Validation of the standardization framework SSTR-RADS 1.0 for neuroendocrine tumors using the novel SSTR‑targeting peptide [18F]SiTATE

OBJECTIVES

Somatostatin receptor positron emission tomography/computed tomography (SSTR-PET/CT) using [68Ga]-labeled tracers is a widely used imaging modality for neuroendocrine tumors (NET). Recently, [18F]SiTATE, a SiFAlin tagged [Tyr3]-octreotate (TATE) PET tracer, has shown great potential due to favorable clinical characteristics. We aimed to evaluate the reproducibility of Somatostatin Receptor-Reporting and Data System 1.0 (SSTR-RADS 1.0) for structured interpretation and treatment planning of NET using [18F]SiTATE.

METHODS

Four readers assessed [18F]SiTATE-PET/CT of 95 patients according to the SSTR-RADS 1.0 criteria at two different time points. Each reader evaluated up to five target lesions per scan. The overall scan score and the decision on peptide receptor radionuclide therapy (PRRT) were considered. Inter- and intra-reader agreement was determined using the intraclass correlation coefficient (ICC).

RESULTS

The ICC analysis on the inter-reader agreement using SSTR-RADS 1.0 for identical target lesions (ICC ≥ 85%), overall scan score (ICC ≥ 90%), and the decision to recommend PRRT (ICC ≥ 85%) showed excellent agreement. However, significant differences were observed in recommending PRRT among experienced readers (ER) (p = 0.020) and inexperienced readers (IR) (p = 0.004). Compartment-based analysis demonstrated good to excellent inter-reader agreement for most organs (ICC ≥ 74%), except for lymph nodes (ICC ≥ 53%).

CONCLUSION

SSTR-RADS 1.0 represents a highly reproducible and consistent framework system for stratifying SSTR-targeted PET/CT scans, even using the novel SSTR-ligand [18F]SiTATE. Some inter-reader variability was observed regarding the evaluation of uptake intensity prior to PRRT as well as compartment scoring of lymph nodes, indicating that those categories require special attention during further clinical validation and might be refined in a future SSTR-RADS version 1.1.

CLINICAL RELEVANCE STATEMENT

SSTR-RADS 1.0 is a consistent framework for categorizing somatostatin receptor-targeted PET/CT scans when using [18F]SiTATE. The framework serves as a valuable tool for facilitating and improving the management of patients with NET.

KEY POINTS

SSTR-RADS 1.0 is a valuable tool for managing patients with NET. SSTR-RADS 1.0 categorizes patients with showing strong agreement across diverse reader expertise. As an alternative to [68Ga]-labeled PET/CT in neuroendocrine tumor imaging, SSTR-RADS 1.0 reliably classifies [18F]SiTATE-PET/CT.

Environmental regularities mitigate attentional misguidance in contextual cueing of visual search

Visual search is faster when a fixed target location is paired with a spatially invariant (vs. randomly changing) distractor configuration, thus indicating that repeated contexts are learned, thereby guiding attention to the target (contextual cueing [CC]). Evidence for memory-guided attention has also been revealed with electrophysiological (electroencephalographic [EEG]) recordings, starting with an enhanced early posterior negativity (N1pc), which signals a preattentive bias toward the target, and, subsequently, attentional and postselective components, such as the posterior contralateral negativity (PCN) and contralateral delay activity (CDA), respectively. Despite effective learning, relearning of previously acquired contexts is inflexible: The CC benefits disappear when the target is relocated to a new position within an otherwise invariant context and corresponding EEG correlates are diminished. The present study tested whether global statistical properties that induce predictions going beyond the immediate invariant layout can facilitate contextual relearning. Global statistical regularities were implemented by presenting repeated and nonrepeated displays in separate streaks (mini blocks) of trials in the relocation phase, with individual displays being presented in a fixed and thus predictable order. Our results revealed a significant CC effect (and an associated modulation of the N1pc, PCN, and CDA components) during initial learning. Critically, the global statistical regularities in the relocation phase also resulted in a reliable CC effect, thus revealing effective relearning with predictive streaks. Moreover, this relearning was reflected in an enhanced PCN amplitude for repeated relative to nonrepeated contexts. Temporally ordered contexts may thus adapt memory-based guidance of attention, particularly the allocation of covert attention in the visual display. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

When experience with scenes foils attentional orienting: ERP evidence against flexible target-context mapping in visual search

Visual search is speeded when a target is repeatedly presented in an invariant scene context of nontargets (contextual cueing), demonstrating observers' capability for using statistical long-term memory (LTM) to make predictions about upcoming sensory events, thus improving attentional orienting. In the current study, we investigated whether expectations arising from individual, learned environmental structures can encompass multiple target locations. We recorded event-related potentials (ERPs) while participants performed a contextual cueing search task with repeated and non-repeated spatial item configurations. Notably, a given search display could be associated with either a single target location (standard contextual cueing) or two possible target locations. Our result showed that LTM-guided attention was always limited to only one target position in single- but also in the dual-target displays, as evidenced by expedited reaction times (RTs) and enhanced N1pc and N2pc deflections contralateral to one ("dominant") target of up to two repeating target locations. This contrasts with the processing of non-learned ("minor") target positions (in dual-target displays), which revealed slowed RTs alongside an initial N1pc "misguidance" signal that then vanished in the subsequent N2pc. This RT slowing was accompanied by enhanced N200 and N400 waveforms over fronto-central electrodes, suggesting that control mechanisms regulate the competition between dominant and minor targets. Our study thus reveals a dissociation in processing dominant versus minor targets: While LTM templates guide attention to dominant targets, minor targets necessitate control processes to overcome the automatic bias towards previously learned, dominant target locations.

Individual peak alpha frequency does not index individual differences in inhibitory cognitive control

Previous work has indicated that individual differences in cognitive performance can be predicted by characteristics of resting state oscillations, such as individual peak alpha frequency (IAF). Although IAF has previously been correlated with cognitive functions, such as memory, attention, or mental speed, its link to cognitive conflict processing remains unexplored. The current work investigated the relationship between IAF and incl-established conflict tasks, Stroop and Navon task, while also controlling for alpha power, theta power, and the 1/f offset of aperiodic broadband activity. In Bayesian analyses on a large sample of 127 healthy participants, we found substantial evidence against the assumption that IAF predicts individual abilities to spontaneously exert cognitive control. Similarly, our findings yielded substantial evidence against links between cognitive control and resting state power in the alpha and theta bands or between cognitive control and aperiodic 1/f offset. In sum, our results challenge frameworks suggesting that an individual's ability to spontaneously engage attentional control networks may be mirrored in resting state EEG characteristics.

Reliability and practicability of PSMA-RADS 1.0 for structured reporting of PSMA-PET/CT scans in prostate cancer patients

OBJECTIVES

As structured reporting is increasingly used in the evaluation of prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA-PET/CT) for prostate cancer, there is a need to assess the reliability of these frameworks. This study aimed to evaluate the intra- and interreader agreement among readers with varying levels of experience using PSMA-RADS 1.0 for interpreting PSMA-PET/CT scans, even when blinded to clinical data, and therefore to determine the feasibility of implementing this reporting system in clinical practice.

METHODS

PSMA-PET/CT scans of 103 patients were independently evaluated by 4 readers with different levels of experience according to the reporting and data system (RADS) for PSMA-PET/CT imaging PSMA-RADS 1.0 at 2 time points within 6 weeks. For each scan, a maximum of five target lesions were freely chosen and stratified according to PSMA-RADS 1.0. Overall scan score and compartment-based scores were assessed. Intra- and interreader agreement was determined using the intraclass correlation coefficient (ICC).

RESULTS

PSMA-RADS 1.0 demonstrated excellent interreader agreement for both overall scan scores (ICC ≥ 0.91) and compartment-based scores (ICC ≥ 0.93) across all four readers. The framework showed excellent intrareader agreement for overall scan scores (ICC ≥ 0.86) and compartment-based scores (ICC ≥ 0.95), even among readers with varying levels of experience.

CONCLUSIONS

PSMA-RADS 1.0 is a reliable method for assessing PSMA-PET/CT with strong consistency and agreement among readers. It shows great potential for establishing a standard approach to diagnosing and planning treatment for prostate cancer patients, and can be used confidently even by readers with less experience.

CLINICAL RELEVANCE STATEMENT

This study underlines that PSMA-RADS 1.0 is a valuable and highly reliable scoring system for PSMA-PET/CT scans of prostate cancer patients and can be used confidently by radiologists with different levels of experience in routine clinical practice.

KEY POINTS

PSMA-RADS version 1.0 is a scoring system for PSMA-PET/CT scans. Its reproducibility needs to be analyzed in order to make it applicable to clinical practice. Excellent interreader and intrareader agreement for overall scan scores and compartment-based scores using PSMA-RADS 1.0 were seen in readers with varying levels of experience. PSMA-RADS 1.0 is a reliable tool for accurately diagnosing and planning treatment for prostate cancer patients, and can be used confidently in clinical routine.

