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This study explores the role of irisin and interleukins in parotid tumors by determining the tissue staining intensity of irisin, the salivary and plasma levels of irisin, and the plasma levels of IL-4, IL-6, IL-10 and TNF-alpha in individuals with parotid tumors. Forty-eight patients and forty healthy individuals were included to the study and allocated into four group. Benign Group I (pleomorphic adenoma), Group II (Warthin's tumor), Group III (mucoepidermoid carcinoma) and Group IV (benign parotid control group, healthy control group). Parotid tissue, plasma and saliva samples were collected from each of the patients with parotid tumors, while plasma and saliva samples were collected from the healthy individuals. Normal parotid tissue for histologic evaluation was obtained from unaffected areas in patients with parotid tumors. The levels of irisin in the plasma and saliva were significantly lower in the parotid tumors, while the plasma levels of IL-6 and TNF-alpha were higher in patients with parotid tumors, but no statistically significant difference in IL-4 and IL-10 levels was found. The histopathological intensity of FNDC-5/irisin staining was significantly decreased in the parotid tumor tissues when compared to the benign parotid control group with normal parotid tissue. The low histopathological tissue staining intensity and plasma and salivary levels of irisin suggest that irisin may be a protective protein in parotid tumors. [ABSTRACT FROM AUTHOR]

Background/Objectives: Parotid surgery is generally performed with the naked eye or using surgical loupes. However, this approach has technical disadvantages. Therefore, this study aimed to compare the use of an exoscope with that of loupe for parotidectomies. Methods: A retrospective review of patients who underwent partial parotidectomies for parotid tumors was conducted. We examined the approach (anterograde/retrograde), tumor localization (superficial/deep), operative time, volume of intraoperative blood loss, and postoperative complications occurring within 6 months. Results: Overall, 174 patients underwent parotidectomies (90 in the exoscope group, 84 in the loupe group). In parotidectomies using the anterograde approach, the exoscope group had significantly fewer reports of facial nerve palsy than the loupe group. Parotidectomy-related complications other than facial palsy were significantly fewer in the exoscope group. However, the operation time was significantly longer in the exoscope group than in the loupe group. Conclusions: An ORBEYETM exoscope provides a magnified view of the surgical field, leading to more accurate operations in parotid surgery and potentially fewer complications. [ABSTRACT FROM AUTHOR]

Objectives: This study investigates the clinical and patient-reported outcomes of full-endoscopic parotidectomy compared to the conventional approach. Methods: Between July 2021 and December 2023, patients who underwent parotidectomy were prospectively enrolled and assigned to either the full-endoscopic parotidectomy group (Group I) or the conventional surgery group (Group II). Clinical outcomes were evaluated, and patient-reported outcomes were assessed using a Visual Analogue Scale and five FACE-Q scales. Results: A total of 293 patients were prospectively included, with 146 in the full-endoscopic group and 147 in the conventional group. Blood loss was significantly lower in the full-endoscopic group (regression coefficient, 0.61; 95% CI, 0.15 to 1.07), as was the rate of immediate facial paralysis (0.76; 95% CI, 0.25 to 1.27). The full-endoscopic group also showed superior outcomes on the Visual Analogue Scale (− 0.14; 95% CI, − 0.23 to − 0.05) and FACE-Q scales for Appearance-Related Psychosocial Distress (1.15; 95% CI, 0.59 to 1.71), Social Function (− 0.37; 95% CI, − 0.59 to − 0.15), Satisfaction with Facial Appearance (− 0.44; 95% CI, − 0.64 to − 0.23), Psychological Function (− 0.39; 95% CI, − 0.58 to − 0.20), and Satisfaction With Outcome (− 0.42; 95% CI, − 0.66 to − 0.19). Conclusions: Full-endoscopic parotidectomy yields less blood loss and a reduced incidence of immediate facial paralysis compared to conventional surgery. Patients undergoing full-endoscopic parotidectomy reported better aesthetic and psychological outcomes. Clinical relevance: The combined analysis of clinical and patient-reported outcomes is valuable in guiding surgical planning. These findings provide valuable insights for patients considering full-endoscopic parotidectomy and underscore the importance of addressing functional, aesthetic, and psychological aspects for both patients and healthcare providers. [ABSTRACT FROM AUTHOR]

Abstract Background This study aimed to analyze the effects of anterior descending mandible (ADM) and free superficial musculoaponeurotic system (SMAS) folding flaps on post-parotidectomy facial depression. Methods This retrospective study examined the effects of sex, age, surgical sample size, method, duration, and blood loss on postoperative complications in 65 patients. Results No significant differences involving sex, age, or sample size for surgical resection were observed between the two groups. The incidence of Frey syndrome (P = 0.175) and the locations of facial nerve injuries and tumors were not significantly different between the two groups. However, a statistically significant difference was observed in postoperative facial depression between the groups (P = 0.045, P

Purpose: This study investigated the characteristics, diagnosis, and treatment of Warthin tumors (WTs) to explore the possibility of managing patients by observation. Methods: We reviewed the records of 1167 patients with benign parotid tumors who were seen in our department between September 1999 and April 2021. Among them, 387 cases were WT and 668 cases were pleomorphic adenoma. We evaluated preoperative diagnoses of WT by symptoms/signs, fine-needle aspiration cytology (FNAC), imaging, such as ultrasonography and magnetic resonance imaging, and technetium-99m pertechnetate (Tc-99m) scintigraphy. Fisher's exact test and the Mann–Whitney U test were used in statistical analyses. Results: Warthin tumors were treated by surgery in 238 cases and follow-up in 149 cases. The 238 patients were diagnosed as WT at the final pathology after surgery. Among them, 172 patients (72.3%) were determined as benign histological type by preoperative FNAC; in these 172 patients, 170 (71.4%) were correctly diagnosed as WT in the final pathology. Preoperative Tc-99m scintigraphy was performed in 69 patients diagnosed with WT by final pathology or FNAC, and the positive rate of Tc-99m scintigraphy in WT was 75.4%. Conclusions: Combining FNAC and Tc-99m scintigraphy, as well as considering clinical findings, enables the diagnosis of WT in most cases. In particular, WT is more common in the elderly, grows more slowly, and is less likely to be malignant. Therefore, if WT can be diagnosed preoperatively with a high rate of correct diagnosis, it could be an accurate and effective means of managing patients through follow-up without surgery. [ABSTRACT FROM AUTHOR]

