Use of enhanced T2 star-weighted angiography (ESWAN) and R2* values to distinguish ovarian cysts due to endometriosis from other causes

Radiomics analysis of R2* maps to predict early recurrence of single hepatocellular carcinoma after hepatectomy

Objectives

This study aimed to evaluate the effectiveness of radiomics analysis with R2* maps in predicting early recurrence (ER) in single hepatocellular carcinoma (HCC) following partial hepatectomy.

Methods

We conducted a retrospective analysis involving 202 patients with surgically confirmed single HCC having undergone preoperative magnetic resonance imaging between 2018 and 2021 at two different institutions. 126 patients from Institution 1 were assigned to the training set, and 76 patients from Institution 2 were assigned to the validation set. A least absolute shrinkage and selection operator (LASSO) regularization was conducted to operate a logistic regression, then features were identified to construct a radiomic score (Rad-score). Uni- and multi-variable tests were used to assess the correlations of clinicopathological features and Rad-score with ER. We then established a combined model encompassing the optimal Rad-score and clinical-pathological risk factors. Additionally, we formulated and validated a predictive nomogram for predicting ER in HCC. The nomogram's discrimination, calibration, and clinical utility were thoroughly evaluated.

Results

Multivariable logistic regression revealed the Rad-score, microvascular invasion (MVI), and α fetoprotein (AFP) level > 400 ng/mL as significant independent predictors of ER in HCC. We constructed a nomogram based on these significant factors. The areas under the receiver operator characteristic curve of the nomogram and precision-recall curve were 0.901 and 0.753, respectively, with an F1 score of 0.831 in the training set. These values in the validation set were 0.827, 0.659, and 0.808.

Conclusion

The nomogram that integrates the radiomic score, MVI, and AFP demonstrates high predictive efficacy for estimating the risk of ER in HCC. It facilitates personalized risk classification and therapeutic decision-making for HCC patients.

Diagnosis of pelvic endometriosis: a preliminary study on the added value of R2*MFGRE sequence in magnetic resonance imaging

BACKGROUND

Identifying and locating endometriotic lesions is crucial for preoperative planning, so new magnetic resonance imaging (MRI) techniques are urgently needed to improve the diagnostic sensitivity for pelvic endometriosis.

PURPOSE

To evaluate the feasibility of R2* multiple fast gradient recalled echo (MFGRE) imaging in the diagnosis of pelvic endometriosis.

MATERIAL AND METHODS

A total of 46 patients with suspected endometriosis underwent routine pelvic MRI and R2*MFGRE imaging. Clinical diagnosis was pathologically confirmed one month after MRI examination. Three radiologists who were blinded to the pathological results evaluated the number of ovarian endometriomas (OMAs) and deep infiltrating endometriosis (DIE) lesions using routine MRI and its combination with R2*MFGRE. The diagnostic sensitivity for OMA or DIE using the two examination methods was determined. Two-correlation sample rank-sum tests were used to compare both methods. Additionally, for all lesions, the R2* values were measured and statistically analyzed.

RESULTS

Among 46 patients, 47 OMAs and 30 DIE lesions were found surgically and pathologically confirmed. The diagnostic sensitivity of the routine MRI was 87.2% for OMA and 46.7% for DIE. The diagnostic sensitivity of the routine imaging combined with R2*MFGRE was 100% for OMA and 90% for DIE. The two-correlation sample rank-sum test showed a significant difference between both methods (P<0.01, z = -4.26). The median R2* value was 25.20 (IQR=14) for the OMA group, and 45.21 (IQR=40) for the DIE group. The difference between both groups was statistically significant (P<0.01, z = -4.89).

CONCLUSION

R2*MFGRE imaging, as a supplement to the routine MRI, could improve the diagnostic sensitivity for pelvic endometriosis, especially for DIE.

Identification of ovarian endometriotic cysts in cystic lesions of the ovary by amide proton transfer-weighted imaging and R2∗ mapping

AIM

To investigate the value of amide proton transfer weighted (APTw) imaging and R2∗ mapping of cystic fluid in differentiating ovarian endometriotic cysts (OE) from other ovarian cystic (OOC) lesions.

