Current status of endoscopic ultrasound in the diagnosis of intraductal papillary mucinous neoplasms.

The new Kyoto guidelines for the management of intraductal papillary mucinous neoplasm (IPMN) provide evidence-based recommendations for the diagnosis and treatment of IPMN. Endoscopic ultrasonography (EUS) is a diagnostic modality with a high spatial resolution that allows detailed observation and obtaining cyst fluid or tissue samples via EUS-guided fine needle aspiration (EUS-FNA). Currently, EUS is an indispensable examination method for the diagnosis of pancreatic diseases. On the other hand, there have been concerns that EUS imaging tends to be highly operator-dependent, and may lack objectivity. Previous guidelines have assigned EUS as an option for patients with worrisome features. However, recent reports indicate that the sensitivity of EUS for the diagnosis of mural nodules (MNs) is more than 90%, comparable or superior to that of contrast-enhanced computed tomography or magnetic resonance cholangiopancreatography. The specific advantages of EUS in the diagnosis of IPMN are: (1) high spatial resolution imaging for the diagnosis of MNs, (2) contrast-enhanced EUS for differentiation of intra-cystic MNs from mucous clots, and (3) pathological diagnosis using EUS-FNA and differential diagnosis of a pancreatic cystic tumor by cystic fluid analysis. In order to utilize EUS in the diagnosis of IPMN, endoscopists are required to have the skills to provide sufficiently objective imaging findings.

Loss of Lateral suppressor gene is associated with evolution of root nodule symbiosis in Leguminosae.

BACKGROUND: Root nodule symbiosis (RNS) is a fascinating evolutionary event. Given that limited genes conferring the evolution of RNS in Leguminosae have been functionally validated, the genetic basis of the evolution of RNS remains largely unknown. Identifying the genes involved in the evolution of RNS will help to reveal the mystery. RESULTS: Here, we investigate the gene loss event during the evolution of RNS in Leguminosae through phylogenomic and synteny analyses in 48 species including 16 Leguminosae species. We reveal that loss of the Lateral suppressor gene, a member of the GRAS-domain protein family, is associated with the evolution of RNS in Leguminosae. Ectopic expression of the Lateral suppressor (Ls) gene from tomato and its homolog MONOCULM 1 (MOC1) and Os7 from rice in soybean and Medicago truncatula result in almost completely lost nodulation capability. Further investigation shows that Lateral suppressor protein, Ls, MOC1, and Os7 might function through an interaction with NODULATION SIGNALING PATHWAY 2 (NSP2) and CYCLOPS to repress the transcription of NODULE INCEPTION (NIN) to inhibit the nodulation in Leguminosae. Additionally, we find that the cathepsin H (CTSH), a conserved protein, could interact with Lateral suppressor protein, Ls, MOC1, and Os7 and affect the nodulation. CONCLUSIONS: This study sheds light on uncovering the genetic basis of the evolution of RNS in Leguminosae and suggests that gene loss plays an essential role.

Federated learning via multi-attention guided UNet for thyroid nodule segmentation of ultrasound images.

Accurate segmentation of thyroid nodules is essential for early screening and diagnosis, but it can be challenging due to the nodules' varying sizes and positions. To address this issue, we propose a multi-attention guided UNet (MAUNet) for thyroid nodule segmentation. We use a multi-scale cross attention (MSCA) module for initial image feature extraction. By integrating interactions between features at different scales, the impact of thyroid nodule shape and size on the segmentation results has been reduced. Additionally, we incorporate a dual attention (DA) module into the skip-connection step of the UNet network, which promotes information exchange and fusion between the encoder and decoder. To test the model's robustness and effectiveness, we conduct the extensive experiments on multi-center ultrasound images provided by 17 local hospitals. The model is trained using the federal learning mechanism to ensure privacy protection. The experimental results show that the Dice scores of the model on the data sets from the three centers are 0.908, 0.912 and 0.887, respectively. Compared to existing methods, our method demonstrates higher generalization ability on multi-center datasets and achieves better segmentation results.

