Changing Threshold-Based Segmentation Has No Relevant Impact on Semi-Quantification in the Context of Structured Reporting for PSMA-PET/CT

Prostate-specific membrane antigen (PSMA)-directed positron emission tomography/computed tomography (PET/CT) is increasingly utilized for staging of men with prostate cancer (PC). To increase interpretive certainty, the standardized PSMA reporting and data system (RADS) has been proposed. Using PSMA-RADS, we characterized lesions in 18 patients imaged with 18F-PSMA-1007 PET/CT for primary staging and determined the stability of semi-quantitative parameters. Six hundred twenty-three lesions were categorized according to PSMA-RADS and manually segmented. In this context, PSMA-RADS-3A (soft-tissue) or -3B (bone) lesions are defined as being indeterminate for the presence of PC. For PMSA-RADS-4 and -5 lesions; however, PC is highly likely or almost certainly present [with further distinction based on absence (PSMA-RADS-4) or presence (PSMA-RADS-5) of correlative findings on CT]. Standardized uptake values (SUVmax, SUVpeak, SUVmean) were recorded, and volumetric parameters [PSMA-derived tumor volume (PSMA-TV); total lesion PSMA (TL-PSMA)] were determined using different maximum intensity thresholds (MIT) (40 vs. 45 vs. 50%). SUVmax was significantly higher in PSMA-RADS-5 lesions compared to all other PSMA-RADS categories (p ≤ 0.0322). In particular, the clinically challenging PSMA-RADS-3A lesions showed significantly lower SUVmax and SUVpeak compared to the entire PSMA-RADS-4 or -5 cohort (p < 0.0001), while for PSMA-RADS-3B this only applies when compared to the entire PSMA-RADS-5 cohort (p < 0.0001), but not to the PSMA-RADS-4 cohort (SUVmax, p = 0.07; SUVpeak, p = 0.08). SUVmean (p = 0.30) and TL-PSMA (p = 0.16) in PSMA-RADS-5 lesions were not influenced by changing the MIT, while PSMA-TV showed significant differences when comparing 40 vs. 50% MIT (p = 0.0066), which was driven by lymph nodes (p = 0.0239), but not bone lesions (p = 0.15). SUVmax was significantly higher in PSMA-RADS-5 lesions compared to all other PSMA-RADS categories in 18F-PSMA-1007 PET/CT. As such, the latter parameter may assist the interpreting molecular imaging specialist in assigning the correct PSMA-RADS score to sites of disease, thereby increasing diagnostic certainty. In addition, changes of the MIT in PSMA-RADS-5 lesions had no significant impact on SUVmean and TL-PSMA in contrast to PSMA-TV.

Early Clinical Utility Data of a Blood Biomarker Test in the Evaluation of Mild Cognitive Impairment

There is an important unmet need for timely, noninvasive, low-burden evaluation of patients presenting with mild cognitive impairment (MCI). The PrecivityAD™ blood test quantifies plasma concentrations of amyloid-β 42 and 40 and apolipoprotein E-specific peptides that are combined with age in an algorithm to identify the likelihood of amyloid plaques in the brain as measured by amyloid PET scans. This test has previously demonstrated 92% sensitivity and 77% specificity. The study objective was to evaluate the clinical utility of the test and the Amyloid Probability Score (APS), the test output value. Eighteen patients (median age 72, 55% male, 88% white) with MCI received the PrecivityAD blood-based biomarker test. The mean APS was 31 (range 0-91): 13 patients had low scores (APS 0-35), 2 had high scores (58-100) and 3 had intermediate (inconclusive) scores (APS 36-57). The mean probability of Alzheimer’s disease (AD) diagnosis was rated by clinicians as 63% (range 25-80) pre-test and 31% post-test (range 5-95) (p &lt; 0.0005). AD probability rated by clinicians was decreased in 12/13 low APS patients and increased in 2/2 high APS patients. Donepezil was discontinued in 5/8 low APS patients on therapy and initiated in 1/1 high APS patients not on therapy, representing a change in treatment management in 33% (6/18) of study patients. In summary, this blood-based biomarker test showed clinical utility in its association with physician decision-making around diagnostic certainty and drug therapy management in MCI patients.

