Current Medical Imaging - Volume 20, Issue 1, 2024

Breast cancer is the most common malignant tumour in women. Radical mastectomy with postoperative radiotherapy is now the standard treatment for locally advanced breast cancer. Intensity-modulated radiotherapy (IMRT) has now been developed, which employs linear accelerators to deliver precise radiation to a tumour while minimizing the dose to surrounding normal tissue. It significantly improves the efficacy of breast cancer treatment. However, there are still some flaws that must be addressed.

To assess the clinical application of the three-dimensional (3D)-printed chest wall conformal device for breast cancer patients who need to be treated by chest wall intensity modulated radiotherapy (IMRT) after radical mastectomy.

The 24 patients were divided into three groups. During a computed tomography (CT) scan, patients in the study group were fixed by a 3D-printed chest wall conformal device, nothing in control group A, and a traditional 1-cm thick silica gel compensatory pad on the chest wall in control group B. The parameters of mean Dmax, Dmean, D2%, D50%, D98%, the conformity index (CI), and the homogeneity index (HI) of the planning target volume (PTV) are compared.

The study group had the best dose uniformity (HI = 0.092) and the highest conformation (CI = 0.97), the worst in control group A (HI = 0.304, CI = 0.84). The mean Dmax, Dmean, and D2% of the study group were lower than control groups A and B (p<0.05). The mean D50% was higher than control group B (p<0.05), while the mean D98% was higher than control groups A and B (p<0.05). The mean Dmax, Dmean, D2%, and HI of control group A were higher than control group B (p<0.05), whereas the mean D98% and CI were lower than control group B (p<0.05).

By improving the efficacy of postoperative radiotherapy for breast cancer, using 3D-printed chest wall conformal devices may greatly improve the accuracy of repeating position fixation, increase the dose on the skin surface of the chest wall, optimise the dose distribution of the target area, and thus further reduce tumour recurrence and prolong patients' survival.

Researchers have made several advancements in this field, including automatic segmentation techniques, computer-aided diagnosis, mobile-based technology, deep learning methods, hybrid methods etc. All these techniques are beneficial in diagnosing melanoma or segregating skin lesions into different categories.

This paper aims to define different types of skin cancers, diagnosis procedures and statistics. This paper presents skin cancer statistics over a period of time in India. The increment in the number of skin carcinoma and melanoma cases from 1990 to 2020 as well as the mortality rates, has been presented in this paper. Also, this paper provides a review of different technologies used by researchers in detecting melanoma.

The rise in the number of cases by 2040 and mortality rates are compared. The statistics that are used in this paper are as per hospital-based cancer registries (HBCR) 2021 prepared by the Indian Council of Medical Research - National Centre for Disease Informatics and Research, Bengaluru (ICMR-NCDIR) and from World Health Organization (WHO).

The present study aimed to analyze the prevalence of hypothyroidism in patients with rheumatoid arthritis (RA). In addition, the study aimed to elucidate the correlation of hypothyroidism with RA activity and to investigate the relationship between RA and thyroid dysfunction.

A total of 314 patients were categorized into two groups according to thyroid stimulating hormone (TSH) level: RA without hypothyroidism and RA with hypothyroidism. All patients underwent routine laboratory investigation, including thyroid function testing, and complete clinical assessment. These included the determination of the erythrocyte sedimentation rate as well as the level of TSH, free triiodothyronine, free thyroxine, total triiodothyronine level, total thyroxine level, C-reactive protein, rheumatoid factor immunoglobulin (RF-Ig), RF-IgA, RF-IgG, RF-IgM, cyclic citrullinated peptide immunoglobulin G (CCP IgG), complement component 3, and complement component 4. Based on these data, thyroid function, and rheumatoid factor levels were analyzed.

Curve estimation using linear regression revealed that CCP Ig level was significantly correlated with the TSH level (r = 0.122, P = 0.031).

TSH level may be used as an auxiliary test to assess disease severity in patients with RA and to evaluate thyroid function. This evaluation parameter may be considered for determining clinical prognosis in patients with RA.

Thyroid disorders are prevalent worldwide and impact many people. The abnormal growth of cells in the thyroid gland region is very common and even found in healthy people. These abnormal cells can be cancerous or non-cancerous, so early detection of this disease is the only solution for minimizing the death rate or maximizing a patient's survival rate. Traditional techniques to detect cancerous nodules are complex and time-consuming; hence, several imaging algorithms are used to detect the malignant status of thyroid nodules timely.

