Improving access to cancer clinical research in Brazil: recent advances and new opportunities. Expert opinions from the 4th CURA meeting, São Paulo, 2023.

Clinical research is the cornerstone of improvements in cancer care. However, it has been conducted predominantly in high-income countries with few clinical trials available in Brazil and other low-and-middle-income countries (LMIC). Of note, less than one-third of registered clinical trials addressing some of the most commonly diagnosed cancers (breast, lung and cervical) recruited patients from LMIC in the last years. The Institute Project CURA promoted the fourth CURA meeting, discussing barriers to cancer clinical research and proposing potential solutions. A meeting was held in São Paulo, Brazil, in June 2023 with representatives from different sectors: Brazilian Health Regulatory Agency (Anvisa), National Commission of Ethics in Research (CONEP), non-governmental organisations, such as the Latin American Cooperative Oncology Group, the Brazilian Society of Clinical Oncology (SBOC), Contract Research Organisations, pharmaceutical companies and investigators. A total of 16 experts pointed out achievements as shortening the time of regulatory processes involving Anvisa and CONEP, development of staff training programs, maintenance of the National Program of Oncological Attention (PRONON), and the foundation of qualified centres in North and Northeast Brazilian regions. Participants also highlighted the need to be more competitive in the field, which requires optimising ongoing policies and implementing new strategies as decentralisation of clinical research centres, public awareness campaigns, community-centered approaches, collaborations and partnerships, expansion of physicians-directed policies, exploring the role of the steering committee. Active and consistent reporting of the initiatives might help to propagate ongoing advances, increasing Brazilian participation in clinical cancer research. Engagement of all players is crucial to maintain continuous progress with further improvements in critical points including regulatory timelines and increments in qualified human resources which aligned with new educational initiatives focused on physicians and the general population will expand access to cancer clinical trials in Brazil.

Interoperable workflows by exchanging grid-based data between quantum-chemical program packages.

Quantum-chemical subsystem and embedding methods require complex workflows that may involve multiple quantum-chemical program packages. Moreover, such workflows require the exchange of voluminous data that go beyond simple quantities, such as molecular structures and energies. Here, we describe our approach for addressing this interoperability challenge by exchanging electron densities and embedding potentials as grid-based data. We describe the approach that we have implemented to this end in a dedicated code, PyEmbed, currently part of a Python scripting framework. We discuss how it has facilitated the development of quantum-chemical subsystem and embedding methods and highlight several applications that have been enabled by PyEmbed, including wave-function theory (WFT) in density-functional theory (DFT) embedding schemes mixing non-relativistic and relativistic electronic structure methods, real-time time-dependent DFT-in-DFT approaches, the density-based many-body expansion, and workflows including real-space data analysis and visualization. Our approach demonstrates, in particular, the merits of exchanging (complex) grid-based data and, in general, the potential of modular software development in quantum chemistry, which hinges upon libraries that facilitate interoperability.

Recurrent acquired ocular toxoplasmosis associated with Kyrieleis plaques and documented allergy to sulfonamide-A treatment proposal for two rare conditions.

The aim of this study was to describe a case of a patient with ocular toxoplasmosis, which has resulted in Kyrieleis plaques formation (segmental periarteritis associated with severe inflammation) and later follow-up and alternative treatment due to documented allergy to sulfonamide. A 33-year-old Brazilian woman diagnosed with acute toxoplasmosis, initially treated with sulfonamide, developed a critical cutaneous rash. Cotrimoxazole was changed to clindamycin and pyrimethamine, and prednisone was started. The medication was maintained for 45 days. Four months later, she developed retinal lesions suggestive of toxoplasmosis with Kyrieleis plaques in the upper temporal vessels. Pyrimethamine, clindamycin, and prednisone were initiated until healing. She presented reactivation months later, and a suppressive treatment with pyrimethamine was instituted for one year. This is the first report to use the combination of clindamycin with pyrimethamine in the treatment and recurrence prophylaxis for OT in a documented allergy to sulfonamide.

A Measure of Synergy Based on Union Information.

