Publications by authors named "Perry J Pickhardt"

405 Publications

Imaging Spectrum of Granulomatous Diseases of the Abdomen and Pelvis.

Radiographics 2021 Apr 16:200172. Epub 2021 Apr 16.

From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110 (M.N., A.J.C., M.Z., D.H.B., V.M.M.); Division of Abdominal Imaging, Department of Radiology, Mayo Clinic Arizona, Scottsdale, Ariz (C.O.M.); and Division of Abdominal Imaging and Intervention, Department of Radiology, University of Wisconsin-Madison, Madison, Wis (P.J.P., D.H.K., M.G.L.).

A is a compact organization of mature macrophages that forms because of persistent antigenic stimulation. At the microscopic level, granulomas can undergo various morphologic changes, ranging from necrosis to fibrosis, which along with other specialized immune cells define the appearance of the granulomatous process. Accordingly, the imaging features of granulomatous diseases vary and can overlap with those of other diseases, such as malignancy, and lead to surgical excisions and biopsy. However, given the heterogeneity of granulomas as a disease group, it is often hard to make a diagnosis on the basis of the histopathologic features of granulomatous diseases alone owing to overlapping microscopic features. Instead, a multidisciplinary approach is often helpful. Radiologists need to be familiar with the salient clinical manifestations and imaging findings of granulomatous diseases to generate an appropriate differential diagnosis. RSNA, 2021.
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http://dx.doi.org/10.1148/rg.2021200172DOI Listing
April 2021

Ultrasound-Guided Omental Biopsy: Diagnostic Yield and Association with CT Features Based on a Single-Institution 18-Year Series.

AJR Am J Roentgenol 2021 Apr 14. Epub 2021 Apr 14.

Department of Radiology, University of Wisconsin School of Medicine and Public Health.

The greater omentum can serve as a useful target for percutaneous biopsy; in clinical practice, CT is commonly used for biopsy guidance. To evaluate the diagnostic yield of percutaneous ultrasound (US)-guided omental biopsy and to explore the association of diagnostic yield with pre-biopsy diagnostic CT findings. This retrospective study included 163 patients (mean age, 65±12 years; 120 women, 43 men; mean BMI, 28.9±7.9) who underwent US-guided omental biopsy between 2002-2020 at a single institution at which US served as the firstline modality for omental biopsy guidance. Biopsies were performed by abdominal radiologists without dedicated interventional radiology fellowship training. Post-biopsy clinical and imaging follow-up were reviewed to establish each patient's ultimate diagnosis. Omental biopsies were characterized as diagnostic or non-diagnostic relative to the ultimate diagnosis. Associations were explored between diagnostic yield and findings on pre-biopsy CT and biopsy US. US-guided omental biopsy was performed by 18-gauge core in 156 and fine-needle aspiration in 7 patients. Mean passes was 2.5±1.0. Mean omental thickness was 2.6±1.2 cm. On pre-biopsy diagnostic CT, omental disease appeared infiltrative in 127 (78%) versus mass-forming in 36 (22%), and appeared hypoechoic in 105 (64%) versus iso-to-hyperechoic in 58 (36%). The ultimate diagnosis was malignant in 154 (95%) [gynecologic in 82 (most commonly high-grade serous adenocarcinoma, n=56) and gastrointestinal in 45] and benign in 9 (6%). The omental biopsy was diagnostic relative to the ultimate diagnosis in 155 (95%). A diagnostic versus non-diagnostic biopsy was not associated (p>.05) with age, BMI, number of passes, or omental target thickness or attenuation. A total of 94% (120/127) of infiltrative and 97% (35/36) of mass-forming cases were diagnostic (p=.50). A total of 96% (102/106) of hypoechoic and 93% (53/57) of iso-to-hyperechoic cases were diagnostic (p=.36). No complication occurred. US-guided biopsy of omental disease suspected on CT is safe and effective for tissue diagnosis. Though omental disease commonly appears on US as diffuse infiltrative thickening without a discrete target, sampling based on pre-biopsy CT landmarks is diagnostic in the large majority of cases. US should be considered the first-line modality for omental biopsy guidance when feasible.
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http://dx.doi.org/10.2214/AJR.21.25545DOI Listing
April 2021

Comparison of CT Texture Analysis Software Platforms in Renal Cell Carcinoma: Reproducibility of Numerical Values and Association With Histologic Subtype Across Platforms.

AJR Am J Roentgenol 2021 Apr 14:1-9. Epub 2021 Apr 14.

Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Sciences Center, 600 Highland Ave, Madison WI 53792.

The purpose of this article is to evaluate interobserver, intraobserver, and interplatform variability and compare the previously established association between texture metrics and tumor histologic subtype using three commercially available CT texture analysis (CTTA) software platforms on the same dataset of large (> 7 cm) renal cell carcinomas (RCCs). CT-based texture analysis was performed on contrast-enhanced MDCT images of large (> 7 cm) untreated RCCs in 124 patients (median age, 62 years; 82 men and 42 women) using three different software platforms. Using this previously studied cohort, texture features were compared across platforms. Features were correlated with histologic subtype, and strength of association was compared between platforms. Single-slice and volumetric measures from one platform were compared. Values for interobserver and intraobserver variability on a tumor subset ( = 30) were assessed across platforms. Metrics including mean gray-level intensity, SD, and volume correlated fairly well across platforms (concordance correlation coefficient [CCC], 0.66-0.99; mean relative difference [MRD], 0.17-5.97%). Entropy showed high variability (CCC, 0.04; MRD, 44.5%). Mean, SD, mean of positive pixels (MPP), and entropy were associated with clear cell histologic subtype on almost all platforms ( < .05). Mean, SD, entropy, and MPP were highly reproducible on most platforms on both interobserver and intraobserver analysis. Select texture metrics were reproducible across platforms and readers, but other metrics were widely variable. If clinical models are developed that use CTTA for medical decision making, these differences in reproducibility of some features across platforms need to be considered, and standardization is critical for more widespread adaptation and implementation.
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http://dx.doi.org/10.2214/AJR.20.22823DOI Listing
April 2021

Magnetic resonance imaging versus computed tomography and ultrasound for the diagnosis of female pelvic pathology.

Emerg Radiol 2021 Mar 17. Epub 2021 Mar 17.

BerbeeWalsh Department of Emergency Medicine, University of Wisconsin - Madison, Madison, Wisconsin, 53706, USA.

Objectives: We sought to determine the diagnostic accuracy of magnetic resonance (MR) imaging compared with computed tomography (CT) and ultrasound (US) when evaluating for five common pelvic pathologies among women presenting to the emergency department (ED) with right lower quadrant abdominal pain.

Methods: This prospective, single-center study was conducted at an academic ED as a sub-analysis of a direct comparison of the diagnostic accuracy of CT and MR in the evaluation of appendicitis. Patients were eligible for participation in the parent study if they were at least 12 years old and had a CT performed for evaluation of possible appendicitis. In the current study, only female patients who also underwent pelvic US were included. Three radiologists independently interpreted each MR examination specifically for the presence of pelvic pathology, knowing that patients had initially undergone imaging evaluation for possible appendicitis. The determination of an independent expert panel of two radiologists and one emergency physician based on surgical pathology, comprehensive chart review, clinical information, and follow-up phone calls served as the reference standard. Test characteristics of MR, CT, and US were calculated based on this; the main outcome measure was the summary sensitivity and specificity of MR versus CT and US.