This research aims to develop computer-aided diagnosis tools for malignant thyroid nodule detection using ultrasound images. This tool will be helpful for doctors and radiologists in the rapid detection of thyroid cancer at its early stages. The individual machine learning models are inferior to medical datasets because the size of medical image datasets is tiny, and there is a vast class imbalance problem. These problems lead to overfitting; hence, accuracy is very poor on the test dataset.

This research proposes ensemble learning models that achieve higher accuracy than individual models. The objective is to design different ensemble models and then utilize benchmarking techniques to select the best model among all trained models.

This research investigates four recently developed image transformer and mixer models for thyroid detection. The weighted average ensemble models are introduced, and model weights are optimized using the hunger games search (HGS) optimization algorithm. The recently developed distance correlation CRITIC (D-CRITIC) based TOPSIS method is utilized to rank the models.

Based on the TOPSIS score, the best model for an 80:20 split is the gMLP + ViT model, which achieved an accuracy of 89.70%, whereas using a 70:30 data split, the gMLP + FNet + Mixer-MLP has achieved the highest accuracy of 82.18% on the publicly available thyroid dataset.

This study shows that the proposed ensemble models have better thyroid detection capabilities than individual base models for the imbalanced thyroid ultrasound dataset.

It is difficult to accurately determine whether emergent patients with small-bowel obstruction (SBO) have small-bowel ischemia and necrosis (SBIN). Therefore, in this study, we aimed to assess the ability of abdominal CT scans to predict SBIN and establish a new predictive model.

From March 2018 to May 2023, a rigorous posthoc analysis was conducted on whether 177 emergent patients with SBO had SBIN. Four clinical indexes and 19 CT signs were analyzed, and a multivariate scoring model for predicting SBIN was established using logistic regression analysis. A receiver operating characteristic (ROC) curve was used to assess the accuracy of this model.

Multivariate analysis showed that mesenteric edema and effusion (OR=23.450), significant thickening and the target sign on the small-bowel wall on plain scans (OR=23.652), significant thinning of the small-bowel wall (OR=30.439), significant decrease in small-bowel wall density (OR=12.885), and significant increase in small-bowel wall density (OR=19.550) were significantly correlated with SBIN (P<0.05). According to their multivariate ORs, an appropriate “predictive score” was assigned to each sign, and the rates of SBIN among those with a total score of 0-4, 5-6, and 7-8 were 2.2%, 86.4%, and 96.9%, respectively. The AUC of this predictive scoring model for SBIN exceeded 0.980.

We have developed a predictive scoring model for SBIN, for which the incidence of SBIN increases with increasing predictive scores. This model can be useful for clinical treatment.

The objective of this study is to investigate whether quantitatively measured infrapatellar fat pad (IPFP) signal intensity alteration is associated with joint effusion-synovitis in people with knee osteoarthritis (OA) over two years.

Among 255 knee OA patients, IPFP signal intensity alteration represented by four measurement parameters [standard deviation of IPFP signal intensity (IPFP sDev), upper quartile value of IPFP high signal intensity region (IPFP UQ (H)), ratio of IPFP high signal intensity region volume to whole IPFP volume (IPFP percentage (H)), and clustering factor of IPFP high signal intensity (IPFP clustering factor (H))] was measured quantitatively at baseline and two-year follow-up using magnetic resonance imaging (MRI). Effusion-synovitis of the suprapatellar pouch and other cavities were measured both quantitatively and semi-quantitatively as effusion-synovitis volume and effusion-synovitis score at baseline and two-year follow-up using MRI. Mixed effects models assessed the associations between IPFP signal intensity alteration and effusion-synovitis over two years.

In multivariable analyses, all four parameters of IPFP signal intensity alteration were positively associated with total effusion-synovitis volume and effusion-synovitis volumes of the suprapatellar pouch and of other cavities over two years (all P<0.05). They were also associated with the semi-quantitative measure of effusion-synovitis except for IPFP percentage (H) with effusion-synovitis in other cavities.

Quantitatively measured IPFP signal intensity alteration is positively associated with joint effusion-synovitis in people with knee OA, suggesting that IPFP signal intensity alteration may contribute to effusion-synovitis and a coexistent pattern of these two imaging biomarkers could exist in knee OA patients.

During the COVID-19 pandemic, various complications have been reported in patients with this infection worldwide, including a wide range of neurological disorders. In this study, we have reported a novel neurological complication in a 46-years-old woman who was referred due to a headache following a mild COVID-19 infection. Also, we have had a quick review of previous reports of dural and leptomeningeal involvements in COVID-19 patients.