The partial information decomposition (PID) framework is concerned with decomposing the information that a set of (two or more) random variables (the sources) has about another variable (the target) into three types of information: unique, redundant, and synergistic. Classical information theory alone does not provide a unique way to decompose information in this manner and additional assumptions have to be made. One often overlooked way to achieve this decomposition is using a so-called measure of union information-which quantifies the information that is present in at least one of the sources-from which a synergy measure stems. In this paper, we introduce a new measure of union information based on adopting a communication channel perspective, compare it with existing measures, and study some of its properties. We also include a comprehensive critical review of characterizations of union information and synergy measures that have been proposed in the literature.

Generating Airy beams through multimode fibres.

Focussing light through a multimode fibre (MMF) is the basis of holographic endoscopes, which currently enable detailed imaging of deep tissue. Achieving high fidelity and purity diffraction-limited foci has been shown to be possible, when fully controlling the amplitude, phase, and two orthogonal polarisation states of the input field. Yet, generating more complex field distributions with similar performance remains to be assessed. Here, we demonstrate the generation of Airy beams through an MMF containing in excess of 90 % of the optical power delivered by the fibre. We discuss two distinct methods for generating optical landscapes: the direct field and the Fourier domain synthesis. Moreover, we showcase the flexibility of the Fourier domain synthesis to modify the generated beam.

Advancing the path to in-vivo imaging in freely moving mice via multimode-multicore fiber based holographic endoscopy.

Significance: Hair-thin multimode optical fiber-based holographic endoscopes have gained considerable interest in modern neuroscience for their ability to achieve cellular and even subcellular resolution during in-vivo deep brain imaging. However, the application of multimode fibers in freely moving animals presents a persistent challenge as it is difficult to maintain optimal imaging performance while the fiber undergoes deformations. Aim: We propose a fiber solution for challenging in-vivo applications with the capability of deep brain high spatial resolution imaging and neuronal activity monitoring in anesthetized as well as awake behaving mice. Approach: We used our previously developed M3CF multimode-multicore fiber to record fluorescently labeled neurons in anesthetized mice. Our M3CF exhibits a cascaded refractive index structure, enabling two distinct regimes of light transport that imitate either a multimode or a multicore fiber. The M3CF has been specifically designed for use in the initial phase of an in-vivo experiment, allowing for the navigation of the endoscope's distal end toward the targeted brain structure. The multicore regime enables the transfer of light to and from each individual neuron within the field of view. For chronic experiments in awake behaving mice, it is crucial to allow for disconnecting the fiber and the animal between experiments. Therefore, we provide here an effective solution and establish a protocol for reconnection of two segments of M3CF with hexagonally arranged corelets. Results: We successfully utilized the M3CF to image neurons in anaesthetized transgenic mice expressing enhanced green fluorescent protein. Additionally, we compared imaging results obtained with the M3CF with larger numerical aperture (NA) fibers in fixed whole-brain tissue. Conclusions: This study focuses on addressing challenges and providing insights into the use of multimode-multicore fibers as imaging solutions for in-vivo applications. We suggest that the upcoming version of the M3CF increases the overall NA between the two cladding layers to allow for access to high resolution spatial imaging. As the NA increases in the multimode regime, the fiber diameter and ring structure must be reduced to minimize the computational burden and invasiveness.

Real-World Effectiveness and Safety of Glecaprevir/Pibrentasvir for the Treatment of Chronic Hepatitis C: A Prospective Cohort Study in Portugal.