Radiomics Combined with ACR TI-RADS for Thyroid Nodules: Diagnostic Performance, Unnecessary Biopsy Rate, and Nomogram Construction.

RATIONALE AND OBJECTIVES: To develop a radiomics model with enhanced diagnostic performance, reduced unnecessary fine needle aspiration biopsy (FNA) rate, and improved clinical net benefit for thyroid nodules. METHODS: We conducted a retrospective study of 217 thyroid nodules. Lesions were divided into training (n = 152) and verification (n = 65) cohorts. Three radiomics scores were derived from B-mode ultrasound (B-US) and strain elastography (SE) images, alone and in combination. A radiomics nomogram was constructed by combining high-frequency ultrasonic features and the best-performing radiomics score. The area under the receiver operating characteristic curve (AUC), unnecessary FNA rate, and decision curve analysis (DCA) results for the nomogram were compared to those obtained with the American College of Radiology Thyroid Imaging, Reporting and Data System (ACR TI-RADS) score and the combined TI-RADS+SE+ contrast-enhanced ultrasound (CEUS) advanced clinical score. RESULTS: The three radiomics scores (B-US, SE, B-US+SE) achieved training AUCs of 0.753 (0.668-0.825), 0.761 (0.674-0.838), and 0.795 (0.715-0.871), and validation AUCs of 0.732 (0.579-0.867), 0.753 (0.609-0.892), and 0.752 (0.592-0.899) respectively. The AUC of the nomogram for the entire patient cohort was 0.909 (0.864-0.954), which was higher than that of the ACR TI-RADS score (P < 0.001) and equivalent to the TI-RADS+SE+CEUS score (P = 0.753). Similarly, the unnecessary FNA rate of the radiomics nomogram was significantly lower than that of the ACR TI-RADS score (P = 0.007) and equivalent to the TI-RADS+SE+CEUS score (P = 0.457). DCA also showed that the radiomics nomogram brought more net clinical benefit than the ACR TI-RADS score but was similar to that of the TI-RADS+SE+CEUS score. CONCLUSION: The radiomics nomogram developed in this study can be used as an objective, accurate, cost-effective, and noninvasive method for the characterization of thyroid nodules.

Cost Effectiveness of Definitive Treatment Strategies for Autonomously Functioning Thyroid Nodules.

OBJECTIVE: Autonomously functioning thyroid nodules (AFTN) can be treated with antithyroid drugs, radioactive iodine (RAI), thyroid lobectomy or radiofrequency ablation (RFA). Although surgery is most definitive, some patients require lifelong hormone supplementation. RFA avoids this sequela, but its efficacy depends on nodule size. This study aims to compare the relative cost-effectiveness of RAI, RFA and lobectomy for treatment of AFTNs. STUDY DESIGN: A Markov analysis model was created to simulate clinical outcomes, costs and utilities for three AFTN treatments: (1) thyroid lobectomy, (2) RAI, and (3) RFA. PATIENTS: This mathematical model was created using published literature and modeling. MEASUREMENTS: Transition probabilities, utilities and costs were extracted from published literature, Medicare, and RedBook. The willingness to pay threshold was set to $100,000 per quality-adjusted life year. The model simulated 2-year outcomes, reflecting RFA literature. Sensitivity analyses were conducted to account for uncertainty in model variables. RESULTS: In the base model, RAI dominated both lobectomy and RFA, with lower estimated cost ($2000 vs. $9452 and $10,087) and higher cumulative utility (1.89 vs. 1.82 and 1.78 quality-adjusted life years). One-way sensitivity analyses demonstrated that relative cost-effectiveness between surgery and RFA was driven by the probability of euthyroidism after RFA and hypothyroidism after lobectomy. RFA becomes more cost-effective than surgery if the rate of euthyroidism after ablation is higher than 69% (baseline 54%). CONCLUSION: Based on published data, RAI is most cost-effective in treating most AFTN. Surgery is more cost-effective than RFA in most scenarios, but RFA may be more resource-efficient for smaller nodules with a high likelihood of complete treatment.

