Comparing RECIST 1.1 and iRECIST in advanced melanoma patients treated with pembrolizumab in a phase II clinical trial.

OBJECTIVES: To compare tumor best overall response (BOR) by RECIST 1.1 and iRECIST, to explore the incidence of pseudoprogression in melanoma treated with pembrolizumab, and to assess the impact of pseudoprogression on overall survival (OS). METHODS: A total of 221 patients with locally advanced/unresectable melanoma who received pembrolizumab as part of KEYNOTE-002 trial were included in this study. Radiological assessment of imaging was centrally reviewed to assess tumor response. Incidence of discordance in BOR between RECIST 1.1 and iRECIST as well as rate of pseudoprogression were measured. OS of patients with pseudoprogression was compared with that of those with uncontrolled disease. RESULTS: Of the 221 patients in this cohort, 136 patients developed PD as per RECIST v1.1 and 78 patients with PD continued treatment and imaging beyond initial RECIST 1.1-defined PD. Among the 78 patients who continued therapy and imaging post-progression, RECIST 1.1 and iRECIST were discordant in 10 patients (12.8%) and pseudoprogression was encountered in 14 patients (17.9%). OS of patients with pseudoprogression was longer than that of patients with uncontrolled disease/true progression (29.9 months versus 8.0 months, p value < 0.001). CONCLUSIONS: Effectiveness of immunotherapy in clinical trials depends on the criterion used to assess tumor response (RECIST 1.1 vs iRECIST) with iRECIST being more appropriate to detect pseudoprogression and potentially prevent premature termination of effective therapy. Pseudoprogression was associated with improved OS in comparison with that of patients with uncontrolled disease. KEY POINTS: • Discordance between iRECIST and RECIST 1.1 was found in 12.8% of unresectable melanoma patients on pembrolizumab who continued therapy beyond initial RECIST 1.1-defined progression. • Pseudoprogression, captured with iRECIST, occurred in 17.9% and was significantly associated with improved overall survival in comparison with uncontrolled disease.

The Negative Predictive Value of a PI-RADS Version 2 Score of 1 on Prostate MRI and the Factors Associated With a False-Negative MRI Study.

OBJECTIVE. The purpose of this study was to calculate the negative predictive value of a prostate MRI study with a Prostate Imaging Reporting and Data System version 2 (PI-RADSv2) score of 1 (hereafter referred to as a PI-RADS 1 MRI study) and to explore the patient characteristics and MRI-based factors associated with an MRI study with false-negative results. MATERIALS AND METHODS. A total of 542 consecutive patients with a PI-RADS 1 MRI study obtained between January 2016 and July 2019 were retrospectively identified. Patient charts were examined to identify those patients who subsequently underwent systematic prostate biopsy within 1 year of undergoing MRI or at any later date if the biopsy was negative. Patient characteristics and MRI-specific factors were recorded. Two blinded radiologists evaluated the quality of the axial T2-weighted, DWI, and apparent diffusion coefficient sequences; measured the volume of the bladder, the prostate gland, and rectal gas; and determined whether the peripheral zone was avidly enhancing and whether low signal intensity was seen in 50% or more of the peripheral zone on T2-weighted images. Interobserver agreement was tested. Univariable and multivariable logistic regression models were built. RESULTS. A total of 150 patients (median age, 63 years; interquartile range, 56-70 years) were included. Of these patients, 19 (13%) had prostate cancer with a Gleason score of 3 + 4 or greater, yielding a negative predictive value of 87%. Both low T2 signal intensity in the peripheral zone and the prostate-specific antigen level were associated with a false-negative PI-RADS 1 assessment (odds ratio, 4.9 [95% CI, 1.6-14.9; p = 0.006] and 1.1 [95% CI, 1.0-1.2; p = 0.03], respectively). A cutoff prostate-specific antigen level of 3.97 ng/mL resulted in sensitivity and specificity of 89% and 21%, respectively. There was moderate interobserver agreement for low T2 signal intensity in the peripheral zone (κ coefficient = 0.75). CONCLUSION. Even among select patients who undergo subsequent biopsy because of a high clinical suspicion of prostate cancer, a PI-RADS 1 prostate MRI study has a high negative predictive value. A T2-hypointense peripheral zone and an elevated prostate-specific antigen level are significantly associated with a false-negative MRI study.