INTRODUCTION: Information about pan-genotypic treatments for hepatitis in Portugal is scarce. We aimed to evaluate the effectiveness and safety of glecaprevir plus pibrentasvir (GLE/PIB) treatment for hepatitis C virus (HCV) infection in real-world clinical practice. METHODS: An observational prospective study was implemented in six hospitals with 121 adult HCV patients who initiated treatment with GLE/PIB between October 2018 and April 2019, according to clinical practice. Eligible patients had confirmed HCV infection genotype (GT) 1 to 6 and were either treatment-naïve or had experience with interferon-, ribavirin- or sofosbuvir-based regimens, with or without compensated cirrhosis. Baseline sociodemographic and safety data are described for the total population (N = 115). Effectiveness [sustained virologic response 12 weeks after treatment (SVR12)] and patient-reported outcomes are presented for the core population with sufficient follow-up data (n = 97). RESULTS: Most patients were male (83.5%), aged < 65 years (94.8%), with current or former alcohol consumption (77.3%), illicit drug use (72.6%), and HCV acquisition through intravenous drug use (62.0%). HIV co-infection occurred in 22.6% of patients. The prevalence of each GT was: GT1 51.3%, GT2 1.7%, GT3 30.4%, GT4 16.5%, and GT5.6 0%. Most patients were non-cirrhotic (80.9%) and treatment-naïve (93.8%). The SVR12 rates were 97.9% (95% CI: 92.8 - 99.4), and > 95% across cirrhosis status, GT, illicit drug use, alcohol consumption, and HCV treatment experience. The adverse event rate was 2.6%, and no patient discontinued treatment due to adverse events related to GLE/PIB. CONCLUSION: Consistent with other real-world studies and clinical trials, treatment with GLE/PIB showed high effectiveness and tolerability overall and in difficult-to-treat subgroups (ClinicalTrials.gov: NCT03303599).

Formulation and Implementation of Frequency-Dependent Linear Response Properties with Relativistic Coupled Cluster Theory for GPU-Accelerated Computer Architectures.

We present the development and implementation of relativistic coupled cluster linear response theory (CC-LR), which allows the determination of molecular properties arising from time-dependent or time-independent electric, magnetic, or mixed electric-magnetic perturbations (within a common gauge origin for the magnetic properties) as well as taking into account the finite lifetime of excited states in the framework of damped response theory. We showcase our implementation, which is capable to offload the computationally intensive tensor contractions characteristic of coupled cluster theory onto graphical processing units, in the calculation of (a) frequency-(in)dependent dipole-dipole polarizabilities of IIB atoms and selected diatomic molecules, with a particular emphasis on the calculation of valence absorption cross sections for the I2 molecule; (b) indirect spin-spin coupling constants for benchmark systems such as the hydrogen halides (HX, X = F-I) as well the H2Se-H2O dimer as a prototypical system containing hydrogen bonds; and (c) optical rotations at the sodium D line for hydrogen peroxide analogues (H2Y2, Y = O, S, Se, Te). Thanks to this implementation, we are able to show the similarities in performance, but often the significant discrepancies, between CC-LR and approximate methods such as density functional theory. Comparing standard CC response theory with the flavor based upon the equation of motion formalism, we find that for valence properties such as polarizabilities, the two frameworks yield very similar results across the periodic table as found elsewhere in the literature; for properties that probe the core region, such as spin-spin couplings, on the other hand, we show a progressive differentiation between the two as relativistic effects become more important. Our results also suggest that as one goes down the periodic table, it may become increasingly difficult to measure pure optical rotation at the sodium D line due to the appearance of absorbing states.

"There's plenty of room at the bottom": deep brain imaging with holographic endo-microscopy.

Significance: Over more than 300 years, microscopic imaging keeps providing fundamental insights into the mechanisms of living organisms. Seeing microscopic structures beyond the reach of free-space light-based microscopy, however, requires dissection of the tissue-an intervention seriously disturbing its physiological functions. The hunt for low-invasiveness tools has led a growing community of physicists and engineers into the realm of complex media photonics. One of its activities represents exploiting multimode optical fibers (MMFs) as ultra-thin endoscopic probes. Employing wavefront shaping, these tools only recently facilitated the first peeks at cells and their sub-cellular compartments at the bottom of the mouse brain with the impact of micro-scale tissue damage. Aim: Here, we aim to highlight advances in MMF-based holographic endo-microscopy facilitating microscopic imaging throughout the whole depth of the mouse brain. Approach: We summarize the important technical and methodological prerequisites for stabile high-resolution imaging in vivo. Results: We showcase images of the microscopic building blocks of brain tissue, including neurons, neuronal processes, vessels, intracellular calcium signaling, and red blood cell velocity in individual vessels. Conclusions: This perspective article helps to understand the complexity behind the technology of holographic endo-microscopy, summarizes its recent advances and challenges, and stimulates the mind of the reader for further exploitation of this tool in the neuroscience research.