Recurrent laryngeal nerve monitoring by flexible laryngoscopy during thyroid radiofrequency ablation in the awake patient.

Objective: Although radiofrequency ablation (RFA) is a safe and effective non-surgical treatment for benign thyroid nodules, injury to the recurrent laryngeal nerve (RLN), is a potential and feared complication. Intermittent voice checks have been proposed to monitor vocal cord (VC) function during RFA, but such assessment is highly subjective and effort-dependent. Methods: We are here reporting the methodological use of flexible laryngoscopy (FL) for VC monitoring during bilateral thyroid RFA treatment. The patient, a 35-year-old woman, was referred to the Endocrinology Unit for subclinical hyperthyroidism due to bilateral autonomously functioning thyroid nodules. Results: At the end of the treatment of the first nodule, the FL performed by an otorhinolaryngologist specialist allowed evaluating VC function and ruling out possible paralysis before proceeding with the contralateral RFA treatment. The patient was awake during the entire procedure and well tolerated the laryngoscopic examination. The TSH serum evaluations performed one month and 9 months after the procedure assessed an euthyroid state (TSH 3.2 mIU/L and 2.8 mIU/L, respectively). Conclusion: During bilateral thyroid RFA the use of FL for VC monitoring treatment resulted in a safe, easy-to-perform, and effective strategy to minimize and anticipate RLN injury risk in the awake patient. The prevention of RLN damage is advisable in the case of single RFA treatment, while it should be strongly recommended when RFA is performed on bilateral nodules.

Current role of interventional radiology in thyroid nodules.

Thyroid nodules are a prevalent health issue in society. Interventional radiological methods are successfully applied for both the diagnosis and treatment of nodules. Diagnostically, a fine-needle aspiration biopsy and a core needle biopsy can be performed to ascertain the benign or malignant nature of a lesion. In recent years, imaging-guided percutaneous treatment methods have become popular in the treatment of thyroid nodules. Aspiration, ablation, and embolization are techniques employed in the treatment process. In this study, we aimed to discuss the current role of interventional radiology in the diagnosis and treatment of thyroid nodules, which occupy an important place in clinical practice.

Detecting thyroid nodules along with surrounding tissues and tracking nodules using motion prior in ultrasound videos.

Ultrasound examination plays a crucial role in the clinical diagnosis of thyroid nodules. Although deep learning technology has been applied to thyroid nodule examinations, the existing methods all overlook the prior knowledge of nodules moving along a straight line in the video. We propose a new detection model, DiffusionVID-Line, and design a novel tracking algorithm, ByteTrack-Line, both of which fully leverage the prior knowledge of linear motion of nodules in thyroid ultrasound videos. Among them, ByteTrack-Line groups detected nodules, further reducing the workload of doctors and significantly improving their diagnostic speed and accuracy. In DiffusionVID-Line, we propose two new modules: Freq-FPN and Attn-Line. Freq-FPN module is used to extract frequency features, taking advantage of these features to reduce the impact of image blur in ultrasound videos. Based on the standard practice of segmented scanning by doctors, Attn-Line module enhances the attention on targets moving along a straight line, thus improving the accuracy of detection. In ByteTrack-Line, considering the characteristic of linear motion of nodules, we propose the Match-Line association module, which reduces the number of nodule ID switches. In the testing of the detection and tracking datasets, DiffusionVID-Line achieved a mean Average Precision (mAP50) of 74.2 for multiple tissues and 85.6 for nodules, while ByteTrack-Line achieved a Multiple Object Tracking Accuracy (MOTA) of 83.4. Both nodule detection and tracking have achieved state-of-the-art performance.

Successful calcium modification of a large calcified nodule using shockwave intravascular lithotripsy in the setting of acute coronary syndrome: a case report.