Background: This study aimed to analyze the effects of anterior descending mandible (ADM) and free superior mesenteric artery (SMAS) folding flaps on post-parotidectomy facial depression. Methods: This retrospective study examined the effects of sex, age, surgical sample size, method, duration, and blood loss on postoperative complications in 65 patients. Results: No significant differences involving sex, age, or sample size for surgical resection were observed between the two groups. The incidence of Frey syndrome (P = 0.175) and the locations of facial nerve injuries and tumors were not significantly different between the two groups. However, a statistically significant difference was observed in postoperative facial depression between the groups (P = 0.045, P < 0.05). No significant difference was found between facial nerve injury and Frey's sign in subgroup analysis of facial depression deformities. Within the facial depression group, tumor locations were significantly different (P = 0.021, P < 0.05). In the cases of facial depression after partial parotid resection, no significant difference was observed between ADM implantation and SMAS flap placement. A significant difference was noted between the ADM implantation and SMAS flap groups in the total parotidectomy group (P = 0.046 and P < 0.05, respectively). Conclusion: Women are more likely to experience facial depression after parotid surgery. Facial depression is most likely to occur after parotid resection if the tumor is located in the deep lobes of the parotid gland. The use of SMAS flaps can prevent facial depression, and both ADM and SMAS flaps can prevent Frey's syndrome. Partial parotid resection reduces the risk of facial nerve injury and facial depression. [ABSTRACT FROM AUTHOR]

Introduction: This study aimed to investigate the relationship between preoperative fine needle aspiration cytology (FNAC) for parotid tumors and the level of surgical training among residents, as well as to further elucidate its effectiveness as a diagnostic tool in the hands of the treating physician. Materials and Methods: Surgical records from patients who underwent parotid surgery between 2014 and 2022 were retrieved. Residents reported their perceived level of training duringthese procedures. Contingency tables were used to correlate the cytological with final histopathological results. Results: A total of 286 patients who had undergone preoperative FNAC were included in the study. A preoperative diagnosis of pleomorphic adenoma or Wharthin's tumor was significantly associated with higher training scores among surgical residents. In contrast, a diagnosis of malignancy, other benign tumors, or indeterminate cytology was correlated with poor training scores (χ2 = 176.35; df = 2; p-value <0.001, Cramer's V 0.79). FNAC demonstrated a sensitivity of 88% and a specificity of 99.2% for detecting malignancy, with a positive likelihood ratio of 103.8 (95% CI: 26.02-414.34) and a negative likelihood ratio of 0.12 (95% CI: 0.06-0.26). Conclusions: Our findingssuggest that preoperative cytological diagnoses of parotid tumors with a favorable prognosis, such as Wharthin's tumors, can enhance training and mentorship opportunities provided by senior surgeons. This is particularly significant for academic institutions with residency programs. [ABSTRACT FROM AUTHOR]

to develop a deep learning radiomics graph network (DLRN) that integrates deep learning features extracted from gray scale ultrasonography, radiomics features and clinical features, for distinguishing parotid pleomorphic adenoma (PA) from adenolymphoma (AL) A total of 287 patients (162 in training cohort, 70 in internal validation cohort and 55 in external validation cohort) from two centers with histologically confirmed PA or AL were enrolled. Deep transfer learning features and radiomics features extracted from gray scale ultrasound images were input to machine learning classifiers including logistic regression (LR), support vector machines (SVM), KNN, RandomForest (RF), ExtraTrees, XGBoost, LightGBM, and MLP to construct deep transfer learning radiomics (DTL) models and Rad models respectively. Deep learning radiomics (DLR) models were constructed by integrating the two features and DLR signatures were generated. Clinical features were further combined with the signatures to develop a DLRN model. The performance of these models was evaluated using receiver operating characteristic (ROC) curve analysis, calibration, decision curve analysis (DCA), and the Hosmer-Lemeshow test. In the internal validation cohort and external validation cohort, comparing to Clinic (AUC=0.767 and 0.777), Rad (AUC=0.841 and 0.748), DTL (AUC=0.740 and 0.825) and DLR (AUC=0.863 and 0.859), the DLRN model showed greatest discriminatory ability (AUC=0.908 and 0.908) showed optimal discriminatory ability. The DLRN model built based on gray scale ultrasonography significantly improved the diagnostic performance for benign salivary gland tumors. It can provide clinicians with a non-invasive and accurate diagnostic approach, which holds important clinical significance and value. Ensemble of multiple models helped alleviate overfitting on the small dataset compared to using Resnet50 alone. [ABSTRACT FROM AUTHOR]

IntroductionAccurate differentiation between pleomorphic adenomas (PA) and Warthin tumors (WT) in the parotid gland is challenging owing to overlapping imaging features. This study aimed to evaluate a nomogram combining dual-energy computed tomography (DECT) quantitative parameters and radiomics to enhance diagnostic precision.MethodsThis retrospective study included 120 patients with pathologically confirmed PA or WT, randomly divided into training and test sets (7:3). DECT features, including tumor CT values from 70 keV virtual monochromatic images (VMIs), iodine concentration (IC), and normalized IC (NIC), were analyzed. Independent predictors were identified via logistic regression. Radiomic features were extracted from segmented regions of interest and filtered using the K-best and least absolute shrinkage and selection operator. Radiomic models based on 70 keV VMIs and material decomposition images were developed using logistic regression (LR), support vector machine (SVM), and random forest (RF). The best-performing radiomics model was combined with independent DECT predictors to construct a model and nomogram. Model performance was assessed using ROC curves, calibration curves, and decision curve analysis (DCA).ResultsIC (venous phase), NIC (arterial phase), and NIC (venous phase) were independent DECT predictors. The DECT feature model achieved AUCs of 0.842 and 0.853 in the training and test sets, respectively, outperforming the traditional radiomics model (AUCs 0.836 and 0.834, respectively). The DECT radiomics model using arterial phase water-based images with LR showed improved performance (AUCs 0.883 and 0.925). The combined model demonstrated the highest discrimination power, with AUCs of 0.910 and 0.947. The combined model outperformed the DECT features and conventional radiomics models, with AUCs of 0.910 and 0.947, respectively (P0.05), it showed higher specificity, accuracy, and precision. DCA found that the nomogram gave the greatest net therapeutic effect across a broad range of threshold probabilities.DiscussionThe nomogram combining DECT features and radiomics offers a promising non-invasive tool for differentiating PA and WT in clinical practice.

