Early diagnosis of impending rupture uterus during U/S: A case report.

INTRODUCTION AND IMPORTANCE: Uterine rupture is a rare condition that typically occurs in a scarred uterus and can happen during late pregnancy, labor, or the early postpartum period. Since most cases are seen in patients with a history of cesarean surgery, the anterior lower uterine segment is the most affected area. Most patients present with acute symptoms that compromise the fetus and the mother in a life-threatening manner. CASE PRESENTATION: We present a case of uterine rupture with subacute symptoms occurring in the second trimester, which is extremely rare. The patient was a stable second-trimester multiparous woman with chronic abdominal pain, but without any signs of peritoneal bleeding or instability. No history of previous cesarean section was present, and she had recently undergone a non-complicated hysteroscopic polypectomy. Transabdominal and transvaginal ultrasounds were performed, revealing a significant full-thickness myometrial defect in the posterior uterine lower segment. This defect allowed the amniotic sac to protrude into the posterior cul-de-sac. No abdominopelvic hematoma was detected. These findings were confirmed in an urgent MRI, and the patient underwent a laparotomy during which a significant full-thickness defect was discovered at the posterior of the uterus. As it was impossible to continue the pregnancy, the fetus was surgically removed and then prepared using multiple layers. CLINICAL DISCUSSION: The difference between our case and the previously reported one is in the aspect of gradual stable presentation and lacks of vaginal bleeding. CONCLUSION: Previous hysteroscopy carries a risk for future pregnancy complications, such as uterine rupture.

Hypofractionated versus standard chemoradiotherapy in the definitive treatment of uterine cervix cancer: interim results of a randomized controlled clinical trial.

PURPOSE: Concurrent chemoradiation has been the mainstay of treatment for cervix cancer. We aimed to evaluate the non-inferiority of hypofractionated chemoradiation. METHODS: This study was designed as a phase 2, 1:1 randomized, investigator-blinded, controlled, non-inferiority trial and we report the interim results after 50% accrual. Cervical cancer patients with FIGO stages IIA-IIIC were recruited from April 2021 to September 2022. The intervention consisted of 40 Gy of 3D-conformal radiation therapy (RT) in 15 fractions over 3 weeks. In the control group, patients received standard chemoradiation of 45 Gy in 25 fractions over 5 weeks. Both groups received concurrent weekly cisplatin (40 mg/m2). Intravaginal brachytherapy of 28 Gy in 4 weekly fractions was delivered starting 1 week after the end of chemoradiation. The primary outcome was complete clinical response(CCR) at 3 months. Secondary outcomes included acute gastrointestinal (GI), genitourinary(GU), skin, and hematologic toxicities. A p value less than 0.05 was considered significant for analyses. RESULTS: 59 patients were randomized; 30 in the control group and 29 in the intervention group. 20/30 (66.7%) of the patients in the control group and 19/29 (65.5%) in the intervention group achieved a CCR (absolute difference of 0.011, 95% CI - 0.23 to 0.25, p value: 0.13). There was a significantly higher rate of acute grade ≥ 3 GI toxicity in the intervention group (27.6%) compared with the control group (6.7%) (p value 0.032). CONCLUSIONS: Despite an absolute difference of 1.1% in the 3-month CCR, our interim analysis failed to show the non-inferiority of the hypofractionated chemoradiation. Due to the higher GI toxicities, we will continue this trial using intensity-modulated radiation therapy. REGISTRATION NUMBER AND DATE: ClinicalTrials.gov: NCT04831437, 2021.4.1.

Modified MR scoring system for assessment of sonographically indeterminate ovarian and adnexal masses in the absence of dynamic contrast-enhanced.

