Development and validation of a clinical decision support system based on PSA, microRNAs, and MRI for the detection of prostate cancer.

OBJECTIVES: The aims of this study are to develop and validate a clinical decision support system based on demographics, prostate-specific antigen (PSA), microRNA (miRNA), and MRI for the detection of prostate cancer (PCa) and clinical significant (cs) PCa, and to assess if this system performs better compared to MRI alone. METHODS: This retrospective, multicenter, observational study included 222 patients (mean age 66, range 46-75 years) who underwent prostate MRI, miRNA (let-7a-5p and miR-103a-3p) assessment, and biopsy. Monoparametric and multiparametric models including age, PSA, miRNA, and MRI outcome were trained on 65% of the data and then validated on the remaining 35% to predict both PCa (any Gleason grade [GG]) and csPCa (GG ≥ 2 vs GG = 1/negative). Accuracy, sensitivity, specificity, positive and negative predictive value (NPV), and area under the receiver operating characteristic curve were calculated. RESULTS: MRI outcome was the best predictor in the monoparametric model for both detection of PCa, with sensitivity of 90% (95%CI 73-98%) and NPV of 93% (95%CI 82-98%), and for csPCa identification, with sensitivity of 91% (95%CI 72-99%) and NPV of 95% (95%CI 84-99%). Sensitivity and NPV of PSA + miRNA for the detection of csPCa were not statistically different from the other models including MRI alone. CONCLUSION: MRI stand-alone yielded the best prediction models for both PCa and csPCa detection in biopsy-naïve patients. The use of miRNAs let-7a-5p and miR-103a-3p did not improve classification performances compared to MRI stand-alone results. CLINICAL RELEVANCE STATEMENT: The use of miRNA (let-7a-5p and miR-103a-3p), PSA, and MRI in a clinical decision support system (CDSS) does not improve MRI stand-alone performance in the detection of PCa and csPCa. KEY POINTS: • Clinical decision support systems including MRI improve the detection of both prostate cancer and clinically significant prostate cancer with respect to PSA test and/or microRNA. • The use of miRNAs let-7a-5p and miR-103a-3p did not significantly improve MRI stand-alone performance. • Results of this study were in line with previous works on MRI and microRNA.

Effect of dose splitting of a low-volume bowel preparation macrogol-based solution on CT colonography tagging quality.

PURPOSE: To compare examination quality and acceptability of three different low-volume bowel preparation regimens differing in scheduling of the oral administration of a Macrogol-based solution, in patients undergoing computed tomographic colonography (CTC). The secondary aim was to compare CTC quality according to anatomical and patient variables (dolichocolon, colonic diverticulosis, functional and secondary constipation). METHODS: One-hundred-eighty patients were randomized into one of three regimens where PEG was administered, respectively: in a single dose the day prior to (A), or in a fractionated dose 2 (B) and 3 days (C) before the examination. Two experienced radiologists evaluated fecal tagging (FT) density and homogeneity both qualitatively and quantitatively by assessing mean segment density (MSD) and relative standard deviation (RSD). Tolerance to the regimens and patient variables were also recorded. RESULTS: Compared to B and C, regimen A showed a lower percentage of segments with inadequate FT and a significantly higher median FT density and/or homogeneity scores as well as significantly higher MSD values in some colonic segments. No statistically significant differences were found in tolerance of the preparations. A higher number of inadequate segments were observed in patients with dolichocolon (p < 0.01) and secondary constipation (p < 0.01). Interobserver agreement was high for the assessment of both FT density (k = 0.887) and homogeneity (k = 0.852). CONCLUSION: The best examination quality was obtained when PEG was administered the day before CTC in a single session. The presence of dolichocolon and secondary constipation represent a risk factor for the presence of inadequately tagged colonic segments.

Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

1: ESGE recommends that the initial assessment of patients presenting with acute lower gastrointestinal bleeding should include: a history of co-morbidities and medications that promote bleeding; hemodynamic parameters; physical examination (including digital rectal examination); and laboratory markers. A risk score can be used to aid, but should not replace, clinician judgment.Strong recommendation, low quality evidence. 2 : ESGE recommends that, in patients presenting with a self-limited bleed and no adverse clinical features, an Oakland score of ≤ 8 points can be used to guide the clinician decision to discharge the patient for outpatient investigation.Strong recommendation, moderate quality evidence. 3 : ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease, a restrictive red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 7 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of 7-9 g/dL is desirable.Strong recommendation, low quality evidence. 4 : ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and a history of acute or chronic cardiovascular disease, a more liberal red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 8 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of ≥ 10 g/dL is desirable.Strong recommendation, low quality evidence. 5: ESGE recommends that, in patients with major acute lower gastrointestinal bleeding, colonoscopy should be performed sometime during their hospital stay because there is no high quality evidence that early colonoscopy influences patient outcomes.Strong recommendation, low quality of evidence. 6 : ESGE recommends that patients with hemodynamic instability and suspected ongoing bleeding undergo computed tomography angiography before endoscopic or radiologic treatment to locate the site of bleeding.Strong recommendation, low quality evidence. 7 : ESGE recommends withholding vitamin K antagonists in patients with major lower gastrointestinal bleeding and correcting their coagulopathy according to the severity of bleeding and their thrombotic risk. In patients with hemodynamic instability, we recommend administering intravenous vitamin K and four-factor prothrombin complex concentrate (PCC), or fresh frozen plasma if PCC is not available.Strong recommendation, low quality evidence. 8 : ESGE recommends temporarily withholding direct oral anticoagulants at presentation in patients with major lower gastrointestinal bleeding.Strong recommendation, low quality evidence. 9: ESGE does not recommend withholding aspirin in patients taking low dose aspirin for secondary cardiovascular prevention. If withheld, low dose aspirin should be resumed, preferably within 5 days or even earlier if hemostasis is achieved or there is no further evidence of bleeding.Strong recommendation, moderate quality evidence. 10: ESGE does not recommend routinely discontinuing dual antiplatelet therapy (low dose aspirin and a P2Y12 receptor antagonist) before cardiology consultation. Continuation of the aspirin is recommended, whereas the P2Y12 receptor antagonist can be continued or temporarily interrupted according to the severity of bleeding and the ischemic risk. If interrupted, the P2Y12 receptor antagonist should be restarted within 5 days, if still indicated.Strong recommendation, low quality evidence.