MATERIALS AND METHODS

A total of 42 patients who underwent 3 T pelvic magnetic resonance imaging (MRI) were enrolled. Nineteen lesions were OE and 27 lesions were OOC. The APTw imaging and R2∗ values of the cystic fluid were measured and compared between the two groups using the independent sample t-test or Mann-Whitney U-test. Receiver operating characteristic (ROC) curves were used to evaluate the diagnostic efficacy of different parameters. The area under ROC curves (AUCs) was compared using the Delong test. Spearman's correlation analysis was used to assess the correlation between APTw imaging and R2∗ values.

RESULTS

APTw imaging values of OE were lower, while R2∗ values were higher in OE than those in OOC (p=0.001 and < 0.001). The AUCs of APTw imaging and R2∗ values to identify OE from OOC were 0.910 and 0.975. The AUC increased to 0.990 when combining APTw imaging and R2∗ values, yet without a significant difference to the APTw imaging or R2∗ value alone (p=0.229 and 0.082, respectively). APTw imaging values were negatively correlated with R2∗ values (r=-0.522, p<0.001).

CONCLUSION

Both APTw imaging and R2∗ values of OE are significantly different from other ovarian cystic lesions. APTw imaging combined with R2∗ values show excellent diagnostic efficacy to differentiate between OE and OOC.

The enhanced T2 star weighted angiography (ESWAN) value for differentiating borderline from malignant epithelial ovarian tumors

PURPOSE

To investigate the potential of ESWAN in differentiating borderline epithelial ovarian tumors (BEOTs) from malignant epithelial ovarian tumors (MEOTs).

METHOD

Thirty-four patients with 37 lesions were enrolled, including 14 BEOTs and 23 MEOTs. The magnitude, phase, R₂* and T₂* maps were analyzed by two observers. The regions of interest were drawn along the boundaries of tumors on the slice with maximal solid area, according to fat suppression T₂WI and T₁WI. The consistency among the three measurements taken by two observers was tested by intra-class correlation coefficients. Agreement of average values measured by two observers was evaluated by Bland-Altman plots. All the data of BEOTs and MEOTs were compared using the independent-sample t test. The receiver operating characteristic curve was used to evaluate the diagnostic performance.

RESULTS

No statistical differences were observed in the magnitude and phase values between two tumor groups. The R₂* value of BEOTs was lower than that of MEOTs (P < 0.001), whereas the T₂* value of BEOTs was higher than that of MEOTs (P = 0.01). The area under the curve of R₂* values was 0.894 and the corresponding cutoff value was 7.50 Hz, with the sensitivity, specificity and accuracy of 85.7%, 82.6% and 86.5%, respectively. The AUC of T₂* values was 0.776 and the corresponding cutoff value was 143.73 ms with the sensitivity, specificity and accuracy of 71.4%, 82.6% and 78.4%, respectively.

CONCLUSIONS

R₂* and T₂* values can be used for quantificationally differentiating BEOTs from MEOTs and the R₂* has better diagnostic performance.

The Blood Oxygenation T2* Values of Resectable Esophageal Squamous Cell Carcinomas as Measured by 3T Magnetic Resonance Imaging: Association with Tumor Stage

Objective

To explore the association between the blood oxygenation T₂^* values of resectable esophageal squamous cell carcinomas (ESCCs) and tumor stages.

Materials and Methods

This study included 48 ESCC patients and 20 healthy participants who had undergone esophageal T₂^*-weighted imaging to obtain T₂^* values of the tumors and normal esophagi. ESCC patients underwent surgical resections less than one week after imaging. Statistical analyses were performed to identify the association between T₂^* values of ESCCs and tumor stages.