Mission impossible? Spatial context relearning following a target relocation event depends on cue predictiveness

Visual search for a target is faster when the spatial layout of distractors is repeatedly encountered, illustrating that statistical learning of contextual invariances facilitates attentional guidance (contextual cueing; Chun & Jiang, 1998, Cognitive Psychology, 36, 28-71). While contextual learning is usually relatively efficient, relocating the target to an unexpected location (within an otherwise unchanged search layout) typically abolishes contextual cueing and the benefits deriving from invariant contexts recover only slowly with extensive training (Zellin et al., 2014, Psychonomic Bulletin & Review, 21(4), 1073-1079). However, a recent study by Peterson et al. (2022, Attention, Perception, & Psychophysics, 84(2), 474-489) in fact reported rather strong adaptation of spatial contextual memories following target position changes, thus contrasting with prior work. Peterson et al. argued that previous studies may have been underpowered to detect a reliable recovery of contextual cueing after the change. However, their experiments also used a specific display design that frequently presented the targets at the same locations, which might reduce the predictability of the contextual cues thereby facilitating its flexible relearning (irrespective of statistical power). The current study was a (high-powered) replication of Peterson et al., taking into account both statistical power and target overlap in context-memory adaptation. We found reliable contextual cueing for the initial target location irrespective of whether the targets shared their location across multiple displays, or not. However, contextual adaptation following a target relocation event occurred only when target locations were shared. This suggests that cue predictability modulates contextual adaptation, over and above a possible (yet negligible) influence of statistical power.

Assessing regional hepatic function changes after hypertrophy induction by radioembolisation: comparison of gadoxetic acid-enhanced MRI and 99mTc-mebrofenin hepatobiliary scintigraphy

BACKGROUND

To compare Gd-ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) and 99mTc-labelled mebrofenin hepatobiliary scintigraphy (HBS) as imaging-based liver function tests after unilateral radioembolisation (RE) in patients with primary or secondary liver malignancies.

METHODS

Twenty-three patients with primary or secondary liver malignancies who underwent Gd-EOB-DTPA-enhanced MRI within a prospective study (REVoluTion) were evaluated. REVoluTion was a prospective open-label, non-randomised, therapy-optimising study of patients undergoing right-sided or sequential RE for contralateral liver hypertrophy at a single centre in Germany. MRI and hepatobiliary scintigraphy were performed before RE (baseline) and 6 weeks after (follow-up). This exploratory subanalysis compared liver enhancement on hepatobiliary phase MRI normalised to the spleen (liver-to-spleen ratio (LSR)) and the muscle (liver-to-muscle ratio (LMR)) with mebrofenin uptake on HBS for the total liver (TL) and separately for the right (RLL) and left liver lobe (LLL).

RESULTS

Mebrofenin uptake at baseline and follow-up each correlated significantly with LSR and LMR on MRI for TL (≤ 0.013) and RLL (≤ 0.049). Regarding the LLL, mebrofenin uptake correlated significantly with LMR (baseline, p = 0.013; follow-up, p = 0.004), whereas with LSR, a borderline significant correlation was only seen at follow-up (p = 0.051; p = 0.046).

CONCLUSION

LSRs and LMR correlate with mebrofenin uptake in HBS. This study indicates that Gd-EOB-DTPA-enhanced MRI and 99mTc-labelled mebrofenin HBS may equally be used to assess an increase in contralateral liver lobe function after right-sided RE.

RELEVANCE STATEMENT

MRI may be a convenient and reliable method for assessing the future liver remnant facilitating treatment planning and monitoring of patients after RE-induced hypertrophy induction.

KEY POINTS

• Both MRI and HBS can assess liver function after RE. • Liver enhancement on MRI correlates with mebrofenin uptake on HBS. • MRI might be a convenient alternative for estimating future liver remnants after hypertrophy induction.

Artificial Intelligence in Oncological Hybrid Imaging

BACKGROUND

 Artificial intelligence (AI) applications have become increasingly relevant across a broad spectrum of settings in medical imaging. Due to the large amount of imaging data that is generated in oncological hybrid imaging, AI applications are desirable for lesion detection and characterization in primary staging, therapy monitoring, and recurrence detection. Given the rapid developments in machine learning (ML) and deep learning (DL) methods, the role of AI will have significant impact on the imaging workflow and will eventually improve clinical decision making and outcomes.

METHODS AND RESULTS

 The first part of this narrative review discusses current research with an introduction to artificial intelligence in oncological hybrid imaging and key concepts in data science. The second part reviews relevant examples with a focus on applications in oncology as well as discussion of challenges and current limitations.

CONCLUSION

 AI applications have the potential to leverage the diagnostic data stream with high efficiency and depth to facilitate automated lesion detection, characterization, and therapy monitoring to ultimately improve quality and efficiency throughout the medical imaging workflow. The goal is to generate reproducible, structured, quantitative diagnostic data for evidence-based therapy guidance in oncology. However, significant challenges remain regarding application development, benchmarking, and clinical implementation.

KEY POINTS

  · Hybrid imaging generates a large amount of multimodality medical imaging data with high complexity and depth.. · Advanced tools are required to enable fast and cost-efficient processing along the whole radiology value chain.. · AI applications promise to facilitate the assessment of oncological disease in hybrid imaging with high quality and efficiency for lesion detection, characterization, and response assessment. The goal is to generate reproducible, structured, quantitative diagnostic data for evidence-based oncological therapy guidance.. · Selected applications in three oncological entities (lung, prostate, and neuroendocrine tumors) demonstrate how AI algorithms may impact imaging-based tasks in hybrid imaging and potentially guide clinical decision making..

Cost-effectiveness analysis of MRI, CE-CT and 18F-FDG PET/CT for detecting colorectal liver metastases eligible for hepatic resection

OBJECTIVES

Colorectal cancer (CRC) is a serious challenge for the health system. In 2022 CRC represented 8% of cancer diagnoses in the United States. 30% of patients already show metastases at the initial tumor staging. The majority of these metastases are sited in the liver. According to their extension and the status of the tumor colorectal liver metastases can be treated in several ways, with hepatic resection being the gold-standard. Contrast-enhanced computed tomography (CE-CT), positron emission tomography/computed tomography (PET/CT) and magnetic resonance imaging (MRI) can be used for evaluation of resectability of these liver metastases. The aim of this study is to assess the most economic imaging modality for detecting liver metastases eligible for hepatic resection by analyzing their cost-effectiveness.

MATERIALS AND METHODS

In our study, a Markov state transition model was built to calculate the quality-adjusted life years (QALYs) and overall costs for each diagnostic strategy in accord with the stated input values obtained from scientific research. Further, probabilistic sensitivity analyses by means of Monte Carlo simulations were performed to consider possible model uncertainties. For evaluation of the cost-effectiveness on an economic threshold, the Willingness-to-pay (WTP) was set at $ 100,000. The applied values and the calculated results are based on the U.S. healthcare system.

RESULTS

CE-CT led to overall costs of $ 42,874.02 and 8.47 QALYs, whereas MRI led to $ 40,863.65 and 8.50 QALYs. PET/CT resulted in overall costs of $ 43,216.74 and 8.48 QALYs. Therefore, MRI was determined to be the dominant strategy in the model. According to the performed sensitivity analyses, MRI remained cost-effective over a wide range of WTPs.

CONCLUSION

In conclusion, according to our analysis, MRI is the dominant strategy for detecting hepatic metastases eligible for hepatic resection in colorectal cancer.

Validation of the SSTR-RADS 1.0 for the structured interpretation of SSTR-PET/CT and treatment planning in neuroendocrine tumor (NET) patients

OBJECTIVES

The recently proposed standardized reporting and data system for somatostatin receptor (SSTR)-targeted PET/CT SSTR-RADS 1.0 showed promising first results in the assessment of diagnosis and treatment planning with peptide receptor radionuclide therapy (PRRT) in neuroendocrine tumors (NET). This study aimed to determine the intra- and interreader agreement of SSTR-RADS 1.0.

METHODS

SSTR-PET/CT scans of 100 patients were independently evaluated by 4 readers with different levels of expertise according to the SSTR-RADS 1.0 criteria at 2 time points within 6 weeks. For each scan, a maximum of five target lesions were freely chosen by each reader (not more than three lesions per organ) and stratified according to the SSTR-RADS 1.0 criteria. Overall scan score and binary decision on PRRT were assessed. Intra- and interreader agreement was determined using the intraclass correlation coefficient (ICC).

RESULTS

Interreader agreement using SSTR-RADS 1.0 for identical target lesions (ICC ≥ 0.91) and overall scan score (ICC ≥ 0.93) was excellent. The decision to state "functional imaging fulfills requirements for PRRT and qualifies patient as potential candidate for PRRT" also demonstrated excellent agreement among all readers (ICC ≥ 0.86). Intrareader agreement was excellent even among different experience levels when comparing target lesion-based scores (ICC ≥ 0.98), overall scan score (ICC ≥ 0.93), and decision for PRRT (ICC ≥ 0.88).