Objective: Parotid tumors are rare neoplasms in adults but are exceedingly infrequent in adolescents. We aimed to determine the clinical characteristics and outcomes of parotid tumors in adolescents under 20 years old. Methods: Between 1999 and 2020, 979 cases of benign parotid tumors and 236 cases of malignant parotid tumors were treated surgically in our department. Of these, 12 benign cases (1.2%) and 9 malignant cases (3.8%) were in adolescents. There were no benign or malignant cases for those aged under 10 years. Results: Regarding the histological type, all benign tumors were pleomorphic adenomas. About half of malignant tumors were mucoepidermoid carcinomas, and excluding one high-grade case, the grade of malignancy was all low/intermediate. The accuracy of fine-needle aspiration cytology among adolescents showed no significant difference with that of adults. In contrast to adults, adolescent benign tumor cases showed a markedly high rate of pleomorphic adenomas and no postoperative facial nerve palsy. Malignant tumors in adolescents had a different trend than adults; low/intermediate-grade malignancies were common and thus few symptoms/signs of malignancy could be observed. As well, the accuracy of fine-needle aspiration cytology was poor. All cases had a good prognosis and are disease-free survival. Conclusion: Parotid tumors in adolescents are rare but have several characteristics that are distinct from adults. As long-term observation is required posttreatment in adolescent patients, recurrence in benign pleomorphic adenomas and poor long-term prognosis in malignant tumors, especially for those with low/intermediate-grade malignancy, are more likely to be observed. [ABSTRACT FROM AUTHOR]

Objective To analyze the influencing factors of postoperative facial paralysis in patients with parotid tumors by using machine learning technique. Methods The data of patients with parotid tumors in the medical record system of Guigang People's Hospital from January 2013 to December 2023 were collected retrospectively. LASSO regression was used to screen the potential risk factors of post-operative facial paralysis, followed by an disordered multi-classification Logistic regression analysis to determine the risk factors of postoperative facial paralysis. Results 54 of 395 patients with parotid tumors experienced facial paralysis, including 40 cases of transient facial paralysis and 14 cases of permanent facial paralysis. Disordered multi-classification LASSO regression identified 26 risk factors of postoperative facial paralysis in patients with parotid tumors under the optimal lambda value, which were included in the disordered multi-classification Logistic regression analysis. The results showed that tumor location, tumor nature, preoperative mass tenderness, smoking, glutamyl transferase, chloride concentration, magnesium concentration, and partial thromboplastin time were the influencing factors for transient facial paralysis (all P<0.05); tumor nature tumor volume, age, and body mass index were influencing factors for permanent facial paralysis (all P<0.05). Conclusions The key influencing factors of postoperative facial paralysis in patients with parotid tumors are identified by using the machine learning technique, helping the early identification of high-risk groups for postoperative facial paralysis and providing a scientific basis for the prevention and prediction of facial paralysis. [ABSTRACT FROM AUTHOR]

It is indisputable that high-resolution ultrasound (US) is the diagnostic gold standard for the evaluation of superficial parotid gland diseases. It is a dynamic, quick, simple, easily available, cost-effective, noninvasive procedure, with absence of ionizing radiation examination that can be performed safely and in special categories of patients such as pregnant women and children. It is widely accepted that on US, benign tumors have clear, smooth and well-defined borders, homogeneous hypoechoic parenchyma and a defined distribution of vessels. On the other hand, malignant lesions usually have unclear borders; also, they are inhomogeneous and sometimes can have areas of necrosis, increased hypoechogenicity and diffuse vascularization. However, many times these findings are not decisive due to the overlap that often occurs in parotid tumors. Shear wave elastography (SWE) represents a new imaging technique that provides additional information about tissue elasticity and stiffness in a selected region of interest. Since malignant tissues show greater stiffness than benign ones, sonoelastography is used to assist differential diagnosis between malignant and benign lesions. In many other organs, such as breast, thyroid, prostate and liver, it has been already successfully used for the differential diagnosis between malignant and benign lesions. The present article highlights the role of elastography in the diagnosis of a small malignant tumor in the left parotid gland of a 73-year-old female patient. [ABSTRACT FROM AUTHOR]

Intraparotid gland neurofibroma is a rare benign tumor that arises from Schwann cells of the facial nerve within the parotid gland. This case report discusses a 41-year-old woman who experienced a painless preauricular swelling on her right side for over 5 years. Clinical examination and ultrasound revealed a well-defined mass in the parotid gland. The patient underwent total mass excision, resulting in transient facial nerve dysfunction but complete recovery. These tumors often manifest as solitary masses in the parotid region and may compress nearby structures, causing facial paralysis or numbness. Their diagnosis can be challenging due to similarities with other parotid gland tumors and possible associations with neurofibromatosis. Managing intraparotid tumors, including neurofibromas, involves a multidisciplinary approach with input from cytopathologists, radiologists, and surgeons. [ABSTRACT FROM AUTHOR]

Background: Sebaceous adenoma of the salivary glands are uncommon benign neoplasms, comprising about 0.1 % of salivary tumors. These tumors can be difficult to recognize with heterogeneous appearance on imaging. Case report: A 67-year-old man presented with a painless, progressively growing left parotid mass. Imaging showed a heterogenous, partially cystic mass in the superficial and deep lobes of the parotid with some areas of adipose density. Intraoperatively, a mass with sebaceous differentiation was found to be encasing the main trunk and pes anserinus of the facial nerve, requiring nerve sacrifice for en bloc resection. Final pathology revealed a sebaceous adenoma with intense xanthomatous reaction compressing the facial nerve. Conclusion: Although benign and associated with little risk of recurrence, sebaceous adenomas may be difficult to recognize on preoperative workup and may be locally aggressive. Complete surgical resection is the mainstay of therapy, but rehabilitation may be required in the event of facial nerve involvement.

