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Conventional imaging using CT and bone scan has insufficient sensitivity when staging men with high-risk localised prostate cancer. We aimed to investigate whether novel imaging using prostate-specific membrane antigen (PSMA) PET-CT might improve accuracy and affect management. In this multicentre, two-arm, randomised study, we recruited men with biopsy-proven prostate cancer and high-risk features at ten hospitals in Australia. Patients were randomly assigned to conventional imaging with CT and bone scanning or gallium-68 PSMA-11 PET-CT. First-line imaging was done within 21 days following randomisation. Patients crossed over unless three or more distant metastases were identified. The primary outcome was accuracy of first-line imaging for identifying either pelvic nodal or distant-metastatic disease defined by the receiver-operating curve using a predefined reference-standard including histopathology, imaging, and biochemistry at 6-month follow-up. This trial is registered with the Australian New Zealand Clinical Trials Registry, ANZCTR12617000005358. From March 22, 2017 to Nov 02, 2018, 339 men were assessed for eligibility and 302 men were randomly assigned. 152 (50%) men were randomly assigned to conventional imaging and 150 (50%) to PSMA PET-CT. Of 295 (98%) men with follow-up, 87 (30%) had pelvic nodal or distant metastatic disease. PSMA PET-CT had a 27% (95% CI 23–31) greater accuracy than that of conventional imaging (92% [88–95] vs 65% [60–69]; p<0·0001). We found a lower sensitivity (38% [24–52] vs 85% [74–96]) and specificity (91% [85–97] vs 98% [95–100]) for conventional imaging compared with PSMA PET-CT. Subgroup analyses also showed the superiority of PSMA PET-CT (area under the curve of the receiver operating characteristic curve 91% vs 59% [32% absolute difference; 28–35] for patients with pelvic nodal metastases, and 95% vs 74% [22% absolute difference; 18–26] for patients with distant metastases). First-line conventional imaging conferred management change less frequently (23 [15%] men [10–22] vs 41 [28%] men [21–36]; p=0·008) and had more equivocal findings (23% [17–31] vs 7% [4–13]) than PSMA PET-CT did. Radiation exposure was 10·9 mSv (95% CI 9·8–12·0) higher for conventional imaging than for PSMA PET-CT (19·2 mSv vs 8·4 mSv; p<0·001). We found high reporter agreement for PSMA PET-CT (κ=0·87 for nodal and κ=0·88 for distant metastases). In patients who underwent second-line image, management change occurred in seven (5%) of 136 patients following conventional imaging, and in 39 (27%) of 146 following PSMA PET-CT. PSMA PET-CT is a suitable replacement for conventional imaging, providing superior accuracy, to the combined findings of CT and bone scanning. Movember and Prostate Cancer Foundation of Australia. [Display omitted]

Objectives To investigate the contribution of whole-body post-mortem computed tomography (PMCT) in sudden unexpected death in infants and children. Methods Forty-seven cases of sudden unexpected death in children investigated with radiographic skeletal survey, whole-body PMCT and autopsy were enrolled. For imaging interpretation, non-specific post-mortem modifications and abnormal findings related to the presumed cause of death were considered separately. All findings were correlated with autopsy findings. Results There were 31 boys and 16 girls. Of these, 44 children (93.6 %) were younger than 2 years. The cause of death was found at autopsy in 18 cases (38.3 %), with 4 confirmed as child abuse, 12 as infectious diseases, 1 as metabolic disease and 1 as bowel volvulus. PMCT results were in accordance with autopsy in all but three of these 18 cases. Death remains unexplained in 29 cases (61.7 %) and was correlated with no abnormal findings on PMCT in 27 cases. Major discrepancies between PMCT and autopsy findings concerned pulmonary analysis. Conclusions Whole-body PMCT may detect relevant findings that can help to explain sudden unexpected death and is essential for detecting non-accidental injuries. We found broad concordance between autopsy and PMCT, except in a few cases of pneumonia. It is a non-invasive technique acceptable to relatives. Key Points • Whole-body post-mortem computed tomography (PMCT) is an effective non-invasive method. • Whole-body PMCT is essential for detecting child abuse in unexpected death. • There is concordance on cause of death between PMCT and autopsy. • Whole-body PMCT could improve autopsy through dissection and sampling guidance. • PMCT shows findings that may be relevant when parents reject autopsy.