Assessment of morphological CT imaging features for the prediction of risk stratification, mutations, and prognosis of gastrointestinal stromal tumors.

OBJECTIVES: To investigate the correlation between CT imaging features and risk stratification of gastrointestinal stromal tumors (GISTs), prediction of mutation status, and prognosis. METHODS: This retrospective dual-institution study included patients with pathologically proven GISTs meeting the following criteria: (i) preoperative contrast-enhanced CT performed between 2008 and 2019; (ii) no treatments before imaging; (iii) available pathological analysis. Tumor risk stratification was determined according to the National Institutes of Health (NIH) 2008 criteria. Two readers evaluated the CT features, including enhancement patterns and tumor characteristics in a blinded fashion. The differences in distribution of CT features were assessed using univariate and multivariate analyses. Survival analyses were performed by using the Cox proportional hazard model, Kaplan-Meier method, and log-rank test. RESULTS: The final population included 88 patients (59 men and 29 women, mean age 60.5 ± 11.1 years) with 45 high-risk and 43 low-to-intermediate-risk GISTs (median size 6.3 cm). At multivariate analysis, lesion size ≥ 5 cm (OR: 10.52, p = 0.009) and enlarged feeding vessels (OR: 12.08, p = 0.040) were independently associated with the high-risk GISTs. Hyperenhancement was significantly more frequent in PDGFRα-mutated/wild-type GISTs compared to GISTs with KIT mutations (59.3% vs 23.0%, p = 0.004). Ill-defined margins were associated with shorter progression-free survival (HR 9.66) at multivariate analysis, while ill-defined margins and hemorrhage remained independently associated with shorter overall survival (HR 44.41 and HR 30.22). Inter-reader agreement ranged from fair to almost perfect (k: 0.32-0.93). CONCLUSIONS: Morphologic contrast-enhanced CT features are significantly different depending on the risk status or mutations and may help to predict prognosis. KEY POINTS: • Lesions size ≥ 5 cm (OR: 10.52, p = 0.009) and enlarged feeding vessels (OR: 12.08, p = 0.040) are independent predictors of high-risk GISTs. • PDGFRα-mutated/wild-type GISTs demonstrate more frequently hyperenhancement compared to GISTs with KIT mutations (59.3% vs 23.0%, p = 0.004). • Ill-defined margins (hazard ratio 9.66) were associated with shorter progression-free survival at multivariate analysis, while ill-defined margins (hazard ratio 44.41) and intralesional hemorrhage (hazard ratio 30.22) were independently associated with shorter overall survival.

Involvement of radiologists in oncologic multidisciplinary team meetings: an international survey by the European Society of Oncologic Imaging.

OBJECTIVES: Multidisciplinary tumour boards (MTBs) play an increasingly important role in managing cancer patients from diagnosis to treatment. However, many problems arise around the organisation of MTBs, both in terms of organisation-administration and time management. In this context, the European Society of Oncologic Imaging (ESOI) conducted a survey among its members, aimed at assessing the quality and amount of involvement of radiologists in MTBs, their role in it and related issues. METHODS: All members were invited to fill in a questionnaire consisting of 15 questions with both open and multiple-choice answers. Simple descriptive analyses and graphs were performed. RESULTS: A total of 292 ESOI members in full standing for the year 2018 joined the survey. Most respondents (89%) declared to attend MT-Bs, but only 114 respondents (43.9%) review over 70% of exams prior to MTB meetings, mainly due to lack of time due to a busy schedule for imaging and reporting (46.6%). Perceived benefits (i.e. surgical and histological feedback (86.9%), improved knowledge of cancer treatment (82.7%) and better interaction between radiologists and referring clinicians for discussing rare cases (56.9%)) and issues (i.e. attending MTB meetings during regular working hours (71.9%) and lack of accreditation with continuing medical education (CME) (85%)) are reported. CONCLUSIONS: Despite the value and benefits of radiologists' participation in MTBs, issues like improper preparation due to a busy schedule and no counterpart in CME accreditation require efforts to improve the role of radiologists for a better patient care. KEY POINTS: • Most radiologists attend multidisciplinary tumour boards, but less than half of them review images in advance, mostly due to time constraints. • Feedback about radiological diagnoses, improved knowledge of cancer treatment and interaction with referring clinicians are perceived as major benefits. • Concerns were expressed about scheduling multidisciplinary tumour boards during regular working hours and lack of accreditation with continuing medical education.