CONCLUSION

SSTR-RADS 1.0 represents a highly reproducible and accurate system for stratifying SSTR-targeted PET/CT scans with high intra- and interreader agreement. The system is a promising approach to standardize the diagnosis and treatment planning in NET patients.

KEY POINTS

• SSTR-RADS 1.0 offers high reproducibility and accuracy. • SSTR-RADS 1.0 is a promising method to standardize diagnosis and treatment planning for patients with NET.

Artificial Intelligence in Oncological Hybrid Imaging

BACKGROUND

Artificial intelligence (AI) applications have become increasingly relevant across a broad spectrum of settings in medical imaging. Due to the large amount of imaging data that is generated in oncological hybrid imaging, AI applications are desirable for lesion detection and characterization in primary staging, therapy monitoring, and recurrence detection. Given the rapid developments in machine learning (ML) and deep learning (DL) methods, the role of AI will have significant impact on the imaging workflow and will eventually improve clinical decision making and outcomes.

METHODS AND RESULTS

The first part of this narrative review discusses current research with an introduction to artificial intelligence in oncological hybrid imaging and key concepts in data science. The second part reviews relevant examples with a focus on applications in oncology as well as discussion of challenges and current limitations.

CONCLUSION

AI applications have the potential to leverage the diagnostic data stream with high efficiency and depth to facilitate automated lesion detection, characterization, and therapy monitoring to ultimately improve quality and efficiency throughout the medical imaging workflow. The goal is to generate reproducible, structured, quantitative diagnostic data for evidence-based therapy guidance in oncology. However, significant challenges remain regarding application development, benchmarking, and clinical implementation.

KEY POINTS

· Hybrid imaging generates a large amount of multimodality medical imaging data with high complexity and depth.. · Advanced tools are required to enable fast and cost-efficient processing along the whole radiology value chain.. · AI applications promise to facilitate the assessment of oncological disease in hybrid imaging with high quality and efficiency for lesion detection, characterization, and response assessment. The goal is to generate reproducible, structured, quantitative diagnostic data for evidence-based oncological therapy guidance.. · Selected applications in three oncological entities (lung, prostate, and neuroendocrine tumors) demonstrate how AI algorithms may impact imaging-based tasks in hybrid imaging and potentially guide clinical decision making..

CITATION FORMAT

· Feuerecker B, Heimer M, Geyer T et al. Artificial Intelligence in Oncological Hybrid Imaging. Fortschr Röntgenstr 2023; 195: 105 - 114.

Multisensory Rather than Unisensory Representations Contribute to Statistical Context Learning in Tactile Search

Using a combination of behavioral and EEG measures in a tactile odd-one-out search task with collocated visual items, we investigated the mechanisms underlying facilitation of search by repeated (vs. nonrepeated) spatial distractor-target configurations ("contextual cueing") when either the tactile (same-modality) or the visual array (different-modality) context was predictive of the location of the tactile singleton target. Importantly, in both conditions, the stimulation was multisensory, consisting of tactile plus visual items, although the target was singled out in the tactile modality and so the visual items were task-irrelevant. We found that when the predictive context was tactile, facilitation of search RTs by repeated configurations was accompanied by, and correlated with, enhanced lateralized ERP markers of pre-attentive (N1, N2) and, respectively focal-attentional processing (contralateral delay activity) not only over central ("somatosensory"), but also posterior ("visual") electrode sites, although the ERP effects were less marked over visual cortex. A similar pattern-of facilitated RTs and enhanced lateralized (N2 and contralateral delay activity) ERP components-was found when the predictive context was visual, although the ERP effects were less marked over somatosensory cortex. These findings indicate that both somatosensory and visual cortical regions contribute to the more efficient processing of the tactile target in repeated stimulus arrays, although their involvement is differentially weighted depending on the sensory modality that contains the predictive information.

Extrahepatic Disease in Hepatocellular Carcinoma: Do We Always Need Whole-Body CT or Is Liver MRI Sufficient? A Subanalysis of the SORAMIC Trial

Background: To investigate whole-body contrast-enhanced CT and hepatobiliary contrast liver MRI for the detection of extrahepatic disease (EHD) in hepatocellular carcinoma (HCC) and to quantify the impact of EHD on therapy decision. Methods: In this post-hoc analysis of the prospective phase II open-label, multicenter, randomized controlled SORAMIC trial, two blinded readers independently analyzed the whole-body contrast-enhanced CT and gadoxetic acid-enhanced liver MRI data sets of 538 HCC patients. EHD (defined as tumor manifestation outside the liver) detection rates of the two imaging modalities were compared using multiparametric statistical tests. In addition, the most appropriate treatment recommendation was determined by a truth panel. Results: EHD was detected significantly more frequently in patients with portal vein infiltration (21% vs. 10%, p < 0.001), macrovascular infiltration (22% vs. 9%, p < 0.001), and bilobar liver involvement (18% vs. 9%, p = 0.006). Further on, the maximum lesion diameter in patients with EHD was significantly higher (8.2 cm vs. 5.8 cm, p = 0.002). CT detected EHD in significantly more patients compared to MRI in both reader groups (p < 0.001). Higher detection rates of EHD in CT led to a change in management only in one patient since EHD was predominantly present in patients with locally advanced HCC, in whom palliative treatment is the standard of care. Conclusions: Whole-body contrast-enhanced CT shows significantly higher EHD detection rates compared to hepatobiliary contrast liver MRI. However, the higher detection rate did not yield a significant impact on patient management in advanced HCC.

Cross-modal contextual memory guides selective attention in visual-search tasks

Visual search is speeded when a target item is positioned consistently within an invariant (repeatedly encountered) configuration of distractor items ("contextual cueing"). Contextual cueing is also observed in cross-modal search, when the location of the-visual-target is predicted by distractors from another-tactile-sensory modality. Previous studies examining lateralized waveforms of the event-related potential (ERP) with millisecond precision have shown that learned visual contexts improve a whole cascade of search-processing stages. Drawing on ERPs, the present study tested alternative accounts of contextual cueing in tasks in which distractor-target contextual associations are established across, as compared to, within sensory modalities. To this end, we devised a novel, cross-modal search task: search for a visual feature singleton, with repeated (and nonrepeated) distractor configurations presented either within the same (visual) or a different (tactile) modality. We found reaction times (RTs) to be faster for repeated versus nonrepeated configurations, with comparable facilitation effects between visual (unimodal) and tactile (crossmodal) context cues. Further, for repeated configurations, there were enhanced amplitudes (and reduced latencies) of ERPs indexing attentional allocation (PCN) and postselective analysis of the target (CDA), respectively; both components correlated positively with the RT facilitation. These effects were again comparable between uni- and crossmodal cueing conditions. In contrast, motor-related processes indexed by the response-locked LRP contributed little to the RT effects. These results indicate that both uni- and crossmodal context cues benefit the same, visual processing stages related to the selection and subsequent analysis of the search target.

Breast Cancer Metastasis Mimicking Meningioma in 68Ga-DOTATOC PET/CT

ABSTRACT

68Ga-DOTATOC PET/CT is a reliable imaging modality in the diagnosis and therapy planning of symptomatic meningiomas. We present a case of a 74-year-old woman where a supposed SSTR-positive sphenoid wing meningioma turned out to be a breast cancer metastasis. Our case shows that dural metastases from breast cancer might represent a clinical pitfall in 68Ga-DOTATOC PET/CT.

Course of Disease and Clinical Management of Patients with Poorly Differentiated Thyroid Carcinoma

Simple Summary

Poorly differentiated thyroid carcinoma (PDTC) represents a rare but aggressive variant of thyroid carcinoma and contributes to a significant proportion of thyroid carcinoma-associated deaths. Studies on PDTC are rare; therefore, we aim to assess the clinical course of these patients, evaluate the prognostic value of response to initial radioiodine therapy and identify risk factors for poor prognosis to optimize the clinical management of patients with PDCT.

Abstract

Background: In patients with poorly differentiated thyroid carcinoma, the clinical course and prognostic value of response to initial radioiodine therapy is evaluated. Methods: In 47 patients, clinical and imaging features were analyzed. Patients were stratified in no (NED), biochemical (B-ED) and structural evidence of disease (S-ED) assessed at the first diagnostic control and its impact on survival was evaluated. Further, possible risk factors for a shorter disease-specific survival rate (DSS) were analyzed. Results: In total, 17/47 patients consisted of NED, 10/47 were B-ED and 20/47 S-ED patients. At the last follow-up, 18/47 patients were NED, 2/47 patients B-ED and 27/47 patients S-ED. The median survival time was only reached for the S-ED group (median 3.9 years, 95%CI 2.8–5.1 years) and was not reached in the B-ED and NED groups. Metastases were diagnosed by a ¹⁸F-FDG-PET/CT scan in all cases and a multivariate analysis showed that the PET-positivity of metastases was the only significant predictor of DSS (p = 0.036). Conclusion: The response to initial surgery and radioiodine therapy in PDTC patients can achieve an excellent outcome and a further follow-up should be refined based on findings at the first diagnostic control. However, patients with an incomplete response and metastatic patients who become mostly radioiodine refractory show a significantly shorter survival, which makes accurate staging by ¹⁸F-FDG-PET/CT imaging crucial.

