Comparison of Four Diagnostic Guidelines for Hepatocellular Carcinoma Using Gadoxetic Acid-enhanced Liver MRI.

Background Noninvasive diagnostic guidelines for hepatocellular carcinoma (HCC) vary across different global geographic areas, especially regarding criteria about gadoxetic acid-enhanced MRI. Purpose To compare the diagnostic performance of four different international HCC diagnosis guidelines and readers' judgment in diagnosing HCC using gadoxetic acid-enhanced MRI in patients at high risk for HCC. Materials and Methods This retrospective study included patients who had not undergone treatment, were at risk for HCC, and who underwent gadoxetic acid-enhanced MRI from January 2015 to June 2018 from 11 tertiary hospitals in South Korea. Four radiologists independently reviewed focal liver lesions (FLLs) according to four guidelines: American Association for the Study of Liver Diseases (AASLD)/Liver Imaging Reporting and Data System (LI-RADS), Korean Liver Cancer Association-National Cancer Center (KLCA-NCC), European Association for the Study of the Liver (EASL), and Asian Pacific Association for the Study of the Liver (APASL). Reader judgment (HCC or not HCC) was also recorded. Malignant FLLs were confirmed at pathology, and histologic and clinical follow-up data were used for benign FLLs. The guidelines' diagnostic performance was compared using generalized estimating equations. Additionally, the diagnostic odds ratio was assessed. Results A total of 2445 FLLs (median size, 27.4 mm) were analyzed in 2237 patients (mean age, 59 years ± 11 [SD]; 1666 male patients); 69.3% (1694 of 2445) were HCCs. KLCA-NCC showed the highest accuracy (80.0%; 95% CI: 78.7, 81.2; P = .001), with high sensitivity in Eastern guidelines (APASL, 89.1% [95% CI: 87.8, 90.3]; KLCA-NCC, 78.2% [95% CI: 76.6, 79.7]) and high specificity in Western guidelines (AASLD/LI-RADS, 89.6% [95% CI: 87.8, 91.2]; EASL, 88.1% [95% CI: 86.2, 89.9]) (P = .001). The diagnostic odds ratios were 20.7 (95% CI: 17.0, 25.3) for AASLD/LI-RADS, 18.9 (95% CI: 15.8, 22.6) for KLCA-NCC, 16.8 (95% CI: 13.8, 20.4) for EASL, and 8.9 (95% CI: 7.4, 10.7) for APASL. The readers' judgment demonstrated higher accuracy than that of the guidelines (accuracy, 86.0%; 95% CI: 84.9, 86.9; P = .001). Conclusion Among four different international HCC diagnosis guidelines, Eastern guidelines demonstrated higher sensitivity, whereas Western guidelines displayed higher specificity. KLCA-NCC achieved the highest accuracy, and AASLD/LI-RADS exhibited the highest diagnostic odds ratio. © RSNA, 2024 Supplemental material is available for this article.

Prevalence and predisposing factors of post-stroke complex regional pain syndrome: Retrospective case-control study.

INTRODUCTION: Poststroke complex regional pain syndrome (CRPS) is an important complication in stroke survivors. The identification of factors associated with post-stroke CRPS is important for preventive measures and early diagnosis. METHODS: A total of 141 first-ever stroke survivors in the subacute stage were retrospectively analyzed. Demographic data, diagnosis time, duration of hospitalization, location of brain lesion, etiology, comorbidities, and blood test findings were investigated. Clinical data included Medical Research Council (MRC) grade, Fugl-Meyer assessment (FMA), National Institute for Health Stroke Scale (NIHSS), Berg Balance Scale (BBS). RESULTS: Among 141 patients with subacute stroke, 22 were diagnosed with CRPS, with a prevalence of 15.6 %. The mean time to diagnosis was 38.6 (±16.5) days. The prevalence according to the degree of paralysis was 33.3 % in MRC grades 0 and 1, 8.6 % in grade 2, and 0 % in grade 3 or higher. The incidence rates within 1 month after stroke were 1.42 % and 22.47 % between 1 and 3 months after stroke, respectively. The independent risk factors for CRPS were hospitalization duration and FMA, NIHSS, and BBS scores. The sensitivity and specificity of the NIHSS score for predicting post-stroke CRPS were 86.4 % and 59.7 %, respectively, with an optimal cutoff value of 7.5. CONCLUSIONS: CRPS of the affected upper limb in stroke patients is associated with stroke severity, including paralysis, and the incidence increases over time during the subacute phase. Additionally, having sufficient strength to move through a full range of motion against gravity had a protective effect against CRPS.

Efficacy and safety of mucous fistula refeeding in preterm infants: an exploratory randomized controlled trial.

