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Li WG, Zeng R, Lu Y, Li WX, Wang TT, Lin H, Peng Y, Gong LG. The value of radiomics-based CT combined with machine learning in the diagnosis of occult vertebral fractures. BMC Musculoskelet Disord 2023; 24:819. [PMID: 37848859 PMCID: PMC10580519 DOI: 10.1186/s12891-023-06939-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 10/05/2023] [Indexed: 10/19/2023] Open
Abstract
PURPOSE To develop and evaluate the performance of radiomics-based computed tomography (CT) combined with machine learning algorithms in detecting occult vertebral fractures (OVFs). MATERIALS AND METHODS 128 vertebrae including 64 with OVF confirmed by magnetic resonance imaging and 64 corresponding control vertebrae from 57 patients who underwent chest/abdominal CT scans, were included. The CT radiomics features on mid-axial and mid-sagittal plane of each vertebra were extracted. The fractured and normal vertebrae were randomly divided into training set and validation set at a ratio of 8:2. Pearson correlation analyses and least absolute shrinkage and selection operator were used for selecting sagittal and axial features, respectively. Three machine-learning algorithms were used to construct the radiomics models based on the residual features. Receiver operating characteristic (ROC) analysis was used to verify the performance of model. RESULTS For mid-axial CT imaging, 6 radiomics parameters were obtained and used for building the models. The logistic regression (LR) algorithm showed the best performance with area under the ROC curves (AUC) of training and validation sets of 0.682 and 0.775. For mid-sagittal CT imaging, 5 parameters were selected, and LR algorithms showed the best performance with AUC of training and validation sets of 0.832 and 0.882. The LR model based on sagittal CT yielded the best performance, with an accuracy of 0.846, sensitivity of 0.846, and specificity of 0.846. CONCLUSION Machine learning based on CT radiomics features allows for the detection of OVFs, especially the LR model based on the radiomics of sagittal imaging, which indicates it is promising to further combine with deep learning to achieve automatic recognition of OVFs to reduce the associated secondary injury.
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Affiliation(s)
- Wu-Gen Li
- Department of Radiology, the Second Affiliated Hospital of Nanchang University, No. 1Minde Road, Nanchang, Jiangxi, 330006, China
| | - Rou Zeng
- Department of Radiology, the Second Affiliated Hospital of Nanchang University, No. 1Minde Road, Nanchang, Jiangxi, 330006, China
| | - Yong Lu
- Department of Radiology, Xinjian County People's Hospital, Nanchang, 330103, China
| | - Wei-Xiang Li
- Department of Radiology, the Second Affiliated Hospital of Nanchang University, No. 1Minde Road, Nanchang, Jiangxi, 330006, China
| | - Tong-Tong Wang
- Department of Radiology, the Second Affiliated Hospital of Nanchang University, No. 1Minde Road, Nanchang, Jiangxi, 330006, China
| | - Huashan Lin
- Department of Pharmaceuticals Diagnosis, GE Healthcare, Changsha, Hunan, 410000, China
| | - Yun Peng
- Department of Radiology, the Second Affiliated Hospital of Nanchang University, No. 1Minde Road, Nanchang, Jiangxi, 330006, China
| | - Liang-Geng Gong
- Department of Radiology, the Second Affiliated Hospital of Nanchang University, No. 1Minde Road, Nanchang, Jiangxi, 330006, China.
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Bodden J, Dieckmeyer M, Sollmann N, Rühling S, Prucker P, Löffler MT, Burian E, Subburaj K, Zimmer C, Kirschke JS, Baum T. Long-term reproducibility of opportunistically assessed vertebral bone mineral density and texture features in routine clinical multi-detector computed tomography using an automated segmentation framework. Quant Imaging Med Surg 2023; 13:5472-5482. [PMID: 37711780 PMCID: PMC10498219 DOI: 10.21037/qims-23-19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 06/08/2023] [Indexed: 09/16/2023]
Abstract
Background To investigate reproducibility of texture features and volumetric bone mineral density (vBMD) extracted from trabecular bone in the thoracolumbar spine in routine clinical multi-detector computed tomography (MDCT) data in a single scanner environment. Methods Patients who underwent two routine clinical thoraco-abdominal MDCT exams at a single scanner with a time interval of 6 to 26 months (n=203, 131 males; time interval mean, 13 months; median, 12 months) were included in this observational study. Exclusion criteria were metabolic and hematological disorders, bone metastases, use of bone-active medications, and history of osteoporotic vertebral fractures (VFs) or prior diagnosis of osteoporosis. A convolutional neural network (CNN)-based framework was used for automated spine labeling and segmentation (T5-L5), asynchronous Hounsfield unit (HU)-to-BMD calibration, and correction for the intravenous contrast medium phase. Vertebral vBMD and six texture features [varianceglobal, entropy, short-run emphasis (SRE), long-run emphasis (LRE), run-length non-uniformity (RLN), and run percentage (RP)] were extracted for mid- (T5-T8) and lower thoracic (T9-T12), and lumbar vertebrae (L1-L5), respectively. Relative annual changes were calculated in texture features and vBMD for each vertebral level and sorted by sex, and changes were checked for statistical significance (P<0.05) using paired t-tests. Root mean square coefficient of variation (RMSCV) and root mean square error (RMSE) were calculated as measures of variability. Results SRE, LRE, RLN, and RP exhibited substantial reproducibility with RMSCV-values below 2%, for both sexes and at all spine levels, while vBMD was less reproducible (RMSCV =11.9-16.2%). Entropy showed highest variability (RMSCV =4.34-7.69%) due to statistically significant increases [range, mean ± standard deviation: (4.40±5.78)% to (8.36±8.66)%, P<0.001]. RMSCV of varianceglobal ranged from 1.60% to 3.03%. Conclusions Opportunistic assessment of texture features in a single scanner environment using the presented CNN-based framework yields substantial reproducibility, outperforming vBMD reproducibility. Lowest scan-rescan variability was found for higher-order texture features. Further studies are warranted to determine, whether microarchitectural changes to the trabecular bone may be assessed through texture features.
