CT-guided percutaneous transthoracic needle biopsy for anterior mediastinal lymphoma: the role of PET/CT.

BACKGROUND: Computed tomography (CT)-guided percutaneous transthoracic needle biopsy (PTNB) is not recommended as the diagnostic modality of choice for anterior mediastinal lymphoma, despite its advantages of minimal invasiveness and easy accessibility. PURPOSE: To identify the modifiable risk factors for non-diagnostic results from CT-guided PTNB for anterior mediastinal lymphoma. MATERIAL AND METHODS: This retrospective study identified CT-guided PTNB for anterior mediastinal lesions diagnosed as lymphoma between May 2007 and December 2021. The diagnostic sensitivity and complications were investigated. The appropriateness of PTNB targeting was evaluated using positron emission tomography (PET)/CT and images from intra-procedural CT-guided PTNB. Targeting was considered inappropriate when the supposed trajectory of the cutting needle was within a region of abnormally low metabolism. The risk factors for non-diagnostic results were determined using logistic regression analysis. RESULTS: A total of 67 PTNBs in 60 patients were included. The diagnostic sensitivity for lymphoma was 76.1% (51/67), with an immediate complication rate of 4.5% (3/67). According to the PET/CT images, PTNB targeting was inappropriate in 10/14 (71.4%) of the non-diagnostic PTNBs but appropriate in all diagnostic PTNBs (P <0.001). Inappropriate targeting was the only significant risk factor for non-diagnostic results (odds ratio = 203.69; 95% confidence interval = 8.17-999.99; P = 0.001). The number of specimen acquisitions was not associated with non-diagnostic results (P = 0.40). CONCLUSIONS: Only inappropriate targeting of the non-viable portion according to PET/CT was an independent risk factor for non-diagnostic results. Acquiring PET/CT scans before biopsy and targeting the viable portion on PET/CT may help improve the diagnostic sensitivity of PTNB.

Deep Learning-Based CT Reconstruction Kernel Conversion in the Quantification of Interstitial Lung Disease: Effect on Reproducibility.

RATIONALE AND OBJECTIVES: The effect of different computed tomography (CT) reconstruction kernels on the quantification of interstitial lung disease (ILD) has not been clearly demonstrated. The study aimed to investigate the effect of reconstruction kernels on the quantification of ILD on CT and determine whether deep learning-based kernel conversion can reduce the variability of automated quantification results between different CT kernels. MATERIALS AND METHODS: Patients with ILD or interstitial lung abnormality who underwent noncontrast high-resolution CT between June 2022 and September 2022 were retrospectively included. Images were reconstructed with three different kernels: B30f, B50f, and B60f. B60f was regarded as the reference standard for quantification, and B30f and B50f images were converted to B60f images using a deep learning-based algorithm. Each disease pattern of ILD and the fibrotic score were quantified using commercial software. The effect of kernel conversion on measurement variability was estimated using intraclass correlation coefficient (ICC) and Bland-Altman method. RESULTS: A total of 194 patients were included in the study. Application of different kernels induced differences in the quantified extent of each pattern. Reticular opacity and honeycombing were underestimated on B30f images and overestimated on B50f images. After kernel conversion, measurement variability was reduced (mean difference, from -2.0 to 3.9 to -0.3 to 0.4%, and 95% limits of agreement [LOA], from [-5.0, 12.7] to [-2.7, 2.1]). The fibrotic score for converted B60f from B50f images was almost equivalent to the original B60f (ICC, 1.000; mean difference, 0.0; and 95% LOA [-0.4, 0.4]). CONCLUSION: Quantitative CT analysis of ILD was affected by the application of different kernels, but deep learning-based kernel conversion effectively reduced measurement variability, improving the reproducibility of quantification.

Deep Learning for Automated Triaging of Stable Chest Radiographs in a Follow-up Setting.

Background Most artificial intelligence algorithms that interpret chest radiographs are restricted to an image from a single time point. However, in clinical practice, multiple radiographs are used for longitudinal follow-up, especially in intensive care units (ICUs). Purpose To develop and validate a deep learning algorithm using thoracic cage registration and subtraction to triage pairs of chest radiographs showing no change by using longitudinal follow-up data. Materials and Methods A deep learning algorithm was retrospectively developed using baseline and follow-up chest radiographs in adults from January 2011 to December 2018 at a tertiary referral hospital. Two thoracic radiologists reviewed randomly selected pairs of "change" and "no change" images to establish the ground truth, including normal or abnormal status. Algorithm performance was evaluated using area under the receiver operating characteristic curve (AUC) analysis in a validation set and temporally separated internal test sets (January 2019 to August 2021) from the emergency department (ED) and ICU. Threshold calibration for the test sets was conducted, and performance with 40% and 60% triage thresholds was assessed. Results This study included 3 304 996 chest radiographs in 329 036 patients (mean age, 59 years ± 14 [SD]; 170 433 male patients). The training set included 550 779 pairs of radiographs. The validation set included 1620 pairs (810 no change, 810 change). The test sets included 533 pairs (ED; 265 no change, 268 change) and 600 pairs (ICU; 310 no change, 290 change). The algorithm had AUCs of 0.77 (validation), 0.80 (ED), and 0.80 (ICU). With a 40% triage threshold, specificity was 88.4% (237 of 268 pairs) and 90.0% (261 of 290 pairs) in the ED and ICU, respectively. With a 60% triage threshold, specificity was 79.9% (214 of 268 pairs) and 79.3% (230 of 290 pairs) in the ED and ICU, respectively. For urgent findings (consolidation, pleural effusion, pneumothorax), specificity was 78.6%-100% (ED) and 85.5%-93.9% (ICU) with a 40% triage threshold. Conclusion The deep learning algorithm could triage pairs of chest radiographs showing no change while detecting urgent interval changes during longitudinal follow-up. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Czum in this issue.

