Search Results (107)

Background/Objectives: This study assesses the outcomes of integrating deep learning-augmented zero echo time (ZTE DL) MRI sequences into standard MRI protocols for assessment of the hands and feet. Methods: In this single-center, retrospective study, a standard MRI protocol of hands and feet at 1.5 T was compared with the same protocol with an added ZTE DL sequence. Pathological changes in the bone, including subcortical sclerosis, osteophytes, joint space narrowing and fractures, were rated as present or absent. Indeterminate intraosseous lesions (erosions/ganglia) and indeterminate extraosseous lesions (ossicles/soft tissue calcifications) were additionally assessed on a semi-quantitative 4-point Likert scale. Diagnostic confidence was rated as low, moderate, or high. Standard MRI vs. ZTE-DL-augmented MRI comparisons were evaluated using a mixed-effects model with reader as a random effect, and X-ray vs. ZTE-DL-augmented MRI comparisons using a paired Wilcoxon signed-rank test. Interreader agreement (two readers) was assessed using Kappa statistics. Results: The cohort encompassed 59 datasets (feet = 22, hands = 37) of 40 patients with an average age of 51.79 (SD ± 11.84) years (58% women (n = 34), 42% men (n = 25)). Additional ZTE DL sequences resulted in similar findings, but with higher diagnostic confidence for assessment of bone changes when compared to conventional MR sequences (p-values < 0.05) and, overall, when compared to radiographs in a subgroup (p < 0.05 for five of six pathologic bone changes). Interreader agreement of diagnostic confidence was moderate to substantial (kappa 0.59–0.71). Conclusions: Addition of ZTE DL sequences to standard MRI protocols of hands and feet at 1.5 T demonstrated similar findings in the assessment of pathological bone changes, but with higher diagnostic confidence compared to conventional MR sequences and radiographs. However, further validation against a reference standard is required to determine diagnostic accuracy. Full article

Background/Objectives: Mammography remains central to breast cancer diagnosis, yet clinically meaningful uncertainty persists in women with dense breasts and in patients with very small lesions or indeterminate imaging findings. We evaluated whether circulating thioredoxin 1 (Trx1) could provide biological information that complements imaging-based assessment. Methods: This multicenter clinical validation study evaluated circulating Trx1 in 1901 serum samples across four predefined cohorts. Diagnostic performance was assessed using receiver operating characteristic (ROC) and precision–recall analyses, together with evaluation of integration with mammographic assessment and decision curve analysis (DCA). A predefined Trx1 cutoff established in prior clinical investigations was applied. Results: Circulating Trx1 concentrations were significantly elevated in breast cancer compared with controls (p < 0.001). Trx1 showed excellent diagnostic discrimination (AUC 0.985; 95% CI, 0.974–0.996), with sensitivity and specificity of 96.4% and 97.3%, respectively. Diagnostic performance was consistent across disease stages, tumor-size categories, molecular subtypes, mammographic categories, and breast-density groups. Trx1 sensitivity remained high in dense breasts (98.9% in BI-RADS density grades C/D), whereas mammographic sensitivity was substantially lower (67.0%). Integration of Trx1 with mammographic assessment improved diagnostic discrimination (AUC 0.980) and provided greater net benefit in decision curve analysis, particularly among women with low-suspicion or indeterminate imaging findings. Conclusions: Circulating Trx1 demonstrated robust diagnostic performance across disease stages, tumor-size categories, and clinically relevant patient subgroups while providing biologically independent information that complements mammographic assessment. Although this retrospective multicenter study requires prospective validation in independent diagnostic populations, Trx1 may serve as a clinically useful adjunct to imaging-based breast cancer evaluation, particularly in diagnostically uncertain settings. Full article