Background: Calcified nodules are associated with suboptimal preparation before stenting due to challenging crossing and unsuccessful pre-dilation and calcium cracking with conventional balloons. In this scenario, we report the use of shockwave intravascular lithotripsy for the successful lesion preparation of an undilatable and challenging calcified nodule in a patient presenting with ACS. Case summary: We report a case of a 79-year-old male patient presented with non-ST elevation myocardial infarction. Coronary angiography revealed 90% stenosis in the proximal segment of the right coronary artery, with a hazy area of inhomogeneous contrast. Intravascular ultrasound (IVUS) imaging identified a large eccentric calcified nodule, with a minimum luminal area (MLA) of 4.18 mm2. Rotablation was done with a ROTAPRO Atherectomy System, post-rotablation IVUS showed no plaque modification. Intravascular lithotripsy (IVL) was performed with the emission of 50 pulses. Post-IVL, IVUS showed that the calcium nodule was successfully cracked with increased MLA to 6.8 mm2. The lesion was pre-dilated with a cutting balloon and stented using a SYNERGY MEGATRON stent and post-dilated with a non-compliant balloon with good final angiographic result and TIMI Grade 3 flow. Post-stenting IVUS confirmed optimal stent apposition and expansion with an MLA of 11.9 mm2. Discussion: In severely calcified lesions, like calcified nodules, lesion preparation before stenting is pivotal for optimal long-term outcomes. As demonstrated in this case, IVL can be used safely in the setting of ACS not only to treat superficial and deep calcium layers but also to crack a large, calcified nodule, after failure of rotablation.

THE IMPACT OF PATIENT ANXIETY AND PAIN PERCEPTION ON THE ADEQUACY OF THYROID FINE-NEEDLE ASPIRATION BIOPSY SAMPLES: A PROSPECTIVE STUDY.

Background: Fine-needle aspiration biopsy (FNAB) is the most accurate diagnostic method to assess the malignancy risk of thyroid nodules. However, non-diagnostic results may delay diagnosis, cause unnecessary interventions, and distress patients. Aim: We aimed to determine whether a correlation exists between patients' situational anxiety, pain perception and non-diagnostic cytology results. Methods: The prospective study included patients who underwent thyroid FNAB at the Endocrinology Clinic of Sultan Abdulhamid Training and Research Hospital between 11/2022 and 02/2023. The State-Trait Anxiety Inventory (STAI) questionnaire and visual analogue scale (VAS) assessed situational anxiety and pain in patients undergoing biopsy procedures. We evaluated whether the STAI-S and VAS score is related to non-diagnostic results. Results: Of the 119 patients included in the study, 98 were female, and 21 were male. 25 (21%) nodules were non-diagnostic. The patients' mean STAI-S score before the biopsy was 47.31±12.37, and the mean VAS score after the thyroid biopsy was 2.57±1.51. A statistically significant relation was found between the patient's STAI-S score and VAS score and the cytology result of non-diagnostic (p= 0.001 and p=0.008). In univariate logistic regression, high pre-procedural anxiety (OR:3.09, 95% CI:1.07-8.94, P =0.037) and VAS score (OR:1.57, 95% CI: 1.17-2.10, P =0.002) were associated with non-diagnostic cytology. In multivariate logistic regression analysis, VAS score (OR: 1.59, 95% CI: 1.07-2.34, p=0.019) was still an independent factor related to specimen adequacy. Conclusions: Anxiety level and pain perception during FNAB may be considered risk factors for non-diagnostic cytology. Thus, reducing anxiety and pain may decrease the incidence of non-diagnostic outcomes.

Clinical and Computed Tomography Characteristics of Inflammatory Solid Pulmonary Nodules with Morphology Suggesting Malignancy.