Ulnar Collateral Ligament Insertional Injuries in Pediatric Overhead Athletes: Are MRI Findings Predictive of Symptoms or Need for Surgery?

OBJECTIVE: The purpose of this study was to determine whether ulnar collateral ligament (UCL) insertion below the articular margin (so-called T sign) exists in the pediatric population and whether MRI features can be used to identify insertional UCL injuries in overhead athletes that are symptomatic or require surgery. MATERIALS AND METHODS: Retrospective review of elbow MR images of patients younger than 21 years from 2011 to 2017 yielded 26 control subjects who were not overhead athletes and 97 overhead athletes. According to the clinical diagnosis, 50 of the overhead athletes had symptoms. Two radiologists evaluated the UCL for thickness, abnormal insertional signal intensity, insertion distance, and adjacent marrow or soft-tissue edema. Insertion distance was defined as the coronal length of any T sign measured from the articular margin. RESULTS: Mean insertion distance was greater in overhead athletes than in control subjects (1.42 vs 0.23 mm, p = 0.001) but not significantly different in athletes with symptoms compared with those without symptoms or in those who underwent operative treatment compared with those who did not. Mean UCL thickness was greater in overhead athletes than in control subjects (2.64 vs 1.74 mm, p < 0.0001), athletes with than those without symptoms (2.84 vs 2.41 mm, p = 0.005), and athletes who did versus those who did not undergo operative treatment (3.40 vs 2.73 mm, p = 0.011). Marrow (p = 0.002) and soft-tissue (p = 0.016) edema were found more frequently in athletes with symptoms. ROC analysis of UCL thickness and insertion distance as predictors of symptoms showed AUCs of 0.69 and 0.49, respectively. CONCLUSION: The T sign is likely not an anatomic variation but is a poor predictor of symptoms and need for surgery. Soft-tissue and marrow edema are more frequently seen in overhead athletes with symptomatic injuries and can aid in the diagnosis of clinically relevant injury.

Anterior Inferior Iliac Spine Morphology: Comparison of Symptomatic Hips With Femoroacetabular Impingement and Asymptomatic Hips.

OBJECTIVE: The objective of our study was to compare anterior inferior iliac spine (AIIS) morphology in symptomatic hips with femoroacetabular impingement (FAI) and in asymptomatic hips, determine the prevalence of impingement morphology in patients with a radiographic "crossover" sign, and identify potential risk factors for having impingement morphology. MATERIALS AND METHODS: For this retrospective study, we identified consecutive symptomatic hips with FAI (n = 54) and asymptomatic hips (n = 35) in patients who underwent CT from 2015 to 2017. Two radiologists blindly and independently evaluated 3D CT images of each hip and graded the AIIS morphology according to the Hetsroni classification scheme. The prevalence of AIIS morphology types was calculated. Associations of AIIS morphology types with symptoms and the crossover sign were evaluated with a chi-square test. A multivariable logistic regression determined risk factors for abnormal AIIS morphology (i.e., type 2 or 3). RESULTS: There was no difference in the prevalence of AIIS morphology types for symptomatic hips with FAI versus asymptomatic hips (p = 0.44) or for hips with a positive versus those with a negative crossover sign (p = 0.21). There was moderate interobserver agreement (κ = 0.44) and good-to-excellent intraobserver agreement (κ = 0.67 and 0.90) for grading AIIS morphology. Age, sex, femoral version, acetabular version, alpha angle, lateral center edge angle, and the crossover sign were not significant risk factors for abnormal AIIS morphology in patients with FAI (p = 0.11-0.79). CONCLUSION: There is no difference in AIIS morphology between symptomatic hips with FAI versus asymptomatic hips or between hips with and those without the radiographic crossover sign. Age, sex, and other FAI parameters are not risk factors for developing AIIS impingement morphology.

