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Introduction: With the implementation of low-dose computed tomography (LDCT) screening, multiple pulmonary tumor nodules (MPTN) are diagnosed with increasing frequency and the selection of surgical treatments versus systemic therapies has become challenging on a daily basis in clinical practice. In the presence of multiple carcinomas, especially adenocarcinomas, pathologically determined to be of pulmonary origin, the distinction between separate primary lung carcinomas (SPLCs) and intrapulmonary metastases (IPMs) is important for staging, management, and prognostication., Methods: We systemically reviewed various means that aid in the differentiation between SPLCs and IPMs explored by histopathologic evaluation and molecular profiling, the latter includes DNA microsatellite analysis, array comparative genomic hybridization, TP53 and oncogenic driver mutation testing and, more recently, with promising effectiveness, next-generation sequencing (NGS) comprising small- or large-scale multi-gene panels., Results: Comprehensive histologic evaluation may suffice to differentiate between SPLCs and IPMs. However, molecular profiling using larger-scale NGS typically provides superior discriminatory power, allowing for more accurate classification. Based on the literature review and expert opinions, we proposed a combined 4-step histologic and molecular classification algorithm for addressing MPTN of adenocarcinoma histology that encourages a multidisciplinary approach. It is also noteworthy that new technologies combining machine learning and digital pathology may develop into valuable diagnostic tools for distinguishing SPLCs from IPMs in the future., Conclusions: Although histopathologic evaluation is often adequate to differentiate SPLCs from IPMs, molecular profiling should be performed when possible, especially in cases with tumors exhibiting similar morphology. This manuscript summarized the previous efforts in resolving the current challenges and highlighted the recent progress in the differentiation methods and algorithms used in categorizing multiple lung adenocarcinomas into SPLCs or IPMs, which are becoming more and more critical in precision lung cancer management., (Copyright © 2024 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.)

In Taiwan, lung cancer remains the leading cause of cancer-related fatalities, resulting in substantial healthcare expenses. This research aims to evaluate both the frequency and the costs of low-dose computed tomography (LDCT) in individuals suspected of having lung cancer until their diagnosis of cancer. LDCT screening was not conducted on a population-wide scale, and asymptomatic participants had to cover the expenses for the screening personally or reimburse from other sources. If the screening results were positive or suspicious, National Health Insurance (NHI) could be utilized for subsequent follow-up examinations. This cohort study utilized the NHI Database and focused on individuals with suspected cases of lung cancer identified between 2010 and 2014. A total of 17,572 suspected new lung cancer cases were initially identified and assigned to the relevant International Classification of Diseases codes. Individuals with suspected lung cancer received a diagnosis following an average follow-up period of 2.24 (95%CI, 2.11-2.37) years, and required the use of 2.36 (95%CI, 2.20-2.51) repeated CT scans. The NHI expenditures incurred by the use of CT scans for monitoring suspected lung cancer cases were relatively modest., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Vy, Chien, Chen, Lin, Chang, Hsu and Chan.)

Purpose: Mycobacterium abscessus complex (MABC) commonly causes lung disease (LD) and has a high treatment failure rate of around 50%. In this study, our objective is to investigate specific CT patterns for predicting treatment prognosis and monitoring treatment response, thus providing valuable insights for clinical physicians in the management of MABC-LD treatment., Methods: We retrospectively assessed 34 patients with MABC-LD treated between January 2015 and December 2020. CT scores for bronchiectasis, cellular bronchiolitis, consolidation, cavities, and nodules were measured at initiation and after treatment. The ability of the CT scores to predict treatment outcomes was analyzed in logistic regression analyses., Results: The CT scoring system had excellent inter-reader agreement (all intraclass correlation coefficients, > 0.82). The treatment failure (TF) group (17/34; 50%) had higher cavitation diameter (p = 0.049) and extension (p = 0.041) at initial CT and higher cavitation diameter (p = 0.049) and extension (p =0 .045), consolidation (p = 0.022), and total (p = 0.013) scores at follow-up CT than the treatment success (TS) group. The changes of total score and consolidation score (p = 0.049 and 0.024, respectively) increased in the TF group more than the TS group between the initial and follow-up CT. Multivariable logistic regression analysis showed initial cavitation extension, follow-up consolidation extension, and change in consolidation extension (adjusted odds ratio: 2.512, 2.495, and 9.094, respectively, per 1-point increase; all p < 0.05) were significant predictors of treatment failure., Conclusions: A high pre-treatment cavitation extension score and an increase in the consolidation extension score during treatment on CT could be alarm signs of treatment failure requiring tailor the treatment of MABC-LD carefully., (© 2024. The Author(s).)

Purpose To develop a prediction model combining both clinical and CT texture analysis radiomics features for predicting pneumothorax complications in patients undergoing CT-guided core needle biopsy. Materials and Methods A total of 424 patients (mean age, 65.6 years ± 12.7 [SD]; 232 male, 192 female) who underwent CT-guided core needle biopsy between January 2021 and October 2022 were retrospectively included as the training data set. Clinical and procedure-related characteristics were documented. Texture analysis radiomics features were extracted from the subpleural lung parenchyma traversed by needle. Moderate pneumothorax was defined as a postprocedure air rim of 2 cm or greater. The prediction model was developed using logistic regression with backward elimination, presented by linear fusion of the selected features weighted by their coefficients. Model performance was assessed using the area under the receiver operating characteristic curve (AUC). Validation was conducted in an external cohort ( n = 45; mean age, 58.2 years ± 12.7; 19 male, 26 female) from a different hospital. Results Moderate pneumothorax occurred in 12.0% (51 of 424) of the training cohort and 8.9% (four of 45) of the external test cohort. Patients with emphysema ( P < .001) or a longer needle path length ( P = .01) exhibited a higher incidence of moderate pneumothorax in the training cohort. Texture analysis features, including gray-level co-occurrence matrix cluster shade ( P < .001), gray-level run-length matrix low gray-level run emphasis ( P = .049), gray-level run-length matrix run entropy ( P = .003), gray-level size-zone matrix gray-level variance ( P < .001), and neighboring gray-tone difference matrix complexity ( P < .001), showed higher values in patients with moderate pneumothorax. The combined clinical-radiomics model demonstrated satisfactory performance in both the training (AUC 0.78, accuracy = 71.9%) and external test cohorts (AUC 0.86, accuracy 73.3%). Conclusion The model integrating both clinical and radiomics features offered practical diagnostic performance and accuracy for predicting moderate pneumothorax in patients undergoing CT-guided core needle biopsy. Keywords: Biopsy/Needle Aspiration, Thorax, CT, Pneumothorax, Core Needle Biopsy, Texture Analysis, Radiomics, CT Supplemental material is available for this article . © RSNA, 2024.

Purpose: To ascertain the performance of dual-energy CT (DECT) with iodine quantification in differentiating malignant mediastinal and hilar lymph nodes (LNs) from benign ones, focusing on patients with lung adenocarcinoma., Materials and Methods: In this study, patients with suspected lung cancer received a preoperative contrast-enhanced DECT scan from Jun 2018 to Dec 2020. Quantitative DECT parameters and the size were compared between metastatic and benign LNs. Their diagnostic performances were analyzed by the ROC curves and compared by using the two-sample t test., Results: 72 patients (23 men, 49 women; mean age 62.5 ± 10.1 years) fulfilled the inclusion criteria. A total of 98 LNs (67 benign, 31 metastatic) were analyzed. The iodine concentration normalized by muscle (NIC muscle ) was significantly higher (P < 0.001) in metastatic LNs (4.79 ± 1.70) than in benign ones (3.00 ± 1.45). The optimal threshold of NIC muscle was 3.44, which yielded AUC: 0.798, sensitivity: 83.9%, specificity: 73.1%, accuracy: 76.5%, respectively. Applying the established size parameters with 10 mm as the threshold yielded AUC: 0.600, sensitivity: 29.0%, specificity: 91.0%, accuracy: 71.4%, respectively. The diagnostic performance of NIC muscle was significantly better (P = 0.007) than the performance obtained using the established size parameters., Conclusions: For lung adenocarcinoma, the quantitative measurement of NIC muscle derived from DECT is useful for differentiating benign and metastatic mediastinal and hilar LNs before surgical intervention., (© 2024. The Author(s) under exclusive licence to Japan Radiological Society.)