RATIONALE AND OBJECTIVES: To investigate the clinical and computed tomography characteristics of inflammatory solid pulmonary nodules (SPNs) with morphology suggesting malignancy, hereinafter referred to as atypical inflammatory SPNs (AI-SPNs). MATERIALS AND METHODS: The CT data of 515 patients with SPNs who underwent surgical resection were retrospectively analyzed. These patients were divided into inflammatory and malignant groups and their clinical and imaging features were compared. Binary logistic regression analysis was performed to identify the independent factors for diagnosing AI-SPNs. An external validation cohort included 133 consecutive patients to test the model's predictive efficiency. RESULTS: Univariate analysis showed that age < 62 years, male sex, maximum spiculation length > 9 mm, polygonal shapes, three-planar ratio > 1.48, Lung window/mediastinal window (L/M) ratio > 1.13, pleural tag type I, satellite lesions, and halo sign were more frequent in AI-SPNs, whereas pleural tag type III, bronchial truncation, and perifocal fibrosis were more common in malignant SPNs (M-SPNs) (all P < 0.05). Binary logistic regression showed age < 62 years, male sex, polygonal shape, three-planar ratio > 1.48, L/M ratio > 1.13, pleural tag type I, satellite lesions, halo sign, and absence of bronchial truncation were independent factors for diagnosing AI-SPNs (AUC, sensitivity, specificity, and accuracy of 0.951, 83.30%, 92.30%, and 87.20%, respectively). In the external validation cohort, the AUC, sensitivity, specificity, and accuracy were 0.969, 90.47%, 90.00%, and 90.23%, respectively. CONCLUSION: AI-SPNs and M-SPNs exhibited different clinical and imaging characteristics. A good understanding of these differences may help reduce diagnostic errors in AI-SPNs and enable to choose an optimal treatment strategy.

Evaluating Umbilical Masses: Lessons Learned From Three Elderly Patients.

The umbilicus, an essential embryonic organ, connects the foetus to the placenta. Postnatally, its remnants can lead to both benign and malignant lesions. Tumour metastasis to the umbilicus, though rare, poses significant diagnostic and therapeutic challenges due to overlapping clinical and radiological features with benign conditions. In this case series, we present three cases of elderly women with similar presentations of umbilical or infraumbilical lesions, investigated using standard imaging protocols, which subsequently led to different diagnoses and management plans. Case 1 involves a 64-year-old postmenopausal woman, who presented with an enlarging umbilical mass and serous discharge. Imaging revealed a vascularized lesion in the umbilicus and a suspicious adnexal mass, which was confirmed to be a Sister Mary Joseph nodule secondary to high-grade serous carcinoma of the right ovary. Case 2 involves an 80-year-old diabetic woman, who presented with a painful umbilical mass. Imaging revealed an aggressive-looking umbilical lesion, which was confirmed to be liposarcoma. Case 3 involves an 80-year-old woman, who presented with infraumbilical abdominal swelling and fever. Imaging revealed an infected urachal cyst. Histopathology confirmed an abscess associated with Actinomycetes infection. An umbilical lesion in an adult, particularly an elderly patient, that does not respond to typical treatment should raise the suspicion of a more sinister diagnosis. Integration of clinical, radiological, and pathological data is crucial for accurate diagnosis and effective management.

A Multi-Task Model for Pulmonary Nodule Segmentation and Classification.

In the computer-aided diagnosis of lung cancer, the automatic segmentation of pulmonary nodules and the classification of benign and malignant tumors are two fundamental tasks. However, deep learning models often overlook the potential benefits of task correlations in improving their respective performances, as they are typically designed for a single task only. Therefore, we propose a multi-task network (MT-Net) that integrates shared backbone architecture and a prediction distillation structure for the simultaneous segmentation and classification of pulmonary nodules. The model comprises a coarse segmentation subnetwork (Coarse Seg-net), a cooperative classification subnetwork (Class-net), and a cooperative segmentation subnetwork (Fine Seg-net). Coarse Seg-net and Fine Seg-net share identical structure, where Coarse Seg-net provides prior location information for the subsequent Fine Seg-net and Class-net, thereby boosting pulmonary nodule segmentation and classification performance. We quantitatively and qualitatively analyzed the performance of the model by using the public dataset LIDC-IDRI. Our results show that the model achieves a Dice similarity coefficient (DI) index of 83.2% for pulmonary nodule segmentation, as well as an accuracy (ACC) of 91.9% for benign and malignant pulmonary nodule classification, which is competitive with other state-of-the-art methods. The experimental results demonstrate that the performance of pulmonary nodule segmentation and classification can be improved by a unified model that leverages the potential correlation between tasks.