Imaging alternatives to colonoscopy: CT colonography and colon capsule. European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastrointestinal and Abdominal Radiology (ESGAR) Guideline - Update 2020.

MAIN RECOMMENDATIONS: 1. ESGE/ESGAR recommend computed tomographic colonography (CTC) as the radiological examination of choice for the diagnosis of colorectal neoplasia. Strong recommendation, high quality evidence. ESGE/ESGAR do not recommend barium enema in this setting. Strong recommendation, high quality evidence.2. ESGE/ESGAR recommend CTC, preferably the same or next day, if colonoscopy is incomplete. The timing depends on an interdisciplinary decision including endoscopic and radiological factors. Strong recommendation, low quality evidence. ESGE/ESGAR suggests that, in centers with expertise in and availability of colon capsule endoscopy (CCE), CCE preferably the same or the next day may be considered if colonoscopy is incomplete. Weak recommendation, low quality evidence.3. When colonoscopy is contraindicated or not possible, ESGE/ESGAR recommend CTC as an acceptable and equally sensitive alternative for patients with alarm symptoms. Strong recommendation, high quality evidence. Because of lack of direct evidence, ESGE/ESGAR do not recommend CCE in this situation. Very low quality evidence. ESGE/ESGAR recommend CTC as an acceptable alternative to colonoscopy for patients with non-alarm symptoms. Strong recommendation, high quality evidence. In centers with availability, ESGE/ESGAR suggests that CCE may be considered in patients with non-alarm symptoms. Weak recommendation, low quality evidence.4. Where there is no organized fecal immunochemical test (FIT)-based population colorectal screening program, ESGE/ESGAR recommend CTC as an option for colorectal cancer screening, providing the screenee is adequately informed about test characteristics, benefits, and risks, and depending on local service- and patient-related factors. Strong recommendation, high quality evidence. ESGE/ESGAR do not suggest CCE as a first-line screening test for colorectal cancer. Weak recommendation, low quality evidence.5. ESGE/ESGAR recommend CTC in the case of a positive fecal occult blood test (FOBT) or FIT with incomplete or unfeasible colonoscopy, within organized population screening programs. Strong recommendation, moderate quality evidence. ESGE/ESGAR also suggest the use of CCE in this setting based on availability. Weak recommendation, moderate quality evidence.6. ESGE/ESGAR suggest CTC with intravenous contrast medium injection for surveillance after curative-intent resection of colorectal cancer only in patients in whom colonoscopy is contraindicated or unfeasible. Weak recommendation, low quality evidence. There is insufficient evidence to recommend CCE in this setting. Very low quality evidence.7. ESGE/ESGAR suggest CTC in patients with high risk polyps undergoing surveillance after polypectomy only when colonoscopy is unfeasible. Weak recommendation, low quality evidence. There is insufficient evidence to recommend CCE in post-polypectomy surveillance. Very low quality evidence.8. ESGE/ESGAR recommend against CTC in patients with acute colonic inflammation and in those who have recently undergone colorectal surgery, pending a multidisciplinary evaluation. Strong recommendation, low quality evidence.9. ESGE/ESGAR recommend referral for endoscopic polypectomy in patients with at least one polyp ≥6 mm detected at CTC or CCE. Follow-up CTC may be clinically considered for 6-9-mm CTC-detected lesions if patients do not undergo polypectomy because of patient choice, comorbidity, and/or low risk profile for advanced neoplasia. Strong recommendation, moderate quality evidence. Source and scope This is an update of the 2014-15 Guideline of the European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of Gastrointestinal and Abdominal Radiology (ESGAR). It addresses the clinical indications for the use of imaging alternatives to standard colonoscopy. A targeted literature search was performed to evaluate the evidence supporting the use of computed tomographic colonography (CTC) or colon capsule endoscopy (CCE). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence.

Artificial intelligence: radiologists' expectations and opinions gleaned from a nationwide online survey.

PURPOSE: To report the results of a nationwide online survey on artificial intelligence (AI) among radiologist members of the Italian Society of Medical and Interventional Radiology (SIRM). METHODS AND MATERIALS: All members were invited to the survey as an initiative by the Imaging Informatics Chapter of SIRM. The survey consisted of 13 questions about the participants' demographic information, perceived advantages and issues related to AI implementation in radiological practice, and their overall opinion about AI. RESULTS: In total, 1032 radiologists (equaling 9.5% of active SIRM members for the year 2019) joined the survey. Perceived AI advantages included a lower diagnostic error rate (750/1027, 73.0%) and optimization of radiologists' work (697/1027, 67.9%). The risk of a poorer professional reputation of radiologists compared with non-radiologists (617/1024, 60.3%), and increased costs and workload due to AI system maintenance and data analysis (399/1024, 39.0%) were seen as potential issues. Most radiologists stated that specific policies should regulate the use of AI (933/1032, 90.4%) and were not afraid of losing their job due to it (917/1032, 88.9%). Overall, 77.0% of respondents (794/1032) were favorable to the adoption of AI, whereas 18.0% (186/1032) were uncertain and 5.0% (52/1032) were unfavorable. CONCLUSIONS: Radiologists had a mostly positive attitude toward the implementation of AI in their working practice. They were not concerned that AI will replace them, but rather that it might diminish their professional reputation.

