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Biciusca T, Gruenewald LD, Martin SS, Gotta J, Mahmoudi S, Eichler K, Booz C, Salbach C, Müller-Hennessen M, Biener M, Yildirim M, Milles B, Sommer CM, Vogl TJ, Giannitsis E, Koch V. Optimizing resource allocation: Cost-effectiveness of specified D-dimer cut-offs in cancer patients with suspected venous thromboembolism. J Thromb Thrombolysis 2024:10.1007/s11239-024-03000-2. [PMID: 38762707 DOI: 10.1007/s11239-024-03000-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/05/2024] [Indexed: 05/20/2024]
Abstract
An accurate diagnosis of venous thromboembolism (VTE) is crucial, given the potential for high mortality in undetected cases. Strategic D-dimer testing may aid in identifying low-risk patients, preventing overdiagnosis and reducing imaging costs. We conducted a retrospective, comparative analysis to assess the potential cost savings that could be achieved by adopting different approaches to determine the most effective D-dimer cut-off value in cancer patients with suspected VTE, compared to the commonly used rule-out cut-off level of 0.5 mg/L. The study included 526 patients (median age 65, IQR 55-75) with a confirmed cancer diagnosis who underwent D-dimer testing. Among these patients, the VTE prevalence was 29% (n = 152). Each diagnostic strategy's sensitivity, specificity, negative likelihood ratio (NLR), as well as positive likelihood ratio (PLR), and the proportion of patients exhibiting a negative D-dimer test result, were calculated. The diagnostic strategy that demonstrated the best balance between specificity, sensitivity, NLR, and PLR, utilized an inverse age-specific cut-off level for D-dimer [0.5 + (66-age) × 0.01 mg/L]. This method yielded a PLR of 2.9 at a very low NLR for the exclusion of VTE. We observed a significant cost reduction of 4.6% and 1.0% for PE and DVT, respectively. The utilization of an age-adjusted cut-off [patient's age × 0.01 mg/L] resulted in the highest cost savings, reaching 8.1% for PE and 3.4% for DVT. Using specified D-dimer cut-offs in the diagnosis of VTE could improve economics, considering the limited occurrence of confirmed cases among patients with suspected VTE.
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Affiliation(s)
- Teodora Biciusca
- Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt, University Hospital, Frankfurt Am Main, Germany.
| | - Leon D Gruenewald
- Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt, University Hospital, Frankfurt Am Main, Germany
| | - Simon S Martin
- Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt, University Hospital, Frankfurt Am Main, Germany
| | - Jennifer Gotta
- Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt, University Hospital, Frankfurt Am Main, Germany
| | - Scherwin Mahmoudi
- Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt, University Hospital, Frankfurt Am Main, Germany
| | - Katrin Eichler
- Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt, University Hospital, Frankfurt Am Main, Germany
| | - Christian Booz
- Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt, University Hospital, Frankfurt Am Main, Germany
| | - Christian Salbach
- Department of Cardiology, Angiology, and Pulmonology, University of Heidelberg, University Hospital, Heidelberg, Germany
| | - Matthias Müller-Hennessen
- Department of Cardiology, Angiology, and Pulmonology, University of Heidelberg, University Hospital, Heidelberg, Germany
| | - Moritz Biener
- Department of Cardiology, Angiology, and Pulmonology, University of Heidelberg, University Hospital, Heidelberg, Germany
| | - Mustafa Yildirim
- Department of Cardiology, Angiology, and Pulmonology, University of Heidelberg, University Hospital, Heidelberg, Germany
| | - Barbara Milles
- Department of Cardiology, Angiology, and Pulmonology, University of Heidelberg, University Hospital, Heidelberg, Germany
| | - Christof M Sommer
- Department of Diagnostic and Interventional Radiology, University of Heidelberg, University Hospital, Heidelberg, Germany
| | - Thomas J Vogl
- Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt, University Hospital, Frankfurt Am Main, Germany
| | - Evangelos Giannitsis
- Department of Cardiology, Angiology, and Pulmonology, University of Heidelberg, University Hospital, Heidelberg, Germany
| | - Vitali Koch
- Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt, University Hospital, Frankfurt Am Main, Germany
- Department of Cardiology, Angiology, and Pulmonology, University of Heidelberg, University Hospital, Heidelberg, Germany
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Gotta J, Koch V, Geyer T, Martin SS, Booz C, Mahmoudi S, Eichler K, Reschke P, D'Angelo T, Klimek K, Vogl TJ, Gruenewald LD. Imaging-based risk stratification of patients with pulmonary embolism based on dual-energy CT-derived radiomics. Eur J Clin Invest 2024; 54:e14139. [PMID: 38063028 DOI: 10.1111/eci.14139] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 11/13/2023] [Accepted: 11/20/2023] [Indexed: 03/13/2024]
Abstract
BACKGROUND Technological progress in the acquisition of medical images and the extraction of underlying quantitative imaging data has introduced exciting prospects for the diagnostic assessment of a wide range of conditions. This study aims to investigate the diagnostic utility of a machine learning classifier based on dual-energy computed tomography (DECT) radiomics for classifying pulmonary embolism (PE) severity and assessing the risk for early death. METHODS Patients who underwent CT pulmonary angiogram (CTPA) between January 2015 and March 2022 were considered for inclusion in this study. Based on DECT imaging, 107 radiomic features were extracted for each patient using standardized image processing. After dividing the dataset into training and test sets, stepwise feature reduction based on reproducibility, variable importance and correlation analyses were performed to select the most relevant features; these were used to train and validate the gradient-boosted tree models. RESULTS The trained machine learning classifier achieved a classification accuracy of .90 for identifying high-risk PE patients with an area under the receiver operating characteristic curve of .59. This CT-based radiomics signature showed good diagnostic accuracy for risk stratification in individuals presenting with central PE, particularly within higher risk groups. CONCLUSION Models utilizing DECT-derived radiomics features can accurately stratify patients with pulmonary embolism into established clinical risk scores. This approach holds the potential to enhance patient management and optimize patient flow by assisting in the clinical decision-making process. It also offers the advantage of saving time and resources by leveraging existing imaging to eliminate the necessity for manual clinical scoring.
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Affiliation(s)
- Jennifer Gotta
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Vitali Koch
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Tobias Geyer
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Simon S Martin
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Christian Booz
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Katrin Eichler
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Philipp Reschke
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Tommaso D'Angelo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy
| | - Konrad Klimek
- Goethe University Frankfurt, University Hospital, Clinic for Nuclear Medicine, Frankfurt am Main, Germany
| | - Thomas J Vogl
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
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Yel I, Koch V, Gruenewald LD, Mahmoudi S, Alizadeh LS, Goekduman A, Eichler K, Vogl TJ, Dimitrova M, Booz C. Advancing Differentiation of Hepatic Metastases in Malignant Melanoma through Dual-Energy Computed Tomography Rho/Z Maps. Diagnostics (Basel) 2024; 14:742. [PMID: 38611654 PMCID: PMC11012221 DOI: 10.3390/diagnostics14070742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/21/2024] [Accepted: 03/28/2024] [Indexed: 04/14/2024] Open
Abstract
OBJECTIVES The aim of this study is to evaluate the diagnostic accuracy of dual-energy computed tomography (DECT)-based Rho/Z maps in differentiating between metastases and benign liver lesions in patients diagnosed with malignant melanoma compared to conventional CT value measurements. METHODS This retrospective study included 73 patients (mean age, 70 ± 13 years; 43 m/30 w) suffering from malignant melanoma who had undergone third-generation DECT as part of tumor staging between December 2017 and December 2021. For this study, we measured Rho (electron density) and Z (effective atomic number) values as well as Hounsfield units (HUs) in hypodense liver lesions. Values were compared, and diagnostic accuracy for differentiation was computed using receiver operating characteristic (ROC) curve analyses. Additional performed MRI or biopsies served as a standard of reference. RESULTS A total of 136 lesions (51 metastases, 71 cysts, and 14 hemangiomas) in contrast-enhanced DECT images were evaluated. The most notable discrepancy (p < 0.001) between measured values and the highest diagnostic accuracy for distinguishing melanoma metastases from benign cysts was observed for the Z (0.992; 95% CI, 0.956-1) parameters, followed by Rho (0.908; 95% CI, 0.842-0.953) and finally HU120kV (0.829; 95% CI, 0.751-0.891). Conversely, when discriminating between liver metastases and hemangiomas, the HU120kV parameters showed the most significant difference (p < 0.001) and yielded the highest values for diagnostic accuracy (0.859; 95% CI, 0.740-0.937), followed by the Z parameters (0.790; 95% CI, 0.681-0.876) and finally the Rho values (0.621; 95% CI, 0.501-0.730). CONCLUSIONS Rho and Z measurements derived from DECT allow for improved differentiation of liver metastases and benign liver cysts in patients with malignant melanoma compared to conventional CT value measurements. In contrast, in differentiation between liver hemangiomas and metastases, Rho/Z maps show inferior diagnostic accuracy. Therefore, differentiation between these two lesions remains a challenge for CT imaging.
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Reschke P, Koch V, Mahmoudi S, Booz C, Yel I, Gotta J, Stahl A, Reschke R, Scholtz JE, Martin SS, Gruber-Rouh T, Eichler K, Vogl TJ, Gruenewald LD. Predictive Value of Dual-Energy CT-Derived Metrics for the Use of Bone Substitutes in Distal Radius Fracture Surgery. Diagnostics (Basel) 2024; 14:697. [PMID: 38611610 PMCID: PMC11011262 DOI: 10.3390/diagnostics14070697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/19/2024] [Accepted: 03/21/2024] [Indexed: 04/14/2024] Open
Abstract
(1) Background: Low bone mineral density (BMD) is a significant risk factor for complicated surgery and leads to the increased use of bone substitutes in patients with distal radius fractures (DRFs). No accepted model has yet been established to predict the use of bone substitutes to facilitate preoperative planning. (2) Methods: Unenhanced dual-energy CT (DECT) images of DRFs were retrospectively acquired between March 2016 and September 2020 using the internal PACS system. Available follow-up imaging and medical health records were reviewed to determine the use of bone substitutes. DECT-based BMD, trabecular Hounsfield units (HU), cortical HU, and cortical thickness ratio were measured in non-fractured segments of the distal radius. Diagnostic accuracy parameters were calculated for all metrics using receiver-operating characteristic (ROC) curves and associations of all metrics with the use of bone substitutes were evaluated using logistic regression models. (3) The final study population comprised 262 patients (median age 55 years [IQR 43-67 years]; 159 females, 103 males). According to logistic regression analysis, DECT-based BMD was the only metric significantly associated with the use of bone substitutes (odds ratio 0.96, p = 0.003). However, no significant associations were found for cortical HU (p = 0.06), trabecular HU (p = 0.33), or cortical thickness ratio (p = 0.21). ROC-curve analysis revealed that a combined model of all four metrics had the highest diagnostic accuracy with an area under the curve (AUC) of 0.76. (4) Conclusions: DECT-based BMD measurements performed better than HU-based measurements and cortical thickness ratio. The diagnostic performance of all four metrics combined was superior to that of the individual parameters.
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Affiliation(s)
- Philipp Reschke
- Department of Diagnostic and Interventional Radiology, Clinic for Radiology and Nuclear Medicine, Hospital of the Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (P.R.); (V.K.); (I.Y.); (J.G.); (A.S.); (L.D.G.)
| | - Vitali Koch
- Department of Diagnostic and Interventional Radiology, Clinic for Radiology and Nuclear Medicine, Hospital of the Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (P.R.); (V.K.); (I.Y.); (J.G.); (A.S.); (L.D.G.)
| | - Scherwin Mahmoudi
- Department of Diagnostic and Interventional Radiology, Clinic for Radiology and Nuclear Medicine, Hospital of the Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (P.R.); (V.K.); (I.Y.); (J.G.); (A.S.); (L.D.G.)
| | - Christian Booz
- Department of Diagnostic and Interventional Radiology, Clinic for Radiology and Nuclear Medicine, Hospital of the Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (P.R.); (V.K.); (I.Y.); (J.G.); (A.S.); (L.D.G.)
| | - Ibrahim Yel
- Department of Diagnostic and Interventional Radiology, Clinic for Radiology and Nuclear Medicine, Hospital of the Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (P.R.); (V.K.); (I.Y.); (J.G.); (A.S.); (L.D.G.)
| | - Jennifer Gotta
- Department of Diagnostic and Interventional Radiology, Clinic for Radiology and Nuclear Medicine, Hospital of the Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (P.R.); (V.K.); (I.Y.); (J.G.); (A.S.); (L.D.G.)
| | - Adrian Stahl
- Department of Diagnostic and Interventional Radiology, Clinic for Radiology and Nuclear Medicine, Hospital of the Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (P.R.); (V.K.); (I.Y.); (J.G.); (A.S.); (L.D.G.)
| | - Robin Reschke
- Department of Dermatology and Venereology, University Medical Center Hamburg-Eppendorf, 20537 Hamburg, Germany
| | - Jan-Erik Scholtz
- Department of Diagnostic and Interventional Radiology, Clinic for Radiology and Nuclear Medicine, Hospital of the Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (P.R.); (V.K.); (I.Y.); (J.G.); (A.S.); (L.D.G.)
| | - Simon S. Martin
- Department of Diagnostic and Interventional Radiology, Clinic for Radiology and Nuclear Medicine, Hospital of the Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (P.R.); (V.K.); (I.Y.); (J.G.); (A.S.); (L.D.G.)
| | - Tatjana Gruber-Rouh
- Department of Diagnostic and Interventional Radiology, Clinic for Radiology and Nuclear Medicine, Hospital of the Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (P.R.); (V.K.); (I.Y.); (J.G.); (A.S.); (L.D.G.)
| | - Katrin Eichler
- Department of Diagnostic and Interventional Radiology, Clinic for Radiology and Nuclear Medicine, Hospital of the Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (P.R.); (V.K.); (I.Y.); (J.G.); (A.S.); (L.D.G.)
| | - Thomas J. Vogl
- Department of Diagnostic and Interventional Radiology, Clinic for Radiology and Nuclear Medicine, Hospital of the Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (P.R.); (V.K.); (I.Y.); (J.G.); (A.S.); (L.D.G.)
| | - Leon D. Gruenewald
- Department of Diagnostic and Interventional Radiology, Clinic for Radiology and Nuclear Medicine, Hospital of the Goethe University Frankfurt, 60590 Frankfurt am Main, Germany; (P.R.); (V.K.); (I.Y.); (J.G.); (A.S.); (L.D.G.)
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Gotta J, Gruenewald LD, Martin SS, Booz C, Mahmoudi S, Eichler K, Gruber-Rouh T, Biciusca T, Reschke P, Juergens LJ, Onay M, Herrmann E, Scholtz JE, Sommer CM, Vogl TJ, Koch V. From pixels to prognosis: Imaging biomarkers for discrimination and outcome prediction of pulmonary embolism : Original Research Article. Emerg Radiol 2024:10.1007/s10140-024-02216-2. [PMID: 38523224 DOI: 10.1007/s10140-024-02216-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 03/11/2024] [Indexed: 03/26/2024]
Abstract
PURPOSE Recent advancements in medical imaging have transformed diagnostic assessments, offering exciting possibilities for extracting biomarker-based information. This study aims to investigate the capabilities of a machine learning classifier that incorporates dual-energy computed tomography (DECT) radiomics. The primary focus is on discerning and predicting outcomes related to pulmonary embolism (PE). METHODS The study included 131 participants who underwent pulmonary artery DECT angiography between January 2015 and March 2022. Among them, 104 patients received the final diagnosis of PE and 27 patients served as a control group. A total of 107 radiomic features were extracted for every case based on DECT imaging. The dataset was divided into training and test sets for model development and validation. Stepwise feature reduction identified the most relevant features, which were used to train a gradient-boosted tree model. Receiver operating characteristics analysis and Cox regression tests assessed the association of texture features with overall survival. RESULTS The trained machine learning classifier achieved a classification accuracy of 0.94 for identifying patients with acute PE with an area under the receiver operating characteristic curve of 0.91. Radiomics features could be valuable for predicting outcomes in patients with PE, demonstrating strong prognostic capabilities in survival prediction (c-index, 0.991 [0.979-1.00], p = 0.0001) with a median follow-up of 130 days (IQR, 38-720). Notably, the inclusion of clinical or DECT parameters did not enhance predictive performance. CONCLUSION In conclusion, our study underscores the promising potential of leveraging radiomics on DECT imaging for the identification of patients with acute PE and predicting their outcomes. This approach has the potential to improve clinical decision-making and patient management, offering efficiencies in time and resources by utilizing existing DECT imaging without the need for an additional scoring system.
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Affiliation(s)
- Jennifer Gotta
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany.
- University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany.
| | | | - Simon S Martin
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Christian Booz
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Katrin Eichler
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Teodora Biciusca
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Philipp Reschke
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Melis Onay
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Eva Herrmann
- Institut for Biostatistics and Mathematic Modelling, Goethe University Frankfurt, Frankfurt, 60590, Germany
| | - Jan-Erik Scholtz
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Christof M Sommer
- Clinic of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas J Vogl
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Vitali Koch
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
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Mahmoudi S, Gruenewald LD, Koch V, Bernatz S, Martin SS, Engelskirchen L, Radic I, Bucolo G, D'Angelo T, Gotta J, Mader C, Dos Santos DP, Scholtz JE, Gruber-Rouh T, Eichler K, Vogl TJ, Booz C, Yel I. Potential of Dual-Energy CT-Based Collagen Maps for the Assessment of Disk Degeneration in the Lumbar Spine. Acad Radiol 2024:S1076-6332(24)00127-2. [PMID: 38519304 DOI: 10.1016/j.acra.2024.02.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 02/16/2024] [Accepted: 02/23/2024] [Indexed: 03/24/2024]
Abstract
RATIONALE AND OBJECTIVES Lumbar disk degeneration is a common condition contributing significantly to back pain. The objective of the study was to evaluate the potential of dual-energy CT (DECT)-derived collagen maps for the assessment of lumbar disk degeneration. PATIENTS AND METHODS We conducted a retrospective analysis of 127 patients who underwent dual-source DECT and MRI of the lumbar spine between 07/2019 and 10/2022. The level of lumbar disk degeneration was categorized by three radiologists as follows: no/mild (Pfirrmann 1&2), moderate (Pfirrmann 3&4), and severe (Pfirrmann 5). Recall (sensitivity) and accuracy of DECT collagen maps were calculated. Intraclass correlation coefficient (ICC) was used to evaluate inter-reader reliability. Subjective evaluations were performed using 5-point Likert scales for diagnostic confidence and image quality. RESULTS We evaluated a total of 762 intervertebral disks from 127 patients (median age, 69.7 (range, 23.0-93.7), female, 56). MRI identified 230 non/mildly degenerated disks (30.2%), 484 moderately degenerated disks (63.5%), and 48 severely degenerated disks (6.3%). DECT collagen maps yielded an overall accuracy of 85.5% (1955/2286). Recall (sensitivity) was 79.3% (547/690) for the detection of no/mild lumbar disk degeneration, 88.7% (1288/1452) for the detection of moderate disk degeneration, and 83.3% (120/144) for the detection of severe disk degeneration (ICC=0.9). Subjective evaluations of DECT collagen maps showed high diagnostic confidence (median 4) and good image quality (median 4). CONCLUSION The use of DECT collagen maps to distinguish different stages of lumbar disk degeneration may have clinical significance in the early diagnosis of disk-related pathologies in patients with contraindications for MRI or in cases of unavailability of MRI.
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Affiliation(s)
- Scherwin Mahmoudi
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany.
| | - Leon D Gruenewald
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Vitali Koch
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Simon Bernatz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany; Dr. Senckenberg Institute for Pathology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Simon S Martin
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Lara Engelskirchen
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Ivana Radic
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Giuseppe Bucolo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy
| | - Tommaso D'Angelo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy
| | - Jennifer Gotta
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Christoph Mader
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Daniel Pinto Dos Santos
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany; Department of Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Jan-Erik Scholtz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Tatjana Gruber-Rouh
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Katrin Eichler
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Thomas J Vogl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Christian Booz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Ibrahim Yel
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
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Bernatz S, Böth I, Ackermann J, Burck I, Mahmoudi S, Lenga L, Martin SS, Scholtz JE, Koch V, Grünewald LD, Koch I, Stöver T, Wild PJ, Winkelmann R, Vogl TJ, Pinto Dos Santos D. Does Dual-Energy Computed Tomography Material Decomposition Improve Radiomics Capability to Predict Survival in Head and Neck Squamous Cell Carcinoma Patients? A Preliminary Investigation. J Comput Assist Tomogr 2024; 48:323-333. [PMID: 38013237 DOI: 10.1097/rct.0000000000001551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
OBJECTIVE Our study objective was to explore the additional value of dual-energy CT (DECT) material decomposition for squamous cell carcinoma of the head and neck (SCCHN) survival prognostication. METHODS A group of 50 SCCHN patients (male, 37; female, 13; mean age, 63.6 ± 10.82 years) with baseline head and neck DECT between September 2014 and August 2020 were retrospectively included. Primary tumors were segmented, radiomics features were extracted, and DECT material decomposition was performed. We used independent train and validation datasets with cross-validation and 100 independent iterations to identify prognostic signatures applying elastic net (EN) and random survival forest (RSF). Features were ranked and intercorrelated according to their prognostic importance. We benchmarked the models against clinical parameters. Intraclass correlation coefficients were used to analyze the interreader variation. RESULTS The exclusively radiomics-trained models achieved similar ( P = 0.947) prognostic performance of area under the curve (AUC) = 0.784 (95% confidence interval [CI], 0.775-0.812) (EN) and AUC = 0.785 (95% CI, 0.759-0.812) (RSF). The additional application of DECT material decomposition did not improve the model's performance (EN, P = 0.594; RSF, P = 0.198). In the clinical benchmark, the top averaged AUC value of 0.643 (95% CI, 0.611-0.675) was inferior to the quantitative imaging-biomarker models ( P < 0.001). A combined imaging and clinical model did not improve the imaging-based models ( P > 0.101). Shape features revealed high prognostic importance. CONCLUSIONS Radiomics AI applications may be used for SCCHN survival prognostication, but the spectral information of DECT material decomposition did not improve the model's performance in our preliminary investigation.