BACKGROUND: This study aimed to evaluate whether mucous fistula refeeding (MFR) is safe and beneficial for the growth and intestinal adaptation of preterm infants with enterostomies. METHODS: This exploratory randomized controlled trial enrolled infants born before 35 weeks' gestation with enterostomy. If the stomal output was ≥ 40 mL/kg/day, infants were assigned to the high-output MFR group and received MFR. If the stoma output was < 40 mL/kg/day, infants were randomized to the normal-output MFR group or the control group. Growth, serum citrulline levels, and bowel diameter in loopograms were compared. The safety of MFR was evaluated. RESULTS: Twenty infants were included. The growth rate increased considerably, and the colon diameter was significantly larger after MFR. However, the citrulline levels did not significantly differ between the normal-output MFR and the control group. One case of bowel perforation occurred during the manual reduction for stoma prolapse. Although the association with MFR was unclear, two cases of culture-proven sepsis during MFR were noted. CONCLUSIONS: MFR benefits the growth and intestinal adaptation of preterm infants with enterostomy and can be safely implemented with a standardized protocol. However, infectious complications need to be investigated further. TRIAL REGISTRATION: clinicaltrials.gov NCT02812095, retrospectively registered on June 6, 2016.

Multidetector CT of Extrahepatic Bile Duct Cancer: Diagnostic Performance of Tumor Resectability and Interreader Agreement.

Background In extrahepatic bile duct (EHD) cancer, accurate assessment of resectability is essential for curative surgery, but pertinent guidelines from the perspectives of radiologists are yet to be developed. Purpose To investigate the performance of multiphasic CT in the assessment of longitudinal tumor extent, vascular invasion, and resectability of EHD cancer according to the Korean Society of Abdominal Radiology consensus recommendation and to evaluate the interreader agreement. Materials and Methods This retrospective study included patients with EHD cancer who underwent multiphasic CT examinations with section thickness of 3 mm or less before surgery from January 2016 to December 2018. Four abdominal radiologists independently evaluated the overall and biliary segment-wise longitudinal tumor extent, the presence of hepatic artery and/or portal vein invasion, and the resectability according to the Korean Society of Abdominal Radiology recommendations. The diagnostic performance was assessed with sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve. Interreader agreement was determined using κ statistics. Results A total of 112 patients (mean age ± SD, 61 years ± 11; 73 men) were evaluated. The accuracy of the overall longitudinal tumor extent assessment ranged from 56.3% (63 of 112 patients) to 74.1% (83 of 112 patients). The sensitivity for detecting secondary confluence involvement (n = 62) was lower than that for the primary confluence or intrapancreatic duct (n = 115; 38.5%-75% vs 72.1%-96.3%, respectively). Vascular invasion (n = 17) had moderate sensitivity (28.6%-71.4%) and high specificity (77.5%-99.0%). For predicting negative-margin (R0) resection (n = 85), the sensitivity and specificity ranged from 71.8% to 96.5% and from 11.1% to 66.7%, respectively, and the areas under the receiver operating characteristic curve ranged from 0.69 to 0.80. Interreader agreements for tumor extent, vascular invasion, and resectability had κ values of 0.65-0.89, 0.21-0.64, and 0.35-0.56, respectively. Conclusion For the preoperative evaluation of extrahepatic bile duct cancer, the Korean Society of Abdominal Radiology consensus recommendation enabled systematic assessment of longitudinal tumor extent and vascular invasion with acceptable performance in predicting negative-margin resection with use of multiphasic CT and with fair to good interreader agreement. © RSNA, 2022 Online supplemental material is available for this article.

Two-dimensional Shear-Wave Elastography and US Attenuation Imaging for Nonalcoholic Steatohepatitis Diagnosis: A Cross-sectional, Multicenter Study.

Background Multiparametric US examination may have potential in the comprehensive evaluation of nonalcoholic fatty liver disease (NAFLD), but multicenter studies are lacking. Purpose To evaluate the diagnostic performance of multiparametric US with the attenuation coefficient (AC) from attenuation imaging (ATI) and liver stiffness (LS) and dispersion slope (DS) from two-dimensional (2D) shear-wave elastography (SWE) in a multicenter study of patients with NAFLD. Materials and Methods This prospective study enrolled consecutive participants between December 2019 and June 2021 with suspected nonalcoholic steatohepatitis (NASH) who were scheduled to undergo liver biopsy in five tertiary hospitals. Before the procedure, all participants underwent US with ATI and 2D SWE according to the study protocol. Multivariable linear regression analyses were performed to determine the significant determinant factors for AC, LS, and DS. Diagnostic performance was decided based on the areas under the receiver operating characteristic curve (AUCs). Results A total of 132 participants (median age, 38 years; IQR, 27-54 years; 69 women) were evaluated. Among the participant characteristics, including pathologic findings, demographic characteristics, body mass index, and serum markers, hepatic steatosis for AC (P < .001), lobular inflammatory activity for DS (P = .007), and both fibrosis (P = .01) and lobular inflammatory activity (P = .04) for LS were significant determinant factors. At histopathologic examination, 53 of the 132 participants (40.2%) had NASH. The risk score system obtained using unweighted sum of scores from AC and DS showed the best diagnostic performance in the detection of NASH (AUC = 0.94; 95% CI: 0.89, 0.98; P < .05 for all), as compared with serum markers or other US parameters alone (AUC ≤ 0.88). Conclusion US attenuation imaging and two-dimensional shear-wave elastography were useful for assessing hepatic steatosis, lobular inflammation, and fibrosis. The risk score system obtained using the attenuation coefficient and dispersion slope showed the best diagnostic performance fo r nonalcoholic steatohepatitis. cris.nih.go.kr no. KCT0004326 © RSNA, 2022 Online supplemental material is available for this article.