Radiomics predicts response of individual HER2-amplified colorectal cancer liver metastases in patients treated with HER2-targeted therapy.

The aim of our study was to develop and validate a machine learning algorithm to predict response of individual HER2-amplified colorectal cancer liver metastases (lmCRC) undergoing dual HER2-targeted therapy. Twenty-four radiomics features were extracted after 3D manual segmentation of 141 lmCRC on pretreatment portal CT scans of a cohort including 38 HER2-amplified patients; feature selection was then performed using genetic algorithms. lmCRC were classified as nonresponders (R-), if their largest diameter increased more than 10% at a CT scan performed after 3 months of treatment, responders (R+) otherwise. Sensitivity, specificity, negative (NPV) and positive (PPV) predictive values in correctly classifying individual lesion and overall patient response were assessed on a training dataset and then validated on a second dataset using a Gaussian naïve Bayesian classifier. Per-lesion sensitivity, specificity, NPV and PPV were 89%, 85%, 93%, 78% and 90%, 42%, 73%, 71% respectively in the testing and validation datasets. Per-patient sensitivity and specificity were 92% and 86%. Heterogeneous response was observed in 9 of 38 patients (24%). Five of nine patients were carriers of nonresponder lesions correctly classified as such by our radiomics signature, including four of seven harboring only one nonresponder lesion. The developed method has been proven effective in predicting behavior of individual metastases to targeted treatment in a cohort of HER2 amplified patients. The model accurately detects responder lesions and identifies nonresponder lesions in patients with heterogeneous response, potentially paving the way to multimodal treatment in selected patients. Further validation will be needed to confirm our findings.

The growth of non-solid neoplastic lung nodules is associated with low PD L1 expression, irrespective of sampling technique.

BACKGROUND: Few data are known regarding the molecular features and patterns of growth and presentation which characterize those lung neoplastic lesions presenting as non-solid nodules (NSN). METHODS: We retrospectively reviewed two different cohorts of NSNs detected by CT scan which, after transthoracic fine-needle aspiration (FNA) and core needle biopsy (CNB) received a final diagnosis of malignancy. All the enrolled patients were then addressed to surgical removal of lung cancer nodules or to exclusive radiotherapy. Exhaustive clinical and radiological features were available for each case. RESULTS: In all 62 analysed cases the diagnosis of adenocarcinoma (ADC) was reached. In cytologic samples, EGFR activating mutations were identified in 2 of the 28 cases (7%); no case showed ALK/EML4 or ROS1 translocations. In the histologic samples EGFR activating mutation were found in 4 out of 25 cases (16%). PD-L1 immunostains could be evaluated in 30 cytologic samples, while the remaining 7 did not reach the cellularity threshold for evaluation. TPS was < 1% in 26 cases, > 1% < 50% in 3, and > 50% in 1. All surgical samples showed TPS < 1%. Of the 17 cases that could be evaluated on both samples, 15 were concordantly TPS 0, and 2 showed TPS > 1% < 50 on the biopsy samples. TPS was < 1% in 14 cases, > 1%/< 5% in 4 cases, > 5%/< 50% in 2 cases, > 50% in 1 case. CONCLUSIONS: Overall PD-L1 immunostaining documented the predominance of low/negative TPS, with high concordance in FNA and corresponding surgical samples. It can be hypothesized that lung ADC with NSN pattern and predominant in situ (i.e. lepidic) components represent the first steps in tumor progression, which have not yet triggered immune response, and/or have not accumulated a significant rate of mutations and neoantigen production, or that they belong to the infiltrated-excluded category of tumors. The negative prediction of response to immunomodulating therapy underlines the importance of rapid surgical treatment of these lesions. Notably, cell block cytology seems to fail in detecting EGFR mutations, thus suggesting that this kind of sampling technique should be not adequate in case of DNA direct sequencing.

Imaging alternatives to colonoscopy: CT colonography and colon capsule. European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastrointestinal and Abdominal Radiology (ESGAR) Guideline - Update 2020.