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Affiliation(s)
| | - Ines Böth
- From the Department of Diagnostic and Interventional Radiology
| | - Jörg Ackermann
- Department of Molecular Bioinformatics, Institute of Computer Science, Johann Wolfgang Goethe-University
| | - Iris Burck
- From the Department of Diagnostic and Interventional Radiology
| | | | - Lukas Lenga
- From the Department of Diagnostic and Interventional Radiology
| | - Simon S Martin
- From the Department of Diagnostic and Interventional Radiology
| | | | - Vitali Koch
- From the Department of Diagnostic and Interventional Radiology
| | | | - Ina Koch
- Department of Molecular Bioinformatics, Institute of Computer Science, Johann Wolfgang Goethe-University
| | - Timo Stöver
- Department of Otorhinolaryngology, University Hospital Frankfurt, Goethe University Frankfurt am Main
| | | | - Ria Winkelmann
- Dr Senckenberg Institute for Pathology, University Hospital Frankfurt, Goethe University Frankfurt am Main
| | - Thomas J Vogl
- From the Department of Diagnostic and Interventional Radiology
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Yel I, Bucolo GM, Mahmoudi S, Koch V, Gökduman A, D Angelo T, Grünewald LD, Dimitrova M, Eichler K, Vogl TJ, Booz C. Dual-Energy CT Iodine Uptake of Head and Neck: Definition of Reference Values in a Big Data Cohort. Diagnostics (Basel) 2024; 14:496. [PMID: 38472968 DOI: 10.3390/diagnostics14050496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 02/22/2024] [Accepted: 02/23/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Despite a considerable amount of literature on dual-energy CT (DECT) iodine uptake of the head and neck, the physiologic iodine uptake of this region has not been defined yet. This study aims to establish reference values for the iodine uptake of healthy organs to facilitate clinical application. METHODS Consecutive venous DECT scans of the head and neck were reviewed, and unremarkable exams were included (n = 617). A total of 35 region of interest measurements were performed in 16 anatomical regions. Iodine uptake was compared among different organs/tissues and subgroup analysis was performed (male (n = 403) vs. female (n = 214); young (n = 207) vs. middle-aged (n = 206) vs. old (n = 204); and normal weight (n = 314) vs. overweight (n = 196) vs. obese (n = 107)). RESULTS Overall mean iodine uptake values ranged between 0.5 and 9.4 mg/mL. Women showed higher iodine concentrations in the cervical vessels and higher uptake for the parotid gland, masseter muscle, submandibular glands, sublingual glands, palatine tonsils, tongue body, thyroid gland, and the sternocleidomastoid muscle than men (p ≤ 0.04). With increasing age, intravascular iodine concentrations increased as well as iodine uptake for cerebellum and thyroid gland, while values for the tongue and palatine tonsils were lower compared to younger subjects (p ≤ 0.03). Iodine concentrations for parotid glands and sternocleidomastoid muscles decreased with a higher BMI (p ≤ 0.004), while normal-weighted patients showed higher iodine values inside the jugular veins, other cervical glands, and tonsils versus patients with a higher BMI (p ≤ 0.04). CONCLUSION physiologic iodine uptake values of cervical organs and tissues show gender-, age-, and BMI-related differences, which should be considered in the clinical routine of head and neck DECT.
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Affiliation(s)
- Ibrahim Yel
- Goethe University Frankfurt, University Hospital Frankfurt, Clinic for Radiology and Nuclear Medicine, 60590 Frankfurt, Germany
| | - Giuseppe Mauro Bucolo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, 98122 Messina, Italy
| | - Scherwin Mahmoudi
- Goethe University Frankfurt, University Hospital Frankfurt, Clinic for Radiology and Nuclear Medicine, 60590 Frankfurt, Germany
| | - Vitali Koch
- Goethe University Frankfurt, University Hospital Frankfurt, Clinic for Radiology and Nuclear Medicine, 60590 Frankfurt, Germany
| | - Aynur Gökduman
- Goethe University Frankfurt, University Hospital Frankfurt, Clinic for Radiology and Nuclear Medicine, 60590 Frankfurt, Germany
| | - Tommaso D Angelo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, 98122 Messina, Italy
| | - Leon David Grünewald
- Goethe University Frankfurt, University Hospital Frankfurt, Clinic for Radiology and Nuclear Medicine, 60590 Frankfurt, Germany
| | - Mirela Dimitrova
- Goethe University Frankfurt, University Hospital Frankfurt, Clinic for Radiology and Nuclear Medicine, 60590 Frankfurt, Germany
| | - Katrin Eichler
- Goethe University Frankfurt, University Hospital Frankfurt, Clinic for Radiology and Nuclear Medicine, 60590 Frankfurt, Germany
| | - Thomas J Vogl
- Goethe University Frankfurt, University Hospital Frankfurt, Clinic for Radiology and Nuclear Medicine, 60590 Frankfurt, Germany
| | - Christian Booz
- Goethe University Frankfurt, University Hospital Frankfurt, Clinic for Radiology and Nuclear Medicine, 60590 Frankfurt, Germany
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9
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Yel I, D'Angelo T, Gruenewald LD, Koch V, Golbach R, Mahmoudi S, Ascenti G, Blandino A, Vogl TJ, Booz C, Bucolo GM. Dual-Energy CT Material Decomposition: The Value in the Detection of Lymph Node Metastasis from Breast Cancer. Diagnostics (Basel) 2024; 14:466. [PMID: 38472939 DOI: 10.3390/diagnostics14050466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 02/16/2024] [Accepted: 02/17/2024] [Indexed: 03/14/2024] Open
Abstract
PURPOSE To evaluate the diagnostic performance of a dual-energy computed tomography (DECT)-based material decomposition algorithm for iodine quantification and fat fraction analysis to detect lymph node metastases in breast cancer patients. MATERIALS AND METHODS 30 female patients (mean age, 63.12 ± 14.2 years) diagnosed with breast cancer who underwent pre-operative chest DECT were included. To establish a reference standard, the study correlated histologic repots after lymphadenectomy or confirming metastasis in previous/follow-up examinations. Iodine concentration and fat fraction were determined through region-of-interest measurements on venous DECT iodine maps. Receiver operating characteristic curve analysis was conducted to identify the optimal threshold for differentiating between metastatic and non-metastatic lymph nodes. RESULTS A total of 168 lymph nodes were evaluated, divided into axillary (metastatic: 46, normal: 101) and intramammary (metastatic: 10, normal: 11). DECT-based fat fraction values exhibited significant differences between metastatic (9.56 ± 6.20%) and non-metastatic lymph nodes (41.52 ± 19.97%) (p < 0.0001). Absolute iodine concentrations showed no significant differences (2.25 ± 0.97 mg/mL vs. 2.08 ± 0.97 mg/mL) (p = 0.7999). The optimal fat fraction threshold for diagnosing metastatic lymph nodes was determined to be 17.75%, offering a sensitivity of 98% and a specificity of 94%. CONCLUSIONS DECT fat fraction analysis emerges as a promising method for identifying metastatic lymph nodes, overcoming the morpho-volumetric limitations of conventional CT regarding lymph node assessment. This innovative approach holds potential for improving pre-operative lymph node evaluation in breast cancer patients, offering enhanced diagnostic accuracy.
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Affiliation(s)
- Ibrahim Yel
- Division of Experimental Imaging, University Hospital, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany
- Clinic for Radiology and Nuclear Medicine, University Hospital, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany
| | - Tommaso D'Angelo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, 98122 Messina, Italy
- Department of Radiology and Nuclear Medicine, Erasmus MC, 3015 GD Rotterdam, The Netherlands
| | - Leon D Gruenewald
- Division of Experimental Imaging, University Hospital, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany
- Clinic for Radiology and Nuclear Medicine, University Hospital, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany
| | - Vitali Koch
- Clinic for Radiology and Nuclear Medicine, University Hospital, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany
| | - Rejane Golbach
- Institute of Biostatistics and Mathematical Modelling, University Hospital Frankfurt, 60596 Frankfurt am Main, Germany
| | - Scherwin Mahmoudi
- Division of Experimental Imaging, University Hospital, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany
- Clinic for Radiology and Nuclear Medicine, University Hospital, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany
| | - Giorgio Ascenti
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, 98122 Messina, Italy
| | - Alfredo Blandino
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, 98122 Messina, Italy
| | - Thomas J Vogl
- Clinic for Radiology and Nuclear Medicine, University Hospital, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany
| | - Christian Booz
- Division of Experimental Imaging, University Hospital, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany
- Clinic for Radiology and Nuclear Medicine, University Hospital, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany
| | - Giuseppe M Bucolo
- Division of Experimental Imaging, University Hospital, Goethe University Frankfurt, 60590 Frankfurt am Main, Germany
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, 98122 Messina, Italy
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10
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Gruenewald LD, Booz C, Gotta J, Reschke P, Martin SS, Mahmoudi S, Bernatz S, Eichler K, D'Angelo T, Chernyak V, Sommer CM, Vogl TJ, Koch V. Incident fractures of the distal radius: Dual-energy CT-derived metrics for opportunistic risk stratification. Eur J Radiol 2024; 171:111283. [PMID: 38183896 DOI: 10.1016/j.ejrad.2023.111283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 12/13/2023] [Accepted: 12/28/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND Dual-energy CT (DECT)-derived bone mineral density (BMD) of the distal radius and other CT-derived metrics related to bone health have been suggested for opportunistic osteoporosis screening and risk evaluation for sustaining distal radius fractures (DRFs). METHODS The distal radius of patients who underwent DECT between 01/2016 and 08/2021 was retrospectively analyzed. Cortical Hounsfield Unit (HU), trabecular HU, cortical thickness, and DECT-based BMD were acquired from a non-fractured, metaphyseal area in all examinations. Receiver-operating characteristic (ROC) analysis was conducted to determine the area under the curve (AUC) values for predicting DRFs based on DECT-derived BMD, HU values, and cortical thickness. Logistic regression models were then employed to assess the associations of these parameters with the occurrence of DRFs. RESULTS In this study, 263 patients (median age: 52 years; interquartile range: 36-64; 132 women; 192 fractures) were included. ROC curve analysis revealed a higher area under the curve (AUC) value for DECT-derived BMD compared to cortical HU, trabecular HU, and cortical thickness (0.91 vs. 0.61, 0.64, and 0.69, respectively; p <.001). Logistic regression models confirmed the association between lower DECT-derived BMD and the occurrence of DRFs (Odds Ratio, 0.83; p <.001); however, no influence was observed for cortical HU, trabecular HU, or cortical thickness. CONCLUSIONS DECT can be used to assess the BMD of the distal radius without dedicated equipment such as calibration phantoms to increase the detection rates of osteoporosis and stratify the individual risk to sustain DRFs. In contrast, assessing HU-based values and cortical thickness does not provide clinical benefit.
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Affiliation(s)
- Leon D Gruenewald
- Goethe University Frankfurt, University Hospital, Department of Diagnostic and Interventional Radiology, Frankfurt am Main, Germany
| | - Christian Booz
- Goethe University Frankfurt, University Hospital, Department of Diagnostic and Interventional Radiology, Frankfurt am Main, Germany
| | - Jennifer Gotta
- Goethe University Frankfurt, University Hospital, Department of Diagnostic and Interventional Radiology, Frankfurt am Main, Germany
| | - Philipp Reschke
- Goethe University Frankfurt, University Hospital, Department of Diagnostic and Interventional Radiology, Frankfurt am Main, Germany
| | - Simon S Martin
- Goethe University Frankfurt, University Hospital, Department of Diagnostic and Interventional Radiology, Frankfurt am Main, Germany
| | - Scherwin Mahmoudi
- Goethe University Frankfurt, University Hospital, Department of Diagnostic and Interventional Radiology, Frankfurt am Main, Germany
| | - Simon Bernatz
- Goethe University Frankfurt, University Hospital, Department of Diagnostic and Interventional Radiology, Frankfurt am Main, Germany
| | - Katrin Eichler
- Goethe University Frankfurt, University Hospital, Department of Diagnostic and Interventional Radiology, Frankfurt am Main, Germany
| | - Tommaso D'Angelo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy
| | - Victoria Chernyak
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Christof M Sommer
- Clinic of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany.
| | - Thomas J Vogl
- Goethe University Frankfurt, University Hospital, Department of Diagnostic and Interventional Radiology, Frankfurt am Main, Germany
| | - Vitali Koch
- Goethe University Frankfurt, University Hospital, Department of Diagnostic and Interventional Radiology, Frankfurt am Main, Germany
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11
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Gotta J, Gruenewald LD, Geyer T, Eichler K, Martin SS, Mahmoudi S, Booz C, Biciusca T, Reschke P, Juergens LJ, Sommer CM, D'Angelo T, Almansour H, Onay M, Herrmann E, Vogl TJ, Koch V. Indicators for Hospitalization in Acute Pulmonary Embolism: Uncover the Association Between D-dimer Levels, Thrombus Volume and Radiomics. Acad Radiol 2024:S1076-6332(23)00724-9. [PMID: 38242733 DOI: 10.1016/j.acra.2023.12.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 12/23/2023] [Accepted: 12/30/2023] [Indexed: 01/21/2024]
Abstract
BACKGROUND The advent of advanced computed tomography (CT) technology and the field of radiomics has opened up new avenues in diagnostic assessments. Increasingly, there is substantial evidence advocating for the incorporation of quantitative imaging biomarkers in the clinical decision-making process. This study aimed to examine the correlation between D-dimer levels and thrombus size in acute pulmonary embolism (PE) combining dual-energy CT (DECT) and radiomics and to investigate the diagnostic utility of a machine learning classifier based on dual-energy computed tomography (DECT) radiomics for identifying patients with a complicated course, defined as at least hospitalization at IMC. METHODS The study was conducted including 136 participants who underwent pulmonary artery CT angiography from January 2015 to March 2022. Based on DECT imaging, 107 radiomic features were extracted for each patient using standardized image processing. After dividing the dataset into training and test sets, stepwise feature reduction based on reproducibility, variable importance and correlation analyses were performed to select the most relevant features; these were used to train and validate the gradient-boosted tree models.Receiver operating characteristics (ROC) analysis was utilized to evaluate the association between volumetric, laboratory data and adverse outcomes. RESULTS In the central PE group, we observed a significant correlation between thrombus volumetrics and D-dimer levels (p = 0.0037), as well as between thrombus volumetrics and hospitalization at the Intermediate Care Unit (IMC) (p = 0.0001). In contrast, no statistically significant differences were identified in thrombus sizes between patients who experienced complications and those who had a favorable course (p = 0.3162). The trained machine learning classifier achieved an accuracy of 61% and 55% in identifying patients with a complicated course, as indicated by an area under the ROC curve of 0.63 and 0.58. CONCLUSION In conclusion, our findings indicate a positive correlation between D-dimer levels and central PE's pulmonary embolic burden. Thrombus volumetrics may serve as an indicator for complications and outcomes in acute PE patients. Thus, thrombus volumetrics, as opposed to D-dimers, could be an additional marker for evaluating embolic disease severity. Moreover, DECT-derived radiomic feature models show promise in identifying patients with a complicated course, such as hospitalization at IMC.
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Affiliation(s)
- Jennifer Gotta
- Goethe University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany (J.G., L.D.G., T.G., K.E., S.S.M., S.M., C.B., T.B., P.R., J.J., T.J.V., V.K.).
| | - Leon D Gruenewald
- Goethe University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany (J.G., L.D.G., T.G., K.E., S.S.M., S.M., C.B., T.B., P.R., J.J., T.J.V., V.K.)
| | - Tobias Geyer
- Goethe University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany (J.G., L.D.G., T.G., K.E., S.S.M., S.M., C.B., T.B., P.R., J.J., T.J.V., V.K.)
| | - Katrin Eichler
- Goethe University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany (J.G., L.D.G., T.G., K.E., S.S.M., S.M., C.B., T.B., P.R., J.J., T.J.V., V.K.)
| | - Simon S Martin
- Goethe University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany (J.G., L.D.G., T.G., K.E., S.S.M., S.M., C.B., T.B., P.R., J.J., T.J.V., V.K.)
| | - Scherwin Mahmoudi
- Goethe University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany (J.G., L.D.G., T.G., K.E., S.S.M., S.M., C.B., T.B., P.R., J.J., T.J.V., V.K.)
| | - Christian Booz
- Goethe University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany (J.G., L.D.G., T.G., K.E., S.S.M., S.M., C.B., T.B., P.R., J.J., T.J.V., V.K.)
| | - Teodora Biciusca
- Goethe University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany (J.G., L.D.G., T.G., K.E., S.S.M., S.M., C.B., T.B., P.R., J.J., T.J.V., V.K.)
| | - Philipp Reschke
- Goethe University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany (J.G., L.D.G., T.G., K.E., S.S.M., S.M., C.B., T.B., P.R., J.J., T.J.V., V.K.)
| | - Lisa-Joy Juergens
- Goethe University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany (J.G., L.D.G., T.G., K.E., S.S.M., S.M., C.B., T.B., P.R., J.J., T.J.V., V.K.)
| | - Christof M Sommer
- Clinic of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany (C.M.S.)
| | - Tommaso D'Angelo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy (T.D.)
| | - Haidara Almansour
- Department of Diagnostic and Interventional Radiology, Tuebingen University Hospital, Tuebingen, Germany (H.A.)
| | - Melis Onay
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (M.O.)
| | - Eva Herrmann
- Institute for Biostatistics and Mathematic Modelling, Goethe University Frankfurt, 60590, Frankfurt, Germany (E.H.)
| | - Thomas J Vogl
- Goethe University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany (J.G., L.D.G., T.G., K.E., S.S.M., S.M., C.B., T.B., P.R., J.J., T.J.V., V.K.)
| | - Vitali Koch
- Goethe University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany (J.G., L.D.G., T.G., K.E., S.S.M., S.M., C.B., T.B., P.R., J.J., T.J.V., V.K.)
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12
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Vogl TJ, Ketelsen HJ, Mahmoudi S, Scholtz JE, Koch V, Grünewald LD, Wild P, Stoever T, Bernatz S. CT-guided core needle biopsies of head and neck tumors: a comprehensive monocenter analysis of safety and outcomes. Eur Radiol 2024:10.1007/s00330-023-10541-2. [PMID: 38221584 DOI: 10.1007/s00330-023-10541-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 11/25/2023] [Accepted: 12/06/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND Although core needle biopsy is an important tool in minimally invasive tissue sampling and diagnostics for head and neck masses, comprehensive data about safety and outcomes is lacking. PURPOSE To retrospectively evaluate the diagnostic performance and safety of computed tomography (CT)-guided percutaneous core needle biopsy of head and neck masses. MATERIAL AND METHODS This retrospective single-center study included patients from 04/2007 to 12/2021, and a total of 156 core needle biopsies were evaluated. The initial histopathological results were compared with the long-term final diagnosis to evaluate the diagnostic yield of CT-guided core needle biopsies. The patients' age, sex, and history of malignancy, as well as procedural complications and radiation exposure were collected. RESULTS A total of 156 biopsies of 150 patients (mean age 56 years ± 17; 89 men) were evaluated. 57.3% (86/150) of patients had a history of malignancy. 55.1% (86/156) of the lesions were accessed by an infrahyoid needle approach. 92.9% (145/156) of biopsies yielded conclusive results. There were no false positives and 4 false negatives, resulting in a total false negative rate of 2.7% (4/145) and a total diagnostic yield of 90.4% (141/156). There were nine puncture-related complications (9/156-5.7%). None of the complications required further reintervention. The average dose length product was 311.3 mGy × cm. CONCLUSION CT-guided core needle biopsies of head and neck masses showed excellent results with high diagnostic yield and clinical safety. CLINICAL RELEVANCE STATEMENT General anesthesia for open biopsy carries a higher risk for elderly patients, and fine needle aspiration has a poor reputation in terms of its diagnostic yield. This study focuses on safety and diagnostic yield of CT-guided core needle biopsies. KEY POINTS • CT-guided core needle biopsy in head and neck tumors was a reliable and safe procedure. • The most common cause for an inconclusive biopsy result was a shortage of tissue collected during the biopsy. • During our study period of nearly 15 years, the radiation exposure of head and neck biopsies decreased.