Results: Forty-one participants were included with a mean age of 27.6 ± 10.8 years. The MR consensus interpretation had an overall sensitivity and specificity of 57.1% (CI 38.8-75.5%) and 97.2% (CI 94.7-99.6%) respectively, for detecting any of the five pelvic pathologies. By comparison, CT exhibited sensitivity and specificity of 66.7% (CI 50.0-83.5%) and 98.3% (CI 96.4-100.0%) while it was 64.3% (CI 46.5-82.0%) and 97.7% (CI 95.6-99.9%) for US, respectively. No significant differences were identified when comparing these modalities. Overall, Fleiss' kappa interrater reliability value for MR interpretation was 0.75, corresponding to substantial agreement between the three readers.

Conclusions: In women who might otherwise undergo multiple imaging tests to evaluate gastrointestinal versus pelvic pathologies, our data suggest that MR may be an acceptable first-line imaging test.
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http://dx.doi.org/10.1007/s10140-021-01923-4DOI Listing
March 2021

PPV and Detection Rate of mt-sDNA, FIT, and CT Colonography for Advanced Neoplasia: A Hierarchical Bayesian Meta-Analysis of the Noninvasive Colorectal Screening Tests.

AJR Am J Roentgenol 2021 03 11. Epub 2021 Mar 11.

Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy.

Noninvasive tests for colorectal cancer (CRC) screening and prevention limit the need for invasive colonoscopy to follow-up positive test results. However, the relative performance characteristics of available noninvasive tests have not yet been adequately compared. To perform a systematic review and meta-analysis to compare the diagnostic performance of the available noninvasive CRC screening tests, including multi-target stool-DNA (mt-sDNA), fecal immunochemical test (FIT), and CT colonography (CTC), with emphasis on comparison of PPV and detection rate (DR) for advanced neoplasia (AN, encompassing advanced adenomas and CRC). After systematic search of MEDLINE and Google Scholar, 10 mt-sDNA, 27 CTC, and 88 FIT published screening studies involving 25,132, 33,493, and 2,355,958 asymptomatic adults, respectively, were included. Meta-analysis with hierarchical Bayesian modeling was conducted in accordance with Cochrane Collaboration and PRISMA guidelines to determine test-positivity rates (TPR) leading to optical colonoscopy, as well as PPV and DR for both AN and CRC. Different positivity thresholds were considered for FIT and CTC. Point estimates (with 95% credible intervals) from pooled Bayesian meta-analysis were as follows [combining all thresholds for FIT and stratifying CTC by ≥6mm (CTC6) and ≥10mm (CTC10) thresholds]: TPR for mt-sDNA=13.5% (9.5-16.6%), FIT=6.4% (5.8-7.2%), CTC6=13.4% (11.4-15.6%), and CTC10=6.6% (5.2-7.7%); AN-PPV for mt-sDNA=26.9% (21.8-33.1%), FIT=31.8% (29.3-34.5%), CTC6=34.4% (27.2-41.0%), and CTC10=61.0% (54.0-70.0%); CRC-PPV for mt-SDNA=2.4% (1.5-3.9%), FIT=4.9% (4.3-5.3%), CTC6=3.5% (2.5-4.8%), and CTC10=6.0% (4.7-8.8%); and AN-DR for mt-SDNA=3.4% (2.5-4.8%), FIT=2.0% (1.8-2.3%), CTC6=4.8% (4.0-6.5%), and CTC10=4.0% (3.0-4.6%). When FIT is restricted to a lower threshold (<10 μg), its performance profile is similar to mt-sDNA, though available data are limited. AN-PPV odds ratios (relative to CTC10 as reference) were 0.24 (0.17-0.33) for mt-sDNA, 0.33 (0.24-0.43) for FIT, and 0.33 (0.25-0.47) for CTC6. Among noninvasive CRC screening tests, CTC with ≥10 mm threshold most effectively targets AN, preserving detection while also decreasing unnecessary colonoscopies compared with mt-sDNA and FIT. CTC performed with a polyp size threshold for colonoscopy referral set at ≥10 mm represents the most effective and efficient non-invasive screening test for CRC prevention and detection.
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http://dx.doi.org/10.2214/AJR.20.25416DOI Listing
March 2021

Opportunistic Screening at Abdominal CT: Use of Automated Body Composition Biomarkers for Added Cardiometabolic Value.

Radiographics 2021 Mar-Apr;41(2):524-542

From the Department of Radiology, University of Wisconsin School of Medicine & Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792-3252 (P.J.P., P.M.G., A.A.P., M.G.L.); and Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (D.C.E., R.M.S.).

Abdominal CT is a frequently performed imaging examination for a wide variety of clinical indications. In addition to the immediate reason for scanning, each CT examination contains robust additional data on body composition that generally go unused in routine clinical practice. There is now growing interest in harnessing this additional information. Prime examples of cardiometabolic information include measurement of bone mineral density for osteoporosis screening, quantification of aortic calcium for assessment of cardiovascular risk, quantification of visceral fat for evaluation of metabolic syndrome, assessment of muscle bulk and density for diagnosis of sarcopenia, and quantification of liver fat for assessment of hepatic steatosis. All of these relevant biometric measures can now be fully automated through the use of artificial intelligence algorithms, which provide rapid and objective assessment and allow large-scale population-based screening. Initial investigations into these measures of body composition have demonstrated promising performance for prediction of future adverse events that matches or exceeds the best available clinical prediction models, particularly when these CT-based measures are used in combination. In this review, the concept of CT-based opportunistic screening is discussed, and an overview of the various automated biomarkers that can be derived from essentially all abdominal CT examinations is provided, drawing heavily on the authors' experience. As radiology transitions from a volume-based to a value-based practice, opportunistic screening represents a promising example of adding value to services that are already provided. If the potentially high added value of these objective CT-based automated measures is ultimately confirmed in subsequent investigations, this opportunistic screening approach could be considered for intentional CT-based screening. RSNA, 2021.
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http://dx.doi.org/10.1148/rg.2021200056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7924410PMC
March 2022

A dynamic lesion model for differentiation of malignant and benign pathologies.

Sci Rep 2021 Feb 10;11(1):3485. Epub 2021 Feb 10.

Department of Radiology, School of Medicine, University of Wisconsin, Madison, WI, USA.

Malignant lesions have a high tendency to invade their surrounding environment compared to benign ones. This paper proposes a dynamic lesion model and explores the 2nd order derivatives at each image voxel, which reflect the rate of change of image intensity, as a quantitative measure of the tendency. The 2nd order derivatives at each image voxel are usually represented by the Hessian matrix, but it is difficult to quantify a matrix field (or image) through the lesion space as a measure of the tendency. We conjecture that the three eigenvalues contain important information of the Hessian matrix and are chosen as the surrogate representation of the Hessian matrix. By treating the three eigenvalues as a vector, called Hessian vector, which is defined in a local coordinate formed by three orthogonal Hessian eigenvectors and further adapting the gray level occurrence computing method to extract the vector texture descriptors (or measures) from the Hessian vector, a quantitative presentation for the dynamic lesion model is completed. The vector texture descriptors were applied to differentiate malignant from benign lesions from two pathologically proven datasets: colon polyps and lung nodules. The classification results not only outperform four state-of-the-art methods but also three radiologist experts.
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http://dx.doi.org/10.1038/s41598-021-83095-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7875978PMC
February 2021

Ligament of Treitz: Anatomy, Relevance of Radiologic Findings, and Radiologic-Pathologic Correlation.