OBJECTIVES: Dynamic contrast-enhanced (DCE) MRI is not available in all imaging centres to investigate adnexal masses. We proposed modified magnetic resonance (MR) scoring system based on an assessment of the enhancement of the solid tissue on early phase postcontrast series and diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) map and investigated the validity of this protocols in the current study. MATERIALS AND METHODS: In this cross-sectional retrospective study, pelvic MRI of a total of 245 patients with 340 adnexal masses were studied based on the proposed modified scoring system and ADNEX MR scoring system. RESULTS: Modified scoring system with the sensitivity of 87.3% and specificity of 94.6% has an accuracy of 92.1%. Sensitivity, specificity, and accuracy of ADNEX MR scoring system is 96.6%, 91%, and 92.9%, respectively. The area under the receiver operating characteristic curve for the modified scoring system and ADNEX MR scoring system is 0.909 (with 0.870-0.938 95% confidence interval [CI]) and 0.938 (with 0.907-0.961 95% CI), respectively. Pairwise comparison of these area under the curves showed no significant difference (P = .053). CONCLUSIONS: Modified scoring system is less sensitive than the ADNEX MR scoring system and more specific but the accuracy is not significantly different. ADVANCES IN KNOWLEDGE: According to our study, MR scoring system based on subjective assessment of the enhancement of the solid tissue on early phase postcontrast series and DWI with ADC map could be applicable in imaging centres that DCE is not available.

Urease-Powered Black TiO2 Micromotors for Photothermal Therapy of Bladder Cancer.

Urease-powered nano/micromotors can move at physiological urea concentrations, making them useful for biomedical applications, such as treating bladder cancer. However, their movement in biological environments is still challenging. Herein, Janus micromotors based on black TiO2 with urease asymmetric catalytic coating were designed to take benefit of the optical properties of black TiO2 under near-infrared light and the movement capability in simulated bladder environments (urea). The black TiO2 microspheres were half-coated with a thin layer of Au, and l-Cysteine was utilized to attach the urease enzyme to the Au surface using its thiol group. Biocatalytic hydrolysis of urea through urease at biologically relevant concentrations provided the driving force for micromotors. A variety of parameters, such as urea fuel concentration, viscosity, and ionic character of the environment, were used to investigate how micromotors moved in different concentrations of urea in water, PBS, NaCl, and urine. The results indicate that micromotors are propelled through ionic self-diffusiophoresis caused by urea enzymatic catalysis. Due to their low toxicity and in vitro anticancer effect, micromotors are effective agents for photothermal therapy, which can help kill bladder cancer cells. These promising results suggest that biocompatible micromotors hold great potential for improving cancer treatment and facilitating diagnosis.

Early versus late physiotherapy following arthroscopic repair of small and medium size rotator cuff tear: a randomized clinical trial.

PURPOSE: We compared early and late physiotherapy for patients with small and medium size rotator cuff tears following arthroscopic repair. METHODS: A single-centre, single-blinded, prospective parallel RCT was performed with two arms: early physiotherapy (start within the first week) versus late physiotherapy (start 4 weeks after surgery). Patients with small- to medium-sized isolated full-thickness superior rotator cuff tears were included and followed for 12 months. The primary outcome measures were shoulder function and range of motion (ROM) measured by the Constant-Murley score (CMS) at three months, six months, and 12 months. The other outcomes were the visual analog scale (VAS) pain and the rotator cuff ultrasound (US) evaluation by the Sugaya classification. RESULTS: In three and six month follow-ups, CMS was significantly superior in the intervention group compared to controls (P < 0.05). However, only at the three month follow-up between-group difference met the minimal clinically important difference (MCID) (MCID = 10.4) (59.8 vs. 48.9). The intervention group experienced less pain than controls in the first six months (P < 0.001), and only the three month follow-up was clinically meaningful based on MCID (MCID = 1.4). Moreover, in the first six months, the shoulder ROM favoured the intervention group (P < 0.05). US grading of the supraspinatus and infraspinatus was similar between groups (P = 0.07). One retear occurred in the intervention group and another in the controls, detected by examination and US evaluation. CONCLUSION: Following the arthroscopic repair of a small- to medium-sized rotator cuff tear, early physiotherapy showed promising results for pain, function, and range of motion. LEVEL OF EVIDENCE: Level I therapeutic.

Intra-Articular Ganglion Cysts of the Knee.