Clinical effect of progressive pulmonary fibrosis on patients with connective tissue disease-associated interstitial lung disease: a single center retrospective cohort study.

The concept of progressive pulmonary fibrosis (PPF) has been introduced to predict the diverse prognosis of interstitial lung disease (ILD). However, the incidence and effect of PPF on outcomes in patients with connective tissue disease-associated interstitial lung disease (CTD-ILD) need to be elucidated. This study reviewed 197 patients with CTD-ILD. Symptomatic worsening, pulmonary function decline, and radiological deterioration were investigated to assess the fulfillment of PPF diagnostic criteria. Clinical outcomes, including mortality, were compared based on the presence or absence of PPF. The median follow-up duration was 17.4 months. The mean age of the patients was 64.0 years, and 60.9% were female. Among the underlying CTDs, rheumatoid arthritis (42.1%), inflammatory myositis (19.8%), and systemic sclerosis (13.2%) were the most common. Of the 197 patients, 37 (18.8%) met the diagnostic criteria for PPF during the follow-up period. Even after adjusting for other significant risk factors, PPF was independently associated with mortality [hazard ratio (HR) 3.856; 95% confidence interval (CI) 1.387-10.715; P = 0.010] and baseline albumin was marginally significantly associated with mortality (HR 0.549; CI 0.298-1.010; P = 0.054). The median survival was also significantly shorter in the PPF group than in the non-PPF group (72.3 ± 12.9 vs. 126.8 ± 15.5 months, P < 0.001). Baseline KL-6 ≥ 1000 (U/mL) was a significant risk factor for PPF (HR 2.885; CI 1.165-7.144; P = 0.022). In addition to increased mortality, the PPF group had significantly higher rates of respiratory-related hospitalizations, pneumonia, acute exacerbations, and weight loss than the non-PPF group. PPF is a significant prognostic indicator in patients with CTD-ILD. Thus, healthcare professionals should know that patients with CTD-ILD are at risk of PPF.

MuSiC-ViT: A multi-task Siamese convolutional vision transformer for differentiating change from no-change in follow-up chest radiographs.

A major responsibility of radiologists in routine clinical practice is to read follow-up chest radiographs (CXRs) to identify changes in a patient's condition. Diagnosing meaningful changes in follow-up CXRs is challenging because radiologists must differentiate disease changes from natural or benign variations. Here, we suggest using a multi-task Siamese convolutional vision transformer (MuSiC-ViT) with an anatomy-matching module (AMM) to mimic the radiologist's cognitive process for differentiating baseline change from no-change. MuSiC-ViT uses the convolutional neural networks (CNNs) meet vision transformers model that combines CNN and transformer architecture. It has three major components: a Siamese network architecture, an AMM, and multi-task learning. Because the input is a pair of CXRs, a Siamese network was adopted for the encoder. The AMM is an attention module that focuses on related regions in the CXR pairs. To mimic a radiologist's cognitive process, MuSiC-ViT was trained using multi-task learning, normal/abnormal and change/no-change classification, and anatomy-matching. Among 406 K CXRs studied, 88 K change and 115 K no-change pairs were acquired for the training dataset. The internal validation dataset consisted of 1,620 pairs. To demonstrate the robustness of MuSiC-ViT, we verified the results with two other validation datasets. MuSiC-ViT respectively achieved accuracies and area under the receiver operating characteristic curves of 0.728 and 0.797 on the internal validation dataset, 0.614 and 0.784 on the first external validation dataset, and 0.745 and 0.858 on a second temporally separated validation dataset. All code is available at https://github.com/chokyungjin/MuSiC-ViT.

Efficacy and safety of transcatheter arterial embolization for hemodynamically unstable bleeding after percutaneous transthoracic needle biopsy.