Background/Objectives: Accurate tissue diagnosis of small pulmonary nodules remains technically challenging with conventional bronchoscopic techniques. Radial probe endobronchial ultrasound-guided transbronchial lung cryobiopsy (RP-EBUS–guided TBLC) with a guide sheath (GS) may improve diagnostic yield; however, target instability during cryobiopsy remains a limitation. We aimed to evaluate the diagnostic yield of RP-EBUS-guided TBLC with a GS for pulmonary nodules < 3 cm that were suspected of malignancy. Methods: This retrospective observational study included patients who underwent RP-EBUS-guided TBLC with a GS for lung lesions suspected of malignancy on computed tomography between 1 February 2024 and 31 December 2025 in South Korea. After the target lesion was identified, the bronchoscope was inserted and fixed within the segment; its position was maintained while RP-EBUS was withdrawn, and lesion stability during respiration was confirmed. Results: A total of 99 patients were included in the final analysis. After patients with an indeterminate diagnosis were excluded, the final diagnostic yield was 83.2%. The sensitivity and specificity were 78.9% and 100.0%, respectively. Pneumothorax occurred in 6.0% (6/99) of patients. Bleeding of grade 3 or higher was observed in two patients, and a Fogarty balloon catheter was preemptively used in five patients at the operator’s discretion. In multivariable logistic regression analysis, the computed tomography bronchus sign was identified as the only significant factor associated with pathological confirmation (odds ratio, 6.090; p = 0.005). Conclusions: RP-EBUS-guided TBLC with a GS provided an acceptable diagnostic yield and safety profile, even in small pulmonary nodules < 3 cm. Full article

Cyst-predominant anterior mediastinal lesions are commonly attributed to benign thymic cysts. However, thymomas—the most common thymic epithelial tumor—may rarely present as a predominantly cystic mass with only a small solid component, posing a diagnostic challenge. The World Health Organization (WHO) classifies thymomas according to the morphology of tumor epithelial cells and the degree of lymphocytic infiltration, a schema that correlates with biological behavior and prognosis. Unlike low-risk subtypes, high-risk thymomas frequently require multimodal treatment because of their more aggressive clinical course. MRI has increasingly been utilized as a problem-solving modality for indeterminate lesions identified on CT. In particular, diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) measurement has emerged as a potentially useful imaging biomarker for predicting histologic subtypes of thymic epithelial tumors. We report a case of a WHO type B3 thymoma presenting as a predominantly cystic anterior mediastinal lesion, in which MRI findings suggested the possibility of a high-risk subtype. The imaging and corresponding histopathologic findings are presented in this paper. Full article

Molecular testing has become an increasingly important adjunct in the evaluation of cytologically indeterminate thyroid nodules. These tests analyze genetic alterations associated with thyroid tumorigenesis, including point mutations, gene fusions, and gene expression profiles, with the aim of refining preoperative risk assessment and reducing unnecessary diagnostic surgery. Despite these advances, the clinical utility of molecular testing remains highly dependent on the context in which results are interpreted. Molecular alterations do not consistently correlate with tumor aggressiveness, and several mutations are observed in both benign and malignant thyroid lesions. In addition, the predictive performance of molecular tests is strongly influenced by the baseline prevalence of malignancy, which varies across clinical settings and is shaped by diagnostic thresholds and patient selection. This commentary summarizes the molecular landscape of thyroid tumors, the diagnostic performance of current molecular testing platforms, and their role in clinical decision-making. Emphasis is placed on the interpretation of molecular findings within a broader diagnostic framework that incorporates cytologic morphology, ultrasound-based risk stratification, and clinical context. A selective, risk-adapted approach to molecular testing may provide the most effective strategy for optimizing patient management while minimizing unnecessary intervention. Full article

Background: Differentiating adrenal adenomas from non-adenomatous lesions remains a critical challenge in the management of adrenal incidentalomas. Conventional unenhanced CT relies on attenuation thresholds of 10 HU and 20 HU, which present trade-offs between sensitivity and specificity. Objectives: To evaluate the diagnostic performance of unenhanced Spectral CT using the attenuation difference between 40 keV and 140 keV virtual monoenergetic images for differentiating adrenal adenomas from non-adenomatous lesions. Methods: In this retrospective single-center study, 60 patients with adrenal lesions who underwent unenhanced dual-energy CT were included. Mean attenuation values were measured on conventional images and on virtual monoenergetic images at 40 keV and 140 keV. The spectral attenuation difference (Δ40–140 keV) was calculated. ROC analysis was performed to determine the optimal threshold and diagnostic performance. Additional analyses included DeLong comparison of correlated ROC curves and bootstrap resampling to estimate 95% confidence intervals for the area under the curve. Results: Forty-nine lesions were adenomas and eleven were non-adenomatous. The optimal threshold for Δ40–140 keV was −17 HU. When evaluated as a continuous variable, Δ40–140 keV yielded an area under the curve of 0.940 (95% confidence interval: 0.851–1.000), compared with 0.939 (95% confidence interval: 0.870–0.992) for conventional unenhanced attenuation. DeLong comparison showed no statistically significant difference between the two curves (p = 0.980). Diagnostic performance was as follows: HU ≤ 10 (AUC 0.816, diagnostic accuracy 0.70), HU ≤ 20 (AUC 0.883, diagnostic accuracy 0.87), and Δ40–140 keV ≤ −17 HU (AUC 0.940, diagnostic accuracy 0.90). The spectral attenuation difference demonstrated the highest overall diagnostic accuracy. Conclusions: Unenhanced Spectral CT using Δ40–140 keV improves discrimination between adrenal adenomas and non-adenomatous lesions compared with conventional attenuation thresholds. This technique may reduce indeterminate findings and limit the need for additional imaging. Full article

