Multimodal modeling with low-dose CT and clinical information for diagnostic artificial intelligence on mediastinal tumors: a preliminary study.

BACKGROUND: Diagnosing mediastinal tumours, including incidental lesions, using low-dose CT (LDCT) performed for lung cancer screening, is challenging. It often requires additional invasive and costly tests for proper characterisation and surgical planning. This indicates the need for a more efficient and patient-centred approach, suggesting a gap in the existing diagnostic methods and the potential for artificial intelligence technologies to address this gap. This study aimed to create a multimodal hybrid transformer model using the Vision Transformer that leverages LDCT features and clinical data to improve surgical decision-making for patients with incidentally detected mediastinal tumours. METHODS: This retrospective study analysed patients with mediastinal tumours between 2010 and 2021. Patients eligible for surgery (n=30) were considered 'positive,' whereas those without tumour enlargement (n=32) were considered 'negative.' We developed a hybrid model combining a convolutional neural network with a transformer to integrate imaging and clinical data. The dataset was split in a 5:3:2 ratio for training, validation and testing. The model's efficacy was evaluated using a receiver operating characteristic (ROC) analysis across 25 iterations of random assignments and compared against conventional radiomics models and models excluding clinical data. RESULTS: The multimodal hybrid model demonstrated a mean area under the curve (AUC) of 0.90, significantly outperforming the non-clinical data model (AUC=0.86, p=0.04) and radiomics models (random forest AUC=0.81, p=0.008; logistic regression AUC=0.77, p=0.004). CONCLUSION: Integrating clinical and LDCT data using a hybrid transformer model can improve surgical decision-making for mediastinal tumours, showing superiority over models lacking clinical data integration.

Successful thoracoscopic operative approach for refractory pneumothorax in interstitial lung disease under local anaesthesia.

Refractory pneumothorax associated with interstitial lung disease (ILD) remains a challenging condition due to the patient's tolerability and lung compliance that restrict the feasibility of aggressive interventions. Additionally, many cases recur after improvement with treatment, and reports of successful management for this complicated condition are limited. Herein, we report the case of a 60-year-old man with ILD, utilizing home oxygen therapy, who experienced a successful recovery from a surgical intervention under local anaesthesia for pneumothorax. This case highlights the potential for operative intervention under local anaesthesia as a viable option for patients who do not respond to internal approaches.

Zero-leak prediction during major lung resection aiming for minimal chest drainage duration: a retrospective analysis.

BACKGROUND: Early chest tube removal should be considered to enhance recovery after surgery. The current study aimed to provide a predictive algorithm for air leak episodes (ALE) and to create a knowledge base for early chest tube removal. METHODS: This retrospective study enrolled patients who underwent thoracoscopic anatomical pulmonary resections in our unit. We defined ALE as any airflow ≥ 10 mL/min recorded in the follow-up charts based on the digital thoracic drainage device. Multivariate regression analysis was used to control for preoperative and intraoperative confounding factors. The ALE prediction algorithm was constructed by combining an additive ALE risk-scoring system using the coefficients of the significant predictive factors with the intraoperative water-sealing test. RESULTS: In 485 consecutive thoracoscopic major pulmonary resections, ALE developed in 209 (43%) patients. Statistically significant ALE-associated preoperative factors included male sex, lower body mass index, radiologically evident emphysema, lobectomy, and upper lobe surgery. Significant ALE-associated intraoperative factors were incomplete fissure and pleural adhesion. The ALE risk scoring demonstrated an average area under the receiver operating characteristic curve of 0.72 in the fivefold cross-validation test. The ALE prediction algorithm correctly predicted ALE-absent patients at a negative predictive value of 80%. CONCLUSIONS: The algorithm may promote the optimization of the chest tube-dwelling duration by identifying potential ALE-absent patients for accelerated tube removal.

Low-Dose CT Screening of Persistent Subsolid Lung Nodules: First-Order Features in Radiomics.

