Imaging features of adrenal masses

Differentiate adrenal lipid-poor adenoma from nodular hyperplasia with CT quantitative parameters: a feasibility study

OBJECTIVES

To explore the potential of CT quantitative parameters in differentiating adrenal lipid-poor adenoma (LPA) from nodular hyperplasia and evaluate diagnostic performance.

MATERIALS AND METHODS

Patients with LPA or nodular hyperplasia who underwent contrast-enhanced CT before adrenalectomy were analyzed retrospectively. The study included 128 patients (83 with LPA and 45 with nodular hyperplasia). Each lesion's unenhanced attenuation, portal-venous phase attenuation (CTp), and the portal-venous phase attenuation of the abdominal aorta were evaluated. We subsequently calculated absolute enhancement [a lesion's portal-venous phase attenuation minus unenhanced attenuation (in HUs)], relative enhancement (absolute enhancement divided by unenhanced attenuation), and the relative enhancement ratio [(absolute enhancement divided by abdominal aorta's portal-venous phase attenuation) ×100%]. Lesion number and size were recorded. Volume was assessed by ITK-snap software and the ratio of lesion volume to ipsilateral adrenal volume (volume ratio) was determined. Intergroup differences were analyzed using Student's t-test and chi-squared test. Logistic regression models were developed, and receiver operating characteristic (ROC) curves were constructed to determine the area under the ROC curve (AUC), sensitivity, and specificity. The model's performance was then compared against radiologists' subjective assessments, and the inter- and intra-reader agreement values among radiologists were calculated.

RESULTS

Portal-venous phase attenuation, volume ratio, and lesion number were independent predictors of LPA. The logistic regression model incorporating CTp, volume ratio, and lesion number achieved an AUC of 0.835, with a sensitivity of 73.5% and a specificity of 80.0%. The radiologists' diagnostic specificity and accuracy appeared to be inferior to the model. The inter-reader agreement among radiologists ranged from 0.082 to 0.535, and the intra-reader agreement of two radiologists were 0.734 and 0.583.

CONCLUSION

The portal-venous phase CT demonstrated potential in distinguishing LPA from nodular hyperplasia. The diagnostic performance of the model integrating CTp, volume ratio, and lesion number outperformed radiologists in terms of variability and reproducibility.

Pseudocysts of the Adrenal Gland: A Systematic Review of Existing Scientific Literature From 2000 to 2023

Adrenal masses are abnormal growths in the adrenal gland, comprising entities such as pheochromocytomas, adrenal adenomas, adrenocortical carcinomas, and adrenal cysts. Pseudocysts are predominant among adrenal cysts. Due to its infrequent presentation, there are no specific guidelines present in the current literature to steer its management. In such circumstances, a systematic review of the existing literature is imperative to develop comprehensive insights and evidence-based protocols. We aimed to comprehensively analyze the clinico-radiological characteristics and management outcomes of adrenal gland pseudocysts. Human adrenal gland pseudocysts identified through imaging and histopathology, as retrieved from the PubMed search engine, were included in the study. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Joanna Briggs Institute (JBI) Critical Appraisal Checklist were used to stratify searched studies published between 2000 and 2023. A total of 39 studies were finally included, of which 36 were case reports and three case series, containing 45 patients in total. Data for clinical, radiological, histopathological, and outcome variables were collected, and descriptive analysis was carried out. All cases presented were adults with a clear female predominance of 66.67%. About 26.67% presented with no palpable mass or clinical symptoms, while 28.89% presented with vague abdominal pain. The most prevalent computed tomography (CT) finding was a cystic lesion with calcification and/or hemorrhage and/or necrosis, occurring in 17.78% of cases. Following this, a cystic lesion with only calcification was observed in 13.33% of cases, and a well-defined cystic mass/lesion was found in 11.11% of cases. The most important indication for surgery was compression effect in 44.44%, increasing size in 20.00%, and suspicion of malignancy in another 20.00% of cases. About 64.44% underwent open surgery, while 35.55% underwent minimally invasive surgery. Most patients, 95.55% of the total, had an uneventful postoperative course without any complications. Adrenal gland pseudocyst, though rare and incidental, warrants consideration in differential diagnosis as it presents with vague symptoms and sometimes no symptoms at all. Our review of existing literature highlights the importance of surgical intervention for symptomatic or potentially malignant cysts, with en bloc adrenalectomy being the preferred approach.

Adrenal washout CT in patients with no history of cancer: a waste of time?

PURPOSE

To validate the diagnostic performance of adrenal washout CT in patients without known malignancy in a Western Australian population.

METHODS

A radiology information system (RIS) search for CT reports containing "adrenal" and "washout" across six networked metropolitan public hospitals between January 2005 and November 2021. Homogenous nodules ≥ 1 cm, ≥ 10 HU without a suspected functional component in patients without a history of malignancy were included. Reported absolute and relative washout percentages were recorded and re-measured from unenhanced, 60-s portal venous and 15-min delayed phase imaging and compared to either histopathological or CT follow up for growth (≥ 12 months) reference standards.

RESULTS

2653 studies were screened with 191 meeting inclusion criteria. 105 nodules underwent washout CT and then had either histopathological (12 patients) or CT follow up (93 patients) reference standards available. Reported absolute washout (aWO) estimated sensitivity and specificity for malignant/indeterminate nodules was low at 33% (95% CI 25-43%) and 77% (95% CI 68-84%) respectively. Reported relative washout (rWO) sensitivity and specificity were 56% (95% CI 46-65%) and 69% (95% CI 60-77%) respectively. Negative predictive values for both aWO and rWO were reassuring at 92% (95% CI 86-96%) and 94% (95%CI 88-97%).

CONCLUSION

Our study validates a recent report suggesting that adrenal washout has poor sensitivity for and consequent limited utility to exclude malignancy in patients with no cancer history. However, patients with incidental adrenal nodules < 4 cm in size with benign washout can be reassured by the high negative predictive value and worked up to exclude functional adenoma and re-imaged in a year to confirm no growth.

A case of posterior mediastinal myelolipoma and a literature review of its imaging manifestations

Mediastinal myelolipoma is a rare condition and has no obvious symptoms. In the past 20 years, some clinical cases have been documented. However, the literature has not systematically summarized its imaging features. The aim of this paper is to present a case of right posterior mediastinal myelolipoma and to review and summarize its imaging features. Twenty-six articles were included in our study, which included a total of 26 patients and 33 lesions; 90.9% of the lesions were located in the mediastinum at the level from the 8th thoracic vertebral body to the thoracic 12th vertebral body. Among the cases with unilateral mediastinum, 68.4% of the cases were located in the right posterior mediastinum. Bilateral lesions accounted for almost one-fourth of all lesions. After contrast medium was injected, 93.9% of the lesions had mild to moderate enhancement; 84.8% of the lesions contained fat density; and 75.8%, 69.7%, 87.9%, and 75.8% of the lesions showed clear boundary, regular shape, heterogeneity and were encapsulated, respectively. Only 12.1% of the lesions contained calcification. An inhomogeneous mass in the right posterior mediastinum near the spine, including fat density, is the predominant imaging marker of most mediastinal myelolipomas.

T1-mapping characterization of two tumor types

T1 mapping is a quantitative method to characterize tissues with magnetic resonance imaging in a quick and efficient manner. It utilizes the relaxation rate of protons to depict the underlying structures within the imaging frame. While T1-mapping techniques are used with some frequency in areas such as cardiac imaging, their application for understanding malignancies and identifying tumor structures has yet to be thoroughly investigated. Utilizing a saturation recovery method to acquire T1 maps for two different tumor models has revealed that longitudinal relaxation mapping is sensitive enough to distinguish between normal and malignant tissue. This is seen even with decreased signal/noise ratios using small voxel sizes to obtain high-resolution images. In both tumor models, it was revealed that relaxation mapping recorded significantly different relaxation values between regions encapsulating the tumor, muscle, kidney, or spleen, as well as between the cell lines themselves. This indicates a potential future application of relaxation mapping as a method to fingerprint various stages of tumor development and may prove a useful measure to identify micro-metastases.

Supratrochlear Rim is Correlated with Isolated Patellar Chondromalacia on Magnetic Resonance Imaging of the Knee

Purpose

To investigate the relationship between the supratrochlear rim and isolated patellar chondromalacia (PC) using magnetic resonance imaging (MRI) scans of the knee.