Accelerated Pancreatobiliary MRI for Pancreatic Cancer Surveillance in Patients With Pancreatic Cystic Neoplasms.

BACKGROUND: Pancreatobiliary MRI is often recommended for patients at risk of developing pancreas cancer. But the surveillance MRI protocol has not yet been widely accepted. PURPOSE: To establish an accelerated MRI protocol targeting the table time of 15 minutes for pancreatic cancer surveillance and test its performance in lesion characterization. STUDY TYPE: Prospective. POPULATION: A total of 30 participants were enrolled, who were undergoing follow-up care for intraductal papillary mucinous neoplasms or newly diagnosed pancreatic cysts (≥10 mm) and were scheduled for or had recently undergone contrast-enhanced CT (CECT). FIELD STRENGTH/SEQUENCE: A 3 T; heavily T2WI, 3D MRCP, DWI, dynamic T1WI, two-point Dixon. ASSESSMENT: In-room time and table time were measured. Seven radiologists independently reviewed image quality of MRI and then the presence of high-risk stigmata and worrisome features in addition to diagnostic confidence for accelerated MRI, CECT, and the noncontrast part of accelerated MRI (NC-MRI). STATISTICAL ANALYSIS: Fisher's exact test was used for categorical variables and either the Student's t-test or Mann-Whitney test was performed for continuous variables. The generalized estimated equation was used to compare the diagnostic performance of examinations on a per-patient basis. Interobserver agreement was evaluated via Fleiss kappa. A P value of <0.05 was considered to be statistically significant. RESULTS: The in-room time was 18.5 ± 2.6 minutes (range: 13.7-24.9) and the table time was 13.9 ± 1.9 minutes (range: 10.7-17.5). There was no significant difference between the diagnostic performances of the three examinations (pooled sensitivity: 75% for accelerated MRI and CECT, 68% for NC-MRI, P = 0.95), with the highest significant diagnostic confidence for accelerated MRI (4.2 ± 0.1). With accelerated MRI, the interobserver agreement was fair to excellent for high-risk stigmata (κ = 0.34-0.98). DATA CONCLUSION: Accelerated MRI protocol affords a table time of 15 minutes, making it potentially suitable for cancer surveillance in patients at risk of developing pancreatic cancer. EVIDENCE LEVEL: 2 TECHNICAL EFFICACY STAGE: 2.

Perfluorobutane-enhanced ultrasonography with a Kupffer phase: improved diagnostic sensitivity for hepatocellular carcinoma.

OBJECTIVES: To evaluate the diagnostic accuracy of perfluorobutane contrast-enhanced ultrasonography (CEUS) for hepatocellular carcinoma (HCC) and to explore how accuracy can be improved compared to conventional diagnostic criteria in at-risk patients. METHODS: A total of 123 hepatic nodules (≥ 1 cm) from 123 at-risk patients who underwent perfluorobutane CEUS between 2013 and 2020 at three institutions were retrospectively analyzed. Ninety-three percent of subjects had pathological results, except benign lesions stable in follow-up images. We evaluated presence of arterial phase hyperenhancement (APHE), washout time and degree, and Kupffer phase (KP) defects. KP defects are defined as hypoenhancing lesions relative to the liver in KP. HCC was diagnosed in two ways: (1) Liver Imaging Reporting and Data System (LI-RADS) criteria defined as APHE and late (≥ 60 s)/mild washout, and (2) APHE and Kupffer (AK) criteria defined as APHE and KP defect. We explored grayscale features that cause misdiagnosis of HCC and reflected in the adjustment. Diagnostic performance was compared using McNemar's test. RESULTS: There were 77 HCCs, 15 non-HCC malignancies, and 31 benign lesions. An ill-defined margin without hypoechoic halo on grayscale applied as a finding that did not suggest HCC. Regarding diagnosis of HCC, sensitivity of AK criteria (83.1%; 95% confidence interval [CI]: 72.9-90.7%) was higher than that of LI-RADS criteria (75.3%; 95% CI: 64.2-84.4%; p = 0.041). Specificity was 91.3% (95% CI: 79.2-97.6%) in both groups. CONCLUSION: On perfluorobutane CEUS, diagnostic criteria for HCC using KP defect with adjustment by grayscale findings had higher diagnostic performance than conventional criteria without losing specificity. KEY POINTS: • Applying Kupffer phase defect instead of late/mild washout and adjusting with grayscale findings can improve the diagnostic performance of perfluorobutane-enhanced US for HCC. • Adjustment with ill-defined margins without a hypoechoic halo for features unlikely to be HCC decreases false positives for HCC diagnosis using the perfluorobutane-enhanced US. • After adjustment with grayscale findings, the sensitivity and accuracy of the APHE and Kupffer criteria were higher than those of the LI-RADS criteria; specificity was 91.3% for both.

How to approach pancreatic cancer after neoadjuvant treatment: assessment of resectability using multidetector CT and tumor markers.