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Affiliation(s)
- Thomas Joseph Vogl
- Institute of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany.
| | - Heinrich Johannes Ketelsen
- Institute of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Scherwin Mahmoudi
- Institute of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Jan-Erik Scholtz
- Institute of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Vitali Koch
- Institute of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Leon David Grünewald
- Institute of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Peter Wild
- Dr. Senckenbergisches Institute of Pathology, University Hospital Frankfurt, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Timo Stoever
- Department of Otorhinolaryngology, University Hospital Frankfurt, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Simon Bernatz
- Institute of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
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13
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Gruenewald LD, Booz C, Martin SS, Mahmoudi S, Yel I, Eichler K, Alizadeh LS, Bernatz S, Gotta J, Reschke P, Weber C, Sommer CM, D'Angelo T, Bucolo G, Leistner DM, Vogl TJ, Koch V. Diagnostic performance of modern computed tomography in cruciate ligament injury detection: A comprehensive study. Eur J Radiol 2024; 170:111235. [PMID: 38071908 DOI: 10.1016/j.ejrad.2023.111235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/30/2023] [Accepted: 11/25/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND This study aimed to evaluate the clinical utility of modern single and dual-energy computed tomography (CT) for assessing the integrity of the cruciate ligaments in patients that sustained acute trauma. METHODS Patients who underwent single- or dual-energy CT followed by 3 Tesla magnetic resonance imaging (MRI) or knee joint arthroscopy between 01/2016 and 12/2022 were included in this retrospective, monocentric study. Three radiologists specialized in musculoskeletal imaging independently evaluated all CT images for the presence of injury to the cruciate ligaments. An MRI consensus reading of two experienced readers and arthroscopy provided the reference standard. Diagnostic accuracy parameters and area under the receiver operator characteristic curve (AUC) were the primary metrics for diagnostic performance. RESULTS CT images of 204 patients (median age, 49 years; IQR 36 - 64; 113 males) were evaluated. Dual-energy CT yielded significantly higher diagnostic accuracy and AUC for the detection of injury to the anterior (94% [240/255] vs 75% [266/357] and 0.89 vs 0.66) and posterior cruciate ligaments (95% [243/255] vs 87% [311/357] and 0.90 vs 0.61) compared to single-energy CT (all parameters, p <.005). Diagnostic confidence and image quality were significantly higher in dual-energy CT compared to single-energy CT (all parameters, p <.005). CONCLUSIONS Modern dual-energy CT is readily available and can serve as a screening tool for detecting or excluding cruciate ligament injuries in patients with acute trauma. Accurate diagnosis of cruciate ligament injuries is crucial to prevent adverse outcomes, including delayed treatment, chronic instability, or long-term functional limitations.
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Affiliation(s)
- Leon D Gruenewald
- Goethe University Frankfurt, University Hospital, Institute for Diagnostic and Interventional Radiology, Frankfurt am Main, Germany
| | - Christian Booz
- Goethe University Frankfurt, University Hospital, Institute for Diagnostic and Interventional Radiology, Frankfurt am Main, Germany
| | - Simon S Martin
- Goethe University Frankfurt, University Hospital, Institute for Diagnostic and Interventional Radiology, Frankfurt am Main, Germany
| | - Scherwin Mahmoudi
- Goethe University Frankfurt, University Hospital, Institute for Diagnostic and Interventional Radiology, Frankfurt am Main, Germany
| | - Ibrahim Yel
- Goethe University Frankfurt, University Hospital, Institute for Diagnostic and Interventional Radiology, Frankfurt am Main, Germany
| | - Katrin Eichler
- Goethe University Frankfurt, University Hospital, Institute for Diagnostic and Interventional Radiology, Frankfurt am Main, Germany
| | - Leona S Alizadeh
- Goethe University Frankfurt, University Hospital, Institute for Diagnostic and Interventional Radiology, Frankfurt am Main, Germany
| | - Simon Bernatz
- Goethe University Frankfurt, University Hospital, Institute for Diagnostic and Interventional Radiology, Frankfurt am Main, Germany
| | - Jennifer Gotta
- Goethe University Frankfurt, University Hospital, Institute for Diagnostic and Interventional Radiology, Frankfurt am Main, Germany
| | - Philipp Reschke
- Goethe University Frankfurt, University Hospital, Institute for Diagnostic and Interventional Radiology, Frankfurt am Main, Germany
| | - Christophe Weber
- Department of Cardiology, Angiology, and Pulmonology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christof M Sommer
- Clinic of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany.
| | - Tommaso D'Angelo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy
| | - Giuseppe Bucolo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy
| | - David M Leistner
- Goethe University Frankfurt, University Hospital, Institute for Diagnostic and Interventional Radiology, Frankfurt am Main, Germany
| | - Thomas J Vogl
- Goethe University Frankfurt, University Hospital, Institute for Diagnostic and Interventional Radiology, Frankfurt am Main, Germany
| | - Vitali Koch
- Goethe University Frankfurt, University Hospital, Institute for Diagnostic and Interventional Radiology, Frankfurt am Main, Germany
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14
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Mahmoudi S, Gruenewald LD, Eichler K, Althoff FC, Martin SS, Bernatz S, Booz C, Yel I, Kinzler MN, Ziegengeist NS, Torgashov K, Mohammed H, Geyer T, Scholtz JE, Hammerstingl RM, Weber C, Hardt SE, Sommer CM, Gruber-Rouh T, Leistner DM, Vogl TJ, Koch V. Multiparametric Evaluation of Radiomics Features and Dual-Energy CT Iodine Maps for Discrimination and Outcome Prediction of Thymic Masses. Acad Radiol 2023; 30:3010-3021. [PMID: 37105804 DOI: 10.1016/j.acra.2023.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/22/2023] [Accepted: 03/23/2023] [Indexed: 04/29/2023]
Abstract
RATIONALE AND OBJECTIVES To investigate the diagnostic value of radiomics features and dual-source dual-energy CT (DECT) based material decomposition in differentiating low-risk thymomas, high-risk thymomas, and thymic carcinomas. MATERIALS AND METHODS This retrospective study included 32 patients (16 males, mean age 66 ± 14 years) with pathologically confirmed thymic masses who underwent contrast-enhanced DECT between 10/2014 and 01/2023. Two experienced readers evaluated all patients regarding conventional radiomics features, as well as DECT-based features, including attenuation (HU), iodine density (mg/mL), and fat fraction (%). Data comparisons were performed using analysis of variance and chi-square statistic tests. Receiver operating characteristic curve analysis and Cox-regression tests were used to discriminate between low-risk/high-risk thymomas and thymic carcinomas. RESULTS Of the 32 thymic tumors, 12 (38%) were low-risk thymomas, 11 (34%) were high-risk thymomas, and 9 (28%) were thymic carcinomas. Values differed significantly between low-risk thymoma, high-risk thymoma, and thymic carcinoma regarding DECT-based features (p ≤ 0.023) and 30 radiomics features (p ≤ 0.037). The area under the curve to differentiate between low-risk/high-risk thymomas and thymic cancer was 0.998 (95% CI, 0.915-1.000; p < 0.001) for the combination of DECT imaging parameters and radiomics features, yielding a sensitivity of 100% and specificity of 96%. During a follow-up of 60 months (IQR, 35-60 months), the multiparametric approach including radiomics features, DECT parameters, and clinical parameters showed an excellent prognostic power to predict all-cause mortality (c-index = 0.978 [95% CI, 0.958-0.998], p = 0.003). CONCLUSION A multiparametric approach including conventional radiomics features and DECT-based features facilitates accurate, non-invasive discrimination between low-risk/high-risk thymomas and thymic carcinomas.
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Affiliation(s)
- Scherwin Mahmoudi
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany (S.M., L.D.G., K.E., S.S.M., S.B., C.B., I.Y., N.S.Z., K.T., H.M., T.G., J.-E.S., R.M.H., T.G.-R., T.J.V., V.K.).
| | - Leon D Gruenewald
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany (S.M., L.D.G., K.E., S.S.M., S.B., C.B., I.Y., N.S.Z., K.T., H.M., T.G., J.-E.S., R.M.H., T.G.-R., T.J.V., V.K.)
| | - Katrin Eichler
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany (S.M., L.D.G., K.E., S.S.M., S.B., C.B., I.Y., N.S.Z., K.T., H.M., T.G., J.-E.S., R.M.H., T.G.-R., T.J.V., V.K.)
| | - Friederike C Althoff
- Department of Internal Medicine II, University Hospital Frankfurt, Frankfurt am Main, Germany (F.C.A.)
| | - Simon S Martin
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany (S.M., L.D.G., K.E., S.S.M., S.B., C.B., I.Y., N.S.Z., K.T., H.M., T.G., J.-E.S., R.M.H., T.G.-R., T.J.V., V.K.)
| | - Simon Bernatz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany (S.M., L.D.G., K.E., S.S.M., S.B., C.B., I.Y., N.S.Z., K.T., H.M., T.G., J.-E.S., R.M.H., T.G.-R., T.J.V., V.K.)
| | - Christian Booz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany (S.M., L.D.G., K.E., S.S.M., S.B., C.B., I.Y., N.S.Z., K.T., H.M., T.G., J.-E.S., R.M.H., T.G.-R., T.J.V., V.K.)
| | - Ibrahim Yel
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany (S.M., L.D.G., K.E., S.S.M., S.B., C.B., I.Y., N.S.Z., K.T., H.M., T.G., J.-E.S., R.M.H., T.G.-R., T.J.V., V.K.)
| | - Maximilian N Kinzler
- Department of Internal Medicine I, University Hospital Frankfurt, Frankfurt am Main, Germany (M.N.K.)
| | - Nicole Suarez Ziegengeist
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany (S.M., L.D.G., K.E., S.S.M., S.B., C.B., I.Y., N.S.Z., K.T., H.M., T.G., J.-E.S., R.M.H., T.G.-R., T.J.V., V.K.)
| | - Katerina Torgashov
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany (S.M., L.D.G., K.E., S.S.M., S.B., C.B., I.Y., N.S.Z., K.T., H.M., T.G., J.-E.S., R.M.H., T.G.-R., T.J.V., V.K.)
| | - Hanin Mohammed
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany (S.M., L.D.G., K.E., S.S.M., S.B., C.B., I.Y., N.S.Z., K.T., H.M., T.G., J.-E.S., R.M.H., T.G.-R., T.J.V., V.K.)
| | - Tobias Geyer
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany (S.M., L.D.G., K.E., S.S.M., S.B., C.B., I.Y., N.S.Z., K.T., H.M., T.G., J.-E.S., R.M.H., T.G.-R., T.J.V., V.K.)
| | - Jan-Erik Scholtz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany (S.M., L.D.G., K.E., S.S.M., S.B., C.B., I.Y., N.S.Z., K.T., H.M., T.G., J.-E.S., R.M.H., T.G.-R., T.J.V., V.K.)
| | - Renate M Hammerstingl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany (S.M., L.D.G., K.E., S.S.M., S.B., C.B., I.Y., N.S.Z., K.T., H.M., T.G., J.-E.S., R.M.H., T.G.-R., T.J.V., V.K.)
| | - Christophe Weber
- Department of Cardiology, Angiology and Pulmonology, University Hospital Heidelberg, Heidelberg, Germany (C.W., S.E.H.)
| | - Stefan E Hardt
- Department of Cardiology, Angiology and Pulmonology, University Hospital Heidelberg, Heidelberg, Germany (C.W., S.E.H.)
| | - Christof M Sommer
- Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany (C.M.S.)
| | - Tatjana Gruber-Rouh
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany (S.M., L.D.G., K.E., S.S.M., S.B., C.B., I.Y., N.S.Z., K.T., H.M., T.G., J.-E.S., R.M.H., T.G.-R., T.J.V., V.K.)
| | - David M Leistner
- Department of Internal Medicine III, University Hospital Frankfurt, Frankfurt am Main, Germany (D.M.L.)
| | - Thomas J Vogl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany (S.M., L.D.G., K.E., S.S.M., S.B., C.B., I.Y., N.S.Z., K.T., H.M., T.G., J.-E.S., R.M.H., T.G.-R., T.J.V., V.K.)
| | - Vitali Koch
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany (S.M., L.D.G., K.E., S.S.M., S.B., C.B., I.Y., N.S.Z., K.T., H.M., T.G., J.-E.S., R.M.H., T.G.-R., T.J.V., V.K.)
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15
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Mahmoudi S, Gruenewald LD, Eichler K, Martin SS, Booz C, Bernatz S, Lahrsow M, Yel I, Gotta J, Biciusca T, Mohammed H, Ziegengeist NS, Torgashov K, Hammerstingl RM, Sommer CM, Weber C, Almansour H, Bucolo G, D'Angelo T, Scholtz JE, Gruber-Rouh T, Vogl TJ, Koch V. Advanced biomedical imaging for accurate discrimination and prognostication of mediastinal masses. Eur J Clin Invest 2023; 53:e14075. [PMID: 37571983 DOI: 10.1111/eci.14075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/06/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023]
Abstract
BACKGROUND To investigate the potential of radiomic features and dual-source dual-energy CT (DECT) parameters in differentiating between benign and malignant mediastinal masses and predicting patient outcomes. METHODS In this retrospective study, we analysed data from 90 patients (38 females, mean age 51 ± 25 years) with confirmed mediastinal masses who underwent contrast-enhanced DECT. Attenuation, radiomic features and DECT-derived imaging parameters were evaluated by two experienced readers. We performed analysis of variance (ANOVA) and Chi-square statistic tests for data comparison. Receiver operating characteristic curve analysis and Cox regression tests were used to differentiate between mediastinal masses. RESULTS Of the 90 mediastinal masses, 49 (54%) were benign, including cases of thymic hyperplasia/thymic rebound (n = 10), mediastinitis (n = 16) and thymoma (n = 23). The remaining 41 (46%) lesions were classified as malignant, consisting of lymphoma (n = 28), mediastinal tumour (n = 4) and thymic carcinoma (n = 9). Significant differences were observed between benign and malignant mediastinal masses in all DECT-derived parameters (p ≤ .001) and 38 radiomic features (p ≤ .044) obtained from contrast-enhanced DECT. The combination of these methods achieved an area under the curve of .98 (95% CI, .893-1.000; p < .001) to differentiate between benign and malignant masses, with 100% sensitivity and 91% specificity. Throughout a follow-up of 1800 days, a multiparametric model incorporating radiomic features, DECT parameters and gender showed promising prognostic power in predicting all-cause mortality (c-index = .8 [95% CI, .702-.890], p < .001). CONCLUSIONS A multiparametric approach combining radiomic features and DECT-derived imaging biomarkers allows for accurate and noninvasive differentiation between benign and malignant masses in the anterior mediastinum.
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Affiliation(s)
- Scherwin Mahmoudi
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Leon D Gruenewald
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Katrin Eichler
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Simon S Martin
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Christian Booz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Simon Bernatz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Maximilian Lahrsow
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Ibrahim Yel
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Jennifer Gotta
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Teodora Biciusca
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Hanin Mohammed
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Nicole Suarez Ziegengeist
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Katerina Torgashov
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Renate M Hammerstingl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Christof M Sommer
- Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christophe Weber
- Department of Cardiology, Angiology and Pulmonology, University Hospital Heidelberg, Heidelberg, Germany
| | - Haidara Almansour
- Department of Diagnostic and Interventional Radiology, Tuebingen University Hospital, Tuebingen, Germany
| | - Giuseppe Bucolo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy
| | - Tommaso D'Angelo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy
| | - Jan-Erik Scholtz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Tatjana Gruber-Rouh
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Thomas J Vogl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Vitali Koch
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
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16
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Gotta J, Gruenewald LD, Eichler K, Martin SS, Mahmoudi S, Booz C, Biciusca T, Reschke P, Bernatz S, Pinto Dos Santos D, Scholtz JE, Alizadeh LS, Nour-Eldin NEA, Hammerstingl RM, Gruber-Rouh T, Mader C, Hardt SE, Sommer CM, Bucolo G, D'Angelo T, Onay M, Finkelmeier F, Leistner DM, Vogl TJ, Giannitsis E, Koch V. Unveiling the diagnostic enigma of D-dimer testing in cancer patients: Current evidence and areas of application. Eur J Clin Invest 2023; 53:e14060. [PMID: 37409393 DOI: 10.1111/eci.14060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 05/30/2023] [Accepted: 06/15/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Cancer is a well-known risk factor for venous thromboembolism (VTE). A combined strategy of D-dimer testing and clinical pre-test probability is usually used to exclude VTE. However, its effectiveness is diminished in cancer patients due to reduced specificity, ultimately leading to a decreased clinical utility. This review article seeks to provide a comprehensive summary of how to interpret D-dimer testing in cancer patients. METHODS In accordance with PRISMA standards, literature pertaining to the diagnostic and prognostic significance of D-dimer testing in cancer patients was carefully chosen from reputable sources such as PubMed and the Cochrane databases. RESULTS D-dimers have not only a diagnostic value in ruling out VTE but can also serve as an aid for rule-in if their values exceed 10-times the upper limit of normal. This threshold allows a diagnosis of VTE in cancer patients with a positive predictive value of more than 80%. Moreover, elevated D-dimers carry important prognostic information and are associated with VTE reoccurrence. A gradual increase in risk for all-cause death suggests that VTE is also an indicator of biologically more aggressive cancer types and advanced cancer stages. Considering the lack of standardization for D-dimer assays, it is essential for clinicians to carefully consider the variations in assay performance and the specific test characteristics of their institution. CONCLUSIONS Standardizing D-dimer assays and developing modified pretest probability models specifically for cancer patients, along with adjusted cut-off values for D-dimer testing, could significantly enhance the accuracy and effectiveness of VTE diagnosis in this population.
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Affiliation(s)
- Jennifer Gotta
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Katrin Eichler
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Simon S Martin
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Christian Booz
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Teodora Biciusca
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Philipp Reschke
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Simon Bernatz
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Jan-Erik Scholtz
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Leona S Alizadeh
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | | | | | - Christoph Mader
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Stefan E Hardt
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christof M Sommer
- Clinic of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Giuseppe Bucolo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy
| | - Tommaso D'Angelo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy
| | - Melis Onay
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - David M Leistner
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Thomas J Vogl
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Evangelos Giannitsis
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Vitali Koch
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
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17
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Bernatz S, Koch V, Dos Santos DP, Ackermann J, Grünewald LD, Weitkamp I, Yel I, Martin SS, Lenga L, Scholtz JE, Vogl TJ, Mahmoudi S. Comparison of radiomics models and dual-energy material decomposition to decipher abdominal lymphoma in contrast-enhanced CT. Int J Comput Assist Radiol Surg 2023; 18:1829-1839. [PMID: 36877288 PMCID: PMC10497439 DOI: 10.1007/s11548-023-02854-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 02/10/2023] [Indexed: 03/07/2023]
Abstract
PURPOSE The radiologists' workload is increasing, and computational imaging techniques may have the potential to identify visually unequivocal lesions, so that the radiologist can focus on equivocal and critical cases. The purpose of this study was to assess radiomics versus dual-energy CT (DECT) material decomposition to objectively distinguish visually unequivocal abdominal lymphoma and benign lymph nodes. METHODS Retrospectively, 72 patients [m, 47; age, 63.5 (27-87) years] with nodal lymphoma (n = 27) or benign abdominal lymph nodes (n = 45) who had contrast-enhanced abdominal DECT between 06/2015 and 07/2019 were included. Three lymph nodes per patient were manually segmented to extract radiomics features and DECT material decomposition values. We used intra-class correlation analysis, Pearson correlation and LASSO to stratify a robust and non-redundant feature subset. Independent train and test data were applied on a pool of four machine learning models. Performance and permutation-based feature importance was assessed to increase the interpretability and allow for comparison of the models. Top performing models were compared by the DeLong test. RESULTS About 38% (19/50) and 36% (8/22) of the train and test set patients had abdominal lymphoma. Clearer entity clusters were seen in t-SNE plots using a combination of DECT and radiomics features compared to DECT features only. Top model performances of AUC = 0.763 (CI = 0.435-0.923) were achieved for the DECT cohort and AUC = 1.000 (CI = 1.000-1.000) for the radiomics feature cohort to stratify visually unequivocal lymphomatous lymph nodes. The performance of the radiomics model was significantly (p = 0.011, DeLong) superior to the DECT model. CONCLUSIONS Radiomics may have the potential to objectively stratify visually unequivocal nodal lymphoma versus benign lymph nodes. Radiomics seems superior to spectral DECT material decomposition in this use case. Therefore, artificial intelligence methodologies may not be restricted to centers with DECT equipment.
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Affiliation(s)
- Simon Bernatz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
- Dr. Senckenberg Institute for Pathology, University Hospital Frankfurt, Goethe University Frankfurt am Main, 60590 Frankfurt am Main, Germany
| | - Vitali Koch
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Daniel Pinto Dos Santos
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
- Department of Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine, University Hospital Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Jörg Ackermann
- Department of Molecular Bioinformatics, Institute of Computer Science, Johann Wolfgang Goethe-University, Robert-Mayer-Str. 11-15, 60325 Frankfurt am Main, Germany
| | - Leon D. Grünewald
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Inga Weitkamp
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Ibrahim Yel
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Simon S. Martin
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Lukas Lenga
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Jan-Erik Scholtz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Thomas J. Vogl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Scherwin Mahmoudi
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
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18
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Gruenewald LD, Koch V, Yel I, Eichler K, Gruber-Rouh T, Alizadeh LS, Mahmoudi S, D'Angelo T, Wichmann JL, Wesarg S, Vogl TJ, Booz C. Association of Phantomless Dual-Energy CT-based Volumetric Bone Mineral Density with the Prevalence of Acute Insufficiency Fractures of the Spine. Acad Radiol 2023; 30:2110-2117. [PMID: 36577605 DOI: 10.1016/j.acra.2022.11.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 11/01/2022] [Accepted: 11/15/2022] [Indexed: 12/27/2022]
Abstract
RATIONALE AND OBJECTIVES To evaluate the bone mineral density (BMD) of the lumbar spine derived from dual-energy CT (DECT)-based volumetric material decomposition and its association with acute insufficiency fractures of the thoracolumbar spine. MATERIALS AND METHODS L1 of 160 patients (77 men, 83 women; mean age 64.3 years, range, 22-94 years) who underwent third-generation dual-source DECT between January 2016 and December 2021 due to suspected insufficiency fractures was retrospectively analyzed. All depicted vertebrae were examined for signs of recent fractures. A dedicated DECT postprocessing software using material decomposition was applied for phantomless BMD assessment. Receiver-operating characteristic (ROC) analysis identified optimal BMD thresholds. Associations of BMD, sex, and age with the occurrence of insufficiency fractures were examined with logistic regression models. RESULTS A DECT-derived BMD threshold of 120.40 mg/cm³ yielded 90.1% specificity and 59.32% sensitivity to differentiate patients with at least one insufficiency fracture from patients without fracture. No patient without fracture had a DECT-derived BMD below 85 mg/cm3. Lower DECT-derived bone mineral density was associated with an increased risk of insufficiency fractures (Odds ratio of 0.93, 95% CI, 0.91-0.96, p < 0.001). Overall ROC-derived AUC was 0.82 (p < 0.0001) for the differentiation of patients that sustained an insufficiency fracture from the control group. CONCLUSION Dual-Energy CT-based BMD assessment can accurately differentiate patients with acute insufficiency fractures of the thoracolumbar spine from patients without fracture. This algorithm can be used for phantomless risk stratification of patients undergoing routine CT to sustain insufficiency fractures of the thoracolumbar spine The identified cut-off value of 120.4 mg/cm³ is in line with current American College of Radiology (ACR) recommendations to differentiate healthy individuals from those with reduced bone mineral density.
