Monitoring the roles of prothrombin activation fragment 1 and 2 (F1 + 2) in patients with atrial fibrillation receiving rivaroxaban and apixaban.

Factor Xa (FXa) inhibitors are recommended for use in fixed doses without laboratory monitoring. However, prior studies reported the importance of establishing biomarkers representing anticoagulation intensity related to bleeding or thrombotic events. To test the hypothesis that prothrombin activation fragment 1 and 2 (F1 + 2), a non-specific marker of thrombin generation, could be altered during FXa inhibitor treatment in patients with atrial fibrillation. We conducted the study in two different clinical settings. First, the interrelations among biomarkers representing coagulation/fibrinolysis were investigated in 80 patients in an outpatient clinic. Second, these biomarkers were evaluated in 75 patients who underwent radiofrequency catheter ablation. Plasma concentration of FXa inhibitors was evaluated using an anti-FXa chromogenic assay (C-Xa). In the outpatient study, only F1 + 2 exhibited a significant and negative association with C-Xa (rS = - 0.315, p = 0.026), and 37% of the variance could be explained by C-Xa levels. F1 + 2 levels above the reference range (> 229 pmol/L) could be considered as a cut-off to identify poor patient compliance or under-dosing. In the peri-ablation study, increased F1 + 2 levels were associated with decline of C-Xa levels after periprocedural discontinuation of FXa inhibitors, which was greater in the rivaroxaban group than in the apixaban group. F1 + 2 showed modest and inverse association with plasma concentration of rivaroxaban and apixaban in patients with atrial fibrillation. Larger study to test the hypothesis that continued thrombin generation despite anticoagulation is associated with a heightened risk of clinical events is required.

Thrombotic Microangiopathy after a 15-year Treatment with Interferon Beta-1b in a Patient with Multiple Sclerosis: A Case Report and Review of Literature.

A 54-year-old woman with multiple sclerosis treated with interferon-ß (IFN-ß)-1b for 15 years presented with sustained hypertension (240/124 mmHg) and retinal bleeding. She had proteinuria, anemia, thrombocytopenia, elevated serum creatinine levels, and haptoglobin depletion. Intravenous nicardipine stabilized her blood pressure, but her renal function and platelet count deteriorated. The initial disintegrin-like metalloprotease with thrombospondin type 1 motifs 13 (ADAMTS13) activity was 28% of normal without its inhibitor. The subsequent peripheral appearance of schistocytes suggested thrombotic microangiopathy (TMA). After IFN-ß-1b cessation, the platelet count increased, and the blood pressure stabilized. The ADAMTS13 activity normalized, although the creatinine level did not. TMA may develop after the long-term use of IFN-ß without adverse events.

JSUM ultrasound elastography practice guidelines: breast.

Ten years have passed since the first elastography application: Real-time Tissue Elastography™. Now there are several elastography applications in existence. The Quality Control Research Team of The Japan Association of Breast and Thyroid Sonology (JABTS) and the Breast Elasticity Imaging Terminology and Diagnostic Criteria Subcommittee, Terminology and Diagnostic Criteria Committee of the Japan Society of Ultrasonics in Medicine (JSUM) have advocated breast elastography classifications for exact knowledge and good clinical use. We suggest two types of classifications: the technical classification and the classification for interpretation. The technical classification has been created to use vibration energy and to make images, and also shows how to obtain a good elastic image. The classification for interpretation has been prepared on the basis of interpretation of evidence in this decade. Finally, we describe the character and specificity of each vender equipment. We expect the present guidelines to be useful for many physicians and examiners throughout the world.

The Japan Society of Ultrasonics in Medicine guidelines on non-mass abnormalities of the breast.

It is possible to appropriately diagnose non-mass abnormalities by elucidating ultrasound non-mass abnormality findings and sharing the concept. If non-mass abnormalities can be diagnosed early, the number of curable cases could increase, leading to fewer breast cancer deaths. The Japan Society of Ultrasonics in Medicine (JSUM) Terminology/Diagnostic Criteria Committee has classified non-mass abnormalities into five subtypes: hypoechoic area in the mammary gland, abnormalities of the ducts, architectural distortion, multiple small cysts, and echogenic foci without a hypoechoic area. We herein define the findings for each of these subtypes and present a summary of the JSUM guidelines on non-mass abnormalities of the breast generated based on those findings.