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Affiliation(s)
- Jannis Bodden
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael Dieckmeyer
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Nico Sollmann
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany
| | - Sebastian Rühling
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Philipp Prucker
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Maximilian T. Löffler
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Diagnostic and Interventional Radiology, University Medical Center Freiburg, Freiburg im Breisgau, Germany
| | - Egon Burian
- Department of Diagnostic and Interventional Radiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Karupppasamy Subburaj
- Department of Mechanical and Production Engineering, Aarhus University, Aarhus, Denmark
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Jan S. Kirschke
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Thomas Baum
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Dichtel LE, Tabari A, Mercaldo ND, Corey KE, Husseini J, Osganian SA, Chicote ML, Rao EM, Miller KK, Bredella MA. CT Texture Analysis in Nonalcoholic Fatty Liver Disease (NAFLD). J Clin Exp Hepatol 2023; 13:760-766. [PMID: 37693260 PMCID: PMC10483004 DOI: 10.1016/j.jceh.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 04/04/2023] [Indexed: 09/12/2023] Open
Abstract
Background Nonalcoholic fatty liver disease (NAFLD) is the most common form of liver disease worldwide. There are limited biomarkers that can detect progression from simple steatosis to nonalcoholic steatohepatitis (NASH). The purpose of our study was to utilize CT texture analysis to distinguish steatosis from NASH. Methods 16 patients with NAFLD (38% male, median (interquartile range): age 57 (48-64) years, BMI 37.5 (35.0-46.8) kg/m2) underwent liver biopsy and abdominal non-contrast CT. CT texture analysis was performed to quantify gray-level tissue summaries (e.g., entropy, kurtosis, skewness, and attenuation) using commercially available software (TexRad, Cambridge England). Logistic regression analyses were performed to quantify the association between steatosis/NASH status and CT texture. ROC curve analysis was performed to determine sensitivity, specificity, AUC, 95% CIs, and cutoff values of texture parameters to differentiate steatosis from NASH. Results By histology, 6/16 (37%) of patients had simple steatosis and 10/16 (63%) had NASH. Patients with NASH had lower entropy (median, interquartile range (IQR): 4.3 (4.1, 4.8) vs. 5.0 (4.9, 5.2), P = 0.013) and lower mean value of positive pixels (MPP) (34.4 (21.8, 52.2) vs. 66.5 (57.0, 70.7), P = 0.009) than those with simple steatosis. Entropy values below 4.73 predict NASH with 100% (95%CI: 67-100%) specificity and 80% (50-100%) sensitivity, AUC: 0.88. MPP values below 54.0 predict NASH with 100% (67-100%) specificity and 100% (50-100%) sensitivity, AUC 0.90. Conclusion Our study provides preliminary evidence that CT texture analysis may serve as a novel imaging biomarker for disease activity in NAFLD and the discrimination of steatosis and NASH.
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Affiliation(s)
- Laura E. Dichtel
- Harvard Medical School, Boston, MA, USA
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Azadeh Tabari
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Nathaniel D. Mercaldo
- Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Kathleen E. Corey
- Harvard Medical School, Boston, MA, USA
- Department of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Jad Husseini
- Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Mark L. Chicote
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Elizabeth M. Rao
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Karen K. Miller
- Harvard Medical School, Boston, MA, USA
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Miriam A. Bredella
- Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
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Hashmi SS, Seifert KD, Massoud TF. Thoracic and Lumbosacral Spine Anatomy. Neuroimaging Clin N Am 2022; 32:889-902. [DOI: 10.1016/j.nic.2022.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Corrias G, Micheletti G, Barberini L, Suri JS, Saba L. Texture analysis imaging "what a clinical radiologist needs to know". Eur J Radiol 2021; 146:110055. [PMID: 34902669 DOI: 10.1016/j.ejrad.2021.110055] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 04/09/2021] [Accepted: 11/15/2021] [Indexed: 02/07/2023]
Abstract
Texture analysis has arisen as a tool to explore the amount of data contained in images that cannot be explored by humans visually. Radiomics is a method that extracts a large number of features from radiographic medical images using data-characterisation algorithms. These features, termed radiomic features, have the potential to uncover disease characteristics. The goal of both radiomics and texture analysis is to go beyond size or human-eye based semantic descriptors, to enable the non-invasive extraction of quantitative radiological data to correlate them with clinical outcomes or pathological characteristics. In the latest years there has been a flourishing sub-field of radiology where texture analysis and radiomics have been used in many settings. It is difficult for the clinical radiologist to cope with such amount of data in all the different radiological sub-fields and to identify the most significant papers. The aim of this review is to provide a tool to better understand the basic principles underlining texture analysis and radiological data mining and a summary of the most significant papers of the latest years.
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Affiliation(s)
| | | | | | - Jasjit S Suri
- Stroke Diagnosis and Monitoring Division, AtheroPoint™, Roseville, CA, USA and Knowledge Engineering Center, Global Biomedical Technologies, Inc, Roseville, CA, USA
| | - Luca Saba
- Department of Radiology, University of Cagliari, Italy.
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Bi Y, Jiang C, Qi H, Zhou H, Sun L. Computed Tomography Image Texture under Feature Extraction Algorithm in the Diagnosis of Effect of Specific Nursing Intervention on Mycoplasma Pneumonia in Children. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:6059060. [PMID: 34697567 PMCID: PMC8541873 DOI: 10.1155/2021/6059060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 09/25/2021] [Accepted: 09/27/2021] [Indexed: 11/17/2022]
Abstract
To evaluate the effect of specific nursing intervention in children with mycoplasma pneumonia (MP), a feature extraction algorithm based on gray level co-occurrence matrix (GLCM) was proposed and combined with computed tomography (CT) image texture features. Then, 98 children with MP were rolled into the observation group with 49 cases (specific nursing) and the control group with 49 cases (routine nursing). CT images based on feature extraction algorithm of optimized GLCM were used to examine the children before and after nursing intervention, and the recovery of the two groups of children was discussed. The results showed that the proportion of lung texture increase, rope shadow, ground glass shadow, atelectasis, and pleural effusion in the observation group (24.11%, 3.86%, 8.53%, 15.03%, and 3.74%) was significantly lower than that in the control group (28.53%, 10.23%, 13.34%, 21.15%, and 8.13%) after nursing (P < 0.05). There were no significant differences in the proportion of small patchy shadows, large patchy consolidation shadows, and bronchiectasis between the observation group and the control group (P > 0.05). In the course of nursing intervention, in the observation group, the disappearance time of cough, normal temperature, disappearance time of lung rales, and absorption time of lung shadow (2.15 ± 0.86 days, 4.81 ± 1.14 days, 3.64 ± 0.55 days, and 5.96 ± 0.62 days) were significantly shorter than those in the control group (2.87 ± 0.95 days, 3.95 ± 1.06 days, 4.51 ± 1.02 days, and 8.14 ± 1.35 days) (P < 0.05). After nursing intervention, the proportion of satisfaction and total satisfaction in the experimental group (67.08% and 28.66%) was significantly higher than that in the control group (40.21% and 47.39%), while the proportion of dissatisfaction (4.26%) was significantly lower than that in the control group (12.4%) (P < 0.05). To sum up, specific nursing intervention was more beneficial to improve the progress of characterization recovery and the overall recovery effect of children with MP relative to conventional nursing. CT image based on feature extraction algorithm of optimized GLCM was of good adoption value in the diagnosis and treatment of MP in children.