Background/purpose: We evaluated the utility of combining quantitative pulmonary vasculature measures with clinical factors for predicting pulmonary hemorrhage after computed tomography (CT)-guided lung biopsy., Methods: Patients who underwent CT-guided lung biopsy were retrospectively included in this study. Clinical and radiographic vasculature variables were evaluated as predictors of pulmonary hemorrhage. The radiographic pulmonary vascular analysis included vessel count, density, diameter, and area, and also blood volume in small vessels with a cross-sectional area ≤5 mm 2 (BV5) and total blood vessel volume (TBV) in the lungs. Univariate and multivariate logistic regressions were used to identify the independent risk factors of higher-grade pulmonary hemorrhage and establish the prediction model presented as a nomogram., Results: The study included 126 patients; discovery cohort n = 103, and validation cohort n = 23. All pulmonary hemorrhage, higher-grade (grade ≥2) pulmonary hemorrhage, and hemoptysis occurred in 42.9%, 15.9%, and 3.2% of patients who underwent CT-guided lung biopsies. In the discovery cohort, patients with larger lesion depth (p = 0.013), higher vessel density (p = 0.033), and higher BV5 (p = 0.039) were more likely to experience higher-grade hemorrhage. The nomogram prediction model for higher-grade hemorrhage built by the discovery cohort showed similar performance in the validation cohort., Conclusions: Higher-grade pulmonary hemorrhage may occur after CT-guided lung biopsy. Lesion depth, vessel density, and BV5 are independent risk factors for higher-grade pulmonary hemorrhage. Nomograms integrating clinical parameters and radiographic pulmonary vasculature measures offer enhanced capability for assessing hemorrhage risk following CT-guided lung biopsy, thereby facilitating improved patient clinical care., Competing Interests: Declaration of competing interest The authors indicate no potential conflicts of interest., (Copyright © 2024 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

Background/purpose: Patients with influenza infection during their period of admission may have worse computed tomography (CT) manifestation according to the clinical status. This study aimed to evaluate the CT findings of in-hospital patients due to clinically significant influenza pneumonia with correlation of clinical presentations., Methods: In this retrospective, single center case series, 144 patients were included. All in-hospital patients were confirmed influenza infection and underwent CT scan. These patients were divided into three groups according to the clinical status of the most significant management: (1) without endotracheal tube and mechanical ventilator (ETTMV) or extracorporeal membrane oxygenation (ECMO); (2) with ETTMV; (3) with ETTMV and ECMO. Pulmonary opacities were scored according to extent. Spearman rank correlation analysis was used to evaluate the correlation between clinical parameters and CT scores., Results: The predominant CT manifestation of influenza infection was mixed ground-glass opacity (GGO) and consolidation with both lung involvement. The CT scores were all reach significant difference among all three groups (8.73 ± 6.29 vs 12.49 ± 6.69 vs 18.94 ± 4.57, p < 0.05). The chest CT score was correlated with age, mortality, and intensive care unit (ICU) days (all p values were less than 0.05). In addition, the CT score was correlated with peak lactate dehydrogenase (LDH) level and peak C-reactive protein (CRP) level (all p values were less than 0.05). Concomitant bacterial infection had higher CT score than primary influenza pneumonia (13.02 ± 7.27 vs 8.95 ± 5.99, p < 0.05)., Conclusion: Thin-section chest CT scores correlated with clinical and laboratory parameters in in-hospital patients with influenza pneumonia., Competing Interests: Declaration of competing interest The authors have no conflicts of interest relevant to this article., (Copyright © 2023. Published by Elsevier B.V.)

Background: Sublobar resection is strongly associated with poor prognosis in early-stage lung adenocarcinoma, with the presence of tumor spread through air spaces (STAS). Thus, preoperative prediction of STAS is important for surgical planning. This study aimed to develop a STAS deep-learning (STAS-DL) prediction model in lung adenocarcinoma with tumor smaller than 3 cm and a consolidation-to-tumor (C/T) ratio less than 0.5., Methods: The study retrospectively enrolled of 581 patients from two institutions between 2015 and 2019. The STAS-DL model was developed to extract the feature of solid components through solid components gated (SCG) for predicting STAS. The STAS-DL model was assessed with external validation in the testing sets and compared with the deep-learning model without SCG (STAS-DL woSCG ), the radiomics-based model, the C/T ratio, and five thoracic surgeons. The performance of the models was evaluated using area under the curve (AUC), accuracy and standardized net benefit of the decision curve analysis., Results: The study evaluated 458 patients (institute 1) in the training set and 123 patients (institute 2) in the testing set. The proposed STAS-DL yielded the best performance compared with the other methods in the testing set, with an AUC of 0.82 and an accuracy of 74%, outperformed the STAS-DL woSCG with an accuracy of 70%, and was superior to the physicians with an AUC of 0.68. Moreover, STAS-DL achieved the highest standardized net benefit compared with the other methods., Conclusion: The proposed STAS-DL model has great potential for the preoperative prediction of STAS and may support decision-making for surgical planning in early-stage, ground glass-predominant lung adenocarcinoma., (© 2023. Society of Surgical Oncology.)

Background: In Taiwan, lung cancers occur predominantly in never-smokers, of whom nearly 60% have stage IV disease at diagnosis. We aimed to assess the efficacy of low-dose CT (LDCT) screening among never-smokers, who had other risk factors for lung cancer., Methods: The Taiwan Lung Cancer Screening in Never-Smoker Trial (TALENT) was a nationwide, multicentre, prospective cohort study done at 17 tertiary medical centres in Taiwan. Eligible individuals had negative chest radiography, were aged 55-75 years, had never smoked or had smoked fewer than 10 pack-years and stopped smoking for more than 15 years (self-report), and had one of the following risk factors: a family history of lung cancer; passive smoke exposure; a history of pulmonary tuberculosis or chronic obstructive pulmonary disorders; a cooking index of 110 or higher; or cooking without using ventilation. Eligible participants underwent LDCT at baseline, then annually for 2 years, and then every 2 years up to 6 years thereafter, with follow-up assessments at each LDCT scan (ie, total follow-up of 8 years). A positive scan was defined as a solid or part-solid nodule larger than 6 mm in mean diameter or a pure ground-glass nodule larger than 5 mm in mean diameter. Lung cancer was diagnosed through invasive procedures, such as image-guided aspiration or biopsy or surgery. Here, we report the results of 1-year follow-up after LDCT screening at baseline. The primary outcome was lung cancer detection rate. The p value for detection rates was estimated by the χ 2 test. Univariate and multivariable logistic regression analyses were used to assess the association between lung cancer incidence and each risk factor. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of LDCT screening were also assessed. This study is registered with ClinicalTrials.gov, NCT02611570, and is ongoing., Findings: Between Dec 1, 2015, and July 31, 2019, 12 011 participants (8868 females) were enrolled, of whom 6009 had a family history of lung cancer. Among 12 011 LDCT scans done at baseline, 2094 (17·4%) were positive. Lung cancer was diagnosed in 318 (2·6%) of 12 011 participants (257 [2·1%] participants had invasive lung cancer and 61 [0·5%] had adenocarcinomas in situ). 317 of 318 participants had adenocarcinoma and 246 (77·4%) of 318 had stage I disease. The prevalence of invasive lung cancer was higher among participants with a family history of lung cancer (161 [2·7%] of 6009 participants) than in those without (96 [1·6%] of 6002 participants). In participants with a family history of lung cancer, the detection rate of invasive lung cancer increased significantly with age, whereas the detection rate of adenocarcinoma in situ remained stable. In multivariable analysis, female sex, a family history of lung cancer, and age older than 60 years were associated with an increased risk of lung cancer and invasive lung cancer; passive smoke exposure, cumulative exposure to cooking, cooking without ventilation, and a previous history of chronic lung diseases were not associated with lung cancer, even after stratification by family history of lung cancer. In participants with a family history of lung cancer, the higher the number of first-degree relatives affected, the higher the risk of lung cancer; participants whose mother or sibling had lung cancer were also at an increased risk. A positive LDCT scan had 92·1% sensitivity, 84·6% specificity, a PPV of 14·0%, and a NPV of 99·7% for lung cancer diagnosis., Interpretation: TALENT had a high invasive lung cancer detection rate at 1 year after baseline LDCT scan. Overdiagnosis could have occurred, especially in participants diagnosed with adenocarcinoma in situ. In individuals who do not smoke, our findings suggest that a family history of lung cancer among first-degree relatives significantly increases the risk of lung cancer as well as the rate of invasive lung cancer with increasing age. Further research on risk factors for lung cancer in this population is needed, particularly for those without a family history of lung cancer., Funding: Ministry of Health and Welfare of Taiwan., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

The automated marker-free longitudinal Infrared (IR) breast image registration overcomes several challenges like no anatomic fiducial markers on the body surface, blurry boundaries, heat pattern variation by environmental and physiological factors, nonrigid deformation, etc, has the ability of quantitative pixel-wise analysis with the heat energy and patterns change in a time course study. To achieve the goal, scale-invariant feature transform, Harris corner, and Hessian matrix were employed to generate the feature points as anatomic fiducial markers, and hybrid genetic algorithm and particle swarm optimization minimizing the matching errors was used to find the appropriate corresponding pairs between the 1st IR image and the n th IR image. Moreover, the mechanism of the IR spectrogram hardware system has a high level of reproducibility. The performance of the proposed longitudinal image registration system was evaluated by the simulated experiments and the clinical trial. In the simulated experiments, the mean difference of our system is 1.64 mm, which increases 57.58% accuracy than manual determination and makes a 17.4% improvement than the previous study. In the clinical trial, 80 patients were captured several times of IR breast images during chemotherapy. Most of them were well aligned in the spatiotemporal domain. In the few cases with evident heat pattern dissipation and spatial deviation, it still provided a reliable comparison of vascular variation. Therefore, the proposed system is accurate and robust, which could be considered as a reliable tool for longitudinal approaches to breast cancer diagnosis., (Creative Commons Attribution license.)

