0.001). Independent pathologic predictors of recurrence beyond MC were the presence of satellite nodules, microvascular invasion, and unfavorable gross findings (multinodular confluent and infiltrative) (all, P<0.05). Patients with all three risk factors experienced recurrence with the highest cumulative incidence of mortality. Among 173 patients with recurrence within MC, the cumulative incidence of HCC progression beyond MC despite resection and locoregional treatment (LRT) was 29% and 60% at 5 and 10 years after recurrence, respectively, and their 10-year OS rate was 25.8%. CONCLUSION: Curative LR achieved a 5-year survival of>85% in patients with transplantable HCC, but early SLT after recurrence within MC is advocated because of poor survival and high risk of progression thereafter. Further, prophylactic LT could be considered for those with high risk of recurrence.

Effects of gadoxetic acid on image quality of arterial multiphase magnetic resonance imaging of liver: comparison study with gadoteric acid-enhanced MRI.

PURPOSE: To compare the effects of gadoxetic acid and gadoteric acid on the image quality of single-breath-hold, triple (first, second, and third) arterial hepatic magnetic resonance imaging (MRI). METHODS: Two hundred and eleven patients were divided into two groups according to the contrast materials used (gadoxetic acid, 108 patients and gadoteric acid, 103 patients). All 3.0-T MR examinations included triple arterial phase acquisition using the 4D enhanced T1-weighted high-resolution isotropic volume examination (eTHRIVE) keyhole technique. The image qualities of the pre-contrast and triple arterial phases were assessed in terms of image artifacts, sharpness of the intrahepatic vessel and liver edge, and overall image quality with a 5-point scale for qualitative analysis. RESULTS: The image quality of gadoxetic acid-enhanced liver MRI in the triple arterial phases was significantly degraded compared with that of gadoteric acid-enhanced liver MRI, although better image scores were observed in the pre-contrast images in the gadoxetic acid group (P < 0.001). The overall image quality gradually improved from the first to the third arterial phases in both groups (P < 0.003). CONCLUSIONS: Intravenous gadoxetic acid could have a detrimental effect on image quality of triple arterial phase MRI with the 4D eTHRIVE Keyhole technique. The third arterial phase images had the best image qualities; thus, they could be used as key scans.

Comparison of 2 curative treatment options for very early hepatocellular carcinoma: Efficacy, recurrence pattern, and retreatment.

Curative treatments for very early-stage hepatocellular carcinoma (HCC), defined as single HCC with a maximum diameter of <2 cm in patients with well-preserved liver function, consist of surgical resection or radiofrequency ablation (RFA). In this retrospective study, we compared the efficacy of both treatments in 154 patients with very early-stage HCCs who underwent resection or RFA as initial therapy and were followed up for a median of 56.8 months. Propensity score matching analysis was also conducted. Overall survival was comparable between treatment groups (median survival time of 143 vs 97 months for resection and RFA, respectively; P = .132). Resection group; however, demonstrated a significantly lower recurrence rate after initial therapy than RFA group (42.3% vs 65.7%; P = .006) with a longer median recurrence-free survival time (66.7 vs 33.8 months; P = .002), which was confirmed even after matching (P = .04). In contrast, the recurrence pattern in advanced-stage (9.6% vs 1.0%; P = .01) or incurable recurrences (19% vs 13%; P = .04) was more frequent following resection than RFA. Recurrent lesions were comparatively more curable in RFA group than in resection group (80% vs 54.5%; P = .02). The recurrence of HCC was independently associated with lower serum albumin level (P = .027), the presence of comorbid diabetes mellitus (P = .010), and RFA (P = .034). In conclusion, in patients with very early-stage HCC, surgical resection has achieved significantly better recurrence-free survival than RFA. A closer follow-up is required after resection.

Predicting the Development of Surgically Induced Chronic Kidney Disease After Total Nephrectomy Using Body Surface Area-Adjusted Renal Cortical Volume on CT Angiography.

OBJECTIVE: The purpose of this study was to predict the probability of surgically induced chronic kidney disease (CKD) developing in patients who underwent total nephrectomy by measuring the body surface area (BSA)-adjusted renal cortical volume (RCV) with preoperative CT angiography (CTA). MATERIALS AND METHODS: A total of 105 patients with a normal preoperative estimated glomerular filtration rate (eGFR) who underwent preoperative CTA and subsequent total nephrectomy for kidney donation (n = 67) or a renal tumor (n = 38) were included in this retrospective study. Patients were divided into group A (patients without surgically induced CKD; n = 61) and group B (patients with surgically induced CKD; n = 44) according to postoperative renal function. The preoperative and postoperative eGFR and other laboratory findings were collected, and the BSA-adjusted postnephrectomy RCV was measured using a semiautomated segmentation technique on CTA. Multiple logistic regression analysis was used to determine the formula for predicting the probability of development of surgically induced CKD; external validation was conducted using the validation dataset (n = 28). RESULTS: The estimated probability of surgically induced CKD developing can be calculated using the following formula: logit (probability of surgically induced CKD developing) = [1.431 × I (reason for operation was renal tumor)] + (-0.097 × preoperative eGFR) + (-0.033 × BSA-adjusted postnephrectomy RCV) + 10.937, where I denotes an indicator function (I = 1, reason for operation was renal tumor; I = 0, reason for operation was kidney donation). The optimal cutoff value derived from 10,000 bootstrapped samples was 0.444 (95% CI, 0.298-0.681). The formula was determined to be a good tool for prediction of surgically induced CKD on external validation (AUC value, 0.894). CONCLUSION: The probability of CKD developing in patients who undergo total nephrectomy may be predicted using a BSA-adjusted postnephrectomy RCV volume measured on preoperative CTA.

Computed tomography and magnetic resonance imaging findings of pancreatic hamartoma: A case report and literature review.

Pancreatic hamartoma is a rare benign malformation that resembles a neoplasm and may be mistaken for a malignancy. The imaging findings of pancreatic hamartoma are not well established, as only one radiological case report has been described since 1983. Herein, we discussed a case of pancreatic hamartoma in a 35-year-old woman and conducted a literature review focused on imaging findings and differential diagnosis of pancreatic hamartoma. Increased late enhancement on post-contrast dynamic study and absence of diffusion restriction may be characteristic MR imaging findings of pancreatic hamartoma that may narrow the differential diagnosis of hypervascular pancreatic lesions.