Methods

Patients without patellofemoral pain (control group) and patients with patellofemoral pain and diagnosed with stage III or IV PC based on MRI (defect group) were retrospectively identified. Patients with a history of patellar subluxation were excluded. We used patient MRI scans to perform 20 anatomical measurements of the patellofemoral joint. We also performed 2 measurements of the anterior femoral curvature. A total of 30 patients (29 ± 8.7 years) were in the control group, and 20 patients were in the defect group (29.4 ± 9.7 years).

Results

The maximum curvature (P < .001) and mean curvature (P < .001) of the anterior femoral condyle were found statistically significantly different between the groups. Patellotrochlear index (P = .03) and Insall-Salvati index (P < .001) were also found statistically significantly different between the 2 groups. Patella type III and trochlear dysplasia grade B were found more common in the defect group.

Conclusions

In this Level III prognostic, case-control study, we have shown through MRI knee measurements that the isolated patellar chondromalacia in patients without a history of patellar subluxation and dislocation is correlated with the increased anterior femoral curvature in combination with patella alta.

Radiomics in the characterization of lipid-poor adrenal adenomas at unenhanced CT: time to look beyond usual density metrics

OBJECTIVES

In this study, we developed a radiomic signature for the classification of benign lipid-poor adenomas, which may potentially help clinicians limit the number of unnecessary investigations in clinical practice. Indeterminate adrenal lesions of benign and malignant nature may exhibit different values of key radiomics features.

METHODS

Patients who had available histopathology reports and a non-contrast-enhanced CT scan were included in the study. Radiomics feature extraction was done after the adrenal lesions were contoured. The primary feature selection and prediction performance scores were calculated using the least absolute shrinkage and selection operator (LASSO). To eliminate redundancy, the best-performing features were further examined using the Pearson correlation coefficient, and new predictive models were created.

RESULTS

This investigation covered 50 lesions in 48 patients. After LASSO-based radiomics feature selection, the test dataset's 30 iterations of logistic regression models produced an average performance of 0.72. The model with the best performance, made up of 13 radiomics features, had an AUC of 0.99 in the training phase and 1.00 in the test phase. The number of features was lowered to 5 after performing Pearson's correlation to prevent overfitting. The final radiomic signature trained a number of machine learning classifiers, with an average AUC of 0.93.

CONCLUSIONS

Including more radiomics features in the identification of adenomas may improve the accuracy of NECT and reduce the need for additional imaging procedures and clinical workup, according to this and other recent radiomics studies that have clear points of contact with current clinical practice.

CLINICAL RELEVANCE STATEMENT

The study developed a radiomic signature using unenhanced CT scans for classifying lipid-poor adenomas, potentially reducing unnecessary investigations that scored a final accuracy of 93%.

KEY POINTS

• Radiomics has potential for differentiating lipid-poor adenomas and avoiding unnecessary further investigations. • Quadratic mean, strength, maximum 3D diameter, volume density, and area density are promising predictors for adenomas. • Radiomics models reach high performance with average AUC of 0.95 in the training phase and 0.72 in the test phase.

Landscape of Adrenal Tumours in Patients with Congenital Adrenal Hyperplasia

Our aim is to update the topic of adrenal tumours (ATs) in congenital adrenal hyperplasia (CAH) based on a multidisciplinary, clinical perspective via an endocrine approach. This narrative review is based on a PubMed search of full-length, English articles between January 2014 and July 2023. We included 52 original papers: 9 studies, 8 case series, and 35 single case reports. Firstly, we introduce a case-based analysis of 59 CAH-ATs cases with four types of enzymatic defects (CYP21A2, CYP17A1, CYP17B1, and HSD3B2). Secondarily, we analysed prevalence studies; their sample size varied from 53 to 26,000 individuals. AT prevalence among CAH was of 13.3-20%. CAH prevalence among individuals with previous imaging diagnosis of AT was of 0.3-3.6%. Overall, this 10-year, sample-based analysis represents one of the most complex studies in the area of CAH-ATs so far. These masses should be taken into consideration. They may reach impressive sizes of up to 30-40 cm, with compressive effects. Adrenalectomy was chosen based on an individual multidisciplinary decision. Many tumours are detected in subjects with a poor disease control, or they represent the first step toward CAH identification. We noted a left lateralization with a less clear pathogenic explanation. The most frequent tumour remains myelolipoma. The risk of adrenocortical carcinoma should not be overlooked. Noting the increasing prevalence of adrenal incidentalomas, CAH testing might be indicated to identify non-classical forms of CAH.

Machine learning for differentiation of lipid-poor adrenal adenoma and subclinical pheochromocytoma based on multiphase CT imaging radiomics

BACKGROUND

There is a paucity of research investigating the application of machine learning techniques for distinguishing between lipid-poor adrenal adenoma (LPA) and subclinical pheochromocytoma (sPHEO) based on radiomic features extracted from non-contrast and dynamic contrast-enhanced computed tomography (CT) scans of the abdomen.

METHODS

We conducted a retrospective analysis of multiphase spiral CT scans, including non-contrast, arterial, venous, and delayed phases, as well as thin- and thick-thickness images from 134 patients with surgically and pathologically confirmed. A total of 52 patients with LPA and 44 patients with sPHEO were randomly assigned to training/testing sets in a 7:3 ratio. Additionally, a validation set was comprised of 22 LPA cases and 16 sPHEO cases from two other hospitals. We used 3D Slicer and PyRadiomics to segment tumors and extract radiomic features, respectively. We then applied T-test and least absolute shrinkage and selection operator (LASSO) to select features. Six binary classifiers, including K-nearest neighbor (KNN), logistic regression (LR), decision tree (DT), random forest (RF), support vector machine (SVM), and multi-layer perceptron (MLP), were employed to differentiate LPA from sPHEO. Receiver operating characteristic (ROC) curves and area under the curve (AUC) values were compared using DeLong's method.

RESULTS

All six classifiers showed good diagnostic performance for each phase and slice thickness, as well as for the entire CT data, with AUC values ranging from 0.706 to 1. Non-contrast CT densities of LPA were significantly lower than those of sPHEO (P < 0.001). However, using the optimal threshold for non-contrast CT density, sensitivity was only 0.743, specificity 0.744, and AUC 0.828. Delayed phase CT density yielded a sensitivity of 0.971, specificity of 0.641, and AUC of 0.814. In radiomics, AUC values for the testing set using non-contrast CT images were: KNN 0.919, LR 0.979, DT 0.835, RF 0.967, SVM 0.979, and MLP 0.981. In the validation set, AUC values were: KNN 0.891, LR 0.974, DT 0.891, RF 0.964, SVM 0.949, and MLP 0.979.

CONCLUSIONS

The machine learning model based on CT radiomics can accurately differentiate LPA from sPHEO, even using non-contrast CT data alone, making contrast-enhanced CT unnecessary for diagnosing LPA and sPHEO.

Correcting statistical CT number biases without access to raw detector counts: Applications to high spatial resolution photon counting CT imaging

BACKGROUND

Due to the nonlinear nature of the logarithmic operation and the stochastic nature of photon counts (N), sinogram data of photon counting detector CT (PCD-CT) are intrinsically biased, which leads to statistical CT number biases. When raw counts are available, nearly unbiased statistical estimators for projection data were developed recently to address the CT number bias issue. However, for most clinical PCD-CT systems, users' access to raw detector counts is limited. Therefore, it remains a challenge for end users to address the CT number bias issue in clinical applications.

PURPOSE

To develop methods to correct statistical biases in PCD-CT without requiring access to raw PCD counts.

METHODS

(1) The sample variance of air-only post-log sinograms was used to estimate air-only detector counts,N ¯ 0 $\bar{N}_0$ . (2) If the post-log sinogram data, y, is available, then N of each detector pixel was estimated usingN = N ¯ 0 e - y $N = \bar{N}_0 \, \mathrm{e}^{-y}$ . Once N was estimated, a closed-form analytical bias correction was applied to the sinogram. (3) If a patient's post-log sinogram data are not archived, a forward projection of the bias-contaminated CT image was used to perform a first-order bias correction. Both the proposed sinogram domain- and image domain-based bias correction methods were validated using experimental PCD-CT data.

RESULTS

Experimental results demonstrated that both sinogram domain- and image domain-based bias correction methods enabled reduced-dose PCD-CT images to match the CT numbers of reference-standard images within [-5, 5] HU. In contrast, uncorrected reduced-dose PCD-CT images demonstrated biases ranging from -25 to 55 HU, depending on the material. No increase in image noise or spatial resolution degradation was observed using the proposed methods.

