Clinical Focus

  • Diagnostic Radiology
  • Genitourinary Cancers
  • Liver Neoplasms
  • Gastrointestinal Hemorrhage

Academic Appointments

Honors & Awards

  • Morton A. Bosniak Research Award, Society of Abdominal Radiology (ACR) (2022)
  • ESGAR Top 20, European Society of Gastrointestinal and Abdominal Radiology (2021)
  • Resident Research Grant, Radiological Society of North America (RSNA) (2019)
  • President's Award: Resident in Radiology Award, American Roentgen Ray Society (ARRS) (2019)
  • Roentgen Resident Research Award, Radiological Society of North America (RSNA) (2019)
  • Goldberg-Reeder Resident Travel Grant, American College of Radiology (ACR) (2019)
  • Dox Foundation Travel Grant: Dar es Salaam, Tanzania, Doximity (2018)
  • Case of the Day 2nd Place Winner, Society of Abdominal Radiology (SAR) (2018)
  • Abstract Travel Award, Radiological Society of North America (RSNA) (2017)
  • Alexander R. Margulis GI Paper Presenter Award, Society of Abdominal Radiology (SAR) (2015)
  • Leo G. Rigler Award for Excellence in Radiological Sciences, UCLA David Geffen School of Medicine (2015)
  • Alpha Omega Alpha Honor Medical Society, Alpha Omega Alpha (AOA) (2014)
  • Carolyn L. Kuckein Student Research Fellowship, Alpha Omega Alpha (AOA) (2014)
  • Research Medical Student Grant, Radiological Society of North America (RSNA) (2014)
  • Summa cum laude, University of California (2011)

Boards, Advisory Committees, Professional Organizations

  • Member, ACR US LI-RADS (2021 - Present)
  • Member, ACR-RADS Steering Committee (2020 - Present)
  • Member, Society of Abdominal Radiology (SAR) GI Bleed Disease Focused Panel (2022 - Present)
  • Member, Society of Abdominal Radiology (SAR) Renal Cell Carcinoma Disease Focused Panel (2020 - Present)

Professional Education

  • Board Certification: American Board of Radiology, Diagnostic Radiology (2021)
  • Fellowship, UCLA David Geffen School of Medicine, Abdominal Imaging / Cross Sectional Interventional Radiology (2021)
  • Residency, Stanford University, Diagnostic Radiology (2020)
  • MD, UCLA David Geffen School of Medicine, Medicine (2015)

All Publications

  • Accuracy of Information Provided by ChatGPT Regarding Liver Cancer Surveillance and Diagnosis. AJR. American journal of roentgenology Cao, J. J., Kwon, D. H., Ghaziani, T. T., Kwo, P., Tse, G., Kesselman, A., Kamaya, A., Tse, J. R. 2023

    View details for DOI 10.2214/AJR.23.29493

    View details for PubMedID 37222278

  • Hepatocellular Adenomas: Molecular Basis and Multimodality Imaging Update. Radiographics : a review publication of the Radiological Society of North America, Inc Tse, J. R., Felker, E. R., Naini, B. V., Shen, L., Shen, J., Lu, D. S., Kamaya, A., Raman, S. S. 2023; 43 (3): e220134


    Hepatocellular adenomas (HCAs) are a family of liver tumors that are associated with variable prognoses. Since the initial description of these tumors, the classification of HCAs has expanded and now includes eight distinct genotypic subtypes based on molecular analysis findings. These genotypic subtypes have unique derangements in their cellular biologic makeup that determine their clinical course and may allow noninvasive identification of certain subtypes. Multiphasic MRI performed with hepatobiliary contrast agents remains the best method to noninvasively detect, characterize, and monitor HCAs. HCAs are generally hypointense during the hepatobiliary phase; the beta-catenin-mutated exon 3 subtype and up to a third of inflammatory HCAs are the exception to this characterization. It is important to understand the appearances of HCAs beyond their depictions at MRI, as these tumors are typically identified with other imaging modalities first. The two most feared related complications are bleeding and malignant transformation to hepatocellular carcinoma, although the risk of these complications depends on tumor size, subtype, and clinical factors. Elective surgical resection is recommended for HCAs that are persistently larger than 5 cm, adenomas of any size in men, and all beta-catenin-mutated exon 3 HCAs. Thermal ablation and transarterial embolization are potential alternatives to surgical resection. In the acute setting of a ruptured HCA, patients typically undergo transarterial embolization with or without delayed surgical resection. This update on HCAs includes a review of radiologic-pathologic correlations by subtype and imaging modality, related complications, and management recommendations. © RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

    View details for DOI 10.1148/rg.220134

    View details for PubMedID 36821508

  • Bosniak Classification, Version 2019 Class IIF: Follow-up Strategy Should be Revised. The Journal of urology Tse, J. R., Shen, L. 2023: 101097JU0000000000003365

    View details for DOI 10.1097/JU.0000000000003365

    View details for PubMedID 36787378

  • Hepatic Adenomas With Hepatobiliary Phase Iso- or Hyperintensity: Standardized Definitions Are Required. AJR. American journal of roentgenology Tse, J. R. 2023: 1

    View details for DOI 10.2214/AJR.22.28471

    View details for PubMedID 36598412

  • Outcomes of Bosniak Classification Version 2019 Class IIF Cystic Renal Masses at Imaging Surveillance. AJR. American journal of roentgenology Shen, L., Yoon, L., Chung, B. I., Kamaya, A., Tse, J. R. 2022


    Background: Bosniak classification system version 2019 (v2019) recommends that class IIF masses undergo follow-up imaging at 6 months, 12 months, and then annually for 5 years. The frequency and timing of upgrade on follow-up imaging are incompletely understood. Purpose: To describe the temporal evolution of Bosniak v2019 class IIF cystic renal masses, with attention to outcomes at 6-month follow-up, time to class upgrade, and malignant histologic diagnoses. Methods: This retrospective study included 219 patients (91 women, 128 men; median age, 72 years) with 246 localized class IIF masses from January 2005 to June 2022. Patients underwent both a baseline and at least one follow-up renal-mass protocol contrast-enhanced CT or MRI. Two radiologists evaluated masses at all follow-up time points to categorize masses as downgraded (class I or II), stable (localized class IIF), or upgraded (class III or IV, solid, or ≥T3a, N1, or M1 disease); a third radiologist resolved discrepancies. Incidence rate of upgrade was determined. Histopathologic outcomes were assessed for resected masses. Results: Median follow-up was 28.4 months (IQR, 13.7-59.4 months). At 6-month follow-up, 5 (2%) masses were downgraded, 241 (98%) were stable, and none were upgraded. Based on final follow-up, 14 (6%) masses were downgraded, 223 (91%) were stable, and 9 (4%) were upgraded. All upgrade events entailed a class increase to III (n=7) or IV (n=2); no mass became solid or developed T3, N1, or M1 disease. Among the nine upgraded masses, median time to upgrade was 53.5 months (IQR, 23.2-63.7 months). Incidence rate of upgrade was 3.006 per 100,000 person-days (95% CI, 1.466-5.516). Ten masses were resected; histopathology was benign in six, and malignant in four. Of the four malignant masses, one was upgraded to class III after 15 months of preoperative follow-up imaging, and three remained class IIF on preoperative follow-up imaging. No resected malignant mass developed postoperative recurrence. Conclusion: Bosniak v2019 class IIF masses are unlikely to represent aggressive malignancy; only 4% were upgraded over time, and never on initial 6-month follow-up. Clinical Impact: The currently recommended initial 6-month follow-up imaging examination for class IIF masses is of questionable clinical utility.

    View details for DOI 10.2214/AJR.22.28599

    View details for PubMedID 36416398

  • Thoracic Endovascular Aortic Repair for Chronic Type B Aortic Dissection: Pre- and Postprocedural Imaging. Radiographics : a review publication of the Radiological Society of North America, Inc Shen, J., Mastrodicasa, D., Al Bulushi, Y., Lin, M. C., Tse, J. R., Watkins, A. C., Lee, J. T., Fleischmann, D. 2022; 42 (6): 1638-1653


    Aortic dissection is a chronic disease that requires lifelong clinical and imaging surveillance, long after the acute event. Imaging has an important role in prognosis, timing of repair, device sizing, and monitoring for complications, especially in the endovascular therapy era. Important anatomic features at preprocedural imaging include the location of the primary intimal tear and aortic zonal and branch vessel involvement, which influence the treatment strategy. Challenges of repair in the chronic phase include a small true lumen in conjunction with a stiff intimal flap, complex anatomy, and retrograde perfusion from distal reentry tears. The role of thoracic endovascular aortic repair (TEVAR) remains controversial for treatment of chronic aortic dissection. Standard TEVAR is aimed at excluding the primary intimal tear to decrease false lumen perfusion, induce false lumen thrombosis, promote aortic remodeling, and prevent aortic growth. In addition to covering the primary intimal tear with an endograft, several adjunctive techniques have been developed to mitigate retrograde false lumen perfusion. These techniques are broadly categorized into false lumen obliteration and landing zone optimization strategies, such as the provisional extension to induce complete attachment (PETTICOAT), false lumen embolization, cheese-wire fenestration, and knickerbocker techniques. Familiarity with these techniques is important to recognize expected changes and complications at postintervention imaging. The authors detail imaging options, provide examples of simple and complex endovascular repairs of aortic dissections, and highlight complications that can be associated with various techniques. Online supplemental material is available for this article. ©RSNA, 2022.