Introduction: The incidence and mortality of lung cancer are highest in Asia compared with Europe and USA, with the incidence and mortality rates being 34.4 and 28.1 per 100,000 respectively in East Asia. Diagnosing lung cancer at early stages makes the disease amenable to curative treatment and reduces mortality. In some areas in Asia, limited availability of robust diagnostic tools and treatment modalities, along with variations in specific health care investment and policies, make it necessary to have a more specific approach for screening, early detection, diagnosis, and treatment of patients with lung cancer in Asia compared with the West., Method: A group of 19 advisors across different specialties from 11 Asian countries, met on a virtual Steering Committee meeting, to discuss and recommend the most affordable and accessible lung cancer screening modalities and their implementation, for the Asian population., Results: Significant risk factors identified for lung cancer in smokers in Asia include age 50 to 75 years and smoking history of more than or equal to 20 pack-years. Family history is the most common risk factor for nonsmokers. Low-dose computed tomography screening is recommended once a year for patients with screening-detected abnormality and persistent exposure to risk factors. However, for high-risk heavy smokers and nonsmokers with risk factors, reassessment scans are recommended at an initial interval of 6 to 12 months with subsequent lengthening of reassessment intervals, and it should be stopped in patients more than 80 years of age or are unable or unwilling to undergo curative treatment., Conclusions: Asian countries face several challenges in implementing low-dose computed tomography screening, such as economic limitations, lack of efforts for early detection, and lack of specific government programs. Various strategies are suggested to overcome these challenges in Asia., (Copyright © 2023 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.)

Background: To investigate the clinical outcomes and risk factors associated with progressive fibrosing interstitial lung disease (PF-ILD) in patients with primary Sjögren's syndrome-associated interstitial lung disease (pSjS-ILD)., Methods: During 2015-2021, pSjS patients with ILD were retrospectively identified. Patients were grouped into non-PF-ILD and PF-ILD. Demographics, laboratory data, pulmonary function tests (PFTs), images, survival outcomes were compared between groups., Results: 153 patients with SjS-ILD were reviewed, of whom 68 having primary SjS-ILD (pSjS-ILD) were classified into non-PF-ILD (n = 34) and PF-ILD groups (n = 34). PF-ILD group had persistently lower albumin levels and a smaller decline in immunoglobulin G (IgG) levels at the 3rd month of follow-up. The multivariate logistic regression analysis revealed that persistently low albumin levels were associated with PF-ILD. At the 12th month, the PF-ILD group experienced a smaller increase in FVC and a greater decline in the diffusion capacity of carbon monoxide (DLCO) than at baseline. The 3-year overall survival rate was 91.2%, and PF-ILD group had significantly poorer 3-year overall survival rate than non-PF-ILD group (82.4% vs. 100%, p = 0.011). Poor survival was also observed among female patients with PF-ILD., Conclusions: Among patients with pSjS-ILD, the PF-ILD group had poorer 3-year survival outcomes. Persistent lower albumin level might be the risk factor of PF-ILD. Early lung function tests could be helpful for the early detection of PF-ILD., (© 2023. The Author(s).)

Objective: To quantitatively assess the pulmonary vasculature using non-contrast computed tomography (CT) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) pre- and post-treatment and correlate CT-based parameters with right heart catheterization (RHC) hemodynamic and clinical parameters., Materials and Methods: A total of 30 patients with CTEPH (mean age, 57.9 years; 53% female) who received multimodal treatment, including riociguat for ≥ 16 weeks with or without balloon pulmonary angioplasty and underwent both non-contrast CT for pulmonary vasculature analysis and RHC pre- and post-treatment were included. The radiographic analysis included subpleural perfusion parameters, including blood volume in small vessels with a cross-sectional area ≤ 5 mm² (BV5) and total blood vessel volume (TBV) in the lungs. The RHC parameters included mean pulmonary artery pressure (mPAP), pulmonary vascular resistance (PVR), and cardiac index (CI). Clinical parameters included the World Health Organization (WHO) functional class and 6-minute walking distance (6MWD)., Results: The number, area, and density of the subpleural small vessels increased after treatment by 35.7% ( P < 0.001), 13.3% ( P = 0.028), and 39.3% ( P < 0.001), respectively. The blood volume shifted from larger to smaller vessels, as indicated by an 11.3% increase in the BV5/TBV ratio ( P = 0.042). The BV5/TBV ratio was negatively correlated with PVR ( r = -0.26; P = 0.035) and positively correlated with CI ( r = 0.33; P = 0.009). The percent change across treatment in the BV5/TBV ratio correlated with the percent change in mPAP ( r = -0.56; P = 0.001), PVR ( r = -0.64; P < 0.001), and CI ( r = 0.28; P = 0.049). Furthermore, the BV5/TBV ratio was inversely associated with the WHO functional classes I-IV ( P = 0.004) and positively associated with 6MWD ( P = 0.013)., Conclusion: Non-contrast CT measures could quantitatively assess changes in the pulmonary vasculature in response to treatment and were correlated with hemodynamic and clinical parameters., Competing Interests: The authors have no potential conflicts of interest to disclose., (Copyright © 2023 The Korean Society of Radiology.)

Background: High-grade adenocarcinoma subtypes (micropapillary and solid) treated with sublobar resection have an unfavorable prognosis compared with those treated with lobectomy. We investigated the potential of incorporating solid attenuation component masks with deep learning in the prediction of high-grade components to optimize surgical strategy preoperatively., Methods: A total of 502 patients with pathologically confirmed high-grade adenocarcinomas were retrospectively enrolled between 2016 and 2020. The SACs attention DL model was developed to apply solid-attenuation-component-like subregion masks (tumor area ≥ - 190 HU) to guide the DL model for predicting high-grade subtypes. The SACA-DL was assessed using 5-fold cross-validation and external validation in the training and testing sets, respectively. The performance, which was evaluated using the area under the curve (AUC), was compared between SACA-DL and the DL model without SACs attention (DL woSACs ), the prior radiomics model, or the model based on the consolidation/tumor (C/T) diameter ratio., Results: We classified 313 and 189 patients into training and testing cohorts, respectively. The SACA-DL achieved an AUC of 0.91 for the cross-validation, which was significantly superior to those of the DL woSACs (AUC = 0.88; P = 0.02), prior radiomics model (AUC = 0.85; P = 0.004), and C/T ratio (AUC = 0.84; P = 0.002). An AUC of 0.93 was achieved for external validation in the SACA-DL and was significantly better than those of the DL woSACs (AUC = 0.89; P = 0.04), prior radiomics model (AUC = 0.85; P < 0.001), and C/T ratio (AUC = 0.85; P < 0.001)., Conclusions: The combination of solid-attenuation-component-like subregion masks with the DL model is a promising approach for the preoperative prediction of high-grade adenocarcinoma subtypes., (© 2022. Society of Surgical Oncology.)