OBJECTIVES: To investigate clinical and CT factors associated with local resectability in patients with nonmetastatic pancreatic cancers after neoadjuvant chemotherapy ± radiation therapy (CRT). METHODS: This retrospective study included consecutive patients with nonmetastatic pancreatic cancers who underwent neoadjuvant CRT between June 2009 and June 2019. Tumor size, tumor-vascular contact with artery/vein, and local resectability categories (resectable, borderline resectable, or locally advanced) were assessed at baseline and post-CRT CT. Baseline and post-CRT carbohydrate antigen (CA) 19-9 levels were also assessed. Clinical or imaging features related to R0 resection were determined using logistic regression analysis. RESULTS: A total of 179 patients (mean age, 62.4 ± 9.3 years; 92 men) were included. After neoadjuvant CRT, 105 (58.7%) patients received R0 resection, while 74 (41.3%) did not. R0 resection rates were significantly different according to post-CRT CT resectability categories (p < 0.001): 82.8% (48/58), 70.1% (47/67), and 18.5% (10/54) for resectable, borderline resectable, and locally advanced disease, respectively. For post-CRT borderline resectable disease, ≥ 50% decrease in CA 19-9 was significantly associated with R0 resection (odds ratio (OR), 3.160; p = 0.02). For post-CRT locally advanced disease, small post-CRT tumor size ≤ 2 cm (OR, 9.668; p = 0.026) and decreased tumor-arterial contact (OR, 24.213; p = 0.022) were significantly associated with R0 resection. CONCLUSION: Post-CRT CT resectability categorization may be useful for the assessment of R0 resectability in patients with pancreatic cancer following neoadjuvant CRT. Additionally, ≥ 50% decrease in CA 19-9 was associated with R0 resection in post-CRT borderline resectable disease, while small post-CRT tumor size and decreased tumor-arterial contact were with locally advanced disease. KEY POINTS: • R0 resection rates following neoadjuvant chemotherapy ± radiation therapy (CRT) were 82.8%, 70.1%, and 18.5% in resectable, borderline resectable, and locally advanced disease, respectively, at post-CRT CT (p < 0.001). • For post-CRT borderline resectable disease, ≥ 50% decrease in carbohydrate antigen (CA) 19-9 was significantly associated with R0 resection. • For post-CRT locally advanced disease, small post-CRT tumor size ≤ 2 cm and decreased tumor-arterial contact were significantly associated with R0 resection.

The transcriptomic landscape of caudal cell mass in different developmental stages of the chick embryo.

INTRODUCTION: The caudal cell mass (CCM) is an aggregate of undifferentiated pluripotent cells and the main player in secondary neurulation. Previous studies have elucidated the dynamic fate of the multipotent cell lineages, with a recent interest in the neuromesodermal progenitors. However, a transcriptomic analysis of the CCM during secondary neurulation has not been performed yet. METHODS: We analyzed RNA sequencing data of CCM samples at three different developmental stages of chicken embryos; HH16 (largest CCM phase), HH20 (secondary neural tube formation phase), and HH28 (degeneration phase). RESULTS: The transcriptomic profiles were clearly distinguishable according to developmental stage, and HH20 was shown to have not only intermediate, but also unique properties in secondary neurulation. A total of 10,666 differentially expressed genes, including FGF18 and GDF11, were identified and enriched in several gene ontologies related to embryogenesis or organogenesis. We also found that genes encoding transcription factors, such as TWIST2, IRX4, HOXB4, HOXD13, LIN28A, CDX4, and Brachyury, were among the top-ranked differentially expressed genes. CONCLUSION: Through transcriptomic profiling, we provided a picture of the developmental process of the CCM. We identified several key molecules or pathways involved in secondary neurulation and the pathogenesis of related diseases.

2D shear wave elastography is better than transient elastography in predicting post-hepatectomy complication after resection.

OBJECTIVES: Both transient elastography (TE) and 2D shear wave elastography (SWE) are accurate methods to evaluate liver fibrosis. We aimed to evaluate the diagnostic performance of 2D-SWE in predicting post-hepatectomy complication and to compare it with TE. METHODS: We prospectively enrolled 125 patients with liver tumors. Liver stiffness (LS) (kilopascal [kPa]) was measured using both TE and 2D-SWE before surgery. All post-operative complication was evaluated using the comprehensive complication index (CCI), and CCI ≥ 26.2 was defined as severe complication. Logistic regression analysis was performed to identify predictive factors for severe complication. Receiver operating characteristic analysis was used to evaluate the diagnostic performance of TE/2D-SWE in detecting liver fibrosis and severe complication. RESULTS: Severe complication developed in 18 patients. The median LS in patients with severe complication was significantly higher for both 2D-SWE (11.4 kPa vs. 7.0 kPa, p < 0.001) and TE (8.9 kPa vs. 6.2 kPa, p = 0.009). LS obtained from 2D-SWE was a significant factor correlated with severe complication (odds ratio: 1.27 per kPa [1.10-1.46], p = 0.001). The diagnostic performance of 2D-SWE was significantly higher than that of TE in detecting both ≥F3 (p = 0.024) and F4 (p = 0.048). The area under the curve of 2D-SWE to predict severe complication was 0.854, significantly higher than 0.692 of TE (p = 0.004). The optimal cut-off LS from 2D-SWE to predict severe complication was 8.6 kPa, with sensitivity of 88.9% (16/18) and specificity of 73.8% (79/107). CONCLUSION: LS obtained from 2D-SWE was a significant predictive factor for severe complication, and 2D-SWE showed significantly a better diagnostic performance than TE in detecting liver fibrosis and severe complication. KEY POINTS: • The diagnostic performance of 2D-SWE was significantly higher than that of TE in detecting both ≥ F3 (AUC: 0.853 vs. 0.779, p = 0.024) and F4 (AUC: 0.929 vs. 0.872, p = 0.048). • Liver stiffness value obtained from 2D-SWE was a significant factor correlated with the development of severe complication defined as CCI ≥ 26.2 after hepatic resection for liver tumors (odds ratio: 1.27 per kPa [1.10-1.46], p = 0.001). • 2D-SWE provided significantly a better diagnostic performance in predicting severe complication after hepatic resection than TE (AUC for 2D-SWE: 0.853 vs. AUC for TE: 0.692, p = 0.004).