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Affiliation(s)
- Yuyan Bi
- Department of Pediatric Ward, Jinan City People's Hospital, Jinan 271199, Shandong Province, China
| | - Cuifeng Jiang
- Department of Pediatric Surgery, Jinan City People's Hospital, Jinan 271199, Shandong Province, China
| | - Hua Qi
- Department of Pediatric Ward, Jinan City People's Hospital, Jinan 271199, Shandong Province, China
| | - Haiwei Zhou
- Department of Pediatric Ward, Jinan City People's Hospital, Jinan 271199, Shandong Province, China
| | - Lixia Sun
- Department of Nursing, Jinan City People's Hospital, Jinan 271199, Shandong Province, China
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Fan Y, Yu Y, Wang X, Hu M, Du M, Guo L, Sun S, Hu C. Texture Analysis Based on Gd-EOB-DTPA-Enhanced MRI for Identifying Vessels Encapsulating Tumor Clusters (VETC)-Positive Hepatocellular Carcinoma. J Hepatocell Carcinoma 2021; 8:349-359. [PMID: 33981636 PMCID: PMC8108126 DOI: 10.2147/jhc.s293755] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 03/25/2021] [Indexed: 12/12/2022] Open
Abstract
Purpose To determine the potential findings associated with vessels encapsulating tumor clusters (VETC)-positive hepatocellular carcinoma (HCC), with particular emphasis on texture analysis based on gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced MRI. Methods Eighty-one patients with VETC-negative HCC and 52 patients with VETC-positive HCC who underwent Gd-EOB-DTPA-enhanced MRI before curative partial hepatectomy were retrospectively evaluated in our institution. MRI texture analysis was performed on arterial phase (AP) and hepatobiliary phase (HBP) images. The least absolute shrinkage and selection operator (LASSO) logistic regression was used to select texture features most useful for identifying VETC-positive HCC. Univariate and multivariate analyses were used to determine significant variables for identifying the VETC-positive HCC in clinical factors and the texture features of MRI. Receiver operating characteristic (ROC) analysis and DeLong test were performed to compare the identified performances of significant variables for identifying VETC-positive HCC. Results LASSO logistic regression selected 3 features in AP and HBP images, respectively. In multivariate analysis, the Log-sigma-4.0-mm-3D first-order Kurtosis derived from AP images (odds ratio [OR] = 4.128, P = 0.001) and the Wavelet-LHL-GLDM Dependence Non Uniformity Normalized derived from HBP images (OR = 2.280, P = 0.004) were independent significant variables associated with VETC-positive HCC. The combination of the two texture features for identifying VETC-positive HCC achieved an AUC value of 0.844 (95% confidence interval CI, 0.777, 0.910) with a sensitivity of 80.8% (95% CI, 70.1%, 91.5%) and specificity of 74.1% (95% CI, 64.5%, 83.6%). Conclusion Texture analysis based on Gd-EOB-DTPA-enhanced MRI can help identify VETC-positive HCC.
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Affiliation(s)
- Yanfen Fan
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, People's Republic of China.,Institute of Medical Imaging of Soochow University, Suzhou, Jiangsu, 215006, People's Republic of China
| | - Yixing Yu
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, People's Republic of China.,Institute of Medical Imaging of Soochow University, Suzhou, Jiangsu, 215006, People's Republic of China
| | - Ximing Wang
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, People's Republic of China.,Institute of Medical Imaging of Soochow University, Suzhou, Jiangsu, 215006, People's Republic of China
| | - Mengjie Hu
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, People's Republic of China.,Institute of Medical Imaging of Soochow University, Suzhou, Jiangsu, 215006, People's Republic of China
| | - Mingzhan Du
- Department of Pathology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, People's Republic of China
| | - Lingchuan Guo
- Department of Pathology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, People's Republic of China
| | - Shifang Sun
- School of Mechatronic Engineering and Automation, Shanghai University, Shanghai, 200444, People's Republic of China
| | - Chunhong Hu
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, People's Republic of China.,Institute of Medical Imaging of Soochow University, Suzhou, Jiangsu, 215006, People's Republic of China
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Zhang T, Zhang Y, Liu X, Xu H, Chen C, Zhou X, Liu Y, Ma X. Application of Radiomics Analysis Based on CT Combined With Machine Learning in Diagnostic of Pancreatic Neuroendocrine Tumors Patient's Pathological Grades. Front Oncol 2021; 10:521831. [PMID: 33643890 PMCID: PMC7905094 DOI: 10.3389/fonc.2020.521831] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 12/11/2020] [Indexed: 02/05/2023] Open
Abstract
Purpose To evaluate the value of multiple machine learning methods in classifying pathological grades (G1,G2, and G3), and to provide the best machine learning method for the identification of pathological grades of pancreatic neuroendocrine tumors (PNETs) based on radiomics. Materials and Methods A retrospective study was conducted on 82 patients with Pancreatic Neuroendocrine tumors. All patients had definite pathological diagnosis and grading results. Using Lifex software to extract the radiomics features from CT images manually. The sensitivity, specificity, area under the curve (AUC) and accuracy were used to evaluate the performance of the classification model. Result Our analysis shows that the CT based radiomics features combined with multi algorithm machine learning method has a strong ability to identify the pathological grades of pancreatic neuroendocrine tumors. DC + AdaBoost, DC + GBDT, and Xgboost+RF were very valuable for the differential diagnosis of three pathological grades of PNET. They showed a strong ability to identify the pathological grade of pancreatic neuroendocrine tumors. The validation set AUC of DC + AdaBoost is 0.82 (G1 vs G2), 0.70 (G2 vs G3), and 0.85 (G1 vs G3), respectively. Conclusion In conclusion, based on enhanced CT radiomics features could differentiate between different pathological grades of pancreatic neuroendocrine tumors. Feature selection method Distance Correlation + classifier method Adaptive Boosting show a good application prospect.
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Affiliation(s)
- Tao Zhang
- Department of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China.,State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - YueHua Zhang
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Xinglong Liu
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Hanyue Xu
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Chaoyue Chen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xuan Zhou
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yichun Liu
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Xuelei Ma
- Department of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China.,State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
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9
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Dieckmeyer M, Sollmann N, El Husseini M, Sekuboyina A, Löffler MT, Zimmer C, Kirschke JS, Subburaj K, Baum T. Gender-, Age- and Region-Specific Characterization of Vertebral Bone Microstructure Through Automated Segmentation and 3D Texture Analysis of Routine Abdominal CT. Front Endocrinol (Lausanne) 2021; 12:792760. [PMID: 35154004 PMCID: PMC8828577 DOI: 10.3389/fendo.2021.792760] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 12/27/2021] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To identify long-term reproducible texture features (TFs) of spinal computed tomography (CT), and characterize variations with regard to gender, age and vertebral level using our automated quantification framework. METHODS We performed texture analysis (TA) on baseline and follow-up CT (follow-up duration: 30-90 days) of 21 subjects (8 females, 13 males, age at baseline 61.2 ± 9.2 years) to determine long-term reproducibility. TFs with a long-term reproducibility error Δrel<5% were further analyzed for an association with age and vertebral level in a cohort of 376 patients (129 females, 247 males, age 62.5 ± 9.2 years). Automated analysis comprised labeling and segmentation of vertebrae into subregions using a convolutional neural network, calculation of volumetric bone mineral density (vBMD) with asynchronous calibration and TF extraction. Varianceglobal measures the spread of the gray-level distribution in an image while Entropy reflects the uniformity of gray-levels. Short-run emphasis (SRE), Long-run emphasis (LRE), Run-length non-uniformity (RLN) and Run percentage (RP) contain information on consecutive voxels of a particular grey-level, or grey-level range, in a particular direction. Long runs (LRE) represent coarse texture while short runs (SRE) represent fine texture. RLN reflects similarities in the length of runs while RP reflects distribution and homogeneity of runs with a specific direction. RESULTS Six of the 24 extracted TFs had Δrel<5% (Varianceglobal, Entropy, SRE, LRE, RLN, RP), and were analyzed further in 4716 thoracolumbar vertebrae. Five TFs (Varianceglobal,SRE,LRE, RLN,RP) showed a significant difference between genders (p<0.001), potentially being caused by a finer and more directional vertebral trabecular microstructure in females compared to males. Varianceglobal and Entropy showed a significant increase from the thoracic to the lumbar spine (p<0.001), indicating a higher degree and earlier initiation of trabecular microstructure deterioration at lower spinal levels. The four higher-order TFs showed significant variations between spine regions without a clear directional gradient (p ≤ 0.001-0.012). No TF showed a clear age dependence. vBMD differed significantly between genders, age groups and spine regions (p ≤ 0.001-0.002). CONCLUSION Long-term reproducible CT-based TFs of the thoracolumbar spine were established and characterized in a predominantly older adult study population. The gender-, age- and vertebral-level-specific values may serve as foundation for osteoporosis diagnostics and facilitate future studies investigating vertebral microstructure.
