Uterine fibroids and longitudinal profiles of the vaginal microbiota in a cohort presenting for transvaginal ultrasound.

Bacterial vaginosis, characterized in part by low levels of vaginal Lactobacillus species, has been associated with pro-inflammatory cytokines which could fuel uterine fibroid development. However, prior work on the associations between uterine fibroids and vaginal bacteria is sparse. Most studies have focused on assessment of individual taxa in a single sample. To address research gaps, we sought to compare short, longitudinal profiles of the vaginal microbiota in uterine fibroid cases versus controls with assessment for hormonal contraceptives (HCs), a possible confounder associated with both protection from fibroid development and increases in Lactobacillus-dominated vaginal microbiota. This is a secondary analysis of 83 reproductive-age cisgender women who presented for transvaginal ultrasound (TVUS) and self-collected mid-vaginal swabs daily for 1-2 weeks before TVUS (Range: 5-16 days, n = 697 samples). Sonography reports detailed uterine fibroid characteristics (N = 21 cases). Vaginal microbiota was assessed by 16S rRNA gene amplicon sequencing and longitudinal microbiota profiles were categorized by hierarchical clustering. We compared longitudinal profiles of the vaginal microbiota among fibroid cases and controls with exact logistic regression. Common indications for TVUS included pelvic mass (34%) and pelvic pain (39%). Fibroid cases tended to be older and report Black race. Cases less often reported HCs versus controls (32% vs. 58%). A larger proportion of cases had low-Lactobacillus longitudinal profiles (48%) than controls (34%). In unadjusted analysis, L. iners-dominated and low-Lactobacillus profiles had higher odds of fibroid case status compared to other Lactobacillus-dominated profiles, however these results were not statistically significant. No association between vaginal microbiota and fibroids was observed after adjusting for race, HC and menstruation. Results were consistent when number of fibroids were considered. There was not a statistically significant association between longitudinal profiles of vaginal microbiota and uterine fibroids after adjustment for common confounders; however, the study was limited by small sample size.

Learning curve for magnetic resonance imaging/ultrasound fusion prostate biopsy in detecting prostate cancer using cumulative sum analysis.

Background: Targeted magnetic resonance (MR) with ultrasound (US) fusion-guided biopsy has been shown to improve detection of prostate cancer. The implementation of this approach requires integration of skills from radiologists and urologists. Objective methods for assessment of learning curves, such as cumulative sum (CUSUM) analysis, may be helpful in identifying the presence and duration of a learning curve. The aim of this study is to determine the learning curve for MR/US fusion-guided biopsy in detecting clinically significant prostate cancer using CUSUM analysis. Materials and methods: Retrospective analysis was performed in this institutional review board-approved study. Two urologists implemented an MR/US fusion-guided prostate biopsy program between March 2015 and September 2017. The primary outcome measure was cancer detection rate (CDR) stratified by Prostate Imaging Reporting and Data System (PI-RADS) scores assigned on the MR imaging. Cumulative sum analysis quantified actual cancer detection versus a predetermined target satisfactory CDR of MR/US fusion biopsies in a sequential case-by-case basis. For this analysis, satisfactory performance was defined as >80% CDR in patients with PI-RADS 5, >50% in PI-RADS 4, and <20% in PI-RADS 1-3. Results: Complete data were available for MR/US fusion-guided biopsies performed on 107 patients. The CUSUM learning curve analysis demonstrated intermittent underperformance until approximately 50 cases. After this inflection point, there was consistently good performance, evidence that no further learning curve was being encountered. Conclusions: At a new center implementing MR/US fusion-guided prostate biopsy, the learning curve was approximately 50 cases before a consistently high performance for prostate cancer detection.

PSA density is complementary to prostate MP-MRI PI-RADS scoring system for risk stratification of clinically significant prostate cancer.

