Deep-learning enabled ultrasound based detection of gallbladder cancer in northern India: a prospective diagnostic study.

Background: Gallbladder cancer (GBC) is highly aggressive. Diagnosis of GBC is challenging as benign gallbladder lesions can have similar imaging features. We aim to develop and validate a deep learning (DL) model for the automatic detection of GBC at abdominal ultrasound (US) and compare its diagnostic performance with that of radiologists. Methods: In this prospective study, a multiscale, second-order pooling-based DL classifier model was trained (training and validation cohorts) using the US data of patients with gallbladder lesions acquired between August 2019 and June 2021 at the Postgraduate Institute of Medical Education and research, a tertiary care hospital in North India. The performance of the DL model to detect GBC was evaluated in a temporally independent test cohort (July 2021-September 2022) and was compared with that of two radiologists. Findings: The study included 233 patients in the training set (mean age, 48 ± (2SD) 23 years; 142 women), 59 patients in the validation set (mean age, 51.4 ± 19.2 years; 38 women), and 273 patients in the test set (mean age, 50.4 ± 22.1 years; 177 women). In the test set, the DL model had sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) of 92.3% (95% CI, 88.1-95.6), 74.4% (95% CI, 65.3-79.9), and 0.887 (95% CI, 0.844-0.930), respectively for detecting GBC which was comparable to both the radiologists. The DL-based approach showed high sensitivity (89.8-93%) and AUC (0.810-0.890) for detecting GBC in the presence of stones, contracted gallbladders, lesion size <10 mm, and neck lesions, which was comparable to both the radiologists (p = 0.052-0.738 for sensitivity and p = 0.061-0.745 for AUC). The sensitivity for DL-based detection of mural thickening type of GBC was significantly greater than one of the radiologists (87.8% vs. 72.8%, p = 0.012), despite a reduced specificity. Interpretation: The DL-based approach demonstrated diagnostic performance comparable to experienced radiologists in detecting GBC using US. However, multicentre studies are warranted to explore the potential of DL-based diagnosis of GBC fully. Funding: None.

Agreement of Gallbladder Reporting and Data System for Gallbladder Wall Thickening at Ultrasonography: A Multireader Validation Study.

Objective: This article aims to evaluate the intrareader and interreader agreement of ultrasound (US) gallbladder reporting and data system (GB-RADS) and validate the risk of malignancy in each GB-RADS category. Materials and methods: This retrospective study comprised consecutive patients with nonacute gallbladder wall thickening who underwent US evaluation between January 2019 and December 2022. Three radiologists independently read the static US images and cine-loops for GB-RADS findings and assigned GB-RADS categories. The intraobserver (static images) and interobserver (static images and cine-loops) agreement was calculated using kappa statistics and Krippendorff's alpha. Another radiologist assigned a consensus GB-RADS category. The percentage of malignancy in each GB-RADS category was calculated. Results: Static US images of 414 patients (median age, 56 years; 288 women, benign = 45.6% and malignant = 54.4%) and cine-loops of 50 patients were read. There was weak to moderate intrareader agreement for most GB-RADS findings and moderate intrareader agreement for the GB-RADS category for all readers. On static images, the interreader agreement was acceptable for GB-RADS categories. On cine-loops, the interreader agreement for GB-RADS findings and categories was better than static images. The percentage of malignancy was 1.2%, 37%, 71.1%, and 89.1% in GB-RADS 2, 3, 4, and 5 categories. Conclusion: GB-RADS has moderate intrareader for GB-RADS categories. As originally proposed, the risk of malignancy is negligible in GB-RADS 2 category and highest in GB-RADS 5 category. However, the discriminatory performance of GB-RADS 3 and 4 categories is low. Larger multicenter studies with more readers must assess the reader agreement and validate the GB-RADS systems for wider clinical utilization.

Diagnostic Performance of Abbreviated MRI for HCC Detection in Patients with Non-alcoholic Fatty Liver Disease.