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Affiliation(s)
- Michael Dieckmeyer
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- *Correspondence: Michael Dieckmeyer,
| | - Nico Sollmann
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany
| | - Malek El Husseini
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Anjany Sekuboyina
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Maximilian T. Löffler
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Radiology, University Medical Center, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Jan S. Kirschke
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Karupppasamy Subburaj
- Pillar of Engineering Product Development, Singapore University of Technology and Design, Singapore, Singapore
- Changi General Hospital, Singapore, Singapore
| | - Thomas Baum
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Bahamonde M, Misra M. Potential applications for rhIGF-I: Bone disease and IGFI. Growth Horm IGF Res 2020; 52:101317. [PMID: 32252004 PMCID: PMC7231643 DOI: 10.1016/j.ghir.2020.101317] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 03/09/2020] [Accepted: 03/21/2020] [Indexed: 12/18/2022]
Abstract
Growth hormone (GH) and insulin like growth factor-I (IGFI) are key bone trophic hormones, whose rising levels during puberty are critical for pubertal bone accrual. Conditions of GH deficiency and genetic resistance impact cortical and trabecular bone deleteriously with reduced estimates of bone strength. In humans, conditions of undernutrition (as in anorexia nervosa (AN), or subsequent to chronic illnesses) are associated with low IGF-I levels, which correlate with disease severity, and also with lower bone mineral density (BMD), impaired bone structure and lower strength estimates. In adolescents and adults with AN, studies have demonstrated a nutritionally acquired GH resistance with low IGF-I levels despite high concentrations of GH. IGF-I levels go up with increasing body weight, and are associated with rising levels of bone turnover markers. In short-term studies lasting 6-10 days, recombinant human IGF-I (rhIGF-I) administration in physiologic replacement doses normalized IGF-I levels and increased levels of bone formation markers in both adults and adolescents with AN. In a randomized controlled trial in adults with AN in which participants were randomized to one of four arms: (i) rhIGF-I with oral estrogen-progesterone (EP), (ii) rhIGF-I alone, (iii) EP alone, or (iv) neither for 9 months, a significant increase in bone formation markers was noted in the groups that received rhIGF-I, and a significant decrease in bone resorption markers in the groups that received EP. The group that received both rhIGF-I and EP had a significant increase in bone density at the spine and hip compared to the group that received neither. Side effects were minimal, with no documented fingerstick glucose of <50 mg/dl. These data thus suggest a potential role for rhIGF-I administration in optimizing bone accrual in states of undernutrition associated with low IGF-I.
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Affiliation(s)
- Marisol Bahamonde
- Department of Pediatrics, Universidad San Francisco de Quito (USFQ), Cumbayá, Ecuador
| | - Madhusmita Misra
- Division of Pediatric Endocrinology, Massachusetts General Hospital for Children, USA; Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, USA.
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Baessler B, Luecke C, Lurz J, Klingel K, Das A, von Roeder M, de Waha-Thiele S, Besler C, Rommel KP, Maintz D, Gutberlet M, Thiele H, Lurz P. Cardiac MRI and Texture Analysis of Myocardial T1 and T2 Maps in Myocarditis with Acute versus Chronic Symptoms of Heart Failure. Radiology 2019; 292:608-617. [PMID: 31361205 DOI: 10.1148/radiol.2019190101] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BackgroundThe establishment of a timely and correct diagnosis in heart failure-like myocarditis remains one of the most challenging in clinical cardiology.PurposeTo assess the diagnostic potential of texture analysis in heart failure-like myocarditis with comparison to endomyocardial biopsy (EMB) as the reference standard.Materials and MethodsSeventy-one study participants from the Magnetic Resonance Imaging in Myocarditis (MyoRacer) trial (ClinicalTrials.gov registration no. NCT02177630) with clinical suspicion for myocarditis and symptoms of heart failure were prospectively included (from August 2012 to May 2015) in the study. Participants underwent biventricular EMB and cardiac MRI at 1.5 T, including native T1 and T2 mapping and standard Lake Louise criteria. Texture analysis was applied on T1 and T2 maps by using an open-source software. Stepwise dimension reduction was performed for selecting features enabling the diagnosis of myocarditis. Diagnostic performance was assessed from the area under the curve (AUC) from receiver operating characteristic analyses with 10-fold cross validation.ResultsIn participants with acute heart failure-like myocarditis (n = 31; mean age, 47 years ± 17; 10 women), the texture feature GrayLevelNonUniformity from T2 maps (T2_GLNU) showed diagnostic performance similar to that of mean myocardial T2 time (AUC, 0.69 for both). The combination of mean T2 time and T2_GLNU had the highest AUC (0.76; 95% confidence interval [CI]: 0.43, 0.95), with sensitivity of 81% (25 of 31) and specificity of 71% (22 of 31). In patients with chronic heart failure-like myocarditis (n = 40; mean age, 48 years ± 13; 12 women), the histogram feature T2_kurtosis demonstrated superior diagnostic performance compared to that of all other single parameters (AUC, 0.81; 95% CI: 0.66, 0.96). The combination of the two texture features, T2_kurtosis and the GrayLevelNonUniformity from T1, had the highest diagnostic performance (AUC, 0.85; 95% CI: 0.57, 0.90; sensitivity, 90% [36 of 40]; and specificity, 72% [29 of 40]).ConclusionIn this proof-of-concept study, texture analysis applied on cardiac MRI T1 and T2 mapping delivers quantitative imaging parameters for the diagnosis of acute or chronic heart failure-like myocarditis and might be superior to Lake Louise criteria or averaged myocardial T1 or T2 values.© RSNA, 2019Online supplemental material is available for this article.See also the editorial by de Roos in this issue.