BACKGROUND: While prostate multiparametric-magnetic resonance imaging (MP-MRI) has improved the diagnosis of clinically significant prostate cancer (CSPC), the complementary use of prostate-specific antigen (PSA) levels to risk-stratify for CSPC requires further study. The objective of this project was to determine if prostate MP-MRI and PSA can provide complementary insights into CSPC risk stratification. METHODS: In an IRB-approved study, pathologic outcomes from patients who underwent MR/US fusion-targeted prostate biopsy were stratified by various parameters including PSA, PSA density (PSAD), age, race, and PI-RADS v2 score. CSPC was defined as a Gleason score ≥7. Logistic regression was used to determine odds ratios (OR) with 95% confidence intervals (CI). P values were reported as two-sided with p < 0.05 considered statistically significant. ROC curves were generated for assessing the predictive value of tests and sensitivity + specificity optimization was performed to determine optimal testing cutoffs. RESULTS: A total of 327 patients with 709 lesions total were analyzed. PSAD and PI-RADS scores provided complementary predictive value for diagnosis of CSPC (AUC PSAD: 0.67, PI-RADS: 0.72, combined: 0.78, p < 0.001). When controlling for PI-RADS score, age, and race, multivariate analysis showed that PSAD was independently associated with CSPC (OR 1.03 per 0.01 PSAD increase, 95% CI 1.02-105, p < 0.001). The optimal cutoff of PSAD ≥ 0.1 ng/ml/cc shows that a high versus low PSAD was roughly equivalent to an increase in 1 in PI-RADS score for the presence of CSPC (4% of PI-RADS ≤3 PSAD low, 6% of PI-RADS 3 PSAD high vs. 5% of PI-RADS 4 PSAD low, 22% of PI-RADS 4 PSAD high vs. 29% of PI-RADS 5 PSAD low, 46% of PI-RADS 5 PSAD high were found to have CSPC). CONCLUSIONS: PSAD with a cutoff of 0.1 ng/ml/cc appears to be a useful marker that can stratify the risk of CSPC in a complementary manner to prostate MP-MRI.

Validation of an MRI-based prostate cancer prebiopsy Gleason score predictive nomogram.

Background: Gleason score grading is a cornerstone of risk stratification and management of patients with prostate cancer (PCa). In this work, we derive and validate a nomogram that uses prostate multiparametric magnetic resonance imaging (MP-MRI) and clinical patient characteristics to predict biopsy Gleason scores (bGS). Materials and methods: A predictive nomogram was derived from 143 men who underwent MP-MRI prior to any prostate biopsy and then validated on an independent cohort of 235 men from a different institution who underwent MP-MRI for PCa workup. Screen positive lesions were defined as lesions positive on T2W and DWI sequences on MP-MRI. Prostate specific antigen (PSA) density, number of screen positive lesions, and MRI suspicion were associated with PCa Gleason score on biopsy and were used to generate a predictive nomogram. The independent cohort was tested on the nomogram and the most likely bGS was noted. Results: The mean PSA in the validation cohort was 9.25ng/mL versus 6.8ng/mL in the original cohort (p = 0.001). The distribution of Gleason scores between the 2 cohorts were not significantly different (p = 0.7). In the original cohort of men, the most probable nomogram generated Gleason score agreed with actual pathologic bGS findings in 61% of the men. In the validation cohort, the most likely nomogram predicted bGS agreed with actual pathologic bGS 51% of the time. The nomogram correctly identified any PCa versus non-PCa 63% of the time and clinically significant (Gleason score ≥ 7) PCa 69% of the time. The negative predictive value for clinically significant PCa using this prebiopsy nomogram was 74% in the validation group. Conclusions: A preintervention nomogram based on PSA and MRI findings can help narrow down the likely pathologic finding on biopsy. Validation of the nomogram demonstrated a significant ability to correctly identify the most likely bGS. This feasibility study demonstrates the potential of a prebiopsy prediction of bGS and based on the high negative predictive value, identification of men who may not need biopsies, which could impact future risk stratification for PCa.

Observational cohort study of the effect of a single lubricant exposure during transvaginal ultrasound on cell-shedding from the vaginal epithelium.