Background/Objectives: Clear-cell renal cell carcinoma (ccRCC) represents the predominant histologic subtype of renal cancer and poses persistent diagnostic challenges, particularly in the evaluation of small renal masses, where conventional imaging and biopsy have relevant limitations. Molecular imaging targeting carbonic anhydrase IX (CAIX) has emerged as a promising non-invasive alternative. This narrative review aims to summarize the biological rationale, diagnostic performance, and potential clinical applications of [⁸⁹Zr]Zr-girentuximab positron emission tomography-computed tomography (girentuximab PET-CT) in ccRCC, as well as to discuss its current limitations and future directions. Methods: A narrative synthesis of published phase 1–3 clinical trials, post hoc analyses, and early clinical series evaluating girentuximab PET-CT was performed, focusing on diagnostic accuracy, clinical impact in localized and metastatic disease, and emerging theranostic applications. Results: The phase 3 ZIRCON trial demonstrated high diagnostic accuracy of girentuximab PET-CT for indeterminate renal masses ≤7 cm, with a sensitivity of 85% and specificity of 87%, as well as performance exceeding 96% for lesions <2 cm. Early studies suggest that this modality may influence clinical decision-making by supporting active surveillance, avoiding biopsy, and refining surgical or ablative strategies, although evidence remains limited by small cohorts and lack of long-term outcome data. Exploratory data indicate improved lesion detection in metastatic ccRCC, but the absence of systematic histopathologic confirmation restricts routine staging use. Conclusions: Girentuximab PET-CT is a highly accurate, CAIX-targeted molecular imaging technique with the potential to transform the diagnostic pathway of ccRCC. While current evidence supports its use in selected localized settings, broader clinical adoption will require prospective validation of its impact on patient outcomes and management strategies. Full article

Background/Objectives: Nontuberculous mycobacterial (NTM) pulmonary infection may present with diverse radiologic manifestations that mimic lung malignancy. Furthermore, in patients with newly detected or progressively enlarging pulmonary lesions, distinguishing benign NTM-related lesions from coexisting malignancy is often challenging. When imaging findings are indeterminate, percutaneous core needle biopsy (PCNB) may be required for diagnostic clarification. This study aimed to evaluate the pathologic results, clinical characteristics, and CT features of pulmonary lesions in patients with NTM infection who underwent PCNB and to identify factors associated with malignancy. Methods: This retrospective study included 38 patients with NTM infection who underwent CT-guided PCNB for lung lesions between 2015 and 2025. Two blinded radiologists reviewed chest CT scans obtained within six weeks prior to the biopsies. Clinical variables and CT features were compared between malignant and benign lesions. Univariable and multivariable logistic regression analyses were performed to explore factors associated with malignancy. Results: Of the 38 patients, 9 (23.7%) were diagnosed with malignancy and 29 (76.3%) had benign lesions. Malignant lesions more frequently demonstrated a lobulated irregular morphology compared to benign lesions (88.9% vs. 37.9%). Emphysema was also more common in the malignancy group (88.9% vs. 24.1%, p < 0.001). In the multivariable logistic regression analysis, lobulated irregular morphology (odds ratio [OR], 19.856; 95% CI, 1.516–260.089; p = 0.023) and emphysema (OR, 35.531; 95% CI, 2.857–441.824; p = 0.005) were associated with malignancy. However, the wide confidence intervals indicate substantial uncertainty due to the limited number of malignant cases. Conclusions: In patients with NTM infection who underwent PCNB for suspicious lung lesions, a lobulated irregular morphology and the presence of emphysema were associated with malignancy in this exploratory cohort. These findings may provide useful information to support clinical decision-making regarding biopsy in patients with NTM infection and indeterminate pulmonary lesions. Full article