AJR Am J Roentgenol 2021 04 10;216(4):927-934. Epub 2021 Feb 10.

Department of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1473, Houston, TX 77030.

The objective of this article is to discuss the anatomy, embryonic origin, normal variants, and various attachments of the ligament of Treitz. We also describe the pathologic processes that develop along the ligament of Treitz and the role of cross-sectional imaging in identifying these conditions. The ligament of Treitz, also known as the suspensory ligament of the duodenum, is an important anatomic landmark in the abdomen. It is essential that radiologists understand the anatomic attachments, normal variants, and various pathologic conditions involving the ligament of Treitz as well as the role of cross-sectional imaging in the assessment of these conditions.
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http://dx.doi.org/10.2214/AJR.20.23273DOI Listing
April 2021

Intestinal malrotation in adults: prevalence and findings based on CT colonography.

Abdom Radiol (NY) 2021 Feb 9. Epub 2021 Feb 9.

Department of Radiology, University of Wisconsin School of Medicine & Public Health, E3/311 Clinical Science Center, 600 Highland Ave., Madison, WI, 53792-3252, USA.

Objectives: Intestinal malrotation is largely a pediatric diagnosis, but initial detection can be made in adulthood. CT colonography (CTC) provides an ideal means for estimating prevalence. Our purpose was to evaluate the prevalence and imaging findings of intestinal malrotation in asymptomatic adults at CTC screening, as well as incomplete optical colonoscopy (OC) referral.

Methods: The CTC database of a single academic institution was searched for cases of intestinal malrotation (developmental nonrotation). Prevalence was estimated from 11,176 adults undergoing CTC. Demographic, clinical, imaging (CTC and other abdominal exams), and surgical data were reviewed.

Results: 27 cases of malrotation were confirmed (mean age 62 ± 9 years; 15 M/12F), including 17 from the CTC screening cohort (0.17% prevalence) and 10 from incomplete OC (0.75% prevalence; p < 0.001). Most cases (59%; 16/27) were initially diagnosed at CTC. In 67% (12/18); the presence of malrotation was missed on at least one relevant abdominal imaging examination. At least 22% (6/27) had a history of unexplained, chronic intermittent abdominal pain. At CTC, the SMA-SMV relationship was normal in only 11% (3/27). The ileocecal valve was located in the RLQ in only 22% (6/27). Two patients (7%) had associated findings of heterotaxy (polysplenia).

Conclusions: The prevalence of intestinal malrotation was four times greater for patients referred from incomplete OC compared with primary screening CTC, likely related to anatomic challenges at endoscopy. Malrotation was frequently missed at other abdominal imaging examinations. CTC can uncover unexpected cases of malrotation in adults, which may be relevant in terms of potential for future complications.
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http://dx.doi.org/10.1007/s00261-021-02959-3DOI Listing
February 2021

Prevalence of Appendicoliths Detected at CT in Adults With Suspected Appendicitis.

AJR Am J Roentgenol 2021 03 21;216(3):677-682. Epub 2021 Jan 21.

All authors: Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792-3252.

With heightened interest in nonoperative antibiotic management of uncomplicated appendicitis, appendicoliths become a more relevant issue, and because of higher failure rates their presence may be considered a contraindication. The purpose of this study was to investigate the prevalence of appendicoliths at CT in adults with suspected appendicitis. Among adults undergoing MDCT for suspected appendicitis, 248 patients (134 women, 114 men; mean age, 35.2 years) consecutively registered over a 3-year period constituted a cohort with surgically proven appendicitis. A cohort of 248 patients (175 women, 73 men; mean age, 37.7 years) without appendicitis consecutively registered over a 1-year period served as control subjects. CT examinations were reviewed for the presence, size, and attenuation of appendicoliths and whether the appendicoliths were obstructing. In the cohort with appendicitis, degree of inflammation (3-point scale) and likelihood for perforation (5-point scale) were scored. The prevalence of appendicoliths at CT was 38.7% (96/248) among patients with appendicitis and 4.4% (11/248) among control subjects ( < .001). Among the 96 patients with appendicitis who had visible appendicoliths, mean width, length, and maximum attenuation of the dominant appendicolith were 6.0 mm, 8.2 mm, and 313 HU, respectively. In 70.8% (68/96) of patients appendicoliths were obstructing, and 32.3% (31/96) of patients had more than one appendicolith. Inflammation (1.75 vs 1.43) and likelihood of perforation (2.07 vs 1.51) ( < .05) scores were higher among patients with appendicitis who had appendicoliths. Extraluminal appendicoliths were seen in five cases of perforated appendicitis. Appendicoliths were identified at CT in nearly 40% of adults with proven appendicitis, compared with slightly more than 4% of those without appendicitis, and were associated with increased inflammation and risk of perforation.
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http://dx.doi.org/10.2214/AJR.20.23149DOI Listing
March 2021

Utility of Multiparametric CT for Identification of High-Risk NAFLD.

AJR Am J Roentgenol 2021 03 21;216(3):659-668. Epub 2021 Jan 21.

Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792.

The purpose of this study was to evaluate the utility of laboratory and CT metrics in identifying patients with high-risk nonalcoholic fatty liver disease (NAFLD). Patients with biopsy-proven NAFLD who underwent CT within 1 year of biopsy were included. Histopathologic review was performed by an experienced gastrointestinal pathologist to determine steatosis, inflammation, and fibrosis. The presence of any lobular inflammation and hepatocyte ballooning was categorized as nonalcoholic steatohepatitis (NASH). Patients with NAFLD and advanced fibrosis (stage F3 or higher) were categorized as having high-risk NAFLD. Aspartate transaminase to platelet ratio index and Fibrosis-4 (FIB-4) laboratory scores were calculated. CT metrics included hepatic attenuation, liver segmental volume ratio (LSVR), splenic volume, liver surface nodularity score, and selected texture features. In addition, two readers subjectively assessed the presence of NASH (present or not present) and fibrosis (stages F0-F4). A total of 186 patients with NAFLD (mean age, 49 years; 74 men and 112 women) were included. Of these, 87 (47%) had NASH and 112 (60%) had moderate to severe steatosis. A total of 51 patients were classified as fibrosis stage F0, 42 as F1, 23 as F2, 37 as F3, and 33 as F4. Additionally, 70 (38%) had advanced fibrosis (stage F3 or F4) and were considered to have high-risk NAFLD. FIB-4 score correlated with fibrosis (ROC AUC of 0.75 for identifying high-risk NAFLD). Of the individual CT parameters, LSVR and splenic volume performed best (AUC of 0.69 for both for detecting high-risk NAFLD). Subjective reader assessment performed best among all parameters (AUCs of 0.78 for reader 1 and 0.79 for reader 2 for detecting high-risk NAFLD). FIB-4 and subjective scores were complementary (combined AUC of 0.82 for detecting high-risk NAFLD). For NASH assessment, FIB-4 performed best (AUC of 0.68), whereas the AUCs were less than 0.60 for all individual CT features and subjective assessments. FIB-4 and multiple CT findings can identify patients with high-risk NAFLD (advanced fibrosis or cirrhosis). However, the presence of NASH is elusive on CT.
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http://dx.doi.org/10.2214/AJR.20.22842DOI Listing
March 2021

Automated assessment of longitudinal biomarker changes at abdominal CT: correlation with subsequent cardiovascular events in an asymptomatic adult screening cohort.