1: ESGE/ESGAR recommend computed tomographic colonography (CTC) as the radiological examination of choice for the diagnosis of colorectal neoplasia.Strong recommendation, high quality evidence.ESGE/ESGAR do not recommend barium enema in this setting.Strong recommendation, high quality evidence. 2: ESGE/ESGAR recommend CTC, preferably the same or next day, if colonoscopy is incomplete. The timing depends on an interdisciplinary decision including endoscopic and radiological factors.Strong recommendation, low quality evidence.ESGE/ESGAR suggests that, in centers with expertise in and availability of colon capsule endoscopy (CCE), CCE preferably the same or the next day may be considered if colonoscopy is incomplete.Weak recommendation, low quality evidence. 3: When colonoscopy is contraindicated or not possible, ESGE/ESGAR recommend CTC as an acceptable and equally sensitive alternative for patients with alarm symptoms.Strong recommendation, high quality evidence.Because of lack of direct evidence, ESGE/ESGAR do not recommend CCE in this situation.Very low quality evidence.ESGE/ESGAR recommend CTC as an acceptable alternative to colonoscopy for patients with non-alarm symptoms.Strong recommendation, high quality evidence.In centers with availability, ESGE/ESGAR suggests that CCE may be considered in patients with non-alarm symptoms.Weak recommendation, low quality evidence. 4: Where there is no organized fecal immunochemical test (FIT)-based population colorectal screening program, ESGE/ESGAR recommend CTC as an option for colorectal cancer screening, providing the screenee is adequately informed about test characteristics, benefits, and risks, and depending on local service- and patient-related factors.Strong recommendation, high quality evidence.ESGE/ESGAR do not suggest CCE as a first-line screening test for colorectal cancer.Weak recommendation, low quality evidence. 5: ESGE/ESGAR recommend CTC in the case of a positive fecal occult blood test (FOBT) or FIT with incomplete or unfeasible colonoscopy, within organized population screening programs.Strong recommendation, moderate quality evidence.ESGE/ESGAR also suggest the use of CCE in this setting based on availability.Weak recommendation, moderate quality evidence. 6: ESGE/ESGAR suggest CTC with intravenous contrast medium injection for surveillance after curative-intent resection of colorectal cancer only in patients in whom colonoscopy is contraindicated or unfeasibleWeak recommendation, low quality evidence.There is insufficient evidence to recommend CCE in this setting.Very low quality evidence. 7: ESGE/ESGAR suggest CTC in patients with high risk polyps undergoing surveillance after polypectomy only when colonoscopy is unfeasible.Weak recommendation, low quality evidence.There is insufficient evidence to recommend CCE in post-polypectomy surveillance.Very low quality evidence. 8: ESGE/ESGAR recommend against CTC in patients with acute colonic inflammation and in those who have recently undergone colorectal surgery, pending a multidisciplinary evaluation.Strong recommendation, low quality evidence. 9: ESGE/ESGAR recommend referral for endoscopic polypectomy in patients with at least one polyp ≥ 6 mm detected at CTC or CCE.Follow-up CTC may be clinically considered for 6 - 9-mm CTC-detected lesions if patients do not undergo polypectomy because of patient choice, comorbidity, and/or low risk profile for advanced neoplasia.Strong recommendation, moderate quality evidence.

Traditional Serrated Adenomas on CT Colonography: International Multicenter Experience With This Rare Colorectal Neoplasm.

OBJECTIVE. Serrated polyps include hyperplastic polyps, sessile serrated polyps, and traditional serrated adenomas (TSAs). Hyperplastic polyps and sessile serrated polyps account for approximately 99% of all serrated lesions; TSAs are rare. However, both sessile serrated polyps and TSAs are now recognized as precursor lesions to carcinogenesis, representing approximately one-fourth of all sporadic colorectal cancers. We report what is, to our knowledge, the first series describing the characteristics of CTAs on CT colonography (CTC). MATERIALS AND METHODS. An international, multicenter, retrospective review of CT colonography-detected TSAs diagnosed between 2008 and 2018 was conducted. Data collected included patient demographics and data from CTC, optical colonoscopy, and pathologic analysis. RESULTS. A total of 67 proven TSAs in 58 patients (mean age, 67 years) were identified. The majority (66%) were located in the distal colon (descending colon, sigmoid colon, and rectum), and their mean size was 19 mm (range, 3-80 mm). Small (< 10 mm) TSAs typically had a simple sessile or pedunculated morphologic appearance, whereas large (≥ 10 mm) TSAs tended to be more lobulated and irregular, pedunculated, or carpetlike. The majority (88%) showed at least some contrast medium surface coating. CONCLUSION. We report what we believe to be the first multicenter experience describing the characteristics of TSAs on CTC. Unlike sessile serrated lesions, TSAs are more often left-sided and tend to be more lobulated and irregular. However, like sessile serrated polyps, most TSAs show contrast medium surface coating. Detection of these rare lesions on CTC is important, given their malignant potential.

A cloud-based computer-aided detection system improves identification of lung nodules on computed tomography scans of patients with extra-thoracic malignancies.

OBJECTIVES: To compare unassisted and CAD-assisted detection and time efficiency of radiologists in reporting lung nodules on CT scans taken from patients with extra-thoracic malignancies using a Cloud-based system. MATERIALS AND METHODS: Three radiologists searched for pulmonary nodules in patients with extra-thoracic malignancy who underwent CT (slice thickness/spacing 2 mm/1.7 mm) between September 2015 and March 2016. All nodules detected by unassisted reading were measured and coordinates were uploaded on a cloud-based system. CAD marks were then reviewed by the same readers using the cloud-based interface. To establish the reference standard all nodules ≥ 3 mm detected by at least one radiologist were validated by two additional experienced radiologists in consensus. Reader detection rate and reporting time with and without CAD were compared. The study was approved by the local ethics committee. All patients signed written informed consent. RESULTS: The series included 225 patients (age range 21-90 years, mean 62 years), including 75 patients having at least one nodule, for a total of 215 nodules. Stand-alone CAD sensitivity for lesions ≥ 3 mm was 85% (183/215, 95% CI: 82-91); mean false-positive rate per scan was 3.8. Sensitivity across readers in detecting lesions ≥ 3 mm was statistically higher using CAD: 65% (95% CI: 61-69) versus 88% (95% CI: 86-91, p<0.01). Reading time increased by 11% using CAD (296 s vs. 329 s; p<0.05). CONCLUSION: In patients with extra-thoracic malignancies, CAD-assisted reading improves detection of ≥ 3-mm lung nodules on CT, slightly increasing reading time. KEY POINTS: • CAD-assisted reading improves the detection of lung nodules compared with unassisted reading on CT scans of patients with primary extra-thoracic tumour, slightly increasing reading time. • Cloud-based CAD systems may represent a cost-effective solution since CAD results can be reviewed while a separated cloud back-end is taking care of computations. • Early identification of lung nodules by CAD-assisted interpretation of CT scans in patients with extra-thoracic primary tumours is of paramount importance as it could anticipate surgery and extend patient life expectancy.