CONCLUSIONS

CT number bias issues can be effectively addressed using the proposed sinogram or image domain method in PCD-CT, allowing PCD-CT acquired at different radiation dose levels to have consistent CT numbers desired for quantitative imaging.

Small Intestinal Volvulus Caused by Lipomatosis in a Middle-Aged Female

Lipomas are benign tumors composed of adipose tissue that can occur in various locations throughout the body, including the gastrointestinal (GI) tract. Lipoma of the small bowel is a rare clinical condition. It infrequently results in small bowel obstruction and volvulus. In most of the patients, it is an incidental diagnosis. However, it may present with abdominal pain, nausea, vomiting, GI bleeding, and constipation. It is commonly diagnosed using imaging studies, such as computerized tomography scan or magnetic resonance imaging. The management of small bowel lipomas depends on the presence of symptoms and the risk of complications. Asymptomatic lipomas can be safely monitored with imaging studies, as the risk of complications is low. However, in symptomatic cases, surgical or endoscopic treatment may be necessary to relieve obstruction and prevent complications. We report a case of volvulus of small bowel in a middle-aged female presenting to our hospital with acute GI symptoms.

Australian sonographers' perceptions of patient safety in ultrasound imaging: Part two - translation into practice

Introduction

A lack of patient safety research hampers capacity to improve safety in healthcare.Ultrasound is often considered 'safe' as it does not use ionising radiation, a simplistic view of patient safety. Understanding sonographers' actions towards patient safety is crucial; however, self-reported measures cannot always predict behaviour. This study is part of a PhD exploring patient safety in medical diagnostic ultrasound. The aim of this paper is to explore sonographers' responses to the patient safety concerns identified in Part one of this study. The ultimate aim of the study is to inform the final phase of the doctoral study which will consider the next steps in improving the quality and safety of healthcare experienced by patients.

Methods

A qualitative study using semi-structured, one-on-one interviews. The Theory of Planned Behaviour (TPB) explained how sonographers respond to perceived patient safety risks in practice.

Results

Thirty-one sonographers were interviewed. Based on the seven themes identified in Part one of the study, results showed that incongruences exist between identifying patient safety risks and the actions taken in practice to manage these risks.

Conclusion

The TPB showed that behavioural, normative and control beliefs impact sonographers' responses to perceived patient safety risks in practice and can lead to risk avoidance. Lack of regulation in ultrasound creates a challenge in dealing with Fitness to Practice issues. Collective actions are required to support sonographers in taking appropriate actions to enhance patient safety from multiple stakeholders including accreditation bodies, regulatory authorities, educational institutions and employers.

Renal cell carcinoma with contralateral adrenal metastasis: Case report

Renal cell carcinoma is the major cause of kidney malignancy. Its adrenal metastasis is less frequent and is even rarer when it is affected contralaterally or bilaterally. We present the case of a 55-year-old man with diffuse abdominal pain. An irregular mass in the lower third of the left renal cortex and another in the right adrenal gland. Pathology showed it was a renal cell carcinoma with metastasis in the contralateral adrenal gland.

Australian sonographers' perceptions of patient safety in ultrasound imaging: Part 1 - identifying the main safety concerns, a qualitative study

Introduction

Patient safety has been an undervalued component of quality healthcare but is a challenging area of research.Ultrasound is the most common imaging modality in the world. Research on patient safety in ultrasound is generally focused on bioeffects and safe operation of ultrasound equipment. However, other safety issues exist in practice that warrant consideration.This paper forms the first part of a PhD study exploring patient safety in medical diagnostic ultrasound, beyond the notion of bioeffects.The ultimate aim of the study is to inform the final phase of the research study which will consider the next steps in improving the quality and safety of healthcare experienced by patients.

Methods

A qualitative study using semi-structured, one-on-one interviews. A thematic analysis categorised data into codes and generated final themes.

Results

A heterogeneous mix of 31 sonographers, who reflected the profile of the profession in Australia, were interviewed between September 2019 and January 2020. Seven themes emerged from the analysis. These were bioeffects, physical safety, workload, reporting, professionalism, intimate examinations and infection control.

Conclusion

This study presents a comprehensive analysis of sonographers' perceptions of patient safety in ultrasound imaging, not previously available in the literature. Consistent with the literature, patient safety in ultrasound tends to be viewed in technical terms through the potential for bioeffects of tissue damage or physical harm to the patient. However, other patient safety issues have emerged, and while not as well recognised, have the potential to negatively impact on patient safety.

Radiation protection measures used in Portuguese interventional radiology departments: A national survey

INTRODUCTION

This study aimed to characterise radiation protection (RP) measures used in interventional radiology (IR) departments in Portugal with respect to European and national recommendations.

METHODS

An online national survey was created to characterise the fluoroscopy technology as well as analyse the frequency of body fluoroscopy-guided intervention procedures (FGIP), RP education and training of the staff, and RP measures used daily.

RESULTS

In Portugal, most equipment for FGIP are single-sourced and have a flat panel detector (70%). The most commonly FGIP are percutaneous biliary drainage, percutaneous arterial and venous thrombolysis/thrombectomy, arteriovenous malformations embolization, and percutaneous transluminal balloon angioplasty for arteriovenous fistulas. Only a few staff members had received postgraduate education and training in RP (30%), with most nurses having not received RP education and training (40%). Some of the recommended RP measures lacked harmonisation. Additionally, >50% of the IR departments do not consider examination dose values to identify patients eligible for tissue reactions follow-up.

CONCLUSION

This is the first study to examine the characteristics of IR departments in Portugal. We observed a lack of RP education and training among staff members; further, there was a need to update some RP measures in some IR departments according to the recommendations.

IMPLICATIONS FOR PRACTICE

Our findings will be presented to the participating IR departments in order to update and promote RP best practices. Moreover, our findings will be presented to the national societies of the different professional groups in order to inform strategies for harmonising RP education and training of the staff.

Machine learning analysis of adrenal lesions: preliminary study evaluating texture analysis in the differentiation of adrenal lesions

PURPOSE

This study aimed to determine the accuracy of texture analysis in differentiating adrenal lesions on unenhanced computed tomography (CT) images.

METHODS

In this single-center retrospective study, 166 adrenal lesions in 140 patients (64 women, 76 men; mean age 56.58 ± 13.65 years) were evaluated between January 2015 and December 2019. The lesions consisted of 54 lipid-rich adrenal adenomas, 37 lipid-poor adrenal adenomas (LPAs), 56 adrenal metastases (ADM), and 19 adrenal pheochromocytomas (APhs). Each adrenal lesion was segmented by manually contouring the borders of the lesion on unenhanced CT images. A texture analysis of the CT images was performed using Local Image Feature Extraction software. First-order and second-order texture parameters were assessed, and 45 features were extracted from each lesion. One-Way analysis of variance with Bonferroni correction and the Mann-Whitney U test was performed to determine the relationships between the texture features and adrenal lesions. Receiver operating characteristic curves were performed for lesion discrimination based on the texture features. Logistic regression analysis was used to generate logistic models, including only the texture parameters with a high-class separation capacity (i.e., P < 0.050). SPSS software was used for all statistical analyses.

RESULTS

First-order and second-order texture parameters were identified as significant factors capable of differentiating among the four lesion types (P < 0.050). The logistic models were evaluated to ascertain the relationships between LPA and ADM, LPA and APh, and ADM and APh. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of the first model (LPA vs. ADM) were 85.7%, 70.3%, 81.3%, 76.4%, and 79.5%, respectively. The sensitivity, specificity, PPV, NPV, and accuracy of the second model (LPA vs. APh) were all 100%. The sensitivity, specificity, PPV, NPV, and accuracy of the third model (ADM vs. APh) were 87.5%, 82%, 36.8%, 98.2%, and 82.7%, respectively.

CONCLUSION

Texture features may help in the characterization of adrenal lesions on unenhanced CT images.