Abstract Background To develop a deep learning(DL) model utilizing ultrasound images, and evaluate its efficacy in distinguishing between benign and malignant parotid tumors (PTs), as well as its practicality in assisting clinicians with accurate diagnosis. Methods A total of 2211 ultrasound images of 980 pathologically confirmed PTs (Training set: n = 721; Validation set: n = 82; Internal-test set: n = 89; External-test set: n = 88) from 907 patients were retrospectively included in this study. The optimal model was selected and the diagnostic performance evaluation is conducted by utilizing the area under curve (AUC) of the receiver-operating characteristic(ROC) based on five different DL networks constructed at varying depths. Furthermore, a comparison of different seniority radiologists was made in the presence of the optimal auxiliary diagnosis model. Additionally, the diagnostic confusion matrix of the optimal model was calculated, and an analysis and summary of misjudged cases’ characteristics were conducted. Results The Resnet18 demonstrated superior diagnostic performance, with an AUC value of 0.947, accuracy of 88.5%, sensitivity of 78.2%, and specificity of 92.7% in internal-test set, and with an AUC value of 0.925, accuracy of 89.8%, sensitivity of 83.3%, and specificity of 90.6% in external-test set. The PTs were subjectively assessed twice by six radiologists, both with and without the assisted of the model. With the assisted of the model, both junior and senior radiologists demonstrated enhanced diagnostic performance. In the internal-test set, there was an increase in AUC values by 0.062 and 0.082 for junior radiologists respectively, while senior radiologists experienced an improvement of 0.066 and 0.106 in their respective AUC values. Conclusions The DL model based on ultrasound images demonstrates exceptional capability in distinguishing between benign and malignant PTs, thereby assisting radiologists of varying expertise levels to achieve heightened diagnostic performance, and serve as a noninvasive imaging adjunct diagnostic method for clinical purposes.

Precise recognition of the intraparotid facial nerve (IFN) is crucial during parotid tumor resection. We aimed to explore the application effect of direct visualization of the IFN in parotid tumor resection. Fifteen patients with parotid tumors were enrolled in this study and underwent specific radiological scanning in which the IFNs were displayed as high-intensity images. After image segmentation, IFN could be preoperatively directly visualized. Mixed reality combined with surgical navigation were applied to intraoperatively directly visualize the segmentation results as real-time three-dimensional holograms, guiding the surgeons in IFN dissection and tumor resection. Radiological visibility of the IFN, accuracy of image segmentation and postoperative facial nerve function were analyzed. The trunks of IFN were directly visible in radiological images for all patients. Of 37 landmark points on the IFN, 36 were accurately segmented. Four patients were classified as House–Brackmann Grade I postoperatively. Two patients with malignancies had postoperative long-standing facial paralysis. Direct visualization of IFN was a feasible novel method with high accuracy that could assist in recognition of IFN and therefore potentially improve the treatment outcome of parotid tumor resection. [ABSTRACT FROM AUTHOR]

Background: To develop a deep learning(DL) model utilizing ultrasound images, and evaluate its efficacy in distinguishing between benign and malignant parotid tumors (PTs), as well as its practicality in assisting clinicians with accurate diagnosis. Methods: A total of 2211 ultrasound images of 980 pathologically confirmed PTs (Training set: n = 721; Validation set: n = 82; Internal-test set: n = 89; External-test set: n = 88) from 907 patients were retrospectively included in this study. The optimal model was selected and the diagnostic performance evaluation is conducted by utilizing the area under curve (AUC) of the receiver-operating characteristic(ROC) based on five different DL networks constructed at varying depths. Furthermore, a comparison of different seniority radiologists was made in the presence of the optimal auxiliary diagnosis model. Additionally, the diagnostic confusion matrix of the optimal model was calculated, and an analysis and summary of misjudged cases' characteristics were conducted. Results: The Resnet18 demonstrated superior diagnostic performance, with an AUC value of 0.947, accuracy of 88.5%, sensitivity of 78.2%, and specificity of 92.7% in internal-test set, and with an AUC value of 0.925, accuracy of 89.8%, sensitivity of 83.3%, and specificity of 90.6% in external-test set. The PTs were subjectively assessed twice by six radiologists, both with and without the assisted of the model. With the assisted of the model, both junior and senior radiologists demonstrated enhanced diagnostic performance. In the internal-test set, there was an increase in AUC values by 0.062 and 0.082 for junior radiologists respectively, while senior radiologists experienced an improvement of 0.066 and 0.106 in their respective AUC values. Conclusions: The DL model based on ultrasound images demonstrates exceptional capability in distinguishing between benign and malignant PTs, thereby assisting radiologists of varying expertise levels to achieve heightened diagnostic performance, and serve as a noninvasive imaging adjunct diagnostic method for clinical purposes. [ABSTRACT FROM AUTHOR]

Objective: The aim of this retrospective article is to evaluate postoperative outcomes after extracapsular dissection for small benign superficial parotid neoplasms (

Simple Summary: Amide proton transfer weighted (APTw) imaging is a contrast-free molecular imaging method based on the chemical exchange saturation transfer (CEST) technique, initially applied and explored in brain cancers. Previous studies of APTw imaging in the head and neck area have applied APTw protocols in the brain, and hyperintensity artifacts remain a problem to solve. A total of 32 lesions and 30 parotid glands were involved in this research to address the effect of B1 power modification on improving APTw imaging quality in parotid tumor identification, aiming to minimize hyperintensity artifacts. We found that hyperintensity artifacts declined with B1 power decreasing, and combinations of different APTw sequences could improve tumor detection feasibility compared to one APTw sequence. Our findings in this research could give an insight into APTw imaging quality improvement in the head and neck area, which might help the noninvasive diagnosis of parotid tumors in the future. Background: In the application of APTw protocols for evaluating tumors and parotid glands, inhomogeneity and hyperintensity artifacts have remained an obstacle. This study aimed to improve APTw imaging quality and evaluate the feasibility of difference B1 values to detect parotid tumors. Methods: A total of 31 patients received three APTw sequences to acquire 32 lesions and 30 parotid glands (one patient had lesions on both sides). Patients received T2WI and 3D turbo-spin-echo (TSE) APTw imaging on a 3.0 T scanner for three sequences (B1 = 2 μT, 1 μT, and 0.7 μT in APTw 1, 2, and 3, respectively). APTw image quality was evaluated using four-point Likert scales in terms of integrity and hyperintensity artifacts. Image quality was compared between the three sequences. An evaluable group and a trustable group were obtained for APTmean value comparison. Results: Tumors in both APT2 and APT3 had fewer hyperintensity artifacts than in APT1. With B1 values decreasing, tumors had less integrity in APTw imaging. APTmean values of tumors were higher than parotid glands in traditional APT1 sequence though not significant, while the APTmean subtraction value was significantly different. Conclusions: Applying a lower B1 value could remove hyperintensity but could also compromise its integrity. Combing different APTw sequences might increase the feasibility of tumor detection. [ABSTRACT FROM AUTHOR]