Diffuse Peripheral Zone T2 Hypointensity: When to Worry About Prostate Cancer.

OBJECTIVE: Evaluate the accuracy of an obscured surgical capsule (OSC) for detecting diffuse prostate cancer (PCa) in the setting of diffusely T2 hypointense peripheral zones (PZs) on prostate magnetic resonance imaging. METHODS: Axial T2-weighted sequences of prostate magnetic resonance imaging performed on July 1, 2015, to August 1, 2017, were blindly assessed for diffusely T2 hypointense PZs, OSC, and focal diffusion abnormalities by 2 radiologists. Diffuse PCa was defined by the presence of bilateral PCa on at least 4 contiguous biopsy cores involving 2/3 levels. Interobserver agreement and multivariate analysis were performed. RESULTS: Seven (10%) of 70 patients had diffuse PCa. There was weak interreader agreement for OSC (κ coefficient = 0.58). Obscured surgical capsule was 57% sensitive and 89% specific for the presence of diffuse PCa and was associated with it (odds ratio, 17.6; P = 0.0008). Multivariate logistic regression demonstrated that OSC was the only significant predictor for the presence of diffuse PCa. CONCLUSION: Obscured surgical capsule is a strong independent predictor for diffuse PCa in T2 hypointense PZs.

Nonenhancing Component of Clear Cell Renal Cell Carcinoma on Computed Tomography Correlates With Tumor Necrosis and Stage and Serves as a Size-Independent Prognostic Biomarker.

OBJECTIVES: This study aimed to quantify nonenhancing tumor (NT) component in clear cell renal cell carcinoma (ccRCC) and assess its association with histologically defined tumor necrosis, stage, and survival outcomes. METHODS: Among 183 patients with ccRCC, multi-institutional changes in computed tomography attenuation of tumor voxels were used to quantify percent of NT. Associations of NT with histologic tumor necrosis and tumor stage/grade were tested using Wilcoxon signed rank test and with survival outcomes using Kaplan-Meier curves/Cox regression analysis. RESULTS: Nonenhancing tumor was higher in ccRCC with tumor necrosis (11% vs 7%; P = 0.040) and higher pathological stage (P = 0.042 and P < 0.001, respectively). Patients with greater NT had higher incidence of cancer recurrence after resection (P < 0.001) and cancer-specific mortality (P < 0.001). CONCLUSION: Nonenhancing tumor on preoperative computed tomographic scans in patients with ccRCC correlates with tumor necrosis and stage and may serve as an independent imaging prognostic biomarker for cancer recurrence and cancer-specific survival.

Stressors contributing to burnout amongst pediatric radiologists: results from a survey of the Society for Pediatric Radiology.

BACKGROUND: A recent study showed a high prevalence of burnout in pediatric radiology. OBJECTIVE: The purpose of this study is to evaluate potential stressors contributing to burnout in pediatric radiology. MATERIALS AND METHODS: Society for Pediatric Radiology members received an invitation for an anonymous survey evaluating stressors contributing to burnout. Stressors evaluated included call burden, financial stress, work-life balance, health care evolution and job market changes, and radiology as a career choice. Additional questions regarding demographics were obtained. RESULTS: The response rate was 460/1,453 (32%). The prevalence of emotional exhaustion was 66% (286/435), depersonalization was 61% (265/433) and perceived lack of personal accomplishment was 15% (67/436). In a backward selective logistic regression model, work-life imbalance and call burden were the only significant factors predicting higher emotional exhaustion (P<0.001). Using a similar model, work-life imbalance, call burden and decreased rate of reimbursement were significantly associated with higher probability of depersonalization (P=0.033, 0.0002 and 0.015, respectively). Emotional exhaustion and depersonalization were significantly associated with higher odds of a radiologist's wish to work in another medical specialty (P=0.011 and 0.002, respectively). CONCLUSION: Key stressors contributing to burnout in pediatric radiology include work-life imbalance, pediatric call burden and a decreased rate of reimbursement. Burnout in pediatric radiology is a serious issue that needs to be addressed and prioritized on the individual and departmental/institutional levels and further investigated to develop effective interventions to mitigate it.