Delayed Diagnosis and Prognostic Impact of Breast Cancer During the COVID-19 Pandemic.

BACKGROUND: Breast screening services were suspended for several months owing to the coronavirus disease 2019 (COVID-19) pandemic. We estimated the potential impact on breast cancer mortality using long-term global observations. However, the magnitude of the impact may vary across countries; therefore, we conducted an analysis and modeling study of this impact in Japan. PATIENTS AND METHODS: We compared the clinicopathological features of breast cancers between the nonpandemicgroup (April 1, 2019 to October 31, 2019) and the pandemic group (April 1, 2020 to October 31, 2020). We also compared the estimated 10-year survival rates between the two groups based on the weighted average of the 10-year survival rate by clinical stage and site (2004-2007). RESULTS: Results...Pandemic-related disruption decreased the number of breast cancer cases from296 to 249 during both 7-month periods. The percentage of patients with stage IIB or higher disease was significantly higher in the pandemic group than in the non-pandemic group (22.0% vs. 31.3%, P = 0.0133). The percentage of cases with a Ki-67 labeling index higher than 20% tended to be higher in the pandemic group than in the non-pandemic group (62.2% vs. 54.4%). The estimated 10-year survival rate was lower in the pandemic group than in the non-pandemic group (83.9% vs. 87.9%, 95% confidence interval of the difference: 0.87-8.8, P > 0.05). CONCLUSION: We found more aggressive and advanced disease afterthe suspension of breast cancer screening services owing to the COVID-19 pandemic. This may have affected the long-term clinical outcomes of patients with breast cancer.

The Breast Cancer Working Group presentation was divided into three sections: the epidemiology, pathology and treatment of breast cancer.

EPIDEMIOLOGY OF BREAST CANCER: The incidence and mortality of breast cancer are lower in Asia than in the West, particularly in post-menopausal women, but they are increasing. The age patterns of the incidence of breast cancer in Asia differ from in the West: in most Asian countries the peak incidence of breast cancer is at about age 45-50, whereas in western countries the incidence continues to increase even at older ages. Mortality is decreasing in western countries, whereas it is still increasing in Asian nations. There are many epidemiological factors involved in breast cancer, and important known risk factors include diet, obesity and diabetes. Asian studies found that high intake of isoflavones reduced the risk of breast cancer. PATHOLOGY OF BREAST CANCER: With regard to the pathology of breast cancer, for the molecular subtype, luminal A and luminal B are being used, while HER2 expression and rapid proliferation are also employed. Study results showed a somewhat higher prevalence of luminal A in Japanese compared with Americans. Ductal carcinoma in situ breast cancer is less frequent in Asian breast cancer patients than in Americans. The Working Group resolved to establish an international committee for pathological assessment of breast cancer in Asia. TREATMENT OF BREAST CANCER: Pharmacokinetics-pharmacodynamics studies are needed between ethnic backgrounds, investigating aromatase inhibitors and tamoxifen (endoxifen), as well as the effects of demographic factors such as diet, medical care, body mass index, etc. Correlations between adverse events and the clinical outcome also need to be studied.

Characteristics of ultrasonographic images of ductal carcinoma in situ with abnormalities of the ducts.

PURPOSE: Although the number of ductal carcinoma in situ (DCIS) cases has increased with the spread of breast cancer screening in Japan, there are very few reports that summarize ultrasound image features of DCIS. The Japan Association of Breast and Thyroid Sonology (JABTS) investigated the incidence of DCIS with masses and non-mass abnormalities and the characteristics of US images in a retrospective, multicenter, observational study (JABTS BC-02 study). The purpose of this report is to clarify the proportion of DCIS with abnormalities of the ducts with each ultrasound finding and the characteristics of US images. METHODS: The JABTS BC-02 study population was comprised of patients who were examined by ultrasonography, underwent surgery, and were histopathologically diagnosed with DCIS at each study site between January 2008 and December 2012. The US images of DCIS and pathology and clinical information were retrospectively collected from 16 institutions in Japan. The US images were evaluated by 22 experts on the Central Image Interpretation Committee of JABTS. RESULTS: Abnormalities of the ducts were noted in 78 (10.5%) of 705 US images of DCIS. Of the 78 cases, the distribution of abnormalities of the ducts was focal or segmental. The second characteristic was the presence of internal echoes in dilated ducts. All cases were accompanied by intraductal solid echoes, and 40 cases (51.3%) were accompanied by echogenic foci. In addition, intraductal solid echoes were continuous or multiple in 72 cases (92.4%), and the shape of the solid echoes was broad-based and/or irregular in 62 cases (79.5%). CONCLUSION: DCIS cases with duct abnormalities on ultrasound were investigated in this study. The important characteristics were as follows: (1) the distribution of ductal dilatation was focal or segmental, (2) solid parts were present in the dilated ducts, (3) the distribution of internal echoes was continuous or multiple, (4) the shape of solid echoes was broad-based and/or irregular, and (5) internal echoes were sometimes accompanied by echogenic foci. Accurate evaluation of these findings may be useful for diagnosing DCIS. Although the duct abnormalities are included in "ASSOCIATED FEATURES" in ACR BI-RADS ATLAS (USA), we emphasize that this concept is very important for understanding US characteristics of DCIS.