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Affiliation(s)
- Bettina Baessler
- From the Institute of Diagnostic and Interventional Radiology, University of Cologne, Medical Faculty and University Hospital Cologne, Kerpener Str 62, D-50937 Cologne, Germany (B.B., A.D., D.M.); Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany (C.L., M.G.); Department of Internal Medicine/Cardiology, Heart Center Leipzig-University Hospital, Leipzig, Germany (J.L., M.v.R., C.B., K.P.R., H.T., P.L.); Department of Cardiopathology, Institute for Pathology and Neuropathology, University Hospital Tuebingen, Tuebingen, Germany (K.K.); Institute of Medical Statistics and Computational Biology, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany (A.D.); Department of Cardiology, Angiology, and Intensive Care Medicine, University Heart Center Luebeck, Luebeck, Germany (S.d.W.T.); German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany (S.d.W.T.); and Leipzig Heart Institute, Leipzig, Germany (M.G., H.T., P.L.)
| | - Christian Luecke
- From the Institute of Diagnostic and Interventional Radiology, University of Cologne, Medical Faculty and University Hospital Cologne, Kerpener Str 62, D-50937 Cologne, Germany (B.B., A.D., D.M.); Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany (C.L., M.G.); Department of Internal Medicine/Cardiology, Heart Center Leipzig-University Hospital, Leipzig, Germany (J.L., M.v.R., C.B., K.P.R., H.T., P.L.); Department of Cardiopathology, Institute for Pathology and Neuropathology, University Hospital Tuebingen, Tuebingen, Germany (K.K.); Institute of Medical Statistics and Computational Biology, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany (A.D.); Department of Cardiology, Angiology, and Intensive Care Medicine, University Heart Center Luebeck, Luebeck, Germany (S.d.W.T.); German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany (S.d.W.T.); and Leipzig Heart Institute, Leipzig, Germany (M.G., H.T., P.L.)
| | - Julia Lurz
- From the Institute of Diagnostic and Interventional Radiology, University of Cologne, Medical Faculty and University Hospital Cologne, Kerpener Str 62, D-50937 Cologne, Germany (B.B., A.D., D.M.); Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany (C.L., M.G.); Department of Internal Medicine/Cardiology, Heart Center Leipzig-University Hospital, Leipzig, Germany (J.L., M.v.R., C.B., K.P.R., H.T., P.L.); Department of Cardiopathology, Institute for Pathology and Neuropathology, University Hospital Tuebingen, Tuebingen, Germany (K.K.); Institute of Medical Statistics and Computational Biology, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany (A.D.); Department of Cardiology, Angiology, and Intensive Care Medicine, University Heart Center Luebeck, Luebeck, Germany (S.d.W.T.); German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany (S.d.W.T.); and Leipzig Heart Institute, Leipzig, Germany (M.G., H.T., P.L.)
| | - Karin Klingel
- From the Institute of Diagnostic and Interventional Radiology, University of Cologne, Medical Faculty and University Hospital Cologne, Kerpener Str 62, D-50937 Cologne, Germany (B.B., A.D., D.M.); Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany (C.L., M.G.); Department of Internal Medicine/Cardiology, Heart Center Leipzig-University Hospital, Leipzig, Germany (J.L., M.v.R., C.B., K.P.R., H.T., P.L.); Department of Cardiopathology, Institute for Pathology and Neuropathology, University Hospital Tuebingen, Tuebingen, Germany (K.K.); Institute of Medical Statistics and Computational Biology, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany (A.D.); Department of Cardiology, Angiology, and Intensive Care Medicine, University Heart Center Luebeck, Luebeck, Germany (S.d.W.T.); German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany (S.d.W.T.); and Leipzig Heart Institute, Leipzig, Germany (M.G., H.T., P.L.)
| | - Arijit Das
- From the Institute of Diagnostic and Interventional Radiology, University of Cologne, Medical Faculty and University Hospital Cologne, Kerpener Str 62, D-50937 Cologne, Germany (B.B., A.D., D.M.); Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany (C.L., M.G.); Department of Internal Medicine/Cardiology, Heart Center Leipzig-University Hospital, Leipzig, Germany (J.L., M.v.R., C.B., K.P.R., H.T., P.L.); Department of Cardiopathology, Institute for Pathology and Neuropathology, University Hospital Tuebingen, Tuebingen, Germany (K.K.); Institute of Medical Statistics and Computational Biology, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany (A.D.); Department of Cardiology, Angiology, and Intensive Care Medicine, University Heart Center Luebeck, Luebeck, Germany (S.d.W.T.); German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany (S.d.W.T.); and Leipzig Heart Institute, Leipzig, Germany (M.G., H.T., P.L.)
| | - Maximilian von Roeder
- From the Institute of Diagnostic and Interventional Radiology, University of Cologne, Medical Faculty and University Hospital Cologne, Kerpener Str 62, D-50937 Cologne, Germany (B.B., A.D., D.M.); Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany (C.L., M.G.); Department of Internal Medicine/Cardiology, Heart Center Leipzig-University Hospital, Leipzig, Germany (J.L., M.v.R., C.B., K.P.R., H.T., P.L.); Department of Cardiopathology, Institute for Pathology and Neuropathology, University Hospital Tuebingen, Tuebingen, Germany (K.K.); Institute of Medical Statistics and Computational Biology, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany (A.D.); Department of Cardiology, Angiology, and Intensive Care Medicine, University Heart Center Luebeck, Luebeck, Germany (S.d.W.T.); German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany (S.d.W.T.); and Leipzig Heart Institute, Leipzig, Germany (M.G., H.T., P.L.)
| | - Suzanne de Waha-Thiele
- From the Institute of Diagnostic and Interventional Radiology, University of Cologne, Medical Faculty and University Hospital Cologne, Kerpener Str 62, D-50937 Cologne, Germany (B.B., A.D., D.M.); Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany (C.L., M.G.); Department of Internal Medicine/Cardiology, Heart Center Leipzig-University Hospital, Leipzig, Germany (J.L., M.v.R., C.B., K.P.R., H.T., P.L.); Department of Cardiopathology, Institute for Pathology and Neuropathology, University Hospital Tuebingen, Tuebingen, Germany (K.K.); Institute of Medical Statistics and Computational Biology, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany (A.D.); Department of Cardiology, Angiology, and Intensive Care Medicine, University Heart Center Luebeck, Luebeck, Germany (S.d.W.T.); German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany (S.d.W.T.); and Leipzig Heart Institute, Leipzig, Germany (M.G., H.T., P.L.)
| | - Christian Besler
- From the Institute of Diagnostic and Interventional Radiology, University of Cologne, Medical Faculty and University Hospital Cologne, Kerpener Str 62, D-50937 Cologne, Germany (B.B., A.D., D.M.); Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany (C.L., M.G.); Department of Internal Medicine/Cardiology, Heart Center Leipzig-University Hospital, Leipzig, Germany (J.L., M.v.R., C.B., K.P.R., H.T., P.L.); Department of Cardiopathology, Institute for Pathology and Neuropathology, University Hospital Tuebingen, Tuebingen, Germany (K.K.); Institute of Medical Statistics and Computational Biology, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany (A.D.); Department of Cardiology, Angiology, and Intensive Care Medicine, University Heart Center Luebeck, Luebeck, Germany (S.d.W.T.); German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany (S.d.W.T.); and Leipzig Heart Institute, Leipzig, Germany (M.G., H.T., P.L.)
| | - Karl-Philipp Rommel
- From the Institute of Diagnostic and Interventional Radiology, University of Cologne, Medical Faculty and University Hospital Cologne, Kerpener Str 62, D-50937 Cologne, Germany (B.B., A.D., D.M.); Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany (C.L., M.G.); Department of Internal Medicine/Cardiology, Heart Center Leipzig-University Hospital, Leipzig, Germany (J.L., M.v.R., C.B., K.P.R., H.T., P.L.); Department of Cardiopathology, Institute for Pathology and Neuropathology, University Hospital Tuebingen, Tuebingen, Germany (K.K.); Institute of Medical Statistics and Computational Biology, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany (A.D.); Department of Cardiology, Angiology, and Intensive Care Medicine, University Heart Center Luebeck, Luebeck, Germany (S.d.W.T.); German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany (S.d.W.T.); and Leipzig Heart Institute, Leipzig, Germany (M.G., H.T., P.L.)