Abdom Radiol (NY) 2021 Jan 3. Epub 2021 Jan 3.

Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.

Background: Cardiovascular (CV) disease is a major public health concern, and automated methods can potentially capture relevant longitudinal changes on CT for opportunistic CV screening purposes.

Methods: Fully-automated and validated algorithms that quantify abdominal fat, muscle, bone, liver, and aortic calcium were retrospectively applied to a longitudinal adult screening cohort undergoing serial non-contrast CT examination between 2005 and 2016. Downstream major adverse events (MI/CVA/CHF/death) were identified via algorithmic EHR search. Logistic regression, ROC curve, and Cox survival analyses assessed for associations between changes in CT variables and adverse events.

Results: Final cohort included 1949 adults (942 M/1007F; mean age, 56.2 ± 6.2 years at initial CT). Mean interval between CT scans was 5.8 ± 2.0 years. Mean clinical follow-up interval from initial CT was 10.4 ± 2.7 years. Major CV events occurred after follow-up CT in 230 total subjects (11.8%). Mean change in aortic calcium Agatston score was significantly higher in CV(+) cohort (591.6 ± 1095.3 vs. 261.1 ± 764.3), as was annualized Agatston change (120.5 ± 263.6 vs. 46.7 ± 143.9) (p < 0.001 for both). 5-year area under the ROC curve (AUC) for Agatston change was 0.611. Hazard ratio for Agatston score change > 500 was 2.8 (95% CI 1.5-4.0) relative to < 500. Agatston score change was the only significant univariate CT biomarker in the survival analysis. Changes in fat and bone measures added no meaningful prediction.

Conclusion: Interval change in automated CT-based abdominal aortic calcium load represents a promising predictive longitudinal tool for assessing cardiovascular and mortality risks. Changes in other body composition measures were less predictive of adverse events.
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http://dx.doi.org/10.1007/s00261-020-02885-wDOI Listing
January 2021

CT imaging review of uncommon peritoneal-based neoplasms: beyond carcinomatosis.

Br J Radiol 2021 Mar 5;94(1119):20201288. Epub 2021 Jan 5.

Department of Abdominal Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA.

Pathologic involvement of the peritoneum can result from a wide variety of conditions, including both neoplastic and non-neoplastic entities. Neoplastic involvement of the peritoneal ligaments, mesenteries, and spaces from malignant spread of epithelial cancers, termed peritoneal carcinomatosis, is frequently encountered at CT evaluation. However, a host of other more unusual benign and malignant neoplasms can manifest with peritoneal disease, including both primary and secondary peritoneal processes, many of which can closely mimic peritoneal carcinomatosis at CT. In this review, we discuss a wide array of unusual peritoneal-based neoplasms that can resemble the more common peritoneal carcinomatosis. Beyond reviewing the salient features for each of these entities, particular emphasis is placed on any specific clinical and CT imaging clues that may allow the interpreting radiologist to appropriately narrow the differential diagnosis and, in some cases, make an imaging-specific diagnosis.
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http://dx.doi.org/10.1259/bjr.20201288DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8011261PMC
March 2021

Opportunistic Screening Using Low-Dose CT and the Prevalence of Osteoporosis in China: A Nationwide, Multicenter Study.

J Bone Miner Res 2021 Mar 4;36(3):427-435. Epub 2020 Nov 4.

Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.

Opportunistic screening for osteoporosis can be performed using low-dose computed tomography (LDCT) imaging obtained for other clinical indications. In this study we explored the CT-derived bone mineral density (BMD) and prevalence of osteoporosis from thoracic LDCT in a large population cohort of Chinese men and women. A total of 69,095 adults (40,733 men and 28,362 women) received a thoracic LDCT scan for the purpose of lung cancer screening between 2018 and 2019, and data were obtained for analysis from the China Biobank Project, a prospective nationwide multicenter population study. Lumbar spine (L -L ) trabecular volumetric bone mineral density (vBMD) was derived from these scans using quantitative computed tomography (QCT) software and the American College of Radiology QCT diagnostic criteria for osteoporosis were applied. Geographic regional differences in the prevalence of osteoporosis were assessed and the age-standardized, population prevalence of osteoporosis in Chinese men and women was estimated from the 2010 China census. The prevalence of osteoporosis by QCT for the Chinese population aged >50 years was 29.0% for women and 13.5% for men, equating to 49.0 million and 22.8 million, respectively. In women, this rate is comparable to estimates from dual-energy X-ray absorptiometry (DXA), but in men, the prevalence is double. Prevalence varied geographically across China, with higher rates in the southwest and lower rates in the northeast. Trabecular vBMD decreased with age in both men and women. Women had higher peak trabecular vBMD (185.4 mg/cm ) than men (176.6 mg/cm ) at age 30 to 34 years, but older women had lower trabecular vBMD (62.4 mg/cm ) than men (92.1 mg/cm ) at age 80 years. We show that LDCT-based opportunistic screening could identify large numbers of patients with low lumbar vBMD, and that future cohort studies are now required to evaluate the clinical utility of such screening in terms of fracture prevention and supporting national health economic analyses. © 2020 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR)..
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http://dx.doi.org/10.1002/jbmr.4187DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7988599PMC
March 2021

Erratum: The Value of Quantitative Musculoskeletal Imaging.

Semin Musculoskelet Radiol 2020 Aug 21;24(4):e1. Epub 2020 Oct 21.

Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.

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http://dx.doi.org/10.1055/s-0040-1719097DOI Listing
August 2020

Stump Appendicitis: Clinical and CT Findings.

AJR Am J Roentgenol 2020 12 6;215(6):1363-1369. Epub 2020 Oct 6.

Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792-3252.