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Affiliation(s)
- Leon D Gruenewald
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, HE, Germany
| | - Vitali Koch
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, HE, Germany
| | - Ibrahim Yel
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, HE, Germany
| | - Katrin Eichler
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, HE, Germany
| | - Tatjana Gruber-Rouh
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, HE, Germany
| | - Leona S Alizadeh
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, HE, Germany
| | - Scherwin Mahmoudi
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, HE, Germany
| | - Tommaso D'Angelo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, ME, Italy
| | - Julian L Wichmann
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, HE, Germany
| | | | - Thomas J Vogl
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, HE, Germany; Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, HE, Germany
| | - Christian Booz
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, HE, Germany.
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19
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Gruenewald LD, Koch V, Martin SS, Yel I, Mahmoudi S, Bernatz S, Eichler K, Alizadeh LS, D'Angelo T, Mazziotti S, Singer H, Heck V, Vogl TJ, Booz C. Diagnostic value of DECT-based colored collagen maps for the assessment of cruciate ligaments in patients with acute trauma. Eur Radiol 2023; 33:6339-6350. [PMID: 37000215 PMCID: PMC10415420 DOI: 10.1007/s00330-023-09558-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/27/2023] [Accepted: 03/10/2023] [Indexed: 04/01/2023]
Abstract
OBJECTIVES The purpose of this study was to evaluate the diagnostic accuracy of third-generation dual-source dual-energy CT (DECT) color-coded collagen reconstructions for the assessment of the cruciate ligaments compared to standard grayscale image reconstruction. METHODS Patients who underwent third-generation dual-source DECT followed by either 3-T MRI or arthroscopy of the knee joint within 14 days between January 2016 and December 2021 were included in this retrospective study. Five radiologists independently evaluated conventional grayscale DECT for the presence of injury to the cruciate ligaments; after 4 weeks, readers re-evaluated the examinations using grayscale images and color-coded collagen reconstructions. A reference standard for MRI was provided by a consensus reading of two experienced readers and arthroscopy. Sensitivity and specificity were the primary metrics of diagnostic performance. RESULTS Eighty-five patients (mean age, 44 years ± 16; 50 male) with injury to the ACL or PCL (n = 31) were ultimately included. Color-coded collagen reconstructions significantly increased overall sensitivity (94/105 [90%] vs. 67/105 [64%]), specificity (248/320 [78%] vs. 215/320 [67%]), PPV (94/166 [57%] vs. 67/162 [39%]), NPV (248/259 [96%] vs. 215/253 [85%]), and accuracy (342/425 [81%] vs. 282/425 [66%]) for the detection of injury to the anterior cruciate ligament (all parameters, p < .001). For injury to the posterior cruciate ligament, diagnostic accuracy increased for complete tears (p < .001). Color-coded collagen reconstructions achieved superior diagnostic confidence, image quality, and noise scores compared to grayscale CT (all parameters, p < .001) and showed good agreement with MRI examinations. CONCLUSIONS DECT-derived color-coded collagen reconstructions yield substantially higher diagnostic accuracy and confidence for assessing the integrity of the cruciate ligaments compared to standard grayscale CT in patients with acute trauma. KEY POINTS • Color-coded collagen reconstructions derived from dual-energy CT yield substantially higher diagnostic accuracy and confidence for the assessment of the cruciate ligaments compared to standard grayscale CT in patients with acute trauma. • Color-coded collagen reconstructions demonstrate good agreement with MRI for the assessment cruciate ligament injury. • Dual-energy CT may serve as a readily available screening approach for patients with acute trauma to the knee when injury to the cruciate ligaments is suspected.
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Affiliation(s)
- Leon D Gruenewald
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt Am Main, Germany.
| | - Vitali Koch
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt Am Main, Germany
| | - Simon S Martin
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt Am Main, Germany
| | - Ibrahim Yel
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt Am Main, Germany
| | - Scherwin Mahmoudi
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt Am Main, Germany
| | - Simon Bernatz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt Am Main, Germany
| | - Katrin Eichler
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt Am Main, Germany
| | - Leona S Alizadeh
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt Am Main, Germany
| | - Tommaso D'Angelo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy
| | - Silvio Mazziotti
- Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy
| | - Hendrik Singer
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt Am Main, Germany
| | - Vincent Heck
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt Am Main, Germany
| | - Thomas J Vogl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt Am Main, Germany
| | - Christian Booz
- Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt Am Main, Germany
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20
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Gruenewald LD, Koch V, Martin SS, Yel I, Mahmoudi S, Bernatz S, Eichler K, Gruber-Rouh T, Pinto Dos Santos D, D'Angelo T, Wesarg S, Herrmann E, Golbach R, Handon M, Vogl TJ, Booz C. Dual-Energy CT-based Opportunistic Volumetric Bone Mineral Density Assessment of the Distal Radius. Radiology 2023; 308:e223150. [PMID: 37552067 DOI: 10.1148/radiol.223150] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
Background In patients with distal radius fractures (DRFs), low bone mineral density (BMD) is associated with bone substitute use during surgery and bone nonunion, but BMD information is not regularly available. Purpose To evaluate the feasibility of dual-energy CT (DECT)-based BMD assessment from routine examinations in the distal radius and the relationship between the obtained BMD values, the occurrence of DRFs, bone nonunion, and use of surgical bone substitute. Materials and Methods Scans in patients who underwent routine dual-source DECT in the distal radius between January 2016 and December 2021 were retrospectively acquired. Phantomless BMD assessment was performed using the delineated trabecular bone of a nonfractured segment of the distal radius and both DECT image series. CT images and health records were examined to determine fracture severity, surgical management, and the occurrence of bone nonunion. Associations of BMD with the occurrence of DRFs, bone nonunion, and bone substitute use at surgical treatment were examined with generalized additive models and receiver operating characteristic analysis. Results This study included 263 patients (median age, 52 years; IQR, 36-64 years; 132 female patients), of whom 192 were diagnosed with fractures. Mean volumetric BMD was lower in patients who sustained a DRF (93.9 mg/cm3 vs 135.4 mg/cm3; P < .001), required bone substitutes (79.6 mg/cm3 vs 95.5 mg/cm3; P < .001), and developed bone nonunion (71.1 mg/cm3 vs 96.5 mg/cm3; P < .001). Receiver operating characteristic curve analysis identified these patients with an area under the curve of 0.71-0.91 (P < .001). Lower BMD increased the risk to sustain DRFs, develop bone nonunion, and receive bone substitutes at surgery (P < .001). Conclusion DECT-based BMD assessment at routine examinations is feasible and could help predict surgical bone substitute use and the occurrence of bone nonunion in patients with DRFs. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Carrino in this issue.
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Affiliation(s)
- Leon D Gruenewald
- From the Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology (L.D.G., V.K., S.S.M., I.Y., C.B.), Department of Diagnostic and Interventional Radiology (S.M., S.B., K.E., T.G.R., D.P.D.S., M.H., T.J.V.), and Department of Biostatistics and Mathematical Modeling (E.H., R.G.), University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy (T.D.); Department of Radiology and Nuclear Medicine, Erasmus Medical College, Rotterdam, the Netherlands (T.D.); and Fraunhofer IGD, Darmstadt, Germany (S.W.)
| | - Vitali Koch
- From the Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology (L.D.G., V.K., S.S.M., I.Y., C.B.), Department of Diagnostic and Interventional Radiology (S.M., S.B., K.E., T.G.R., D.P.D.S., M.H., T.J.V.), and Department of Biostatistics and Mathematical Modeling (E.H., R.G.), University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy (T.D.); Department of Radiology and Nuclear Medicine, Erasmus Medical College, Rotterdam, the Netherlands (T.D.); and Fraunhofer IGD, Darmstadt, Germany (S.W.)
| | - Simon S Martin
- From the Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology (L.D.G., V.K., S.S.M., I.Y., C.B.), Department of Diagnostic and Interventional Radiology (S.M., S.B., K.E., T.G.R., D.P.D.S., M.H., T.J.V.), and Department of Biostatistics and Mathematical Modeling (E.H., R.G.), University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy (T.D.); Department of Radiology and Nuclear Medicine, Erasmus Medical College, Rotterdam, the Netherlands (T.D.); and Fraunhofer IGD, Darmstadt, Germany (S.W.)
| | - Ibrahim Yel
- From the Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology (L.D.G., V.K., S.S.M., I.Y., C.B.), Department of Diagnostic and Interventional Radiology (S.M., S.B., K.E., T.G.R., D.P.D.S., M.H., T.J.V.), and Department of Biostatistics and Mathematical Modeling (E.H., R.G.), University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy (T.D.); Department of Radiology and Nuclear Medicine, Erasmus Medical College, Rotterdam, the Netherlands (T.D.); and Fraunhofer IGD, Darmstadt, Germany (S.W.)
| | - Scherwin Mahmoudi
- From the Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology (L.D.G., V.K., S.S.M., I.Y., C.B.), Department of Diagnostic and Interventional Radiology (S.M., S.B., K.E., T.G.R., D.P.D.S., M.H., T.J.V.), and Department of Biostatistics and Mathematical Modeling (E.H., R.G.), University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy (T.D.); Department of Radiology and Nuclear Medicine, Erasmus Medical College, Rotterdam, the Netherlands (T.D.); and Fraunhofer IGD, Darmstadt, Germany (S.W.)
| | - Simon Bernatz
- From the Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology (L.D.G., V.K., S.S.M., I.Y., C.B.), Department of Diagnostic and Interventional Radiology (S.M., S.B., K.E., T.G.R., D.P.D.S., M.H., T.J.V.), and Department of Biostatistics and Mathematical Modeling (E.H., R.G.), University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy (T.D.); Department of Radiology and Nuclear Medicine, Erasmus Medical College, Rotterdam, the Netherlands (T.D.); and Fraunhofer IGD, Darmstadt, Germany (S.W.)
| | - Katrin Eichler
- From the Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology (L.D.G., V.K., S.S.M., I.Y., C.B.), Department of Diagnostic and Interventional Radiology (S.M., S.B., K.E., T.G.R., D.P.D.S., M.H., T.J.V.), and Department of Biostatistics and Mathematical Modeling (E.H., R.G.), University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy (T.D.); Department of Radiology and Nuclear Medicine, Erasmus Medical College, Rotterdam, the Netherlands (T.D.); and Fraunhofer IGD, Darmstadt, Germany (S.W.)
| | - Tatjana Gruber-Rouh
- From the Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology (L.D.G., V.K., S.S.M., I.Y., C.B.), Department of Diagnostic and Interventional Radiology (S.M., S.B., K.E., T.G.R., D.P.D.S., M.H., T.J.V.), and Department of Biostatistics and Mathematical Modeling (E.H., R.G.), University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy (T.D.); Department of Radiology and Nuclear Medicine, Erasmus Medical College, Rotterdam, the Netherlands (T.D.); and Fraunhofer IGD, Darmstadt, Germany (S.W.)
| | - Daniel Pinto Dos Santos
- From the Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology (L.D.G., V.K., S.S.M., I.Y., C.B.), Department of Diagnostic and Interventional Radiology (S.M., S.B., K.E., T.G.R., D.P.D.S., M.H., T.J.V.), and Department of Biostatistics and Mathematical Modeling (E.H., R.G.), University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy (T.D.); Department of Radiology and Nuclear Medicine, Erasmus Medical College, Rotterdam, the Netherlands (T.D.); and Fraunhofer IGD, Darmstadt, Germany (S.W.)
| | - Tommaso D'Angelo
- From the Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology (L.D.G., V.K., S.S.M., I.Y., C.B.), Department of Diagnostic and Interventional Radiology (S.M., S.B., K.E., T.G.R., D.P.D.S., M.H., T.J.V.), and Department of Biostatistics and Mathematical Modeling (E.H., R.G.), University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy (T.D.); Department of Radiology and Nuclear Medicine, Erasmus Medical College, Rotterdam, the Netherlands (T.D.); and Fraunhofer IGD, Darmstadt, Germany (S.W.)
| | - Stefan Wesarg
- From the Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology (L.D.G., V.K., S.S.M., I.Y., C.B.), Department of Diagnostic and Interventional Radiology (S.M., S.B., K.E., T.G.R., D.P.D.S., M.H., T.J.V.), and Department of Biostatistics and Mathematical Modeling (E.H., R.G.), University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy (T.D.); Department of Radiology and Nuclear Medicine, Erasmus Medical College, Rotterdam, the Netherlands (T.D.); and Fraunhofer IGD, Darmstadt, Germany (S.W.)
| | - Eva Herrmann
- From the Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology (L.D.G., V.K., S.S.M., I.Y., C.B.), Department of Diagnostic and Interventional Radiology (S.M., S.B., K.E., T.G.R., D.P.D.S., M.H., T.J.V.), and Department of Biostatistics and Mathematical Modeling (E.H., R.G.), University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy (T.D.); Department of Radiology and Nuclear Medicine, Erasmus Medical College, Rotterdam, the Netherlands (T.D.); and Fraunhofer IGD, Darmstadt, Germany (S.W.)
| | - Rejane Golbach
- From the Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology (L.D.G., V.K., S.S.M., I.Y., C.B.), Department of Diagnostic and Interventional Radiology (S.M., S.B., K.E., T.G.R., D.P.D.S., M.H., T.J.V.), and Department of Biostatistics and Mathematical Modeling (E.H., R.G.), University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy (T.D.); Department of Radiology and Nuclear Medicine, Erasmus Medical College, Rotterdam, the Netherlands (T.D.); and Fraunhofer IGD, Darmstadt, Germany (S.W.)
| | - Marlin Handon
- From the Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology (L.D.G., V.K., S.S.M., I.Y., C.B.), Department of Diagnostic and Interventional Radiology (S.M., S.B., K.E., T.G.R., D.P.D.S., M.H., T.J.V.), and Department of Biostatistics and Mathematical Modeling (E.H., R.G.), University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy (T.D.); Department of Radiology and Nuclear Medicine, Erasmus Medical College, Rotterdam, the Netherlands (T.D.); and Fraunhofer IGD, Darmstadt, Germany (S.W.)
| | - Thomas J Vogl
- From the Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology (L.D.G., V.K., S.S.M., I.Y., C.B.), Department of Diagnostic and Interventional Radiology (S.M., S.B., K.E., T.G.R., D.P.D.S., M.H., T.J.V.), and Department of Biostatistics and Mathematical Modeling (E.H., R.G.), University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy (T.D.); Department of Radiology and Nuclear Medicine, Erasmus Medical College, Rotterdam, the Netherlands (T.D.); and Fraunhofer IGD, Darmstadt, Germany (S.W.)
| | - Christian Booz
- From the Division of Experimental Imaging, Department of Diagnostic and Interventional Radiology (L.D.G., V.K., S.S.M., I.Y., C.B.), Department of Diagnostic and Interventional Radiology (S.M., S.B., K.E., T.G.R., D.P.D.S., M.H., T.J.V.), and Department of Biostatistics and Mathematical Modeling (E.H., R.G.), University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy (T.D.); Department of Radiology and Nuclear Medicine, Erasmus Medical College, Rotterdam, the Netherlands (T.D.); and Fraunhofer IGD, Darmstadt, Germany (S.W.)
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Bernatz S, Böth I, Ackermann J, Burck I, Mahmoudi S, Lenga L, Martin SS, Scholtz JE, Koch V, Grünewald LD, Koch I, Stöver T, Wild PJ, Winkelmann R, Vogl TJ, Dos Santos DP. Radiomics for therapy-specific head and neck squamous cell carcinoma survival prognostication (part I). BMC Med Imaging 2023; 23:71. [PMID: 37268876 DOI: 10.1186/s12880-023-01034-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 05/25/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Treatment plans for squamous cell carcinoma of the head and neck (SCCHN) are individually decided in tumor board meetings but some treatment decision-steps lack objective prognostic estimates. Our purpose was to explore the potential of radiomics for SCCHN therapy-specific survival prognostication and to increase the models' interpretability by ranking the features based on their predictive importance. METHODS We included 157 SCCHN patients (male, 119; female, 38; mean age, 64.39 ± 10.71 years) with baseline head and neck CT between 09/2014 and 08/2020 in this retrospective study. Patients were stratified according to their treatment. Using independent training and test datasets with cross-validation and 100 iterations, we identified, ranked and inter-correlated prognostic signatures using elastic net (EN) and random survival forest (RSF). We benchmarked the models against clinical parameters. Inter-reader variation was analyzed using intraclass-correlation coefficients (ICC). RESULTS EN and RSF achieved top prognostication performances of AUC = 0.795 (95% CI 0.767-0.822) and AUC = 0.811 (95% CI 0.782-0.839). RSF prognostication slightly outperformed the EN for the complete (ΔAUC 0.035, p = 0.002) and radiochemotherapy (ΔAUC 0.092, p < 0.001) cohort. RSF was superior to most clinical benchmarking (p ≤ 0.006). The inter-reader correlation was moderate or high for all features classes (ICC ≥ 0.77 (± 0.19)). Shape features had the highest prognostic importance, followed by texture features. CONCLUSIONS EN and RSF built on radiomics features may be used for survival prognostication. The prognostically leading features may vary between treatment subgroups. This warrants further validation to potentially aid clinical treatment decision making in the future.
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Affiliation(s)
- Simon Bernatz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt Am Main, Theodor-Stern-Kai 7, Frankfurt Am Main, 60590, Germany.
- Dr. Senckenberg Institute for Pathology, University Hospital Frankfurt, Goethe University Frankfurt Am Main, Frankfurt Am Main, 60590, Germany.