    View details for DOI 10.1148/rg.220028

    View details for PubMedID 36190862

  • Hepatocellular Adenoma Subtypes Based on 2017 Classification System: Exploratory Study of Gadoxetate Disodium-Enhanced MRI Features With Proposal of a Diagnostic Algorithm. AJR. American journal of roentgenology Tse, J. R., Felker, E. R., Cao, J. J., Naini, B. V., Liang, T., Lu, D. S., Raman, S. S. 2022


    Background: The classification of hepatocellular adenomas (HCAs) was updated in 2017 based on genetic and molecular analysis. Objective: To evaluate features on gadoxetate disodium-enhanced MRI of HCA subtypes based on the 2017 classification and to propose a diagnostic algorithm for determining subtype using these features. Methods: This retrospective study included 56 patients (49 women, 7 men; mean age, 37±13 years) with histologically confirmed HCA evaluated by gadoxetate disodium-enhanced MRI from January 2010 to January 2021. Subtypes were reclassified using 2017 criteria: hepatocyte nuclear factor-1β mutated HCA (H-HCA), inflammatory HCA (I-HCA), β-catenin exon 3 HCA (β-HCA), mixed inflammatory and β-catenin exon 3 HCA (βI-HCA), sonic hedgehog HCA (SH-HCA), unclassified HCA (U-HCA). Qualitative MRI features were assessed. Liver-to-lesion contrast enhancement ratios (LLCER) were measured. Subtypes were compared, and a diagnostic algorithm was proposed. Results: The analysis included 65 HCAs: 16 H-HCAs, 31 I-HCAs, 6 β-HCA, 4 βI-HCA, 5 SH-HCA, and 3 U-HCA. H-HCAs showed homogeneous/diffuse intralesional steatosis in 94%, whereas all other HCAs showed this finding in 0% (p<.001). I-HCAs showed atoll sign in 58%, whereas all other HCAs showed this finding in 12% (p<.001). I-HCAs showed moderate T2-hyperintensity in 52%, whereas all other HCAs showed this finding in 12% (p<.001). β-HCAs and βI-HCAs occurred in men in 63%, whereas all other HCAs occurred in men in 4% (p<.001). β-HCAs and βI-HCAs had mean size of 10.1±6.8 cm, whereas all other HCAs had mean size of 5.1±2.9 cm (p=.03). β-HCAs and βI-HCAs showed fluid components in 60%, whereas all other HCAs showed this finding in 5% (p<.001). Hepatobiliary-phase iso- or hyperintensity was observed in 80% of β-HCA and βI-HCAs, versus 5% of all other HCAs (p<.001). Hepatobiliary-phase LLCER was positive in nine HCAs (eight β-HCAs and βI-HCAs; one I-HCA). SH-HCA and U-HCA did not show distinguishing features. The proposed diagnostic algorithm had accuracy of 98% for H-HCA, 82% for I-HCA, and 91% for β-HCA or βI-HCAs. Conclusion: Findings on gadoxetate disodium-enhanced MRI, including hepatobiliary-phase characteristics, were associated with HCA subtypes using the 2017 classification. Clinical Impact: The algorithm identified common HCA subtypes with high accuracy, including those with β-catenin exon 3 mutations.

    View details for DOI 10.2214/AJR.22.28233

    View details for PubMedID 36169546

  • Outcomes of LI-RADS US-2 Subthreshold Observations Detected on Surveillance Ultrasound. AJR. American journal of roentgenology Tse, J. R., Shen, L., Bird, K. N., Yoon, L., Kamaya, A. 2022


    Background: Ultrasound LI-RADS version 2017 recommends that patients with US-2 subthreshold observations undergo repeat surveillance ultrasound in 3-6 months and return to routine surveillance if the observation shows no growth for 2 years. However, outcomes of US-2 observations are unknown. Objective: To determine imaging outcomes of US-2 observations detected on surveillance ultrasound examinations. Methods: This retrospective study included 175 patients (median age, 59 years; 70 women, 105 men) at high risk for hepatocellular carcinoma (HCC) with US-2 observations (i.e., subcentimeter observations) on surveillance ultrasound. Observations were classified on ≥2-year follow-up ultrasound as showing no correlate, stable (if remaining subcentimeter), or progressed (if measuring ≥10 mm, meeting US-3 criteria). Observations were classified on follow-up multiphasic CT or MR (stratified as <2-year vs ≥2-year follow-up) as showing no correlate or, if showing a correlate, using CT/MRI LI-RADS version 2018. Results: A total of 111 patients had ≥2-year follow-up ultrasound and 106 had follow-up CT or MRI (79 before 2 years, 27 after 2 years). Based on final follow-up examinations, 173/175 observations were stable on ≥2-year follow-up ultrasound (n=68); showed no correlate on follow-up ultrasound, CT, or MRI (n=88); or were classified as LR-1 or LR-2 on CT or MRI (n=17). The remaining 2/175 observations were LR-3 on CT or MRI. No observations progressed to US-3 on follow-up ultrasound or were classified as ≥LR-4 on CT or MRI. A correlate was observed in 25 of the 106 follow-up CT or MRI examinations, (LR-1 or LR-2 in 23; LR-3 in 2). Eight patients developed HCC at a median of 2.0 years after initial US-2 observation detection; all HCCs were in separate locations from the baseline observations and were preceded by a surveillance ultrasound that could not re-identify the baseline observation. In three patients who underwent liver transplant, the explant showed no dysplastic nodule or HCC. Conclusion: US-2 subthreshold observations are unlikely to progress or become HCC and commonly have no correlate on follow-up imaging. Clinical Impact: Because of the low progression rate of US-2 subthreshold observations, it is unclear if an extended period of intensive surveillance, as recommended by multiple professional societies, is warranted.

    View details for DOI 10.2214/AJR.22.27812

    View details for PubMedID 35703411

  • Editorial Comment: Clear Cell Likelihood Score-Another Step Towards Non-Invasive Risk Stratification. AJR. American journal of roentgenology Tse, J. R. 2022

    View details for DOI 10.2214/AJR.22.28087

    View details for PubMedID 35703414

  • Nyquist sampling theorem and Bosniak classification, version 2019: effect of thin axial sections on categorization and agreement. European radiology Tse, J. R., Shen, L., Shen, J., Yoon, L., Kamaya, A. 2022


    To determine if CT axial images reconstructed at current standard of care (SOC; 2.5-3 mm) or thin (≤ 1 mm) sections affect categorization and inter-rater agreement of cystic renal masses assessed with Bosniak classification, version 2019.In this retrospective single-center study, 3 abdominal radiologists reviewed 131 consecutive cystic renal masses from 100 patients performed with CT renal mass protocol from 2015 to 2021. Images were reviewed in two sessions: first with SOC and then the addition of thin sections. Individual and overall categorizations are reported, latter of which is based on majority opinion with 3-way discrepancies resolved by a fourth reader. Major categorization changes were defined as differences between classes I-II, IIF, or III-IV.Thin sections led to a statistically significant major category change with class II for all readers individually (p = 0.004-0.041; McNemar test), upgrading 10-17% of class II masses, most commonly to class IIF followed by III. Modal reason for upgrades was due to identification of additional septa followed by larger measurement of enhancing features. Masses categorized as class I, III, or IV on SOC sections were unaffected, as were identification of protrusions. Inter-rater agreements using weighted Cohen's kappa were 0.679 for SOC and 0.691 for thin sections (both substantial).Thin axial sections upgraded up to one in six class II masses to IIF or III through identification of additional septa or larger feature. Other classes, including III-IV, were unaffected. Inter-rater agreements were substantial regardless of section thickness.• Thin axial sections (≤ 1 mm) compared to standard of care sections (2.5-3 mm) led to identification of additional septa but did not affect identification of protrusions. • Thin axial sections (≤ 1 mm) compared to standard of care sections (2.5-3 mm) can upgrade a small proportion of cystic renal masses from class II to IIF or III when applying Bosniak classification, version 2019. • Inter-rater agreements were substantial regardless of section thickness.

    View details for DOI 10.1007/s00330-022-08876-3

    View details for PubMedID 35705828

  • ACR-RADS Programs Current State and Future Opportunities: Defining a Governance Structure to Enable Sustained Success. Journal of the American College of Radiology : JACR Davenport, M. S., Chatfield, M., Hoang, J., Maturen, K. E., Obuchowski, N., Tse, J., Weinreb, J., Kaur, D., Attridge, L., Kurth, D., Larson, D. 2022


    In the spring of 2021, the ACR approved a proposal to improve the consistency, transparency, and administrative oversight of the ACR Reporting and Data Systems (RADS). A working group of experts and stakeholders was convened to draft this governance document. Major advances include (1) forming a RADS Steering Committee, (2) establishing minimum requirements and evidence standards for new and existing RADS, and (3) outlining a governance structure and communication strategy for RADS.