Recurrent inflammation of the appendiceal stump after appendectomy is rare; published case series have included no more than six patients. The purpose of this study was to report the clinical and CT findings in a larger original series. A combined PACS and electronic medical record search identified the cases of 14 patients (nine men, five women; mean age, 42.8 years) with a confident diagnosis of stump appendicitis evaluated at CT. In seven cases, CT images obtained at the initial presentation of appendicitis were available for review. Relevant clinical and CT findings were reviewed by three abdominal radiologists in consensus. The mean time interval between initial appendectomy and stump appendicitis was 5.1 years (range, 5 weeks-17.5 years); seven cases occurred within 1 year of appendectomy. Ten (71%) of initial appendectomies were performed by a laparoscopic approach. CT showed the mean appendiceal stump length was 3.2 cm (range, 1.3-7.0 cm); residual stump length measured 2 cm or longer in all but one case. Appendicoliths were identified at the stump in seven (50%) cases; the mean diameter was 0.9 cm and mean maximal attenuation, 247 HU. Extensive inflammatory changes surrounded the appendiceal stump at CT in all cases, including peristump abscess in four (29%) cases. Seven of the 14 patients (50%) went on to open surgical management with either remnant appendectomy or partial ileocecectomy. Stump appendicitis has a characteristic CT appearance and may occur within the first year after appendectomy or many years later. A long (≥ 2 cm) appendiceal stump from laparoscopic appendectomy and retained appendicolith may predispose adult patients to recurrent obstruction and inflammation.
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http://dx.doi.org/10.2214/AJR.20.22911DOI Listing
December 2020

The Value of Quantitative Musculoskeletal Imaging.

Semin Musculoskelet Radiol 2020 Aug 29;24(4):460-474. Epub 2020 Sep 29.

Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.

Musculoskeletal imaging is mainly based on the subjective and qualitative analysis of imaging examinations. However, integration of quantitative assessment of imaging data could increase the value of imaging in both research and clinical practice. Some imaging modalities, such as perfusion magnetic resonance imaging (MRI), diffusion MRI, or T2 mapping, are intrinsically quantitative. But conventional morphological imaging can also be analyzed through the quantification of various parameters. The quantitative data retrieved from imaging examinations can serve as biomarkers and be used to support diagnosis, determine patient prognosis, or monitor therapy.We focus on the value, or clinical utility, of quantitative imaging in the musculoskeletal field. There is currently a trend to move from volume- to value-based payments. This review contains definitions and examines the role that quantitative imaging may play in the implementation of value-based health care. The influence of artificial intelligence on the value of quantitative musculoskeletal imaging is also discussed.
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http://dx.doi.org/10.1055/s-0040-1710356DOI Listing
August 2020

Atherosclerotic Plaque Burden on Abdominal CT: Automated Assessment With Deep Learning on Noncontrast and Contrast-enhanced Scans.

Acad Radiol 2020 Sep 18. Epub 2020 Sep 18.

Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

Background: Abdominal aortic atherosclerotic plaque burden may have clinical significance but manual measurement is time-consuming and impractical.

Purpose: To perform external validation on an automated atherosclerotic plaque detector for noncontrast and postcontrast abdominal CT.

Materials And Methods: The training data consisted of 114 noncontrast CT scans and 23 postcontrast CT urography scans. The testing data set consisted of 922 CT colonography (CTC) scans, and 1207 paired noncontrast and postcontrast CT scans from renal donors from a second institution. Reference standard data included manual plaque segmentations in the 137 training scans and manual plaque burden measurements in the 922 CTC scans. The total Agatston score and group (0-3) was determined using fully-automated deep learning software. Performance was assessed by measures of agreement, linear regression, and paired evaluations.

Results: On CTC scans, automated Agatston scoring correlated highly with manual assessment (R = 0.94). On paired renal donor CT scans, automated Agatston scoring on postcontrast CT correlated highly with noncontrast CT (R = 0.95). When plaque burden was expressed as a group score, there was excellent agreement for both the CTC (weighted kappa 0.80 ± 0.01 [95% confidence interval: 0.78-0.83]) and renal donor (0.83 ± 0.02 [0.79-0.86]) assessments.

Conclusion: Fully automated detection, segmentation, and scoring of abdominal aortic atherosclerotic plaques on both pre- and post-contrast CT was validated and may have application for population-based studies.
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http://dx.doi.org/10.1016/j.acra.2020.08.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7969468PMC
September 2020

Fully automated CT imaging biomarkers of bone, muscle, and fat: correcting for the effect of intravenous contrast.

Abdom Radiol (NY) 2021 03 18;46(3):1229-1235. Epub 2020 Sep 18.

Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA.

Purpose: Fully automated CT-based algorithms for quantifying bone, muscle, and fat have been validated for unenhanced abdominal scans. The purpose of this study was to determine and correct for the effect of intravenous (IV) contrast on these automated body composition measures.

Materials And Methods: Initial study cohort consisted of 1211 healthy adults (mean age, 45.2 years; 733 women) undergoing abdominal CT for potential renal donation. Multiphasic CT protocol consisted of pre-contrast, arterial, and parenchymal phases. Fully automated CT-based algorithms for quantifying bone mineral density (BMD, L1 trabecular HU), muscle area and density (L3-level MA and M-HU), and fat (visceral/subcutaneous (V/S) fat ratio) were applied to pre-contrast and parenchymal phases. Effect of IV contrast upon these body composition measures was analyzed. Square of the Pearson correlation coefficient (r) was generated for each comparison.

Results: Mean changes (± SD) in L1 BMD, L3-level MA and M-HU, and V/S fat ratio were 26.7 ± 27.2 HU, 2.9 ± 10.2 cm, 18.8 ± 6.0 HU, - 0.1 ± 0.2, respectively. Good linear correlation between pre- and post-contrast values was observed for all automated measures: BMD (pre = 0.87 × post; r = 0.72), MA (pre = 0.98 × post; r = 0.92), M-HU (pre = 0.75 × post  + 5.7; r = 0.75), and V/S (pre = 1.11 × post; r = 0.94); p < 0.001 for all r values. There were no significant trends according to patient age or gender that required further correction.

Conclusion: Fully automated quantitative tissue measures of bone, muscle, and fat at contrast-enhanced abdominal CT can be correlated with non-contrast equivalents using simple, linear relationships. These findings will facilitate evaluation of mixed CT cohorts involving larger patient populations and could greatly expand the potential for opportunistic screening.
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http://dx.doi.org/10.1007/s00261-020-02755-5DOI Listing
March 2021

Liver Steatosis Categorization on Contrast-Enhanced CT Using a Fully-Automated Deep Learning Volumetric Segmentation Tool: Evaluation in 1,204 Heathy Adults Using Unenhanced CT as Reference Standard.

AJR Am J Roentgenol 2020 Sep 16. Epub 2020 Sep 16.

Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD.