| | - David Maintz
- From the Institute of Diagnostic and Interventional Radiology, University of Cologne, Medical Faculty and University Hospital Cologne, Kerpener Str 62, D-50937 Cologne, Germany (B.B., A.D., D.M.); Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany (C.L., M.G.); Department of Internal Medicine/Cardiology, Heart Center Leipzig-University Hospital, Leipzig, Germany (J.L., M.v.R., C.B., K.P.R., H.T., P.L.); Department of Cardiopathology, Institute for Pathology and Neuropathology, University Hospital Tuebingen, Tuebingen, Germany (K.K.); Institute of Medical Statistics and Computational Biology, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany (A.D.); Department of Cardiology, Angiology, and Intensive Care Medicine, University Heart Center Luebeck, Luebeck, Germany (S.d.W.T.); German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany (S.d.W.T.); and Leipzig Heart Institute, Leipzig, Germany (M.G., H.T., P.L.)
| | - Matthias Gutberlet
- From the Institute of Diagnostic and Interventional Radiology, University of Cologne, Medical Faculty and University Hospital Cologne, Kerpener Str 62, D-50937 Cologne, Germany (B.B., A.D., D.M.); Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany (C.L., M.G.); Department of Internal Medicine/Cardiology, Heart Center Leipzig-University Hospital, Leipzig, Germany (J.L., M.v.R., C.B., K.P.R., H.T., P.L.); Department of Cardiopathology, Institute for Pathology and Neuropathology, University Hospital Tuebingen, Tuebingen, Germany (K.K.); Institute of Medical Statistics and Computational Biology, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany (A.D.); Department of Cardiology, Angiology, and Intensive Care Medicine, University Heart Center Luebeck, Luebeck, Germany (S.d.W.T.); German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany (S.d.W.T.); and Leipzig Heart Institute, Leipzig, Germany (M.G., H.T., P.L.)
| | - Holger Thiele
- From the Institute of Diagnostic and Interventional Radiology, University of Cologne, Medical Faculty and University Hospital Cologne, Kerpener Str 62, D-50937 Cologne, Germany (B.B., A.D., D.M.); Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany (C.L., M.G.); Department of Internal Medicine/Cardiology, Heart Center Leipzig-University Hospital, Leipzig, Germany (J.L., M.v.R., C.B., K.P.R., H.T., P.L.); Department of Cardiopathology, Institute for Pathology and Neuropathology, University Hospital Tuebingen, Tuebingen, Germany (K.K.); Institute of Medical Statistics and Computational Biology, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany (A.D.); Department of Cardiology, Angiology, and Intensive Care Medicine, University Heart Center Luebeck, Luebeck, Germany (S.d.W.T.); German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany (S.d.W.T.); and Leipzig Heart Institute, Leipzig, Germany (M.G., H.T., P.L.)
| | - Philipp Lurz
- From the Institute of Diagnostic and Interventional Radiology, University of Cologne, Medical Faculty and University Hospital Cologne, Kerpener Str 62, D-50937 Cologne, Germany (B.B., A.D., D.M.); Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany (C.L., M.G.); Department of Internal Medicine/Cardiology, Heart Center Leipzig-University Hospital, Leipzig, Germany (J.L., M.v.R., C.B., K.P.R., H.T., P.L.); Department of Cardiopathology, Institute for Pathology and Neuropathology, University Hospital Tuebingen, Tuebingen, Germany (K.K.); Institute of Medical Statistics and Computational Biology, University of Cologne, Medical Faculty and University Hospital Cologne, Cologne, Germany (A.D.); Department of Cardiology, Angiology, and Intensive Care Medicine, University Heart Center Luebeck, Luebeck, Germany (S.d.W.T.); German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany (S.d.W.T.); and Leipzig Heart Institute, Leipzig, Germany (M.G., H.T., P.L.)
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Muehlematter UJ, Mannil M, Becker AS, Vokinger KN, Finkenstaedt T, Osterhoff G, Fischer MA, Guggenberger R. Vertebral body insufficiency fractures: detection of vertebrae at risk on standard CT images using texture analysis and machine learning. Eur Radiol 2018; 29:2207-2217. [PMID: 30519934 DOI: 10.1007/s00330-018-5846-8] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Revised: 09/30/2018] [Accepted: 10/22/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate the diagnostic performance of bone texture analysis (TA) combined with machine learning (ML) algorithms in standard CT scans to identify patients with vertebrae at risk for insufficiency fractures. MATERIALS AND METHODS Standard CT scans of 58 patients with insufficiency fractures of the spine, performed between 2006 and 2013, were analyzed retrospectively. Every included patient had at least two CT scans. Intact vertebrae in a first scan that either fractured ("unstable") or remained intact ("stable") in the consecutive scan were manually segmented on mid-sagittal reformations. TA features for all vertebrae were extracted using open-source software (MaZda). In a paired control study, all vertebrae of the study cohort "cases" and matched controls were classified using ROC analysis of Hounsfield unit (HU) measurements and supervised ML techniques. In a within-subject vertebra comparison, vertebrae of the cases were classified into "unstable" and "stable" using identical techniques. RESULTS One hundred twenty vertebrae were included. Classification of cases/controls using ROC analysis of HU measurements showed an AUC of 0.83 (95% confidence interval [CI], 0.77-0.88), and ML-based classification showed an AUC of 0.97 (CI, 0.97-0.98). Classification of unstable/stable vertebrae using ROC analysis showed an AUC of 0.52 (CI, 0.42-0.63), and ML-based classification showed an AUC of 0.64 (CI, 0.61-0.67). CONCLUSION TA combined with ML allows to identifying patients who will suffer from vertebral insufficiency fractures in standard CT scans with high accuracy. However, identification of single vertebra at risk remains challenging. KEY POINTS • Bone texture analysis combined with machine learning allows to identify patients at risk for vertebral body insufficiency fractures on standard CT scans with high accuracy. • Compared to mere Hounsfield unit measurements on CT scans, application of bone texture analysis combined with machine learning improve fracture risk prediction. • This analysis has the potential to identify vertebrae at risk for insufficiency fracture and may thus increase diagnostic value of standard CT scans.