    View details for DOI 10.1016/j.jacr.2022.03.012

    View details for PubMedID 35487247

  • Colonoscopy Versus Catheter Angiography for Lower Gastrointestinal Bleeding After Localization on CT Angiography. Journal of the American College of Radiology : JACR Tse, J. R., Felker, E. R., Tse, G. G., Liang, T., Shen, J., Kamaya, A. 2022


    The aim of this study was to compare catheter angiography (CA) and colonoscopy outcomes after successful CT angiographic (CTA) localization for patients with overt lower gastrointestinal bleeding (LGIB).Seventy-one consecutive patients from two institutions between 2010 and 2020 had both contrast extravasation on CTA imaging in the lower gastrointestinal tract and subsequent CA or colonoscopy. The primary outcome was confirmation of active bleeding during CA or colonoscopy (defined as confirmation yield). The secondary outcomes were to determine therapeutic yield (hemostatic therapy), time to procedure, rebleeding rate, and adverse outcome rates (defined as surgery, acute kidney injury, initiation of dialysis, and overall mortality). Univariate analyses and multivariable analyses with P < .05 were used to determine statistical significance.Forty-four patients underwent CA and 27 underwent colonoscopy. CA had higher overall confirmation yield (55% vs 26%, P = .026), while therapeutic yields were similar (70% vs 56%, P = .214). Time to procedure was 5.1 ± 3.4 hours for CA and 15.5 ± 13.6 hours for colonoscopy (P < .0001). On multivariable analysis, shorter time to procedure was the only statistically significant predictor of confirmation yield (P = .037) and therapeutic yield (P = .013), while procedure, hemoglobin, transfusions, and hemodynamic instability were not. Adverse events and rebleeding were not statistically different between patients who underwent CA and colonoscopy (P > .05).Shorter time to procedure was the only statistically significant predictor of confirmation and therapeutic yield after CTA localization of LGIB. Because CA can be performed sooner than colonoscopy without increased rates of adverse outcomes or rebleeding, CA may be a reasonable first-line treatment option in patients with CTA localization of LGIB.

    View details for DOI 10.1016/j.jacr.2022.01.010

    View details for PubMedID 35240106

  • Growth Kinetics and Progression Rate of Bosniak Classification, Version 2019 III and IV Cystic Renal Masses on Imaging Surveillance. AJR. American journal of roentgenology Tse, J. R., Shen, L., Shen, J., Yoon, L., Chung, B. I., Kamaya, A. 2022


    Background: Active surveillance is increasingly used as first-line management for localized renal masses. Triggers for intervention primarily reflect growth kinetics, which are poorly investigated for cystic masses defined by Bosniak classification version 2019 (v2019). Objective: To determine growth kinetics and incidence rates of progression of class III and IV cystic renal masses, as defined by Bosniak classification v2019. Methods: This retrospective study included 105 patients (68 men, 37 women; median age, 67 years) with 112 Bosniak v2019 class III or IV cystic renal masses on baseline renal-mass protocol CT or MRI examinations from January 2005 to September 2021. Mass dimensions were measured. Progression was defined as any of: linear growth rate (LGR) ≥5 mm per year (representing clinical guideline threshold for intervention), volume doubling time <1 year, T category increase, or N1 or M1 disease. Class III and IV masses were compared. Time-to-progression was estimated using Kaplan-Meier curve analysis. Results: At baseline, 58 masses were class III and 54 were class IV. Median follow-up was 406 days. Median LGR was for class III masses 0.0 mm per year [interquartile range (IQR) -1.3 to 1.8] and for class IV masses 2.3 mm per year (IQR 0.0¬¬-5.7) (p<.001). LGR exceeded 5 mm per year in 4 (7%) class 3 masses and 15 (28%) class IV masses (p=.005). Two patients, both with class IV masses, developed distant metastases. Incidence rate of progression was for class III masses 11.0 (95% CI 4.5-22.8) and for class IV masses 73.6 (95% CI 47.8-108.7) per 100,000 person-days of follow-up. Median time-to-progression was undefined for class III mases given small number of progression events and 710 days for class IV masses. Hazard ratio of progression for class IV relative to class III masses was 5.1 (95% CI 2.5-10.8) (p<.001). Conclusion: During active surveillance of cystic masses evaluated using Bosniak classification v2019, class IV masses grew faster and were more likely to progress than class III masses. Clinical Impact: In comparison with current active surveillance guidelines that treat class III and IV masses similarly, future iterations may incorporate relatively more intensive surveillance for class IV masses.

    View details for DOI 10.2214/AJR.22.27400

    View details for PubMedID 35293234

  • CT Angiography of Venoarterial Extracorporeal Membrane Oxygenation. Radiographics : a review publication of the Radiological Society of North America, Inc Shen, J., Tse, J. R., Chan, F., Fleischmann, D. 2021: 210079


    Imaging plays a central role in the workup of thromboembolic events and bleeding complications in patients treated with venoarterial extracorporeal membrane oxygenation (ECMO) (VA-ECMO), and radiologists should be familiar with the expected hemodynamic changes and flow-related artifacts associated with the VA-ECMO system. VA-ECMO is a form of temporary mechanical circulatory support for critically ill patients with acute, refractory cardiac or cardiopulmonary failure. As the use of VA-ECMO continues to increase, it is important to be aware of associated hemodynamic changes and challenges at imaging. Patients treated with VA-ECMO are at high risk for thromboembolic events and bleeding complications and, thus, often require evaluation with CT angiography (CTA). VA-ECMO can be implemented by using central or peripheral cannulation. The peripheral femorofemoral VA-ECMO circuit in particular alters the sequence and direction of contrast medium enhancement substantially, resulting in flow-related artifacts that can mimic or obscure disease at CTA. Nonopacification can be mistaken for spurious thrombus or simulate complete vascular occlusion, while mixing artifacts can mimic dissections. Misinterpretation of flow-related CTA artifacts can lead to inappropriate surgical or medical intervention. A methodical and multiphasic approach should be taken to CTA imaging strategies and interpretation for patients treated with VA-ECMO. There is no universal CTA protocol for patients on VA-ECMO. Each protocol must be designed for the study indication, with consideration of the configuration of the ECMO cannulas, contrast material injection site, region of interest, native cardiac output, and ECMO flow rate. The authors provide examples of common and unusual VA-ECMO-related artifacts, with a focus on strategies for optimizing CTA image acquisition. Online supplemental material is available for this article. ©RSNA, 2021.

    View details for DOI 10.1148/rg.210079

    View details for PubMedID 34890275

  • Regulatory Frameworks for Development and Evaluation of Artificial Intelligence-Based Diagnostic Imaging Algorithms: Summary and Recommendations JOURNAL OF THE AMERICAN COLLEGE OF RADIOLOGY Larson, D. B., Harvey, H., Rubin, D. L., Irani, N., Tse, J. R., Langlotz, C. P. 2021; 18 (3): 413–24
  • Extravasation Volume at Computed Tomography Angiography Correlates With Bleeding Rate and Prognosis in Patients With Overt Gastrointestinal Bleeding. Investigative radiology Tse, J. R., Shen, J. n., Shah, R. n., Fleischmann, D. n., Kamaya, A. n. 2021


    Despite the identification of active extravasation on computed tomography angiography (CTA) in patients with overt gastrointestinal bleeding (GIB), a large proportion do not have active bleeding or require hemostatic therapy at endoscopy, catheter angiography, or surgery. The objective of our proof-of-concept study was to improve triage of patients with GIB by correlating extravasation volume of first-pass CTA with bleeding rate and clinical outcomes.All patients who presented with overt GIB and active extravasation on CTA from January 2014 to July 2019 were reviewed in this retrospective, institutional review board-approved and Health Insurance Portability and Accountability Act-compliant study. Extravasation volume was assessed using 3-dimensional software and correlated with hemostatic therapy (primary endpoint) and with intraprocedural bleeding, blood transfusions, and mortality as secondary endpoints using logistic regression models (P < 0.0125 indicating statistical significance). Odds ratios were used to determine the effect size of a threshold extravasation volume. Quantitative data (extravasation volume, aorta attenuation, extravasation attenuation and time) were input into a mathematical model to calculate bleeding rate.Fifty consecutive patients including 6 (12%) upper, 18 (36%) small bowel, and 26 (52%) lower GIB met inclusion criteria. Forty-two underwent catheter angiography, endoscopy, or surgery; 16 had intraprocedural active bleeding, and 24 required hemostatic therapy. Higher extravasation volumes correlated with hemostatic therapy (P = 0.007), intraprocedural active bleeding (P = 0.003), and massive transfusion (P = 0.0001), but not mortality (P = 0.936). Using a threshold volume of 0.80 mL or greater, the odds ratio of hemostatic therapy was 8.1 (95% confidence interval, 2.1-26), active bleeding was 11.8 (2.6-45), and massive transfusion was 18 (2.3-65). With mathematical modeling, extravasation volume had a direct and linear relationship with bleeding rate, and the lowest calculated detectable bleeding rate with CTA was less than 0.1 mL/min.Larger extravasation volumes correlate with higher bleeding rates and may identify patients who require hemostatic therapy, have intraprocedural bleeding, and require blood transfusions. Current CTAs can detect bleeding rates less than 0.1 mL/min.