Background: Preoperative two-dimensional manual measurement of pulmonary artery diameter in a single-cut axial view computed tomography (CT) image is a commonly used non-invasive prediction method for pulmonary hypertension. However, the accuracy may be unreliable. Thus, this study aimed to evaluate the correlation of short-term surgical outcomes and pulmonary artery/aorta (PA/Ao) diameter ratio measured by automated three-dimensional (3D) segmentation in lung cancer patients who underwent thoracoscopic lobectomy., Materials and Methods: We included 383 consecutive lung cancer patients with thin-slice CT images who underwent lobectomy at a single institute between January 1, 2011 and December 31, 2019. Automated 3D segmentation models were used for 3D vascular reconstruction and measurement of the average diameters of Ao and PA. Propensity-score matching incorporating age, Charlson comorbidity index, and lobectomy performed by uniportal VATS was used to compare clinical outcomes in patients with PA/Ao ratio ≥1 and those <1., Results: Our segmentation method measured 29 (7.57%) patients with a PA/Ao ratio ≥1. After propensity-score matching, a higher overall postoperative complication classified by the Clavien-Dindo classification (p = 0.016) were noted in patients with 3D PA/Ao diameter ratio ≥1 than those of <1. By multivariate logistic regression, patients with a 3D PA/Ao ratio ≥ 1 (p = 0.013) and tumor diameter > 3 cm (p = 0.002) both significantly predict the incidence of postoperative complications., Conclusions: Pulmonary artery/aorta diameter ratio ≥ 1 measured by automated 3D segmentation may predict postoperative complications in lung cancer patients who underwent lobectomy., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Lee, Chung, Wang, Chiang, Chen, Lin, Lee, Hsu, Chang, Chen, Lin and Chen.)

Background: We aimed to establish a radiomic prediction model for tumor spread through air spaces (STAS) in lung adenocarcinoma using radiomic values from high-grade subtypes (solid and micropapillary)., Methods: We retrospectively reviewed 327 patients with lung adenocarcinoma from 2 institutions (cohort 1: 227 patients; cohort 2: 100 patients) between March 2017 and March 2019. STAS was identified in 113 (34.6%) patients. A high-grade likelihood prediction model was constructed based on a historical cohort of 82 patients with "near-pure" pathologic subtype. The STAS prediction model based on the patch-wise mechanism identified the high-grade likelihood area for each voxel within the internal border of the tumor. STAS presence was indirectly predicted by a volume percentage threshold of the high-grade likelihood area. Performance was evaluated by receiver operating curve analysis with 10-repetition, 3-fold cross-validation in cohort 1, and was individually tested in cohort 2., Results: Overall, 227 patients (STAS-positive: 77 [33.9%]) were enrolled for cross-validation (cohort 1) while 100 (STAS-positive: 36 [36.0%]) underwent individual testing (cohort 2). The gray level cooccurrence matrix (variance) and histogram (75th percentile) features were selected to construct the high-grade likelihood prediction model, which was used as the STAS prediction model. The proposed model achieved good performance in cohort 1 with an area under the curve, sensitivity, and specificity, of 81.44%, 86.75%, and 62.60%, respectively, and correspondingly, in cohort 2, they were 83.16%, 83.33%, and 63.90%, respectively., Conclusions: The proposed computed tomography-based radiomic prediction model could help guide preoperative prediction of STAS in early-stage lung adenocarcinoma and relevant surgeries., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: To propose and evaluate a set of radiomic features, called morphological dynamics features, for pulmonary nodule detection, which were rooted in the dynamic patterns of morphological variation and needless precise lesion segmentation., Materials and Methods: Two datasets were involved, namely, university hospital (UH) and LIDC datasets, comprising 72 CT scans (360 nodules) and 888 CT scans (2230 nodules), respectively. Each nodule was annotated by multiple radiologists. Denoted the category of nodules identified by at least k radiologists as ALk. A nodule detection algorithm, called CAD-MD algorithm, was proposed based on the morphological dynamics radiomic features, characterizing a lesion by ten sets of the same features with different values extracted from ten different thresholding results. Each nodule candidate was classified by a two-level classifier, including ten decision trees and a random forest, respectively. The CAD-MD algorithm was compared with a deep learning approach, the N-Net, using the UH dataset., Results: On the AL1 and AL2 of the UH dataset, the AUC of the AFROC curves were 0.777 and 0.851 for the CAD-MD algorithm and 0.478 and 0.472 for the N-Net, respectively. The CAD-MD algorithm achieved the sensitivities of 84.4% and 91.4% with 2.98 and 3.69 FPs/scan and the N-Net 74.4% and 80.7% with 3.90 and 4.49 FPs/scan, respectively. On the LIDC dataset, the CAD-MD algorithm attained the sensitivities of 87.6%, 89.2%, 92.2%, and 95.0% with 4 FPs/scan for AL1-AL4, respectively., Conclusion: The morphological dynamics radiomic features might serve as an effective set of radiomic features for lung nodule detection., Key Points: • Texture features varied with such CT system settings as reconstruction kernels of CT images, CT scanner models, and parameter settings, and so on. • Shape and first-order statistics were shown to be the most robust features against variation in CT imaging parameters. • The morphological dynamics radiomic features, which mainly characterized the dynamic patterns of morphological variation, were shown to be effective for lung nodule detection., (© 2022. The Author(s), under exclusive licence to European Society of Radiology.)

Advanced bronchoscopic lung volume reduction treatment (BLVR) is now a routine care option for treating patients with severe emphysema. Patterns of low attenuation clusters indicating emphysema and functional small airway disease (fSAD) on paired CT, which may provide additional insights to the target selection of the segmental or subsegmental lobe of the treatments, require further investigation. The low attenuation clusters (LACS) were segmented to identify the scalar and spatial distribution of the lung destructions, in terms of 10 fractions scales of low attenuation density (LAD) located in upper lobes and lower lobes. The LACs of functional small airway disease (fSAD) were delineated by applying the technique of parametric response map (PRM) on the co-registered CT image data. Both emphysematous LACs of inspiratory CT and fSAD LACs on expiratory CT were used to derive the coefficients of the predictive model for estimating the airflow limitation. The voxel-wise severity is then predicted using the regional LACs on the co-registered CT to indicate the functional localization, namely, the bullous parametric response map (BPRM). A total of 100 subjects, 88 patients with mild to very severe COPD and 12 control participants with normal lung functions (FEV 1 /FVC % > 70%), were evaluated. Pearson's correlations between FEV 1 /FVC% and LAV% HU-950 of severe emphysema are - 0.55 comparing to - 0.67 and - 0.62 of LAV% HU-856 of air-trapping and LAV% fSAD respectively. Pearson's correlation between FEV 1 /FVC% and FEV 1 /FVC% predicted by the proposed model using LAD% of HU-950 and fSAD on BPRM is 0.82 (p < 0.01). The result of the Bullous Parametric Response Map (BPRM) is capable of identifying the less functional area of the lung, where the BLVR treatment is aimed at removing from a hyperinflated area of emphysematous regions., (© 2021. The Author(s).)

Objectives: Solitary pulmonary capillary haemangioma (SPCH) is a benign lung tumour that presents as ground-glass nodules on computed tomography (CT) images and mimics lepidic-predominant adenocarcinoma. This study aimed to establish a discriminant model using a radiomic feature analysis to distinguish SPCH from lepidic-predominant adenocarcinoma., Methods: In the adenocarcinoma group, all tumours were of the lepidic-predominant subtype with high purity (>70%). A classification model was proposed based on a two-level decision tree and 26 radiomic features extracted from each segmented lesion. For comparison, a baseline model was built with the same 26 features using a support vector machine as the classifier. Both models were assessed by the leave-one-out cross-validation method., Results: This study included 13 and 49 patients who underwent complete resection for SPCH and adenocarcinoma, respectively. Two sets of features were identified for discrimination between the 2 different histology types. The first set included 2 principal components corresponding to the 2 largest eigenvalues for the root node of the two-level decision tree. The second set comprised 4 selected radiomic features. The area under the receiver operating characteristic curve, accuracy, sensitivity, specificity were 0.954, 91.9%, 92.3% and 91.8% in the proposed classification model, and were 0.805, 85.5%, 61.5% and 91.8% in the baseline model, respectively. The proposed classification model significantly outperformed the baseline model (P < 0.05)., Conclusions: The proposed model could differentiate the 2 different histology types on CT images, and this may help surgeons to preoperatively discriminate SPCH from adenocarcinoma., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Lymph node metastasis also called nodal metastasis (Nmet), is a clinically primary task for physicians. The survival and recurrence of lung cancer are related to the Nmet staging from Tumor-Node-Metastasis (TNM) reports. Furthermore, preoperative Nmet prediction is still a challenge for the patient in managing the surgical plan and making treatment decisions. We proposed a multi-energy level fusion model with a principal feature enhancement (PFE) block incorporating radiologist and computer science knowledge for Nmet prediction. The proposed model is custom-designed by gemstone spectral imaging (GSI) with different energy levels on dual-energy computer tomography (CT) from a primary tumor of lung cancer. In the experiment, we take three different energy level fusion datasets: lower energy level fusion (40, 50, 60, 70 keV), higher energy level fusion (110, 120, 130, 140 keV), and average energy level fusion (40, 70, 100, 140 keV). The proposed model is trained by lower energy level fusion that is 93% accurate and the value of Kappa is 86%. When we used the lower energy level images to train the fusion model, there has been a significant difference to other energy level fusion models. Hence, we apply 5-fold cross-validation, which is used to validate the performance result of the multi-keV model with different fusion datasets of energy level images in the pathology report. The cross-validation result also demonstrates that the model with the lower energy level dataset is more robust and suitable in predicting the Nmet of the primary tumor. The lower energy level shows more information of tumor angiogenesis or heterogeneity provided the proposed fusion model with a PFE block and channel attention blocks to predict Nmet from primary tumors., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