Cerebrovascular Accidents During Mechanical Circulatory Support: New Predictors of Ischemic and Hemorrhagic Strokes and Outcome.

BACKGROUND AND PURPOSE: Left ventricular assist devices (LVADs) have emerged as an effective treatment for patients with advanced heart failure refractory to medical therapy. Post-LVAD strokes are an important cause of morbidity and reduced quality of life. Data on risks that distinguish between ischemic and hemorrhagic post-LVAD strokes are limited. The aim of this study was to determine the incidence of post-LVAD ischemic and hemorrhagic strokes, their association with stroke risk factors, and their effect on mortality. METHODS: Data are collected prospectively on all patients with LVADs implanted at Brigham and Women's Hospital. We added retrospectively collected clinical data for these analyses. RESULTS: From 2007 to 2016, 183 patients (median age, 57; 80% male) underwent implantation of HeartMate II LVAD as a bridge to transplant (52%), destination therapy (39%), or bridge to transplant candidacy (8%). A total of 48 strokes occurred in 39 patients (21%): 28 acute ischemic strokes in 24 patients (13%) and 20 intracerebral hemorrhages in 19 patients (10.3%). First events occurred at a median of 238 days from implantation (interquartile range, 93-515) among those who developed post-LVAD stroke. All but 9 patients (4.9%) were on warfarin (goal international normalized ratio, 2-3.5) and all received aspirin (81-325 mg). Patients with chronic obstructive pulmonary disease were more likely to have an ischemic stroke (odds ratio, 2.96; 95% confidence interval, 1.14-7.70). Dialysis-dependent patients showed a trend toward a higher risk of hemorrhagic stroke (odds ratio, 6.31; 95% confidence interval, 0.99-40.47). Hemorrhagic stroke was associated with higher mortality (odds ratio, 3.92; 95% confidence interval, 1.34-11.45) than ischemic stroke (odds ratio, 3.17; 95% confidence interval, 1.13-8.85). CONCLUSIONS: Stroke is a major cause of morbidity and mortality in patients on LVAD support. Chronic obstructive pulmonary disease increases the risk of ischemic stroke, whereas dialysis may increase the risk of hemorrhagic stroke. Although any stroke increases mortality, post-LVAD hemorrhagic stroke was associated with higher mortality compared with ischemic stroke.

Cholesterol, lipoproteins and subclinical interstitial lung disease: the MESA study.

We investigated associations of plasma lipoproteins with subclinical interstitial lung disease (ILD) by measuring high attenuation areas (HAA: lung voxels between -600 and -250 Hounsfield units) in 6700 adults and serum MMP-7 and SP-A in 1216 adults age 45-84 without clinical cardiovascular disease in Multi-Ethnic Study of Atherosclerosis. In cross-sectional analyses, each SD decrement in high density lipoprotein cholesterol (HDL-C) was associated with a 2.12% HAA increment (95% CI 1.44% to 2.79%), a 3.53% MMP-7 increment (95% CI 0.93% to 6.07%) and a 6.37% SP-A increment (95% CI 1.35% to 11.13%), independent of demographics, smoking and inflammatory biomarkers. These findings support a novel hypothesis that HDL-C might influence subclinical lung injury and extracellular matrix remodelling.

APOM and high-density lipoprotein cholesterol are associated with lung function and per cent emphysema.