Results

One-way ANOVA and Student-Newman-Keuls tests revealed that the T₂^* value could differentiate stage T1 ESCCs (17.7 ± 3.3 ms) from stage T2 and T3 tumors (24.6 ± 2.7 ms and 27.8 ± 5.6 ms, respectively; all p_s < 0.001). Receiver operating curve (ROC) analysis showed the suitable cutoff T₂^* value of 21.3 ms for either differentiation. The former statistical tests demonstrated that the T₂^* value could not differentiate between stages T2 and T3 (24.6 ± 2.7 ms vs. 27.8 ± 5.6 ms, respectively, p > 0.05) or between N stages (N1 vs. N2 vs. N3: 24.7 ± 6.9 ms vs. 25.4 ± 4.5 ms vs. 26.8 ± 3.9 ms, respectively; all p_s > 0.05). The former tests illustrated that the T₂^* value could differentiate anatomic stages I and II (18.8 ± 4.8 ms and 26.9 ± 5.9 ms, respectively) or stages I and III (27.3 ± 3.6 ms). ROC analysis depicted the same cutoff T₂^* value of 21.3 ms for either differentiation. In addition, the Student's t test revealed that the T₂^* value could determine grouped T stages (T0 vs. T1–3: 17.0 ± 2.9 ms vs. 25.2 ± 6.2 ms; T0–1 vs. T2–3: 17.3 ± 3.0 ms vs. 27.1 ± 5.3 ms; and T0–2 vs. T3: 18.8 ± 4.2 ms vs. 27.8 ± 5.6 ms, all p_s < 0.001). ROC analysis indicated that the T₂^* value could detect ESCCs (cutoff, 20 ms), and discriminate between stages T0–1 and T2–3 (cutoff, 21.3 ms) and between T0–2 and T3 (cutoff, 20.4 ms).

Conclusion

The T₂^* value can be an additional quantitative indicator for detecting ESCC except for stage T1 cancer, and can preoperatively discriminate between some T stages and between anatomic stages of this tumor.

Imaging modalities for the non-invasive diagnosis of endometriosis

BACKGROUND

About 10% of women of reproductive age suffer from endometriosis. Endometriosis is a costly chronic disease that causes pelvic pain and subfertility. Laparoscopy, the gold standard diagnostic test for endometriosis, is expensive and carries surgical risks. Currently, no non-invasive tests that can be used to accurately diagnose endometriosis are available in clinical practice. This is the first review of diagnostic test accuracy of imaging tests for endometriosis that uses Cochrane methods to provide an update on the rapidly expanding literature in this field.

OBJECTIVES

• To provide estimates of the diagnostic accuracy of imaging modalities for the diagnosis of pelvic endometriosis, ovarian endometriosis and deeply infiltrating endometriosis (DIE) versus surgical diagnosis as a reference standard.• To describe performance of imaging tests for mapping of deep endometriotic lesions in the pelvis at specific anatomical sites.Imaging tests were evaluated as replacement tests for diagnostic surgery and as triage tests that would assist decision making regarding diagnostic surgery for endometriosis.

SEARCH METHODS

We searched the following databases to 20 April 2015: MEDLINE, CENTRAL, EMBASE, CINAHL, PsycINFO, Web of Science, LILACS, OAIster, TRIP, ClinicalTrials.gov, MEDION, DARE, and PubMed. Searches were not restricted to a particular study design or language nor to specific publication dates. The search strategy incorporated words in the title, abstracts, text words across the record and medical subject headings (MeSH).

SELECTION CRITERIA

We considered published peer-reviewed cross-sectional studies and randomised controlled trials of any size that included prospectively recruited women of reproductive age suspected of having one or more of the following target conditions: endometrioma, pelvic endometriosis, DIE or endometriotic lesions at specific intrapelvic anatomical locations. We included studies that compared the diagnostic test accuracy of one or more imaging modalities versus findings of surgical visualisation of endometriotic lesions.

DATA COLLECTION AND ANALYSIS

Two review authors independently collected and performed a quality assessment of data from each study. For each imaging test, data were classified as positive or negative for surgical detection of endometriosis, and sensitivity and specificity estimates were calculated. If two or more tests were evaluated in the same cohort, each was considered as a separate data set. We used the bivariate model to obtain pooled estimates of sensitivity and specificity when sufficient data sets were available. Predetermined criteria for a clinically useful imaging test to replace diagnostic surgery included sensitivity ≥ 94% and specificity ≥ 79%. Criteria for triage tests were set at sensitivity ≥ 95% and specificity ≥ 50%, ruling out the diagnosis with a negative result (SnNout test - if sensitivity is high, a negative test rules out pathology) or at sensitivity ≥ 50% with specificity ≥ 95%, ruling in the diagnosis with a positive result (SpPin test - if specificity is high, a positive test rules in pathology).