    View details for DOI 10.1097/RLI.0000000000000753

    View details for PubMedID 33449577

  • Prevalence of Malignancy and Histopathologic Association of Bosniak Classification, Version 2019 Class III and IV Cystic Renal Masses. The Journal of urology Tse, J. R., Shen, L., Shen, J., Yoon, L., Kamaya, A. 2020: 101097JU0000000000001438


    PURPOSE: Bosniak Classification, version 2019 (v2019) describes two types of class III and IV masses each: 1) thick, wall/septa ≥4 mm (III-WS), 2) obtuse protrusion ≤3 mm (III-OP), 3) obtuse protrusion ≥4 mm (IV-OP), and 4) acute protrusion of any size (IV-AP). The purposes were to determine the prevalence of malignancy and histopathologic features of class III and IV masses and subclasses.MATERIALS AND METHODS: In this IRB-approved and HIPAA-compliant study, three fellowship-trained abdominal radiologists (R1-3) reviewed cystic renal masses that had tissue pathology and pre-operative renal mass protocol CT or MRI. Classes based on v2019 and prior classification systems were retrospectively re-assigned and associated with malignancy, aggressive histologic features (necrosis or high Fuhrman grade), and radiologic progression following resection.RESULTS: The final sample included 79 masses (59 malignant, 20 benign) from 74 patients. Based on v2019, prevalence of malignancy ranged from 56-61% (mean 60%) for class III and 83-83% (mean 83%) for class IV (p=0.036, 0.013, 0.036 for R1-3). Prevalence of malignancy within subclasses were: III-WS (47-53%); III-OP (71-85%); IV-OP (75-87%); IV-AP (87-95%; p=0.029, 0.001, 0.005). All readers were more likely to classify malignancies with aggressive histologic features as class IV (88-100%) rather than class III (0-12%; p=0.012, <0.001, 0.002), corresponding to a negative predictive value of 96-100%. Following treatment (mean follow-up length 1210 days), one patient developed metastases.CONCLUSIONS: Bosniak Classification, version 2019 can help risk stratification of class III-IV masses by identifying those likely to be malignant and have aggressive histologic features.

    View details for DOI 10.1097/JU.0000000000001438

    View details for PubMedID 33085925

  • Bosniak Classification Version 2019 of Cystic Renal Masses Assessed With MRI. AJR. American journal of roentgenology Tse, J. R., Shen, J. n., Yoon, L. n., Kamaya, A. n. 2020: 1–7


    OBJECTIVE. The purpose of this study was to determine how use of Bosniak classification version 2019 affects categorization and overall accuracy of MRI evaluation of cystic renal masses with tissue pathologic analysis as the reference standard. MATERIALS AND METHODS. MR images of 50 consecutively registered patients with tissue pathologic results from 2005 to 2019 were retrospectively reviewed by two abdominal radiologists. Each radiologist independently assigned a category based on the original and Bosniak classification version 2019 systems. Interreader agreements (kappa statistic) for both were calculated, and consensus reading was performed. Tissue pathologic analysis was used as the reference standard to determine whether a lesion was benign or renal cell carcinoma. RESULTS. Fifty-nine cystic renal masses were characterized as 38 renal cell carcinomas and 21 benign lesions on the basis of the results of tissue pathologic analysis. By consensus, according to the original Bosniak criteria, the renal masses were classified into three category I, five category II, four category IIF, 25 category III, and 22 category IV lesions. By consensus, according to the version 2019 criteria, the renal masses were classified into three category I, two category II, 12 category IIF, 18 category III, and 24 category IV lesions. Overall sensitivity and specificity for identifying renal cell carcinoma were 95% and 81%, respectively, with the original classification system and 100% and 86%, respectively, with version 2019. Weighted interreader agreement was moderate for both the original system (κ = 0.57) and version 2019 (κ = 0.55). CONCLUSION. Use of Bosniak classification version 2019 system improves sensitivity and specificity for malignancy among cystic renal masses characterized with MRI. Most lesions that changed categories were reclassified as Bosniak category IIF.

    View details for DOI 10.2214/AJR.19.22740

    View details for PubMedID 32515608

  • Bosniak Classification of Cystic Renal Masses Version 2019: Comparison of Categorization using CT and MRI. AJR. American journal of roentgenology Tse, J. R., Shen, J. n., Shen, L. n., Yoon, L. n., Kamaya, A. n. 2020


    Please see the Author Video associated with this article. Background: Bosniak Classification, version 2019 recently proposed refinements for cystic renal mass characterization and now formally incorporates MRI, which may improve concordance with CT. Purpose: To compare concordance of CT and MRI in evaluation of cystic renal masses using Bosniak Classification, version 2019. Materials and Methods: In this IRB-approved and HIPAA compliant study, three abdominal radiologists (R1-R3) retrospectively reviewed 68 consecutive cystic renal masses from 45 patients assessed with both CT and MR renal mass protocols within a year between 2005-2019. CT and MRI were reviewed independently and in separate sessions, using both the original and version 2019 Bosniak Classification systems. Results: Using Bosniak Classification, version 2019, cystic renal masses were classified into 12 category I, 19 category II, 13 category IIF, 4 category III, and 20 category IV by CT and 8 category I, 15 category II, 23 category IIF, 9 category III, and 13 category IV by MRI. Among individual features, MRI depicted more septa (p<0.001, p=0.046, p=0.005 for R1-R3; McNemar's test) for all radiologists, though both CT and MRI showed a similar number of protrusions (p=0.823, 1.0, 0.302) and maximal septa/wall thickness (p=1.0, 1.0, 0.145). Of discordant cases with version 2019, MRI led to the higher category in 12 masses. Reason for upgrade was most commonly due to protrusions identified only on MRI (n=4), increased number of septa (n=3), and a new category of heterogeneously T1-hyperintense (n=3). Neither modality was more likely to lead to a category change for both version 2019 (p=0.502; McNemar's test) and the original Bosniak classification system (p=0.823). Overall inter-rater agreement was substantial for both CT (κ=0.745) and MRI (κ=0.655) using version 2019 and was slightly higher than that of the original system (CT κ=0.707; MRI κ=0.623). Conclusion: CT and MRI were concordant in the majority of cases using Bosniak Classification, version 2019 and category changes by modality were not statistically significant. Inter-rater agreements were substantial for both CT and MRI. Clinical Impact: Bosniak Classification, version 2019 applied to cystic renal masses has substantial inter-rater agreement and does not lead to systematic category upgrades with either CT or MRI.

    View details for DOI 10.2214/AJR.20.23656

    View details for PubMedID 32755181

  • Qualitative and Quantitative Gadoxetic Acid-enhanced MR Imaging Helps Subtype Hepatocellular Adenomas RADIOLOGY Tse, J. R., Naini, B. V., Lu, D. S., Raman, S. S. 2016; 279 (1): 118-127


    To determine which clinical variables and gadoxetic acid disodium (Gd-EOB-DTPA)-enhanced magnetic resonance (MR) imaging features are associated with histologically proved hepatocellular adenoma (HCA) genotypic subtypes.In this institutional review board-approved and Health Insurance Portability and Accountability Act-compliant study, clinical information and MR images of 49 histologically proved HCAs from January 2002 to December 2013 (21 patients; mean age, 39 years; age range, 15-59 years) were retrospectively reviewed by two radiologists. Qualitative and quantitative imaging features, including the signal intensity ratio relative to liver in each phase, were studied. HCA tissues were stained with subtype-specific markers and subclassified by a pathologist. Clinical and imaging data were correlated with pathologic findings and compared by using Fisher exact or t test, with a Bonferroni correction for multiple comparisons.Forty-nine HCAs were subclassified into 14 inflammatory, 20 hepatocyte nuclear factor (HNF)-1α-mutated, one β-catenin-activated, and 14 unclassified lesions. Intralesional steatosis was exclusively seen in HNF-1α-mutated lesions. Marked hyperintensity on T2-weighted images was seen in 12 of 14 (86%) inflammatory lesions compared with four of 21 (19%) HNF-1α-mutated, seven of 14 (50%) unclassified, and zero of one (0%) β-catenin-activated lesion. Two large lesions (one β-catenin-activated and one unclassified) transformed into hepatocellular carcinomas and were the only lesions to enhance with marked heterogeneity. In the hepatobiliary phase, all HCA subtypes were hypoenhancing compared with surrounding liver parenchyma, and they reached their nadir signal intensity by 10 minutes after the administration of contrast material before plateauing. HNF-1α-mutated lesions had the lowest lesion signal intensity ratio of 0.47 ± 0.09, compared with 0.73 ± 0.18 for inflammatory lesions (P = .0004), 0.82 for the β-catenin-activated lesion, and 0.73 ± 0.06 for the unclassified lesion (P = .00002).In this study, all HCA subtypes were hypoenhancing at Gd-EOB-DTPA-enhanced MR imaging in the hepatobiliary phase and reached their nadir signal intensity at 10 minutes. HNF-1α-mutated lesions could be distinguished from other subtypes by having the lowest lesion signal intensity ratio.

    View details for DOI 10.1148/radiol.2015142449

    View details for Web of Science ID 000378709700011

    View details for PubMedID 26505921

  • Stiffness Gradients Mimicking In Vivo Tissue Variation Regulate Mesenchymal Stem Cell Fate PLOS ONE Tse, J. R., Engler, A. J. 2011; 6 (1)


    Mesenchymal stem cell (MSC) differentiation is regulated in part by tissue stiffness, yet MSCs can often encounter stiffness gradients within tissues caused by pathological, e.g., myocardial infarction ∼8.7±1.5 kPa/mm, or normal tissue variation, e.g., myocardium ∼0.6±0.9 kPa/mm; since migration predominantly occurs through physiological rather than pathological gradients, it is not clear whether MSC differentiate or migrate first. MSCs cultured up to 21 days on a hydrogel containing a physiological gradient of 1.0±0.1 kPa/mm undergo directed migration, or durotaxis, up stiffness gradients rather than remain stationary. Temporal assessment of morphology and differentiation markers indicates that MSCs migrate to stiffer matrix and then differentiate into a more contractile myogenic phenotype. In those cells migrating from soft to stiff regions however, phenotype is not completely determined by the stiff hydrogel as some cells retain expression of a neural marker. These data may indicate that stiffness variation, not just stiffness alone, can be an important regulator of MSC behavior.