Approach to the Patient With Adrenal Hemorrhage

Adrenal hemorrhage is an uncommon, underrecognized condition that can be encountered in several clinical contexts. Diagnosing adrenal hemorrhage is challenging due to its nonspecific clinical features. Therefore, it remains a diagnosis that is made serendipitously on imaging of acutely unwell patients rather than with prospective clinical suspicion. Adrenal hemorrhage can follow abdominal trauma or appear on a background of predisposing conditions such as adrenal tumors, sepsis, or coagulopathy. Adrenal hemorrhage is also increasingly reported in patients with COVID-19 infection and in the context of vaccine-induced immune thrombocytopenia and thrombosis. Unexplained abdominal pain with hemodynamic instability in a patient with a predisposing condition should alert the physician to the possibility of adrenal hemorrhage. Bilateral adrenal hemorrhage can lead to adrenal insufficiency and potentially fatal adrenal crisis without timely recognition and treatment. In this article, we highlight the clinical circumstances that are associated with higher risk of adrenal hemorrhage, encouraging clinicians to prospectively consider the diagnosis, and we share a diagnostic and management strategy.

Management of giant adrenal pseudocyst in pregnancy - A unique approach and review of literature

Pseudocysts of the adrenal gland are rare and in the majority of cases are non- functioning. They become symptomatic only when they are complicated by hormonal excess, rupture, haemorrhage or infection. Described here is a 26-year-old woman who developed an acute abdomen at 28 weeks of gestation due to a left adrenal haemorrhagic pseudocyst. A conservative approach was adopted, which was followed by elective term caesarean delivery with surgical intervention at the same time. The described case is unique in terms of strategizing timing and mode of management and thus minimizing the risk of prematurity and maternal morbidity associated with interval surgery.

Two nomograms based on radiomics models using triphasic CT for differentiation of adrenal lipid-poor benign lesions and metastases in a cancer population: an exploratory study

OBJECTIVES

To investigate the effectiveness of CT-based radiomics nomograms in differentiating adrenal lipid-poor benign lesions and metastases in a cancer population.

METHODS

This retrospective study enrolled 178 patients with cancer history from three medical centres categorised as those with adrenal lipid-poor benign lesions or metastases. Patients were divided into training, validation, and external testing cohorts. Radiomics features were extracted from triphasic CT images (unenhanced, arterial, and venous) to establish three single-phase models and one triphasic radiomics model using logistic regression. Unenhanced and triphasic nomograms were established by incorporating significant clinico-radiological factors and radscores. The models were evaluated by the receiver operating characteristic curve, Delong's test, calibration curve, and decision curve.

RESULTS

Lesion side, diameter, and enhancement ratio resulted as independent factors and were selected into nomograms. The areas under the curves (AUCs) of unenhanced and triphasic radiomics models in validation (0.878, 0.914, p = 0.381) and external testing cohorts (0.900, 0.893, p = 0.882) were similar and higher than arterial and venous models (validation: 0.842, 0.765; testing: 0.814, 0.806). Unenhanced and triphasic nomograms yielded similar AUCs in validation (0.903, 0.906, p = 0.955) and testing cohorts (0.928, 0.946, p = 0.528). The calibration curves showed good agreement and decision curves indicated satisfactory clinical benefits.

CONCLUSION

Unenhanced and triphasic CT-based radiomics nomograms resulted as a useful tool to differentiate adrenal lipid-poor benign lesions from metastases in a cancer population. They exhibited similar predictive efficacies, indicating that enhanced examinations could be avoided in special populations.

KEY POINTS

• All four radiomics models and two nomograms using triphasic CT images exhibited favourable performances in three cohorts to characterise the cancer population's adrenal benign lesions and metastases. • Unenhanced and triphasic radiomics models had similar predictive performances, outperforming arterial and venous models. • Unenhanced and triphasic nomograms also exhibited similar efficacies and good clinical benefits, indicating that contrast-enhanced examinations could be avoided when identifying adrenal benign lesions and metastases.

Imaging of pregnant and lactating patients with suspected adrenal disorders

A high level of clinical suspicion is essential in the diagnosis and management of a suspected adrenal mass during pregnancy and the peripartum period. Timely recognition is important in order to improve fetal and maternal outcomes. Imaging is often performed to confirm a suspected adrenal lesion; however, increasing usage of diagnostic imaging during pregnancy and lactation has also increased awareness, concerns and confusion regarding the safety risks regarding fetal and maternal exposure to radiation and imaging intravenous contrast agents. This may lead to anxiety and avoidance of imaging examinations which can delay diagnosis and appropriate treatment. This article briefly reviews evidence-based recommended imaging modalities during pregnancy and the lactation period for the assessment of a suspected adrenal mass while recognizing that no examination should be withheld when the exam is necessary to confirm an important clinical suspicion. The imaging characteristics of the more common adrenal pathologies that may affect pregnant women are also discussed.

Imaging Recommendations for Diagnosis, Staging, and Management of Adrenal Tumors

Adrenal glands are affected by a wide variety of tumors apart from infective and inflammatory lesions and their noninvasive characterization on imaging is important for the management of these patients. Incidentalomas form the major bulk of adrenal tumors and differentiation of benign adenomas from other malignant lesions, especially in patients with a known malignancy, guide further management. Imaging is an integral part of management along with clinical and biochemical features. The cornerstone of clinical and biochemical evaluation of adrenal tumors is to determine whether the lesion is functional or nonfunctional. Computed tomography (CT) is considered as the workhorse for imaging evaluation of adrenal lesions. CT densitometry and CT contrast washout characteristics are quite reliable in differentiating adenomas from malignant lesions. CT is also the modality of choice for the evaluation of resectability and staging of primary adrenal tumors. Magnetic resonance imaging (MRI) has superior contrast resolution compared to other morphological imaging modalities and is generally used as a problem-solving tool. MRI chemical shift imaging can also be used to reliably detect adrenal adenomas. Ultrasonography (USG) is used as a screening tool that is usually followed by either CT or MRI to better characterize the tumor and it is not routinely used for assessing the resectability, staging, and characterization of adrenal tumors. Another important role of USG is in image-guided sampling of tumors. Fluorodeoxyglucose positron emission tomography-computed tomography and other nuclear medicine modalities are a valuable addition to morphological imaging modalities. Image-guided interventions also play an important role in obtaining tissue samples where diagnostic imaging is not able to characterize adrenal tumors. In the functioning of adrenal tumors, adrenal venous sampling is widely used to accurately lateralize the secreting tumor.

The True Value of Quantitative Imaging for Adrenal Mass Characterization: Reality or Possibility?

The widespread use of cross-sectional imaging modalities, such as computed tomography (CT) and magnetic resonance imaging (MRI), in the evaluation of abdominal disorders has significantly increased the number of incidentally detected adrenal abnormalities, particularly adrenal masses [...].

Dual-energy spectral detector computed tomography differential diagnosis of adrenal adenoma and pheochromocytoma: Changes in the energy level curve, a phenomenon caused by lipid components?

Background and objectives

Pheochromocytoma and adrenal adenoma are common space-occupying lesions of the adrenal gland, and incorrect surgery may lead to adrenal crisis. We used a new method, dual-energy spectral detector computed tomography (SDCT), to differentiate between the two.

Materials and methods

We analysed the imaging images of patients with SDCT scans and pathologically confirmed adrenal adenomas (n=70) and pheochromocytomas (n=15). The 40, 70, and 100 KeV virtual monoenergetic images (VMIs) were reconstructed based on the SCDT arterial phase, and the correlation between the arterial/venous phase iodine concentration (AP-IC/VP-IC), the effective atomic number (Z-effect), the slope of the Hounsfield unit attenuation plot (VMI slope) and the pathological results was tested. The Shapiro-Wilk test was used to determine whether the above data conformed to a normal distribution. For parameters with P greater than 0.05, Student's t test was used, and the Mann-Whitney test was used for the remaining parameters. A ROC curve was drawn based on the results.

Results

Student's t test showed that the 40 KeV VMI and the VMI slope were both statistically significant (P<0.01). The Mann-Whitney U test showed that ID-A was statistically significant (P=0.004). ROC curve analysis showed that 40 keV VMI (AUC=0.818), AP-IC (AUC=0.736), difference (AUC=0.817) and VMI-Slope (0.817) could be used to differentiate adrenal adenoma from pheochromocytoma.

Conclusion

The effect of lipid components on SDCT parameters can be used to differentiate adrenal adenoma from pheochromocytoma.

Mentoring as an Appropriate Strategy for Medical Faculty Member Development in Higher Education: A Systematic Review

INTRODUCTION

Human resources development, especially faculty members who play a substantial role in education, is of great importance and can lead to enhanced competence and participation of employees in university affairs. Mentoring is one of the programs that have attracted the attention of activists in this field today. This review aims to integrate the evidence about the goals, methods, implementation steps, and consequences of the mentoring methods for faculty member development in higher education institutions.