Background/Aim: Hepatocellular carcinoma (HCC) surveillance is recommended in nonalcoholic fatty liver disease (NAFLD)-related cirrhosis. The performance of ultrasound (US) is impaired in NAFLD. This study aimed to evaluate the diagnostic performance of non-contrast abbreviated magnetic resonance imaging (AMRI) for HCC detection in NAFLD. Methods: Consecutive contrast-enhanced magnetic resonance imaging (CE-MRI) scans of NAFLD patients between June 2017 and December 2021 were retrieved. A radiologist extracted and anonymized a noncontrast AMRI dataset comprising T2-weighted, T1-weighted, and diffusion-weighted imaging (DWI) sequences. Two radiologists blinded to CE-MRI reports and treatment details independently reviewed the AMRI for liver lesion and portal vein (PV) characteristics. HCC and malignant PV thrombosis were diagnosed based on the original dynamic CE-MRI diagnostic reports. The diagnostic performance of AMRI and the interobserver agreement for detecting HCC and malignant PV thrombosis were calculated. Results: Seventy-five patients (52 males; mean age (±SD), 56 ± 17.6 years; 61 cirrhotic) were included. Nine patients had HCC (14 HCCs). The sensitivity, specificity, positive predictive value, and negative predictive value of AMRI for detecting HCC were 100%, 93.9%, 69.2%, and 100%, respectively, and malignant PV thrombosis was 100%, 98.5%, 80%, and 100%, respectively. There was substantial interobserver agreement for detecting HCC (kappa = 0.721) and malignant PV thrombosis (kappa = 0.645) on AMRI. Conclusion: AMRI has high diagnostic performance in HCC detection in patients with NAFLD. However, prospective studies must compare the diagnostic performance of AMRI with that of US.

Spectrum of Multidetector Computed Tomography Imaging Findings in Iatrogenic Abdominopelvic Injuries: A Comprehensive Pictorial Review.

Iatrogenic injuries are unavoidable complications of surgeries and minimally invasive procedures. They are generally classified into vascular and nonvascular injuries and based on the time of injury into early and late injuries. Iatrogenic injuries, particularly vascular injuries, increase the mortality and morbidity, with prolongation of hospital-stay. Multidetector computed tomography (MDCT) is a highly sensitive, and often the first imaging modality in suspected iatrogenic injuries. This pictorial review elucidates the imaging considerations and appearances of iatrogenic injuries of the abdominopelvic organs on MDCT.

Sonographic "Cervix Sign": A New Ancillary Sign of Gallbladder Neck Malignancy.

Background: The differentiation of benign and malignant gallbladder wall thickening is challenging. The purpose of this study is to evaluate a new sonographic sign, "cervix sign" for differentiation of benign and malignant gallbladder neck thickening. Methods: This retrospective study comprised consecutive patients with gallbladder neck thickening who underwent sonography between August 2019 and December 2021. The presence of "cervix sign" was assessed by two radiologists independently. Results: Sixty-five patients had gallbladder neck thickening (28 malignant and 37 benign). The sonographic "cervix sign" was present in 18 (64%) patients with malignant thickening and in only one (2.7%) patient with benign thickening (P = 0.0001). The mean wall thickness was greater, and symmetric wall thickening and liver metastases were more common in malignant thickening with "cervix sign" (without reaching statistical significance). There was substantial agreement (kappa = 0.78) between the two observers for the cervix sign. Conclusion: Sonographic "cervix sign" is a useful ancillary feature of gallbladder neck cancer.

Gastrointestinal involvement in gallbladder cancer: Computed tomography findings and proposal of a classification system.