➢: Magnetic resonance imaging (MRI) without contrast is sufficient to diagnose an intra-articular ganglion cyst of the knee. MRI with intravenous contrast may be considered for cysts in the infrapatellar fat pad, which are not a typical presentation. ➢: The current literature supports treating symptomatic cases or those discovered accidently during knee arthroscopy with arthroscopic excision. ➢: Although aspiration of these cysts results in a higher recurrence rate than excision, it is associated with quicker recovery. Thus, aspiration might be chosen as an initial treatment for anyone who would like to avoid surgery or requires a rapid recovery, including professional athletes. ➢: Open excision may be considered for infrapatellar fat pad cysts that are >4.5 cm in size.

Clinical and laboratory findings following transplantation of allogeneic adipose-derived mesenchymal stromal cells in knee osteoarthritis, a brief report.

BACKGROUND: Mesenchymal stromal cells (MSCs) injection has been proposed as an innovative treatment for knee osteoarthritis (KOA). Since, allogeneic MSCs can be available as off-the-shelf products, they are preferable in regenerative medicine. Among different sources for MSCs, adipose-derived MSCs (AD-MSCs) appear to be more available. METHODS: Three patients with KOA were enrolled in this study. A total number of 100 × 106 AD-MSCs was injected intra-articularly, per affected knee. They were followed up for 6 months by the assessment of clinical outcomes, magnetic resonance imaging (MRI), and serum inflammatory biomarkers. RESULTS: The primary outcome of this study was safety and feasibility of allogeneic AD-MSCs injection during the 6 months follow-up. Fortunately, no serious adverse events (SAEs) were reported. Assessment of secondary outcomes of visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and knee osteoarthritis outcome score (KOOS) indicated improvement in all patients. Comparison between baseline and endpoint findings of MRI demonstrated a slight improvement in two patients. In addition, decrease in serum cartilage oligomeric matrix protein (COMP) and hyaluronic acid (HA) indicated the possibility of reduced cartilage degeneration. Moreover, quantification of serum interleukin-10 (IL-10) and interleukin-6 (IL-6) levels indicated that the host immune system immunomodulated after infusion of AD-MSCs. CONCLUSION: Intra-articular injection of AD-MSCs is safe and could be effective in cartilage regeneration in KOA. Preliminary assessment after six-month follow-up suggests the potential efficacy of this intervention which would need to be confirmed in randomized controlled trials on a larger population. TRIAL REGISTRATION: This study was registered in the Iranian registry of clinical trials (https://en.irct.ir/trial/46) in 24 April 2018 with identifier IRCT20080728001031N23.

A patient with scleroderma associated with severe acro-osteolysis: A case report.

Systemic sclerosis is an autoimmune chronic sclerotic disease that can damage organs and cause serious complications for the patient such as musculoskeletal manifestations, Gastrointestinal involvement, pulmonary involvement, and renal disease. Acro-osteolysis is one of the musculoskeletal manifestations that causes corrosion of the bones in the fingertips of the hand and feet. In this paper, we have reported the rarely current evidence of severe Acro-osteolysis of the distal phalanges of the hands by radiological x-ray.

Prediction of lymphovascular space invasion in cervical carcinoma using diffusion kurtosis imaging.

BACKGROUND: This study aimed to investigate the potential relationship between diffusion kurtosis imaging (DKI)- derived parameters and lymphovascular space invasion (LVSI) in patients with cervical carcinoma. PATIENTS AND METHODS: This prospective study included 30 patients with cervical carcinoma. The patients underwent MRI, diffusion-weighted imaging (DWI), and DKI prior to surgery. The surgical pathology results were accepted as the reference standard for determining the LVSI status. The DKI-derived parameters, including mean diffusivity (MD) and mean kurtosis (MK), were measured. The apparent diffusion coefficient (ADC) value was also assessed. RESULTS: The MD value of LVSI positive cervical carcinomas was significantly lower than LVSI negative carcinomas (p-value = 0.01). MK value was significantly higher in LVSI positive tumors (p-value = 0.01). However, the ADC value did not show a significant difference between LVSI positive and LVSI negative tumors (p-value = 0.2). MD and MK parameters showed similar diagnostic accuracy in identifying the LVSI status, with the area under the curve of 0.77 and 0.78, respectively. CONCLUSION: In this study, DKI-derived parameters were associated with the LVSI status in cervical carcinomas. Further studies with larger sample size are required to confirm these results.