Transabdominal Ultrasound for Follow-Up of Incidentally Detected Low-Risk Pancreatic Cysts: A Prospective Multicenter Study.

OBJECTIVE. The purpose of this study is to investigate the detection rate of transabdominal ultrasound (TAUS) for pancreatic cysts incidentally detected on CT or MRI as well as the factors that influence detection rates. SUBJECTS AND METHODS. Fifty-seven patients with low-risk pancreatic cysts (n = 77; cyst size, 5 mm to 3 cm) that were incidentally detected on CT or MRI were prospectively enrolled at five institutions. At each institution, TAUS was independently performed by two radiologists who assessed detection of cysts, cyst location and size, and the diameter of the main pancreatic duct (MPD). Cyst detection rates based on cyst size, location, and multiplicity and the body mass index of the patient were compared using the Mann-Whitney test. Kappa statistics and the interclass correlation coefficient were used to evaluate interobserver agreement regarding cyst detection and consistency of cyst size and the diameter of the MPD on TAUS versus prior CT or MRI. RESULTS. The detection rate for known low-risk pancreatic cysts was 81.8% (63/77) and 83.1% (64/77) for TAUS conducted by each of the two radiologists. The detection rate for larger (≥ 10 mm) cysts was significantly higher than that for smaller cysts (89.0% vs 63.6% for TAUS performed and interpreted by radiologist 1 [TAUS 1] and 89.0% vs 68.2% for TAUS conducted and interpreted by radiologist 2 [TAUS 2]; p < .05). A higher detection rate was noted for cysts located outside the tail of the pancreas compared with those located in the tail (89.5% vs 65.0% for TAUS 2; p = .01), and the detection rate was also significantly higher for single cysts than for multiple cysts (90.9% vs 69.7% for TAUS 1; p = .02). However, no significant difference was observed for body mass index. Interobserver agreement was excellent regarding the size of the detected cysts (inter-class correlation coefficient: 0.964 [95% CI, 0.940-0.979] for CT, TAUS 1, and TAUS 2 and 0.965 [95% CI. 0.924-986] for MRI, TAUS 1, and TAUS 2) and the diameter of the MPD (interclass correlation coefficient, 0.934; 95% CI, 0.898-0.959). CONCLUSION. TAUS could be a useful alternative imaging tool for surveillance of known low-risk pancreatic cysts, especially single pancreatic cysts and those that are of larger size (≥ 1 cm) or are located outside the tail.

Factors associated with neurodevelopment in preterm infants with systematic inflammation.

BACKGROUND: Several studies have suggested that adverse neurodevelopment could be induced by systemic inflammation in preterm infants. We aimed to investigate whether preterm infants with systemic inflammation would have impaired neurodevelopment and which biomarkers and neurophysiologic studies during inflammation are associated with poor neurodevelopment. METHODS: This prospective cohort study enrolled infants born before 30 weeks of gestation or with birth weight < 1250 g. Infants were grouped according to the presence of systemic inflammation: Control (no inflammation, n = 49), I (systemic inflammation, n = 45). Blood and cerebrospinal fluid samples for markers of brain injury and inflammation were collected and amplitude-integrated electroencephalography (aEEG) was performed within 4 h of septic workup. We evaluated aEEG at 35 weeks postmenstrual age (PMA), head circumference at 36 weeks PMA, and brain MRI at discharge. The Bayley Scales of Infant and Toddler Development III (Bayley-III) was performed at a corrected age (CA) of 18 months. RESULTS: The I group had more white matter injuries (2 vs. 26.7%, Control vs. I, respectively) at the time of discharge, lower brain functional maturation (9.5 vs. 8), and smaller head size (z-score - 1.45 vs. -2.12) at near-term age and poorer neurodevelopment at a CA of 18 months than the control (p < 0.05). Among the I group, the proportion of immature neutrophils (I/T ratios) and IL-1 beta levels in the CSF were associated with aEEG measures at the day of symptom onset (D0). Seizure spike on aEEG at D0 was significantly correlated with motor and social-emotional domains of Bayley-III (p < 0.05). The I/T ratio and CRP and TNF-α levels of blood at D0, white matter injury on MRI at discharge, head circumference and seizure spikes on aEEG at near-term age were associated with Bayley-III scores at a CA of 18 months. CONCLUSIONS: Systemic inflammation induced by clinical infection and NEC are associated with neurodevelopmental impairment in preterm infants. The seizure spike on aEEG, elevated I/T ratio, CRP, and plasma TNF-alpha during inflammatory episodes are associated with poor neurodevelopment.