The outer layers of the vaginal epithelium (VE) are important because they accumulate glycogen which, under optimal conditions, Lactobacillus spp. consume to grow and acidify the vaginal microenvironment with lactic acid. We hypothesized that exposure to lubricant, for example in the conduct of a transvaginal ultrasound (TVUS), may contribute to the shedding of mature epithelial cells, exposing immature cells. Cervicovaginal fluid (CVF) was sampled at four time points by menstrual cup (Softdisc™) from 50 women referred for TVUS, during which a controlled volume of lubricant was applied to the TVUS wand. Samples were collected (1) immediately before TVUS and (2) 6-12 hours, (3) within one week, and (4) two weeks after TVUS. Clinical vaginal lubricants are similar to commercial lubricants, and often have a high osmolality or pH, and contain bactericides such as methylparaben and propylparaben. The number and maturity of epithelial cells in each CVF sample were measured by quantitative and differential fluorimetry (maturity index, MI). Comparisons of cell-counts and maturity were made by paired Wilcoxon signed-rank tests. Among women with a high pre-TVUS MI (> 3), there was a decrease in median cell-count and mean MI in the sample collected 6-12 hours after TVUS (p<0.001, n = 26 and p < 0.001, n = 26, respectively). For these women, cell-count and MI remained lower in the sample collected within the subsequent week (p<0.001, n = 29 and p<0.01, n = 29, respectively), and MI remained lower in the sample collected within two weeks of TVUS (p<0.01, n = 25), compared to the pre-TVUS sample. Among participants with a low pre-TVUS MI (< 3), cell-count was higher in the sample collected within two weeks of TVUS compared to the pre-TVUS sample (p = 0.03, n = 15), but no significant changes in MI were observed. Results were similar when restricted to reproductive-age women. This preliminary data indicates hypertonic vaginal lubricants may increase vaginal epithelial cell shedding.

Role of metabolic imaging in diagnosis of primary, metastatic, and recurrent prostate cancer.

PURPOSE OF REVIEW: The present review describes the current role of metabolic imaging techniques such as multiparametric MRI (mpMRI), magnetic resonance spectroscopic imaging (MRSI), hyperpolarized MRSI, and positron emission tomography (PET) in the diagnosis of primary prostate cancer, surveillance of low-grade disease, detection of metastases, and evaluation of biochemical recurrence after therapy. RECENT FINDINGS: The natural history of prostate cancer ranges from indolent disease that is optimally monitored by active surveillance, to highly aggressive disease that can be lethal. Current diagnostic methods remain imperfect in noninvasively distinguishing between silent versus aggressive tumors. Hence, there is a high demand for noninvasive imaging techniques that offer insight into biological behavior of prostate cancer cells. Characterization of prostate cancer metabolism is a promising area to provide such insights. SUMMARY: Metabolic imaging may allow for greater detection and ultimately characterization of tumor based on aggressiveness and spread. Hence, it has the potential to monitor tumor activity, predict prognostic outcomes, and guide individualized therapies.

Performance of PI-RADS v2 assessment categories assigned prior to MR-US fusion biopsy in a new fusion biopsy program.

OBJECTIVE: To validate the performance of PI-RADS v2 for detection of clinically significant prostate cancer (csPca, Gleason ≥7) within the context of a new fusion biopsy program. MATERIAL AND METHODS: Patients with a PI-RADS v2 assessment category assigned on pre-biopsy mpMRI between March 2015 and November 2017 were identified. Diagnostic performance of PI-RADS v2 was calculated using fusion biopsy results as reference standard using receiver operating characteristic curve analysis. Patient and lesion characteristics were analyzed with one-way ANOVA and Wilcoxon rank sum test. RESULTS: Of 83 patients with 175 lesions, 115/175 (65.7%) were benign, 21/175 (12%) were Gleason 6, and 39/175 (22.3%) were Gleason ≥7. csPCa rates were 0% (0/5) for PI-RADS 1, 7.4% (2/27) for PI-RADS 2, 5.8% (3/52) for PI-RADS 3, 31.2% (24/77) for PI-RADS 4, and 71.4% (10/14) for PI-RADS 5 (p < 0.0001). For prediction of csPCa, patient-level AUC was 0.68 and lesion-level AUC was 0.77. Biopsy threshold of PI-RADS ≥3 was 92.6% sensitive and 22.1% specific. A threshold of PI-RADS ≥4 was 87.2% sensitive and 58.1% specific. Rate of csPca detection on concurrent standard 12 core biopsy only was 6.7%. CONCLUSION: PI-RADS v2 assessment categories assigned prior to biopsy predict pathologic outcome reasonably well in a new prostate fusion biopsy program. Biopsy threshold of PI-RADS ≥3 is highly sensitive. A threshold of ≥4 increases specificity but misses some csPCa.

re: Diffusion Tensor Imaging (DTI) of the Cesarean-Scarred Uterus in vivo at 3T: Comparison Study of DTI Parameters Between Nonpregnant and Pregnant Cases.