- Frankfurt Cancer Institute (FCI), Frankfurt Am Main, 60590, Germany.
| | - Ines Böth
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt Am Main, Theodor-Stern-Kai 7, Frankfurt Am Main, 60590, Germany
| | - Jörg Ackermann
- Department of Molecular Bioinformatics, Institute of Computer Science, Johann Wolfgang Goethe-University, Robert-Mayer-Str. 11-15, Frankfurt Am Main, 60325, Germany
| | - Iris Burck
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt Am Main, Theodor-Stern-Kai 7, Frankfurt Am Main, 60590, Germany
| | - Scherwin Mahmoudi
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt Am Main, Theodor-Stern-Kai 7, Frankfurt Am Main, 60590, Germany
| | - Lukas Lenga
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt Am Main, Theodor-Stern-Kai 7, Frankfurt Am Main, 60590, Germany
| | - Simon S Martin
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt Am Main, Theodor-Stern-Kai 7, Frankfurt Am Main, 60590, Germany
| | - Jan-Erik Scholtz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt Am Main, Theodor-Stern-Kai 7, Frankfurt Am Main, 60590, Germany
| | - Vitali Koch
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt Am Main, Theodor-Stern-Kai 7, Frankfurt Am Main, 60590, Germany
| | - Leon D Grünewald
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt Am Main, Theodor-Stern-Kai 7, Frankfurt Am Main, 60590, Germany
| | - Ina Koch
- Department of Molecular Bioinformatics, Institute of Computer Science, Johann Wolfgang Goethe-University, Robert-Mayer-Str. 11-15, Frankfurt Am Main, 60325, Germany
| | - Timo Stöver
- Department of Otorhinolaryngology, University Hospital Frankfurt, Goethe University Frankfurt Am Main, Theodor-Stern-Kai 7, Frankfurt Am Main, 60590, Germany
| | - Peter J Wild
- Dr. Senckenberg Institute for Pathology, University Hospital Frankfurt, Goethe University Frankfurt Am Main, Frankfurt Am Main, 60590, Germany
- Frankfurt Institute for Advanced Studies (FIAS), Frankfurt Am Main, 60438, Germany
| | - Ria Winkelmann
- Dr. Senckenberg Institute for Pathology, University Hospital Frankfurt, Goethe University Frankfurt Am Main, Frankfurt Am Main, 60590, Germany
| | - Thomas J Vogl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt Am Main, Theodor-Stern-Kai 7, Frankfurt Am Main, 60590, Germany
| | - Daniel Pinto Dos Santos
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt Am Main, Theodor-Stern-Kai 7, Frankfurt Am Main, 60590, Germany
- Department of Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str. 62, Cologne, 50937, Germany
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Rosbach N, Fischer S, Koch V, Vogl TJ, Bochennek K, Lehrnbecher T, Mahmoudi S, Grünewald L, Grünwald F, Bernatz S. Correlation of mean apparent diffusion coefficient (ADC) and maximal standard uptake value (SUVmax) evaluated by diffusion-weighted MRI and 18F-FDG-PET/CT in children with Hodgkin lymphoma: a feasibility study. Radiol Oncol 2023; 57:150-157. [PMID: 37341195 DOI: 10.2478/raon-2023-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 03/27/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND The objective was to analyse if magnetic resonance imaging (MRI) can act as a non-radiation exposure surrogate for (18)F-Fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in children with histologically confirmed Hodgkin lymphoma (HL) before treatment. This was done by analysing a potential correlation between apparent diffusion coefficient (ADC) in MRI and the maximum standardized uptake value (SUVmax) in FDG-PET/CT. PATIENTS AND METHODS Seventeen patients (six female, eleven male, median age: 16 years, range: 12-20 years) with histologically confirmed HL were retrospectively analysed. The patients underwent both MRI and (18)F-FDG PET/CT before the start of treatment. (18)F-FDG PET/CT data and correlating ADC maps in MRI were collected. For each HL-lesion two readers independently evaluated the SUVmax and correlating meanADC. RESULTS The seventeen patients had a total of 72 evaluable lesions of HL and there was no significant difference in the number of lesions between male and female patients (median male: 15, range: 12-19 years, median female: 17 range: 12-18 years, p = 0.021). The mean duration between MRI and PET/CT was 5.9 ± 5.3 days. The inter-reader agreement as assessed by the intraclass correlation coefficient (ICC) was excellent (ICC = 0.98, 95% CI: 0.97-0.99). The correlated SUVmax and meanADC of all 17 patients (ROIs n = 72) showed a strong negative correlation of -0.75 (95% CI: -0.84, - -0.63, p = 0.001). Analysis revealed a difference in the correlations of the examination fields. The correlated SUVmax and meanADC showed a strong correlation at neck and thoracal examinations (neck: -0.83, 95% CI: -0.93, - -0.63, p < 0.0001, thoracal: -0.82, 95% CI: -0.91, - -0.64, p < 0.0001) and a fair correlation at abdominal examinations of -0.62 (95% CI: -0.83, - -0.28, p = 0.001). CONCLUSIONS SUVmax and meanADC showed a strong negative correlation in paediatric HL lesions. The assessment seemed robust according to inter-reader agreements. Our results suggest that ADC maps and meanADC have the potential to replace PET/CT in the analysis of disease activity in paediatric Hodgkin lymphoma patients. This may help reduce the number of PET/CT examinations and decrease radiation exposure to children.
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Affiliation(s)
- Nicolas Rosbach
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Sebastian Fischer
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Vitali Koch
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Thomas J Vogl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Konrad Bochennek
- Division of Paediatric Haematology and Oncology, Hospital for Children and Adolescents, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Thomas Lehrnbecher
- Division of Paediatric Haematology and Oncology, Hospital for Children and Adolescents, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Scherwin Mahmoudi
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Leon Grünewald
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Frank Grünwald
- Department of Nuclear Medicine, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Simon Bernatz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
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Gruenewald LD, Koch V, Eichler K, Bauer J, Gruber-Rouh T, Booz C, Yel I, Mahmoudi S, Vogl TJ, El Saman A. Injury patterns of the spine following blunt trauma: A per-segment analysis of spinal structures and their detection rates in CT and MRI. Heliyon 2023; 9:e17396. [PMID: 37408923 PMCID: PMC10318444 DOI: 10.1016/j.heliyon.2023.e17396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 07/07/2023] Open
Abstract
Rationale and objectives To provide a detailed analysis of injury patterns of the spine following blunt trauma and establish the role of supplementary MRI by evaluating discrepancies in the detection rates of damaged structures in CT and MRI. Method 216 patients with blunt trauma to the spine who underwent CT followed by supplementary MRI were included in this study. Two board-certified radiologists blinded to clinical symptoms and injury mechanisms independently interpreted all acquired CT and MRI images. The interpretation was performed using a dedicated catalogue of typical findings associated with spinal trauma and assessed for spinal stability using the AO classification systems. Results Lesions to structures associated with spinal instability were present in 31.0% in the cervical spine, 12.3% in the thoracic spine, and 29.9% in the lumbar spine. In all spinal segments, MRI provided additional information regarding potentially unstable injuries. Novel information derived from supplementary MRI changed clinical management in 3.6% of patients with injury to the cervical spine. No change in clinical management resulted from novel information on the thoracolumbar spine. Patients with injuries to the vertebral body, intervertebral disc, or spinous process were significantly more likely to benefit from supplementary MRI. Conclusion In patients that sustained blunt spinal trauma, supplementary MRI of the cervical spine should routinely be performed to detect injuries that require surgical treatment, whereas CT is the superior imaging modality for the detection of unstable injuries in the thoracolumbar spine.
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Affiliation(s)
- Leon David Gruenewald
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Vitali Koch
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Katrin Eichler
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Jasmin Bauer
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Tatjana Gruber-Rouh
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Christian Booz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Ibrahim Yel
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Scherwin Mahmoudi
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Thomas J. Vogl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - André El Saman
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
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Koch V, Weitzer N, Dos Santos DP, Gruenewald LD, Mahmoudi S, Martin SS, Eichler K, Bernatz S, Gruber-Rouh T, Booz C, Hammerstingl RM, Biciusca T, Rosbach N, Gökduman A, D'Angelo T, Finkelmeier F, Yel I, Alizadeh LS, Sommer CM, Cengiz D, Vogl TJ, Albrecht MH. Multiparametric detection and outcome prediction of pancreatic cancer involving dual-energy CT, diffusion-weighted MRI, and radiomics. Cancer Imaging 2023; 23:38. [PMID: 37072856 PMCID: PMC10114410 DOI: 10.1186/s40644-023-00549-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/17/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND The advent of next-generation computed tomography (CT)- and magnetic resonance imaging (MRI) opened many new perspectives in the evaluation of tumor characteristics. An increasing body of evidence suggests the incorporation of quantitative imaging biomarkers into clinical decision-making to provide mineable tissue information. The present study sought to evaluate the diagnostic and predictive value of a multiparametric approach involving radiomics texture analysis, dual-energy CT-derived iodine concentration (DECT-IC), and diffusion-weighted MRI (DWI) in participants with histologically proven pancreatic cancer. METHODS In this study, a total of 143 participants (63 years ± 13, 48 females) who underwent third-generation dual-source DECT and DWI between November 2014 and October 2022 were included. Among these, 83 received a final diagnosis of pancreatic cancer, 20 had pancreatitis, and 40 had no evidence of pancreatic pathologies. Data comparisons were performed using chi-square statistic tests, one-way ANOVA, or two-tailed Student's t-test. For the assessment of the association of texture features with overall survival, receiver operating characteristics analysis and Cox regression tests were used. RESULTS Malignant pancreatic tissue differed significantly from normal or inflamed tissue regarding radiomics features (overall P < .001, respectively) and iodine uptake (overall P < .001, respectively). The performance for the distinction of malignant from normal or inflamed pancreatic tissue ranged between an AUC of ≥ 0.995 (95% CI, 0.955-1.0; P < .001) for radiomics features, ≥ 0.852 (95% CI, 0.767-0.914; P < .001) for DECT-IC, and ≥ 0.690 (95% CI, 0.587-0.780; P = .01) for DWI, respectively. During a follow-up of 14 ± 12 months (range, 10-44 months), the multiparametric approach showed a moderate prognostic power to predict all-cause mortality (c-index = 0.778 [95% CI, 0.697-0.864], P = .01). CONCLUSIONS Our reported multiparametric approach allowed for accurate discrimination of pancreatic cancer and revealed great potential to provide independent prognostic information on all-cause mortality.
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Affiliation(s)
- Vitali Koch
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany.
| | - Nils Weitzer
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany
| | - Daniel Pinto Dos Santos
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany
| | - Leon D Gruenewald
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany
| | - Scherwin Mahmoudi
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany
| | - Simon S Martin
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany
| | - Katrin Eichler
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany
| | - Simon Bernatz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany
| | - Tatjana Gruber-Rouh
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany
| | - Christian Booz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany
| | - Renate M Hammerstingl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany
| | - Teodora Biciusca
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany
| | - Nicolas Rosbach
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany
| | - Aynur Gökduman
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany
| | - Tommaso D'Angelo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy
| | - Fabian Finkelmeier
- Department of Internal Medicine, University Hospital Frankfurt, Frankfurt Am Main, Germany
| | - Ibrahim Yel
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany
| | - Leona S Alizadeh
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany
| | - Christof M Sommer
- Clinic of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Duygu Cengiz
- Department of Radiology, University of Koc School of Medicine, Istanbul, Turkey
| | - Thomas J Vogl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany
| | - Moritz H Albrecht
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany
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25
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Koch V, Martin SS, Gruber-Rouh T, Eichler K, Mahmoudi S, Leistner DM, Scholtz JE, Bernatz S, Puntmann VO, Nagel E, Booz C, D'Angelo T, Alizadeh LS, Yel I, Ziegengeist NS, Torgashov K, Geyer T, Hardt SE, Vogl TJ, Gruenewald LD, Giannitsis E. Cancer patients with venous thromboembolism: Diagnostic and prognostic value of elevated D-dimers. Eur J Clin Invest 2023; 53:e13914. [PMID: 36444723 DOI: 10.1111/eci.13914] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 11/22/2022] [Accepted: 11/23/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND D-dimer testing is known to have a high sensitivity at simultaneously low specificity, resulting in nonspecific elevations in a variety of conditions. METHODS This retrospective study sought to assess diagnostic and prognostic features of D-dimers in cancer patients referred to the emergency department for suspected pulmonary embolism (PE) and deep vein thrombosis (DVT). In total, 526 patients with a final adjudicated diagnosis of PE (n = 83) and DVT (n = 69) were enrolled, whereas 374 patients served as the comparative group, in which venous thromboembolism (VTE) has been excluded. RESULTS For the identification of VTE, D-dimers yielded the highest positive predictive value of 96% (95% confidence interval (CI), 85-99) at concentrations of 9.9 mg/L and a negative predictive value of 100% at .6 mg/L (95% CI, 97-100). At the established rule-out cut-off level of .5 mg/L, D-dimers were found to be very sensitive (100%) at a moderate specificity of nearly 65%. Using an optimised cut-off value of 4.9 mg/L increased the specificity to 95% for the detection of life-threatening VTE at the cost of moderate sensitivities (64%). During a median follow-up of 30 months, D-dimers positively correlated with the reoccurrence of VTE (p = .0299) and mortality in both cancer patients with VTE (p < .0001) and without VTE (p = .0008). CONCLUSIONS Although D-dimer testing in cancer patients is discouraged by current guidelines, very high concentrations above the 10-fold upper reference limit contain diagnostic and prognostic information and might be helpful in risk assessment, while low concentrations remain useful for ruling out VTE.
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Affiliation(s)
- Vitali Koch
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany.,Department of Cardiology, Angiology, and Pulmonology, University Hospital Heidelberg, Heidelberg, Germany
| | - Simon S Martin
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Katrin Eichler
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - David M Leistner
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Jan-Erik Scholtz
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Simon Bernatz
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Eike Nagel
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Christian Booz
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Tommaso D'Angelo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy
| | - Leona S Alizadeh
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Ibrahim Yel
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | | | - Tobias Geyer
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Stefan E Hardt
- Department of Cardiology, Angiology, and Pulmonology, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas J Vogl
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Evangelos Giannitsis
- Department of Cardiology, Angiology, and Pulmonology, University Hospital Heidelberg, Heidelberg, Germany
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26
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Kinzler MN, Bankov K, Bein J, Döring C, Schulze F, Reis H, Mahmoudi S, Koch V, Grünewald LD, Stehle A, Walter D, Finkelmeier F, Zeuzem S, Wild PJ, Vogl TJ, Bernatz S. CXCL1 and CXCL6 Are Potential Predictors for HCC Response to TACE. Curr Oncol 2023; 30:3516-3528. [PMID: 36975480 PMCID: PMC10046993 DOI: 10.3390/curroncol30030267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/14/2023] [Accepted: 03/16/2023] [Indexed: 03/29/2023] Open
Abstract
Distinct immune patterns of hepatocellular carcinoma (HCC) may have prognostic implications in the response to transarterial chemoembolization (TACE). Thus, we aimed to exploratively analyze tumor tissue of HCC patients who do or do not respond to TACE, and to identify novel prognostic biomarkers predictive of response to TACE. We retrospectively included 15 HCC patients who had three consecutive TACE between January 2019 and November 2019. Eight patients had a response while seven patients had no response to TACE. All patients had measurable disease according to mRECIST. Corresponding tumor tissue samples were processed for differential expression profiling using NanoString nCounter® PanCancer immune profiling panel. Immune-related pathways were broadly upregulated in TACE responders. The top differentially regulated genes were the upregulated CXCL1 (log2fc 4.98, Benjamini-Hochberg (BH)-p < 0.001), CXCL6 (log2fc 4.43, BH-p = 0.016) and the downregulated MME (log2fc -4.33, BH-p 0.001). CD8/T-regs was highly increased in responders, whereas the relative number of T-regs to tumor-infiltrating lymphocytes (TIL) was highly decreased. We preliminary identified CXCL1 and CXCL6 as candidate genes that might have the potential to serve as therapeutically relevant biomarkers in HCC patients. This might pave the way to improve patient selection for TACE in HCC patients beyond expert consensus.
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Affiliation(s)
- Maximilian N Kinzler
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University-Frankfurt am Main, 60590 Frankfurt am Main, Germany
| | - Katrin Bankov
- Dr. Senckenberg Institute for Pathology, University Hospital Frankfurt, Goethe University Frankfurt am Main, 60590 Frankfurt am Main, Germany
| | - Julia Bein
- Dr. Senckenberg Institute for Pathology, University Hospital Frankfurt, Goethe University Frankfurt am Main, 60590 Frankfurt am Main, Germany
| | - Claudia Döring
- Dr. Senckenberg Institute for Pathology, University Hospital Frankfurt, Goethe University Frankfurt am Main, 60590 Frankfurt am Main, Germany
| | - Falko Schulze
- Dr. Senckenberg Institute for Pathology, University Hospital Frankfurt, Goethe University Frankfurt am Main, 60590 Frankfurt am Main, Germany
| | - Henning Reis
- Dr. Senckenberg Institute for Pathology, University Hospital Frankfurt, Goethe University Frankfurt am Main, 60590 Frankfurt am Main, Germany
| | - Scherwin Mahmoudi
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Vitali Koch
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Leon D Grünewald
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Angelika Stehle
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University-Frankfurt am Main, 60590 Frankfurt am Main, Germany
| | - Dirk Walter
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University-Frankfurt am Main, 60590 Frankfurt am Main, Germany
| | - Fabian Finkelmeier
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University-Frankfurt am Main, 60590 Frankfurt am Main, Germany
| | - Stefan Zeuzem
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University-Frankfurt am Main, 60590 Frankfurt am Main, Germany
| | - Peter J Wild
- Dr. Senckenberg Institute for Pathology, University Hospital Frankfurt, Goethe University Frankfurt am Main, 60590 Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), Goethe University, 60590 Frankfurt am Main, Germany
- Frankfurt Institute for Advanced Studies (FIAS), 60438 Frankfurt am Main, Germany
| | - Thomas J Vogl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Simon Bernatz
- Dr. Senckenberg Institute for Pathology, University Hospital Frankfurt, Goethe University Frankfurt am Main, 60590 Frankfurt am Main, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), Goethe University, 60590 Frankfurt am Main, Germany
- University Cancer Center Frankfurt (UCT), University Hospital, Goethe University, 60590 Frankfurt am Main, Germany
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27
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Gruenewald LD, Koch V, Gruber-Rouh T, Thalhammer A, Frank J, Marzi I, Booz C, Yel I, Mahmoudi S, Bernatz S, Laudenberger I, Lingwal N, Vogl TJ, Eichler K. MR angiography facilitates the differentiation of aneurysmal from unicameral bone cysts. Br J Radiol 2023; 96:20220849. [PMID: 36745072 PMCID: PMC10078881 DOI: 10.1259/bjr.20220849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES The objective of this work was to evaluate the incremental value of MR angiography over plain radiographs and MRI for the differentiation of aneurysmal bone cysts (ABCs) from unicameral bone cysts (UBCs). METHODS Thirty-six juvenile patients with histologically secured primary ABCs or UBCs were included in this retrospective study. Two radiologists assessed all obtained images in a blinded fashion using a catalog of previously suggested imaging findings. A second readout with supplementary MR angiography images was performed after 8 weeks to prevent observer recall bias. Diagnostic accuracy parameters were calculated for individual imaging findings, and overall diagnostic accuracy and diagnostic confidence were assessed for all readouts. Receiver operating characteristic (ROC) curve comparison was used to determine the incremental value of MR angiography. RESULTS Of 16 imaging features, only abnormal vascularization in MR angiography provided sufficient diagnostic accuracy for the identification of ABCs. Other imaging features such as fluid-fluid levels and internal septations were insufficient for the differentiation of UBCs from ABCs. Availability of MR angiography images significantly increased diagnostic accuracy (94.4 vs 75.0% and 83.3 vs 69.4%, respectively, p < 0.05) and diagnostic confidence (4.5 vs 3.7, p < 0.05) of reading radiologists. CONCLUSION The presence of arterial feeders in MR angiography can accurately discriminate primary ABCs from UBCs and increases the diagnostic accuracy and diagnostic confidence of reporting radiologists. ADVANCES IN KNOWLEDGE Radiographic differentiation of cystic bone lesions such as ABCs and UBCs remains challenging. We demonstrate that MR angiography provides incremental value and suggest inclusion in standard examination protocols.
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Affiliation(s)
- Leon David Gruenewald
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Vitali Koch
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Tatjana Gruber-Rouh
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Axel Thalhammer
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Johannes Frank
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Christian Booz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Ibrahim Yel
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Scherwin Mahmoudi
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Simon Bernatz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Isabella Laudenberger
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Neelam Lingwal
- Department of Biostatistics and Mathematical Modeling, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Thomas J Vogl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Katrin Eichler
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
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28
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Koch V, Merklein D, Zangos S, Eichler K, Gruenewald LD, Mahmoudi S, Booz C, Yel I, D'Angelo T, Martin SS, Bernatz S, Hammerstingl RM, Albrecht MH, Scholtz JE, Kaltenbach B, Vogl TJ, Langenbach M, Gruber-Rouh T. Free-breathing accelerated whole-body MRI using an automated workflow: Comparison with conventional breath-hold sequences. NMR Biomed 2023; 36:e4828. [PMID: 36082477 DOI: 10.1002/nbm.4828] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/15/2022] [Accepted: 09/06/2022] [Indexed: 06/15/2023]
Abstract
Whole-body magnetic resonance imaging (MRI) has become increasingly popular in oncology. However, the long acquisition time might hamper its widespread application. We sought to assess and compare free-breathing sequences with conventional breath-hold examinations in whole-body MRI using an automated workflow process. This prospective study consisted of 20 volunteers and six patients with a variety of pathologies who had undergone whole-body 1.5-T MRI that included T1-weighted radial and Dixon volumetric interpolated breath-hold examination sequences. Free-breathing sequences were operated by using an automated user interface. Image quality, diagnostic confidence, and image noise were evaluated by two experienced radiologists. Additionally, signal-to-noise ratio was measured. Diagnostic performance for the overall detection of pathologies was assessed using the area under the receiver operating characteristics curve (AUC). Study participants were asked to rate their examination experiences in a satisfaction survey. MR free-breathing scans were rated as at least equivalent to conventional MR scans in more than 92% of cases, showing high overall diagnostic accuracy (95% [95% CI 92-100]) and performance (AUC 0.971, 95% CI 0.942-0.988; p < 0.0001) for the assessment of pathologies at simultaneously reduced examination times (25 ± 2 vs. 32 ± 3 min; p < 0.0001). Interrater agreement was excellent for both free-breathing (ϰ = 0.96 [95% CI 0.88-1.00]) and conventional scans (ϰ = 0.93 [95% CI 0.84-1.00]). Qualitative and quantitative assessment for image quality, image noise, and diagnostic confidence did not differ between the two types of MR image acquisition (all p > 0.05). Scores for patient satisfaction were significantly better for free-breathing compared with breath-hold examinations (p = 0.0145), including significant correlations for the grade of noise (r = 0.79, p < 0.0001), tightness (r = 0.71, p < 0.0001), and physical fatigue (r = 0.52, p = 0.0065). In summary, free-breathing whole-body MRI in tandem with an automated user interface yielded similar diagnostic performance at equivalent image quality and shorter acquisition times compared to conventional breath-hold sequences.