The patient's headache was persistent, global, and compressive with radiation to the eyes. The severity of the headache was increased during the disease course and was exacerbated by walking, coughing, and sneezing but decreased with rest. The high severity of the headache disrupted the patient’s sleep. Neurological examinations were completely normal, and laboratory tests did not have abnormal findings except for an inflammatory pattern. Finally, in the brain MRI, a concurrent diffuse dural enhancement and leptomeningeal involvement were observed, which is a new finding in COVID-19 patients and has not been reported so far. The patient was hospitalized and treated with Methylprednisolone pulses. After completing the therapeutic course, she was discharged from the hospital in good condition and with an improved headache. A repeated brain MRI was requested 2 months after discharge, which was completely normal and showed no evidence of dural and leptomeningeal involvements.

Inflammatory complications of the central nervous system caused by COVID-19 can occur in different forms and types, and clinicians should consider them.

The application of compressed sensing (CS) has enabled breath-hold 3D-MRCP with a shorter acquisition time in clinical practice.

To compare the image quality of breath-hold (BH) and respiratory-triggered (RT) 3D-MRCP with or without CS application in the same study population.

In this retrospective study, from February to July 2020, a total of 98 consecutive patients underwent four different acquisition types of 3D-MRCP.; 1) BH MRCP with the generalized autocalibrating partially parallel acquisition (GRAPPA) (BH-GRAPPA), 2) RT-GRAPPA-MRCP, 3) RT-CS-MRCP and 4) BH-CS-MRCP. Relative contrast of common bile duct, 5-scale visibility score of biliary pancreatic ducts, 3-scale artifact score and 5-scale overall image quality score were evaluated by two abdominal radiologists.

Relative contrast value was significantly higher in BH-CS or RT-CS than in RT-GRAPPA (0.90 ± 0.057 and 0.89 ± 0.079, respectively, vs. 0.82 ± 0.071, p < 0.01) or BH-GRAPPA (vs. 0.77 ± 0.080, p < 0.01). The area affected by artifact was significantly lower in BH-CS among 4 MRCPs (p < 0.01). Overall image quality score in BH-CS was significantly higher than BH-GRAPPA (3.40 vs. 2.71, p < 0.01). There were no significant differences between RT-GRAPPA and BH-CS (vs. 3.13, p = 0.67) in overall image quality.

In this study, our results revealed BH-CS had higher relative contrast and comparable or superior image quality among four MRCP sequences.

Symmetrical bilateral lower extremity edema (BLEE) needs to be treated effectively. Finding the cause of this condition increases the success of treatment. Fluid increase in the interstitial space (FIIS) is always present as a cause or a result. Subcutaneously administered nanocolloid is transported by uptake by lymphatic pre-collectors, and this uptake takes place in the interstitium. We aimed to evaluate the interstitium with labeled nanocolloid and contribute to the differential diagnosis in cases with BLEE.

Our retrospective study included 74 female patients who underwent lymphoscintigraphy for bilateral lower extremity edema. Technetium 99m (Tc-99m) albumin colloid (nanocolloid), a marked colloidal suspension, was applied subcutaneously to two different areas on the dorsum of both feet with a 26 gauge needle The dose volume administered intradermally is approximately 0.2-0.3 ml, and each injector has 22-25MBq of activity. Siemens E-Cam dual-headed SPECT gamma camera was used for imaging. Dynamic and scanning images were taken with a high-resolution parallel hole collimator. Ankle images were re-evaluated by two nuclear medicine specialists, independent of physical examination and scintigraphy findings.

74 female patients with bilateral lower extremity edema were divided into two groups based on physical examination and lymphoscintigraphy findings. There were 40 and 34 patients in Groups I and II, respectively. In the physical examination, patients in Group I were evaluated as lymphedema, and patients in Group II were evaluated as lipedema. The main lymphatic channel (MLC) was not observed in any of the patients in Group I in the early images, and the MLC was observed at a low level in the late imaging in 12 patients. The sensitivity of the presence of distal collateral flows (DCF) in the presence of significant MLC in early imaging in demonstrating increased fluid in the interstitial space (FIIS) was calculated as 80%, specificity as 80%, PPV 80%, and NPV 84%.

While MLC is present in early images, concomitant DCF occurs in cases of lipoedema. The transport of increased lymph fluid production in this group of patients can be covered by the existing MLC. Although MLC is evident, the presence of significant DCF supports the presence of lipedema. It can be used as an important parameter in the diagnosis in early cases where physical examination findings are not evident.

Chondrosarcoma in the mastoid is extremely rare, and it is easily misdiagnosed as a facial nerve schwannoma.