LEVEL OF EVIDENCE: 5 Technical Efficacy Stage: 2 J. Magn. Reson. Imaging 2020;51:131-132.

Patterns in On-time, Daily Submission of a Short Web-Based Personal Behavior Survey in a Longitudinal Women's Health Study.

We evaluated compliance with submitting a short Web-based personal behavior survey daily during a 10-week study (n = 52 women/3419 diaries). Time-stamped forms revealed that 50% of diaries were submitted within 24 hours of the email prompt, and 19% were missing or submitted more than 3 days late. Late submissions may affect data quality.

A comparison of segmented abdominopelvic fluid volumes with conventional CT signs of abdominal compartment syndrome in a trauma population.

PURPOSE: To compare the utility of abdominopelvic fluid volume measurements with established computed tomography signs for refractory post-traumatic abdominal compartment syndrome. METHODS: This retrospective observational cohort study included 64 consecutive adult trauma patients with preoperative CT and diagnosis of refractory abdominal compartment syndrome requiring decompressive laparotomy at a level I trauma referral center between 2004 and 2014. We hypothesized that abdominal fluid volume measurements would be more predictive of the need for early laparotomy than previously described conventional CT signs of refractory ACS. Abdominopelvic fluid volumes were determined quantitatively using semi-automated segmentation software. The following conventional imaging parameters were recorded: abdominal anteroposterior:transverse ratio (round belly sign); infrahepatic vena cava diameter; distal abdominal aortic diameter; largest single small bowel wall diameter; hydronephrosis, inguinal herniation; and mesenteric and body wall edema. For outcome analysis, patients were stratified into two groups: those who underwent early (< 24 h) and late (≥ 24 h) decompressive laparotomy following CT. Correlation analysis, comparison of means, and multivariate logistic regression were performed. RESULTS: Abdominal fluid volumes (p = 0.001) and anteroposterior:transverse ratio (p = 0.009) were increased and inferior vena cava diameter (p = 0.009) was decreased in the early decompressive laparotomy group. Multivariate analysis including conventional CT variables, fluid volumes, and laboratory values revealed abdominal fluid volumes (p = 0.012; Δ in log odds of 1.002/mL) as the only independent predictor of early decompressive laparotomy. CONCLUSIONS: Segmented abdominopelvic free fluid volumes had greater predictive utility for decision to perform early decompressive laparotomy than previously described ACS-related CT signs in trauma patients who developed refractory abdominal compartment syndrome.

Mucin-Containing Rectal Carcinomas: Overview of Unique Clinical and Imaging Features.

OBJECTIVE. The purpose of this study is to review the unique clinical and imaging features of mucin-containing rectal carcinomas. CONCLUSION. Mucinous rectal carcinoma is an uncommon tumor subtype with a worse prognosis. At MRI, it is marked by T2-hyperintense extracellular mucin. Difficulty in distinguishing cellular from acellular mucin and persistent tumor bulk can cause errors at restaging. Signet ring cell carcinoma contains intracellular mucin. The classic imaging appearance is rectal linitis plastica. Both tumor subtypes have a unique metastatic pattern.

Hyperpolarized 13C magnetic resonance imaging, using metabolic imaging to improve the detection and management of prostate, bladder, and kidney urologic malignancies.

Approximately 25% of the 2 million new cancer diagnoses in the United States in 2018 were comprised of malignancies of the urogenital system. Of these cancers, 75% occurred in the kidney/renal pelvis, prostate, and urinary bladder. Early diagnosis is beneficial to long-term survival. Currently, urologists rely heavily on computed tomography (CT), magnetic resonance imaging (MRI), ultrasound (US), and positron emission tomography (PET) to both diagnose and offer prognoses, but these techniques are limited in their resolution and are more effective when cancers have reached macroscopic size in later stages. Recent developments in cancer metabolomics have revealed that cancerous cells preferentially upregulate specific metabolic pathways as a means of conserving their resources and maximizing their growth potential. This has opened a new avenue for early diagnosis with much higher resolution, reliability, and accuracy through 13C hyperpolarized MRI. Preferential cancer pathways can be elucidated through this technique using 13C-labeled molecules utilized for energy generation and tumor growth. As these pathways are identified, targeted therapies are being designed to inhibit these pathways to allow for treatment that is cytotoxic to malignant cells but preserves native cells. In this paper, we review the current understanding of urologic cancer metabolomics, specifically in the kidney, prostate, and bladder. We will review the basic physics of MRI and demonstrate how hyperpolarized 13C MRI offers an innovative solution to early diagnosis as well as creates novel avenues for more targeted therapy.