Safety assessment and diagnostic evaluation of patients undergoing contrast-enhanced urosonography in the setting of vesicoureteral reflux confirmation

BACKGROUND

Vesicoureteral reflux (VUR) represents a common pediatric anomaly in children with an upper urinary tract infection (UTI) and is defined as a retrograde flow of urine from the bladder into the upper urinary tract. There are many diagnostic options available, including voiding cystourethrography (VCUG) and contrasted-enhanced urosonography (ceVUS). ceVUS combines a diagnostic tool with a high sensitivity and specificity which, according to previous study results, was even shown to be superior to VCUG. Nevertheless, despite the recommendation of the EFSUMB, the ceVUS has not found a widespread use in clinical diagnostics in Europe yet.

MATERIALS AND METHODS

Between 2016 and 2020, 49 patients with a marked female dominance (n = 37) were included. The youngest patient had an age of 5 months, the oldest patient 60 years. The contrast agent used in ceVUS was SonoVue®, a second-generation blood-pool agent. All examinations were performed and interpreted by a single experienced radiologist (EFSUMB Level 3).

RESULTS

The 49 patients included in the study showed no adverse effects. 51% of patients (n = 26) were referred with the initial diagnosis of suspected VUR, while 49% of patients (n = 23) came for follow-up examination or to rule out recurrence of VUR. The vast majority had at least one febrile urinary tract infection in their recent medical history (n = 45; 91,8%).

CONCLUSION

ceVUS is an examination method with a low risk profile which represents with its high sensitivity and specificity an excellent diagnostic tool in the evaluation of vesicoureteral reflux, especially in consideration of a generally very young patient cohort.

Diagnostic Value of Contrast-Enhanced Ultrasound for Evaluation of Transjugular Intrahepatic Portosystemic Shunt Perfusion

BACKGROUND

In patients with liver cirrhosis, transjugular intrahepatic portosystemic shunt (TIPS) displays an effective method for treating portal hypertension. Main indications include refractory ascites and secondary prevention of esophageal bleeding. Color Doppler ultrasound (CDUS) plays a leading role in the follow-up management, whereas contrast-enhanced ultrasound (CEUS) is not routinely considered. We compared the efficacy of CEUS to CDUS and highlighted differences compared to findings of corresponding computed tomography (CT) and magnetic resonance imaging (MRI). (2) Methods: On a retrospective basis, 106 patients with CEUS examination after TIPS were included. The enrollment period was 12 years (between 2008 and 2020) and the age group ranged from 23.3 to 82.1 years. In addition, 92 CDUS, 43 CT and 58 MRI scans were evaluated for intermodal comparison. (3) Results: Intermodal analysis and comparison revealed a high level of concordance between CDUS, CT and MRI in the vast majority of cases. In comparison to CDUS, the correlation of the relevant findings was 92.5%, 95.3% for CT and 87.9% for MRI. In some cases, however, additional information was provided by CEUS (4) Conclusions: CEUS depicts a safe and effective imaging modality for follow-up after TIPS. In addition to CDUS, CEUS enables specific assessment of stent pathologies and stent dysfunction due to its capacity to dynamically visualize single microbubbles at high spatial and temporal resolution. Due to the low number of adverse events regarding the application of contrast agents, CEUS can be administered to a very broad patient population, thus avoiding additional radiation exposure compared to CT angiography in cases with divergent findings during follow-up.

Quantitative Analysis of the Time-Intensity Curve of Contrast-Enhanced Ultrasound of the Liver: Differentiation of Benign and Malignant Liver Lesions

Background: To evaluate the diagnostic accuracy of quantitative perfusion parameters in contrast-enhanced ultrasound to differentiate malignant from benign liver lesions. Methods: In this retrospective study 134 patients with a total of 139 focal liver lesions were included who underwent contrast enhanced ultrasound (CEUS) between 2008 and 2018. All examinations were performed by a single radiologist with more than 15 years of experience using a second-generation blood pool contrast agent. The standard of reference was histopathology (n = 60), MRI or CT (n = 75) or long-term CEUS follow up (n = 4). For post processing regions of interests were drawn both inside of target lesions and the liver background. Time–intensity curves were fitted to the CEUS DICOM dataset and the rise time (RT) of contrast enhancement until peak enhancement, and a late-phase ratio (LPR) of signal intensities within the lesion and the background tissue, were calculated and compared between malignant and benign liver lesion using Student’s t-test. Quantitative parameters were evaluated with respect to their diagnostic accuracy using receiver operator characteristic curves. Both features were then combined in a logistic regression model and the cumulated accuracy was assessed. Results: RT of benign lesions (14.8 ± 13.8 s, p = 0.005), and in a subgroup analysis, particular hemangiomas (23.4 ± 16.2 s, p < 0.001) differed significantly to malignant lesions (9.3 ± 3.8 s). The LPR was significantly different between benign (1.59 ± 1.59, p < 0.001) and malignant lesions (0.38 ± 0.23). Logistic regression analysis with RT and LPR combined showed a high diagnostic accuracy of quantitative CEUS parameters with areas under the curve of 0.923 (benign vs. malignant) and 0.929 (hemangioma vs. malignant. Conclusions: Quantified CEUS parameters are helpful to differentiate malignant from benign liver lesions, in particular in case of atypical hemangiomas.

NMR-Based Lipid Metabolite Profiles to Predict Outcomes in Patients Undergoing Interventional Therapy for a Hepatocellular Carcinoma (HCC): A Substudy of the SORAMIC Trial

Simple Summary

A hepatocellular carcinoma (HCC) is the most common cause of death in patients suffering from chronic liver diseases. In order to improve the prediction of outcomes in HCC patients, there is a need for new biomarkers. This pilot study aimed at identifying serum metabolites for the prediction of outcomes of HCC patients using nuclear magnetic resonance (NMR) spectroscopy. This analysis revealed that high serum concentrations of myo-inositol or dimethylamine were associated with an improved overall survival. In contrast, high concentrations of total cholesterol, LDL-cholesterol and LDL particles (LDL-P) were associated with a decreased overall survival. The identification of novel biomarkers using this NMR-based technology holds promise for opening new directions in the conduction of interventional trials in HCCs.

Abstract

Background: This exploratory study aimed to evaluate lipidomic and metabolomic profiles in patients with early and advanced HCCs and to investigate whether certain metabolic parameters may predict the overall survival in these patients. Methods: A total of 60 patients from the prospective, randomized-controlled, multicenter phase II SORAMIC trial were included in this substudy; among them were 30 patients with an early HCC who underwent radiofrequency ablation combined with sorafenib or a placebo and 30 patients with an advanced HCC who were treated with a selective internal radiation therapy (SIRT) plus sorafenib vs. sorafenib alone. The blood serum of these patients was analyzed using a standardized nuclear magnetic resonance (NMR) platform. All tested metabolites were correlated with the overall survival. Results: The overall survival (OS) was significantly higher in patients with an early HCC (median OS: 34.0 months) compared with patients with an advanced HCC (median OS: 12.0 months) (p < 0.0001). Patients with high serum concentrations of myo-inositol (MI) had a higher overall survival compared with patients with low concentrations (21.6 vs. 13.8 months) with a Pearson correlation coefficient of 0.331 (p = 0.011). Patients with high serum concentrations of dimethylamine had a higher overall survival compared with patients with low concentrations (25.1 vs. 19.7 months) with a Pearson correlation coefficient of 0.279 (p = 0.034). High concentrations of total cholesterol, LDL-cholesterol and LDL particles (LDL-P) were associated with a decreased overall survival. Conclusions: NMR-based lipidomic and metabolomic profiling has the potential to identify individual metabolite biomarkers that predict the outcome of patients with an HCC exposed to non-invasive therapeutic management.

Reduction of missed thoracic findings in emergency whole-body computed tomography using artificial intelligence assistance

Background

Radiology reporting of emergency whole-body computed tomography (CT) scans is time-critical and therefore involves a significant risk of pathology under-detection. We hypothesize a relevant number of initially missed secondary thoracic findings that would have been detected by an artificial intelligence (AI) software platform including several pathology-specific AI algorithms.

Methods

This retrospective proof-of-concept-study consecutively included 105 shock-room whole-body CT scans. Image data was analyzed by platform-bundled AI-algorithms, findings were reviewed by radiology experts and compared with the original radiologist's reports. We focused on secondary thoracic findings, such as cardiomegaly, coronary artery plaques, lung lesions, aortic aneurysms and vertebral fractures.

