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.

Proposal for a new morphological "combined type" of gallbladder cancer: description of radiopathological characteristics and comparison with other morphological types.

OBJECTIVE: To describe the radiopathological characteristics of a new morphological "combined type" of gallbladder cancer (GBC) and compare it with the mass replacing gallbladder and thickening types of GBC. MATERIALS AND METHODS: The imaging and pathological details of consecutive patients with GBC between August 2020 and December 2022 were retrospectively reviewed. Two radiologists reviewed computed tomography/magnetic resonance imaging in consensus for the morphological type of GBC. The radiologists classified GBC as mass replacing gallbladder, wall thickening, and combined type. The combined type was defined as a mass arising from the thickened wall of an adequately distended gallbladder that extended exophytically into the adjacent liver parenchyma. The presence of calculi, site, and size of lesion, biliary/portal vein involvement, liver, lymph node, and omental metastases was compared among the various types. The pathological characteristics were also compared. RESULTS: Of the 481 patients (median age 55 years, 63.2% females) included in the study, mass replacing gallbladder, wall thickening, and combined-type GBC were seen in 42.8% (206/481), 40.5% (195/481), and 16.6% (80/481) of patients, respectively. In the combined type of GBC, biliary/portal vein involvement was seen in 63.7% (51/80) and 7.5% (6/80) of patients. Liver, lymph node, and omental metastases were seen in 67.5% (54/80), 40% (32/80), and 41.2% (33/80) patients, respectively. Liver metastases were significantly more common in the combined type (p = 0.002). There were no significant differences in pathological characteristics among the various types. CONCLUSION: Combined-type GBC is less common than the mass replacing gallbladder and thickening types and is associated with a higher risk of liver metastases.

Imaging Diagnosis and Management of Fistulas in Pancreatitis.

Pancreatic fistula is a highly morbid complication of pancreatitis. External pancreatic fistulas result when pancreatic secretions leak externally into the percutaneous drains or external wound (following surgery) due to the communication of the peripancreatic collection with the main pancreatic duct (MPD). Internal pancreatic fistulas include communication of the pancreatic duct (directly or via intervening collection) with the pleura, pericardium, mediastinum, peritoneal cavity, or gastrointestinal tract. Cross-sectional imaging plays an essential role in the management of pancreatic fistulas. With the help of multiplanar imaging, fistulous tracts can be delineated clearly. Thin computed tomography sections and magnetic resonance cholangiopancreatography images may demonstrate the communication between MPD and pancreatic fluid collections or body cavities. Endoscopic retrograde cholangiography (ERCP) is diagnostic as well as therapeutic. In this review, we discuss the imaging diagnosis and management of various types of pancreatic fistulas with the aim to sensitize radiologists to timely diagnosis of this critical complication of pancreatitis.

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.

2D Shear wave elastography for evaluation of renal cortex and medulla: stiffness values in healthy children.

PURPOSE: To evaluate renal cortical and medullary stiffness using 2D Shear-wave elastography (SWE) in healthy children. METHODS: In this IRB approved prospective study, we measured the stiffness of cortex and medulla of children (4 months-17 years) at the upper pole, mid pole, and lower pole in bilateral kidneys. RESULTS: The median (IQR) values of renal cortex in <1 year age group was 8.7 (5.7-11.7) kPa for right and 8.7 (4.2-14.1) kPa for the left side. For 1-5 years age group, it was 7.3 (5.3-10) kPa for the right and 8.9 (6-12.3) kPa for the left side. For >5 years, it was 7.4 (5.3-11.2) kPa for the right and 9.6 (6.2-12.7) kPa for the left side. The median (IQR) values of renal medulla in <1 year age group was 7.1 (5.1-12.5) kPa for right and 6.8 (4-10.6) kPa for the left side. For 1-5 years age group, it was 7.2 (4.9-9.7) kPa for the right and 6.9 (5.6-9.9) kPa for the left side. For >5 years, it was 6.8 (5.1-9.6) kPa for the right and 7 (5-10.2) kPa for the left side. The differences in the elasticity values amongst these groups were statistically insignificant (p>0.05). There was a significant correlation between SWE values of cortex and medulla of right kidney (ρ=0.64) and of left kidney (ρ=0.61), respectively. CONCLUSION: SWE values of renal cortical and medullary stiffness in healthy children do not correlate with age. There is a significant correlation between SWE values of cortex and medulla of the kidneys in healthy children.

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.

Hemorrhagic Lesions in the Central Nervous System: Toxoplasmosis in a Person Living With Human Immunodeficiency Virus Infection and Acquired Immunodeficiency Syndrome.

Central nervous system (CNS) toxoplasmosis is one of the common causes of hemorrhagic brain lesions in people living with HIV and AIDS (PLWHA), resulting in high mortality and morbidity. It has a broad clinical and neuro-radiological spectrum, which may or may not be limited to typical findings of focal and subacute neurological deficits or ring-enhancing lesions in the basal ganglia. Here, we present a case of a patient who is a newly detected person living with HIV and AIDS with a low CD4 cell count and classical imaging findings of central nervous system toxoplasmosis on his magnetic resonance imaging (MRI) of the brain. The incidence of opportunistic infections has been reduced after introducing highly active antiretroviral therapy (HAART); this case will be helpful to clinicians in identifying CNS toxoplasmosis as it has classical imaging findings on the MRI brain.

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.

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.

Effect of change in sequence of administration of DTwP and Hepatitis B vaccines on perception of pain in infants: A randomized control trial.

OBJECTIVE: This study was designed with objective to study pain response of infants to change in sequence of administration of Hepatitis B and DTwP vaccines. METHODS: This was a randomized parallel control trial. The study was carried out in the immunization clinic of the Department of Pediatrics, LLRM Medical College, Meerut. One hundred and thirty healthy term infants up to 4 months of age were injected either DTwP vaccine first or Hepatitis B vaccine first, followed one minute later by the other vaccine. RESULT: Baseline characteristics did not differ between the groups. The mean (SD) of AUC of MFCS and NIPS was significantly more in DF group as compared to HF group (for MFCS 25.5 ± 5.4 versus 22.5 ± 5.5, p<0.01; for NIPS 31.77 ± 5.5 versus 27.64 ± 6.9, p < 0.01). Similarly mean (SD) of AUC of Heart rate and saturation of oxygen showed significant variation in DF group as compared to HF group (for heart rate 591.6 ± 55 versus 559.6 ± 49, p< 0.01; for SpO2 326.4 ± 12 versus 335 ± 8, p < 0.01). CONCLUSION: These results showed that infant experienced lesser pain when Hepatitis B was administered first than when DTwP vaccine was given first.