    View details for DOI 10.1371/journal.pone.0015978

    View details for Web of Science ID 000286511200030

    View details for PubMedID 21246050

    View details for PubMedCentralID PMC3016411

  • Preparation of hydrogel substrates with tunable mechanical properties. Current protocols in cell biology Tse, J. R., Engler, A. J. 2010; Chapter 10: Unit 10 16-?


    The modulus of elasticity of the extracellular matrix (ECM), often referred to in a biological context as "stiffness," naturally varies within the body, e.g., hard bones and soft tissue. Moreover, it has been found to have a profound effect on the behavior of anchorage-dependent cells. The fabrication of matrix substrates with a defined modulus of elasticity can be a useful technique to study the interactions of cells with their biophysical microenvironment. Matrix substrates composed of polyacrylamide hydrogels have an easily quantifiable elasticity that can be changed by adjusting the relative concentrations of its monomer, acrylamide, and cross-linker, bis-acrylamide. In this unit, we detail a protocol for the fabrication of statically compliant and radial-gradient polyacrylamide hydrogels, as well as the functionalization of these hydrogels with ECM proteins for cell culture. Included as well are suggestions to optimize this protocol to the choice of cell type or stiffness with a table of relative bis-acrylamide and acrylamide concentrations and expected elasticity after polymerization.

    View details for DOI 10.1002/0471143030.cb1016s47

    View details for PubMedID 20521229

  • Risk of malignancy in T1-hyperintense Bosniak version 2019 class II and IIF cystic renal masses. Abdominal radiology (New York) Shen, L., Tse, J. R., Lemieux, S., Yoon, L., Mullane, P. C., Liang, T., Davenport, M. S., Pedrosa, I., Silverman, S. G. 2023


    Bosniak classification version 2019 includes cystic masses in class II and IIF based partly on their hyperintense appearance at T1-weighted MRI. The prevalence of malignancy in non-enhancing heterogeneously T1-hyperintense masses is unknown, nor whether the pattern of T1 hyperintensity affects malignancy likelihood.To determine the malignancy proportion among six patterns of T1 hyperintensity within non-enhancing cystic renal masses.This retrospective, single-institution study included 72 Bosniak class II and IIF, non-enhancing, T1-hyperintense cystic renal masses. Diagnosis was confirmed by histopathology or by follow-up imaging demonstrating 5-year size and morphologic stability, decreased in size by ≥ 30%, resolution, or Bosniak down-classification. Six patterns of T1 hyperintensity were pre-defined: homogeneous (pattern A), fluid-fluid level (pattern B), peripherally markedly T1-hyperintense (pattern C), containing a T1-hyperintense non-enhancing nodule (pattern D), peripherally T1-hypointense (pattern E), and heterogeneously T1-hyperintense without a distinct pattern (pattern F). Three readers independently assigned each mass to a pattern. Individual and mean malignancy proportion were determined. Mann-Whitney test and Fischer's exact test compared the likelihood of malignancy between patterns. Inter-reader agreement was analyzed with Gwet's agreement coefficient (AC).Among 72 masses, the mean number of masses assigned was 11 (15%) to pattern A, 21 (29%) to pattern B, 6 (8%) to pattern C, 7 (10%) to pattern D, 5 (7%) to pattern E, and 22 (31%) to pattern F. Five of 72 masses (7%) were malignant; none was assigned pattern A, B, or D. Mean malignancy proportion was 5% (0/9, 1/6, and 0/4) for pattern C, 13% (0/4, 1/3, and 1/7) for pattern E, and 18% (5/20, 3/21, and 4/25) for pattern F. Malignant masses were more likely assigned to pattern E or F (p = 0.003-0.039). Inter-reader agreement was substantial (Gwet's AC: 0.68).Bosniak version 2019 class IIF masses that are non-enhancing and heterogeneously T1-hyperintense with a fluid-fluid level are likely benign. Those that are non-enhancing and heterogeneously T1-hyperintense without a distinct pattern have a malignancy proportion up to 25% (5/20).

    View details for DOI 10.1007/s00261-023-03955-5

    View details for PubMedID 37202641

    View details for PubMedCentralID 2550668

  • External Validation of a Five-Tiered CT Algorithm for the Diagnosis of Clear-Cell Renal Cell Carcinoma: A Retrospective Five-Reader Study. AJR. American journal of roentgenology Lemieux, S., Shen, L., Liang, T., Lo, E., Chu, Y., Kamaya, A., Tse, J. R. 2023


    Background: A 5-tiered CT algorithm was proposed in 2022 for predicting whether a small (cT1a) solid renal mass represents clear-cell renal cell carcinoma (ccRCC). Purpose: To perform an external-validation study of the proposed CT algorithm for diagnosis of ccRCC among small solid renal masses. Methods: This retrospective study included 93 patients [median age, 62 years; 42 women, 51 men] with 97 small solid renal masses on corticomedullary-phase contrast-enhanced CT performed between January 2012 and July 2022 that underwent surgical resection. Five readers (three attending radiologists, two clinical fellows) independently evaluated masses for mass-to-cortex corticomedullary attenuation ratio and heterogeneity score; these scores were used to derive the CT score by the previously proposed CT algorithm. The CT score's sensitivity, specificity, and PPV for ccRCC were calculated at threshold of ≥4, and NPV for ccRCC was calculated at threshold of ≥3 (consistent with thresholds in studies of the MRI-based clear-cell likelihood score and the CT algorithm's initial study). The CT score's sensitivity and specificity for papillary RCC were calculated at a threshold of ≤2. Interreader agreement was assessed using Gwet's AC1. Results: Overall, 61/97 (63%) masses were malignant; 44/97 (44%) were ccRCC. Across readers, CT score had sensitivity ranging from 47% to 95% [pooled sensitivity, 74% (95% CI, 68-80%)], specificity ranging from 19% to 83% [pooled specificity, 59% (95% CI, 52-67%)], PPV ranging from 48% to 76% [pooled PPV, 59% (95% CI, 49-71%)], and NPV ranging from 83% to 100% [pooled NPV, 90% (95% CI, 84-95%)], for ccRCC. CT score ≤2 had sensitivity ranging from 44% to 100% and specificity ranging from 77% to 98% for papillary RCC (representing 9/97 masses). Interreader agreement was substantial for attenuation score (AC1=0.70), poor for heterogeneity score (AC1=0.17), fair for 5-tiered CT score (AC1=0.32), and fair for dichotomous CT score at threshold of ≥4 (AC1=0.24; 95% CI, 0.14-0.33). Conclusion: The 5-tiered CT algorithm for evaluation of small solid renal masses was tested in an external sample and showed high NPV for ccRCC. Clinical Impact: The CT algorithm may be used for risk stratification and patient selection for active surveillance by identifying patients unlikely to have ccRCC.

    View details for DOI 10.2214/AJR.23.29151

    View details for PubMedID 37162037

  • Diagnostic performance of the "drooping" sign in CT diagnosis of exophytic renal angiomyolipoma. Abdominal radiology (New York) Shen, L., Nawaz, R., Tse, J. R., Negrete, L. M., Lubner, M. G., Toia, G. V., Liang, T., Wentland, A. L., Kamaya, A. 2023


    To evaluate the prevalence of angular interface and the "drooping" sign in exophytic renal angiomyolipomas (AMLs) and the diagnostic performance in differentiating exophytic lipid-poor AMLs from other solid renal masses.This IRB-approved, two-center study included 185 patients with 188 exophytic solid renal masses < 4 cm with histopathology and pre-operative CT within 30 days of surgical resection or biopsy. Images were reviewed for the presence of angular interface and the "drooping" sign qualitatively by three readers blinded to the final diagnosis, with majority rules applied. Both features were assessed quantitatively by cohort creators (who are not readers) independently. Free-marginal kappa was used to assess inter-reader agreement and agreement between two methods assessing each feature. Fisher's exact test, Mann-Whitney test, and multivariable logistic regression with two-tailed p < 0.05 were used to determine statistical significance. Diagnostic performance was assessed.Ninety-four patients had 96 AMLs, and 91 patients had 92 non-AMLs. Seventy-four (77%) of AMLs were lipid-poor based on quantitative assessment on CT. The presence of angular interface and the "drooping" sign by both qualitative and quantitative assessment were statistically significantly associated with AMLs (39% (qualitative) and 45% (quantitative) vs 15% (qualitative) and 13% (quantitative), and 48% (qualitative) and 43% (quantitative) vs 4% (qualitative) and 1% (quantitative), respectively, all p < 0.001) in univariable analysis. In multivariable analysis, only the "drooping" sign in either qualitative or quantitative assessment was a statistically significant predictor of AMLs (both p < 0.001). Inter-reader agreement for the "drooping" sign was moderate (k = 0.55) and for angular interface was fair (k = 0.33). Agreement between the two methods of assessing the "drooping" sign was substantial (k = 0.84) and of assessing the angular interface was moderate (k = 0.59). The "drooping" sign both qualitatively and quantitatively, alone or in combination of angular interface, had very high specificity (96-100%) and positive predictive value (PPV) (89-100%), moderate negative predictive value (62-68%), but limited sensitivity (23-49%) for lipid-poor AMLs.The "drooping" sign by both qualitative and quantitative assessment is highly specific for lipid-rich and lipid-poor AMLs. This feature alone or in combination with angular interface can aid in CT diagnosis of lipid-poor AMLs with very high specificity and PPV.