Objectives To evaluate whole-body MRI (WB-MRI) parameters significantly associated with treatment response in multiple myeloma (MM). Methods Twenty-one MM patients underwent WB-MRI at diagnosis and after two cycles of chemotherapy. Scans acquired at 3.0 T included T2, diffusion-weighted-imaging (DWI) and mDixon pre- and post-contrast. Twenty focal lesions (FLs) matched on DWI and post-contrast mDixon were selected for each time point. Estimated tumour volume (eTV), apparent diffusion coefficient (ADC), enhancement ratio (ER) and signal fat fraction (sFF) were derived. Clinical treatment response to chemotherapy was assessed using conventional criteria. Significance of temporal parameter change was assessed by the paired t test and receiver operating characteristics/area under the curve (AUC) analysis was performed. Parameter repeatability was assessed by interclass correlation (ICC) and Bland–Altman analysis of 10 healthy volunteers scanned at two time points. Results Fifteen of 21 patients responded to treatment. Of 254 FLs analysed, sFF ( p  < 0.0001) and ADC ( p  = 0.001) significantly increased in responders but not non-responders. eTV significantly decreased in 19/21 cases. Focal lesion sFF was the best discriminator of treatment response (AUC 1.0). Bone sFF repeatability was excellent (ICC 0.98) and better than bone ADC (ICC 0.47). Conclusion WB-MRI derived focal lesion sFF shows promise as an imaging biomarker of treatment response in newly diagnosed MM. Key Points • Bone signal fat fraction using mDixon is a robust quantifiable parameter • Fat fraction and ADC significantly increase in myeloma lesions responding to treatment • Bone lesion fat fraction is the best discriminator of myeloma treatment response

In several countries, whole-body imaging has been introduced in the routine follow-up of individuals with high-risk cutaneous malignant melanoma after surgery. However, there is scarce evidence that earlier detection of recurrent disease by regular scanning improves survival. In this interim analysis, we investigated whether imaging in the follow-up programme for high-risk cutaneous malignant melanoma improves survival and assessed whether the study should continue to include participants. TRIM is a multicentre, randomised, phase 3 trial in Sweden. Eligible participants are aged 18 years and older with sufficient renal function for intravenously contrast-enhanced CT and are expected to be fit for treatment in case of recurrence. After radical surgery of stage IIB–C and III cutaneous malignant melanoma, participants were randomly assigned (1:1, stratified by tumour stage and method of radiological assessment) to 3 years of follow-up by physical examinations alone (standard group) or to physical examinations plus whole-body imaging with CT or [18F]fluorodeoxyglucose-PET-CT at baseline, 6, 12, 24, and 36 months (experimental group). The goal is to include 1300 participants. The primary endpoint is overall survival at 5 years and will be reported in the final analysis when data are mature. In this interim report, no endpoints were predefined; we present overall survival, relapse-free survival, locoregional relapse-free survival, and distant metastasis-free survival, analysed by intention to intervene. This study is registered with ClinicalTrials.gov, NCT03116412, and recruitment is ongoing. Between June 8, 2017, and July 28, 2023, 983 participants were randomly allocated to the standard (n=498; 296 [59%] male, 202 [41%] female) or experimental (n=485; 309 [64%] male, 176 [36%] female) group. There were no statistically significant differences in overall survival (not reached [NR; 95% CI NR–NR] vs NR [NR–NR]; hazard ratio [HR] 1·04 [95% CI 0·71–1·51], p=0·85) or distant metastasis-free survival (NR [NR–NR] vs NR [NR–NR]; HR 1·20 [0·89–1·64], p=0·24) between the groups at a median follow-up time of 33·6 months (IQR 16·3–49·8). 3-year overall survival rates were 88·2% (95% CI 85·0–91·6) in the standard group versus 87·7% (84·3–91·3) in the experimental group and distant metastasis-free survival was 81·6% (77·9–85·6) in the standard group versus 79·3% (75·3–83·5) in the control group. This interim analysis indicated that there is no benefit from imaging in the follow-up programme for individuals with high-risk cutaneous malignant melanoma. However, only a few participants have completed the follow-up time of 5 years, and the numerical difference between the study groups in distant metastasis-free survival motivates us to continue the study according to protocol. Stiftelsen Onkologiska Klinikens i Uppsala Forskningsfond and Uppsala University Hospital.