Technical success rates and reliability of spin-echo echo-planar imaging (SE-EPI) MR elastography in patients with chronic liver disease or liver cirrhosis.

OBJECTIVES: To determine the technical success rates of MR elastography (MRE) according to established gradient-recalled echo (GRE) and spin-echo echo-planar imaging (SE-EPI) sequences and to compare liver stiffness (LS) values between the sequences during expiratory and inspiratory phases in patients with chronic liver disease or liver cirrhosis. METHODS: One hundred and eight patients who underwent MRE were included in this retrospective study. MRE was performed at 3 T based on both sequences during expiration as well as inspiration. Technical failure of MRE was determined if there was no pixel value with a confidence index higher than 95% and/or no apparent shear waves imaged. LS measurements were performed using free-drawing region of interest. To evaluate clinical factors related to the technical success rate of MRE, we assessed etiology of liver disease, ascites, body habitus, iron deposition, and liver morphology of patients. Statistical analysis was performed with the Wilcoxon test, Bland-Altman plot, independent t test, Mann-Whitney test, and McNemar test. RESULTS: The technical success rate of MRE in SE-EPI was significantly higher than that of GRE (98.1% vs. 80.7%, p < 0.0001). On the basis of univariate analysis, height, weight, and BMI were significantly associated with failure of MRE (p < 0.05). There was no significant difference in LS values between GRE and SE-EPI (2.82 kPa vs. 2.92 kPa (p > 0.05)). However, the LS values were significantly higher during inspiration than expiration with both GRE and SE-EPI (p < 0.0001). CONCLUSION: MRE in SE-EPI during expiratory breath-hold can be used as a reliable examination to evaluate liver fibrosis. KEY POINTS: • The technical success rate of MR elastography in spin-echo echo-planar imaging (SE-EPI) was significantly higher than that in gradient-recalled echo (GRE) during both the inspiratory and expiratory phases. • Liver stiffness values were significantly higher during inspiration than during expiration in both GRE and SE-EPI. • MR elastography in SE-EPI during expiratory breath-hold can be used as a reliable examination in patients with liver fibrosis.

Preoperative CT Classification of the Resectability of Pancreatic Cancer: Interobserver Agreement.

Background Accurate assessment of local resectability of pancreatic cancer at initial workup is critical to determine the most appropriate management strategy among up-front operation, neoadjuvant treatment, or palliative treatment. Purpose To investigate the interobserver agreement of the preoperative CT classification of the local resectability of pancreatic cancer and to determine if radiologist experience level impacts evaluation, and to evaluate the reader performance in assessing resectability at CT in a subset of patients with a reference standard for local resectability. Materials and Methods This retrospective study was composed of patients with pathologic-analysis-confirmed pancreatic cancers between January 2013 and December 2014 who underwent baseline multiphasic contrast agent-enhanced CT. Eight board-certified radiologists with different levels of experience (more experienced, ≥6 years, n = 4; less experienced, 1st- or 2nd-year fellows, n = 4) reviewed the CT images and classified cancers as resectable, borderline resectable, or unresectable. Interobserver agreements were determined for all reviewers and subgroups of reviewers stratified according to experience (more vs less) by using Fleiss κ statistics. In patients with reference standards for local resectability, diagnostic performances of each reviewer were assessed by using receiver operating characteristic curve analysis. Results There were 110 patients (mean age, 61 years ± 11; 60 men) who were evaluated. Overall interobserver agreements were moderate for resectability classification (κ = 0.48; 95% confidence interval: 0.45, 0.50). Only 30.0% of patients (33 of 110) were given the same resectability classification from all reviewers. More experienced reviewers demonstrated higher agreement in category assignments than less experienced reviewers (κ = 0.55 [95% confidence interval: 0.50, 0.60] vs 0.43 [95% confidence interval: 0.38, 0.49], respectively). For prediction at CT of margin-negative (ie, R0) resections (n = 82), areas under the receiver operating characteristic curve of all reviewers were greater than 0.80 (range, 0.83-0.96). However, borderline resectable cancers showed diverse R0 rates ranging from 0% to 74% depending on the reviewers. Conclusion Considerable interobserver variability exists in the assignment at CT of the local resectability of pancreatic cancer, even among experienced radiologists. © RSNA, 2019 Online supplemental material is available for this article.

Magnetic Resonance Imaging-Detected Extramural Venous Invasion in Rectal Cancer before and after Preoperative Chemoradiotherapy: Diagnostic Performance and Prognostic Significance.