Results

We identified a relevant number of initially missed findings, with their quantification based on 105 analyzed CT scans as follows: up to 25 patients (23.8%) with cardiomegaly or borderline heart size, 17 patients (16.2%) with coronary plaques, 34 patients (32.4%) with aortic ectasia, 2 patients (1.9%) with lung lesions classified as "recommended to control" and 13 initially missed vertebral fractures (two with an acute traumatic origin). A high number of false positive or non-relevant AI-based findings remain problematic especially regarding lung lesions and vertebral fractures.

Conclusions

We consider AI to be a promising approach to reduce the number of missed findings in clinical settings with a necessary time-critical radiological reporting. Nevertheless, algorithm improvement is necessary focusing on a reduction of "false positive" findings and on algorithm features assessing the finding relevance, e.g., fracture age or lung lesion malignancy.

Affective Modulation of Working Memory Maintenance: The Role of Positive and Negative Emotions

The present study investigated the impact of task-irrelevant emotional images on the retention of information in spatial working memory (WM). Two experiments employed a delayed matching to-sample task where participants had to maintain the locations of four briefly presented squares. After a short retention interval, a probe item appeared and participants were required to indicate whether the probe position matched one of the previously occupied square positions. During the retention interval, task-irrelevant negative, positive, or neutral emotional pictures were presented. The results revealed a dissociation between negative and positive affect on the participants' ability to hold spatial locations in WM. While negative affective pictures reduced WM capacity, positive pictures increased WM capacity relative to the neutral images. Moreover, the specific valence and arousal of a given emotional picture was also related to WM performance: While higher valence enhanced WM capacity, higher levels of arousal in turn reduced WM capacity. Together, our findings suggest that emotions up- or down-regulate attention to items in WM and thus modulate the short term storage of visual information in memory.

Multisensory visuo-tactile context learning enhances the guidance of unisensory visual search

Does multisensory distractor-target context learning enhance visual search over and above unisensory learning? To address this, we had participants perform a visual search task under both uni- and multisensory conditions. Search arrays consisted of one Gabor target that differed from three homogeneous distractors in orientation; participants had to discriminate the target's orientation. In the multisensory session, additional tactile (vibration-pattern) stimulation was delivered to two fingers of each hand, with the odd-one-out tactile target and the distractors co-located with the corresponding visual items in half the trials; the other half presented the visual array only. In both sessions, the visual target was embedded within identical (repeated) spatial arrangements of distractors in half of the trials. The results revealed faster response times to targets in repeated versus non-repeated arrays, evidencing 'contextual cueing'. This effect was enhanced in the multisensory session-importantly, even when the visual arrays presented without concurrent tactile stimulation. Drift-diffusion modeling confirmed that contextual cueing increased the rate at which task-relevant information was accumulated, as well as decreasing the amount of evidence required for a response decision. Importantly, multisensory learning selectively enhanced the evidence-accumulation rate, expediting target detection even when the context memories were triggered by visual stimuli alone.

Why Are Acquired Search-Guiding Context Memories Resistant to Updating?

Looking for goal-relevant objects in our various environments is one of the most ubiquitous tasks the human visual system has to accomplish (Wolfe, 1998). Visual search is guided by a number of separable selective-attention mechanisms that can be categorized as bottom-up driven – guidance by salient physical properties of the current stimuli – or top-down controlled – guidance by observers' “online” knowledge of search-critical object properties (e.g., Liesefeld and Müller, 2019). In addition, observers' expectations based on past experience also play also a significant role in goal-directed visual selection. Because sensory environments are typically stable, it is beneficial for the visual system to extract and learn the environmental regularities that are predictive of (the location of) the target stimulus. This perspective article is concerned with one of these predictive mechanisms: statistical context learning of consistent spatial patterns of target and distractor items in visual search. We review recent studies on context learning and its adaptability to incorporate consistent changes, with the aim to provide new directions to the study of processes involved in the acquisition of search-guiding context memories and their adaptation to consistent contextual changes – from a three-pronged, psychological, computational, and neurobiological perspective.

The diagnostic value of contrast-enhanced ultrasound (CEUS) for assessing hepatocellular carcinoma compared to histopathology; a retrospective single-center analysis of 119 patients1

BACKGROUND

HCC as the 6th most common tumor entity with the fourth highest mortality and an increasing prevalence especially due to today's lifestyle acquires a high attention in the clinical setting. Beside CECT and CEMRI, CEUS depicts a dynamic, low-risk and radiation free imaging method that finds its use mainly in screening and active surveillance programs.

PURPOSE

The aim of the retrospective study was to evaluate the diagnostic value of CEUS in correlation to pathologic findings.

MATERIALS AND METHODS

Between 2004 and 2018 a total number of 119 patients were included in this retrospective single-center study. Every patient underwent CEUS in addition to a native B-mode and Color-Doppler scan. After given informed consent SonoVue® (Bracco, Milan, Italy), a second-generation blood-pool agent, was used as contrast medium. Every examination was performed and interpreted by a single experienced radiologist (EFSUMB level 3). A low mechanical index (MI) of <0,2 was chosen to obtain a good imaging quality.

RESULTS

All 119 included patients received CEUS followed by a liver biopsy for inter-modality comparison. In correlation to the pathology results, CEUS showed a diagnostic sensitivity of 96,6%, a specificity of 63,9%, a PPV of 86,7% and a NPV of 88,5% by detecting liver lesions suspicious for HCC. According to the Cohen's Kappa coefficient (k = 0,659) CEUS shows a strong inter-modality agreement in comparison to the histopathological finding.

CONCLUSION

With a high sensitivity and a strong cross-modality comparability to histopathology, the CEUS is highly effective in the detection of suspicious HCC lesions.

Structured Reporting in the Characterization of Renal Cysts by Contrast-Enhanced Ultrasound (CEUS) Using the Bosniak Classification System-Improvement of Report Quality and Interdisciplinary Communication

BACKGROUND

This study aims to evaluate the potential benefits of structured reporting (SR) compared to conventional free-text reporting (FTR) in contrast-enhanced ultrasound (CEUS) of cystic renal lesions, based on the Bosniak classification.

METHODS

Fifty patients with cystic renal lesions who underwent CEUS were included in this single-center study. FTR created in clinical routine were compared to SR retrospectively generated by using a structured reporting template. Two experienced urologists evaluated the reports regarding integrity, effort for information extraction, linguistic quality, and overall quality.

RESULTS

The required information could easily be extracted by the reviewers in 100% of SR vs. 82% of FTR (p < 0.001). The reviewers trusted the information given by SR significantly more with a mean of 5.99 vs. 5.52 for FTR (p < 0.001). SR significantly improved the linguistic quality (6.0 for SR vs. 5.68 for FTR (p < 0.001)) and the overall report quality (5.98 for SR vs. 5.58 for FTR (p < 0.001)).

CONCLUSIONS

SR significantly increases the quality of radiologic reports in CEUS examinations of cystic renal lesions compared to conventional FTR and represents a promising approach to facilitate interdisciplinary communication in the future.

Structured Reporting Using CEUS LI-RADS for the Diagnosis of Hepatocellular Carcinoma (HCC)-Impact and Advantages on Report Integrity, Quality and Interdisciplinary Communication

Simple Summary

Contrast-enhanced ultrasound (CEUS) is an increasingly accepted imaging modality for visualizing hepatocellular carcinoma (HCC) and is recommended as a secondary imaging option by most leading hepatology societies. In recent years, the use of structured reporting (SR) has been recommended by several societies to standardize report content and improve report quality of various diagnostic modalities when compared to conventional free-text reports (FTR). Our single-center study aimed to evaluate the use of SR using a CEUS LI-RADS software template in CEUS examinations of 50 HCC patients. SR significantly increased report integrity, satisfaction of the referring physicians, linguistic quality and overall report quality compared to FTR. Therefore, the use of SR in CEUS examinations of HCC patients may represent a valuable tool to facilitate clinical decision-making and improve interdisciplinary communication in the future.

Abstract

Background: Our retrospective single-center study aims to evaluate the impact of structured reporting (SR) using a CEUS LI-RADS template on report quality compared to conventional free-text reporting (FTR) in contrast-enhanced ultrasound (CEUS) for the diagnosis of hepatocellular carcinoma (HCC). Methods: We included 50 patients who underwent CEUS for HCC staging. FTR created after these examinations were compared to SR retrospectively generated by using template-based online software with clickable decision trees. The reports were evaluated regarding report completeness, information extraction, linguistic quality and overall report quality by two readers specialized in internal medicine and visceral surgery. Results: SR significantly increased report completeness with at least one key feature missing in 31% of FTR vs. 2% of SR (p < 0.001). Information extraction was considered easy in 98% of SR vs. 86% of FTR (p = 0.004). The trust of referring physicians in the report was significantly increased by SR with a mean of 5.68 for SR vs. 4.96 for FTR (p < 0.001). SR received significantly higher ratings regarding linguistic quality (5.79 for SR vs. 4.83 for FTR (p < 0.001)) and overall report quality (5.75 for SR vs. 5.01 for FTR (p < 0.001)). Conclusions: Using SR instead of conventional FTR increases the overall quality of reports in CEUS examinations of HCC patients and may represent a valuable tool to facilitate clinical decision-making and improve interdisciplinary communication in the future.