Total-body CT scans are useful in saving trauma patients; however, interpreting numerous images with varied window settings slows injury detection. We developed an algorithm for “unified total-body CT image with multiple organ-specific windowings (Uni-CT)”, and assessing its impact on physician accuracy and speed in trauma CT interpretation. From November 7, 2008, to June 19, 2020, 40 cases of total-body CT images for blunt trauma with multiple injuries, were collected from the emergency department of Osaka General Medical Center and randomly divided into two groups. In half of the cases, the Uni-CT algorithm using semantic segmentation assigned visibility-friendly window settings to each organ. Four physicians with varying levels of experience interpreted 20 cases using the algorithm and 20 cases in conventional settings. The performance was analyzed based on the accuracy, sensitivity, specificity of the target findings, and diagnosis speed. In the proposal and conventional groups, patients had an average of 2.6 and 2.5 targeting findings, mean ages of 51.8 and 57.7 years, and male proportions of 60% and 45%, respectively. The agreement rate for physicians’ diagnoses was κ = 0.70. Average accuracy, sensitivity, and specificity of target findings were 84.8%, 74.3%, 96.9% and 85.5%, 81.2%, 91.5%, respectively, with no significant differences. Diagnostic speed per case averaged 71.9 and 110.4 s in each group ( p  < 0.05). The Uni-CT algorithm improved the diagnostic speed of total-body CT for trauma, maintaining accuracy comparable to that of conventional methods.

Purpose Concerns of imaging-related radiation exposure in young patients with high survival rates have increased the use of magnetic resonance imaging (MRI) in testicular cancer (TC) stage I. However, computed tomography (CT) is still preferred for metastatic TC. The purpose of this study was to compare whole-body MRI incl. diffusion-weighted whole-body imaging with background body signal suppression (DWIBS) with contrast-enhanced, thoracoabdominal CT in metastatic TC. Methods A prospective, non-inferiority study of 84 consecutive patients (median age 33 years) with newly diagnosed metastatic TC (February 2018–January 2021). Patients had both MRI and CT before and after treatment. Anonymised images were reviewed by experienced radiologists. Lesion malignancy was evaluated on a Likert scale (1 benign–4 malignant). Sensitivity, specificity, positive predictive value, negative predictive value and accuracy were calculated on patient and lesion level. The primary outcome was demonstrating non-inferiority regarding sensitivity of MRI compared to CT. The non-inferiority margin was set at 5%. ROC curves and interobserver agreement were calculated. Results On patient level, MRI had 98% sensitivity and 75% specificity compared to CT. On lesion level within each modality, MRI had 99% sensitivity and 78% specificity, whereas CT had 98% sensitivity and 88% specificity. MRI sensitivity was non-inferior to CT (difference 0.57% (95% CI − 1.4–2.5%)). The interobserver agreement was substantial between CT and MRI. Conclusion MRI with DWIBS was non-inferior to contrast-enhanced CT in detecting metastatic TC disease. Trial registration www.clinicaltrials.gov NCT03436901, finished July 1st 2021.

Objectives To determine whether there is a difference in frequency and clinical relevance of incidental findings detected by total-body computed tomography scanning (TBCT) compared to those by the standard work-up (STWU) with selective computed tomography (CT) scanning. Methods Trauma patients from five trauma centres were randomized between April 2011 and January 2014 to TBCT imaging or STWU consisting of conventional imaging with selective CT scanning. Incidental findings were divided into three categories: 1) major finding, may cause mortality; 2) moderate finding, may cause morbidity; and 3) minor finding, hardly relevant. Generalized estimating equations were applied to assess differences in incidental findings. Results In total, 1083 patients were enrolled, of which 541 patients (49.9 %) were randomized for TBCT and 542 patients (50.1 %) for STWU. Major findings were detected in 23 patients (4.3 %) in the TBCT group compared to 9 patients (1.7 %) in the STWU group (adjusted rate ratio 2.851; 95%CI 1.337–6.077; p  < 0.007). Findings of moderate relevance were detected in 120 patients (22.2 %) in the TBCT group compared to 86 patients (15.9 %) in the STWU group (adjusted rate ratio 1.421; 95%CI 1.088–1.854; p  < 0.010). Conclusions Compared to selective CT scanning, more patients with clinically relevant incidental findings can be expected by TBCT scanning. Key points • Total - body CT scanning in trauma results in 1.5 times more incidental findings . • Evaluation by TBCT in trauma results in more patients with incidental findings . • In every category of clinical relevance , TBCT detects more incidental findings .