Hepatic attenuation at unenhanced CT is linearly correlated with MR proton density fat fraction (PDFF). Liver fat quantification at contrast-enhanced CT is more challenging. To evaluate liver steatosis categorization on contrast-enhanced CT using a fully-automated deep learning volumetric hepatosplenic segmentation algorithm and unenhanced CT as the reference standard. A fully-automated volumetric hepatosplenic segmentation algorithm using 3D convolutional neural networks was applied to unenhanced and contrast-enhanced series from a sample of 1204 healthy adults (mean age, 45.2 years; 726 women, 478 men) undergoing CT evaluation for renal donation. The mean volumetric attenuation was computed from all designated liver and spleen voxels. PDFF was estimated from unenhanced CT attenuation and served as the reference standard. Contrast-enhanced attenuations were evaluated for detecting PDFF thresholds of 5% (mild steatosis), 10%, and 15% (moderate); PDFF<5% was considered normal. Using unenhanced CT as reference, estimated PDFF was ≥5% (mild steatosis), ≥10%, and ≥15% (moderate) in 50.1% (n=603), 12.5% (n=151) and 4.8% (n=58) of patients, respectively. ROC-AUC values for predicting PDFF thresholds of 5%, 10%, and 15% using contrast-enhanced liver attenuation were 0.669, 0.854, and 0.962, respectively, and using contrast-enhanced liver-spleen attenuation difference were 0.662, 0.866, and 0.986, respectively. A total of 96.8% (90/93) of patients with contrast-enhanced liver attenuation <90 HU had steatosis (PDFF≥5%); this <90 HU threshold achieved sensitivity 75.9% and specificity 95.7% for moderate steatosis (PDFF≥15%). Liver attenuation <100 HU achieved sensitivity 34.0% and specificity 94.2% for any steatosis (PDFF≥5%). A total of 93.8% (30/32) of patients with contrast-enhanced liver-spleen attenuation difference <-10 HU had moderate steatosis (PDFF≥15%); a liver-spleen difference <5 HU achieved sensitivity 91.4% and specificity 95.0% for moderate steatosis. Liver-spleen difference <10 HU achieved sensitivity 29.5% and specificity 95.5% for any steatosis (PDFF≥5%). Contrast-enhanced volumetric hepatosplenic attenuation derived using a fully-automated deep-learning CT tool may allow objective categorical assessment of hepatic steatosis. Accuracy was better for moderate than mild steatosis. Further confirmation using different scanning protocols and vendors is warranted. If these results are confirmed in independent patient samples, this automated approach could prove useful for both individualized and population-based steatosis assessment.
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http://dx.doi.org/10.2214/AJR.20.24415DOI Listing
September 2020

Automated CT biomarkers for opportunistic prediction of future cardiovascular events and mortality in an asymptomatic screening population: a retrospective cohort study.

Lancet Digit Health 2020 04 2;2(4):e192-e200. Epub 2020 Mar 2.

Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD.

Background: Body CT scans are frequently performed for a wide variety of clinical indications, but potentially valuable biometric information typically goes unused. We investigated the prognostic ability of automated CT-based body composition biomarkers derived from previously-developed deep-learning and feature-based algorithms for predicting major cardiovascular events and overall survival in an adult screening cohort, compared with clinical parameters.

Methods: Mature and fully-automated CT-based algorithms with pre-defined metrics for quantifying aortic calcification, muscle density, visceral/subcutaneous fat, liver fat, and bone mineral density (BMD) were applied to a generally-healthy asymptomatic outpatient cohort of 9223 adults (mean age, 57.1 years; 5152 women) undergoing abdominal CT for routine colorectal cancer screening. Longitudinal clinical follow-up (median, 8.8 years; IQR, 5.1-11.6 years) documented subsequent major cardiovascular events or death in 19.7% (n=1831). Predictive ability of CT-based biomarkers was compared against the Framingham Risk Score (FRS) and body mass index (BMI).

Findings: Significant differences were observed for all five automated CT-based body composition measures according to adverse events (p<0.001). Univariate 5-year AUROC (with 95% CI) for automated CT-based aortic calcification, muscle density, visceral/subcutaneous fat ratio, liver density, and vertebral density for predicting death were 0.743(0.705-0.780)/0.721(0.683-0.759)/0.661(0.625-0.697)/0.619 (0.582-0.656)/0.646(0.603-0.688), respectively, compared with 0.499(0.454-0.544) for BMI and 0.688(0.650-0.727) for FRS (p<0.05 for aortic calcification vs. FRS and BMI); all trends were similar for 2-year and 10-year ROC analyses. Univariate hazard ratios (with 95% CIs) for highest-risk quartile versus others for these same CT measures were 4.53(3.82-5.37) /3.58(3.02-4.23)/2.28(1.92-2.71)/1.82(1.52-2.17)/2.73(2.31-3.23), compared with 1.36(1.13-1.64) and 2.82(2.36-3.37) for BMI and FRS, respectively. Similar significant trends were observed for cardiovascular events. Multivariate combinations of CT biomarkers further improved prediction over clinical parameters (p<0.05 for AUROCs). For example, by combining aortic calcification, muscle density, and liver density, the 2-year AUROC for predicting overall survival was 0.811 (0.761-0.860).

Interpretation: Fully-automated quantitative tissue biomarkers derived from CT scans can outperform established clinical parameters for pre-symptomatic risk stratification for future serious adverse events, and add opportunistic value to CT scans performed for other indications.
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http://dx.doi.org/10.1016/S2589-7500(20)30025-XDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7454161PMC
April 2020

Automated Abdominal CT Imaging Biomarkers for Opportunistic Prediction of Future Major Osteoporotic Fractures in Asymptomatic Adults.

Radiology 2020 10 11;297(1):64-72. Epub 2020 Aug 11.

From the Department of Radiology, University of Wisconsin School of Medicine & Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792-3252 (P.J.P., P.M.G., R.Z., S.J.L.); and Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Md (J.L., V.S., R.M.S.).

Background Body composition data from abdominal CT scans have the potential to opportunistically identify those at risk for future fracture. Purpose To apply automated bone, muscle, and fat tools to noncontrast CT to assess performance for predicting major osteoporotic fractures and to compare with the Fracture Risk Assessment Tool (FRAX) reference standard. Materials and Methods Fully automated bone attenuation (L1-level attenuation), muscle attenuation (L3-level attenuation), and fat (L1-level visceral-to-subcutaneous [V/S] ratio) measures were derived from noncontrast low-dose abdominal CT scans in a generally healthy asymptomatic adult outpatient cohort from 2004 to 2016. The FRAX score was calculated from data derived from an algorithmic electronic health record search. The cohort was assessed for subsequent future fragility fractures. Subset analysis was performed for patients evaluated with dual x-ray absorptiometry ( = 2106). Hazard ratios (HRs) and receiver operating characteristic curve analyses were performed. Results A total of 9223 adults were evaluated (mean age, 57 years ± 8 [standard deviation]; 5152 women) at CT and were followed over a median time of 8.8 years (interquartile range, 5.1-11.6 years), with documented subsequent major osteoporotic fractures in 7.4% ( = 686), including hip fractures in 2.4% ( = 219). Comparing the highest-risk quartile with the other three quartiles, HRs for bone attenuation, muscle attenuation, V/S fat ratio, and FRAX were 2.1, 1.9, 0.98, and 2.5 for any fragility fracture and 2.0, 2.5, 1.1, and 2.5 for femoral fractures, respectively ( < .001 for all except V/S ratio, which was ≥ .51). Area under the receiver operating characteristic curve (AUC) values for fragility fracture were 0.71, 0.65, 0.51, and 0.72 at 2 years and 0.63, 0.62, 0.52, and 0.65 at 10 years, respectively. For hip fractures, 2-year AUC for muscle attenuation alone was 0.75 compared with 0.73 for FRAX ( = .43). Multivariable 2-year AUC combining bone and muscle attenuation was 0.73 for any fragility fracture and 0.76 for hip fractures, respectively ( ≥ .73 compared with FRAX). For the subset with dual x-ray absorptiometry T-scores, 2-year AUC was 0.74 for bone attenuation and 0.65 for FRAX ( = .11). Conclusion Automated bone and muscle imaging biomarkers derived from CT scans provided comparable performance to Fracture Risk Assessment Tool score for presymptomatic prediction of future osteoporotic fractures. Muscle attenuation alone provided effective hip fracture prediction. © RSNA, 2020 See also the editorial by Smith in this issue.
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http://dx.doi.org/10.1148/radiol.2020200466DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7526945PMC
October 2020

Diagnostic Performance of Multitarget Stool DNA and CT Colonography for Noninvasive Colorectal Cancer Screening.