PURPOSE: To evaluate the safety and efficacy of transcatheter arterial embolization (TAE) in controlling hemodynamically unstable bleeding following a percutaneous transthoracic needle biopsy (PTNB). METHODS: A total of seven patients (four men and three women; mean age, 62 ± 12 years) who received TAE for post-PTNB bleeding between May 2007 and March 2022 were included. The observed types of bleeding were hemothorax (n = 3), hemoptysis (n = 2), and a combination of both (n = 2). In patients with active bleeding, the technical success of TAE was defined as superselective embolization of the target artery with no active bleeding visible on post-TAE angiography. Clinical success was defined as sustained cessation of bleeding without hemodynamic instability, requirement of repeat TAE, or the need for post-TAE hemostatic surgery during the initial admission. The metrics analyzed included technical and clinical success rates, complications, and 30-day mortality. RESULTS: All seven patients achieved technical success, with a clinical success rate of 86% (6/7). Six patients were discharged alive, while one patient died of respiratory failure accompanied by hemothorax 19 days post-biopsy. The angiographic findings associated with bleeding were contrast media extravasation or pseudoaneurysm (n = 3) and vascular hypertrophy with tortuosity (n = 2). The implicated bleeding arteries included the intercostal artery (n = 2), bronchial artery (n = 2), and internal thoracic artery (n = 1). In two cases, no clear bleeding foci were identified; nonetheless, prophylactic embolization was performed on the right intercostal artery (n = 1) and right intercostobronchial trunk (n = 1). The embolic agents utilized included microcoils (n = 1), gelatin sponge particles (n = 2), polyvinyl alcohol (PVA) with gelatin sponge particles (n = 1), PVA with microcoils (n = 1), microcoils with gelatin sponge particles (n = 1), and microcoils with n-butyl-2-cyanoacrylate and gelatin sponge particles (n = 1). The 30-day mortality rate was 14% (1/7). No ischemic complications related to TAE were observed. CONCLUSION: The study suggests that TAE is safe and effective for controlling hemodynamically unstable bleeding following a PTNB.

CT Coronary Angiography and Dynamic CT Myocardial Perfusion for Detection of Cardiac Allograft Vasculopathy.

BACKGROUND: Cardiac allograft vasculopathy (CAV) is a major obstacle limiting long-term graft survival. Effective noninvasive surveillance modalities reflecting both coronary artery and microvascular components of CAV are needed. OBJECTIVES: The authors evaluated the diagnostic performance of dynamic computed tomography-myocardial perfusion imaging (CT-MPI) and coronary computed tomography angiography (CCTA) for CAV. METHODS: A total of 63 heart transplantation patients underwent combined CT-MPI and CCTA plus invasive coronary angiography (ICA) with intravascular ultrasonography (IVUS) between December 2018 and October 2021. The median interval between CT-MPI and heart transplantation was 4.3 years. Peak myocardial blood flow (MBF) of the whole myocardium (MBFglobal) and minimum MBF (MBFmin) among the 16 segments according to the American Heart Association model, except the left ventricular apex, were calculated from CT-MPI. CCTA was assessed qualitatively, and the degree of coronary artery stenosis was recorded. CAV was diagnosed based on both ICA (ISHLT criteria) and IVUS. Patients were followed up for a median time of 2.3 years after CT-MPI and a median time of 5.7 years after transplantation. RESULTS: Among the 63 recipients, 35 (55.6%) had diagnoses of CAV. The median MBFglobal and MBFmin were significantly lower in patients with CAV (128.7 vs 150.4 mL/100 mL/min; P = 0.014; and 96.9 vs 122.8 mL/100 mL/min; P < 0.001, respectively). The combined use of coronary artery stenosis on CCTA and MBFmin showed the highest diagnostic performance with an area under the curve of 0.886 (sensitivity: 74.3%, specificity: 96.4%, positive predictive value: 96.3%, and negative predictive value: 75.0%). CONCLUSIONS: The combination of CT-MPI and CCTA demonstrated excellent diagnostic performance for the detection of CAV. One-stop evaluation of the coronary artery and microvascular components involved in CAV using combined CCTA and CT-MPI may be a potent noninvasive screening method for early detection of CAV.

Prognostic Implications of Synchronous Subsolid Nodules in Patients with Resected Subsolid Lung Adenocarcinoma.

Background For multiple subsolid nodules (SSNs) observed at lung CT, current management focuses on removal of the dominant (≥6 mm) nodule and monitoring of remaining SSNs. Whether the presence of these synchronous SSNs is related to postoperative patient outcomes has not been well established. Purpose To evaluate the prognostic value of single versus multiple synchronous SSNs at preoperative CT in patients with resected subsolid lung adenocarcinoma nodules. Materials and Methods This retrospective study included patients who underwent lobectomy or sublobar resection for lung adenocarcinoma manifesting as an SSN and clinical stage IA from January 2010 to December 2017. The radiologic features of the resected SSN (dominant nodule) and synchronous SSNs were assessed on preoperative CT scans. The effects of synchronous SSNs on time to secondary intervention, time to recurrence (TTR), and overall survival (OS) were evaluated using Cox regression analysis. Results Of the 684 included patients (mean age, 60.9 years ± 9.5 [SD]; 389 female), 515 (75.3%) had a single SSN and 169 (24.7%) had multiple SSNs on preoperative CT scans. During follow-up (median, 71.8 months), 38 secondary interventions were performed, primarily due to growth of synchronous SSNs (21 of 38) or metachronous nodules (14 of 38). As the number of synchronous SSNs greater than or equal to 6 mm in size increased, the time to secondary intervention decreased (P < .001). No association was observed between synchronous SSNs and TTR (P = .53) or OS (P = .65), but these measures were associated with features of the resected nodule, specifically solid portion size for TTR (P = .01) and histologic subtype for TTR and OS (P < .001 for both). Conclusion In patients with subsolid lung adenocarcinoma, the presence of synchronous SSNs on preoperative CT scans was not associated with TTR or OS, but the presence of synchronous SSNs greater than or equal to 6 mm in size was associated with an increased likelihood of secondary intervention. © RSNA, 2023 Supplemental material is available for this article.