Outcome of liver lesions indeterminate for malignancy on ultrasound: the role of patient age, risk status, and lesion echogenicity.

PURPOSE: The purpose of this study was to evaluate the relationship between final outcome of lesions indeterminate for malignancy on ultrasound (US) and patient and imaging characteristics. METHODS: We identified all patients with indeterminate liver lesions on US between 9/1/2013 and 12/31/2014 using institutional codes based on radiologist opinion. Miscoded lesions (n = 30) and patients with no imaging, pathology, or clinical follow-up at our health system (n = 6) were excluded. Final diagnostic category of malignant, benign, pseudolesion, or indeterminate was assigned using imaging, pathology, and clinical follow-up. Differences in diagnostic categories were compared by patient (age, gender, race, known malignancy. or liver disease) and imaging characteristics (lesion size, echogenicity. and number). Independent likelihood of a benign final diagnostic category was adjusted for significant variables on univariate analysis. RESULTS: Indeterminate liver lesions on US were found in 153/6813 patients (2%). Final diagnostic categories were malignant (11/153, 7%), benign (94/153, 61%), pseudolesion (42/153, 27%). and indeterminate (6/153, 4%). Nearly one-third of hypoechoic masses in patients with known malignancy or liver disease (i.e., high-risk status) ≥ 46 years of age were malignant (9/28, 32%). On multivariate analysis, patients of age ≥ 61 years and high-risk status were associated with decreased likelihood of benign diagnostic category (OR .19 (95% CI .07-.51) and OR .40 (95% CI .18-.88), p values .001 and .022, respectively). CONCLUSIONS: 2% of patients undergoing abdominal US have sonographically indeterminate liver lesions, of which 7% are malignant. Older, high-risk patients with hypoechoic lesions should receive short-term follow-up as one-third will have malignant lesions. Younger, low-risk patients should receive conservative follow-up, regardless of US imaging features.

Hyperirritable stomach as a cause of obstructive symptoms after sleeve gastrectomy: clinical and radiographic findings.

PURPOSE: To characterize clinical and radiographic features of a hyperirritable stomach after sleeve gastrectomy. MATERIALS/METHODS: Radiology reports revealed that 10/76 patients (13%) with obstructive symptoms after sleeve gastrectomy had a hyperirritable stomach. RESULTS: All 10 patients presented with nausea, vomiting, and/or regurgitation. All 10 had emesis on barium studies in the absence of gastric outlet obstruction, gastroparesis, or small bowel obstruction/ileus. Five had extraintestinal causes of nausea/vomiting. Eight had improvement/resolution of symptoms on medical treatment. CONCLUSION: In 13% of patients with nausea/vomiting after sleeve gastrectomy, barium studies revealed a hyperirritable stomach, which likely is multifactorial and self-limited in most patients.

Diagnostic Yield of Triple-Rule-Out CT in an Emergency Setting.

OBJECTIVE: The objective of the present study is to quantify the diagnostic yield of triple-rule-out (TRO) CT for the evaluation of acute chest pain in emergency department patients. MATERIALS AND METHODS: All TRO CT studies performed at our institution from 2006 to 2015 were reviewed. Scans were performed on a 256-MDCT scanner, with the use of ECG gating and a biphasic contrast injection. Radiology reports were reviewed to identify diagnoses that could explain chest pain, including coronary and noncoronary diagnoses, and significant incidental findings that did not account for the patient's presentation. The total numbers of coronary and noncoronary diagnoses and incidental findings were calculated. RESULTS: Four of 1196 total cases that were identified were excluded from the study because of inadequate image quality. A total of 970 patients (81.4%) had a negative study result without a significant coronary or noncoronary diagnosis. A total of 139 patients (11.7%) had significant coronary artery disease (50% stenosis or greater). One hundred six patients (8.9%) had a noncoronary diagnosis that could explain chest pain (p < 0.02), most commonly pulmonary embolism (28 patients [2.3%]), aortic aneurysm (24 patients [2.0%]), or pneumonia (20 patients [1.7%]). Thirty cases (27.3%) of pulmonary embolism and aortic pathologic findings would not have been detected with coronary CT angiography because of unopacified right-side circulation or limited z-axis coverage. A total of 528 incidental findings not considered to explain chest pain were noted in 418 patients (35.1%). CONCLUSION: In 8.9% of patients, TRO CT detected a significant noncoronary diagnosis that could explain acute chest pain, including pathologic findings that would not be identified on dedicated coronary CT angiography.