BACKGROUND: Nondisappearing subsolid nodules requiring follow-up are often detected during lung cancer screening, but changes in their invasiveness can be overlooked owing to slow growth. We aimed to develop a method for automatic identification of invasive tumors among subsolid nodules during multiple health checkups using radiomics technology based on low-dose computed tomography (LD-CT) and examine its effectiveness. METHODS: We examined patients who underwent LD-CT screening from 2014 to 2019 and had lung adenocarcinomas resected after 5-year follow-ups. They were categorized into the invasive or less-invasive group; the annual growth/change rate (Δ) of the nodule voxel histogram using three-dimensional CT (e.g., tumor volume, solid volume percentage, mean CT value, variance, kurtosis, skewness, and entropy) was assessed. A discriminant model was designed through multivariate regression analysis with internal validation to compare its efficacy with that of a volume doubling time of < 400 days. RESULTS: The study included 47 tumors (23 invasive, 24 less invasive), with no significant difference in the initial tumor volumes. Δskewness was identified as an independent predictor of invasiveness (adjusted odds ratio, 0.021; p = 0.043), and when combined with Δvariance, it yielded high accuracy in detecting invasive lesions (88% true-positive, 80% false-positive). The detection model indicated surgery 2 years earlier than the volume doubling time, maintaining accuracy (median 3 years vs.1 year before actual surgery, p = 0.011). CONCLUSION: LD-CT radiomics showed promising potential in ensuring timely detection and monitoring of subsolid nodules that warrant follow-up over time.

A case of a thoracic mass negative on thoracentesis diagnosed by cryobiopsy from the visceral pleura.

Thoracoscopy under local anaesthesia is recommended for malignant tumours with negative pleural effusion cytology. Cryobiopsy from the visceral pleura by thoracoscopy under local anaesthesia can provide more diagnostic options for patients with thoracentesis-negative malignant effusions. Here we present the first case in which this technique was used. The patient had a pleural metastasis that could not be diagnosed even with rapid cytology of the parietal pleura biopsy. Indications, technical pitfalls, and safety tips are discussed.

Fish Bone Descending in the Mediastinum.

Ingested sharp foreign bodies rarely migrate extraluminally into adjacent organs such as the pharynx, lungs, and liver. Herein, we report a case of fish bone ingestion where the foreign body followed a unique migration trajectory. Computed tomography revealed a fish bone extraluminally located in the aortopulmonary space in the left mediastinum and peri-esophageal pneumomediastinum. Endoscopic examination indicated no injury to the esophageal mucosa but showed mucosal lacerations in the left hypopharynx. Accordingly, we reasoned that the fish bone penetrated the laryngopharynx and then descended in the mediastinum.

Single-Direction Approach for Thoracoscopic Segmentectomy of the Left Upper Lobe Anterior Segment With Mediastinal Lingular Artery.

Thoracoscopic resection of the anterior segment of the left upper lobe (S3) is technically challenging because of the intricate hilar structure and multiple intersegmental planes to be dissected. A single-direction approach for S3 segmentectomy is a technique in which surgeons dissect the hilum structures exclusively from the ventral side without dividing the interlobar fissure. Our consecutive case series and a representative surgical video demonstrated the feasibility of this approach in cases where the lingular artery arises from the first branch of the left pulmonary artery (mediastinal lingular artery).

Epidermal growth factor receptor (EGFR) mutation testing is useful for primary lung cancer diagnosis and appropriate surgical resection: A case series.

Primary lung cancer was suspected in three patients upon chest computed tomography (CT) and bronchoscopy. Wash cytology revealed that all patients had lesions categorized as class III or lower (Papanicolaou classification), and the wash solution was then subjected to an epidermal growth factor receptor (EGFR) mutation search. As a result, exon 19 deletion was found in two patients, whereas an exon 21 L858R mutation was found in one. Therefore, all three patients underwent surgery without pathological evidence, and surgical pathology subsequently confirmed the diagnosis of primary lung adenocarcinoma. As observed, EGFR mutation testing was useful for cancer diagnosis.

Efficacy of the Segment-Counting Method in Predicting Lung Function and Volume Following Stapler-Based Thoracoscopic Segmentectomy.