Abstract Background Pilomatrixoma is a rare benign tumor of the hair follicle. It is more common in children and women. The cervical and facial region are the most frequent location for this type of tumor. Due to its variable clinical presentations, it can sometimes be misdiagnosed as a malignant tumor of surrounding tissues, as described in our case. The diagnosis confirmation is pathological. Case presentation We report the case of a 34-year-old patient, who presented a swelling in the right parotid region gradually increasing in size for two years, with no facial asymmetry. Clinical examination revealed a rounded, well-defined mass, fixed to the superficial plan, without any cervical lymph nodes. The MRI showed a tumor that seems to be evolving from the superficial lobe of the right parotid, suggesting a pleomorphic adenoma. Total excision of the tumor without margins was performed, preserving the parotid tissue and the facial nerve. The postoperative course was normal; and the pathological study confirmed the diagnosis of pilomatrixoma. Conclusion Pilomatrixoma is a rare benign tumor but it remains a differential diagnosis of large tumors of the neck and parotid. It is mainly a pathological diagnosis, The treatment of choice still complete surgical excision.

ObjectivesTo differentiate parotid pleomorphic adenoma (PA) from adenolymphoma (AL) using radiomics of grayscale ultrasonography in combination with clinical features.MethodsThis retrospective study aimed to analyze the clinical and radiographic characteristics of 162 cases from December 2019 to March 2023. The study population consisted of a training cohort of 113 patients and a validation cohort of 49 patients. Grayscale ultrasonography was processed using ITP-Snap software and Python to delineate regions of interest (ROIs) and extract radiomic features. Univariate analysis, Spearman’s correlation, greedy recursive elimination strategy, and least absolute shrinkage and selection operator (LASSO) correlation were employed to select relevant radiographic features. Subsequently, eight machine learning methods (LR, SVM, KNN, RandomForest, ExtraTrees, XGBoost, LightGBM, and MLP) were employed to build a quantitative radiomic model using the selected features. A radiomic nomogram was developed through the utilization of multivariate logistic regression analysis, integrating both clinical and radiomic data. The accuracy of the nomogram was assessed using receiver operating characteristic (ROC) curve analysis, calibration, decision curve analysis (DCA), and the Hosmer–Lemeshow test.ResultsTo differentiate PA from AL, the radiomic model using SVM showed optimal discriminatory ability (accuracy = 0.929 and 0.857, sensitivity = 0.946 and 0.800, specificity = 0.921 and 0.897, positive predictive value = 0.854 and 0.842, and negative predictive value = 0.972 and 0.867 in the training and validation cohorts, respectively). A nomogram incorporating rad-Signature and clinical features achieved an area under the ROC curve (AUC) of 0.983 (95% confidence interval [CI]: 0.965–1) and 0.910 (95% CI: 0.830–0.990) in the training and validation cohorts, respectively. Decision curve analysis showed that the nomogram and radiomic model outperformed the clinical-factor model in terms of clinical usefulness.ConclusionA nomogram based on grayscale ultrasonic radiomics and clinical features served as a non-invasive tool capable of differentiating PA and AL.

Background: Salivary cancers are relatively uncommon with important types of head and neck malignancies with poor prognosis in the vast majority of cases. Objectives: Prompt diagnosis and treatment are critical to attaining a good prognosis; hence, recognition of the epidemiological characteristics is worthwhile. Accordingly, in this study, the epidemiological characteristics of cases with salivary sarcoma among Iranian patients were assessed. Methods: In this epidemiological study, 70 consecutive cases with salivary sarcoma in Iran within 22 provinces were assessed from 2009 to 2014. The dataset utilized in this study was sourced from the Iran National Cancer Registry (INCR). These included both parotid (n = 53) and major salivary glands (n = 17). The age, sex, anatomical location, province, and year were the main variables extracted from existing medical data. Results: The present study reports 53 cases of parotid tumor sarcoma, with the mixed tumor exhibiting a predominant malignant component being the most frequently observed pathological subtype. The preponderance of these instances was noted among individuals classified as adults within the working demographic (ranging from 15 to 64 years of age). However, our age-adjusted incidence rate indicates a higher occurrence of salivary gland tumors in individuals above 64. The study reported 17 instances of sarcomas in other major salivary glands, with the malignant type mixed tumor being the most frequently occurring subtype within this group. The gender distribution did not exhibit a statistically significant pattern. Conclusions: Thoroughly, according to the obtained results in this study, it maybe concluded that salivary sarcoma in the Iranian population is usually the mixed malignant tumor subtype and there are similar patterns according to the age and sex in patients with slight male predominance (F/M ratio: 0.75). [ABSTRACT FROM AUTHOR]

Postoperative facial nerve paralysis is the most problematic complication after surgical treatment of parotid tumors. Localization of tumors is highly relevant for the surgical approach, but existing classification systems do not focus on the association between localization and surgical technique. Therefore, we created a new localization-based classification system for benign parotid tumors and investigated the characteristics of tumors in each localization and the frequency of postoperative facial nerve paralysis by retrospectively applying the classification to previous cases. First, we defined 6 portions of the parotid gland (upper, U; lower, L; posterior, P; anterior, A; superficial, S; deep, D) by dividing the transverse plane into an upper and lower portion at the mandibular marginal branch, the longitudinal plane into a posterior and anterior portion at the midline of the parotid anteroposterior diameter, and the sagittal plane into a superficial and deep portion along the course of the facial nerve. Then, we defined 8 locations by combining the 6 portions in all possible ways (i.e., U-P-S, U-P-D, U-A-S, U-A-D, L-P-S, L-P-D, L-A-S, L-A-D). We used this classification to define the tumor localization in 948 patients who had undergone partial superficial parotidectomy for benign parotid tumors and then investigated the incidence, histopathological type, signs/symptoms, diagnosis, surgery, and complications in each area. Pleomorphic adenomas comprised approximately 70% of tumors in the upper portion but only approximately 35% in the lower portion. The rate of postoperative facial nerve paralysis was significantly higher for tumors in deep locations than in superficial locations (33.9% vs 14.9%, respectively), and the odds ratios for postoperative facial nerve paralysis in the U-P-D and U-A-D locations were 7.6 and 4.8 compared to the L-P-S location. When maximum diameter, operation time, bleeding volume, sex (reference: female), and age were added as control variables, the odds ratios were 4.2 and 3.0. Determining tumor localization preoperatively with the new localization-based classification of parotid tumors is helpful not only for predicting the histopathological type but also for predicting surgical complications, particularly postoperative facial nerve paralysis. [ABSTRACT FROM AUTHOR]