Incidental Thyroid Nodules on Computed Tomography: A Systematic Review and Meta-Analysis Examining Prevalence, Follow-Up, and Risk of Malignancy.

Background: The increased utilization of computed tomography (CT) has led to a higher detection rate of thyroid incidentalomas. Currently, there are no widely agreed-upon guidelines for managing these incidentalomas. This study aims to investigate the prevalence, follow-up practices, and malignancy rates of thyroid incidentalomas detected by CT. Methods: We conducted a comprehensive search of PubMed, Embase, and Cochrane databases to identify relevant studies published before April 12, 2024 (PROSPERO #42024535501). Studies reporting on the prevalence, follow-up, and risk of malignancy (ROM) of thyroid incidentalomas detected by CT were included. Combined outcomes were analyzed using pooled proportion with a random-effects model. The risk of bias was assessed using the Cochrane risk-of-bias tool for randomized trials (RoB 2) and the Newcastle-Ottawa Scale tool. Subgroup analyses were conducted based on characteristics including size of the incidentaloma, CT area, and age of the study population. Results: Thirty-eight studies involving 195,959 patients were included in the prevalence analysis, revealing a prevalence of thyroid incidentalomas on CT of 8.3% (confidence interval [CI], 7.4-9.3). The prevalence was higher in neck CT (16.5%, CI, 11.0-22.1) compared with chest CT (6.6%, CI, 5.3-7.9). Multiple incidentalomas were found in 27.0% (CI, 12.9-41.1) of patients. Of the nodules, 46.3% (CI, 32.3-60.3) were ≥1 cm, and 28.6% (CI, 19.9-37.3) were ≥1.5 cm. Thyroid ultrasounds, biopsies, and surgeries were performed in 34.9% (CI, 26.1-43.7), 28.4% (CI, 19.9-36.9), and 8.2% (CI, 2.1-14.4) of cases, respectively. Additionally, 25 studies with 6272 patients reported a ROM of 3.9% (CI, 3.0-4.9) for thyroid incidentalomas detected on CT. A higher ROM was observed in incidentalomas ≥1 cm (11.7%, CI, 3.9-19.4) and ≥1.5 cm (24.9%, CI, 0-52.7) compared with those <1 cm (0.1%, CI, 0-0.8) and <1.5 cm (0%, CI, 0-0.2). Conclusions: Most thyroid incidentalomas identified on CT are benign. Implementing a collaborative protocol between radiologists and thyroid specialists to manage high-risk thyroid incidentalomas can ensure appropriate follow-up and optimal patient care.

Clinical Utility of an Artificial Intelligence Radiomics-based Tool for Risk Stratification of Pulmonary Nodules.

BACKGROUND: Clinical utility data on pulmonary nodule (PN) risk stratification biomarkers are lacking. We aimed to determine the incremental predictive value and clinical utility of using an artificial intelligence (AI) radiomics-based computer-aided diagnosis (CAD) tool in addition to routine clinical information to risk stratify PNs among real-world patients. METHODS: We performed a retrospective cohort study of patients with PNs who underwent lung biopsy. We collected clinical data and used a commercially available AI radiomics-based CAD tool to calculate a Lung Cancer Prediction (LCP) score. We developed logistic regression models to evaluate a well-validated clinical risk prediction model (the Mayo Clinic model) with and without the LCP score (Mayo vs Mayo + LCP) using area under the curve (AUC), risk stratification table, and standardized net benefit analyses. RESULTS: Among the 134 patients undergoing PN biopsy, cancer prevalence was 61%. Addition of the radiomics-based LCP score to the Mayo model was associated with increased predictive accuracy (likelihood ratio test, P = .012). The AUCs for the Mayo and Mayo + LCP models were 0.58 (95% CI, 0.48-0.69) and 0.65 (95% CI, 0.56-0.75), respectively. At the 65% risk threshold, the Mayo + LCP model was associated with increased sensitivity (56% vs 38%; P = .019), similar false positive rate (33% vs 35%; P = .8), and increased standardized net benefit (18% vs -3.3%) compared to the Mayo model. CONCLUSIONS: Use of a commercially available AI radiomics-based CAD tool as a supplement to clinical information improved PN cancer risk prediction and may result in clinically meaningful changes in risk stratification.