IUD perforation and embedment within omentum: A rare and perplexing incidence.

Intrauterine devices rarely fail, which results in pregnancy. Meanwhile, these devices can perforate uterine and migrate through abdomen. Our case experienced IUD failure and perforation simultaneously, and the device was embedded in omentum and shifted rapidly, which made it hard to localize and could only be removed using ultrasonography guidance.

Duodenal Obstruction during Pregnancy.

Intractable vomiting and elevated liver enzymes during pregnancy seem to be associated to the obstetric etiologies; however, other causes such as acute surgical emergencies should be considered. The patient was a 26-year-old woman at 18 weeks of gestation with intractable vomiting, intolerability of oral intake, weight loss, and absence of abdominal pain. Her physical examinations and laboratory tests had no remarkable findings except elevated liver function test (LFT) and hypokalemia. Considering the lab data and normal abdominopelvic ultrasound, magnetic resonance imaging was performed which revealed dilation of the D1-3 and collapse the D4 sections of duodenum. She underwent exploratory laparotomy which confirmed duodenal obstruction caused by Ladd's band. After the Ladd's operation, the patient started oral intake of nutritious, and her LFT decreased to normal ranges. After the last follow-up, she has had gained 18 kg and gave birth at 36 weeks of gestation due to the premature rapture of membranes and delivered a 2 kg small for gestational age otherwise healthy infant. The experience gained from this case was to consider all possibilities (such as small bowel obstruction) and evaluate them in a pregnant patient to consider other causes of nausea, vomiting, and abnormal LFTs in a pregnant patient.

Aggressive angiomyxoma of the pelvis surgical management in a case with delayed diagnosis.

INTRODUCTION AND IMPORTANCE: Aggressive angiomyxoma is characterized as a non-capsulated soft mass with the ability to progress to surrounding tissues but without metastasis to distant tissues. Slowing tumor extension leading delayed tumor diagnosis, expression of different types of hormonal receptors, therapeutic ineffectiveness of noninvasive treatment approaches and misdiagnosis have remained as the major challenges for managing this tumor. CASE PRESENTATION: Herein, we described a case of aggressive angiomyxoma located in the posterior of the uterus and vagina that as successfully managed surgically to remove tumor mass followed by gonadotropin-releasing hormone (GnRH) agonist to prevent tumor recurrence. CLINICAL DISCUSSION: Surgical resection is the treatment of choice in aggressive angiomyxoma with complete success rate, however despite such successfulness, about two-thirds of patients experienced postoperative recurrence rate that could be prevented by hormone-based therapy especially GnRH agonist. CONCLUSION: Aggressive angiomyxoma is a rare tumor with locally invasive behavior. As misdiagnosis is common imaging like MRI with DWI should be considered. The best treatment is surgical resection by experienced surgeons in tertiary referral hospitals. Even with complete resection, the recurrence rate is high. So adjuvant medical treatment seems to be necessary.

A Diagnostic Algorithm using Multi-parametric MRI to Differentiate Benign from Malignant Myometrial Tumors: Machine-Learning Method.

This study aimed to develop a diagnostic algorithm for preoperative differentiating uterine sarcoma from leiomyoma through a supervised machine-learning method using multi-parametric MRI. A total of 65 participants with 105 myometrial tumors were included: 84 benign and 21 malignant lesions (belonged to 51 and 14 patients, respectively; based on their postoperative tissue diagnosis). Multi-parametric MRI including T1-, T2-, and diffusion-weighted (DW) sequences with ADC-map, contrast-enhanced images, as well as MR spectroscopy (MRS), was performed for each lesion. Thirteen singular MRI features were extracted from the mentioned sequences. Various combination sets of selective features were fed into a machine classifier (coarse decision-tree) to predict malignant or benign tumors. The accuracy metrics of either singular or combinational models were assessed. Eventually, two diagnostic algorithms, a simple decision-tree and a complex one were proposed using the most accurate models. Our final simple decision-tree obtained accuracy = 96.2%, sensitivity = 100% and specificity = 95%; while the complex tree yielded accuracy, sensitivity and specificity of 100%. To summarise, the complex diagnostic algorithm, compared to the simple one, can differentiate tumors with equal sensitivity, but a higher specificity and accuracy. However, it needs some further time-consuming modalities and difficult imaging calculations. Trading-off costs and benefits in appropriate situations must be determinative.

