Development and validation of a CT algorithm for the identification of nonperforated duodenal bulb ulcer.

PURPOSE: To assess the value of multiplanar computed tomography (CT) in the diagnosis of nonperforated duodenal bulb ulcer (NPDBU). METHOD: We retrospectively analyzed data from 135 patients with NPDBU (ulcer group) and 150 patients with a normal duodenal bulb (control group) who underwent contrast-enhanced abdominal CT and were diagnosed via upper endoscopy from January 2018 to February 2022. The clinical and CT features were compared between the two groups. Independent prognostic factors for diagnosing NPDBU were determined using binary logistic regression analysis. An external validation cohort to determine the model's efficiency comprised 80 patients from another center. RESULTS: Gastrointestinal bleeding was more frequent in patients with NPDBU than in those without (p < 0.001). No significant differences in age and sex were observed between the groups (all p > 0.05). The duodenal bulbar wall was significantly thicker in the ulcer group than in the control group, as determined using CT (p < 0.001). Irregular mucosal surface, layered enhancement, and blurred fat space around the duodenal bulb were more common in the ulcer group than in the control group (all p < 0.001). Binary logistic regression analysis revealed that gastrointestinal bleeding, wall thickness of ≥ 4.85 mm, irregular mucosal surface, and blurred peripheral fat space were the most significant variations associated with NPDBU, with an area under the curve (AUC) of 0.974. The external validation cohort had an AUC of 0.916. CONCLUSIONS: Careful multiplanar CT interpretation suggests the underlying presence of NPDBU and allows timely endoscopic verification and appropriate treatment.

Using combined CT-clinical radiomics models to identify epidermal growth factor receptor mutation subtypes in lung adenocarcinoma.

Background: To investigate the value of computed tomography (CT)-based radiomics signatures in combination with clinical and CT morphological features to identify epidermal growth factor receptor (EGFR)-mutation subtypes in lung adenocarcinoma (LADC). Methods: From February 2012 to October 2019, 608 patients were confirmed with LADC and underwent chest CT scans. Among them, 307 (50.5%) patients had a positive EGFR-mutation and 301 (49.5%) had a negative EGFR-mutation. Of the EGFR-mutant patients, 114 (37.1%) had a 19del -mutation, 155 (50.5%) had a L858R-mutation, and 38 (12.4%) had other rare mutations. Three combined models were generated by incorporating radiomics signatures, clinical, and CT morphological features to predict EGFR-mutation status. Patients were randomly split into training and testing cohorts, 80% and 20%, respectively. Model 1 was used to predict positive and negative EGFR-mutation, model 2 was used to predict 19del and non-19del mutations, and model 3 was used to predict L858R and non-L858R mutations. The receiver operating characteristic curve and the area under the curve (AUC) were used to evaluate their performance. Results: For the three models, model 1 had AUC values of 0.969 and 0.886 in the training and validation cohorts, respectively. Model 2 had AUC values of 0.999 and 0.847 in the training and validation cohorts, respectively. Model 3 had AUC values of 0.984 and 0.806 in the training and validation cohorts, respectively. Conclusion: Combined models that incorporate radiomics signature, clinical, and CT morphological features may serve as an auxiliary tool to predict EGFR-mutation subtypes and contribute to individualized treatment for patients with LADC.

Differential diagnosis of localized pneumonic-type lung adenocarcinoma and pulmonary inflammatory lesion.

BACKGROUND: In clinical practice, a number of delayed diagnoses of localized pneumonic-type lung adenocarcinoma (L-PLADC) mimicking pneumonia have been identified due to the lack of knowledge regarding the radiological findings associated with this condition. Here, we defined L-PLADC as a special type of lung adenocarcinoma that presents as a focal consolidation involving < 50% of the area of a lobe and aimed to investigate the differential clinical and imaging features between L-PLADC and localized pulmonary inflammatory lesion (L-PIL). RESULTS: The data of 120 patients with L-PLADC and 125 patients with L-PIL who underwent contrast-enhanced chest computed tomography (CT) scan were retrospectively analyzed. For clinical characteristics, older age, women, nonsmokers, and no symptom were more common in L-PLADC (all p < 0.001). With regard to CT features, air bronchogram, irregular air bronchogram, ground-glass opacity (GGO) component, and pleural retraction were more frequently observed in L-PLADC, while necrosis, satellite lesions, halo sign, bronchial wall thickening, interlobular septa thickening, pleural attachment, and pleural thickening were more commonly seen in L-PIL (all p < 0.001). Multivariate analysis showed age ≥ 58 years, female sex, GGO component, irregular air bronchogram, pleural retraction, and the absence of necrosis and pleural attachment were the most effective variations associated with L-PLADC with an AUC of 0.979. Furthermore, an external validation cohort containing 62 patients obtained an AUC of 0.929. CONCLUSIONS: L-PLADC and L-PIL have different clinical and imaging characteristics. An adequate understanding of these differential features can contribute to the early diagnosis of L-PLADC and the subsequent therapeutic strategy.