This study aimed to establish more practical standardized barium stimuli formulas for the videofluoroscopic swallowing study (VFSS) for clinical use. For clinical practice, we established the formula for preparing barium stimuli to comply with different International Dysphagia Diet Standardization Initiative (IDDSI) levels. To comply with the definition of IDDSI levels 0-4, the gum-based thickener concentration of thickened barium was 0, 0.3, 0.6, 1.0, and 2.0 g/100 mL, respectively. The formulas established in this study may replace traditional barium stimuli for dysphagia assessment in clinical settings., Competing Interests: Declaration of competing interest The authors have no conflicts of interest relevant to this article., (Copyright © 2021 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

This prospective study aimed to investigate the ability of spiral ultrashort echo time (UTE) and compressed sensing volumetric interpolated breath-hold examination (CS-VIBE) sequences in magnetic resonance imaging (MRI) compared to conventional VIBE and chest computed tomography (CT) in terms of image quality and small nodule detection. Patients with small lung nodules scheduled for video-assisted thoracoscopic surgery (VATS) for lung wedge resection were prospectively enrolled. Each patient underwent non-contrast chest CT and non-contrast MRI on the same day prior to thoracic surgery. The chest CT was performed to obtain a standard reference for nodule size, location, and morphology. The chest MRI included breath-hold conventional VIBE and CS-VIBE with scanning durations of 11 and 13 s, respectively, and free-breathing spiral UTE for 3.5-5 min. The signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and normal structure visualizations were measured to evaluate MRI quality. Nodule detection sensitivity was evaluated on a lobe-by-lobe basis. Inter-reader and inter-modality reliability analyses were performed using the Cohen κ statistic and the nodule size comparison was performed using Bland-Altman plots. Among 96 pulmonary nodules requiring surgery, the average nodule diameter was 7.7 ± 3.9 mm (range: 4-20 mm); of the 73 resected nodules, most were invasive cancer (74%) or pre-invasive carcinoma in situ (15%). Both spiral UTE and CS-VIBE images achieved significantly higher overall image quality scores, SNRs, and CNRs than conventional VIBE. Spiral UTE (81%) and CS-VIBE (83%) achieved a higher lung nodule detection rate than conventional VIBE (53%). Specifically, the nodule detection rate for spiral UTE and CS-VIBE reached 95% and 100% for nodules >8 and >10 mm, respectively. A 90% detection rate was achieved for nodules of all sizes with a part-solid or solid morphology. Spiral UTE and CS-VIBE under-estimated the nodule size by 0.2 ± 1.4 mm with 95% limits of agreement from -2.6 to 2.9 mm and by 0.2 ± 1.7 mm with 95% limits of agreement from -3.3 to 3.5 mm, respectively, compared to the reference CT. In conclusion, chest CT remains the gold standard for lung nodule detection due to its high image resolutions. Both spiral UTE and CS-VIBE MRI could detect small lung nodules requiring surgery and could be considered a potential alternative to chest CT; however, their clinical application requires further investigation.

Objective: This study investigated ultrashort echo time (UTE) sequences in 1.5 T magnetic resonance imaging (MRI) for small lung nodule detection., Materials and Methods: A total of 120 patients with 165 small lung nodules before video-associated thoracoscopic resection were enrolled. MRI sequences included conventional volumetric interpolated breath-hold examination (VIBE, scan time 16 s), spiral UTE (TE 0.05 ms) with free-breathing (scan time 3.5-5 min), and breath-hold sequences (scan time 20 s). Chest CT provided a standard reference for nodule size and morphology. Nodule detection sensitivity was evaluated on a lobe-by-lobe basis., Results: The nodule detection rate was significantly higher in spiral UTE free-breathing (> 78%, p < 0.05) and breath-hold sequences (> 75%, p < 0.05) compared with conventional VIBE (> 55%), reaching 100% when nodule size was > 16 mm, and reaching 95% when nodules were in solid morphology, regardless of size. The inter-sequence reliability between free-breathing and breath-hold spiral UTE was good (κ > 0.80). Inter-reader agreement was also high (κ > 0.77) for spiral UTE sequences. Nodule size measurements were consistent between CT and spiral UTE MRI, with a minimal bias up to 0.2 mm., Discussion: Spiral UTE sequences detect small lung nodules that warrant surgery, offers realistic scan times for clinical work, and could be implemented as part of routine lung MRI.

Objective: To understand the status of pre-procedural safety practices in radiological examinations at radiology residency training institutions in various Asian regions., Methods: A questionnaire based on the Joint Commission International Accreditation Standards was electronically sent to 3 institutions each in 10 geographical regions across 9 Asian countries. Questions addressing 45 practices were divided into 3 categories. A five-tier scale with numerical scores was used to evaluate safety practices in each institution. Responses obtained from three institutions in the United States were used to validate the execution rate of each surveyed safety practice., Results: The institutional response rate was 70.0% (7 Asian regions, 21 institutions). 44 practices (all those surveyed except for the application of wrist tags for identifying patients with fall risks) were validated using the US participants. Overall, the Asian participants reached a consensus on 89% of the safety practices. Comparatively, most Asian participants did not routinely perform three pre-procedural practices in the examination appropriateness topic., Conclusion: Based on the responses from 21 participating Asian institutions, most routinely perform standard practices during radiological examinations except when it comes to examination appropriateness. This study can provide direction for safety policymakers scrutinizing and improving regional standards of care., Advances in Knowledge: This is the first multicenter survey study to elucidate pre-procedural safety practices in radiological examinations in seven Asian regions.

Background/purpose: The aim of this study was to predict outcomes of adrenalectomy for unilateral primary aldosteronism (PA) using non-stimulated adrenal venous sampling (AVS) indices and the standardized Primary Aldosteronism Surgical Outcome (PASO) criteria., Methods: Patients with unilateral PA who underwent adrenalectomy based on non-stimulated AVS and had follow-up data regarding surgical outcomes between 2011 and 2016 were enrolled. Demographic data and non-stimulated AVS indices, including lateralization index (LI) and contralateral suppression, were collected for analysis., Results: This study included 54 patients who underwent adrenalectomy. Clinical and biochemical outcomes were evaluated in all patients and in 52 (96.3%) patients, respectively. Complete clinical and biochemical success was achieved in 31 (57.4%) of 54 patients and 42 (80.8%) of 52 patients, respectively. An LI > 4 was significantly associated with complete clinical and biochemical success (OR = 4.30, 95% CI 1.18-15.68, p = 0.03, and OR = 7.55, 95% CI 1.28-44.47, p = 0.03, respectively). Contralateral suppression was an independent predictor of complete biochemical success (OR = 17.27, 95% CI 1.95-153.21, p = 0.01)., Conclusion: Non-stimulated AVS indices including LI and contralateral suppression are reliable preoperative determinants for predicting the outcomes of adrenalectomy in patients with unilateral PA. Our findings provide more evidence and confidence to clinicians when applying non-stimulated AVS to determine PA treatment., (Copyright © 2020 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

The COVID-19 global pandemic has emerged as an unprecedented health care crisis. To reduce risks of severe acute respiratory syndrome coronavirus 2 transmission in the Radiology Department, this article describes measures to increase the preparedness of Radiology Department, such as careful screening of staff and patients, thorough disinfection of equipments and rooms, appropriate use of personal protection equipment, and early isolation of patients with incidentally detected computed tomography findings suspicious for COVID-19. The familiarity of radiologists with clinical and imaging manifestations of COVID-19 pneumonia and their prognostic implications is essential to provide optimal care to patients.