Dematerialisation of patient's informed consent in radiology: insights on current status and radiologists' opinion from an Italian online survey.

PURPOSE: To assess the current status of patient's informed consent (PIC) management at radiological centres and the overall opinion of radiologist active members of the Italian Society of Medical Radiology (SIRM) about PIC dematerialisation through an online survey. METHODS AND MATERIALS: All members were invited to join the survey as an initiative by the Imaging Informatics Chapter of SIRM. The survey consisted of 11 multiple-choice questions about participants' demographics, current local modalities of PIC acquisition and storage, perceived advantages and disadvantages of PIC dematerialisation over conventional paper-based PIC, and overall opinion about PIC dematerialisation. RESULTS: A total of 1791 radiologists (amounting to 17.4% of active SIRM members for the year 2016) joined the survey. Perceived advantages of PIC dematerialisation were easier and faster PIC recovery (96.5%), safer storage and conservation (94.5%), and reduced costs (90.7%). Conversely, the need to create dedicated areas for PIC acquisition inside each radiological unit (64.0%) and to gain preliminary approval for the use of advanced digital signature tools from patients (51.8%) were seen as potential disadvantages. Overall, 94.5% of respondents had a positive opinion about PIC dematerialisation. CONCLUSION: Radiologists were mostly favourable to PIC dematerialisation. However, concerns were raised that its practical implementation might face hurdles due to its complexity in current real life working conditions.

Flexible Sigmoidoscopy and CT Colonography Screening: Patients' Experience with and Factors for Undergoing Screening-Insight from the Proteus Colon Trial.

Purpose To compare the acceptability of computed tomographic (CT) colonography and flexible sigmoidoscopy (FS) screening and the factors predicting CT colonographic screening participation, targeting participants in a randomized screening trial. Materials and Methods Eligible individuals aged 58 years (n = 1984) living in Turin, Italy, were randomly assigned to be invited to screening for colorectal cancer with FS or CT colonography. After individuals who had died or moved away (n = 28) were excluded, 264 of 976 (27.0%) underwent screening with FS and 298 of 980 (30.4%) underwent CT colonography. All attendees and a sample of CT colonography nonattendees (n = 299) were contacted for a telephone interview 3-6 months after invitation for screening, and screening experience and factors affecting participation were investigated. Odds ratios (ORs) were computed by means of multivariable logistic regression. Results For the telephone interviews, 239 of 264 (90.6%) FS attendees, 237 of 298 (79.5%) CT colonography attendees, and 182 of 299 (60.9%) CT colonography nonattendees responded. The percentage of attendees who would recommend the test to friends or relatives was 99.1% among FS and 93.3% among CT colonography attendees. Discomfort associated with bowel preparation was higher among CT colonography than FS attendees (OR, 2.77; 95% confidence interval [CI]: 1.47, 5.24). CT colonography nonattendees were less likely to be men (OR, 0.36; 95% CI: 0.18, 0.71), retired (OR, 0.31; 95% CI: 0.13, 0.75), to report regular physical activity (OR, 0.37; 95% CI: 0.20, 0.70), or to have read the information leaflet (OR, 0.18; 95% CI: 0.08, 0.41). They were more likely to mention screening-related anxiety (mild: OR, 6.30; 95% CI: 2.48, 15.97; moderate or severe: OR, 3.63; 95% CI: 1.87, 7.04), erroneous beliefs about screening (OR, 32.15; 95% CI: 6.26, 165.19), or having undergone a recent fecal occult blood test (OR, 13.69; 95% CI: 3.66, 51.29). Conclusion CT colonography and FS screening are well accepted, but further reducing the discomfort from bowel preparation may increase CT colonography screening acceptability. Negative attitudes, erroneous beliefs about screening, and organizational barriers are limiting screening uptake; all these factors are modifiable and therefore potentially susceptible to interventions. © RSNA, 2017 Online supplemental material is available for this article.

Computer-based self-training for CT colonography with and without CAD.