Miniprobe endoscopic ultrasonography (mEUS) combines high-resolution imaging of the gastrointestinal (GI) wall and bile ducts with ease of applicability during routine endoscopy. This narrative review aims to provide an overview of known and emerging fields of application for mEUS in gastrointestinal endoscopy. After its initial development in pancreatobiliary scenarios in the early 1990s, mEUS has been recently reconsidered a third-space endoscopic technique that is progressively developing and spreading for the treatment of early gastrointestinal neoplastic lesions. The high spatial resolution of mEUS provides an accurate assessment of the degree of submucosal invasion in early esophageal, gastric, and colorectal neoplasia, while the small caliber of catheters allows for mEUS employment in settings where standard echoendoscopes are impractical (e.g., severe stenoses or proximal colonic lesions). Beyond cancer staging, mEUS offers point-of-care characterization of subepithelial lesions by defining the layer of origin and echo-pattern, eventually defining endoscopic resectability, but definitive diagnosis remains histological. In pancreatobiliary diseases, miniprobe intraductal ultrasonography (IDUS) shows its strongest application for indeterminate biliary strictures when endoscopic retrograde cholangiopancreatography (ERCP)-based sampling strategies and brushing cytology show inconclusive diagnoses, and in choledocholithiasis, particularly for the detection of small stones/sludge and confirmation of duct clearance. IDUS is also valuable for the staging of ampullary tumors, for longitudinal extension mapping in hilar cholangiocarcinoma and for selected portal biliopathy scenarios. Overall, mEUS and IDUS are high-resolution adjuncts that can meaningfully refine local decision-making in the treatment of superficial epithelial/subepithelial tumors or lesions involving the bile ducts. Limitations include shallow penetration, lack of tissue acquisition capability, a relative increase in post-ERCP pancreatitis risk for intraductal use, and substantial cost with limited availability in lower-volume centers. Full article

Background/Objectives: To develop and assess the feasibility of a natural language processing (NLP) framework for automated assessment of radiology–pathology concordance in breast biopsy using machine learning-based analysis of unstructured reports. Methods: This retrospective study included 766 paired radiology and pathology reports from ultrasound- or mammography-guided breast biopsies (August 2020–May 2024). Reports underwent translation, normalization, tokenization, lemmatization, and synonym expansion, followed by structured encoding of BI-RADS and pathology categories. Three models were trained: a Decision Tree, a LightGBM classifier, and a fine-tuned BioBERT model. Concordance labels were defined by multidisciplinary consensus. Performance metrics included accuracy, sensitivity, specificity, F1-score, area under the curve (AUC), and Cohen’s kappa. SHapley Additive exPlanations (SHAP) analysis was used to identify influential features. Results: Among 766 cases, 707 (92.3%) were concordant and 59 (7.7%) were initially discordant. After excluding B3 lesions (n = 46), 13 true discordant cases remained (1.7%). Including B3 lesions increased clinically non-concordant or indeterminate cases from 1.7% to 7.7%, indicating that the apparent performance of the models is likely sensitive to case definition and dataset composition. BI-RADS 4a was the most common category (31.3%), and benign pathology (B2) accounted for 64.4% of biopsies. Within this dataset, LightGBM yielded the highest apparent AUC (0.999) (however, given the extremely small number of true discordant cases, this estimate is likely unstable and should be interpreted with caution), while BioBERT showed the strongest agreement with expert consensus (κ = 0.89). SHAP analysis identified clinically meaningful terms such as calcification, hypoechoic, ductal, and carcinoma as key contributors to model predictions. Given the very limited number of true discordant cases, these performance estimates are likely unstable and should be regarded as preliminary, requiring validation in larger, multi-center cohorts. Conclusions: This study presents a proof-of-concept NLP-based framework for radiology–pathology concordance assessment. The models showed promising performance in identifying potentially discordant cases; however, given the limited number of true discordant samples, these findings should be considered preliminary and require further validation in larger, multi-center datasets before clinical implementation. Full article