Purpose: We investigated whether radiologic parameters by dynamic contrast-enhanced (DCE) integrated magnetic resonance-positron-emission tomography (MR-PET) predicts tumor response to treatment and survival in non-metastatic non-small-cell lung cancer (NSCLC) patients receiving chemoradiotherapy (CRT)., Methods: Patients underwent DCE integrated MR-PET imaging 1 week before CRT. The following parameters were analyzed: primary tumor size, gross tumor volume, maximal standardized uptake value (SUV max ), total lesion glycolysis (TLG), apparent diffusion coefficient (ADC), volume transfer constant (K trans ), reverse reflux rate constant (k ep ), extracellular extravascular volume fraction (v e ), blood plasma volume fraction (v p ), and initial area under the time-concentration curve defined over the first 60 s post-enhancement (iAUC 60 ). CRT responses were defined using the revised Response Evaluation Criteria in Solid Tumors (RECIST) guideline (version 1.1)., Results: Thirty patients were included. Non-responders demonstrated higher baseline TLG (p = 0.012), and lower baseline K trans (p = 0.020) and iAUC 60 (p = 0.016) compared to responders, indicating the usefulness of DCE integrated MR-PET to predict treatment responses. Receiver operating characteristic curve indicated that TLG has the best differentiation capability to predict responders. By setting the threshold of TLG to 277, the sensitivity, specificity, and accuracy were 66.7%, 83.3%, and 75.0%, respectively, with an area under the curve of 0.776. The median follow-up time was 19.6 (range 7.8-32.0) months. In univariate analyses, baseline TLG >277 (p = 0.005) and baseline K t rans <254 (10 -3  min -1 ; p = 0.015) correlated with poor survival after CRT. In multivariate analysis, baseline TLG >277 remained the significant factor in predicting progression (p = 0.012) and death (p = 0.031)., Conclusions: The radiologic parameters derived from DCE integrated MR-PET scans are useful for predicting treatment response in NSCLC patients treated with CRT; furthermore, these parameters are correlated with clinical and survival outcomes including tumor progression and death.

Background/purpose: In video-assisted thoracic surgery (VATS) resection of small lung nodules, preoperative dye marking around the visceral pleura provides surface localization to help initiate resection, while implantation of a fiducial marker such as a microcoil can provide inner localization to aid nodule resection under fluoroscopic guidance. We aimed to determine whether dual localization with microcoil placement and dye marking is safe and useful for guiding the resection of small deep-seated lung nodules., Methods: We retrospectively evaluated data pertaining to 39 consecutive patients (40 nodules) managed between January 2016 and December 2017 in our hospital. Dual localization with patent blue V dye and microcoil was performed preoperatively because the pulmonary nodules were expected to be difficult to visualize or palpate intraoperatively. The patients underwent computed tomography-guided dual localization in a single puncture and were then transferred to the operation room. Intraoperative fluoroscopy was used to ensure that the lung tissue resected included the microcoil., Results: All 40 lesions were successfully resected using the dual localization technique followed by fluoroscopy-assisted thoracoscopic surgery. The median lesion diameter and depth were 0.9 and 1.7 cm, respectively, while the median margin/diameter ratio in the first resected specimen was 1.25. One patient had failure of localization due to partial release of the microcoil into the chest wall. Localization-related pneumothorax was detected in six of 39 patients (15.4%) and was always self-limited., Conclusion: Dual localization with microcoil placement and dye marking is safe and supports successful VATS resection of small deep-seated lung nodules., (Copyright © 2019 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

Background/purpose: Research biopsies (RBs) are crucial for developing novel molecular targeted agents. However, the safety and diagnostic yields of RBs have not been investigated in EGFR mutation-positive non-small cell lung cancer (NSCLC) patients pretreated with epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs)., Methods: We searched the medical records of NSCLC patients who participated in lung cancer clinical trials and underwent mandatory RBs between 2012 and 2014 at our institution. Only patients with EGFR mutation-positive NSCLC pretreated with at least 1 EGFR-TKI were enrolled., Results: Of 140 enrolled patients, 73 (52.1%) and 59 (42.1%) had exon 19 deletions and exon 21 L858R mutation, respectively. Before RBs, 108 (77.1%), 83 (59.3%), and 36 (25.7%) patients had been treated with gefitinib, erlotinib, and afatinib, respectively. Computed tomography-guided percutaneous core needle biopsy was the most frequently used modality among 181 RBs performed (50.8%), followed by ultrasonography-guided (32.0%) and endoscopic RBs (16.0%). The most common RB sites were the lung (69.6%), pleura (8.8%), and liver (6.1%). Pathologic examinations revealed malignant cells in most RB specimens (72.9%). Complications due to RBs included pneumothorax (11.6%), bleeding (6.1%), and infection (1.1%). Only 1 patient required chest tube placement for pneumothorax, and 2 patients underwent endotracheal intubation because of bleeding., Conclusion: RBs in this patient population were generally safe. Pneumothorax was the most frequent complication; bleeding, while infrequent, increased the risk of severe events. The diagnostic yields and complications of any particular modality should therefore be discussed with prospective clinical trial participants., (Copyright © 2017. Published by Elsevier B.V.)

Purpose: To explore the utility of integrated positron emission tomography (PET) / magnetic resonance imaging (MRI) for evaluating subclinical inflammation in patients with ulcerative colitis (UC)., Materials and Methods: This prospective study was approved by the Institutional Review Board and informed consent was obtained. Between November 2015 and April 2016, 19 consecutive patients with UC in clinical remission were enrolled. These patients underwent 18F-fluorodeoxyglucose PET/MRI (3T) and colonoscopy. Serum high-sensitivity C-reactive protein (hs-CRP) and fecal calprotectin (FC) levels were also obtained. The findings of colonoscopy were graded using the Mayo endoscopic subscore. Quantitative (minimum apparent diffusion coefficient [ADC min ] and maximum standardized uptake value [SUV max ]), semiquantitative, and qualitative parameters of PET/MRI were evaluated and correlated with colonoscopic findings., Results: In per-segment analysis, ADC min was significantly lower and SUV max and ratio of SUV max to ADC min were significantly higher in the colonic segments with active inflammation (Mayo endoscopic subscore ≥2) (P < 0.05). Qualitative MRI score, PET activity grade, and PET/MRI score were also significantly higher in the colonic segments with active inflammation (P < 0.05). Among these parameters, the ratio of SUV max to ADC min exhibited the highest area under the receiver operating characteristic curve (AUC) (0.763). In per-patient analysis, the AUC of PET activity grade was 0.778, higher than those of hs-CRP (0.589) and FC (0.722). Using a combined index of FC and PET, an even higher AUC (0.867) was achieved., Conclusion: PET/MRI is a potentially useful tool in identifying subclinical inflammation in patients with UC., Level of Evidence: 1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;47:737-745., (© 2017 International Society for Magnetic Resonance in Medicine.)

Purpose: To evaluate the response in patients undergoing SBRT using dynamic contrast-enhanced (DCE) integrated magnetic resonance positron emission tomography (MR-PET). Stereotactic body radiation therapy (SBRT) is efficacious as a front-line local treatment for non-small cell lung cancer (NSCLC)., Materials and Methods: We prospectively enrolled 19 lung tumors in 17 nonmetastatic NSCLC patients who were receiving SBRT as a primary treatment. They underwent DCE-integrated 3T MR-PET before and 6 weeks after SBRT. The following image parameters were analyzed: tumor size, standardized uptake value (SUV), apparent diffusion coefficient, K trans , k ep , v e , v p , and iAUC 60 . Chest computed tomography (CT) was performed at 3 months after SBRT., Results: SBRT treatment led to tumor changes including significant decreases in the SUV max (-61%, P < 0.001), K trans mean (-72%, P = 0.005), K trans standard deviation (SD; -85%, P = 0.046), k ep mean (-53%, P = 0.014), k ep SD (-63%, P = 0.001), and v p SD (-58%, P = 0.002). The PET SUV max was correlated with the MR k ep mean (P = 0.002) and k ep SD (P < 0.001). The percentage reduction in K trans mean (P < 0.001) and k ep mean (P = 0.034) at 6 weeks post-SBRT were significantly correlated with the percentage reduction in tumor size, as measured using CT at 3 months after SBRT. Univariate analyses revealed a trend toward disease progression when the initial SUV max > 10 (P = 0.083)., Conclusion: In patients with NSCLC who are receiving SBRT, DCE-integrated MR-PET can be used to evaluate the response after SBRT and to predict the local treatment outcome., Level of Evidence: 2 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2018;47:191-199., (© 2017 International Society for Magnetic Resonance in Medicine.)