OBJECTIVES: To determine whether (1) computer-based self-training for CT colonography (CTC) improves interpretation performance of novice readers; (2) computer-aided detection (CAD) use during training affects learning. METHODS: Institutional review board approval and patients' informed consent were obtained for all cases included in this study. Twenty readers (17 radiology residents, 3 radiologists) with no experience in CTC interpretation were recruited in three centres. After an introductory course, readers performed a baseline assessment test (37 cases) using CAD as second reader. Then they were randomized (1:1) to perform either a computer-based self-training (150 cases verified at colonoscopy) with CAD as second reader or the same training without CAD. The same assessment test was repeated after completion of the training programs. Main outcome was per lesion sensitivity (≥ 6 mm). A generalized estimating equation model was applied to evaluate readers' performance and the impact of CAD use during training. RESULTS: After training, there was a significant improvement in average per lesion sensitivity in the unassisted phase, from 74% (356/480) to 83% (396/480) (p < 0.001), and in the CAD-assisted phase, from 83% (399/480) to 87% (417/480) (p = 0.021), but not in average per patient sensitivity, from 93% (390/420) to 94% (395/420) (p = 0.41), and specificity, from 81% (260/320) to 86% (276/320) (p = 0.15). No significant effect of CAD use during training was observed on per patient sensitivity and specificity, nor on per lesion sensitivity. CONCLUSIONS: A computer-based self-training program for CTC improves readers' per lesion sensitivity. CAD as second reader does not have a significant impact on learning if used during training. KEY POINTS: • Computer-based self-training for CT colonography improves per lesion sensitivity of novice readers. • Self-training program does not increase per patient specificity of novice readers. • CAD used during training does not have significant impact on learning.

CT Colonography Performance for the Detection of Polyps and Cancer in Adults ≥ 65 Years Old: Systematic Review and Meta-Analysis.

OBJECTIVE: We sought to perform a systematic review and meta-analysis of published CT colonography (CTC) studies assessing lesion detection in senior-age (≥ 65 years old) cohorts. MATERIALS AND METHODS: We conducted a systematic review of CTC studies published between January 1994 and August 2017 containing data on senior-age adults. The primary endpoint was the CTC-positive rate for large colorectal polyps (≥ 10 mm) and masses. Secondary endpoints included lesions ≥ 6 mm, proven advanced neoplasia, and colorectal cancer (CRC). Study authors were contacted for additional missing data. Random-effects and meta-regression analyses were used to generate pooled estimates and explore contributing factors. RESULTS: A total of 34 studies with 41,680 (18,798 senior-age) subjects were included. Pooled CTC-positive rates among senior-age patients using the 10-mm size threshold were significantly lower in cohorts of patients with no symptoms (8.2%; 95% CI, 6.0-11.1%) compared with cohorts of patients with positive fecal occult blood tests (32.8%; 95% CI, 15.4-56.7%) and other symptoms of CRC (14.0%; 95% CI, 12.0-16.1%). However, a uniformly high positive predictive value for advanced neoplasia at colonoscopy was seen for all senior-age cohorts using a 10-mm threshold (84.3%; 95% CI, 79.3-88.3%; I2 = 0.0) where such data were available. CTC sensitivity for CRC was 93.0% (95% CI, 89.0-95.0%) in senior-age patients compared with 92.0% (95% CI, 84.0-93.0%) in younger patients. Overall, CTC detection rates were higher in senior-age adults compared with younger adults. CONCLUSION: On average, one in every 12 senior-age adults without symptoms of CRC who underwent screening would be referred to colonoscopy using the 10-mm threshold, with a high yield for advanced neoplasia and high sensitivity for cancer detection. As expected, CTC-positive rates were higher in cohorts of patients 65 years old or older with symptoms of CRC. These results should help inform the Centers for Medicare & Medicaid Services regarding coverage determination of CTC screening for Medicare beneficiaries.

JOURNAL CLUB: Extracolonic Findings at CT Colonography: Systematic Review and Meta-Analysis.

OBJECTIVE: The purpose of this study was to perform a systematic review and meta-analysis of published studies on CT colonography (CTC) in which extracolonic findings were assessed. MATERIALS AND METHODS: A systematic review of studies of screening CTC and of CTC to evaluate symptoms (1994-June 2017) was conducted to estimate the rate of extra-colonic findings and associated additional workup recommendations. The primary outcome was potentially important extracolonic findings, defined as CT Colonography Imaging Reporting and Data System (C-RADS) category E4 or as having high clinical importance (if C-RADS was not used). Secondary outcomes included likely unimportant extracolonic findings (i.e., C-RADS category E3 or similar). Random-effects and meta-regression analyses were used to generate pooled estimates and to explore risk factors for extracolonic findings related to various cohort characteristics. RESULTS: Primary data were acquired from 44 studies (49,676 patients). The pooled rate of potentially important extracolonic findings was 4.9% (95% CI, 3.7-6.4%) with a high degree of heterogeneity (I2 = 95%). This estimate progressively declined over time (9% per year since 2006) and was significantly related to the reporting system (lower for C-RADS than for low, moderate, high clinical significance reporting). C-RADS-specific meta-analysis (32,746 patients) showed rates of potentially significant extracolonic findings in 2.8% (95% CI, 1.9-3.5%) of the cohort without symptoms and 5.2% (95% CI, 3.5-7.6%) of the cohort with symptoms and in 5.7% (95% CI, 3.3-9.8%) of seniors (≥ 65 years) versus 2.3% (95% CI, 1.2-4.5%) of those younger than 65 years. The overall pooled rates of recommended workup were 8.2% (95% CI, 6.6-10.1%) for all extracolonic findings and 4.0% (95% CI, 2.7-5.9%) for potentially important extracolonic findings. CONCLUSION: With use of the more robust C-RADS classification, potentially important extracolonic findings at CTC occur in less than 3% of cohorts without symptoms. For all extracolonic findings, the rate of suggested or recommended additional workup is approximately 8% but decreases to 4% for potentially important extracolonic findings.