METHODS

We used a systematic review in this study. Keywords related to the mentoring program were searched in gateways and databases such as PubMed, Scopus, Web of Science, and ERIC from 2000 to 2021. In the initial search, 638 articles were found, and 16 studies were reviewed after excluding those unrelated to the research objective.

RESULTS

The results showed that the mentoring program included three stages: "Targeting and Familiarization with the Implementation of the Mentoring Program", "Mentoring Program Implementation", and "Evaluation of the Mentoring Program". The implementation approaches included Traditional One-to-one Mentoring Program, Peer Mentoring Program, and Distance Education Mentoring Program.

CONCLUSION

This study identified the stages and types of mentoring programs and revealed that their employment, especially the distance education mentoring program, led to the advancement of faculty members in various fields. A mixed-method approach to program evaluation can provide more appropriate views of the effects of these programs.

Role of preoperative CT angiography with multimodality imaging reconstruction to perform laparoscopic Complete Mesocolic Excision (CME) and Central Vascular Ligation (CVL) in right-sided colon cancer: Is it really useful? A prospective clinical study

BACKGROUND

The concept of complete mesocolic excision (CME) and central vascular ligation (CVL) in right colonic resections appears to improve the oncological outcomes. The highest rate of complications reported in the literature in patients undergoing CME is related to difficult surgical manuevers and intraoperative bleeding due to the central vascular dissection.

METHODS

We used preoperative findings obtained with the CT angiography, multiplanar reformation (MPR), maximum intesity projection (MIP) and 3D volume rendering (VR) technique to verify if this preoperative radiological assessment had significant benefits regarding the difficulty of dissection of the embryological planes, the identification of vascular structures and central lymph nodes with reduction in mean operative time, intraoperative complications and better short-term outcomes versus standard contrast enhanced CT scan. We also have administered a questionnaire to investigate the subjective responses on the degree of difficulty of the surgical procedure both by the surgical team expert in CME and by a group of young surgeons.

RESULTS

Statistical analysis showed that overall operative time was significant shorter in patients underwent to radiological assessment (224,5 min; range 160-300 versus 252,6 min; range 200-340; p-value 0.023) with a significant lower rate of intraoperative complication (2.7% versus 4.2%; p-value 0.043). No differences were reported with respect to blood loss, conversion rate, anastomotic leakage or other surgical results. Analysis of the questionnaire underlined a progressive awareness of the correspondence between the radiological imaging and the surgical field.

CONCLUSION

The possibility of identifying the characteristics and course of the vascular structures along the axis of the superior mesenteric vessels certainly increases the surgeon's knowledge of the operating field, making him more confident with surgical maneuvers and significantly reducing the duration of the operating time and intraoperative complications.

Teaching radiology in Egyptian medical schools: Where do we stand and how can we start?

Background

Radiology serves in the diagnosis and management of many diseases. Despite its rising importance and use, radiology is not a core component of a lot of medical school curricula. This survey aims to clarify current gaps in the radiological education in Egyptian medical schools. In February–May 2021, 5318 students enrolled in Egyptian medical schools were recruited and given a 20-multiple-choice-question survey assessing their radiology knowledge, radiograph interpretation, and encountered imaging experiences. We measured the objective parameters as a percentage. We conducted descriptive analysis and used Likert scales where values were represented as numerical values. Percentages were graphed afterwards.

Results

A total of 5318 medical students in Egypt answered our survey. Gender distribution was 45% males and 54% females. The results represented all 7 class years of medical school (six academic years and a final training year). In assessing students’ knowledge of radiology, most students (75%) reported that they received ‘too little’ education, while 20% stated the amount was ‘just right’ and only 4% reported it was ‘too much.’ Sixty-two percent of students stated they were taught radiology through medical imaging lectures. Participants’ future career plans were almost equally distributed. Near half of participants (43%) have not heard about the American College of Radiology Appropriateness Criteria (ACR-AR), while 39% have heard about it but are not familiar with.

Conclusions

Radiology is a novel underestimated field. Therefore, medical students need more imaging exposure. To accomplish this, attention and efforts should be directed toward undergraduate radiology education to dissolve the gap between radiology and other specialties during clinical practice. A survey answered by medical students can bridge between presence of any current defect in undergraduate radiology teaching and future solutions for this topic.

The augmented radiologist: artificial intelligence in the practice of radiology

In medicine, particularly in radiology, there are great expectations in artificial intelligence (AI), which can "see" more than human radiologists in regard to, for example, tumor size, shape, morphology, texture and kinetics - thus enabling better care by earlier detection or more precise reports. Another point is that AI can handle large data sets in high-dimensional spaces. But it should not be forgotten that AI is only as good as the training samples available, which should ideally be numerous enough to cover all variants. On the other hand, the main feature of human intelligence is content knowledge and the ability to find near-optimal solutions. The purpose of this paper is to review the current complexity of radiology working places, to describe their advantages and shortcomings. Further, we give an AI overview of the different types and features as used so far. We also touch on the differences between AI and human intelligence in problem-solving. We present a new AI type, labeled "explainable AI," which should enable a balance/cooperation between AI and human intelligence - thus bringing both worlds in compliance with legal requirements. For support of (pediatric) radiologists, we propose the creation of an AI assistant that augments radiologists and keeps their brain free for generic tasks.

Adrenal Lesions: A Review of Imaging

Adrenal lesions are frequently incidentally diagnosed during investigations for other clinical conditions. Despite being usually benign, nonfunctioning, and silent, they can occasionally cause discomfort or be responsible for various clinical conditions due to hormonal dysregulation; therefore, their characterization is of paramount importance for establishing the best therapeutic strategy. Imaging techniques such as ultrasound, computed tomography, magnetic resonance, and PET-TC, providing anatomical and functional information, play a central role in the diagnostic workup, allowing clinicians and surgeons to choose the optimal lesion management. This review aims at providing an overview of the most encountered adrenal lesions, both benign and malignant, including describing their imaging characteristics.

Detection of incidental adrenal nodules on computed tomography by radiographers

INTRODUCTION

This research investigated whether radiographers' age, qualifications, shift rotations and years of post-qualification experience as a radiographer affect the detection rate of incidental adrenal nodules, also known as adrenal incidentalomas in Malta. Additionally, local statistics of adrenal incidentaloma findings were evaluated.

METHODS

This research consisted of two phases and employed a non-experimental, cross-sectional quantitative approach. Phase 1 comprised of a self-designed data collection sheet to retrospectively determine the occurrence of recalled computed tomography (CT) examinations resulting from an adrenal incidentaloma finding during a six-month period between July 2020 and December 2020. In phase 2, a self-designed questionnaire with anonymised CT scan images (n = 30) displayed on ViewDex (Viewer for Digital Evaluation of X-ray images) was prospectively completed by CT radiographers (n = 23) to identify adrenal incidentalomas on the images.

RESULTS

In phase 1, adrenal incidentalomas were present in 1.4% of contrast-enhanced CT (CECT) examinations (n = 12139), out of which, 79.8% were not acknowledged by the radiographers on the initial scans and patients had to be recalled for a dedicated adrenal CT scan. In phase 2, a statistically significant (p < 0.05) relationship was determined between the radiographers' qualifications, shift rotations and years of post-qualification experience as a radiographer, with their detection rate of adrenal incidentalomas.

CONCLUSION

Findings suggest that radiographers' qualifications, shift rotations and years of post-qualification experience were found to be statistically significant factors affecting their detection rate of adrenal incidentalomas. These could have contributed to one of the reasons for recalling patients, which in turn results in an added burden to both the patient and the Radiology Department.

IMPLICATIONS FOR PRACTICE

Detection of adrenal incidentalomas by radiographers has a direct impact on clinical practice. If identified during the initial CT examination and a further delay scan is performed, this will benefit patients by reducing the risks of additional radiation and potential risks from contrast media administration; prompt diagnosis and treatment. While the Radiology Department benefits in terms of cost effectiveness, work load and appointment scheduling.

Automated vetting of radiology referrals: exploring natural language processing and traditional machine learning approaches

Background

With a significant increase in utilisation of computed tomography (CT), inappropriate imaging is a significant concern. Manual justification audits of radiology referrals are time-consuming and require financial resources. We aimed to retrospectively audit justification of brain CT referrals by applying natural language processing and traditional machine learning (ML) techniques to predict their justification based on the audit outcomes.