Investigating the diagnostic value of quantitative parameters based on T2-weighted and contrast-enhanced MRI with psoas muscle and outer myometrium as internal references for differentiating uterine sarcomas from leiomyomas at 3T MRI.

BACKGROUND: Post-hysterectomy histopathological examination is currently the main diagnostic tool for differentiating uterine sarcomas from leiomyomas. This study aimed to investigate the diagnostic accuracy of preoperative quantitative metrics based on T2-weighted sequences and contrast-enhanced MRI (CE-MRI) for distinguishing uterine sarcomas from leiomyomas. MATERIALS AND METHODS: The institutional review board approved the study. Sixty-five women confirmed to have a total of 105 lesions participated. Routine pelvic MRI sequences, T2 map and CE-MRI images were performed preoperatively using a 3 T MR scanner. Six quantitative metrics-T2 mapping parameter, T2 scaled ratio, tumor myometrium contrast ratio on T2, tumor psoas contrast ratio on T2, tumor myometrium contrast-enhanced ratio, and tumor psoas contrast-enhanced ratio-were extracted from the acquired image sets. Chi-square test was used to compare the percentage of malignant lesions with the central necrosis to the corresponding percentage for the benign masses. Using the area under receiver operating characteristic (AUC) curve, the performance of different metrics for distinguishing uterine sarcomas from leiomyomas was measured. Moreover, for each metric, we extracted the optimal cut-off value. The values of sensitivity, specificity, negative predictive value, and positive predictive value were calculted for the classifiers based on different metrics. RESULTS: The average age, average lesion size, and proportion of premenopausal women in benign and malignant groups were comparable in our dataset. The signal intensity of uterine sarcomas at T2-weighted sequences was significantly higher than that of leiomyomas (p < 0.001), while intensity at T1-weighted sequences exhibited no significant difference between the two masses (p = 0.201). Our data also suggested that a central necrosis was ten times more common among malignant lesions compared to benign ones (p < 0.001). Among different metrics, T2 mapping parameter achieved the highest AUC value and accuracy in differentiating two groups. Three measures-T2 scaled ratio, tumor myometrium contrast ratio on T2, and tumor myometrium contrast-enhanced ratio-achieved a sensitivity of 100%, therefore none of the malignant lesions would have been missed if these metrics had been adopted in patient management. CONCLUSIONS: The findings suggested that the evaluated metrics could be useful in the preoperative assessment of myometrial masses to differentiate uterine sarcomas from leiomyomas. The proposed framework has major implications for improving current practice in the management of myometrial masses.

A machine learning approach for distinguishing uterine sarcoma from leiomyomas based on perfusion weighted MRI parameters.