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Affiliation(s)
- Vitali Koch
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Domenica Merklein
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Stephan Zangos
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Katrin Eichler
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Leon D Gruenewald
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Scherwin Mahmoudi
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Christian Booz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Ibrahim Yel
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Tommaso D'Angelo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy
| | - Simon S Martin
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Simon Bernatz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Renate M Hammerstingl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Moritz H Albrecht
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Jan-Erik Scholtz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Benjamin Kaltenbach
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Thomas J Vogl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Marcel Langenbach
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Tatjana Gruber-Rouh
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
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29
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Mahmoudi S, Bernatz S, Ackermann J, Koch V, Dos Santos DP, Grünewald LD, Yel I, Martin SS, Scholtz JE, Stehle A, Walter D, Zeuzem S, Wild PJ, Vogl TJ, Kinzler MN. Computed Tomography Radiomics to Differentiate Intrahepatic Cholangiocarcinoma and Hepatocellular Carcinoma. Clin Oncol (R Coll Radiol) 2023; 35:e312-e318. [PMID: 36804153 DOI: 10.1016/j.clon.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/05/2022] [Accepted: 01/25/2023] [Indexed: 02/04/2023]
Abstract
AIMS Intrahepatic cholangiocarcinoma (iCCA) and hepatocellular carcinoma (HCC) differ in prognosis and treatment. We aimed to non-invasively differentiate iCCA and HCC by means of radiomics extracted from contrast-enhanced standard-of-care computed tomography (CT). MATERIALS AND METHODS In total, 94 patients (male, n = 68, mean age 63.3 ± 12.4 years) with histologically confirmed iCCA (n = 47) or HCC (n = 47) who underwent contrast-enhanced abdominal CT between August 2014 and November 2021 were retrospectively included. The enhancing tumour border was manually segmented in a clinically feasible way by defining three three-dimensional volumes of interest per tumour. Radiomics features were extracted. Intraclass correlation analysis and Pearson metrics were used to stratify robust and non-redundant features with further feature reduction by LASSO (least absolute shrinkage and selection operator). Independent training and testing datasets were used to build four different machine learning models. Performance metrics and feature importance values were computed to increase the models' interpretability. RESULTS The patient population was split into 65 patients for training (iCCA, n = 32) and 29 patients for testing (iCCA, n = 15). A final combined feature set of three radiomics features and the clinical features age and sex revealed a top test model performance of receiver operating characteristic (ROC) area under the curve (AUC) = 0.82 (95% confidence interval =0.66-0.98; train ROC AUC = 0.82) using a logistic regression classifier. The model was well calibrated, and the Youden J Index suggested an optimal cut-off of 0.501 to discriminate between iCCA and HCC with a sensitivity of 0.733 and a specificity of 0.857. CONCLUSIONS Radiomics-based imaging biomarkers can potentially help to non-invasively discriminate between iCCA and HCC.
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Affiliation(s)
- S Mahmoudi
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany.
| | - S Bernatz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany; Dr. Senckenberg Institute for Pathology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany; Frankfurt Cancer Institute (FCI), Goethe University, Frankfurt am Main, Germany; University Cancer Center Frankfurt (UCT), University Hospital, Goethe University, Frankfurt am Main, Germany
| | - J Ackermann
- Department of Molecular Bioinformatics, Institute of Computer Science, Goethe University, Frankfurt am Main, Germany
| | - V Koch
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - D P Dos Santos
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany; Department of Diagnostic and Interventional Radiology, University Hospital Cologne, Cologne, Germany
| | - L D Grünewald
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - I Yel
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - S S Martin
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - J-E Scholtz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - A Stehle
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - D Walter
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - S Zeuzem
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - P J Wild
- Dr. Senckenberg Institute for Pathology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany; Frankfurt Cancer Institute (FCI), Goethe University, Frankfurt am Main, Germany; Frankfurt Institute for Advanced Studies (FIAS), Frankfurt am Main, Germany
| | - T J Vogl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - M N Kinzler
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
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30
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Bernatz S, Elenberger O, Ackermann J, Lenga L, Martin SS, Scholtz JE, Koch V, Grünewald LD, Herrmann Y, Kinzler MN, Stehle A, Koch I, Zeuzem S, Bankov K, Doering C, Reis H, Flinner N, Schulze F, Wild PJ, Hammerstingl R, Eichler K, Gruber-Rouh T, Vogl TJ, dos Santos DP, Mahmoudi S. CT-radiomics and clinical risk scores for response and overall survival prognostication in TACE HCC patients. Sci Rep 2023; 13:533. [PMID: 36631548 PMCID: PMC9834236 DOI: 10.1038/s41598-023-27714-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 01/06/2023] [Indexed: 01/12/2023] Open
Abstract
We aimed to identify hepatocellular carcinoma (HCC) patients who will respond to repetitive transarterial chemoembolization (TACE) to improve the treatment algorithm. Retrospectively, 61 patients (mean age, 65.3 years ± 10.0 [SD]; 49 men) with 94 HCC mRECIST target-lesions who had three consecutive TACE between 01/2012 and 01/2020 were included. Robust and non-redundant radiomics features were extracted from the 24 h post-embolization CT. Five different clinical TACE-scores were assessed. Seven different feature selection methods and machine learning models were used. Radiomics, clinical and combined models were built to predict response to TACE on a lesion-wise and patient-wise level as well as its impact on overall-survival prognostication. 29 target-lesions of 19 patients were evaluated in the test set. Response rates were 37.9% (11/29) on the lesion-level and 42.1% (8/19) on the patient-level. Radiomics top lesion-wise response prognostications was AUC 0.55-0.67. Clinical scores revealed top AUCs of 0.65-0.69. The best working model combined the radiomic feature LargeDependenceHighGrayLevelEmphasis and the clinical score mHAP_II_score_group with AUC = 0.70, accuracy = 0.72. We transferred this model on a patient-level to achieve AUC = 0.62, CI = 0.41-0.83. The two radiomics-clinical features revealed overall-survival prognostication of C-index = 0.67. In conclusion, a random forest model using the radiomic feature LargeDependenceHighGrayLevelEmphasis and the clinical mHAP-II-score-group seems promising for TACE response prognostication.
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Affiliation(s)
- Simon Bernatz
- University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany. .,Dr. Senckenberg Institute for Pathology, University Hospital Frankfurt, Goethe University Frankfurt am Main, 60590, Frankfurt am Main, Germany. .,Frankfurt Cancer Institute (FCI), 60590, Frankfurt am Main, Germany.
| | - Oleg Elenberger
- grid.7839.50000 0004 1936 9721University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Jörg Ackermann
- grid.7839.50000 0004 1936 9721Department of Molecular Bioinformatics, Institute of Computer Science, Goethe University Frankfurt am Main, Robert-Mayer-Str. 11-15, 60325 Frankfurt am Main, Germany
| | - Lukas Lenga
- grid.7839.50000 0004 1936 9721University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Simon S. Martin
- grid.7839.50000 0004 1936 9721University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Jan-Erik Scholtz
- grid.7839.50000 0004 1936 9721University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Vitali Koch
- grid.7839.50000 0004 1936 9721University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Leon D. Grünewald
- grid.7839.50000 0004 1936 9721University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Yannis Herrmann
- grid.7839.50000 0004 1936 9721University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Maximilian N. Kinzler
- grid.411088.40000 0004 0578 8220Department of Internal Medicine I, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Angelika Stehle
- grid.411088.40000 0004 0578 8220Department of Internal Medicine I, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Ina Koch
- grid.7839.50000 0004 1936 9721Department of Molecular Bioinformatics, Institute of Computer Science, Goethe University Frankfurt am Main, Robert-Mayer-Str. 11-15, 60325 Frankfurt am Main, Germany
| | - Stefan Zeuzem
- grid.411088.40000 0004 0578 8220Department of Internal Medicine I, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Katrin Bankov
- grid.7839.50000 0004 1936 9721Dr. Senckenberg Institute for Pathology, University Hospital Frankfurt, Goethe University Frankfurt am Main, 60590 Frankfurt am Main, Germany
| | - Claudia Doering
- grid.7839.50000 0004 1936 9721Dr. Senckenberg Institute for Pathology, University Hospital Frankfurt, Goethe University Frankfurt am Main, 60590 Frankfurt am Main, Germany
| | - Henning Reis
- grid.7839.50000 0004 1936 9721Dr. Senckenberg Institute for Pathology, University Hospital Frankfurt, Goethe University Frankfurt am Main, 60590 Frankfurt am Main, Germany
| | - Nadine Flinner
- grid.7839.50000 0004 1936 9721Dr. Senckenberg Institute for Pathology, University Hospital Frankfurt, Goethe University Frankfurt am Main, 60590 Frankfurt am Main, Germany
| | - Falko Schulze
- grid.7839.50000 0004 1936 9721Dr. Senckenberg Institute for Pathology, University Hospital Frankfurt, Goethe University Frankfurt am Main, 60590 Frankfurt am Main, Germany
| | - Peter J. Wild
- grid.7839.50000 0004 1936 9721Dr. Senckenberg Institute for Pathology, University Hospital Frankfurt, Goethe University Frankfurt am Main, 60590 Frankfurt am Main, Germany ,grid.511198.5Frankfurt Cancer Institute (FCI), 60590 Frankfurt am Main, Germany ,grid.417999.b0000 0000 9260 4223Frankfurt Institute for Advanced Studies (FIAS), 60438 Frankfurt am Main, Germany
| | - Renate Hammerstingl
- grid.7839.50000 0004 1936 9721University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Katrin Eichler
- grid.7839.50000 0004 1936 9721University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Tatjana Gruber-Rouh
- grid.7839.50000 0004 1936 9721University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Thomas J. Vogl
- grid.7839.50000 0004 1936 9721University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Daniel Pinto dos Santos
- grid.7839.50000 0004 1936 9721University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany ,grid.6190.e0000 0000 8580 3777Department of Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Scherwin Mahmoudi
- grid.7839.50000 0004 1936 9721University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
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Koch V, Conrades LM, Gruenewald LD, Eichler K, Martin SS, Booz C, D'Angelo T, Yel I, Bernatz S, Mahmoudi S, Albrecht MH, Scholtz J, Thalhammer A, Zangos S, Vogl TJ, Gruber‐Rouh T. Reduction of radiation dose using real-time visual feedback dosimetry during angiographic interventions. J Appl Clin Med Phys 2022; 24:e13860. [PMID: 36565180 PMCID: PMC9924107 DOI: 10.1002/acm2.13860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 10/31/2022] [Accepted: 11/15/2022] [Indexed: 12/25/2022] Open
Abstract
This prospective study sought to evaluate potential savings of radiation dose to medical staff using real-time dosimetry coupled with visual radiation dose feedback during angiographic interventions. For this purpose, we analyzed a total of 214 angiographic examinations that consisted of chemoembolizations and several other types of therapeutic interventions. The Unfors RaySafe i2 dosimeter was worn by the interventionalist at chest height over the lead protection. A total of 110 interventions were performed with real-time radiation dosimetry allowing the interventionalist to react upon higher x-ray exposure and 104 examinations served as the comparative group without real-time radiation monitoring. By using the real-time display during interventions, the overall mean operator radiation dose decreased from 3.67 (IQR, 0.95-23.01) to 2.36 μSv (IQR, 0.52-12.66) (-36%; p = 0.032) at simultaneously reduced operator exposure time by 4.5 min (p = 0.071). Dividing interventions into chemoembolizations and other types of therapeutic interventions, radiation dose decreased from 1.31 (IQR, 0.46-3.62) to 0.95 μSv (IQR, 0.53-3.11) and from 24.39 (IQR, 12.14-63.0) to 10.37 μSv (IQR, 0.85-36.84), respectively, using live-screen dosimetry (p ≤ 0.005). Radiation dose reductions were also observed for the participating assistants, indicating that they could also benefit from real-time visual feedback dosimetry during interventions (-30%; p = 0.039). Integration of real-time dosimetry into clinical processes might be useful in reducing occupational radiation exposure time during angiographic interventions. The real-time visual feedback raised the awareness of interventionalists and their assistants to the potential danger of prolonged radiation exposure leading to the adoption of radiation-sparing practices. Therefore, it might create a safer environment for the medical staff by keeping the applied radiation exposure as low as possible.
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Affiliation(s)
- Vitali Koch
- Department of Diagnostic and Interventional RadiologyUniversity Hospital FrankfurtFrankfurt am MainGermany
| | - Lena Marie Conrades
- Department of Diagnostic and Interventional RadiologyUniversity Hospital FrankfurtFrankfurt am MainGermany
| | - Leon D. Gruenewald
- Department of Diagnostic and Interventional RadiologyUniversity Hospital FrankfurtFrankfurt am MainGermany
| | - Katrin Eichler
- Department of Diagnostic and Interventional RadiologyUniversity Hospital FrankfurtFrankfurt am MainGermany
| | - Simon S. Martin
- Department of Diagnostic and Interventional RadiologyUniversity Hospital FrankfurtFrankfurt am MainGermany
| | - Christian Booz
- Department of Diagnostic and Interventional RadiologyUniversity Hospital FrankfurtFrankfurt am MainGermany
| | - Tommaso D'Angelo
- Department of Biomedical Sciences and Morphological and Functional ImagingUniversity Hospital MessinaMessinaItaly
| | - Ibrahim Yel
- Department of Diagnostic and Interventional RadiologyUniversity Hospital FrankfurtFrankfurt am MainGermany
| | - Simon Bernatz
- Department of Diagnostic and Interventional RadiologyUniversity Hospital FrankfurtFrankfurt am MainGermany
| | - Scherwin Mahmoudi
- Department of Diagnostic and Interventional RadiologyUniversity Hospital FrankfurtFrankfurt am MainGermany
| | - Moritz H. Albrecht
- Department of Diagnostic and Interventional RadiologyUniversity Hospital FrankfurtFrankfurt am MainGermany
| | - Jan‐Erik Scholtz
- Department of Diagnostic and Interventional RadiologyUniversity Hospital FrankfurtFrankfurt am MainGermany
| | - Axel Thalhammer
- Department of Diagnostic and Interventional RadiologyUniversity Hospital FrankfurtFrankfurt am MainGermany
| | - Stephan Zangos
- Department of Diagnostic and Interventional RadiologyUniversity Hospital FrankfurtFrankfurt am MainGermany
| | - Thomas J. Vogl
- Department of Diagnostic and Interventional RadiologyUniversity Hospital FrankfurtFrankfurt am MainGermany
| | - Tatjana Gruber‐Rouh
- Department of Diagnostic and Interventional RadiologyUniversity Hospital FrankfurtFrankfurt am MainGermany
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32
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Koch V, Gruenewald LD, Gruber-Rouh T, Eichler K, Leistner DM, Mahmoudi S, Booz C, Bernatz S, D'Angelo T, Albrecht MH, Alizadeh LS, Nour-Eldin NEA, Scholtz JE, Yel I, Vogl TJ, März W, Hardt SE, Martin SS. Homoarginine in the cardiovascular system: Pathophysiology and recent developments. Fundam Clin Pharmacol 2022; 37:519-529. [PMID: 36509694 DOI: 10.1111/fcp.12858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 12/04/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022]
Abstract
Upcoming experimental and epidemiological data have identified the endogenous non-proteinogenic amino acid L-homoarginine (L-hArg) not only as a novel biomarker for cardiovascular disease but also as being directly involved in the pathogenesis of cardiac dysfunction. The association of low L-hArg levels with adverse cardiovascular events and mortality has proposed the idea of nutritional supplementation to rescue pathways inversely associated with cardiovascular health. Subsequent clinical and experimental studies contributed significantly to our knowledge of potential effects on the cardiorenal axis, acting either as a biomarker or a cardiovascular active agent. In this review article, we provide a comprehensive summary of the L-hArg metabolism, pathophysiological aspects, and current developments in the field of experimental and clinical evidence in favor of protective cardiovascular effects. Establishing a reliable biomarker to identify patients at high risk to die of cardiovascular disease represents one of the main goals for tackling this disease and providing individual therapeutic guidance.
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Affiliation(s)
- Vitali Koch
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany.,Department of Cardiology, Angiology, and Pulmonology, University Hospital Heidelberg, Heidelberg, Germany
| | | | | | - Katrin Eichler
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - David M Leistner
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Christian Booz
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Simon Bernatz
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Tommaso D'Angelo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy
| | | | - Leona S Alizadeh
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Jan-Erik Scholtz
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Ibrahim Yel
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Thomas J Vogl
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Winfried März
- Fifth Department of Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Stefan E Hardt
- Department of Cardiology, Angiology, and Pulmonology, University Hospital Heidelberg, Heidelberg, Germany
| | - Simon S Martin
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
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33
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Mahmoudi S, Koch V, Santos DPD, Ackermann J, Grünewald LD, Weitkamp I, Yel I, Martin SS, Albrecht MH, Scholtz JE, Vogl TJ, Bernatz S. Imaging biomarkers to stratify lymph node metastases in abdominal CT - Is radiomics superior to dual-energy material decomposition? Eur J Radiol Open 2022; 10:100459. [PMID: 36561422 PMCID: PMC9763741 DOI: 10.1016/j.ejro.2022.100459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/16/2022] [Accepted: 11/30/2022] [Indexed: 12/13/2022] Open
Abstract
Purpose To assess the potential of radiomic features in comparison to dual-energy CT (DECT) material decomposition to objectively stratify abdominal lymph node metastases. Materials and methods In this retrospective study, we included 81 patients (m, 57; median age, 65 (interquartile range, 58.7-73.3) years) with either lymph node metastases (n = 36) or benign lymph nodes (n = 45) who underwent contrast-enhanced abdominal DECT between 06/2015-07/2019. All malignant lymph nodes were classified as unequivocal according to RECIST criteria and confirmed by histopathology, PET-CT or follow-up imaging. Three investigators segmented lymph nodes to extract DECT and radiomics features. Intra-class correlation analysis was applied to stratify a robust feature subset with further feature reduction by Pearson correlation analysis and LASSO. Independent training and testing datasets were applied on four different machine learning models. We calculated the performance metrics and permutation-based feature importance values to increase interpretability of the models. DeLong test was used to compare the top performing models. Results Distance matrices and t-SNE plots revealed clearer clusters using a combination of DECT and radiomic features compared to DECT features only. Feature reduction by LASSO excluded all DECT features of the combined feature cohort. The top performing radiomic features model (AUC = 1.000; F1 = 1.000; precision = 1.000; Random Forest) was significantly superior to the top performing DECT features model (AUC = 0.942; F1 = 0.762; precision = 0.800; Stochastic Gradient Boosting) (DeLong < 0.001). Conclusion Imaging biomarkers have the potential to stratify unequivocal lymph node metastases. Radiomics models were superior to DECT material decomposition and may serve as a support tool to facilitate stratification of abdominal lymph node metastases.
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Key Words
- ADB, AdaBoost
- AUC, Area under the curve
- Abdominal imaging
- CT, Computed tomography
- CTDI, Computed tomography dose index
- DECT, Dual-energy computed tomography
- DICOM, Digital Imaging and Communications in Medicine
- DLP, Dose-length product
- Dual-energy computed tomography
- GLCM, Gray Level Co-occurrence Matrix
- GLDM, Gray Level Dependence Matrix
- GLRLM, Gray Level Run Length Matrix
- GLSZM, Gray Level Size Zone Matrix
- HU, Hounsfield Units
- ICC, Intra-class correlation coefficient
- ID%, Normalized iodine uptake
- ID, Iodine density
- LR, Logistic Regression
- Lymph node metastasis
- Machine Learning
- NGTDM, Neighboring Gray Tone Difference Matrix
- Oncology
- PET, Positron emission tomography
- RF, Random Forest
- ROC, Receiver operating characteristics
- ROI, Region of interest
- Radiomics
- SGB, Stochastic Gradient Boosting
- VOI, Volume of interest
- mGy, Milligray
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Affiliation(s)
- Scherwin Mahmoudi
- University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany,Corresponding author.
| | - Vitali Koch
- University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Daniel Pinto Dos Santos
- University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany,University Hospital Cologne, Department of Diagnostic and Interventional Radiology, Kerpener Str. 62, 50937 Cologne, Germany
| | - Jörg Ackermann
- Department of Molecular Bioinformatics, Institute of Computer Science, Johann Wolfgang Goethe-University, Robert-Mayer-Str. 11-15, 60325 Frankfurt am Main, Germany
| | - Leon D. Grünewald
- University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Inga Weitkamp
- University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Ibrahim Yel
- University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Simon S. Martin
- University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Moritz H. Albrecht
- University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Jan-Erik Scholtz
- University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Thomas J. Vogl
- University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Simon Bernatz
- University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany,Dr. Senckenberg Institute for Pathology, University Hospital Frankfurt, Goethe University Frankfurt am Main, 60590 Frankfurt am Main, Germany
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34
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Mahmoudi S, Bernatz S, Althoff FC, Koch V, Grünewald LD, Scholtz JE, Walter D, Zeuzem S, Wild PJ, Vogl TJ, Kinzler MN. Dual-energy CT based material decomposition to differentiate intrahepatic cholangiocarcinoma from hepatocellular carcinoma. Eur J Radiol 2022; 156:110556. [PMID: 36270195 DOI: 10.1016/j.ejrad.2022.110556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 07/29/2022] [Accepted: 10/07/2022] [Indexed: 11/20/2022]
Abstract
PURPOSE To assess the potential of material decomposition in dual-energy CT (DECT) to differentiate intrahepatic cholangiocarcinoma (iCCA) from hepatocellular carcinoma (HCC). METHOD In this retrospective study, we included 94 patients (26 female (27.7 %), median age 64.5 (interquartile range 55.5-74.5) years) with either iCCA or HCC who underwent abdominal contrast-enhanced DECT in arterial phase. To test for differences between iCCA (n = 47) and HCC (n = 47), we evaluated mean attenuation and DECT material density values including iodine density (ID), normalized iodine uptake (NIU), fat fraction, and lesion-to-liver parenchyma ratio. Histopathology served as reference standard for all lesions. We used univariate logistic regression models for the outcome iCCA versus HCC. ROC curve analysis was applied to assess discriminative ability of the model. Model accuracy was evaluated by calculating the Brier score. Youden index was applied to establish thresholds to differentiate between iCCA and HCC. RESULTS Comparison of quantitative image parameters revealed significant differences between iCCA and HCC for ID (1.6 ± 0.5 mg/ml vs 2.8 ± 0.8 mg/ml, p < 0.001), NIU (14.5 ± 4.8 vs 24.8 ± 10.3, p < 0.001), attenuation (41.9 ± 10.1 HU vs 47.9 ± 8.9 HU, p = 0.003), and fat fraction (12.0 ± 7.8 % vs 9.0 ± 6.4 %, p = 0.045). ROC curve analysis revealed highest ability to differentiate iCCA from HCC for ID (AUC = 0.93, 95 % CI 0.89-0.98). For ID, an optimal threshold of 2.33 mg/dl was determined to discriminate between iCCA and HCC (sensitivity 89.4 %, specificity 76.6 %). CONCLUSIONS DECT-based iodine quantification can serve as a tool for the differentiation of iCCA and HCC in contrast-enhanced CT. ID yielded the highest diagnostic performance and may assist in clinical routine CT diagnostics.