Inflammatory bowel disease (IBD)—including Crohn’s disease, ulcerative colitis, and indeterminate colitis—is a chronic immune-mediated condition that primarily affects the intestinal mucosa but often presents with extraintestinal digestive manifestations, which are important yet frequently underrecognized sources of morbidity. These heterogeneous manifestations reflect diverse genetic, microbial, immunologic, and environmental influences, highlighting the value of a personalized medicine approach. Hepatobiliary involvement affects IBD adults patients and is even more common in children, ranging from mild liver enzyme elevations to severe complications such as liver failure, with autoimmune disorders, cholelithiasis, portal vein thrombosis, and non-alcoholic fatty liver disease as key considerations. Pancreatic manifestations may include autoimmune or acute pancreatitis, often linked to gallstones, thiopurine exposure, or duodenal Crohn’s disease, while splenic abnormalities, such as granulomatous lesions, splenomegaly, or functional hyposplenism, reflect systemic immune dysregulation. Oral findings—including aphthous ulcers, periodontitis, pyostomatitis vegetans, and granulomatous cheilitis—can serve as early, patient-specific indicators of disease activity. Personalized approaches, encompassing investigations tailored to the individual profile and selected targeted therapies, are essential for improving diagnostic accuracy, preventing complications, and optimizing multidisciplinary care in patients with IBD. Full article

Background: Fine-needle aspiration biopsy (FNAB) is the standard initial diagnostic procedure for thyroid nodules; however, a considerable proportion of results are non-diagnostic or indeterminate, often requiring repeat procedures and delaying management. Core needle biopsy (CNB) has been proposed as a second-line option. This study evaluated the frequency of non-conclusive FNAB and CNB results and assessed the diagnostic contribution of CNB in nodules with initially non-conclusive FNAB findings. Methods: A retrospective–prospective study was conducted between 2019 and 2025 at a tertiary referral center, including 434 thyroid nodules. Ultrasound risk stratification followed ACR TI-RADS criteria. FNAB was performed in 430 nodules, and CNB in 85 nodules, including 82 evaluated by both methods. Biopsy results were classified according to the Bethesda system as conclusive or non-conclusive. Paired comparisons were analyzed using the McNemar test, and associations with ultrasound risk were assessed. Results: FNAB produced non-conclusive results in 56.5% of cases, compared with 23.5% for CNB. In paired analysis, 53.7% of nodules with non-conclusive FNAB were reclassified as conclusive after CNB (p < 0.001). CNB significantly distinguished benign from malignant lesions, unlike FNAB. Hypoechogenicity, irregular margins, and punctate echogenic foci were independent predictors of malignancy. Minor complications were more frequent after CNB, while major complications were rare in both groups. Conclusions: CNB improves diagnostic yield when used as a second-line procedure in nodules with non-conclusive FNAB findings. Selective use in higher-risk nodules may reduce repeat procedures and facilitate more structured clinical management. Full article

Radiomics may aid the noninvasive characterization of adrenal incidentalomas; however, reproducibility is limited by methodological heterogeneity. In this retrospective, single-center, exploratory study, we tested whether radiomic features from baseline non-enhanced computed tomography (NECT) discriminate benign from malignant/metastatic adrenal lesions and contextualized results with a PRISMA 2020 systematic review (PubMed/Scopus 2017–2025; PROSPERO CRD420251276627). Thirty-three patients (36 lesions: 12 lipid-rich adenomas, 9 lipid-poor adenomas, 6 pheochromocytomas, 7 malignant/metastatic lesions, 2 myelolipomas) were included; myelolipomas were excluded from primary comparisons. Two abdominal radiologists performed consensus 3D segmentation on NECT. Using LIFEx (v7.8.0) and IBSI definitions, 42 features were extracted and z-score standardized. LASSO selected four heterogeneity descriptors: First-order Entropy, gray-level co-occurrence matrix (GLCM) entropy, gray-level size zone matrix (GLSZM) non-uniformity, and neighboring gray tone difference matrix (NGTDM) busyness. Heterogeneity increased from lipid-rich adenomas to pheochromocytomas and malignant/metastatic lesions (Kruskal–Wallis, all p < 0.001. Pairwise separability, measured using the Vargha–Delaney A index (VDA) as a rank-based measure of separability, was highest for lipid-rich adenomas versus malignant/metastatic lesions (0.93), intermediate for lipid-poor adenomas versus pheochromocytomas (0.73), and lowest for lipid-rich versus lipid-poor adenomas (0.64). The review identified 18 eligible CT radiomics studies that consistently reported higher entropy/non-uniformity in pheochromocytomas and malignant lesions than in lipid-rich adenomas. Global heterogeneity metrics on NECT may complement conventional CT criteria in indeterminate lesions; external validation with robust reference standards is needed in larger, multicenter cohorts with harmonization. Full article