Multicenter Prospective Study of Color Doppler Ultrasound for Breast Masses: Utility of Our Color Doppler Method.

The use of color Doppler ultrasound (CD) for distinguishing between benign and malignant breast lesions remains controversial. This study (JABTS BC-04 study) was aimed at confirming the usefulness of our CD diagnostic criteria. We evaluated ultrasound images of 1408 solid breast masses from 16 institutions in Japan (malignant: 839, benign: 569). Multivariate analysis indicated that vascularity (amount of blood flow), vascular flow pattern ("surrounding marginal flow" or "penetrating flow") and the incident angle of penetrating flow were significant findings for distinguishing between benign and malignant lesions. However, the sensitivity and specificity of B-mode alone did not improve significantly with CD addition (97.6% → 97.9%, 38.3% → 41.5%, respectively). We explored the causes of these negative results and found that age should have been considered when evaluating vascularity. Simulation experiments suggested that specificity is significantly improved when age is taken into consideration (38.3% → 46.0%, p < 0.001) and we thereby improved our diagnostic criteria.

Growth suppression of thyroid cancer cells by adenylcyclase activator.

Thyroid stimulating hormone (TSH) is known to increase intracytoplasmic cyclic adenosine monophosphate (cAMP) and to regulate the growth of normal follicular cells. The aim of this study was to explore the role of the cAMP-mediated signaling pathway stimulated by TSH as a cell growth modulator in human thyroid cancer cells. One papillary thyroid cancer cell line, K1 cells and two anaplastic thyroid cancer cell lines, TTA1 and TTA2 cells were treated with forskolin, which directly activates adenyl cyclase to raise the level of intracellular cAMP. Forskolin suppressed thyroid cancer cell proliferations, especially in K1 cells, in a dose-dependent manner and induced growth arrest at the G0/G1 phase of the cell cycle. We also examined the expression of mitogen activated protein kinase (MAPK) after the forskolin treatment. Forskolin reduced the activation of growth factor induced MAPK activity. In conclusion, we demonstrated that forskolin was involved in G1 arrest and MAPK activation in K1 thyroid cancer cells. Our study suggests that the TSH signal mediated by cAMP acts as a negative regulator in thyroid cancer cells, unlike that in normal follicular cells.

Ultrasound Image Classification of Ductal Carcinoma In Situ (DCIS) of the Breast: Analysis of 705 DCIS Lesions.

The Japan Association of Breast and Thyroid Sonology (JABTS) proposed, in 2003, a conceptual classification system for non-mass abnormalities to be applied in addition to the conventional concept of masses, to facilitate detecting ductal carcinoma in situ (DCIS) lesions. The aim of this study was to confirm the utility of this system and to clarify the distribution of these findings in DCIS lesions. Data on 705 surgically treated DCIS lesions from 16 institutions in Japan were retrospectively reviewed. All 705 DCIS lesions could be classified according to the JABTS classification system. The most frequent findings were hypo-echoic areas in the mammary gland (48.6%), followed by solid masses (28.0%) and duct abnormalities (10.2%) or mixed masses (8.1%). Distortion (1.3%), clustered microcysts (1.4%) and echogenic foci without a hypo-echoic area (2.5%) were uncommon. These results suggest that the concept of non-mass abnormalities is useful in detecting DCIS lesions.

Detection of intraductal component around invasive breast cancer using ultrasound: correlation with MRI and histopathological findings.