Objective: To explore the application of enhanced computed tomography (CT)-based texture analysis combined with machine learning in the differential diagnosis of adenolymphomas and mixed tumors of the parotid gland. Methods: We retrospectively analyzed 21 and 19 cases of adenolymphomas and mixed tumors of the parotid gland, respectively. Regions of interest (ROI) were chosen on axial enhanced-CT images of the tumor’s maximum cross section using the Mazda software. The optimal texture parameters were selected using Fisher’s coefficient, probability of classification error and average correlation coefficients, mutual information, and a combination of the three. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the diagnostic efficacy. Finally, the texture parameters were classified and analyzed using the following four machine-learning methods: raw data analysis, principal component analysis, linear discriminant analysis, and nonlinear discriminant analysis (NDA). The diagnostic efficiencies of these classification algorithms were analyzed. Results: WavEnHH_s-4, GrVariance, 45dgr_Fraction, WavEnLL_s-4, and GrSkewness were the statistically significant texture feature parameters for differentiating between parotid adenolymphomas and mixed tumors.. ROC curve analysis revealed that WavEnLL_s-4 had a balanced sensitivity and specificity, and the area under the curve, sensitivity, and specificity were 0.797, 84.2%, and 62.5%, respectively. The misclassification rate of NDA (5.0%–12.5%) was lower than that of the other algorithms. The NDA of FPM had the lowest misclassification rate (5.0%); its accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were 95.0%, 95.2%, 94.7%, 95.2, and 94.7, respectively. Conclusion: The optimum enhanced CT-based texture features differed significantly between parotid adenolymphomas and mixed tumors. A combination of FPM and NDA had the lowest misclassification rate; it can contribute toward the identification of parotid adenolymphomas and mixed tumors.

Background: Lymphadenomas are rare benign tumors of the major salivary glands that are further classified as sebaceous and non-sebaceous. No association with viruses has been reported so far. Little is known about the mechanisms that allow lymphadenomas to undergo malignant transformation. Among these rare instances, there has never been a malignant transformation to Epstein–Barr virus (EBV)-associated lymphoepithelial carcinoma. Methods: Clinical data of the reported case were retrieved from the patient's electronic medical record. Hematoxylin & eosin-stained slides, immunohistochemical tests, and in situ hybridization performed for routine diagnostic purposes were reviewed. Results: We report a salivary gland sebaceous lymphadenoma in which the luminal components were mostly replaced by malignant epithelial cells with markedly atypical nuclear features. Presence of EBV was demonstrated in all components by EBER. The morphological and immunohistochemical findings were consistent with a lymphoepithelial carcinoma arising from a sebaceous lymphadenoma. Conclusion: We report the first case of an Epstein–Barr virus-associated lymphoepithelial carcinoma arising from a sebaceous lymphadenoma. [ABSTRACT FROM AUTHOR]

Objective: Little information is available about deep learning methods used in ultrasound images of salivary gland tumors. We aimed to compare the accuracy of the ultrasound‐trained model to computed tomography or magnetic resonance imaging trained model. Materials and methods: Six hundred and thirty‐eight patients were included in this retrospective study. There were 558 benign and 80 malignant salivary gland tumors. A total of 500 images (250 benign and 250 malignant) were acquired in the training and validation set, then 62 images (31 benign and 31 malignant) in the test set. Both machine learning and deep learning were used in our model. Results: The test accuracy, sensitivity, and specificity of our final model were 93.5%, 100%, and 87%, respectively. There were no over fitting in our model as the validation accuracy was similar with the test accuracy. Conclusions: The sensitivity and specificity were comparable with current MRI and CT images using artificial intelligence. [ABSTRACT FROM AUTHOR]

Huge head and neck tumors are known to cause difficult ventilation and difficult intubation. Edentulous mouth can result in difficult mask ventilation. Head and neck tumor resections can also present hemodynamic challenge, due to their proximity to large vessels. We herein report a clinical case of difficult ventilation due to large parotid tumor in an edentulous patient.

Basal cell adenocarcinoma (BCAC) is a rare malignant tumor of the salivary glands, representing 1–2% of salivary gland neoplasms. It is considered a low-grade tumor, often associated with a good prognosis. We report a case of a 60-year-old man with 3-month history of a growing, painless mass in the right ascending ramus of the mandible. Ultrasound and CT scan showed an asymmetry between parotid glands, depicting a nodular structure on the right side. A parotid fine needle aspiration cytology revealed neoplastic cells suggestive of adenoid cystic carcinoma. The patient underwent a total parotidectomy with lymph node dissection. Histopathology result was reported as BCAC. The patient concluded adjuvant radiotherapy and continued follow-up surveillance without evidence of relapse. The adjuvant approach in this case was decided by a multidisciplinary team given the absence of classically known risk factors. We highlight the importance of considering BCAC in the differential diagnosis in salivary gland tumors.

Abstract Objectives Parotidectomy increases childhood challenges. This study aimed to determine the clinical profiles, investigations, and outcomes of pediatric patients who had undergone parotidectomy. Methods A multicenter retrospective review of parotidectomy in pediatric patients between 2007 and 2020. Results In 108 parotidectomies, the final diagnoses were benign (47.22%), malignant (36.11%), and non‐neoplastic (16.67%). The incidence of facial palsy was 37.03%, which was significantly lower in the superficial group than that in the total parotidectomy group (p = .021). The incidence of facial nerve palsy was significantly higher in the malignancy group than that in the benign group (p = .035). Magnetic resonance imaging (MRI) detected malignancy with 92.8% overall accuracy, 83.3% sensitivity, and 100% specificity. The sensitivity and specificity of fine‐needle aspiration (FNA) were 54.2% and 92.7%, respectively. Conclusions Parotidectomy is commonly performed for benign and non‐neoplastic diseases in pediatric patients. Facial nerve palsy is significantly associated with malignant tumors and total parotidectomy. MRI is the most accurate imaging modality for diagnosing malignant lesions. FNA exhibits moderate agreement with the final pathology. Level of Evidence Level IV.