Deep Learning Electronic Cleansing for Single- and Dual-Energy CT Colonography.

Electronic cleansing (EC) is used for computational removal of residual feces and fluid tagged with an orally administered contrast agent on CT colonographic images to improve the visibility of polyps during virtual endoscopic "fly-through" reading. A recent trend in CT colonography is to perform a low-dose CT scanning protocol with the patient having undergone reduced- or noncathartic bowel preparation. Although several EC schemes exist, they have been developed for use with cathartic bowel preparation and high-radiation-dose CT, and thus, at a low dose with noncathartic bowel preparation, they tend to generate cleansing artifacts that distract and mislead readers. Deep learning can be used for improvement of the image quality with EC at CT colonography. Deep learning EC can produce substantially fewer cleansing artifacts at dual-energy than at single-energy CT colonography, because the dual-energy information can be used to identify relevant material in the colon more precisely than is possible with the single x-ray attenuation value. Because the number of annotated training images is limited at CT colonography, transfer learning can be used for appropriate training of deep learning algorithms. The purposes of this article are to review the causes of cleansing artifacts that distract and mislead readers in conventional EC schemes, to describe the applications of deep learning and dual-energy CT colonography to EC of the colon, and to demonstrate the improvements in image quality with EC and deep learning at single-energy and dual-energy CT colonography with noncathartic bowel preparation. ©RSNA, 2018.

Comparing CT colonography and flexible sigmoidoscopy: a randomised trial within a population-based screening programme.

IMPORTANCE AND AIMS: The role of CT colonography (CTC) as a colorectal cancer (CRC) screening test is uncertain. The aim of our trial was to compare participation and detection rate (DR) with sigmoidoscopy (flexible sigmoidoscopy (FS)) and CTC in a screening setting. DESIGN SETTING AND PARTICIPANTS: We conducted two randomised clinical trials (RCTs). (1) Participation RCT: individuals, aged 58 years, living in Turin (Italy), were randomly assigned to be invited to FS or CTC screening; (2) detection RCT: residents in northern Italy, aged 58-60, giving their consent to recruitment, were randomly allocated to CTC or FS. Polyps ≥6 mm at CTC, or 'high-risk' distal lesions at FS, were referred for colonoscopy (TC). MAIN OUTCOME MEASURES: Participation rate (proportion of invitees examined); DR of advanced adenomas or CRC (advanced neoplasia (AN)). RESULTS: Participation was 30.4% (298/980) for CTC and 27.4% (267/976) for FS (relative risk (RR) 1.1; 95% CI 0.98 to 1.29). Among men, participation was higher with CTC than with FS (34.1% vs 26.5%, p=0.011). In the detection RCT, 2673 subjects had FS and 2595 had CTC: the AN DR was 4.8% (127/2673, including 9 CRCs) with FS and 5.1% (133/2595, including 10 CRCs) with CTC (RR 1.08; 95% CI 0.85 to 1.37). Distal AN DR was 3.9% (109/2673) with FS and 2.9% (76/2595) with CTC (RR 0.72; 95% CI 0.54 to 0.96); proximal AN DR was 1.2% (34/2595) for FS vs 2.7% (69/2595) for CTC (RR 2.06; 95% CI 1.37 to 3.10). CONCLUSIONS AND RELEVANCE: Participation and DR for FS and CTC were comparable. AN DR was twice as high in the proximal colon and lower in the distal colon with CTC than with FS. Men were more likely to participate in CTC screening. TRIAL REGISTRATION NUMBER: NCT01739608; Pre-results.

Usage of structured reporting in radiological practice: results from an Italian online survey.

OBJECTIVES: To assess the opinion on structured reporting (SR) and its usage by radiologist members of the Italian Society of Medical Radiology (SIRM) via an online survey. METHODS: All members received an email invitation to join the survey as an initiative by the SIRM Imaging Informatics Chapter. The survey included 10 questions about demographic information, definition of radiological SR, its usage in everyday practice, perceived advantages and disadvantages over conventional reporting and overall opinion about SR. RESULTS: 1159 SIRM members participated in the survey. 40.3 % of respondents gave a correct definition of radiological SR, but as many as 56 % of them never used it at work. Compared with conventional reporting, the most appreciated advantages of SR were higher reproducibility (70.5 %), better interaction with referring clinicians (58.3 %) and the option to link metadata (36.7 %). Risk of excessive simplification (59.8 %), template rigidity (56.1 %) and poor user compliance (42.1 %) were the most significant disadvantages. Overall, most respondents (87.0 %) were in favour of the adoption of radiological SR. CONCLUSIONS: Most radiologists were interested in radiological SR and in favour of its adoption. However, concerns about semantic, technical and professional issues limited its diffusion in real working life, encouraging efforts towards improved SR standardisation and engineering. KEY POINTS: • Despite radiologists' awareness, radiological SR is little used in working practice. • Perceived SR advantages are reproducibility, better clinico-radiological interaction and link to metadata. • Perceived SR disadvantages are excessive simplification, template rigidity and poor user compliance. • Improved standardisation and engineering may be helpful to boost SR diffusion.