To identify and compare computed tomography (CT) and magnetic resonance imaging (MRI) features of chondrosarcoma in the mastoid involving the facial nerve, including diffusion-weighted MRI characteristics, with those of facial nerve schwannoma.

CT and MRI features of 11 chondrosarcomas in the mastoid involving the facial nerve and 15 facial nerve schwannomas, confirmed by histopathology, were retrospectively reviewed. The tumor location, size, morphological features, bone change, calcification, signal intensity, texture, enhancement characteristics, the extent of lesions, and apparent diffusion coefficients (ADCs) were evaluated.

On CT imaging, calcification could be found in 81.8% of chondrosarcomas (9/11) and 33.3% of facial nerve schwannomas (5/15). Chondrosarcoma in the mastoid appeared significantly hyperintense on T2-weighted images (T2WI) with low signal intensity septa in eight patients (72.7%, 8/11). After contrast, all chondrosarcomas showed inhomogeneous enhancement, and septal and peripheral enhancement could be found in six cases (54.5%, 6/11). Facial nerve schwannoma demonstrated inhomogeneous hyperintensity on T2WI in 12 cases (80%, 12/15), with obvious hyperintense cystic changes in seven cases. There were significant differences in calcification (P=0.014), T2 signal intensity (P=0.006), and septal and peripheral enhancement (P=0.001) between chondrosarcomas and facial nerve schwannomas. The ADCs of chondrosarcoma were significantly higher than those of facial nerve schwannomas (P<0.001).

CT and MRI with ADCs had the potential to improve the diagnostic accuracy of chondrosarcoma in the mastoid involving the facial nerve.

For patients with acetabular osteolytic metastases involving the articular surfaces, current treatments cannot efficiently rebuild the acetabular bone frame structure and strengthen bone defect area mechanics for weight-bearing. The purpose of this study is to show the operational procedure and clinical outcomes of multisite percutaneous bone augmentation (PBA) for the treatment of incidental acetabular osteolytic metastases involving the articular surfaces.

According to the inclusion and exclusion criteria, 8 patients (4 males and 4 females) were included in this study. Multisite (3 or 4 sites) PBA was successfully performed in all patients. The pain and function evaluation and imaging observation were examined by VAS and Harris hip joint function scores at the different time points (pre-procedure, 7 days, one month, last follow-up in 5-20 months).

There were significant differences (p<0.05) in VAS and Harris scores before and after the surgical procedure. Moreover, these two scores had no obvious changes during the follow-up process (7 days after the procedure, one month after the procedure, and the last follow-up) after the procedure.

The proposed multisite PBA is an effective and safe procedure for the treatment of acetabular osteolytic metastases involving the articular surfaces.

Clinical Trial Reg # The clinical trial registration number was ChiCTR2000032667

To analyze the value of magnetic resonance imaging (MRI) in suspicious cases for prenatal detection of placenta accreta (PA).

A total of 50 placental MRI exams performed on a 1.5T scanner were retrospectively reviewed by two radiologists in consensus. HASTE (half-Fourier acquisition single-shot turbo spin echo)and True-FISP (true fast imaging with steady-state precession) sequences were acquired. Findings from MRI were compared with the final diagnosis, which was determined by clinical findings at delivery and pathological examination of specimens.

Of 50 pregnant women in the analysis, 33 required cesarean hysterectomy, and 17 underwent cesarean delivery.MRI signs such as myometrial thinning, loss of T2 hypointense interface(loss of retroplacental clear space on US), heterogenous intraplacental sign, and intraplacental T2 dark bands were more likely to be seen in this group.

In this group, the cases that were finally clinically and pathologically confirmed were 12, 16, and 22 cases of placenta accreta vera, placenta increta, and placenta percreta respectively.

MRI is particularly useful in cases where US is inconclusive and to assess the extent to which the placenta penetrates the uterine serosa and invades outward into surrounding tissues.MRI has become a routine examination for patients with suspected PA in clinical practice.

Massive parenchymal hemorrhage of the thyroid gland is very rare. Some of these can reach a life-threatening level.

A 70-year-old female patient approached the emergency department with swelling and redness on her neck after a routine dialysis session. In the neck computed tomography obtained, there was a massive hematoma originating from the thyroid gland parenchyma. The hematoma was causing airway compression. We performed thyroid artery embolization and within days, hematoma dimensions and compression effect disappeared without surgical treatment.

Massive hemorrhage of the thyroid gland parenchyma is very rare and can reach life-threatening dimensions. Effective and rapid treatment should be done. As an alternative to surgery, endovascular treatment can be life-saving.