OBJECTIVES: We evaluated the diagnostic performance of magnetic resonance imaging (MRI) in terms of identifying extramural venous invasion (EMVI) in rectal cancer patients with preoperative chemoradiotherapy (CRT) and its prognostic significance. METHODS: During 2008-2010, 200 patients underwent surgery following preoperative CRT for rectal cancer. Two radiologists independently reviewed all pre- and post-CRT MRI retrospectively. We investigated diagnostic performance of pre-CRT MR-EMVI (MR-EMVI) and post-CRT MR-EMVI (yMR-EMVI), based on pathological EMVI as the standard of reference. We assessed correlation between MRI findings and patients' prognosis, such as disease-free survival (DFS) and overall survival (OS). Additionally, subgroup analysis in MR- or yMR-EMVI-positive patients was performed to confirm the significance of the severity of EMVI in MRI on patient's prognosis. RESULTS: The sensitivity and specificity of yMR-EMVI were 76.19% and 79.75% (area under the curve: 0.830), respectively. In univariate analysis, yMR-EMVI was the only significant MRI factor in DFS (P = 0.027). The mean DFS for yMR-EMVI (+) patients was significantly less than for yMR-EMVI (-) patients: 57.56 months versus 72.46 months. CONCLUSION: yMR-EMVI demonstrated good diagnostic performance. yMR-EMVI was the only significant EMVI-related MRI factor that correlated with patients' DFS in univariate analysis; however, it was not significant in multivariate analysis. KEY POINTS: • Diagnostic performance of MRI for EMVI after preoperative chemoradiotherapy is good. • The mean DFS was lower in yMR-EMVI-positive than yMR-EMVI-negative patients. • MRI can facilitate prognosis prediction of rectal cancer patients with preoperative chemoradiotherapy.

Early Prediction of the Severity of Acute Pancreatitis Using Radiologic and Clinical Scoring Systems With Classification Tree Analysis.

OBJECTIVE: The objective of our study was to develop a decision tree model for the early prediction of the severity of acute pancreatitis (AP) using clinical and radiologic scoring systems. MATERIALS AND METHODS: For this retrospective study, 192 patients with AP who underwent CT 72 hours or less after symptom onset were divided into two cohorts: a training cohort (n = 115) and a validation cohort (n = 77). Univariate analysis was performed to identify significant parameters for the prediction of severe AP in the training cohort. For early prediction of disease severity, a classification tree analysis (CTA) model was constructed using significant scoring systems shown by univariate analysis. To assess the diagnostic performance of the model, we compared the area under the ROC curve (AUC) with each selected single parameter. We also evaluated the diagnostic performance in the validation cohort. RESULTS: The Acute Physiology and Chronic Health Evaluation (APACHE)-II score, bedside index for severity in acute pancreatitis (BISAP) score, extrapancreatic inflammation on CT (EPIC) score, and Balthazar grade were included in the CTA model. In the training cohort, our CTA model showed a trend of a higher AUC (0.853) than the AUC of each single parameter (APACHE-II score, 0.835; BISAP score, 0.842; EPIC score, 0.739; Balthazar grade, 0.700) (all, p > 0.0125) while achieving specificity (100%) higher than and accuracy (94.8%) comparable to each single parameter (both, p < 0.0125). In the validation cohort, the CTA model achieved diagnostic performance similar to the training cohort with an AUC of 0.833. CONCLUSION: Our CTA model consisted of clinical (i.e., APACHE-II and BISAP scores) and radiologic (i.e., Balthazar grade and EPIC score) scoring systems and may be useful for the early prediction of the severity of AP and identification of high-risk patients who require close surveillance.

Preoperative MDCT Assessment of Resectability in Borderline Resectable Pancreatic Cancer: Effect of Neoadjuvant Chemoradiation Therapy.

OBJECTIVE: The purpose of this study is to evaluate the diagnostic performance of MDCT in assessing tumor resectability in patients with borderline resectable pancreatic cancers after receiving neoadjuvant chemoradiation therapy (CRT) in comparison with those undergoing upfront surgery. SUBJECTS AND METHODS: Thirty-seven patients with borderline resectable pancreatic cancers were randomly allocated to the neoadjuvant CRT group (arm 1; n = 18) or up-front surgery group (arm 2; n = 19). Three radiologists rated the likelihood of local resectability on a 5-point scale at preoperative MDCT in two separate sessions (session 1: post-CRT of arm 1, baseline of arm 2; session 2: using new imaging criteria reflecting the changes during CRT of arm 1). The AUC of each reviewer, as well as sensitivity, specificity, and accuracy based on consensus interpretation, were compared between arms and sessions. RESULTS: For local resectability (n = 30), AUC values at session 1 were 0.664, 0.669, and 0.588 for reviewers 1, 2, and 3, respectively, and were not significantly different between arms 1 (n = 15; 0.759, 0.713, and 0.593) and 2 (n = 15; 0.852, 0.685, and 0.722) (p > 0.05). In arm 1, MDCT sensitivity, specificity, accuracy were 22%, 100%, and 53%, respectively, at session 1 versus 78%, 67%, and 73%, respectively, at session 2 (p > 0.05). CONCLUSION: In patients with borderline resectable pancreatic cancers, neoadjuvant CRT did not significantly decrease the performance of MDCT for the prediction of local resectability. However, by considering post-CRT changes, such as nonprogression in tumor-vascular contact, MDCT may provide better sensitivity for locally resectable disease.

Risk Factors Associated With Incomplete Colonoscopy Based on the Analysis of Computed Tomographic Colonography Findings.