Chronic obstructive pulmonary disease (COPD) is linked to cardiovascular disease; however, there are few studies on the associations of cardiovascular genes with COPD. We assessed the association of lung function with 2100 genes selected for cardiovascular diseases among 20 077 European-Americans and 6900 African-Americans. We performed replication of significant loci in the other racial group and an independent consortium of Europeans, tested the associations of significant loci with per cent emphysema and examined gene expression in an independent sample. We then tested the association of a related lipid biomarker with forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio and per cent emphysema. We identified one new polymorphism for FEV1/FVC (rs805301) in European-Americans (p=1.3×10(-6)) and a second (rs707974) in the combined European-American and African-American analysis (p=1.38×10(-7)). Both single-nucleotide polymorphisms (SNPs) flank the gene for apolipoprotein M (APOM), a component of high-density lipoprotein (HDL) cholesterol. Both were replicated in an independent cohort. SNPs in a second gene related to apolipoprotein M and HDL, PCSK9, were associated with FEV1/FVC ratio among African-Americans. rs707974 was associated with per cent emphysema among European-Americans and African-Americans and APOM expression was related to FEV1/FVC ratio and per cent emphysema. Higher HDL levels were associated with lower FEV1/FVC ratio and greater per cent emphysema. These findings suggest a novel role for the apolipoprotein M/HDL pathway in the pathogenesis of COPD and emphysema.

Plasma sphingomyelin and longitudinal change in percent emphysema on CT. The MESA lung study.

CONTEXT: Ceramide causes endothelial apoptosis and emphysema-like changes in animal models. OBJECTIVES: Test if plasma sphingomyelin, a major precursor of ceramide, would predict longitudinal increase in the percentage of emphysema-like lung on computed tomography (CT). MATERIALS AND METHODS: 3840 participants had their plasma sphingomyelin measured at baseline examination and their pulmonary emphysema measured on cardiac CT scans at baseline and on follow-up visits. Mixed effects models were used to adjust for potential confounders. RESULTS: One standard deviation increase in sphingomyelin predicted a 0.12% per year (95% CI: 0.02-0.22; p = 0.019) greater increase of percent emphysema. DISCUSSION AND CONCLUSION: Higher plasma levels of sphingomyelin predicted greater annual increase in quantitatively measured percent emphysema.

Asthma and lung structure on computed tomography: the Multi-Ethnic Study of Atherosclerosis Lung Study.

BACKGROUND: The potential consequences of asthma in childhood and young adulthood on lung structure in older adults have not been studied in a large, population-based cohort. OBJECTIVE: The authors hypothesized that a history of asthma onset in childhood (age 18 years or before) or young adulthood (age 19-45 years) was associated with altered lung structure on computed tomography in later life. METHODS: The Multi-Ethnic Study of Atherosclerosis Lung Study recruited 3965 participants and assessed asthma history by using standardized questionnaires, guideline-based spirometry, and segmental airway dimensions and percentage of low attenuation area (%LAA) on computed tomographic scans. RESULTS: Asthma with onset in childhood and young adulthood was associated with large decrements in FEV(1) among participants with a mean age of 66 years (-365 mL and -343 mL, respectively; P < .001). Asthma with onset in childhood and young adulthood was associated with increased mean airway wall thickness standardized to an internal perimeter of 10 mm (0.1 mm, P < .001 for both), predominantly from narrower segmental airway lumens (-0.39 mm and -0.34 mm, respectively; P < .001). Asthma with onset in childhood and young adulthood also was associated with a greater %LAA (1.69% and 4.30%, respectively; P < .001). Findings were similar among never smokers, except that differential %LAA in childhood-onset asthma were not seen in them. CONCLUSION: Asthma with onset in childhood or young adulthood was associated with reduced lung function, narrower airways, and among asthmatic patients who smoked, greater %LAA in later life.

Percent emphysema, airflow obstruction, and impaired left ventricular filling.