PURPOSE: The purpose of this study was preoperatively to diagnose the intraductal component, which is indispensable in planning for breast conservation therapy, and also to minimize local recurrence. This study investigated the efficacy of ultrasound (US) in the detection of intraductal component in comparison with magnetic resonance imaging (MRI) and histopathological findings. PATIENTS AND METHODS: In 47 patients with invasive breast cancer, US features of the intraductal component were classified as (a) solid ductal dilatation radiating from the tumor, (b) presence of satellite lesion in the same segment without ductal dilatation, and (c) ductal dilatation between the main tumor and satellite lesion. MRI depicted intraductal extension as the most enhanced area during the first or second phase of the dynamic study. Other criteria for the detection of the intraductal component by MRI were as follows: (a) a satellite lesion around the main tumor, (b) bridging enhancement between the main tumor and satellite lesions. The extent of the intraductal component was measured and classified as mimimal (0-5 mm), moderate (6-15 mm) or wide (>15 mm). RESULTS: In 28 of 47 (60.0%) patients, a wide intraductal component of more than 15 mm was proved histopathologically. Of 28 patients, US and MRI could accurately detect wide intraductal components in 16 patients and 14 patients, respectively. Sensitivity, specificity, and accuracy were 57.1%, 84.2%, and 68.1% respectively for US and 50.0%, 89.5% and 65.9% for MRI, respectively. When both US and MRI results were combined, sensitivity, specificity, and accuracy were 75.0%, 84.2%, and 78.7%. CONCLUSION: Current US examination depicted the intraductal component of breast cancer more accurately than MRI. Further, our study suggests that the use of both US and MRI together is complementary and offers more advantage than US alone.

Establishment of seminars to improve the diagnostic accuracy and effectiveness of breast ultrasound.

PURPOSE: To improve the ability of technicians and physicians to find and diagnose breast lesions in breast ultrasound screening. METHODS: Seminars were organized for technicians and physicians engaged in breast ultrasound screening, and tests were carried out to evaluate the usefulness of the seminars. Each seminar lasted 2 days and comprised lectures and group activities. Pretests and post-tests conducted before and after each seminar, respectively, consisted of 100 questions: 50 about animated images, and 50 about static images. The tests required the participant to find lesions in animated images and estimate the probability of malignancy from static images. RESULTS: In the animated image tests, sensitivity was greater after the seminar, although specificity did not change significantly. In the static image tests, sensitivity increased, and a significant increase was also observed in the receiver operating curve analysis for degree of certainty in diagnosing cancer. CONCLUSION: The seminars improved the participants' ability to find and diagnose breast lesions during ultrasound screening.

Circulating Glutamate and Taurine Levels Are Associated with the Generation of Reactive Oxygen Species in Paroxysmal Atrial Fibrillation.

Atrial fibrillation (AF) is the most common cardiac arrhythmia, but its proarrhythmic mechanism remains to be elucidated. Glutamate (Glu) and taurine (Tau) are present in the myocardium at substantially higher concentrations than in the plasma, suggesting their active role in myocardium. Here, we tested the hypothesis that the metabolism of Glu and Tau is altered in association with the generation of reactive oxygen species (ROS) in patients with AF. Fifty patients with paroxysmal AF and 50 control subjects without a history of AF were consecutively enrolled. Circulating Glu and Tau levels were measured and correlations between Glu/Tau and ROS levels were examined. Glu/Tau content was significantly higher in patients with AF versus controls (Glu: 79.2 ± 23.9 versus 60.5 ± 25.2 nmol/L; Tau: 78.8 ± 19.8 versus 68.5 ± 20.8 nmol/L; mean ± standard deviation (SD), p < 0.001 for both). Glu/Tau levels also showed an independent association with AF by multiple logistic regression analysis. Glu and Tau levels both showed significant positive associations with plasma hydroperoxide concentrations. These data suggest a novel pathophysiological role of Glu and Tau in association with ROS production in paroxysmal AF, providing new insights into the elevated amino acid content in cardiac disease.

Altered expression patterns of heterogeneous nuclear ribonucleoproteins A2 and B1 in the adrenal cortex.