OBJECTIVE: This study aimed to identify the computed tomographic colonography (CTC) findings of incomplete colonoscopy compared with those of complete colonoscopy. METHODS: The clinical data and CTC imaging data from January 2004 to December 2012 were retrospectively obtained at 2 different institutions and reviewed by the central review system. A total of 71 patients who underwent both videocolonoscopy and CTC were included in this study. The CTC findings and clinical data were evaluated for the completeness of colonoscopy. RESULTS: In the CTC analysis, differences in total colon length, abdominal circumference, and sigmoid colon diameter were statistically significant between both groups (P < 0.05). Body mass index (BMI) and height were identified as significant clinical factors influencing the completeness of colonoscopy. In multiple logistic regression tests, only BMI and sigmoid colon diameter were independent factors (P < 0.05). CONCLUSIONS: High BMI larger diameter of sigmoid colon was associated with incomplete colonoscopy based on CTC.

Nonhypervascular Pancreatic Neuroendocrine Tumors: Differential Diagnosis from Pancreatic Ductal Adenocarcinomas at MR Imaging-Retrospective Cross-sectional Study.

Purpose To determine useful magnetic resonance (MR) imaging features to differentiate nonhypervascular pancreatic neuroendocrine tumors (PNETs) from pancreatic ductal adenocarcinomas (PDACs). Materials and Methods The institutional review board approved this retrospective study and waived the informed consent requirement. Seventy-four patients with surgically confirmed PNETs and 82 patients with PDACs who underwent gadobutrol-enhanced MR imaging were included. Two radiologists independently evaluated the morphologic characteristics and temporal enhancement patterns of each tumor. Quantitative analysis, including measurement of tumor size, maximal upstream parenchymal thickness (MUPT), contrast-to-noise ratio, and apparent diffusion coefficient values, was performed. Uni- and multivariate logistic regression analyses were performed to identify relevant features to differentiate between PNETs and PDACs. Results On the basis of arterial enhancement, 38 PNETs (51%, 38 of 74) were hypervascular and 36 PNETs (49%, 36 of 74) were nonhypervascular. At MR imaging, nonhypervascular PNETs showed significantly higher frequencies of a well-defined margin, portal hyper- or isoenhancement, and MUPT of 10 mm or greater but lower frequencies of ductal dilatation, vascular invasion, and peripancreatic infiltration when compared with PDACs (P < .05 for all). At multivariate analysis, a well-defined margin and portal hyper- or isoenhancement were independent significant differentiators of PNETs from PDACs (odds ratio, 20.3 and 16.1, respectively). When applying the criteria of a well-defined margin and portal hyper- or isoenhancement, 64% of sensitivity and 99% of specificity were observed for the differential diagnosis of PNETs from PDACs. Conclusion A well-defined margin and hyper- or isoenhancement in the portal venous phase are useful MR imaging features that are more common in nonhypervascular PNETs and may help discriminate nonhypervascular PNETs from PDACs. © RSNA, 2017 Online supplemental material is available for this article.

Preoperative Assessment of Pancreatic Cancer with FDG PET/MR Imaging versus FDG PET/CT Plus Contrast-enhanced Multidetector CT: A Prospective Preliminary Study.

Purpose To determine the diagnostic performance of fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET)/magnetic resonance (MR) imaging in the preoperative assessment of pancreatic cancer in comparison with that of FDG PET/computed tomography (CT) plus contrast material-enhanced multidetector CT. Materials and Methods This prospective study was approved by the institutional review board; written informed consent was obtained. Thirty-seven patients with 39 pancreatic tumors underwent preoperative FDG PET/MR imaging, PET/CT, and contrast-enhanced multidetector CT. The authors measured maximal and mean standardized uptake values (SUVmax and SUVmean, respectively) of pancreatic cancer at PET/MR imaging and PET/CT. Two radiologists independently reviewed the two imaging sets (set 1, PET/MR imaging; set 2, PET/CT plus multidetector CT) to determine tumor resectability according to a five-point scale, N stage (N0 or N positive), and M stage (M0 or M1). With use of clinical-surgical-pathologic findings as the standard of reference (n = 20), diagnostic performances of the two imaging sets were compared by using the McNemar test. Results Both SUVmax and SUVmean of pancreatic tumors showed strong correlations between PET/MR imaging and PET/CT (r = 0.897 and 0.890, respectively; P < .001). The diagnostic performance of PET/MR imaging was not significantly different from that of PET/CT plus multidetector CT in the assessment of tumor resectability (area under the receiver operating characteristic curve: 0.891 vs 0.776, respectively, for reviewer 1 [P = .109] and 0.859 vs 0.797 for reviewer 2 [P = .561]), N stage (accuracy: 54% [seven of 13 patients] vs 31% [four of 13 patients]; P = .250 for both reviewers), and M stage (accuracy: 94% [16 of 17 patients] vs 88% [15 of 17 patients] for reviewer 1 [P > .999] and 94% [16 of 17 patients] vs 82% [14 of 17 patients] for reviewer 2 [P = .500]). Conclusion FDG PET/MR imaging showed a diagnostic performance similar to that of PET/CT plus contrast-enhanced multidetector CT in the preoperative evaluation of the resectability and staging of pancreatic tumors. © RSNA, 2016 Online supplemental material is available for this article.