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Affiliation(s)
- Scherwin Mahmoudi
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Germany.
| | - Simon Bernatz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Germany.
| | - Friederike C Althoff
- Department of Internal Medicine II, University Hospital Frankfurt, Goethe University Frankfurt am Main, Germany.
| | - Vitali Koch
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Germany.
| | - Leon D Grünewald
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Germany.
| | - Jan-Erik Scholtz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Germany.
| | - Dirk Walter
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt am Main, Germany.
| | - Stefan Zeuzem
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt am Main, Germany.
| | - Peter J Wild
- Dr. Senckenberg Institute of Pathology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Germany; Wildlab, University Hospital Frankfurt MVZ GmbH, Frankfurt am Main, Germany.
| | - Thomas J Vogl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Germany.
| | - Maximilian N Kinzler
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt am Main, Germany.
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35
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Koch V, Abt J, Gruenewald LD, Eichler K, D’Angelo T, Martin SS, Albrecht MH, Thalhammer A, Booz C, Yel I, Bernatz S, Mahmoudi S, Harth M, Derwich W, Vogl TJ, Gray D, Gruber-Rouh T, Jung G. Systematic evaluation of imaging techniques and baseline characteristics in patients with suspected vasculitis. Eur J Radiol Open 2022; 9:100445. [PMID: 36262692 PMCID: PMC9574707 DOI: 10.1016/j.ejro.2022.100445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 10/03/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022] Open
Abstract
Purpose To assess the diagnostic value of different imaging modalities in distinguishing systemic vasculitis from other internal and immunological diseases. Methods This retrospective study included 134 patients with suspected vasculitis who underwent ultrasound, magnetic resonance imaging (MRI), or 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) between 01/2010 and 01/2019, finally consisting of 70 individuals with vasculitis. The main study parameter was the confirmation of the diagnosis using one of the three different imaging modalities, with the adjudicated clinical and histopathological diagnosis as the gold standard. A secondary parameter was the morphological appearance of the vessel affected by vasculitis. Results Patients with systemic vasculitis had myriad clinical manifestations with joint pain as the most common symptom. We found significant correlations between different imaging findings suggestive of vasculitis and the final adjudicated clinical diagnosis. In this context, on MRI, vessel wall thickening, edema, and diameter differed significantly between vasculitis and non-vasculitis groups (p < 0.05). Ultrasound revealed different findings that may serve as red flags in identifying patients with vasculitis, such as vascular occlusion or halo sign (p = 0.02 vs. non-vasculitis group). Interestingly, comparing maximal standardized uptake values from PET/CT examinations with vessel wall thickening or vessel diameter did not result in significant differences (p > 0.05). Conclusions We observed significant correlations between different imaging findings suggestive of vasculitis on ultrasound or MRI and the final adjudicated diagnosis. While ultrasound and MRI were considered suitable imaging methods for detecting and discriminating typical vascular changes, 18F-FDG PET/CT requires careful timing and patient selection given its moderate diagnostic accuracy.
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Affiliation(s)
- Vitali Koch
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany,Correspondence to: University Hospital Frankfurt, Department of Diagnostic and Interventional Radiology, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany.
| | - Julia Abt
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Leon D. Gruenewald
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Katrin Eichler
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Tommaso D’Angelo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy
| | - Simon S. Martin
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Moritz H. Albrecht
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Axel Thalhammer
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Christian Booz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Ibrahim Yel
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Simon Bernatz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Scherwin Mahmoudi
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Marc Harth
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Wojciech Derwich
- Department of Vascular Surgery, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Thomas J. Vogl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Daphne Gray
- Department of Vascular Surgery, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Tatjana Gruber-Rouh
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Georg Jung
- Department of Vascular Surgery, University Hospital Frankfurt, Frankfurt am Main, Germany
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Koch V, Loos G, Gruenewald LD, Eichler K, Booz C, D'Angelo T, Yel I, Mahmoudi S, Martin SS, Harth M, Albrecht MH, Zangos S, Bernatz S, Thalhammer A, Scholtz JE, Vogl TJ, Gruber-Rouh T. Comprehensive comparison of three different workstations for accurate planning of endovascular stent implantation in patients with thoracic aortic aneurysms. Eur J Radiol Open 2022; 9:100427. [PMID: 35757233 PMCID: PMC9213697 DOI: 10.1016/j.ejro.2022.100427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/12/2022] [Accepted: 05/25/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose To assess the diagnostic precision of three different workstations for measuring thoracic aortic aneurysms (TAAs) in vivo and ex vivo using either pre-interventional computed tomography angiography scans (CTA) or a specifically designed phantom model. Methods This retrospective study included 23 patients with confirmed TAA on routinely performed CTAs. In addition to phantom tube diameters, one experienced blinded radiologist evaluated the dimensions of TAAs on three different workstations in two separate rounds. Precision was assessed by calculating measurement errors. In addition, correlation analysis was performed using Pearson correlation. Results Measurements acquired at the Siemens workstation deviated by 3.54% (range, 2.78–4.03%; p = 0.14) from the true size, those at General Electric by 4.05% (range, 1.46–7.09%; p < 0.0001), and at TeraRecon by 4.86% (range, 3.22–6.45%; p < 0.0001). Accordingly, Siemens provided the most precise workstation at simultaneously most fluctuating values (scattering of 4.46%). TeraRecon had the smallest fluctuation (scattering of 2.83%), but the largest deviation from the true size of the phantom. The workstation from General Electric showed a scattering of 2.94%. The highest overall correlation between the 1st and 2nd rounds was observed with measurements from Siemens (r = 0.898), followed by TeraRecon (r = 0.799), and General Electric (r = 0.703). Repetition of measurements reduced processing times by 40% when using General Electric, by 20% with Siemens, and by 18% with TeraRecon. Conclusions In conclusion, all three workstations facilitated precise assessment of dimensions in the majority of cases at simultaneously high reproducibility, ensuring accurate pre-interventional planning of thoracic endovascular aortic repair. Pre-interventional planning of TEVAR in patients with TAAs using CTA is feasible. All three workstations facilitated accurate measurements in vivo and ex vivo. Repetition of measurements resulted in faster processing due to learning effects.
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Affiliation(s)
- Vitali Koch
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Gerald Loos
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Leon D Gruenewald
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Katrin Eichler
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Christian Booz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Tommaso D'Angelo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy
| | - Ibrahim Yel
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Scherwin Mahmoudi
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Simon S Martin
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Marc Harth
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Moritz H Albrecht
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Stephan Zangos
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Simon Bernatz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Axel Thalhammer
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Jan-Erik Scholtz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Thomas J Vogl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Tatjana Gruber-Rouh
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
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Koch V, Gruenewald LD, Albrecht MH, Eichler K, Gruber-Rouh T, Yel I, Alizadeh LS, Mahmoudi S, Scholtz JE, Martin SS, Lenga L, Vogl TJ, Nour-Eldin NEA, Bienenfeld F, Hammerstingl RM, Graf C, Sommer CM, Hardt SE, Mazziotti S, Ascenti G, Versace GA, D'Angelo T, Booz C. Lung Opacity and Coronary Artery Calcium Score: A Combined Tool for Risk Stratification and Outcome Prediction in COVID-19 Patients. Acad Radiol 2022; 29:861-870. [PMID: 35346565 PMCID: PMC8882413 DOI: 10.1016/j.acra.2022.02.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 02/21/2022] [Accepted: 02/21/2022] [Indexed: 01/01/2023]
Abstract
PURPOSE To assess and correlate pulmonary involvement and outcome of SARS-CoV-2 pneumonia with the degree of coronary plaque burden based on the CAC-DRS classification (Coronary Artery Calcium Data and Reporting System). METHODS This retrospective study included 142 patients with confirmed SARS-CoV-2 pneumonia (58 ± 16 years; 57 women) who underwent non-contrast CT between January 2020 and August 2021 and were followed up for 129 ± 72 days. One experienced blinded radiologist analyzed CT series for the presence and extent of calcified plaque burden according to the visual and quantitative HU-based CAC-DRS Score. Pulmonary involvement was automatically evaluated with a dedicated software prototype by another two experienced radiologists and expressed as Opacity Score. RESULTS CAC-DRS Scores derived from visual and quantitative image evaluation correlated well with the Opacity Score (r=0.81, 95% CI 0.76-0.86, and r=0.83, 95% CI 0.77-0.89, respectively; p<0.0001) with higher correlation in severe than in mild stage SARS-CoV-2 pneumonia (p<0.0001). Combined, CAC-DRS and Opacity Scores revealed great potential to discriminate fatal outcomes from a mild course of disease (AUC 0.938, 95% CI 0.89-0.97), and the need for intensive care treatment (AUC 0.801, 95% CI 0.77-0.83). Visual and quantitative CAC-DRS Scores provided independent prognostic information on all-cause mortality (p=0.0016 and p<0.0001, respectively), both in univariate and multivariate analysis. CONCLUSIONS Coronary plaque burden is strongly correlated to pulmonary involvement, adverse outcome, and death due to respiratory failure in patients with SARS-CoV-2 pneumonia, offering great potential to identify individuals at high risk.
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Mahmoudi S, Lange M, Lenga L, Yel I, Koch V, Booz C, Martin S, Bernatz S, Vogl T, Albrecht M, Scholtz JE. Salvaging low contrast abdominal CT studies using noise-optimised virtual monoenergetic image reconstruction. BJR Open 2022; 4:20220006. [PMID: 36105416 PMCID: PMC9446156 DOI: 10.1259/bjro.20220006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 04/21/2022] [Accepted: 04/22/2022] [Indexed: 11/25/2022] Open
Abstract
Objectives To assess the impact of noise-optimised virtual monoenergetic imaging (VMI+) on image quality and diagnostic evaluation in abdominal dual-energy CT scans with impaired portal-venous contrast. Methods We screened 11,746 patients who underwent portal-venous abdominal dual-energy CT for cancer staging between 08/2014 and 11/2019 and identified those with poor portal-venous contrast.Standard linearly-blended image series and VMI+ image series at 40, 50, and 60 keV were reconstructed. Signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) of abdominal organs and vascular structures were calculated. Image noise, image contrast and overall image quality were rated by three radiologists using 5-point Likert scale. Results 452 of 11,746 (4%) exams were poorly opacified. We excluded 190 cases due to incomplete datasets or multiple exams of the same patient with a final study group of 262. Highest CNR values in all abdominal organs (liver, 6.4 ± 3.0; kidney, 17.4 ± 7.5; spleen, 8.0 ± 3.5) and vascular structures (aorta, 16.0 ± 7.3; intrahepatic vein, 11.3 ± 4.7; portal vein, 15.5 ± 6.7) were measured at 40 keV VMI+ with significantly superior values compared to all other series. In subjective analysis, highest image contrast was seen at 40 keV VMI+ (4.8 ± 0.4), whereas overall image quality peaked at 50 keV VMI+ (4.2 ± 0.5) with significantly superior results compared to all other series (p < 0.001). Conclusions Image reconstruction using VMI+ algorithm at 50 keV significantly improves image contrast and image quality of originally poorly opacified abdominal CT scans and reduces the number of non-diagnostic scans. Advances in knowledge We validated the impact of VMI+ reconstructions in poorly attenuated DECT studies of the abdomen in a big data cohort.
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Affiliation(s)
- Scherwin Mahmoudi
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai, Frankfurt, Germany
| | - Marvin Lange
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai, Frankfurt, Germany
| | - Lukas Lenga
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai, Frankfurt, Germany
| | - Ibrahim Yel
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai, Frankfurt, Germany
| | - Vitali Koch
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai, Frankfurt, Germany
| | - Christian Booz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai, Frankfurt, Germany
| | - Simon Martin
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai, Frankfurt, Germany
| | - Simon Bernatz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai, Frankfurt, Germany
| | - Thomas Vogl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai, Frankfurt, Germany
| | - Moritz Albrecht
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai, Frankfurt, Germany
| | - Jan-Erik Scholtz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai, Frankfurt, Germany
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Koch V, Booz C, Gruenewald LD, Albrecht MH, Gruber-RouhMD T, Eichler K, Yel I, Mahmoudi S, Scholtz JE, Martin SS, Graf C, Vogl TJ, Weber C, Hardt SE, Frey N, Giannitsis E. Diagnostic performance and predictive value of D-dimer testing in patients referred to the emergency department for suspected myocardial infarction. Clin Biochem 2022; 104:22-29. [PMID: 35181290 DOI: 10.1016/j.clinbiochem.2022.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 01/08/2022] [Accepted: 02/08/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE The study sought to assess the performance of D-dimer testing for the diagnosis of acute coronary syndrome (ACS) and prediction of outcomes in patients admitted for suspected myocardial infarction (MI). RESULTS A total of 3,557 patients with suspected ACS presenting to a single center with a broad range of symptoms including atypical chest pain were retrospectively recruited between 02/2012-01/2019. Of the study cohort, 435 patients had unstable angina (UA), 420 non-ST-segment elevation myocardial infarction (NSTEMI), 22 ST-segment elevation myocardial infarction (STEMI), and 2,680 non-coronary chest pain. Plasma D-dimer concentrations in patients with hs-cTnT >14 ng/L differed significantly from those with hs-cTnT <14 ng/L (1.5 ± 3.6 mg/L vs. 0.5 ± 0.8 mg/L; p<0.0001). Positive predictive value for a final diagnosis of ACS increased proportionally to rising D-dimer concentrations. The area under the curve (AUC) to discriminate STEMI from non-coronary chest pain (AUC 0.729, 95% confidence interval [CI] 0.71-0.75) was moderate and differed not significantly to UA (AUC 0.595, 95% CI 0.58-0.61; p=0.0653). During a median follow-up of 29 months, higher D-dimer was associated with a significantly increased risk of recurrent MI (quartile 4 vs. 1: hazard ratio [HR], 6.9 [95% CI 1.2-39.9]; p<0.0001) and higher all-cause mortality (HR, 17.4 [95% CI 4.3-69.9]; p<0.0001). D-dimer was an independent predictor of all-cause mortality (p<0.0001) and subsequent MI events (p=0.0333). CONCLUSIONS D-dimer testing revealed great potential to provide independent prognostic information on recurrent MI and all-cause mortality. However, D-dimers do not improve the diagnostic performance except if values exceed the 95th percentile.
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Affiliation(s)
- Vitali Koch
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany.
| | | | | | | | | | | | - Ibrahim Yel
- Goethe University, Frankfurt Frankfurt am Main, Germany
| | | | | | | | | | - Thomas J Vogl
- Goethe University, Frankfurt Frankfurt am Main, Germany
| | - Christophe Weber
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan E Hardt
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Norbert Frey
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Evangelos Giannitsis
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
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Mahmoudi S, Martin SS, Ackermann J, Zhdanovich Y, Koch I, Vogl TJ, Albrecht MH, Lenga L, Bernatz S. Potential of high dimensional radiomic features to assess blood components in intraaortic vessels in non-contrast CT scans. BMC Med Imaging 2021; 21:123. [PMID: 34384385 PMCID: PMC8359593 DOI: 10.1186/s12880-021-00654-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 07/30/2021] [Indexed: 11/10/2022] Open
Abstract
Background To assess the potential of radiomic features to quantify components of blood in intraaortic vessels to non-invasively predict moderate-to-severe anemia in non-contrast enhanced CT scans. Methods One hundred patients (median age, 69 years; range, 19–94 years) who received CT scans of the thoracolumbar spine and blood-testing for hemoglobin and hematocrit levels ± 24 h between 08/2018 and 11/2019 were retrospectively included. Intraaortic blood was segmented using a spherical volume of interest of 1 cm diameter with consecutive radiomic analysis applying PyRadiomics software. Feature selection was performed applying analysis of correlation and collinearity. The final feature set was obtained to differentiate moderate-to-severe anemia. Random forest machine learning was applied and predictive performance was assessed. A decision-tree was obtained to propose a cut-off value of CT Hounsfield units (HU). Results High correlation with hemoglobin and hematocrit levels was shown for first-order radiomic features (p < 0.001 to p = 0.032). The top 3 features showed high correlation to hemoglobin values (p) and minimal collinearity (r) to the top ranked feature Median (p < 0.001), Energy (p = 0.002, r = 0.387), Minimum (p = 0.032, r = 0.437). Median (p < 0.001) and Minimum (p = 0.003) differed in moderate-to-severe anemia compared to non-anemic state. Median yielded superiority to the combination of Median and Minimum (p(AUC) = 0.015, p(precision) = 0.017, p(accuracy) = 0.612) in the predictive performance employing random forest analysis. A Median HU value ≤ 36.5 indicated moderate-to-severe anemia (accuracy = 0.90, precision = 0.80). Conclusions First-order radiomic features correlate with hemoglobin levels and may be feasible for the prediction of moderate-to-severe anemia. High dimensional radiomic features did not aid augmenting the data in our exemplary use case of intraluminal blood component assessment. Trial registration Retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s12880-021-00654-9.
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Affiliation(s)
- Scherwin Mahmoudi
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Simon S Martin
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Jörg Ackermann
- Department of Molecular Bioinformatics, Institute of Computer Science, Johann Wolfgang Goethe-University, Robert-Mayer-Str. 11-15, 60325, Frankfurt am Main, Germany
| | - Yauheniya Zhdanovich
- Department of Molecular Bioinformatics, Institute of Computer Science, Johann Wolfgang Goethe-University, Robert-Mayer-Str. 11-15, 60325, Frankfurt am Main, Germany
| | - Ina Koch
- Department of Molecular Bioinformatics, Institute of Computer Science, Johann Wolfgang Goethe-University, Robert-Mayer-Str. 11-15, 60325, Frankfurt am Main, Germany
| | - Thomas J Vogl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Moritz H Albrecht
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Lukas Lenga
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Simon Bernatz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
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Mader C, Bernatz S, Michalik S, Koch V, Martin SS, Mahmoudi S, Basten L, Grünewald LD, Bucher A, Albrecht MH, Vogl TJ, Booz C. Quantification of COVID-19 Opacities on Chest CT - Evaluation of a Fully Automatic AI-approach to Noninvasively Differentiate Critical Versus Noncritical Patients. Acad Radiol 2021; 28:1048-1057. [PMID: 33741210 PMCID: PMC7936551 DOI: 10.1016/j.acra.2021.03.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/14/2021] [Accepted: 03/01/2021] [Indexed: 12/31/2022]
Abstract
Objectives To evaluate the potential of a fully automatic artificial intelligence (AI)-driven computed tomography (CT) software prototype to quantify severity of COVID-19 infection on chest CT in relationship with clinical and laboratory data. Methods We retrospectively analyzed 50 patients with laboratory confirmed COVID-19 infection who had received chest CT between March and July 2020. Pulmonary opacifications were automatically evaluated by an AI-driven software and correlated with clinical and laboratory parameters using Spearman-Rho and linear regression analysis. We divided the patients into sub cohorts with or without necessity of intensive care unit (ICU) treatment. Sub cohort differences were evaluated employing Wilcoxon-Mann-Whitney-Test. Results We included 50 CT examinations (mean age, 57.24 years), of whom 24 (48%) had an ICU stay. Extent of COVID-19 like opacities on chest CT showed correlations (all p < 0.001 if not otherwise stated) with occurrence of ICU stay (R = 0.74), length of ICU stay (R = 0.81), lethal outcome (R = 0.56) and length of hospital stay (R = 0.33, p < 0.05). The opacities extent was correlated with laboratory parameters: neutrophil count (NEU) (R = 0.60), lactate dehydrogenase (LDH) (R = 0.60), troponin (TNTHS) (R = 0.55) and c-reactive protein (CRP) (R = 0.51). Differences (p < 0.001) between ICU group and non-ICU group concerned longer length of hospital stay (24.04 vs. 10.92 days), higher opacity score (12.50 vs. 4.96) and severity of laboratory data changes such as c-reactive protein (11.64 vs. 5.07 mg/dl, p < 0.01). Conclusions Automatically AI-driven quantification of opacities on chest CT correlates with laboratory and clinical data in patients with confirmed COVID-19 infection and may serve as non-invasive predictive marker for clinical course of COVID-19.