Frequency-Dependent Quadratic Response Properties and Two-Photon Absorption from Relativistic Equation-of-Motion Coupled Cluster Theory.

We present the implementation of quadratic response theory based upon the relativistic equation-of-motion coupled cluster method. We showcase our implementation, whose generality allows us to consider both time-dependent and time-independent electric and magnetic perturbations, by considering the static and frequency-dependent hyperpolarizability of hydrogen halides (HX, X = F-At), providing comprehensive insights into their electronic response characteristics. Additionally, we evaluated the Verdet constant for noble gases Xe and Rn and discussed the relative importance of relativistic and electron correlation effects for these magneto-optical properties. Finally, we calculate the two-photon absorption cross sections of transition [ns1S0 → (n + 1)s1S0] of Ga+ and In+, which are suggested as candidates for new ion clocks. As our implementation allows for the use of nonrelativistic Hamiltonians as well, we have compared our EOM-QRCC results to the QR-CC implementation in the DALTON code and show that the differences between CC and EOMCC response are in general smaller than 5% for the properties considered. Collectively, the results underscore the versatility of our implementation and its potential as a benchmark tool for other approximated models, such as density functional theory for higher-order properties.

Are we ready to stratify BI-RADS 4 lesions observed on magnetic resonance imaging? A real-world noninferiority/equivalence analysis / Estamos prontos para estratificar lesões BI-RADS 4 na ressonância magnética? Uma análise de não inferioridade/equivalência do mundo real

Abstract Objective: To demonstrate that positive predictive values (PPVs) for suspicious (category 4) magnetic resonance imaging (MRI) findings that have been stratified are equivalent to those stipulated in the American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) for mammography and ultrasound. Materials and Methods: This retrospective analysis of electronic medical records generated between January 4, 2016 and December 29, 2021 provided 365 patients in which 419 suspicious (BI-RADS category 4) findings were subcategorized as BI-RADS 4A, 4B or 4C. Malignant and nonmalignant outcomes were determined by pathologic analyses, follow-up, or both. For each subcategory, the level 2 PPV (PPV2) was calculated and tested for equivalence/noninferiority against the established benchmarks. Results: Of the 419 findings evaluated, 168 (40.1%) were categorized as malignant and 251 (59.9%) were categorized as nonmalignant. The PPV2 for subcategory 4A was 14.2% (95% CI: 9.3-20.4%), whereas it was 41.2% (95% CI: 32.8-49.9%) for subcategory 4B and 77.2% (95% CI: 68.4-84.5%) for subcategory 4C. Multivariate analysis showed a significantly different cancer yield for each subcategory (p < 0.001). Conclusion: We found that stratification of suspicious findings by MRI criteria is feasible, and malignancy probabilities for sub-categories 4B and 4C are equivalent to the values established for the other imaging methods in the BI-RADS. Nevertheless, low suspicion (4A) findings might show slightly higher malignancy rates.

Resumo Objetivo: Demonstrar que os valores preditivos positivos (VPPs) para lesões suspeitas (categoria 4) identificadas por ressonância magnética (RM) são equivalentes aos estipulados no ACR BI-RADS para mamografia e ultrassonografia. Materiais e Métodos: Análise retrospectiva de dados em prontuário eletrônico, entre 4 de janeiro de 2016 e 29 de dezembro de 2021, resultou em 365 pacientes elegíveis, com 419 lesões classificadas como BI-RADS 4A, 4B ou 4C. Desfechos malignos e não malignos foram determinados por estudo patológico e/ou acompanhamento. Realizamos o cálculo do VPP nível 2 (VPP2) para cada subcategoria e testamos para não inferioridade/equivalência em relação aos valores de referência. Resultados: Dos 419 achados, 168 (40,1%) foram malignos e 251 (59,9%), não malignos. O VPP2 para subcategoria 4A foi 14,2% (IC 95%: 9,3-20,4%), para 4B foi 41,2% (IC 95%:, 32,8-49,9%) e para 4C foi 77,2% (IC 95%: 68,4-84,5%). Análise multivariada demonstrou diferenças estatisticamente significantes entre as subcategorias (p < 0,001). Conclusão: A estratificação de achados suspeitos por RM é factível, sendo que a probabilidade de malignidade das subcategorias 4B e 4C é equivalente à estabelecida para outros métodos de imagem pelo BI-RADS. Contudo, lesões de baixa suspeição (4A) podem apresentar taxas mais altas de malignidade.