When visual distractors predict tactile search: The temporal profile of cross-modal spatial learning

Contextual cueing refers to the guidance of search by associative learning of the location of task-relevant target items in relation to the consistent arrangement of distractor ("context") items in the search display. The present study investigated whether such target-distractor associations could also be formed in a cross-modal search task in which the invariant distractor context is visual and the target is tactile. Each trial display consisted of 8 vibrotactile stimuli delivered to 4 fingers of each hand, with the target singled out by a vibrotactile feature difference relative to the homogeneous nontarget vibrations. In addition, there were 4 visual (Gabor) distractors and 4 empty circles colocated (on a different depth plane) with the vibrotactile stimuli. Crucially, in half of the trials, the location of the tactile target was associated with an identical (repeated) configuration, or "context," of visual distractors. The results revealed facilitated RTs to the tactile targets when they were presented (250 to) 450 ms prior to-but not simultaneously with or after-a repeated visual distractor configuration, demonstrating a novel visuo-tactile contextual-cueing effect. Additional tests indicated that the optimal tactile preview period is broadly in line with the time required to recode the (initially) somatotopically sensed tactile stimuli into an external format shared with the visual items. We propose that, besides divided attention between the 2 modalities, the acquisition of search-guiding cross-modal context associations critically depends on the spatiotemporal colocation of the visuo-tactile stimuli. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

18F-FDG-PET/CT in Patients with Advanced, Radioiodine Refractory Thyroid Cancer Treated with Lenvatinib

Simple Summary

In patients with advanced radioiodine refractory differentiated thyroid carcinoma (DTC), therapeutic options are limited. In the “Study of (E7080) Lenvatinib in Differentiated Cancer of the Thyroid (SELECT)”, Lenvatinib significantly prolonged the progression-free survival, resulting in a more frequent use in clinical practice for this patient group. Due to considerable side effects, an accurate assessment of response to treatment is crucial in these patients. Therefore, we aimed to improve treatment individualization and reduce unnecessary therapies by selecting patients who will most likely benefit from Lenvatinib treatment using 2-deoxy-2-[¹⁸F] fluoro-D-glucose positron-emission-tomography/computed-tomography.

Abstract

Background: The tyrosine kinase inhibitor (TKI) Lenvatinib represents one of the most effective therapeutic options in patients with advanced radioiodine refractory differentiated thyroid carcinoma (DTC). We aimed to assess the role of 2-deoxy-2-[¹⁸F] fluoro-D-glucose positron-emission-tomography/computed-tomography (¹⁸F-FDG-PET/CT) in the monitoring of functional tumor response compared to morphological response. Methods: In 22 patients, a modified Positron Emission Tomography Response Criteria In Solid Tumors (mPERCIST) evaluation before treatment with Lenvatinib and at 3 and 6 month follow up was performed. Further PET-parameters and morphologic tumor response using Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 were assessed and their prediction of progression-free survival (PFS) and disease-specific survival (DSS) was evaluated. Results: Most patients were rated stable in morphological evaluation and progressive using a metabolic response. All patients who responded to therapy through RECIST showed a decline in nearly all Positron Emission Tomography (PET)-parameters. For both time-points, non-responders according to mPERCIST showed significantly lower median PFS and DSS, whereas according to RECIST, only DSS was significantly lower. Conclusion: Tumor response assessment by ¹⁸F-FDG-PET outperforms morphological response assessment by CT in patients with advanced radioiodine refractory DTC treated with Lenvatinib, which seems to be correlated with clinical outcomes.

Contrast-Enhanced Ultrasound (CEUS) for the Evaluation of Bosniak III Complex Renal Cystic Lesions-A 10-Year Specialized European Single-Center Experience with Histopathological Validation

Background and objectives: The aim of the present retrospective single-center study is to evaluate the diagnostic performance of contrast-enhanced ultrasound (CEUS) for assessing Bosniak III complex renal cystic lesions with histopathological validation. Materials and Methods: 49 patients with CEUS-categorized Bosniak III renal cystic lesions were included in this retrospective study. All patients underwent native B-mode, Color Doppler, contrast-enhanced ultrasound (CEUS) between 2010-2020. Eight and five patients underwent computed tomography (CT) and magnetic resonance imaging (MRI), respectively. Twenty-nine underwent (partial) nephrectomy allowing for histopathological analysis. The applied contrast agent for CEUS was a second-generation blood pool agent. Ultrasonography examinations were performed and interpreted by a single experienced radiologist with more than 15 years of experience (EFSUMB Level 3). Results: CEUS examinations were successfully performed in all included patients without registering any adverse effects. The malignancy rate of CEUS-categorized Bosniak III renal lesions accounted for 66%. Initially, cystic complexity was visualized in native B-mode. In none of the renal lesions hypervascularization was detected in Color Doppler. CEUS allowed for detection of contrast enhancement patterns in all included Bosniak III renal lesions. Delayed wash-out could be detected in 6/29 renal lesions. In two cases of histopathologically confirmed clear-cell RCC, appropriate up-grading from Bosniak IIF to III was achieved by CEUS. Conclusions: CEUS depicts a promising imaging modality for the precise diagnostic workup and stratification of renal cystic lesions according to the Bosniak classification system, thereby helping guidance of adequate clinical management in the future.

Artificial intelligence assistance improves reporting efficiency of thoracic aortic aneurysm CT follow-up

OBJECTIVE

Follow-up of aortic aneurysms by computed tomography (CT) is crucial to balance the risks of treatment and rupture. Artificial intelligence (AI)-assisted radiology reporting promises time savings and reduced inter-reader variabilities.

METHODS

The influence of AI assistance on the efficiency and accuracy of aortic aneurysm reporting according to the AHA / ESC guidelines was quantified based on 324 AI measurements and 1944 radiological measurements: 18 aortic aneurysm patients, each with two CT scans (arterial contrast phase, electrocardiogram-gated) with an interval of at least six months have been included. One board-certified radiologist and two residents (8/4/2 years of experience in vascular imaging) independently assessed aortic diameters at nine landmark positions. Aneurysm extensions were compared with original CT reports. After three weeks washout period, CTs were re-assessed, based on graphically illustrated AI measurements.

RESULTS

Time-consuming guideline-compliant aortic measurements revealed additional affections of the root / arch for 80 % of aneurysms that had initially been reported to be limited to the ascending aorta. AI assistance reduced mean reporting time by 63 % from 13:01 to 04:46 min including manual corrections of AI measurements (performed for 33.6 % of all measurements with predominance at the sinuses of Vasalva). AI assistance reduced total diameter inter-reader variability by 42.5 % (0.42 / 1.16 mm with / without AI assistance, mean of all patients and landmark positions, significant reduction for 6 out of 9 measuring positions). Conventional and AI-assisted quantification aneurysm progress varied to small extent (mean of 0.75 mm over all patients / landmark positions) not significantly exceeding radiologist's inter-reader variabilities.

CONCLUSIONS

Guideline-compliant aorta measurement is crucial to report detailed aneurysm extension which might affect the strategy of interventional repair. AI assistance promises improved reporting efficiency and has high potential to reduce radiologist's inter-reader variabilities that can hamper diagnostic follow-up accuracy.

KEY POINT

The time-consuming guideline-compliant aorta aneurysm assessment is crucial to report aneurysm extension in detail; AI-assisted measurement reduces reporting time, improves extension evaluation and reduces inter-reader variability.

Diagnostic Performance of Contrast-Enhanced Ultrasound (CEUS) in the Evaluation of Solid Renal Masses

Background: The present study aims to evaluate the diagnostic performance of contrast-enhanced ultrasound (CEUS) for discriminating between benign and malignant solid renal masses. Methods: 18 patients with histopathologically confirmed benign solid renal masses (11 oncocytomas, seven angiomyolipomas) as well as 96 patients with confirmed renal cell carcinoma (RCC) who underwent CEUS followed by radical or partial nephrectomy were included in this single-center study. CEUS examinations were performed by an experienced radiologist (EFSUMB Level 3) and included the application of a second-generation contrast agent. Results: Renal angiomyolipomas, oncocytomas, and renal cell carcinomas showed varying sonomorphological characteristics in CEUS. Angiomyolipomas showed heterogeneous echogenicity (57% hypo-, 43% hyperechoic), while all lesions showed rapid contrast-enhancement with two lesions also showing venous wash-out (29%). Notably, 9/11 oncocytomas could be detected in conventional ultrasound (64% hypo-, 9% hyper-, 9% isoechoic) and 2/11 only demarcated upon intravenous application of contrast agent (18%). All oncocytomas showed hyperenhancement in CEUS, venous wash-out was registered in 7/11 lesions (64%). Conclusions: In line with the current state of knowledge, no specific sonomorphological characteristics allowing for accurate distinction between benign and malignant solid renal masses in CEUS could be detected in our study.