PURPOSE: To investigate the accuracy of a segment-counting method in predicting lung function and volume after stapler-based thoracoscopic segmentectomy in comparison with lobectomy. METHODS: Between 2014 and 2018, patients who underwent these procedures were retrospectively reviewed. Thoracic computed tomography and spirometry data before and 1 year after the surgery were assessed. We evaluated the differences between the predicted values using a segment-counting method and the actual postoperative values for lung function and volume in each group. Sub-analyses were also performed to assess the impact of the number of staples and resected segments in predicting patient outcomes. RESULTS: We included 116 patients (segmentectomy, 69; lobectomy, 47). Actual postoperative lung function and volume values matched the predicted values in the stapler-based segmentectomy group, and significantly exceeded the predictions in the lobectomy group (P <0.01). Sub-analyses revealed lower postoperative lung function values than predicted existed after single segmentectomy, with an odds ratio of 3.29 (95% confidence interval: 1.02-10.70, P = 0.04) in a multivariable analysis. The degree of predicted error regarding lung function was negligible. CONCLUSIONS: The segment-counting method was useful in predicting lung function after stapler-based thoracoscopic segmentectomy. Segmentectomy rarely yielded lower-than-predicted lung function and volume values.

Radiomics technology for identifying early-stage lung adenocarcinomas suitable for sublobar resection.

OBJECTIVE: Early-stage lung adenocarcinomas that are suitable for limited resection to preserve lung function are difficult to identify. Using a radiomics approach, we investigated the efficiency of voxel-based histogram analysis of 3-dimensional computed tomography images for detecting less-invasive lesions suitable for sublobar resection. METHODS: We retrospectively reviewed the medical records of 197 patients with pathological stage 0 or IA adenocarcinomas who underwent lung resection for primary lung cancer at our institution between January 2014 and June 2018. The lesions were categorized as either less invasive or invasive. We evaluated tumor volumes, solid volume percentages, mean computed tomography values, and variance, kurtosis, skewness, and entropy levels. We analyzed the relationships between these variables and pathologically less-invasive lesions and designed an optimal model for detecting less-invasive adenocarcinomas. RESULTS: Univariate analysis revealed seven variables that differed significantly between less invasive (n = 71) and invasive (n = 141) lesions. A multivariate analysis revealed odds ratios for tumor volumes (0.64; 95% confidence interval (CI), 0.46-0.89; P = .008), solid volume percentages (0.96; 95% CI, 0.93-0.99; P = .024), skewness (3.45; 95% CI, 1.38-8.65; P = .008), and entropy levels (0.21; 95% CI, 0.07-0.58; P = .003). The area under the receiver operating characteristic curve was 0.90 (95% CI, 0.85-0.94) for the optimal model containing these 4 variables, with 85% sensitivity and 79% specificity. CONCLUSIONS: Voxel-based histogram analysis of 3-dimensional computed tomography images accurately detected early-stage lung adenocarcinomas suitable for sublobar resection.

The treatment and survival of patients with postoperative recurrent thymic carcinoma and neuroendocrine carcinoma: a multicenter retrospective study.

PURPOSE: There are few data available on the outcomes of postoperative recurrent thymic carcinoma (TC) and thymic neuroendocrine carcinoma (TNEC). The aim of this study is to evaluate the treatment and survival in patients with recurrent TC and TNEC after undergoing surgical resection. METHODS: A retrospective chart review was performed using our multicenter database to identify patients with a postoperative recurrence of TC and TNEC from 1995 to 2018. The clinicopathological factors were reviewed and the survival outcomes were analyzed. RESULTS: Sixty patients were identified among 152 patients who underwent resection of TC and TNEC. The median follow-up period from the first recurrence was 14.8 months (range 0-144). The 5-year post-recurrence survival was 23% for the whole cohort. According to a univariable analysis, advanced stage [hazard ratio (HR) 2.81, 95% confidence interval (CI) 1.09-9.54], interval between primary surgery and recurrence (HR 0.97, 95% CI 0.95-0.99), any treatment for recurrence (HR: 0.27, 95% CI 0.13-0.58) and chemotherapy for recurrence (HR: 0.46, 95% CI 0.22-0.95) were significant factors related to post-recurrence survival. CONCLUSIONS: Chemotherapy rather than surgery appears to be the mainstay treatment for managing patients with postoperative recurrent TC and TNEC and it may also be considered in multidisciplinary management. Further studies with a larger sample size are required to confirm our findings.

Incidental mediastinal masses detected at low-dose CT screening: prevalence and radiological characteristics.