    View details for DOI 10.1007/s00261-023-03880-7

    View details for PubMedID 36947205

    View details for PubMedCentralID 4040184

  • Diagnostic performance of hypoechoic perinephric fat as a predictor of prediabetes and diabetes. Abdominal radiology (New York) Shen, L., Tse, J. R., Negrete, L. M., Shon, A., Yoon, L., Liang, T., Kamaya, A. 2022


    To evaluate prevalence and predictive value of hypoechoic perinephric fat (HPF) in patients with prediabetes and diabetes compared to non-diabetics.Of 240 patients with renal ultrasound and hemoglobin A1c (HbA1c) measurements, 114 patients had either prediabetes (HbA1c 5.7-6.4%) or diabetes (HbA1c ≥ 6.5%), and 126 patients did not. Two radiologists (blinded to diagnosis) reviewed images and discrepancies were resolved by a third. Inter-reader agreement was compared using free-marginal kappa and intraclass correlation coefficient. Fisher's exact test, Mann-Whitney test, multivariable logistic regression, and Spearman's rank correlation test with two-tailed p < 0.05 were used to determine statistical significance.HPF was exclusively identified in prediabetic and diabetic patients with a prevalence of 23% (vs 0%; p < 0.001). Identification of HPF had almost perfect inter-reader agreement (k = 0.94) and was statistically significant (p = 0.034) while controlling for body mass index (BMI) and estimated glomerular filtration rate in multivariable analysis. HPF had extremely high specificity and positive predictive value (100% for both) in patients with prediabetes and diabetes although it was not a sensitive finding (23% sensitivity). In patients with prediabetes and diabetes, those with HPF were statistically significantly more likely to have chronic kidney disease (CKD) (p = 0.003). There was no statistically significant difference in BMI, stages of CKD, and types of diabetes.Hypoechoic perirenal fat has almost perfect inter-reader agreement and is highly specific for and predictive of prediabetes and diabetes. Its presence may also help identify those with chronic kidney disease among prediabetic and diabetic patients.

    View details for DOI 10.1007/s00261-022-03763-3

    View details for PubMedID 36480029

  • Positive predictive value of LI-RADS US-3 observations: multivariable analysis of clinical and imaging features. Abdominal radiology (New York) Tse, J. R., Shen, L., Tiyarattanachai, T., Bird, K. N., Liang, T., Yoon, L., Kamaya, A. 2022


    PURPOSE: To determine how clinical and imaging features affect the positive predictive values (PPV) of US-3 observations.METHODS: In this retrospective study, 10,546 adult patients who were high risk for hepatocellular carcinoma (HCC) from 2017 to 2021 underwent ultrasound screening/surveillance. Of these, 225 adult patients (100 women, 125 men) with an US-3 observation underwent diagnostic characterization with multiphasic CT (93; 41%), MRI (130; 58%), or contrast-enhanced ultrasound (2; 1%). US-3 observations included focal observations≥10mm in 216 patients and new venous thrombi in 9 patients. PPV with 95% confidence intervals were calculated using diagnostic characterization as the reference standard. Multivariable analysis of clinical and imaging features was performed to determine the strongest associations with cancer.RESULTS: Overall PPV for an US-3 observationwas 33% (27-39%) for at least intermediate probability of cancer (≥LR-3) and 15% (10-20%) for at least probable cancer (≥LR-4). At multivariable analysis, cirrhosis had the strongest effect size for at least probable cancer (p<0.001; odds ratio OR 20.4), followed by observation size (p<0.001; OR 2.65) and age (p=0.004; OR 1.05). Alpha-fetoprotein, visualization score, and observation echogenicity were not statistically significant associations. Modality (MRI versus CT) did not affect PPV. Due to the large effect of cirrhosis, PPV was then stratified by the presence (n=116; 52%) or absence (n=109; 48%) of cirrhosis. For at least probable cancer (≥LR-4), PPV increased from 4% (0-7%; non-cirrhotic) to 26% (18-34%; p<0.001; cirrhosis).CONCLUSION: Cirrhosis most strongly affects PPV of US-3 observations for at least probable cancer at diagnostic characterization among high-risk patients, increasing to 1 in 4 among cirrhotic patients from 1 in 25 among non-cirrhotic patients.

    View details for DOI 10.1007/s00261-022-03681-4

    View details for PubMedID 36253490

  • Imaging Challenges in Chronic Dissection. Seminars in roentgenology Shen, J., Mastrodicasa, D., Tse, J. R., Fleischmann, D. 2022; 57 (4): 345-356


    Chronic aortic dissection comprises a heterogeneous group of unrepaired and repaired disease requiring lifelong clinical and imaging surveillance. CT and MRI are the main imaging modalities for longitudinal surveillance, with growing interest in emerging imaging techniques for prognostic potential. Imaging difficulties span technical and diagnostic challenges, some of which are unique to the repaired aorta, with specific complications depending on the type of repair. This review describes existing and emerging imaging techniques, outlines the technical and diagnostic challenges encountered at CT and MRI, and highlights the diagnostic pitfalls of chronic aortic dissection.

    View details for DOI 10.1053/

    View details for PubMedID 36265986

  • Predictive value and prevalence of refractive edge shadow in diagnosis of ovarian dermoids. Abdominal radiology (New York) Shen, L., Tse, J. R., Negrete, L. M., Lo, E., Yoon, L., Kamaya, A. 2022


    To evaluate the diagnostic performance of refractive edge shadow in evaluation of ovarian dermoids compared to other benign adnexal masses.Ultrasound images of 139 patients with 154 dermoids, endometriomas, and hemorrhagic cysts were retrospectively reviewed by 3 radiologists blinded to final diagnosis. Ultrasound and clinical features were compared to pathology or follow-up ultrasound results as reference standard. Inter-reader agreements with free-marginal kappa and diagnostic performance were evaluated. The former was compared using Fisher's exact test or Mann-Whitney test with p < 0.05 to determine statistical significance.The study sample consisted of 154 lesions: 50 dermoids, 50 endometriomas, and 54 hemorrhagic cysts. Refractive edge shadow, homogeneous echogenic appearance, tip of the iceberg sign, mural echogenic nodule, echogenic shadowing focus, and dot-dash sign all were statistically significant across all readers for the diagnosis of dermoid. Prevalence of each feature in dermoids compared to other entities were as follows: refractive edge shadow (70% vs 8%; p < 0.001), homogeneously echogenic appearance (34% vs 2%; p < 0.001), tip of the iceberg sign (16% vs 1%; p < 0.001), mural echogenic nodule (38% vs 2%; p < 0.001), echogenic shadowing focus (13% vs 1%; p < 0.001), and dot-dash sign (44% vs 1%; p < 0.001). Refractive edge shadow had the highest sensitivity, negative predictive value, and accuracy among all ultrasound features associated with dermoids (70%, 86%, and 85%, respectively).Refractive edge shadow is a promising ultrasound feature for diagnosis of dermoids, with the highest diagnostic accuracy and prevalence compared to other previously described features associated with dermoids.

    View details for DOI 10.1007/s00261-022-03666-3

    View details for PubMedID 36098759

  • Proportion of malignancy in Bosniak classification of cystic renal masses version 2019 (v2019) classes: systematic review and meta-analysis. European radiology McGrath, T. A., Bai, X., Kamaya, A., Park, K. J., Park, M. Y., Tse, J. R., Wang, H., McInnes, M. D., Schieda, N. 2022


    Determine the proportion of malignancy within Bosniak v2019 classes.MEDLINE and EMBASE were searched. Eligible studies contained patients with cystic renal masses undergoing CT or MRI renal protocol examinations with pathology confirmation, applying Bosniak v2019. Proportion of malignancy was estimated within Bosniak v2019 class. Risk of bias was assessed using QUADAS-2.We included 471 patients with 480 cystic renal masses. No class I malignant masses were observed. Pooled proportion of malignancy were class II, 12% (6/51, 95% CI 5-24%); class IIF, 46% (37/85, 95% CI 28-66%); class III, 79% (138/173, 95% CI 68-88%); and class IV, 84% (114/135, 95% CI 77-90%). Proportion of malignancy differed between Bosniak v2019 II-IV classes (p = 0.004). Four studies reported the proportion of malignancy by wall/septa feature. The pooled proportion of malignancy with 95% CI were class III thick smooth wall/septa, 77% (41/56, 95% CI 53-91%); class III obtuse protrusion ≤ 3 mm (irregularity), 83% (97/117, 95% CI 75-89%); and class IV nodule with acute angulation, 86% (50/58, 95% CI 75-93%) or obtuse angulation ≥ 4 mm, 83%, (64/77, 95% CI 73-90%). Subgroup analysis by wall/septa feature was limited by sample size; however, no differences were found comparing class III masses with irregularity to class IV masses (p = 0.74) or between class IV masses by acute versus obtuse angles (p = 0.62).Preliminary data suggest Bosniak v2019 class IIF masses have higher proportion of malignancy compared to the original classification, controlling for pathologic reference standard. There are no differences in proportion of malignancy comparing class III masses with irregularities to class IV masses with acute or obtuse nodules.• The proportion of malignancy in Bosniak v2019 class IIF cystic masses is 46% (37 malignant/85 total IIF masses, 95% confidence intervals (CI) 28-66%). • The proportion of malignancy in Bosniak v2019 class III cystic masses is 79% (138/173, 95% CI 68-88%) and in Bosniak v2019 class IV cystic masses is 84% (114/135, 95% CI 77-90%). • Class III cystic masses with irregularities had similar proportion of malignancy (83%, 97/117, 95% CI 75-89%) compared to Bosniak class IV masses (84%, 114/135, 95% CI 77-90%) overall (p = 0.74) with no difference within class IV masses by acute versus obtuse angulation (p = 0.62).