Methods

Two human experts retrospectively analysed justification of 375 adult brain CT referrals performed in a tertiary referral hospital during the 2019 calendar year, using a cloud-based platform for structured referring. Cohen’s kappa was computed to measure inter-rater reliability. Referrals were represented as bag-of-words (BOW) and term frequency-inverse document frequency models. Text preprocessing techniques, including custom stop words (CSW) and spell correction (SC), were applied to the referral text. Logistic regression, random forest, and support vector machines (SVM) were used to predict the justification of referrals. A test set (300/75) was used to compute weighted accuracy, sensitivity, specificity, and the area under the curve (AUC).

Results

In total, 253 (67.5%) examinations were deemed justified, 75 (20.0%) as unjustified, and 47 (12.5%) as maybe justified. The agreement between the annotators was strong (κ = 0.835). The BOW + CSW + SC + SVM outperformed other binary models with a weighted accuracy of 92%, a sensitivity of 91%, a specificity of 93%, and an AUC of 0.948.

Conclusions

Traditional ML models can accurately predict justification of unstructured brain CT referrals. This offers potential for automated justification analysis of CT referrals in clinical departments.

MR imaging of acute abdominal pain in pregnancy

Abdominal pain in pregnancy is a diagnostic challenge with many potential aetiologies. Diagnostic imaging is a valuable tool in the assessment of these patients, with ultrasound commonly employed first line. MRI is an excellent problem-solving adjunct to ultrasound and has many advantages in terms of improved spatial resolution and soft tissue characterisation. This pictorial review aims to outline the role of MRI in the work up of acute abdominal pain in pregnancy and provide imaging examples of pathologies which may be encountered.

Fluoro-2-Deoxyglucose-Positron Emission Tomography/Computed Tomography in the Diagnosis and Management of Adrenocortical Carcinoma: A 10-Year Experience from a Tertiary Care Institute

Purpose

Adrenocortical carcinoma (ACC) is a rare primary malignancy of the adrenal gland. The present study was aimed to compare the performance of fluoro-2-deoxyglucose-positron emission tomography-computed tomography (FDG-PET-CT) compared to contrast-enhanced computed tomography (CECT) in diagnosis and management of ACC.

Materials and Methods

A retrospective analysis of the PET-CT studies from January 2010 to October 2020 was performed. Patients with adrenal lesions suspicious of ACC and diagnosed cases of ACC who underwent PET-CT for staging, restaging, and surveillance were reanalyzed. The PET-CT parameters were compared with the clinical, biochemical, histopathological, and CECT parameters.

Results

The study included 96 scans performed in 77 patients (36 males, aged 40.4 ± 17.9 years). Of these, 55 scans were performed to diagnose and stage suspected ACC (30 of them diagnosed as ACC), 31 for restaging, and 10 scans for surveillance of ACC. PET/CT revealed metastases from an extra-adrenal primary in 5/55 patients. FDG-PET-CT had a sensitivity and specificity of 100% and 70% to diagnose ACC. Standardized uptake value-peak more than 5.4 had a sensitivity of 90.9% and specificity of 91.7% for differentiating ACC from non-ACC lesions, while tumor-to-liver ratio peak (TLRpeak) of 3.3 was most specific. PET-CT changed the staging in 23.3% of the patients with an accuracy of 100%. PET-CT changed the management plan in 25.8% of the patients during restaging with a sensitivity and specificity of 95.6% and 100%, respectively. For surveillance, CECT was as sensitive as PET-CT; however, PET-CT was more specific (100% vs. 97.9%).

Conclusion

FDG-PET-CT performs better than CECT in the diagnosis, staging, restaging, and surveillance of ACC.

The Impacts of Vertical Off-Centring, Localiser Direction, Phantom Positioning and Tube Voltage on CT Number Accuracy: An Experimental Study

Background: This study investigates the effects of vertical off-centring, localiser direction, tube voltage, and phantom positioning (supine and prone) on computed tomography (CT) numbers and radiation dose. Methods: An anthropomorphic phantom was scanned using a Discovery CT750 HD—128 slice (GE Healthcare) scanner at different tube voltages (80, 120, and 140 kVp). Images employing 0° and 180° localisers were acquired in supine and prone positions for each vertical off-centring (±100, ±60, and ±30 mm from the iso-centre). CT numbers and displayed volume CT dose index (CTDIvol) were recorded. The relationship between dose variation and CT number was investigated. Results: The maximum changes in CT number between the two phantom positions as a function of vertical-off-centring were for the upper thorax 34 HU (0° localiser, 120 kVp), mid thorax 43 HU (180° localiser, 80 kVp), and for the abdominal section 31 HU (0° localiser, 80 kVp) in the prone position. A strong positive correlation was reported between the variation in dose and CT number (r = 0.969, p < 0.001); 95% CI (0.93, 0.99). Conclusions: Patient positioning demands an approach with a high degree of accuracy, especially in cases where clinical decisions depend on CT number accuracy for tissue lesion characterisation.

Results of Port-A-Cath Implantation: A Cross-Sectional Study about a Single Tertiary Cancer Center Experience

Background: Identifying possible complications accompanying central venous catheterization may improve the results. The current study was conducted to clarify the complication rate among port-a-cath implantation in children referred to Ali-Asghar hospital from 2011 to 2015. This study was designed to determine complication rates among the pediatric population who underwent port-a-cath implantation for chemotherapy. Methods: The current observational study reviewed the medical documents of children who were referred to Ali-Asghar hospital from 2011 to 2015. Factors such as underlying disease, demographic characteristics, complications and their management were considered. We analyzed the results of this study using multivariate logistic regression. Results: A total number of 100 patients met the eligibility criteria. In Thirty-two cases, chemoport catheters were removed due to complication management or termination of adjuvant chemotherapeutic treatment. Fifty-one boys and forty-nine girls enrolled in the study. The mean duration of catheter preservation defined per patient was 693 days ±1 year SD. 14 catheters were removed followed by planned treatment termination, while 18 catheters were complicated due to port dysfunction, infection, skin necrosis, and extravasation, hematoma in order of decreasing. Conclusion: Chemo port utilization is mandatory in pediatric patients with cancers demanding adjuvant treatment. The possible complications would be managed by a variety of protocols. Respecting anti-septic principles by trained personnel will prevent the majority of associated complications.

A narrative review of current and emerging MRI safety issues: What every MRI technologist (radiographer) needs to know

Magnetic resonance imaging (MRI) has been traditionally regarded as a safe imaging modality due to the absence of ionising radiation. However, MRI is a source of potential hazards with a variety of risks including, but not limited to, those associated with the various electromagnetic fields used for imaging. All MRI technologists (radiographers) require sound knowledge of the physical principles of the MRI scanner and must understand the associated safety risks and how to avoid adverse events from occurring. MRI technologists now assume more responsibility in clinical decision-making, and their knowledge base has consequently had to expand significantly. In addition, rapid advancements in MRI technology and other correlated areas such as medical implant technology, and the associated increase in MRI safety issues, place increasing demands on the MRI technologist to constantly keep abreast of current and future developments. This article reviews current and emerging MRI safety issues relevant to the three MRI electromagnetic fields and highlights the key information that all MRI technologists should be fully cognisant of to ensure competent and safe practice within the MRI environment.

Correlation between Radiological Images and Histopathological Type of Meningioma: A Cohort Study

Background

Histologically affirmed meningiomas represent 37.6% of all essential central nervous system tumors and half of all types of critical central nervous system tumors. This study compares computed tomography (CT) scans of the head with histological findings to establish the characteristics of different types of meningiomas observed in eastern Indonesia.

Methods

This prospective study evaluated 224 patients by examining the correlation between histological and CT data collected from January to December 2020 at Wahidin Sudirohusodo Hospital, Makassar, Indonesia. We assessed data including the location of pre- and post-contrast CT scans, number of tumors, margin, density, contrast enhancement, bony reaction, calcification, and perifocal edema. Patients underwent biopsies followed by an examination of the anatomical pathology tissue.