ABR Core Examination Changes That Affect Residency Candidate Decisions.

PURPOSE: The recent restructuring of the ABR core examination has prompted changes to radiology residency training. The purpose of this study is to determine how factors related to the core examination restructuring influenced radiology applicants' match decisions. METHODS: We surveyed 626 applicants to our institution's radiology residency, after the 2014 match. Applicants rated 21 factors on a 5-point scale. Eight of the factors pertained to the core examination. The respondents additionally listed the top three factors in order of importance. RESULTS: The response rate was 153 of 626 (24.4%). The three most influential factors were current resident satisfaction (average score: 4.74 of 5.00 [95% confidence interval (CI) = 4.64-4.83]), quality of faculty (4.63 [95% CI = 4.52-4.73]) and quality of educational curriculum and clinical training (4.60 [95% CI = 4.50-4.70]). Of factors related to the core examination, the highest rated were core examination pass rate (4.21 [95% CI = 4.07-4.35]) and program resources/time off for external review courses (3.92 [95% CI = 3.79-4.04]). Core examination pass rate (16 of 459 [3.5%]) and time off from clinical duties to study for the examination (6 of 459 [1.3%]) appeared infrequently in respondents' lists of the top three most influential factors. CONCLUSIONS: Factors influencing candidates' choice of radiology program are similar to those reported previously, despite the addition of topics related to core examination restructuring. Although programs vary in how they have addressed the changes, these issues are less important to candidates than are more traditional factors.

How to perform and interpret cine MR enterography.

Magnetic resonance (MR) enterography has become a fundamental tool for small bowel evaluation. Multiphasic cine imaging is a useful component of MR enterography evaluation because it provides functional information about bowel motility. Cine MR enterography can be used to evaluate for strictures and adhesions. Bowel motility evaluation has been shown to increase pathologic lesion detection in Crohn's disease and has been incorporated into disease activity scoring systems. Currently, cine MR enterography remains underutilized. The purpose of this article is to outline how to perform and interpret cine MR enterography. The authors describe how to perform a multiphasic balanced steady state free precession sequence using different MR systems and give practical advice on how to display and interpret the cine sequence. Sample cases illustrate how the cine sequence complements standard MR enterography evaluation with T2 -weighted, contrast-enhanced T1 -weighted, and diffusion-weighted imaging.

The management of EGFR inhibitor adverse events: a case series and treatment paradigm.

BACKGROUND: Epidermal growth factor receptor (EGFR) inhibitors are widely used medications in the treatment of cancers. OBJECTIVE: To review the cutaneous adverse events related to EGFR inhibitors. METHODS: A retrospective chart review of all cases referred for the management of cutaneous adverse events after the initiation of EGFR inhibitor therapy between the years of 2006 and 2009 was performed. The study was approved by the institutional review board. RESULTS: Four men and 11 women had cutaneous adverse events while receiving erlotinib (mean dose: 112.5 mg) for lung and pancreatic cancer. The most common cutaneous adverse reaction observed was a papulopustular rash in 12 cases (80%). Eczema and xerosis were the only findings in three patients, alopecia in one case, and nail changes in three cases. The treatment modalities prescribed were doxycycline and topical antibiotics for the papulopustular rash; topical high potency steroids, tacrolimus, pimecrolimus, and moisturizers for xerosis and eczema; and cetirizine for the pruritus. The paronychia was treated with warm soaks, topical steroids, and podiatry referral. The majority of patients improved with symptomatic therapy, with the exception of one patient who experienced herpes zoster super infection and Stevens-Johnson syndrome. The patient was hospitalized and required discontinuation of the erlotinib therapy. CONCLUSION: The most common cutaneous adverse event in our cohort was papulopustular rash, followed by eczema and xerosis. Patients were managed with symptom target therapy, and suspension of the EGFR inhibitor was rarely required. As the use of EGFR inhibitors increases, it is important to promptly identify and treat adverse events. Further studies are necessary to develop targeted therapeutic and preventative measures.