Automated CT quantification of interstitial lung abnormality and interstitial lung disease according to the Fleischner Society in patients with resectable lung cancer: prognostic significance.

OBJECTIVE: To assess the prognostic significance of automatically quantified interstitial lung abnormality (ILA) according to the definition by the Fleischner Society in patients with resectable non-small-cell lung cancer (NSCLC). METHODS: Patients who underwent lobectomy or pneumonectomy for NSCLC between January 2015 and December 2019 were retrospectively included. Preoperative CT scans were analyzed using the commercially available deep-learning-based automated quantification software for ILA. According to quantified results and the definition by the Fleischner Society and multidisciplinary discussion, patients were divided into normal, ILA, and interstitial lung disease (ILD) groups. RESULTS: Of the 1524 patients, 87 (5.7%) and 20 (1.3%) patients had ILA and ILD, respectively. Both ILA (HR, 1.81; 95% CI: 1.25-2.61; p = .002) and ILD (HR, 5.26; 95% CI: 2.99-9.24; p < .001) groups had poor recurrence-free survival (RFS). Overall survival (OS) decreased (HR 2.13 [95% CI: 1.27-3.58; p = .004] for the ILA group and 7.20 [95% CI: 3.80-13.62, p < .001] for the ILD group) as the disease severity increased. Both quantified fibrotic and non-fibrotic ILA components were associated with poor RFS (HR, 1.57; 95% CI: 1.12-2.21; p = .009; and HR, 1.11; 95% CI: 1.01-1.23; p = .03) and OS (HR, 1.59; 95% CI: 1.06-2.37; p = .02; and HR, 1.17; 95% CI: 1.03-1.33; and p = .01) in normal and ILA groups. CONCLUSIONS: The automated CT quantification of ILA based on the definition by the Fleischner Society predicts outcomes of patients with resectable lung cancer based on the disease category and quantified fibrotic and non-fibrotic ILA components. CLINICAL RELEVANCE STATEMENT: Quantitative CT assessment of ILA provides prognostic information for lung cancer patients after surgery, which can help in considering active surveillance for recurrence, especially in those with a larger extent of quantified ILA. KEY POINTS: • Of the 1524 patients with resectable lung cancer, 1417 (93.0%) patients were categorized as normal, 87 (5.7%) as interstitial lung abnormality (ILA), and 20 (1.3%) as interstitial lung disease (ILD). • Both ILA and ILD groups were associated with poor recurrence-free survival (hazard ratio [HR], 1.81, p = .002; HR, 5.26, p < .001, respectively) and overall survival (HR, 2.13; p = .004; HR, 7.20; p < .001). • Both quantified fibrotic and non-fibrotic ILA components were associated with recurrence-free survival and overall survival in normal and ILA groups.

Evaluation of Chylothorax Using Dynamic Contrast-Enhanced Magnetic Resonance Lymphangiography After Lung Cancer Surgery.

Background: To determine the role of dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) in the management of postoperative chylothorax after lung cancer surgery. Methods and Results: Between July 2017 and November 2021, patients who developed postoperative chylothorax following pulmonary resection and mediastinal lymph node dissection were assessed and those who underwent DCMRL for the evaluation of chyle leak were evaluated. The findings of DCMRL and conventional lymphangiography were compared. The incidence of postoperative chylothorax was 0.9% (50/5587). Among the patients with chylothorax, a total of 22 patients (44.0% [22/50]; mean age, 67.6 ± 7.9 years; 15 men) underwent DCMRL. Treatment outcomes were compared between patients with conservative management (n = 10) and those with intervention (n = 12). The patients demonstrated unilateral pleural effusion, ipsilateral to the operation site, and showed right-sided dominance. The most frequent site of thoracic duct injury showing contrast media leakage was visualized at the subcarinal level. No DCMRL-related complication occurred. DCMRL showed comparable performance to conventional lymphangiography in visualizing the central lymphatics, including cisterna chyli (DCMRL vs. conventional lymphangiography, 72.7% vs. 45.5%, p = 0.25) and thoracic duct (90.9% vs. 54.5%, p = 0.13), and in localizing thoracic duct injury (90.9% vs. 54.5%, p = 0.13). On follow-up, the amount of chest tube drainage after lymphatic intervention showed a significant difference over time from that after medical treatment only (p = 0.02). Conclusion: DCMRL can provide detailed information about the leak site and the central lymphatic anatomy in patients with chylothorax after lung cancer surgery. The findings of DCMRL can guide subsequent treatment planning for optimal outcomes.

Dynamic Contrast-Enhanced Magnetic Resonance Lymphangiography and Lymphatic Interventions for Pediatric Patients with Various Lymphatic Diseases.