BACKGROUND: Very severe chronic obstructive pulmonary disease causes cor pulmonale with elevated pulmonary vascular resistance and secondary reductions in left ventricular filling, stroke volume, and cardiac output. We hypothesized that emphysema, as detected on computed tomography (CT), and airflow obstruction are inversely related to left ventricular end-diastolic volume, stroke volume, and cardiac output among persons without very severe lung disease. METHODS: We measured left ventricular structure and function with the use of magnetic resonance imaging in 2816 persons who were 45 to 84 years of age. The extent of emphysema (expressed as percent emphysema) was defined as the percentage of voxels below -910 Hounsfield units in the lung windows on cardiac computed tomographic scans. Spirometry was performed according to American Thoracic Society guidelines. Generalized additive models were used to test for threshold effects. RESULTS: Of the study participants, 13% were current smokers, 38% were former smokers, and 49% had never smoked. A 10-point increase in percent emphysema was linearly related to reductions in left ventricular end-diastolic volume (-4.1 ml; 95% confidence interval [CI], -3.3 to -4.9; P<0.001), stroke volume (-2.7 ml; 95% CI, -2.2 to -3.3; P<0.001), and cardiac output (-0.19 liters per minute; 95% CI, -0.14 to -0.23; P<0.001). These associations were of greater magnitude among current smokers than among former smokers and those who had never smoked. The extent of airflow obstruction was similarly associated with left ventricular structure and function, and smoking status had similar modifying effects on these associations. Percent emphysema and airflow obstruction were not associated with the left ventricular ejection fraction. CONCLUSIONS: In a population-based study, a greater extent of emphysema on CT scanning and more severe airflow obstruction were linearly related to impaired left ventricular filling, reduced stroke volume, and lower cardiac output without changes in the ejection fraction.

Visceral adiposity in cirrhosis: Association with disease severity and impact of liver transplantation.

BACKGROUND: Changes in adipose tissue distribution in liver cirrhosis are poorly characterized and may affect clinical outcomes. METHODS: Adult liver transplant (LT) January 2008-August 2017 recipients with abdominal MRI within 6 months pre-LT were retrospectively assessed. Visceral adipose tissue, subcutaneous adipose tissue, and skeletal muscle area (cm2) were determined at L3. Visceral-to-subcutaneous adipose tissue ratio (VSR) was used to define relative adipose distribution, stratified by sex. Correlation was tested with Pearson. Body composition measures were compared by Child-Turcotte-Pugh (CTP) class, before and after LT, and evaluated as predictors of clinical outcomes. RESULTS: A total of 318 patients were studied. Mean age was 56 years, 33.64% were female, and 47.80% had CTP C cirrhosis. CTP C was associated with a 0.42-point increase in VSR compared with CTP A (95% CI = 0.13-0.71, p < 0.01), adjusting for age, sex, diabetes, and HCC. Among the 79 (24.84%) patients with repeat MRI 1-2 years after LT, VSR significantly improved from before LT (1.31 vs. 0.95, p < 0.01). In adjusted analysis, CTP C was associated with a 0.86-point decrease in post-LT VSR compared with pre-LT VSR (95% CI = -1.27 to -0.44, p < 0.01). Body mass index poorly correlated with VSR before and after LT. Elevated pre-LT VSR trended toward an association with a 7.17-point decrease in pre-LT glomerular filtration rate (95% CI = -14.35 to -0.02, p = 0.05), adjusting for CTP C, age, sex, diabetes, hypertension, pre-LT sarcopenia, and hepatocellular carcinoma. Elevated pre-LT VSR did not affect 3-year post-LT mortality (log-rank p = 0.24). CONCLUSIONS: Poorly represented by body mass index, visceral adiposity is increased in cirrhosis and is associated with CTP class. However, this adipose redistribution may be modifiable by LT.

The utility of an under-distended gallbladder on ultrasound in ruling out acute cholecystitis.