BACKGROUND: There is relatively scarce data on the computed tomography (CT) detection of gastrointestinal (GI) involvement in gallbladder cancer (GBC). We aim to assess the GI involvement in GBC on CT and propose a CT-based classification. METHODS: This retrospective study comprized consecutive patients with GBC who underwent contrast-enhanced computed tomography (CECT) for staging between January 2019 and April 2022. Two radiologists evaluated the CT images independently for the morphological type of GBC and the presence of GI involvement. GI involvement was classified into probable involvement, definite involvement and GI fistulization. The incidence of GI involvement and the association of GI involvement with the morphological type of GBC was evaluated. In addition, the inter-observer agreement for GI involvement was assessed. RESULTS: Over the study period, 260 patients with GBC were evaluated. Forty-three (16.5%) patients had GI involvement. Probable GI involvement, definite GI involvement and GI fistulization were seen in 18 (41.9%), 19 (44.2%) and six (13.9%) patients, respectively. Duodenum was the most common site of involvement (55.8%), followed by hepatic flexure (23.3%), antropyloric region (9.3%) and transverse colon (2.3%). There was no association between GI involvement and morphological type of GBC. There was substantial to near-perfect agreement between the two radiologists for the overall GI involvement (k = 0.790), definite GI involvement (k = 0.815) and GI fistulization (k = 0.943). There was moderate agreement (k = 0.567) for probable GI involvement. CONCLUSION: GBC frequently involves the GI tract and CT can be used to categorize the GI involvement. However, the proposed CT classification needs validation.

An Aberrant Right Subclavian Artery-Esophageal Fistula-A Fatal Complication of a Common Anomaly: A Case Report and Review of Literature.

An aberrant right subclavian artery (ARSA), also called as arteria lusoria, is one of the most common aortic arch anomalies. ARSA-esophageal fistula is a rare, life-threatening complication, with only 37 cases reported in literature. We describe a case of a young girl who developed acute episode of massive hematemesis after the recovery from novel coronavirus disease 2019 (COVID-19) pneumonia. Computed tomography (CT) angiography showed ARSA with retroesophageal course and active contrast leak in esophagus. Digital subtraction angiography confirmed the site of active contrast extravasation from the ARSA. However, the patient succumbed to hypovolemic shock even before the endovascular or surgical interventions could be done.

Two-dimensional Shear Wave Elastography: Utility in Differentiating Gallbladder Cancer From Chronic Cholecystitis.

OBJECTIVE: To study the utility of 2D shear wave elastography (SWE) and ascertain cut-off values of shear wave elasticity (SWe) to differentiate benign and malignant thickening of the gallbladder wall. METHODS: This study was a prospective study of patients with symptomatic gallstone disease (GSD, n = 51) and gallbladder cancer (GBC, n = 46) and controls without any biliary disease (n = 46). All the participants underwent 2D USG and SWE of the gallbladder. Grey-scale ultrasound and SWE were done in the different regions in the gallbladder. RESULTS: The median age of the patients with GSD was 49 years (interquartile range [IQR]: 33-55), GBC was 55 years (IQR: 46-65), and controls was 37 years (IQR: 27-48.25). In patients with GBC, asymmetrical mural thickening was the predominant imaging pattern (n = 24, 52.2%). The mean SWe of the abnormal area in GBC (34.99 ± 17.77 kPa [n = 46]) was significantly higher than that of the uninvolved region (18.27 ± 8.12 kPa [n = 35]; P < .01). The mean SWe of the uninvolved region in GBC (18.27 ± 8.12 kPa [n = 35]) was also significantly higher (P < .01) than that of GSD (12.27 ± 4.13 kPa [n = 51]) and controls (10.52 ± 3.75 kPa [n = 46]). On ROC analysis, AUC of 0.927, at a cut-off of 20 kPa, sensitivity was 91.3%, specificity was 83.5%, positive likelihood ratio was 5.54, and negative likelihood ratio was 0.10 to diagnose GBC. CONCLUSION: The 2D SWE is a reliable adjunctive tool to grey-scale USG in differentiating the malignant from benign gallbladder wall and may help to pick up early malignancy in GSD.

Home-based intensive nutrition therapy improves frailty and sarcopenia in patients with decompensated cirrhosis: A randomized clinical trial.