Risk Stratification of Thyroid Nodules Diagnosed as Bethesda Category III by Ultrasound, Size, and Cytology.

OBJECTIVE: This study aimed to evaluate the performance of an integrated risk stratification system (RSS) based on ultrasound (US) RSSs, nodule size, and cytology subcategory for diagnosing malignancy in thyroid nodules initially identified as Bethesda category III on fine-needle aspiration. MATERIALS AND METHODS: This retrospective study was conducted at two institutions and included consecutive patients with Bethesda category III nodules, and final diagnoses confirmed by repeat biopsy or surgery. A total of 320 Bethesda category III nodules (≥1 cm) from 309 patients (223 female and 86 male; mean age, 50.9 ± 12.0 years) were included. The malignancy risk of Bethesda category III nodules and predictors of malignancy were assessed according to US RSSs, nodule size, and cytology subcategory. The diagnostic performances of US-size cytology (USC) RSS and US RSS alone for malignancy were compared. RESULTS: The intermediate or high suspicion US category independently increased the malignancy risk in all US RSSs (P ≤ 0.001). Large nodule size (≥3 cm) independently increased the malignancy risk of low- or intermediate suspicion US category nodules. Additionally, the atypia of undetermined significance cytology subcategory independently increased the malignancy risk of low suspicion US category nodules in most US RSSs. The area under the receiver operating characteristic curve of the USC RSSs was greater than that of the US RSSs alone (P < 0.048). Malignancy was not found in the very low risk category of USC RSS. CONCLUSION: The diagnostic performance of USC RSS for malignancy was superior to that of US RSS alone in Bethesda category III nodules. Malignancy can be ruled out in the very low-risk category of USC RSS.

Use of high throughput DNA analysis to characterize the nodule-associated bacterial community from four ages of Inga punctata trees in a Costa Rican cloud forest.

Leguminous tree root nodule nitrogen-fixing bacteria are critical for recuperation of soil C and N cycle processes after disturbance in tropical forests, while other nodule-associated bacteria (NAB) may enhance nodule development and activity, and plant growth. However, little is known of these root nodule microbiomes. Through DNA analysis, we evaluated the bacterial taxa associated with the root nodules of the 1-year-old, 2-year-old, 13-year-old, and old growth Inga punctata trees in a cloud forest. Bradyrhizobium diazoefficiens was the dominant taxon found in all nodules at 63.16% to 85.71% mean percent sequences (MPS) of the total nodule bacterial DNA and was found in the youngest nodules examined (1 year old), suggesting that it is the primary nodular bacteria. There were 26 other NAB genera with collective MPS levels between 7.4% to 12.2%, while 15 of these genera were found in the Bulk Forest soils at collective MPS levels of 4.6%. These bacterial community compositions were different between the NAB and Bulk Forest soils, suggesting the NAB became concentrated within the root nodules, resulting in communities with different compositions from the Bulk Forest soils. Twenty-three of the 26 NAB genera were previously identified with the potential to perform 9 plant growth promoting (PGP) activities, suggesting their importance in root nodule development and plant growth. These NAB communities appeared to successionally develop over time into more complex taxonomic communities, which is consistent with the outcome of advanced microbial communities following succession. The presence of both B. diazoefficiens and the NAB communities in the nodules across all ages of tree roots, and the potential for PGP activities linked with most of the NAB genera, suggest the importance of B. diazoefficiens and the NAB community for nodule development and enhanced development and growth of I. punctata throughout its lifespan, and most critically in the younger plants.

Case report: Ovarian mucinous tumor with a mural nodule of liposarcoma: a rare case.