PURPOSE: To study the association between gallbladder dimensions and acute cholecystitis and to define a sensitive cutoff for excluding the disease. MATERIALS AND METHODS: 456 consecutive patients with an abdominal ultrasound performed for right upper quadrant pain, from 1/2019 to 4/2019, were retrospectively collected. Length and width of the gallbladder were measured by a blinded radiology fellow. Patient charts were examined for prospective sonographic findings, clinical data, and pathology from subsequent cholecystectomy or at least 1 month of follow-up with symptom resolution. Univariable and multivariable logistic regression analysis were conducted to define the association of gallbladder dimensions and other sonographic and clinical variables with acute cholecystitis. Optimal and sensitive cutoffs of gallbladder widths were defined. The determined sensitive cutoff was validated with a separate cohort of 501 consecutive patients. RESULTS: 319 patients (median age 48 ± 19 years) including 11%, 19%, and 70% with acute, chronic, and no cholecystitis were included in the experimental cohort, respectively, and 298 patients (median age 50 ± 19 years) including 10%, 12%, and 79% with acute, chronic, and no cholecystitis were included in the validation cohort, respectively. Of all sonographic findings and clinical data, gallbladder width produced the best univariate ROC curve with an AUC of 0.91 (Odds ratio 5.1, 95% CI 3.1-8.5, p < 0.001). 2.2 cm was the gallbladder width cutoff below which there were no cases of acute cholecystitis in the experimental cohort. Multivariable logistic regression analysis using sonographic findings only produced an ROC curve with an AUC of 0.94. Applying the 2.2 cm cutoff in the validation cohort resulted in 100% sensitivity. CONCLUSION: Lack of gallbladder distention, defined as a width less than 2.2 cm, has potential to serve as a highly sensitive sign for exclusion of acute cholecystitis, regardless of additional sonographic findings and clinical data.

How Many Radiographs Does It Take to Screen for Femoral Cam Morphology?: A Noninferiority Study.

PURPOSE: To compare a 2-view radiograph series (AP of the pelvis and 45° Dunn of the hip) with a 5-view radiograph series for sensitivity in identifying femoral cam morphology. MATERIALS AND METHODS: This is a retrospective review of consecutive patients with a 5-view radiograph series (AP pelvis and AP, 45° Dunn, frog lateral, and false profile of the affected hip) from 2016 to 2017. Three fellowship trained radiologists blindly and independently evaluated 2 views (AP pelvis and Dunn) for a femoral cam lesion, acetabular rim calcification, Tonnis grade, and important incidental findings. Two weeks later, the same assessment was made on all 5 views. A noninferiority test of the 2-view series vs the 5-view series for sensitivity in identifying femoral cam morphology was conducted. Individual reader sensitivity calculations were performed and agreement was determined with the kappa statistic. RESULTS: The 2-view series was noninferior to the 5-view series for cam identification (P value = 0.010). In comparing the 2-view vs 5-view series for individual readers, there was no difference in the sensitivities (84%-100% vs 85%-98%, P = 0.85-1.0) or specificities (11%-56% vs 7%-56%, P = 0.58-1.0) for cam identification. There was fair to excellent 2-view intrareader agreement (k = 0.38-0.93) and similar inter-reader agreement between the 2-view and 5-view (k = 0.33 vs 0.37). CONCLUSIONS: A 2-view radiograph series (AP pelvis and Dunn hip) is noninferior to a 5-view radiograph series for sensitivity in identifying femoral cam morphology.

Deep Learning of Computed Tomography Virtual Wedge Resection for Prediction of Histologic Usual Interstitial Pneumonitis.

Rationale: The computed tomography (CT) pattern of definite or probable usual interstitial pneumonia (UIP) can be diagnostic of idiopathic pulmonary fibrosis and may obviate the need for invasive surgical biopsy. Few machine-learning studies have investigated the classification of interstitial lung disease (ILD) on CT imaging, but none have used histopathology as a reference standard.Objectives: To predict histopathologic UIP using deep learning of high-resolution computed tomography (HRCT).Methods: Institutional databases were retrospectively searched for consecutive patients with ILD, HRCT, and diagnostic histopathology from 2011 to 2014 (training cohort) and from 2016 to 2017 (testing cohort). A blinded expert radiologist and pulmonologist reviewed all training HRCT scans in consensus and classified HRCT scans based on the 2018 American Thoracic Society/European Respriatory Society/Japanese Respiratory Society/Latin American Thoracic Association diagnostic criteria for idiopathic pulmonary fibrosis. A convolutional neural network (CNN) was built accepting 4 × 4 × 2 cm virtual wedges of peripheral lung on HRCT as input and outputting the UIP histopathologic pattern. The CNN was trained and evaluated on the training cohort using fivefold cross validation and was then tested on the hold-out testing cohort. CNN and human performance were compared in the training cohort. Logistic regression and survival analyses were performed.Results: The CNN was trained on 221 patients (median age 60 yr; interquartile range [IQR], 53-66), including 71 patients (32%) with UIP or probable UIP histopathologic patterns. The CNN was tested on a separate hold-out cohort of 80 patients (median age 66 yr; IQR, 58-69), including 22 patients (27%) with UIP or probable UIP histopathologic patterns. An average of 516 wedges were generated per patient. The percentage of wedges with CNN-predicted UIP yielded a cross validation area under the curve of 74% for histopathological UIP pattern per patient. The optimal cutoff point for classifying patients on the training cohort was 16.5% of virtual lung wedges with CNN-predicted UIP and resulted in sensitivity and specificity of 74% and 58%, respectively, in the testing cohort. CNN-predicted UIP was associated with an increased risk of death or lung transplantation during cross validation (hazard ratio, 1.5; 95% confidence interval, 1.1-2.2; P = 0.03).Conclusions: Virtual lung wedge resection in patients with ILD can be used as an input to a CNN for predicting the histopathologic UIP pattern and transplant-free survival.