Radiology 2020 10 11;297(1):120-129. Epub 2020 Aug 11.

From the Department of Radiology (P.J.P., P.M.G., B.W.) and the Department of Medicine (N.D.Y., J.M.W.), University of Wisconsin School of Medicine & Public Health, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792-3252; and Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy (C.H.).

BackgroundMultitarget stool DNA (mt-sDNA) screening has increased rapidly since simultaneous approval by the U.S. Food and Drug Administration and Centers for Medicare and Medicaid Services in 2014, whereas CT colonography screening remains underused and is not covered by Centers for Medicare and Medicaid Services.PurposeTo report postapproval clinical experience with mt-sDNA screening for colorectal cancer (CRC) and compare results with CT colonography screening at the same center.Materials and MethodsIn this retrospective cohort study, asymptomatic adults underwent clinical mt-sDNA screening during a 5-year interval (2014-2019). Electronic medical records were searched to verify test results and document subsequent optical colonoscopy and histopathologic findings. A similar analysis was performed for CT colonography screening during a 15-year interval (2004-2019), with consideration of thresholds for positivity of both 6-mm and 10-mm polyp sizes. χ or two-sample tests were used for group comparisons.ResultsA total of 3987 asymptomatic adult patients (mean age, 64 years ± 9 [standard deviation]; 2567 women) underwent mt-sDNA screening and 9656 patients (mean age, 57 years ± 8; 5200 women) underwent CT colonography. Test-positive rates for mt-sDNA and for 6-mm- and 10-mm-threshold CT colonography were 15.2%, 16.4%, and 6.7%, respectively. Optical colonoscopy follow-up rates for positive results of mt-sDNA and 6-mm- and 10-mm-threshold CT colonography were 13.1%, 12.3%, and 5.9%, respectively. Positive predictive values (PPVs) for any neoplasm 6 mm or greater, advanced neoplasia, and CRC for mt-sDNA were 54.2%, 22.7%, and 1.9% respectively; for 6-mm-threshold CT colonography, PPVs were 76.8%, 44.3%, and 2.7%; for 10-mm-threshold CT colonography, PPVs were 84.5%, 75.2%, and 5.2%, respectively ( < .001 for mt-sDNA vs CT colonography for all except 6-mm CRC at CT colonography). For mt-sDNA versus 6-mm-threshold CT colonography, overall detection rates for advanced neoplasia were 2.7% and 5.0%, respectively ( < .001); corresponding detection rates for CRC were 0.23% and 0.31%, respectively ( = .43).ConclusionThe detection rates of advanced neoplasia at CT colonography screening were greater than those of multitarget stool DNA. Detection rates were similar for colorectal cancer.© RSNA, 2020See also the editorial by Yee in this issue.
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http://dx.doi.org/10.1148/radiol.2020201018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7945994PMC
October 2020

Multiple Endocrine Neoplasia: Spectrum of Abdominal Manifestations.

AJR Am J Roentgenol 2020 10 13;215(4):885-895. Epub 2020 Jul 13.

Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Houston, TX 77030.

Multiple endocrine neoplasia (MEN) syndromes are autosomal-dominant genetic disorders that predispose two or more organs of the endocrine system to tumor development. Although the diagnosis relies on clinical and serologic findings, imaging provides critical information for surgical management with the ultimate goal of complete tumor resection. This article reviews abdominal neoplasms associated with the various subtypes of MEN syndromes, with a focus on clinical presentation and characteristic imaging features.
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http://dx.doi.org/10.2214/AJR.19.22542DOI Listing
October 2020

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

Abdom Radiol (NY) 2021 02 3;46(2):486-490. Epub 2020 Aug 3.

Department of Radiology, Boston University School of Medicine, Boston, MA, USA.

Purpose: To describe the favorable procedural profile of CT colonography (CTC) during the COVID-19 pandemic.

Conclusion: Postponement of cancer screening due to COVID-19 has resulted in a backlog of individuals needing to undergo structural examination of the colon. The experience during the initial COVID-19 surge with urgent evaluation of the colon for transplant patients prior to transplant suggests that CTC can be done in a lower risk manner as compared to other structural examinations. The procedural profile of CTC is advantageous during this pandemic as maintaining social distancing and preserving healthcare supplies including PPE are of paramount importance. CTC is an important option to utilize in the screening armamentarium to allow effective screening of average risk asymptomatic individuals in the COVID-19 era.
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http://dx.doi.org/10.1007/s00261-020-02674-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7398602PMC
February 2021

CT colonography followed by elective surgery in patients with acute diverticulitis: a radiological-pathological correlation study.

Abdom Radiol (NY) 2021 02 3;46(2):491-497. Epub 2020 Aug 3.

Unità di Radiologia, IRCCS Policlinico San Donato, San Donato Milanese, Italy.

Purpose: To perform a radiologic-pathologic correlation analysis of sigmoid colon in patients undergoing pre-operative CT Colonography (CTC) after an episode of acute diverticulitis (AD).

Methods: Fifty-nine consecutive patients (31/28 M/F; 58 ± 13 years) underwent CTC 55 ± 18 days after AD, 8 ± 4 weeks before surgery. Thirty-seven patients (63%) underwent conventional abdominal CT at time of AD. An experienced blinded radiologist retrospectively analyzed all images: disease severity was graded according to the Ambrosetti classification on conventional CT and according to the diverticular disease severity score (DDSS) on CTC. A GI pathologist performed a dedicated analysis, evaluating the presence of acute and chronic inflammation, and fibrosis, using 0-3 point scale for each variable.

Results: Of 59 patients, 41 (69%) had at least one previous AD episode; twenty-six patients (44%) had a complicated AD. DDSS was mild-moderate in 34/59 (58%), and severe in 25/59 (42%). All patients had chronic inflammation, while 90% had low-to-severe fibrosis. Patients with moderate/severe fibrosis were older than those with no/mild fibrosis (61 ± 13 versus 54 ± 13). We found a significant correlation between DDSS and chronic inflammation (p = 0.004), as well as DDSS and fibrosis (p = 0.005). Furthermore, fibrosis was correlated with complicated acute diverticulitis (p = 0.0.27), and with age (p = 0.067). At multivariate analysis, complicated diverticulitis was the best predictor of fibrosis (odds ratio 4.4). Patient age and DDSS were other independent predictors.

Conclusion: DDSS-based assessment on preoperative CTC was a good predictor of chronic colonic inflammation and fibrosis. In addition, the presence of complicated diverticulitis on CT during the acute episode was most predictive of fibrosis.
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http://dx.doi.org/10.1007/s00261-020-02690-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7897191PMC
February 2021

MR image-based radiomics to differentiate type Ι and type ΙΙ epithelial ovarian cancers.