Recent advances on molecular dynamics-based techniques to address drug membrane permeability with atomistic detail.

Several factors affect the passive membrane permeation of small molecules, including size, charge, pH, or the presence of specific chemical groups. Understanding these features is paramount to identifying or designing drug candidates with optimal ADMET properties and this can be achieved through experimental/knowledge-based methodologies or using computational approaches. Empirical methods often lack detailed information about the underlying molecular mechanism. In contrast, Molecular Dynamics-based approaches are a powerful strategy, providing an atomistic description of this process. This technique is continuously growing, featuring new related methodologies. In this work, the recent advances in this research area will be discussed.

Orders between Channels and Implications for Partial Information Decomposition.

The partial information decomposition (PID) framework is concerned with decomposing the information that a set of random variables has with respect to a target variable into three types of components: redundant, synergistic, and unique. Classical information theory alone does not provide a unique way to decompose information in this manner, and additional assumptions have to be made. Recently, Kolchinsky proposed a new general axiomatic approach to obtain measures of redundant information based on choosing an order relation between information sources (equivalently, order between communication channels). In this paper, we exploit this approach to introduce three new measures of redundant information (and the resulting decompositions) based on well-known preorders between channels, contributing to the enrichment of the PID landscape. We relate the new decompositions to existing ones, study several of their properties, and provide examples illustrating their novelty. As a side result, we prove that any preorder that satisfies Kolchinsky's axioms yields a decomposition that meets the axioms originally introduced by Williams and Beer when they first proposed PID.

Core Excitations of Uranyl in Cs2UO2Cl4 from Relativistic Embedded Damped Response Time-Dependent Density Functional Theory Calculations.

X-ray spectroscopies, by their high selectivity and sensitivity to the chemical environment around the atoms probed, provide significant insights into the electronic structures of molecules and materials. Interpreting experimental results requires reliable theoretical models, accounting for environmental, relativistic, electron correlation, and orbital relaxation effects in a balanced manner. In this work, we present a protocol for the simulation of core excited spectra with damped response time-dependent density functional theory based on the Dirac-Coulomb Hamiltonian (4c-DR-TD-DFT), in which environmental effects are accounted for through the frozen density embedding (FDE) method. We showcase this approach for the uranium M4- and L3-edges and oxygen K-edge of the uranyl tetrachloride (UO2Cl42-) unit as found in a host Cs2UO2Cl4 crystal. We have found that the 4c-DR-TD-DFT simulations yield excitation spectra that very closely match the experiment for the uranium M4-edge and the oxygen K-edge, with good agreement for the broad experimental spectra for the L3-edge. By decomposing the complex polarizability in terms of its components, we have been able to correlate our results with angle-resolved spectra. We have observed that for all edges, but in particular the uranium M4-edge, an embedded model in which the chloride ligands are replaced by an embedding potential reproduces rather well the spectral profile obtained for UO2Cl42-. Our results underscore the importance of the equatorial ligands to simulating core spectra at both uranium and oxygen edges.

How Does Bending the Uranyl Unit Influence Its Spectroscopy and Luminescence?

Bent uranyl complexes can be formed with chloride ligands and 1,10-phenanthroline (phen) ligands bound to the equatorial and axial planes of the uranyl(VI) moiety, as revealed by the crystal structures, IR and Raman spectroscopy, and quantum-chemical calculations. With the goal of probing the influence of chloride and phenanthroline coordination enforcing the bending on the absorption and emission spectra of this complex, spin-orbit time-dependent density functional theory calculations for the bare uranyl complexes as well as for the free UO2Cl2 subunit and the UO2Cl2(phen)2 complex were performed. The emission spectra have been fully simulated by ab initio methods and compared to experimental photoluminescence spectra, recorded for the first time for UO2Cl2(phen)2. Notably, the bending of uranyl in UO2Cl2 and UO2Cl2(phen)2 triggers excitations of the uranyl bending mode, yielding a denser luminescence spectrum.