PURPOSE: The primary and secondary aims were to investigate the prevalence of incidental mediastinal masses on low-dose chest CT examinations during health check-ups, and to review the radiological characteristics of prevascular mediastinal masses, respectively. MATERIALS AND METHODS: This retrospective study included 38,861 participants (mean age: 57.1 years; range: 21-99 years; men: 51.3%; never-smokers: 57.4%) who underwent low-dose chest CT examinations between January 2011 and December 2016. All images with incidental mediastinal masses were reviewed, and prevascular mediastinal masses were assessed for qualitative and quantitative imaging characteristics by two radiologists. Univariate and multivariate analyses were performed in clinical and CT features between some combinations of participants. RESULTS: Overall, 653 participants (1.68%, 653 of 38,861) had incidental mediastinal masses; 578 in prevascular mediastinum, including 93 intrathymic cysts and 24 thymic epithelial tumors. Presence of mediastinal mass was not significantly associated with sex (p = 0.089) and smoking history (p = 0.098) but with age (p < 0.001). Significant differences were found between intrathymic cysts and thymic epithelial tumors in terms of shapes (p = 0.049), contours (p = 0.018), and CT values (p = 0.012). CONCLUSION: The prevalence of asymptomatic mediastinal masses on low-dose chest CT was 1.68%. CT values, shapes, and contours may effectively distinguish intrathymic cysts from thymic epithelial tumors.

Early postoperative inflammatory response by procedure types: stapler-based segmentectomy versus lobectomy.

OBJECTIVE: Perioperative C-reactive protein (CRP) levels have become a contentious topic on the surgical outcome of lung cancer, but the influence of the procedure types has not been precisely investigated. From this viewpoint, we compared two types of thoracoscopic anatomical lung resection: segmentectomy and lobectomy. METHODS: This was a retrospective study involving patients who underwent standardized anatomical lung resection at a single institute from 2014 to 2017; CRP levels were routinely measured on postoperative days 1, 3, and 5. Changes in the CRP levels from the preoperative period were calculated (ΔCRP), and factors associated with a higher ΔCRP value were analyzed. RESULTS: Among 186 patients included, 91 (48.9%) patients underwent stapler-based segmentectomy and 95 (51.1%) patients underwent lobectomy. The segmentectomy group showed significantly higher ΔCRP values on every measurement day than the lobectomy group, in spite of shorter operation time, smaller blood loss, shorter drainage periods, shorter dissection time, and limited lymph node dissection. The number of stapler cartridges for the lung parenchyma was significantly larger in the segmentectomy group. Regression analyses indicated that procedure type and smoking history were associated with a higher ΔCRP value, whereas no significant difference was indicated in the smoking history between the groups. CONCLUSION: In our cohort, stapler-based thoracoscopic segmentectomy was associated with an increase in acute inflammatory response despite favorable perioperative outcome compared to lobectomy. Local surgical stress and damage in the remaining segments might play a key role and warrants further investigation.

The impact of surgical chest wall damage caused by classic thoracotomy on pulmonary function and morphology.

OBJECTIVES: Postoperative changes in pulmonary function (PF) and morphology due to surgical chest wall damage by thoracotomy with rib resection are unclear. Therefore, we evaluated the effects of surgical damage on PF and morphology at > 6 months postoperatively by comparing different lung lobectomy approaches. METHODS: A total of 140 patients who underwent lobectomy for lung diseases between January 2006 and March 2016 were analyzed. Patients who underwent PF tests and computed tomography (CT) scans preoperatively and postoperatively were divided into posterolateral thoracotomy with one rib resection (PT) group and video-assisted thoracoscopic surgery (VATS) group. A 1:1 propensity score-matched (PSM) analysis was used to balance clinically important confounders between the groups. Regarding morphology, lung volume was measured semi-automatically using image analysis software and reconstructed three-dimensional (3D) images. RESULTS: After PSM, 31 patients in each group were compared. Perioperative reduction ratios in forced vital capacity (FVC) (- 23% vs. - 13%; P = 0.006) and forced expiratory volume in 1 s (FEV1) (- 19% vs. - 12%; P = 0.02) were significantly larger for the PT group. No significant differences in lung volume values based on 3D CT volumetry (PT vs. VATS; total lung volume: - 7.9% vs. - 7.2%, P = 0.82; non-resected ipsilateral lung volume: + 36% vs. + 40%, P = 0.69; contralateral lung volume: + 9.3% vs. + 9.4%, P = 0.98) were found in either group. CONCLUSIONS: Among the patients underwent lobectomy, classic thoracotomy decreased PF by an additional FVC loss of 10% and FEV1 loss of 7% compared with VATS, without affecting residual lung volume.