    View details for DOI 10.1007/s00330-022-09102-w

    View details for PubMedID 35999371

  • Clinical and ultrasound features of dermoid-associated adnexal torsion. Abdominal radiology (New York) Shen, L., Tse, J. R., Negrete, L. M., Flory, M. N., Yoon, L., Kamaya, A. 2022


    To determine the clinical and ultrasound features of dermoid-associated adnexal torsion.Forty-four patients with at least one dermoid and ultrasound ≤ 30 days of surgery were retrospectively reviewed by three radiologists. Ultrasound and clinical findings were compared to intra-operative findings using Fisher's exact test or Mann-Whitney test with p < 0.05 to determine statistical significance.Please check and confirm that the authors and their respective affiliations have been correctly identified and amend if necessary.Correct. No edit RESULTS: Twenty patients had torsion, while 24 patients did not. Patients with dermoid-associated torsion were more likely to present to emergency department (ED) (100% vs 13%; p < 0.001) and have acute unilateral pelvic pain (100% vs 42%; p < 0.001). On ultrasound, patients with torsion had larger dermoids (median largest dimension 9.0 cm (IQR 7.7-11.1) vs 6.0 cm (IQR 4.4-7.5); p < 0.001), displaced dermoid anterior or superior to the uterus (59% vs 21%; p = 0.016), and ipsilateral adnexal fluid (41% vs 4%; p = 0.003). Displaced dermoid and ipsilateral adnexal fluid had substantial (kappa = 0.72) and moderate inter-rater agreement (kappa = 0.49), respectively. The combination of ED presentation and each statistically significant ultrasound feature (dermoid size ≥ 5.0 cm, displaced dermoid, and ipsilateral adnexal fluid) yielded high specificity and positive predictive value (ranging from 93-100% to 92-100%, respectively). The combination of ED presentation and dermoid size ≥ 5.0 cm yielded the highest sensitivity, negative predicative value, and accuracy (100%, 100%, and 96%, respectively).Please check and confirm whether the edit made to the article title is in order.Looks great. No edits. Thank you!Although the diagnosis of adnexal torsion in the presence of an ovarian dermoid is traditionally challenging, the combination of ED presentation and ultrasound features increase diagnostic confidence of dermoid-associated adnexal torsion.

    View details for DOI 10.1007/s00261-022-03601-6

    View details for PubMedID 35809127

  • Safety of percutaneous, image-guided biopsy of hepatocellular carcinoma with and without concurrent ablation. Abdominal radiology (New York) Tse, J. R., Terashima, K., Shen, L., McWilliams, J. P., Lu, D. S., Raman, S. S. 2022


    PURPOSE: To determine the prevalence of adverse events after image-guided biopsy of histologically proven hepatocellular carcinomas (HCC) using a standardized, indirect access, coaxial biopsy technique.METHODS: In this IRB-approved, HIPAA compliant, and retrospective study, we evaluated all consecutive adult patients from 2011 to 2016 who underwent image-guided biopsy of HCC with and without concurrent ablation. Tumor seeding was defined as any new lesion along the needle tract on subsequent imaging. Adverse events were graded using both the Clavien-Dindo Complication Classification system and the most recently proposed Society of Interventional Radiology (SIR) Adverse Event Classification System.RESULTS: A total of 383 patients underwent 398 biopsies (64±11years; 112 women, 271 men). Most patients (282; 71%) underwent concurrent ablation. Adverse events occurred after 18 biopsies (4.5%): 13 were Grade I (Clavien-Dindo) or minor (SIR) and included hematoma (7), hepatic vein thrombus (2), portal vein thrombus (2), moderate pleural effusion (1), and small pneumothorax (1). The remaining 5 (1.3%) adverse events were classified as Grade II-IIIa (Clavien-Dindo) or moderate (SIR) and included hematoma requiring blood products (n=1), arrhythmia (n=1), and symptomatic pleural effusions requiring treatment (n=3). Baseline age, sex, cause of liver disease, HCC diameter, and HCC grade were not associated with adverse events. There were no tumor seeding events after a median follow-up of 611days (interquartile range of 211-1104).CONCLUSION: Percutaneous image-guided tissue sampling using a standardized, indirect access, coaxial technique can be performed safely with and without concurrent ablation by trained cross-sectional interventional radiologists at a tertiary liver transplant center.

    View details for DOI 10.1007/s00261-022-03494-5

    View details for PubMedID 35396970

  • Evaluation of early sonographic predictors of gangrenous cholecystitis: mucosal discontinuity and echogenic pericholecystic fat. Abdominal radiology (New York) Tse, J. R., Gologorsky, R., Shen, L., Bingham, D. B., Jeffrey, R. B., Kamaya, A. 1800


    PURPOSE: To identify early sonographic features of gangrenous cholecystitis.MATERIALS AND METHODS: 101 patients with acute cholecystitis and a pre-operative sonogram were retrospectively reviewed by three radiologists in this IRB-approved and HIPAA-compliant study. Imaging data were correlated with histologic findings and compared using the Fisher's exact test or Student t test with p<0.05 to determine statistical significance.RESULTS: Forty-eight patients had gangrenous cholecystitis and 53 had non-gangrenous acute cholecystitis. Patients with gangrenous cholecystitis tended to be older (67±17 vs 48±18years; p=0.0001), male (ratio of male:female 2:1 vs 0.6:1; p=0.005), tachycardic (60% vs 28%; p=0.001), and diabetic (25% vs 8%; p=0.001). Median time between pre-operative sonogram and surgery was 1day. On imaging, patients with gangrenous cholecystitis were more likely to have echogenic pericholecystic fat (p=0.001), mucosal discontinuity (p=0.010), and frank perforation (p=0.004), while no statistically significant differences were seen in the presence of sloughed mucosa (p=0.104), pericholecystic fluid (p=0.523) or wall striations (p=0.839). In patients with gangrenous cholecystitis and echogenic pericholecystic fat, a smaller subset had concurrent mucosal discontinuity (57%), and a smaller subset of those had concurrent frank perforation (58%). The positive likelihood ratios for gangrenous cholecystitis with echogenic fat and mucosal discontinuity were 4.6 (95% confidence interval 1.9-11.3) and 14.4 (2.0-106), respectively.CONCLUSION: Echogenic pericholecystic fat and mucosal discontinuity are early sonographic findings that may help identify gangrenous cholecystitis prior to late findings of frank perforation.

    View details for DOI 10.1007/s00261-021-03320-4

    View details for PubMedID 34985635

  • Cystic artery velocity as a predictor of acute cholecystitis. Abdominal radiology (New York) Perez, M. G., Tse, J. R., Bird, K. N., Liang, T., Brooke Jeffrey, R., Kamaya, A. 2021


    To evaluate angle-corrected peak systolic cystic artery velocity (CAv) as a predictor of acute cholecystitis among patients presenting to the emergency department (ED) with right upper quadrant (RUQ) pain.In this IRB-approved and retrospective study, CAv was evaluated in 73 patients, 43 who underwent definitive treatment with cholecystectomy or percutaneous cholecystostomy and 30 control patients without clinical suspicion for cholecystitis. In addition to CAv, the following were reviewed by 3 radiologists: CBD diameter, cholelithiasis, impacted stone in the neck, sludge, gallbladder wall thickness > 3 mm, gallbladder transverse dimension ≥ 4 cm, longitudinal dimension ≥ 8 cm, tensile gallbladder fundus sign, pericholecystic fluid, pericholecystic echogenic fat, and sonographic Murphy sign.Of the 43 patients who underwent definitive treatment, 25 had acute cholecystitis (34%) and 18 (25%) had chronic cholecystitis. Average CAv measurements were 50 ± 16 cm/s (acute), 28 ± 8 cm/s (chronic), and 22 ± 8 cm/s (control; p < 0.0001). In univariate analysis, among patients who underwent definitive therapy, CAv ≥ 40 cm/s, gallbladder wall thickness, stone impaction, GB long dimension ≥ 8 cm, and elevated WBC were associated with acute cholecystitis (p < 0.05). In multivariate analysis, CAv ≥ 40 cm/s was the only statistically significant variable (p = 0.016). CAv ≥ 40 cm/s alone had a PPV of 94.7% and overall accuracy of 81.4% in diagnosing acute cholecystitis.CAv ≥ 40 cm/s is highly associated with acute cholecystitis in patients presenting to the ED with RUQ pain.