Uncontrolled Confounders May Lead to False or Overvalued Radiomics Signature: A Proof of Concept Using Survival Analysis in a Multicenter Cohort of Kidney Cancer.

PURPOSE: We aimed to explore potential confounders of prognostic radiomics signature predicting survival outcomes in clear cell renal cell carcinoma (ccRCC) patients and demonstrate how to control for them. MATERIALS AND METHODS: Preoperative contrast enhanced abdominal CT scan of ccRCC patients along with pathological grade/stage, gene mutation status, and survival outcomes were retrieved from The Cancer Imaging Archive (TCIA)/The Cancer Genome Atlas-Kidney Renal Clear Cell Carcinoma (TCGA-KIRC) database, a publicly available dataset. A semi-automatic segmentation method was applied to segment ccRCC tumors, and 1,160 radiomics features were extracted from each segmented tumor on the CT images. Non-parametric principal component decomposition (PCD) and unsupervised hierarchical clustering were applied to build the radiomics signature models. The factors confounding the radiomics signature were investigated and controlled sequentially. Kaplan-Meier curves and Cox regression analyses were performed to test the association between radiomics signatures and survival outcomes. RESULTS: 183 patients of TCGA-KIRC cohort with available imaging, pathological, and clinical outcomes were included in this study. All 1,160 radiomics features were included in the first radiomics signature. Three additional radiomics signatures were then modelled in successive steps removing redundant radiomics features first, removing radiomics features biased by CT slice thickness second, and removing radiomics features dependent on tumor size third. The final radiomics signature model was the most parsimonious, unbiased by CT slice thickness, and independent of tumor size. This final radiomics signature stratified the cohort into radiomics phenotypes that are different by cancer-specific and recurrence-free survival; HR (95% CI) = 3.0 (1.5-5.7), p <0.05 and HR (95% CI) = 6.6 (3.1-14.1), p <0.05, respectively. CONCLUSION: Radiomics signature can be confounded by multiple factors, including feature redundancy, image acquisition parameters like slice thickness, and tumor size. Attention to and proper control for these potential confounders are necessary for a reliable and clinically valuable radiomics signature.

CT colonography's role in the COVID-19 pandemic: a safe(r), socially distanced total colon examination.

PURPOSE: To describe the favorable procedural profile of CT colonography (CTC) during the COVID-19 pandemic. CONCLUSION: Postponement of cancer screening due to COVID-19 has resulted in a backlog of individuals needing to undergo structural examination of the colon. The experience during the initial COVID-19 surge with urgent evaluation of the colon for transplant patients prior to transplant suggests that CTC can be done in a lower risk manner as compared to other structural examinations. The procedural profile of CTC is advantageous during this pandemic as maintaining social distancing and preserving healthcare supplies including PPE are of paramount importance. CTC is an important option to utilize in the screening armamentarium to allow effective screening of average risk asymptomatic individuals in the COVID-19 era.