PURPOSE: To propose a computer-assisted method for distinguishing uterine sarcoma from leiomyomas based on perfusion weighted magnetic resonance imaging (PWI). MATERIALS AND METHODS: Forty-two women confirmed to have a total of 60 masses (10 uterine sarcomas and 50 benign leiomyomas) were included. The reference diagnosis was based on postoperative histopathological examination. All women underwent the standard MRI protocol with 3-Tesla MR imager (Magnetom Trio, Siemens, Erlangen, Germany) for assessment of myometrial masses, followed by PWI. For each mass, two regions of interest (ROI) were outlined manually by an experienced radiologist; one (ROIL) represented the entire tumor while the other (ROIs) was placed on the area of the lesion with the most marked contrast enhancement. Two additional ROIs with diameters similar to ROIs (3.0 to 3.1 mm) were placed on psoas muscle (ROIP) and myometrium (ROIM) in order to provide baselines for comparisons. The obtained ROIs of PWI images were then analyzed using the DCE Tool plug-in (version 2.0SP1) within ClearCanvas (Toronto, Ontario, Canada) framework. The DCE Tool provides seven parameters (Ktrans, kep, Vb, IAUC, initial slope, peak, the mean squared error) for modelling contrast uptake within an ROI using the modified Tofts model. Parameters extracted from the ROIs were fed into a decision tree ensemble, which classified the corresponding lesions either as malignant or benign. The leave-one-out cross validation (LOOCV) was utilized to evaluate the performance of the classifier. RESULTS: None of the parameters extracted from ROIL or ROIs differed significantly between uterine sarcoma and benign leiomyomas (all p > 0.05). The overall accuracy of 66.7% was obtained by feeding seven parameters extracted from ROIL to the classifier. When 21 features extracted from ROIL, ROIM, and ROIP were fed into the classifier an accuracy of 91.7%, sensitivity of 100%, and specificity of 90% were achieved in the optimal operating point of classifier. CONCLUSION: Although none of the PWI parameters differed significantly between benign and malignant lesions, when the information provided by the extracted features was aggregated using a machine learning method, a promising discriminative power was obtained. This suggests that the proposed model for combining the PWI parameters is potentially useful for differentiating uterine sarcoma from leiomyomas.

ADC-derived spatial features can accurately classify adnexal lesions.

BACKGROUND: The role of quantitative apparent diffusion coefficient (ADC) maps in differentiating adnexal masses is unresolved. PURPOSE/HYPOTHESIS: To propose an objective diagnostic method devised based on spatial features for predicting benignity/malignancy of adnexal masses in ADC maps. STUDY TYPE: Prospective. POPULATION: In all, 70 women with sonographically indeterminate and histopathologically confirmed adnexal masses (38 benign, 3 borderline, and 29 malignant) were considered for this study. FIELD STRENGTH/SEQUENCE: Conventional and diffusion-weighted magnetic resonance (MR) images (b-values = 50, 400, 1000 s/mm2 ) were acquired on a 3T scanner. ASSESSMENT: For each patient, two radiologists in consensus manually delineated lesion borders in whole ADC map volumes, which were consequently analyzed using spatial models (first-order histogram [FOH], gray-level co-occurrence matrix [GLCM], run-length matrix [RLM], and Gabor filters). Two independent radiologists were asked to identify the attributed (benign/malignant) classes of adnexal masses based on morphological features on conventional MRI. STATISTICAL TESTS: Leave-one-out cross-validated feature selection followed by cross-validated classification were applied to the feature space to choose the spatial models that best discriminate benign from malignant adnexal lesions. Two schemes of feature selection/classification were evaluated: 1) including all benign and malignant masses, and 2) scheme 1 after excluding endometrioma, hemorrhagic cysts, and teratoma (14 benign, 29 malignant masses). The constructed feature subspaces for benign/malignant lesion differentiation were tested for classification of benign/borderline/malignant and also borderline/malignant adnexal lesions. RESULTS: The selected feature subspace consisting of RLM features differentiated benign from malignant adnexal masses with a classification accuracy of ∼92%. The same model discriminated benign, borderline, and malignant lesions with 87% and borderline from malignant with 100% accuracy. Qualitative assessment of the radiologists based on conventional MRI features reached an accuracy of 80%. DATA CONCLUSION: The spatial quantification methodology proposed in this study, which works based on cellular distributions within ADC maps of adnexal masses, may provide a helpful computer-aided strategy for objective characterization of adnexal masses. LEVEL OF EVIDENCE: 1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;47:1061-1071.

Peripheral T-Cell Lymphoma Presenting as a Primary Uterine Cervix Mass: A Report of a Rare Case.