Background: To demonstrate the magnetic resonance lymphangiography (MRL) imaging findings of lymphatic diseases and the clinical outcomes of lymphatic embolization in pediatric patients. Methods and Results: This retrospective study included 10 consecutive pediatric patients who underwent MRL for lymphatic diseases between June 2017 and June 2021. Nine patients underwent dynamic contrast-enhanced MRL with bilateral inguinal lymph node injection of diluted gadolinium, and one patient underwent nonenhanced MRL with a heavily T2-weighted image. The etiology of lymphatic disease was classified into three categories based on the magnetic resonance findings. The resolution of chylous fluid and weight-adjusted amounts of chylous fluid collected from a drainage tube were evaluated as outcomes. Patients were classified as postoperative lymphatic leak (n = 3), pulmonary lymphatic perfusion syndrome (n = 3), central lymphatic flow disorder (CLFD; n = 3), and primary lymphatic dysfunction (Gorham-Stout syndrome; n = 1). Three patients underwent radiological lymphatic intervention, and one CLFD patient underwent surgical intervention. In patients with postoperative lymphatic leak, the median chest tube drainage decreased significantly after the intervention [from 87.9 to 12.4 mL/(kg·d); p = 0.02]. However, in one CLFD patient, the amount of chylous fluid did not decrease until 7 days after intervention. Conclusion: The etiology of lymphatic disease in pediatrics can be recognized on MRL, and lymphatic intervention can be performed for cessation of lymphatic leak, even though the treatment outcomes may differ according to the underlying etiology. MRL can play an important role in classifying lymphatic disease, and in planning treatment on the basis of the lymphatic anatomy and underlying etiology.

Air embolism in CT-guided transthoracic needle biopsy: emphasis on pulmonary vein injury.

OBJECTIVE: To assess whether pulmonary vein injury is detectable on CT and associated with air embolism after percutaneous transthoracic needle biopsy (PTNB) in a tertiary referral hospital. METHODS: Between January 2012 and November 2021, 11,691 consecutive CT-guided PTNBs in 10,685 patients were retrospectively evaluated. Air embolism was identified by reviewing radiologic reports. Pulmonary vein injury was defined as the presence of the pulmonary vein in the needle pathway or shooting range of the cutting needle with the presence of parenchymal hemorrhage. The association between pulmonary vein injury and air embolism was assessed using logistic regression analysis in matched patients with and without air embolism with a ratio of 1:4. RESULTS: A total of 27 cases of air embolism (median age, 67 years; range, 48-80 years; 24 men) were found with an incidence of 0.23% (27/11,691). Pulmonary vein injury during the procedures was identifiable on CT in 24 of 27 patients (88.9%), whereas it was 1.9% (2/108) for matched patients without air embolism The veins beyond the target lesion (70.8% [17/24]) were injured more frequently than the veins in the needle pathway before the target lesion (29.2% [7/24]). In univariable and multivariable analyses, pulmonary vein injury was associated with air embolism (odds ratio, 485.19; 95% confidence interval, 68.67-3428.19, p <.001). CONCLUSION: Pulmonary vein injury was detected on CT and was associated with air embolism. Avoiding pulmonary vein injury with careful planning of the needle pathway on CT may reduce air embolism risk. KEY POINTS: • Pulmonary vein injury during CT-guided biopsy was identifiable on CT in most of the patients (88.9% [24/27]). • The veins beyond the target lesion (70.8% [17/24]) were injured more frequently than the veins in the needle pathway before the target lesion (29.2% [7/24]). • Avoiding the distinguishable pulmonary vein along the pathway or shooting range of the needle on CT may reduce the air embolism risk.

Characteristics and outcomes of anterior mediastinal cystic lesions diagnosed on chest MRI: implications for management of cystic lesions.

BACKGROUND: Chest MRI is a useful diagnostic modality for the evaluation of anterior mediastinal lesions but the outcomes of anterior mediastinal cystic lesions diagnosed on chest MRI are unclear. METHODS: In this multicenter retrospective study, patients who underwent contrast-enhanced chest MRI in two tertiary centers to assess anterior mediastinal cystic lesions were included after excluding overt solid tumors and thymic hyperplasia. Anterior mediastinal cystic lesions were classified into two categories: probable (simple) cyst or indeterminate lesion (complex cyst). Size and imaging features of lesions during follow-up were evaluated and clinical outcomes were assessed. RESULTS: A total of 204 patients (mean age, 59 ± 11 years; M:F = 111:93) were studied; 186 (91.2%) were classified as probable cysts and 18 (8.8%) as indeterminate lesions on MRI. Among patients with probable cysts and more than 2 years of follow-up, lesion size was unchanged in 39.6% (36/91), decreased in 16.5% (15/91), and fluctuated in 8.8% (8/91). All patients who underwent surgery were confirmed cysts. None developed mural nodules or irregular wall thickening, suspicious for malignancy during follow-up. In patients with indeterminate lesions, 16.7% (3/18) had pathologically confirmed thymoma and 44.4% (8/18) had proven cysts. Follow-up numbers and intervals after MRI in patients with probable cysts were variable among physicians and institutions in clinical practice (p < 0.05) but more than half were followed for up to 2 years in two centers. CONCLUSION: Diagnosing anterior mediastinal cysts using MRI is reliable. MRI-based management of anterior mediastinal lesions may reduce the number of unnecessary follow-ups and surgeries.