BACKGROUND AND AIM: The majority of patients with decompensated cirrhosis suffer from malnutrition, a potentially modifiable contributor to frailty and sarcopenia. The present study investigated the impact of a 6-month dietician-supported home-based intensive nutrition therapy (HINT) intervention on objective frailty and sarcopenia metrics in patients with decompensated cirrhosis. METHODS: One hundred adult patients with decompensated cirrhosis, frailty, and sarcopenia at baseline were randomized 1:1 to receive standard medical therapy (SMT) plus HINT (intervention) versus SMT (control) alone. The primary outcome was an improvement in frailty as measured by the liver frailty index (LFI). Secondary outcome measures included sarcopenia metrics, liver disease severity scores, hospitalization, and death. RESULTS: The LFI improved more in the intervention arm as compared with controls (0.8 vs 0.4; P < 0.001). Baseline and end-of-study skeletal muscle index (SMI) was available in a subset of 32 male patients, with greater improvements seen in the intervention arm compared with controls (6.36 vs 0.80; P = 0.02). Patients in the intervention arm had less hospitalizations over the 6-month follow-up (19 [38%] vs 29 [58%]; P = 0.04). On subgroup analysis, in the 64% of patients who were adherent to calorie and protein intake targets at 6 months, significant improvement was seen in liver disease severity scores and survival (P < 0.05). CONCLUSION: In patients with decompensated cirrhosis, frailty, and sarcopenia, a 6-month dietitian-supported home-based intensive outpatient nutrition therapy was associated with statistically and clinically relevant improvement in frailty. The subgroup of adherent patients showed improvement in their liver disease scores and reduction in mortality. These findings support the key role of food as medicine in the management of cirrhosis.

Congenital unilateral pulmonary vein atresia: A rare disease with successful outcome in a child.

Unilateral pulmonary vein atresia is a rare congenital anomaly that may occur in association with other congenital heart diseases. We report a rare case of left-sided pulmonary vein atresia in a 2-year-old child who presented with recurrent hemoptysis and was managed surgically with left pneumonectomy.

Role of dual energy computed tomography in evaluation of suspected wall thickening type of gallbladder cancer.

Introduction: Accurate characterization of gallbladder wall thickening is of paramount importance. This study evaluated the role of dual-energy computed tomography (DECT) in the evaluation of gallbladder wall thickening. Material and methods: Seven consecutive patients (mean age 52.3 years, 5 males) with suspected wall thickening type of gallbladder cancer (GBC) who underwent DECT between August 2020 and March 2021 were included. Independent radiologists blinded to the final diagnosis reviewed the iodine maps, 80 keV, and 140 keV images separately. The final diagnosis was based on histopathology or cytology. Results: Two patients had xanthogranulomatous cholecystitis and 5 had GBC. Asymmetrical mural thickening was identified in six patients on iodine maps and five patients at 80 keV. Non-layered mural thickening was seen in all patients on iodine maps, 80 keV, and 140 keV. Iodine maps identified heterogeneous enhancement in all patients. Conclusions: These preliminary results suggest that DECT has the potential to characterize gallbladder wall thickening.

Gallbladder reporting and data system (GB-RADS) for risk stratification of gallbladder wall thickening on ultrasonography: an international expert consensus.

The Gallbladder Reporting and Data System (GB-RADS) ultrasound (US) risk stratification is proposed to improve consistency in US interpretations, reporting, and assessment of risk of malignancy in gallbladder wall thickening in non-acute setting. It was developed based on a systematic review of the literature and the consensus of an international multidisciplinary committee comprising expert radiologists, gastroenterologists, gastrointestinal surgeons, surgical oncologists, medical oncologists, and pathologists using modified Delphi method. For risk stratification, the GB-RADS system recommends six categories (GB-RADS 0-5) of gallbladder wall thickening with gradually increasing risk of malignancy. GB-RADS is based on gallbladder wall features on US including symmetry and extent (focal vs. circumferential) of involvement, layered appearance, intramural features (including intramural cysts and echogenic foci), and interface with the liver. GB-RADS represents the first collaborative effort at risk stratifying the gallbladder wall thickening. This concept is in line with the other US-based risk stratification systems which have been shown to increase the accuracy of detection of malignant lesions and improve management.

Grayscale ultrasonography findings for characterization of gallbladder wall thickening in non-acute setting: a systematic review and meta-analysis.