ObjectivesInitial trauma care could potentially be improved when conventional imaging and selective CT scanning is omitted and replaced by immediate total-body CT (iTBCT) scanning. Because of the potentially increased radiation exposure by this diagnostic approach, proper selection of the severely injured patients is mandatory.MethodsIn the REACT-2 trial, severe trauma patients were randomized to iTBCT or conventional imaging and selective CT based on predefined criteria regarding compromised vital parameters, clinical suspicion of severe injuries, or high-risk trauma mechanisms in five trauma centers. By logistic regression analysis with backward selection on the 15 study inclusion criteria, a revised set of criteria was derived and subsequently tested for prediction of severe injury and shifts in radiation exposure.ResultsIn total, 1083 patients were enrolled with median ISS of 20 (IQR 9–29) and median GCS of 13 (IQR 3–15). Backward logistic regression resulted in a revised set consisting of nine original and one adjusted criteria. Positive predictive value improved from 76% (95% CI 74–79%) to 82% (95% CI 80–85%). Sensitivity decreased by 9% (95% CI 7–11%). The area under the receiver operating characteristics curve remained equal and was 0.80 (95% CI 0.77–0.83), original set 0.80 (95% CI 0.77–0.83). The revised set retains 8.78 mSv (95% CI 6.01–11.56) for 36% of the non-severely injured patients.ConclusionsSelection criteria for iTBCT can be reduced from 15 to 10 clinically criteria. This improves the positive predictive value for severe injury and reduces radiation exposure for less severely injured patients.Key Points• Selection criteria for iTBCT can be reduced to 10 clinically useful criteria.• This reduces radiation exposure in 36% of less severely injured patients.• Overall discriminative capacity for selection of severely injured patients remained equal.

To identify the whole-body MRI (WB-MRI) image type(s) with the highest value for assessment of multiple myeloma, in order to optimise acquisition protocols and read times. Thirty patients with clinically-suspected MM underwent WB-MRI at 3 Tesla. Unenhanced Dixon images [fat-only (FO) and water-only (WO)], post contrast Dixon [fat-only plus contrast (FOC) and water-only plus contrast (WOC)] and diffusion weighted images (DWI) of the pelvis from all 30 patients were randomised and read by three experienced readers. For each image type, each reader identified and labelled all visible myeloma lesions. Each identified lesion was compared with a composite reference standard achieved by review of a complete imaging dataset by a further experienced consultant radiologist to determine truly positive lesions. Lesion count, true positives, sensitivity, and positive predictive value were determined. Time to read each scan set was recorded. Confidence for a diagnosis of myeloma was scored using a Likert scale. Conspicuity of focal lesions was assessed in terms of percent contrast and contrast to noise ratio (CNR). Lesion count, true positives, sensitivity and confidence scores were significantly higher when compared to other image types for DWI (P<0.0001 to 0.003), followed by WOC (significant for sensitivity (P<0.0001 to 0.004), true positives (P = 0.003 to 0.049) and positive predictive value (P< 0.0001 to 0.006)). There was no statistically significant difference in these metrics between FO and FOC. Percent contrast was highest for WOC (P = 0.001 to 0.005) and contrast to noise ratio (CNR) was highest for DWI (P = 0.03 to 0.05). Reading times were fastest for DWI across all observers (P< 0.0001 to 0.014). Observers detected more myeloma lesions on DWI images and WOC images when compared to other image types. We suggest that these image types should be read preferentially by radiologists to improve diagnostic accuracy and reporting efficiency.

Background 18-Fluoro-deoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) is a valuable imaging tool widely used in the management of cancer patients. Deep learning models excel at segmenting highly metabolic tumors but face challenges in regions with complex anatomy and normal cell uptake, such as the gastro-intestinal tract. Despite these challenges, it remains important to achieve accurate segmentation of gastro-intestinal tumors. Methods Here, we present an international multicenter comparative study between a novel organ-focused approach and a whole-body training method to evaluate the effectiveness of training data homogeneity in accurately identifying gastro-intestinal tumors. In the organ-focused method, the training data is limited to cases with intestinal tumors which makes the network trained with more homogeneous data and with stronger presence of intestinal tumor signals. The whole body approach extracts the intestinal tumors from the results of a model trained on the whole-body scans. Both approaches were trained using diffuse large B cell (DLBCL) patients from a large multi-center clinical trial (NCT01287741). Results We report an improved mean(±std) Dice score of 0.78(±0.21) for the organ-based approach on the hold-out set, compared to 0.63(±0.30) for the whole-body approach, with the p -value of less than 0.0001. At the lesion level, the proposed organ-based approach also shows increased precision, recall, and F1-score. An independent trial was used to evaluate the generalizability of the proposed method to non-Hodgkin’s lymphoma (NHL) patients with follicular lymphoma (FL). Conclusion Given the variability in structure and metabolism across tissues in the body, our quantitative findings suggest organ-focused training enhances intestinal tumor segmentation by leveraging tissue homogeneity in the training data, contrasting with the whole-body training approach, which, by its very nature, is a more heterogeneous data set.