The association between epicardial fat and coronary artery disease (CAD) might be affected by general adiposity. We aimed to determine whether the percentage of epicardial adipose tissue (%EAT), defined as the mass ratio of epicardial fat to body fat, could improve prediction of asymptomatic CAD. We consecutively enrolled 846 adults who underwent coronary computed tomography angiography as part of a health check-up and assessed their coronary stenosis severity and epicardial fat mass. Body fat mass was measured by bioelectrical impedance analysis. Subjects with CAD history, hyperthyroidism, pitting edema, or subjects taking diuretics or thiazolidinedione were excluded. Obstructive CAD was defined as at least one coronary artery with 50 % or greater obstruction, and severe CAD was defined as 70 % or greater obstruction. The %EAT had the maximum area under the curve for predicting the presence of CAD and superior discriminative performance to EAT and other EAT-indexed parameters. Multivariable logistic regression analysis revealed that %EAT >0.41 % was a predictor of obstructive CAD [odds ratio 3.59 (95 % confidence interval 2.28-5.64)], and %EAT >0.47 % was a predictor of severe CAD [4.01 (2.01-7.99)] after adjustment for calcium score and Framingham risk score. This prediction was more pronounced in subjects with higher body fat percentage (≥25 % for men and ≥35 % for women), Framingham risk score (≥10 %), or calcium score (≥100). A spillover of body fat at epicardium over a critical threshold is associated with significant coronary stenosis. This association was independent of obesity, coronary calcium burden, and Framingham risk factors.

Unlabelled: Coronary computed tomographic angiography (CCTA) has been widely available since 2004. After that, the diagnostic accuracy of CCTA has been extensively validated with invasive coronary angiography for detection of coronary arterial stenosis. In this paper, we reviewed the updated evidence of the role of CCTA in both scenarios including acute chest pain and screening in asymptomatic adults. Several large-scale studies have been conducted to evaluate the diagnostic value of CCTA in the context of acute chest pain patients. CCTA could play a role in delivering more efficient care. For risk stratification of asymptomatic patients using CCTA, latest studies have revealed incremental benefits. Future studies evaluating the totality of plaque characteristics may be useful for determining the role of noncalcified plaque for risk stratification in asymptomatic individuals., Key Words: Acute chest pain • Computed tomography • Coronary artery disease • Health screening • Stable angina.

Purpose: To evaluate the treatment response of locally advanced breast cancer (LABC) to neoadjuvant chemotherapy using magnetic resonance (MR) vascular maps and apparent diffusion coefficient (ADC) at 3T. Materials and Methods Thirty-one patients with LABC who underwent breast MR studies before, after the first course, and after completing neoadjuvant chemotherapy were enrolled. Vascular morphology was retrieved via Hessian matrix and the voxels of the vessels and volume of vessels were measured automatically. Whole tumor mean ADC values were calculated. Clinical responders were defined as >50% tumor reduction in the final MR studies. Pathologically complete responders were also recorded., Results: There were 21 clinical responders and 10 nonresponders. Compared to the nonresponders after the first course, the responders were characterized by more vascular reduction of the breast lesion and decreased bilateral vascular discrepancy (voxels and volume), and increments in the ADC value and ADC percentage of the lesions (all P < 0.05). There were three pathological complete responders who showed more apparent early vascular reduction of the lesion breast (voxels and volume) and increments in the ADC value than others (P = 0.02, 0.01 and 0.02, respectively)., Conclusion: The early changes of MR vascular maps and ADC are associated with the final treatment response of LABC., (© 2015 Wiley Periodicals, Inc.)

Background: Elastography is a new sonographic imaging technique to acquire the strain information of tissues and transform the information into images. Radiologists have to observe the gray-scale distribution of tissues on the elastographic image interpreted as the reciprocal of Young's modulus to evaluate the pathological changes such as scirrhous carcinoma. In this study, a computer-aided diagnosis (CAD) system was developed to extract quantitative strain features from elastographic images to reduce operator-dependence and provide an automatic procedure for breast mass classification., Method: The collected image database was composed of 45 malignant and 45 benign breast masses. For each case, tumor segmentation was performed on the B-mode image to obtain tumor contour which was then mapped to the elastographic images to define the corresponding tumor area. The gray-scale pixels around tumor area were classified into white, gray, and black by fuzzy c-means clustering to highlight stiff tissues with darker values. Quantitative strain features were then extracted from the black cluster and compared with the B-mode features in the classification of breast masses., Results: The performance of the proposed strain features achieved an accuracy of 80% (72/90), a sensitivity of 80% (36/45), a specificity of 80% (36/45), and a normalized area under the receiver operating characteristic curve, Az=0.84. Combining the strain features with the B-mode features obtained a significantly better Az=0.93, p-value<0.05., Conclusions: Summarily, the quantified strain features can be combined with the B-mode features to provide a promising suggestion in distinguishing malignant from benign tumors., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

This study aimed to investigate a computer-aided system for detecting breast masses using dynamic contrast-enhanced magnetic resonance imaging for clinical use. Detection performance of the system was analyzed on 61 biopsy-confirmed lesions (21 benign and 40 malignant lesions) in 34 women. The breast region was determined using the demons deformable algorithm. After the suspicious tissues were identified by kinetic feature (area under the curve) and the fuzzy c-means clustering method, all breast masses were detected based on the rotation-invariant and multi-scale blob characteristics. Subsequently, the masses were further distinguished from other detected non-tumor regions (false positives). Free-response operating characteristics (FROC) curve and detection rate were used to evaluate the detection performance. Using the combined features, including blob, enhancement, morphologic, and texture features with 10-fold cross validation, the mass detection rate was 100 % (61/61) with 15.15 false positives per case and 91.80 % (56/61) with 4.56 false positives per case. In conclusion, the proposed computer-aided detection system can help radiologists reduce inter-observer variability and the cost associated with detection of suspicious lesions from a large number of images. Our results illustrated that breast masses can be efficiently detected and that enhancement and morphologic characteristics were useful for reducing non-tumor regions.

Introduction: Germline Bcl-2-like protein 11 (BIM) deletion polymorphism in Asian is a poor predictive factor for treatment outcomes to tyrosine kinase inhibitors (TKIs) in malignancies. We explored the impact of BIM deletion polymorphism on treatment outcome of advanced non-small-cell lung cancer (NSCLC)., Methods: We prospectively collected tissue samples, blood, and clinical data from two cohorts of advanced NSCLC patients. BIM deletion polymorphism was correlated with overall survival (OS) and progression-free survival (PFS) to epidermal growth factor receptor (EGFR) TKIs and chemotherapy treatment., Results: BIM deletion polymorphism was detected in blood of 16.2% (33 of 204) patients. The PFS to first-line EGFR-TKIs in 153 patients were 8.6 and 4.6 months for patients with wild-type BIM and BIM deletion polymorphism, respectively (p = 0.004). Among 120 patients who received chemotherapies, the PFS to chemotherapies were 5.6 and 3.5 months for patients with wild-type BIM and BIM deletion polymorphism, respectively (p = 0.050). The OS of all 204 patients was 24.8 and 16.8 months for patients with wild-type BIM and BIM deletion polymorphism, respectively (p = 0.005). Multivariate analyses suggested that BIM deletion polymorphism was an independent predictor for shorter PFS to EGFR-TKIs (hazard ratio [HR] 2.15, p = 0.002), PFS to chemotherapy (HR 2.40, p = 0.016), and OS (HR 1.65, p = 0.039)., Conclusions: BIM deletion polymorphism predicts shorter PFS to EGFR-TKIs and OS in advanced NSCLC.

Background/purpose: The role computed tomography (CT) performed prior to thoracoscopic surgery for primary spontaneous pneumothorax (PSP) remains unclear., Methods: We retrospectively reviewed medical records of all patients who underwent thoracoscopic surgery for PSP during 2008-2012. Patients were stratified into two groups: CT group (patients who received preoperative CT scanning) and control group (patients who did not receive preoperative scanning). Short-term postoperative results and long-term pneumothorax recurrence rates were compared., Results: A total of 298 patients were studied. Preoperative CT scanning was performed in 140 of them. The duration of operation, incidence of bullae formation, number of excised specimens, rate of complications, and postoperative hospital stay were similar between the two groups. After a mean follow-up of 20 months, the recurrence rates were 8.6% (12/140) in the CT group and 5.7% (9/158) in the control group (p = 0.371). In the CT group, five patients had unexpected pulmonary findings and three of them (60%) developed pneumothorax recurrence, the rate of which was significantly higher than that in patients without unexpected pulmonary findings (9/135, 6.7%, p = 0.004). Unexpected pulmonary lesions were more commonly noted in females (4/19, 21.1%) than in males (1/121, 0.8%; p < 0.001)., Conclusion: Preoperative CT scanning was not associated with better results after thoracoscopic surgery for PSP and is, therefore, not justified as a routine examination prior to the operation. In female patients, however, preoperative CT scanning might be needed because these patients tended to have a higher incidence of unexpected pulmonary lesions, which were associated with a higher rate of recurrence., (Copyright © 2014. Published by Elsevier B.V.)