Radiological classification, gene-mutation status, and surgical prognosis of synchronous multiple primary lung cancer.

OBJECTIVE: To investigate the radiological classification, gene-mutation status, and surgical prognosis of synchronous multiple primary lung cancer (sMPLC). METHODS: From January 2013 to October 2019, 192 consecutive patients with sMPLC were investigated. The clinical, CT, molecular, and pathological features of all patients were analyzed. Furthermore, the prognosis of 89 patients who only underwent surgical resection was evaluated. RESULTS: Among 192 patients, all lesions pathologically confirmed or highly suspected as tumors based on radiological findings were retrospectively analyzed, and the CT findings of sMPLC were classified into three types: (I) all lesions manifested as solid nodules/masses (14.06%, 27/192), (II) all lesions manifested as subsolid nodules/masses (43.23%, 83/192), and (III) tumor lesions manifested as a combination of ≥ 2 of the following patterns: solid nodules/masses, subsolid nodules/masses, cystic airspace, and focal consolidation (42.71%, 82/192). For 252 tumors undergoing epidermal growth factor receptor (EGFR)-mutation testing, the EGFR-mutation rate was higher in subsolid tumors than that in solid tumors (p < 0.05). Among 19 patients with all tumors undergoing surgery and driver-gene testing, genetic heterogeneity was prevalent among the multiple tumors (63.16%,12/19). The highest clinical stage of non-I, ipsilateral distribution of tumors, and CT classification of I indicated a poor prognosis for patients with sMPLC (all p < 0.05). CONCLUSION: Subsolid lesions are the most common presentation of sMPLC. Genetic heterogeneity in driver mutations among sMPLC may be present. Prognosis in patients with sMPLC is determined by the highest clinical TNM stage, distribution, and radiological classification among the multiple tumors. KEY POINTS: • Synchronous multiple primary lung cancer (sMPLC) has three types of CT findings. • Genetic heterogeneity may be prevalent among the multiple tumors. • Prognosis in patients with sMPLC is associated with the highest clinical TNM stage, distribution, and radiological classification among the multiple tumors.

Pneumonic-type lung adenocarcinoma with different ranges exhibiting different clinical, imaging, and pathological characteristics.

BACKGROUND: Pneumonic-type lung adenocarcinoma (PLADC) with different ranges might exhibit different imaging and clinicopathological features. This study divided PLADC into localized PLADC (L-PLADC) and diffuse PLADC (D-PLADC) based on imaging and aimed to clarify the differences in clinical, imaging, and pathologic characteristics between the two new subtypes. RESULTS: The data of 131 patients with L-PLADC and 117 patients with D-PLADC who were pathologically confirmed and underwent chest computed tomography (CT) at our institute from December 2014 to December 2020 were retrospectively collected. Patients with L-PLADC were predominantly female, non-smokers, and without respiratory symptoms and elevated white blood cell count and C-reactive protein level, whereas those with D-PLADC were predominantly male, smokers, and had respiratory symptoms and elevated white blood cell count and C-reactive protein level (all p < 0.05). Pleural retraction was more common in L-PLADC, whereas interlobular fissure bulging, hypodense sign, air space, CT angiogram sign, coexisting nodules, pleural effusion, and lymphadenopathy were more frequent in D-PLADC (all p < 0.001). Among the 129 patients with surgically resected PLADC, the most common histological subtype of L-PLADC was acinar-predominant growth pattern (76.7%, 79/103), whereas that of D-PLADC was invasive mucinous adenocarcinoma (80.8%, 21/26). Among the 136 patients with EGFR mutation status, L-PLADC had a significantly higher EGFR mutation rate than D-PLADC (p < 0.001). CONCLUSIONS: L-PLADC and D-PLADC have different clinical, imaging, and pathological characteristics. This new imaging-based classification may help improve our understanding of PLADC and develop personalized treatment plans, with concomitant implications for patient outcomes.

Clinicopathological and computed tomographic features associated with occult lymph node metastasis in patients with peripheral solid non-small cell lung cancer.