Classification of severe aortic stenosis and outcomes after aortic valve replacement.

Aortic valve calcium scoring by cardiac computed tomographic (CT) has been recommended as an alternative to classify the AS (aortic stenosis) severity, but it is unclear that whether CT findings would have additional value to discriminate significant AS subtypes including high gradient severe AS, classic low-flow, low gradient (LF-LG) AS, paradoxical LF-LG AS, and moderate AS. In this study, we examined the preoperative clinical and cardiac CT findings of different subtypes of AS in patients with surgical aortic valve replacement (AVR) and evaluated the subtype classification as a factor affecting post-surgical outcomes. This study included 511 (66.9 ± 8.8 years, 55% men) consecutive patients with severe AS who underwent surgical AVR. Aortic valve area (AVA) was obtained by echocardiography (AVAecho) and by CT (AVACT) using each modalities measurement of the left ventricular outflow tract. Patients with AS were classified as (1) high-gradient severe (n = 438), (2) classic LF-LG (n = 18), and (3) paradoxical LF-LG (n = 55) based on echocardiography. In all patients, 455 (89.0%) patients were categorized as severe AS according to the AVACT. However, 56 patients were re-classified as moderate AS (43 [9.8%] high-gradient severe AS, 5 [27.8%] classic LF-LG AS, and 8 [14.5%] paradoxical LF-LG AS) by AVACT. The classic LF-LG AS group presented larger AVACT and aortic annulus than those in high-gradient severe AS group and one third of them had AVACT ≥ 1.2 cm2. After multivariable adjustment, old age (hazard ratio [HR], 1.04, P = 0.049), high B-type natriuretic peptide (BNP) (HR, 1.005; P < 0.001), preoperative atrial fibrillation (HR, 2.75; P = 0.003), classic LF-LG AS (HR, 5.53, P = 0.004), and small aortic annulus on CT (HR, 0.57; P = 0.002) were independently associated with major adverse cardiac and cerebrovascular events (MACCE) after surgical AVR.

Impact of the Liver Imaging Reporting and Data System on Research Studies of Diagnosing Hepatocellular Carcinoma Using MRI.

OBJECTIVE: Since its introduction in 2011, the CT/MRI diagnostic Liver Imaging Reporting and Data System (LI-RADS) has been updated in 2014, 2017, and 2018. We evaluated the impact of CT/MRI diagnostic LI-RADS on liver MRI research methodology for the diagnosis of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: The MEDLINE, EMBASE, and Cochrane databases were searched for original articles reporting the diagnostic performance of liver MRI for HCC between 2011 and 2019. The MRI techniques, image analysis methods, and diagnostic criteria for HCC used in each study were investigated. The studies were classified into three groups according to the year of publication (2011-2013, 2014-2016, and 2017-2019). We compared the percentage of studies adopting MRI techniques recommended by LI-RADS, image analysis methods in accordance with the lexicon defined in LI-RADS, and diagnostic criteria endorsed by LI-RADS. We compared the pooled sensitivity and specificity between studies that used the LI-RADS and those that did not. RESULTS: This systematic review included 179 studies. The percentages of studies using imaging techniques recommended by LI-RADS were 77.8% for 2011-2013, 85.7% for 2014-2016, and 84.2% for 2017-2019, with no significant difference (p = 0.951). After the introduction of LI-RADS, the percentages of studies following the LI-RADS lexicon were 0.0%, 18.4%, and 56.6% in the respective periods (p < 0.001), while the percentages of studies using the LI-RADS diagnostic imaging criteria were 0.0%, 22.9%, and 60.7%, respectively (p < 0.001). Studies that did not use the LI-RADS and those that used the LI-RADS version 2018 showed no significant difference in sensitivity and specificity (86.3% vs. 77.7%, p = 0.102 and 91.4% vs. 89.9%, p = 0.770, respectively), with some difference in heterogeneity (I² = 94.3% vs. 86.7% in sensitivity and I² = 86.6% vs. 53.2% in specificity). CONCLUSION: LI-RADS imparted significant changes in the image analysis methods and diagnostic criteria used in liver MRI research for the diagnosis of HCC.

Targeted Delivery of Exosomes Armed with Anti-Cancer Therapeutics.

Among extracellular vesicles, exosomes have gained great attention for their role as therapeutic vehicles for delivering various active pharmaceutical ingredients (APIs). Exosomes "armed" with anti-cancer therapeutics possess great potential for an efficient intracellular delivery of anti-cancer APIs and enhanced targetability to tumor cells. Various technologies are being developed to efficiently incorporate anti-cancer APIs such as genetic materials (miRNA, siRNA, mRNA), chemotherapeutics, and proteins into exosomes and to induce targeted delivery to tumor burden by exosomal surface modification. Exosomes can incorporate the desired therapeutic molecules via direct exogenous methods (e.g., electroporation and sonication) or indirect methods by modifying cells to produce "armed" exosomes. The targeted delivery of "armed" exosomes to tumor burden could be accomplished either by "passive" targeting using the natural tropism of exosomes or by "active" targeting via the surface engineering of exosomal membranes. Although anti-cancer exosome therapeutics demonstrated promising results in preclinical studies, success in clinical trials requires thorough validation in terms of chemistry, manufacturing, and control techniques. While exosomes possess multiple advantages over synthetic nanoparticles, challenges remain in increasing the loading efficiency of anti-cancer agents into exosomes, as well as establishing quantitative and qualitative analytical methods for monitoring the delivery of in vivo administered exosomes and exosome-incorporated anti-cancer agents to the tumor parenchyma.