Automatic Guidance (and Misguidance) of Visuospatial Attention by Acquired Scene Memory: Evidence From an N1pc Polarity Reversal

Visual search is facilitated when the target is repeatedly encountered at a fixed position within an invariant (vs. randomly variable) distractor layout—that is, when the layout is learned and guides attention to the target, a phenomenon known as contextual cuing. Subsequently changing the target location within a learned layout abolishes contextual cuing, which is difficult to relearn. Here, we used lateralized event-related electroencephalogram (EEG) potentials to explore memory-based attentional guidance (N = 16). The results revealed reliable contextual cuing during initial learning and an associated EEG-amplitude increase for repeated layouts in attention-related components, starting with an early posterior negativity (N1pc, 80–180 ms). When the target was relocated to the opposite hemifield following learning, contextual cuing was effectively abolished, and the N1pc was reversed in polarity (indicative of persistent misguidance of attention to the original target location). Thus, once learned, repeated layouts trigger attentional-priority signals from memory that proactively interfere with contextual relearning after target relocation.

Task-based memory systems in contextual-cueing of visual search and explicit recognition

Visual search is facilitated when observers encounter targets in repeated display arrangements. This 'contextual-cueing' (CC) effect is attributed to incidental learning of spatial distractor-target relations. Prior work has typically used only one recognition measure (administered after the search task) to establish whether CC is based on implicit or explicit memory of repeated displays, with the outcome depending on the diagnostic accuracy of the test. The present study compared two explicit memory tests to tackle this issue: yes/no recognition of a given search display as repeated versus generation of the quadrant in which the target (which was replaced by a distractor) had been located during the search task, thus closely matching the processes involved in performing the search. While repeated displays elicited a CC effect in the search task, both tests revealed above-chance knowledge of repeated displays, though explicit-memory accuracy and its correlation with contextual facilitation in the search task were more pronounced for the generation task. These findings argue in favor of a one-system, explicit-memory account of CC. Further, they demonstrate the superiority of the generation task for revealing the explicitness of CC, likely because both the search and the memory task involve overlapping processes (in line with 'transfer-appropriate processing').

Advanced Fusion Imaging and Contrast-Enhanced Imaging (CT/MRI-CEUS) in Oncology

Simple Summary

Fusion imaging depicts an innovative technique by which previously performed computed tomography/magnetic resonance imaging can be integrated and reconstructed with advanced contrast-enhanced ultrasound using modern ultrasound devices in a real-time manner. Fusion imaging allows for complementing strengths and reducing restrictions of the combined imaging modalities. The visualization of parenchymal and tumoral microperfusion by contrast-enhanced ultrasound can be dynamically fused and assessed with images from previous cross-sectional studies and may help to decipher underlying entities of indeterminate lesions or validate suspicious morphology. The findings from our study demonstrate the benefits of fusion imaging for evaluating focal hepatic and renal lesions. The excellent safety profile, accessibility, repeatability and cost-effectiveness are advantages of fusion imaging which make it a powerful diagnostic tool for the modern radiologist.

Abstract

Fusion imaging depicts an innovative technique that facilitates combining assets and reducing restrictions of advanced ultrasound and cross-sectional imaging. The purpose of the present retrospective study was to evaluate the role of fusion imaging for assessing hepatic and renal lesions. Between 02/2011–08/2020, 92 patients in total were included in the study, of which 32 patients had hepatic lesions, 60 patients had renal lesions. Fusion imaging was technically successful in all patients. No adverse side effects upon intravenous (i.v.) application of SonoVue^® (Bracco, Milan, Italy) were registered. Fusion imaging could clarify all 11 (100%) initially as indeterminate described hepatic lesions by computed tomography/magnetic resonance imaging (CT/MRI). Moreover, 5/14 (36%) initially suspicious hepatic lesions could be validated by fusion imaging, whereas in 8/14 (57%), malignant morphology was disproved. Moreover, fusion imaging allowed for the clarification of 29/30 (97%) renal lesions initially characterized as suspicious by CT/MRI, of which 19/30 (63%) underwent renal surgery, histopathology revealed malignancy in 16/19 (84%), and benignity in 3/19 (16%). Indeterminate findings could be elucidated by fusion imaging in 20/20 (100%) renal lesions. Its accessibility and repeatability, even during pregnancy and in childhood, its cost-effectiveness, and its excellent safety profile, make fusion imaging a promising instrument for the thorough evaluation of hepatic and renal lesions in the future.

Distributed attention beats the down-side of statistical context learning in visual search

Spatial attention can be deployed with a narrower focus to process individual items or distributed relatively broadly to process larger parts of a scene. This study investigated how focused- versus distributed-attention modes contribute to the adaptation of context-based memories that guide visual search. In two experiments, participants were either required to fixate the screen center and use peripheral vision for search ("distributed attention"), or they could freely move their eyes, enabling serial scanning of the search array ("focused attention"). Both experiments consisted of an initial learning phase and a subsequent test phase. During learning, participants searched for targets presented either among repeated (invariant) or nonrepeated (randomly generated) spatial layouts of distractor items. Prior research showed that repeated encounters of invariant display arrangements lead to long-term context memory about these arrays, which can then come to guide search (contextual-cueing effect). The crucial manipulation in the test phase was a change of the target location within an otherwise constant distractor layout, which has previously been shown to abolish the cueing effect. The current results replicated these findings, although importantly only when attention was focused. By contrast, with distributed attention, the cueing effect recovered rapidly and attained a level comparable to the initial effect (before the target location change). This indicates that contextual cueing can adapt more easily when attention is distributed, likely because a broad attentional set facilitates the flexible updating of global (distractor-distractor), as compared to more local (distractor-target), context representations-allowing local changes to be incorporated more readily.

Crossmodal learning of target-context associations: When would tactile context predict visual search?

It is well established that statistical learning of visual target locations in relation to constantly positioned visual distractors facilitates visual search. In the present study, we investigated whether such a contextual-cueing effect would also work crossmodally, from touch onto vision. Participants responded to the orientation of a visual target singleton presented among seven homogenous visual distractors. Four tactile stimuli, two to different fingers of each hand, were presented either simultaneously with or prior to the visual stimuli. The identity of the stimulated fingers provided the crossmodal context cue: in half of the trials, a given visual target location was consistently paired with a given tactile configuration. The visual stimuli were presented above the unseen fingers, ensuring spatial correspondence between vision and touch. We found no evidence of crossmodal contextual cueing when the two sets of items (tactile, visual) were presented simultaneously (Experiment 1). However, a reliable crossmodal effect emerged when the tactile distractors preceded the onset of visual stimuli 700 ms (Experiment 2). But crossmodal cueing disappeared again when, after an initial learning phase, participants flipped their hands, making the tactile distractors appear at different positions in external space while their somatotopic positions remained unchanged (Experiment 3). In all experiments, participants were unable to explicitly discriminate learned from novel multisensory arrays. These findings indicate that search-facilitating context memory can be established across vision and touch. However, in order to guide visual search, the (predictive) tactile configurations must be remapped from their initial somatotopic into a common external representational format.

Reading English-language haiku: An eye-movement study of the 'cut effect'

The current study, set within the larger enterprise of Neuro-Cognitive Poetics, was designed to examine how readers deal with the ‘cut’ – a more or less sharp semantic-conceptual break – in normative, three-line English-language haiku poems (ELH). Readers were presented with three-line haiku that consisted of two (seemingly) disparate parts, a (two-line) ‘phrase’ image and a one-line ‘fragment’ image, in order to determine how they process the conceptual gap between these images when constructing the poem’s meaning – as reflected in their patterns of reading eye movements. In addition to replicating the basic ‘cut effect’, i.e., the extended fixation dwell time on the fragment line relative to the other lines, the present study examined (a) how this effect is influenced by whether the cut is purely implicit or explicitly marked by punctuation, and (b) whether the effect pattern could be delineated against a control condition of ‘uncut’, one-image haiku. For ‘cut’ vs. ‘uncut’ haiku, the results revealed the distribution of fixations across the poems to be modulated by the position of the cut (after line 1 vs. after line 2), the presence vs. absence of a cut marker, and the semanticconceptual distance between the two images (context–action vs. juxtaposition haiku). These formal-structural and conceptual-semantic properties were associated with systematic changes in how individual poem lines were scanned at first reading and then (selectively) re-sampled in second- and third-pass reading to construct and check global meaning. No such effects were found for one-image (control) haiku. We attribute this pattern to the operation of different meaning resolution processes during the comprehension of two-image haiku, which are invoked by both form- and meaning-related features of the poems.

Dataset on tip vortex formation noise produced by wall-mounted finite airfoils with flat and rounded tip geometries

The vortex generated at the tip of an airfoil such as an aircraft wing, wind turbine blade, submarine fin or propeller blade can dominate its wake and be a significant source of unwanted noise. The data collection presented in this paper consists of measurements of tip vortex formation noise produced by finite length airfoils with flat and rounded tips. These data were obtained using the specialist aeroacoustic test facilities at the Brandenburg University of Technology (BTU) in Cottbus, Germany and a 47-channel planar microphone array. Over 1200 unique test cases with variations in airfoil profile shape, tip geometry, angle of attack and Reynolds number were measured during the experimental campaign. The dataset contains one-third-octave band tip noise spectra that have been processed using Acoular, a Python module for acoustic beamforming.