Malignant lymphoma is a rare form of malignancy in the uterine cervix. Most of the previously reported cases were B-cell lymphomas. We present a case of primary peripheral T-cell lymphoma, not otherwise specified, in the uterine cervix in a 49-year-old woman with a history of severe vaginal bleeding. The patient was treated with a CHOP (cyclophosphamide, adriamycin, vincristine, and prednisolone) chemotherapy regimen and 28 cycles of radiotherapy. Three months later, she presented with generalized lymphadenopathy and sudden left-eye ptosis as a complication of CNS involvement and died after 20 months from the initial disease presentation.

Semiquantitative dynamic contrast-enhanced MRI for accurate classification of complex adnexal masses.

PURPOSE: To identify the best dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) descriptive parameters in predicting malignancy of complex ovarian masses, and develop an optimal decision tree for accurate classification of benign and malignant complex ovarian masses. MATERIALS AND METHODS: Preoperative DCE-MR images of 55 sonographically indeterminate ovarian masses (27 benign and 28 malignant) were analyzed prospectively. Four descriptive parameters of the dynamic curve, namely, time-to-peak (TTP), wash-in-rate (WIR), relative signal intensity (SIrel ), and the initial area under the curve (IAUC60 ) were calculated on the normalized curves of specified regions-of-interest (ROIs). A two-tailed Student's t-test and two automated classifiers, linear discriminant analysis (LDA) and support vector machines (SVMs), were used to compare the performance of the mentioned parameters individually and in combination with each other. RESULTS: TTP (P = 6.15E-8) and WIR (P = 5.65E-5) parameters induced the highest sensitivity (89% for LDA, and 97% for SVM) and specificity (93% for LDA, and 100% for SVM), respectively. Regarding the high sensitivity of TTP and high specificity of WIR and through their combination, an accurate and simple decision-tree classifier was designed using the line equation obtained by LDA classification model. The proposed classifier achieved an accuracy of 89% and area under the ROC curve of 93%. CONCLUSION: In this study an accurate decision-tree classifier based on a combination of TTP and WIR parameters was proposed, which provides a clinically flexible framework to aid radiologists/clinicians to reach a conclusive preoperative diagnosis and patient-specific therapy plan for distinguishing malignant from benign complex ovarian masses. LEVEL OF EVIDENCE: 2 J. Magn. Reson. Imaging 2017;45:418-427.

The effect of superparamagnetic iron oxide nanoparticles surface engineering on relaxivity of magnetoliposome.

The purpose of this work is evaluating the effect of ultra small superparamagnetic iron oxide nanoparticles (USPIONs) coatings on encapsulation efficiency in liposomes and cellular cytotoxicity assay. Moreover, we assessed the effects of surface engineering on the relaxivity of magnetoliposome nanoparticles in order to create a targeted reagent for the intelligent diagnosis of cancers by MRI. For estimating the effect of nanoparticle coatings on encapsulation, several kinds of USPIONs coated by dextran, PEG5000 and citrate were used. All kinds of samples are monodispersed and below 100 ± 10 nm and the coatings of USPIONs have no significant effect on magnetoliposome diameter. The coating of USPIONs could have effect on percentage of encapsulation. The dextran coated USPIONs have more stability and quality accordingly the encapsulation increased up to 92%, then the magnetoliposome nano particles have been targeted by Herceptin and anti-HER2 VHH, separately. Over storage period of four weeks the resulting particles were stable and physico-chemical properties such as size and zetapotential did not show any significant changes. The relaxivity of contrast agents was measured using a 1.5 T MRI. The r2/r1 ratio was more than two for all samples which demonstrate the negative contrast enhancing of all SPION embedded specimens. The high ratio of r2/r1 as well as high r2 is the best combination of a negative contrast agent as it is obtained for pure magnetite. The value of r2/r1 for all other samples including Herceptin targeted magnetoliposome, anti-HER2 VHH targeted magnetoliposome and non-targeted magnetoliposome were between ~21 to ~28, which show the magnetite embedded samples have enough negative contrast to be detectable by MRI. Therefore the HER2 targeted magnetoliposomes are a good and stable candidate as contrast agents in clinical radiology and biomedical research with minimal cytotoxicity and biocompatibility effects. Copyright © 2016 John Wiley & Sons, Ltd.