[Thoracic Incisions for Open Chest Surgery;Posterolateral Thoracotomy, Anterolateral Thoracotomy, Axillary Thoracotomy, and Muscle Sparing Thoracotomy].

Lung disease requiring surgical treatment has shifted from pulmonary tuberculosis that was prevalent in the 1940s during wartime to lung cancer in the last half century. The surgical approach for pulmonary tuberculosis was open chest surgery. Likewise for lung cancer, a thoracotomy approach had initially been used for a while. Thoracoscopic minimally invasive surgery became more widely used around 1990 and was shown to improve the patient's quality of life (QOL). Currently, thoracoscopic surgery and robotic surgery are the mainstream procedures for patients with lung cancer, and thoracotomy procedures have fallen out of favor. However, in some cases of unexpected bleeding from the pulmonary artery or tumor infiltration into the pulmonary artery, appropriate thoracotomy must be performed. In this volume, 4 representative methods of performing thoracotomy are described with some tips in Japanese.

Lifesaving surgery for a ruptured invasive thymoma using the hemi-clamshell approach: a case report.

BACKGROUND: Among anterior mediastinal tumors, a teratoma is known to rupture with growth, but there have been few previous reports about thymoma rupture. We here report a rare case of an invasive thymoma with intrapulmonary and intrathoracic rupture requiring emergency life-saving surgery. To our knowledge, this is the first such case in the literature. CASE PRESENTATION: A 56-year-old woman suddenly experienced right precordial pain and hemoptysis. Enhanced computed tomography revealed a large mediastinal tumor pressing against the pulmonary hilar vascularity, with extravasation of blood into the right lung. Tumor rupture into the lungs was suspected. Given the deterioration of her respiratory status and hemodynamics, thymomectomy with removal of the involved tissues was urgently performed using the hemi-clamshell approach and intrapericardial dissection, with veno-arterial extracorporeal membrane oxygenation on standby. She survived, and no recurrence has been noted for 2 years postoperatively. CONCLUSIONS: A large thymoma can suddenly rupture into the thorax, similar to the rupture of a teratoma. Additionally, in cases with hemoptysis, an appropriate procedure should be selected to reach both the pulmonary hilum and thorax for complete resection, as hemoptysis might suggest tumor invasion into the lungs.

Primary Synovial Sarcoma of the Mediastinum with Long-term Follow-up.

Chest radiography showed a right posterior mass on the mediastinum of an 84-year-old woman. The mass had been growing gradually for four years. Surgical excision was performed, and a pathological examination found the mass to be consistent with primary synovial sarcoma (SS) of the mediastinum. To our knowledge, this is a rare case in which follow-up imaging was able to be performed over a period of four years. This disease is aggressive, and its early diagnosis is key to achieving a cure. It is important to consider primary SS in the differential diagnosis of a primary intra-thoracic tumor, even if the tumor grows slowly.

Hepatic Cytochrome P450 Activity and Nitric Oxide Production During Multiple Ovalbumin Challenges.

BACKGROUND AND OBJECTIVES: Mast cell-mediated allergic diseases are a significant global health problem. Nitric oxide (NO) produced by acute type 1 allergies greatly suppresses hepatic cytochrome P450 (CYP) metabolism. A recent in vitro study demonstrated that repeated FcεRI-mediated activation intrinsically modulates mast cell function. We investigated the effect of ovalbumin (OVA) challenges on CYP activity and NO production under real immune responses. METHODS: After repeated sensitization with OVA once a week, serum nitrate plus nitrite (NOx) and total plasma immunoglobulin E concentrations were measured using commercially available kits. Hepatic microsomal CYP-specific activities and protein expression were determined using typical substrates and by western blot, respectively. In the liver, the levels of inducible NO synthase (iNOS), F4/80, and c-kit mRNA were determined by real-time polymerase chain reaction. Hepatic total NOS activity was measured using a colorimetric assay kit. RESULTS: When mice received multiple OVA challenges, the 11th sensitization elevated NOx concentrations in serum and suppressed the activities of five major CYPs without altering protein expression levels. After the 7th, 11th, and 15th sensitizations, F4/80-positive Kupffer cell and hepatic c-kit-dependent mast cell mRNA levels were similar to those of the control. The 7th and 11th sensitizations increased hepatic iNOS mRNA expression to 15-fold and threefold above control levels, respectively, but did not enhance the total NOS activity in the liver. CONCLUSIONS: Multiple OVA challenges, unlike acute sensitization, greatly reduced serum NOx levels. The challenge-suppressed hepatic CYP metabolism was likely related to the increased serum NOx. Serum NOx may be an endogenous marker for CYP metabolism inhibition in type 1 allergic diseases.