Impact of Brain MRI on the Diagnosis of Infective Endocarditis and Treatment Decisions: Systematic Review and Meta-Analysis.

BACKGROUND. Despite increasing use of brain MRI to evaluate patients with suspected infective endocarditis, the clinical impact of brain MRI in this setting has not yet been systematically reviewed. OBJECTIVE. The purpose of this study was to evaluate the frequency of brain MRI findings in patients with suspected or confirmed infective endocarditis and to determine the impact of such findings on clinical decisions. EVIDENCE ACQUISITION. A systematic search of the PubMed, Embase, and Cochrane databases was performed from January 1, 1990, to December 31, 2020, to identify original research investigations of brain MRI in patients with suspected or confirmed infective endocarditis. Study quality was assessed with QUADAS-2. Study endpoints included the frequency of brain MRI findings and the frequency of diagnostic modifications, modification of therapeutic plan, and modification of valve surgery plan resulting from MRI findings. Frequencies were pooled by means of the inverse variance method. Subgroup analysis was performed. EVIDENCE SYNTHESIS. A total of 21 studies with 2133 patients were included. Overall study quality was considered moderate. In terms of brain MRI findings, the pooled frequency of acute ischemic lesions was 61.9% (95% CI, 50.7-71.9%); of cerebral microbleeds, 52.9% (95% CI, 41.6-63.9%); hemorrhagic lesions, 24.7% (95% CI, 15.1-37.9%); abscess or meningitis, 9.5% (95% CI, 5.6-15.6%); and intracranial mycotic aneurysm, 6.2% (95% CI, 4.0-9.4%). Subgroup analysis after exclusion of three studies in which neurologic findings were the indication for all brain MRI examinations yielded similar frequencies of these findings. Six studies included results on the impact of brain MRI findings on clinical decisions. The frequencies of diagnostic modifications in two studies were 5.4% and 32.1%. The pooled frequency of therapeutic plan modification in six studies was 12.8% (95% CI, 6.5-23.7%) and of surgical plan modification in five studies was 14.2% (95% CI, 8.2-23.4%). CONCLUSION. In patients with suspected or confirmed infective endocarditis, brain MRI examinations commonly show relevant abnormalities that affect diagnostic and therapeutic clinical decisions. CLINICAL IMPACT. The findings support a potential role for screening brain MRI in the evaluation of patients with suspected or confirmed infective endocarditis, regardless of the presence or absence of neurologic symptoms.

Application of computer-aided diagnosis for Lung-RADS categorization in CT screening for lung cancer: effect on inter-reader agreement.

OBJECTIVES: To evaluate the effects of computer-aided diagnosis (CAD) on inter-reader agreement in Lung Imaging Reporting and Data System (Lung-RADS) categorization. METHODS: Two hundred baseline CT scans covering all Lung-RADS categories were randomly selected from the National Lung Cancer Screening Trial. Five radiologists independently reviewed the CT scans and assigned Lung-RADS categories without CAD and with CAD. The CAD system presented up to five of the most risk-dominant nodules with measurements and predicted Lung-RADS category. Inter-reader agreement was analyzed using multirater Fleiss κ statistics. RESULTS: The five readers reported 139-151 negative screening results without CAD and 126-142 with CAD. With CAD, readers tended to upstage (average, 12.3%) rather than downstage Lung-RADS category (average, 4.4%). Inter-reader agreement of five readers for Lung-RADS categorization was moderate (Fleiss kappa, 0.60 [95% confidence interval, 0.57, 0.63]) without CAD, and slightly improved to substantial (Fleiss kappa, 0.65 [95% CI, 0.63, 0.68]) with CAD. The major cause for disagreement was assignment of different risk-dominant nodules in the reading sessions without and with CAD (54.2% [201/371] vs. 63.6% [232/365]). The proportion of disagreement in nodule size measurement was reduced from 5.1% (102/2000) to 3.1% (62/2000) with the use of CAD (p < 0.001). In 31 cancer-positive cases, substantial management discrepancies (category 1/2 vs. 4A/B) between reader pairs decreased with application of CAD (pooled sensitivity, 85.2% vs. 91.6%; p = 0.004). CONCLUSIONS: Application of CAD demonstrated a minor improvement in inter-reader agreement of Lung-RADS category, while showing the potential to reduce measurement variability and substantial management change in cancer-positive cases. KEY POINTS: • Inter-reader agreement of five readers for Lung-RADS categorization was minimally improved by application of CAD, with a Fleiss kappa value of 0.60 to 0.65. • The major cause for disagreement was assignment of different risk-dominant nodules in the reading sessions without and with CAD (54.2% vs. 63.6%). • In 31 cancer-positive cases, substantial management discrepancies between reader pairs, referring to a difference in follow-up interval of at least 9 months (category 1/2 vs. 4A/B), were reduced in half by application of CAD (32/310 to 16/310) (pooled sensitivity, 85.2% vs. 91.6%; p = 0.004).