Calcific tendinopathy is a common cause of painful shoulder easily identified with ultrasound or conventional radiography. Although the rotator cuff is by far the most common location of the disease and diagnostic or treatment strategies are well known in clinical practice, a lack of awareness characterizes the assessment of the other sites affected by this condition; consequently, the risk of underestimating the prevalence of atypical non-rotator cuff calcific tendinopathy is high. This may lead to expensive or invasive diagnostic exams and/or inappropriate treatment, whereas the condition is usually self-limited.

The present study aims at analysing the frequency of calcific tendinitis in uncommon sites, in order to fill a gap in knowledge and awareness regarding non-rotator cuff calcific tendinopathy, thus avoiding improper clinical choices and helping to identify this condition.

This systematic review was conducted following the PRISMA guidelines. We performed a search on Pubmed and Scopus databases concerning atypically sited extra-rotator cuff calcific tendinopathy published since 1950.

The research found a total of 267 articles and 793 non-rotator cuff cases of calcific tendinopathy registered. The spine (213 – 26.86%), foot and ankle (191 – 23.95%), and hip (175 – 22.06%) appeared to be the most common sites of calcific tendinopathy after the rotator cuff, whereas the longus colli C1-C2 (204 – 25.72%), Achilles (173 – 21.81%), and rectus femori (61 – 7.69%) were the most commonly affected tendons.

A better awareness of this condition in several different sites of the body than the rotator cuff could avoid unnecessary choices both in assessment and treatment.

Volumetric Modulated Arc Therapy (VMAT) has recently become a pivotal treatment of oncological diseases due to the high-precise delineation of target volume contours with sparing organs at risk. This procedure requires a high level of experience and precision and is achievable only with advanced diagnostic support. Magnetic Resonance (MRI) and multimodality imaging, such as 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT), are fundamental in implementing radiotherapy guidance.

A 54-year-old patient underwent surgery twice to remove primitive and recurrent cardiac sarcomas of the left atrium. The appearance of a further relapse required radiotherapy as the only possible treatment. Cardiac MRI was then performed to define the degree of atrial mass invasiveness, and 18F-FDG PET/CT was performed to assess the activity and staging of the cardiac lesion. It revealed high 18F-FDG uptake not only in the left atrium lesion but also in a pancreatic lesion with elevated 18F-FDG uptake (SUV max 5.5). The pancreatic biopsy performed a few days later confirmed the myxoid sarcoma metastasis, and surgeons defined it as not operable due to the patient’s clinical condition. Radiotherapy was then urgently performed with the VMAT technique. After 40 days, a cardiac MRI showed a reduction in the cardiac mass with improvement in the respiratory and cardiac symptoms; then, the patient started chemotherapy. One year after diagnosis, the patient is still alive and is receiving chemotherapy with gemcitabine and docetaxel with good compliance.

The correct and timely management of a patient suffering from a rare oncological disease has allowed a better and longer survival, especially due to VMAT, a sophisticated procedure that requires high expertise. This case also demonstrates that cardiac MRI and whole-body imaging procedures, such as 18FDG PET/CT, can be useful in staging patients with oncological diseases.

Portal hypertension has various manifestations, and varices are a common manifestation. Varices can appear in any vein in the body associated with the portal venous system.

Herein, we report a case of portal hypertension with gallbladder varices as the main manifestation, which was confirmed by abdominal contrast-enhanced CT with three-dimensional reconstruction and color Doppler ultrasonography. The patient had concomitant liver cirrhosis and portal vein thrombosis. Various auxiliary examinations and biochemical indicators of the patient confirmed liver cirrhosis, portal vein thrombosis, and portal hypertension, all of which were mild and did not reach the decompensation stage.

As illustrated by this case, when there is an embolism in certain parts of the portal system, portal hypertension can appear during the compensatory period and transition into severe varices in the thrombotic part during the de-compensatory period.

Lemmel’s syndrome is defined as obstructive jaundice due to a PDD in the absence of choledocholithiasis or a neoplasm. The most common cause is the presence of PDD which arise within 2-3 cm from the ampulla of Vater. Currently, there are very few case reports of this condition, which was first named in 1934 after Dr. Gerhard Lemmel.

A 74-year-old female patient presented to the emergency department with complaints of abdominal pain and jaundice, and also had signs of pancreatitis, with laboratory results showing elevated liver and pancreatic enzymes and hyperbilirubinemia. We present a case of a patient who was diagnosed with Lemmel’s syndrome after abdominal CT, MRCP, and ERCP.

Although rare, it is imperative for physicians to recognize this syndrome in order to deliver prompt care. Because making the correct diagnosis in these patients is very important for correct treatment and preventing the development of complications.