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Affiliation(s)
- Urs J Muehlematter
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland.
| | - Manoj Mannil
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Anton S Becker
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Kerstin N Vokinger
- University Hospital of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Tim Finkenstaedt
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Georg Osterhoff
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | - Michael A Fischer
- Department of Radiology, University Hospital Balgrist, University of Zurich, Zurich, Switzerland
| | - Roman Guggenberger
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
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Mannil M, Burgstaller JM, Thanabalasingam A, Winklhofer S, Betz M, Held U, Guggenberger R. Texture analysis of paraspinal musculature in MRI of the lumbar spine: analysis of the lumbar stenosis outcome study (LSOS) data. Skeletal Radiol 2018; 47:947-954. [PMID: 29497775 DOI: 10.1007/s00256-018-2919-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 02/12/2018] [Accepted: 02/16/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate association of fatty infiltration in paraspinal musculature with clinical outcomes in patients suffering from lumbar spinal stenosis (LSS) using qualitative and quantitative grading in magnetic resonance imaging (MRI). MATERIALS AND METHODS In this retrospective study, texture analysis (TA) was performed on postprocessed axial T2 weighted (w) MR images at level L3/4 using dedicated software (MaZda) in 62 patients with LSS. Associations in fatty infiltration between qualitative Goutallier and quantitative TA findings with two clinical outcome measures, Spinal stenosis measure (SSM) score and walking distance, at baseline and regarding change over time were assessed using machine learning algorithms and multiple logistic regression models. RESULTS Quantitative assessment of fatty infiltration using the histogram TA feature "mean" showed higher interreader reliability (ICC 0.83-0.97) compared to the Goutallier staging (κ = 0.69-0.93). No correlation between Goutallier staging and clinical outcome measures was observed. Among 151 TA features, only TA feature "mean" of the spinotransverse group showed a significant but weak correlation with worsened SSM (p = 0.046). TA feature "S(3,3) entropy" showed a significant but weak association with worsened WD over 12 months (p = 0.046). CONCLUSION MR TA is a reproducible tool to quantitatively assess paraspinal fatty infiltration, but there is no clear association with the clinical outcome in asymptomatic LSS patients.
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Affiliation(s)
- Manoj Mannil
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
| | - Jakob M Burgstaller
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Pestalozzistrasse 24, 8032, Zurich, Switzerland
| | - Arjun Thanabalasingam
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
| | - Sebastian Winklhofer
- Department of Neuroradiology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Michael Betz
- Department of Orthopaedics, Balgrist University Hospital University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Ulrike Held
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Pestalozzistrasse 24, 8032, Zurich, Switzerland
| | - Roman Guggenberger
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland.
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Lubner MG, Smith AD, Sandrasegaran K, Sahani DV, Pickhardt PJ. CT Texture Analysis: Definitions, Applications, Biologic Correlates, and Challenges. Radiographics 2017; 37:1483-1503. [PMID: 28898189 DOI: 10.1148/rg.2017170056] [Citation(s) in RCA: 526] [Impact Index Per Article: 75.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This review discusses potential oncologic and nononcologic applications of CT texture analysis ( CTTA CT texture analysis ), an emerging area of "radiomics" that extracts, analyzes, and interprets quantitative imaging features. CTTA CT texture analysis allows objective assessment of lesion and organ heterogeneity beyond what is possible with subjective visual interpretation and may reflect information about the tissue microenvironment. CTTA CT texture analysis has shown promise in lesion characterization, such as differentiating benign from malignant or more biologically aggressive lesions. Pretreatment CT texture features are associated with histopathologic correlates such as tumor grade, tumor cellular processes such as hypoxia or angiogenesis, and genetic features such as KRAS or epidermal growth factor receptor (EGFR) mutation status. In addition, and likely as a result, these CT texture features have been linked to prognosis and clinical outcomes in some tumor types. CTTA CT texture analysis has also been used to assess response to therapy, with decreases in tumor heterogeneity generally associated with pathologic response and improved outcomes. A variety of nononcologic applications of CTTA CT texture analysis are emerging, particularly quantifying fibrosis in the liver and lung. Although CTTA CT texture analysis seems to be a promising imaging biomarker, there is marked variability in methods, parameters reported, and strength of associations with biologic correlates. Before CTTA CT texture analysis can be considered for widespread clinical implementation, standardization of tumor segmentation and measurement techniques, image filtration and postprocessing techniques, and methods for mathematically handling multiple tumors and time points is needed, in addition to identification of key texture parameters among hundreds of potential candidates, continued investigation and external validation of histopathologic correlates, and structured reporting of findings. ©RSNA, 2017.
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Affiliation(s)
- Meghan G Lubner
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Sciences Center, 600 Highland Ave, Madison, WI 35792 (M.G.L., P.J.P.); Department of Radiology, University of Mississippi Medical Center, Jackson, Miss (A.D.S.); Department of Radiology, Indiana University School of Medicine, Indianapolis, Ind (K.S.); and Department of Radiology, Harvard Medical School, Boston, Mass (D.V.S.)
| | - Andrew D Smith
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Sciences Center, 600 Highland Ave, Madison, WI 35792 (M.G.L., P.J.P.); Department of Radiology, University of Mississippi Medical Center, Jackson, Miss (A.D.S.); Department of Radiology, Indiana University School of Medicine, Indianapolis, Ind (K.S.); and Department of Radiology, Harvard Medical School, Boston, Mass (D.V.S.)
| | - Kumar Sandrasegaran
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Sciences Center, 600 Highland Ave, Madison, WI 35792 (M.G.L., P.J.P.); Department of Radiology, University of Mississippi Medical Center, Jackson, Miss (A.D.S.); Department of Radiology, Indiana University School of Medicine, Indianapolis, Ind (K.S.); and Department of Radiology, Harvard Medical School, Boston, Mass (D.V.S.)
| | - Dushyant V Sahani
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Sciences Center, 600 Highland Ave, Madison, WI 35792 (M.G.L., P.J.P.); Department of Radiology, University of Mississippi Medical Center, Jackson, Miss (A.D.S.); Department of Radiology, Indiana University School of Medicine, Indianapolis, Ind (K.S.); and Department of Radiology, Harvard Medical School, Boston, Mass (D.V.S.)
| | - Perry J Pickhardt
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Sciences Center, 600 Highland Ave, Madison, WI 35792 (M.G.L., P.J.P.); Department of Radiology, University of Mississippi Medical Center, Jackson, Miss (A.D.S.); Department of Radiology, Indiana University School of Medicine, Indianapolis, Ind (K.S.); and Department of Radiology, Harvard Medical School, Boston, Mass (D.V.S.)
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15
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Mannil M, Eberhard M, Becker AS, Schönenberg D, Osterhoff G, Frey DP, Konukoglu E, Alkadhi H, Guggenberger R. Normative values for CT-based texture analysis of vertebral bodies in dual X-ray absorptiometry-confirmed, normally mineralized subjects. Skeletal Radiol 2017; 46:1541-1551. [PMID: 28780746 DOI: 10.1007/s00256-017-2728-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 06/19/2017] [Accepted: 07/10/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To develop age-, gender-, and regional-specific normative values for texture analysis (TA) of spinal computed tomography (CT) in subjects with normal bone mineral density (BMD), as defined by dual X-ray absorptiometry (DXA), and to determine age-, gender-, and regional-specific differences. MATERIALS AND METHODS In this retrospective, IRB-approved study, TA was performed on sagittal CT bone images of the thoracic and lumbar spine using dedicated software (MaZda) in 141 individuals with normal DXA BMD findings. Numbers of female and male subjects were balanced in each of six age decades. Three hundred and five TA features were analyzed in thoracic and lumbar vertebrae using free-hand regions-of-interest. Intraclass correlation (ICC) coefficients were calculated for determining intra- and inter-observer agreement of each feature. Further dimension reduction was performed with correlation analyses. RESULTS The TA features with an ICC < 0.81 indicating compromised intra- and inter-observer agreement and with Pearson correlation scores r > 0.8 with other features were excluded from further analysis for dimension reduction. From the remaining 31 texture features, a significant correlation with age was found for the features mean (r = -0.489, p < 0.001), variance (r = -0.681, p < 0.001), kurtosis (r = 0.273, p < 0.001), and WavEnLL_s4 (r = 0.273, p < 0.001). Significant differences were found between genders for various higher-level texture features (p < 0.001). Regional differences among the thoracic spine, thoracic-lumbar junction, and lumbar spine were found for most TA features (p < 0.021). CONCLUSION This study established normative values of TA features on CT images of the spine and showed age-, gender-, and regional-specific differences in individuals with normal BMD as defined by DXA.