Hepatic cytochrome P450 metabolism suppressed by mast cells in type 1 allergic mice.

Mast cells and Kupffer cells secrete interleukin (IL)-1ß, interferon (IFN)-γ, and tumor necrosis factor (TNF)-α, which stimulate excess nitric oxide (NO) producing-inducible NO synthase (iNOS). Unlike Kupffer cells, immunoglobulin E-sensitized mast cells elicit sustained NO production. We investigated the participation of mast cell-released NO and cytokine-derived iNOS activation in type 1 allergy-suppressed hepatic cytochrome P450 (CYP) metabolism. Aminoguanidine, a selective iNOS inhibitor, completely suppressed serum nitrate plus nitrite (NOx) concentrations after primary and secondary sensitization of ICR mice and markedly attenuated allergy-suppressed hepatic CYP1A2, CYP2C, CYP2E1, and CYP3A activities. In the liver, primary and secondary sensitization enhanced iNOS-stimulating IFN-γ (5-15-fold) and TNF-α (3-5-fold) mRNA levels more than IL-1ß (2-fold) and F4/80-positive Kupffer cell (2-fold) mRNA levels. When mast cell-deficient (-/-) mice were sensitized, hepatic CYP activities were not suppressed. Serum NOx levels in the sensitized -/- mice were similar with those in saline-treated ICR and -/- mice. In the liver of -/- mice, secondary sensitization markedly enhanced mRNA expression of iNOS (20-fold), IFN-γ (15-fold), and TNF-α (3-fold). However, hepatic total NOS activities in -/- mice were not significantly different between saline treatment and sensitization. Similarly, primary and secondary ICR mice did not significantly enhance total NOS activities in the liver and hepatocytes. The total NOS activities observed did not relate to the high levels of iNOS, IFN-γ, and TNF-α mRNA in the liver. Hepatic c-kit-positive mast cells in sensitized ICR mice were maintained at control levels. Therefore, our data suggest that mast cell-released NO participates in type 1 allergy-suppressed CYP1A2, CYP2C, CYP2E1, and CYP3A metabolism.

A novel model uses metabolic and volumetric parameters to predict less invasive lung adenocarcinomas†.

OBJECTIVES: This study aimed to develop a prediction model for less invasive lesions of pathological Stage IA adenocarcinomas. METHODS: We retrospectively evaluated 121 lesions from 114 patients with pathological Stage IA adenocarcinoma who underwent surgery after fluorodeoxyglucose positron emission tomography and high-resolution computed tomography. Less invasive lesions were adenocarcinoma in situ and minimally invasive adenocarcinoma. The 3D parameter, solid tumour ratio, was the volume ratio of the solid part to the whole tumour. The 2D parameter was the consolidation-to-tumour ratio. The maximum standardized uptake value (SUVmax) in fluorodeoxyglucose positron emission tomography was the metabolic parameter. A volumetric analysis programme semiautomatically measured these 3 parameters. The cut-off values were 0.5, 0.125 and 1.0 for the consolidation-to-tumour ratio, solid tumour ratio and SUVmax, respectively. Multivariable logistic regression analysis was used to select the prediction model parameters. RESULTS: There were 34 (28.1%) less invasive lesions. A consolidation-to-tumour ratio <0.5 was an insignificant predictive factor for less invasive lesions in the multivariable analysis. The prediction model had a total score of 3 points: 1 point for SUVmax <1.0 and 2 points for the solid tumour ratio <0.125. The area under the receiver operating characteristic curve in this model was 0.86 (95% confidence interval 0.78-0.94). The total score indicated 89.5% probability of possessing less invasive lesions. CONCLUSIONS: The solid tumour ratio and SUVmax effectively predicted less invasive lesions in early-stage lung adenocarcinomas. The prediction model generated by volumetric and metabolic parameters showed higher predictive power in this clinical setting.