Extramedullary haematopoiesis (EMH) refers to haematopoietic proliferation outside the bone marrow, most often arising as a compensatory response to ineffective marrow function in chronic anaemias and myeloid neoplasms, particularly myelofibrosis and other myeloproliferative neoplasms. While the liver and spleen are typical sites, renal involvement remains particularly uncommon and may mimic infiltrative malignancy or infection on cross-sectional imaging. We report a 35-year-old woman with biopsy-proven grade 2 myelofibrosis who presented with constitutional symptoms, namely asthenia, progressive weight loss, and intermittent fever, in the setting of pancytopenia. Contrast-enhanced CT demonstrated bilateral thoracic paravertebral and presacral soft-tissue masses, with left peripelvic/pelvicalyceal infiltration, raising concern for infiltrative malignancy or infection. [¹⁸F]-FDG-PET/CT showed low-grade uptake in the paravertebral and presacral lesions, while the renal lesion remained indeterminate because of adjacent urinary tracer activity. Given the haemorrhagic risk of renal biopsy in a cytopenic patient, [^99mTc]-sulphur colloid scintigraphy with SPECT/CT was performed and demonstrated concordant tracer uptake in all lesions, supporting multifocal EMH. After disease-directed treatment, follow-up CT at 12 months showed marked regression of the renal and other EMH lesions. This case highlights renal peripelvic EMH as a rare imaging pitfall and underscores the value of multimodality imaging when biopsy is high risk. Full article

Background: Precise staging of prostate cancer is vital for treatment planning and prognosis. While [⁶⁸Ga]Ga-PSMA-11 PET-CT has demonstrated high diagnostic accuracy in detecting metastatic disease, the interpretation of indeterminate or potentially benign PSMA-avid bone lesions remains a clinical challenge in routine practice. Methods: We conducted a retrospective single-centre study involving 214 patients who underwent [⁶⁸Ga]Ga-PSMA-11 PET-CT between January 2021 and January 2024. Patients with prior known bone metastases or alternative PSMA radiotracers were excluded. Only those with follow-up imaging were included for diagnostic accuracy analysis. Follow-up modalities included PSMA PET-CT, CT, MRI, and bone scintigraphy. Final classification (metastatic or benign) was based on radiological and clinical assessment. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated using follow-up imaging as the reference standard. Lesions classified as indeterminate were analysed separately and excluded from diagnostic performance calculations. Results: Of the 214 included patients, 142 had follow-up imaging. Among 80 patients with bone lesions initially reported as metastatic, 74 (92.5%) were confirmed. Among 28 patients initially reported as having benign bone lesions, 26 (92.9%) remained benign on follow-up. Thirty-four patients with indeterminate lesions were reviewed; four were ultimately metastatic. Excluding indeterminate cases, sensitivity, specificity, PPV, and NPV were 97.4%, 86.7%, 94.9%, and 92.9%, respectively. Diagnostic discordance was primarily associated with benign uptake in the ribs, iliac bones, pubic rami and degenerative changes. Conclusions: [⁶⁸Ga]Ga-PSMA-11 PET-CT shows excellent sensitivity and positive predictive value for detecting metastatic bone disease in prostate cancer. However, benign lesions may also exhibit uptake, emphasising the importance of integrating imaging results with PSA levels, Gleason scores, and TNM staging. Prospective studies are needed to validate these findings and assess their impact on long-term outcomes. Full article