Background: Ovarian mucinous tumor with a mural nodule is a rare and special type of ovarian surface epithelial-stromal tumor. Mural nodules are morphologically classified into three types: sarcoma-like, anaplastic carcinomatous, and true sarcomatous nodules. Ovarian mucinous tumors with true sarcomatous mural nodules are rare and challenging to diagnose, with only 10 cases reported worldwide. Currently, liposarcoma mural nodules remain unreported. Case presentation: A 91-year-old woman was hospitalized for postmenopausal vaginal bleeding for 3 weeks. Imaging revealed a large cystic mass (20.0 cm × 17.7 cm × 12.8 cm) on the right ovary. The mass was multilocular cystic, with a mural nodule (1.4 cm × 1.2 cm × 1.0 cm) in the focal cyst wall. Based on histological morphology, immunohistochemical staining, and MDM2/CDK4 fluorescence in situ hybridization testing, the diagnosis was ovarian mucinous cystadenoma with a mural nodule of well-differentiated liposarcoma. To the best of our knowledge, this has never been reported before. High-throughput sequencing identified KRAS mutations in the ovarian mucinous cystadenoma. However, the liposarcoma mural nodule did not exhibit KRAS mutations but displayed copy number amplifications of CDK4 and DDR2, as well as a frameshift mutation in exon 13 of ASXL1 (p. A627Gfs*8). Conclusions: This case broadens the morphological spectrum of mural nodules in ovarian mucinous tumors, deepening our knowledge of this rare morphology. Meanwhile, through high-throughput sequencing, we found no overlapping genetic evidence between the liposarcoma mural nodule and associated ovarian mucinous cystadenoma.

Safety, efficacy, and optical coherence tomography insights into intravascular lithotripsy for the modification of non-eruptive calcified nodules: A prospective observational study.

BACKGROUND: Non-eruptive calcium nodules (CNs) are commonly seen in heavily calcified coronary artery disease. They are the most difficult subset for modification, and may result in stent damage, malapposition and under-expansion. There are only limited options available for non-eruptive CN modification. Intravascular lithotripsy (IVL) is being explored as a potentially safe and effective modality in these lesions. AIMS: This study aimed to investigate the safety and efficacy of the use of IVL for the modification of non-eruptive CNs. The study also explored the OCT features of calcium nodule modification by IVL. METHODS: This is a single-center, prospective, observational study in which patients with angiographic heavy calcification and non-eruptive CN on OCT and undergoing PCI were enrolled. The primary safety endpoint was freedom from perforation, no-reflow/slow flow, flow-limiting dissection after IVL therapy, and major adverse cardiac events (MACE) during hospitalization and at 30 days. MACE was defined as a composite of cardiac death, myocardial infarction (MI), and ischemia-driven target lesion revascularization (TLR). The primary efficacy endpoint was procedural success, defined as residual diameter stenosis of <30% on angiography and stent expansion of more than 80% as assessed by OCT. RESULTS: A total of 21 patients with 54 non-eruptive CNs undergoing PCI were prospectively enrolled in the study. Before IVL, OCT revealed a mean calcium score of 3.7 ± 0.5 and a mean MLA at CN of 3.9 ± 2.1 mm2. Following IVL, OCT revealed calcium fractures in 40 out of 54 (74.1%) CNs with an average of 1.05 ± 0.72 fractures per CN. Fractures were predominantly observed at the base of the CN (80%). Post IVL, the mean MLA at CN increased to 4.9 ± 2.3 mm2. After PCI, the mean MSA at the CN was 7.9 ± 2.5 mm2. Optimal stent expansion (stent expansion >80%) at the CN was achieved in 85.71% of patients. All patients remained free from MACE during hospitalization and at the 30-day follow-up. At 1-year follow-up, all-cause death had occurred in 3 (14.3%) patients. CONCLUSIONS: This single-arm study demonstrated the safety, efficacy, and utility of the IVL in a subset of patients with non-eruptive calcified nodules. In this study, minimal procedural complications, excellent lesion modifications, and favorable 30-day and 1-year outcomes were observed.