MAIN RESULTS

We included 49 studies involving 4807 women: 13 studies evaluated pelvic endometriosis, 10 endometriomas and 15 DIE, and 33 studies addressed endometriosis at specific anatomical sites. Most studies were of poor methodological quality. The most studied modalities were transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI), with outcome measures commonly demonstrating diversity in diagnostic estimates; however, sources of heterogeneity could not be reliably determined. No imaging test met the criteria for a replacement or triage test for detecting pelvic endometriosis, albeit TVUS approached the criteria for a SpPin triage test. For endometrioma, TVUS (eight studies, 765 participants; sensitivity 0.93 (95% confidence interval (CI) 0.87, 0.99), specificity 0.96 (95% CI 0.92, 0.99)) qualified as a SpPin triage test and approached the criteria for a replacement and SnNout triage test, whereas MRI (three studies, 179 participants; sensitivity 0.95 (95% CI 0.90, 1.00), specificity 0.91 (95% CI 0.86, 0.97)) met the criteria for a replacement and SnNout triage test and approached the criteria for a SpPin test. For DIE, TVUS (nine studies, 12 data sets, 934 participants; sensitivity 0.79 (95% CI 0.69, 0.89) and specificity 0.94 (95% CI 0.88, 1.00)) approached the criteria for a SpPin triage test, and MRI (six studies, seven data sets, 266 participants; sensitivity 0.94 (95% CI 0.90, 0.97), specificity 0.77 (95% CI 0.44, 1.00)) approached the criteria for a replacement and SnNout triage test. Other imaging tests assessed in small individual studies could not be statistically evaluated.TVUS met the criteria for a SpPin triage test in mapping DIE to uterosacral ligaments, rectovaginal septum, vaginal wall, pouch of Douglas (POD) and rectosigmoid. MRI met the criteria for a SpPin triage test for POD and vaginal and rectosigmoid endometriosis. Transrectal ultrasonography (TRUS) might qualify as a SpPin triage test for rectosigmoid involvement but could not be adequately assessed for other anatomical sites because heterogeneous data were scant. Multi-detector computerised tomography enema (MDCT-e) displayed the highest diagnostic performance for rectosigmoid and other bowel endometriosis and met the criteria for both SpPin and SnNout triage tests, but studies were too few to provide meaningful results.Diagnostic accuracies were higher for TVUS with bowel preparation (TVUS-BP) and rectal water contrast (RWC-TVS) and for 3.0TMRI than for conventional methods, although the paucity of studies precluded statistical evaluation.

AUTHORS' CONCLUSIONS

None of the evaluated imaging modalities were able to detect overall pelvic endometriosis with enough accuracy that they would be suggested to replace surgery. Specifically for endometrioma, TVUS qualified as a SpPin triage test. MRI displayed sufficient accuracy to suggest utility as a replacement test, but the data were too scant to permit meaningful conclusions. TVUS could be used clinically to identify additional anatomical sites of DIE compared with MRI, thus facilitating preoperative planning. Rectosigmoid endometriosis was the only site that could be accurately mapped by using TVUS, TRUS, MRI or MDCT-e. Studies evaluating recent advances in imaging modalities such as TVUS-BP, RWC-TVS, 3.0TMRI and MDCT-e were observed to have high diagnostic accuracies but were too few to allow prudent evaluation of their diagnostic role. In view of the low quality of most of the included studies, the findings of this review should be interpreted with caution. Future well-designed diagnostic studies undertaken to compare imaging tests for diagnostic test accuracy and costs are recommended.

An Update on Surgical versus Expectant Management of Ovarian Endometriomas in Infertile Women

Ovarian endometriomas are a common manifestation of endometriosis that can represent a more severe stage of the disease. There is much debate over the treatment of these cysts in infertile women, particularly before use of assisted reproductive technologies. Evidence exists that supports surgical excision of ovarian endometriomas, as well as evidence that cautions against surgical intervention. Certain factors need to be examined closely before proceeding with surgery or continuing with expectant management. These include the patient's symptoms, age, ovarian reserve, size and laterality of the cyst, prior surgical treatment, and level of suspicion for malignancy. The most recent evidence appears to suggest that certain patient profiles may benefit from proceeding directly to in vitro fertilization (IVF). These include symptomatic infertile patients, especially those that are older, those that have diminished ovarian reserve, those that have bilateral endometriomas, or those that have had prior surgical treatment. Although endometriomas can be detrimental to the ovarian reserve, surgical therapy may further lower a woman's ovarian reserve. Nevertheless, the presence of an endometrioma does not appear to adversely affect IVF outcomes, and surgical excision of endometriomas does not appear to improve IVF outcomes. Regardless of treatment plan, infertile patients with endometriomas must be counseled appropriately before choosing either treatment path.