Several proteins implicated in hormonogenesis of the adrenal cortex have alternatively spliced isoforms, which respond differently to adrenocorticotropic hormone (ACTH). Heterogeneous nuclear ribonucleoproteins A2 and B1 are among the abundant pre-mRNA-binding proteins involved in alternative splicing. We examined the expression of A2 and B1 in normal adrenal cortex and tumors. B1 was variably expressed in the zona fasciculata-reticularis, although A2 was diffusely expressed in the three zones. B1 was more abundant in compact cells than clear cells, and B1 expression was frequent in the zona reticularis, which consists mainly of compact cells. In three kinds of cortical adenomas autonomously producing hormones, B1 was generally overexpressed and there were no significant differences among them. In cortisol-producing tumors, non-tumor parts of the cortex, which were generally atrophic due to low ACTH, had less B1 protein than normal adrenals. These results suggested a correlation between B1 expression and the hormonal activity responding to ACTH. In vitro ACTH stimulation induced a biphasic expression of B1 in an H295R cortical carcinoma cell line, and it paralleled hormonogenesis. Conclusively, B1 expression varied in relation to the hormonal activity responding to the ACTH, and it may provide a key to elucidating the splicing mechanisms involved in hormonogenesis.

Distinct diagnostic criteria for ultrasonographic examination of papillary thyroid carcinoma: a multicenter study.

Recent advances permitting high-resolution ultrasonography have made ultrasonographic examination of nodular thyroid diseases an accessible examination for routine practice. However, diagnostic criteria for ultrasonographic examination of thyroid nodules are not surely established. To identify the optimal strategy for well standardized differential diagnosis of papillary thyroid carcinoma and benign nodules, we evaluated the significance of individual ultrasonographic characteristics of thyroid nodules in a multicenter study. Ten characteristics in ultrasonograms from 53 patients scored by 17 investigators from 15 centers were analyzed by t tests and logistic regression analyses. Between benign and papillary thyroid cancer groups, all characteristics but not size or multiplicity of strong echoes, which suggest calcifications, were significant parameters. Logistic regression analyses showed that border character, shape, and internal echo level are highly significant parameters (p < 0.0005). A multiple logistic regression showed to be the most important predictors of pathologic diagnosis. The diagnostic criterion with border character and internal echo level yielded 93% sensitivity and 92% specificity. In conclusion, univariate and multivariate analyses identified border character, shape, internal echo level, but not strong echoes (calcifications), as important characteristics in differentiating papillary thyroid carcinoma from benign nodules. These results will contribute to standardization of accurate ultrasonographic diagnosis of papillary thyroid carcinoma.

Microsatellite instability and expression of mismatch repair genes in sporadic endometrial cancer coexisting with colorectal or breast cancer.

The molecular background of sporadic endometrial cancer coexisting with colorectal or breast cancer is not clear. We investigated microsatellite instability (MSI) and status of mismatch repair (MMR) gene product, MLH1, MSH2 and MSH6, in 63 sporadic endometrial cancers coexisting with colorectal or breast cancer. Sixteen sporadic endometrial cancers with colorectal cancers (EC), 26 sporadic endometrial cancers with breast cancer (EB) and 21 endometrial cancers without a coexisting cancer (control) were analyzed. EC had the highest frequency of MSI among the 3 groups (EC, 69%; EB, 23%; and control, 43%). Incidence of low-frequency MSI was significantly higher in EC (38%). Among endometrial cancer cases diagnosed before age 50, all high-frequency MSI (MSI-H) cases belonged to EC. Interestingly, incidence of MSI-H was significantly higher in tamoxifen-non-treated cases (75%) than that of treated cases (14%). These results suggest that alterations in MMR genes appear to be involved in carcinogenesis of EC but seem to be uncommon in those of EB. Presence of MSI in sporadic endometrial cancer may be a useful marker to predict the risk of colorectal cancer.

Gene expression profiling identifies platelet-derived growth factor as a diagnostic molecular marker for papillary thyroid carcinoma.