Comparison of Pipelle and Hysteroscopy with D&C in Postmenopausal Patients

Objective: The aim of the study is to compare the pipelle method and hysteroscopy with D&C in postmenopausal patients Methods: In this prospective study, only those postmenopausal patients with postmenopausal bleeding and/or with a sonographically highly developed endometrium who were referred for hysteroscopy with D&C were included. A total of 92 patients were included in this study. Before each procedure, patients were explicitly informed about the study and gave consent. On the condition of anonymity of personal data (surname and first name, date of birth) and after signing a special informed consent form, the patients were allowed to be included in the study. The study was performed as a double-blind study. The obtained histologies (from pipelle and D&C) were sent separately to the same pathologist. Results: The group with malignant and premalignant findings has a central role in our study. After evaluation of the histologically malignant findings from the pipelle and the D&C, the sensitivity of the pipelle in our study was 82%. Conclusion: Endometrial biopsy is an important step to exclude endometrial carcinoma in postmenopausal bleeding. The aim is to minimize the burden and invasiveness of the procedure while maintaining a high degree of diagnostic certainty to avoid unnecessary invasive surgery. The pipelle sampling can be used as an outpatient method without anaesthesia during routine examination. Our study shows that this method of sampling is a safe, accurate and cost-effective outpatient procedure with high sensitivity for the detection of endometrial carcinoma.

Solitary neurofibroma of the right lateral wall of the oropharynx

Solitary neurofibroma of the oropharynx is extremely rare. Imaging explorations may be necessary, but the diagnostic certainty is pathological. We report a case of benign tumour of the oropharynx in a 25-year-old woman who was seen for a consultation with dysphagia, a change in voice and dyspnea in the supine position. The excision was performed under general anaesthesia with orotracheal intubation via the oropharyngeal route. Pathological examination of the surgical specimen revealed neurofibroma. Although rare, solitary neurofibroma of the oropharynx should be considered in any benign tumour in the area.

Thyreotroop adenoom van de hypofyse: een zeldzame oorzaak van hyperthyreoïdie

TSH-secreting pituitary adenoma: a rare cause of hyperthyroidism Central hyperthyroidism is noted in a 35-year-old man with recurrent panic attacks. Thyroid-stimulating hormone-secreting pituitary adenoma (TSH-secreting adenoma) is found to be the underlying etiology. A pituitary adenomectomy is carried out, with regression of the symptoms and hyperthyroidism. TSH-secreting adenomas are rare and cause hyperthyroidism due to autonomous TSH secretion. In addition to hyperthyroidism, dysfunction of other pituitary axes and neurological problems due to local compression may also be present. Biochemically, TSH adenoma is characterized by elevated levels of thyroid hormones without suppression of the TSH concentration. After analytical interference has been ruled out, additional biochemical and radiological investigations are necessary in the differential diagnosis and to establish diagnostic certainty. Neurosurgical resection is the cornerstone of the treatment, although radiotherapy and somatostatin analogs may also be considered.

Diagnostic and prognostic implications of 2018 guideline for the diagnosis of idiopathic pulmonary fibrosis in clinical practice

The purpose of this study was to evaluate the implications of the 2018 updated guideline for the diagnosis of idiopathic pulmonary fibrosis (IPF) in clinical practice compared to 2011 guideline. This study involved 535 patients including 339 IPF and 196 non-IPF, and we retrospectively evaluated CT classifications of usual interstitial pneumonia (UIP) by two guidelines. Interobserver agreement of 2018 criteria showed moderate reliability (κ = 0.53) comparable to 2011 (κ = 0.56) but interobserver agreement for probable UIP was fair (κ = 0.40). CT pattern of indeterminate for UIP was associated with better prognosis compared with the other groups (adjusted hazard ratio [HR] = 0.36, p < 0.001). Compared to possible UIP, probable UIP demonstrated a lower positive predictive value (PPV, 62.9% vs 65.8%). In analysis of patients with CT patterns of non-definite UIP, diagnosing IPF when CT pattern showed probable UIP with lymphocyte count ≤ 15% in BAL fluid, and either male sex or age ≥ 60 years showed a high specificity of 90.6% and a PPV of 80.8% in the validation cohort. The 2018 criteria provide better prognostic stratification than the 2011 in patients with possible UIP. BAL fluid analysis can improve the diagnostic certainty for IPF diagnosis in patients with probable UIP CT pattern.

Capsule Endoscopy in Children

Since its clearance for use throughout the world, capsule endoscopy (CE) has become an important diagnostic tool, helping us to understand and document both normal and abnormal findings in the small intestine, especially in children, since CE usually can be employed without sedation or radiation. The indications in children and adults are similar, though their relative frequencies are different, with evaluation of potential and known inflammatory bowel disease the most common in the pediatric population, with CE also yielding increased diagnostic certainty compared to radiographic studies and surrogate biomarkers. Newer capsules now create opportunities to expand that understanding and our practices so that we can learn when and how to employ CE and pan-enteric CE to better monitor and guide therapy. It will take further studies to determine the best uses for CE and how to select the appropriate candidates, especially with ongoing concern about capsule ingestion vs. placement, the potential for capsule retention (particularly in known Crohn's disease), still elusive optimal methods for bowel cleansing, and the most meaningful scoring for research and clinical use.