OBJECTIVES: To investigate the value of combining clinicopathological characteristics with computed tomographic (CT) features of tumours for predicting occult lymph node metastasis (OLNM) in peripheral solid non-small cell lung cancer (PS-NSCLC). METHODS: The study included 478 NSCLC clinically N0 (cN0) patients who underwent lobectomy and systemic lymph node dissection from January 2014 to August 2019. Patients were classified into OLNM and negative lymph node metastasis (NLNM) groups. The CT features of non-metastatic and metastatic lymph nodes with a largest short-diameter > 5 mm were compared in the OLNM group. Thereafter, the clinicopathological characteristics and CT morphological features of tumours were compared between both groups. Multivariable logistic regression analysis and receiver-operating characteristic curve were developed. RESULTS: CT images detected 103 metastatic and 705 non-metastatic lymph nodes, and no significant differences in CT features of lymph nodes were found in all 161 OLNM patients (P > 0.05). For both groups, sex, carcinoembryonic antigen and pathological type differed significantly (all P < 0.05), while tumour size, necrosis, calcification, vascular convergence, pleural involvement, and the shortest interval of tumour-pleura differed significantly on CT images (all P < 0.05). Multivariable logistic regression analysis showed that carcinoembryonic antigen > 5.00 ng/ml, adenocarcinoma, absence of vascular convergence, and pleural involvement of Type II (one linear or cord-like pleural tag or tumour abut to the pleura with a broad base observed on both lung and mediastinal window images) were independent predicting factors of OLNM. CONCLUSIONS: CT findings of lymph nodes can provide limited value and integrating clinicopathological characteristics with the CT morphological features of tumours is helpful in predicting OLNM in patients with PS-NSCLC.

Computed Tomography Morphological Classification of Lung Adenocarcinoma and Its Correlation with Epidermal Growth Factor Receptor Mutation Status: A Report of 1075 Cases.

BACKGROUND: Many delayed diagnoses of lung adenocarcinoma (LADC) are identified due to poor understanding of protean imaging findings. Moreover, clarifying the relationship between computed tomography (CT) morphological classification and epidermal growth factor receptor (EGFR) mutations of LADC might inform therapeutic decision-making while obtaining pathological specimens is difficult. Here, we retrospectively analyzed CT manifestations of LADC and investigated the morphological classification of tumors in relation to EGFR mutation status. METHODS: We included 1075 LADC patients undergoing chest CT and EGFR genotype examinations from January 2013 to January 2019. CT morphological characteristics of tumors were carefully evaluated and their correlation with EGFR mutation status was analyzed using the chi-squared test. RESULTS: Tumors were divided into eight types: I (peripheral solid nodule/mass; 526/1075, 48.93%), II (central solid nodule/mass; 220/1075, 20.47%), III (subsolid nodule/mass; 92/1075, 8.56%), IV (focal consolidation; 32/1075, 2.98%), V (cystic airspace; 14/1075, 1.30%), VI (multiple lesions with similar appearances to I-V; 85/1075, 7.91%), VII (diffuse consolidation; 53/1075, 4.93%), VIII (occult lesion usually obscured by nonobstructive atelectasis; 53/1075, 4.93%). Type III and IV tumors were more frequent in patients with EGFR mutation, whereas type II and VII tumors were more common in patients without EGFR mutation (all P < 0.05). However, we did not identify any significant associations between other tumor types and EGFR mutation status (all P > 0.05). Among patients with type VI tumors, EGFR mutation status was closely related to tumor density (all P < 0.05). Furthermore, type VII tumors were associated with 19 deletion mutation positive and non-L858R mutation positive (all P < 0.05). CONCLUSION: LADC can be categorized into eight types based on CT imaging. Improving our understanding of the morphological classification and correlation with EGFR mutation status may contribute to the accurate diagnosis of LADC, while suggesting the presence of underlying EGFR genetic mutations.

Spectral CT in Lung Cancer: Usefulness of Iodine Concentration for Evaluation of Tumor Angiogenesis and Prognosis.

OBJECTIVE. The purpose of this study was to investigate the correlation between iodine concentration (IC) derived from spectral CT and angiogenesis and the relationships between IC and clinical-pathologic features associated with lung cancer prognosis. SUBJECTS AND METHODS. Sixty patients with lung cancer were enrolled and underwent spectral CT. The IC, IC difference (ICD), and normalized IC (NIC) of tumors were measured in the arterial phase, venous phase (VP), and delayed phase. The microvessel densities (MVDs) of CD34-stained specimens were evaluated. Correlation analysis was performed for IC and MVD. The relationships between the IC index showing the best correlations with MVD and clinical-pathologic findings of pathologic types, histologic differentiation, tumor size, lymph node status, pathologic TNM stage, and intratumoral necrosis were investigated. RESULTS. The mean (± IQR) MVD of all tumors was 42.00 ± 27.50 vessels per field at ×400 magnification, with two MVD distribution types. The MVD of lung cancer correlated positively with the IC, ICD, and NIC on three-phase contrast-enhanced scanning (r range, 0.581-0.800; all p < 0.001), and the IC in the VP showed the strongest correlation with MVD (r = 0.800; p < 0.001). The correlations between IC and MVD, ICD and MVD, and NIC and MVD varied depending on whether the same scanning phase or same IC index was used. The IC in the VP showed statistically significant differences in the pathologic types of adenocarcinoma and squamous cell carcinoma, histologic differentiation, tumor size, and status of intratumoral necrosis of lung cancer (p < 0.05), but was not associated with nodal metastasis and pathologic TNM stages (p > 0.05). CONCLUSION. IC indexes derived from spectral CT, especially the IC in the VP, were useful indicators for evaluating tumor angiogenesis and prognosis.