    View details for DOI 10.1007/s00261-021-03020-z

    View details for PubMedID 34216245

  • Does measurement of the hepatic artery velocity improve the sonographic diagnosis of cholangitis? Abdominal radiology (New York) Tse, J. R., Liang, T. n., Jeffrey, R. B., Kamaya, A. n. 2019


    To determine the frequency of elevated peak systolic proper hepatic artery velocity (HAV) in patients with acute cholangitis and to determine the diagnostic performance of this metric relative to existing criteria.Between 9/2016 and 11/2017, 107 patients clinically suspected to have cholangitis were referred for an abdominal ultrasound. Of these, 56 patients had HAV measurements and were included in the final analysis. Clinical and imaging features, including HAV, HAV resistive index (RI), portal vein velocity (PVV), biliary dilation, and presence of an obstructive etiology were extracted. The diagnostic performance of HAV was compared to the existing available clinical criteria (Charcot's triad and 2018 Tokyo Guidelines). Elevated HAV was defined as HAV > 100 cm/s. Presence of cholangitis was determined by the discharge summary following medical workup and admission or observation.32% had cholangitis while 68% did not. Average HAV for patients with cholangitis was 152 ± 54 cm/s versus 91 ± 44 cm/s for those without (p < 0.0001; t test). The HAV was elevated in 83% of patients with cholangitis. When considered in isolation, an elevated HAV had a high negative predictive value (90%), was more accurate (77%; 95% confidence interval 64-87%) than Charcot's triad (73%; 60-83%), and had similar accuracy compared to 2018 Tokyo Guidelines (79%; 66-88%). Substitution of conventional imaging criteria with elevated HAV in the 2018 Tokyo Guidelines yielded the highest overall accuracy of 84% (72-92%).HAV is elevated in the majority of patients with cholangitis. Substitution of an elevated HAV for conventional sonographic criteria is more accurate than existing clinical criteria in identifying patients with cholangitis.

    View details for DOI 10.1007/s00261-019-02284-w

    View details for PubMedID 31673717

  • Performance of Hepatic Artery Velocity in Evaluation of Causes of Markedly Elevated Liver Tests. Ultrasound in medicine & biology Tse, J. R., Jeffrey, R. B., Kamaya, A. 2018


    The purpose of this study was to assess the utility of peak systolic proper hepatic artery velocity (HAV) in differentiating causes of severely elevated liver function tests. HAV, hepatic artery resistive index and portal vein velocity of 41 patients with severely elevated liver function tests were evaluated. In 19 patients (46%), the causes were structural (e.g., cholecystitis, cholangitis), whereas in 22 patients (54%) the causes were non-structural (e.g., rhabdomyolysis, drug-induced liver injury). The average HAV for structural causes was 138 ± 68 cm/s, and for non-structural causes, 65 ± 29 cm/s (p < 0.0001). An HAV >100 cm/s was correlated with structural causes (p = 0.0001). With respect to diagnostic performance, this threshold was 79% sensitive and 86% specific, with a high positive likelihood ratio (5.8) and low negative likelihood ratio (0.24). The resistive index and portal vein velocity were not statistically different. In patients with severely elevated liver function tests, an HAV >100 cm/s can help distinguish structural from non-structural causes, which may guide management while awaiting definitive laboratory tests.

    View details for PubMedID 30143340

  • Bayonet sign in dysphagia lusoria. Abdominal radiology (New York) Tse, J. R., Desser, T. S. 2018

    View details for PubMedID 29796846

  • The utility of hepatic artery velocity in diagnosing patients with acute cholecystitis. Abdominal radiology (New York) Loehfelm, T. W., Tse, J. R., Jeffrey, R. B., Kamaya, A. n. 2017


    To test the diagnostic performance of elevated peak systolic hepatic arterial velocity (HAv) in the diagnosis of acute cholecystitis.229 patients with an ultrasound (US) performed for right upper quadrant (RUQ) pain were retrospectively reviewed. 35 had cholecystectomy within 10 days of ultrasound and were included as test subjects. 47 had normal US and serology and were included as controls. Each test patient US was reviewed for the presence of gallstones, gallbladder distention, sludge, echogenic pericholecystic fat, pericholecystic fluid, gallbladder wall thickening, gallbladder wall hyperemia, and reported sonographic Murphy sign. Demographic, clinical, and hepatic artery parameters at time of original imaging were recorded. Acute cholecystitis at pathology was the primary outcome variable.21 patients had acute cholecystitis and 14 had chronic cholecystitis by pathology. For patients who went to cholecystectomy, HAv ≥100 cm/s to diagnose acute cholecystitis was more accurate (69%) than the original radiology report (63%), the presence of gallstones (51%), and sonographic Murphy sign (50%). Statistically significant predictors of acute cholecystitis included HAv ≥100 cm/s (p = 0.008), older age (p = 0.012), and elevated WBC (p = 0.002), while gallstones (p = 0.077), hepatic artery resistive index (HARI) (p = 0.199), gallbladder distension (p = 0.252), sludge (p = 0.147), echogenic fat (p = 0.184), pericholecystic fluid (p = 0.357), wall thickening (p = 0.434), hyperemia (p = 0.999), and sonographic Murphy sign (p = 0.765) were not significantly correlated with acute cholecystitis compared to chronic cholecystitis.HAv ≥100 cm/s is a useful objective parameter that may improve the performance of US in the diagnosis of acute cholecystitis.

    View details for PubMedID 28840272

  • Effects of vocal fold epithelium removal on vibration in an excised human larynx model JOURNAL OF THE ACOUSTICAL SOCIETY OF AMERICA Tse, J. R., Zhang, Z., Long, J. L. 2015; 138 (1): EL60-EL64


    This study investigated the impact of selective epithelial injury on phonation in an excised human larynx apparatus. With intact epithelium, the vocal folds exhibited a symmetrical vibration pattern with complete glottal closure during vibration. The epithelium was then enzymatically removed from one, then both vocal folds, which led to left-right asymmetric vibration and a decreased closed quotient. Although the mechanisms underlying these vibratory changes are unclear, these results demonstrate that some component of an intact surface layer may play an important role in achieving normal symmetric vibration and glottal closure.

    View details for DOI 10.1121/1.4922765

    View details for Web of Science ID 000358929000011

    View details for PubMedID 26233062

  • Rituximab: an emerging treatment for recurrent diffuse alveolar hemorrhage in systemic lupus erythematosus LUPUS Tse, J. R., Schwab, K. E., McMahon, M., Simon, W. 2015; 24 (7): 756-759


    Diffuse alveolar hemorrhage (DAH) is a rare manifestation of systemic lupus erythematosus (SLE) and is associated with high mortality rates. Treatment typically consists of aggressive immunosuppression with pulse-dose steroids, cyclophosphamide, and plasma exchange therapy. Mortality rates remain high despite use of multiple medical therapies. We present a case of recurrent DAH in a 52-year-old female with SLE after a deceased donor renal transplant who was successfully treated with rituximab. Our report highlights the pathophysiologic importance of B-cell-mediated immunosuppression in SLE-associated DAH and suggests that rituximab may represent a viable alternative to cyclophosphamide in the treatment of this disease. We also review eight other reported cases of rituximab use in SLE-associated DAH.

    View details for DOI 10.1177/0961203314564235

    View details for Web of Science ID 000354558900014

    View details for PubMedID 25527066

  • Microstructure Characterization of a Decellularized Vocal Fold Scaffold for Laryngeal Tissue Engineering LARYNGOSCOPE Tse, J. R., Long, J. L. 2014; 124 (8): E326-E331


    One potential treatment for vocal fold injury or neoplasia is to replace the entire vocal fold with a tissue-engineered scaffold. This scaffold should ideally have similar mechanical properties and extracellular matrix composition as the native vocal fold. As one approach toward this goal, we decellularized human vocal folds and characterized their mechanical properties and extracellular matrix microstructure.Basic science investigation.Human vocal folds were dissected from the laryngeal framework and treated with sodium dodecyl sulfate (SDS) to remove all cells. Mechanical properties were measured by indentation before and after SDS treatment. The extracellular matrix components of collagen, laminin, elastin, and hyaluronic acid were also characterized before and after decellularization using histology and immunofluorescence.After 4 days of SDS treatment, we obtained a scaffold that retained the original geometry of the vocal fold but was devoid of cells. The elastic modulus of the vocal folds did not change significantly before and after decellularization. Upon qualitative inspection, the decellularized vocal folds retained the original collagen, elastin, and laminin content and orientation but lost the original hyaluronic acid.Vocal folds can be decellularized using SDS without adversely affecting its mechanical stiffness and fibrous extracellular matrix. This preliminary study demonstrates the potential of a decellularized scaffold to serve as a tissue-engineered construct for vocal fold replacement.

    View details for DOI 10.1002/lary.24605

    View details for Web of Science ID 000339482100005

    View details for PubMedID 24448829

  • Pancytopenia secondary to cytomegalovirus reactivation. BMJ case reports Tse, J. R., Ng, G. X. 2014; 2014


    A 64-year-old woman with a 1-year history of microscopic polyangiitis developed isolated pancytopenia secondary to cytomegalovirus (CMV) reactivation. The patient was originally admitted to the medical service for the management of a rapidly progressing 10 cm ulcer on her left lower extremity. Prior to admission, the patient had been on several immunosuppressive agents for the treatment of microscopic polyangiitis, including prednisone, azathioprine, cyclophosphamide and rituximab. Her hospital course was notable for pancytopenia and after a very thorough diagnostic work-up, the aetiology was found to be secondary to CMV reactivation. This was confirmed by blood analysis that revealed a highly elevated CMV level at 899 100 copies/mL by quantitative PCR. The patient was promptly treated with intravenous ganciclovir for a total course of 14 days before transitioning to an oral regimen. She had a pronounced response to the anti-CMV therapy with complete recovery of her white cell count, haemoglobin and platelet count to baseline.

    View details for DOI 10.1136/bcr-2013-201857

    View details for PubMedID 24419641