Volume Doubling Times of Pulmonary Metastases in Patients With Bone and Soft-Tissue Sarcomas: Associations With Subsequent New Metastases and Survival After Metastasectomy.

BACKGROUND. Pulmonary metastases of bone and soft-tissue sarcoma are common and have a high recurrence rate after metastasectomy. Factors associated with postmetastasectomy recurrence are not well studied. OBJECTIVE. The purpose of this study was to investigate the association of the volume doubling time (VDT) of pulmonary metastases with the subsequent development of new pulmonary nodules and survival after metastasectomy in patients with bone or soft-tissue sarcoma. METHODS. This retrospective study included patients with bone or soft-tissue sarcoma who, between January 2010 and December 2020, underwent first complete metastasectomy of pulmonary nodules visualized on two sequential preoperative CT scans. Semiautomatic volumetric segmentation of the pulmonary metastases was performed on the two CT scans, and VDTs were calculated. VDT was compared between patients with and without subsequent new metastases after metastasectomy. Cox proportional hazards regression analyses were performed to determine risk factors for recurrence-free survival (RFS) after metastasectomy and for postmetastasectomy overall survival (OS). RESULTS. Forty patients (21 women, 19 men; mean age, 51.1 ± 14.3 [SD] years) were included. Of these patients, 23 (57.5%) developed new metastatic nodules after metastasectomy, and 10 (25.0%) died during follow-up. Median VDT was shorter in patients with, versus those without, new metastases after metastasectomy (56 vs 140 days, p = .002). Only four of 23 patients with new metastases had VDT of 140 days or more. In multivariable analysis, older age (hazard ratio [HR], 1.06; p = .004), female sex (HR, 2.80; p = .03), and VDT less than 140 days (HR, 4.22; p = .01) were independent predictors of worse RFS. Also in multivariable analysis, only older age (HR, 1.17; p = .005) and VDT less than 50 days (HR, 8.60; p = .02) were independent predictors of worse OS. OS was significantly worse in patients with VDT less than 140 days (10 deaths among 27 patients) than in patients with VDT of 140 days or more (no deaths in 13 patients) (p = .01). CONCLUSION. In patients with bone and soft-tissue sarcoma, shorter VDT of pulmonary metastases is independently associated with subsequent new metastases after metastasectomy and worse OS. CLINICAL IMPACT. VDT of pulmonary nodules may be considered in patient selection for pulmonary metastasectomy and in postoperative patient management.

Identification of predictors for brain metastasis in newly diagnosed non-small cell lung cancer: a single-center cohort study.

OBJECTIVES: To identify clinical and staging chest CT characteristics predictive of brain metastasis in patients with newly diagnosed NSCLC dichotomized according to resectability. METHODS: Patients newly diagnosed with NSCLC of clinical stages II-IV between November 2017 and October 2018 were enrolled and classified into resectable (stage II+IIIA) and unresectable stages (stage IIIB/C+IV) according to chest CT. Associations of clinicopathological characteristics and CT findings with brain metastasis were analyzed using logistic regression. Predictive models were evaluated using receiver operating characteristics curve analysis. A subgroup analysis for unresectable-stage patients with known epidermal growth factor receptor gene (EGFR) mutation status was performed. RESULTS: This study included 911 NSCLC patients (mean age, 65 ± 11 years; 620 men), 194 of whom were diagnosed with brain metastasis. For resectable stages, independent predictors for brain metastasis were N2-stage (13 of 25 patients), absence of air-bronchogram/bubble lucency (23 of 25 patients), and presence of spiculation (15 of 25 patients), with a model combining the two imaging features showing an AUC of 0.723. In unresectable stages, independent predictors of brain metastasis were younger age, female sex, extrathoracic metastasis, and adenocarcinoma, with models combining these showing AUCs of 0.675-0.766. In the subgroup with known EGFR-mutation status, extrathoracic metastasis and positive EGFR mutation were independent predictors of brain metastasis, with the model showing AUCs of 0.641-0.732. CONCLUSION: CT-derived imaging features, clinical stages, lung cancer subtype, and EGFR mutation were associated with brain metastasis in patients with newly diagnosed NSCLC. The predictors were completely different between resectable and unresectable stages. KEY POINTS: • In resectable stages of NSCLC, two imaging features (absence of air-bronchogram/bubble lucency and presence of spiculation) and N2 stage were independent predictors of brain metastasis. • In unresectable stages of NSCLC, younger age, female sex, extrathoracic metastasis, and adenocarcinoma were associated with brain metastasis. • In the subgroup of NSCLC with known EGFR-mutation status, extrathoracic metastasis and positive EGFR mutation were independent predictors of brain metastasis.