110 µm thin endo-microscope for deep-brain in vivo observations of neuronal connectivity, activity and blood flow dynamics.

Light-based in-vivo brain imaging relies on light transport over large distances of highly scattering tissues. Scattering gradually reduces imaging contrast and resolution, making it difficult to reach structures at greater depths even with the use of multiphoton techniques. To reach deeper, minimally invasive endo-microscopy techniques have been established. These most commonly exploit graded-index rod lenses and enable a variety of modalities in head-fixed and freely moving animals. A recently proposed alternative is the use of holographic control of light transport through multimode optical fibres promising much less traumatic application and superior imaging performance. We present a 110 µm thin laser-scanning endo-microscope based on this prospect, enabling in-vivo volumetric imaging throughout the whole depth of the mouse brain. The instrument is equipped with multi-wavelength detection and three-dimensional random access options, and it performs at lateral resolution below 1 µm. We showcase various modes of its application through the observations of fluorescently labelled neurones, their processes and blood vessels. Finally, we demonstrate how to exploit the instrument to monitor calcium signalling of neurones and to measure blood flow velocity in individual vessels at high speeds.

Vitreoretinal Surgery in Uveitis: From Old to New Concepts - A Review.

PURPOSE: The aim of this article is to do a comprehensive literature review about the current role of pars plana vitrectomy in uveitis and in its different structural complications such as cystoid macular edema, epiretinal membrane, macular hole, and retinal detachment. METHODS: This comprehensive literature review was performed based on a search on PubMed, BioMed Central, Science Open, and CORE databases, of relevant articles abording pars plana vitrectomy in uveitis. DISCUSSION: Uveitis is a complex disease with multiple etiologies and pathogenic mechanisms. Therapeutic pars plana vitrectomy (PPV) may aid in uveitic structural complications such as cystoid macular edema, epiretinal membranes, macular hole, and retinal detachments even though some cases may present unpredictable visual outcomes. Diagnostic PPV with appropriate ancillary testing is also a valuable tool for the assessment and diagnosis of uveitis in a large proportion of patients. CONCLUSION: Over the years, pars plana vitrectomy has undergone significant transformations since its invention nearly 5 decades ago, however, the quality of evidence in the literature regarding its use for uveitis has not improved in the same way. Even though some structural uveitis complications (as previously mentioned) may respond well to surgery, there is still a certain unpredictability regarding its visual outcomes. On the other hand, diagnostic vitrectomy with appropriate ancillary testing is also a valuable tool for the assessment and diagnosis of uveitis in a large proportion of patients.

Endophytic species of Induratia from coffee and carqueja plants from Brazil and its potential for the biological control of toxicogenic fungi on coffee beans by means of antimicrobial volatiles.

Several endophytic fungi have been reported to have produced bioactive metabolites. Some of them, including the Induratia species, have the capacity to emit volatile compounds with antimicrobial properties with broad spectrum against human and plant pathogens. The present study aimed to prospect the Induratia species producing volatile organic compounds (VOCs), in carqueja plants used in alternative medicine and coffee plants in Brazil. A total of 11 fungal isolates producing volatile metabolites were obtained by a parallel growth technique, using I. alba 620 as a reference strain. Phylogenetic relationships revealed the presence of at least three distinct species, I. coffeana, I. yucatanensis, and Induratia sp. SPME/GC/MS analyses of the VOCs in the headspace above the mycelium from Induratia species cultured for 10 days on PDA revealed the volatile profile emitted by I. coffeana CCF 572, I. coffeana COAD 2055, I. yucatanensis COAD 2062, and Induratia sp. COAD 2059. Volatile organic compounds produced by I. coffeana isolates presented antimicrobial activity against Aspergillus ochraceus, A. sclerotiorum, A. elegans, A. foetidus, A. flavus, A. tamari, A. tubingensis, A. sydowii, A. niger, A. caespitosus, A. versicolor, and A. expansum, sometimes by decreasing the growth rate or, mainly, by fully inhibiting colony growth. Fifty-eight percent of the target species died after 6 days of exposure to VOCs emitted by I. coffeana CCF 572. In addition, VOCs emitted by the same fungus inhibited the growth in A. ochraceus inoculated into coffee beans, which indicates that plants which have I. coffeana as an endophyte may be protected from attacks by this plant pathogen.