Eur Radiol 2021 Jan 2;31(1):403-410. Epub 2020 Aug 2.

Department of Radiology, Jinshan Hospital, Fudan University, 1508 Longhang Road, Jinshan District, Shanghai, 201508, China.

Objectives: Epithelial ovarian cancers (EOC) can be divided into type I and type II according to etiology and prognosis. Accurate subtype differentiation can substantially impact patient management. In this study, we aimed to construct an MR image-based radiomics model to differentiate between type I and type II EOC.

Methods: In this multicenter retrospective study, a total of 294 EOC patients from January 2010 to February 2019 were enrolled. Quantitative MR imaging features were extracted from the following axial sequences: T2WI FS, DWI, ADC, and CE-T1WI. A combined model was constructed based on the combination of these four MR sequences. The diagnostic performance was evaluated by ROC-AUC. In addition, an occlusion test was carried out to identify the most critical region for EOC differentiation.

Results: The combined radiomics model exhibited superior diagnostic capability over all four single-parametric radiomics models, both in internal and external validation cohorts (AUC of 0.806 and 0.847, respectively). The occlusion test revealed that the most critical region for differential diagnosis was the border zone between the solid and cystic components, or the less compact areas of solid component on direct visual inspection.

Conclusions: MR image-based radiomics modeling can differentiate between type I and type II EOC and identify the most critical region for differential diagnosis.

Key Points: • Combined radiomics models exhibited superior diagnostic capability over all four single-parametric radiomics models, both in internal and external validation cohorts (AUC of 0.834 and 0.847, respectively). • The occlusion test revealed that the most crucial region for differentiating type Ι and type ΙΙ EOC was the border zone between the solid and cystic components, or the less compact areas of solid component on direct visual inspection on T2WI FS. • The light-combined model (constructed by T2WI FS, DWI, and ADC sequences) can be used for patients who are not suitable for contrast agent use.
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http://dx.doi.org/10.1007/s00330-020-07091-2DOI Listing
January 2021

Hormonal Evaluation of Incidental Adrenal Masses: The Exception, Not the Rule.

World J Surg 2020 Nov;44(11):3778-3785

Division of Surgical Oncology, Department of Surgery, Ohio State University Comprehensive Cancer Center and Ohio State University Wexner Medical Center, N924 Doan Hall, 410 W. 10th Avenue, Columbus, OH, 43210, USA.

Background: Incidental adrenal masses (IAMs) occur in approximately 4% of patients undergoing abdominal CT scans for any indication. Hormonal evaluation is recommended for all IAMs. The purpose of this study was to identify the rate of IAMs in a screening population and to determine the adequacy of endocrine evaluation of newly identified IAMs based on established guidelines.

Methods: This was a retrospective analysis of 6913 patients undergoing a non-contrast screening CT colonography at a single academic medical center between June 2004 and July 2012.

Results: The prevalence of IAMs in this asymptomatic screening population was 2.1% (n = 148). Of those patients, 8.8% (n = 11) underwent some form of hormonal evaluation and only 6.4% (n = 8) patients had a "complete" workup. Cortisol, metanephrines, and an aldosterone-renin ratio were evaluated in 8.0%, 7.2%, and 4.0% of patients, respectively. Of the patients (n = 11) who underwent hormonal evaluation, 27.3% had functional masses and 36.4% underwent surgery. Of those who did not have hormonal evaluation, 42.1% (n = 48) had comorbidities that should have prompted hormonal evaluation based on established guidelines. Hormonal evaluation was not performed in 89.4% of patients with hypertension and 21.1% of patients with diabetes. 88.9% of patients on three or more antihypertensive medications did not undergo any hormonal evaluation.

Conclusions: Compliance with IAM workup guidelines is poor, which may result in missed diagnosis of functional adrenal masses. Establishment of a robust protocol and education on appropriate workup for IAMs is necessary for adequate hormonal evaluation.
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http://dx.doi.org/10.1007/s00268-020-05679-9DOI Listing
November 2020

Update: Venous Thrombosis and Hypercoagulability in the Abdomen and Pelvis-Findings in COVID-19.

Radiographics 2020 Sep-Oct;40(5):E24-E28. Epub 2020 Jul 10.

From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Sciences Center, 600 Highland Ave, Madison, WI 53792 (M.C.O., M.G.L., L.M.G., D.H.K., P.J.P.); Department of Radiology, Mayo Clinic Scottsdale, Scottsdale, Ariz (C.O.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (V.M.M.); and Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (K.M.E.).

Articles in the Update section provide current knowledge to supplement or update information found in full-length articles previously published in . Authors of the previously published article provide a brief synopsis that emphasizes important new information such as technological advances, revised imaging protocols, new clinical guidelines involving imaging, or updated classification schemes. Articles in this section are published solely online and are linked to the original article.
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http://dx.doi.org/10.1148/rg.2020200119DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7534456PMC
September 2020

Utilizing Fully Automated Abdominal CT-Based Biomarkers for Opportunistic Screening for Metabolic Syndrome in Adults Without Symptoms.

AJR Am J Roentgenol 2021 01 10;216(1):85-92. Epub 2020 Nov 10.

Imaging Biomarkers and Computer-Aided Diagnosis Laboratory, Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD.

Objective: Metabolic syndrome describes a constellation of reversible cardiometabolic abnormalities associated with cardiovascular risk and diabetes. The present study investigates the use of fully automated abdominal CT-based biometric measures for opportunistic identification of metabolic syndrome in adults without symptoms.

Materials And Methods: International Diabetes Federation criteria were applied to a cohort of 9223 adults without symptoms who underwent unenhanced abdominal CT. After patients with insufficient clinical data for diagnosis were excluded, the final cohort consisted of 7785 adults (mean age, 57.0 years; 4361 women and 3424 men). Previously validated and fully automated CT-based algorithms for quantifying muscle, visceral and subcutaneous fat, liver fat, and abdominal aortic calcification were applied to this final cohort.

Results: A total of 738 subjects (9.5% of all subjects; mean age, 56.7 years; 372 women and 366 men) met the clinical criteria for metabolic syndrome. Subsequent major cardiovascular events occurred more frequently in the cohort with metabolic syndrome ( < 0.001). Significant differences were observed between the two groups for all CT-based biomarkers ( < 0.001). Univariate L1-level total abdominal fat (area under the ROC curve [AUROC] = 0.909; odds ratio [OR] = 27.2), L3-level skeletal muscle index (AUROC = 0.776; OR = 5.8), and volumetric liver attenuation (AUROC = 0.738; OR = 5.1) performed well when compared with abdominal aortic calcification scoring (AUROC = 0.578; OR = 1.6). An L1-level total abdominal fat threshold of 460.6 cm was 80.1% sensitive and 85.4% specific for metabolic syndrome. For women, the AUROC was 0.930 when fat and muscle measures were combined.

Conclusion: Fully automated quantitative tissue measures of fat, muscle, and liver derived from abdominal CT scans can help identify individuals who are at risk for metabolic syndrome. These visceral measures can be opportunistically applied to CT scans obtained for other clinical indications, and they may ultimately provide a more direct and useful definition of metabolic syndrome.
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http://dx.doi.org/10.2214/AJR.20.23049DOI Listing
January 2021