Diagnostic Accuracy of Breast Medical Tactile Examiners (MTEs): A Prospective Pilot Study

Background

The usefulness of clinical breast examination (CBE) in general and in breast cancer screening programs has been a matter of debate. This study investigated whether adding vision-impaired medical tactile examiners (MTEs) improves the predictiveness of CBE for suspicious lesions and analyzed the feasibility and acceptability of this approach.

Methods

The prospective study included 104 patients. Physicians and MTEs performed CBEs, and mammography and ultrasound results were used as the gold standard. Sensitivity and specificity were calculated and logistic regression models were used to compare the predictive value of CBE by physicians alone, MTEs alone, and physicians and MTEs combined.

Results

For CBEs by physicians alone, MTEs alone, and both combined, sensitivity was 71, 82, and 89% and specificity was 55, 45, and 35%, respectively. Using adjusted logistic regression models, the validated areas under the curve were 0.685, 0.692, and 0.710 (median bootstrapped p value (DeLong) = 0.381).

Conclusion

The predictive value for a suspicious breast lesion in CBEs performed by MTEs in patients without prior surgery was similar to that of physician-conducted CBEs. Including MTEs in the CBE procedure in breast units thus appears feasible and could be a way of utilizing their skills.

Recognition of incidentally learned visual search arrays is supported by fixational eye movements

Repeated encounter of abstract target-distractor letter arrangements leads to improved visual search for such displays. This contextual-cueing effect is attributed to incidental learning of display configurations. Whether observers can consciously access the memory underlying the cueing effect is still a controversial issue. The current study uses a novel recognition task and eyetracking to tackle this question. Experiment 1 investigated observers' ability to recognize or "generate" the display quadrant of the target in a previous search array when the target was now substituted by distractor element as well as where observers' eye fixations would fall while they freely viewed the recognition display, examining the link between the fixation pattern and explicit recognition judgments. Experiment 2 tested whether eye fixations would serve a critical role for explicit retrieval from context memory. Experiment 3 asked whether eye fixations of the target region are critical for context-based facilitation of search reaction times to manifest. The results revealed longer fixational dwell times in the target quadrant for learned relative to foil displays. Further, explicit recognition was enhanced, and above chance level, when observers were made to fixate the target quadrant as compared to when they were prevented from doing so. However, the manifestation of contextual cueing of visual search did itself not require fixations of the target quadrant. Moreover, contextual-cueing of search reaction times was significantly correlated with both fixational dwell times and observers' explicit generation performance. The results argue in favor of contextual cueing of visual search being the result of a single, explicit, memory system, though it could nevertheless receive support from separable-automatic versus controlled-retrieval processes. Fixational eye movements, that is, the directed overt allocation of visual attention, provide an interface between these processes in context cueing. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Why does a point of care guided transfusion algorithm not improve blood loss and transfusion practice in patients undergoing high-risk cardiac surgery? A prospective randomized controlled pilot study

Background

Adult cardiac surgery is often complicated by elevated blood losses that account for elevated transfusion requirements. Perioperative bleeding and transfusion of blood products are major risk factors for morbidity and mortality. Timely diagnostic and goal-directed therapies aim at the reduction of bleeding and need for allogeneic transfusions.

Methods

Single-centre, prospective, randomized trial assessing blood loss and transfusion requirements of 26 adult patients undergoing elective cardiac surgery at high risk for perioperative bleeding. Primary endpoint was blood loss at 24 h postoperatively. Random assignment to intra- and postoperative haemostatic management following either an algorithm based on conventional coagulation assays (conventional group: platelet count, aPTT, PT, fibrinogen) or based on point-of-care (PoC-group) monitoring, i.e. activated rotational thromboelastometry (ROTEM®) combined with multiple aggregometry (Multiplate®). Differences between groups were analysed using nonparametric tests for independent samples.

Results

The study was terminated after interim analysis (n = 26). Chest tube drainage volume was 360 ml (IQR 229-599 ml) in the conventional group, and 380 ml (IQR 310-590 ml) in the PoC-group (p = 0.767) after 24 h. Basic patient characteristics, results of PoC coagulation assays, and transfusion requirements of red blood cells and fresh frozen plasma did not differ between groups. Coagulation results were comparable. Platelets were transfused in the PoC group only.

Conclusion

Blood loss via chest tube drainage and transfusion amounts were not different comparing PoC- and central lab-driven transfusion algorithms in subjects that underwent high-risk cardiac surgery. Routine PoC coagulation diagnostics do not seem to be beneficial when actual blood loss is low. High risk procedures might not suffice as a sole risk factor for increased blood loss.

Trial registration

NCT01402739, Date of registration July 26, 2011.

Taking Attention Out of Context: Frontopolar Transcranial Magnetic Stimulation Abolishes the Formation of New Context Memories in Visual Search

This study investigates the causal contribution of the left frontopolar cortex (FPC) to the processing of violated expectations from learned target-distractor spatial contingencies during visual search. The experiment consisted of two phases: learning and test. Participants searched for targets presented either among repeated or nonrepeated target-distractor configurations. Prior research showed that repeated encounters of identically arranged displays lead to memory about these arrays, which then can come to guide search (contextual cueing effect). The crucial manipulation was a change of the target location, in a nevertheless constant distractor layout, at the transition from learning to test. In addition to this change, we applied repetitive transcranial magnetic stimulation (rTMS) over the left lateral FPC, over a posterior control site, or no rTMS at all (baseline; between-group manipulation) to see how FPC rTMS influences the ability of observers to adapt context-based memories acquired in the training phase. The learning phase showed expedited search in repeated relative to nonrepeated displays, with this context-based facilitation being comparable across all experimental groups. For the test phase, the recovery of cueing was critically dependent on the stimulation site: Although there was evidence of context adaptation toward the end of the experiment in the occipital and no-rTMS conditions, observers with FPC rTMS showed no evidence of relearning at all after target location changes. This finding shows that FPC plays an important role in the regulation of prediction errors in statistical context learning, thus contributing to an update of the spatial target-distractor contingencies after target position changes in learned spatial arrays.

Efficacy of neoadjuvant pertuzumab in addition to chemotherapy and trastuzumab in routine clinical treatment of patients with primary breast cancer: a multicentric analysis

PURPOSE

Neoadjuvant combination treatment with chemotherapy (CTX), trastuzumab (TZM), and pertuzumab (PTZ) has been shown to result in higher pathological complete response rates (pCR) in comparison with treatment with chemotherapy and trastuzumab (CTX/TZM). This analysis was aimed at real-world validation of these results from prospective randomized trials.

METHODS

In a retrospective analysis conducted in the PRAEGNANT network, patients were eligible for inclusion if they had either received neoadjuvant therapy with CTX/TZM or chemotherapy, trastuzumab, and pertuzumab (CTX/TZM/PTZ) and subsequently underwent surgery for their primary breast cancer. The effect of the two neoadjuvant regimens on pCR in addition to commonly applicable predictors of pCR was analyzed in 300 patients from three study sites, using logistic regression analyses with treatment arm, age, clinical tumor stage, grading, and hormone receptor status as predictors.

RESULTS

pCR with complete disappearance of all tumor cells was seen in 30.2% (n = 58) of patients treated with CTX/TZM and in 52.8% (n = 57) of those treated with CTX/TZM/PTZ. CTX/TZM/PTZ was positively associated with pCR (adjusted odds ratio 2.44; 95% CI 1.49-4.02). Mastectomy rates were not influenced by the therapy.

CONCLUSIONS

The results of clinical trials were confirmed in this dataset of patients who were treated outside of clinical trials in everyday routine work. pCR rates can be improved by 20% with pertuzumab in routine clinical use.

Spatial remapping in visual search: Remapping cues are provided at attended and ignored locations

We experience the world as stable and continuous, despite the fact that visual input is overwritten on the retina with each new ocular fixation. Spatial remapping is the process that integrates selected visual information into successive (continuous) representations of our spatial environment, thereby allowing us to keep track of objects, and experience the world as stable, despite frequent eye (re-)fixations. The present paper investigates spatial remapping in the context of visual pop-out search. Within standard instances of the pop-out paradigm, reactions to stimuli at previously attended locations are facilitated (faster and more accurate), and reactions to stimuli at previously ignored locations are inhibited (slower and less accurate). The mechanisms that support facilitation at previously attended locations, and inhibition at previously ignored locations, serve to enhance the efficiency of visual search. It is thus natural to expect that information about which locations were previously attended to or ignored is stored and remapped as a concomitant to successive representations of the spatial environment. Using variants of the pop-out paradigm, we corroborate this expectation, and show that information concerning the prior status of locations, as attended to or ignored, is remapped following attention shifts, with some degradation of information concerning ignored locations.