Tuberculosis (TB) is a significant health problem and mortality in most developing countries. It is a chronic granulomatous disease caused by Mycobacterium tuberculosis and M. tuberculosis complex. It can be pulmonary form or Extra pulmonary form. Extrapulmonary tuberculosis involving temporomandibular joint is infrequent presentation of Skeletal TB. Here we present a rare case of extrapulmonary tuberculosis that was initially misdiagnosed as a parotid lesion due to atypical signs and symptoms and multiple in-conclusive FNAC reports. The final diagnosis was established by histopathological report. [ABSTRACT FROM AUTHOR]

Objective: To determine the outcomes of patients undergone parotidectomy with or without facial nerve monitoring. Materials and Methods: The present study was a retrospective study that included 35 patients underwent superficial parotidectomy with pathologic findings of benign parotid tumor. The patients were divided into two groups. Intraoperative facial nerve monitoring was performed in 15 patients and did not monitor in 20 patients. Data were compared between the surgical groups with intraoperative facial nerve monitoring and the groups without intraoperative facial nerve monitoring using the chi-square test and independent t-test. Results: Patients who underwent parotidectomy between January 1, 2020 and December 31, 2022, whose pathologic findings were benign, a total of 35 cases were divided into 15 patients underwent surgery with intraoperative facial nerve monitoring and 20 patients underwent surgery without intraoperative facial nerve monitoring. There was no statistical difference in operation time and saliva leakage. However, there was a statistical difference in intraoperative blood loss, postoperative facial nerve weakness rate, and postoperative earlobe numbness. Conclusion: The most common complication of parotidectomy is paralysis of the facial nerve. The present study showed that intraoperative facial nerve monitoring can reduce facial nerve paralysis, blood loss during surgery and postoperative earlobe numbness. [ABSTRACT FROM AUTHOR]

Pleomorphic adenoma (PA) is the most common benign salivary gland tumor of which parotid gland involvement is the most common. PA may arise from minor salivary glands as well, however, PA is very rare in the sinonasal and nasopharyngeal areas. It usually affects middle aged females. They are frequently misdiagnosed due to high cellularity and myxoid stroma, leading to delay in diagnosis & further appropriate management. Here we present a case report of a female who presented with gradually progressive nasal obstruction, on examination found to have a nasal mass in right nasal cavity. Imaging was done and the nasal mass was excised. Histopathological report revealed a PA. Common tumor in an uncommon location: Pleomorphic adenoma of the nasal cavity – a case report. [ABSTRACT FROM AUTHOR]

Recently, diffusion-weighted imaging (DWI) is an essential magnetic resonance imaging (MRI) protocol for head and neck imaging in clinical practice as it plays an important role in lesion detection, tumor extension evaluation, differential diagnosis, therapeutic effect prediction, therapy evaluation, and recurrence diagnosis. Especially in the parotid gland, several studies have already attempted to achieve accurate differentiation between benign and malignant tumors using DWI. A conventional single-shot echo-planar-based DWI is widely used for head and neck imaging, whereas advanced DWI sequences, such as intravoxel incoherent motion, diffusion kurtosis imaging, periodically rotated overlapping parallel lines with enhanced reconstruction, and readout-segmented echo-planar imaging (readout segmentation of long variable echo-trains), have been used to characterize parotid tumors. The mean apparent diffusion coefficient values are easily measured and useful for assessing cellularity and histological characteristics, whereas advanced image analyses, such as histogram analysis, texture analysis, and machine and deep learning, have been rapidly developed. Furthermore, a combination of DWI and other MRI protocols has reportedly improved the diagnostic accuracy of parotid tumors. This review article summarizes the current state of DWI in differentiating parotid tumors. [ABSTRACT FROM AUTHOR]

Adenoid cystic carcinoma is a slowly growing malignant tumor with high local recurrence, perineural and vascular invasion. This tumor might arise from the glands of upper respiratory tract and oral cavity (eg, salivary or serous or mucous). Here we report the case of a 65-year-old woman who was referred to our unit for left retro-auricular radiating pain with trigger points and frontal headache since 6 months. There was no involvement of cranial nerves. Imaging screening using MRI, Positron emission tomography with 2-[fluorine-18] fluoro-2-deoxy-D-glucose, Gallium-68 DOTA-Phe1-Tyr3-Octreotide (68Ga DOTATOC) Positron emission tomography-CT suggested a suspicion of schwannoma or paraganglioma of the jugular foramen. However, the CT-guided biopsy revealed presence of adenoid cystic carcinoma. These warrants performing mandatory histological analysis combined with imaging screening suspicion of schwannoma or paraganglioma.

Abstract Objective Lymphoepithelial carcinoma (LEC) accounts for 0.4% of malignant tumors of the salivary gland and 0.8% of parotid gland malignancies. Over the past 50 years, less than 300 cases have been reported in the literature. The purpose of this study was to investigate the characteristics of salivary gland LEC. Methods We retrospectively reviewed the medical records and analyzed clinical data obtained from 10 patients seen at our hospital between 2005 and 2020 with salivary gland LEC. Results All patients presented with a self‐palpable, non‐tender, hard swelling, or lump near the jaw or infra‐auricular region. Most cases (n = 8) were of solitary tumors, and enhancing patterns on computed tomography mainly were homogenous (n = 8). Interestingly, eight patients tested positive for the Epstein–Barr encoding region in in situ hybridization. Still, only three patients had detectable circulating Epstein–Barr virus (EBV) DNA, and one patient had detectable EBV IgA. All patients underwent complete tumor resection, followed by radiotherapy, and six also underwent chemotherapy. Nine patients became disease‐free within 5 years, and one died due to disease 4 years after surgery. Conclusion Although rare and considered to be a high‐risk malignancy, LECs have favorable treatment outcomes. Circulating EBV DNA is still not considered a marker for preoperative assessment or postoperative treatment response. The role of EBV DNA requires further investigation. Level of Evidence: 4

Introduction: Understanding the pathophysiology, clinical characteristics, and postoperative complications of parotid tumors is crucial in light of the growing emphasis on the occurrence and development of parotid tumor disease. Materials and methods: The study population consisted of 387 cases of primary parotid tumors treated surgically at our institution between July 2015 and November 2020. We statistically analyzed the gender, age, and pathological findings of patients, 307 of whom underwent postoperative return visits and were included in the study of postoperative complications. Results: The ratio of male to female parotid tumor patients was 1.39:1, and the best possible age range was between 51 and 60 years. The percentage of benign to malignant tumors (342/45) was 7.6:1. Pleomorphic adenoma constituted the majority of benign tumors. Adenoid cystic carcinoma constituted the majority of malignant tumors.The sensory deficit of the auricle, salivary fistula, facial nerve paralysis, and Frey's syndrome were the most prevalent postoperative complications of parotid tumors. Conclusions: Our efforts should focus on active prevention and treating parotid tumor postoperative complications.