Results

The female-to-male ratio of participants was 4.2 to 1, and the highest incidence was observed in participants of both genders aged 40-60 years. The most common meningioma subtype was meningothelial, while the most commonly observed locations involved the convexity and sphenoid regions. Most meningiomas had well-defined margins on CT imaging: 54.5% of patients exhibited isodense lesions on pre-contrast scans, and 64.7% exhibited high-contrast enhancement. Bone destruction developed in 4.1% of patients, while hyperostosis was observed in 17.4%, and calcification was present in 10.3% of the participants. Edema was identified in 65.2% of cases, of which moderate edema was the most common manifestation.

Conclusion

Meningioma should be highly suspected in female patients aged 40-60 with isodense lesions on pre-contrast CT scans and high-contrast enhancement on post-contrast CT scans. Meningiomas were primarily classified as convexity meningiomas with well-defined margins. The presence of hyperostosis, calcification, and brain edema supported the meningioma diagnosis.

A qualitative study to explore opinions of Saudi Arabian radiologists concerning AI-based applications and their impact on the future of the radiology

Objective

The aim of this study was to explore opinions and views towards radiology AI among Saudi Arabian radiologists including both consultants and trainees.

Methods

A qualitative approach was adopted, with radiologists working in radiology departments in the Western region of Saudi Arabia invited to participate in this interview-based study. Semi-structured interviews (n = 30) were conducted with consultant radiologists and trainees. A qualitative data analysis framework was used based on Miles and Huberman's philosophical underpinnings.

Results

Several factors, such as lack of training and support, were attributed to the non-use of AI-based applications in clinical practice and the absence of radiologists' involvement in AI development. Despite the expected benefits and positive impacts of AI on radiology, a reluctance to use AI-based applications might exist due to a lack of knowledge, fear of error and concerns about losing jobs and/or power. Medical students' radiology education and training appeared to be influenced by the absence of a governing body and training programmes.

Conclusion

The results of this study support the establishment of a governing body or national association to work in parallel with universities in monitoring training and integrating AI into the medical education curriculum and residency programmes.

Advances in knowledge

An extensive debate about AI-based applications and their potential effects was noted, and considerable exceptions of transformative impact may occur when AI is fully integrated into clinical practice. Therefore, future education and training programmes on how to work with AI-based applications in clinical practice may be recommended.

Influence of COVID-19 pandemic lockdown on a sample of Egyptian children with Down syndrome

Background

Down syndrome (DS) is characterized by variable degrees of intellectual disability (ID). The coronavirus disease-2019 (COVID-19) lockdown prevented children with DS from reaching their rehabilitation facilities. This could have led to deterioration of their abilities and mental health hazards. The aim of this cohort study was to investigate frequency of COVID-19, the influence of COVID-19 pandemic on health, and some abilities of children with DS, and to explore factors that could have governed receiving home-based training during the lockdown. A survey of 150 individuals with Down syndrome was answered by their caregivers. Additionally, 135 participants were subjected to assessment of cognitive, language, and motor abilities using Portage program. They were divided into 2 groups: group I who received online therapy sessions during the lockdown and group II who did not receive sessions. Logistic regression was used to determine the factors which influenced getting home-based training.

Results

The percentage of COVID-19 cases was 3.3%. All evaluated abilities were reduced despite receiving online sessions particularly language performance (P < 0.001). Male gender, having severe ID and low parental education were among the factors which encouraged parents to get virtual training.

Conclusion

COVID-19 pandemic had a negative impact on the abilities of DS children even those who got rehabilitation sessions. Their dependence on social interaction could have limited the benefit of virtual sessions. Factors that influence a parent's decision to get home-based training should be monitored and targeted in order to overcome obstacles or concepts that may prevent families from enduring home-based intervention.

Radiomics in Cross-Sectional Adrenal Imaging: A Systematic Review and Quality Assessment Study

In this study, we aimed to systematically review the current literature on radiomics applied to cross-sectional adrenal imaging and assess its methodological quality. Scopus, PubMed and Web of Science were searched to identify original research articles investigating radiomics applications on cross-sectional adrenal imaging (search end date February 2021). For qualitative synthesis, details regarding study design, aim, sample size and imaging modality were recorded as well as those regarding the radiomics pipeline (e.g., segmentation and feature extraction strategy). The methodological quality of each study was evaluated using the radiomics quality score (RQS). After duplicate removal and selection criteria application, 25 full-text articles were included and evaluated. All were retrospective studies, mostly based on CT images (17/25, 68%), with manual (19/25, 76%) and two-dimensional segmentation (13/25, 52%) being preferred. Machine learning was paired to radiomics in about half of the studies (12/25, 48%). The median total and percentage RQS scores were 2 (interquartile range, IQR = −5–8) and 6% (IQR = 0–22%), respectively. The highest and lowest scores registered were 12/36 (33%) and −5/36 (0%). The most critical issues were the absence of proper feature selection, the lack of appropriate model validation and poor data openness. The methodological quality of radiomics studies on adrenal cross-sectional imaging is heterogeneous and lower than desirable. Efforts toward building higher quality evidence are essential to facilitate the future translation into clinical practice.

Intra- and inter-rater reliability of compressed breast thickness, applied force, and pressure distribution in screening mammography

Background

Ensuring equivalent and reproducible breast compression between mammographic screening rounds is important for the diagnostic performance of mammography, yet the extent to which screening mammography positioning and compression is reproducible for the individual woman is unknown.

Purpose

To investigate the intra- and inter-rater reliability of breast compression in screening mammography.

Materials and Methods

Eleven breast-healthy women participated in the study. Two experienced radiographers independently positioned and compressed the breasts of each participant in two projections—right craniocaudal and left mediolateral oblique—and at two time points. The spatial pressure distribution on the compressed breast was measured using a pressure sensor matrix. Applied force, compressed breast thickness, force in field of view, contact area, mean pressure, and center of mass (anterio-posterior and mediolateral axes) were measured. The reliabilities of the measures between the time points for each radiographer (intra-rater reliability) and between the radiographers (inter-rater reliability) were analyzed using the intraclass correlation coefficient (ICC).

Results

Intra- and inter-rater reliabilities from both projections demonstrated good to excellent ICCs (≥0.82) for compressed breast thickness, contact area, and anterio-posterior center of mass. The other measures produced ICCs that varied from poor (≤0.42) to excellent (≥0.93) between time points and between radiographers.

Conclusion

Intra- and inter-rater reliability of breast compression was consistently high for compressed breast thickness, contact area, and anterio-posterior center of mass but low for mediolateral center of mass and applied force. Further research is needed to establish objective and clinically useful parameters for the standardization of breast compression.

Osteolytic bone lesions in patients with primary myelofibrosis: A systematic review

Philadelphia negative myeloproliferative neoplasms (MPNs) are classically characterized by excess production of terminal myeloid cells in the peripheral blood. They include polycythemia vera, essential thrombocythemia, and primary myelofibrosis. Among this group, primary myelofibrosis is the least common and usually carries the worst prognosis. Bone involvement in primary myelofibrosis has many forms; it affects bone marrow leading to bone marrow fibrosis, it can cause periostitis, in addition to bone and joint pain. A common radiologic finding in primary myelofibrosis is the presence of osteosclerotic lesions. However, the presence of osteolytic lesions in bone imaging was described in few reports. In this review, we searched English literature using the PRISMA guidelines looking for patients with Primary myelofibrosis who had osteolytic bone lesions to assess the impact of such findings on the disease and its effect on prognosis. We found the vast majority of lesions were painful affecting most commonly the vertebral column, pelvis, and ribs, and were detected in patients above 50 years of age with no gender preference, unfortunately they represented advanced disease stages, resulting in inadequate treatment response and poor outcome.

Feminizing adrenocortical adenoma in a girl from a resource-limited setting: a case report

Background

An adrenocortical tumor is a rare tumor in pediatrics, which can be functional or nonfunctional. Functional tumors present with virilization, feminization, or hypercortisolism. Feminizing adrenal tumors, though rare in pediatrics, need to be excluded in any child presenting with features of feminization.

Case presentation

We report a case of a 4-year-old Sudanese girl who presented with gradually progressive bilateral breast enlargement and accelerated growth since the age of 6 months. The family had sought medical advice several times in numerous health facilities without much gain. Investigations showed pubertal luteinizing hormone levels, high estradiol E2, and dehydroepiandrosterone sulfate, with normal early morning cortisol level. Abdominal ultrasound revealed a right-sided hypoechoic suprarenal mass. Abdominal computed tomography scan showed a right adrenal mass. The diagnosis of feminizing adrenal neoplasm was confirmed and right adrenalectomy was done. Histopathological examination of the resected adrenal gland showed adrenocortical adenoma. The patient was started on gonadotrophin-releasing hormone agonist for secondary central precocious puberty.