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Affiliation(s)
- Christoph Mader
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany.
| | - Simon Bernatz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany; Dr. Senckenberg Institute for Pathology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Sabine Michalik
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Vitali Koch
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Simon S Martin
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Scherwin Mahmoudi
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Lajos Basten
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Leon D Grünewald
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Andreas Bucher
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Moritz H Albrecht
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Thomas J Vogl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Christian Booz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
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Bernatz S, Mahmoudi S, Martin SS, Burck I, Vogl TJ, Ackermann J, Stöver T, Balster S, Gröger M. Differences in mastoid and middle-ear cavity opacification in CT between intensive care patients and patients with acute mastoiditis requiring surgical treatment. Eur J Radiol Open 2021; 8:100365. [PMID: 34195304 PMCID: PMC8227832 DOI: 10.1016/j.ejro.2021.100365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 06/15/2021] [Accepted: 06/17/2021] [Indexed: 11/19/2022] Open
Abstract
Purpose To stratify differences in visual semantic and quantitative imaging features in intensive care patients with nonspecific mastoid effusions versus patients with acute mastoiditis (AM) requiring surgical treatment. Methods We included 48 patients (male, 28; female, 20; mean age, 59.5 ± 18.1 years) with mastoid opacification (AM, n = 24; control, n = 24) who underwent clinically indicated cerebral CT between 12/2007 and 07/2018 in this retrospective study. Semantic features described the extend and asymmetry of mastoid and middle-ear cavity opacification and complications like erosive changes. Minimum, maximum and mean Hounsfield unit (HU) values were obtained as quantitative features. We analyzed the features employing univariate testing. Results Compared to intensive care patients, AM patients revealed asymmetric mastoid or middle-ear cavity opacification (likelihood-ratio (LR) < 0.001). Applying a dedicated threshold of the extent of opacification, AM patients reached significance levels of LR = 0.042 and 0.002 for mastoid and middle-ear cavity opacification. AM cases showed higher maximum and mean HU values (p = 0.009, p = 0.024). Conclusions We revealed that the extent and asymmetry of mastoid and middle-ear cavity opacification differs significantly between AM patients and intensive care patients. Multicenter research is needed to expand our cohort and possibly pave the way to build a non-invasive predictive model for AM in the future.
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Affiliation(s)
- Simon Bernatz
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
- Corresponding author.
| | - Scherwin Mahmoudi
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Simon S. Martin
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Iris Burck
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Thomas J. Vogl
- Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Jörg Ackermann
- Department of Molecular Bioinformatics, Institute of Computer Science, Johann Wolfgang Goethe-University, Robert-Mayer-Str. 11-15, 60325 Frankfurt am Main, Germany
| | - Timo Stöver
- Department of Otorhinolaryngology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Sven Balster
- Department of Otorhinolaryngology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Maximilian Gröger
- Department of Otorhinolaryngology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
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Toutaoui A, Baroudi T, Mahmoudi S, Louelh R. PO-0906: MRI contrast clearance analysis for follow-up of brain tumors treated with VMAT and SRT. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(21)00923-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Pourakbari B, Mamishi S, Banar M, Keshtkar AA, Mahmoudi S. Prevalence of TB/ HIV co-infection in Iran: a systematic review and meta-analysis. Ann Ig 2020; 31:333-348. [PMID: 31268118 DOI: 10.7416/ai.2019.2295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Co-infection of TB/ HIV is an emerging threat to a global public health. Although several studies have investigated the prevalence of TB/HIV co-infection in Iran, the results are inconsistent. The current systematic review and meta-analysis was planned to estimate the overall prevalence of TB/HIV co-infection in Iran. METHODS Electronic databases, including MEDLINE (via PubMed), SCOPUS, SID and Mag Iran (two Persian scientific search engines) were searched up to 27 Apr 2017. The random effect model was used for estimating the prevalence of TB/ HIV co-infection. Heterogeneity was assessed by subgroup analysis. RESULTS Forty-eight articles met our inclusion criteria, with a total of 21,388 individuals. The meta-analysis demonstrates that the prevalence of TB/ HIV co-infection in Iran was 14% [95% confidence interval CI:12-15%]. According to the meta-analysis of 5 subgroups, the prevalence of TB/ HIV co-infection in the subgroup with high intravenous drug users (IVDU) [27%, 95% CI: 20-35%], in border provinces of Iran [17%, 95% CI: 13-21%], in the subgroup with pulmonary tuberculosis (PTB) ≥ 20% [22%, 95% CI: 17-27%], in patients <40 years of age [25%, 95 CI: 19-31%] was significantly higher. There were no significant differences between the prevalence of co-infection among low and high-quality studies. Pulmonary TB was the predominant type of TB among co-infected patients [77%, 95% CI: 71 to 84%]. CONCLUSIONS Our study demonstrates that the overall prevalence of TB/HIV co-infection in Iran was 14% [95% CI: 12-15%], which was a high rate. Some factors such as using intravenous drugs, living in border provinces of Iran, having PTB, and age <40 years had an impact on the prevalence of co-infection. Results revealed the need of HIV surveillance program among TB patients and screening of HIV-positive patients for diagnosis and treatment of TB. Further large-scale studies about the prevalence of this infection in all provinces of Iran are needed.
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Affiliation(s)
- B Pourakbari
- Pediatric Infectious Disease Research Center, Tehran University of Medical Science, Tehran, Iran
| | - S Mamishi
- Pediatric Infectious Disease Research Center, Tehran University of Medical Science, Tehran, Iran - Department of Infectious Diseases, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - M Banar
- Pediatric Infectious Disease Research Center, Tehran University of Medical Science, Tehran, Iran
| | - A A Keshtkar
- Department of Health Sciences Education Development, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - S Mahmoudi
- Pediatric Infectious Disease Research Center, Tehran University of Medical Science, Tehran, Iran
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Mamishi S, Arab Yazdi Z, Mahmoudi S, Moradzadeh M, Taghi Haghi Ashtiani M, Pourakbari B. Antimicrobial-resistance pattern of Shigella species in children: a six-year study in an Iranian referral Hospital. Ann Ig 2020; 31:356-364. [PMID: 31268120 DOI: 10.7416/ai.2019.2297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Shigella species are a frequent cause of shigellosis and shigellosis is considered as one of the most common causes of diarrhea in children. This disease is endemic in many developing countries such as Iran. This study was carried out to determine the prevalence and pattern of antimicrobial resistance of Shigella species among pediatric patients with acute diarrhea in Children Medical Center (CMC) Hospital, with a diagnosis of acute diarrhea to CMC Hospital from March 2011 through March 2016. Isolation and identification techniques, as well as the susceptibility tests are described in detail. RESULTS Of the 46,795 stool specimens that were sent to the microbiology laboratory of the CMC Hospital for culture and susceptibility testing, 573 (1.2%) were positive for Shigella species. The most common species of Shigella were S. sonnei (n= 335, 58.4%) and S. flexneri (n=229, 40%), followed by S. boydii (n=8, 1.4%) and S. dysenteriae (n=1, 0.2%). S. flexneri was most sensitive to gentamicin (n=17/19, 89%) and amikacin (n=15/18, 83%), while high frequency of resistance to trimethoprim- sulfamethoxazole (n=204/224, 91%) and ampicillin (n=216/228, 95%) was seen. S. boydii was most sensitive to ampicillin (n=5 out of 7, 71%) and cefotaxime (n=6/7, 86%) and the high frequency of resistance was seen against trimethoprim-sulfamethoxazole (n=5/7, 71%). For S. sonnei, the highest sensitivity was reported against amikacin and gentamicin (87% and 80%, respectively), while the highest resistance to trimethoprim- sulfamethoxazole (n=325/331, 98%) and ciprofloxacin (n= 66 out of 76, 87%) was reported. Ciprofloxacin was examined on 115 out of 573 isolates and 84 isolates were resistant (73%). Multidrug-resistance (MDR), (i.e. resistance to three or more classes of antimicrobial agents) was classified into 11 distinct patterns. CONCLUSIONS In this study, S. sonnei was the predominant Shigella species. High frequency of resistance to common antimicrobials such as trimethoprim-sulfamethoxazole and ampicillin limits the empirical therapy for the management of shigellosis in Iran. On the other hand, it should be noted that third-generation cephalosporins can be convenient replacing drugs.
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Affiliation(s)
- S Mamishi
- Pediatric Infectious Disease Research Center, Tehran University of Medical Sciences, Tehran, Iran - Department of Infectious Diseases, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Z Arab Yazdi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - S Mahmoudi
- Pediatric Infectious Disease Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - M Moradzadeh
- Pediatric Infectious Disease Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - M Taghi Haghi Ashtiani
- Department of Pathology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - B Pourakbari
- Pediatric Infectious Disease Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Ekbatani MS, Hassani SA, Tahernia L, Yaghmaei B, Mahmoudi S, Navaeian A, Rostamyan M, Zamani F, Mamishi S. Atypical and novel presentations of Coronavirus Disease 2019: a case series of three children. Br J Biomed Sci 2020; 78:47-52. [PMID: 32552415 DOI: 10.1080/09674845.2020.1785102] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Typical presentations of Coronavirus Disease 2019 (Covid-19) including respiratory symptoms (cough, respiratory distress and hypoxia), fever and dyspnoea are considered main symptoms in adults, but atypical presentation in children could be a diagnostic challenge. We report three children whose initial presentation was gastrointestinal, and in whom Covid-19 infection was found, concluding that cases of acute appendicitis, mesenteric adenitis and flank tenderness may mask an infection with this virus, and should therefore be investigated.
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Affiliation(s)
- M S Ekbatani
- Division of Pediatric Intensive Care Unit, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences , Tehran, Iran
| | - S A Hassani
- Division of Pediatric Intensive Care Unit, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences , Tehran, Iran
| | - L Tahernia
- Division of Pediatric Intensive Care Unit, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences , Tehran, Iran
| | - B Yaghmaei
- Division of Pediatric Intensive Care Unit, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences , Tehran, Iran
| | - S Mahmoudi
- Pediatric Infectious Disease Research Center, Tehran University of Medical Science , Tehran, Iran
| | - A Navaeian
- Department of Infectious Diseases, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences , Tehran, Iran
| | - M Rostamyan
- Department of Infectious Diseases, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences , Tehran, Iran
| | - F Zamani
- Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences , Tehran, Iran
| | - S Mamishi
- Pediatric Infectious Disease Research Center, Tehran University of Medical Science , Tehran, Iran.,Department of Infectious Diseases, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences , Tehran, Iran
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Pourakbari B, Mamishi S, Shokrollahi MR, Heydari H, Mahmoudi S, Banar M, Sadeghi RH, Movahedi Z. Molecular characteristics and antibiotic resistance profiles of Escherichia coli strains isolated from urinary tract infections in children admitted to children's referral hospital of Qom, Iran. Ann Ig 2020; 31:252-262. [PMID: 31069370 DOI: 10.7416/ai.2019.2288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Urinary tract infections (UTIs) are a highly prevalent infection among children and Escherichia coli is one of the most important pathogens causing pediatric UTIs. Production of extended spectrum b-lactamase (ESBL) enzymes is an important factor in the emergence of antibiotic resistance among these bacteria. This study aimed to determine the resistance patterns, the frequency of ESBL-encoding genes and the genetic diversity of E. coli strains isolated from children with UTIs who were admitted to children's referral hospital of Hazrat Masoumeh, Qom, Iran. METHODS A total of 102 consecutive non-duplicative strains of E.coli that were isolated from children with UTIs were included into the study. Antibiotic susceptibility of the isolates was determined by disk diffusion method according to the CLSI guidelines. The ability of the isolates to produce ESBLs was phenotypically determined by both combined disk test and double disk synergy test. The ESBL encoding genes (bla CTX-M, bla SHV, and bla TEM) in phenotypically confirmed ESBL-positive isolates was detected by PCR method. The genetic relatedness of the isolates was designated by enterobacterial repetitive intergenic consensus-PCR (ERIC-PCR). RESULTS Eighty-three percent (n=85) of the children were female. Most of the infected boys (88%, n=15) were less than 1 year of age and most of the infected girls (48%, n=41) aged 1 to 6 years old. The highest sensitivity was observed to nitrofurantoin (8%, n=8), followed by amikacin (12%, n=12) and piperacillin-tazobactam (17%, n=17). In contrast, the highest resistance rate was seen to ampicillin (94%, n=96) and cefazolin (93%, n=95). Eighty-eight percent (90 out of 102) of the strains were multidrug-resistant (MDR). Fifty-eight percent (n=59) of the strains were ESBL-positive and results of the combined disk test was in concordance with PCR. The blaCTX-M was the most frequent ESBL encoding gene (88%, n=52), followed by blaTEM (54%, n=32), and blaSHV (15%, n=9). Based on the ERIC-PCR technique, isolates were clustered in 13 different types. There was no relationship between different ERIC types and origin of the isolates (i.e. hospitalized or outpatients), ESBL-producing ability, and antibiotic resistance patterns. CONCLUSIONS High prevalence of ESBL-positive isolates of E. coli (58%) was found in our study and all of them were MDR. In addition, there were statistically significant differences in the resistance rates of ESBL-producers, and non-producers to some antibiotics, which result in limiting their therapeutic options. Continuous surveillance of the emergence of ESBL-producing isolates and their antibiotic resistance profiles as well as using appropriate typing methods is needed for reducing their spread, selecting appropriate treatment regimens and finding hospital outbreaks.
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Affiliation(s)
- B Pourakbari
- Pediatric Infectious Disease Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - S Mamishi
- Pediatric Infectious Disease Research Center, Tehran University of Medical Sciences, Tehran, Iran - Department of Infectious Diseases, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - M R Shokrollahi
- Department of Pediatric Infectious Disease, Faculty of Medicine, Qom University of Medical Sciences and Health Services, Qom, Iran - Pediatric Medicine Research Center, Qom University of Medical Sciences and Health Services, Qom, Iran
| | - H Heydari
- Department of Pediatric Infectious Disease, Faculty of Medicine, Qom University of Medical Sciences and Health Services, Qom, Iran - Pediatric Medicine Research Center, Qom University of Medical Sciences and Health Services, Qom, Iran
| | - S Mahmoudi
- Pediatric Infectious Disease Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - M Banar
- Pediatric Infectious Disease Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - R H Sadeghi
- Pediatric Infectious Disease Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Z Movahedi
- Department of Pediatric Infectious Disease, Faculty of Medicine, Qom University of Medical Sciences and Health Services, Qom, Iran - Pediatric Medicine Research Center, Qom University of Medical Sciences and Health Services, Qom, Iran
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Khodavaisy S, Badali H, Meis JF, Modiri M, Mahmoudi S, Abtahi H, Salehi M, Dehghan Manshadi SA, Aala F, Agha Kuchak Afshari S, Lotfali E, Ahangarkani F, Rezaie S. Comparative in vitro activities of seven antifungal drugs against clinical isolates of Candida parapsilosis complex. J Mycol Med 2020; 30:100968. [PMID: 32386800 DOI: 10.1016/j.mycmed.2020.100968] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 03/15/2020] [Accepted: 03/31/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Candida parapsilosis species complex, an important set of non-albicans Candida species, is known to cause candidaemia particularly in neonates and infants. However, the incidence has increased in recent years, owing to higher numbers of at individuals at risk for these infections. Our objective was to evaluate the in vitro susceptibility of clinical isolates of C. parapsilosis complex isolates from Iran to seven antifungal drugs. MATERIAL AND METHODS One hundred-one clinical isolates of C. parapsilosis species complex cultured from humans were included. Species identification had been previously confirmed by combined phenotypic characteristics, matrix-assisted laser desorption ionization-time of flight mass spectrometry-based assay and reconfirmed by DNA sequence analysis of the ITS rDNA region and D1/D2 gene. Minimum inhibitory concentrations (MICs) for amphotericin B, fluconazole, itraconazole, voriconazole, posaconazole, micafungin and anidulafungin were determined against well-characterized isolates by broth microdilution susceptibility testing according to the CLSI M27-A3 guideline. RESULTS Species identifications were performed on 101 isolates, of which 88 (87.2%) C. parapsilosis sensu stricto and 13 (12.8%) C. orthopsilosis. Amphotericin B and posaconazole were the most active drugs with 100% of isolates being wild-type (WT). Voriconazole and micafungin, 99% of isolates were WT. The low activity was recorded for fluconazole and itraconazole with 93.1% and 89.1% of isolates being WT, respectively. At the species level, all Candida parapsilosis sensu stricto isolates were WT to amphotericin B and posaconazole and all Candida orthopsilosis isolates were WT to amphotericin B, voriconazole, posaconazole, anidulafungin and micafungin. In contrast, the highest rate of non-WT was observed in C. orthopsilosis to itraconazole (4 of 13, 30.8%). CONCLUSIONS Although almost all of the tested drugs demonstrated potent activity against C. parapsilosis species complex, it seems that more especially C. orthopsilosis isolates had decreased susceptibility to itraconazole. Further studies are needed to determine how these findings may switch into in vivo efficacy.
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Affiliation(s)
- S Khodavaisy
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - H Badali
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran; Antimicrobial Resistance Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - J F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital (CWZ), Nijmegen, The Netherlands; Centre of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands
| | - M Modiri
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - S Mahmoudi
- Department of Medical Parasitology and Mycology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - H Abtahi
- Department of Pulmonary and Critical Care, Advanced Thoracic Research Center, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - M Salehi
- Department of Infectious Diseases and tropical medicines, School of Medicine, Imam Khomeini Hospital complex, Tehran University of Medical Sciences, Tehran, Iran
| | - S A Dehghan Manshadi
- Department of Infectious Diseases and tropical medicines, School of Medicine, Imam Khomeini Hospital complex, Tehran University of Medical Sciences, Tehran, Iran
| | - F Aala
- Department of Parasitology and Mycology, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - S Agha Kuchak Afshari
- Department of Medical Parasitology and Mycology, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - E Lotfali
- Department of Medical Parasitology and Mycology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - F Ahangarkani
- Antimicrobial Resistance Research Center, Mazandaran University of Medical Sciences, Sari, Iran; Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran
| | - S Rezaie
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
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Pour SH, Mahmoudi S, Masoumi S, Rezaie S, Barac A, Ranjbaran M, Oliya S, Mehravar F, Sasani E, Noorbakhsh F, Khodavaisy S. Aflatoxin M1 contamination level in Iranian milk and dairy products: a systematic review and meta-analysis. WORLD MYCOTOXIN J 2020. [DOI: 10.3920/wmj2019.2485] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Aflatoxin M1 is a derivate of aflatoxin B1 and an important contaminant of milk and dairy products. This systematic review and meta-analysis was conducted on relevant Persian and English original articles in national and international databases with no time limits until 1 January 2018. In total 605 articles were found among which 70 articles met the inclusion criteria for meta-analysis. The prevalence (95% confidence interval (CI)) and mean concentration (95% CI) of aflatoxin M1 was found to be 64% (53-75%) and 39.7 ng/l (31.9-47.4 ng/l) in raw milk, 95% (89-98%) and 62.3 ng/l (40.6-84 ng/l) in pasteurised milk, 71% (56-84%) and 60.1 ng/l (30.9-89.3 ng/l) in sterilised milk, 59% (20-93%) and 5.5 ng/l (3.3-7.7 ng/l) in breast milk and 72% (61-81%) and 82.3 ng/kg (63.7-100.9 ng/kg) in dairy products. In general, 9% (4-16%) of milks and 10% (4-17%) of dairy products had aflatoxin M1 in concentrations exceeding the permitted level of Iranian standards (500 ng/l). Based on the maximum permitted aflatoxin M1 concentration in standards of Europe (50 ng/l), these percentages increase to 25% (18-32%) for milks and 18% (9-29%) for dairy products. According to the results, further control and preventive measures should be applied on livestock feeds because decreased aflatoxin B1 contamination at this level results in decreased aflatoxin M1 in milk and dairy products.
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Affiliation(s)
- S. Hamzeh Pour
- Department of Pathobiology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - S. Mahmoudi
- Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - S. Masoumi
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - S. Rezaie
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - A. Barac
- Clinic for Infectious and Tropical Diseases, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - M. Ranjbaran
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - S. Oliya
- Department of Nutrition, School of Public Health, Qazvin University of Medical Sciences, Qazvin, Iran
| | - F. Mehravar
- Health Management and Social Development Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | - E. Sasani
- Department of Medical Mycology, Tarbiat Modares University, Tehran, Iran
| | - F. Noorbakhsh
- Department of Microbiology, Biological Science college, Varamin- pishva branch, Islamic Azad University, Varamin-pishva, Iran
| | - S. Khodavaisy
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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Pourakbari B, Movahedi Z, Mahmoudi S, Sabouni F, Ashtiani MTH, Sadeghi RH, Mamishi S. Genotypic characteristics of Pseudomonas aeruginosa strains circulating in the tertiary referral Children's Medical Hospital in Tehran, Iran. Br J Biomed Sci 2019. [DOI: 10.1080/09674845.2012.12069147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- B. Pourakbari
- Pediatrics Infectious Diseases Research Center, Tehran University of Medical Sciences
| | - Z. Movahedi
- Department of Infectious Disease, School of Medicine, Qom University of Medical Sciences
| | - S. Mahmoudi
- Pediatrics Infectious Diseases Research Center, Tehran University of Medical Sciences
| | - F. Sabouni
- Department of Pediatric Infectious Disease, School of Medicine Tehran University of Medical Sciences
| | - M. T. H. Ashtiani
- Department of Pathology, School of Medicine, Tehran University of Medical Sciences, Iran
| | - R. H. Sadeghi
- Pediatrics Infectious Diseases Research Center, Tehran University of Medical Sciences
| | - S. Mamishi
- Pediatrics Infectious Diseases Research Center, Tehran University of Medical Sciences
- Department of Pediatric Infectious Disease, School of Medicine Tehran University of Medical Sciences
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