Phenotype of BTK-lacking myeloid cells during prolonged COVID-19 and upon convalescent plasma.

XLA patient with 7-month course of COVID-19 with persistent plasma SARS-CoV-2 load revealed a sustained non-inflammatory profile of myeloid cells in association with contained severity of disease, arguing in favor of the use of BTK inhibitors in SARS-COV-2 infection.

Are we ready to stratify BI-RADS 4 lesions observed on magnetic resonance imaging? A real-world noninferiority/equivalence analysis.

Objective: To demonstrate that positive predictive values (PPVs) for suspicious (category 4) magnetic resonance imaging (MRI) findings that have been stratified are equivalent to those stipulated in the American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) for mammography and ultrasound. Materials and Methods: This retrospective analysis of electronic medical records generated between January 4, 2016 and December 29, 2021 provided 365 patients in which 419 suspicious (BI-RADS category 4) findings were subcategorized as BI-RADS 4A, 4B or 4C. Malignant and nonmalignant outcomes were determined by pathologic analyses, follow-up, or both. For each subcategory, the level 2 PPV (PPV2) was calculated and tested for equivalence/noninferiority against the established benchmarks. Results: Of the 419 findings evaluated, 168 (40.1%) were categorized as malignant and 251 (59.9%) were categorized as nonmalignant. The PPV2 for subcategory 4A was 14.2% (95% CI: 9.3-20.4%), whereas it was 41.2% (95% CI: 32.8-49.9%) for subcategory 4B and 77.2% (95% CI: 68.4-84.5%) for subcategory 4C. Multivariate analysis showed a significantly different cancer yield for each subcategory (p < 0.001). Conclusion: We found that stratification of suspicious findings by MRI criteria is feasible, and malignancy probabilities for sub-categories 4B and 4C are equivalent to the values established for the other imaging methods in the BI-RADS. Nevertheless, low suspicion (4A) findings might show slightly higher malignancy rates.

Objetivo: Demonstrar que os valores preditivos positivos (VPPs) para lesões suspeitas (categoria 4) identificadas por ressonância magnética (RM) são equivalentes aos estipulados no ACR BI-RADS para mamografia e ultrassonografia. Materiais e Métodos: Análise retrospectiva de dados em prontuário eletrônico, entre 4 de janeiro de 2016 e 29 de dezembro de 2021, resultou em 365 pacientes elegíveis, com 419 lesões classificadas como BI-RADS 4A, 4B ou 4C. Desfechos malignos e não malignos foram determinados por estudo patológico e/ou acompanhamento. Realizamos o cálculo do VPP nível 2 (VPP2) para cada subcategoria e testamos para não inferioridade/equivalência em relação aos valores de referência. Resultados: Dos 419 achados, 168 (40,1%) foram malignos e 251 (59,9%), não malignos. O VPP2 para subcategoria 4A foi 14,2% (IC 95%: 9,3­20,4%), para 4B foi 41,2% (IC 95%:, 32,8­49,9%) e para 4C foi 77,2% (IC 95%: 68,4­84,5%). Análise multivariada demonstrou diferenças estatisticamente significantes entre as subcategorias (p < 0,001). Conclusão: A estratificação de achados suspeitos por RM é factível, sendo que a probabilidade de malignidade das subcategorias 4B e 4C é equivalente à estabelecida para outros métodos de imagem pelo BI-RADS. Contudo, lesões de baixa suspeição (4A) podem apresentar taxas mais altas de malignidade.