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Objectives: To evaluate the effectiveness of machine learning models based on morphological magnetic resonance imaging (MRI) radiomics in the classification of parotid tumors. Methods: In total, 298 patients with parotid tumors were randomly assigned to a training and test set at a ratio of 7:3. Radiomics features were extracted from the morphological MRI images and screened using the Select K Best and LASSO algorithm. Three-step machine learning models with XGBoost, SVM, and DT algorithms were developed to classify the parotid neoplasms into four subtypes. The ROC curve was used to measure the performance in each step. Diagnostic confusion matrices of these models were calculated for the test cohort and compared with those of the radiologists. Results: Six, twelve, and eight optimal features were selected in each step of the three-step process, respectively. XGBoost produced the highest area under the curve (AUC) for all three steps in the training cohort (0.857, 0.882, and 0.908, respectively), and for the first step in the test cohort (0.826), but produced slightly lower AUCs than SVM in the latter two steps in the test cohort (0.817 vs. 0.833, and 0.789 vs. 0.821, respectively). The total accuracies of XGBoost and SVM in the confusion matrices (70.8% and 59.6%) outperformed those of DT and the radiologist (46.1% and 49.2%). Conclusion: This study demonstrated that machine learning models based on morphological MRI radiomics might be an assistive tool for parotid tumor classification, especially for preliminary screening in absence of more advanced scanning sequences, such as DWI. Key Points: • Machine learning algorithms combined with morphological MRI radiomics could be useful in the preliminary classification of parotid tumors. • XGBoost algorithm performed better than SVM and DT in subtype differentiation of parotid tumors, while DT seemed to have a poor validation performance. • Using morphological MRI only, the XGBoost and SVM algorithms outperformed radiologists in the four-type classification task for parotid tumors, thus making these models a useful assistant diagnostic tool in clinical practice. [ABSTRACT FROM AUTHOR]

Parotidectomy is the treatment of choice for benign tumors of the parotid gland, with the modified Blair incision most commonly utilized. This retrospective analysis aimed to determine the incidence of complications and assess the relationship between the mass and scar characteristics, in patients who had undergone parotidectomy. The scar characteristics of patients who had undergone parotidectomy for benign neoplasms at our medical center between 2013 and 2019 were evaluated. Overall, 49 patients met the inclusion criteria, of whom 33 agreed to participate in the study. The mean patient age was 52.8 years; 57.5% were males. No correlation was identified between the parotid mass size or location and scar type or length. The most common complications in this study were similar to those reported in the literature. The results of this study suggest that the smaller, tailored modified Blair incision for parotidectomy does not increase complication rates. Future studies with larger cohorts should be conducted to further assess the potential benefits of tailored incision size during modified Blair parotidectomies. [ABSTRACT FROM AUTHOR]

Copyright of Chinese Medical Equipment Journal is the property of Chinese Medical Equipment Journal Editorial Office and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objectives: Parotidectomy increases childhood challenges. This study aimed to determine the clinical profiles, investigations, and outcomes of pediatric patients who had undergone parotidectomy. Methods: A multicenter retrospective review of parotidectomy in pediatric patients between 2007 and 2020. Results: In 108 parotidectomies, the final diagnoses were benign (47.22%), malignant (36.11%), and non‐neoplastic (16.67%). The incidence of facial palsy was 37.03%, which was significantly lower in the superficial group than that in the total parotidectomy group (p =.021). The incidence of facial nerve palsy was significantly higher in the malignancy group than that in the benign group (p =.035). Magnetic resonance imaging (MRI) detected malignancy with 92.8% overall accuracy, 83.3% sensitivity, and 100% specificity. The sensitivity and specificity of fine‐needle aspiration (FNA) were 54.2% and 92.7%, respectively. Conclusions: Parotidectomy is commonly performed for benign and non‐neoplastic diseases in pediatric patients. Facial nerve palsy is significantly associated with malignant tumors and total parotidectomy. MRI is the most accurate imaging modality for diagnosing malignant lesions. FNA exhibits moderate agreement with the final pathology. Level of Evidence: Level IV. [ABSTRACT FROM AUTHOR]

Abstract Objective Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) histograms were used to investigate whether their parameters can distinguish between benign and malignant parotid gland tumors and further differentiate tumor subgroups. Materials and methods A total of 117 patients (32 malignant and 85 benign) who had undergone DCE-MRI for pretreatment evaluation were retrospectively included. Histogram parameters including mean, median, entropy, skewness, kurtosis and 10th, 90th percentiles were calculated from time to peak (TTP) (s), wash in rate (WIR) (l/s), wash out rate (WOR) (l/s), and maximum relative enhancement (MRE) (%) mono-exponential models. The Mann–Whitney U test was used to compare the differences between the benign and malignant groups. The diagnostic value of each significant parameter was determined on Receiver operating characteristic (ROC) analysis. Multivariate stepwise logistic regression analysis was used to identify the independent predictors of the different tumor groups. Results For both the benign and malignant groups and the comparisons among the subgroups, the parameters of TTP and MRE showed better performance among the various parameters. WOR can be used as an indicator to distinguish Warthin’s tumors from other tumors. Warthin’s tumors showed significantly lower values on 10th MRE and significantly higher values on skewness TTP and 10th WOR, and the combination of 10th MRE, skewness TTP and 10th WOR showed optimal diagnostic performance (AUC, 0.971) and provided 93.12% sensitivity and 96.70% specificity. After Warthin’s tumors were removed from among the benign tumors, malignant parotid tumors showed significantly lower values on the 10th TTP (AUC, 0.847; sensitivity 90.62%; specificity 69.09%; P