PURPOSE: Cancer diagnostics and therapeutics are often based on clinically relevant markers that are expressed specifically in a malignant tissue at levels higher than in normal tissue. We examined potential markers for papillary thyroid carcinoma (PTC) by monitoring PTC-specific gene expression using cDNA microarray. EXPERIMENTAL DESIGN: Gene expression profiles for PTC tissue, normal thyroid tissue, and healthy peripheral blood cells were compared by use of a human 4000-gene cDNA microarray. Protein expressions of the up-regulated genes in PTC were examined in thyroid tissues by immunohistochemistry. RESULTS: Sixty-four genes were overexpressed in PTC tissue relative to normal thyroid tissue and healthy peripheral blood cells. The genes that were up-regulated in PTC were involved in cell cycle regulation, DNA damage response, angiogenesis, and oncogenesis. Among these genes, basic fibroblast growth factor and platelet-derived growth factor were identified by immunochemical methods as proteins that are specifically expressed at high levels in thyroid neoplasms. Basic fibroblast growth factor, which has been identified as a biomarker for PTC, was overexpressed in 54% of PTC cases, 67% of follicular thyroid carcinomas, and 36% of benign thyroid neoplasms. Platelet-derived growth factor was overexpressed in 81% of PTC cases and 100% of follicular carcinomas, but was immunonegative in normal thyroid tissues and benign thyroid neoplasms. CONCLUSIONS: Platelet-derived growth factor may be a potential biomarker for PTC and follicular carcinoma. Expression profile analysis using a microarray followed by immunohistochemical study can be used to facilitate the development of molecular biomarkers for cancer.

Expression of heterogeneous nuclear ribonucleoproteins A2 and b1 in the thyroid follicular cells.

Several proteins implicated in hormonogenesis of the thyroid have alternatively spliced isoforms. Alternative splicing of pre-mRNA is considered to be important to regulate the hormonal activity. Heterogeneous nuclear ribonucleoproteins (hnRNP) A2 and B1 are two of the abundant nuclear RNA-binding proteins involved in alternative splicing. We examined the expression of hnRNP A2 and B1 in the thyroid, paying particular attention to the relationship between their function and the cellular morphology. B1 was expressed more frequently in cuboidal follicular cells that are hormonally active than in flat follicular cells in normal thyroid, although A2 expression showed no significant difference in two cell types. In Graves' disease, the patients who had high serum levels of triiodothyronine and thyroxine showed significantly increased expression of B1. B1 expression did not differ significantly between normal thyroids and thyroid neoplasms, except undifferentiated (anaplastic) carcinoma. Conclusively, B1 expression varied in relation to hormonal activity in thyroid follicular cells. B1 protein is a good immunohistological marker to detect hormonal activity of follicular cells, and may provide a key to elucidate the splicing mechanisms involved in thyroid hormonogenesis.

Ultrasound (US) diagnosis of nonpalpable breast cancer.

BACKGROUND: Ultrasound (US) is a standard modality to diagnose breast diseases. To elucidate the usefulness of US in the diagnosis of nonpalpable breast cancers, we reviewed the cases that were treated at our institution. METHODS: Of the 106 cancers that were operated upon at the Tsukuba University Hospital between February 2004 and March 2005, 12 cancers were nonpalpable. We reviewed their US findings, results of US-guided fine needle aspiration cytology (FNAC), core biopsy results, and histological diagnoses. RESULTS: On US, 9 tumors appeared as masses. The US observations were valuable, but a confirmatory diagnosis could not be made. US-guided FNAC was performed in 8 cases; malignancy was suspected in 6 cases. US-guided core biopsy was performed in 9 cases, and it was diagnostic in 7 cases. CONCLUSIONS: Nonpalpable breast cancers can be effectively detected by US, and the diagnosis can be confirmed by US-guided FNAC or core biopsy.

A preliminary prospective study to compare the diagnostic performance of assist strain ratio versus manual strain ratio.

OBJECTIVES: The objectives of this study were to demonstrate the non-inferiority of assist strain ratio (ASR)-a newly developed application tool-to manual strain ratio (MSR)-a currently available standard diagnostic tool-and to calculate the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of MSR and ASR. METHODS: Ninety-eight mass lesions in the mammary gland (30 malignant and 68 benign) were included in the study. Skilled physicians performed the elastography scanning by applying minimal vibration. MSRs were obtained and compared with ASRs calculated from the same elastography image to test the correlation between the two groups of data. RESULTS: Diagnostic performance of MSR at a cut-off of 5.0 showed a sensitivity of 84.4 %, a specificity of 80.4 %, an accuracy of 81.6 %, a PPV of 65.5 %, and an NPV of 92.1 %. Diagnostic performance of ASR at a cut-off of 5.0 showed a sensitivity of 74.4 %, a specificity of 84.3 %, an accuracy of 81.3 %, a PPV of 67.7 %, and an NPV of 88.2 %. The areas under the curve (AUCs) for MSR and ASR were found to be 0.885 and 0.875, respectively. CONCLUSION: ASR demonstrated excellent diagnostic potential and was highly correlated with MSR performed by skilled physicians (r = 0.69, p < 0.05).