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Affiliation(s)
- Manoj Mannil
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Matthias Eberhard
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Anton S Becker
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Denise Schönenberg
- Division of Trauma Surgery, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Georg Osterhoff
- Division of Trauma Surgery, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Diana P Frey
- Department of Rheumatology, University Hospital Zurich, Gloriastrasse 25, 8091, Zurich, Switzerland
| | - Ender Konukoglu
- Department of Information Technology and Electrical Engineering, Computer Vision Laboratory, ETH Zurich, Sternwartstrasse 7, 8092, Zurich, Switzerland
| | - Hatem Alkadhi
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Roman Guggenberger
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
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16
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Baessler B, Mannil M, Oebel S, Maintz D, Alkadhi H, Manka R. Subacute and Chronic Left Ventricular Myocardial Scar: Accuracy of Texture Analysis on Nonenhanced Cine MR Images. Radiology 2017; 286:103-112. [PMID: 28836886 DOI: 10.1148/radiol.2017170213] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To test whether texture analysis (TA) allows for the diagnosis of subacute and chronic myocardial infarction (MI) on noncontrast material-enhanced cine cardiac magnetic resonance (MR) images. Materials and Methods In this retrospective, institutional review board-approved study, 120 patients who underwent cardiac MR imaging and showed large transmural (volume of enhancement on late gadolinium enhancement [LGE] images >20%, n = 72) or small (enhanced volume ≤20%, n = 48) subacute or chronic ischemic scars were included. Sixty patients with normal cardiac MR imaging findings served as control subjects. Regions of interest for TA encompassing the left ventricle were drawn by two blinded, independent readers on cine images in end systole by using a freely available software package. Stepwise dimension reduction and texture feature selection based on reproducibility, machine learning, and correlation analyses were performed for selecting features, enabling the diagnosis of MI on nonenhanced cine MR images by using LGE imaging as the standard of reference. Results Five independent texture features allowed for differentiation between ischemic scar and normal myocardium on cine MR images in both subgroups: Teta1, Perc.01, Variance, WavEnHH.s-3, and S(5,5)SumEntrp (in patients with large MI: all P values < .001; in patients with small MI: Teta1 and Perc.01, P < .001; Variance, P = .026; WavEnHH.s-3, P = .007; S[5,5]SumEntrp, P = .045). Multiple logistic regression models revealed that combining the features Teta1 and Perc.01 resulted in the highest accuracy for diagnosing large and small MI on cine MR images, with an area under the curve of 0.93 and 0.92, respectively. Conclusion This proof-of-concept study indicates that TA of nonenhanced cine MR images allows for the diagnosis of subacute and chronic MI with high accuracy. © RSNA, 2017 Online supplemental material is available for this article.
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Affiliation(s)
- Bettina Baessler
- From the Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland (B.B., M.M., S.O., H.A., R.M.); Department of Radiology, University Hospital of Cologne, Cologne, Germany (B.B., D.M.); Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland (S.O., R.M.); and Institute for Biomedical Engineering, University and ETH Zurich, Zurich, Switzerland (R.M.)
| | - Manoj Mannil
- From the Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland (B.B., M.M., S.O., H.A., R.M.); Department of Radiology, University Hospital of Cologne, Cologne, Germany (B.B., D.M.); Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland (S.O., R.M.); and Institute for Biomedical Engineering, University and ETH Zurich, Zurich, Switzerland (R.M.)
| | - Sabrina Oebel
- From the Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland (B.B., M.M., S.O., H.A., R.M.); Department of Radiology, University Hospital of Cologne, Cologne, Germany (B.B., D.M.); Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland (S.O., R.M.); and Institute for Biomedical Engineering, University and ETH Zurich, Zurich, Switzerland (R.M.)
| | - David Maintz
- From the Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland (B.B., M.M., S.O., H.A., R.M.); Department of Radiology, University Hospital of Cologne, Cologne, Germany (B.B., D.M.); Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland (S.O., R.M.); and Institute for Biomedical Engineering, University and ETH Zurich, Zurich, Switzerland (R.M.)
| | - Hatem Alkadhi
- From the Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland (B.B., M.M., S.O., H.A., R.M.); Department of Radiology, University Hospital of Cologne, Cologne, Germany (B.B., D.M.); Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland (S.O., R.M.); and Institute for Biomedical Engineering, University and ETH Zurich, Zurich, Switzerland (R.M.)
| | - Robert Manka
- From the Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland (B.B., M.M., S.O., H.A., R.M.); Department of Radiology, University Hospital of Cologne, Cologne, Germany (B.B., D.M.); Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland (S.O., R.M.); and Institute for Biomedical Engineering, University and ETH Zurich, Zurich, Switzerland (R.M.)
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17
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Abstract
PURPOSE OF REVIEW Eating Disorders are psychiatric disorders associated with a high risk for low bone mineral density (BMD) and fractures. Low BMD is a consequence of undernutrition, changes in body composition, and hormonal alterations. This review summarizes recent findings regarding novel strategies for assessing bone outcomes in patients with eating disorders, factors contributing to altered bone metabolism, and possible therapeutic strategies. RECENT FINDINGS Emerging research in this field suggests that not only anorexia nervosa, but also bulimia nervosa results in lower BMD compared to controls. To date studies of bone structure, and all randomized controlled trials examining the impact of various therapies on bone outcomes in anorexia nervosa, have focused on adolescent girls and women. We discuss the impact of anorexia nervosa on bone structure, and associations of resting energy expenditure, marrow adipose tissue (including the ratio of saturated to unsaturated fat), and cold activated brown adipose tissue with BMD and bone structure. Promising strategies for treatment include physiological estrogen replacement (rather than oral contraceptives) in adolescent girls with anorexia nervosa, and bisphosphonates, as well as teriparatide, in adult women with anorexia nervosa. SUMMARY Recent data on (i) BMD and bone structure in adolescent girls and women with eating disorders, (ii) factors that contribute to altered bone metabolism, and (iii) randomized controlled trials reporting positive effects of physiologic estrogen replacement, bisphosphonates and teriparatide on bone health, provide us with a greater understanding of the impact of eating disorders on bone and novel management strategies.
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Affiliation(s)
- Lauren Robinson
- Institute of Child Health, University College London, Gower Street, London, WC1E 6BT, UK
| | - Nadia Micali
- Institute of Child Health, University College London, Gower Street, London, WC1E 6BT, UK
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Madhusmita Misra
- Pediatric Endocrine and Neuroendocrine Units, Massachusetts General Hospital, Boston, MA 02114, USA
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