This study aimed to evaluate the value of using 3-D breast MRI morphologic features to differentiate benign and malignant breast lesions. The 3-D morphological features extracted from breast MRI were used to analyze the malignant likelihood of tumor from ninety-five solid breast masses (44 benign and 51 malignant) of 82 patients. Each mass-like lesion was examined with regards to three categories of morphologic features, including texture-based gray-level co-occurrence matrix (GLCM) feature, shape, and ellipsoid fitting features. For obtaining a robust combination of features from different categories, the biserial correlation coefficient (|r(pb)|)≧0.4 was used as the feature selection criterion. Receiver operating characteristic (ROC) curve was used to evaluate performance and Student's t-test to verify the classification accuracy. The combination of the selected 3-D morphological features, including conventional compactness, radius, spiculation, surface ratio, volume covering ratio, number of inside angular regions, sum of number of inside and outside angular regions, showed an accuracy of 88.42% (84/95), sensitivity of 88.24% (45/51), and specificity of 88.64% (39/44), respectively. The AZ value was 0.8926 for these seven combined morphological features. In conclusion, 3-D MR morphological features specified by GLCM, tumor shape and ellipsoid fitting were useful for differentiating benign and malignant breast masses., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Nonsmall cell lung cancer (NSCLC) presenting with miliary intrapulmonary carcinomatosis (MIPC) is rare. We investigated the clinical characteristics and epidermal growth factor receptor (EGFR) mutation rate of NSCLC patients with MIPC at initial diagnosis. From June 2004 to December 2008, we screened newly diagnosed NSCLC patients for MIPC using image-based criteria. We recorded clinical data and analysed EGFR mutation status. For comparison, we collected specimens from stage IV NSCLC patients without MIPC tested for EGFR mutations from April 2001 to November 2008. From 3,612 NSCLC patients, 85 patients with MIPC at initial diagnosis were identified; 81 had adenocarcinoma. Of the 85 patients, 60 had specimen sequencing to detect EGFR mutation; 42 (70%) were positive. Compared with 673 stage IV patients without MIPC, patients with MIPC had higher EGFR mutation rate (p=0.036); even male smokers had a high EGFR mutation rate (91%). Multivariate analysis of prognostic factors for overall survival of the 85 patients with MIPC revealed that adenocarcinoma, absence of extrapulmonary metastasis and having EGFR mutation were associated with longer overall survival. NSCLC patients with MIPC at initial diagnosis had higher rates of adenocarcinoma and EGFR mutation. EGFR tyrosine kinase inhibition may be the treatment of choice for NSCLC patients with MIPC at initial diagnosis among Asians.

Purpose: To develop a computer-aided diagnostic algorithm with automatic boundary delineation for differential diagnosis of benign and malignant breast lesions at ultrasonography (US) and investigate the effect of boundary quality on the performance of a computer-aided diagnostic algorithm., Materials and Methods: This was an institutional review board-approved retrospective study with waiver of informed consent. A cell-based contour grouping (CBCG) segmentation algorithm was used to delineate the lesion boundaries automatically. Seven morphologic features were extracted. The classifier was a logistic regression function. Five hundred twenty breast US scans were obtained from 520 subjects (age range, 15-89 years), including 275 benign (mean size, 15 mm; range, 5-35 mm) and 245 malignant (mean size, 18 mm; range, 8-29 mm) lesions. The newly developed computer-aided diagnostic algorithm was evaluated on the basis of boundary quality and differentiation performance. The segmentation algorithms and features in two conventional computer-aided diagnostic algorithms were used for comparative study., Results: The CBCG-generated boundaries were shown to be comparable with the manually delineated boundaries. The area under the receiver operating characteristic curve (AUC) and differentiation accuracy were 0.968 +/- 0.010 and 93.1% +/- 0.7, respectively, for all 520 breast lesions. At the 5% significance level, the newly developed algorithm was shown to be superior to the use of the boundaries and features of the two conventional computer-aided diagnostic algorithms in terms of AUC (0.974 +/- 0.007 versus 0.890 +/- 0.008 and 0.788 +/- 0.024, respectively)., Conclusion: The newly developed computer-aided diagnostic algorithm that used a CBCG segmentation method to measure boundaries achieved a high differentiation performance., (Copyright RSNA, 2010)

Blood vessel abstraction is an important procedure for quantitative analysis of blood vessel densities determined by immunostaining the tumor cells. Due to the weak contrast of object boundaries and background clutter, it is difficult to identify the vessel and non-vessel region clearly. In this paper we present a novel algorithm to automatically abstract salient regions in blood vessel images using Gaussian perceptually color space for producing the detail and large-scale layer. The first component of Gaussian color model is used to represent the large-scale layer after bilateral filtering. The detail layer of salient region in the blood vessel image is obtained by normalizing the color of the color layer in the image. Using these two features, we can reconstruct the image using intensity-color coupling. The abstraction result is then processed by luminance quantization algorithm to provide both boundary and region information of blood vessel images. This proposed algorithm has been applied on a wide range of complex blood vessel images with promising results.

Endobronchial lipoma is a rare benign tumor in the bronchial tree. We report a case of endobronchial lipoma in a 73-year-old man with hemoptysis. Chest radiograph revealed atelectasis of the right upper lung. Bronchoscopy revealed a well-defined endobronchial lesion in the right upper lobe bronchus with near total occlusion, but a biopsy was not performed. An endobronchial tumor was identified on CT scan with demonstration of fat within the tumor. Endobronchial lipoma was diagnosed and a sleeve lobectomy of the right upper lobe bronchus was performed. The pathological diagnosis was submucosal lipoma. The patient's symptoms improved during follow-up of more than 1 year. CT scan can be used to diagnose endobronchial lipoma and can help in the development of a management plan.

Objective: To characterize the sonographic patterns of teratomas located within the mediastinum and to correlate them with pathologic findings, because there have been few reports concerning the application of sonography in the diagnosis of mediastinal teratoma., Methods: Over a 9-year period, we carried out an image analysis of the sonographic findings of 28 mediastinal teratomas whose diagnoses were proved surgically., Results: Sonography showed that 18 patients had a complex mass of heterogeneous echogenicity, including regional bright echoes (n = 12), acoustic shadows (n = 8), hyperechoic lines and dots (n = 7), soft tissue septa (n = 9), dermoid plugs (n = 6), and hypoechoic areas (n = 11). This type of mediastinal teratoma revealed, in pathologic findings, varying combinations of fat, sebaceous and mucinous materials, hair, mineralized elements, and multiple compartments. Eight patients had a homogeneous hyperechoic mass, and the 2 remaining patients had floating spherules within a cystic mass. Pathologically, the homogeneous mass mainly contained hair and sebaceous material. The floating spherules were also composed of sebaceous tissue and were above the fluid of the cyst., Conclusions: On the basis of the evaluation of the sonographic and pathologic findings, we described 3 major patterns of mediastinal teratoma: a complex mass of heterogeneous echogenicity, homogeneous high echogenicity within a solid mass, and floating spherules within a cystic mass. Thus, sonography can improve the diagnosis of mediastinal teratoma. However, additional prospective studies are needed to test the sensitivity and specificity of these sonographic patterns in the diagnosis of mediastinal teratoma.

Pedunculated hepatic hemangioma may be confused with pedunculated hepatocellular carcinoma (HCC) in clinical practice because of their similar ultrasonographic pattern. We report two cases of asymptomatic pedunculated hepatic hemangioma. Both patients presented with intraabdominal masses of unknown nature measuring about 5 cm in diameter. Pedunculated HCC was suspected because of a pedicle and ultrasonographic pattern in both patients, positive hepatitis B surface antigen as a risk factor in one patient, and the high prevalence of HCC in Taiwan. Diagnosis was established by computerized tomography, magnetic resonance imaging, radionuclide scintigraphy, and angiography in both patients and confirmed by histopathology of the surgical specimen in one patient. Pedunculated hepatic hemangioma should be included in the differential diagnosis of a mass located in the upper abdomen.