BACKGROUND: The accurate characterization of gallbladder wall thickening (GWT) into benign or malignant on ultrasound (US) is a significant challenge. METHODS: We searched the MEDLINE and EMBASE databases for studies reporting two-dimensional grayscale US in benign and malignant GWT. The pooled prevalence was calculated using a generalized linear mixed method with a random-effects model. The pooled sensitivity and specificity were calculated using a bivariate random-effects model. RESULTS: Of the 7309 studies screened by titles, 73 studies with 18,008 patients were included. The most common findings in xanthogranulomatous cholecystitis (XGC) were lack of wall disruption and intramural hypoechoic nodules while adenomyomatosis (ADM) was frequently associated with intramural cysts and intramural echogenic foci. Echogenic foci, lack of gallbladder wall disruption, and hypoechoic nodules had a sensitivity of 89%, 77%, and 66% and specificity of 86%, 51%, and 80%, respectively for the diagnosis of benign GWT. Focal thickening and indistinct liver interface had a sensitivity of 75% and 55% and specificity of 64% and 69%, respectively for the diagnosis of malignant GWT. CONCLUSION: intramural features (echogenic foci, hypoechoic nodules), gallbladder wall disruption, and liver interface are useful US features for the characterization of GWT.

Imaging patterns of wall thickening type of gallbladder cancer.

Gallbladder cancer (GBC) has a high incidence in certain geographical regions. Morphologically, GBC presents as a mass replacing the gallbladder, a polypoidal lesion, or wall thickening. The incidence of preoperative diagnosis of wall thickening type of GBC is less well studied. The patterns of mural involvement and extramural spread are not well described in the literature. Additionally, wall thickening in the gallbladder does not always indicate malignancy and can be secondary to inflammatory or benign gallbladder diseases and extracholecystic causes and systemic pathologies. Objective reporting of gallbladder wall thickening will help us appreciate GBC's early features. In this review, we illustrate the imaging patterns of wall thickening type of GBC.

Abbreviated MRI for hepatocellular carcinoma screening: A systematic review and meta-analysis.

BACKGROUND & AIMS: Biannual ultrasound has poor sensitivity for hepatocellular carcinoma (HCC) screening. MRI is accurate for the detection of HCC, but a complete MRI is not feasible as a screening tool. Abbreviated MRI (AMRI) is an acceptable alternative. The diagnostic performance of different AMRI protocols is not known. We performed a systematic review to determine the diagnostic accuracy of AMRI for HCC screening. METHODS: We searched the MEDLINE and EMBASE databases for studies reporting the diagnostic accuracy of AMRI for HCC screening. The pooled sensitivity and specificity of different AMRI protocols were calculated based on a random intercept logistic regression model. The diagnostic performance of AMRI was compared with ultrasound. Study quality was assessed using the QUADAS-2 tool. RESULTS: Of the 11,327 studies screened by titles, 15 studies (3 prospective and 12 retrospective: 2,807 patients, 917 with HCC) were included in the final analysis. The pooled per-patient sensitivity and specificity were 86% (95% CI 84-88%, I2 0%) and 94% (95% CI 91-96%, I2 83%), respectively. Pooled per-lesion sensitivity was 77% (95% CI 74-81%, I2 8%). There was no influence of study type, screening setting, reference standard, and presence and etiology of cirrhosis on the performance of AMRI. The sensitivity of AMRI for detection of HCC <2 cm was lower than that for HCC ≥2 cm (69% vs. 86%). The sensitivity and specificity of non-contrast AMRI were comparable to contrast-enhanced AMRI (86% and 94% vs. 87% and 94%, respectively). The diagnostic performance of different non-contrast AMRI and contrast-enhanced AMRI protocols was comparable. The sensitivity of ultrasound was lower than AMRI (53% vs. 82%). CONCLUSIONS: AMRI has high sensitivity and specificity for HCC screening. Different AMRI protocols have comparable diagnostic performance. LAY SUMMARY: Abbreviated MRI (AMRI) has been suggested as an alternative to ultrasound and complete MRI for hepatocellular carcinoma (HCC) screening. Our study results showed that AMRI has a high per-patient and per-lesion sensitivity for HCC. Although the sensitivity of AMRI for detection of HCC <2 cm is considerably lower than for HCC ≥2 cm, it is substantially higher than ultrasound, making it a potential alternative for HCC screening in high-risk populations.