Conclusion

Adrenocortical tumors, though rare in pediatrics, are a documented cause of precocious puberty; biochemical and imaging screening protocol should be adopted for patients with precocious puberty, even in a resource-limited setting, for early detection and treatment.

Adrenocortical Carcinoma Diagnosed by Endoscopic Ultrasound-guided Fine-needle Aspiration

Adrenocortical carcinoma (ACC) is a rare malignancy with a very poor prognosis. A 77-year-old man underwent imaging studies due to poorly controlled hypertension, which revealed a mass measuring 43 mm in diameter near the left adrenal gland. There were no findings indicative of pheochromocytoma. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed for the preoperative pathological evaluation, and the findings indicated a possibility of ACC. Based on these results, curative surgery was performed. If the diagnosis of pheochromocytoma is excluded, then EUS-FNA for adrenal lesions is relatively safe. It can also be used for the preoperative diagnosis of ACC.

The reliability of CT numbers as absolute values for diagnostic scanning, dental imaging, and radiation therapy simulation: A narrative review

BACKGROUND AND PURPOSE

The purpose of this review was to examine the reported factors that affect the reliability of Computed Tomography (CT) numbers and their impact on clinical applications in diagnostic scanning, dental imaging, and radiation therapy dose calculation.

METHODS

A comprehensive search of the literature was conducted using Medline (PubMed), Google Scholar, and Ovid databases which were searched using the keywords CT number variability, CT number accuracy and uniformity, tube voltage, patient positioning, patient off-centring, and size dependence. A narrative summary was used to compile the findings under the overarching theme.

DISCUSSION

A total of 47 articles were identified to address the aim of this review. There is clear evidence that CT numbers are highly dependent on the energy level applied based on the effective atomic number of the scanned tissue. Furthermore, body size and anatomical location have also indicated an influence on measured CT numbers, especially for high-density materials such as bone tissue and dental implants. Patient off-centring was reported during CT imaging, affecting dose and CT number reliability, which was demonstrated to be dependent on the shaping filter size.

CONCLUSION

CT number accuracy for all energy levels, body sizes, anatomical locations, and degrees of patient off-centring is observed to be a variable under certain common conditions. This has significant implications for several clinical applications. It is crucial for those involved in CT imaging to understand the limitations of their CT system to ensure radiologists and operators avoid potential pitfalls associated with using CT numbers as absolute values for diagnostic scanning, dental imaging, and radiation therapy dose calculation.

Primary adrenal tuberculosis infection in patients with Behcet's disease presenting as isolated adrenal metastasis by 18F-FDG PET/CT: a rare case report and literature review

Primary adrenal tuberculosis (TB) is a rare type of extrapulmonary tuberculosis (EPTB). A pathological biopsy is usually required to make a definite diagnosis due to nonspecific symptoms. Antituberculous chemotherapy is the main treatment regimen, and cortisol replacement therapy should be added when adrenal insufficiency is involved. Here, we present a 59-year-old man who had recurrence of oral and genital aphthosis for 3 years and was diagnosed with Behcet's disease (BD), which was cured by thalidomide. After 10 days of admission, the patient had sudden abdominal pain in the right upper quadrant with high fever and was diagnosed with acute cholecystitis attack, which was treated by percutaneous transhepatic gallbladder drainage (PTGBD). Further contrast-enhanced CT showed a right adrenal mass with a diameter of 2.0 cm, and PET-CT indicated intense ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) uptake in the right adrenal mass with a maximum standardized uptake value (SUV_max) of 15.2. As a metastatic adrenal mass was suspected, the patient underwent retroperitoneal laparoscopic adrenalectomy. Histopathological and immunohistochemical analysis revealed primary adrenal TB. After routine anti-tuberculosis treatment with isoniazid, rifampin, pyrazinamide and ethambutol for six months, the patient was cured and discharged. In summary, primary unilateral adrenal TB without adrenal insufficiency is difficult to diagnose only on the basis of clinical manifestations and examinations. Further studies are needed to develop an easier and more accurate diagnostic examination.

Low-Field Magnetic Resonance Imaging: Its History and Renaissance

ABSTRACT

Low-field magnetic resonance imaging (MRI) systems have seen a renaissance recently due to improvements in technology (both hardware and software). Originally, the performance of low-field MRI systems was rated lower than their actual clinical usefulness, and they were viewed as low-cost but poorly performing systems. However, various applications similar to high-field MRI systems (1.5 T and 3 T) have gradually become possible, culminating with high-performance low-field MRI systems and their adaptations now being proposed that have unique advantages over high-field MRI systems in various aspects. This review article describes the physical characteristics of low-field MRI systems and presents both their advantages and disadvantages for clinical use (past to present), along with their cutting-edge clinical applications.

Mixed cortico-medullary adrenal carcinoma in children: looks are deceptive!!

Background

Mixed cortico-medullary adrenal carcinoma (MCMAC) is an extremely rare entity with scarce literature on its cytomorphology.

Case presentation

A 2-year-old girl presented with abdominal pain for 3 days and a past history of fever with significant weight loss. On examination, a non-tender left hypochondrial firm mass and an enlarged left supraclavicular node were found. Twenty-four-hour urinary levels of VMA were marginally high. Contrast-enhanced computed tomography of the abdomen showed a suprarenal heterogeneous mass encasing major vessels. Aspiration cytology of both mass and node showed similar features comprising a predominant population of singly scattered large cells with moderate cytoplasm, eccentric nucleus and prominent nucleolus in a necrotic background. Tumour cells expressed Synaptophysin and Melan-A. In view of increasing respiratory distress, debulking surgery was performed, and histopathology of the specimen revealed the presence of both malignant medullary and cortical components supported by immunohistochemistry making a final diagnosis of MCMAC. The patient succumbed to death in the postoperative period. The cytology slides were reviewed and were seen to show a dual cell population.

Conclusion

Coexistent malignant cortical and medullary tumour of the adrenal gland is the first case reported in the paediatric age group in the literature with only three previous case reports in adults.

Adrenal hemorrhage and hemorrhagic masses; diagnostic workup and imaging findings

Adrenal hemorrhage (AH) is a rare condition. It can be traumatic or non-traumatic. Most common causes are septicemia, coagulopathy or bleeding diathesis, and underlying neoplasms. Other reported less common causes of AH are COVID-19 and neonatal stress. Clinical diagnosis of AH is challenging due to its non-specific presentation and occurrence in the setting of acute medical illness. Therefore, most cases are diagnosed incidentally on imaging. Having high clinical suspicion in the proper clinical setting for AH is crucial to avoid life-threatening adrenal insufficiency that occurs in 16-50% of patients with bilateral AH. We discuss the clinical situations that predispose to AH, review the imaging features on different imaging modalities, highlight a variety of clinical cases, imaging features that should be concerning for an underlying neoplasm, and outline the potential role of interventional radiology in management of AH.

A deep look into radiomics

Radiomics is a process that allows the extraction and analysis of quantitative data from medical images. It is an evolving field of research with many potential applications in medical imaging. The purpose of this review is to offer a deep look into radiomics, from the basis, deeply discussed from a technical point of view, through the main applications, to the challenges that have to be addressed to translate this process in clinical practice. A detailed description of the main techniques used in the various steps of radiomics workflow, which includes image acquisition, reconstruction, pre-processing, segmentation, features extraction and analysis, is here proposed, as well as an overview of the main promising results achieved in various applications, focusing on the limitations and possible solutions for clinical implementation. Only an in-depth and comprehensive description of current methods and applications can suggest the potential power of radiomics in fostering precision medicine and thus the care of patients, especially in cancer detection, diagnosis, prognosis and treatment evaluation.

Adrenal pheochromocytoma: is it all or the tip of the iceberg?

Adrenal pheochromocytoma is not always a simple retroperitoneal tumor but may be part of a more complicated condition. It often has a spectrum of complex and variable imaging features, may present as a collision tumor and composite tumor, and is associated with a variety of clinical syndromes. A comprehensive understanding of the clinical, pathological, and variable imaging manifestations of pheochromocytoma can help radiologists make an accurate diagnosis. This article reviews various special imaging features of pheochromocytoma and pheochromocytoma-related diseases.